Fatal thoracic aortic aneurysm and dissection in a large family with a novel MYLK gene mutation: delineation of the clinical phenotype

Background

Thoracic and abdominal aortic aneurysms and dissection often develop in hypertensive elderly patients. At higher risk are smokers and those who have a family history of aortic aneurysms. In most affected families, the aortic aneurysms and dissection is inherited in an autosomal dominant manner with decreased penetrance and variable expressivity. Mutations at two chromosomal loci, TAA1 at 11q23 and the TAA2 at 5q13–14, and eight genes, MYLK, MYH11, TGFBR2, TGFBR1, ACTA2, SMAD3, TGFB2, and MAT2A, have been identified as being responsible for the disease in 23% of affected families.

Results

Herein, we inform on the clinical, genetic and pathological characteristics of nine living and deceased members of a large consanguineous Arab family with thoracic aortic aneurysm and dissection who carry a missense mutation c.4471G > T (Ala1491Ser), in exon 27 of MYLK gene. We show a reduced kinase activity of the Ala1491Ser protein compared to wildtype protein. This mutation is expressed as aortic aneurysm and dissection in one of two distinct phenotypes. A severe fatal and early onset symptom in homozygous or mild late onset in heterozygous genotypes.

Conclusions

We found that MYLK gene Ala1491Ser mutation affect the kinase activity and clinically, it presents with vascular aneurysms and dissection. We describe a distinct genotype phenotype correlation where; heterozygous patients have mild late onset and incomplete penetrance disease compared with the early onset severe and generally fatal outcome in homozygous patients.

Abstract P2-13-01: Differential protein expression in primary breast cancer tumors spreading to liver or elsewhere

Breast cancer (BC) outcome is determined mainly by its ability to spread to distant sites, since this is the lethal phase of the disease. Metastasizing cells have to acquire various molecular aberrations in order to go through the metastatic cascade and gain organ tropism. These are probably reflected at the primary tumor. This study was aimed to identify a set of abnormally expressed proteins in primary human BC tumors, which spread preferentially to the liver or elsewhere. Methods: We collected archival paraffin embedded primary BC samples from 48 patients who were divided into 3 groups: 10 who developed liver metastases (A), 20 with metastases to other sites (B) and 18 with no BC recurrence (C). Tissue microarray (TMA) were constructed, sliced and subjected to immuno-histochemical staining. A pre-defined panel of 11 proteins was selected, based on published data that were available at the time of study initiation. Level of expression (coded by IRS scoring) and the intra/extracellular location of each protein was determined by an expert pathologist and compared between the three groups. The panel included: cell-cell interaction proteins (CDH1, BIGH3, MMP14, CD44s, Galectin-3), transcription factors (FRA-1, c-Jun, GATA-3, TP53), an inflammatory chemokine (CCL5), cell signaling protein (Wnt-5a). Results: Metastatic tropism to the liver was studied by comparing results between A and B. When similar, A and B were combined and compared with C group. CDH1 protein expression was significantly reduced in the cytoplasm in groups A and B in comparison to C (p=0.004)and over-expressed in the membrane (p<0.001) in both. Hence, cytoplasmic CDH1was higher in group A than B (p=0.03). In group A only, a trend of BIGH3 over-expression was noted, though it did not reach significance. No further differences were found between A versus B. MMP14 was over-expressed both in the membrane and cytoplasm (p=0.001) of A and B, in comparison with C. CD44s was over-expressed in the membrane in A&B versus C (p<0.001). Galectin-3 was over-expressed in the cytoplasm (p=0.005) and down regulated in the nucleus (p=0.015) in both metastatic groups. CCL5 (RANTES) level was significantly reduced in the cytoplasm in A & B (p<0.001) while significantly over-expressed in the nuclei (p=0.005). c-Jun (part of AP1 complex) was over-expressed in both A and B (p=0.021). On the other hand, levels of FRA-1, localized in both cytoplasm and nucleus in C, were reduced in both compartments in A & B (p=0.029). No difference was noted between the 3 groups in level and localization of TP53, GATA-3 and Wnt-5a. Conclusions: Assessment of the expression of proteins in tumor cells should include protein localization besides its level of expression. Both CDH1 and BIGH3 seem to be over-expressed in tumors that spread preferentially to the liver. No significant changes in pattern of expression of the other proteins studied could be correlated with metastatic propensity to the liver. Compartmental translocation of various proteins is correlated with the acquisition of metastatic potential, such as CDH1 and CCL5 which presented a shift from nucleus to cytoplasm, and Galectin-3 and CCL5, where translocation from cytoplasm to membrane were observed in both metastatic groups.

Citation Format: Goldberg H, Fell R, Apel-Sarid L. Differential protein expression in primary breast cancer tumors spreading to liver or elsewhere [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-13-01.

CD8+ lymphocyte depletion without SIV infection does not produce metabolic changes or pathological abnormalities in the rhesus macaque brain

BACKGROUND

Simian immunodeficiency virus (SIV) infection and persistent CD8(+) lymphocyte depletion rapidly leads to encephalitis and neuronal injury. The objective of this study is to confirm that CD8 depletion alone does not induce brain lesions in the absence of SIV infection.

METHODS

Four rhesus macaques were monitored by proton magnetic resonance spectroscopy ((1) H-MRS) before and biweekly after anti-CD8 antibody treatment for 8 weeks and compared with four SIV-infected animals. Post-mortem immunohistochemistry was performed on these eight animals and compared with six uninfected, non-CD8-depleted controls.

RESULTS

CD8-depleted animals showed stable metabolite levels and revealed no neuronal injury, astrogliosis or microglial activation in contrast to SIV-infected animals.

CONCLUSIONS

Alterations observed in MRS and lesions in this accelerated model of neuroAIDS result from unrestricted viral expansion in the setting of immunodeficiency rather than from CD8(+) lymphocyte depletion alone.

Diagnostic conscious pain mapping using laparoscopy under local anaesthetic and sedation in general surgical patients

BACKGROUND

Patients in whom extensive investigations have failed to identify the cause of abdominal pain present a challenge to surgeons. We present our initial experience of using laparoscopy under local anaesthetic and sedation in the diagnosis of chronic abdominal pain.

METHODS AND PATIENTS

Nine patients with chronic abdominal pain and multiple normal investigations underwent laparoscopy under local anaesthetic and sedation. By touching and grasping intra-abdominal viscera and peritoneum, an attempt was made to reproduce the patient's pain.

RESULTS

Two patients were found to have pain arising from the gall bladder and subsequently underwent laparoscopic cholecystectomy with resolution of their symptoms. A third patient had a clinical presentation of chronic acalculous cholecystitis and a normal laparoscopy. She decided to undergo laparoscopic cholecystectomy, which cured her pain. Another patient had pain arising from the appendix, which resolved after an appendicectomy. Three patients had pelvic adhesions, which caused chronic abdominal pain. After adhesiolysis, one is pain free; the others declined surgery for adhesions and their pain resolved. Conscious pain mapping was negative in two patients.

CONCLUSION

Laparoscopy can be carried out in the conscious patient, who is then usually able to collaborate with the surgeon in establishing the source of the pain experienced during conscious pain mapping. Long-term effectiveness and diagnostic accuracy has not yet been established.

Validity of specific subscales of the positive and negative symptom scales in older schizophrenia outpatients

We investigated the construct validity of subscales of the Scale for the Assessment of Positive Symptoms (SAPS) and the Scale for the Assessment of Negative Symptoms (SANS) along with other measures of psychopathology in 109 schizophrenia outpatients aged 45-84 years. Scores on subscales of the SAPS, SANS and Brief Psychiatric Rating Scale (BPRS) and on the Hamilton Depression Scale (HAM-D) were subjected to a principal components analysis and orthogonal rotation followed by an extension analysis. In both analyses, three of four SAPS subscales had their highest loading on the positive symptom factor and four of five SANS subscales had their highest factor loading on the negative symptom factor. The SAPS bizarre behavior subscale, however, had a much higher loading on the depressive symptom factor than on the positive symptom factor, and the SANS avolition-apathy subscale had moderate loadings on both the negative symptom factor and the depressive symptom factor. The use of SAPS and SANS subscales to represent two constructs was largely (but not entirely) validated among middle-aged and elderly schizophrenia outpatients. The SAPS bizarre behavior subscale and, to a lesser extent, the SANS avolition-apathy subscale appear to represent in this older population a separate construct which may be related to depressive symptoms.

Use of wrist activity for monitoring sleep/wake in demented nursing-home patients

Actigraphy is applicable for studying sleep in populations who are unable to tolerate traditional sleep-recording techniques, such as nursing-home patients who are infirm and demented. This study examined whether actigraphy can accurately reflect sleep/wake activity in this population by testing the reliability of a wrist-activity monitor, the Actillume, against traditional sleep measurements and against observations of nursing-home patients. Data from the Actillume are presented as two variables, the sum (total of all activity movements within the prescribed epoch) and the maximum activity (the largest or maximum movement recorded during the prescribed epoch), and by electroencephalogram (EEG). One difficulty in making comparisons was that the EEG records showed diffuse slowing, making it extremely difficult to score sleep/wake activity and making it difficult to use the EEG as a "gold standard". Nevertheless, the correlation for total sleep time from EEG and Actillume was r = 0.91 (p < 0.001) for sum activity and r = 0.81 for maximum activity (p < 0.005). Correlations for percent sleep were r = 0.78 (p < 0.01) for maximum activity and r = 0.61 for sum activity. The comparison of sleep/wake determined by the Actillume vs. observations resulted in a sensitivity of 87% and specificity of 90%. We conclude that the Actillume is the most feasible technique for studying sleep and wake activity in demented nursing-home patients.

Variations in circadian rhythms of activity, sleep, and light exposure related to dementia in nursing-home patients

We measured 24-hour circadian-rhythm patterns of activity and sleep/wake activity in a group of nursing-home patients (58 women and 19 men with a mean age of 85.7 years). Severely demented patients were contrasted with a composite group of moderate y, mild, or not-demented patients. Sleep/wake activity and light exposure were recorded with the Actillume recorder. Cosinor analyses were computed to determine the mesor, amplitude, acrophase, and circadian quotient of the activity rhythms. The diagnosis of dementia was based on the Mini Mental Examination and on examination of medical records. Sleep was extremely fragmented in both groups of nursing-home patients. Severely demented patients slept more both at night and during the day, but there were no significant differences in the number of awakenings during the night or in the number of naps during the day when compared to the composite group of moderate, mild, or no-dementia patients. The severely demented group had lower activity mesor, more blunted amplitude, and were more phase delayed (i.e. had later acrophases) than the other group. In addition, the severely demented patients spent less time exposed to bright light. These results confirm that circadian rhythms in nursing-home patients are disturbed with more disturbance in the severely demented. Much of the disturbance may be related not just to age but to mental status.

Morbidity, mortality and sleep-disordered breathing in community dwelling elderly

A population-based probability sample of elderly individuals (n = 426), who were originally studied between 1981 and 1986 (mean age at initial study was 72.5 years), were followed for mortality. Those with > or = 30 respiratory disturbances per hour of sleep had significantly shorter survival (p = 0.0034), but the respiratory disturbance index (RDI) was not an independent predictor of death. When Cox proportional hazards analysis was done, only age (the strongest predictor), cardiovascular disease and pulmonary disease were independent predictors of death. It may be that factors that are secondary to or associated with sleep-disordered breathing (SDB), such as cardiovascular or pulmonary disease, predispose these elderly to death.

Validating specific psychopathology scales in older outpatients with schizophrenia

To our knowledge, there have been no published studies validating commonly used psychopathology rating scales in older outpatients with schizophrenia. We studied specific psychopathology rating scales (three subscales of the Brief Psychiatric Rating Scale: positive symptoms, negative symptoms, and depression subscales; the Scale for Assessment of Positive Symptoms; the Scale for the Assessment of Positive Symptoms; the Scale for the Assessment of Negative Symptoms; and the Hamilton Depression Rating Scale) in 101 (age > 45 years) DSM-III-R-diagnosed schizophrenia outpatients. We found high interrater reliability (intra-class correlated coefficient > or = .77) on these scales. Using principal components analysis, we demonstrated satisfactory construct validity, suggesting three factors-positive symptoms, negative symptoms, and depressive symptoms.

Sleep-disordered breathing in African-American elderly

Although sleep-disordered breathing (SDB) has been shown to be very prevalent in the elderly, little has been done to examine differences between the elderly of different racial groups. It has been well documented that SDB often results in hypertension and that hypertension is more common in African-Americans than in Caucasians. Therefore, one might suspect that SDB might be more common in African-Americans. Caucasians (n = 346) and African-Americans (n = 54) older than 65 yr of age were studied. African-Americans reported less satisfaction with sleep (p = 0.017), more difficulty falling asleep (p < 0.001), more daytime sleepiness (p = 0.0014), and more frequent morning headaches (p = 0.0043). African-Americans napped 0.8 times more frequently per evening (p = 0.05) and 11 min longer per nap (p = 0.019) than did Caucasians, and they showed a trend toward more total sleep time (428 versus 408 min). Of greater interest was the fact that more African-Americans had severe SDB with a relative risk twofold as great (relative risk = 2.13) as that for Caucasians, which was confirmed in a logistic regression analysis where race was associated with the presence of SDB (RDI > or = 30) independently of age, sex, and body mass index. The mean RDI for those African-Americans with severe SDB was significantly higher than that for Caucasians (72.1 versus 43.3; p = 0.014).

Natural history of sleep disordered breathing in community dwelling elderly

Mild sleep disordered breathing is very common in the elderly, but little is known about the course of the disorder over time. Twenty-four elderly people from a population-based study were recorded three times over an 8.5-year period. There were no significant changes in either apnea index or in respiratory disturbance index (RDI) over time, even when controlled for body mass index. For most subjects, there was great variability over time in the number of respiratory disturbances. The sensitivity of RDI > or = 15 at visit 1 predicting RDI > or = 15 at visit 3 was only 20%. The predictive value was 50%. Sleep disordered breathing measured at a single point in time is rather weakly predictive of the severity of breathing disorder 4-8 years later.

Sleep-disordered breathing in community-dwelling elderly

These are the final results of a survey of sleep-disordered breathing, which examined objective and subjective information from a large randomly selected elderly sample. We randomly selected 427 elderly people aged 65 yr and over in the city of San Diego, California. Twenty-four percent had an apnea index, AI, greater than or equal to 5 and 62% had a respiratory disturbance index, RDI, greater than or equal to 10. Correlates of sleep-disordered breathing included high relative weight and reports of snoring, breathing cessation at night, nocturnal wandering or confusion, daytime sleepiness and depression. Body mass index, falling asleep at inappropriate times, male gender, no alcohol within 2 hr of bedtime and napping were the best predictors of sleep-disordered breathing. Despite statistical significance, all of the associations between interview variables and apnea indices were small. No combination of demographic variables and symptoms allowed highly reliable prediction of AI or RDI.

Periodic limb movements in sleep in community-dwelling elderly

The prevalence of periodic limb movements in sleep (PLMS) in a randomly selected elderly sample is reported. In San Diego, 427 elderly volunteers aged 65 yr and over were recorded in their homes. Forty-five percent had a myoclonus index, MI greater than or equal to 5. Correlates of PLMS included dissatisfaction with sleep, sleeping alone and reported kicking at night. Although statistically significant, the strengths of the associations between interview variables and myoclonus indices were all small. No combination of demographic variables and symptoms allowed highly reliable prediction of PLMS.

The effect of an aldose reductase inhibitor on cardiovascular performance in patients with diabetes mellitus

Because some aldose reductase inhibitor studies have demonstrated clinical improvement in scored neurological signs and symptoms of diabetic neuropathy, a prospective study of the effect on cardiovascular performance of sorbinil 250 mg/day for 12 months was conducted on patients with diabetic autonomic neuropathy who were free of atherosclerotic coronary artery disease and/or cardiomyopathy. After 1 year of treatment, the study group (n = 14) demonstrated significant improvement in both the resting cardiac output (P = 0.02), and the maximal cardiac output (P = 0.03). This observation suggests that the use of an aldose reductase inhibitor may be useful in treating suboptimal cardiovascular performance in patients with diabetic cardiac autonomic neuropathy.

Loreto House: a pattern of care

This short article is primarily concerned with, what the authors consider to be, two important considerations in any form of residential child care, particularly long-term: 1 The great need for a coherent overall philosophy, which is clearly understood by all members of staff. It is felt that, all too often, assumptions are made about general agreement, which are not necessarily borne out by observed practice. 2 The need for the meticulous selection of primary caring staff, followed by relevant in-service training rather than an overreliance upon, what are sometimes, quite arbitrary qualifications. The article attempts to present a broad profile of a unit which, although it does not claim to represent the ideal, is nonetheless beginning to assume a purposive and identifiable character. The point is made that clinicism, professionalism and academic discussion are important but they are not the only considerations. The children must remain the raison d'etre for such a unit, not the justification. The authors hope to have conveyed their conviction that cooperation and communication between the members of a multidisciplinary team presents the most practical and the most productive approach to the care of profoundly and multiply handicapped children.