The weapons of mass destruction-civil support team PA

ABSTRACT

The weapons of mass destruction-civil support team (WMD-CST) physician associate/assistant (PA) is an autonomous PA who balances military and civilian roles to achieve mission success and support the safety of the US public. This article by multiple WMD-CST PAs across the nation describes the WMD-CST PA profession and how traditional PA roles continue to advance.

Combating Fentanyl: National Guard Physician Assistants on the Front Lines of America's War Against Synthetic Opioids

There is a significant threat to global health security due to synthetic opioids, illicitly manufactured fentanyl (IMF), and nefarious uses of pharmaceutical based agents (PBA). Since 2014, increased distribution of synthetic opioids including IMF into the US through China, India, and Mexico has resulted in devastating consequences to the average street drug user. Additionally, clandestine lab operations for pill manufacturing and distribution have increased, along with unintentional drug overdoses due to drugs being laced with fentanyl or some other synthetic opioid derivative. Naloxone has been shown to be an effective and useful tool for reversing signs and symptoms of synthetic opioid overdose, though additional doses may be required depending on the analog. In addition to the risk of overdose in US civilians, other state actors have utilized fentanyl and its analogs as incapacitants resulting in significant numbers of casualties. The National Guard Weapons of Mass Destruction-Civil Support Teams (WMD-CST) have been on the front lines supporting federal law enforcement agencies with hazard identification and assessment. Physician Assistants (PA) are assigned to these units and provide the necessary skills and expertise to keep on scene personnel safe. This article aims to dispel some of the rumors and myths surrounding fentanyl in an effort to educate first receivers, first responders, and hospital providers. Lastly, this article provides a review of synthetic opioid production, overdose, hazards, treatment/countermeasures, decontamination for responders, and the potential use of synthetic opioids as WMDs.

National Guard Response to COVID-19: A Snapshot in Time during the Pandemic

BACKGROUND

Since March of 2020, thousands of National Guard service members have played a key role in the domestic response to COVID-19, ranging from medical support, health screening, decontamination, personal protective equipment (PPE) training, and more. As a result of these missions, there was a hypothesized potential increase in COVID-19 exposure risk.

OBJECTIVES

Assess COVID-19 transmission rates and mortality rates in the US population compared to the National Guard.

METHODS

Six months of retrospective data were assessed with analysis of a snapshot in time for pandemic data on 29 July 2020. Potential relationships between National Guard COVID-19 response personnel, cumulative US COVID-19 cases, National Guard COVID-19 cases, and National Guard COVID-19 fatalities were assessed.

RESULTS

No evidence of correlations exist between the number of National Guard personnel supporting the COVID-19 response and the number of deaths in the National Guard due to COVID-19 (p=0.547), and the number of National Guard COVID-19 cases and the number of deaths in the National Guard due to COVID-19 (p=0.214). The number of COVID-19 cases in the US was positively correlated to the number of deaths in the US due to COVID-19 (rs=0.947, p is less than.001).

CONCLUSIONS

Though much of the data could not be reported due to operational security (OPSEC) and capabilities, activities, limitations, and intentions (CALI) concerns, the data herein demonstrate National Guard service members are significantly less likely to suffer COVID-19 related mortality compared to US civilians. Since the National Guard adheres the same medical and physical fitness standards as set by their parent service (Army and Air Force), it follows overall levels of medical readiness and fitness should start with a higher baseline. Age, medical screening, PPE, and physical fitness requirements have likely contributed to this phenomenon. These results should empower National Guard service members to feel more confident in their roles as they continue to support the COVID-19 response efforts.

Long-term outcomes in patients treated with flecainide for atrial fibrillation with stable coronary artery disease

BACKGROUND

Class 1C antiarrhythmic drugs (AAD) have been associated with harm in patients treated for ventricular arrhythmias with a prior myocardial infarction. Consensus guidelines have advocated that these drugs not be used in patients with stable coronary artery disease (CAD). However, long-term data are lacking to know if unique risks exist when these drugs are used for atrial fibrillation (AF) in patients with CAD without a prior myocardial infarction.

METHODS

In 24,315 patients treated with the initiation of AADs, two populations were evaluated: (1) propensity-matched AF patients with CAD were created based upon AAD class (flecainide, n = 1,114, vs class-3 AAD, n = 1,114) and (2) AF patients who had undergone a percutaneous coronary intervention or coronary artery bypass graft (flecainide, n = 150, and class-3 AAD, n = 1,453). Outcomes at 3 years for mortality, heart failure (HF) hospitalization, ventricular tachycardia (VT), and MACE were compared between the groups.

RESULTS

At 3 years, mortality (9.1% vs 19.3%, P < .0001), HF hospitalization (12.5% vs 18.3%, P < .0001), MACE (22.9% vs 36.6%, P < .0001), and VT (5.8% vs 8.5%, P = .02) rates were significantly lower in the flecainide group for population 1. In population 2, adverse event rates were also lower, although not significantly, in the flecainide compared to the class-3 AAD group for mortality (20.9% vs 25.8%, P = .26), HF hospitalization (24.5% vs 26.1%, P = .73), VT (10.9% vs 14.7%, P = .28) and MACE (44.5% vs 49.5%, P = .32).

CONCLUSIONS

Flecainide in select patients with stable CAD for AF has a favorable safety profile compared to class-3 AADs. These data suggest the need for prospective trials of flecainide in AF patients with CAD to determine if the current guideline-recommended exclusion is warranted.

Adult Plant Leaf Rust Resistance in AC Taber Wheat Maps to Chromosomes 2BS and 3BS

AC Taber is a hard red spring wheat cultivar that has had long-lasting resistance to the leaf rust fungus Puccinia triticina. The objective of this study was to determine the chromosome location of the leaf rust resistance genes in AC Taber. The leaf rust-susceptible cultivar Thatcher was crossed with AC Taber to develop an F₆ recombinant inbred line (RIL) population. The RILs and parents were evaluated for segregation of leaf rust resistance in five field plot tests and in two seedling tests to race BBBDB of P. triticina. A genetic map of the RIL population was developed using 90,000 single nucleotide polymorphism markers with the Illumina Infinium iSelect 90K wheat bead array. Quantitative trait loci (QTLs) with significant effects for lower leaf rust severity in the field plot tests were found on chromosomes 2BS and 3BS. The same QTLs also had significant effects for lower infection type in seedlings to leaf rust race BBBDB. The gene on 2BS was the adult plant resistance gene Lr13, and the gene on 3BS mapped to the same region as the adult plant resistance gene Lr74 and other QTLs for leaf rust resistance. Kompetitive allele-specific PCR assay markers linked to the 2BS and 3BS regions were developed and should be useful for marker-based selection of these genes.

Thatcher wheat line RL6149 carries Lr64 and a second leaf rust resistance gene on chromosome 1DS

The leaf rust resistance gene Lr64 in the Thatcher wheat RL6149 was mapped to chromosome 6AL with SNP and KASP markers and a second leaf rust resistance gene was mapped to chromosome 1DS. RL6149, a near-isogenic line of Thatcher wheat, carries leaf rust resistance gene Lr64 on chromosome arm 6AL. The objective of this study was to develop molecular markers that can be easily used to select wheat lines with Lr64. RL6149 was crossed with Thatcher and F₂ plants derived from a single F₁ plant were advanced to F₆ lines by single seed descent. The 100 F₇ recombinant inbred lines (RIL) were inoculated with two races of P.triticina that differed widely for virulence in order to identify resistant and susceptible RIL. Thirty RIL that differed for resistance and the parental lines were genotyped with the 90 K Infinium iSelect single nucleotide polymorphism (SNP) array to find closely linked markers with Lr64. Seven linked SNPs on chromosome arm 6AL were converted into Kompetitive Allele Specific PCR (KASP) markers that were genotyped on the 100 RIL. A genetic linkage map for the seven KASP markers spanned 19.1 cM on chromosome arm 6AL. KASP marker K-IWB59855 was tightly linked to Lr64. A second unexpected gene for leaf rust resistance also segregated in the F₇ lines. Four KASP markers that spanned 18.6 cM located the gene on chromosome 1DS. The KASP marker K-IWB38437 was tightly linked to the second leaf rust resistance gene.

Views from the clinic: Healthcare provider perspectives on whole genome sequencing in paediatrics

Whole genome sequencing (WGS) is a transformative technology which promises improved diagnostic rates compared to conventional genetic testing strategies and tailored approaches to patient care. Due to the practical and ethical complexities associated with using WGS, particularly in the paediatric context, input from a broad spectrum of healthcare providers can guide implementation strategies. We recruited healthcare providers from the largest paediatric academic health science centre in Canada and conducted semi-structured qualitative interviews, exploring experiences with and perceptions of the opportunities and challenges associated with WGS. Interview transcripts were coded and analyzed thematically. Interviews were completed with 14 genetics professionals (geneticists and genetic counsellors) and 15 non-genetics professionals (physician sub-specialists and nurses). Genetics professionals ordered genetic tests more often and reported greater confidence on pre- and post-test genetic counselling compared to non-genetics professionals. Most healthcare providers endorsed WGS when a more specific test was either not available or not likely to yield a diagnosis. While genetics professionals raised concerns regarding the time demands associated with reviewing WGS variants, non-genetics professionals reflected concerns about knowledge and training. Providers' position on reporting secondary variants to parents drew upon but was not limited to the concept of best interests. Taken together, understanding practical and principled matters of WGS from healthcare providers' perspectives can guide ongoing efforts to implement WGS in paediatrics.

Parents perspectives on whole genome sequencing for their children: qualified enthusiasm?

OBJECTIVE

To better understand the consequences of returning whole genome sequencing (WGS) results in paediatrics and facilitate its evidence-based clinical implementation, we studied parents' experiences with WGS and their preferences for the return of adult-onset secondary variants (SVs)-medically actionable genomic variants unrelated to their child's current medical condition that predict adult-onset disease.

METHODS

We conducted qualitative interviews with parents whose children were undergoing WGS as part of the SickKids Genome Clinic, a research project that studies the impact of clinical WGS on patients, families, and the healthcare system. Interviews probed parents' experience with and motivation for WGS as well as their preferences related to SVs. Interviews were analysed thematically.

RESULTS

Of 83 invited, 23 parents from 18 families participated. These parents supported WGS as a diagnostic test, perceiving clear intrinsic and instrumental value. However, many parents were ambivalent about receiving SVs, conveying a sense of self-imposed obligation to take on the 'weight' of knowing their child's SVs, however unpleasant. Some parents chose to learn about adult-onset SVs for their child but not for themselves.

CONCLUSIONS

Despite general enthusiasm for WGS as a diagnostic test, many parents felt a duty to learn adult-onset SVs. Analogous to 'inflicted insight', we call this phenomenon 'inflicted ought'. Importantly, not all parents of children undergoing WGS view the best interests of their child in relational terms, thereby challenging an underlying justification for current ACMG guidelines for reporting incidental secondary findings from whole exome and WGS.

Caregiving for youth with co-occurring developmental disabilities and behavioral health issues when caregivers face additional health-related stressors: Analysis of risk and protective factors from a national sample

BACKGROUND

Family caregivers of youth with DD and behavioral health issues experience the highest level of caregiving strain. Many must also deal with their own or another family member's chronic health condition, which may place them at additional risk for poor outcomes.

AIMS

(1) Provide a "snapshot" of DD family caregivers based on a national sample; (2) identify risk and protective factors among groups of DD caregivers with graduated levels of health-related stressors; (3) examine the impact of risk and protective factors on strain for DD caregivers.

METHODS AND PROCEDURES

We conducted a secondary analysis of data from N=600 DD caregivers recruited through sites across the United States. Risk and protective factors were compared among three groups of caregivers at study enrollment: (1) those focused on providing care for the target youth with DD, without additional health-related stressors with which to contend; (2) those contending with minor additional health-related stressors; and, (3) those contending with major additional health-related stressors. Predictors of caregiving strain at six months post-enrollment were identified.

RESULTS

52% of the overall sample was unemployed and 71% were living at or below poverty. Differences were found among groups on a variety of risk and protective factors. With some exceptions, predictors of caregiving strain were similar to non-DD populations.

CONCLUSIONS AND IMPLICATIONS

This study provides valuable information about a population of caregivers who are highly vulnerable to poor outcomes. Findings highlight the importance of considering the needs, strengths, and outcomes of family caregivers.

Prediction of histological stage based on cystoscopic appearances of newly diagnosed bladder tumours

INTRODUCTION In the 75-80% of urothelial bladder cancers (UBC) presenting as non-muscle invasive bladder cancer (NMIBC), transurethral resection of bladder tumour (TURBT) is the key treatment and staging procedure. In the 20-25% of patients with muscle invasive bladder cancer (MIBC), further cross-sectional imaging is required to complete the staging process before considering radical treatment. Given the adverse effects of ionising radiation, clinicians identify patients believed to have MIBC, and so requiring further imaging pre-TURBT, at the tumour histology/stage based on the tumour's visual characteristics. There is minimal evidence describing the accuracy of such predictions in newly-diagnosed patients. METHODS Over a 6-year period, a database of patients undergoing resection of newly-diagnosed bladder lesions in a single UK centre was prospectively established. Predictions based on histology were simultaneously recorded, and the accuracy of these predictions of histology/stage subsequently assessed. RESULTS One hundred and twenty two (73.1%) patients with histologically confirmed NMIBC had predictions recorded versus 45 (26.9%) patients with MIBC. Visual assessment predictions of MIBC had a sensitivity of 88.9% (95% confidence interval [CI] 76.5%-95.2%) and a specificity of 91.0% (95% CI 84.6%-94.9%), giving a positive predictive value of 78.4% (95% CI 65.4%-87.5%) and a negative predictive value of 95.7% (95% CI 90.3%-98.1%). CONCLUSIONS We find that visual assessment is accurate in predicting the presence of MIBC. This supports the practice of stratifying patients at the time of initial cystoscopy for those requiring further radiological staging pre-TURBT.

Non-Pharmacological Factors in Drug Therapy—The Inter-Action of Doctor, Patient and Tablet Appearance in the Treatment of Anxiety/Depressive Syndromes

The degree to which placebo response is involved in an active treatment situation in normal clinical practice, and the factors comprising the placebo response, have been analyzed in a study on patients with anxiety/depressive syndromes. Four tablet preparations of different appearance but identical pharmacological activity were used over a three week period, and a comparison of therapeutic benefits between ‘treatments', doctors, and doctor—patient groupings was made, in addition to an analysis of the relationship of patients' self-assessments with their physicians' ratings.

The results showed that although direct pharmacological effect was paramount in determining therapeutic outcome, detailed differences were related to various placebo factors. The similarity between physicians' and patients' ratings tends to decrease during the course of treatment, and possible reasons for this are reviewed in the light of previous work.

Association mapping of North American spring wheat breeding germplasm reveals loci conferring resistance to Ug99 and other African stem rust races

BACKGROUND

The recently identified Puccinia graminis f. sp. tritici (Pgt) race TTKSK (Ug99) poses a severe threat to global wheat production because of its broad virulence on several widely deployed resistance genes. Additional virulences have been detected in the Ug99 group of races, and the spread of this race group has been documented across wheat growing regions in Africa, the Middle East (Yemen), and West Asia (Iran). Other broadly virulent Pgt races, such as TRTTF and TKTTF, present further difficulties in maintaining abundant genetic resistance for their effective use in wheat breeding against this destructive fungal disease of wheat. In an effort to identify loci conferring resistance to these races, a genome-wide association study was carried out on a panel of 250 spring wheat breeding lines from the International Maize and Wheat Improvement Center (CIMMYT), six wheat breeding programs in the United States and three wheat breeding programs in Canada.

RESULTS

The lines included in this study were grouped into two major clusters, based on the results of principal component analysis using 23,976 SNP markers. Upon screening for adult plant resistance (APR) to Ug99 during 2013 and 2014 in artificial stem rust screening nurseries at Njoro, Kenya and at Debre Zeit, Ethiopia, several wheat lines were found to exhibit APR. The lines were also screened for resistance at the seedling stage against races TTKSK, TRTTF, and TKTTF at USDA-ARS Cereal Disease Laboratory in St. Paul, Minnesota; and only 9 of the 250 lines displayed seedling resistance to all the races. Using a mixed linear model, 27 SNP markers associated with APR against Ug99 were detected, including markers linked with the known APR gene Sr2. Using the same model, 23, 86, and 111 SNP markers associated with seedling resistance against races TTKSK, TRTTF, and TKTTF were identified, respectively. These included markers linked to the genes Sr8a and Sr11 providing seedling resistance to races TRTTF and TKTTF, respectively. We also identified putatively novel Sr resistance genes on chromosomes 3B, 4D, 5A, 5B, 6A, 7A, and 7B.

CONCLUSION

Our results demonstrate that the North American wheat breeding lines have several resistance loci that provide APR and seedling resistance to highly virulent Pgt races. Using the resistant lines and the SNP markers identified in this study, marker-assisted resistance breeding can assist in development of varieties with elevated levels of resistance to virulent stem rust races including TTKSK.

Ongoing HIV Transmission and the HIV Care Continuum in North Carolina

OBJECTIVE

HIV transmission is influenced by status awareness and receipt of care and treatment. We analyzed these attributes of named partners of persons with acute HIV infection (index AHI cases) to characterize the transmission landscape in North Carolina (NC).

DESIGN

Secondary analysis of programmatic data.

METHODS

We used data from the NC Screening and Tracing of Active Transmission Program (2002-2013) to determine HIV status (uninfected, AHI, or chronic HIV infection [CHI]), diagnosis status (new or previously-diagnosed), and care and treatment status (not in care, in care and not on treatment, in care and on treatment) of index AHI cases' named partners. We developed an algorithm identifying the most likely transmission source among known HIV-infected partners to estimate the proportion of transmissions arising from contact with persons at different HIV continuum stages. We conducted a complementary analysis among a subset of index AHI cases and partners with phylogenetically-linked viruses.

RESULTS

Overall, 358 index AHI cases named 932 partners, of which 218 were found to be HIV-infected (162 (74.3%) previously-diagnosed, 11 (5.0%) new AHI, 45 (20.6%) new CHI). Most transmission events appeared attributable to previously-diagnosed partners (77.4%, 95% confidence interval 69.4-85.3%). Among these previously-diagnosed partners, 23.2% (14.0-32.3%) were reported as in care and on treatment near the index AHI case diagnosis date. In the subset study of 33 phylogenetically-linked cases and partners, 60.6% of partners were previously diagnosed (43.9-77.3%).

CONCLUSIONS

A substantial proportion of HIV transmission in this setting appears attributable to contact with previously-diagnosed partners, reinforcing the need for improved engagement in care after diagnosis.

Primer ID Informs Next-Generation Sequencing Platforms and Reveals Preexisting Drug Resistance Mutations in the HIV-1 Reverse Transcriptase Coding Domain

Sequencing of a bulk polymerase chain reaction (PCR) product to identify drug resistance mutations informs antiretroviral therapy selection but has limited sensitivity for minority variants. Alternatively, deep sequencing is capable of detecting minority variants but is subject to sequencing errors and PCR resampling due to low input templates. We screened for resistance mutations among 184 HIV-1-infected, therapy-naive subjects using the 454 sequencing platform to sequence two amplicons spanning HIV-1 reverse transcriptase codons 34-245. Samples from 19 subjects were also analyzed using the MiSeq sequencing platform for comparison. Errors and PCR resampling were addressed by tagging each HIV-1 RNA template copy (i.e., cDNA) with a unique sequence tag (Primer ID), allowing a consensus sequence to be constructed for each original template from resampled sequences. In control reactions, Primer ID reduced 454 and MiSeq errors from 71 to 2.6 and from 24 to 1.2 errors/10,000 nucleotides, respectively. MiSeq also allowed accurate sequencing of codon 65, an important drug resistance position embedded in a homopolymeric run that is poorly resolved by the 454 platform. Excluding homopolymeric positions, 14% of subjects had evidence of ≥1 resistance mutation among Primer ID consensus sequences, compared to 2.7% by bulk population sequencing. When calls were restricted to mutations that appeared twice among consensus sequence populations, 6% of subjects had detectable resistance mutations. The use of Primer ID revealed 5-15% template utilization on average, limiting the depth of deep sequencing sampling and revealing sampling variation due to low template utilization. Primer ID addresses important limitations of deep sequencing and produces less biased estimates of low-level resistance mutations in the viral population.

Infection and Colonization of Several Bermudagrasses by Ophiosphaerella korrae

Bermudagrass (Cynodon spp.) is the most commonly used turfgrass in the southern United States where it is severely affected by spring dead spot (SDS) caused by Ophiosphaerella herpotricha, O. korrae, and O. narmari. In this study, infection of bermudagrass roots and stolons by O. korrae was characterized using a transformant that expressed the red fluorescent protein tdTomato. Roots of interspecific hybrid cultivars Midlawn and Tifway 419, C. transvaalensis accessions Uganda and 3200, and C. dactylon cultivar U3 were inoculated and observed from 2 to 14 days postinoculation (DPI) while stolons were observed from 2 to 22 DPI. For all five cultivars tested, a similar level of root colonization was observed; however, differences were observed in the rate of necrosis development. Necrosis of Tifway 419 and Midlawn tissues was evident at 2 DPI, in Uganda and 3200 at 8 DPI, and in U3 necrosis was often absent as late as 14 DPI. The fungus rapidly penetrated the root epidermis and colonized the cortex of all cultivars by 4 DPI. Colonization of stele tissues by O. korrae was rare in hybrid cultivars but common in C. transvaalensis and C. dactylon accessions. On intact stolons, the fungus did not penetrate the epidermis 22 DPI though epidermal necrosis was evident on the surface of only the hybrid bermudagrasses. Wounded stolons became necrotic in all cultivars. Infection and colonization of various bermudagrasses by O. korrae was found to be similar to that by O. herpotricha, suggesting that host genetic resistance may be used for effective management of SDS caused by both species.

Predictive genetic testing for adult-onset disorders in minors: a critical analysis of the arguments for and against the 2013 ACMG guidelines

The publication of the ACMG recommendations has reignited the debate over predictive testing for adult-onset disorders in minors. Response has been polarized. With this in mind, we review and critically analyze this debate. First, we identify long-standing inconsistencies between consensus guidelines and clinical practice regarding risk assessment for adult-onset genetic disorders in children using family history and molecular analysis. Second, we discuss the disparate assumptions regarding the nature of whole genome and exome sequencing underlying arguments of both supporters and critics, and the role these assumptions play in the arguments for and against reporting. Third, we suggest that implicit differences regarding the definition of best interests of the child underlie disparate conclusions as to the best interests of children in this context. We conclude by calling for clarity and consensus concerning the central foci of this debate.

Fluoroscopic sentinel events in neuroendovascular procedures: how to screen, prevent, and address occurrence

Radiation-induced skin injury during fluoroscopic procedures has been recently addressed by The Joint Commission, which defined prolonged fluoroscopy resulting in a cumulative peak skin dose of ≥15 Gy to a single field as a sentinel event (FSE). Neuroendovascular procedures can be associated with a high radiation skin dose and present risks such as potential FSEs. Managing these risks is the responsibility of the interventional neuroradiologist. In this review, we discuss hospital policies needed for screening and preventing FSEs, methods for minimizing radiation-induced skin injury, and actions necessary to address potential FSEs once they have occurred.

Comparison of viral Env proteins from acute and chronic infections with subtype C human immunodeficiency virus type 1 identifies differences in glycosylation and CCR5 utilization and suggests a new strategy for immunogen design

Understanding human immunodeficiency virus type 1 (HIV-1) transmission is central to developing effective prevention strategies, including a vaccine. We compared phenotypic and genetic variation in HIV-1 env genes from subjects in acute/early infection and subjects with chronic infections in the context of subtype C heterosexual transmission. We found that the transmitted viruses all used CCR5 and required high levels of CD4 to infect target cells, suggesting selection for replication in T cells and not macrophages after transmission. In addition, the transmitted viruses were more likely to use a maraviroc-sensitive conformation of CCR5, perhaps identifying a feature of the target T cell. We confirmed an earlier observation that the transmitted viruses were, on average, modestly underglycosylated relative to the viruses from chronically infected subjects. This difference was most pronounced in comparing the viruses in acutely infected men to those in chronically infected women. These features of the transmitted virus point to selective pressures during the transmission event. We did not observe a consistent difference either in heterologous neutralization sensitivity or in sensitivity to soluble CD4 between the two groups, suggesting similar conformations between viruses from acute and chronic infection. However, the presence or absence of glycosylation sites had differential effects on neutralization sensitivity for different antibodies. We suggest that the occasional absence of glycosylation sites encoded in the conserved regions of env, further reduced in transmitted viruses, could expose specific surface structures on the protein as antibody targets.

Vertical T cell immunodominance and epitope entropy determine HIV-1 escape

HIV-1 accumulates mutations in and around reactive epitopes to escape recognition and killing by CD8+ T cells. Measurements of HIV-1 time to escape should therefore provide information on which parameters are most important for T cell-mediated in vivo control of HIV-1. Primary HIV-1-specific T cell responses were fully mapped in 17 individuals, and the time to virus escape, which ranged from days to years, was measured for each epitope. While higher magnitude of an individual T cell response was associated with more rapid escape, the most significant T cell measure was its relative immunodominance measured in acute infection. This identified subject-level or "vertical" immunodominance as the primary determinant of in vivo CD8+ T cell pressure in HIV-1 infection. Conversely, escape was slowed significantly by lower population variability, or entropy, of the epitope targeted. Immunodominance and epitope entropy combined to explain half of all the variability in time to escape. These data explain how CD8+ T cells can exert significant and sustained HIV-1 pressure even when escape is very slow and that within an individual, the impacts of other T cell factors on HIV-1 escape should be considered in the context of immunodominance.

Interspecific nuclear-cytoplasmic compatibility controlled by genes on group 1 chromosomes in durum wheat

Triticum longissimum cytoplasm is incompatible with the T. turgidum nuclear genome. Two nuclear genes, scs and Vi, derived from the nuclear genome of T. timopheevii and by a spontaneous mutation, respectively, restore nuclear-cytoplasmic compatibility, normal plant vigor, and male fertility in these alloplasmic genotypes. The objectives of this study were (i) to determine the chromosomal locations of scs and Vi; (ii) to identify DNA markers for scs and Vi; and (iii) to determine the interactions involving the dosage of scs and Vi. Two populations segregating for scs and Vi were produced and scored for seedling vigor (indicating presence of scs) and degree of self-fertility (indicating presence of Vi). Four RFLP markers were mapped near scs. Aneuploid analysis revealed that these markers, and hence the scs gene, are located on the long arm of chromosome 1A. Four RFLP markers were mapped near Vi on 1BS. Results indicated that other factors may be inhibiting the expression of Vi. We determined the dosage of scs and Vi in both populations with the aid of the linked RFLP markers. Individuals with two versus one dose of scs had reduced self-fertility, while individuals with two versus one dose of Vi had similar self-fertility.

SU-E-I-10: Putting Teeth into Your CT Dosimetry Program: Approaches to Cone- Beam Dental/Maxillofacial CT Dosimetry

PURPOSE

To review and compare different approaches to the problem of dosimetry for limited field-of-view (FOV) cone beam CT devices for dental and maxillofacial applications.

METHODS

The determination of patient doses from specialized, cone-beam CT devices for dental and maxillofacial work requires medical physicists to re-evaluate their dosimetry methods. These devices work in cone-beam geometry, with an axial field dimension on the order of the lengths of the standard head CTDI phantom and pencil ionization chamber. They may also utilize less than 360 degree scans, resulting in asymmetrical radiation distributions. This operating regime is far from that for which conventional CT dosimetry was designed, and alternative approaches must be considered. The alternatives include extensions of conventional CT dosimetry currently used for large axial FOV scanners (e.g. the extended CTDI parameter (CTDIe) for the Toshiba Aquillion One with 160 mm axial FOV) and the new method based on point dosimetry measurements recently formalized in AAPM Report TG-111. Conventional, modified-conventional, and TG-111 dosimetry measurements are used in two CT dose phantoms (adult head and pediatric head) to obtain dose indices for the Planmeca ProMax 3D Max dental CT scanner. Surface dose maps are generated using radiochromic film for correlation with the chamber dosimetry.

RESULTS

Results for the three dosimetry approaches are compared for the specific case of the ProMax 3D Max scanner. Strengths and weaknesses of the three measurement paradigms for this type of application are compared.

CONCLUSIONS

The increasing availability of specialized scanners operating in full cone-beam mode will require the clinical medical physicist to be conversant with extensions to the CT dose index methodology suitable for this equipment.

Recurrent signature patterns in HIV-1 B clade envelope glycoproteins associated with either early or chronic infections

Here we have identified HIV-1 B clade Envelope (Env) amino acid signatures from early in infection that may be favored at transmission, as well as patterns of recurrent mutation in chronic infection that may reflect common pathways of immune evasion. To accomplish this, we compared thousands of sequences derived by single genome amplification from several hundred individuals that were sampled either early in infection or were chronically infected. Samples were divided at the outset into hypothesis-forming and validation sets, and we used phylogenetically corrected statistical strategies to identify signatures, systematically scanning all of Env. Signatures included single amino acids, glycosylation motifs, and multi-site patterns based on functional or structural groupings of amino acids. We identified signatures near the CCR5 co-receptor-binding region, near the CD4 binding site, and in the signal peptide and cytoplasmic domain, which may influence Env expression and processing. Two signatures patterns associated with transmission were particularly interesting. The first was the most statistically robust signature, located in position 12 in the signal peptide. The second was the loss of an N-linked glycosylation site at positions 413-415; the presence of this site has been recently found to be associated with escape from potent and broad neutralizing antibodies, consistent with enabling a common pathway for immune escape during chronic infection. Its recurrent loss in early infection suggests it may impact fitness at the time of transmission or during early viral expansion. The signature patterns we identified implicate Env expression levels in selection at viral transmission or in early expansion, and suggest that immune evasion patterns that recur in many individuals during chronic infection when antibodies are present can be selected against when the infection is being established prior to the adaptive immune response.

First Detection in North America of Virulence in Wheat Leaf Rust (Puccinia triticina) to Seedling Plants of Wheat with Lr21

Leaf rust resistance gene Lr21 is present in hard red spring wheat (Triticum aestivum) cultivars grown in Minnesota, North Dakota, South Dakota, Manitoba, and Saskatchewan. Isolates of Puccinia triticina, the causal organism of wheat leaf rust, with virulence to this gene have not been previously detected in annual virulence surveys in the United States. (2). In 2010, hard red spring wheat cvs. Faller, RB07 (1), and Glenn, all with Lr21, had 0 to 5% levels of leaf rust severity, which was higher than in previous years in research plots in North Dakota and Minnesota. Leaf rust collections from wheat cultivars and germplasm lines with Lr21 at three locations in Minnesota and North Dakota were increased on plants of the leaf rust susceptible wheat Thatcher and the Thatcher line with Lr21. Single uredinia from the collections were isolated and increased on seedlings of Thatcher. The single uredinial isolates were inoculated to 7- to 8-day-old seedling plants of the set of 19 differential lines that are currently used in the leaf rust virulence surveys (2). Thatcher lines with Lr3bg, Lr14b, Lr20, and Lr23 were also tested. The isolates were also inoculated to seedling plants of hard red spring wheat cultivars with Lr21: Glenn, Steele-ND, Faller, RB07, Amidon, AC Cora, and McKenzie (3). Previous standardized methods for growing seedling plants, increase of rust isolates, inoculation, incubation, and evaluation of infection types (IT) were used (2). All tests with the Thatcher differential lines and the cultivars with Lr21 were repeated at least twice. Virulence phenotypes were described based on virulence to the 19 differentials in the P. triticina virulence nomenclature system used in the United States. (2). Two virulence phenotypes, TFBJQ and TFBGQ, with virulence to Lr21 were found at the three locations. TFBJQ is virulent (IT 3 to 4) to genes Lr1, 2a, 2c, 3, 10, 14a, 14b, 20, 21, 24, 26, 28, and avirulent (IT 0 to 2⁺) to genes Lr3ka, Lr3bg, Lr9, Lr11, Lr17, Lr18, Lr30, LrB, and Lr39/41. TFBGQ was avirulent to Lr14a and Lr20, but identical to TFBJQ for virulence and avirulence to the other resistance genes. Isolates of both phenotypes were virulent on seedlings of Faller, Glenn, RB07 (1), Steele-ND, AC Cora, and Amidon. McKenzie had IT of 2⁺ due to the additional presence of Lr16 (3). Both TFBJQ and TFBGQ have intermediate IT of 2⁺ to Lr16; IT 2⁺3 to Lr23, and are completely virulent to Lr1, Lr2a, and Lr10 that are present in hard red spring wheat cultivars. Both phenotypes have high IT to Lr24 and Lr26 that are present in soft red winter wheat and hard red winter wheat cultivars. The Lr21 virulent phenotypes likely arose by mutation from the group of P. triticina genotypes in the simple sequence repeat group NA-5 (4) that have intermediate IT of ;2^- to ;2⁺ to the Thatcher line with Lr21. P. triticina isolates with virulence to Lr21 are a new threat to wheat production since in 2010 more than 50% of the hard red spring wheat acreage in Minnesota and North Dakota relied on Lr21 for effective resistance to leaf rust. References: (1) J. A. Anderson et al. J. Plant Regist. 3:175, 2009. (2) J. A. Kolmer et al. Plant Dis. 94:775, 2010. (3) B. McCallum and P. Seto-Goh. Can. J. Plant Pathol. 32:387, 2010. (4) M. E. Ordoñez and J. A. Kolmer. Phytopathology 99:750, 2009.

Cross-sectional detection of acute HIV infection: timing of transmission, inflammation and antiretroviral therapy

BACKGROUND

Acute HIV infection (AHI) is a critical phase of infection when irreparable damage to the immune system occurs and subjects are very infectious. We studied subjects with AHI prospectively to develop better treatment and public health interventions.

METHODS

Cross-sectional screening was employed to detect HIV RNA positive, antibody negative subjects. Date of HIV acquisition was estimated from clinical history and correlated with sequence diversity assessed by single genome amplification (SGA). Twenty-two cytokines/chemokines were measured from enrollment through week 24.

RESULTS

Thirty-seven AHI subjects were studied. In 7 participants with limited exposure windows, the median exposure to HIV occurred 14 days before symptom onset. Lack of viral sequence diversification confirmed the short duration of infection. Transmission dates estimated by SGA/sequencing using molecular clock models correlated with transmission dates estimated by symptom onset in individuals infected with single HIV variants (mean of 28 versus 33 days). Only 10 of 22 cytokines/chemokines were significantly elevated among AHI participants at enrollment compared to uninfected controls, and only 4 participants remained seronegative at enrollment.

DISCUSSION

The results emphasize the difficulty in recruiting subjects early in AHI. Viral sequence diversity proved accurate in estimating time of infection. Regardless of aggressive screening, peak viremia and inflammation occurred before enrollment and potential intervention. Given the personal and public health importance, improved AHI detection is urgently needed.

Mapping QTL in the porcine MHC region affecting fatness and growth traits in a Meishan/Large White composite population

A number of studies have mapped QTL regulating porcine fatness and growth traits to the region of the major histocompatibility complex (MHC) on porcine chromosome 7 using various experimental crosses. The QTL results from crosses using the Chinese Meishan (MS) (slow growing and fat) are particularly interesting because the MS alleles have been found to be associated with increased growth rate and reduced backfat depth. We investigated these QTL further in a composite population derived previously over eight generations by intercrossing Meishan and the European Large White breeds. Genotype information from 32 markers in a 15cM target region was used in linkage and association analyses. A two-step variance component analysis identified QTL for three growth-related traits, explaining 19 ∼ 24% of the phenotypic variance with a confidence interval of 4 cM in the target region. SNP association analyses found that ss181128966 and ss181128924 within the QTL interval were strongly associated with the growth traits. Only weak signals for an effect on backfat depth were found in the association and linkage analyses, possibly because of past directional selection in the composite population.

Design of polymer nanocomposites in solution by polymer functionalization

Polymer nanocomposites, materials combining polymers and inorganic components such as nanosized crystallites or nanoparticles have attracted significant attention in recent years. A successful strategy for designing polymer nanocomposites is polymer functionalization via attaching functional groups with specific affinity for the inorganic component. In this paper, a systematic investigation by molecular dynamics of polymer functionalization for design of composites combining nanosize crystallites with multiblock polymers in solution is presented. It is shown that functionalization is an example of active self-assembly, where the resulting polymer nanocomposite exhibits a different type of order than the original pure polymer system (without inorganic components). Optimal polymer architectures and concentrations are identified appropriate for different applications, alongside an in-depth analysis on the origin and stability of the resulting phases as well as its experimental implications.

A substantial transmission bottleneck among newly and recently HIV-1-infected injection drug users in St Petersburg, Russia

There are limited data on the genetic complexity of human immunodeficiency virus type 1 (HIV-1) after transmission among a cohort of injection drug users (IDUs). We used single-genome amplification of HIV-1 env to determine the genotypic characteristics of virus among IDUs with acute infection in St Petersburg, Russia. Our results indicate that a single variant was transmitted in a majority of cases (9 of 13 participants), which is analogous to what is observed in sexual transmission. These data are most consistent with a genetic bottleneck during transmission by injection drug use that is due to a small inoculum, which most often results in the transmission of a low-complexity viral population.

A rev1-vpu polymorphism unique to HIV-1 subtype A and C strains impairs envelope glycoprotein expression from rev-vpu-env cassettes and reduces virion infectivity in pseudotyping assays

Functional studies of HIV-1 envelope glycoproteins (Envs) commonly include the generation of pseudoviruses, which are produced by co-transfection of rev-vpu-env cassettes with an env-deficient provirus. Here, we describe six Env constructs from transmitted/founder HIV-1 that were defective in the pseudotyping assay, although two produced infectious virions when expressed from their cognate proviruses. All of these constructs exhibited an unusual gene arrangement in which the first exon of rev (rev1) and vpu were in the same reading frame without an intervening stop codon. Disruption of the rev1-vpu fusion gene by frameshift mutation, stop codon, or abrogation of the rev initiation codon restored pseudovirion infectivity. Introduction of the fusion gene into wildtype Env cassettes severely compromised their function. The defect was not due to altered env and rev transcription or a dominant negative effect of the expressed fusion protein, but seemed to be caused by inefficient translation at the env initiation codon. Although the rev1-vpu polymorphism affects Env expression only in vitro, it can cause problems in studies requiring Env complementation, such as analyses of co-receptor usage and neutralization properties, since 3% of subtype A, 20% of subtype C and 5% of CRF01_A/E viruses encode the fusion gene. A solution is to eliminate the rev initiation codon when amplifying rev-vpu-env cassettes since this increases Env expression irrespective of the presence of the polymorphism.

Pneumonia risk in COPD patients receiving inhaled corticosteroids alone or in combination: TORCH study results

Inhaled corticosteroids (ICS) are important in reducing exacerbation frequency associated with chronic obstructive pulmonary disease (COPD). However, little is known about the risk of associated infections. In a post hoc analysis of the TOwards a Revolution in COPD Health (TORCH) study, we analysed and identified potential risk factors for adverse event reports of pneumonia in this randomised, double-blind trial comparing twice-daily inhaled salmeterol (SAL) 50 microg, fluticasone propionate (FP) 500 microg, and the combination (SFC) with placebo in 6,184 patients with moderate-to-severe COPD over 3 yrs. Despite a higher withdrawal rate in the placebo arm, after adjusting for time on treatment, a greater rate of pneumonia was reported in the FP and SFC treatment arms (84 and 88 per 1,000 treatment-yrs, respectively) compared with SAL and placebo (52 and 52 per 1,000 treatment-yrs, respectively). Risk factors for pneumonia were age > or =55 yrs, forced expiratory volume in 1 s <50% predicted, COPD exacerbations in the year prior to the study, worse Medical Research Council dyspnoea scores and body mass index <25 kg.m(-2). No increase in pneumonia deaths with SFC was observed; this could not be concluded for FP. Despite the benefits of ICS-containing regimens in COPD management, healthcare providers should remain vigilant regarding the possible development of pneumonia as a complication in COPD patients receiving such therapies.

Adherence to inhaled therapy, mortality and hospital admission in COPD

BACKGROUND

Little is known about adherence to inhaled medication in chronic obstructive pulmonary disease (COPD) and the impact on mortality and morbidity.

METHODS

Data on drug adherence from a randomised double-blind trial comparing inhaled salmeterol 50 microg + fluticasone propionate 500 microg twice daily with placebo and each drug individually in 6112 patients with moderate to severe COPD over 3 years in the TORCH study were used. All-cause mortality and exacerbations leading to hospital admission were primary and secondary end points. The study of adherence was not specified a priori as an ancillary study.

RESULTS

Of the 4880 patients (79.8%) with good adherence defined as >80% use of study medication, 11.3% died compared with 26.4% of the 1232 patients (20.2%) with poor adherence. The annual rates of hospital admission for exacerbations were 0.15 and 0.27, respectively. The association between adherence and mortality remained unchanged and statistically significant after adjusting for other factors related to prognosis (hazard ratio 0.40 (95% CI 0.35 to 0.46), p<0.001). The association was even stronger when analysing on-treatment deaths only. Similarly, the association between adherence and hospital admission remained unchanged and significant in a multivariate analysis (rate ratio 0.58 (95% CI 0.44 to 0.73, p<0.001). The association between increased adherence and improved mortality and reduction in hospital admission was independent of study treatment. The effect of treatment was more pronounced in patients with good adherence than in those with poor adherence.

CONCLUSION

Adherence to inhaled medication is significantly associated with reduced risk of death and admission to hospital due to exacerbations in COPD. Further research is needed to understand these strong associations.

Mutations in LAMB2 causing a severe form of synaptic congenital myasthenic syndrome

Background:

We describe a severe form of congenital myasthenic syndrome (CMS) associated with congenital nephrosis and ocular malformations caused by two truncating mutations in the gene encoding the laminin β2 subunit (LAMB2).

Methods and results:

Mutational analysis in the affected patient, who has a history of a serious untoward reaction to treatment with acetylcholinesterase inhibition, revealed two frame-shifting heteroallelic mutations, a maternally inherited 1478delG and a paternally inherited 4804delC. An anconeus muscle biopsy demonstrated a profound distortion of the architecture and function of the neuromuscular junction, which was strikingly similar to that seen in mice lacking laminin β2 subunit. The findings included: pronounced reduction of the axon terminal size with encasement of the nerve endings by Schwann cells, severe widening of the primary synaptic cleft and invasion of the synaptic space by the processes of Schwann cells, and moderate simplification of postsynaptic folds and intact expression of the endplate acetylcholinesterase. The endplate potential quantal content was notably reduced, while the frequencies and amplitudes of miniature endplate potentials were only moderately diminished and the decay phases of miniature endplate potentials were normal. Western blot analysis of muscle and kidney tissue and immunohistochemistry of kidney tissue showed no laminin β2 expression.

Conclusion:

This case, which represents a new type of synaptic CMS, exemplifies the wide variability of phenotypes associated with LAMB2 mutations and underscores the fundamental role that laminin β2 plays in the development of the human neuromuscular junction.

Micellar crystals in solution from molecular dynamics simulations

Polymers with both soluble and insoluble blocks typically self-assemble into micelles, which are aggregates of a finite number of polymers where the soluble blocks shield the insoluble ones from contact with the solvent. Upon increasing concentration, these micelles often form gels that exhibit crystalline order in many systems. In this paper, we present a study of both the dynamics and the equilibrium properties of micellar crystals of triblock polymers using molecular dynamics simulations. Our results show that equilibration of single micelle degrees of freedom and crystal formation occur by polymer transfer between micelles, a process that is described by transition state theory. Near the disordered (or melting) transition, bcc lattices are favored for all triblocks studied. Lattices with fcc ordering are also found but only at lower kinetic temperatures and for triblocks with short hydrophilic blocks. Our results lead to a number of theoretical considerations and suggest a range of implications to experimental systems with a particular emphasis on Pluronic polymers.

Genetics of Leaf Rust Resistance in Brambling Wheat

The CIMMYT-developed spring wheat 'Brambling' has a high level of adult-plant resistance (APR) to leaf rust caused by Puccinia triticina. Our objectives were to determine the genetic basis of resistance in seedlings and adult plants and the magnitude of genotype × environment effects on the expression of APR. Brambling was crossed with spring wheat 'Jupateco 73S' that is highly susceptible to current predominant P. triticina races in Mexico and the United States. The F₁, F_2:3, F_4:5, F_4:6, and F_5:7 recombinant inbred lines (RILs) were evaluated under artificial field epidemics in Mexico and St. Paul, MN. The RILs also were tested with five races of P. triticina in greenhouse seedling experiments. A DNA marker was used to postulate the presence of slow-rusting gene Lr34 in the RILs. F₁ data suggested strong dominant effect of the APR genes in Brambling. The proportion of homozygous susceptible lines in each generation indicated the presence of three effective resistance genes in adult plants of Brambling in tests in Mexico and three or four genes in tests in St. Paul. The RILs segregated for seedling genes Lr14a and Lr23 and adult-plant slow-rusting gene Lr34 derived from Brambling and Lr17a from Jupateco 73S. Gene Lr23 conditioned APR to P. triticina races present in the St. Paul nursery and accounted for the additional effective gene at this location. Expression of APR was influenced by the environment in the RILs, even though Brambling displayed a consistent response, indicating that stability of APR can be achieved by combinations of slow-rusting resistance genes.

Genotypic susceptibility scores and HIV type 1 RNA responses in treatment-experienced subjects with HIV type 1 infection

This study compared the role of genotypic susceptibility scores (GSS) as a predictor of virologic response in a group (n = 234) of HIV-infected, protease inhibitor (PI)-experienced subjects. Two scoring methods [discrete genotypic susceptibility score (dGSS) and continuous genotypic susceptibility score (cGSS)] were developed. Each drug in the subject's regimen was given a binary susceptibility score using Stanford inferred drug resistance scores to calculate the dGSS. In contrast to the dGSS, the cGSS model was designed to reflect partial susceptibility to a drug. Both GSS were independent predictors of week 16 virologic response. We also compared the GSS to a phenotypic susceptibility score (PSS) model on a subset of subjects that had both GSS and PSS performed, and found that both models were predictive of virologic response. Genotypic analyses at enrollment showed that subjects who were virologic nonresponders at week 16 revealed enrichment of several mutated codons associated with nucleoside reverse transcriptase inhibitors (NRTI) (codons 67, 69, 70, 118, 215, and 219) or PI resistance (codons 10, 24, 71, 73, and 88) compared to subjects who were virologic responders. Regression analyses revealed that protease mutations at codons 24 and 90 were most predictive of poor virologic response, whereas mutations at 82 were associated with enhanced virologic response. Certain NNRTI-associated mutations, such as K103N, were rapidly selected in the absence of NRTIs. These data indicate that GSS may be a useful tool in selecting drug regimens in HIV-1-infected subjects to maximize virologic response and improve treatment outcomes.

Reaction of Elite Wheat Genotypes from the Northern Great Plains of North America to Septoria Diseases

Stagonospora nodorum blotch (SNB), caused by Phaeosphaeria nodorum, and Septoria tritici blotch (STB), caused by Mycosphaerella graminicola, are the main pathogens of the Septoria disease complex of wheat (Triticum aestivum) in North America. This study was conducted to determine the disease reaction of 126 elite hard red spring, white, and durum wheat cultivars and advanced breeding lines collected from the northern Great Plains of the United States and Canada to SNB and STB. Seedlings of the 126 wheat genotypes were evaluated for resistance to SNB and STB under controlled environmental conditions. Moreover, these 126 wheat genotypes also were infiltrated with culture filtrate of P. nodorum isolate Sn2000. Based on disease reactions, three cultivars (McNeal, Dapps, and Oklee) and 12 advanced breeding lines (CA-901-580W, 97SO254-8-1, MN03291, MN03308, WA007925, MT0245, ND756, ND801, ND803, ND808, ND809, and ND811) adapted to the northern Great Plains were found to be resistant to both Septoria diseases and insensitive to the culture filtrate. Additionally, eight genetically diverse lines and cultivars, including two tetraploid wheat genotypes, were identified to be resistant to both Septoria diseases. These results suggest that the wheat genotypes contain a broad genetic base for resistance to the Septoria diseases in the northern Great Plains of the United States and Canada, and the resistant sources identified in this study may be utilized in wheat-breeding programs.

PTHrP increases transcriptional activity of the integrin subunit alpha5

Increasing evidence is emerging highlighting the role of parathyroid hormone-related protein (PTHrP) during metastasis by regulating cell adhesion. The current study demonstrated that modulation of PTHrP expression by PTHrP overexpression and small interfering RNA-induced silencing resulted in changes in cell adhesion and integrin expression. RNA interference of endogenous PTHrP caused a significant reduction in cell adhesion of a breast cancer cell line to collagen type I, fibronectin and laminin (P<0.05) and of a colon cancer cell to collagen type I and fibronectin (P<0.05). Overexpression of PTHrP induced a significant increase in cell adhesion of colon (P<0.0001) and breast (P<0.05) cancer cells to the same extracellular matrix proteins. These PTHrP-mediated effects were attributed to changes in integrin expression as the differences in adhesion profile correlated with the integrin expression profile. In an attempt to elucidate the mechanism whereby PTHrP regulates integrin expression, promoter activity of the integrin α₅ subunit was analysed and significant increases in transcriptional activity were observed in PTHrP overexpressing cells (P<0.0001), which was dependent on nuclear localisation. These results indicate that modulation of cell adhesion is a normal physiological action of PTHrP, mediated by increasing integrin gene transcription.

Bilateral total hip arthroplasty in siblings with Stickler Syndrome

Stickler Syndrome is an infrequent autosomal dominant connective tissue disorder. The most prevalent mutation affects type II collagen gene and results in abnormalities in cartilage, vitreous and nucleus pulposus. Orthopaedic manifestations include joint hyper- mobility and pain with early development of secondary osteoarthritis. The condition has a predilection for the femoral head and patients usually present in their third to fourth decade with secondary hip arthritis. We report on two siblings with Stickler Syndrome who presented with hip osteoarthritis in their third decade of life and underwent staged bilateral total hip arthroplasties (THA). The patients experienced pain relief and improved quality of life after surgery.

Use of a large-scale Triticeae expressed sequence tag resource to reveal gene expression profiles in hexaploid wheat (Triticum aestivum L.)

The US Wheat Genome Project, funded by the National Science Foundation, developed the first large public Triticeae expressed sequence tag (EST) resource. Altogether, 116,272 ESTs were produced, comprising 100,674 5' ESTs and 15 598 3' ESTs. These ESTs were derived from 42 cDNA libraries, which were created from hexaploid bread wheat (Triticum aestivum L.) and its close relatives, including diploid wheat (T. monococcum L. and Aegilops speltoides L.), tetraploid wheat (T. turgidum L.), and rye (Secale cereale L.), using tissues collected from various stages of plant growth and development and under diverse regimes of abiotic and biotic stress treatments. ESTs were assembled into 18,876 contigs and 23,034 singletons, or 41,910 wheat unigenes. Over 90% of the contigs contained fewer than 10 EST members, implying that the ESTs represented a diverse selection of genes and that genes expressed at low and moderate to high levels were well sampled. Statistical methods were used to study the correlation of gene expression patterns, based on the ESTs clustered in the 1536 contigs that contained at least 10 5' EST members and thus representing the most abundant genes expressed in wheat. Analysis further identified genes in wheat that were significantly upregulated (p < 0.05) in tissues under various abiotic stresses when compared with control tissues. Though the function annotation cannot be assigned for many of these genes, it is likely that they play a role associated with the stress response. This study predicted the possible functionality for 4% of total wheat unigenes, which leaves the remaining 96% with their functional roles and expression patterns largely unknown. Nonetheless, the EST data generated in this project provide a diverse and rich source for gene discovery in wheat.

Use of continuous positive airway pressure during spinal anaesthesia in a patient with severe chronic obstructive pulmonary disease

We report the case of a patient with severe chronic obstructive pulmonary disease who underwent local resection of a carcinoma of the rectum under spinal anaesthesia. Although the patient was keen to avoid general anaesthesia and to have the operation under a spinal anaesthetic, pre-operative assessment showed that he could not lie flat. As the surgical procedure required the patient to be in the lithotomy position, ideally with a head-down tilt, it was hoped that continuous positive airway pressure with a facemask during spinal anaesthesia might help him to tolerate the position comfortably. Continuous positive airway pressure at 7.5 cmH(2)O was successfully used to facilitate breathing during surgery under spinal anaesthesia. A combination of regional anaesthesia and continuous positive airway pressure via a facemask is easy to use and may be a useful option in the management of these challenging patients.

Evaluation of Elite Wheat Germ Plasm for Resistance to Tan Spot

Tan spot, caused by Pyrenophora tritici-repentis, is a serious foliar disease of wheat (Triticum aestivum) in North America. Control of tan spot through management practices and fungicide application is possible; however, the use of resistant varieties is the most effective and economical means of controlling tan spot. This study was conducted to determine the disease reaction of 126 elite hard red spring, white, and durum wheat varieties and advanced breeding lines collected from the northern Great Plains of the United States and Canada to individual races/toxins of P. tritici-repentis. Seedling evaluation of the 126 genotypes was done under controlled environmental conditions with virulent races 2, 3, and 5 of P. tritici-repentis and toxins Ptr ToxA and Ptr ToxB. Based on disease reactions, two resistant varieties and two advanced breeding lines adapted to the northern Great Plains were found to be resistant to all the races and insensitive to the toxins tested. Additionally, six genetically diverse lines/varieties were identified to be resistant to tan spot; however, these sources may not be well adapted to the northern Great Plains. These results suggest that the wheat germ plasm contains a broad genetic base for resistance to the most prevalent races of P. tritici-repentis in North America, and the resistant sources identified in this study may be utilized in wheat breeding programs to develop tan spot resistant varieties.