The quality of psychosocial assessment of children in consultations varies widely. One reason for this difference is the variability in effective mental health and communication training at undergraduate and post-qualification levels. In recognition of this problem, the Royal College of Paediatrics and Child Health in the United Kingdom have developed the Child in Mind Project that aims to meet this deficit in medical training. This paper describes the evaluation of a workshop that explored the experiences and expectations of health care professionals in the development of a training programme for doctors.The one-day inter-professional workshop was attended by 63 participants who were invited to complete evaluation forms before and immediately after the workshop.The results showed that the workshop was partially successful in providing an opportunity for an inter-professional group to exchange ideas and influence the development of a significant project. Exploring the content and process of the proposed training programme and the opportunity for participants to share experiences of effective practice were valued. Participants identified that the current culture within many health care settings would be an obstacle to successful implementation of a training programme. Working within existing training structures will be essential. Areas for improvement in the workshop included clearer statement of goals at the outset and a more suitable environment for the numbers of participants.The participants made a valuable contribution to the development of the training programme identifying specific challenges. Inter-professional collaborations are likely to result in more deliverable and relevant training programmes. Continued consultation with potential users of the programme – both trainers and trainees will be essential. Childhood mental health disorders are common. A Department of Health survey of 5 to 15 year-olds in England and Wales, 5% had conduct disorder, 4% had emotional disorders and 1% rated as hyperactive -7. FurthKnowledge of psychosocial and mental health problems is only part of the patient assessment process. The ability to communicate effectively with the patient is pivotal for accurate assessment -13. A unNew graduates in the United Kingdom are expected to be able to "communicate clearly, sensitively and effectively with patients and their relatives" . Teachin(RCPCH) aims to develop psychosocial awareness and interviewing skills of paediatricians (in training). This will improve the assessment and management of psychosocial issues that effect children. To achieve this goal, a modular training programme in child and adolescent mental health is proposed. The programme will be piloted with senior house officers (SHOs) on paediatric rotations. Building additional modules into existing SHO training programmes is problematic since clinical and other commitments already consume a shrinking working week. Therefore, a key consideration in developing the training modules is to work within existing SHO training by maximising both planned and opportunistic teaching and learning in psychosocial care and interviewing skills appropriate for working with children, adolescents and their families.In order to address these two issues, the Child in Mind Project at the Royal College of Paediatrics and Child Health At an early stage in the project, the team thought it appropriate to elicit ideas and experiences of interested professionals as well as recruit individuals to help with developing the project. An open invitation to attend a one-day workshop held at the RCPCH was advertised in relevant professional newsletters for paediatricians, child psychiatrists, and child psychologists and by word of mouth in other disciplines. The invitation stated that the workshop would elicit the views of an inter-professional group interested in developing a training programme to improve psychosocial assessment and child-centred communication skills of doctors. Participants were chosen from twice the number of applicants to represent a balance of disciplines and geographical spread. Selection within these criteria was made on the order of receipt of applications. Numbers were limited by the capacity of the College facilities.This paper describes the evaluation of the inter-professional workshop in the development of the training programme.The opening plenary session introduced the Child in Mind Project together with the aims of the workshop Table . These aImmediately after lunch, a plenary session was held in which the key issues from the morning sessions were shared with the entire group. The four parallel sessions that followed focused on core process issues in training: promoting role-play, introducing technology, integrating new with existing programmes, and assessment. The final plenary session provided an opportunity for groups to share their experiences and then a wider discussion considered key issues from both morning and afternoon sessions. An action plan was devised based on this discussion and was shared with participants providing an opportunity for participants to continue to be involved in the project.All participants were invited to complete evaluation forms immediately before and after the workshop. The pre workshop form explored participants' reasons for attending, their expectations, their most important issue in relation to the workshop, their experiences in learning about communication and education, their current role, age and sex Figure . The posSixty-three participants attended the workshop of whom 23 were clinical psychologists (36.5%), 18 paediatricians (28.6%), 9 psychiatrists (14.3%), 9 nurses (14.3%) and one representative from each of the following professions: social work, education, play therapy and occupational therapy (6.4%). Forty-one participants were female (65.1%) and 22 were male (34.9%). Approximately twenty participants (31.8%) left the workshop immediately prior to the closing plenary session. This was unexpected and apparently not triggered by anything more than a need to catch commuter and intercity trains. That is, the exodus seemed unrelated to the quality of the meeting. Twenty-two participants (34.9%) completed the pre workshop form and 28 completed the post workshop form (44.4%).Of the 22 respondents completing the pre workshop form, 17 were female (77.3%) and 5 were male (22.7%) with an age range of 34 to 58 years and mean age of 45. Although the group were inter-professional, the respondents were predominantly medical with 10 paediatricians (45.5%), 5 child and adolescent psychiatrists (22.7%), 4 clinical psychologists (18.2%), one occupational therapist (4.5%) and one educator (4.5%).Nineteen (86.4%) participants reported previous formal training in communication as part of undergraduate, post-graduate and continuing professional development. Training included theoretical and skills practice within and outside of paediatrics at fundamental  and advanced levels . Eighteen participants (81.1%) reported at least some previous formal training in education.Participants' reasons for attending the workshop were diverse and included a strong interest and or experience in the major themes of the workshop – assessment and management of psychosocial issues in paediatrics, paediatric interviewing and training.To enhance the "voice of the child" in paediatrics. (4)I have a long standing interest and involvement in the teaching of junior paediatricians the skills of communication, family therapy and management of behavioural and emotional issues. I have been trying to find ways of formalizing mental health training for paediatricians. (1)Because I have a very real interest in improving the awareness and training of paediatricians in the psychosocial aspects of paediatrics. (7)To participate in the development of paediatric psychological training. (17)To help develop teaching of mental health issues in childhood. (18)Having worked in the area of paediatric psychology for some years, I am particularly interested in developing the awareness of paediatricians re psychological issues. (19)To contribute to the planning of teaching paediatricians how to tackle social and emotional issues. (20)To better understand needs of paediatricians for training in psychological needs of children and families. (11)Some participants wanted to develop existing local programmes.To feedback ideas to our paediatric College/Clinical Tutor who did not get a place at the course. (12)To try and improve our in-house teaching of psychological factors in paediatrics. (13)One participant acknowledged a deficit in current training.I realize we are generally very poor at integrating psychological aspects of child and family health into the busy acute training programme. (2)The second question asked participants what they were expecting from the workshop. Various themes emerged and included the generation of ideas for the Child in Mind project generally and specifically in the development of training materials. Participants expected to be able to exchange ideas on what and how to change existing training and there was an expressed desire not only to influence these developments but to ensure they are deliverable.To meet, share and hopefully influence colleagues. (17)To participate in putting together relevant training modules and to have a voice in the future training of paediatricians. (19)To ensure that programmes will be acceptable. To broaden ideas around what to include in communication programme. (5)To offer my experience in direct work with children, adolescents and families. (9)An understanding of where the project is so far – aims, methods, plans. A chance to contribute. (14)A second theme related to expectations of inter-professional collaboration both in the development and delivery of the training module and the third and overlapping theme focussed on the opportunity for networking.Decrease inter-professional tension and enhance collaboration. (4)Participants' perceptions of the most important issue to be addressed in the workshop reflected their different expectations. Training issues were dominant and focused on both the content and process. Content issues included thinking about ways of raising the significance of the assessment and management of psychological problems in children and adolescents together with the need to identify the child and adolescent's perspective separately to their family's and health care professionals.Developing a culture of respect for child and family. Accessing children's thoughts and feelings independently of their parents or other professionals. (4)Process issues included identifying ways to maximise existing expertise, to use limited resources efficiently, to encourage participation from paediatric trainers and trainees and to consider assessment and evaluation as integral to the training programme.Twenty-eight (44.4%) participants completed the post workshop form. Demographic data was not collected. The "did not attend" option on the evaluation form is not included in Table Using a 3-point scale from not at all, partially to completely, participants rated the helpfulness of the sessions in meeting the objectives of the workshop Table . The majRespondents were asked to identify the most important issues that they thought had been addressed in the workshop. Several participants wrote of the need to change the existing culture to one in which psychosocial assessment and communication skills are valued. There was also acceptance of diversity in workplaces and the training offered therein. To ensure that the new training programme is deliverable it must be sufficiently flexible to fit within these diverse settings and that it must be evaluated. The need for training both supervisors and trainers was considered requisite for implementing any programme.Learning about the hospital paediatric culture and previous difficulties of teaching SHOs and getting the culture right. (20)The importance of mental health teaching/learning for all doctors caring for children/families. (2)Delivering training for trainers and that the child mental health programme needs to be integrated into existing paediatric training. (3)Need to address appropriate training and supervision of SHOs and for consultants to be trained first themselves. (5)The importance of introducing a general shift. The extreme inflexibility of the system as a whole. (9)The realities of teaching busy SHOs who are preoccupied with passing exams. (14)Changing culture of consultants to understand importance of training for mental health and communication skills. (24)Some participants valued the opportunity to learn about existing effective practices while others gave consideration to who should teach, how and that whatever is taught must be relevant.The importance of taking a full history and empowering SHOs to ask difficult questions, to reflect on their practice and to have supervision in order to understand what to do with the information they have gathered. (17)Introduction of video review of consultations/interactions with children and parents to paediatrics. (22)Participants used a 3-point scale from not at all, partially to completely to rate the degree to which they met their expectations. Eight participants completely met their expectations (28.6%) while twenty participants (71.4%) partially met their expectations.In response to being asked what worked well in the workshop, participants identified the opportunity to exchange ideas with colleagues with different levels of experience, who work in different settings and have different professional backgrounds.The group sizes for sessions were valued since they were sufficiently small to enable several participants to express their views and large enough for diverse experiences to be shared. The plenary sessions were helpful in summarising group sessions and consolidating broad ranging issues.The enthusiasm of delegates was thought to contribute to the success of the workshop together with the relaxed atmosphere and the genuine desire of participants and organisers to change existing practices.Most participants recorded at least one response to being asked how the workshop could be improved. The single most frequently cited issue related to the venue. Groups were too large for their rooms and for two groups, their presence in the same large room impeded discussion.Other improvements included stronger facilitation in some groups to ensure all views were heard and that the discussion stayed focused. Providing delegates with basic information prior to the workshop on the aims, objectives and content of group sessions could have improved the quality of the discussions. Participants expressed a desire to attend the group sessions of their choice. One participant thought that the workshop was too rigidly organised between content and process and that this limited creativity in thinking about training. Two participants suggested including SHOs for whom the training will initially be delivered.I felt unable to contribute much of my experience and knowledge with the tight preset agenda. I was particularly wanting to discuss raising awareness of child protection issues, and working with children in complex and or chaotic home situations. Also were there many current paediatric SHOs here today. If not, there should have been. If so, could they have contributed more? (17)Sign up for preferred workshops on arrival – I don't remember what preferences I indicated but they certainly weren't the ones I was allocated. More general paediatricians – meeting seemed to be dominated by psychiatrists/psychologists (23)The workshop was planned with definite areas for discussion and a very strong split between content and process. This defined structure led to cramping of ideas (27)Maybe including some real SHOs just for the occasional reality check (14)The workshop was valuable in contributing to the development of the Child in Mind Project training programme. The content and process of the programme were explored and several issues emerged that will need serious consideration by the Child in Mind project team. These include the strongly expressed need for a change in culture within the health care system that will embrace child-centred mental health care. The magnitude of change required is uncertain but may well be extensive given evidence that a study based in general practice in The Netherlands reported that the inclusion of the child in all phases of the consultation was "limited" with parents frequently speaking for the child, the child not questioning the parent, and the GP supporting this behaviour by minimal exploration of meta-communicative behaviours. The authors described this process resulting in a dyadic emphasis as being "institutionally co-constructed" .Ways to change the health care culture in the United Kingdom were not explicitly identified. However, the project teams' desire to implement the training programme in a few centres that were already enthusiastic suggests that creating centres of best practice is inherent in their approach for change. This supports theoretical approaches for effective institutional change ,26. ThatThe inter-professional nature of the workshop was beneficial in exchanging views from different perspectives. This supports the findings of the few studies in medical curriculum development that reports this approach . Most paAlthough consultation with other stakeholders  was not identified by this group, it is important that they are also included in the development and evaluation of the training programme. Community participation – especially of key stakeholders, is often lacking in all phases of professional education . In order that the training can best meet the needs of its intended targets their voices should be considered. The medical education literature strongly supports inclusion of patient voices in all aspects of curricula development -30.The importance of training the trainers of the programme was identified as key to success of implementation. Although agreement was not sought, there was a powerful sentiment that trainers should be inter-professional. This notion may also address cultural barriers that relate to doctors' lack of understanding of other health care professional roles by exposing them to trainers who have mental health assessment and/or communication skills expertise. The nature of support provided to trainers may vary reflecting the diverse settings in which the training programme will eventually be implemented.There appeared to be agreement that the workshop was not an appropriate forum for identifying the details of content and process of the training programme. Rather core issues were identified in psychosocial assessment, mental health and communication. Effective approaches to learning patient-centred communication skills are labour-intensive (videotaped interviews with feedback) ,32 so maThe purpose of eliciting participants' reasons for attending and their expectations of the workshop is to help make sense of their satisfaction afterwards. Although the invitation outlined the purpose of the workshop, participants came with varied views that to some extent reflected their level of experience, their unique professional perspective and their interpretation of the information provided in the invitation. However, there was an overarching expectation that each would contribute to the development of a training programme. It is important to reflect on the reasons that only 28.6% of the participants reported that their expectations were completely met.The suggestions given for improvements offer insight into why more participants did not meet their expectations. Restating the project team's aims at the commencement of the workshop may have been helpful. Although some participants felt able to express their views others were unable to do so because of the structure of sessions, the way in which they were facilitated and the settings in which the discussions took place. Providing a more open forum for discussion may have generated different ideas. The breadth and depth of the "culture change" some participants consider essential for implementation of the training programme is extensive and is likely to have influenced their judgement as to what could be realistically achieved both in the workshop and the training programme.The physical limitations of the workshop impeded discussion in some groups.Although group sizes were thought appropriate, providing spaces in which they could work will need to be considered in future workshops.There are several limitations with this evaluation project some of which were beyond the control of the evaluator (DN).• Higher response rates may have improved the quality of the evaluation. It is possible that respondents differed to non-respondents which may influence the results in someway although it is difficult speculate how.• Scheduling the evaluation forms as part of the workshop may have increased response rates and may also help participants to focus on their expectations immediately before the meeting and then afterwards in considering what they achieved.• The low response rate in relation to the final plenary session may be explained by the request to complete the forms immediately after the workshop. It is possible that some participants wanted more time to reflect on their experiences. It may have been more helpful to contact participants after the workshop.• Further, the responses may not represent the diversity of opinions expressed during the workshop nor were the professional groups equally represented in the evaluation forms. For example, no nurses completed the pre workshop evaluation form. It is unclear why this was the case as all respondents were equally encouraged to complete the forms.Future evaluations of workshops attended by disparate groups may consider:• Scheduling the completion of evaluation forms into the workshop timetable• Using identifiers to link pre and post workshop evaluation forms• Following-up participants some time after the workshop to elicit their considered viewsDespite these methodological weaknesses, the evaluation offers useful insights to the management of an inter-professional workshop for curricula development.The workshop provided the Child in Mind project team with valuable insight relevant to the development of a deliverable training programme in mental health and communication. This was an adequate forum in which the ideas and experiences of an interested inter-professional group could contribute although there were several ways in which this could have been improved. The diversity of the settings in which the programme will be delivered was highlighted as was the need for cultural change and support not only for trainees but the trainers themselves. Continued consultation with this inter-professional group together with broadening the consultation process to include other stakeholders may lead to the development of an effective training programme. Commencing the programme in sites with clinicians who are receptive to change of this nature is likely to influence its' success. Evaluation will continue to be essential to monitor the process. The enthusiasm of the participants needs to be harnessed to ensure that the long-term goals of the project team will be met.The author(s) declare that they have no competing interests.All authors contributed to each phase of the project although DN took a lead role in writing the paper. DN was responsible for the evaluation while ST and QS were instrumental in the development of the workshop.The pre-publication history for this paper can be accessed here:


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This paper attempts to clarify the usefulness of various simple pre-operative measures in estimating the potential for a visually successful capsulotomy.24 patients attending for capsulotomy had pre-operative measures of glare with BAT tester, visibility of posterior pole and grading of posterior capsular pearls and fibrosis seen at slit lamp. Visual function was measured before and after standardised capsulotomy. Correlations of the various preoperative measures with eventual visual function improvements were calculated.Pearls at slit lamp and poor posterior pole visualisation were all correlated with improvements in visual acuity and contrast sensitivity after capsulotomy. Amount of fibrosis visible at slit lamp and glare assessment were not correlated with vision improvements after laser.Of the various measures that are taken prior to Nd : YAG capsulotomy, some correlate with eventual visual improvement but for others no clinical utility was found. Practitioners should note these findings as they are especially of use in more questionable or high-risk cases to help determine whether referral for PCO treatment by Nd: YAG capsulotomy is likely to benefit the patient. Posterior capsular opacification (PCO) remains one of the most common post operative morbidities in modern day cataract surgery ,2 and NdHowever, the Nd: YAG capsulotomy procedure has been associated with complications such as damage to intraocular lenses , post opUntil recently Nd:YAG laser treatments have cost the U.S healthcare system up to $250 million annually . Apart fPCO is an extremely common development in patients after cataract extraction and in many mild cases it may not be immediately obvious whether it is visually significant. Patients may have reduced vision from other undetermined causes or have some measures of visual function that are not reduced at all.Information is needed that will help the practitioners to decide on the visual significance of a patient's PCO using tools that are easily available.The specific aim of this study was to assess the correlation between preoperative measures that are easily performed  with eventual visual function improvements after Nd: YAG capsulotomy. This information would be of use to practitioners when deciding whether a patient had PCO that was clinically significant. In other words, we aimed to test the clinical utility of these preoperative tests for Nd:YAG laser capsulotomy.Local research ethical committee approval for the study was obtained and the study was performed in accordance with the treaty of Helsinki. 26 consecutive patients who had been referred for Nd: YAG capsulotomies for posterior capsular opacification were recruited and full informed consent was obtained. Patients excluded were those that had media opacities other than PCO or were not suitable for capsulotomy treatment. Patients in whom macular or disc pathologies were present were excluded from posterior pole assessment arm of the study as grading of visualisation would not be valid. Patients were roughly equally divided between silicone and acrylic IOLs.Prior to Nd:YAG capsulotomy, the patients visual function was assessed with their normal physiological pupil state in terms of best corrected distance and near visual acuity using Bailey Lovie logMAR charts and contrast sensitivity with and without glare, using a Pelli-Robson chart under standard illumination levels at 1 meter. Glare was tested using a Mentor brightness acuity tester (BAT) instrument (set at medium illumination levels) and recorded as the level of contrast sensitivity chart read when exposed to the BAT.Pupils were dilated with topical 1% tropicamide. After a minimum of 20 minutes, the size of the pupil was recorded using a millimetre ruler and the PCO was graded according to the slit-lamp appearance (grade 0 to 4). Use of such slit lamp grading has been established in scientific literature for PCO assessment -16 There0 None visible at all1 Visible but none reaching to IOL edge2 At IOL edge3 Well Inside IOL edge but visual axis clear4 Across visual axisVisualisation of the posterior pole was then assessed by examining the optic disc and macula using a Volk 90D lens. Visualisation of the optic disc was subjectively graded according to the following scale (adapted from the Madurai Intraocular lens study IV ):0 Clear view of optic disc margin, blood vessels at the optic disc and nerve fibre layer (NFL examined using the red-free filter)1 Clear view of optic disc margin, but disc blood vessels and/or nerve fibre layer are not clearly seen2 Optic disc margin, as well as disc blood vessels and nerve fibre layer are not clearly seenVisualisation of the macula was subjectively graded according to the following scale:0 Clear view of foveal reflex, peri-foveal blood vessels and nerve fibre layer1 Diminished foveal reflex, but clear view of peri-foveal blood vessels and nerve fibre layer2 Blurred foveal reflex, peri-foveal blood vessels and/or nerve fibre layerPolVS), ranging from 0 to 4 in order of decreasing visualisation.The totals for the visualisations of the optic disc and the macula were combined to produce a total posterior pole visualisation score (All examinations of the posterior pole were carried out by the same examiner (NP). In order to be masked as to whether the patient was pre- or post- Nd:YAG capsulotomy, NP examined the fundus with the lenses already placed in front of the eye, thus obscuring any anterior segment view.The patients then had Nd:YAG capsulotomy by the same surgeon (TA). This involved initial setting of 1 mJ and subsequent rises of 0.5 mJ as necessary to pierce the posterior capsule. The laser treatment was initiated off axis in a horizontal line across centre, followed by a line in the vertical axis to form a cross. Any obvious lines of capsule tear were treated with laser if deemed beneficial and overall energy used was kept to a minimum. Treatments in this manner produced small capsulotomies of size 2–3 mm diameter. Size of capsulotomy was dictated by ease of making openings, and concerns over energy used. In general the aim was to create an opening using minimum energy, which might be small, but which could be enlarged at follow up visits if deemed necessary.Four weeks post Nd: YAG capsulotomy, the patients were reassessed again in terms of visual function as described earlier, by the same practitioner (TA). The pupils were dilated using 1% tropicamide and after a minimum 20-minute interval, the size of the pupil was recorded. The PolVS was again graded according to the same scales as before, by the same examiner (NP), again masked as to the state of the posterior capsule. Four weeks post-capsulotomy was chosen for re-examination, on the basis of evidence suggesting that capsulotomies enlarged progressively up to one month after Nd: YAG laser and then stabilised thereafter On inspection, the data was found to be of skewed distribution. All correlation calculations were therefore performed using the Spearman's rank correlation coefficients. Means were compared using Wilcoxon signed ranks test for non-normally distributed data. Significance was at the p < 0.05 level. Because the visualisation scale was composed of a combination of sub-scales (2 items for PolVS), internal validity was determined by the Cronbach test of reliability19,20. This is a commonly used test statistic to determine the degree with which constituent items within a scale correlate with each other. An alpha coefficient of = 0.7 is considered necessary for a composite of measurements to be considered a scale. Statistical analysis was performed using SPSS for Windows (version 8.0) for all calculations.A total of 26 eyes of 26 patients were recruited into the study. Mean age was 75.2 years (range 52 to 90). There were 14 females and 12 males. 2 patients only had one examination pre-Nd:YAG capsulotomy, and declined any further examinations. Therefore, 24 patients were seen pre- and post- Nd:YAG capsulotomy. The PolVS scale was found to be internally reliable and consistent (α coefficient = 0.7824). Mean "pearl" grading score was 3.3 (± 1.3) and mean "fibrosis" grading score was 2.3 (± 1.4).5 patients were omitted from PolVS score as macular or disc pathology prevented objective grading. Mean improvement of PolVS (n = 19) was 1.95 (S.D. ± 1.31) (95% C.I. 1.32 to 2.58) .Improvements in the PolVS score after Nd: YAG capsulotomies are shown in fig. Mean improvement of distance logMAR visual acuity was 0.32 (± 0.29) (95% CI 0.20 to 0.44) and near logMAR visual acuity was 0.32 (± 0.29) (95% CI 0.20 to 0.44). Mean improvement of log contrast sensitivity was -0.41 (± 0.39) (95% CI 0.25 to 0.57) and glare testing vision was -0.35 (S.D. ± 0.41) (95% CI 0.18 to 0.52).  For all the above analyses, p < 0.0001, except for mean improvement in glare testing (p = 0.001) (Wilcoxon signed ranks test).The main aim of the study was to determine which pre-operative assessments on patients attending for Nd: YAG capsulotomy would correlate with eventual visual function outcome of the patient, and thus be useful clinical measures. The results of the various correlation coefficient analyses are shown in table Measurements of fibrosis at slit lamp and of glare do not correlate with eventual improvements in vision after capsulotomy.If it is decided to offer a patient Nd; YAG capsulotomy treatment they need to be told of the likely benefits of the treatment as well as risks. Information on potential visual function improvements for each specific patient would be especially welcome in decisions in uncertain cases and higher risk patients such as high myopes.Practitioners should have some evidence for the potential benefit to visual function before suggesting treatment. Retroilluminated photograph analysis by computer have been correlated with improvements in vision  but thesAlthough all of the above tests have been used to try to assess how much benefit a particular patient may gain from capsulotomy, there has previously been little empirical evidence supporting their use. This study provides some evidence for the use and avoidance of various preoperative tests in assessing potential benefit from Nd; YAG laser capsulotomy.There has been some controversy as to the relative usefulness of the different measures of visual function for assessing PCO severity -27, withThere were two types of PCO assessed, pearls and fibrosis, both graded 0–4 with identical criteria for severity. The study shows very clearly that the fibrosis score was not significantly correlated to any improvements in visual function. The pearl score however was significant in correlating with the eventual improvement of all visual functions. This agrees with previous work using computerised analysis of retro-illumination photographs, which showed that only very central fibrosis affected vision whereas pearls could be detrimental even in para-axial locations  Other stThe assessment of fibrosis at slit lamp is commonly performed before Nd:YAG capsulotomy, but according to this study does not correlate with eventual visual outcomes. This finding was perhaps the most poignant due to the common clinical use of amount of fibrosis at slit lamp when deciding whether a patient would benefit from capsulotomy. The finding deserves further investigation, but it may be that antero-posterior thickness of the fibrosis as well as density of opacification are important contributory variables to any visual loss. This thickness of PCO would not be easily assessed accurately and routinely at slit lamp, and was not incorporated into the grading scale used for this experiment.In contrast, clinical utility of pearl assessment is demonstrated, by its correlation with eventual improvement of visual function.Visualisation of posterior pole according to the scale above correlated with improvements in visual acuity and contrast sensitivity. Using the specific criteria as described may have increased the objectivity of the test. This confirms expected agreement between the difficulty of visualization of the posterior pole and the patient's own vision of the outside world.An assessment of the posterior pole along the suggested guidelines is shown to have significant clinical utility.It may be that some of the correlations found were due to some criteria measured being closely related, for example, pearls at sit lamp and visualisation of fundus. The numbers in this analysis were unfortunately insufficient for stepwise multiple linear regression analysis, which could be used in future studies to determine the relative importance of the different measures. However the principle aims of the current study were realised with the presented experimental protocol and statistical analysis.This study confirms the clinical value of pre-YAG measurements of pearls graded at slit lamp and posterior pole visualisation.However, other measures were not significantly correlated with improvements in visual function, namely pre-YAG testing of glare with BAT and pre-YAG grading of fibrosis seen at slit lamp.If a practitioner is uncertain as to the potential visual benefit of an Nd:YAG capsulotomy, an assessment of posterior pole visualisation or pearls at slit lamp should be useful. There is little clinical utility shown from this study in attempting glare assessment or assessment of fibrosis at slit lamp and these assessments may lead to erroneous expectations from treatment.This information is of practical value to practitioners faced with the common problem of assessing suitability of patients for Nd: YAG capsulotomy. It should especially be of use in more uncertain or high-risk cases to determine whether referral to PCO treatment by Nd: YAG capsulotomy is clinically appropriate.The author(s) declare that they have no competing interests.Both authors were involved in planning, design, execution and writing of this paper. Both read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Clinical trials on osteoarthritis (OA) flare-ups treatment usually focus only on objective measures of health status, albeit recent literature suggestions on the importance of patients' subjectivity. Aim of the study was to evaluate the effects of OA and of its different types of medical treatment(s) on Health Related Quality of Life (HRQoL) in terms of both subjective satisfaction and functional status.An observational study on prospective data collected from the Evaluation of Quality of life in OA (EQuO) clinical trial (April 1999-November 2000) was conducted; outpatients from 70 participating centers  with a diagnosis of OA of the hip or knee were consecutively enrolled. Patients were observed at OA flare-ups (baseline) and at follow up 4 weeks after treatment. Patients' objective and subjective HRQoL were assessed by means of the SF-36 and the Satisfaction Profile ; Present Pain at baseline and Pain Relief at follow up were also evaluated.Among the 1323 patients, 1138 (86%) were prescribed one drug/treatment of osteoarthritis, 169 (13%) 2 drugs/treatments, and 16 (1%) 3 drugs/treatments; most of treatments involved the prescription of NSAIDs; non-coxib, COX2 selective NSAIDs were prescribed in about 50% of patients. Follow-up visits were performed after 29.0 days on average (± 7.69 SD). For all SF-36 domains, all SAT-P items and factors, the differences between baseline and follow up scores resulted statistically significant (p < 0.001), enlighting an improvement both in health status and in subjective HRQoL.Besides the classic health status measures, the assessment of patients' subjective satisfaction provides important clues on treatments efficacy of OA within the patient-centered medicine model. In clinical practice this could lead to a better doctor-patient communication and to higher levels of treatment adherence. The impact of osteoarthritis (OA) on patient's functional levels is well known -3. Pain Usually OA affects elderly people, and is one of the main causes of physical disability. In OA patients, Health Related Quality of Life (HRQoL) and activities of daily living are negatively affected. Significant work disability, reduced ability to deal with household duties and sleep disorders are reported in patients with symptoms of OA flare-ups, together with dysfunctions in the areas of ambulation, body-care and movement , and emotional behaviour  ,2,4-8.As a chronic condition, the impact of OA has been studied mainly focusing on its consequences on health status. Similarly, treatment efficacy is assessed within the context of health status and/or symptomatology in many clinical trials ,7,9-12. In literature, HRQoL refers to patients' appraisals of their current levels of functioning and satisfaction, compared to what they perceive to be ideal . HRQoL aThe aim of the present study is to evaluate the effects of OA and of its different types of medical treatment(s) on HRQoL in terms of both subjective satisfaction and functional status.Data from collaborating, educated outpatients aged 50–80 years with a diagnosis of OA of the hip or knee according to the criteria of the American College of Rheumatology  were colOutpatients (n = 1340) were consecutively enrolled in 70 Italian participating centers  from April 1999 to November 2000. 147 patients withdrawn OA treatment before follow-up visit.All patients signed an informed consent in which the purposes of the study  were clearly stated. Approval for this research was obtained by the ethics committee, patients did not receive any remuneration for their participation.Patients with concomitant osteoarticular disorders, impairment of motor function not due to OA of the hip or knee, concomitant systemic disease(s) affecting HRQoL or requiring NSAIDs/steroids use on a regular basis were not included into the study, in order to avoid biases in the results due to treatments other than OA treatments.Patients were observed at OA flare-ups, when attending for a visit (baseline) and at follow up 4 weeks after treatment. According to the observational design of this trial, no "study treatments" were assigned to patients, but any drug(s)/medical treatment(s) considered by the physician as adequate to the patient's clinical condition was freely prescribed; therefore patients were not previously randomized to treatment.During both visits, patients were administered the following: the Visual Analogue Scale (VAS)  on PreseMoreover, at follow up, the global assessments of efficacy and tolerability of the medical treatment(s) prescribed for OA flare ups  were collected. Side effects to this/these treatment(s), if any, were registered as well.The assessment procedure was standardized for all the participating centres. During the visit patients were invited to compile alone all the questionnaires and rating scales, only if required patients were assisted by a trained health professional.Self-reporting bias in HRQoL improvements was kept under control by the assessment procedure and by the adoption of valid and reliable questionnaires.The VAS is perhaps the most widely used instrument for the measurement of pain intensity. The classic version of the VAS was administered: 10 centimeter line, horizontal. "It is a simple, robust, sensitive, and reproducible instrument that enables a patient to express the severity of his pain in such a way that it can be given a numerical value."  Its psycThe SF-36 is a well known self-administered and generic health status measure which encompasses 8 domains related to daily life activities: physical functioning, role limitations due to physical problems, role limitations due to emotional problems, vitality, bodily pain, social functioning, mental health and general health perception -35. EachThe SAT-P is a self-administered, generic questionnaire which provides a satisfaction profile in daily life and can be considered as an indicator of subjective QoL. Satisfaction can be defined as the cognitive product of the comparison between ideal life and reality, and can therefore be quantitatively measured. The subject is asked to evaluate his/her satisfaction about 32 life aspects with reference to the last month  independently of his/her objective health status . It provides 32 individual scores and 5 factor scores, all ranging from 0 (lowest level of satisfaction) to 100 (highest level of satisfaction). Together with its ability to detect patient's subjective satisfaction, the SAT-P addresses some aspects of daily life which are not included in SF-36 items . Its psychometric properties and clinical utility have been confirmed ,36,37.Sociodemographic data and clinical values were analysed by means of descriptive statistics. Since the incidence of withdrawals resulted low, analyses were performed on complete cases and no solutions for handling missing data was adopted.Baseline and follow-up of SF-36 and SAT-P item and factor scores were compared by means of Analusis of Covariance (ANCOVA). Moreover, ANCOVAs were adopted in order to evaluate the impact of clinical variables on SF-36 and SAT-P factor delta scores . The variables included into the models were: age, gender, body weight, OA localization , VAS Present Pain, presence of concomitant disease(s), type of treatment (COX2 selective NSAIDs vs. other treatments). Results were summarized using mean ± SE for continuous variables and frequency (absolute and percent) for categorical variables. All p values are two-tailed and p < .05 was considered statistically significant. All computations were carried-out by resorting to SAS 8.0 procedures.Patients demographic and clinical characteristics , VAS Present Pain, type of medical treatment(s) of OA flare-ups, concomitant diseases and treatments are shown in Table The most frequent concomitant diseases were: hypertension (19.1%), metabolic and nutritional disorders 9.2%), muscoloskeletal, connective tissue and bone disorders (8.2%) and gastrointestinal system disorders (4.3%). The most frequently prescribed concomitant treatments were: cardiologic drugs (9.7%) and antihypertensive (9.4%), antidiabetic drugs (8.4%), antithrombotic agents (4.5%), antiacids (6.7%), sedatives (4.8%). 1138 patients (86%) were prescribed one drug/treatment of OA, 169 patients (13%) 2 drugs/treatments, and 16 patients (1%) received 3 drugs/treatments. Most of treatments involved the prescription of NSAIDs; non-coxib, COX2 selective NSAIDs  were prescribed in about 50% of patients . Only a small number of patients  did not attend follow-up visit.For all SF-36 domains, the difference between baseline and follow up scores resulted statistically significant (p < 0.001)  Table .Baseline pain was significantly associated with all SAT-P factors Table . The preFigure At follow-up, mean VAS Pain Relief was 61.1 mm (± 24.3 SD).In 65% of cases treatment efficacy was evaluated as good or excellent by patients themselves, in 67% of cases it was evaluated as good or excellent by physicians. In 81% of cases treatment tolerability was evaluated as good or excellent by patients themselves, in 84% of cases it was evaluated as good or excellent by physicians. It was evaluated as poor in 7% and 6% of cases respectively  and of a tool addressing subjective satisfaction (SAT-P) allows to wider the focus on patients' life.This methodological approach could help clinicians and researchers in transferring into practice the ICF model issues , with spANCOVA Analysis of CovarianceHRQoL Health Related Quality of LifeNSAID Non Steroid Anti Inflammatory DrugsOA OsteoarthritisSAT -P Satisfaction ProfileSF-36 Medical Outcome Study Short-Form 36 Health Status SurveyVAS Visual Analogue ScaleThe author AS is employee of the company that partially funded the study.GM: responsible for the design of the study, contributed to the statistical evaluation, contributed to the writing of the paper.AG: responsible for the statistical evaluation, contributed to the writing of the paper.AS: contributed to the design of the study and data collection, contributed to the statistical evaluation, contributed to revise the manuscript.Appendix A – Participating CentersClick here for file


At Stanford University, the Virtual Labs project takes full advantage of information technology to provide innovative resources for learning and teaching Because of the explosive growth in our scientific understanding, today's students are required to learn and maintain a rapidly expanding knowledge base. Students are also expected to understand and follow the crossover of information between different disciplines. As a result, they often have to understand the fundamentals of several disciplines, and be able to integrate that knowledge.Students of every discipline are facing these new challenges, and it is clear that today's students are markedly different from those of the past. Influenced by a lifetime surrounded by media, computers, and the Internet, they bring with them different expectations. As educators, we need to meet these expectations in order to motivate students to move forward.And it's not just the student population that is driving change. The National Institutes of Health, which sponsors many biological and medical advances in the United States, has a new initiative called “Digital Biology: The Emerging Paradigm,” whose goal is to merge biomedical computation with biology and medicine over the next ten years. One way to facilitate this movement is to use information technology (IT) as a teaching tool, so that students, in turn, learn how to use IT most effectively.IT presents educators and teachers with a unique opportunity to devise innovative methods of teaching. Students today are more likely than ever to use new tools and technologies to advance their understanding of the sciences. Currently, this usage is mainly limited to searching the Web for information. However, computers and the Web can be used for much more—with computers, you can create learning scenarios like virtual patient simulations, and with the Web, these learning resources can be disseminated to the global community. Educators must harness the power of these enabling technologies, which students have already adopted, to create new and more powerful methods of teaching that will better prepare the students for the next phase of their lives.The Virtual Labs Project at SUMMIT  in the Stanford University School of Medicine has been funded by the Howard Hughes Medical Institute  since 1998. It is an initiative to augment the Department of Biological Sciences and the Program in Human Biology at Stanford University by developing technology-enhanced materials for these curricula. A major goal of the Virtual Labs Project is to increase scientific literacy by using interactive multimedia to teach the fundamental concepts of biology, and to share those resources via the Internet. The Virtual Labs material is currently hosted on a password-protected site and is freely available to interested parties for educational use.A wise individual once said that a picture is worth a thousand words; with Virtual Labs we use not just pictures, but also animations and interactive simulations. Students are able to visualize and interact with dynamic processes in the body. We have developed learning modules in cardiovascular, gastrointestinal, respiratory, renal , visual Virtual Labs also strives to make learning science fun. The more engaged the user is, the more likely the learning experience is to be positive. For example, after learning about how the kidney filters blood  we are designing content for the education of local schoolchildren. Abroad, we are working with global partners in Sweden via the Wallenberg Global Learning Network (http://www.wgln.org). We have also partnered with the MedFarmDoIT group at Uppsala University in Uppsala, Sweden (http://doit.medfarm.uu.se/multimedia.html) to help them with multimedia development and IT integration in the classroom. The MedFarmDoIT group shares our vision of bringing IT into the classroom, and together, we are designing content for their medicine/pharmacy program.Local schools and other universities are looking for opportunities to bring IT into their classrooms. Access to resources like Virtual Labs, and expertise on how to develop and integrate multimedia content into curricula, are on the rise. In 2003, the Virtual Labs Project began building a network of collaborators in the community and abroad. Together with H.E.L.P for Kids (The Virtual Labs Project is dedicated to supporting its partners by distributing customized Virtual Labs content and offering consultation or workshops to train teachers and developers. As integrated partners, we can bridge the gap between the physical and information sciences, and in doing so, can improve the learning process of students for years to come.


Many caregivers with chronically ill relatives suffer from depression. However, the relationship of depression to other outcomes of chronic caregiving remains unclear. This study tested a hypothesized model which proposed that hours of care, stressful life events, social support, age and gender would predict caregivers' outcomes through perceived caregiver stress. Depression was expected to mediate the relationship between perceived stress and outcomes of chronic caregiving .The sample for this secondary data analysis consisted of 236 and 271 subjects from the Americans' Changing Lives, Wave 1, 1986, and Wave 2, 1989, data sets. Measures were constructed from the original study. Structural equation modeling was used to test the hypothesized model, and an exploratory structural modeling method, specification search, was used to develop a data-derived model. Cross-validation was used to verify the paths among variables.Hours of care, age, and gender predicted caregivers' outcomes directly or through perceived caregiver stress (p < .01). Depression mediated the relationship between perceived stress and psychological outcomes and explained 40% and 11% of the variance in self-esteem and marital satisfaction, respectively.Depression predicted psychological outcomes. Whether depression predicts physical health outcomes needs to be further explored. It is estimated that 31–55% of caregivers of chronically ill elderly relatives experience depression  and mostFactors that may be related to stress and depression in caregivers include hours of care, stressful life events, social support, age, and gender. Studies have found that hours of care were significantly related to caregivers' anxiety/depression and somatic symptoms ,11, and Social support may enhance the ability of the individual to cope with events or change the individual's cognitive appraisal of events . QuayhagAge has been shown to have indirect effects on depression through its influence on perceived stress, the coping process, and perceived efficacy . YoungerTsai et al. have suggested that stress and depression are emotional aspects of coping mechanisms and depression is the outcome of perceived caregiver stress . Stress Although the associations between depression and self-esteem and marital satisfaction have been examined extensively, only a few studies have been conducted in the context of caregiving. Caregivers have been shown to have lower self-esteem , and thiA recently developed Theory of Caregiver Stress  based onData for the study were obtained from the Americans' Changing Lives (ACL) Survey: Wave 1, 1986 , and Wave 2, 1989  . The ACLOnly individuals with experience in caregiving to a chronically ill aged relative were included in the analyses reported here. This reduced the number of cases available for study to 335 from Wave 1 and 271 from Wave 2. The two samples were not completely independent because 99 cases were included in both waves; therefore, to ensure the independence of samples, these 99 cases were dropped from Wave 1. The final samples from Wave 1 and Wave 2 were thus 236 and 271, respectively.Since the study was a secondary data analysis, indicators of the study variables  were selected from the Americans' Changing Lives Survey questionnaires, based on face validity. That is, the questions selected gave the appearance of measuring the content of interest. Exploratory factor analysis, confirmatory factor analysis, and internal consistency tests were then conducted to confirm the underlying structures of established scales and develop outcome measures for the current study.Hours of care were the total hours estimated by the caregiver in the past year, categorized as less than 20 hours, 20 to 39 hours, 40–79 hours, 80–159 hours, and 160 hours or more. Providing more hours of care was expected to indicate more burden of caregiving.Stressful life events were measured by a 12-item checklist of negative or undesirable events, such as being robbed or burglarized, losing a job, being physically attacked, or experiencing the death of spouse, death of a parent, death of a close friend/relative, serious illness, life-threatening illness/accident, divorce/separation, serious financial problem, death of children, and other such events. Respondents were asked to report whether they had experienced any of these events within the past 2 years. A simple score, the stressful life events index, was created by summing the number of events reported by each respondent. A high score reflected more stressful life events.Social support was measured by two items: friends/relatives' love and care, and their willingness to listen. Alphas reliabilities were .73 and .74 for Wave 1 and Wave 2, respectively. Higher scores indicated greater support from friends/relatives. Demographic data included age, defined as the chronological age of the caregiver, and gender, coded as biological sex identity.Perceived caregiver stress was measured by one item asking how much stress the caregiver felt about caring for or arranging care for the elderly relative. Responses were on a 5-point scale ranging from not stressful to very stressful; a higher score reflected more perceived stress. Other studies have shown that stress was associated psychosocial well-being, such as depression ,43; in tDepression was measured by the 11-item Center for Epidemiological Studies Depression (CES-D) scale , which aPhysical function was defined as consisting of functional health, number of chronic illnesses, and self-rated health. Functional health was measured by asking the caregiver whether the caregiver was bedbound, and whether the caregiver had difficulty bathing, climbing stairs, walking, or doing heavy housework, and the degree of difficulty of these tasks. Higher scores reflected a higher level of physical function. The number of chronic illnesses was the sum of the following: arthritis or rheumatism, lung disease, hypertension, heart disease, diabetes, cancer, circulation problems, stroke, fracture, and urinary incontinence. A low score on this measure indicated high physical function. Self-rated health was measured by a single item that asked caregivers to rate their own health on a 4-point scale ranging from poor to excellent. A high score reflected high physical function.The caregiver's self-esteem was measured by five items: "I take a positive attitude toward self," "I am no good at all," "I see myself as a failure," "I have the feeling of being pushed around in life," and "I perceive myself able to solve problems." These items were measured on a 4-point scale ranging from strongly agree to strongly disagree. A higher score indicated higher self-esteem.Marital satisfaction was also measured by five items: "Overall satisfaction with relationship," "love and affection expressed from spouse or significant other," "spouse treats me well," "thinking about divorce or separation," and "things happened that I can never forget." Higher scores indicated more marital satisfaction.Cronbach's alphas for all measures were above the acceptable criterion of .70 in both waves except for self-esteem in Wave 1. However, that measure was on the margin of acceptance, at .68. Since Cronbach's alpha is a conservative estimate of internal consistency , the selUnivariate and bivariate analyses were used to examine the descriptive findings. To test the appropriateness of the indicators for each latent variable in both waves, the following procedures were used. First, a single indicator was extracted when applicable , and summary scale scores were used as single indicators. This strategy was used to reduce the number of parameter estimations in a complex model; it is considered appropriate when individual factor item loadings in a specific scale are high . Second,2], the goodness-of-fit index [GFI], and the adjusted goodness-of-fit [AGFI]) and comparative fit indices . Values of GFI, AGFI, RNI, and RNFI between 0.90 and 1.00 were considered to indicate a good fit between the model and the data [A covariance matrix derived from data in the Wave 2 sample was analyzed as input data in the process of model testing. Hypothesized models were tested using the maximal likelihood procedure in the LISREL statistics program. The model tests used absolute goodness-of-fit indices . Depression also differed significantly (p < 0.05). Respondents in Wave 1 reported more depression than those in Wave 2, with mean scores on the 11-item CES-D of 16.00 (SD = 4.14) and 15.15 (SD = 3.87) for Waves 1 and 2, respectively.2 = 237.22; d.f. = 73; GFI = .89; AGFI = .84; RNFI = .85).When the hypothesized model was tested to determine whether depression mediated the relationship between perceived caregiver stress and caregiving outcomes , the statistics showed a moderate fit between the model and the data , close to that of the measurement model, with an insignificant difference .Since the hypothesized model fit the data only moderately well, a data-derived model was built to compare with the hypothesized model. After all the insignificant paths in the hypothesized model had been dropped, paths were added at each step to improve the goodness-of-fit statistics based on the modification index and pre-set assumptions. The resulting data-derived model had a good fit with the data  declare that they have no competing interests.Author 1, PT, developed the research proposal, carried out the data analysis, interpreted the data and participated in the sequence alignment of the manuscript. Author 2, MMJ, participated in developing the research proposal and interpreting the data.The pre-publication history for this paper can be accessed here:


In mammals, males usually have one X and one Y chromosome and females have two X chromosomes. This crucial difference sets the sexes apart, but also creates a problem—female cells have the potential to turn out twice as much X-based gene product as necessary. Males with multiple–X chromosome syndromes face a similar problem. As if to avoid an overdose of X-related proteins, cells in the early embryo inactivate all but one X chromosome. The choice of which X (or Xs) to inactivate is apparently random, but once made, it persists across cell divisions and the specializations that determine a cell's ultimate fate, or type.Xist—which resides on the X chromosome—has a central role in X chromosome inactivation. It creates a special RNA molecule that spreads from its point of production down the length of the X chromosome, repressing its genes and inactivating the chromosome. After about one cell cycle, this gene silencing no longer requires Xist RNA. Daughter cells somehow remember which X to keep mute. In this month's PLoS Biology, geneticist Anton Wutz and colleagues at the Research Institute of Molecular Pathology in Vienna show that Xist expression during a critical period very early in embryonic development creates a chromosomal memory, independent of X silencing, that might help maintain X inactivation across cell generations.A gene called Xist gene mediates alterations to histones  along the X chromosome, which result in heterochromatin formation. As this structure is passed on to daughter cells, X silencing is perpetuated.The molecular underpinnings of X inactivation seem to center on histones, the protein spools around which DNA coils its length. DNA and histones form complexes called chromatin, which undergoes many structural modifications that have important effects on gene expression. For example, tightly packed chromatin inhibits gene expression in its closely curled segments. Not surprisingly, the inactivated X chromosome is coiled into this dense form, called heterochromatin. In the standing model of X inactivation, the Xist gene into the X chromosome of male mouse embryonic stem cells, so they could turn Xist expression “on” and “off” at will. The stem cells represent the earliest, unspecialized cells of a mouse embryo. Since the cells can be induced to differentiate in culture, they provide the opportunity to study the relationship between differentiation and X chromosome inactivation . Using this system, the authors have shown previously that Xist must act during a critical window very early during stem cell differentiation—within the first 24 hours. Wutz and colleagues now show that after that window the X chromosome inactivation can still be reversed, but after an additional 24 hours, it cannot. There appears to be a “memory” of Xist action, which leads to the permanent shutting down of the chromosome.To explore the molecular changes that mediate X chromosome inactivation, Wutz and colleagues inserted a special Xist and the establishment of irreversible silencing. By looking at the kinetics of histone modification, gene silencing, and Xist action, Wutz and colleagues further show that although certain histones are methylated at specific locations during this period in response to Xist, these modifications do not themselves constitute the chromosomal memory. The nature of the memory remains mysterious. Further experiments, perhaps looking at different histone modifications, will be required. Clarification of the events that lead to X inactivation will also improve our knowledge of how changes in the organization and structure of chromosomes can influence the activity of genes.The importance of this observation is that it establishes a new step in the process of X chromosome inactivation—between the action of


It is possible that the insulin secreting liver cells will be destroyed by the immune system because hepatocytes express major histocompatibility complex (MHC) class I molecules and exhibit constitutive Fas expression; moreover the liver has antigen presenting activity. Together with previous reports that proinsulin is a possible autoantigen in the development of Type 1 diabetes, the autoimmune destruction of insulin producing liver cells is a distinct possibility.The liver has been suggested as a suitable target organ for gene therapy of Type 1 diabetes. However, the fundamental issue whether insulin-secreting hepatocytes To address this question, transgenic Non-Obese Diabetic (NOD) mice which express insulin in the liver were made using the Phosphoenolpyruvate Carboxykinase (PEPCK) promoter to drive the mouse insulin I gene (Ins).in vivo and release it when exposed to 100 nmol/l glucagon in vitro. The amount of insulin produced was however significantly lower than that produced by the pancreas. The transgenic PEPCK-Ins NOD mice became diabetic at 20–25 weeks of age, with blood glucose levels of 24.1 ± 1.7 mmol/l. Haematoxylin and eosin staining of liver sections from these transgenic NOD PEPCK-Ins mice revealed the absence of an infiltrate of immune cells, a feature that characterised the pancreatic islets of these mice.The liver cells were found to possess preproinsulin mRNA, translate (pro)insulin These data show that hepatocytes induced to produce (pro)insulin in NOD mice are not destroyed by an ongoing autoimmune response; furthermore the expression of (pro)insulin in hepatocytes is insufficient to prevent development of diabetes in NOD mice. These results support the use of liver cells as a potential therapy for type 1 diabetes. However it is possible that a certain threshold level of (pro)insulin production might have to be reached to trigger the autoimmune response. The [35]-S-labelled riboprobes were synthesized by in vitro transcription (SP6/T7) incorporation of [35]-S-dUTP using RNA polymerase . The template used was mouse insulin I cDNA that was generously donated by Chirgwin JM . The hybridisation buffer consisted of a 25μl hybridisation cocktail . After hybridisation, the slides were soaked in 2X standard saline citrate (SSC), rinsed with deionised water and then treated with RNase A (20μg/ml) for 30 min at room temperature. High stringency washes were then performed on the slides with 2XSSC followed by 0.2XSSC. The slides were then dried by ethanol, air dried for 20 min and the results viewed by NBT2 emulsion autoradiography . For controls, sense-probe instead of anti-sense was used for hybridisation. The photos were taken using the Olympus IX70 microscope  with a dark field condenser.2O2, and then incubated in PBS containing 10% goat serum or 1% BSA for 20 minutes at room temperature to block nonspecific binding.Sections of the liver and pancreas from the transgenic mice were washed twice in Phosphate Buffered Saline (PBS), fixed in 10% formalin overnight and embedded into paraffin. Consecutive 5μm sections were cut and placed on poly-L-lysine-coated slides. After dewaxing and serial alcohol rehydration, the tissue sections were treated with HFor insulin staining, primary insulin antibody  at 1:1250 was added and the sections were incubated overnight. The next morning the sections were washed in PBS and incubated with anti-guinea pig IgG (1:400) at room temperature for 20 minutes. Thereafter the sections were washed again with PBS, and biotinylated anti-rabbit / mouse antibody added to the sections for 15 minutes followed by streptavidin-peroxidase conjugate for a further 15 minutes. Finally, the sections were treated with substrate-chromogen AEC. A standard concentration (0.1%) of haematoxylin was added as a counterstain. The primary antibody was omitted for the negative control. The haematoxylin and eosin staining of sections was performed automatically by the Jung Autostainer XL machine .The log rank-test was used to determine whether the occurrence of diabetes in the transgenic mice was significantly different from the wild type NOD mice. The non-parametric t-test (Mann-Whitney U test) was used to determine whether the blood glucose levels of the diabetic transgenic and wild type NOD mice were significantly different.To confirm that the PEPCK-Ins transgene Figure  was funcFrom a series of two microinjections, 43 mice were obtained of which 4 were positive for the PEPCK-Ins transgene when analysed by PCR Figure  and SoutOf the two lines only one was found to transcribe insulin mRNA in the liver, as determined by mouse insulin I RT-PCR Figure  and mousin vivo. This was not possible since any (pro)insulin released from the liver would be indistinguishable from that secreted from pancreatic β cells. Two methods were used to analyse if (pro)insulin was produced from liver tissue removed from the mice. The liver was both extracted for its hormonal content, and placed in organ culture with analysis of the conditioned culture medium for (pro)insulin. In both cases, (pro)insulin was measurable. The (pro)insulin content was 0.5 ± 1 ng/mg (n = 5), which is equivalent to 8% of the (pro)insulin content of the pancreas (Table The ability of the liver cells from PEPCK-Ins positive transgenic mice to produce (pro)insulin was examined on liver removed from mice that had been sacrificed. Ideally production of (pro)insulin from the liver would be sought In situ hybridisation confirmed the presence of (pro)insulin mRNA in the pancreatic and liver sections of diabetic PEPCK-Ins transgenic mice Figure  and 3C bOne out of 14 males (7%) and four out of 25 females (16%) of the F1 and F2 progeny of the PEPCK-Ins transgenic NOD mice became diabetic insulin content of the liver of the diabetic mice was determined. This was similar to that from the liver of normoglycaemic transgenic mice Table . (Pro)inAt the end of the study, 5 heterozygous transgenic PEPCK-Ins NOD mice had become diabetic. Nevertheless, preproinsulin mRNA was localised to the hepatocytes by in situ hybridisation and was detected in total RNA extracts of the livers of these transgenic mice by both RT-PCR and RPA. (Pro)insulin was detected in acid ethanol extracts of the livers from the transgenic mice by RIA. Furthermore, (pro)insulin was released from explants of transgenic liver placed in organ culture. These results indicate that the liver cells from these transgenic PEPCK-Ins NOD mice did synthesise and produce (pro)insulin.Histological examination of the livers of the diabetic transgenic mice showed no infiltration of the liver by immune cells even though insulitis was observed in the pancreatic sections. This indicates that hepatic insulin production did not cause the development of tolerance to insulin in these PEPCK-Ins transgenic NOD mice. The lack of infiltration of immune cells in the livers of the diabetic transgenic mice also suggests that the mouse insulin I mRNA transcribing hepatocytes were not targeted or destroyed by the immune system. In addition, as the transgenic mice were sacrificed 4 weeks after the onset of diabetes, this reduces the possibility of delayed destruction of the (pro)insulin expressing hepatocytes. During this time, hepatic insulin expression was at least equal to that found in the pancreas. At the apparently low levels of transgene expression, these results suggest that (pro)insulin is not targeted by the immune system in this transgenic PEPCK-Ins mouse model superimposed on the autoimmune diabetes model of the NOD mouse. Likewise, Lipes et al reported that when pituitary cells in transgenic NOD mice were made to produce insulin, the cells were not targeted by the immune system even though the pancreatic β cells were. No cellular infiltrate also was shown when the pituitary cells that produced (pro)insulin were taken outside the blood brain barrier and transplanted beneath the renal capsule of NOD mice . Our datThe blood glucose levels of the diabetic transgenic NOD PEPCK-Ins mice (24.8 ± 1.9 mmol/l) were significantly lower (P = 0.004) than those of the diabetic wild type NOD mice (>33 ± 2.1 mmol/l). This is consistent with some (pro)insulin being released from the liver. These results are in agreement with those of Valera et al in which the majority of their high copy number PEPCK human insulin C57BL/6 mice also became diabetic when injected with streptozotocin despite the constitutive release of human (pro)insulin from the livers of the mice (7). Similarly, the transgenic mice which Valera et al made diabetic by streptozotocin injections also had lower blood glucose levels compared to the diabetic wild type NOD mice suggesting that the constitutive hepatic insulin release lowered the blood glucose levels of the diabetic mice but not to normal. This lack of therapeutic effect could be due to the fact that the PEPCK promoter is induced by glucagon and cyclic AMP. The high glucose levels in the diabetic transgenic mice might have resulted in the inhibition of endogenous glucagon release and thus shutting down (pro)insulin production in the liver.However it is possible that in some of our transgenic mice, enough (pro)insulin was produced to prevent diabetes. This would explain the significantly lower incidence of diabetes in the transgenic PEPCK-Ins (13%) compared to the wild type (28%) NOD mice (P < 0.001). One possibility is a protective effect of insulin, whether by allowing exhausted beta cells to rest or by altering the makeup of the T cells in the pancreas destroying the β cells there. The first reason was the basis for the large North American trial in pre-diabetic people in the late 90's with small doses of parenteral insulin . The secIt is possible that a critical amount of (pro)insulin needs to be produced for an autoimmune effect to be observed. The (pro)insulin content of the transgenic liver cells in normoglycaemic mice was much lower than that of a pancreatic β cell and was also lower than that in the liver of PEPCK-human insulin C57BL/6 transgenic mice produced by Valera et al , resultiAnother possible explanation for the lack of an autoimmune effect is that presentation of insulin peptides by hepatocytes might be limited by the ability of the liver cells to cleave proinsulin. The enzymes responsible for this in the β cell, prohormone convertases (PC) 1/3 and PC2, are absent from normal liver cells, but the endopeptidase furin is present . CleavagIn summary, we have shown that transgenic NOD mice that produce (pro)insulin in their liver do not develop cellular infiltration of their liver when autoimmune destruction of pancreatic β cells occur. Furthermore the expression of (pro)insulin in hepatocytes is insufficient to prevent development of diabetes in NOD mice. These results offer hope that eventually liver cells, or a subpopulation of them, may be of value as a therapy for type 1 diabetes.


The formylpeptide receptor family members FPR and FPRL1, expressed in myeloid phagocytes, belong to the G-protein coupled seven transmembrane receptor family (GPCRs). They share a high degree of sequence similarity, particularly in the cytoplasmic domains involved in intracellular signaling. The established model of cell activation through GPCRs states that the receptors isomerize from an inactive to an active state upon ligand binding, and this receptor transformation subsequently activates the signal transducing G-protein. Accordingly, the activation of human neutrophil FPR and FPRL1 induces identical, pertussis toxin-sensitive functional responses and a transient increase in intracellular calcium is followed by a secretory response leading to mobilization of receptors from intracellular stores, as well as a release of reactive oxygen metabolites.2) binding region of gelsolin (an uncapper of actin filaments) blocks granule mobilization as well as secretion of oxygen radicals. The inhibitory effect of PBP10 is, however, receptor specific and affects the FPRL1-, but not the FPR-, induced cellular response. The transient rise in intracellular calcium induced by the active receptors is not affected by PBP10, suggesting that the blockage occurs in a parallel, novel signaling pathway used by FPRL1 to induce oxygen radical production and secretion. Also the FPR can activate neutrophils through a PBP10-sensitive signaling pathway, but this signal is normally blocked by the cytoskeleton.We report that a cell permeable ten amino acid peptide (PBP10) derived from the phosphatidylinositol 4,5-bisphosphate (PIP2-binding peptide PBP10 selectively inhibits FPRL1-mediated superoxide production and granule mobilization. Furthermore, the activity of this novel PBP10 sensitive pathway in neutrophils is modulated by the actin cytoskeleton network.This study demonstrates that the two very closely related chemoattractant receptors, FPR and FPRL1, use distinct signaling pathways in activation of human neutrophils. The PIP Cells challenged with peptide agonists with or without PBP10 were fixed with ice-cold paraformaldehyde and washed with FACSwash  was from Boehringer-Mannheim . Isoluminol, cytochalasin B, and pertussis toxin were purchased from Sigma. Dextran and Ficoll-Paque were from Pharmacia , and Wortmannin was from Calbiochem . Fura-2AM was from Molecular Probes Inc. .Two-tailed, paired Students's t-tests were performed to determine statistical significance, and a P-value of < 0.05 was regarded as significant.GPCR – G-protein coupled receptorPBP – Phosphoinositide binding peptideFPR – formyl peptide receptorFPRL1 – formyl peptide receptor-like 1PIP2 – phosphatidylinositol 4,5-bisphosphatePI3K – phosphatidylinositol 3-kinasefMLF – formyl-methionly-leucyl-phenylalaninThe scientific question raised in the paper was formulated during discussions between HF and CD, about the mechanisms behind receptor activation/deactivation/reactivation (see ref ). HF was


How does your brain pass the time while you're sleeping? If you've ever wrestled the demons of insomnia, you know what sleepless nights can do to your mental agility. Sleep cycles in mammals are characterized by two distinct, successive sleep stages: slow wave and rapid eye movement (REM). Both stages of sleep have uniquely associated electrical activity in the brain, which neuroscientists can measure by placing elec-trodes on the brain during sleeping and waking states. What neuroscientists can't easily measure is the purpose of these two sequential sleep stages.The notion that sleep helps to improve memory was introduced over 80 years ago. Since then, several studies have demonstrated that sleep deprivation following the acqui-sition of a new memory strongly impairs its consolidation. Insight into the mechanisms underlying this effect came from the observation that neuronal activity patterns detected during waking reappear during ensuing sleep, suggesting that newly acquired “memory traces” may be replayed in the brain to solidify neural connections and thus “consolidate” memory. These reverberating patterns of activity have been observed in both mammals and birds, pointing to a very general biological phenomenon.Still, the relationship between brain reverberation and memory consolidation remains unclear for a number of reasons. First, studies to date have observed only subtle, short-lived reverberations lasting less than an hour and can't explain the memory-disrupting effects of sleep deprivation applied several hours and even days after initial memory encoding. And since brain reverberation in mammals has only been investigated in the hippocampus and cerebral cortex, it is unclear whether the phenomenon is specific to this neural circuit or is a more general property of the brain. Furthermore, reverberation studies have so far relied on neural activity measured in animals that were highly trained on specific laboratory tasks and therefore may simply not be representative of the acquisition of new memories. Finally, experience-dependent neural reverberation has been detected in both phases of sleep as well as waking, but no quantitative comparison of the different contributions of each state has been established.In a study designed to address these concerns, Sidarta Ribeiro and his colleagues at Duke University in Durham, North Carolina, recorded over a hundred neurons continuously over the course of the normal sleep--wake cycle in rats, focusing on four major forebrain areas that are essential for rodent-specific behaviors. Halfway through the recording time, animals were transiently allowed to explore four strictly novel objects, each of them designed to provide different spatial and sensory cues. The researchers found that in all the forebrain areas examined the neuronal firing patterns recorded when the rats initially explored the new objects reverberated for up to 48 hours after these objects were removed. The reverberation of neuronal activity sampled when rats explored familiar environs was insignificant. Reverberation was most significant during slow-wave sleep (a state that accounts for nearly 40% of a rat's life), decreased during waking periods, and was highly variable during REM sleep.In this study, Ribeiro et al. demonstrate that long-lasting neuronal reverberation following novel waking experiences can occur in several forebrain sites and is strongly enhanced during slow-wave sleep. Because neuronal reverberations are sustained for long periods, this may provide a mechanism to recall and amplify memories until they are effectively stored. On the basis of differences observed between REM and slow-wave sleep in this and previous studies, the authors propose that the two phases of sleep play separate and complementary roles in memory consolidation. Thus, the two stages of sleep give the brain a chance to process the novel events of the day in peace.