We care but we're not carers: perceptions and experiences of social prescribing in a UK national community organisation.

AIMS: (1) To explore how social prescribing referrals impact experiences of existing members of a voluntary and community-based organisation and (2) to describe the processes and relationships associated with joining community and voluntary organisations. METHODS: Online survey and qualitative interviews with members of Men's Sheds, a global volunteer-led initiative to address loneliness and social isolation in men. 93 self-selecting Shed members (average age 67 years, 93% male) from across England and Scotland took part in the survey about demographics, joining the Shed, and free-text questions about experiences in the Shed. From the survey participants, 21 Shed members were purposively sampled and interviewed to explore the impact of social prescribing and referrals on the Sheds. RESULTS: Participating in the Men's Shed was often associated with a significant change in personal circumstances, and Sheds provided a unique social support space, particularly valuable for men. Key factors around experiences of social prescribing and referral mechanisms were identified. We developed three themes: the experience of joining a Shed, success factors and risks of social prescribing, and 'we care but we're not carers'. CONCLUSIONS: The results show that Men's Sheds are a caring organisation, but their members are not trained as professional carers, and men come to the Shed for their own personal reasons. They are concerned about the potential additional responsibilities associated with formal referrals. They encourage the development of relationships and local-level understanding of the essence of Sheds to enable social prescribing. As models of social prescribing grow nationally and internationally, collaboratively working with voluntary and community organisations to develop a mutually beneficial approach is essential for the effectiveness and sustainability of social prescribing in community health.

Child Proton Beam Therapy: A qualitative study of parental views on treatment and information sources.

INTRODUCTION: Proton Beam Therapy (PBT) is often described as an advanced mode of radiotherapy. Whilst PBT offers an equivalent chance of cure to conventional radiotherapy, it is said to offer a theoretical reduction in long term side effects. NHS patients have had access to PBT since 2008 and approximately 65% of the 1144 approved referrals have been for paediatric cases. Yet, there is little research on how parents in these paediatric cases perceive their child's PBT and the information sources they encounter. METHODS: This is a qualitative inquiry informed by in-depth interviews carried out with 27 parents of children treated with PBT. RESULTS: Parents primarily frame PBT as a form of radiation but one which is better than alternatives. Whilst medical professionals do play a role, wider sources of information - such as other families and the internet - are important to both initial decision-making and treatment/recovery experiences. CONCLUSION: Parents are faced with the challenge of a 'fragmented expertise' which comes with the 'novelty' of the radiation therapy, the 'rare' nature of the tumours and the remote location of clinical specialists. IMPLICATIONS FOR PRACTICE: This article will prove useful for practitioners dealing with parents and care givers of children undergoing proton therapy, and is especially valuable and timely for practitioners based in the newly installed proton centres in the UK. Two high energy proton centres are expected to become fully operational in the UK by the end of 2020. Understanding parents' experiences and perspectives can help avoid undue anxiety and lead to service improvements and overall satisfaction.

Once-daily USL255 as adjunctive treatment of partial-onset seizures: randomized phase III study.

OBJECTIVE: To evaluate the efficacy and safety of USL255, Qudexy(™) XR (topiramate) extended-release capsules, as an adjunctive treatment for refractory partial-onset seizures (POS) in adults taking one to three concomitant antiepileptic drugs. METHODS: In this global phase III study (PREVAIL; NCT01142193), 249 adults with POS were randomized 1:1 to once-daily USL255 (200 mg/day) or placebo. The primary and key secondary efficacy endpoints were median percent reduction in weekly POS frequency and responder rate (proportion of patients with ≥ 50% reduction in seizure frequency). Seizure freedom was also assessed. Safety (adverse events, clinical and laboratory findings), as well as treatment effects on quality of life (QOLIE-31-P) and clinical global impression of change (CGI-C), were evaluated. RESULTS: Across the entire 11-week treatment phase, USL255 significantly reduced the median percent seizure frequency and significantly improved responder rate compared with placebo. Efficacy over placebo was observed early in treatment, in patients with highly refractory POS, and in those with the most debilitating seizure types (i.e., complex partial, partial secondarily generalized). USL255 was safe and generally well tolerated with a low incidence of neurocognitive adverse events. USL255 was associated with significant clinical improvement without adversely affecting quality of life. SIGNIFICANCE: The PREVAIL phase III clinical study demonstrated that once-daily USL255 (200 mg/day) significantly improved seizure control and was safe and generally well tolerated with few neurocognitive side effects.

Increased hippocampal CA1 density of serotonergic terminals in a triple transgenic mouse model of Alzheimer's disease: an ultrastructural study.

Alzheimer's disease (AD) is a neurodegenerative pathology that deteriorates mnesic functions and associated brain regions including the hippocampus. Serotonin (5-HT) has an important role in cognition. We recently demonstrated an increase in 5-HT transporter (SERT) fibre density in the hippocampal CA1 in an AD triple transgenic mouse model (3xTg-AD). Here, we analyse the ultrastructural localisation, distribution and numerical density (N(v)) of hippocampal SERT axons (SERT-Ax) and terminals (SERT-Te) and their relationship with SERT fibre sprouting and altered synaptic N(v) in 3xTg-AD compared with non-transgenic control mice. 3xTg-AD animals showed a significant increase in SERT-Te N(v) in CA1 at both, 3 (95%) and 18 months of age (144%), being restricted to the CA1 stratum moleculare (S. Mol; 227% at 3 and 180% at 18 months). 3xTg-AD animals also exhibit reduced N(v) of perforated axospinous synapses (PS) in CA1 S. Mol (56% at 3 and 52% at 18 months). No changes were observed in the N(v) of symmetric and asymmetrical synapses or SERT-Ax. Our results suggest that concomitant SERT-Te N(v) increase and PS reduction in 3xTg-AD mice may act as a compensatory mechanism maintaining synaptic efficacy as a response to the AD cognitive impairment.

Investigation into the suitability of a portable psychometric device to be used in the field: an illicit drugs field investigation.

RATIONALE: Driving performance is easily disrupted as a direct consequence of the use of alcohol, licit and illicit drugs. The use of such drugs has a high degree of correlation with increased accident risk. Europe wide research projects into drugged driving have called for the development of a portable objective device capable of screening those impaired through drug use which can be used at the roadside. OBJECTIVE: This study investigated the cognitive and psychomotor performance of a cohort of polydrug drug users in field conditions. Volunteers completed a psychometric test battery on a hand held device in music festival conditions. The test battery comprised a critical tracking task (CTT) and a sustained attention to response task (SART). Volunteers also took a breathanalyser and provided a saliva sample for a DOA screen. RESULTS: On the CTT significance was observed for tracking error following response to a peripheral stimulus in the high alcohol (>80 mg/100 ml) illicit drug group (p=0.0090) and approached significance for the low alcohol (<80 mg/100 ml) illicit drug group (p=0.088). For the SART, incorrect presses to the target stimulus was impaired for volunteers in both the low (<80 mg/100 ml) alcohol illicit drug group (p=0.0080) and the high alcohol (>80 mg/100 ml) illicit drug group (p=0.0415). Discrimination analysis demonstrated that the impairment device was able to discriminate between those individuals who had consumed neither alcohol nor drugs (94.12%), those in the low alcohol drug group (46.67%) and those in the high alcohol drug group (60.00%). CONCLUSION: It is possible to derive an impairment ratio. Further research will demonstrate whether this device could significantly contribute to drug driving detection and road traffic safety.

Investigating couples' sleep: an evaluation of actigraphic analysis techniques.

'Blip' analysis, fast wavelet transformations (FWT) and correlation analysis have all been used to actigraphically assess the impact one person is having on another's sleep, yet no review exists as to the differences between, and applicability of, these methods for investigating couples' sleep. Using actigraphy data and audio sleep diaries collected from 18 couples, this paper provides such a review. This paper constructs and assesses two novel, analytical methods: Lotjonen's sleep/wake algorithm, and the partner impact on sleep wake analysis (PISWA). Both 'blip' analysis and correlation suggest that the strongest relationship between bed partners occurs on an epoch-to-epoch basis. However, 'blips' deal strictly with onset of movement and fail to incorporate strength and duration of movement. Conversely, correlation analysis incorporates some elements of strength and duration of movement but makes identification of onset problematic. FWT offer useful 'relativistic' pattern recognition, identifying onset, strength and duration of movement, but are difficult to quantify. Although audio diary data support the potential of Lotjonen's sleep/wake algorithm to identify sleep non-movement, sleep movement, wake non-movement (or quiet wakefulness) and wake movement, the problem remains that this method also relies on visualization. Of most promise, we argue, is the PISWA, which examines 'impact' of bed partners through incorporating elements of 'blip' analysis and the sleep/wake algorithm.

A placebo controlled investigation into the effects of paroxetine and mirtazapine on measures related to car driving performance.

OBJECTIVE: To assess the effects of paroxetine and mirtazapine on psychometric performance related to car driving, including an on-the-road test of BRT. METHOD: In a 4-way, double blind randomised crossover study, 12 healthy volunteers received paroxetine 20mg mane, mirtazapine 15mg/30mg nocte (comparator), mirtazapine 15mg mane/15 mg b.i.d.(verum) and placebo over a 5 day period with a washout period of 7 days between treatments. Psychometric assessments included 'on-the-road' BRT (BRT), CFF (CFF), CRT (CRT) and subjective measures of sedation and sleep parameters. RESULTS: Paroxetine had no significant effect on BRT compared with placebo. Although subjective ratings of sleep quality and sedation were impaired, there were significant improvements in both CFF and the recognition reaction component of CRT with paroxetine. Mirtazapine 15mg/30mg nocte impaired laboratory performance and some subjective tests. Mirtazapine 15mg mane/15mg b.i.d. improved sleep, but significantly impaired all other measures. CONCLUSION: Paroxetine 20 mg/day has no psychomotor or behavioural toxicity and has no negative impact on BRT. Further research into the chronic and sub-chronic effects of mirtazapine is needed to establish the clinical significance of these results.

Collagen fibril organisation in mammalian vitreous by freeze etch/rotary shadowing electron microscopy.

Mammalian vitreous gel contains two major network-forming polymeric systems: long, thin fibrils comprising predominantly type II collagen and a meshwork of hyaluronan. The gel structure is maintained primarily by the collagen component, but little is known about the mechanisms of spacing of the collagen fibrils and of interactions between fibrils to form a stable network. In this study we have applied the technique of freeze etching/rotary shadowing electron microscopy in order to reveal the fibrillar network in central, cortical and basal vitreous and to understand the structural relationship between the collagen fibrils. The fibrils were arranged side by side in narrow bundles that frequently branched to link one bundle to another. Only a minor part of the fibrillar network consisted of segments that had a diameter of a single fibril (16.4nm mean diameter). In addition, three morphologically distinct filamentous structures were observed that appeared to form links within the collagen fibrillar network: short, single interlinking filaments of 7.0nm mean diameter, network-forming filaments of 6.7nm mean diameter, and longer filaments of 8.2nm mean diameter. All three types of filamentous structure were removed by digestion of the vitreous gels with Streptomyces hyaluronan lyase prior to freeze etching, indicating that these structures contain or are stabilised by hyaluronan. These filamentous structures may contribute to the structural stability of the vitreous gel.

Cartilage oligomeric matrix protein interacts with type IX collagen, and disruptions to these interactions identify a pathogenetic mechanism in a bone dysplasia family.

Cartilage oligomeric matrix protein (COMP) and type IX collagen are key structural components of the cartilage extracellular matrix and have important roles in tissue development and homeostasis. Mutations in the genes encoding these glycoproteins result in two related human bone dysplasias, pseudoachondroplasia and multiple epiphyseal dysplasia, which together comprise a "bone dysplasia family." It has been proposed that these diseases have a similar pathophysiology, which is highlighted by the fact that mutations in either the COMP or the type IX collagen genes produce multiple epiphyseal dysplasia, suggesting that their gene products interact. To investigate the interactions between COMP and type IX collagen, we have used rotary shadowing electron microscopy and real time biomolecular (BIAcore) analysis. Analysis of COMP-type IX collagen complexes demonstrated that COMP interacts with type IX collagen through the noncollagenous domains of type IX collagen and the C-terminal domain of COMP. Furthermore, peptide mapping identified a putative collagen-binding site that is associated with known human mutations. These data provide evidence that disruptions to COMP-type IX collagen interactions define a pathogenetic mechanism in a bone dysplasia family.

The acute and sub-chronic effects of levocetirizine, cetirizine, loratadine, promethazine and placebo on cognitive function, psychomotor performance, and weal and flare.

AIM: To compare the central and peripheral H1 inhibitory effects of acute and sub-chronic doses of levocetirizine (L-CTZ), cetirizine (CTZ), loratadine (LOR) and promethazine (PRM) versus placebo, using a battery of psychomotor and cognitive tests together with measures of the weal and flare reaction. PRM was included in the study as a positive internal control to validate the sensitivity of the psychometric test battery to the CNS effects of the various treatments. METHODS: Twenty healthy volunteers (18-50 years) received L-CTZ 5mg, CTZ 10 mg, LOR 10 mg, PRM 30 mg and placebo once daily for four days in a five-way, double-blind, crossover study. For each treatment condition, subjects were assessed using a psychometric test system and a pinprick weal and flare response to 100 mg/ml histamine solution at baseline and at 1, 2, 3 ,4, 6, 8, 10 and 122 hours post-dose on days 1 and 4. The psychometrics comprised critical flicker fusion (CFF), choice reaction time (CRT), a continuous tracking task (CTT) and subjective rating scales for sedation (LARS). On days 2 and 3, subjects took their medication at pre-designated times while out of the unit. RESULTS: The verum (PRM) established the sensitivity of the test battery: a significant overall reduction in CFF thresholds on both days 1 and 4 (p < 0.05); an overall significant increase (impairment) in recognition, motor and total reaction times on day 1 (p < 0.05); a significant impairment of both the tracking accuracy and reaction time aspects of the CTT task on day 1 (p < 0.005) and significantly higher ratings of subjective sedation on day 1 (p < 0.05). L-CTZ, CTZ and LOR were not distinguishable from placebo in any of the objective and subjective tests at any time point on either day 1 or day 4. With regards to the peripheral inhibitory effects, L-CTZ inhibited both the weal and flare reaction, with maximum inhibition (almost 100%) occurring within two hours of drug ingestion. CTZ also showed evidence of potent peripheral inhibition of histamine, whereas PRM, and especially LOR, showed only a weak weal and flare reaction which had completely attenuated at day 4. CONCLUSIONS: In a study where the psychometric assessments were shown to be sensitive to impairment, L-CTZ 5 mg was found following both initial and repeated doses, but also to be demonstrably free from disruptive and sedative effects on objective measures of psychomotor and cognitive function. Similarly, CTZ showed evidence of pronounced antihistaminic activity and significantly reduced weal and flare scores after both acute and repeated doses, again without evidence of cognitive or psychomotor impairment. LOR also was non-sedative but the antihistaminic reaction was demonstrably weak.

NMR structure and mutagenesis of the third Bir domain of the inhibitor of apoptosis protein XIAP.

The inhibitor of apoptosis proteins (IAPs) regulate the caspase family of cysteine proteases, which play an important role in the execution of programmed cell death. Human X-linked inhibitor of apoptosis protein (XIAP) is a potent inhibitor of caspases-3, -7, and -9. Here we show that the Bir3 domain is the minimal region of XIAP that is needed for potent caspase-9 inhibition. The three-dimensional structure of the Bir3 domain of XIAP, determined by NMR spectroscopy, resembles a classical zinc finger and consists of five alpha-helices, a three-stranded beta-sheet, and a zinc atom chelated to three cysteines and one histidine. The structure of the Bir3 domain is similar to that of the Bir2 domain of XIAP but differs from the previously determined structure of the Bir3 domain of MIHB. Based on site-directed mutagenesis, we have identified the regions of the Bir3 domain of XIAP that are important for inhibiting caspase-9. Despite the structural similarities of the Bir2 and Bir3 domain of XIAP, a different set of residues were found to be critical for inhibiting the individual caspases. These results suggest that XIAP inhibits caspase-3 and caspase-9 in a different manner.

Structural basis for binding of Smac/DIABLO to the XIAP BIR3 domain.

The inhibitor-of-apoptosis proteins (IAPs) regulate programmed cell death by inhibiting members of the caspase family of enzymes. Recently, a mammalian protein called Smac (also named DIABLO) was identified that binds to the IAPs and promotes caspase activation. Although undefined in the X-ray structure, the amino-terminal residues of Smac are critical for its function. To understand the structural basis for molecular recognition between Smac and the IAPs, we determined the solution structure of the BIR3 domain of X-linked IAP (XIAP) complexed with a functionally active nine-residue peptide derived from the N terminus of Smac. The peptide binds across the third beta-strand of the BIR3 domain in an extended conformation with only the first four residues contacting the protein. The complex is stabilized by four intermolecular hydrogen bonds, an electrostatic interaction involving the N terminus of the peptide, and several hydrophobic interactions. This structural information, along with the binding data from BIR3 and Smac peptide mutants reported here, should aid in the design of small molecules that may be used for the treatment of cancers that overexpress IAPs.

An approach for high-throughput structure determination of proteins by NMR spectroscopy.

An approach is described for rapidly determining protein structures by NMR that utilizes proteins containing 13C-methyl labeled Val, Leu, and Ile (delta1) and protonated Phe and Tyr in a deuterated background. Using this strategy, the key NOEs that define the hydrophobic core and overall fold of the protein are easily obtained. NMR data are acquired using cryogenic probe technology which markedly reduces the spectrometer time needed for data acquisition. The approach is demonstrated by determining the overall fold of the antiapoptotic protein, Bcl-xL, from data collected in only 4 days. Refinement of the Bcl-xL structure to a backbone rmsd of 0.95 A was accomplished with data collected in an additional 3 days. A distance analysis of 180 different proteins and structure calculations using simulated data suggests that our method will allow the global folds of a wide variety of proteins to be determined.

Rationale for Bcl-xL/Bad peptide complex formation from structure, mutagenesis, and biophysical studies.

The three-dimensional structure of the anti-apoptotic protein Bcl-xL complexed to a 25-residue peptide from the death promoting region of Bad was determined using NMR spectroscopy. Although the overall structure is similar to Bcl-xL bound to a 16-residue peptide from the Bak protein (Sattler et al., 1997), the Bad peptide forms additional interactions with Bcl-xL. However, based upon site-directed mutagenesis experiments, these additional contacts do not account for the increased affinity of the Bad 25-mer for Bcl-xL compared to the Bad 16-mer. Rather, the increased helix propensity of the Bad 25-mer is primarily responsible for its greater affinity for Bcl-xL. Based on this observation, a pair of 16-residue peptides were designed and synthesized that were predicted to have a high helix propensity while maintaining the interactions important for complexation with Bcl-xL. Both peptides showed an increase in helix propensity compared to the wild-type and exhibited an enhanced affinity for Bcl-xL.

NMR structure and mutagenesis of the inhibitor-of-apoptosis protein XIAP.

The inhibitor-of-apoptosis (IAP) family of proteins, originally identified in baculoviruses, regulate programmed cell death in a variety of organisms. IAPs inhibit specific enzymes (caspases) in the death cascade and contain one to three modules of a common 70-amino-acid motif called the BIR domain. Here we describe the nuclear magnetic resonance structure of a region encompassing the second BIR domain (BIR2) of a human IAP family member, XIAP (also called hILP or MIHA). The structure of the BIR domain consists of a three-stranded antiparallel beta-sheet and four alpha-helices and resembles a classical zinc finger. Unexpectedly, conserved amino acids within the linker region between the BIR1 and BIR2 domains were found to be critical for inhibiting caspase-3. The absence or presence of these residues may explain the differences in caspase inhibition observed for different truncated and full-length IAPs. Our data further indicate that these residues may bind to the active site and that the BIR domain may interact with an adjacent site on the enzyme.

Accurate measurement of H(N)-H(alpha) residual dipolar couplings in proteins.

A method for accurately measuring H(N)-H(alpha) residual dipolar couplings is described. Using this technique, both the sign and magnitude of the coupling can be determined easily. Residual dipolar coupling between H(N)(i)-H(alpha)(i) and H(N)(i)-H(alpha)(i-1) were measured for the FK506 binding protein complexed to FK506. The experimental values were in excellent agreement with predictions based on an X-ray crystal structure of the protein/ligand complex, suggesting that these residual dipolar couplings will provide accurate structural constraints for the refinement of protein structures determined by NMR.

NMR structure and mutagenesis of the N-terminal Dbl homology domain of the nucleotide exchange factor Trio.

Guanine nucleotide exchange factors for the Rho family of GTPases contain a Dbl homology (DH) domain responsible for catalysis and a pleckstrin homology (PH) domain whose function is unknown. Here we describe the solution structure of the N-terminal DH domain of Trio that catalyzes nucleotide exchange for Rac1. The all-alpha-helical protein has a very different structure compared to other exchange factors. Based on site-directed mutagenesis, functionally important residues of the DH domain were identified. They are all highly conserved and reside in close proximity on two a helices. In addition, we have discovered a unique capability of the PH domain to enhance nucleotide exchange in DH domain-containing proteins.