Development of a core descriptor set for Crohn's anal fistula

AIM

Crohn's anal fistula (CAF) is a complex condition, with no agreement on which patient characteristics should be routinely reported in studies. The aim of this study was to develop a core descriptor set of key patient characteristics for reporting in all CAF research.

METHOD

Candidate descriptors were generated from published literature and stakeholder suggestions. Colorectal surgeons, gastroenterologists and specialist nurses in inflammatory bowel disease took part in three rounds of an international modified Delphi process using nine-point Likert scales to rank the importance of descriptors. Feedback was provided between rounds to allow refinement of the next ratings. Patterns in descriptor voting were assessed using principal component analysis (PCA). Resulting PCA groups were used to organize items in rounds two and three. Consensus descriptors were submitted to a patient panel for feedback. Items meeting predetermined thresholds were included in the final set and ratified at the consensus meeting.

RESULTS

One hundred and thirty three respondents from 22 countries completed round one, of whom 67.0% completed round three. Ninety seven descriptors were rated across three rounds in 11 PCA-based groups. Forty descriptors were shortlisted. The consensus meeting ratified a core descriptor set of 37 descriptors within six domains: fistula anatomy, current disease activity and phenotype, risk factors, medical interventions for CAF, surgical interventions for CAF, and patient symptoms and impact on quality of life.

CONCLUSION

The core descriptor set proposed for all future CAF research reflects characteristics important to gastroenterologists and surgeons. This might aid transparent reporting in future studies.

630 Hailey-Hailey Disease: A Rare Presentation in the Hypopharnyx

Background

Hailey-Hailey disease or familial benign pemphigus is a rare genetic blistering skin disease due to mutation of the ATP2C1 gene inherited in autosomal dominant fashion. Prevalence is around 1 in 50,000 and positive family history is observed in 75% of cases. Patients typically present with well-demarcated painful erosive and yellow-crusted rash in the skin folds, following a relapsing-remitting pattern. There are very limited known cases of extra-dermatological presentation of this disease.

Case

64-year-old gentleman presented with dysphagia, hoarseness, sore throat, dry cough, and intermittent haemoptysis. Initial flexible nasendoscopy showed mild erythema of epiglottis and false cords, post-cricoid oedema and very mild Reinke's oedema. He was treated as acid reflux with omeprazole but to little effect. Endoscopy 4 months later showed similar findings hence biopsy of the hypopharynx was taken. The sample demonstrated intraepithelial clefting, suspicious of intraepithelial vesiculobullous disorder particularly pemphigus vulgaris.

Looking into this gentleman's medical history, it was found that he is under the care of dermatology for Hailey-Hailey disease, which he was diagnosed 30 years ago. He also has a strong family history of this condition. Based on the biopsy findings and patient profile, it was concluded that this gentleman has a hypopharyngeal manifestation of Hailey-Hailey disease.

Discussion

Hailey-Hailey disease is traditionally described as a dermatological condition. This gentleman is one of the rare few cases of non-dermatological manifestation of this disease.

715 Implementation of Enhanced Recovery After Surgery (ERAS) in Total Laryngectomies

Aim

The Enhanced Recovery After Surgery (ERAS) protocol for total laryngectomies was first implemented in our tertiary head and neck centre from November 2019. It includes pre-operative carbohydrate loading and an early swallow test which facilitates recommencement of oral intake to improve outcomes. Protocol adherence rate and patient outcomes were measured to determine the effectiveness and benefits of ERAS in laryngectomy patients.

Method

22 total laryngectomy patients from November 2019 to September 2021 were enrolled onto the ERAS protocol, 18 primary and 3 salvage cases. An analysis of the respective patient cohorts was performed to determine adherence to the ERAS protocol and outcomes such as complications and length of inpatient stay were measured.

Results

19 patients (86%) received pre-operative carbohydrate loading successfully, while 3 patients were contraindicated due to background of diabetes. Early swallow test was performed in 59% of patients. Potential reasons for delay were stoma dehiscence or clinical suspicion of neo-pharyngeal leak. 59% of primary cases were deemed medically fit for discharge within the target timeframe of 12–14 days whereas no target was set for salvage cases due to expected poor healing. Main complication in primary cases was neo-pharyngeal leak followed by stoma dehiscence with 28% and 11% respectively.

Conclusion

Limitations of our study include small sample size due to the COVID-19 pandemic. Despite its infancy, the ERAS protocol has achieved good outcomes in early recommencement of oral intake post-laryngectomy and encouraging early safe discharge from hospital. Future plans include establishment of Prehab Clinic and application of ERAS to neck dissection patients.

Persistent infection with neurotropic herpes viruses and cognitive impairment

BACKGROUND

Herpes virus infections can cause cognitive impairment during and after acute encephalitis. Although chronic, latent/persistent infection is considered to be relatively benign, some studies have documented cognitive impairment in exposed persons that is untraceable to encephalitis. These studies were conducted among schizophrenia (SZ) patients or older community dwellers, among whom it is difficult to control for the effects of co-morbid illness and medications. To determine whether the associations can be generalized to other groups, we examined a large sample of younger control individuals, SZ patients and their non-psychotic relatives (n=1852). Method Using multivariate models, cognitive performance was evaluated in relation to exposures to herpes simplex virus type 1 (HSV-1), herpes simplex virus type 2 (HSV-2) and cytomegalovirus (CMV), controlling for familial and diagnostic status and sociodemographic variables, including occupation and educational status. Composite cognitive measures were derived from nine cognitive domains using principal components of heritability (PCH). Exposure was indexed by antibodies to viral antigens.

RESULTS

PCH1, the most heritable component of cognitive performance, declines with exposure to CMV or HSV-1 regardless of case/relative/control group status (p = 1.09 × 10-5 and 0.01 respectively), with stronger association with exposure to multiple herpes viruses (β = -0.25, p = 7.28 × 10-10). There were no significant interactions between exposure and group status.

CONCLUSIONS

Latent/persistent herpes virus infections can be associated with cognitive impairments regardless of other health status.

Microbicide dosage forms

Microbicides are topically applied, user controlled dosage forms that are being developed to prevent the transmission of HIV during coitus. Early candidates focused on coitally dependent dosage forms such as gels and creams. More recent development has focused on broadening the coitally dependent options through the introduction of films and fast dissolving tablets. Additionally, it has become important to have longer acting products to minimize the burden of user compliance and thus vaginal rings have been developed providing sustained delivery of antiretroviral drugs. This chapter discusses the history of microbicides along with a detailed description of coitally dependent products, gels, films, tablets diaphragms, as well as coitally independent dosage forms such as vaginal rings and the introduction of a new technology, electrospun fibers.

Heritability of functioning in families with schizophrenia in relation to neurocognition

The role of daily functioning is an integral part of the schizophrenia (SZ) phenotype and deficits in this trait appear to be present in both affected persons and some unaffected relatives; hence we have examined its heritability in our cohort of African American schizophrenia families. There is now ample evidence that deficits in cognitive function can impact family members who are not themselves diagnosed with SZ; there is some, but less evidence that role function behaves likewise. We evaluate whether role function tends to "run in families" who were ascertained because they contain an African American proband diagnosed with SZ.

METHODS

We analyzed heritability for selected traits related to daily function, employment, living situation, marital status, and Global Assessment Scale (GAS) score; modeling age, gender, along with neurocognition and diagnosis as covariates in a family based African-American sample (N=2488 individuals including 979 probands).

RESULTS

Measures of role function were heritable in models including neurocognitive domains and factor analytically derived neurocognitive summary scores and demographics as covariates; the most heritable estimate was obtained from the current GAS scores (h2=0.72). Neurocognition was not a significant contributor to heritability of role function.

CONCLUSIONS

Commonly assessed demographic and clinical indicators of functioning are heritable with a global rating of functioning being the most heritable. Measures of neurocognition had little impact on heritability of functioning overall. The family covariance for functioning, reflected in its heritability, supports the concept that interventions at the family level, such as evidenced-based family psychoeducation may be beneficial in schizophrenia.

Using linkage information to weight a genome-wide association of bipolar disorder

Issues of multiple-testing and statistical significance in genomewide association studies (GWAS) have prompted statistical methods utilizing prior data to increase the power of association results. Using prior findings from genome-wide linkage studies on bipolar disorder (BPD), we employed a weighted false discovery approach (wFDR; [Roeder et al. 2006. Am J Hum Genet 78(2): 243–252]) to previously reported GWAS data drawn from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Using this method, association signals are up or down-weighted given the linkage score in that genomic region. Although no SNPs in our sample reached genome-wide significance through the wFDR approach, the strongest single SNP result from the original GWAS results (rs4939921 in myosin VB) is strongly up-weighted as it occurs on a linkage peak of chromosome 18. We also identify regions on chromosome 9, 17, and 18 where modestly associated SNP clusters coincide with strong linkage scores, implicating them as possible candidate regions for further analysis. Moving forward, we believe the application of prior linkage information will be increasingly useful to future GWAS studies that incorporate rarer variants into their analysis.

Gene flow by pollen into small populations: Data from experimental and natural stands of wild radish

Gene flow can have an especially strong impact on the evolution of small populations. However, empirical studies on the actual rates and patterns of gene flow into small populations are few. Thus, we sought to measure gene flow into small populations of wild radish. Raphanus sativus. We found significant differences in gene flow receipt among experimental populations and within those populations over a season. A maximum-likelihood estimate revealed that almost all of the gene flow into these synthetic populations had its origin in relatively distant (>650 m), large natural populations rather than the proximal (255-400 m), small synthetic populations. We also estimated rates of interpopulation mating from simple paternity analysis of progeny produced by seven small (ca. 50 plants) natural populations. Again, we found significant heterogeneity in gene flow receipt. Although these populations varied 10-fold in their range of isolation distances (100-1000 m), gene flow rates did not vary with distance. The magnitude of gene flow rates estimated in all but one population was great enough for gene flow to play an important role in the evolution of these small populations.

Pleiotropy and principal components of heritability combine to increase power for association analysis

When many correlated traits are measured the potential exists to discover the coordinated control of these traits via genotyped polymorphisms. A common statistical approach to this problem involves assessing the relationship between each phenotype and each single nucleotide polymorphism (SNP) individually (PHN); and taking a Bonferroni correction for the effective number of independent tests conducted. Alternatively, one can apply a dimension reduction technique, such as estimation of principal components, and test for an association with the principal components of the phenotypes (PCP) rather than the individual phenotypes. Building on the work of Lange and colleagues we develop an alternative method based on the principal component of heritability (PCH). For each SNP the PCH approach reduces the phenotypes to a single trait that has a higher heritability than any other linear combination of the phenotypes. As a result, the association between a SNP and derived trait is often easier to detect than an association with any of the individual phenotypes or the PCP. When applied to unrelated subjects, PCH has a drawback. For each SNP it is necessary to estimate the vector of loadings that maximize the heritability over all phenotypes. We develop a method of iterated sample splitting that uses one portion of the data for training and the remainder for testing. This cross-validation approach maintains the type I error control and yet utilizes the data efficiently, resulting in a powerful test for association.

Improving power in genome-wide association studies: weights tip the scale

The potential of genome-wide association analysis can only be realized when they have power to detect signals despite the detrimental effect of multiple testing on power. We develop a weighted multiple testing procedure that facilitates the input of prior information in the form of groupings of tests. For each group a weight is estimated from the observed test statistics within the group. Differentially weighting groups improves the power to detect signals in likely groupings. The advantage of the grouped-weighting concept, over fixed weights based on prior information, is that it often leads to an increase in power even if many of the groupings are not correlated with the signal. Being data dependent, the procedure is remarkably robust to poor choices in groupings. Power is typically improved if one (or more) of the groups clusters multiple tests with signals, yet little power is lost when the groupings are totally random. If there is no apparent signal in a group, relative to a group that appears to have several tests with signals, the former group will be down-weighted relative to the latter. If no groups show apparent signals, then the weights will be approximately equal. The only restriction on the procedure is that the number of groups be small, relative to the total number of tests performed.

Paediatric airway emergencies in Northern Ireland, 1990–2003

The management of paediatric airway emergencies is part of ENT practice. The most common conditions are acute viral laryngotracheobronchitis (croup), acute epiglottitis and bacterial tracheitis. Management of these conditions is significantly different and accurate diagnosis is crucial. We performed a retrospective analysis of all acute airway admissions to the paediatric intensive care unit (PICU) at the Royal Belfast Hospital for Sick Children from 1990 to 2003. The results showed a gradual decrease in the number of admissions due to croup. Acute epiglottitis admissions decreased markedly after 1992 but rose again in 2000, with a peak in 2002. Bacterial tracheitis is now the most common paediatric airway emergency requiring PICU admission and its incidence has been steadily increasing since 1990, peaking in 2003. The total number of admissions showed little change over the 14-year period audited. The significant shift in the nature of these conditions and these findings confirm the ongoing requirement for caution in dealing with a suspected airway emergency.

Association study of eight circadian genes with bipolar I disorder, schizoaffective disorder and schizophrenia

We hypothesize that circadian dysfunction could underlie, at least partially, the liability for bipolar 1 disorder (BD1). Our hypothesis motivated tests for the association between the polymorphisms of genes that mediate circadian function and liability for BD1. The US Caucasian patients with BD1 (DSM-IV criteria) and available parents were recruited from Pittsburgh and surrounding areas (n = 138 cases, 196 parents) and also selected from the NIMH Genetics Collaborative Initiative (n = 96 cases, 192 parents). We assayed 44 informative single-nucleotide polymorphisms (SNPs) from eight circadian genes in the BD1 samples. A population-based sample, specifically cord blood samples from local live births, served as community-based controls (n = 180). It was used as a contrast for genotype and haplotype distributions with those of patients. US patients with schizophrenia/schizoaffective disorder (SZ/SZA, n = 331) and available parents from Pittsburgh (n = 344) were assayed for a smaller set of SNPs based on the results from the BD1 samples. Modest associations with SNPs at ARNTL (BmaL1) and TIMELESS genes were observed in the BD1 samples. The associations were detected using family-based and case-control analyses, albeit with different SNPs. Associations with TIMELESS and PERIOD3 were also detected in the Pittsburgh SZ/SZA group. Thus far, evidence for association between specific SNPs at the circadian gene loci and BD1 is tentative. Additional studies using larger samples are required to evaluate the associations reported here.

Using linkage genome scans to improve power of association in genome scans

Scanning the genome for association between markers and complex diseases typically requires testing hundreds of thousands of genetic polymorphisms. Testing such a large number of hypotheses exacerbates the trade-off between power to detect meaningful associations and the chance of making false discoveries. Even before the full genome is scanned, investigators often favor certain regions on the basis of the results of prior investigations, such as previous linkage scans. The remaining regions of the genome are investigated simultaneously because genotyping is relatively inexpensive compared with the cost of recruiting participants for a genetic study and because prior evidence is rarely sufficient to rule out these regions as harboring genes with variation of conferring liability (liability genes). However, the multiple testing inherent in broad genomic searches diminishes power to detect association, even for genes falling in regions of the genome favored a priori. Multiple testing problems of this nature are well suited for application of the false-discovery rate (FDR) principle, which can improve power. To enhance power further, a new FDR approach is proposed that involves weighting the hypotheses on the basis of prior data. We present a method for using linkage data to weight the association P values. Our investigations reveal that if the linkage study is informative, the procedure improves power considerably. Remarkably, the loss in power is small, even when the linkage study is uninformative. For a class of genetic models, we calculate the sample size required to obtain useful prior information from a linkage study. This inquiry reveals that, among genetic models that are seemingly equal in genetic information, some are much more promising than others for this mode of analysis.

Autism and the serotonin transporter: the long and short of it

Autism is a neurodevelopmental disorder manifesting early in childhood. Some symptoms of autism are alleviated by treatment with selective serotonin reuptake inhibitors, which are known to interact with the serotonin transporter. Moreover, variation in the gene that encodes the transporter (SLC6A4), especially the HTTLPR locus, is known to modulate its expression. It is natural, therefore, to evaluate whether this variation plays a role in liability to autism. We investigated the impact of alleles at HTTLPR and three other loci in SLC6A4 by using a large, independent family-based sample (390 families, 1528 individuals) from the NIH Collaborative Programs of Excellence in Autism (CPEA) network. Allele transmissions to individuals diagnosed with autism were biased only for HTTLPR, both for the narrow diagnosis of autism (P=0.035) and for the broader diagnosis of autism spectrum (P=0.007). The short allele of HTTLPR was significantly overtransmitted. Investigation of haplotype transmissions suggested that, in our data, biased transmission was only due to HTTLPR. With respect to this locus, there are now seven of 12 studies reporting significant transmission bias of HTTLPR alleles, a noteworthy result in itself. However, the studies with significant findings are almost equally divided between overtransmission of short and overtransmission of long alleles. We place our results within this extremely heterogeneous field of studies. Determining the factors influencing the relationship between autism phenotypes and HTTLPR variation, as well as other loci in SLC6A4, could be an important advance in our understanding of this complex disorder.

Catechol-O-methyltransferase haplotypes are associated with psychosis in Alzheimer disease

Psychotic symptoms in subjects with Alzheimer disease (AD with psychosis, AD+P) define a phenotype characterized by greater cognitive burden than in AD without psychosis. We have proposed that genes of small effect may contribute to the risk for expression of psychosis in multiple disorders, including AD. Recently, sex-differential association of a three-locus haplotype, including a G-->A transition at codon 108/158 of catechol-O-methyltransferase (COMT) resulting in a Val-->Met substitution, has been reported to confer an increased risk for schizophrenia. The main objective of the study was to determine if COMT genetic variation is associated with risk of psychosis in AD, and included a case-control study of 373 individuals diagnosed with AD with, or without, psychosis. All subjects were characterized for alleles at the three loci associated with schizophrenia, RS737865, COMT G-->A 108/158 (RS4680), and RS165599, and for a C/T transition adjacent to an estrogen response element (ERE6) in the COMT P2 promoter region. Both single locus and haplotype tests of association were conducted. Logit models were used to examine independent and interacting effects of alleles at the associated loci. All analyses were stratified by sex. In female subjects, RS4680 demonstrated a modest association with AD+P; RS737865 demonstrated a trend towards an association. There was a highly significant association of AD+P with the four-locus haplotype, which resulted from additive effects of alleles at RS4680 and ERE6 (or RS737865, as this locus was in almost absolute linkage disequilibrium (LD) with ERE6). In male subjects, no single locus test was significant, but there remained a strong association between AD+P and the four-locus haplotype. This association appeared to result from interaction of the ERE6/RS737865, RS4680, and RS165599 loci. Genetic variation in COMT is associated with AD+P, and thus appears to contribute to psychosis risk across disorders. Sex-differential associations of COMT with psychosis may result from variation at, or in LD with, ERE6. Examination of variation at ERE6 in subjects with schizophrenia, and further examination of the independent and additive effects of variations in COMT on gene expression, is warranted.

Combined analysis from eleven linkage studies of bipolar disorder provides strong evidence of susceptibility loci on chromosomes 6q and 8q

Several independent studies and meta-analyses aimed at identifying genomic regions linked to bipolar disorder (BP) have failed to find clear and consistent evidence of linkage regions. Our hypothesis is that combining the original genotype data provides benefits of increased power and control over sources of heterogeneity that outweigh the difficulty and potential pitfalls of the implementation. We conducted a combined analysis using the original genotype data from 11 BP genomewide linkage scans comprising 5,179 individuals from 1,067 families. Heterogeneity among studies was minimized in our analyses by using uniform methods of analysis and a common, standardized marker map and was assessed using novel methods developed for meta-analysis of genome scans. To date, this collaboration is the largest and most comprehensive analysis of linkage samples involving a psychiatric disorder. We demonstrate that combining original genome-scan data is a powerful approach for the elucidation of linkage regions underlying complex disease. Our results establish genomewide significant linkage to BP on chromosomes 6q and 8q, which provides solid information to guide future gene-finding efforts that rely on fine-mapping and association approaches.

Brain-derived neurotrophic factor variants are associated with childhood-onset mood disorder: confirmation in a Hungarian sample

Brain-derived neurotrophic factor (BDNF) is a nerve growth factor that has been implicated in the neurobiology of depression. Our group has previously reported an association between a BDNF variant and childhood-onset mood disorder (COMD) in an adult sample from Pittsburgh. We hypothesize that variants at the BDNF locus are associated with COMD. Six BDNF polymorphisms were genotyped in 258 trios having juvenile probands with childhood-onset DSM-IV major depressive or dysthymic disorder. BDNF markers included the (GT)n microsatellite, Val66Met and four other single-nucleotide polymorphisms (SNPs) distributed across the BDNF gene. Family-based association and evolutionary haplotype analysis methods were used. Analysis of linkage disequilibrium (LD) revealed substantial LD among all six polymorphisms. Analyses of the Val66Met polymorphism demonstrated significant overtransmission of the val allele (chi2=7.12, d.f.=1, P=0.0076). Consistent with the pattern of LD, all other SNPs showed significant biased transmission. The (GT)n microsatellite alleles also indicated a trend towards biased transmission (170 bp: Z=2.095, P=0.036). Significant haplotypes involved Val66Met and BDNF2 (P=0.0029). In this Hungarian sample, we found all five BDNF SNPs tested and a haplotype containing the BDNF Val66Met Val allele to be associated with COMD. These results provide evidence that BDNF variants affect liability to juvenile-onset mood disorders, supported by data from two independent samples.

Characterization of multilocus linkage disequilibrium

Linkage disequilibrium (LD) in the human genome, often measured as pairwise correlation between adjacent markers, shows substantial spatial heterogeneity. Congruent with these results, studies have found that certain regions of the genome have far less haplotype diversity than expected if the alleles at multiple markers were independent, while other sets of adjacent markers behave almost independently. Regions with limited haplotype diversity have been described as "blocked" or "haplotype blocks." In this article, we propose a new method that aims to distinguish between blocked and unblocked regions in the genome. Like some other approaches, the method analyses haplotype diversity. Unlike other methods, it allows for adjacent, distinct blocks and also multiple, independent single nucleotide polymorphisms (SNPs) separating blocks. Based on an approximate likelihood model and a parsimony criterion to penalize for model complexity, the method partitions a genomic region into blocks relatively quickly, and simulations suggest that its partitions are accurate. We also propose a new, efficient method to select SNPs for association analysis, namely tag SNPs. These methods compare favorably to similar blocking and tagging methods using simulations.

Analysis of single-locus tests to detect gene/disease associations

A goal of association analysis is to determine whether variation in a particular candidate region or gene is associated with liability to complex disease. To evaluate such candidates, ubiquitous Single Nucleotide Polymorphisms (SNPs) are useful. It is critical, however, to select a set of SNPs that are in substantial linkage disequilibrium (LD) with all other polymorphisms in the region. Whether there is an ideal statistical framework to test such a set of 'tag SNPs' for association is unknown. Compared to tests for association based on frequencies of haplotypes, recent evidence suggests tests for association based on linear combinations of the tag SNPs (Hotelling T(2) test) are more powerful. Following this logical progression, we wondered if single-locus tests would prove generally more powerful than the regression-based tests? We answer this question by investigating four inferential procedures: the maximum of a series of test statistics corrected for multiple testing by the Bonferroni procedure, T(B), or by permutation of case-control status, T(P); a procedure that tests the maximum of a smoothed curve fitted to the series of of test statistics, T(S); and the Hotelling T(2) procedure, which we call T(R). These procedures are evaluated by simulating data like that from human populations, including realistic levels of LD and realistic effects of alleles conferring liability to disease. We find that power depends on the correlation structure of SNPs within a gene, the density of tag SNPs, and the placement of the liability allele. The clearest pattern emerges between power and the number of SNPs selected. When a large fraction of the SNPs within a gene are tested, and multiple SNPs are highly correlated with the liability allele, T(S) has better power. Using a SNP selection scheme that optimizes power but also requires a substantial number of SNPs to be genotyped (roughly 10-20 SNPs per gene), power of T(P) is generally superior to that for the other procedures, including T(R). Finally, when a SNP selection procedure that targets a minimal number of SNPs per gene is applied, the average performances of T(P) and T(R) are indistinguishable.

Newspaper coverage of a violent assault by a mentally ill person

The media is an important source of public information on mental ill-health. A man with a serious psychiatric illness attacked a minister with a knife at a Remembrance Sunday service in a remote, rural part of the Highlands, inflicting a severe facial wound. We aimed to identify lessons for the National Health Service (NHS) from the media coverage of the incident and of a subsequent court case and NHS Highland inquiry and in addition to explore how newspaper reporters approached reporting such incidents. We searched local and regional, national Scottish, and the Scottish editions of three UK newspapers for relevant coverage. We also conducted structured telephone interviews with eight reporters who had attended the inquiry press conference. Most of the media coverage was associated with the assault and the court case, rather than the inquiry results. Only three of 10 inquiry recommendations were mentioned in any reports. Coverage largely dealt with identified shortfalls, rather than proposed solutions. The NHS had made little comment in advance of the announcement of the inquiry results. Most of the newspaper coverage had already occurred. The NHS therefore limited its opportunity to influence newspaper coverage. The interpretation of the results is limited by the size of the study, but the coverage of such events forms part of the discourse on mental health in the media episodes and may have some affect on public perception of mental health issues. We conclude that, without providing confidential information, the NHS should take a more active stance in providing information on the nature and treatment of mental illness in such instances, even in advance of court cases.

Association study of brain-derived neurotrophic factor in adults with a history of childhood onset mood disorder

Brain-derived neurotrophic factor (BDNF) is a nerve growth factor that has antidepressant-like effects in animals. BDNF gene polymorphisms have been associated with bipolar disorder. We tested two genetic polymorphisms of BDNF for their association with childhood-onset mood disorders (COMD) within the context of a case-control design. Two BDNF polymorphisms, a dinucleotide repeat (GT)(n), and a single nucleotide polymorphism (SNP) in the coding region, val66met, were genotyped in 99 adults with a history of COMD and matched psychiatrically healthy controls. A genomic control (GC) method was used to evaluate population substructure. Alleles at (GT)(n) were highly associated with COMD in this sample (chi(2) = 17.8; d.f. = 5; P = 0.0032). The odds of carrying the 168 bp allele were 3.94 times greater for cases than controls (CI = 1.72-9.04). Alleles of val66met were not significantly associated with COMD. GC analysis suggested population substructure was not a confounder of association. Analysis of haplotypes, in which (GT)(n) was treated as a binary variable (long vs. short alleles), provided significant evidence that the haplotype val/short contributes to liability to COMD. The BDNF (GT)(n) marker and the val/short haplotype are associated with COMD in this sample, in accordance with the previously described neurotrophic hypothesis of depression and some previous studies of association for bipolar disorder and neuroticism.

Yield of human adipose-derived adult stem cells from liposuction aspirates

BACKGROUND

Primary cultures of isolated human adipose-derived adult stem (ADAS) cells are multipotent and differentiate in vitro along the adipocyte, chondrocyte, neuronal, osteoblast, and skeletal muscle pathways.

METHODS

We examined the ADAS cell yield per unit volume of liposuction tissue, and their surface protein phenotype by flow cytometry. Adipogenesis was assessed by Oil Red O staining and ELISA analysis of leptin secretion.

RESULTS

The donor population was 87.5% female (n=18) with a mean age (+/-SD) of 44+/-10 years and body mass index (BMI) of 24.9+/-2.7. The mean cell yield was 404 000+/-206 000 cells per milliliter of lipoaspirate (n=18). Linear regression analysis of the cells derived from the female donors demonstrated a significant negative correlation between the number of cells obtained per milliliter of lipoaspirate with the BMI but not the age of the donor. The undifferentiated ADAS cells were homogeneously positive for the cell-surface markers CD10, CD13, CD29, CD44, CD49e, CD59, CD90, and HLA-ABC, and homogeneously negative for the cell surface markers CD11b, CD45, and HLA-DR. The absence of the panhematopoietic marker, CD45, indicates that the ADAS cells do not derive from circulating BM hematopoietic stem cells. Adipocyte differentiation led to a 5.1-fold increase in Oil Red O staining, and a 196-fold increase in leptin secretion levels. Culture of the cells in the presence of antibiotic and fungizone did not alter the undifferentiated ADAS cell immunophenotype based on flow cytometry, or their adipocyte differentiation based on leptin secretion.

DISCUSSION

The ability to isolate a consistently homogeneous population of undifferentiated adult stem cells from adipose tissue of multiple donors supports their potential utility in future tissue-engineering applications.

Role of different B-cell subsets in the specific and polyclonal immune response to T-independent antigens type 2

Role of different B-cell subsets in the immune response to T-independent antigen type 2 (TI-2) was studied. BALB/c and C57BL/6 mice were immunized by polyvinylpyrrolidon (PVP), and the numbers of antibody- and Ig-forming cells (AFC and IFC, respectively) were determined by ELISPOT method. The number of cells producing non-specific Ig (nIFC) was calculated as the difference between the number of IFC and AFC; the number of nIFC induced by PVP was calculated as the difference between the number of nIFC in immune and control splenocytes. Immunization by PVP induced not only the AFC appearance, but also the increase in the number of the antigen-induced nIFC. The treatment of splenocytes by anti-CD5 antibodies and guinea pig complement reduced the increase in the numbers of newly formed AFC and nIFC to approximately 40% of control level. It means that CD5+ cells play an important role not only in the specific, but also in polyclonal immune response to non-self TI-2. To be sure that the decrease of AFC and nIFC numbers is due to depletion for CD5+ B-cells, but not CD5+ T-cells, splenocytes were separated to B-1 and B-2 subsets, and the numbers of AFC, IFC and nIFC were determined in each B-cell subpopulation separately. The overwhelming majority of newly formed AFC and nIFC was detected in B-1 subset. The numbers of AFC and nIFC in B-1 compartment was approximately 10-fold greater than in B-2 cells. A close parallelism between AFC and nIFC formation was observed. It is concluded that specific and polyclonal immune response to non-self TI-2-PVP-depends mainly on CD5+ B-1 subset.

Evolutionary-based association analysis using haplotype data

Association studies, both family-based and population-based, can be powerful means of detecting disease-liability alleles. To increase the information of the test, various researchers have proposed targeting haplotypes. The larger number of haplotypes, however, relative to alleles at individual loci, could decrease power because of the additional degrees of freedom required for the test. An optimal strategy would focus the test on particular haplotypes or groups of haplotypes, much as is done with cladistic-based association analysis. First suggested by Templeton et al. ([1987] Genetics 117:343-351), such analyses use the evolutionary relationships among haplotypes to produce a limited set of hypothesis tests and to increase the interpretability of these tests. To more fully utilize the information contained in the evolutionary relationships among haplotypes and in the sample, we propose generalized linear models (GLM) for the analysis of data from family-based and population-based studies. These models fully account for haplotype phase ambiguity and allow for covariates. The models are encoded into a software package (the Evolutionary-Based Haplotype Analysis Package, EHAP), which also provides for various kinds of exploratory data analysis. The exploratory analyses, such as error checking, estimation of haplotype frequencies, and tools for building cladograms, should facilitate the implementation of cladistic-based association analysis with haplotypes.

Analysis of multilocus models of association

It is increasingly recognized that multiple genetic variants, within the same or different genes, combine to affect liability for many common diseases. Indeed, the variants may interact among themselves and with environmental factors. Thus realistic genetic/statistical models can include an extremely large number of parameters, and it is by no means obvious how to find the variants contributing to liability. For models of multiple candidate genes and their interactions, we prove that statistical inference can be based on controlling the false discovery rate (FDR), which is defined as the expected number of false rejections divided by the number of rejections. Controlling the FDR automatically controls the overall error rate in the special case that all the null hypotheses are true. So do more standard methods such as Bonferroni correction. However, when some null hypotheses are false, the goals of Bonferroni and FDR differ, and FDR will have better power. Model selection procedures, such as forward stepwise regression, are often used to choose important predictors for complex models. By analysis of simulations of such models, we compare a computationally efficient form of forward stepwise regression against the FDR methods. We show that model selection includes numerous genetic variants having no impact on the trait, whereas FDR maintains a false-positive rate very close to the nominal rate. With good control over false positives and better power than Bonferroni, the FDR-based methods we introduce present a viable means of evaluating complex, multivariate genetic models. Naturally, as for any method seeking to explore complex genetic models, the power of the methods is limited by sample size and model complexity.

On the identification of disease mutations by the analysis of haplotype similarity and goodness of fit

The observation that haplotypes from a particular region of the genome differ between affected and unaffected individuals or between chromosomes transmitted to affected individuals versus those not transmitted is sound evidence for a disease-liability mutation in the region. Tests for differentiation of haplotype distributions often take the form of either Pearson's chi(2) statistic or tests based on the similarity among haplotypes in the different populations. In this article, we show that many measures of haplotype similarity can be expressed in the same quadratic form, and we give the general form of the variance. As we describe, these methods can be applied to either phase-known or phase-unknown data. We investigate the performance of Pearson's chi(2) statistic and haplotype similarity tests through use of evolutionary simulations. We show that both approaches can be powerful, but under quite different conditions. Moreover, we show that the power of both approaches can be enhanced by clustering rare haplotypes from the distributions before performing a test.

Psychotic symptoms in Alzheimer disease: evidence for a distinct phenotype

Though efforts to identify the genetic etiology of Alzheimer disease (AD) have made substantial progress, to date only some of the genes contributing to AD risk have been identified. Utilization of more etiologically homogeneous subphenotypes represents one strategy to facilitate the identification of novel risk genes in complex disorders. In this review, we evaluate the hypothesis that psychotic symptoms, such as delusions and hallucinations, define a suitable subphenotype in AD patients for gene-mapping efforts. Psychotic symptoms occur in 40-60% of patients with AD and are associated with more severe cognitive deficits and a more rapidly deteriorating course. The presence of psychotic symptoms in AD confers increased risk of similar symptoms to affected siblings. Candidate gene association analyses and initial linkage analysis have yielded significant results. We discuss possible genetic models of psychotic symptoms in AD, and suggest strategies for further investigation. Identification of such genetic factors may facilitate gene-mapping studies for both AD and idiopathic psychoses.

Genome-wide multipoint linkage analyses of multiplex schizophrenia pedigrees from the oceanic nation of Palau

The oceanic nation of Palau has been geographically and culturally isolated over most of its 2000 year history. As part of a study of the genetic basis of schizophrenia in Palau, we genotyped five large, multigenerational schizophrenia pedigrees using markers every 10 cM (CHLC/Weber screening set 6). The number of affected/unaffected individuals genotyped per family ranged from 11/21 to 5/5. Thus the pedigrees varied in their information for linkage, but each was capable of producing a substantial LOD score. We fitted a simple dominant and recessive model to these data using multipoint linkage analysis implemented by Simwalk2. Predictably, the most informative pedigrees produced the best linkage results. After genotyping additional markers in the region, one pedigree produced a LOD = 3.4 (5q distal) under the dominant model. Seven of nine schizophrenics in the pedigree, mostly 3rd-4th degree relatives, share a 15-cM, 7-marker haplotype. For a different pedigree, another promising signal occurred on distal 3q, LOD = 2.6, for the recessive model. For two other pedigrees, the best LODs were modest, slightly better than 2.0 on 5q and 9p, while the fifth pedigree produced no noteworthy linkage signal. Similar to the results for other populations, our results suggest there are multiple genes conferring liability to schizophrenia even in the small population of Palau (roughly 21,000 individuals) in remote Oceania.

Significant linkage on chromosome 10p in families with bulimia nervosa

Bulimia nervosa (BN) is strongly familial, and additive genetic effects appear to contribute substantially to the observed familiality. In turn, behavioral components of BN, such as self-induced vomiting, are reliably measured and heritable. To identify regions of the genome harboring genetic variants conferring susceptibility to BN, we conducted a linkage analysis of multiplex families with eating disorders that were identified through a proband with BN. Linkage analysis of the entire sample of 308 families yielded a double peak, with the highest nonparametric multipoint maximum LOD score (MLS), of 2.92, on chromosome 10. Given the high heritability of self-induced vomiting and the reliability with which it can be measured, we performed linkage analysis in a subset (n=133) of families in which at least two affected relatives reported a symptom pattern that included self-induced vomiting. The highest MLS (3.39) observed was on chromosome 10, between markers D10S1430 and D10S1423. These results provide evidence of the presence of a susceptibility locus for BN on chromosome 10p. Using simulations, we demonstrate that both of these scores, 2.92 and 3.39, meet the widely accepted criterion for genomewide significance. Another region on 14q meets the criterion for genomewide suggestive linkage, with MLSs of 1.97 (full sample) and 1.75 (subset) at 62 centimorgans from p-ter.

Linkage analysis of Alzheimer disease with psychosis

Although a portion of risk for late-onset AD (LOAD) is attributable to APOE, the search for other loci is ongoing. The authors hypothesize that psychotic symptoms with LOAD (LOAD+P) identify a potentially more etiologically homogeneous form of AD. Linkage analysis of families with LOAD+P identified one significant and several suggestive novel linkage signals, which bolsters the conjecture of greater etiologic homogeneity.

Increased familial risk of the psychotic phenotype of Alzheimer disease

BACKGROUND

Psychotic symptoms in patients with AD (AD with psychosis [AD+P]) define a phenotype characterized by more rapid cognitive and functional decline and a liability to aggressive behaviors.

OBJECTIVE

To determine if AD+P aggregates within families.

METHODS

Case-control study of AD+P frequency in 461 siblings of 371 probands diagnosed with AD. All siblings were ascertained as part of a genetic investigation and also were diagnosed with AD. Statistical analysis used Generalized Estimating Equations to adjust for clustering within families.

RESULTS

AD+P in probands was associated with a significantly increased risk for AD+P in family members (OR, 2.41; 95% CI 1.46-4.0; p = 0.0006). The correlation among siblings for AD+P status was modest: 0.16.

CONCLUSION

AD+P demonstrates familial aggregation. Further studies are required to investigate a possible genetic basis of AD+P.

Unbiased methods for population-based association studies

Large, population-based samples and large-scale genotyping are being used to evaluate disease/gene associations. A substantial drawback to such samples is the fact that population substructure can induce spurious associations between genes and disease. We review two methods, called genomic control (GC) and structured association (SA), that obviate many of the concerns about population substructure by using the features of the genomes present in the sample to correct for stratification. The GC approach exploits the fact that population substructure generates "over dispersion" of statistics used to assess association. By testing multiple polymorphisms throughout the genome, only some of which are pertinent to the disease of interest, the degree of overdispersion generated by population substructure can be estimated and taken into account. The SA approach assumes that the sampled population, although heterogeneous, is composed of subpopulations that are themselves homogeneous. By using multiple polymorphisms throughout the genome, this "latent class method" estimates the probability sampled individuals derive from each of these latent subpopulations. GC has the advantage of robustness, simplicity, and wide applicability, even to experimental designs such as DNA pooling. SA is a bit more complicated but has the advantage of greater power in some realistic settings, such as admixed populations or when association varies widely across subpopulations. It, too, is widely applicable. Both also have weaknesses, as elaborated in our review.

Genomic control, a new approach to genetic-based association studies

During the past decade, mutations affecting liability to human disease have been discovered at a phenomenal rate, and that rate is increasing. For the most part, however, those diseases have a relatively simple genetic basis. For diseases with a complex genetic and environmental basis, new approaches are needed to pave the way for more rapid discovery of genes affecting liability. One such approach exploits large, population-based samples and large-scale genotyping to evaluate disease/gene associations. A substantial drawback to such samples is the fact that population heterogeneity can induce spurious associations between genes and disease. We describe a method called genomic control (GC), which obviates many of the concerns about population substructure by using the features of the genomes present in the sample to correct for stratification. Two such approaches are now available. The GC approach exploits the fact that population substructure generate "overdispersion" of statistics used to assess association. By testing multiple polymorphisms throughout the genome, only some of which are pertinent to the disease of interest, the degree of overdispersion generated by population substructure can be estimated and taken into account. The other approach, called Structured Association (SA), assumes that the sampled population, while heterogeneous, is composed of subpopulations that are themselves homogeneous. By using multiple polymorphisms throughout the genome, SA probabilistically assigns sampled individuals to these latent subpopulations. We review in detail the overdispersion GC. In addition to outlining the published ideas on this method, we describe several extensions: quantitative trait studies and case-control studies with haplotypes and multiallelic markers. For each study design our goal is to achieve control similar to that obtained for a family-based study, but with the convenience found in a population-based design.

Genome-wide distribution of linkage disequilibrium in the population of Palau and its implications for gene flow in Remote Oceania

Linkage disequilibrium (LD) between alleles on the same human chromosome results from various evolutionary processes and is thus telling about the history of populations. Recently, LD has garnered substantial interest for its value to map and fine-map disease genes. We examine the distribution of LD between short tandem repeat alleles on autosomes and sex chromosomes in the Remote Oceanic population of Palau to evaluate whether the data are consistent with a recent hypothesis about the origins of genetic variation in Palau, specifically that the population experienced extensive male-biased gene flow following initial settlement. Consistent with evolutionary theory based on effective population size, LD between X-linked alleles is stochastically greater than LD between autosomal alleles, however, small but detectable LD occurs for autosomal markers separated by substantial distances. By contrast, while Y-linked alleles experience only one-third the effective population size of X-linked alleles, their mean value for pairwise LD is only slightly larger than X-linked alleles. For a small population known to experience at least two extreme bottlenecks, 56 six-locus Y haplotypes exhibit remarkable diversity (0.96), comparable to Y diversity of Europeans, however, autosomal and X-linked markers display significantly less diversity, as measured by heterozygosity (4.1% less). Palauan Y haplotypes also fall into distinct clusters, again unlike that of Europe. We argue these data are consistent with waves of male-biased gene flow.

Transmission/disequilibrium test meets measured haplotype analysis: family-based association analysis guided by evolution of haplotypes

Family data teamed with the transmission/disequilibrium test (TDT), which simultaneously evaluates linkage and association, is a powerful means of detecting disease-liability alleles. To increase the information provided by the test, various researchers have proposed TDT-based methods for haplotype transmission. Haplotypes indeed produce more-definitive transmissions than do the alleles comprising them, and this tends to increase power. However, the larger number of haplotypes, relative to alleles at individual loci, tends to decrease power, because of the additional degrees of freedom required for the test. An optimal strategy would focus the test on particular haplotypes or groups of haplotypes. In this report we develop such an approach by combining the theory of TDT with that of measured haplotype analysis (MHA). MHA uses the evolutionary relationships among haplotypes to produce a limited set of hypothesis tests and to increase the interpretability of these tests. The theory of our approach, called the "evolutionary tree" (ET)-TDT, is developed for two cases: when haplotype transmission is certain and when it is not. Simulations show the ET-TDT can be more powerful than other proposed methods under reasonable conditions. More importantly, our results show that, when multiple polymorphisms are found within the gene, the ET-TDT can be useful for determining which polymorphisms affect liability.

Genomic control for association studies

A dense set of single nucleotide polymorphisms (SNP) covering the genome and an efficient method to assess SNP genotypes are expected to be available in the near future. An outstanding question is how to use these technologies efficiently to identify genes affecting liability to complex disorders. To achieve this goal, we propose a statistical method that has several optimal properties: It can be used with case control data and yet, like family-based designs, controls for population heterogeneity; it is insensitive to the usual violations of model assumptions, such as cases failing to be strictly independent; and, by using Bayesian outlier methods, it circumvents the need for Bonferroni correction for multiple tests, leading to better performance in many settings while still constraining risk for false positives. The performance of our genomic control method is quite good for plausible effects of liability genes, which bodes well for future genetic analyses of complex disorders.