Intrinsic risk factors for alpha-gal syndrome in a case-control study, 2019 to 2020

BACKGROUND

Alpha-gal syndrome (AGS) is an allergy to galactose-α-1,3-galactose (alpha-gal), a carbohydrate found in most mammals. Evidence indicates that AGS develops after a tick bite, and in the United States, AGS is most associated with bites from Amblyomma americanum (lone star tick); however, not all persons bitten by ticks develop clinical AGS.

OBJECTIVE

To investigate intrinsic risk factors associated with the development of AGS.

METHODS

We performed a case-control study among adults presenting for diagnosis or management of AGS at an allergy clinic in North Carolina during 2019 to 2020 and compared them with controls enrolled from 2 nearby internal medicine clinics. A questionnaire gathered epidemiologic and tick exposure data, and blood was obtained for alpha-gal-specific IgE and other testing.

RESULTS

The 82 enrolled case patients and 191 controls did not differ significantly by age or sex. Case patients were more likely than controls to have A or O blood types (non B-antigen), have experienced childhood allergies, and have a family history of AGS and other food allergies. Case patients were also more likely to report experiencing long healing times for insect bites or stings and a family history of allergy to stinging or biting insects.

CONCLUSION

This study suggested that intrinsic factors contribute to risk of developing AGS. Some traits are genetic, but common behaviors among households and family units likely also contribute. Identification of these risk factors can inform personal risk, aid health care providers in understanding susceptible populations, and contribute to ongoing understanding of AGS epidemiology.

The Effect of Age on Dengue Presentation and the Diagnostic Accuracy of the 2015 Pan American Health Organization Case Criteria in a Puerto Rican Cohort

Background

We evaluated dengue presentation by age, the performance of the 2015 Pan American Health Organization (PAHO) case criteria in identifying dengue cases, and variables to improve specificity.

Methods

Patients with fever ≤7 days (N = 10 408) were recruited from 2 emergency departments from May 2012 through December 2015. Serum samples were tested for dengue, chikungunya, and nasopharyngeal swabs for respiratory viruses. Smoothing splines assessed differences in the frequencies of signs/symptoms by age. Least absolute shrinkage and selection operator regressions identified the variables that best predicted dengue.

Results

Among 985 dengue cases, children aged <5 years were least likely to have leukopenia, but most likely to have rash and petechiae. Adults had the highest odds of aches/pains and headaches/retro-orbital pain. The 2015 PAHO criteria had sensitivity of 93% and specificity of 25%. Specificity could be improved by requiring at least 2 of the following criteria: vomiting/nausea, petechiae, rash, or leukopenia (specificity 68%, sensitivity 71%) or by using 2015 PAHO criteria plus either (1) aspartate aminotransferase >50 IU/L or platelet count <100 000 platelets/μL (specificity 81%, sensitivity 56%) or (2) itchy skin or absence of rhinorrhea or cough (specificity 51%, sensitivity 82%).

Conclusions

The 2015 PAHO dengue case criteria had excellent sensitivity but poor specificity. This can be improved by adding signs/symptoms associated with dengue diagnosis.

Clinical and laboratory features of patients diagnosed with alpha-gal syndrome-2010-2019

BACKGROUND

Alpha-gal syndrome (AGS) is an IgE-mediated allergy to galactose-alpha-1,3-galactose. Clinical presentation ranges from hives to anaphylaxis; episodes typically occur 2-6 h after exposure to alpha-gal-containing products. In the United States, lone star tick bites are associated with the development of AGS. To characterize features of AGS, we evaluated a cohort of patients presenting for care at the University of North Carolina, focusing on symptoms, severity, and identifying features unique to specific alpha-gal-containing product exposures.

METHODS

We performed a chart review and descriptive analysis of 100 randomly selected patients with AGS during 2010-2019.

RESULTS

Median age at onset was 53 years, 56% were female, 95% reported White race, 86% reported a history of tick bite, and 75% met the criteria for anaphylaxis based on the involvement of ≥2 organ systems. Those reporting dairy reactions were significantly less likely to report isolated mucocutaneous symptoms (3% vs. 24%; ratio [95% CI]: 0.1 [0.1, 0.3]) than those who tolerated dairy, and were more likely to report gastrointestinal symptoms (79% vs. 59%; ratio [95% CI]: 1.3 [0.7, 2.6]), although this difference was not statistically significant. Dairy-tolerant patients demonstrated higher alpha-gal sIgE titers (as a percentage of total IgE) than dairy-reactive patients (GM 4.1 [95% CI: 2.7, 6.1] vs. GM 2.5 [95% CI: 1.3, 4.8], respectively; ratio -1.6 [95% CI: -1.0, 3.9]).

CONCLUSION

While tick exposure is common in the southern United States, nearly all AGS patients reported a tick bite. Gastrointestinal symptoms were prominent among those reporting reactions to dairy. Anaphylaxis was common, underscoring the severity and need to raise awareness of AGS among patients and providers.

Predominance of Severe Plasma Leakage in Pediatric Patients With Severe Dengue in Puerto Rico

BACKGROUND

We evaluated clinical and laboratory findings among patients with nonsevere or severe dengue in Puerto Rico to examine whether clinical manifestations vary by age.

METHODS

During 2012-2014, we enrolled patients who arrived at the emergency department with fever or history of fever within 7 days of presentation. Serum samples were tested for dengue virus (DENV) by reverse transcriptase-polymerase chain reaction (RT-PCR) and IgM enzyme-linked immunosorbent assay (ELISA). Severe dengue was defined as severe plasma leakage or shock, severe bleeding, or organ involvement at presentation, during hospitalization, or follow-up.

RESULTS

Of 1089 dengue patients identified, 281 (26%) were severe. Compared to those with nonsevere dengue, patients with severe dengue were more often aged 10-19 years (55% vs 40%, P < .001) and hospitalized (87% vs 30%, P < .001). Severe plasma leakage or shock was more common among children aged 0-9 (59%) or 10-19 years (86%) than adults (49%) (P < .01). Severe bleeding was less common among 10-19 year olds (24%) compared to 0-9 year olds (45%) and adults (52%; P < .01).

CONCLUSIONS

Severe plasma leakage was the most common presentation among children, highlighting important differences from adults. Vaccination against dengue could help prevent severe dengue among children in Puerto Rico.

Tick bite as a risk factor for alpha-gal specific IgE antibodies and development of alpha-gal syndrome

BACKGROUND

The disaccharide galactose-α-1,3-galactose (alpha-gal) is expressed in mammals other than humans, apes, and old-world monkeys. In humans, elevated immunoglobulin-E (IgE) antibodies specific for alpha-gal can result in allergic hypersensitivity known as alpha-gal syndrome (AGS). Case reports and series suggest that tick bites can induce alpha-gal specific IgE antibodies.

OBJECTIVE

Evaluate tick exposure as a risk factor for AGS and elevated alpha-gal specific IgE (sIgE).

METHODS

We conducted a case-control study comparing AGS patients from a North Carolina allergy clinic with controls who were patients at a nearby internal medicine clinic. Cases and controls were administered a questionnaire to obtain information about demographics, home environment, outdoor activities, and recollection of tick bite. Serum samples taken at the time of enrollment were tested for total IgE, alpha-gal sIgE, and antibodies to other tickborne pathogens.

RESULTS

AGS patients were more likely to recall finding a tick on themselves (OR=11.20, 95% CI 4.97-25.15), live near wooded forest (OR=2.27, 95% CI 0.92-5.55), and spend 17 or more hours per week outdoors in wooded areas (OR=5.58, 95% CI 2.56-12.19). AGS patients were also more likely to report 4 or more tick bites (OR=33.05, 95% CI 9.92-155.12) and reactions at the site of tick bites (OR=7.93, 95% CI 3.74-16.80). Elevated alpha-gal sIgE was also observed in 33% of controls and was also associated with tick exposure in the controls (OR=4.25, 95% CI 2.21-8.18).

CONCLUSION

The results define tick bite as a risk factor for AGS and elevated alpha-gal sIgE.

Large animal veterinarians' knowledge, attitudes, and practices regarding livestock abortion-associated zoonoses in the United States indicate potential occupational health risk

OBJECTIVE

To understand large animal veterinarians' knowledge of select zoonotic diseases that cause livestock abortions and identify barriers to using personal protective equipment (PPE).

SAMPLE

A convenience sample of 469 veterinarians currently working with livestock.

PROCEDURES

We sent an electronic survey invitation to large animal veterinarians through various veterinary organizations. Respondents answered questions addressing knowledge and prior experience with select abortion-associated zoonotic diseases, resources available for infection control, attitudes and barriers to PPE use, and demographics.

RESULTS

Median participant age was 49 years (range, 22 to 82 years), and 54% (235/438) were male. Half of veterinarians (185/348) were contacted 5 or fewer times per year to consult on livestock abortions. No veterinarians surveyed answered all questions on zoonotic disease transmission correctly. Personal protective equipment access varied, from 99% (289/290) having access to gloves to 20% (59/290) having access to respirators. Concerns for spreading disease to other animals (136/289 [47%]) and to other humans (108/287 [38%]) ranked as the most common reported motivators for PPE use. Reported barriers to PPE use among survey participants were the inconvenience of taking PPE into the field (101/286 [35%]) and the inconvenience of wearing PPE (97/286 [34%]). Access to PPE was not correlated with PPE use.

CLINICAL RELEVANCE

Surveyed veterinarians had limited knowledge of transmission of select abortion-associated zoonotic diseases. Incomplete understanding might lead to inappropriate PPE selection, preventable disease exposure, or missed opportunities for client education. Inconvenience was a primary reason PPE was not used.

Estimating the early impact of the US COVID-19 vaccination programme on COVID-19 cases, emergency department visits, hospital admissions, and deaths among adults aged 65 years and older: an ecological analysis of national surveillance data

BACKGROUND

In the USA, COVID-19 vaccines became available in mid-December, 2020, with adults aged 65 years and older among the first groups prioritised for vaccination. We estimated the national-level impact of the initial phases of the US COVID-19 vaccination programme on COVID-19 cases, emergency department visits, hospital admissions, and deaths among adults aged 65 years and older.

METHODS

We analysed population-based data reported to US federal agencies on COVID-19 cases, emergency department visits, hospital admissions, and deaths among adults aged 50 years and older during the period Nov 1, 2020, to April 10, 2021. We calculated the relative change in incidence among older age groups compared with a younger reference group for pre-vaccination and post-vaccination periods, defined by the week when vaccination coverage in a given age group first exceeded coverage in the reference age group by at least 1%; time lags for immune response and time to outcome were incorporated. We assessed whether the ratio of these relative changes differed when comparing the pre-vaccination and post-vaccination periods.

FINDINGS

The ratio of relative changes comparing the change in the COVID-19 case incidence ratio over the post-vaccine versus pre-vaccine periods showed relative decreases of 53% (95% CI 50 to 55) and 62% (59 to 64) among adults aged 65 to 74 years and 75 years and older, respectively, compared with those aged 50 to 64 years. We found similar results for emergency department visits with relative decreases of 61% (52 to 68) for adults aged 65 to 74 years and 77% (71 to 78) for those aged 75 years and older compared with adults aged 50 to 64 years. Hospital admissions declined by 39% (29 to 48) among those aged 60 to 69 years, 60% (54 to 66) among those aged 70 to 79 years, and 68% (62 to 73), among those aged 80 years and older, compared with adults aged 50 to 59 years. COVID-19 deaths also declined (by 41%, 95% CI -14 to 69 among adults aged 65-74 years and by 30%, -47 to 66 among those aged ≥75 years, compared with adults aged 50 to 64 years), but the magnitude of the impact of vaccination roll-out on deaths was unclear.

INTERPRETATION

The initial roll-out of the US COVID-19 vaccination programme was associated with reductions in COVID-19 cases, emergency department visits, and hospital admissions among older adults.

FUNDING

None.

COVID-19 vaccination coverage among hospital-based healthcare personnel reported through the Department of Health and Human Services Unified Hospital Data Surveillance System, United States, January 20, 2021-September 15, 2021

To protect both patients and staff, healthcare personnel (HCP) were among the first groups in the United States recommended to receive the COVID-19 vaccine. We analyzed data reported to the U.S. Department of Health and Human Services (HHS) Unified Hospital Data Surveillance System on COVID-19 vaccination coverage among hospital-based HCP. After vaccine introduction in December 2020, COVID-19 vaccine coverage rose steadily through April 2021, but the rate of uptake has since slowed; as of September 15, 2021, among 3,357,348 HCP in 2,086 hospitals included in this analysis, 70.0% were fully vaccinated. Additional efforts are needed to improve COVID-19 vaccine coverage among HCP.

PASCAR commentary on the International Society of Hypertension global guidelines 2020: relevance to sub-Saharan Africa

Hypertension guidelines have been based on country-specific data until the publication of the International Society of Hypertension (ISH) global guidelines. The major differences between the ISH global guidelines and other international guidelines are the stratified recommendations to accommodate differences in available resources between countries and within countries. This is a key and novel proposal in the new ISH guidelines. There is the separation of optimal versus essential criteria for diagnosis and treatment according to availability of resources. This guideline includes recommendations for sub-Saharan Africa. The Pan-African Society of Cardiology (PASCAR) continues to promote awareness and recommendations on hypertension in Africa. This commentary provides a summary and discussion of the global guidelines in order to clarify the position of PASCAR.

Reproductive incompatibility between Amblyomma maculatum (Acari: Ixodidae) group ticks from two disjunct geographical regions within the USA

The Amblyomma maculatum Koch group of ixodid ticks consists of three species: A. maculatum, A. triste, and A. tigrinum. However, since Koch described this group in 1844, the systematics of its members has been the subject of ongoing debate. This is especially true of A. maculatum and A. triste; recent molecular analyses reveal insufficient genetic divergence to separate these as distinct species. Further confounding this issue is the discovery in 2014 of A. maculatum group ticks in southern Arizona (AZ), USA, that share morphological characteristics with both A. triste and A. maculatum. To biologically evaluate the identity of A. maculatum group ticks from southern Arizona, we analyzed the reproductive compatibility between specimens of A. maculatum group ticks collected from Georgia (GA), USA, and southern Arizona. Female ticks from both Arizona and Georgia were mated with males from both the Georgia and Arizona Amblyomma populations, creating two homologous and two heterologous F1 cohorts of ticks: GA ♀/GA ♂, AZ ♀/AZ ♂, GA ♀/AZ ♂, and AZ ♀/GA ♂. Each cohort was maintained separately into the F2 generation with F1 females mating only with F1 males from their same cohort. Survival and fecundity parameters were measured for all developmental stages. The observed survival parameters for heterologous cohorts were comparable to those of the homologous cohorts through the F1 generation. However, the F1 heterologous females produced F2 egg clutches that did not hatch, thus indicating that the Arizona and Georgia populations of A. maculatum group ticks tested here represent different biological species.

Serelaxin and the AT2 Receptor Agonist CGP42112 Evoked a Similar, Nonadditive, Cardiac Antifibrotic Effect in High Salt-Fed Mice That Were Refractory to Candesartan Cilexetil

Fibrosis is involved in the majority of cardiovascular diseases and is a key contributor to end-organ dysfunction. In the current study, the antifibrotic effects of recombinant human relaxin-2 (serelaxin; RLX) and/or the AT₂R agonist CGP42112 (CGP) were compared with those of the established AT₁R antagonist, candesartan cilexetil (CAND), in a high salt-induced cardiac fibrosis model. High salt (HS; 5%) for 8 weeks did not increase systolic blood pressure in male FVB/N mice, but CAND treatment alone significantly reduced systolic blood pressure from HS-induced levels. HS significantly increased cardiac interstitial fibrosis, which was reduced by either RLX and/or CGP, which were not additive under the current experimental conditions, while CAND failed to reduce HS-induced cardiac fibrosis. The antifibrotic effects induced by RLX and/or CGP were associated with reduced myofibroblast differentiation. Additionally, all treatments inhibited the HS-induced elevation in tissue inhibitor of matrix metalloproteinases-1, together with trends for increased MMP-13 expression, that collectively would favor collagen degradation. Furthermore, these antifibrotic effects were associated with reduced cardiac inflammation. Collectively, these results highlight that either RXFP1 or AT₂R stimulation represents novel therapeutic strategies to target fibrotic conditions, particularly in HS states that may be refractory to AT₁R blockade.

The impact of the Emergency Department target upon the discharge decision for people who self-harm

Purpose

The purpose of this paper is to consider the influence of the Emergency Department (ED) target wait time upon the discharge decision in ED, specifically for patients who have self-harmed. Pressures to discharge patients to avoid breaching the 4-h target wait time, potentially increase the risk of adverse responses from clinicians. For the patient who has self-harmed, such interactions may be experienced as invalidating and may result in adverse outcomes.

Design/methodology/approach

Secondary data analysis was applied to the retrospective referral data of a Mental Health Liaison Team (MHLT), collected over a period of 11 months from a single hospital in the North of England. In total, 734 episodes of care were referred to the team from ED, where the primary presentation was recorded as self-harm.

Findings

Over half of patients referred to the MHLT from ED having self-harmed were seen after already breaching the target and the potential for a more restrictive outcome reduced. Of those patients seen within 4 h, the potential for a more restrictive treatment option was increased.

Practical implications

Recommendations to improve the patient journey for those who have self-harmed include mental health triage and treatment in clinical areas outside of the target.

Social implications

This study challenges the concept of the target as being realistic and attainable for patients who have self-harmed.

Originality/value

This exploratory study provides a starting point from which to explore the impact of the target time upon discharge decisions and clinical outcomes specifically for those who have self-harmed.

"They're Really PD Today"

The therapeutic relationship is of particular importance when working with patients with antisocial personality disorder, but despite this, there is a paucity of literature exploring student nurses' perceptions of developing a therapeutic relationship with such patients. Hence, this qualitative study explored the perceptions of second-year mental health nursing students of developing a therapeutic relationship with this patient group. Student nurses from a University in the Northwest of England participated in two focus groups, to compare the perceptions of a group of student nurses who had experience in secure settings (forensic hospital) with those who had not. Four key themes emerged: diagnosis, safety, engagement, and finally environmental influences. Both groups commented on looking beyond the diagnosis and seeing the person. The student nurses cited other staff in their clinical placement areas as hugely influential in terms of the development of their perceptions of patients with antisocial personality disorder and how to relate to them.

Electronic sculpting of ligand-GPCR subtype selectivity: the case of angiotensin II

GPCR subtypes possess distinct functional and pharmacological profiles, and thus development of subtype-selective ligands has immense therapeutic potential. This is especially the case for the angiotensin receptor subtypes AT1R and AT2R, where a functional negative control has been described and AT2R activation highlighted as an important cancer drug target. We describe a strategy to fine-tune ligand selectivity for the AT2R/AT1R subtypes through electronic control of ligand aromatic-prolyl interactions. Through this strategy an AT2R high affinity (K_i = 3 nM) agonist analogue that exerted 18,000-fold higher selectivity for AT2R versus AT1R was obtained. We show that this compound is a negative regulator of AT1R signaling since it is able to inhibit MCF-7 breast carcinoma cellular proliferation in the low nanomolar range.

Reversal of vascular macrophage accumulation and hypertension by a CCR2 antagonist in deoxycorticosterone/salt-treated mice

Infiltration of macrophages into the artery wall plays detrimental roles during hypertension by promoting vascular inflammation and endothelial dysfunction, and it occurs via a chemo-attractant action of chemokines on macrophage cytokine receptors. We sought to identify the key chemokine receptors associated with macrophage infiltration into the vascular wall during deoxycorticosterone acetate (DOCA)/salt-induced hypertension in mice and to evaluate the impact of pharmacological inhibition of these receptors on blood pressure and leukocyte accumulation. Mice treated with DOCA/salt for 21 days displayed markedly elevated systolic blood pressure (158 ± 2 versus 114 ± 5 mm Hg in sham group; P<0.0001). Polymerase chain reaction screening via a gene array of 20 chemokine receptors indicated an increased expression of CCR2 in aortas of DOCA/salt-treated mice. Real-time polymerase chain reaction confirmed mRNA upregulation of CCR2 in aortas from DOCA/salt-treated animals and of the CCR2 ligands CCL2, CCL7, CCL8, and CCL12 (all >2-fold versus sham; P<0.05). Flow cytometry revealed 2.9-fold higher macrophage numbers (ie, CD45(+) CD11b(+) F4/80(+) cells) in the aortic wall of DOCA/salt versus sham-treated mice. Intervention with a CCR2 antagonist, INCB3344 (30 mg/kg per day, IP), 10 days after the induction of hypertension with DOCA/salt treatment, reduced the aortic expression of CCR2 mRNA and completely reversed the DOCA/salt-induced influx of macrophages. Importantly, INCB3344 substantially reduced the elevated blood pressure in DOCA/salt-treated mice. Hence, our findings highlight CCR2 as a promising therapeutic target to reduce both macrophage accumulation in the vascular wall and blood pressure in hypertension.

Neuroprotective effect of an angiotensin receptor type 2 agonist following cerebral ischemia in vitro and in vivo

Background

Intracerebral administration of the angiotensin II type 2 receptor (AT₂R) agonist, CGP42112, is neuroprotective in a rat model of ischemic stroke. To explore further its possible cellular target(s) and therapeutic utility, we firstly examined whether CGP42112 may exert direct protective effects on primary neurons following glucose deprivation in vitro. Secondly, we tested whether CGP42112 is effective when administered systemically in a mouse model of cerebral ischemia.

Methods

Primary cortical neurons were cultured from E17 C57Bl6 mouse embryos for 9 d, exposed to glucose deprivation for 24 h alone or with drug treatments, and percent cell survival assessed using trypan blue exclusion. Ischemic stroke was induced in adult male C57Bl6 mice by middle cerebral artery occlusion for 30 min, followed by reperfusion for 23.5 h. Neurological assessment was performed and then mice were euthanized and infarct and edema volume were analysed.

Results

During glucose deprivation, CGP42112 (1x10^-8 M and 1x10^-7 M) reduced cell death by ~30%, an effect that was prevented by the AT₂R antagonist, PD123319 (1x10^-6 M). Neuroprotection by CGP42112 was lost at a higher concentration (1x10^-6 M) but was unmasked by co-application with the AT₁R antagonist, candesartan (1x10^-7 M). By contrast, Compound 21 (1x10^-8 M to 1x10^-6 M), a second AT₂R agonist, had no effect on neuronal survival. Mice treated with CGP42112 (1 mg/kg i.p.) after cerebral ischemia had improved functional outcomes over vehicle-treated mice as well as reduced total and cortical infarct volumes.

Conclusions

These results indicate that CGP42112 can directly protect neurons from ischemia-like injury in vitro via activation of AT₂Rs, an effect opposed by AT₁R activation at high concentrations. Furthermore, systemic administration of CGP42112 can reduce functional deficits and infarct volume following cerebral ischemia in vivo.

Sex-specific influence of angiotensin type 2 receptor stimulation on renal function: a novel therapeutic target for hypertension

The renin-angiotensin system is a powerful regulator of arterial pressure and body fluid volume. Increasing evidence suggests that the angiotensin type 2 receptor (AT(2)R), which mediates the vasodilatory and natriuretic actions of angiotensin peptides, is enhanced in females and may, therefore, represent an innovative therapeutic target. We investigated the therapeutic potential of direct AT(2)R stimulation on renal function in 11- to 12-week-old anesthetized male and female Sprague-Dawley rats. Renal blood flow was examined in response to a graded infusion of the highly selective, nonpeptide AT(2)R agonist, compound 21 (100, 200, and 300 ng/kg per minute), in the presence and absence of AT(2)R blockade (PD123319; 1 mg/kg per hour). Direct AT(2)R stimulation significantly increased renal blood flow in both males and females, without influencing arterial pressure. This was dose dependent in females only and occurred to a greater extent in females at the highest dose of compound 21 administered (males: 13.1±2.4% versus females: 23.0±3.2% change in renal blood flow at 300 ng/kg per minute versus baseline; P<0.01). In addition, AT(2)R stimulation significantly increased sodium and water excretion to a similar extent in males and females (P(Group)=0.05 and 0.005). However, there was no significant change in glomerular filtration rate in either sex, suggesting that altered tubular function may be responsible for AT(2)R-induced natriuresis rather than hemodynamic effects. Taken together, this study provides evidence that direct AT(2)R stimulation produces vasodilatory and natriuretic effects in the male and female kidney. The AT(2)R may, therefore, represent a valuable therapeutic target for the treatment of renal and cardiovascular diseases in both men and women.

Sex differences in the pressor and tubuloglomerular feedback response to angiotensin II

Awareness of sex differences in the pathology of cardiovascular disease is increasing. Previously, we have shown a role for the angiotensin type 2 receptor (AT(2)R) in the sex differences in the arterial pressure response to Ang II. Tubuloglomerular feedback (TGF) contributes in setting pressure-natriuresis properties, and its responsiveness is closely coupled to renal Ang II levels. We hypothesize that, in females, the attenuated pressor response to Ang II is mediated via an enhanced AT(2)R mechanism that, in part, offsets Ang II-induced sensitization of the TGF mechanism. Mean arterial pressure was measured via telemetry in male and female wild-type (WT) and AT(2)R knockout (AT(2)R-KO) mice receiving Ang II (600 ng/kg per minute SC). Basal 24-hour mean arterial pressure did not differ among the 4 groups. After 10 days of Ang II infusion, mean arterial pressure increased in the male WT (28±6 mm Hg), male AT(2)R-KO (26±2 mm Hg), and female AT(2)R-KO (26±4 mm Hg) mice, however, the response was attenuated in female WT mice (12±4 mm Hg; P between sex and genotype=0.016). TGF characteristics were determined before and during acute subpressor Ang II infusion (100 ng/kg per minute IV). Basal TGF responses did not differ between groups. The expected increase in maximal change in stop-flow pressure and enhancement of TGF sensitivity in response to Ang II was observed in the male WT, male AT(2)R-KO, and female AT(2)R-KO but not in the female WT mice (P between sex and genotype <0.05; both). In conclusion, these data indicate that an enhanced AT(2)R-mediated pathway counterbalances the hypertensive effects of Ang II and attenuates the Ang II-dependent resetting of TGF activity in females. Thus, the enhancement of the AT(2)R may, in part, underlie the protection that premenopausal women demonstrate against cardiovascular disease.

The R563Q mutation of the epithelial sodium channel beta-subunit is associated with hypertension

BACKGROUND

A high prevalence of the R563Q mutation of the epithelial sodium channel β-subunit has been reported in South African hypertensives compared with unrelated normotensive controls. To delineate the effects of this mutation against a more uniform genetic background, this study investigated the association of the mutation with hypertension within affected kindreds.

METHODS

Forty-five index patients and members of their kindreds were studied. Blood pressure, serum potassium and the presence of the R563Q mutation were determined.

RESULTS

Of the 136 individuals studied, 89 were heterozygous for the R563Q mutation and 47 homozygous RR. The mean arterial pressure was significantly higher in the R563Q heterozygous group (p = 0.005) after adjusting for gender, race, age and kindred membership. Of the R563Q heterozygous subjects, 71 (80%) had hypertension, while 17 (36%) of the R563Q homozygous RR subjects were hypertensive. Six R563Q heterozygous subjects had hypokalaemia and one R563Q homozygous RR subject had hypokalaemia, but the difference was not statistically significant. Two heterozygous patients had Liddle's syndrome, both occurring during pregnancy.

CONCLUSION

The R563Q mutation of β-ENaC is associated with hypertension within affected kindreds, but does not usually cause the full Liddle's syndrome phenotype.

Stimulation of angiotensin AT2 receptors by the non-peptide agonist, Compound 21, evokes vasodepressor effects in conscious spontaneously hypertensive rats

BACKGROUND AND PURPOSE

Angiotensin type 2 receptor (AT(2) receptor) stimulation evokes vasodilator effects in vitro and in vivo that oppose the vasoconstrictor effects of angiotensin type 1 receptors (AT(1) receptors). Recently, a novel non-peptide AT(2) receptor agonist, Compound 21, was described, which exhibited high AT(2) receptor selectivity.

EXPERIMENTAL APPROACH

Functional cardiovascular effects of the drug candidate Compound 21 were assessed, using mouse isolated aorta and rat mesenteric arteries in vitro and in conscious spontaneously hypertensive rats (SHR).

KEY RESULTS

Compound 21 evoked dose-dependent vasorelaxations in aortic and mesenteric vessels, abolished by the AT(2) receptor antagonist, PD123319. In vivo, Compound 21 administered alone, at doses ranging from 50 to 1000 ng.kg(-1).min(-1) over 4 h did not decrease blood pressure in conscious normotensive Wistar-Kyoto rats or SHR. However, when given in combination with the AT(1) receptor antagonist, candesartan, Compound 21 (300 ng.kg(-1).min(-1)) lowered blood pressure in SHR only. Further analysis in separate groups of conscious SHR revealed that, at a sixfold lower dose, Compound 21 (50 ng.kg(-1).min(-1)) still evoked a significant depressor response in adult SHR ( approximately 30 mmHg) when combined with different doses of candesartan (0.01 or 0.1 mg.kg(-1)). Moreover, the Compound 21-evoked depressor effect was abolished when co-infused (50 microg.kg(-1).min(-1) for 2 h) with the AT(2) receptor antagonist PD123319.

CONCLUSION AND IMPLICATIONS

Collectively, our results indicate that acute administration of Compound 21 evoked blood pressure reductions via AT(2) receptor stimulation. Thus Compound 21 can be considered an excellent drug candidate for further study of AT(2) receptor function in cardiovascular disease.

AT2 receptors: functional relevance in cardiovascular disease

The renin angiotensin system (RAS) is intricately involved in normal cardiovascular homeostasis. Excessive stimulation by the octapeptide angiotensin II contributes to a range of cardiovascular pathologies and diseases via angiotensin type 1 receptor (AT₁R) activation. On the other hand, tElsevier Inc.he angiotensin type 2 receptor (AT₂R) is thought to counter-regulate AT₁R function. In this review, we describe the enhanced expression and function of AT₂R in various cardiovascular disease settings. In addition, we illustrate that the RAS consists of a family of angiotensin peptides that exert cardiovascular effects that are often distinct from those of Ang II. During cardiovascular disease, there is likely to be an increased functional importance of AT₂R, stimulated by Ang II, or even shorter angiotensin peptide fragments, to limit AT₁R-mediated overactivity and cardiovascular pathologies.

A comparison of simple sequence repeat and single nucleotide polymorphism marker technologies for the genotypic analysis of maize (Zea mays L.)

We report on the comparative utilities of simple sequence repeat (SSR) and single nucleotide polymorphism (SNP) markers for characterizing maize germplasm in terms of their informativeness, levels of missing data, repeatability and the ability to detect expected alleles in hybrids and DNA pools. Two different SNP chemistries were compared; single-base extension detected by Sequenom MassARRAY, and invasive cleavage detected by Invader chemistry with PCR. A total of 58 maize inbreds and four hybrids were genotyped with 80 SSR markers, 69 Invader SNP markers and 118 MassARRAY SNP markers, with 64 SNP loci being common to the two SNP marker chemistries. Average expected heterozygosity values were 0.62 for SSRs, 0.43 for SNPs (pre-selected for their high level of polymorphism) and 0.63 for the underlying sequence haplotypes. All individual SNP markers within the same set of sequences had an average expected heterozygosity value of 0.26. SNP marker data had more than a fourfold lower level of missing data (2.1-3.1%) compared with SSRs (13.8%). Data repeatability was higher for SNPs (98.1% for MassARRAY SNPs and 99.3% for Invader) than for SSRs (91.7%). Parental alleles were observed in hybrid genotypes in 97.0% of the cases for MassARRAY SNPs, 95.5% for Invader SNPs and 81.9% for SSRs. In pooled samples with mixtures of alleles, SSRs, MassARRAY SNPs and Invader SNPs were equally capable of detecting alleles at mid to high frequencies. However, at low frequencies, alleles were least likely to be detected using Invader SNP markers, and this technology had the highest level of missing data. Collectively, these results showed that SNP technologies can provide increased marker data quality and quantity compared with SSRs. The relative loss in polymorphism compared with SSRs can be compensated by increasing SNP numbers and by using SNP haplotypes. Determining the most appropriate SNP chemistry will be dependent upon matching the technical features of the method within the context of application, particularly in consideration of whether genotypic samples will be pooled or assayed individually.

Individual and multi-environment combined analyses identify QTLs for morphogenetic and reproductive development traits in white clover (Trifolium repens L.)

White clover (Trifolium repens L.) is a key component legume of temperate pasture agriculture and an important target for molecular marker-assisted plant breeding. A genetic map of white clover has been used to assess genetic control of agronomically important traits that vary in the F2(I.4RxI.5J) mapping family. Phenotypic analysis was performed for a range of vegetative morphogenesis traits (such as leaf area, internode length, plant height and plant spread) and reproductive morphogenesis and development traits (such as flowering date, floral intensity and seed yield), with both spatial and temporal replication. A multi-environment combined analysis (combined analysis) has been performed for traits assessed across multiple experimental datasets in order to identify consistent genetic effects. Quantitative trait locus (QTLs) were detected for the majority of traits, and the locations and magnitudes of QTL effects were compared between individual and combined analyses. This molecular genetic dissection of agronomic traits in white clover provides the basis for equivalent studies in more complex populations, design of marker-assisted selection strategies and comparative genetics with model legume species. Selection for QTLs derived from the combined analysis will permit robust improvement of phenotypic traits over different environments.

Gene expression and genetic mapping analyses of a perennial ryegrass glycine-rich RNA-binding protein gene suggest a role in cold adaptation

A perennial ryegrass cDNA clone encoding a putative glycine-rich RNA binding protein (LpGRP1) was isolated from a cDNA library constructed from crown tissues of cold-treated plants. The deduced polypeptide sequence consists of 107 amino acids with a single N-terminal RNA recognition motif (RRM) and a single C-terminal glycine-rich domain. The sequence showed extensive homology to glycine-rich RNA binding proteins previously identified in other plant species. LpGRP1-specific genomic DNA sequence was isolated by an inverse PCR amplification. A single intron which shows conserved locations in plant genes was detected between the sequence motifs encoding RNP-1 and RNP-2 consensus protein domains. A significant increase in the mRNA level of LpGRP1 was detected in root, crown and leaf tissues during the treatment of plants at 4 degrees C, through which freezing tolerance is attained. The increase in the mRNA level was prominent at least 2 h after the commencement of the cold treatment, and persisted for at least 1 week. Changes in mRNA level induced by cold treatment were more obvious than those due to treatments with abscisic acid (ABA) and drought. The LpGRP1 protein was found to localise in the nucleus in onion epidermal cells, suggesting that it may be involved in pre-mRNA processing. The LpGRP1 gene locus was mapped to linkage group 2. Possible roles for the LpGRP1 protein in adaptation to cold environments are discussed.

Molecular cloning and genetic mapping of perennial ryegrass casein protein kinase 2 alpha-subunit genes

The alpha-subunit of the casein protein kinase CK2 has been implicated in both light-regulated and circadian rhythm-controlled plant gene expression, including control of the flowering time. Two putative CK2alpha genes of perennial ryegrass (Lolium perenne L.) have been obtained from a cDNA library constructed with mRNA isolated from cold-acclimated crown tissue. The genomic organisation of the two genes was determined by Southern hybridisation analysis. Primer designs to the Lpck2a-1 and Lpck2a-2 cDNA sequences permitted the amplification of genomic products containing large intron sequences. Amplicon sequence analysis detected single nucleotide polymorphisms (SNPs) within the p150/112 reference mapping population. Validated SNPs, within diagnostic restriction enzyme sites, were used to design cleaved amplified polymorphic sequence (CAPS) assays. The Lpck2a-1 CAPS marker was assigned to perennial ryegrass linkage group (LG) 4 and the Lpck2a-2 CAPS marker was assigned to LG2. The location of the Lpck2a-1 gene locus supports the previous conclusion of conserved synteny between perennial ryegrass LG4, the Triticeae homoeologous group 5L chromosomes and the corresponding segment of rice chromosome 3. Allelic variation at the Lpck2a-1 and Lpck2a-2 gene loci was correlated with phenotypic variation for heading date and winter survival, respectively. SNP polymorphism may be used for the further study of the role of CK2alpha genes in the initiation of reproductive development and winter hardiness in grasses.

QTL analysis and comparative genomics of herbage quality traits in perennial ryegrass (Lolium perenne L.)

Genetic control of herbage quality variation was assessed through the use of the molecular marker-based reference genetic map of perennial ryegrass (Lolium perenne L.). The restriction fragment length polymorphism (RFLP), amplified fragment length polymorphism (AFLP) and genomic DNA-derived simple sequence repeat-based (SSR) framework marker set was enhanced, with RFLP loci corresponding to genes for key enzymes involved in lignin biosynthesis and fructan metabolism. Quality traits such as crude protein (CP) content, estimated in vivo dry matter digestibility (IVVDMD), neutral detergent fibre content (NDF), estimated metabolisable energy (EstME) and water soluble carbohydrate (WSC) content were measured by near infrared reflectance spectroscopy (NIRS) analysis of herbage harvests. Quantitative trait locus (QTL) analysis was performed using single-marker regression, simple interval mapping and composite interval mapping approaches, detecting a total of 42 QTLs from six different sampling experiments varying by developmental stage (anthesis or vegetative growth), location or year. Coincident QTLs were detected on linkage groups (LGs) 3, 5 and 7. The region on LG3 was associated with variation for all measured traits across various experimental datasets. The region on LG7 was associated with variation for all traits except CP, and is located in the vicinity of the lignin biosynthesis gene loci xlpomt1 (caffeic acid-O-methyltransferase), xlpccr1 (cinnamoyl CoA-reductase) and xlpssrcad 2.1 (cinnamyl alcohol dehydrogenase). Comparative genomics analysis of these gene classes with wheat (Triticum aestivum L.) provides evidence for conservation of gene order over evolutionary time and the basis for cross-specific genetic information transfer. The identification of co-location between QTLs and functionally associated genetic markers is critical for the implementation of marker-assisted selection programs and for linkage disequilibrium studies, which will enable future improvement strategies for perennial ryegrass.

Functionally associated molecular genetic marker map construction in perennial ryegrass (Lolium perenne L.)

A molecular marker-based map of perennial ryegrass (Lolium perenne L.) has been constructed through the use of polymorphisms associated with expressed sequence tags (ESTs). A pair-cross between genotypes from a North African ecotype and the cultivar Aurora was used to generate a two-way pseudo-testcross population. A selection of 157 cDNAs assigned to eight different functional categories associated with agronomically important biological processes was used to detect polymorphic EST-RFLP loci in the F(1)(NA(6) x AU(6)) population. A comprehensive set of EST-SSR markers was developed from the analysis of 14,767 unigenes, with 310 primer pairs showing efficient amplification and detecting 113 polymorphic loci. Two parental genetic maps were produced: the NA(6) genetic map contains 88 EST-RFLP and 71 EST-SSR loci with a total map length of 963 cM, while the AU(6) genetic map contains 67 EST-RFLP and 58 EST-SSR loci with a total map length of 757 cM. Bridging loci permitted the alignment of homologous chromosomes between the parental maps, and a sub-set of genomic DNA-derived SSRs was used to relate linkage groups to the perennial ryegrass reference map. Regions of segregation distortion were identified, in some instances in common with other perennial ryegrass maps. The EST-derived marker-based map provides the basis for in silico comparative genetic mapping, as well as the evaluation of co-location between QTLs and functionally associated genetic loci.

Functionally associated molecular genetic marker map construction in perennial ryegrass (Lolium perenne L.)

A molecular marker-based map of perennial ryegrass (Lolium perenne L.) has been constructed through the use of polymorphisms associated with expressed sequence tags (ESTs). A pair-cross between genotypes from a North African ecotype and the cultivar Aurora was used to generate a two-way pseudo-testcross population. A selection of 157 cDNAs assigned to eight different functional categories associated with agronomically important biological processes was used to detect polymorphic EST-RFLP loci in the F(1)(NA(6) x AU(6)) population. A comprehensive set of EST-SSR markers was developed from the analysis of 14,767 unigenes, with 310 primer pairs showing efficient amplification and detecting 113 polymorphic loci. Two parental genetic maps were produced: the NA(6) genetic map contains 88 EST-RFLP and 71 EST-SSR loci with a total map length of 963 cM, while the AU(6) genetic map contains 67 EST-RFLP and 58 EST-SSR loci with a total map length of 757 cM. Bridging loci permitted the alignment of homologous chromosomes between the parental maps, and a sub-set of genomic DNA-derived SSRs was used to relate linkage groups to the perennial ryegrass reference map. Regions of segregation distortion were identified, in some instances in common with other perennial ryegrass maps. The EST-derived marker-based map provides the basis for in silico comparative genetic mapping, as well as the evaluation of co-location between QTLs and functionally associated genetic loci.

Angiotensin AT receptor contributes to cardiovascular remodelling of aged rats during chronic AT receptor blockade

Ang II acting at AT(1)Rs has well documented effects on cardiovascular structure such as the promotion of cardiovascular hypertrophy and fibrosis, effects which are believed to be opposed by AT(2)R stimulation. AT(1) and AT(2)R expression are up regulated in senescent hearts, and other components of the local renin-angiotensin system are also dramatically increased in the ageing heart. Therefore, the aim of this study was to determine the role of the AT(2)R in aged rats by determining their potential contribution to the chronic antihypertensive and cardiovascular effects of AT(1)R blockade. Radiotelemetry probes were implanted into senescent (20 months) male Wistar-Kyoto (WKY) rats, and baseline recordings of mean arterial pressure (MAP) were made for 1 week. Candesartan cilexetil (2 mg/kg per day) was given in drinking water, while an additional group simultaneously received the AT(2)R antagonist, PD123319 (10 mg/kg per day) via osmotic mini-pump. At the end of the 4 weeks treatment period, animals were perfusion-fixed to enable histological analysis of cardiovascular structure. MAP was decreased by candesartan cilexetil, however, this effect was not further influenced by PD123319. Cardiac hypertrophy and fibrosis, and aortic hypertrophy were all significantly reduced by candesartan cilexetil. Most interestingly, these structural changes were reversed by concomitant PD123319 administration, despite the lack of AT(2)R-mediated effects on MAP. These results suggest that the AT(2)R does not exert a significant influence on chronic blood pressure regulation in senescent rats. However, PD123319 did reverse AT(1)R-mediated regression of cardiovascular hypertrophy and fibrosis, highlighting the important role of the AT(2)R on cardiovascular structure in the ageing heart and vasculature.

Angiotensin AT2 receptors: cardiovascular hope or hype?

British Journal of Pharmacology (2003) 140, 809–824. doi:10.1038/sj.bjp.0705448

Status epilepticus treated with a muscle relaxant: the first success

In 1958, an 11-year-old girl with status epilepticus was given the current treatments which failed to control the convulsions. In order to stop the fits, protect the airway, prevent hypoxia and hyperpyrexia, intermittent positive pressure ventilation (IPPV) and complete muscle paralysis with d-tubocurarine was used for a total of 6 h. The girl made a complete recovery, the first patient to do so using this plan of action.

Attitudes toward environmental tobacco smoke in Mississippi: still a burning issue

Mississippi is one of eight states without any form of legislation restricting tobacco use in public places or work sites. In a telephone survey of 1,210 Mississippi adults, 95 percent of respondents, including 90 percent of current smokers, were in favor of prohibiting or restricting smoking in public areas and 91 percent of respondents, including 81 percent of current smokers, were in favor of smoking restrictions at work sites. Mississippi needs to undertake public health initiatives to promote the rights of nonsmokers and reduce the adverse health effects to nonsmokers of exposure to environmental tobacco smoke in public places and work sites.

I smell a rat!

This is a case history with a difference. The year was 1938 and the story was told to one of us in 1946 by Henry Cohen (HC), then Professor of Medicine at Liverpool (Figure 1). Bothdiagnosis and successful treatment were made in the patient's home without any of the customary investigations. The case is reported because it still provides lessons: there are no substitutes for wide-ranging knowledge and its thorough clinical application

Effective clinical policies in a district general hospital

Effective clinical practice in a hospital needs current knowledge together with the skills and right attitude; these should be applied continuously. Failure of this system can be due to ignorance or arrogance. We attempted to correct these deficiencies by formulating a set of policies which were enforced from 1962 to 1983. The policies related to the following: intensive care (including asthma, nutrition and organ donation), drug prescribing and resuscitation. We believe that these rules improved patient care and the standards of training; the prescribing policy also saved money.

The evolution and nursing history of a general intensive care unit (1962-1983)

In this paper we have reviewed the origin and evolution of Whiston Hospital's General Intensive Care Unit (ICU) from its humble beginnings as an offshoot of a general ward in the early 1960s. The length of service of the senior nursing staff over a period of 21 years was also calculated. The average duration of service was 16.5 years--a figure which significantly surpassed those quoted in the literature. In addition, we have outlined the development of nurse training in intensive care as well as the role of the nurses in research in the ICU. The question as to whether later college-based training was superior to the previous hospital-based course remained unanswered.

Mapping quantitative trait loci for downy mildew resistance in pearl millet

Quantitative trait loci (QTLs) for resistance to pathogen populations of Scelerospora graminicola from India, Nigeria, Niger and Senegal were mapped using a resistant x susceptible pearl millet cross. An RFLP map constructed using F2 plants was used to map QTLs for traits scored on F4 families. QTL analysis was carried out using the interval mapping programme Mapmaker/QTL. Independent inheritance of resistance to pathogen populations from India, Senegal, and populations from Niger and Nigeria was shown. These results demonstrate the existence of differing virulences in the pathogen populations from within Africa and between Africa and India. QTLs of large effect, contributing towards a large porportion of the variation in resistance, were consistently detected in repeated screens. QTLs of smaller and more variable effect were also detected. There was no QTLs that were effective against all four pathogen populations, demonstrating that pathotype-specific resistance is a major mechanism of downy mildew resistance in this cross. For all but one of the QTLs, resistance was inherited from the resistant parent and the inheritance of resistance tended to be the result of dominance or over-dominance. The implications of this research for pearl millet breeding are discussed.