Successful ingredients of effective Collaborative Care programs in low- and middle-income countries: A rapid review

Integrating mental health care in primary healthcare settings is a compelling strategy to address the mental health treatment gap in low- and middle-income countries (LMICs). Collaborative Care is the integrated care model with the most evidence supporting its effectiveness, but most research has been conducted in high-income countries. Efforts to implement this complex multi-component model at scale in LMICs will be enhanced by understanding the model components that have been effective in LMIC settings. Following Cochrane Rapid Reviews Methods Group recommendations, we conducted a rapid review to identify studies of the effectiveness of Collaborative Care for priority adult mental disorders of mhGAP (mood and anxiety disorders, psychosis, substance use disorders and epilepsy) in outpatient medical settings in LMICs. Article screening and data extraction were performed using Covidence software. Data extraction by two authors utilized a checklist of key components of effective interventions. Information was aggregated to examine how frequently the components were applied. Our search yielded 25 articles describing 20 Collaborative Care models that treated depression, anxiety, schizophrenia, alcohol use disorder or epilepsy in nine different LMICs. Fourteen of these models demonstrated statistically significantly improved clinical outcomes compared to comparison groups. Successful models shared key structural and process-of-care elements: a multi-disciplinary care team with structured communication; standardized protocols for evidence-based treatments; systematic identification of mental disorders, and a stepped-care approach to treatment intensification. There was substantial heterogeneity across studies with respect to the specifics of model components, and clear evidence of the importance of tailoring the model to the local context. This review provides evidence that Collaborative Care is effective across a range of mental disorders in LMICs. More work is needed to demonstrate population-level and longer-term outcomes, and to identify strategies that will support successful and sustained implementation in routine clinical settings.

Real-world deployment of lateral flow SARS-CoV-2 antigen detection in the emergency department to provide rapid, accurate and safe diagnosis of COVID-19

BACKGROUND

Point-of-care (POC) SARS-CoV-2 lateral-flow antigen detection (LFD) testing in the emergency department (ED) could inform rapid infection control decisions but requirements for safe deployment have not been fully defined.

METHODS

Review of LFD test results, laboratory and POC-RT-PCR results and ED-performance metrics during a two-week high SARS-CoV-2 prevalence period followed by several months of falling prevalence.

AIM

Determine whether LFD testing can be safely deployed in ED to provide an effective universal SARS-CoV-2 testing capability.

FINDINGS

93% (345/371) of COVID-19 patients left ED with a virological diagnosis during the 2-week universal LFD evaluation period compared to 77% with targeted POC-RT-PCR deployment alone, on background of approximately one-third having an NHS Track and Trace RT-PCR test-result at presentation. LFD sensitivity and specificity was 70.7% and 99.1% respectively providing a PPV of 97.7% and NPV of 86.4% with disease prevalence of 34.7%. ED discharge-delays (breaches) attributable to COVID-19 fell to 33/3532 (0.94%) compared with the preceding POC-RT-PCR period (107/4114 (2.6%); p=<0.0001). Importantly, LFD testing identified 1 or 2 clinically-unsuspected COVID-19 patients/day. Three clinically-confirmed LFD false positive patients were appropriately triaged based on LFD action-card flowchart, and only 5 of 95 false-negative LFD results were inappropriately admitted to non-COVID-19 areas where no onward-transmission was identified. LFD testing was restricted to asymptomatic patients when disease prevalence fell below 5% and detected 1-3 cases/week.

CONCLUSION

Universal SARS-CoV-2 LFD testing can be safely and effectively deployed in ED alongside POC-RT-PCR testing during periods of high and low disease prevalence.

Remote Collaborative Care with Off-Site Behavioral Health Care Managers: A Systematic Review of Clinical Trials

BACKGROUND

In the United States, the majority of patients who require behavioral health care do not receive it due to an overall shortage of behavioral health specialists. The Collaborative Care Model (CoCM) is a team-based, highly-coordinated approach to treating common mental health conditions in primary care that has a robust evidence base. Several recent randomized controlled trials (RCTs) have demonstrated the effectiveness of remote CoCM teams. As telehealth technology and uptake expands, understanding the evidence for remote CoCM becomes increasingly crucial to inform CoCM practice and implementation.

OBJECTIVE

To systematically review RCTs regarding the effectiveness of remote CoCM teams in treating common psychiatric conditions in primary care and medical settings.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to structure our review. Our search strategy and development of search terms was informed by knowledge and review of the CoCM literature. Articles were reviewed by three authors and once selected, sent to two authors for further data extraction to describe various study characteristics and process measures relating to remote CoCM.

RESULTS

The literature search identified 13,211 articles, nine of which met inclusion criteria. The nine studies collectively demonstrate effectiveness of remote CoCM in treating a range of behavioral health conditions [(depression (n=7), anxiety (n=2), and PTSD (n=1)], across various populations and settings. Sample sizes ranged from 191 patients to 704 patients, publication dates from 2004 to 2018, and studies were conducted from 2000 to 2014. Various process measures were also reported.

CONCLUSIONS

As the nine studies included in our systematic review demonstrate, remote CoCM can be effective in treating a range of behavioral health conditions in various primary care and specialty medical settings. These findings suggest organizations may have more flexibility in building their CoCM team and drawing upon wider workforces than previously recognized. As recent shifts in telehealth policy and practice continue to motivate telehealth approaches, further research that can inform best practices for remote CoCM will be useful and valuable to those making organizational decisions when implementing integrated care models.

The Dichotic Digits difference Test (DDdT): Development, Normative Data, and Test–Retest Reliability Studies Part 1

Background: The dichotic digits test is one of the most widely used assessment tools for central auditory processing disorder. However, questions remain concerning the impact of cognitive factors on test results.

Purpose: To develop the Dichotic Digits difference Test (DDdT), an assessment tool that could differentiate children with cognitive deficits from children with genuine dichotic deficits based on differential test results. The DDdT consists of four subtests: dichotic free recall (FR), dichotic directed left ear (DLE), dichotic directed right ear (DRE), and diotic. Scores for six conditions are calculated (FR left ear [LE], FR right ear [RE], and FR total, as well as DLE, DRE, and diotic). Scores for four difference measures are also calculated: dichotic advantage, right-ear advantage (REA) FR, REA directed, and attention advantage.

Research Design: Experiment 1 involved development of the DDdT, including error rate analysis. Experiment 2 involved collection of normative and test–retest reliability data.

Study Sample: Twenty adults (aged 25 yr 10 mo to 50 yr 7 mo, mean 36 yr 4 mo) took part in the development study; 62 normal-hearing, typically developing, primary-school children (aged 7 yr 1 mo to 11 yr 11 mo, mean 9 yr 4 mo) and 10 adults (aged 25 yr 0 mo to 51 yr 6 mo, mean 34 yr 10 mo) took part in the normative and test–retest reliability study.

Data Collection and Analysis: In Experiment 1, error rate analysis was conducted on the 36 digit-pair combinations of the DDdT. Normative data collected in Experiment 2 were arcsine transformed to achieve a distribution that was closer to a normal distribution and z-scores calculated. Pearson product-moment correlations were used to determine the strength of relationships between DDdT conditions.

Results: The development study revealed no significant differences in the adult population between test and retest on any DDdT condition. Error rates on 36 digit pairs ranged from 1.5% to 16.7%. The most and the least error-prone digits were removed before commencement of the normative data study, leaving 25 unique digit pairs. Average z-scores calculated from the arcsine-transformed data collected from the 62 children who took part in the normative data study revealed that FR dichotic processing (LE, RE, and total) was highly correlated with diotic processing (r ranging from 0.5 to 0.6; p < 0.0001). Significant improvements in performance on retest occurred for the FR LE, RE, total, and diotic conditions (p ranging from 0.05 to 0.0004), the conditions that would be expected to improve with practice if the participant’s response strategies are better the second time around.

Conclusions: The addition of a diotic control task—that shares many response demands with the usual dichotic tasks—opens up the possibility of differentiating children who perform below expectations because of poor dichotic processing skills from those who perform poorly because of impaired attention, memory, or other cognitive abilities. The high correlation between dichotic and diotic performance suggests that factors other than dichotic performance play a substantial role in a child’s ability to perform a dichotic listening task. This hypothesis is investigated further in the cognitive correlation study that follows in the companion paper (DDdT Study Part 2; Cameron et al, 2016).

Investigating the Interaction between Dichotic Deficits and Cognitive Abilities Using the Dichotic Digits difference Test (DDdT) Part 2

Background: The Dichotic Digits difference Test (DDdT) was developed to investigate the relationship between dichotic processing and cognitive abilities and, through the use of differential test scores, to provide professionals with a clinical tool that could aid in differentiation of clients with genuine dichotic deficits from those where cognitive disorders affect test performance. The DDdT consists of four subtests: dichotic free recall (FR), dichotic directed left ear, dichotic directed right ear, and diotic. Scores are calculated for six conditions: FR left ear (LE), right ear (RE), and total, as well as the directed left ear, directed right ear, and diotic, and four difference measures: dichotic advantage, RE advantage FR, RE advantage directed, and attention advantage.

Purpose: To investigate the role of cognitive abilities on DDdT test performance.

Research Design: Correlational analysis between the various DDdT conditions and difference measures, as well as between dichotic, diotic, and cognitive factors (memory, intelligence, and attention).

Study Sample: Fifty typically developing children (aged 7 yr 0 mo to 12 yr 1 mo, mean = 9 yr 2 mo) and ten children recruited from the Australian Hearing CAPD Service who were diagnosed with a memory or dichotic deficit (aged 7 yr 0 mo to 15 yr 0 mo, mean = 9 yr 5 mo) took part in the study.

Data Collection and Analysis: The Pearson product moment correlations were used to determine the strength of relationships between DDdT conditions as well as relationships between scores on these conditions and performance on the various cognitive assessment tools, which included the number memory forward and reversed subtests of the Test of Auditory Processing Skills – Third Edition, IVA + Plus Continuous Performance Test, and the Test of Non-Verbal Intelligence-4 (TONI-4). A parent questionnaire (Fisher’s Auditory Checklist) and a participant questionnaire (Listening Inventory for Education) were also administered.

Results: Diotic performance was significantly correlated with performance on all the DDdT dichotic FR conditions (r = 0.6–0.8; p < 0.00001). Further, significant correlations were found between the FR LE, total, and diotic conditions, and the cognitive measures of attention and memory, with r ranging from 0.4 to 0.5 (p < 0.01–0.001). Right-ear performance was not significantly correlated to any cognitive measure, except for FR RE and number memory forward (r = 0.35; p = 0.006). The DDdT dichotic advantage measure was investigated in a subset of clinical children and found to aid in differentiating true dichotic from spurious results.

Conclusions: As found in the DDdT normative data study that precedes in the companion paper (DDdT Study Part 1; Cameron et al, 2016), the high correlation between dichotic and diotic performances by the clinical and typically developing participants suggests that factors other than dichotic performance play a substantial role in a child’s ability to perform a dichotic listening task. Indeed, 61% of the variance in FR total scores for the children in this study was accounted for by factors that do not involve the perception of dichotic stimuli. This view is supported by the correlations between measures of attention and memory and dichotic scores. This result has wide-spread implications in respect to interpretation of central auditory processing disorder test results and further investigation of the use of the DDdT in a clinical population is warranted.

Factors influencing parents' decisions about communication choices during early education of their child with hearing loss: a qualitative study

OBJECTIVE

To explore the factors influencing parents' choice of communication mode during early education of their child with hearing loss.

DESIGN

Qualitative descriptive analysis of semi-structured interviews of parents of children with hearing loss.

STUDY SAMPLE

Fourteen parents of children who participated in the Longitudinal Outcomes of Children with Hearing Impairment study.

RESULTS

Four themes emerged from thematic analysis of the interview data: (1) parents draw on a variety of experiences and information to make decisions; (2) parents' preferred outcomes for their children drive their choices; (3) child's preference and proficiency drive parental choice; and (4) parents' fears and worries influence decisions. Parents required unbiased, descriptive information as well as evaluative information from professionals, so that they could consider all options in making a decision that met their needs. They required continual support for implementation of their choices as they adjusted to their children's changing needs.

CONCLUSIONS

Decisions around communication mode are rarely made in isolation, but occur within a larger decision-making matrix that include device choices, early intervention agency choices and "future-proofing" the child's future communication options.

Psychosocial development of 5-year-old children with hearing loss: Risks and protective factors

OBJECTIVE

The aims of this paper were to report on the global psychosocial functioning of 5-year-old DHH children and examine the risk and protective factors that predict outcomes.

DESIGN

A cross-sectional analysis of data collected from a prospective, population-based longitudinal study.

STUDY SAMPLE

Parents/caregivers of 356 children completed questionnaires on psychosocial development (CDI, SDQ), functional communication (PEACH) and demographic information. Children completed standardized assessments of non-verbal cognitive ability (WNV) and language (PLS-4).

RESULTS

On average, global psychosocial functioning was within the range of typically developing children; however, variability was high and 12% of children had scores that were more than 2 SDs below the norm. Non-verbal cognitive ability, presence of additional disabilities, language and functional communication significantly predicted outcomes. In contrast, type of hearing device, severity of hearing loss and age at intervention did not.

CONCLUSION

The global psychosocial functioning of this cohort of 5-year-old DHH children fell within the range of typically developing children. The findings suggest that spoken language ability and functional communication skills are vital for healthy psychosocial development.

Psychosocial Development in 5-Year-Old Children With Hearing Loss Using Hearing Aids or Cochlear Implants

This article reports on the psychosocial development and factors influencing outcomes of 5-year-old children with cochlear implants (CIs) or hearing aids (HAs). It further examines differences between children with CIs and HAs with similar levels of hearing loss. Data were collected as part of the Longitudinal Outcomes of Children with Hearing Impairment study-a prospective, population-based study. Parents/caregivers of children completed the Strengths and Difficulties Questionnaire ( n = 333), the Social Skills subscale from the Child Development Inventory ( n = 317), and questionnaires on functional auditory behavior (Parents' Evaluation of Aural/oral performance of Children), and demographics. Children completed assessments of nonverbal cognitive ability (Wechsler Non-verbal Scale of Ability) and language (Preschool Language Scale - fourth edition). On average, parent-rated Strengths and Difficulties Questionnaire scores on emotional or behavioral difficulties were within 1 SD of the normative mean; however, Child Development Inventory scores on social skills were more than 1 SD below the norm. Children with severe-to-profound hearing losses using HAs had significantly more behavioral problems than children with CIs. Regression analyses showed that non-verbal cognitive ability, language, and functional auditory behavior were significantly associated with psychosocial outcomes for children with HAs, whereas outcomes for children with CIs were associated with functional auditory behavior and the presence of additional disabilities. Age at hearing intervention, severity of hearing loss, and communication mode were not associated with outcomes. The results suggest that even children who develop good language ability with the help of a HA or CI may have psychosocial problems if they exhibit difficulties with listening and communicating in everyday environments. The findings have implications for developing interventions for young children with hearing loss.

Exploring the Social Capital of Adolescents Who Are Deaf or Hard of Hearing and Their Parents: A Preliminary Investigation

The study explored the social capital of Australian adolescents who were deaf or hard of hearing (DHH) and their parents, and investigated the relationship between social capital and individual characteristics, language, literacy, and psychosocial outcomes. Sixteen adolescents (ages 11-14 years) and 24 parents enrolled in the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study completed an online questionnaire on social capital and psychosocial outcomes. Information about demographics, language, and literacy was retrieved from the LOCHI study database. On average, parent-rated social capital was positively related to adolescent-rated social capital, but not to child outcomes. Aspects of adolescent-reported social capital were significantly related to the adolescents' language and reading skills, but not to psychosocial outcomes. This study gives support to the promotion of social capital in adolescents who are DHH and their families, and considers how social capital promotion could be applied in interventions.

Spoken language and everyday functioning in 5-year-old children using hearing aids or cochlear implants

OBJECTIVE

This study investigated the factors influencing 5-year language, speech and everyday functioning of children with congenital hearing loss.

DESIGN

Standardised tests including PLS-4, PPVT-4 and DEAP were directly administered to children. Parent reports on language (CDI) and everyday functioning (PEACH) were collected. Regression analyses were conducted to examine the influence of a range of demographic variables on outcomes.

STUDY SAMPLE

Participants were 339 children enrolled in the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study.

RESULTS

Children's average receptive and expressive language scores were approximately 1 SD below the mean of typically developing children, and scores on speech production and everyday functioning were more than 1 SD below. Regression models accounted for 70-23% of variance in scores across different tests. Earlier CI switch-on and higher non-verbal ability were associated with better outcomes in most domains. Earlier HA fitting and use of oral communication were associated with better outcomes on directly administered language assessments. Severity of hearing loss and maternal education influenced outcomes of children with HAs. The presence of additional disabilities affected outcomes of children with CIs.

CONCLUSIONS

The findings provide strong evidence for the benefits of early HA fitting and early CI for improving children's outcomes.

Language and speech outcomes of children with hearing loss and additional disabilities: identifying the variables that influence performance at five years of age

OBJECTIVE

This study examined language and speech outcomes in young children with hearing loss and additional disabilities.

DESIGN

Receptive and expressive language skills and speech output accuracy were evaluated using direct assessment and caregiver report. Results were analysed first for the entire participant cohort, and then to compare results for children with hearing aids (HAs) versus cochlear implants (CIs).

STUDY SAMPLE

A population-based cohort of 146 five-year-old children with hearing loss and additional disabilities took part.

RESULTS

Across all participants, multiple regressions showed that better language outcomes were associated with milder hearing loss, use of oral communication, higher levels of cognitive ability and maternal education, and earlier device fitting. Speech output accuracy was associated with use of oral communication only. Average outcomes were similar for children with HAs versus CIs, but their associations with demographic variables differed. For HA users, results resembled those for the whole cohort. For CI users, only use of oral communication and higher cognitive ability levels were significantly associated with better language outcomes.

CONCLUSIONS

The results underscore the importance of early device fitting for children with additional disabilities. Strong conclusions cannot be drawn for CI users given the small number of participants with complete data.

Beetroot juice supplementation reduces whole body oxygen consumption but does not improve indices of mitochondrial efficiency in human skeletal muscle

KEY POINTS

Oral consumption of nitrate (NO3(-)) in beetroot juice has been shown to decrease the oxygen cost of submaximal exercise; however, the mechanism of action remains unresolved. We supplemented recreationally active males with beetroot juice to determine if this altered mitochondrial bioenergetics. Despite reduced submaximal exercise oxygen consumption, measures of mitochondrial coupling and respiratory efficiency were not altered in muscle. In contrast, rates of mitochondrial hydrogen peroxide (H2O2) emission were increased in the absence of markers of lipid or protein oxidative damage. These results suggest that improvements in mitochondrial oxidative metabolism are not the cause of beetroot juice-mediated improvements in whole body oxygen consumption.

ABSTRACT

Ingestion of sodium nitrate (NO3(-)) simultaneously reduces whole body oxygen consumption (V̇O2) during submaximal exercise while improving mitochondrial efficiency, suggesting a causal link. Consumption of beetroot juice (BRJ) elicits similar decreases in V̇O2 but potential effects on the mitochondria remain unknown. Therefore we examined the effects of 7-day supplementation with BRJ (280 ml day(-1), ∼26 mmol NO3(-)) in young active males (n = 10) who had muscle biopsies taken before and after supplementation for assessments of mitochondrial bioenergetics. Subjects performed 20 min of cycling (10 min at 50% and 70% V̇O2 peak) 48 h before 'Pre' (baseline) and 'Post' (day 5 of supplementation) biopsies. Whole body V̇O2 decreased (P < 0.05) by ∼3% at 70% V̇O2 peak following supplementation. Mitochondrial respiration in permeabilized muscle fibres showed no change in leak respiration, the content of proteins associated with uncoupling (UCP3, ANT1, ANT2), maximal substrate-supported respiration, or ADP sensitivity (apparent Km). In addition, isolated subsarcolemmal and intermyofibrillar mitochondria showed unaltered assessments of mitochondrial efficiency, including ADP consumed/oxygen consumed (P/O ratio), respiratory control ratios and membrane potential determined fluorometrically using Safranine-O. In contrast, rates of mitochondrial hydrogen peroxide (H2O2) emission were increased following BRJ. Therefore, in contrast to sodium nitrate, BRJ supplementation does not alter key parameters of mitochondrial efficiency. This occurred despite a decrease in exercise V̇O2, suggesting that the ergogenic effects of BRJ ingestion are not due to a change in mitochondrial coupling or efficiency. It remains to be determined if increased mitochondrial H2O2 contributes to this response.

Omega-3 supplementation alters mitochondrial membrane composition and respiration kinetics in human skeletal muscle

Studies have shown increased incorporation of omega-3 fatty acids into whole skeletal muscle following supplementation, although little has been done to investigate the potential impact on the fatty acid composition of mitochondrial membranes and the functional consequences on mitochondrial bioenergetics. Therefore, we supplemented young healthy male subjects (n = 18) with fish oils [2 g eicosapentaenoic acid (EPA) and 1 g docosahexanoic acid (DHA) per day] for 12 weeks and skeletal muscle biopsies were taken prior to (Pre) and following (Post) supplementation for the analysis of mitochondrial membrane phospholipid composition and various assessments of mitochondrial bioenergetics. Total EPA and DHA content in mitochondrial membranes increased (P < 0.05) ∼450 and ∼320%, respectively, and displaced some omega-6 species in several phospholipid populations. Mitochondrial respiration, determined in permeabilized muscle fibres, demonstrated no change in maximal substrate-supported respiration, or in the sensitivity (apparent Km) and maximal capacity for pyruvate-supported respiration. In contrast, mitochondrial responses during ADP titrations demonstrated an enhanced ADP sensitivity (decreased apparent Km) that was independent of the creatine kinase shuttle. As the content of ANT1, ANT2, and subunits of the electron transport chain were unaltered by supplementation, these data suggest that prolonged omega-3 intake improves ADP kinetics in human skeletal muscle mitochondria through alterations in membrane structure and/or post-translational modification of ATP synthase and ANT isoforms. Omega-3 supplementation also increased the capacity for mitochondrial reactive oxygen species emission without altering the content of oxidative products, suggesting the absence of oxidative damage. The current data strongly emphasize a role for omega-3s in reorganizing the composition of mitochondrial membranes while promoting improvements in ADP sensitivity.

Sequential Cdk1 and Plk1 phosphorylation of protein tyrosine phosphatase 1B promotes mitotic cell death

Mitotic cell death following prolonged arrest is an important death mechanism that is not completely understood. This study shows that Protein Tyrosine Phosphatase 1B (PTP1B) undergoes phosphorylation during mitotic arrest induced by microtubule-targeting agents (MTAs) in chronic myeloid leukaemia cells. Inhibition of cyclin-dependent kinase 1 (Cdk1) or polo-like kinase 1 (Plk1) during mitosis prevents PTP1B phosphorylation, implicating these kinases in PTP1B phosphorylation. In support of this, Cdk1 and Plk1 co-immunoprecipitate with endogenous PTP1B from mitotic cells. In addition, active recombinant Cdk1-cyclin B1 directly phosphorylates PTP1B at serine 386 in a kinase assay. Recombinant Plk1 phosphorylates PTP1B on serine 286 and 393 in vitro, however, it requires a priming phosphorylation by Cdk1 at serine 386 highlighting a novel co-operation between Cdk1 and Plk1 in the regulation of PTP1B. Furthermore, overexpression of wild-type PTP1B induced mitotic cell death, which is potentiated by MTAs. Moreover, mutation of serine 286 abrogates the cell death induced by PTP1B, whereas mutation of serine 393 does not, highlighting the importance of serine 286 phosphorylation in the execution of mitotic cell death. Finally, phosphorylation on serine 286 enhanced PTP1B phosphatase activity. Collectively, these data reveal that PTP1B activity promotes mitotic cell death and is regulated by the co-operative action of Cdk1 and Plk1 during mitotic arrest.

Complementary sex determination in the parasitoid wasp Cotesia vestalis (C. plutellae)

In the Hymenoptera, single locus complementary sex determination (sl-CSD) describes a system where males develop either from unfertilized haploid eggs or from fertilized diploid eggs that are homozygous at a single polymorphic sex locus. Diploid males are often inviable or sterile, and are produced more frequently under inbreeding. Within families where sl-CSD has been demonstrated, we predict that sl-CSD should be more likely in species with solitary development than in species where siblings develop gregariously (and likely inbreed). We examine this prediction in the parasitoid wasp genus Cotesia, which contains both solitary and gregarious species. Previous studies have shown that sl-CSD is absent in two gregarious species of Cotesia, but present in one gregarious species. Here, we demonstrate CSD in the solitary Cotesia vestalis, using microsatellite markers. Diploid sons are produced by inbred, but not outbred, females. However, frequencies of diploid males were lower than expected under sl-CSD, suggesting that CSD in C. vestalis involves more than one locus.

Near-threshold production of the multistrange Xi- hyperon

The yield for the multistrange Xi(-) hyperon has been measured in 6A GeV Au+Au collisions via reconstruction of its decay products pi(-) and Lambda, the latter also being reconstructed from its daughter tracks of pi(-) and p. The measurement is rather close to the threshold for Xi(-) production and therefore provides an important test of model predictions. The measured yield for Xi(-) and Lambda are compared for several centralities. In central collisions the Xi(-) yield is found to be in excellent agreement with statistical and transport model predictions, suggesting that multistrange hadron production approaches chemical equilibrium in high baryon density nuclear matter.

Comparison of source images for protons, pi-'s, and lambda's in 6A GeV Au+Au collisions

Source images are extracted from two-particle correlations constructed from strange and nonstrange hadrons produced in 6A GeV Au+Au collisions. Very different source images result from pp vs p Lambda vs pi(-)pi(-) correlations. Scaling by transverse mass can describe the apparent source size ratio for p/pi(-) but not for Lambda/pi(-) or Lambda/p. These observations suggest important differences in the space-time emission histories for protons, pions, and neutral strange baryons produced in the same events.

Longitudinal flow of protons from (2-8)A GeV central Au+Au collisions

Rapidity distributions of protons from central 197Au+197Au collisions measured by the E895 Collaboration in the energy range from (2-8)A GeV at the Brookhaven AGS are presented. Longitudinal flow parameters derived using a thermal model including collective longitudinal expansion are extracted from these distributions. The results show an approximately linear increase in the longitudinal flow velocity, <betagamma>(L), as a function of the logarithm of beam energy.

Transforming growth factor beta (TGFbeta) mediates Schwann cell death in vitro and in vivo: examination of c-Jun activation, interactions with survival signals, and the relationship of TGFbeta-mediated death to Schwann cell differentiation

In some situations, cell death in the nervous system is controlled by an interplay between survival factors and negative survival signals that actively induce apoptosis. The present work indicates that the survival of Schwann cells is regulated by such a dual mechanism involving the negative survival signal transforming growth factor beta (TGFbeta), a family of growth factors that is present in the Schwann cells themselves. We analyze the interactions between this putative autocrine death signal and previously defined paracrine and autocrine survival signals and show that expression of a dominant negative c-Jun inhibits TGFbeta-induced apoptosis. This and other findings pinpoint activation of c-Jun as a key downstream event in TGFbeta-induced Schwann cell death. The ability of TGFbeta to kill Schwann cells, like normal Schwann cell death in vivo, is under a strong developmental regulation, and we show that the decreasing ability of TGFbeta to kill older cells is attributable to a decreasing ability of TGFbeta to phosphorylate c-Jun in more differentiated cells.

Model-independent source imaging using two-pion correlations in (2 to 8)a GeV Au+Au collisions

We report a particle source imaging analysis based on two-pion correlations in high multiplicity Au+Au collisions at beam energies between 2A and 8A GeV. We apply the imaging technique introduced by Brown and Danielewicz, which allows a model-independent extraction of source functions with useful accuracy out to relative pion separations of about 20 fm. The extracted source functions have Gaussian shapes. Values of source functions at zero separation are almost constant across the energy range under study. Imaging results are found to be consistent with conventional source parameters obtained from a multidimensional Hanburg-Brown-Twiss analysis.

WHP/ISBRA study on state and trait markers in alcoholism

This article represents the proceedings of a symposium at the 2000 ISBRA Meeting in Yokohama, Japan. The chair was Boris Tabakoff. The presentations were (1) Overview of the WHO/ISBRA study on state and trait markers in alcoholism, by Boris Tabakoff; (2) Biochemical markers of acute and chronic drinking: Results of the WHO/ISBRA study, by Anders Helander; (3) The impact of country of recruitment and body mass index on biological marker dose-response curves in the WHO/ISBRA Study, by Kate M. Conigrave; (4) Relationship of body water to carbohydrate-deficient transferrin measures, by Larry Martinez; and (5) Platelet adenylyl cyclase activity as a trait marker of alcohol dependence, by Paula L. Hoffman.

Directed flow of lambda hyperons in (2-6 )A GeV Au+Au collisions

Directed flow measurements for Lambda hyperons are presented and compared to those for protons produced in the same Au+Au collisions (2A, 4A, and 6A GeV; b<5-6 fm). The measurements indicate that Lambda hyperons flow consistently in the same direction but with smaller magnitudes. A strong positive flow [for Lambdas] has been predicted in calculations which include the influence of the Lambda-nucleon potential. The experimental flow ratio Lambda/p is in qualitative agreement with expectations (approximately 2/3) from the quark counting rule at 2A GeV but is found to decrease with increasing beam energy.

Dominant-negative c-Jun promotes neuronal survival by reducing BIM expression and inhibiting mitochondrial cytochrome c release

Sympathetic neurons require nerve growth factor for survival and die by apoptosis in its absence. Key steps in the death pathway include c-Jun activation, mitochondrial cytochrome c release, and caspase activation. Here, we show that neurons rescued from NGF withdrawal-induced apoptosis by expression of dominant-negative c-Jun do not release cytochrome c from their mitochondria. Furthermore, we find that the mRNA for BIM(EL), a proapoptotic BCL-2 family member, increases in level after NGF withdrawal and that this is reduced by dominant-negative c-Jun. Finally, overexpression of BIM(EL) in neurons induces cytochrome c redistribution and apoptosis in the presence of NGF, and neurons injected with Bim antisense oligonucleotides or isolated from Bim(-/-) knockout mice die more slowly after NGF withdrawal.

Direct inhibition of c-Jun N-terminal kinase in sympathetic neurones prevents c-jun promoter activation and NGF withdrawal-induced death

c-Jun N-terminal kinases (JNKs) regulate gene expression by phosphorylating transcription factors, such as c-Jun. Studies with JNK: knockout mice suggest that JNK activity may be required for excitotoxin-induced apoptosis in the adult hippocampus and for apoptosis in the developing embryonic neural tube. Here we investigate the role of JNKs in classical neurotrophin-regulated developmental neuronal death by using nerve growth factor (NGF)-dependent sympathetic neurones. In this system, NGF withdrawal leads to an increase in JNK activity, an increase in c-Jun protein levels and c-Jun N-terminal phosphorylation before the cell death commitment point, and c-Jun activity is required for cell death. To inhibit JNK activity in sympathetic neurones we have used two different JNK inhibitors that act by distinct mechanisms: the compound SB 203580 and the JNK binding domain (JBD) of JNK interacting protein 1 (JIP-1). We demonstrate that JNK activity is required for c-Jun phosphorylation, c-jun promoter activation and NGF withdrawal-induced apoptosis. We also show that ATF-2, a c-Jun dimerization partner that can regulate c-jun gene expression, is activated following NGF deprivation. Finally, by co-expressing the JBD and a regulatable c-Jun dominant negative mutant we demonstrate that JNK and AP-1 function in the same pro-apoptotic signalling pathway after NGF withdrawal.

In Search of Excellence—The Neonatal Intensive Care Quality Improvement Collaborative

As part of its effort to improve the quality of care in the neonatal intensive care unit at Baylor University Medical Center (BUMC), the unit has participated in the Vermont Oxford Network. This network tracks outcomes and pools data, allowing comparisons and benchmarking. A group of 34 nurseries from the Vermont Oxford Network has collaborated in an innovative quality improvement initiative. This article describes this initiative, called the Neonatal Intensive Care Quality Collaborative 2000 project, and its impact on the neonatal service at BUMC. The project promotes the practice of 4 key habits: the habit for change, the habit for understanding the processes of care, the habit for collaborative learning, and the habit for using evidence-based practices of care.

c-Jun and the transcriptional control of neuronal apoptosis

There has been considerable interest in the molecular mechanisms of apoptosis in mammalian neurons because this form of neuronal cell death is important for the normal development of the nervous system and because inappropriate neuronal apoptosis may contribute to the pathology of human neurodegenerative diseases. The aim of recent research has been to identify the key components of the cell death machinery in neurons and understand how the cell death programme is regulated by intracellular signalling pathways activated by the binding of neurotrophins or death factors to specific cell surface receptors. The aim of this commentary was to review research that has investigated the role of the Jun N-terminal kinase (JNK)/c-Jun signalling pathway in neuronal apoptosis, focusing in particular on work carried out with developing sympathetic neurons. Experiments with sympathetic neurons cultured in vitro, as well as with cerebellar granule neurons and differentiated PC12 cells, have demonstrated that JNK/c-Jun signalling can promote apoptosis following survival factor withdrawal. In addition, experiments with Jnk(-/-) knockout mice have provided evidence that Jnk3 may be required for apoptosis in the hippocampus in vivo following injection of kainic acid, an excitotoxin, and that Jnk1 and Jnk2 are required for apoptosis in the developing embryonic neural tube. However, in the embryonic forebrain, Jnk1 and Jnk2 have the opposite function and are necessary for the survival of developing cortical neurons. These results suggest that JNKs and c-Jun are important regulators of the cell death programme in the mammalian nervous system, but that their biological effects depend on the neuronal type and stage of development.

The parathyroid hormone, its fragments and analogues--potent bone-builders for treating osteoporosis

As populations age a rising number of men and women, but especially women during the first decade after menopause, become victims of a severe, accelerated loss of bone with crippling fractures known as osteoporosis. This often results in costly, prolonged hospitalisation and perhaps indirectly, death. Osteoporosis in women is caused by the menopausal oestrogen decline, which removes several key restraints on the generation, longevity and activity of bone-resorbing osteoclasts. Although there are many antiresorptive drugs on or coming onto the market (calcitonin, bisphosphonates, oestrogen and SERMS) that can slow or stop further bone loss, there are none that can restore lost bone mechanical strength by directly stimulating osteoblast activity and bone growth. However, there is a family of potent bone-building peptides, namely the 84 amino acid parathyroid hormone (PTH). Its 31 to 38 amino acid N-terminal fragments are currently in or about to enter clinical trials. We can predict that these peptides will be effective therapeutics for osteoporosis especially when supplemented with bisphosphonates or SERMs to protect the new bone from osteoclasts. These peptides should also accelerate the healing of fractures in persons of all ages and restore lost bone mass and mechanical strength to astronauts following their return to earth after long voyages in space.