A novel TTC26 variant in a patient with hexadactyly, pituitary stalk interruption, hepatopathy, nephropathy, and bilateral lip-palate cleft: A case report and expansion of the phenotype

Biallelic pathogenic variants in the TTC26 gene are known to cause BRENS (biliary, renal, neurological, skeletal) syndrome, an ultra-rare autosomal recessive condition with only few patients published to date. BRENS syndrome is characterized by hexadactyly, severe neonatal cholestasis, and involvement of the brain, heart, and kidney, however the full phenotypic and genotypic spectrum is unknown. Here, we report on a previously undescribed homozygous intronic TTC26 variant (c.1006-5 T > C) in a patient showing some of the known TTC26-associated features like hexadactyly, hypopituitarism, hepatopathy, nephropathy, and congenital heart defect. Moreover, he presented with a suspected unilateral hearing loss and bilateral cleft lip-palate. The variant is considered to affect correct splicing by the loss of the canonical acceptor splice site and activation of a cryptic acceptor splice site. Hereby, our patient represents one additional patient with BRENS syndrome carrying a previously unreported TTC26 variant. Furthermore, we confirm the involvement of the pituitary gland to be a common clinical feature of the syndrome and broaden the clinical spectrum of TTC26 ciliopathy to include facial clefts and a probable hearing involvement.

Reduced Humoral and Cellular Immune Response to Primary COVID-19 mRNA Vaccination in Kidney Transplanted Children Aged 5-11 Years

The situation of limited data concerning the response to COVID-19 mRNA vaccinations in immunocom-promised children hinders evidence-based recommendations. This prospective observational study investigated humoral and T cell responses after primary BNT162b2 vaccination in secondary immunocompromised and healthy children aged 5-11 years. Participants were categorized as: children after kidney transplantation (KTx, n = 9), proteinuric glomerulonephritis (GN, n = 4) and healthy children (controls, n = 8). Expression of activation-induced markers and cytokine secretion were determined to quantify the T cell response from PBMCs stimulated with peptide pools covering the spike glycoprotein of SARS-CoV-2 Wuhan Hu-1 and Omicron BA.5. Antibodies against SARS-CoV-2 spike receptor-binding domain were quantified in serum. Seroconversion was detected in 56% of KTx patients and in 100% of the GN patients and controls. Titer levels were significantly higher in GN patients and controls than in KTx patients. In Ktx patients, the humoral response increased after a third immunization. No differences in the frequency of antigen-specific CD4+ and CD8+ T cells between all groups were observed. T cells showed a predominant anti-viral capacity in their secreted cytokines; however, this capacity was reduced in KTx patients. This study provides missing evidence concerning the humoral and T cell response in immunocompromised children after COVID-19 vaccination.

Tools for assessing health research partnership outcomes and impacts: a systematic review

OBJECTIVE

To identify and assess the globally available valid, reliable and acceptable tools for assessing health research partnership outcomes and impacts.

METHODS

We searched Ovid MEDLINE, Embase, CINAHL Plus and PsycINFO from origin to 2 June 2021, without limits, using an a priori strategy and registered protocol. We screened citations independently and in duplicate, resolving discrepancies by consensus and retaining studies involving health research partnerships, the development, use and/or assessment of tools to evaluate partnership outcomes and impacts, and reporting empirical psychometric evidence. Study, tool, psychometric and pragmatic characteristics were abstracted using a hybrid approach, then synthesized using descriptive statistics and thematic analysis. Study quality was assessed using the quality of survey studies in psychology (Q-SSP) checklist.

RESULTS

From 56 123 total citations, we screened 36 027 citations, assessed 2784 full-text papers, abstracted data from 48 studies and one companion report, and identified 58 tools. Most tools comprised surveys, questionnaires and scales. Studies used cross-sectional or mixed-method/embedded survey designs and employed quantitative and mixed methods. Both studies and tools were conceptually well grounded, focusing mainly on outcomes, then process, and less frequently on impact measurement. Multiple forms of empirical validity and reliability evidence was present for most tools; however, psychometric characteristics were inconsistently assessed and reported. We identified a subset of studies (22) and accompanying tools distinguished by their empirical psychometric, pragmatic and study quality characteristics. While our review demonstrated psychometric and pragmatic improvements over previous reviews, challenges related to health research partnership assessment and the nascency of partnership science persist.

CONCLUSION

This systematic review identified multiple tools demonstrating empirical psychometric evidence, pragmatic strength and moderate study quality. Increased attention to psychometric and pragmatic requirements in tool development, testing and reporting is key to advancing health research partnership assessment and partnership science. PROSPERO CRD42021137932.

Long-Term Antibody Response to SARS-CoV-2 in Children

Almost 2 years into the pandemic and with vaccination of children significantly lagging behind adults, long-term pediatric humoral immune responses to SARS-CoV-2 are understudied. The C19.CHILD Hamburg (COVID-19 Child Health Investigation of Latent Disease) Study is a prospective cohort study designed to identify and follow up children and their household contacts infected in the early 2020 first wave of SARS-CoV-2. We screened 6113 children < 18 years by nasopharyngeal swab-PCR in a low-incidence setting after general lockdown, from May 11 to June 30, 2020. A total of 4657 participants underwent antibody testing. Positive tests were followed up by repeated PCR and serological testing of all household contacts over 6 months. In total, the study identified 67 seropositive children (1.44%); the median time after infection at first presentation was 83 days post-symptom onset (PSO). Follow-up of household contacts showed less than 100% seroprevalence in most families, with higher seroprevalence in families with adult index cases compared to pediatric index cases (OR 1.79, P = 0.047). Most importantly, children showed sustained seroconversion up to 9 months PSO, and serum antibody concentrations persistently surpassed adult levels (ratio serum IgG spike children vs. adults 90 days PSO 1.75, P < 0.001; 180 days 1.38, P = 0.01; 270 days 1.54, P = 0.001). In a low-incidence setting, SARS-CoV-2 infection and humoral immune response present distinct patterns in children including higher antibody levels, and lower seroprevalence in families with pediatric index cases. Children show long-term SARS-CoV-2 antibody responses. These findings are relevant to novel variants with increased disease burden in children, as well as for the planning of age-appropriate vaccination strategies.

How are health research partnerships assessed? A systematic review of outcomes, impacts, terminology and the use of theories, models and frameworks

Background

Accurate, consistent assessment of outcomes and impacts is challenging in the health research partnerships domain. Increased focus on tool quality, including conceptual, psychometric and pragmatic characteristics, could improve the quantification, measurement and reporting partnership outcomes and impacts. This cascading review was undertaken as part of a coordinated, multicentre effort to identify, synthesize and assess a vast body of health research partnership literature.

Objective

To systematically assess the outcomes and impacts of health research partnerships, relevant terminology and the type/use of theories, models and frameworks (TMF) arising from studies using partnership assessment tools with known conceptual, psychometric and pragmatic characteristics.

Methods

Four electronic databases were searched (MEDLINE, Embase, CINAHL Plus and PsycINFO) from inception to 2 June 2021. We retained studies containing partnership evaluation tools with (1) conceptual foundations (reference to TMF), (2) empirical, quantitative psychometric evidence (evidence of validity and reliability, at minimum) and (3) one or more pragmatic characteristics. Outcomes, impacts, terminology, definitions and TMF type/use were abstracted verbatim from eligible studies using a hybrid (independent abstraction–validation) approach and synthesized using summary statistics (quantitative), inductive thematic analysis and deductive categories (qualitative). Methodological quality was assessed using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD).

Results

Application of inclusion criteria yielded 37 eligible studies. Study quality scores were high (mean 80%, standard deviation 0.11%) but revealed needed improvements (i.e. methodological, reporting, user involvement in research design). Only 14 (38%) studies reported 48 partnership outcomes and 55 impacts; most were positive effects (43, 90% and 47, 89%, respectively). Most outcomes were positive personal, functional, structural and contextual effects; most impacts were personal, functional and contextual in nature. Most terms described outcomes (39, 89%), and 30 of 44 outcomes/impacts terms were unique, but few were explicitly defined (9, 20%). Terms were complex and mixed on one or more dimensions (e.g. type, temporality, stage, perspective). Most studies made explicit use of study-related TMF (34, 92%). There were 138 unique TMF sources, and these informed tool construct type/choice and hypothesis testing in almost all cases (36, 97%).

Conclusion

This study synthesized partnership outcomes and impacts, deconstructed term complexities and evolved our understanding of TMF use in tool development, testing and refinement studies. Renewed attention to basic concepts is necessary to advance partnership measurement and research innovation in the field.

Systematic review protocol registration: PROSPERO protocol registration: CRD42021137932 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=137932.

Health promotion among unemployed people – meta-analytic evidence

Background

It is well known that unemployment impairs health. However, less is known about health promotion among unemployed people and healthy coping strategies to deal with unemployment.

Methods

A random-effect meta-analysis was applied to statistically integrate quantitative controlled intervention studies among unemployed people.

Results

The meta-analysis included 34 eligible primary studies with 36 independent intervention samples. For mental health, the average meta-analytic effect sizes for the comparison of intervention group and comparison group was significant and of small size after the intervention d = 0.25; 95% CI [0.10, 0.39], and at follow-up, d = 0.13; 95% CI [0.04, 0.22]. For health behavior (measured as physical activity), the effects were also significant after the intervention, d = 0.30; 95% CI [0.12, 0.47] (no data available at follow-up). Effects on self-assessed physical health status were very small and not significant. However, when health improvement was the only goal of the respective intervention (in contrast to studies with multiple goals, e.g., health improvement plus re-employment), the effect on physical health was significant, too, d = 0.15; 95% CI [0.04, 0.25]. Moderator tests showed that intervention effects on mental health were significantly stronger when cognitive-behavioral methods were used (p &lt; .05), while the use other kinds of stress-management techniques (p &lt; .05), of methods to increase social support (p &lt; .05), or of relaxation techniques (p &lt; .07) did not improve the effectiveness of the intervention.

Conclusions

The present meta-analyses provided evidence that, on average, interventions aiming at improving unemployed people’s health do indeed improve participants’ health.

Key messages

• The present meta-analysis confirms that it is possible to promote unemployed people’ health. The moderator effects for type of intervention that were found here might be helpful for health promotion.

• The inclusion of cognitive-behavioral methods, appears to be a successful approach for health-oriented interventions with unemployed people.

Specific CD4+ T Cell Responses to Ancestral SARS-CoV-2 in Children Increase With Age and Show Cross-Reactivity to Beta Variant

SARS-CoV-2 is still a major burden for global health despite effective vaccines. With the reduction of social distancing measures, infection rates are increasing in children, while data on the pediatric immune response to SARS-CoV-2 infection is still lacking. Although the typical disease course in children has been mild, emerging variants may present new challenges in this age group. Peripheral blood mononuclear cells (PBMC) from 51 convalescent children, 24 seronegative siblings from early 2020, and 51 unexposed controls were stimulated with SARS-CoV-2-derived peptide MegaPools from the ancestral and beta variants. Flow cytometric determination of activation-induced markers and secreted cytokines were used to quantify the CD4+ T cell response. The average time after infection was over 80 days. CD4+ T cell responses were detected in 61% of convalescent children and were markedly reduced in preschool children. Cross-reactive T cells for the SARS-CoV-2 beta variant were identified in 45% of cases after infection with an ancestral SARS-CoV-2 variant. The CD4+ T cell response was accompanied most predominantly by IFN-γ and Granzyme B secretion. An antiviral CD4+ T cell response was present in children after ancestral SARS-CoV-2 infection, which was reduced in the youngest age group. We detected significant cross-reactivity of CD4+ T cell responses to the more recently evolved immune-escaping beta variant. Our findings have epidemiologic relevance for children regarding novel viral variants of concern and vaccination efforts.

Phenotypic analysis of the pediatric immune response to SARS-CoV-2 by flow cytometry

INTRODUCTION

Pediatric SARS-CoV-2 infection is often mild or asymptomatic and the immune responses of children are understudied compared to adults. Here, we present and evaluate the performance of a two-panel (16- and 17 parameter) flow cytometry-based approach for immune phenotypic analysis of cryopreserved PBMC samples from children after SARS-CoV-2 infection. The panels were optimized based on previous SARS-CoV-2 related studies for the pediatric immune system.

METHODS

PBMC samples from seven SARS-CoV-2 seropositive children from early 2020 and five age-matched healthy controls were stained for analysis of T cells (Panel T), B and innate immune cells (Panel B). Performance of the panels was evaluated in two parallel approaches, namely classical manual gating of known subpopulations and unbiased clustering using the R-based algorithm PhenoGraph.

RESULTS

Using manual gating we clearly identified 14 predefined subpopulations of interest for Panel T and 19 populations in Panel B in low-volume pediatric samples. PhenoGraph found 18 clusters within the T cell panel and 21 clusters within the innate and B cell panel that could be unmistakably annotated. Combining the data of the two panels and analysis approaches, we found expected differentially abundant clusters in SARS-CoV-2 seropositive children compared to healthy controls, underscoring the value of these two panels for the analysis of immune response to SARS-CoV-2.

CONCLUSION

We established a two-panel flow cytometry approach that can be used with limited amounts of cryopreserved pediatric samples. Our workflow allowed for a rapid, comprehensive, and robust pediatric immune phenotyping with comparable performance in manual gating and unbiased clustering. These panels may be adapted for large multi-center cohort studies to investigate the pediatric immune response to emerging virus variants in the ongoing and future pandemics. This article is protected by copyright. All rights reserved.

Discrimination impairs cognitive function in ageing men and women

Background

We sought to assess changes in episodic memory and executive functioning among men and women in the Midlife in the United States (MIDUS) cohort study; and to delineate variations in episodic memory and executive functioning by gender; and to determine the impact of discrimination on longitudinal changes in episodic memory and executive functioning.

Methods

We used data from the MIDUS study - a national probability sample of non-institutionalized, English speaking respondents aged 25-74 living in the 48 contiguous states of the United States. The initial wave in our study (1995) included 4963 non-institutionalized adults aged 32 to 84 (M = 55, SD = 12.4). Dependent variables are episodic memory and executive functioning, assessed with the Brief Test for Cognition. The independent variables were discrimination (lifetime and daily discrimination) variables. Furthermore, we investigated baseline cognition score, race/ethnicity (White, Hispanic, other), education (some college or more vs high school of less), whether or not living with partner, income (per 100% above Federal Poverty Level), unemployed (vs employed), retired (vs employed), physical health (self-reported), vigorous physical activity, depression (continuous scale), anxiety (continuous scale). To assess cognition changes we estimated adjusted linear regression models.

Results

Cross-sectional, work discrimination was associated with cognition in men and women. Longitudinally, adjusting for baseline cognition score, race/ethnicity, education, living situation, income, (un)employed, (not)retired, physical health, vigorous physical activity, depression, and anxiety, we found an association of family strain with cognition changes in high-income men, and an association of daily discrimination with cognition changes in men (Beta 0.01, P-value: 0.001).

Conclusions

Reducing discrimination might be an important measure to support cognitive function in ageing populations.

Bacteriophage Rescue Therapy of a Vancomycin-Resistant Enterococcus faecium Infection in a One-Year-Old Child following a Third Liver Transplantation

Phage therapy is an experimental therapeutic approach used to target multidrug-resistant bacterial infections. A lack of reliable data with regard to its efficacy and regulatory hurdles hinders a broad application. Here we report, for the first time, a case of vancomycin-resistant Enterococcus faecium abdominal infection in a one-year-old, critically ill, and three times liver transplanted girl, which was successfully treated with intravenous injections (twice per day for 20 days) of a magistral preparation containing two Enterococcus phages. This correlated with a reduction in baseline C-reactive protein (CRP), successful weaning from mechanical ventilation and without associated clinical adverse events. Prior to clinical use, phage genome was sequenced to confirm the absence of genetic determinants conferring lysogeny, virulence or antibiotic resistance, and thus their safety. Using a phage neutralization assay, no neutralizing anti-phage antibodies in the patient's serum could be detected. Vancomycin-susceptible E. faecium isolates were identified in close relation to phage therapy and, by using whole-genome sequencing, it was demonstrated that vancomycin-susceptible E. faecium emerged from vancomycin-resistant progenitors. Covering a one year follow up, we provide further evidence for the feasibility of bacteriophage therapy that can serve as a basis for urgently needed controlled clinical trials.

A facilitated home-based cardiac rehabilitation intervention for people with heart failure and their caregivers: a research programme including the REACH-HF RCT

Background

Rates of participation in centre (hospital)-cardiac rehabilitation by patients with heart failure are suboptimal. Heart failure has two main phenotypes differing in underlying pathophysiology: heart failure with reduced ejection fraction is characterised by depressed left ventricular systolic function (‘reduced ejection fraction’), whereas heart failure with preserved ejection fraction is diagnosed after excluding other causes of dyspnoea with normal ejection fraction. This programme aimed to develop and evaluate a facilitated home-based cardiac rehabilitation intervention that could increase the uptake of cardiac rehabilitation while delivering the clinical benefits of centre-based cardiac rehabilitation.

Objectives

To develop an evidence-informed, home-based, self-care cardiac rehabilitation programme for patients with heart failure and their caregivers [the REACH-HF (Rehabilitation Enablement in Chronic Heart Failure) intervention]. To conduct a pilot randomised controlled trial to assess the feasibility of a full trial of the clinical effectiveness and cost-effectiveness of the REACH-HF intervention in addition to usual care in patients with heart failure with preserved ejection fraction. To assess the short- and long-term clinical effectiveness and cost-effectiveness of the REACH-HF intervention in addition to usual care in patients with heart failure with reduced ejection fraction and their caregivers.

Design

Intervention mapping to develop the REACH-HF intervention; uncontrolled feasibility study; pilot randomised controlled trial in those with heart failure with preserved ejection fraction; randomised controlled trial with a trial-based cost-effectiveness analysis in those with heart failure with reduced ejection fraction; qualitative studies including process evaluation; systematic review of cardiac rehabilitation in heart failure; and modelling to assess long-term cost-effectiveness (in those with heart failure with reduced ejection fraction).

Setting

Four centres in England and Wales (Birmingham, Cornwall, Gwent and York); one centre in Scotland (Dundee) for a pilot randomised controlled trial.

Participants

Adults aged ≥ 18 years with heart failure with reduced ejection fraction (left ventricular ejection fraction < 45%) for the main randomised controlled trial (n = 216), and those with heart failure with preserved ejection fraction (left ventricular ejection fraction ≥ 45%) for the pilot randomised controlled trial (n = 50).

Intervention

A self-care, facilitated cardiac rehabilitation manual was offered to patients (and participating caregivers) at home over 12 weeks by trained health-care professionals in addition to usual care or usual care alone.

Main outcome measures

The primary outcome was disease-specific health-related quality of life measured using the Minnesota Living with Heart Failure Questionnaire at 12 months. Secondary outcomes included deaths and hospitalisations.

Results

The main randomised controlled trial recruited 216 participants with heart failure with reduced ejection fraction and 97 caregivers. A significant and clinically meaningful between-group difference in the Minnesota Living with Heart Failure Questionnaire score (primary outcome) at 12 months (–5.7 points, 95% confidence interval –10.6 to –0.7 points) favoured the REACH-HF intervention (p = 0.025). Eight (4%) patients (four in each group) had died at 12 months. There was no significant difference in hospital admissions, at 12 months, with 19 participants in the REACH-HF intervention group having at least one hospital admission, compared with 24 participants in the control group (odds ratio 0.72, 95% confidence interval 0.35 to 1.51; p = 0.386). The mean cost of the intervention was £418 per participant with heart failure with reduced ejection fraction. The costs at 12 months were, on average, £401 higher in the intervention group than in the usual care alone group. Model-based economic evaluation, extrapolating from the main randomised controlled trial in those with heart failure with reduced ejection fraction over 4 years, found that adding the REACH-HF intervention to usual care had an estimated mean cost per participant of £15,452 (95% confidence interval £14,240 to £16,780) and a mean quality-adjusted life-year gain of 4.47 (95% confidence interval 3.83 to 4.91) years, compared with £15,051 (95% confidence interval £13,844 to £16,289) and 4.24 (95% confidence interval 4.05 to 4.43) years, respectively, for usual care alone. This gave an incremental cost per quality-adjusted life-year of £1721. The probabilistic sensitivity analysis indicated 78% probability that the intervention plus usual care versus usual care alone has a cost-effectiveness below the willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained. The intervention was well received by participants with heart failure with reduced ejection fraction and those with heart failure with preserved ejection fraction, as well as their caregivers. Both randomised controlled trials recruited to target, with > 85% retention at follow-up.

Limitations

Key limitations included (1) lack of blinding – given the nature of the intervention and the control we could not mask participants to treatments, so our results may reflect participant expectation bias; (2) that we were not able to capture consistent participant-level data on level of intervention adherence; (3) that there may be an impact on the generalisability of findings due to the demographics of the trial patients, as most were male (78%) and we recruited only seven people from ethnic minorities.

Conclusions

Evaluation of the comprehensive, facilitated, home-based REACH-HF intervention for participants with heart failure with reduced ejection fraction and caregivers indicated clinical effectiveness in terms of health-related quality of life and patient self-care but no other secondary outcomes. Although the economic analysis conducted alongside the full randomised controlled trial did not produce significant differences on the EuroQol-5 Dimensions or in quality-adjusted life-years, economic modelling suggested greater cost-effectiveness of the intervention than usual care. Our REACH-HF intervention offers a new evidence-based cardiac rehabilitation option that could increase uptake of cardiac rehabilitation in patients with heart failure not attracted to or able to access hospital-based programmes.

Future work

Systematic collection of real-world data would track future changes in uptake of and adherence to alternative cardiac rehabilitation interventions in heart failure with reduced ejection fraction and increase understanding of how changes in service delivery might affect clinical and health economic outcomes. The findings of our pilot randomised controlled trial in patients with heart failure with preserved ejection fraction support progression to a full multicentre randomised controlled trial.

Trial registration

Current Controlled Trials ISRCTN86234930 and ISRCTN78539530.

Funding details

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 1. See the NIHR Journals Library website for further project information.

Process evaluation of a randomised pilot trial of home-based rehabilitation compared to usual care in patients with heart failure with preserved ejection fraction and their caregiver's

Background

Whilst almost 50% of heart failure (HF) patients have preserved ejection fraction (HFpEF), evidence-based treatment options for this patient group remain limited. However, there is growing evidence of the potential value of exercise-based cardiac rehabilitation. This study reports the process evaluation of the Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) intervention for HFpEF patients and their caregivers conducted as part of the REACH-HFpEF pilot trial.

Methods

Process evaluation sub-study parallels to a single-centre (Tayside, Scotland) randomised controlled pilot trial with qualitative assessment of both intervention fidelity delivery and HFpEF patients’ and caregivers’ experiences. The REACH-HF intervention consisted of self-help manual for patients and caregivers, facilitated over 12 weeks by trained healthcare professionals. Interviews were conducted following completion of intervention in a purposeful sample of 15 HFpEF patients and seven caregivers.

Results

Qualitative information from the facilitator interactions and interviews identified three key themes for patients and caregivers: (1) understanding their condition, (2) emotional consequences of HF, and (3) responses to the REACH-HF intervention. Fidelity analysis found the interventions to be delivered adequately with scope for improvement in caregiver engagement. The differing professional backgrounds of REACH-HF facilitators in this study demonstrate the possibility of delivery of the intervention by healthcare staff with expertise in HF, cardiac rehabilitation, or both.

Conclusions

The REACH-HF home-based facilitated intervention for HFpEF appears to be a feasible and a well-accepted model for the delivery of rehabilitation, with the potential to address key unmet needs of patients and their caregivers who are often excluded from HF and current cardiac rehabilitation programmes. Results of this study will inform a recently funded full multicentre randomised clinical trial.

Trial registration

ISRCTN78539530 (date of registration 7 July 2015).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-020-00747-2.

0426 Time Restricted Feeding Consolidates Sleep in the BACHD Mouse Model of Huntington’s Disease

Introduction

Disturbances in the daily sleep-wake cycle are common in individuals with neurodegenerative disorders. Huntington’s disease (HD) is a genetic neurodegenerative disorder in which patients exhibit a variety of impairments that include, poor motor function, disrupted circadian rhythms, and sleep abnormalities such as difficulty initiating sleep at bedtime and more frequent nighttime arousals. In the BACHD mouse model time restricted feeding (TRF) has been successful at improving motor functions and circadian rhythms. The BACHD mouse model has a bacterial artificial chromosome that expresses the full-length human mutant huntingtin gene.

Methods

In order to determine the effects of TRF on sleep-wake architecture, EEG/EMG polysomnographic records were examined in mice between 3-4 months old bearing the BAC knock-in of a human genetic mutation of HD and WT litter mates, first during ad libitum (ad lib) feeding then during an 18 hour fasting protocol. TRF protocol consisted of 6 hours of food access limited between ZT15-ZT21 and 18 hours of fasting.

Results

A two-way ANOVA revealed that TRF significantly decreased the amount of total sleep (p=0.04) and NREM sleep (p=0.04) in the dark phase in both WT and BACHD mice. TRF did not significantly affect sleep in the light phase, however trends suggest that BACHD mice have more sleep in the light phase under TRF than ad lib.

Conclusion

This data suggests that TRF improves sleep by consolidating sleep to the light phase and wake to the dark phase. In conclusion, TRF may be a promising tool that can improve the negative effects of neurodegenerative diseases on sleep-wake processes.

Support

These experiments were supported by R01-NS078410 and UCLA start-up funds.

0309 Stress Induced Nitric Oxide Synthase Activation in the Basal Forebrain is a Result of Sleep Loss

Introduction

The mechanisms underlying the reciprocal relationship between stress and sleep are unclear. Nitric oxide, a diffusible signaling molecule, plays an important role in physiological stress responses and sleep. The medial septum (MS) and vertical diagonal band (VDB) are sleep regulatory regions of the basal forebrain whose cells express nitric oxide synthase (NOS). In this study, we examined the effects of sleep loss and restraint stress on NOS activation in the MS and VDB.

Methods

Adult male and female C57BL/J6 mice were randomly assigned to a control, total sleep deprivation (TSD), or restraint stress group. TSD was performed for 6h using gentle handling, and restraint was performed for 6h by immobilizing the mice in a plastic restraint device. Both procedures began at light onset in a 12:12 light:dark cycle. Immediately following the procedures, mice were sacrificed, and NADPH-diaphorase (NADPH-d) was measured in the MS and VDB to determine NOS activity.

Results

A multivariate ANOVA revealed main effects of TSD and restraint stress on NADPH-d in the MS (F(2,13) = 7.0921, p = 0.011) and VDB (F(2,13)=6.416, p = 0.014) in females. A post hoc analysis showed a significant difference between control and TSD (p = 0.011 (MS), p = 0.014 (VDB)), and between control and restraint (p = 0.032 (MS), p = 0.048 (VDB)), but no significant difference between TSD and restraint. There is a sex difference in NADPH-d in these regions (p &lt; 0.005) that reverses direction following TSD and restraint stress.

Conclusion

Our findings provide evidence that NOS activity in the basal forebrain may underlie sex differences in stress responses. Since there is no significant difference between the TSD and restraint stress, this suggests that the effect of restraint stress on NOS activation is a result of sleep loss, and not due to induction of a stress mechanism.

Support

This study was partly funded by R01-NS078410 and UCLA start-up funds.

Home-based rehabilitation for heart failure with reduced ejection fraction: mixed methods process evaluation of the REACH-HF multicentre randomised controlled trial

OBJECTIVE

To identify and explore change processes explaining the effects of the Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) intervention taking account of reach, amount of intervention received, delivery fidelity and patient and caregiver perspectives.

DESIGN

Mixed methods process evaluation parallel to a randomised controlled trial using data from the intervention group (REACH-HF plus usual care).

SETTING

Four centres in the UK (Birmingham, Cornwall, Gwent and York).

PARTICIPANTS

People with heart failure with reduced ejection fraction (HFrEF) and their caregivers.

METHODS

The REACH-HF intervention consisted of a self-help manual for patients with HFrEF and caregivers facilitated over 12 weeks by trained healthcare professionals. The process evaluation used multimodal mixed methods analysis. Data consisted of audio recorded intervention sessions; demographic data; intervention fidelity scores for intervention group participants (107 patients and 53 caregivers); qualitative interviews at 4 and 12 months with a sample of 19 patients and 17 caregivers.

OUTCOME MEASURES

Quantitative data: intervention fidelity and number, frequency and duration of intervention sessions received. Qualitative data: experiences and perspectives of intervention participants and caregivers.

RESULTS

Intervention session attendance with facilitators was high. Fidelity scores were indicative of adequate quality of REACH-HF intervention delivery, although indicating scope for improvement in several areas. Intervention effectiveness was contingent on matching the intervention implementation to the concerns, beliefs and goals of participants. Behaviour change was sustained when shared meaning was established. Respondents' comorbidities, socio-economic circumstances and existing networks of support also affected changes in health-related quality of life.

CONCLUSIONS

By combining longitudinal mixed methods data, the essential ingredients of complex interventions can be better identified, interrogated and tested. This can maximise the clinical application of research findings and enhance the capacity of multidisciplinary and multisite teams to implement the intervention.

TRIAL REGISTRATION NUMBER

ISRCTN25032672; Pre-results.

The cost effectiveness of REACH-HF and home-based cardiac rehabilitation compared with the usual medical care for heart failure with reduced ejection fraction: A decision model-based analysis

BACKGROUND

The REACH-HF (Rehabilitation EnAblement in CHronic Heart Failure) trial found that the REACH-HF home-based cardiac rehabilitation intervention resulted in a clinically meaningful improvement in disease-specific health-related quality of life in patients with reduced ejection fraction heart failure (HFrEF). The aims of this study were to assess the long-term cost-effectiveness of the addition of REACH-HF intervention or home-based cardiac rehabilitation to usual care compared with usual care alone in patients with HFrEF.

DESIGN AND METHODS

A Markov model was developed using a patient lifetime horizon and integrating evidence from the REACH-HF trial, a systematic review/meta-analysis of randomised trials, estimates of mortality and hospital admission and UK costs at 2015/2016 prices. Taking a UK National Health and Personal Social Services perspective we report the incremental cost per quality-adjusted life-year (QALY) gained, assessing uncertainty using probabilistic and deterministic sensitivity analyses.

RESULTS

In base case analysis, the REACH-HF intervention was associated with per patient mean QALY gain of 0.23 and an increased mean cost of £400 compared with usual care, resulting in a cost per QALY gained of £1720. Probabilistic sensitivity analysis indicated a 78% probability that REACH-HF is cost effective versus usual care at a threshold of £20,000 per QALY gained. Results were similar for home-based cardiac rehabilitation versus usual care. Sensitivity analyses indicate the findings to be robust to changes in model assumptions and parameters.

CONCLUSIONS

Our cost-utility analyses indicate that the addition of the REACH-HF intervention and home-based cardiac rehabilitation programmes are likely to be cost-effective treatment options versus usual care alone in patients with HFrEF.

Caregiver outcomes of the REACH-HF multicentre randomized controlled trial of home-based rehabilitation for heart failure with reduced ejection fraction

BACKGROUND

Caregivers frequently provide support to people living with long-term conditions. However, there is paucity of evidence of interventions that support caregivers in their role. Rehabilitation EnAblement in Chronic Heart Failure (REACH-HF) is a novel home-based, health-professional-facilitated, self-management programme for patients with heart failure (HF) and their caregivers.

METHODS

Based on the random allocation of individual adult patients with reduced ejection fraction (HFrEF) and left ventricular ejection fraction <45% within the past five years, the caregiver of patients was allocated to receive the REACH-HF intervention over 12 weeks (REACH-HF group) or not (control group). Caregiver outcomes were generic health-related quality of life (EQ-5D-5L), Family Caregiver Quality of Life Scale questionnaire (FamQol), Caregiver Burden Questionnaire HF (CBQ-HF), Caregiver Contribution to Self-care of HF Index questionnaire (CC-SCHFI) and Hospital Anxiety and Depression Scale (HADS). Outcomes were compared between groups at 4, 6 and 12 months follow-up. Twenty caregivers receiving REACH-HF were purposively selected for qualitative interviews at 4 and 12 months.

RESULTS

Compared with controls (44 caregivers), the REACH-HF group (53 caregivers) had a higher mean CC-SCHFI confidence score at 12 months (57.5 vs 62.8, adjusted mean difference: 9.3, 95% confidence interval: 1.8-16.8, p = 0.016). No significant between group differences were seen in other caregiver outcomes. Qualitative interviews showed that most caregivers who received the REACH-HF intervention made positive changes to how they supported the HF patient they were caring for, and perceived that they had increased their confidence in the caregiver role over time.

CONCLUSION

Provision of the REACH-HF intervention for caregivers of HF patients improved their confidence of self-management and was perceived for some to be helpful in supporting their caregiver role.

The effects and costs of home-based rehabilitation for heart failure with reduced ejection fraction: The REACH-HF multicentre randomized controlled trial

Background

Cardiac rehabilitation improves health-related quality of life (HRQoL) and reduces hospitalizations in patients with heart failure, but international uptake of cardiac rehabilitation for heart failure remains low.

Design and methods

The aim of this multicentre randomized trial was to compare the REACH-HF (Rehabilitation EnAblement in CHronicHeart Failure) intervention, a facilitated self-care and home-based cardiac rehabilitation programme to usual care for adults with heart failure with reduced ejection fraction (HFrEF). The study primary hypothesis was that the addition of the REACH-HF intervention to usual care would improve disease-specific HRQoL (Minnesota Living with Heart Failure questionnaire (MLHFQ)) at 12 months compared with usual care alone.

Results

The study recruited 216 participants, predominantly men (78%), with an average age of 70 years and mean left ventricular ejection fraction of 34%. Overall, 185 (86%) participants provided data for the primary outcome. At 12 months, there was a significant and clinically meaningful between-group difference in the MLHFQ score of –5.7 points (95% confidence interval –10.6 to –0.7) in favour of the REACH-HF intervention group (p = 0.025). With the exception of patient self-care (p < 0.001) there was no significant difference in other secondary outcomes, including clinical events (p > 0.05) at follow-up compared with usual care. The mean cost of the REACH-HF intervention was £418 per participant.

Conclusions

The novel REACH-HF home-based facilitated intervention for HFrEF was clinically superior in disease-specific HRQoL at 12 months and offers an affordable alternative to traditional centre-based programmes to address current low cardiac rehabilitation uptake rates for heart failure.

A randomised controlled trial of a facilitated home-based rehabilitation intervention in patients with heart failure with preserved ejection fraction and their caregivers: the REACH-HFpEF Pilot Study

INTRODUCTION

Home-based cardiac rehabilitation may overcome suboptimal rates of participation. The overarching aim of this study was to assess the feasibility and acceptability of the novel Rehabilitation EnAblement in CHronic Hear Failure (REACH-HF) rehabilitation intervention for patients with heart failure with preserved ejection fraction (HFpEF) and their caregivers.

METHODS AND RESULTS

Patients were randomised 1:1 to REACH-HF intervention plus usual care (intervention group) or usual care alone (control group). REACH-HF is a home-based comprehensive self-management rehabilitation programme that comprises patient and carer manuals with supplementary tools, delivered by trained healthcare facilitators over a 12 week period. Patient outcomes were collected by blinded assessors at baseline, 3 months and 6 months postrandomisation and included health-related quality of life (primary) and psychological well-being, exercise capacity, physical activity and HF-related hospitalisation (secondary). Outcomes were also collected in caregivers.We enrolled 50 symptomatic patients with HF from Tayside, Scotland with a left ventricular ejection fraction ≥45% (mean age 73.9 years, 54% female, 100% white British) and 21 caregivers. Study retention (90%) and intervention uptake (92%) were excellent. At 6 months, data from 45 patients showed a potential direction of effect in favour of the intervention group, including the primary outcome of Minnesota Living with Heart Failure Questionnaire total score (between-group mean difference -11.5, 95% CI -22.8 to 0.3). A total of 11 (4 intervention, 7 control) patients experienced a hospital admission over the 6 months of follow-up with 4 (control patients) of these admissions being HF-related. Improvements were seen in a number intervention caregivers' mental health and burden compared with control.

CONCLUSIONS

Our findings support the feasibility and rationale for delivering the REACH-HF facilitated home-based rehabilitation intervention for patients with HFpEF and their caregivers and progression to a full multicentre randomised clinical trial to test its clinical effectiveness and cost-effectiveness.

TRIAL REGISTRATION NUMBER

ISRCTN78539530.

Rehabilitation Enablement in Chronic Heart Failure-a facilitated self-care rehabilitation intervention in patients with heart failure with preserved ejection fraction (REACH-HFpEF) and their caregivers: rationale and protocol for a single-centre pilot randomised controlled trial

INTRODUCTION

The Rehabilitation EnAblement in CHronic Heart Failure in patients with Heart Failure (HF) with preserved ejection fraction (REACH-HFpEF) pilot trial is part of a research programme designed to develop and evaluate a facilitated, home-based, self-help rehabilitation intervention to improve self-care and quality of life (QoL) in heart failure patients and their caregivers. We will assess the feasibility of a definitive trial of the REACH-HF intervention in patients with HFpEF and their caregivers. The impact of the REACH-HF intervention on echocardiographic outcomes and bloodborne biomarkers will also be assessed.

METHODS AND ANALYSIS

A single-centre parallel two-group randomised controlled trial (RCT) with 1:1 individual allocation to the REACH-HF intervention plus usual care (intervention) or usual care alone (control) in 50 HFpEF patients and their caregivers. The REACH-HF intervention comprises a REACH-HF manual with supplementary tools, delivered by trained facilitators over 12 weeks. A mixed methods approach will be used to assess estimation of recruitment and retention rates; fidelity of REACH-HF manual delivery; identification of barriers to participation and adherence to the intervention and study protocol; feasibility of data collection and outcome burden. We will assess the variance in study outcomes to inform a definitive study sample size and assess methods for the collection of resource use and intervention delivery cost data to develop the cost-effectiveness analyses framework for any future trial. Patient outcomes collected at baseline, 4 and 6 months include QoL, psychological well-being, exercise capacity, physical activity and HF-related hospitalisation. Caregiver outcomes will also be assessed, and a substudy will evaluate impact of the REACH-HF manual on resting global cardiovascular function and bloodborne biomarkers in HFpEF patients.

ETHICS AND DISSEMINATION

The study is approved by the East of Scotland Research Ethics Service (Ref: 15/ES/0036). Findings will be disseminated via journals and presentations to clinicians, commissioners and service users.

TRIAL REGISTRATION NUMBER

ISRCTN78539530; Pre-results .

Inflammation, vitamin D and dendritic cell precursors in chronic kidney disease

Decreased blood dendritic cell precursors (DCP) count is linked with atherosclerotic disease, while reduction of circulating DCP is also seen in patients with chronic kidney disease (CKD). As poor vitamin D status could be linked to a compromised innate immune response, we hypothesized that vitamin D status might be involved in the decrease in circulating DCP in CKD. Moreover, the potential role of inflammation was considered. Circulating myeloid (mDCP), plasmacytoid (pDCP) and total DCP (tDCP) were analysed using flow cytometry in 287 patients with CKD stage 3. Serum 25(OH)D and 1,25(OH)2D levels were measured using enzyme-linked immunosorbent assays (ELISA), interleukin (IL)-6, IL-10 and tumour necrosis factor (TNF)-α using cytometric bead array, C-reactive protein (CRP) using a high-sensitivity (hs) ELISA. Contrary to our hypothesis, there was no association between vitamin D levels and DCP, although their number was decreased significantly in CKD (P < 0·001). Instead, mDCP (r = -0·211) and tDCP (r = -0·188,) were associated slightly negatively with hsCRP but positively with the estimated glomerular filtration rate (eGFR, r = 0·314 for tDCP). According to multivariate linear regression, only higher hsCRP concentration and the presence of diabetes mellitus had a significant negative influence on DCP count (P < 0·03, respectively) but not vitamin D, age and eGFR. A significant impact of vitamin D on the reduction of circulating DCP in CKD 3 patients can be neglected. Instead, inflammation as a common phenomenon in CKD and diabetes mellitus had the main influence on the decrease in DCP. Thus, a potential role for DCP as a sensitive marker of inflammation and cardiovascular risk should be elucidated in future studies.

Optimising self-care support for people with heart failure and their caregivers: development of the Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) intervention using intervention mapping

BACKGROUND

We aimed to establish the support needs of people with heart failure and their caregivers and develop an intervention to improve their health-related quality of life.

METHODS

We used intervention mapping to guide the development of our intervention. We identified "targets for change" by synthesising research evidence and international guidelines and consulting with patients, caregivers and health service providers. We then used behaviour change theory, expert opinion and a taxonomy of behaviour change techniques, to identify barriers to and facilitators of change and to match intervention strategies to each target. A patient and public involvement group helped to identify patient and caregiver needs, refine the intervention objectives and strategies and deliver training to the intervention facilitators. A feasibility study (ISRCTN25032672) involving 23 patients, 12 caregivers and seven trained facilitators at four sites assessed the feasibility and acceptability of the intervention and quality of delivery and generated ideas to help refine the intervention.

RESULTS

The Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) intervention is a comprehensive self-care support programme comprising the "Heart Failure Manual", a choice of two exercise programmes for patients, a "Family and Friends Resource" for caregivers, a "Progress Tracker" tool and a facilitator training course. The main targets for change are engaging in exercise training, monitoring for symptom deterioration, managing stress and anxiety, managing medications and understanding heart failure. Secondary targets include managing low mood and smoking cessation. The intervention is facilitated by trained healthcare professionals with specialist cardiac experience over 12 weeks, via home and telephone contacts. The feasibility study found high levels of satisfaction and engagement with the intervention from facilitators, patients and caregivers. Intervention fidelity analysis and stakeholder feedback suggested that there was room for improvement in several areas, especially in terms of addressing caregivers' needs. The REACH-HF materials were revised accordingly.

CONCLUSIONS

We have developed a comprehensive, evidence-informed, theoretically driven self-care and rehabilitation intervention that is grounded in the needs of patients and caregivers. A randomised controlled trial is underway to assess the effectiveness and cost-effectiveness of the REACH-HF intervention in people with heart failure and their caregivers.

Using Art as a Medium for First Nations Youth to Express Their Pain: A Two-Eyed Seeing Qualitative Study

BACKGROUND: First Nations (FN) youth in Canada have the highest rates of pain-related conditions (ear, dental, headaches) yet may be least likely to be treated for them. Untreated pain has an arresting impact on growth and development and is detrimental to the achievement of life goals. In recent research conducted by the Aboriginal Children’s Hurt & Healing Initiative (ACHH), community participants reported that First Nation children are stoic and are reluctant to talk about their pain (Latimer & Rudderham, 2013). Clinicians are trained to assess pain based on overt signs of expression (cry, facial grimace, ability to describe) however if you do not present your pain this way it may reduce the chance of proper assessment and treatment.

OBJECTIVES: Using a Two-Eyed Seeing qualitative perspective (best of Indigenous and Western knowledge) the purpose of this research was to provide FN youth with the method of art making to determine how they express their pain.

DESIGN/METHODS: Youth from four FN communities, in three Maritime Provinces were invited to participate in art workshops facilitated by internationally renowned Mi’kmaq artist Alan Syliboy. The workshop began with a conversation circle about pain experiences and then proceeded to the art making. A FN documentary cinematographer captured the workshops and the results are documented in art and film. Three team members independently themed the data using thematic analysis and the inter-rater reliability was &gt;85%.

RESULTS: 39 youth aged 10-18 years participated in 4 community-based conversation and art sessions. The themes for the sessions were themed using the four dimensions of the Medicine Wheel. While the overwhelming theme discussed in the conversation sessions was physical pain, when provided the nonverbal, art mode of expression, the youth painted emotional pain more frequently than physical, spiritual and mental pain. There was overlap between the four themes but 70% of the artwork prominently illustrated emotional pain with 54% overlapping with physical, 30% mental and 31% spiritual.

CONCLUSION: These results present a more complicated issue regarding the integration of the different types of pain, intertwined together. The finding that when asked-youth primarily discussed physical pain but given the opportunity, more frequently painted emotional pain may shed new light on the degree to which emotional pain is a factor for these youth. The artwork and accompanying narratives are powerful and have implications for understanding the complexity of assessing the different dimensions of pain in a culturally meaningful manner and for clinician education purposes. A sample of the artwork is attached.

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D1 receptor-mediated inhibition of medial prefrontal cortex neurons is disrupted in adult rats exposed to amphetamine in adolescence

Amphetamine (AMPH) exposure leads to changes in behavior and dopamine receptor function in the prefrontal cortex (PFC). Since dopamine plays an important role in regulating GABAergic transmission in the PFC, we investigated if AMPH exposure induces long-lasting changes in dopamine's ability to modulate inhibitory transmission in the PFC as well as whether the effects of AMPH differed depending on the age of exposure. Male Sprague-Dawley rats were given saline or 3 mg/kg AMPH (i.p.) repeatedly during adolescence or adulthood and following a withdrawal period of up to 5 weeks (Experiment 1) or up to 14 weeks (Experiment 2), they were sacrificed for in vitro whole-cell recordings in layer V/VI of the medial PFC. We found that in brain slices from either adolescent- or adult-exposed rats, there was an attenuation of dopamine-induced increases in inhibitory synaptic currents in pyramidal cells. These effects did not depend on age of exposure, were mediated at least partially by a reduced sensitivity of D1 receptors in AMPH-treated rats, and were associated with an enhanced behavioral response to the drug in a separate group of rats given an AMPH challenge following the longest withdrawal period. Together, these data reveal a prolonged effect of AMPH exposure on medial PFC function that persisted for up to 14 weeks in adolescent-exposed animals. These long-lasting neurophysiological changes may be a contributing mechanism to the behavioral consequences that have been observed in those with a history of amphetamine abuse.

Clinical effectiveness and cost-effectiveness of the Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) facilitated self-care rehabilitation intervention in heart failure patients and caregivers: rationale and protocol for a multicentre randomised controlled trial

INTRODUCTION

The Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) trial is part of a research programme designed to develop and evaluate a health professional facilitated, home-based, self-help rehabilitation intervention to improve self-care and health-related quality of life in people with heart failure and their caregivers. The trial will assess the clinical effectiveness and cost-effectiveness of the REACH-HF intervention in patients with systolic heart failure and impact on the outcomes of their caregivers.

METHODS AND ANALYSIS

A parallel two group randomised controlled trial with 1:1 individual allocation to the REACH-HF intervention plus usual care (intervention group) or usual care alone (control group) in 216 patients with systolic heart failure (ejection fraction <45%) and their caregivers. The intervention comprises a self-help manual delivered by specially trained facilitators over a 12-week period. The primary outcome measure is patients' disease-specific health-related quality of life measured using the Minnesota Living with Heart Failure questionnaire at 12 months' follow-up. Secondary outcomes include survival and heart failure related hospitalisation, blood biomarkers, psychological well-being, exercise capacity, physical activity, other measures of quality of life, patient safety and the quality of life, psychological well-being and perceived burden of caregivers at 4, 6 and 12 months' follow-up. A process evaluation will assess fidelity of intervention delivery and explore potential mediators and moderators of changes in health-related quality of life in intervention and control group patients. Qualitative studies will describe patient and caregiver experiences of the intervention. An economic evaluation will estimate the cost-effectiveness of the REACH-HF intervention plus usual care versus usual care alone in patients with systolic heart failure.

ETHICS AND DISSEMINATION

The study is approved by the North West-Lancaster Research Ethics Committee (ref 14/NW/1351). Findings will be disseminated via journals and presentations to publicise the research to clinicians, commissioners and service users.

TRIAL REGISTRATION NUMBER

ISRCTN86234930; Pre-results.

[Diffusion Weighted Magnetic Resonance Imaging and its Application in Ophthalmology]

The value of diffusion-weighted magnet resonance imaging (DWI-MRI) has been demonstrated for an ever growing range of clinical indications. DWI is sensitive to the diffusion of water molecules and probes their random displacement within tissue. DWI provides both qualitative and quantitative information on tissue characteristics, e.g. tissue cellularity. This review provides an overview of diffusion-weighted imaging and its emerging applications in ophthalmology. The basic physics and technical foundations of DWI are introduced. The emerging applications of DWI are surveyed, particularly in diseases of the eye, orbit and optical nerve.

Effect of nutrition education on exclusive breastfeeding for nutritional outcome of low birth weight babies

BACKGROUND/OBJECTIVES

Low birth weight (LBW), defined as the body weight at birth of less than 2500 g, is a major public health problem in Bangladesh, where 37% of the babies are born with LBW. The objective of this study is to see the impact of nutrition education on growth of LBW babies with early initiation and exclusive breastfeeding compared to control group.

SUBJECTS/METHODS

A total of 184 LBW babies and their mothers who attended the Maternal Care and Health Training Institute and Dhaka Medical College Hospital were randomly allocated to either intervention or control group. Enrollment of the study population started in May 2008 and was completed in October 2008. Nutrition education was given to mothers twice weekly for 2 months, on initiation of breastfeeding within 1 h, exclusive breastfeeding and increasing their dietary intake. Nutritional status of LBW babies was assessed for length and weight every 2 weeks. Data were analyzed using SPSS/Window's version 12. Comparison of mean of data was done using standard Student's t-test.

RESULTS

Mean initial body weight and length of LBW babies were similar in both groups (2261±198 g vs 2241±244 g, P=0.535 and 43.0±1.3 cm vs 43.0±1.7 cm, P=0.77). Body weight and length of the LBW babies after 2 months increased significantly (3620±229 g vs 3315±301 g, P<0.001 and 50.2±1.3 cm vs 48.7±1.6 cm, P<0.001). It was found that the intervention group suffered less from respiratory illness compared with the control group (39% vs 66%, P<0.001). The rate of early initiation of breastfeeding was also significantly higher with nutrition intervention (59.8% vs 37.2%, P<0.001). Exclusive breastfeeding rate was significantly higher in intervention group (59.8% vs 37%, P=0.003).

CONCLUSIONS

The present study showed that weight and length gain of LBW babies significantly increased by breastfeeding and nutrition education. Therefore, nutrition education on breastfeeding proves to be a strong tool to reduce the high risk of malnutrition and mortality of the LBW babies.

Gender, age and ethnic aspects of analgesia in acute abdominal pain: is analgesia even across the groups?

BACKGROUND

Numerous studies have shown differences in pain perception between men and women, which may affect pain management strategies.

AIM

Our primary aim was to investigate whether there are gender-based differences in pain management in patients admitted to our emergency department with acute, non-specific abdominal pain (NSAP). Our secondary aim was to evaluate if other factors influence administration of analgesia for patients admitted with NSAP.

METHODS

From June 2007 to June 2008, we carried out a retrospective, gender-based, frequency-matched control study with 150 patients (75 consecutive men and 75 women) who presented with NSAP at our emergency department. Pain was documented using a numerical rating scale ('0' no pain, '10' most severe pain). A multinomial regression model was used to assess factors that might influence pain management.

RESULTS

No statistically significant difference was seen between men and women with respect to pain management (P= 0.085). Younger patients were, however, more likely to receive weaker (P= 0.011) and fewer analgesics (P < 0.001). Patients with previous abdominal surgery (P= 0.012), known chronic pain conditions (P= 0.029) or relevant comorbidities (P= 0.048) received stronger analgesia. Nationality (P= 0.244), employment status (P= 0.988), time of admission (P= 0.487) and known psychiatric illness (P= 0.579) did not influence pain management.

CONCLUSIONS

No statistically significant gender-dependent differences in pain management were observed. However, younger patients received less potent analgesic treatment. There is no reason for certain groups to receive suboptimal treatment, and greater efforts should be made to offer consistent treatment to all patients.

Phenotype determining alleles in GM1 gangliosidosis patients bearing novel GLB1 mutations

GM1 gangliosidosis manifests with progressive psychomotor deterioration and dysostosis of infantile, juvenile, or adult onset, caused by alterations in the structural gene coding for lysosomal acid beta-galactosidase (GLB1). In addition, allelic variants of this gene can result in Morquio B disease (MBD), a phenotype with dysostosis multiplex and entire lack of neurologic involvement. More than 100 sequence alterations in the GLB1 gene have been identified so far, but only few could be proven to be predictive for one of the GM1 gangliosidosis subtypes or MBD. We performed genotype analyses in 16 GM1 gangliosidosis patients of all phenotypes and detected 28 different genetic lesions. Among these, p.I55FfsX16, p.W65X, p.F107L, p.H112P, p.C127Y, p.W161X, p.I181K, p.C230R, p.W273X, p.R299VfsX5, p.A301V, p.F357L, p.K359KfsX23, p.L389P, p.D448V, p.D448GfsX8, and the intronic mutation IVS6-8A>G have not been published so far. Due to their occurrence in homozygous patients, four mutations could be correlated to a distinct GM1 gangliosidosis phenotype. Furthermore, the missense mutations from heteroallelic patients and three artificial nonsense mutations were characterized by overexpression in COS-1 cells, and the subcellular localization of the mutant proteins in fibroblasts was assessed. The phenotype specificity of 10 alleles can be proposed on the basis of our results and previous data.

Multivariate analysis of full-term neonatal polysomnographic data

INTRODUCTION

Polysomnography (PSG) is one of the most important noninvasive methods for studying maturation of the child brain. Sleep in infants is significantly different from sleep in adults. This paper addresses the problem of computer analysis of neonatal polygraphic signals.

METHODS

We applied methods designed for differentiating three important neonatal behavioral states: quiet sleep, active sleep, and wakefulness. The proportion of these states is a significant indicator of the maturity of the newborn brain in clinical practice. In this study, we used data provided by the Institute for Care of Mother and Child, Prague (12 newborn infants of similar postconceptional age). The data were scored by an experienced physician to four states (wake, quiet sleep, active sleep, movement artifact). For accurate classification, it was necessary to determine the most informative features. We used a method based on power spectral density (PSD) applied to each EEG channel. We also used features derived from electrooculogram (EOG), electromyogram (EMG), ECG, and respiration [pneumogram (PNG)] signals. The most informative feature was the measure of regularity of respiration from the PNG signal. We designed an algorithm for interpreting these characteristics. This algorithm was based on Markov models.

RESULTS

The results of automatic detection of sleep states were compared to the "sleep profiles" determined visually. We evaluated both the success rate and the true positive rate of the classification, and statistically significant agreement of the two scorings was found. Two variants, for learning and for testing, were applied, namely learning from the data of all 12 newborns and tenfold cross-validation, and learning from the data of 11 newborns and testing on the data from the 12th newborn. We utilized information obtained from several biological signals (EEG, ECG, PNG, EMG, EOG) for our final classification. We reached the final success rate of 82.5%. The true positive rate was 81.8% and the false positive rate was 6.1%.

DISCUSSION

The most important step in the whole process is feature extraction and feature selection. In this process, we used visualization as an additional tool that helped us to decide which features to select. Proper selection of features may significantly influence the success rate of the classification. We made a visual comparison of the computed features with the manual scoring provided by the expert. A hidden Markov model was used for classification. The advantage of this model is that it determines the future behavior of the process by its present state. In this way, it preserves information about temporal development.

Pyridoxine-dependent epilepsy: normal outcome in a patient with late diagnosis after prolonged status epilepticus causing cortical blindness

We report on a male proband with pyridoxine-dependent epilepsy (PDE) and neonatal seizure onset. At the age of 31 months, a prolonged status epilepticus led to severe neurological regression with cortical blindness, loss of speech and muscular hypotonia with slow recovery over the following 3 months. At 33 months of age pyridoxine therapy was initiated with excellent response and the boy remained seizure-free on pyridoxine monotherapy, except for two occasions with seizure recurrence 10 days after accidental pyridoxine withdrawal. alpha-aminoadipic semialdehyde dehydrogenase (antiquitin) deficiency was indicated by elevated pipecolic acid concentrations in plasma and alpha-aminoadipic semialdehyde excretion in urine. Molecular analysis of the antiquitin gene revealed a novel missense mutation c.57insA, while the mutation of the other allele remained unidentified so far. Despite the delay in diagnosis and prolonged status epilepticus, neuropsychological evaluations at the ages of 11 and 18 years demonstrated full-scale IQ of 93 and 92, respectively, with better verbal IQ (103 and 101) than performance IQ (85 and 82).