Patient and caregiver involvement in the formulation of guideline questions: findings from the European Academy of Neurology guideline on palliative care of people with severe multiple sclerosis.

BACKGROUND AND PURPOSE: Patient and public involvement in clinical practice guideline development is recommended to increase guideline trustworthiness and relevance. The aim was to engage multiple sclerosis (MS) patients and caregivers in the definition of the key questions to be answered in the European Academy of Neurology guideline on palliative care of people with severe MS. METHODS: A mixed methods approach was used: an international online survey launched by the national MS societies of eight countries, after pilot testing/debriefing on 20 MS patients and 18 caregivers, focus group meetings of Italian and German MS patients and caregivers. RESULTS: Of 1199 participants, 951 (79%) completed the whole online survey and 934 from seven countries were analysed: 751 (80%) were MS patients (74% women, mean age 46.1) and 183 (20%) were caregivers (36% spouses/partners, 72% women, mean age 47.4). Participants agreed/strongly agreed on inclusion of the nine pre-specified topics (from 89% for 'advance care planning' to 98% for 'multidisciplinary rehabilitation'), and <5% replied 'I prefer not to answer' to any topic. There were 569 free comments: 182 (32%) on the pre-specified topics, 227 (40%) on additional topics (16 guideline-pertinent) and 160 (28%) on outcomes. Five focus group meetings (three of MS patients, two of caregivers, and overall 35 participants) corroborated the survey findings. In addition, they allowed an explanation of the guideline production process and the exploration of patient-important outcomes and of taxing issues. CONCLUSIONS: Multiple sclerosis patient and caregiver involvement was resource and time intensive, but rewarding. It was the key for the formulation of the 10 guideline questions and for the identification of patient-important outcomes.

European Academy of Neurology/European Association for Palliative Care Taskforce on Neurology Consensus recommendations on palliative care for patients with chronic and progressive neurological disease - acceptability for Belgian neurologists.

BACKGROUND AND PURPOSE: A Consensus document on palliative care and neurology has made recommendations on the care of people with chronic and progressive neurological disease. This study aimed to investigate whether these recommendations are understood by, acceptable to and used in practice by neurologists in Belgium. METHODS: An online survey was undertaken of 100 neurologists in Belgium, asking for their opinion on all of the recommendations in the Consensus document. RESULTS: Sixty-four of the neurologists replied. Overall, they expressed support for the recommendations, in particular open communication with patients, open assessment of patient and family needs, and discussion of dying. There was less understanding of the role of palliative care in the implementation of palliative care early in disease progression and the role of palliative care multidisciplinary teams. CONCLUSIONS: The survey shows that many of the recommendations in the European Academy of Neurology/European Association for Palliative Care Taskforce on Neurology Consensus document are understood by neurologists, and several are now seen as part of normal clinical practice. However, there is still a need to develop a more collaborative approach between neurology and palliative care services, for the benefit of patients and families.

A consensus review on the development of palliative care for patients with chronic and progressive neurological disease.

BACKGROUND AND PURPOSE: The European Association of Palliative Care Taskforce, in collaboration with the Scientific Panel on Palliative Care in Neurology of the European Federation of Neurological Societies (now the European Academy of Neurology), aimed to undertake a review of the literature to establish an evidence-based consensus for palliative and end of life care for patients with progressive neurological disease, and their families. METHODS: A search of the literature yielded 942 articles on this area. These were reviewed by two investigators to determine the main areas and the subsections. A draft list of papers supporting the evidence for each area was circulated to the other authors in an iterative process leading to the agreed recommendations. RESULTS: Overall there is limited evidence to support the recommendations but there is increasing evidence that palliative care and a multidisciplinary approach to care do lead to improved symptoms (Level B) and quality of life of patients and their families (Level C). The main areas in which consensus was found and recommendations could be made are in the early integration of palliative care (Level C), involvement of the wider multidisciplinary team (Level B), communication with patients and families including advance care planning (Level C), symptom management (Level B), end of life care (Level C), carer support and training (Level C), and education for all professionals involved in the care of these patients and families (Good Practice Point). CONCLUSIONS: The care of patients with progressive neurological disease and their families continues to improve and develop. There is a pressing need for increased collaboration between neurology and palliative care.

One-to-one spatially matched experiment and atomistic simulations of nanometre-scale indentation.

We have carried out nanoindentation studies of gold in which the indenter is atomically characterized by field-ion microscopy and the scale of deformation is sufficiently small to be directly compared with atomistic simulations. We find that many features of the experiment are correctly reproduced by molecular dynamics simulations, in some cases only when an atomically rough indenter rather than a smooth repulsive-potential indenter is used. Heterogeneous nucleation of dislocations is found to take place at surface defect sites. Using input from atomistic simulations, a model of indentation based on stochastic transitions between continuum elastic-plastic states is developed, which accurately predicts the size distributions of plastic 'pop-in' events and their dependence on tip geometry.

E. coli propionyl-CoA synthetase is regulated in vitro by an intramolecular disulfide bond.

The E. coli propionyl-CoA synthetase (PCS) was cloned, expressed, purified, and analyzed. Kinetic analyses suggested that the enzyme preferred propionate as substrate but would also use acetate. The purified, stored protein had relatively low activity but was activated up to about 10-fold by incubation with dithiothreitol (DTT). The enzyme activation by DTT was reversed by diamide. This suggests that the protein contains a regulatory disulfide bond and that the reduction to two sulfhydryl groups activates PCS while the oxidation to a disulfide leads to its inactivation. This idea was tested by sequential mutagenesis of the 9 Cys in the protein to Ala. It was revealed that the C128A and C315A mutants had wildtype enzyme activity but were no longer activated by DTT or inhibited by diamide. The data obtained indicate that two Cys residues could be involved in redox-regulated system through formation of an intramolecular disulfide bridge in PCS.

Increasing photosynthesis by inhibiting photorespiration with glyoxylate.

Glyoxylate treatment doubles net photosynthetic carbon dioxide fixation by tobacco leaf disks because inhibition of glycolate synthesis by glyoxylate results in decreased photorespiration. These observations show that photorespiration can be metabolically regulated and suggest that genetic or chemical alteration of pool sizes of certain metabolites can produce plants with increased photosynthesis.

Specialist palliative care improves the quality of life in advanced neurodegenerative disorders: NE-PAL, a pilot randomised controlled study.

BACKGROUND: This study analysed the impact on palliative care outcomes of a new specialist palliative care service for patients severely affected by amyotrophic lateral sclerosis (ALS/MND), multiple sclerosis, Parkinson's disease and related disorders (multiple system atrophy progressive supranuclear palsy, MSA-PSP). METHODS: The design followed the Medical Research Council Framework for the evaluation of complex interventions. A phase II randomised controlled trial (RCT) was undertaken comparing an immediate referral to the service (FT, fast track) to a 16-week wait (standard track (ST), standard best practice) using a parallel arm design. The main outcome measures were Quality of Life (measured with Schedule for the Evaluation of Individual Quality of Life Direct Weight, SEIQoL-DW) and burden of the carers (Caregivers Burden Inventory, CBI), with secondary outcomes of symptoms, psychosocial and spiritual issues. RESULTS: 50 patients severely affected by neurodegenerative conditions and their informal family carers were randomised: 25 FT, 25 ST. At baseline (T0), there were no differences between groups. 4 patients died during the follow-up (2 FT, 2 ST) and 2 FT patients dropped out before the end of the study. After 16 weeks (T1), FT participants scored significant improvement in the SEIQoL-DW index, pain dyspnoea sleep disturbance and bowel symptoms. CONCLUSIONS: This exploratory RCT provides evidence that no harm was experienced by SPCS for patients severely affected by neurodegenerative disorders. There was an improvement in quality of life and physical symptoms for neurological patients in palliative care. Caregiver burden was not affected by the service.

Leaf-targeted phytochelatin synthase in Arabidopsis thaliana.

One of the key steps in developing transgenic plants for the phytoremediation of metal containing soils is to develop plants that accumulate metals in the aerial tissues. With the goal of changing the distribution of phytochelatin (PC)-dependent cadmium accumulation from roots to the leaves, the phytochelatin synthase (PCS) deficient cad1-3 mutant and wild type (Col-0) Arabidopsis plants were transformed with an Arabidopsis phytochelatin synthase (AtPCS1) under the control of a leaf-specific promoter. Three independent transformant lines from each genetic background were chosen for further analysis and designated cad-PCS and WT-PCS. PCS activity in the cadPCS lines was restored in the leaves, but not in the roots. Additionally, when whole plants were treated with cadmium, PCs were found only in the leaves of cad-PCS plants. Although the inserted AtPCS1 gene was leaf-specific, cad-PCS lines showed an overall decrease in cadmium toxicity evidenced by a partial amelioration of the "brown-root" phenotype and root growth was restored to wild type levels when treated with cadmium and arsenate. WT-PCS lines showed an increase in leaf PCS activity but had only wild type PC levels. In addition, cadmium uptake studies indicated that there was no difference in cadmium accumulation among all types tested. So, while we were able to protect the plants against cadmium by expressing PC synthase only in the leaves, we were not able to limit cadmium accumulation to aerial tissues.

The Phosphate Transporter from Pea Mitochondria (Isolation and Characterization in Proteolipid Vesicles).

The phosphate transporter from mitochondria will exchange matrix phosphate for cytosolic phosphate and facilitate either phosphate/proton symport or phosphate/hydroxyl ion antiport. The phosphate transported into the matrix by this carrier is either used for ATP synthesis or exchanges back out to the cytosol on the dicarboxylate transporter, permitting entry of malate and succinate into the matrix. The phosphate transporter was solubilized from etiolated pea (Pisum sativum L. cv Alaska) mitochondrial membranes with Triton X-114, purified approximately 500-fold by hydroxylapatite chromatography, and reconstituted into azolectin vesicles that were preloaded with 0.1 or 10 mM phosphate. Phosphate transport was measured as the exchange of preloaded phosphate for external [32P]phosphate. Phosphate/phosphate exchange occurred for over 40 min at room temperature with an apparent K0.5 of 1.6 mM and a maximum velocity of over 700 nmol (mg protein)-1 min-1. Diethyl pyrocarbonate was used as an inhibitor-stop reagent. Transport was inhibited by p-hydroxyphenylglyoxal, p-hydroxymercuribenzoate, pyridoxal 5-phosphate, and dansyl chloride but was insensitive to sulfate, nitrate, and N-ethylmaleimide, the standard inhibitor for the mammalian phosphate transporter. Phosphate/hydroxyl exchange was stimulated when the proton gradient was collapsed with carbonyl cyanide m-chlorophenylhydrazone, but phosphate/phosphate exchange was unaffected by the uncoupler.

Molecular evidence of a unique lipoamide dehydrogenase in plastids: analysis of plastidic lipoamide dehydrogenase from Arabidopsis thaliana.

Lipoamide dehydrogenase is a subunit of the alpha-ketoacid dehydrogenases and the glycine decarboxylase complex in mitochondria, and the pyruvate dehydrogenase complex in plastids. We report here the unexpected finding of two plastidic isoforms of lipoamide dehydrogenase from Arabidopsis thaliana that are different from the mitochondrial form of the enzyme. The cDNA clones were confirmed by sequence alignment analysis and their location verified by chloroplast import assay. They are single copy genes that appear to be expressed in parallel in different tissues with highest level in developing siliques. Phylogenetic analysis gives further exemplary evidence for the plastidic evolution derived from cyanobacteria.

Timing of surgery during the menstrual cycle for breast cancer: possible role of growth factors.

Premenopausal patients undergoing surgery for breast cancer were prospectively studied. Data regarding menstrual history, pathological parameters and hormone receptor status were collected. Serum oestradiol, prolactin and progesterone levels, tumour epidermal growth factor receptor (EGFR) levels, tumour epidermal growth factor (EGF) levels and flow cytometry were measured. Patients were allocated to the follicular or luteal phase of their cycle both by history and progesterone level. No significant differences were seen in hormone receptor levels, pathological parameters or EGF levels between the two groups. EGFR levels were significantly higher in women undergoing surgery during the follicular phase of their cycle, when classified by menstrual history. Patients operated on during this phase have previously been found to have a poorer prognosis, and these results may provide a basis for this finding. This may have implications for prognosis and timing of surgery, and further investigation is warranted.

Thickness-dependent phase transformation in nanoindented germanium thin films.

We investigate the mechanical response of 50-600 nm epitaxial Ge films on a Si substrate using nanoindentation with a nominally spherical (R≈4.3 µm) diamond tip. The inelastic deformation mechanism is found to depend critically on the film thickness. Sub-100 nm Ge films deform by pressure-induced phase transformation, whereas thicker films deform only by shear-induced dislocation slip and twinning. Nanoindentation fracture response is similarly dependent on film thickness. Elastic stress modelling shows that differing stress modes vary in their spatial distribution, and consequently the film thickness governs the stress state in the film, in conjunction with the radius of the nanoindenter tip. This opens the prospect of tailoring the contact response of Ge and related materials in thin film form by varying film thickness and indenter radius.

Inhibition of photorespiration and increase of net photosynthesis in isolated maize bundle sheath cells treated with glutamate or aspartate.

Net photosynthetic (14)CO(2) fixation by isolated maize (Zea mays) bundle sheath strands was stimulated 20 to 35% by the inclusion of l-glutamate or l-aspartate in the reaction mixture. Maximal stimulation occurred at a 7.5 mm concentration of either amino acid. Since the photosynthetic rate and the glutamate-dependent stimulation in the rate were equally sensitive to a photosynthetic electron transport inhibitor, 3-(p-chlorophenyl)-1,1-dimethylurea, it was concluded that glutamate did not stimulate CO(2) fixation by supplying needed NADPH (NADH) through glutamate dehydrogenase. Treatment of the bundle sheath strands with glutamate inhibited glycolate synthesis by 59%. Photorespiration in this tissue, measured as the O(2) inhibition of CO(2) fixation (the Warburg effect), was inhibited by treatment with glutamate. The stimulation in net photosynthetic CO(2) fixation probably results from the decrease in photorespiratory CO(2) loss. This metabolic regulation of the rate of glycolate synthesis and photorespiration observed with isolated bundle sheath strands could account for the inability to detect rapid photorespiration in the mature intact maize leaf.

Effect of Glyoxylate on the Sensitivity of Net Photosynthesis to Oxygen (the Warburg Effect) in Tobacco.

The addition of glyoxylate to tobacco (Nicotiana tabacum) leaf discs inhibited glycolate synthesis and photorespiration and increased net photosynthetic (14)CO(2) fixation. This inhibition of photorespiration was investigated further by studying the effect of glyoxylate on the stimulation of photosynthesis that occurs when the atmospheric O(2) level was decreased from 21 to 3% (the Warburg effect). The Warburg effect is usually ascribed to the increased glycolate synthesis and metabolism that occurs at higher O(2) concentrations. Photosynthesis in control discs increased from 59.1 to 94.7 micromoles of CO(2) per gram fresh weight per hour (a 60% increase) when the O(2) level was lowered from 21 to 3%, while the rate for discs floated on 15 millimolar glyoxylate increased only from 82.0 to 99.7 micromoles of CO(2) per gram fresh weight per hour (a 22% increase). The decrease in the O(2) sensitivity of photosynthesis in the presence of glyoxylate was explained by changes in the rate of glycolate synthesis under the same conditions.The rate of metabolism of the added glyoxylate by tobacco leaf discs was about 1.35 micromoles per gram fresh weight per hour and was not dependent on the O(2) concentration in the atmosphere. This rate of metabolism is about 10% the amount of stimulation in the rate of CO(2) fixation caused by the glyoxylate treatment on a molar carbon basis. Glyoxylate (10 millimolar) had no effect on the carboxylase/oxygenase activity of isolated ribulose diphosphate carboxylase. Although the biochemical mechanism by which glyoxylate inhibits glycolate synthesis and photorespiration and thereby decreases the Warburg effect is still uncertain, these results show that cellular metabolites can regulate the extent of the Warburg effect.

Mechanism of decarboxylation of glycine and glycolate by isolated soybean cells.

Isolated soybean leaf mesophyll cells decarboxylated exogenously added [1-(14)C]glycolate and [1-(14)C]glycine in the dark. The rate of CO(2) release from glycine was inhibited over 90% by isonicotinic acid hydrazide and about 80% by KCN, two inhibitors of the glycine to serine plus CO(2) reaction. The release of CO(2) from glycolate was inhibited by less than 50% under the same conditions. This indicates that about 50% of the CO(2) released from glycolate occurred at a site other than the glycine to serine reaction. The sensitivity of this alternative site of CO(2) release to an inhibitor of glycolate oxidase (methyl-2-hydroxy-3-butynoate) but not an inhibitor of the glutamate:glyoxylate aminotransferase (2,3-epoxypropionate) indicates that this alternative (isonicotinic acid hydrazide insensitive) site of CO(2) release involved glyoxylate. Catalase inhibited this CO(2) release. Under the conditions used it is suggested that about half of the CO(2) released from glycolate occurred at the conversion of glycine to serine plus CO(2) while the remaining half of the CO(2) loss resulted from the direct oxidation of glyoxylate by H(2)O(2).The rate of glycine decarboxylation by the glycine to serine reaction was apparently controlled by the amount of NAD in the mitochondria. Mitochondrial electron transport inhibitors, KCN and actinomycin A, inhibited glycine decarboxylation while an uncoupler, 2,4-dinitrophenol, stimulated the reaction. Competition within the mitochondria between the enzymes of dark respiration and glycine decarboxylation for limiting NAD may force substantial amounts of the glycolate formed to be decarboxylated by the direct oxidation of glyoxylate.