Attitudes of women with gestational diabetes toward diet and exercise: a qualitative study

OBJECTIVE

Gestational diabetes (GDM) refers to glucose intolerance of varying severity first occurring in pregnancy. Following a diagnosis of GDM, exercise and dietary modification has a positive effect on improving glycemic control. Lifestyle changes affected in pregnancies affected by GDM have beneficial effects on long-term health if continued following birth. In addition, the psychological impact of a diagnosis of GDM should not be overlooked. Reports of maternal stress, anxiety, and fear are commonly reported issues in the literature. Support, both socially and from health care professionals, is also linked with higher rates of success in GDM management. Research to date had focused on women's reaction to a diagnosis of GDM, their mood and quality of life following a diagnosis, and their knowledge or opinions on the management of GDM. This qualitative study explored the attitudes of women with GDM toward these lifestyle changes, specifically diet and exercise. Women were also asked to identify advice that would be useful for other women newly diagnosed with GDM.

METHODS

With ethical approval a qualitative study was conducted using semi-structured interviews which were examined using Thematic Analysis. Patients were invited to participate and gave written consent after a discussion with a study researcher. The question plan for semi-structured interviews was designed with the advice of patient advocates. Recurrent themes were developed until the saturation of data.

RESULTS

Thirty-two women took part in the study. Time, convenience, and lack of educational awareness were common barriers to healthy eating and physical activity plans. Enablers for change included meal planning and organization. Women regarded their diets pre-diagnosis as healthy, with small "tweaks" (such as portion control) required to comply with recommendations. Another significant facilitator to change was support from the woman's partner. This also set a benchmark for plans of diet maintenance within the family structure after pregnancy. Unlike dietary changes, a consistent theme was that exercise was considered a "chore" in managing GDM and was unlikely to be continued in the long term. Practical advice offered by participants for other women with GDM included organization, realistic approaches, and lack of self-blame.

CONCLUSION

Women reported that changes in diet would be more achievable in the long term than changes in exercise patterns. Partners and the clinical team were significant sources of support. Women's views are crucial to providing clinicians with a comprehensive and holistic understanding of disease management. Involving women in self-care decisions and empowering women to manage their own health are key contributors to long-term behavior change as well as service provision and policy implementation.

Exposure to bisphenol A differentially impacts neurodevelopment and behavior in Drosophila melanogaster from distinct genetic backgrounds

Bisphenol A (BPA) is a ubiquitous environmental chemical that has been linked to behavioral differences in children and shown to impact critical neurodevelopmental processes in animal models. Though data is emerging, we still have an incomplete picture of how BPA disrupts neurodevelopment; in particular, how its impacts may vary across different genetic backgrounds. Given the genetic tractability of Drosophila melanogaster, they present a valuable model to address this question. Fruit flies are increasingly being used for assessment of neurotoxicants because of their relatively simple brain structure and variety of measurable behaviors. Here we investigated the neurodevelopmental impacts of BPA across two genetic strains of Drosophila-w¹¹¹⁸ (control) and the Fragile X Syndrome (FXS) model-by examining both behavioral and neuronal phenotypes. We show that BPA induces hyperactivity in larvae, increases repetitive grooming behavior in adults, reduces courtship behavior, impairs axon guidance in the mushroom body, and disrupts neural stem cell development in the w¹¹¹⁸ genetic strain. Remarkably, for every behavioral and neuronal phenotype examined, the impact of BPA in FXS flies was either insignificant or contrasted with the phenotypes observed in the w¹¹¹⁸ strain. This data indicates that the neurodevelopmental impacts of BPA can vary widely depending on genetic background and suggests BPA may elicit a gene-environment interaction with Drosophila fragile X mental retardation 1 (dFmr1)-the ortholog of human FMR1, which causes Fragile X Syndrome and is associated with autism spectrum disorder.

PARE0018 WEBSITE FOR PARENTS OF CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS REDUCES PARENTING STRESS

Background:

Having a child with JIA presents many challenges. Many parents experience considerable stress. Parental distress and functioning have been found to be related to child outcomes (Cousino, 2013), therefore interventions that help parents to manage their child’s illness are important for both parents and child. We developed a website for parents of children with newly diagnosed JIA to help increase parental confidence in managing their child’s arthritis and reduce parenting stress.

Objectives:

To evaluate the efficacy of a web-based tool ‘WebParC’ for parents of children with JIA.

Methods:

Design:Multi-centre randomised controlled trial conducted in 16 tertiary paediatric rheumatology centres in England.

Participants:Parent(s) of children aged ≤12 years, diagnosed with JIA within the previous six months.

Procedures:Parents were enrolled when they attended the rheumatology service and were randomised by household to either the intervention arm (I) who were given access to the website in addition to their child’s standard care or the control arm (C) who received standard care alone.

The primary outcome was parenting stress, measured with the Pediatric Inventory for Parents (PIP) (Streisand, 2001), which parents completed prior to randomisation and at 4-months and 12-months post randomisation.

Website content was developed by a multidisciplinary team including rheumatology, physiotherapy, ophthalmology, social work, podiatry, occupational therapy, clinical and health psychology along with parents of children with JIA. It includes information about JIA and its treatment plus a ‘toolkit’ for parents. The toolkit is based on cognitive-behavioural principles to develop skills for managing JIA-related issues.

Analysis:We conducted linear mixed models to examine the main effect of trial arm (I vs C), main effect of time (between 4M and 12M scores), and interaction between trial arm and time on PIP scores, after controlling for baseline scores.

Results:

A total of 220 parents (183 mothers, 37 fathers) of 203 children were randomised, 106 intervention and 114 controls. Parents mean (SD) age was 36.5 (6.5). Their children with JIA were mostly female (137/203, 67.5%), mean (SD) age of 6.1 (3.4) years. There were 107 (52.7%) with oligoarthritis, 65 (32%) polyarthritis, 8 (3.9%) systemic and 23 (11.3%) other JIA subtypes. Seventy (34.5%) were prescribed methotrexate.

Trial arms did not differ significantly at baseline except for parent education, which was higher in the intervention group and was controlled for in the analysis.

Follow-up assessments were completed by 133 (I60, C73) at 4M and 124 (I58, C66) at 12M.

We found significant main effects of trial arm on PIP Difficulty (p=0.022, Control (Mean=93.62, SE=2.717) > Intervention (Mean=84.23, SE=3.025)) and PIP Frequency (p= 0.008, Control (Mean=95.78, SE=2.400) > Intervention (Mean=86.23, SE=2.622), with Controls reporting significantly greater frequency and difficulty of stressful events than the Intervention group (Fig 1).

Conclusion:

This trial found that a website for parents of children with JIA can help to reduce parenting stress.

References:

[1]Cousino MK, Hazen RA. J Pediatr Psychol 2013; 38(8):809-28

[2]Streisand R, Braniecki S, Tercyak KP, Kazak AE. J Pediatr Psychol 2001; 26(3):155-62.

Acknowledgments:

We thank all parent participants, the health professionals and parents who developed website content and the clinical teams who supported recruitment.

Funded by NIHR RfPB.

Disclosure of Interests:

Kathleen Mulligan: None declared, Shashivadan Hirani: None declared, Sally Clarke: None declared, Neil Evans: None declared, Chris Flood: None declared, Jo Taylor: None declared, Lucy Wedderburn Speakers bureau: Pfizer, Stanton Newman Grant/research support from: Yes Baxter Healthcare Educational Grants not in relation to rheumatology, Speakers bureau: Yes Baxter Healthcare and Merke Sharp and Dome

Doctor-Patient Communication in an Outpatient Setting

Aim To evaluate doctor patient communication within gynaecological oncology services in Ireland. Methods An anonymous and confidential 20 question survey was designed by the patient advocacy group ISGOPPI and distributed in three gynaecological oncology outpatient clinics in tertiary referral centres. Results A total of 84 patients completed the survey in the 3 Dublin hospitals. Doctors surveyed ranged from senior house officer to consultant level. Overall women were very satisfied with the communication they had received from their doctor. 85% felt that they the doctor listened to them and took their opinion into account. 84% of patients felt that the doctor’s body language was appropriate throughout the consultation. One of the main issues for women surveyed was waiting times. 33% of women waited over an hour to see their doctor and over 30% of women did not receive contact details of the clinical nurse specialist. Conclusion Overall our study shows that patients in gynae-oncology clinics are satisfied with the communication from their doctors. The main issues for patients were waiting times and contact details for follow up questions.

Barriers to and enablers of insulin self-titration in adults with Type 2 diabetes: a qualitative study

AIMS

To identify the barriers to and enablers of effective insulin self-titration in people with Type 2 diabetes.

METHODS

A qualitative semi-structured interview approach was used. Questions were structured according to the Theoretical Domains Framework, which outlines 14 domains that can act as barriers to and enablers of changing behaviour. Interviews were audio-recorded and transcribed verbatim. The data were coded according to the 14 domains, belief statements were created within each domain, and a frequency count of the most reported barriers and enablers was then carried out. Analyses were conducted by two researchers, and discrepancies agreed with a third researcher.

RESULTS

A total of 18 adults with Type 2 diabetes took part in an interview. The majority were of South-Asian ethnicity (n = 8) and were men (n = 12). Their mean age was 61 years old. The mean duration of diabetes was 16 years and time on insulin 9 years. Inter-rater reliability for each of the domains varied (29-100%). The most frequently reported domains were Social Influence and Beliefs about Consequences; the least frequently reported were Optimism and Reinforcement. Interviewees reported receiving support to self-titrate from a range of sources. Self-titrating was perceived to have a range of both positive and negative consequences, as was not titrating.

CONCLUSIONS

The findings highlight that those interviewed experienced a range of barriers and enablers when attempting to self-titrate. Improved education and training when initiating insulin treatment among adults with Type 2 diabetes, and throughout their journey on insulin therapy could help identify and address these barriers in order to optimize self-titration.

The place of health and the health of place: dengue fever and urban governance in Putrajaya, Malaysia

This case study investigates the connections among urban planning, governance and dengue fever in an emerging market context in the Global South. Key informant interviews were conducted with leading figures in public health, urban planning and governance in the planned city of Putrajaya, Malaysia. Drawing on theories of urban political ecology and ecosocial epidemiology, the qualitative study found the health of place - expressed as dengue-bearing mosquitoes and dengue fever in human bodies in the urban environment - was influenced by the place of health in a hierarchy of urban priorities.

Psycho-educational interventions designed to prevent deployment-related psychological ill-health in Armed Forces personnel: a review

BACKGROUND

Employers such as the Armed Forces (AF) and emergency services, who predictably expose their staff to potentially traumatic events (PTEs), often provide psycho-educational briefings in an attempt to mitigate possible adverse psychological sequelae. Within the military, psycho-educational briefings are widely used, particularly following exposure to PTEs on operations. The aim of this review was to evaluate the efficacy of these interventions and make appropriate recommendations.

METHOD

A search of Medline, PsycINFO and EMBASE was conducted, bibliographies of retrieved articles were searched and experts in the field were consulted.

RESULTS

Two surveys and seven intervention studies were identified for inclusion in the review. Only three studies were randomized controlled trials (RCTs). Overall, the review found some evidence of benefit of psycho-educational interventions but it was not consistent across studies or outcomes and effects were small. However, there was also little evidence to suggest that they caused harm. There was some evidence that the beneficial effects may be greater for those who have been exposed to a higher number of PTEs.

CONCLUSIONS

Given the high operational tempo currently faced by coalition forces personnel, there remains a pressing need to identify the most effective way of minimizing the impact of exposure to potentially traumatic deployment incidents. To date, few psycho-educational interventions designed to prevent deployment-related psychological ill-health have been evaluated systematically in methodologically robust studies. The review recommends that future interventions are theoretically based and evaluated in cluster RCTs that examine both process and outcome variables.

Suitability of an automated nucleic acid extractor (easyMAG) for use with hepatitis C virus and human immunodeficiency virus type 1 nucleic acid amplification testing

Serological screening assays have greatly reduced, but not eliminated, the risk of transmission of viral infections by transfusion of blood and blood products. In addition, the 1999 regulation of the European Agency for the Evaluation of Medicinal Products requiring all plasma for fractionation to have tested negative for hepatitis C virus (HCV) RNA (CPMP/BWP/390/97, 1998) led many blood transfusion services to introduce nucleic acid amplification technology (NAT) to screen blood donations for HCV, and in some services for human immunodeficiency virus (HIV) and hepatitis B virus (HBV). BioMérieux's second-generation system, the NucliSENS easyMAG, was evaluated as a suitable platform for the automated extraction of nucleic acids for use with the existing SNBTS NAT assays. Two nucleic acid extraction protocols were examined, either lysis on the easyMAG (on board) or a 30-min pre-incubation of the sample with lysis buffer at 37 °C (off board). Off board lysis was found to extract nucleic acid more efficiently for both HCV and HIV NAT assays although the improvement was more marked with HIV. The 95% limit of detections (LODs) were 10.11 IU/ml (on board) and 7.21 IU/ml (off board) for HCV and 55.11 IU/ml (on board) and 34.13 (off board) for HIV. Using the more sensitive off board lysis, nucleic acid extraction specificity, robustness and reliability of the easyMAG were examined and over 10,000 Scottish blood donations (in 107 pools of 95 donations) were tested for HCV and HIV in parallel with the existing assay. The results indicate that the easyMAG is a suitable and flexible nucleic acid extraction system, providing high quality nucleic acids and a rapid response alternative to commercial, fully automated, approved blood screening platforms.

Detecting regional lung properties using audio transfer functions of the respiratory system

In this study, a novel instrument has been developed for measuring changes in the distribution of lung fluid the respiratory system. The instrument consists of a speaker that inputs a 0-4kHz White Gaussian Noise (WGN) signal into a patient's mouth and an array of 4 electronic stethoscopes, linked via a fully adjustable harness, used to recover signals on the chest surface. The software system for processing the data utilizes the principles of adaptive filtering in order to obtain a transfer function that represents the input-output relationship for the signal as the volume of fluid in the lungs is varied. A chest phantom model was constructed to simulate the behavior of fluid related diseases within the lungs through the injection of varying volumes of water. Tests from the phantom model were compared to healthy subjects. Results show the instrument can obtain similar transfer functions and sound propagation delays between both human and phantom chests.

Gene Expression Profiling of Formalin-Fixed, Pariffin-Embedded (FFPE) Tissues from Triple-Negative (TN) Breast Cancer (BC) Patients

Background: FFPE tumor samples present a technical challenge for gene expression profiling studies. Newer technologies are resulting in quality data and new insights from these archived tissues. TNBC is a sub-type of BC characterized by a lack of erbB2 gene amplification and estrogen and progesterone receptor expression. This clinically-defined BC sub-type carries a poor prognosis, is insensitive to hormonal or HER-2 targeted therapeutic agents, and has different incidence among ethnic groups. A better understanding of the genetic and molecular mechanisms underlying TNBC is critical to improving clinic outcomes and developing individualized therapies.Study Objective: We demonstrate the utility of FFPE samples in obtaining consistent, reproducible data from gene expression arrays, and apply this technology to the identification of differentially expressed genes between TNBC and normal breast tissue that are common or unique among selected ethnic groups.Methods: RNA isolation and labeled cDNA preparation from freshly cut FFPE blocks (marked by a pathologist as to normal vs. tumor tissue) was performed using the NuGEN™ WT-Ovation™ FFPE RNA Amplification System. Hybridization of tumor and normal cDNAs occurred to a breast cancer focused gene expression array (Breast Cancer DSA Research Tool, Almac Diagnostics Inc). Each patient' sample served as it's own control (tumor vs. normal). In total, 75 FFPE samples were profiled. The quality of each DSA chip was assessed on parameters selected automatically from GCOS report files per chip using MATLAB script based web application developed by Almac Dx. Data pre-processing used the Resolver Error Model. All parameters including Raw Q, Background, Scaling Factor and all controls met quality criteria set by Affymetrix and Almac Dx SOPs. Hybridization results were assessed using Principal Component Analysis and Clustering Analysis in Rosetta Resolver Gene Expression Data Analysis System 7.1 to identify potential outliers, contamination, or intra-tumor heterogeneity.Results: A Sign Agreement Matrix of FFPE and fresh frozen tissue samples during validation of the Breast Cancer DSA demonstrated that 98% of the probesets showed the same direction of fold change [p Spearman(FC)=0.84]. The FFPE samples had an average present call ∼ 43%, and more than 90% of the FFPE samples had present call rates greater than 25%. QC analysis demonstrated that the Almac Breast Cancer DSA was able to clearly and consistently separate tumor samples from normal in FFPE tissues and to identify samples of quality or integrity issues. Application of this methodology to analyses of differentially expressed transcripts between cancer and normal tissue samples across ethnicities in the TNBC samples, detected 1350 differentially expressed genes in the African-American group, 1220 genes in the Caucasian group and 1226 genes in the White Hispanic group. We also observed certain subtle ethnic-specific expression patterns across these three ethnic groups.Summary: The above-described methodology can be used to reliably measure gene expression in FFPE breast samples. Our study results are being validated in a larger data set.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6125.

Distinct multiethnic genome-wide alterations in breast cancer using paraffin embedded samples: preliminary analysis

Abstract #2024

Background and Rational: Ethnic-specific disparities in breast cancer (BC) stage of presentation and survival rates are well documented. To further investigate possible ethnic-specific genetic contributions to these disparities, we are completing gene expression profiling studies in a multi-ethnic cohort consisting of thirty “Triple Negative” BC patients [10 each African-American (AA), Hispanic (His) and non-Hispanic white (Cauc) women] matched for age of diagnosis and hormone receptor status. The overall study aim is an increased understanding of the biological basis of ethnic-specific BC disparities, leading ultimately to individualized, ethnic-specific diagnostic and therapeutic approaches. Two immediate study goals are to demonstrate the utility of FFPE samples in obtaining consistent, reproducible data from gene expression arrays, and secondly, to identify differentially expressed genes between tumor and normal tissue that are common or unique among the three ethnic groups. Methods: Pathology specimens were freshly cut from FFPE blocks and marked by a pathologist as to normal vs. tumor tissue. RNA isolation, labeled cDNA preparation, and hybridization of tumor and normal cDNAs to a breast cancer focused gene expression microarray (Breast Cancer DSA Research Tool) was performed by Almac Diagnostics. Each patient was self-matched (tumor vs. normal tissue) for gene expression studies. Results: Using 36 matched tumor and normal FFPE samples from 18 patients, approximately 17516 transcripts were detected on the Breast Cancer DSA with intensity significantly greater than background. For normal and tumor tissue samples, 9399 and 10,296 transcripts respectively, were detected in all three ethnic groups. Importantly, a subset of transcripts (hundreds to one thousand) was detected in only one or two ethnic groups. Using two-way ANOVA (disease state and ethnicity), a subset of 6479 transcripts was identified with p-value less than 0.01 in the statistical test and was selected and further used in data quality control. Data QC indicated that patient samples clustered well with respect to both ethnicity and normal versus tumor tissue. Additional analytical methods included K-means 2-Dimensional clustering and Principal Component Analysis. From these analyses, we identified ethnic-specific expression patterns in the matched normal and tumor tissue samples. We are completing these studies by increasing sample size and matching for stage of diagnosis, mapping clusters of differentially-expressed genes in pathway analysis, and validation by real-time PCR. In the longer term, DNA copy number variation (CNV) and chromosomal alterations will be investigated by high density arrays. Summary: These preliminary analyses shows that high quality gene expression data can be generated from FFPE samples, and that ethnic specific gene expression differences can be detected in tumor and matched normal breast tissue samples across ethnic groups.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2024.

Current concepts in the diagnosis and management of metabolic complications of HIV infection and its therapy

Changes in fat distribution, dyslipidemia, disordered glucose metabolism, and lactic acidosis have emerged as significant challenges to the treatment of human immunodeficiency virus (HIV) infection. Over the past decade, numerous investigations have been conducted to better define these conditions, identify risk factors associated with their development, and test potential therapeutic interventions. The lack of standardized diagnostic criteria, as well as disparate study populations and research methods, have led to conflicting data regarding the diagnosis and treatment of metabolic and body shape disorders associated with HIV infection. On the basis of a review of the medical literature published and/or data presented before April 2006, we have prepared a guide to assist the clinician in the detection and management of these complications.

A genetic signature of relapse in stage II colorectal cancer derived from formalin fixed paraffin embedded tissue (FFPE) tissue using a unique disease specific colorectal array

3519

Background: We have developed the first disease specific microarray for colorectal cancer using a transcriptome-based approach. This unique tool has been specially designed and optimised for analysis of gene expression profiles from formalin fixed paraffin embedded tissues (FFPE). To evaluate this tool we are conducting a study in patients with Dukes B (stage II) colorectal cancer (CRC) using FFPE tissues to determine a prognostic genetic signature predicting disease recurrence. Methods: The colorectal array was developed using a high-throughput transcriptome-based approach and encodes over 52,500 transcripts expressed in normal and diseased colorectal tissue. To date, tumours from 32 patients have been selected (mean FFPE tissue block age - 10.4 years) from the stage II CRC cohort of a phase III randomized trial comparing 5-FU/Leucovorin versus no adjuvant treatment (NI240). The patients were from the observation alone arm;19 of whom were disease-free for 5 years post-randomisation, while 13 suffered relapse prior to 3 years. Results: RNA was extracted from all 32 FFPE tissue samples, amplified, labelled and hybridised to the colorectal cancer disease specific array. Raw data was normalised using scalar, median-polish and z-score strategies and scalar was selected as the best strategy in relation to predictive error. Within this data set genes selected by correlation using ANOVA performed best in both KNN and support vector machine algorithms (supervised). Using this approach a gene signature containing 48 genes demonstrated 100% accuracy in the prediction of relapse in stage II CRC (p<0.001). This signature was also able to separate samples at the meta-node level using unsupervised hierarchical clustering. Conclusion: We have developed the first colorectal cancer disease specific microarray and demonstrated its use using FFPE tissues. Using this approach we have derived a gene signature that predicts for a high likelihood of early relapse in stage II CRC.

[Table: see text]

Cortactin underpins CD44-promoted invasion and adhesion of breast cancer cells to bone marrow endothelial cells

Using a validated tetracycline (tet)-regulated MCF7-founder (MCF7F) expression system to modulate expression of CD44 standard form (CD44s), we report the functional importance of CD44s and that of a novel transcriptional target of hyaluronan (HA)/CD44s signaling, EMS1/cortactin, in underpinning breast cancer metastasis. In functional experiments, tet-regulated induction of CD44s potentiated the migration and invasion of MCF7F cells through HA-supplemented Matrigel. EMS1/cortactin was identified by expression profiling as a novel transcriptional target of HA/CD44 signaling, an association validated by quantitative PCR and immunoblotting experiments in a range of breast cancer cell lines. The mechanistic basis underpinning CD44-promoted transcription of EMS1/cortactin was shown to be dependent upon a NFkappaB mechanism, since pharmacological inhibition of IkappaKinase-2 or suppression of p65 Rel A expression attenuated CD44-induced increases in cortactin mRNA transcript levels. Overexpression of a c-myc tagged murine cortactin construct in the weakly invasive, CD44-deficient MCF7F and T47D cells potentiated their invasion. Furthermore, the functional importance of cortactin to CD44s-promoted metastasis was demonstrated by selective suppression of cortactin in CD44-expressing MCF7F-B5 and MDA-MB-231 breast cancer cells using RNAi, which was shown to result in attenuated CD44-promoted invasion and CD44-promoted adhesion to bone marrow endothelial cells (BMECs).

Changes in Weight and Lean Body Mass during Highly Active Antiretroviral Therapy

BACKGROUND

Few studies have prospectively evaluated the impact of highly active antiretroviral therapy (HAART) on body weight and lean body mass (LBM) or explored the impact of baseline immunologic or virological changes on these parameters.

METHODS

Adult AIDS Clinical Trials Group (ACTG) protocol 892 was a prospective, 48-week, multisite observational study of body composition conducted during 1997-2000 among 224 antiretroviral-naive and antiretroviral-experienced subjects coenrolled into various adult ACTG antiretroviral studies. Assessments included human immunodeficiency virus type 1 (HIV-1) RNA load (by polymerase chain reaction); T lymphocyte subset analysis; Karnofsky score; height (baseline only); weight, LBM, and fat (by bioelectrical impedance analysis); and functional performance (by questionnaire).

RESULTS

Overall, only modest median increases in body weight (1.9 kg) and LBM (0.6 kg) occurred after 16 weeks of therapy. Significantly greater median increases in body weight (2.1 vs. 0.5 kg; P=.045) occurred in subjects who achieved virological suppression (HIV-1 RNA load, <500 copies/mL) at week 16 than in subjects who did not. Subjects who were antiretroviral naive at baseline gained more weight (median increase in body weight, 2.6 vs. 0.0 kg; P<.001) and LBM (1.0 vs. 0.1 kg; P=.002) after 16 weeks of treatment than did subjects who were antiretroviral experienced. Subjects with lower baseline CD4 cell counts (<200 cells/mm3) and subjects with higher baseline HIV-1 RNA loads (> or =100,000 copies/mL) were more likely to show increases in LBM of >1.5 kg (P=.013 and P=.005, respectively).

CONCLUSIONS

HAART had modestly favorable effects on body composition, particularly in patients with greater pretreatment immunocompromise and virological compromise. The difference between antiretroviral-naive and antiretroviral-experienced subjects with regard to the ability to achieve increased body weight and LBM requires more study.

Oestrogen receptor beta is the predominant oestrogen receptor in human scalp skin

Oestrogens play a major role in non-classic target tissues in both sexes, yet there have been few studies on estrogens and skin. Recently a second oestrogen receptor (ERbeta) has been discovered. Therefore, we have compared the expression of oestrogen receptor alpha (ERalpha), beta (ERbeta), the androgen receptor (AR) and a cell proliferation marker in male and female non-balding scalp skin. ERbeta was the major steroid receptor expressed in human skin. It was highly expressed in epidermis, blood vessels and dermal fibroblasts, in contrast to ERalpha and AR. In the hair follicle, ERbeta expression was localized to nuclei of outer root sheath, epithelial matrix and dermal papilla cells, in contrast to ERalpha, and the AR, which was only expressed in dermal papilla cells. Serial sections also showed strong nuclear expression of ERbeta in the cells of the bulge, while neither ERalpha nor AR was expressed. In the sebaceous gland, ERbeta was expressed in both basal and partially differentiated sebocytes. ERalpha exhibited a similar pattern of expression, while the AR was expressed in the basal and very early differentiated sebocytes. There was no obvious difference in the expression of either oestrogen receptor in male or female skin. The wide distribution of ERbeta in human skin suggests that oestrogens may play an important role in the maintenance of skin and in the regulation of the pilosebaceous unit, and provides further evidence for oestrogen action in non-classic target tissues. The differential expression of ERalpha, ERbeta and AR in human skin suggests that the mechanisms by which steroid hormones mediate their effects may be more complex than previously thought.

Oestrogen receptor beta is not present in the pilosebaceous unit of red deer skin during the non-breeding season

Androgens and oestrogens both have roles in skin physiology. Recently a second oestrogen receptor (ERbeta) has been identified in androgen-dependent tissues. The red deer grows a breeding season, androgen-dependent mane when plasma testosterone rises; this is replaced with small neck hairs during the non-breeding season. In non-breeding season deer skin, ERbeta was localised to the blood vessels and arrector pili muscle, but in contrast to human skin, not in the pilosebaceous unit or epidermis. The androgen receptor was not expressed. Further studies with breeding season skin may help to elucidate whether serum androgens or androgen receptor expression can modulate the expression of ERbeta in skin.

Frequency of anovulation and early menopause among women enrolled in selected adult AIDS clinical trials group studies

To obtain information on the prevalence of anovulation and early menopause and on pituitary-gonadal function among human immunodeficiency virus type 1-infected women, a study was undertaken that used stored serum samples from women aged 20-42 years who participated in selected Adult AIDS Clinical Trials Group protocols. Defined progesterone and follicle-stimulating hormone (FSH) levels were considered presumptive evidence of ovulation and of menopause, respectively. Anovulation occurred in 16 (48%) of 33 women for whom progesterone levels were tested; early menopause occurred in 2 (8%) of 24 women for whom FSH levels were tested. No statistically significant differences were seen in the demographic and clinical characteristics of anovulatory and ovulatory women, although women who ovulated had higher CD4 T cell counts and were less likely to have reported a recent change in menstrual periods. These data support the findings of prior studies of increased frequency of amenorrhea and/or irregular menstrual cycles, particularly among women with lower CD4 T cell counts.

Neuroticism and conscientiousness as predictors of emotional, external, and restrained eating behaviors

OBJECTIVE

We investigated the extent to which different forms of eating behavior as assessed by the Dutch Eating Behaviour Questionnaire are related to facets of the Big Five personality domains.

METHOD

Respondents were 167 psychology students (126 females and 41 males) who volunteered for the study.

RESULTS

Body mass index (BMI) and gender had significant main effects on eating behaviors. These results were moderated by a significant BMI x Gender interaction on emotional eating. Eating behaviors were significantly related to the personality facets associated with Neuroticism and Conscientiousness.

DISCUSSION

The results are discussed with reference to previous research on eating behaviors and the nature of Neuroticism and Conscientiousness.

The effects of recombinant human growth hormone on body composition and glucose metabolism in HIV-infected patients with fat accumulation

GH has been proposed as a therapy for patients with HIV-associated fat accumulation, but the pharmacological doses (6 mg/d) used have been associated with impaired fasting glucose and hyperglycemia. In contrast, physiologic doses of GH ( approximately 1 mg/d) in HIV-negative men reduced visceral adiposity and eventually improved insulin sensitivity, despite initially causing insulin resistance. We conducted an open-label study to evaluate the effects of a lower pharmacologic dose of GH (3 mg/d) in eight men with HIV-associated fat accumulation. Oral glucose tolerance, insulin sensitivity, and body composition were measured at baseline, and 1 and 6 months. Six patients completed 1 month and 5, 6 months of GH therapy. IGF-I levels increased 4-fold within 1 month of GH treatment. Over 6 months, GH reduced buffalo hump size and excess visceral adipose tissue. Total body fat decreased (17.9 +/- 10.9 to 13.5 +/- 8.4 kg, P = 0.05), primarily in the trunk region. Lean body mass increased (62.9 +/- 6.4 to 68.3 +/- 9.1 kg, P = 0.03). Insulin-mediated glucose disposal, measured by a euglycemic hyperinsulinemic clamp, declined at month 1 (49.7 +/- 27.5 to 25.6 +/- 6.6 nmol/kg(LBM).min/pmol(INSULIN)/liter, P = 0.04); values improved at month 6 (49.2 +/- 22.6, P = 0.03, compared with month 1) and did not differ significantly from baseline. Similarly, the integrated response to an oral glucose load worsened at month 1 (glucose area under the curve 20.1 +/- 2.3 to 24.6 +/- 3.7 mmol.h/liter, P < 0.01), whereas values improved at month 6 (22.1 +/- 1.5, P = 0.02, compared with month 1) and did not differ significantly from baseline. One patient developed symptomatic hyperglycemia within 2 wk of GH initiation; baseline oral glucose tolerance testing revealed preexisting diabetes despite normal fasting glucose. In conclusion, GH at 3 mg/d resulted in a decrease in total body fat and an increase in lean body mass in this open-label trial. While insulin sensitivity and glucose tolerance initially worsened, they subsequently improved toward baseline. However, the dose of GH used in this trial was supraphysiologic and led to an increase in IGF-I levels up to three times the upper normal range. Because there are known adverse effects of long-term GH excess, the effectiveness of lower doses of GH should be studied. We also recommend a screening oral glucose tolerance test be performed to exclude subjects at risk for GH-induced hyperglycemia.

Metabolic effects of indinavir in healthy HIV-seronegative men

BACKGROUND

Therapy with HIV protease inhibitors (PI) has been associated with hyperglycemia, hyperlipidemia and changes in body composition. It is unclear whether these adverse effects are drug related, involve an interaction with the host response to HIV or reflect changes in body composition.

METHODS

Indinavir 800 mg twice daily was given to 10 HIV-seronegative healthy men to distinguish direct metabolic effects of a PI from those related to HIV infection. Fasting glucose and insulin, lipid and lipoprotein profiles, oral glucose tolerance (OGTT), insulin sensitivity by hyperinsulinemic euglycemic clamp, and body composition were measured prior to and after 4 weeks of indinavir therapy.

RESULTS

Fasting glucose (4.9 +/- 0.1 versus 5.2 +/- 0.2 mmol/l; P = 0.05) insulin concentrations (61.7 +/- 12.2 versus 83.9 +/- 12.2 pmol/l; P < 0.05), insulin : glucose ratio (12.6 +/- 1.7 versus 15.9 +/- 1.9 pmol/mmol; P < 0.05) and insulin resistance index by homeostasis model assessment (1.9 +/- 0.3 versus 2.8 +/- 0.5;P < 0.05) all increased significantly. During OGTT, 2 h glucose (5.1 +/- 0.4 versus 6.5 +/- 0.6 mmol/l; P < 0.05) and insulin levels (223.1 +/- 48.8 versus 390.3 +/- 108.8 pmol/l;P =0.05) also increased significantly. Insulin-mediated glucose disposal decreased significantly (10.4 +/- 1.4 versus 8.6 +/- 1.2 mg/kg x min per microU/ml insulin; 95% confidence interval 0.6--.0;P < 0.01). There was no significant change in lipoprotein, triglycerides or free fatty acid levels. There was a small loss of total body fat (15.8 +/- 1.4 versus 15.2 +/- 1.4 kg;P = 0.01) by X-ray absorptiometry without significant changes in weight, waist : hip ratio, and visceral or subcutaneous adipose tissue by computed tomography.

CONCLUSIONS

In the absence of HIV infection, treatment with indinavir for 4 weeks causes insulin resistance independent of increases in visceral adipose tissue or lipid and lipoprotein levels.

Altered fat distribution in HIV-positive men on nucleoside analog reverse transcriptase inhibitor therapy

To determine whether HIV infection, the wasting syndrome, or nucleoside analog reverse transcriptase inhibitor (NRTI) or protease inhibitor (PI) therapy uniquely affect fat distribution in men, we performed manual regional analysis of total, appendicular, trunk, and central abdominal fat measured by dual-energy X-ray absorptiometry (DEXA). Five groups of study subjects were identified for this cross-sectional analysis: HIV-negative controls (HIV-; N = 44) and four groups of HIV-positive subjects: antiretroviral (ARV)-naive or with limited prior use of NRTIs (ARV-; N = 23); on NRTIs for > or =6 months but PI-naive (NRTI; N = 30); on an NRTI/PI regimen for > or =6 months but with no complaints of abnormal fat distribution (NRTI/PI; N = 26); and those on NRTIs but PI-naive with the wasting syndrome (NRTI/WS; N = 40). Total, appendicular, trunk, and central abdominal fat was significantly lower in NRTI/WS. The ratio of trunk fat to appendicular fat was virtually identical in HIV- and ARV-. This ratio was significantly higher in the NRTI, NRTI/PI, and NRTI/WS groups, and values in these three groups were similar. These cross-sectional data suggest that HIV-infected men receiving NRTIs have an altered pattern of fat distribution, compared with HIV-negative men and HIV-positive men who are not receiving antiretroviral therapy. This effect was independent of the concomitant use of a PI or a diagnosis of the wasting syndrome. We saw no evidence of a unique effect of HIV infection per se on regional fat distribution. Although the fat ratio is increasingly employed, its physiologic significance is unclear. Our results, which have been obtained retrospectively, are intended to provide the impetus for prospective, controlled studies of the interactions among drug and host factors in the development of fat distribution abnormalities.

The psychology of rheumatic diseases

Most chronic rheumatological disorders require major psychological adaptation, and levels of psychological distress among those with rheumatological disease have been found to be higher than in the general population. Research suggests that the relationship between disease severity, disablement and psychological well-being is not simple. This chapter highlights the complex nature of this relationship and will indicate, in particular, how psychological factors can impact on patients' perceptions of their symptoms and physical functioning. Psychological concepts that may mediate between the disease and its consequences are also discussed. A range of psychosocial interventions have been developed for individuals with rheumatological disorders. Most have related to rheumatoid arthritis, and although their primary focus has usually been on alleviating pain and improving physical functioning, this chapter examines their impact on psychological well-being. It also discusses a number of methodological issues that need to be addressed in this area of work.