Genetic mutations and phenotype characteristics in peripheral vascular malformations: A systematic review

Vascular malformations (VMs) are clinically diverse with regard to the vessel type, anatomical location, tissue involvement and size. Consequently, symptoms and disease impact differ significantly. Diverse causative mutations in more and more genes are discovered and play a major role in the development of VMs. However, the relationship between the underlying causative mutations and the highly variable phenotype of VMs is not yet fully understood. In this systematic review, we aimed to provide an overview of known causative mutations in genes in VMs and discuss associations between the causative mutations and clinical phenotypes. PubMed and EMBASE libraries were systematically searched on November 9th, 2022 for randomized controlled trials and observational studies reporting causative mutations in at least five patients with peripheral venous, lymphatic, arteriovenous and combined malformations. Study quality was assessed with the Newcastle-Ottawa Scale. Data were extracted on patient and VM characteristics, molecular sequencing method and results of molecular analysis. In total, 5667 articles were found of which 69 studies were included, reporting molecular analysis in a total of 4261 patients and 1686 (40%) patients with peripheral VMs a causative mutation was detected. In conclusion, this systematic review provides a comprehensive overview of causative germline and somatic mutations in various genes and associated phenotypes in peripheral VMs. With these findings, we attempt to better understand how the underlying causative mutations in various genes contribute to the highly variable clinical characteristics of VMs. Our study shows that some causative mutations lead to a uniform phenotype, while other causal variants lead to more varying phenotypes. By contrast, distinct causative mutations may lead to similar phenotypes and result in almost indistinguishable VMs. VMs are currently classified based on clinical and histopathology features, however, the findings of this systematic review suggest a larger role for genotype in current diagnostics and classification.

The fusion of multiple scale data indicates that the carbon sink function of the Qinghai-Tibet Plateau is substantial

BACKGROUND

The Qinghai-Tibet Plateau is the "sensitive area" of climate change, and also the "driver" and "amplifier" of global change. The response and feedback of its carbon dynamics to climate change will significantly affect the content of greenhouse gases in the atmosphere. However, due to the unique geographical environment characteristics of the Qinghai-Tibet Plateau, there is still much controversy about its carbon source and sink estimation results. This study designed a new algorithm based on machine learning to improve the accuracy of carbon source and sink estimation by integrating multiple scale carbon input (net primary productivity, NPP) and output (soil heterotrophic respiration, Rh) information from remote sensing and ground observations. Then, we compared spatial patterns of NPP and Rh derived from the fusion of multiple scale data with other widely used products and tried to quantify the differences and uncertainties of carbon sink simulation at a regional scale.

RESULTS

Our results indicate that although global warming has potentially increased the Rh of the Qinghai-Tibet Plateau, it will also increase its NPP, and its current performance is a net carbon sink area (carbon sink amount is 22.3 Tg C/year). Comparative analysis with other data products shows that CASA, GLOPEM, and MODIS products based on remote sensing underestimate the carbon input of the Qinghai-Tibet Plateau (30-70%), which is the main reason for the severe underestimation of the carbon sink level of the Qinghai-Tibet Plateau (even considered as a carbon source).

CONCLUSIONS

The estimation of the carbon sink in the Qinghai-Tibet Plateau is of great significance for ensuring its ecological barrier function. It can deepen the community's understanding of the response to climate change in sensitive areas of the plateau. This study can provide an essential basis for assessing the uncertainty of carbon sources and sinks in the Qinghai-Tibet Plateau, and also provide a scientific reference for helping China achieve "carbon neutrality" by 2060.

Neurological pain relief interventional radiology procedures

Neurological interventions have taken on a significant role in interventional radiology (IR) practice. Indications fall under three main categories: (1) intraprocedural pain management, (2) cancer pain palliation, and (3) chronic non-cancer pain control. Short-term regional anaesthesia can be achieved with local anaesthetics, while longer-term pain control can be attained with radiofrequency neuromodulation (pulsed or otherwise) or thermal/chemical neurolysis. This review article summarises the therapeutic options, applications, and techniques of commonly used peripheral nerve and plexus interventions in IR.

Age Cutoff for Early-Onset Parkinson's Disease: Recommendations from the International Parkinson and Movement Disorder Society Task Force on Early Onset Parkinson's Disease

Background

Early-onset Parkinson's disease (EOPD)/young-onset Parkinson's disease (YOPD) is defined as Parkinson's disease (PD) with an age at onset (AAO) after age 21 years but before the usual AAO for PD. Consensus is lacking, and the reported maximal age for EOPD/YOPD has varied from 40 to 60 years, leading to a lack of uniformity in published studies and difficulty in harmonization of data. EOPD and YOPD have both been used in the literature, somewhat interchangeably.

Objective

To define the nomenclature and AAO cutoff for EOPD/YOPD.

Methods

An extensive review of the literature and task force meetings were conducted. Conclusions were reached by consensus.

Results

First, the literature has seen a shift from the use of YOPD toward EOPD. This seems motivated by an attempt to avoid age-related stigmatization of patients. Second, in defining EOPD, 56% of the countries use 50 or 51 years as the cutoff age. Third, the majority of international genetic studies in PD use an age cutoff of younger than 50 years to define EOPD. Fourth, many studies suggest that changes in the estrogen level can affect the predisposition to develop PD, making the average age at menopause of 50 years an important factor to consider when defining EOPD. Fifth, considering the differential impact of the AAO of PD on professional and social life, using 50 years as the upper cutoff for the definition of EOPD seems reasonable.

Conclusions

This task force recommends the use of EOPD rather than YOPD. It defines EOPD as PD with AAO after 21 years but before 50 years.

Aqua: A new questionnaire assessing anticholinergic side effects in neurogenic population (Aqua: Anticholinergic side effects questionnaire)

AIMS

Validate a new questionnaire to assess the side effects secondary to anticholinergics in neurogenic population suffering from Adult neurogenic lower urinary tract dysfunction (ANLUTD).

METHODS

We conducted a prospective, monocentric study in a Neuro-urology Department of a University Hospital between February 2015 and April 2020. To allow a full psychometric validation of a questionnaire, the study protocol included 3 steps: qualitative interviews, feasibility study and validation study. The primary outcome was good psychometric properties defined with good internal consistency reliability (Cronbach's α>0.7) and good test-retest reliability (intraclass correlation coefficient (ICC)>0.7).

RESULTS

we included 64 patients with ANLUTD secondary to neurogenic disorders. Feasibility study demonstrate very good acceptation and comprehension for 97% of patients. Validation study showed good internal consistency with Cronbach's α=0,69 and very good ICC=0,73. AQUA is composed with 8 items scoring 0 (no side effect) to 2 (major side effect) for a total score between 0 to 16. Time to fulfill is very quick. Mean score in our population was 4,1 (sd 2,9).

CONCLUSION

AQUA is the first validated tool to assess side effects secondary to antimuscarinic treatment for neurogenic population suffering from ANLUTD.

LEVEL OF PROOF

2.

POS1111 WHAT DOES GRIP STRENGTH REFLECT IN HAND OSTEOARTHRITIS? RESULTS FROM THE DIGICOD COHORT

Background

Among the general population over 60 years-old, the decrease in grip strength is a marker of morbidity and mortality: its measurement during follow-up consultations is considered as a predictive marker of good health status or the patient’s overall fragility (1). However, hand osteoarthritis (HOA), which can modulate grip strength and is also associated with comorbidities is never taken into account, while it is a very common disease.

Objectives

The objectives of this study are to describe grip strength in a symptomatic HOA population, to investigate painful osteoarthritic joints associated with decreased grip strength, and to determine whether decreased grip strength is independently associated with comorbidities in this population.

Methods

DIGICOD is a hospital-based observational cohort including patients with radiographic features of HOA of at least 2 joints or radiographic thumb base OA. Inflammatory rheumatism or crystal arthropathy were excluded. The data at baseline were used for the analysis. Grip strength was the higher score of 3 repeated measures using a Jamar dynamometer. Baseline grip strength of the dominant hand was compared in the cohort between men and women (Student’s T test) and was described by age (by 10-year age groups using Kruskal-Wallis test). In this cross-sectional study, factors associated with a decreased grip strength were investigated using univariate and then multivariate linear regression analysis (with adjustment on age, BMI and variables with p ≤ 0.2 in univariate analysis) with stratification by sex. Results were presented by beta coefficients and their 95% confidence intervals. A first analysis focused on the association of grip strength with local factors: painful locations in the dominant hand by row and radiographic severity according to the total Kellgren-Lawrence (KL) score. The second analysis assessed the patient-level association between decreased grip strength and general characteristics, including cumulative comorbidities and markers of radio-clinical severity of hand OA, namely the AUSCAN pain score and total KL score. A sensitivity analysis was performed to look for association between grip strength and each comorbidity.

Results

394 patients were analyzed, including 329 women (mean ± SD of the dominant hand’s grip strength of 21.6 ± 6.9 kg) and 65 men (34.9 ± 9.8 kg) with a mean age of 66.9 ± 7.3 years. Grip strength decreased with age (p<0.001) and was lower for women (p<0.0001).

Among women, locally, decreased grip strength was independently associated with painful involvement of at least 2 metacarpophalangeal joints (MCPs) (estimated coefficient [95% CI] -3.6 [-6.2; -1.0] kg versus no painful MCPs) but not with proximal and distal interphalangeal joints, and with a high KL total sum score (-0.06 [-0.10; -0.01] kg per additional point). At the patient-level, decreased grip strength was not associated with comorbidities but with radio-clinical severity (p<0.05), i.e. a higher KL total sum score and AUSCAN pain score.

Among men, neither radiographic severity nor painful locations were independently associated with a decrease of grip strength. Conversely, decreased grip strength was associated with at least 3 comorbidities (-8.5 [-15.5; -1.43] kg versus a single comorbidity being OA), independently of radiographic severity. The study of comorbidities individually did not show any particular association with grip strength.

Conclusion

In this cohort of symptomatic HOA, the decrease of grip strength reflects the radio-clinical severity of hand OA among women, whereas among men, it is independently associated with the accumulation of comorbidities. The presence of hand OA should be considered for further studies investigation the relationship between grip strength and morbi-mortality.

References

[1]Bohannon RW. Grip Strength: An Indispensable Biomarker For Older Adults. CIA. oct 2019;Volume 14:1681‑91.

Graph 1.

Grip strength according to the number of comorbidities among men and women

Disclosure of Interests

None declared

Fecal incontinence subtype assessment (FI-SA): A new tool to distinguish among subtypes of fecal incontinence in a neurogenic population

INTRODUCTION

Two subtypes of fecal incontinence (FI) are defined in the literature (urge and passive FI). The pertinence of this classification is unknown due to conflicting findings and heterogeneity of definitions. However, no questionnaire is available to clearly classify patients among subtypes. The objective of the present study was to develop and validate a new tool (Fecal incontinence subtype assessment, FI-SA) in order to better classify patients among the different subtypes of FI.

METHODS

A prospective monocentric study was conducted in consecutive patients with FI according to Rome IV criteria. To validate psychometric properties of the FI-SA questionnaire, a literature review and qualitative interviews were performed and discussed with an expert panel. A feasibility study was realized to assess acceptability and comprehension of items. The reproducibility was investigated in a validation study.

RESULTS

Comprehension and acceptability were excellent in 90% of patients in the feasibility study (n = 30). Validation study (n = 100) showed a good reproducibility with an intra-class correlation coefficient of 0.91 and 0.89 for questions 1 and 2. Time to fill the questionnaire was 40.0 s. 98.0% patients were classified among subtypes of FI: 34.0% passive FI, 32.0% urge FI and 32.0% mixed FI.

CONCLUSION

FI-SA is the first questionnaire to classify patients among subtypes of FI with good psychometric characteristics and the first questionnaire introducing the concept of mixed FI. FI-SA could help to determine the pertinence of this classification of FI in the management of these patients.

Acute procedural outcomes of his bundle pacing with or without electrophysiology mapping system: a multicenter study

Funding Acknowledgements

Type of funding sources: None.

Introduction

His bundle pacing (HBP) is associated with improved clinical outcomes compared to right ventricular apical pacing. However, it can be technically challenging and may result in prolonged fluoroscopy and procedural time.

Purpose

We sought to compare the feasibility of performing HBP with or without electrophysiology mapping (EP) system, focusing on evaluating acute procedural success, complication rates and short-term outcomes.

Methods

HBP patients at 3 hospitals were recruited between August 2018 to December 2020. HBP was performed with EP mapping system in 1 center, and without EP mapping in the other 2 centers. Acute procedural success was defined as either selective or non-selective His bundle capture with a threshold of less than or equal to 1.5V at 1ms at the end of procedure implantation.

Results

A total of 233 patients were recruited, of which HBP was performed with EP mapping in 77 patients (33.0%) and without EP mapping in 156 patients (67.0%). Both groups were similar in age (73.2 ± 11.0 years vs 75.3 ± 9.5 years, p = 0.125) and male sex (58.4% vs 48.1%, p = 0.136). There were more patients with ischemic heart disease (45.5% vs 22.4%, p &lt; 0.01) and reduced left ventricular ejection fraction ≤ 40% (28.6% vs 10.9%, p &lt; 0.01) in the group with EP mapping. The indications for HBP was for high-grade atrioventricular block (55.8%), sick sinus syndrome (35.6%) and cardiac resynchronization therapy (CRT) (8.6%). There were more patients who required CRT in the center with EP mapping (18.2% vs 3.8%, p &lt; 0.01). HBP was successful in 39 patients (50.6%) with EP mapping and 93 patients (59.6%) without EP mapping (p= 0.382). The median R wave at implant was similar in both groups [4.0 (2.9 – 6.2) mV vs 4.3 (4.3 – 7.0) mV, p = 0.808]. Impedance at implant (607 ± 195 ohms vs 547 ± 166 ohms, p &lt; 0.01) and selective His bundle bipolar threshold at implant [1.25 (0.75-1.75) V vs 0.7 (0.5 – 1.25) V, p = 0.01] was higher in patients with EP mapping while non-selective His bundle bipolar threshold at implant [1.75 (1.0 – 3.0) V vs 1.5 (0.9 – 2.2) V, p = 0.133] and paced QRS duration (116.4 ± 25.4 ms vs 114.4 ± 24.2 ms, p =0.655) were similar. There were no differences in procedural or fluoroscopy time between groups (111 ± 36.9 min vs 107 ± 40.7 min, p = 0.479; and 10.3 ± 8.9 min vs 12.1± 14.0 min, p = 0.328 respectively). There was a similar rate of acute procedural complications (5.2% vs 1.3%, p = 0.076) and patients requiring wound or lead revision (6.8% vs 1.9%, p = 0.115) after a median follow up duration of 205 days (67-397). The prevalence of new onset paroxysmal atrial fibrillation  (11.7% vs 4.2%, p = 0.037) and all cause mortality (12.3% vs 3.2%, p = 0.029) was increased in patients who underwent HBP with EP mapping.

Conclusion

HBP in centers with or without EP mapping showed similar acute procedure success and complication rates. The use of EP mapping system was not shown to affect procedural or fluoroscopy duration.

Neglected cutaneous skin malignancy: A patient with concurrent giant basal cell carcinoma and melanoma

Background

Giant basal cell carcinomas (BCCs) are a rare subtype of BCC that grow to be greater than 5 cm in diameter. With the increase in size, there is a corresponding increase in metastatic rate and state of local invasion, with a clinical morphology that can be hard to differentiate from other subtypes of cutaneous malignancy. Although histologically equivalent to their common sub‐centimetre counterparts, giant BCCs can precipitate significant systematic medical morbidity as well as psychological trauma, and can be a real surgical reconstructive challenge to clinicians.

Aims

To add breadth to the existing cases in the literature, as well as a fresh patient perspective on the psychological challenges in a patient with Giant BCC.

Materials & Methods

A case from the Waikato Hospital, New Zealand referred to the Plastic and Reconstructive Department is carefully photographed, ordered, and presented.

Results

We present a case of a 15 cm giant BCC of the back existing alongside a neglected thick exophytic melanoma of the elbow in a patient who had been too embarrassed to approach healthcare professionals. These skin lesions were an incidental discovery by the general practitioner after the patient presented with symptoms of shortness of breath.

Discussion

Neglected skin cancers can fungate and be clinically morphologically confusing. Photographs of examples of these tumours can hone clinician awareness of the existance of Giant BCCs.

Conclusion

Giant BCCs are an entity yet to receive standardized treatment stratification. Prompt diagnosis and staging scans mean an expedited path to wide local excision and reconstruction, resulting in timely resolution of patients' immediate morbidity from their oncological disease burden.

1351 Primary Pituitary Abscess Presenting as An Isolated Bitemporal Hemianopia

Pituitary abscesses are rare yet life-threatening entities. Most common presenting features are headache, hypopituitarism, and visual changes. Majority of patients are found to have a predisposing risk factor, such as a pre-existing pituitary lesion, recent pituitary surgery or irradiation, or a primary source of infection. We present the case of a 53-year-old male with a spontaneous pituitary abscess, who presented with an isolated bitemporal hemianopia, but was otherwise asymptomatic with no known risk factors. Magnetic resonance imaging showed a sellar and suprasellar mass, thought to be a pituitary macroadenoma. He underwent endoscopic transsphenoidal adenectomy and cystic fluid was seen intraoperatively. Microbiology analysis showed Staphylococcus Aureus, and a course of intravenous ceftriaxone was commenced. Histopathology reported no evidence of adenoma and impression was of a pituitary abscess. Following transsphenoidal resection and commencement of antibiotic therapy, the bitemporal hemianopia resolved. We therefore report a rare case of primary pituitary abscess and emphasise the importance of including this condition as a differential diagnosis in any patient with a visual deficit or new pituitary lesion.

Expression of 20-hydroxyecdysone-related genes during gonadal development of Teleogryllus emma (Orthoptera: Gryllidae)

Insect gonads develop under endocrine signals. In this study, we assessed the characters of partial complementary DNAs encoding the Teleogryllus emma orthologs of 20-hydroxyecdysone (20E)-related genes (RXR, E75, HR3, Hsc70, and Hsp90) and analyzed their expression patterns in both nymph and adult crickets. 20E treatment suppressed expression of TeEcR, TeRXR, TeE75, TeHR3, TeHsc70, and TeHsp90. Temporal expression analysis demonstrated that TeERR and 20E-related genes were expressed in four stages of gonadal development from the fourth-instar nymph stage to the adult stage. The expression pattern of these genes differed in testicular and ovarian development. TeRXR, HR3, TeHsc70, and TeHsp90 were irregularly expressed in gonads of the same developmental stages, while mRNAs encoding TeERR, TeEcR, and TeE75 accumulated in higher levels in ovaries than in testes. RNA interference (RNAi) of TeEcR expression led to decrease of the expression levels of TeEcR, TeRXR, TeHR3, and TeHsc70, while it enhanced TeE75 and TeHsp90 expressions. These results demonstrate that the TeERR and 20E-related genes help regulate gonadal development, while TeEcR appears to inhibit TeE75 expression, TeE75 inhibits HR3 expression. Hsc70 indirectly regulated the expression of the primary and secondary response genes E74A, E75B, and HR3. Hsp90 regulated Usp expression with no direct regulatory relationship with EcR.

Trans-Ethnic Fine-Mapping of the Major Histocompatibility Complex Region Linked to Parkinson's Disease

BACKGROUND

Despite evidence for the role of human leukocyte antigen (HLA) in the genetic predisposition to Parkinson's disease (PD), the complex haplotype structure and highly polymorphic feature of the major histocompatibility complex (MHC) region has hampered a unified insight on the genetic risk of PD. In addition, a majority of the reports focused on Europeans, lacking evidence on other populations.

OBJECTIVES

The aim of this study is to elucidate the genetic features of the MHC region associated with PD risk in trans-ethnic cohorts.

METHODS

We conducted trans-ethnic fine-mapping of the MHC region for European populations (14,650 cases and 1,288,625 controls) and East Asian populations (7712 cases and 27,372 controls). We adopted a hybrid fine-mapping approach including both HLA genotype imputation of genome-wide association study (GWAS) data and direct imputation of HLA variant risk from the GWAS summary statistics.

RESULTS

Through trans-ethnic MHC fine-mapping, we identified the strongest associations at amino acid position 13 of HLA-DRβ1 (P = 6.0 × 10-15 ), which explains the majority of the risk in HLA-DRB1. In silico prediction revealed that HLA-DRB1 alleles with histidine at amino acid position 13 (His13) had significantly weaker binding affinity to an α-synuclein epitope than other alleles (P = 9.6 × 10-4 ). Stepwise conditional analysis suggested additional independent associations at Ala69 in HLA-B (P = 1.0 × 10-7 ). A subanalysis in Europeans suggested additional independent associations at non-HLA genes in the class III MHC region (EHMT2; P = 2.5 × 10-7 ).

CONCLUSIONS

Our study highlights the shared and distinct genetic features of the MHC region in patients with PD across ethnicities. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Atrial fibrillation and the prognostic performance of biomarkers in heart failure

Background

Consideration of circulating biomarkers for risk stratification in heart failure (HF) is recommended in authoritative international guidelines but the influence of atrial fibrillation (AF) on the prognostic performance of many markers is unclear. Therefore we investigated the interactions between AF and biomarkers in prediction of important clinical outcomes in HF.

Methods

NT-proBNP, pro-atrial natriuretic peptide (MR-proANP), C-type natriuretic peptide (CNP), NT-proCNP, high-sensitivity troponin-T, high-sensitivity troponin-I, mid-regional-propeptide adrenomedullin (MR-proADM), co-peptin (PAVP), growth differentiation factor-15 (GDF-15), sST2, Galectin-3 and procalcitonin levels were measured in a prospectively designed, multicenter, longitudinal study of adults with HF. AF was defined as a documented history of AF based on medical records, and/or presence of AF/atrial flutter on baseline 12-lead ECG. The primary outcome considered was the composite of HF-hospitalization or all-cause mortality on prospective follow-up at 2-years. Cox proportional-hazards models were used in the prognostic evaluation of biomarkers, and each was tested for interaction with AF.

Results

Among 1,099 patients with HF (mean age 62±12 years, 28% female, mean left ventricular ejection fraction 35±16%), 261 (24%) patients had AF. Median levels of NT-proBNP, GDF-15, ST2, MR-proADM, proANP and CNP were higher in AF (p&lt;0.05). Above-median levels of all 12 biomarkers were independently associated with increased risk of the primary outcome. Significant interactions with AF were detected for Galectin-3 and sST2. Galectin-3 (&gt;7.7ng/mL) was associated with increased HF-hospitalizations (adjusted hazard ratio [AHR] 1.75, 95% C.I. 1.10–2.77) and all-cause mortality (AHR 1.95, 95% C.I. 1.04–3.63) only among patients with AF. The prognostic performance of sST2 (&gt;35.6ng/mL) was also stronger in AF especially for the primary outcome (AF: AHR 2.06 95% C.I. 1.32–3.21; non-AF: AHR 1.49 95% C.I. 1.18–1.88) and HF-hospitalization (AF: AHR 1.65, 95% C.I. 1.01–2.69; non-AF: AHR 1.32, 95% C.I. 1.02–1.71). The association of Galectin-3 with the composite outcome was not modified by HF type (HFpEF vs HFrEF) (p for 3-way interaction=0.61) except for sST2 (p for 3-way interaction=0.018) where the association appeared stronger in patients with HFpEF and AF (HR 3.12, 95% C.I. 1.26–7.78) compared to those with HFrEF and AF (HR 1.83, 95% C.I. 1.01–3.33) although numbers of events in each subgroup were small. Notably, no such interactions were observed for the most frequently measured prognostic markers in HF including NT-proBNP and the high-sensitivity cardiac troponins.

Conclusion

AF modified the prognostic utility of guideline-endorsed HF-biomarkers, wherein prognostic associations of Galectin-3 and ST2 were limited to, or stronger in, patients with AF. Application of markers for prognostic purposes in HF requires consideration of the presence or absence of AF.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): National Medical Research Council of Singapore

Association between minimum inhibitory concentration, beta-lactamase genes and mortality for patients treated with piperacillin/tazobactam or meropenem from the MERINO study

INTRODUCTION

This study aims to assess the association of piperacillin/tazobactam and meropenem minimum inhibitory concentration (MIC) and beta-lactam resistance genes with mortality in the MERINO trial.

METHODS

Blood culture isolates from enrolled patients were tested by broth microdilution and whole genome sequencing at a central laboratory. Multivariate logistic regression was performed to account for confounders. Absolute risk increase for 30-day mortality between treatment groups was calculated for the primary analysis (PA) and the microbiologic assessable (MA) populations.

RESULTS

320 isolates from 379 enrolled patients were available with susceptibility to piperacillin/tazobactam 94% and meropenem 100%. The piperacillin/tazobactam non-susceptible breakpoint (MIC > 16 mg/L) best predicted 30-day mortality after accounting for confounders (odds ratio 14.9, 95% CI 2.8 - 87.2). The absolute risk increase for 30-day mortality for patients treated with piperacillin/tazobactam compared with meropenem was 9% (95% CI 3% - 15%) and 8% (95% CI 2% - 15%) for the original PA population and the post-hoc MA populations, which reduced to 5% (95% CI -1% - 10%) after excluding strains with piperacillin/tazobactam MIC values > 16 mg/L. Isolates co-harboring ESBL and OXA-1 genes were associated with elevated piperacillin/tazobactam MICs and the highest risk increase in 30-mortality of 14% (95% CI 2% - 28%).

CONCLUSION

After excluding non-susceptible strains, the 30-day mortality difference was from the MERINO trial was less pronounced for piperacillin/tazobactam. Poor reliability in susceptibility testing performance for piperacillin/tazobactam and the high prevalence of OXA co-harboring ESBLs suggests meropenem remains the preferred choice for definitive treatment of ceftriaxone non-susceptible E. coli and Klebsiella.

Dietary Antioxidants and Risk of Parkinson's Disease in the Singapore Chinese Health Study

BACKGROUND

Despite experimental evidence implicating oxidative stress in the pathogenesis of PD, epidemiological studies have provided inconsistent associations between dietary antioxidants and risk of developing PD. Furthermore, no study has been done in any Asian population.

OBJECTIVES

We examined the associations for intake levels of dietary carotenoids (α-carotene, β-carotene, lycopene, β-cryptoxanthin, and lutein) and vitamins (vitamin A, C and E) and the risk of developing PD.

METHODS

We used data from the Singapore Chinese Health Study, a population-based prospective cohort of 63,257 men and women aged 45 to 74 years during enrollment in 1993-1998. Antioxidant intake was derived from a validated semiquantitative food frequency questionnaire. Incident cases were identified through follow-up interviews, hospital records, or PD registries through 31 July 2018. Hazard ratios and corresponding 95% confidence intervals were derived from multivariable Cox proportional hazard regression models with adjustment for other lifestyle and dietary factors.

RESULTS

During an average 19.4 years of follow-up, 544 incident PD cases were identified. No association was found for dietary carotenoids, individually or summed. Hazard ratio comparing highest to lowest quartile for total carotenoids was 0.98 (95% confidence interval: 0.76-1.28; Ptrend = 0.83). There were also no clear dose-dependent associations of dietary vitamins A, C, and E with risk of developing PD (all Ptrend  ≥ 0.10). Sensitive analyses with lag time and excluding supplement use did not materially alter results.

CONCLUSIONS

Intake of dietary antioxidants, such as carotenoids and vitamins, was not associated with the risk of developing PD in Singaporean Chinese. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Pulmonary granulomas in a patient with positive ANCA and history of tuberculosis: case report

BACKGROUND

Granulomatous polyangiitis (GPA) is a rare multisystem autoimmune disease of unknown aetiology that is pathologically characterised by necrotising vasculitis, tissue necrosis and granulomatous inflammation, typically in the presence of anti-neutrophil cytoplasmic antibodies (ANCA). However infectious diseases may induce high titre ANCA and mimic vasculitis. Tuberculosis may share many clinical features with GPA including fever, arthralgia, granulomatous inflammation and pulmonary lesions and patients.

CASE PRESENTATION

A 39 year old patient was admitted with ocular irritation and redness, arthralgia and multiple new pulmonary lesions. The past medical history was significant for two episodes of tuberculosis previously requiring prolonged treatment. ANCA antibodies were positive and CT showed multiple pulmonary lesions including cavitatory lesions. After extensive investigation, the patient was treated for GPA with high dose immune suppression with good clinical response.

CONCLUSIONS

Here we review the diagnostic considerations between differentiating GPA and tuberculosis in patients from endemic regions. It is recommended that biopsies of lung lesions, sputum microscopy and multidisciplinary team input are sought as part of the workup when these two differentials are being considered.

LRRK2 N551K and R1398H variants are protective in Malays and Chinese in Malaysia: A case-control association study for Parkinson's disease

BACKGROUND

The LRRK2 gene is associated with Parkinson's disease (PD) as a number of mutations within the gene have been shown to be susceptibility factors. Studies on various global populations have determined that mutations such as G2019S, G2385R, and R1628P in LRRK2 increase the risk of developing PD while the N551K-R1398H haplotype is associated with conferring protection against developing PD. Here we report a study looking at the N551K and R1398H variants for the first time in the Malaysian population.

METHODS

Cases (523) which conformed to the United Kingdom PD Brain Bank Criteria for PD were recruited through trained neurologists and age- and ethnically matched controls (491) were individuals free of any neurological disorder. The N551K and R1398H mutations were genotyped using the Taqman SNP genotyping assay.

RESULTS

A significant protective association for N551K was found in those of Malay ancestry, with a protective trend seen for R1398H. A meta-analysis of Chinese individuals in this cohort with other published cohorts of Chinese ancestry indicated a significant protective role for N551K and R1398H.

CONCLUSION

This study reports that the N551K-R1398H haplotype is also relevant to the Malaysian population, with a significant protective effect found in those of Malay and Chinese ancestries.

[Urethral pain during clean intermittent self catheterization: Retrospective analysis of 77 patients]

OBJECTIVE

Clean self-intermittent catheterization (CIC) is the gold standard of the therapeutic approach of chronic urinary retention. Usually, CIC are safe, effective but in some cases catheterization can determine urethral pain during catheter insertion or withdrawal leading to poor adherence and compliance. To determine prevalence of pain during CIC and verify its impact on adherence to treatment.

METHOD

Retrospective study with evaluation of pain during CIC one month following CIC teaching session by means specific and validated questionnaires: ICDQ (Intermittent Catheterization Difficulties Questionnaire), InCasaq (Intermittent Catheterization Satisfaction Questionnaire), I-CAS (Intermittent Catheterization Adherence Scale).

RESULTS

Seventy-seven patients were recruited and 28 (36%) described pain during CIC. There is a strong relationship between pain and poor adherence (P<0.01). Female patients had a higher risk of urethral pain during CIC and in contrary BMI>25kg/m² seems to be a protective factor of pain.

CONCLUSION

In this series, urethral pain was associated with low compliance and adherence to CIC.

LEVEL OF EVIDENCE

4.

Transcriptomic analysis of immunoglobulin novel antigen receptor (IgNAR) heavy chain constant domains of brownbanded bamboo shark (Chiloscyllium punctatum)

Cartilaginous fish are the evolutionarily oldest group of animals which possess antibodies, T cell receptors and major histocompatibility complex (MHC). The immunoglobulin novel antigen receptor (IgNAR) found in cartilaginous fish is a heavy chain homodimer which lacks light chain. The presence of non-canonical cysteine molecules and lack of CDR2 region make it more significant. To synthesize active binding domains based on variable region of IgNAR (VNAR), knowledge on the constant region dynamics play a significant role. The IgNAR exhibit species variations in its primary sequence features; hence, this study was conducted to determine the IgNAR heavy chain constant domain of the brownbanded bamboo shark (Chiloscyllium punctatum). Peripheral blood leukocytes (PBL) isolated from adult bamboo sharks were used to synthesize a cDNA library. A total of four billion residues of two million sequences (average length 218.41 bp) were obtained. Assembled sequences were aligned with published cartilaginous fish IgNAR constant region sequences. Transcriptome analysis revealed two distinct types of IgNAR in the brownbanded bamboo shark. Also, constant-1 domain sequences displayed 13 unique sequences which may reflect the least number of IgNAR gene clusters. The phylogenetic analysis revealed the closest relationship with the nurse shark (Ginglymostoma cirratum) followed by the wobbegong shark (Orectolobus maculatus) which belong to the same order Orectolobiformes. Analysis of the constant domains of the brownbanded bamboo shark IgNAR revealed an evolutionarily conserved nature and this knowledge can be used to design primers for VNAR cloning. Furthermore, knowledge on the structural features in IgNAR constant domains that increase the stability could be useful in the process of stabilizing human immunoglobulins.

Activity of ceftolozane/tazobactam against a collection of Pseudomonas aeruginosa isolates from bloodstream infections in Australia

Pseudomonas aeruginosa is a common pathogen causing nosocomial infection. In particular, bloodstream infection (BSI) is associated with a high rate of morbidity and mortality. Ceftolozane/tazobactam is a new β-lactam/β-lactamase antimicrobial with activity against P. aeruginosa as well as multidrug resistant (MDR) Gram negative Enterobacteriaceae. Ceftolozane/tazobactam has frequently been used in salvage therapy for MDR P. aeruginosa infections. The aim of this study was to determine the activity of ceftolozane/tazobactam against P. aeruginosa isolates from BSIs collected from three clinical microbiology laboratories in Queensland, Australia, with a high proportion of isolates demonstrating β-lactam resistance. Antimicrobial susceptibility testing was performed by broth microdilution using custom made sensititre plates sourced from ThermoFisher Scientific. In addition to ceftolozane/tazobactam, we also tested piperacillin/tazobactam, ceftazidime, cefepime, meropenem, doripenem, imipenem, aztreonam, ciprofloxacin, levofloxacin, gentamicin, amikacin, tobramycin and colistin. Overall, ceftolozane/tazobactam was the most active agent tested [(MIC_50/90 = 1/2 μg/mL, 96% susceptible (S)]. Against 44 isolates with resistance to at least one other β-lactam agent, 40 were susceptible to ceftolozane/tazobactam. Three ceftolozane/tazobactam resistant isolates were susceptible to colistin, with one of those isolates also susceptible to levofloxacin but not to any other antimicrobials tested. One ceftolozane/tazobactam resistant isolate was susceptible only to meropenem and doripenem but was non-susceptible to imipenem. An association was found between fluoroquinolone resistance and aminoglycoside resistance but not with β-lactam resistance. In summary, ceftolozane/tazobactam was active against most strains tested, including those resistant to other β-lactams. Laboratories should consider testing P. aeruginosa against ceftolozane/tazobactam in suspected MDR or extensively drug resistant (XDR) infections.