Frequency of mutations in the genes associated with hereditary sensory and autonomic neuropathy in a UK cohort

The hereditary sensory and autonomic neuropathies (HSAN, also known as the hereditary sensory neuropathies) are a clinically and genetically heterogeneous group of disorders, characterised by a progressive sensory neuropathy often complicated by ulcers and amputations, with variable motor and autonomic involvement. To date, mutations in twelve genes have been identified as causing HSAN. To study the frequency of mutations in these genes and the associated phenotypes, we screened 140 index patients in our inherited neuropathy cohort with a clinical diagnosis of HSAN for mutations in the coding regions of SPTLC1, RAB7, WNK1/HSN2, FAM134B, NTRK1 (TRKA) and NGFB. We identified 25 index patients with mutations in six genes associated with HSAN (SPTLC1, RAB7, WNK1/HSN2, FAM134B, NTRK1 and NGFB); 20 of which appear to be pathogenic giving an overall mutation frequency of 14.3%. Mutations in the known genes for HSAN are rare suggesting that further HSAN genes are yet to be identified. The p.Cys133Trp mutation in SPTLC1 is the most common cause of HSAN in the UK population and should be screened first in all patients with sporadic or autosomal dominant HSAN.

Modafinil for excessive daytime sleepiness in myotonic dystrophy type 1--the patients' perspective

Excessive daytime sleepiness (EDS), of very similar pattern to that seen in narcolepsy syndrome, is extremely common in myotonic dystrophy type 1 (DM1). In a significant minority it has a profound disabling effect on employment, social functioning and activities of daily living. Limited published studies have shown inconsistent results from use of the psychostimulant drug modafinil. A recent European Medicines Agency (EMA) review concluded that on current evidence regarding safety and efficacy, modafinil's use should be restricted to the treatment of narcolepsy. In other conditions (although DM1 was not specifically considered) it was concluded that there was insufficient evidence of benefit to outweigh potentially serious side-effects, including severe skin reactions and cardiac arrhythmia. Clinicians with extensive experience in the management of DM1 have found modafinil to be extremely effective in appropriately selected patients with a very low incidence of serious side-effects. Given the recent EMA review, patients have expressed concern about the potential restriction of the use of modafinil in DM1. This brief review is an audit of the experience of a large group of patients and their clinicians concerning EDS and DM1 and concludes that despite the limited literature there is strong evidence to support the use of modafinil in carefully selected patients.

Comparison of broiler performance and carcass yields when fed transgenic maize grain containing event DP-O9814O-6 and processed fractions from transgenic soybeans containing event DP-356O43-5

The performance of broilers fed diets containing maize grain from event DP-Ø9814Ø-6 (98140; gat4621 and zm-hra genes) and processed fractions (meal, hulls, and oil) from soybeans containing event DP-356Ø43-5 (356043; gat4601 and gm-hra genes) was evaluated in a 42-d feeding study. Diets were produced with nontransgenic maize grain and soybean fractions from controls with comparable genetic backgrounds to 98140 and 356043 (control), 98140 maize and 356043 soybean (98140 + 356043), or 3 commercially available nontransgenic maize and soybean combinations. Ross 708 broilers (n = 120/group; 50% male, 50% female) were fed diets in 3 phases: starter (d 0 to 21), grower (d 22 to 35), and finisher (d 36 to 42). Starter diets contained (on average) 63% maize and 28% soybean meal, grower diets 66% maize and 26% soybean meal, and finisher diets 72% maize and 21% soybean meal; soybean hulls and oils were held constant at 1.0 and 0.5%, respectively, across all diets in all phases. Weight gain, feed intake, and mortality-adjusted feed efficiency were calculated for d 0 to 42. Standard organ and carcass yield data were collected on d 42. Data were analyzed using a mixed model ANOVA with differences between control and 98140 + 356043 group means considered significant at P < 0.05. Reference group data were used only to estimate experimental variability and to generate tolerance intervals. No significant differences were observed in weight gain, mortality, mortality-adjusted feed efficiency, organ yields, or carcass yields between broilers consuming diets produced with 98140 + 356043 and those consuming diets produced with control maize and soybean fractions. All values of response variables evaluated in the control and 98140 + 356043 groups fell within calculated tolerance intervals. Based on these results, it was concluded that the combination of genetically modified 98140 maize and 356043 soybean fractions was nutritionally equivalent to nontransgenic maize and soybean controls with comparable genetic backgrounds.

Changes in mandibular cortical width measurements with age in men and women

Automated software was used to measure the mandibular cortical width in a large sample of dental radiographs. We determined that cortical thinning normally starts in women at age 42.5 years and accelerates thereafter. We can estimate population referral rates and thus enable cost benefit analyses for osteoporosis detection by dentists.

INTRODUCTION

Previous studies have shown that the mandibular cortical width is significantly correlated with the bone mineral density at sites which may undergo osteoporotic fracture, e.g. hip. Mandibular cortical width can be determined automatically from dental panoramic radiographs that dentists frequently request, using appropriate software. We study the distribution of cortical width given age to predict those patients requiring further investigation for osteoporosis.

METHODS

The mandibular cortical width was measured in 4,949 dental panoramic tomograms, in patients aged 15-94 years. The inferior and superior cortical edges were detected automatically using a global active shape model image search, followed by an active appearance model search. Nonparametric statistical analysis and nonlinear piecewise linear/quadratic regression were used to analyse the data.

RESULTS

For females, the mean cortical width had a linear increase before the age of 17 years, a period of no change (estimate = 3.25 mm, se = 0.01) until the age of 42.5 years, followed by a quadratic decrease with age. For males, it had a linear increase before the age of 19 years, a constant value (estimate = 0.37 mm, se = 0.01) until the age of 36 years and then a slow linear decrease. The rate of decrease in mean cortical width goes from 0.049 to 0.105 standard deviations per year in the 60-80-year-old female age group, in line with published bone mineral density T-score reductions.

CONCLUSIONS

The pattern of decrease in mandibular cortical width with age was similar to the known pattern of bone loss from the hip, accelerating in women after the age of 42.5 years.

Nutritional equivalency evaluation of transgenic maize grain from event DP-O9814O-6 and transgenic soybeans containing event DP-356O43-5: laying hen performance and egg quality measures

The objective of this study was to compare the nutritional performance of laying hens fed maize grain from event DP-Ø9814Ø-6 (98140; gat4621 and zm-hra genes) and processed soybean meal from soybeans containing event DP-356Ø43-5 (356043; gat4601 and gm-hra genes), individually or in combination, with the performance of hens fed diets containing nontransgenic maize and soybean meal. Healthy pullets (n = 216) placed in cages (3 hens/cage) were randomly assigned to 9 dietary treatments (8 cages/treatment): nontransgenic controls 1, 2, and 3 (comparable genetic background controls for 98140, 356043, and 98140 + 356043, respectively); reference 1, reference 2, and reference 3 (commercially available nontransgenic maize-soybean meal sources); and 98140 (test 1), 356043 (test 2), and 98140 + 356043 (test 3). The experiment was divided into three 4-wk phases (24 to 28 wk, 28 to 32 wk, and 32 to 36 wk of age), during which time hens were fed mash diets. Performance (BW, feed intake, and egg production) and egg quality data were collected. Data were analyzed using a mixed model ANOVA; differences between the control and respective test group means were considered significant at P < 0.05. Data generated from the reference groups were used only in the estimation of experimental variability and in generating the tolerance interval. Body weight and BW gain, egg production, and production efficiency for hens fed the test diets were similar to the respective values for hens fed the corresponding control diets. Haugh unit measures and egg component weights were similar between the respective test and control groups, and no differences were observed in quality grades or crack measures. All observed values of the control and test groups were within the calculated tolerance intervals. This research indicates that the performance and egg quality of hens fed diets containing 98140 maize grain, 356043 soybean meal, or a combination of the 2 was comparable with that of hens fed diets formulated with nontransgenic maize grain or soybean meal control diets with comparable genetic backgrounds.

McArdle disease: a clinical review

METHODS

The clinical phenotype of 45 genetically confirmed McArdle patients is described.

RESULTS

In the majority of patients (84%), the onset of symptoms was from early childhood but diagnosis was frequently delayed until after 30 years of age. Not all patients could recognise a second wind although it was always seen with exercise assessment. A history of myoglobinuria was not universal and episodes of acute renal failure had occurred in a minority (11%). The condition does not appear to adversely affect pregnancy and childbirth. Clinical examination was normal in most patients, muscle hypertrophy was present in 24% and mild muscle wasting and weakness were seen only in patients over 40 years of age and was limited to shoulder girdle and axial muscles. The serum creatine kinase was elevated in all but one pregnant patient. Screening for the mutations pArg50X (R50X) and pGly205Ser (G205S) showed at least one mutated allele in 96% of Caucasian British patients, with an allele frequency of 77% for pArg50X in this population. A 12 min walking test to evaluate patients is described.

CONCLUSION

The results demonstrated a wide spectrum of severity with the range of distance walked (195-1980&emsp14;m); the mean distance walked was 512&emsp14;m, suggesting significant functional impairment in most patients.

Skeletal integrity and visceral transplantation

Despite continuous improvement in long-term survival, there is no knowledge about risk of bone health impairment and management strategies before and after intestinal transplantation. Therefore, 147 adults were retrospectively studied via chart review; 70 long-term survivors, 53 candidates and 24 recipients with longitudinal follow-up. Evaluation process included measurement of bone mineral density (BMD) and allied biochemical markers. Both long-term survivors and candidates showed low bone mass with lower (p < 0.05) z-scores at hip, femoral neck and spine. Vitamin D deficiency and secondary hyperparathyroidism were observed in both groups. Prevalence of osteoporosis was 44% among long-term survivors and 36% in candidates with age, BMD, duration of parenteral nutrition, type of immunosuppression and rejection being significant risk factors. Fragility fractures occurred at a higher (p = 0.02) rate among long-term survivors (20%) compared to candidates (6%). The longitudinal study documented acceleration (p = 0.025) of bone loss after transplantation with a decline of 13.4% (femoral neck), 12.7% (hip) and 2.1% (spine). Alendronate reduced (p < 0.05) but did not prevent bone loss. In conclusion, intestinal transplant recipients are at risk of osteoporosis secondary to bone loss before and after transplantation. Accordingly, current management includes comprehensive preventive measures with prompt therapeutic intervention utilizing intravenous bisphosphonates or subcutaneous human PTH.

Acute central nervous system infections in adults--a retrospective cohort study in the NHS North West region

BACKGROUND

Over the last 15 years, bacterial meningitis has received considerable attention, including national guidelines, whilst viral central nervous system (CNS) infections have been relatively neglected. A recent pilot study suggested that management of patients with suspected viral encephalitis was often suboptimal.

AIM

To examine the relative incidence, clinical features and management of suspected acute CNS infections in adults across the NHS North West Region.

DESIGN

A multicentre cross-sectional retrospective cohort study at 10 hospitals across the region over 3 months (from September to December 2007). Following a screen of all patients who had cerebrospinal fluid (CSF) analysis or received intravenous aciclovir and/or third-generation cephalosporin, those with clinical features suspicious of a CNS infection were included. Management was compared with the national meningitis and regional encephalitis guidelines.

RESULTS

Three hundred and eighty-five patients were screened; 217 patients had a suspected CNS infection and 44 (20%) had a CNS infection: 18 aseptic meningitis (one herpes simplex virus [HSV]-2), 13 purulent meningitis (four Streptococcus pneumoniae) and 13 encephalitis (three HSV-1). The median (range) time from admission to suspicion of CNS infection and to LP was longer for patients with encephalitis than meningitis [4 (0.3-312) vs. 0.3 (0.1-12) h, P<0.001, and 23 (4-360) vs. 12 (2-48) h, P=0.042, respectively]; and the median time to treatment was longer for aciclovir than cephalosporin [7 (0.5-312) vs. 3 (0.3-312) h, P=0.002].

DISCUSSION

Encephalitis was as common as purulent meningitis, and HSV as common as Streptococcus pneumoniae. However, the management of patients with encephalitis was worse than meningitis. National encephalitis guidelines are needed.

The momentum of human behavior in a natural setting

Adults with mental retardation in a group home received popcorn or coffee reinforcers for sorting plastic dinnerware. In Part 1 of the experiment, reinforcers were dispensed according to a variable-interval 60-s schedule for sorting dinnerware of one color and according to a variable-interval 240-s schedule for sorting dinnerware of a different color in successive components of a multiple schedule. Sorting rates were similar in baseline, but when a video program was shown concurrently, sorting of dinnerware was more resistant to distraction when correlated with a higher rate of reinforcement. In Part 2 of the experiment, popcorn or coffee reinforcers were contingent upon sorting both colors of dinnerware according to variable-interval 60-s schedules, but additional reinforcers were given independently of sorting according to a variable-time 30-s schedule during one dinnerware-color component. Baseline sorting rate was lower but resistance to distraction by the video program was greater in the component with additional variable-time reinforcers. These results demonstrate that resistance to distraction depends on the rate of reinforcers obtained in the presence of component stimuli but is independent of baseline response rates and response-reinforcer contingencies. Moreover, these results are similar to those obtained in laboratory studies with pigeons, demonstrating that the determination of resistance to change by stimulus-reinforcer relations is not confined to controlled laboratory settings or unique to the pigeon.

The clinical, histochemical, and molecular spectrum of PEO1 (Twinkle)-linked adPEO

BACKGROUND

Mutations in the Twinkle (PEO1) gene are a recognized cause of autosomal dominant progressive external ophthalmoplegia (adPEO), resulting in the accumulation of multiple mitochondrial DNA (mtDNA) deletions and cytochrome c oxidase (COX)-deficient fibers in skeletal muscle secondary to a disorder of mtDNA maintenance. Patients typically present with isolated extraocular muscle involvement, with little apparent evidence of the clinical heterogeneity documented in other mtDNA maintenance disorders, in particular POLG-related disease.

METHODS

We reviewed the clinical, histochemical, and molecular genetics analysis of 33 unreported patients from 26 families together with all previous cases described in the literature to define the clinical phenotype associated with PEO1 mutations.

RESULTS

Ptosis and ophthalmoparesis were almost universal clinical features among this cohort, with 52% (17/33) reporting fatigue and 33% (11/33) having mild proximal myopathy. Features consistent with CNS involvement were rarely described; however, in 24% (8/33) of the patients, cardiac abnormalities were reported. Mitochondrial histochemical changes observed in muscle showed remarkable variability, as did the secondary mtDNA deletions, which in some patients were only detected by PCR-based assays and not Southern blotting. Moreover, we report 7 novel PEO1 variants.

CONCLUSIONS

Our data suggest a shared clinical phenotype with variable mild multiorgan involvement, and that the contribution of PEO1 mutations as a cause of adPEO may well be underestimated. Direct sequencing of the PEO1 gene should be considered in adPEO patients prior to muscle biopsy.

Service user involvement and the restrictive sense of psychiatric categories: the challenge facing mental health nurses

The active involvement of those people who have at one time used, or who continue to use, mental health services has come to be seen as a central feature of both the policy and the practice of modern mental health care. However, while those people who use mental health services may face a variety of obstacles to active participation in their care and in the provision of mental health services more generally, this paper will draw on the work of Gilles Deleuze, arguably one of the most important philosophers of the late 20th century, to suggest that the language of psychiatry--and, in particular, the attendant valuations or 'sense' of psychiatry's diagnostic categories--serve to restrict the participation of people in their individual care and in the provision of mental health services. Accordingly, it will be suggested that the challenge, as well as the opportunity, that confronts mental health nurses is to facilitate greater, more active user participation by practising in a manner that elicits the resources, capabilities and potential that service users possess, thereby challenging the prevailing and restrictive sense of the diagnostic categories by which people are identified, and by which they come to identify themselves.

Indications of proton-dominated cosmic-ray composition above 1.6 EeV

We report studies of ultrahigh-energy cosmic-ray composition via analysis of depth of air shower maximum (X(max)), for air shower events collected by the High-Resolution Fly's Eye (HiRes) observatory. The HiRes data are consistent with a constant elongation rate d<X(max)>/d[log(E)] of 47.9+/-6.0(stat)+/-3.2(syst) g/cm2/decade for energies between 1.6 and 63 EeV, and are consistent with a predominantly protonic composition of cosmic rays when interpreted via the QGSJET01 and QGSJET-II high-energy hadronic interaction models. These measurements constrain models in which the galactic-to-extragalactic transition is the cause of the energy spectrum ankle at 4x10(18) eV.

Emotional intelligence, empathy and the educative power of poetry: a Deleuzo-Guattarian perspective

The concept of emotional intelligence is gaining increasing precedence in the nursing literature, with particular emphasis placed upon its importance for various aspects of the nursing profession and the demand for greater attention to be given to its development in the education of nurses. Accordingly, this paper will seek to contribute to this emerging body of research by proposing that the employment of poetry in the education of mental health nurses provides a valuable opportunity for the development of emotional intelligence and, in particular, the development of one of the central characteristics of emotional intelligence; namely, empathy. Moreover, while the nature of the relationship between nursing and the arts is gaining increasing attention, this paper will focus upon the account of art given by Gilles Deleuze - one of the most important philosophers of the 20th century - and his long-time collaborator Felix Guattari. In particular, in order to develop a Deleuzo-Guattarian account of the educative power of poetry, and the manner in which it provides a valuable opportunity for the development of emotional intelligence, and of empathy in particular, this paper will employ their account of the 'percept' and the 'affect', introduced in their final collaborative work What is Philosophy?