Multiplexed Functional Assessment of Genetic Variants in CARD11

Genetic testing has increased the number of variants identified in disease genes, but the diagnostic utility is limited by lack of understanding variant function. CARD11 encodes an adaptor protein that expresses dominant-negative and gain-of-function variants associated with distinct immunodeficiencies. Here, we used a "cloning-free" saturation genome editing approach in a diploid cell line to simultaneously score 2,542 variants for decreased or increased function in the region of CARD11 associated with immunodeficiency. We also described an exon-skipping mechanism for CARD11 dominant-negative activity. The classification of reported clinical variants was sensitive (94.6%) and specific (88.9%), which rendered the data immediately useful for interpretation of seven coding and splicing variants implicated in immunodeficiency found in our clinic. This approach is generalizable for variant interpretation in many other clinically actionable genes, in any relevant cell type.

First United States Outbreak of Mycobacterium abscessus Hand and Foot Disease Among Children Associated With a Wading Pool

BACKGROUND

Mycobacterium abscessus, an emerging pathogen in healthcare settings, has rarely been associated with community outbreaks. During February-May 2013, Idaho public health officials and pediatric infectious disease physicians investigated an outbreak of M abscessus skin infections in children whose only common exposure was an indoor wading pool.

METHODS

Healthcare providers and parents reported possible M abscessus cases. We used a standardized questionnaire to interview parents of affected children. Clinical specimens were submitted for mycobacterial examination. We conducted an environmental investigation of the pool. Microbial isolates from clinical and environmental samples were identified by sequencing polymerase chain reaction amplicons and underwent pulsed-field gel electrophoresis.

RESULTS

Twelve cases were identified. Specimens from 4 of 7 children grew M abscessus or Mycobacterium abscessus/Mycobacterium chelonae . Ten (83%) of 12 children were female; median age was 3 years (range, 2 to 6 years); and all were immunocompetent. Pool maintenance did not fully comply with Idaho state rules governing pool operation. Mycobacterium abscessus/chelonae was isolated from pool equipment. Pulsed-field gel electrophoresis composite patterns were 87% similar between isolates from the pool ladder and 1 patient, and they were 90% similar between isolates from 2 patients. Environmental remediation included hyperchlorination, scrubbing and disinfection of pool surfaces, draining the pool, and replacement of worn pool materials.

CONCLUSIONS

Immunocompetent children acquired M abscessus cutaneous infection involving hands and feet after exposure to a wading pool. Environmental remediation and proper pool maintenance likely halted transmission. Medical and public health professionals' collaboration effectively detected and controlled an outbreak caused by an emerging recreational waterborne pathogen.

Emotions in labour: Italian obstetricians' experiences of presence during childbirth

OBJECTIVE

The present study represents a qualitative research aimed to explore the obstetricians' psychological experiences of birth.

BACKGROUND

During labour the role of obstetricians assumes a fundamental importance in hospitalised childbirth. However, literature analysis has shown that the psychological side of birth has been investigated only considering the woman's and midwife's points of view. The obstetricians' psychological experiences have not been considered enough and only a few studies at a quantitative level have been performed.

METHODS

Seven focus groups for a total of 72 obstetricians were conducted in hospital contexts in Italy. The qualitative methodology of grounded theory was adopted.

FINDINGS

The results were divided into three different core themes: obstetricians' approaches to delivery, critical aspects about relationships in the delivery room, and obstetricians' feelings and emotions in the delivery room. Each theme was subdivided into different subthemes.

CONCLUSION

The results highlight different ways obstetricians approach their profession, the complex and multifaceted relationship with the woman and the extraordinary variety of feelings and emotions, which enrich, but also may complicate, life in the delivery room. Further studies could provide more details to help researchers to develop new and more effective strategies to support obstetricians' training and work.

The experience of pregnancy: a hermeneutical/phenomenological study

The aim of this study was to describe women's experience of pregnancy. The setting was the Alternative Birth Center at Sahlgrenska University Hospital in Göteborg, Sweden, from 1996 to 1997. Anonymous diaries were written by 12 women and analyzed using a hermeneutical/phenomenological approach. The essential structure and interpretation of women's experience of pregnancy can be expressed as "transition to the unknown," which includes three themes: (1) meeting one's life situation, (2) meeting something inevitable, and (3) preparing for the unknown.The essential structure and interpretation of women's experience of pregnancy can be expressed as "transition to the unknown" …

Stimulation of IL-6 Cytokines in Fibroblasts by Toll-like Receptors 2

The osteotropic interleukin-6 (IL-6) types of cytokines IL-6, IL-11, and leukemia inhibitory factor (LIF), but not oncostatin M, are expressed by human gingival fibroblasts, and their expressions are regulated by IL-1 and tumor necrosis factor-α (TNF-α). In the present study, we investigated whether signaling through Toll-like receptor 2 (TLR2) can affect the expression of these cytokines in human gingival fibroblasts. Lipopolysac-charide (LPS) from P. gingivalis was found to stimulate IL-6 and LIF mRNA and protein, but not IL-11 or OSM mRNA. Using two synthetic ligands acting specifically at TLR2 and siRNA knockdown of TLR2, we demonstrated the important role of TLR2 in the stimulation of IL-6 and LIF in gingival fibroblasts. Analysis of these data suggests that signaling through the innate immune system controls the expression of osteotropic cytokines in human gingival fibroblasts.

IL-1beta and TNF-alpha regulate IL-6-type cytokines in gingival fibroblasts

Interleukin-6 (IL-6)-type cytokines are pleiotropic molecules capable of stimulating bone resorption and expressed by numerous cell types. In the present study, we tested the hypothesis that gingival fibroblasts may exert local osteotropic effects through production of IL-6 and related cytokines. IL-6-type cytokine expression and regulation by IL-1beta and tumor necrosis factor-alpha (TNF-alpha) were studied in fibroblasts from the non-inflamed gingiva of healthy individuals. Constitutive mRNA expression of IL-6, IL-11, and leukemia inhibitory factor (LIF), but not of oncostatin M (OSM), was demonstrated, as was concentration-dependent stimulation of IL-6 and LIF mRNA and of protein by IL-1beta and TNF-alpha. IL-11 mRNA and protein were concentration-dependently stimulated by IL-1beta. The signaling pathway involved in IL-6 and LIF mRNA stimulation involved MAP kinases, but not NF-kappaB. The findings support the view that resident cells may influence the pathogenesis of periodontal disease through osteotropic IL-6-type cytokine production mediated by activation of MAP kinases.

ABBREVIATIONS

IL-1alpha (interleukin-1alpha); IL-1beta (interleukin-1beta); IL-6 (interleukin-6); IL-11 (interleukin-11); LIF (leukemia inhibitory factor); OSM (oncostatin M); alpha(1)-coll. I (alpha(1)-collagen I); ALP (alkaline phosphatase); BMP-2 (bone morphogenetic protein-2); OC (osteocalcin); BSP (bone sialoprotein); TNFR I (tumor necrosis factor receptor I); TNFR II (tumor necrosis factor receptor II); IL-1R1 (interleukin-1 receptor 1); GAPDH (glyceraldehyde-3-phosphate dehydrogenase); RPL13A (ribosomal protein L13A); mRNA (messenger ribonucleic acid); cDNA (complementary deoxyribonucleic acid); PCR (polymerase chain-reaction); BCA (bicinchoninic acid); ELISA (enzyme-linked immunosorbent assay); alpha-MEM (alpha modification of Minimum Essential Medium); and FCS (fetal calf serum).

Fosmidomycin plus clindamycin for treatment of pediatric patients aged 1 to 14 years with Plasmodium falciparum malaria

Fosmidomycin plus clindamycin was shown to be efficacious in the treatment of uncomplicated Plasmodium falciparum malaria in a small cohort of pediatric patients aged 7 to 14 years, but more data, including data on younger children with less antiparasitic immunity, are needed to determine the potential value of this new antimalarial combination. We conducted a single-arm study to improve the precision of efficacy estimates for an oral 3-day fixed-ratio combination of fosmidomycin and clindamycin at 30 and 10 mg/kg of body weight, respectively, every 12 hours for the treatment of uncomplicated P. falciparum malaria in 51 pediatric outpatients aged 1 to 14 years. Fosmidomycin plus clindamycin was generally well tolerated, but relatively high rates of treatment-associated neutropenia (8/51 [16%]) and falls of hemoglobin concentrations of > or =2 g/dl (7/51 [14%]) are of concern. Asexual parasites and fever were cleared within median periods of 42 h and 38 h, respectively. All patients who could be evaluated were parasitologically and clinically cured by day 14 (49/49; 95% confidence interval [CI], 93 to 100%). The per-protocol, PCR-adjusted day 28 cure rate was 89% (42/47; 95% CI, 77 to 96%). Efficacy appeared to be significantly reduced in children aged 1 to 2 years, with a day 28 cure rate of only 62% for this small subgroup (5/8). The inadequate efficacy in children of <3 years highlights the need for continued systematic studies of the current dosing regimen, which should include randomized trial designs.

Short-course regimens of artesunate-fosmidomycin in treatment of uncomplicated Plasmodium falciparum malaria

Fosmidomycin is effective against malaria, but it needs to be given for > or =4 days when used alone. We conducted a study of 50 children with Plasmodium falciparum malaria to evaluate the safety and efficacy of consecutively shortened regimens of artesunate-fosmidomycin (1 to 2 mg/kg of body weight and 30 mg/kg of body weight, respectively; doses given every 12 hours). All dosing regimens were well tolerated. Artesunate-fosmidomycin acted rapidly, resulting in consolidated geometric mean parasite and fever clearance times of 24 h and 15 h, respectively. Treatment regimens of > or =2 days led to cure ratios of 100% by day 14 (39/39; 95% confidence interval [95% CI], 91% to 100%). Most importantly, the 3-day regimen achieved 100% cure on day 28 (10/10; 95% CI, 69% to 100%). Treatment with artesunate-fosmidomycin was associated with transient grade I or II neutropenia (absolute neutrophil counts of 750 to 1,200/microl and 400 to 749/microl, respectively) in six or two patients, respectively. Artesunate-fosmidomycin demonstrates the feasibility and potential value of short-course artemisinin-based combination chemotherapy with rapidly eliminated combination partners.

Vasoactive intestinal peptide (VIP)/pituitary adenylate cyclase-activating peptide receptor subtypes in mouse calvarial osteoblasts: presence of VIP-2 receptors and differentiation-induced expression of VIP-1 receptors

Three distinct complementary DNAs for vasoactive intestinal peptide (VIP) and pituitary adenylate cyclase-activating peptide (PACAP) receptors have been cloned and designated VIP-1 receptor (VIP-1R), VIP-2 receptor (VIP-2R), and PACAP receptor (PACAP-R). In the present study, we have characterized the binding sites on primary mouse calvarial osteoblasts for VIP and related peptides. By analyzing the cAMP response, the rank order of response observed was PACAP 38 > PACAP 27 > helodermin > VIP > helospectin > glucagon > PHI >>> secretin. The VIP-2R/PACAP-R antagonist, PACAP 6-38, inhibited both VIP- and PACAP-stimulated cAMP formation. Binding studies using an atomic force microscopy (AFM) technique showed high affinity binding for VIP and PACAP 38, but not for secretin. Radioligand binding studies using (125)I-VIP and (125)I-PACAP 38 demonstrated a more specific and higher affinity binding for PACAP 38 than for VIP. Secretin failed to inhibit both (125)I-VIP and (125)I-PACAP 38 binding. RT-PCR demonstrated that undifferentiated mouse calvarial osteoblasts express messenger RNA for VIP-2R, but not for VIP-1R or PACAP-R. When the osteoblasts were cultured for 20 days to induce bone noduli formation, VIP-1R, in addition to VIP-2R, were expressed when the nodules started to mineralize at 12 days. Taken together, these data demonstrate that mouse calvarial osteoblasts express functional VIP-2R with higher affinity binding for PACAP than for VIP and that the VIP-1R expression is induced during osteoblastic differentiation.

Women's experience of pain during childbirth

OBJECTIVE

To describe women's experience of pain during childbirth.

DESIGN

A qualitative study using a phenomenological approach. Data were collected by tape-recorded interviews.

SETTING

An Alternative Birth Care Centre at a university hospital in Sweden in 1995.

PARTICIPANTS

Nine women, four primiparous and five multiparous who were two to four days post delivery.

KEY FINDINGS

Four themes were identified in the meanings of experience: (1) pain is hard to describe and is contradictory; (2) trust in oneself and one's body; (3) trust in the midwife and husband; and (4) transition to motherhood. The essential structure of the studied phenomenon was described as 'being one's body', which includes a non-objectifying view of the body, a presence in the delivery process, and a meaning connected to the transition to motherhood.

IMPLICATIONS FOR PRACTICE

The women felt that pain was a natural part of the delivery process, and that the strength and power to cope with it came from within the women. A conclusion is that midwives can help birthing women to find their own ability to cope, and should interfere only if the woman asks or if the natural process is disturbed, e.g. by complications. The experience of pain during childbirth, together with the experience of strength during childbirth, gives meaning to the transition to motherhood.

Women's experience of the encounter with the midwife during childbirth

OBJECTIVE

to describe women's experience of the encounter with the midwife during childbirth.

DESIGN

a qualitative study using a phenomenological approach. Data were collected via tape-recorded interviews.

SETTING

the Alternative Birth Care Centre, Sahlgrenska University Hospital, Gothenburg, Sweden in 1994.

PARTICIPANTS

18 women, six primiparous and 12 multiparous who were two to four days post delivery.

KEY FINDINGS

the essential structure of the studied phenomenon was described as 'presence' and included three themes: to be seen as an individual, to have a trusting relationship and to be supported and guided on one's own terms.

IMPLICATIONS FOR PRACTICE

the need to be seen as an individual can be realised by affirmation and familiarity with the midwife and surroundings. A trusting relationship can be obtained by good communication and proficient behaviour. By providing a sense of control the women can be supported and guided on their own terms. Above all they must feel that the midwife is present.