Fibrinogen Bonn (p. Arg510Cys) in the Aα-Chain Is Associated with High Risk of Venous Thrombosis

INTRODUCTION

 Inherited dysfibrinogenemia is a qualitative defect of fibrinogen caused by various mutations among three fibrinogen genes. Dysfibrinogenemia can be associated with an increased risk of thrombosis, bleeding, or both. Here, we report a 36-year-old female with dysfibrinogenemia who experienced two successful pregnancies under thromboprophylaxis after cerebral venous sinus thrombosis (CVST).

PATIENTS AND METHODS

 In addition to plasmatic coagulation tests, fibrinogen genes FGA, FGB, and FGG were screened using direct genomic DNA sequencing. The structural-functional implications of the detected mutation were analyzed in silico.

RESULTS

 Inherited dysfibrinogenemia was diagnosed in an index patient after CVST in a risk situation. Anticoagulation with warfarin was stopped after 12 months when the first pregnancy was planned. Pregnancy and spontaneous delivery (2020) was uncomplicated. A second pregnancy was interrupted because of acute cytomegalovirus infection and the third pregnancy was successful in 2022. Pregnancies were accompanied by thromboprophylaxis with enoxaparin 40 mg once daily until 6 weeks postpartum. Substitution of fibrinogen has not become necessary in the index patient so far. Genetic analysis revealed a novel missense mutation (p. Arg510Cys) in the FGA gene ("fibrinogen Bonn") in the index patient, as well as an asymptomatic sister, and their father who experienced recurrent pulmonary embolism. Surface exposure of wild-type Arg510 suggested the mutated Cys510 to form nonnative disulfide bonds with surface-exposed reactive cysteines from other plasma proteins like albumin leading to formation of aggregates and impaired fibrinolysis.

CONCLUSIONS

 Fibrinogen Bonn might be associated with an increased risk of thrombosis, possibly due to impaired polymerization.

Sealing or infiltrating proximal carious lesions

OBJECTIVES

Micro-invasive treatment (sealing, infiltration) seems more efficacious to arrest early (non-cavitated) proximal carious lesions than non-invasive treatment (NI). Uncertainty remains as to the efficacy of sealing versus infiltration and the robustness of the evidence. We aimed to review and synthesize this evidence using pairwise and network meta-analysis (NMA) and to perform trial sequential analysis (TSA).

SOURCES

Searching three electronic databases (Medline, Embase, Cochrane Central) was complemented by hand searches and cross-referencing.

STUDY SELECTION

Randomized controlled trials comparing micro-invasive strategies against each other, NI or placebo for managing proximal carious lesions were included. The primary outcome was radiographically assessed lesion progression. Pairwise and Bayesian network meta-analyses as well as TSA were used for synthesis.

DATA

Thirteen split-mouth studies (486 participants, mean age 15 years) were included. Mean follow-up was 25 months (min/max 12/36 months). Firm evidence on the superior efficacy of sealing/infiltration over NI (OR; 95% CI: 0.25; 0.18-0.32) was reached. Firm evidence was also reached on the superior efficacy of sealing (OR; 95% CI: 0.29; 0.18-0.46, 7 studies) and infiltration (OR; 95% CI: 0.22; 0.15-0.33, 7 studies) over NI. One study compared infiltration versus sealing and found no significant difference (0.70; 0.34-1.47). Based on Bayesian NMA, infiltration was ranked first in 80% of the simulations (sealing 20%, NI 0%). The surface-under-the-cumulative-ranking (SUCRA) values were 0.90 for infiltration, 0.60 for sealing and 0.00 for NI. We did not detect significant inconsistency (p = 0.89, node-split).

CONCLUSIONS

Sealing or infiltration are likely to be more efficacious for arresting early (non-cavitated) proximal lesions than NI.

CLINICAL SIGNIFICANCE

Practitioners should strive to perform micro-invasive treatment instead of NI for early proximal lesions. The decision between sealing or infiltration should be guided by practical concerns beyond efficacy.

Oral manifestations, dental management, and a rare homozygous mutation of the PRDM12 gene in a boy with hereditary sensory and autonomic neuropathy type VIII: a case report and review of the literature

BACKGROUND

Hereditary sensory and autonomic neuropathy type VIII is a rare autosomal recessive inherited disorder. Chen et al. recently identified the causative gene and characterized biallelic mutations in the PR domain-containing protein 12 gene, which plays a role in the development of pain-sensing nerve cells. Our patient's family was included in Chen and colleagues' study. We performed a literature review of the PubMed library (January 1985 to December 2016) on hereditary sensory and autonomic neuropathy type I to VIII genetic disorders and their orofacial manifestations. This case report is the first to describe the oral manifestations, and their treatment, of the recently discovered hereditary sensory and autonomic neuropathy type VIII in the medical and dental literature.

CASE PRESENTATION

We report on the oral manifestations and dental management of an 8-month-old white boy with hereditary sensory and autonomic neuropathy-VIII over a period of 16 years. Our patient was homozygous for a mutation of PR domain-containing protein 12 gene and was characterized by insensitivity to pain and thermal stimuli, self-mutilation behavior, reduced sweat and tear production, absence of corneal reflexes, and multiple skin and bone infections. Oral manifestations included premature loss of teeth, associated with dental traumata and self-mutilation, severe soft tissue injuries, dental caries and submucosal abscesses, hypomineralization of primary teeth, and mandibular osteomyelitis.

CONCLUSIONS

The lack of scientific knowledge on hereditary sensory and autonomic neuropathy due to the rarity of the disease often results in a delay in diagnosis, which is of substantial importance for the prevention of many complications and symptoms. Interdisciplinary work of specialized medical and dental teams and development of a standardized treatment protocols are essential for the management of the disease. There are many knowledge gaps concerning the management of patients with hereditary sensory and autonomic neuropathy-VIII, therefore more research on an international basis is needed.

Long-QT syndrome-associated caveolin-3 mutations differentially regulate the hyperpolarization-activated cyclic nucleotide gated channel 4

Background

Caveolin-3 (cav-3) mutations are linked to the long-QT syndrome (LQTS) causing distinct clinical symptoms. Hyperpolarization-activated cyclic nucleotide channel 4 (HCN4) underlies the pacemaker current If. It associates with cav-3 and both form a macromolecular complex.

Methods

To examine the effects of human LQTS-associated cav-3 mutations on HCN4-channel function, HEK293-cells were cotransfected with HCN4 and wild-type (WT) cav-3 or a LQTS-associated cav-3 mutant (T78M, A85T, S141R, or F97C). HCN4 currents were recorded using the whole-cell patch-clamp technique.

Results

WT cav-3 significantly decreased HCN4 current density and shifted midpoint of activation into negative direction. HCN4 current properties were differentially modulated by LQTS-associated cav-3 mutations. When compared with WT cav-3, A85T, F97C, and T78M did not alter the specific effect of cav-3, but S141R significantly increased HCN4 current density. Compared with WT cav-3, no significant modifications of voltage dependence of steady-state activation curves were observed. However, while WT cav-3 alone had no significant effect on HCN4 current activation, all LQTS-associated cav-3 mutations significantly accelerated HCN4 activation kinetics.

Conclusions

Our results indicate that HCN4 channel function is modulated by cav-3. LQTS-associated mutations of cav-3 differentially influence pacemaker current properties indicating a pathophysiological role in clinical manifestations.

[Heart failure and anemia]

Chronic heart failure has an age-dependent prevalence of 2% and is therefore one of the most frequent diseases in western societies. A reduced hemoglobin concentration according to the definition of the World Health Organization is a common comorbidity affecting more than half of all heart failure patients. Elderly patients, patients suffering from renal impairment and women are more likely to develop anemia but a definitive etiology of anemia is only identified in the minority of cases. Anemia is associated with a poor clinical status and a greater risk of hospitalization and is a predictive factor for increased mortality. The incidence of anemia appears to increase with a poorer functional class. Intravenous iron therapy improves the exercise capacity in patients with systolic heart failure and iron deficiency and is currently being recommended for patients with persistent symptoms despite optimal medical and device therapy. However, erythropoietin-stimulating agents as a treatment for anemia in chronic heart failure have failed to improve clinical outcome in a large randomized trial. In patients with heart failure but with maintained ejection fraction, anemia is also associated with a poor prognosis. Specific therapeutic recommendations for these patients are still not available.

[New tyrosine kinase and EGFR inhibitors in cancer therapy. Cardiac and skin toxicity as relevant side effects. Part A: heart]

Cardiotoxicity is a serious side effect of targeted molecular therapies in cancer treatment. Monoclonal antibodies and tyrosine kinase inhibitors are known to be potent therapies in various neoplastic diseases due to inhibition of specific signal transduction pathways. Although targeted therapies are considered to be less toxic and better tolerated than common chemotherapies certain cardiac side effects have been observed. Cardiac toxicity may range from asymptomatic reduction of left ventricular function to life-threatening events like heart failure and acute coronary syndrome. Further side effects are arterial hypertension, thrombosis and arrhythmias. Cardiovascular side effects are common for anti-HER2 therapy in combination with anthracyclines and for inhibitors of angiogenesis. In these patients careful cardiac monitoring is warranted. Because of missing randomized long-term follow-ups, information about cardiac side effects is limited in newly developed targeted molecular therapies. In case of cardiac side effects or preexisting cardiac disease before therapy initiation, assessments by a cardiologist throughout the course of treatment are important. For patients with severe cardiac side effects, discontinuation of treatment is warranted; in case of asymptomatic cardiac side effects symptom-specific therapy should be performed.

Prompts to encourage appointment attendance for people with serious mental illness

BACKGROUND

Prompts to encourage attendance at clinics are often used in day-to-day practice by diligent carers of people with mental health problems. These may take the form of telephone prompting, financial incentives or issuing a copy of the referral letter to the appointee.

OBJECTIVES

To estimate the effects of simple prompting by professional carers to encourage attendance at clinics for those with serious mental illness.

SEARCH STRATEGY

Methodical searches of Biological Abstracts (1985-2000), CINAHL (1982-2000), Cochrane Schizophrenia Group's Register (June 2000), Cochrane Library (Issue 2, 2000), EMBASE (1980-2000), MEDLINE (1966-2000) and PsycLIT (1887-2000) were undertaken. These were supplemented by searching of reference lists, personal contact and hand searching of high yield journals.

SELECTION CRITERIA

All relevant randomised (or quasi-randomised) studies comparing the addition of 'prompts' to standard care for those with serious mental illnesses such as schizophrenia. Prompts had the stated purpose of encouraging attendance or contact with mental health teams and could be text-based, electronic, by telephone call, by personal visit, or could employ financial or other rewards.

DATA COLLECTION AND ANALYSIS

Studies and data were independently selected and extracted. For homogeneous dichotomous data the random effects relative risk (RR), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data the reviewers calculated weighted mean differences.

MAIN RESULTS

Only three relevant trials were identified (total n=597). It is not clear whether there is any real difference between attendance of those prompted by telephone one or two days before the appointment, and those given the standard appointment management system (2 trials, n=457, RR missed appointment 0.84 CI 0.7 to 1.1). Text-based prompts, a few days before the appointment day, did increase clinic attendance when compared with no prompt (2 trials, n=200, RR missed appointment 0.6 CI 0.4 to 0.9, NNT 6 CI 2 to 14). Only one small study (n=61) reported data on the combination of telephone and text-based prompts versus no prompt (RR missed appointments 0.7 CI 0.4 to 1.2). When telephone prompts were compared with text-based prompts (1 trial, n=75), the latter, in the form of an 'orientation statement' (a short paragraph, taking about 30 seconds to read, explaining the programme of care, the fee system, and providing gentle encouragement) may be somewhat more effective than the telephone prompt (RR missed appointments 1.9 CI 0.98 to 3.8). One last study (n=120) compared a standard letter prompt with a letter 'orientation statement'. Overall, results tended to favour the orientation statement approach rather than the simple letter prompting attendance but the results did not reach conventional levels of statistical significance (RR missed appointments 1.6 CI 0.9 to 2.9).

REVIEWER'S CONCLUSIONS

There is evidence that a simple prompt to attend clinic, very close to the time of the appointment may encourage attendance, and a simple orientation-type letter, 24 hours before the clinic appointment, may be more effective than a telephone prompt. This simple intervention could be a more cost effective means of encouraging compliance at first attendance, but supplementing these data with the results of large, well designed, conducted and reported randomised studies would be desirable.

Public perceptions of former psychiatric patients in England

To determine whether casual contact with former psychiatric patients changes public perceptions of and attitudes toward persons with mental illness, 100 residents of urban North London, England, were interviewed before and six months after a residential facility for former patients was opened in their neighborhood. Their responses were compared with those of a control group of residents living elsewhere. The semistructured, door-to-door interviews revealed extremely negative attitudes toward persons with mental illness, largely formed by the media. No differences between the study and control groups were found. The negative attitudes in the study group had not changed at the six-month interview.

Public perception of discharged psychiatric patients: a community survey

The trend in psychiatric care in the National Health Service in Britain is to move patients into the community. However, few attempts have been made to identify public opinions about such moves. This paper describes public beliefs of mental illness and their attitudes towards patients moved from two large institutions into their neighbourhood. Residents local to a community mental health facility were interviewed before and six months after opening the facility. The results shows that public attitudes remain negative. It seems that deinstitutionalisation has little impact on public attitudes. No distinction could be drawn between the study and control groups.

Staff perception of their roles during the transition of psychiatric care into the community

The objective of this study was to investigate the staff's experiences involved in the processes of the transition of 20 non-demented long-stay psychiatric patients. Staff members expressed satisfaction from working outside the hospital. They believed that the patients' condition and their quality of life had improved and that they were likely to achieve successful resettlement after a lengthy process of rehabilitation. However, staff members considered that their roles were demanding and involved a lot of domestic activities. They recommended gradual and slow preparation for the patients, and an educational programme for the public as well as appropriate preparation and continuing professional support for staff.

The TAPS Project. 9: The reliability of the Patient Attitude Questionnaire

The development of the hospital and community versions of the Patient Attitude Questionnaire is described. The instrument rates the attitudes of psychiatric patients towards their treatment settings and staff, and is framed specifically to assess attitudinal change during the transfer of patients from hospital. For the items rated using the kappa coefficient of agreement, the mean test-retest reliability value was 0.51, and the average inter-rater value was 0.82. This study shows that long-term psychiatric patients are able to give clear and consistent views about their living arrangements--views that should be sought and respected by staff.