Global down-regulation of HOX gene expression in PML-RARalpha + acute promyelocytic leukemia identified by small-array real-time PCR

Acute promyelocytic leukemia (APL) is associated with a reciprocal and balanced translocation involving the retinoic acid receptor-alpha (RARalpha). All-trans retinoic acid (ATRA) is used to treat APL and is a potent morphogen that regulates HOX gene expression in embryogenesis and organogenesis. HOX genes are also involved in hematopoiesis and leukemogenesis. Thirty-nine mammalian HOX genes have been identified and classified into 13 paralogous groups clustered on 4 chromosomes. They encode a complex network of transcription regulatory proteins whose precise targets remain poorly understood. The overall function of the network appears to be dictated by gene dosage. To investigate the mechanisms involved in HOX gene regulation in hematopoiesis and leukemogenesis by precise measurement of individual HOX genes, a small-array real-time HOX (SMART-HOX) quantitative polymerase chain reaction (PCR) platform was designed and validated. Application of SMART-HOX to 16 APL bone marrow samples revealed a global down-regulation of 26 HOX genes compared with normal controls. HOX gene expression was also altered during differentiation induced by ATRA in the PML-RARalpha(+) NB4 cell line. PML-RARalpha fusion proteins have been reported to act as part of a repressor complex during myeloid cell differentiation, and a model linking HOX gene expression to this PML-RARalpha repressor complex is now proposed.

HOXA/PBX3 knockdown impairs growth and sensitizes cytogenetically normal acute myeloid leukemia cells to chemotherapy

The cytogenetically normal subtype of acute myeloid leukemia (CN-AML) is associated with Intermediate risk which complicates therapeutic options. Lower overall HOX/TALE expression appears to correlate with more favorable prognosis/better response to treatment in some leukemias and solid cancer. The functional significance of the associated gene expression and response to chemotherapy is not known. Three independent microarray datasets obtained from large patient cohorts along with quantitative PCR validation was used to identify a four gene HOXA/TALE signature capable of prognostic stratification. Biochemical analysis was used to identify interactions between the four encoded proteins and targeted knockdown used to examine the functional importance of sustained expression of the signature in leukemia maintenance and response to chemotherapy. An eleven HOXA/TALE code identified in an Intermediate risk (n=315) compared to a Favourable group of patients (n=105) was reduced to a four gene signature of HOXA6, HOXA9, PBX3 and MEIS1 by iterative analysis of independent platforms. This signature maintained the Favorable/Intermediate risk partition and where applicable, correlated with overall survival in CN-AML. We further show that cell growth and function is dependent on maintained levels of these core genes and that direct targeting of HOXA/PBX3 sensitizes CN-AML cells to standard chemotherapy. Together the data support a key role for HOXA/TALE in CN-AML and demonstrate that targeting of clinically significant HOXA/PBX3 elements may provide therapeutic benefit to these patients.

Hirschsprung's disease prevalence in Europe: A register based study

Background: Hirschsprung's disease is a congenital gut motility disorder, characterised by the absence of the enteric ganglion cells along the distal gut. The aim of this study was to describe the epidemiology of Hirschsprung's disease, including additional congenital anomalies, total prevalence, trends, and association with maternal age. Methods: Cases of Hirschsprung's disease delivered during 1980 to 2009 notified to 31 European Surveillance of Congenital Anomaly registers formed the population-based case-series. Prevalence rates and 95% confidence intervals were calculated as the number of cases per 10,000 births. Multilevel Poisson regression was performed to investigate trends in prevalence, geographical variation and the association with maternal age. Results: There were 1,322 cases of Hirschsprung's disease among 12,146,210 births. The total prevalence was 1.09 (95% confidence interval, 1.03–1.15) per 10,000 births and there was a small but significant increase in prevalence over time (relative risk = 1.01; 95% credible interval, 1.00–1.02; p = 0.004). There was evidence of geographical heterogeneity in prevalence (p < 0.001). Excluding 146 (11.0%) cases with chromosomal anomalies or genetic syndromes, there were 1,176 cases (prevalence = 0.97; 95% confidence interval, 0.91–1.03 per 10,000 births), of which 137 (11.6%) had major structural anomalies. There was no evidence of a significant increased risk of Hirschsprung's disease in cases born to women aged ≥35 years compared with those aged 25 to 29 (relative risk = 1.09; 95% credible interval, 0.91–1.31; p = 0.355). Conclusion: This large population-based study found evidence of a small increasing trend in Hirschsprung's disease and differences in prevalence by geographic location. There was also no evidence of an association with maternal age.

Pathways Project Final Report Volume 1: Field Investigation and Catchment Conceptual Models

viii
Executive Summary
The Pathways Project field studies were targeted at improving the understanding of contaminant transport along different hydrological pathways in Irish catchments, including their associated impacts on water quality and river ecology. The contaminants of interest were phosphorus, nitrogen and sediment. The working Pathways conceptual model included overland flow, interflow, shallow groundwater flow, and deep groundwater flow. This research informed the development of a set of Catchment Management Support Tools (CMSTs) comprising an Exploratory Tool, Catchment Characterization Tool (CCT) and Catchment Modelling Tool (CMT) as outlined in Pathways Project Final Reports Volumes 3 and 4.
In order to inform the CMST, four suitable study catchments were selected following an extensive selection process, namely the Mattock catchment, Co. Louth/Meath; Gortinlieve catchment, Co. Donegal; Nuenna catchment, Co. Kilkenny and the Glen Burn catchment, Co. Down. The Nuenna catchment is well drained as it is underlain by a regionally important karstified limestone aquifer with permeable limestone tills and gravels, while the other three catchments are underlain by poorly productive aquifers and low permeability clayey tills, and are poorly drained.
All catchments were instrumented, and groundwater, surface and near-surface water and aquatic ecology were monitored for a period of two years. Intensive water quality sampling during rainfall events was used to investigate the pathways delivering nutrients. The proportion of flow along each pathway was determined using chemical and physical hydrograph separation techniques, supported by numerical modelling.
The outcome of the field studies broadly supported the use of the initial four-pathway conceptual model used in the Pathways CMT (time-variant model). The artificial drainage network was found to be a significant contributing pathway in the poorly drained catchments, at low flows and during peak flows in wet antecedent conditions. The transition zone (TZ), i.e. the broken up weathered zone at the top of the bedrock, was also found to be an important pathway. It was observed to operate in two contrasting hydrogeological scenarios: in groundwater discharge zones the TZ can be regarded as being part of the shallow groundwater pathway, whereas in groundwater recharge zones it behaves more like interflow.
In the catchments overlying poorly productive aquifers, only a few fractures or fracture zones were found to be hydraulically active and the TZ, where present, was the main groundwater pathway. In the karstified Nuenna catchment, the springs, which are linked to conduits as well as to a diffuse fracture network, delivered the majority of the flow. These findings confirm the two-component groundwater contribution from bedrock but suggest that the size and nature of the hydraulically active fractures and the nature of the TZ are the dominant factors at the scale of a stream flow event.
Diffuse sources of nitrate were found to be typically delivered via the subsurface pathways, especially in the TZ and land drains in the poorly productive aquifer catchments, and via the bedrock groundwater in the Nuenna. Phosphorus was primarily transported via overland flow in both particulate and soluble forms. Where preferential flow paths existed in the soil and subsoil, soluble P, and to a lesser extent particulate P, were also transported via the TZ and in drains and ditches. Arable land was found to be the most important land use for
ix
the delivery of sediment, although channel bank and in-stream sources were the most significant in the Glen Burn catchment. Overland flow was found to be the predominant transport sediment pathway in the poorly productive catchments. These findings informed the development of the transport and attenuation equations used in the CCT and CMT. From an assessment of the relationship between physico-chemical and biological conditions, it is suggested that in the Nuenna, Glen Burn and Gortinlieve catchments, a relationship may exist between biological water quality and nitrogen concentrations, as well as with P. In the Nuenna, there was also a relationship between macroinvertebrate status and alkalinity.
Further research is recommended on the transport and delivery of phosphorus in groundwater, the transport and attenuation dynamics in the TZ in different hydrogeological settings and the relationship between macroinvertebrates and co-limiting factors. High resolution temporal and spatial sampling was found to be important for constraining the conceptual understanding of nutrient and sediment dynamics which should also be considered in future studies.

PAlliative Care in chronic Kidney diSease: the PACKS study—quality of life, decision making, costs and impact on carers in people managed without dialysis

BACKGROUND: The number of patients with advanced chronic kidney disease opting for conservative management rather than dialysis is unknown but likely to be growing as increasingly frail patients with advanced renal disease present to renal services. Conservative kidney management includes ongoing medical input and support from a multidisciplinary team. There is limited evidence concerning patient and carer experience of this choice. This study will explore quality of life, symptoms, cognition, frailty, performance decision making, costs and impact on carers in people with advanced chronic kidney disease managed without dialysis and is funded by the National Institute of Health Research in the UK.

METHODS: In this prospective, multicentre, longitudinal study, patients will be recruited in the UK, by renal research nurses, once they have made the decision not to embark on dialysis. Carers will be asked to 'opt-in' with consent from patients. The approach includes longitudinal quantitative surveys of quality of life, symptoms, decision making and costs for patients and quality of life and costs for carers, with questionnaires administered quarterly over 12 months. Additionally, the decision making process will be explored via qualitative interviews with renal physicians/clinical nurse specialists.

DISCUSSION: The study is designed to capture patient and carer profiles when conservative kidney management is implemented, and understand trajectories of care-receiving and care-giving with the aim of optimising palliative care for this population. It will explore the interactions that lead to clinical care decisions and the impact of these decisions on informal carers with the intention of improving clinical outcomes for patients and the experiences of care givers.

John Thompson: Seeing through China

In 1848, Karl Marx predicted that a flow of cheap commodities would be the heavy artillery which would batter down all Chinese walls and open up the country to the west (Marx, 1978, p. 477). The Scottish photographer John Thomson (1837-1921) was both chronicler of and participant in the early moments of this process. Thomson was a commercial photographer who first arrived in the Far East in 1862. He earned the moniker of 'China' in a decade-long stay during which he photographed what he considered to be the key aspects of its culture and landscape. In this body of work, Illustrations of China and its People (first published in 1874) is perhaps the most comprehensive. It explores, through two hundred photographs and accompanying texts, a series of phenomena from the macro-scale of landscape, infrastructure and industry to the smaller scales of streetscapes, domestic spaces, individual portraits, and other details of everyday life. Despite his own description of the volumes as encyclopedic, Illustrations is geographically quite limited. Thomson's explorations into the hinterland proceed up the country’s principal rivers from those coastal ports which had already been wrested into western hands during the Opium Wars (of the 1840s) and subsequently opened up to trade. This is perhaps one of the reasons why Illustrations has been described as an explicitly colonial text, a guide-book for the prospective settler whose content offered the strategic knowledge of land, culture and natural resources necessary if the territorial advantages of the coastal periphery were to extended to the interior (Jeffrey, 1981, p. 64). It can also be argued, however, that Thomson’s volume offered justification for a potential colonial presence. Faced with a civilization whose history was as sophisticated as the west, it depicts a culture that is static and moribund, its addiction to traditional values an impediment to progress. While this is perhaps most explicit in the texts of Illustrations of China, it can also be seen in the images whose uniform chemical rendering also serves to make an essentially diverse culture seem homogenous. Yet it is these images that distinguish Illustrations from previous attempts to collate China’s culture and landscape. Here, the mechanical precision of his camera captures a reality that often subverts the colonial narrative, confounding stereotypes as Thomson’s mass-produced images allow another China to emerge.

Introduction to the Transforming Dementia Care in Hospitals Series

A short series of articles in Nursing Older People, starting in September, presents case study examples of the positive work achieved by trusts that participated in the RCN’s development programme to improve dementia care in acute hospitals. This introductory article reports on the independent evaluation of the programme. The programme included a launch event, development days, site visits, ongoing support by the RCN lead and carer representatives and a conference to showcase service improvements. The evaluation drew on data from a survey, the site visits, trust action plans and a range of self-assessment tools for dementia care. The findings highlight substantial progress towards programme objectives and learning outcomes and suggest that the programme provided the focus, impetus and structure for trusts to make sustainable changes. It also equipped participants with the strategies and confidence to change practice. Recommendations are made for taking the programme forward.

Understanding the Needs of People with Dementia and Family Carers

This is the first in a short series that presents case study examples of the positive work achieved by trusts who participated in the Royal College of Nursing's development programme to improve dementia care in acute hospitals. When a person with dementia is in hospital, poor understanding of individual needs and preferences can contribute to a lack of person-centred care. Similarly, the needs of family carers can often be overlooked and staff do not always appreciate these needs at such a stressful time. This article illustrates how three NHS trusts have addressed these issues. To help staff get to know patients with dementia, Salford Royal NHS Foundation Trust has implemented a patient passport. Similarly, The Shrewsbury and Telford Hospital NHS Trust has implemented a carer passport that overcomes the restrictions imposed by hospital visiting hours. Royal Devon and Exeter NHS Foundation Trust also focused on carers, holding a workshop to elicit feedback on what was important to them. This was a useful means of engaging with carers and helped staff to realise that even simple changes can have a significant effect.