Genetic Findings as the Potential Basis of Personalized Pharmacotherapy in Phelan-McDermid Syndrome

Phelan-McDermid syndrome (PMS) is a genetic disorder often characterized by autism or autistic-like behavior. Most cases are associated with haploinsufficiency of the SHANK3 gene resulting from deletion of the gene at 22q13.3 or from a pathogenic variant in the gene. Treatment of PMS often targets SHANK3, yet deletion size varies from <50 kb to >9 Mb, potentially encompassing dozens of genes and disrupting regulatory elements altering gene expression, inferring the potential for multiple therapeutic targets. Repurposed drugs have been used in clinical trials investigating therapies for PMS: insulin-like growth factor 1 (IGF-1) for its effect on social and aberrant behaviors, intranasal insulin for improvements in cognitive and social ability, and lithium for reversing regression and stabilizing behavior. The pharmacogenomics of PMS is complicated by the CYP2D6 enzyme which metabolizes antidepressants and antipsychotics often used for treatment. The gene coding for CYP2D6 maps to 22q13.2 and is lost in individuals with deletions larger than 8 Mb. Because PMS has diverse neurological and medical symptoms, many concurrent medications may be prescribed, increasing the risk for adverse drug reactions. At present, there is no single best treatment for PMS. Approaches to therapy are necessarily complex and must target variable behavioral and physical symptoms of PMS.

Genetic and environmental factors influencing the interaction between the gut microbiota and the human host: implications for gastrointestinal disorders and treatment approaches

The growing knowledge on the microbiota hosted in the human intestine has allowed researchers and clinicians to discover a critical role for these microorganisms in the pathogenesis of several human disorders. In particular, perturbation in the microbiotic strains populating the gastrointestinal tract has been associated with several conditions affecting the digestive system. The composition of the human gut microbiota is influenced by both genetic factors, like the human and the microbiotic genomes, and environmental ones, such as diet or drugs. Alteration of the interaction between the gut microbiota and the human host has been proven to be associated with several gastrointestinal disorders as well as potential effects on pharmacological therapies.

Increased apoptosis in human amnion is associated with labor at term

PROBLEM

To characterize whether increased apoptosis in human amnion was associated with labor at term.

METHOD OF STUDY

Human amnion were obtained from term patients with vaginal delivery (n = 5) or who underwent elective Cesarean section (C/S) without labor (n = 5). Apoptosis was performed by the TUNEL (Terminal dUTP Nuclear End Labeling) assay. All nucleated cells stained with propidium iodide in the amnion epithelial cells were identified in red fluorescence. TUNEL positive apoptotic nuclei were identified in green fluorescence. Five random fields of each specimen were blindly counted by investigators. The percentage of apoptotic nuclei of total nuclei (apoptotic index) was calculated and compared between the two groups (25 microscopic fields for each group, respectively).

RESULTS

Patients with term labor had a significantly higher mean apoptotic index in amnion epithelial cells than that with elective C/S without labor (27.3 +/- 4.1% versus 3.6 +/- 1.6%, P < 0.001).

CONCLUSIONS

Our data indicate that apoptosis in human amnion is significantly increased and associated with labor at term.

The role of amniotic fluid interleukin-6, and cell adhesion molecules, intercellular adhesion molecule-1 and leukocyte adhesion molecule-1, in intra-amniotic infection

PROBLEM

To determine amniotic fluid concentrations and correlations of interleukin-6 (IL-6), intercellular adhesion molecule-1 (ICAM-1), and leukocyte adhesion molecule-1 (LAM-1) in patients with and without intra-amniotic infection.

METHOD OF STUDY

Fourteen specimens with intra-amniotic infection and 45 without intra-amniotic infection were studied. Intra-amniotic infection was defined as the presence of a positive amniotic fluid culture. Amniotic fluid IL-6, ICAM-1, and LAM-1 levels were determined by an enzyme-linked immunoassay, and normalized by amniotic fluid creatinine levels.

RESULTS

Amniotic fluid concentrations of IL-6 and LAM-1 were significantly higher in patients with than without intra-amniotic infection. However, amniotic fluid ICAM-1 concentrations were not significantly different between two groups. Amniotic fluid IL-6, LAM-1, and ICAM-1 were positively correlated.

CONCLUSIONS

Our data indicate that amniotic fluid IL-6 is significantly associated with an increased adhesion molecule expression in intra-amniotic infection. However, LAM-1 plays a more important role than ICAM-1 in intra-amniotic infection.

Nitric oxide: a clinically important amniotic fluid marker to distinguish between intra-amniotic mycoplasma and non-mycoplasma infections

The objective of this study was to determine whether the measurements of amniotic fluid nitric oxide metabolite (NOx: nitrate + nitrite) concentrations could be a clinically useful marker to differentiate between intra-amniotic mycoplasma and nonmycoplasma infections. Amniocentesis was performed on 76 pregnant women with suspicion of intra-amniotic infection. Intra-amniotic infection was defined as the presence of a positive amniotic fluid culture with either mycoplasma or nonmycoplasma infections. Rapid amniotic fluid tests for Gram stain, glucose, leukocyte counts, interleukin-6, and NOx were performed. Amniotic fluid NOx was measured with aspergillus nitrate reductase and Griess reagent. Interleukin-6 was determined by enzyme immunoassays. Amniotic fluid NOx and interleukin-6 were normalized by amniotic fluid creatinine levels. Patients with intra-amniotic mycoplasma (n = 7) and nonmycoplasma infections (n = 8) had significantly higher amniotic fluid leukocyte counts and interleukin-6 concentrations and significantly lower amniotic fluid glucose levels than noninfected controls (n = 61). Amniotic fluid concentrations of NOx were significantly higher in those with intraamniotic nonmycoplasma infection as compared to those with intraamniotic mycoplasma infection and noninfected controls (NOx: 3.35+/-0.74 vs. 2.03+/-0.41 micromol/mg creatinine, p = 0.005, and 3.35+/-0.74 vs. 1.72+/-0.07 micromol/mg creatinine, p < 0.0001, respectively). However, patients with intra-amniotic mycoplasma infection did not differ significantly from noninfected controls. Our data indicate that clinical characteristics of intra-amniotic mycoplasma infection may differ from intra-amniotic nonmycoplasma infection. As delivery is not always indicated in intra-amniotic mycoplasma infection, elevated rapid amniotic fluid tests (leukocyte counts, interleukin-6, and glucose) may not be appropriate in the clinical management of intra-amniotic mycoplasma infection. In addition to these rapid amniotic fluid tests, incorporation of the measurement of amniotic fluid NOx may be of clinical importance in the differentiation and management of patients with suspected intra-amniotic mycoplasma and nonmycoplasma infection.

Dual roles of amniotic fluid nitric oxide and prostaglandin E2 in preterm labor with intra-amniotic infection

We hypothesized that induction of nitric oxide synthase and cyclo-oxygenase-2 by bacterial products in intra-amniotic infection could increase the production of proinflammatory nitric oxide and prostaglandin E2 (PGE2) and cause preterm labor. Thus, we sought to determine amniotic fluid levels of nitric oxide metabolites (NOx) and PGE2 in preterm labor patients with and without intra-amniotic infection. Amniotic fluid from 13 preterm labor patients with intra-amniotic infection and 24 without intra-amniotic infection were studied. Intra-amniotic infection was defined as the presence of a positive amniotic fluid culture. Amniotic fluid was tested for NOx, PGE2, glucose, leukocyte counts, Gram stains, creatinine, pH, and specific gravity. NOx was determined using Griess reagent after reduction of nitrate to nitrite with aspergillus nitrate reductase. PGE2 was measured by an enzyme-linked immunoassay. Both amniotic fluid NOx and PGE2 were normalized by amniotic fluid creatinine. We found that amniotic fluid concentrations of NOx and PGE2 were significantly higher in preterm labor patients with intra-amniotic infection compared to those without intraamniotic infection (NOx: median 1.8 micromol/mg creatinine, range 0.7 to 6.8 vs. 1.3 micromol/mg creatinine, range 0.9 to 2.1, p=0.03; PGE2: median 33.5 ng/mg creatinine, range 0.0 to 1048.6 vs. 0.0 ng/mg creatinine, range 0.0 to 33.6, p=0.004). In addition, amniotic fluid NOx and PGE2 were positively correlated (r=0.343, p=0.0398). We conclude that there may be an interaction between the nitric oxide and prostaglandin pathways in intraamniotic infection. Increased production of amniotic fluid pro-inflammatory nitric oxide and PGE2 may play an important role in the pathogenesis of preterm labor in patients with intra-amniotic infection.

Elevated amniotic fluid levels of leukemia inhibitory factor, interleukin 6, and interleukin 8 in intra-amniotic infection

OBJECTIVE

The study's objective was to determine and correlate amniotic fluid levels of leukemia inhibitory factor, interleukin 6, and interleukin 8 in patients with and without intra-amniotic infection.

STUDY DESIGN

Amniocentesis was performed on 41 pregnant women with preterm contractions, labor, or premature rupture of membranes. Intra-amniotic infection was defined as the presence of a positive amniotic fluid culture result. Amniotic fluid tests for Gram stain, glucose, leukocyte counts, creatinine level, pH, and specific gravity were performed. Amniotic fluid levels of leukemia inhibitory factor, interleukin 6, and interleukin 8 were measured by an enzyme-linked immunoassay. Unlike in previous reports, cytokines were normalized by amniotic fluid creatinine levels.

RESULTS

Fifteen patients had intra-amniotic infection and 26 did not. Amniotic fluid median levels of leukemia inhibitory factor, interleukin 6, and interleukin 8 were significantly higher in pregnant women with intra-amniotic infection than in those without intra-amniotic infection (leukemia inhibitory factor median 3912 pg/mg creatinine, range 0.0-199314, vs 56 pg/mg creatinine, range 0. 0-12148, P =.01; interleukin 6 median 2005 ng/mg creatinine, range 27-4071, vs 990 ng/mg creatinine, range 7.5-3409, P =.005; interleukin 8: median 4933 ng/mg creatinine, range 0.0-55058, vs 61 ng/mg creatinine, range 0.0-2399, P =.005). Amniotic fluid levels of leukemia inhibitory factor, interleukin 6, and interleukin 8 were positively correlated.

CONCLUSIONS

The data indicate that leukemia inhibitory factor plays an important role in the pathogenesis of intra-amniotic infection. In addition, significant elevations of and correlations among amniotic fluid levels of leukemia inhibitory factor, interleukin 6, and interleukin 8 suggest that measurements of these cytokines in amniotic fluid may be of diagnostic and prognostic importance.

Immunohistochemical localization of inducible nitric oxide synthase on human fetal amnion in intra-amniotic infection

OBJECTIVES

Amniotic fluid levels of nitric oxide metabolites are significantly elevated in intra-amniotic infection. We hypothesized that fetal amnion is a possible site for the production of nitric oxide. Because inducible nitric oxide synthase is the key enzyme responsible for the generation of nitric oxide in patients with intra-amniotic infection, we used immunohistochemistry to localize it on human fetal amnion.

STUDY DESIGN

Human fetal amnions were obtained from patients with and without intra-amniotic infection (n = 5, respectively). Intra-amniotic infection was diagnosed by positive amniotic fluid cultures and placental pathologic features. Human fetal amniotic membranes were processed into tissue blocks and embedded in paraffin. A rabbit polyclonal antibody against human inducible nitric oxide synthase was used as the primary antibody, followed by avidin-biotin immunoperoxidase localization. Normal rabbit serum was used as a negative control and ovarian carcinoma cells were used as the positive control.

RESULTS

Anti-inducible nitric oxide synthase labeling of human fetal amniotic membranes in patients with intra-amniotic infection showed positive immunostaining of epithelial cells, specifically in the cytoplasm of the perinuclear area. In contrast, no anti-inducible nitric oxide synthase immunostaining on human fetal amniotic membranes could be identified in patients without intra-amniotic infection.

CONCLUSIONS

Our data provide important evidence that inducible nitric oxide synthase can be induced on human fetal amnion in intra-amniotic infection. These findings strongly support our hypothesis that human fetal amnion may be a possible site for the synthesis of nitric oxide after inducible nitric oxide synthase is induced in response to infectious products in intra-amniotic infection.

The role of amniotic fluid L-selectin, GRO-alpha, and interleukin-8 in the pathogenesis of intraamniotic infection

OBJECTIVE

Our purpose was to compare and correlate amniotic fluid GRO-alpha, interleukin-8, and L-selectin in patients with and without intraamniotic infection.

STUDY DESIGN

Amniocentesis was performed on 45 pregnant women with preterm contractions, labor, or rupture of membranes. Fourteen patients had intraamniotic infection, and 31 did not. Intraamniotic infection was defined as the presence of a positive amniotic fluid culture. Amniotic fluid tests for Gram stain, glucose, neutrophil counts, creatinine, pH, and specific gravity were performed. Amniotic fluid levels of soluble L-selectin, interleukin-8, and GRO-alpha were measured by an enzyme-linked immunoassay and normalized by amniotic fluid creatinine levels. The Mann-Whitney Utest and Spearman's rank correlation test were used for statistical analyses.

RESULTS

Amniotic fluid median levels of soluble L-selectin, interleukin-8, and GRO-alpha were significantly higher in pregnant women with intraamniotic infection than in those without intraamniotic infection (soluble L-selectin: median 3334.6 ng/mg creatinine, range 408.4 to 15,956.8 vs 717.2 ng/mg creatinine, range 129.4 to 4601.9, p = 0.009; GRO-alpha: median 841.6 ng/mg creatinine, range 28.1 to 8591.7 vs 56.8 ng/mg creatinine, range 0.0 to 440.2, p < 0.0001; interleukin-8: median 4932.7 ng/mg creatinine, range 0.0 to 55,058.7 vs 28.3 ng/mg creatinine, range 0.0 to 1161.6, p = 0.0004). Patients with intraamniotic infection had significantly higher amniotic fluid leukocyte counts and leukocyte esterase activities and significantly lower amniotic fluid glucose concentrations compared with those without intraamniotic infection. Amniotic fluid GRO-alpha, interleukin-8, and soluble L-selectin were positively correlated, and each was positively correlated with amniotic fluid leukocytes and negatively correlated with amniotic fluid levels of glucose.

CONCLUSIONS

Our data indicate amniotic fluid GRO-alpha and interleukin-8 may be two potent leukocyte chemoattractants and activators, and L-selectin is rapidly shed from leukocytes in the amniotic fluid in patients with intraamniotic infection.

Elevated amniotic fluid nitric oxide metabolites and interleukin-6 in intra-amniotic infection

OBJECTIVE

To compare amniotic fluid nitric oxide metabolites and interleukin-6 (IL-6) concentrations in patients with and without intra-amniotic infection.

METHODS

Amniotic fluid nitric oxide metabolites, IL-6, Gram stains, glucose, leukocyte counts, leukocyte esterase activity, creatinine, pH, and specific gravity were determined in 14 patients with intra-amniotic infection and 26 patients without intra-amniotic infection. Intra-amniotic infection was defined as the presence of a positive amniotic fluid culture. The nitric oxide metabolites, nitrate and nitrite (NOx), were measured using Greiss reagent after reduction of nitrate to nitrite with aspergillus nitrate reductase. Interleukin-6 was measured by a two-site, enzyme-linked immunosorbent assay. Amniotic fluid nitric oxide metabolites and IL-6 concentrations were normalized by amniotic fluid creatinine levels. The Mann-Whitney U test, contingency table method, and Spearman's rank correlation test were used for statistical analyses.

RESULTS

Amniotic fluid NOx and IL-6 levels were significantly higher in patients with intra-amniotic infection than in those without intra-amniotic infection (NOx: median = 2.06 mumol/mg creatinine, range = 0.74-6.81 versus 1.35 mumol/mg creatinine, range = 0.99-1.60, P = .01, IL-6: median = 2.00 micrograms/mg creatinine, range = 0.026-4.07 versus median = 0.04 micrograms/mg creatinine, range = 0.004-3.210, P = .0009, respectively). Patients with intra-amniotic infection had significantly elevated leukocyte counts, leukocyte esterase activity, Gram positive stains, and significantly lower amniotic fluid glucose levels compared with those without intra-amniotic infection. There were no differences in gestational age, maternal age, parity, race, pH, or specific gravity between the two groups. Amniotic fluid NOx was significantly correlated with IL-6 (r = .4, P = .02). Both amniotic fluid NOx and IL-6 were also positively correlated with amniotic fluid leukocyte counts, leukocyte esterase activity and Gram stains, and negatively correlated with glucose levels.

CONCLUSIONS

Amniotic fluid NOx and IL-6 are significantly elevated and positively correlated during intra-amniotic infection. Both increased amniotic fluid IL-6 and nitric oxide may exert cytotoxic and cytostatic effects on the target cells. We suggest that measurements of amniotic fluid NOx and IL-6 may serve as useful clinical markers in patients with intra-amniotic infection.

Elevated amniotic fluid nitric oxide metabolites and cyclic guanosine 3',5'-monophosphate in pregnant women with intraamniotic infection

OBJECTIVE

Our purpose was to compare amniotic fluid nitric oxide metabolites and cyclic guanosine 3',5'-monophosphate in pregnant women with and without intraamniotic infection.

STUDY DESIGN

Amniocentesis was performed on 72 pregnant women with preterm contractions, labor, or rupture of membranes. Fourteen patients had intraamniotic infection and 58 did not. Intraamniotic infection was defined as the presence of a positive amniotic fluid culture. Amniotic fluid Gram stain, glucose, leukocyte counts, leukocyte esterase activity, creatinine, pH, and specific gravity were performed. Endogenous nitrite was determined using Griess reagent. Amniotic fluid nitric oxide metabolites (nitrite and nitrate) were measured after reduction of nitrate to nitrite with Aspergillus nitrate reductase. Tests for amniotic fluid cyclic guanosine monophosphate levels were determined by enzyme immunoassay. Two-tailed t test, contingency table methods, linear regression, and correlation were used for statistical analyses.

RESULTS

Amniotic fluid levels of nitric oxide metabolites, endogenous nitrite, nitrate, and cyclic guanosine monophosphate were significantly higher in pregnant women with intraamniotic infection than in those without intraamniotic infection (2.66 +/- 0.49 vs 1.77 +/- 0.07 mumol/mg creatinine, p = 0.002; 0.69 +/- 0.15 vs 0.38 +/- 0.03 mumol/mg creatinine, p = 0.003; 1.99 +/- 0.41 vs 1.38 +/- 0.07 mumol/mg creatinine, p = 0.02; and 1.47 +/- 0.22 vs 0.90 +/- 0.08 nmol/mg creatinine, p = 0.004, respectively). Both amniotic fluid nitric oxide metabolites and cyclic guanosine monophosphate were positively correlated with amniotic fluid leukocyte counts and leukocyte esterase activity and negatively correlated with amniotic fluid glucose concentrations.

CONCLUSIONS

Our data indicate that amniotic fluid nitric oxide and cyclic guanosine monophosphate may play important roles in the pathogenesis of intraamniotic infection. Measurements of amniotic fluid nitric oxide metabolites and cyclic guanosine monophosphate may be part of a panel of tests that can be used to detect intraamniotic infection.