Rabies post-exposure prophylaxis in travellers returning from Bali, Indonesia, November 2008 to March 2010

Since 2008, when the outbreak of rabies in Bali began, 45 patients have attended GeoSentinel or EuroTravNet sites for rabies post-exposure prophylaxis (PEP), representing 12.6% of all travellers seen for PEP in all network clinics during the same time period. This suggests that Bali is emerging as a commonly visited destination among travellers presenting for rabies PEP. The data demonstrate that the majority of animal-related injuries in travellers returning from Bali are associated with exposure to monkeys, and not dog bites/scratches. The clinical implications of this are discussed.

Variability in Adequacy of Ventilation during Transport of Cardiac Surgery Patients: A Cohort Study

Inadequate ventilation of intubated patients during transport from the operating theatre to the intensive care unit with attendant hypercarbia may adversely affect haemodynamics. In a retrospective observational study, we assessed the incidence of inadequate ventilation during transport from the operating theatre to the intensive care unit in 99 consecutive cardiac surgery patients admitted to our university tertiary hospital.

Demographic, clinical, arterial blood gas and haemodynamic measurements were made on arrival in the intensive care unit after cardiac surgery. The relationships between arterial carbon dioxide tension (PaCO2), mean pulmonary artery pressure (MPAP) and other relevant haemodynamic variables were explored. Overall, hypocarbia (PaCO2<35 mmHg) occurred in 18.2% of patients, while 28.3% of patients had hypercarbia (PaCO2 >45 mmHg). Pulmonary hypertension was common, with nearly half of the cohort having MPAP ≥25 mmHg and 17.2% ≥30 mmHg. However, there was no association between PaCO2 and MPAP (R2=0.0076, P=0.39). Contrary to expectation, neither hypercarbia nor high MPAP were associated with measured adverse outcomes, although this may have been because we studied an insufficient number of patients with extreme values. Associations of higher MPAP, which would be expected to compromise cardiovascular status, included acidaemia, hypoxia and the requirement for noradrenaline. These factors define a group of high-risk patients who should receive particular attention and who should be the focus of future studies.

Review of studies of ADHD: Long-term outcomes with and without treatment

Introduction

As awareness of ADHD has increased worldwide, interest has grown beyond the constellation of ADHD symptoms, to include long-term impact on people's lives and society in general.

Objectives

Examine the results of studies of long-term life consequences of ADHD.

Aims

To identify areas of life affected long-term by ADHD and differences in outcomes with and without ADHD treatment.

Methods

Following Cochrane guidelines, 12 databases were searched for studies published in English (1980–2010). Limiting criteria maximized study inclusion while maintaining high study rigor: (1) peer-reviewed, (2) primary study reports, (3) including a comparator condition, and (4) reporting long-term outcomes (mean 8 years, range 6 months-40 years from study start for prospective studies; subjects in adolescence or adulthood for retrospective or cross-sectional studies). The fully-defined electronic search yielded 4615 citations. Manual review based on titles and abstracts yielded 340 studies included in this analysis of outcomes.

Results

The majority of studies (86%, 243 of 281; studies of untreated ADHD only) showed that untreated ADHD has substantial negative long-term outcomes, encompassing nine broad-ranging areas of life: non-medicinal drug use/addictive behaviour, antisocial behaviour, academic achievement, occupational achievement, public services use, self-esteem, social function, obesity, and driving outcomes. In contrast, most studies including ADHD pharmacotherapy and/or non-pharmacotherapy (94%, 46 of 49) showed that compared with baseline or untreated ADHD, long-term outcomes improved or stabilized with treatment of ADHD.

Conclusions

ADHD has notable negative long-term consequences, and this negative impact may be reduced with treatment of ADHD. Supported by Shire Development Inc.

Long-term outcomes of ADHD: Global and regional study publication trends

Introduction

As awareness of ADHD has increased throughout the world, interest has grown beyond the constellation of ADHD symptoms, including long-term effects and impact on people's lives.

Objectives

To examine the consequences of childhood ADHD and the relevance of these outcomes in different world regions.

Aims

This analysis examined the publication trends of studies of long-term outcomes of ADHD over time and among world regions.

Methods

Study identification followed Cochrane guidelines. Twelve databases were searched for reports published in English 1980–2010. Limiting criteria were designed to maximize study inclusion while maintaining a high level of study rigor: the studies were to

(1)

The fully-defined electronic search yielded 4615 citations, which were then reviewed manually based on the titles and abstracts, yielding a final of 371 studies.

Results

Study publication trends analysed included: publication year, country and world region of origin, outcome types, and study types. In general, the numbers of studies published per year globally has increased substantially (from 2 in 1980 to more than 40/year in 2007 and 2008) with differences observed between Europe and North America.

Conclusions

Analysis of publication trends can provide insight into outcomes of ADHD and the focus of specific world regions.

Supported by Shire Development Inc.

A novel role for BRCA1 in regulating breast cancer cell spreading and motility

BRCA1 C-terminal (BRCT) domains in BRCA1 are essential for tumor suppressor function, though the underlying mechanisms remain unclear. We identified ezrin, radixin, and moesin as BRCA1 BRCT domain-interacting proteins. Ezrin-radixin-moesin (ERM) and F-actin colocalized with BRCA1 at the plasma membrane (PM) of cancer cells, especially at leading edges and focal adhesion sites. In stably expressing cancer cells, high levels of enhanced green fluorescent protein (EGFP)-BRCA1(1634-1863) acted as a dominant-negative factor, displacing endogenous BRCA1 from the PM. This led to delayed cell spreading, increased spontaneous motility, and irregular monolayer wound healing. MCF-7 cells (intact BRCA1) showed lower motility than HCC1937 cells (truncated BRCA1), but expression of EGFP-BRCA1(1634-1863) in MCF-7 increased motility. Conversely, full-length BRCA1 expression in HCC1937 decreased motility but only if the protein retained ubiquitin ligase activity. We conclude that full-length BRCA1 is important for complete tumor suppressor activity via interaction of its BRCT domains with ERM at the PM, controlling spreading and motility of cancer cells via ubiquitin ligase activity.

Abstract PD01-06: Activation of the Insulin-Like Growth Factor Pathway Distinguishes African American from European American Patients with Triple-Negative Breast Cancer by Gene Expression Profiling

Background: Triple-negative breast cancer (TNBC) is characterized by high histologic grade, high rates of distant recurrence and a poor overall prognosis. Treatment options are limited due to the lack of specific targets such as hormone receptors or HER2 which drive other breast cancer subtypes. Epidemiological studies show a markedly higher prevalence of TNBC in young women of African ancestry. In this study we sought to identify transcriptional modules that are differentially regulated between African American (AA) and European American (EA) women. Methods: A hospital-based cohort of 130 breast cancer patients diagnosed between 1985 and 2007 was selected by an institutional pathology database (CoPath) search for invasive, triple-negative breast cancer and enriched for patients of African American ethnicity. Racial distribution 47% AA, 33% EA, 8% Hispanic and 12% other or unknown. Clinical data was extracted from the Yale and Bridgeport Hospitals Tumor Registry following IRB approval. Invasive disease was identified on H&E sections and an average of 3 tissue cores from FFPE blocks were subjected to RNA extraction using the RecoverAll Total Nucleic Acid Isolation kit (Applied Biosystems) following the manufacturer's protocol. The extracted material was hybridized to Whole Genome-DASL assays (Illumina). Statistical analysis of gene expression data was carried out using Bioconductor/R software. A set of relevant signatures was selected by enrichment analysis of modules identified by principal component analysis. Signature scores were computed as Pearson correlation between the signature vector of gene contributions and each sample's expression profile for these genes. Results: African American patients show a significantly higher activation score for a 273-gene Insulin-like Growth Factor 1 signature compared with European American patients (stage-adjusted p=0.0006). Similarly, samples from AA patients show higher scores in a BRCA 1 mutant signature defined by van ‘t Veer and colleagues in 2002 (p=0.001) and in a luminal progenitor (CD49f+EpCAM+) signature from Lim et al. (2009) (p=0.01). The Genomic Grade Index (GGI, Sotiriou et al. 2006) in samples from AA patients was also found to be significantly elevated (p=0.0007). Conclusions: Our findings indicate significant activation of the IGF pathway in AA compared to EA patients with TNBC. The 273-gene IGF signature was associated with poor differentiation and high proliferation in an independent cohort, which is in agreement with the high GGI score observed in AA patients. BRCA1 mutant-like and luminal progenitor-like properties in AA tumor samples further support this hypothesis as they both are related to basal-like histology which constitutes an aggressive subgroup of triple-negative tumors. These data suggest that African American patients may benefit from IGF pathway inhibiting drugs.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD01-06.

Combined zebrafish-yeast chemical-genetic screens reveal gene-copper-nutrition interactions that modulate melanocyte pigmentation

Hypopigmentation is a feature of copper deficiency in humans, as caused by mutation of the copper (Cu(2+)) transporter ATP7A in Menkes disease, or an inability to absorb copper after gastric surgery. However, many causes of copper deficiency are unknown, and genetic polymorphisms might underlie sensitivity to suboptimal environmental copper conditions. Here, we combined phenotypic screens in zebrafish for compounds that affect copper metabolism with yeast chemical-genetic profiles to identify pathways that are sensitive to copper depletion. Yeast chemical-genetic interactions revealed that defects in intracellular trafficking pathways cause sensitivity to low-copper conditions; partial knockdown of the analogous Ap3s1 and Ap1s1 trafficking components in zebrafish sensitized developing melanocytes to hypopigmentation in low-copper environmental conditions. Because trafficking pathways are essential for copper loading into cuproproteins, our results suggest that hypomorphic alleles of trafficking components might underlie sensitivity to reduced-copper nutrient conditions. In addition, we used zebrafish-yeast screening to identify a novel target pathway in copper metabolism for the small-molecule MEK kinase inhibitor U0126. The zebrafish-yeast screening method combines the power of zebrafish as a disease model with facile genome-scale identification of chemical-genetic interactions in yeast to enable the discovery and dissection of complex multigenic interactions in disease-gene networks.

High normal fasting glucose level in obese youth: a marker for insulin resistance and beta cell dysregulation

AIMS/HYPOTHESIS

A high but normal fasting plasma glucose level in adults is a risk factor for future development of type 2 diabetes mellitus and cardiovascular disease. We investigated whether normal fasting plasma glucose levels (<5.60 mmol/l) are associated with decreases in insulin sensitivity and beta cell function, as well as an adverse cardiovascular profile in obese youth.

METHODS

We performed a cross-sectional analysis in a multiethnic sample of 1,020 obese youth (614 girls and 406 boys; mean age 12.9 years [CI 95% 12.7-13.1], BMI z score 2.34 [CI 95% 2.31-2.38]) with normal fasting plasma glucose. All participants had a standard OGTT, with calculation of indices of insulin sensitivity and beta cell function. For the analysis, prepubertal and pubertal participants were stratified into quartiles of normal fasting plasma glucose.

RESULTS

We observed a significant increase in fasting insulin and AUC 2 h glucose across quartiles. Pronounced changes were observed in insulin sensitivity and secretion, particularly in the pubertal group. Moreover, the odds of presenting with impaired glucose tolerance increased by 4.5% with each 0.06 mmol/l increase in fasting plasma glucose. No significant differences in cardiovascular indices were seen across quartiles.

CONCLUSIONS/INTERPRETATION

These data suggest that in obese youth, independent of age, BMI z score, sex, family history and ethnicity, insulin sensitivity and secretion decline when moving from low to high normal fasting plasma glucose. The simple measure of fasting plasma glucose could assist clinicians in identifying children for targeted diabetes screening and subsequent lifestyle management.

Bioanalysis of N-acetyl-aspartyl-glutamate as a marker of glutamate carboxypeptidase II inhibition

We report the characterization of two methods for the analysis of N-acetyl-aspartyl-glutamate (NAAG) in biological fluids. In the first method, NAAG concentrations were calculated based on differences between glutamate concentrations before and after NAAG hydrolysis with exogenous glutamate carboxypeptidase II (GCP II) using high-performance liquid chromatography (HPLC) followed by fluorescence detection. In the second method, NAAG levels were quantified directly using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Analyses of NAAG levels in human cerebrospinal fluid samples using either method gave similar results within experimental error, confirming the validity of the two independent measurements. These methods will be useful in future clinical trials to assess drug-induced GCP II inhibition in biological matrices.

Characterization of deformable mirrors for spherical aberration correction in optical sectioning microscopy

In this paper we describe the wavefront aberrations that arise when imaging biological specimens using an optical sectioning microscope and generate simulated wavefronts for a planar refractive index mismatch. We then investigate the capability of two deformable mirrors for correcting spherical aberration at different focusing depths for three different microscope objective lenses. Along with measurement and analysis of the mirror influence functions we determine the optimum mirror pupil size and number of spatial modes included in the wavefront expansion and we present measurements of actuator linearity and hysteresis. We find that both mirrors are capable of correcting the wavefront aberration to improve imaging and greatly extend the depth at which diffraction limited imaging is possible.

Genomic events underlying the changes in adamantane resistance among influenza A(H3N2) viruses during 2006-2008

Background  Adamantanes resistance in H3N2 viruses has been increasing since 2000, and in 2005–2006 reached nearly 100% in most countries, with the circulation of the N‐lineage. In 2006–2007, however, a significant decrease in resistance was observed in many regions.

Objectives  To explore potential links between adamantane resistance and the A(H3N2) viruses that circulated between 2006 and 2008.

Methods  A total of 1451 Influenza A (H3N2) viruses collected globally in 2001–2008 were screened for the presence of adamantane resistance markers. A subset of 100 viruses representing the broad genetic and geographic spectrum of these viruses was selected for complete genome sequencing and phylogenetic analyses.

Results  Full genome sequence analysis of 2006–2007 viruses revealed co‐circulation of four distinct genotypes, designated A–D. Phylogenetic analyses demonstrated reassortment between viruses from the N‐lineage and other viruses that had circulated in prior seasons, including those bearing an adamantane sensitive marker. Genotype D viruses became dominant in late 2006–2007 and continued to be the main H3N2 genotype in 2007–2008. Viruses of this genotype retained all N‐lineage genome segments except PB2 and NP, which were acquired through reassortment.

Conclusions  The decrease in adamantane resistance at that time was due to transient co‐circulation of genotypes that emerged through reassortment. Our findings emphasize the importance of complete genome sequencing in understanding the complex nature of the relationship between influenza virus evolution and antiviral resistance. The recent emergence of the pandemic multi‐reassortant H1N1 virus underscores the importance of whole genome sequence monitoring for rapid detection of such unusual and novel strains.

Biomedical infertility care in sub-Saharan Africa: a social science-- review of current practices, experiences and view points

Some sort of infertility treatments, including the use of advanced reproductive technologies (ARTs), is nowadays provided at several places in sub-Saharan Africa. Yet, to date only a few studies have actually looked into the way these treatments are offered, used and experienced. In this review article the authors present and discuss empirical study findings that give insight into the way biomedical infertility care is provided, considered, experienced and/or used in sub-Saharan African countries. They concentrate on four themes that were often referred to in the reviewed studies and underline the importance of taking into account the local sociocultural context and notions when developing and implementing infertility care, namely: counselling, male involvement, acceptability of ARTs and the use of donor material (semen and embryos). In the conclusion the authors emphasize the importance of preventing infertility as part of integrated reproductive health programs and the need to improve the quality of (low tech) infertility care in the public health sector by means of standardized guidelines, training of health staff and improved counselling. In addition, from a reproductive rights perspective, they support initiatives to introduce low cost ARTs to treat tubal factor related infertility. They also point to potential unintended side effects of the introduction of ARTs and the use of donor material in the sub-Saharan African context, affecting gender inequity and inequity between citizens from different social classes, and argue that such effects should be acknowledged and avoided by all possible means. Finally, they present an agenda for future social science research on this topic in sub-Saharan Africa.

Antigenic and genetic characteristics of swine-origin 2009 A(H1N1) influenza viruses circulating in humans

Since its identification in April 2009, an A(H1N1) virus containing a unique combination of gene segments from both North American and Eurasian swine lineages has continued to circulate in humans. The lack of similarity between the 2009 A(H1N1) virus and its nearest relatives indicates that its gene segments have been circulating undetected for an extended period. Its low genetic diversity suggests that the introduction into humans was a single event or multiple events of similar viruses. Molecular markers predictive of adaptation to humans are not currently present in 2009 A(H1N1) viruses, suggesting that previously unrecognized molecular determinants could be responsible for the transmission among humans. Antigenically the viruses are homogeneous and similar to North American swine A(H1N1) viruses but distinct from seasonal human A(H1N1).

Localisation of DivIVA by targeting to negatively curved membranes

DivIVA is a conserved protein in Gram-positive bacteria and involved in various processes related to cell growth, cell division and spore formation. DivIVA is specifically targeted to cell division sites and cell poles. In Bacillus subtilis, DivIVA helps to localise other proteins, such as the conserved cell division inhibitor proteins, MinC/MinD, and the chromosome segregation protein, RacA. Little is known about the mechanism that localises DivIVA. Here we show that DivIVA binds to liposomes, and that the N terminus harbours the membrane targeting sequence. The purified protein can stimulate binding of RacA to membranes. In mutants with aberrant cell shapes, DivIVA accumulates where the cell membrane is most strongly curved. On the basis of electron microscopic studies and other data, we propose that this is due to molecular bridging of the curvature by DivIVA multimers. This model may explain why DivIVA localises at cell division sites. A Monte-Carlo simulation study showed that molecular bridging can be a general mechanism for binding of proteins to negatively curved membranes.

Hypothalamic AMP-activated protein kinase activation with AICAR amplifies counterregulatory responses to hypoglycemia in a rodent model of type 1 diabetes

In nondiabetic rodents, AMP-activated protein kinase (AMPK) plays a role in the glucose-sensing mechanism used by the ventromedial hypothalamus (VMH), a key brain region involved in the detection of hypoglycemia. However, AMPK is regulated by both hyper- and hypoglycemia, so whether AMPK plays a similar role in type 1 diabetes (T1DM) is unknown. To address this issue, we used four groups of chronically catheterized male diabetic BB rats, a rodent model of autoimmune T1DM with established insulin-requiring diabetes (40 +/- 4 pmol/l basal c-peptide). Two groups were subjected to 3 days of recurrent hypoglycemia (RH), while the other two groups were kept hyperglycemic [chronic hyperglycemia (CH)]. All groups subsequently underwent hyperinsulinemic hypoglycemic clamp studies on day 4 in conjunction with VMH microinjection with either saline (control) or AICAR (5-aminoimidazole-4-carboxamide) to activate AMPK. Compared with controls, local VMH application of AICAR during hypoglycemia amplified both glucagon [means +/- SE, area under the curve over time (AUC/t) 144 +/- 43 vs. 50 +/- 11 ng.l(-1).min(-1); P < 0.05] and epinephrine [4.27 +/- 0.96 vs. 1.06 +/- 0.26 nmol.l(-1).min(-1); P < 0.05] responses in RH-BB rats, and amplified the glucagon [151 +/- 22 vs. 85 +/- 22 ng.l(-1).min(-1); P < 0.05] response in CH-BB rats. We conclude that VMH AMPK also plays a role in glucose-sensing during hypoglycemia in a rodent model of T1DM. Moreover, our data suggest that it may be possible to partially restore the hypoglycemia-specific glucagon secretory defect characteristic of T1DM through manipulation of VMH AMPK.

Undergraduate research. Genomics Education Partnership

The Genomics Education Partnership offers an inclusive model for undergraduate research experiences incorporated into the academic year science curriculum, with students pooling their work to contribute to international data bases.

Undergraduate research. Genomics Education Partnership

The Genomics Education Partnership offers an inclusive model for undergraduate research experiences incorporated into the academic year science curriculum, with students pooling their work to contribute to international data bases.

Array-based goniospectroradiometer for measurement of spectral radiant intensity and spectral total flux of light sources

We present a description of a new goniospectroradiometric measurement system developed at the National Physical Laboratory (NPL). The instrument incorporates a modified array spectrometer and a series of rotary stages to allow measurement of the spectral radiant intensity distribution of a variety of different types of light source from 350 to 830 nm. Associated source properties such as chromaticity and correlated color temperature distributions and total spectral flux are then calculated from the radiant intensity data. A preliminary comparison with NPL's integrating sphere-based luminous flux scale shows agreement to within 0.4%, well within the combined measurement uncertainty. Measurements of the luminous intensity and color temperature distributions and the spectral total flux of a tungsten filament flux standard, a white LED cluster and a compact fluorescent source made using the goniospectroradiometer, are also presented.

Cardiovascular high-risk patients--treat to protect, but whom?

Current guidelines for the prevention of coronary heart disease emphasize the importance of global cardiovascular risk, which requires the evaluation and treatment of multiple risk factors. Cardiovascular risk can be stratified with the Framingham algorithm, which produces a numerical score related to the presence of risk factors, such as hypertension, dyslipidemia, and smoking. However, this algorithm is not generally applicable to European countries, particularly for those countries where the risk for cardiovascular disease is low. The SCORE (Systematic COronary Risk Evaluation) project has produced risk charts that are based on cholesterol, blood pressure, and age for low-risk European countries (Belgium, France, Greece, Italy, Luxembourg, Spain, and Switzerland) and high-risk countries. Assessments of end-organ damage can provide further prognostic information, particularly in intermediate-risk patients, but the value of including additional biomarkers in risk stratification remains to be confirmed. Risk for coronary heart disease is high or very high in more than 50% of hypertensive patients. Risk appears to be underestimated in clinical practice, particularly in those patients at highest risk. Major intervention trials with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers have shown that these agents reduce the risk for cardiovascular events in patients at all levels of risk, with the greatest benefits seen in those at highest risk.

No HOPE without proof: do ARBs meet the standard for cardiovascular protection?

Blockade of the renin-angiotensin system (RAS) by angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) plays an important role in the protection and prevention of cardiovascular disease. The Heart Outcomes Prevention Evaluation (HOPE) study established the significant effect of ACE inhibition on cardiovascular morbidity and mortality beyond blood pressure control. Smaller studies have demonstrated the efficacy of ARBs. In addition, a recent analysis from the Blood Pressure Lowering Treatment Trialists' Collaboration showed that ARB-based and ACE inhibitor-based treatment regimens were comparable in terms of the odds ratio for stroke and heart failure, independent of blood pressure reduction. There is an emerging body of evidence to suggest that a combination approach to RAS blockade with an ARB and an ACE inhibitor may further improve cardiovascular outcome compared with monotherapy with either agent alone. The large-scale ONgoing Telmisartan Alone or in combination with Ramipril Global Endpoint Trial (ONTARGET), comparing high-dose ramipril (HOPE study dosage) with telmisartan or a combination of the two, should provide important insight into the benefits of RAS blockade intervention. The results of ONTARGET are anticipated to be available in 2008.

Cardiac and vascular protection: the potential of ONTARGET

Cardiovascular risk is determined by multiple risk factors. Blockade of the renin-angiotensin system is an important approach to the prevention of cardiovascular events. In the largest angiotensin receptor blocker cardiovascular outcome study to date, the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) program will compare the efficacy of therapy with telmisartan and ramipril, in reducing cardiovascular events in patients at high risk (history of coronary artery disease, stroke or transient ischemic attack, peripheral artery disease, or diabetes with evidence of end-organ damage). Recruited patients (n = 31,546) will be followed up for a period of 6 years, and more than 150,000 patient-years of data will be recorded. The primary endpoint is a composite of cardiovascular death, stroke, acute myocardial infarction, and hospitalization for congestive heart failure; secondary endpoints focus on reductions in newly diagnosed heart failure, new-onset type 2 diabetes, cognitive decline, atrial fibrillation, and nephropathy. In addition, an ambulatory blood pressure monitoring substudy will be conducted to assess the effect of treatment on endpoints after adjustment for 24-hour blood pressure values. Other substudies of the treatment effects on erectile dysfunction, blood markers, arterial stiffness, oral glucose tolerance, and the progression of target organ damage are also planned. The results of the ONTARGET program are due in 2008, and the findings are expected to have important clinical implications for the management of patients at high cardiovascular risk.

Targeting cardiovascular protection: the concept of dual renin-angiotensin system control

The renin-angiotensin system plays a key role in the regulation of blood pressure, and blockade of this system now forms a central part of strategies to reduce the risk for cardiovascular events in high-risk patients. Both angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have been shown to be effective in lowering blood pressure and reducing the risk for cardiovascular events, but both classes of drug have some limitations. Plasma concentrations of angiotensin II increase during ACE-inhibitor therapy in some patients, partly as a result of the production of angiotensin II via non-ACE pathways; furthermore, elevated aldosterone concentrations can occur in a significant proportion of patients. ARBs block the deleterious effects of angiotensin II at angiotensin type 1 receptors irrespective of the origin of the peptide, but the beneficial effects of kinins may be diminished. ARB therapy results in activation of angiotensin type 2 receptors, resulting in potentially beneficial anti-inflammatory, antithrombotic, and antiproliferative effects, but the clinical significance of these effects remains controversial. Some ARBs, particularly telmisartan, have been shown to act as partial agonists of peroxisome proliferator-activated receptor gamma, thereby increasing insulin sensitivity. Combination therapy with ACE inhibitors and ARBs offers the potential for effective blood pressure control, decreased aldosterone production, enhanced kinin activity, and increased insulin sensitivity. The potential clinical benefits of this approach in high-risk patients are currently being investigated in the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET), which is comparing therapy using a combination of telmisartan plus ramipril with the use of each drug in monotherapy.

Prospects for renovascular protection by more aggressive renin-angiotensin system control

Risk factors such as hypertension or diabetes result in a continuum of renal damage. Without intervention, initial subclinical endothelial damage progresses to incipient disease, identified by microalbuminuria. Glomerular filtration rate declines, macroalbuminuria develops, and eventually end-stage renal disease (ESRD) emerges. Because of the interrelationship between cardiovascular and renal disease and their common pathophysiologies involving angiotensin II, many patients die of cardiovascular disease before renal replacement therapy is needed. Blood pressure control is key to renoprotection, but blood pressure-independent mechanisms are also implicated. Targeting the renin-angiotensin system (RAS) using angiotensin-converting enzyme (ACE) inhibitors and/or angiotensin receptor blockers (ARBs) is a logical approach to managing all at-risk patients. In advanced nephropathy, therapy aims at retarding progression to ESRD. For incipient nephropathy, ideal therapy should bring about microalbuminuria regression. In patients at risk of renal damage, preventing early target-organ damage is essential. Although evidence of ACE inhibitor benefit is limited, data show that ARBs provide renoprotection throughout the continuum and that this may be related to their cardioprotective effects. More aggressive RAS targeting by combination blockade is under investigation. Telmisartan is an ARB that delays progression of incipient and overt diabetic nephropathy and brings about regression from microalbuminuria to normoalbuminuria in hypertensive and normotensive patients. The ultimate proof of benefit will come from the ONTARGET trial, which will evaluate the cardiovascular and renal protective effects of the combination of telmisartan and ramipril.

Treating to protect: current cardiovascular treatment approaches and remaining needs

Current best practice to reduce cardiovascular disease involves evaluating patients' global cardiovascular risk profiles and devising treatment strategies accordingly. Despite the proven efficacy of this approach, very few physicians are adequately assessing risk, and consequently patients are failing to achieve desired treatment targets. Modifying lifestyle factors, such as diet, exercise, and cessation of smoking, remains one of the simplest and most potent means of reducing risk. Newly emerging evidence suggests that moderate physical activity (such as brisk walking for 30 minutes a day), eg, by raising levels of circulating endothelial progenitor cells, improves endothelial function and enhances vascular repair. However, patients remain remarkably reluctant to lifestyle changes, even in the face of overt, life-threatening disease. Statin treatment reduces cardiovascular morbidity and death in both primary and secondary prevention studies. However, over 90% of adults at high risk for coronary heart disease fail to achieve target low-density lipoprotein cholesterol levels in spite of statin therapy. Similarly, only about 37% of patients with hypertension meet blood pressure targets. Antihypertensive drugs achieve different levels of cardioprotection. Mounting evidence links regimens containing beta-blockers or diuretics with higher incidence of type 2 diabetes. In contrast, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers appear to confer extra protection on target organs on top of blood pressure reduction. The ONTARGET Trial Program is designed to clarify the importance of this effect. Educating patients, raising physicians' awareness, and implementing effective and safe treatment regimens are all necessary steps to bring about the much-needed improvements in cardiac health outcomes.

A review of the association between antipsychotic use and hyperprolactinaemia

Recent evidence linking hyperprolactinaemia to longer-term clinical sequelae, including osteoporosis, hip fractures and possibly breast cancer, is increasing clinical awareness of the relevance of hyperprolactinaemia. A review of the literature finds clinical trials reporting some degree of comparative prolactin data among antipsychotics. Many of the randomised clinical trials (RCTs) do not report categorical rates of hyperprolactinaemia in contrast with the naturalistic studies, making it complex for clinicians to evaluate the extent and severity of hyperprolactinaemia. Hyperprolactinaemia is one of the commonest adverse events reported in clinical trials and can be found in association with all antipsychotics. The highest rates of hyperprolactinaemia are reported in association with risperidone and amisulpride, often as high as 80-90% of all female subjects and consistently greater than with the typical antipsychotics. Significant rates of hyperprolactinaemia of lesser severity and more transience have also been reported in association with other atypical antipsychotics.

Prevalence of hyperprolactinaemia in a naturalistic cohort of schizophrenia and bipolar outpatients during treatment with typical and atypical antipsychotics

Hyperprolactinaemia is a common finding in patients treated with antipsychotics. A complete cohort of 194 schizophrenia and bipolar disorder patients receiving antipsychotics in a single community mental health trust in Halifax UK underwent routine prolactin screening in the absence of any reLevant symptomatoLogy. Values above the upper limit of normal were measured in 38% of the cohort and were more common in females (52%) than males (26%). Significantly elevated levels (>1000 mIU/l) were measured in 21% of the cohort. Risperidone monotherapy treatment was associated with hyperprolactinaemia in 69% of patients ( n = 35) and in 100% of female patients (n = 16) and amisulpride monotherapy in 100% (n = 7). Prolactin screening is not currently undertaken routinely in the UK. These data give some indication of prevalence of varying degrees of hyperproLactinaemia that might be found when screening an asymptomatic cohort of schizophrenia and bipolar outpatients. Clinicians may be helped by the reporting of such categorical data from clinical trials in addition to mean cohort values of prolactin. Long-term hyperprolactinaemia may be associated with clinical sequeLae in some patients.

Rapid onset intratubular calcification following renal transplantation requiring urgent parathyroidectomy

BACKGROUND

Secondary hyperparathyroidism is a common complication of end-stage renal disease often requiring parathyroidectomy. Renal transplant with the restoration of normal renal function often allows resolution of hyperparathyroidism, avoiding the need for parathyroid surgery. However, a proportion of patients with hyperparathyroidism become overtly hypercalcemic after renal transplantation which poses management dilemmas between medical and surgical treatment.

CASE

We present the case of a 48-yearold man with end-stage renal failure known to have secondary hyperparathyroidism who received a living related renal transplant. Postoperatively he developed prompt hypercalcemia, polyuria, polydipsia and rapid onset intratubular calcification, leading to acute tubular necrosis diagnosed on renal biopsy on Day 7 post transplantation. He underwent surgical parathyroidectomy with resolution of his hypercalcemia and improved renal transplant function.

DISCUSSION

This case emphasizes the need for good management of secondary hyperparathyroidism together with close surveillance of PTH in patients awaiting renal transplantation. With good renal transplant function hyperparathyroidism usually resolves. Posttransplant surgical parathyroidectomy should be reserved for severe progressive end organ damage.

Nod1/RICK and TLR signaling regulate chemokine and antimicrobial innate immune responses in mesothelial cells

Mesothelial cells that line the serous cavities and outer surface of internal organs are involved in inflammatory responses induced by microbial stimuli and bacterial infection. Upon exposure to bacterial products, mesothelial cells secrete chemokines, but the signaling pathways by which these cells recognize bacteria to mediate innate immune responses remain largely unknown. We report that stimulation of primary peritoneal mesothelial cells via nucleotide-binding oligomerization domain (Nod)1, a member of the intracytoplasmic Nod-like receptor family, induced potent secretion of the chemokines CXCL1 and CCL2 as well as expression of inducible NO synthase and such responses required the kinase RICK. Mesothelial cells also produced chemokines in response to TLR2, TLR3, TLR4, and TLR5 agonists, but unlike that induced by Nod1 stimulation, the TLR-mediated responses were independent of RICK. Yet, Nod1 stimulation of mesothelial cells via RICK enhanced chemokine secretion induced by LPS or IFN-gamma and cooperated with IFN-gamma in the production of NO. The i.p. administration of KF1B, a synthetic Nod1 agonist, elicited chemokine production in the serum and peritoneal fluid as well as the recruitment of neutrophils into the peritoneal cavity of wild-type mice, but not RICK-deficient mice. Finally, infection of mesothelial cells with Listeria monocytogenes induced production of CXCL1 and this response was significantly reduced in Nod1- or RICK-deficient cells. These results define mesothelial cells as microbial sensors through TLRs and Nod-like receptors and identify Nod1 and RICK as important mediators of chemokine and antimicrobial responses in mesothelial cells.

Heterologous amyloid seeding: revisiting the role of acetylcholinesterase in Alzheimer's disease

Neurodegenerative diseases associated with abnormal protein folding and ordered aggregation require an initial trigger which may be infectious, inherited, post-inflammatory or idiopathic. Proteolytic cleavage to generate vulnerable precursors, such as amyloid-beta peptide (Abeta) production via beta and gamma secretases in Alzheimer's Disease (AD), is one such trigger, but the proteolytic removal of these fragments is also aetiologically important. The levels of Abeta in the central nervous system are regulated by several catabolic proteases, including insulysin (IDE) and neprilysin (NEP). The known association of human acetylcholinesterase (hAChE) with pathological aggregates in AD together with its ability to increase Abeta fibrilization prompted us to search for proteolytic triggers that could enhance this process. The hAChE C-terminal domain (T40, AChE(575-614)) is an exposed amphiphilic alpha-helix involved in enzyme oligomerisation, but it also contains a conformational switch region (CSR) with high propensity for conversion to non-native (hidden) beta-strand, a property associated with amyloidogenicity. A synthetic peptide (AChE(586-599)) encompassing the CSR region shares homology with Abeta and forms beta-sheet amyloid fibrils. We investigated the influence of IDE and NEP proteolysis on the formation and degradation of relevant hAChE beta-sheet species. By combining reverse-phase HPLC and mass spectrometry, we established that the enzyme digestion profiles on T40 versus AChE(586-599), or versus Abeta, differed. Moreover, IDE digestion of T40 triggered the conformational switch from alpha- to beta-structures, resulting in surfactant CSR species that self-assembled into amyloid fibril precursors (oligomers). Crucially, these CSR species significantly increased Abeta fibril formation both by seeding the energetically unfavorable formation of amyloid nuclei and by enhancing the rate of amyloid elongation. Hence, these results may offer an explanation for observations that implicate hAChE in the extent of Abeta deposition in the brain. Furthermore, this process of heterologous amyloid seeding by a proteolytic fragment from another protein may represent a previously underestimated pathological trigger, implying that the abundance of the major amyloidogenic species (Abeta in AD, for example) may not be the only important factor in neurodegeneration.

Surveillance of resistance to adamantanes among influenza A(H3N2) and A(H1N1) viruses isolated worldwide

Our previous reports demonstrated an alarming increase in resistance to adamantanes among influenza A(H3N2) viruses isolated in 2001-2005. To continue monitoring drug resistance, we conducted a comprehensive analysis of influenza A(H3N2) and A(H1N1) viruses isolated globally in 2005-2006. The results obtained by pyrosequencing indicate that 96.4% (n=761) of A(H3N2) viruses circulating in the United States were adamantane resistant. Drug resistance has reached 100% among isolates from some Asian countries. Analysis of correlation between the appearance of drug resistance and the evolutionary pathway of the hemagglutinin (HA) gene suggests at least 2 separate introductions of resistance into circulating populations that gave rise to identifiable subclades. It also indicates that resistant A(H3N2) viruses may have emerged in Asia in late 2001. Among A(H1N1) viruses isolated worldwide, resistance reached 15.5% in 2005-2006; in the United States alone, it was 4.0%. Phylogenetic analysis of the HA and M genes indicates that the acquisition of resistance in A(H1N1) viruses can be linked to a specific genetic group and was not a result of reassortment between A(H3N2) and A(H1N1) viruses. The results of the study highlight the necessity of close monitoring of resistance to existing antivirals as wells as the need for new therapeutics.

Cloning and functional analysis of an IL-13 splice variant lacking exon 2 which has inflammatory activity (95.22)

Interleukin 13 is a Th2 type (anti-inflammatory) cytokine produced by activated T cells. We have cloned a naturally occurring mRNA splice variant of IL-13 in which the second exon is omitted (termed δE2). We have developed RT-PCR assays for quantitation and discrimination of δE2/IL-13 gene expression, and cloned each of the molecules as HIS-tagged proteins for use in in vivo and in vitro studies.

We find that unlike IL-13, δE2 is expressed predominantly under Th1 conditions: δE2 is expressed by spleen cells stimulated with polyclonal activators and in the lymph nodes of mice immunized with CFA as adjuvant. Addition of exogenous δE2 to cultured antigen presenting cells induces phenotypic changes characteristic of an inflammatory (Th1) response, such as increased inflammatory cytokine secretion (TNF-α and IL-12). Addition of exogenous δE2 to antigen specific T cell cultures results in an increase in TNF-α producing cells as determined by ELIspot. Treatment of mice with exogenous δE2 at the time of immunization with CFA and antigen results in significant increases in the expression of inflammatory genes, including IL-12, CD28, and CD5. Lastly, we find that this splice variant is produced primarily by activated (CD19+, CD86+) B cells

Given the expression pattern of δE2 and its ability to modulate the expression of inflammatory cytokines, we hypothesis that δE2 is a unique cytokine involved in inflammatory immune responses