The Mendelian disorders of chromatin machinery: Harnessing metabolic pathways and therapies for treatment

The Mendelian disorders of chromatin machinery (MDCMs) represent a distinct subgroup of disorders that present with neurodevelopmental disability. The chromatin machinery regulates gene expression by a range of mechanisms, including by post-translational modification of histones, responding to histone marks, and remodelling nucleosomes. Some of the MDCMs that impact on histone modification may have potential therapeutic interventions. Two potential treatment strategies are to enhance the intracellular pool of metabolites that can act as substrates for histone modifiers and the use of medications that may inhibit or promote the modification of histone residues to influence gene expression. In this article we discuss the influence and potential treatments of histone modifications involving histone acetylation and histone methylation. Genomic technologies are facilitating earlier diagnosis of many Mendelian disorders, providing potential opportunities for early treatment from infancy. This has parallels with how inborn errors of metabolism have been afforded early treatment with newborn screening. Before this promise can be fulfilled, we require greater understanding of the biochemical fingerprint of these conditions, which may provide opportunities to supplement metabolites that can act as substrates for chromatin modifying enzymes. Importantly, understanding the metabolomic profile of affected individuals may also provide disorder-specific biomarkers that will be critical for demonstrating efficacy of treatment, as treatment response may not be able to be accurately assessed by clinical measures.

Gathering the Stakeholder's Perspective: Experiences and Opportunities in Rare Genetic Disease Research

BACKGROUND

Research participant feedback is rarely collected; therefore, investigators have limited understanding regarding stakeholders' (affected individuals/caregivers) motivation to participate. Members of the Genes to Mental Health Network (G2MH) surveyed stakeholders affected by copy number variants (CNVs) regarding perceived incentives for study participation, opinions concerning research priorities, and the necessity for future funding. Respondents were also asked about feelings of preparedness, research burden, and satisfaction with research study participation.

METHODS

Modified validated surveys were used to assess stakeholders´ views across three domains: (1) Research Study Enrollment, Retainment, Withdrawal, and Future Participation; (2) Overall Research Experience, Burden, and Preparedness; (3) Research Priorities and Obstacles. Top box score analyses were performed.

RESULTS

A total of 704 stakeholders´ responded from 29 countries representing 55 CNVs. The top reasons for initial participation in the research included reasons related to education and altruism. The top reasons for leaving a research study included treatment risks and side effects. The importance of sharing research findings and laboratory results with stakeholders was underscored by participants. Most stakeholders reported positive research experiences.

CONCLUSIONS

This study provides important insight into how individuals and families affected with a rare CNV feel toward research participation and their overall experience in rare disease research. There are clear targets for areas of improvement for study teams, although many stakeholders reported positive research experiences. Key findings from this international survey may help advance collaborative research and improve the experience of participants, investigators, and other stakeholders moving forward.

The experience of one pediatric geneticist with telemedicine-based clinical diagnosis

Telemedicine has long been considered as an attractive alternative methodology in clinical genetics to improve patient access and convenience. Given the importance of the dysmorphology physical examination and anthropometric measurement in clinical genetics, many have wondered if lost information would hamper diagnosis. We previously addressed this question by analyzing thousands of diagnostic encounters in a single practice involving multiple practitioners and found no evidence for a difference in new molecular diagnosis rates. However, our previous study design resulted in variability in providers between in-person and telemedicine evaluation groups. To address this in our present study, we expanded our analysis to 1104 new patient evaluations seen by one highly experienced clinical geneticist across two 10-month periods before and after the start of the COVID-19 pandemic. Comparing patients seen in-person to those seen by telemedicine, we found significant differences in race and ethnicity, preferred language, and home zip code median income. The clinical geneticist intended to send more genetic testing for those patients seen by telemedicine, but due to issues with test authorization and sample collection, there was no difference in ultimate completion rate between groups. We found no significant difference in new molecular diagnosis rate. Overall, we find telemedicine to be an acceptable alternative to in-person evaluation for routine pediatric clinical genetics care.

Novel chorioretinal findings in two siblings with mucopolysaccharidosis type VI

PURPOSE

To describe and compare the systemic and ocular findings in two siblings with mucopolysaccharidosis type VI (Maroteaux-Lamy syndrome), one treated with recombinant galsulfase, and one who was untreated.

METHOD

One female patient aged 33 years (case 1) who had received galsulfase enzyme replacement therapy for 11 years, and her younger male sibling by 3 years (case 2), who had declined systemic treatment, underwent clinical ophthalmic examination and retinal ocular coherence tomography. The female sibling underwent electrophysiology testing of visual function.

RESULTS

Case 1 had best corrected visual acuity right 6/4.8 and left 6/6. Case 2 had best corrected visual acuity of 6/6 in each eye. Case 1 had bilateral mild corneal haze and a clinically unremarkable posterior segment examination. Case 2 had bilateral very mild corneal haze and retinal striae on examination. Ocular coherence tomography showed choroidal folds at the maculae in both patients, more pronounced in Case 2, who also had retinal folds and epiretinal membrane. Electroretinography showed very mild involvement of the rods only in Case 1.

CONCLUSION

These two siblings with mucopolysaccharidosis type VI, one treated and one untreated, displayed variable levels of systemic, corneal, and chorioretinal involvement in their disease Further studies of choroidal changes in MPS VI may prove useful as a biomarker of ocular response to treatment outside the blood-retina barrier. Both patients have provided written consent to publish case details.

Distinct diagnostic trajectories in NBAS ‐associated acute liver failure highlights the need for timely functional studies

Variants of uncertain significance (VUS) are commonly found following genomic sequencing, particularly in ethnically diverse populations that are underrepresented in large population databases. Functional characterization of VUS may assist in variant reclassification, however these studies are not readily available and often rely on research funding and good will. We present four individuals from three families at different stages of their diagnostic trajectory with recurrent acute liver failure (RALF) and biallelic NBAS variants, confirmed by either trio analysis or cDNA studies. Functional characterization was undertaken, measuring NBAS and p31 levels by Western blotting, demonstrating reduced NBAS levels in two of three families, and reduced p31 levels in all three families. These results provided functional characterization of the molecular impact of a missense VUS, allowing reclassification of the variant and molecular confirmation of NBAS‐associated RALF. Importantly, p31 was decreased in all individuals, including an individual with two missense variants where NBAS protein levels were preserved. These results highlight the importance of access to timely functional studies after identification of putative variants, and the importance of considering a range of assays to validate variants whose pathogenicity is uncertain. We suggest that funding models for genomic sequencing should consider incorporating capabilities for adjunct RNA, protein, biochemical, and other specialized tests to increase the diagnostic yield which will lead to improved medical care, increased equity, and access to molecular diagnoses for all patients.

Consolidation of the clinical and genetic definition of a SOX4-related neurodevelopmental syndrome

BACKGROUND

A neurodevelopmental syndrome was recently reported in four patients with SOX4 heterozygous missense variants in the high-mobility-group (HMG) DNA-binding domain. The present study aimed to consolidate clinical and genetic knowledge of this syndrome.

METHODS

We newly identified 17 patients with SOX4 variants, predicted variant pathogenicity using in silico tests and in vitro functional assays and analysed the patients' phenotypes.

RESULTS

All variants were novel, distinct and heterozygous. Seven HMG-domain missense and five stop-gain variants were classified as pathogenic or likely pathogenic variant (L/PV) as they precluded SOX4 transcriptional activity in vitro. Five HMG-domain and non-HMG-domain missense variants were classified as of uncertain significance (VUS) due to negative results from functional tests. When known, inheritance was de novo or from a mosaic unaffected or non-mosaic affected parent for patients with L/PV, and from a non-mosaic asymptomatic or affected parent for patients with VUS. All patients had neurodevelopmental, neurological and dysmorphic features, and at least one cardiovascular, ophthalmological, musculoskeletal or other somatic anomaly. Patients with L/PV were overall more affected than patients with VUS. They resembled patients with other neurodevelopmental diseases, including the SOX11-related and Coffin-Siris (CSS) syndromes, but lacked the most specific features of CSS.

CONCLUSION

These findings consolidate evidence of a fairly non-specific neurodevelopmental syndrome due to SOX4 haploinsufficiency in neurogenesis and multiple other developmental processes.

Expanding the genotypic and phenotypic spectrum in a diverse cohort of 104 individuals with Wiedemann-Steiner syndrome

Wiedemann-Steiner syndrome (WSS) is an autosomal dominant disorder caused by monoallelic variants in KMT2A and characterized by intellectual disability and hypertrichosis. We performed a retrospective, multicenter, observational study of 104 individuals with WSS from five continents to characterize the clinical and molecular spectrum of WSS in diverse populations, to identify physical features that may be more prevalent in White versus Black Indigenous People of Color individuals, to delineate genotype-phenotype correlations, to define developmental milestones, to describe the syndrome through adulthood, and to examine clinicians' differential diagnoses. Sixty-nine of the 82 variants (84%) observed in the study were not previously reported in the literature. Common clinical features identified in the cohort included: developmental delay or intellectual disability (97%), constipation (63.8%), failure to thrive (67.7%), feeding difficulties (66.3%), hypertrichosis cubiti (57%), short stature (57.8%), and vertebral anomalies (46.9%). The median ages at walking and first words were 20 months and 18 months, respectively. Hypotonia was associated with loss of function (LoF) variants, and seizures were associated with non-LoF variants. This study identifies genotype-phenotype correlations as well as race-facial feature associations in an ethnically diverse cohort, and accurately defines developmental trajectories, medical comorbidities, and long-term outcomes in individuals with WSS.

Early-onset vitamin B6-dependent epilepsy due to pathogenic PLPBP variants in a premature infant: A case report and review of the literature

Vitamin B6-dependent epilepsies are a heterogeneous group of disorders characterized by decreased availability of the active cofactor pyridoxal-5'-phosphate (PLP). While pathogenic variants in ALDH7A1 or PNPO genes account for most cases of these disorders, biallelic pathogenic variants in PLPBP have been shown to cause a form of early onset vitamin B6-dependent epilepsy (EPVB6D). PLPBP is thought to play a role in the homeostatic regulation of vitamin B6, by supplying PLP to apoenzymes while limiting side-reaction toxicity related to excess unbound PLP. Neonatal-onset intractable seizures that respond to pyridoxine and/or PLP are a predominant feature of EPVB6D in humans. Unlike other causes of vitamin B6-dependent epilepsies; however, a specific biomarker for this disorder has yet to be identified. Here we present data from a premature infant found to have pathogenic variants in PLPBP and propose that prematurity may provide an additional clue for early consideration of this diagnosis. We discuss these findings in context of previously published genotypic, phenotypic, and metabolic data from similarly affected patients.

International consensus guidelines for phosphoglucomutase 1 deficiency (PGM1-CDG): Diagnosis, follow-up, and management

Phosphoglucomutase 1 (PGM1) deficiency is a rare genetic disorder that affects glycogen metabolism, glycolysis, and protein glycosylation. Previously known as GSD XIV, it was recently reclassified as a congenital disorder of glycosylation, PGM1-CDG. PGM1-CDG usually manifests as a multisystem disease. Most patients present as infants with cleft palate, liver function abnormalities and hypoglycemia, but some patients present in adulthood with isolated muscle involvement. Some patients develop life-threatening cardiomyopathy. Unlike most other CDG, PGM1-CDG has an effective treatment option, d-galactose, which has been shown to improve many of the patients' symptoms. Therefore, early diagnosis and initiation of treatment for PGM1-CDG patients are crucial decisions. In this article, our group of international experts suggests diagnostic, follow-up, and management guidelines for PGM1-CDG. These guidelines are based on the best available evidence-based data and experts' opinions aiming to provide a practical resource for health care providers to facilitate successful diagnosis and optimal management of PGM1-CDG patients.

Acute liver dysfunction with delayed peak of serum aminotransferase levels as a presentation of ornithine transcarbamylase deficiency in females

We describe 10 females with ornithine transcarbamylase (OTC) deficiency and liver dysfunction, revealing a unique pattern of hepatocyte injury in which initial hyperammonemia and coagulopathy is followed by a delayed peak in aminotransferase levels. None of the patients required urgent liver transplantation, though five eventually underwent transplant for recurrent metabolic crises. We intend that this novel observation will initiate further investigations into the pathophysiology of liver dysfunction in OTC-deficient patients, and ultimately lead to the development of therapies and prevent the need for liver transplant.

Cost effectiveness of intraoperative laparoscopic ultrasound for suspected choledocholithiasis; outcomes from a specialist benign upper gastrointestinal unit

INTRODUCTION

Common bile duct stones are present in 10% of patients with symptomatic gallstones. One-third of UK patients undergoing cholecystectomy will have preoperative ductal imaging, commonly with magnetic resonance cholangiopancreatography. Intraoperative laparoscopic ultrasound is a valid alternative but is not widely used. The primary aim of this study was to assess cost effectiveness of laparoscopic ultrasound compared with magnetic resonance cholangiopancreatography.

MATERIALS AND METHODS

A prospective database of all patients undergoing laparoscopic cholecystectomy between 2015 and 2018 at a district general hospital was assessed. Inclusion criteria were all patients, emergency and elective, with symptomatic gallstones and suspicion of common bile duct stones (derangement of liver function tests with or without dilated common bile duct on preoperative ultrasound, or history of pancreatitis). Patients with known common bile duct stones (magnetic resonance cholangiopancreatography or failed endoscopic retrograde cholangiogram) were excluded. Ninety-day morbidity data were also collected.

RESULTS

A total of 420 (334 elective and 86 emergency) patients were suspected to have common bile duct stones and were included in the study. The cost of a laparoscopic ultrasound was £183 per use. The cost of using the magnetic resonance cholangiopancreatography unit was £365 per use. Ten postoperative magnetic resonance cholangiopancreatographies were performed for inconclusive intraoperative imaging. The estimated cost saving was £74,650. Some 128 patients had common bile duct stones detected intraoperatively and treated. There was a false positive rate of 4.7%, and the false negative rate at 90 days was 0.7%. laparoscopic ultrasound use saved 129 bed days for emergency patients and 240 magnetic resonance cholangiopancreatography hours of magnetic resonance imaging.

CONCLUSION

The use of laparoscopic ultrasound during laparoscopic cholecystectomy for the detection of common bile duct stone is safe, accurate and cost effective. Equipment and maintenance costs are quickly offset and hospital bed days can be saved with its use.

Malignant brain tumors in patients with glutaric aciduria type I

Three young patients with glutaric aciduria type I (age 6-23 years) of different ethnic origins, treated for their metabolic disease since early childhood, presented with malignant central nervous system tumors. We recommend continuing clinical follow-up, including monitoring of neurological manifestations and neuroradiological findings, in all patients with glutaric aciduria type I beyond early childhood, especially if adherence to diet is poor or the treatment was not started neonatally.

Advances in genomic testing

BACKGROUND

Advances in genomic technology and our understanding of Mendelian disease-causing genes have led to an increased use of genomic testing in clinical practice.

OBJECTIVE

The aim of this paper is to outline recent advances in genetic and genomic testing and the implications for clinical practice.

DISCUSSION

Next-generation genomic sequencing is improving the diagnostic yield for patients with suspected genetic disease. A molecular diagnosis for a patient with genetic disease can provide information regarding a patient's prognosis, management and reproductive risk, and identify molecular targets for treatment. However, genomic testing frequently identifies variants of uncertain significance. This is illustrated by two case examples.

Evaluation of the safety and immunogenicity of synthetic A 42 (AN1792) in patients with AD

BACKGROUND

Abeta42-immunization reduces plaque burden and improves cognition in transgenic mouse models of Alzheimer disease (AD). This phase 1 study evaluated the safety, tolerability, and immunogenicity of AN1792 (human aggregated Abeta42) in patients with mild to moderate AD.

METHODS

Twenty patients were enrolled into each of four dose groups and randomly assigned to receive IM AN1792 (50 or 225 microg) with QS-21 adjuvant (50 or 100 microg) or QS-21 only (control) in a 4:1 active:control ratio on day 0 and at weeks 4, 12, and 24. Patients could receive up to four additional injections of a polysorbate 80 modified formulation at weeks 36, 48, 60, and 72. Safety, tolerability, immunogenicity, and exploratory evidence of efficacy were evaluated.

RESULTS

Treatment-related adverse events were reported in 19 (23.8%) patients, but no relationship was observed between AN1792 dose and incidence. One patient developed meningoencephalitis that was diagnosed after death (not directly related to study treatment) and 219 days after discontinuing from the study. Five deaths occurred during the study follow-up, but none was considered to be directly related to study treatment. During the period of the first four injections, 23.4% of AN1792-treated patients had a positive anti-AN1792 antibody titer (an anti-AN1792 antibody titer of > or =1:1,000). This increased to 58.8% after additional injections with the modified formulation. Disability Assessment for Dementia scores showed less decline among active compared with control patients at week 84 (p = 0.002). No treatment differences were observed in three other efficacy measures.

CONCLUSIONS

AN1792 + QS-21 elicited a positive antibody response to Abeta42 in more than half of this elderly study population.

A pilot study of treatment of active ulcerative colitis with natalizumab, a humanized monoclonal antibody to alpha-4 integrin

BACKGROUND

Alpha-4 integrins facilitate leucocyte migration across vascular endothelium.

AIM

To assess the safety and efficacy of natalizumab (Antegren), a humanized antibody to alpha-4 integrin, in patients with active ulcerative colitis.

METHODS

Ten patients with active ulcerative colitis, defined by a Powell-Tuck activity score > 4, received a single 3 mg/kg natalizumab infusion. The primary end-point was the change in Powell-Tuck score at 2 weeks post-infusion.

RESULTS

Significant decreases in the median Powell-Tuck score were observed at 2 and 4 weeks post-infusion (7.5 and 6, respectively) compared to the median baseline score (10). Five of 10 patients achieved a good clinical response at 2 weeks and one more patient by 4 weeks, defined by a Powell-Tuck score of < or = 5. Significant improvements in quality of life scores were found at week 4. Rescue medication was required by two (20%), three (30%) and eight (80%) patients by weeks 2, 4 and 8, respectively (median, 34 days; range, 8-43 days). One patient remained in remission at 12 weeks. The median C-reactive protein at 2 weeks (6 mg/L) was lower than that pre-treatment (16 mg/L).

CONCLUSIONS

A single 3 mg/kg infusion of natalizumab was well tolerated by ulcerative colitis patients. The positive efficacy demonstrated in this study merits further investigation by randomized, placebo-controlled trials.

Is first trimester exposure to the combination of antiretroviral therapy and folate antagonists a risk factor for congenital abnormalities?

OBJECTIVES

To assess use of antiretroviral therapy (ART) by HIV positive pregnant women in London since 1994 and the risk of congenital abnormalities associated with multidrug exposure during the first trimester of pregnancy.

METHODS

Retrospective multicentre study of medical, obstetric, and paediatric notes of all mother-infant pairs, where the mother was known to be HIV infected before delivery, using a standardised proforma.

RESULTS

In this study of 195 mother-infant pairs, use of ART during any stage of pregnancy increased from 33.3% in 1994 to 92.5% in 1999 (p=0.01, trend). First trimester exposure increased from 0% in 1994 to 27.5% in 1999 (p=0.00045, trend). Congenital malformations were observed in nine infants (4.6%). Compared with infants not exposed to ART or folate antagonists during the first trimester (n=148), exposure to both ART and folate antagonists during the first trimester (n=13) was associated with an increased risk of congenital abnormalities (4% v 23.1%; OR 7.10, 95% CI 1.5, 34.2). No malformations were observed in the 34 children exposed to either ART or folate antagonists alone during the first trimester.

CONCLUSION

An increasing number of HIV infected women conceived while on ART. Although there is no evidence of teratogenicity caused by ART if given alone during the first trimester, exposure to the combination of ART and folate antagonists was associated with a significantly higher risk of congenital abnormalities in this cohort.

A randomized placebo-controlled trial of a humanized monoclonal antibody to alpha4 integrin in active Crohn's disease

BACKGROUND & AIMS

alpha4 integrins are important mediators of leukocyte migration across vascular endothelium. This pilot placebo-controlled study aimed to assess the safety and efficacy of natalizumab, a recombinant humanized monoclonal antibody to alpha4 integrin, in patients with mild to moderately active Crohn's disease.

METHODS

Thirty patients with active Crohn's disease (Crohn's Disease Activity Index [CDAI] > or =151 and < or =450) received a 3-mg/kg infusion of natalizumab (n = 18) or placebo (n = 12) by double-blind randomization. The study's primary endpoint was change in CDAI at week 2.

RESULTS

At week 2, the CDAI decreased significantly from baseline after infusion of natalizumab (mean 45 points) but not placebo (mean 11 points). Seven (39%) natalizumab-treated patients achieved remission at week 2, compared with 1 (8%) treated with placebo. In contrast, 4 (33%) of the placebo-treated patients required rescue medication by week 2, compared with 2 (11%) natalizumab-treated patients. Significant increases in circulating B and T lymphocytes were detected only after natalizumab administration. The frequency of commonly reported adverse events did not differ significantly between groups.

CONCLUSIONS

A single 3-mg/kg natalizumab infusion was well tolerated by Crohn's disease patients, although the dose used may have been suboptimal. Elevated circulating lymphocyte levels after natalizumab suggest interrupted lymphocyte trafficking. Natalizumab therapy in active Crohn's disease merits further investigation.

Drugs in development for the treatment of multiple sclerosis: antigen non-specific therapies--an update

In the past few years there has been significant progress in the development of therapy for the treatment of relapsing remitting and secondary progressive multiple sclerosis. Research interest in multiple sclerosis (MS) therapeutics has remained high and clinical investigation into potential new therapies continues. This review summarises the advances with currently available therapies and briefly outlines the results from studies with other drugs being developed for the treatment of multiple sclerosis.

Immunohistochemical localization of caspase-3 correlates with clinical outcome in B-cell diffuse large-cell lymphoma

Although B-cell diffuse large-cell lymphoma (DLCL) can respond to chemotherapy and radiotherapy, a large number of patients are still resistant to treatment. Caspase-3 is an enzyme crucial to the apoptotic process and may be important in the clinical outcome of these patients. The pattern of caspase-3 expression was studied in 54 cases of DLCL using immunohistochemistry and quantitative reverse-transcription PCR. Tumor cells displayed both a diffuse cytosolic and a punctate cytosolic staining for caspase-3. Kaplan-Meier survival curves indicated that tumor cells with a diffuse cytosolic expression of caspase-3 correlated with a poor prognosis (P > 0.0004). In addition, a punctate cellular localization was associated with complete response to treatment (P = 0.011). Cases with a small percentage of lymphoma cells expressing caspase-3 also tended to show poor survival (P > 0.09). Levels of caspase-3 mRNA were not significant (P > 0.17), although a weak trend was observed similar to the immunohistochemical analysis. The pattern of expression of caspase-3 was also assessed with respect to terminal deoxynucleotidyl transferase-mediated nick end labeling (TUNEL) positivity in both reactive lymph nodes and B-cell DLCL cases. Our results suggest that TUNEL-positive cells are not caspase-3-positive and that there is no correlation between DLCL cases with a high degree of DNA fragmentation and caspase-3 immunostaining. Furthermore, a survival curve indicated that a high TUNEL positivity was associated with a poor survival probability (P < 0.02) and a poor response to treatment (P = 0.04). These results confirm the dynamic nature of caspase-3 expression in DLCL and suggests that the pattern of expression of the enzyme has prognostic significance.

The effect of anti-alpha4 integrin antibody on brain lesion activity in MS. The UK Antegren Study Group

OBJECTIVE

To determine the effect of humanized monoclonal antibody against alpha4 integrin (reactive with alpha4beta1 integrin or very-late antigen-4) on MRI lesion activity in MS.

METHODS

A randomized, double-blind, placebo-controlled trial in 72 patients with active relapsing-remitting and secondary progressive MS was performed. Each patient received two IV infusions of anti-alpha4 integrin antibody (natalizumab; Antegren) or placebo 4 weeks apart and was followed up for 24 weeks with serial MRI and clinical assessment.

RESULTS

The treated group exhibited significantly fewer new active lesions (mean 1.8 versus 3.6 per patient) and new enhancing lesions (mean 1.6 versus 3.3 per patient) than the placebo group over the first 12 weeks. There was no significant difference in the number of new active or new enhancing lesions in the second 12 weeks of the study. The number of baseline-enhancing lesions (i.e., lesions that enhanced on the baseline scan) that continued to enhance 4 weeks following the first treatment was not significantly different between the two groups. The number of patients with acute MS exacerbations was not significantly different in the two groups during the first 12 weeks (9 in the treated group versus 10 in placebo) but was higher in the treatment group in the second 12 weeks (14 versus 3; p = 0.005). The study was not, however, designed to look definitively at the effect of treatment on relapse rate. Treatment was well tolerated.

CONCLUSIONS

Short-term treatment with monoclonal antibody against alpha4 integrin results in a significant reduction in the number of new active lesions on MRI. Further studies will be required to determine the longer term effect of this treatment on MRI and clinical outcomes.

Nutrition of captive reptiles

In reptile practice, most nutritional problems arise from improper husbandry, including poor feeding management and provision of imbalanced diets. Each reptile species has its own requirements for temperature and humidity, space and social interaction, lighting, and habitat components. Failure, to provide these requirements often results in failure to thrive and secondary nutritional disorders. Common dietary problems include deficiencies of energy, calcium, vitamin D3, vitamin A, and fiber.

Associations between body condition and disease in cats

OBJECTIVE

To determine the association between body condition and disease in cats.

DESIGN

Prospective study.

SAMPLE POPULATION

Information on 1,457 cats without major illnesses from 27 veterinary hospitals in the northeastern United States.

PROCEDURE

Cats that had body conditions determined from 1991 to 1992, using a set of 6 body condition silhouettes, had their health experiences and body conditions assessed for the subsequent 4.5 years. Cats were described by the following 6 body conditions: cachectic, lean, optimally lean, optimal weight, heavy, and obese. Data obtained from medical records and owner interviews were collected, using standard forms. Associations between body condition and specific diseases were analyzed. Findings in cats with body conditions other than optimal were compared with findings in cats with optimal body condition.

RESULTS

Compared with optimal weight cats, heavy cats were 2.9 times as likely to be taken to veterinarians because of lameness not associated with cat bite abscesses. Obese cats were also 3.9 times as likely to develop diabetes mellitus, 2.3 times as likely to develop nonallergic skin conditions, and 4.9 times as likely to develop lameness requiring veterinary care. Cats considered thin (cachectic and lean) were 1.7 times as likely to be presented to veterinary hospitals for diarrhea.

CLINICAL IMPLICATIONS

Results of this study substantiate reports of health risks associated with excess body weight in cats. Efforts to reduce weight in heavy and obese cats can lead to reduced risks of diabetes mellitus, lameness (presumably related to osteoarthritis and soft-tissue injuries), and skin problems unrelated to allergies. Cachectic and lean cats are more likely to have diarrhea that is not associated with a definitive diagnosis.

Troglitazone, an insulin action enhancer, improves metabolic control in NIDDM patients. Troglitazone Study Group

The effects of troglitazone, a novel thiazolidinedione, in non-insulin-dependent diabetic (NIDDM) patients were studied in a double-blind, parallel-group, placebo-controlled, dose-ranging trial. A total of 330 patients (63% male), mean age 57 years (range 39-72), with two fasting capillary blood glucose values > or = 7 and < or = 15 mmol/l (within 2.5 mmol/l of each other) were randomised to treatment with placebo or troglitazone at doses of 200, 400, 600 or 800 mg once daily, or 200 or 400 mg twice daily, for 12 weeks. Prior to the study, treatment had been with diet alone (38% patients) or with oral hypoglycaemic agents which were stopped 3-4 weeks before study treatment started. During treatment, HbA1c tended to rise in patients taking placebo (7.2-8.0%), but remained unchanged with all doses of troglitazone. After 12 weeks of treatment, HbA1c was significantly lower in the troglitazone-treated (mean 7.0-7.4%) compared to the placebo-treated (8.0%) patients (p = 0.055 to < 0.001), as was fasting serum glucose concentration (troglitazone, 9.3-11.0 mmol/l vs placebo, 12.9 mmol/l, p < 0.001). All doses of troglitazone were equally effective. Troglitazone also lowered fasting plasma insulin concentration, by 12-26% compared to placebo (p = 0.074 to < 0.001). Insulin sensitivity assessed by homeostasis model assessment (HOMA) was greater after 12 weeks of treatment in troglitazone-treated patients (troglitazone, 34.3-42.8% vs placebo, 29.9%, p < 0.05). In addition, serum triglyceride and non-esterified fatty acid concentrations were significantly lower and HDL cholesterol higher at troglitazone doses of 600 and 800 mg/day. LDL cholesterol increased at 400 and 600 mg doses only (from 4.3 and 3.9 mmol/l at baseline to 4.8 and 4.5 mmol/l, respectively at 12 weeks, p < 0.05), but not at doses of 800 mg once daily or 400 mg twice daily. LDL/HDL ratio did not change during treatment. All doses were well tolerated; incidence of adverse events in troglitazone-treated patients was no higher than in those treated with placebo. However, a tendency to reduced neutrophil counts was observed in patients taking the highest doses of troglitazone. We conclude that troglitazone is effective and well-tolerated and shows potential as a new therapeutic agent for the treatment of NIDDM.

Growth of juvenile green iguanas (Iguana iguana) fed four diets

Wild green iguanas consume a primarily folivorous diet. As pets in captivity, they suffer high mortality and malnutrition. Nutrient requirements are not established. The purpose of this study was to compare growth in juvenile iguanas fed three commercial diets and a romaine-based diet. Twelve nominally 4-wk-old iguanas were fed in a latin square design each of four diets for 8 wk, consisting of a 2-wk accommodation period and a 6-wk collection period. Diets were analyzed at the beginning and end of the study. Food consumption was measured daily; body weights and lengths were measured weekly. For Diets A, B, C and D mean body weight gains were--3, 6, 31 and 60% in 6 wk, respectively. Gain in body weight and snout-vent length increased linearly with dietary protein and fiber and with dry matter intake. The data suggest that growth in pet green iguanas may achieve rates for farmed and wild green iguanas when diets are palatable and contain adequate protein and fiber.

Clinical nutrition of exotic pets

Successful nutritional management requires knowledge of the natural history of exotic pets, nutrient contents of foods, and roles of water, calories, and nutrients in optimal health. Unestablished dietary requirements, lack of balanced commercial diets and mismanagement by owners cause nutritional problems that affect health and recovery from illness and trauma. When presented with a sick exotic pet, veterinarians should check for provision of appropriate wholesome water and food in optimal amounts. Malnutrition and dehydration are common in exotic pets and often result from mismanagement. Starvation is common in carnivores eating whole vertebrate prey, whereas specific nutrient deficiencies are more common in herbivores and insectivores. The more common nutritional deficiencies are calcium and vitamin D3, vitamin A, thiamin, and vitamin E. When treating sick exotic pets, nutrition and fluid support may be critical to recovery.

Nutritional support of hospitalised dogs and cats

Nutritional support of hospitalised dogs and cats improves recovery from illness, reduces mortality, and improves responses to trauma and stress. The primary goal of nutritional support is to prevent use of tissue protein. This is accomplished by the provision of sufficient calories and dietary protein in optimal proportions. For nutritional support, calorie intake is adjusted according to the patient's metabolic rate so that the animal may be fed above or below its usual intake. Nutritional support should always be started gradually, no matter what the final calorie goal may be. For many sick dogs fed enterally, diets proved about 30% of calories from fat and at least 27% of calories from protein. Carbohydrates in nutritional support diets should not include maize, wheat or, especially, soy. Sick cats fed enterally should receive at least 30% of calories from both fat and protein.

Overweight cats: prevalence and risk factors

Body condition was assessed by owners and veterinarians for over 2000 cats presented to 31 private veterinary hospitals in the Northeastern United States. Each owner completed a questionnaire querying potential factors associated with his/her cat's body condition. Veterinarians reported twenty-five percent of cats were overweight (heavy or obese), while owners estimated 29% of their pets were overweight. Apartment dwelling, inactivity, middle age, being male, neutered, of mixed breeding, and certain dietary factors were associated with being overweight.

Diet and exercise as potential risk factors for osteochondritis dissecans in dogs

A matched case-control study was conducted to evaluate dietary components and exercise patterns as potential risk factors for osteochondritis dissecans in dogs. A telephone interview, with a standard questionnaire and protocol, was used to collect data on dietary intake of calories and nutrients and on the usual amounts and types of exercise of each dog. Thirty-one dogs with osteochondritis dissecans and 60 controls were matched on the basis of breed, sex, and age. Using a conditional logistic regression model, high dietary calcium, playing with other dogs, and drinking well water (rather than city water) were associated with increased risk of osteochondritis dissecans. Feeding of specialty dry dog foods was associated with decreased risk.

Pronounced effects of the combination of a new thromboxane antagonist (GR32191) and heparin on bleeding time in man

Potential pharmacokinetic and pharmacodynamic interactions between two oral doses of GR32191 (40 and 80 mg), a new thromboxane antagonist, and heparin (5,000 IU bolus + 1,000 IU/h for 3 h) were studied in eighteen healthy male volunteers using two separate double-blind, randomised, placebo-controlled, cross-over studies. Mean (range) bleeding time values were 8.4 min (7.5-9.7) during heparin/placebo, 12.1 min (9.2-18.6) (GR32191/placebo) and 16.3 min (11.5-21.4) (GR32191/heparin) in the 40 mg study, while these values were 8.7 min (5.5-15.5), 16.0 min (9.3 - greater than 36.0) and 23.8 min (10.7 - greater than 36.0), respectively in the 80 mg study. Compared to screening values, the combination of 80 mg of GR32191 and heparin had a greater effect on the bleeding time than the sum of the prolongations after the separate treatments (p = 0.05). In the 40 mg study this was not the case. Pharmacokinetics of heparin (as assessed by plasma anti-Xa and antithrombin activity) and GR32191 were unaltered during co-administration of the two drugs. GR32191 did not influence the effects of heparin on APTT. Heparin slightly diminished the inhibition of collagen induced platelet aggregation by 80 mg of GR32191 and the U-46619 (thromboxane A2-mimetic) induced platelet aggregation remained unchanged. Overall fibrinolytic activity (as evaluated by the fibrin plate test) was similar during all three treatments in the study with 80 mg. The combination of 80 mg of GR32191 and heparin caused a prolongation of the bleeding time which was more than expected on the basis of their individual effects.

Nutritional support of hospitalized animals

Nutritional support of hospitalized animals is new and encouraging, although it is in need of rigorous evaluation. Principles and procedures of established value in human patients appear to be readily applied to other species, with due regard to comparative physiologic properties and medicine.

Pronounced Effects of the Combination of a New Thromboxane Antagonist (GR32191) and Heparin on Bleeding Time in Man

Potential pharmacokinetic and pharmacodynamic interactions between two oral doses of GR32191 (40 and 80 mg), a new thromboxane antagonist, and heparin (5,000 IU bolus + 1,000 IU/h for 3 h) were studied in eighteen healthy male volunteers using two separate double-blind, randomised, placebo-controlled, cross-over studies.

Mean (range) bleeding time values were 8.4 min (7.5–9.7) during heparin/placebo, 12.1 min (9.2–18.6) (GR32191/placebo) and 16.3 min (11.5–21.4) (GR32191/heparin) in the 40 mg study, while these values were 8.7 min (5.5–15.5), 16.0 min (9.3 – >36.0) and 23.8 min (10.7 – >36.0), respectively in the 80 mg study. Compared to screening values, the combination of 80 mg of GR 32191 and heparin had a greater effect on the bleeding time than the sum of the prolongations after the separate treatments (p = 0.05). In the 40 mg study this was not the case. Pharmacokinetics of heparin (as assessed by plasma anti-Xa and antithrombin activity) and GR32191 were unaltered during coadministration of the two drugs. GR32191 did not influence the effects of heparin on APTT. Heparin slightly diminished the inhibition of collagen induced platelet aggregation by 80 mg of GR32191 and the U-46619 (thromboxane A2-mimetic) induced platelet aggregation remained unchanged. Overall fibrinolytic activity (as evaluated by the fibrin plate test) was similar during all three treatments in the study with 80 mg.

The combination of 80 mg of GR32191 and heparin caused a prolongation of the bleeding time which was more than expected on the basis of their individual effects.

A quantitative summary of nutrition support services in a veterinary teaching hospital

A full-time nutrition support service provided 1,133 consultations in a small animal teaching hospital from July 1986 to June 1988, consisting of 840 dogs, 260 cats, 23 exotic species, and 10 consultations with incomplete information. The dog and cat consultations represented 2.1 and 3.7% of canine and feline admissions, respectively. Consultations involved the determination of nutritional goals which led to recommendations of specific dietary regimens. Most frequent requests were for diet evaluation and diet formulation to meet estimated calorie and protein needs during illness and stress (23%), for specific calorie or nutrient modification given a working diagnosis (23%), and for avoidance of tissue utilization or weight loss (23%). Frequently involved single organ systems were gastrointestinal (16%), liver (12%), kidney (9%), and pancreas (4%), but multiple system involvement was more common (19%). Most frequent diagnostic categories were metabolic disorders (17%), chronic organ failure (17%), and neoplasia (12%). Enteral nutrition was preferred for 98% of consultations. Voluntary consumption was deemed adequate in 81% of consultations, and highly palatable balanced homemade diets and specialty products were recommended in 74% of these. Human hospital liquid enteral products were used in 95% of consultations recommending involuntary feeding, either fed alone, blended with petfoods, or supplemented with modules of protein or fat. The service demonstrated that full-time nutrition support can be utilized effectively in a small animal teaching hospital. Further development of such services will depend on research focused especially on determination of case-specific nutritional goals, patient responses, and cost effectiveness.

Clinical nutrition of sheep and goats

Management systems and client goals are integral components of clinical nutrition and vary among and within sheep and goat producers. Evaluation includes client interview and history taking, record examination, forage analyses, animal examination, and occasionally blood or tissue assays. The types of nutritional disorders that are likely to be observed in sheep and goats vary according to the type of management and can be grouped according to feedlot, intensive production, farm flocks, dairy, and browse systems. Examples described include nutritional problems that may be overlooked (water deprivation), widespread (energy imbalance), currently difficult to prevent and treat (selenium deficiency), and reflective of soil-plant-animal complexities (copper-molybdenum balance).

Dietary aspects of developmental orthopedic disease in young horses

The clinician may choose between two approaches to nutritional intervention. One is to evaluate the ration and make a painstaking effort to identify those specific factors operating in a particular case, then correct them. The second is to evaluate the ration, inspect for obvious aberrations, and, if finding none, proceed with no further delay to formulate an optimal diet, or a series, for the animals, and design a feeding program to suit farm management. Veterinarians should counsel clients on the possible or probable consequences of level of feeding on growth rate and clinical expression of DOD. In our view, retardation of growth rate by feeding poor quality hay is irresponsible. At present, we suggest that the new approach to retarded growth in weanlings and yearlings--a carefully formulated diet that specifically restricts starch and protein while supplying NRC minimum requirements of other essential nutrients--should be confined to selected individuals and be conducted under strict professional supervision.

A conceptual approach to optimal nutrition of brood mares

Cumulative nutritional demands on good brood mares are unrivalled among domestic livestock, but little attention has been given to the influence of nutrition on their reproductive performance and efficiency. We suggest that part of the decline in racing performance of progeny of mares over 10 years of age may be caused by suboptimal nutrition. This article contrasts the concepts of minimal and optimal nutrient requirements, revives Hammond's concept of nutrient partitioning to the conceptus and mammary gland, and discusses energy and nutrient requirements during gestation and lactation. Further consideration is given to the aged brood mare.

Nutritional support of hospitalized patients

Effective nutritional support requires sound knowledge of both basic and clinical nutrition of dogs and cats as well as familiarity with products and delivery systems. Case management includes assessment of nutritional status and estimation of fuel sources. Most starved or stressed patients use fatty acids for over 70 per cent kcalME and protein for over 20 per cent kcalME. Approximate kcal needs are calculated from maintenance energy equations. Most patients respond best to enteral nutrition. Meat-based pet foods, liquid enteral products, and nutrient modules are offered in slurries or are tube-fed. Management includes careful monitoring of patients and gradual transitions to diets with more complex nutrient sources.

Effects of BW A256C, a novel class 1 antiarrhythmic agent, on maximum rate of depolarisation of cardiac action potentials in vitro: frequency, use, and voltage dependence

The frequency, use, and voltage-dependence of the effects of a novel antiarrhythmic agent, BW A256C, on the maximum rate of depolarization (Vmax) of action potentials in guinea-pig right ventricle were studied using standard microelectrode recording techniques in vitro. BW A256C (10(-6) M) reduced Vmax in a frequency-dependent way in the range 0.33-3.3 Hz; the maximum reduction was at the highest frequency. BW A256C did not cause resting block of Vmax. The onset of use-dependent Vmax reduction at 3.3 Hz followed a monoexponential function with a very slow rate constant, 0.019 +/- 0.003 AP-1. The recovery from use-dependent reduction, studied by applying single extra stimuli at various times after trains of stimuli at 3.3 Hz, was also very slow; half-life (t 1/2) for recovery was 119.0 +/- 19.2 s, and the time constant tre was 171.7 +/- 27.7 s. For comparison, the values for Flecainide (10(-5) M), obtained under identical conditions, were: rateon, 0.106 +/- 0.010 AP-1; t 1/2, 7.68 +/- 0.20 s; tre 11.07 +/- 0.29 s (means +/- SEM). In the presence of BW A256C (10(-6) M), the normalised diastolic membrane potential-Vmax curve was significantly shifted in the hyperpolarizing direction. The mean shift was 5.5 +/- 1.1 mV, measured at the 50% reduction of Vmax level. BW A256C is therefore classified as a novel "slow" class 1C antiarrhythmic agent.

BW A256C, a chemically novel class 1 antiarrhythmic agent. A comparison of in vitro and in vivo activity with other class 1 antiarrhythmic agents

BW A256C (5(3)-amino-6-(2,3-dichlorophenyl)-2,3(2,5)-dihydro-3(5)-imino-2 -isopropyl-1,2,4-triazine) is a novel class 1 antiarrhythmic agent designed to combine the features of potency with reduced central nervous system penetration. BW A256C reduced the maximum rate of depolarization of guinea-pig ventricle and dog Purkinje fibres in vitro (EC50, 2.2 X 10(-6) M and 1.8 X 10(-6) M, respectively), being significantly more potent than quinidine, lidocaine, disopyramide and flecainide. BW A256C was also more potent than these agents at inhibiting aconitine-induced arrhythmias in anaesthetized rats; however, unlike these agents, BW A256C was devoid of hypotensive activity at antiarrhythmic doses. In anaesthetized dogs, intravenous administration of BW A256C (0.25-1 mg kg-1) caused a dose-dependent suppression of ventricular arrhythmias that occurred on reperfusion of an occluded coronary artery. In conscious dogs, intravenous infusion (total dose, 1.5 mg kg-1) or oral administration of BW A256C (1.25-5 mg kg-1) caused dose-dependent suppression of the ventricular ectopic activity that occurred following 20-24 h of permanent coronary artery ligation. In the conscious dog, BW A256C was approximately 7 times more potent and was also longer acting than flecainide. Administration of BW A256C was not associated with any evidence of peripheral or CNS toxicity. However, plasma levels 3-4 times greater than the antiarrhythmic levels were associated with a proarrhythmic activity.

Thersitina gasterostei (Pagenstecher, 1861) (Copepoda: Ergasilidae) infecting the stickleback Pungitius pungitius L. at Chalk Marshes, Gravesend, Kent

10-spined sticklebacks, Pungitius pungitius, taken from a drainage dyke at Chalk Marshes, Kent, between October 1979 and July 1980 were infested with adult females of the parasitic copepod Thersitina gasterostei. Relative density of the overwintering parasite population fell during the winter months to a minimum in April; however during this winter period the proportion of ovigerous females rose, reaching 100% in April. Young infective adults were first seen in May, and the peak of infection by the first summer generation occurred in June. The parasite was found to be overdispersed within the host population: in 8 of 10 monthly samples the negative binomial distribution was a good model for the observed data. Relative density was related to host length in only 3 of the 10 samples. Evidence is presented to suggest that infected fish are more likely than non-infected fish to recruit young parasite.