Implementing the capability approach in health promotion projects: Recommendations for implementation based on empirical evidence

OBJECTIVE

The aim of this paper was to develop a framework for the use of the capability approach in health promotion projects, which could guide future projects as well as improve the comparability of the projects' effectiveness.

METHOD

The study involved a three-stage process comprising a total of six steps. We first developed a theoretical model and then analyzed data from four empirical studies that had implemented projects using the capability approach between 2015 and 2018 in the settings of kindergartens, schools, vocational training, and communities to promote an active lifestyle. Finally, we developed a framework for the use of the capability approach in health promotion projects based on the analysis of the data.

RESULTS

We developed a theoretical model of the "capability cycle," which was used for further analysis. There were divergent understandings of the capability approach due to existing theoretical constructs that are commonly used by the scientific teams of the projects. Further, the conceptualization, implementation, and evaluation of the capability approach within the four settings showed discrepancies, which inhibited a comparison of their effectiveness. The developed framework comprises recommendations regarding the planning of a project, its implementation, and especially its evaluation in future comparisons of project effectiveness.

CONCLUSION

This paper provides a comprehensive analysis of four projects for which we developed a framework using a participatory approach. The findings can help research teams in the conceptualization, implementation, and evaluation of future projects that focus on improving capabilities in the field of health promotion. Further, the established framework will help facilitate comparisons of capability-oriented health promotion projects in terms of their effectiveness.

O4-8 Measuring capabilities for physical activity-related health outcomes: A Systematic review

Background

Health promotion projects commonly measure health outcomes and behavior to provide proof of effectiveness. An alternative concept that focuses on the real opportunities a person can choose from to influence their health is Amartya Sen's capability approach. Numerous tools have been developed to measure capability change in general, but it remains unclear which ones can be applied specifically to physical activity (PA).We therefore conducted a systematic review to identify appropriate tools to measure capabilities for physical activity and health and provide information on their quality.

Methods

The review included a total of 6,850 articles published between 2000 and June 2019 that were identified via searches on PubMed, EbscoHost, and ProQuest. Screenings of titles/abstracts and full texts were conducted independently by two researchers using Endnote X9 and Microsoft Excel. Identified tools are currently being analyzed regarding their indicators, evaluation methods, quality, and the extent to which they address capabilities for physical activity.

Results

The screening resulted in a total of 49 articles included in the analysis. Preliminary results show a diverse use of methods for measuring capabilities for healthy lifestyles. Preliminary results show that three categories of instruments can be identified: (a) Five studies employed secondary data analysis of specific datasets to extrapolate capabilities for healthy living; (b) five articles dealt with measuring capabilities using qualitative approaches (interviews, video recordings); (c) 39 articles reported on a total of 10 different questionnaires to measure capabilities. We identified only one instrument (employing both a questionnaire and qualitative measures) that explicitly measured capabilities for PA, albeit only for a specific target group.

Conclusions

The identified articles show that capabilities for healthy lifestyles are mostly measured by questionnaire. Available tools are mostly target group- and setting-specific. Currently, there is a dearth of tools that explicitly cover capabilities for PA, especially across settings or target groups. Therefore, more research is needed to work towards the development of universally applicable tools to measure PA capability.

O4-7 An alternative framework for HEPA projects: Developing recommendations for the use of the Capability Approach

Background

Using Amartya Sen's capability approach (CA) to conceptualize physical activity (PA) promotion projects has been suggested as a promising alternative to conventional theories, as it focuses on the real opportunities people have to engage in PA rather than on PA behavior alone. The Capital4Health research consortium used the CA to conceptualize and implement PA projects in four different settings across the life-course. The aim of the study was to evaluate the implementation of the CA in these projects and to develop recommendations for the use of the concept in future PA promotion projects.

Methods

Based on an overarching analytical framework, we investigated the utilization of the CA in the individual projects using document analysis, workshops, and group interviews with project teams. Results were used to develop a set of draft principles and recommendations for effectively employing the CA in future projects and as a bridging framework for larger consortia. A participatory process combining elements of action research and Delphi surveys is currently conducted with all members of the Capital4Health consortium to arrive at final set of agreed-upon principles.

Results

Preliminary results show that the use of the CA varied substantially between projects and settings, but that a number of common conclusions can be drawn. A future framework for using capabilities for PA promotion may focus on three areas: (a) Project conceptualization should address both the target group and relevant multipliers. It should also consider both individual PA competences and structural factors, (b) Evaluation should cover both capabilities for PA as well as actual changes in PA levels to assess health impact on multiple levels, (c) The CA may be very useful to research consortia for developing shared goals and evaluation frameworks. This, however, requires a shared knowledge base and agreement about central theoretical concepts.

Conclusions

The CA constitutes a potentially useful theoretical basis for both individual PA promotion projects and multi-setting research consortia. However, the application of the concept is complex and may vary significantly between settings. The proposed guiding principles may therefore provide a useful aid to future projects wishing to apply this innovative approach.

S11 Improving knowledge co-creation and participation in physical activity promotion: The cooperative planning approach

A central problem of current efforts to promote health and physical activity (PA) is that many successful projects remain stuck in the demonstration phase and are not implemented successfully at scale. The use of participatory and/or co-creation approaches has been suggested to avoid this ?pilot project trap? and better adapt interventions to target group needs and setting specificities.

This symposium intends to introduce to an international audience a particular participatory concept that has become increasingly popular in PA promotion in Germany in recent years: The Cooperative Planning approach has been successfully used in sport facility planning, local and regional PA policy development, and various settings of PA promotion (incl. kindergartens, schools, vocational training, and communities). The workshop will shed light on the theoretical background and methodology of Cooperative Planning as well as its specific application in select settings.

The first presentation will introduce the concept of Cooperative Planning, outline potential areas of application, and compare it with other popular participatory and co-creation approaches in PA promotion. Following this, we will provide evidence from ongoing projects employing the approach to promote PA in kindergartens (Presentation 2) and in the community setting (Presentation 3). Presentation 4 will introduce an example from the retirement home setting and also highlight ways of combining Cooperative Planning with other approaches such as photovoice and participatory evaluation. The final presentation will provide an outlook on the future extension of the concept by introducing the idea of the Practice Dive, which may be used to further optimize knowledge co-creation between researchers and practitioners.

A closer look at the Cooperative Planning approach is both timely and relevant for an international audience for a number of reasons: Conceptually, Cooperative Planning is a theory-based framework that combines ideas of participation and co-creation for PA into an innovative whole-of-system approach. From a practical PA promotion perspective, it transcends many existing techniques by focusing both on engaging multipliers and members of the target group, and by involving all of them in the decisive intervention development process (e.g. rather than only via opinion polls or focus groups). This symposium will allow us to combine evidence from four different projects, highlighting both the specificities of working in different settings as well as different aspects and possible extensions of the Cooperative Planning approach.

Präventionsdilemma auf kommunaler Ebene?

Hintergrund

Von Gesundheitsförderung profitieren häufig vorwiegend sozial privilegierte Personen während sozial Benachteiligte seltener erreicht werden. Ob dieses Präventionsdilemma auch auf kommunaler Ebene besteht, wurde bislang kaum erforscht.

Ziel der Arbeit

Die Studie untersucht anhand von zwei bayernweiten Projektausschreibungen zur kommunalen Bewegungsförderung, ob sozioökonomisch deprivierte Kommunen, die geringe Angebotsstrukturen der Gesundheitsförderung aufweisen, durch solche Ausschreibungen erreicht werden und welche Faktoren die Bereitschaft zur Beteiligung beeinflussen.

Methoden

Es werden Bevölkerungsdaten und sozioökonomische Deprivationsdaten von (n = 171) Kommunen aus drei Gruppen (teilnehmende/interessierte Kommunen und deprivierte Vergleichskommunen) verglichen. Durch eine systematische Internetrecherche werden die Gesundheitsförderungsaktivitäten ausgewählter Kommunen erhoben. Barrieren und Förderfaktoren für die Umsetzung der Projekte werden mittels einer Dokumentenanalyse erfasst.

Ergebnisse

Die teilnehmenden und interessierten Kommunen weisen höhere Einwohnerzahlen und geringere Deprivationswerte als der Durchschnitt der Kommunen in Bayern auf und stellen mehr Angebote der Gesundheitsförderung bereit als deprivierte Vergleichskommunen. Großen Einfluss auf die Teilnahme an den Projekten haben finanzielle Faktoren, politische Unterstützung und engagierte Personen.

Diskussion

Die Ergebnisse dieser Studie deuten auf ein Präventionsdilemma auf kommunaler Ebene hin. Um gesundheitlichen Ungleichheiten zwischen Kommunen vorzubeugen, sollten benachteiligte Kommunen in die Gestaltung von Förderprogrammen einbezogen werden, um diese Programme an deren Bedürfnisse anzupassen.

Scaling Up Physical Activity Promotion Projects on the Community Level for Women in Difficult Life Situations and Older People: BIG-5 and GET-10—A Study Protocol

Introduction

Physical inactivity is a major risk factor for a population's health, especially among socially disadvantaged groups. Many health promotion projects focus on increasing physical activity among their respective target groups. However, because they are mostly developed and implemented under laboratory conditions, they fail when being scaled to real-world settings. The community-based participatory research projects BIG and GESTALT have demonstrated their effectiveness regarding the physical activity promotion in real-world settings by employing a participatory method.

Material and Analysis

Within the context of the BIG-5 and GET-10 projects, these previously implemented and tested participatory projects are scaled to 15 additional settings in Bavaria, Germany. By applying an overarching mixed-methods evaluation framework, the aim is to gain insights into a) the recruitment of communities for scale-up; b) the specific results of the projects according to the RE-AIM framework. In the recruitment of communities, standardized information on the first contact, the consultation process, the person in charge, and previously implemented health promotion projects are collected. A systematic web search will complete information on each community and their health promotion activities. Results will be compared with information on those communities most in need, here according to the deprivation index of communities in Bavaria, Germany. The scale-up process and its results will be measured using semi-structured interviews with project coordinators. A standardized questionnaire will be used with the course's participants. Applying the RE-AIM framework, the collected data will be analyzed deductively.

Discussion

We expect the results to be highly relevant for the effective scale-up of any health promotion project. The study will enhance the understanding of how to reach those communities most in need of health promotion projects and will identify the barriers coordinators face in reaching socially disadvantaged groups.

Conclusion

Although participatory projects are often used as individual projects, little is known about the scaling up of participatory health promotion projects. This cross-cutting evaluation of two projects aims at producing data on the barriers and facilitators for the reach of settings most in need, and those success factors for a durable implementation.

Scientific Cooperation and the Co-production of Scientific Outcomes for Physical Activity Promotion: Results From a Transdisciplinary Research Consortium

Background: To tackle complex societal challenges such as the high prevalence of physical inactivity, research funding is increasingly channeled toward cross-disciplinary research consortia. This study focused on exchange and cooperation (E&C) among the scientists of a 5-year transdisciplinary research initiative in Germany. Researchers' perceptions of E&C were combined with numbers of collaborative products during the project's life to make the developments of E&C and the quality of collaborative products visible.

Methods: We applied a mixed-methods design including a qualitative content analysis of pre-interviews, focus-group interviews, and documents as well as a quantitative analysis of research (scientific publications, books, conference participations) and training outcomes (supervised bachelor's, master's, and Ph.D. theses). Inductive and deductive approaches were combined to analyze factors of collaborative readiness and to identify perceptions of E&C among project teams. Based on Hall et al.'s “Conceptual Model for Evaluation of Collaborative Initiatives,” the project period was separated into phases of “collaborative readiness,” “collaborative capacity,” and “collaborative products.”

Results: Our findings revealed a discrepancy between the objectively assessed concepts of collaborative readiness and researchers' reported perceptions of E&C during the early project stage. A set of E&C hindering factors identified during the initial project phase remained present until the final project stage. Further, E&C among scientists increased over time, as reflected by researchers' perceptions. Reports of scientists also showed that outcomes were co-produced at the final project stage for the first time, while knowledge integration had not yet been achieved. Generally, the number of collaborative products (particularly scientific publications) also substantially increased over time. E&C was supported and promoted by the efforts of the coordinating sub-project.

Conclusion: Scientific E&C is a learning process and needs time to develop. A participatory research approach taking into account the perspectives on and requirements for E&C during the project's design might lay the ground for suitable, supportive, and transparent conditions for effective and successful E&C. Despite their time- and resource-consuming nature, cross-disciplinary research initiatives provide a fertile context in which to generate new solutions for pressing societal issues given that long-term funding and the establishment of an overarching coordination organ is assured.

The Long-Term Public Health Impact of a Community-Based Participatory Research Project for Health Promotion Among Socially Disadvantaged Women-A Case Study Protocol

Introduction: Community-based participatory research (CBPR) is considered to be of high potential for health promotion among socially disadvantaged groups. However, the long-term implementation and transfer of these approaches remain challenging, and the public health impact they achieve is difficult to study. This also pertains to the potential health effects and cost-effectiveness of CBPR. This study protocol describes the follow-up case study (NU-BIG) after 15 years of the BIG project (“movement as investment in health”), a project to promote physical activity among socially disadvantaged women. Through a participatory approach, BIG empowers the addressed women to plan and implement low-threshold physical activity offers. Since the project started in 2005, it was transferred to 17 communities in Germany.

Materials and Analysis: NU-BIG intends to examine the long-term effects, including economic aspects, of the BIG project on individual and structural levels at all project sites, as well as its long-term implementation and transfer. NU-BIG is a cross-sectional and longitudinal study using a mixed method approach. For the longitudinal section, we re-analyze existing data from former BIG evaluations. For cross-sectional data collection, we use questionnaires and conduct qualitative interviews and focus groups. Women who take part in BIG program offers are part of the research team and will use the photo-voice approach to report on the effects of BIG. The study population consists of about 800 women who participate in BIG project offers and 50 persons involved in the implementation of the BIG project at local sites.

Discussion: The expected results from NU-BIG are highly relevant for studying the long-term public health impact of CBPR. In particular, this project intends to answer questions on how the transfer of such projects can succeed and which factors determine if a CBPR project can be sustained at the community level. Eventually, these results can contribute to the further development of participatory approaches to provide effective health promotion among socially disadvantaged groups.

Conclusion: Although CBPR is seen of having the potential to reduce health disparities, there is still a lack of research on its long-term effects and public health impact. NU-BIG aims at generating knowledge about the economic effects, reach, efficacy, adoption, implementation, and maintenance of a CBPR project. The expected results could be of high interest for BIG and other CBPR-projects.

Measuring capabilities in health and physical activity promotion: a systematic review

BACKGROUND

The capability approach by Amartya Sen and Martha Nussbaum has gained increasing attention in the field of public health. As it combines individual, social and structural factors and shifts the focus of attention from the actual behavior towards available options for health behaviors that people can actually choose from, it may help advance our understanding of complex health issues.

OBJECTIVES

The aim of this article is to identify and describe tools available to measure capabilities within the context of health, with a specific focus on capabilities for health-enhancing physical activity.

METHOD

We conducted a systematic literature review using 11 databases covering scientific journal articles published in English or German between the years 2000 and 2020 with a focus on capabilities for health or physical activity.

RESULTS

We found a total of 51 articles meeting our inclusion criteria. Four articles measured capabilities using qualitative methods, one combined qualitative and quantitative methods, while the rest used quantitative methods. We identified a total 11 different capability questionnaires, all showing moderate to good validity/reliability. Only one questionnaire and one interview-based tool specifically dealt with capabilities for health enhancing physical activity.

CONCLUSION

Although we were able to identify measurement tools for capabilities in health, this review has shown that there is no generic tool available for the measurement across all population- and age-groups, and tools focusing on physical activity are scarce. However, our results can be used as guide for future projects that aim at measuring capabilities.

Prenatal microarray comparative genomic hybridization: Experience from the two first years of activity at the Lyon university-hospital

OBJECTIVES

This study aims to describe how microarray comparative genomic hybridization (aCGH) has shifted to become a prenatal diagnosis tool at the Lyon university-hospital.

MATERIALS AND METHODS

This retrospective study included all patients who were referred in the 3 pluridisciplinary centers for prenatal diagnosis of the Lyon university-hospital and who received a prenatal aCGH between June 2013 and June 2015. aCGH was systematically performed in parallel with a karyotype, using the PréCytoNEM array design.

RESULTS

A total of 260 microarrays were performed for the following indications: 249 abnormal ultrasounds (95.8%), 7 characterizations of chromosomal rearrangements (2.7%), and 4 twins with no abnormal ultrasounds (1.5%). With a resolution of 1 mega base, we found 235 normal results (90.4%), 23 abnormal results (8.8%) and 2 non-returns (0.8%). For the chromosomal rearrangements visible on the karyotype, aCGH identified all of the 12 unbalanced rearrangements and did not identify the 2 balanced rearrangements. Among the fetuses with normal karyotypes, 11 showed abnormal microarray results, corresponding to unbalanced cryptic chromosomal rearrangements (4.2%).

CONCLUSION

Transferring aCGH to a prenatal diagnosis at the Lyon university-hospital has increased the detection rate of chromosomal abnormalities by 4.2% compared to the single karyotype.

Genetic counselling difficulties and ethical implications of incidental findings from array-CGH: a 7-year national survey

Microarray-based comparative genomic hybridization (aCGH) is commonly used in diagnosing patients with intellectual disability (ID) with or without congenital malformation. Because aCGH interrogates with the whole genome, there is a risk of being confronted with incidental findings (IF). In order to anticipate the ethical issues of IF with the generalization of new genome-wide analysis technologies, we questioned French clinicians and cytogeneticists about the situations they have faced regarding IF from aCGH. Sixty-five IF were reported. Forty corresponded to autosomal dominant diseases with incomplete penetrance, 7 to autosomal dominant diseases with complete penetrance, 14 to X-linked diseases, and 4 were heterozygotes for autosomal recessive diseases with a high prevalence of heterozygotes in the population. Therapeutic/preventive measures or genetic counselling could be argued for all cases except four. These four IF were intentionally not returned to the patients. Clinicians reported difficulties in returning the results in 29% of the cases, mainly when the question of IF had not been anticipated. Indeed, at the time of the investigation, only 48% of the clinicians used consents mentioning the risk of IF. With the emergence of new technologies, there is a need to report such national experiences; they show the importance of pre-test information on IF.

Whole-exome sequencing improves the diagnosis yield in sporadic infantile spasm syndrome

Infantile spasms syndrome (ISs) is characterized by clinical spasms with ictal electrodecrement, usually occurring before the age of 1 year and frequently associated with cognitive impairment. Etiology is widely heterogeneous, the cause remaining elusive in 40% of patients. We searched for de novo mutations in 10 probands with ISs and their parents using whole-exome sequencing (WES). Patients had neither consanguinity nor family history of epilepsy. Common causes of ISs were excluded by brain magnetic resonance imaging (MRI), metabolic screening, array-comparative genomic hybridization (CGH) and testing for mutations in CDKL5, STXBP1, and for ARX duplications. We found a probably pathogenic mutation in four patients. Missense mutations in SCN2A (p.Leu1342Pro) and KCNQ2 (p.Ala306Thr) were found in two patients with no history of epilepsy before the onset of ISs. The p.Asn107Ser missense mutation of ALG13 had been previously reported in four females with ISs. The fourth mutation was an in-frame deletion (p.Phe110del) in NR2F1, a gene whose mutations cause intellectual disability, epilepsy, and optic atrophy. In addition, we found a possibly pathogenic variant in KIF3C that encodes a kinesin expressed during neural development. Our results confirm that WES improves significantly the diagnosis yield in patients with sporadic ISs.

Structural analysis of the GH43 enzyme Xsa43E from Butyrivibrio proteoclasticus

The rumen of dairy cattle can be thought of as a large, stable fermentation vat and as such it houses a large and diverse community of microorganisms. The bacterium Butyrivibrio proteoclasticus is a representative of a significant component of this microbial community. It is a xylan-degrading organism whose genome encodes a large number of open reading frames annotated as fibre-degrading enzymes. This suite of enzymes is essential for the organism to utilize the plant material within the rumen as a fuel source, facilitating its survival in this competitive environment. Xsa43E, a GH43 enzyme from B. proteoclasticus, has been structurally and functionally characterized. Here, the structure of selenomethionine-derived Xsa43E determined to 1.3 Å resolution using single-wavelength anomalous diffraction is reported. Xsa43E possesses the characteristic five-bladed β-propeller domain seen in all GH43 enzymes. GH43 enzymes can have a range of functions, and the functional characterization of Xsa43E shows it to be an arabinofuranosidase capable of cleaving arabinose side chains from short segments of xylan. Full functional and structural characterization of xylan-degrading enzymes will aid in creating an enzyme cocktail that can be used to completely degrade plant material into simple sugars. These molecules have a range of applications as starting materials for many industrial processes, including renewable alternatives to fossil fuels.

Progress challenges and opportunities for the re-engineering of trans-AT polyketide synthases

Polyketides are a structurally and functionally diverse family of bioactive natural products that are used extensively as pharmaceuticals and agrochemicals. In bacteria these molecules are biosynthesized by giant, multi-functional enzymatic complexes, termed modular polyketide synthases (PKSs), that function in assembly-line like fashion to fuse and tailor simple carboxylic acid monomers into a vast array of elaborate chemical scaffolds. Modifying PKSs through targeted synthase re-engineering is a promising approach for accessing functionally-optimized polyketides. Due to their highly mosaic architectures the recently identified trans-AT family of modular synthases appear inherently more amenable to re-engineering than their well studied cis-AT counterparts. Here, we review recent progress in the re-engineering of trans-AT PKSs, summarize opportunities for harnessing the biosynthetic potential of these systems, and highlight challenges that such re-engineering approaches present.

A French collaborative survey of 272 fetuses with 22q11.2 deletion: ultrasound findings, fetal autopsies and pregnancy outcomes

OBJECTIVE

The 22q11.2 deletion (del22q11.2) is one of the most common microdeletions. We performed a collaborative, retrospective analysis in France of prenatal diagnoses and outcomes of fetuses carrying the del22q11.2.

METHODS

A total of 272 fetuses were included. Data on prenatal diagnosis, ultrasound findings, pathological features, outcomes and inheritance were analyzed.

RESULTS

The mean time of prenatal diagnosis was 25.6 ± 6 weeks of gestation. Most of the diagnoses (86.8%) were prompted by abnormal ultrasound findings [heart defects (HDs), in 83.8% of cases]. On fetal autopsy, HDs were again the most common disease feature, but thymus, kidney abnormalities and facial dysmorphism were also described. The deletion was inherited in 27% of cases. Termination of pregnancy (TOP) occurred in 68.9% of cases and did not appear to depend on the inheritance status. However, early diagnosis was associated with a higher TOP rate.

CONCLUSION

This is the largest cohort of prenatal del22q11.2 diagnoses. As in postnatally diagnosed cases, HDs were the most frequently observed abnormalities. However, thymus and kidney abnormalities and polyhydramnios should also be screened for in the prenatal diagnosis of del22q11.2. Only the time of diagnosis appeared to be strongly associated with the pregnancy outcome: the earlier the diagnosis, the higher the TOP rate.

Evaluation of Tumorigenic Risk of Tissue-Engineered Oral Mucosal Epithelial Cells by Using Combinational Examinations

Recently, oral mucosal epithelial cells were proposed as a cell source of the autologous cell transplant therapy for corneal trauma or disease. The question addressed is to know if the biological conditions of grafting could induce certain cellular, molecular, and genetic alterations that might increase the risk of mutations and possibly of cellular transformation. Recent progress in cancer research enables us to depict the generation mechanisms and basic characteristics of human cancer cells from molecular, cytological, and biological aspects. The aim of this study is to evaluate the risk of tumorigenicity of the oral mucosal epithelial culture process in order to mitigate that risk, if any, before clinical application. Oral mucosal epithelial cells from three different human donors were investigated by combinational examinations to detect possible tumorigenic transformation. We investigated (i) clonogenic and karyology types, (ii) the validation of proliferation rate, (iii) the epithelial–mesenchymal transition, (iv) anchorage-independent growth potential, and (v) tumorigenicity on nude mice. Results show that the culture process used in this study presents no risk of tumorigenicity.

[New chromosomal syndromes]

Mental retardation occurs in 2-3% of the general population either in isolation or in combination with facial dysmorphism and/or malformations. Chromosomal abnormalities are a most common etiology. Karyotype displays chromosome aberrations in about 10% of patients but it has a limited resolution (5 Mb). Recently, the development of new molecular cytogenetic tools, especially array CGH, allowed to detect smaller abnormalities and increased the diagnosis capability of 15-20%. Among these newly detected rearrangements, some of them are recurrent and define new recognized syndromes. We will first briefly explain the non-allelic homologous recombination (NAHR) mechanism that underlines the origin of recurrent microdeletions and microduplications. Then we will describe eight new syndromes, four microdeletions (del 17q21.31, del 3q29, del 15q24, del 2q32.3q33) and four microduplications (dup 22q11.2, dup 7q11.23, dup 17p11.2, duplication of MECP2). A better knowledge of these new recurrent chromosomal syndromes will allow to improve care for patients, to develop targeted chromosomal diagnosis and to identify genes involved in neurocognitive functions.

Six cases of cryptic subtelomeric translocations in four families: the use of subtelomeric FISH probes as a diagnostic tool

Finding the diagnosis in children with mental retardation and a normal karyotype, whether or not associated with dysmorphic features, is important for defining an eventual syndrome and for genetic counselling of the families. Telomeric re-arrangements may be a common and underestimated-to-date cause of non-syndromic mental retardation. Using a FISH-based approach combining subtelomeric probes, we report the detection of 4 cases of cryptic translocations t(2;10)(p25.3;q26.3), t(4;17)(p16.2;q25), t(4;20)(p16.2;q13) and t(5;7)(p15.3;q36) associated with MR and dysmorphic features. We discuss the usefulness of subtelomeric FISH in children with unexplained delayed psychomotor development, when the genetic cause remains unknown and the karyotype is normal.

Le syndrome de Netherton : une ectodermatose du petit nourrisson avec retard de croissance, déficit immunitaire et rachitisme. À propos de 3 cas

We report the cases of 2 boys and 1 girl suffering from Netherton syndrome. Both boys presented with a non-bullous congenital erythroderma and were diagnosed early as Netherton syndrome with hair biopsies. Both had severe failure to thrive, signs of atopy, several episodes of bacterial infection, and rickets (with a high blood level of vitamin D in the first boy, and vitamin D deficiency in the second). In the third case, the pilar abnormality appeared at the age of 3 years. The girl had ichtyosis linearis circumflexa, failure to thrive and severe constipation. Netherton syndrome is a rare disorder characterized by severe ichtyosis, signs of atopy, immune deficiency and failure to thrive. The disease is severe and comprises many complications in early infancy. It is due to a genetic disorder of recessive autosomal transmission, and the gene, SPINK5, is located in the chromosome 5. Prenatal diagnosis is possible. Two of our patients had rickets, which has never been described in such patients population.

Prenatal diagnosis of Aicardi-Goutières syndrome

OBJECTIVES

Aicardi-Goutières syndrome is an autosomal recessive neurodegenerative disorder inducing cerebral atrophy, intracerebral calcification and developmental arrest. Diagnosis requires the presence of progressive encephalopathy with clinical onset shortly after birth, typical neuroimaging features associated with a raised blood and cerebrospinal fluid interferon-alpha level.A case of prenatal diagnosis of Aicardi-Goutières syndrome is reported.

METHODS

An MRI performed at 26 gestational weeks showed bilateral calcifications and white matter abnormalities, cerebral anomalies typically described in this disease. The fetal blood analysis revealed an increase in interferon-alpha.

RESULTS

Therefore, the prenatal diagnosis of Aicardi-Goutières syndrome in this fetus was based on the following facts: the familial background with the affected first child and consanguineous parents, a normal pregnancy and normal fetal growth, cerebral anomalies diagnosed on prenatal ultrasound and cerebral MRI, raised interferon-alpha in the fetal serum and no evidence of any infectious etiology. The autopsy performed postdelivery at 28 1/2 weeks' gestation confirmed the diagnosis of Aicardi-Goutières syndrome.

CONCLUSION

To the best of our knowledge, this is the first prenatal diagnosis of this syndrome. Such a diagnosis may prove useful for families at risk as long as genetic screening is not available.

Extended antiretroviral treatment interruption in HIV-infected patients with long-term suppression of plasma HIV RNA

OBJECTIVES

Evaluation of extended treatment interruption (TI) in chronic HIV infection among patients successfully treated with antiretroviral therapy.

METHODS

An observational analysis of 25 patients in a prospectively followed cohort with chronic HIV infection, viral loads <500 HIV-1 RNA copies/mL for at least 6 months, and an interruption in therapy of >/=28 days duration was carried out. Follow up was divided into 3-month time periods for analysis. The effects of time period, stratification group and stratification group by time period interactions on CD4 counts were tested using a mixed model. Univariate comparisons among patient characteristics and responses were performed using Fisher's exact test or the Wilcoxon rank sum test.

RESULTS

At initiation of TI, the median CD4 count was 799 cells/microL. TI duration was a median of 7.1 months. HIV RNA rebounded to a median maximum level of 75 000 copies/mL. Maximum viral rebound was significantly greater in patients who were male, had lipodystrophy and had zenith HIV RNA prior to TI of >/=50 000 copies/mL. Lower CD4 cell counts were observed during TI in patients with lipodystrophy, zenith HIV RNA >/=50 000 copies/mL, history of AIDS, HIV infection >/=5 years and presuppression CD4 count </=350 cells/muL. Patients who reinitiated therapy had shorter TI duration, presuppression CD4 count </=350 cells/microL, previous AIDS diagnosis and lipodystrophy. No patients developed adverse or AIDS-defining events during TI.

CONCLUSIONS

Long-term TI resulted in greater immune deterioration in patients with high viral set points or low CD4 cell counts prior to initiation of suppressive antiretroviral therapy.

[Hypomelanosis of Ito in a girl with Trisomy 13 mosaicism: a cytogenetic study]

BACKGROUND

Hypomelanosis of Ito was first described by Ito in 1952 as incontinentia pigmenti achromians. The consistent feature of the disease is a characteristic cutaneous hypopigmentation area following the lines of Blaschko, but the clinical manifestations are varied and hypomelanosis of Ito is regarded as a neurocutaneous syndrome. Hypomelanosis of Ito is sporadic but is probably a non-specific expression of chromosomal mosaicism; we report a case with four clones.

CASE REPORT

We report the case of a 26 year-old woman with neurocutaneous hypomelanosis of Ito and Trisomy 13 mosaicism. She also exhibited skeletal and ophthalmologic disorders. Immunohistology revealed a PS100 and Melan A decrease in hypopigmented skin. Cytogenetic study of normal and hypopigmented skin fibroblasts showed mosaicism with four clones.

DISCUSSION

This is the third case of Trisomy 13 mosaicism associated with hypomelanosis of Ito, although other anomalies on chromosome 13 have been described. Happle published "phylloid" pigmented cases, which are mainly associated with Trisomy 13. This is the first observation of four-clone mosaicism and can be explained by successive mutations during embryogenesis. Anomalies on chromosomes 5,6 and 21 have never been described. The definition of hypomelanosis of Ito is not well established and the disease is presently included in a group of "pigmentary dysplasia" with genetic mosaicism.

Large-scale deletions and SMADIP1 truncating mutations in syndromic Hirschsprung disease with involvement of midline structures

Hirschsprung disease (HSCR) is a common malformation of neural-crest-derived enteric neurons that is frequently associated with other congenital abnormalities. The SMADIP1 gene recently has been recognized as disease causing in some patients with 2q22 chromosomal rearrangement, resulting in syndromic HSCR with mental retardation, with microcephaly, and with facial dysmorphism. We screened 19 patients with HSCR and mental retardation and eventually identified large-scale SMADIP1 deletions or truncating mutations in 8 of 19 patients. These results allow further delineation of the spectrum of malformations ascribed to SMADIP1 haploinsufficiency, which includes frequent features such as hypospadias and agenesis of the corpus callosum. Thus, SMADIP1, which encodes a transcriptional corepressor of Smad target genes, may play a role not only in the patterning of neural-crest-derived cells and of CNS but also in the development of midline structures in humans.

Diversification of cardiac insulin signaling involves the p85 alpha/beta subunits of phosphatidylinositol 3-kinase

Ventricular cardiomyocytes and cardiac tissue of lean and genetically obese (fa/fa) Zucker rats were used 1) to study the role of the p85 regulatory subunit isoforms p85 alpha and p85 beta for insulin signaling through the phosphatidylinositol (PI) 3-kinase pathway, and 2) to elucidate the implications of these mechanisms for cardiac insulin resistance. Western blot analysis of cardiomyocyte lysates revealed expression of p85 alpha and p85 beta but no detectable amounts of the splice variants of p85 alpha. Essentially no p85 alpha subunit of PI 3-kinase was found to be associated with insulin receptor substrate (IRS)-1 or IRS-2 in basal and insulin-stimulated (5 min) cardiomyocytes. Instead, insulin produced a twofold increase in p85 beta associated with IRS-1, leading to a three- to fourfold increase in p85 beta-associated PI 3-kinase activity. This response was significantly reduced in obese animals. Comparable results were obtained in the intact heart after in vivo stimulation. In GLUT-4-containing vesicles, an increased abundance (3.7 +/- 0.7-fold over basal) of p85 alpha was observed after insulin stimulation of lean animals, with no significant effect in the obese group. No p85 beta could be detected in GLUT-4-containing vesicles. Recruitment of the p110 catalytic subunit of PI 3-kinase and a twofold increase in enzyme activity in GLUT-4-containing vesicles by insulin was observed only in lean rats. We conclude that, in the heart, p85 alpha recruits PI 3-kinase activity to GLUT-4 vesicles, whereas p85 beta represents the main regulator of IRS-1- and IRS-2-mediated PI 3-kinase activation. Furthermore, multiple defects of PI 3-kinase activation, involving both the p85 alpha and the p85 beta adaptor subunits, may contribute to cardiac insulin resistance.

Mapping of X chromosome inversion breakpoints [inv(X)(q11q28)] associated with FG syndrome: a second FG locus [FGS2]?

FG syndrome is an X-linked condition comprising mental retardation, congenital hypotonia, macrocephaly, distinctive facial changes, and constipation or anal malformations. In a linkage analysis, we mapped a major FG syndrome locus [FGS1] to Xq13, between loci DXS135 and DXS1066. The same data, however, clearly demonstrated genetic heterogeneity. Recently, we studied a French family in which an inversion [inv(X)(q12q28)] segregates with clinical symptoms of FG syndrome. This suggests that one of the breakpoints corresponds to a second FG syndrome locus [FGS2]. We report the results of fluorescence in situ hybridization analysis performed in this family using YACs and cosmids encompassing the Xq11q12 and Xq28 regions. Two YACs, one positive for the DXS1 locus at Xq11.2 and one positive for the color vision pigment genes and G6PD loci at Xq28, were found to cross the breakpoints, respectively. We postulate that a gene might be disrupted by one of the breakpoints.

Treatment of cervical carcinoma in situ in HIV positive women

OBJECTIVES

To evaluate the safety and effectiveness of hysterectomy vs. cone biopsy in HIV seropositive patients with carcinoma in situ of the cervix (CIS).

METHODS

We performed a retrospective case-control study of all HIV seropositive patients diagnosed with carcinoma in situ of the cervix from 1989 to 1995. A control group of HIV(-) women with CIS was also ascertained matched for date of diagnosis of CIS, race and age.

RESULTS

There were 439 patients with CIS, of which 45 were HIV seropositive (10.3%). Nine were treated by hysterectomy, 30 by cone biopsy, and six remained untreated. Overall, 63% of HIV(+) patients did not receive any follow-up Pap smear (44% of hysterectomy patients, 50% of cone biopsy patients, and 83% of untreated patients; chi(2) P=0.41). According to Pap smear results, 67% (10/15) cone biopsy patients and 60% (3/5) hysterectomy patients had an abnormal Pap smear after treatment (P=0.9). Median time to recurrence was 12 months in hysterectomy patients vs. 14 months in cone biopsy patients. Deaths occurred in 22% of hysterectomy patients, 17% of cone biopsy patients, and 50% of untreated patients, none due to cervical cancer. Median time to death from presentation was 27.5 months for hysterectomy patients, 11 months for cone biopsy patients, and 7 months for untreated patients (P<0.05). There were no complications in the hysterectomy group, however, two patients were readmitted after cone biopsy for bleeding. When compared to HIV(-) women with CIS, HIV(+) patients were more likely to be treated by hysterectomy (chi(2) P=0.01).

CONCLUSION

All patients diagnosed with CIS should be counseled regarding HIV prevention and testing because of a significant seropositive rate. Compliance with gynecologic follow-up is very poor in this patient population. Special efforts should be made to enhance compliance. Cone biopsy and hysterectomy appear to be equally safe and effective in the treatment of CIS. CIS in HIV patients is a poor prognostic indicator for death from any cause.

Tryptanthrins and other tryptophan-derived agonists of the dioxin receptor

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) and related environmental pollutants exert most of their adverse effects via the aryl hydrocarbon or dioxin receptor (AhR). While most potent agonists of the AhR are of synthetic origin, an increasing number of natural compounds is now recognized as receptor agonists. Our findings demonstrate that some tryptanthrin derivatives biosynthesized in incubations of Candida lipolytica with tryptophan and anthranilic acid or its derivatives activate the AhR measured as induction of cytochrome P4501A1 mRNA and protein in rat hepatocytes in primary culture. The specificity of the inducing effect of tryptanthrins was demonstrated in gel retardation experiments in Hepa-1 mouse hepatoma cells using an oliogonucleotide comprising the sequence of the dioxin-responsive element. Furthermore, unidentified AhR agonists were formed in incubations of rat feces with a minimal medium supplemented with tryptophan. It is suggested that the receptor may be part of a defense system protecting higher organisms from secondary tryptophan-derived metabolites formed by the microflora of the host or its environment.

Molecular mechanisms of contraction-regulated cardiac glucose transport

Insulin and contraction are the most important regulators of glucose utilization in cardiac muscle. In contrast with insulin, the intracellular signalling elements of contraction have remained unexplored. In the present studies, adult rat ventricular cardiomyocytes were electrically stimulated to perform rhythmic contractions to permit the determination of potential sites of convergence of contraction and insulin signalling to glucose transport. The participation of phosphoinositide 3-kinase (PI-3K) in Ca(2+)- and contraction-stimulated 3-O-methylglucose transport was suggested by the great sensitivity of this process towards the PI-3K inhibitors wortmannin and LY294002 and by the presence of PI-3K activity in anti-phosphotyrosine immunoprecipitates from contracted cells. Initial signalling events of insulin action, including receptor kinase activation, the tyrosine phosphorylation of insulin receptor substrate (IRS)-1 and IRS-2 and the recruitment of PI-3K to IRS-1 and IRS-2, were found not to be involved in contraction-mediated signalling. However, immunoprecipitation of p85alpha revealed a markedly enhanced tyrosine phosphorylation of an unknown co-precipitated 200 kDa protein in response to both stimuli. It is concluded that contraction-regulated cardiac glucose transport involves the activation of PI-3K in response to upstream signalling pathways different from that of insulin.

Trisomy 17 mosaicism in amniotic fluid cells not found at birth in blood but present in skin fibroblasts

This article describes a case of fetal trisomy 17 mosaicism found in amniotic fluid cells in one of two bichorial biamniotic twins without any sonographic anomaly. The extra chromosome 17 was absent from cord blood cells at birth but present on karyotype and in situ hybridization in cultured fibroblasts from skin biopsy. Clinical examination showed a few mild dysmorphic features and a moderate neurological involvement which may rather be related to prematurity. It therefore seemed important to obtain the karyotype on fibroblasts when a trisomic cell line was found in amniocentesis and not confirmed on blood lymphocytes, even in the absence of dysmorphic features. This should help to differentiate a real mosaic from a mosaic restricted to extra-fetal tissues.

Genetic and functional characterization of the alpAB gene locus essential for the adhesion of Helicobacter pylori to human gastric tissue

In this study, we isolated and characterized a chromosomal locus of Helicobacter pylori previously identified by transposon shuttle mutagenesis as being involved in the adhesion of the pathogen to gastric epithelial cells. Two closely homologous genes were identified, designated as alpA and alpB, encoding outer membrane (OM) proteins of 518 amino acids each. They are members of the outer membrane protein supergene family identified in the H. pylori 26695 complete genome sequence. AlpA carries a functional lipoprotein signal sequence. AlpB carries a putative standard N-terminal signal sequence and shows a strong amino-acid sequence identity to AlpA. Transposon insertion mutagenesis, immunoblotting and primer extension studies indicate that both genes are organized in an operon, but no obvious consensus promoter sequence was found upstream of the transcriptional start site. The C-terminal portion of both proteins is predicted to form a porin-like beta-barrel in the outer membrane, consisting of 14 transmembrane amphipathic beta-strands. Adhesion experiments with defined isogenic mutants indicate that both proteins are necessary for specific adherence of H. pylori to human gastric tissue. The pattern of AlpAB-dependent adherence of H. pylori to the gastric epithelial surface shows a clear difference to the BabA2-mediated adherence to Lewis, suggesting that a different receptor is involved.

Potency of various polycyclic aromatic hydrocarbons as inducers of CYP1A1 in rat hepatocyte cultures

A number of highly toxic environmental pollutants including certain polychlorinated dibenzo-p-dioxins (PCDD), polychlorinated dibenzofurans (PCDF), and 'dioxin-like' polychlorinated biphenyls (PCB) are among the most potent agonists of the aryl hydrocarbon receptor (AHR). Induction of cytochrome P4501A1 (CYP1A1) in mammalian cell culture is widely used as a functional parameter for AHR activation providing an estimate for 'dioxin-like' inducing equivalents in extracts from environmental samples. Since a number of polycyclic aromatic hydrocarbons (PAHs) also act as AHR-agonists, the CYP1A1-inducing potencies, measured as induction of 7-ethoxyresorufin O-deethylase (EROD) activity in rat hepatocyte cultures were analyzed for 16 PAHs frequently present in environmental samples. Among these, seven PAHs including benzo[a]pyrene were relatively potent inducers allowing the determination of Induction Equivalency Factors (IEF). For three PAHs including benzo[k]fluoranthene which acted as weak inducers, IEFs were estimated, while six PAHs including acenaphthylene were classified as inactive. Based on different efficacies the concentration-response characteristics of CYP1A1 induction were analyzed in more detail for benzo[a]pyrene, benzo[k]fluoranthene, and acenaphthylene. Benzo[k]fluoranthene was markedly less effective than benzo[a]pyrene as inducer of EROD activity but even more effective than benzo[a]pyrene as inducer of CYP1A1 protein and mRNA. Acenaphthylene was highly more effective on the level of mRNA than on the levels of protein or EROD activity. Further analysis revealed that the low efficacy of acenaphthylene as inducer of CYP1A1 protein and EROD activity is due to its marked cytotoxicity while no clear-cut explanation was found for the differences in efficacy between benzo[k]fluoranthene and benzo[a]pyrene. The EROD-inducing potency of a mixture of 16 PAH was about 2-fold higher than that calculated on the basis of IEFs of the individual constituents of the mixture.