The BRAF and NRAS mutation prevalence in dermoscopic subtypes of acquired naevi reveals constitutive mitogen-activated protein kinase pathway activation.

BACKGROUND: Acquired naevi can have unique dermoscopic patterns that correspond to distinct microanatomical growth patterns. Previous studies on acquired naevi stratified according to dermoscopic pattern focused on the frequency of somatic BRAF mutations, whereas NRAS mutations remained to be elucidated. OBJECTIVES: To investigate the BRAF and NRAS mutation prevalence and activation of the mitogen-activated protein kinase (MAPK) pathway in distinct dermoscopic subtypes of acquired naevi. METHODS: Common mutations present in BRAF and NRAS were assessed in 40 globular, reticular and peripheral rim of globules (PG) subtypes of acquired naevi from 27 participants (19 male, 8 female; mean age 46·7 years) selected from 1261 eligible volunteers. Mutations were determined using the highly sensitive and quantitative QX200 droplet digital™ polymerase chain reaction (ddPCR) system. RESULTS: The BRAF V600E (c.1799T>A or c.1799_1800delTGinsA) and BRAF V600K mutations were detected in 85% (n = 34/40) of naevi. All BRAF wild-type naevi (15%; n = 6/40) harboured an NRAS codon 12/13 or 61 mutation. BRAF mutations were present in 92% (n = 12/13) of globular and 100% (n = 12/12) of PG naevi, whereas reticular naevi were 67% (n = 10/15) BRAF- and 33% (n = 5/15) NRAS-mutant (P = 0·037). CONCLUSIONS: We discovered that 100% of the assessed acquired naevi had either a BRAF or NRAS mutation. Using sensitive techniques capable of single-cell mutation detection, it is likely that all acquired naevi will be mutated for BRAF or NRAS. Because both of these mutations are prevalent in distinct dermoscopic naevus subsets, our study supports the role of the MAPK pathway in the development of benign melanocytic proliferations, indicating that additional genomic events besides somatic mutations in BRAF or NRAS are required for melanoma development.

Histopathology and reflectance confocal microscopy features of photodamaged skin and actinic keratosis.

BACKGROUND: Actinic keratosis (AK) usually co-exists in areas of severe photodamage, but the clinical applicability of reflectance confocal microscopy (RCM) in diagnosing AK currently depends on a set of parameters yet to be defined in comparison to photodamaged skin (PD). OBJECTIVE: To correlate the RCM features of PD and AK with histopathology. METHODS: Twenty participants with a mean age of 64 years and skin phototype I and II were studied. RCM was performed on two PD and one AK within a field of 25 cm2 on the left dorsal forearm, followed by shave biopsies. Blinded evaluation of the histopathological and RCM images using established parameters in AK were performed retrospectively in consensus with an expert confocalist, correlated with the histopathological diagnosis by a board-certified dermatopathologist. RESULTS: A total of 57/60 areas were included. There were 43/57 (75%) and 14/57 (25%) histopathologically confirmed PD and AK respectively. Individual corneocytes, stratum corneum disruption, dermal inflammatory cells, increased vascularity/dilated vessels and solar elastosis were detected in PD and AK upon histopathology and RCM. The features in favour of AK were parakeratosis, hyperkeratosis, more severe keratinocyte pleomorphism and architectural disruption, and the presence of epidermal inflammatory cells. PD also demonstrated keratinocyte pleomorphism and architectural disruption though this was generally less severe than AK. A small subset of PD exhibited a comparable degree of keratinocyte pleomorphism and architectural disruption to the AKs in the cohort. CONCLUSIONS: The viable epidermis demonstrates PD and AK to be part of a disease continuum corresponding to field cancerization. Individual corneocytes, stratum corneum disruption, dermal inflammatory cells, increased vascularity/dilated vessels and solar elastosis may be present in PD; whereas, parakeratosis and hyperkeratosis may represent the key to distinguishing AK from PD using RCM. The significance of epidermal inflammatory cells in the RCM diagnosis of AK remains to be elucidated.

How spirituality is understood and taught in New Zealand medical schools.

OBJECTIVES: The objective of this research was to explore how spirituality is currently understood and taught in New Zealand Medical Schools. METHODS: A mixed methods study was carried out involving interviews (n = 14) and a survey (n = 73). The first stage of the study involved recorded semi-structured interviews of people involved in curriculum development from the Dunedin School of Medicine (n = 14); which then informed a cross-sectional self-reported electronic survey (n = 73). RESULTS: The results indicate that spirituality is regarded by many involved in medical education in New Zealand as an important part of healthcare that may be taught in medical schools, but also that there is little consensus among this group as to what the topic is about. SIGNIFICANCE OF RESULTS: These findings provide a basis for further discussion about including spirituality in medical curricula, and in particular indicate a need to develop a shared understanding of what 'spirituality' means and how it can be taught appropriately. As a highly secular country, these New Zealand findings are significant for medical education in other secular Western countries. Addressing spirituality with patients has been shown to positively impact a range of health outcomes, but how spirituality is taught in medical schools is still developing across the globe.

Disability in multiple sclerosis and the provision of social and medical services: findings in Wellington, New Zealand.

A study of the incapacity and socioeconomic scales in 120 patients with multiple sclerosis (MS) living in Wellington, New Zealand, is described. The questionnaire has been compared by different health professionals. There was good correlation between the observations of different professionals on incapacity analysis and this may be improved by reducing the questions to six. The findings on the socioeconomic scale, however, cannot be predicted accurately from the incapacity scale. The socioeconomic survey revealed major improvement in patient support in New Zealand during the last decade. We consider that our New Zealand findings indicate the value of field officers concerned with co-ordination of services and provision of information for patients with MS. Future research should be directed towards assessment of support systems.

Effects of ethanol on plasma catecholamines and norepinephrine clearance.

Plasma catecholamines were measured in nine men after they had drunk either 0.5 or 1 ml/kg ethanol. Ethanol was found to induce a dose-dependent rise in plasma norepinephrine concentrations. Epinephrine concentrations were also raised in the initial intoxication phase. To determine whether ethanol raises plasma norepinephrine through increased release or decreased clearance (Cl), we infused norepinephrine into eight male subjects with and without prior ethanol, each subject acting as his own control. During infusions after ethanol, norepinephrine concentrations rose higher, and the mean circulatory Cl of norepinephrine was reduced from 76 to 47 ml/kg/min. This was associated with a prolongation of norepinephrine t 1/2 from 1.7 to 2.05 min. No significant difference in circulatory input of norepinephrine was found between infusions with and without ethanol. These results indicate that ethanol consumption increases plasma norepinephrine by reducing its circulatory Cl.

Comparative trial of valproate sodium and clonazepam in chronic epilepsy.

A crossover comparative study of valproate sodium and clonazepam in the treatment of 32 adult epileptic patients receiving multiple drug therapy is described. Serum concentrations of other anticonvulsant drugs were unchanged by the addition of clonazepam. However, patients receiving high doses of other anticonvulsant drugs had lower serum concentrations of clonazepam (p less than .01). With valproate sodium, phenobarbital concentrations increased (P less than .05) in patients receiving phenobarbital but not significantly in patients receiving primidone. Phenytoin concentrations were reduced (P less than .05) during treatment with valproate sodium. Both drugs significantly reduced the frequency of minor seizures, with valproate sodium having the greater effect. However, it is important to monitor serum concentrations of other anticonvulsant drugs during treatment with valproate sodium since changes in these may influence seizure control or cause side effects.

Drugs and folate metabolism.

Folates are a group of compounds which are required in the diet and are important in DNA, amino acids and possibly also amine metabolism. The biologically active folates are in the tetrahydro form. Tetrahydrofolates are produced from unreduced dietary folates by the enzyme dihydrofolate reductase. A number of drugs such as aminopterin, methotrexate (amethopterin), pyrimethamine, trimethoprim and triamterene act as folate antagonists and produce folate deficiency by inhibiting this enzyme. With other drugs which produce low serum and tissue concentrations of folate such as anticonvulsants, antituberculosis drugs, alcohol and oral contraceptives, the mechanism of this effect is uncertain. Possible mechanism include reduced absorption, prevention of release of folate from tissue stores, altered plasma protein binding, or increased folate metabolism in the liver. Treatment with folic acid antagonists such as methotrexate readily causes megaloblastic anaemia; this can be prevented by therapy with folinic acid (5-formyltetrahydrofolate). The role of other drugs in producing megaloblastic anaemia is less certain, e.g. it occurs in less than 0.75% of patients receiving anticonvulsants. The possible neurological and psychiatric effects of folate deficiency are also uncertain. However, in patients with folate deficiency who have neuropsychiatric symptoms, neuropathy or myelopathy, and normal vitamin B12 levels, it may be of value to try therapy with folic or folinic acid.

The role of folate deficiency in the development of peripheral neuropathy caused by anticonvulsants.

To investigate the role of folate deficiency in neuropathy caused by anticonvulsants, electrophysiological studies of peripheral nerve function were carried out on 29 epileptic patients on long-term anticonvulsant therapy. All but three patients showed abnormalities in one or more electrophysiological measurements, the main abnormality being in amplitude of sensory nerve action potential--this was reduced or absent in 76% of patients. All patients had low concentrations of folate in serum and CSF, these being below the normal ranges in 19 patients. These 19 patients were treated with folate, either 5-formyltetrahydrofolate (10 patients) or folic acid (9 patients), over a period of one month. After therapy all patients had normal levels of folate in serum and CSF, slightly higher levels in CSF being obtained in those receiving 5-formyltetrahydrofolate. Folate therapy significantly reversed abnormalities in motor and sensory nerve distal latencies; the effect was greater with 5-formyltetrahydrofolate, apparently because this produced higher CSF folate concentrations than folic acid. We conclude that folate deficiency may be involved in the development of peripheral neuropathy due to anticonvulsants.

The effects of acute and chronic ingestion of ethanol on the autonomic nervous system.

Evidence is reviewed linking clinical effects of ethanol with actions on the sympathetic and parasympathetic nervous systems. The studies reported include a series of investigations by the authors. Acutely, ethanol causes peripheral vasodilation and may also result in changes in heart rate and blood pressure. Ethanol may contribute to acute problems which may present clinically, including micturition syncope, accidental hypothermia and facial flushing. However, increased sympathetic nervous activity plays a role in causing hypertension and other symptoms during ethanol withdrawal in chronic alcoholics. Some chronic alcoholics may have neuropathy involving sympathetic nerves, and this can result in distal sweating loss and occasionally in orthostatic hypotension. Also, hypothalamic lesions associated with Wernicke's encephalopathy may result in hypothermia. Neuropathy involving parasympathetic nerves in not uncommon in alcoholics with other evidence of nervous system damage, but it is generally asymptomatic. Occasionally, vagal neuropathy may cause disorder of gastrointestinal motility, and neuropathy affecting the sacral innervation may be a factor in alcoholic impotence.

No improvement in ethanol-induced memory deficits after administration of a vasopressin analog.

Acute ingestion of ethanol impairs memory, an effect which might be related to ethanol-induced inhibition of vasopressin release. This was studied using tests of memory and cognitive function in 26 normal subjects before and after ethanol ingestion. Equal numbers of subjects received randomly, by double-blind intranasal administration, placebo or 1-desamino-8-D-arginine vasopressin prior to ethanol ingestion. Administration of the vasopressin analog did not reverse the ethanol-induced deficits in memory and cognitive function.

Effects of ethanol on cardiovascular and catecholamine responses to mental stress.

The purpose of this study was to examine the effects of ethanol on heart rate, blood pressure and plasma noradrenaline and adrenaline responses to mental stress, involving reactions to anxiety and excitement produced using a cognitive task with electric shock and a competitive electronic game respectively. Twenty subjects were studied, each subject acting as his own control by participating twice, with and without prior ethanol consumption. Mental stress was associated with significant increases in all variables except plasma noradrenaline during the cognitive task. Ethanol raised baseline heart rate and plasma adrenaline, but significantly reduced the responses of these variables to the cognitive task but not to the electronic game. Systolic blood pressure responses to both experimental stressors and diastolic blood pressure responses to the electronic game were also significantly reduced after ethanol. These results may reflect a tension-reducing effect of ethanol in situations associated with anxiety, but suggest a more general effect of ethanol on blood pressure reactivity.

Alcoholic brain damage and neurological symptoms of alcohol withdrawal--manifestations of overhydration.

Central nervous system damage is a major complication of alcohol abuse. Vitamin deficiency, particularly thiamine deficiency, has a role in producing pathological and psychological changes of alcoholic brain damage, but it is likely that alcohol has a direct toxic effect on the brain. It is proposed that neuropathological abnormalities seen in alcoholics, and also neurological symptoms during alcohol withdrawal, may reflect cerebral edema caused by alcohol. The neurological symptoms of alcohol withdrawal show a similarity to those seen in hyponatremia or water intoxication. It is suggested that alcoholics show overhydration particularly during withdrawal and that pathological changes in the alcoholic brain are related to cerebral edema. Cerebral edema in withdrawing alcoholics may be caused by inappropriate section of vasopressin (antidiuretic hormone).

Prescribing patterns for epilepsy.

All prescriptions for anticonvulsants written over a four month period for patients in the Wellington area were identified. Of 1479 patients receiving anticonvulsants, 139 were suspected of receiving medication for conditions other than epilepsy. The prevalence of treated epilepsy in Wellington is 4.1 per 1000 population. Thirty-eight percent of patients were on multiple anticonvulsants, which compares favourably with reports of excessive polypharmacy in Europe. However, there was excessive reliance on standard anticonvulsant doses, given at frequent intervals regardless of probable rates of metabolism. Failure of compliance, as assessed by the time intervals between collection of drugs, was shown by 21 percent of patients.

Non-compliance with anticonvulsant therapy as a cause of seizures.

Compliance with anticonvulsant therapy was assessed in 95 epileptic subjects with uncontrolled seizures. Following a seizure for which an ambulance was called, patients were interviewed and questioned on their medication taking. Compliance was also determined from measurement of anticonvulsant concentrations in saliva, and from intervals between collection of drugs from pharmacy. Compliance failure was found to be instrumental in precipitating 29 (31%) of seizures for which the ambulance was called. At the time of interview, 35 (37%) subjects were not taking their medication regularly in accordance with prescribing instructions. In addition to forgetting medication, many subjects deliberately stopped or changed doses of drugs. Other causes of non-compliance which were indentified included patient misunderstanding of prescribing instructions. Compliance with therapy was positively related to perceived benefit from anticonvulsant therapy.

Epilepsy and driving.

A survey was made of driving habits of 103 epileptic patients who, having suffered a seizure, were picked up by the Wellington Free Ambulance Service. It was found that 21 (20%) subjects were driving a motor vehicle--for nine this was necessary for their employment; 57% of drivers with epilepsy reported that the Ministry of Transport had not been informed of their epilepsy. For three subjects a driving accident was a direct result of their seizure. Forty-three percent of subjects in this study claimed never to have had any professional advice about driving. Of the 21 subjects who continued to drive, 13 were receiving inadequate drug therapy at the time of seizure. Advice and drug therapy for epileptic patients therefore required regular review. We consider that the Ministry of Transport should issue a simple statement about epilepsy and driving which should explain the law, risks, precipitating factors for epilepsy, and the need for good drug control. This should be issued to doctors and also be available for those applying for a driving licence.

Mortality associated with alcoholism in New Zealand.

Rates of mortality were determined in patients attending an alcoholic assessment centre. The study group comprised 1068 patients, studied for a mean of 1.5 years after referral. A total of 50 deaths occurred, being four times the expected death rate in the general population. Significantly increased mortality rates were found for deaths from cirrhosis, other digestive disease, cardiovascular disease, neoplasms, trauma and alcoholism. In 15 patients death was due to definite alcohol-related causes.

A potent Chk1 inhibitor is selectively cytotoxic in melanomas with high levels of replicative stress.

There are few effective treatments for metastatic melanoma. Checkpoint kinase 1 (Chk1) inhibitors are being trialled for their efficacy in enhancing conventional chemotherapeutic agents, but their effectiveness as single agents is not known. We have examined the effectiveness of two novel Chk1 selective inhibitors, AR323 and AR678, in a panel of melanoma cell lines and normal cell types. We demonstrate that these drugs display single-agent activity, with IC50s in the low nanomolar range. The drugs produce cytotoxic effects in cell lines that are most sensitive to these drugs, whereas normal cells are only sensitive to these drugs at the higher concentrations where they have cytostatic activity. The cytotoxic effect is the consequence of inhibition of S-phase Chk1, which drives cells prematurely from late S phase into an aberrant mitosis and results in either failure of cytokinesis or cell death through an apoptotic mechanism. The sensitivity to the Chk1 inhibitors was correlated with the level of endogenous DNA damage indicating replicative stress. Chk1 inhibitors are viable single-agent therapies that target melanoma cells with high levels of endogenous DNA damage. This sensitivity suggests that Chk1 is a critical component of an adaptation to replicative stress in these cells. It also suggests that markers of DNA damage may be useful in identifying the melanomas and potentially other tumour types that are more likely to be sensitive to Chk1 inhibitors as single agents.