Functional analysis of rare variants found in schizophrenia implicates a critical role for GIT1-PAK3 signaling in neuroplasticity.

Although the pathogenesis of schizophrenia (SCZ) is proposed to involve alterations of neural circuits via synaptic dysfunction, the underlying molecular mechanisms remain poorly understood. Recent exome sequencing studies of SCZ have uncovered numerous single-nucleotide variants (SNVs); however, the majority of these SNVs have unknown functional consequences, leaving their disease relevance uncertain. Filling this knowledge gap requires systematic application of quantitative and scalable assays to assess known and novel biological functions of genes. Here we demonstrate loss-of-function effects of multiple rare coding SNVs found in SCZ subjects in the GIT1 (G protein-coupled receptor kinase interacting ArfGAP 1) gene using functional cell-based assays involving coexpression of GIT1 and PAK3 (p21 protein (Cdc42/Rac)-activated kinase 3). Most notably, a GIT1-R283W variant reported in four independent SCZ cases was defective in activating PAK3 as well as MAPK (mitogen-activated protein kinase). Similar functional deficits were found for a de novo SCZ variant GIT1-S601N. Additional assays revealed deficits in the capacity of GIT1-R283W to stimulate PAK phosphorylation in cultured hippocampal neurons. In addition, GIT1-R283W showed deficits in the induction of GAD1 (glutamate decarboxylase 1) protein expression. Extending these functional assays to 10 additional rare GIT1 variants revealed the existence of an allelic series with the majority of the SCZ case variants exhibiting loss of function toward MAPK activation in a manner correlated with loss of PAK3 activation. Taken together, we propose that rare variants in GIT1, along with other genetic and environmental factors, cause dysregulation of PAK3 leading to synaptic deficits in SCZ.

Copy number variation in schizophrenia in Sweden.

Schizophrenia (SCZ) is a highly heritable neuropsychiatric disorder of complex genetic etiology. Previous genome-wide surveys have revealed a greater burden of large, rare copy number variations (CNVs) in SCZ cases and identified multiple rare recurrent CNVs that increase risk of SCZ although with incomplete penetrance and pleiotropic effects. Identification of additional recurrent CNVs and biological pathways enriched for SCZ CNVs requires greater sample sizes. We conducted a genome-wide survey for CNVs associated with SCZ using a Swedish national sample (4719 cases and 5917 controls). High-confidence CNV calls were generated using genotyping array intensity data, and their effect on risk of SCZ was measured. Our data confirm increased burden of large, rare CNVs in SCZ cases as well as significant associations for recurrent 16p11.2 duplications, 22q11.2 deletions and 3q29 deletions. We report a novel association for 17q12 duplications (odds ratio=4.16, P=0.018), previously associated with autism and mental retardation but not SCZ. Intriguingly, gene set association analyses implicate biological pathways previously associated with SCZ through common variation and exome sequencing (calcium channel signaling and binding partners of the fragile X mental retardation protein). We found significantly increased burden of the largest CNVs (>500 kb) in genes present in the postsynaptic density, in genomic regions implicated via SCZ genome-wide association studies and in gene products localized to mitochondria and cytoplasm. Our findings suggest that multiple lines of genomic inquiry--genome-wide screens for CNVs, common variation and exonic variation--are converging on similar sets of pathways and/or genes.

Detecting large copy number variants using exome genotyping arrays in a large Swedish schizophrenia sample.

Although copy number variants (CNVs) are important in genomic medicine, CNVs have not been systematically assessed for many complex traits. Several large rare CNVs increase risk for schizophrenia (SCZ) and autism and often demonstrate pleiotropic effects; however, their frequencies in the general population and other complex traits are unknown. Genotyping large numbers of samples is essential for progress. Large cohorts from many different diseases are being genotyped using exome-focused arrays designed to detect uncommon or rare protein-altering sequence variation. Although these arrays were not designed for CNV detection, the hybridization intensity data generated in each experiment could, in principle, be used for gene-focused CNV analysis. Our goal was to evaluate the extent to which CNVs can be detected using data from one particular exome array (the Illumina Human Exome Bead Chip). We genotyped 9100 Swedish subjects (3962 cases with SCZ and 5138 controls) using both standard genome-wide association study (GWAS) and exome arrays. In comparison with CNVs detected using GWAS arrays, we observed high sensitivity and specificity for detecting genic CNVs 400 kb including known pathogenic CNVs along with replicating the literature finding that cases with SCZ had greater enrichment for genic CNVs. Our data confirm the association of SCZ with 16p11.2 duplications and 22q11.2 deletions, and suggest a novel association with deletions at 11q12.2. Our results suggest the utility of exome-focused arrays in surveying large genic CNVs in very large samples; and thereby open the door for new opportunities such as conducting well-powered CNV assessment and comparisons between different diseases. The use of a single platform also minimizes potential confounding factors that could impact accurate detection.

[Implantable cardiac defibrillator (ICD): basics and present clinical guidelines]. / Défibrillateur automatique implantable (DAI): principes de base et indications cliniques actuelles.

An implantable cardiac defibrillator (ICD) is a cardiac implantable electronic device that is capable of identifying and treating ventricular arrhythmias. Consideration about the type of ICD to select for a given patient include whether the patient has bradycardia requiring pacing support, has associated atrial tachyarrhythmias, or would benefit from cardiac resynchronization therapy. The ICD functions by continuously monitoring the patient's cardiac rate and delivering therapies (anti-tachycardia pacing, shocks) when the rate exceeds the programmed rate "cutoff". Secondary prevention trials have demonstrated that ICDs reduce the incidence of arrhythmic death and total mortality in patients presenting with a cardiac arrest. ICDs are also indicated for primary prevention of sudden cardiac death in specific high-risk subgroups of patients.

[Percutaneous closure of left atrial appendage: a new hope for patients with atrial fibrillation?]. / Fermeture percutanée de l'auricule gauche: un nouvel espoir pour le patient en fibrillation auriculaire?

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The risk of thromboembolic events is important, and at that time, there is no definite treatment for AF. Oral anticoagulation also represents a hemorrhagic risk factor. Ninety percent of atrial thrombi are located within the left atrial appendage. The percutaneous closure of this left atrial appendage with a device has been shown to decrease thromboembolic events even after interruption of oral anticoagulation as compared to warfarin in a recent randomized study. Recent data support this innovative technique as a reasonable alternative to long term anticoagulation in patients at high risk of bleeding.

[Past, present and future of percutaneous catheter ablation technologies for cardiac arrhythmias]. / Passé, present et futur des technologies d'ablation percutanée des arythmies cardiaques.

Drug therapy treatment of cardiac arrhythmias has been disappointing, while percutaneous catheter ablation, efficient and at low risk, has become the first line therapy of the majority of rhythm disturbances, in only two decades. The ultimate challenge, which is atrial fibrillation ablation, is on the way to be successfully solved. This is mainly due to: innovative ablational energy sources; 3D virtual electro-anatomical reconstructions of heart cavities, to map and understand complex arrhythmias' circuits; revolutionary magnetic navigation systems that permit the target positioning of the catheters in the most inaccessible places, even though the operator works at a command board placed away from the patient.

The utility of the MELD score in predicting mortality following liver resection for metastasis.

BACKGROUND: The MELD score has been demonstrated to be predictive of hepatectomy outcomes in mixed patient samples of primary and secondary liver cancers. Because MELD is a measure of hepatic dysfunction, prior conclusions may rely on the high prevalence of cirrhosis observed with primary lesions. This study aims to evaluate MELD score as a predictor of mortality and develop a risk prediction model for patients specifically undergoing hepatic metastasectomy. METHODS: ACS-NSQIP 2005-2013 was analyzed to select patients who had undergone liver resections for metastases. A receiver operating characteristic (ROC) analysis determined the MELD score most associated with 30-day mortality. A literature review identified variables that impact hepatectomy outcomes. Significant factors were included in a multivariable analysis (MVA). A risk calculator was derived from the final multivariable model. RESULTS: Among the 14,919 patients assessed, the mortality rate was 2.7%, and the median MELD was 7.3 (range = 34.4). A MELD of 7.24 was identified by ROC (sensitivity = 81%, specificity = 51%, c-statistic = 0.71). Of all patients above this threshold, 4.4% died at 30 days vs. 1.1% in the group ≤7.24. This faction represented 50.1% of the population but accounted for 80.3% of all deaths (p < 0.001). The MVA revealed mortality to be increased 2.6-times (OR = 2.55, 95%CI 1.69-3.84, p < 0.001). A risk calculator was successfully developed and validated. CONCLUSIONS: MELD>7.24 is an important predictor of death following hepatectomy for metastasis and may prompt a detailed assessment with the provided risk calculator. Attention to MELD in the preoperative setting will improve treatment planning and patient education prior to oncologic liver resection.

Heart rate dynamics at the onset of ventricular tachyarrhythmias as retrieved from implantable cardioverter-defibrillators in patients with coronary artery disease.

BACKGROUND: The recent availability of implantable cardioverter-defibrillators (ICDs) that record 1024 R-R intervals preceding a ventricular tachyarrhythmia (VTA) provides a unique opportunity to analyze heart rate variability (HRV) before the onset of VTA. METHODS AND RESULTS: Fifty-eight post-myocardial infarction patients with an implanted ICD for recurrent VTA provided 2 sets of 98 heart rate recordings in sinus rhythm: (1) before a VTA and (2) during control conditions. Three subgroups were considered according to the antiarrhythmic (AA) drug regimen. A state of sympathoexcitation was suggested by the significant reduction in HRV before VTA onset compared with control conditions. beta-Blockers and dl-sotalol enhanced HRV in control recordings; nevertheless, HRV declined before VTA independent of AA drugs. A gradual increase in heart rate and decrease in sinus arrhythmia at VTA onset were specific findings of patients who received dl-sotalol. CONCLUSIONS: The peculiar heart rate dynamics observed before VTA onset are suggestive of a state of sympathoexcitation that is independent of AA drugs.

Ultrarapid subthreshold stimulation for termination of atrioventricular node reentrant tachycardia.

OBJECTIVES: We investigated the efficacy and safety of ultrarapid subthreshold electrical stimuli in terminating sustained atrioventricular (AV) node reentrant tachycardia. BACKGROUND: Subthreshold stimuli, singly and in trains, have been reported to prolong the effective refractory period, inhibit the response to subsequent suprathreshold extrastimuli and to terminate ventricular tachycardia and reciprocating tachycardia. METHODS: Seventeen consecutive patients with inducible sustained slow-fast AV node reentrant tachycardia (mean tachycardia cycle length 358 +/- 61 ms) were studied. Trains of subthreshold stimuli were tested at various right atrial sites. RESULTS: Trains of subthreshold stimuli reproducibly terminated AV node reentrant tachycardia in 15 patients without administration of adjunctive pharmacologic agents. Effective subthreshold current strength ranged from 0.5 to 1.5 mA (mean 0.9 +/- 0.3). The cycle length of effective subthreshold stimuli trains ranged from 30 to 80 ms (mean 57 +/- 17), and the number of stimuli in the train ranged from 4 to 16 (mean 8 +/- 4). The site of successful termination was the proximal coronary sinus in 6 patients and the right low atrial septum in 12. During successful subthreshold termination, no atrial capture could be detected. Neither atrial fibrillation nor flutter nor tachycardia acceleration occurred. CONCLUSIONS: Low current, high frequency trains of stimuli, when applied at a site presumed to be close to the reentrant circuit, provided a safe and effective method of terminating the common type of AV node reentrant tachycardia. This technique could be used to identify critical parts of the reentrant circuit suitable for ablation and further investigations with this method are warranted.

Effect of induced ventricular tachycardia on atrial natriuretic peptide in humans.

The effects of induced sustained ventricular tachycardia on the release of plasma-immunoreactive atrial natriuretic peptide were evaluated in 11 adult patients undergoing diagnostic electrophysiologic study. Plasma concentrations of atrial natriuretic peptide withdrawn from the right atrium before and during sustained ventricular tachycardia (mean tachycardia cycle length 320 +/- 68 ms, duration greater than 30 s) were determined by radioimmunoassay. Hemodynamic measurements included phasic femoral artery blood pressure and mean right atrial blood pressure before and during ventricular tachycardia. During ventricular tachycardia, atrial natriuretic peptide increased from 93 +/- 49 pg/ml to 234 +/- 195 pg/ml (p less than 0.05), systolic arterial blood pressure decreased from 120 +/- 16 to 70 +/- 23 mm Hg (p less than 0.001), diastolic arterial blood pressure decreased from 63 +/- 8 to 51 +/- 16 mm Hg (p = NS) and mean right atrial blood pressure increased from 3 +/- 1 to 8 +/- 5 mm Hg (p less than 0.02). In six patients, all hemodynamic variables and the atrial natriuretic peptide were measured during repeated stimulation protocols to investigate the effect of ventricular stimulation for ventricular tachycardia induction on atrial natriuretic factor release. Compared with the values obtained during sinus rhythm, there was no significant increase in atrial natriuretic factor during ventricular stimulation at a cycle length of 600 ms (45 +/- 20 versus 52 +/- 21 pg/ml) or at a cycle length of 400 ms (45 +/- 20 versus 57 +/- 18 pg/ml). No significant linear relation could be found among the changes in mean right atrial pressure, systolic arterial blood pressure and the increase in atrial natriuretic peptide.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical efficacy of radiofrequency current in the treatment of patients with atrioventricular node reentrant tachycardia.

Eight women (mean age 41 years, range 24 to 62) with drug-resistant atrioventricular (AV) node reentrant tachycardia underwent radiofrequency catheter ablation. Radiofrequency energy was delivered in a unipolar mode with use of a back paddle as the anode placed between the two scapulae. The total applied energy was 2,233 +/- 1,919 J. The AH interval increased from 87 +/- 13 to 113 +/- 17 ms (p less than 0.05) and the PQ interval increased from 141 +/- 15 to 169 +/- 34 ms (p less than 0.05). The anterograde Wenckebach cycle length increased from 300 +/- 41 to 320 +/- 42 ms (p less than 0.05). Retrograde conduction was abolished in five patients. Atrioventricular node tachycardia was still inducible in three patients. During a follow-up period of 9 +/- 3 months, four patients remained clinically asymptomatic without drug therapy and four patients had recurrent symptoms. Three of the latter responded to previously unsuccessful antiarrhythmic drugs and the fourth patient underwent surgical cure for persistence of tachycardia. Right bundle branch block occurred in five patients; it was permanent in four and transient in one. In conclusion, radiofrequency catheter ablation represents a valuable but still investigational therapy in patients with drug-refractory AV node reentrant tachycardia.

Morphological, clinical and genetic aspects in a family with a novel LAMP-2 gene mutation (Danon disease).

A family with several cases of severe cardiomyopathy and moderate myopathy is described, affecting two brothers and their cousin as well as their mothers. One boy died of sudden cardiac arrest at 17 years of age. The two brothers were treated with an implantable defibrillator and their mother died suddenly at 40 years of age. Muscle biopsy in males showed vacuolar myopathy in two cases, and no abnormality on standard staining in the third case. Cardiac biopsies showed hypertrophic and vacuolated fibres. Complete absence of LAMP-2 was demonstrated by immunohistochemistry on the vacuolated skeletal and cardiac muscle, but also on the morphologically normal skeletal muscle. Sequencing of LAMP-2 gene showed a novel S157X mutation in exon 4. Danon disease is a rare and potentially lethal cause of hypertrophic cardiomyopathy. Diagnosis can be made by immunohistochemistry performed on cardiac or muscle biopsy, and confirmed by genetic analysis, which also allows for easy family screening and counselling.

Vg1 RBP intracellular distribution and evolutionarily conserved expression at multiple stages during development.

We have analyzed the expression and intracellular distribution, during oogenesis and embryogenesis, of Vg1 RBP, a protein implicated in the intracellular localization of Vg1 mRNA to the vegetal cortex of Xenopus oocytes. Vg1 RBP (protein) colocalizes with Vg1 RNA at all stages of oogenesis. Vg1 RBP RNA, however, localizes to the animal pole during late oogenesis, and remains in the animal blastomeres and ectodermal precursors until its zygotic transcription is activated, around stage 12. Vg1 RBP mRNA then becomes expressed throughout the neural epithelium. Vg1 RBP mRNA expression is also detected in what appears to be neural crest cells undergoing delamination and lateral migration. By tailbud stages, Vg1 RBP expression is present in the branchial arches, otic vesicle, pronephros, and along the neural tube. To examine the expression pattern in different species, we cloned the zebrafish homolog of Vg1 RBP by using a highly homologous EST clone to screen an embryonic cDNA library. In situ hybridization reveals that Vg1 RBP RNA localizes early in oogenesis to the animal pole. Although Vg1 RBP RNA is detected in all blastomeres of the early embryo, the expression pattern in the one day old zebrafish embryo is almost identical to that of the equivalent stage Xenopus embryo. These results indicate that the zygotic expression pattern is similar in frogs and fish, and that there is a conserved zygotic expression of Vg1 RBP distinct from its expression in the oocyte.

[What do we actually know about out-of-hospital cardiac arrest?]. / Arrêt cardiaque extrahospitalier: la situation actuelle.

Each year at least 300,000 people in the United States and 8000 to 10,000 people in Switzerland suffer from out-of-hospital cardiac arrest, mostly due to ventricular fibrillation. Early defibrillation provides definitive treatment for most of cardiac arrest victims. Semi-automatic external defibrillators are easy to handle devices allowing to deliver an early electric shock and can be successfully used by lay people following minimal training. Newer strategies of defibrillation designed to respond faster to out-of-hospital cardiac arrest, including public access defibrillation, as well as improvement of each link of the chain of survival appears as the best strategy for the management of out-of-hospital cardiac arrest.

Analysis of exome sequence in 604 trios for recessive genotypes in schizophrenia.

Genetic associations involving both rare and common alleles have been reported for schizophrenia but there have been no systematic scans for rare recessive genotypes using fully phased trio data. Here, we use exome sequencing in 604 schizophrenia proband-parent trios to investigate the role of recessive (homozygous or compound heterozygous) nonsynonymous genotypes in the disorder. The burden of recessive genotypes was not significantly increased in probands at either a genome-wide level or in any individual gene after adjustment for multiple testing. At a system level, probands had an excess of nonsynonymous compound heterozygous genotypes (minor allele frequency, MAF ⩽ 1%) in voltage-gated sodium channels (VGSCs; eight in probands and none in parents, P = 1.5 × 10(-)(4)). Previous findings of multiple de novo loss-of-function mutations in this gene family, particularly SCN2A, in autism and intellectual disability provide biological and genetic plausibility for this finding. Pointing further to the involvement of VGSCs in schizophrenia, we found that these genes were enriched for nonsynonymous mutations (MAF ⩽ 0.1%) in cases genotyped using an exome array, (5585 schizophrenia cases and 8103 controls), and that in the trios data, synaptic proteins interacting with VGSCs were also enriched for both compound heterozygosity (P = 0.018) and de novo mutations (P = 0.04). However, we were unable to replicate the specific association with compound heterozygosity at VGSCs in an independent sample of Taiwanese schizophrenia trios (N = 614). We conclude that recessive genotypes do not appear to make a substantial contribution to schizophrenia at a genome-wide level. Although multiple lines of evidence, including several from this study, suggest that rare mutations in VGSCs contribute to the disorder, in the absence of replication of the original findings regarding compound heterozygosity, this conclusion requires evaluation in a larger sample of trios.

Algorithm for the prevention of ventricular tachycardia onset: the Prevent Study.

The Prevent Study is designed to investigate the effect of a rate-smoothing algorithm on the onset of ventricular tachycardia in patients with implanted cardioverter defibrillators (ICD) with dual-chamber pacing and sensing function. Included in the study are patients who require ICD therapy for recurrent ventricular tachycardia or aborted cardiac arrest. After giving informed consent to the study, the patients receive a Ventak AV ICD (CPI-Guidant, St. Paul, MN). The patients are randomized to start either with active or inactive rate-smoothing algorithm. After 3 months, all patients cross over to the opposite group. Questionnaires are used to investigate quality-of-life issues. A total of 240 patients will be enrolled in the study, with a minimum follow-up of 6 months.

What risk should justify implantable cardioverter defibrillator therapy?

Implantable cardioverter defibrillators (ICDs) were developed to prevent sudden cardiac death in patients with ventricular tachycardia (VT) or ventricular fibrillation (VF). Their safety and efficacy have been proved in multiple retrospective and prospective studies. Many of the published trials were directed at secondary prevention for patients who had already had a sudden cardiac death or a sustained VT. For primary prevention, the information available is limited, as only 2 trials have yet been published. Ongoing trials will probably allow us to broaden the indications for prophylactic ICD implantation. Justification of the risk will have to be evaluated against complexity of the implant, the latter including not only cost but quality of life and morbidity associated with an ICD. However, our efforts still have to be directed to improve risk stratification and to decrease the complexity of the procedure.

Efficacy of amiodarone in the Wolff-Parkinson-White syndrome with rapid ventricular response via accessory pathway during atrial fibrillation.

Sudden death in Wolff-Parkinson-White syndrome (WPW) is related to a very fast ventricular response to spontaneous atrial fibrillation (AF) conducted via accessory pathway (AP). The effect of oral amiodarone was studied in 12 patients with WPW syndrome and life-threatening rapid ventricular response via an AP during spontaneous AF. The effective refractory period of the AP in the anterograde direction was 280 ms or less during control study in all patients. After amiodarone therapy, the effective refractory period remained 280 ms or less in 7 of the 12 patients. During incremental atrial pacing, the longest atrial pacing cycle length that produced block over an AP ranged from 200 to 310 ms (mean 261 +/- 42) during the control period and 240 to 980 ms (mean 377 +/- 198) after amiodarone therapy. During AF the shortest ventricular response via the AP could be measured in 10 of 12 of the patients both before and after amiodarone treatment and ranged from 200 to 290 ms (234 +/- 30) and 250 to 500 (mean 302 +/- 75), respectively (p less than 0.01). The average RR interval during AF before and after the drug ranged from 200 to 390 ms (mean 280 +/- 55) and 280 to 650 ms (mean 396 +/- 116), respectively (p less than 0.01). Thus, the safety of amiodarone in the WPW syndrome should be established by electrophysiologic studies and induction of AF, because amiodarone is not protective in all patients with WPW.

Evidence rather than costs must guide use of the implantable cardioverter defibrillator.

Randomized controlled trials have shown superior survival rates with implantable cardioverter defibrillators (ICDs) compared with antiarrhythmic drugs in survivors of cardiac arrest and life-threatening ventricular tachyarrhythmias, as well as in high-risk patients with ischemic heart disease and inducible ventricular tachycardia (VT). Current defibrillators are small and implanted with techniques similar to standard pacemakers. They provide high-energy shocks for ventricular fibrillation (VF) and rapid VT, antitachycardia pacing for monomorphic VT, and antibradycardia pacing. Limited evidence suggests that ICD therapy is cost-effective when compared with other widely accepted treatments. The use of ICDs is likely to continue to expand in the future. Ongoing clinical trials will define further prophylactic indications of the ICD and clarify its cost-effectiveness ratio in different clinical settings.

Effect of intravenous and oral calcium antagonists (diltiazem and verapamil) on sustenance of atrial fibrillation.

Both verapamil and diltiazem are used to control ventricular response during atrial fibrillation (AF). Their effect on the maintenance of AF is not known. The effects of the intravenous and oral administration of verapamil and diltiazem were investigated in 35 patients, 18 with (group I) and 17 without (group II) documented paroxysmal AF. Programmed electrical stimulation, either extra-stimuli or burst atrial pacing, was used to induce AF. In group I, the mean values of the duration of AF before and after the intravenous and oral administration of the calcium antagonists were 31 +/- 12, 112 +/- 49 and 69 +/- 25 minutes, respectively. For group II, the values were 5 +/- 3.4, 39 +/- 13 and 14 +/- 7 minutes, respectively. The differences were statistically highly significant (p less than 0.001), after both oral and intravenous administration compared with the baseline value in both groups. The data suggest that both intravenously and orally administered calcium antagonists enhance sustenance of electrically induced AF, especially in patients with spontaneous arrhythmia. Thus, in patients with paroxysmal AF, verapamil or diltiazem should be administered cautiously, because these drugs may prolong the duration of arrhythmia. Further studies are warranted to investigate the role of calcium antagonists in spontaneously occurring paroxysmal AF.