Phylogenetic analysis of the cadherin superfamily allows identification of six major subfamilies besides several solitary members

Cadherins play an important role in specific cell-cell adhesion events. Their expression appears to be tightly regulated during development and each tissue or cell type shows a characteristic pattern of cadherin molecules. Inappropriate regulation of their expression levels or functionality has been observed in human malignancies, in many cases leading to aggravated cancer cell invasion and metastasis. The cadherins form a superfamily with at least six subfamilies, which can be distinguished on the basis of protein domain composition, genomic structure, and phylogenetic analysis of the protein sequences. These subfamilies comprise classical or type-I cadherins, atypical or type-II cadherins, desmocollins, desmogleins, protocadherins and Flamingo cadherins. In addition, several cadherins clearly occupy isolated positions in the cadherin superfamily (cadherin-13, -15, -16, -17, Dachsous, RET, FAT, MEGF1 and most invertebrate cadherins). We suggest a different evolutionary origin of the protocadherin and Flamingo cadherin genes versus the genes encoding desmogleins, desmocollins, classical cadherins, and atypical cadherins. The present phylogenetic analysis may accelerate the functional investigation of the whole cadherin superfamily by allowing focused research of prototype cadherins within each subfamily.

E-cadherin is a tumour/invasion suppressor gene mutated in human lobular breast cancers

Compelling experimental evidence exists for a potent invasion suppressor role of the cell-cell adhesion molecule E-cadherin. In addition, a tumour suppressor effect has been suggested for E-cadherin. In human cancers, partial or complete loss of E-cadherin expression correlates with malignancy. To investigate the molecular basis for this altered expression we developed a comprehensive PCR/SSCP mutation screen for the human E-cadherin gene. For 49 breast cancer patients the occurrence of tumour-specific mutations in the E-cadherin gene was examined. No relevant DNA changes were encountered in any of 42 infiltrative ductal or medullary breast carcinoma samples. In contrast, four out of seven infiltrative lobular breast carcinomas harboured protein truncation mutations (three nonsense and one frameshift) in the extracellular part of the E-cadherin protein. Each of the four lobular carcinomas with E-cadherin mutations showed tumour-specific loss of heterozygosity of chromosomal region 16q22.1 containing the E-cadherin locus. In compliance with this, no E-cadherin expression was detectable by immunohistochemistry in these four tumours. These findings offer a molecular explanation for the typical scattered tumour cell growth in infiltrative lobular breast cancer.

Predominance of beta-catenin mutations and beta-catenin dysregulation in sporadic aggressive fibromatosis (desmoid tumor)

Aggressive fibromatosis (also called desmoid tumor) occurs as a sporadic lesion or as part of Familial Adenomatous Polyposis, which is caused by germ line mutations in the Adenomatous polyposis Coli (APC) gene. APC is involved in the regulation of the cellular level of beta-catenin, which is a mediator in Wnt signaling. Mutational analysis of the beta-catenin and APC genes was performed in 42 sporadic aggressive fibromatoses. Nine tumors had mutations in APC, and 22 had a point mutation in beta-catenin at either codon 45 or codon 41 (producing a stabilized beta-catenin protein product). Immunohistochemistry showed an elevated beta-catenin protein level in all tumors, regardless of mutational status. Beta-catenin localized to the nucleus, and was not tyrosine phosphorylated in the six tumors in which this was tested. The demonstration of mutations in two mediators in the Wnt-APC-beta-catenin pathway implicates beta-catenin stabilization as the key factor in the pathogenesis of aggressive fibromatosis. This is the first demonstration of somatic beta-catenin mutations in a locally invasive, but non metastatic lesion composed of spindle cells, illustrating the importance of beta-catenin stabilization in a variety of cell types and neoplastic processes. Moreover, this tumor has one of the highest reported frequencies of beta-catenin mutations of any tumor type.

Effect of custom-made footwear on foot ulcer recurrence in diabetes: a multicenter randomized controlled trial

OBJECTIVE

Custom-made footwear is the treatment of choice to prevent foot ulcer recurrence in diabetes. This footwear primarily aims to offload plantar regions at high ulcer risk. However, ulcer recurrence rates are high. We assessed the effect of offloading-improved custom-made footwear and the role of footwear adherence on plantar foot ulcer recurrence.

RESEARCH DESIGN AND METHODS

We randomly assigned 171 neuropathic diabetic patients with a recently healed plantar foot ulcer to custom-made footwear with improved and subsequently preserved offloading (∼20% peak pressure relief by modifying the footwear) or to usual care (i.e., nonimproved custom-made footwear). Primary outcome was plantar foot ulcer recurrence in 18 months. Secondary outcome was ulcer recurrence in patients with an objectively measured adherence of ≥80% of steps taken.

RESULTS

On the basis of intention-to-treat, 33 of 85 patients (38.8%) with improved footwear and 38 of 86 patients (44.2%) with usual care had a recurrent ulcer (relative risk -11%, odds ratio 0.80 [95% CI 0.44-1.47], P = 0.48). Ulcer-free survival curves were not significantly different between groups (P = 0.40). In the 79 patients (46% of total group) with high adherence, 9 of 35 (25.7%) with improved footwear and 21 of 44 (47.8%) with usual care had a recurrent ulcer (relative risk -46%, odds ratio 0.38 [0.15-0.99], P = 0.045).

CONCLUSIONS

Offloading-improved custom-made footwear does not significantly reduce the incidence of plantar foot ulcer recurrence in diabetes compared with custom-made footwear that does not undergo such improvement, unless it is worn as recommended.

Risk factors for plantar foot ulcer recurrence in neuropathic diabetic patients

OBJECTIVE

Recurrence of plantar foot ulcers is a common and major problem in diabetes but not well understood. Foot biomechanics and patient behavior may be important. The aim was to identify risk factors for ulcer recurrence and to establish targets for ulcer prevention.

RESEARCH DESIGN AND METHODS

As part of a footwear trial, 171 neuropathic diabetic patients with a recently healed plantar foot ulcer and custom-made footwear were followed for 18 months or until ulceration. Demographic data, disease-related parameters, presence of minor lesions, barefoot and in-shoe plantar peak pressures, footwear adherence, and daily stride count were entered in a multivariate multilevel logistic regression model of plantar foot ulcer recurrence.

RESULTS

A total of 71 patients had a recurrent ulcer. Significant independent predictors were presence of minor lesions (odds ratio 9.06 [95% CI 2.98-27.57]), day-to-day variation in stride count (0.93 [0.89-0.99]), and cumulative duration of past foot ulcers (1.03 [1.00-1.06]). Significant independent predictors for those 41 recurrences suggested to be the result of unrecognized repetitive trauma were presence of minor lesions (10.95 [5.01-23.96]), in-shoe peak pressure <200 kPa with footwear adherence >80% (0.43 [0.20-0.94]), barefoot peak pressure (1.11 [1.00-1.22]), and day-to-day variation in stride count (0.91 [0.86-0.96]).

CONCLUSIONS

The presence of a minor lesion was clearly the strongest predictor, while recommended use of adequately offloading footwear was a strong protector against ulcer recurrence from unrecognized repetitive trauma. These outcomes define clear targets for diabetic foot screening and ulcer prevention.

The role of the E-cadherin/catenin adhesion complex in the development and progression of cancer

The E-cadherin/catenin protein complex regulates the functional integrity of epithelia by mediating specific intercellular adhesion, Defects in the transmembrane E-cadherin protein play an important role in several human cancer types. E-cadherin-inactivating mutations were mainly found in sporadic lobular breast carcinoma and in both familial and sporadic diffuse gastric carcinoma. Armadillo proteins such as beta-catenin and p120ctn are complexed to the cytoplasmic tail of E-cadherin, whereas the vinculin-related alphaE-catenin protein forms a link to the actin cytoskeleton. The latter shows inactivating deletions in various tumor cell lines. Apparently, both E-cadherin and alphaE-catenin serve as tumor suppressor and invasion suppressor molecules. On the other hand, protein-stabilizing oncogenic mutations of beta-catenin were found at high frequency in particular human tumor types. Mutated beta-catenin protein is imported into the nucleus, and its binding to LEF/TCF transcription factors modulates transcription of intriguing target genes. Also p120ctn was recently found to arrive in the nucleus and to interact with a transcription factor. Furthermore, a wide variety of mechanisms have been described to regulate in a reversible way E-cadherin/catenin-mediated cell adhesion and differentiation. These phenomena appear to be crucial in human cancer development and progression.

Impact of ICU-acquired weakness on post-ICU physical functioning: a follow-up study

Introduction

ICU-acquired weakness is thought to mediate physical impairments in survivors of critical illness, but few studies have investigated this thoroughly. The purpose was to investigate differences in post-ICU mortality and physical functioning between patients with and without ICU-acquired weakness at 6 months after ICU discharge.

Method

ICU patients, mechanically ventilated ≥2 days, were included in a single-center prospective observational cohort study. ICU-acquired weakness was diagnosed when the average Medical Research Council score was <4 in awake and attentive patients. Post-ICU mortality was recorded until 6 months after ICU discharge; in surviving patients, physical functioning was assessed using the Short-Form Health Survey physical functioning domain. The independent effect of ICU-acquired weakness on post-ICU mortality was analyzed using a multivariable Cox proportional hazards model. The independent effect of ICU-acquired weakness on the physical functioning domain score was analyzed using a multivariable linear regression model.

Results

Of the 156 patients included, 80 had ICU-acquired weakness. Twenty-three patients died in the ICU (20 with ICU-acquired weakness); during 6 months follow-up after ICU discharge another 25 patients died (17 with ICU-acquired weakness). Physical functioning domain scores were available for 96 survivors (39 patients with ICU-acquired weakness). ICU-acquired weakness was independently associated with an increase in post-ICU mortality (hazard ratio 3.6, 95% confidence interval, 1.3 to 9.8; P = 0.01) and with a decrease in physical functioning (β: -16.7 points; 95% confidence interval, -30.2 to -3.1; P = 0.02).

Conclusion

ICU-acquired weakness is independently associated with higher post-ICU mortality and with clinically relevant lower physical functioning in survivors at 6 months after ICU discharge.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0937-2) contains supplementary material, which is available to authorized users.

Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations

OBJECTIVE

To develop evidence-based recommendations for effective and safe diagnostic assessment and intervention strategies for the physiotherapy treatment of patients in intensive care units.

METHODS

We used the EBRO method, as recommended by the 'Dutch Evidence Based Guideline Development Platform' to develop an 'evidence statement for physiotherapy in the intensive care unit'. This method consists of the identification of clinically relevant questions, followed by a systematic literature search, and summary of the evidence with final recommendations being moderated by feedback from experts.

RESULTS

Three relevant clinical domains were identified by experts: criteria to initiate treatment; measures to assess patients; evidence for effectiveness of treatments. In a systematic literature search, 129 relevant studies were identified and assessed for methodological quality and classified according to the level of evidence. The final evidence statement consisted of recommendations on eight absolute and four relative contra-indications to mobilization; a core set of nine specific instruments to assess impairments and activity restrictions; and six passive and four active effective interventions, with advice on (a) physiological measures to observe during treatment (with stopping criteria) and (b) what to record after the treatment.

CONCLUSIONS

These recommendations form a protocol for treating people in an intensive care unit, based on best available evidence in mid-2014.

Molecular cloning of the human p120ctn catenin gene (CTNND1): expression of multiple alternatively spliced isoforms

Catenins were discovered as proteins that are linked to the cytoplasmic domain of transmembrane cadherins. Among these junctional plaque proteins are several members of the Armadillo gene family: beta-catenin, plakoglobin, and p120ctn. Recently it became clear that some catenins also mediate nuclear signaling. We performed a detailed analysis of the human p120ctn gene (HGMW-approved symbol CTNND1) and its transcripts. The human p120ctn gene comprises 21 exons, potentially encoding up to 32 protein isoforms as products of alternative splicing. Human isoforms, designated 1 to 4, differ from each other by the start codon used. Additional isoforms are derived from combinations with alternatively used exons A (exon 18) and B (20), near the end of the open reading frame, and also with exon C (11) in the middle of the open reading frame. Hence, the longest isoform is of type 1ABC and comprises 968 amino acid residues. The functional consequence of the observed multitude of p120ctn splice variants awaits further study, but tissue-specific expression was obvious. Further, we demonstrate that the exon organization, which is not simply related to the Armadillo repeat structure, is very well conserved between the p120ctn gene and the related ARVCF gene, but not at all between these two genes and the beta-catenin or plakoglobin genes. The present data favor the concept that p120ctn is the prototype of a subfamily of Armadillo proteins, comprising ARVCF, p0071, delta-catenin/NPRAP, and plakophilins 1 and 2, that are more related to each other than to other Armadillo proteins.

EFNS guideline on diagnosis and management of post-polio syndrome. Report of an EFNS task force

Post-polio syndrome (PPS) is characterized by new or increased muscular weakness, atrophy, muscle pain and fatigue several years after acute polio. The aim of the article is to prepare diagnostic criteria for PPS, and to evaluate the existing evidence for therapeutic interventions. The Medline, EMBASE and ISI databases were searched. Consensus in the group was reached after discussion by e-mail. We recommend Halstead's definition of PPS from 1991 as diagnostic criteria. Supervised, aerobic muscular training, both isokinetic and isometric, is a safe and effective way to prevent further decline for patients with moderate weakness (Level B). Muscular training can also improve muscular fatigue, muscle weakness and pain. Training in a warm climate and non-swimming water exercises are particularly useful (Level B). Respiratory muscle training can improve pulmonary function. Recognition of respiratory impairment and early introduction of non-invasive ventilatory aids prevent or delay further respiratory decline and the need for invasive respiratory aid (Level C). Group training, regular follow-up and patient education are useful for the patients' mental status and well-being. Weight loss, adjustment and introduction of properly fitted assistive devices should be considered (good practice points). A small number of controlled studies of potential-specific treatments for PPS have been completed, but no definitive therapeutic effect has been reported for the agents evaluated (pyridostigmine, corticosteroids, amantadine). Future randomized trials should particularly address the treatment of pain, which is commonly reported by PPS patients. There is also a need for studies evaluating the long-term effects of muscular training.

Intracavernous self-injection of vasoactive drugs in the treatment of impotence: 8-year experience with 615 cases

Of 615 patients with impotence of varying etiologies who were followed from 12 to 96 months after the institution of intracavernous self-injection therapy with vasoactive drugs (papaverine alone, papaverine and alpha-blockers, and Ceritine, a new multilevel acting drug) 87% (533 patients) returned for followup visits or were regularly contacted. Of these patients sexual activity was restored in 91%. The dropout rate was 11.25%. The 114 episodes of prolonged erections among 51 patients (4.57%) represented less than 3 per 1,000 of the 34,875 recorded injections. All patients were treated without complications. The percentage of patients suffering from nodules or permanent deformations was 2.8%. There were no cases of intracavernous fibrosis. The percentage of satisfied patients (satisfaction index 7 or greater) was 84.8%. Improvement in spontaneous erections during sexual intercourse was obtained in 65% of the cases: 15% no longer needed self-injections and 50% only used them occasionally while 35% remained entirely dependent.

The reproducibility and validity of the Canadian Occupational Performance Measure in parents of children with disabilities

OBJECTIVE

To study the reproducibility (inter-rater agreement), the construct and criterion validity of the Canadian Occupational Performance Measure (COPM) in the parents of children with disabilities.

DESIGN

The COPM was administered twice by two different occupational therapists. The inter-rater agreement of the content of the prioritized problems was explored. Data analysis of the reproducibility of the scores was based on the Bland and Altman method. Measures used: The construct validity was studied by comparing the results of the COPM with the Pediatric Evaluation of Disability Inventory, and a quality of life questionnaire. The criterion validity was verified with an open-ended question.

SETTING

Occupational therapy departments of a university hospital and three rehabilitation institutes.

SUBJECTS

One hundred and twenty-nine consecutive parents of children referred for occupational therapy.

RESULTS

Data were obtained for 80 children with a mean age of 3.7 years (range 1-7.5). Of the prioritized problems identified in the first interview, 80% were also prioritized in the second interview. The limits of agreement were - 2.4 to +2.3 for the mean performance score and - 2.3 to + 2.6 for the mean satisfaction score. Assumptions about the construct and criterion validity were confirmed.

CONCLUSIONS

The inter-rater agreement of the prioritized problems is good enough for client-centred occupational therapy. The reproducibility of the performance and satisfaction scores is moderate. The results support the construct and criterion validity. The COPM identifies many child-unique problems that are not assessed with existing standardized measurement instruments or with a simple open-ended question.

Adherence to wearing prescription custom-made footwear in patients with diabetes at high risk for plantar foot ulceration

OBJECTIVE

Prescription custom-made footwear can only be effective in preventing diabetic foot ulcers if worn by the patient. Particularly, the high prevalence of recurrent foot ulcers focuses the attention on adherence, for which objective data are nonexisting. We objectively assessed adherence in patients with high risk of ulcer recurrence and evaluated what determines adherence.

RESEARCH DESIGN AND METHODS

In 107 patients with diabetes, neuropathy, a recently healed plantar foot ulcer, and custom-made footwear, footwear use was measured during 7 consecutive days using a shoe-worn, temperature-based monitor. Daily step count was measured simultaneously using an ankle-worn activity monitor. Patients logged time away from home. Adherence was calculated as the percentage of steps that prescription footwear was worn. Determinants of adherence were evaluated in multivariate linear regression analysis.

RESULTS

Mean ± SD adherence was 71 ± 25%. Adherence at home was 61 ± 32%, over 3,959 ± 2,594 steps, and away from home 87 ± 26%, over 2,604 ± 2,507 steps. In 35 patients with low adherence (<60%), adherence at home was 28 ± 24%. Lower BMI, more severe foot deformity, and more appealing footwear were significantly associated with higher adherence.

CONCLUSIONS

The results show that adherence to wearing custom-made footwear is insufficient, particularly at home where patients exhibit their largest walking activity. This low adherence is a major threat for reulceration. These objective findings provide directions for improvement in adherence, which could include prescribing specific off-loading footwear for indoors, and they set a reference for future comparative research on footwear adherence in diabetes.

Plakophilin-3, a novel armadillo-like protein present in nuclei and desmosomes of epithelial cells

We report on a novel Armadillo-like protein, termed plakophilin-3. The human protein, which is encoded by a 2.8 kb messenger RNA, has a predicted molecular mass of 87 kDa. The protein comprises 10 Armadillo-like repeats, preceded by an amino-terminal region of 293 amino acid residues and followed by a short carboxy-terminal region of 27 amino acid residues. Plakophilin-3 is classified as a member of the p120(ctn)/plakophilin subfamily of Armadillo proteins based on the number and organization of the Armadillo repeats and its high sequence similarity to other members of this family. CLUSTAL W alignment of p120(ctn)/plakophilin subfamily members showed the plakophilin-3 protein to be most similar to plakophilin-1 and -2. Western blot analysis of plakophilin-3 revealed expression in all epithelial cell lines tested but not in foreskin fibroblasts and various sarcoma-derived cell lines. This is unlike most other members of the p120(ctn)/plakophilin subfamily, which are widely expressed. By immunofluorescence, the plakophilin-3 protein was colocalized with desmoglein in desmosomes of epithelial cells. In addition, an intriguing speckle-like nuclear staining was observed. Hence, like plakophilin-1 and -2, plakophilin-3 displays a dual intracellular location, i.e. in the desmosomal plaque and in the nucleus. These results suggest the involvement of plakophilin-3 in both desmosome-dependent adhesion and signaling pathways. Furthermore, the human plakophilin-3 gene was mapped on the chromosomal locus 11p15 by fluorescent in situ hybridization.

Standardisation of multiplex fluorescent short tandem repeat analysis for chimerism testing

To evaluate the origin of cells after allogeneic haematopoietic stem cell transplantation we optimised and evaluated two commercially available systems (AmpFlSTR Profiler Plus and GenePrint Powerplex-16) which are based on multiplex fluorescent short tandem repeat (STR) analysis. A standard procedure for interpretation of electropherographs was found essential to obtain reproducible results. On the basis of the relative length of donor and recipient alleles, TYPE-I (no shared alleles are used to calculate chimerism), TYPE-II (one shared and one unshared allele is used to calculate chimerism) or TYPE-III (not informative) allelic distribution types were distinguished. Also, stutter peaks were recognised as an important criterion to exclude a marker for analysis. Intralaboratory and multicentre evaluation of the AmpFlSTR Profiler Plus system showed that mixed blood samples could be determined with an absolute deviation of less than 2%. A sensitivity threshold was set at 5% for TYPE-I and 10% for TYPE-II markers since relative imprecision increases at low chimerism values. No significant difference of calculated chimerism values was observed between STR markers shared between both systems. By monitoring 26 allogeneic peripheral blood stem cell transplants, the applicability of the proposed method was demonstrated.

Disability and functional assessment in former polio patients with and without postpolio syndrome

OBJECTIVES

To compare perceived health problems and disability in former polio subjects with postpolio syndrome (PPS) and those without postpolio syndrome (non-PPS), and to evaluate perceived health problems, disability, physical performance, and muscle strength.

DESIGN

Cross-sectional survey; partially blinded data collection.

SUBJECTS

One hundred three former polio subjects, aged 32 to 60yrs. This volunteer sample came from referrals and patient contacts. Criterion for PPS: new muscle weakness among symptoms.

MAIN OUTCOME MEASURES

Nottingham Health Profile (NHP), adapted D-code of the International Classification of Impairments, Disabilities and Handicaps, performance test, and muscle strength assessment.

RESULTS

PPS subjects (n = 76) showed higher scores (p < .001) than non-PPS subjects (n = 27) within the NHP categories of physical mobility, energy, and pain. On a 16-item Polio Problems List, 78% of PPS subjects selected fatigue as their major problem, followed by walking outdoors (46%) and climbing stairs (41%). The disabilities of PPS subjects were mainly seen in physical and social functioning. No differences in manually tested strength were found between patient groups. PPS subjects needed significantly more time for the performance test than non-PPS subjects and their perceived exertion was higher. Perceived health problems (NHP-PhysMobility) correlated significantly with physical disability (r = .66), performance-time (r = .54), and muscle strength (r = .38). With linear regression analysis, 54% of the NHP-PhysMobility score could be explained by the performance test (time and exertion), presence of PPS, and muscle strength, whereas strength itself explained only 14% of the NHP-PhysMobility score.

CONCLUSIONS

PPS subjects are more prone to fatigue and have more physical mobility problems than non-PPS subjects. In former polio patients, measurements of perceived health problems and performance tests are the most appropriate instruments for functional evaluation.

Functional status after intensive care: a challenge for rehabilitation professionals to improve outcome

OBJECTIVE

To examine restrictions in daily functioning from a rehabilitation perspective in patients one year after discharge from the intensive care unit, and to identify prognostic factors for functional status.

DESIGN

Cross-sectional design.

PATIENTS

Consecutive patients who were admitted to the intensive care unit for more than 48 h (n = 255).

METHODS

One year after intensive care, functional status (Sickness Impact Profile) as primary outcome, and Quality of Life (SF-36), anxiety and depression (Hospital Anxiety Depression Scale), and post-traumatic stress disorder (Impact of Events Scale) were evaluated.

RESULTS

Fifty-four percent of the patients had restrictions in daily functioning. Walking and social activities were most frequently restricted (30-60% of the patients). Quality of life was lower than the general Dutch population. Symptoms of anxiety and depression were found in 14%, and post-traumatic stress disorder in 18%. Severity of illness at admission and length of stay in the intensive care unit were identified as prognostic factors, although they explained only 10% of functional status.

CONCLUSION

The high prevalence of long-lasting restrictions in physical, social and psychological functioning among patients who stayed in the intensive care unit for at least 2 days implies that these patients are a potential target population for rehabilitation medicine. Multidisciplinary therapies need to be developed and evaluated in order to improve outcome.

Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial

OBJECTIVE

To evaluate the effectiveness of treatment with collar or physiotherapy compared with a wait and see policy in recent onset cervical radiculopathy.

DESIGN

Randomised controlled trial.

SETTING

Neurology outpatient clinics in three Dutch hospitals.

PARTICIPANTS

205 patients with symptoms and signs of cervical radiculopathy of less than one month's duration

INTERVENTIONS

Treatment with a semi-hard collar and taking rest for three to six weeks; 12 twice weekly sessions of physiotherapy and home exercises for six weeks; or continuation of daily activities as much as possible without specific treatment (control group).

MAIN OUTCOME MEASURES

Time course of changes in pain scores for arm and neck pain on a 100 mm visual analogue scale and in the neck disability index during the first six weeks.

RESULTS

In the wait and see group, arm pain diminished by 3 mm/week on the visual analogue scale (beta=-3.1 mm, 95% confidence interval -4.0 to -2.2 mm) and by 19 mm in total over six weeks. Patients who were treated with cervical collar or physiotherapy achieved additional pain reduction (collar: beta=-1.9 mm, -3.3 to -0.5 mm; physiotherapy: beta=-1.9, -3.3 to -0.8), resulting in an extra pain reduction compared with the control group of 12 mm after six weeks. In the wait and see group, neck pain did not decrease significantly in the first six weeks (beta=-0.9 mm, -2.0 to 0.3). Treatment with the collar resulted in a weekly reduction on the visual analogue scale of 2.8 mm (-4.2 to -1.3), amounting to 17 mm in six weeks, whereas physiotherapy gave a weekly reduction of 2.4 mm (-3.9 to -0.8) resulting in a decrease of 14 mm after six weeks. Compared with a wait and see policy, the neck disability index showed a significant change with the use of the collar and rest (beta=-0.9 mm, -1.6 to -0.1) and a non-significant effect with physiotherapy and home exercises.

CONCLUSION

A semi-hard cervical collar and rest for three to six weeks or physiotherapy accompanied by home exercises for six weeks reduced neck and arm pain substantially compared with a wait and see policy in the early phase of cervical radiculopathy. Trial registration Clinical trials NCT00129714.

Dysregulation of the E-cadherin/catenin complex by irreversible mutations in human carcinomas

The different proteins of the E-cadherin/catenin cell-cell adhesion complex are believed to play a predominant role in carcinogenesis. Aberrant expression of these proteins has been found in many different human carcinomas, indicating abnormal regulation. In general, inactivating mutations of the human E-cadherin gene are rare; they are, however, highly frequent in infiltrating lobular breast carcinomas and in diffuse gastric carcinomas. These mutations mostly occur in combination with loss of heterozygosity (LOH) of the wild-type allele. Mutations were found at very early non-invasive stages, thus associating E-cadherin mutations with loss of growth control and defining E-cadherin as a real tumour suppressor for these particular tumour types. Defects affecting both alleles of the alpha E-catenin gene have been found in different human carcinoma cell lines, resulting in the loss of E-cadherin-mediated cell-cell adhesion. Mutations of the beta-catenin gene in colon tumours and melanomas were found to result in an accumulation of the protein in the cytosol. Upon translocation to the nucleus, this beta-catenin enhances TCF/LEF-dependent transcriptional activity. This suggests that mutated beta-catenin can act as an oncogene in these particular tumour types. The multiple interaction partners of beta-catenin are known to be involved in signal transduction, actin organization, protein phosphorylation or transcriptional regulation. This makes this protein an intriguing alternative target for either activation or inactivation in human cancer types characterized by frequent E-cadherin or APC deficiencies.

Genomic organization of the human beta-catenin gene (CTNNB1)

The cytoplasmic beta-catenin protein is implicated in signal transduction and associates with both the cell-cell adhesion protein E-cadherin and the tumor suppressor gene product APC. We determined the primary structure of the human beta-catenin gene (CTNNB1) by analysis of cDNA and genomic clones. The size of the complete gene was determined to be 23.2 kb. Restriction mapping and partial sequence analysis revealed 16 exons. All splice donor and acceptor sites were conformable to the GT/AG rule. The exon size ranged from 61 to 790 bp. Half of the introns were smaller than 550 bp, with the smallest being 84 bp and the longest being 6700 bp. The intron-exon boundaries did not coincide either with conserved sites in the 12 armadillo repeat sequences of beta-catenin or with intron-exon boundaries in the armadillo gene of Drosophila. A major site for transcription initiation was identified as an A residue 214 nucleotides upstream of the ATG initiation codon. The resulting transcript is 3362 nucleotides long. Compared to the previously published mRNA sequence, additional residues were identified, 16 at the 5' end and 766 at the 3' end of the mRNA. An alternative splice acceptor site within exon 16 reduced the 3' UTR sequence by 159 bp. Polymerase chain reaction on cDNA from 14 human cell lines demonstrated the general occurrence of both splice variants. The 5'-flanking region is highly GC-rich and lacks a CCAAT box, but contains a TATA box and potential binding sites for several transcription factors, such as NF kappa B, SP1, AP2, and EGR1. Both a 437-bp fragment and a 6-kb fragment, containing about 4.7 kb of the 5'-flanking region in addition to the noncoding exon 1 and 1 kb of intron 1, showed clear promoter activity when these fragments were linked to a secreted alkaline phosphatase reporter gene and transfected into a mouse epithelial cell line.

Randomized controlled trial on the effects of a supervised high intensity exercise program in patients with a hematologic malignancy treated with autologous stem cell transplantation: Results from the EXIST study

BACKGROUND

This single blind, multicenter randomized controlled trial aimed to evaluate the effectiveness of a supervised high intensity exercise program on physical fitness and fatigue in patients with multiple myeloma or lymphoma recently treated with autologous stem cell transplantation.

METHODS

109 patients were randomly assigned to the 18-week exercise intervention or the usual care control group. The primary outcomes included physical fitness (VO2peak and Wpeak determined using a cardiopulmonary exercise test; grip strength and the 30s chair stand test) and fatigue (Multidimensional Fatigue Inventory) and were assessed prior to randomization and after completion of the intervention or at similar time points for the control group. Multivariable multilevel linear regression analyses were performed to assess intervention effects.

RESULTS

Patients in the intervention group attended 86% of the prescribed exercise sessions. Of the patients in the control group, 47% reported ≥10 physiotherapy sessions, which most likely included supervised exercise, suggesting a high rate of contamination. Median improvements in physical fitness ranged between 16 and 25% in the intervention group and between 12 and 19% in the control group. Fatigue decreased in both groups. There were no significant differences between the intervention and control group.

CONCLUSION

We found no significant beneficial effects of the supervised high intensity exercise program on physical fitness and fatigue when compared to usual care. We hypothesized that the lack of significant intervention effects may relate to suboptimal timing of intervention delivery, contamination in the control group and/or suboptimal compliance to the prescribed exercise intervention.

TRIAL REGISTRATION

Netherlands Trial Register-NTR2341.

Deformities of the shoulder in infants younger than 12 months with an obstetric lesion of the brachial plexus

We performed a prospective study using MRI in 16 consecutive infants with a mean age of 5.2 months (2.7 to 8.7) who had shown inadequate recovery from an obstetric lesion of the brachial plexus in the first three months of life, in order to identify early secondary deformities of the shoulder. Shoulders were analysed according to a standardised MRI protocol. Measurements were made of the appearance of the glenoid, glenoid version and the position of the humeral head. The appearance of the glenoid on the affected side was normal in only seven shoulders. In the remainder it was convex in seven and bioconcave in three. The degree of subluxation of the humeral head was significantly greater (p = 0.01) in the affected shoulders than in normal shoulders (157 degrees v 170 degrees). The presence of an abnormal appearance of the glenoid, retroversion of the glenoid and subluxation of the humeral head increased with age. There was a statistical difference (p = 0.05) between infants younger than five months and those who were older.

Surviving critical illness: what is next? An expert consensus statement on physical rehabilitation after hospital discharge

BACKGROUND

The study objective was to obtain consensus on physical therapy (PT) in the rehabilitation of critical illness survivors after hospital discharge. Research questions were: what are PT goals, what are recommended measurement tools, and what constitutes an optimal PT intervention for survivors of critical illness?

METHODS

A Delphi consensus study was conducted. Panelists were included based on relevant fields of expertise, years of clinical experience, and publication record. A literature review determined five themes, forming the basis for Delphi round one, which was aimed at generating ideas. Statements were drafted and ranked on a 5-point Likert scale in two additional rounds with the objective to reach consensus. Results were expressed as median and semi-interquartile range, with the consensus threshold set at ≤0.5.

RESULTS

Ten internationally established researchers and clinicians participated in this Delphi panel, with a response rate of 80 %, 100 %, and 100 % across three rounds. Consensus was reached on 88.5 % of the statements, resulting in a framework for PT after hospital discharge. Essential handover information should include information on 15 parameters. A core set of outcomes should test exercise capacity, skeletal muscle strength, function in activities of daily living, mobility, quality of life, and pain. PT interventions should include functional exercises, circuit and endurance training, strengthening exercises for limb and respiratory muscles, education on recovery, and a nutritional component. Screening tools to identify impairments in other health domains and referral to specialists are proposed.

CONCLUSIONS

A consensus-based framework for optimal PT after hospital discharge is proposed. Future research should focus on feasibility testing of this framework, developing risk stratification tools and validating core outcome measures for ICU survivors.

Poor functional recovery after a critical illness: a longitudinal study

OBJECTIVE

To determine the time course of functional health status, and to inventory impairments in body functions, limitations in activities, and restrictions in participation after critical illness.

DESIGN

Prospective observational cohort study.

SETTING

Mixed medical and surgical closed format; intensive care unit of an academic medical hospital.

PATIENTS

Consecutive patients over a period of 3 months who were ventilated in the intensive care unit for more than 48 h (n = 116).

METHODS

Functional health status was assessed 3, 6 and 12 months after discharge from the intensive care unit using the Sickness Impact Profile 68. Impairments in function, limitations in activities, and restrictions in participation, classified according to the International Classification of Functioning, Disability, and Health (ICF), were evaluated after 3 and 12 months.

RESULTS

Due to a high mortality rate (48%) and poor health conditions, data could not be obtained from all participants at all measurement points. Physical functioning and social behaviour improved predominantly within the first 6 months, while impaired psychological functioning remained unchanged within one year after discharge from the intensive care unit. After one year, 69% of patients were still restricted in performing daily activities and only 50% had resumed work.

CONCLUSION

The extent and severity of lasting intensive care unit-related disability necessitates the development of multidisciplinary after-care to improve health status, functional independence and return to work.

The Infant Behavioral Assessment and Intervention Program for very low birth weight infants at 6 months corrected age

OBJECTIVE

To determine whether the Infant Behavioral Assessment and Intervention Program (IBAIP), designed to support and enhance infants' self-regulatory competence, improved developmental and neurobehavioral outcomes in very low birth weight (VLBW) infants.

STUDY DESIGN

We randomized 86 infants to 1 intervention before discharge and to 6 to 8 home interventions until 6 months corrected age, and 90 control infants received standard care. Developmental and behavioral outcomes were evaluated at 6 months corrected age with the Bayley Scales of Infant Development-II (BSID-II). Neurobehavioral functioning was evaluated with the Infant Behavioral Assessment (IBA) at baseline and at 6 months corrected age.

RESULTS

Despite randomization, some differences in neonatal characteristics were found between the intervention and control infants. After adjustment, intervention effects of 7.2 points (+/- standard error 3.1) on the Mental Developmental Index and 6.4 +/- 2.4 points on the Psychomotor Developmental Index favored the intervention infants. The Behavioral Rating Scale of the BSID-II (P = .000) and the IBA (more approach [P = .003] and less stress [P = .001] over time) also favored the intervention infants.

CONCLUSIONS

The IBAIP improved the mental, motor, and behavioral outcomes of VLBW infants at 6 months corrected age.