Enhancement of mediodorsal thalamus rescues aberrant belief dynamics in a mouse model with schizophrenia-associated mutation

Optimizing behavioral strategy requires belief updating based on new evidence, a process that engages higher cognition. In schizophrenia, aberrant belief dynamics may lead to psychosis, but the mechanisms underlying this process are unknown, in part, due to lack of appropriate animal models and behavior readouts. Here, we address this challenge by taking two synergistic approaches. First, we generate a mouse model bearing patient-derived point mutation in Grin2a (Grin2aY700X+/-), a gene that confers high-risk for schizophrenia and recently identified by large-scale exome sequencing. Second, we develop a computationally trackable foraging task, in which mice form and update belief-driven strategies in a dynamic environment. We found that Grin2aY700X+/- mice perform less optimally than their wild-type (WT) littermates, showing unstable behavioral states and a slower belief update rate. Using functional ultrasound imaging, we identified the mediodorsal (MD) thalamus as hypofunctional in Grin2aY700X+/- mice, and in vivo task recordings showed that MD neurons encoded dynamic values and behavioral states in WT mice. Optogenetic inhibition of MD neurons in WT mice phenocopied Grin2aY700X+/- mice, and enhancing MD activity rescued task deficits in Grin2aY700X+/- mice. Together, our study identifies the MD thalamus as a key node for schizophrenia-relevant cognitive dysfunction, and a potential target for future therapeutics.

Molecular profiling of dedicated lung cancer biopsy tissue sample collected at time of diagnostic bronchoscopy

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Background: The combined use of molecular biomarker testing and targeted precision therapeutics has led to improved survival in lung cancer. Broadening access to national guideline recommended comprehensive molecular testing requires overcoming the challenges of inadequate tissue biopsies, which can lead to the need for additional procedures and ultimately, delays in initiation of care. We show Percepta Genomic Atlas identifies key molecular alterations in transbronchial needle aspirate (TBNA) and transbronchial biopsy (TBB) samples of lung or lymph node collected during the initial diagnostic bronchoscopy. Methods: Percepta Genomic Atlas combines the whole exome TruSeq RNA Exome and targeted AmpliSeq Focus DNA assays (Illumina) for a comprehensive gene panel including ALK, RET, ROS1, NTRK1/3, MET, EGFR, BRAF, KRAS and HER2. TruSight Oncology 500 DNA and AmpliSeq Focus RNA assays (Illumina) were used as reference assays. DNA and RNA were extracted from samples with the AllPrep Micro kit (Qiagen) and analyzed by Percepta Genomic Atlas and reference assays. 94 biopsy samples (73 TBNA and 21 TBB from 71 patients undergoing a diagnostic bronchoscopy for suspected lung cancer were collected into RNAprotect (Qiagen) under an IRB approved protocol. Local molecular testing results from FFPE biopsy samples taken during the same bronchoscopy procedure were collected. Results: RNA and DNA in sufficient amounts to run the Percepta Genomic Atlas and reference assays was obtained from 85 of 94 lung biopsies from 63 of 71 patients. Percepta Genomic Atlas identified pathogenic variants in 29 bronchoscopy biopsy samples from 23 patients including single nucleotide variants in EGFR, KRAS, BRAF and PIK3CA, an EGFR exon 19 deletion/insertion and copy number amplications in AR, EGFR, CDK4, CCND1, MYC, MYCN and PIK3CA. No fusions were identified. This results in a 100% sensitivity for detecting pathogenic alterations when compared to reference assay results. When comparing Percepta Genomic Atlas results to local molecular testing of bronchoscopy samples performed as part of routine clinical care, we found 100% concordance with 7 of 7 alterations detected in 7 patients, including mutations in EGFR, KRAS and BRAF. In a further 4 patients, Percepta Genomic Atlas and local multi-gene NGS testing results agreed, with neither assay identifying guideline recommended alterations. Conclusions: Using a combination of whole exome RNA and targeted DNA sequencing, Percepta Genomic Atlas detects the clinically actionable mutations in patients with non-small cell lung cancer using fresh tissue specimens collected during bronchoscopic tissue sampling, with high concordance to standard of care testing. By initiating broad molecular testing at the time of the bronchoscopy, Percepta Genomic Atlas may provide timelier results for patients with lung cancer.

Detection of actionable molecular alterations through combined DNA/RNA molecular profiling of biopsies collected in early-stage lung cancer at time of diagnosis

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Background: Significant progress has been made in improving progression-free survival in lung cancer through the combination of molecular biomarker testing and personalized therapeutics. Broadening access to national guideline recommended comprehensive molecular testing requires overcoming challenges of inadequate tissue biopsies, which can lead to the need for additional procedures and ultimately, delays in obtaining molecular testing. Additionally, there is growing evidence for the use of targeted therapies to treat early stage lung cancer and therefore a need for molecular testing across all stages of lung cancer. We show Percepta Genomic Atlas can identify key molecular alterations in early stage and advanced lung cancers and that it can successfully detect these alterations in surgical lung biopsy (SLB) specimens, transbronchial needle aspirates (TBNA) and bronchial brush specimens obtained during the initial bronchoscopy at the time of diagnosis. Methods: Percepta Genomic Atlas combines the whole exome TruSeq RNA Exome and targeted AmpliSeq Focus DNA assays (Illumina) for a comprehensive gene panel including ALK, RET, ROS1, NTRK1/3, MET, EGFR, BRAF, KRAS and HER2. TruSight Oncology 500 DNA and AmpliSeq Focus RNA assays (Illumina) were used as orthogonal assays. 92 fresh-frozen SLB samples were purchased from BioIVT and biopsies from 25 patients undergoing a diagnostic bronchoscopy during an IRB approved clinical study were collected into RNAprotect (Qiagen). DNA and RNA were extracted from both sample sets with the AllPrep Micro kit (Qiagen) and analyzed by Percepta Genomic Atlas and orthogonal assays. Results: The Percepta Genomic Atlas assay was used to profile small amounts of RNA and DNA from lung cancer SLB tissues, of which 60% were Stage I, 24% Stage II and 16% Stage III. Genomic alterations were observed in 65% of Stage I, 64% of Stage II and 73% of Stage III samples including single nucleotide variants (SNV) in KRAS, EGFR, and PIK3CA, indels in HER2 exon 20, multiple copy number variants, and RET and MET exon 14 skip rearrangements. Percepta Genomic Atlas was used to successfully profile TBNA and bronchial brush specimens providing molecular data from all 25 patients and identifying multiple alterations including KRAS, EGFR and PIK3CA SNVs. Conclusions: Percepta Genomic Atlas detects clinically actionable alterations in both SLB of early stage lung cancer tumors and in specimens collected at the time of diagnostic bronchoscopy or needle aspiration prior to surgery. The early detection of actionable alterations at the time of initial tissue acquisition could minimize need for additional diagnostic procedures and inform earlier treatment decisions with the expanding field of targeted adjuvant therapy.

A comprehensive targeted next-generation sequencing panel for genetic diagnosis of patients with suspected inherited thrombocytopenia

BACKGROUND

Inherited thrombocytopenias (ITs) are a heterogeneous group of disorders characterized by low platelet counts and often disproportionate bleeding with over 30 genes currently implicated. Previously the UK-GAPP study using whole exome sequencing (WES) identified a pathogenic variant in 19 of 47 (40%) patients of which 71% had variants in genes known to cause IT.

AIMS

To employ a targeted next-generation sequencing platform to improve efficiency of diagnostic testing and reduce overall costs.

METHODS

We have developed an IT-specific gene panel as a pre-screen for patients prior to WES using the Agilent SureSelectQXT transposon-based enrichment system.

RESULTS

Thirty-one patients were analyzed using the panel-based sequencing, of which; 10% (3/31) were identified with a classified pathogenic variant, 16% (5/31) were identified with a likely pathogenic variant, 51% (16/31) were identified with variants of unknown significance, and 23% (7/31) were identified with either no variant or a benign variant.

DISCUSSION AND CONCLUSION

Although requiring further clarification of the impact of the genetic variations, the application of an IT-specific next generation sequencing panel is an viable method of pre-screening patients for variants in known IT-causing genes prior to WES. With an added benefit of distinguishing IT from idiopathic thrombocytopenic purpura (ITP) and the potential to identify variants in genes known to have a predisposition to hematological malignancies, it could become a critical step in improving patient clinical management.

Phenotypic approaches to gene mapping in platelet function disorders

Platelet number or function disorders cause a range of bleeding symptoms from mild to severe. Patients with platelet dysfunction but normal platelet number are the most prevalent and typically have mild bleeding symptoms. The study of this group of patients is particularly difficult because of the lack of a gold-standard test of platelet function and the variable penetrance of the bleeding phenotype among affected individuals.

The purpose of this short review is to discuss the way in which this group of patients can be investigated through platelet phenotyping in combination with targeted gene sequencing. This approach has been used recently to identify patients with mutations in key platelet activation receptors, namely those for ADP, collagen and thromboxane A2 (TxA2). One interesting finding from this work is that for some patients, mild bleeding is associated with heterozygous mutations in platelet proteins that are co-inherited with other genetic disorders of haemostasis such as type 1 von Willebrand‘s disease. Thus, the phenotype of mild bleeding may be multifactorial in some patients and may be considered to be a complex trait.

The Role of ITAM- and ITIM-coupled Receptors in Platelet Activation by Collagen

The major activation-inducing collagen receptor glycoprotein VI (GPVI) has been cloned within the last two years. It is a member of the Ig superfamily of proteins and is constitutively associated with the ITAM-bearing Fc receptor γ-chain (FcR γ-chain). GPVI signals through a pathway that involves several of the proteins used by Fc, B- and T-lymphocyte receptors and which takes place in glycolipid-enriched membrane domains in the plasma membrane known as GEMs. Responses to GPVI are regulated by PECAM-1 (CD31) and possibly other ITIM-bearing receptors. Despite a pivotal role for GPVI, there are important differences between signalling events to collagen and GPVI-specific ligands. This may reflect a role for co-receptors in the response to collagen.

Elective Surgery on Factor VIII Inhibitor Patients Using Continuous Infusion of Recombinant Activated Factor VII

We examined recombinant activated factor VII (rVIIa) administered by continuous infusion to eight patients with inhibitors to factor VIII, undergoing elective surgery. rVIIa was infused at a fixed rate of 16.5 μg/kg/h for a median of 13.5 days (range 1-26). There was effective haemostasis at this infusion rate in only one of two minor procedures and two of six major operations. Three patients experienced excessive bleeding despite plasma factor VII activity around 10 IU/ml. Serious bleeding occurred in two other patients caused by procedural errors unrelated to rVIIa and required re-operation. The median rVIIa clearance on day 1 was 57 ml/h/kg (range 18-100) and on day 3 was 100 ml/h/kg (range 61-200). Clearance on the final infusion day was not significantly different from day 3. The infusion did not induce pathological activation of the coagulation mechanism. The only thrombotic adverse events were two episodes of superficial thrombophlebitis of the infused vein in one subject. In conclusion, the 16.5 μg/kg/h infusion rate reliably achieves plasma factor VII activity levels of 10 IU/ml, but this level does not provide reliable haemostasis.

Whole exome sequencing identifies genetic variants in inherited thrombocytopenia with secondary qualitative function defects

Inherited thrombocytopenias are a heterogeneous group of disorders characterized by abnormally low platelet counts which can be associated with abnormal bleeding. Next-generation sequencing has previously been employed in these disorders for the confirmation of suspected genetic abnormalities, and more recently in the discovery of novel disease-causing genes. However its full potential has not yet been exploited. Over the past 6 years we have sequenced the exomes from 55 patients, including 37 index cases and 18 additional family members, all of whom were recruited to the UK Genotyping and Phenotyping of Platelets study. All patients had inherited or sustained thrombocytopenia of unknown etiology with platelet counts varying from 11×10⁹/L to 186×10⁹/L. Of the 51 patients phenotypically tested, 37 (73%), had an additional secondary qualitative platelet defect. Using whole exome sequencing analysis we have identified "pathogenic" or "likely pathogenic" variants in 46% (17/37) of our index patients with thrombocytopenia. In addition, we report variants of uncertain significance in 12 index cases, including novel candidate genetic variants in previously unreported genes in four index cases. These results demonstrate that whole exome sequencing is an efficient method for elucidating potential pathogenic genetic variants in inherited thrombocytopenia. Whole exome sequencing also has the added benefit of discovering potentially pathogenic genetic variants for further study in novel genes not previously implicated in inherited thrombocytopenia.

Role of focused assessment with sonography for trauma as a screening tool for blunt abdominal trauma in young children after high energy trauma

BACKGROUND

The objective of the study was to review the utility of focused assessement with sonography for trauma (FAST) as a screening tool for blunt abdominal trauma (BAT) in children involved in high energy trauma (HET), and to determine whether a FAST could replace computed tomography (CT) in clinical decision-making regarding paediatric BAT.

METHOD

Children presented at the Trauma Unit of the Red Cross War Memorial Children's Hospital, Cape Town, after HET, and underwent both a physical examination and a FAST. The presence of free fluid in the abdomen and pelvis was assessed using a FAST. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) for identifying intraabdominal injury were calculated for the physical examination and the FAST, both individually and when combined.

RESULTS

Seventy-five patients were included as per the criteria for HET as follows: pedestrian motor vehicle crashes (MVCs) (n = 46), assault (n = 14), fall from a height (n = 9), MVC passenger (n = 4) and other (n = 2). The ages of the patients ranged from 3 months to 13 years. The sensitivity of the physical examination was 0.80, specificity 0.83, PPV 0.42 and NPV 0.96. The sensitivity of the FAST was 0.50, specificity 1.00, PPV 1.00 and NPV 0.93. Sensitivity increased to 0.90 when the physical examination was combined with the FAST. Nonoperative management was used in 73 patients. Two underwent an operation.

CONCLUSION

A FAST should be performed in combination with a physical examination on every paediatric patient involved in HET to detect BAT. When both are negative, nonoperative management can be implemented without fear of missing a clinically significant injury. FAST is a safe, effective and easily accessible alternative to CT, which avoids ionising radiation and aids in clinical decision-making.

Outcome of liver transplantation in patients with hereditary bleeding disorders: a single centre UK experience

INTRODUCTION

Patients with hereditary bleeding disorders who have developed end-stage liver disease as a consequence of hepatitis C infection (HCV) acquired from factor concentrates prior to the introduction of viral inactivation continue to be referred for liver transplantation.

METHODS

A retrospective review of case notes and electronic records was performed on all patients with bleeding disorders who have undergone liver transplantation at the University Hospital Birmingham (UHB).

RESULTS

Between 1990 and 2014, 35 liver transplants have been performed in 33 patients with hereditary bleeding disorders. The indication for transplantation was mainly end-stage liver disease secondary to HCV. Five patients had human immunodeficiency virus (HIV) co-infection. No excess mortality due to bleeding occurred in the peri or postoperative period. Median overall survival post transplant is 9.7 years. Overall survival rates at 1, 3 and 5 years are 90%, 72% and 64% respectively. The predominant cause of mortality was liver failure secondary to either recurrent HCV or recurrent hepatocellular carcinoma (HCC). The median overall survival in patients with HIV co-infection is shorter than in those with mono-infection but this is not statistically significant. Patients with a pre-existing HCC had a statistically significant shorter survival (2.4 years vs. 13.6 years, P = 0.007).

CONCLUSION

Liver transplantation has become an accepted treatment option for patients with hereditary bleeding disorders and HCV associated end-stage liver disease with survival rates similar to non-bleeding disorder patients.

Local vibrations and negative thermal expansion in ZrW2O8

We present an x-ray pair distribution function (XPDF) analysis and extended x-ray absorption fine structure (EXAFS) data for ZrW2O8 (10-500 K) with a focus on the stiffness of the Zr-O-W linkage. The XPDF is highly sensitive to W-Zr and W-W correlations, but much less so to O-O or W-O correlations. The Zr-W peak in the XPDF data has a weak temperature dependence and, hence, this linkage is relatively stiff and does not permit bending of the Zr-O-W link. We propose that the low energy vibrational modes that lead to negative thermal expansion involve correlated rotations of ZrO6 octahedra that produce large <111> translations of the WO4 tetrahedra, rather than a transverse motion of O atoms that imply a flexible Zr-O-W linkage.

IgE-mediated food allergy--diagnosis and management in New Zealand children

AIM

To summarise the diagnosis and management of IgE-mediated food allergy (FA) in New Zealand children.

METHOD

A review of the scientific literature and subsequent consensus development.

RESULTS

FA is a common problem in New Zealand children with management necessitating accurate diagnosis, appropriate risk management, and reassessment over time.

CONCLUSION

This paper highlights the importance of a structured approach to diagnosis and management of FA in New Zealand children, guided by appropriately skilled health professionals.

Identifying and testing candidate genetic polymorphisms in the irritable bowel syndrome (IBS): association with TNFSF15 and TNFα

OBJECTIVES

The postinfectious irritable bowel syndrome (PI-IBS) suggests that impaired resolution of inflammation could cause IBS symptoms. The authors hypothesised that polymorphisms in genes whose expression were altered by gastroenteritis might be linked to IBS with diarrhoea (IBS-D) which closely resembles PI-IBS.

DESIGN

Part 1: 25 healthy volunteers (HVs), 21 patients 6 months after Campylobacter jejuni infection, 37 IBS-D and 19 IBS with constipation (IBS-C) underwent rectal biopsy for gene expression analysis and peripheral blood mononuclear cell cytokine production assessment. Part 2: Polymorphisms in genes whose expression was altered in Part 1 were assessed in 179 HV, 179 IBS-D, 122 IBS-C and 41 PI-IBS.

RESULTS

Part 1: Mucosal expression of seven genes was altered in IBS: CCL11, CCL13, Calpain 8 and TNFSF15 increased while NR1D1, GPR161 and GABRE decreased with similar patterns after infection with C jejuni. Part 2: The authors assessed 21 known single nucleotide polymorphisms (SNPs) in these seven genes and one SNP in each of the TNFα and IL-10 genes. Three out of five TNFSF15 SNPs (rs6478108, rs6478109 and rs7848647) showed reduced minor allele frequency (MAF) (0.28, 0.27 and 0.27) in subjects with IBS-D compared with HV (0.38, 0.36 and 0.37; p=0.007, 0.015 and 0.007, respectively) confirming others recent findings. The authors also replicated the previously reported association of the TNFα SNP rs1800629 with PI-IBS which showed an increase in the MAF at 0.30 versus 0.19 for HV (p=0.04).

CONCLUSION

IBS-D and PI-IBS patients are associated with TNFSF15 and TNFα genetic polymorphisms which also predispose to Crohn's disease suggesting possible common underlying pathogenesis.

["Catecholamine refractory" cardiogenic shock? "Bridging-to-recovery" by implantation of a percutaneous cardiac assist device]

HISTORY AND ADMISSION FINDINGS

A 27-year-old man presented with acute dyspnea and a previous respiratory tract infection with progressive dyspnoea and chest pain over 2 weeks. Clinical findings revealed severe cardiac failure with development of cardiogenic shock and need for adrenergic drug therapy for circulatory support.

INVESTIGATIONS

The electrocardiogram showed a sinus tachycardia with unspecific T-wave-inversions, the echocardiogram revealed a dilated left ventricle and severely reduced systolic LV-function. An acute coronary syndrome could be excluded by coronary angiogram.

TREATMENT AND COURSE

A myocardial biopsy was taken to exclude giant cell myocarditis. The immediate initiation of a mechanical circulatory support by an Extracorporal Membrane Oxygenator (ECMO) facilitated rapid hemodynamic stabilization and recovery of organ function.

CONCLUSIONS

A drug-only circulatory support very often does not enable stabilization of a patient in progressive cardiogenic shock and cannot prevent multiorgan dysfunction. Therefore implantation of an assist device facilitates a "bridging-to-recovery" or a "bridging-to transplant" concept in critically ill patients presenting with cardiogenic shock. The bridging also allows for reviewing etiology and evaluation of further treatment options. In case of recovery continuous care in a specialized Heart Failure Clinic can help to maintain the clinical status and offer frequent reevaluation of cardiac status and therapeutic concepts.

A genome-wide association study of resistance to HIV infection in highly exposed uninfected individuals with hemophilia A

Human genetic variation contributes to differences in susceptibility to HIV-1 infection. To search for novel host resistance factors, we performed a genome-wide association study (GWAS) in hemophilia patients highly exposed to potentially contaminated factor VIII infusions. Individuals with hemophilia A and a documented history of factor VIII infusions before the introduction of viral inactivation procedures (1979-1984) were recruited from 36 hemophilia treatment centers (HTCs), and their genome-wide genetic variants were compared with those from matched HIV-infected individuals. Homozygous carriers of known CCR5 resistance mutations were excluded. Single nucleotide polymorphisms (SNPs) and inferred copy number variants (CNVs) were tested using logistic regression. In addition, we performed a pathway enrichment analysis, a heritability analysis, and a search for epistatic interactions with CCR5 Δ32 heterozygosity. A total of 560 HIV-uninfected cases were recruited: 36 (6.4%) were homozygous for CCR5 Δ32 or m303. After quality control and SNP imputation, we tested 1 081 435 SNPs and 3686 CNVs for association with HIV-1 serostatus in 431 cases and 765 HIV-infected controls. No SNP or CNV reached genome-wide significance. The additional analyses did not reveal any strong genetic effect. Highly exposed, yet uninfected hemophiliacs form an ideal study group to investigate host resistance factors. Using a genome-wide approach, we did not detect any significant associations between SNPs and HIV-1 susceptibility, indicating that common genetic variants of major effect are unlikely to explain the observed resistance phenotype in this population.

Scribble is required for normal epithelial cell-cell contacts and lumen morphogenesis in the mammalian lung

During lung development, proper epithelial cell arrangements are critical for the formation of an arborized network of tubes. Each tube requires a lumen, the diameter of which must be tightly regulated to enable optimal lung function. Lung branching and lumen morphogenesis require close epithelial cell–cell contacts that are maintained as a result of adherens junctions, tight junctions and by intact apical–basal (A/B) polarity. However, the molecular mechanisms that maintain epithelial cohesion and lumen diameter in the mammalian lung are unknown. Here we show that Scribble, a protein implicated in planar cell polarity (PCP) signalling, is necessary for normal lung morphogenesis. Lungs of the Scrib mouse mutant Circletail (Crc) are abnormally shaped with fewer airways, and these airways often lack a visible, ‘open’ lumen. Mechanistically we show that Scrib genetically interacts with the core PCP gene Vangl2 in the developing lung and that the distribution of PCP pathway proteins and Rho mediated cytoskeletal modification is perturbed in Scrib^Crc/Crc lungs. However A/B polarity, which is disrupted in Drosophila Scrib mutants, is largely unaffected. Notably, we find that Scrib mediates functions not attributed to other PCP proteins in the lung. Specifically, Scrib localises to both adherens and tight junctions of lung epithelia and knockdown of Scrib in lung explants and organotypic cultures leads to reduced cohesion of lung epithelial cells. Live imaging of Scrib knockdown lungs shows that Scrib does not affect bud bifurcation, as previously shown for the PCP protein Celsr1, but is required to maintain epithelial cohesion. To understand the mechanism leading to reduced cell–cell association, we show that Scrib associates with β-catenin in embryonic lung and the sub-cellular distribution of adherens and tight junction proteins is perturbed in mutant lung epithelia. Our data reveal that Scrib is required for normal lung epithelial organisation and lumen morphogenesis by maintaining cell–cell contacts. Thus we reveal novel and important roles for Scrib in lung development operating via the PCP pathway, and in regulating junctional complexes and cell cohesion.

Randomized, prospective, observational simulation study comparing residents' needle-guided vs free-hand ultrasound techniques for central venous catheter access

BACKGROUND

Short-axis ultrasound-guided placement of central venous catheters (CVCs) is widely accepted as safe practice. However, utilizing the long-axis approach could further improve safety, as it allows for better visualization of the needle as it is advanced to the target vessel. However, the long-axis approach has not widely been used due to the technical difficulty. Recently, a new needle guidance device has become available to aid in the long-axis approach. We hypothesized that the use of a needle guide paired with the long-axis approach would facilitate puncture of the target vessel in a simulation model more effectively than similar free-hand techniques.

METHODS

A prospective observational study of anaesthesia residents using a CVC partial-task training device was conducted. Each resident performed needle puncture of the target vessel with three different techniques, assigned in random order: short-axis free hand (S-FH), long-axis free hand (L-FH), and long-axis needle guide (NG). To prove the effectiveness of the needle guide, the fraction of time the needle tip remained in view of the ultrasound was recorded and compared. Time required for completing the task and the number of needle sticks and needle re-directions were compared.

RESULTS

Thirty-three residents participated in the study. The fraction of time the needle tip remained in view of the ultrasound was significantly higher for the residents using NG [0.90 (0.10)] compared with residents using the other techniques [L-FH: 0.36 (0.20), S-FH: 0.18 (0.10)] (P<0.001). For each resident, the use of the needle guide in the long-axis approach increased visualization by 352 (276)% compared with that of L-FH and by 1028 (1804) % compared with that of S-FH. There was no significant difference in time required to puncture the target between NG [23.7 (14.6) s] and L-FH [30.3 (36.5) s] (P=0.21); however, both were significantly longer than S-FH [17.0 (13.3) s] (P=0.012). The numbers of needle sticks and of needle re-directions did not differ among the groups.

CONCLUSIONS

The needle guide device used in the long-axis approach improved the needle visualization compared with free-hand techniques. The needle guide used in the long-axis technique, however, did not facilitate puncture of the target vessel in this simulation model when compared with free-hand techniques.

Discovery and characterization of small molecule inhibitors of the BET family bromodomains

Epigenetic mechanisms of gene regulation have a profound role in normal development and disease processes. An integral part of this mechanism occurs through lysine acetylation of histone tails which are recognized by bromodomains. While the biological and structural characterization of many bromodomain containing proteins has advanced considerably, the therapeutic tractability of this protein family is only now becoming understood. This paper describes the discovery and molecular characterization of potent (nM) small molecule inhibitors that disrupt the function of the BET family of bromodomains (Brd2, Brd3, and Brd4). By using a combination of phenotypic screening, chemoproteomics, and biophysical studies, we have discovered that the protein-protein interactions between bromodomains and acetylated histones can be antagonized by selective small molecules that bind at the acetylated lysine recognition pocket. X-ray crystal structures of compounds bound into bromodomains of Brd2 and Brd4 elucidate the molecular interactions of binding and explain the precisely defined stereochemistry required for activity.

Src family kinases are essential for primary aggregation by G(i) -coupled receptors

INTRODUCTION AND BACKGROUND

Adrenaline stimulates biphasic aggregation in plasma through the G(i) -coupled α(2A) -adrenoreceptor. In the present study, we demonstrate that both primary and secondary wave aggregation induced by adrenaline in plasma is blocked by two structurally distinct inhibitors of Src family kinases, dasatinib and PD0173952.

METHODS AND RESULTS

In contrast, primary aggregation is partially inhibited or unaffected in the presence of inhibitors of cyclo-oxygenase, phosphoinositide (PI) 3-kinases, and P2Y(1) and P2Y(12) ADP receptors, although secondary aggregation is abolished. The ability of adrenaline to inhibit adenylyl cyclase and to synergize with platelet agonists in mediating platelet activation in plasma is retained in the presence of Src family kinase inhibition. Moreover, adrenaline does not activate Src family kinases, as determined by western blotting of their regulatory tyrosines, suggesting that constitutive signaling from Src family kinases may underlie their role in activation. Adrenaline is widely used in clinical laboratories for investigation of patients with suspected bleeding disorders. In a group of 90 unrelated patients with a clinically diagnosed platelet bleeding disorder, we identified four who did not exhibit primary wave aggregation in response to adrenaline, although the catecholamine potentiated the response to other agonists, and five who failed to undergo secondary wave aggregation. In contrast, adrenaline stimulated biphasic aggregation in 60 controls. All of the patients with a defective response to adrenaline had impaired ADP-induced platelet activation.

CONCLUSIONS

The present results indicate a previously unappreciated role for Src family kinases in mediating G(i) signaling in plasma, and demonstrate heterogeneity in response to adrenaline in patients with a clinically diagnosed platelet disorder.

Translating evidence into practice: a shared priority in public health?

Translational and transdisciplinary research is needed to tackle complex public health problems. This article has three aims. Firstly, to determine how academics and non-academics (practitioners, policy makers and community workers) identified with the goals of the UKCRC Centre of Excellence for Public Health in Northern Ireland and how their attitudes varied in terms of knowledge brokerage and translation. Secondly, to map and analyse the network structure of the public health sector and the placement of the Centre within this. Thirdly, to aggregate responses from members of the network by work setting to construct the trans-sectoral network and devise the Root Mean Sum of Squares to determine the quality and potential value of connections across this network. The analysis was based on data collected from 98 individuals who attended the launch of the Centre in June 2008. Analysis of participant expectations and personal goals suggests that the academic members of the network were more likely to expect the work of the Centre to produce new knowledge than non-academics, but less likely to expect the Centre to generate health interventions and influence health policy. Academics were also less strongly oriented than non-academics to knowledge transfer as a personal goal, though more confident that research findings would be diffused beyond the immediate network. A central core of five nodes is crucial to the overall configuration of the regional public health network in Northern Ireland, with the Centre being well placed to exert influence within this. Though the overall network structure is fairly robust, the connections between some component parts of the network--such as academics and the third sector--are unidirectional. Identifying these differences and core network structure is key to translational and transdisciplinary research. Though exemplified in a regional study, these techniques are generalisable and applicable to many networks of interest: public health, interdisciplinary research or organisational involvement and stakeholder linkage.

Phenotypic approaches to gene mapping in platelet function disorders - identification of new variant of P2Y12, TxA2 and GPVI receptors

Platelet number or function disorders cause a range of bleeding symptoms from mild to severe. Patients with platelet dysfunction but normal platelet number are the most prevalent and typically have mild bleeding symptoms. The study of this group of patients is particularly difficult because of the lack of a gold-standard test of platelet function and the variable penetrance of the bleeding phenotype among affected individuals. The purpose of this short review is to discuss the way in which this group of patients can be investigated through platelet phenotyping in combination with targeted gene sequencing. This approach has been used recently to identify patients with mutations in key platelet activation receptors, namely those for ADP, collagen and thromboxane A2 (TxA2). One interesting finding from this work is that for some patients, mild bleeding is associated with heterozygous mutations in platelet proteins that are co-inherited with other genetic disorders of haemostasis such as type 1 von Willebrand's disease. Thus, the phenotype of mild bleeding may be multifactorial in some patients and may be considered to be a complex trait.

Disordered macrophage cytokine secretion underlies impaired acute inflammation and bacterial clearance in Crohn's disease

The cause of Crohn's disease (CD) remains poorly understood. Counterintuitively, these patients possess an impaired acute inflammatory response, which could result in delayed clearance of bacteria penetrating the lining of the bowel and predispose to granuloma formation and chronicity. We tested this hypothesis in human subjects by monitoring responses to killed Escherichia coli injected subcutaneously into the forearm. Accumulation of (111)In-labeled neutrophils at these sites and clearance of (32)P-labeled bacteria from them were markedly impaired in CD. Locally increased blood flow and bacterial clearance were dependent on the numbers of bacteria injected. Secretion of proinflammatory cytokines by CD macrophages was grossly impaired in response to E. coli or specific Toll-like receptor agonists. Despite normal levels and stability of cytokine messenger RNA, intracellular levels of tumor necrosis factor (TNF) were abnormally low in CD macrophages. Coupled with reduced secretion, these findings indicate accelerated intracellular breakdown. Differential transcription profiles identified disease-specific genes, notably including those encoding proteins involved in vesicle trafficking. Intracellular destruction of TNF was decreased by inhibitors of lysosomal function. Together, our findings suggest that in CD macrophages, an abnormal proportion of cytokines are routed to lysosomes and degraded rather than being released through the normal secretory pathway.

Warfarin thromboprophylaxis in cancer patients with central venous catheters (WARP): an open-label randomised trial

BACKGROUND

The role and dose of anticoagulants in thromboprophylaxis for patients with cancer receiving chemotherapy through central venous catheters (CVCs) is controversial. We therefore assessed whether warfarin reduces catheter-related thrombosis compared with no warfarin and whether the dose of warfarin determines the thromboprophylactic effect.

METHODS

In 68 clinical centres in the UK, we randomly assigned 1590 patients aged at least 16 years with cancer who were receiving chemotherapy through CVCs to no warfarin, fixed-dose warfarin 1 mg per day, or dose-adjusted warfarin per day to maintain an international normalised ratio between 1.5 and 2.0. Clinicians who were certain of the benefit of warfarin randomly assigned patients to fixed-dose or dose-adjusted warfarin groups. The primary outcome was the rate of radiologically proven, symptomatic catheter-related thrombosis. Analysis was by intention to treat. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN 50312145.

FINDINGS

Compared with no warfarin (n=404), warfarin (n=408; 324 [79%] on fixed-dose and 84 [21%] on dose-adjusted) did not reduce the rate of catheter-related thromboses (24 [6%] vs 24 [6%]; relative risk 0.99, 95% CI 0.57-1.72, p=0.98). However, compared with fixed-dose warfarin (n=471), dose-adjusted warfarin (n=473) was superior in the prevention of catheter-related thromboses (13 [3%] vs 34 [7%]; 0.38, 0.20-0.71, p=0.002). Major bleeding events were rare; an excess was noted with warfarin compared with no warfarin (7 vs 1, p=0.07) and with dose-adjusted warfarin compared with fixed-dose warfarin (16 vs 7, p=0.09). A combined endpoint of thromboses and major bleeding showed no difference between comparisons. We did not note a survival benefit in either comparison.

INTERPRETATION

The findings show that prophylactic warfarin compared with no warfarin is not associated with a reduction in symptomatic catheter-related or other thromboses in patients with cancer and therefore we should consider newer treatments.

FUNDING

Medical Research Council and Cancer Research UK.

Reference curves for aggregation and ATP secretion to aid diagnose of platelet-based bleeding disorders: effect of inhibition of ADP and thromboxane A(2) pathways

Platelet aggregation is widely used in clinical laboratories to evaluate patients with bleeding disorders of suspected platelet aetiology. Simultaneous monitoring of ATP release as a measure of dense granule secretion provides additional information to aid diagnosis. There is, however, no standard way of performing or interpreting these tests. The present study has evaluated aggregation and ATP secretion to eight platelet agonists in healthy donors and has evaluated the reproducibility of response for a number of variables, including platelet number and time after donation. The effect of inhibition of the two major platelet feedback mediators, ADP and thromboxane A(2) (TxA(2)), was investigated using the P2Y(1) and P2Y(12) receptor antagonists, MRS2179 and AR-C67085, and the cyclooxygenase inhibitor, indomethacin. The results demonstrate that, if used within certain boundaries, the investigation of platelet aggregation and secretion is a powerful way to discriminate between differing pathways of platelet activation. The present data-set are an invaluable resource to the clinical laboratory to aid evaluation of patients with suspected platelet-based bleeding disorders.

[Diagnostic image (310). A man with a knife in his head]

A 30-year-old man presented with a knife in his head; it had perforated the left temporal area and its point was located in the mouth. After surgical removal of the knife, the patient left the hospital without functional deficits.

IkappaB kinase epsilon interacts with p52 and promotes transactivation via p65

The members of the NF-kappaB transcription factor family are key regulators of gene expression in the immune response. Different combinations of NF-kappaB subunits not only diverge in timing to induce transcription but also recognize varying sequences of the NF-kappaB-binding site of their target genes. The p52 subunit is generated as a result of processing of NF-kappaB2 p100. Here, we demonstrate that the non-canonical IkappaB kinase epsilon (IKKepsilon) directly interacts with p100. In a transactivation assay, IKKepsilon promoted the ability of p52 to transactivate gene expression. This effect was indirect, requiring p65, which was shown to be part of the IKKepsilon-p52 complex and to be phosphorylated by IKKepsilon. These novel interactions reveal a hitherto unknown function of IKKepsilon in the regulation of the alternative NF-kappaB activation pathway involving p52 and p65.

A germline mutation in BLOC1S3/reduced pigmentation causes a novel variant of Hermansky-Pudlak syndrome (HPS8)

Hermansky-Pudlak syndrome (HPS) is genetically heterogeneous, and mutations in seven genes have been reported to cause HPS. Autozygosity mapping studies were undertaken in a large consanguineous family with HPS. Affected individuals displayed features of incomplete oculocutaneous albinism and platelet dysfunction. Skin biopsy demonstrated abnormal aggregates of melanosomes within basal epidermal keratinocytes. A homozygous germline frameshift mutation in BLOC1S3 (p.Gln150ArgfsX75) was identified in all affected individuals. BLOC1S3 mutations have not been previously described in patients with HPS, but BLOC1S3 encodes a subunit of the biogenesis of lysosome-related organelles complex 1 (BLOC-1). Mutations in other BLOC-1 subunits have been associated with an HPS phenotype in humans and/or mouse, and a nonsense mutation in the murine orthologue of BLOC1S3 causes the reduced pigmentation (rp) model of HPS. Interestingly, eye pigment formation is reported to be normal in rp, but we found visual defects (nystagmus, iris transilluminancy, foveal hypoplasia, reduced visual acuity, and evidence of optic pathway misrouting) in affected individuals. These findings define a novel form of human HPS (HPS8) and extend genotype-phenotype correlations in HPS.

High prevalence of vitamin D deficiency, secondary hyperparathyroidism and generalized bone pain in Turkish immigrants in Germany: identification of risk factors

INTRODUCTION

The aim of the study was to determine the prevalence of vitamin D deficiency, secondary hyperparathyroidism (sHPT), generalized bone pain and predictors of vitamin D deficiency in a cohort of 994 healthy adult urban residents (589 males, 405 females; age range: 16-69 years) consisting of 101 Germans, 327 Turkish residents of Turkey and 566 Turkish immigrants living in Germany.

METHODS

The mean (+/- standard deviation) for 25-hydroxyvitamin D [25(OH)D] and biointact parathyroid hormone (BioPTH) for the German men and women was 68.4 nmol/l and 26.7 pg/ml, respectively. Turkish residents of Turkey had a mean 25(OH)D and BioPTH of 40.6 nmol/l and 27.5 pg/ml, respectively, whereas Turkish residents of Germany had a 25(OH)D of 38.1 nmol/l and a BioPTH of 35.6 pg/ml.

RESULTS

Vitamin D insufficiency was common among Turkish nationals independent of whether they lived in Turkey or Germany; 75% had 25(OH)D levels of <50 nmol/l. Turkish females had a higher prevalence of 25(OH)D deficiency (<25 nmol/l) than Turkish males: 30 and 19% of Turkish females living in Germany and Turkey were severely vitamin D deficient compared to 8% and 6% of Turkish males living in Germany and Turkey, respectively. With respect to BioPTH levels, 31% of Turkish females and 21% of Turkish males had elevated BioPTH levels in contrast to only 15% of females and 4% of males living in Turkey. Unconditional logistic regression analysis identified the most important predictors for low 25(OH)D levels as sex, body mass index, lack of sun exposure and living at a higher latitude. Additionally, wearing a scarf and number of children were found to be an independent risk factor for vitamin D deficiency in Turkish women living in Turkey and Germany. A strong correlation between low 25(OH)D levels and higher rates and longer duration of generalized bone and/or muscle aches and pains (often diagnosed as fibromyalgia) was observed.

CONCLUSION

Secondary hyperparathyroidism and vitamin D deficiency was found to be common among Turkish immigrants living in Germany, especially in veiled women. Therefore, the monitoring of vitamin D status--i.e. 25(OH)D and PTH--in Turkish immigrants is warranted and once a deficiency is identified, it should be appropriately treated.

Indications for HIV testing in paediatric surgical patients

HIV testing is done in paediatric surgical patients at Queen Elizabeth Central Hospital, when HIV infection is suspected to be the underlying cause of the clinical presentation or contributing to morbidity. We conducted a retrospective, descriptive analysis of children with surgical conditions under the age of 15 who underwent HIV tests between January 2001 to April 2004. A total of 279 children were tested - 50.2% were boys and 49.8% were girls. Overall HIV prevalence was 39.8%. The most common indications for testing and those with highest HIV prevalence were sepsis (31% of the diagnoses and HIV prevalence of 38%), head and neck swellings (22% and HIV prevalence of 39%) and urogenital problems (17% of cases and HIV prevalence of 51%).

[How to recognize POAD? The diagnosis of peripheral occlusive arterial disease in the physician's office]

Peripheral occlusive arterial disease (POAD) encompasses all stenotic and occlusive changes affecting the aorta and arteries supplying the extremities, and in 90% of the cases is due to atherosclerosis. In the majority of patients the lower extremities are involved, andonly every third patient has symptoms. Apart from its significance as an independent disease entity, POAD is also an important coincidence marker, in particular for coronary heart disease. For the diagnostic clarification of POAD, a stepped strategy is recommended, including clinical function testing, such as an exercise treadmill test. Doppler sonography and determination of the Doppler pressure index (ankle-brachial index) make possible a noninvasive accurate staging. Color-coded duplex sonography and imaging procedures provide further information, and are indispensable for establishing the indication for interventional measures.

[How well aware of their risk profile are patients with peripheral occlusive arterial disease?]

Today, the majority of physicians no longer consider the well-informed patient to be something of a headache--rather, they welcome him as a partner in the management of his disease. The reason for this is that the more he knows about his illness, the more reliably will he comply with the physician's proposed treatment, the more readily he will be- come aware of side effects, and will thus actively contribute to his recovery. With the aid of easy-to-complete questionnaires, the state of knowledge of POAD patients about their disease was determined. The information thus gained may be considered the basis for an individual physician/patient talk.

Open-air-nesting honey bees Apis dorsata and Apis laboriosa differ from the cavity-nesting Apis mellifera and Apis cerana in brood hygiene behaviour

The cavity-nesting Apis mellifera and Apis cerana bees detect, uncap, and remove diseased brood. The hygiene behaviour of open-air-nesting bees Apis dorsata and Apis laboriosa was investigated in India and Nepal. Sealed A. dorsata pupae were pin-killed or deep-frozen. The workers removed 73 or 37% of damaged pin-killed pupae depending on the diameter of the pins, and only 7% of the frozen undamaged pupae. Migrating A. dorsata and A. laboriosa left unopened the sealed brood in deserted combs. Thus, A. dorsata and A. laboriosa do not open undamaged cells with dead brood. This behaviour is a more efficient mechanism in preventing the spread of diseases and parasitic mites than uncapping and removing dead pupae by A. mellifera and A. cerana. It may be beneficial for migrating A. dorsata and A. laboriosa to temporarily disuse part of the comb cells in exchange for arresting the mites there and thus reducing the increase of their population.

Pharmacological thrombolysis in Budd Chiari syndrome: a single centre experience and review of the literature

BACKGROUND/AIMS

To review our experience of thrombolytic therapy in patients with acute Budd Chiari syndrome (BCS).

METHODS

Records of 10 patients with BCS, treated by thrombolysis over a 12-year period were retrospectively analysed for demographics, clinical presentation/duration, primary disease, thrombolytic regimen, and follow-up. The same characteristics were also studied in previously reported patients. The agent used was recombinant tissue plasminogen activator (tPA) in all patients.

RESULTS

Thrombolysis was used 12 times in 10 patients. Infusion was made systemically in three patients, into the hepatic artery in one patient, locally into a hepatic vein and/or IVC in four patients and locally within TIPS/portal vein in two patients. Only one infusion made systemically was partially successful. Adjunctive balloon angioplasty and/or stent insertion was undertaken for all eight procedures (in six patients) where local infusion was into the hepatic vein or TIPS. Six of these were ultimately successful (in five patients) and two were unsuccessful. Thrombolysis was more likely to be successful in the presence of a short history of thrombosis, when the thrombolytic agent was locally infused and when it was combined with a successful radiological procedure. Mean follow-up was 4.5 years (range 1-10 years). No serious bleeding complication occurred.

CONCLUSIONS

We observed no benefit from thrombolysis when delivered systemically or arterially except in one case. Thrombolysis was useful in adjunctive management of BCS when the drug was infused locally into recently thrombosed veins that had appreciable flow following partial recanalisation. Thrombolysis was clearly of benefit in the repermeation of occluded/partially occluded hepatic veins/TIPS when early detection of new thrombus followed interventional procedures such as balloon angioplasty or stenting of hepatic veins.

Selective interactions between helix VIII of the human mu-opioid receptors and the C terminus of periplakin disrupt G protein activation

Analysis of interactions between the C-terminal tail of the MOP-1 and MOP-1A variants of the human mu-opioid receptor with proteins derived from a human brain cDNA library resulted in identification of the actin and intermediate filament-binding protein periplakin. Mapping of this interaction indicated that the predicted fourth intracellular loop/helix VIII of the receptor interacts with the C-terminal rod and linker region of periplakin. Periplakin is widely expressed in the central nervous system of both man and rat and demonstrated an overlapping but not identical distribution with mu-opioid (MOP) receptors. Co-expression of periplakin with MOP-1 or a MOP-1-eYFP fusion construct in HEK293 cells did not interfere with agonist-mediated internalization of the receptor. When co-expressed with a MOP-1-Gi1 alpha fusion protein periplakin significantly reduced the capacity of the agonist to stimulate binding of 35S-labeled guanosine 5'-3-O-(thio)triphosphate ([35S]GTP gamma S) to the receptor-associated G protein. By contrast, periplakin did not interfere with agonist-stimulation of [35S]GTP gamma S binding to either an alpha 2A-adrenoreceptor-Gi1 alpha fusion protein or a beta2-adrenoreceptor-Gs alpha fusion protein, indicating its selectivity of function. This represents the first example of an opioid receptor-interacting protein that functions to disrupt agonist-mediated G protein activation.

Liver transplantation in haemophilia

We report our UK single-centre experience of liver transplantation in haemophilia patients with chronic hepatitis C (HCV) infection. Between March 1990 and March 2001, 16 patients were referred for transplant assessment and 11 (mean age 46 years: nine haemophilia A, two haemophilia B) have been transplanted. Factor concentrate replacement was administered using a continuous infusion regimen following initial bolus dosing. Concentrate infusion was discontinued at a median of 36 h (range 24-72 h) post transplant. Nine patients remain alive at a median of 5 years post transplant (6 months to 11 years). One patient died 6 years post transplant from myocardial infarction. The other patient died of liver failure as a consequence of HCV infection 3 months following a second transplant, having developed HCV cirrhosis within 1 year of receiving his initial graft. Five of the seven patients who have had annual liver biopsy surveillance have developed histological changes of HCV hepatitis at a median of 3 years post transplant (1 year to 9 years). One of these patients progressed to cirrhosis at 3 years 5 months post transplant. Two patients have shown no evidence of HCV hepatitis at 2 years 8 months and 9 years post transplant respectively. The outcome of liver transplantation in haemophilic patients is good and is associated with relatively little morbidity.

An anatomical variant of the extensor carpi radialis brevis muscle

BACKGROUND

Variations in musculature are of interest not only to the anatomist but also to the surgeon, insofar as they can be a source of error in both diagnosis and treatment. Muscular anomalies in the lower arm and in the hand have frequently been described in the literature; some of the lesions they can be confused with are ganglia and other soft tissue tumors.

CASE REPORT

In the course of preparation of a small, fine-jointed right upper extremity, an accessory muscle was discovered in the forearm and hand region; it branched off from the extensor carpi radialis brevis (ECRB) muscle. Its tendon crossed over the extensor retinaculum and attached to the dorsal digital expansion of the index finger. Both muscles were innervated by a branch of the deep branch of the radial nerve. The observations made here supplement our knowledge of variations in the antebrachial and dorsal regions of the arm and hand, which should be quite useful in hand surgery.

Atomic force microscopy imaging of the human trigeminal ganglion

This paper describes an investigation of gangliocytes via imaging semithin sections of two human trigeminal ganglia with an atomic force microscope (AFM). Whereas semithin sections are usually employed for transmission electron microscopy, we adopted this special type of sample preparation for our AFM studies to extract topographical data from the gangliocyte itself and from the nucleus, the nucleolus, the crystal-arranged lipofuscin granules, and the cell-surrounding mantle cells; simultaneously we characterized the samples with error signal mode. This AFM-related technique revealed no information concerning friction force and elasticity due to the presence of the embedding material (epoxy), but it gave additional topographical contrast. These are the first images of the human trigeminal ganglion by AFM.