Brain biopsies requiring Creutzfeldt-Jakob disease precautions in the Republic of Ireland 2005-2016

AIMS

Creutzfeldt-Jakob disease (CJD) risk precautions are required when performing brain biopsies on patients with a dementing illness and in 'risk' groups. The impact on a diagnostic neuropathology service is considerable. We sought to determine if better case selection might reduce the necessity for application of CJD risk precautions.

METHODS

We reviewed the clinical information, contributory investigations and final neuropathologic diagnosis in a cohort of patients (n = 21), referred to the National CJD Surveillance Centre between January 1, 2005, and December 31, 2016.

RESULTS

Of this 21-patient cohort, five were positive for CJD, four belonged to the 'at risk of CJD' category requiring brain surgery, while the remaining 12 were referred to the National CJD Surveillance Unit with CJD as part of their differential diagnosis. CJD was confirmed in 5/21 (three sporadic [s]CJD, one variant [v]CJD and one iatrogenic [i] CJD). CJD was clinically probable in 4/5 proven CJD patients (80%). The patients (n = 4) in the 'at risk of CJD' group were diagnosed with tumour (n = 2), inflammation (n = 1) and non-specific changes (n = 1). Of the remaining 12 patients (in whom CJD was included in the differential diagnosis), the final neuropathologic diagnoses included tumour (n = 2), neurodegenerative (n = 2), inflammatory (n = 1), metabolic (n = 2), vascular (n = 2) and non-specific gliosis (n = 3).

CONCLUSIONS

More often than not, the clinical suspicion of CJD was not borne out by the final neuropathological diagnosis. Failure by clinicians to adhere to the recommended CJD investigation algorithm impacts adversely on the neuropathology workload and causes unnecessary concern among operating theatre, laboratory and nursing personnel.

The role of androgen ablation in patients with biochemical or local failure after definitive radiation therapy: a survey of practice patterns of urologists and radiation oncologists in the United States

To identify therapeutic patterns for putative prostate cancer treatment failures and the role played by androgen ablation therapy in these patients, a questionnaire study was undertaken with urologists and radiation oncologists who had attended a brachytherapy forum at the Seattle Prostate Institute (SPI). Hypothetical questions were asked about recommendations the physicians would give to a patient demonstrating biochemical or local failure after external-beam radiation therapy. Most of the physicians queried were in private practice; 53% were radiation oncologists and 47% were urologists. The respondents' recommendations for a hypothetical patient, who was 45 to 65 years of age, with a biopsy-proven local recurrence was treatment with androgen ablation (35% of respondents), radical prostatectomy (25%), interstitial brachytherapy (20%), and observation (19%). In the 65- to 75-year-old patient with a local recurrence, the respondents recommended observation (43%), androgen ablation (35%), interstitial brachytherapy (17%), and radical prostatectomy (4%). In patients receiving androgen ablation for a biochemical failure alone, there was no consensus on whether to use luteinizing hormone-releasing hormone agonist alone, total androgen ablation, orchiectomy, or intermittent androgen ablation. Criteria that prompted physicians to initiate androgen ablation were based on the rate of prostate-specific antigen (PSA) increase (67%), an absolute PSA number (24%), or clinical failure (9%). In the younger patient with a local recurrence, local intervention with radical prostatectomy or interstitial brachytherapy was recommended most often, followed by androgen ablation, then by observation. In the older patient, observation was recommended most often, followed closely by androgen ablation. Overall, there was a lack of consensus on how to deliver androgen ablation. However, there was remarkable agreement between urologists and radiation oncologists on virtually all issues queried.

The intervention research process in occupational safety and health: an overview from the National Occupational Research Agenda Intervention Effectiveness Research team

The goal of occupational safety and health intervention effectiveness research is to determine whether specific interventions work to prevent work-related injury and illness. But that is not the whole story. It is also important that the development and implementation of the intervention be evaluated. All three phases (development, implementation, and effectiveness) are central to a model of intervention research proposed by the National Occupational Research Agenda Intervention Effectiveness Research team. Areas for future research are also presented.

Predicting recovery using continuous low back pain outcome measures

BACKGROUND CONTEXT

There is a lack of research evaluating multiple follow-up visits, specifically when using continuous outcome measures. Continuous outcome measures with several follow-up assessments would allow us to evaluate rate of recovery.

PURPOSE

To predict low back pain outcomes based on the quantification of initial conditions.

STUDY DESIGN/SETTING

This was a prospective study where patients were enrolled within the first month of low back pain symptoms and evaluated for 3 months. Patients were recruited from several primary care facilities.

PATIENT SAMPLE

Thirty-two patients with local low back pain symptoms were recruited for the study.

OUTCOME MEASURES

There were four major outcome measures, including functional performance probability, symptom intensity, impairment of activities of daily living, and a summary outcome measure.

METHODS

Regression models were constructed using the initial conditions, including psychological, psychosocial, physical workplace, and personal factors, to predict the rate of recovery for each outcome measure.

RESULTS

Twenty-eight patients completed the study. The r2 value for the rate of recovery regression models were 0.77 symptom intensity prediction, 0.85 activities of daily living prediction, 0.87 functional performance probability prediction, and 0.96 summary outcome measure prediction. Two functional performance patterns of recovery were found, including a steady improvement and a large jump in improvement. A discriminant function model identified the pattern of recovery in 91% of cases given initial conditions.

CONCLUSIONS

Continuous outcome measures can be accurately predicted given the initial conditions.

CRKL binding to BCR-ABL and BCR-ABL transformation

The SH2-SH3 domain-containing adaptor protein CRKL is the predominant tyrosine phosphorylated protein in chronic myelogenous leukemia (CML) neutrophils and BCR-ABL-expressing cell lines. The amino terminal CRKL SH3 domain binds directly to a proline-rich region in the C-terminus of BCR-ABL. BCR-ABL mutants with deletions of this region were constructed to assess biologic effects of eliminating the CRKL binding site. Yeast two-hybrid analysis and gel overlay assays show eradication of the direct interaction of CRKL with BCR-ABL in the proline deletion mutants. However, these BCR-ABL mutants transform myeloid cells to growth factor independence, and in these cells CRKL is tyrosine phosphorylated and associates with BCR-ABL. These findings suggest both direct and indirect interactions of CRKL with BCR-ABL. Thus, disruption of the direct interaction with BCR-ABL has not excluded a role for CRKL in BCR-ABL-mediated transformation.

Structural requirements for function of the Crkl adapter protein in fibroblasts and hematopoietic cells

Crkl is an adapter protein and phosphotyrosine-containing substrate implicated in transformation by the bcr-abl oncogene and in signaling by cytokines. When phosphorylated, Crkl binds through its Src homology 2 (SH2) domain to other tyrosine phosphoproteins such as paxillin and Cbl. Overexpression of Crkl in fibroblasts induces transformation. Here we examine the role of Crkl in hematopoietic cells and find that overexpression of Crkl confers a signal leading to increased adhesion to fibronectin. In both fibroblasts and hematopoietic cells, individual mutations or deletions of each SH2 and SH3 domain abrogated transformation and adhesion, respectively, indicating that interactions with other proteins such as Cbl and paxillin (SH2 domain) and Abl, Sos, and C3G (N-terminal SH3 domain) are essential for biological activity. In vivo and in vitro tryptic phosphopeptide mapping studies show that Crkl is phosphorylated on multiple tyrosine residues when overexpressed or when activated by Bcr-Abl. Mutation at tyrosine 207, a residue conserved in c-Crk, abrogates all in vivo tyrosine phosphorylation of Crkl. Despite this loss of phosphotyrosine, mutation at this site enhanced Crkl function as measured by complex formation with SH2 binding proteins, signal transduction to Jun Kinase, and fibroblast transformation. These observations implicate Crkl in cellular adhesion and demonstrate that Y207 functions as a negative regulatory site.

Human autosomal recessive osteopetrosis maps to 11q13, a position predicted by comparative mapping of the murine osteosclerosis (oc) mutation

Autosomal recessive osteopetrosis is a rare congenital disorder characterized by the development of abnormally dense bones, acrocephaly, severe anemia, hepatosplenomegaly and progressive deafness and blindness. The clinical course is rapidly progressive and is lethal at a very young age in the absence of a bone marrow transplant. The failure to remodel developing bone that is the basis of the disease process is most likely due to a dysfunction of the bone resorptive cell, the osteoclast. This phenotype is similar to that of the murine mutation osteosclerosis (oc), which is localized to proximal mouse chromosome 19. Given the similarity between the human and murine phenotypes, we tested whether human osteopetrosis maps to a region of conserved synteny. Microsatellite markers in the region of 11q12-13 were found to be linked to osteopetrosis in two consanguineous Bedouin kindreds. Recombination events were used to define the disease interval to an approximately 14 cM region between D11S1983 and D11S2371. A maximum LOD score of 7. 94 was obtained with D11S449 at straight theta = 0.

Interactions of CBL with BCR-ABL and CRKL in BCR-ABL-transformed myeloid cells

The Philadelphia chromosome, detected in virtually all cases of chronic myelogenous leukemia (CML), is formed by a reciprocal translocation between chromosomes 9 and 22 that fuses BCR-encoded sequences upstream of exon 2 of c-ABL. The BCR-ABL fusion creates a gene whose protein product, p210BCR-ABL, has been implicated as the cause of the disease. Although ABL kinase activity has been shown to be required for the transforming abilities of BCR-ABL and numerous substrates of the BCR-ABL tyrosine kinase have been identified, the requirement of most of these substrates for the transforming function of BCR-ABL is unknown. In this study we mapped a direct binding site of the c-CBL proto-oncogene to the SH2 domain of BCR-ABL. This interaction only occurs under conditions where c-CBL is tyrosine-phosphorylated. Despite the direct interaction of c-CBL with the SH2 domain of BCR-ABL, deletion of the SH2 domain of BCR-ABL did not result in an alteration in the complex formation of BCR-ABL and c-CBL, suggesting that another site of direct interaction between c-CBL and BCR-ABL exists or that another protein mediates an indirect interaction of c-CBL and BCR-ABL. Since CRKL, an SH2, SH3 domain-containing adapter protein is known to bind directly to BCR-ABL and also binds to tyrosine-phosphorylated c-CBL, the ability of CRKL to mediate a complex between c-CBL and BCR-ABL was examined.

Direct binding of CRKL to BCR-ABL is not required for BCR-ABL transformation

CRKL has previously been shown to be a major tyrosine phosphorylated protein in neutrophils of patients with BCR-ABL+ chronic myelogenous leukemia and in cell lines expressing BCR-ABL CRKL and BCR-ABL form a complex as demonstrated by coimmunoprecipitation and are capable of a direct interaction in a yeast two-hybrid assay. We have mapped the site of interaction of CRKL and BCR-ABL to the amino terminal SH3 domain of CRKL with a proline rich region in the C-terminus of ABL. The proline-rich region was mutated and the effect of this deletion on BCR-ABL transforming function was assayed. Our data show that this deletion does not impair the ability of BCR-ABL to render myeloid cells factor independent for growth. In cells expressing the proline deletion mutation of BCR-ABL, CRKL is still tyrosine phosphorylated and forms a complex with BCR-ABL as demonstrated by coimmunoprecipitation. Our data suggest that the interaction between CRKL and the proline deletion mutant of BCR-ABL is an indirect interaction as CRKL does not interact directly with the proline deletion mutant of BCR-ABL in a gel overlay assay or in a yeast two-hybrid assay. Thus, a direct interaction of CRKL and BCR-ABL is not required for CRKL to become tyrosine phosphorylated by BCR-ABL and suggests that CRKL function may still be required for BCR-ABL function through an indirect interaction.

Crkl is the major tyrosine-phosphorylated protein in neutrophils from patients with chronic myelogenous leukemia

The Philadelphia chromosome (Ph1), detected in virtually all cases of chronic myelogenous leukemia (CML), is formed by a reciprocal translocation between chromosome 9 and 22 that fuses Bcr-encoded sequences upstream of exon 2 of c-Abl. This oncogene produces a fusion protein, p210bcr-abl, in which the Abl tyrosine kinase activity is elevated. Using anti-phosphotyrosine immunoblotting, we have compared the pattern of phosphotyrosine-containing proteins from freshly prepared neutrophils of patients in the stable phase of CML to normal controls. The only consistent difference was the presence of a 39-kDa tyrosine-phosphorylated protein in 18 out of 18 neutrophil samples from CML patients that was not seen in normal controls. This same protein, as assessed by two-dimensional anti-phosphotyrosine immunoblotting, was also present in cell lines expressing p210bcr-abl, including K562 cells. Using K562 cells as a source of protein, the 39-kDa protein was purified and identified by microsequencing as Crkl, an SH2/SH3 adaptor protein related to the crk oncogene of the avian sarcoma virus, CT10. A direct interaction between Crkl and Abl has also been shown using a yeast two-hybrid screen.

The integration of inpatient treatment and transitional day hospital: application of a problem-solving approach

Because of the trend in inpatient psychiatry toward a marked decrease in length of hospitalization, clinicians must reconceptualize the manner in which psychosocial treatments are organized in the inpatient milieu. Considerable data suggest that problem-solving therapies may be a productive way to integrate the groups and activities in the therapeutic milieu. This paper describes the application of a problem-solving approach to the therapeutic milieu and indicates that the therapeutic gains from this approach may be enhanced by combining inpatient treatment with a transitional day hospital program. We identify the empirical underpinnings of this model and describe how it has been used to treat a schizophrenic patient. We suggest that problem-solving therapies are effective for promoting behavioral change on the general psychiatric inpatient unit.

A problem-solving approach to group psychotherapy in the inpatient milieu

Because of the trend toward a marked decrease in length of psychiatric hospitalization, clinicians need to improve the organization of the therapeutic milieu so that behavioral changes can be effected more rapidly. A university general psychiatric unit has adapted a problem-solving model that integrates groups and activities so that each one focuses on complementary behavioral objectives for each patient with the aim of effecting more rapid behavior change. The stages of the model are incorporated in a weekly sequence that begins with a goal-setting group. In a series of subsequent groups, each patient tries to develop and implement a solution to the problem identified that week. At the end of each week, patients participate in a goal review group, with feedback from staff and peers and self-reinforcement. The model can be used with a diverse patient population without interfering with each patient's individual psychotherapy or pharmacotherapy.

Objective comparison of manual dexterity in physicians and surgeons

Recent interest in the assessment of manual dexterity of surgical residency applicants prompted an investigation of psychomotor skills in surgeons and physicians. The Purdue Pegboard and Minnesota Manual Dexterity tests were given to 57 subjects. Analysis of the data revealed no significant difference in dexterity between medical and surgical residents, suggesting that medical students do not select specialty training programs because of the presence or absence of manual skills. The data also revealed that surgical staffmen performed substantially worse than those in the other groups on some of the tests, possibly because of an older average age. The authors conclude from their data that manual dexterity tests should not be used in assessing candidates for surgical residency training positions.

Parent-child activity group treatment in preventive psychiatry

This article describes the role that occupational therapy played in a community outreach program instituted collabora- tively by a major teaching hospital and a local day care center. The program focused on preschool children at risk for developing psychiatric disorders. A parent-child activity group was introduced and developed by an occupational therapist who was a member of the hospital staff. The frame of reference, the parent-child intervention including the use of play and group process, and the method of monitoring change in families are explained. A case study is also provided.

Evaluation of smoking prohibition policy in a health maintenance organization

Four months after Group Health Cooperative of Puget Sound adopted a policy prohibiting smoking in its 35 facilities, we assessed attitudes and behavior of a sample of 447 employees. Results indicated that 85 per cent of employees approved of the decision to go smoke-free, the rate of reported smoking decreased, and a large proportion of non-smokers believed that their own and co-workers' work performance had improved. Suggestions for successful implementation of future programs are provided.

The use of alternated stimuli to reduce response decrement in the auditory testing of newborn infants

Two narrow-band noises, one centered on 2000 Hz (Stimulus A), the other on 1250 Hz (Stimulus B), were used to study behavioral response decrement among 400 newborn infants. A set of three presentations was administered to each subject at 90 dB SPL. Interstimulus intervals were not less than 60 seconds. For half of the subjects, stimuli within sets were repeated (either AAA or BBB); for the remainder, alternated (either ABA or BAB). Response decrement occurred under the first condition, but not under the second.