A low-burden, self-weighing intervention to prevent weight gain in adults with obesity who do not enroll in comprehensive treatment

Background

For individuals who are eligible but unlikely to join comprehensive weight loss programs, a low burden self-weighing intervention may be a more acceptable approach to weight management.

Methods

This was a single-arm feasibility trial of a 12-month self-weighing intervention. Participants were healthcare patients with a BMI ≥25 kg/m2 with a weight-related comorbidity or a BMI >30 kg/m2 who reported lack of interest in joining a comprehensive weight loss program, or did not enroll in a comprehensive program after being provided program information. In the self-weighing intervention, participants were asked to weigh themselves daily on a cellular connected scale and were sent text messages every other week with tailored weight change feedback, including messages encouraging use of comprehensive programs if weight gain occurred.

Results

Of 86 eligible patients, 39 enrolled (45.3%) in the self-weighing intervention. Self-weighing occurred on average 4.6 days/week (SD = 1.4). At 12 months, 12 participants (30.8%) lost ≥3% baseline weight, 11 (28.2%) experienced weight stability (±3% baseline), 6 (15.4%) gained ≥3% of baseline weight, and 10 (25.6%) did not have available weight data to evaluate. Three participants reported joining a weight loss program during the intervention (7.7%). Participants reported high intervention satisfaction in quantitative ratings (4.1 of 5), and qualitative interviews identified areas of satisfaction (e.g., timing and content of text messages) and areas for improvement (e.g., increasing personalization of text messages).

Conclusion

A low-burden self-weighing intervention can reach adults with overweight/obesity who would be unlikely to engage in comprehensive weight loss programs; the efficacy of this intervention for preventing weight gain should be further evaluated in a randomized trial.

QOL-17. UNDERSTANDING MULTIDISCIPLINARY PROVIDER PERSPECTIVES AND PREFERENCES FOR INCORPORATING EXERCISE INTO PRIMARY BRAIN TUMOR MANAGEMENT

BACKGROUND

Exercise has proven benefit in patients with cancer with most studies focused on patients with high functional and neurocognitive status. Patients with brain tumors, however, frequently have deficits in cognition, motor, balance, or other symptoms that are further exacerbated by surgery and adjuvant treatment. We sought to determine providers’ knowledge, attitudes, motivating factors and preferences for integrating exercise into the treatment of patients with brain tumors.

METHODS

We surveyed multidisciplinary providers in Neurosurgery, Radiation Oncology and Neuro-Oncology from a single, quaternary medical center. Questions assessed demographics, current practices, attitudes, knowledge, motivating factors and barriers for integrating exercise into treatment. Questions were extrapolated from existing published questionnaires and sent electronically.

RESULTS

Most providers (92%) reported that exercise was important for patients' lifestyle and 80% felt it should be integrated into the treatment of patients with primary brain tumors. Nighty-six percent felt that exercise improved quality of life, decreased fatigue (100%) and reduced treatment related side effects (92%) yet only 57% of providers initiated a conversation about exercise with patients. Top motivating factors for promoting exercise were perceived benefit to patients’ quality of life and disease outcomes. Barriers to provider/patient discussions about exercise included, lack of time or appropriate expertise to discuss exercise with patients, and concern that patients have competing priorities. Some providers (23%) were concerned about potential limitations/complications with patients exercising including inability to participate from side effects of treatment (38%), physical deficits (61%) and fatigue (42%).

CONCLUSION

Understanding barriers for providers to incorporate exercise into their patients’ treatment regimens is critical to strategizing best practices. Findings from this study help to expand our understanding of barriers and facilitators to incorporating exercise interventions into brain cancer treatment and will assist with the implementation of a structured exercise program to enhance physical health for our patients.

Parental Knowledge on Prevention of SUID

Background

According to the 2018 America’s Health Ranking Annual Report, the U.S. infant mortality rate (IMR) was 5.9 deaths per 1,000 live infant births, which placed the U.S. at No. 33 out of 36 countries with the world’s largest economies in 2018. The IMR in Georgia has been on the rise since 2014. Even though there was a sharp decline in sudden unexpected/unexplained causes of death (SUID) beginning in 1990, the decrease has considerably slowed down since 1999. In 2017, the top ten leading causes of infant death were responsible for 67.8% of all infant deaths in the United States. Sudden Infant Death Syndrome (SIDS) and death from unintentional injuries were in third and fourth place. Therefore, the purpose of this research is to utilize qualitative research guided by the Socio-Ecological model to understand better how prepared first-time mothers are to take care of their infant upon hospital release.

Methods

An intensity sampling was utilized to recruit participants. The inclusion criteria for the participants included first-time mothers with children under one year of age, women, Georgia residents over 18 years of age, and English speaking. A semi-structured guide was based on research queries and the ideological concepts of the Socio-Ecological Model. For the qualitative data examination, the thematic analysis was performed. All the interviews were transcribed verbatim and coded by using the program NVivo 11.

Results

A total of 25 women participated in the study. We will finish the data analysis by the end of May, 2022. The results of this qualitative study will help to fully understand the knowledge, perceptions, skills, and confidence of mothers about infant care.

Conclusions

The study’s results will help develop an information guide on primary infant care. Besides, health professionals and community organizations can utilize the study results to determine the information and support needed for new mothers.

Key messages

• The results of this qualitative study will help to fully understand the knowledge, perceptions, skills, and confidence of mothers about infant care.

• This study’s results will help develop an information guide (electronic or/and printed) on primary infant care based on first-time mothers’ needs.

Sleep-disordered breathing in severe mental illness: clinical evaluation of oximetry diagnosis and management limitations

BACKGROUND

To describe the diagnosis and management pathway of sleep-disordered breathing (SDB) in a sample of patients with severe mental illness (SMI), and to assess the feasibility and patient acceptability of overnight oximetry as a first-step screening method for detecting severe SDB in this population.

METHODS

The study was a retrospective audit of patients with SMI seen at a Collaborative Centre for Cardiometabolic Health in Psychosis service who were invited for overnight oximetry between November 2015 and May 2018. The adjusted oxygen desaturation index (ODI) was calculated using 4% desaturation criteria. Results were discussed with a sleep specialist and categorized into a 4-level risk probability tool for SDB.

RESULTS

Of 91 adults consenting for overnight oximetry, 90 collected some oximetry data, though 11 of these 90 patients collected technically unsatisfactory oximetry. Thus 79/90 patients (88%) collected adequate oximetry data for at least one night. The oximetry traces suggested likely minimal obstructive sleep apnea (OSA) in 41 cases, moderate to severe OSA in 25 patients, severe OSA in 9 patients and possible obesity hypoventilation syndrome (OHS) in 4 cases. Full polysomnography was recommended for 39 patients but only one-third underwent testing. Nineteen patients were reviewed by a sleep specialist. Of the 10 patients who initiated CPAP, four were considered adherent to treatment.

CONCLUSION

Home oximetry may be a pragmatic option for SDB screening in patients with SMI but reliable full diagnostic and management pathways need to be developed.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Abstract P2-06-02: BIN3 is an 8p21 tumor suppressor regulating the epithelial attachment checkpoint

An important characteristic of multicellular organisms is the control that tissue architecture exerts on the growth and differentiation of individual cells. Epithelial cells sense their location through interactions with the extracellular matrix (ECM) as well as neighboring cells. These interactions generate input signals, including survival, that are critical to maintain tissue and cellular homeostasis. When attachment is compromised, epithelial cells undergo an intrinsically programmed cell death (apoptosis) that is termed anoikis (from the Greek "loss of home"). Importantly, failure to execute the anoikis program could result in adherent epithelial cells surviving in suspension or being able to proliiferate at sites different from their original environment. Thus, anoikis is a line of defense that must be circumvented by cancerous epithelial cells for them to leave their home niche, thrive in inappropriate ECM environments, and establish long distance metastases. Thus, elucidating how epithelial cancer cells escape anoikis is critical to understanding cancer progression.

In order to uncover genes that modulate the anoikis response and are altered in human cancers, we performed a functional genomics study. We couple genome wide RNAi to identify gene functions that, when silenced, induce resistance to anoikis with a novel computational method, ISAR-DEL, specifically aimed at pinpointing candidate tumor suppressor genes based on recurrent loss of copy number. Our studies identified Bridging Integrator 3 (BIN3) as a novel tumor suppressor located on the chromosomal region 8p21.3, one of the most frequently lost regions in epithelial cancers.

Mechanistically, we link BIN3 tumor suppression function to its ability to sense changes in the curvature of the cell membrane and relocate to the cell membrane after cell detachment to induce a proapoptotic cascade. Once BIN3 has translocated to the cell membrane it modulates the relocation and function of CDC42. In these conditions, CDC42 transmits the signal that leads to the activation of the stress protein P38-α and programmed cell death mediated by accumulation of the apoptotic facilitator BimEL. Overall, our results explain how changes in cell geometry are integrated in the cellular signaling network and present, for the first time, BIN3 as a novel breast cancer tumors suppressor.

Citation Format: Silva J, Marshall N, Sanchez-Garcia F, Parsons R, Pe'er D. BIN3 is an 8p21 tumor suppressor regulating the epithelial attachment checkpoint. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-06-02.

Does gender or mode of HIV acquisition affect virological response to modern antiretroviral therapy (ART)?

OBJECTIVES

Previous UK studies have reported disparities in HIV treatment outcomes for women. We investigated whether these differences persist in the modern antiretroviral treatment (ART) era.

METHODS

A single-centre cohort analysis was carried out. We included in the study all previously ART-naïve individuals at our clinic starting triple ART from 1 January 2006 onwards with at least one follow-up viral load (VL). Time to viral suppression (VS; first viral load < 50 HIV-1 RNA copies/mL), virological failure (VF; first of two consecutive VLs > 200 copies/mL more than 6 months post-ART) and treatment modification were estimated using standard survival methods.

RESULTS

Of 1086 individuals, 563 (52%) were men whose risk for HIV acquisition was sex with other men (MSM), 207 (19%) were men whose risk for HIV acquisition was sex with women (MSW) and 316 (29%) were women. Median pre-ART CD4 count and time since HIV diagnosis in these groups were 298, 215 and 219 cells/μL, and 2.3, 0.3 and 0.3 years, respectively. Time to VS was comparable between groups, but women [adjusted hazard ratio (aHR) 2.32; 95% confidence interval (CI) 1.28-4.22] and MSW (aHR 3.28; 95% CI 1.91-5.64) were at considerably higher risk of VF than MSM. Treatment switches and complete discontinuation were also more common among MSW [aHR 1.38 (95% CI 1.04-1.81) and aHR 1.73 (95% CI 0.97-3.16), respectively] and women [aHR 1.87 (95% CI 1.43-2.46) and aHR 3.20 (95% CI 2.03-5.03), respectively] than MSM.

CONCLUSIONS

Although response rates were good in all groups, poorer virological outcomes for women and MSW have persisted into the modern ART era. Factors that might influence the differences include socioeconomic status and mental health disorders. Further interventions to ensure excellent response rates in women and MSW are required.

Evaluation of automated CDMAM readings for non-standard CDMAM imaging conditions: grid-less acquisitions and scatter correction

Recently, Siemens introduced a software-based scatter correction in combination with grid-less digital mammography for dose-reduced breast imaging. In this study, the potential dose reduction when compared with using a grid was calculated. Image quality was evaluated using the CDMAM phantom. Nine hundred and sixty CDMAM measurements were performed with and without grid. The images were analysed with the CDCOM software. The correlation of CDCOM readings of gold thickness thresholds with human readings for grid-less imaging was found to be linear, with slope 2.157 and off-set 0.024 (R(2) = 1), validating the further use of CDCOM. Dose reduction for 21, 32, 45, 60, 75 and 90 mm equivalent breast thickness was found to be 28, 17, 21, 18, 8 and 3 %. Scatter correction did not influence CDCOM readings, but image homogeneity was improved. Grid-less acquisitions, with or without scatter correction, can be used for reducing the dose while maintaining image quality as evaluated from the CDMAM phantom.

Monte Carlo modeling for dose assessment in cone beam CT for oral and maxillofacial applications

PURPOSE

To adjust Monte Carlo modeling for dose assessment in dedicated cone beam computed tomography (CBCT) of the oral and maxillofacial region.

METHODS

Two different CBCT systems with different fields of view (FOVs), beam qualities, and scan geometries were modeled using Monte Carlo simulation. Dose calculations for typical CBCT examinations were performed with the head and neck part of four computational anatomical phantoms.

RESULTS

Simulation results compared favorably to values acquired experimentally using physical phantoms (in the literature). For a given phantom scanned with 90 kV and 60 × 60 mm FOV, effective dose per mAs was on average the same for the two different systems. Exposing the four phantoms under identical settings for the same CBCT system resulted in variations in organ doses of greater than 100%, leading to differences in effective dose of 30%. For one system, the dose dependence on the operating tube potential can be described with a quadratic polynomial function. Dose distributions over the axial plane were presented as contour plots.

CONCLUSIONS

Monte Carlo modeling is an efficient and accurate means of evaluating dose distributions for dedicated cone beam oral and maxillofacial CT. Results suggest large dose differences among patients undergoing the same examination on a given system, supporting approaches toward patient specific dosimetry. A dedicated and standardized computational phantom for head and neck dosimetry should be established.

Bowtie filtration for dedicated cone beam CT of the head and neck: a simulation study

OBJECTIVE

To investigate the influence of bowtie filtration on dedicated cone beam CT (CBCT) of the head and neck.

METHODS

A validated hybrid simulation technique was used to model a commercial CBCT system with offset scanning geometry, 90 kV tube potential and 145×75 mm imaging field of view. Three bowtie filters were formulated to produce uniform flux intensity in the projection image of cylindrical objects of diameter 14, 16 and 18 cm. The influence of these simulated filters was compared with the original flat filtration in terms of the output radiation field, the dose delivered to the object, the scatter distribution in projections and the quality of the reconstructed image.

RESULTS

Compared against flat filtration, dose reduction for the bowtie case, examined as a function of radial distance within a 16-cm-diameter water cylinder, varied from 8.7% at the centre to 53.8% at the periphery. Scatter reduction, quantified using scatter-to-primary ratio in projection images, was up to 37.6% for a 14-cm-diameter cylindrical contrast phantom. Using the supplied routine image reconstruction, bowtie filtration resulted in comparable noise appearance, contrast resolution and artefact pattern for computational anatomical phantoms, with <5% difference in contrast-to-noise ratio.

CONCLUSION

Bowtie filtration can effectively reduce the dose and scatter in CBCT of the head and neck. For better image quality, corresponding modification to the image pre-processing and reconstruction is needed.

ADVANCES IN KNOWLEDGE

The hybrid simulation approach can usefully explore the impact of proposed system component and design changes.

Development and validation of a hybrid simulation technique for cone beam CT: application to an oral imaging system

This paper proposes a hybrid technique to simulate the complete chain of an oral cone beam computed tomography (CBCT) system for the study of both radiation dose and image quality. The model was developed around a 3D Accuitomo 170 unit (J Morita, Japan) with a tube potential range of 60-90 kV. The Monte Carlo technique was adopted to simulate the x-ray generation, filtration and collimation. Exact dimensions of the bow-tie filter were estimated iteratively using experimentally acquired flood images. Non-flat radiation fields for different exposure settings were mediated via 'phase spaces'. Primary projection images were obtained by ray tracing at discrete energies and were fused according to the two-dimensional energy modulation templates derived from the phase space. Coarse Monte Carlo simulations were performed for scatter projections and the resulting noisy images were smoothed by Richardson-Lucy fitting. Resolution and noise characteristics of the flat panel detector were included using the measured modulation transfer function (MTF) and the noise power spectrum (NPS), respectively. The Monte Carlo dose calculation was calibrated in terms of kerma free-in-air about the isocenter, using an ionization chamber, and was subsequently validated by comparison against the measured air kerma in water at various positions of a cylindrical water phantom. The resulting dose discrepancies were found <10% for most cases. Intensity profiles of the experimentally acquired and simulated projection images of the water phantom showed comparable fractional increase over the common area as changing from a small to a large field of view, suggesting that the scatter was accurately accounted. Image validation was conducted using two small phantoms and the built-in quality assurance protocol of the system. The reconstructed simulated images showed high resemblance on contrast resolution, noise appearance and artifact pattern in comparison to experimentally acquired images, with <5% difference for voxel values of the aluminum and air insert regions and <3% difference for voxel uniformity across the homogeneous PMMA region. The detector simulation by use of the MTF and NPS data exhibited a big influence on noise and the sharpness of the resulting images. The hybrid simulation technique is flexible and has wide applicability to CBCT systems.

Necrotising fasciitis associated withEscherichia coliin a dog

CASE HISTORY

Lameness and limb pain associated with a laceration in the inner thigh of a Border Collie dog progressed over 4 days to extensive necrosis of the full-thickness of skin and subcutaneous (S/C) tissue. A successful outcome was achieved using surgical debridement and intensive supportive care, followed by limited local closure, axial pattern flap development, and free skin grafting.

CLINICAL FINDINGS

Clinical findings included severe pain, depression, pyrexia and hypoalbuminaemia, and full-thickness loss of skin from the caudal thigh to the hock. Histopathologically, debrided tissue showed extensive necrosis of the dermis, adipose and muscle tissues, and the presence of numerous Gram-negative rods. Escherichia coli was cultured from deep tissue samples.

DIAGNOSIS

Necrotising fasciitis (NF) associated with E. coli infection.

CLINICAL RELEVANCE

NF associated with E. coli has not been previously reported in dogs. The importance of early diagnosis and surgical debridement is noted and the relevant medical literature is reviewed.

A functional MRI study of verbal fluency in adults with bipolar disorder and their unaffected relatives

BACKGROUND

Individuals with a history of bipolar disorder demonstrate abnormalities of executive function, even during euthymia. The neural architecture underlying this and its relationship with genetic susceptibility for illness remain unclear.

METHOD

We assessed 18 remitted individuals with bipolar disorder, 19 of their unaffected first degree relatives and 19 healthy controls using functional magnetic resonance imaging (fMRI) and a paced verbal fluency task with two levels of difficulty.

RESULTS

Bipolar patients made significantly more errors in the easy level of the verbal fluency task than their relatives or controls. Analysis of variance of fMRI data demonstrated a significant main effect of group in a large cluster including retrosplenial cortex and adjacent precuneate cortex (x=7, y=-56, x=15). All three groups showed deactivation in these areas during task performance relative to a neutral or rest condition. Group differences comprised a lesser amount of deactivation in unaffected relatives compared with controls in the easy condition [F(2, 55)=3.42, p=0.04] and in unaffected relatives compared with bipolar patients in the hard condition [F(2, 55)=4.34, p=0.018]. Comparison with the control group indicated that both bipolar patients and their relatives showed similar deficits of deactivation in retrosplenial cortex and reduced activation of left prefrontal cortex.

CONCLUSIONS

Bipolar disorder may be associated with an inherited abnormality of a neural network incorporating left prefrontal cortex and bilateral retrosplenial cortex.

Exaggerated neural response to emotional faces in patients with bipolar disorder and their first-degree relatives

Neuroimaging studies have demonstrated abnormalities in patients with bipolar disorder, including overactivity in anterior limbic structures in response to fearful or happy facial expressions. We investigated whether such anomalies might constitute heritable deviations underlying bipolar disorder, by virtue of being detectable in unaffected relatives carrying genetic liability for illness. Twenty patients with bipolar I disorder, twenty of their unaffected 1st degree relatives and twenty healthy volunteers participated in functional magnetic resonance imaging experiments of facial emotion processing. In one of these experiments, the participants watched faces expressing fear of varying intensities (moderate and high), intermixed with the non-emotional faces, and in another experiment - faces expressing moderate or high degrees of happiness intermixed with non-emotional faces. Repeated measures 2x3x3 ANOVA with emotion (fear and happy), intensity (neutral, moderate, and high) as within-subjects variables and group (patients, relatives, and controls) as between-subjects variable produced two clusters of differential activation, located in medial prefrontal cortex and left putamen. Activity in medial prefrontal cortex was greater in patients and in relatives compared with healthy volunteers in response to both fearful and happy faces. Activity in left putamen in response to moderate fear was greater in patients and in relatives compared with controls. Patients (but not relatives) showed also a greater activation in response to high intensity happy faces, compared with controls. Region of Interest analysis of amygdala activation showed increased activity in left amygdala in both patients and relatives groups in response to intensively happy faces. Exaggerated medial prefrontal cortical and subcortical (putamen and amygdala) responses to emotional signals may represent heritable neurobiological abnormalities underlying bipolar disorder.

The effect of COMT, BDNF, 5-HTT, NRG1 and DTNBP1 genes on hippocampal and lateral ventricular volume in psychosis

BACKGROUND

Morphometric endophenotypes which have been proposed for psychotic disorders include lateral ventricular enlargement and hippocampal volume reductions. Genetic epidemiological studies support an overlap between schizophrenia and bipolar disorder, and COMT, BDNF, 5-HTT, NRG1 and DTNBP1 genes have been implicated in the aetiology of both these disorders. This study examined associations between these candidate genes and morphometric endophenotypes for psychosis.

METHOD

A total of 383 subjects (128 patients with psychosis, 194 of their unaffected relatives and 61 healthy controls) from the Maudsley Family Psychosis Study underwent structural magnetic resonance imaging and genotyping. The effect of candidate genes on brain morphometry was examined using linear regression models adjusting for clinical group, age, sex and correlations between members of the same family.

RESULTS

The results showed no evidence of association between variation in COMT genotype and lateral ventricular, and left or right hippocampal volumes. Neither was there any effect of the BDNF, 5-HTTLPR, NRG1 and DTNBP1 genotypes on these regional brain volumes.

CONCLUSIONS

Abnormal hippocampal and lateral ventricular volumes are among the most replicated endophenotypes for psychosis; however, the influences of COMT, BDNF, 5-HTT, NRG1 and DTNBP1 genes on these key brain regions must be very subtle if at all present.

Patient perspective of hand osteoarthritis in relation to concepts covered by instruments measuring functioning: a qualitative European multicentre study

OBJECTIVE

To explore whether the concepts important to patients with hand osteoarthritis (OA) are covered by the most commonly used instruments measuring functioning.

METHOD

A qualitative multicentre study using a focus group technique was performed in five European countries: Austria, The Netherlands, Norway, Sweden and the United Kingdom. The qualitative data analysis followed a modified form of "meaning condensation" and used the International Classification of Functioning, Disability and Health (ICF) as a theoretical framework. Finally, the concepts from the focus groups were compared with the content of the most commonly used instruments which had been identified in an earlier theoretical analysis.

RESULTS

Fifty-six people (51 women, mean (SD) age 62.7 (7.9) years) with hand OA participated in this study in two focus groups per centre. 63 concepts were extracted from the focus groups. Twenty-one (33%) of the 63 concepts were covered by at least one instrument. Psychological consequences, different qualities of pain, aesthetic changes and leisure activities are important concepts from the focus groups which were not covered by the instruments. The qualitative analysis revealed detailed descriptions of pain-concerning sensations, levels and a certain relation to activity, none of which were fully represented in the instruments routinely used.

CONCLUSION

It was possible to combine the concepts of the focus groups from each centre into a common qualitative analysis. The concepts important to people with hand OA are not fully represented in the most commonly used instruments.

Cost and efficiency of HIV voluntary counselling and testing centres in Andhra Pradesh, India

BACKGROUND

[corrected] As part of the effort to control HIV/AIDS, the number of HlV voluntarycounselling and testingcentres (VCTCs) is increasing rapidly in the public health system of the Indian state of Andhra Pradesh, which is estimated to have one of the highest rates of HIV infection in India. However, systematic data on the cost and efficiency of providing VCT services in India are not available to help guide efficient use of resources for these services.

METHODS

We used standardized methods to obtain detailed cost and output data for the 2002-03 fiscal year from written records and interviews in 17 VCTCs in the public health system in Andhra Pradesh. We calculated the economic cost per client receiving VCT services, and analysed the variation and determinants of total and unit costs across VCTCs. We used multivariate regression techniques to estimate incremental unit costs. We assessed hurdles towards serving an optimal number of clients by VCTCs.

RESULTS

In the 2002-03 fiscal year, 32 413 clients received the complete sequence of services at the 17 VCTCs, including post-HIV test counselling. The number of clients served by each VCTC ranged from 334 to 7802 (median 979). The overall HIV-positive rate in post-test counselled clients was 20.5% (range 5.4%-52.6%). The cost per client for the complete VCT sequence varied 6-fold between VCTCs (range Rs 141.5-829.6 [US 2.92-17.14 dollars], median Rs 363.5 [US 7.51 dollars]). The cost per client was significantly lower at VCTCs with more clients (p < 0.001, R2 = 0.83; power function) due to substantial fixed costs. Personnel made up the largest component of cost (53.7%). The cost per client had a significant direct relation with percent personnel cost for VCTCs (p < 0.001, R2 = 0.58; exponential function). A multiple regression model revealed that the incremental cost of providing complete VCT services to each HIV-positive and -negative client was Rs 123.5 (US 2.54 dollars) and Rs 59.2 (US 1.22 dollars), respectively. Fourteen VCTCs (82.4%) reported that they could serve more clients with the available personnel and infrastructure, and that inadequate demand for their services was the main hurdle towards achieving this.

CONCLUSION

These data suggest that the efforts of the National AIDS Control Organisation of India and the Andhra Pradesh State AIDS Control Society in increasing VCTCs could yield even higher benefit if the demand for these services was enhanced, as this would increase the number of clients served and reduce the cost per client. Ongoing systematic cost-efficiency analysis is necessary to help guide efficient use of HIV-control resources in India.

An association between the CTLA4 exon 1 polymorphism and early rheumatoid arthritis with autoimmune endocrinopathies

OBJECTIVE

To examine the allelic association of the single nucleotide polymorphism (CTLA4A/G) in exon 1 of the cytotoxic T lymphocyte antigen-4 (CTLA4) gene with early rheumatoid arthritis (RA).

METHODS

One hundred and twenty-three unrelated white probands with early RA from the north-east of England and 349 local ethnically matched controls were studied. The CTLA4A/G polymorphism was genotyped with a polymerase chain reaction (PCR) method and digestion with the restriction enzyme Bst71I. Probands were also screened by allele-specific PCR for alleles HLA DRB1*01 and DRB1*04.

RESULTS

The frequency of the G allele at CTLA4A/G was significantly increased in probands with early RA compared with controls [43 vs 36%; P=0.028, odds ratio (OR) 1.35, 95% confidence interval (CI) 1.01-1.82]. Most of this increased frequency was attributable to RA individuals with coexisting autoimmune thyroid disease or type 1 diabetes (58 vs 36% in controls; P=0.005, OR 2.50, CI 1.29-4.84). The frequency of the G allele in RA patients without autoimmune endocrinopathy was 40%, which was not significantly different from that in controls (P=0.140).

CONCLUSION

The association between the CTLA4 G allele and early RA is largely explained by individuals with RA who have coexisting autoimmune endocrinopathies.

Identification, cloning, and recombinant expression of procalin, a major triatomine allergen

Among the most frequent anaphylactic reactions to insects are those attributed to reduviid bugs. We report the purification and identification of the major salivary allergen of these insects. This 20-kDa protein (procalin) is a member of the lipocalin family, which includes salivary allergens from other invertebrates and mammals. An expression system capable of producing reagent quantities of recombinant allergen was developed in Saccharomyces cerevisiae. Antisera produced against recombinant protein cross-reacts with ELISA with salivary allergen. Recombinant Ag is also shown to react with sera from an allergic patient but not with control sera. By immunolocalization, the source of the salivary Ag is the salivary gland epithelium and its secretions.

MHC class I restricted T cell responses to Listeria monocytogenes, an intracellular bacterial pathogen

Studies of the murine immune response to infection with the intracellular bacterial pathogen Listeria monocytogenes have provided a wealth of information about innate and acquired immune defenses in the setting of an infectious disease. Our studies have focused on the MHC class I restricted, CD8+ T cell responses of Balb/c mice to L. monocytogenes infection. Four peptides that derive from proteins that L. monocytogenes secretes into the cytosol of infected cells are presented to cytotoxic T lymphocyte (CTL) by the H2-Kd major histocompatibility complex (MHC) class I molecule. We have found that bacterially secreted proteins are rapidly degraded in the host cell cytosol by proteasomes that utilize, at least in part, the N-end rule to determine the rate of degradation. The MHC class I antigen processing pathway is remarkably efficient at generating peptides that bind to MHC class I molecules. The magnitude of in vivo T cell responses, however, is influenced to only a small degree by the amount of antigen or the efficiency of antigen presentation. Measurements of in vivo T cell expansion following L. monocytogenes infection indicate that differences in the sizes of peptide-specific T cell responses are more likely owing to differences in the repertoire of naive T cells than to differences in peptide presentation. This notion is supported by our additional finding that dominant T cell populations express a more diverse T cell receptor (TCR) repertoire than do subdominant T cell populations.

Recognition specificity of monoclonal antibodies which protect mice against Salmonella typhimurium infection

We used enzyme-linked immunosorbent assay (ELISA), competitive inhibition ELISA, flow cytometry and western immunoblots to study the antigenic specificity of two monoclonal antibodies (mAbs) raised against the cell surface antigens of Salmonella typhimurium. These mAbs (SH6.11 and WB60.4) protect CAF1 (Ity(r)) mice against endotoxemia and mouse typhoid. We found that SH6.11 and WB60.4 recognize Salmonella serogroup B-specific lipopolysaccharide O4 and O5 factors, respectively. These mAbs did not bind to Salmonella serotypes that belong to serogroup A, D1, E4, G2, or R and did not cross-react with other enteric and nonenteric bacterial species.

FCP1, the RAP74-interacting subunit of a human protein phosphatase that dephosphorylates the carboxyl-terminal domain of RNA polymerase IIO

TFIIF (RAP30/74) is a general initiation factor that also increases the rate of elongation by RNA polymerase II. A two-hybrid screen for RAP74-interacting proteins produced cDNAs encoding FCP1a, a novel, ubiquitously expressed human protein that interacts with the carboxyl-terminal evolutionarily conserved domain of RAP74. Related cDNAs encoding FCP1b lack a carboxyl-terminal RAP74-binding domain of FCP1a. FCP1 is an essential subunit of a RAP74-stimulated phosphatase that processively dephosphorylates the carboxyl-terminal domain of the largest RNA polymerase II subunit. FCP1 is also a stoichiometric component of a human RNA polymerase II holoenzyme complex.

Transcription elongation factor P-TEFb is required for HIV-1 tat transactivation in vitro

P-TEFb is a key regulator of the process controlling the processivity of RNA polymerase II and possesses a kinase activity that can phosphorylate the carboxy-terminal domain of the largest subunit of RNA polymerase II. Here we report the cloning of the small subunit of Drosophila P-TEFb and the finding that it encodes a Cdc2-related protein kinase. Sequence comparison suggests that a protein with 72% identity, PITALRE, could be the human homolog of the Drosophila protein. Functional homology was suggested by transcriptional analysis of an RNA polymerase II promoter with HeLa nuclear extract depleted of PITALRE. Because the depleted extract lost the ability to produce long DRB-sensitive transcripts and this loss was reversed by the addition of purified Drosophila P-TEFb, we propose that PITALRE is a component of human P-TEFb. In addition, we found that PITALRE associated with the activation domain of HIV-1 Tat, indicating that P-TEFb is a Tat-associated kinase (TAK). An in vitro transcription assay demonstrates that the effect of Tat on transcription elongation requires P-TEFb and suggests that the enhancement of transcriptional processivity by Tat is attributable to enhanced function of P-TEFb on the HIV-1 LTR.

'Deep-sea spiders' that walk through the water

Deep-sea isopods of the family Munnopsidae exhibit four modes of swimming: forward striding, slow backward pedalling, fast backward pedalling and escape, the first two of which use asymmetric phases of leg movement. Instead of moving the left and right limbs (pereopods, P2&shy;P7) of a segment in-phase (e.g. RP2LP2, RP3LP3, RP4LP4), as do most aquatic insects, leg movement is more like that of fast-walking insects, where closest synchrony occurs between diagonal limbs (e.g. RP2LP3, RP3LP4, RP4LP2). This is similar to the alternating tripod gait used by many animals on land to prevent them from toppling over. It therefore seems likely that this group of isopods learned to walk before they could swim.

Locally advanced breast cancer: is surgery warranted following chemotherapy?

Various methods of management of locally advanced breast cancer have been proposed, including combinations of chemotherapy, surgery, radiotherapy, immunotherapy and hormone manipulation. This retrospective study evaluated the effectiveness of chemotherapy in the management of locally advanced breast cancer in pre- and perimenopausal women by examining the pathology of the mastectomy specimens. Sixteen women who on initial clinical examination had breast cancers measuring 5 cm or greater underwent chemotherapy prior to surgery. Four women were also treated with radiotherapy prior to surgery. All 16 women underwent mastectomy and axillary clearance. All specimens showed residual tumour in the mastectomy specimen or the regional lymph nodes. Chemotherapy is useful in reducing tumour burden to allow surgical resection, but does not produce centripetal shrinkage of tumour, nor sterilize the breast of cancer. In this small series, the addition of radiotherapy also failed to clear the patient of tumour. Wide surgical excision including the original tumour margins is thus required to achieve locoregional control. Until chemotherapy and radiotherapy regimens can be proved to sterilize the breast of tumour, we caution against the use of any surgery less than total mastectomy if optimal local control is to be achieved for locally advanced breast cancer in pre- and perimenopausal women.