Seema Khan

Background Tofacitinib (CP-690,550) is a novel Janus kinase inhibitor in development as an oral formulation for the treatment of several inflammatory diseases including psoriasis. Objectives This phase 2a study aimed to assess the efficacy, systemic safety, local tolerability and systemic pharmacokinetics of topical tofacitinib in mild-to-moderate plaque psoriasis. Methods Two tofacitinib ointment formulations were evaluated in this multicentre, double-blind, vehicle-controlled trial (NCT01246583). Seventy-one patients were randomized 2 : 1 : 2 : 1 to 2% tofacitinib ointment 1, vehicle 1, 2% tofacitinib ointment 2 and vehicle 2, each administered twice daily for 4 weeks to a single fixed 300 cm2 treatment area containing a target plaque with or without one or more nontarget plaques and normal skin. Results The primary endpoint of percentage change from baseline in the Target Plaque Severity Score at week 4 demonstrated statistically significant improvement for ointment 1 [least squares mean (LSM) –54·4%] vs. vehicle 1 (LSM –41·5%), but not ointment 2 (LSM –24·2%) vs. vehicle 2 (LSM –17·2%). Secondary endpoints (target plaque area and Itch Severity Item) improved similarly for tofacitinib ointment vs. corresponding vehicle. Adverse event (AE) occurrence was similar across treatment groups. All AEs were mild or moderate and none were serious or led to subject discontinuation. One application-site AE (erythema) was reported. Tofacitinib mean systemic exposure was minimal and was greater for ointment 1 than for ointment 2. Conclusions Tofacitinib ointment 1 was well tolerated and efficacious compared with vehicle for the treatment of plaque psoriasis. Further study of topical tofacitinib for psoriasis treatment is warranted.

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis may play a role in panic disorder. HPA studies in patients with panic disorder, however, have produced inconsistent results. Seeking to understand the inconsistencies, we reexamined endocrine data from four studies of patients with panic disorder, in light of animal data highlighting the salience of novelty, control, and social support to HPA axis activity. Patients with panic disorder were studied (1) at rest over a full circadian cycle, (2) before and after activation by a panicogenic respiratory stimulant (doxapram) that does not directly stimulate the HPA axis, and (3) before and after a cholecystokinin B (CCK-B) agonist that is panicogenic and does directly stimulate the HPA axis. Patients with panic disorder had elevated overnight cortisol levels, which correlated with sleep disruption. ACTH and cortisol levels were higher in a challenge paradigm (doxapram) than in a resting state study, and paradigm-related ACTH secretion was exaggerated in patients with panic disorder. Panic itself could be elicited without HPA axis activation. Patients with panic disorder showed an exaggerated ACTH response to pentagastrin stimulation, but this response was normalized by prior exposure to the experimental context or psychological preparation to reduce novelty and enhance sense of control. Novelty is one of a number of contextual cues known from animal work to activate the HPA axis. The HPA axis abnormalities seen in patients with panic disorder in the four experiments reviewed here might all be due to exaggerated HPA axis reactivity to novelty cues. Most of the published panic/HPA literature is consistent with the hypothesis that HPA axis dysregulation in panic is due to hypersensitivity to contextual cues. This hypothesis requires experimental testing.

Exaggerated acoustic startle is a prominent symptom of post-traumatic stress disorder (PTSD); however, its physiological basis is not well understood, and there are few available treatments. Neurobiological research has suggested that anti-kindling agents and/or glutamate antagonists can attenuate the acoustic startle response (ASR) in animal models. The anticonvulsant topiramate is an AMPA antagonist that also demonstrates potent anti-kindling effects and may, therefore, have promise in treating trauma-enhanced ASR.To evaluate the ability of topiramate to attenuate stress-induced increases in ASR in a previously validated animal model of PTSD.Male Sprague-Dawley rats ( n=36) served as controls or received single prolonged stress (SPS). SPS consisted of 2 h restraint, forced swim and ether anesthesia, then a 7-day "undisturbed" period. Animals then received vehicle, 10 mg/kg or 30 mg/kg of topiramate orally, twice daily for 7 days. ASR was assessed for all animals before and after the study, in light and dark environments.SPS produced a sustained increase in the ASR in both environments, an effect that was significantly reduced by topiramate. Meanwhile the ASR of control animals remained unaffected by topiramate.The current results provide one of the few demonstrations of a single stress episode producing sustained enhancement of ASR. In addition, topiramate demonstrates promise in treating exaggerated acoustic startle symptoms in PTSD or other stress-related disorders.

Structures of the amino-terminal region of inositol-1,4,5-trisphosphate receptor 1 with and without InsP3 bound reveal two discrete interfaces between the InsP3-binding core and suppressor domain that are similar to and functionally interchangeable with those in the equivalent domains of ryanodine receptor 1. Almost all known responses to the stimuli that evoke Ca2+ release from intracellular stores are mediated by two families of intracellular Ca2+ channels: inositol-1,4,5-trisphosphate receptors (InsP3Rs) and ryanodine receptors (RyRs). The structures of the amino-terminal region of InsP3R1 have now been determined with and without IP3 bound. Two discrete inter-domain interfaces are present, a feature also seen in a previously published structure of RyR1. The physiological importance of one of these interfaces was confirmed by mutagenesis. This work has implications for the study of known disease-causing mutations in ryanodine receptors. Inositol-1,4,5-trisphosphate receptors (InsP3Rs) and ryanodine receptors (RyRs) are tetrameric intracellular Ca2+ channels1. In each of these receptor families, the pore, which is formed by carboxy-terminal transmembrane domains, is regulated by signals that are detected by large cytosolic structures. InsP3R gating is initiated by InsP3 binding to the InsP3-binding core (IBC, residues 224–604 of InsP3R1)2 and it requires the suppressor domain (SD, residues 1–223 of InsP3R1)2,3,4,5,6,7,8. Here we present structures of the amino-terminal region (NT, residues 1–604) of rat InsP3R1 with (3.6 Å) and without (3.0 Å) InsP3 bound. The arrangement of the three NT domains, SD, IBC-β and IBC-α, identifies two discrete interfaces (α and β) between the IBC and SD. Similar interfaces occur between equivalent domains (A, B and C) in RyR1 (ref. 9). The orientations of the three domains when docked into a tetrameric structure of InsP3R10 and of the ABC domains docked into RyR9 are remarkably similar. The importance of the α-interface for activation of InsP3R and RyR is confirmed by mutagenesis and, for RyR, by disease-causing mutations9,11,12. Binding of InsP3 causes partial closure of the clam-like IBC, disrupting the β-interface and pulling the SD towards the IBC. This reorients an exposed SD loop (‘hotspot’ (HS) loop) that is essential for InsP3R activation7. The loop is conserved in RyR and includes mutations that are associated with malignant hyperthermia and central core disease9,11,12. The HS loop interacts with an adjacent NT, suggesting that activation re-arranges inter-subunit interactions. The A domain of RyR functionally replaced the SD in full-length InsP3R, and an InsP3R in which its C-terminal transmembrane region was replaced by that from RyR1 was gated by InsP3 and blocked by ryanodine. Activation mechanisms are conserved between InsP3R and RyR. Allosteric modulation of two similar domain interfaces within an N-terminal subunit reorients the first domain (SD or A domain), allowing it, through interactions of the second domain of an adjacent subunit (IBC-β or B domain), to gate the pore.

There is considerable anecdotal and some scientific evidence that stress triggers eating behavior, but underlying physiological mechanisms remain uncertain. The hypothalamic-pituitary-adrenal (HPA) axis is a key mediator of physiological stress responses and may play a role in the link between stress and food intake. Cortisol responses to laboratory stressors predict consumption but it is unclear whether such responses mark a vulnerability to stress-related eating or whether cortisol directly stimulates eating in humans.We infused healthy adults with corticotropin-releasing hormone (CRH) at a dose that is subjectively undetectable but elicits a robust endogenous cortisol response, and measured subsequent intake of snack foods, allowing analysis of HPA reactivity effects on food intake without the complex psychological effects of a stress paradigm.CRH elevated cortisol levels relative to placebo but did not impact subjective anxious distress. Subjects ate more following CRH than following placebo and peak cortisol response to CRH was strongly related to both caloric intake and total consumption.These data show that HPA axis reactivity to pharmacological stimulation predicts subsequent food intake and suggest that cortisol itself may directly stimulate food consumption in humans. Understanding the physiological mechanisms that underlie stress-related eating may prove useful in efforts to attack the public health crises created by obesity.

Eosinophilic gastroenteritis despite its uncommon occurrence is one of the most important primary eosinophilic gastrointestinal disorders, and most commonly presents with abdominal pain. The terminology is, however, misleading because all levels of the gastrointestinal tract from the esophagus to the rectum may be affected. A history of atopy and allergies is present in 25-75% cases. The heterogeneity in the clinical presentations of EG is determined by the site and depth of eosinophilic infiltration. Eosinophilic intestinal inflammation also occurs secondarily in the gastrointestinal tract in inflammatory bowel disease, autoimmune diseases, as reactions to medications, infections, hypereosinophilia syndrome, and after solid organ transplantation. Recent investigations providing an insight into the pathogenesis of eosinophilic gastroenteritis support a critical role for allergens, eosinophils, Th-2 type cytokines, and eotaxin in mediating eosinophilic inflammation. The diagnosis is confirmed by demonstrating prominent tissue eosinophilia on histopathology. Treatment recommendations based on data extrapolated from retrospective, uncontrolled studies, and expert opinion support the use of restricted diets, corticosteroids, leukotriene receptor antagonists, and mast cell stabilizers. Many unanswered questions remain with regard to the natural history, optimal duration of therapy, safer steroid-sparing long-term treatment agents, and the means of reliable and non-invasive follow-up.

In the pediatric population, gastroesophageal reflux most often presents in infancy as effortless regurgitation, but pathologic GERD is accompanied by signs of malnutrition, respiratory diseases, and esophagitis or its complications. Because of the distinctive pathophysiology predisposing infants to GERD, the diagnostic approach must begin with a thorough history that determines the extent of further diagnostic tests and the course of management. Empiric therapy assumes importance in infants with GERD because of the limited differential diagnoses in consideration. Conservative therapy is of utmost importance because of the unique provocative factors in the pathophysiology of infantile GERD. Prokinetic pharmacotherapy takes precedence over acid suppression because of the more important role of motility factors compared with acid secretion in infantile GERD.

Eosinophilic gastroenteritis is an infrequently diagnosed condition that is characterized by prominent eosinophilic infiltration of the stomach or small intestine, generally localized to one level of the intestinal wall; the variable organ locus and wall depth produce heterogeneous clinical presentations. A strong association with atopy is present in most cases, supported by circumstantial evidence and the demonstration of Th-2 proinflammatory cytokine profiles in animal studies. A high degree of suspicion is required to establish the diagnosis, which must be based on intense gastrointestinal eosinophilia. Management is directed toward removal of offending allergens and use of anti-inflammatory agents. Novel and emerging treatments on the horizon are biologic therapies and selective anti-eosinophil agents.

To evaluate the clinical presentation and to assess the usefulness of antroduodenal manometry (ADM) and the results of multidisciplinary team management in 12 neurologically normal adolescents (9 girls) with rumination.All patients had extensive investigations that ruled out other causes of their chronic symptoms. We performed ADM in all patients. A multidisciplinary approach was used for the nutritional and behavioral rehabilitation of these patients.The median age at presentation was 14 years (range, 9-19 years), and the average duration of symptoms was 17 months. All patients complained of postprandial, effortless regurgitation, and the majority had weight loss and abdominal pain. Results of fasting ADM were normal in all. The postprandial ADM showed brief, simultaneous pressure increases at all recording sites, associated with regurgitation in 8 patients. No emesis was observed in the other 4 children during the study. Treatment included nutritional support in combination with antidepressants and anxiolytics (n = 6), cognitive therapy with biofeedback or relaxation techniques (n = 7), and pain management (n = 2). Resolution or improvement of symptoms was seen in 10 of the 12 patients, and successful transition to oral feedings was achieved in all during the follow-up period, which ranged from 5 to 36 months.Rumination is a distinct functional gastrointestinal disorder of otherwise healthy children and adolescents, which can be diagnosed on the basis of clinical features. The ADM shows a characteristic pattern and rules out motility disorders that are often confused with rumination. A multidisciplinary team approach is associated with satisfactory recovery in most patients.

Abstract The brain corticotropin‐releasing hormone (CRH) circuits are activated by stressful stimuli, contributing to behavioral and emotional responses. The present study assessed anxiety‐like responses and in vivo neurochemical alterations at the central nucleus of the amygdala (CeA) evoked by exposure to an unfamiliar (anxiogenic) environment. Also, the impact of anxiolytic treatments and those that affect CRH were assessed in this paradigm. Novel environment (new cage) markedly suppressed ingestion of a palatable snack. This effect was dose‐dependently antagonized by diazepam and was utilized as an index of anxiety in the rodent. Although exposure to a novel environment also stimulated the in vivo release of CRH and glutamate at the CeA, various CRH antagonists (e.g. αh‐CRH, Cα‐MeCRH, CP‐154,526, antisauvagine‐30, preproTRH178‐199) did not attenuate the stressor‐elicited behavioral suppression, although Cα‐MeCRH was found to attenuate the freezing response elicited by contextual stimuli that were associated with previously administered footshock. Moreover, central infusion of CRH failed to suppress snack consumption in the home cage. Although diazepam had potent anxiolytic effects in this paradigm, this treatment did not prevent the stressor‐associated release of CRH and glutamate at the CeA. Thus, while neural circuits involving CRH and/or glutamatergic receptors at the CeA may be activated by an unfamiliar environment, the data challenge the view that activation of these receptors is necessary for the expression of anxiety‐like behavioral responses. Rather than provoking anxiety, these systems might serve to draw attention to events or cues of biological significance, including those posing a threat to survival.

The hypothalamic-pituitary-adrenal (HPA) axis may mediate the deleterious effects of stress on health. It is sensitive to cognitive and emotional aspects of organism-environment interactions, such as familiarity, control, and social support. Scientific study of how such factors moderate human HPA axis activity has been limited. Their relevance to HPA axis disturbances in psychiatric patients is largely unexplored.To determine whether cognitive manipulation can alter HPA axis activity in laboratory studies and whether patients with panic disorder are differentially sensitive to the manipulated factors.Pharmacological activation paradigm (cholecystokinin-B agonist pentagastrin) by which we examined symptom and endocrine effects on subjects randomly assigned to a standard introduction or a cognitive intervention.Clinical research center.Recruited from university clinic and newspaper advertisements. Fourteen patients with panic disorder and 14 controls, individually matched for age and sex. Intervention Half of each group received a 9-minute cognitive intervention designed to reduce novelty, increase cognitive coping, and provide a sense of control.Corticotropin (ACTH) and cortisol levels.The cognitive intervention significantly reduced cortisol (P = .02) and ACTH (P = .01) levels, despite pentagastrin's robust stimulation of both hormones (P<.001). The intervention effect was evident in patients and controls, who did not differ in basal HPA axis activity or response to pentagastrin. They did differ in panic symptom responses, which were unaffected by the intervention, and in ACTH effects of the intervention. Patients' exaggerated anxiety responses to pentagastrin were normalized by the intervention.Cognitive/emotional manipulation can substantially modulate HPA axis responses to pharmacological activation in humans, and HPA disturbances in panic disorder may be secondary to manipulable cognitive/emotional sensitivities. Further study of such factors as novelty, control, and coping may help clarify the origins of HPA axis disturbance in psychiatric disorders and the mediators linking psychosocial stress to disease.

Background The hypothalamic-pituitary-adrenal (HPA) axis may mediate negative health effects of stress. It is sensitive to cognitive/emotional factors like novelty, perceived control, and coping. Psychological intervention that reduces novelty and enhances cognitive coping and sense of control can reduce cortisol responses to pentagastrin, a pharmacological HPA activator. This study attempted to identify the core factors that modulate HPA axis activity in this model. Methods Varying instructions were administered prior to drug exposure in a two-visit (placebo first) pentagastrin infusion paradigm. Healthy subjects (n = 40) were randomly assigned to one of four instruction groups: 1) standard instruction (SI); 2) full cognitive intervention (CI); 3) the CI control component alone; or 4) the CI novelty reduction/coping components alone. Blood samples were obtained via intravenous catheter before and after pentagastrin. Results Subjects receiving an intervention had smaller cortisol responses than subjects receiving standard instructions. Coping alone had as strong an impact as the more complex intervention that combined coping and control. Control alone also reduced cortisol but its HPA impact appeared less robust. Conclusions Brief psychological manipulation can significantly reduce HPA activation in challenge paradigms. Cognitive preparation that focused on side effects, reduced potential surprise, and enhanced cognitive coping modulated HPA axis activity as effectively as a previously tested intervention that combined coping and control manipulations. A sense of control alone also reduced cortisol release. The results support development of control or coping techniques to combat negative health effects of stress that are mediated by HPA axis activation. The hypothalamic-pituitary-adrenal (HPA) axis may mediate negative health effects of stress. It is sensitive to cognitive/emotional factors like novelty, perceived control, and coping. Psychological intervention that reduces novelty and enhances cognitive coping and sense of control can reduce cortisol responses to pentagastrin, a pharmacological HPA activator. This study attempted to identify the core factors that modulate HPA axis activity in this model. Varying instructions were administered prior to drug exposure in a two-visit (placebo first) pentagastrin infusion paradigm. Healthy subjects (n = 40) were randomly assigned to one of four instruction groups: 1) standard instruction (SI); 2) full cognitive intervention (CI); 3) the CI control component alone; or 4) the CI novelty reduction/coping components alone. Blood samples were obtained via intravenous catheter before and after pentagastrin. Subjects receiving an intervention had smaller cortisol responses than subjects receiving standard instructions. Coping alone had as strong an impact as the more complex intervention that combined coping and control. Control alone also reduced cortisol but its HPA impact appeared less robust. Brief psychological manipulation can significantly reduce HPA activation in challenge paradigms. Cognitive preparation that focused on side effects, reduced potential surprise, and enhanced cognitive coping modulated HPA axis activity as effectively as a previously tested intervention that combined coping and control manipulations. A sense of control alone also reduced cortisol release. The results support development of control or coping techniques to combat negative health effects of stress that are mediated by HPA axis activation.

Given clear connections between respiratory distress and subjective anxiety, it is not surprising that respiratory psychophysiologists have been interested in the psychobiology of anxiety. Given parallel links between anxiety and stress, it is not surprising that the hypothalamic-pituitary adrenal (HPA) stress system has also been a focus in anxiety research. However, despite extensive work in respiratory psychophysiology and stress neuroendocrinology--and evidence that these systems are jointly dysregulated in anxiety disorders--direct studies of their interactions are rare. This paper reviews evidence for scientific intersections, providing an overview of the HPA axis, its psychobiology, and shared neural substrates for HPA and respiratory control. We examine HPA hormone effects on respiration, immune/inflammatory mediators, and lung maturation. We also examine respiratory/dyspnea effects on HPA axis. There are clear points of intersection in the neuroscience of respiration and stress. Given the importance of both systems to an organism's ability to survive and adapt in challenging and changing environments, further study of their interactions is needed.

Medullary carcinoma of the thyroid (MTC) is a rare neuroendocrine tumour (NET) that expresses somatostatin receptors on the cell membrane and secretes calcitonin. Surgery is the primary curative modality but is achieved only when the diagnosis is timely so there is a high rate of persistent and recurrent disease indicated by a rise in the serum calcitonin levels. Successful management of recurrent disease requires accurate localisation with cross sectional and functional imaging. The introduction of gallium-68-Dotatate ((68)Ga-Dotatate) peptides positron emission tomography/computerized tomography (PET/CT) has significantly improved the detection of NET and has been reported as a valuable adjunct in MTC localisation. We retrospectively reviewed our cases of MTC to correlate the detectability of (68)Ga-Dotatate in relation to calcitonin levels and assess suitability of inoperable patients for peptide receptor radionuclide therapy (PRRT).Seven patients (age range 31-66 years, M:F 3:4) with raised calcitonin (mean=7,143pg/mL) were referred for (68)Ga-Dotatate PET/CT scan for localisation of persisting recurrent MTC. Six patients were known to have MTC treated with thyroidectomy and one patient was presenting for the first time. All patients had multiple imaging including ultrasound (US), CT, magnetic resonance imaging (MRI), fluorine-18-fluorodeoxyglucose ((18)F-FDG) PET/CT and iodine-123-metaiodobenzylguanidine ((123)I-MIBG). Positive findings were defined as areas of increased uptake other than the organs of normal distribution and were correlated with results of biopsies, other imaging, long term monitoring of calcitonin and clinical follow up.In 6/7 patients with very high serum calcitonin (range= 672-37,180, mean=8,320pg/mL) (68)Ga-Dotatate PET/CT confirmed the presence of active disease seen on other modalities or detected hitherto unsuspected lesions. In at least 3 cases, (68)Ga-Dotatate PET/CT showed many more lesions compared to other imaging combined. In 1/7 patient (68)Ga-Dotatate PET/CT was negative in line with a relatively low calcitonin level (80pg/mL) and negative disease on fine needle aspiration.(68)Ga-Dotatate PET/CT is an effective tool for localising metastatic spread of MTC. It appears to be most effective in the presence of higher levels of serum calcitonin, probably in excess of 500pg/mL. The results of our small cohort had an impact on staging and management with the introduction of peptide receptor radionuclide therapy for inoperable disease.

Abstract Background Mosaic chromosomal alterations (mCAs) are large chromosomal gains, losses and copy-neutral losses of heterozygosity (LOH) in peripheral leukocytes. While many individuals with detectable mCAs have no notable adverse outcomes, mCA-associated gene dosage alterations as well as clonal expansion of mutated leukocyte clones could increase susceptibility to disease. Results We performed a phenome-wide association study (PheWAS) using existing data from 482,396 UK Biobank (UKBB) participants to investigate potential associations between mCAs and incident disease. Of the 1290 ICD codes we examined, our adjusted analysis identified a total of 50 incident disease outcomes associated with mCAs at PheWAS significance levels. We observed striking differences in the diseases associated with each type of alteration, with autosomal mCAs most associated with increased hematologic malignancies, incident infections and possibly cancer therapy-related conditions. Alterations of chromosome X were associated with increased lymphoid leukemia risk and, mCAs of chromosome Y were linked to potential reduced metabolic disease risk. Conclusions Our findings demonstrate that a wide range of diseases are potential sequelae of mCAs and highlight the critical importance of careful covariate adjustment in mCA disease association studies.

Ewing sarcoma (EwS) is a rare bone and soft tissue malignancy driven by chromosomal translocations encoding chimeric transcription factors, such as EWSR1-FLI1, that bind GGAA motifs forming novel enhancers that alter nearby expression. We propose that germline microsatellite variation at the 6p25.1 EwS susceptibility locus could impact downstream gene expression and EwS biology. We performed targeted long-read sequencing of EwS blood DNA to characterize variation and genomic features important for EWSR1-FLI1 binding. We identified 50 microsatellite alleles at 6p25.1 and observed that EwS-affected individuals had longer alleles (>135 bp) with more GGAA repeats. The 6p25.1 GGAA microsatellite showed chromatin features of an EWSR1-FLI1 enhancer and regulated expression of RREB1, a transcription factor associated with RAS/MAPK signaling. RREB1 knockdown reduced proliferation and clonogenic potential and reduced expression of cell cycle and DNA replication genes. Our integrative analysis at 6p25.1 details increased binding of longer GGAA microsatellite alleles with acquired EWSR-FLI1 to promote Ewing sarcomagenesis by RREB1-mediated proliferation.

IP(3)R (IP(3) [inositol 1,4,5-trisphosphate] receptors) and ryanodine receptors are the most widely expressed intracellular Ca(2+) channels and both are regulated by thiol reagents. In DT40 cells stably expressing single subtypes of mammalian IP(3)R, low concentrations of thimerosal (also known as thiomersal), which oxidizes thiols to form a thiomercurylethyl complex, increased the sensitivity of IP(3)-evoked Ca(2+) release via IP(3)R1 and IP(3)R2, but inhibited IP(3)R3. Activation of IP(3)R is initiated by IP(3) binding to the IBC (IP(3)-binding core; residues 224-604) and proceeds via re-arrangement of an interface between the IBC and SD (suppressor domain; residues 1-223). Thimerosal (100 μM) stimulated IP(3) binding to the isolated NT (N-terminal; residues 1-604) of IP(3)R1 and IP(3)R2, but not to that of IP(3)R3. Binding of a competitive antagonist (heparin) or partial agonist (dimeric-IP(3)) to NT1 was unaffected by thiomersal, suggesting that the effect of thimerosal is specifically related to IP(3)R activation. IP(3) binding to NT1 in which all cysteine residues were replaced by alanine was insensitive to thimerosal, so too were NT1 in which cysteine residues were replaced in either the SD or IBC. This demonstrates that thimerosal interacts directly with cysteine in both the SD and IBC. Chimaeric proteins in which the SD of the IP(3)R was replaced by the structurally related A domain of a ryanodine receptor were functional, but thimerosal inhibited both IP(3) binding to the chimaeric NT and IP(3)-evoked Ca(2+) release from the chimaeric IP(3)R. This is the first systematic analysis of the effects of a thiol reagent on each IP(3)R subtype. We conclude that thimerosal selectively sensitizes IP(3)R1 and IP(3)R2 to IP(3) by modifying cysteine residues within both the SD and IBC and thereby stabilizing an active conformation of the receptor.

Abstract Background: Monitoring for acute allograft rejection improves outcomes after cardiac transplantation. Endomyocardial biopsy is the gold standard test defining rejection, but carries risk and has limitations. Cardiac magnetic resonance T2 mapping may be able to predict rejection in adults, but has not been studied in children. Our aim was to evaluate T2 mapping in identifying paediatric cardiac transplant patients with acute rejection. Methods: Eleven paediatric transplant patients presenting 18 times were prospectively enrolled for non-contrast cardiac magnetic resonance at 1.5 T followed by endomyocardial biopsy. Imaging included volumetry, flow, and T2 mapping. Regions of interest were manually selected on the T2 maps using the middle-third technique in the left ventricular septal and lateral wall in a short-axis and four-chamber slice. Mean and maximum T2 values were compared with Student’s t-tests analysis. Results: Five cases of acute rejection were identified in three patients, including two cases of grade 2R on biopsy and three cases of negative biopsy treated for clinical symptoms attributed to rejection (new arrhythmia, decreased exercise capacity). A monotonic trend between increasing T2 values and higher biopsy grades was observed: grade 0R T2 53.4 ± 3 ms, grade 1R T2 54.5 ms ± 3 ms, grade 2R T2 61.3 ± 1 ms. The five rejection cases had significantly higher mean T2 values compared to cases without rejection (58.3 ± 4 ms versus 53 ± 2 ms, p = 0.001). Conclusions: Cardiac magnetic resonance with quantitative T2 mapping may offer a non-invasive method for screening paediatric cardiac transplant patients for acute allograft rejection. More data are needed to understand the relationship between T2 and rejection in children.

Exposure to intense noise can trigger a cascade of neuroendocrine events reminiscent of a stress response, including activation of the hypothalamic-pituitary-adrenocortical (HPA) axis. Using male Fischer and Lewis rats, which exhibit differences in their corticosterone response to stressors, this investigation assessed effects of acute noise exposure on neurochemical and neuroendocrine responses. In response to the noise exposure, Fischer rats displayed greater plasma adrenocorticotropin-releasing hormone (ACTH) and corticosterone responses than their Lewis counterparts. However, both strains responded with similar increases of plasma prolactin, suggesting that strain differences in the HPA response were not likely because of differences in noise perception. Post-mortem analyses revealed that noise exposure induced strain-dependent variations of corticotropin-releasing hormone (CRH) across several brain regions. These effects were evident irrespective of whether the rats were noise exposed in a familiar (home cage) or unfamiliar environment. In vivo, dynamic assessment of immunoreactive (ir)-CRH at the pituitary gland revealed that noise exposure elicited an immediate rise in ir-CRH among Fischer rats, relative to the delayed response in Lewis rats. Similarly, the rise in local interstitial corticosterone was more rapid and pronounced in Fischer rats. In contrast to these differences, ir-CRH released at the central nucleus of the amygdala (CeA) was gradual and protracted following noise exposure in both strains. Behaviorally, the Fischer rats displayed an active stress response, whereas the Lewis strain adopted freezing as a defensive style. The role of CRH in the genesis of the overall strain-dependent response to stressors is discussed.

Dysregulation within both respiratory control systems and the hypothalamic-pituitary adrenal (HPA) axis has been implicated in the pathophysiological of panic disorder. However, potential linkages between respiration and the HPA axis have rarely been examined in panic patients. We have previously published neuroendocrine and psychophysiological response data from a laboratory panic model using the respiratory stimulant doxapram. We now present a new, theoretically driven re-examination of linkages between HPA axis and respiratory measures in this model. Previous analyses showed elevated corticotropin (ACTH) and persistent tidal volume irregularity in panic patients, due to a high frequency of sighs. Regression analyses now show that tidal volume irregularity and sigh frequency were strongly predicted by pre-challenge ACTH levels, but not by subjective distress or panic symptoms. We predicted this relationship on the basis of our hypothesis that both the HPA axis and respiratory control systems may be reactive to contextual cues such as novelty or anticipation of future challenge. Follow-up work is needed to directly test this hypothesis.

In ischemic preconditioning, prior exposure to a short 3-min global ischemia provides substantial protection against the deleterious effects of a subsequent prolonged ischemic insult in rats. The objective of the present study was to determine if the neuronal protection induced by ischemic preconditioning influence functional recovery following a 6-min ischemic insult in rats. Animals received either sham-operation, a 3-min ischemia, a preconditioning 3-min global ischemia followed 3 days later by a 6-min global ischemia or a single 6-min global ischemia. Open field habituation, memory performance in the 8-arm radial maze and object recognition were assessed at different intervals following ischemia. Our findings revealed that preconditioning reversed ischemia-induced spatial memory deficits in the 8-arm radial maze, as suggested by significant reduction of working memory errors in preconditioned as compared to ischemic animals. Preconditioning also attenuated ischemia-induced object recognition deficits at short-term intervals. Nonetheless, preconditioning failed to alter ischemia-induced hyperactivity as demonstrated by enhanced behavioral activity in the open field in both preconditioned and ischemic animals compared to 3-min ischemic and sham-operated rats. CA1 cell counts revealed significant neuronal sparing in preconditioned animals that was observed 6-month following reperfusion. Together, these findings suggest that neuronal survival in preconditioned rats is associated with significant improvements of hippocampal-dependent memory functions and, further support that ischemia-induced hyperactivity may not solely depend on selective neuronal damage to hippocampal neurons.

Age-related male Y and female X chromosome mosaicism is commonly observed in large population-based studies. To investigate the frequency of male X chromosome mosaicism, we scanned for deviations in chromosome X genotyping array intensity data in a population-based survey of 196,219 UK Biobank men. We detected 12 (0.006%) men with mosaic chromosome X gains ≥ 2 Mb and found no evidence for mosaic chromosome X loss, a level of detection substantially lower than for autosomes or other sex chromosomes. The rarity of chromosome X mosaicism in males relative to females reflects the importance of chromosome X gene dosage for leukocyte function.

Most patients with heart failure (HF) are diagnosed following a hospital admission. The clinical and health economic impacts of index HF diagnosis made on admission to hospital versus community settings are not known.We used the North West London Discover database to examine 34 208 patients receiving an index diagnosis of HF between January 2015 and December 2020. A propensity score-matched (PSM) cohort was identified to adjust for differences in socioeconomic status, cardiovascular risk and pre-diagnosis health resource utilisation cost. Outcomes were stratified by two pathways to index HF diagnosis: a 'hospital pathway' was defined by diagnosis following hospital admission; and a 'community pathway' by diagnosis via a general practitioner or outpatient services. The primary clinical and health economic endpoints were all-cause mortality and cost-consequence differential, respectively.The diagnosis of HF was via hospital pathway in 68% (23 273) of patients. The PSM cohort included 17 174 patients (8582 per group) and was matched across all selected confounders (p>0.05). The ratio of deaths per person-months at 24 months comparing community versus hospital diagnosis was 0.780 (95% CI 0.722 to 0.841, p<0.0001). By 72 months, the ratio of deaths was 0.960 (0.905 to 1.020, p=0.18). Diagnosis via hospital pathway incurred an overall extra longitudinal cost of £2485 per patient.Index diagnosis of HF through hospital admission continues to dominate and is associated with a significantly greater short-term risk of mortality and substantially increased long-term costs than if first diagnosed in the community. This study highlights the potential for community diagnosis-early, before symptoms necessitate hospitalisation-to improve both clinical and health economic outcomes.

Drug shortages are a common issue that healthcare systems face and can result in adverse health outcomes for patients requiring inferior alternate treatment. The United States recently experienced a national drug shortage of intravenous immunoglobulin (IVIG). Several reported strategies to address the IVIG and other drug shortages have been proposed; however, there is a lack of evidence-based methods for protocol development and implementation.To evaluate the efficacy of introducing a multidisciplinary task force and tier system of indications and to minimize adverse effects during a shortage of IVIG.Faculty members across disciplines with expertise in IVIG use were invited to participate in a task force to address the shortage and ensure adequate supply for emergent indications. A tier system of IVIG indications was established according to the severity of diagnosis, urgency of indication, and quality of supporting evidence. Based on inventory, indications in selected tiers were auto-approved. Orders that could not be automatically approved were escalated for task force review.Overall, there were 342 distinct requests for IVIG during the study period (August 1, 2019 to December 31, 2019). All Tier 1 indications were approved. Of all requests, only 2.6% (9) of requests were denied, none of which resulted in adverse effects based on retrospective chart review. Seven patients who regularly receive IVIG had possible adverse effects due to dose reduction or spacing of treatment; however, each complication was multifactorial and not attributed to the shortage or tier system implementation alone.Implementation of a multidisciplinary task force and tier system to appropriately triage high-priority indications for limited pharmaceutical agents should be considered in health institutions faced with a drug shortage.

There is a clinical need for ¹⁸F-labeled somatostatin analogs for the imaging of neuroendocrine tumors (NET), given the limitations of using [⁶⁸Ga]Ga-DOTA-peptides, particularly with regard to widespread accessibility. We have shown that [¹⁸F]fluoroethyl-triazole-[Tyr³]-octreotate ([¹⁸F]FET-βAG-TOCA) has favorable dosimetry and biodistribution. As a step toward clinical implementation, we conducted a prospective, noninferiority study of [¹⁸F]FET-βAG-TOCA PET/CT compared with [⁶⁸Ga]Ga-DOTA- peptide PET/CT in patients with NET. <b>Methods:</b> Forty-five patients with histologically confirmed NET, grades 1 and 2, underwent PET/CT imaging with both [¹⁸F]FET-βAG-TOCA and [⁶⁸Ga]Ga-peptide performed within a 6-mo window (median, 77 d; range, 6–180 d). Whole-body PET/CT was conducted 50 min after injection of 165 MBq of [¹⁸F]FET-βAG-TOCA. Tracer uptake was evaluated by comparing SUV_max and tumor-to-background ratios at both lesion and regional levels by 2 unblinded, experienced readers. A randomized, blinded reading of both scans was also then undertaken by 3 experienced readers, and consensus was assessed at a regional level. The ability of both tracers to visualize liver metastases was also assessed. <b>Results:</b> A total of 285 lesions were detected on both imaging modalities. An additional 13 tumor deposits were seen in 8 patients on [¹⁸F]FET-βAG-TOCA PET/CT, and [⁶⁸Ga]Ga-DOTA-peptide PET/CT detected an additional 7 lesions in 5 patients. Excellent correlation in SUV_max was observed between both tracers (<i>r</i> = 0.91; <i>P</i> &lt; 0.001). No difference was observed between median SUV_max across regions, except in the liver, where the median tumor-to-background ratio of [¹⁸F]FET-βAG-TOCA was significantly lower than that of [⁶⁸Ga]Ga-DOTA-peptide (2.5 ± 1.9 vs. 3.5 ± 2.3; <i>P</i> &lt; 0.001). <b>Conclusion:</b> [¹⁸F]FET-βAG-TOCA was not inferior to [⁶⁸Ga]Ga-DOTA-peptide in visualizing NET and may be considered in routine clinical practice given the longer half-life and availability of the cyclotron-produced fluorine radioisotope.

Abstract Mosaic loss of the Y chromosome (mLOY), a type of clonal hematopoiesis, is the most frequent chromosomal alteration observed in leukocytes of aging men. mLOY is a putative biomarker of genomic instability with evidence of associations with risk of some solid tumors, but more studies are needed to refine associations and identify potential mechanisms for cancer risk. Prostate cancer (PCa), the most common non-cutaneous cancer in males, is also associated with aging. To further investigate potential relationships between mLOY and PCa, we examined DNA derived from leukocytes of male participants in two large biobanks: the UK Biobank (UKBB; N = 210,103) and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO, N = 26,795). Of the 236,898 male participants without previous cancer diagnosis, 14,253 (6.0%) were diagnosed with incident PCa after DNA collection. High-density genotyping array data collected during the studies were used to create virtual karyotypes for detecting mLOY in whole blood samples utilizing a phase-based detection method in MoChA software. Analyses were restricted to men without cancer at genotyping and multivariable regression models were adjusted for age, smoking status, and genetic similarity. Men with detectable mLOY were older (mean = 62 vs 56 years) and more likely to be smokers (14.8% vs 9.7%) than men without mLOY. A total of 3,848 (27.0%) men with PCa and 42,835 (19.2%) men free of PCa had detectable mLOY. mLOY clonal fraction ranged from 0.01% to 72.1% of total leukocytes. 18.7% of PCa cases and 13.6% of men free of PCa had high clonal fraction mLOY, defined as greater than 10% of leukocytes with mLOY. Fixed effect meta-analysis of multivariable models from UKBB and PLCO produced evidence for a positive association between mLOY in leukocytes and incident PCa; (Odds Ratio (OR) = 1.062, 95% Confidence Interval (CI) [1.020, 1.107], P-Value (p) = 0.004). The effect estimate was the same in men with low clonal fraction of mLOY (OR = 1.062, 95% CI [1.012, 1.113], p = 0.014) and men with high clonal fraction of mLOY (OR = 1.065, 95% CI [0.998, 1.137], p = 0.057). Age at PCa diagnosis was not associated with mLOY or the clonal fraction of mLOY. A sub-analysis of separate participants from PLCO with mLOY detected in buccal cells (n = 18,011) also showed a small positive effect between mLOY and PCa risk, but the relationship did not reach statistical significance (OR = 1.036, 95% CI [0.877, 1.224], p = 0.673)). Our investigation of the relationship between mLOY and PCa in two large prospective studies provides additional evidence for an association between mLOY detected in the blood and increased PCa risk, meriting additional studies of potential biologic mechanisms underlying the relationship. Citation Format: Rebecca L. Kelly, Weiyin Zhou, Kara M. Barnao, Corey D. Young, Aubrey K. Hubbard, Sairah M. Khan, Wen-Yi Huang, Stephen J. Chanock, Mitchell J. Machiela. Mosaic loss of the Y chromosome is associated with prostate cancer risk [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3430.

The excitatory actions of corticotropin-releasing hormone (CRH) in the brain and the neuroprotective effects of CRH antagonists in models of ischemia suggest a role for this peptide in the cascade of events leading to cellular damage. The present study aimed to characterize endogenous activation of CRH in discrete brain regions following global ischemia. Time-dependent changes in CRH concentrations were assessed in 10 brain regions including hippocampal, parahippocampal, and hypothalamic regions as well as the amygdala and the frontal cortex at three post-ischemic intervals: 4, 24, and 72 h (Experiment 1). The impact of pretreatment with a neuroprotective dose of the NMDA antagonist (5R,10S)-(+)-5-Methyl-10,11-dihydro-5H-dibenzo[a,d]cyclohepten-5,10-imine hydrogen maleate (MK-801; hydrogen maleate) on 24-h ischemia-induced CRH concentrations in the 10 brain regions was also determined (Experiment 2). In vivo microdialysis was used to assess dynamic fluctuations in CRH release at the dorsal hippocampus (CA1 pyramidal layer) and central nucleus of the amygdala (CeA; Experiment 3). Our findings revealed a rapid elevation of CRH concentrations at the piriform cortex (Pir) and hypothalamic nuclei following global ischemia. This was followed by decreased CRH concentrations at the amygdala, the frontal cortex (FC), the CA3, and the hypothalamus 24-h post-ischemia. MK-801 reversed the decreases in the hypothalamic nuclei but not in the other brain regions. Seventy-two hours post-ischemia, CRH levels returned to control values in all regions except the dentate gyrus (DG) where elevated CRH levels were observed. In vivo, a significant increase in CRH release in response to global ischemia was found at the CeA with no alterations at the CA1. These findings support brain region-specific ischemia-induced CRH alterations and suggest that CRH actions to mediate neuronal damage at the hippocampal CA1 layer may be indirect.

<h2>Abstract</h2> The aim was to determine the feasibility of vascular quantification of the bowel wall for different anatomical segments of the colorectum. Following institutional ethical approval and informed consent, 39 patients with colorectal cancer underwent perfusion CT. Blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability surface area product (PS) were assessed for different segments of the colorectum: ascending, transverse, descending colon, sigmoid, or rectum, that were distant from the tumor, and which were proven normal on contemporary colonoscopy, and subsequent imaging and clinical follow up. Mean (SD) for BF, BV, MTT and PS for the different anatomical colorectal segments were obtained and compared using a pooled <i>t</i>-test. Significance was at 5%. Assessment was not possible in 9 of 39 (23%) patients as the bowel wall was ≤5mm precluding quantitative analysis. Forty-four segments were evaluated in the remaining 30 patients. Mean BF was higher in the proximal than distal colon: 24.0 versus 17.8mL/min/100g tissue; <i>p</i>=0.009; BV, MTT and PS were not significantly different; BV: 3.46 versus 3.15mL/100g tissue, <i>p</i>=0.45; MTT: 15.1 versus 18.3s; <i>p</i>=0.10; PS: 6.84 versus 8.97mL/min/100 tissue, <i>p</i>=0.13, respectively. In conclusion, assessment of bowel wall perfusion may fail in 23% of patients. The colorectum demonstrates segmental differences in perfusion.

Myelofibrosis is a rare myeloproliferative neoplasm (MPN) with high risk for progression to acute myeloid leukemia. Our integrated genomic analysis of up to 933 myelofibrosis cases identifies 6 germline susceptibility loci, 4 of which overlap with previously identified MPN loci. Virtual karyotyping identifies high frequencies of mosaic chromosomal alterations (mCAs), with enrichment at myelofibrosis GWAS susceptibility loci and recurrently somatically mutated MPN genes (e.g., JAK2). We replicate prior MPN associations showing germline variation at the 9p24.1 risk haplotype confers elevated risk of acquiring JAK2V617F mutations, demonstrating with long-read sequencing that this relationship occurs in cis. We also describe recurrent 9p24.1 large mCAs that selectively retained JAK2V617F mutations. Germline variation associated with longer telomeres is associated with increased myelofibrosis risk. Myelofibrosis cases with high-frequency JAK2 mCAs have marked reductions in measured telomere length - suggesting a relationship between telomere biology and myelofibrosis clonal expansion. Our results advance understanding of the germline-somatic interaction at JAK2 and implicate mCAs involving JAK2 as strong promoters of clonal expansion of those mutated clones.

Intravenous injections of CCK-B agonists, such as pentagastrin, produce symptoms of panic and potent activation of the human hypothalamic-pituitary-adrenal (HPA) axis. It is unclear whether these psychological and endocrine effects are mediated by similar or independent processes. Independence is supported by prior evidence that beta-adrenergic receptor blockade attenuates cardiovascular and symptom but not vasopressin responses to CCK-4. To further explore associations between somatic, emotional and endocrine responses to CCK-B agents, and potential beta-adrenergic mediating mechanisms, symptom and endocrine responses to pentagastrin were examined after propranolol pre-treatment. Cardiovascular, symptom, and endocrine (ACTH, cortisol, epinephrine) responses to pentagastrin were measured in 16 healthy adult subjects randomly assigned to receive propranolol or placebo pre-treatment. Propranolol significantly blocked the normal cardiac acceleration produced by pentagastrin, but did not reduce panic symptom or anxiety effects. It delayed and perhaps enhanced the cortisol response. No relationship between HPA and symptom responses following pentagastrin could be detected, though pre-pentagastrin cortisol was inversely related to post-injection panic symptom intensity. Endocrine, cardiovascular and symptom responses to pentagastrin appear to be separately mediated, as they did not change in concert in response to propranolol pre-treatment, nor were they correlated with one another. The results are consistent with the presence of inhibitory beta-adrenergic mediation of the HPA axis in humans. They support the hypothesis that the HPA response to pentagastrin is not secondary to the psychological stress of its side effects.

Central administration of bombesin (BN) (into the ventricular system) increased circulating levels of ACTH, corticosterone, epinephrine, norepinephrine and glucose, indicating that this peptide activates the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system. We then assessed the potential contribution of corticotropin-releasing hormone (CRH) system, in the mediation of these BN effects. Blockade of CRH receptors with alphah-CRF (10 microg) attenuated or blocked the BN-induced rise in plasma ACTH, epinephrine, norepinephrine, glucose and corticosterone levels. These findings support the notion that BN-induced HPA axis and sympathetic activation are mediated, at least in part, via activation of CRH neurons.

Evaluate the role of balloon aortic valvuloplasty (BAV) in improving candidacy of patients for transcatheter aortic valve replacement (TAVR).Patients who are not candidates for TAVR may undergo BAV to improve functional and clinical status.117 inoperable or high-risk patients with critical aortic stenosis underwent BAV as a bridge-to-decision for TAVR. Frailty measures including gait speed, serum albumin, hand grip, activities of daily living (ADL); and NYHA functional class before and after BAV were compared.Mean age was 81.6 ± 8.5 years and the mean Society of Thoracic Surgeons predicted risk of mortality was 9.57 ± 5.51, with 19/117 (16.2%) patients non-ambulatory. There was no significant change in mean GS post-BAV, but all non-ambulatory patients completed GS testing at follow-up. Albumin and hand grip did not change after BAV, but there was a significant improvement in mean ADL score (4.85 ± 1.41 baseline to 5.20 ± 1.17, P = 0.021). The number of patients with Class IV congestive heart failure (CHF) was significantly lower post BAV (71/117 [60.7%] baseline versus 18/117 [15.4%], P = 0.008). 78/117 (66.7%) of patients were referred to definitive valve therapy after BAV.When evaluating frailty measures post BAV, we saw no significant improvement in mean GS, however, we observed a significant improvement in non-ambulatory patients and ADL scores. We also describe improved Class IV CHF symptoms. With this improved health status, the majority of patients underwent subsequent valve therapy, demonstrating that BAV may improve candidacy of patients for TAVR.

Question: A 2-year-old boy with a past medical history of spinocerebellar degeneration with cerebellar ataxia presented with a 2-month history of 6–12 watery stools per day, weight loss, and 1 month of emesis and low-grade intermittent fevers. His parents never saw any blood or mucus in his stool. Four months prior he had a brief self-limited episode of emesis and diarrhea, which was presumed to be due to a viral infection. Before admission, a trial of loperamide and a low lactose and refined sugar diet did not alter the diarrhea. His physical examination was normal except for a weak general appearance, an ataxic stance, and spastic extremities. Initial studies showed: sodium, 131 mmol/L (normal, 135–148); potassium, 4.4 mmol/L (normal, 3.7–5.3); CI, 95 mmol/L (normal, 98–106); CO2, 20 mmol/L (normal, 18–28); blood urea nitrogen, 12 mg/dL (normal, 5–25); creatinine, 0.5 mg/dL (normal, 0–0.7); total bilirubin. 0.3 mg/dL (normal, 0–1.0); aspartate aminotransferase, 30 U/L (normal, 15–37); alanine aminotransferase, 36 U/L (normal, 30–65); albumin, 3.1 g/dL (normal, 3.8–5.4); white blood cells, 9.4 k/μL (normal, 3.6–11.8); hemoglobin, 13.7 g/dL (normal, 11.5–15.5); hematocrit, 42% (normal, 38–51); platelets, 674 k/μL (normal, 150–400); and erythrocyte sedimentation rate (ESR), 28 mm/hr (normal, 0–20). Despite bowel rest, he had profuse diarrhea with a low fecal osmotic gap and albumin dropped to 2.5 g/dL. Stool studies were negative for infections, reducing substances, and fat; stool α-1-antitrypsin was 33 mg/dL (normal, <55). Other laboratory studies including anti-enterocyte antibody, celiac panel, anti-Saccharomyces cerevisiae antibodies immunoglobulin (Ig)A, antineutrophil cytoplasmic autoantibodies IgG, antinuclear antibodies, lymphocyte enumeration, total IgM and IgA, and complement levels were within normal limits. Total IgG and subclasses were low. Computed tomography of the abdomen showed dilated, fluid-filled bowel loops. Upper and lower endoscopy revealed erythema and petechiae in the gastric body and increased vascularity, mild diffuse edema and erythema throughout the colon (Figure A). Multiple biopsies obtained from the stomach, duodenum (Figure B, long arrow), and colon (Figure C, arrow) showed increased thickening of the subepithelial plate (>5 microns, best seen with trichrome stain; Figure D, arrow). The antrum had focal chronic active gastritis; there was chronic active duodenitis with marked villous blunting and reactive epithelial atypia (Figure B, short arrow). All colonic biopsies had widespread thickening of the subepithelial plate, with focal sloughing of the surface epithelium (Figure D), and extensive degenerative changes including reactive epithelial atypia. There was also prominent acute inflammation, including abundant neutrophils as well as significant chronic inflammation with plasma cells and lymphocytes. What is the most likely diagnosis? Look on page 327 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The diagnosis of collagenous gastroduodenocolitis was made based on histologic appearance and confirmatory trichrome and immunohistochemical stains. He was symptom free after 2 weeks of intravenous steroids and bowel rest. Repeat biopsies at the end of 2 weeks revealed less inflammation, but persistent presence of thickened baseline membrane throughout. He was then treated with a proton pump inhibitor, mesalamine, and 8 weeks of oral steroids, but relapsed 2 weeks after finishing oral steroids. The patient was then started on bismuth subsalicylate, which continued for 4 weeks with resolution of his symptoms. Total IgG and subclasses and albumin normalized. We were not able to specifically associate his neurologic condition with the gastrointestinal presentation. Just >30 years ago, Lindstrom described collagenous colitis, a disease that is now found predominantly in middle-aged women with minimal gross endoscopic changes. Since the first 2 pediatric cases were reported in 1989, no more than 10 pediatric case reports have been published. Most adult and pediatric cases have collagenous disease limited to the colon with less common reports of collagenous gastritis, and even fewer reports of collagenous duodenitis. Key to ensuring appropriate diagnosis is the presence of mucosal inflammation and subepithelial collagenous thickening and not mistaking for an artifact from tangential sectioning of the specimen.1Lazenby A.J. Yardley J.H. Giardiello F.M. et al.Pitfalls in the diagnosis of collagenous colitis: experience with 75 cases from a registry of collagenous colitis at the Johns Hopkins Hospital.Hum Pathol. 1990; 21: 905-910Abstract Full Text PDF PubMed Scopus (125) Google Scholar Although the underlying etiology of collagenous colitis is unknown, it is hypothesized that a luminal agent, such as bacteria or toxin, may act as a trigger to the onset of disease. Recent studies suggest altered nitric oxide production in the pathogenesis.2Camarero C. Leon F. Colino E. et al.Collagenous colitis in children: clinicopathologic, microbiologic, and immunologic features.J Pediatr Gastroenterol Nutr. 2003; 37: 508-513Crossref PubMed Scopus (38) Google Scholar, 3Freeman H.J. Collagenous mucosal inflammatory diseases of the gastrointestinal tract.Gastroenterology. 2005; 129: 338-350Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar Secretory diarrhea is a common finding in both in vivo and in vitro studies. In adults, an association with celiac disease and inflammatory bowel disease has been noted.3Freeman H.J. Collagenous mucosal inflammatory diseases of the gastrointestinal tract.Gastroenterology. 2005; 129: 338-350Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar In children, these diseases as well as a variety of others, including juvenile scleroderma, hypothyroidism, diabetes mellitus, and Aeromonas hydrophilia infection, have been found in association with collagenous colitis. A mildly elevated ESR has been noted in a number of the pediatric cases and in our patient as well.2Camarero C. Leon F. Colino E. et al.Collagenous colitis in children: clinicopathologic, microbiologic, and immunologic features.J Pediatr Gastroenterol Nutr. 2003; 37: 508-513Crossref PubMed Scopus (38) Google Scholar Treatment of this disorder can be challenging, because symptoms may be intermittent with prolonged asymptomatic phases, when maintenance therapy may not be needed, or continuous without periods of remission. For most, the disease is benign; dehydration and other complications occur rarely. Variable therapeutic responses have been seen with mesalamine, antibiotics, bismuth, and loperamide as well as probiotics. Some patients have also required treatment with steroids and immunosuppressants including azathioprine and methotrexate.3Freeman H.J. Collagenous mucosal inflammatory diseases of the gastrointestinal tract.Gastroenterology. 2005; 129: 338-350Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar

The hypothalamic-pituitary adrenal (HPA) axis is critical for biobehavioral adaptation to challenge and appears dysregulated in a range of psychiatric disorders. Its precise role in psychopathology remains unclear and discrepant and difficult to explain findings abound in the clinical literature. Basic research suggests this system is sensitive to psychosocial cues, but psychosocial milieu factors are rarely controlled or examined in psychiatric studies using biological probes of the HPA axis. To test the hypothesis that psychological factors might complicate HPA study results even in direct, pharmacological challenge paradigms, endocrine responses to corticotropin-releasing hormone (CRH) were examined under two different cognitive preparation conditions. Healthy subjects (n = 32) received standard instructions or a cognitive intervention (CI) prior to injection with CRH and placebo, given on separate days in random order. The CI combined access to control over drug exposure with novelty reduction and coping enhancement. Blood samples were obtained via intravenous catheter before and after CRH. Cognitive intervention reduced corticotropin (ACTH) levels, but only when CRH was given first (intervention by order interaction). It did not reduce cortisol response. The CI and visit (1st or 2nd) both impacted cortisol levels on placebo day. Modifiable psychological factors may amplify or inhibit HPA axis activity in pharmacological activation paradigms, including CRH stimulation tests. The factors manipulated by the CI (novelty/familiarity, control and coping) may have particular salience to the HPA axis. Differential sensitivity to such factors could impact results in studies applying biological HPA probes to psychiatric populations.

ABSTRACT The Influenza A virus (IAV) hemagglutinin protein (HA) has been studied extensively, but its evolution has not been thoroughly compared among major host species. We compared H3 and H1 evolutionary rates among 49 lineages differentiated by host (avian, canine, equine, human, swine), phylogeny, and geography. Rates of nonsynonymous evolution, relative to synonymous rates, were higher in mammalian than avian hosts. Human seasonal HA and classical swine H1 accumulated 11-13 glycosylation sites, primarily in the antigenically important head domain, whereas lower numbers were maintained in other hosts. Canines had the highest ratio of nonsynonymous to synonymous changes in the more conserved stalk domain. Amino acid changes in canine viruses occurred disproportionately at residues located at protein interfaces. This suggests that they were adaptations affecting the major structural rearrangement of HA, which is critical for cell entry. These findings invite further study of how host ecology and physiology affect natural selection. AUTHOR SUMMARY Influenza virus evolution is of practical importance to health in addition to being an excellent system for the study of parasite/host evolution. Our work explores a largely untapped aspect of influenza evolution: sequence evolution in non-human hosts. This is important in its own right, in terms of both science and domestic animal health. It also puts the evolution of human influenza in a larger, comparative context. Our results also provide evidence concerning the evolution of the hemagglutinin stem domain, which has not been a focus of study but has new importance due to the development of stem-based universal influenza vaccines.

Adrenomedullin (ADM) is a 52 amino acid peptide, with a potent hypotensive/vasodilatory action. Levels of ADM are significantly elevated in patients with hypertension, and it has been postulated that such stressor-related increases may serve a regulatory or protective function. The current study assessed the effects of acute restraint stress on ADM levels in regions of the brain, plasma and peripheral tissue including heart, lung and the adrenal glands of rats. This stressor, known to stimulate sympathetic activity as well as the hypothalamic-pituitary adrenal (HPA) axis, produced a significant increase in ADM levels in the pituitary gland, plasma and adrenal glands, all of which are key components of the HPA axis. The results suggest a regulatory and/or protective role for ADM in countering HPA activation following a variety of physiological and psychological stressors.

Corticotropin-releasing hormone (CRH) has been implicated in ischemia-induced neurotoxicity, due in part to excitatory effects at the hippocampus, and the demonstrated neuroprotective effects of centrally administered, non-specific CRH antagonists. However, a number of issues remain to be clarified from these studies, including the relative contribution of CRH receptor subtypes, and the efficacy of these compounds to alter ischemia-induced behavioral impairments. In the current study, a highly selective, systemically administered CRH1 antagonist (CP154,526) failed to reverse global ischemia-induced cell death in hippocampal CA1 neurons or spatial memory impairments as assessed in the radial arm maze. Similarly, central administration of alpha-helical CRH failed to confer protection against ischemic damage. Interestingly, CRH1 antagonism reversed ischemia-induced hyperactivity in a novel open field, suggesting that modulation of this behavior is independent of effects on hippocampal CA1 cell loss. Failure of the current study to demonstrate neuroprotective effects of either the selective or non-selective CRH antagonists tested challenges the proposed neurotoxic role of CRH in global ischemia. These findings are discussed in relationship to recent findings reconsidering the participation of CRH in excitotoxic-mediated cellular damage.

HIV infection in India is unique as it occurs predominantly by CCR5-utilizing isolates that exhibit no co-receptor switch. To study HIV-1 co-receptor dynamics on T cells and monocytes following viral infection. HIV co-receptor expression was evaluated by flow cytometry on various cell subsets in HIV-infected Indians and in vitro in human peripheral blood mononuclear cells infected with CCR5- or CXCR4-utilizing HIV-1. Transfection of the T cell line CEM-CCR5 (which expresses CD4, CCR5 and CXCR4) with HIV-1 Nef or Vpu expression vectors, or treatment with recombinant soluble gp120 from CCR5- and CXCR4-tropic HIV-1, was carried out to determine their effects on co-receptor expression. Indian HIV patients had fewer CD4+CCR5+ T cells and CCR5-expressing activated CD4+ T cells, but higher CXCR4-expressing activated CD4+ T cells compared with controls. Expression of CCR5 was not different on monocytes in HIV patients as compared to controls. The CCR5 downregulation on T cells was HIV infection specific and was governed by the co-receptor-utilization phenotype of the virus. The Nef and soluble gp120 proteins induced CCR5 downregulation, the latter in a co-receptor-utilization phenotype specific manner. The HIV-1 co-receptor dynamics in Indian patients is distinct from western patients and depends upon the virus surface protein. We propose this to be a viral survival strategy.

Although mortality has decreased considerably in pediatric heart transplantation, waitlist and post-transplant death rates remain notable. End-of-life focused research in this population, however, is very limited. This Pediatric Heart Transplant Society study aimed to describe the circumstances surrounding death of pediatric heart transplant patients.A retrospective analysis of the multi-institutional, international, Pediatric Heart Transplant Society registry was conducted. Descriptive statistics and univariate analyses were performed to 1) describe end-of-life in pediatric pre- and post-heart transplant patients and 2) examine associations between location of death and technological interventions at end-of-life with demographic and disease factors.Of 9217 patients (0-18 years) enrolled in the registry between 1993 and 2018, 2804 (30%) deaths occurred; 1310 while awaiting heart transplant and 1494 post-heart transplant. The majority of waitlist deaths (89%) occurred in the hospital, primarily in ICU (74%) with most receiving mechanical ventilation (77%). Fewer post-transplant deaths occurred in the hospital (22%). Out-of-hospital death was associated with older patient age (p < .01).ICU deaths with high use of technological interventions at end-of-life were common, particularly in patients awaiting heart transplant. In this high mortality population, findings raise challenging considerations for clinicians, families, and policy makers on how to balance quality of life amidst high risk for hospital-based death.

Eosinophilic inflammation may occur in any part of the intestinal tract from the esophagus to the rectum. Despite 70 yr having passed since the first reference to a case of eosinophilic gastroenteritis, the epidemiology and natural history of eosinophilic gastrointestinal disorders are still poorly known. Insights into their etiology and pathogenesis have revealed an important role for allergens; interleukins 4, 5, and 13; the eotaxin family of chemokines; and eosinophil‐derived proteins. Diagnosis is confirmed by typical histologic features in a patient with a suggestive clinical phenotype. Treatment involves eliminating triggering allergens, making dietary restrictions the first choice of therapy in a compliant patient; corticosteroids [topical in eosinophilic esophagitis (EE)], despite the potential for serious side effects, are used with success in refractory and non‐compliant patients. In this study we discuss EE and gastroduodenitis against the backdrop of clinical case presentations.

Background QRS prolongation may be a predictor of mortality in certain forms of congenital heart disease. Minimal data exist describing changes in QRS duration in patients with single ventricles (SVs). The goal was to describe changes in QRS duration in patients with SV and to determine if differences existed between single right ventricle (sRV) versus single left ventricle (sLV) patients. Methods Chart review was performed on patients with SV physiology. Patients were divided into sRV and sLV groups. QRS durations were measured monthly for the first 6 months, at 1 year, and then yearly until 10 years. t ‐tests were used for analysis. Results One hundred sixty patients were evaluated (95 sRV, 65 sLV). The greatest change in QRS duration for the entire cohort occurred in the first 6 months of life versus 6 months to 10 years of age (1.81 ms/month vs 0.20 ms/month). sRV QRS durations were significantly longer than sLV QRS durations at 1 year (78.9 ± 12.6 ms vs 73.2 ± 11.9 ms), 2 year (81.7 ± 14.7 ms vs 73.4 ± 12.5 ms), 4 year (84.2 ± 12.1 ms vs 77.9 ± 16.4 ms), 6 year (90.8 ± 12.7 ms vs 83.4 ± 13.4 ms), 7 year (90.8 ± 16.5 ms vs 81.2 ± 16.6 ms), and 8 year (96.7 ± 13.6 ms vs 84.8 ± 13.9 ms) time points. Conclusion The greatest change in QRS duration in SV patients occurred in the first 6 months of life when these patients’ ventricles were volume loaded. Differences in QRS duration between sRV and sLV patients occurred early in life. Further studies are needed to determine if minimizing volume load early in life decreases the rate of change in QRS duration.

Several converging lines of evidence from molecular, animal, and clinical studies have demonstrated that the gamma-aminobutyric type A (GABAA) receptor complex plays a central role in the modulation of anxiety. While currently available therapeutic agents that act on this receptor (e.g., benzodiazepines) are effective anxiolytics, they are limited by side effects, tolerance, and abuse potential. Promising strategies to address these limitations include the development of subunit-selective agonists and partial agonists, which specifically ameliorate anxiety without causing sedation or motor impairment. In vivo neuroimaging studies have identified several limbic and paralimbic brain regions involved in the generation or modulation of anxiety and fear responses, suggesting that the neuroinhibitory processes of GABAA receptors may be localized in certain brain areas which may serve as specific sites for drug action. Indeed, neurochemical brain imaging studies have reported decreased ligand binding to GABAA benzodiazepine receptors in prefrontal and medial temporal cortex in a variety of anxiety disorders. This paper reviews recent findings from molecular neuropsychopharmacology and in vivo neuroimaging of GABAA benzodiazepine receptors which offer novel perspectives on the genesis of normal anxiety and on pathophysiology of anxiety disorders. Collectively, these findings suggest several potentially successful avenues for future development of GABAA receptor-mediated anxiolytic treatments, and prompt further exploration of this neurochemical system in pathogenesis of anxiety disorders. Keywords: gabaa receptor, anxiety, clinical psychopharmacology, brain imaging studies, benzodiazepines

The cholecystokinin (CCK-B) agonist pentagastrin stimulates dose-dependent release of adrenocorticotropin (ACTH) and cortisol in humans, likely via direct pharmacological action at pituitary CCK-B receptors. Pentagastrin also produces side effects, however, which may be experienced as novel or anxiety arousing and could contribute to ACTH release. Available data suggest that pentagastrin's activation of the hypothalamic-pituitary-adrenal (HPA) axis is unrelated to anxiety symptoms themselves, but novelty effects have not been examined in this model and do strongly activate this system in animals. To further explore the impact of novelty and anxiety symptoms on HPA responses, pentagastrin was administered twice to 12 subjects (six male, six female) under single-blind conditions. Repeat pentagastrin injection was associated with a slight habituation in the magnitude of symptom and HPA axis responses, but robust HPA and symptom responses were seen following both injections. No relationships were found between anxiety symptoms and HPA activity and the modest symptomatic and neuroendocrine habituation appeared to occur independently. Pentagastrin may release ACTH and cortisol through direct pharmacological action, perhaps enhanced on first exposure by psychologically mediated novelty effects. Novelty, per se, is not likely the primary mediator of the HPA response. This model may be useful for further study of cognitive-emotional modulators of HPA axis activity.

Acute pancreatitis has occasionally been reported in association with Campylobacter jejuni infection in humans. However, the mechanism linking Campylobacter jejuni infection and pancreatitis is unclear. Acute pancreatitis in association with an infectious illness may be related to underlying genetic mutations. For instance, studies show that mutations in the cystic fibrosis transmembrane conductance regulator gene increase the susceptibility for acute and chronic pancreatitis.We describe a patient with Campylobacter jejuni infection who developed acute pancreatitis in the setting of an underlying cystic fibrosis transmembrane conductance regulator gene mutation.In this patient with an underlying mutation in the CFTR gene, we propose that the interaction between the mutant gene and an environmental factor, Campylobacter jejuni infection, resulted in pancreatitis.

Summarize the therapeutic pain-reducing effects of GnRF for refractory post-TKA knee pain. A secondary objective was to summarize improvements in physical function after GnRF. A protocol was registered, and a database search conducted by an experienced librarian of all available studies in the English language up until November 3, 2021. Study inclusion criteria were randomized controlled trials (RCTs), prospective and retrospective longitudinal studies, cross-sectional studies, case series, case reports, studies involving adults ≥18 years of age, and studies written about the use of GnRF for the alleviation of chronic knee pain after receiving a TKA. The study quality and risk of bias was assessed using NHLBI Study Quality of Assessment Tools and Murad et al.'s Quality Assessment of Case Reports. Certainty in the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach. A total of 229 studies were screened, 11 met the inclusion criteria, and 265 patients underwent GnRF. Study designs included 1 double-blind pragmatic RCT, 5 retrospective cohort studies, 2 retrospective case series, and 3 case reports. The overall study quality assessment demonstrated three studies had “good”, six “fair”, and two “poor” quality. There have been positive responses to GnRF for post-TKA chronic knee pain in a range of 30–100% of patients. According to GRADE, there is limited evidence, associated with low certainty to support the use of GnRF to ameliorate chronic knee pain after TKA, largely due to inconsistency and risk of bias. The studies included in this review reported positive results in pain and disability, and relatively few adverse events.

Modic change grading is heterogeneous, inconsistent, and lacks a single nomenclature across the published literature. A new method of Modic change classification has been established by Dr. Peter Udby which hopes to unify how Modic changes are classified while also adding grading of the cranial/caudal extent of the Modic change across the vertebral body from the respective endplate involved to best capture the clinically relevant information of Modic changes. Twenty magnetic resonance images of potential basivertebral nerve ablation candidates were independently reviewed by two board-certified and fellowship trained neuroradiologist and two board-certified and fellowship-trained interventional spine physiatrists for the presence and characterization of Modic changes using the newly described Udby classification. 100% agreement of all four reviewers of Modic change presence, Type, and Udby classification was required to be classified as agreement. There were 480 total data points each with 10 unique choices to compare across the four independent reviewers. The kappa value of their agreement was 0.5899 (95% CI 0.4860–0.6939). This study, requiring unanimous agreement between 4 physicians in application of the Udby classification, demonstrated an interrater reliability score of 0.5899 (95% CI 0.4860–0.6939). While this figure provides a first estimate, larger scale research is necessary before definitive claims regarding the interrater agreement validity of the Udby characterization system may be made.

It has been postulated that inflammatory bowel disease (IBD) occurs because of environmental and host factors that alter immune responses in a genetically susceptible host. Therapy is intended to suppress active inflammation and maintain remission with anti-inflammatory and immunomodulatory agents. The reported incidence of hepatobiliary disorders associated with IBD is 5% to 95% (1). This is a brief report of the development of ulcerative colitis (UC) in three patients who were maintained with immunosuppressive therapy after liver transplant. In this context, the usually implicated immune mechanisms in IBD and possible immune dysregulation after transplantation and administration of immunosuppressive agents is discussed. CASE 1 A 16-year-old girl, 5 years after orthotopic liver transplant for autoimmune hepatitis (AIH), was evaluated for abdominal pain and bloody diarrhea of 2 weeks' duration. Autoimmune hepatitis was diagnosed based on histologic analysis of the hepatectomy specimen, which showed portal-to-portal bridging fibrosis, bile ductular proliferation, and chronic inflammatory cells. Abdominal pain was nondescript, diffuse, and aggravated by meals. Bowel movements occurred four to five times a day, were loose, and contained bright to dark red blood. There was no history of infectious contacts, recent travel, or antibiotic use, but she admitted to stress due to academic examinations. The posttransplant course had been complicated by episodes of graft rejection at 10 days, 7 months, and 10 months, treated by increased immunosuppression. Cytomegalovirus (CMV) status was known to be positive in the donor and negative in the recipient. Within the first year after transplantation, the patient was treated for CMV hepatitis and Clostridium difficile colitis with ganciclovir and metronidazole, respectively. One year after transplantation, posttransplantation lymphoproliferative disorder (PTLD) developed, complicated by bowel perforation. It was treated with acyclovir, ganciclovir, lowering of immunosuppression, and resection of a portion of the mid ileum. She recuperated from these complications and was well until the current manifestations. Her medications were 3 mg tacrolimus twice daily and trimethoprim sulfamethoxazole. On examination she appeared well nourished, with weight of 64.9 kg and height of 165 cm. She had well-healed abdominal surgical scars, generalized deep palpation tenderness, a perianal tag, and guaiac-positive stools. Initial investigations showed mild leukopenia (leukocyte count, 3500/mm3 × 1000); thrombocytopenia (92000 103/mm3); and Epstein-Barr virus (EBV), determined by polymerase chain reaction, of 40 genomes/100,000 lymphocytes (N = none detected). Findings were normal in a liver profile; stool cultures for ova, parasites, and C. difficile toxin were negative; and a computed tomographic scan of the chest and abdomen was normal. On colonoileoscopy, pancolitis and normal terminal ileum were seen. Histologic analysis showed a dense infiltration of plasma cells and lymphocytes mixed with neutrophils and eosinophils, cryptitis, crypt abscesses, reduced number of goblet cells, no granulomas, and scattered EBER (EBV early RNA)-positive cells (Fig. 1). No CMV inclusions were seen. She was treated with ganciclovir and temporary cessation of immunosuppression for suspected PTLD. Findings in a second colonoscopy with biopsies for persistent symptoms 3 weeks later were unchanged. Change in medication to sulfasalazine brought on a gradual resolution of diarrhea and abdominal pain within 3 weeks. Follow-up has lasted almost most 11 months, during which time maintenance immunosuppression therapy has consisted of 1 g sulfasalazine three times daily, 4 mg tacrolimus twice daily, and prednisone tapered to 5 mg every day. Her liver functions have been stable, and there has been no recurrence of UC.FIG. 1: A section of colonic mucosa with in situ hybridization for Epstein-Barr virus showing positive cells (arrows) in the background of diffuse mixed inflammation.CASE 2 A 14-year-old girl exhibited ascites, rapid weight gain, splenomegaly, and pitting edema of lower extremities from ankles to knees. Anti-smooth muscle antibody was 1:1280 (normal, <1:40); immunoglobulin (Ig) G, 4.8 g/dl (normal, 0.3-1.5 g/dl); total protein, 8.6 mg/dl (normal, 5.5-7.5 mg/dl); albumin, 1.6 g/dl (normal, 3.5-5.0 g/dl); prothrombin time, 19 seconds (normal, < 12.8 seconds); aspartate aminotransferase, 150 IU/L (normal, < 50 IU/L); alanine aminotransferase, 188 IU/L (normal, < 50 IU/L), and platelet, 71,000/mm3 (150-300 × 103/mm3). α1-Antitrypsin level; ceruloplasmin; 24-hour urine copper concentration; serum ferritin concentration; hepatitis A, B, and C serologies; antinuclear antibody, antimitochondrial antibody, antiliver kidney-microsomal antibody, and thyroid functions were all normal. Analysis of a liver biopsy specimen showed extensive interlobular fibrosis with hepatocellular degeneration. An endoscopic retrograde cholangiopancreatographic study produced normal findings. Because of an incomplete response to prednisone and azathioprine, evident by persistently elevated liver transaminases and advanced cirrhosis on a second liver biopsy, she eventually received a liver transplant 17 months after the diagnosis was made. One year after transplant, while receiving 7.5 mg prednisone and 75 mg azathioprine daily and 225 mg cyclosporine twice daily, bloody diarrhea developed. Cyclosporine levels ranged between 180 and 275 ng/ml. Stool studies were negative for bacterial enteropathogens, C. difficile, ova, and parasites. The CMV serology was negative for IgM and positive for IgG. A colonoscopy with biopsies that did not include intubation of the terminal ileum showed marked chronic active colitis, crypt abscesses, and crypt branching. No CMV inclusions were seen. With the exception of a mild relapse of colitis treated by increasing the dose of prednisone to 40 mg per day, her symptoms have abated, and she has maintained normal liver enzyme levels. Length of follow-up has been 34 months, and she is presently taking 1 g sulfasalazine and 175 mg cyclosporine twice daily and 100 mg azathioprine daily. CASE 3 A female infant at 20 months of age exhibited jaundice and marked hepatosplenomegaly. A diagnosis of AIH was considered on the basis of a liver specimen that showed fibrosis and piecemeal necrosis. Abnormal laboratory values were total bilirubin, 4.7 (normal, <1.5, mg/dl); direct bilirubin, 3.2 mg/dl (normal, <1 mg/dl); alanine aminotransferase, 190 IU/l (normal, <50 IU/l); aspartate aminotransferase, 174 IU/L (normal, <50 IU/l); γ-glutamyl transpeptidase, 387 IU/L (normal, <39 IU/l); alkaline phosphatase, 480 IU/L (normal, 125-500 IU/l); and prothrombin time, 14.6 seconds (normal, < 12.8 seconds). Results of tests for metabolic defects of amino and organic acids, α1-antitrypsin deficiency, Wilson's disease, bile acid metabolism disorders, and hepatitis B were negative. Elimination of fructose from the diet did not affect her status. Because of a poor response to daily doses of 2 mg/kg prednisone and 1.5 mg/kg azathioprine during the ensuing 2 years, the medications were discontinued. She had recurrent episodes of jaundice characterized by transaminase levels elevated 10-fold, cholestatic enzyme levels elevated 10- to 20-fold, and poor liver synthetic function. A re-evaluation was significant for positive perinuclear antineutrophil cytoplasmic antibodies and small ductal sclerosing cholangitis determined by endoscopic retrograde cholangiopancreatography. At age 13 years she underwent liver transplant. Pathologic analysis of the explant showed micronodular cirrhosis, multifocal loss of ductules, piecemeal necrosis, and parenchymal cholestasis consistent with primary sclerosing cholangitis (PSC). Two months after transplantation, she was treated for CMV antigenemia with ganciclovir and intravenous immunoglobulin. Six months after transplant, bloody diarrhea developed with nocturnal symptoms. At the time, immunosuppression therapy consisted of 5 mg prednisone every other day and 2 mg tacrolimus and 750 mg mycophenolate mofetil twice daily. Serum tacrolimus concentrations varied between 8.4 and 12.9 ng/ml. Infectious causes were excluded by stool studies. A diagnosis of UC was made on the basis of a colonoscopy limited to the colon, showing pancolitis and biopsy findings of chronic active colitis and crypt abscesses. No CMV inclusions were present on biopsy specimens. She has been observed for 6 months and has had no recurrence of UC. Medications include 10 mg prednisone and 50 mg azathioprine daily and 500 mg sulfasalazine and 2 mg tacrolimus twice daily. DISCUSSION The incidence of IBD in the general population is 3 to 20 per 100,000 cases annually (2,3). An alarmingly high incidence (206 in 100,000) of new-onset IBD has been reported in solid-organ transplant recipients (4). Riley et al. (4) described 14 adult transplant recipients with new-onset IBD at a mean of 4 years after transplant while undergoing different immunosuppression regimens. The presentation, immunosuppressive agents, and response to conventional anti-inflammatory therapy in our patients are similar to those in their patients. None of the children we report had a family history of chronic diarrhea, bloody stools, or IBD. Patients 2 and 3 represent the earliest diagnosed cases of IBD after transplant (1 year in patient 2 and 6 months in patient 3). Epstein-Barr virus-associated PTLD was an important consideration in the first case in view of the patient's previous history and EBER-positive cells seen in colonic specimens. The patient's subsequent clinical course marked by clinical improvement in response to azulfidine was more typical of IBD. Although not fully understood, an immune-mediated mechanism is thought to be basic to the cause of IBD. This notion is supported by its association with other disorders with an autoimmune basis. Specifically, the incidences of PSC and AIH in IBD patients are 70% and 13%, respectively (1,5). There is considerable overlap in the clinical, biochemical, immunologic, and histologic features of PSC and AIH. A high prevalence of perinuclear antineutrophil cytoplasm antibodies has been identified in the serum of patients with UC (50-80%); PSC (70%), and AIH (92%) (6). Perdigoto et al. (7) in a review of 12 patients with UC and AIH found cholangiographic abnormalities typical of PSC on re-evaluation in 5 of them. The results of a cholangiogram changed the diagnosis in our patient 3 from AIH to PSC. It appears from reports in the literature that in the context of IBD and associated liver disorders, either disease can remain active or even progress, regardless of the status of the other (8-10). In recent years, new therapeutic methods targeting immune mediators have emerged in the field of autoimmune diseases. In the pathogenesis of IBD, the most important cytokines are interleukin (IL)-1, -2, -6, and -8; interferon-γ and tumor necrosis factor-α produced by activated T-helper lymphocytes. Cyclosporine and tacrolimus are potent immunosuppressive agents that control cytokine production and have been shown to improve disease activity in UC and Crohn's disease (11). Tacrolimus inhibits IL-2 transcription, thereby inhibiting the CD4 T-helper-1 lymphocyte response to foreign antigens (12). It is also selectively inhibits secretion of IL-3, IL-4, and interferon-γ (11). Cyclosporine has comparable actions and inhibits the function of T-helper lymphocytes (13). Based on experience with renal transplants, impaired T-cell IL-10 secretion together with impaired T- and CD4-helper cells may be important in maintaining stable graft function in patients with liver grafts treated with tacrolimus and cyclosporine (14). Interleukin-10 is important in the regulation of proinflammatory cytokines and T-cell responses. Human and murine CD4+ T cells in the presence of IL-10 produce a clone of the CD4+ T-cell subset with low proliferative action, low levels of IL-2, and no IL-4, thus preventing colitis (15). To our knowledge, cytokine profiles in transplant recipients with IBD have not been studied. An imbalance of T-cell types and impaired interleukin responses in susceptible patients with liver grafts may allow IBD to develop. Specifically, CD8 suppressor cells may decrease to a greater extent, thereby increasing the T-helper-T-suppressor ratio. This is based on cases describing an association of IBD disease activity with low CD4 counts and exogenous IL-2 in immunosuppressed patients with HIV and renal cell carcinoma (16,17). In 55 liver transplant recipients with PSC, graft rejection was more frequent and severe in younger patients with associated IBD. In this study there was also a higher incidence of severe acute rejection in patients receiving transplants for immunologic liver diseases (8). Such rejection is characterized by progressive lymphocytic infiltration of the graft and is thought to be T-cell mediated (18). Younger patients had a greater risk of severe rejection, recurrent PSC, and poor control of IBD after transplantation (8). The patients we reported, however, have maintained stable graft function and have not experienced chronic or severe rejection. In summary, these cases describe the unusual development of ulcerative colitis after liver transplantation and immunosuppression therapy. Future research in the immunology of IBD and better characterization of transplant recipients with IBD may answer questions related to its cause in this unique group of patients.

Objectives: People with HIV (PWH) have an elevated risk of non-Hodgkin lymphoma (NHL) and other diseases. Studying clonal hematopoiesis (CH), the clonal expansion of mutated hematopoietic stem cells, could provide insights regarding elevated NHL risk. Design: Cohort analysis of participants in the Multicenter AIDS Cohort Study ( N = 5979). Methods: Mosaic chromosomal alterations (mCAs), a type of CH, were detected from genotyping array data using MoChA. We compared CH prevalence in men with HIV (MWH) to HIV-uninfected men using logistic regression, and among MWH, assessed the associations of CH with NHL incidence and overall mortality using Poisson regression. Results: Comparing MWH to HIV-uninfected men, we observed no difference in the frequency of autosomal mCAs (3.9% vs. 3.6%, P -value = 0.09) or mosaic loss of the Y chromosome (mLOY) (1.4% vs. 2.9%, P -value = 0.13). Autosomal mCAs involving copy-neutral loss of heterozygosity (CN-LOH) of chromosome 14q were more common in MWH. Among MWH, mCAs were not associated with subsequent NHL incidence (autosomal mCA P -value = 0.65, mLOY P -value = 0.48). However, two MWH with diffuse large B-cell lymphoma had overlapping CN-LOH mCAs on chromosome 19 spanning U2AF2 (involved in RNA splicing), and one MWH with Burkitt lymphoma had high-frequency mCAs involving chromosome 1 gain and chromosome 17 CN-LOH (cell fractions 22.1% and 25.0%, respectively). mCAs were not associated with mortality among MWH (autosomal mCA P -value = 0.52, mLOY P -value = 0.93). Conclusions: We found limited evidence for a relationship between HIV infection and mCAs. Although mCAs were not significantly associated with NHL, mCAs detected in several NHL cases indicate a need for further investigation.

Abstract Background Cardiac transplants increasingly occur following placement of ventricular assist devices (VADs). A strong association exists between human leukocyte antigen (HLA) sensitization and VAD placement; however, desensitization protocols that utilize therapeutic plasma exchange (TPE) are fraught with technical challenges and are at increased risk of adverse events. In response to increased VAD utilization in our pre‐transplant population, we developed a new institutional standard for TPE in the operating room. Methods Through a multidisciplinary effort, we developed an institutional protocol for intraoperative TPE immediately prior to cardiac transplantation after cannulation onto cardiopulmonary bypass (CPB). All procedures used the standard TPE protocol on the Terumo Optia (Terumo BCT, Lakewood, CO, USA), but incorporated multiple modifications to limit patients' bypass times, and to coordinate with the surgical teams. These modifications included deliberate misidentification of replacement fluid and maximization of the citrate infusion rate. Results These adjustments allowed the machine to run at maximal inlet speeds, minimizing duration of TPE. To date, 11 patients have been treated with this protocol. All survived their cardiac transplantation operation. Hypocalcemia and hypotension were noted; however, none of these adverse events appeared to have clinical impact. Technical complications included unexpected fibrin deposition in the TPE circuit and air in the inlet line due to surgical manipulation of the CPB cannula. No thromboembolic complications occurred in any patient. Conclusion We feel that this procedure can be rapidly and safely performed in HLA sensitized pediatric patients on CPB to limit the risk of antibody mediated rejection of their heart transplant.

Background And Aims: Traumatic and non-traumatic tendon lesions are common at the hand and foot. For the diagnosis, therapy management, and long-term prognosis of tendon lesions, a detailed understanding of the complex anatomy and knowledge of typical injury patterns is crucial for both radiologists and clinicians. The aim of the study was to evaluate the various non-traumatic or traumatic pathologies of the tendon of the hand and foot by USG and MRI. Materials And Methods: In this cross-sectional study, 50 patients referred from various departments of Silchar Medical College and Hospital to the department of Radiology for pain and swelling of the hand and foot, as well as hand and foot injuries following trauma, were evaluated with USG and MRI. USG examination done by using SAMSUNG PRESTIGE RS-80A via high frequency probes. MRI evaluation was carried out on SIEMENS TIM AVANTO 1.5T Scanner. Results: In our study, the 20-30 year age group had the highest number of cases, accounting for 26% of all cases. The right side was mainly involved, constituting 68% of pathologies (34/50). Our study included 50 patients with an age range of 10 to 61 years, with 24 males (48%) and 26 females (52%)—a slight predominance of females over males in our study. Thus, the male-to-female ratio in our study was 1: 0.92. In our study, we found that the sensitivity, specicity, and accuracy of the USG assessment of tendon pathologies of the hand and foot were 94.3%, 98.2%, and 95.1%, respectively. MRI and US are imaging modalities that allow for anatomi Conclusion: c evaluation of tendons as well as the identication of tendon pathologies. Tenosynovitis can be diagnosed and treated quickly using high-quality sonographic exams.

Obesity and T2D are closely associated with Nonalcoholic Fatty Liver Disease, which can advance to Nonalcoholic Steatohepatitis (NASH) with fibrosis. We previously found that liver pyruvate carboxylase (PC) is required for hepatic gluconeogenesis and the concentration of metabolites essential to mediating redox state and antioxidant function. Liver PC knockout (LPCKO) mice are protected from HFD-induced hyperinsulinemia and glucose intolerance despite retaining excess liver fat and exhibiting reduced antioxidant capacity. Here, we report that despite impaired antioxidant markers and increased inflammatory markers on a HFD, PC loss protected the liver from fibrosis and other indices of liver damage induced by a long-term NASH diet. LPCKO and control mice were fed a high fat, high cholesterol Western Diet (WD) for 13-14 months. After 10 mos. of WD, markers of insulin resistance were assessed by lactate/pyruvate, glucose, and insulin tolerance tests. After sacrifice, liver damage was assessed by serum markers and histology. Oxidative stress and inflammation were evaluated by gene expression, MDA concentration, GSH/GSSG and NADPH/NADP+ redox states, and H2O2 emission potential in isolated mitochondria. LPCKO-WD mice were more sensitive to an insulin tolerance test and exhibited lower fasting blood glucose and better glycemic control during a lactate/pyruvate or glucose tolerance test than controls. Liver malate/pyruvate indicated substantially lower NADPH/NADP+ in LPCKO-WD mice, but there were no differences in MDA levels, GSH/GSSG, and H2O2 emission potential. Despite similar hepatic steatosis, inflammation, and ballooning between LPCKO-WD and controls, fibrosis and serum markers of liver injury were markedly lower in LPCKO-WD mice. The data suggest that liver PC deletion improves glycemia and insulin resistance during chronic Western Diet exposure by reducing hepatic gluconeogenesis and prevents fibrosis independent of steatosis, inflammation, ballooning, and oxidative stress. Disclosure M. R. Iñigo-Vollmer: None. B. Kucejova: None. M. N. Mizerska: None. S. Khan: None. P. A. Szweda: None. H. Zaki: None. L. I. Szweda: None. X. Fu: None. S. C. Burgess: None.

ABSTRACT The influenza A virus hemagglutinin protein (HA) has been studied extensively in humans but less so in other host species. Here, we compared the rates of nucleotide substitution, protein evolution, and glycosylation in the H1 and H3 head and stalk domains among five host classes (avian, canine, equine, human, and swine). For further resolution, we separately analyzed 49 lineages differentiated by host and geography. HA evolution in non-human hosts was more dynamic than expected. For example, the classical swine H1 head domain accumulated glycosylation sites in the antigenically important head domain at a rate as high as in humans. However, whereas the stalk domain was highly conserved in humans, with a low ratio of non-synonymous to synonymous changes, this ratio was approximately 2.5-fold higher in canines. Together, these findings highlight the need for further study of HA evolution in non-human hosts. IMPORTANCE For decades, researchers have studied the rapid evolution of influenza A viruses for vaccine design and as a useful model system for the study of host/parasite evolution. By performing an exhaustive analysis of hemagglutinin protein (HA) sequences from 49 lineages independently evolving in birds, swine, canines, equines, and humans over the last century, our work uncovers surprising features of HA evolution. In particular, the canine H3 stalk, unlike human H3 and H1 stalk domains, is not evolving slowly, suggesting that evolution in the stalk domain is not universally constrained across all host species. Therefore, a broader multi-host perspective on HA evolution may be useful during the evaluation and design of stalk-targeted vaccine candidates.

Posttraumatic stress disorder (PTSD) is a potential consequence of being exposed to or witnessing an event provoking fear, helplessness, or horror. It is characterized by several debilitating symptoms including persistent hyperarousal, unwanted memories and thought intrusions, and hyperavoidance of stimuli or situations associated with the original trauma. The neurobiological mediators of these symptoms, however, still require elucidation, and animal models are particularly well suited for investigation of these mechanisms. Although the behavioral literature contains a large number of models that involve exposing animals to intense stressors, only a few of these are able to reproduce the biological and behavioral features of PTSD characteristic of a pathophysiological stress response. Among these are models involving single episodes of inescapable shock, which produce several bio-behavioral effects characteristic of PTSD, including opioid-mediated analgesia, noradrenergic sensitization as well as fear-conditioning effects. Single prolonged stress, involving the sequential exposure of rats to restraint, forced swim, and ether anesthesia, is able to produce an enhanced negative feedback of the HPA axis, as observed in PTSD patients, as well as a sustained exaggeration of the acoustic startle response. Predator exposure models, which invoke a significant threat of injury or death to particular animals, are effective in producing behavioral changes potentially analogous to hyperarousal symptoms, as well as changes in amygdala sensitization and long-term potentiation. In addition to these PTSD-specific models, several putative models, including single episodes of restraint/immobilization, forced swim, or early-life maternal separation, show promise as potential PTSD models, but require further validation and characterization before they might be considered specific to this disorder. Given the complexity of PTSD, both in terms of causal factors and symptoms, it is becoming apparent that multiple, independent physiological pathways might mediate this disorder. Future research may, therefore, wish to focus on endophenotypic models, which attend to one specific physiological pathway or neurobiological system, rather than attempt to reproduce the broad range of PTSD symptomatology. Combining information from numerous such models may prove a more efficient strategy.

Ranitidine is widely used for gastroesophageal reflux disease (GERD) in children, but optimal dosing is unclear. We compared effects of weight-based doses of oral ranitidine on gastric pH in children with clinical GERD.Children ages 4-11 years with clinical GERD were enrolled in a multi-center prospective randomized study comparing a fixed dose of ranitidine (Zantac 75) with placebo after an overnight fast; gastric pH was measured for 6 h after the fixed dose (Phase 1). Of the six enrollees from our center, four received active drug during Phase 1; 12 h after the fixed dose, these four children received ranitidine 5 mg/kg (maximum 150 mg) and gastric pH was measured for another 6-12 hours (Phase 2). This report details the effects of two dose ranges (Low Dose, < 3 mg/kg/dose, and High Dose, ≥ 3 mg/kg/dose) on gastric pH in children.The four children were 6.9-11.3 years old and weighed 20.4-49.5 kg. The Low Doses were 1.5-2.7 mg/kg; the High Doses were 3-5 mg/kg. Although the mean percentage of time with gastric pH > 4 during the entire 6 hours following dosing was similar after Low and High Dose (50% vs. 57%, NS), during the last two hours of this interval the mean percentage of time with gastric pH > 4 was only 29% for Low Dose vs. 89% for High Dose (P = 0.006). Moreover, during those two hours, none of the Low Doses kept gastric pH above 4 for > 60% of the time, while all of the High Doses kept pH above 4 for > 60% of the time (P = 0.03). In three of four patients who underwent extended (9-12 h) gastric pH monitoring after High Dose ranitidine, gastric pH was above 4 for more than 40% of total time.Doses of ranitidine ≥ 3 mg/kg/dose may be required for acid suppression lasting beyond 6 hours.

Pentagastrin is a cholecystokinin (CCK)-B agonist and laboratory panicogenic agent that produces endocrine (ACTH and cortisol), symptom (anxiety, panic) and cardiovascular (heart rate) responses. Although in vitro data have supported its chemical stability, preliminary data suggested that increasing time between drug preparation and drug infusion could reduce the magnitude of endocrine and symptom responses. The current study examined this possibility. Twenty-one healthy subjects presented at the University of Michigan General Clinical Research Center (GCRC) and had an intravenous catheter inserted. Heart rate, cortisol levels and subjective anxiety were measured before and after pentagastrin and placebo injections. Pentagastrin was prepared either within 60 min of IV infusion (Normal Preparation group) or at least 3.5 h prior to infusion (Early Preparation group). Relative to the Normal Preparation group, Early Preparation subjects had similar heart rate responses but significantly smaller cortisol and subjective anxiety responses. Early preparation of pentagastrin thus appears to weaken endocrine and subjective anxiety responses, highlighting the importance of attending to often overlooked procedural variables (e.g., time between preparation and administration) in studies of this type. The sensitivity of cortisol and anxiety responses to preparation time, but insensitivity of heart rate, is consistent with previous studies suggesting different thresholds of activation for the three response modalities. These differential sensitivities may suggest different and separable CCK-B stimulated pathways for each response, which combine to produce panic, rather than a single, unified CCK-B mediated panicogenic response.

Chemoprevention represents an attractive modality against colorectal cancer (CRC) although widespread clinical implementation of promising agents (e.g. aspirin/NSAIDS) have been stymied by both suboptimal efficacy and concerns over toxicity. This highlights the need for better agents. Several groups, including our own, have reported that the over-the-counter laxative polyethylene glycol (PEG) has remarkable efficacy in rodent models of colon carcinogenesis. In this study, we undertook the first randomized human trial to address the role of PEG in prevention of human colonic neoplasia. This was a double-blind, placebo-controlled, three-arm trial where eligible subjects were randomized to 8g PEG-3350 (n = 27) or 17g PEG-3350 (n = 24), or placebo (n = 24; maltodextrin) orally for a duration of six months. Our initial primary endpoint was rectal aberrant crypt foci (ACF) but this was changed during protocol period to rectal mucosal epidermal growth factor receptor (EGFR). Of the 87 patients randomized, 48 completed study primary endpoints and rectal EGFR unchanged PEG treatment. Rectal ACF had a trend suggesting potentially reduction with PEG treatment (pre-post change 1.7 in placebo versus -0.3 in PEG 8+ 17g doses, p = 0.108). Other endpoints (proliferation, apoptosis, expression of SNAIL and E-cadherin), previously noted to be modulated in rodent models, appeared unchanged with PEG treatment in this clinical trial. We conclude that PEG was generally well tolerated with the trial failing to meet primary efficacy endpoints. However, rectal ACFs demonstrated a trend (albeit statistically insignificant) for suppression with PEG. Moreover, all molecular assays including EGFR were unaltered with PEG underscoring issues with lack of translatability of biomarkers from preclinical to clinical trials. This data may provide the impetus for future clinical trials on PEG using more robust biomarkers of chemoprevention. Trial registration: ClinicalTrials.gov NCT00828984

Abstract Background Emerging literature supports the use of basivertebral nerve ablation (BVNA) for a specific cohort of patients with chronic low back pain and Type 1 or Type 2 Modic changes from vertebral levels L3–S1. The early literature warrants further evaluation. Studies establishing the efficacy of BVNA use highly selective patient criteria. Objective Provide a first estimate of the prevalence of BVNA candidates in a spine clinic over a year using the foundational studies patient selection criteria? Methods A retrospective review of four fellowhsip trained spine physiatrists patient encounters at a large academic medical center using relevant ICD-10 codes to isolate chronic low back pain without radiating symptoms from January 1, 2019 to January 1, 2020. Charts were then reviewed by a team of physicians for exclusionary criteria from the foundational studies which have demonstrated benefit from BVNA. MRI’s from qualifying charts which did not meet exclusionary criteria were then independently reviewed by four physician for localization and characterization of Modic changes. Results The relevant diagnostic codes query yielded 338 unique patient records. Based on exclusionary criteria or lack of imaging availability, 318 charts were eliminated. The remaining 20 charts qualified for imaging review. There were 11 charts in which there was 100% agreement between all reviewers regarding the presence and either Type 1 or Type 2 Modic changes between vertebral levels L3 to S1. Accordingly, the prevalence of eligibility for BVNA was 3% (11/338, 95% CI 1–5%). Conclusion The population which may benefit from BVNA is small. Our study demonstrated that over a year, the prevalence for BVNA candidacy using the foundational studies criteria was 3% (95% CI 1% – 5%). While physicians may be tempted to use less stringent selection criteria in practice, upon doing so they cannot cite the foundational studies as evidence for the outcomes they expect to achieve. Those outcomes will require more studies which formally assess the benefits of BVNA when selection criteria are relaxed.

Introduction: Successful strategy for bowel preparation (prep) for colonoscopy aims at administering small–volume oral cathartics coupled with restricted solid food intake. An effective, safe, and standardized bowel preparation in children that is easily administered and acceptable has not yet been determined for children undergoing colonoscopy. Methods: This study compared the efficacy and acceptability of oral sodium phosphate (NaP) regimen 1 day prior to the examination at 1 mL/kg/day with a maximum 90 mL (2/3 dose in the morning, a maximum 45 mL, the remainder in the evening) (regimen A) to our standard prep regimen magnesium citrate 4 mL/kg/day in the morning (maximum 240 mL) for 3 days prior to, and a NaP enema the morning of the colonoscopy (regimen B). Both groups were only allowed clear liquids on prep days and nothing by mouth after midnight. After informed consent, 45 children (22 females) were randomized. Weight, vital signs, electrolytes, calcium, phosphorus and magnesium were taken at screening and on the day of the colonoscopy. Questionnaires were given to the subjects to assess acceptability and 10 possible side effects with intensity rating at none, mild, moderate or severe. An endoscopist blinded to the medication rated the bowel prep on a 4-level scale of excellent, good, fair or poor for overall quality of the colon prep and within each of its 5 segments. Results: Median [range] age (yr) and weight (kg) at screening was 13 [9–17], 53 [27–88], and 15 [8–18], 51 [28–109] in A and B, respectively. Mean weight loss of 0.88 and 1.05, SD ± 1.04 kg for A and B, respectively was not significantly different between groups. The mean increase in serum magnesium (mEq/L) was −0.01 vs 0.14 (p=0.001), and the mean increase in serum phosphorus (mg/dL) was 0.40 vs 0.33 (p=NS) in A vs B, respectively. No statistically significant difference was observed in other electrolytes between both groups. There were no serious adverse events reported from both regimens. The side effects were not statistically significant between both regimens, apart from higher nausea intensity in regimen A (p=0.012). Bowel cleansing was similar between the groups; 71% were rated excellent or good. Willingness to repeat the prep was higher in A vs B (77% vs 32%, p<0.006). Ten subjects in regimen A had prior colonoscopies using regimen B; 9 rated A better, 1 rated A the same. Conclusion: Oral NaP is safe and effective for bowel cleansing prior to colonoscopy in children and adolescents. It has a shorter prep time, comparable side effects and is more acceptable than our standard magnesium citrate regimen.

Abstract Background Newer echocardiographic techniques may allow for more accurate assessment of right ventricular function. Adult studies have correlated these echocardiographic measurements with invasive data, but minimal data exist in the paediatric congenital heart population. The purpose of this study was to evaluate echocardiographic measurements that correlate best with right ventricular systolic and diastolic catheterisation parameters. Methods Patients with two-ventricle physiology who underwent simultaneous echocardiogram and cardiac catheterisation were included in this study. Right ventricular systolic echocardiographic data included fractional area change, displacement, tissue Doppler imaging s’ wave, global longitudinal strain, and strain rate s’ wave. Diastolic echocardiographic data included tricuspid E and A waves, tissue Doppler imaging e’ and a’ waves, and strain rate e’ and a’ waves. E/tissue Doppler imaging e’, tissue Doppler imaging e’/tissue Doppler imaging a’, E/strain rate e’, and strain rate e’/strain rate a’ ratios were also calculated. Catheterisation dP/dt was used as a marker for systolic function and right ventricular end-diastolic pressure for diastolic function. Results A total of 32 patients were included in this study. The median age at catheterisation was 3.1 years (0.3–17.6 years). The DP/dt was 493±327 mmHg/second, and the right ventricular end-diastolic pressure was 7.7±2.4 mmHg. There were no significant correlations between catheterisation dP/dt and systolic echocardiographic parameters. Right ventricular end-diastolic pressure correlated significantly with strain rate e’ (r=−0.4, p=0.02), strain rate a’ (r=−0.5, p=0.03), and E/tissue Doppler imaging e’ (r=0.4, p=0.04). Conclusion Catheterisation dP/dt did not correlate with echocardiographic measurements of right ventricular systolic function. Strain rate and tissue Doppler imaging analysis significantly correlated with right ventricular end-diastolic pressure. These values should be further studied to determine whether they may be used as an alternative method to estimate right ventricular end-diastolic pressure in this patient population.

Introduction: The Institute of Medicine called for scientific investigation and the development of guidelines to improve end of life care for pediatric patients with serious illnesses. Despite high morbidity and mortality in pediatric heart transplantation (HTx), research on the end of life care needs of this population is extremely limited. Aims: This study aimed to describe the circumstances surrounding death of pediatric HTx patients and examine associations between location of death and technological interventions at end-of-life with demographic, disease, and HTx-related factors. Methods: This retrospective analysis of the Pediatric Heart Transplant Society registry utilized descriptive statistics and standard univariate analysis to examine associations between location of death and patient factors. Results: Of 9,217 registry entries, 2,804 (30%) deaths occurred; 1,310 while awaiting HTx; 1,494 post-HTx. Location of death was only recorded for 1,113 patients which included 804 waitlist deaths; 89% occurred in the hospital, primarily in ICU settings (74%) with most requiring mechanical ventilation (77%). A subset (39%) were supported by ECMO/VAD at time of death with 69% receiving inotrope support. Location of death was captured for 309 post-HTx patients with only 22% occurring in hospital; primarily in the ICU (74%) with half receiving mechanical ventilation (52%) and a smaller proportion supported by ECMO/VAD (18%) or inotropes (21%) at time of death. Overall, location of death was not associated with patient sex, race, ethnicity, insurance type, or primary etiology. Out of hospital death was associated with older patient age (p&lt;0.01). Family decision to withdraw life-sustaining interventions was included as a contributing cause of death in 5.4% of waitlist cases and 3.5% of post-HTx cases. Conclusions: Death occurred in ~1/3 of patients captured in this pediatric HTx registry. ICU deaths with high use of technological interventions were common, particularly in waitlisted patients, but family decision to discontinue interventions was infrequently cited. Findings underscore the need for palliative care interventions and improved research strategies to better understand end of life in pre- and post-HTx pediatric populations.

Background: We have previously identified a seasonal variation in the prevalence of abdominal pain (AP) in school-age children at the community level. Aims: To investigate the seasonal pattern of consultations for AP in pediatric gastroenterology clinics at different institutions. Methods: The number of outpatient consultations with the diagnosis of AP (ICD-9 789) and the total number of outpatient consultations was obtained from 2 tertiary care institutions (Children's Hospital of Pittsburgh, Children's Memorial Hospital in Chicago) for the years 2001-04. Rates were compared across time periods (period 1: mo February-April vs. period 2: mo June-August) and across cities. In order to assess seasonal variation of comorbidities we analyzed the ratio of consultations for headaches (HA) (ICD-9 784) from one of the centers. Results: The data reveals a similar seasonal pattern every year with a significantly higher ratio of consultations for AP in the winter months and a lower number during summer time in both institutions in 7/8 analyzed periods (<0.005). No significant variation was found in 1/8 periods. A similar and significant pattern was found for the diagnosis of HA every year (p < 0.002) in Pittsburgh with the exception of 2001. Discussion: The pathogenesis of functional gastrointestinal disorders remains unknown. Stress, infections and other environmental factors could play a role. Our data reveals a similar pattern regardless of the geographical location. The fact that a similar curve was found in distant locations with the same academic year, relativizes the role of the environment and makes a possible influence of school stressors more likely. The similar seasonal pattern found for other somatic complaints (HA) reinforces a possible role of stress. Conclusion: We have demonstrated a seasonal variation on the prevalence of AP.

Background QRS prolongation may be a predictor of mortality in certain forms of congenital heart disease. Minimal data exist describing changes in QRS duration in patients with single ventricles (SVs). The goal was to describe changes in QRS duration in patients with SV and to determine if differences existed between single right ventricle (sRV) versus single left ventricle (sLV) patients. Methods Chart review was performed on patients with SV physiology. Patients were divided into sRV and sLV groups. QRS durations were measured monthly for the first 6 months, at 1 year, and then yearly until 10 years. t-tests were used for analysis. Results One hundred sixty patients were evaluated (95 sRV, 65 sLV). The greatest change in QRS duration for the entire cohort occurred in the first 6 months of life versus 6 months to 10 years of age (1.81 ms/month vs 0.20 ms/month). sRV QRS durations were significantly longer than sLV QRS durations at 1 year (78.9 ± 12.6 ms vs 73.2 ± 11.9 ms), 2 year (81.7 ± 14.7 ms vs 73.4 ± 12.5 ms), 4 year (84.2 ± 12.1 ms vs 77.9 ± 16.4 ms), 6 year (90.8 ± 12.7 ms vs 83.4 ± 13.4 ms), 7 year (90.8 ± 16.5 ms vs 81.2 ± 16.6 ms), and 8 year (96.7 ± 13.6 ms vs 84.8 ± 13.9 ms) time points. Conclusion The greatest change in QRS duration in SV patients occurred in the first 6 months of life when these patients’ ventricles were volume loaded. Differences in QRS duration between sRV and sLV patients occurred early in life. Further studies are needed to determine if minimizing volume load early in life decreases the rate of change in QRS duration.

HLA donor-specific antibodies (DSAs) of immunoglobulin (IgG) type are associated with antibody-mediated rejection. Aim of this study was to determine if the IgG subtype was associated with cellular rejection in patients who underwent cardiac transplantation at a pediatric center. Serum samples were obtained in conjunction with endomyocardial biopsies (EMB), which were graded for cellular rejection. DSAs were identified by single-antigen beads (Luminex). A modified single antigen bead assay was used to detect the presence of individual immunoglobulin G subclasses (1-2-3-4). Rejection was classified as higher grade (HR), defined by ISHLT guidelines > grade 1B or no/low grade (NLR), defined as ISHLT guidelines < grade 2. We compared the proportions of IgG subclasses between those with HR and those with NLR. Of 66 patients, 28 were positive for DSA and 38 were negative. In the DSA-positive group, 15 patients had HR and 13 patients had NLR. In the HR group, 14 patients (93.3%) were positive for IgG3 DSA, compared with only 1 patient (7.7%) in the NLR group (p value <0.01). Furthermore, in the HR group, 14/15 (93.3%) patients exhibited DSAs of multiple IgG subtype, compared with only 3/13 (23.1%) in the NLR group (p <0.01). The positive predictive value of the presence of IgG3 subclass for HR was 93%, negative predictive value was 92%, sensitivity was 93%, and specificity was 92%. The prevalence of HLA DSAs of IgG3 subtype was significantly elevated in patients with HR. High-grade rejectors were characterized by multiple IgG subtypes, while low-grade rejectors exhibited DSAs of a single subtype (non-IgG3). The determination of the IgG subclass in DSA-positive patients may be a less invasive method for identifying patients at risk for higher grade cellular rejection.

Factors that determine histopathologic phenotype of antibody mediated heart allograft rejection (AMR) are not known. The purpose of this study was to evaluate associations between histopathology and IgG subtype of anti-HLA donor-specific antibody (DSA) in a single-center pediatric heart transplantation program. We analyzed data from 66 consecutive patients with biopsy proven rejection. Serum samples were timely matched with heart allograft biopsies, which were graded for cellular rejection. DSAs were identified by single-antigen multi-bead array, both by generic IgG, and IgG1-2-3-4 subtype. Rejection was classified as ISHLT higher grade (HR, grade 2) or no/low grade (NLR, grade 1B). We compared the prevalence of IgG subclasses between those with HR and those with NLR. Out of 66 cases, we identified DSAs in 28 patients, while 38 were negative. In the DSA-positive group (table), 15 patients had HR and 13 patients had NLR. IgG3 subtype was more prevalent in the HR group, compared with NLR group (14/15 HR vs 1/13 NLR, p < 0.001). Furthermore, high-grade rejectors with DSA exhibited more IgG subtype combinations when compared to NLR (13/15 HR vs 3/13 NLR, p < 0.01). The positive predictive value of the presence of IgG3 subclass for HR was 93%, negative p. The prevalence of DSAs of IgG3 subtype was significantly elevated in patients with HR. High-grade rejectors were characterized by multiple IgG subtypes, while low-grade rejectors exhibited DSAs of a single subtype (non-IgG3). The determination of the IgG subclass in DSA-positive patients may be a less invasive method for identifying patients at risk for higher grade cellular rejection.Download : Download high-res image (71KB)Download : Download full-size image

Introduction: Advances in pediatric heart failure (HF) therapies have resulted in improved survival and a resultant shift toward improving long-term quality of life. Aim of this study was to determ...

Mini‐Abstract Implantation of the Melody valve in the pulmonary position is well described, but implantation of this valve in other valvular positions is limited to small case series. Intra‐cardiac and three‐dimensional echocardiography clearly delineates the mechanism of tricuspid valve failure and subsequent competency of the Melody valve in the tricuspid position in this 5‐year‐old male with complex medical history. As percutaneous implantation of this valve increases in the other valve positions, obtaining images that clearly define the mechanism of the initial valve failure as well as verifying proper placement and function of the implanted valve will be essential.

G‐protein‐coupled receptors (GPCRs) represent one of the largest and most important classes of membrane proteins for drug discovery. However, due to their inherent flexibility and instability outside of the membrane, they are challenging targets for structural and biophysical studies. Here we demonstrate how these challenges have been overcome through protein engineering, by identifying a minimal number of thermostabilising mutations that can lock a receptor in a single conformation and enhance its survival in a detergent environment. This has been applied to GPCRs from families A, B and C, with peptide or small molecule ligands, and to orphan receptors with no known ligand. The resulting stabilised receptors (StaRs) are more amenable to purification, crystallisation and biophysical analysis of ligand binding. Using this approach, StaRs were generated for Orexin 1 and Orexin 2, two peptide GPCRs involved in regulating the sleep‐wake cycle. The StaRs show decreased agonist signalling, whilst maintaining antagonist binding, consistent with a shift to the antagonist conformation. Structural determination, together with biophysical mapping and fragment screening using surface plasmon resonance (SPR), has led to the rapid identification of highly optimised dual Orexin receptor antagonists (DORAs) with very high affinity, good pharmacokinetics and excellent in vivo activity in models of insomnia.

Xeroderma pigmentosum (XP) is a rare autosomal recessive disorder with defective nucleotide excision repair (NER). XP complementation group C (XP-C) patients have normal sunburn reaction but develop skin cancers at an early age (< 10 years). XP-C patients have a 2,000 to 10,000-fold increase in melanoma and non-melanoma skin cancer but no neurological abnormalities. Previous studies have reported that XP-C patients harboring missense, in-frame deletions, splice site or splice lariat mutations are clinically milder and live longer than XP-C patients with premature termination codon (PTC) mutations. mRNA containing PTC is removed by nonsense mediated decay resulting in reduced levels of XPC mRNA. To investigate the relationship between the amount of XPC protein and the clinical phenotype, we studied the expression of XPC protein in patients’ cells using a sensitive capillary western system. Four XP-C patients (XP24BE, XP54BE, XP59DC, XP518BE) with PTC mutations had no detectable XPC protein and severe clinical disease. In contrast, cells from patients with missense (XP495BE) or splice lariat (XP72TMA, XP14BE and XP377BE) mutations had 0.8 to 4.5 % of normal XPC protein and mild clinical disease. Quantitation of XPC protein may be useful for prediction of severe or mild phenotypes in XP-C patients.

Current guideline-driven recommendations for controlling the potentially life-threatening arrhythmias (torsades de pointes) associated with congenital long QT syndrome (LQTS) include lifestyle modification, avoidance of QT-prolonging drugs, and beta-blocker therapy. A subset of patients require advanced therapies, including placement of an implantable cardioverter–defibrillator, concomitant antiarrhythmic medications (sodium channel blockers, among others), and/or left or bilateral cardiac sympathetic denervation because of persistent malignant arrhythmias. 1 Priori S. Wilde A. Horie M. et al. HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes. Heart Rhythm. 2013; 10: 1932-1963 Abstract Full Text Full Text PDF PubMed Scopus (1249) Google Scholar , 2 Zipes D.P. Camm A.J. Borggrefe M. et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death- executive summary. Circulation. 2006; 114: e385-e484 Crossref PubMed Scopus (994) Google Scholar , 3 Hocini M. Pison L. Proclemer A. Larson T.B. Madrid A. Blomstrom-Lundqvist C. Diagnosis and management of patients with inherited arrhythmia syndromes in Europe. Europace. 2014; 16: 600-603 Crossref PubMed Scopus (29) Google Scholar Cardiac transplantation in children and adolescents with long QT syndromeHeart RhythmVol. 14Issue 8PreviewLong QT syndrome (LQTS) is a potentially lethal, yet highly treatable, cardiac channelopathy. Cardiac transplantation has been reported anecdotally for patients with severe LQTS refractory to standard therapies. Full-Text PDF

1. Kazem I. A new scintigraphic technique for the study of esophagus. Am J Roentgenol 1972;115:681–5. 2. Kjellen G, Svedberg JB, Tibbling L. Solid bolus transit by esophageal scintigraphy in patients with dysphagia and normal manometry and radiography. Dig Dis Sci 1984;29:1– 4. 3. Taillefer R, Beauchamp G, Duranceau A, et al. Nuclear medicine and esophageal surgery. Clin Nucl Med 1986;11:445–51. 4. Gross R, Johnson LP, Haminski DJ. Esophageal emptying in achalasia quantitated by radioisotope technique. Dig Dis Sci 1979;24:945–9. 5. Blackwell JN, Hannan WJ, Adam RD. Radionuclide transit studies in detection of esophageal dysmotility. Gut 1983;24:421–4. 6. Russell COH, Hill LD, Homes ER, et al. Radionuclide transit: a sensitive screening test for esophageal dysfunction. Gastroenterology 1981;80:887–91. 7. Taillefer R, Jadiwalla M, Pellerin E, et al. Radionuclide esophageal transit study in detection of esophageal motor dysfunction: comparison with motility studies (manometry). J Nucl Med 1990;31:1921–6.

Introduction: Eosinophilic Esophagitis (EoE) is a chronic immunologic disorder characterized by esophageal dysfunction and dense esophageal eosinophilia. The incidence rates are 5.1 and 7 per 100,000 person years in children and adults respectively, and is described to affect a predominantly caucasian population. An initial histologic response to Proton Pump Inhibitor has long been viewed as favoring Gastroesophageal reflux disease and its use is thus proposed in the diagnostic approach. It is evident from recent literature that PPI therapy has an anti-eosinophil effect, thereby inducing a histologic response independent of GERD status. We investigated the response to the initial PPI regimen in a uniquely diverse cohort of children with EoE. Methods: We performed a retrospective review of data pertaining to children referred to the multidisciplinary EoE clinic at Children's National Medical Center (CNMC). We included children with EoE (peak >15 eos/hpf at any esophageal level) who underwent a histologic reassessment after 8 weeks of PPI (1-3 mg/kg/day) at CNMC. Histologic response was defined as 5-15 eos/hpf and remission as <5 eos/hpf. Results: We reviewed data for 71 children with EoE, age 8 mo-17 yr (6 yr), Caucasian 26 (36.6%), and 43% African Americans (AA) among non-Caucasians. Only 15 children met inclusion criteria comprising of 73% males, 53% non-Caucasians including 33% AA, age range 1-17 yr (7.6 yr). Histologic remission with minimal symptomatic improvement occurred in only 1 patient. The pre-PPI and post-PPI therapy peak eos/hpf were 10-100 (52) and 1-100 (54), p = 0.74). Conclusion: We did not observe PPI therapy as sufficient to alter esophageal histologic status favorably in contrast to adults with EoE. To our knowledge, our Pediatric EoE, is the only uniquely non Caucasian predominant cohort reported to date. The retrospective nature, variable regimens, and absence of formal GERD investigations are limitations of the study. Extending the analysis to additional patients is expected to provide useful insight into PPI effects in EoE.

Introduction: Non-ulcer dyspepsia (NUD) is a symptom complex of upper abdominal pain, nausea, vomiting, early satiety and fullness. We propose to test the hypothesis that children with NUD compared with organic dyspepsia (OD) have gastric sensorimotor abnormalities by using the gastric barostat. Methods: Children 8–18 years old with dyspepsia were enrolled prospectively to undergo a gastric barostat study. Rome II criteria were used to define NUD while OD was referred to abnormal upper GI pathology or other abnormal investigations. The barostat catheter and polyethylene bag assembly was placed per os in the fundus at the time of an elective upper endoscopy. Compliance and sensory thresholds were determined by the ascending method of limits. Gastric tone was measured for 10 minutes at minimal distending pressure plus 2 mm Hg; accommodation to an 8 oz isocaloric liquid meal was assessed and compared with results from 5 healthy adults. Results: Twenty two children were enrolled in the study and 20 completed the barostat. Five (2 males) healthy controls had a median age of 26 year (21–45)[P=0.00 v NUD and OD]. Children with OD were diagnosed to have one or more of the following: peptic esophagitis=5, eosinophilic esophagitis=1, acute gastritis=1, chronic gastritis=4, duodenitis=1, food allergies=1, and lactose intolerance=1. Gasric compliance (mmHg/mL)curves were similar in both groups. The mean (SD) pre- and post-meal volumes were: NUD=164.3 mL (140.5) and 214 mL (160.4) [P=NS], OD=217.5 mL (44.7) and 311.5 mL (144) [P=NS], and controls=250 mL (84.8) and 430 mL (172) [P=0.01] respectively. Accommodation volumes were 49.7 mL (NUD), 94 mL (OD) and 180 mL (controls, P=0.05 v NUD). The first sensory perception was at a pressure of 12.5 mm Hg in NUD and 12.7 mm Hg in OD.Table 1Conclusion: There are similarities in the gastric sensorimotor parameters in children with NUD compared with OD. Organic disorders may lead to or co-exist with altered visceral perception, and thus overlap with NUD. A longer duration of symptoms preceded the diagnosis of NUD compared with OD. Data in dyspepsia free children may provide support to the proposed hypotheses of impaired accommodation and hypersensitivity in NUD.

Aims: To determine the occurrence of GERD in children following gastrostomy tubes (GT), and the predictors of escalation of anti-reflux interventions. Methods: Retrospective chart review to identify all children with ICD-9 codes for GT at our hospital during 8/1/2004 to 5/1/2006: PEG (43246), PEG tube placement (43750), Gastrostomy/G-tube (43832), and Nissen (43324). Data related to the indications for the procedure, pre and post GT evaluation of GERD & aspiration (history, UGI, pH-Impedance, EGD & biopsies, gastric scintigraphy), neurological disorders, and anti-reflux therapy were reviewed. The diagnosis of GERD was based on the primary GI provider's global assessment of the pre-procedure evaluation. Results: 47 children (20 males) had GT at a mean age of 65 mo (2-242) for nutritional management. 43 (91%) under went PEG tube placement. The mean follow-up post-GT was 9.8 mo (1-25 mo). GERD was diagnosed in 32 (68%) children in the pre-GT evaluation; 30 (64%) were treated with acid suppression, and 11 (23%) with prokinetics. Neurological disorders were diagnosed in 25 (53%) and 17 (68%) of them also had co-existing GERD. Aspiration was detected in 10 (21%) patients. In the post-GT evaluation GERD was assessed as having worsened in 17 (36%) children. Four (23 %) of these children required conversion to a jejunal tube on an average of 3.5 mo (1-5) after GT. Thirteen (76%) of all patients requiring escalation of anti-reflux therapy had a previous diagnosis of a neurological disorder. All of the patients requiring conversion to jejunal tube were also previously diagnosed and treated for GERD, but aspiration evaluation had been negative. Conclusions: 1) There was increased, but statistically non-significant, rate of conversion to jejunal tube with diagnosis of neurological disorders prior to gastrostomy placement. 2) Escalation of anti-reflux therapy was common in patients with neurological disorders. 3) Diagnosis of aspiration prior to GT placement did not predict need for escalation of anti-reflux therapy and/or the need for conversion to a jejunal tube.