Modelling the Relationship Between Resilience to Depression and Recent Stressful Life Events in University Students

Resilience, or successful coping with the experience of stressful life events (SLEs), protects against depression, but its operational mechanisms are unclear. Views diverge whether resilience intervenes as a trait or as a process of dynamic interactions of protective factors, such as self-esteem, social support and family cohesion. We evaluated five theoretically-based models of how resilience, defined as either a trait or a process, interacts with recent SLEs, to explain depressive symptomatology in 2434 university students. The moderating effect of problematic, age-inappropriate parenting (i.e., helicopter parenting) was also assessed. SLEs moderated both the effects of trait and process resilience on depression, but models conceptualising resilience as a dynamic process of interacting components showed better explanatory power than models conceptualising resilience solely as a trait. Trait resilience was protective through self-esteem at all levels of SLEs exposure (low, mild, moderate or high), and significantly, but less so through hope or social support. Experiencing helicopter parenting weakened the protective influence of process resilience, through decreasing family cohesion in the presence of SLEs. The overall assessment of the five models supports a process conceptualisation of resilience to depression in the face of adversity. However, the results also suggest that not all protective factors are equally important, with self-esteem appearing a significant and strong mediator of resilience to depression in all models including it as a variable. Building process resilience is proposed as a key intervention target for depressive symptoms. Clinical assessments and interventions following SLEs should routinely consider both trait resilience and self-esteem, as the interaction of these two factors protects against depression even at the highest levels of adversity exposure. Depression prevention approaches should address the individual's experience of overparenting, given the deleterious influence of helicopter parenting on resilience.

Revisiting CT Signs of Unilateral Vocal Fold Paralysis: A Single, Blinded Study

BACKGROUND AND PURPOSE

Several CT findings are thought to be indicative of vocal cord paralysis; however, these signs have never been validated in a blinded fashion. This study attempts to compare and validate these signs and determine their accuracy in predicting vocal cord paralysis.

MATERIALS AND METHODS

A retrospective chart review was performed, and CT scans from patients with known unilateral vocal cord paralysis and known normal vocal cord movement were reviewed by 3 radiologists who were blinded to the status of the patients' laryngeal function. The scans were reviewed and scored for 8 accepted signs of vocal cord paralysis as well as for predicting a final diagnostic conclusion. Statistical analysis using odds ratios for signs and the Fleiss κ for criterion agreement among the radiologists was performed for diagnostic accuracy.

RESULTS

The presence of medial displacement of the posterior ipsilateral vocal fold margin and ipsilateral laryngeal ventricular dilation yielded the greatest positive predictive value. Other signs demonstrated high specificity, but interrater discrepancy was greater than expected and diminished the reliability of these signs in predicting vocal cord paralysis. Overall, sensitivity and negative predictive values were low.

CONCLUSIONS

Predicting vocal cord paralysis on the basis of CT findings is not as accurate or straightforward in prospectively predicting vocal cord paralysis as implied in prior studies.

Clinical and histologic features associated with lentigo maligna clearance after imiquimod treatment

BACKGROUND

Imiquimod cream may be used as a non-surgical treatment for lentigo maligna or as adjuvant therapy following excision to decrease the risk of recurrence.

OBJECTIVES

To evaluate histologic and clinical factors associated with clinical clearance of lentigo maligna treated with imiquimod.

METHODS

We performed a retrospective review of all patients diagnosed with lentigo maligna and treated with imiquimod between 1997 and 2019 at our academic institution.

RESULTS

We observed clinical clearance in 93% (66/71) of participants who received adjuvant imiquimod following surgery and 79% (19/24) in the primary non-surgical treatment group over a median of 38 months of follow-up. In the adjuvant therapy group, positive surgical margins were associated with a decreased rate of clinical clearance when compared to cases with close (<1 mm) margins or background melanocytic dysplasia (83.3 vs. 100%, p = .01). The presence of an inflammatory response during treatment was associated with increased clearance (94.1 vs. 66.7%, p = .02).

CONCLUSIONS

Adjuvant imiquimod treatment may decrease LM recurrence rates in cases with background melanocytic dysplasia or close margins. LM cases with positive surgical margins need close clinical follow-up given higher recurrence rates.

Beyond the Revolving Door: Long-Term Lived Experience of Eating Disorders and Specialist Service Provision

In this study, we undertook a narrative analysis of participants' long-term lived experience of eating disorders and specialist service provision. Eight participants were recruited with service experience across five National Health Service (NHS) Trusts in the United Kingdom. All participants had a minimum of 10 years self-reported experience living with an eating disorder. The data are presented across different temporal stages that demonstrate the development of participants' self-construct in relation to their first contact with specialist services, what had happened in their lives for this to become necessary, and their current relationships with services, before exploring what participants need from services to help them feel heard going forward. Findings suggest that current methods of service delivery result in delayed and inappropriate supports and a consequent "battling" against professionals, which can provide an obstacle to compassionate and collaborative working and promote "revolving door" experiences.

Time to progression from discoid lupus erythematosus to systemic lupus erythematosus: a retrospective cohort study

Determining the risk of progression to systemic lupus erythematosus (SLE) among patients diagnosed with discoid lupus erythematosus (DLE), and the time frame of this risk, are important clinical questions. Past reports have demonstrated a wide time frame of progression from DLE to SLE, with mean time to progression of approximately 8 years. Using data obtained from an academic lupus centre, we identified 32 patients who progressed from DLE to SLE. In our cohort, we found that the median time to progression from DLE to SLE was 453 days, much sooner than previously reported. We believe this information can help inform clinicians on monitoring visit intervals and how best to counsel patients on SLE progression.

Near-Hanging as Presenting to Hospitals in Queensland: Recommendations for Practice

Near-hanging is an increasing presentation to hospitals in Australasia. We reviewed the clinical management and outcome of these patients as they presented to public hospitals in Queensland. A retrospective clinical record audit was made at five public hospitals between 1991 and 2000. Of 161 patients enrolled, 82% were male, 8% were indigenous and 10% had made a previous hanging attempt. Chronic medical illnesses were documented in 11% and previous psychiatric disorders in 42%. Of the 38 patients with a Glasgow Coma Scale score (GCS) of 3 on arrival at hospital, 32% returned to independent living and 63% died. Fifty-two patients received CPR, of whom 46% had an independent functional outcome. Independent predictors of mortality were a GCS on hospital arrival of 3 (AOR 150, CI 95% 12.4–1818, P<0.001), taking plain X-rays of the cervical spine (AOR 0.06, CI 95% 0.004–0.97, P=0.047) and contact with the ground (AOR 0.03, CI 95% 0.002–0.62, P=0.02). Only 66% had imaging of the cervical spine performed with other imaging performed infrequently. There were three laryngeal, two hyoid bone and three cervical spine injuries and one carotid dissection. The number of cervical spine X-rays required to find a significant cervical spine fracture was 54. Near-hanging presenting to hospital with a poor conscious state or even cardiac arrest can have a favourable clinical outcome. Radiological investigations are infrequently performed despite a low GCS precluding early accurate assessment. Given the general favourable outcome, an aggressive approach to searching for correctable injuries is recommended.

Patient characteristics, interventions and outcomes of 1151 rapid response team activations in a tertiary hospital: a prospective study

BACKGROUND

The characteristics of mature contemporary rapid response systems are unclear.

AIM

To determine the patient characteristics, processes and outcomes, both in-hospital and post-discharge, of a well-established rapid response system in a tertiary adult hospital.

METHODS

This is a prospective study of consecutive rapid response team (RRT) activations between 1 July and 25 November 2015. Variables included patient characteristics, timing, location and triggers of RRT activations, interventions undertaken, mortality and readmission status at 28 days post-discharge.

RESULTS

A total of 1151 RRT activations was analysed (69.1 per 1000 admissions), involving 800 patients, of whom 81.5% were emergency admissions. A total of 351 (30.5%) activations comprised repeat activations for the same patient. Most activations (723; 62.8%) occurred out of hours, and 495 (43%) occurred within 48 h of admission. Hypotension, decreased level of consciousness and oxygen desaturation were the most common triggers. Advanced life support was undertaken in less than 7%; 198 (17.2%) responses led to transfer to higher-level care units. Acute resuscitation plans were noted for only 29.1% of RRT activations, with 80.3% stipulating supportive care only. A total of 103 (12.6%) patients died in hospital, equalling 14 deaths per 100 RRT activations. At 28 days, 150 (18.8%) patients had died, significantly more among those with multiple versus single RRT activations (24.9 vs 16.6%; odds ratio 1.66, 95% confidence interval 1.31-2.44; P = 0.013).

CONCLUSION

Relatively few RRT activations are associated with acute resuscitation plans, and most interventions during RRT responses are low level. The high rate of post-RRT deaths and transfers to higher-level care units calls for the prospective identification of such patients in targeting appropriate care.

Preventing depression: Qualitatively examining the benefits of depression-focused iCBT for participants who do not meet clinical thresholds

•First qualitative study on the benefits of iCBT for those who do not meet clinical thresholds•Successful application of cognitive and behavioural strategies reported•Increased insight/awareness and improved self-efficacy reported•The format of online delivery was reported as helpful.•Findings align with previous face-to-face and iCBT treatments.

Facilitated subcutaneous immunoglobulin (fSCIg) therapy--practical considerations

There is an increasing range of therapeutic options for primary antibody-deficient patients who require replacement immunoglobulin. These include intravenous immunoglobulin (IVIg), subcutaneous immunoglobulin (SCIg), rapid push SCIg and most recently recombinant human hyaluronidase-facilitated SCIg (fSCIg). Advantages of fSCIg include fewer needle punctures, longer infusion intervals and an improved adverse effect profile relative to IVIg. Limited real-life experience exists concerning the practical aspects of switching or starting patients on fSCIg. We describe the first 14 patients who have been treated with fSCIg at the Immunodeficiency Centre for Wales (ICW), representing more than 6 patient-years of experience. The regimen was well tolerated, with high levels of satisfaction and no increase in training requirement, including for a treatment-naive patient. Two patients discontinued fSCIg due to pain and swelling at the infusion site, and one paused therapy following post-infusion migraines. Ultrasound imaging of paired conventional and facilitated SCIg demonstrated clear differences in subcutaneous space distribution associated with a 10-fold increase in rate and volume delivery with fSCIg. Patient profiles for those choosing fSCIg fell into two main categories: those experiencing clinical problems with their current treatment and those seeking greater convenience and flexibility. When introducing fSCIg, consideration of the type and programming of infusion pump, needle gauge and length, infusion site, up-dosing schedule, home training and patient information are important, as these may differ from conventional SCIg. This paper provides guidance on practical aspects of the administration, training and outcomes to help inform decision-making for this new treatment modality.

Internet-delivered treatment: its potential as a low-intensity community intervention for adults with symptoms of depression: protocol for a randomized controlled trial

BACKGROUND

Depression is a high prevalence disorder, displaying high rates of lifetime incidence, early age onset, high chronicity, and role impairment. In Ireland 12-month prevalence of depression has been reported to be 10.3%. A large percentage of affected individuals have no medical diagnosis nor seek treatment. Cognitive Behavior Therapy (CBT) has established itself as an option for the treatment of depression. Many Irish adults with depression find it difficult to access evidence-based CBT, this is due to several factors, like stigma and costs. However, systematic factors including the shortage of trained professionals and the relative underdevelopment of services also make access difficult.Stepped-care can increase access to evidence-based CBT. One option is tailored internet-delivered treatment programs. Preliminary research from Ireland needs now to include large-scale studies on effectiveness. Thus the current study seeks to examine the potential of an internet-delivered low-intensity treatment for symptoms of depression in an Irish adult community sample.

METHOD/DESIGN

The study is a randomized controlled trial of an online CBT (iCBT) program for the treatment of adults with depressive symptoms. The trial will include an active treatment group and a waiting-list control group. The active condition will consist of 8 weekly modules of iCBT, with post-session feedback support. Participants in the waiting list will receive access to the treatment at week 8. Participants will complete the Beck Depression Inventory (BDI-II) and eligibility criteria will also apply. Primary outcomes are depressive symptoms. Secondary outcomes include quality of life indicators, significant events and satisfaction with online treatment. Data will be collected at baseline and at post-treatment, week 8, and at follow-up week 20 (3-months) and week 32 (6-months). Analysis will be conducted on the intention-to-treat basis.

DISCUSSION

The study seeks to evaluate the effectiveness of an online delivered treatment for depression in a community sample of Irish adults with symptoms of depression. The study will be a first contribution and depending on the sample recruited the results may be generalizable to people with similar difficulties in Ireland and may therefore give insight into the potential of low-intensity interventions for Irish people with depressive symptoms.

TRIAL REGISTRATION NUMBER

Current Controlled Trials ISRCTN03704676. DOI: 10.1186/ISRCTN03704676.

Low-intensity internet-delivered treatment for generalized anxiety symptoms in routine care: protocol for a randomized controlled trial

BACKGROUND

Worldwide prevalence of generalized anxiety disorder (GAD) is considered high; in Europe lifetime prevalence has been estimated at 4.3 to 5.9%. High levels of anxiety disorders have been reported in university students, affecting 25 to 30% of the population. Young adults are some of the most vulnerable for the onset of mental health disorders and any stressors may act as a catalyst for their onset. The absence of resources can often mean that many do not seek treatment. Other factors that impede access to resources include such things as a lack of trained professionals, personal stigma, and waiting lists. Anxiety disorders can be treated successfully; indeed brief forms of cognitive-behavior therapy have been recommended. One potential avenue for research and development is that of delivering low-intensity interventions online for students with GAD. Therefore, the current study seeks to investigate the potential effectiveness for a low-intensity online CBT-based treatment for GAD in a service-based setting; implemented as one step in a stepped-care model.

METHODS/DESIGN

The research is a service-based effectiveness study utilizing a randomized waiting-list controlled design. The active intervention consists of six weekly modules of online CBT. Participants are assigned a supporter who provides weekly post-session feedback on progress and exercises. Participants will complete the GAD-7 as the primary outcome measure. Secondary outcomes include pathological worry, depression and measures of well-being. At three-months follow-up data will be collected using the GAD-7, BDI-II, PSWQ, ED-Q5 and WSAS. Post-session data will be collected on significant in-session events in treatment (HAT). A satisfaction with treatment measure will be administered post-treatment (SAT).

DISCUSSION

The study will be a contribution to the potential for a low-intensity internet-delivered program implemented in a service-based setting; implemented as one step in a stepped-care model. The study will be a contribution to the already established work in online treatments for anxiety worldwide. The study will assess the utility of an innovative digital health solution (SilverCloud) to deliver such interventions.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN16303842.

Maternal serum cholesterol levels are elevated from the 1st trimester of pregnancy: a cross-sectional study

Cholesterol is monitored in the non-pregnant adult population, where normal values are established. Although reported to be elevated in pregnancy, cholesterol is neither routinely measured nor treated. We aimed to investigate cholesterol levels throughout pregnancy and to establish reference values for cholesterol in healthy pregnant women. This was a cross-sectional analysis of serum cholesterol in healthy women with an uncomplicated singleton pregnancy. Pregnant women attending for antenatal care were recruited and cholesterol levels assayed at 12, 20, 28 and 36 weeks' gestation and on day 1-3 postpartum. A total of 222 women were recruited. The majority (95%) were white Irish, with a median age of 31 years (range 16-46). Median BMI was 25.9 kg/m2 (range 18-40) and 16% were smokers. Cholesterol levels were elevated in all trimesters of pregnancy, with median values from 1st trimester raised outside the non-pregnant adult range. High-density lipoprotein (HDL) levels ranged from 0.9 to 3.7 mmol/l and low-density lipoprotein (LDL) levels ranged from 1.3 to 6.1 mmol/l. Fasting, smoking and obesity did not have any significant effects on results. Total and LDL-cholesterol levels were raised throughout pregnancy. Levels were above non-pregnant adult ranges as early as the 1st trimester. The implications of this on fetus and mother are undetermined and deserve further investigation.

First reported case in Ireland of MEN2A due to a rare mutation in exon 8 of the RET oncogene

We present the case of a 30-year-old female who was diagnosed with hereditary phaeochromocytoma secondary to a rare gene mutation in exon 8 of the RET oncogene. This genetic mutation was picked up as part of an extended genetic screen using a method known as next generation sequencing. Detection of this genetic mutation prompted further screening for the manifestation of multiple endocrine neoplasia type 2A (MEN2A). The patient subsequently underwent a thyroidectomy with histology confirming C-cell hyperplasia.

Prevalence of subclinical and undiagnosed overt hypothyroidism in a pregnancy loss clinic

Recent studies have associated pregnancy loss with subclinical hypothyroidism, defined as elevated thyroid-stimulating-hormone level, with normal free thyroxine. In overt hypothyroidism, the free thyroxine is low. Subclinical and overt hypothyroidism occurs in 0.25-2.5% and 0.2-0.3% of pregnancies respectively. We examined the prevalence of subclinical and undiagnosed overt hypothyroidism in women with recurrent miscarriage, late miscarriage and stillbirth attending the Pregnancy Loss Clinic. Data was collected from the Pregnancy Loss Clinic records. Women with sporadic miscarriages, autoimmune disorders, thrombophilias and known hypothyroidism were excluded. Two-hundred-and-sixty-two women were included. Median maternal age was 35 years (range 18-47). Subclinical and undiagnosed overt hypothyroidism was found in 11.45% of women. Twenty-two women (8.39%) had subclinical hypothyroidism, eight (3.05%) had undiagnosed overt hypothyroidism. Results were compared to women with ongoing pregnancies. A proportion of women attending the clinic had subclinical or undiagnosed overt hypothyroidism, raising the suspicion of causation in unexplained pregnancy loss.

Life events, coping, and antihypertensive medication adherence among older adults: the cohort study of medication adherence among older adults

The authors examined the association between life events and antihypertensive medication adherence in older adults and the moderating role of coping. A cross-sectional analysis was conducted by using data (n = 1,817) from the Cohort Study of Medication Adherence among Older Adults (recruitment conducted from August 2006 through September 2007). Life events occurring in the 12 months preceding the study interview were assessed via the Holmes Rahe Social Readjustment Rating Scale (SRRS), and coping levels were assessed via an adapted version of the John Henry Active Coping Scale. Low adherence to antihypertensive medication was defined as scores less than 6 on the 8-item Morisky Medication Adherence Scale (known as "MMAS-8"). Of study participants, 13.2% had low adherence, and 27.2% and 5.0% had medium (150-299) and high (≥300) SRRS scores, respectively. After multivariable adjustment, the odds ratios for low adherence associated with medium and high, versus low, SRRS were 1.50 (95% confidence interval: 1.11, 2.02) and 2.11 (95% confidence interval: 1.24, 3.58), respectively. When multivariable models were stratified by coping level, the association between life events and adherence was evident only among participants with low coping levels.

Developing environment-specific water quality guidelines for suspended particulate matter

It is generally well recognised that suspended particulate matter (SPM), from nano-scale particles to sand-sized sediments, can cause serious degradation of aquatic ecosystems. However, at present there is a poor understanding of the SPM conditions that water quality managers should aim to achieve in contrasting environments in order to support good ecological status. In this article, we analyse long-term SPM data collected from a wide range of reference-condition temperate environments in the UK (638 stream/river sites comprising 42 different ecosystem-types). One-way analysis of variance reveals that there is a statistically significant difference (p < 0.001) between the background SPM concentrations observed in contrasting ecosystems that are in reference condition (minimal anthropogenic disturbance). One of the 42 ecosystems studied had mean background concentrations of SPM in excess of the current European Union (EU) water quality guideline, despite being in reference condition. The implications of this finding are that the EU's current blanket water quality guideline (25 mg L(-1) for all environments) is inappropriate for this specific ecosystem-type which will be non-compliant with the guideline regardless of the intensity of land-use. The other 41 ecosystems studied had mean concentrations below the current EU water quality guideline. However, this does not necessarily mean that the guideline is appropriate for these ecosystems, as previous research has demonstrated that detrimental impacts can be experienced by some freshwater organisms, of all trophic levels, when exposed to concentrations below 25 mg L(-1). Therefore, it is suggested here that it is likely that some ecosystems, particularly those with mean concentrations in the 0.00-5.99 mg L(-1) range, require much lower guideline values in order to be effectively protected. We propose a model for predicting environment-specific water quality guidelines for SPM. In order to develop this model, the 638 reference condition sites were first classified into one of five mean background SPM ranges (0.00-5.99, 6.00-11.99, 12.00-17.99, 18.00-23.99 and >24.00 mg L(-1)). Stepwise Multiple Discriminant Analysis (MDA) of these ranges showed that a site's SPM range can be predicted as a function of: mean annual air temperature, mean annual precipitation, mean altitude of upstream catchment, distance from source, slope to source, channel width and depth, the percentage of catchment area comprised of clay, chalk, and hard rock solid geology, and the percentage of the catchment area comprised of blown sand as the surface (drift) material. The MDA technique, with cross-validation (Wilks-Lambda 0.358, p 0.000), can predict the correct or the next closest SPM range of a site in 90% of cases. This technique can also predict SPM range membership in a probabilistic manner, allowing for an estimate of uncertainty to be made in the allocation of a site to an environment-specific SPM range.

Models of transitional care for young people with complex health needs: a scoping review

BACKGROUND

Young people with complex healthcare needs (CHNs) face the challenge of transferring from child to adult health services. This study sought to identify successful models of transitional care for young people with CHNs. Three conditions were used as exemplars: cerebral palsy, autism spectrum disorders and diabetes.

METHODS

Scoping review: using search terms concerning transitional care, four databases were systematically searched for papers published in English between 1980 and April 2010. Additional informal search methods included recommendations from colleagues working with young people with each of the three conditions and making contact with clinical and research teams with expertise in transitional care. Inclusion and exclusion criteria were applied to define the papers selected for review. A separate review of policy documents, adolescent health and transition literature was also undertaken; 10 common summary categories for the components of high-quality services were identified. All papers were coded using a framework analysis which evaluated the data in two ways using the 10 transition categories and four elements of Normalization Process Theory that are important for successful implementation and integration of healthcare interventions.

RESULTS

Nineteen papers were selected for review. A very limited literature of models of service provision was identified for young people with cerebral palsy and diabetes. No models were identified for young people with autism spectrum disorders. Furthermore most publications were either descriptions of new service provision or time-limited pilot studies with little service evaluation or consideration of key elements of effective implementation.

CONCLUSIONS

Despite agreement about the importance of effective transitional care, there is a paucity of evidence to inform best practice about both the process of and what constitutes effective transitional care. There is therefore an urgent need for research to evaluate current transitional care practices for young people with CHNs.

Functional and prognostic relevance of the homeobox protein MSX2 in malignant melanoma

Background:

The homeobox containing transcription factor MSX2 is a key regulator of embryonic development and has been implicated to have a role in breast and pancreatic cancer.

Methods:

Using a selection of two- and three-dimensional in vitro assays and tissue microarrays (TMAs), the clinical and functional relevance of MSX2 in malignant melanoma was explored. A doxycyline-inducible over-expression system was applied to study the relevance of MSX2 in vitro. For TMA construction, tumour material from 218 melanoma patients was used.

Results:

Ectopic expression of MSX2 resulted in the induction of apoptosis and reduced the invasive capacity of melanoma cells in three-dimensional culture. MSX2 over-expression was shown to affect several signalling pathways associated with cell invasion and survival. Downregulation of N-Cadherin, induction of p21 and inhibition of both BCL2 and Survivin were observed. Cytoplasmic MSX2 expression was found to correlate significantly with increased recurrence-free survival (P=0.008). Nuclear expression of MSX2 did not result in significant survival correlations, suggesting that the beneficial effect of MSX2 may be independent of its DNA binding activity.

Conclusions:

MSX2 may be an important regulator of melanoma cell invasion and survival. Cytoplasmic expression of the protein was identified as biomarker for good prognosis in malignant melanoma patients.

A clinician's guide to predicting fluid responsiveness in critical illness: applied physiology and research methodology

Intravenous fluid administration is often used in critical care with the goal of improving haemodynamics and consequently tissue perfusion and oxygen delivery. While inotropic and vasoactive drugs are often necessary to correct haemodynamic instability, resuscitation usually begins with fluid therapy. As fluid challenge can result in clinical deterioration, the ability to predict haemodynamic response is desirable. In this way it might be possible to avoid unnecessary volume replacement in critically ill patients. Cardiac preload is a concept that accounts for the relationship between ventricular filling and stroke volume. It has been challenging to apply this concept to clinical practice. For this reason, the study of fluid responsiveness is of increasing research and clinical interest. The clinical application of predicting fluid responsiveness requires an understanding of relevant physiological principles. Furthermore, an improved understanding of these principles should assist the clinician in appraising published data, which has been characterised by significant methodological differences. This review aims to assist the clinician by detailing the physiological principles that underlie the prediction of fluid responsiveness in the critically ill. In addition, the potential importance of methodological differences in the cutrent literature will be considered.

Solving the IRAK-4 enigma: application of kinase-dead knock-in mice

Interleukin-1 receptor-associated kinase (IRAK-4) is an essential component of the signal transduction complex downstream of the interleukin (IL)-1- and Toll-like receptors. Though regarded as the first kinase in the signaling cascade, the role of IRAK-4 kinase activity versus its scaffold function has been controversial. In order to investigate the role of IRAK-4 kinase function in vivo, we generated "knock-in" mice where the wild-type IRAK-4 gene is replaced with a mutant gene encoding kinase-deficient IRAK-4 protein (IRAK-4 KD). IRAK-4 kinase is rendered inactive by mutating the conserved lysine residues in the ATP pocket essential for coordinating ATP. Analyses of embryonic fibroblasts and macrophages obtained from IRAK-4 KD mice demonstrated lack of cellular responsiveness to stimulation with IL-1beta or Toll-like receptor 4 (TLR4) and TLR7 agonists. IRAK-4 KD cells were severely impaired in NF-kappaB, JNK, and p38 activation in response to IL-1beta or TLR7 ligand. In addition, activation of JNK and p38 was affected in lipopolysaccharide (LPS)-stimulated IRAK-4 KD macrophages. As a consequence, IL-1 receptor/TLR4/TLR7-mediated production of cytokines and chemokines was largely absent in these cells. Additionally, microarray analysis identified IL-1beta response genes and revealed that the induction of IL-1beta-responsive mRNAs is largely ablated in IRAK-4 KD cells. In summary, our results suggest that IRAK-4 kinase activity plays a critical role in IL-1R-, TLR4-, and TLR7-mediated induction of inflammatory responses.

Co-occurrence of autoimmune thyroid disease in a multiple sclerosis cohort

Background

Multiple sclerosis (MS), Hashimoto's disease and Graves' disease are autoimmune diseases that may share similar pathogenic mechanisms. The co-occurrence rates and demographic characteristics of Graves' disease and Hashimoto's disease (HT) in our MS population are compared with the general population.

Methods

The prevalence of thyroid disease in our MS patients was determined by chart review and survey. Previous diagnosis of thyroid disease, age at diagnosis, treatment used, and about the use of disease modifying medications used to treat their MS were asked. Chart reviews were used to estimate the population prevalence of Graves' disease and Hashimoto's disease and to estimate the demographics of patients with thyroid disease.

Results

A significant co-occurrence of Graves' disease with MS (p = 0.002), and a non-significant co-occurrence of Hashimoto's disease were noted (p = 0.097). No difference in the age of onset or gender of thyroid disease in MS patients compared to the general population was found.

Conclusion

There is a significant co-occurrence in patients with MS and Graves' disease, and a trend to co-occurrence in patients with MS and Hashimoto's disease. There are no differences in the demographics of patients with thyroid disease in our MS patients compared to the general population.

Pre-prandial vs. post-prandial capillary glucose measurements as targets for repaglinide dose titration in people with diet-treated or metformin-treated Type 2 diabetes: a randomized controlled clinical trial

OBJECTIVE

Repaglinide is an oral anti-diabetic agent that has a short duration of action, and is suitable for preventing post-prandial rises in glucose levels. Targeting post-prandial glucose levels may lead to lower HbA(1c) levels and rates of hypoglycaemia than targeting pre-prandial glucose levels.

RESEARCH DESIGN AND METHODS

In 42 centres, 193 drug-naive (n = 122) or metformin-treated (n = 71) individuals with Type 2 diabetes were randomly allocated to a 40-day period of repaglinide dose-titration (starting at 0.5 mg three times daily) based on either self-measured pre-prandial or post-prandial glucose levels. They were followed for a further 12 weeks and HbA(1c) and hypoglycaemia rates were recorded.

RESULTS

Repaglinide reduced HbA(1c) by 1.25 and 1.07% in the post-prandial and pre-prandial groups, respectively (P for difference = 0.6), and achieved target glucose levels in 80.7 and 66.7%, respectively (P = 0.16). The effect of titration strategy differed by baseline drug therapy, and was more effective in the metformin-treated individuals who experienced a HbA(1c) fall of 0.6 vs. 1.10% with pre-prandial vs. post-prandial titration (P for metformin-allocated group interaction = 0.043). The rate of hypoglycaemia did not differ by group.

CONCLUSIONS

In drug-naive individuals with Type 2 diabetes, similar HbA(1c) levels are achieved with repaglinide when dosing is adjusted according to either post-prandial or pre-prandial levels. Conversely, in metformin-treated individuals, repaglinide dosing according to post-prandial levels may lead to better glycaemic control than dosing according to pre-prandial levels.

The association between osteoporotic fractures and health-related quality of life as measured by the Health Utilities Index in the Canadian Multicentre Osteoporosis Study (CaMos)

Osteoporotic fractures can be a major cause of morbidity. It is important to determine the impact of fractures on health-related quality of life (HRQL). A total of 3,394 women and 1,122 men 50 years of age and older, who were recruited for the Canadian Multicentre Osteoporosis Study (CaMos), participated in this cross-sectional study. Minimal trauma fractures of the hip, pelvis, spine, lower body (included upper and lower leg, knee, ankle, and foot), upper body (included arm, elbow, sternum, shoulder, and clavicle), wrist and hand (included forearm, hand, and finger), and ribs were studied. Participants with subclinical vertebral deformities were also examined. The Health Utilities Index Mark II and III Systems were used to assess HRQL. Past osteoporotic fractures varied in prevalence from 1.2% (pelvis) to 27.8% (lower body) in women and 0.3% (pelvis) to 29.3% (wrist) in men. Multivariate linear regression analyses [parameter estimates and corresponding 95% confidence intervals (CI)] indicated that minimal trauma fractures were negatively associated with HRQL and that this relationship depends on fracture type and gender. The multi-attribute scores for the Mark II system were negatively related to hip (-0.05; 95% CI: -0.09, -0.01), lower body (-0.02; 95% CI: -0.03, -0.000), and subclinical vertebral fractures (-0.02; 95% CI: -0.03, -0.00) for women. The multi-attribute scores for the Mark III system were negatively related to hip (-0.09; 95% CI: -0.14, -0.03) and rib fractures (-0.06; 95% CI: -0.11, -0.00) for women, and rib fractures (-0.06; 95% CI: -0.12, -0.00) for men. In conclusion, this study demonstrates a negative association between osteoporotic fractures and quality of life in both women and men.

Associations among disease conditions, bone mineral density, and prevalent vertebral deformities in men and women 50 years of age and older: cross-sectional results from the Canadian Multicentre Osteoporosis Study

This cross-sectional cohort study of 5566 women and 2187 men 50 years of age and older in the population-based Canadian Multicentre Osteoporosis Study was conducted to determine whether reported past diseases are associated with bone mineral density or prevalent vertebral deformities. We examined 12 self-reported disease conditions including diabetes mellitus (types 1 or 2), nephrolithiasis, hypertension, heart attack, rheumatoid arthritis, thyroid disease, breast cancer, inflammatory bowel disease, neuromuscular disease, Paget's disease, and chronic obstructive pulmonary disease. Multivariate linear and logistic regression analyses were performed to determine whether there were associations among these disease conditions and bone mineral density of the lumbar spine, femoral neck, and trochanter, as well as prevalent vertebral deformities. Bone mineral density measurements were higher in women and men with type 2 diabetes compared with those without after appropriate adjustments. The differences were most notable at the lumbar spine (+0.053 g/cm2), femoral neck (+0.028 g/cm2), and trochanter (+0.025 g/cm2) in women, and at the femoral neck (+0.025 g/cm2) in men. Hypertension was also associated with higher bone mineral density measurements for both women and men. The differences were most pronounced at the lumbar spine (+0.022 g/cm2) and femoral neck (+0.007 g/cm2) in women and at the lumbar spine (+0.028 g/cm2) in men. Although results were statistically inconclusive, men reporting versus not reporting past nephrolithiasis appeared to have clinically relevant lower bone mineral density values. Bone mineral density differences were -0.022, -0.015, and -0.016 g/cm2 at the lumbar spine, femoral neck, and trochanter, respectively. Disease conditions were not strongly associated with vertebral deformities. In summary, these cross-sectional population-based data show that type 2 diabetes and hypertension are associated with higher bone mineral density in women and men, and nephrolithiasis may be associated with lower bone mineral density in men. The importance of these associations for osteoporosis case finding and management require further and prospective studies.