Hospital bed replacement for acute care of children at home during the COVID-19 pandemic through a Hospital-in-the-Home programme

OBJECTIVES

During the COVID-19 pandemic, we expanded our Hospital-in-the-Home (HITH) programme to increase capacity and manage COVID-19-positive children. We aimed to assess impact on overall HITH activity and COVID-19-positive outcomes.

DESIGN

Prospective comparative cohort study.

SETTING

The largest paediatric HITH in Australasia, at The Royal Children's Hospital Melbourne.

PATIENTS

Children 0-18 years admitted to HITH during the pandemic.

INTERVENTION

We developed a COVID-19 responsive service, and a guideline for COVID-19-positive patients. We compared overall activity prior to and during the pandemic, and COVID-19-positive admissions with different variants.

MAIN OUTCOMES

We compared outcomes for all HITH patients before and during the pandemic, and for COVID-19-positive patients admitted first to hospital versus directly to HITH.

RESULTS

HITH managed 7319 patients from March 2020 to March 2022, a 21% increase to previously, with a 132% telehealth increase. 421 COVID-19-positive patients (3 days-18.9 years) were admitted to HITH, predominantly high risk (63%) or moderately unwell (33%). Rates of childhood infection in Victoria, with proportion admitted to HITH were: original/alpha variant-3/100 000/month, 0.7%; delta-92/100 000/month, 0.8%; omicron-593/100 000/month, 0.3%. Eligible parents of only 29 of 71 (41%) high-risk children were vaccinated. COVID-19-positive children admitted directly to HITH were less likely to receive COVID-19-specific treatment than those admitted to hospital first (14 of 113 (12%) vs 33 of 46 (72%), p<0.001), reflecting more severe respiratory, but not other features in inpatients. 15 of 159 (10%) were readmitted to hospital, but none deteriorated rapidly.

CONCLUSIONS

COVID-19-positive children at high risk or with moderate symptoms can be managed safely via HITH at home, the ideal place for children during the pandemic.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Smartphone videos to predict the severity of obstructive sleep apnoea

OBJECTIVE

Diagnosis of obstructive sleep apnoea (OSA) is made on overnight polysomnography (PSG). Given the widespread availability of smartphone video technology, we aimed to develop and test a standardised scoring system for smartphone videos and compare these scores to PSG results.

METHODS

Children aged 1-16 years undergoing PSG for suspected OSA were included. Parents were asked to take 1-2 min videos of the breathing they were concerned about. Videos were scored using a newly developed and tested tool on five components: inspiratory obstructive noises (1-4), presence of obstructive events (0-1), increased work of breathing (0-1), mouth breathing (0-1) and neck extension (0-1). Video scores and the Obstructive Apnoea Hypopnoea Index (OAHI) were compared using Spearman correlation. Sensitivity, specificity, positive predictive value and negative predictive value were calculated for different cut-off scores to achieve the best results.

RESULTS

Videos from 43 children (28 men (65.1%), median age 5.7 years (range 2.6-14.0 years), median OAHI 3.8/hour (range 0-82 events/hour) were included. Nine children (20.9%) had a video score of <3, all of whom had an OAHI of ≤5 events/hour. For a video score of ≥3, sensitivity was 100%; specificity was 36%; positive predictive value was 53%; and negative predictive value 100% for moderate to severe OSA (OAHI>5 events/hour) .

CONCLUSION

We have developed and validated a simple clinical tool (the Monash Obstructive Sleep Apnoea Video Score) to quantify abnormalities in breathing seen on short video recordings made on a smartphone. A low score rules out moderate-severe OSA and may be valuable in the triage of children with symptoms of OSA.

Adverse effects and duration of treatment of TB in Canterbury, New Zealand

BACKGROUND Treatment of TB is often extended beyond the recommended duration. The aim of this study was to assess prevalence of extended treatment and to identify associated risk factors. We also aimed to determine the frequency and type of adverse drug reactions (ADR) experienced by this study population.METHODS We performed a retrospective cohort study of all patients treated for active TB at Christchurch Hospital, Christchurch, New Zealand, between 1 March 2012 and 31 December 2018. Data for 192 patients were collected on patient demographics, disease characteristics and treatment characteristics, including planned and actual duration of treatment and ADRs.RESULTS Of 192 patients, 35 (18.2%) had treatment extended, and 85 (46.5%) of 183 with fully drug-susceptible TB received ≥9 months treatment. The most common reasons for extension were persistent or extensive disease and ADR. Extended treatment duration was not associated with any patient or disease characteristics. We found 35 (18.2%) patients experienced at least one ADR. The most common ADRs were hepatitis, rash and peripheral neuropathy.CONCLUSION TB treatment extension beyond WHO guidelines is common. Further research is needed to guide management of those with slow response to treatment. Methods for early detection of ADR, systems to improve adherence and therapeutic drug monitoring are potentially useful strategies.

Demonstrable professionalism: linking patient-centred care and revalidation

The move by the Medical Board of Australia to commence a conversation with the medical profession about revalidation reflects that patient-centred care is at the heart of good medical practice. Patients judge their doctors' commitment to them based on whether their individual interactions with doctors meet their needs. We argue that ensuring that doctors are continuing to perform at a level that the community regards as acceptable is a demonstration of an individual doctor's professionalism and thus their commitment to patient-centred care. This impacts on the profession as a whole, which needs to commit to what we call 'demonstrable professionalism'--the ongoing and active demonstration of performance that the community regards as acceptable. This needs to be supported by organisations in which doctors work, reflecting the importance of organisational context to clinical practice. Revalidation processes thus need both to reflect the work of doctors and be meaningful to the community. The move to consider revalidation of doctors by regulatory authorities should not be seen by the profession as a threat, but more as an opportunity to demonstrate the profession's commitment to patient-centred care.

Magnetic Meckel's: an unusual case report of foreign body ingestion

Foreign body ingestion in children is common. Most items pass spontaneously, however rarer cases may result in obstruction and or perforation. Ingestion of multiple magnetic items can be more troublesome, as a consequence of the ability of the items to attract across different sections of bowel, or by coalescing to form a larger foreign body. Very few cases of foreign body ingestion have led to the presentation of a complicated Meckel's diverticulum. We present of a case of an adolescent boy with intestinal obstruction secondary to multiple magnetic foreign body ingestion and sequestration within a Meckel's diverticulum.

[Bring fruit at school: promotion of healthy food habit in primary school-children]

The many nutrition education guidelines formulated by different organizations and institutions are the frames for the program actions targeting nutrition awareness in the school-age population. But while the guidelines represent a solid starting block they still need to be backed up by programs giving concrete form to the guiding principles, a program whose efficacy is demonstrated by specific applications studies. The aim of the "Bring Fruit at School" nutrition education program is to encourage elementary school children to change their eating habits for the better. And in particular to eat more fruit, vegetables, legumes, and fish and to cut down on junk-food and sugar-sweetened drink.

Bridging osteophyte of the anterosuperior sacroiliac joint as a cause of lumbar back pain

A case report is presented of a patient with an anterosuperior osteophytic bone bridge of the sacroiliac joint causing lumbar back pain. After prolonged physiotherapy, the bone bridge was excised, with complete resolution of the symptoms. Excision should only be considered in cases of symptomatic sacroiliac joint pain that does not respond to rehabilitation programmes and conservative treatment.

Mechanisms by which area-based regeneration programmes might impact on community health: a case study of the new deal for communities initiative

STUDY OBJECTIVE

To explore mechanisms by which area-based regeneration initiatives may impact on health.

DESIGN

Case study of the New Deal for Communities programme, part of the UK National Strategy for Neighbourhood Renewal.

MAIN RESULTS

Health impacts may result from three mechanisms: sociospatial stigma, community participation and the commissioning of projects designed to change the distribution of determinants of health, including access to services and healthy lifestyles.

CONCLUSIONS

The present UK National Strategy for Neighbourhood Renewal includes improving health status as one of its key outcome measures. Area-based regeneration schemes such as the New Deal for Communities initiative should, intuitively, bring about health gain through their participatory approach to changing the physical and socio-economic environments. At present, however, the direction and magnitudes of these impacts are not clear.

Gender and the shifting ground of revolutionary politics: the case of Madame Roland

Whereas much of the literature on women and the French Revolution continues to see political activity as incommensurate with a desire to behave properly as a woman, studying the correspondence of Marie-Jeanne Roland from 1788 to 1793 shows how she combined political action with respect for gender norms in the last six years of her life. Both while living in the countryside near Lyon and in Paris itself, Roland assumed three roles which she deemed proper to a woman patriot: inciting revolutionary action, formulating policy, and informing others of revolutionary events. The importance of each of these roles shifted with changes in political climate, as did Roland’s conception of what constituted appropriate female behaviour. What made these changes possible was Roland’s ability both to adapt her political strategy to her circumstance and to create a mutable gender code to fit her political needs.

Forkhead transcription factors, Fkh1p and Fkh2p, collaborate with Mcm1p to control transcription required for M-phase

BACKGROUND

The 'CLB2 cluster' in Saccharomyces cerevisiae consists of approximately 33 genes whose transcription peaks in late G2/early M phase of the cell cycle. Many of these genes are required for execution of the mitotic program and then for cytokinesis. The transcription factor SFF (SWI5 factor) is thought to regulate a program of mitotic transcription in conjunction with the general transcription factor Mcm1p. The identity of SFF has yet to be determined; hence further understanding of the mechanisms that regulate entry to M phase at the transcriptional level requires characterization of SFF at the molecular level.

RESULTS

We have purified the biochemical activity corresponding to SFF and identified it as the forkhead transcription factor Fkh2p. Fkh2p assembles into ternary complexes with Mcm1p on both the SWI5 and CLB2 cell-cycle-regulated upstream activating sequence (UAS) elements in vitro, and in an Mcm1 p-dependent manner in vivo. Another closely related forkhead protein, Fkh1p, is also recruited to the CLB2 promoter in vivo. We show that both FKH1 and FKH2 play essential roles in the activation of the CLB2 cluster genes during G2-M and in establishing their transcriptional periodicity. Hence, Fkh1p and Fkhp2 show the properties expected of SFF, both in vitro and in vivo.

CONCLUSIONS

Forkhead transcription factors have redundant roles in the control of CLB2 cluster genes during the G2-M period of the cell cycle, in collaboration with Mcm1p.

Cell cycle control of chromosomal DNA replication

Accurate replication and segregation of chromosomal DNA is essential for high-fidelity transmission of genetic information from generation to generation. Eukaryotic cells typically replicate by first duplicating their chromosomes during the S phase followed by their segregation between two daughter cells during the M phase. Over recent years, advances in our understanding of this process at the molecular level have been incredibly rapid. The present review will focus on molecular control of DNA replication and the mechanisms which operate to ensure that once replicated, chromosomes are not rereplicated in the same cell cycle.

The dietitians' philosophy and practice in multidisciplinary weight management

Dietitians are developing a philosophy and a practice protocol of weight management. A professional philosophy of weight management addresses questions about the social, psychological, and biological spectra of weight management: Should overweight be considered in terms of size acceptance or gluttony and sloth? How should emotional overeating and obsessive restriction be managed? Should obesity be considered a chronic disease, or should the idea that health at every size is possible be espoused? A professional practice protocol addresses another set of questions: Is obesity to be viewed as a short-term and long-term health challenge? Regarding the spectrum of antiobesity agents and antidieting approaches of weight management, what professional position and individual practice will be adopted? Should professional contact with patients be continuous or aimed toward self-care? What measures of successful outcomes will be used: weight change or life quality improvement? How should professional responsibility be balanced with personal concerns about eating and health behaviors that affect body weight? What are examples of closing the gap between the vision and the reality of the roles and goals of the dietitian on a weight management team? Dietitians are translating philosophy into practice. Because dietary control alone has a record of limited success in weight loss and less success in maintaining weight loss, the dietitian's expanded role includes helping patients manage weight with coping skills, motivation techniques, physical activity, and food behavior change. The challenge is integrating functional components of practice with dietitians' unique food and nutrition skills that include selection of alternative foods, portion control, and preparing acceptable, tasty foods for lifelong weight management.

Recovery and relapse in geriatric depression after treatment with antidepressants and ECT in a medical-psychiatric population

The objective of this naturalistic, longitudinal treatment outcome study was to determine relapse rates in geriatric depression following treatment with antidepressants and electroconvulsive therapy in a medical-psychiatric population. Thirty-nine elderly patients (average age 71 years) with unipolar major depression were treated with either antidepressants (AD) or, if resistant to AD treatment, ECT followed by maintenance antidepressants. Patients were monitored over 18 months, and relapse rates were closely determined using the Longitudinal Interval Follow-up Evaluation (LIFE) and the 21-item Hamilton Depression Rating Scale. Although 90% of patients recovered from their index episode of depression, relapse rates were approximately 29%. These results indicate that in spite of high chances of recovery from geriatric depression, intensive psychopharmacologic and psychotherapeutic strategies are needed to decrease relapse rates in geriatric depression.

Lithium intolerance in a medical-psychiatric population

This pilot study was designed to explore the tolerance and efficacy of lithium as an adjunctive prophylactic agent when added to maintenance antidepressant regimens following an episode of depression in an older medical-psychiatric population. In a randomized controlled trial, 27 depressed patients had either lithium carbonate or placebo added to their maintenance antidepressant (AD) regimen following an index episode of depression. Of 17 patients who received lithium carbonate, 76% (13/17) were unable to tolerate this agent for the duration of the study because of side effects (e.g., gastrointestinal disturbances or tremor). The four patients who tolerated lithium were monitored for relapse of depression over a 15-month follow-up period, and one relapsed (after a 49-week remission) whereas 60% (6/10) of the placebo patients relapsed. Cognitive functioning was stable in the lithium-treated patients who remained on therapy. The high rate of lithium intolerance in this study indicates that lithium dosing and serum levels must be conservatively managed in this clinical population.

Chefs' attitudes toward healthful food preparation are more positive than their food science knowledge and practices

OBJECTIVE

To determine if chefs' and student chefs' attitudes, knowledge, and practices regarding healthful food preparation are consistent with the Dietary Guidelines for Americans.

DESIGN

An analytical survey questionnaire was distributed to 4 chef groups. Sections 1 and 2 of the survey measured chefs' food science knowledge (13 questions) and likelihood of using food preparation practices (15 questions) necessary to meet the 1990 Dietary Guidelines for Americans. Section 3 (22 questions) measured chefs' attitudes toward nutrition in general, toward the importance of healthful food preparation practices, and toward the US Dietary Guidelines.

SAMPLE

Of 512 surveys distributed by mail, at culinary meetings, and in classes at 2 culinary schools, 447 (86%) were returned (158 from practicing chefs and 289 from student chefs). Practicing chefs included chef educators, foodservice chefs from a national corporation, and independent chef members of the American Culinary Federation of New York City.

STATISTICAL ANALYSIS

Descriptive statistics included frequencies, means, and standard deviations of survey items and of individual survey sections. Reliability and validity were determined using alpha coefficients and principal components analysis. Analysis of variance was used to examine differences in practice, attitudes, and knowledge among chef groups.

RESULTS

Both practicing chefs and student chefs answered more than 70% of the food science questions correctly; independent chefs scored significantly lower than educator and corporate chefs. More than two thirds of the chefs and student chefs correctly responded to questions about the nutrient composition of food and how cooking affects the nutrient content of food. All chef groups were confused about fat and cholesterol in food and in the body. Few healthful food preparation practices were likely to be used by any chef group more than two thirds of the time, although the subscale of the attitude toward the importance of these practices was very positive. The majority of practicing chefs thought that customers do not care about the US Dietary Guidelines and nutrition; student chefs thought that customers do care. Both groups strongly agreed that, as chefs, they are responsible for the nutritional content of the food they prepared.

APPLICATION

Both chefs and student chefs are willing to learn about food science and recipe modification principles as they apply to healthful cooking practices. The opportunities are clear: Dietitians have the expertise to teach chefs healthful food preparation techniques, recipe modification, and food composition information.

Characterization of Cdc47p-minichromosome maintenance complexes in Saccharomyces cerevisiae: identification of Cdc45p as a subunit

Cdc47p is a member of the minichromosome maintenance (MCM) family of polypeptides, which have a role in the early stages of chromosomal DNA replication. Here, we show that Cdc47p assembles into stable complexes with two other members of the MCM family, Cdc46p and Mcm3p. The assembly of Cdc47p into complexes with Cdc46p does not appear to be cell cycle regulated, making it unlikely that these interactions per se are a rate-limiting step in the control of S phase. Cdc45p is also shown to interact with Cdc47p in vivo and to be a component of high-molecular-weight MCM complexes in cell lysates. Like MCM polypeptides, Cdc45p is essential for the initiation of chromosomal DNA replication in Saccharomyces cerevisiae; however, Cdc45p remains in the nucleus throughout the cell cycle, whereas MCMs are nuclear only during G1. We characterize two mutations in CDC47 and CDC46 which arrest cells with unduplicated DNA as a result of single base substitutions. The corresponding amino acid substitutions in Cdc46p and Cdc47p severely reduce the ability of these polypeptides to assemble in a complex with each other in vivo and in vitro. This argues that assembly of Cdc47p into complexes with other MCM polypeptides is important for its role in the initiation of chromosomal DNA replication.

Phosphorylation of MCM4 by cdc2 protein kinase inhibits the activity of the minichromosome maintenance complex

In eukaryotes, tight regulatory mechanisms ensure the ordered progression through the cell cycle phases. The mechanisms that prevent chromosomal DNA replication from taking place more than once each cell cycle are thought to involve the function of proteins of the minichromosome maintenance (MCM) family. Here, we demonstrate that Xenopus MCM4, a member of the MCM protein family related to Spcdc21/ ScCDC54, is part of a large protein complex comprising several other MCM proteins. MCM4 undergoes cell cycle-dependent phosphorylation both in cleaving embryos and in cell-free extracts. MCM4 phosphorylation starts concomitantly with the clearing of the MCM complex from the chromatin during S phase. Phosphorylation is carried out by cdc2/cyclinB protein kinase, which phosphorylates MCM4 in vitro at identical sites as the ones phosphorylated in vivo. Phosphorylation is specific for cdc2 protein kinase since MCM4 is not a substrate for other members of the cdk family. Furthermore, phosphorylation of MCM4 dramatically reduces its affinity for the chromatin. We propose that the cell cycle-dependent phosphorylation of MCM4 is a mechanism which inactivates the MCM complex from late S phase through mitosis, thus preventing illegitimate DNA replication during that period of the cell cycle.

Cdc45p assembles into a complex with Cdc46p/Mcm5p, is required for minichromosome maintenance, and is essential for chromosomal DNA replication

We report the isolation and characterization of CDC45, which encodes a polypeptide of 650 amino acids that is essential for the initiation of chromosomal DNA replication in the budding yeast, Saccharomyces cerevisiae. CDC45 genetically interacts with at least two members of the MCM (minichromosome maintenance) family of replication genes, CDC46 and CDC47, which are proposed to perform a role in restricting initiation of DNA replication to once per cell cycle. Like mutants in several MCM genes, alleles of CDC45 also show a severe minichromosome maintenance defect. Together, these observations imply that Cdc45p performs a role in the control of initiation events at chromosomal replication origins. We investigated this possibility further and present evidence demonstrating that Cdc45p is assembled into complexes with one MCM family member, Cdc46p/Mcm5p. These observations point to a role for Cdc45p in controlling the early steps of chromosomal DNA replication in conjunction with MCM polypeptide complexes. Unlike the MCMs, however, the subcellular localization of Cdc45p does not vary with the cell cycle, making it likely that Cdc45p interacts with MCMs only during the nuclear phase of MCM localization in G1.

The yeast tribrid system--genetic detection of trans-phosphorylated ITAM-SH2-interactions

Protein-protein interactions are often dependent on the post-translational modification of one component of a complex. To facilitate the study of these interactions in signal transduction, we have developed the yeast tribrid system, a modification of the yeast two-hybrid system. We demonstrate that the interactions are dependent upon the presence of a tyrosine kinase, an SH2 domain and a tyrosine containing substrate. Using the gamma subunit of the high-affinity IgE receptor, Fc epsilon RI, this approach has been used to isolate a novel SH2-containing family member. The mRNA encoding this novel protein is differentially expressed in rat tissues. The yeast tribrid system can be readily adapted for the characterization of novel tyrosine kinases or substrates, as well as the study of protein-protein interactions which involve other post-translational modifications.

Human shoulder tendon biopsy samples in organ culture produce procollagenase and tissue inhibitor of metalloproteinases

OBJECTIVE

To investigate the production of the matrix metalloproteinase (MMP), collagenase (MMP-1), and its natural inhibitor, the tissue inhibitor of metalloproteinases (TIMP) by diseased human tendon samples in organ culture.

METHODS

Portions of tendons were excised from the shoulders of patients undergoing shoulder surgery, classified as either proximal to the lesion (abnormal) or distal to the lesion (normal) according to their macroscopic appearance at surgery, and placed in organ culture for periods of up to 28 days. The release of collagenase and TIMP activity in the conditioned culture medium was measured.

RESULTS

Procollagenase and TIMP were both produced by all the tendon samples for an extended period of time. The levels of enzyme and inhibitor varied between patients, but in most of them TIMP levels were greater than collagenase levels. In one sample of calcified tendon, procollagenase levels were greater than those of TIMP. The mean level of collagenase produced by tendon proximal to the lesion and tendon distal to the lesion were not significantly different (95.2 (SD 106.8) U/g and 34.0 (45.3) U/g, respectively), while the corresponding figures for TIMP were 109.7 (62.3) U/g and 53.0 (27.9) U/g (p = < 0.05), although there was considerable variation in some samples. Western blotting and collagen fragment analysis confirmed that the collagenolytic activity detected was attributable to the metalloproteinase fibroblast collagenase (MMP-1).

CONCLUSIONS

Tendon tissue can actively secrete procollagenase, an enzyme that, once activated, is capable of remodelling collagen, the major connective tissue component of tendon. Collagenase is produced even in unstimulated cultures, although the concentrations of TIMP are usually greater than that of collagenase in most samples. Some activation of collagenase appeared to have occurred. These results indicate that tendon tissue cells are capable of producing a remodelling response, even in end stage tendon disease.

Cell cycle-regulated transcription of the CLB2 gene is dependent on Mcm1 and a ternary complex factor

Clb2 is the major B-type mitotic cyclin required for entry into mitosis in the budding yeast Saccharomyces cerevisiae. We showed that accumulation of CLB2 transcripts in G2 cells is controlled at the transcriptional level and identified a 55-bp upstream activating sequence (UAS) containing an Mcm1 binding site as being necessary and sufficient for cell cycle regulation. Sequences within the cell cycle-regulated UAS were shown to bind Mcm1 in vitro, and mutation which abolished Mcm1-dependent DNA binding activity eliminated cell cycle-regulated transcription in vivo. A second protein with no autonomous DNA binding activity was also recruited into Mcm1-UAS complexes, generating a ternary complex. A point mutation in the CLB2 UAS which blocked ternary complex formation, but still allowed Mcm1 to bind, resulted in loss of cell cycle regulation in vivo, suggesting that the ternary complex factor is also important in control of CLB2 transcription. We discuss the possibility that the CLB2 gene is coregulated with other genes known to be regulated with the same periodicity and suggest that Mcm1 and the ternary complex factor may coordinately regulate several other G2-regulated transcripts.

Cell cycle-regulated nuclear import and export of Cdc47, a protein essential for initiation of DNA replication in budding yeast

The CDC47 gene was isolated by complementation of a cdc47 temperature-sensitive mutant in Saccharomyces cerevisiae and was shown to encode a predicted polypeptide, Cdc47, of 845 aa. Cdc47 belongs to the Cdc46/Mcm family of proteins, previously shown to be essential for initiation of DNA replication. Using indirect immunofluorescence microscopy and subcellular fractionation techniques, we show that Cdc47 undergoes cell cycle-regulated changes in its subcellular localization. At mitosis, Cdc47 enters the nucleus, where it remains until soon after the initiation of DNA replication, when it is rapidly exported back into the cytoplasm. Cdc47 protein levels do not vary with the cell cycle, but expression of CDC47 and nascent synthesis of Cdc47 occur late in the cell cycle, coinciding with mitosis. Together, these results show that Cdc47 is not only imported into the nucleus at the end of mitosis but is also exported back into the cytoplasm at the beginning of S phase. The observation that Cdc47 is exported from the nucleus at the beginning of S phase has important implications for how initiation of DNA replication is controlled.

Cdc54 belongs to the Cdc46/Mcm3 family of proteins which are essential for initiation of eukaryotic DNA replication

CDC54 is a gene essential for initiation of DNA replication in Saccharomyces cerevisiae, and which is known to genetically interact with other regulators of the S-phase, including CDC46. We describe the isolation and sequencing of CDC54 and show that it encodes a protein structurally related to Cdc46p, Mcm2p and Mcm3p by the presence of a conserved domain of 145 amino acids which is internal to each polypeptide. This conserved domain resembles the DEAD box of RNA helicases and is similar to the conserved domain associated with a group of transcription and replication factors with known or assumed DNA-dependent ATPase activity, suggesting it may be involved in nucleic-acid recognition. Comparison of Cdc54p to related proteins from other species revealed that it closely resembles cdc21p from Schizosaccharomyces pombe.

Mapping of the human SAP1 (SRF accessory protein 1) gene and SAP2, a gene encoding a related protein, to chromosomal bands 1q32 and 12q23, respectively

SAP1, SAP2, and ELK1 form a related subgroup of ETS-domain proteins that can form ternary complexes with the transcription factor SRF at the c-fos serum response element (SRE). SAP1 was identified by a genetic screen for proteins interacting with SRF expressed in yeast, and SAP2 by its homology with SAP1; ELK1 was previously identified by its homology to the ETS domain. cDNA probes were used to isolate cosmid and phage clones harboring genes encoding SAP1 and SAP2. These clones were subsequently used to map the genes to 1q32 and 12q23, respectively, by fluorescence in situ hybridization.

Obesity surgery: dietary and psychosocial expectations and reality

Psychosocial and dietary habits have been compared in patients considering (Pre n = 33) or who had (Post n = 32) surgery for morbid obesity. Failure of conventional diets was attributed to lack of self-discipline (Pre 92% [22/24] vs. Post 87% [20/23], NS). Consumption of fast foods fell (Pre 70% [23/33] vs. Post 16% [5/32], p < 0.0001). Preoperative patients had unrealistic social expectations. They exaggerated the prospect of improved friendship (Pre 67% [22/32] vs. Post 34% [11/21], p < 0.05), erroneously anticipated better sex (Pre 78% [25/32] vs. Post 50% [15/30], p < or = 0.05), predicted better acceptance at work (Pre 85% [23/27] vs. Post 50% [15/30], p < or = 0.05), and misanticipated improved relationship with their partner (Pre 77% [20/26] vs. Post [47% 8/17], p < or = 0.05). Two factors predicted becoming employed following surgery: age (became employed [n = 5] 28 +/- 2 years vs. remained unemployed [n = 12] 44 +/- 4 years, p < 0.05) and percentage of excess weight lost (became employed 76 +/- 11 vs. remained unemployed 51 +/- 7, p < 0.05). The free support group was "useful" (17/17), yet only 5% attended regularly. Patients considering obesity surgery had specific unrealistic psychosocial expectations. They infrequently availed themselves of postoperative professional help. We identify the features associated with gaining employment.

Factors predicting death, survival and functional outcome in a prospective study of early rheumatoid disease over fifteen years

Sixty-four survivors from a prospective study of early rheumatoid disease were assessed again at a mean of 15.2 years from presentation and their status compared with 29 patients who had died. Eleven of the dead and only two of the survivors had been treated with steroids. There was a small increase in mortality due to the disease itself but only one death was directly caused by it. As might be expected, those who died were older. In the first year of disease, they had lower haemoglobin levels, a lower body mass, higher sedimentation rates and higher levels of blood urea. One-fifth at entry to the study and two-fifths by the time of death, had poor functional capacity. Of 64 survivors, six had poor functional capacity at entry and nine after 15 years. Discriminant analysis was performed to identify the most powerful combination of early features predicting a poor functional outcome. A combination including early erosive change, seropositivity, poor grip strength and cervical subluxation predicted the outcome correctly in 73% of survivors. Almost 60% of survivors remained with or improved to normal function at 15 years suggesting that morbidity is not as bad as has been suggested in the past.

Isolation and characterization of SRF accessory proteins

Many genes which are regulated by growth factors contain a common regulatory element, the serum response element (SRE). Activation of transcription by the SRE involves a ternary complex formed between a ubiquitous factor, serum response factor (SRF), and a second protein, p62/TCF. We used a yeast genetic screen to isolate cDNAs encoding a protein, SAP-1, with the DNA binding properties of p62/TCF. The SAP-1 sequence contains three regions of homology to the previously uncharacterized Elk-1 protein, which also acts as an SRF accessory protein. Only two of these regions are required for cooperative interactions with SRF in the ternary complex. The third contains several conserved sites for the MAP kinases, whose activity is regulated in response to growth factor stimulation. We discuss the potential role of these proteins in regulation of the c-fos SRE.

Functional analysis of a growth factor-responsive transcription factor complex

Serum response factor (SRF) forms a ternary complex at the c-fos serum response element (SRE) with an accessory factor, Elk-1. We constructed altered-binding specificity derivatives of SRF and Elk-1 that form a ternary complex at a mutated, inactive SRE; like Elk-1, the Elk-1 variant only binds its target as part of a ternary complex with SRF. Simultaneous expression of these SRF and Elk-1 derivatives restores serum-regulated activity to the mutated SRE in transfected cells. Efficient transcriptional activation is dependent on the regulated phosphorylation of Elk-1 C-terminal MAP kinase sites and requires the C-terminal sequences of SRF as well as SRF sequences that mediate ternary complex formation. These experiments provide direct evidence that SRF and Elk-1 functionally cooperate in the ternary complex at the SRE to regulate transcription.