Inability in Delirium to Name the Physician's Vocation on Command, with Retention of the Ability to Name it Spontaneously: An Illustration of Hughlings Jackson's Law of “Reduction to a More Automatic Condition”

In talking to delirious patients I have observed a curious and characteristic phenomenon: the patient, in spontaneous conversation, addresses me as “Doctor”, yet when the very next moment I ask him my vocation he cannot answer correctly. I propose to show that this is not merely a capricious phenomenon without meaning, but that it demonstrates the soundness of one of Hughlings Jackson's most important principles. I have observed the phenomenon in no less than nine cases of delirium, and more than once in several. Three cases will serve as examples.

Delirious Disorientation: The Law of the Unfamiliar Mistaken for the Familiar

Psychiatry made a great advance when it began to recognize the psychological meaning of mental symptoms—when it took the stand that it is not enough to establish that a patient has, say, delusions, but that one must relate the content of the delusions to the patient's life experience. Another stride has yet to be made, and that is the recognition of the physiological meaning of symptoms. Mental activity being the manifestation of cerebral activity, mental aberration must signify some aberration in the function of the brain, however normal this organ may appear to the eye. In a case of mental disorder, therefore, just as much as in hemiplegia, one must inquire how the laws of physiology reveal themselves in the signs and symptoms of the disease. To return to the example, it is not enough to show that the content of a delusion represents the patient's thoughts and strivings, but there remains the question: What has happened to his brain to cause his thoughts and strivings to assume the guise of delusions, when in a normal man they merely take the form of fancies? When a deluded patient says he is a very rich man, a certain psychological cause is at work. A healthy man, too, may be worried about money, but, in response to this cause, he merely fancies himself a rich man. The demonstration of a psychological cause, therefore, does not explain the sick man's delusion. All it explains is the content of the delusion; since the patient is worried about money, his delusion deals with wealth rather than some other topic. But it does not explain why the patient has delusions. The explanation of this must lie in some cerebral defect which permits inferior modes of thought to occur in response to certain situations. Psychiatry will not reach its full stature as a science until it regards each mentally sick person and each of his symptoms as a problem in cerebral physiology.

Zoonotic helminth exposure and risk of allergic diseases: A study of two generations in Norway

BACKGROUND

Animal and human studies indicate that definitive host helminth infections may confer protection from allergies. However, zoonotic helminths, such as Toxocara species (spp.), have been associated with increased allergies.

OBJECTIVE

We describe the prevalence of Toxocara spp. and Ascaris spp. seropositivity and associations with allergic diseases and sensitization, in 2 generations in Bergen, Norway.

METHODS

Serum levels of total IgG4, anti-Toxocara spp. IgG4 and Ascaris spp. IgG4 were established by ELISA in 2 cohorts: parents born 1945-1972 (n = 171) and their offspring born 1969-2003 (n = 264). Allergic outcomes and covariates were recorded through interviews and clinical examinations including serum IgEs and skin prick tests.

RESULTS

Anti-Ascaris spp. IgG4 was detected in 29.2% of parents and 10.3% of offspring, and anti-Toxocara spp. IgG4 in 17.5% and 8.0% of parents and offspring, respectively. Among offspring, anti-Toxocara spp. IgG4 was associated with pet keeping before age 15 (OR = 6.15; 95% CI = 1.37-27.5) and increasing BMI (1.16[1.06-1.25] per kg/m² ). Toxocara spp. seropositivity was associated with wheeze (2.97[1.45- 7.76]), hayfever (4.03[1.63-9.95]), eczema (2.89[1.08-7.76]) and cat sensitization (5.65[1.92-16.6]) among offspring, but was not associated with allergic outcomes among parents. Adjustment for childhood or current pet keeping did not alter associations with allergies. Parental Toxocara spp. seropositivity was associated with increased offspring allergies following a sex-specific pattern.

CONCLUSIONS & CLINICAL RELEVANCE

Zoonotic helminth exposure in Norway was less frequent in offspring than parents; however, Toxocara spp. seropositivity was associated with increased risk of allergic manifestations in the offspring generation, but not among parents. Changes in response to helminth exposure may provide insights into the increase in allergy incidence in affluent countries.

Tissue Factor Pathway Inhibitor (TFPI) Levels in the Plasma and Urine of Children with Meningococcal Disease

Tissue factor pathway inhibitor (TFPI) is a potent inhibitor of the TF-dependent coagulation system. In meningococcal disease, up-regulation of tissue factor expression on blood monocytes and possibly on endothelial cells has the potential to trigger the activation of the TF-dependent pathway of coagulation. Intravascular coagulation is considered to be a major pathogenic factor in meningococcal disease. We postulated that imbalance between TF expression and TFPI concentration might lead to uncontrolled coagulation in meningococcal disease. The aim of this study was to assess the levels of total TFPI in the plasma of patients with meningococcal disease and assess whether increased leaking of the TFPI was occurring. TFPI antigen levels and activity were measured in the plasma of 54 patients with meningococcal disease, and 13 healthy control children. TFPI antigen level were also determined in the urines of 14 of the 54 and 9 healthy control children. Plasma TFPI activity was reduced in the meningococcal diseased patients (mean of 0.503 ± 0.341 U/ml; control, 1.010 ± 0.199 U/ml; p <0.0001), as was the TFPI antigen levels (mean of 54.85 ± 35.05 ng/ ml; Control, 94.51 ± 11.44 ng/ml; p <0.0001). In contrast, TFPI antigen levels were increased in the urine of these patients when compared to the levels found in the urine of the healthy control children (mean of 12.96 ± 5.392 ng/mmol creatinine; Control, 0.239 ± 0.191 ng/mmol creatinine; p <0.035). A lack of correlation between TFPI-activity and TFPI-antigen plasma levels was observed (r = 0.002, p = 0.85). This data is consistent with the hypothesis that in meningococcal disease there is increased inactivation of plasma TFPI by the up regulation of tissue factor expression but in addition increased clearance of TFPI in urine is occurring.

Deficiency in perilipin 5 reduces mitochondrial function and membrane depolarization in mouse hearts

Myocardial triglycerides stored in lipid droplets are important in regulating the intracellular delivery of fatty acids for energy generation in mitochondria, for membrane biosynthesis, and as agonists for intracellular signaling. Previously, we showed that deficiency in the lipid droplet protein perilipin 5 (Plin5) markedly reduces triglyceride storage in cardiomyocytes and increases the flux of fatty acids into phospholipids. Here, we investigated whether Plin5 deficiency in cardiomyocytes alters mitochondrial function. We found that Plin5 deficiency reduced mitochondrial oxidative capacity. Furthermore, in mitochondria from Plin5^-/- hearts, the fatty acyl composition of phospholipids in mitochondrial membranes was altered and mitochondrial membrane depolarization was markedly compromised. These findings suggest that mitochondria isolated from hearts deficient in Plin5, have specific functional defects.

Depletion of ATP and glucose in advanced human atherosclerotic plaques

Objective

Severe hypoxia develops close to the necrotic core of advanced human atherosclerotic plaques, but the energy metabolic consequences of this hypoxia are not known. In animal models, plaque hypoxia is also associated with depletion of glucose and ATP. ATP depletion may impair healing of plaques and promote necrotic core expansion. To investigate if ATP depletion is present in human plaques, we analyzed the distribution of energy metabolites (ATP, glucose, glycogen and lactate) in intermediate and advanced human plaques.

Approach and results

Snap frozen carotid endarterectomies from 6 symptomatic patients were analyzed. Each endarterectomy included a large plaque ranging from the common carotid artery (CCA) to the internal carotid artery (ICA). ATP, glucose, and glycogen concentrations were lower in advanced (ICA) compared to intermediate plaques (CCA), whereas lactate concentrations were higher. The lowest concentrations of ATP, glucose and glycogen were detected in the perinecrotic zone of advanced plaques.

Conclusions

Our study demonstrates severe ATP depletion and glucose deficiency in the perinecrotic zone of human advanced atherosclerotic plaques. ATP depletion may impair healing of plaques and promote disease progression.

Metabolic effects of Lactobacillus reuteri DSM 17938 in people with type 2 diabetes: A randomized controlled trial

AIMS

To investigate the metabolic effects of 12-week oral supplementation with Lactobacillus reuteri DSM 17938 in patients with type 2 diabetes on insulin therapy.

MATERIALS AND METHODS

In a double-blind trial, we randomized 46 people with type 2 diabetes to placebo or a low (10⁸  CFU/d) or high dose (10¹⁰  CFU/d) of L. reuteri DSM 17938 for 12 weeks. The primary endpoint was the effect of supplementation on glycated haemoglobin (HbA1c). Secondary endpoints were insulin sensitivity (assessed by glucose clamp), liver fat content, body composition, body fat distribution, faecal microbiota composition and serum bile acids.

RESULTS

Supplementation with L. reuteri DSM 17938 for 12 weeks did not affect HbA1c, liver steatosis, adiposity or microbiota composition. Participants who received the highest dose of L. reuteri exhibited increases in insulin sensitivity index (ISI) and serum levels of the secondary bile acid deoxycholic acid (DCA) compared with baseline, but these differences were not significant in the between-group analyses. Post hoc analysis showed that participants who responded with increased ISI after L. reuteri supplementation had higher microbial diversity at baseline, and increased serum levels of DCA after supplementation. In addition, increases in DCA levels correlated with improvement in insulin sensitivity in the probiotic recipients.

CONCLUSIONS

Intake of L. reuteri DSM 17938 for 12 weeks did not affect HbA1c in people with type 2 diabetes on insulin therapy; however, L. reuteri improved insulin sensitivity in a subset of participants and we propose that high diversity of the gut microbiota at baseline may be important.

Stable Transmission of Borrelia burgdorferi Sensu Stricto on the Outer Banks of North Carolina

The spirochaete (Borrelia burgdorferi) associated with Lyme disease was detected in questing ticks and rodents during a period of 18 years, 1991-2009, at five locations on the Outer Banks of North Carolina. The black-legged tick (Ixodes scapularis) was collected at varied intervals between 1991 and 2009 and examined for B. burgdorferi. The white-footed mouse (Peromyscus leucopus), house mouse (Mus musculus) marsh rice rat (Oryzomys palustris), marsh rabbit (Sylvilagus palustris), eastern cottontail (Sylvilagus floridanus) and six-lined racerunner (Cnemidophorus sexlineatus) were live-trapped, and their tissues cultured to isolate spirochaetes. Borrelia burgdorferi isolates were obtained from questing adult I. scapularis and engorged I. scapularis removed from P. leucopus, O. palustris and S. floridanus. The prevalence of B. burgdorferi infection was variable at different times and sites ranging from 7 to 14% of examined questing I. scapularis. Mitochondrial (16S) rRNA gene phylogenetic analysis from 65 adult I. scapularis identified 12 haplotypes in two major clades. Nine haplotypes were associated with northern/Midwestern I. scapularis populations and three with southern I. scapularis populations. Sixteen isolates obtained from tick hosts in 2005 were confirmed to be B. burgdorferi by amplifying and sequencing of 16S rRNA and 5S-23S intergenic spacer fragments. The sequences had 98-99% identity to B. burgdorferi sensu stricto strains B31, JD1 and M11p. Taken together, these studies indicate that B. burgdorferi sensu stricto is endemic in questing I. scapularis and mammalian tick hosts on the Outer Banks of North Carolina.

A nucleic acid strand displacement system for the multiplexed detection of tuberculosis-specific mRNA using quantum dots

The development of rapid, robust and high performance point-of-care diagnostics relies on the advancement and combination of various areas of research. We have developed an assay for the detection of multiple mRNA molecules that combines DNA nanotechnology with fluorescent nanomaterials. The core switching mechanism is toehold-mediated strand displacement. We have used fluorescent quantum dots (QDs) as signal transducers in this assay, as they bring many benefits including bright fluorescence and multiplexing abilities. The resulting assay is capable of multiplexed detection of long RNA targets against a high concentration of background non-target RNA, with high sensitivity and specificity and limits of detection in the nanomolar range using only a standard laboratory plate reader. We demonstrate the utility of our QD-based system for the detection of two genes selected from a microarray-derived tuberculosis-specific gene expression signature. Levels of up- and downregulated gene transcripts comprising this signature can be combined to give a disease risk score, making the signature more amenable for use as a diagnostic marker. Our QD-based approach to detect these transcripts could pave the way for novel diagnostic assays for tuberculosis.

Re-membering the body: applications of computational neuroscience to the top-down control of regeneration of limbs and other complex organs

A major goal of regenerative medicine and bioengineering is the regeneration of complex organs, such as limbs, and the capability to create artificial constructs (so-called biobots) with defined morphologies and robust self-repair capabilities. Developmental biology presents remarkable examples of systems that self-assemble and regenerate complex structures toward their correct shape despite significant perturbations. A fundamental challenge is to translate progress in molecular genetics into control of large-scale organismal anatomy, and the field is still searching for an appropriate theoretical paradigm for facilitating control of pattern homeostasis. However, computational neuroscience provides many examples in which cell networks - brains - store memories (e.g., of geometric configurations, rules, and patterns) and coordinate their activity towards proximal and distant goals. In this Perspective, we propose that programming large-scale morphogenesis requires exploiting the information processing by which cellular structures work toward specific shapes. In non-neural cells, as in the brain, bioelectric signaling implements information processing, decision-making, and memory in regulating pattern and its remodeling. Thus, approaches used in computational neuroscience to understand goal-seeking neural systems offer a toolbox of techniques to model and control regenerative pattern formation. Here, we review recent data on developmental bioelectricity as a regulator of patterning, and propose that target morphology could be encoded within tissues as a kind of memory, using the same molecular mechanisms and algorithms so successfully exploited by the brain. We highlight the next steps of an unconventional research program, which may allow top-down control of growth and form for numerous applications in regenerative medicine and synthetic bioengineering.

A conceptual model of morphogenesis and regeneration

This paper is devoted to computer modelling of the development and regeneration of multicellular biological structures. Some species (e.g. planaria and salamanders) are able to regenerate parts of their body after amputation damage, but the global rules governing cooperative cell behaviour during morphogenesis are not known. Here, we consider a simplified model organism, which consists of tissues formed around special cells that can be interpreted as stem cells. We assume that stem cells communicate with each other by a set of signals, and that the values of these signals depend on the distance between cells. Thus the signal distribution characterizes location of stem cells. If the signal distribution is changed, then the difference between the initial and the current signal distribution affects the behaviour of stem cells-e.g. as a result of an amputation of a part of tissue the signal distribution changes which stimulates stem cells to migrate to new locations, appropriate for regeneration of the proper pattern. Moreover, as stem cells divide and form tissues around them, they control the form and the size of regenerating tissues. This two-level organization of the model organism, with global regulation of stem cells and local regulation of tissues, allows its reproducible development and regeneration.

Cardiovascular status after Kawasaki disease in the UK

OBJECTIVE

Kawasaki disease (KD) is an acute vasculitis that causes coronary artery aneurysms (CAA) in young children. Previous studies have emphasised poor long-term outcomes for those with severe CAA. Little is known about the fate of those without CAA or patients with regressed CAA. We aimed to study long-term cardiovascular status after KD by examining the relationship between coronary artery (CA) status, endothelial injury, systemic inflammatory markers, cardiovascular risk factors (CRF), pulse-wave velocity (PWV) and carotid intima media thickness (cIMT) after KD.

METHODS

Circulating endothelial cells (CECs), endothelial microparticles (EMPs), soluble cell-adhesion molecules cytokines, CRF, PWV and cIMT were compared between patients with KD and healthy controls (HC). CA status of the patients with KD was classified as CAA present (CAA+) or absent (CAA-) according to their worst-ever CA status. Data are median (range).

RESULTS

Ninety-two KD subjects were studied, aged 11.9 years (4.3-32.2), 8.3 years (1.0-30.7) from KD diagnosis. 54 (59%) were CAA-, and 38 (41%) were CAA+. There were 51 demographically similar HC. Patients with KD had higher CECs than HC (p=0.00003), most evident in the CAA+ group (p=0.00009), but also higher in the CAA- group than HC (p=0.0010). Patients with persistent CAA had the highest CECs, but even those with regressed CAA had higher CECs than HC (p=0.011). CD105 EMPs were also higher in the KD group versus HC (p=0.04), particularly in the CAA+ group (p=0.02), with similar findings for soluble vascular cell adhesion molecule 1 and soluble intercellular adhesion molecule 1. There was no difference in PWV, cIMT, CRF or in markers of systemic inflammation in the patients with KD (CAA+ or CAA-) compared with HC.

CONCLUSIONS

Markers of endothelial injury persist for years after KD, including in a subset of patients without CAA.

Multiple independent IgE epitopes on the highly allergenic grass pollen allergen Phl p 5

Background

Group 5 allergens are small proteins that consist of two domains. They belong to the most potent respiratory allergens.

Objective

To determine the binding sites and to study allergic patients' IgE recognition of the group 5 allergen (Phl p 5) from timothy grass pollen using human monoclonal IgE antibodies that have been isolated from grass pollen allergic patients.

Methods

Using recombinant isoallergens, fragments, mutants and synthetic peptides of Phl p 5, as well as peptide-specific antibodies, the interaction of recombinant human monoclonal IgE and Phl p 5 was studied using direct binding and blocking assays. Cross-reactivity of monoclonal IgE with group 5 allergens in several grasses was studied and inhibition experiments with patients' polyclonal IgE were performed.

Results

Monoclonal human IgE showed extensive cross-reactivity with group 5 allergens in several grasses. Despite its small size of 29 kDa, four independent epitope clusters on isoallergen Phl p 5.0101, two in each domain, were recognized by human IgE. Isoallergen Phl p 5.0201 carried two of these epitopes. Inhibition studies with allergic patients' polyclonal IgE suggest the presence of additional IgE epitopes on Phl p 5.

Conclusions & Clinical Relevance

Our results reveal the presence of a large number of independent IgE epitopes on the Phl p 5 allergen explaining the high allergenic activity of this protein and its ability to induce severe allergic symptoms. High-density IgE recognition may be a general feature of many potent allergens and form a basis for the development of improved diagnostic and therapeutic procedures in allergic disease.

Imaging of Intracellular and Extracellular ROS Levels in Atherosclerotic Mouse Aortas Ex Vivo: Effects of Lipid Lowering by Diet or Atorvastatin

Objective

The first objective was to investigate if intracellular and extracellular levels of reactive oxygen species (ROS) within the mouse aorta increase before or after diet-induced lesion formation. The second objective was to investigate if intracellular and extracellular ROS correlates to cell composition in atherosclerotic lesions. The third objective was to investigate if intracellular and extracellular ROS levels within established atherosclerotic lesions can be reduced by lipid lowering by diet or atorvastatin.

Approach and Results

To address our objectives, we established a new imaging technique to visualize and quantify intracellular and extracellular ROS levels within intact mouse aortas ex vivo. Using this technique, we found that intracellular, but not extracellular, ROS levels increased prior to lesion formation in mouse aortas. Both intracellular and extracellular ROS levels were increased in advanced lesions. Intracellular ROS correlated with lesion content of macrophages. Extracellular ROS correlated with lesion content of smooth muscle cells. The high levels of ROS in advanced lesions were reduced by 5 days high dose atorvastatin treatment but not by lipid lowering by diet. Atorvastatin treatment did not affect lesion inflammation (aortic arch mRNA levels of CXCL 1, ICAM-1, MCP-1, TNF-α, VCAM, IL-6, and IL-1β) or cellular composition (smooth muscle cell, macrophage, and T-cell content).

Conclusions

Aortic levels of intracellular ROS increase prior to lesion formation and may be important in initiation of atherosclerosis. Our results suggest that within lesions, macrophages produce mainly intracellular ROS whereas smooth muscle cells produce extracellular ROS. Short term atorvastatin treatment, but not lipid lowering by diet, decreases ROS levels within established advanced lesions; this may help explain the lesion stabilizing and anti-inflammatory effects of long term statin treatment.

Testing the near field/far field model performance for prediction of particulate matter emissions in a paint factory

A Near Field/Far Field (NF/FF) model is a well-accepted tool for precautionary exposure assessment but its capability to estimate particulate matter (PM) concentrations is not well studied. The main concern is related to emission source characterization which is not as well defined for PM emitters compared to e.g. for solvents. One way to characterize PM emission source strength is by using the material dustiness index which is scaled to correspond to industrial use by using modifying factors, such as handling energy factors. In this study we investigate how well the NF/FF model predicts PM concentration levels in a paint factory. PM concentration levels were measured during big bag and small bag powder pouring. Rotating drum dustiness indices were determined for the specific powders used and applied in the NF/FF model to predict mass concentrations. Modeled process specific concentration levels were adjusted to be similar to the measured concentration levels by adjusting the handling energy factor. The handling energy factors were found to vary considerably depending on the material and process even-though they have the same values as modifying factors in the exposure models. This suggests that the PM source characteristics and process-specific handling energies should be studied in more detail to improve the model-based exposure assessment.

Human IgE against the major allergen Bet v 1--defining an epitope with limited cross-reactivity between different PR-10 family proteins

Background

The interaction between IgE and allergen is a key event at the initiation of an allergic response, and its characteristics have substantial effects on the clinical manifestation. Despite this, the molecular details of the interaction between human IgE and the major birch allergen Bet v 1, one of the most potent tree allergens, still remain poorly investigated.

Objective

To isolate Bet v 1-specific human monoclonal IgE and characterize their interaction with the allergen.

Methods

Recombinant human IgE were isolated from a combinatorial antibody fragment library and their interaction with Bet v 1 assessed using various immunological assays. The structure of one such IgE in the single-chain fragment variable format was determined using X-ray crystallography.

Results

We present four novel Bet v 1-specific IgE, for one of which we solve the structure, all with their genetic origin in the IGHV5 germline gene, and demonstrate that they target two non-overlapping epitopes on the surface of Bet v 1, thereby fulfilling the basic criteria for FcεRI cross-linkage. We further define these epitopes and for one epitope pinpoint single amino acid residues important for the interaction with human IgE. This provides a potential explanation, at the molecular level, for the differences in recognition of isoforms of Bet v 1 and other allergens in the PR-10 protein family displayed by IgE targeting this epitope. Finally, we present the first high-resolution structure of a human allergen-specific IgE fragment in the single-chain fragment variable (scFv) format.

Conclusions and Clinical Relevance

We here display the usefulness of allergen-specific human monoclonal IgE as a tool in studies of the crucial molecular interaction taking place at the initiation of an allergic response. Such studies may aid us in development of better diagnostic tools and guide us in the development of new therapeutic compounds.

Pulmonary toxicity following exposure to a tile coating product containing alkylsiloxanes. A clinical and toxicological evaluation

CONTEXT

Coating products are widely used for making surfaces water and dirt repellent. However, on several occasions the use of these products has been associated with lung toxicity.

OBJECTIVE

In the present study, we evaluated the toxic effects of an aerosolized tile-coating product.

METHODS

Thirty-nine persons, who reported respiratory and systemic symptoms following exposure to the tile-coating product, were clinically examined. The product was analysed chemically and furthermore, the exposure scenario was reconstructed using a climate chamber and the toxicological properties of the product were studied using in vivo and by in vitro surfactometry.

RESULTS

The symptoms developed within few hours and included coughing, tachypnoea, chest pain, general malaise and fever. The physical examination revealed perihilar lung infiltrates on chest radiograph and reduced blood oxygen saturation. The acute symptoms resolved gradually within 1-3 days and no delayed symptoms were observed. By means of mass spectrometry and X-ray spectroscopy, it was shown that the product contained non-fluorinated alkylsiloxanes. The exposure conditions in the supermarket were reconstructed under controlled conditions in a climate chamber and particle and gas exposure levels were monitored over time allowing estimation of human exposure levels. Mice exposed to the product developed symptoms of acute pulmonary toxicity in a concentration-and time-dependent manner. The symptoms of acute pulmonary toxicity likely resulted from inhibition of the pulmonary surfactant function as demonstrated by in vitro surfactometry. Among these patients only a partial association between the level of exposure and the degree of respiratory symptoms was observed, which could be because of a high inter-individual difference in sensitivity and time-dependent changes in the chemical composition of the aerosol.

CONCLUSION

Workers need to cautiously apply surface coating products because the contents can be highly toxic through inhalation, and the aerosols can disperse to locations remote from the worksite and affect bystanders.

Management of Kawasaki disease

Kawasaki disease (KD) is an acute self-limiting inflammatory disorder, associated with vasculitis, affecting predominantly medium-sized arteries, particularly the coronary arteries. In developed countries KD is the commonest cause of acquired heart disease in childhood. The aetiology of KD remains unknown, and it is currently believed that one or more as yet unidentified infectious agents induce an intense inflammatory host response in genetically susceptible individuals. Genetic studies have identified several susceptibility genes for KD and its sequelae in different ethnic populations, including FCGR2A, CD40, ITPKC, FAM167A-BLK and CASP3, as well as genes influencing response to intravenous immunoglobulin (IVIG) and aneurysm formation such as FCGR3B, and transforming growth factor (TGF) β pathway genes. IVIG and aspirin are effective therapeutically, but recent clinical trials and meta-analyses have demonstrated that the addition of corticosteroids to IVIG is beneficial for the prevention of coronary artery aneurysms (CAA) in severe cases with highest risk of IVIG resistance. Outside of Japan, however, clinical scores to predict IVIG resistance perform suboptimally. Furthermore, the evidence base does not provide clear guidance on which corticosteroid regimen is most effective. Other therapies, including anti-TNFα, could also have a role for IVIG-resistant KD. Irrespective of these caveats, it is clear that therapy that reduces inflammation in acute KD, improves outcome. This paper summarises recent advances in the understanding of KD pathogenesis and therapeutics, and provides an approach for managing KD patients in the UK in the light of these advances.

Abstract P4-04-12: Identification of a common genotype in patients (pts) with HER2-positive, ER-negative, inflammatory breast cancer (IBC) that was primary-refractory to trastuzumab who have had 5+ years of disease control with lapatinib therapy

Background: HER2-amplified inflammatory breast cancer (IBC) that is primary-refractory to trastuzumab has a poor prognosis. The objective of this study was to describe the genotypes of the IBC obtained from 3 pts with high grade, ER-negative, HER2+ classical IBC, primary-refractory to trastuzumab, with chest wall disease, who remain with no evidence of disease (NED) on lapatinib for 5+ years.

The 3 postmenopausal pts presented with locally advanced IBC, 2 with disease extending onto the chest wall, and the third with chest wall recurrence while on adjuvant trastuzumab. Two pts were treated with preoperative trastuzumab with multiple chemotherapy agents with no response. They were then treated with preoperative lapatinib and had a clinical partial response. They underwent salvage mastectomy showing extensive residual disease, followed by chest wall/regional radiotherapy (RT), continuing on lapatinib. The third patient received preoperative AC followed by docetaxel and had extensive residual disease at mastectomy. She underwent chest wall/regional RT and then had chest wall recurrence while on adjuvant trastuzumab. She was treated with lapatinib and resection of residual chest wall disease. All 3 pts remain NED on 1250mg lapatinib daily. The 3 pts have a strong family history of breast cancer; two have known wild type germline BRCA1/2.

Methods: Following IRB-approved informed consent, targeted next generation DNA sequencing (NGS) was performed using HiSeq-2000 (Illumina) on pts’ FFPE primary IBC at a CLIA-certified laboratory, to characterize all classes of genomic alterations across 4,604 exons of 287 cancer-related genes. Phosphoprotein analysis was performed using a proprietary Reverse Phase Protein Microarray (RPMA) platform on pts's FFPE IBC to characterize the activity of the targets of anti-HER2 therapy, and their downstream pathways.

Results: In 2 pts’ IBCs NGS identified a common genotype with amplified ERBB2, mutant p53 and PIK3CA (c.3140A&gt;G_p.H1047R), homozygous deletions of both CDKN2A and CDKN2B, and truncated BRCA2 (1 pt) or PALB2 (1 pt). The third pt's FFPE residual disease from her mastectomy did not yield sufficient DNA from invasive tumor cells for sequencing and we plan to sequence DNA from her original diagnostic core biopsy. Phosphoprotein analysis of one pt's trastuzumab-refractory, lapatinib-naive IBC showed 3+ expression of HER1 (but not pHER1 Y1068 nor pHER2 Y1248), pAkt S473, pS6 ribosomal S235-236 protein (2+), p4E-BP1 S65 and Notch1. The second pt's lapatinib-treated IBC showed 3+ overexpression of only p4E-BP1 S65.

Conclusions: Pts with a common tumor phenotype who have highly durable responses with a targeted therapy may share a common tumor genotype. Two pts’ trastuzumab-refractory HER2+ IBCs that have been very durably responsive to lapatinib share p53, PIK3CA, p16 and BRCA2-related mutations, potentially enabling the prospective identification of trastuzumab-refractory IBC pts who may benefit substantially from lapatinib.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-04-12.

Kidney hypoxia, attributable to increased oxygen consumption, induces nephropathy independently of hyperglycemia and oxidative stress

Diabetic nephropathy is strongly associated with both increased oxidative stress and kidney tissue hypoxia. The increased oxidative stress causes increased kidney oxygen consumption resulting in kidney tissue hypoxia. To date, it has been difficult to determine the role of kidney hypoxia, per se, for the development of nephropathy. We tested the hypothesis that kidney hypoxia, without confounding factors such as hyperglycemia or elevated oxidative stress, results in nephropathy. To induce kidney hypoxia, dinitrophenol (30 mg per day per kg bodyweight by gavage), a mitochondrial uncoupler that increases oxygen consumption and causes kidney hypoxia, was administered for 30 consecutive days to rats. Thereafter, glomerular filtration rate, renal blood flow, kidney oxygen consumption, kidney oxygen tension, kidney concentrations of glucose and glycogen, markers of oxidative stress, urinary protein excretion, and histological findings were determined and compared with vehicle-treated controls. Dinitrophenol did not affect arterial blood pressure, renal blood flow, glomerular filtration rate, blood glucose, or markers of oxidative stress but increased kidney oxygen consumption, and reduced cortical and medullary concentrations of glucose and glycogen, and resulted in intrarenal tissue hypoxia. Furthermore, dinitrophenol treatment increased urinary protein excretion, kidney vimentin expression, and infiltration of inflammatory cells. In conclusion, increased mitochondrial oxygen consumption results in kidney hypoxia and subsequent nephropathy. Importantly, these results demonstrate that kidney tissue hypoxia, per se, without confounding hyperglycemia or oxidative stress, may be sufficient to initiate the development of nephropathy and therefore demonstrate a new interventional target for treating kidney disease.

Rabies prevention and management of cats in the context of trap-neuter-vaccinate-release programmes

Domestic cats are an important part of many Americans' lives, but effective control of the 60-100 million feral cats living throughout the country remains problematic. Although trap-neuter-vaccinate-return (TNVR) programmes are growing in popularity as alternatives to euthanizing feral cats, their ability to adequately address disease threats and population growth within managed cat colonies is dubious. Rabies transmission via feral cats is a particular concern as demonstrated by the significant proportion of rabies post-exposure prophylaxis associated with exposures involving cats. Moreover, TNVR has not been shown to reliably reduce feral cat colony populations because of low implementation rates, inconsistent maintenance and immigration of unsterilized cats into colonies. For these reasons, TNVR programmes are not effective methods for reducing public health concerns or for controlling feral cat populations. Instead, responsible pet ownership, universal rabies vaccination of pets and removal of strays remain integral components to control rabies and other diseases.

Ectopic lipid storage and insulin resistance: a harmful relationship

Obesity increases the risk of metabolic diseases, including insulin resistance and type 2 diabetes, as well as cardiovascular disease. In addition to lipid accumulation in adipose tissue, obesity is associated with increased lipid storage in ectopic tissues, such as skeletal muscle and liver. Furthermore, lipid accumulation in the heart may result in cardiac dysfunction and heart failure. It has recently been demonstrated that intracellular lipid accumulation in ectopic tissues leads to pathological responses and impaired insulin signalling. Here, we will review the current understanding of how lipid storage and lipid droplet physiology affect the risk of developing metabolic diseases.

Association of intraoperative blood pressure instability with adverse outcomes after liver transplantation

BACKGROUND

Blood pressure derangements are common in orthotopic liver transplantation (OLT), and are potentially associated with adverse outcomes if they are sustained. While this concept is often believed to be true, few have rigorously demonstrated the validity of this claim, especially in likely vulnerable OLT patients.

METHODS

We retrospectively investigated 827 patients who underwent OLT to determine the magnitude of these hemodynamic associations with adverse outcomes. The median value of the mean arterial pressure (MAP) and the fractional change in the median MAP between subsequent epochs (FCM) were calculated for every 5-minute epoch intraoperatively. Epochs were classified according to prespecified ranges of MAP and fractional changes in MAP (lability) between epochs. Multivariate stepwise logistic regression was used to model associations of risk factors and epochs of intraoperative blood pressure (BP) instability with primary (30-day mortality and/or graft failure) and secondary adverse outcomes.

RESULTS

Primary adverse outcomes occurred in 10.9% and 12.2% of patients for 30-day mortality and 30-day graft failure, respectively. Independent hemodynamic predictors for 30-day mortality and graft failure included sustained periods of MAP <50 mmHg and BP lability where the MAP changed >25%. All of these values were statistically significant.

CONCLUSION

Although severe intraoperative hypotension and BP lability during OLT are often observed in current practice as consequences of major surgical manipulations and patient vulnerability, these are likely not benign conditions based on this retrospective analysis. Prospective trials are warranted to investigate the possibility that interventions tailored to avoidance of hypotension and BP lability may improve outcomes.

Implementing the Affordable Care Act: choosing an essential health benefits benchmark plan

To improve the adequacy of private health insurance, the Affordable Care Act requires insurers to cover a minimum set of medical benefits, known as "essential health benefits." In implementing this requirement, states were asked to select a "benchmark plan" to serve as a reference point. This issue brief examines state action to select an essential health benefits benchmark plan and finds that 24 states and the District of Columbia selected a plan. All but five states will have a small-group plan as their benchmark. Each state, whether or not it made a benchmark selection, will have a set of essential health benefits that reflects local, employer-based health insurance coverage currently sold in the state. States adopted a variety of approaches to selecting a benchmark, including intergov­ernmental collaboration, stakeholder engagement, and research on benchmark options.

Increased expression of the very low-density lipoprotein receptor mediates lipid accumulation in clear-cell renal cell carcinoma

Clear-cell renal cell carcinoma (RCC) is, in most cases, caused by loss of function of the tumor suppressor gene von Hippel-Lindau, resulting in constitutive activation of hypoxia-inducible factor (HIF)-1α and expression of hypoxia-induced genes in normoxic conditions. Clear-cell RCC cells are characterized histologically by accumulation of cholesterol, mainly in its ester form. The origin of the increased cholesterol remains unclear, but it is likely explained by an HIF-1α-driven imbalance between cholesterol uptake and excretion. Here, we showed that expression of the very low-density lipoprotein receptor (VLDL-R) was significantly increased in clear-cell RCC human biopsies compared with normal kidney tissue. Partial knockdown of HIF-1α in clear-cell RCC cells significantly reduced the VLDL-R expression, and knockdown of either HIF-1α or VLDL-R reduced the increased lipid accumulation observed in these cells. We also showed increased uptake of fluorescently labeled lipoproteins in clear-cell RCC cells, which was significantly reduced by knockdown of HIF-1α or VLDL-R. Taken together, our results support the concept that the pathological increase of HIF-1α in clear-cell RCC cells upregulates VLDL-R, which mediates increased uptake and accumulation of lipids. These results explain the morphological characteristics of clear-cell RCC, and open up novel possibilities for detection and treatment of clear-cell RCC.

Computerized Determination of Adipocyte Size

OBJECTIVE

Fat cell size is a fundamental parameter in the study of adipose tissue metabolism, because it markedly influences the cellular rates of metabolism. Previous techniques for the sizing of adipocytes are often complicated or time-consuming. The aim of this study was to develop a new, computerized method for rapid and accurate determination of adipocyte size in a cell suspension obtained by incubating human or rat adipose tissue biopsies with collagenase.

RESEARCH METHODS AND PROCEDURES

The cell suspension was placed between a siliconized glass slide and a cover slip. Using the reference method [designated as (R)], the cell diameters were determined manually using a microscope with a calibrated ocular. The new method presented here [designated as (C)] was based on computerized image analysis.

RESULTS

After two well-defined corrective adjustments, measurements with (R) and (C) agreed very well. The small remaining differences seemed, in fact, to depend on inconsistencies in (R).

DISCUSSION

We propose that (C) constitutes a valuable tool to study fat cell size, because this method is fast and allows the assessment of a sufficient number of cells to get reliable data on size distribution. Furthermore, images of cell preparations may be stored for future reference.

Arachidonate 15-lipoxygenase type B knockdown leads to reduced lipid accumulation and inflammation in atherosclerosis

Inflammation in the vascular wall is important for development of atherosclerosis. We have shown previously that arachidonate 15-lipoxygenase type B (ALOX15B) is more highly expressed in human atherosclerotic lesions than in healthy arteries. This enzyme oxidizes fatty acids to substances that promote local inflammation and is expressed in lipid-loaded macrophages (foam cells) present in the atherosclerotic lesions. Here, we investigated the role of ALOX15B in foam cell formation in human primary macrophages and found that silencing of human ALOX15B decreased cellular lipid accumulation as well as proinflammatory cytokine secretion from macrophages. To investigate the role of ALOX15B in promoting the development of atherosclerosis in vivo, we used lentiviral shRNA silencing and bone marrow transplantation to knockdown mouse Alox15b gene expression in LDL-receptor-deficient (Ldlr(-/-)) mice. Knockdown of mouse Alox15b in vivo decreased plaque lipid content and markers of inflammation. In summary, we have shown that ALOX15B influences progression of atherosclerosis, indicating that this enzyme has an active proatherogenic role.

Bioluminescence imaging of energy depletion in vascular pathology: patent ductus arteriosus and atherosclerosis

The artery wall may develop energy depletion due to insufficient nutritional supply. However, until recently it has not been possible to validate this hypothesis because no available technology has allowed assessment of energy metabolism with sufficient spatial resolution. We use high resolution bioluminescence metabolic imaging to study energy metabolism in two mechanistically different vascular pathologies: patent ductus arteriosus and atherosclerosis. Physiological energy depletion in postnatally constricting ductus arteriosus promotes permanent closure. Insufficient ductus energy depletion, common in preterm infants, is associated with persistent patent ductus arteriosus, a condition with significantly increased morbidity and mortality. In contrast, in atherosclerosis, energy depletion in the macrophage-rich lesion core promotes cell death contributing to lesion instability and disease progression.