Mild Hypoxia Accelerates Cerebral Cavernous Malformation Disease Through CX3CR1-CX3CL1 Signaling

BACKGROUND

Heterogeneity in the severity of cerebral cavernous malformations (CCMs) disease, including brain bleedings and thrombosis that cause neurological disabilities in patients, suggests that environmental, genetic, or biological factors act as disease modifiers. Still, the underlying mechanisms are not entirely understood. Here, we report that mild hypoxia accelerates CCM disease by promoting angiogenesis, neuroinflammation, and vascular thrombosis in the brains of CCM mouse models.

METHODS

We used genetic studies, RNA sequencing, spatial transcriptome, micro-computed tomography, fluorescence-activated cell sorting, multiplex immunofluorescence, coculture studies, and imaging techniques to reveal that sustained mild hypoxia via the CX3CR1-CX3CL1 signaling pathway influences cell-specific neuroinflammatory interactions, contributing to heterogeneity in CCM severity.

RESULTS

Histological and expression profiles of CCM neurovascular lesions (Slco1c1-iCreERT2;Pdcd10fl/fl; Pdcd10BECKO) in male and female mice found that sustained mild hypoxia (12% O2, 7 days) accelerates CCM disease. Our findings indicate that a small reduction in oxygen levels can significantly increase angiogenesis, neuroinflammation, and thrombosis in CCM disease by enhancing the interactions between endothelium, astrocytes, and immune cells. Our study indicates that the interactions between CX3CR1 and CX3CL1 are crucial in the maturation of CCM lesions and propensity to CCM immunothrombosis. In particular, this pathway regulates the recruitment and activation of microglia and other immune cells in CCM lesions, which leads to lesion growth and thrombosis. We found that human CX3CR1 variants are linked to lower lesion burden in familial CCMs, proving it is a genetic modifier in human disease and a potential marker for aggressiveness. Moreover, monoclonal blocking antibody against CX3CL1 or reducing 1 copy of the Cx3cr1 gene significantly reduces hypoxia-induced CCM immunothrombosis.

CONCLUSIONS

Our study reveals that interactions between CX3CR1 and CX3CL1 can modify CCM neuropathology when lesions are accelerated by environmental hypoxia. Moreover, a hypoxic environment or hypoxia signaling caused by CCM disease influences the balance between neuroinflammation and neuroprotection mediated by CX3CR1-CX3CL1 signaling. These results establish CX3CR1 as a genetic marker for patient stratification and a potential predictor of CCM aggressiveness.

Recurrence of Drug-Induced Lupus Secondary to Vedolizumab Use in a Patient With Crohn's Disease

Drug-induced lupus is an autoimmune phenomenon characterized by the development of systemic lupus erythematosus-like clinical features after drug exposure. The entity is a clinical diagnosis. Evaluation consists of recognizing systemic lupus erythematosus-like features, identifying an appropriate causative agent, observing elevations of characteristic autoantibodies, and obtaining positive response with drug discontinuation. Vedolizumab is an anti-α4β7 antibody used in the treatment of ulcerative colitis and Crohn's disease. We report a novel case of drug-induced lupus recurrence secondary to vedolizumab use in a patient with Crohn's disease, emphasizing diagnostic evaluation, and provide a brief review of the published literature.

Long-Term Effectiveness of a Nonsurgical BPH Treatment System in Prostate Radiation Patients with Medication-Refractory Lower Urinary Tract Symptoms

PURPOSE/OBJECTIVE(S)

To evaluate the long-term outcomes and toxicity of a nonsurgical prostatic urethral lift system in patients with prior prostate cancer radiation therapy (RT).

MATERIALS/METHODS

From 2018 to 2020, nineteen patients with a history of prior prostate RT underwent a nonsurgical prostatic urethral lift (PUL) procedure for lower urinary track symptoms (LUTS) refractory to alpha blocker medications. Prostate cancer RT was completed a median of 17.8 months (IQR 13.4-27.4) prior to PUL procedure. All patients were assessed with IPSS/quality of life (QOL) scores and urinary post void residual (PVR) ultrasound before and after PUL. Patients were also assessed for ability to discontinue alpha blockade medications for their LUTS and any post PUL toxicity based on CTCAE v5.0 criteria.

RESULTS

All patients underwent successful placement of the PUL implants. Median pre-PUL IPSS score was 20 (IOR 17.5-22.5) and the median prostate volume was 41cc (IQR 33-49). Median follow up was 22 months (IQR 5-30). The average improvement in IPSS score was 8.5 points (IRQ 5.5-11) at 3 months and 7.5 points (IQR 6-10) at last follow-up. Two patients (10%) initially had improvement in IPSS score at 3 months with subsequent significant increase in IPSS (>5 points) at last follow-up. Overall, there was minimal change in reported QOL scores (median 0, IQR 0-1.75). The average reduction in PVR was 90cc. The percentage of patients able to discontinue alpha blockade at last follow-up was 68%. There was no grade 3 or higher GU toxicity in either group.

CONCLUSION

Use of a nonsurgical prostatic urethral lift system in patients with prior prostate RT refractory to alpha blocker medications results in significant long-term improvement of LUTS after radiation therapy for the majority of patients with minimal toxicity.

Initial Clinical Outcomes of a Phase II Trial of Focal Salvage LDR Brachytherapy for Local Recurrence of Prostate Cancer after External Beam Radiation Therapy

PURPOSE/OBJECTIVE(S)

To evaluate the clinical outcomes of focal salvage low dose rate brachytherapy (FSB) for biopsy proven local recurrence of prostate cancer after definitive external beam radiation therapy (EBRT).

MATERIALS/METHODS

Patients with a Phoenix definition PSA recurrence (nadir + 2.0ng/dL) after definitive EBRT for localized prostate cancer and a negative metastatic work up were enrolled in a Phase II clinical trial. Patients first underwent MR-guided transperineal mapping biopsy of the prostate using a template grid. Patients with a pathologically confirmed recurrence underwent FSB using iodine-125 seeds to a prescription dose of 145 Gy. The brachytherapy planning target volume (PTV) was defined by the positions of the pathologically negative core biopsies adjacent to the positive core biopsies as recorded on the template grid during the biopsy procedure. An intraoperative treatment plan was then developed to cover the PTV with the 145 Gy isodose line. Follow up included assessment of genitourinary (GU) and gastrointestinal (GI) toxicities using Common Terminology Criteria for Adverse Events version 4.03 (CTCAEv4.03), patient reported outcomes using the International Prostate Symptom Score (IPSS) and Expanded Prostate Cancer Index-26 (EPIC-26) forms, and serial PSA blood draws.

RESULTS

Ten patients underwent FSB. The median prior EBRT dose was 7805 cGy (interquartile range IQR 7560-7920) and the median time from completion of EBRT to FSB was 81 months (IQR 68-134). The median PSA prior to FSB was 3.2 ng/dL (IQR 2.3 - 4.5). The median follow up after FSB was 32 months (IQR 18-57). Eight patients were free of Phoenix definition PSA failure at last follow up. Of the two patients who experienced a PSA failure, one developed distant metastases 5 months after FSB and the other a biopsy proven seminal vesicle recurrence 3 years after FSB. The median change in post FSB IPSS score compared to the pre-FSB IPSS score was an increase of 1.5 (IQR -1.5 to 8) at 3 month follow up and an increase of 3.5 (IQR 0.5 to 5.5) at last follow up (≥1 year). The median change in post FSB EPIC-26 urinary domain score compared to the pre-FSB score was -1 (IQR -26 to +14.5) at 3 month follow up and +2 (IQR -12.5 to +14.5) at last follow up (≥1 year). The median change in post FSB EPIC-26 bowel domain score compared to the pre-FSB score was -2 (IQR -9.5 to 0.0) at 3 month follow up and 0 (IQR -6.0 to +3.0) at last follow up (≥1 year). No patients experienced post FSB Grade 3 or higher GU or GI toxicities.

CONCLUSION

High dose FSB for a local recurrence of prostate cancer after EBRT can be delivered with good biochemical control and a favorable toxicity profile. Further clinical trial enrollment and longer follow up will be needed to better assess long term outcomes.

Discharged on Enteral Nutrition: What Now? The Poor State of Outpatient Support for Patients on Enteral Nutrition Support

PURPOSE OF REVIEW

While the use of enteral nutrition (EN) has increased, and more medical centers have developed inpatient programs to address the unique needs of these patients, our collective experience at a few large institutions indicates that there is very little systemic support for patients after discharge. Here, we discuss what we have observed to be some of the barriers to providing outpatient follow up care, summarize the impact we have seen on patients, and propose some possible solutions.

RECENT FINDINGS

We have observed and identified some of the root causes to include financial barriers; uncoordinated care transitions; high complexity of care, including medication management; and diffuse leadership to a multidisciplinary problem. Systematic support for outpatient care for patients discharged on enteral nutrition is rare and limited, due to many root causes. There are a few tools and tips that we have summarized here for individual providers, and a few promising methods in development, but a systematic approach is in great need.

Wernicke's Encephalopathy in Type 2 Achalasia: Case Report and Literature Review

Achalasia is primarily a smooth muscle motility disorder of the esophagus driven by aberrant peristalsis and failure of sphincter relaxation. Notably, achalasia is a heterogeneous disease with primarily 3 possible pattern subtypes. According to the review of current cases and literature regarding achalasia, patients primarily present with dysphagia, usually to solids and, if progressed, to solids and liquids. Rarely, untreated achalasia may result in thiamine deficiency and present as Wernicke-Korsakoff syndrome (WKS). This acute neurologic condition primarily affects the central and peripheral nervous system and is known by the triad of ataxia, ophthalmoplegia, and confusion. Individuals who present with WKS typically have a notable history of chronic alcohol abuse with decreased thiamine intake and metabolism. Although less common, individuals with WKS may have a pertinent history of starvation, anorexia nervosa, and malnutrition. This case highlights a unique presentation of Wernicke's encephalopathy (WE) in a 30-year-old woman with severe type II achalasia complicated by a 60-pound weight loss in a span of 2 months. According to our literature review, there have only been 2 previously reported cases of severe achalasia leading to the development of WE. Considering the limited number of case reports available, WE must be in the differentials in patients with underlying achalasia, and our case report highlights this unusual presentation with corresponding brain imaging and manometry testing.

Failure to thrive: A severe manifestation of interleukin 10 receptor A mutation in adult inflammatory bowel disease

BACKGROUND

Very early-onset inflammatory bowel disease (VEO-IBD) secondary to interleukin 10 receptor A (IL-10RA) mutations has aggressive disease courses with increased nutrition needs compared with those in other monogenic forms of IBD.

PRESENTATION

A male patient was hospitalized when he was 18 days old for bloody diarrhea, which was diagnosed as Crohn's disease at 6 months old. He showed failure to thrive (FTT) and worsening inflammation while receiving enteral nutrition (EN) and standard IBD treatment. He was hospitalized in 2016, at 28 years old, for a Crohn's flare when sequencing confirmed a heterozygous mutation in IL10-RA. His weight and plasma micronutrient levels improved when he transitioned to parenteral nutrition (PN). He was initiated on anakinra while awaiting hematopoietic stem cell transplant, with substantial decrease in inflammation. He was able to gain weight, initiate an oral diet, and decrease his PN requirement.

CONCLUSION

Our patient experienced progressive FTT while receiving EN. VEO-IBD incidence is rising, and its diagnosis is often delayed. Therefore, prompt recognition with treatment initiation is essential to improving nutrition outcomes in this patient population. Further investigation is warranted to determine whether these patients would benefit from early initiation of PN.

Astrocytes propel neurovascular dysfunction during cerebral cavernous malformation lesion formation

Cerebral cavernous malformations (CCMs) are common neurovascular lesions caused by loss-of-function mutations in 1 of 3 genes, including KRIT1 (CCM1), CCM2, and PDCD10 (CCM3), and generally regarded as an endothelial cell-autonomous disease. Here we reported that proliferative astrocytes played a critical role in CCM pathogenesis by serving as a major source of VEGF during CCM lesion formation. An increase in astrocyte VEGF synthesis is driven by endothelial nitric oxide (NO) generated as a consequence of KLF2- and KLF4-dependent elevation of eNOS in CCM endothelium. The increased brain endothelial production of NO stabilized HIF-1α in astrocytes, resulting in increased VEGF production and expression of a "hypoxic" program under normoxic conditions. We showed that the upregulation of cyclooxygenase-2 (COX-2), a direct HIF-1α target gene and a known component of the hypoxic program, contributed to the development of CCM lesions because the administration of a COX-2 inhibitor significantly prevented the progression of CCM lesions. Thus, non-cell-autonomous crosstalk between CCM endothelium and astrocytes propels vascular lesion development, and components of the hypoxic program represent potential therapeutic targets for CCMs.

Discovery and fine mapping of Rph28: a new gene conferring resistance to Puccinia hordei from wild barley

A new gene Rph28 conferring resistance to barley leaf rust was discovered and fine-mapped on chromosome 5H from wild barley. Leaf rust is a highly destructive disease of barley caused by the fungal pathogen Puccinia hordei. Genetic resistance is considered to be the most effective, economical and eco-friendly approach to minimize losses caused by this disease. A study was undertaken to characterize and fine map a seedling resistance gene identified in a Hordeum vulgare ssp. spontaneum-derived barley line, HEB-04-101, that is broadly effective against a diverse set of Australian P. hordei pathotypes. Genetic analysis of an F₃ population derived from a cross between HEB-04-101 and the H. vulgare cultivar Flagship (seedling susceptible) confirmed the presence of a single dominant gene for resistance in HEB-04-101. Selective genotyping was performed on representative plants from non-segregating homozygous resistant and homozygous susceptible F₃ families using the targeted genotyping-by-sequencing (tGBS) assay. Putatively linked SNP markers with complete fixation were identified on the long arm of chromosome 5H spanning a physical interval between 622 and 669 Mb based on the 2017 Morex barley reference genome assembly. Several CAPS (cleaved amplified polymorphic sequences) markers were designed from the pseudomolecule sequence of the Morex assembly (v1.0 and v2.0), and 16 polymorphic markers were able to delineate the RphHEB locus to a 0.05 cM genetic interval spanning 98.6 kb. Based on its effectiveness and wild origin, RphHEB is distinct from all other designated Rph genes located on chromosome 5H and therefore the new locus symbol Rph28 is recommended for RphHEB in accordance with the rules and cataloguing system of barley gene nomenclature.

Concurrent zinc and vitamin B6 deficiencies in acutely exacerbated inflammatory bowel disease: Case reports

BACKGROUND

Limited evidence is available to describe the prevalence, causes, and consequences of zinc and vitamin B₆ deficiencies in those with acutely exacerbated inflammatory bowel disease (IBD). Zinc is important for immune function and wound healing, and B₆ is needed for metabolic and neurological function. Patients with IBD are at risk of micronutrient deficiencies, particularly during flares.

PRESENTATIONS

The cases of 2 patients with IBD exacerbations were reviewed in which deficiencies of both zinc and vitamin B₆ were identified.

CONCLUSIONS

These cases highlight the need for increased screening for zinc and pyridoxine deficiencies in IBD population, especially during disease exacerbation. Therefore, we recommend a comprehensive nutrition workup with physical exam, diet history, and a complete micronutrient panel while ruling out contributing factors. If patients are susceptible to deficiencies during flares, prophylactic oral zinc and pyridoxine supplementation may be considered, with close monitoring for subsequent iron and copper deficiencies.

Recycling waste plastics in roads: A life-cycle assessment study using primary data

The present study investigates - from an environmental perspective - the processes that lead to the conversion of waste plastics into recycled plastic pellets to be used either as an additive (wet method) or as a replacement of natural aggregate (dry method) in the production of asphalt mixes. Data from recycling facilities in Victoria, Australia, were collected and used as the basis for a comparative life cycle assessment (LCA) study. Analyses were conducted by considering several replacement ratios of virgin material by its recycled counterpart in the so-called wet and dry method. A case study considering the production of recycled-plastic asphalt to be applied in the construction of a typical surface layer of a road in Victoria was evaluated. In general, the results show that recycling plastics as a polymer for bitumen modification and as a synthetic aggregate replacement in asphalt mixes has the potential to be environmentally advantageous compared to their virgin counterpart (i.e. virgin polymers and natural quarry aggregates).

Exposure to perfluorobutane sulfonate and perfluorooctanesulfonic acid disrupts the production of angiogenesis factors and stress responses in human placental syncytiotrophoblast

Poly- and per-fluoroalkyl substances (PFAS) have attracted widespread attention in recent years due to their bioaccumulation, toxicity, and ubiquitous nature. We and others have reported that maternal exposure to PFAS is associated with adverse birth outcomes due to altered placental functions. In this study, we investigated the effects of two major PFAS compounds, perfluorobutane sulfonate (PFBS) and perfluorooctanesulfonic acid (PFOS), on the regulation of the production of angiogenic factors and stress response in placental multinucleated syncytial BeWo cells using qRT-PCR and ELISA. Using this in vitro model, we showed that 1) PFOS or PFBS treatment did not seem to interrupt BeWo cell fusion through syncytins; 2) Exposure to PFOS at 10 μM decreased a potent angiogenic factor PlGF gene expression, which is implicated in preeclampsia; 3) Exposure to either PFOS or PFBS significantly decreased the production of CGB7 and hCG except hCG secretion in PFOS (10 nM) and PFBS (100 nM) treatment groups; 4) Exposure to PFOS (10 μM) increased the gene expression of the stress response molecules CRH while neither PFOS nor PFBS treatment affected a stress mitigation factor 11β-HSD2 expression. Our results demonstrate that exposure to PFOS or PFBS impacts several key pathways involved in placental cell functions. PFOS seems more potent than PFBS. These novel findings provide a potential explanation for the adverse reproductive complications associated with prenatal exposure to PFOS or PFBS, including preeclampsia and contribute to our knowledge of the reproductive toxicity of PFAS, specifically PFOS and PFBS.

Extending the window for thrombolysis for treatment of acute ischaemic stroke during pregnancy: a review

Historically, safety of intravenous recombinant tissue plasminogen activator (IV rt-PA) for the treatment of acute ischaemic stroke (AIS) is limited to use within 4.5 hours from symptom onset. Recent studies suggest the treatment window may be extended when patients have salvageable brain tissue on advanced neuroimaging. This paper describes a novel use of IV rt-PA for treatment of AIS in a pregnant patient within an extended-time window (>4.5 hours, and <9 hours) based on advanced neuroimaging with a favourable outcome. TWEETABLE ABSTRACT: Novel use of IV rt-PA for treatment of AIS in pregnancy within an extended-time window based on advanced imaging with a favourable outcome.

College Students with Inflammatory Bowel Disease: A Qualitative Study of Challenges Associated with College Transition and Self-Care

Introduction: The social impact of inflammatory bowel disease (IBD) on student transition to college is significant, yet poorly understood.

Methods: Two 90-min focus groups (FGs) were conducted with eight student-patients with IBD. Reflective journals were used to corroborate, elaborate, or challenge emergent FG findings.

Results: Six themes emerged: (1) transitioning to college, (2) interacting with physicians, (3) affecting social life, (4) managing the disease by yourself and through support, (5) coping strategies, and (6) facing disease challenges. These themes remained relevant in the reflective writings. Analysis of serial journal entries showed that students' social life and engagement in coursework was affected 66% and 54% of the time, respectively.

Conclusion: Our findings offer guidance for improving students' college success, quality of care, and enhancing physician–patient interactions. Students with IBD have a disability that may not be obvious or visible. They require specific support to help them transition and succeed in college.

Amalgam Strength Resistance to Various Contaminants

Purpose:

The purpose of this study was to quantify the relative strength tolerance of 1-day and 30-day amalgam following saturation contamination with water, saliva, blood, and handpiece lubricant oil during condensation.

Methods and Materials:

Valiant PhD XT amalgam was tested with 300 shear-strength (N=15) and 120 compressive-strength (N=6) specimens, divided into 1-day and 30-day groups, each with control, water, saliva, blood, and lubricant oil contamination samples. Shear specimens were condensed in 4 × 4-mm anchor wells inundated with contaminant fluids before adding a ring mold with 3.5-mm-diameter central hole adapted immediately to the top for continued condensation under contaminant-submerged conditions. Compressive specimen samples were condensed while completely inundated by each contaminant using the American Dental Association Specification No. 1 amalgam mold apparatus. All specimens were tested with the Instron E3000 and E10000 at 0.5 mm/min, with data statistically evaluated using the Kruskal-Wallis procedure with IBM SPSS v25 and Wilcoxon signed ranks test.

Results:

Shear test values (mean±SD) following intracapsular and extracapsular contamination after 30 days under 100% humidity at 37°C were as follows: control, 30.97±5.41 MPa; water, 30.63 ±4.41 MPa; saliva, 27.54 ±4.56 MPa; blood, 24.92 ±3.48 MPa; lubricant oil, 26.06 ±4.06 MPa. Compressive strengths (±SD) of similarly contaminated samples were as follows: control, 447.7 ±76.3 MPa; water, 343.6 ±70.1 MPa; saliva, 307.7 ±24.0 MPa; blood, 281.6 ±35.2 MPa; lubricant oil, 227.8 ±16.9 MPa.

Conclusions:

Saliva, blood, and handpiece oil diminish compressive strength significantly, but water shows no statistically significant effect (p&gt;0.05). Amalgam 30-day shear strength is significantly altered by contamination with water, blood, or handpiece lubricant oil (p&lt;0.05). Remaining amalgam strength after extensive contamination may still be clinically functional relative to a previous ADA recommendation and when compared with resin-based direct restorative materials.

Effective communication of cross-sectional imaging findings in Crohn's disease: comparing conventional EMR reporting to a published scoring system

PURPOSE

The purpose of the article is to compare information regarding small bowel lesions in Crohn's disease (CD) patients communicated by a published scoring system and radiology reports from electronic medical record (EMR) of cross-sectional abdominal imaging.

METHODS

Two gastrointestinal radiologists (reference readers) blinded to EMR reports scored cross-sectional imaging exams using a published scoring system. Investigators compared EMR and radiologist scores based on the mentioned findings and severity documentation of each variable. Statistical analysis involved means and difference in proportions and logistic regression modeling.

RESULTS

Seventy-three CD patients, with average age 40.6 years (± SD 14.4), having 80 small bowel lesions on imaging were included. EMR reports reliably mentioned within the consensus score included thickness (79%, p = 0.000), enhancement (70%, p = 0.000), active inflammation (86%, p = 0.000), perienteric fluid (82%, p = 0.000), and presence of stricture (62%, p = 0.002). Minimal lumen diameter (19%, p = 0.000), comb sign (19%, p = 0.000), lesion length (57%, p = 0.06), and fistula (50%, p = 1.0) were reported less often. There was a strong association between the EMR and scoring scale in noting severity of active inflammation (88%, p = 0.000), perienteric fluid (76%, p = 0.000), and internal fistula (71%, p = 0.000). The proportion matching severity values of comb sign and minimal lumen were 24% and 21%, respectively (p = 0.000). Severity matches for stricture were less likely among the non-GI radiologists (odds ratio = 0.33, SE = 0.168, p = 0.029). The odds of reporting stricture and fistula severity were 3.6 and 5.7, respectively, on MRE.

CONCLUSIONS

Findings and severity of inflammation were communicated consistently. Stricture severity including minimal luminal diameter, was less reliably reported, though its prognostic significance impacts management.

Chronic pancreatitis: review and update of etiology, risk factors, and management

Chronic pancreatitis is a syndrome involving inflammation, fibrosis, and loss of acinar and islet cells which can manifest in unrelenting abdominal pain, malnutrition, and exocrine and endocrine insufficiency. The Toxic-Metabolic, Idiopathic, Genetic, Autoimmune, Recurrent and Severe Acute Pancreatitis, Obstructive (TIGAR-O) classification system categorizes known causes and factors that contribute to chronic pancreatitis. Although determining disease etiology provides a framework for focused and specific treatments, chronic pancreatitis remains a challenging condition to treat owing to the often refractory, centrally mediated pain and the lack of consensus regarding when endoscopic therapy and surgery are indicated. Further complications incurred include both exocrine and endocrine pancreatic insufficiency, pseudocyst formation, bile duct obstruction, and pancreatic cancer. Medical treatment of chronic pancreatitis involves controlling pain, addressing malnutrition via the treatment of vitamin and mineral deficiencies and recognizing the risk of osteoporosis, and administering appropriate pancreatic enzyme supplementation and diabetic agents. Cornerstones in treatment include the recognition of pancreatic exocrine insufficiency and administration of pancreatic enzyme replacement therapy, support to cease smoking and alcohol consumption, consultation with a dietitian, and a systematic follow-up to assure optimal treatment effect.

Thrombospondin1 (TSP1) replacement prevents cerebral cavernous malformations

KRIT1 mutations are the most common cause of cerebral cavernous malformation (CCM). Acute Krit1 gene inactivation in mouse brain microvascular endothelial cells (BMECs) changes expression of multiple genes involved in vascular development. These changes include suppression of Thbs1, which encodes thrombospondin1 (TSP1) and has been ascribed to KLF2- and KLF4-mediated repression of Thbs1 In vitro reconstitution of TSP1 with either full-length TSP1 or 3TSR, an anti-angiogenic TSP1 fragment, suppresses heightened vascular endothelial growth factor signaling and preserves BMEC tight junctions. Furthermore, administration of 3TSR prevents the development of lesions in a mouse model of CCM1 (Krit1ECKO ) as judged by histology and quantitative micro-computed tomography. Conversely, reduced TSP1 expression contributes to the pathogenesis of CCM, because inactivation of one or two copies of Thbs1 exacerbated CCM formation. Thus, loss of Krit1 function disables an angiogenic checkpoint to enable CCM formation. These results suggest that 3TSR, or other angiogenesis inhibitors, can be repurposed for TSP1 replacement therapy for CCMs.

From Brain Disease to Brain Health: Primary Prevention of Alzheimer's Disease and Related Disorders in a Health System Using an Electronic Medical Record-Based Approach

BACKGROUND

Alzheimer's disease and aging brain disorders are progressive, often fatal neurodegenerative diseases. Successful aging, modern lifestyles and behaviors have combined to result in an expected epidemic. Risks for these diseases include genetic, medical, and lifestyle factors; over 20 modifiable risks have been reported.

OBJECTIVES

We aim to primarily prevent Alzheimer's disease and related disorders through electronic medical record (EMR)-based screening, risk assessments, interventions, and surveillance.

DESIGN

We identified modifiable risks; developed human, systems and infrastructural resources; developed interventions; and targeted at-risk groups for the intervention.

SETTING

A Community Based Health System.

PARTICIPANTS

In year one (June 2015 to May 2016), 133 at-risk patients received brain health services with the goal of delaying or preventing Alzheimer's disease and related disorders.

MEASUREMENTS

We created mechanisms to identify patients at high risk of neurodegenerative disease; EMR-based structured clinical documentation support tools to evaluate risk factors and history; evidence-based interventions to modify risk; and the capacity for annual surveillance, pragmatic trials, and practice-based and genomic research using the EMR.

RESULTS

This paper describes our Center for Brain Health, our EMR tools, and our first year of healthy but at-risk patients.

CONCLUSION

We are translating research into primary prevention of Alzheimer's disease and related disorders in our health system and aim to shift the paradigm in Neurology from brain disease to brain health.

Theoretical prediction of long-range ferromagnetism in transition-metal atom-doped d0 dichalcogenide single layers SnS2 and ZrS2

We have systematically investigated the effects of transition-metal (TM) atom (Sc-Zn) doping in 2D d⁰ materials SnS₂ and ZrS₂via the density functional theory method. Our results demonstrate that the conductivity and magnetism of SnS₂ and ZrS₂ can be engineered to spin-polarize half-metal/metal with appropriate TM dopants. For both materials, nontrivial magnetic interactions can be induced by V/Cr/Mn/Fe/Co doping. Specifically, the various behaviors of the magnetic exchanges in TM-doped SnS₂ and ZrS₂ are due to the competition between the super-exchange, the double exchange, and the p-d exchange interactions, which are dependent on the dopants' chemistry and spatial positions. Thus, our results give potential guidance for future experiments to create functionalized d⁰ nano-electronic devices.

Redefined clinical features and diagnostic criteria in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare primary immunodeficiency disorder typically caused by homozygous AIRE mutations. It classically presents with chronic mucocutaneous candidiasis and autoimmunity that primarily targets endocrine tissues; hypoparathyroidism and adrenal insufficiency are most common. Developing any two of these classic triad manifestations establishes the diagnosis. Although widely recognized in Europe, where nonendocrine autoimmune manifestations are uncommon, APECED is less defined in patients from the Western Hemisphere. We enrolled 35 consecutive American APECED patients (33 from the US) in a prospective observational natural history study and systematically examined their genetic, clinical, autoantibody, and immunological characteristics. Most patients were compound heterozygous; the most common AIRE mutation was c.967_979del13. All but one patient had anti-IFN-ω autoantibodies, including 4 of 5 patients without biallelic AIRE mutations. Urticarial eruption, hepatitis, gastritis, intestinal dysfunction, pneumonitis, and Sjögren's-like syndrome, uncommon entities in European APECED cohorts, affected 40%-80% of American cases. Development of a classic diagnostic dyad was delayed at mean 7.38 years. Eighty percent of patients developed a median of 3 non-triad manifestations before a diagnostic dyad. Only 20% of patients had their first two manifestations among the classic triad. Urticarial eruption, intestinal dysfunction, and enamel hypoplasia were prominent among early manifestations. Patients exhibited expanded peripheral CD4⁺ T cells and CD21^loCD38^lo B lymphocytes. In summary, American APECED patients develop a diverse syndrome, with dramatic enrichment in organ-specific nonendocrine manifestations starting early in life, compared with European patients. Incorporation of these new manifestations into American diagnostic criteria would accelerate diagnosis by approximately 4 years and potentially prevent life-threatening endocrine complications.

Engineering the electronic and magnetic properties of d(0) 2D dichalcogenide materials through vacancy doping and lattice strains

We have systematically investigated the effects of different vacancy defects in 2D d(0) materials SnS2 and ZrS2 using first principles calculations. The theoretical results show that the single cation vacancy and the vacancy complex like V-SnS6 can induce large magnetic moments (3-4 μB) in these single layer materials. Other defects, such as V-SnS3, V-S, V-ZrS3 and V-ZrS6, can result in n-type conductivity. In addition, the ab initio studies also reveal that the magnetic and conductive properties from the cation vacancy and the defect complex V-SnS6 can be modified using the compressive/tensile strain of the in-plane lattices. Specifically, the V-Zr doped ZrS2 monolayer can be tuned from a ferromagnetic semiconductor to a metallic/half-metallic material with decreasing/increasing magnetic moments depending on the external compressive/tensile strains. On the other hand, the semiconducting and magnetic properties of V-Sn doped SnS2 is preserved under different lattice compression and tension. For the defect complex like V-SnS6, only the lattice compression can tune the magnetic moments in SnS2. As a result, by manipulating the fabrication parameters, the magnetic and conductive properties of SnS2 and ZrS2 can be tuned without the need for chemical doping.

Arrhythmias in the setting of hematopoietic cell transplants

Prior studies report 9–27% of persons receiving a hematopoietic cell transplant develop arrhythmias, but the effect on outcomes is largely unknown. We reviewed data from 1177 consecutive patients {greater than or equal to}40 years old receiving a hematopoietic cell transplant at one center during 1999–2009. Transplant indication was predominately leukemia, lymphoma and multiple myeloma. Overall, 104 patients were found to have clinically significant arrhythmia: 43 prior to and 61 following transplant. Post-transplant arrhythmias were most frequently atrial fibrillation(N=30), atrial flutter(N=7) and supraventricular tachycardia(N=11). Subjects with an arrhythmia post-transplant were more likely to have longer median hospital stays (32 days vs 23, P=<.001,) a greater probability of an ICU admission (52% vs 7%; P<.001), more inhospital deaths (28% vs 3%, P<0.001), and more deaths within one year of transplant (41% vs 15%; P<0.001) than patients without arrhythmia at any time. In a multivariate model including age at transplant, diagnosis, history of pre-transplant arrhythmia, and transplant-related variables, post-transplant arrhythmia was associated with a greater risk of death within a year of transplant (OR 3.5, 95% CI: 2.1, 5.9; P < 0.001). Our data suggest arrhythmias after transplants are associated with significant morbidity and mortality. A prospective study of arrhythmia in the transplant setting is warranted.

Syntaxin 4 is concentrated on plasma membrane of astrocytes

Syntaxins are a family of transmembrane proteins that participate in SNARE complexes to mediate membrane fusion events including exocytosis. Different syntaxins are thought to participate in exocytosis in different compartments of the nervous system such as the axon, the soma/dendrites or astrocytes. It is well known that exocytosis of synaptic vesicles at axonal presynaptic terminals involves syntaxin 1 but distributions of syntaxins on neuronal somal and dendritic, postsynaptic or astroglial plasma membranes are less well characterized. Here, we use pre-embedding immunogold labeling to compare the distribution of two plasma membrane-enriched syntaxins (1 and 4) in dissociated rat hippocampal cultures as well as in perfusion-fixed mouse brains. Comparison of Western blots of neuronal cultures, consisting of a mixture of hippocampal neurons and glia, with glial cultures, consisting of mostly astrocytes, shows that syntaxin 1 is enriched in neuronal cultures, whereas syntaxin 4 is enriched in glial cultures. Electron microscopy (EM)-immunogold labeling shows that syntaxin 1 is most abundant at the plasma membranes of axons and terminals, while syntaxin 4 is most abundant at astroglial plasma membranes. This differential distribution was evident even at close appositions of membranes at synapses, where syntaxin 1 was localized to the plasma membrane of the presynaptic terminal, including that at the active zone, while syntaxin 4 was localized to nearby peri-synaptic astroglial processes. These results show that syntaxin 4 is available to support exocytosis in astroglia.