A multicentre cross-sectional observational study to determine the effect of living with frailty on digital exclusion from video consultations: (Access-VIGIL).

OBJECTIVES: Many older people regularly access digital services, but many others are totally excluded. Age alone may not explain these discrepancies. As health care services offer more video consultations, we aimed to determine if living with frailty is a significant risk factor for digital exclusion in accessing video consultations, and if this changes if a person has a support network to help with access. DESIGN: We undertook a muticenter cross-sectional survey across South West England. SETTING AND PARTICIPANTS: Patients in primary care, hospital at home, and secondary care services were enrolled between February 21 and April 12, 2022. METHODS: The primary outcome was complete digital exclusion defined as no individual access or network support access to video consultations. Secondary analysis looked at the person's digital exclusion when ignoring any network support. The association between frailty and outcomes was analyzed with logistic regression. In addition, older people's digital skills, motivation, and confidence were examined. RESULTS: 255 patients were included in the analysis. The median age was 63 years (interquartile range 43-77) with 148 (57%) women. Complete digital exclusion was rare (5.1%). Only 1 of 155 who were not frail (Clinical Frailty Scale 1-3) experienced complete digital exclusion compared with 12 of 99 (10.7%) who were living with frailty (Clinical Frailty Scale 4-8). There was no association between frailty and complete digital exclusion. Frailty was associated with individual digital exclusion when no network support was available to assist. CONCLUSIONS AND IMPLICATIONS: When taking into account a person's support network, complete digital exclusion from video consultation was rare. When no support network was available, frailty was associated with individual digital exclusion. Health care services should ask about a person's support network to help people living with frailty access video consultations.

1 H-13 C cross-polarization kinetics to probe hydration-dependent organic components of bone extracellular matrix.

Bone is a living tissue made up of organic proteins, inorganic minerals, and water. The organic component of bone (mainly made up of Type-I collagen) provides flexibility and tensile strength. Solid-state nuclear magnetic resonance (ssNMR) is one of the few techniques that can provide atomic-level structural insights of such biomaterials in their native state. In the present article, we employed the variable contact time cross-polarization (1 H-13 C CP) kinetics experiments to study the hydration-dependent atomic-level structural changes in the bone extracellular matrix (ECM). The natural abundant 13 C CP intensity of the bone ECM is measured by varying CP contact time and best fitted to the nonclassical kinetic model. Different relaxation parameters were measured by the best-fit equation corresponding to the different hydration conditions of the bone ECM. The associated changes in the measured parameters due to varying levels of hydration observed at different sites of collagen protein have provided its structural arrangements and interaction with water molecules in bone ECM. Overall, the present study reveals a better understanding of the kinetics of the organic part inside the bone ECM that will help in comprehending the disease-associated pathways.

Identification of a Novel GRHL3/HOPX/Wnt/ß-Catenin Proto-oncogenic Axis in Squamous Cell Carcinoma of the Esophagus.

BACKGROUND & AIMS: Esophageal squamous cell carcinoma (ESCC) is an aggressive malignancy with a poor long-term prognosis. The molecular mechanisms underlying the initiation and progression of this tumor are largely unknown. The transcription factor GRHL3 functions as a potent tumor suppressor in SCC of skin, head, and neck. This study aims to determine whether GRHL3 also plays a role in the homeostasis of the esophageal epithelium and in the development of ESCC. METHODS: The effects of Grhl3 deletion on squamous epithelial homeostasis in embryos and adult mice were examined using immunohistochemistry, transmission electron microscopy, and real-time polymerase chain reaction. The conditionally deleted mice were subsequently used to determine susceptibility to ESCC. Whole-transcriptome sequencing (RNA-seq) was performed on ESCC in wild-type and Grhl3 deleted animals. To decipher the signaling pathways, real-time polymerase chain reaction, immunohistochemistry, analysis of chromatin immunoprecipitation sequencing, chromatin immunoprecipitation-polymerase chain reaction, and RNA seq datasets were used. Primary human samples were used to validate the findings in the mouse model. RESULTS: Loss of Grhl3 perturbs the proliferation-differentiation balance in the esophageal epithelium, thereby increasing the susceptibility to esophageal carcinogenesis in adult mice. Grhl3 imparts its tumor suppressor function by regulating the expression of HOPX. We have identified the Wnt/ß-catenin pathway as the downstream effectors of GRHL3 and HOPX through our integrated approach using patient-derived ESCC samples and mouse models. CONCLUSIONS: GRHL3 conveys its tumor suppressor function in ESCC through regulating its target gene HOPX, which limits Wnt/ß-catenin signaling. Targeted therapies to inhibit this pathway could be a potential treatment strategy for ESCC patients with reduced GRHL3 expression.

Animal-derived medicinal products: community representatives' views of their use.

In the UK, there are a variety of religious or cultural beliefs and preferences that guide people in a range of lifestyle decisions. This qualitative study aimed to better understand the views of the public around prescribing animal-derived products, in particular low-molecular-weight heparin (LMWH), from a potential patient perspective. A series of quality improvement focus groups with stakeholders were undertaken to understand perceptions and to evaluate and inform an established treatment pathway. Stakeholders discussed finding out about the porcine nature of LMWH asking 'Why don't they tell us?', suggesting that they 'shouldn't have to give out clues' about their personal preferences. Participants' thoughts about 'how' information be provided, by 'whom' and 'when' were gained. The stakeholders indicated that current practice is unacceptable for patients. They require greater knowledge and transparency regarding product components and recommend that healthcare professionals provide more dialogue and choice to patients.

Factoring patients' beliefs and values into decisions around anticoagulation: a community-led multi-cycle quality improvement project.

Low-molecular-weight heparin (LMWH), prescribed for prophylaxis of venous thromboembolism, is derived from porcine animal products. An audit in our Trust showed that most healthcare professionals (95%, n=58/61) did not consider religious or dietary preferences when prescribing LMWH. Focus groups with local stakeholders helped develop project aims. Quality improvement methods were used to develop, test and optimise interventions over two cycles in our medical unit. Interventions included written and audiovisual information for patients, a staff eLearning module, a policy to guide switching from LMWH to a synthetic alternative and a written prompt reminding doctors to consent patients before prescribing LMWH. The proportion of patients being appropriately consented for LMWH prescriptions increased following our interventions (from <5% at baseline to >80%). Patient and staff feedback was positive, with high demand for a non-animal-derived alternative to LMWH. Simple measures, increasing awareness and knowledge among staff and patients, can improve the number of patients being appropriately consented for LMWH prescriptions.

Leaving No One Behind: Interventions and Outcomes of the COVID-19 Vaccine Maximising Uptake Programme.

The devastating impact of COVID-19 on individuals and communities has accelerated the development of vaccines and the deployment of ambitious vaccination programmes to reduce the risks of infection, infection transmission and symptom severity. However, many people delay or refuse to get vaccinated against COVID-19, for many complex reasons. Vaccination programmes that are tailored to address individual and communities' COVID-19 concerns can improve vaccine uptake rates and help achieve the required herd-immunity threshold. The Maximising Uptake Programme has led to the vaccination of 7979 people from February-August 2021 in the South West of England, UK, who are at high risk of severe illness from COVID-19 and/or may not access the COVID-19 vaccines through mass vaccination centres and general practices. These include: people experiencing homelessness; non-English-speaking people; people from minority ethnic groups; refugees and asylum seekers; Gypsy, Roma, Travelers and boat people; and those who are less able to access vaccination centres, such as people with learning difficulties, serious mental illness, drug and alcohol dependence, people with physical and sensory impairment, and people with dementia. Outreach work coupled with a targeted communication and engagement campaign, co-designed with community leaders and influencers, have led to significant engagement and COVID-19 vaccine uptake among the target populations.

Unraveling Water-Mediated 31P Relaxation in Bone Mineral.

Bone is a dynamic tissue composed of organic proteins (mainly type I collagen), inorganic components (hydroxyapatite), lipids, and water that undergoes a continuous rebuilding process over the lifespan of human beings. Bone mineral is mainly composed of a crystalline apatitic core surrounded by an amorphous surface layer. The supramolecular arrangement of different constituents gives rise to its unique mechanical properties, which become altered in various bone-related disease conditions. Many of the interactions among the different components are poorly understood. Recently, solid-state nuclear magnetic resonance (ssNMR) has become a popular spectroscopic tool for studying bone. In this article, we present a study probing the interaction of water molecules with amorphous and crystalline parts of the bone mineral through 31P ssNMR relaxation parameters (T 1 and T 2) and dynamics (correlation time). The method was developed to selectively measure the 31P NMR relaxation parameters and dynamics of the crystalline apatitic core and the amorphous surface layer of the bone mineral. The measured 31P correlation times (in the range of 10-6-10-7 s) indicated the different dynamic behaviors of both the mineral components. Additionally, we observed that dehydration affected the apatitic core region more significantly, while H-D exchange showed changes in the amorphous surface layer to a greater extent. Overall, the present work provides a significant understanding of the relaxation and dynamics of bone mineral components inside the bone matrix.

Prognostic value of National Early Warning Scores (NEWS2) and component physiology in hospitalised patients with COVID-19: a multicentre study.

BACKGROUND: National Early Warning Scores (NEWS2) are used to detect all-cause deterioration. While studies have looked at NEWS2, the use of virtual consultation and remote monitoring of patients with COVID-19 mean there is a need to know which physiological observations are important. AIM: To investigate the relationship between outcome and NEWS2, change in NEWS2 and component physiology in COVID-19 inpatients. METHODS: A multi-centre retrospective study of electronically recorded, routinely collected physiological measurements between March and June 2020. First and maximum NEWS2, component scores and outcomes were recorded. Areas under the curve (AUCs) for 2-day, 7-day and 30-day mortality were calculated. RESULTS: Of 1263 patients, 26% died, 7% were admitted to intensive care units (ICUs) before discharge and 67% were discharged without ICU. Of 1071 patients with initial NEWS2, most values were low: 50% NEWS2=0-2, 27% NEWS2=3-4, 14% NEWS2=5-6 and 9% NEWS2=7+. Maximum scores were: 14% NEWS2=0-2, 22% NEWS2=3-4, 17% NEWS2=5-6 and 47% NEWS2=7+. Higher first and maximum scores were predictive of mortality, ICU admission and longer length of stay. AUCs based on 2-day, 7-day, 30-day and any hospital mortality were 0.77 (95% CI 0.70 to 0.84), 0.70 (0.65 to 0.74), 0.65 (0.61 to 0.68) and 0.65 (0.61 to 0.68), respectively. The AUCs for 2-day mortality were 0.71 (0.65 to 0.77) for supplemental oxygen, 0.65 (0.56 to 0.73) oxygen saturation and 0.64 (0.56 to 0.73) respiratory rate. CONCLUSION: While respiratory parameters were most predictive, no individual parameter was as good as a full NEWS2, which is an acceptable predictor of short-term mortality in patients with COVID-19. This supports recommendation to use NEWS2 alongside clinical judgement to assess patients with COVID-19.

Association between National Early Warning Scores in primary care and clinical outcomes: an observational study in UK primary and secondary care.

BACKGROUND: NHS England has mandated use of the National Early Warning Score (NEWS), more recently NEWS2, in acute settings, and suggested its use in primary care. However, there is reluctance from GPs to adopt NEWS/NEWS2. AIM: To assess whether NEWS calculated at the point of GP referral into hospital is associated with outcomes in secondary care. DESIGN AND SETTING: An observational study using routinely collected data from primary and secondary care. METHOD: NEWS values were prospectively collected for 13 047 GP referrals into acute care between July 2017 and December 2018. NEWS values were examined and multivariate linear and logistic regression used to assess associations with process measures and clinical outcomes. RESULTS: Higher NEWS values were associated with faster conveyance for patients travelling by ambulance, for example, median 94 minutes (interquartile range [IQR] 69-139) for NEWS ≥7; median 132 minutes, (IQR 84-236) for NEWS = 0 to 2); faster time from hospital arrival to medical review (54 minutes [IQR 25-114] for NEWS ≥7; 78 minutes [IQR 34-158] for NEWS = 0 to 2); as well as increased length of stay (5 days [IQR 2-11] versus 1 day [IQR 0-5]); intensive care unit admissions (2.0% versus 0.5%); sepsis diagnosis (11.7% versus 2.5%); and mortality, for example, 30-day mortality 12.0% versus 4.1% for NEWS ≥7 versus NEWS = 0 to 2, respectively. On average, for patients referred without a NEWS value (NEWS = NR), most clinical outcomes were comparable with patients with NEWS = 3 to 4, but ambulance conveyance time and time to medical review were comparable with patients with NEWS = 0 to 2. CONCLUSION: This study has demonstrated that higher NEWS values calculated at GP referral into hospital are associated with a faster medical review and poorer clinical outcomes.

Dose exposure of Bisphenol- A on female Wistar rats fertility.

Background 2, 2-Bis (4-hydroxyphenyl propane [bisphenol A (BPA)] is one of the major environmental pollutants and has the adverse effects on human health. BPA mimics the structure of estrogen and binds to estrogen receptors and alters the secretion of the hormone. It is ingested in humans through the regular use of plastic containers, bottles and food cans. Materials and methods Female Wistar rats were exposed orally to 5, 50, 300, 600 and 800 mg BPA/kg body weight (bd. wt.)/week mixed in olive oil and administered every 168 h for 3 months continuing through the mating, gestation and lactation and its effects on fertility, reproductive organ weight and hormones [LH (luteinizing hormone), FSH (follicle stimulating hormone), estradiol (E2), progesterone (PROG) and PRL (prolactin)] were evaluated. Results The findings revealed that females exposed to BPA exhibited a decrease in female fertility rate and weight of reproductive organs (ovary and uterus) with significant decreased levels of LH, FSH, E2, PROG and PRL in the non-pregnancy phase whereas in cesarean and post-term females, no significance difference was found in fertility rate, reproductive organ weight and hormonal levels. Conclusions These data indicate an increased sensitivity to BPA needs careful evaluation of the current levels of exposure.

Loss of GRHL3 leads to TARC/CCL17-mediated keratinocyte proliferation in the epidermis.

Identifying soluble factors that influence epidermal integrity is critical for the development of preventative and therapeutic strategies for disorders such as ichthyosis, psoriasis, dermatitis and epidermal cancers. The transcription factor Grainyhead-like 3 (GRHL3) is essential for maintaining barrier integrity and preventing development of cutaneous squamous cell carcinoma (SCC); however, how loss of this factor, which in the skin is expressed exclusively within suprabasal epidermal layers triggers proliferation of basal keratinocytes, had thus far remained elusive. Our present study identifies thymus and activation-regulated chemokine (TARC) as a novel soluble chemokine mediator of keratinocyte proliferation following loss of GRHL3. Knockdown of GRHL3 in human keratinocytes showed that of 42 cytokines examined, TARC was the only significantly upregulated chemokine. Mouse skin lacking Grhl3 presented an inflammatory response with hallmarks of TARC activation, including heightened induction of blood clotting, increased infiltration of mast cells and pro-inflammatory T cells, increased expression of the pro-proliferative/pro-inflammatory markers CD3 and pSTAT3, and significantly elevated basal keratinocyte proliferation. Treatment of skin cultures lacking Grhl3 with the broad spectrum anti-inflammatory 5-aminosalicylic acid (5ASA) partially restored epidermal differentiation, indicating that abnormal keratinocyte proliferation/differentiation balance is a key driver of barrier dysfunction following loss of Grhl3, and providing a promising therapeutic avenue in the treatment of GRHL3-mediated epidermal disorders.

Alteration in apoptotic rate of testicular cells and sperms following administration of Bisphenol A (BPA) in Wistar albino rats.

The aim of the study was to evaluate the effect of Bisphenol A [BPA] widely used as a plasticizer in the formation of polycarbonate plastics and epoxy resins, exposure causing alteration in apoptosis rate, and protective effect of Vitamin E when supplemented with BPA orally. Adult male Wistar albino rats aged 3 months were randomly divided into seven groups: control (olive oil treated) BPA-treated (dose 5, 50,100 µg/100gmBW) and Vitamin E intervention group (dose 5, 50, 100 µg/100gmBW BPA+ Vitamin E dose 4 mg/100gmBW). Animals were sacrificed 3 months later, and blood and tissue samples were collected. Apoptotic changes were analyzed in epididymal spermatozoa and testis tissue by binding of annexin V apoptotic biomarker. A significant decline in the weight of testis, testosterone level, and sperm count was observed. Histopathological and apoptotic changes were observed in testis tissue. In epididymal sperms, the early apoptotic cells were observed by staining of annexin V-conjugated FITC and PI green fluorescence in spermatozoa head which indicated the damage of membrane and late apoptotic cells. These changes reduced significantly in Vitamin E-treated groups though were not found to be comparable to control animals. All these changes were attributed to disrupted spermatogenesis that would interfere with sperm formation. Thus, the study infers that BPA affects the apoptosis process in the testis and epididymal sperm that would interfere with its function and contribute to infertility, whereas Vitamin E-supplemented dose has a protective effect towards these changes, indicating its role in improving male fertility.

Stage-dependent therapeutic efficacy in PI3K/mTOR-driven squamous cell carcinoma of the skin.

Cutaneous squamous cell carcinoma (SCC) is a recurrent cancer that is prevalent in predisposed subjects such as immunosuppressed patients and patients being treated for other malignancies. Model systems to trial therapies at different stages of SCC development are lacking, therefore precluding efficient therapeutic interventions. Here, we have disrupted the expression of the tumor suppressor GRHL3 to induce loss of PTEN and activation of the PI3K/mTOR signaling pathway in mice and human skin, promoting aggressive SCC development. We then examined the potential for targeting PI3K/mTOR and an oncogenic driver miR-21, alone and in combination, for the prevention and treatment of SCC during the initiation, promotion/progression and establishment stages. Treatment with PI3K/mTOR inhibitors completely prevented tumor initiation, and these inhibitors significantly delayed the course of papilloma progression to malignancy. However, established SCC did not undergo any growth regression, indicating that this therapy is ineffective in established cancers. Mechanistically, the resistant SCCs displayed increased miR-21 expression in mice and humans where antagonists of miR-21 rescued expression levels of GRHL3/PTEN, but the combination of miR-21 antagonism with PI3K/mTOR inhibition resulted in acquired SCC resistance in part via c-MYC and OCT-4 upregulation. In conclusion, our data provide molecular evidence for the efficacy of targeting oncogenic drivers of SCC during the initiation and promotion stages and indicate that combination therapy may induce an aggressive phenotype when applied in the establishment stage.

Prevention of acute kidney injury through accurate fluid balance monitoring.

Acute kidney injury (AKI) is associated with increased patient morbidity, mortality and an extended hospital stay. The financial burden to the National Health Service is high and it can affect up to one in five inpatients. Optimal fluid balance management is essential for the prevention of AKI and this can be particularly challenging in the patient with trauma. Our aim was to reduce the rate of AKI in patients with traumatic injuries in the regional trauma centre. We developed new fluid balance charts and documented how well these were completed. The number of AKI alerts per month was calculated on our pathology system. Scenario training was delivered at handover meetings and an e-learning tool was designed at three levels: healthcare assistants; nurses; and medical staff, dietetics and pharmacists. Educational posters were placed in clinical areas and patient information leaflets produced. Junior doctors were regularly informed of AKI rates on the ward. The number of AKI alerts on our trauma ward declined from 50 in January 2016 to 19 in November 2016. The mean monthly rate of AKI fell 33% following the invention (P<0.001). Completion of fluid balance charts improved; 6 hourly urine output documentation increased from 36% to 68% and running 1 hourly output increased from 80% to 96%. Calculation of total daily fluid balance rose from 12% to 72%, before decreasing to 32%. This highlighted the need for continued encouragement. Improved fluid balance monitoring led to a reduction in the prevalence of AKI in patients admitted to this trauma centre.

Two Ancient Gene Families Are Critical for Maintenance of the Mammalian Skin Barrier in Postnatal Life.

The skin barrier is critical for mammalian survival in the terrestrial environment, affording protection against fluid loss, microbes, toxins, and UV exposure. Many genes indispensable for barrier formation in the embryo have been identified, but loss of these genes in adult mice does not induce barrier regression. We describe a complex regulatory network centered on two ancient gene families, the grainyhead-like (Grhl) transcription factors and the protein cross-linking enzymes (tissue transglutaminases [Tgms]), which are essential for skin permeability barrier maintenance in adult mice. Embryonic deletion of Grhl3 induces loss of Tgm1 expression, which disrupts the cornified envelope, thus preventing permeability barrier formation leading to neonatal death. However, gene deletion of Grhl3 in adult mice does not disrupt the preformed barrier, with cornified envelope integrity maintained by Grhl1 and Tgm5, which are up-regulated in response to postnatal loss of Grhl3. Concomitant deletion of both Grhl factors in adult mice induced loss of Tgm1 and Tgm5 expression, perturbation of the cornified envelope, and complete permeability barrier regression that was incompatible with life. These findings define the molecular safeguards for barrier function that accompany the transition from intrauterine to terrestrial life.

Identification of a Novel Proto-oncogenic Network in Head and Neck Squamous Cell Carcinoma.

BACKGROUND: The developmental transcription factor Grainyhead-like 3 (GRHL3) plays a critical tumor suppressor role in the mammalian epidermis through direct regulation of PTEN and the PI3K/AKT/mTOR signaling pathway. GRHL3 is highly expressed in all tissues derived from the surface ectoderm, including the oral cavity, raising a question about its potential role in suppression of head and neck squamous cell carcinoma (HNSCC). METHODS: We explored the tumor suppressor role of Grhl3 in HNSCC using a conditional knockout (Grhl3 (∆/-) /K14Cre (+) ) mouse line (n = 26) exposed to an oral chemical carcinogen. We defined the proto-oncogenic pathway activated in the HNSCC derived from these mice and assessed it in primary human HNSCC samples, normal oral epithelial cell lines carrying shRNA to GRHL3, and human HNSCC cell lines. Data were analyzed with two-sided chi square and Student's t tests. RESULTS: Deletion of Grhl3 in oral epithelium in mice did not perturb PTEN/PI3K/AKT/mTOR signaling, but instead evoked loss of GSK3B expression, resulting in stabilization and accumulation of c-MYC and aggressive HNSCC. This molecular signature was also evident in a subset of primary human HNSCC and HNSCC cell lines. Loss of Gsk3b in mice, independent of Grhl3, predisposed to chemical-induced HNSCC. Restoration of GSK3B expression blocked proliferation of normal oral epithelial cell lines carrying shRNA to GRHL3 (cell no., Day 8: Scramble ctl, 616±21.8 x 10(3) vs GRHL3-kd, 1194±44 X 10(3), P < .001; GRHL3-kd vs GRHL3-kd + GSK3B, 800±98.84 X 10(3), P = .003) and human HNSCC cells. CONCLUSIONS: We defined a novel molecular signature in mammalian HNSCC, suggesting new treatment strategies targeting the GRHL3/GSK3B/c-MYC proto-oncogenic network.

Bisphenol A: a threat to human health?

All of us now carry in our bodily tissues a virtual stew of heavy metals and hundreds of synthetic chemicals: persistent ones, which can have a "half-life" in the body of several years; and nonpersistent compounds, which may pass through the body in a matter of hours. Bisphenol A (BPA) is a nonpersistent compound that can alter the reproductive system of laboratory animals even at extremely low exposure levels. This is relevant because BPA is chronically present in our environment with the potential for constant exposure, making it functionally equivalent to a persistent compound. In this review the authors emphasize particular outcomes that occur in response to the relevant dose of BPA exposure that causes developmental effects on reproductive systems, brain and metabolic processes, and the male germ line. At a specific dose level, BPA exposure also shows oxidative toxicity and carcinogenic effects.

Poly(3-methylpyrrole): vibrational dynamics, phonon dispersion and heat capacity.

Normal modes of vibration and their dispersions in poly(3-methylpyrrole) (P3MPy) based on the Urey-Bradley force field are reported. It provides a detailed interpretation of previously reported I.R. spectra. Characteristic features of dispersion curves, such as regions of high density-of-states, repulsion, and character mixing of dispersive modes are discussed. Predictive values of heat capacity as a function of temperature are calculated from dispersion curves via density-of-states.

Phonon dispersion and heat capacity in polyfuran.

A study of the normal modes of vibration and their dispersion in polyfuran (Pfu) based on the Urey-Bradley force field is reported. It provides a detailed interpretation of IR and Raman spectra. Characteristic features of dispersion curves such as regions of high density-of-states, repulsion and character mixing of dispersive modes are discussed. Predictive values of heat capacity as a function of temperature are calculated.

Midbrain-hindbrain boundary patterning and morphogenesis are regulated by diverse grainy head-like 2-dependent pathways.

The isthmic organiser located at the midbrain-hindbrain boundary (MHB) is the crucial developmental signalling centre responsible for patterning mesencephalic and metencephalic regions of the vertebrate brain. Formation and maintenance of the MHB is characterised by a hierarchical program of gene expression initiated by fibroblast growth factor 8 (Fgf8), coupled with cellular morphogenesis, culminating in the formation of the tectal-isthmo-cerebellar structures. Here, we show in zebrafish that one orthologue of the transcription factor grainy head-like 2 (Grhl2), zebrafish grhl2b plays a central role in both MHB maintenance and folding by regulating two distinct, non-linear pathways. Loss of grhl2b expression induces neural apoptosis and extinction of MHB markers, which are rescued by re-expression of engrailed 2a (eng2a), an evolutionarily conserved target of the Grhl family. Co-injection of sub-phenotypic doses of grhl2b and eng2a morpholinos reproduces the apoptosis and MHB marker loss, but fails to substantially disrupt formation of the isthmic constriction. By contrast, a novel direct grhl2b target, spec1, identified by phylogenetic analysis and confirmed by ChIP, functionally cooperates with grhl2b to induce MHB morphogenesis, but plays no role in apoptosis or maintenance of MHB markers. Collectively, these data show that MHB maintenance and morphogenesis are dissociable events regulated by grhl2b through diverse transcriptional targets.