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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

A Pseudo-Outbreak of Skin Disease in British Troops

When a newspaper report claimed that a serious outbreak of skin disease had occurred in British Army troops stationed at the Bočac Dam, in western Bosnia, all troops at the Bočac Dam location (n=96), followed by a matched control group of troops (n=91) at a nearby location, were examined by two investigators.

14% of the study population and 21% of the control group were found to have skin disorders. Most were complaints that are commonly encountered in general medical practice. There was a striking absence of skin infestations. The historical consultation rate for skin disorders had not increased. It was concluded that an outbreak of skin disease had not occurred in British troops guarding the dam.

This epidemiological study shows that, even under conditions of modern field hygiene, up to one in five soldiers will have skin disease. Skin infestations, however, have become progressively less common during military campaigns this century, probably because of better personal hygiene, good preventive medicine practices and better access to effective health care.

Neuroleptic prescribing in an adolescent psychiatric in-patient unit

The Royal College of Psychiatrists' consensus statement suggests that prescribing high dose antipsychotic medication in children and adolescents should rarely be necessary. Our objective was to study the prescribing of antipsychotic medication in a regional adolescent unit during a three-year period. We found that antipsychotic prescribing on this unit is common in psychotic disorders and often high closes are required. This is not in keeping with the recommendations of the consensus statement. Review of clinical practice on other adolescent units is needed, together with a more comprehensive evaluation of the outcome of psychotic disorders in this age group.

Pragmatic randomized controlled trial of an allergy intervention for children aged 6-16 with asthma and rhinitis in general practice

BACKGROUND

It is widely believed that for allergic rhinitis and asthma, avoidance of specific triggers can improve symptom control. Whilst many children with asthma or rhinitis are sensitized to airborne allergens, primary care diagnostic and management decisions are often made without a detailed history of the allergic triggers or allergy testing. Thus, treatment decisions are empirical and allergen avoidance advice is either not given or, if given, not tailored to the child's sensitivities.

OBJECTIVE

To ascertain whether allergy assessment and tailored advice in general practice enhances outcomes of children with asthma and rhinitis.

METHOD

Pragmatic RCT of allergy intervention (structured allergy history, skin prick testing and appropriate allergy avoidance advice) vs. usual care in children with asthma and/or rhinoconjunctivitis. A blinded observer assessed outcomes at 12 months. Main outcome measures were symptom scores and disease-specific health-related QoL. Secondary outcomes were healthcare utilization, days unable to pursue usual activities and self-rated improvement.

RESULTS

A total of 335 participants were randomized to formal allergy assessment or normal care. There were no differences in participants' demographic or clinical characteristics at baseline (all P > 0.05). At 12 months, participants receiving the allergy intervention had fewer rhinitis symptoms (MD - 3.14, 95% CI - 6.01, - 0.81) and an improvement in QoL (MD - 0.50, 95% CI 0.32, 0.68). There were no significant changes in asthma symptoms, healthcare utilization or number of days unable to pursue usual activities.

CONCLUSION

Amongst children with known asthma and/or rhinitis in primary care, taking a structured allergy history with skin prick testing and tailored advice on allergy avoidance resulted in reduced symptoms of rhinitis and improved QoL.

A follow-up study of selected biomarkers of health in cod Gadus morhua L. collected from the southern Baltic off the Polish coast

Selected biomarkers of health were examined in 50 post-spawning cod Gadus morhua collected in November 2015 from the southern Baltic. The biomarkers included condition factor (CF), macroscopic lesions, histopathology of spleen, liver and gonads, and morphometry of follicular atresia and hepatic and splenic melanomacrophage cells (MMC). All fish appeared in good body condition. One fish had a dermal ulcer, and in seven, macroscopic nematodes were noted within body cavity. Microscopic lesions in the liver included biliary myxozoanosis, microsporidial and necrocentric granulomas, parasitic hepatitis, multifocal necrosis, foci of cellular alterations, spongiosis, peliosis and cytoplasmic fibrillar inclusions. The spleen and gonads had microsporidial and/or necrocentric granulomas. Some of the biomarkers showed differences as compared to spawning cod collected in May from the same location in 2012, most importantly values an order of magnitude lower for splenic MMC in post-spawning fish. In post-spawning fish, there were statistically significant correlations between MMC, CF, follicular atresia, parasitic hepatitis and microsporidiosis. This is the first comparison of biomarkers of health in post-spawning and spawning Baltic cod. Future studies need to examine the relationships of biomarkers to levels of pollutants in the environment and in tissues of cod.

Off to a Good Start: The Early Development of the Neural Substrates Underlying Visual Working Memory

Current neuroscientific models describe the functional neural architecture of visual working memory (VWM) as an interaction of the frontal-parietal control network and more posterior areas in the ventral visual stream (Jonides et al., 2008; D'Esposito and Postle, 2015; Eriksson et al., 2015). These models are primarily based on adult neuroimaging studies. However, VWM undergoes significant development in infancy and early childhood, and the goal of this mini-review is to examine how recent findings from neuroscientific studies of early VWM development can be reconciled with this model. We surveyed 29 recent empirical reports that present neuroimaging findings in infants, toddlers, and preschoolers (using EEG, fNIRS, rs-fMRI) and neonatal lesion studies in non-human primates. We conclude that (1) both the frontal-parietal control network and the posterior cortical storage areas are active from early infancy; (2) this system undergoes focalization and some reorganization during early development; (3) and the MTL plays a significant role in this process as well. Motivated by both theoretical and methodological considerations, we offer some recommendations for future directions for the field.

Use of information technology by biological researchers

Recent studies of computer-based information-handling by scientists have tended to look at such activities across all the sciences. This is true, in particular, of the recent detailed Royal Society (RS)/British Library (BL)/Association of Learned and Professional Society Publishers (ALPSP) survey. The present study aims to complement these by concentrating on the biological sciences only. It surveys the usage of information technology and related factors by researchers at four institutions - an agricultural faculty, a university school of biology, a government research estab lishment and a pharmaceutical laboratory.

The spread of non-OIE-listed avian diseases through international trade of chicken meat: an assessment of the risks to New Zealand

Twelve avian diseases are listed by the World Organisation for Animal Health (OIE), although more than 100 infectious diseases have been described in commercial poultry. This article summarises a recent assessment of the biosecurity risks posed by non-listed avian diseases associated with imports of chilled or frozen chicken meat and meat products into New Zealand. Following the guidelines described in Chapter 2.1 of the OIE Terrestrial Animal Health Code, avian adenovirus splenomegaly virus, avian paramyxovirus-2 (APMV-2), Bordetella avium, Mycoplasma spp., Ureaplasma spp., Ornithobacterium rhinotracheale, Riemerella anatipestifer, and Salmonella arizonae have been identified as hazards. However, of all the non-listed avian diseases discussed here, only APMV-2 and S. arizonae are assessed as being risks associated with the commercial import of chicken meat into New Zealand. Specific control measures may have to be implemented to mitigate such risks. This conclusion is likely to reflect both the high-health status of New Zealand poultry and the threat posed by these infectious agents to New Zealand's unique population of native psittacine species.

Cytomegalovirus-Associated CD4(+) CD28(null) Cells in NKG2D-Dependent Glomerular Endothelial Injury and Kidney Allograft Dysfunction

Emerging data suggest that expansion of a circulating population of atypical, cytotoxic CD4(+) T cells lacking costimulatory CD28 (CD4(+) CD28(null) cells) is associated with latent cytomegalovirus (CMV) infection. The purpose of the current study was to increase the understanding of the relevance of these cells in 100 unselected kidney transplant recipients followed prospectively for a median of 54 months. Multicolor flow cytometry of peripheral blood mononuclear cells before transplantation and serially posttransplantation was undertaken. CD4(+) CD28(null) cells were found predominantly in CMV-seropositive patients and expanded in the posttransplantation period. These cells were predominantly effector-memory phenotype and expressed markers of endothelial homing (CX3CR1) and cytotoxicity (NKG2D and perforin). Isolated CD4(+) CD27(-) CD28(null) cells proliferated in response to peripheral blood mononuclear cells previously exposed to CMV-derived (but not HLA-derived) antigens and following such priming incubation with glomerular endothelium resulted in signs of endothelial damage and apoptosis (release of fractalkine and von Willebrand factor; increased caspase 3 expression). This effect was mitigated by NKG2D-blocking antibody. Increased CD4(+) CD28(null) cell frequencies were associated with delayed graft function and lower estimated glomerular filtration rate at end follow-up. This study suggests an important role for this atypical cytotoxic CD4(+) CD28(null) cell subset in kidney transplantation and points to strategies that may minimize the impact on clinical outcomes.

Meta-analysis of the diagnostic accuracy of laparoscopic ultrasonography and intraoperative cholangiography in detection of common bile duct stones

Introduction During laparoscopic cholecystectomy, intraoperative cholangiography (IOC) is currently regarded as the gold standard in the detection of choledocholithiasis. Laparoscopic ultrasonography (LUS) is an attractive alternative with several potential advantages. Methods A systematic review was undertaken of the published literature comparing LUS with IOC in the assessment of common bile duct (CBD) stones. Results Twenty-one comparative studies were analysed. There were 4,566 patients in the IOC group and 5,044 in the LUS group. The combined sensitivity and specificity of IOC in the detection of CBD stones were 0.87 (95% confidence interval [CI]: 0.83-0.89) and 0.98 (95% CI: 0.98-0.98) respectively with a pooled area under the curve (AUC) of 0.985 and a diagnostic odds ratio (OR) of 260.65 (95% CI: 160.44-423.45). This compares with a sensitivity and specificity for LUS of 0.90 (95% CI: 0.87-0.92) and 0.99 (95% CI: 0.99-0.99) respectively with a pooled AUC of 0.982 and a diagnostic OR of 765.15 (95% CI: 450.78-1,298.76). LUS appeared to be more successful in terms of coming to a clinical decision regarding CBD stones than IOC (random effects, risk ratio: 0.95, 95% CI: 0.93-0.98, df=20, z=-3.7, p<0.005). Furthermore, LUS took less time (random effects, standardised mean difference: 0.95, 95% CI: 0.93-0.98, df=20, z=-3.7, p<0.005). Conclusions LUS is comparable with IOC in the detection of CBD stones. The main advantages of LUS are that it does not involve ionising radiation, is quicker to perform, has a lower failure rate and can be repeated during the procedure as required.

Unimpaired attentional disengagement in toddlers with autism spectrum disorder

A prominent hypothesis holds that 'sticky' attention early in life in children with autism spectrum disorder (ASD) limits their ability to explore and learn about the world. Under this hypothesis, the core clinical symptoms of ASD - restricted interests, repetitive behaviors and impaired social/communication abilities - could all result from impaired attentional disengagement during development. However, the existence of disengagement deficits in children with ASD is controversial, and a recent study found no deficit in 5- to 12-year-olds with ASD. Nonetheless, the possibility remains that disengagement is impaired earlier in development in children with ASD, altering their developmental trajectory even if the attentional deficit itself is remediated or compensated for by the time children with ASD reach school age. Here, we tested this possibility by characterizing attentional disengagement in a group of toddlers just diagnosed with ASD (age 21 to 37 months). We found strikingly similar performance between the ASD and age-matched typically developing (TD) toddlers, and no evidence of impaired attentional disengagement. These results show that even at a young age when the clinical symptoms of ASD are first emerging, disengagement abilities are intact. Sticky attention is not a fundamental characteristic of ASD, and probably does not play a causal role in its etiology.

Gene expression of INPP5F as an independent prognostic marker in fludarabine-based therapy of chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is a heterogeneous disease. Various disease-related and patient-related factors have been shown to influence the course of the disease. The aim of this study was to identify novel biomarkers of significant clinical relevance. Pretreatment CD19-separated lymphocytes (n=237; discovery set) and peripheral blood mononuclear cells (n=92; validation set) from the REACH trial, a randomized phase III trial in relapsed CLL comparing rituximab plus fludarabine plus cyclophosphamide with fludarabine plus cyclophosphamide alone, underwent gene expression profiling. By using Cox regression survival analysis on the discovery set, we identified inositol polyphosphate-5-phosphatase F (INPP5F) as a prognostic factor for progression-free survival (P<0.001; hazard ratio (HR), 1.63; 95% confidence interval (CI), 1.35-1.98) and overall survival (P<0.001; HR, 1.47; 95% CI, 1.18-1.84), regardless of adjusting for known prognostic factors. These findings were confirmed on the validation set, suggesting that INPP5F may serve as a novel, easy-to-assess future prognostic biomarker for fludarabine-based therapy in CLL.

Transitional B lymphocytes are associated with protection from kidney allograft rejection: a prospective study

Recent cross-sectional studies suggest an important role for transitional B lymphocytes (CD19 + CD24hiCD38hi) in promoting transplant tolerance, and protecting from late antibody-mediated rejection (ABMR). However, prospective studies are lacking. This study enrolled 73 de novo transplant recipients, and collected serial clinical, immunological and biochemical information over 48 ± 6 months. Cell phenotyping was conducted immediately prior to transplantation, and then on five occasions during the first year posttransplantation. When modeled as a time-dependent covariate, transitional B cell frequencies (but not total B cells or "regulatory" T cells) were associated with protection from acute rejection (any Banff grade; HR: 0.60; 95% CI: 0.37-0.95; p = 0.03). No association between transitional B cell proportions and either de novo donor-specific or nondonor-specific antibody (dnDSA; dnNDSA) formation was evident, although preserved transitional B cell proportions were associated with reduced rejection rates in those patients developing dnDSA. Three episodes of ABMR occurred, all in the context of nonadherence, and all associated with in vitro anti-HLA T cell responses in an ELISPOT assay (p = 0.008 versus antibody-positive patients not experiencing ABMR). This prospective study supports the potential relevance of transitional ("regulatory") B cells as a biomarker and therapeutic intervention in transplantation, and highlights relationships between humoral immunity, cellular immunity and nonadherence.

Pragmatic randomized controlled trial of a structured allergy intervention for adults with asthma and rhinitis in general practice

BACKGROUND

It is widely believed that in patients with allergic rhinitis and asthma, avoidance of specific triggers can help improve symptom control and reduce need for medication. Whilst most patients with asthma or rhinitis are sensitized to airborne allergens, primary care diagnostic and management decisions are often made without either obtaining a detailed history of the patient's allergic triggers or performing skin prick tests. Thus, management decisions are empirical and allergen avoidance advice is either not given or, if given, not tailored to the patient's sensitivities.

METHOD

To ascertain whether allergy assessment and tailored advice in general practice for patients with asthma and rhinitis enhance well-being, we conducted a pragmatic, open, randomized controlled trial of allergy intervention (structured allergy history and skin prick testing and appropriate advice on allergy avoidance) versus usual care in adult patients with a working diagnosis of asthma and/or rhino-conjunctivitis. Outcomes were assessed after 12 months by an observer who was blinded to allocation. The main outcome measures were asthma and rhinitis symptoms, disease-specific health-related quality of life, generic quality of life and lung function.

RESULTS

There were no significant differences in baseline demographics or disease characteristics between patients assigned to immediate or delayed skin prick testing. No significant differences were observed between groups for any measures of symptoms, quality of life or lung function at 12 months (all P > 0.05).

CONCLUSION

Amongst adults with known asthma and/or rhinitis in primary care, taking a structured allergy history with skin prick tests and giving tailored advice on allergy avoidance made no difference to their symptoms, quality of life or lung function as measured twelve months later.

Supraspinal stimulation for treatment of refractory pain

Refractory pain syndromes often have far reaching effects and are quite a challenge for primary care providers and specialists alike to treat. With the help of site-specific neuromodulation and appropriate patient selection these difficult to treat pain syndromes may be managed. In this article, we focus on supraspinal stimulation (SSS) for treatment of intractable pain and discuss off-label uses of deep brain stimulation (DBS) and motor cortex stimulation (MCS) in context to emerging indications in neuromodulation. Consideration for neuromodulatory treatment begins with rigorous patient selection based on exhaustive conservative management, elimination of secondary gains, and a proper psychology evaluation. Trial stimulation prior to DBS is nearly always performed while trial stimulation prior to MCS surgery is symptom dependent. Overall, a review of the literature demonstrates that DBS should be considered for refractory conditions including nociceptive/neuropathic pain, phantom limb pain, and chronic cluster headache (CCH). MCS should be considered primarily for trigeminal neuropathic pain (TNP) and central pain. DBS outcome studies for post-stroke pain as well as MCS studies for complex regional pain syndrome (CRPS) show more modest results and are also discussed in detail.