Utility of clinical high-depth next generation sequencing for somatic variant detection in the PIK3CA-related overgrowth spectrum.

Next-generation sequencing (NGS) has revolutionized the approach of studying sequence variation, and has been well described in the clinical laboratory setting for the detection of constitutional alterations, as well as somatic tumor-associated variants. It is increasingly recognized that post-zygotic somatic alteration can be associated with congenital phenotypic abnormalities. Variation within the PI3K/AKT/mTOR pathway, including PIK3CA, has been described in somatic overgrowth syndromes and vascular malformations. Detection of PIK3CA somatic alteration is challenging because of low variant allele frequency (VAF) along with the need to assay involved tissue, thus necessitating a highly sensitive methodology. Here we describe the utility of target hybrid capture coupled with NGS for the identification of somatic variation in the PIK3CA-related overgrowth spectrum (PROS) among 14 patients submitted for clinical testing. Assay detection of low allelic fraction variation is coverage dependent with >90% sensitivity at 400× unique read depth for VAF of 10%, and approaching 100% at 1000×. Average read depth among the patient dataset across PIK3CA coding regions was 788.4. The diagnostic yield among this cohort was 71%, including the detection of two PIK3CA alterations novel in the setting of PROS. This report expands the mutational scope and phenotypic attributes of PROS disorders.

Characterization of alkaline hydroxide-preserved whole poultry as a dry byproduct meal.

Studies were conducted to examine the chemical preservation of whole broiler carcasses by using aqueous alkaline hydroxide solutions. Conversion of the preserved carcasses and solutions into an acceptable poultry byproduct meal was examined. Carcasses and alkaline solutions at a 1:1 ratio were blended and freeze-dried to produce a high fat whole poultry byproduct meal. The dry meal was analyzed for nutrient composition, true metabolizable energy, and amino acid content. Viable bacteria were not recovered after inoculation of the experimental meal with Salmonella enteritidis. The meal was incorporated at 5 and 10% of chick starter diets. Chicks found the meal-containing diets acceptable. Feed consumption, water consumption, BW, and mortality were not significantly different among the dietary treatments in either of the two feeding trials. Necropsy samples revealed no pathological or histological differences attributable to consumption of the alkaline poultry byproduct and blood serum evaluation found no variation in blood chemistry. Alkaline treatment of whole broiler carcasses was an effective preservation method and acceptable as a dry poultry byproduct meal.

Chemical preservation of whole broiler carcasses utilizing alkaline hydroxides.

The chemical preservation of whole broiler carcasses utilizing aqueous alkaline hydroxide solutions was examined as an alternative method of mortality management. Conversion of the preserved carcasses and solutions into an acceptable poultry by-product meal was examined. This research identified the basic parameters for effective preservative solutions that simultaneously hydrolyzed feathers and preserved the carcass. Euthanized, fully feathered, mature broilers were placed in potassium hydroxide (0.5 to 2.0 M) and sodium hydroxide (0.12 to 2.0 M) solutions for 5 and 10 d. Effectiveness was evaluated by visible feather degradation and carcass solubilization, odor production, inhibition of microbial growth, and solids content of the alkaline solutions. Sodium hydroxide at 1.9 and 2.0 M diffused throughout the carcass and produced adequate preservation without apparent putrefaction through 10 d. Aerobic bacteria were not recovered from sodium hydroxide solutions, carcass skin, or intestine samples at the 1.9 M concentration. Treatments of 2.0 M potassium hydroxide and a mixture of 1.5 M potassium hydroxide with 0.5 M sodium hydroxide produced the highest degree of carcass liquification at 10 d without visible putrefaction. Sodium hydroxide solution (2.0 M):carcass weight ratios ranging from 1:1 through 4:1 (wt:wt) were effective in preserving individual carcasses for more than 60 d without putrefaction.

Cost accounting helps ensure group practice profitability.

Physician practice managers are faced with the challenge of developing overall practice budgets, identifying strategies for the practice, and negotiating profitable managed care contracts. To accomplish these objectives, they need to understand and manage the costs associated with practice operations. Practices that have used cost accounting methodologies to identify their operational costs in greater detail and have developed methods to effectively manage their costs are likely to be more attractive partners to health plans and better positioned to thrive under managed care.

Composing our future: a retrospective and forecast of a specialty practice's achievements in a best practice.

This article documents the practice's achievements resulting from the planning efforts and suggests that several key factors, such as establishing and communicating a practice direction and empowering and valuing people, resulted in the physicians' successful planning.

Drug susceptibility of Mycobacterium tuberculosis isolates from recent Haitian migrants: correlation with clinical response.

Between November 1991 and June 1993, approximately 11,000 Haitian migrants were screened for active tuberculosis and human immunodeficiency virus type 1 (HIV-1) infection at the U.S. Naval Base in Guantánamo Bay, Cuba. Cultures of specimens from 37 of these patients yielded Mycobacterium tuberculosis; eight (22%) of these isolates were resistant to standard medications, including isoniazid (22%), rifampin (0), ethambutol (3%), and streptomycin (3%). Two isolates (5.4%) were resistant to two drugs simultaneously. All but one of 340 patients who were treated for presumptive active tuberculosis and who were followed up for about 1 month had a favorable initial clinical response to a standard four-drug regimen. Among 259 HIV-1-infected patients who had normal findings on screening chest radiographs and who received prophylaxis with isoniazid, there were 1.8 incident cases of active tuberculosis per 100 person-years; this rate was 76% lower than that (reported by others) among HIV-1-infected Haitian patients who were not treated with isoniazid. No serious toxic effects due to standard four-drug regimens or to prophylaxis with isoniazid were observed. These data suggest that standard empirical therapeutic interventions for tuberculosis are adequate and well tolerated in Haitian migrants.

The absolute bioavailability and dose proportionality of intravenous and oral dosage regimens of recainam.

Recainam is a novel class I antiarrhythmic agent with electrophysiologic characteristics of all three subclasses. The authors evaluated the absolute bioavailability and dose proportionality of three oral doses and two 2-stage intravenous (IV) infusion doses. Single oral doses of 200, 400, and 800 mg and IV infusions consisting of 0.8 mg/kg/5 min + 1.2 mg/kg/hr (3.75 mg/kg) and 1.6 mg/kg/5 min + 1.2 mg/kg/hr for 4 hours and 55 minutes (7.50 mg/kg) were administered to 15 healthy men. Plasma and urine samples were collected during the 36-hour period after drug administration and analyzed for recainam concentrations by HPLC. No significant differences were found in any of the pharmacokinetic parameters between the two IV dosage regimens. The absolute bioavailability of orally administered recainam increased from 73% for the 200 mg dose to 81% and 84% for the 400 and 800 mg doses, respectively. Dose proportionality deviated from linearity by 13% for the 200 vs. 400 mg doses, and 10% for the 400 vs. 800 mg doses. The slight deviation from linearity was apparently caused by increased absorption at the higher oral doses. The slight disproportionality in the disposition of recainam is not expected to be clinically significant.

The influence of age on salicylate pharmacokinetics in humans.

The pharmacokinetics of salicylate after a single oral solution dose of 600 mg of sodium salicylate were investigated in 22 male subjects. Subjects were healthy nonsmokers and were not taking any regular medication. The plasma concentration and urinary excretion of salicylic acid and its metabolite, salicyluric acid, as well as the urinary excretion of salicyl glucuronides were determined. Urinary recovery essentially accounted for the administered dose and was not influenced by age, nor was the apparent oral clearance of salicylic acid. Assuming no presystemic elimination, it could be concluded that systemic availability is unaffected by age. An increase in the apparent volume of distribution, Varea, and a decrease in the maximum plasma salicylic acid concentration with age were observed. Renal clearance of salicyluric acid decreased significantly with age and was found to correlate significantly with creatinine clearance. The authors conclude that age does not have a major influence on salicylate disposition in healthy adult men.

Comparison of methods for estimating body composition in young and elderly women.

Estimates of percent body fat and fat-free mass (FFM) were made in healthy young and elderly female subjects using five different methods: bioelectrical impedance analysis (BIA); regression equations involving skinfold measurements at two (Durnin and Womersley; SKF-DW) or three (Jackson and Pollack; SKF-JP) sites; the body mass index (BMI); and an equation relating height and weight to total body water (TBW). Three of the five methods indicated that the percent body fat was significantly greater in the elderly age group. Similarly, three methods estimated FFM values that were significantly lower in the elderly group. In the young group the SKF-DW and TBW methods produced percent fat estimates significantly higher than the other three methods. In the elderly group the percent fat estimates were as follows: SKF-DW greater than BIA greater than SKF-JP = TBW greater than BMI. FFM estimates in both age groups were in inverse rank order to the percent fat estimates. In elderly subjects SKF-DW produced results closest to those from BIA, whereas in young subjects SKF-JP provided the best agreement with the BIA procedure.

Effects of age and intake on vitamin C disposition in females.

The pharmacokinetics of vitamin C following a 500 mg oral tablet dose were compared in a group of fourteen healthy young women whose age was 26.0 +/- 2.8 years (mean +/- s.d.), and in a group of fourteen healthy elderly women aged 68.1 +/- 2.6 years. The body composition of each subject was assessed using several anthropometric measurements in order to help explain any observed differences in the pharmacokinetic behavior of vitamin C. The vitamin C doses were characterized with the subjects in two states of vitamin C nutriture: a 'depleted' state which was achieved by 4-5 weeks on a vitamin C-restricted diet of less than 10 mg/d and a 'supplemented' state in which the subjects were given daily doses of 500 mg of vitamin C for 3 weeks. Plasma and urine samples were collected for 72 h following the dose of vitamin C from subjects in a 'depleted' state and for 24 h from subjects in a 'supplemented' state and analysed for their vitamin C content. None of the pharmacokinetic parameters measured differed significantly between the two age groups. In contrast, the vast majority of these parameters were significantly different in depleted and supplemented subjects. The peak times (tmax) were greater in the depleted state in both young and elderly groups whereas the peak concentrations (Cmax) were greater in the supplemented state. The absorption rate constant (Ka) was significantly larger in the supplemented state compared to the depleted state in the young group and the absorption half-life (t 1/2, Ka) was significantly greater in the depleted state in the young group only. The absorption lag time (tlag) did not differ with respect to age or nutritional status. The elimination half-life (t 1/2, Ke) was significantly longer in supplemented subjects. Although the apparent high volume of distribution (Vd) was not significantly different within each age group the Vd was significantly greater in the depleted state when the two age groups were combined. The clearance (CL), and the nonrenal clearance (CLNR) were significantly greater in the depleted state. The renal clearance (CLR) and the amounts of vitamin C excreted in the 0- to 12- and 12- to 24-h intervals were significantly larger in the supplemented state. The urinary excretion data also indicate that, in supplemented subjects, an average of about 40 percent of the administered dose is excreted as unchanged vitamin C in the first 12 h after dosing, with very little being excreted thereafter.

Vitamin C disposition in young and elderly men.

The pharmacokinetics of vitamin C after a 500-mg oral tablet dose were compared in 15 healthy young men aged 25.20 +/- 2.54 (means +/- SD) and in 15 healthy elderly men aged 69.31 +/- 2.52 y. The doses were characterized with the subjects in two states of vitamin C nutriture: a depleted state, which was achieved by 4-5 wk of compliance with a vitamin C-restricted diet of less than 10 mg/d and a supplemented state, in which the subjects were given 500 mg vitamin C/d for 3 wk. Plasma and urine samples were collected for 72 h after the dose of vitamin C from depleted subjects and for 24 h from supplemented subjects and analyzed for vitamin C. Several of the pharmacokinetic indices measured were different in depleted vs supplemented subjects but none exhibited any age-related differences. This indicates that vitamin C nutriture affects vitamin C pharmacokinetics but age does not.

Relationship between age and the cardiovascular response to meals.

In 82 healthy normotensive and hypertensive subjects aged 19-79, blood pressure and heart rate were measured for 1 hour before and 2 hours after a meal. Mean blood pressure decreased from 147/93 to 139/83 mmHg supine and from 148/101 to 142/94 mmHg standing (all p less than .001). Older subjects had higher premeal blood pressures. There were significant correlations between age and the reductions in supine systolic and diastolic blood pressures and standing systolic blood pressure, i.e., older patients had greater reductions. However, after statistical correction for premeal blood pressure, there was no longer any significant relationship between age and the cardiovascular response to meals. The greater blood pressure reduction after meals in older patients may be due to decreased baroreflex sensitivity in association with higher arterial pressures. The changes in blood pressure due to meals may confound the diagnosis of hypertension and interfere with the interpretation of the response to antihypertensive treatment.

Nicardipine and hydrochlorothiazide in essential hypertension.

Nicardipine is an investigational dihydropyridine calcium channel blocking agent. One hundred fifty-one patients with hypertension received either 30 mg nicardipine t.i.d. or 25 mg hydrochlorothiazide b.i.d. in a double-blind, randomized, multicenter trial. After 4 weeks of therapy and at the end of the dosing interval, nicardipine reduced arterial pressure by 10/6 mm Hg and 12/6 mm Hg in the supine and standing positions, respectively (all p less than 0.01). In the hydrochlorothiazide group, the reductions were 12/6 mm Hg and 14/6 mm Hg, respectively (all p less than 0.01). The maximum reduction in blood pressure of 16/14 mm Hg supine and 20/15 mm Hg standing occurred within 1 hour after administration of nicardipine. The mean reduction in the hydrochlorothiazide group after 1 hour was 14/11 mm Hg supine and 16/12 mm Hg standing. Neither drug affected autonomic reflexes associated with maximum exercise. Nicardipine increased urinary sodium excretion during the 4-hour period after the first dose. Adverse effects of nicardipine were primarily extensions of its vasodilator effect and included flushing, headache, and edema.