Unclassified white matter disorders: A diagnostic journey requiring close collaboration between clinical and laboratory services

BACKGROUND

Next generation sequencing studies have revealed an ever-increasing number of causes for genetic disorders of central nervous system white matter. A substantial number of disorders are identifiable from their specific pattern of biochemical and/or imaging findings for which single gene testing may be indicated. Beyond this group, the causes of genetic white matter disorders are unclear and a broader approach to genomic testing is recommended.

AIM

This study aimed to identify the genetic causes for a group of individuals with unclassified white matter disorders with suspected genetic aetiology and highlight the investigations required when the initial testing is non-diagnostic.

METHODS

Twenty-six individuals from 22 families with unclassified white matter disorders underwent deep phenotyping and genome sequencing performed on trio, or larger, family groups. Functional studies and transcriptomics were used to resolve variants of uncertain significance with potential clinical relevance.

RESULTS

Causative or candidate variants were identified in 15/22 (68.2%) families. Six of the 15 implicated genes had been previously associated with white matter disease (COL4A1, NDUFV1, SLC17A5, TUBB4A, BOLA3, DARS2). Patients with variants in the latter two presented with an atypical phenotype. The other nine genes had not been specifically associated with white matter disease at the time of diagnosis and included genes associated with monogenic syndromes, developmental disorders, and developmental and epileptic encephalopathies (STAG2, LSS, FIG4, GLS, PMPCA, SPTBN1, AGO2, SCN2A, SCN8A). Consequently, only 46% of the diagnoses would have been made via a current leukodystrophy gene panel test.

DISCUSSION

These results confirm the importance of broad genomic testing for patients with white matter disorders. The high diagnostic yield reflects the integration of deep phenotyping, whole genome sequencing, trio analysis, functional studies, and transcriptomic analyses.

CONCLUSIONS

Genetic white matter disorders are genetically and phenotypically heterogeneous. Deep phenotyping together with a range of genomic technologies underpin the identification of causes of unclassified white matter disease. A molecular diagnosis is essential for prognostication, appropriate management, and accurate reproductive counseling.

The Fetus with Ganglionic Eminence Abnormality: Head Size and Extracranial Sonographic Findings Predict Genetic Diagnoses and Postnatal Outcomes

BACKGROUND AND PURPOSE

Ganglionic eminence abnormalities on fetal MR imaging are associated with cerebral malformations. Their presumed genetic basis and associated postnatal outcomes remain largely unknown. We aimed to elucidate these through a multicenter study.

MATERIALS AND METHODS

Between January 2010 and June 2020, seven hospitals in 2 countries performing fetal MR imaging examinations identified fetal MR imaging studies demonstrating ganglionic eminence enlargement, cavitation, or both. Cases with no genetic diagnosis, no whole exome sequencing, or no outcome of a liveborn child were excluded. Head size was classified as large (fronto-occipital diameter > 95th centile), small (fronto-occipital diameter <5th centile), or normal.

RESULTS

Twenty-two fetuses with ganglionic eminence abnormalities were identified. Of 8 with large heads, 2 were diagnosed with MTOR mutations; 1 with PIK3CA mutation-producing megalencephaly, polymicrogyria, polydactyly, hydrocephalus (MPPH) syndrome; 3 with TSC mutations; 1 with megalencephaly capillary malformation syndrome; and 1 with hemimegalencephaly. Cardiac rhabdomyoma was present prenatally in all cases of TSC; mutation postaxial polydactyly accompanied megalencephaly capillary malformation and MPPH. Of 12 fetuses with small heads, 7 had TUBA1A mutations, 1 had a TUBB3 mutation, 2 had cobblestone lissencephaly postnatally with no genetic diagnosis, 1 had a PDHA1 mutation, and 1 had a fetal akinesia dyskinesia sequence with no pathogenic mutation on trio whole exome sequencing. One of the fetuses with a normal head size had an OPHN1 mutation with postnatal febrile seizures, and the other had peri-Sylvian polymicrogyria, seizures, and severe developmental delay but no explanatory mutation on whole exome sequencing.

CONCLUSIONS

Fetal head size and extracranial prenatal sonographic findings can refine the phenotype and facilitate genetic diagnosis when ganglionic eminence abnormality is diagnosed with MR imaging.

Acute disseminated encephalomyelitis and routine childhood vaccinations - a self-controlled case series

Acute disseminated encephalomyelitis (ADEM) is an autoimmune, central nervous system demyelinating disorder that follows antecedent immunologic challenges, such as infection or vaccination. This study aimed to investigate the potential association between routine childhood vaccinations and ADEM. Children under 7 years of age admitted to the two tertiary level pediatric hospitals in Victoria, Australia with ADEM from 2000-2015 had their clinical information linked to vaccination records from the Australian Childhood Immunization Register. Chart review was undertaken utilizing the Brighton Collaboration ADEM criteria. The self-controlled case-series (SCCS) methodology was employed to determine the relative incidences of ADEM post-vaccination in two risk intervals: 5-28 days and 2-42 days. Forty-six cases were eligible for SCCS analysis with a median age of 3.2 years. Of the forty-six cases, three were vaccine proximate cases and received vaccinations 23, 25 and 28 days before ADEM onset. Two vaccine proximate cases received their 4-year-old scheduled vaccinations (MMR and DTPa-IPV) and one vaccine proximate case the 1-year old scheduled vaccinations (MMR and Hib-MenC). The relative incidence of ADEM during the narrow and broad risk intervals were 1.041 (95% CI 0.323-3.356, p = 0.946) and 0.585 (95% CI 0.182-1.886, p = 0.370) respectively. Sensitivity analyses did not yield any substantial deviations. These results do not provide evidence of an association between vaccinations routinely provided to children aged under 7 years in Australia and the incidence of ADEM. However, these results should be interpreted with caution as the number of ADEM cases identified was limited and further research is warranted.

A checklist for trauma quality improvement meetings: A process improvement study

BACKGROUND

Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM.

METHODS

This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop.

RESULTS

There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001).

CONCLUSION

This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.

Onabotulinum toxin-A (Botox) for spastic equinus in cerebral palsy: a prospective kinematic study

PURPOSE

Botulinum toxin-A (or Botox) is widely used for the management of equinus gait in children with cerebral palsy but few recent studies have included instrumented gait analysis.

METHODS

This was a prospective cohort study. Gait analysis was performed four weeks before and four weeks after Botulinum toxin-A injection for spastic equinus to detect the maximum effects on gait kinematics. Outcome measures included the Gait Profile Score (GPS), the Gait Variable Score (GVS) for the ankle, maximal ankle dorsiflexion and maximal knee extension at midstance.

RESULTS

In all, 37 children participated (20 boys); mean age five years seven months (4 years 1 month to 8 years 2 months); 19 with unilateral and 18 bilateral involvement. At a mean four weeks post-injection, the GPS and ankle GVS were unchanged. However maximum ankle dorsiflexion increased for the whole group; median 7.7° (confidence interval (CI) 4° to 10.6°) to 11.5° (CI 7.7° to 12.9°), p = 0.02. Maximum midstance knee extension was unchanged for the whole group, but median knee flexion increased in children with bilateral involvement; 10.9° (CI 7.4° to 20.8°) to 16.5° (CI 8.4° to 19.7°), p = 0.58.

CONCLUSION

Injections of the gastrocsoleus for spastic equinus did not result in objective improvements in overall gait. Improvements in ankle dorsiflexion for children with bilateral involvement may be offset by deterioration at the knee.

LEVEL OF EVIDENCE

II - prospective cohort study, before and after intervention.

Size and shape of the corpus callosum in adult Niemann-Pick type C reflects state and trait illness variables

BACKGROUND AND PURPOSE

Variable alterations to the structure of the corpus callosum have been described in adults with NPC, a neurometabolic disorder known to result in both white and gray matter pathology. This study sought to examine the structure of the callosum in a group of adult patients with NPC and compared callosal structure with a group of matched controls, and to relate callosal structure with state and trait illness variables.

MATERIALS AND METHODS

Nine adult patients with NPC were matched to control subjects (n = 26) on age and sex. The corpus callosum was segmented from the midsagittal section of T1-weighted images on all subjects, and total area, length, bending angle, and mean thickness were calculated. In addition, 39 regional thickness measures were derived by using a previously published method. All measures were compared between groups, and analyzed alongside symptom measures, biochemical parameters, and ocular-motor measures.

RESULTS

The callosal area and mean thickness were significantly reduced in the patient group, and regional thickness differences were greatest in the genu, posterior body, isthmus, and anterior splenium. Global callosal measures correlated significantly with duration of illness and symptom score, and at trend level with degree of filipin staining. Measures of reflexive saccadic peak velocity and gain, and self-paced saccades, correlated strongly with total callosal area.

CONCLUSIONS

Callosal structure and size reflect both state and trait markers in adult NPC, and they may be useful biomarkers to index both white and gray matter changes that reflect illness severity and progression.

Audit of a laxative policy for elderly patients

A laxative policy was introduced at Charing Cross hospital, London, which recommended co-danthrusate and co-danthramer as first line treatment for constipation in the elderly. As a result of this policy the prescribing of lactulose was virtually eliminated and the use of phosphate enemas fell significantly.

White and gray matter alterations in adults with Niemann-Pick disease type C: a cross-sectional study

OBJECTIVE

Niemann-Pick disease type C (NPC) is a progressive neurovisceral disorder with disrupted intracellular cholesterol metabolism that results in significant alterations to neuronal and axonal structure. Adult patients present with ataxia, gaze palsy, impaired cognition, and neuropsychiatric illness, but the neural substrate has not been well-characterized in vivo. Our aim was to investigate a well-characterized sample of adults with confirmed NPC for gray and white matter abnormalities.

METHODS

We utilized a combination of optimized voxel-based morphometry of T1-weighted images and tract-based spatial statistics of diffusion tensor images to examine gray matter volume and white matter structural differences in 6 adult patients with NPC and 18 gender- and age-matched controls.

RESULTS

Patients with NPC demonstrated bilateral gray matter reductions in large clusters in bilateral hippocampus, thalamus, superior cerebellum, and insula, in addition to smaller regions of inferoposterior cortex. Patients demonstrated widespread reductions in fractional anisotropy in major white matter tracts. Subsequent analysis of measures of axial and radial diffusivity suggest that these changes are contributed to by both impaired myelination and altered axonal structure.

CONCLUSIONS

Findings in gray matter areas are broadly consistent with human and animal studies of selective vulnerability of neuronal populations to the neuropathology of NPC, whereas more widespread white matter changes are consistent with the hypothesis that disrupted myelination and axonal structure predate changes to the neuronal cell body. These findings suggest that volumetric analysis of gray matter and diffusion tensor imaging may be useful modalities for indexing illness stage and monitoring response to emerging treatment.

Alopecia in Rhesus macaques correlates with immunophenotypic alterations in dermal inflammatory infiltrates consistent with hypersensitivity etiology

BACKGROUND

Although alopecia is a commonly recognized problem affecting many captive Rhesus macaque colonies, there is no consensus as to the underlying etiology or appropriate course of management.

METHODS

We performed skin biopsies to assess underlying pathology in alopecic Rhesus macaques and performed immunohistochemical and metachromatic staining of these biopsies to assess the cellular infiltrates.

RESULTS

Alopecia is associated with superficial dermal perivascular mononuclear cell infiltrates and skin pathology consistent with chronic hypersensitivity dermatitis. The inflammation is primarily composed of CD4+ cells admixed with histiocytes and mast cells. Inflammation is correlated with degree of alopecia. Further analysis in different groups of macaques revealed that animals born outdoors or infected with lung mites had reduced dermal inflammatory cell infiltrates and a lower incidence of alopecia.

CONCLUSIONS

These findings support a hypothesis that an altered housing status resulting in decreased pathogen burden in Rhesus macaque colonies may contribute to dermal immunophenotypic alterations and subsequent development of dermatitis with resultant alopecia.

A new dominantly inherited pure cerebellar ataxia, SCA 30

BACKGROUND

The spinocerebellar ataxias (SCAs) are clinically and genetically heterogeneous. Currently, 27 forms are known, with the causative gene identified in 16. Although the majority of dominant pedigrees worldwide have SCAs 1, 2, 3, 6 or 8, new SCAs continue to be delineated. We describe a new disorder: SCA 30.

METHODS

An Australian family of Anglo-Celtic ethnicity manifested a relatively pure, slowly evolving ataxia. Six affected and four unaffected members were personally examined in a standardised fashion. MRI and nerve conduction studies were performed in two. An autosomal genome-wide linkage study was undertaken, and an in silico analysis of potential candidate genes in the linkage region was performed.

RESULTS

The six affected members had a relatively pure, slowly evolving ataxia developing in mid to late life, with only minor pyramidal signs and no evidence of neuropathy. All had hypermetric saccades with normal vestibulo-ocular reflex gain. Only one displayed (slight) gaze-evoked nystagmus. MRI showed cerebellar atrophy with preservation of nodulus/uvula and brainstem. Linkage analysis excluded currently known SCAs and identified a logarithm (base 10) of odds score of 3.0 at chromosome 4q34.3-q35.1, distinct from all previously reported loci. In silico prioritisation identified the gene ODZ3 as the most likely contender.

CONCLUSIONS

SCA 30 is a previously undescribed cause of (relatively) pure adult-onset autosomal dominant cerebellar ataxia. The responsible gene is yet to be determined, but ODZ3 is a plausible candidate.

NGF receptor TrkAd5: therapeutic agent and drug design target

Biochemical studies have shown that domain 5 of the TrkA (tropomyosin receptor kinase A) receptor is involved in the binding of NGF (nerve growth factor). Crystallographic studies have confirmed this, demonstrating that one homodimer of NGF binds to two TrkAd5 molecules. TrkAd5 has been made recombinantly in Escherichia coli, purified and shown to bind NGF with picomolar affinity. We have used the co-ordinates of the crystal structure of the NGF-TrkAd5 complex to screen approximately two million compounds in silico for the identification of small molecule agonists/antagonists. Selected hits were shown to be active in an in vitro ligand-binding assay; structure-activity relationships are now being investigated. In addition, TrkAd5 has been shown to be efficacious in preclinical models of inflammatory pain and asthma by the sequestration of excess levels of endogenous NGF, and therefore represents a novel therapeutic agent.

Measurement of Adherence to Anti-Hypertensive Medication as Perceived by Doctors and Patients

Introduction: In the absence of objective evidence, doc-tors frequently overestimate the level of their patient's ad-herence to medication and there is no published work look-ing at what factors influence the doctor's perceptions of medication adherence by hypertensive patients. Therefore, the aim of this study to determine the doctor's perceptions of adherence to antihypertensive medication and to com-pare this with their perceptions of the clinical situation and with the patient's self -reported medication adherence.

Methods: An English self reporting measure (7-item questionnaire) was adapted and translated to Arabic and used to determine the adherence to hypertensive medica-tion. Also, a 10-item questionnaire was developed to elicit the doctor's perception of adherence (taking > 80% of doses) and the treatment and overall condition. This de-scriptive study was conducted in across 2 primary health centers in Abu-Dhabi, UAE.

Results: About 40 % of them were controlled regard-ing BP and 30% of hypertensive patients were diabetics. The doctors estimated adherence to be high (taking more than 80% of doses) in 143 (71%) of patients compared with 103(52%) patients who reported high adherence by using Morisky score where, there was a statistically significant relationship between them. Of the 143 subjects perceived by their doctors as having high adherence, only 64 (45%) succeeded to achieve the target blood pressure (p <  0.001) while 55 (52%) of the adherent patients from the self-reported point of view achieved their target BP (p <  0.001). The doctor evaluation was not as good as expected for treatment effectiveness and quality of communication (57% only were evaluated as good). Only the doctor's evaluation of the seriousness of the medical situation showed a sig-nificant correlation with the self-reported adherence and this was in the opposite direction (gamma = - 0.32, p < 0.05). 71% of the adherent patients perceived by doctors were estimated to have effective treatment (p <  0.0001) while 81% of patients achieved their target BP were estimated to have effective treatment by their doctors.

Conclusion: The practical assessment of adherence and drug management would have been greatly enhanced if the results of the Arabic/English self-reporting measure had been available to the doctors in the course of routine practice.

Growth, behavior, and clinical findings in 27 patients with Kabuki (Niikawa-Kuroki) syndrome

This study was undertaken to document the phenotype of Kabuki (Niikawa-Kuroki) syndrome in patients from Australia and New Zealand, with particular emphasis on growth patterns, behavior, and relationship between head circumference and intellectual level. Data on 27 children and adults with Kabuki (Niikawa-Kuroki) syndrome from Australia and New Zealand were collected by questionnaire and clinical assessment. The patients ranged in age from 7 months to 36 years with a mean age of 7 years and 2 months. The mean age at diagnosis was 3(5/6) years, but in most cases, the facial phenotype was evident from infancy. The minimum birth prevalence was calculated at 1 in 86,000. Three of our patients died. Parents reported a behavior phenotype characterized by an excellent long-term memory and avoidance of eye contact. No correlation was found between head circumference and severity of intellectual disability. Eight of 14 patients over the age of 5 years were overweight or obese. Six of these eight patients had failure to thrive in infancy. One patient developed insulin-dependent diabetes mellitus in adolescence. Some individuals with Kabuki (Niikawa-Kuroki) syndrome show a characteristic growth profile with failure to thrive in infancy progressing to obesity or overweight in middle childhood or adolescence. A behavior phenotype was noted which requires further investigation. Head size is not a predictor of degree of intellectual disability.

Diversity of dietary patterns observed in the European Prospective Investigation into Cancer and Nutrition (EPIC) project

OBJECTIVE

To describe the diversity in dietary patterns existing across centres/regions participating in the European Prospective Investigation into Cancer and Nutrition (EPIC).

DESIGN AND SETTING

Single 24-hour dietary recall measurements were obtained by means of standardised face-to-face interviews using the EPIC-SOFT software. These have been used to present a graphic multi-dimensional comparison of the adjusted mean consumption of 22 food groups.

SUBJECTS

In total, 35 955 men and women, aged 35-74 years, participating in the EPIC nested calibration study.

RESULTS

Although wide differences were observed across centres, the countries participating in EPIC are characterised by specific dietary patterns. Overall, Italy and Greece have a dietary pattern characterised by plant foods (except potatoes) and a lower consumption of animal and processed foods, compared with the other EPIC countries. France and particularly Spain have more heterogeneous dietary patterns, with a relatively high consumption of both plant foods and animal products. Apart from characteristics specific to vegetarian groups, the UK 'health-conscious' group shares with the UK general population a relatively high consumption of tea, sauces, cakes, soft drinks (women), margarine and butter. In contrast, the diet in the Nordic countries, The Netherlands, Germany and the UK general population is relatively high in potatoes and animal, processed and sweetened/refined foods, with proportions varying across countries/centres. In these countries, consumption of vegetables and fruit is similar to, or below, the overall EPIC means, and is low for legumes and vegetable oils. Overall, dietary patterns were similar for men and women, although there were large gender differences for certain food groups.

CONCLUSIONS

There are considerable differences in food group consumption and dietary patterns among the EPIC study populations. This large heterogeneity should be an advantage when investigating the relationship between diet and cancer and formulating new aetiological hypotheses related to dietary patterns and disease.

European Prospective Investigation into Cancer and Nutrition (EPIC): study populations and data collection

The European Prospective Investigation into Cancer and Nutrition (EPIC) is an ongoing multi-centre prospective cohort study designed to investigate the relationship between nutrition and cancer, with the potential for studying other diseases as well. The study currently includes 519 978 participants (366 521 women and 153 457 men, mostly aged 35-70 years) in 23 centres located in 10 European countries, to be followed for cancer incidence and cause-specific mortality for several decades. At enrollment, which took place between 1992 and 2000 at each of the different centres, information was collected through a non-dietary questionnaire on lifestyle variables and through a dietary questionnaire addressing usual diet. Anthropometric measurements were performed and blood samples taken, from which plasma, serum, red cells and buffy coat fractions were separated and aliquoted for long-term storage, mostly in liquid nitrogen. To calibrate dietary measurements, a standardised, computer-assisted 24-hour dietary recall was implemented at each centre on stratified random samples of the participants, for a total of 36 900 subjects. EPIC represents the largest single resource available today world-wide for prospective investigations on the aetiology of cancers (and other diseases) that can integrate questionnaire data on lifestyle and diet, biomarkers of diet and of endogenous metabolism (e.g. hormones and growth factors) and genetic polymorphisms. First results of case-control studies nested within the cohort are expected early in 2003. The present paper provides a description of the EPIC study, with the aim of simplifying reference to it in future papers reporting substantive or methodological studies carried out in the EPIC cohort.

Use and costs of ambulatory care services among Medicare enrollees with schizophrenia

OBJECTIVE

The objective of this study was to identify predictors of the use and cost of ambulatory care services among Medicare recipients with schizophrenia.

METHODS

The design was a cross-sectional analysis of Medicare claims in 1991. The study subjects were a 5 percent random sample of all persons in the United States who had at least one Medicare service claim in 1991 and who were diagnosed as having schizophrenia in any care setting. Outcome measures included use and cost of any ambulatory care service, individual therapy, psychiatric somatotherapy, group therapy, or family therapy.

RESULTS

For nearly 25 percent of the total sample of 12,440, no claims were filed for ambulatory care services in 1991. The mean+/-SD number of ambulatory care visits during the year was 7.9+/-21. The most frequently used type of therapy was individual therapy (5+/-14 visits). The mean+/-SD yearly cost of care for persons who received ambulatory care services was $470+/-$1,028. Among persons under 65 years of age, Caucasians were about 1.5 times as likely as African Americans to have received an ambulatory care service and 1.3 times as likely to have received individual therapy. Persons who were 65 or older were less likely to have received any service. Among service recipients, costs of care were lower for African Americans and for older people.

CONCLUSIONS

The use of Medicare-funded ambulatory care services by persons with schizophrenia varied by race and age. Further investigation is required to determine whether subgroups of individuals who do not have additional insurance coverage or access to services are receiving substandard care.

Decreased expression of TGF-beta cell surface receptors during progression of human oral squamous cell carcinoma

This study examined the immunocytochemical expression of the transforming growth factor-beta (TGF-beta) isoforms TGF-beta1, TGF-beta2, and TGF-beta3, together with the TGF-beta cell surface receptors TbetaR-I and TbetaR-II, in patient-matched tissue pairs of normal human oral epithelium, primary squamous cell carcinomas, and metastatic lymph node tumour deposits. There were no significant differences in the intensity of TGF-beta isoform specific staining between the normal oral epithelium, the primary tumours, and the lymph node metastases. By contrast, there was significantly less TbetaR-II in the metastases than in the primary tumour and between the primary tumour and the normal oral epithelium. Similar trends were evident with TbetaR-I, but not at a statistically significant level. This study also examined the structure of TbetaR-I and TbetaR-II in normal human oral keratinocytes in vitro and in 14 human oral carcinoma cell lines with known responses to TGF-beta1. No structural abnormalities of TbetaR-II were present in the normal keratinocytes or in 13 of 14 malignant cell lines; in one line, there were both normal and mutant forms of TbetaR-II, the latter being in the form of a frameshift mutation with the insertion of a single adenine base (bases 709-718, codons 125-128), predicting a truncated receptor having no kinase domain. No defects were present in TbetaR-I. The structures of TbetaR-I and TbetaR-II did not correlate with growth inhibition by TGF-beta1. The data suggest that decreased expression of TGF-beta receptors, rather than structural defects of these genes, may be important in oral epithelial tumour progression. In order to examine the functional significance of a specific decrease in TbetaR-II expression, a dominant-negative TbetaR-II construct (dnTbetaR-II) was transfected into a human oral carcinoma cell line with a normal TGF-beta receptor profile and known to be markedly inhibited by TGF-beta1. In those clones that overexpressed the dnTbetaR-II, growth inhibition and Smad binding activity were decreased, whilst the regulation of Fra-1 and collagenase-1 remained unchanged following treatment with TGF-beta1. The results demonstrate that a decrease in TbetaR-II relative to TbetaR-I leads to selective gene regulation with loss of growth inhibition but continued transcription of AP-1-dependent genes that are involved in the regulation of the extracellular matrix.

Decreased expression of TGF-beta cell surface receptors during progression of human oral squamous cell carcinoma

This study examined the immunocytochemical expression of the transforming growth factor-beta (TGF-beta) isoforms TGF-beta1, TGF-beta2, and TGF-beta3, together with the TGF-beta cell surface receptors TbetaR-I and TbetaR-II, in patient-matched tissue pairs of normal human oral epithelium, primary squamous cell carcinomas, and metastatic lymph node tumour deposits. There were no significant differences in the intensity of TGF-beta isoform specific staining between the normal oral epithelium, the primary tumours, and the lymph node metastases. By contrast, there was significantly less TbetaR-II in the metastases than in the primary tumour and between the primary tumour and the normal oral epithelium. Similar trends were evident with TbetaR-I, but not at a statistically significant level. This study also examined the structure of TbetaR-I and TbetaR-II in normal human oral keratinocytes in vitro and in 14 human oral carcinoma cell lines with known responses to TGF-beta1. No structural abnormalities of TbetaR-II were present in the normal keratinocytes or in 13 of 14 malignant cell lines; in one line, there were both normal and mutant forms of TbetaR-II, the latter being in the form of a frameshift mutation with the insertion of a single adenine base (bases 709-718, codons 125-128), predicting a truncated receptor having no kinase domain. No defects were present in TbetaR-I. The structures of TbetaR-I and TbetaR-II did not correlate with growth inhibition by TGF-beta1. The data suggest that decreased expression of TGF-beta receptors, rather than structural defects of these genes, may be important in oral epithelial tumour progression. In order to examine the functional significance of a specific decrease in TbetaR-II expression, a dominant-negative TbetaR-II construct (dnTbetaR-II) was transfected into a human oral carcinoma cell line with a normal TGF-beta receptor profile and known to be markedly inhibited by TGF-beta1. In those clones that overexpressed the dnTbetaR-II, growth inhibition and Smad binding activity were decreased, whilst the regulation of Fra-1 and collagenase-1 remained unchanged following treatment with TGF-beta1. The results demonstrate that a decrease in TbetaR-II relative to TbetaR-I leads to selective gene regulation with loss of growth inhibition but continued transcription of AP-1-dependent genes that are involved in the regulation of the extracellular matrix.

Autoantibodies against the processed ectodomain of collagen XVII (BPAG2, BP180) define a canine homologue of linear IgA disease of humans

Linear IgA disease (LAD) is an acquired autoimmune subepidermal blistering dermatosis that affects human children and adults. In contrast to bullous pemphigoid, in which autoantibodies recognize transmembrane type XVII collagen (BP180, BPAG2), LAD is associated with skin-fixed and circulating IgA autoantibodies that target LAD-1, the processed extracellular form of type XVII collagen. An immunologic homologue of LAD in humans was identified in two dogs according to the following criteria: 1) erosive, ulcerative, and crusted lesions seen on the face, in the oral cavity, and on the extremities, 2) dermoepidermal clefting present in the basement membrane lamina lucida without inflammation or with mild neutrophilic infiltration, 3) basement membrane-fixed IgG and/or IgA antibodies, and 4) circulating IgA and IgG autoantibodies that target the 120-kd soluble protein LAD-1. The present study establishes unequivocally the existence of a naturally occurring canine model of LAD of humans.

Novel feline autoimmune blistering disease resembling bullous pemphigoid in humans: IgG autoantibodies target the NC16A ectodomain of type XVII collagen (BP180/BPAG2)

In humans and dogs, bullous pemphigoid (BP) is an autoimmune blistering disease associated with the production of basement membrane autoantibodies that target the 180-kd type XVII collagen (BP180, BPAG2) and/or the 230-kd plakin epidermal isoform BPAG1e (BP230). In two adult cats, an acquired dermatosis and stomatitis was diagnosed as BP subsequent to the fulfillment of the following criteria: 1) presence of cutaneous vesicles, erosions, and ulcers; 2) histologic demonstration of subepidermal vesiculation with inflammatory cells, including eosinophils; 3) in vivo deposition of IgG autoantibodies at the epidermal basement membrane zone; and 4) serum IgG autoantibodies targeting a 180-kd epidermal protein identified as type XVII collagen. In both cats, the antigenic epitopes targeted by IgG autoantibodies were shown to be situated in the NC16A ectodomain of type XVII collagen, a situation similar to that of humans and dogs with BP. Feline BP therefore can be considered a clinical, histopathologic, and immunologic homologue of BP in humans and dogs.

What causes p53 mutations in patients with lung cancer?

We studied the association between occurrence of p53 mutations and both smoking history and family history of cancer (FH) in 109 lung cancer patients using the logistic regression model. A dose-response relationship between smoking defined as pack-years smoked (PY) and p53 mutations was clearly demonstrated [Odds ratio (OR) for PY 30-59: 1.92 (0.55-7.94); OR for PY 60: 4.21 (1.09-19.0); trend P=0. 04], but no association between p53 mutations and FH was obtained in male patients. In females, smoking habit [OR: 3.23 (0.48-25.4)] and FH [OR: 4.17 (0.84-25.0)] might both be associated with p53 mutations.

Comparative analysis of transforming growth factor-beta isoforms 1-3 in human and rabbit dentine matrices

Previous studies have implicated transforming growth factor-beta (s)(TGF-beta) in both development. Here TGF-beta isoforms in dentine extracellular matrix were analysed because these molecules may participate in dental issue repair. EDTA-soluble and collagenase-released fractions were isolated from human crown and root and rabbit incisor dentine samples and analysed for TGF-beta isoforms. TGF-beta(1) was the major isoform detected in all samples and the only isoform detected in human dentine samples. TGF-beta(2) was detected only in the collagenase-released fraction of rabbit incisor dentine and was present at low levels. TGF-beta(3) was detected in both EDTA-soluble and collagenase-released fractions of rabbit dentine. Greater levels of the TGF-beta(1) isoform were detected in the rabbit than human dentine samples and some differences in distribution amongst the two tissue fractions were observed between these species. The presence of these isoforms of TGF-beta in dentine may provide a reservoir of growth factor in the matrix that could participate in processes leading to tissue repair after injury.

Two women and their mothers: on the internalization and development of mother-daughter relationships

This is a report from a 30-year followup study conducted by a member of Margaret Mahler's original separation-individuation research team. Based on a series of unstructured, clinical interviews with the original subjects and psychological testing of the subjects and their mothers, two mother-daughter pairs are compared from the perspective of the meaning of each daughter to her mother, how that meaning influenced the separation-individuation process, and how it influenced the unfolding of each daughter's life as a woman. Because the mother-child pairs were observed several times a week by both participant and nonparticipant observers beginning during the preverbal period, this study offers a unique opportunity to examine the influence of the earliest interactions on adult life.

Meta-analytic methods for diagnostic test accuracy

Meta-analyses of diagnostic test accuracy are uncommon and often based on separate pooling of sensitivity and specificity, which can lead to biased estimates. Recently, several appropriate methods have been developed for meta-analysing diagnostic test data from primary studies. Primary studies usually only provide binary test data, for which Moses et al. have developed a method to estimate Summary Receiver Operating Characteristic Curves, thereby taking account of possible test threshold differences between studies. Several methods are also available for analysing multicategory and continuous test data. The usefulness of applying these methods is constrained by publication bias and the generally poor quality of primary studies of diagnostic test accuracy. Meta-analysts need to highlight important defects in quality and how they affect summary estimates to ensure that better primary studies are available for meta-analysis in the future.

Bone tunnel enlargement after anterior cruciate ligament replacement

Radiographic increase in the size of tibial and femoral tunnels has been observed. This retrospective study compared tibial tunnel diameter in 56 autograft and 87 allograft patellar tendon bone-tendon-bone anterior cruciate ligament replacements whose observed tunnel changes were correlated with clinical results at 1 year postoperatively. Tibial tunnel sclerotic margins were measured approximately 1 cm below the joint line. Exact tunnel dimension was calculated by using a magnification factor determined by the interference screw of known diameter within the same tunnel. Average allograft tunnel enlargement was 1.2 mm (-2.5 to 6.0) compared with the autograft tunnel enlargement of 0.26 mm (-2.5 to 2.7); the difference was significant (P > 0.0002). No significant difference was seen in KT-1000 arthrometer measurements between autograft or allograft groups, and no correlation was seen between increased tunnel size and clinical outcome as determined by the modified Hughston knee evaluation system. Tunnel measurement reproducibility was confirmed by independent repeated measurements. The significance of this tunnel enlargement is unknown and does not appear to adversely affect clinical outcome of allograft utilization. Possible explanations include an immune response with resorption, stress shielding proximal to the interference screw resulting in resorption, or an inflammatory response by synovium in the tunnel.

Impact of hospital discharge planning on meeting patient needs after returning home

This study examines the contribution of hospital discharge planning in meeting the needs of patients for care after their return home. A random sample of 919 admissions (age 60 and over) to five hospitals was studied to obtain information on characteristics of discharge planning during the patients' hospital stay. Specifically, information was obtained on the involvement of a designated professional for managing and coordinating the discharge plan, and the extent to which the planning was interdisciplinary. Patient interviews conducted two weeks after discharge provided information on needs for care related to: (1) treatment, (2) activity limitations, and (3) other self-sufficiency limitations. Patients were asked about their need for care in these three areas and about whether or not these needs were being met. Overall, 97 percent reported one or more needs for care and 33 percent reported that at least one of these needs was not being met. Findings show that the involvement of a discharge planning case manager is related to a significant reduction in unmet treatment needs, but not to reductions in activity limitation, other self-sufficiency needs, or overall needs. No significant effects of interdisciplinary planning were identified. These findings suggest that treatment-related benefits result when a case manager has specific responsibility for the discharge planning of elderly patients returning home after hospitalization. These results provide insights into what is being achieved through current discharge planning practices. The meeting of specific patient needs through enhanced discharge planning may save future costs by reducing the rates of complications and hospital readmissions in an era of prospective payment, thus potentially offsetting the increased costs involved in planning and coordinating postdischarge care for older adults.

Osteosarcoma of the pelvis. A clinical and histopathological study of twenty-five patients

Twenty-five patients who had an osteosarcoma of the pelvis were treated at the University of Florida between 1967 and 1990. Two of these patients had underlying Paget disease, and five had received previous radiation therapy to the pelvis. Common problems in this series of patients included delays and errors in establishment of the diagnosis, underestimation of the extent of the tumor on the radiographic staging studies, histopathological findings of local extension next to and into pelvic structures, widespread invasion into major pelvic veins, and microscopic foci of tumor in otherwise normal tissue. These problems led to difficulty in gaining local control of the tumor with any type of operative procedure. Of the eighteen patients who had a resection, only four had a contamination-free wide margin, and a local recurrence developed in thirteen. Only one patient, who had no evidence of disease eleven years after treatment, was alive at the time of writing. Because of the tendency for venous invasion, the radiographic staging studies should include a thorough evaluation of the blood vessels adjacent to the tumor.

Acute hospital costs of pediatric trauma in the United States: how much and who pays?

National estimates of the numbers and expenditures associated with hospitalization due to injury among children (aged 0 to 14) were derived using data from the 1984, 1985, and 1986 National Hospital Discharge Surveys (NHDS) and the 1980 National Medical Care Utilization and Expenditures Study (NMCUES). In this report, age- and sex-specific estimates of the numbers of hospital admissions and expenditures are reported for subgroup of patients defined by external cause of the injury and by nature and severity of the injury. In 1985, over 266,000 children sustained a traumatic injury resulting in hospitalization (rate of 51 per 10,000 children). Expenditures totaled nearly $1 billion. Over 80% of the hospitalizations and two thirds of total expenditures were for minor (Maximum AIS = 1.2) trauma. Moderate (Maximum AIS = 3) and severe (Maximum AIS = 4,5) trauma accounted for 18% and 2% of admissions and 31% and 8% of expenditures, respectively. Falls ranked first in expenditures and admissions (36% of the total). Motor vehicle-related injuries accounted for 19% of trauma admissions and 24% of expenditures. Other less common causes included bicycle injuries, penetrating injuries and injuries caused by the child being hit by an object or person. An estimated 28% of the total hospital charges were paid for by public sources (15% from federal government programs, 13% from state and local programs). An additional 63% of total expenditures were paid for by private sources, with the remaining 9% considered uninsured care.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute hospital costs of trauma in the United States: implications for regionalized systems of care

As part of a larger effort to determine total direct and indirect costs of injury in the United States, national estimates of the numbers and expenditures associated with acute hospitalization due to traumatic injury were derived using data from the 1984, 1985, and 1986 National Hospital Discharge Surveys (NHDS). Estimates of the numbers of hospital episodes and total expenditures are reported in this paper for subgroups of patients defined by age, sex, and body region and AIS severity of the injuries sustained. In 1985 2.1 million individuals sustained a traumatic injury which resulted in hospitalization. Hospital expenditures totaled $11.4 billion inclusive of professional fees. Adolescents and young adults aged 15-44 years accounted for nearly one half of all discharges and total hospital costs. The elderly, who represent only 12% of the population, accounted for an additional one quarter of total discharges and hospital costs. Nearly three quarters of the hospitalizations and one half of total expenditures were for minor (ICD/AIS = 1, 2) injuries. Moderate (ICD/AIS = 3) and severe (ICD/AIS = 4, 5), injuries respectively accounted for 23% and 3% of total episodes and 37% and 11% of total expenditures. Only 12% of patients and 25% of trauma care dollars involved injuries sufficiently severe to require treatment at a trauma center.(ABSTRACT TRUNCATED AT 250 WORDS)

The distribution of GAWK-like immunoreactivity in neuroendocrine cells of the human gut, pancreas, adrenal and pituitary glands and its co-localisation with chromogranin B

GAWK is a recently discovered peptide isolated from extracts of human pituitary gland and subsequently shown to be identical to sequence 420-493 of human chromogranin B. The distribution of this peptide was studied in human gut, pancreas, adrenal and pituitary glands using antisera to two portions of the 74 amino acid peptide (sequences 1-17 and 20-38). In addition, the co-existence of GAWK immunoreactivity with other peptides and chromogranin B was investigated using comparative immunocytochemistry. In the gut, GAWK was localised mainly to serotonin-containing cells of the mucosal epithelium, where electron microscopy showed it to be stored in typical electron-dense (250 nm diameter) granules, and to a moderate population of nerve fibres in the gut wall. Considerable quantities of GAWK-like immunoreactivity were measured in the gut, up to 36.3 +/- 18 pmol GAWK 1-17/g wet weight of tissue (mean +/- SEM) and 12.4 +/- 2.9 pmol GAWK 20-38/g. Chromatography of gut extracts revealed several GAWK-like immunoreactive peaks. GAWK-like immunoreactivity was also detected in endocrine cells of pancreas, pituitary gland and adrenal medulla, where the highest concentrations of GAWK-like immunoreactivity were measured (GAWK 1-17 2071.8 +/- 873.2 and GAWK 20-38 1292.7 +/- 542.7 pmol/g). Endocrine cells containing GAWK-like immunoreactivity were found also to be immunoreactive for chromogranin B. Our results define a discrete distribution of GAWK immunoreactivity in human endocrine cells and nerves and provide morphological support for the postulated precursor-product relationship between chromogranin B and GAWK. Details of the functions of this peptide are awaited.

Pancreastatin distribution and plasma levels in the pig

Pancreastatin is a peptide isolated from porcine pancreas which has insulin-suppressive actions in vitro and sequence homology with chromogranin A. Using radioimmunoassay and immunocytochemistry we investigated whether pancreastatin has a more widespread distribution and a possible endocrine role in the pig. Pancreastatin immunoreactivity was found in plasma, adrenal gland, pancreas, anterior pituitary and throughout the gastrointestinal tract. The immunoreactivity was colocalized with chromogranin immunoreactivity in endocrine cells and ultrastructurally (in the pancreas) to storage granules. Characterization of pancreastatin-like immunoreactivity, using gel permeation and high performance liquid chromatography, separated 3 different pancreastatin-like immunoreactive forms: one molecular form, indistinguishable from synthetic pancreastatin 1-49, was predominant in pancreas and thyroid and released into the circulation postprandially. However, a high dose (greater than 1 nmol/l) infusion of pancreastatin 33-49 (the biologically active moiety in vitro) into conscious pigs had no effect on either basal or glucose-stimulated insulin secretion.

The occurrence of pancreastatin in tumours of the diffuse neuroendocrine system

We have reported previously the localization of the 49 amino acid peptide pancreastatin to all identifiable endocrine cells of porcine gut, pancreas and adrenal, thyroid and pituitary glands. In this study, we have investigated the occurrence of pancreastatin in a series of human neuroendocrine tumours using an antibody to whole synthetic porcine pancreastatin. The most consistent immunostaining for pancreastatin was found in carcinoid tumours of ileum (four out of six), rectum (four out of six), ovary (two out of two) and lung (nine out of 10). Radioimmunoassay of tumour extracts showed that the concentrations of pancreastatin in ileal carcinoids were very high (mean 71.6, range 31.0-184.0 pmol g-1). The high rate of positivity in lung carcinoids contrasted sharply with the results of 10 pulmonary small cell carcinomas which displayed no immunoreactivity and contained minimal concentrations of pancreastatin (mean 2.0, range 0-6.0 pmol g-1). Extra-adrenal paragangliomas also contained pancreastatin (seven out of 10), but although radioimmunoassay detected peptide in phaeochromocytomas (mean 29.8, range 8.0-69.0 pmol g-1), immunocytochemistry did not. Porcine pancreastatin shows structural homology with bovine chromogranin A, an observation which has led to suggestions that chromogranin is a precursor for the peptide. More recently, a sequence homologous to porcine pancreastatin has been identified in the human chromogranin A molecule. In this study, immunostaining with an antiserum to human chromogranin gave positive results in most cases of each tumour type except the small cell carcinomas. The lack of consistent relationships between chromogranin and pancreastatin immunoreactivities may reflect the fact that the antiserum to pancreastatin was raised against the porcine peptide. When antibodies to human pancreastatin become available, the peptide may prove to be a more consistent marker for neuroendocrine tumours.

Occurrence and developmental pattern of neuromedin U-immunoreactive nerves in the gastrointestinal tract and brain of the rat

Neuromedin U is a newly described regulatory peptide, found by radioimmunoassay in significant concentrations in both the brain and gut of the rat. The aim of the present study was to localize this peptide immunoreactivity to discrete structures of the gut and brain and to map its distribution using immunocytochemistry. In the gut, neuromedin U was confined to nerve fibres mainly in the myenteric and submucous plexuses and the mucosa of all areas except stomach. Immunoreactive ganglion cells were seen in both ganglionated plexuses and their number did not increase following colchicine administration. This observation and the finding that the population of neuromedin U-immunoreactive nerves in the ileum was not affected by complete extrinsic denervation indicated that the nerves are mostly intrinsic in origin. Colocalization studies revealed neuromedin U and calcitonin gene-related peptide were present in the same myenteric and submucosal ganglion cells. Transection experiments showed that, like calcitonin gene-related peptide-immunoreactive nerves, fibres containing neuromedin U project for very short distances in both an oral and anal direction. At the electron microscopic level, neuromedin U immunoreactivity, demonstrated using the immunogold technique, was localized to large granular vesicles. In the central nervous system, neuromedin U immunoreactivity was localized to fibres which were widespread throughout the brain, except in the cerebellum. The presence of neuromedin U-immunoreactive cell bodies was restricted to the rostrocaudal part of the arcuate nucleus. Colocalization studies showed that a proportion of the neuromedin U-immunoreactive cell bodies in the arcuate nucleus also contained pro-opiomelanocortin. Neuromedin U-immunoreactive fibres were first detected in the rat intestinal mucosa at day 1 after birth. In the brain, the arcuate nucleus showed neuromedin U-immunoreactive neuronal cell bodies at E16 but not at E14. In conclusion, neuromedin U is a new member of the group of molecules known as brain-gut peptides.

Immunohistochemical markers of small cell carcinoma and related neuroendocrine tumours of the lung

A selected group of 263 pulmonary neuroendocrine tumours comprised 156 small cell carcinomas, five combined cell carcinomas, nine atypical carcinoid/small cell carcinomas, 32 atypical carcinoids, ten large cell/small cell carcinomas, and 51 carcinoid tumours. These were compared with a group of 109 non-small cell carcinomas, using four markers of neuroendocrine differentiation to determine differences in reactivity between the two groups and among the variants of neuroendocrine tumour. The antibodies used were neuron-specific enolase (NSE), protein gene product (PGP) 9.5, human bombesin, and the C-terminal flanking peptide of human bombesin (CTP). Most small cell carcinomas, carcinoid tumours, and atypical carcinoid variants showed immunoreactivity for both NSE and PGP 9.5 but a significant number of non-small cell carcinomas, mainly squamous cell carcinomas, were also positive (11 and 35 per cent, respectively). Bombesin was specific for neuroendocrine tumours, being demonstrable in 35 per cent carcinoids and 24 per cent small cell carcinomas, but staining was focal and often confined to scattered cells. Diffuse strongly positive immunoreactivity for CTP was seen in the majority of malignant neuroendocrine tumours, but only 12 per cent of carcinoid tumours were positive and non-small cell carcinomas were negative. CTP is therefore of potential value as a specific marker of malignant neuroendocrine tumours, particularly if the amount of biopsy material is limited and the tumour is an unusual variant, such as atypical carcinoid or large cell-small cell carcinoma.

Management of pneumonia in the prospective payment era. A need for more clinician and support service interaction

We compared the diagnostic and therapeutic management of pneumonia during 1970 and 1971 with that during 1979 and 1980 in clinically similar populations at The Johns Hopkins Hospital, Baltimore. More patients received aminoglycoside and cephalosporin therapy during 1979 and 1980. Guidelines for the use of chest roentgenograms and cultures were exceeded in 14% to 24% of cases. Patients whose cases were judged to be suboptimally managed had significantly higher charges and length of stay. Aged patients and those requiring thoracentesis also used resources more intensively. Given the technologic explosion, clinicians cannot know the performance characteristics of all tests and medications they can order. To minimize inefficient and ineffective practices, it is essential that clinicians and support service directors develop guidelines for testing and antibiotic use. Deviations should trigger timely interventions. Management under prospective payment will also require identifying specific patient subgroups to verify appropriate utilization and to assure equitable reimbursement.

Effects of chronic estrogen treatment on water exchange in rats

Intact female rats implanted subcutaneously with Silastic tubes containing estradiol benzoate (EB) (28.7 micrograms X kg-1 X day-1) for 28 wk had a significantly greater daily intake of water, a higher water-to-food intake ratio, and a greater urine output than untreated control rats. Ovariectomized (OVX) rats also implanted for 14 wk with EB tubes (15 and 36 micrograms X kg-1 X day-1) showed identical results. Dipsogenic responses of the EB-treated rats to isoproterenol (25 micrograms/kg sc), angiotensin II (200 micrograms/kg ip), and hypertonic saline (1 M, 1% of body wt ip) were significantly attenuated. Both intact and OVX rats were subjected to a 24-h dehydration to assess renal concentrating ability. EB-treated rats lost significantly more weight and excreted significantly more urine of lower osmolality than controls. Administration of vasopressin to volume-loaded, EB-treated rats revealed no abnormalities in the ability to concentrate urine to the level of controls. Thus, in spite of a reduced responsiveness to several dipsogenic stimuli, EB-treated rats have an increased daily water turnover apparently related to an inability to concentrate their urine. This in turn may be related to abnormalities in either synthesis or release of antidiuretic hormone or both.