[A microcytic sideroblastic anemia successfully treated with B6 vitamin]

INTRODUCTION

Sideroblastic anemia is a rare cause of microcytic anemia, which is characterized by ring sideroblasts on bone marrow aspirate. This anemia can be congenital or acquired.

CASE REPORT

We report the case of an alcoholic 49-year-old man who presented with a severe microcytic sideroblastic anemia related to pyridoxine (B6 vitamin) deficiency. Acid folic deficiency was associated. The blood count normalized within one month after vitamin supplementation.

CONCLUSION

Pyridoxine deficiency must be sought in sideroblastic anemia in patients at risk.

Domestication and crop evolution of wheat and barley: Genes, genomics, and future directions

Wheat and barley are two of the founder crops of the agricultural revolution that took place 10,000 years ago in the Fertile Crescent and both crops remain among the world's most important crops. Domestication of these crops from their wild ancestors required the evolution of traits useful to humans, rather than survival in their natural environment. Of these traits, grain retention and threshability, yield improvement, changes to photoperiod sensitivity and nutritional value are most pronounced between wild and domesticated forms. Knowledge about the geographical origins of these crops and the genes responsible for domestication traits largely pre-dates the era of next-generation sequencing, although sequencing will lead to new insights. Molecular markers were initially used to calculate distance (relatedness), genetic diversity and to generate genetic maps which were useful in cloning major domestication genes. Both crops are characterized by large, complex genomes which were long thought to be beyond the scope of whole-genome sequencing. However, advances in sequencing technologies have improved the state of genomic resources for both wheat and barley. The availability of reference genomes for wheat and some of its progenitors, as well as for barley, sets the stage for answering unresolved questions in domestication genomics of wheat and barley.

QTL Mapping of Fusarium Head Blight and Correlated Agromorphological Traits in an Elite Barley Cultivar Rasmusson

Fusarium head blight (FHB) is an important fungal disease affecting the yield and quality of barley and other small grains. Developing and deploying resistant barley cultivars is an essential component of an integrated strategy for reducing the adverse effects of FHB. Genetic mapping studies have revealed that resistance to FHB and the accumulation of pathogen-produced mycotoxins are controlled by many quantitative trait loci (QTL) with minor effects and are highly influenced by plant morphological traits and environmental conditions. Some prior studies aimed at mapping FHB resistance have used populations derived from crossing a Swiss landrace Chevron with elite breeding lines/cultivars. Both Chevron and Peatland, a sib-line of Chevron, were used as founders in the University of Minnesota barley breeding program. To understand the native resistance that might be present in the Minnesota breeding materials, a cross of an elite cultivar with a susceptible unadapted genotype is required. Here, a mapping population of 93 recombinant inbred lines (RILs) was developed from a cross between a moderately susceptible elite cultivar 'Rasmusson' and a highly susceptible Japanese landrace PI 383933. This population was evaluated for FHB severity, deoxynivalenol (DON) accumulation and various agromorphological traits. Genotyping of the population was performed with the barley iSelect 9K SNP chip and 1,394 SNPs were used to develop a genetic map. FHB severity and DON accumulation were negatively correlated with plant height (HT) and spike length (SL), and positively correlated with spike density (SD). QTL analysis using composite interval mapping (CIM) identified the largest effect QTL associated with FHB and DON on the centromeric region of chromosome 7H, which was also associated with HT, SL, and SD. A minor FHB QTL and a minor DON QTL were detected on chromosome 6H and chromosome 3H, respectively, and the Rasmusson alleles contributed to resistance. The 3H DON QTL likely represents native resistance in elite germplasm as the marker haplotype of Rasmusson at this QTL is distinct from that of Chevron. This study highlights the relationship between FHB resistance/susceptibility and morphological traits and the need for breeders to account for morphology when developing FHB resistant genotypes.

Efficacy of gemcitabine plus erlotinib in rash-positive patients with metastatic pancreatic cancer selected according to eligibility for FOLFIRINOX: A prospective phase II study of the 'Arbeitsgemeinschaft Internistische Onkologie'

INTRODUCTION

In metastatic pancreatic ductal adenocarcinoma (mPDAC) treatment, erlotinib is known to be more effective in patients developing skin rash. Treatment with the FOLFIRINOX regimen is only performed in fit patients following defined inclusion criteria. The present study investigates the efficacy of gemcitabine plus erlotinib (gem/erlotinib) in rash-positive patients fit for FOLFIRINOX.

PATIENTS AND METHODS

For this prospective phase II study, 150 patients were recruited in 20 centres. All patients received gem/erlotinib for 4 weeks (run-in phase); the subsequent treatment was determined by the development of skin rash: patients with rash grades 1-4 continued with gem/erlotinib, rash-negative patients were switched to FOLFIRINOX. Primary study end-point was to achieve a 1-year survival rate in rash-positive patients ≥40%.

RESULTS

Ninety patients were deemed positive for skin rash by the end of the run-in phase, showing a 1-year survival rate of 40.0% (95% confidence interval [CI] 29.8-50.9). Median overall survival (OS) was 10.1 months, progression-free survival (PFS) was 3.8 months and overall response rate (ORR) was 23.3%. Patients switched to FOLFIRINOX (n = 27) had a 1-year survival rate of 48.1% (95% CI 28.7-68.1), a median OS of 10.9 months, a median PFS of 6.6 months and an ORR of 33.3%. Rash-negative patients had a lower quality of life at baseline but seemed to experience an improved control of pain during FOLFIRINOX.

CONCLUSIONS

First-line treatment with gem/erlotinib was effective in fit, rash-positive mPDAC patients achieving a 1-year survival rate comparable to previous reports for FOLFIRINOX. The study was registered at clinicaltrials.gov (NCT0172948) and Eudra-CT (2011-005471-17).

Impact of a mental health clinical pharmacist on a primary care mental health integration team

Introduction

Primary care mental health integration (PCMHI) teams function to improve access and quality of integrative physical and mental health (MH) care through a stepped care treatment approach. The project's primary objective was to evaluate the impact a PCMHI clinical pharmacist made on treatment outcomes and interventions. The secondary objective was to assess medication adherence rates.

Methods

An electronic medical record was used to identify PCMHI patient referrals for medication management during an 8-month period. Patients were included if they were at least 18 years old and referred for medication management of depression, anxiety, posttraumatic stress disorder, or alcohol use disorder. The scores for the Patient Health Questionnaire (PHQ-9), the Generalized Anxiety Disorder Questionnaire (GAD-7), and the Posttraumatic Stress Disorder Checklist (PCL-C) were recorded at baseline and weeks 4, 8, and 12 during treatment.

Results

The analysis included 50 patients, which resulted in a total of 156 contacts between July 2014 and March 2015. The mean change in PHQ-9, GAD-7, and PCL-C scores at week 12 as compared to baseline were a decrease of 10 (95% confidence interval [CI], 6.2-13.8, P < .001), 8 (95% CI, 3.1-12.9, P = .006), and 14.5 (95% CI, -17.3-46.3, P = .109), respectively. A total of 336 treatment interventions were made, and the overall medication adherence rate was 82.9%.

Discussion

Medication management, provided by a clinical pharmacist, was associated with a statistically and clinically significant improvement on several MH disorder rating scale scores.

Overcoming barriers to monitoring patients taking second-generation antipsychotics

INTRODUCTION

Patients taking second-generation antipsychotics (SGAs) are at increased risk of developing metabolic syndrome because of the side effect profiles of these medications. A medication use evaluation (MUE) was conducted and showed that baseline monitoring rates of metabolic parameters in patients taking SGAs are low. A pharmacist-run metabolic syndrome monitoring clinic (MSMC) is available to mental health (MH) outpatients; however, the clinic is underused by providers. The purpose of this project was to increase baseline metabolic syndrome monitoring rates in patients taking SGAs by implementing interventions to overcome barriers to monitoring and to accessing the MSMC.

METHODS

Appropriate tools to improve monitoring were obtained, and an electronic consult for the MSMC was created. A presentation and pamphlet were developed to improve awareness. Information about free patient transportation was obtained and distributed. Efficacy was assessed by evaluating patient referrals to the clinic before and after intervention, comparing baseline monitoring rates after implementation with the MUE data, and administering an anonymous survey to outpatient MH providers.

RESULTS

There was a 37.5% increase in overall referral rates to the MSMC after intervention, but only 51.5% of patients attended appointments as scheduled. Monitoring of vital signs increased, but monitoring of laboratory parameters decreased. A total of 60% (9 of 15) of providers completed a survey, of which one third indicated they still forget to refer patients to the MSMC.

DISCUSSION

Overall, baseline metabolic monitoring rates remained low despite implementing several interventions. Patient and provider outreach is crucial for initiating and maintaining a successful metabolic monitoring system for patients taking SGAs.

The Banff 2017 Kidney Meeting Report: Revised diagnostic criteria for chronic active T cell-mediated rejection, antibody-mediated rejection, and prospects for integrative endpoints for next-generation clinical trials

The kidney sessions of the 2017 Banff Conference focused on 2 areas: clinical implications of inflammation in areas of interstitial fibrosis and tubular atrophy (i-IFTA) and its relationship to T cell-mediated rejection (TCMR), and the continued evolution of molecular diagnostics, particularly in the diagnosis of antibody-mediated rejection (ABMR). In confirmation of previous studies, it was independently demonstrated by 2 groups that i-IFTA is associated with reduced graft survival. Furthermore, these groups presented that i-IFTA, particularly when involving >25% of sclerotic cortex in association with tubulitis, is often a sequela of acute TCMR in association with underimmunosuppression. The classification was thus revised to include moderate i-IFTA plus moderate or severe tubulitis as diagnostic of chronic active TCMR. Other studies demonstrated that certain molecular classifiers improve diagnosis of ABMR beyond what is possible with histology, C4d, and detection of donor-specific antibodies (DSAs) and that both C4d and validated molecular assays can serve as potential alternatives and/or complements to DSAs in the diagnosis of ABMR. The Banff ABMR criteria are thus updated to include these alternatives. Finally, the present report paves the way for the Banff scheme to be part of an integrative approach for defining surrogate endpoints in next-generation clinical trials.

Assessment of Tocilizumab (Anti-Interleukin-6 Receptor Monoclonal) as a Potential Treatment for Chronic Antibody-Mediated Rejection and Transplant Glomerulopathy in HLA-Sensitized Renal Allograft Recipients

Extending the functional integrity of renal allografts is the primary goal of transplant medicine. The development of donor-specific antibodies (DSAs) posttransplantation leads to chronic active antibody-mediated rejection (cAMR) and transplant glomerulopathy (TG), resulting in the majority of graft losses that occur in the United States. This reduces the quality and length of life for patients and increases cost. There are no approved treatments for cAMR. Evidence suggests the proinflammatory cytokine interleukin 6 (IL-6) may play an important role in DSA generation and cAMR. We identified 36 renal transplant patients with cAMR plus DSAs and TG who failed standard of care treatment with IVIg plus rituximab with or without plasma exchange. Patients were offered rescue therapy with the anti-IL-6 receptor monoclonal tocilizumab with monthly infusions and monitored for DSAs and long-term outcomes. Tocilizumab-treated patients demonstrated graft survival and patient survival rates of 80% and 91% at 6 years, respectively. Significant reductions in DSAs and stabilization of renal function were seen at 2 years. No significant adverse events or severe adverse events were seen. Tocilizumab provides good long-term outcomes for patients with cAMR and TG, especially compared with historical published treatments. Inhibition of the IL-6-IL-6 receptor pathway may represent a novel approach to stabilize allograft function and extend patient lives.

The Banff 2015 Kidney Meeting Report: Current Challenges in Rejection Classification and Prospects for Adopting Molecular Pathology

The XIII Banff meeting, held in conjunction the Canadian Society of Transplantation in Vancouver, Canada, reviewed the clinical impact of updates of C4d-negative antibody-mediated rejection (ABMR) from the 2013 meeting, reports from active Banff Working Groups, the relationships of donor-specific antibody tests (anti-HLA and non-HLA) with transplant histopathology, and questions of molecular transplant diagnostics. The use of transcriptome gene sets, their resultant diagnostic classifiers, or common key genes to supplement the diagnosis and classification of rejection requires further consensus agreement and validation in biopsies. Newly introduced concepts include the i-IFTA score, comprising inflammation within areas of fibrosis and atrophy and acceptance of transplant arteriolopathy within the descriptions of chronic active T cell-mediated rejection (TCMR) or chronic ABMR. The pattern of mixed TCMR and ABMR was increasingly recognized. This report also includes improved definitions of TCMR and ABMR in pancreas transplants with specification of vascular lesions and prospects for defining a vascularized composite allograft rejection classification. The goal of the Banff process is ongoing integration of advances in histologic, serologic, and molecular diagnostic techniques to produce a consensus-based reporting system that offers precise composite scores, accurate routine diagnostics, and applicability to next-generation clinical trials.

Banff Histopathological Consensus Criteria for Preimplantation Kidney Biopsies

The Banff working group on preimplantation biopsy was established to develop consensus criteria (best practice guidelines) for the interpretation of preimplantation kidney biopsies. Digitally scanned slides were used (i) to evaluate interobserver variability of histopathologic findings, comparing frozen sections with formalin-fixed, paraffin-embedded tissue of wedge and needle core biopsies, and (ii) to correlate consensus histopathologic findings with graft outcome in a cohort of biopsies from international medical centers. Intraclass correlations (ICCs) and univariable and multivariable statistical analyses were performed. Good to fair reproducibility was observed in semiquantitative scores for percentage of glomerulosclerosis, arterial intimal fibrosis and interstitial fibrosis on frozen wedge biopsies. Evaluation of frozen wedge and core biopsies was comparable for number of glomeruli, but needle biopsies showed worse ICCs for glomerulosclerosis, interstitial fibrosis and tubular atrophy. A consensus evaluation form is provided to help standardize the reporting of histopathologic lesions in donor biopsies. It should be recognized that histologic parameters may not correlate with graft outcome in studies based on organs deemed to be acceptable after careful clinical assessment. Significant limitations remain in the assessment of implantation biopsies.

The XIIIth Banff Conference on Allograft Pathology: The Banff 2015 Heart Meeting Report: Improving Antibody-Mediated Rejection Diagnostics: Strengths, Unmet Needs, and Future Directions

The 13th Banff Conference on Allograft Pathology was held in Vancouver, British Columbia, Canada from October 5 to 10, 2015. The cardiac session was devoted to current diagnostic issues in heart transplantation with a focus on antibody-mediated rejection (AMR) and small vessel arteriopathy. Specific topics included the strengths and limitations of the current rejection grading system, the central role of microvascular injury in AMR and approaches to semiquantitative assessment of histopathologic and immunophenotypic indicators, the role of AMR in the development of cardiac allograft vasculopathy, the important role of serologic antibody detection in the management of transplant recipients, and the potential application of new molecular approaches to the elucidation of the pathophysiology of AMR and potential for improving the current diagnostic system. Herein we summarize the key points from the presentations, the comprehensive, open and wide-ranging multidisciplinary discussion that was generated, and considerations for future endeavors.

Mapping quantitative trait loci conferring resistance to a widely virulent isolate of Cochliobolus sativus in wild barley accession PI 466423

This research characterized the genetics of resistance of wild barley accession PI 466423 to a widely virulent pathotype of Cochliobolus sativus . Breeding lines were identified that combine the Midwest Six-rowed Durable Resistance Haplotype and resistance to the virulent isolate ND4008. Spot blotch, caused by Cochliobolus sativus, is a historically important foliar disease of barley (Hordeum vulgare L.) in the Upper Midwest region of the USA. However, for the last 50 years this disease has been of little consequence due to the deployment of resistant six-rowed malting cultivars. These durably resistant cultivars carry the Midwest Six-rowed Durable Resistant Haplotype (MSDRH) comprised of three Quantitative Trait Loci (QTL) on chromosomes 1H, 3H and 7H, originally contributed by breeding line NDB112. Recent reports of C. sativus isolates (e.g. ND4008) with virulence on NDB112 indicate that widely grown cultivars of the region are vulnerable to spot blotch epidemics. Wild barley (H. vulgare ssp. spontaneum), the progenitor of cultivated barley, is a rich source of novel alleles, especially for disease resistance. Wild barley accession PI 466423 is highly resistant to C. sativus isolate ND4008. To determine the genetic architecture of resistance to isolate ND4008 in PI 466423, we phenotyped and genotyped an advanced backcross population (N = 244) derived from the wild accession and the recurrent parent 'Rasmusson', a Minnesota cultivar with the MSDRH. Disease phenotyping was done on BC2F4 seedlings in the greenhouse using isolate ND4008. The Rasmusson/PI 466423 population was genotyped with 7842 single nucleotide polymorphic markers. QTL analysis using composite interval mapping revealed four resistance loci on chromosomes 1H, 2H, 4H and 5H explaining 10.3, 7.4, 6.4 and 8.4 % of the variance, respectively. Resistance alleles on chromosomes 1H, 4H and 5H were contributed by PI 466423, whereas the one on chromosome 2H was contributed by Rasmusson. All four resistance QTL are likely coincident with previously identified QTL. Agronomically advanced two- and six-rowed lines combining the MSDRH and resistance alleles to isolate ND4008 have been identified and are being utilized in breeding. These results reaffirm the value of using wild relatives as a source of novel resistance alleles.

[Implications of PI-RADS Version 1 and Updated Version 2 on the Scoring of Prostatic Lesions in Multiparametric MRI]

BACKGROUND

A revised version of the PI-RADS scoring system has been introduced and score-related variability between version 1 and 2 may be suspected. This study aimed to assess the PI-RADS scores derived from version 1 (v1) and the updated version 2 (v2).

MATERIAL AND METHODS

61 patients with biopsy-proven prostate cancer (PCa) and 90 lesions detected on pre-biopsy 3-Tesla multiparametric MRI were included in this retrospective analysis. 2 experienced radiologists scored all lesions in consensus. Lesion scores differing between PI-RADS v1 and v2 were further analyzed. Histology data from radical prostatectomy (RP) were included when available.

RESULTS

The PI-RADS v1 and v2 score differed in 52% of patients (32/61) and in 39% of lesions (35/90). On a lesion basis, the reason for the differences were related to sum score in v1 vs. categorical system in v2 in 51% (18/35) of lesions, cutoff between PI-RADS 4 and 5 based on lesion size in v2 as opposed to the sum score in v1 in 31% (11/35) and were inconclusive in 17% (6/35). The RP subgroup indicates enhanced detection of PCas with GS 3+3 and GS 3+4 in v2.

CONCLUSION

PI-RADS scores of prostatic lesions frequently differed between v1 and v2, the major reasons for these differences being score-related. In men undergoing RP, PI-RADS v2 improved detection of low risk PCa, but did not increase accuracy for discrimination of GS 3+4 vs. GS≥4+3 compared to v1. Urologists should be aware of the system-related differences when interpreting PI-RADS scores.