Shared and divergent mental health characteristics of ADNP-, CHD8- and DYRK1A-related neurodevelopmental conditions

BACKGROUND

Neurodevelopmental conditions such as intellectual disability (ID) and autism spectrum disorder (ASD) can stem from a broad array of inherited and de novo genetic differences, with marked physiological and behavioral impacts. We currently know little about the psychiatric phenotypes of rare genetic variants associated with ASD, despite heightened risk of psychiatric concerns in ASD more broadly. Understanding behavioral features of these variants can identify shared versus specific phenotypes across gene groups, facilitate mechanistic models, and provide prognostic insights to inform clinical practice. In this paper, we evaluate behavioral features within three gene groups associated with ID and ASD - ADNP, CHD8, and DYRK1A - with two aims: (1) characterize phenotypes across behavioral domains of anxiety, depression, ADHD, and challenging behavior; and (2) understand whether age and early developmental milestones are associated with later mental health outcomes.

METHODS

Phenotypic data were obtained for youth with disruptive variants in ADNP, CHD8, or DYRK1A (N = 65, mean age = 8.7 years, 40% female) within a long-running, genetics-first study. Standardized caregiver-report measures of mental health features (anxiety, depression, attention-deficit/hyperactivity, oppositional behavior) and developmental history were extracted and analyzed for effects of gene group, age, and early developmental milestones on mental health features.

RESULTS

Patterns of mental health features varied by group, with anxiety most prominent for CHD8, oppositional features overrepresented among ADNP, and attentional and depressive features most prominent for DYRK1A. For the full sample, age was positively associated with anxiety features, such that elevations in anxiety relative to same-age and same-sex peers may worsen with increasing age. Predictive utility of early developmental milestones was limited, with evidence of early language delays predicting greater difficulties across behavioral domains only for the CHD8 group.

CONCLUSIONS

Despite shared associations with autism and intellectual disability, disruptive variants in ADNP, CHD8, and DYRK1A may yield variable psychiatric phenotypes among children and adolescents. With replication in larger samples over time, efforts such as these may contribute to improved clinical care for affected children and adolescents, allow for earlier identification of emerging mental health difficulties, and promote early intervention to alleviate concerns and improve quality of life.

Prevalence and Clinical Significance of Electrocardiographic Complete Right Bundle Branch Block in Young Individuals

BACKGROUND AND AIMS

There is limited information on the clinical significance of complete right bundle branch block (CRBBB) in young individuals. The aim of this study was to determine the prevalence and significance of CRBBB in a large cohort of young individuals aged 14-35 years old.

METHODS

From 2008 to 2018, 104,369 consecutive individuals underwent a cardiovascular assessment with a health questionnaire, electrocardiogram, clinical consultation, and selective echocardiography. Follow-up was obtained via direct telephone consultations. Mean follow-up was 7.3 ± 2.7 years.

RESULTS

CRBBB was identified in 154 (0.1%) individuals and was more prevalent in males compared with females (0.20% vs. 0.06%; p<0.05) and in athletes compared with non-athletes (0.25% vs. 0.14%; p<0.05). CRBBB-related cardiac conditions were identified in 7 (5%) individuals (4 with atrial septal defect, 1 with Brugada syndrome, 1 with progressive cardiac conduction disease and 1 with atrial fibrillation). Pathology was more frequently identified in individuals with non-isolated CRBBB compared with individuals with isolated CRBBB (14% vs 1%; p < 0.05) and in individuals with a QRS duration of ≥130 milliseconds (ms) compared with individuals with a QRS of <130ms (10% vs 1%; p<0.05).

CONCLUSION

The prevalence of CRBBB in young individuals was 0.1% and was more prevalent in males and athletes. CRBBB-related conditions were identified in 5% of individuals and were more common in individuals with non-isolated CRBBB and more pronounced intraventricular conduction delay (QRS duration of ≥130ms). Secondary evaluation should be considered for young individuals with CRBBB with symptoms, concerning family history, additional electrocardiographic anomalies or significant QRS prolongation (≥130ms).

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Prevalence and outcomes of WPW pattern in the young: a report from a nationwide cardiac screening programme

Funding Acknowledgements

Type of funding sources: None.

Background

Individuals with accessory pathways, also referred as the Wolff-Parkinson-White pattern (WPWp), are usually asymptomatic and fatal arrhythmias may be the first presentation. Risk stratification is recommended, with electrophysiological study (EPS) being the gold standard. Catheter ablation offers a widely available, curative option, and provides incentive for screening, particularly in high-risk populations such as athletes.

Purpose

We sought to assess the prevalence, real-world clinical practice and outcomes of WPWp in young individuals identified through a nationwide cardiac screening programme.

Method

Between 2008 and 2018, 113,209 consecutive individuals (14 to 35 years old, 38% female) underwent cardiac screening with a health questionnaire, 12-lead electrocardiogram (ECG) and cardiology consultation. Individuals with suspected cardiac disease were referred for further investigations as necessary. Clinical outcomes were obtained via an online questionnaire and matched de-identified records from the Office of National Statistics database. Individuals were classified as elite athletes, non-elite athletes and non-athletes.

Results

A total of 214 (0.2%) individuals were referred for secondary evaluation with a suspected WPWp (Figure 1). Clinical outcomes were unavailable for 30 (14%) individuals. Follow-up confirmed an additional 13 individuals with a WPWp who were deemed to have normal investigations at screening, of which 8 (61%) had reported cardiovascular symptoms on their HQ and, in retrospect, 4 (30%) demonstrated subtle WPWp on their ECG. A WPWp was confirmed in 187 individuals (0.2%), of which 149 (80%) individuals were considered non-athletes, 114 (61%) reported cardiovascular symptoms, 116 (62%) underwent risk stratification with an EPS and 95 (43%) underwent catheter ablation. Report of palpitation was significantly greater in non-athletes than athletes (p=0.034). In asymptomatic individuals, those engaging in sports at elite level were more likely to be referred for an EPS (p=0.04). Four adverse cardiac events were reported over a follow up period of 7.4 years (IQR 4.9 to 9.2), including 3 individuals (16 years, 20 years, 40 years) with life-threatening arrhythmic events (LAE) requiring cardioversion, and 1 individual (20 years) with sudden cardiac death. Of these 4 individuals, only 1 with a LAE had undergone risk stratification with EPS.

Conclusions

The incidence of SCD in this young screened population was 0.72 per 1000 person-years. Clinical practice was variable and EPS was not offered to a significant proportion of patients, despite inadequate non-invasive risk stratification. The indication to EPS was driven by the athletic status in the asymptomatic individuals. The WPW syndrome may manifest with subtle ECG changes, posing a diagnostic challenge to interpreting physicians.

Characterisation of hypertensive heart disease: pathological insights from a sudden cardiac death cohort to inform clinical practice

Hypertensive heart disease refers to changes in the myocardium that result from hypertension. The relationship between hypertensive heart disease and sudden cardiac death is well established, but there are few pathological studies. We examined the clinical and pathological features of hypertensive heart disease in sudden cardiac death victims from a national cardiovascular pathology registry. We investigated 5239 cases of sudden cardiac death between 1994 and 2018. Hearts were examined by two expert cardiac pathologists. Diagnostic criteria included history of hypertension, increased heart weight and left ventricular wall thickness in the absence of other causes. Collagen was quantified using picrosirius red staining and imaging software. Of 75 sudden cardiac death cases due to hypertensive heart disease (age at death: 54 ± 16 years; 56% males), 56 (75%) reported no prior cardiac symptoms. Thirty-four (45%) recorded a BMI ≥ 30. Only two (2.7%) had hypertensive heart disease diagnosed antemortem. Four (5%) were diagnosed clinically with hypertrophic cardiomyopathy, but lacked myocyte disarray at autopsy. All hearts showed concentric left ventricular hypertrophy and myocyte hypertrophy. Fibrosis was identified microscopically in 59 cases (81%). The posterior left ventricular wall showed the greatest increase in the percentage of collagen in hypertensive diseased hearts compared to controls (25.2% vs 17.9%, p = 0.034). Most sudden deaths due to hypertensive heart disease occur without prior cardiac symptoms; thus, clinical risk stratification is challenging. Hypertensive heart disease can be misdiagnosed in life as hypertrophic cardiomyopathy which has major implications for relatives. Pathologists require a history of hypertension and histology for a definitive diagnosis of hypertensive heart disease.

Results of a nationally implemented cardiac screening programme in elite cricket players in England and Wales

OBJECTIVES

We assessed the diagnostic yield and costs of an electrocardiogram-based national screening programme in elite cricket players and the incremental value of transthoracic echocardiography and periodic evaluation.

DESIGN

Cross-sectional study.

METHODS

Between 2008 and 2019, 1208 cricketers underwent screening with a health questionnaire, 12-lead electrocardiogram and cardiology consultation. Athletes with concerning findings underwent on-site transthoracic echocardiography and further investigations as necessary. In addition, despite a normal health questionnaire and electrocardiogram, 342 (28.3%) athletes had a transthoracic echocardiogram and 493 (40.8%) underwent repeat evaluations.

RESULTS

After initial evaluation, 47 (3.9%) athletes underwent on-site transthoracic echocardiography of whom 35 (2.8%) were referred for further evaluation. Four athletes (0.3%) were diagnosed with major cardiac conditions; hypertrophic cardiomyopathy (n = 1), arrhythmogenic cardiomyopathy (n = 1) and Wolff-Parkinson-White pattern (n = 2). Two athletes were identified with minor valvular abnormalities. Repeat evaluation of 493 athletes identified hypertrophic cardiomyopathy in a 22-year-old athlete, two years after his initial normal screening. During a follow-up of 5.8 ± 2.9 years no additional diagnoses or adverse cardiac events were reported. The cost of the electrocardiogram-based programme was £127,844, translating to £106 per athlete and £25,569 per major cardiac condition identified.Routine transthoracic echocardiography in 342 athletes identified two athletes with major cardiac conditions (bicuspid aortic valve with severe aortopathy and aortic regurgitation and an atrial septal defect associated with right ventricular volume overload) and 10 athletes with minor abnormalities.

CONCLUSIONS

An electrocardiogram-based national screening programme identified a major cardiac condition in 0.3% of athletes. Routine transthoracic echocardiography and periodic evaluation increased the diagnostic yield to 0.6%, at an incremental cost.

Determinants of high-risk coronary artery disease in ostensibly healthy male master endurance athletes

Background

Healthy male master endurance athletes have a greater prevalence of high coronary calcium (CAC) scores compared to healthy sedentary counterparts, and some demonstrate high-risk plaque features. A number of theories have been postulated but reasons remain unclear. Concurrently atherosclerotic coronary artery disease (CAD) is the most common cause of sudden cardiac death in male master athletes drawing much public and scientific interest and making this an important public health issue.

Purpose

To examine the relationship of age, resting systolic blood pressure (SBP), exercise dose and sporting discipline with high-risk CAD markers in male master endurance athletes.

Methods

A prospective study undertaken over 19 months evaluated 214 male master (40–65 years) endurance athletes, free from known cardiovascular risk factors, symptoms or relevant health conditions. Clinical evaluation included cardiopulmonary exercise test, resting blood pressure (BP) and coronary computed tomogram angiography (CCTA). CCTA assessed CAC score, significant stenosis, (&gt;50%) and plaque vulnerability markers. Exercise dose was defined by years of endurance exercise and average MET-hours/week (lifetime exercise volume multiplied by the metabolic equivalent scores). Resting BP was the average of 3 consecutive supine measures after at least 5 minutes rest.

Results

Athletes (mean age 51, SD 70.1) exercised for minimum 6 hours/week (median 8.5) for a median of 15 years (2–26). Almost half (60.2%) were multi-endurance athletes i.e. any combination swimming, cycling and running. The remainder were runners (22.4%) and cyclists (15.4%). Median Framingham risk score 3.2% (1.8–5.8). The mean resting BP was 129/80 mmHg and a quarter (26%) of athletes were hypertensive (≥140/90 mmHg) at rest. A CAC score &gt;100 Agatston units (AU) was present in 16% of athletes. There was a total of 15 stenotic lesions in 11 (5%) athletes. 13% had plaque vulnerability markers.

Logistic regression evaluated whether age, resting SBP, exercise dose measures and sporting discipline were predictive for a CAC score &gt;100 AU, significant stenosis and plaque vulnerability markers (table 1). CAC score was associated with age, years of endurance exercise and resting SBP. A Stenosis &gt;50% and plaque vulnerability markers were associated with resting SBP and cycling compared with all other sporting disciplines.

Conclusion

Despite correcting for age, higher exercise dose (years endurance exercise) is associated with CAC score &gt;100 AU but does not predict significant stenosis or plaque vulnerability markers. Resting SBP and cycling strongly predict high-risk disease. Cycling enables a greater intensity of exercise compared with other endurance sports, which may be associated with prolonged rises in SBP. Resting SBP and cycling are important determinants for high-risk CAD in middle-aged male endurance athletes and should be considered when risk stratifying in pre-participation evaluation.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship

Six-month outcomes of a high intensity exercise programme in young patients with hypertrophic cardiomyopathy: The SAFE-HCM trial

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Cardiac Risk in the Young

Background

Moderate intensity exercise training in older patients with hypertrophic cardiomyopathy (HCM) can improve functional capacity, without significant harm. However, younger patients are attracted to high intensity training (HIT) regimes. The SAFE-HCM study demonstrated that an individually tailored, HIT programme in young patients with HCM was feasible, and provided both health and psychological benefits, without an increase in the burden of arrhythmia.

Purpose

To assess whether observed benefits of a HIT programme in young patients with HCM are sustained at 6 months.

Methods

Eighty patients with HCM (45.7y+/-8.6) underwent baseline clinical and psychological assessment. Individuals were randomised to a 12-week HIT programme (n = 40) or usual care (n = 40). Baseline evaluation was repeated at 12 weeks (T12). Feasibility, safety, health and psychological benefits were assessed. At 12-weeks individuals were encouraged to continue with the frequency and intensity of physical activity (PA) achieved at the end of the cardiac rehabilitation programme. Participants in the exercise arm were invited to follow-up at 6 months (T6m).

Results

The majority (83%) of participants completed the 12-week study. At T12 there was no significant difference between groups in the composite arrhythmia safety outcome (p = 0.99). The indices of exercise capacity were significantly improved in the exercise compared to the control group; peak VO2 (+3.7ml/kg/min [CI 1.1,6.3], p = 0.006), VO2/kg at anaerobic threshold (VO2/kgAT) (+2.44ml/kg/min [CI 0.6,4.2], p = 0.009), time to AT (+115s [CI 54.3,175.9], p &lt; 0.001) and exercise time (max ET) (+108s [CI 33.7,182.2], p = 0.005). The exercise group also demonstrated greater reduction in systolic BP (-7.3mmHg [CI -11.7,-2.8], p = 0.002), BMI (-0.8kg/m2 [CI-1.1,-0.4], p &lt; 0.001), anxiety (-2.6 [CI-3.6,-1.6], p= &lt;0.001) and depression (-1.1 [CI -2.0,-0.2], p = 0.015) scores. At T6m patient reported exercise adherence was comparable to baseline PA in 33/34 of the exercise group attending for follow up. Most exercise gains dissipated with the exception of time to AT (p = 0.002), max ET (p = 0.003), VO2/kgAT (p = 0.04) and anxiety score (p &lt; 0.001) (Figure 1). There were no sustained episodes of atrial or ventricular arrhythmias. The incidence of NSVT did not differ between time points (p = 0.09).

Conclusion

A 12-week HIT programme in young patients with HCM offers considerable gains in fitness and psychological outcomes, with no increase in arrhythmic burden. At T6m exercise levels as well as most physiological adaptations and health benefits returned to baseline, as seen in other studies when formal participation in an exercise programme comes to an end. This highlights the importance of the implementation of strategies to encourage ongoing engagement in PA. Potential solutions include identification of barriers to exercise, as well as adoption of novel tele-rehabilation approaches.

Abstract Figure 1 Sustained benefits at T6m

ESC 2019 guidelines on chronic coronary syndromes: could calcium scoring improve detection of coronary artery disease in patients with low risk score. Findings from a retrospective cohort of patients in a district general hospital

BACKGROUND

The European Society of Cardiology (ESC) published an updated stable chest pain guideline in 2019, recommending the use of an updated pre-test probability (PTP) risk score (RS) to assess the likelihood of coronary artery disease (CAD). We sought to compare the 2019 and 2013 PTPRS in a contemporary cohort of patients.

METHODS

612 patients who were investigated with computed tomography coronary angiography (CTCA) for stable chest pain were included in a retrospective analysis.

RESULTS

There were 255 patients with 2019 PTPRS 15-50% with a 9% yield of severe CAD on CTCA, compared with 402 patients and a 4% yield using the 2013 PTPRS (p = 0.01). 355 patients had a 2019 PTPRS of <15%, with 3% found to have severe CAD, compared with 67 patients and none with severe CAD using the 2013 PTPRS (p = 0.14). 336 of patients with 2019 PTPRS of <15% had a calcium score as part of the CTCA. 223 of these had a zero calcium score and only one had severe CAD. In comparison, 113 patients had a positive calcium score, and 10 (9%) had severe CAD (p < 0.001).

DISCUSSION

The ESC 2019 PTPRS classifies more patients as at lower risk of CAD and hence reduces the risk overestimation associated with the 2013 PTPRS. However, in patients with a 2019 PTPRS of <15%, who would not be investigated, the use of the calcium score detected the majority of patients with significant CAD, who may benefit from secondary prevention and an associated mortality benefit as per the SCOT-Heart trial.

Sustained ventricular tachycardia of left, right or both bundle branch block morphology in patients with Arrhythmogenic Cardiomyopathy

Aims

In arrhythmogenic cardiomyopathy (ACM) sustained monomorphic ventricular tachycardia (VT) typically displays left bundle branch block (LBBB) morphology. Sustained VT with right bundle branch block (RBBB) morphology is very rare despite the frequent left ventricular involvement. The present study sought to assess the prevalence of spontaneous sustained LBBB-VT, RBBB-VT or both as well as clinical and genetic differences associated with these VT types.

Methods and results

Twenty-six centers from 11 European countries provided information on 952 patients with ACM and &gt;1 episode of sustained VT observed during the patients' clinical course. VT was classified as: LBBB-VT; RBBB-VT or LBBB+RBBB-VT.

Among 952 patients, 881 (92.5%) had LBBB-VT alone, 71 (7.5%) had RBBB-VT [alone in 42 (4.4%) patients or with LBBB-VT in 29 (3.0%) patients]. Male prevalence was 90.5%, 79.2% and 55.9% in the RBBB-VT, LBBB-VT and LBBB+RBBB-VT groups, respectively (P=0.001). Patients' age at first VT did not differ amongst the 3 VT groups. ICD implantation was more frequent for the RBBB-VT and the LBBB+RBBB groups (≈90% each) vs. 67.9% for the LBBB-VT group (P=0.001). Death incidence (9.5%–17.2%) was not significantly different between the 3 groups (P=0.425). Plakophylin-2 mutations predominated in the LBBB-VT and LBBB-VT+RBBB-VT groups (47.2% and 27.3%, respectively) and Desmoplakin mutations in the RBBB-VT group (36.7%).

Conclusion

This large European survey demonstrates: 1) Sustained RBBB-VT is documented in 7.5% patients with ACM; 2) Males markedly predominate in the RBBB-VT and LBBB-VT groups but not in the LBBB+RBBB VT group; 3) Distribution of desmosomal mutations appears to be different in the 3 VT groups.

Funding Acknowledgement

Type of funding source: None

Safety and outcomes of a structured exercise programme in young patients with hypertrophic cardiomyopathy: the SAFE-HCM trial

Background

Contemporary studies in hypertrophic cardiomyopathy (HCM) suggest that moderate intensity exercise can improve cardiorespiratory fitness without raising significant safety concerns. Although low/moderate intensity exercise may be appropriate for older HCM patients, it is unlikely to attract younger, often asymptomatic patients, who wish to engage in higher intensity regimes.

Purpose

To assess the feasibility, safety and outcomes of an individually tailored, high intensity exercise programme in young patients with HCM.

Methods

In this RCT, 80 patients with HCM, aged 16–60 (mean 45.7, [SD8.6]) underwent baseline testing with ECG, echocardiography, blood testing, exercise testing, 48-hour ECG and psychological assessment. Individuals were randomised to a 12-week supervised exercise programme (HRR increased from 70–85%) (n=40) or usual activity (n=40). Baseline investigations were repeated at 12 weeks.

Feasibility was assessed by a) recruitment, adherence and retention rates; b) staffing ratios and logistics; c) acceptability of the intervention/educational materials. Safety was assessed as a composite of 1) cardiovascular death, 2) cardiac arrest, 3) device therapy, 4) exercise induced syncope, 5) sustained/non-sustained (NS) ventricular tachycardia (VT) or 6) sustained atrial arrhythmias. Secondary outcomes included health and psychological benefits.

Results

67 individuals (82.5%) completed the study. Reasons for refusal included travel, work and family commitments. The majority (64.7%) of exercising individuals progressed to 85%HRR. Resource requirements were similar to other programmes. All individuals felt supported, more confident to exercise, and found educational materials clear and informative.

There was no significant difference between groups for the composite safety outcome. One individual experienced exercise induced syncope due to ventricular standstill (exercise) and another sustained VT (control). Both required device implantation. There was no significant difference between groups in episodes of NSVT (p=0.573) or ectopic burden (p=0.729).

At 12 weeks, exercise group participants demonstrated greater activity levels (+1.1 hours [CI 0.2–2.1], p=0.024). The change in peak aerobic capacity (+255.2ml/min [CI 93.2–417.1], p=0.003), time to anaerobic threshold (AT) (+115s [CI 54.2–176.0], p&lt;0.001), total exercise time (+108.1s [CI 33.1–183.0], p=0.005) and oxygen uptake at AT (+2.44ml/kg/min [CI 0.6–4.2], p=0.009) were all significantly greater in the exercise group. HADS anxiety (p&lt;0.001) and depression (p=0.017) scores demonstrated the greatest reduction in the exercise group.

Conclusions

A high intensity exercise programme is feasible in young patients with HCM, with considerable gains in cardiorespiratory fitness and psychological outcomes. Importantly, arrhythmia burden was not increased in the exercise group. Further research is still required to assess the long-term safety of high intensity exercise in the HCM population.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Cardiac Risk in the Young

P3839Hypertension or hypertrophic cardiomyopathy? Using cardiovascular magnetic resonance imaging to unmask the great imitator

Background

Structural cardiac adaptations due to hypertension (HTN) present a diagnostic challenge when differentiating from hypertrophic cardiomyopathy (HCM), using traditional imaging techniques such as echocardiography (echo). Cardiac magnetic resonance imaging (CMR) offers reproducible anatomical, functional quantification and myocardial tissue characterisation which discriminates between hypertension and HCM.

Purpose

To identify hypertensive individuals with undiagnosed HCM using CMR imaging.

Methods

100 consecutive hypertensive patients underwent CMR at a tertiary centre dedicated blood pressure clinic (55% male, mean age 51 years). In keeping with ESC guidelines, end diastolic wall thickness (EDWT) ≥15mm identified individuals within the “grey zone” between hypertension and with a potential HCM diagnosis. 19 individuals were referred on to the dedicated inherited cardiac conditions clinic for further evaluation. Four patients expressed a definitive LV phenotype and were diagnosed with HCM. CMR parameters were compared in three groups: Hypertensive (HTN), “grey zone” Hypertensive (GZH) and HCM.

Results

CMR demonstrated end diastolic wall thickness (EDWT) >11 mm in 50% of hypertensives. 73% of the referred patients were Afro-Caribbean (AC) and all 4 HCM patients were AC. All referrals demonstrated EDWTs ≥14mm, 9 (47%) demonstrated late gadolinium enhancement of which 3 (16%) had HCM. Three had asymmetrical septal hypertrophy – 2 were in the HCM cohort and one underwent endomyocardial biopsy confirming HTN. Left ventricular mass index (LVMI) was significantly higher in GZH compared to HTN (p<0.0001) and in HCM compared to HTN (p=0.0004). EDWT was significantly greater in GZH compared to HTN (p<0.0001) and in HCM compared to HTN (p=0.0002). There was no significant difference in these parameters between GZH and HCM.

Table 1. P-values for CMR data in hypertensive (HTN), gray zone hypertensive (GZH) and hypertrophic cardiomyopathy (HCM) cohorts CMR Parameter HCM vs. HTN GZH vs. HTN GZH vs. HCM EDVI NS p=0.025 NS EDWT p=0.0002 p<0.0001 NS LVMI p=0.0004 p<0.0001 NS

Conclusion

This study reports a 4% prevalence of HCM among hypertensive patients - 20 x greater than in the general population - which would be left undiagnosed using echo alone. Screening hypertensive individuals with CMR is not routine but we advocate its use in these individuals especially in Afro Caribbeans and in those in the “grey zone”, to identify undiagnosed HCM, which has significant implications for lifestyle modification and family screening.

Acknowledgement/Funding

Cardiac Risk in the Young

Enhancing social functioning in young people at Ultra High Risk (UHR) for psychosis: A pilot study of a novel strengths and mindfulness-based online social therapy

BACKGROUND

Psychological and pharmacological treatments have been shown to reduce rates of transition to psychosis in Ultra High Risk (UHR) young people. However, social functioning deficits have been unresponsive to current treatments.

AIMS

The study aims were to: i) describe the theoretical basis and therapeutic targets of a novel intervention targeting social functioning in UHR young people; and ii) examine its acceptability, safety and preliminary effect on social functioning.

METHODS

An international, multidisciplinary team developed a new intervention (MOMENTUM) to improve social functioning in UHR young people. MOMENTUM blends two novel approaches to social recovery: strengths and mindfulness-based intervention embedded within a social media environment, and application of the self-determination theory of motivation. The acceptability and safety of MOMENTUM were tested through a 2-month pilot study with 14 UHR participants.

RESULTS

System usage was high, with over 70% of users being actively engaged over the trial. All participants reported a positive experience using MOMENTUM, considered it safe and would recommend it to others. 93% reported it to be helpful. There were large, reliable improvements in social functioning (d = 1.83, p < 0.001) and subjective wellbeing (d = 0.75, p = 0.03) at follow-up. There were significant increases in the mechanisms targeted by the intervention including strengths usage (d = 0.70, p = 0.03), mindfulness skills (d = 0.66, p = 0.04) and components of social support. Social functioning improvement was significantly correlated with indicators of system usage.

CONCLUSION

MOMENTUM is engaging and safe. MOMENTUM appeared to engage the hypothesized mechanisms and showed promise as a new avenue to improve social functioning in UHR young people.

First Report of Verticillium Wilt on Lettuce (Lactuca sativa) in Washington Caused by Verticillium tricorpus

Symptoms of Verticillium wilt were observed on lettuce (Lactuca sativa L.) harvested from high tunnel and open field experimental plots in annual, consecutive spring plantings in western Washington from 2010 to 2012. Leaves had v-shaped, chlorotic lesions, and yellow or brown vascular tissue was noted in the crowns. Total disease incidence increased from 0.2% in 2010 to 1.9% in 2011 and to 14.4% in 2012. Verticillium spp. obtained from infected crown tissues and cultured on half-strength potato dextrose agar medium produced yellow pigment, black microsclerotia, white mycelia, tan chlamydospores, and uniseptate conidia averaging 10.6 × 3.7 μm. Isolates were identified tentatively as Verticillium tricorpus I. (3). Three isolates, Vt.Ls.2010, Vt.Ls.2011-1, and Vt.Ls.2011-2, were evaluated for pathogenicity on 4-week-old 'Coastal Star' seedlings in two greenhouse trials. In Trial I, four replicates of two duplicate plants per each isolate, and in Trial II, five replicates of one plant per each isolate were inoculated with conidial suspensions adjusted to 2.0 × 10⁶ and 5.0 × 10⁶ conidia/ml, respectively. Additionally, in each trial, two sets of control treatments of five plants each were inoculated with either an isolate of V. dahliae at the same conidial concentration or with sterile water. Root tips were cut and exposed to the suspensions for 5 s, then seedlings were transplanted into Sunshine Mix #1 (SunGro Horticulture Distribution Inc., Bellevue, WA), and kept in a greenhouse at 17.7 ± 3.4°C. Plants were harvested 8 to 9 weeks post-inoculation, and symptoms were rated visually. Vt.Ls.2010, Vt.Ls.2011-1, and Vt.Ls.2011-2 caused chlorosis and vascular discoloration on 25, 13, and 13% of the plants in Trial I; and 40, 60, and 20% of plants in Trial II, respectively. V. dahliae caused similar symptoms on 25 and 40% of the plants in the two trials, respectively, but these plants had greater intensity and length of vascular discoloration compared with the three test isolates. None of the water control plants were symptomatic. All V. tricorpus isolates were recovered from inoculated plants, and colony morphologies were similar to the original isolates. The internal transcribed spacer (ITS) rDNA of isolate Vt.Ls.2010 was amplified with ITS4 and ITS6 primer sets. ITS rDNA sequences between Vt.Ls.2010 and two isolates of V. tricorpus in GenBank (Accession Nos. FJ900211 and AB353343) were 100% identical. V. tricorpus is considered a weak pathogen of lettuce crops in California (2), but authors in Japan recently reported pathogenic isolates of V. tricorpus on lettuce (4). To our knowledge, this is the first report of Verticillium wilt caused by V. tricorpus in Washington. Lettuce is the number two crop grown in high tunnels in the United States (1), and cropping lettuce continuously in them can increase the risk of this and other soilborne pathogens. References: (1) E. E. Carey et al. HortTechnology 19:37, 2009. (2) Q.-M. Qin et al. Plant Dis. 92:69, 2008. (3) H. C. Smith. N. Z. J. Agric. Res. 8:450, 1965. (4) T. Usami et al. J. Gen. Plant Pathol. 77:17, 2010.

First Report of Verticillium Wilt Caused by V. dahliae on Grafted Solanum aethiopicum in Washington

Solanum aethiopicum L., previously S. integrifolium Poir. (4), has been used as a rootstock for commercial, grafted eggplant production throughout Asia (3). In August 2010 and 2011, symptoms of Verticillium wilt were observed on 'Epic' eggplant (S. melongena L.) grafted onto S. aethiopicum at two sites with a history of the disease: one in the irrigated, dryland Columbia Basin of eastern Washington near Eltopia, and the other in maritime western Washington near Mount Vernon. Interveinal chlorosis, V-shaped necrotic lesions, and wilting were evident at both sites in both years. Each year, stems of 20 symptomatic plants from each field site were cut at the soil line to a 20-cm length, surface sterilized for 5 min in a 10% bleach solution, rinsed in tap water for 30 s, cut longitudinally, and incubated in moisture chambers for 4 weeks at room temperature in the dark. Microsclerotia that formed in the stems were typical of those produced by V. dahliae. One isolate, 'MVEgg301', from an infected stem at Mount Vernon, developed dark microsclerotia and verticillate conidiophores in a radiating pattern, typical of Verticillium on half-strength potato dextrose agar (1/2 PDA) medium. The internal transcribed spacer (ITS) region of rDNA amplified by PCR assay using primers ITS6 and ITS4 from mycelia sampled directly from 1/2 PDA media revealed a 100% match with ITS rDNA sequences of >50 V. dahliae accessions in GenBank (1). Pathogenicity of 'MVEgg301' was assessed in two tests. In both, 12 each of non-grafted and grafted (with cv. Epic) S. aethiopicum plants were inoculated with 'MVEgg301' by cutting approximately 5 mm off the root tips and dipping the remaining roots in a suspension of 10⁶ conidia/ml for 5 s. Similarly, 12 each of non-grafted and grafted S. aethiopicum plants were cut and dipped similarly in sterile water as controls. Chlorosis, necrosis, and wilting were observed in 11 of the 12 inoculated, non-grafted plants and 8 of the 12 inoculated, grafted plants in Test I. The same symptoms were observed in 10 of the 12 inoculated, non-grafted plants and 10 of the 12 inoculated, grafted plants in Test II. V. dahliae was reisolated and confirmed from symptomatic, inoculated non-grafted and grafted plants using the stem assay and direct PCR assay described above. Chlorosis, necrosis, and wilting were observed in one non-grafted control plant in Test I, and two non-grafted and four grafted control plants in Test II. The symptoms were mild and likely due to nutritional deficiencies; microsclerotia were not observed in any assayed water-inoculated plant stems. Although there are several reports of V. albo-atrum infecting S. aethiopicum in the United States (2), to our knowledge, this is the first report of V. dahliae causing Verticillium wilt on this eggplant species. This finding is significant because S. aethiopicum is used as a rootstock for control of soilborne diseases like Verticillium wilt in commercial grafted eggplant production (3). References: (1) G. Calmin et al. Biotechnol. Biotechnol. Equ. 21:40, 2007. (2) D. F. Farr et al. Fungi on Plants and Plant Products in the United States. American Phytopathological Society, St. Paul, MN, 1989. (3) M. Oda. Food Fert. Technol. Ctr. Ext. Bul. 480:1, 1999. (4) PBI Solanum Project. 2012. Solanaceae Source. Accessed at http://www.nhm.ac.uk/solanaceaesource/ . Natural History Museum, London, 29 Aug. 2012.

Emergency department contact prior to suicide in mental health patients

OBJECTIVES

To describe attendance at emergency departments (EDs) in the year prior to suicide for a sample of mental health patients. To examine the characteristics of those who attended (particularly those who attended frequently) prior to suicide.

DESIGN

Case review of ED records for 286 individuals who died within 12 months of mental health contact in North West England (2003-2005).

METHOD

Cases identified through the National Confidential Inquiry into Suicide were checked against regional EDs to establish attendance in the year prior to death. Records were examined to establish the number of attendances, reason for the final, non-fatal attendance, treatment offered and outcome.

RESULTS

One hundred and twenty-four (43%) individuals had attended the ED at least once in the year prior to their death, and of these, 35 (28%) had attended the ED on more than three occasions. These frequent attenders died by suicide significantly sooner after their final, non-fatal attendance than other attenders. A clinical history of alcohol misuse was also associated with early death following ED attendance.

CONCLUSIONS

Over 40% of our clinical sample attended an ED in the year prior to death, and some individuals attended particularly frequently. EDs may therefore represent an important additional setting for suicide prevention in mental health patients. The majority of attendances prior to suicide were for self-harm or to request psychiatric help. Clinicians should be alert to the risk associated with such presentations and to the possible association between frequent attendance and suicide.

DNA sequence analysis of gamma radiation-induced deletions and insertions at the APRT locus of hamster cells

Gamma radiation-induced gene rearrangements at the Chinese hamster ovary cell locus coding for the purine salvage enzyme adenine phosphoribosyl transferase (APRT) consist of both simple deletions and more complex alterations that are presumably the result of multiple strand breaks. To characterize these mutations at the DNA sequence level, fragments altered by deletion and insertion mutations were obtained by cloning in lambda phage vectors or by using the polymerase chain reaction. The radiation-induced deletions characterized here eliminate 3-4 kb and have at least one breakpoint in an AT-rich region or near short direct or inverted repeats. Insertions involve small fragments (102 and 456 bp) of repetitive DNA that appear to be related to B2 (short interspersed repetitive) and long interspersed repeat families. The novel fragments bear little resemblance to each other or to sequences at the integration sites, and their introduction is accompanied by a small target site deletion.

hnRNP-U directly interacts with WT1 and modulates WT1 transcriptional activation

The Wilms' tumour suppressor gene, WT1, encodes a zinc-finger protein that is mutated in Wilms' tumours and highly expressed in a wide variety of other malignancies. WT1 is a transcription factor that is likely to have additional, post-transcriptional, regulatory roles, although the molecular mechanisms by which WT1 acts remain poorly understood. We have combined genetic and biochemical approaches to show, that endogenous WT1 binds to heterogeneous nuclear ribonuclear protein U (hnRNP-U), that this interaction does not require any other proteins or nucleic acids, involves the zinc-fingers of WT1 and the middle domain of hnRNP-U, and that hnRNP-U can modulate WT1 transcriptional activation of a bona fide WT1 target gene. These findings increase our knowledge of how WT1 exerts its transcriptional regulatory role and suggests that hnRNP-U may be a candidate Wilms' tumour gene at 1q44.

Low vision services for vision rehabilitation in the United Kingdom

AIM

Little is known about the distribution and methods of delivery of low vision services across the United Kingdom. The purpose of this study was to determine the type and location of low vision services within the UK.

METHODS

Survey by means of a 29 point postal questionnaire, followed when necessary by a five point telephone questionnaire. All known potential providers of low vision services (n = 2539) including hospitals (n = 277), optician/optometry practices (n = 1683), social services (n = 177), voluntary groups (n = 190), specialist teachers (n = 205), and universities (n = 6) were surveyed. For each service provider, the type, magnitude, and geographical location were determined. The distribution of services across the United Kingdom and the ratio of providers to population density of people with a visual impairment were mapped using the Geographic Information System (GIS).

RESULTS

Data were obtained on 1945 (77%) service providers: 1679 (66%) responded to the postal questionnaire and 266 (11%) to the telephone questionnaire. Of all respondents, 59% (n = 1135) offer some form of help to people with a visual disability, of which 26% (n = 497) only sell magnifiers and 33% (n = 638) provide low vision services. It is estimated that in total just under 155,000 low vision consultations are offered annually, the bulk of which are provided by hospital eye departments. The distribution was geographically uneven and there appears to be scarcity in some areas.

CONCLUSION

When compared to the probable number of people with a visual impairment in the UK there are apparent inadequacies in service provision in terms of distribution, magnitude, and coordination. The results highlight a need to review current services.

Truncation of WT1 results in downregulation of cyclin G1 and IGFBP-4 expression

Mutations in the WT1 gene are found in a subset of Wilms' tumours and in certain other disorders such as Denys-Drash syndrome. The WT1 gene product is a zinc finger transcription factor for which many target genes have been suggested. Here we utilise gene targeting to generate cells containing only truncated forms of WT1, in which the DNA-binding region is disrupted. Examination of gene expression in these cells using cDNA macroarrays suggests two novel WT1 transcriptional targets, cyclin G1 (Ccng1), and insulin-like growth factor binding protein 4 (Igfbp4).

Drug use and barriers to use of health care services

This paper examines barriers to health care utilization and the correlates associated with these barriers. As part of a larger study of health services utilization, the study sample of 1085 including injection drug users, other chronic users of heroin or cocaine, and a demographically similar group who had used neither heroin nor cocaine, was selected based on the criterion of not having received health care for at least one health problem within the previous 12 months. Both categories of chronic drug users were more likely than non-users not to want health care treatment and to put off seeking needed health care.

Risk of acute first myocardial infarction and use of nicotine patches in a general population

OBJECTIVES

To determine if nicotine patches, both as prescribed and used over-the-counter, increase the risk of first myocardial infarction (MI).

BACKGROUND

Although nicotine patches improve smoking cessation rates, case reports have raised the hypothesis that they may increase the risk of MI.

METHODS

A population-based case-control study among 68 hospitals in an eight-county region surrounding Philadelphia was performed to determine if nicotine patches increase the risk of first MI. Cases were smokers (current or within the prior year) admitted to all hospitals in the region with a first MI. Controls were smokers (current or within the prior year) without prior MI selected from the same region using random-digit dialing. Data were collected by telephone interviews and chart reviews. The study had 80% power to detect an odds ratio (OR) of 2.5.

RESULTS

A total of 653 cases and 2,990 controls were interviewed. There was no association between nicotine patches and MI (OR 0.46; 95% CI: 0.09, 1.47), and the confidence interval (CI) excluded an effect from nicotine patches equal to that from cigarette smoking itself (OR < 2.5). Among those who abstained from smoking, the OR for use of nicotine patches was 0.25 (95% CI: 0.01, 1.67); among those who smoked concomitantly, the OR for patch use was 0.83 (95% CI: 0.09, 3.81). Adjustment for confounding did not alter the study's findings (OR adjusted for confounders that could mask a harmful effect of patches: 0.70; 95% CI: 0.20, 2.46).

CONCLUSIONS

Nicotine patches, as used in actual practice, do not appear to be associated with an increased risk of MI.

Effects of coronary stents on cardiovascular outcomes in broad-based clinical practice

BACKGROUND

Although stents have been shown to reduce the need for repeated percutaneous coronary intervention (PCI) in randomized trials, the effects of stents in broad-based, diverse clinical practice have not been well studied, nor has their effect on subsequent myocardial infarction or cardiac death.

METHODS

A retrospective cohort study was performed that included all 43 hospitals performing PCI in Pennsylvania in the last quarter of 1995, with the use of the Pennsylvania Health Care Cost Containment Council database. All 5258 patients who underwent PCI, excluding those with previous PCI within the preceding 6 months, were included. The primary outcomes were in-hospital events (death or coronary bypass), 6-month revascularization rates, and 6-month rates of cardiac death or myocardial infarction.

RESULTS

A total of 1240 patients (24%) had a stent procedure. Compared with nonstent procedures, stents reduced the risk of in-hospital events (multivariable odds ratio adjusted for patient and hospital level differences, 0.63; 95% confidence interval, 0.41-0.97), primarily because of a 52% reduction in the need for coronary bypass. Stents also reduced the need for follow-up revascularization procedures (multivariable hazard ratio, 0.72; 95% confidence interval, 0.59-0. 87), primarily because of a 31% reduction in repeated PCI. However, stents had no effect on 6-month rate of myocardial infarction or cardiac death (multivariable hazard ratio, 0.97; 95% confidence interval, 0.71-1.33).

CONCLUSIONS

Using stents decreases the need for repeated PCI in broad-based clinical practice, confirming results from randomized trials. However, this study did not detect any effect on subsequent myocardial infarction or cardiac death.

Recency and suffix effects with immediate recall of olfactory stimuli

In contrast to our understanding of the immediate recall of auditory and visual material, little is known about the corresponding characteristics of short-term olfactory memory. The current study investigated the pattern of immediate serial recall and the associated suffix effect using olfactory stimuli. Subjects were trained initially to identify and name correctly nine different odours. Experiment 1 established an immediate correct recall span of approximately six items. In Experiment 2 participants recalled serially span equivalent lists which were followed by a visual, auditory, or olfactory suffix. Primacy was evident in the recall curves for all three suffix conditions. Recency, in contrast, was evident in the auditory and visual suffix conditions only; there was a strong suffix effect in the olfactory suffix condition. Experiment 3 replicated this pattern of effects using seven-item lists, and demonstrated that the magnitude of the recency and suffix effects obtained in the olfactory modality can equate to that obtained in the auditory modality. It is concluded that the pattern of recency and suffix effects in the olfactory modality is reliable, and poses difficulties for those theories that rely on the presence of a primary linguistic code, sound, or changing state as determinants of these effects in serial recall.

Multiple roles for the Wilms' tumor suppressor, WT1

Wilms' tumor is a childhood kidney tumor that is a striking example of the way that cancer may arise through development gone awry. A proportion of these tumors develop as a result of the loss of function mutations in the Wilms' tumor suppressor gene, WT1. Inherited mutations in the WT1 gene can lead to childhood kidney cancer, severe gonadal dysplasia, and life-threatening hypertension. Knockouts show that the gene is essential for the early stages of kidney and gonad formation. These tissues are completely absent in null mice. The WT1 gene encodes numerous protein isoforms, all of which share four zinc fingers. There is a large body of evidence supporting the notion that WT1 is a transcription factor, particularly a transcriptional repressor. Recently, however, we obtained evidence that WT1 colocalizes and is physically associated with splice factors. What is more, one alternative splice isoform of WT1 containing three amino acids, Lys-Thr-Ser (KTS; inserted between zinc fingers 3 and 4) is preferentially associated with splice factors, whereas the other alternative splice version, lacking these three amino acids, preferentially associates with the transcriptional apparatus. Both genetic and evolutionary considerations suggest that these two different forms of the protein have different functions. We will discuss recent evidence to further implicate WT1 in splicing. Our results raise the possibility that regulation of splicing is a crucial factor in the development of the genitourinary system, and that tumors may arise through aberrant splicing. To pursue the regulation and function of WT1 in whole animals, we have been introducing the human gene and large flanking regions cloned in yeast artificial chromosomes directly into mice. These studies have allowed us to dissect the function of WT1 at late as well as at early stages in organogenesis and to identify new sites and surprising new potential functions for the gene.

A zinc finger truncation of murine WT1 results in the characteristic urogenital abnormalities of Denys-Drash syndrome

The Wilms tumor-suppressor gene, WT1, plays a key role in urogenital development, and WT1 dysfunction is implicated in both neoplastic (Wilms tumor, mesothelioma, leukemias, and breast cancer) and nonneoplastic (glomerulosclerosis) disease. The analysis of diseases linked specifically with WT1 mutations, such as Denys-Drash syndrome (DDS), can provide valuable insight concerning the role of WT1 in development and disease. DDS is a rare childhood disease characterized by a nephropathy involving mesangial sclerosis, XY pseudohermaphroditism, and/or Wilms tumor (WT). DDS patients are constitutionally heterozygous for exonic point mutations in WT1, which include mutations predicted to truncate the protein within the C-terminal zinc finger (ZF) region. We report that heterozygosity for a targeted murine Wt1 allele, Wt1(tmT396), which truncates ZF3 at codon 396, induces mesangial sclerosis characteristic of DDS in adult heterozygous and chimeric mice. Male genital defects also were evident and there was a single case of Wilms tumor in which the transcript of the nontargeted allele showed an exon 9 skipping event, implying a causal link between Wt1 dysfunction and Wilms tumorigenesis in mice. However, the mutant WT1(tmT396) protein accounted for only 5% of WT1 in both heterozygous embryonic stem cells and the WT. This has implications regarding the mechanism by which the mutant allele exerts its effect.

Complete sequencing of the Fugu WAGR region from WT1 to PAX6: dramatic compaction and conservation of synteny with human chromosome 11p13

The pufferfish Fugu rubripes has a genome approximately 7.5 times smaller than that of mammals but with a similar number of genes. Although conserved synteny has been demonstrated between pufferfish and mammals across some regions of the genome, there is some controversy as to what extent Fugu will be a useful model for the human genome, e.g., [Gilley, J., Armes, N. & Fried, M. (1997) Nature (London) 385, 305-306]. We report extensive conservation of synteny between a 1.5-Mb region of human chromosome 11 and <100 kb of the Fugu genome in three overlapping cosmids. Our findings support the idea that the majority of DNA in the region of human chromosome 11p13 is intergenic. Comparative analysis of three unrelated genes with quite different roles, WT1, RCN1, and PAX6, has revealed differences in their structural evolution. Whereas the human WT1 gene can generate 16 protein isoforms via a combination of alternative splicing, RNA editing, and alternative start site usage, our data predict that Fugu WT1 is capable of generating only two isoforms. This raises the question of the extent to which the evolution of WT1 isoforms is related to the evolution of the mammalian genitourinary system. In addition, this region of the Fugu genome shows a much greater overall compaction than usual but with significant noncoding homology observed at the PAX6 locus, implying that comparative genomics has identified regulatory elements associated with this gene.

Estrogen and memory in a transsexual population

The association between administered estrogen and performance on verbal memory and other cognitive tasks was examined. Male-to-female transsexuals undergoing estrogen treatment for sex reassignment (n = 29) scored higher on Paired Associate Learning (PAL) compared to a similar transsexual control group, awaiting estrogen treatment (n = 30) (P < 0.05). No differences between groups receiving and not receiving estrogen were detected on a control memory task (Digit Span) or on other cognitive tasks including Mental Rotations and Controlled Associations. There were no group differences in age. Group differences in mood or in general intellectual ability also did not explain the findings. Results suggest a specific influence of estrogen in men on verbal memory tasks, similar to that seen in prior studies of women. They are discussed in terms of differential processing demands of the two memory tasks and possible differences between estrogenic influences on Mental Rotations and Controlled Associations in men versus women.

The role of the physician as an information source on mammography

PURPOSE

The value of mammography for asymptomatic women younger than 50 years of age has been under debate, and it had been suggested that each woman should decide for herself whether to start having mammograms in her 40s. This decision-making process requires women to have knowledge of screening guidelines. This study reported key determining informational factors that led women age 40 and older to obtain a mammogram.

DESCRIPTION OF STUDY

To examine the relationship between sources of information and utilization of mammography, the authors conducted a communitywide telephone survey, in English and Spanish, of a stratified random sample of 999 white, black, and Hispanic women in Dade County, Florida. The survey was designed to measure knowledge, attitudes, practices, and beliefs about breast cancer, its prevention, and its early detection. Data for 784 women 40 years and older are analyzed and reported here.

RESULTS

The most commonly cited source of information was the media (90.2%). In a logistic regression, having had a checkup in the past year was the strongest predictor of having had a recent mammogram as opposed to a distant one (OR 4.17; 95% CI 2.92-5.95). Women who named their physician as an important source of information about health and prevention were also more likely to have had a recent examination (OR 1.85; 95% CI 1.27-2.69).

CLINICAL IMPLICATIONS

This analysis of the relationship between the source of information and utilization of mammography suggests that physicians, as sources of information, serve to motivate women to obtain a mammogram. This is true even after taking into account the patient's age and utilization of the healthcare system for preventive care in general. For this reason, it is imperative that clinicians be aware of national guidelines for breast cancer screening; of the risks and benefits of screening measures; and of the implications of a positive and negative test result. In addition, clinicians must realize the importance of follow-up to remind the patient to obtain a mammogram or other screening test and should develop strategies to provide this service.

Abnormal spinal fluid in hypertensive encephalopathy

A 44-year-old white male presented with marked hypertension and encephalopathy. His spinal fluid showed a neutrophilic pleocytosis in the absence of infection. While cases of hypertensive encephalopathy with concomitant minor lymphocytic pleocytosis have been occasionally described, it is distinctly abnormal to have a neutrophilic pleocytosis in this setting.

State-dependent memory produced by aerobic exercise

In a free recall experiment, participants learned lists of words in two physiological states: at rest and while exercising aerobically on a bicycle ergometer. Recall of the words was required in either the state consistent with learning or in the alternative state. Word lists learned during aerobic exercise were recalled best during aerobic exercise and vice versa. Greater changes in heart rate in the changed state conditions were associated with greater retrieval decrements. Recall levels for words both learned and recalled at exercise were equivalent to those for words both learned and recalled at rest. This finding rules out the possibility that exercise per se interfered with the original learning. The study is consistent with the view that state-dependent memory should be viewed as a particular form of cue-dependent memory.

The role of late-onset autoimmune diabetes in white familial NIDDM pedigrees

OBJECTIVE

To determine whether autoimmunity is a prominent feature of NIDDM among diabetic members in families with a strong history of NIDDM or in families with a mixture of NIDDM and IDDM.

RESEARCH DESIGN AND METHODS

We determined GAD and islet cell (ICA512) autoantibodies from 215 NIDDM individuals and from 14 individuals with impaired glucose tolerance (IGT) of 68 families, including 1 family with maturity-onset diabetes of the young (MODY) and 3 families ascertained specifically for a mixture of NIDDM and IDDM. We tested 2 control populations: 50 unrelated spouses form Utah families, including 29 spouses with either IGT or NIDDM and 198 random nondiabetic white individuals from Colorado.

RESULTS

We detected either GAD or ICA512 autoantibodies in 11 members of seven families and in one spouse used as a control subject. In two families, two affected individuals showed evidence of autoimmunity, but NIDDM individuals in each of the seven families showed no evidence of autoimmunity. Among the five families with both IDDM and NIDDM individuals (three families ascertained for a mixture and two families ascertained with an incidental IDDM child), antibodies were detected in members of only one family. Antibody-positive individuals were significantly younger at diabetes onset and had low waist-to-hip ratios, but were not more likely to be insulin treated.

CONCLUSIONS

Autoimmunity is an important cause of apparent NIDDM, even among families with a strong history of NIDDM. However, autoimmunity among affected family members appeared to be a chance event and not the manifestation of a different genetic cause of diabetes.

CCK antagonist pre-treatment inhibits meal-enhanced drug absorption in dogs

Duodenal administration of casein and oleate increased plasma levels from oral administration of a poorly water-soluble antiepileptic drug as compared to duodenal glucose and saline in a canine model. Pre-treatment with intravenous MK-329, benzodiazepine CCK A-receptor antagonist, blocked the duodenal oleate effect on drug plasma levels in a single dog preliminary study. In a follow-up study, oral drug co-administration with Intralipid increased drug plasma levels as compared to drug co-administration with a noncaloric equivalent-volume load in seven dogs. Pre-treatment with MK-329 reduced drug plasma levels from co-administration with Intralipid toward fasted-state values. While increased drug solubility in the lipid vehicle might have been projected to account for the fed-state effect in the oral studies, the gut peptide inhibitor studies suggest that biliary secretion plays a major role in promoting the dissolution and subsequent absorption of this lipophilic drug. The data also support the hypothesis that meal-enhanced pancreatic secretion provides a greater fluid volume for drug dissolution in the small intestine. An increase in the extent of drug dissolution in the stomach, as a result of meal prolongation of gastric residence time, does not appear to contribute substantially to fed-state increases in drug plasma levels from oral drug co-administration with a lipid meal.

Expression of the Ly-6E.1 (Sca-1) transgene in adult hematopoietic stem cells and the developing mouse embryo

The mouse hematopoietic marker Sca-1, encoded by the Ly-6E.1 and Ly-6A.2 genes, has been instrumental in the enrichment and characterization of the stem cell for the adult blood system. In the studies reported here, we use Ly-6E.1 genomic fragments to direct expression of a lacZ marker transgene in vivo to study Ly-6E.1 specific regulatory elements in the hematopoietic stem cell and to localize these cells in the developing mouse embryo. We demonstrate that a region approximately 9 kb downstream from the transcriptional start site is required for the distinct, restricted expression pattern of the Ly-6E.1-lacZ transgene within adult hematopoietic stem cells and embryos. We also demonstrate that viable and functional lacZ-expressing hematopoietic stem cells can be enriched by FDG staining and flow cytometric sorting. The Ly-6E.1-lacZ-mediated enrichment of hematopoietic stem cells from adult transgenic bone marrow in combination with the temporal expression pattern of the transgene in the pro/mesonephros suggest an intraembryonic site of development for these cells in the mouse.

Role of the beta 3-adrenergic receptor locus in obesity and noninsulin-dependent diabetes among members of Caucasian families with a diabetic sibling pair

Obesity and insulin resistance are important risk factors for the development of noninsulin-dependent diabetes (NIDDM) and are prevalent among predisposed first degree relatives of diabetic individuals. Recent molecular screening and analysis of a common missense mutation of the beta 3-adrenergic receptor gene suggested this locus as a strong candidate for increased obesity, earlier age of diabetes onset, and insulin resistance. To test the hypothesis that the beta 3-adrenergic receptor locus affects diabetes susceptibility, obesity as measured by body mass index, and components of the insulin resistance syndrome, we examined the role of this region in families ascertained for two or more NIDDM siblings. Linkage analysis was conducted using both parametric and nonparametric analyses, including multipoint sibling pair analysis. We found no evidence for linkage to NIDDM as a dichotomous trait and no evidence for linkage to body mass index, waist/hip ratio, insulin levels, or glucose levels as quantitative traits or to reported age of onset among NIDDM individuals. The Trp64 Arg missense mutation was present in 11% of the population. The mutation was not associated with NIDDM, and Arg64 carriers did not have earlier NIDDM onset, higher body mass index, or higher waist/hip ratio than Trp64 homozygotes. Among relatives, Arg64 carriers had significantly lower fasting glucose levels and lower waist/hip ratios than Trp64 homozygotes, but no characteristics of the insulin resistance syndrome. We conclude that the beta 3-adrenergic receptor locus does not play an important role in NIDDM susceptibility or in the insulin resistance syndrome among members of families with a strong predisposition to NIDDM.