Visual outcome, ocular findings, and visual quality of life in patients with Fabry disease

BACKGROUND

Fabry disease (FD) is an X-linked lysosomal disease, in which diagnosis is often established several years after onset of symptoms. Ocular manifestations can occur in childhood and be a clue to earlier diagnosis. The aim was to report ocular outcome and visual quality of life (QoL) in patients with FD.

MATERIAL AND METHODS

FD-patients recruited from Karolinska University Hospital underwent ophthalmological examinations including best corrected visual acuity (BCVA), refraction, biomicroscopy, optical coherence tomography, keratometry, review of medical records and QoL Inventories. A total severity score (TSS), as estimated via Fabry Stabilization Index, was calculated.

RESULTS

Twenty-six FD-patients (16 men) mean age 36.4 years (range 5.0-63.5 years) were included. BCVA was median 1.0 (range 0.5-1.6). Conjunctival blood vessel tortuosity occurred in 15/26 patients, chemosis in 2/26 patients, cornea verticillata in 23/26 patients, lens opacities in 19/26 patients, and tortuous or dilated retinal vessels in 20/25 patients. Group-wise comparisons of adult patients showed no differences regarding age, TSS, or ocular parameters. Overall, TSS was correlated to age (r = 0.53, p = 0.02). A linear regression model showed that age and sex explained 38% of the variance in TSS. Keratometry did not reveal corneal ectasia in any of the 12 patients examined. VFQ 25 in 15 patients showed a high median composite score, 93.6 (range: 78.1-100).

CONCLUSIONS

BCVA in FD-patients was good despite corneal and lens pathology. Ocular variables did not show an association with TSS in adult patients. Corneal or lens opacities should also lead to a suspicion of FD in children.

Anophthalmia and microphthalmia in children: associated ocular, somatic and genetic morbidities and quality of life

PURPOSE

To report ocular outcome, somatic co-morbidities, genetics, and quality of life in children born with anophthalmia (A) or microphthalmia (M).

METHODS

Thirty-five children (19 boys) with A/M underwent ophthalmological examinations and a review of medical records. Parents of 12/22 cases completed the Pediatric Quality of Life Inventory (PedsQL).

RESULTS

Age at examination ranged from 7 months to 18 years (median 2.3 years). Ten cases were totally blind or had light perception. Isolated A/M occurred in 16/35 cases, while somatic, psychomotor, neuroradiological and/or genetic pathology occurred in 19/35 cases both in the bilateral (7/9) and in the unilateral group (12/26). Among 26 unilateral cases, 4/16 with one normal eye had associated problems compared to 9/10 if the contralateral eye was pathological (p < .01). There was an increased risk for heart defects in children with psychomotor delay (p = .04). Pathogenic genetic abnormalities were identified in 10/24 cases. Neuroimaging demonstrated pathology in 14/20 cases with corpus callosum dysgenesis (6/20) being the most common. The median total PedsQL score of parent reports for ages 2-12 was 52.4 (range 22.6-100).

CONCLUSIONS

Somatic, psychomotor and/or neuroradiological pathologies were more common in bila-teral than unilateral cases, but the difference was not significant. There was decreased risk in unilateral cases with one normal eye. Genetic defects occurred in both unilateral and bilateral cases. Health-related quality of life was reduced.

Visual and ocular findings in a family with X-linked cone dysfunction and protanopia

Background: Bornholm eye disease (BED) is a rare X-linked cone dysfunction disorder with high myopia, amblyopia, and color vision defects.Materials and methods: Visual and ocular outcomes in a family where two of five siblings had molecularly confirmed BED are reported. Ophthalmological assessments included best-corrected visual acuity (BCVA), color vision test, and optical coherence tomography (OCT). Medical records, electroretinography (ERG), and genetic analyses were re-evaluated.Results: Two male siblings had confirmed BED with myopia and protanopia. The younger brother had high myopia, subnormal BCVA, and ocular fundi that showed tilted discs, crescent shaped peripapillary atrophy, and visible choroidal vessels. OCT confirmed retinal and choroidal atrophy. The older brother was lightly myopic with normal/subnormal BCVA and subtle findings in the fundi. Both brothers had abnormal ERG recordings with a decreased cone response. They also had a structurally intact OPN1LW/OPN1MW gene cluster. The OPN1LW gene was shown to carry a deleterious variant combination in exon 3 known to result in mis-splicing of opsin mRNA and acknowledged as LIAVA amino acid delineation (Leu153-Ile171-Ala174-Val178-Ala180), while the OPN1MW gene exon 3 showed a non-pathogenic variant combination (MVVVA). Another normal-sighted brother carried another wildtype variant combination (LVAIS) in exon 3 of the OPN1LW gene.Conclusions: The two affected brothers demonstrated a large variability in their phenotypes even though the genotypes were identical. They presented a disease-associated haplotype in exon 3 of OPN1LW that has been described as the molecular cause of BED.

Individual telomere dynamics and their links to life history in a viviparous lizard

Emerging patterns suggest telomere dynamics and life history are fundamentally linked in endotherms through life-history traits that mediate the processes underlying telomere attrition. Unlike endotherms, ectotherms maintain the ability to lengthen somatic telomeres throughout life and the link between life-history strategies and ectotherm telomere dynamics is unknown. In a well-characterized model system (Niveoscincus ocellatus), we used long-term longitudinal data to study telomere dynamics across climatically divergent populations. We found longer telomeres in individuals from the cool highlands than those from the warm lowlands at birth and as adults. The key determinant of adult telomere length across populations was telomere length at birth, with population-specific effects of age and growth on adult telomere length. The reproductive effort had no proximate effect on telomere length in either population. Maternal factors influenced telomere length at birth in the warm lowlands but not the cool highlands. Our results demonstrate that life-history traits can have pervasive and context-dependent effects on telomere dynamics in ectotherms both within and between populations. We argue that these telomere dynamics may reflect the populations' different life histories, with the slow-growing cool highland population investing more into telomere lengthening compared to the earlier-maturing warm lowland population.

Transcriptomes from German shepherd dogs reveal differences in immune activity between atopic dermatitis affected and control skin

Canine atopic dermatitis (CAD) is an inflammatory and pruritic allergic skin disease with both genetic and environmental risk factors described. We performed mRNA sequencing of non-lesional axillary skin biopsies from nine German shepherd dogs. Obtained RNA sequences were mapped to the dog genome (CanFam3.1) and a high-quality skin transcriptome was generated with 23,510 expressed gene transcripts. Differentially expressed genes (DEGs) were defined by comparing three controls to five treated CAD cases. Using a leave-one-out analysis, we identified seven DEGs: five known to encode proteins with functions related to an activated immune system (CD209, CLEC4G, LOC102156842 (lipopolysaccharide-binding protein-like), LOC480601 (regakine-1-like), LOC479668 (haptoglobin-like)), one (OBP) encoding an odorant-binding protein potentially connected to rhinitis, and the last (LOC607095) encoding a novel long non-coding RNA. Furthermore, high mRNA expression of inflammatory genes was found in axillary skin from an untreated mild CAD case compared with healthy skin. In conclusion, we define genes with different expression patterns in CAD case skin helping us understand post-treatment atopic skin. Further studies in larger sample sets are warranted to confirm and to transfer these results into clinical practice.

Temperature and telomeres: thermal treatment influences telomere dynamics through a complex interplay of cellular processes in a cold-climate skink

Telomere dynamics vary fundamentally between endothermic populations and species as a result of differences in life history, yet we know little about these patterns in ectotherms. In ectotherms, the relationships between climate, metabolism and life history suggest that telomere attrition should be higher at relatively high environmental temperatures compared to relatively low environmental temperatures, but these effects may vary between populations due to local adaptation. To address this hypothesis, we sampled reactive oxygen species (ROS) and telomere length of lizards from warm lowland and cool highland populations of a climatically widespread lizard species that we exposed to hot or cold basking treatments. The hot treatment increased relative telomere length compared to the cold treatment independent of climatic origin or ROS levels. Lizards from the cool highland region had lower ROS levels than those from the warm lowland region. Within the highland lizards, ROS increased more in the cold basking treatment than the hot basking treatment. These results are in the opposite direction to those predicted, suggesting that the relationships between temperature, metabolism, ROS and telomere dynamics are not straightforward. Future work incorporating detailed understanding of the thermal reaction norms of these and other linked traits is needed to fully understand these processes.

Optic Disc Coloboma in children - prevalence, clinical characteristics and associated morbidity

PURPOSE

The aim of the study was to report prevalence, ocular outcome, neurological characteristics, cognitive and behavioural problems in children with optic disc coloboma (ODC).

METHODS

This was a population-based, cross-sectional study of 31 children between 2 and 18 years of age diagnosed with ODC. The children were part of a larger cohort of 184 children with congenital optic disc malformations. Clinical ophthalmological examinations, neurological assessments, behavioural and developmental screening were performed.

RESULTS

The prevalence of ODC was 8.9/100 000 children. Of the 31 patients, 18 had unilateral ODC (p = 0.21). The best-corrected visual acuity (BCVA) in the ODC eye ranged from blindness to 1.3 (median 0.3). BCVA was 0.82 in eyes with an isolated ODC (range 0.4-1.3) and 0.15 (range 0-0.5) in eyes with concurrent macular involvement (p < 0.0001). Nystagmus was observed more often in patients with bilateral ODC (9/13 versus 3/17, p = 0.004). Two patients had retinal detachment. Behavioural/psychological screening was performed in 21 patients with severe deficits identified in six cases. Intellectual disability was present in seven patients. Neurological dysfunction was diagnosed in 8/22 cases. All of the above children had already systemic diagnoses before the ODC diagnosis was made.

CONCLUSIONS

ODC was the second most common optic disc malformation in this cohort after optic nerve hypoplasia. The children had a wide range of ocular comorbidity. An isolated ODC without macular involvement was not associated with profound vision loss. The ability of screening in the regular child care centres to diagnose extraocular comorbidities was very good and referral to a paediatrician appears redundant in cases of normal development.

Tail loss and telomeres: consequences of large-scale tissue regeneration in a terrestrial ectotherm

Large-scale tissue regeneration has potential consequences for telomere length through increases in cell division and changes in metabolism which increase the potential for oxidative stress damage to telomeres. The effects of regeneration on telomere dynamics have been studied in fish and marine invertebrates, but the literature is scarce for terrestrial species. We experimentally induced tail autotomy in a lizard ( Niveoscincus ocellatus) and assessed relative telomere length (RTL) in blood samples before and after partial tail regeneration while concurrently measuring reactive oxygen species (ROS) levels. The change in ROS levels was a significant explanatory variable for the change in RTL over the 60-day experiment. At the average value of ROS change, the mean RTL increased significantly in the control group (intact tails), but there was no such evidence in the regenerating group. By contrast, ROS levels decreased significantly in the regenerating group, but there was no such evidence in the control group. Combined, these results suggest that tail regeneration following autotomy involves a response to oxidative stress and this potentially comes at a cost to telomere repair. This change in telomere maintenance demonstrates a potential long-term cost of tail regeneration beyond the regrowth of tissue itself.

Children with mucopolysaccharidosis risk progressive visual dysfunction despite haematopoietic stem cell transplants

AIM

This prospective study assessed the long-term ocular and visual outcomes of children with mucopolysaccharidoses type I Hurler syndrome (MPS IH) who were treated with haematopoietic stem cell transplants (HSCT).

METHODS

Clinical ophthalmological assessments were performed on eight patients at the St Erik Eye Hospital, Huddinge, Stockholm, Sweden, from 2001-2018: The median age at diagnosis and HSCT were 12.2 (range 5.0-16.4) and 16.7 (8.0-20.4) months. The last eye examination was at a median of 13.4 (6.3-19.0) years and follow-up lasted a median of 12.0 (5.0-17.4) years.

RESULTS

Poor visual acuity, poor night vision and, or, photophobia were reported by six children. The best corrected visual acuity at the last visit was a median of 0.4 and 0.5 in the right and left eye and had declined significantly in two patients. Corneal opacities had increased despite HSCT in five patients. High hyperopia, at a median of +6 Dioptres, occurred in all patients and stiff corneas in all four patients that were measured. The patients' corrected intraocular pressures were normal. Retinal degeneration was identified in two patients.

CONCLUSION

Despite HSCT, the long-term follow-up of patients with MPS IH showed reduced visual acuity due to corneal opacities or retinal degeneration.

Genome-wide analysis of genetic determinants of circulating factor VII-activating protease (FSAP) activity

Essentials Knowledge of genetic regulators of plasma factor VII activating protease (FSAP) levels is limited. We performed a genome-wide analysis of variants influencing FSAP activity in Scandinavian cohorts. We replicated an association for Marburg-1 and identified an association for a HABP2 stop variant. We identified a novel locus near ADCY2 as a potential additional regulator of FSAP activity.

SUMMARY

Background Factor VII-activating protease (FSAP) has roles in both coagulation and fibrinolysis. Recent data indicate its involvement in several other processes, such as vascular remodeling and inflammation. Plasma FSAP activity is highly variable among healthy individuals and, apart from the low-frequency missense variant Marburg-I (rs7080536) in the FSAP-encoding gene HABP2, determinants of this variation are unclear. Objectives To identify novel genetic variants within and outside of the HABP2 locus that influence circulating FSAP activity. Patients/Methods We performed an exploratory genome-wide association study (GWAS) on plasma FSAP activity amongst 3230 Swedish subjects. Directly genotyped rare variants were also analyzed with gene-based tests. Using GWAS, we confirmed the strong association between the Marburg-I variant and FSAP activity. HABP2 was also significant in the gene-based analysis, and remained significant after exclusion of Marburg-I carriers. This was attributable to a rare HABP2 stop variant (rs41292628). Carriers of this stop variant showed a similar reduction in FSAP activity as Marburg-I carriers, and this finding was replicated. A secondary genome-wide significant locus was identified at a 5p15 locus (rs35510613), and this finding requires future replication. This common variant is located upstream of ADCY2, which encodes a protein catalyzing the formation of cAMP. Results and Conclusions This study verified the Marburg-I variant to be a strong regulator of FSAP activity, and identified an HABP2 stop variant with a similar impact on FSAP activity. A novel locus near ADCY2 was identified as a potential additional regulator of FSAP activity.

High rate of latent tuberculosis treatment completion in immigrants seeking asylum in Sweden

BACKGROUND/AIM

Treatment of latently infected individuals at increased risk of reactivation is a cornerstone in tuberculosis control. Although asylum seekers without residence permit in Sweden are offered screening for both active tuberculosis and latent tuberculosis infection (LTBI), treatment for LTBI is often not initiated due to anticipated low rates of treatment completion. We aimed to compare completion rates for LTBI treatment between asylum seekers and other patients, and between asylum seekers with and without residence permit.

METHODS

Data were collected retrospectively from tuberculosis clinic registers and medical records. For comparison of treatment completion rates, relative risks (RR) and confidence intervals (CI) were calculated. Predictors of completion were assessed by logistic regression multivariate analysis.

RESULTS

Treatment completion was achieved in 506/606 subjects (83%). RR of non-completion for asylum seekers (n = 297) compared to other subjects (n = 309) was 1.13 (95% CI: 0.79-1.61; p = .51), and 0.91 (95% CI: 0.53-1.56; p = .72) for asylum seekers without residence permit (n = 217) compared to asylum seekers with residence permit (n = 80). Completion rates increased from 53% in 2008 to 92% in 2015-2016. The following factors were associated with completion: scheduled interpreter-assisted appointments throughout the course of therapy, shorter treatment duration (6 vs. 9 months), and being treated in connection with immunosuppressive therapy.

CONCLUSION

Treatment completion rates were similar between asylum seekers and other subjects, supporting initiation of latent tuberculosis treatment in immigrants with recent arrival to low-endemic countries.

Visual perceptual skills and visual motor integration in children and adolescents after allogeneic hematopoietic stem cell transplantation

The aim of the study was to study visual acuity, visual perceptual, and VMI skills in patients after HSCT in childhood. Tests of visual perceptual skills, VMI, and visual acuity were performed in 102 children/adolescents (age range 4.3-20.9 years). Mean time from HSCT to testing was 6.0 years (0.9-17.5 years). Visual acuity was median 1.0 decimal (range 0.16-1.6). Visual perceptual skills (memory, form constancy, visual sequential memory) and VMI were low compared to age-equivalent normative data with, respectively, 36%, 45%, 60%, and 46% of all patients performing below the 25 percentile. All patients performed significantly lower than the 50 percentile in the reference material in visual sequential memory, P < .001 (boys P < .001 and girls P < .05). All patients also performed significantly lower than the 50 percentile in VMI (P < .01) (boys P < .05). Pretransplant conditioning regimen did not affect outcome if the results were corrected for age at HSCT. Visual perceptual skill problems and VMI problems frequently occur in patients after HSCT in childhood. Age at HSCT and original diagnosis influence the outcome. Neuropsychological assessment including visual perception is recommended in children after HSCT.

Ocular Motor Function in Children with Spastic Hemiplegia Evaluated by the Ocular Motor Score

PURPOSE

To assess the ocular motor functions in children with spastic hemiplegia by using the Ocular Motor Score (OMS).

MATERIAL

This study included 34 children, median age 11 years. The children were divided into 3 groups according to the underlying brain lesion; group 1 malformations, group 2 white matter damage of immaturity (WMDI), and group 3 cortical/subcortical lesions.

METHODS

The OMS protocol consists of 15 different subtests evaluating ocular motor functions. The OMS is divided into 2 parts, a static and a dynamic. The results from each subtest are scored 0, 0.3, 0.5, or 1, according to the level of disturbance, where 0 corresponds to normal function and 1 represents the maximum disability in the certain subtest. A total OMS (tOMS) between 0 and 15 can be obtained.

RESULTS

The median tOMS in the whole spastic hemiplegia group was 2.5 (range 1.3-5.8). The highest median tOMS 5.2 was seen in group 1, in the children with malformations. Strabismus was found in 45% (15/34) of the children, with an equal percentage in all 3 groups.

CONCLUSIONS

The children with spastic hemiplegia had a median tOMS of 2.7 and the highest median tOMS was seen in children with malformations. The OMS protocol is easy to use clinically and gives a quick overview of the patient´s ocular motor functions.

Caspase-2: an orphan enzyme out of the shadows

Caspase-2 has been embodied as an initiator or executioner protease in diverse apoptotic scenarios. However, accumulating evidence is challenging this view, pertaining to its true role. The enzyme's catalytic activity is currently implicated in various functions required for correct cell proliferation, such as counteracting genomic instability, as well as suppressing tumorigenesis. Here, apart from summarizing the latest observations in caspase-2-related research, we make an attempt to reconcile these findings and discuss their implications for future directions.

Exome array analysis of ischaemic stroke: results from a southern Swedish study

BACKGROUND AND PURPOSE

Genome-wide association (GWA) studies have identified a few risk loci for ischaemic stroke, but these variants explain only a small part of the genetic contribution to the disease. Coding variants associated with amino acid substitutions or premature termination of protein synthesis could have a large effect on disease risk. We performed an exome array analysis for ischaemic stroke.

METHODS

Patients with ischaemic stroke (n = 2385) and control subjects (n = 6077) from three Swedish studies were genotyped with the Illumina HumanOmniExpressExome BeadChip. Single-variant association analysis and gene-based tests were performed of exome variants with minor allele frequency of < 5%. A separate GWA analysis was also performed, based on 700 000 genotyped common markers and subsequent imputation.

RESULTS

No exome variant or gene was significantly associated with all ischaemic stroke after Bonferroni correction (all P > 1.8 × 10^-6 for single-variant and >4.15 × 10^-6 for gene-based analysis). The strongest association in single-variant analysis was found for a missense variant in the DNAH11 gene (rs143362381; P = 5.01 × 10^-6 ). In gene-based tests, the strongest association was for the ZBTB20 gene (P = 7.9 × 10^-5 ). The GWA analysis showed that the sample was homogenous (median genomic inflation factor = 1.006). No genome-wide significant association with overall ischaemic stroke risk was found. However, previously reported associations for the PITX2 and ZFHX3 gene loci with cardioembolic stroke subtype were replicated (P = 7 × 10^-15 and 6 × 10^-3 ).

CONCLUSIONS

This exome array analysis did not identify any single variants or genes reaching the pre-defined significance level for association with ischaemic stroke. Further studies on exome variants should be performed in even larger, well-defined and subtyped samples.

No evidence for genetic linkage between development of multiple sclerosis and components of the IFN system and the JA K-STAT pathway

Multiple sclerosis (MS) is an inflammatory, demyelinating disease of the central nervous system (CNS). Several observations suggest that the interferon system may be of interest in the study of MS development. To investigate whether polymorphism in components of the IFN system and the JA K-STAT pathway influence susceptibility to MS, we performed a linkage analysis between polymorphic loci in or close to the IFN gamma, IFN gamma recepto r, IFN alpha/beta recepto r, JA K 1, STAT 1 and STAT 3 genes in 27 Swedish families with at least two members having MS. Tests for transmission disequilibrium and nonparametric linkage analysis gave negative results. We found no evidence for linkage between MS and any of these loci.

Absolute quantification reveals the stable transmission of a high copy number variant linked to autoinflammatory disease

BACKGROUND

Dissecting the role copy number variants (CNVs) play in disease pathogenesis is directly reliant on accurate methods for quantification. The Shar-Pei dog breed is predisposed to a complex autoinflammatory disease with numerous clinical manifestations. One such sign, recurrent fever, was previously shown to be significantly associated with a novel, but unstable CNV (CNV_16.1). Droplet digital PCR (ddPCR) offers a new mechanism for CNV detection via absolute quantification with the promise of added precision and reliability. The aim of this study was to evaluate ddPCR in relation to quantitative PCR (qPCR) and to assess the suitability of the favoured method as a genetic test for Shar-Pei Autoinflammatory Disease (SPAID).

RESULTS

One hundred and ninety-six individuals were assayed using both PCR methods at two CNV positions (CNV_14.3 and CNV_16.1). The digital method revealed a striking result. The CNVs did not follow a continuum of alleles as previously reported, rather the alleles were stable and pedigree analysis showed they adhered to Mendelian segregation. Subsequent analysis of ddPCR case/control data confirmed that both CNVs remained significantly associated with the subphenotype of fever, but also to the encompassing SPAID complex (p < 0.001). In addition, harbouring CNV_16.1 allele five (CNV_16.1|5) resulted in a four-fold increase in the odds for SPAID (p < 0.001). The inclusion of a genetic marker for CNV_16.1 in a genome-wide association test revealed that this variant explained 9.7 % of genetic variance and 25.8 % of the additive genetic heritability of this autoinflammatory disease.

CONCLUSIONS

This data shows the utility of the ddPCR method to resolve cryptic copy number inheritance patterns and so open avenues of genetic testing. In its current form, the ddPCR test presented here could be used in canine breeding to reduce the number of homozygote CNV_16.1|5 individuals and thereby to reduce the prevalence of disease in this breed.

Selection and constraints on offspring size-number trade-offs in sand lizards (Lacerta agilis)

The trade-off between offspring size and number is a central component of life-history theory, postulating that larger investment into offspring size inevitably decreases offspring number. This trade-off is generally discussed in terms of genetic, physiological or morphological constraints; however, as among-individual differences can mask individual trade-offs, the underlying mechanisms may be difficult to reveal. In this study, we use multivariate analyses to investigate whether there is a trade-off between offspring size and number in a population of sand lizards by separating among- and within-individual patterns using a 15-year data set collected in the wild. We also explore the ecological and evolutionary causes and consequences of this trade-off by investigating how a female's resource (condition)- vs. age-related size (snout-vent length) influences her investment into offspring size vs. number (OSN), whether these traits are heritable and under selection and whether the OSN trade-off has a genetic component. We found a negative correlation between offspring size and number within individual females and physical constraints (size of body cavity) appear to limit the number of eggs that a female can produce. This suggests that the OSN trade-off occurs due to resource constraints as a female continues to grow throughout life and, thus, produces larger clutches. In contrast to the assumptions of classic OSN theory, we did not detect selection on offspring size; however, there was directional selection for larger clutch sizes. The repeatabilities of both offspring size and number were low and we did not detect any additive genetic variance in either trait. This could be due to strong selection (past or current) on these life-history traits, or to insufficient statistical power to detect significant additive genetic effects. Overall, the findings of this study are an important illustration of how analyses of within-individual patterns can reveal trade-offs and their underlying causes, with potential evolutionary and ecological consequences that are otherwise hidden by among-individual variation.

Cataract after allogeneic hematopoietic stem cell transplantation in childhood

AIM

The aim of this study was to study long-term visual outcome and cataract development in children and adolescents after hematopoietic stem cell transplantation (HSCT) in childhood.

METHODS

Best corrected visual acuity (BCVA), refraction and lens status were examined in a prospective study of 139 children and adolescents.

RESULTS

In total, 139 patients (58 female), median age 6.6 years at HSCT (range 0.4-17.5 years), were followed up for a median of 8.0 years (1-19.4 years). Median BCVA in the better eye was 1.0 decimal. Altogether 19 of 131 patients developed cataract requiring surgery, while 46 developed less prominent lens opacities and 66 had clear lenses at time of latest follow-up. Patients conditioned with total body irradiation had a higher risk of developing lens opacities or cataract (p < 0.0001) as did patients with malignant disease, irrespective of irradiation treatment (p < 0.0001). Cumulative analysis showed that 50% of all patients had developed lens opacities/cataract after 10.2 years. Patients who ultimately needed cataract surgery developed cataract earlier than others (p = 0.006).

CONCLUSION

Lens opacities or cataract were more common in children or adolescents with malignant disease and after conditioning with irradiation. Regular ophthalmological follow-up is important after HSCT for early intervention to avoid amblyopia.

Morning glory disc anomaly in childhood - a population-based study

PURPOSE

To report prevalence, ocular characteristics and coexisting neurological, behavioural, somatic and neuroradiological abnormalities in children and adolescents with morning glory disc anomaly (MGDA).

METHODS

In a cross-sectional population-based study, 12 patients with MGDA, aged 2-20 years, were identified. All 12 agreed to ophthalmological assessments including visual functions, refraction, fundus photography, optical coherence tomography (OCT) and ocular motor score (OMS). Neurological examinations and behavioural/developmental screening were carried out. Data from previous or new neuroradiological investigations were collected.

RESULTS

The prevalence of MGDA was 2.6/100 000. MGDA was unilateral in 11/12 patients with a best-corrected visual acuity (BCVA) in the MGDA eye ranging from hand motion to 0.65 (median 0.06). Severe microphthalmus prevented unilaterality to be determined in one adolescent. All patients had a binocular BCVA of ≥0.5. OMS showed abnormalities in pupil response, vestibulo-ocular reflex, stereo visual acuity, strabismus and convergence. OCT revealed peripapillary or macular oedema in 5/8 patients and foveal aplasia in 3/8 patients. Three patients had extensive capillary hemangiomas, of which one had PHACES syndrome and one had additional cerebrovascular anomalies and corpus callosum agenesis. Neuroradiology showed craniovascular anomalies in two patients. Neurology was mostly normal. Behavioural/developmental screening showed attention deficit hyperactivity disorder in one patient.

CONCLUSIONS

The prevalence data, previously not reported, of morning glory disc anomaly was 2.6/100 000. Coexisting retinal peripapillary or macular oedema was common, as were cerebral abnormalities and/or cutaneous vascular malformations. The associated findings may not be discovered through routine ophthalmological examination why OCT and neuroimaging are called for.

Ocular Motor Score (OMS): a clinical tool to evaluating ocular motor functions in children. Intrarater and inter-rater agreement

PURPOSE

Ocular motor score (OMS) is a new clinical test protocol for evaluating ocular motor functions in children and young adults. OMS is a set of 15 important and relevant non-invasive ocular motor function parameters derived from clinical practice. The aim of the study was to evaluate OMS according to intrarater and inter-rater agreement.

METHODS

Forty children aged 4-10 years, 23 girls median age 6.5 (range 4.3-9.3) and 17 boys median age 5.8 (range 4.1-9.8) were included. The ocular motor functions were assessed and scored according to the OMS protocol. The examinations were videotaped. To obtain the intrarater agreement, the first author examined and scored the children twice, first in the clinic and 2 weeks later by watching the videotape. To obtain the inter-rater agreement, three other raters independently scored the ocular motor function of the children by watching the videotapes.

RESULTS

The overall observed intrarater agreement was 88%, and the observed inter-rater agreement between the three raters was 80%. For none of the subtests was there an observed intrarater agreement lower than 65%. Three of the subtests had an observed inter-rater agreement of 65% or below.

CONCLUSION

Overall there was high observed intra- and inter-rater agreement for the OMS test protocol. Subtests such as saccades and smooth pursuit were more difficult for raters to score similarly according the clinical OMS test protocol.

Chorioretinal scars and visual deprivation are common in children with cochlear implants after congenital cytomegalovirus infection

AIM

The aim of this study was to compare visual function and ocular characteristics in children with cochlear implants, due to severe hearing impairment caused by the congenital cytomegalovirus (CMV) infection, with control children fitted with cochlear implants due to connexin 26 mutations (Cx26), a genetic cause of hearing impairment.

METHODS

We carried out ophthalmological assessments, including visual acuity, ocular alignment, Ocular Motor Score, biomicroscopy and fundus photography, on 26 children with congenital CMV (median age 8.3 years, range 1.4-16.7) and 13 Cx26 controls (median age 5.6 years, range 1.7-12.5).

RESULTS

We found unilateral chorioretinal macular scars that reduced best-corrected visual acuity ≤0.3 in five (19%) of the children with congenital CMV, but in none of the children with Cx26 (p = 0.15). Ocular motility problems were more common among children with congenital CMV, but the difference was not significant (p = 0.20). The vestibulo-ocular reflex was more frequently pathological in children with congenital CMV (p = 0.011).

CONCLUSION

Ocular complications with central chorioretinal scars and ocular motility disturbances were common in children treated with cochlear implants due to severe hearing impairment caused by the congenital CMV infection. Ophthalmological assessments are advisable in such children for early identification, intervention and follow-up.

The association between BMI and hospitalization for heart failure in 83,021 persons with Type 2 diabetes: a population-based study from the Swedish National Diabetes Registry

AIM'S

The aim was to To study the relationship between BMI and hospitalization for heart failure in people with Type 2 diabetes.

METHODS

We identified 83 021 individuals with Type 2 diabetes from the Swedish National Diabetes Registry during 1998-2003, who were followed until hospitalization for heart failure, death or end of follow-up on 31 December 2009. Cox regression analyses were performed, adjusting for age, sex, HbA(1c), blood pressure, diabetes duration, smoking, microalbuminuria, cardiac co-morbidities, glucose-lowering and anti-hypertensive medications.

RESULTS

During a median follow-up of 7.2 years, 10 969 patients (13.2%) were hospitalized with heart failure. By categories of BMI, with BMI 20 to < 25 kg/m(2) as the reference, hazard ratios for patients during follow-up were 1.07 (95% CI 0.91-1.26) for a mean BMI of < 20 kg/m(2), 1.04 (95% CI 0.98-1.11) for BMI 25 to < 27.5 kg/m(2), 1.22 (95% CI 1.15-1.30) for BMI 27.5 to < 30 kg/m(2), 1.54 (95% CI 1.45-1.63) for BMI 30 to < 35 kg/m(2), 2.16 (95% CI 2.00-2.33) for BMI 35 to < 40 kg/m(2) and 3.22 (95% CI 2.88-3.60) for BMI 40 kg/m(2) or higher. There was a significant interaction between BMI and sex (P = 0.0006), with numerically higher hazard ratios for hospitalization for heart failure within each BMI category for men than for women.

CONCLUSIONS

Obesity is strongly related to hospitalization for heart failure in people with Type 2 diabetes, and the relationship is somewhat stronger for men than for women. Preventing weight gain and promoting weight loss may be crucial in reducing the incidence of future hospitalizations for heart failure in this population.

Effect of anaerobic digestion at 35, 55 and 60 °C on pharmaceuticals and organic contaminants

The application of treated sewage sludge on farmland is a suggested method for recycling nutrients and reducing demand for commercial fertilizer. However, sludge needs to be safe from possible contaminants which can cause acute and long-term health and environmental problems. Residual pharmaceuticals and organic contaminants are mentioned as emerging threats since wastewater treatment plants are not designed to degrade these substances. The aim of this study was to screen and evaluate the presence, and reduction, of pharmaceuticals and polycyclic aromatic hydrocarbons (PAHs) during anaerobic digestion of mixed primary and waste-activated sludge at 35, 55 and 60 °C and during pasteurization at 70 °C. The study showed the difficulty of analysing pharmaceutical compounds in low concentrations in the sludge matrix. No general reduction of these compounds was seen during treatment, but for individual substances some reduction occurred. The PAHs were generally not reduced during digestion or pasteurization, but for three substances (indeno[1,2,3-cd]pyrene and dibenzo[a,h]anthracene (analysed together) and benzo[g,h,i]perylene) reduction (up to 60%) during digestion was seen. Digestion at 35 and 55 °C resulted in about the same order of reduction of the three individual PAHs, which was higher than for digestion at 60 °C.

Caspase-2 promotes cytoskeleton protein degradation during apoptotic cell death

The caspase family of proteases cleaves large number of proteins resulting in major morphological and biochemical changes during apoptosis. Yet, only a few of these proteins have been reported to selectively cleaved by caspase-2. Numerous observations link caspase-2 to the disruption of the cytoskeleton, although it remains elusive whether any of the cytoskeleton proteins serve as bona fide substrates for caspase-2. Here, we undertook an unbiased proteomic approach to address this question. By differential proteome analysis using two-dimensional gel electrophoresis, we identified four cytoskeleton proteins that were degraded upon treatment with active recombinant caspase-2 in vitro. These proteins were degraded in a caspase-2-dependent manner during apoptosis induced by DNA damage, cytoskeleton disruption or endoplasmic reticulum stress. Hence, degradation of these cytoskeleton proteins was blunted by siRNA targeting of caspase-2 and when caspase-2 activity was pharmacologically inhibited. However, none of these proteins was cleaved directly by caspase-2. Instead, we provide evidence that in cells exposed to apoptotic stimuli, caspase-2 probed these proteins for proteasomal degradation. Taken together, our results depict a new role for caspase-2 in the regulation of the level of cytoskeleton proteins during apoptosis.

Ocular motor score a novel clinical approach to evaluating ocular motor function in children

PURPOSE

Ocular motility disturbances are common in a number of neuropaediatric and neurometabolic disorders. Assessment of ocular motor function can be a source of information for diagnosis and follow-up of these patients.

AIM

To evaluate a new clinical ocular motor function test: ocular motor score (OMS) and provide reference values in children and young adults without known ocular or neurological disorders.

MATERIAL AND METHODS

A total of 233 children and young adults, 103 males and 130 females between the ages of 6 months and 19 years, were assessed according to a specific OMS protocol. They were divided into four different age groups: 0.5-3, 4-6, 7-10 and 11-19 years. The OMS protocol consists of 15 different subtests evaluating ocular motor function, and a total score of minimum 0 up to max 15 can be obtained: the minimum score, 0, is considered normal while 1 represents an abnormal function.

RESULTS

The median OMS in the whole reference group was 0.3 (range 0-4.8). The median OMS in the different age groups, starting with the youngest, was: 0.9 (range 0.3-4.8), 0.3 (range 0-3.4), 0.3 (range 0-2.3) and 0 (range 0-3.5), respectively. The youngest subjects, aged 0.5-3, showed a significantly higher total OMS compared with the other age groups (p < 0.001).

CONCLUSION

This study provides reference values for the OMS test in a population aged 0.5-19 years. The test may be valuable as a screening tool for identification and follow-up of ocular motor dysfunction in children and young adults.

Infliximab as rescue therapy in hospitalised patients with steroid-refractory acute ulcerative colitis: a long-term follow-up of 211 Swedish patients

BACKGROUND

Rescue therapy with infliximab (IFX) has been proven effective in a steroid-refractory attack of ulcerative colitis (UC). The long-term efficacy is not well described.

AIM

To present a retrospective study of IFX as rescue therapy in UC. Primary end points were colectomy-free survival at 3 and 12 months.

METHODS

In this multicentre study, 211 adult patients hospitalised between 1999 and 2010 received IFX 5 mg/kg as rescue therapy due to a steroid-refractory, moderate-to-severe attack of UC. Exclusion criteria were duration of current flare for >12 weeks, corticosteroid treatment for >8 weeks before hospitalisation, previous IFX therapy or Crohn's disease.

RESULTS

Probability of colectomy-free survival at 3 months was 0.71 (95% CI, 0.64-0.77), at 12 months 0.64 (95% CI, 0.57-0.70), at 3 years 0.59 (95% CI, 0.52-0.66) and at 5 years 0.53 (95% CI, 0.44-0.61). Steroid-free, clinical remission was achieved in 105/211 (50%) and 112/209 (54%) patients at 3 and 12 months respectively. Of 75 colectomies during the first year, 48 (64%) were carried out during the first 14 days, 13 (17%) on days 15-90 and 14 (19%) between 3 and 12 months. There were three (1.4%) deaths during the first 3 months.

CONCLUSIONS

Infliximab is an effective rescue treatment, both short- and long-term, in a steroid-refractory attack of UC. Most IFX failures underwent surgery during the first 14 days, which calls for studies on how to optimise induction treatment with IFX. Serious complications, including mortality, were rare.

The relationship between glycaemic control and heart failure in 83,021 patients with type 2 diabetes

AIMS/HYPOTHESIS

The aim of this study was to examine the relationship between glycaemic control and hospitalisation for heart failure in patients with type 2 diabetes.

METHODS

Patients included in the Swedish National Diabetes Register (NDR) during 1998-2003 were followed until hospitalisation for heart failure, death or 31 December 2009. Unadjusted and adjusted incidence rates for heart failure were estimated by Poisson regression and relative risk was estimated by Cox regression.

RESULTS

In 83,021 patients with type 2 diabetes, 10,969 (13.2%) were hospitalised with a primary or secondary diagnosis of heart failure during a mean follow-up of 7.2 years. The incidence increased by male sex (p < 0.001), older age (p < 0.001) and longer diabetes duration (p < 0.001). In Cox regression adjusting for risk factors of heart failure the HR per each percentage unit higher HbA(1c) (10 mmol/mol) for heart-failure hospitalisation was 1.12 (95% CI 1.10, 1.14). By category of HbA(1c) the HR for heart failure hospitalisation was: HbA(1c) 6.0 to <7.0% (42 to <53 mmol/mol), 0.91 (95% CI 0.84, 0.98); HbA(1c) 7.0 to <8.0% (53 to <64 mmol/mol), 0.99 (95% CI 0.91, 1.07); HbA(1c) 8.0 to <9.0% (64 to < 75 mmol/mol), 1.10 (95% CI 1.01, 1.20); HbA(1c) 9.0 to <10.0% (75 to <86 mmol/mol), 1.27 (95% CI 1.15, 1.41); HbA(1c) ≥ 10.0 % (≥ 86 mmol/mol), 1.71 (1.51, 1.93) (reference HbA(1c) <6% [42 mmol/mol]). The HR for patients with HbA(1c) 7.0 to <8.0% (53 to < 64 mmol/mol) compared with patients with HbA(1c) 6.0 to <7.0% (42 to <53 mmol/mol) was 1.09 (95% CI 1.03, 1.14).

CONCLUSIONS/INTERPRETATION

Poor glycaemic control (HbA(1c) >7% [53 mmol/mol]) is associated with an increased risk of hospitalisation for heart failure in patients with type 2 diabetes.

Clinical guidelines for diagnosing and managing ocular manifestations in children with mucopolysaccharidosis

The mucopolysaccharidoses (MPS) are a group of rare lysosomal storage disorders characterized by the accumulation of glycosaminoglycans in several tissues and organs. This accumulation results in an array of clinical manifestations and premature death in severe cases. Ocular problems are very common in children with MPS and may involve the cornea, sclera, trabecular meshwork, retina, optic nerve and also the posterior visual pathways. The aims of this study are to give an overview of ocular problems in MPS and to provide clinical guidelines for paediatric ophthalmologists for early diagnosis and management of ocular manifestations in children with MPS. Diagnostic problems may arise in children with severe corneal clouding, hampering visualization of the fundus. Intraocular pressures may be falsely high, even leading to suspicion and unnecessary pressure-lowering treatment. Simple interventions such as the use of prescription glasses or photochromatic glasses can considerably improve quality of life in children with MPS.

Women's reflections and actions regarding working after breast cancer surgery - a focus group study

BACKGROUND

To better understand processes affecting return to work (RTW) after breast cancer, more knowledge from the perspective of sickness absentees is warranted. Still, research based on women's own reasoning and actions in RTW is very scarce. This study aims to elucidate how women with breast cancer reflect and act on work-related issues.

MATERIAL AND METHODS

Thematic analyses of data from four focus group interviews with 23 women who had had breast cancer surgery in the previous 3-13 months were carried out.

RESULTS

The five following themes of reflections regarding RTW were identified: 'health and functioning', 'self-esteem/integrity', 'value of work', 'relationships at work', and 'social circumstances'. These reflections were associated with the three identified themes of actions taken by the women: 'to work or to be sickness absent', 'to adjust work according to own needs or not', and 'to disclose or to hide one's cancer'. There was a distinct difference between women who experienced work as a source of well-being and those who needed a respite from work.

CONCLUSION

This study adds knowledge to the process of RTW after breast cancer and focuses on factors that lead the women to an active role in this process. We point to the interplay between women's own preferences, perceived competence, outer opportunities, and the actions each woman take with regard to RTW, which need to be recognized by all stakeholders involved. Furthermore, it continues to be essential to address the specific issue of disclosure in the workplace because this may be distressing for women.

OS089. Elevated levels of the heme scavenger alpha-1-microglobulin in maternal plasma at the end of first trimester in patients who subsequently develop preeclampsia

INTRODUCTION

Resent research has revealed an increased concentration of free fetal hemoglobin (HbF) in maternal serum from patients who subsequently develops preeclampsia (PE). In a previous study of 96 patients we have shown that HbF in combination with the heme-scavenger alpha-1-microglobulin (A1M) are potential predictive biomarkers of PE.

OBJECTIVES

In this validating case-control study we aimed to confirm the previous findings, that A1M is elevated in the maternal circulation at the end of first trimester in patients who subsequently develops PE. In this study A1M was measured in plasma instead of serum.

METHODS

Patients were recruited from an ongoing prospective study of new biomarkers to predict and diagnose PE. In total we included 84 patients. 8 patients subsequently developed PE, 4 developed pregnancy induced hypertension (PIH) and 72 were controls with uncomplicated pregnancies. The plasma samples were all taken at 7+0-18+0 weeks of gestation (mean 12+1) and analyzed for concentrations of A1M with Radioimmuno Assay (RIA). This method has been previously described in details. Statistics was performed using one-way ANOVA.

RESULTS

The mean plasma concentration of A1M in the PE group was 8.6mg/ml, 6.0 in the PIH group and 7.1mg/ml in the controls group. The PE group differed significantly from the controls group (p=0.004), whereas the PIH group did not differ significantly from the controls.

CONCLUSION

Our findings in plasma confirm previous findings described for serum, i.e. A1M is significantly increased in in first trimester maternal plasma in patients who subsequently develops PE. Since A1M is the most efficient heme scavenger we suggest that A1M may be a physiological defense mechanism against the elevated levels of free HbF found in patients who subsequently develops PE or in patients with manifest PE. Furthermore, A1M did not increase in patients who develops PIH later in their pregnancies indicating its specificity for PE.

The origin of Indonesian cattle and conservation genetics of the Bali cattle breed

Both Bos indicus (zebu) and Bos javanicus (banteng) contribute to the Indonesian indigenous livestock, which is supposedly of a mixed species origin, not by direct breeding but by secondary cross-breeding. Here, the analysis of mitochondrial, Y-chromosomal and microsatellite DNA showed banteng introgression of 10-16% in Indonesian zebu breeds with East-Javanese Madura and Galekan cattle having higher levels of autosomal banteng introgression (20-30%) and combine a zebu paternal lineage with a predominant (Madura) or even complete (Galekan) maternal banteng origin. Two Madura bulls carried taurine Y-chromosomal haplotypes, presumably of French Limousin origin. There was no evidence for zebu introgression in five populations of the Bali cattle, a domestic form of the banteng.

Visual function, ocular motility and ocular characteristics in patients with mitochondrial complex I deficiency

PURPOSE

The aims of the present study were to investigate visual function, ocular motility and ocular characteristics in children and young adults with complex I deficiency.

MATERIAL AND METHODS

In a prospective study with longitudinal follow-up, the visual and ocular outcome in 13 patients with deficiency in complex I [nicotine-amide adenine dinucleotide (NADH) dehydrogenase] in the mitochondrial respiratory chain is presented. The patients were diagnosed during 1995-2007 and assessed during 1997-2009 at a median age of 12.8 years (range 3.1-23.4).

RESULTS

Twelve of 13 patients had visual impairment and/or ocular pathology. Four of 10 patients who co-operated in visual assessment had a best corrected decimal visual acuity of ≤ 0.5 in one or both eyes. Cataract surgery was performed in one patient and another patient showed retinal pigmentations and ptosis. Eleven patients demonstrated ocular motility problems, mainly saccade deficiencies. Five patients had optic atrophy (OA), which was bilateral in four patients. In four siblings, the OA showed a similarity to Leber's Hereditary Optic Neuropathy. These patients also had the 11778 G → A mutation in mitochondrial DNA. Only one patient had normal visual acuity and ocular outcome including refraction and visual fields. Follow-up time was median 3.0 years (range 0-11).

CONCLUSION

Visual impairment, ocular motility problems and OA are common in children and young adults with complex I deficiency and should prompt the paediatric ophthalmologist to consider mitochondrial disorders.

Caspases and cancer

Evasion of apoptosis is considered to be one of the hallmarks of human cancers. This cell death modality is executed by caspases and several upstream regulatory factors, which direct their proteolytic activity, have been defined as either tumor suppressors or oncogenes. Often these regulatory factors, in addition to being potent apoptosis inducers, function in cell survival or repair signaling pathways in response to cellular stress. Thus, loss of function in a distinct regulatory mechanism does not necessarily mean that tumor formation is due to apoptosis malfunction resulting from insufficient caspase activation. Although each caspase has been assigned a distinct role in apoptosis, some redundancy with respect to their regulatory functions and substrate recognition is evident. Jointly, these proteases could be considered to possess solid tumor suppressor function, but what is the evidence that deregulation of specific caspases per se induces inappropriate cell survival, leading to enhanced tumorigenic potential? This question will be addressed in this review, which covers basic molecular mechanisms derived from in vitro analyses and emphasizes new insights that have emerged from in vivo and clinical studies.

Complex selection associated with Hox genes in a natural population of lizards

Hox genes are recognized for their explanatory power of bilateral development. However, relatively little is known about natural variation in, and the evolutionary dynamics of, Hox genes within wild populations. Utilizing a natural population of sand lizards (Lacerta agilis), we screened HoxA13 for genetic variation and an association with incidence of offspring malformations. We found significant effects of parental genetic similarity and offspring sex, and their interaction, on risk of hatching malformed as an offspring. We also found within population genetic variation in HoxA13, and identified a significant effect of a three-way interaction among Hox genotype, parental genetic similarity, and offspring sex on the risk of hatching malformation. Since malformed offspring in this population do not survive to maturity, this study reveals complex and ongoing selection associated with Hox genes in a wild reptile population. Importantly, this demonstrates the utility of natural populations in unveiling microevolutionary processes shaping variation in highly conserved genes.

Pet shop workers: exposure, sensitization, and work-related symptoms

BACKGROUND

Allergy to laboratory animals is a well-known occupational hazard. The aim was to investigate the frequency of allergic sensitization and respiratory symptoms among pet shop staff and to document their work environment.

METHODS

Subjects (n = 59) from 24 pet shops were investigated with a questionnaire and lung function tests and skin prick tests against a panel of common inhalant and pet shop allergens. Blood samples were taken for immunoglobulin E (IgE) and IgE antibodies against Phadiatop and specific pet shop allergens. Personal airborne rodent allergen (n = 40) and endotoxin exposure (n = 40) was measured during work. Airborne rodent allergens were also collected using petri dishes at work (n = 40) and at home (n = 45).

RESULTS

Fifty-three percent reported nasal symptoms, 34% eye symptoms, and 22% had experienced symptoms indicating asthma. However, only four workers (7%) were previously diagnosed with asthma. One-third reported respiratory symptoms at work, mostly against rodents, birds, insects, and hay, and 29% were sensitized to work-related allergens, mainly rodents and fodder insects, e.g., Zophobas. Atopy and total IgE > 100 kU/l increased prevalence of pet shop sensitization [prevalence ratio (PR) 17 and 5.5, respectively], and atopy increased work-related symptoms (PR 3.2). Endotoxin levels were similar between shops with and without rodents. Exposure to animals outside of work was extensive.

CONCLUSIONS

A third of the pet shop workers reported airway symptoms at work or were sensitized, sometimes to unusual pet shop allergens, especially among atopics. The findings stress the importance of improving the knowledge of health risks and allergen avoidance measures among pet shop staff.

What is a 'secure base' when death is approaching? A study applying attachment theory to adult patients' and family members' experiences of palliative home care

OBJECTIVE

Attachment theory has received much interest lately in relation to how adults cope with stress and severe illness. The aim of this study was using the experiences of patients and family members to explore palliative home care as a 'secure base' (a central concept within the theory).

METHODS

Twelve patients and 14 family members were interviewed during ongoing palliative home care. The interviews were analysed with deductive qualitative content analysis.

RESULTS

Informants expressed the relevance of sensing security during palliative home care because death and dying were threats that contributed to vulnerability. Palliative home care could foster a feeling of security and provide a secure base. This was facilitated when informants had trust in staff (e.g. due to availability and competence in providing symptom relief), felt recognised as individuals and welcomed to contact the team in times of needs. Being comfortable, informed and having an everyday life also contributed to a perception of palliative home care as a secure base. Family members stressed the importance of being relieved from responsibilities that were too heavy. The underlying meanings of experiencing palliative home care as a secure base involved gaining a sense of control and of inner peace, perceiving that despite a demanding and changed life situation, one could continue partially being oneself and having something to hope for, even if this no longer concerned cure for the ill person.

CONCLUSIONS

Important aspects of palliative home care as providing a secure base were identified and these have implications for clinical practice.