Pregnancy in Patients with the Fontan Operation

Improved survival rates for patients with a Fontan circulation has allowed more women with this complex cardiac physiology to contemplate pregnancy. However, pregnancy in women with a Fontan circulation is associated with a high risk of adverse maternal and fetal outcomes, high rates of miscarriage and preterm delivery. Factors associated with a successful pregnancy outcome are: younger age, normal body weight, absence of significant functional limitation, no Fontan-related complications, and well-functioning single ventricle physiology. Appropriate care with timely preconception counselling and regular, frequent clinical reviews by a multidisciplinary team based at a tertiary centre, improves the chance of a successful pregnancy. Empowerment of patients with education on their specific congenital cardiac condition and its projected trajectory, helps them make informed choices regarding their health, reproductive choices and assists them to achieve their life goals.

Improved outcomes of large B-cell lymphoma patients treated with CD19 CAR T in the UK over time

The success of CD19 Chimeric antigen receptor (CAR) T-cell therapy in large B-cell lymphoma (LBCL) has been partially offset by toxicity and logistical challenges, which off-the-shelf agents like CD20xCD3 bispecific antibodies might potentially overcome. However, when using CAR T outcomes as the 'standard-of-care comparator̕ for relapsed/refractory (r/r) LBCL, a potential learning curve with implementing a novel, complex therapy like CAR T needs to be considered. To address this, we analysed 726 UK patients intended to be treated with CD19 CAR T for r/r LBCL and compared outcomes between the first year of the national CAR T programme (Era 1; 2019) and the more recent treatment era (Era 2; 2020-2022). We identified significant improvements for Era 2 versus Era 1 in dropout rate (17% vs. 27%, p = 0.001), progression-free survival (1-year PFS 50% vs. 32%, p < 0.001) and overall survival (1-year OS 60% vs. 40%, p < 0.001). We also observed increased use of bridging therapy, improvement in bridging outcomes, more tocilizumab/corticosteroid use, reduced high-grade cytokine release syndrome (4% vs. 9%, p = 0.01) and intensive care unit admissions (20% vs. 32%, p = 0.001). Our results demonstrate significant improvement in CAR T outcomes over time, highlighting the importance of using up-to-date clinical data when comparing CAR T against new treatment options for r/r LBCL.

POS1468 PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY IN A PATIENT WITH A BACKGROUND OF LUPUS NEPHRITIS AND CEREBRAL LUPUS

Background

Progressive multifocal leukocencephalopathy (PML) is a potentially fatal degenerative condition caused by reactivation of the human polyomavirus 2 (JC virus) in immunodeficient individuals. It is well recognised in individuals who have received Rituximab, but patients treated with other immunosuppressants are at risk also (1). Moreover, patients with SLE may be at increased risk, even when they are not taking immunosuppressants (1, 2).

Objectives

Describe the case of a patient with a history of lupus nephritis and cerebral lupus, on long-term Mycophenolate mofetil (MMF) and Prednisolone, diagnosed with PML complicated by immune reconstitution inflammatory syndrome (IRIS).

Methods

Case report.

Results

This patient first presented in 2010 at the age of 18 with ankle swelling and proteinuria. She had high ANA and anti-dsDNA titres, and renal biopsy showed class IV lupus nephritis. She went into remission on high dose Prednisolone and MMF and elected to stop her MMF. Four months later, she developed behaviour changes and worsening proteinuria. MRI showed a mild high signal lesion in the right cerebral hemisphere, and she was diagnosed with cerebral lupus. She recovered after treatment with IV methylprednisolone and MMF. Over the subsequent eight years, she had three flares of her lupus nephritis, with repeat biopsies in 2013 and 2018 showing active proliferative (class IVA) glomerulonephritis. Consequently she was treated with varying doses of oral Prednisolone and MMF for most of this period. She never received any B-cell depleting therapies.

In October 2020, she presented to A&E with numbness in her left face and down her left arm and leg. MRI demonstrated signal abnormalities in her right hemisphere, involving the cortex, white matter and leptomeninges. She was lymphopenic (0.58x10^9/L) with a low CD4 count of 136 cells/uL (normal range 620-1990 cells/uL). A recent dsDNA had risen to 70 IU/ml. Her cerebrospinal fluid revealed mildly raised white cells and a weakly positive JC virus PCR. The differential diagnoses included cerebral lupus, opportunistic infection and malignancy. During this period of diagnostic uncertainty, she was treated with an increased dose of oral Prednisolone and plasma exchange. She went on to have a brain biopsy that showed peri-vascular lymphocytic infiltration and JC virus was present in high copy numbers in the brain tissue (49221.8 IU/mL), confirming a diagnosis of PML. Her MMF was stopped but she continued a low dose Prednisolone with the addition of Hydroxychloroquine.

She was re-admitted two weeks after discharge in December 2020 with a right-sided headache, left facial weakness and loss of dexterity in her left hand. MRI showed evidence of IRIS in the right hemisphere with cerebral oedema causing midline shift. She was treated with IV Dexamethasone then Prednisolone 30 mg daily, with a gradual taper over a year.

She has made a good recovery with minimal neurological deficit; she had recurrent seizures which responded well to anticonvulsant therapy. Her SLE has not flared.

Conclusion

This describes a case of PML in the context of longstanding lupus nephritis, treated with prednisolone and MMF. Her longstanding lymphopenia with low CD4 counts were attributed to the combined consequences of active lupus and her cumulative immunosuppressive burden. CD4 lymphopenia is associated with PML in the HIV population, and may provide information about which patients on immunosuppressive treatments are at risk of developing PML (3). However, not enough is known to routinely screen patients and the counts of other lymphocyte subsets are likely to be important too.

The case highlights that PML can be associated with different immunosuppressants, other than B-cell depletion. The prompt diagnosis, facilitated by brain biopsy, and appropriate management led to a good medium-term outcome for this patient, showing that PML is eminently survivable.

References

[1]Calabrese LH, Molloy ES. ARD 2008;67:iii64-iii65

[2]Henegar CE et al. Lupus 2016;25(6):617-26

[3]Mills EA, Mao-Draayer Y. Front Immunol 2018;9:138

Disclosure of Interests

None declared

Oro-Naso-Sino-Orbital-Cutaneous Fistula From Prolonged Cocaine Use

Presentation We present the case of a 48-year-old man with nasal cellulitis and subsequent oro-naso-sino-orbital-cutaneous fistula from prolonged cocaine use. Diagnosis Initial laboratory investigations reported a raised white cell count (WBC) and C-Reactive Protein (CRP) and subsequently a positive atypical anti-neutrophil cytoplasm antibodies (ANCA) and positive anti-proteinase (PR3). Perihilar lung nodularity on chest imaging raised the possibility of a systemic autoimmune response. His urinalysis was positive for cocaine. Treatment He was commenced on Augmentin, Amphotericin B and Prednisolone. An obturator was created to manage the oro-nasal fistula. A subsequent naso-cutaneous defect was re-approximated. Daily nasal saline douche and abstinence of cocaine were recommended. Discussion Cocaine use in the community is rising and poses a challenge to multiple facets of our health care system.

OP0079 LIMB GIRDLE MUSCULAR DYSTROPHY TYPE 2B - A RARE MYOSITIS MIMIC

Background:

Proximal muscle weakness with associated raised creatine kinase (CK) commonly leads to referral to Rheumatology for the investigation of Idiopathic Inflammatory Myopathy (IIM). Some genetic myopathies can have a similar presentation with investigations that suggest inflammatory disease, leading to difficulty with accurate diagnosis (Amato & Brown, 2011; Harlan & Mammen, 2019).

Objectives:

To describe the case of a patient with Limb Girdle Muscular Dystrophy Type 2B (LGMD2B), whose initial presentation mimicked an inflammatory myopathy.

Methods:

Case report.

Results:

A 43-year-old patient was reviewed by Rheumatology due to proximal muscle weakness with a raised CK. Muscle biopsy was suggestive of inflammatory myopathy. Therefore, he was started on treatment with corticosteroids. Corticosteroid treatment resulted in no improvement in his weakness or CK. His diagnosis was reviewed, and he was referred to the Neurology and Genetics services. Following molecular genetic analysis, a diagnosis of Limb Girdle Muscular Dystrophy Type 2B was made.

Conclusion:

Muscle biopsies can suggest an inflammatory aetiology in some genetic myopathies (Amato & Brown, 2011; Harlan & Mammen, 2019). If a patient with suspected IIM presents with atypical features, or they do not respond as expected to treatment, then consider a genetic myopathy such as LGMD2B as a cause and involve the Neurology and Genetics services in the case.

References:

[1]Amato, A. A., & Brown, R. H., Jr. (2011). Dysferlinopathies. Handb Clin Neurol, 101, 111-118. https://doi.org/10.1016/b978-0-08-045031-5.00007-4

[2]Harlan, M & Mammen A. L (2019). Myositis Mimics: The Differential Diagnosis of Myositis. In: R. Aggarwal and C. V. Oddis (Eds.) Managing Myositis (pp. 209-223). Springer, Cham.

Disclosure of Interests:

None declared

Process evaluation of a cluster-randomised controlled trial of multi-component weight management programme in adults with intellectual disabilities and obesity

BACKGROUND

Providing effective weight management to adults with intellectual disabilities is necessary to challenge the high rates of obesity. The aim of this process evaluation was to explore the feasibility of conducting a full-scale clinical trial of the TAKE 5 multi-component weight management programme.

METHODS

The study was a 12-month pilot cluster-randomised controlled trial. Adults with intellectual disabilities and obesity were randomised to either TAKE 5, which included an energy deficit diet (EDD) or Waist Winners Too, based on health education principles. A mixed-methods process evaluation was conducted focussing on the reach, recruitment, fidelity, implementation, dose (delivered/received) and context.

RESULTS

The study successfully recruited adults with intellectual disabilities. Both weight management programmes were delivered with high fidelity and implemented as intended. Only one weight management programme, TAKE 5, demonstrated potential efficacy in reducing body weight and body composition. The effectiveness was largely attributed to the EDD and social support from carers.

CONCLUSIONS

The extensive process evaluation illustrated that a full-scale trial of a multi-component programme including an EDD is feasible and an acceptable approach to weight management for adults with intellectual disabilities and obesity.

A Pilot Study Using Preoperative Cerebral Tissue Oxygen Saturation to Stratify Cardiovascular Risk in Major Non-Cardiac Surgery

This prospective pilot study evaluated whether low preoperative cerebral tissue oxygen saturation is associated with unfavourable outcomes after major elective non-cardiac surgery. Eighty-one patients over 60 years of age, American Society of Anesthesiologists physical status 3 or 4, were recruited. Resting cerebral tissue oxygen saturation was recorded on room air, and after oxygen supplementation, using cerebral oximetry. The primary outcome was 30-day major adverse event of combined mortality or severe morbidity, and the secondary outcome was 30-day new disability. Eleven patients (13.6%) suffered a major adverse event, and 28 patients (34.6%) experienced new disability. Room air cerebral tissue oxygen saturation was significantly different between patients who had a major adverse event, 67% (95% confidence interval [CI] 65–70) versus unaffected, 71% (95% CI 70–72; P=0.04). No statistical difference was found between patients for new disability (range 70%– 74%; P=0.73). Room air cerebral tissue oxygen saturation was significantly associated with major adverse events (odds ratio 1.36 (95% CI 1.03–1.79), P=0.03). Saturation levels ≤68% carried a positive likelihood ratio of 2.2 for death or severe morbidity, P=0.04. A definitive trial is required to confirm if cerebral oximetry can be used to stratify the cardiovascular risk of patients presenting for non-cardiac surgery.

Attrition and weight loss outcomes for patients with complex obesity, anxiety and depression attending a weight management programme with targeted psychological treatment

The objective of the study is to investigate the effect of baseline anxiety and depression, using different definitions for caseness, on attrition and weight outcomes following a multidisciplinary weight management programme. The study design is a prospective observational study. The Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety and depression with 'caseness' scoring ≥11 and severity ≥14. The participants were all patients who began a weight management programme between 1 October 2008 and 30 September 2009 (n = 1838). The setting was the Glasgow and Clyde Weight Management Service (GCWMS), a specialist multidisciplinary service, which aims to achieve a minimum of ≥5 kg weight loss. The results were as follows: patients with HADS score ≥14 were referred to the integrated psychology service for psychological assessment or intervention. Patients with caseness (HADS ≥11) for anxiety (33%) and depression (27%) were significantly younger, heavier, more socio-economically deprived and a higher proportion was female. There was a significant positive correlation between HADS anxiety and depression scores and increasing body mass index (r(2)  = 0.094, P < 0.001 and r(2)  = 0.175, P < 0.001, respectively). Attendance and completion was lower throughout follow-up amongst patients with anxiety or depression. More patients with HADS score ≥11 achieved ≥5 kg or ≥5% weight loss and by 12 months those with anxiety had a significantly higher mean weight loss (P = 0.032). Participants who scored for severe anxiety (HADS ≥14) achieved similar weight loss to those without, whilst participants who scored for severe depression achieved significantly greater weight loss than non-cases at 3, 6 and 12 months of follow-up (P < 0.01). Despite a less favourable case-mix of risk-factors for poor weight loss, patients who scored caseness for severe anxiety or depression and were offered additional psychological input achieved similar or better weight loss outcomes.

PRC2-independent chromatin compaction and transcriptional repression in cancer

The silencing of large chromosomal regions by epigenetic mechanisms has been reported to occur frequently in cancer. Epigenetic marks, such as histone methylation and acetylation, are altered at these loci. However, the mechanisms of formation of such aberrant gene clusters remain largely unknown. Here, we show that, in cancer cells, the epigenetic remodeling of chromatin into hypoacetylated domains covered with histone H3K27 trimethylation is paralleled by changes in higher-order chromatin structures. Using fluorescence in situ hybridization, we demonstrate that regional epigenetic silencing corresponds to the establishment of compact chromatin domains. We show that gene repression is tightly correlated to the state of chromatin compaction and not to the levels of H3K27me3-its removal through the knockdown of EZH2 does not induce significant gene expression nor chromatin decompaction. Moreover, transcription can occur with intact high-H3K27me3 levels; treatment with histone deacetylase inhibitors can relieve chromatin compaction and gene repression, without altering H3K27me3 levels. Our findings imply that compaction and subsequent repression of large chromatin domains are not direct consequences of PRC2 deregulation in cancer cells. By challenging the role of EZH2 in aberrant gene silencing in cancer, these findings have therapeutical implications, notably for the choice of epigenetic drugs for tumors with multiple regional epigenetic alterations.

Carers' perspectives of a weight loss intervention for adults with intellectual disabilities and obesity: a qualitative study

BACKGROUND

To date, no studies have explored the role of carers in supporting adults with intellectual disabilities (ID) and obesity during a weight loss intervention. The present study explored perceptions of carers supporting adults with ID, as they participated in a 6-month multi-component weight loss intervention (TAKE 5).

METHODS

Semi-structured interviews were used to explore the experiences of 24 carers. The transcripts were analysed qualitatively using thematic analysis.

RESULTS

Three themes emerged from the analysis: carers' perceptions of participants' health; barriers and facilitators to weight loss; and carers' perceptions of the weight loss intervention. Data analysis showed similarities between the experiences reported by the carers who supported participants who lost weight and participants who did not. Lack of sufficient support from people from the internal and external environment of individuals with ID and poor communication among carers, were identified as being barriers to change. The need for accessible resources tailored to aid weight loss among adults with ID was also highlighted.

CONCLUSION

This study identified specific facilitators and barriers experienced by carers during the process of supporting obese adults with ID to lose weight. Future research could utilise these findings to inform appropriate and effective weight management interventions for individuals with ID.

Unsuspected pulmonary emboli adversely impact survival in patients with cancer undergoing routine staging multi-row detector computed tomography scanning

BACKGROUND

While symptomatic venous thromboembolism adversely impacts survival among cancer patients, the outcome of cancer patients with unsuspected pulmonary embolism (UPE) found on routine cancer staging multi-row detector computed tomography (MDCT) scans is unknown.

OBJECTIVE

To determine whether UPE detected on routine staging MDCT scans impacts overall survival among cancer patients.

PATIENTS AND METHODS

We performed a matched cohort study of cancer patients diagnosed with UPE on routine staging scans between May 2003 and August 2006. Two controls (n = 137) were individually matched by age (± 5 years), cancer type and stage for each UPE patient (n = 70). We used Cox's proportional hazard models to compare the mortality between UPE patients and their matched controls.

RESULTS

The hazard ratio (HR) for death among UPE patients was 1.51 (95% CI 1.01-2.27, P = 0.048). Compared with their matched controls, patients with UPE more proximal than the subsegmental arterial branches had a HR for death at 6 months of 2.28 (95% CI 1.20-4.33, P = 0.011) and an overall HR of 1.70 (95% CI 1.06-2.74, P = 0.027). Survival among UPE patients with isolated subsegmental PE (ISSPE) was not significantly different than that of matched controls (HR 1.04 95% CI 0.44-2.39, P = 0.92).

CONCLUSIONS

UPE identified more proximal than the subsegmental arterial branches has a significant negative impact on survival among cancer patients.

A review of weight loss interventions for adults with intellectual disabilities

Obesity is more prevalent in adults with intellectual disabilities than in the general population, and has been shown to contribute to their reduced life expectancy, and increased health needs. Relatively few studies have examined the effectiveness of weight loss interventions for adults with intellectual disabilities. However, there is evidence to support interventions that take account of the context of the lives of adults with intellectual disabilities, including carer involvement in interventions. To reduce the health inequalities experienced by adults with intellectual disabilities, there is a clear need to develop accessible, evidence-based clinical weight management services.

The prevalence and determinants of obesity in adults with intellectual disabilities

People with intellectual disabilities experience significant health inequalities compared with the general population, including a shorter life expectancy and high levels of unmet health needs. Another accepted measure of health inequalities, the prevalence of obesity, has been shown to be higher in adults with intellectual disabilities than in the general population. While the factors contributing to the increased prevalence among adults with intellectual disabilities are not well understood, the high rates of obesity among younger adults highlight the need for further research involving children and adolescents with intellectual disabilities. To take forward the priorities for research and the development of effective, accessible services, there is a need for collaboration between professionals working in the fields of intellectual disabilities and obesity.

Rib impingement in first class cricketers: case reports of two patients who underwent rib resection

Two first class cricket bowlers presented with costoiliac pain secondary to rib impingement. In both patients, conservative management of the injury had failed to improve symptoms. Surgical resection of the affected rib was undertaken. At follow up, both patients had made a good recovery and had returned to competitive cricket.

Development of the Safe Tractor Assessment Rating System

We describe the development of the Safe Tractor Assessment and Rating System (STARS), a design-based tractor safety rating system that can be applied to new or used tractors to provide an objective assessment of their inherent safety features. A predictive rating system model, based on technical inspection, was used. Key principles underlying the system included the potential for design features to reduce the risk of an injury event occurring, and to reduce the risk of injury if such an event did occur. The rating system was based on current standards, research literature, injury and fatality data, and farmer input via focus groups. Development was an iterative process involving field, pilot, and inter-rater reliability tests. The final system was divided into six domains: rollover protection, runover protection, user protection, information and controls, pedestrian protection, and options. Within each domain, optimum design features were described for the common or serious potential injury risks, and a score was assigned for each feature. Scores were translated into a star rating, from zero stars for virtually no inherent safety features to five stars for the highest inherent safety, for each of the six domains. STARS distinguished well between older tractor models known to have few inherent safety features and newer tractor models known to have higher levels of inherent safety. STARS can provide tractor manufacturers, dealers, and users with information critical for managing tractor-associated injury risk. In Australia, it is initially being implemented within the curriculum of the technical education and training sector.

Mild and moderate varicose vein reflux does not deteriorate over time

Objective: To prioritize varicose vein (VV) waiting lists, superficial venous reflux was timed in patients with primary VVs using hand-held Doppler (HHD) and classified as 'severe' (≤4s), 'moderate' (>4; ≤6s) or 'mild' (>6s). Only patients with severe reflux were offered surgery. The progression of reflux in those not offered surgery was investigated over two years.

Methods: Patients seen in the VV clinic between November 1999 and October 2000 with reflux ≥4s were re-assessed two years later. Reflux was timed at the saphenofemoral (SFJ) and saphenopopliteal (SPJ) junctions using HHD. Patients completed a basic symptom questionnaire. The severity of VVs and skin changes of venous insufficiency were graded.

Results: In all, 38/54 patients attended for review at two years. There were 44 limbs with 48 sites of reflux, 38 at the SFJ and 10 at the SPJ. Reflux improved at 27 sites, remained the same at five and deteriorated at 16. Reflux became 'severe' in eight limbs, but only four patients requested surgery. Median (interquartile range) reflux time was 6.0 (5–6)s in 1999–2000 and 7.0 (4–10)s in 2002 ( P = 0.13). Median symptom scores for aching and the severity of VV remained unchanged. The cosmetic appearance of VV and skin signs of venous insufficiency significantly improved ( P < 0.01).

Conclusions: Mild and moderate reflux did not deteriorate in most VV patients. HHD may be a useful adjunct to grade venous reflux and prioritize patients for VV surgery.

Eosinophilic angiocentric fibrosis as a cause of nasal obstruction

We present the tenth case of Eosinophilic Angiocentric Fibrosis (EAF) in the english literature, which presented as nasal obstruction in a patient of Indian descent. The histopathological and clinical features of this underreported condition is discussed as well as other lesions that may show similar features to EAF.

Late results of selective axillary surgery based on contact cytology in women with operable breast cancer

BACKGROUND

Interest in the possibility of intraoperative analysis of sentinel lymph nodes to select patients with operable breast cancer for immediate axillary clearance encouraged this review of a long-term experience of selective axillary surgery based on intraoperative contact cytology of conventionally sampled nodes. Survival was assessed as a potential marker for understaging.

METHODS

Records of 437 patients who had surgery between 1991 and 1994 were reviewed to compare rates of axillary recurrence in patients who had contact cytology only with those who had contact cytology and axillary clearance.

RESULTS

Axillary recurrence occurred in seven (3 per cent) of 219 patients who had negative contact cytology, three (4 per cent) of 75 patients who had positive contact cytology with axillary clearance and one (1 per cent) of 93 who had axillary clearance alone. In patients with positive contact cytology, 131 (78 per cent) of 168 positive nodes were in the sample specimen, which included all positive nodes on 19 occasions. Survival probability at 36, 72 and 96 months was 92, 87 and 84 per cent respectively for patients with negative contact cytology, and 85, 73 and 71 per cent for patients with positive cytology and axillary clearance.

CONCLUSION

A selective approach to axillary surgery based on intraoperative contact cytology of sampled lymph nodes gave good long-term control of axillary disease.

NHS activity. Short measure

Despite a large increase in NHS funding, the rate of activity has slowed and may be decreasing. Elective activity has fallen at times when more money is going in. Growth in elective activity has tended to be in planned admissions, which have no direct impact on waiting lists. Unless money is redirected into activity-generating areas that impact on waiting times, the NHS will struggle to deliver on waiting-time targets.

Health spending. Extra time

The government is committed to raise spending on healthcare in the UK up to the European average by 2006. There is debate about the exact target figure, but agreement that the key consideration is how the extra money will be spent. If the UK is to achieve the EU average, it will probably have to increase private as well as public spending. To match German levels of staffing, the UK would need an extra 100,000 doctors and 300,000 nurses. There has been little analysis of how the extra expenditure will improve outcomes.

Dual Y-chromosome painting and immunofluorescence staining of archival human liver transplant biopsies

Combining fluorescence in situ hybridization (FISH) and indirect immunofluorescence staining of protein markers provides a highly specific method for identifying chromosomes in phenotypically defined cells and tissues. We developed a technique enabling dual chromosome painting and immunofluorescence staining of archival formalin-fixed, paraffin-embedded material, and used this to phenotype chimeric cells in female-to-male human liver transplants.

The spatial organization of human chromosomes within the nuclei of normal and emerin-mutant cells

To fully understand genome function, the linear genome map must be integrated with a spatial map of chromosomes in the nucleus. Distinct nuclear addresses for a few human chromosomes have been described. Previously we have demonstrated that the gene-rich human chromosome 19 is located in a more central position in the nucleus than the similarly sized, but gene-poor, chromosome 18. To determine whether these two chromosomes are a paradigm for the organization of chromatin in the human nucleus, we have now analysed the nuclear organization of every human chromosome in diploid lymphoblasts and primary fibroblasts. We find that the most gene-rich chromosomes concentrate at the centre of the nucleus, whereas the more gene-poor chromosomes are located towards the nuclear periphery. In contrast, we find no significant relationship between chromosome size and position within the nucleus. Proteins of the nuclear membrane or lamina are candidates for molecules that might anchor regions of the genome at the nuclear periphery and it has been suggested that disruption of this organization may play a role in some disease pathologies. We show that the intranuclear organization of chromosomes is not altered in cells that lack the integral nuclear membrane protein emerin, from an individual with X-linked Emery--Dreifuss muscular dystrophy. This suggests that emerin is not necessary for localizing chromosomes at the nuclear periphery and that the muscular dystrophy phenotype in such individuals is not due to grossly altered nuclear organization of chromatin.

The human preprotachykinin-A gene promoter has been highly conserved and can drive human-like marker gene expression in the adult mouse CNS

Toward an understanding of the mechanisms controlling Preprotachykinin-A (PPTA) transcription, we introduced a 380-kb human yeast artificial chromosome containing the PPTA gene tagged with the beta-galactosidase gene into transgenic mice. This resulted in a pattern of LacZ expression in the central nervous system (CNS) remarkably similar to that reported for PPTA mRNA in the rat. However, the human gene drove expression in areas of the mouse CNS not associated with strong PPTA expression in rodents but which have been shown to express PPTA in the human. This study clearly demonstrates the high degree of conservation of the mechanisms involved in PPTA transcription that has occurred throughout 100 million of divergent human and rodent evolution. This study also defines the maximum linear extent of the human PPT-A promoter. We believe these findings constitute the removal of a significant obstacle in studying the transcriptional regulation of the human PPTA gene in vivo.

The long-term psychological effects of a disaster experienced in adolescence: I: The incidence and course of PTSD

Previous studies have shown that children and adolescents exposed to traumatic experience in a disaster can suffer from high levels of post-traumatic stress. The present paper is the first a series reporting on the long-term follow-up of a group of young adults who as teenagers had survived a shipping disaster-the sinking of the "Jupiter" in Greek waters-between 5 and 8 years previously. The general methodology of the follow-up study as a whole is described, and the incidence and long-term course of Post-Traumatic Stress Disorder (PTSD). It is the first study of its kind on a relatively large, representative sample of survivors, using a standardised diagnostic interview, and comparing survivors with a community control group. Survivors of the Jupiter disaster (N = 217), and 87 young people as controls, were interviewed using the Clinician Administered PTSD Scale (CAPS). Of the 217 survivors, 111 (51.7%) had developed PTSD at some time during the follow-up period, compared with an incidence in the control group of 3.4 % (N = 87). In the large majority of cases of PTSD in the survivors for whom time of onset was recorded, 90 % (N = 110), onset was not delayed, being within 6 months of the disaster. About a third of those survivors who developed PTSD (30%, N = 111) recovered within a year of onset, through another third (34 %, N = 111) were still suffering from the disorder at the time of follow-up, between 5 and 8 years after the disaster. Issues relating to the generalisability of these findings are discussed.