Rapid Point-of-Care Genotyping to Avoid Aminoglycoside-Induced Ototoxicity in Neonatal Intensive Care

Importance

Aminoglycosides are commonly prescribed antibiotics used for the treatment of neonatal sepsis. The MT-RNR1 m.1555A>G variant predisposes to profound aminoglycoside-induced ototoxicity (AIO). Current genotyping approaches take several days, which is unfeasible in acute settings.

Objective

To develop a rapid point-of-care test (POCT) for the m.1555A>G variant before implementation of this technology in the acute neonatal setting to guide antibiotic prescribing and avoid AIO.

Design, Setting, and Participants

This pragmatic prospective implementation trial recruited neonates admitted to 2 large neonatal intensive care units between January 6, 2020, and November 30, 2020, in the UK.

Interventions

Neonates were tested for the m.1555A>G variant via the rapid POCT on admission to the neonatal intensive care unit.

Main Outcomes and Measures

The primary outcome assessed the proportion of neonates successfully tested for the variant of all infants prescribed antibiotics. Secondary outcomes measured whether implementation was negatively associated with routine clinical practice and the performance of the system. The study was statistically powered to detect a significant difference between time to antibiotic administration before and after implementation of the MT-RNR1 POCT.

Results

A total of 751 neonates were recruited and had a median (range) age of 2.5 (0-198) days. The MT-RNR1 POCT was able to genotype the m.1555A>G variant in 26 minutes. Preclinical validation demonstrated a 100% sensitivity (95% CI, 93.9%-100.0%) and specificity (95% CI, 98.5%-100.0%). Three participants with the m.1555A>G variant were identified, all of whom avoided aminoglycoside antibiotics. Overall, 424 infants (80.6%) receiving antibiotics were successfully tested for the variant, and the mean time to antibiotics was equivalent to previous practice.

Conclusions and Relevance

The MT-RNR1 POCT was integrated without disrupting normal clinical practice, and genotype was used to guide antibiotic prescription and avoid AIO. This approach identified the m.1555A>G variant in a practice-changing time frame, and wide adoption could significantly reduce the burden of AIO.

A family systems approach to genetic counseling: Development of narrative interventions

To what extent are family systems approaches relevant in the genomics era? What difference does it make to remember the wider social context within which ‘problems’ associated with a genetic diagnosis reside? How does this influence the conversations we have with our patients? These questions will be considered in relation to systemic approaches to genetic counseling practice. Narrative therapy with an emphasis on people's strengths, wishes, and ways of resisting the effects of a problem may be a particularly useful framework for genetic counselors. Narrative practice views people as multi‐storied and is concerned with the question of how we encourage people to tell their stories in ways that make them feel stronger. Increased uptake of genomic testing and the number of people seeking genetic counseling present opportunities to consider new ways of working, particularly around support following a new genetic diagnosis. One option is to realize the potential of group interventions. Family therapy and narrative practices have the potential to encourage communication and for families to learn from each other.

Intraventricular haemorrhage in a Ugandan cohort of low birth weight neonates: the IVHU study

Background

Globally, 15 million neonates are born prematurely every year, over half in low income countries (LICs). Premature and low birth weight neonates have a higher risk of intraventricular haemorrhage (IVH). There are minimal data regarding IVH in sub-Saharan Africa. This study aimed to examine the incidence, severity and timing of and modifiable risk factors for IVH amongst low-birth-weight neonates in Uganda.

Methods

This is a prospective cohort study of neonates with birthweights of ≤2000 g admitted to a neonatal unit (NU) in a regional referral hospital in eastern Uganda. Maternal data were collected from interviews and medical records. Neonates had cranial ultrasound (cUS) scans on the day of recruitment and days 3, 7 and 28 after birth. Risk factors were tabulated and are presented alongside odds ratios (ORs) and adjusted odds ratios (aORs) for IVH incidence. Outcomes included incidence, timing and severity of IVH and 28-day survival.

Results

Overall, 120 neonates were recruited. IVH was reported in 34.2% of neonates; 19.2% had low grade (Papile grades 1–2) and 15% had high grade (Papile grades 3–4). Almost all IVH (90.2%) occurred by day 7, including 88.9% of high grade IVH. Of those with known outcomes, 70.4% (81/115) were alive on day 28 and survival was not associated with IVH. We found that vaginal delivery, gestational age (GA) < 32 weeks and resuscitation in the NU increased the odds of IVH. Of the 6 neonates who received 2 doses of antenatal steroids, none had IVH.

Conclusion

In this resource limited NU in eastern Uganda, more than a third of neonates born weighing ≤2000 g had an IVH and the majority of these occurred by day 7. We found that vaginal birth, earlier gestation and need for resuscitation after admission to the NU increased the risk of IVH. This study had a high rate of SGA neonates and the risk factors and relationship of these factors with IVH in this setting needs further investigation. The role of antenatal steroids in the prevention of IVH in LICs also needs urgent exploration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-020-02464-4.

"It's being part of the big picture, even though you're a tiny jigsaw piece"-motivations and expectations of individuals participating in the Enroll-HD observational study

Predictive test guidelines for Huntington's disease (HD) recommend individuals are offered opportunities to participate in research regardless of test outcome. Consistent with most HD centres of excellence, the Manchester Centre for Genomic Medicine (MCGM) invites eligible individuals to participate in the observational study, Enroll-HD. Limited research has been conducted to date on the views of research participants and the possible impact of participation. The aim of this qualitative study was to explore the experiences of ten individuals taking part in the Enroll-HD study following pre-symptomatic testing for HD. Half of the individuals had tested positive for the HD mutation and the other half had tested negative. Participants were generally motivated to take part in the study by both personal and altruistic reasons. Overall, they were very positive about participation in Enroll-HD. Valuable aspects included good relationships with the research/clinical team, increased understanding of the condition, an enhanced self-image and a shared experience with affected parents. Issues for improvement to encourage participation included access to study site and more regular communication about study progress. Participants, while generally optimistic about research progress, were realistic about challenges.

Evaluating a genetic counseling narrative group session for people who have tested positive for the Huntington's disease expansion: An interpretative phenomenological analysis

Huntington's disease (HD) is an inherited neurodegenerative disorder characterized by motor problems, cognitive impairment, and mood disturbances. Given the emotional elements of both HD itself and the testing process for it, psychological interventions may be helpful for those families impacted by HD. A stand-alone genetic counseling narrative group has been offered by one regional genetics clinic in the north of England to support people's coping following predictive genetic testing for HD. Groups are held 4-5 times per year with patients attending a group on a single occasion. This study assessed participants' experiences of attending a group using the qualitative method interpretative phenomenological analysis (IPA). Telephone interviews were conducted with 12 people who had a mutation-positive HD predictive test result and who had taken part in a genetic counseling narrative group session between November 2017 and February 2018. Participants were asked about their experiences of the group and any impact it had had on their lives. Four themes emerged: 'The power of the group, 'Active elements of the narrative exercise', 'Subsequent impact of the session', and 'Another voice'. Participants described the positive impact of being able to meet and empathize with others in a similar situation, the group's positive impact on their mood and future outlook, and its beneficial impact on disclosure. While most participants were positive about the session, the final theme presented the voices of two participants for whom the groups were poorly timed. Given the sessions' generally positive impact, we recommend other centers consider offering people impacted by HD similar sessions.

Genetic Counselling and Narrative Practices: A Model of Support following a "Negative" Predictive Test for Huntington's Disease

BACKGROUND

Predictive testing for Huntington's disease (HD) has been available for individuals at risk of HD by direct mutation analysis since 1993. International Predictive test guidelines recommend that support is offered following the result regardless of test outcome. However, there is lack of an evidence base regarding what this support should look like and how it might work in practice.

OBJECTIVE

A service improvement initiative looked at the feasibility of offering a narrative group session co-facilitated by a genetic counsellor and clinical psychologist, to individuals who had tested mutation negative for HD. The narrative session was evaluated from the perspective of group participants.

METHODS

Individuals who tested mutation negative at a genetic centre in the North of England over a 5-year period were invited to attend a narrative group session. 52 people were contacted and 9 people agreed to participate. Participants completed standardised questionnaires (PHQ-9 and GAD-7) before and after the session and a detailed written evaluation. Participants' comments were analysed thematically.

RESULTS

Participants were overwhelmingly positive about the narrative session finding it a safe and enjoyable way to explore difficult life experiences. Reported benefits included feeling less isolated, being inspired by other people's stories and connecting as a group. All 9 participants said they would recommend the narrative session to anyone impacted by HD.

CONCLUSIONS

The narrative group session was considered an interesting and useful approach to facilitating adaptation following a negative predictive test result for HD.

P6555A self-adaptive approach to antitachycardia pacing - a head to head comparison using advanced computational modeling

Background

Antitachycardia pacing (ATP) for monomorphic VT (MVT) reduces painful defibrillation shocks. Most ICD-treated ventricular arrhythmias are MVT, suggesting an opportunity for improved ATP to decrease shocks. We report on a new algorithm (Yee, Circ AE 2017) that uses electrophysiologic (EP) first-principles to design ATP sequences in real-time. Heart-rate history is used to design the first ATP sequence, and failed ATP post-pacing interval is used to design later sequences.

Purpose

The purpose of this modeling study was to understand how this new ATP algorithm would perform in a head-to-head comparison with traditional burst ATP. Modeling allows direct comparison of the two algorithms in identical, realistic, patient-derived cardiac arrythmias.

Methods

Patient-specific late gadolinium enhanced MRI and EP data were used to build an adjudicated cohort of realistic numerical heart models with varied EP, infarct, border zone. Publicly available EP modeling software CARPentry was used to calculate sustained reentrant VT initiated with the programmed electrical stimulation used to induce VT clinically. The VTs were physician-adjudicated to validate models. Burst ATP was 3 sequences of 8 pulses at 88% of VT cycle length, each decremented by 10ms. The new ATP was limited to 3 automatically designed sequences.

Results

Three hundred unique VT scenarios were generated from 6 human hearts with multiple VT circuits, 5 electrophysiologic states, and 10 pacing locations. Burst ATP terminated 168/300 VTs (56%) and accelerated 2.7%. The new ATP terminated 234/300 VTs (78%) with the same acceleration. The two dominant ATP failure mechanisms were identified as 1) insufficient prematurity to close the excitable gap, and 2) failure to reach the critical isthmus of the VT circuit. For these mechanisms, the new ATP algorithm reduce failures from 64 to 28 (44% reduction) without increasing acceleration.

Conclusion

The new automated ATP algorithm successfully adapted ATP sequences for VT episodes that burst ATP failed to terminate. The new ATP was successful even with complex scar geometries and electrophysiology heterogeneity as seen in the real world.

Short-term glioblastoma cultures may contain normal "glia-like" cells

OBJECTIVES

Currently used glioblastoma cultures have many disadvantages and are being replaced by short-term cultures. However, these may include normal brain cells.

BACKGROUND

A comparative model of normal and glioma cultures is lacking. A significant contributory factor is because cultures from adult human brain contain small amounts of cells with glial phenotypes. The predominant population of flat or spindle shaped cells does not express glial markers and are often termed as "glia-like".

METHODS

Cryopreserved glioblastoma cultures from 28 bioptic samples were examined by immunofluorescence using antibodies to intermediate filaments (IF): glial fibrillary acidic protein (GFAP), cytokeratins (CK), nestin (Nes), vimentin (Vim) and neurofilaments (NF).

RESULTS

In short-term glioblastoma cultures GFAP-positive cells occured at higher percentages in 3/28 cultures and in lower percentages in further 5 cultures. Subpopulation of nestin positive cells were observed in all cultures and CK-positive cells were found in 25/28 cultures. All cells in all cultures were positively stained only for vimentin and negatively for NF. Cells grew slowly in 5 cultures which showed early proliferation arrest between passages 7 to 8. A further 23 cultures showed growth arrest by passages 10 to 15.

CONCLUSION

The presence of normal cells in short-term glioblastoma cultures may be caused by the infiltrative growth of these tumors. Our comparative analysis of morphological, growth and cytoskeletal properties revealed similarities between glioblastoma and normal brain cultures. In this study, the majority (28/30) of short-term glioblastoma showed limited life spans, similar to normal cells lacking spontaneous immortalization. The use of short-term glioblastoma cultures has two main problematic areas: cultures may contain a major subpopulation of normal "glia-like" cells; or they may contain the inital phases of spontaneously immortalized glioblastoma cells bearing properties of permanent cell lines (Tab. 1, Fig. 2, Ref. 19).

A case-note review of continued pregnancies found to be at a high risk of Huntington's disease: considerations for clinical practice

Huntington's disease (HD) is a severe neurodegenerative condition that impacts the whole family. Prenatal diagnosis by direct or exclusion testing is available for couples at risk of transmitting HD to their children. An ethical problem can arise after prenatal diagnosis for HD if a known 'high risk' pregnancy is continued to term: international guidelines emphasise that this situation should be avoided where possible, as it removes the resulting child's future right to make an informed, autonomous decision about predictive testing. The UK Huntington's Disease Predictive Testing Consortium recorded 21 pregnancies that were tested, identified as high-risk and then continued. In this qualitative study, health professionals reviewed the case notes of 15 of these pregnancies. This analysis generated guidelines for clinical practice. It is recommended that practitioners: (i) remind couples of the long-term consequences of continuing a high risk pregnancy, (ii) ensure couples understand the information provided, (iii) collaborate closely with other professionals involved in the couple's prenatal care, (iv) prepare couples for the procedural aspects of prenatal diagnosis and a possible termination of pregnancy, (v) allow time for in-depth pre-test counselling, (vi) explain the rationale for only making prenatal diagnosis available subject to conditions, whilst allowing for human ambivalence and acknowledging that these 'conditions' cannot be enforced, (vii) monitor the whole clinical process to ensure that it works 'smoothly', (viii) recommend couples do not disclose the result of the prenatal test to protect the confidentiality and autonomy of the future 'high-risk' child, and (ix) offer on-going contact and support.

Diagnosing and Preventing Hearing Loss in the Genomic Age

Over the past two decades, significant technological advances have facilitated the identification of hundreds of genes associated with hearing loss. Variants in many of these genes result in severe congenital hearing loss with profound implications for the affected individual and their family. This review collates these advances, summarizing the current state of genomic knowledge in childhood hearing loss. We consider how current and emerging genetic technologies have the potential to alter our approach to the management and diagnosis of hearing loss. We review approaches being taken to ensure that these discoveries are used in clinical practice to detect genetic hearing loss as soon as possible to reduce unnecessary investigations, provide information about reproductive risks, and facilitate regular follow-up and early treatment. We also highlight how rapid sequencing technology has the potential to identify children susceptible to antibiotic-induced hearing loss and how this adverse reaction can be avoided.

The Process of Disclosure: Mothers' Experiences of Communicating X-Linked Carrier Risk Information to At-Risk Daughters

When a boy is diagnosed with an X-linked condition such as Duchenne or Becker muscular dystrophy (D/BMD), the mother learns not only of her own potential carrier risk but also that of her daughters. Before the daughters are seen in the Genetics Clinic, responsibility for disclosing carrier risk information falls mainly to their mothers. We know little about if when and how these daughters are being told about their risk, and how mothers find the experience. Should we be doing more to help and support them? Using qualitative methods, six mothers known to the Manchester Centre for Genomic Medicine were interviewed about the disclosure of D/BMD carrier risk information to their daughters. The four key themes that arose are presented: communication process, facilitators of disclosure, barriers to disclosure and support and information. Despite the participants' endeavours to be open and honest with their daughters and their belief that they had fully disclosed, key information was often withheld. Major barriers to discussion of the future, including reproductive options, were apparent. These were partly overcome by the involvement of genetic counsellors (GCs). The participants suggested a greater involvement of GCs, proactively sending appointments and written information, and offering carrier testing more flexibly.

Predictive testing of minors for Huntington's disease: The UK and Netherlands experiences

A consistent feature of predictive testing guidelines for Huntington's disease (HD) is the recommendation not to undertake predictive tests on those < 18 years. Exceptions are made but the extent of, and reasons for, deviation from the guidelines are unknown. The UK Huntington's Prediction Consortium has collected data annually on predictive tests undertaken from the 23 UK genetic centers. DNA analysis for HD in the Netherlands is centralized in the Laboratory for Diagnostic Genome Analysis in Leiden. In the UK, 60 tests were performed on minors between 1994 and 2015 representing 0.63% of the total number of tests performed. In the Netherlands, 23 tests were performed on minors between 1997 and 2016. The majority of the tests were performed on those aged 16 and 17 years for both countries (23% and 57% for the UK, and 26% and 57% for the Netherlands). Data on the reasons for testing were identified for 36 UK and 22 Netherlands cases and included: close to the age of 18 years, pregnancy, currently in local authority care and likely to have less support available after 18 years, person never having the capacity to consent and other miscellaneous reasons. This study documents the extent of HD testing of minors in the UK and the Netherlands and suggests that, in general, the recommendation is being followed. We provide some empirical evidence as to reasons why clinicians have departed from the recommendation. We do not advise changing the recommendation but suggest that testing of minors continues to be monitored.

Training Genetic Counsellors to Deliver an Innovative Therapeutic Intervention: their Views and Experience of Facilitating Multi-Family Discussion Groups

Innovations in clinical genetics have increased diagnosis, treatment and prognosis of inherited genetic conditions (IGCs). This has led to an increased number of families seeking genetic testing and / or genetic counselling and increased the clinical load for genetic counsellors (GCs). Keeping pace with biomedical discoveries, interventions are required to support families to understand, communicate and cope with their Inherited Genetic Condition. The Socio-Psychological Research in Genomics (SPRinG) collaborative have developed a new intervention, based on multi-family discussion groups (MFDGs), to support families affected by IGCs and train GCs in its delivery. A potential challenge to implementing the intervention was whether GCs were willing and able to undergo the training to deliver the MFDG. In analysing three multi-perspective interviews with GCs, this paper evaluates the training received. Findings suggests that MFDGs are a potential valuable resource in supporting families to communicate genetic risk information and can enhance family function and emotional well-being. Furthermore, we demonstrate that it is feasible to train GCs in the delivery of the intervention and that it has the potential to be integrated into clinical practice. Its longer term implementation into routine clinical practice however relies on changes in both organisation of clinical genetics services and genetic counsellors' professional development.

Navigating physical activity engagement following a diagnosis of cancer: A qualitative exploration

This qualitative descriptive study explored cancer survivors' experiences of barriers and facilitators to undertaking physical activity to inform how services and professionals might offer better support. Purposive and theoretical sampling was used to recruit 25 people who were up to 5 years post-cancer diagnosis. Participants took part in face to face, semi-structured interviews, and transcripts were analysed using thematic analysis. The analysis identified five interrelated themes which represented cancer survivors' views: 1) You're on your own-a sense of abandonment post-treatment, and lack of sufficient and tailored information; 2) Dis-ease-disruption to self and identity, and a heightened awareness of physical self and fragility; 3) Becoming acclimatised-physical activity in the face of treatment-related side effects and residual impairment; 4) Importance of others-encouragement and support from health professionals, family and friends, and cancer-specific exercise groups; 5) Meanings people ascribed to physical activity-these were central and could help or hinder engagement. Our findings suggest being able to live well and re-engage in meaningful activities following a diagnosis of cancer is both complex and challenging. There appear to be gaps in current service provision in supporting the broader health and well-being of cancer survivors.

Disrupted seasonal biology impacts health, food security and ecosystems

The rhythm of life on earth is shaped by seasonal changes in the environment. Plants and animals show profound annual cycles in physiology, health, morphology, behaviour and demography in response to environmental cues. Seasonal biology impacts ecosystems and agriculture, with consequences for humans and biodiversity. Human populations show robust annual rhythms in health and well-being, and the birth month can have lasting effects that persist throughout life. This review emphasizes the need for a better understanding of seasonal biology against the backdrop of its rapidly progressing disruption through climate change, human lifestyles and other anthropogenic impact. Climate change is modifying annual rhythms to which numerous organisms have adapted, with potential consequences for industries relating to health, ecosystems and food security. Disconcertingly, human lifestyles under artificial conditions of eternal summer provide the most extreme example for disconnect from natural seasons, making humans vulnerable to increased morbidity and mortality. In this review, we introduce scenarios of seasonal disruption, highlight key aspects of seasonal biology and summarize from biomedical, anthropological, veterinary, agricultural and environmental perspectives the recent evidence for seasonal desynchronization between environmental factors and internal rhythms. Because annual rhythms are pervasive across biological systems, they provide a common framework for trans-disciplinary research.

Developing an intervention to facilitate family communication about inherited genetic conditions, and training genetic counsellors in its delivery

Many families experience difficulty in talking about an inherited genetic condition that affects one or more of them. There have now been a number of studies identifying the issues in detail, however few have developed interventions to assist families. The SPRinG collaborative have used the UK Medical Research Council's guidance on Developing and Evaluating Complex Interventions, to work with families and genetic counsellors (GCs) to co-design a psycho-educational intervention to facilitate family communication and promote better coping and adaptation to living with an inherited genetic condition for parents and their children (<18 years). The intervention is modelled on multi-family discussion groups (MFDGs) used in psychiatric settings. The MFDG was developed and tested over three phases. First focus groups with parents, young people, children and health professionals discussed whether MFDG was acceptable and proposed a suitable design. Using evidence and focus group data, the intervention and a training manual were developed and three GCs were trained in its delivery. Finally, a prototype MFDG was led by a family therapist and co-facilitated by the three GCs. Data analysis showed that families attending the focus groups and intervention thought MFDG highly beneficial, and the pilot sessions had a significant impact on their family' functioning. We also demonstrated that it is possible to train GCs to deliver the MFDG intervention. Further studies are now required to test the feasibility of undertaking a definitive randomised controlled trial to evaluate its effectiveness in improving family outcomes before implementing into genetic counselling practice.

30 GENERATION OF CLONED TRANSGENIC GOATS WITH CARDIAC SPECIFIC OVEREXPRESSION OF TRANSFORMING GROWTH FACTOR β1

Transforming growth factor β1 (TGF-β1) has a potent profibrotic function and is central to signaling cascades involved in interstitial fibrosis, which plays a critical role in the pathobiology of cardiomyopathy and contributes to diastolic and systolic dysfunction. In addition, fibrotic remodeling is responsible for generation of re-entry circuits that promote arrhythmias (Bujak and Frangogiannis 2007 Cardiovasc. Res. 74, 184–195). Due to the small size of the heart, functional electrophysiology of transgenic mice is problematic. Large transgenic animal models have the potential to offer insights into conduction heterogeneity associated with fibrosis and the role of fibrosis in cardiovascular diseases. The goal of this study was to generate transgenic goats overexpressing an active form of TGFβ-1 under control of the cardiac-specific α-myosin heavy chain promoter (α-MHC). A pcDNA3.1DV5-MHC-TGF-β1cys33ser vector was constructed by subcloning the MHC-TGF-β1 fragment from the plasmid pUC-BM20-MHC-TGF-β1 (Nakajima et al. 2000 Circ. Res. 86, 571–579) into the pcDNA3.1D V5 vector. The Neon transfection system was used to electroporate primary goat fetal fibroblasts. After G418 selection and PCR screening, transgenic cells were used for SCNT. Oocytes were collected by slicing ovaries from an abattoir and matured in vitro in an incubator with 5% CO2 in air. Cumulus cells were removed at 21 to 23 h post-maturation. Oocytes were enucleated by aspirating the first polar body and nearby cytoplasm by micromanipulation in Hepes-buffered SOF medium with 10 µg of cytochalasin B mL–1. Transgenic somatic cells were individually inserted into the perivitelline space and fused with enucleated oocytes using double electrical pulses of 1.8 kV cm–1 (40 µs each). Reconstructed embryos were activated by ionomycin (5 min) and DMAP and cycloheximide (CHX) treatments. Cloned embryos were cultured in G1 medium for 12 to 60 h in vitro and then transferred into synchronized recipient females. Pregnancy was examined by ultrasonography on day 30 post-transfer. A total of 246 cloned embryos were transferred into 14 recipients that resulted in production of 7 kids. The pregnancy rate was higher in the group cultured for 12 h compared with those cultured 36 to 60 h [44.4% (n = 9) v. 20% (n = 5)]. The kidding rates per embryo transferred of these 2 groups were 3.8% (n = 156) and 1.1% (n = 90), respectively. The PCR results confirmed that all the clones were transgenic. Phenotype characterization [e.g. gene expression, electrocardiogram (ECG), and magnetic resonance imaging (MRI)] is underway. We demonstrated successful production of transgenic goat via SCNT. To our knowledge, this is the first transgenic goat model produced for cardiovascular research. This work was supported by the Utah Science Technology and Research Initiative, Utah Multidisciplinary Arrhythmia Consortium.

Developing and evaluating a culturally appropriate genetic service for consanguineous South Asian families

Blackburn with Darwen Primary Care Trust (PCT) provides services to a substantial Asian population in which the practice of consanguineous marriage is common and there is a high incidence of autosomal recessive disorders. The aim was to provide and evaluate a genetic service accessible to consanguineous families from the South Asian community who had a child affected by an autosomal recessive disorder. Information on genetic risk was provided along with the offer of genetic testing for members of the extended family to identify gene carriers and facilitate informed reproductive choices. An Urdu-speaking health visitor was employed to establish a community-based, hospital-linked genetic service in conjunction with local paediatric and regional genetic services offered to parents who had an affected child and 71 of their relatives. The service was evaluated using a specifically designed questionnaire. There was a high uptake of the service (95% of index parents and 92% of relatives to whom it was offered) and a high uptake of carrier testing (94% of relatives to whom it was offered). Eight requests for prenatal diagnosis were made during the course of the service development. Many individuals stated they would consider genetic risk when making future marriage and reproductive plans. Input from a health care worker from the same ethnic background who provided information in their own language was highly valued. Family orientated genetic services for ethnic groups practicing consanguinity can be acceptable and effective when provided in a culturally appropriate manner.

Explaining Mendelian inheritance in genetic consultations: an IPR study of counselor and counselee experiences

The explanation of Mendelian inheritance is a key component of most genetic counselling consultations, yet no evidence base exists for this area of practice. This qualitative study used Interpersonal Process Recall (IPR) to explore how information about X-linked inheritance is provided and received in genetic counseling. Twelve consultations involving two senior genetic counselors and 21 counselees were videotaped. Section(s) of videotape featuring the explanation were subsequently played back separately to both counselees and counselors and their responses and reflections recorded. All interviews were fully transcribed and analysed using the constant comparison method. A personalized diagram, drawn "live" by the counselor during the consultation was recalled by counselees as being central to their understanding of the "bottom line". This helped bridge the gap between scientific information and their family experience and did not appear to require a baseline understanding of genetic concepts such as genes or chromosomes. Counselors reflected on the diagram's positive impact on the way they sequenced, paced and tailored the explanation. A positive counselor-counselee relationship was vital even during this educative exchange: for counselees to feel at ease discussing complex genetic information and to help gauge counselee understanding.

The emotional effects of genetic diseases: implications for clinical genetics

The aim of this qualitative study was to explore the emotional effects that may be common to many genetic conditions, or risk of genetic conditions, that could be appropriately targeted by clinical genetics services. The study sample comprised 52 individuals. Seven focus groups with patients of clinical genetics services, their representatives from patient support organizations and genetics healthcare providers were conducted. Focus groups were supplemented by 19 face-to-face interviews with patients and patient group representatives. Focus groups and interviews were audio taped, transcribed in full, and analyzed using the constant comparative method. Eight emotional effects of genetic diseases were identified: anxiety, worry about risks to children, guilt, anger, uncertainty, sadness and grief, depression, and redemptive adjustment. Two factors were identified that could modify the emotional effects; these were variability of genetic diseases, and lack of diagnosis/inappropriate care. Despite many negative effects of genetic disease being identified, results also suggest that redemptive adjustment is possible where a genetic condition is present in a family. Interventions designed to (1) adjust the modifying conditions and (2) help manage the emotional effects may facilitate adjustment and improve patient outcomes.

Mass-dependent predation risk and lethal dolphin-porpoise interactions

In small birds, mass-dependent predation risk (MDPR) is known to make the trade-off between avoiding starvation and avoiding predation dependent on individual mass. This occurs because carrying increased fat reserves not only reduces starvation risk but also results in a higher predation risk due to reduced escape flight performance and/or the increased foraging exposure needed to maintain a higher body mass. In principle, the theory of MDPR could also apply to any animal capable of storing energy reserves to reduce starvation and whose escape performance decreases with increasing mass. We used a unique situation along certain parts of coastal Britain, where harbour porpoises (Phocoena phocoena) are pursued and killed but crucially not eaten by bottlenose dolphins (Tursiops truncatus), to investigate whether a MDPR effect can occur in non-avian species. We show that where high levels of dolphin 'predation' occur, porpoises carry significantly less energy reserves than would otherwise be expected and this equates to reducing by approximately 37% the length of time that a porpoise could survive without feeding. These results provide the first evidence that a mass-dependent starvation-predation risk trade-off may be a general ecological principle that can apply to widely different animal types rather than, as is currently thought, only to birds.

Outcome measures for clinical genetics services: A comparison of genetics healthcare professionals and patients’ views

OBJECTIVES

To explore genetics professionals' and patients' views about which outcome domains are most appropriate to measure the patient benefits of using a clinical genetics service.

METHODS

A postal Delphi survey was sent to: 115 consultant geneticists; 162 genetic counsellors; 156 support group representatives; 106 patients. The survey contained 19 outcome domains and respondents assessed the usefulness of each for clinical genetics services.

RESULTS

The final professional panel comprised 115 genetics healthcare professionals and the patient panel comprised 72 patients. The outcome domains that achieved consensus (at least 75% of panel rated 'useful') for the patient and professional panels were: decision-making; knowledge of the genetic condition; perceived personal control; risk perception; satisfaction; meeting expectations; ability to cope; diagnosis accuracy; quality of life. Comparison of the ratings between the professional panel and the patient panel showed there was no statistical difference (chi(2), p<0.01) between the ratings ('useful' compared to 'not useful') for 14 of the 19 outcome domains but found differences for the perceived usefulness of: level of depression; health status; spiritual well-being; test accuracy; rate of termination.

CONCLUSIONS

This Delphi survey identified nine outcome domains which are good starting points to develop a core set of outcome measures for evaluating clinical genetics services.

Improving service evaluation in clinical genetics: identifying effects of genetic diseases on individuals and families

Outcome measurement in clinical genetics is challenging. Outcome attributes used currently have been developed by service providers or adapted from measures used in other areas of healthcare. Many of the 'patients' in clinical genetics are healthy but at risk of developing or transmitting a condition. Usually no pharmacological or surgical treatment is offered, although information-giving is an objective of most consultations. We argue that services should be evaluated on the basis of how well they alleviate the effects of disease, from a patient perspective. This paper describes a qualitative study using seven focus groups with health professionals, patients and patient representatives. Social and emotional effects of genetics diseases were identified. Some differences emerged between the effects identified by health professionals and those identified by patients. These findings will be used to inform the evaluation of existing outcome measures and develop robust measures of outcome for clinical genetics services.

Learning from Sir William Osler about the teaching of palliative care

The publication by Michael Bliss of his authoritative and illuminating text William Osler: a Life in Medicine (1) provides a wonderful opportunity to reflect on the life of a great man who had a major influence on medical undergraduate teaching and medical practice. His approach to the care of both patients and colleagues was warm and encouraging. He demonstrated a humanistic approach to medicine that was reflected in his clinical practice, his teaching, and his writings, and that remains influential today. He had the ability to blend wide knowledge with high ideals and common sense to influence the ways in which the doctor-patient relationship developed. Drawing on passages from the biography of William Osler, and linking his practice with the work of Donald Schön and the development of reflective practice, this paper identifies elements of our roles as clinicians and teachers that could be enhanced by further examination of the life of a man who has been described as the "greatest doctor in the world" (1, p. 480); a physician "whose work lies on the confines of the shadowland" (1, p. 291).

A national strategy for palliative care in New Zealand

Despite the evidence that palliative care is effective in improving the quality of life for people who are dying, it is still poorly understood by many health professionals in New Zealand. Many in the general public still see the focus of hospice care as dying rather than living. In 1998, the New Zealand National Advisory Committee on Health and Disability (National Health Committee) established a Working Party on the "Care of People Who Are Dying." This was in response to the failure of other earlier processes to produce any lasting, noticeable change in the provision of or access to palliative care services. During 1999/2000 an advisory group, comprising members with differing areas of expertise in palliative care, drew on that previous work and with the Ministry of Health, Health Funding Authority, and National Health Committee produced a report, The New Zealand Palliative Care Strategy. This article summarizes the recommendations of the report, and describes the professional-governmental collaboration that led to its publication.

Hospital referrals to a hospice: timing of referrals, referrers' expectations, and the nature of referral information

Hospital referrals to Mary Potter Hospice were reviewed prior to the implementation of a new hospital palliative care support service. The hospital palliative care service aims to improve the communication between health professionals in the acute hospital and hospice, and to advise the hospital staff on its management of terminally ill patients. The purpose of this review was to provide baseline information that would assist the hospice with the planning and future evaluation of the new service. Information included the timing of the referrals, the type of referral information provided by hospital doctors, and their expectations of hospice care. One fifth of patients were referred near to death. While medical information was nearly always provided on referral, information on the psychological, spiritual and social dimensions of care was often absent. A third of hospital doctors expressed their expectation of the hospice as "to take over" the patient's care. This suggests the hospital palliative care support service should encourage health professionals to take a more active role in caring for dying patients. The findings are discussed in relation to the goals of the new hospital palliative care support service.

Learning to care: a medical perspective

The development of palliative care as a recognizable specialty has been supported by an acknowledgment of palliative medicine as a discrete discipline within the medical profession. While the knowledge and skills required for training in palliative medicine are well defined, there are elements of the medical care of people at the end of life that are more difficult to outline. Nursing practitioners and academics in particular have made important contributions in defining caring as an entity, and published work in the field of nursing, bio-ethics and philosophy has encouraged an understanding of what caring is and how it is practised. However, it has rarely been addressed specifically in the medical literature. Undergraduate and postgraduate curricula outline some of the attitudes required to practise palliative medicine but the way in which doctors learn to care and indeed should care has not been clearly detailed. This paper reviews some of the literature pertinent to this aspect of palliative care, with particular reference to some of the elements that may influence how and why doctors learn to care in the way that they do in their practice of medicine.

Diversity among hospice volunteers: a challenge for the development of a responsive volunteer program

Voluntary organizations such as hospices are increasingly being called upon to substitute for state health and social welfare delivery at a time when volunteer contributions are threatened because of organizational and demographic changes. These changes include: the adoption by the nonprofit sector of market strategies in response to health and social welfare reforms, increases in the size and complexity of hospices, increasing professionalization of staff, and the move of women away from voluntary work in the health and welfare services to paid employment. With these changes, hospices must be knowledgeable about their volunteer workforce and resourceful if they are to continue to attract and retain volunteers. A survey of volunteers conducted at the Mary Potter Hospice, Wellington, New Zealand, examined differences in volunteers' characteristics, motivations for joining hospice, and factors affecting work satisfaction according to age, gender, and the length of time volunteers had worked. Those findings of particular relevance to program development were: (1) the tendency for the recently recruited volunteers to be in paid employment; (2) the mixed motivations of the younger volunteers, reflecting both altruistic and personal gain needs; and (3) the rewards commonly identified by volunteers, such as feeling their work is of value, being accepted by hospice staff, and feeling like important team members. Practical outcomes of the study are described.

The development of funding policies for hospices: is casemix-based funding an option?

The 1993 health reforms, with their emphasis on the purchasing of defined amounts or units of service, have led to the implementation of casemix-based funding for the acute medical and surgical services of the public hospitals. Despite growing interest in New Zealand in casemix-based funding for non-acute services such as palliative care, the nature of this service and the characteristics of its patient population pose particular difficulties for the development and implementation of casemix. This paper examines the feasibility of implementing casemix-based funding for hospice/palliative care services and discusses the development of casemix classification systems for palliative care. Problems associated with implementing casemix-based funding are considered including: the dual funding of hospices, the multi-agency nature of palliative care service provision and the need for the Health Funding Authority to identify and specify the hospice services it is willing to fund. While it is concluded that these problems will impede the introduction of casemix-based funding of hospice care, they highlight important issues that the hospice movement must address if it is to ensure its future within the new health environment.

A clinical study of type 1 neurofibromatosis in north west England

A clinical study of patients on the North West Regional Genetic Register with neurofibromatosis type 1 (NF1) identified 523 affected cases from 304 families. In those for whom relevant information was available, 86.7% (383 of 442) had more than six café au lait patches, 83.8% (310 of 370) had axillary freckling, 42.3% (151 of 357) had inguinal freckling, and 63% (157 of 249) had Lisch nodules. Cutaneous neurofibromas were present in 59.4% (217 of 365) and 45.5% (150 of 330) were noted to have subcutaneous tumours. Plexiform neurofibromas were present in 15.3% (80 of 523). A positive family history of NF1 was found in 71.2% (327 of 459) and 28.8% (132 of 459) of affected patients were considered to be the result of a new mutation. Learning difficulties of varying severity occurred in 62% (186 of 300). CNS tumours associated with NF1 were reported in 9.4% (49) of patients, optic gliomas occurring in 25 of these, 4.8% of patients. Some degree of scoliosis was reported for 11.7% (61), 1.9% (10) had pseudoarthrosis, 4.3% (23) had epilepsy, and 2.1% (11) had spinal neurofibromas. Actuarial analyses were carried out for both optic glioma and malignant nerve sheath tumours and the data are presented.

Health professionals' responses to multiple sclerosis and motor neurone disease

This study compares the responses of health professionals to multiple sclerosis (MS) and motor neurone disease (MND) in order to determine similarities and variations in responses to the two disorders and the issues critical to caring for patients with these conditions. Health professionals were more negative about MND compared with MS in terms of the amount they felt able to offer patients, their confidence in managing patients and their ability to convey hope. For a number of issues concerning the management of patients, the level of difficulty experienced by health professionals was similar for both MS and MND. These were resource issues, the health professionals' ability to remain positive in the face of progressive disability, interdisciplinary team problems and difficulties regarding patient care. The main concern of health professionals, for both conditions, was the effect of progressive disability on the patient. For MND, management issues which health professionals found comparatively more difficult than for MS were patients' short prognosis and impending death, communication problems and progressive disability. Issues which were comparatively more difficult for MS than MND were changes in patients' affect, cognition and personality, problems with planning care because of the disorder's unpredictable course, problems with diagnosis such as making and disclosing the diagnosis, and the tendency for patients to be difficult or demanding. Some notable differences in responses between health professionals in different health care settings were found. The findings have implications for changing health professionals' conceptualization of 'hope', developing ways of improving communication between health professionals in different health care settings so as to enable them to learn from each other's expertise and experiences and redressing gaps in service provision, especially for young people with MS.

Anatomical architecture and electrical activity of the heart

In most early studies of cardiac electrophysiology, the correlation between propagation of excitation and the architecture of cardiac fibers was not addressed. More recently, it has become apparent that the spread of excitation, the sequence of recovery, the associated time-varying potential distributions and the intra- and extracardiac electrocardiograms are strongly affected by the complex orientation of myocardial fibers. This article is a review of older and very recent, partly unpublished, mathematical simulations and experimental findings that document the relationships between cardiac electrophysiology and fiber structure. Important anatomical factors that affect propagation and recovery are: the elongated shape of myocardial fibers which is the basis for electrical anisotropy; the epi-endocardial rotation of fiber direction in the ventricular walls; the epi-endocardial obliqueness of the fibers ("imbrication angle"), and the conduction system. Due to the complex architecture of the fibers, many different pathways are available to an excitation wavefront as it spreads from a pacing site: the straight line; the multiple, bent pathways resulting from the epi-endocardial rotation of fiber direction; the coiling intramural pathways associated with the "imbrication" angles (Streeter) and the pathways involving the Purkinje network. Only in a few cases is the straight line the fastest pathway. The shape of an excitation wavefront at a given time instant results from the competition between all possible pathways. To compute the potential distributions and ECG waveforms generated by a spreading excitation wave we must know the successive shapes and positions of the wavefront, the architecture of the fibers through which it propagates and the spatial distribution of their anisotropic electrical properties.

Establishment and characterization of two novel cytokine-responsive acute myeloid and monocytic leukemia cell lines, MUTZ-2 and MUTZ-3

Human permanent leukemia cell lines represent powerful research tools in a multitude of investigations. The two new continuous leukemia cell lines MUTZ-2 and MUTZ-3 were derived from the peripheral blood of patients with acute myeloid leukemia (AML) FAB M2 and AML FAB M4. MUTZ-2 and MUTZ-3 cells have morphological and immunophenotypical features of myeloid and monocytic cells, respectively. While MUTZ-2 is negative, MUTZ-3 cells express the monocytic surface marker CD14, albeit weakly. The monocytic nature of MUTZ-3 cells is underlined by the expression of the monocyte-specific esterase (MSE), myeloperoxidase (MPO) and tartrateresistant acid phosphatase (TRAP) enzymes; MUTZ-2 is negative for MSE and TRAP, but expresses MPO. For sustained cell growth, both cell lines require constitutively the addition of cytokines to the culture medium and retain an absolute dependence on conditioned medium or recombinant growth factors for proliferation and survival. Incubation with single recombinant cytokines from a broad spectrum of growth factors established that the strongest proliferation response of MUTZ-2 cells was elicited by FLT-3 ligand, granulocyte colony-stimulating factor (G-CSF), macrophage CSF (M-CSF), interferon-gamma (IFN-gamma) and stem cell factor (SCF), whereas granulocyte-macrophage CSF (GM-CSF), M-CSF, interleukin-3 (IL-3) and SCF were the most effective growth factors in inducing proliferation of MUTZ-3. Both cell lines were proliferatively responsive to several further cytokines, however, to a lesser extent. Exposure to phorbol ester 12-O-tetradecanoyl-phorbol-13-acetate (TPA) or the physiological all-trans retinoic acid (ATRA) had growth-inhibitory and differentiation-inducing effects on both cell lines. Using a clonogenic cell recovery assay, both cell lines were found to be sensitive to the chemotherapeutic drugs cytosine arabinoside (Ara-C) and daunorubicin (DNR), MUTZ-2 cells being more sensitive to both Ara-C and DNR treatment than MUTZ-3 cells. Chromosomal trisomies 8 and 10 were found in MUTZ-2 cells without any additional structural abnormalities. MUTZ-3 carries the rare, but recurrent AML-associated translocation (12;22)(p13;q11-q12) reflecting the karyotype of the original tumor. The main characteristics of these cell lines remained the same during about 1 year of continuous culture as well as after freezing and thawing. In summary, we established and characterized two new leukemia cell lines with myeloid or monocytic features which are growth factor-responsive, one of them carrying a unique chromosomal translocation. These cells will be of particular value for investigating the complex cytokine network and molecular events caused by chromosomal aberrations.