Process evaluation results of a cluster randomised controlled childhood obesity prevention trial: the WAVES study.

BACKGROUND: Increasing prevalence of childhood obesity and its related consequences emphasises the importance of developing and evaluating interventions aimed at prevention. The importance of process evaluation in health intervention research is increasingly recognised, assessing implementation and participant response, and how these may relate to intervention success or failure. A comprehensive process evaluation was designed and undertaken for the West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study that tested the effectiveness of an obesity prevention programme for children aged 6-7 years, delivered in 24 UK schools. The four intervention components were: additional daily school-time physical activity (PA); cooking workshops for children and parents; Villa Vitality (VV), a 6-week healthy lifestyle promotion programme run by a local football club; and signposting to local PA opportunities. METHODS: Data relating to six dimensions (Fidelity, Reach, Recruitment, Quality, Participant Responsiveness, Context) were collected via questionnaires, logbooks, direct observations, focus groups and interviews. Multiple data collection methods allowed for data triangulation and validation of methods, comparing research observations with teacher records. The 6-stage WAVES study model ((i) Data collection, (ii) Collation, (iii) Tabulation, (iv) Score allocation and discussion, (v) Consultation, (vi) Final score allocation) was developed to guide the collection, assimilation and analysis of process evaluation data. Two researchers independently allocated school scores on a 5-point Likert scale for each process evaluation dimension. Researchers then discussed school score allocations and reached a consensus. Schools were ranked by total score, and grouped to reflect low, medium or high intervention implementation. RESULTS: The intervention was predominantly well-implemented and well-received by teachers, parents and children. The PA component was identified as the most challenging, VV the least. Median implementation score across schools was 56/75 (IQR, 51.0 - 60.8). Agreement between teacher logbooks and researcher observations was generally high, the main discrepancies occurred in session duration reporting where in some cases teachers' estimations tended to be higher than researchers'. CONCLUSIONS: The WAVES study model provides a rigorous and replicable approach to undertaking and analysing a multi-component process evaluation. Challenges to implementing school-based obesity prevention interventions have been identified which can be used to inform future trials. TRIAL REGISTRATION: ISRCTN97000586 . 19 May 2010.

Obesity prevention in English primary schools: headteacher perspectives.

Schools are seen as important contributors to obesity prevention, yet face barriers in fulfilling this function. This qualitative study investigates headteacher views on the primary school role in preventing obesity. Semi-structured interviews were held with 22 headteachers from ethnically and socio-economically diverse schools in the West Midlands, UK. Data analysis was conducted using the framework approach. Two over-arching categories were identified: 'School roles and responsibilities' and 'Influencing factors'. Participants agreed that although schools contribute towards obesity prevention in many ways, a moral responsibility to support children's holistic development was the principal motivator, rather than preventing obesity per se. The perceived impact on learning was a key driver for promoting health. Parents were believed to have the main responsibility for preventing obesity, but barriers were identified. Whilst headteachers recognized the advantageous position of schools in offering support to parents, opinion varied on the degree to which schools could and should take on this role. Headteachers serving more deprived areas reported adopting certain responsibilities that elsewhere were fulfilled by parents, and were more likely to view working with families on healthy lifestyles as an important school function. Several factors were perceived as barriers to schools doing more to prevent obesity, including academic pressure, access to expert support and space. In conclusion, school leaders need more support, through resources and government policy, to enable them to maximize their role in obesity prevention. Additionally, school-based obesity prevention should be an integral part of the education agenda rather than bolt-on initiatives.

Testicular Microlithiasis: Is Sonographic Surveillance Necessary? Single Centre 14 Year Experience in 442 Patients with Testicular Microlithiasis.

PURPOSE: Increased prevalence of germ cell tumour (GCT) is seen with testicular microlithiasis (TM) suggesting TM is a premalignant condition with US surveillance advocated. We present a cohort of patients with TM followed up in a single centre and deliberate on the value of US surveillance. MATERIALS AND METHODS: A retrospective analysis of subjects with underlying US diagnosis of TM between 1998 and 2012. One-yearly US follow-up was offered to all patients with TM and a database maintained. Any co-existing tumour at presentation with TM was recorded. TM was divided into limited (< 5 microliths/field), classical (≥ 5 microliths/field) and florid ('snowstorm' appearance). Patient demographics, follow-up details and the development of any scrotal abnormalities were recorded. The radiological and histological findings were documented when a testicular lesion occurred during the follow-up period. RESULTS: 20 224 patients were examined: 867/20 224 (4.3 %) had TM. 21/867 (2.4 %) patients had histology proven malignant tumours at presentation. All TM patients consented to follow-up with 442/867 (51.0 %) achieving this and entering into a follow-up program (mean duration 28 months, range 8 - 165 months). Two patients developed primary GCT during the follow up period. One patient (limited TM) had undergone a previous orchiectomy for contralateral GCT and developed a palpable mass at follow up month 21. The other (limited TM) had an atrophic testis; a tumour was found on US at follow up month 62. CONCLUSION: Two patients of 442 (0.5 %) followed up for all forms of TM in a single centre developed a GCT over a mean duration of 28 months, both had independent risk factors for the development of GCT. These findings suggest that US surveillance is not required when TM is the only abnormality in the absence of any clinical risk factors for the development of GCT.

Scrotal calcification in a symptomatic paediatric population: Prevalence, location, and appearance in a cohort of 516 patients.

AIM: To describe the prevalence of all forms of scrotal calcification within a symptomatic paediatric population and to compare this with previous reported data in paediatric and adult populations. MATERIALS AND METHODS: A retrospective analysis of testicular ultrasound examinations performed in a single institution over a 55 month period. All examinations were performed by experienced operators using high-frequency linear array transducers. Types of scrotal calcification and position were recorded with all available images analysed by experienced radiologists. RESULTS: A total 516 male patients under the age of 19 years (mean age 10.5 years) were included. The prevalence of testicular microlithiasis (TM) was 8.7% and the prevalence of non-TM macrocalcification was 0.4%. 2.3% of the patients had scrotal pearls and 0.2% had epididymal calcification recorded. No other form of calcification was identified. A single patient had a co-existing testicular tumour and TM at examination. CONCLUSION: The prevalence of TM in the symptomatic paediatric population is greater than that reported in the symptomatic adult population, whereas the prevalence of intra-testicular macrocalcification is lower. It is speculated that TM and macrocalcification represent different pathways for the possible risk of testicular tumour development.

Leptomeningeal metastases in the MRI era.

BACKGROUND: Diagnosis of leptomeningeal metastasis (LM) has become increasingly frequent. The diagnostic gold standard has been CSF cytology, but MRI is now used routinely for diagnosis. Diagnosis and prognosis of LM has not been studied in the MRI era. METHODS: Patients with LM from 2002 through 2004 were identified through a neurology database, as well as by reviewing all abnormal CSF cytologies from a pathology database. Diagnosis was made by malignant cytology or imaging; suspicious cases treated as LM were also included. RESULTS: A total of 187 patients with LM were analyzed in this retrospective review. Of these, 150 had solid and 37 had hematopoietic malignancies. Median age was 56.4 years, and median Karnofsky performance status (KPS) was 70. The most common types of solid tumor were breast (65 patients), lung (47), gastrointestinal (11), and melanoma (9). Of the hematopoietic tumors, 21 were lymphoma and 15 were leukemia. Fifty-three percent of patients were diagnosed by imaging, 23% by cytology, and 24% by both. Treatment included radiation therapy in 55%, intrathecal chemotherapy in 29%, and systemic chemotherapy in 18%; 21% received supportive care alone. Median overall survival was 2.4 (95% confidence interval 1.9-3.1) months. Median survival for patients with hematopoietic tumors was 4.7 months and for solid tumors was 2.3 months (p = 0.0006). In multivariate analysis, initial KPS and tumor type (solid vs hematopoietic) were significant predictors of survival. CONCLUSIONS: Despite enhanced diagnosis with MRI, prognosis remains poor in leptomeningeal metastasis. Those with hematopoietic tumors continue to fare better than those with solid tumors.

Intratesticular haematoma: differentiation from tumour on clinical history and ultrasound appearances in two cases.

Intratesticular haematoma is not well described in the ultrasound literature and may be mistaken for a primary testicular malignancy if a detailed clinical history and careful ultrasound examination are not performed. We report two cases of intratesticular haematoma (one complicated by the presence of microlithiasis), describe the ultrasound appearances and document the natural history of the haematomas. A clinical history coupled with Doppler ultrasound features is crucial for conservative management.

Scrotal calcification: ultrasound appearances, distribution and aetiology.

This pictorial review illustrates the ultrasound appearances of scrotal calcification, distinguishing between intratesticular and extratesticular calcification. Intratesticular calcification may be due to phleboliths, spermatic granulomas or vascular calcification, or it may occur in association with tumours. Extratesticular calcification is more frequently encountered and is usually related to previous inflammatory disease of the epididymis. Testicular microlithiasis, a rare condition characterized by multiple scattered echogenic foci within the testis, is produced by the formation of microliths from degenerating cells in the seminiferous tubules. Testicular microlithiasis has been demonstrated as an incidental finding as well as in association with both benign and malignant tumours of the testis.

Glucose-6-phosphate dehydrogenase-6-phosphogluconolactonase. A novel bifunctional enzyme in malaria parasites.

Plasmodium falciparum glucose 6-phosphate dehydrogenase (Pf Glc6PD), compared to other Glc6PDs has an additional 300 amino acids at the N-terminus. They are not related to Glc6PD but are similar to a family of proteins (devb) of unknown function, some of which are encoded next to Glc6PD in certain bacteria. The human devb homologue has recently been shown to have 6-phosphogluconolactonase (6PGL) activity. This suggests Pf Glc6PD may be a bifunctional enzyme, the evolution of which has involved the fusion of adjacent genes. Further functional analysis of Pf Glc6PD has been hampered because parts of the gene could not be cloned. We have isolated and sequenced the corresponding Plasmodium berghei gene and shown it encodes an enzyme (Pb Glc6PD) with the same structure as the P. falciparum enzyme. Pb Glc6PD is 950 amino acids long with significant sequence similarity in both the devb and Glc6PD domains with the P. falciparum enzyme. The P. berghei enzyme does not have an asparagine-rich segment between the N and C halves and it contains an insertion at the same point in the Glc6PD region as the P. falciparum enzyme but the insertion in the P. berghei is longer (110 versus 62 amino acids) and unrelated in sequence to the P. falciparum insertion. Though expression of this enzyme in bacteria produced largely insoluble protein, conditions were found where the full-length enzyme was produced in a soluble form which was purified via a histidine tag. We show that this enzyme has both Glc6PD and 6PGL activities. Thus the first two steps of the pentose phosphate pathway are catalysed by a single novel bifunctional enzyme in these parasites.

The genetic regulation of fucosylated and sialylated antigens on developing myeloid cells.

The first part of this article reviews the stages of normal development of haemopoietic cells committed to the myeloid lineage, properties of leukaemic cell lines that are arrested at specific maturation stages along the granulocytic pathway, the structures of carbohydrate antigenic markers that appear on myeloid cell surfaces, with especial reference to sialyl-Le(x) (NeuAcalpha2-3Galbeta1-4[Fucalpha1-3]GlcNAc), and the role of this antigen on mature granulocytes as a ligand for selectin molecules. The families of fucosyl- and sialyltransferase genes encoding enzymes responsible for the biosynthesis of sialyl-Le(x), and the pathways leading to the formation of this antigen, and more complex related structures, are described. The second part of the article outlines the work carried out in the authors' laboratory with leukaemic cell lines in an attempt to ascertain the biochemical and genetic basis of the lowering of sialyl-Le(x) expression that occurs at intermediate stages of normal haemopoietic development. Analysis of enzyme levels and mRNA expression of the fucosyl- and sialyltransferase genes has led to the conclusion that depletion of substrate resulting from high levels of enzyme activity from co-expressed genes FUT4 and ST6Gal1 probably accounts for the dip in expression of sialyl-Le(x), rather than a change in the level of expression of FUT7, the gene in myeloid cells encoding the enzyme ultimately responsible for the synthesis of sialyl-Le(x). The possible significance of this change in relation to normal cell maturation is discussed.

A randomised crossover trial of chemotherapy in the home: patient preferences and cost analysis.

OBJECTIVES: To determine patient preferences and cost differences between home-based and hospital-based chemotherapy. DESIGN: Randomised crossover trial. SETTING: A tertiary cancer hospital in Melbourne, Victoria. PARTICIPANTS: 20 patients who required chemotherapy suitable for administration at home. INTERVENTIONS: Patients were assigned at random to receive their first chemotherapy treatment in either the home or the hospital and the second treatment in the alternative setting. MAIN OUTCOME MEASURES: Patient preference, costs. RESULTS: There was universal agreement by the 20 patients in the randomised trial that home-based chemotherapy was the preferred option (P < 0.0001). No problems were nominated by the patients as being associated with home-based chemotherapy. Home-based treatment was estimated to result in an increased cost of $83 (P = 0.0002) for each chemotherapy treatment compared with hospital-based treatment. Reported advantages for chemotherapy in the home included the elimination of travel, reduction in treatment-associated anxiety, reduction in the burden on carers and family, and the ability to continue other duties. There were no significant complications associated with administration of chemotherapy in the home. CONCLUSIONS: Patients prefer home-based chemotherapy to hospital-based treatment. The future of chemotherapy-in-the-home programs in Australia will depend on whether patient preferences are deemed to offset any potential increase in costs.

Meckel's diverticulitis in an elderly man diagnosed by computed tomography.

Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. Complications most frequently arise in children younger than 2 years who present with gastrointestinal bleeding. The diagnosis is usually made via radionuclide scintigraphy or intraoperatively. The authors report a 71-year-old man who developed a sudden onset of right lower quadrant abdominal pain, without bleeding, and was diagnosed as having Meckel's diverticulitis via computed tomography. The presence of Meckel' s diverticulitis was confirmed at surgery. Complications of a Meckel's diverticulum must be considered at any age. Computed tomography is another modality that may be helpful in the preoperative diagnosis.

Expression of human alpha-l-fucosyltransferase gene homologs in monkey kidney COS cells and modification of potential fucosyltransferase acceptor substrates by an endogenous glycosidase.

Previous investigations on the monkey kidney COS cell line demonstrated the weak expression of fucosylated cell surface antigens and presence of endogenous fucosyltransferase activities in cell extracts. RT-PCR analyses have now revealed expression of five homologs of human fucosyltransferase genes, FUT1, FUT4, FUT5, FUT7, and FUT8, in COS cell mRNA. The enzyme in COS cell extracts acting on unsialylated Type 2 structures is closely similar in its properties to the alpha1,3-fucosyltransferase encoded by human FUT4 gene and does not resemble the product of the FUT5 gene. Although FUT1 is expressed in the COS cell mRNA, it has not been possible to demonstrate alpha1,2-fucosyltransferase activity in cell extracts but the presence of Le(y) and blood-group A antigenic determinants on the cell surface imply the formation of H-precursor structures at some stage. The most strongly expressed fucosyltransferase in the COS cells is the alpha1,6-enzyme transferring fucose to the innermost N -acetylglucosamine unit in N -glycan chains; this enzyme is similar in its properties to the product of the human FUT8 gene. The enzymes resembling the human FUT4 and FUT8 gene products both had pH optima of 7.0 and were resistant to 10 mM NEM. The incorporation of fucose into asialo-fetuin was optimal at 5.5 and was inhibited by 10 mM NEM. This result initially suggested the presence of a third fucosyltransferase expressed in the COS cells but we have now shown that triantennary N- glycans with terminal nonreducing galactose units, similar to those present in asialo-fetuin, are modified by a weak endogenous beta-galactosidase in the COS cell extracts and thereby rendered suitable substrates for the alpha1,6-fucosyltransferase.

Independent regulation of Fuc-TIV and Fuc-TVII genes leading to modulation of cell surface antigen expression in developing myeloid cells.

Fucosylated antigen expression, fucosyltransferase activities and expression of Fuc-TIV and Fuc-TVII genes have been measured in the human leukemic cell lines KG1a, arrested at the undifferentiated myeloblast stage of maturation and KG1, arrested at the myeloblast and early promyelocytic stage. The results are compared with those we earlier found for the later promyelocytic cell line HL-60 and the myelocyte form into which HL-60 cells can be induced to differentiate. These leukemic cell lines, and the differentiated HL-60 cells, are believed to correspond to four successive stages of myeloid maturation in the bone marrow. Fuc-TVII mRNA was strongly expressed in the myeloblastic KG1a cells but expression was less in KG1 and HL-60 cells. In contrast to the sharp fall in Fuc-TIV expression observed on differentiation of HL-60 cells, the expression of Fuc-TIV mRNA showed a progressive increase from KG1a to HL-60 cells; thus the peak of expression of this gene was at the HL-60 promyelocyte stage. This peak correlated with an increase in fucosyltransferase activity with nonsialylated acceptors and the transitory downregulation of cell surface sialyl-Le(x) expression and upregulation of Le(x), VIM-2 and Le(y) expression. The variations in levels of expression of the fucosylated antigens on the surface of the developing myeloid cells therefore correlate with variations in mRNA expression arising from the independent regulation of Fuc-TIV and Fuc-TVII genes.

Three different endogenous alpha-L-fucosyltransferases expressed in COS cells.

The monkey kidney COS cell line is frequently used for the transient expression of cloned human fucosyltransferase cDNAs in the belief that negligible endogenous expression of fucosyltransferase genes occurs in these cells. In the course of transfection experiments we observed weak cell surface expression of sialyl-Lex and weak fucosyltransferase activity in extracts of control untransfected cells. Since these activities could complicate interpretation of the results with the transfected genes, a more detailed examination was undertaken that has now revealed expression of three different fucosyltransferases in the cells. One enzyme, which utilises N-acetyllactosamine as substrate, has a pH optimum of 7.0, is resistant to heat inactivation, and has been tentatively identified as an alpha1,3-fucosyltransferase. A second enzyme which acts on asialo-fetuin has a pH optimum of 5.5 and is rapidly inactivated by heat; the acceptor sugar and positional linkage of the transferred fucose are not yet established. A third enzyme that utilises asialo-agalacto-fetuin as acceptor is provisionally identified as an alpha1,6-fucosyltransferase.

Developmental regulation of alpha 1,3-fucosyltransferase expression in CD34 positive progenitors and maturing myeloid cells isolated from normal human bone marrow.

The adhesive interactions of hemopoietic cells within the bone marrow regulate their distribution, growth, and development. Fucosylated structures, of which sialyl Lewis x has been most extensively studied, are important ligands for selectins, but little is known about their function or regulation during normal hemopoietic development. We have studied alpha 1,3-fucosyltransferase activity in CD34 positive progenitors and myeloid cells at different stages of maturation isolated form normal human bone marrow, together with mRNA levels of Fuc-TIV and Fuc-TVII. Enzyme activity measured with H type 2 acceptor was present at all stages but was markedly elevated in fractions of early myeloid cells enriched for promyelocytes, correlating with the appearance of Lewis x on these cells, and thereafter fell progressively as cells matured. Activity measured with 3'sialyllactosamine was present in CD34+ cells and at all stages of maturation. Levels were low in promyelocyte/myelocyte transitional cells and increased, relative to those measured with H type 2, during the later stages of maturation; these changes correlate directly with a maturation-related increase in sialyl Lewis x expression. Using competitive quantitative RT-PCR, mRNA levels of Fuc-TIV and Fuc-TVII were similar in CD34+ cells, early myeloid and late myeloid cells. The significance of these findings in relation to fucosyltransferase activity, the synthesis of selectin ligands and differences between normal cells and leukemic cell lines is discussed.

Alpha1,3-L-fucosyltransferase expression in developing human myeloid cells. Antigenic, enzymatic, and mRNA analyses.

In an attempt to correlate the cell surface expression of Lex and sialyl-Lex structures in immature and mature myeloid cells with the genes expressing alpha1,3-fucosyltransferase(s) we have examined: 1) the properties of the cellular alpha1,3-fucosyltransferases and the mRNA transcripts corresponding to the five cloned genes, Fuc-TIII, Fuc-TIV, Fuc-TV, Fuc-TVI, and Fuc-TVII, in mature granulocytes and in the myeloid cell line HL-60, before and after dimethyl sulfoxide-induced differentiation and 2) the properties of the alpha1,3-fucosyltransferases expressed in COS-7 cells transfected with plasmids containing Fuc-TIV and Fuc-TVII cDNAs. The previously shown increase in cell surface expression of sialyl-Lex on differentiation of HL-60 cells (Skacel P. O., Edwards A. J., Harrison C. T., and Watkins W. M. (1991) Blood 78, 1452-1460) is accompanied by a sharp fall in expression of Fuc-TIV mRNA and a persistence of expression of Fuc-TVII mRNA. The properties of the alpha1,3-fucosyltransferase expressed in COS-7 cells transfected with Fuc-TIV are consistent with this being the major gene responsible for the expression of Lex in the immature myeloid cells. In Northern blot analyses, no transcripts of Fuc-TIII, Fuc-TV, or Fuc-TVI were detected in total RNA from mature granulocytes or mRNA from HL-60 cells before or after differentiation. In total RNA from mature granulocytes, Fuc-TIV transcripts were only faintly visible, whereas Fuc-TVII transcripts were quite definitely expressed. The specificity properties of Fuc-TVII expressed in COS-7 cells are consistent with this gene being the major candidate alpha1, 3-fucosyltransferase controlling the expression of sialyl-Lex on mature cells. However, Lex continues to be expressed on the surface of mature granulocytes and cell extracts retain the capacity to transfer fucose to non-sialylated acceptor substrates. The question therefore remains as to whether these properties result from the weakly expressed Fuc-TIV gene or whether another alpha1, 3-fucosyltransferase gene remains to be identified.

Purification, properties and possible gene assignment of an alpha 1,3-fucosyltransferase expressed in human liver.

alpha 1,3-Fucosyltransferase solubilized from human liver has been purified 40,000-fold to apparent homogeneity by a multistage process involving cation exchange chromatography on CM-Sephadex, hydrophobic interaction chromatography on Phenyl Sepharose, affinity chromatography on GDP-hexanolamine Sepharose and HPLC gel exclusion chromatography. The final step gave a major protein peak that co-chromatographed with alpha 1,3-fucosyltransferase activity and had a specific activity of approximately 5-6 mumol min-1 mg-1 and an M(r) approximately 44,000 deduced from SDS-PAGE and HPLC analysis. The purified enzyme readily utilized Gal beta 1-4GlcNAc, NeuAc alpha 2-3Gal beta 1-4GlcNAc and Fuc alpha 1-2Gal beta 1-4GlcNAc, with a preference for sialylated and fucosylated Type 2 acceptors. Fuc alpha 1-2Gal beta 1-4Glc and the Type 1 compound Gal beta 1-3GlcNAc were very poor acceptors and no incorporation was observed with NeuAc alpha 2-6Gal beta 1-4GlcNAc. A polyclonal antibody raised against the liver preparation reacted with the homologous enzyme and also with the blood group Lewis gene-associated alpha 1,3/1,4-fucosyltransferase purified from the human A431 epidermoid carcinoma cell line. No cross reactivity was found with alpha 1,3-fucosyltransferase(s) isolated from myeloid cells. Examination by Northern blot analysis of mRNA from normal liver and from the HepG2 cell line, together with a comparison of the specificity pattern of the purified enzyme with that reported for the enzyme expressed in mammalian cells transfected with the Fuc-TVI cDNA, suggests a provisional identification of Fuc-TVI as the major alpha 1,3-fucosyltransferase gene expressed in human liver.