A case study of a community-organized wastewater surveillance in a small community: correlating weekly reported COVID-19 cases with SARS-CoV-2 RNA concentrations during fall 2020 to summer 2021 in Yarmouth, ME

Wastewater surveillance offers a rapid evaluation of SARS-CoV-2 transmission in a community. We describe how a community group, the Yarmouth Wastewater Testing Team (YWTT), in Yarmouth, Maine, (population 8,990) utilized an asset-based community design framework to organize and manage a program to monitor SARS-CoV-2 RNA concentrations. From September 22, 2020 through June 8, 2021, the YWTT disseminated weekly reports of the wastewater results and reported COVID-19 cases within the Yarmouth postal code. After high and increasing SARS-CoV-2 RNA concentrations, the YWTT issued two community advisories to encourage extra care to reduce exposure. Correlations between SARS-CoV-2 RNA concentrations and COVID-19 cases were stronger the week after sampling, and the average of the COVID-19 cases during the week of sampling and the following week, indicating that surveillance provided advance notice of cases. A 10% increase in SARS-CoV-2 RNA concentrations was associated with a 13.29% increase in the average number of weekly reported cases of COVID-19 during the week of sampling and the following week (R2 = 0.42; p < 0.001). Adjusting for viral recovery (December 21, 2020 through June 8, 2021), improved R2 from 0.60 to 0.68. Wastewater surveillance was an effective tool for the YWTT to quickly respond to viral transmission.

Suicide bereavement in the UK: Descriptive findings from a national survey

BACKGROUND

Those bereaved by suicide are a high-risk group of adverse health outcomes and suicidal behavior, yet little is known about the experiences and support needs of these individuals in the UK.

METHODS

We conducted a national cross-sectional study using an online survey and analyzed the experiences of 7158 participants who had been bereaved or affected by suicide.

RESULTS

Suicide had a major impact on 77% of participants, including those who had lost a friend and those exposed to suicide at a professional level. Mental and physical health problems linked to the suicide were reported in half. Adverse social outcomes and engaging in high-risk behaviors following the suicide were common. Over a third reported suicidal ideation and 8% had attempted suicide as a direct result of the suicide loss. Most had not accessed support services, with the majority viewing provision of local suicide bereavement support as inadequate.

CONCLUSIONS

Our results highlight the need for a multi-disciplinary approach in postvention and the provision of proactive outreach to support those bereaved by suicide. Postvention efforts need to acknowledge the death of a friend by suicide as a significant loss.

International Consensus Statement on the diagnosis, multidisciplinary management and lifelong care of individuals with achondroplasia

Achondroplasia, the most common skeletal dysplasia, is characterized by a variety of medical, functional and psychosocial challenges across the lifespan. The condition is caused by a common, recurring, gain-of-function mutation in FGFR3, the gene that encodes fibroblast growth factor receptor 3. This mutation leads to impaired endochondral ossification of the human skeleton. The clinical and radiographic hallmarks of achondroplasia make accurate diagnosis possible in most patients. However, marked variability exists in the clinical care pathways and protocols practised by clinicians who manage children and adults with this condition. A group of 55 international experts from 16 countries and 5 continents have developed consensus statements and recommendations that aim to capture the key challenges and optimal management of achondroplasia across each major life stage and sub-specialty area, using a modified Delphi process. The primary purpose of this first International Consensus Statement is to facilitate the improvement and standardization of care for children and adults with achondroplasia worldwide in order to optimize their clinical outcomes and quality of life.

Ethnic Minority Groups' Experiences of Suicide Bereavement: A Qualitative Exploratory Study

It is estimated that between 36,000 and 360,000 people are affected by suicide every year in the UK, and a proportion may develop depression and post-traumatic stress disorder, or engage in high-risk behaviours. Recent systematic analyses have revealed a clear gap in research on suicide bereavement in minority ethnic groups. This study aimed to understand the experiences and support needs of individuals from ethnic minority backgrounds bereaved by suicide and was the first in the UK to investigate this matter. The study was a secondary analysis of data. Participants were 7158 people residing in the UK who completed an online survey about their experiences of suicide. Free-text qualitative responses of 227 participants who did not identify as White British were analysed using thematic analysis. Four themes were identified: maladaptive coping strategies, emotional processes following suicide, lack of support from agencies, and the importance of mental health awareness. Ethnic minority groups reported a lack of support despite attempts to engage with services, noted the prevalence of stigma within ethnic minority groups, and expressed a need to tackle this. These preliminary results suggest that ethnic minority individuals require visible and accessible services that can successfully engage with and support them.

'We're the First Port of Call' - Perspectives of Ambulance Staff on Responding to Deaths by Suicide: A Qualitative Study

Introduction

Exposure to suicide is a known risk factor for suicide. Ambulance staff are exposed to work-related stressors including attending suicides, which may elevate their risk for mental health problems/suicide. Little is known about ambulance staff’s perspectives on how they experience these events and whether they feel equipped to respond to bereaved families at the scene of death. This study explores the perspectives of ambulance staff about responding to deaths by suicide.

Materials and Methods

A convenience sample of ambulance staff recruited from one ambulance service in England. In-depth, qualitative, semi-structured face-to-face interviews conducted with nine ambulance staff (six male, three female) to explore experiences of responding to suicide. Data analyzed using thematic analysis.

Results

Participants reported the experience of job-related strain including exposure to the suicide/suicidal ideation of colleagues; they described suppressing their distress despite significant emotional impact. All participants had been personally bereaved by suicide and responding to suicide was a common part of their job. They were often the first professionals at the scene, and undertook varied and often conflicting roles: negotiating with patients in crisis; informing individuals of the death of a loved one; preserving the body/potential crime scene; dealing with the intense emotional reactions of bereaved individuals. Participants reported long-term, salient memories of these events; however, there was a reported lack of acknowledgment in the workplace that suicides may be traumatic and no guidance for staff on how to cope. Opportunities to debrief were reportedly rare, and there was reluctance to access work-based liaison services. Training in how to respond to individuals bereaved by suicide was also lacking.

Discussion

The study is the first to reveal the complex challenges faced by ambulance staff in responding to suicide without adequate training and support. It demonstrates the potential impact that responding to suicide can have personally and professionally on staff, and emphasizes the need for employers to support staff wellbeing in better ways. Training and postvention support could enable better coping among staff, more effective support for bereaved individuals and reduce the risk of death by suicide both in those bereaved by suicide and in ambulance staff.

Experiences of support from primary care and perceived needs of parents bereaved by suicide: a qualitative study

BACKGROUND

People bereaved by suicide are a vulnerable group, also at risk of dying by suicide. The importance of postvention support (intervention after suicide) has recently been highlighted; however, little is known about the support needs of parents bereaved by suicide in the UK, and the role played by general practice.

AIM

To explore the perspectives, experiences, and support needs of parents bereaved by suicide.

DESIGN AND SETTING

This was a qualitative study, with semi-structured interviews conducted between 2012 and 2014 in the north of England and the Midlands, with parents bereaved by their son or daughter's suicide.

METHOD

Interviews explored parents' experiences of suicide bereavement following the death of their son or daughter, with a focus on their experiences of support from primary care. Interviews were analysed thematically using constant comparison.

RESULTS

Twenty-three interviews were conducted. Three themes were identified from the data: the importance of not feeling alone; perceived barriers to accessing support; and the need for signposting for additional support. Some parents reported having experienced good support from their general practice; others described a number of barriers to accessing help, including triage processes. Primary care was considered to be an important avenue of support but GPs were often perceived as uncertain how to respond. The need for information, signposting to avenues of support, and the helpfulness of group support were also highlighted.

CONCLUSION

Parents believed it was important that people working in general practice have an awareness of suicide bereavement and understanding of their needs, including knowledge of where to direct people for further support.

Evaluation of the Impact of the PABBS Suicide Bereavement Training on Clinicians' Knowledge and Skills

Background: Health-care professionals do not routinely receive training on how best to support parents bereaved by suicide. Evidence-based training - Postvention Assisting Those Bereaved by Suicide (PABBS) - was designed to address this gap. Aims: The study aimed (a) to pilot PABBS training and evaluate its perceived effectiveness (impact on self-reported knowledge, skills and confidence) in managing suicide bereavement; and (b) to explore training acceptability. Method: A pre- and postevaluation design was used. Professionals attended intensive, structured 1-day PABBS training comprising: didactic/interactive teaching; practice-orientated activities supported with real-life materials and a manual/workbook. Evaluation forms completed immediately before and after training analyzed: (a) self-reported changes in knowledge, skills, and confidence (perceived effectiveness of training); and (b) the acceptability of training. Results: In total, 62 professionals completed training. Perceived knowledge, skills, and confidence improved after training as did self-reported understanding, motivation to learn more, and intention to change practice. Training was highly rated, particularly the evidence-based, real-life materials, with some suggestions for improvement. Limitations: Self-selected sample and reliance on self-report measures are the study's limitations. Conclusion: PABBS training may help address gaps in professionals' capacity to support parents bereaved by suicide. The evidence-based content was highly acceptable and appeared to be a key ingredient in effecting self-reported changes in attitudes/intentions.

Vitamin D and Omega 3 Field Study on Progression of Type 1 Diabetes

Chronic inflammation has been linked to the progression of type 1 diabetes (T1D). Supplementation with vitamin D and omega-3 fatty acids, which have anti-inflammatory properties, may slow or stop the progression of T1D. A field study is underway to assess the relationship between these nutrients and T1D progression among auto-antibody positive individuals who have not been diagnosed with T1D. The T1D Prevention Field Study is currently recruiting participants to complete online health surveys and home blood-spot tests for 25-hydroxyvitamin D [25(OH)D], Omega-3 Index, AA:EPA Ratio, high-sensitivity C-reactive protein, and HbA1c every three to four months for 5 years. Participants (or their parents/guardians) are given information about the importance of achieving a 25(OH)D level between 40-60 ng/ml and an AA:EPA Ratio between 1.5-3.0 to reduce inflammation. However, participants are free to choose their own supplement or dietary regimens. Data analysis will focus on associations between vitamin D and omega-3 status and progression of T1D. Initial enrollment in the T1D Prevention Field Study includes 103 participants from fifteen countries; total enrollment is expected to reach at least 400 participants by the end of 2022. The field study approach allows for cost-effective research that capitalizes on new technologies for recruitment, data collection, and blood level testing from home. However, some challenges have arisen. Many individuals are reading the open source protocols and some choose to supplement and test on their own so incentives may be needed to increase enrollment. Additionally, some participants do not have access to auto-antibody testing or are unable to get access to their test results; therefore, there is a need to provide blood spot auto-antibody testing through the field study.

Diagnostic accuracy of midtrimester antenatal ultrasound for multicystic dysplastic kidneys

OBJECTIVES

To establish the diagnostic accuracy of obstetric ultrasound at a tertiary fetal medicine center in the prenatal detection of unilateral and bilateral multicystic dysplastic kidney (MCDK) in fetuses in which this condition was suspected, and to undertake a systematic review of the relevant literature.

METHODS

This was a retrospective observational study of all cases referred to a regional tertiary fetal medicine unit due to suspicion of either unilateral or bilateral MCDK between 1997 and 2015. Diagnosis was confirmed by postnatal ultrasound reports or postmortem examination. The accuracy of prenatal ultrasound in the diagnosis of MCDK was calculated. Using a systematic search strategy we also performed a review of the literature regarding the prenatal diagnosis and diagnostic accuracy of MCDK.

RESULTS

We included 144 women in our analysis; 37 (25.7%) opted for pregnancy termination (TOP) (due to unilateral MCDK with additional abnormalities, suspected bilateral MCDK or severe obstructive uropathy). Complete pre- and postnatal data were available in 126 pregnancies, including 104 livebirths, 19 TOPs with postmortem findings available and three intrauterine fetal deaths. Two infants died shortly after birth (due to known bilateral MCDK or known cranial vault defect). The overall number of cases of MCDK confirmed postnatally was 100; of these, 98 were diagnosed prenatally (true positive), while two were thought to be hydronephrosis prenatally (false negative) and the diagnosis of MCDK was made after birth. In nine cases, the initial antenatal diagnosis of suspected MCDK was revised, either later in pregnancy (n = 2) or postnatally (n = 7) (false positive). Overall, the diagnostic accuracy in our population for the use of antenatal ultrasound to detect MCDK was 91.3%, while that reported in the existing literature was found to range from 53.3% to 100%. MCDK was isolated in the majority (71%) of cases, while in 29% of cases it was found to be associated with other renal and extrarenal fetal abnormalities.

CONCLUSIONS

Antenatal ultrasound had a diagnostic accuracy of about 91% in the prediction of postnatal MCDK and can therefore be used to guide antenatal counseling. However, prenatal or postnatal revision of the diagnosis occurred in about 7% of cases and parents should be counseled appropriately. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

The mental health and substance misuse needs of male ex-armed forces personnel in prison

Ex-armed forces personnel constitute the largest known occupational group in prison but there is little evidence regarding their mental health, or substance misuse, needs. A total of 105 participants were interviewed and measures assessing symptoms of common mental health (CMH) problems and substance misuse were completed along with a review of their health care records. Forty (38%) participants screened for current CMH problems (CCMH) and high levels of dual symptomology and alcohol misuse were assessed. Thirty-nine (37%) had a mental health diagnosis recorded, most commonly for post-traumatic stress disorder (PTSD), depression and personality disorder. Those who screened for a CCMH problem were more likely to have pre-service vulnerability to negative health outcomes and those with dual symptomology were more likely to have experienced deployment during their service. Findings suggest the mental health needs of this group are similar to the general prison population. Potentially higher prevalences of PTSD and alcohol misuse may direct service provision.

Treatment Barriers and Support for Male Ex-Armed Forces Personnel in Prison: Professional and Service User Perspectives

Ex-armed forces personnel represent a potentially vulnerable group within the prison population. To provide support to this group, we need to understand their needs and help-seeking behavior. A focus group with professionals and semi-structured interviews with service users explored perspectives of the treatment barriers faced by this group and their support needs. Data were analyzed using constant comparison methods, and four primary themes were identified. The findings suggest ex-armed forces personnel consider prison an opportunity to access support but find it difficult to ask for help. Staff having an awareness of military issues was thought to encourage help-seeking, but the variability of provision across prison establishments was considered a barrier. Resettlement was a prominent concern, and access to support when preparing for, and after, release was felt by all participants to be important. Implications for the provision of support in prison are discussed along with recommendations for practice.

Soldier, civilian, criminal: identifying pathways to offending of ex-armed forces personnel in prison

Little is known about why some ex-armed forces personnel become involved in the criminal justice system, however, they represent the largest known occupational group in prison. In-depth interviews were employed to explore possible pathways to offending. Twenty ex-armed forces personnel in prison were recruited from five prisons in England. Data were analysed using a combination of thematic analysis and constant comparison methods rooted in grounded theory. Four predominant themes were identified: experiences of trauma and adversity; belonging; impulsivity and creating a soldier. Participants had experienced a number of traumatic incidents and adversity in their lives, encompassing pre, during and post-service but felt a sense of belonging in the armed forces. Participants demonstrated impulsivity in a number of areas with links to both their service in the armed forces and offending behaviour. The creation of the identity of 'soldier' was perceived to impact participants' lives in a number of ways, including their offending, alcohol use and coping with trauma. The interplay of these themes and their potential impact on participants' pathways to offending are discussed.

Post-hoc analysis of vitamin D status and reduced risk of preterm birth in two vitamin D pregnancy cohorts compared with South Carolina March of Dimes 2009-2011 rates

BACKGROUND

Two vitamin D pregnancy supplementation trials were recently undertaken in South Carolina: The NICHD (n=346) and Thrasher Research Fund (TRF, n=163) studies. The findings suggest increased dosages of supplemental vitamin D were associated with improved health outcomes of both mother and newborn, including risk of preterm birth (<37 weeks gestation). How that risk was associated with 25(OH)D serum concentration, a better indicator of vitamin D status than dosage, by race/ethnic group and the potential impact in the community was not previously explored. While a recent IOM report suggested a concentration of 20 ng/mL should be targeted, more recent work suggests optimal conversion of 25(OH)D-1,25(OH)2D takes place at 40 ng/mL in pregnant women.

OBJECTIVE

Post-hoc analysis of the relationship between 25(OH)D concentration and preterm birth rates in the NICHD and TRF studies with comparison to Charleston County, South Carolina March of Dimes (CC-MOD) published rates of preterm birth to assess potential risk reduction in the community.

METHODS

Using the combined cohort datasets (n=509), preterm birth rates both for the overall population and for the subpopulations achieving 25(OH)D concentrations of ≤20 ng/mL, >20 to <40 ng/mL, and ≥40 ng/mL were calculated; subpopulations broken down by race/ethnicity were also examined. Log-binomial regression was used to test if an association between 25(OH)D serum concentration and preterm birth was present when adjusted for covariates; locally weighted regression (LOESS) was used to explore the relationship between 25(OH)D concentration and gestational age (weeks) at delivery in more detail. These rates were compared with 2009-2011 CC-MOD data to assess potential risk reductions in preterm birth.

RESULTS

Women with serum 25(OH)D concentrations ≥40 ng/mL (n=233) had a 57% lower risk of preterm birth compared to those with concentrations ≤20 ng/mL [n=82; RR=0.43, 95% confidence interval (CI)=0.22,0.83]; this lower risk was essentially unchanged after adjusting for covariates (RR=0.41, 95% CI=0.20,0.86). The fitted LOESS curve shows gestation week at birth initially rising steadily with increasing 25(OH)D and then plateauing at ∼40 ng/mL. Broken down by race/ethnicity, there was a 79% lower risk of preterm birth among Hispanic women with 25(OH)D concentrations ≥40 ng/mL (n=92) compared to those with 25(OH)D concentrations ≤20 ng/mL (n=29; RR=0.21, 95% CI=0.06,0.69) and a 45% lower risk among Black women (n=52 and n=50; RR=0.55, 95% CI=0.17,1.76). There were too few white women with low 25(OH)D concentrations for assessment (n=3). Differences by race/ethnicity were not statistically significant with 25(OH)D included as a covariate. Compared to the CC-MOD reference group, women with serum concentrations ≥40 ng/mL in the combined cohort had a 46% lower rate of preterm birth overall (n=233, p=0.004) with a 66% lower rate among Hispanic women (n=92, p=0.01) and a 58% lower rate among black women (n=52, p=0.04).

CONCLUSIONS

In this post-hoc analysis, achieving a 25(OH)D serum concentration ≥40 ng/mL significantly decreased the risk of preterm birth compared to ≤20 ng/mL. These findings suggest the importance of raising 25(OH)D levels substantially above 20 ng/mL; reaching 40 ng/mL during pregnancy would reduce the risk of preterm birth and achieve the maximal production of the active hormone.

Obtaining and communicating information about genetics and genomics

This is the eighth article in a series looking at how nurses can develop competence in genetics and genomics health care. The article explores the many ways in which nurses can acquire up to date and accurate genetic and genomic information, with the intention of improving their knowledge base. It enables nurses to discover the best ways of giving specific and complex information to patients and colleagues effectively and using straightforward language.

Information sharing between the National Health Service and criminal justice system in the United Kingdom

Offenders with mental health problems often have complex and interrelated needs which separately challenge the criminal justice system (CJS) and National Health Service (NHS) in the United Kingdom (U.K.). Consequently, interagency collaboration and timely information sharing are essential. This study focused on the sharing of information about people with mental health problems in contact with the CJS. Questionnaires were distributed to a range of health and criminal justice personnel. The results showed that there was a mismatch between what service user information criminal justice agencies felt they needed and what was routinely received. Prison Service staff received more information (between 15% and 37%) from health agencies than the police (between 6% and 22%). Health professionals received most of the information they needed from criminal justice agencies (between 55% and 85%). Sharing service user information was impeded by incompatible computer systems and restrictions due to data protection/confidentiality requirements. In the U.K., recent governmental publications have highlighted the importance of information sharing; however there remains a clear mismatch between what health related information about service users criminal justice agencies need, and what is actually received. Better guidance is required to encourage and empower people to share.

Molecular basis of invasion in breast cancer

Cancer cell invasion involves the breaching of tissue barriers by cancer cells, and the subsequent infiltration of these cells throughout the surrounding tissue. In breast cancer, invasion at the molecular level requires the coordinated efforts of numerous processes within the cancer cell and its surroundings. Accumulation of genetic changes which impair the regulation of cell growth and death is generally accepted to initiate cancer. Loss of cell-adhesion molecules, resulting in a loss in tissue architecture, in parallel with matrix remodelling may also confer a motile or migratory advantage to breast cancer cells. The tumour microenvironment may further influence the behaviour of these cancer cells through expression of cytokines, growth factors, and proteases promoting chemotaxis and invasion. This review will attempt to summarise recent work on these fundamental processes influencing or facilitating breast cancer cell invasion. (Part of a Multi-author Review).

Reduced penetrance alleles for Huntington's disease: a multi-centre direct observational study

OBJECTIVE

To obtain penetrance data for Huntington's disease when DNA results are in the range of 36-39 CAG repeats and assess the consistency of reporting the upper allele from two reference centres.

METHOD

Data were collected anonymously on age of onset or age last known to be unaffected from a cohort of individuals with results in this range. DNA samples were re-analysed in two reference centres. Kaplan-Meier analysis was used to construct an age of onset curve and penetrance figures.

RESULTS

Clinical data and concordant DNA results from both reference centres were available for 176 samples; penetrance figures (and 95% confidence intervals) for this cohort, at age 65 and 75 years, were 63.9% (55.5% to 73.2%) and 74.2% (64.2% to 84.2%), respectively. Inclusion of 28 additional subjects for whom repeat DNA results were unavailable, obtained from only one reference centre, or discrepant by one repeat within this range, gave penetrance data (including 95% confidence intervals) at ages 65 and 75 years of 62.4% (54.4% to 70.4%) and 72.7.% (63.3% to 82.1%), respectively. 238 duplicate results were available from the reference centres; 10 (4.2%) differed by one CAG repeat in the reporting of the upper allele and in two (0.84%) of these cases the discrepancy was between 39 and 40 repeats.

CONCLUSION

When DNA results are in this range, a conservative approach is to say that there is at least a 40% chance the person will be asymptomatic at age 65 years and at least a 30% chance the person will be asymptomatic at age 75 years.

Pharmacokinetics of boldenone and stanozolol and the results of quantification of anabolic and androgenic steroids in race horses and nonrace horses

Anabolic steroids (ABS) boldenone (BL; 1.1 mg/kg) and stanozolol (ST; 0.55 mg/kg) were administered i.m. to horses and the plasma samples collected up to 64 days. Anabolic steroids and androgenic steroids (ANS) in plasma were quantified using liquid chromatography-tandem mass spectrometry (LC-MS/MS). The limit of detection of all analytes was 25 pg/mL. The median absorption (t1/2 partial differential) and elimination (t1/2e) half-lives for BL were 8.5 h and 123.0 h, respectively, and the area under the plasma concentration-time curve (AUCho) was 274.8 ng.h/mL. The median t1/2e for ST was 82.1 h and the was 700.1 ng.h/mL. Peak mean (X+/-SD) plasma concentrations (Cmax) for BL and ST were 1127.8 and 4118.2 pg/mL, respectively. Quantifiable concentrations of ABS and ANS were found in 61.7% of the 988 plasma samples tested from race tracks. In 17.3% of the plasma samples two or more ABS or ANS were quantifiable. Testosterone (TES) concentrations mean (X+/-SE) in racing and nonracing intact males were 241.3+/-61.3 and 490.4+/-35.1 pg/mL, respectively. TES was not quantified in nonracing geldings and female horses, but was in racing females and geldings. Plasma concentrations of endogenous 19-nortestosterone (nandrolone; NA) from racing and nonracing males were 50.2+/-5.5 and 71.8+/-4.6 pg/mL, respectively.

Social interaction patterns of children and adolescents with and without oral clefts during a videotaped analogue social encounter

OBJECTIVES

To examine the social interaction patterns of children with and without oral clefts.

DESIGN

Participants were videotaped while interacting with a peer confederate. Oral cleft and control groups were compared on social behavior and several self- and parent-report measures.

PARTICIPANTS

Thirty-four 8- to 15-year-olds with oral clefts, matched for sex, age, and socioeconomic status with 34 noncleft controls.

MAIN OUTCOME MEASURES

Data were obtained on social behaviors coded from videotapes and on child and parent ratings of social acceptance/competence and facial appearance.

RESULTS

Statistically significant differences were found between groups: children with clefts made fewer choices and more often failed to respond to peer questions; children with clefts and their parents reported greater dissatisfaction with the child's facial appearance; and parents of children with clefts rated them as less socially competent. Significant within-group associations were also found. Parent perception of child social competence and child self-perception of social acceptance were positively correlated for both groups. Children with clefts who felt more socially accepted more often looked a peer in the face. Controls who felt more socially accepted chose an activity less often during the social encounter.

CONCLUSIONS

Differing patterns of overt social behavior as well as parent and self-perception can be measured between children with and without oral clefts. Such results may be helpful in developing interventions to enhance social skills and parent/child adjustment.

Who supports the support workers? Cross-sectional survey of support workers’ experience and views

Support groups provide information and emotional support to families. Despite a recent growth in the number and size of these groups, there are no formal structures in place to provide support for the support worker. We performed a cross-sectional survey using a self-completion postal questionnaire, with the aim of identifying the structure, training needs and support given to workers. The participants were support workers from 112 United Kingdom-based organisations listed on the 'Contact a Family' website (www.cafamily.co.uk). We received 104 replies from 50/112 organisations (44%). Of these, 94/104 (90%) worked from home as volunteers. Two-thirds, 69/104, admitted times when they struggled to cope. A total of 43 (41%) admitted occasions of concern over the care given by a client to their affected relative. No group employed a professional to act in a clinical supervisory role. Our study suggests that support workers are highly committed to their role; these workers need support to ensure that they give appropriate advice under difficult circumstances.

Increasing film-focus distance (FFD) reduces radiation dose for x-ray examinations

Increasing film-focus distance (FFD) from the traditional 100 cm has been shown to be an effective method of reducing dose whilst maintaining image quality. In particular, previous work increasing the FFD from 100 to 130 cm for lumbar spine examinations demonstrated an effective dose reduction of 44%. Objective. The current study continues on from this work by investigating the dose-reducing efficacy of this FFD change for pelvis X-ray examinations. Materials and methods. Dose measurements at 100 and 130 cm using thermoluminescent dosemeters were undertaken using an anthropomorphic phantom and patients. Image quality was assessed using CEC anatomical criteria and psychophysical tests. Results. The results showed that increasing the FFD results in a reduction in effective dose of 33%, with no change in image quality. The data provided in this and previous studies demonstrate the need for rapid implementation of this simple cost-effective procedure across imaging departments, leading to an important reduction in collective dose. Conclusion. The CEC recommendation of using 115 cm FFD for a number of procedures, although useful compared with 100 cm, undervalues by a factor between 2 and 3 the potential of this dose-reducing tool.

Assessment of facial emotion encoding and decoding skills in children with and without oral clefts

PURPOSE

Investigated the facial emotion decoding and encoding skills and perceived social acceptance in children with and without oral clefts.

PATIENTS

8-15 year-old children with surgically repaired facial clefts (n=19) and non-cleft controls (n=19).

METHODS

The children viewed photographs of facial emotions expressed by other children and identified the emotion in each photograph. They were videotaped while listening to a series of brief vignettes designed to evoke facial emotions and while posing prototypic facial expressions. They also completed a measure of their perceived social acceptance. Judges, blind to experimental group and targeted emotion, viewed systematically sampled video images, then recorded their subjective judgement of the emotion expressed in each. Trained coders also scored selected images using objective measures of the degree to which specific facial movements associated with emotion-specified expressions were present.

RESULTS

Analysis of variance procedures detected significantly different patterns of facial responses between the oral cleft and control groups, and within group. Pearson correlation analyses found significant relationships between specific facial movements and perceived social acceptance.

CONCLUSION

Systematic assessment of facial expression in children with oral clefts can identify unique differences in their encoding of facial emotion and may lead to behavioural interventions to improve social functioning by training facial expression skills.

Polio eradication initiative in Africa: influence on other infectious disease surveillance development

BACKGROUND

The World Health Organization (WHO) and partners are collaborating to eradicate poliomyelitis. To monitor progress, countries perform surveillance for acute flaccid paralysis (AFP). The WHO African Regional Office (WHO-AFRO) and the U.S Centers for Disease Control and Prevention are also involved in strengthening infectious disease surveillance and response in Africa. We assessed whether polio-eradication initiative resources are used in the surveillance for and response to other infectious diseases in Africa.

METHODS

During October 1999-March 2000, we developed and administered a survey questionnaire to at least one key informant from the 38 countries that regularly report on polio activities to WHO. The key informants included WHO-AFRO staff assigned to the countries and Ministry of Health personnel.

RESULTS

We obtained responses from 32 (84%) of the 38 countries. Thirty-one (97%) of the 32 countries had designated surveillance officers for AFP surveillance, and 25 (78%) used the AFP resources for the surveillance and response to other infectious diseases. In 28 (87%) countries, AFP program staff combined detection for AFP and other infectious diseases. Fourteen countries (44%) had used the AFP laboratory specimen transportation system to transport specimens to confirm other infectious disease outbreaks. The majority of the countries that performed AFP surveillance adequately (i.e., non polio AFP rate = 1/100,000 children aged <15 years) in 1999 had added 1-5 diseases to their AFP surveillance program.

CONCLUSIONS

Despite concerns regarding the targeted nature of AFP surveillance, it is partially integrated into existing surveillance and response systems in multiple African countries. Resources provided for polio eradication should be used to improve surveillance for and response to other priority infectious diseases in Africa.

A complex rearrangement involving simultaneous translocation and inversion is associated with a change in chromatin compaction

Detailed fluorescence in situ hybridisation analysis of a previously described translocation revealed it to be a more complex rearrangement consisting of both a translocation and a paracentric inversion with an apparent coincident breakpoint at 16p13.3, t(14;16)(p32;p13.3) inv16(p13.3p12.1). This unusual three-breakpoint rearrangement was not obvious from examination of G-banding. Such rearrangements may be undiagnosed in cytogenetic studies. The presence of an interstitial deletion of 16p was unlikely as the rearranged chromosome contained probes distributed along the short arm of chromosome 16. Fluorescence in situ hybridisation studies suggested that the inverted segment was smaller in size than that on the normal chromosome. Measurements of distances between probes on metaphase chromosomes confirmed that there was differential compaction of the inverted portion on 16p. The inverted region was significantly reduced in size by 21% compared with the same region on the normal chromosome 16. The size reduction across the region was non-uniform, with one region showing a 55% increase in compaction. The change in compaction was also associated with a change in the lateral position of a probe on the chromatids. The finding that a single chromosome breakpoint can change the compaction of chromatin over an extensive region has implications for models of the structure of metaphase chromosomes. Possible explanations are either a localized severe disruption of DNA packaging over relatively short distances (hundreds of kilobases) or a more generalized change that extends over many megabases. These results raise the important possibility that chromosome breaks may result in a more global change in DNA compaction across large segments of a chromosome.

Examining the relationship between cancer invasion/metastasis and drug resistance

Studies of cancer invasion/metastasis and drug resistance have in the past generally proceeded along the separate pathways of research. Recently, however, interest has been focused on the possible relationship between drug resistance and cancer invasion and metastasis. A relationship between these two phenotypes has been demonstrated by two types of observation: firstly, some tumor cells selected for resistance to drugs are more invasive/metastatic relative to non-resistant parental cells; secondly, in some cases, secondary (more metastatic) tumors are more resistant to chemotherapeutic drugs than their primary counterparts. In other instances reported in the literature, no correlation is seen between drug exposure/resistance and cancer invasion/metastasis. The possibility that treatment with some chemotherapeutic drugs may be able to promote cancer invasion and metastasis needs further investigation because of its potential clinical relevance. A better understanding of any relationship between drug resistance and cancer invasion could lead to more effective cancer treatment.

Clinical features of a novel TIMP-3 mutation causing Sorsby's fundus dystrophy: implications for disease mechanism

AIMS

To describe the phenotype in three family members affected by a novel mutation in the gene coding for the enzyme tissue inhibitor of metalloproteinase-3 (TIMP-3).

METHODS

Three members of the same family were seen with a history of nyctalopia and visual loss due to maculopathy. Clinical features were consistent with Sorsby's fundus dystrophy. Exon 5 of the gene coding for TIMP-3 was amplified by the polymerase chain reaction, single strand conformation polymorphism analysis undertaken and exon 5 amplicons were directly sequenced.

RESULTS

Onset of symptoms was in the third to fourth decade. Five of six eyes had geographic macular atrophy rather than neovascularisation as a cause for central visual loss. Peripheral retinal pigmentary disturbances were present. Scotopic ERGs were abnormal in all three. Mutation analysis showed a G-->T transversion in all three resulting in a premature termination codon, E139X, deleting most of the carboxy terminal domain of TIMP-3.

CONCLUSIONS

The patients described had a form of Sorsby's fundus dystrophy which fell at the severe end of the spectrum of this disease. Postulated disease mechanisms include deposition of dimerised TIMP-3 protein.

The role of matrilysin (MMP-7) in leukaemia cell invasion

The matrix metalloproteinases (MMPs) are important in tumour cell invasion and metastasis in many common cancers. However, relatively few studies have investigated the role of MMPs and their inhibitors, the tissue inhibitors of metalloproteinases (TIMPs), in leukaemia cell invasion. This study examined two leukaemia cell lines, K562 and HL-60 and showed that the K562 cell line was four times more invasive than the HL-60 cell line. The expression of MMP-2, matrilysin (MMP-7), MMP-9. TIMP-1, TIMP-2 and TIMP-3 was analysed. Both cell lines produced similar amounts of MMP-2, MMP-9 and TIMP-2. The K562 cells expressed more TIMP-1 than the HL-60 cells and neither cell line expressed TIMP-3. Interestingly, only the K562 cells expressed matrilysin suggesting a potential role for matrilysin in leukaemia cell invasion. in vitro invasion assays performed in the presence of a matrilysin blocking antibody showed a 40% reduction in invasive ability. This data suggests that matrilysin plays an important role in leukaemia cell invasion.

Selection with melphalan or paclitaxel (Taxol) yields variants with different patterns of multidrug resistance, integrin expression and in vitro invasiveness

A melphalan-resistant variant (Roswell Park Memorial Institute (RPMI)-2650Ml) and a paclitaxel-resistant variant (RPMI-2650Tx) of the drug-sensitive human nasal carcinoma cell line, RPMI-2650, were established. The multidrug resistance (MDR) phenotype in the RPMI-2650Tx appeared to be P-glycoprotein (PgP)-mediated. Overexpression of multidrug resistant protein (MRP) family members was observed in the RPMI-2650Ml cells, which were also much more invasive in vitro than the parental cell line or the paclitaxel-resistant variant. Increased expression of alpha(2), alpha(5), alpha(6), beta(1) and beta(4) integrin subunits, decreased expression of alpha(4) integrin subunit, stronger adhesion to collagen type IV, laminin, fibronectin and matrigel, increased expression of MMP-2 and MMP-9 and significant motility compared with the parental cells were observed, along with a high invasiveness in the RPMI-2650Ml cells. Decreased expression of the alpha(2) integrin subunit, decreased attachment to collagen type IV, absence of cytokeratin 18 expression, no detectable expression of gelatin-degrading proteases and poor motility may be associated with the non-invasiveness of the RPMI-2650Tx variant. These results suggest that melphalan exposure can result in not only a MDR phenotype, but could also make cancer cells more invasive, whereas paclitaxel exposure resulted in MDR without increasing the in vitro invasiveness in the RPMI-2650 cells.

Evidence for a prostate cancer susceptibility locus on the X chromosome

Over 200,000 new prostate cancer cases are diagnosed in the United States each year, accounting for more than 35% of all cancer cases affecting men, and resulting in 40,000 deaths annually. Attempts to characterize genes predisposing to prostate cancer have been hampered by a high phenocopy rate, the late age of onset of the disease and, in the absence of distinguishing clinical features, the inability to stratify patients into subgroups relative to suspected genetic locus heterogeneity. We previously performed a genome-wide search for hereditary prostate cancer (HPC) genes, finding evidence of a prostate cancer susceptibility locus on chromosome 1 (termed HPC1; ref. 2). Here we present evidence for the location of a second prostate cancer susceptibility gene, which by heterogeneity estimates accounts for approximately 16% of HPC cases. This HPC locus resides on the X chromosome (Xq27-28), a finding consistent with results of previous population-based studies suggesting an X-linked mode of HPC inheritance. Linkage to Xq27-28 was observed in a combined study population of 360 prostate cancer families collected at four independent sites in North America, Finland and Sweden. A maximum two-point lod score of 4.60 was observed at DXS1113, theta=0.26, in the combined data set. Parametric multipoint and non-parametric analyses provided results consistent with the two-point analysis. Significant evidence for genetic locus heterogeneity was observed, with similar estimates of the proportion of linked families in each separate family collection. Genetic mapping of the locus represents an important initial step in the identification of an X-linked gene implicated in the aetiology of HPC.

Expression of metalloproteinases and their inhibitors in human trophoblast continuous cell lines

Trophoblasts cells which are derived from the outer layer of the blastocyst have developed mechanisms by which they can invade the uterus and tap into the maternal circulation. In contrast to tumor cell invasion trophoblast invasion is precisely regulated, being confined spatially to the uterus and temporally to early pregnancy. The invasive properties manifested by trophoblasts are made possible by the secretion of proteolytic enzymes which can degrade components of the extracellular matrix (ECM). A number of investigators have shown that the matrix metalloproteinases (MMPs) are important mediators of trophoblast invasion. The two type IV collagenases, MMP-2 and MMP-9, which specifically degrade type IV collagen and gelatins have been of particular interest in this respect. In this paper we examine the expression and regulation of MMPs and their inhibitors in a series of trophoblast continuous cell lines. These cell lines, ED27, ED31, ED77, and a choriocarcinoma cell line, BeWo, were initially characterized with respect to various properties, including cytokeratin, hCG, and hPL expression. We have looked at the expression of MMPs and their inhibitors in these cell lines and their in vitro invasive behavior. Using zymography and RT-PCR we show that the trophoblast cell lines produce both MMP-2 and MMP-9, while the BeWo produce only MMP-2. Using an in vitro invasion assay the trophoblast cell lines were shown to be capable of invading while the BeWo were unable to invade. These results suggest that expression of MMP-9 in these cells is crucial for invasion. We have also examined the regulation of MMP expression by cytokines and found that MMP-9 expression could be modulated by IL-1 beta in these cell lines. The data presented in this paper suggest that these trophoblast cell lines present an ideal model system to investigate the regulation of metalloproteinases in trophoblast invasion.

Electroretinographic findings in macular dystrophy

The flash and pattern electroretinogram were investigated in a group of families with rare forms of inherited macular dystrophy, which included Sorsby's fundus dystrophy, X-linked retinoschisis and macular dystrophy of uncertain classification and variable expression. Flash electroretinograms, under both photopic and scotopic conditions, were attenuated in both Sorsby's fundus dystrophy and X-linked retinoschisis--with some effect on implicit time being noted in the latter condition--but in the unknown group the effect was less demonstrable, only 50% having attenuated flash electroretinograms. Pattern electroretinograms were reduced in all three conditions and in almost all cases. The study demonstrates that some so-called macular dystrophies also have widespread abnormalities affecting the peripheral retina. These findings may contribute to a better understanding of the underlying pathophysiologic mechanisms in these rare forms of retinal dysfunction.

Using YPLL in health planning

OBJECTIVE

The measurement of years of potential life lost before age 65 (YPLL) is one of the Health Outcome Indicators defined by the state of Florida to measure progress toward Healthy People 2000 objectives. The authors describe the outcomes of their work with county health agencies to encourage use of the YPLL statistic.

METHODS

Calculations of the 1993 YPLL rates for Florida counties with populations greater than 50,000 and of inter-county variability in YPLL rates were used to train county health agencies in the use of YPLL.

RESULTS

Sixty-eight percent of all years of potential life lost in Florida in 1993 were attributed to 10 causes. While the total YPLL rates ranged from 3500 per 100,000 to 7000 per 100,000 across Florida counties, the leading causes differed substantially across counties. The YPLL measure was found to be useful in helping county health agencies plan programs to reduce premature mortality.

CONCLUSIONS

Federal, state, and county health units can use YPLL rates to help guide activities toward Healthy People 2000 and to help identify new health problems that require forming new community alliances, but staff members must be trained to use the YPLL statistic appropriately. Causes that vary little across counties enable the implementation of statewide prevention approaches while causes that differ greatly by county will require locally designed interventions.

Outbreak of sporotrichosis among tree nursery workers

In spring 1994, an outbreak of sporotrichosis occurred at a tree nursery in Florida; 9 (14%) of 65 workers involved in production of sphagnum moss topiaries developed lymphocutaneous sporotrichosis. A cohort study of all 65 employees was conducted to identify risk factors for sporotrichosis, and an environmental investigation was done. The risk of sporotrichosis increased significantly with the duration of working with sphagnum moss (P < .05), in particular with filling topiaries (P < .05), and with having less gardening experience (P < .05). Wearing gloves was protective (P < .005). Sporothrix schenckii was cultured from patients and sphagnum moss used in topiary production. Use of restriction fragment length polymorphism revealed an identical pattern for patient isolates that was different from the patterns of environmental isolates. Physicians should be aware of sporotrichosis in patients with ulcerative skin lesions who have a history of occupational or recreational exposure to sphagnum moss.