The potential unintended consequences of Mental Health Act reforms in England and Wales on people with intellectual disability and/or autism

The draft Mental Health Bill, which amends the Mental Health Act 1983 for England and Wales, proposes protections for people with intellectual disability and/or autism (ID/A) to prevent detention in hospital in the absence of mental illness. This editorial critically appraises the positive impact and unintended consequences of the proposed reforms for people with ID/A.

Shared-care survivorship program for testicular cancer patients: safe and feasible

Background

Testicular cancer survivors are at risk for cardiovascular disease, often preceded by early development of cardiovascular risk factors due to chemotherapeutic treatment. Therefore, close collaboration between oncologists and primary care physicians (PCPs) is needed during follow-up to monitor and manage cardiovascular risk factors. We designed a shared-care survivorship program, in which testicular cancer patients visit both their oncologist and their PCP. The objective of this study was to test the safety and feasibility of shared-care follow-up after treatment for metastatic testicular cancer.

Patients and methods

The study was designed as an observational cohort study with a stopping rule to check for the safety of follow-up. Safety boundaries were defined for failures in the detection of signals indicating cancer recurrence. Secondary outcomes were the proportion of carried out cardiovascular risk assessments, psychosocial status and patient preferences measured with an evaluation questionnaire.

Results

One hundred and sixty-two patients were enrolled (69% of eligible testicular cancer patients). Almost all (99%, n = 150) PCPs of the enrolled patients agreed to participate in the study. In total, 364 primary care visits took place. No failures occurred in the detection of relapsed testicular cancer. Four follow-up visits were considered as failures because of organizational issues, without activation of the stopping rule. Eventually, the safe boundary was crossed indicating that this shared-care model is a safe alternative for follow-up after testicular cancer. Patients were satisfied with the knowledge level of PCPs. PCPs were willing to further extend their role in follow-up care after cancer.

Conclusions

Shared-care follow-up is safe and feasible in this patient population. Patients benefit from personalized care, partly close to their home. Within shared care, PCPs can have an important role in cardiovascular risk management and psychosocial survivorship issues.

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Shared-care follow-up by oncologists and PCPs is safe and feasible for testicular cancer patients.

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The participation of PCPs in survivorship care improves cardiovascular risk management.

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PCPs are willing to expand their role in survivorship care.

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Less visits to the oncologist did not increase anxiety in testicular cancer survivors.

[Neuropsychiatric manifestations of COVID-19 in intensive care unit patients]

It has become clear that COVID-19 can lead to neuropsychiatric complications. In this article, three cases are discussed that illustrate how neuropsychiatric complications can manifest within the COVID-19 disease course. Patients are at risk to develop a severe, hyperactive delirium, which is often accompanied by anxiety and sometimes neurological symptoms. The treatment of the neuropsychiatric complications is characterized by unusually high doses of antipsychotics and sedatives. Timely psychiatric consultation is advised for adequate recognition and effective treatment of delirium and other neuropsychiatric symptoms.

Antidepressant prescribing prior to suicide: role of doctors

The pharmacological treatment of depression and the time elapsed since last seen by a doctor were investigated among 507 adults who subsequently killed themselves. The proportion of people consulting a general practitioner or psychiatrist prior to suicide was lower than reported by the British government in the Health of the Nation document. General practitioners prescribed relatively low doses of antidepressants. Nineteen out of the 115 people receiving antidepressants used the drugs to kill themselves. Our findings emphasise the importance of prescribing adequate doses of antidepressants and underline the need for safer prescribing.

Vascular fingerprint and vascular damage markers associated with vascular events in testicular cancer patients during and after chemotherapy

BACKGROUND

Metastatic testicular cancer (TC) can be cured with bleomycin, etoposide and cisplatin (BEP) chemotherapy. This comes at the price of an increased cardiovascular disease risk, not only years afterwards, but also during and shortly after chemotherapy. To prevent cardiovascular events, high-risk patients should be identified. The aim of this study was to assess BEP-chemotherapy induced vascular damage and to find risk factors for early vascular events.

PATIENTS AND METHODS

A prospective cohort study was performed in (B)EP treated TC patients. Development of venous and arterial vascular events was assessed. Vascular damage markers (von Willebrand factor [vWF], coagulation factor VIII [FVIII], intima media thickness [IMT]) and cardiovascular risk factors were assessed before and until 1 year after chemotherapy. Before start of chemotherapy a vascular fingerprint was estimated. Presence of ≥3 risk factors was defined as high-risk vascular fingerprint: body mass index >25 kg/m(2), current smoking, blood pressure >140/90 mm Hg, total cholesterol >5.1 and/or low-density lipoprotein >2.5 mmol/L or glucose ≥7 mmol/L.

RESULTS

Seventy-three patients were included. Eight (11%) developed vascular events (four arterial events, four pulmonary embolisms). vWF and FVIII increased during chemotherapy, especially in patients with vascular events. Sixteen patients (22%) had a high-risk vascular fingerprint before start of chemotherapy. These patients had arterial events more often (3/16 [19%] versus 1/57 [2%]; p = 0.031) and higher vWF levels and IMT.

CONCLUSIONS

Endothelial activation and upregulation of procoagulant activity seem important mechanisms involved in early (B)EP-chemotherapy-induced vascular events. Before chemotherapy, a quarter already had cardiovascular risk factors. A vascular fingerprint could identify patients at risk for arterial events. This vascular fingerprint, when validated, can be used as a tool to select patients who may benefit from preventive strategies.

Long-term exposure to circulating platinum is associated with late effects of treatment in testicular cancer survivors

Cisplatin is an essential part of testicular cancer treatment. We investigated whether long-term exposure to circulating platinum (Pt) plays a role in the development of late effects in survivors. We assessed Pt decay in samples collected 1–13 years after chemotherapy. Renal function is a strong determinant of exposure to Pt. Higher exposure to Pt is associated with an increased prevalence of adverse effects hypogonadism and hypertension.

Background

The success of cisplatin-based (Platinol, Bristol-Myers Squibb Company, New York, NY, USA) chemotherapy for testicular cancer comes at the price of long-term and late effects related to healthy tissue damage. We assessed and modelled serum platinum (Pt) decay after chemotherapy and determined relationships between long-term circulating Pt levels and known late effects.

Patients and methods

In 99 testicular cancer survivors, treated with cisplatin-based chemotherapy, serum and 24-h urine samples were collected during follow-up (1–13 years after treatment). To build a population pharmacokinetic model, measured Pt data were simultaneously analysed, together with cisplatin dose, age, weight and height using the NONMEM software. Based on this model, area under the curve between 1 and 3 years after treatment (Pt AUC_{1–3 years}) was calculated for each patient. Predicted long-term Pt exposure was related to renal function and to late effects of treatment assessed median 9 (3–15) years after chemotherapy.

Results

Decay of Pt was best described by a two-compartment model. Mean terminal T_1/2 was 3.7 (range 2.5–5.2) years. Pt AUC_{1–3 years} correlated with cumulative cisplatin dose, and creatinine clearance before and 1 year after treatment. Patients with paraesthesia had higher Pt AUC_{1–3 years} (30.9 versus 27.0 µg/l month) compared with those without paraesthesia (P = 0.021). Patients with hypogonadism, elevated LDL-cholesterol levels or hypertension also had higher Pt AUC_{1–3 years}.

Conclusions

Renal function before and after cisplatin treatment is an important determinant of long-term Pt exposure. Known long-term effects of testicular cancer treatment, such as paraesthesia, hypogonadism, hypercholesterolaemia and hypertension, are associated with long-term circulating Pt exposure.

Psychopathology in adults with 22q11 deletion syndrome and moderate and severe intellectual disability

BACKGROUND

22q11 deletion syndrome (22q11DS) is associated with mild or borderline intellectual disability (ID). There are hardly any reports on subjects with 22q11DS with moderate or severe ID, and therefore its behavioural and psychiatric characteristics are unknown.

METHOD

We describe behavioural and psychiatric characteristics of 33 adults with 22q11DS and a Full-Scale IQ (FSIQ) below 55. Participants were divided into two groups: one group having a FSIQ ≤ 55 caused by intellectual decline (n = 21) and one group with a FSIQ ≤ 55 who had always functioned at this level (n = 12).

RESULTS

High scores on psychopathology sub-scales were found for both subgroups. 22q11DS patients with intellectual decline showed higher rates of co-morbid psychopathology, particularly psychosis. Furthermore, psychosis and intellectual decline were positive correlated.

CONCLUSION

This is the first report addressing adult patients with 22q11DS and moderate to severe ID. Overall we found high levels of psychopathology with higher scores of psychopathology in the intellectual decline group. Life time psychosis seems to be related to deterioration.

The use of medical care and the prevalence of serious illness in an adult Prader-Willi syndrome cohort

INTRODUCTION

Adults with Prader-Willi syndrome (PWS) have an increased occurrence of several medical conditions. We report on the consequences of high morbidity rates such as prevalence rate of hospital admissions, medication use and surgery in a Dutch cohort of adults with PWS. Special attention is paid to causes and symptoms of serious illness.

METHOD

Participants were contacted via the Dutch Prader-Willi Parent Association and through physicians specializing in persons with ID. The persons with PWS and their main caregivers were visited at home. Information was collected through semi-structured interviews on 102 adults with PWS.

RESULTS

The need for medical care in the neonatal period is associated with hypotonia and feeding problems. Hospital admissions for respiratory tract infections are frequent. During childhood most hospital admissions were due to PWS syndrome specific surgery. During adolescence hospital admissions occurred for scoliosis surgery and endocrine evaluations. At adult age, hospitalization was associated with inguinal hernia surgery, diabetes mellitus, psychosis, erysipelas, water and drug intoxications. In the older group, respiratory infections were again the main reason for hospital admissions. Frequently used medications at adult age included psychotropics, laxatives, anti-diabetics and dermatologic preparations. Abnormal drinking patterns, problems with anesthesia, decreased ability to vomit, abnormal pain awareness and unpredictable fever responses were frequent and often lead to delayed diagnoses of serious conditions.

DISCUSSION

People with PWS are frequent users of medical-care. Reasons for hospitalization and medication use are age specific. Knowledge on the different presentation of symptoms in people with PWS is needed. In case of unexplained illness, disturbances of consciousness and behavioral changes in people with PWS, an infection should be ruled out in the first place. Information from this study may help in preventing conditions and recognizing conditions in an early stage. Adequate preventive management and treatment of PWS related morbidity, could reduce medical care use in the long term and could improve quality adjusted life years.

Org-2766, an acth(4-9)-msh(4-9) analog, modulates vincristine-induced neurotoxicity in the snail lymnaea-stagnalis

In vincristine (VCR) chemotherapy the dose-limiting factor is neurotoxicity, a side-effect which probably is caused by the action of the drug on axonal microtubules. VCR transforms them into paracrystalline structures. ORG 2766, an ACTH(4-9)/MSH(4-9), analogue, might have protective properties against this toxicity, because of its potency to induce the formation of microtubules. Therefore, the effects were studied of co-treatment with VCR and ORG 2766 on paracrystals and on microtubules in axons of the cerebral commissure (CC) of the snail Lymnaea stagnalis. In vitro experiments were carried out, incubating cerebral ganglia including the CC, for various periods of time (5-25 h) in Ringer's solution, in ORG 2766 (10(-6) M), in VCR (10(-4) M), or in VCR+ORG 2766. Furthermore, the effects of VCR (5 h) were studied in CC, pre- and/or post-treated with ORG 2766 (10 h). In another experiment VCR was used at a concentration at which no paracrystals were formed (2x10(-6) M). In this experiment VCR-treatment (5, 15 h) was compared to pre treatment and pre- and post-treatment with ORG 2766 (10 h). The numbers of microtubules (per mu m(2) axoplasm) and paracrystals (number encountered along perpendicular axes of the CC) were counted and the size of the paracrystals was measured in cross-sections of the CC, using electron microscopy. Irrespective of the type of additional treatment, significant differences were not observed in the numbers of paracrystals (32+/-10) after VCR-treatment for 5 h. Between 5 and 10 h of incubation the number increased (to 55+/-21) and remained approximately at this level. The number of microtubules decreased during the first 5 h of VCR treatment from 128+/-16 (control) to 37+/-10, and decreased further 19+/-5 between 5 and 10 h of incubation. The size of the paracrystals of all groups treated for 5 h with either VCR or VCR+ORG 2766 were similar (x=1.7 mu m(2)) However, the paracrystals were significantly larger in all groups co-treated for longer periods (10, 15 or 20 h) with ORG 2766 (VCR: x=2.3-3.0 mu m(2); VCR+ORG 2766: x=3.0-3.4 mu m(2)). This indicates that after an initial period of formation of paracrystals, tubulin is added to the existing paracrystals. At the low VCR concentration studied no paracrystals were formed. However, the number of microtubules had decreased significantly (from 159+/-10 to 84+/-17 after 15 h treatment). Pre- as well as pre- and post-treatment with ORG 2766 resulted in microtubule numbers which were not different from control values, indicating the positive effect of ORG 2766. In the groups pre- and/or post-treated with the high concentration of ORG 2766 (especially in the pre-treated group), the remaining number of microtubules was higher than in those co-treated with VCR and ORG 2766, but lower than in the controls. Although translation of the present results into clinical terms is difficult, they suggest that pre-and/or post-treatment with ORG 2766 may have a benificial effect on VCR-induced neurotoxicity. This conclusion is based on the observation that when ORG 2766 is given before VCR administration or after VCR clearance, larger numbers of microtubules were found in the nervous tissue than after treatment with VCR alone.

Properties of wr2721 (ethiofos) as modulator of Cisplatin-induced neurotoxicity studied at the ultrastructural level in the pond snail lymnaea-stagnalis

Modulating effects of WR2721 were studied on cisplatin-induced histological and ultrastructural changes in the ganglia of the central nervous system of the pond snail Lymnaea stagnalis. The relevance of the study was indicated by showing histochemically that alkaline phosphatase, the enzyme converting WR2721 into the active drug WR1065, is present in the snail brain. Central nervous systems of the snail were either preincubated in 5 mM WR2721 or in snail Ringer for 1 h and then postincubated for 10 or 20 h in: (i) Ringer (control), (ii) WR2721 (5 mM), (iii) cisplatin (0.4 mM), or (iv) cisplatin (0.4 mM) plus WR2721 (5 mM). The following parameters were studied: (i) general morphology, (ii) chromatin (number and mean clump size per unit surface ama, clump size frequency distribution), (iii) nucleoli (ratio of granular/fibrillar areas, (iv), Golgi zones (mean surface area, area containing electron dense material), (v) secretory granules (number), (vi) lysosomes (number per unit surface area of cytoplasm). The focus was on two types of identified neuroendocrine cells. Incubation in Ringer alone (controls) caused slight inactivation of the cells between 10 and 20 h of incubation (e.g. relative decrease of the granular part of the nucleoli). WR2721 alone had comparable effects on the tissue. In addition, in this group, a reduction in the electron dense material of the Golgi zones was observed. No major differences in number of secretory granules were observed in any of the groups. Treatment with cisplatin alone for 20 h caused a disappearance of the orange colour of the ganglia, swelling of axons and distension of intercellular spaces. Such changes were not observed in the group treated with cisplatin plus WR2721 or any of the other experimental groups. Both cisplatin alone and cisplatin plus WR2721 caused an increase in the number of chromatin clumps and a decrease in the mean chromatin clump size after 10 and 20 h of incubation. With regard to these parameters no differences were observed between the two groups. The chromatin clump size distribution curves of both groups were significantly different from the curve of the controls. Compared to that of the cisplatin group, the curve of the cisplatin plus WR2721 group, especially after 10 h, had shifted in the direction of that of the controls. Treatment with cisplatin alone induced drastic changes in nucleolar morphology. After 20 h of incubation the nucleoli had transformed into homogeneous dense structures. After 10 h of incubation in cisplatin plus WR2721 nucleoli still had a normal appearance. After 20 h those of the co-treated group had also become electron dense and appeared to contain numerous dark dots. Cisplatin caused a significant decrease in the extent of the Golgi zones. Co-treatment with WR2721 prevented this decrease to a certain degree. In both groups the electron dense material had disappeared from the Golgi zones. Furthermore, cisplatin alone induced an increase in the number of lysosomes. This increase was slightly (but not significantly) prevented by co-treatment with WR2721. The observations on the snail neurons show that WR2721 at the concentration studied induced only minor morphological changes. The drug modulates to some extent the pathological changes caused by cisplatin. The results support clinical data indicating that cisplatin-induced neurotoxicity is reduced by WR2721.

Psychiatric illness in a cohort of adults with Prader-Willi syndrome

Previous studies have suggested an association between PWS and comorbid psychiatric illness. Data on prevalence rates of psychopathology is still scarce. This paper describes a large-scale, systematic study investigating the prevalence of psychiatric illness in a Dutch adult PWS cohort. One hundred and two individuals were screened for psychiatric illness. Case vignettes were written by the first author on 63 individuals with a positive screening on psychopathology according to the interviews, medical history, medication use and behavioural questionnaires. These case vignettes were rated by two psychiatrists specializing in intellectual disability (ID). Psychopathology was divided into four diagnostic categories: bipolar disorder with psychotic symptoms, psychotic illness, depressive illness with psychotic symptoms and depressive illness without psychotic symptoms. Nine out of 53 persons (17%) with a 15q11-13 deletion and 28 out of 44 (64%) persons with maternal uniparental disomy (mUPD) were diagnosed with a current or previous psychiatric illness. Depressive illness with psychotic symptoms was the cause of psychiatric problems in the majority of persons with PWS due to deletion (56%). In the case of mUPD, almost all individuals with histories of psychopathology suffered from psychotic symptoms (85%) with or without affective component. Psychiatric examination should be part of general management of adults with PWS, especially when caused by mUPD. More attention should be paid to the presence of precursor symptoms, indicating a developing psychiatric episode. Longitudinal studies are needed to gain more insight into the natural history of psychiatric illness in adults with PWS.

What's in a name? - The Psychiatric Identity Conundrum

BACKGROUND

The proper label to describe people receiving care has evoked considerable debate and controversy among providers and bio-ethicists. Fashionable terms in current use include "patient, client, consumer, customer and service user." There is little evidence to show that changes in nomenclature actually take patients preferences as to how they would like to be addressed into account

AIMS

This aim of this study is to survey the views of the people with learning disability in inpatient settings to establish the term they prefer. This is the first study of its kind looking at the views of people with learning disability about how they would like to be addressed and to identify factors associated with various preferences.

METHOD

Approval was obtained from the local clinical governance board. The target population covered a tertiary level inpatient service including acute assessment and respite services, forensic (male/female and low/medium secure services) and CAMHS LD covering the Coventry, Warwickshire and Birmingham areas (rural and inner city population). Participants were provided with an information sheet on the research project. The questionnaire was administered by means of a joint interview carried out by the authors of the study. Dictionary definitions were analyzed as to the derivation and connotations of various terminologies. A questionnaire was developed which was tailored for use in PWLD after consultation with Speech & Language Therapists and local peer review. Responses were than analyzed to identify factors associated with various preferences.

RESULTS

Evidence indicates lack of universality in preferences for terms and suggests the need for dialogue about preferred terms between service providers and recipients. This study shows a preference for the term "patient" in all categories that were measured within an LD inpatient setting and very interesting demographic preferences were identified. A more differentiated approach may be suggested by taking professional background and some demographic characteristics into consideration. A positive therapeutic relationship is a fundamental component of psychiatry and should take into account patients' preferences regarding how they are addressed by professionals.

Behavioral phenotype in adults with Prader-Willi syndrome

Prader-Willi syndrome (PWS) is characterized by temper tantrums, impulsivity, mood fluctuations, difficulty with change in routine, skinpicking, stubbornness and aggression. Many studies on behavior in PWS are limited by sample size, age range, a lack of genetically confirmed diagnosis of PWS and inconsistent assessment of behavior. The aim of this study was to explore systematically the relation between behavioral problems and age groups, genetic subtypes and BMI categories in an adult PWS population. Participants were contacted via the Dutch Prader-Willi Parent Association and through physicians specialized in persons with ID. Behaviors were studied using the Developmental Behavior Checklist for Adults (DBC-A). The forms were completed by the main caregivers of 98 adults with a genetically confirmed diagnosis of PWS. Differences between age groups were statistically significant (ANOVA, p=0.03). DBC-A total scores were higher in the consecutive age groups, with the most behavioral problems in the oldest age groups. Differences between genetic subtypes were also statistically significant (ANOVA, p<0.01). Persons with mUPD had higher total scores on the DBC-A than persons with a deletion. Those with a Type I deletion showed higher total DBC-A scores than persons with a Type II deletion. There were no statistically significant differences in DBC-A total scores between the different BMI categories. Individuals with a BMI<25 had higher scores on the self-absorbed subscale compared to persons with a BMI between 25 and 30. Unlike previous descriptions of the behavioral phenotype in adults with PWS, we did not find a reduction in behavioral problems in older adults. Therefore, special attention should be paid to behavioral problems as part of general management of adults with PWS. Longitudinal studies are warranted to gain more insight into the natural history and course of behavioral problems in adults and older people with PWS over the long term and possible risk and preventive factors.

Women's opinions about attending for breast cancer screening: Stability of cognitive determinants during three rounds of screening

OBJECTIVES

To examine the stability of beliefs and intentions towards repeat attendance at breast cancer screening, using the Theory of Planned Behaviour. The aims of the study were to examine whether and how cognitions changed in the course of the programme, and whether intentions that were assessed proximally were better predictors of behaviour than those assessed distally.

DESIGN AND METHODS

A total of 2,657 women filled out a baseline questionnaire (T(1)), 2 months after being invited for an initial mammogram in the Dutch Breast Cancer Screening Programme. Actual attendance data in the second and third screening rounds were subsequently collected and follow-up questionnaires were sent to parts of the sample at four points in time: shortly before (T(2)) and after (T(3)) the second screening round, and shortly before (T(4)) and after (T(5)) the third screening round.

RESULTS

Only minor changes in beliefs and intentions were found. In the assessments shortly before screening, women were somewhat less positive about attending than in the assessments shortly after screening. Throughout the course of the programme, women's opinions about attending remained positive. In fact, women became somewhat more convinced that they were vulnerable to getting breast cancer, and that participating in screening was beneficial to them. Actual attendance in subsequent rounds of screening was higher than expected. Proximal beliefs and intentions were only slightly more predictive of actual behaviour than distal beliefs.

CONCLUSIONS

In organized breast cancer screening, beliefs and intentions remain positive and rather stable. Although our results should be interpreted with caution, due to little variation in behaviour, they suggest that the gap between intentions and behaviour could not be substantially reduced by proximal assessment of determinants.

The phenomenology and diagnosis of psychiatric illness in people with Prader-Willi syndrome

BACKGROUND

Psychotic illness is strongly associated with the maternal uniparental disomy (mUPD) genetic subtype of Prader-Willi syndrome (PWS), but not the deletion subtype (delPWS). This study investigates the clinical features of psychiatric illness associated with PWS. We consider possible genetic and other mechanisms that may be responsible for the development of psychotic illness, predominantly in those with mUPD.

METHOD

The study sample comprised 119 individuals with genetically confirmed PWS, of whom 46 had a history of psychiatric illness. A detailed clinical and family psychiatric history was obtained from these 46 using the PAS-ADD, OPCRIT, Family History and Life Events Questionnaires.

RESULTS

Individuals with mUPD had a higher rate of psychiatric illness than those with delPWS (22/34 v. 24/85, p<0.001). The profile of psychiatric illness in both genetic subtypes resembled an atypical affective disorder with or without psychotic symptoms. Those with delPWS were more likely to have developed a non-psychotic depressive illness (p=0.005) and those with mUPD a bipolar disorder with psychotic symptoms (p=0.00005). Individuals with delPWS and psychotic illness had an increased family history of affective disorder. This was confined exclusively to their mothers.

CONCLUSIONS

Psychiatric illness in PWS is predominately affective with atypical features. The prevalence and possibly the severity of illness are greater in those with mUPD. We present a 'two-hit' hypothesis, involving imprinted genes on chromosome 15, for the development of affective psychosis in people with PWS, regardless of genetic subtype.

Using the theory of planned behaviour to understand the motivation to learn about HIV/AIDS prevention among adolescents in Tigray, Ethiopia

Various studies indicate that school- or university-based HIV prevention curricula can reduce the prevalence of sexual risk behaviour among adolescent youth in Sub-Saharan Africa. However, effective HIV/AIDS prevention education may be problematic, if the needs of youth are not served adequately. To date, little attention has been given to the motivation of youth to learn about HIV/AIDS and about their preferences for HIV/AIDS curriculum design options. The aim of this study was to get insight into the determinants of the motivation of youth to learn about HIV/AIDS prevention and to assess their curriculum design preferences. Students from a university in Tigray, Ethiopia, filled out a structured questionnaire, which assessed demographics, variables that according to the Theory of Planned Behaviour are related to the motivation to learn, and their preferences for independent, carrier and integrated HIV/AIDS curriculum designs. On average, participants were highly motivated to learn about HIV/AIDS. Motivation to learn was primarily related to social norms and was not related to self-efficacy to discuss HIV/AIDS in class. The often discussed reluctance to discuss sexuality and condom use in curricula in Sub-Saharan Africa, seems to be more related to existing negative social norms, than to lack of self-efficacy. Participants revealed a high preference for the independent, carrier and integrated curriculum design options. However, students with a higher motivation to learn about HIV/AIDS were more attracted to the independent course design.

Analysis of candidate imprinted genes in PWS subjects with atypical genetics: a possible inactivating mutation in the SNURF/SNRPN minimal promoter

Prader-Willi syndrome (PWS) is a neurodevelopmental disorder associated with abnormalities of chromosome 15q11q13. The majority of cases result either from a deletion approximately 4 Mb in size, affecting chromosome 15 of paternal origin or from UPD(15)mat; these account for approximately 70 and approximately 20-25% of PWS cases, respectively. In the remaining 3-5% of PWS cases where neither the deletion nor UPD is detectable, PWS is thought to be caused either by a defect in the imprinting centre resulting in a failure to reset the paternally inherited chromosome 15 derived from the paternal grandmother or, very occasionally, from a balanced translocation involving a breakpoint in 15q11q13. Nine probands with a firm clinical diagnosis of PWS but who had neither a typical deletion in the PWS region nor UPD(15)mat were investigated for inactivating mutations in 11 genes located in the PWS region, including SNURF and SNRPN, which are associated with the imprinting centre. Other genes studied for mutations included MKRN3, NDN, IPW, HBII-85, HBII-13, HBII-436, HBII-438a, PAR1 and PAR5. A possibly inactivating mutation in the SNRPN minimal promoter region was identified. No other inactivating mutations were found in the remainder of our panel of PWS subjects with atypical genetics. Expression levels of several of the candidate genes for PWS were also investigated in this series of probands. The results indicate that PWS may result from a stochastic partial inactivation of important genes.

The course and outcome of psychiatric illness in people with Prader-Willi syndrome: implications for management and treatment

BACKGROUND

This study is part of a larger UK-wide study investigating psychiatric illness in people with Prader-Willi syndrome (PWS), and describes the longitudinal aspect of psychiatric illness, in particular psychotic illness, and examines the use and role of psychotropic medication.

METHOD

A total of 119 individuals with genetically confirmed PWS were included in the study. An informant-based questionnaire was administered for each participant to screen for a history of psychopathology. Those who screened positive were visited at their homes to obtain further information. This assessment included a full psychiatric history and mental state examination using the Psychiatric Assessment Schedule for Adults with Developmental Disability and the Operational Criteria Checklist for psychotic and affective illness to collect information regarding phenomenology and course of illness, and a modified life events questionnaire. At the end of the study period, informant-based telephone interviews were again carried out, up to 2.5 years after the initial screening. Information regarding medication usage was collected.

RESULTS

The results confirm previous findings that psychiatric illness in people with PWS resembles an affective disorder. Individuals with the maternal uniparental disomy genetic subtype had a more severe course of illness than those with the deletion genetic subtype in terms of a greater risk of recurrence, more episodes, higher incidence and a possibly poorer response to medication with more side-effects. Individuals with a recurrent episode during the follow-up period had a poorer course of illness. Selective serotonin reuptake inhibitor medication is frequently used, and beneficial effects may reflect fundamental pathological processes in PWS. Mood-stabilizing medication was found to be of little benefit and reasons for this are examined.

CONCLUSION

The longitudinal course of psychiatric illness and response to medication in people with PWS is fully described. Further research is needed regarding the effect of psychotropic medications, particularly mood-stabilizing medication. These data will enable informed decisions to be made regarding management options and provide information on the possible long-term outcome of illness.

CD36 expression and its relationship with obesity in blood cells from people with and without Prader-Willi syndrome

Although Prader-Willi syndrome (PWS) has been linked to the loss of function of imprinted genes in 15q11q13, very little is known about the pathogenesis. Using quantitative real-time PCR, we have confirmed the previous observation of an abnormality of CD36 expression in cells with maternal uniparental disomy 15, obtained from a proband with mosaicism for PWS, by demonstrating reduced expression levels in blood cells from a series of non-mosaic probands with PWS. Furthermore, we have extended these observations to show that CD36 expression in a non-PWS population is inversely correlated with body mass index but that this correlation does not hold in PWS. CD36 which maps to 7q11.2 is the first gene outside the 15q11q13 region whose level of expression appears to be reduced in people with PWS. Low CD36 expression levels in PWS point to an abnormal control of lipid and glucose homeostasis which may explain the insatiable hunger in these patients.

Differences in behavioural phenotype between parental deletion and maternal uniparental disomy in Prader-Willi syndrome: an ERP study

OBJECTIVE

Paternal deletion and maternal uniparental disomy are the principal genetic subtypes associated with Prader-Willi syndrome (PWS). Recent clinical findings suggest differences in phenotype between these subtypes. The present experimental study addresses this issue using a cognitive psycho-physiological setup.

METHODS

Behaviour and event-related brain activity (ERP) was recorded by a continuous performance response inhibition task (CPT-AX) in adults with paternal deletion PWS (n=11), maternal uniparental disomy PWS (n=11) and normal controls (n=11). The dependent behavioural variables of the CPT-AX task were reaction time and correct scores. For the ERPs the N200 and P300 components were included which are related to early modality-specific inhibition and late general inhibition, respectively.

RESULTS

The disomy group had fewer correct scores and increased reaction times as compared to the CPT-AX task than the control and deletion group. Both PWS subgroups differed significantly from the control group for the N200 amplitude. Only the control group showed the typical task modulation for the N200 amplitude. The amplitude of the P300 component was considerably smaller in the uniparental disomy group than in the deletion and control groups.

CONCLUSIONS

The ERP results suggest that early modality specific inhibition is impaired in both PWS genetic subtypes. Late general inhibition is impaired in the uniparental disomy group only. Thus, although the ERP data suggests a common impairment in early visual inhibition processing, uniparental disomy and parental deletion genetic PWS subtypes clearly differ in their behavioural and brain activation phenotypes.

SIGNIFICANCE

The present study is the first experimental demonstration which explains the two principal genetic mechanisms that hinder the expression of the genes at 15q11-q13g in PWS result in different behavioural phenotype.

Accurate and inaccurate HIV transmission beliefs, stigmatizing and HIV protection motivation in northern Thailand

We assessed the relation between accurate beliefs about HIV transmission and inaccurate beliefs about HIV transmission and emotional reactions to people with AIDS (PWA) and AIDS risk groups, stigmatizing attitudes and motivation to protect from HIV. In Chiang Rai, northern Thailand, 219 respondents filled in a structured questionnaire assessing accurate and inaccurate HIV transmission beliefs, emotional reactions towards PWA and AIDS risk groups, stigmatizing attitudes and motivation to protect from HIV according to variables from Protection Motivation Theory. Complete accurate beliefs about documented modes of HIV transmission were present in 47% of the respondents, while 26% of the respondents held one or more inaccurate beliefs about HIV transmission. Incomplete beliefs about documented modes of transmission were significantly related to stigmatizing beliefs towards people with AIDS (PWA), to lower vulnerability of HIV infection and lower self-efficacy in protection. Those who held inaccurate beliefs about HIV transmission reported more fear towards PWA and homosexuals and more irritation towards PWA and commercial sex workers. Persons who held inaccurate beliefs about HIV transmission also reported more stigmatizing attitudes, perceived AIDS as less severe, perceived a lower vulnerability and were less motivated to use condoms. Results of this study suggest that inaccurate beliefs about HIV transmission are related to fear and stigmatizing and undermine HIV prevention behaviour.

Cognitive abilities and genotype in a population-based sample of people with Prader-Willi syndrome

BACKGROUND

Prader-Willi syndrome (PWS) is characterized by extreme floppiness at birth, impaired sexual development, short stature, severe over-eating, characteristic physical features and learning disabilities (LD). Impaired social cognition, literal mindedness and cognitive inflexibility are also present. The syndrome has two main genetic subtypes that both result in the failure of expression of maternally imprinted genes on chromosome 15 at the locus q11-13.

METHODS

Through multiple sources, we attempted to identify all people with PWS living in one health region in the UK. Additional people with PWS identified in other regions were also recruited to augment the study sample. A comparison group of people with LD as a result of aetiologies other than PWS was also identified. All people from these three groups, over age three, who gave their consent, were assessed using tests of ability and attainment. In addition, their main carers were interviewed using a semistructured interview. Blood samples for genetic diagnosis were obtained from all consenting participants.

FINDINGS

The IQ distribution of the population sample was approximately normal with a mean IQ 40 points below that of the general population. There were systematic differences between the two main genetic subtypes. Those with disomies differed in cognitive profiles from both those with deletions and the comparison LD group (the latter two groups were very similar) in terms of better verbal abilities and impaired coding ability. Some people with PWS deletions had strong visuospatial skills.

INTERPRETATION

We propose that the normal distribution of IQ, shifted downwards relative to that of the general population, is the result of a global effect on IQ of the PWS gene(s), and that the different cognitive profile seen in those with chromosome 15 maternal disomies is a specific effect of a gene, or genes, on chromosome 15 which is differentially either expressed or not expressed in those with disomies relative to those with deletions. One hypothesis is that these subtle cognitive differences are a manifestation of the genetic influences of gender-specific imprinted genes on cerebral lateralization. This requires further investigation.

Academic underachievement by people with Prader-Willi syndrome

BACKGROUND

Prader-Willi syndrome (PWS) is a genetically determined neurodevelopmental disorder that is associated with the under-expression of maternally imprinted genes at the 15q11-q13 chromosomal locus. In addition to a characteristic physical and behavioural phenotype, those with the syndrome have impaired social cognition, literal mindedness and inflexibility. The present authors investigated the relationship between the PWS cognitive and behavioural phenotype, educational experience, and levels of attainment in reading, writing and arithmetic.

METHODS

All subjects from a population-based sample of people with PWS, augmented by those with PWS living in other regions together with a contrast group of people with learning disability (LD) of other aetiologies, are included in the present study. Those children over 3 years of age whose families consented or adults who themselves consented were assessed for ability and attainment (over 7 years of age), and information on functional ability was also obtained from an informant. Underachievement was defined as the difference between the score predicted from full-scale IQ and the actual achievement score.

RESULTS

Commonly, levels of achievement were lower than would have been predicted on the basis of IQ among those in the groups with PWS and LD. In the group with PWS, underachievement across academic domains was positively correlated with the percentage of time in education in a special school and negatively correlated with Vineland Socialization domain standard score. There were no across-domain significant correlations in the group with LD. When using multiple regression analysis, the percentage of time in special school was the only predictor of underachievement and only in the group with PWS. However, some children with PWS in special schools did achieve as expected in at least one academic domain.

CONCLUSIONS

Children with PWS may be placed in special schools largely because of their behavioural problems or physical disabilities, or expectations based on their PWS status. Their intellectual abilities may well be masked by their immature social behaviour. The present authors propose that a failure to recognize and address the specific educational needs which follow from this combination of poor socialization skills and complex maladaptive behaviours, in the context of relatively mild LD, may explain their findings.

Monitoring women's experiences during three rounds of breast cancer screening: results from a longitudinal study

OBJECTIVES

(a) To monitor experiences of women during three successive rounds of breast screening; (b) to examine the impact of previous experiences (obtained either immediately after the latest mammogram or shortly before the subsequent one) on reattendance; and (c) to examine which factors are associated with the experience of pain and distress during screening.

SETTING

The Dutch Breast Cancer Screening Programme

METHODS

2657 women completed a baseline measurement (response rate 67%) about 8 weeks after they had been invited for an initial mammogram (T(1)). Actual participation data of these women in the second and third rounds of screening were collected. Follow up questionnaires were sent to subgroups of the sample at different times: shortly before the second screening (T(2); response rate 86%), shortly after the second screening (T(3); response rate 85%), shortly before the third screening (T(4); response rate 80%), and shortly after the third screening (T(5); response rate 78%).

RESULTS

Most women were satisfied with the first screening round and remained positive about subsequent screens. Although pain and anxiety were not uncommon, only a few (10%-15%) experienced moderate or severe levels of distress or pain. Experiences were relatively stable: women who experienced pain in the first screen were more likely to experience pain in subsequent screens (r values from 0.39 to 0.50). Fear of breast cancer was associated with increased distress related to mammography and, to a lesser extent, with increased pain during the mammography. Evidence was found for a relief effect: women were more positive about their previous screen when asked shortly after this screen, than when asked just before the subsequent one. Previous experiences (obtained either proximally or distally) were only slightly predictive for future attendance.

CONCLUSION

Experiences during mammography are fairly stable. Negative experiences were generally not a reason to drop out of the programme.

Behavioural phenotypes associated with specific genetic disorders: evidence from a population-based study of people with Prader-Willi syndrome

BACKGROUND

Prader-Willi syndrome (PWS) is a genetic disorder resulting in obesity, short stature, cryptorchidism, learning disabilities (mental retardation) and severe neonatal hypotonia. Associated with the syndrome are a number of behaviours that are sufficiently distinctive that the syndrome is considered to have a specific 'behavioural phenotype'.

METHODS

Through multiple sources we attempted to identify all people with PWS living in one region in the U K. This cohort was augmented by people with PWS from other regions, and a contrast group of people with learning disabilities of varied aetiologies. The main carers were interviewed, using structured and semi-structured interview schedules, to establish the presence and severity of specific behaviours, and PWS diagnostic criteria. The intellectual functioning and attainments of all were determined. Blood samples were obtained for genetic diagnosis from all consenting participants.

RESULTS

Although excessive eating was recognized as a potentially severe problem in those with PWS, it was almost universally controlled by food restriction, and therefore not seen as a 'problem behaviour'. Those with PWS differed from a learning disabled group of other aetiologies in the prevalence rates of skin picking, temper tantrums, compulsive behaviours and mood fluctuations, and also in the profile of their adaptive behaviours.

CONCLUSIONS

The study confirms the distinct behavioural phenotype of PWS. Specific behaviours occurred significantly more frequently in PWS, compared with an age and BMI matched learning disabled comparison group. A factor analysis of the behaviours involved resulted in three factors that we hypothesized to be independent, and to arise from different mechanisms.

A study of the influence of different genotypes on the physical and behavioral phenotypes of children and adults ascertained clinically as having PWS

A population-based cohort of people with a clinical diagnosis of Prader-Willi syndrome (PWS) was genetically assessed using molecular diagnostic methods and subsequently divided into the following genetic subtypes involving chromosome 15: 'deletion', 'disomy' and genetically negative (referred to as 'PWS-like'). The physical and behavioral characteristics of the three groups were compared in order to evaluate the unique characteristics of the phenotype resulting from loss of expression of imprinted genes at 15q11q13 (PWS vs. PWS-like cases), the possible effect of either haploid insufficiency of non-imprinted genes (deletion cases), or gain of function of imprinted genes (disomy cases) located within the PWS critical region at 15q11q13. In this study, the main differences between probands with either a deletion or disomy are considered, and the possible involvement of contributing genes discussed. The differences within the PWS group proved difficult to quantify. It would appear that haploid insufficiency or gain of function are more subtle contributors than gender-specific genomic imprinting in the production of the PWS phenotype.