A Scan of Pleiotropic Immune Mediated Disease Genes Identifies Novel Determinants of Baseline FVIII Inhibitor Status in Hemophilia-A

Hemophilia-A (HA) is caused by heterogeneous loss-of-function factor (F)VIII gene (F8)-mutations and deficiencies in plasma-FVIII-activity that impair intrinsic-pathway-mediated coagulation-amplification. The standard-of-care for severe-HA-patients is regular infusions of therapeutic-FVIII-proteins (tFVIIIs) but ~30% develop neutralizing-tFVIII-antibodies called "FVIII-inhibitors (FEIs)" and become refractory. We used the PATH study and ImmunoChip to scan immune-mediated-disease (IMD)-genes for novel and/or replicated genomic-sequence-variations associated with baseline-FEI-status while accounting for non-independence of data due to genetic-relatedness and F8-mutational-heterogeneity. The baseline-FEI-status of 450 North American PATH subjects-206 with black-African-ancestry and 244 with white-European-ancestry-was the dependent variable. The F8-mutation-data and a genetic-relatedness matrix were incorporated into a binary linear-mixed model of genetic association with baseline-FEI-status. We adopted a gene-centric-association-strategy to scan, as candidates, pleiotropic-IMD-genes implicated in the development of either ³2 autoimmune-/autoinflammatory-disorders (AADs) or ³1 AAD and FEIs. Baseline-FEI-status was significantly associated with SNPs assigned to NOS2A (rs117382854; p=3.2E-6) and B3GNT2 (rs10176009; p=5.1E-6), which have functions in anti-microbial-/-tumoral-immunity. Among IMD-genes implicated in FEI-risk previously, we identified strong associations with CTLA4 assigned SNPs (p=2.2E-5). The F8-mutation-effect underlies ~15% of the total heritability for baseline-FEI-status. Additive genetic heritability and SNPs in IMD-genes account for >50% of the patient-specific variability in baseline-FEI-status. Race is a significant determinant independent of F8-mutation-effects and non-F8-genetics.

The ABCD stop signal data: Response to Bissett et al

This paper responds to a recent critique by Bissett et al. of the fMRI Stop task used in the Adolescent Brain Cognitive Development℠ Study (ABCD Study®). The critique focuses primarily on a task design feature related to race model assumptions (i.e., that the Go and Stop processes are fully independent). In response, we note that the race model is quite robust against violations of its assumptions. Most importantly, while Bissett raises conceptual concerns with the task we focus here on analyzes of the task data and conclude that the concerns appear to have minimal impact on the neuroimaging data (the validity of which do not rely on race model assumptions) and have far less of an impact on the performance data than the critique suggests. We note that Bissett did not apply any performance-based exclusions to the data they analyzed, a number of the trial coding errors they flagged were already identified and corrected in ABCD annual data releases, a number of their secondary concerns reflect sensible design decisions and, indeed, their own computational modeling of the ABCD Stop task suggests the problems they identify have just a modest impact on the rank ordering of individual differences in subject performance.

Group B Streptococcus (GBS) colonisation is dynamic over time, whilst GBS capsular polysaccharides-specific antibody remains stable

Group B Streptococcus (GBS) is a leading cause of adverse pregnancy outcomes due to invasive infection. This study investigated longitudinal variation in GBS rectovaginal colonization, serum and vaginal GBS capsular polysaccharide (CPS)-specific antibody levels. Non-pregnant women were recruited in the UK and were sampled every 2 weeks over a 12-week period. GBS isolates were taken from recto-vaginal swabs and serotyped by polymerase chain reaction. Serum and vaginal immunoglobulin G (IgG) and nasal immunoglobulin A (IgA) specific to CPS were measured by Luminex, and total IgG/A by ELISA. Seventy women were enrolled, of median age 26. Out of the 66 participants who completed at least three visits: 14/47 (29.8%) women that were GBS negative at screening became positive in follow-up visits and 16/19 (84.2%) women who were GBS positive at screening became negative. There was 50% probability of becoming negative 36 days after the first positive swab. The rate of detectable GBS carriage fluctuated over time, although serum, vaginal, and nasal CPS-specific antibody levels remained constant. Levels of CPS-specific antibodies were higher in the serum of individuals colonized with GBS than in non-colonized, but similar in the vaginal and nasal mucosa. We found correlations between antibody levels in serum and the vaginal and nasal mucosa. Our study demonstrates the feasibility of elution methods to retrieve vaginal and nasal antibodies, and the optimization of immunoassays to measure GBS-CPS-specific antibodies. The difference between the dynamics of colonization and antibody response is interesting and further investigation is required for vaccine development.

Baseline brain function in the preadolescents of the ABCD Study

The Adolescent Brain Cognitive Development (ABCD) Study® is a 10-year longitudinal study of children recruited at ages 9 and 10. A battery of neuroimaging tasks are administered biennially to track neurodevelopment and identify individual differences in brain function. This study reports activation patterns from functional MRI (fMRI) tasks completed at baseline, which were designed to measure cognitive impulse control with a stop signal task (SST; N = 5,547), reward anticipation and receipt with a monetary incentive delay (MID) task (N = 6,657) and working memory and emotion reactivity with an emotional N-back (EN-back) task (N = 6,009). Further, we report the spatial reproducibility of activation patterns by assessing between-group vertex/voxelwise correlations of blood oxygen level-dependent (BOLD) activation. Analyses reveal robust brain activations that are consistent with the published literature, vary across fMRI tasks/contrasts and slightly correlate with individual behavioral performance on the tasks. These results establish the preadolescent brain function baseline, guide interpretation of cross-sectional analyses and will enable the investigation of longitudinal changes during adolescent development.

FRI0198 OCULAR MORBIDITY IN PATIENTS WITH PMR AND GCA IN THE UK - A CPRD STUDY

Background:

Visual loss is the most serious consequences of a diagnosis of polymyalgia rheumatic (PMR) and giant cell arteritis (GCA). To date, information on the occurrence of eye disease in GCA has been based almost exclusively on small hospital-based patient series. Furthermore the lack of control group for these studies results in a lack of relative risk estimates for visual loss.

There are no accurate data on the prevalence and nature of eye complications among patients in the community. Patients with GCA may be exclusively managed in the primary care setting without referral for either temporal artery biopsy or ophthalmic department examination. Currently the incidence and prevalence of eye complications within this group are unknown.

Objectives:

Examine the absolute rate and relative risk of ocular morbidity, in a longitudinal community setting, in patients with PMR and or GCA including visual loss, AOIN including optic atrophy, cataract and glaucoma identified from Read codes in the (Clinical Practice Research Datalink) CPRD dataset.

Methods:

Construction of a disease cohort of incident diagnoses of PMR and GCA from patients in the CPRD matched to controls on age, sex (+/- 2 years) and practice location. Diagnosis were identified by CPRD researchers of those individuals between January 1997 to December 2015, with a minimum age at diagnosis of 50 years. Those with both a diagnosis of PMR and GCA were analysed in the GCA group. The outcomes of ocular morbidity included Read codes for severe visual impairment (multiple codes covered: blindness, severe visual impairment, registered partially sighted, issue of certificate of visual impairment, examination findings of 4/60 or worse), anterior ischaemic optic neuropathy (including codes of optic neuropathy and atrophy but not codes of glaucomatous atrophy), cataract, cataract extraction and glaucoma. Statistically modelling with Cox proportional hazards was used to generate hazard ratios for ocular morbidity taking account of censorship through death and moving out of area.

Results:

We identified 30,714 individuals with PMR (20,270 women; 66%) with a mean age at diagnosis of 72.9 year (sd 9.1) and 6,104 with GCA (4,309 women; 70.6%) with a mean age of 72.1 years (sd 9.4). Of those diagnosed with GCA 1,669 were also diagnosed with PMR. Using Read codes for severe visual impairment and blindness 5.9% of patients with GCA and 2.7% with PMR had this complication compared with 1.6% of the matched controls. The hazard ratio for the various ocular morbidities and by cases of PMR or GCA are shown in the table below:

Ocular morbidityPMR HR (95% CI) p valueGCA HR (95% CI) p valueSevere visual impairment1.76 (1.60, 1.94) p=<0.0013.55 (3.10, 4.08) p=<0.001Anterior ischaemic optic atrophy3.37 (2.15, 5.31) p=<0.00136.33 (25.19, 52.39) p=<0.001Cataract2.18 (2.04, 2.32) p=<0.0012.48 (2.22, 2.78) p=<0.001Cataract operation2.11 (1.97, 2.25) p=<0.0012.41 (2.13, 2.72) p=<0.001Glaucoma2.10 (1.91, 2.32) p=<0.0012.50 (2.10, 2.97) p=<0.001

Conclusion:

These community-based national data on risk of ocular morbidity in PMR and GCA show for the first time the risk of various ocular morbidities are increased for both groups. In addition this are the first estimates of relative risk compared to an age and sex matched population. These data are crucial for providing information to patients about their relative risk of ocular morbidity following a diagnosis of PMR or GCA.

Acknowledgments:

We would like to thank Dr Helen Strongman at the CPRD for carrying out patient searchers. We thank Dr Ferran Espuny Pujol for completion of the linkage request for dates of death.

Disclosure of Interests:

Max Yates: None declared, Allan Clark: None declared, Richard Watts: None declared, Alex MacGregor: None declared, Sarah Mackie Grant/research support from: Roche (attendance of EULAR 2019; co-applicant on research grant), Consultant of: Sanofi, Roche/Chugai (monies paid to my institution not to me)

Measuring Glymphatic Flow in Man Using Quantitative Contrast-Enhanced MRI

On the basis of animal models, glymphatic flow disruption is hypothesized to be a factor in the development of Alzheimer's disease. We report the first quantitative study of glymphatic flow in man, combining intrathecal administration of gadobutrol with serial T1 mapping to produce contrast concentration maps up to 3 days postinjection, demonstrating performing a quantitative study using the techniques described feasibility and providing data on pharmacokinetics.

Effect of metformin and flutamide on insulin, lipogenic and androgen-estrogen signaling, and cardiometabolic risk in a PCOS-prone metabolic syndrome rodent model

Polycystic ovary syndrome (PCOS) is highly associated with cardiometabolic risk and the metabolic syndrome (MetS), predisposing women to increased risk of developing type 2 diabetes and cardiovascular disease. Metformin is commonly used to treat insulin resistance-glucose intolerance, and flutamide, an androgen receptor (AR) antagonist, is used to target hyperandrogenemia and dyslipidemia. Currently, the physiological mechanism of action of these treatments on androgen, lipidogenic, and insulin signaling pathways remains unclear in PCOS. The aim of this study was to investigate the effects and mechanisms of action of metformin and flutamide on plasma lipid-apolipoprotein (Apo)B-lipoprotein and insulin-glucose metabolism, and endocrine-reproductive indices in a PCOS-prone MetS rodent model. PCOS-prone rodents were treated with metformin (300 mg/kg body wt), flutamide (30 mg/kg body wt), or metformin + flutamide combination treatment for 6 wk. Metformin was shown to improve fasting insulin and HOMA-IR, whereas flutamide and combination treatment were shown to reduce plasma triglycerides, ApoB48, and ApoB100, and this was associated with decreased intestinal secretion of ApoB48/triglyceride. Flutamide and metformin were shown to reduce plasma androgen indices and to improve ovarian primary and preovulatory follicle frequency. Metformin treatment increased hepatic estrogen receptor (ER)α, and metformin-flutamide decreased intestinal AR and increased ERα mRNA expression. Metformin-flutamide treatment upregulated hepatic and intestinal insulin signaling, including insulin receptor, MAPK1, and AKT2. In conclusion, cardiometabolic risk factors, in particular ApoB-hypertriglyceridemia, are independently modulated via the AR, and understanding the contribution of AR and insulin-signaling pathways further may facilitate the development of targeted interventions in high-risk women with PCOS and MetS.

Automated Integration of Multimodal MRI for the Probabilistic Detection of the Central Vein Sign in White Matter Lesions

BACKGROUND AND PURPOSE

The central vein sign is a promising MR imaging diagnostic biomarker for multiple sclerosis. Recent studies have demonstrated that patients with MS have higher proportions of white matter lesions with the central vein sign compared with those with diseases that mimic MS on MR imaging. However, the clinical application of the central vein sign as a biomarker is limited by interrater differences in the adjudication of the central vein sign as well as the time burden required for the determination of the central vein sign for each lesion in a patient's full MR imaging scan. In this study, we present an automated technique for the detection of the central vein sign in white matter lesions.

MATERIALS AND METHODS

Using multimodal MR imaging, the proposed method derives a central vein sign probability, π_ij, for each lesion, as well as a patient-level central vein sign biomarker, ψ_i. The method is probabilistic in nature, allows site-specific lesion segmentation methods, and is potentially robust to intersite variability. The proposed algorithm was tested on imaging acquired at the University of Vermont in 16 participants who have MS and 15 participants who do not.

RESULTS

By means of the proposed automated technique, participants with MS were found to have significantly higher values of ψ than those without MS (ψ_MS = 0.55 ± 0.18; ψ_non-MS = 0.31 ± 0.12; P < .001). The algorithm was also found to show strong discriminative ability between patients with and without MS, with an area under the curve of 0.88.

CONCLUSIONS

The current study presents the first fully automated method for detecting the central vein sign in white matter lesions and demonstrates promising performance in a sample of patients with and without MS.

Psychedelics and connectedness

Psychedelic drugs are creating ripples in psychiatry as evidence accumulates of their therapeutic potential. An important question remains unresolved however: how are psychedelics effective? We propose that a sense of connectedness is key, provide some preliminary evidence to support this, and suggest a roadmap for testing it further.

Psilocybin with psychological support for treatment-resistant depression: six-month follow-up

RATIONALE

Recent clinical trials are reporting marked improvements in mental health outcomes with psychedelic drug-assisted psychotherapy.

OBJECTIVES

Here, we report on safety and efficacy outcomes for up to 6 months in an open-label trial of psilocybin for treatment-resistant depression.

METHODS

Twenty patients (six females) with (mostly) severe, unipolar, treatment-resistant major depression received two oral doses of psilocybin (10 and 25 mg, 7 days apart) in a supportive setting. Depressive symptoms were assessed from 1 week to 6 months post-treatment, with the self-rated QIDS-SR16 as the primary outcome measure.

RESULTS

Treatment was generally well tolerated. Relative to baseline, marked reductions in depressive symptoms were observed for the first 5 weeks post-treatment (Cohen's d = 2.2 at week 1 and 2.3 at week 5, both p < 0.001); nine and four patients met the criteria for response and remission at week 5. Results remained positive at 3 and 6 months (Cohen's d = 1.5 and 1.4, respectively, both p < 0.001). No patients sought conventional antidepressant treatment within 5 weeks of psilocybin. Reductions in depressive symptoms at 5 weeks were predicted by the quality of the acute psychedelic experience.

CONCLUSIONS

Although limited conclusions can be drawn about treatment efficacy from open-label trials, tolerability was good, effect sizes large and symptom improvements appeared rapidly after just two psilocybin treatment sessions and remained significant 6 months post-treatment in a treatment-resistant cohort. Psilocybin represents a promising paradigm for unresponsive depression that warrants further research in double-blind randomised control trials.

Tunable terahertz wave generation through a bimodal laser diode and plasmonic photomixer

We demonstrate a compact, robust, and stable terahertz source based on a novel two section digital distributed feedback laser diode and plasmonic photomixer. Terahertz wave generation is achieved through difference frequency generation by pumping the plasmonic photomixer with two output optical beams of the two section digital distributed feedback laser diode. The laser is designed to offer an adjustable terahertz frequency difference between the emitted wavelengths by varying the applied currents to the laser sections. The plasmonic photomixer is comprised of an ultrafast photoconductor with plasmonic contact electrodes integrated with a logarithmic spiral antenna. We demonstrate terahertz wave generation with 0.15-3 THz frequency tunability, 2 MHz linewidth, and less than 5 MHz frequency stability over 1 minute, at useful power levels for practical imaging and sensing applications.

Nerve growth factor acts through the TrkA receptor to protect sensory neurons from the damaging effects of the HIV-1 viral protein, Vpr

Distal sensory polyneuropathy (DSP) with associated neuropathic pain is the most common neurological disorder affecting patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Viral protein R (Vpr) is a neurotoxic protein encoded by HIV-1 and secreted by infected macrophages. Vpr reduces neuronal viability, increases cytosolic calcium and membrane excitability of cultured dorsal root ganglion (DRG) sensory neurons, and is associated with mechanical allodynia in vivo. A clinical trial with HIV/AIDS patients demonstrated that nerve growth factor (NGF) reduced the severity of DSP-associated neuropathic pain, a problem linked to damage to small diameter, potentially NGF-responsive fibers. Herein, the actions of NGF were investigated in our Vpr model of DSP and we demonstrated that NGF significantly protected sensory neurons from the effects of Vpr. Footpads of immunodeficient Vpr transgenic (vpr/RAG1(-/-)) mice displayed allodynia (p<0.05), diminished epidermalinnervation (p<0.01) and reduced NGF mRNA expression (p<0.001) compared to immunodeficient (wildtype/RAG1(-/-)) littermate control mice. Compartmented cultures confirmed recombinant Vpr exposure to the DRG neuronal perikarya decreased distal neurite extension (p<0.01), whereas NGF exposure at these distal axons protected the DRG neurons from the Vpr-induced effect on their cell bodies. NGF prevented Vpr-induced attenuation of the phosphorylated glycogen synthase-3 axon extension pathway and tropomyosin-related kinase A (TrkA) receptor expression in DRG neurons (p<0.05) and it directly counteracted the cytosolic calcium burst caused by Vpr exposure to DRG neurons (p<0.01). TrkA receptor agonist indicated that NGFacted through the TrkA receptor to block the Vpr-mediated decrease in axon outgrowth in neonatal and adult rat and fetal human DRG neurons (p<0.05). Similarly, inhibiting the lower affinity NGF receptor, p75, blocked Vpr's effect on DRG neurons. Overall, NGF/TrkA signaling or p75 receptor inhibition protects somatic sensory neurons exposed to Vpr, thus laying the groundwork for potential therapeutic options for HIV/AIDS patients suffering from DSP.

Lumbar vertebral canal size in adults and children: observations from a skeletal sample from London, England

The morphometry of the lumbar vertebral canal is of importance to clinical and bioarchaeological researchers, yet there are no growth standards for its diameters and there is a disagreement over the age at which its development is complete. Direct measurements of the midsagittal and interpedicular diameters of the lumbar vertebral canal (L1-L5) were taken from 65 children (3-17 years) and 120 adults (>17 years) from the East Smithfield Black Death cemetery, London (1348-1350 CE) to discover the age at which these diameters reached their final adult size in an historical population from later mediaeval London. Children were grouped into age categories: 3-5 years; 6-10 years; 11-14 years; 15-17 years, and the group means of each diameter were compared with the mean adult diameters using one-way ANOVAs. The child midsagittal diameters were not significantly different from adults in any age category, indicating that this diameter reached adult size by 3-5 years of age. However, interpedicular diameters increased with age until 15-17 years when they reached full adult size. Mean diameters and percentiles (10th and 90th) are provided for each age category.

A review of potential contaminants in Australian livestock feeds and proposed guidance levels for feed

Contaminants of man-made and natural origin need to be managed in livestock feeds to protect the health of livestock and that of human consumers of livestock products. This requires access to information on the transfer from feed to food to inform risk profiles and assessments, and to guide management interventions such as regulation or Hazard Analysis Critical Control Point approaches. This paper reviews contaminants of known and potential concern in the production of livestock feeds in Australia and compares existing but differing state and national regulatory standards with international standards. The contaminants considered include man-made organic chemical contaminants (e.g. legacy pesticides), elemental contaminants (e.g. arsenic, cadmium, lead), phytotoxins (e.g. gossypol) and mycotoxins (e.g. aflatoxins). Reference is made to scientific literature and evaluations by regulators to propose maximum levels that can be used for guidance by those involved in managing contamination incidents or developing feed safety programs.

Progressive elevation of ap-1 activity during preneoplastic-to-neoplastic progression as modeled in mouse jb6 cell variants

The JB6 mouse epidermal cell system has been used extensively as an in vitro model for the study of tumor promotion and progression. The present study was directed to assessing the role of basal AP-1 activity in JB6 variants which represent preneoplastic to neoplastic progression and to addressing whether AP-1 activity is required for maintenance of the tumor phenotype. Constitutively higher AP-1 activity was found in tumorigenic JB6 RT101 cells than in later or earlier preneoplastic P+ or P- cells. Levels of c-jun mRNA and protein correlated with progression stage. Enhancement of AP-1 activity by TPA increased the formation of anchorage independent colonies by tumorigenic RT101 cells. Inhibition of AP-1 activity by retinoic acid or fluocinolone acetonide inhibited expression of tumor phenotype as measured by AI growth. These data together with our previous results suggest that in the JB6 model (i) basal levels of Jun and AP-1 appear to be important for preneoplastic-to-neoplastic progression; (ii) induced AP-1 appears to be required for further progression by tumor cells; (iii) constitutively elevated AP-I activity may be important for the expression of transformed phenotype; (iv) inhibition of AP-1 activity by RA or FA is not a general suppression of transcription but is gene-specific; and (v) even though both inhibition of AP-1 activity and activation of RARE-dependent or GRE-dependent gene transcription correlate with inhibition of AI growth in RT101 cells by RA or FA, transactivation of RARE or GRE might better correlate with the inhibition of AI growth than the inhibition of AP-1 activity in RT101 cells.

Nomenclature and classification of vasculitis - update on the ACR/EULAR diagnosis and classification of vasculitis study (DCVAS)

Classification of vasculitis remains unsatisfactory. This is largely because the pathogenetic mechanisms of this family of related disorders have not been fully understood. Existing classification criteria are useful but limited. This has become more apparent with the advent of more effective and more specific therapies. A rational basis for classification could significantly improve our approach to treatment. The development of diagnostic criteria in vasculitis is an even greater challenge but may ultimately provide more useful for the non-specialist clinician. International efforts are underway to provide more effective classification and diagnostic criteria.

Thrombocytopenic syndromes masquerading as childhood immune thrombocytopenic purpura

Immune thrombocytopenic purpura (ITP) is the most common cause of thrombocytopenia in children and adolescents. However, there are a number of other diagnoses that are often mistaken for ITP. A 10-year retrospective chart review was performed at the Children's Hospital of Alabama to characterize ITP. Initially, 492 patients who had the coded diagnosis of ITP (ICD 287.3) were identified. However, 83 (17%) of patients were found to have alternative diagnoses on chart review. Of the 83 patients, 13 patients (3%) represented coding errors or study classification errors. The 70 remaining patients (14%) had an alternative explanation for their thrombocytopenia, consisting of 31 different diagnoses. The most common diagnoses were familial thrombocytopenia (10%), systemic lupus erythematosus (9%), hypersplenism (9%), neonatal alloimmune thrombocytopenia (7%), Wiskott-Aldrich syndrome (7%), or systemic infection (6%). In total, 16 of the patients (23%) were ultimately diagnosed with one of a number of congenital syndromes with concurrent thrombocytopenia. Although this review confirms that most children with thrombocytopenia are diagnosed with ITP, 14% of the study population manifested other diagnoses. The clinician evaluating a child with thrombocytopenia must keep an open mind about the possible diagnosis and perform a comprehensive and thoughtful evaluation based on the clinical picture. ITP must be a diagnosis of exclusion as misdiagnosis in a child with thrombocytopenia may have a significant impact on morbidity and mortality.

The MoCA: well-suited screen for cognitive impairment in Parkinson disease

OBJECTIVE

To establish the diagnostic accuracy of the Montreal Cognitive Assessment (MoCA) when screening externally validated cognition in Parkinson disease (PD), by comparison with a PD-focused test (Scales for Outcomes in Parkinson disease-Cognition [SCOPA-COG]) and the standardized Mini-Mental State Examination (S-MMSE) as benchmarks.

METHODS

A convenience sample of 114 patients with idiopathic PD and 47 healthy controls was examined in a movement disorders center. The 21 patients with dementia (PD-D) were diagnosed using Movement Disorders Society criteria, externally validated by detailed independent functional and neuropsychological tests. The 21 patients with mild cognitive impairment (PD-MCI) scored 1.5 SD or more below normative data in at least 2 measures in 1 of 4 cognitive domains. Other patients had normal cognition (PD-N).

RESULTS

Primary outcomes using receiver operating characteristic (ROC) curve analyses showed that all 3 mental status tests produced excellent discrimination of PD-D from patients without dementia (area under the curve [AUC], 87%-91%) and PD-MCI from PD-N patients (AUC, 78%-90%), but the MoCA was generally better suited across both assessments. The optimal MoCA screening cutoffs were <21/30 for PD-D (sensitivity 81%; specificity 95%; negative predictive value [NPV] 92%) and <26/30 for PD-MCI (sensitivity 90%; specificity 75%; NPV 95%). Further support that the MoCA is at least equivalent to the SCOPA-COG, and superior to the S-MMSE, came from the simultaneous classification of the 3 PD patient groups (volumes under a 3-dimensional ROC surface, chance = 17%: MoCA 79%, confidence interval [CI] 70%-89%; SCOPA-COG 74%, CI 62%-86%; MMSE-Sevens item 56%, CI 44%-68%; MMSE-World item 62%, CI 50%-73%).

CONCLUSIONS

The MoCA is a suitably accurate, brief test when screening all levels of cognition in PD.

Gene delivery of AAV2-neurturin for Parkinson's disease: a double-blind, randomised, controlled trial

BACKGROUND

In an open-label phase 1 trial, gene delivery of the trophic factor neurturin via an adeno-associated type-2 vector (AAV2) was well tolerated and seemed to improve motor function in patients with advanced Parkinson's disease. We aimed to assess the safety and efficacy of AAV2-neurturin in a double-blind, phase 2 randomised trial.

METHODS

We did a multicentre, double-blind, sham-surgery controlled trial in patients with advanced Parkinson's disease. Patients were randomly assigned (2:1) by a central, computer generated, randomisation code to receive either AAV2-neurturin (5·4 × 10¹¹ vector genomes) injected bilaterally into the putamen or sham surgery. All patients and study personnel with the exception of the neurosurgical team were masked to treatment assignment. The primary endpoint was change from baseline to 12 months in the motor subscore of the unified Parkinson's disease rating scale in the practically-defined off state. All randomly assigned patients who had at least one assessment after baseline were included in the primary analyses. This trial is registered at ClinicalTrials.gov, NCT00400634.

RESULTS

Between December, 2006, and November, 2008, 58 patients from nine sites in the USA participated in the trial. There was no significant difference in the primary endpoint in patients treated with AAV2-neurturin compared with control individuals (difference -0·31 [SE 2·63], 95% CI -5·58 to 4·97; p=0·91). Serious adverse events occurred in 13 of 38 patients treated with AAV2-neurturin and four of 20 control individuals. Three patients in the AAV2-neurturin group and two in the sham surgery group developed tumours.

INTERPRETATION

Intraputaminal AAV2-neurturin is not superior to sham surgery when assessed using the UPDRS motor score at 12 months. However, the possibility of a benefit with additional targeting of the substantia nigra and longer term follow-up should be investigated in further studies.

FUNDING

Ceregene and Michael J Fox Foundation for Parkinson's Research.

Development of a clinically relevant liquid chromatography tandem mass spectrometry assay for 13 drugs of abuse in urine, designed to meet the needs of the service users

Background

The clinical requirements of the users of assay results must be at the centre of assay development. We aimed to develop a single liquid chromatography tandem mass spectrometry (LC-MS/MS) assay for drugs of abuse in urine that would meet the needs of our service users and replace the multiple screening and confirmatory techniques previously in use.

Methods

After discussion with our users, it was decided that 13 drugs and metabolites should be measured in our panel: morphine, codeine, norcodeine, dihydrocodeine, 6-monoacetylmorphine, acetyl codeine, methadone and its metabolite, buprenorphine and its metabolite, amphetamine, benzoylecgonine and cotinine. Urine samples were prepared by the addition of internal standard, enzymatic hydrolysis and solid-phase extraction. Chromatography conditions were optimized so that the analytes were separated within a run time of 6 min. Optimal parent to daughter m/z ion transitions were chosen for all drugs and daughter ion ratios were used.

Results

The LC-MS/MS assay was successfully validated with acceptable precision and lower limits of quantification for all drugs. No matrix effects were seen. The results produced by the LC-MS/MS assay compared well with the previous combination of techniques in use.

Conclusions

We have developed and validated a fit-for-purpose LC-MS/MS assay for 13 drugs of abuse in urine that obviates the need for multiple screening and confirmatory analytical techniques.

Sexual identity and its contribution to MSM risk behavior in Bangaluru (Bangalore), India: the results of a two-stage cluster sampling survey

In India, there are categories of MSM (hijras, kothis, double-deckers, panthis and bisexuals), which are generally associated with different HIV-risk behaviors. Our objective was to quantify differences across MSM identities (n = 357) and assess the extent they conform to typecasts that prevail in policy-orientated discourse. More feminine kothis (26%) and hijras (13%) mostly reported receptive sex, and masculine panthis (15%) and bisexuals (23%) insertive anal sex. However, behavior did not always conform to expectation, with 25% and 16% of the sample reporting both insertive and receptive anal intercourse with known and unknown noncommercial partners, respectively (p < 0.000). Although behavior often complied with stereotyped role and identity, male-with-male sexual practices were fluid. Reification of these categories in an intervention context may hinder our understanding of the differential HIV risk among MSM.

Wegener's granulomatosis occurring de novo during pregnancy

Wegener's granulomatosis (WG) is rarely diagnosed during the reproductive years and uncommonly manifests for the first time during pregnancy. We report a case of de novo WG presenting at 30 weeks gestation with classical symptoms of WG (ENT, pulmonary). The diagnosis was confirmed by radiological, laboratory, and histological investigations. With a multidisciplinary approach, she had a successful vaginal delivery of a healthy baby. She was treated successfully by a combination of steroids, azathioprine and intravenous immunoglobulin in the active phase of disease for induction of remission and by azathioprine and steroids for maintenance of remission. The significant improvement in her symptoms allowed us to continue her pregnancy to 37 weeks when delivery was electively induced. Transplacental transmission of PR3-ANCA occurred but the neonate remained well. This case of de novo WG during pregnancy highlights the seriousness of this disease and the challenge in management of such patients.