Adaptive tail-length evolution in deer mice is associated with differential Hoxd13 expression in early development

Variation in the size and number of axial segments underlies much of the diversity in animal body plans. Here we investigate the evolutionary, genetic and developmental mechanisms driving tail-length differences between forest and prairie ecotypes of deer mice (Peromyscus maniculatus). We first show that long-tailed forest mice perform better in an arboreal locomotion assay, consistent with tails being important for balance during climbing. We then identify six genomic regions that contribute to differences in tail length, three of which associate with caudal vertebra length and the other three with vertebra number. For all six loci, the forest allele increases tail length, indicative of the cumulative effect of natural selection. Two of the genomic regions associated with variation in vertebra number contain Hox gene clusters. Of those, we find an allele-specific decrease in Hoxd13 expression in the embryonic tail bud of long-tailed forest mice, consistent with its role in axial elongation. Additionally, we find that forest embryos have more presomitic mesoderm than prairie embryos and that this correlates with an increase in the number of neuromesodermal progenitors, which are modulated by Hox13 paralogues. Together, these results suggest a role for Hoxd13 in the development of natural variation in adaptive morphology on a microevolutionary timescale.

A chromosomal inversion contributes to divergence in multiple traits between deer mouse ecotypes

How locally adapted ecotypes are established and maintained within a species is a long-standing question in evolutionary biology. Using forest and prairie ecotypes of deer mice (Peromyscus maniculatus), we characterized the genetic basis of variation in two defining traits-tail length and coat color-and discovered a 41-megabase chromosomal inversion linked to both. The inversion frequency is 90% in the dark, long-tailed forest ecotype; decreases across a habitat transition; and is absent from the light, short-tailed prairie ecotype. We implicate divergent selection in maintaining the inversion at frequencies observed in the wild, despite high levels of gene flow, and explore fitness benefits that arise from suppressed recombination within the inversion. We uncover a key role for a large, previously uncharacterized inversion in the evolution and maintenance of classic mammalian ecotypes.

Establishing a multidisciplinary initiative for interoperable electronic health record innovations at an academic medical center

Objective

To establish an enterprise initiative for improving health and health care through interoperable electronic health record (EHR) innovations.

Materials and Methods

We developed a unifying mission and vision, established multidisciplinary governance, and formulated a strategic plan. Key elements of our strategy include establishing a world-class team; creating shared infrastructure to support individual innovations; developing and implementing innovations with high anticipated impact and a clear path to adoption; incorporating best practices such as the use of Fast Healthcare Interoperability Resources (FHIR) and related interoperability standards; and maximizing synergies across research and operations and with partner organizations.

Results

University of Utah Health launched the ReImagine EHR initiative in 2016. Supportive infrastructure developed by the initiative include various FHIR-related tooling and a systematic evaluation framework. More than 10 EHR-integrated digital innovations have been implemented to support preventive care, shared decision-making, chronic disease management, and acute clinical care. Initial evaluations of these innovations have demonstrated positive impact on user satisfaction, provider efficiency, and compliance with evidence-based guidelines. Return on investment has included improvements in care; over $35 million in external grant funding; commercial opportunities; and increased ability to adapt to a changing healthcare landscape.

Discussion

Key lessons learned include the value of investing in digital innovation initiatives leveraging FHIR; the importance of supportive infrastructure for accelerating innovation; and the critical role of user-centered design, implementation science, and evaluation.

Conclusion

EHR-integrated digital innovation initiatives can be key assets for enhancing the EHR user experience, improving patient care, and reducing provider burnout.

Leveraging Artificial Intelligence to Improve Chronic Disease Care: Methods and Application to Pharmacotherapy Decision Support for Type-2 Diabetes Mellitus

OBJECTIVES

Artificial intelligence (AI), including predictive analytics, has great potential to improve the care of common chronic conditions with high morbidity and mortality. However, there are still many challenges to achieving this vision. The goal of this project was to develop and apply methods for enhancing chronic disease care using AI.

METHODS

Using a dataset of 27,904 patients with diabetes, an analytical method was developed and validated for generating a treatment pathway graph which consists of models that predict the likelihood of alternate treatment strategies achieving care goals. An AI-driven clinical decision support system (CDSS) integrated with the electronic health record (EHR) was developed by encapsulating the prediction models in an OpenCDS Web service module and delivering the model outputs through a SMART on FHIR (Substitutable Medical Applications and Reusable Technologies on Fast Healthcare Interoperability Resources) web-based dashboard. This CDSS enables clinicians and patients to review relevant patient parameters, select treatment goals, and review alternate treatment strategies based on prediction results.

RESULTS

The proposed analytical method outperformed previous machine-learning algorithms on prediction accuracy. The CDSS was successfully integrated with the Epic EHR at the University of Utah.

CONCLUSION

A predictive analytics-based CDSS was developed and successfully integrated with the EHR through standards-based interoperability frameworks. The approach used could potentially be applied to many other chronic conditions to bring AI-driven CDSS to the point of care.

The complete clinician model

Historically, medical education has focused on acquiring knowledge of basic science and clinical medicine. Relationship management skills are an essential aspect of excellent clinicians that may have been overlooked in the educational curriculum and undervalued in practice. The complete clinician model is a theoretical model for clinician development that describes why knowledge acquisition and relationship management are both imperative skills to refine when progressing to be an excellent clinician. Four quadrants are described, with ideal progress going from the trainee quadrant to the golden quadrant, ultimately aiming for competence in both knowledge acquisition and relationship management. The pediatric resident milestones from the Accreditation Council for Graduate Medical Education were placed in the model to underscore the importance placed on both knowledge acquisition and relationship management skills. Relationship management training should be integrated into the medical curriculum. This model may be applicable to professional education in other health care disciplines.

Identification of critical factors for forming collaborative relationships between physicians and pharmacists

PURPOSE

The purpose of this study was to identify and describe strategies that have successfully achieved collaboration among physicians and pharmacists providing comprehensive medication management (CMM) to support development of CMM services.

METHODS

A 2-phase, mixed-methods approach was employed to identify successful strategies for building pharmacist-physician relationships in primary care clinic settings. Phase I used a qualitative approach to identify strategies deemed successful in building relationships with physicians. An advisory group of pharmacists with experience building CMM practices assisted in the development of minimum criteria characterizing pharmacists as having strong collaborative relationships. Semi-structured interviews were conducted with 10 interviewees meeting established criteria. Researchers coded interview transcripts and identified the resulting strategies. Phase II employed a survey instrument to determine how frequently identified strategies are used and evaluate the relative level of perceived impact of each strategy, which was distributed to a national audience of pharmacists practicing in ambulatory care settings. Responses from pharmacists meeting prespecified criteria were included in the analysis.

RESULTS

Thirty-three strategies were identified and grouped into 8 themes. In phase II, 104 survey respondents met defined criteria and were eligible to endorse use of identified strategies and rate their relative influence.

CONCLUSIONS

Thirty-three strategies were identified and grouped into 8 themes to aid pharmacists practicing CMM in developing stronger collaborative relationships with physician colleagues. A national sampling found many of these strategies were employed by a majority of pharmacists, who had found them to be influential in creating collaborative relationships.

Social behaviour in bees influences the abundance of Sodalis (Enterobacteriaceae) symbionts

Social interactions can facilitate transmission of microbes between individuals, reducing variation in gut communities within social groups. Thus, the evolution of social behaviours and symbiont community composition have the potential to be tightly linked. We explored this connection by characterizing the diversity of bacteria associated with both eusocial and solitary bee species within the behaviourally variable family Halictidae using 16S amplicon sequencing. Contrary to expectations, we found few differences in bacterial abundance or variation between social forms; most halictid species appear to share similar gut bacterial communities. However, several strains of Sodalis, a genus described as a symbiont in a variety of insects but yet to be characterized in bees, differ in abundance between eusocial and solitary bees. Phylogenetic reconstructions based on whole-genome alignments indicate that Sodalis has independently colonized halictids at least three times. These strains appear to be mutually exclusive within individual bees, although they are not host-species-specific and no signatures of vertical transmission were observed, suggesting that Sodalis strains compete for access to hosts. The symbiosis between halictids and Sodalis therefore appears to be in its early stages.

No effect of prenatal vitamin D deficiency on autism-relevant behaviours in multiple inbred strains of mice

Autism Spectrum Disorders (ASD) is a group of neurodevelopmental disorders commonly characterised by verbal and non-verbal communication deficits, impaired social interaction and repetitive, stereotypic behaviours. The aetiology of ASD is most likely a combination of genetic and environmental factors. Epidemiological evidence suggests that prenatal vitamin D deficiency is associated with an increased incidence of ASD. The overall aim of this study was to investigate prenatal vitamin D deficiency on ASD-related behavioural phenotypes in multiple inbred strains of mice. We included two commonly used inbred mouse strains (C57BL/6J and BALB/c) as well as inbred BTBR mice, which show ASD-related behaviours, such as excessive self-grooming, hyperlocomotion, social interaction deficits and altered communication. We also studied the effect of prenatal vitamin D deficiency in a fourth strain; an F1 cross of C57BL/6J x BTBR mice, which have a partial BTBR phenotype. To implement prenatal vitamin D deficiency, female mice were placed on vitamin D deplete diets for ten weeks, including mating and gestation, until littering, when all dams were switched to the control diet. Behavioural symptoms related to ASD were measured, including isolation-induced ultrasonic vocalisations to measure communication, the three-chambered social interaction task to observe social interaction, the open field test to examine hyperlocomotion, assessment of grooming and rearing behaviour and finally the active place avoidance task to observe spatial learning and memory in response to a mild foot shock. Prenatal vitamin D deficiency had a negative impact on preference for social novelty in C57BL/6J mice, despite similar vocalisation phenotypes, and prenatal vitamin D-deficient F1 mice were found to be hypolocomotive in the open field test yet performed better on the active place avoidance task. Despite clear differences between strains, there were no other consistent significant main effects of maternal diet on the behaviour of the offspring. Vitamin D deficiency has been implicated as a risk factor for ASD and these data show that there is greater variation between different inbred strains in ASD-related behaviour, suggesting that prenatal vitamin D deficiency is not sufficient to recapitulate an ASD phenotype in multiple inbred strains of mice.

An ant-plant mutualism through the lens of cGMP-dependent kinase genes

In plant-animal mutualisms, how an animal forages often determines how much benefit its plant partner receives. In many animals, foraging behaviour changes in response to foraging gene expression or activation of the cGMP-dependent protein kinase (PKG) that foraging encodes. Here, we show that this highly conserved molecular mechanism affects the outcome of a plant-animal mutualism. We studied the two PKG genes of Allomerus octoarticulatus, an Amazonian ant that defends the ant-plant Cordia nodosa against herbivores. Some ant colonies are better 'bodyguards' than others. Working in the field in Peru, we found that colonies fed with a PKG activator recruited more workers to attack herbivores than control colonies. This resulted in less herbivore damage. PKG gene expression in ant workers correlated with whether an ant colony discovered an herbivore and how much damage herbivores inflicted on leaves in a complex way; natural variation in expression levels of the two genes had significant interaction effects on ant behaviour and herbivory. Our results suggest a molecular basis for ant protection of plants in this mutualism.

Psychological treatment of depression and anxiety in patients with co-morbid personality disorder: A scoping study of trial evidence

It is unclear what the best psychological treatment is for depression and anxiety in people with co-morbid personality disorder. Trials of different psychological treatment options for this patient group have been conducted, but this evidence has not previously been systematically reviewed or critically appraised. We set out to conduct a scoping review in order to describe which psychological therapies appear most effective in treating depression and/or anxiety in patients with co-morbid personality disorder. PsycINFO, Cochrane library trials, Medline and Embase databases were searched for studies involving randomized, controlled, experimental, parallel-arm comparisons, examining any well-defined, psychotherapeutic intervention for adults, in an outpatient setting, with a clearly defined diagnosis of depression and/or anxiety, and co-morbid personality disorder. A total of 1662 papers were identified. Fifteen met criteria for inclusion and were reviewed. There was weak evidence to support the use of cognitive behavioural therapy as a psychological treatment for depression in patients with co-morbid personality disorder. However, the literature is characterized by considerable methodological heterogeneity, and further research is needed before there is sufficient evidence to indicate which psychological treatment would be most effective in treating anxiety and/or depression in this patient group. Copyright © 2017 John Wiley & Sons, Ltd.

A pragmatic randomized controlled trial to evaluate the effectiveness of a facilitated exercise intervention as a treatment for postnatal depression: the PAM-PeRS trial

BACKGROUND

Postnatal depression affects about 10-15% of women in the year after giving birth. Many women and healthcare professionals would like an effective and accessible non-pharmacological treatment for postnatal depression.

METHOD

Women who fulfilled the International Classification of Diseases (ICD)-10 criteria for major depression in the first 6 months postnatally were randomized to receive usual care plus a facilitated exercise intervention or usual care only. The intervention involved two face-to-face consultations and two telephone support calls with a physical activity facilitator over 6 months to support participants to engage in regular exercise. The primary outcome was symptoms of depression using the Edinburgh Postnatal Depression Scale (EPDS) at 6 months post-randomization. Secondary outcomes included EPDS score as a binary variable (recovered and improved) at 6 and 12 months post-randomization.

RESULTS

A total of 146 women were potentially eligible and 94 were randomized. Of these, 34% reported thoughts of self-harming at baseline. After adjusting for baseline EPDS, analyses revealed a -2.04 mean difference in EPDS score, favouring the exercise group [95% confidence interval (CI) -4.11 to 0.03, p = 0.05]. When also adjusting for pre-specified demographic variables the effect was larger and statistically significant (mean difference = -2.26, 95% CI -4.36 to -0.16, p = 0.03). Based on EPDS score a larger proportion of the intervention group was recovered (46.5% v. 23.8%, p = 0.03) compared with usual care at 6 months follow-up.

CONCLUSIONS

This trial shows that an exercise intervention that involved encouragement to exercise and to seek out social support to exercise may be an effective treatment for women with postnatal depression, including those with thoughts of self-harming.

Hard and soft selection on phenology through seasonal shifts in the general and social environments: A study on plant emergence time

The timing of transition out of one life-history phase determines where in the seasonal succession of environments the next phase is spent. Shifts in the general environment (e.g., seasonal climate) affect the expected fitness for particular transition dates. Variation in transition date also leads to temporal variation in the social environment. For instance, early transition may confer a competitive advantage over later individuals. If so, the social environment will impose frequency- and density-dependent selection components. In effect, the general environment imposes hard selection, whereas the social environment imposes soft selection on phenology. We examined hard and soft selection on seedling emergence time in an experiment on Brassica rapa. In monoculture (uniform social environment), early emergence results in up to a 1.5-fold increase in seed production. In bicultures (heterogeneous social environment), early-emerging plants capitalized on their head start, suppressing their late neighbors and increasing their fitness advantage to as much as 38-fold, depending on density. We devised a novel adaptation of contextual analysis to partition total selection (i.e., cov(ω, z)) into the hard and soft components. Hard and soft components had similar strengths at low density, whereas soft selection was five times stronger than hard at high density.

Adolescents' views and experiences of treatments for Type 2 diabetes: a qualitative study

AIM

To explore adolescents' views and experiences of different treatments for Type 2 diabetes, in order to improve treatment concordance and consider how the current treatment pathway for adolescent Type 2 diabetes could be improved.

METHODS

In-depth interviews were held with 12 adolescents who had been diagnosed with Type 2 diabetes. Adolescents were sampled from a UK cohort study. Data were analysed thematically.

RESULTS

Interviewees struggled to maintain lifestyle changes. Insulin, metformin and liraglutide were described as effective but, in some cases, as resulting in side effects. Injected treatments were viewed less favourably than oral medications. Weight loss surgery was considered an acceptable treatment for obese adolescents who had tried other treatments for their diabetes. It was apparent that some adolescents had not been surprised by their diagnosis and did not fully appreciate the implications of having diabetes. It was also evident that some individuals had not told peers about their diagnosis due to fearing how they would react. Factors identified as improving treatment concordance included reminders and viewing treatment as effective and easy to take.

CONCLUSIONS

Adolescents want treatments that are effective, discrete, easy to take and do not make them different from their peers. As liraglutide was described as effective, and surgery viewed as acceptable in certain circumstances, greater consideration should be given to their potential role in treating adolescent Type 2 diabetes. Practitioners need to ensure that adolescents appreciate the implications of having diabetes and may want to address adolescents' concerns regarding how others view this condition.

Dairy consumption and insulin sensitivity: a systematic review of short- and long-term intervention studies

AIM

Evidence from epidemiological studies suggests that higher consumption of dairy products may be inversely associated with risk of type 2 diabetes and other components of the metabolic syndrome, although the evidence is mixed. Intervention studies that increase dairy intake often involve lifestyle changes, including weight loss, which alone will improve insulin sensitivity. The aim of this review was to examine weight stable intervention studies that assess the effect of an increased intake of dairy products or dairy derived supplements on glucose metabolism and insulin sensitivity.

DATA SYNTHESIS

An electronic search was conducted using MEDLINE, EMBASE, the Cochrane Database and Web of Science for randomised controlled trials altering only dairy intake in humans with no other lifestyle or dietary change, particularly no weight change, and with measurement of glucose or insulin. Healthy participants and those with features of the metabolic syndrome were included. Chronic whey protein supplementation was also included. Ten studies were included in this systematic review.

CONCLUSIONS

In adults, four of the dairy interventions showed a positive effect on insulin sensitivity as assessed by Homeostasis Model Assessment (HOMA); one was negative and five had no effect. As the number of weight stable intervention studies is very limited and participant numbers small, these findings need to be confirmed by larger trials in order to conclusively determine any relationship between dairy intake and insulin sensitivity.

The effect of developmental vitamin D deficiency in male and female Sprague-Dawley rats on decision-making using a rodent gambling task

Developmental vitamin D (DVD) deficiency is a plausible risk factor for schizophrenia that has been associated with behavioural alterations including disruptions in latent inhibition and response inhibition. The rodent gambling task (rGT) assesses risk-based decision-making, which is a key cognitive deficit observed in schizophrenia patients. The primary aim of this study was to examine risk-based decision-making in DVD-deficient and control rats on the rGT. We also evaluated the performance of female Sprague-Dawley rats on the rGT for the first time. Adult male and female Sprague-Dawley rats from control and vitamin D deficient dams were trained to perform the rGT in standard operant chambers and their performance and choice-preferences were assessed. Female rats were significantly faster to reach rGT training criteria compared with male rats and DVD-deficient rats were faster to reach training criteria than control animals. After reaching stable performance on the rGT DVD-deficient and control rats showed a significant preference for the optimal choice-option in the rGT, but there were no significant effects of sex or diet on these responses. DVD deficiency did not alter the decision-making processes on the rGT because no significant changes in choice-preferences were evident. This is the first study to demonstrate that once established, the performance of females is comparable to male Sprague-Dawley rats on the rGT.

Remission of diabetes in patients with long-standing type 2 diabetes following placement of adjustable gastric band: a retrospective case control study

Rates of remission in obese patients with long-standing type 2 diabetes (>2 years), following an adjustable gastric band are unclear. We conducted a retrospective case-control study of patients (n = 89) matched for age and body mass index with non-surgical controls. Cases had a longer duration of diabetes (99 ± 53 and 80 ± 59 months, p < 0.05) and a lower HbA1c than controls (7.9 ± 1.6 vs. 8.5 ± 1.9%, p < 0.05). At follow-up (median 105 weeks) cases had lost 16.8 ± 13.5 kg and controls 1.7 ± 8.9 kg (p < 0.001) and HbA1c decreased by 0.6-0.8% (p < 0.001 for time) with no difference between cases and controls. Diabetes resolution, defined by HbA1c less than 6.5% and taking no medications, occurred in 14 (16%) cases and 2 controls. This is in contrast to published outcomes of resolution of type 2 diabetes after bariatric surgery. We conclude that there is a clear need for randomized studies of the effect of gastric banding in patients with long-standing type 2 diabetes.

A pragmatic randomised controlled trial to evaluate the cost-effectiveness of a physical activity intervention as a treatment for depression: the treating depression with physical activity (TREAD) trial

OBJECTIVE

The TREAting Depression with physical activity (TREAD) study investigated the cost-effectiveness of a physical activity intervention, in addition to usual general practitioner care, as a treatment for people with depression.

DESIGN

An individually randomised, pragmatic, multicentre randomised controlled trial with follow-up at 4, 8 and 12 months. A subset of participants took part in a qualitative study that investigated the acceptability and perceived benefits of the intervention.

SETTING

General practices in the Bristol and Exeter areas.

PARTICIPANTS

Aged 18-69 years with an International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10) diagnosis of depression and scoring ≥ 14 on the Beck Depression Inventory (BDI). Those who were unable to complete self-administered questionnaires in English, with medical contraindications to physical activity or with psychosis, bipolar disorder or serious drug abuse were excluded.

INTERVENTIONS

We devised an intervention designed to encourage choice and autonomy in the adoption of physical activity. It consisted of up to three face-to-face and ten telephone contacts delivered by a trained physical activity facilitator over an 8-month period.

MAIN OUTCOME MEASURES

The primary outcome was the BDI score measured at 4 months. Secondary outcomes included depressive symptoms over the 12 months and quality of life, antidepressant use and level of physical activity.

RESULTS

The study recruited 361 patients, with 182 randomised to the intervention arm and 179 to the usual care arm; there was 80% retention at the 4-month follow-up. The intervention group had a slightly lower BDI score at 4 months [-0.54, 95% confidence interval (CI) -3.06 to 1.99] but there was no evidence that the intervention improved outcome for depression. Neither was there any evidence to suggest a difference in the prescription of or self-reported use of antidepressants. However, the amount of physical activity undertaken by those who had received the intervention was increased (odds ratio 2.3, 95% CI 1.3 to 3.9) and was sustained beyond the end of the intervention. From a health-care perspective, the intervention group was more costly than the usual care group, with the cost of the intervention £220 per person on average. It is therefore extremely unlikely that the intervention is cost-effective as a treatment for depression using current willingness-to-pay thresholds.

CONCLUSIONS

This physical activity intervention is very unlikely to lead to any clinical benefit in terms of depressive symptoms or to be a cost-effective treatment for depression. Previous research has reported some benefit and there are three possible reasons for this discrepancy: first, even though the intervention increased self-reported physical activity, the increase in activity was not sufficiently large to lead to a measurable influence; second, only more vigorous activity might be of benefit; and third, previous studies had recruited individuals with a pre-existing commitment to physical activity. Future research is needed to identify and explain the mechanisms by which depression might be effectively treated, including, in particular, specific guidance on the optimum type, intensity and duration of physical activity required to produce a therapeutic effect.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN16900744.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 10. See the HTA programme website for further project information.

A pragmatic randomised controlled trial to compare antidepressants with a community-based psychosocial intervention for the treatment of women with postnatal depression: the RESPOND trial

OBJECTIVES

To evaluate clinical effectiveness at 4 weeks of antidepressant therapy for mothers with postnatal depression (PND) compared with general supportive care; to compare outcome at 18 weeks of those randomised to antidepressant therapy with those randomised to listening visits as the first intervention (both groups were to be allowed to receive the alternative intervention after 4 weeks if the woman or her doctor so decided); and to assess acceptability of antidepressants and listening visits to users and health professionals.

DESIGN

A pragmatic two-arm individually randomised controlled trial.

SETTING

Participants were recruited from 77 general practices: 21 in Bristol, 21 in south London and 35 in Manchester.

PARTICIPANTS

A total of 254 women who fulfilled International Classification of Diseases version 10 criteria for major depression in the first 6 postnatal months were recruited and randomised.

INTERVENTIONS

Women were randomised to receive either an antidepressant, usually a selective serotonin reuptake inhibitor prescribed by their general practitioner (GP), or non-directive counselling (listening visits) from a specially trained research health visitor (HV). The trial was designed to compare antidepressants with general supportive care for the first 4 weeks, after which women allocated to listening visits commenced their sessions. It allowed for women to receive the alternative intervention if they had not responded to their allocated intervention or wished to change to, or add in, the alternative intervention at any time after 4 weeks.

MAIN OUTCOME MEASURES

The duration of the trial was 18 weeks. Primary outcome, measured at 4 weeks and 18 weeks post randomisation, was the proportion of women improved on the Edinburgh Postnatal Depression Scale (EPDS), that is scoring < 13. Secondary outcomes were the EPDS measured as a continuous variable at 4 and 18 weeks, and scores on various other questionnaires.

RESULTS

At 4 weeks, women were more than twice as likely to have improved if they had been randomised to antidepressants compared with listening visits, which started after the 4-week follow-up, i.e. after 4 weeks of general supportive care [primary intention-to-treat (ITT), 45% versus 20%; odds ratio (OR) 3.4, 95% confidence interval (CI) 1.8 to 6.5, p < 0.001]. Explanatory analyses emphasised these findings. At 18 weeks, ITT analysis revealed that the proportion of women improving was 11% greater in the antidepressant group, but logistic regression analysis showed no clear benefit for one group over the other [62% versus 51%, OR 1.5 (95% CI 0.8 to 2.6), p = 0.19]. Overall, there was a difference between the groups in favour of the antidepressant group of about 25 percentage points at 4 weeks, which reduced at 18 weeks. No statistical support existed for a benefit of antidepressants at 18 weeks, but 95% CIs could not rule out a clinically important benefit. It was difficult for GPs not to prescribe antidepressants to women randomised to listening visits after the initial 4 weeks, so many women received both interventions in both groups by 18 weeks and consequently power was reduced. Qualitative interviews with women revealed a preference for listening visits but an acceptance that antidepressants might be necessary. They wished to be reassured that their GP and HV were offering continuity of care focusing on their particular set of circumstances. Interviews with GPs and HVs revealed lack of collaboration in managing care for women with PND; neither professional group was willing to assume responsibility.

CONCLUSIONS

At 4 weeks, antidepressants were significantly superior to general supportive care. Trial design meant that by 18 weeks many of the women initially randomised to listening visits were also receiving antidepressants, and more vice versa. The lack of evidence for differences at 18 weeks is likely to reflect a combination of reduced power and the considerable degree of switching across the two interventions. Qualitative study revealed that women found both antidepressants and listening visits effective depending on their circumstances and preferences. The trial indicates that early treatment with antidepressants leads to clinical benefit for women with PND.

A fresh perspective on a rank issue: pupils' accounts of staff enforcement of smoking restrictions

Evidence on the effectiveness of school-based smoking restrictions on reducing pupil smoking rates is mixed. So far, the effect of such policies has only been considered using quantitative methods and 'level of enforcement' has primarily been measured according to data collected from staff. This qualitative study is based on data collected during 25 discussion groups held with 13-year-old pupils concerning whether and how staff in their school addressed pupil smoking. Groups were conducted in two schools. Both served relatively deprived communities but varied in their pupil smoking rates. Pupils made reference to members of the Senior Management Team, teaching and non-teaching staff. They mentioned a range of possible staff reactions and discussed what factors they felt influenced how staff responded. It appeared that a more proactive, firm line was being taken in the 'high' than in the 'low' smoking school.

Butt in, butt out: pupils' views on the extent to which staff could and should enforce smoking restrictions

Schools which enforce a no-smoking policy may experience lower rates of pupil smoking. Little is known, however, about how young people view such restrictions and it has been argued that smoking bans might actually encourage adolescent smoking. This paper presents pupils' views on the extent to which staff could, and should, enforce smoking restrictions. Twenty-five single-sex discussion groups were held with 13-year-old pupils who had been purposively selected from two Scottish secondary schools. Both schools served relatively deprived communities and ostensibly had no-smoking policies, but varied in their pupil smoking rates. The pupils' accounts suggested that staff enforcement could interrupt pupil smoking and discourage smoking on school premises, but did not affect whether or not they actually smoked. Pupils viewed staff efforts as ineffective and felt staff did not always have the authority or status needed to enforce a ban. Differences were found between the schools, but these did not explain the variation in their smoking profiles.

School differences in pupil smoking: a consequence of a trade-off between health and education agendas?

Current policy documents stress that raising standards in education and health are inextricably linked, with schools identified as well placed to advance both agendas. This paper considers these assumptions in the light of data derived from 27 staff interviews conducted in two secondary schools. These schools served relatively disadvantaged communities, but differed in their pupil smoking rates with one school being 'high-smoking', the other 'low-smoking'. It explores whether this difference reflects the differential emphasis placed by each school on education or health. Analysis reveals that the 'low-smoking' school subscribes to holistic values and operates according to a child-centred bottom-up philosophy offering a differentiated programme of pupil support contingent on needs. In contrast, the 'high-smoking' school maintains a narrow focus on educational outcomes, and its high expectations are viewed as running counter to those held by pupils and parents. The contrasting school philosophies bring different unintended consequences. The holistic focus of the low-smoking school is associated with tempered educational expectations, thus conflicting with recommendations in education policies. The singular education focus of the high-smoking school leaves little room for a health agenda, and can overlook and disenfranchise the educationally disinclined. The school systems' impact on pupil engagement may explain their different smoking rates.

Ifs, maybes and butts: factors influencing staff enforcement of pupil smoking restrictions

Levels of pupil smoking are reported to be associated with the extent to which school staff consistently enforce smoking restrictions. Little is known, however, about factors which might motivate or discourage staff from doing so. Following analysis of interviews conducted with 27 members of school personnel purposively selected from two Scottish secondary schools serving relatively deprived communities, this paper identifies various issues that hinder staff intervention when confronted with pupil smoking. Both schools had no-smoking policies. In each, staff assumed or understood that smoking within the buildings was forbidden, yet were unsure about how far the bans extended. While the risk of fire in the school buildings prompted staff to intervene when smoking was witnessed indoors, where this risk was absent, decisions were largely context dependent or motivated by personal and professional values. Concerns about staff-pupil relationships, attention to pupils' wider welfare, lack of authority and staff levels of discomfort were salient issues inhibiting intervention. Implications for smoking policies and their enforcement are discussed. The concept of the Health Promoting School is considered in the light of the findings and inherent tensions highlighted.

Phosphorylation of cysteine string protein by protein kinase A. Implications for the modulation of exocytosis

Cyclic AMP-dependent protein kinase (PKA) enhances regulated exocytosis in neurons and most other secretory cells. To explore the molecular basis of this effect, known exocytotic proteins were screened for PKA substrates. Both cysteine string protein (CSP) and soluble NSF attachment protein-alpha (alpha-SNAP) were phosphorylated by PKA in vitro, but immunoprecipitation of cellular alpha-SNAP failed to detect (32)P incorporation. In contrast, endogenous CSP was phosphorylated in synaptosomes, PC12 cells, and chromaffin cells. In-gel kinase assays confirmed PKA to be a cellular CSP kinase, with phosphorylation occurring on Ser(10). PKA phosphorylation of CSP reduced its binding to syntaxin by 10-fold but had little effect on its interaction with HSC70 or G-protein subunits. Furthermore, an in vivo role for Ser(10) phosphorylation at a late stage of exocytosis is suggested by analysis of chromaffin cells transfected with wild type or non-phosphorylatable mutant CSP. We propose that PKA phosphorylation of CSP could modulate the exocytotic machinery, by selectively altering its availability for protein-protein interactions.

Efficacy of chromocult coliform agar for coliform and Escherichia coil detection in foods

Chromocult coliform agar (CCA) was compared with Petrifilm Escherichia coli count plate (PEC) for identifying coliforms and E. coli in a variety of meat products. Products examined included 45 raw beef samples, 12 sausage emulsion samples, 11 samples of meat-based ready-to-eat appetizers, and 8 pork trimming samples. Coliforms from CCA and PEC were confirmed by gassing in brilliant green lactose broth plus a positive reaction on purple broth agar plus lactose after incubation at 35 degrees C for 48 h. Lauryl sulfate tryptose plus methylumbelliferyl-beta-glucuronide and tryptophan broth were used to confirm E. coli from CCA and PEC with 48-h incubations at 35 and 42.5 degrees C, respectively. API 20E test strips were inoculated for final confirmation. The overall respective confirmation percentages (CFU/g) for the PEC and the CCA methods were 93.1 and 93.7% for coliforms and 99.8 and 98.1% for E. coli, although the CCA method yielded significantly (P < 0.001) higher mean CFU/g values for both coliforms and E. coli. Regression analyses of these data indicated a strong positive linear relationship existed between the two methods over a wide CFU/g range for both coliforms and E. coli. The respective correlation coefficients obtained for coliforms and E. coli of 0.89 and 0.86 indicate that the CCA method provides a reliable optional method for these determinations in meat products.

Protein phosphorylation and the regulation of synaptic membrane traffic

It is well established that protein phosphorylation has an important role in synaptic plasticity. This is achieved, in part, via the presynaptic modulation of neurotransmitter release by protein kinases and protein phosphatases. In recent years, the increase in information available about proteins that are involved in synaptic exocytosis and endocytosis has been exploited in order to study the effects of protein phosphorylation on synaptic-vesicle cycling at the molecular level. The best-characterized protein in this respect is synapsin, whose function in the release of synaptic vesicles from the reserve pool is regulated by phosphorylation. More recently, it has emerged that proteins that function at other stages of the synaptic-vesicle cycle, which include priming of vesicles for docking-fusion and endocytic recycling, are also controlled by phosphorylation. Furthermore, recent work suggests that this regulation of membrane traffic by phosphorylation also occurs postsynaptically, where it contributes to synaptic plasticity.

A chromogenic plating medium for isolating Escherichia coli O157:H7 from beef

There was no significant difference (P > 0.05) in the percentages of Escherichia coli O157:H7 cells recovered on BCM O157:H7 (+) agar (69.7%) and MacConkey sorbitol agar containing 5-bromo-4-chloro-3-indoxyl-beta-D-glucuronic acid (MSA-BCIG) (76.8%) vs Tryptic soy agar. Three E. coli O157:H7 strains (ATCC 35150, 43890 and 43894) were separately inoculated into raw ground beef at low (mean 0.32 cfu g-1) and high (mean 3.12 cfu g-1) levels. Using the United States Department of Agriculture (USDA) m-EC + novobiocin enrichment broth, BCM O157:H7 (+) medium surpassed MSA-BCIG agar with overall percentage sensitivities for BCM O157:H7 (+) of 92.1 and 94.4 compared with 52.6 and 84.7 for MSA-BCIG at low and high levels, respectively. A comparison of BCM O157:H7 (+) and MSA-BCIG agars using naturally contaminated beef samples was made utilizing presumptively positive enrichment broths previously identified by rapid methods. The E. coli O157:H7 cells in these broths were concentrated with Dynabeads anti-E. coli O157 before inoculating the agars. The respective percentage sensitivity and specificity values were 90.0 and 78.5 for BCM O157:H7 (+) and 70.0 and 46.4 for MSA-BCIG. Thus, under identical pre-plating conditions, BCM O157:H7 (+) medium displayed a greater sensitivity than MSA-BCIG for detecting E. coli O157:H7 in artificially inoculated beef, and both greater sensitivity and specificity upon examining naturally contaminated beef samples.

Mealtime behavior and parent-child interaction: a comparison of children with cystic fibrosis, children with feeding problems, and nonclinic controls

Examined the role of family interaction factors in dietary compliance problems reported by parents of children with cystic fibrosis (CF). The family mealtime interactions of children with CF, children with feeding problems and nonclinic controls were observed, and parents monitored children's eating behavior at home. Parents of children with CF reported more concern about feeding problems and recorded more disruptive mealtime behavior than parents of nonclinic children. Observational data showed children with CF to display overall rates of disruptive mealtime behavior not significantly different from either comparison group. Mothers of children with CF were observed to engage in higher rates of aversive interaction with their child than did mothers of nonclinic controls. Fathers of children with CF reported lower marital satisfaction than fathers of controls. Both mothers and fathers of children with CF reported lower parenting self-efficacy than non-CF families. Clinical implications are discussed.

Improving breast screening uptake: persuading initial non-attenders to attend

OBJECTIVES

Firstly, to determine whether the acceptance rate of the second invitation for breast screening (sent to women who have failed to attend after the first invitation) might be increased by an accompanying letter from a general practitioner (GP letter). Secondly, to identify the additional costs of sending such a letter.

METHODS

465 women registered with four practices in a single health centre were recruited into a randomised controlled trial in which the intervention was the inclusion of a standard, photocopied letter signed by the non-attender's doctor with the second invitation to attend for breast screening. The control group received only the standard invitation from the breast screening centre. The costs associated with the intervention were assessed from data supplied by the breast screening centre, supplemented by direct observation of the preparation of second invitations and semistructured interviews with the staff taking part.

RESULTS

The attendance rate of the test group one month after the second invitation for screening was significantly higher than that of the control group (21% v 10%, P < 0.01). The average cost of a GP letter included with the invitation was 1.1 pence and the marginal cost for each extra attender was 9.6 pence. No non-monetary costs were identified.

CONCLUSIONS

The inclusion of a GP letter appeared to be effective and feasible in increasing the attendance rate to the second invitation. This intervention should be tested in other screening groups to confirm the effectiveness of a GP letter and its cost effectiveness.