Screening for Anxiety and Depression in Children with Congenital Adrenal Hyperplasia

Objective

Congenital adrenal hyperplasia (CAH) is an inherited condition in which individuals require multiple daily doses of medication and are at risk for life-threatening adrenal crisis. The chronic nature and severity of CAH place children at risk for psychiatric morbidity. The aim was to assess the degree of anxiety and depressive symptoms in children with CAH.

Methods

A cross-sectional cohort study of children (7-17 years) with CAH and their caregivers were recruited between May and December 2021. Children with hypothyroidism (HT) and their caregivers served as unaffected controls. Validated mental health questionnaires [Children’s Depression Inventory 2 Self Report-Short (CDI-2), Screen for Child Anxiety Related Disorders (SCARED), Patient Health Questionnaire modified for Adolescents (PHQ-A); self and proxy] were completed by participants at one clinic visit. Higher scores indicated greater symptoms of anxiety and depression.

Results

A total of 60 children and 56 parents participated. Among the children 34 had CAH (68% female, mean age 11.41±2.5, CAH duration 8.5±4.1) and 26 had HT (73% female, mean age 12.7±2.9 years, HT duration 6.0±4.2 years). There was no increase in anxiety and depression symptoms in children with CAH compared to controls. In sub-analyses, children with CAH and controls reported a greater number of anxiety and depression symptoms than their caregivers on the SCARED and CDI-2, respectively. There was no association between adrenal control and the degree of anxiety or depression symptoms.

Conclusion

Children with CAH do not have more symptoms of anxiety or depression compared to controls. Child and caregiver-proxy responses lack agreement, suggesting that children with CAH may continue to benefit from routine mental health evaluation, regardless of voiced caregiver concern.

On-site treatment of avalanche victims: Scoping review and 2023 recommendations of the international commission for mountain emergency medicine (ICAR MedCom)

INTRODUCTION

The International Commission for Mountain Emergency Medicine (ICAR MedCom) developed updated recommendations for the management of avalanche victims.

METHODS

ICAR MedCom created Population Intervention Comparator Outcome (PICO) questions and conducted a scoping review of the literature. We evaluated and graded the evidence using the American College of Chest Physicians system.

RESULTS

We included 120 studies including original data in the qualitative synthesis. There were 45 retrospective studies (38%), 44 case reports or case series (37%), and 18 prospective studies on volunteers (15%). The main cause of death from avalanche burial was asphyxia (range of all studies 65-100%). Trauma was the second most common cause of death (5-29%). Hypothermia accounted for few deaths (0-4%).

CONCLUSIONS AND RECOMMENDATIONS

For a victim with a burial time ≤ 60 minutes without signs of life, presume asphyxia and provide rescue breaths as soon as possible, regardless of airway patency. For a victim with a burial time > 60 minutes, no signs of life but a patent airway or airway with unknown patency, presume that a primary hypothermic CA has occurred and initiate cardiopulmonary resuscitation (CPR) unless temperature can be measured to rule out hypothermic cardiac arrest. For a victim buried > 60 minutes without signs of life and with an obstructed airway, if core temperature cannot be measured, rescuers can presume asphyxia-induced CA, and should not initiate CPR. If core temperature can be measured, for a victim without signs of life, with a patent airway, and with a core temperature < 30 °C attempt resuscitation, regardless of burial duration.

ODP394 Prevalence of Anxiety and Depressive Symptoms in Children and Adolescents with Congenital Adrenal Hyperplasia (CAH)

Background

CAH is a life-long inherited condition in which individuals require multiple daily doses of medication and are at risk for life-threatening adrenal crises. Adult studies have demonstrated increased rates of psychiatric morbidity with CAH. Given the chronicity and severity of CAH, children are at risk for psychiatric morbidity as well. This study aimed to examine the prevalence of anxiety and depressive symptoms in children and adolescents with CAH. Method: This was a cross-sectional cohort study in which children and adolescents (ages 7-17 years) with CAH (classical or non-classical, on steroid treatment) and their parents were recruited from our institution's urban outpatient clinics from May to December 2021. Healthy, well-controlled children and adolescents with congenital or autoimmune hypothyroidism (HT) and their respective parents served as control participants. Children and adolescents completed questionnaires, based on age eligibility: Screen for Child Anxiety Related Disorders (SCARED), Children's Depression Inventory 2 Self Report – Short (CDI-2), and Patient Health Questionnaire modified for Adolescents (PHQ-A). Parents completed respective parent-proxy questionnaires. Higher scores indicated greater symptoms of anxiety and depression. "At risk" scores were specific to each questionnaire. Measures were completed at a clinic visit, and demographic and past medical history were collected via a separate survey and the electronic medical record.

Results

A total of 58 child-parent dyads completed questionnaires. Thirty-two children had CAH (66% female, age 11.4 ±2.6 years, CAH duration 8.9 ±3.9 years) and 26 had HT (73% female, age 12.7 ±2.9 years, HT duration 6. 0±4.2 years). Thirty-two, 30 and 13 CAH children and 25, 26 and 16 HT children completed the SCARED, CDI-2 and PHQ-A, respectively. There was no significant difference in level of anxiety and depressive symptoms in children with CAH as compared to the HT group (SCARED 19 ±12 vs. 26±17, P=0.200; CDI-2 53±11 vs. 55±11, P=0.400). The CAH group had fewer depressive symptoms than the HT group on the PHQ-A (4±6 vs 6±5, P=0. 038). There was no difference in rate of "at risk" scores between the CAH and HT groups (SCARED 33% vs. 44%, P=0.400; CDI-2 24% vs. 31%, P=0.500; PHQ-A 15% vs. 31%, P=0.400). No adolescent participants were found to have active suicidal ideation or intent. Children with CAH were more likely to score higher than parent-proxy responses for anxiety-related disorder (19 ±12 vs. 10±8, P=0. 003) and depressive symptoms (CDI-2 53±11 vs. 49±10, P=0. 046).

Conclusions

Prevalence of anxiety and depressive symptoms does not appear to be higher in children and adolescents with CAH as compared to controls. There is a lack of agreement between child and parent-proxy responses with parents endorsing fewer anxiety and depression symptoms than children. Findings suggest that children with CAH may benefit from routine mental health evaluations as part of CAH care and not only after voiced parental concern.

Presentation: No date and time listed

Positron emission tomography/computed tomography perfusion imaging with myocardial blood flow has diagnostic and prognostic value for cardiac allograft vasculopathy

Background

Cardiac allograft vasculopathy (CAV) is a leading cause of morbidity and mortality in patients with orthotopic heart transplantation (OHT). Invasive coronary angiography is the traditional method of screening for and diagnosing CAV. Alternative non-invasive modalities have been sought to screen for CAV. A small, single-center study utilizing Positron Emission Tomography/Computed Tomography Perfusion Imaging (PET/CT) with stress myocardial blood flow (MBF) demonstrated good diagnostic and prognostic value for CAV.

Purpose

The purpose of this study was to validate the proposed algorithm for diagnosing and prognosticating CAV by PET/CT with stress MBF in a large and contemporary series.

Methods

Patients with a history of OHT with no prior revascularization in the transplanted heart who underwent PET/CT with MBF were included in the prognostic portion of the study. For the diagnostic value of PET/CT with MBF, only patients who had a PET/CT within 12 months of coronary angiography were included. The diagnostic accuracy of PET/CT was compared to the most recent coronary angiogram. A composite outcome of death, heart failure hospitalization, acute coronary syndrome, revascularization, and re-transplantation was used to validate the prognostic ability of PET/CT with MBF.

Results

450 PET/CT scans with MBF were performed and included in the prognostic portion of the study. 78 patients had PET/CT within 12 months of coronary angiography and were included in the diagnostic portion. Normal perfusion with normal myocardial blood flow had a 100% negative predictive value for moderate-severe CAV by angiography. PET/CT CAV 2/3 had a positive predictive value of 69% for moderate-severe CAV. Over 24 months, there were 20 events in the 39 patients with a PET CAV grade of 2/3 versus 21 events in the 411 patients with a PET CAV grade of 0/1 with a hazard ratio 13.3 (p&lt;0.001).

Conclusions

The current proposed algorithm for diagnosing CAV by PET/CT with stress MBF has excellent negative predictive value along with good positive predictive value for detecting moderate-severe CAV by coronary angiography. A PET/CT with stress MBF with CAV classification of 2/3 is associated with a poor prognosis.

Funding Acknowledgement

Type of funding sources: None.

Communicating a Scientific Story

Public health organizations typically try to raise literacy or counter misinformation with fact sheets and other data-centric messages. Yet research shows that disseminating more information does not necessarily combat myths. Storytelling offers the oral health community another option for engaging audiences and complementing the facts. The early-20th century research into fluoride is one example of an interesting story. Data and stories can complement each other. Using the elements of storytelling to report or summarize research findings could make such findings more relevant to health policy makers, whose decisions are often driven by values and evidence. Although the scientific literature has not produced a definitive template for instilling stories in a study manuscript, I provide several techniques and caveats for oral health researchers to consider.

Perioperative stress dose steroid management of children with classical congenital adrenal hyperplasia: Too much or too little?

BACKGROUND

Children with congenital adrenal hyperplasia (CAH) are at risk for adrenal crises in the perioperative period and require higher doses of glucocorticoids. However, there are no specific protocols detailing the appropriate stress dosing required for children with CAH undergoing surgery with anesthesia.

OBJECTIVE

To evaluate CAH patients using our current hydrocortisone stress dose surgical protocol. We hypothesized that current clinical protocols may overestimate the endogenous response to perioperative stress.

STUDY DESIGN

14 children with CAH scheduled to have genital surgery and a control group of 10 unaffected children scheduled to have cardiac or urologic surgery (of a similar duration) were evaluated in a prospective observational study. Urinary free cortisol (UFC) and urinary 17-hydroxycorticosteroids (17-OHCS) per body surface area were measured in the postoperative period.

RESULTS

UFC levels were significantly higher in CAH patients (115.8 ± 24.6 nmol/m²) than in controls (26.5 ± 12.2 nmol/m²), P < 0.05.17-OHCS levels were also higher in CAH patients than in controls (6.5 ± 0.5 nmol/m² vs. 3.4 ± 0.5 nmol/m²), P < 0.05).

CONCLUSION

In the immediate postoperative period, urinary cortisol and its metabolites are significantly higher in pediatric CAH patients receiving stress dose corticosteroids compared to controls. Results suggest that the amount of hydrocortisone given during our stress dose protocol may be higher than physiologic needs. Future dynamic studies are needed to determine appropriate perioperative and postoperative cortisol requirements in pediatric CAH patients in order to develop optimal stress dose regimens.

6-Year-Old Girl With a Luteinized Follicular Ovarian Cyst and an Estradiol Level &gt; 1,000 PG/ML

Background: Precocious puberty in girls is defined as onset of secondary sexual characteristics, such as breast development, before 8 years of age. To differentiate between central and peripheral precocious puberty, laboratory and imaging evaluation is helpful. When gonadotropins are low but estradiol is elevated, results may suggest a primary ovarian source of estrogen production. Small ovarian cysts are not uncommon, are benign and self-resolve. However, large ovarian cysts are rare, let alone ones requiring surgical removal.

Clinical Case: A 6 year 7 month old girl presented with several days of breast tenderness and palpable bilateral breast tissue noted by her mother. There was no history of vaginal bleeding. There were no reported exposures to estrogen-containing products. Her mother reached menarche at age 14 years. The patient was born full term and was otherwise healthy. On exam, her height was at the 90-95^th %ile (mid-parental height at the 95^th %ile) and her growth velocity was 10.9 cm/yr. She had Tanner 2 breasts (1 cm breast bud on the left and 1.5 cm on the right), Tanner 1 pubic hair and no axillary hair, body odor, acne or café-au-lait macules. A bone age was read as 6 years at a chronological age of 6 years 7 months. A laboratory evaluation revealed an estradiol of 1,029 pg/mL (<15 pg/mL), LH <0.02 mIU/mL, FSH <0.09 mIU/mL, 17-hydroxyprogesterone (17-OHP) 410 ng/dL (<91 ng/dL), AFP 2.3 ng/mL (<6.1 ng/mL), beta-hCG <2 mIU/mL, TSH 2.41 mIU/L (0.5-3.2 mIU/L), and free T4 0.9 ng/dL (0.9-1.4 ng/dL). Pelvic ultrasound revealed a large unilocular cystic structure measuring 6.5 x 4.1 x 6.1 cm in the left adnexal region with no left ovary visualized. The right ovary appeared prepubertal. The uterus was prepubertal in appearance with endometrial thickness of 2 mm. Abdominal ultrasound showed no evidence of a suprarenal mass. A laparoscopic cyst resection was completed, given the risk of left ovarian torsion. Cytology was negative; pathology revealed a luteinized follicular cyst. Repeat labs in one month showed a prepubertal estradiol level of 6.7 pg/mL with LH 0.02 mIU/mL and FSH 0.38 mIU/mL. 17-OHP normalized to 29 ng/dL. Breast tissue had regressed.

Conclusion: This case describes the rare finding of a large luteinized follicular ovarian cyst that required surgical removal in a 6-year-old girl in the setting of a significantly elevated estradiol level. Luteinized follicular cysts have been described in newborns, though rare. To our knowledge, this is the first described case of a luteinized follicular cyst in this patient’s age group. Laboratory and imaging evaluation should be considered in girls presenting with precocious puberty, despite the extent of thelarche, as the clinical examination does not always correlate with degree of estradiol elevation. This is especially important if clinical changes are acute and other features are consistent with puberty, such as rapid linear growth.

Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel

Background

Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments.

Objective

To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments.

Eligibility criteria

All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms.

Sources of evidence

PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles.

Charting methods

Evidence was searched according to clinically relevant topics and PICO questions.

Results

Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland.

Conclusions

Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.

Clostridioides difficile carriage in animals and the associated changes in the host fecal microbiota

The relationship between the gut microbiota and Clostridioides difficile, and its role in the severity of C. difficile infection in humans is an area of active research. Intestinal carriage of toxigenic and non-toxigenic C. difficile strains, with and without clinical signs, is reported in animals, however few studies have looked at the risk factors associated with C. difficile carriage and the role of the host gut microbiota. Here, we isolated and characterized C. difficile strains from different animal species (predominantly canines (dogs), felines (cats), and equines (horses)) that were brought in for tertiary care at North Carolina State University Veterinary Hospital. C. difficile strains were characterized by toxin gene profiling, fluorescent PCR ribotyping, and antimicrobial susceptibility testing. 16S rRNA gene sequencing was done on animal feces to investigate the relationship between the presence of C. difficile and the gut microbiota in different hosts. Here, we show that C. difficile was recovered from 20.9% of samples (42/201), which included 33 canines, 2 felines, and 7 equines. Over 69% (29/42) of the isolates were toxigenic and belonged to 14 different ribotypes including ones known to cause CDI in humans. The presence of C. difficile results in a shift in the fecal microbial community structure in both canines and equines. Commensal Clostridium hiranonis was negatively associated with C. difficile in canines. Further experimentation showed a clear antagonistic relationship between the two strains in vitro, suggesting that commensal Clostridia might play a role in colonization resistance against C. difficile in different hosts.

Predicting lung nodules malignancy

BACKGROUND

It is critical to developing an accurate method for differentiating between malignant and benign solitary pulmonary nodules. This study aimed was to establish a predicting model of lung nodules malignancy in a real-world setting.

METHODS

The authors retrospectively analysed the clinical and computed tomography (CT) data of 121 patients with lung nodules, submitted to percutaneous CT-guided transthoracic biopsy, between 2014 and 2015. Multiple logistic regression was used to screen independent predictors for malignancy and to establish a clinical prediction model to evaluate the probability of malignancy.

RESULTS

From a total of 121 patients, 75 (62%) were men and with a mean age of 64.7 years old. Multivariate logistic regression analysis identified six independent predictors of malignancy: age, gender, smoking status, current extra-pulmonary cancer, air bronchogram and nodule size (p<0.05). The area under the curve (AUC) was 0.8573.

CONCLUSIONS

The prediction model established in this study can be used to assess the probability of malignancy in the Portuguese population, thereby providing help for the diagnosis of lung nodules and the selection of follow-up interventions.

[Is the discipline associated with self-confidence in handling rational antibiotic prescription? : Results from the MR2 study in German hospitals]

BACKGROUND

Besides public awareness and specialist knowledge and training of physicians, their self-confidence plays a key role for clinical decision-making in the respective area.

OBJECTIVE

This exploratory study investigated the influence of the discipline on differences in self-confidence in dealing with antibiotics and in the self-rated knowledge.

METHODS

In 2015 the multi-institutional reconnaissance of practice with multiresistant bacteria (MR2) questionnaire containing items on antibiotic prescription and multiresistant pathogens was sent out to 1061 physicians working in departments for internal medicine, general surgery, gynecology and obstetrics and urology. In 2017 a similar MR2 survey was sent to 1268 specialist and assistant physicians in anesthesiology in Germany. Besides demographic data 4 items on self-confidence in the use of antibiotic treatment and 11 items concerning self-rated knowledge about rational antibiotic therapy and multiresistant pathogens were included in the present analysis. Logistic regression analysis, the χ²-test and the Kruskal-Wallis test were used for statistical analysis of the influence of the discipline on these items.

RESULTS

The response rates were 43% (456 out of 1061) from the non-anesthetists and 56% (705 out of 1268) from the anesthetists. Of the non-anesthetists 44% and 57% of the anesthetists had had no advanced training on antibiotic stewardship during the year before the study. In the overall analysis anesthetists (mean±SD: 2.53±0.54) were significantly less self-confident about antibiotics than colleagues from other departments (internal medicine: 3.10±0.50, general surgery: 2.97±0.44, gynecology and obstetrics: 3.12±0.42 and urology: 3.15±0.44) in the unadjusted (all p<0.001) and adjusted comparison. The analysis of self-rated knowledge about rational antibiotic prescription showed similar results. Senior consultant status and advanced training in infectiology were significantly associated with self-confidence and self-rated knowledge about antibiotics.

CONCLUSION

Anesthetists showed significantly less self-confidence in dealing with antibiotics than colleagues from other disciplines. Advanced training on a rational prescription of antibiotics was associated with a greater self-confidence, so that the implementation of compulsory courses on rational antibiotic stewardship in the respective residency curriculum needs to be considered.

Looking Back and Ahead: The Food and Drug Administration's Regulation of the Tobacco Industry and Next-Generation Products

Regulatory policy toward tobacco significantly affects oral health because tobacco use is a driver of diseases that manifest themselves in or near the oral cavity. Tobacco use in the United States has been associated with millions of cases of periodontal disease. Researchers have identified the role of combusted and noncombusted tobacco products in promoting cancers of the head and neck, leading to disease and premature death. Tobacco companies have moved increasingly toward so-called next-generation products (NGPs)-products that may emit fewer toxins than combustible forms of tobacco. Although NGPs may negatively affect the lungs and other bodily systems, they shift the injection site of nicotine from the lungs to the oral cavity and oral tissues. Because the long-term effects of NGPs are unknown, this tobacco marketing development has profound implications for oral disease. The US Food and Drug Administration exercises regulatory authority over tobacco products. The tobacco industry has avoided meaningful regulation of its products, especially smokeless forms. By publishing new research, oral health scientists can meaningfully shape the climate in which the administration's policy making occurs.

8p 11 Microduplication Is Associated with Neonatal Stridor

We report a term male infant with congenital stridor secondary to tracheomalacia and a mild coarctation of the aorta. Developmental delay was noted upon follow-up. Whole genome SNP microarray analysis showed an ∼846-kb interstitial duplication of the short arm of chromosome 8 (8p11.21p11.1). We report novel clinical findings of this rare genetic condition.

Impact of pore anisotropy on the thermal conductivity of porous Si nanowires

Porous materials display enhanced scattering mechanisms that greatly influence their transport properties. Metal-assisted chemical etching (MACE) enables fabrication of porous silicon nanowires starting from a doped Si wafer by using a metal template that catalyzes the etching process. Here, we report on the low thermal conductivity (κ) of individual porous Si nanowires (NWs) prepared from MACE, with values as low as 0.87 W·m⁻¹·K⁻¹ for 90 nm diameter wires with 35–40% porosity. Despite the strong suppression of long mean free path phonons in porous materials, we find a linear correlation of κ with the NW diameter. We ascribe this dependence to the anisotropic porous structure that arises during chemical etching and modifies the phonon percolation pathway in the center and outer regions of the nanowire. The inner microstructure of the NWs is visualized by means of electron tomography. In addition, we have used molecular dynamics simulations to provide guidance for how a porosity gradient influences phonon transport along the axis of the NW. Our findings are important towards the rational design of porous materials with tailored thermal and electronic properties for improved thermoelectric devices.

Selection between a natural and a cryptic 5' splice site: a kinetic study of the effect of upstream exon sequences

To study the mechanism of selection of 5' splice sites, we first analyzed the in vitro time course of appearance of intermediates and products of splicing at a natural and at a cryptic 5' splice site. Our model system was a transcript derived from the early transcription unit 3 of adenovirus-2 harboring a cryptic 5' splice site Dcr1, 74 nucleotides downstream of the natural site D1. When studied in isolation, the two sites have different kinetics of splicing, Dcr1 being spliced markedly more slowly than D1. The upstream exon, shown elsewhere to have a positive effect on the selection of D1, has no influence on these kinetics; thus, it does not affect selection by modifying the kinetics of splicing. Nevertheless, this exon is of crucial importance for the exclusive selection of D1. We demonstrate that the cryptic site is recognized in all cases, but that exons harboring a potential stem-loop structure (HP1) prevent Dcr1 usage. The data suggest that the upstream exon sequences play the role of a cis-acting selector for the natural 5' splice site. The intrinsically rapid and efficient kinetics of splicing at the natural site and the selector function of the exon sequence may result in the exclusive use of the D1 site in the natural context.

Establishing a canine superficial pyoderma model

AIMS

Pyoderma, predominantly associated with Staphylococcus pseudintermedius, is a common skin infection of dogs that typically requires long-lasting treatments, complicated by increasing antimicrobial resistance. To investigate new treatment strategies, we aimed at establishing a dog model of pyoderma that closely mimics the natural disease.

METHODS AND RESULTS

We inoculated six laboratory beagles with a methicillin-susceptible strain of S. pseudintermedius. One millilitre of approximately 10⁷ , 10⁸ , 10⁹ CFU per ml was topically applied onto clipped and tape stripped area of dog skin, which was then treated with a dermaroller (microneedle size: 500 μm) immediately after administration. Dogs were monitored daily, suspect pustules were cultured for S. pseudintermedius and evaluated by cytological and histopathological methods. After 24 h, all dogs developed papules and pustules at all three bacterial inoculation sites, which worsened over the next 48 h. Cytological samples of all skin lesions revealed neutrophils with intracellular cocci. Histopathology confirmed subcorneal neutrophilic pustular dermatitis with intralesional cocci and acantholytic keratinocytes, consistent with superficial pyoderma. Staphylococcus pseudintermedius was isolated from pustules of all dogs and confirmed to be the inoculating strain. The results were replicated in all dogs after a wash out period of 6 weeks.

CONCLUSIONS

These data demonstrate the feasibility of establishing a dog model of pyoderma.

SIGNIFICANCE AND IMPACT OF THE STUDY

The new model can be used to evaluate novel prevention and treatment options for canine pyoderma.

Comparison of lipopolysaccharides and soluble CD14 measurement between clinically endotoxaemic and nonendotoxaemic horses

REASONS FOR PERFORMING STUDY

Clinically useful biomarkers are needed for early identification of endotoxaemic horses. Soluble CD14 (sCD14) is amplified early in response to inflammatory signals, including bacterial lipopolysaccharide (LPS), and may prove a useful biomarker for clinical endotoxaemia.

OBJECTIVES

The aim of this study was to determine if sCD14 could serve as a more reliable biomarker of the clinical signs of endotoxaemia, compared to measuring LPS alone.

STUDY DESIGN

Prospective observational study in horses at a veterinary teaching hospital.

METHODS

Plasma samples were collected from 20 healthy horses and 35 horses presenting for emergency evaluation. Horses were classified as clinically endotoxaemic, using previously established criteria, if they had a heart rate >70 beats/min, packed cell volume >45% and/or a lesion likely to result in endotoxaemia. Soluble CD14 was measured using a cytometric bead-based assay and LPS was measured using a Limulus amoebocyte lysate (LAL) assay.

RESULTS

Soluble CD14 was higher in horses classified as clinically endotoxaemic (median 1102 ng/ml, interquartile range 439 ng/ml), compared to clinically nonendotoxaemic (median 692 ng/ml, interquartile range 455 ng/ml, P = 0.03. There was no difference in LPS concentrations between clinically nonendotoxaemic (median 5.4 endotoxin units [EU]/ml, interquartile range 5 EU/ml) and endotoxaemic horses (median 7.2 EU/ml, interquartile range 17 EU/ml, P = 0.2). There was no correlation between sCD14 and LPS values in paired serum samples. LPS and sCD14 values were used to generate a receiver operating characteristic curve. The area under the curve for LPS and sCD14 was <0.7, suggesting that sCD14 and LPS were poor predictors of clinical endotoxaemia for the horses in this study.

CONCLUSIONS

Further investigation is warranted to assess the utility of sCD14 measurement as a clinically useful biomarker to identify endotoxaemia in horses.

Biogeography of Deep-sea benthic bacteria at regional scale (LTER HAUSGARTEN, Fram Strait, Arctic)

Knowledge on spatial scales of the distribution of deep-sea life is still sparse, but highly relevant to the understanding of dispersal, habitat ranges and ecological processes. We examined regional spatial distribution patterns of the benthic bacterial community and covarying environmental parameters such as water depth, biomass and energy availability at the Arctic Long-Term Ecological Research (LTER) site HAUSGARTEN (Eastern Fram Strait). Samples from 13 stations were retrieved from a bathymetric (1,284-3,535 m water depth, 54 km in length) and a latitudinal transect (∼ 2,500 m water depth; 123 km in length). 454 massively parallel tag sequencing (MPTS) and automated ribosomal intergenic spacer analysis (ARISA) were combined to describe both abundant and rare types shaping the bacterial community. This spatial sampling scheme allowed detection of up to 99% of the estimated richness on phylum and class levels. At the resolution of operational taxonomic units (97% sequence identity; OTU3%) only 36% of the Chao1 estimated richness was recovered, indicating a high diversity, mostly due to rare types (62% of all OTU3%). Accordingly, a high turnover of the bacterial community was also observed between any two sampling stations (average replacement of 79% of OTU3%), yet no direct correlation with spatial distance was observed within the region. Bacterial community composition and structure differed significantly with increasing water depth along the bathymetric transect. The relative sequence abundance of Verrucomicrobia and Planctomycetes decreased significantly with water depth, and that of Deferribacteres increased. Energy availability, estimated from phytodetrital pigment concentrations in the sediments, partly explained the variation in community structure. Overall, this study indicates a high proportion of unique bacterial types on relatively small spatial scales (tens of kilometers), and supports the sampling design of the LTER site HAUSGARTEN to study bacterial community shifts in this rapidly changing area of the world's oceans.

Fibroblast activation protein in remodeling tissues

Tissue remodeling is critical during development and wound healing. It also characterizes a number of pathologic conditions, including chronic inflammation, fibrosis and cancer. It is well appreciated that reactive stromal cells play critical roles in these settings. However, understanding of the mechanisms involved in the differentiation of reactive stromal cells and their biologic activities has been hampered by the fact that they are generated from diverse progenitors, and by their phenotypic and function heterogeneity. Furthermore, molecular markers that are expressed by all reactive stromal cells and that distinguish them from all other cell types have been lacking. Fibroblast activation protein (FAP) is a serine protease that was originally discovered as a cell surface protein expressed on astrocytomas and sarcomas. Over the last two decades, FAP has attracted increasing attention as a selective marker of carcinoma-associated fibroblasts (CAFs) and more broadly, of activated fibroblasts in tissues undergoing remodeling of their extracellular matrix (ECM) due to chronic inflammation, fibrosis or wound healing. Herein we review the evidence that FAP is indeed a robust and selective marker for reactive mesenchymal stromal cells associated with pathophysiologic tissue remodeling. We also review recent insights obtained using FAP as a tool to define the relationship between subpopulations of reactive stromal cells in various settings of tissue remodeling. Furthermore, we review recent genetic and pharmacologic data indicating that FAP and FAP-expressing cells play important roles in such conditions. Finally, we discuss the potential risks and therapeutic benefits of targeting FAP and FAP-expressing cells, as well as approaches to do so.

Outcome definitions and clinical predictors influence pharmacogenetic associations between HTR3A gene polymorphisms and response to clozapine in patients with schizophrenia

RATIONALE

Pharmacogenetics of schizophrenia has not yet delivered anticipated clinical dividends. Clinical heterogeneity of schizophrenia contributes to the poor replication of the findings of pharmacogenetic association studies. Functionally important HTR3A gene single-nucleotide polymorphisms (SNPs) were reported to be associated with response to clozapine.

OBJECTIVE

The aim of this study was to investigate how the association between HTR3A gene SNP and response to clozapine is influenced by various clinical predictors and by differing outcome definitions in patients with treatment-resistant schizophrenia (TRS).

METHODS

We recruited 101 consecutive patients with TRS, on stable doses of clozapine, and evaluated their HTR3A gene SNP (rs1062613 and rs2276302), psychopathology, and serum clozapine levels. We assessed their socio-demographic and clinical profiles, premorbid adjustment, traumatic events, cognition, and disability using standard assessment schedules. We evaluated their response to clozapine, by employing six differing outcome definitions. We employed appropriate multivariate statistics to calculate allelic and genotypic association, accounting for the effects of various clinical variables.

RESULTS

T allele of rs1062613 and G allele of rs2276302 were significantly associated with good clinical response to clozapine (p = 0.02). However, varying outcome definitions make these associations inconsistent. rs1062613 and rs2276302 could explain only 13.8 % variability in the responses to clozapine, while combined clinical predictors and HTR3A pharmacogenetic association model could explain 38 % variability.

CONCLUSIONS

We demonstrated that the results of pharmacogenetic studies in schizophrenia depend heavily on their outcome definitions and that combined clinical and pharmacogenetic models have better predictive values. Future pharmacogenetic studies should employ multiple outcome definitions and should evaluate associated clinical variables.

The HPB Clinic: Do Patients Want a Copy of Their Clinic Letter?

The NHS plan published by the Department of Health (DH) in 2000 recommended that patients should receive copies of all clinician-generated correspondence written about them. Concerns from many groups delayed widespread implementation of the policy and a committee set up under the NHS Modernisation Board recommended that further research was required in this area prior to rolling out the policy fully. Good practice guidelines on copying letters to patients were subsequently produced by the DH in 2001.

[Hypernatremic alkalosis. Possible counterpart of hyperchloremic acidosis in intensive care patients?]

BACKGROUND

With broad acceptance of Stewart's acid-base model "hyperchloremic acidosis" is regarded as an independent form of metabolic disorder. It is unknown whether hypernatremia plays a corresponding role with respect to the development of alkalosis.

METHODS

A total of 201 artificially ventilated, critically ill patients were monitored for hypernatremic episodes. Inclusion criterion was a serum sodium concentration above 145 mmol/l.

RESULTS

In 20 patients a total of 78 periods of elevated plasma sodium levels lasting at least 24 h were observed. In 86% of these cases sodium and chloride concentrations were simultaneously increased. The development of alkalosis correlated with the strong ion difference (r=0.80, p<0.01) but not with the serum sodium concentration (r=-0.031, p=0.78). In cases without accompanying hyperchloremia (13%) metabolic alkalosis regularly occurred and a correlation between serum sodium concentration and base excess could be verified (r=0.66, p=0.03). Alkalosis occurred in 84.8% of cases where the strong on difference exceeded 39 mmol/l.

CONCLUSION

From the available data hypernatremic alkalosis could not be defined as an independent metabolic disorder. In would seem more appropriate to use the term "strong ion alkalosis" in this context.