Assessing the use of minimally invasive self-sampling at home for long-term monitoring of the microbiota within UK families

Monitoring the presence of commensal and pathogenic respiratory microorganisms is of critical global importance. However, community-based surveillance is difficult because nasopharyngeal swabs are uncomfortable and painful for a wide age range of participants. We designed a methodology for minimally invasive self-sampling at home and assessed its use for longitudinal monitoring of the oral, nasal and hand microbiota of adults and children within families. Healthy families with two adults and up to three children, living in and near Liverpool, United Kingdom, self-collected saliva, nasal lining fluid using synthetic absorptive matrices and hand swabs at home every two weeks for six months. Questionnaires were used to collect demographic and epidemiological data and assess feasibility and acceptability. Participants were invited to take part in an exit interview. Thirty-three families completed the study. Sampling using our approach was acceptable to 25/33 (76%) families, as sampling was fast (76%), easy (76%) and painless (60%). Saliva and hand sampling was acceptable to all participants of any age, whereas nasal sampling was accepted mostly by adults and children older than 5 years. Multi-niche self-sampling at home can be used by adults and children for longitudinal surveillance of respiratory microorganisms, providing key data for design of future studies.

POS0685 LONG-TERM SAFETY AND EFFICACY OF UPADACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: FINAL RESULTS FROM THE BALANCE-EXTEND OPEN-LABEL EXTENSION STUDY

Background

Upadacitinib (UPA) was previously evaluated in two Phase 2, randomized, controlled trials (RCTs) in patients (pts) with rheumatoid arthritis (RA) and inadequate response to tumor necrosis factor inhibitors (BALANCE-1) or methotrexate (BALANCE-2).

Objectives

To assess the final safety and efficacy of UPA in BALANCE-EXTEND, a 312-week open-label extension (OLE) enrolling pts who completed either BALANCE-1 or BALANCE-2.

Methods

All pts initially received UPA 6 mg twice daily (BID). Increase to 12 mg BID was required for pts with <20% improvement in swollen or tender joint counts (S/TJC) at Week 6 or 12, and permitted for those not achieving Clinical Disease Activity Index (CDAI) low disease activity (LDA). Pts with <20% improvement in SJC or TJC 6 weeks after escalation, or at any two consecutive visits, discontinued. Return to 6 mg BID was permitted for safety or tolerability reasons. After January 2017, the 6 and 12 mg BID doses were replaced by 15 and 30 mg once-daily (QD) extended-release equivalents. As-observed efficacy data are shown at Week 312 for three subgroups: pts who received 6 mg BID/15 mg QD throughout (“Never titrated”), those titrated up to 12 mg BID/30 mg QD for efficacy (“Titrated up”), and those titrated up to 12 BID/30 mg QD and then back to 6 mg BID/15 mg QD due to safety concerns (“Titrated up and down”). Exposure-adjusted adverse events (EAERs) per 100 patient-years (PY) of exposure were summarized from OLE Day 1 in all pts who received UPA (Any UPA).

Results

Overall, 493 pts entered the OLE, receiving UPA for ≤6.2 years (Never titrated, n=306; Titrated up, n=149; Titrated up and down, n=38), and 270 pts (54.8%) discontinued, mostly due to withdrawal of consent (16.8%; n=83) or AEs (14.6%; n=72). Mean (standard deviation) duration of UPA exposure was 3.8 (2.4) years (range <1–6.2 years); cumulative exposure was 1863 PY. The AE profile in pts receiving UPA 15 mg was generally similar to the Any UPA population, and to that observed in the Phase 3 UPA 15 mg clinical trial population (Table 1). Efficacy was maintained to Week 312, with 84.5% and 86.6% of pts in the Never titrated group achieving DAS28-CRP ≤3.2 and CDAI LDA, respectively (Figure 1).

Table 1.

Summary of AEs in pts who received UPA 6 mg BID/15 mg QD in the OLE and in the UPA 15 mg Phase 3 study program

BALANCE-EXTEND (UPA 6 mg BID/15 mg QD)UPA 15 mg – Phase 3 programbEvents/100 PY (95 CI)aEvents/100 PY (95% CI)aN=493, PY=1277N=3209, PY=9079Any AE138.4 (132.0, 145.0)205.5 (202.5, 208.5)Any SAE7.9 (6.4, 9.6)12.4 (11.7, 13.2)AE leading to discontinuation4.2 (3.2, 5.5)4.9 (4.4, 5.3)Death0.4 (0.1, 0.9)0.5 (0.4, 0.7)cInfection49.2 (45.5, 53.2)63.9 (62.3, 65.6) Serious infection1.4 (0.8, 2.2)2.8 (2.4, 3.1) Opportunistic infection0.2 (0.0, 0.6)0.3 (0.2, 0.4) Herpes zoster2.0 (1.3, 3.0)3.0 (2.6, 3.3)Anemia1.1 (0.6, 1.8)3.0 (2.7, 3.4)Neutropenia1.3 (0.8, 2.1)2.1 (1.8, 2.5)Lymphopenia1.7 (1.1, 2.6)1.7 (1.4, 1.9)Gastrointestinal perforation0<0.1 (0.0, 0.1)Any malignancy1.2 (0.7, 1.9)1.1 (0.9, 1.4)Non-melanoma skin cancer (NMSC)0.4 (0.1, 0.9)0.4 (0.3, 0.5) Excluding NMSC0.8 (0.4, 1.4)0.7 (0.6, 0.9)Creatinine phosphokinase elevation3.4 (2.5, 4.6)4.4 (4.0, 4.9)Hepatic disorder4.1 (3.0, 5.3)10.2 (9.5, 10.8)Venous thromboembolism0.5 (0.2, 1.0)0.4 (0.3, 0.6)Major adverse cardiovascular event0.5 (0.2, 1.0)0.4 (0.3, 0.5)

aMultiple events occurring in the same pts are counted in the calculation of events/100 PY. bCut-off, June 30, 2021. cBased on 9080 PY.

Conclusion

In this OLE, UPA treatment over ~312 weeks showed sustained long-term efficacy in pts with RA who had completed Phase 2 RCTs. Overall safety results showed that UPA was well tolerated over time; the types and frequencies of AEs were consistent with those in pts with similar populations of moderately to severely active RA receiving Janus kinase inhibitors.

Acknowledgements

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and participated in the writing, review, and approval of the abstract. AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. No honoraria or payments were made for authorship. Medical writing support was provided by Dan Booth, PhD, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests

Alan Kivitz Shareholder of: Amgen, Gilead, GlaxoSmithKline, Novartis, Pfizer, and Sanofi (stocks or options), Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Eli Lilly, Flexion, Genzyme, Gilead, Horizon, Janssen, Merck, Novartis, Pfizer, Regeneron, Sanofi, Sanofi Aventis, SUN Pharma Advanced Research, and UCB, Grant/research support from: AbbVie (his institution received fees for his role as a Principal Investigator in the study), Alvin F. Wells Consultant of: AbbVie, Juan Ignacio Vargas Consultant of: AbbVie, Grant/research support from: AbbVie (as a Principal Investigator in the study), Herbert S.B. Baraf Consultant of: Gilead and Janssen, Grant/research support from: AbbVie, Eli Lilly, Genentech, Gilead, and Janssen, Maureen Rischmueller Consultant of: AbbVie, Bristol-Myers Squibb, CSL Behring, Eli Lilly, Gilead Sciences, Janssen Global Services, Pfizer, Sanofi US Services, and UCB Biosciences, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Janssen Global Services, Novartis, Pfizer, Sanofi Pasteur Biologics, and UCB Biosciences, Justin Klaff Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Nasser Khan Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Yihan Li Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Kyle Carter Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Alan Friedman Shareholder of: AbbVie (may own stocks or options), Employee of: AbbVie, Patrick Durez Speakers bureau: Eli Lilly and Galapagos

The Gut Microbiome of Heart Failure With Preserved Ejection Fraction

Background

Risk factors for heart failure with preserved ejection fraction (HFpEF) include hypertension, age, sex, and obesity. Emerging evidence suggests that the gut microbiota independently contributes to each one of these risk factors, potentially mediated via gut microbial‐derived metabolites such as short‐chain fatty acids. In this study, we determined whether the gut microbiota were associated with HFpEF and its risk factors.

Methods and Results

We recruited 26 patients with HFpEF and 67 control participants from 2 independent communities. Patients with HFpEF were diagnosed by exercise right heart catheterization. We assessed the gut microbiome by bacterial 16S rRNA sequencing and food intake by the food frequency questionnaire. There was a significant difference in α‐diversity (eg, number of microbes) and β‐diversity (eg, type and abundance of microbes) between both cohorts of controls and patients with HFpEF (P=0.001). We did not find an association between β‐diversity and specific demographic or hemodynamic parameters or risk factors for HFpEF. The Firmicutes to Bacteroidetes ratio, a commonly used marker of gut dysbiosis, was lower, but not significantly so (P=0.093), in the patients with HFpEF. Compared with controls, the gut microbiome of patients with HFpEF was depleted of bacteria that are short‐chain fatty acid producers. Consistent with this, participants with HFpEF consumed less dietary fiber (17.6±7.7 versus 23.2±8.8 g/day; P=0.016).

Conclusions

We demonstrate key changes in the gut microbiota in patients with HFpEF, including the depletion of bacteria that generate metabolites known to be important for cardiovascular homeostasis. Further studies are required to validate the role of these gut microbiota and metabolites in the pathophysiology of HFpEF.

Extended-Release Oral Milrinone for the Treatment of Heart Failure With Preserved Ejection Fraction

Background

Heart failure with preserved ejection fraction (HFpEF) is an increasingly prevalent form of heart failure, representing half of the total burden of heart failure. We hypothesised that modulation of the phosphodiesterase type 3/cyclic AMP using a novel oral formulation of milrinone might exert favorable effects HFpEF via pulmonary and systemic vasodilation and enhancement of ventricular relaxation. We assessed the safety and efficacy of oral milrinone on quality of life and functional outcomes in patients with HFpEF.

Methods and Results

The MilHFPEF (Extended Release Oral Milrinone for the Treatment of Heart Failure With Preserved Ejection Fraction) study was a randomized, double‐blind, placebo‐controlled pilot study in 23 patients with symptomatic HFpEF. Efficacy end points included changes from baseline in Kansas City Cardiomyopathy Questionnaire summary score and 6‐minute walk distance. The primary safety end point was the development of clinically significant arrhythmia. The Kansas City Cardiomyopathy Questionnaire score improved significantly in milrinone‐treated patients compared with placebo (+10±13 versus −3±15; P=0.046). Six‐minute walk distance also tended to improve in the treatment group compared with placebo (+22 [−8 to 49] versus −47 [−97 to 12]; P=0.092). Heart rate (−1±5 versus −2±9 bpm; P=0.9) and systolic blood pressure (−3±18 versus +1±12 mm Hg; P=0.57) were unchanged. Early filling velocity/early mitral annular velocity (−0.3±3.0 versus −1.9±4.8; P=0.38) was unchanged. One patient in the placebo arm was hospitalized for heart failure. Holter monitoring did not demonstrate evidence of a proarrhythmic effect of milrinone.

Conclusions

In this novel pilot study, extended release oral milrinone was well tolerated and associated with improved quality of life in patients with HFpEF. Further longer‐term studies are warranted to establish the role of this therapeutic approach in HFpEF.

Registration

URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12616000619448.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Increasing podiatry referrals for patients with inflammatory arthritis at a tertiary hospital in Singapore: A quality improvement project

BACKGROUND

Foot disease is highly prevalent in people with inflammatory arthritis and is often under-recognized. Podiatry intervention can significantly reduce foot pain and disability, with timely access being the key factor. The aim of this study was to plan and implement a quality improvement project to identify the barriers to, and improve, uptake of podiatry services among patients with inflammatory arthritis-related foot problems seen at a tertiary hospital in Singapore.

METHOD

A 6-month quality improvement program was conducted by a team of key stakeholders using quality improvement tools to identify, implement and test several interventions designed to improve uptake of podiatry services. The number of patients referred for podiatry assessment was recorded on a weekly basis by an experienced podiatrist. The criterion for appropriate referral to podiatry was those patients with current or previous foot problems such as foot pain, swelling and deformity.

RESULTS

Interventions included education initiatives, revised workflow, development of national guidelines for inflammatory arthritis, local podiatry guidelines for the management of foot and ankle problems, routine use of outcome measures, and introduction of a fully integrated rheumatology-podiatry service with reduced cost package. Referral rates increased from 8% to 11%, and were sustained beyond the study period. Complete incorporation of podiatry into the rheumatology consultation as part of the multidisciplinary team package further increased referrals to achieve the target of full uptake of the podiatry service.

CONCLUSION

Through a structured quality improvement program, referrals to podiatry increased and improved the uptake and acceptance of rheumatology-podiatry services.

Prevalence of foot problems in people with inflammatory arthritis in Singapore

Background

Foot problems are highly prevalent in people with inflammatory arthritis reported from studies in the UK, Europe and New Zealand, but there is limited evidence from Southeast Asia. The study aim was to evaluate the prevalence of foot problems in people with inflammatory arthritis in Singapore.

Methods

People with inflammatory arthritis were recruited from the rheumatology outpatient clinic of a tertiary hospital in Singapore. Disease and clinical characteristics included age, sex, disease duration, current blood tests and medications. The Leeds Foot Impact Scale was used to evaluate foot impairment/disability and the Modified Health Assessment Questionnaire was used to assess global function.

Results

We recruited 101 people with inflammatory arthritis, of which 50 % were female. The majority of participants were Chinese (70 %). The mean (SD) age was 52 (15) years, and the mean (SD) disease duration was 9.3 (0.3) years. The most commonly reported inflammatory arthritic conditions were rheumatoid arthritis (46), gout (31) and spondyloarthritis (15 %). The mean (SD) of the total Leeds Foot Impact Scale was 17 (13) indicating moderate to severe levels of foot impairment and activity limitation. Over 80 of participants reported foot pain during the course of their condition, and 48 % reported current foot pain. Despite the high prevalence of foot pain, only 21 participants (21 %) had been referred to a podiatrist.

Conclusion

This is the first study to investigate the prevalence of foot problems in people with inflammatory arthritis from Singapore. The majority of the participants reported foot problems, but had not been referred to a podiatry service.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-016-0169-y) contains supplementary material, which is available to authorized users.

Footwear characteristics in people with inflammatory arthritis in Singapore

Background

Foot problems are common in people with inflammatory arthritis. Despite suitable footwear having the potential to alleviate pain, improve mobility and maintain independence, previous studies have found many people with inflammatory arthritis wearing poorly fitting and inappropriate footwear. Footwear styles and characteristics have not been reported in a Singapore inflammatory arthritis population. The objective of this study was to identify current footwear styles and characteristics of footwear worn by people with inflammatory arthritis in Singapore.

Methods

One-hundred-and-one participants with inflammatory arthritis were recruited from the rheumatology outpatient clinic of a large public hospital in Singapore. Disease and clinical characteristics were recorded. A patient-reported outcome included current foot pain. An objective footwear assessment of style, age of shoe, fit and construction was conducted.

Results

The majority of participants were Chinese women with a mean (SD) age was 52.0 (15.0) years old and a mean (SD) disease duration of 9.3 (0.3) years. We found 50 % of participants (n = 51) reported footwear problems. Sandals (n = 27, 26 %), flip-flops (n = 19, 19 %) and moccasin type (n = 19, 19 %) was the most common footwear choice. Evaluation of footwear characteristics found that there was a lack of motion control features. Only 32 (32 %) participants had correctly fitting footwear with regard to length, width and depth. No participant was wearing therapeutic footwear.

Conclusion

This study provides the first insight into footwear preferences of people with inflammatory arthritis in Singapore. Use of slip-on and poorly fitting footwear was found to be common in people with inflammatory arthritis. Further research on footwear preferences in Southeast-Asian communities needs to take into account cultural habit and preference, socio-economic status, footwear options and affordability.

Intranasal insulin protects against substantia nigra dopaminergic neuronal loss and alleviates motor deficits induced by 6-OHDA in rats

Protection of substantia nigra (SN) dopaminergic (DA) neurons by neurotrophic factors (NTFs) is one of the promising strategies in Parkinson's disease (PD) therapy. A major clinical challenge for NTF-based therapy is that NTFs need to be delivered into the brain via invasive means, which often shows limited delivery efficiency. The nose to brain pathway is a non-invasive brain drug delivery approach developed in recent years. Of particular interest is the finding that intranasal insulin improves cognitive functions in Alzheimer's patients. In vitro, insulin has been shown to protect neurons against various insults. Therefore, the current study was designed to test whether intranasal insulin could afford neuroprotection in the 6-hydroxydopamine (6-OHDA)-based rat PD model. 6-OHDA was injected into the right side of striatum to induce a progressive DA neuronal lesion in the ipsilateral SN pars compact (SNc). Recombinant human insulin was applied intranasally to rats starting from 24h post lesion, once per day, for 2 weeks. A battery of motor behavioral tests was conducted on day 8 and 15. The number of DA neurons in the SNc was estimated by stereological counting. Our results showed that 6-OHDA injection led to significant motor deficits and 53% of DA neuron loss in the ipsilateral side of injection. Treatment with insulin significantly ameliorated 6-OHDA-induced motor impairments, as shown by improved locomotor activity, tapered/ledged beam-walking performance, vibrissa-elicited forelimb-placing, initial steps, as well as methamphetamine-induced rotational behavior. Consistent with behavioral improvements, insulin treatment provided a potent protection of DA neurons in the SNc against 6-OHDA neurotoxicity, as shown by a 74.8% increase in tyrosine hydroxylase (TH)-positive neurons compared to the vehicle group. Intranasal insulin treatment did not affect body weight and blood glucose levels. In conclusion, our study showed that intranasal insulin provided strong neuroprotection in the 6-OHDA rat PD model, suggesting that insulin signaling may be a novel therapeutic target in broad neurodegenerative disorders.

Predictors of Third Molar Impaction

The objective of this meta-analysis was to evaluate the prevalence of third molar (M3) impaction worldwide in individuals ≥17 y, from either sex, who had undergone oral radiography and presented with no orofacial syndromes or defects. We performed a literature search using PubMed, ISI Web of Science, and Google Scholar and retrieved English and non-English articles from any period for review. We included studies reporting M3 impaction prevalence based on radiographic examination. Risk of bias was assessed regarding individuals with craniofacial syndromes, prior extraction of permanent teeth, multiple effect size estimates, and studies conflating lack of eruption with impaction. Our search yielded 49 studies involving 83,484 individuals. Worldwide M3 impaction prevalence was found to be 24.40% (95% confidence interval [95% CI]: 18.97% to 30.80%). The odds of M3 impaction in the mandible were 57.58% (95% CI: 43.3% to 68.3%, P < 0.0001) higher than in the maxilla, but we did not detect any difference in the odds of impaction between men and women (18.62%, 95% CI: –4.9% to 48.0%, P = 0.12). Mesioangular impaction was most common (41.17%, 95% CI: 33.8% to 49.0%), followed by vertical (25.55%, 95% CI: 20.0% to 32.0%), distoangular (12.17%, 95% CI: 9.1% to 16.0%), and horizontal (11.06%, 95% CI: 8.3% to 14.6%). Impaction of 1 (42.71%, 95% CI: 30.0% to 56.5%) or 2 (29.64%, 95% CI: 19.5% to 42.3%) M3s was much more common than 3 (12.04%, 95% CI: 7.2% to 19.3%) or 4 (8.74%, 95% CI: 5.2% to 14.5%). There were small differences among impaction prevalence depending on geographic region ( F test, P = 0.049). Selection bias was evident because individuals had to undergo radiographic examination to be included in the analysis. The subgroup analysis by sex was underpowered. Worldwide M3 impaction prevalence is lower than previously reported. The percentage of individuals with impacted M3s is much smaller than the percentage that undergoes clinical treatment for M3 problems.

Morphologic and Demographic Predictors of Third Molar Agenesis: A Systematic Review and Meta-analysis

We aimed to consolidate all available data on worldwide third molar agenesis frequencies, with a particular emphasis on exploring the factors leading authors to find contradictory results for the demographic and morphologic predictors of this anomaly. A total of 12,376 studies were originally identified, then narrowed down to 1,312 for title/abstract screening. On the basis of our inclusion and exclusion criteria, we selected 92 studies, containing 100 effect sizes and 63,314 subjects, for systematic review and metaregression. The worldwide rate of agenesis was found to be 22.63% (95% confidence interval = 20.64% to 24.76%), although the estimates ranged from 5.32% to 56.0%. Our subgroup analyses revealed that women are 14% more likely than men to have agenesis of ≥1 third molars and that maxillary agenesis was 36% more likely than mandibular agenesis in both sexes. Furthermore, we found that having agenesis of 1 or 2 molars was most common, while agenesis of 3 or 4 molars was least common. Finally, we found large differences among agenesis frequency depending on geographic region. This information is expected to be of use not only to clinicians and patients but also to policy makers, given the implications for third molar extraction protocols.

Characterization of large deletions in the DHCR7 gene

Pathogenic variants in the DHCR7 gene cause Smith-Lemli-Opitz syndrome (SLOS), a defect of cholesterol biosynthesis resulting in an autosomal recessive congenital metabolic malformation disorder. In approximately 4% of patients, the second mutation remains unidentified. In this study, 12 SLOS patients diagnosed clinically and/or by elevated 7-dehydrocholesterol (7-DHC) have been investigated by customized multiplex ligation-dependent probe amplification (MLPA) analysis, because only one DHCR7 sequence variant has been detected. Two unrelated patients of this cohort carry different large deletions in the DHCR7 gene. One patient showed a deletion of exons 3-6. The second patient has a deletion of exons 1 and 2 (non-coding) and lacks the major part of the promoter. These two patients show typical clinical and biochemical phenotypes of SLOS. Second disease-causing mutations are p.(Arg352Trp) and p.(Thr93Met), respectively. Deletion breakpoints were characterized successfully in both cases. Such large deletions are rare in the DHCR7 gene but will resolve some of the patients in whom a second mutation has not been detected.

Spatial and Temporal Variability of Movement Parameters in Individuals with down Syndrome

This investigation compared spatial and temporal gait movement parameters of a sample of individuals with Down syndrome ( n = 12) and one of individuals without disabilities ( n = 12). All participants were evaluated on responses to a preferred pace and fast walk with the GAITRite Electronic Walkway. Spatial outcomes included step and stride length, step and stride width, toe-in/toe-out, and base of support. Temporal outcomes included step time, velocity, single and double leg support time, stance, and swing time. There were significant group differences for step length, step width, stride length, and velocity in the preferred walk condition. Significant group differences for step length, step width, and stride length were observed in the fast walk condition. Percentage differences also indicated lower scores for all spatial and temporal variables in relation to the control group. The ability to control gait movements appears to reflect earlier movement experiences, so it may be possible to use variable sensory feedback and specific training to modify and adjust movement responses and improve gait performance in Down syndrome.

Polymorphisms associated with normal memory variation also affect memory impairment in schizophrenia

Neurocognitive dysfunction is a core feature of schizophrenia with particularly prominent deficits in verbal episodic memory. The molecular basis of this memory impairment is poorly understood and its relatedness to normal variation in memory performance is unclear. In this study, we explore, in a sample of cognitively impaired schizophrenia patients, the role of polymorphisms in seven genes recently reported to modulate episodic memory in normal subjects. Three polymorphisms (GRIN2B rs220599, GRM3 rs2189814 and PRKCA rs8074995) were associated with episodic verbal memory in both control and patients with cognitive deficit, but not in cognitively spared patients or the pooled schizophrenia sample. GRM3 and PRKCA acted in opposite directions in patients compared to controls, possibly reflecting an abnormal brain milieu and/or adverse environmental effects in schizophrenia. The encoded proteins balance glutamate signalling vs. excitotoxicity in complex interactions involving the excitatory amino acid transporter 2 (EAAT2), implicated in the dysfunctional glutamatergic signalling in schizophrenia. Double carrier status of the GRM3 and PRKCA minor alleles was associated with lower memory test scores and with increased risk of schizophrenia. Single nucleotide polymorphism (SNP) rs8074995 lies within the PRKCA region spanned by a rare haplotype associated with schizophrenia in a recent UK study and provides further evidence of PRKCA contribution to memory impairment and susceptibility to schizophrenia. Our study supports the utility of parsing the broad phenotype of schizophrenia into component cognitive endophenotypes that reduce heterogeneity and enable the capture of potentially important genetic associations.

Anaesthesia in the prone position

Prone positioning of patients during anaesthesia is required to provide operative access for a wide variety of surgical procedures. It is associated with predictable changes in physiology but also with a number of complications, and safe use of the prone position requires an understanding of both issues. We have reviewed the development of the prone position and its variants and the physiological changes which occur on prone positioning. The complications associated with this position and the published techniques for various practical procedures in this position will be discussed. The aim of this review is to identify the risks associated with prone positioning and how these risks may be anticipated and minimized.

Iron loading and morbidity among relatives of HFE C282Y homozygotes identified either by population genetic testing or presenting as patients

BACKGROUND AND AIMS

Although most cases of hereditary haemochromatosis are associated with homozygosity for the C282Y mutation of the HFE gene, clinical penetrance varies and other genes may modify disease expression. If so, relatives from clinically affected families, by inheriting such genes, may accumulate more iron. To seek evidence for this, we compared iron status and morbidity in unselected first degree relatives of two groups of index cases from South Wales, namely asymptomatic C282Y homozygotes identified by genetic screening of blood donors (n = 56) and C282Y homozygous haemochromatosis patients presenting clinically (n = 60).

METHODS

All participating relatives had a structured interview, clinical assessment, and laboratory investigations. Health related quality of life was measured (SF-36 version 2).

RESULTS

In total, 92% of 180 eligible first degree relatives were interviewed in the "screened" family group and 85% of 143 eligible relatives in the "patient" group. Of 59 relatives homozygous for C282Y, 76% of men and 32% of women had the "iron phenotype" (raised transferrin saturation and serum ferritin). Logistic regression modelling of the iron phenotype risk showed that 42% of the initial model deviance could be explained by homozygosity for C282Y, another 6% by lifestyle factors, and 6% by being male. Family group membership was not a significant risk factor. Morbidity and SF-36 scores did not differ significantly either between C282Y homozygotes and relatives lacking C282Y, or between C282Y homozygotes from the "screened" and "patient" groups. Serious morbidity (including cirrhosis) was low in both groups of relatives.

CONCLUSIONS

HFE C282Y homozygosity has a high penetrance for iron accumulation but a low clinical penetrance. Lack of excess morbidity among C282Y homozygous relatives of index cases who presented clinically suggests that residual unknown genetic or environmental factors do not greatly influence clinical outcome among C282Y homozygotes.