Symptom appraisal, help seeking, and lay consultancy for symptoms of head and neck cancer.

OBJECTIVE: Early diagnosis is important in head and neck cancer (HNC) patients to maximize the effectiveness of the treatments and minimize the debilitation associated with both the cancer and the invasive treatments of advanced disease. Many patients present with advanced disease, and there is little understanding as to why. This study investigated patients' symptom appraisal, help seeking, and lay consultancy up to the time they first went to see a health care professional (HCP). METHODS: We interviewed 83 patients diagnosed with HNC. The study design was cross sectional and consisted of structured telephone interviews and a medical chart review. We gathered information on the participant's personal reactions to their symptoms, characteristics of their social network, and the feedback they received. RESULTS: We found that 18% of the participants thought that their symptoms were urgent enough to warrant further investigation. Participants rarely (6%) attributed their symptoms to cancer. Eighty-nine percent reported that they were unaware of the early warning signs and symptoms of HNC. Fifty-seven percent of the participants disclosed their symptoms to at least one lay consultant before seeking help from an HCP. The lay consultants were usually their spouse (77%), and the most common advice they offered was to see a doctor (76%). Lastly, 81% of the participants report that their spouse influenced their decision to see an HCP. CONCLUSIONS: The results of this study suggest that patients frequently believe that their symptoms were nonurgent and that their lay consultants influence their decision to seek help from an HCP.

Long-term safety and effectiveness of etanercept in children with selected categories of juvenile idiopathic arthritis.

OBJECTIVE: This study was undertaken to evaluate the long-term safety and effectiveness of etanercept alone or in combination with methotrexate (MTX) in children with selected categories of juvenile idiopathic arthritis (JIA). METHODS: Patients ages 2-18 years with rheumatoid factor (RF)-positive or RF-negative polyarthritis, systemic JIA, or extended oligoarthritis were eligible for the study. Patients received MTX alone (> or =10 mg/m(2)/week [ approximately 0.3 mg/kg/week], maximum dosage 1 mg/kg/week), etanercept alone (0.8 mg/kg/week, maximum dose 50 mg), or etanercept plus MTX for 3 years in an open-label, nonrandomized study. Safety was assessed by measuring rates of adverse events, and effectiveness was assessed using the physician's global assessment of disease activity and the pediatric total joint assessment. RESULTS: A total of 197, 103, and 294 patients were enrolled in the MTX, etanercept, and etanercept plus MTX groups, respectively. Exposure-adjusted rates of adverse events were similar among the 3 treatment groups (18.3, 18.7, and 21.6 per 100 patient-years in the MTX, etanercept, and etanercept plus MTX groups, respectively). Respective rates per 100 patient-years of serious adverse events (4.6, 7.1, and 6.0) and medically important infections (1.3, 1.8, and 2.1) were also similar among the 3 treatment groups. Scores for physician's global assessment and total active joints improved from baseline, and improvement was maintained for the duration of the study. CONCLUSION: These data confirm the findings of other long-term studies and suggest that etanercept or etanercept plus MTX has an acceptable safety and effectiveness profile in children with selected categories of JIA. Improvement was maintained for 3 years in those continuing to receive medication.

Recommendations for locus-specific databases and their curation.

Expert curation and complete collection of mutations in genes that affect human health is essential for proper genetic healthcare and research. Expert curation is given by the curators of gene-specific mutation databases or locus-specific databases (LSDBs). While there are over 700 such databases, they vary in their content, completeness, time available for curation, and the expertise of the curator. Curation and LSDBs have been discussed, written about, and protocols have been provided for over 10 years, but there have been no formal recommendations for the ideal form of these entities. This work initiates a discussion on this topic to assist future efforts in human genetics. Further discussion is welcome.

Androgen receptor CAG repeat length contraction in diseased and non-diseased prostatic tissues.

To investigate contraction of CAG repeats within the androgen receptor gene (AR) as shorter CAG repeats have been implicated as a possible risk factor in prostate cancer (PCa). AR CAG repeat lengths were analyzed in DNA from microdissected diseased prostates, leukocytes from matched peripheral blood, and control non-diseased prostates. Consistently, all prostatic tissues, whether from benign or cancerous areas of diseased prostates, or from control prostates, showed multiple AR CAG repeat contractions. Germline DNA from blood leukocytes had single CAG repeat lengths in the normal range. AR CAG repeat length contraction may be involved in prostate carcinogenesis and may precede the pathological process.

Progress in Spinobulbar muscular atrophy research: insights into neuronal dysfunction caused by the polyglutamine-expanded androgen receptor.

Spinobulbar muscular atrophy (SBMA, Kennedy's disease) results from the dysfunction and degeneration of specific motor and sensory neurons. The underlying cause of this ligand-dependent neurodegenerative disease is expansion of the CAG trinucleotide repeat in the androgen receptor (AR) gene which leads to lengthening of the polyglutamine tract in the AR protein. Recently, the effects of the polyglutamine-expanded AR have been explored in a number of cellular and animal models. Common themes include research on polyglutamine-containing nuclear inclusions and the effect of molecular chaperone overexpression on their formation. In addition, investigations have highlighted the role that abnormal transcriptional regulation, proteasome dysfunction and altered axonal transport may play in disease pathogenesis. These studies suggest a number of potential treatments for restoring neuronal function. One of the most interesting advances in SBMA research has been the creation of mouse models that recapitulate the key features of SBMA progression in men. Lowering testosterone levels in affected transgenic male mice rescued, and even reversed the polyglutamine-induced neuromuscular phenotype, indicating that manipulating androgen levels in men could be of therapeutic benefit. Although the question of why only a distinct subset of neurons is affected by polyglutamine expansion of the AR remains unsolved, future research will provide further insights into the mechanisms contributing to disease progression in SBMA.

Coping effectiveness: determinants and relevance to the mental health and affect of family caregivers of persons with dementia.

Family caregivers of persons with dementia (n = 141) rated their effectiveness in coping with a challenging symptom displayed by their relative, and completed measures of their ways of coping, their general (optimism) and specific (caregiving self-efficacy) outcome expectancies, their affect (positive and negative), and the mental health subscale of the SF-36. Hierarchical regression analyses revealed that coping effectiveness is more highly influenced by relatively stable outcome expectancies than by the ways of coping that are employed. In addition, optimism exerted a consistent and relatively strong impact on affect and mental health, overshadowing the influence of coping and judgments of its effectiveness. However, coping effectiveness not only had a significant main effect on the caregivers' mental health and negative affect, but also served a stress buffering function by reducing negative affect.

Coping with family caregiving to persons with dementia: a critical review.

Seventeen empirical studies that relate the ways of coping employed by family caregivers of persons affected by dementia to their health and morale are critically reviewed for the purposes of determining whether there is any consensus regarding ways of coping that serve health-protective functions, and whether the studies' designs and measurement strategies are faithful to the transactional theory of coping upon which they are founded. Due to the use of cross-sectional designs, the adoption of different coping and outcome measures, the lack of specificity and the incomparability of the target stressors, the reliance on retrospective reports, and the use of inappropriate response formats, among other limitations, the interpretability of the cumulative body of empirical findings on caregiver coping is questionable. Ways of strengthening and broadening coping research to make it more fruitful and theoretically coherent are presented.

Design of an intervention addressing multiple levels of influence on dietary and activity patterns of low-income, postpartum women.

Low-income, multi-ethnic women are at elevated risk for obesity and chronic diseases, yet influences at different levels may act as barriers to changing risk behaviors. Following the birth of a child, childrearing and social isolation can exacerbate these influences. The social ecological framework integrates behavior-change strategies at different levels, providing a strong theoretical base for developing interventions in this high-risk population. The primary purpose of this randomized controlled trial is to test the efficacy of an educational model delivered by community-based paraprofessionals in improving diet, activity and weight loss among new mothers over a 12-month postpartum period and a 6-month maintenance period. This model fosters institutional change to support behavior changes influenced at intrapersonal and interpersonal levels, through collaboration with federal programs for low-income families: the Special Supplemental Food Program for Women, Infants and Children (WIC), and the Expanded Food and Nutrition Education Program (EFNEP). Participants are randomized to the Usual Care, e.g. WIC nutrition and breastfeeding education, or Enhanced EFNEP intervention arm, consisting of Usual WIC Care plus a sustained, multi-component intervention including home visits, group classes and monthly telephone counseling. If shown to be efficacious, this program will be readily sustainable through existing federal agencies.

Cloning and characterization of an androgen receptor N-terminal-interacting protein with ubiquitin-protein ligase activity.

The androgen receptor (AR) N-terminal domain plays a critical role in androgen-responsive gene regulation. A novel AR N-terminal-interacting protein (ARNIP) was isolated using the yeast two-hybrid system and its interaction with amino acids 11-172 of the normal or corresponding region of the polyglutamine-expanded human AR confirmed by glutathione S-transferase pulldown assays. ARNIP cDNAs cloned from NSC-34 (mouse neuroblastoma/spinal cord) or PC-3 (human prostate adenocarcinoma) mRNA encoded highly homologous 30 kDa (261 amino acids) cysteine-rich proteins with a RING-H2 (C3H2C3 zinc finger) domain; this motif is highly conserved in predicted ARNIP-homologous proteins from several other species. Expression of the approximately 1.7 kb ARNIP mRNA was detected in various tissues by Northern blotting, but was highest in mouse testes, kidney and several neuronal cell lines. In addition, the human ARNIP protein was found to be encoded by nine exons spanning 32 kb on chromosome 4q21. In COS-1 cells, coexpression of ARNIP and AR did not affect AR ligand-binding kinetics, nor did ARNIP act as a coactivator or corepressor in transactivation assays. However, AR N-terminal:C-terminal interaction was reduced in the presence of ARNIP. Intriguingly, ARNIP, and in particular its RING-H2 domain, functioned as a ubiquitin-protein ligase in vitro in the presence of a specific ubiquitin-conjugating enzyme, Ubc4-1. Mutation of a single cysteine residue in the ARNIP RING-H2 domain (Cys145Ala) abolished this E3 ubiquitin ligase activity. Fluorescent protein tagging studies revealed that AR-ARNIP interaction was hormone-independent in COS-1 cells, and suggest that colocalization of both AR and ARNIP to the nucleus upon androgen addition may allow ARNIP to play a role in nuclear processes. Thus, identification of a novel AR-interacting protein with ubiquitin ligase activity will stimulate further investigation into the role of ubiquitination and the ubiquitin-proteasome system in AR-mediated cellular functions.

Cytochrome c oxidase subunit Vb interacts with human androgen receptor: a potential mechanism for neurotoxicity in spinobulbar muscular atrophy.

Spinobulbar muscular atrophy (SBMA) is a neurodegenerative disease caused by the expansion of the polyglutamine (polyGln) tract in the human androgen receptor (hAR). One mechanism by which polyGln-expanded proteins are believed to cause neuronotoxicity is through aberrant interaction(s) with, and possible sequestration of, critical cellular protein(s). Our goal was to confirm and further characterize the interaction between hAR and cytochrome c oxidase subunit Vb (COXVb), a nuclear-encoded mitochondrial protein. We initially isolated COXVb as an AR-interacting protein in a yeast two-hybrid screen to identify candidate proteins that interacted with normal and polyGln-expanded AR. Using the mammalian two-hybrid system, we confirm that COXVb interacts with normal and mutant AR and demonstrated that the COXVb-normal AR interaction is stimulated by heat shock protein 70. In addition, blue fluorescent protein-tagged AR specifically co-localized with cytoplasmic aggregates formed by green fluorescent protein-labeled polyGln-expanded AR in androgen-treated cells. Mitochondrial dysfunction may precede neuropathological findings in polyGln-expanded disorders and may thus represent an early event in neuronotoxicity. Interaction of COXVb and hAR, with subsequent sequestration of COXVb, may provide a mechanism for putative mitochondrial dysfunction in SBMA.

A G577R mutation in the human AR P box results in selective decreases in DNA binding and in partial androgen insensitivity syndrome.

We have characterized a novel mutation of the human AR, G577R, associated with partial androgen insensitivity syndrome. G577 is the first amino acid of the P box, a region crucial for the selectivity of receptor/DNA interaction. Although the equivalent amino acid in the GR (also Gly) is not involved in DNA interaction, the residue at the same position in the ER (Glu) interacts with the two central base pairs in the PuGGTCA motif. Using a panel of 16 palindromic probes that differ in these base pairs (PuGNNCA) in gel shift experiments with either the AR DNA-binding domain or the full length receptor, we observed that the G577R mutation does not induce binding to probes that are not recognized by the wild-type AR. However, binding to the four PuGNACA elements recognized by the wild-type AR was affected to different degrees, resulting in an altered selectivity of DNA response element recognition. In particular, AR-G577R did not interact with PuGGACA palindromes. Modeling of the complex between mutant AR and PuGNACA motifs indicates that the destabilizing effect of the mutation is attributable to a steric clash between the C beta of Arg at position 1 of the P box and the methyl group of the second thymine residue in the TGTTCPy arm of the palindrome. In addition, the Arg side chain can interact with G or T at the next position (PuGCACA and PuGAACA elements, respectively). The presence of C is not favorable, however, because of incompatible charges, abrogating binding to the PuGGACA element. Transactivation of several natural or synthetic promoters containing PuGGACA motifs was drastically reduced by the G577R mutation. These data suggest that androgen target genes may be differentially affected by the G577R mutation, the first natural mutation characterized that alters the selectivity of the AR/DNA interaction. This type of mutation may thus contribute to the diversity of phenotypes associated with partial androgen insensitivity syndrome.

Variable expressivity and mutation databases: The androgen receptor gene mutations database.

For over 50 years genetics has presumed that variations in phenotypic expression have, for the most part, been the result of alterations in genotype. The importance and value of mutation databases has been based on the premise that the same gene or allelic variation in a specific gene that has been proven to determine a specific phenotype, will always produce the same phenotype. However, recent evidence has shown that so called "simple" Mendelian disorders or monogenic traits are often far from simple, exhibiting phenotypic variation (variable expressivity) that cannot be explained solely by a gene or allelic alteration. The AR gene mutations database now lists 25 cases where different degrees of androgen insensitivity are caused by identical mutations in the androgen receptor gene. In five of these cases the phenotypic variability is due to somatic mosaicism, that is, somatic mutations that occur in only certain cells of androgen-sensitive tissue. Recently, a number of other cases of variable expressivity have also been linked to somatic mosaicism. The impact of variable expressivity due to somatic mutations and mosaicism on mutation databases is discussed. In particular, the effect of an organism exhibiting genetic heterogeneity within its tissues, and the possibility of an organism's genotype changing over its lifetime, are considered to have important implications for mutation databases in the future.

Somatic mosaicism and variable expressivity.

For more than 50 years geneticists have assumed that variations in phenotypic expression are caused by alterations in genotype. Recent evidence shows that 'simple' mendelian disorders or monogenic traits are often far from simple, exhibiting phenotypic variation (variable expressivity) that cannot be explained entirely by a gene or allelic alteration. In certain cases of androgen insensitivity syndrome caused by identical mutations in the androgen receptor gene, phenotypic variability is caused by somatic mosaicism, that is, somatic mutations that occur only in certain androgen-sensitive cells. Recently, more than 30 other genetic conditions that exhibit variable expressivity have been linked to somatic mosaicism. Somatic mutations have also been identified in diseases such as prostate and colorectal cancer. Therefore, the concept of somatic mutations and mosaicism is likely to have far reaching consequences for genetics, in particular in areas such as genetic counseling.

The polymorphic CAG repeat of the androgen receptor gene: a potential role in breast cancer in women over 40.

Previous investigations into the relationship of CAG-repeat lengths in the androgen receptor (AR) gene to female breast cancer (BC) have yielded somewhat confusing results. Decreased AR transactivational activity lowers androgen:estrogen balance, and may thereby effect functional hyperestrogenicity. This may promote the pathogenesis of BC. To elucidate whether longer CAG repeats of the AR gene (AR), which correlate with lower transactivational activity of the AR, are associated with BC in women over 40, we examined the distribution of CAG-repeat lengths in BC tissue from this population. The BC tissue was histologically graded as: Grade 1, well differentiated (WD); Grade 2, moderately differentiated (MD); and Grade 3, poorly-differentiated (PD). Analysis showed significant differences as compared to controls when CAG lengths greater than 21 were examined, and that alleles with > or = 26 repeats were 2.4-fold more frequent in BC samples than in constitutional samples from a normal population. A significant shift to greater CAG-repeat lengths, appeared in WD and MD tumors only. Our results give some indication as to the progression of BC by suggesting that hypotransactive ARs with long polyglutamine (polyGln) tracts may have a role in the initiation and/or progression of BC. PD tumors tended to have shorter than normal CAG-repeat lengths. In this case it is hypothesized that the ARs have now become hypertransactive, possibly coinciding with the estrogen resistance that is associated with PD tumors. Whether this shift is of germline or somatic origin was not clear, though the appearance in 14% of the BC samples of a third CAG-repeat length indicates that it may be somatic.

Characterization of intracellular aggregates using fluorescently-tagged polyglutamine-expanded androgen receptor.

Spinal bulbar muscular atrophy (SBMA) is a classic CAG-repeat neurodegenerative disease. It is caused by expansion of a polyglutamine (polyGln) tract in the androgen receptor (AR). Recent evidence has indicated a potential role for nuclear and cytoplasmic inclusions in the pathogenesis of these diseases. We have used blue and green fluorescently-tagged AR to show that both wild-type (WT) and poly-Gln-expanded full-length AR can form aggregates and that aggregation is not related to cytotoxicity. Twenty to thirty-five percent of all cell types transfected into COS cells showed aggregation containing both amino- and carboxy-terminal fluorescent tags. The aggregates reacted with (F39.4.1), an anti-AR antibody and with IC2, an expanded polyGln tract antibody. Western analysis of protein extracts revealed little evidence of proteolysis although some cleavage of the fusion proteins was seen. The general caspase inhibitor, Z-DEVD-FMK, did not affect aggregation in either wild type or polyGln-expanded GFP-AR transfected cells. Surprisingly, addition of Mibolerone a synthetic androgen significantly decreased inclusion formation in both WT and polyGln-expanded AR-transfected cells. Overall, we show that both WT and polyGln expanded full-length AR are found in aggregates and that proteolysis is not a requirement for aggregation. Our results also suggest that toxicity is not related to intracellular aggregation of polyGln expanded AR.

Interactions between androgen and estrogen receptors and the effects on their transactivational properties.

The physiological interplay of androgen and estrogen action in endocrine tissues is well recognized. The biochemical processes responsible for this interplay have yet to be fully defined. We have demonstrated that the androgen receptor (AR) and estrogen receptor-alpha (ERalpha) can interact directly using the yeast and mammalian two-hybrid systems. These interactions occurred between the C-terminal ERalpha ligand-binding domain and either the N-terminal AR transactivational domain or the full-length AR. Estrogen receptor-beta (ERbeta) did not interact with the AR. DNA cotransfection studies employing AR, ERalpha and ERbeta expression vectors and AR- or ER-reporter gene constructs were used to identify and measure potential functional effects of AR-ER interaction. Coexpression of ERalpha with AR decreased AR transactivation by 35%; coexpression of AR with ERalpha decreased ERalpha transactivation by 74%. Coexpression of AR and ERbeta did not significantly modulate AR or ERbeta transactivation. In summary, we have shown that specific domains of AR and ERalpha physically interact and have demonstrated the functional consequences of such interaction. These results may help explain the nature of the physiological interplay between androgens and estrogens.

[Improving the quality of clinical interview teaching: evaluation of an intervention with medical students]. / Mejorando la calidad de la enseñanza de entrevista clínica: evaluación de una intervención en estudiantes de medicina.

BACKGROUND: Quality of clinical interview is a key issue both for patient satisfaction and for diagnostic efficiency. Its adequacy relates to better clinical diagnosis treatment plans and patient compliance. AIM: To measure the quality of interviews performed by medical students in three Chilean medical schools before receiving specific training on the subject and to compare the scores obtained after introductory courses on interview. MATERIAL AND METHODS: The interviews were videotaped and then evaluated using an objective scale, that measures 33 skills grouped in six areas: opening, problem exploration, non verbal facilitation, interpersonal patient reaction and closing. The students were assigned to an experimental group that received an interactive workshop with role-plays, vignettes and videotape feedback, and to a non intervention group that received the usual bedside training on medical interviews. RESULTS: Both groups shared the same skill level before the training, with better scores on nonverbal, patient reaction and problem exploration, and worse ones on closing and interpersonal skills. Comparing pre and post-test results, the overall score improved in the experimental group (from 33.2 to 38.3, p = 0.002) and worsened among non intervened students. There were statistically significant changes for opening (p < 0.002), problem exploration (p < 0.05), non verbal facilitation (p < 0.0001) and closing (p < 0.0001). CONCLUSIONS: It is important to train students not only in specific knowledge contents but in the process of interview. This training should encourage the development of empathy and closing skills.

[A new instrument for the evaluation of the medical profession. Use of the OSCE method]. / Hacia un nuevo instrumento de evaluación en la carrera de Medicina. Uso del método OSCE.

BACKGROUND: Objective structured clinical examination has advantages over traditional oral examination of medical student. However, it is not routinely used in Chile. AIM: To describe the objective structured clinical examination system and report the results of its first use with Chilean medical students. MATERIAL AND METHODS: Thirteen interns ware evaluated at the end of their surgical rotation, using the objective structured clinical examination. Thirteen stations were structured for this examination: one for history taking, two for physical examination, four for problem solving and knowledge, one for radiological interpretation, one for instrumental recognition, one for skills and one for text comprehension. There were a total of 88 questions. RESULTS: All students exceeded 60% of requirements. Mean approval score was 73%. The higher score was 80% and the lower 61%. Ten students had a score over 70%. The method was well accepted by teachers and students. CONCLUSIONS: This first local experience with the objective structured clinical examination was successful.