Development of Therapeutic Alliance and Social Presence in a Digital Intervention for Pediatric Concussion: Qualitative Exploratory Study

BACKGROUND

Despite the promising benefits of self-guided digital interventions for adolescents recovering from concussion, attrition rates for such interventions are high. Evidence suggests that adults can develop therapeutic alliance with self-guided digital interventions, which is in turn associated with intervention engagement. However, no research has examined whether adolescents develop therapeutic alliance with self-guided digital interventions and what factors are important to its development. Additionally, social presence-the extent to which digital encounters feel like they are occurring in person-may be another relevant factor to understanding the nature of the connection between adolescents and a self-guided digital intervention, though this has yet to be explored.

OBJECTIVE

This qualitative study explored the extent to which adolescents recovering from concussion developed therapeutic alliance and social presence during their use of a self-guided digital mindfulness-based intervention. Additionally, this study aimed to determine factors important to adolescents' development of therapeutic alliance and social presence with the intervention.

METHODS

Adolescents aged between 12 and 17.99 years who sustained a concussion were recruited from 2 sites: a pediatric emergency department up to 48 hours after a concussion and a tertiary care clinic over 1 month following a concussion to capture adolescents who had both acute and persisting symptoms after concussion. Participants (N=10) completed a 4-week mindfulness-based intervention delivered through a smartphone app. Within the app, participants listened to audio recordings of mindfulness guides (voice actors) narrating psychoeducation and mindfulness practices. At 4 weeks, participants completed questionnaires and a semistructured interview exploring their experience of therapeutic alliance and social presence with the mindfulness guides in the intervention.

RESULTS

Themes identified within the qualitative results revealed that participants developed therapeutic alliance and social presence by "developing a genuine connection" with their mindfulness guides and "sensing real people." Particularly important to the development of therapeutic alliance and social presence were the mindfulness guides' "personal backgrounds and voices," such that participants felt more connected to the guides by knowing information about them and through the guides' calm tone of voice in audio recordings. Quantitative findings supported qualitative results; participants' average score for therapeutic alliance was far above the scale midpoint, while the mixed results for social presence measures aligned with qualitative findings that participants felt that the mindfulness guides seemed real but not quite as real as an in-person connection would.

CONCLUSIONS

Our data suggest that adolescents can develop therapeutic alliance and social presence when using digital interventions with no direct human contact. Adolescents' development of therapeutic alliance and social presence with self-guided digital interventions can be bolstered by increasing human-like qualities (eg, real voices) within interventions. Maximizing therapeutic alliance and social presence may be a promising way to reduce attrition in self-guided digital interventions while providing accessible treatment.

Head-torso coordination in police officers wearing loaded tactical vests during running

BACKGROUND

The influence of load carriage in operational police officers is not well understood despite a relatively high injury rate. Assessing load related changes in head and torso coordination may provide valuable insight into plausible injury mechanisms.

RESEARCH QUESTION

Do typical police tactical vest loads alter head and torso coordination during running?

METHODS

Thirty-eight UK police officers ran at a self-selected pace (>2 ms-1) on a non-motorised treadmill in four vest load conditions (unloaded, and low, high and evenly distributed loads). Peak head and torso tilt, and peak vest displacement were compared between all four conditions. Timings between vest and torso change of direction were compared between the three loaded conditions. The coupling angle between the head and torso calculated using modified vector coding were compared between unloaded and each loaded conditions using Statistical Parametric Mapping.

RESULTS

No significant differences were found between conditions for peak head or torso tilt alone (p > 0.05). Loading equipment low on the vest led to significantly greater mediolateral vest displacements (38 mm) away from the torso than a high (34 mm) or evenly distributed (30 mm) conditions. The vest was found to change direction vertically before the torso in the anterior-posterior direction, and then influence torso motion. The loaded conditions changed the head-torso coupling from in-phase (with head-dominancy) to anti-phase (with torso dominancy) between 55% and 77% stance. Anti-phase with a relatively stationary head and the torso rotating forward likely places a greater concentric demand on the posterior neck muscles relative to unloaded running.

SIGNIFICANCE

Current tactical vest designs allow significant extra displacement of load away from the body during running, altering coordination at the head and torso.

Letter to the editor on "Increased low-frequency brain responses to music after psilocybin therapy for depression"

The recent publication in the Journal of Affective Disorders titled "Increased low-frequency brain responses to music after psilocybin therapy for depression" identified significant region-of-interest based effects of treatment in the task scans. In this letter to the editor, I am hoping to raise methodological concerns with regards to the ANOVA ROI analysis that were otherwise not acknowledged in this study. These concerns raise questions as to the impact of confounds, including as age and biological sex, on the reported proportion variance explained by the effects of psilocybin treatment for depression.

Associations between psychological resilience and metrics of white matter microstructure in pediatric concussion

This study investigated associations between psychological resilience and characteristics of white matter microstructure in pediatric concussion. This is a case control study and a planned substudy of a larger randomized controlled trial. Children with an acute concussion or orthopedic injury were recruited from the emergency department. Participants completed both the Connor-Davidson Resilience Scale 10 and an MRI at 72 h and 4-weeks post-injury. The association between resiliency and fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) at both timepoints were examined. We examined whether these associations were moderated by group. The association between resiliency captured at 72 h and diffusion tensor imaging metrics at 4 weeks was also investigated. Clusters were extracted using a significance threshold of threshold-free cluster enhancement corrected p < .05. A total of 66 children with concussion (median (IQR) age = 12.88 (IQR: 11.80-14.36); 47% female) and 29 children with orthopedic-injury (median (IQR) age = 12.49 (IQR: 11.18-14.01); 41% female) were included. A negative correlation was identified in the concussion group between 72 h resilience and 72 h FA. Meanwhile, positive correlations were identified in the concussion group with concussion between 72 h resilience and both 72 h MD and 72 h RD. These findings suggest that 72 h resilience is associated with white matter microstructure of the forceps minor, superior longitudinal fasciculus, and anterior thalamic radiation at 72 h post-concussion. Resilience seems to be associated with neural integrity only in the acute phase of concussion and thus may be considered when researching concussion recovery.

The effect of alcohol marketing on people with, or at risk of, an alcohol problem: A rapid review

Background

Little is known about the impact of alcohol marketing on people with, or at risk of, an alcohol problem. A rapid review of primary studies was conducted with the aim of exploring the effect of alcohol marketing in this population.

Methods

People with, or at risk of an alcohol problem were defined as people with an alcohol use disorder, in recovery from an alcohol use disorder, and hazardous and harmful drinkers. Searches for relevant literature were conducted through Medline, EMBASE and PsychINFO; reference list scanning and citation tracking of included studies; and grey literature searching of relevant websites. A narrative synthesis of included studies was undertaken.

Results

The review included 11 studies, which focused on participants recovering from an alcohol use disorder (AUD, 6 studies) and those with hazardous or harmful consumption levels of alcohol (5 studies). 7 studies were quantitative and 4 were qualitative. The effect of alcohol advertising on alcohol use was only assessed in one small experimental study of young adult heavy drinkers, which found no apparent effect. Studies looking at other outcomes suggested that a significant proportion of people with or at risk of alcohol problems notice alcohol advertisements and can find them appealing, and that advertisements may have an effect on positive alcohol-related emotions and cognitions. Among people in recovery from an alcohol use disorder, findings suggested that there could be an effect on craving, and that alcohol marketing may be perceived to trigger a desire to drink.

Conclusions

Several studies report effects of alcohol marketing which may translate into effects on consumption. There is also evidence that alcohol marketing is perceived to act as a trigger by people in recovery from alcohol problems. Further longitudinal and experimental research is needed to determine whether alcohol marketing has a causal effect on alcohol use in this population.

Key messages

• The findings of the studies included in the review suggest that an effect of alcohol marketing in people with, or at risk of, an alcohol problem is likely.

• The impact of alcohol marketing on people with or at risk of an alcohol problem should be a concern for marketing regulators and a focus for future research.

Increased gray matter following mindfulness-based stress reduction in breast cancer survivors with chronic neuropathic pain: preliminary evidence using voxel-based morphometry

PURPOSE

To investigate the impact of Mindfulness-Based Stress Reduction (MBSR) on gray matter volume (GMV) in female breast cancer survivors who suffer from chronic neuropathic pain (CNP).

METHODS

Voxel-based morphometry (VBM) was used to explore differences in GMV in 13 MBSR trainees and 10 waitlisted controls, with MRI scans and self-report measures completed pre- and post-8 weeks of training.

RESULTS

Compared to controls, the MBSR group had greater GMV in the angular gyrus and middle frontal gyrus post-training. The MBSR group's right parahippocampal gyrus GMV increased from pre- to post-training, whereas the control group's left parahippocampal gyrus, precuneus, middle temporal gyrus, and right cuneus GMV decreased over the same time period. Pain interference was significantly reduced and mindfulness was significantly increased following MBSR for the intervention group only.

CONCLUSIONS

MBSR was associated with increased GMV in regions where GMV is known to (1) increase with mindfulness and reorientation of attention and (2) decrease with the experience of chronic neuropathic pain. By contrast, the control group's decreases in GMV may be due to the negative effects of CNP which potentially may be reduced with MBSR, though further research is needed.

IMPLICATIONS FOR CANCER SURVIVORS

Given the poor efficiency of pharmacotherapies in a high percentage of women with neuropathic pain following breast cancer treatment, adjunct methods are required. MBSR may affect the brain to help alter attention and perception of pain, thus playing a potentially important role in the path to wellness for breast cancer survivors.

93 The Effects of Kinesiophobia on Outcome following Total Knee Replacement: A Systematic Review

Aim

Kinesiophobia, the fear of physical movement and activity related to injury vulnerability, has been linked to sub-optimal outcomes following total knee replacement (TKR). This systematic review has two aims: to define the relationship between kinesiophobia and functional outcomes, pain and range of motion following TKR, and to evaluate published treatments for kinesiophobia following TKR.

Method

A primary search was performed in March 2020. English-language studies recruiting adult primary TKR patients, using the Tampa Scale of Kinesiophobia (TSK) were included. Study quality was assessed using the Newcastle Ottawa Scale for cohort or case control studies, and the Cochrane Collaboration Risk of Bias tool for randomised controlled trials.

Results

All thirteen included papers (82 identified) showed adequately low risk of methodological bias. TSK1 (activity avoidance) correlated with WOMAC functional score at 12 months in three studies (r = 0.20 p &lt; 0.05, R = 0.317 p = 0.001, and correlation coefficient 0.197 p = 0.005). TSK score significantly correlated with mean active range of motion (ROM) at six months (105.33 (SD = 12.34) vs 85.53 (SD = 14.77) p = 0.000) post-operation. Three post-operative interventions improved TSK score vs control following TKR: a home-based functional exercise programme (TSK -14.30 (SD = 0.80) vs -2.10 (SD = 0.80) p &lt; 0.001)), an outpatient CBT programme (TSK 27.76 (SD = 4.56) vs 36.54 (SD = 3.58), and video-based psychological treatment (TSK 24 (SD = 5) vs 29 (SD = 5) p &lt; 0.01).

Conclusions

Kinesiophobia negatively affects functional outcomes up until one year post-operatively, while active ROM is reduced up to six months post procedure. Post-operative functional and psychological interventions can improve kinesiophobia following TKR.

108 Neck of Femur Fractures: Streamlined Approach to Improve Consenting Practices

Aim

Neck of femur fractures (NOFs) are synonymous with frailty, and successful outcomes are achieved with operative fixation. The United Kingdom’s General Medical Council guidance governing consent highlights the importance of thorough pre-operative discussion of risk with the patient. We aimed to audit consenting practices in NOF patients within our unit against the British Orthopaedic Association’s (BOA) criteria, with the addition of delirium as a risk factor.

Method

In cycle one all operatively managed NOFs over a two-month period in October-November 2019 were retrospectively reviewed. Consent forms 1 (CF1) and 4 (CF4) were assessed against BOA-endorsed criteria. Our intervention included a standardised sticker detailing 14 important risks was introduced and a departmental seminar on delirium. A second cycle was undertaken from August-October 2020 to close the audit loop

Results

No consent form documented all BOA-approved risk factors in cycle one (N = 35). Of cycle two’s 35 patients, 70.8% CF1 were completed using the novel sticker. All of these had 100% BOA-approved risk documentation. Consent forms without the sticker in cycle two documented 9/14 risks (mean value). No CF4 had any risks documented in either cycle. Delirium was documented in 51% in total and in 75% patients with CF1. Delirium documentation improved from 2.9% in cycle one to 51.4% in cycle two.

Conclusions

Clear lapses in operative consenting processes were identified, especially regarding delirium and CF4 documentation. The introduction of a novel consent sticker drastically improved compliance with BOA guidance for CF1. Recognition and departmental education regarding delirium significantly reduced incidence between cycles.

92 Increased Proportion of Alcohol-Related Trauma in A South London Major Trauma Centre During Lockdown, A Cohort Study

Background

Alcohol has been associated with 10-35% trauma admissions and 40% trauma-related deaths globally. In response to the Covid-19 pandemic, the United Kingdom (UK) entered a state of ‘lockdown’ on 23rd March 2020. Restrictions were most significantly eased on 1st June 2020, when shops and schools re-opened. The purpose of this study was to quantify the effect of lockdown on alcohol-related trauma admissions.

Method

All adult patients admitted as ‘trauma calls’ to a London Major Trauma Centre (MTC) during April 2018 and April 2019 (pre-lockdown; N = 316), and 1st April – 31st May 2020 (lockdown; N = 191) had electronic patient records analysed. Patients’ blood alcohol level and records of intoxication were used to identify alcohol-related trauma. Trauma admissions from pre- and post-lockdown cohorts were compared using multiple regression analyses.

Results

Alcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.4%), versus pre-lockdown 62/316 (19.6%); (Odds Ratio (OR) 0.83, 95% CI 0.38 to 1.28, p &lt; 0.001). Lockdown was also associated with increased weekend admissions of trauma (lockdown 125/191 weekend (65.5%) vs pre-lockdown 179/316 (56.7%); OR -0.40, 95% CI -0.79 to -0.02, p = 0.041). No significant difference existed in the age, gender, or mechanism between pre-lockdown and lockdown cohorts (p &gt; 0.05).

Conclusions

UK lockdown was independently associated with an increased proportion of alcohol-related trauma. Trauma admissions were increased during the weekend when staffing levels are reduced. With the possibility of subsequent global ‘waves’ of Covid-19, the risk of long-term repercussions of dangerous alcohol-related behaviour to public health must be addressed.

918 COVID-19: A Detailed Analysis on Fit-Testing for Respiratory Protective Equipment in the UK

Introduction

There is limited data in the literature regarding the adequacy of generic FFP3 masks and their facial fit to ensure adequate protection. Mask fit-testing is therefore essential to protect healthcare workers.

Method

Using the Freedom of Information Act, 137 acute NHS trusts in the UK were approached on the 26/3/2020 by an independent researcher to provide data on the outcome of fit testing at each site.

Results

85 Trusts responded to the FOI with 51 trusts providing pertinent data relevant to the FOI request. There was a total of 72 mask types used across 51 trusts. The commonest of which was the FFP3M1863 (used by 47/51 trusts, 92.16%). A positive correlation was found between staff members and number of mask types used (r = 0.75, P = &lt;0.05).

Overall fit-testing pass rates were provided by 32 trusts. The mean percentage pass rate was 80.74%.

Gender specific failure rates were provided by seven trusts. 4386 males underwent fit-testing in comparison to 16305 females. Across all seven trusts 20.08% of men tested failed the fit-test while only 19.89% of women failed the fit-test.

Conclusions

Our results may be utilised in choosing respirators for fit testing programme in healthcare-workers during the COVID-19 pandemic.

186 Acute Kidney Injury in Skeletal Trauma Admissions to Intensive Care: An Under-Estimated Complication

Introduction

Acute kidney injury (AKI) is associated with prolonged admission and 3.5 times increased mortality for trauma patients requiring intensive care (ICU) treatment. Blunt trauma confers greater risk of AKI than penetrating trauma, potentially related to long bone fracture. The relationship between skeletal trauma and AKI in ICU has not previously been investigated.

Method

Retrospective data was analysed from 202 consecutive adult patients admitted to ICU with skeletal trauma from 01/06/2018 to 01/06/2019. AKI was defined by creatinine rise &gt;1.5 times baseline.

Results

AKI was found in 70/202 (34.65%) patients aged 16-99 years, 138 males and 64 females. Mean limb Abbreviated Injury Scale (AIS) was significantly higher in AKI (AIS= 2.57 (SD 0.53) versus non-AKI AIS=2.38 (SD 0.61), p = 0.027). Other body regions and total Injury Severity Score (ISS) were non-significant.

AKI was associated with a significantly worse Glasgow Outcome Score (AKI 3.28 (SD 1.52) versus 4.02 (SD 1.08) p &lt; 0.001), increased intensive care stay (AKI 7.03 (SD 8.30) days versus non-AKI 3.8 (SD 4.1) days p &lt; 0.001) and increased 30-day mortality (AKI 18/70 (25.71%) versus non-AKI 10/132 (7.58%) p &lt; 0.001)

Conclusions

Skeletal trauma patients have a high incidence of AKI, which was significantly correlated with severity of skeletal limb trauma but not overall ISS.

Fit-testing of respiratory protective equipment in the UK during the initial response to the COVID-19 pandemic

Background

Public Health England guidance stipulates the use of filtering facepiece (FFP3) masks for healthcare workers engaged in aerosol-generating procedures. Mask fit-testing of respiratory protective equipment is essential to protect healthcare workers from aerosolized particles.

Aim

To analyse the outcome of mask fit-testing across National Health Service (NHS) hospitals in the UK during the first wave of the coronavirus disease 2019 (COVID-19) pandemic.

Methods

Using the Freedom of Information Act, 137 NHS hospitals were approached on May 26^th, 2020 by an independent researcher to provide data on the outcome of fit-testing at each site.

Findings

Ninety-six hospitals responded to the request between May 26^th, 2020 to October 29^th, 2020. There was a total of 86 mask types used across 56 hospitals, 13 of which were used in at least 10% of these hospitals; the most frequently used was the FFP3M1863, used by 92.86% of hospitals. Overall fit-testing pass rates were provided by 32 hospitals with mean pass rate of 80.74%. The most successful masks, in terms of fit-test failure rates, were the Alpha Solway 3030V and the Alpha Solway S–3V (both reporting mean fit-test failures of 2%). Male- and female-specific pass and failure rates were provided by seven hospitals. Across the seven hospitals, 20.1% of men tested failed the fit-test for all masks used, whereas 19.9% of women tested failed the fit-test for all masks used. Failure rates were significantly higher in staff from Black, Asian, and Minority Ethnic (BAME) backgrounds 644/2507 (25.69%) across four hospitals.

Conclusion

Twenty percent of healthcare workers tested during the first response to the pandemic failed fit-testing for masks. A small sample revealed that this was most prominent in staff from BAME backgrounds.

7X multiplexed, optofluidic detection of nucleic acids for antibiotic-resistance bacterial screening

Rapid and accurate diagnosis of bacterial infections resistant to multiple antibiotics requires development of new bio-sensors for differentiated detection of multiple targets. This work demonstrates 7x multiplexed detection for antibiotic-resistance bacterial screening on an optofluidic platform. We utilize spectrally multiplexed multi-spot excitation for simultaneous detection of nucleic acid strands corresponding to bacterial targets and resistance genes. This is enabled by multi-mode interference (MMI) waveguides integrated in an optofluidic device. We employ a combinatorial three-color labeling scheme for the nucleic acid assays to scale up their multiplexing capability to seven different nucleic acids, representing three species and four resistance genes.

Perceptual Similarity Can Drive Age-Related Elevation of False Recognition

Older adults consistently show elevated rates of false recognition of new items that are related to studied items. This finding has been largely attributed to a greater tendency for older adults to rely on conceptual gist during memory recognition tasks. However, perceptual factors may also be implicated considering that related items are not only conceptually but also perceptually similar. While some findings do suggest that age-related increases in false recognitions can be driven by perceptual factors, little is known about the nature and circumstances under which these factors operate. To address this gap, we measured basic visual ability as well as false recognition for four different image categories (upright faces, inverted faces, chairs, houses) in younger (n = 34) and older (n = 34) adults. Each image category represented different levels of variability in perceptual similarity and pre-experimental exposure. Perceptual similarity was objectively defined on the basis of the low-level properties of the images. We found evidence that perceptual similarity can contribute to elevated rates of false recognition in older adults. Our results also suggest that declines in basic visual abilities influence elevated false recognition in older adults for perceptually similar but not perceptually dissimilar items. We conclude that both perceptual and conceptual similarity can drive age-related differences in false recognition.

Path Analysis of Campus Walkability/Bikeability and College Students' Physical Activity Attitudes, Behaviors, and Body Mass Index

PURPOSE

The purpose of this study was to assess the relationship between the walkability/bikeability of college campuses and students' body mass index (BMI) with student physical activity (PA) attitudes and behaviors as potential mediators.

DESIGN

Cross-sectional.

SETTING

Thirteen university campuses.

PARTICIPANTS

A total of 1384 student participants.

MEASURES

Walkability/bikeability environmental score (ES): 12-item audit assessed an average of 44 path segments per campus. Students were measured for height and weight and completed online surveys. Physical activity stage of change/behavior intentions were assessed using the transtheoretical model. The Cognitive Behavioral Physical Activity Questionnaire assessed outcome expectations, self-regulation, and personal barriers. International Physical Activity Questionnaire assessed walking-, moderate-, and vigorous-intensity PA.

ANALYSIS

Descriptive statistics, zero-order correlations, and path analysis with maximum likelihood estimation.

RESULTS

The overall model fit was good with χ² of 171.388 ( df = 18), P < .001, comparative fit index value of .95, and a root mean square of approximation of .079. After controlling for gender, there was a direct negative association between walkability/bikeability ES and BMI (β = -.085) and positive association between personal barriers and BMI (β = .134). Walkability/bikeability ES was positively associated with walking-intensity PA (β = .010). Self-regulation was positively associated with moderate-intensity PA (β = .213), which, in turn, was negatively associated with BMI (β = -.057).

CONCLUSIONS

The ease of walking and biking on a campus was related to college students' walking behavior and their BMI. Students' PA behavioral intentions were associated with moderate PA and lower BMI. These results provide evidence to focus on policies and structural supports for walkable/bikeable environments to supplement and enhance interventions encouraging individual behavior change for PA and weight management.

Conditional reasoning difficulties in polysubstance-dependent patients

Polysubstance dependence has been associated with many neurocognitive impairments. The present study explored one of these deficits, namely conditional reasoning, using the Wason selection task. In healthy individuals, social contract and precautionary content improve conditional reasoning performance compared with descriptive or abstract content. Twenty-two recently detoxified polysubstance-dependent patients were compared with 22 controls matched for sex, age, and education level on their performance on the Wason selection task across problems involving social contract, precautionary, and descriptive conditional rules, controlling for depression, anxiety levels, and verbal intelligence. Conditional reasoning on descriptive and social contract rules was severely impaired in polysubstance-dependent patients. Precautionary reasoning was also impaired, but to a lesser degree than the other modalities of conditional reasoning. These results may reflect a toxic effect of chronic multiple-drug consumption on the prefrontal areas of the brain. Alternatively, conditional reasoning difficulties could be present, at least partially, before polysubstance dependence onset. This population may have difficulties properly understanding social contracts in real-life settings, suggesting a potential target for clinical intervention.

Sintering of biphasic calcium phosphates

Biphasic calcium phosphate (BCP) discs were fabricated and then sintered using two different sintering programs to establish whether the phases present could be controlled at low and high sintering temperatures. X-ray diffraction (XRD) was used to establish the phases present after sintering and scanning electron microscopy (SEM) determined the microstructure. Sintering program 1 involved a simple heating and cooling schedule and temperatures of 1100, 1250, 1275 and 1300 degrees C. It produced samples containing an additional alpha-tricalcium phosphate (alpha-TCP) phase at temperatures above 1100 degrees C. The original ratio of hydroxyapatite/beta-tricalcium phosphate (HA/beta-TCP) could not be maintained above this temperature. Sintering program 2 combined the heating and cooling schedules of the first program with a 900 degrees C hold stage to allow alpha-TCP to beta-TCP conversion to take place. At temperatures of 1250 and 1275 degrees C, this program was successful in completely removing the alpha-TCP phase and preserving the HA:beta-TCP ratio. The SEM results show that the surface morphology of the discs was not greatly affected by choice of sintering program.

Diagnostic and treatment difficulties in systemic lupus erythematosus coexisting with sickle cell disease

BACKGROUND

Patients with Sickle cell disease present with a wide range of symptoms and signs which overlap with other chronic illnesses. This often leads to a delay in diagnoses of the associated disorder.

OBJECTIVE

In view of the high prevalence of SCD in our environment, it is important to know that this association can occur and should be considered when patients present with pyrexia, arthritis, seizures and a recurrent rash.

CASE REPORT

We present an 8-year-old boy with sickle cell disease who presented with recurrent fever, back pains, and 'cutaneous eruptions' to multiple drugs. He had several admissions within two years due to above symptoms. Examination at the onset of the illness revealed a young boy with fever, no jaundice, and periorbital oedema and generalized lymphadenopathy. He had scanty fluffy hair and post inflammatory hyper pigmentation on the trunk and extremities. He also had a hepatomegaly. He was started on Ibuprofen and ceftraixone to which he reacted. He had corticosteroids and antimalarials and improved. During the 2-year-follow up period he was admitted for recurrent seizures, arthritis and a leg ulcer. On last visit to hospital, he developed a malar rash. Discoid rash with mouth ulcers. A diagnosis of SLE was made in the patient.

CONCLUSION

There are only 23 reported cases of SLE occurring in patients with sickle cell disease in literature, suggesting that the association is rare, it should be considered in patients with sickle cell disease presenting with pyrexia, rash and seizures.

Subcellular post-transcriptional targeting: delivery of an intracellular protein to the extracellular leaflet of the plasma membrane using a glycosyl-phosphatidylinositol (GPI) membrane anchor in neurons and polarised epithelial cells

The effectiveness of viral vector-mediated gene transfer depends on the expression of therapeutic transgenes in the correct target cell types. So far, however, little attention has been given to targeted subcellular distribution of expressed transgenes. Targeting individual transgenes to particular subcellular compartments will provide various advantages in increasing the safety, efficacy, and specificity of viral vector-mediated gene delivery. Viruses normally hijack the cellular protein synthesis machinery for their own advantages. It is thus unknown whether cells infected with viral vectors will be able to target proteins to the correct subcellular organelles, or whether the subcellular targeting machinery would be selectively disrupted by viral infection. In this article we explored whether a herpes simplex virus type 1-derived vector could be used to deliver a transgene engineered to be targeted to the extracellular membrane of target cells. To do so we constructed a temperature-sensitive mutant HSV-1 vector, tsK-TT21 expressing a recombinant marker protein, tissue inhibitor of metalloproteinases (TIMP), linked to sequence encoding a signal for the addition of a glycosyl-phosphatidylinositol (GPI)-anchor within the endoplasmic reticulum. Our results demonstrate that HSV1-derived viral vectors can be used to target transgenes as GPI anchored proteins to the outside leaflet of plasma membranes, without disrupting the targeting machinery of host epithelial cells or neurons. This approach could then be used to target specific proteins to the cell membrane to modify cell-cell interactions, the function of specific plasma membrane proteins, or their interactions with other membrane proteins, and also to target a prodrug converting enzyme to the plasma membrane of target cells, therefore enhancing its cell killing effects.

Twin pregnancy in a uterus didelphys, with unilateral placental abruption and onset of labour

A dizygotic twin pregnancy with a fetus in each side of a uterus didelphys is described. An antepartum haemorrhage at 26 weeks' gestation, with subsequent onset of contractions in the right-sided uterus, precipitated delivery by Caesarean section.

Dihydropyrimidine dehydrogenase pharmacogenetics in Caucasian subjects

AIMS

Dihydropyrimidine dehydrogenase (DPD) catalyses the reduction of pyrimidines, including the anticancer agent 5-fluorouracil (5FU). Impaired 5FU degradation, through low DPD activity, has led to severe, life-threatening or fatal toxicity after administration of 5FU. Complete DPD deficiency is associated with the inherited metabolic disease thymine uraciluria. Several mutations in the gene encoding DPD have recently been identified, but the phenotype-genotype concordance of these alterations in the general population has not been reported.

METHODS

Mononuclear cells were isolated from whole blood and DPD activity was determined after ex vivo incubation with 14C-5FU followed by h.p.1.c. analysis of 5FU metabolites. Analysis of mutations in the DPD gene at an exon splice site, codons 534, 543, and 732, and a deletion at base 1897 (deltaC1897) were performed in 30 subjects with the lowest and 30 subjects with the highest enzyme activity using PCR-RFLP.

RESULTS

DPD activity was measured in 226 Caucasian subjects and was highly variable (range 19.1-401.4 pmol min(-1)mg(-1) protein). Mutations were frequently observed at codons 543 (allele frequency 28%), 732 (allele frequency 5.8%), and 534 (allele frequency 0.8%), but were not associated with low DPD activity. There were no splice site or deltaC1897 mutations found in this population.

CONCLUSIONS

The five mutations analysed in this study are insufficient for identification of patients at risk for 5FU toxicity or thymine uraciluria. Both the splice site mutation and deltaC1897 are relatively rare in the general Caucasian population. Therefore, identification of further molecular alterations is required to facilitate the use of DPD analysis in genetic diagnosis and cancer therapeutics.

Dihydropyrimidine dehydrogenase pharmacogenetics in patients with colorectal cancer

Individuals with a deficiency in the enzyme dihydropyrimidine dehydrogenase (DPD) may experience severe life-threatening toxicity when treated with 5-fluorouracil (5-FU). As routine measurement of enzyme activity is not practical in many clinical centres, we have investigated the use of DNA mutation analysis to identify cancer patients with low enzyme levels. We have identified two new mutations at codons 534 and 543 in the DPD cDNA of a patient with low enzyme activity and screened the DNA from 75 colorectal cancer patients for these mutations and the previously reported splice site mutation (Vreken et al, 1996; Wei et al, 1996). In all cases, DPD enzyme activity was also measured. The splice site mutation was detected in a patient (1 out of 72) with low enzyme activity whereas mutations at codons 534 (2 out of 75) and 543 (11 out of 23) were not associated with low enzyme activity. These studies highlight the need to combine DPD genotype and phenotype analysis to identify mutations that result in reduced enzyme activity.

Mutations at codon 974 of the DPYD gene are a rare event

A mutation at codon 974 of the dihydropyrimidine dehydrogenase (DPD) gene was previously described in a cancer patient with undetectable DPD enzyme activity who experienced severe toxicity when treated with 5-fluorouracil. We have studied the frequency of this mutation in 29 Scottish subjects with low DPD enzyme activity and in 274 American subjects. We detected no mutations in the 606 alleles studied and conclude that mutations at codon 974 are a rare event.