A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

The effect of structured consent on recall of information pre- and post-electroconvulsive therapy: a pilot study

Aims and method

A randomised, blind comparison of a structured consent procedure against routine consent was conducted to determine whether it had any utility in improving treatment knowledge In patients receiving electroconvulsive therapy (ECT). Additionally we aimed to determine whether degree of cognitive impairment intelligence and severity of depression influenced recall of information.

Results

Thirty-two subjects were investigated. Structured consent significantly improved the number of knowledge items recalled pre-ECT (P<0.05). Knowledge scores declined significantly after completion of the treatment course in both structured consent (P<0.05) and control groups (P<0.06). There was a significant correlation between Mini-Mental State Examination (MMSE) scores and the number of knowledge items recalled both pre- (r=0.43, P<0.05) and post-ECT (r=0.53, P<0.01).

Clinical implications

Structured consent procedures may be a useful way of improving patient knowledge of ECT and merit further study. Low scores on MMSE should caution clinicians to take particular care when consenting patients to ECT.

Molecular analysis of novel PROP1 mutations associated with combined pituitary hormone deficiency (CPHD)

OBJECTIVE

Homozygous mutations in the gene encoding the pituitary transcription factor PROP1 are associated with combined pituitary hormone deficiency (CPHD) in both mice and humans with a highly variable phenotype with respect to the severity and time of initiation of pituitary hormone deficiency. We have ascertained three pedigrees with PROP1 mutations from a large cohort of patients with variable degrees of CPHD who were screened for mutations in PROP1.

RESULTS

Affected individuals from all three pedigrees were found to harbour novel PROP1 mutations. We have identified two siblings in one family who were homozygous for an intronic mutation (c.343-11C > G) that disrupts correct splicing resulting in the loss of exon 3 from the PROP1 transcript. Two siblings from a second, unrelated family are compound heterozygotes for two point mutations in the coding region, a missense mutation (p.R125W) that leads to impaired transcriptional activation, and a deletion of a single nucleotide (c.310delC) resulting in a frameshift and nonfunctional mutant protein. Additionally, we identified a homozygous deletion of the PROP1 locus in two patients born to consanguineous parents.

CONCLUSION

Mutations in PROP1 are a frequent cause of familial CPHD. We have described four novel mutations in PROP1 in 3 pedigrees, all resulting in PROP1 deficiency by different mechanisms. The phenotypic variation observed in association with PROP1 mutations both within and between families, together with the evolving nature of hormone deficiencies and sometimes changing pituitary morphology indicates a need for continual monitoring of these patients.

Expression of nephrin by human pancreatic islet endothelial cells

AIMS/HYPOTHESIS

The islet microcirculation has morphological characteristics resembling those of renal glomeruli. Transcription of the nephrin gene, a highly specific barrier protein of the slit diaphragm of podocyte foot processes, has been reported in the pancreas, although its cellular localisation and function remain to be defined. In this study, we purified and characterised microvascular endothelial cells (MECs) isolated from human islets and investigated the expression and distribution of nephrin on these cells.

METHODS

Human islet MECs were extracted and purified using anti-CD105-coated immunomagnetic beads and their endothelial characteristics were confirmed by expression of classical endothelial markers and basal high-level expression of intercellular adhesion molecule-1 and TNF-alpha-inducible vascular cell adhesion molecule-1. Nephrin expression was assessed by immunofluorescence, flow cytometric analysis and western blotting on cell lysates, as well as by RT-PCR.

RESULTS

Immunofluorescence studies detected nephrin in a fine, punctate, diffuse pattern on cultured islet MECs, and also in human pancreatic islet sections. In both cases nephrin colocalised with endothelial markers. TNF-alpha treatment induced a marked reduction and redistribution of the protein in one or multiple aggregates. Nephrin expression was confirmed by flow cytometry, western blotting and RT-PCR studies. In contrast, nephrin could not be detected at the protein or mRNA level in human macro- and microvascular cells from other sites.

CONCLUSIONS/INTERPRETATION

Nephrin is expressed at protein and mRNA levels in islet microendothelium, supporting the hypothesis that islet MECs exhibit distinctive morphological characteristics that indicate functional specialisation of potential pathophysiological importance.

Longitudinal sliding of the median nerve in patients with carpal tunnel syndrome

In nerve compression syndromes restricted nerve sliding may lead to increased strain, possibly contributing to symptoms. Ultrasound was used to examine longitudinal median nerve sliding in 17 carpal tunnel syndrome patients and 19 controls during metacarpophalangeal joint movement. Longitudinal movement in the forearm averaged 2.62 mm in controls and was not significantly reduced in carpal tunnel syndrome (CTS) patients (mean=2.20 mm). In contrast, CTS patients had a 40% reduction in transverse nerve movement at the wrist on the most, compared to least, affected side and nerve areas were enlarged by 34%. Normal longitudinal sliding in the patients indicates that nerve strain is not increased and will not contribute to symptoms.

Association studies of bipolar disorder

Association studies in outbred populations represent an important paradigm for investigation of complex traits, such as bipolar disorder, both to follow-up regions of interest from linkage studies (by systematic linkage disequilibrium mapping and positional candidate studies) and for pure functional studies. The advantages of the association method include its relative robustness to genetic heterogeneity and the ability to detect much smaller effect sizes than are detectable using feasible sample sizes in linkage studies. The candidate gene approach is potentially very powerful, particularly when used within the context of a VAPSE (variation affecting protein structure or expression) paradigm, but a major problem is that the efficiency in the choice of candidates is inevitably a function of the level of previous understanding of disease pathophysiology. To date, most candidate gene studies in bipolar disorder have focussed on the major neurotransmitter systems that are influenced by medication used in clinical management of the disorder. Early studies often used anonymous markers in the hope of detecting linkage disequilibrium but recently direct examination of polymorphisms of known or presumed functional relevance has become more usual. Most studies in the literature have been of the unrelated case-control design with samples rarely exceeding 200-300 subjects. No definitive findings have yet emerged although there have been some interesting preliminary findings including those with polymorphisms within the genes encoding catechol-o-methyl transferase (COMT), monoamine oxidase A (MAOA) and the serotonin transporter (hSERT; 5-HTT). In this article we critically review the current status of the literature within the context of the important methodological issues and limitations inherent in the use of association studies for genetic dissection of bipolar disorder. We conclude by examining likely future directions and developments in the field.

The use of ultrasound imaging to demonstrate reduced movement of the median nerve during wrist flexion in patients with non-specific arm pain

Following clinical screening, we examined movement of the median nerve at the wrist using high-resolution (10-22 MHz) ultrasound in 16 controls and 12 patients with non-specific arm pain (also referred to as repetitive strain injury). Imaging was performed just proximal to the carpal tunnel with the wrist in neutral, 30 degrees of extension and 30 degrees of flexion. In control subjects the position of the median nerve was 4.8 (SE=0.4) mm more radial with the wrist flexed than with the wrist extended. In the twelve arm pain patients the average change was only 1.2 (SE=0.5) mm. It appears that ultrasound imaging may be helpful in diagnosing non-specific arm pain, a condition for which there are no well-defined diagnostic tests at present. The reduced nerve movement seen with ultrasound imaging confirms previous work with magnetic resonance imaging.

The use of cross-correlation analysis between high-frequency ultrasound images to measure longitudinal median nerve movement

Impaired nerve movement can lead to nerve injury (e.g., carpal tunnel syndrome). A noninvasive method to measure nerve movement in longitudinal section would enable an extensive analysis of nerve entrapment syndromes. A method has been developed using cross-correlation between successive high-frequency ultrasound (US) images to measure longitudinal movement of nerve and muscle. Control "phantom" experiments demonstrated the accuracy and reliability of this method at velocities of 1-10 mm/s. Increasing the frame interval between the compared frames enabled the accurate calculation of slower velocities. The correlation algorithm successfully measured relative movement when the US transducer was moved 1-3 mm over the surface of the forearm. Median nerve movement was repeatedly measured in the forearm during 30 degrees passive wrist extension in three subjects (range 2.63-4.12 mm) and index finger extension in seven subjects (range 1.59-4.48 mm). Median nerve movement values were consistent with those from cadaver studies.

Reduced movement of median nerve in carpal tunnel during wrist flexion in patients with non-specific arm pain

Magnetic resonance scans on patients with non-specific arm pain (repetitive strain injury) show reduced median-nerve movement in the carpal tunnel, suggesting that this common condition may involve nerve entrapment.

Vibration sense in the upper limb in patients with repetitive strain injury and a group of at-risk office workers

OBJECTIVES

To investigate in patients with repetitive strain injury (RSI) and in office workers using computer keyboard equipment (a) whether the vibration threshold in the hand was altered, (b) the immediate effects of keyboard use on vibration thresholds and (c) whether the tolerance of suprathreshold vibration was normal.

METHOD

A vibrametre (Somedic Ab, Stockholm Sweden) was used to obtain threshold vibration measurements, by the method of limits, for all peripheral-nerve cutaneous distributions in the hand. Tolerance of suprathreshold stimulation was obtained by stimulation of the soft tissues of the forearm by increasing the amplitude of vibration.

RESULTS

Thresholds for vibration were significantly raised for the median nerve in both the patient and office-worker groups. The patient group additionally had raised thresholds for the ulnar nerve. Following use of the keyboard, thresholds for the median nerve were further elevated in the patient group, but not in the other groups, demonstrating a work-related exacerbation. At suprathreshold stimulation. 14 members (82%) of the patient group experienced an allodynic response to vibration, indicating, possible changes in the central processing of non-noxious sensory information. This changed sensory response was not seen in either the office-worker or control groups.

CONCLUSION

Patients may have a minor polyneuropathy, whereas the office workers demonstrate early signs of the condition. Quantitative measurement of vibration perception may prove useful in patient assessment and for detection of the early onset of RSI in the work environment.