REV7-p53 interaction inhibits ATM-mediated DNA damage signaling

REV7 is an abundant, multifunctional protein that is a known factor in cell cycle regulation and in several key DNA repair pathways including Trans-Lesion Synthesis (TLS), the Fanconi Anemia (FA) pathway, and DNA Double-Strand Break (DSB) repair pathway choice. Thus far, no direct role has been studied for REV7 in the DNA damage response (DDR) signaling pathway. Here we describe a novel function for REV7 in DSB-induced p53 signaling. We show that REV7 binds directly to p53 to block ATM-dependent p53 Ser15 phosphorylation. We also report that REV7 is involved in the destabilization of p53. These findings affirm REV7's participation in fundamental cell cycle and DNA repair pathways. Furthermore, they highlight REV7 as a critical factor for the integration of multiple processes that determine viability and genome stability.

O-141 Mapping of SARS-CoV-2-associated receptors and proteases mRNA in human endometrium during natural and stimulated cycles

Study question

Covid-19 pandemic has significantly affected the assisted reproductive technology (ART) practice. Understanding whether SARS-CoV-2 could infect endometrial tissues during ART is crucial for risk mitigation

Summary answer

Analyses of gene expression profiles of SARS-CoV-2 host entry candidates from microarray data suggest that endometrium should be considered as potential target for SARS-CoV-2 infection.

What is known already

Very few studies analyzed the gene expression profiles of SARS-CoV-2-associated receptors and proteases, mainly focusing on ACE2 and TMPRSS2 expression, resulting incomplete knowledge in different specimens from female genital tract. However, no studies have analyzed the potential impact of controlled ovarian stimulation (COS) protocols during ART procedure on the endometrial gene expression profiles of SARS-CoV-2-associated receptors and proteases

Study design, size, duration

To address this question, we retrospectively examined the gene expression profile of SARS-CoV-2-associated receptors and proteases in endometrial biopsies of a cohort of ART candidates using Affymetrix microarray data

Participants/materials, setting, methods

Human endometrial tissue under natural (n = 62) and COS cycles (n = 42) were analyzed. A focus was particularly made on the renin-angiotensin system relates genes with a prominent role in the virus infection, and gene expression levels of receptors and proteases closely related to SARS-CoV-2 infectionwas also studied.

Main results and the role of chance

Using our large cohort of endometrial samples, we reported a high prevalence of genes related to the ACE2 pathway, including AGT, AGTR1, ANPEP, CTSA, ENPEP, LNPEP, MME, NLN, THOP1, BSG and CTSL during both phases(early- and mid-secretory phase), and mainly during the mid-secretory phase for ACE2. The highest signal intensities were found for CTSA, LNPEP, MME, NLN, BSG and CTSL. The most representative of dual coexpression of SARS-CoV-2-associated receptor and protease in endometrium was BSG-CSTL and BSG-CTSA. It s also important to note high variation of SARS-CoV-2 receptors inter-patients under natural cycle.Globally, the impact of COS on endometrial gene expression profile of SARS-CoV-2-associated receptors and proteases of non Covid-19 patients is low, suggesting no additional potential risks of SARS-CoV-2 infection during stimulated ART procedure compared with natural cycles.

Limitations, reasons for caution

Analyses of Affymetrix microarray gene expression data were performed in non-COVID-19 patients. Whether the SARS-CoV-2 infection changes the endometrial gene expression profile of SARS-CoV-2-associated receptors and proteases is under investigation

Wider implications of the findings

Specimens from female genital tract may be considered as potential targets for SARS-CoV-2.

Trial registration number

not applicable

Characterization of cell fusion in an experimental mouse model of endometriosis†

Cell fusion is involved in the development of some adult organs, is implicated in the pathogenesis of specific types of cancer, and is known to participate in repair/regeneration processes mediated by bone-marrow-derived cells (BMDCs). Endometriosis is a disease characterized by growth of functional endometrial tissue outside of the uterine cavity. Endometriosis shares some molecular properties with cancer and BMDCs home to endometriosis lesions in a mouse model. Our objective was to determine if cell fusion can occur in endometriosis and establish whether bone-marrow-derived cells participate in cell fusion events in lesions. We employed a Cre-Lox system to identify cell fusion events in a mouse model of endometriosis. Fused cells were detected in endometriotic lesions, albeit at a low frequency (∼1 in 400 cells), localized to the stromal compartment, and displayed restricted proliferation. Using 5-fluorouracil-based nongonadotoxic bone marrow transplantation model, we demonstrate that bone marrow cells represent a principal cell source for fusion events in lesions. Cell fusion progeny uniformly lacked expression of selected markers of hematopoietic, endothelial, and epithelial markers, though they expressed the mesenchymal/stromal markers Sca-1 and CD29. This study is the first to describe the phenomenon of cell fusion in endometriosis and points to a mesenchymal population derived from cell fusion events with limited proliferative activity, properties previously attributed to endometrial stem cells. Their putative role in the pathogenesis of the disease remains to be elucidated.

Absolventen-Nachbefragung (ABNA) des MSc-Studiengangs Physiotherapie – Was bringt der MSc-Abschluss im Berufsalltag?

Hintergrund: Aufgrund der veränderten Anforderungen an die Gesundheitsfachpersonen übernehmen auch Physiotherapeuten Aufgaben, die über ihre klinische Expertise hinausgehen. Ein MSc-Abschluss qualifiziert sie sowohl für erweiterte Aufgaben in der Klinik als auch für Tätigkeiten in der Forschung und Lehre.

Ziel: Das Ziel der Absolventen-Nachbefragung (ABNA) war, die Umsetzbarkeit der im Studium vermittelten Kompetenzen in den Berufsalltag zu untersuchen.

Methode: Im Herbst 2015 wurden die ersten beiden Abschlussjahrgänge 2013 und 2014 (n = 51) des MSc in Physiotherapie mit einem Online-Fragebogen befragt.

Ergebnisse: An der Befragung nahmen 34 Absolventen teil. Die Rücklaufquote betrug 68 %. Die Mehrheit der Teilnehmenden (84 %) arbeitet in direktem Patientenkontakt, häufig in Kombination mit erweiterten Tätigkeiten (92 %) wie etwa Fachentwicklung, Forschungs- oder Unterrichtstätigkeit. Als Veränderungen im Berufsalltag, die auf den MSc-Abschluss zurückzuführen sind, wurden interessantere und abwechslungsreichere Tätigkeiten (74 %), erweiterte Aufgabenfelder (71 %) oder Projektverantwortung (41 %) genannt. Rund ein Viertel der Absolventen treibt die akademische Karriere voran.

Schlussfolgerung: Die Erfahrungen der Absolventen der ersten beiden Studienjahrgänge zeigen, dass der MSc-Abschluss einen beruflichen Aufstieg ermöglicht und dies zu einer Vielzahl an beruflichen Veränderungen, wie z. B. neue Tätigkeiten, erweiterte Aufgabenfelder oder Projekt- und Personalverantwortung führt. Für MSc-Physiotherapeuten gibt es adäquate Stellen auf dem Arbeitsmarkt, in denen sie ihre Kompetenzen einsetzen können. Weiter ermöglicht der MSc-Abschluss den Zugang zu einem PhD.

Metabolic Abnormalities in the Hippocampus of Patients with Schizophrenia: A 3D Multivoxel MR Spectroscopic Imaging Study at 3T

BACKGROUND AND PURPOSE

Schizophrenia is well-known to be associated with hippocampal structural abnormalities. We used ¹H-MR spectroscopy to test the hypothesis that these abnormalities are accompanied by NAA deficits, reflecting neuronal dysfunction, in patients compared with healthy controls.

MATERIALS AND METHODS

Nineteen patients with schizophrenia (11 men; mean age, 40.6 ± 10.1 years; mean disease duration, 19.5 ± 10.5 years) and 11 matched healthy controls (5 men; mean age, 33.7 ± 10.1 years) underwent MR imaging and multivoxel point-resolved spectroscopy (TE/TR, 35/1400 ms) ¹H-MRS at 3T to obtain their hippocampal GM absolute NAA, Cr, Cho, and mIns concentrations. Unequal variance t tests and ANCOVA were used to compare patients with controls. Bilateral volumes from manually outlined hippocampal masks were compared by using unequal variance t tests.

RESULTS

Patients' average hippocampal GM Cr concentrations were 19% higher than that of controls, 8.7 ± 2.2 versus 7.4 ± 1.2 mmol/L (P < .05); showing no differences, concentrations in NAA were 8.8 ± 1.6 versus 8.7 ± 1.2 mmol/L; in Cho, 2.3 ± 0.7 versus 2.1 ± 0.3 mmol/L; and in mIns, 6.1 ± 1.5 versus 5.2 ± 0.9 (all P > .1). There was a positive correlation between mIns and Cr in patients (r = 0.57, P = .05) but not in controls. The mean bilateral hippocampal volume was ∼10% lower in patients: 7.5 ± 0.9 versus 8.4 ± 0.7 cm³ (P < .05).

CONCLUSIONS

These findings suggest that the hippocampal volume deficit in schizophrenia is not due to net loss of neurons, in agreement with histopathology studies but not with prior ¹H-MR spectroscopy reports. Elevated Cr is consistent with hippocampal hypermetabolism, and its correlation with mIns may also suggest an inflammatory process affecting some cases; these findings may suggest treatment targets and markers to monitor them.

A p53-bound enhancer region controls a long intergenic noncoding RNA required for p53 stress response

Genome-wide chromatin studies identified the tumor suppressor p53 as both a promoter and an enhancer-binding transcription factor. As an enhancer factor, p53 can induce local production of enhancer RNAs, as well as transcriptional activation of distal neighboring genes. Beyond the regulation of protein-coding genes, p53 has the capacity to regulate long intergenic noncoding RNA molecules (lincRNAs); however, their importance to the p53 tumor suppressive function remains poorly characterized. Here, we identified and characterized a novel p53-bound intronic enhancer that controls the expression of its host, the lincRNA00475 (linc-475). We demonstrate the requirement of linc-475 for the proper induction of a p53-dependent cell cycle inhibitory response. We further confirm the functional importance of linc-475 in the maintenance of CDKN1A/p21 levels, a cell cycle inhibitor and a major p53 target gene, following p53 activation. Interestingly, loss of linc-475 reduced the binding of both p53 and RNA polymerase II (RNAPII) to the promoter of p21, attenuating its transcription rate following p53 activation. Altogether, our data suggest a direct role of p53-bound enhancer domains in the activation of lincRNAs required for an efficient p53 transcriptional response.

Early glial activation precedes neurodegeneration in the cerebral cortex after SIV infection: a 3D, multivoxel proton magnetic resonance spectroscopy study

OBJECTIVES

As ∼40% of HIV-infected individuals experience neurocognitive decline, we investigated whether proton magnetic resonance spectroscopic imaging ((1) H-MRSI) detects early metabolic abnormalities in the cerebral cortex of a simian immunodeficiency virus (SIV)-infected rhesus monkey model of neuroAIDS.

METHODS

The brains of five rhesus monkeys before and 4 or 6 weeks after SIV infection (with CD8(+) T-cell depletion) were assessed with T2 -weighted quantitative magnetic resonance imaging (MRI) and 16×16×4 multivoxel (1) H-MRSI (echo time/repetition time = 33/1440 ms). Grey matter and white matter masks were segmented from the animal MRIs and used to produce cortical masks co-registered to (1) H-MRSI data to yield cortical metabolite concentrations of the glial markers myo-inositol (mI), creatine (Cr) and choline (Cho), and of the neuronal marker N-acetylaspartate (NAA). The cortex volume within the large, 28 cm(3) (∼35% of total monkey brain) volume of interest was also calculated for each animal pre- and post-infection. Mean metabolite concentrations and cortex volumes were compared pre- and post-infection using paired sample t-tests.

RESULTS

The mean (± standard deviation) pre-infection concentrations of the glial markers mI, Cr and Cho were 5.8 ± 0.9, 7.2 ± 0.4 and 0.9 ± 0.1 mM, respectively; these concentrations increased 28% (p ≈ 0.06), 15% and 10% (both p < 0.05), respectively, post-infection. The mean concentration of neuronal marker NAA remained unchanged (7.0 ± 0.6 mM pre-infection vs. 7.3 ± 0.8 mM post-infection; p ≈ 0.37). The mean cortex volume was also unchanged (8.1 ± 1.1 cm(3) pre-infection vs. 8.3 ± 0.5 cm(3) post-infection; p ≈ 0.76).

CONCLUSIONS

These results support the hypothesis that early cortical glial activation occurs after SIV infection prior to the onset of neurodegeneration. This suggests HIV therapeutic interventions should potentially target early glial activation in the cerebral cortex.

Trace element concentration in hair samples as an indicator of exposure of population in the Negev, Israel

The concentration of the toxic elements Ag, As, Cd, Co, Mn, Mo, Pb, Se, and U and the elements Al, Mg, Cu, Fe, and Zn in human hair samples of population living in the north of the Negev Desert in Israel was determined. The study population consisted of three subgroups: Jewish urban population, Bedouin urban population, and Bedouins living in unrecognized villages (the "dispersion"). The main focus is on the differences between these subgroups in an attempt to explore factors responsible for the variation in trace metal contents in hair samples. The results show that the level of several elements, particularly Ag, Mn, and Pb, in the female Bedouin group significantly differed from the other groups in the study. Exploring the reasons for these differences, we concluded that the lifestyle of those women is the main cause. The female Bedouin subgroup is exposed to heavy metals from kitchen utensils, jewelry, and makeup. Therefore, differences in the heavy metal concentration in the hair samples of this group were attributed to the traditional unique lifestyle and social behavior of the females in the Bedouin society.

Circulating cytokines in patients undergoing tonsillectomy with fibrin glue

OBJECTIVE

Fibrin glue is used as a haemostatic agent or as a sealant. The aim of this study is to objectively evaluate the efficacy of the use of fibrin glue Quixil - a human surgical sealer - in tonsillectomy, for the reduction of post-operative inflammatory response.

STUDY DESIGN

A prospective randomized single-blind study.

METHODS

The study was performed on 40 consecutive patients undergoing adenotonsillectomy (T&A). Patients were randomly assigned to one of two sub-groups: a study group and a control group. The tonsillar beds of patients in the study group were coated with fibrin glue (Quixil, OMRIX biopharmaceuticals) at the end of the operation; the patients in the control group were treated for hemostasis without the use of fibrin glue. Complete blood counts and circulating pro-inflammatory cytokines (assayed by specific immunoassay - ELISA) were assessed in samples drawn pre- and 16 h post-tonsillectomy.

RESULTS

Forty patients (aged 5.8 ± 2.4 years) were consecutively enrolled; 45% (18) of the patients were treated with fibrin glue, 55% (22) were not. Compared to controls, Quixil-treated patients demonstrated a reduction in post-tonsillectomy circulating leukocytes (29.2% vs. 45.4%, p<0.05), neutrophiles (28.3% vs. 42.1%, p<0.05), IL-6 (+1% vs. +42%, p<0.05), and TNF-alpha (+8% vs. +26%, p<0.05.

CONCLUSIONS

Intra-operative fibrin glue therapy is associated with decreased immediate inflammatory response following T&A. Further studies are warranted to assess long-term outcome.

LEVEL OF EVIDENCE

1B.

Dried leaves of Rosmarinus officinalis as a treatment for streptococcosis in tilapia

Dietary application of dried Rosmarinus officinalis (rosemary) leaves as a treatment for streptococcal infection was studied in tilapia, Oreochromis sp. Feeding with dried rosemary leaves significantly reduced mortality following infection with Streptococcus iniae: 44% mortality in the group fed 8% rosemary, similar to oxytetracycline treatment (43% mortality), and significantly lower than the control (65%). Dietary administration of 16% rosemary significantly reduced mortality because of Streptococcus agalactiae infection in 44 g fish (62% and 76% in 16% rosemary and control, respectively), but not in a similar experiment conducted with 5.5 g fish. The antibacterial effect of rosemary on S. iniae was studied. Activity of rosemary cultivar Israel was reduced during the winter, but there was no significant change in cultivars Oranit and Star. Storage of powdered rosemary leaves at 50 degrees C resulted in fourfold and eightfold higher MIC(24 h) values after 3 and 4.5 months, respectively. Storage at -20 degrees C, 4 degrees C and 25 degrees C and autoclaving (120 degrees C) each resulted in a twofold increase in MIC(24 h). Repeated exposures of S. iniae to rosemary did not affect minimal inhibitory concentration, suggesting no development of resistance to rosemary.

Budesonide/formoterol in a single inhaler versus inhaled corticosteroids alone in the treatment of asthma

The aim of this study was to evaluate the efficacy (expressed as effect on lung function) and tolerability of Symbicort (budesonide/formoterol in a single inhaler) in children with asthma. This was a double-blind, double-dummy, randomized, parallel-group, multicenter trial. After a 2-4-week run-in period, 286 asthmatic children (177 boys, 109 girls; mean age, 11 years; mean forced expiratory volume in 1 sec (FEV(1)), 75% predicted normal), previously treated with inhaled corticosteroids (average dose 548 microg/day), were randomized to 12 weeks' treatment with either budesonide/formoterol 80/4.5 microg, two inhalations twice daily (n = 148), or an equivalent dose of budesonide 100 microg, two inhalations twice daily (n = 138). Efficacy variables included morning and evening peak expiratory flow (PEF), spirometery, asthma symptoms, and use of rescue medication (beta(2)-agonists). Serial FEV(1) assessments were carried out on a subgroup of children (budesonide/formoterol, n = 41; budesonide, n = 40) at randomization and at week 12. Relative to baseline, morning PEF (primary variable) increased to a significantly greater extent with budesonide/formoterol than with budesonide alone (7.22% predicted normal vs 3.45% predicted normal; P < 0.001). Evening PEF also increased significantly with budesonide/formoterol (6.13% predicted normal vs. 2.73% predicted normal; P < 0.001), as did mean FEV(1) and serial FEV(1) measured over 12 hr (both P < 0.05). Similar improvements in asthma symptoms and rescue medication use were observed in both groups. The two treatment groups were similar in terms of their adverse-event profile and rates of discontinuation. Budesonide/formoterol in a single inhaler provided rapid improvements in PEF and FEV(1) compared to inhaled budesonide alone. These improvements were sustained throughout the study period. Budesonide/formoterol was well-tolerated in children with moderate persistent asthma.

Symbicort: controlling asthma in children

Asthma is now widely recognized as a chronic inflammatory condition of the airways that requires early pharmacological treatment and long-term management. Anti-inflammatory agents, particularly inhaled corticosteroids, are currently the most effective long-term preventative medication. Moreover, early intervention with inhaled corticosteroids plays an important role in airway remodelling. Despite significant advances in the understanding of asthma and its pharmacological management, the prevalence of asthma in children, teenagers and young adults is on the increase. For patients whose asthma is not fully controlled with daily inhaled corticosteroid therapy, national guidelines advocate the addition of long-acting inhaled beta2-agonist therapy, rather than an increase in dose of inhaled corticosteroids, for the treatment of persistent childhood asthma. However, adherence to treatment with asthma medication declines as the regimen becomes more complicated. Adherence to therapy and therapy convenience are key to the successful pharmacological management of asthma, particularly in children. The administration of prescribed medication via a single inhaler offers a convenient treatment regimen that has the potential to improve adherence to treatment. This paper presents data to show that the combined administration of budesonide and formoterol via a single inhaler (Symbicort Turbuhaler) is effective and well tolerated in the treatment of asthma in children.

[Impaired daytime functions in children with sleep disorders]

Sleep in adequate amount and quality is essential for normal child development. Sleep disorders may affect the childs daytime functions resulting in behavioral problems such as attention deficit, aggressiveness and hyperactivity. Recent reports have suggested that chronic sleep disturbance can cause neurocognitive deficits and impaired learning abilities. Obstructive sleep apnea syndrome, asthma, atopic dermatitis and juvenile rheumatoid arthritis--are common childhood diseases that can impair normal sleep. This article reviews the sleep characteristics in these diseases and the relation between sleep quality and the social and intellectual performance of the child during the day.

[Oral rehydration in acute gastroenteritis in infants and children--advantages of a standardized protocol]

Oral rehydration (OR) for acute gastroenteritis in infants and children has been shown to be as effective as IV therapy, with less discomfort and lower costs. In this retrospective study we compared 2 pediatric wards, in 1 of which only a standardized, simplified, bedside protocol, based on American Academy of Pediatrics guidelines, was used. There were no significant clinical characteristics in the 208 patients. In the ward which used the above protocol, OR utilization was significantly more frequent than in the other ward (48% versus 15%), thus saving equipment costs of nearly $1,000/3 months. There were no significant differences in outcome between the wards. We conclude that introducing a standardized management protocol may increase OR utilization in hospitalized children with acute diarrhea.

The effect of adenotonsillectomy on serum insulin-like growth factor-I and growth in children with obstructive sleep apnea syndrome

OBJECTIVE

Obstructive sleep apnea syndrome (OSAS) in children is frequently associated with growth interruption. The objective of this study was to evaluate the effect of OSAS and adenotonsillectomy on the insulin-like growth factor-I (IGF-I) axis in children.

STUDY DESIGN

Thirteen prepubertal children (mean age, 6.0 +/- 2.8 years) were studied before and after adenotonsillectomy (T&A). Weight, height, overnight polysomnography, and IGF-I and IGF-binding protein-3 levels were evaluated before and 3 to 12 months after T&A. The children's weights and heights were monitored for 18 months.

RESULTS

The respiratory disturbance index improved from 7.8 +/- 9.1 events/h to 1.0 +/- 2.1 events/h after T&A (P <.02). Slow-wave sleep increased from 29.1% +/- 7.2% to 34.6% +/- 9.8% after T&A (P <.02). The weight standard deviation score increased from 0.86 +/- 1 to 1. 24 +/- 0.9, 18 months after T&A (P <.01). Serum IGF-I levels increased from 146.3 +/- 76.2 ng/mL before T&A to 210.3 +/- 112.5 ng/mL after surgery (P <.01), but IGF-binding protein-3 levels did not change significantly.

CONCLUSION

The respiratory improvement after T&A in children with OSAS is associated with a significant increase in serum IGF-I levels and weight. We conclude that the IGF-I axis is affected in children with OSAS.

Sleep characteristics in children with Down syndrome

BACKGROUND

Obstructive sleep apnea syndrome is common in children with Down syndrome (DS). Little is known about sleep patterns, especially arousals, awakenings, and movements during sleep in children with DS.

OBJECTIVE

To determine the characteristics of sleep disorders in children with DS and to define the associations between respiratory disturbance and arousals, awakenings, and movements.

METHODS

The study included 23 children with DS, compared with 13 children with primary snoring. All underwent a 6- to 8-hour sleep study.

RESULTS

The respiratory disturbance index was significantly higher in the children with DS (2.8 +/- 2.3 events/h vs 0.6 +/- 0.4 events/h; P <.05). Sleep was significantly fragmented in children with DS, who had a significantly higher arousal/awakening (A/Aw) index (24.6 +/- 7.9 events/h) compared with the comparison group (17.6 +/- 4.0 events/h) (P <.02). A higher percentage of jerks associated with A/Aw and respiratory event-associated A/Aw was observed in patients with DS (45.2% +/- 25% and 8.6% +/- 6.4%, respectively) compared with the control patients (10.2% +/- 4.5% and 1.5% +/- 2.1%) (P <.02). The median length of occurrences of stage 2 sleep was 27% shorter in the DS group (P <.03). The number of shifts from "deeper" to "lighter" stages of non-rapid eye movement sleep was 30% greater (P <.02) in the DS group.

CONCLUSION

Children with DS have significant sleep fragmentation, manifested by frequent awakenings and arousals, which are only partially related to obstructive sleep apnea syndrome.

Sleep fragmentation in children with atopic dermatitis

OBJECTIVE

To characterize the sleep pattern of children with atopic dermatitis in clinical remission.

METHODS

Fourteen children with atopic dermatitis, with a mean+/-SD age of 6+/-2 years, were recruited consecutively from a pediatric dermatology clinic. No participant had any other medical or psychiatric illness. The control group (n = 9, mean age 7+/-1.8 years) was composed of children with mild "benign" snoring and no evidence of respiratory disturbance during sleep. All participating children were evaluated by formal all-night polysomnography, scratch electrodes, and self-reported questionnaires filled in by their parents.

RESULTS

The patients were studied when their skin condition was in remission. Sleep latency, total sleep time, and sleep efficiency were similar to the control group. The atopic dermatitis group had an average of 24.1+/-8.1 events per hour of arousals and awakenings, compared with 15.4+/-6.2 events per hour in the control group (P<.001). Direct observation, video monitoring, and scratch electrodes provided evidence of between 1 to 19 bouts of scratching per night, accounting for only 15% of the arousals and awakenings. The rest of the arousals and awakenings were not associated with any specific, identifiable polysomnographic event, such as apnea or jerks.

CONCLUSION

Children with atopic dermatitis in clinical remission have sleep disturbances that are not related to scratching per se.

The molecular basis of disease variability among cystic fibrosis patients carrying the 3849+10 kb C-->T mutation

Disease severity varies among cystic fibrosis (CF) patients carrying the same CFTR genotype. Here we studied the mechanism underlying disease variability in individuals carrying a splicing CFTR mutation, 3849+10 kb C-->T. This mutation was shown to produce both correctly and aberrantly spliced CFTR transcripts containing an additional cryptic exon. Semiquantitative nondifferential RT-PCR showed considerable variability in the level (0-28%) of aberrantly spliced RNA transcribed from the 3849+10 kb C-->T mutation in nasal epithelium from 10 patients. A significant inverse correlation was found between the level of the aberrantly spliced CFTR transcripts and pulmonary function, expressed as FEV1 (r = 0.92, P < 0.0001). Patients with normal pulmonary function (FEV1 > 80% predicted) had lower levels of aberrantly spliced CFTR RNA (0 to 3%) than those with FEV1 < 80%, (9 to 28% aberrantly spliced RNA). Only aberrantly spliced CFTR RNA was detected in the lung of a patient with severe lung disease who underwent lung transplantation. Our results show that the severity of CF lung disease correlates with insufficiency of normal CFTR RNA. Thus, the regulation of alternative splice site selection may be an important mechanism underlying partial penetrance in CF. Further understanding of this regulation will contribute to potential therapy for patients carrying splicing mutations in human disease genes.

Sleep fragmentation in children with juvenile rheumatoid arthritis

OBJECTIVE

To characterize sleep patterns of patients with juvenile rheumatoid arthritis (JRA).

METHODS

Sixteen patients with JRA aged 12+/-4 years and 9 controls aged 11+/-3 years underwent a comprehensive evaluation by self-report questionnaire and formal all night polysomnographic recordings. Multiple sleep latency test was performed in 7 patients.

RESULTS

Patients had 90% more arousals and awakenings (p<0.01) and the median length of occurrences of uninterrupted sleep in stages 2 and 3 and rapid eye movement (REM) sleep was 60% shorter than in controls (p<0.01). The overall amount of sleep stage shift from deeper to lighter sleep was 23.5+/-10.8 events in patients compared to 14.9+/-4.0 in controls (p<0.05). In 15 of 16 patients 15% of non-REM sleep consisted of alpha-delta (alpha-rating) sleep, compared with less than 1% in controls (p<0.001). Multiple sleep latency test for patients was 10.3+/-2.6 min. There were no differences between JRA and controls in self-reported questions. However, patients reported longer afternoon naps, 1.8+/-1.3 h compared to 0.3+/-0.8 h in controls (p<0.05).

CONCLUSION

Objective polysomnographic evidence of abnormal sleep has been confirmed in patients with JRA. Sleep disturbance was associated with daytime sleepiness as evidenced by abnormal multiple sleep latency test and longer afternoon naptime.

Rhabdomyolysis associated with simvastatin-gemfibrozil therapy

Simvastatin is a potent inhibitor of hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase intended for use as a hypocholesterolemic agent. The long-term clinical experience with simvastatin indicates that it is a safe, effective, and well-tolerated hypolipidemic agent. Laboratory adverse events involving elevations of serum transaminase levels and serum creatine kinase (CK) levels to more than three times the upper limit of normal range have been seen in 1.5% and 3.4% of cases, respectively. We describe a case of severe myopathy and rhabdomyolysis associated with concomitant use of simvastatin and gemfibrozil. Seven days after discontinuing administration of gemfibrozil and simvastatin, the patient's condition improved and she was discharged home. Although this is the first report to indicate an association between myopathy and concomitant use of simvastatin and gemfibrozil, we strongly recommend caution and careful monitoring if simvastatin is given to patients receiving gemfibrozil.

Status epilepticus following intravenous N-acetylcysteine therapy

A previously healthy 2 1/2-year-old girl developed status epilepticus followed by cortical blindness during intravenous N-acetylcysteine therapy for paracetamol ingestion. The child's vision was almost completely recovered during the 18 months follow-up period. We assume that the cortical blindness was a postictal sequela after prolonged seizure episode, most probably due to respiratory depression induced by N-acetylcysteine.

Intravenous pamidronate for hypercalcemia of primary hyperparathyroidism

Intravenous pamidronate disodium has been used successfully in the treatment of malignancy-associated hypercalcemia and Paget's disease of bone. Although the definitive treatment of primary hyperparathyroidism (PHPT) is surgical, intravenous pamidronate has been used to treat hypercalcemia of PHPT when surgery was contraindicated. We report two cases of PHPT in which intravenous pamidronate effectively reduced hypercalcemia and significantly improved the clinical symptoms. The results of our study and the experience in the literature suggest that pamidronate is a safe and effective method of reducing serum calcium in patients with PHPT when definitive surgery is contraindicated or must be postponed.

Milk-alkali syndrome induced by 1,25(OH)2D in a patient with hypoparathyroidism

Milk-alkali syndrome was first described 70 years ago in the context of the treatment of peptic ulcer disease with large amounts of calcium and alkali. Although with current ulcer therapy (H-2 blockers, omeprazole, and sucralfate), the frequency of milk-alkali syndrome has decreased significantly, the classic triad of hypercalcemia, alkalosis, and renal impairment remains the hallmark of the syndrome. Milk-alkali syndrome can present serious and occasionally life-threatening illness unless diagnosed and treated appropriately. This article presents a patient with hypoparathyroidism who was treated with calcium carbonate and calcitriol resulting in two admissions to the hospital for milk-alkali syndrome. The patient was successfully treated with intravenous pamidronate on his first admission and with hydrocortisone on the second. This illustrates intravenous pamidronate as a valuable therapeutic tool when milk-alkali syndrome presents as hypercalcemic emergency.

Deposition pattern of radiolabeled salbutamol inhaled from a metered-dose inhaler by means of a spacer with mask in young children with airway obstruction

BACKGROUND

The exact amount of drug deposited in the respiratory and gastrointestinal tract in children with airway obstruction, when delivered from a metered-dose inhaler (MDI) via a spacer with mask, and its distribution in children with airway obstruction, are unknown.

METHODS

We studied 15 children, using salbutamol labeled with technetium 99m. Each patient was imaged with a gamma-camera immediately after one puff of labeled salbutamol was administered via a spacer with mask. Drug deposition was then analyzed to measure the distribution of the labeled spray in the oropharynx, the lungs, the stomach, and the spacer with mask (Aerochamber) itself.

RESULTS

Fifteen infants and children (mean age, 21 months (range, 3 months to 5 years); mean weight, 9.3 kg (range, 3.2 to 15 kg)) were studied. Mean aerosol deposition was 1.97% +/- 1.4% in the lungs, 1.28% +/- 0.77% in the oropharynx, and 1.11% +/- 2.4% in the stomach. The remainder was trapped in the spacer. Lung imaging after inhalation from an MDI via a spacer showed widespread deposition of the drug in central and peripheral intrapulmonary airways. In two adult volunteers the deposition after one puff of the same radiolabeled drug, inhaled from an MDI via a spacer with a mouthpiece, was 19% in the lungs and 2% in the stomach.

CONCLUSIONS

Infants and toddlers with obstructive lung disease can be reliably and safely treated with inhaled medication administered with an MDI via a spacer with mask. The doses of a drug given from an MDI to infants and toddlers when a spacer with mask is used are not yet well defined but should be higher than the currently recommended doses, perhaps as much as an adult dose.

Severe complications of measles requiring intensive care in infants and young children

OBJECTIVE

To evaluate the characteristics of severe complications of measles in patients admitted to a pediatric intensive care unit.

DESIGN

Clinical description of a case series.

SETTING

The Pediatric Intensive Care Unit of Soroka Medical Center, Beer-Sheva, Israel, during a measles epidemic.

PATIENTS

Fifteen pediatric patients with measles requiring intensive care.

RESULTS

Fifteen of 237 hospitalized children with measles required intensive care in the Pediatric Intensive Care Unit. Eleven patients were malnourished; none had been vaccinated for measles. All 15 patients required mechanical ventilation for pneumonia that had caused severe respiratory distress. Twelve of 15 patients were severely hypoxemic before intubation. Seven had a clinical syndrome consistent with adult respiratory distress syndrome. Other complications on admission to the intensive care unit included spontaneous pneumothorax in three patients, empyema in two, encephalopathy in seven, shock in three, sepsis in five, hypocalcemia in 11, thrombocytopenia in eight, and coagulopathy in seven. Complications during treatment included pneumothorax in four patients, fibrosing alveolitis in one, brain infarct in one, thrombus formation in three, and nosocomial sepsis in one. Four patients had long-term sequelae (chronic lung disease, subacute sclerosing panencephalitis, hemiplegia, and partial amputation of a limb), and seven patients recovered uneventfully. Four patients died; all had adult respiratory distress syndrome, three had pneumothorax, and one had nosocomial sepsis.

CONCLUSIONS

Patients with measles who require intensive care have a high risk for death or long-term complications, even when treated in a modern pediatric intensive care unit. Adult respiratory distress syndrome and air leaks were the most severe complications in these patients. To reduce the severity of these complications, mechanical ventilation should be based on using the lowest possible inspiratory pressure and fraction of inspired oxygen, while accepting an arterial oxygen pressure less than 60 mm Hg. Secondary bacteremia was an early and prominent complication, and antibiotic treatment should be instituted early in patients with measles requiring intensive care.

Highly variable incidence of cystic fibrosis and different mutation distribution among different Jewish ethnic groups in Israel

The incidence of cystic fibrosis (CF) and the frequency of disease-causing mutations varies among different ethnic and geographic populations. The Jewish population around the world is comprised of two major ethnic groups; Ashkenazi and non-Ashkenazi. The latter is further classified according to country of origin. In this study, we analyzed the incidence of CF and the distribution of CF mutations in the general Jewish population in Israel and in most of the Jewish ethnic subgroups. The disease frequency varies considerably among the latter. Among Ashkenazi Jews, the frequency of CF is 1:3300, which is similar to the frequency in most Caucasian populations. Among non-Ashkenazi Jews, the disease occurs at a similar frequency among Jews from Libya (1:2700), Georgia (1:2700), Greece and Bulgaria (1:2400), but is rare in Jews from Yemen (1:8800), Morocco (1:15000), Iraq (1:32000), and Iran (1:39000). So far, only 12 mutations have been identified in Israeli Jews, and this enables the identification of 91% of the CF chromosomes in the entire Jewish CF population. However, in each Jewish ethnic group, the disease is caused by a different repertoire of mutations. The frequency of identified mutations is high in Ashkenazi Jews (95%), and in Jews originating from Tunisia (100%), Libya (91%), Turkey (90%), and Georgia (88%). However, a lower frequency of mutations can be identified in Moroccan (85%), Egyptian (50%), and Yemenite (0%) Jews. For genetic counseling of a Jewish individual, it is necessary to calculate the residual risk according to ethnic origin. Carrier screening of healthy Jewish individuals is currently feasible for Ashkenazi Tunisian, Libyan, Turkish, and Georgian Jews. These results provide the required information for genetic counseling of Jewish CF families and screening programs of Jewish populations worldwide.

Effect of prolonged use of inhaled steroids on the cellular immunity of children with asthma

BACKGROUND

Systemic corticosteroids may affect the cellular immunity, but there is no available controlled data on such effects associated with a prolonged use of inhaled corticosteroids.

OBJECTIVE

The investigation was designed to study the effect of long-term inhaled beclomethasone dipropionate in daily doses of up to 600 micrograms on cellular immune functions.

METHODS

Twenty-four children with asthma treated with inhaled beclomethasone dipropionate for a mean of 22.6 months were compared with 16 children with asthma not treated with an inhaled steroid and with 20 healthy adults. Cellular immune parameters included differential white blood count, T- and B-cell numbers, T helper and suppressor counts, T-cell mitogenic transformation, and interleukin-1 and interleukin-2 secretion.

RESULTS

There was no difference in any of the studied cellular immune functions among the three study groups.

CONCLUSION

Long-term use of inhaled beclomethasone dipropionate by children with asthma, at daily doses of up to 600 micrograms, has no effect on certain parameters of cellular immunity.

Angioedema following the intravenous administration of metoprolol

A 72-year-old woman was admitted to the hospital with "flash" pulmonary edema, preceded by chest pain, requiring intubation. Her medical history included coronary artery disease with previous myocardial infarctions, hypertension, and diabetes mellitus. A history of angioedema secondary to lisinopril therapy was elicited. Current medications did not include angiotensin-converting enzyme inhibitors or beta-blockers. She had no previous beta-blocking drug exposure. During the first day of hospitalization (while intubated), intravenous metoprolol was given, resulting in severe angioedema. The angioedema resolved after therapy with intravenous steroids and diphenhydramine hydrochloride.

Purine nucleotide modulation of complex assembly between the Drosophila caccc and dre, binding-proteins in ras2 regulation

Previous characterisation of the Drosophila ras2/rop bidirectional promoter regulatory mechanism revealed two DNA-binding protein factors. These were named DCF (Drosophila CACCC-binding Factor) and DREF (Drosophila Replication Related Element-binding Factor) respectively. A major protein complex consisting of these two transcription factors specifically binds the CACCC and DRE sites. In the present study we show that limited trypsin digestion of the major complex dissociates DCF and DREF, in the active conformation, able to bind the CACCC and DRE motifs. In addition, we show that DNA-binding activity of the DREF/DCF heterodimer is specifically inhibited by the presence of purine nucleotides, while that of the individual factors remains unaltered.

[Plasma cell granuloma of the chest and lung in childhood]

Plasma cell granuloma is a benign, non-neoplastic lesion rarely found in children. It occurs mainly in the chest and lungs, the right lung mostly. Most cases are asymptomatic and are discovered incidentally on routine chest X-ray, although there may have been atypical upper respiratory symptoms. The X-ray findings, as well as those of other imaging modalities, are nonspecific, making the exact localization and diagnosis of the lesion difficult, as demonstrated in the cases of 2 boys aged 8 and 9 years, respectively. Locating the right diaphragm and its relation to the large lesion by various imaging modalities was unreliable in 1 of the cases. The large, dense, firm, adherent lesions were carefully and completely resected in both cases. In 1 case it was located in the right lung, pulmonary hilum and mediastinum. In the other, in the right pleural space in the supradiaphragmatic region, adherent to the posterolateral aspect of the lower ribs. Biopsies for frozen section should always be taken before deciding on the extent of surgery. Radical resection of normal surrounding tissue should be avoided. Our cases have been followed for 2 and 3 years respectively, with no evidence of recurrence. Prognosis is excellent when lesions are completely removed.

Similar levels of mRNA from the W1282X and the delta F508 cystic fibrosis alleles, in nasal epithelial cells

The effect of nonsense mutations on mRNA levels is variable. The levels of some mRNAs are not affected and truncated proteins are produced, while the levels of others are severely decreased and null phenotypes are observed. The effect on mRNA levels is important for the understanding of phenotype-genotype association. Cystic fibrosis (CF) is a lethal autosomal recessive disease with variable clinical presentation. Recently, two CF patients with mild pulmonary disease carrying nonsense mutations (R553X, W1316X) were found to have severe deficiency of mRNA. In the Jewish Ashkenazi CF patient population, 60% of the chromosomes carry a nonsense mutation, W1282X. Patients homozygous for this mutation have severe disease presentation with variable pulmonary disease. The presence of CF transcripts in a group of patients homozygous and heterozygous for this mutation was studied by reverse transcriptase PCR of various regions of the gene. Subsequent hybridization to specific CF PCR probes and densitometry analysis indicated that the CF mRNA levels in patients homozygous for the W1282X mutation are not significantly decreased by the mutation. mRNA levels were compared for patients heterozygous for the W1282X mutation. The relative levels of mRNA with the W1282X, and the delta F508 or the normal alleles, were similar in each patient. These results indicate that the severe clinical phenotype of patients carrying the W1282X mutation is not due to a severe deficiency of mRNA. In addition, the severity, progression, and variability of the pulmonary disease are affected by other, as yet unknown factors.

Oral hypoglycemic agents in the treatment of type II diabetes

The cornerstones of therapy for non-insulin-dependent diabetes mellitus are patient education, dietary modification with weight loss, and regular exercise. If diet and exercise fail to control hyperglycemia, pharmacologic intervention is warranted. The sulfonylureas are the only hypoglycemic agents approved for use in the United States. Their hypoglycemic effect is achieved through stimulation of insulin secretion and reduction of insulin resistance in the peripheral tissues. Two classes of sulfonylureas are available. First-generation drugs, such as tolbutamide and tolazamide, are less expensive and less powerful than second-generation drugs, such as glipizide and glyburide.

Mild cystic fibrosis and normal or borderline sweat test in patients with the 3849 + 10 kb C-->T mutation

Different mutations in the cystic fibrosis (CF) gene appear to contribute to heterogeneity of the CF phenotype. We investigated 15 patients with CF who have the 3849 + 10 kb C-->T mutation. All were Ashkenazi Jews. Their clinical features were compared with those of CF patients with the delta F508/delta F508, W1282X/W1282X, W1282X/delta F508 mutations, which are known to be associated with a severe disease. Patients with the 3849 + 10 kb mutation were older, had been diagnosed as having CF at a more advanced age, and were in a better nutritional state. Sweat chloride values were normal (below 60 mmol/L) in 5 3849 + 10 kb patients (33%). 4 of these patients and 6 others (total 66%) had normal pancreatic function. However, age-adjusted pulmonary function did not differ between the two groups. None of the patients with 3849 + 10 kb C-->T had had meconium ileus or had liver disease or diabetes mellitus. We conclude that this mutation is associated with a mild type of CF.

Hospitalization of Jewish and Bedouin infants in southern Israel for bronchiolitis caused by respiratory syncytial virus

We conducted a prospective study to determine the clinical picture and impact of respiratory syncytial virus (RSV) on hospitalization for acute bronchiolitis of pediatric patients less than 2 years of age belonging to two different ethnic groups in Southern Israel: Jews and Bedouins. All patients younger than 2 years of age hospitalized for bronchiolitis during a typical RSV season were enrolled. During the study period 120 patients with bronchiolitis were hospitalized, and 83 (69%) were RSV-positive. Their age ranged from 20 days to 9 months. Fifty-five percent of all patients with RSV bronchiolitis were < or = 3 months old and 92% were < or = 6 months old. Patients with RSV bronchiolitis represented 18% of all hospitalized infants < or = 9 months old and 35% of all hospitalizations for respiratory problems of infants < or = 9 months old. The yearly incidence of hospitalization for RSV bronchiolitis was 5.4/1000 live births for Jews and 18/1000 live births for Bedouins. The total number of hospitalization days calculated for 1000 births was 32.1 for the Jews and 86.7 for the Bedouins. RSV has a serious impact on infant morbidity in Southern Israel.