Giant Retinal Astrocytoma: A Case Report of an Uncommon Presentation of Tuberous Sclerosis in a Young Female

Tuberous sclerosis (TS) is a rare multisystem autosomal dominant genetic disorder with characteristic pathognomonic genetic mutations involving the TSC (tuberous sclerosis complex) group of genes. Ocular signs are fairly common and include an achromic patch and retinal astrocytic hamartomas, which usually have a maximum size of between 0.5 and 5 mm. The incidence of tuberous sclerosis is estimated to be 1 in 5000-10,000 individuals, with both familial and sporadic cases reported. The diagnostic criteria for tuberous sclerosis include the presence of major and/or minor clinical features as well as genetic mutations. We present the case of a 15-year-old girl, presented with a history of seizures and blurred vision. Physical examination revealed angiofibroma on the face. Further evaluation, including contrast-enhanced MRI of the brain and ophthalmological consultation, led to the diagnosis of tuberous sclerosis. Additional imaging studies confirmed the presence of subependymal giant cell astrocytoma, retinal astrocytoma, lymphangioleiomyomatosis in the lungs, and renal angiomyolipoma. This case highlights the importance of considering tuberous sclerosis in patients presenting with seizures and ocular symptoms. This case sheds light on early diagnosis and appropriate management which are crucial in preventing complications and improving patient outcomes.

Building partnerships with local schools

BACKGROUND

Medical schools have a responsibility to support their students in developing an understanding of the complex concepts of a 'VUCA' (volatile, uncertain, complex and ambiguous) world. To achieve this, service learning approaches have been increasingly successfully employed for students to learn through participating in activities addressing local community priorities. Sharing outcomes and lessons from such programmes is essential for advancing service learning. We present the evaluation of a new service learning module co-designed at Imperial College London with local schools and wider stakeholders.

APPROACH

Students partnered with local schoolteachers to design and implement inclusive science-based after-school sessions for secondary school pupils. The module aimed to foster critical reflection on social accountability, power and privilege whilst encouraging aspirations for higher education in school pupils.

EVALUATION

Our evaluation draws on the perspectives of stakeholders in the first iteration of the module in 2021. Qualitative data were collected through university student reflections, presentations and debriefs (n = 20); semi-structured interviews with schoolteachers (n = 6); and questionnaires with wider stakeholders (n = 6). The evaluation revealed mutual benefits, as students reflected on their own societal roles, whilst considering the complexities of concepts such as inclusivity, power and privilege. Schoolteachers highlighted students' impact as inspiring role models for pupils, fostering aspirations for higher education.

IMPLICATIONS

This module provides a replicable framework for supporting students in developing their reflections on their role in our VUCA world whilst addressing the priorities identified by local schools. The evaluation highlighted the importance of working collaboratively with community stakeholders when embarking on service learning projects.

A qualitative evaluation of the impact of a medical student school outreach project on both medical students and school pupils

OBJECTIVE

To explore medical student and school pupil experiences of an outreach school teaching project.

SETTING

Community engagement is increasingly commonplace within medical school. Secondary schools offer ample opportunities for community engagement as medical students teach and engage in service learning. There is a lack of research regarding the impact of school community engagement projects and the impact on pupils, as critical stakeholders in the service medical students provide. In this qualitative study, we explore the perspectives of medical students and school pupils involved in a school teaching project.

PARTICIPANTS

Ten medical students participated in individual interviews, and 17 school pupils across three schools participated in group interviews. Data were analysed using thematic analysis and the concept of service learning.

RESULTS

For medical students, the project fostered communication and teaching skills, but a lack of reflection hampered further benefit. For school pupils, experiences varied - learning about careers in medicine could be inspiring, but content pitched at the incorrect level disengaged some pupils. The conflict between session timing and medical students' exams negatively influenced engagement.

CONCLUSIONS

To shift the focus of community engagement projects that promote service-learning towards mutual benefit, designing in partnership with relevant community stakeholders and integrating opportunities to reflect on these experiences are critical.

Learning machines or the key to care: a qualitative study exploring the impact of the hidden curriculum on medical students' longitudinal experiences in primary care

OBJECTIVE

Longitudinal learning often faces implementation challenges within UK medical schools. Some have suggested that the hidden curriculum may be implicated, but there is little evidence regarding how the hidden curriculum influences student experiences of, and engagement with longitudinal learning. Given this, our objective was to explore the impact of the hidden curriculum on student experiences of a longitudinal curriculum based in primary care at a research-intensive medical school.

DESIGN

We conducted a longitudinal qualitative study. Students participated in three serial, in-depth semistructured interviews. We conducted a longitudinal thematic analysis.

SETTING

One research-intensive medical school based in the UK. Data collection occurred in 2021-2022.

PARTICIPANTS

12 penultimate year medical students taking part in a longitudinal primary care placement for 1 day a week over the course of one academic year.

RESULTS

We constructed four themes capturing insights on how hidden curricula influenced students' experiences: (1) A culture which stresses assessment influences student engagement with longitudinal learning; (2) Longitudinal relationships can challenge the hidden curriculum; (3) Support and continuity within primary care improves skills and can influence belonging and (4) Logistical issues influence engagement with longitudinal learning.

CONCLUSIONS

The hidden curriculum, particularly related to assessment, plays a large role in student perceptions of educational value and subsequent engagement with curricula. In a research-intensive institution, longitudinal learning, particularly within primary care, was perceived as at odds with what was important for assessments. Where longitudinal relationships were successfully established, students became more aware of the benefits of person-centred practice. For primary care longitudinal education to succeed in more research-intensive institutions, there must first be advocacy for greater representation of primary care and person-centred values within organisational structures to ensure meaningful curricular alignment.

Cardiovascular Complications of Diabetes: From Microvascular to Macrovascular Pathways

Diabetes mellitus, with a growing risk of developing complications, has a significant negative impact on cardiovascular health, including microvascular and macrovascular issues. This thorough narrative study methodically examines the complex connection between cardiovascular problems and diabetes. We start by thoroughly introducing diabetes mellitus, classifying its various forms, and discussing its growing global impact. Then, we examine retinopathy, nephropathy, and neuropathy in detail, illuminating their biology, clinical presentations, and treatment options. Moving on to macrovascular consequences, we investigate the complex relationships between diabetes and coronary artery disease, stroke, and peripheral arterial disease, emphasizing risk factors, diagnostic standards, and treatment plans designed for people with diabetes. The review analyzes the pathophysiological pathways that link diabetes to cardiovascular problems, including endothelial dysfunction, chronic inflammation, immune system dysregulation, and oxidative stress brought on by hyperglycemia. Additionally, we review the critical function of risk monitoring, assessment, and predictive tools in early detection. While highlighting current research paths and the need for tailored medical approaches to address this complex health issue, the story also includes prevention and management strategies, ranging from lifestyle changes to developing medications. This narrative review concludes by providing a thorough summary of current information, highlighting research gaps, and advocating for interdisciplinary efforts to reduce the cardiovascular effects of diabetes.

Rab11 is essential to pancreas morphogenesis, lumen formation and endocrine mass

The molecular links between tissue-level morphogenesis and the differentiation of cell lineages in the pancreas remain elusive despite a decade of studies. We previously showed that in pancreas both processes depend on proper lumenogenesis. The Rab GTPase Rab11 is essential for epithelial lumen formation in vitro, however few studies have addressed its functions in vivo and none have tested its requirement in pancreas. Here, we show that Rab11 is critical for proper pancreas development. Co-deletion of the Rab11 isoforms Rab11A and Rab11B in the developing pancreatic epithelium (Rab11pancDKO) results in ∼50% neonatal lethality and surviving adult Rab11^pancDKO mice exhibit defective endocrine function. Loss of both Rab11A and Rab11B in the embryonic pancreas results in morphogenetic defects of the epithelium, including defective lumen formation and lumen interconnection. In contrast to wildtype cells, Rab11pancDKO cells initiate the formation of multiple ectopic lumens, resulting in a failure to coordinate a single apical membrane initiation site (AMIS) between groups of cells. This results in a failure to form ducts with continuous lumens. Here, we show that these defects are due to failures in vesicle trafficking, as apical and junctional components remain trapped within Rab11^pancDKO cells. Together, these observations suggest that Rab11 directly regulates epithelial lumen formation and morphogenesis. Our report links intracellular trafficking to organ morphogenesis in vivo and presents a novel framework for decoding pancreatic development.

Improved loss-of-function CRISPR-Cas9 genome editing in human cells concomitant with inhibition of TGF-β signaling

Strategies to modulate cellular DNA repair pathways hold immense potential to enhance the efficiency of CRISPR-Cas9 genome editing platform. In the absence of a repair template, CRISPR-Cas9-induced DNA double-strand breaks are repaired by the endogenous cellular DNA repair pathways to generate loss-of-function edits. Here, we describe a reporter-based assay for expeditious measurement of loss-of-function editing by CRISPR-Cas9. An unbiased chemical screen performed using this assay enabled the identification of small molecules that promote loss-of-function editing. Iterative rounds of screens reveal Repsox, a TGF-β signaling inhibitor, as a CRISPR-Cas9 editing efficiency enhancer. Repsox invariably increased CRISPR-Cas9 editing in a panel of commonly used cell lines in biomedical research and primary cells. Furthermore, Repsox-mediated editing enhancement in primary human CD4+ T cells enabled the generation of HIV-1-resistant cells with high efficiency. This study demonstrates the potential of transiently targeting cellular pathways by small molecules to improve genome editing for research applications and is expected to benefit gene therapy efforts.

The cell cortex as mediator of pancreatic epithelial development and endocrine differentiation

Organogenesis is the complex process of cells coordinating their own proliferation with changes to their shape, cell migration and cell-cell signaling, so that they transform into a three dimensional functional tissue, with its own custom range of differentiated cell types. Understanding when and where critical signals emanate from, and how those signals are transduced and interpreted, is the fundamental challenge of developmental biology. Here, we review recent findings regarding how progenitor cells interpret cues during pancreatic morphogenesis and how they coordinate cell fate determination. Recent evidence suggests that molecules located in the cell cortex play a crticial role in determining cellular behavior during pancreatic morphogenesis. Specifically, we find that control of cell adhesion, polarity, and constriction are all integral to both initiation of epithelial development and to later cell differentiation. Here, we review key molecules that coordinate these processes and suggest that the cell cortex acts as a signaling center that relays cues during pancreas development.

Viral Aetiology of Severe Acute Lower Respiratory Tract Infection in Children from the Paediatric Intensive Care Unit at a Tertiary Care Hospital, Eastern India- A Retrospective Study

Introduction: Viral infections are the common source of lower respiratory tract infection worldwide. Rapid and accurate detection of viral infections is important that can prevent antibiotic abuse. However, there are few studies determining viral etiologies in paediatric subjects in Eastern India. Aim: To study viral aetiology in children hospitalised with severe Acute Lower Respiratory Tract Infection (ALRTI) over a period of two years and to detect the impact of co-infection on severity and duration of hospitalization. Materials and Methods: This was a retrospective study based on electronic database in a tertiary care Paediatric Intensive Care Unit (PICU) of Bhagirathi Neotia Women and Child Care Hospital, Kolkata, West Bengal, India. Data were collected for all the patients who fulfilled the selection criteria and were admitted to PICU with ALRTI from March 2018 to March 2020. The medical records were reviewed in 51 patients with positive viral Reverse Transcription Polymerase Chain Reaction (RT-PCR). Data was collected for the type of viruses infecting the subjects and whether there were single infection or co-infection. Co-infection is simultaneous infection with more than one virus. Statistical analysis was done using the IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows, version 24.0 (Armonk, NY: IBM Corp). Student’s t-test and Chi-square test were used to compare single infection and co-infection. A p-value <0.05 was considered significant assuming the confidence interval of 95% as the level of significance. Results: The highest positivity rate was 66.6% (34/51) observed in children in the age group 1-12 months. The common viruses detected were adenovirus seen in 51% of samples, Respiratory Syncytial Virus (RSV) in 31.3% and rhinovirus in 11.8%. Clustering of cases was observed for RSV and influenza A in the colder months of the year. Single infection was seen in 74.5% of samples and co-infection in 25.5%. Comparison between single and co-infection with two viruses in terms of complications (p-value=0.163), average duration of PICU stay (p-value=0.70), C-reactive protein (p-value=0.952), procalcitonin (p-value=0.198), white blood cell count (p-value=0.737), absolute neutrophil count (p-value=0.612) were not significant. Conclusion: This present study found that adenovirus and RSV were the leading viral pathogens for ALRTI in the PICU. Co-infection with multiple viruses compared with a single viral infection in a patient did not impact severity.

E2F1 and epigenetic modifiers orchestrate breast cancer progression by regulating oxygen-dependent ESRP1 expression

Epithelial splicing regulatory protein 1 (ESRP1) is an RNA binding protein that governs the alternative splicing events related to epithelial phenotypes. ESRP1 contributes significantly at different stages of cancer progression. ESRP1 expression is substantially elevated in carcinoma in situ compared to the normal epithelium, whereas it is drastically ablated in cancer cells within hypoxic niches, which promotes epithelial to mesenchymal transition (EMT). Although a considerable body of research sought to understand the EMT-associated ESRP1 downregulation, the regulatory mechanisms underlying ESRP1 upregulation in primary tumors remained largely uncharted. This study seeks to unveil the regulatory mechanisms that spatiotemporally fine-tune the ESRP1 expression during breast carcinogenesis. Our results reveal that an elevated expression of transcription factor E2F1 and increased CpG hydroxymethylation of the E2F1 binding motif conjointly induce ESRP1 expression in breast carcinoma. However, E2F1 fails to upregulate ESRP1 despite its abundance in oxygen-deprived breast cancer cells. Mechanistically, impelled by the hypoxia-driven reduction of tet methylcytosine dioxygenase 3 (TET3) activity, CpG sites across the E2F1 binding motif lose the hydroxymethylation marks while gaining the de novo methyltransferase-elicited methylation marks. These two oxygen-sensitive epigenetic events work in concert to repel E2F1 from the ESRP1 promoter, thereby diminishing ESRP1 expression under hypoxia. Furthermore, E2F1 skews the cancer spliceome by upregulating splicing factor SRSF7 in hypoxic breast cancer cells. Our findings provide previously unreported mechanistic insights into the plastic nature of ESRP1 expression and insinuate important implications in therapeutics targeting breast cancer progression.

Reference Value of Nasal Peak Inspiratory Flow Rate in Indian Children: A Cross-sectional Study

Introduction: Peak Nasal Inspiratory Flow (PNIF) measurement is a basic, convenient, easy to use and low cost method of determining the nasal airway patency. However, normative data for paediatric population is scarce and not available for Indian children aged 6 to 12 years. Aim: To establish reference value of PNIF in Indian children aged 6 to 12 years of age. Materials and Methods: A descriptive cross-sectional study was conducted between July 2012 and June 2013 in the Himalayan range of east Sikkim district and Sub-Himalayan Terai region of Darjeeling district of West Bengal. Total 1001 children aged 6 to 12 years were selected from 16 schools by simple random sampling. Of these 1001 children, 784 children were enrolled in the study after taking into account inclusion and exclusion criteria. Repeated PNIF measurements were taken from these 784 children. Mean PNIF value was calculated. The effect of age and height on PNIF was studied. The mean and standard deviation of Peak Inhalation Flow Rate (PIFR) are calculated and compared across groups using a one-way ANOVA test. Regression analysis was done to establish an equation of predicting PNIF level based on height for normal children. The analysis was carried out using Statistical Package for Social Sciences (SPSS) version 16 statistical software. An alpha level of 5% was chosen, which means that any p-value less than 0.05 was considered significant. Results: Mean value of PNIF age group; 6-7 years-53.36 L/min, >7-8 years-56.79 L/min, >8-9 years-63.91 L/min, >9-10 years- 69.45 L/min, >10-11years- 80.71 L/min, >11-12 years-85.69 L/ min. PNIF increases with age and height. A simple formula has also been established to calculate mean PNIF at a given height. PNIF or PIFR (L/min)=-52.716+0.945×height in cm. Conclusion: PNIF measurements are possible in children aged six years and older. Age and height also affect PNIF.

Morbidity and mortality in Danio rerio and Pimephales promelas exposed to antilipidemic drug mixtures (fibrates and statins) during embryogenesis: Comprehensive assessment via ante and post mortem endpoints

Antilipidemic drugs are routinely detected in effluent and surface waters downstream of wastewater treatment plants. A mixture exposure study with nine environmentally relevant antilipidemic drugs was performed with zebrafish (Danio rerio, ZF) and fathead minnow (Pimephales promelas, FHM) embryos to investigate the effects on sensitive embryologic stages. Zebrafish embryos were exposed nominally to: (a) 0.005 μM, (b) 0.05 μM, or (c) 0.5 μM of each drug in the mixture. Fathead minnow embryos were exposed nominally to: (a) 0.0005 μM, (b) 0.005 μM, or (c) 0.05 μM of each drug in the mixture. Several of the individual drug concentrations were within ranges previously found in the environment. Multiple metrics demonstrate that (a) exposure of ZF and FHM embryos to antilipidemic drugs during embryonic development results in lethal and sublethal effects, (b) ZF were more sensitive than FHM based on median lethal concentration (LC₅₀ 0.02 μM and 0.05 μM, respectively), but FHM exhibited more severe abnormal sublethal morphologies than zebrafish embryos, and (c) the sublethal effects differed between the two species. This model identified novel specific endpoints for assessing sensitive, sublethal effects of pharmaceuticals in the environment. Abnormal myofiber birefringence pattern, hemorrhage, and heart rate are not included in standard evaluations but each of these metrics demonstrated a dose-dependent response in this study. Results demonstrate risk to fish development with potential repercussions at the population level, especially if environmental concentrations increase.

In Vivo Pressurization of the Zebrafish Embryonic Heart as a Tool to Characterize Tissue Properties During Development

Cardiac morphogenesis requires an intricate orchestration of mechanical stress to sculpt the heart as it transitions from a straight tube to a multichambered adult heart. Mechanical properties are fundamental to this process, involved in a complex interplay with function, morphology, and mechanotransduction. In the current work, we propose a pressurization technique applied to the zebrafish atrium to quantify mechanical properties of the myocardium under passive tension. By further measuring deformation, we obtain a pressure-stretch relationship that is used to identify constitutive models of the zebrafish embryonic cardiac tissue. Two-dimensional results are compared with a three-dimensional finite element analysis based on reconstructed embryonic heart geometry. Through these steps, we found that the myocardium of zebrafish results in a stiffness on the order of 10 kPa immediately after the looping stage of development. This work enables the ability to determine how these properties change under normal and pathological heart development.

Hypoxia-induced TGF-β-RBFOX2-ESRP1 axis regulates human MENA alternative splicing and promotes EMT in breast cancer

Hypoxic microenvironment heralds epithelial-mesenchymal transition (EMT), invasion and metastasis in solid tumors. Deregulation of alternative splicing (AS) of several cancer-associated genes has been instrumental in hypoxia-induced EMT. Our study in breast cancer unveils a previously unreported mechanism underlying hypoxia-mediated AS of hMENA, a crucial cytoskeleton remodeler during EMT. We report that the hypoxia-driven depletion of splicing regulator ESRP1 leads to skipping of hMENA exon 11a producing a pro-metastatic isoform, hMENAΔ11a. The transcriptional repression of ESRP1 is mediated by SLUG, which gets stimulated via hypoxia-driven TGF-β signaling. Interestingly, RBFOX2, an otherwise RNA-binding protein, is also found to transcriptionally repress ESRP1 while interacting with SLUG. Similar to SLUG, RBFOX2 gets upregulated under hypoxia via TGF-β signaling. Notably, we found that the exosomal delivery of TGF-β contributes to the elevation of TGF-β signaling under hypoxia. Moreover, our results show that in addition to hMENA, hypoxia-induced TGF-β signaling contributes to global changes in AS of genes associated with EMT. Overall, our findings reveal a new paradigm of hypoxia-driven AS regulation of hMENA and insinuate important implications in therapeutics targeting EMT.

Abstract 602: Mir-182-5p is a Conserved Downstream Effector of Tbx5 Involved in Heart Development and Arrhythmia in Zebrafish

Background: TBX5 mutations cause Holt-Oram syndrome (HOS) characterized by upper limb and cardiac malformations, but can also contribute to early-onset of atrial fibrillation. Focusing on miRNAs involved in TBX5 regulatory circuits with a cardiac relevant role, we identified miR-182-5p, belonging to miR-183 cluster, found upregulated in Tbx5-depleted hearts of mouse and zebrafish embryos.

Methods: To functionally analyse the miR-182-5p role in developing heart, miR-182-5p was dysregulated in zebrafish zygotes of Tg(Myl7:EGFP) and Tg(myl7:gCaMP) transgenic lines. To stably deregulate miR-182-5p in zebrafish heart we exploited the Gal4/UAS system to restrict the miR-182 expression into cardiac context. For physiological analyses we performed the mechanogram of cardiac contraction and electrocardiogram recording. To understand miR-182-5p downstream regulation, in silico analyses, followed by ddPCR/real-time quantifications on dissected zebrafish hearts and rescue experiments both in transient and stable miR-182-5p overexpressing zebrafish embryos were performed.

Results: Depletion of Tbx5 from cardiomyocytes increased the expression of miR-182 cluster family that is controlled by Kruppel-like factor 4 (KLF4), a transcription factor repressed by Tbx5. Both transient and stable upregulation of miR-182 in zebrafish affect heart morphology, calcium handling and the onset of arrhythmia while its cardiac-specific downregulation decreases cardiac defects in zebrafish HOS hearts. Expression analyses on selected miR-182-5p putative targets revealed that several calcium channel proteins resulted downregulated in miR-182-5p overexpressing hearts. Transgenic zebrafish line stably overexpressing miR-182-5p in the heart manifested arrhythmia overtime with or without cardiac structural defects.

Conclusion: We identified miR-182-5p as a potential suitable target to interfere in the circuit between upstream genetic abnormalities and downstream effectors leading to arrhythmia occurrence.

I have heard about it for the first time from you! Implementation of tobacco control law by police personnel in India

Setting and Objetives: Police personnel, alongside other key stakeholders, are responsible for implementing the Cigarettes and Other Tobacco Products Act (COTPA) in India. This study aimed to assess knowledge and attitudes about COTPA among police personnel and explore enablers and barriers in implementing it. Design: This convergent parallel mixed-methods study used a self-administered questionnaire (quantitative) and key informant interviews (qualitative). Of 300 police personnel across all eight police stations in Daman, 155 participated. Quantitative data were analysed using descriptive statistics and the χ² test. Qualitative data from in-depth interviews of six key informants from all coordinating departments were analysed thematically. Results: Overall, 63.2% of responders were aware of any tobacco control law in India, and only 12.9% were trained in its implementation. One person had conducted inspections for COTPA compliance in the last 12 months. The majority (78.1%) of the police personnel, and significantly more tobacco non-users than users (81.2% vs. 52.9%, P = 0.016), felt that enforcing anti-tobacco regulations is one of their most important functions. Perceived benefits of the act and formal authority to act were the two main enablers of COTPA implementation. Lack of awareness and coordination, competing priorities, concentration of authority with higher-ranking officials and evasion of the law by retailers and the public hampered effective implementation of the law. Conclusion: Knowledge about the COTPA was average and implementation poor. Sensitisation and training of implementers, systematic transparent reporting and creating awareness among public are recommended for effective implementation.

Post-transcriptional Modulation of Sphingosine-1-Phosphate Receptor 1 by miR-19a Affects Cardiovascular Development in Zebrafish

Sphingosine-1-phosphate is a bioactive lipid and a signaling molecule integrated into many physiological systems such as differentiation, proliferation and migration. In mammals S1P acts through binding to a family of five trans-membrane, G-protein coupled receptors (S1PRs) whose complex role has not been completely elucidated. In this study we use zebrafish, in which seven s1prs have been identified, to investigate the role of s1pr1. In mammals S1PR1 is the most highly expressed S1P receptor in the developing heart and regulates vascular development, but in zebrafish the data concerning its role are contradictory. Here we show that overexpression of zebrafish s1pr1 affects both vascular and cardiac development. Moreover we demonstrate that s1pr1 expression is strongly repressed by miR-19a during the early phases of zebrafish development. In line with this observation and with a recent study showing that miR-19a is downregulated in a zebrafish Holt-Oram model, we now demonstrate that s1pr1 is upregulated in heartstring hearts. Next we investigated whether defects induced by s1pr1 upregulation might contribute to the morphological alterations caused by Tbx5 depletion. We show that downregulation of s1pr1 is able to partially rescue cardiac and fin defects induced by Tbx5 depletion. Taken together, these data support a role for s1pr1 in zebrafish cardiovascular development, suggest the involvement of this receptor in the Tbx5 regulatory circuitry, and further support the crucial role of microRNAs in early phase of zebrafish development.

Aripiprazole reversed gastroparesis in a child with 1q21.1-q21.2 microdeletion

An 11-year-old Caucasian boy, with a microdeletion in the 1q21.1-q21.2 region, had multiple medical conditions including gastroparesis documented initially at the age of 5. The patient had a history of poor feeding since infancy and had been treated for gastro-oesophageal reflux disease (GERD), constipation and multiple food allergies. As a consequence of the GERD and his concurrent immunoglobulin (IgG) subclass deficiency, the patient had multiple otolaryngologic (ENT) infections and required two sinus surgeries. The patient had poor weight gain (below the third percentile for weight-for-age) and required a short course of parenteral nutrition and eventually a gastrostomy tube. He was started on metoclopramide as treatment for gastroparesis with an increase in his appetite, oral intake and weight gain. However, severe headaches and worsening in his behaviour caused the agent to be discontinued. He had little weight gain and after a course of parenteral nutrition he was converted to a transpyloric feeding tube. Because of ongoing behavioural problems that interfered with his school performance, a psychiatrist started him on aripiprazole. After aripiprazole was prescribed at age 11, his appetite and oral intake dramatically increased and a repeat gastric emptying study was normal. The increased oral intake and weight gain continued, allowing removal of the feeding tube. More than 2 years later, on aripiprazole, he continues to gain weight without any supplemental feedings.

Evaluation of parameters affecting switchgrass tissue culture: toward a consolidated procedure for Agrobacterium-mediated transformation of switchgrass (Panicum virgatum)

BACKGROUND

Switchgrass (Panicum virgatum), a robust perennial C4-type grass, has been evaluated and designated as a model bioenergy crop by the U.S. DOE and USDA. Conventional breeding of switchgrass biomass is difficult because it displays self-incompatible hindrance. Therefore, direct genetic modifications of switchgrass have been considered the more effective approach to tailor switchgrass with traits of interest. Successful transformations have demonstrated increased biomass yields, reduction in the recalcitrance of cell walls and enhanced saccharification efficiency. Several tissue culture protocols have been previously described to produce transgenic switchgrass lines using different nutrient-based media, co-cultivation approaches, and antibiotic strengths for selection.

RESULTS

After evaluating the published protocols, we consolidated these approaches and optimized the process to develop a more efficient protocol for producing transgenic switchgrass. First, seed sterilization was optimized, which led to a 20% increase in yield of induced calluses. Second, we have selected a N6 macronutrient/B5 micronutrient (NB)-based medium for callus induction from mature seeds of the Alamo cultivar, and chose a Murashige and Skoog-based medium to regenerate both Type I and Type II calluses. Third, Agrobacterium-mediated transformation was adopted that resulted in 50-100% positive regenerated transformants after three rounds (2 weeks/round) of selection with antibiotic. Genomic DNA PCR, RT-PCR, Southern blot, visualization of the red fluorescent protein and histochemical β-glucuronidase (GUS) staining were conducted to confirm the positive switchgrass transformants. The optimized methods developed here provide an improved strategy to promote the production and selection of callus and generation of transgenic switchgrass lines.

CONCLUSION

The process for switchgrass transformation has been evaluated and consolidated to devise an improved approach for transgenic switchgrass production. With the optimization of seed sterilization, callus induction, and regeneration steps, a reliable and effective protocol is established to facilitate switchgrass engineering.

The characteristics and impact of source of infection on sepsis-related ICU outcomes

BACKGROUND

Source of infection is an independent predictor of sepsis-related mortality. To date, studies have failed to evaluate differences in septic patients based on the source of infection.

METHODS

Retrospective study of all patients with sepsis admitted to the ICU of a university hospital within a 12month time period.

RESULTS

Sepsis due to intravascular device and multiple sources had the highest number of positive blood cultures and microbiology whereas lung and abdominal sepsis had the least. The observed hospital mortality was highest for sepsis due to multiple sources and unknown cause, and was lowest when due to abdominal, genitourinary (GU) or skin/soft tissue. Patients with sepsis due to lungs, unknown and multiple sources had the highest rates of multi-organ failure, whereas those with sepsis due to GU and skin/soft tissue had the lowest rates. Those with multisource sepsis had a significantly higher median ICU length of stay and hospital cost.

CONCLUSION

There are significant differences in patient characteristics, microbiology positivity, organs affected, mortality, length of stay and cost based on the source of sepsis. These differences should be considered in future studies to be able to deliver personalized care.

The effectiveness of computed tomography-guided biopsy for the diagnosis of spondylodiscitis: an analysis of variables affecting the outcome

OBJECTIVE

To analyze: (i) the effectiveness of CT-guided biopsy for the diagnosis of suspected spinal infections (spondylodiscitis); (ii) identify common causative microorganisms and assess factors that could affect the diagnostic yield.

PATIENTS AND METHODS

Forty-five patients undergoing CT-guided biopsy for suspected spinal infection between November 2012 and October 2014 were analyzed. The time from presentation to diagnosis, administration of antibiotics before biopsy, blood culture results, admission C-reactive protein (CRP)/white cell count, presence of fever or neurological deficits, and soft tissue collections on MRI were analyzed. Multivariable logistic regression was performed to determine variables independently associated with a positive biopsy.

RESULTS

Eleven (24.4%) patients had positive blood cultures. The first biopsy was positive in 19 (42.2%) patients. Thirty-eight (84.4%) patients had a single biopsy, while seven (15.5%) patients underwent repeat biopsy with a positive yield in one (14.2%) patient. Overall, causative microorganisms were identified in 26 (57.8%) cases. Admission CRP was significantly associated with isolating the causative pathogen from CT-guided biopsy (p<0.001). A soft tissue collection on MRI was associated with identification of a microorganism in blood cultures (p=0.001). CRP was the only independent variable associated with a positive yield on CT-guided biopsy (p=0.007, OR 1.042) and was more likely in patients with CRP>50 (p<0.001). Administration of empirical antibiotics before biopsy did not affect the yield (p=0.572).

CONCLUSIONS

A high CRP was a strong predictor of isolation of the causative organism. Repeat CT-guided biopsy was found to have limited value with a low positive yield (14.2%) in our study.

Differential expression of hENT1 and hENT2 in colon cancer cell lines

Human equilibrative nucleoside transporters (hENT) 1 and 2, encoded by SLC29A1 and SLC29A2, permit the bidirectional passage of nucleoside analogues into cells and may correlate with clinical responses to chemotherapy in patients with colorectal cancer (CRC). The purpose of this study was to evaluate the expression profiles of SLC29A1 and SLC29A2 in human cancer cell lines. Using quantitative real-time polymerase chain reaction, we comprehensively profiled the transcription levels of SLC29A1 and SLC29A2 in 16 colon cancer cell lines. We validated the ubiquitous and heterogeneous distribution of SLC29A1 and SLC29A2 in human colon cancer cell lines and demonstrated that SLC29A1 was highly expressed in 25% of metastatic cell lines (Colo201 and Colo205) and 62.5% of primary cell lines (Caco2, Colo320, HCT116, RKO, and SW48). For the first time, we showed that both SLC29A1 and SLC29A2 were expressed at lower levels in colon cancer cell lines originating from metastatic sites than from primary sites. These findings indicate that most patients with metastatic CRC (mCRC) may have low hENT1 expression, and treatment with nucleoside analogues may be inefficient. However, some patients still show high hENT1 expression and have a high probability of benefiting from these drugs. Therefore, evaluating transporter expression profiles and different drug responses between primary and metastatic tumors in patients with mCRC is important. Further assessment of the association between hENTs and drug-based treatment of mCRC is required to elucidate the mechanisms of chemotherapy resistance.

Impact of End-Stage Renal Disease and Acute Kidney Injury on ICU Outcomes in Patients With Sepsis

PURPOSE

To report the characteristics and outcomes of patients with sepsis in the intensive care unit (ICU) with end-stage renal disease (ESRD) and acute kidney injury (AKI) compared to patients with nonkidney injury (non-KI).

METHODS

Retrospective study of all patients with sepsis admitted to the ICU of a university hospital within a 12-month time period. Data were obtained from the University Health Consortium database and a chart review of the electronic medical records.

RESULTS

We identified 39 cases of ESRD, 106 cases of AKI, and 103 cases of non-KI. Intensive care unit mortality was 15.4% for ESRD, 30.2% for AKI, and 13.6% for non-KI ( P < .01). Hospital mortality was 20.5% for ESRD, 32.1% for AKI, and 13.6% for non-KI ( P < .01). Early AKI and late AKI had an ICU mortality of 24.4% versus 50% ( P <.01), hospital mortality of 26.8% versus 50% ( P = .03), ICU length of stay (LOS) of 3 and 6 days ( P = .04), and hospital LOS of 7 and 12.5 days ( P <.01), respectively.

CONCLUSION

Patients with sepsis having AKI have a higher mortality rate than those with ESRD and non-KI. Hospital and ICU mortality rates for patients with ESRD were similar to non-KI patients. Late AKI compared to early AKI had a higher mortality and longer LOS.

Prognostic value of CpG island methylator phenotype among colorectal cancer patients: a systematic review and meta-analysis

BACKGROUND

Divergent findings regarding the prognostic value of CpG island methylator phenotype (CIMP) in colorectal cancer (CRC) patients exist in current literature. We aim to review data from published studies in order to examine the association between CIMP and CRC prognosis.

MATERIALS AND METHODS

A comprehensive search for studies reporting disease-free survival (DFS), overall survival (OS), or cancer-specific mortality of CRC patients stratified by CIMP is carried out. Study findings are summarized descriptively and quantitatively, using adjusted hazard ratios (HRs) as summary statistics.

RESULTS

Thirty-three studies reporting survival in 10 635 patients are included for review. Nineteen studies provide data suitable for meta-analysis. The definition of CIMP regarding gene panel, marker threshold, and laboratory method varies across studies. Pooled analysis shows that CIMP is significantly associated with shorter DFS (pooled HR estimate 1.45; 95% confidence interval (CI) 1.07-1.97, Q = 3.95, I(2) = 0%) and OS (pooled HR estimate 1.43; 95% CI 1.18-1.73, Q = 4.03, I(2) = 0%) among CRC patients irrespective of microsatellite instability (MSI) status. Subgroup analysis of microsatellite stable (MSS) CRC patients also shows significant association between shorter OS (pooled HR estimate 1.37; 95% CI 1.12-1.68, Q = 4.45, I(2) = 33%) and CIMP. Seven studies have explored CIMP's value as a predictive factor on stage II and III CRC patient's DFS after receiving adjuvant 5-fluorouracil (5-FU) therapy: of these, four studies showed that adjuvant chemotherapy conferred a DFS benefit among CIMP(+) patients, one concluded to the contrary, and two found no significant correlation. Insufficient data was present for statistical synthesis of CIMP's predictive value among CRC patients receiving adjuvant 5-FU therapy.

CONCLUSION

CIMP is independently associated with significantly worse prognosis in CRC patients. However, CIMP's value as a predictive factor in assessing whether adjuvant 5-FU therapy will confer additional survival benefit to CRC patients remained to be determined through future prospective randomized studies.

Unusual presentation of eosinophilic enteritis as multiple strictures of small intestine

Eosinophilic enteritis is a rare disease of unknown etiology. It is characterized by eosinophilic infiltration of the bowel wall to a variable depth and symptoms associated with gastrointestinal tract depending upon the predominant layer involved. Diagnosis of eosinophilic enteritis requires a high index of suspicion and exclusion of various disorders that are associated with peripheral eosinophilia. We report a case of unusual presentation of eosinophilic enteritis clinically presenting as intestinal obstruction due to multiple strictures of the small bowel in an adult male.

OT3-01-06: A Phase 2 Study Investigating the Safety, Efficacy and Surrogate Biomarkers of Response of 5-Azacitidine (5-AZA) and Entinostat (MS-275) in Patients with Advanced Breast Cancer

Background: Epigenetic alterations in the genome, including abnormal DNA methylation and histone hypoacetylation, initiate and promote cancerous changes via several mechanisms, including inactivation of tumor suppressor genes. Preclinical investigations in breast cancer suggest that use of epigenetic modifiers results in re-expression of aberrantly silenced genes and proteins that represent important therapeutic targets (e.g. estrogen receptor alpha, ER). Combination therapy with a DNA methyltransferase inhibitor (DNMTI) and a histone deacetylase inhibitor (HDACI) has yielded superior ER reexpression and greater restoration of tamoxifen responsiveness than with HDACI alone. We hypothesize that clinically tolerable doses of the DNMTI 5-azacitidine (5-AZA) and the HDACI entinostat may not only effect changes in DNA methylation and gene expression, but also yield objective disease responses in women with advanced breast cancer.

Trial design: This multicenter phase II study (NCT01349959) is enrolling patients with advanced human epidermal growth factor receptor 2 (HER2)-negative breast cancer with triple negative (ER/progesterone receptor [PR]/HER2−negative, Cohort A) or hormone-resistant (Cohort B) disease. Patients will receive 5-AZA 40 mg/m2 subcutaneously days 1–5 and 8–10 and entinostat 7 mg orally days 3 and 10 every 28 days. Because of the potential for re-expression of the ER with epigenetic agents, patients will be offered continuation of 5-AZA and entinostat at progression with the addition of hormonal therapy (investigator discretion). Mandatory tumor biopsies will be performed at baseline and after 8 weeks of therapy to evaluate correlative biomarkers.

Eligibility Criteria: Eligible patients must be ≥ 18 years, have measurable locally advanced/metastatic triple-negative (at least one prior chemotherapy received adjuvant/metastatic setting) or hormone-resistant (must have received two prior hormonal agents and one prior chemotherapy) disease, adequate organ function and ECOG PS ≤ 2.

Specific Aims:

1. Objective response rate (ORR) by RECIST 1.1 criteria.

2. Safety and tolerability

3. Progression-free survival, overall survival and clinical benefit rate.

4. Safety and toxicity data, feasibility and response rate where hormonal therapy is added to the combination under investigation at the time of progressive disease.

5. Pharmacokinetics, cytidine deaminase, changes from baseline of candidate gene methylation and expression in circulating deoxyribonucleic acid (DNA) and malignant tissue.

Statistical Methods:

Using a two-stage three-outcome design to assess the efficacy of the combination, a maximum of 30 patients (requiring 27 evaluable) will be accrued to each cohort unless undue toxicity is encountered for a maximum sample size of 60 patients. The study design tests the null hypothesis that the ORR is at most 5% against the alternative hypothesis that it is at least 20% with a type I error of 4% and power of 90%.

Present and Targeted Accrual: This study has just opened to patient enrollment. We anticipate a rapid accrual of 60 patients within 1 year.br](Funding from Stand Up to Cancer and CTEP).

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT3-01-06.

Olanzapine-induced hyperglycaemic coma and neuroleptic malignant syndrome: case report and review of literature

Although the relationship between antipsychotic medication, particularly second-generation antipsychotics (SGAs), and metabolic disturbance is increasingly accepted, there is an important, but little recognised, potential interaction between this and the other important serious adverse effect of neuroleptic malignant syndrome (NMS). We report a case of a 35-year old female who developed new onset type II diabetes mellitus with hyperosmolar hyperglycaemic coma and acute renal failure following treatment with a SGA for a first manic episode. The history is strongly suggestive of concurrent NMS. This case raises important questions about non-ketotic, hyperosmolar diabetic coma with antipsychotics, the possible association between hyperglycaemia and hyperthermia, and the direction of causality in this, the recognition of either syndrome when they co-exist and management issues in such patients. These questions are considered in the context of currently available literature.