The 8th International RASopathies Symposium: Expanding research and care practice through global collaboration and advocacy

Germline pathogenic variants in the RAS/mitogen-activated protein kinase (MAPK) signaling pathway are the molecular cause of RASopathies, a group of clinically overlapping genetic syndromes. RASopathies constitute a wide clinical spectrum characterized by distinct facial features, short stature, predisposition to cancer, and variable anomalies in nearly all the major body systems. With increasing global recognition of these conditions, the 8th International RASopathies Symposium spotlighted global perspectives on clinical care and research, including strategies for building international collaborations and developing diverse patient cohorts in anticipation of interventional trials. This biannual meeting, organized by RASopathies Network, was held in a hybrid virtual/in-person format. The agenda featured emerging discoveries and case findings as well as progress in preclinical and therapeutic pipelines. Stakeholders including basic scientists, clinician-scientists, practitioners, industry representatives, patients, and family advocates gathered to discuss cutting edge science, recognize current gaps in knowledge, and hear from people with RASopathies about the experience of daily living. Presentations by RASopathy self-advocates and early-stage investigators were featured throughout the program to encourage a sustainable, diverse, long-term research and advocacy partnership focused on improving health and bringing treatments to people with RASopathies.

970 FRAILTY IS INVERSELY CORRELATED WITH SERUM ALBUMIN IN ACUTE HIP FRACTURE

Introduction

Frailty and sarcopenia have been shown to significantly increase the risk of falls, traumatic hip fractures and all-cause mortality in the elderly. The assessment of frailty using a validated clinical frailty scale such as that proposed by Rockwood et al., therefore, continues to remain an important step in determining post-operative prognosis in patients undergoing hip fracture surgery. The purpose of this study was to examine the relationship between frailty and serum albumin—an independent biochemical predictor of survival in hip fracture patients (1).

Method

This retrospective cross-sectional study analysed 190 patients, aged above 60 years, admitted to Queen’s Hospital Burton (QHB) between the 1st January and 28th December 2019 with a newly diagnosed hip fracture. Pre-operative serum albumin levels (g/L) and Rockwood clinical frailty scores (rCFS) were recorded from electronic medical records (EMR). Using the SPSS 27 statistical package, Pearson’s correlation co-efficient and linear regression analysis were carried out using these variables.

Results

A total of 190 patients were included in the study (57 male, 133 female). Mean patient age was 82.2 ± 8.47 years. More than 50% of patients had a Rockwood CFS ≥5. Mean serum albumin (g/L) was 37.3 ± 6.56. A statistically significant inverse correlation was demonstrated between pre-operative serum albumin levels and Rockwood CFS (r = −0.243, p < 0.001).

Conclusion

This study showed how serum albumin, a negative acute phase reactant and marker of chronic malnutrition, is inversely associated with frailty in hip fracture patients and the important role of Rockwood CFS and pre-operative serum albumin levels in the prognostication of hip fractures in the elderly. References 1) Bohl D, Shen M, Hannon C, Fillingham Y, Darrith B, Della Valle C. Serum Albumin Predicts Survival and Postoperative Course Following Surgery for Geriatric Hip Fracture. Journal of Bone and Joint Surgery. 2017;99(24):2110–2,118.

Association between idiopathic achalasia and IL23R gene

BACKGROUND

Idiopathic achalasia is a primary esophageal motor disorder of unknown etiology. Different evidences have been reported in support of achalasia as the result of an autoimmune and inflammatory process leading to neuronal cell loss. According to this, idiopathic achalasia has been significantly associated with specific alleles of the human leukocyte antigen system class II, although few reports studying association with other loci can be found in the literature. Recent studies have shown association of a non-synonymous polymorphism within the IL23R gene with different chronic inflammatory disorders, including Barrett's esophagus. The purpose of this study was to assess whether the IL23R coding variant Arg381Gln polymorphism is involved in susceptibility to idiopathic achalasia.

METHODS

We performed a case-control study including 262 patients with idiopathic achalasia and 802 healthy subjects, all of them white Spaniards. Achalasia patients were diagnosed on the basis of clinical, radiographic, endoscopic, and manometric criteria. All samples were genotyped for the IL23R Arg381Gln polymorphism using TaqMan technology.

KEY RESULTS

The minor allele of the Arg381Gln polymorphism was significantly increased in patients compared with healthy controls (OR = 1.46, 95% CI = 1.01-2.11, P = 0.036). This association seems to be specific to male patients with disease onset after 40 years (OR = 2.33, 95% CI = 1.29-4.16, P = 0.002).

CONCLUSIONS & INFERENCES

Our results suggest a role of IL23R in idiopathic achalasia predisposition and extend the evidence of the general influence of this gene in autoimmune and inflammatory diseases.

Current treatments of Alzheimer disease: are main caregivers satisfied with the drug treatments received by their patients?

BACKGROUND/AIMS

A full comparison of the satisfaction with treatment using the current Alzheimer's disease (AD) therapies from the perspective of caregivers has not yet been done. The aim of this study was thus to find out the degree of satisfaction with the main available drug treatments in monotherapy for AD from this point of view.

METHODS

A cross-sectional, multicentre study of patients with possible/probable AD according to DSM-IV/NINCDS-ADRDA criteria, on monotherapy with donepezil, galantamine, rivastigmine or memantine, was carried out. Treatment satisfaction was measured by a caregiver proxy-administration of the generic SATMED-Q questionnaire [range: 0 (not satisfied at all) to 100 (totally satisfied)], overall and in 6 domains: tolerability, efficacy, medical care, ease and convenience, impact on daily activities and overall satisfaction.

RESULTS

A total of 829 patients were included: 63.3% women, aged 78.2 +/- 6.8 years; 546 (67.3%) on donepezil, 106 (13.1%) on rivastigmine, 99 (12.2%) on galantamine and 60 (7.4%) on memantine. SATMED-Q scores p values were adjusted by MMSE and treatment duration. Caregivers of patients on donepezil showed significantly higher SATMED-Q total (71.8 +/- 12.3; p < 0.05) and overall satisfaction domain scores (81.6 +/- 18.4; p < 0.01) than those of patients on any other drugs, as well as significantly higher ease and convenience of use domain (81.5 +/- 17.4; p < 0.01) and undesirable effects domain (96.0 +/- 12.9; p < 0.05) scores than those of rivastigmine- and galantamine-treated patients. Of the caregivers of donepezil-treated patients, 76.7% were satisfied with treatment versus 68.7, 61.4 and 46.7% of those caregivers whose patients were treated with galantamine, rivastigmine and memantine, respectively (p = 0.0002).

CONCLUSION

Caregivers of AD patients undergoing donepezil monotherapy seem to be more satisfied with treatment than those of patients receiving the other usual AD treatments in this study, particularly due to the ease and convenience of use of this drug. The higher level of satisfaction of these caregivers could be explained by the fact that, within the donepezil group, a high percentage of patients were treated with orally disintegrating tablets, which are easier for the patient to swallow.

[Orally disintegrating donepezil: are the main caregivers of patients with Alzheimer's disease more satisfied with this formulation of donepezil than with the traditional one?]

AIM

To know whether caregivers of Alzheimer's disease (AD) patients on donepezil treatment are more satisfied with the orally disintegrating tablet (ODT) formulation than with the film-coated tablets.

PATIENTS AND METHODS

Multicenter, cross-sectional study of patients with probably AD by DSM-IV or NINCDS-ADRDA criteria, on monotherapy with donepezil, ODT or film-coated tablets. Satisfaction with treatment was assessed by the caregiver self-administered generic Treatment Satisfaction with Medicines Questionnaire (SATMED-Q) -range: 0, no satisfaction, to 100, maximal satisfaction-, total and in six dimensions: undesirable effects, efficacy, medical care, medication ease and convenience, medication impact on daily activities, and overall satisfaction.

RESULTS

546 patients were enrolled (9,6% institutionalized); 64,8% women; 78,2 +/- 6,5 years of age; disease evolution of 22.5 +/- 24.6 months, Minimental State Examination (MMSE) mean score: 18,5 +/- 5; 67.9% on film-coated tablets and 32.1% on ODT. After adjusting by MMSE and time of treatment, caregivers of patients on ODT showed significantly higher SATMED-Q total score (74.5 +/- 11.8 vs. 70.4 +/- 12.3; p lower than 0.0004) and medication ease and convenience (84.9 +/- 16.4 vs. 79.8 +/- 17.6; p = 0.0059), impact of medication on daily activities (50.2 +/- 22.8 vs. 43.7 +/- 25.5; p = 0.0006) and satisfaction with medical care (79.4 +/- 19.5 vs. 75.6 +/- 21.8; p = 0.04894) scores. 91.6% of caregivers of patients on ODT (versus 82.9% of those on film-coated tablets; p = 0.023) stated that taking the medication was easy for their relatives.

CONCLUSIONS

Results show that caregivers of AD patients on donepezil treatment are more satisfied with ODT versus film-coated tablets, especially due to its better ease of use.

Benefits of cognitive-motor intervention in MCI and mild to moderate Alzheimer disease

OBJECTIVE

To evaluate the efficacy of a cognitive-motor program in patients with early Alzheimer disease (AD) who are treated with a cholinesterase inhibitor (ChEI).

METHODS

Patients with mild cognitive impairment (MCI) (12), mild AD (48), and moderate AD (24) (Global Deterioration Scale stages 3, 4, and 5) were randomized to receive psychosocial support plus cognitive-motor intervention (experimental group) or psychosocial support alone (control group). Cognitive-motor intervention (CMI) consisted of a 1-year structured program of 103 sessions of cognitive exercises, plus social and psychomotor activities. The primary efficacy measure was the cognitive subscale of the AD Assessment Scale (ADAS-cog). Secondary efficacy measures were the Mini-Mental State Examination, the Functional Activities Questionnaire, and the Geriatric Depression Scale. Evaluations were conducted at 1, 3, 6, and 12 months by blinded evaluators.

RESULTS

Patients in the CMI group maintained cognitive status at month 6, whereas patients in the control group had significantly declined at that time. Cognitive response was higher in the patients with fewer years of formal education. In addition, more patients in the experimental group maintained or improved their affective status at month 12 (experimental group, 75%; control group, 47%; p = 0.017).

CONCLUSIONS

A long-term CMI in ChEI-treated early Alzheimer disease patients produced additional mood and cognitive benefits.

Cancer Genetics Service Provision: A Comparison of Seven European Centres

OBJECTIVE

To conduct a survey in seven European cancer genetics centres to compare service provision, organisation and practices for familial breast and colon cancer consultations and testing. Information was obtained on aspects of services both nationally and locally.

METHODS

A detailed survey questionnaire was adapted collaboratively to obtain the required information. Initial survey data were collected within each centre and interim results were discussed at two European Workshops. Where differences in practice existed, details were clarified to ensure accuracy and adequacy of information. Participating centres were Haifa (Israel), Hannover (Germany), Leiden (The Netherlands), Leuven (Belgium), Manchester (UK), Marseille (France) and Milan (Italy), representing countries with populations ranging from 6.5 to 80 million.

RESULTS

The European countries diverged in regard to the number of cancer genetics centres nationally (from 8 in Belgium to 37 in France), and the average population served by each centre (from 0.59 million in Israel to 3.32 million in Italy). All centres offered free care at the point of access, but referral to specialist care varied according to national health care provision. At a centre level, staff roles varied due to differences in training and health care provision. The annual number of counsellees seen in each participating centre ranged from 200 to over 1,700. Access to breast surveillance or bowel screening varied between countries, again reflecting differences in medical care pathways. These countries converged in regard to the wide availability of professional bodies and published guidelines promoting aspects of service provision. Similarities between centres included provision of a multidisciplinary team, with access to psychological support, albeit with varying degrees of integration. All services were dominated (70-90%) by referrals from families with an increased risk of breast cancer despite wide variation in referral patterns. Collection of pedigree data and risk assessment strategies were broadly similar, and centres used comparable genetic testing protocols. Average consultation times ranged between 45 and 90 min. All centres had access to a laboratory offering DNA testing for breast and bowel cancer-predisposing genes, although testing rates varied, reflecting the stage of service development and the type of population. Israel offered the highest number of genetic tests for breast cancer susceptibility because of the existence of specific founder mutations, in part explaining why the cancer genetics service in Haifa differed most from the other six.

CONCLUSION

Despite considerable differences in service organisation, there were broad similarities in the provision of cancer genetic services in the centres surveyed.

L’offre de tests de prédisposition génétique au cancer du sein ou de l’ovaire en France

One example of the recent advances of scientific research on the human genome is the identification of two susceptibility genes to breast/ovarian cancer, BRCA1 and BRCA2, making possible the introduction in medical practices of genetic testing to detect patients with an increased risk of developing such cancers. In this context of diffusion, two surveys were carried out to appraise the activity profiles in 1998 and in 2001 of all the different participants in those new medical practices in France, physicians in charge of genetic counselling, medical centres where consultations take place and laboratories. Results show that over the period 1998-2001, few changes occurred, mainly the reduction of the average waiting time to get the result of a genetic test, the increase in the annual number of BRCA2 families identified to a level similar to the one of BRCA1 and the automation of the biological analyses without noting a considerable increase in the annual output of laboratories till 2001 however. This surprising moderate evolution must be connected to the existence of some particular external factors making the framework of the development of these new medical and biological practices and their future really uncertain. The diffusion of BRCA1/2 genetic testing has been carried out facing the traditional difficulties of any innovating activities, but also the uncertainties related to intellectual property rights on genes and the reimbursement of genetic counselling and biological testing. These uncertainties have certainly restrained the pace of change as many actors in this field have opted for a wait and see strategy bearing in mind the possible future constraints imposed to their future activity, especially if European patents on the BRCA1/2 genes are finally granted by the European patent office (EPO).

Impact of gene patents on the cost-effective delivery of care: the case of BRCA1 genetic testing

BACKGROUND

In 1994/95, two genes, BRCA1/2, associated with a predisposition to breast or ovarian cancer were identified. Genetic testing of deleterious BRCA1/2 mutations consequently can be proposed to individuals with a family history of breast or ovarian cancer to identify who is at risk. The granting of U.S. patents on BRCA1/2 to a privately owned company has led to the monopoly use of a unique technique (Direct Sequencing of the gene, DS) for BRCA1/2 testing in this country. Alternative strategies using prescreening techniques, however, have been experienced worldwide.

METHODS

On the basis of data collected at three laboratories of French public hospitals, we carried out a cost-effectiveness study comparing DS to 19 alternative strategies with the number of deleterious BRCA1 mutations detected as the outcome.

RESULTS

Results show that the DS strategy presents the highest average cost per mutation detected (9,882.5 Euro) and that there exist strategies using prescreening techniques that can reach similar effectiveness while reducing total costs. Moreover, other strategies can obtain a four- to sevenfold reduction in the average cost per mutation detected as soon as some rates of false negatives (2% to 13%) are deemed to be acceptable.

CONCLUSIONS

Results suggest that gene patents with a very broad scope, covering all potential medical applications, may prevent health care systems from identifying and adopting the most efficient genetic testing strategies due to the monopoly granted for the exploitation of the gene. Policy implications for regulatory authorities, in the current context of the extension of BRCA1/2 patents in other countries, are discussed.

Testing for BRCA1 mutations: a cost-effectiveness analysis

Breast carcinoma is the most common type of cancer affecting women in the Western world. The hereditary forms, which amount from 5 to 10% of all the cases of breast cancer, mainly involve BRCA1 or BRCA2 mutations. Due to the diagnostic strategy used by the patent owner, Direct DNA sequencing (DS) may become the only BRCA1/2 test procedure available, although there exist several alternative strategies. A cost-effectiveness study was carried out using BRCA1 testing as a model. The main techniques available for performing mutation searches were assessed: DS, denaturing high performance liquid chromatography (DHPLC), single-strand conformation polymorphism (SSCP), denaturing gradient gel electrophoresis (DGGE), heteroduplex analysis (HA), fluorescent assisted mismatch analysis (FAMA) and the protein truncation test (PTT). Twenty strategies involving the use of one or more techniques were then devised for performing the complete genetic analysis. DS was adopted as the 'gold standard' for effectiveness. All the strategies except for DS involved a two-step procedure. The first step consisted of pre-screening the 22 coding exons of BRCA1. The second step consisted of performing DS only on the variations detected in the coding sequence. The cost of the strategies tested, including a pre-screening stage, turned out to be 30 to 90% lower than that of DS, whatever annual use was made of the equipment. The most cost-effective strategy, ie, that corresponding to the lowest cost per mutation detected, was found to be a combination between PTT on exon 11 (60% of the coding sequence) and HA on the remaining 21 exons (PTT(11)+ HA(21)). However, since a high false negative rate is associated with this strategy, at least four other strategies are worth mentioning: PTT(11)+ DHPLC(21), DHPLC alone, FAMA(11)+ DHPLC(21) and FAMA alone. Our results on genetic testing for breast cancer show that DS is not the most cost-effective method available. The monopolist approach of the firm which owns the patents on the BRCA1/2 genes, may, therefore limit the use of the most cost-effective strategies.

Impact of the recommendations made by Spanish Club for the Study of Helicobacter pylori on eradication indications

AIM

A Spanish Consensus Conference had been arranged by the Spanish Club for the Study of Helicobacter pylori to encourage the use of eradication regimens in appropriate indications. The aim of our study was to assess whether the publication of these recommendations in November 1999 induced a change on the indications of eradication in the referring primary care district.

METHOD

Patients who had undergone Helicobacter pylori eradication therapy indicated by a gastroenterologist and referred to perform the 13C-labelled marked urea breath test were evaluated. Indications of eradication therapy were analysed and divided in: a) use of Conference recommended procedures (duodenal or gastric ulcer, erosive duodenitis, gastric MALT lymphoma and after resection of gastric adenocarcinoma); and b) other procedures not included in the recommendations (the rest). Indications established during former and latter years of publication of the Club's recommendations were compared.

RESULTS

A total of 659 established eradications in 1999 against 537 in 2000, were studied. Regarding established eradications in 1999, 418 out of 659 (63%) followed the recommendations made by the Spanish Club, while 241 (37%) did not. In 2000, the proportion of eradication therapy administered using the recommendations made by the Spanish Club was similar to previous year: 338 (63%) followed the recommendations, against 199 (37%) that did not (p = not significant). In both years, considering those indications not recommended, patients either with superficial chronic gastritis with or without dyspepsia or with gastrooesophageal reflux disease were the main disorders to indicate eradication therapy.

CONCLUSIONS

The recommendations of the Spanish Helicobacter pylori Study Club have not triggered a significant change after their publication on the indications for Helicobacter pylori eradication therapy in the setting studied.

Paragonimosis in the Cajabamba and Condebamba districts, Cajamarca, Peru

Stool samples from 409 pre-school and school students, living in six villages of the Cajabamba and Condebamba districts, Cajamarca, Perú, were examined using wet preparations and Lumbreras' method, looking for Paragonimus eggs. Fecal and sputum samples from two children (0. 5%) of 6 and 8 year-old showed eggs of Paragonimus. One hundred and twenty freshwater crabs, Hypolobocera chilensis eigenmanni, were collected from the Condebamba valley and 21 (17.5%) of them were infected with P. mexicanus (syn. P. peruvianus) metacercariae. Our results show the persistence of Paragonimus in human beings and in the main source of infection, the crabs.

Expression of Retinoid X Receptor alpha is increased upon monocytic cell differentiation

1 alpha, 25-Dihydroxyvitamin D3 (VD) is a potent inducer of monocytic differentiation of both normal and leukemic cells. Its effects are mediated by its nuclear receptor (VDR). Efficient gene activation requires the heterodimerization of VDR with Retinoid X Receptors (RXR). In the present study using specific antibodies, we analyzed the expression of the RXR alpha protein in blood mononuclear cells from acute myeloid patients (AML) (10 cases) and from myelomonocytic cell lines arrested at different stages of differentiation. We observed that the RXR alpha expression increased during myelomonocytic differentiation, since the highest levels were found in AML samples and in myelomonocytic cell lines having the highest amounts of monocytic precursors. We also demonstrated that fresh leukemic cells, whatever their stage of differentiation, as well as myelomonocytic cell lines, respond to VD by an increase in RXR alpha levels. Combinations of all-trans retinoic acid (RA) and VD, in some cases, increased this effect. This response suggests the involvement of RXR alpha in monocytic differentiation upon VD treatment.

Differentiation of U937 myelomonocytic cell line by all-trans retinoic acid and 1,25-dihydroxyvitamin D3: synergistic effects on tissue transglutaminase

We studied tissue transglutaminase (TGase) expression in human myelomonocytic leukemia cells treated by combinations of all-trans retinoic acid (RA) and 1,25 dihydroxyvitamin D3 (VD). We found that in U937 cells, as in HL-60 and THP-1 cells, RA alone caused an early induction of enzyme activity, correlated with increased mRNA expression. VD alone also induced rapid TGase mRNA expression but in this case TGase enzymatic activity was not measurable until 96 h following onset of treatment. Combinations of both agents had no additional effects over those of RA alone on HL-60 cells, THP-1, and U937 cells during the first 48 h. However, following further incubation, U937 cells expressed increased levels of TGase when treated by both agents. By many criteria, including their sensitivity to various inducers of oxidative burst, lipopolysaccharide-induced production of monokines and in the present work, lysozyme secretion and TGase expression, U937 cells exposed to combinations of RA and VD exhibit a behavior different from those of HL-60 and THP-1 cells. They represent a type of leukemia cell amenable by this treatment to a stage close to that of a terminally differentiated macrophage.

Different combinations of retinoids and vitamin D3 analogs efficiently promote growth inhibition and differentiation of myelomonocytic leukemia cell lines

The efficacy of all-trans retinoic acid (RA) in the treatment of acute promyelocytic leukemia results from the ability of RA to differentiate these peculiar leukemic cells. The efficacy of differentiation therapy could be improved and extended to other forms of leukemia by associating retinoids with other differentiating agents. Here we have compared the effects of different combinations of retinoids with 1 alpha,25-dihydroxyvitamin D3 (VD3) analogs on myelomonocytic cell lines HL-60, U937 and THP-1. All-trans RA, its natural isomer 9-cis RA and the arotinoid TTNPB, which differ by their respective specificities for the RA receptor families (retinoic acid receptor and retinoid X receptor), were found to cooperate with VD3 in inhibiting cell growth of the leukemic cell lines. Although the three cell lines displayed different susceptibilities to retinoids, each molecule was able to cooperate with VD3 in inducing U937 cell differentiation. Because the effects of VD3 on calcium metabolism limit its therapeutic use, we studied the effects of two synthetic analogs, MC903 and KH1060. Both agents cooperate with RA, acting more efficiently than the natural molecule in inhibiting cell growth and inducing some parameters of U937 cell differentiation. These results extend our previous data demonstrating that RA and VD3 exert synergistic effects on the differentiation of the myelomonocytic cell line U937. They demonstrate that combinations of agents able to inhibit leukemia cell growth with limited side effects may be found among a wide array of retinoids and vitamin D3 analogs.

Synergistic differentiation of U937 cells by all-trans retinoic acid and 1 alpha, 25-dihydroxyvitamin D3 is associated with the expression of retinoid X receptor alpha

Among the nuclear hormone receptors, the retinoid X receptors (RXRs) play a central role through their ability to heterodimerize with other members of this family of transcription factors, including retinoic acid (RA) and vitamin D (VD3) receptors. We have previously found that all-trans retinoic acid and 1 alpha, 25-dihydroxyvitamin D3 cooperate to induce monocytic differentiation of U937 human leukemic cells. Here the expression of RXR alpha protein in myelomonocytic cells was studied by immunodetection using polyclonal antibodies. RXR alpha was detected upon exposure of cells to VD3 and higher levels were found in cells treated by combinations of RA and VD3 under conditions where both agents synergized for inducing monocytic properties.

[Oniscoidea hemocyanins. Effect of pH on dissociation and structural data]

The pH has an influence on the molecular dissociation of the Oniscoidea hemocyanins. The dissociation electrophoretic patterns are characteristic for the species investigated. This method allows to confirm the systematic evolution and the adaptative possibilities of terrestrial Isopods. The hemocyanins of Oniscoidea are similar to those of Decapoda having a structure of comparable molecular weight protomers.