Case report: Novel variants in RELA associated with familial Behcet's-like disease.

RELA haploinsufficiency is a recently described autoinflammatory condition presenting with intermittent fevers and mucocutaneous ulcerations. The RELA gene encodes the p65 protein, one of five NF-κB family transcription factors. As RELA is an essential regulator of mucosal homeostasis, haploinsufficiency leads to decreased NF-κB signaling which promotes TNF-driven mucosal apoptosis with impaired epithelial recovery. Thus far, only eight cases have been reported in the literature. Here, we report four families with three novel and one previously described pathogenic variant in RELA. These four families included 23 affected individuals for which genetic testing was available in 16. Almost half of these patients had been previously diagnosed with more common rheumatologic entities (such as Behcet's Disease; BD) prior to the discovery of their pathogenic RELA variants. The most common clinical features were orogenital ulcers, rash, joint inflammation, and fever. The least common were conjunctivitis and recurrent infections. Clinical variability was remarkable even among familial cases, and incomplete penetrance was observed. Patients in our series were treated with a variety of medications, and benefit was observed with glucocorticoids, colchicine, and TNF inhibitors. Altogether, our work adds to the current literature and doubles the number of reported cases with RELA-Associated Inflammatory Disease (RAID). It reaffirms the central importance of the NF-κB pathway in immunity and inflammation, as well as the important regulatory role of RELA in mucosal homeostasis. RELA associated inflammatory disease should be considered in all patients with BD, particularly those with early onset and/or with a strong family history.

Pyrroloiminoquinone Alkaloids: Total Synthesis of Makaluvamines A and K.

Herein, an efficient, scalable, and concise approach to an advanced pyrroloiminoquinone synthetic intermediate (6b) by way of a Larock indole synthesis is reported. The synthetic utility of this intermediate is demonstrated by its ready conversion to makaluvamines A (1) and K (4).

Protective Equipment Preparedness and Accessibility: A Survey of Medical Trainees.

Introduction: After being removed from patient care due to equipment shortages, medical students and new residents around the United States are returning to clinical medicine/acute care settings as the SARS-CoV-2 (COVID-19) pandemic continues. We hypothesize that trainees returned with increased preparedness and had better access to and knowledge of personal protective equipment (PPE). Methods: Anonymous online surveys were distributed via snowball sampling to medical students and residents performing clinical duties in the United States. Respondents completed self-assessments for preparedness regarding PPE use, access to PPE and COVID-19 testing, and access to COVID-19 positive patients. Group comparisons were conducted using chi-square analysis and the Kruskal Wallis rank sum test. Multivariate ordinary least squares regression analysis was used to estimate the relationship between feeling prepared and other variables. Results: A total of 194 trainees (63 year 3 [MS3] medical students, 95 year 4 [MS4] medical students, and 36 year 1 [PGY1] postgraduates]) completed the survey. Collectively, 27% provided their own PPE on ≥ 1 rotation, 27% did not know how/where to obtain PPE, 36% did not know how/where to get tested, and 57% were never asked to demonstrate proficiency with PPE. In-person training was reported at 31.3% prior to 2020, which decreased to 21% during 2020. Mask-fit testing decreased from 83.1% to 56.9%. Online video lectures on PPE training increased from 52% to 80%. The mean (±SD) preparedness for return to clinical duty for MS3 students was 3.4/5 (±1.0), for MS4 students was 3.8/5 (±.90), and for PGY1 residents was 4.1/5(± .89) (P = .002). PPE training in 2020 was not associated with feeling prepared (P = .81). Conclusion: Survey respondents felt prepared by their institutions to return to clinical duties during the COVID-19 pandemic. There was some apprehension about knowledge of or access to PPE and COVID-19 testing. The confidence in the ability to don/doff PPE was the main factor associated with increased feelings of preparedness. While in-person training decreased from pre-2020 to during 2020, an increase of in-person training with supervised donning and doffing provides one potential avenue of further increasing the preparedness of trainees.

Case Report: It's a Small Whirl Afterall.

Recognition of the whirl sign on computed tomography (CT) imaging can improve patient outcomes in those presenting with small bowel obstruction (SBO). In the case highlighted in this report, a 40-year-old woman with a remote history of gastric bypass presented to the emergency department (ED) with four hours of abdominal pain and vomiting. Findings on the initial CT of the abdomen and pelvis were suggestive of SBO with a whirl sign pattern. The whirl sign occurs after the bowel rotates around the mesentery, leading to a visual "whirl" of mesenteric vessels. Unfortunately, despite prompt diagnosis, the patient developed an ischemic bowel and ultimately sustained a prolonged hospital course requiring multiple bowel resections. ED providers should familiarize themselves with the whirl sign because its presence in patients with SBO increases the likelihood of ischemia. These patients should have urgent surgical consultation to decrease overall morbidity and mortality. Topics: Whirl sign, small bowel obstruction, gastric bypass, internal hernia.

Unusual Transformations of Strain-Heightened Oxetanes.

Oxetanes are important motifs for drug discovery and are valuable templates in organic synthesis. Much of their use as synthetic intermediates exploits their inherent strain, often resulting in chain extensions at the expense of the heterocycle. Modifications on the carbon alpha to the oxygen of oxetanes, such as the C═O of ß-lactones, extend the modes of reactivity. Nevertheless, the outcomes are still largely predictable. On the other hand, other alpha modifications, such as a ═CH2, a spiro-oxiranyl moiety, or a spiro-cyclopropyl group, increase strain and open pathways not available to simple oxetanes or ß-lactones. Methods in generating 2-methyleneoxetanes, 1,5-dioxaspiro[3.2]hexanes, and 4-oxaspiro[2.3]hexanes have been developed by us and others. To date, reactions of these systems have sometimes been predictable, but often the outcomes have been unexpected. This has provided fertile ground for thinking about what controls reactivity and what other reaction pathways might be accessible to these strain-heightened oxetanes.This Account summarizes the published literature on the most straightforward approaches to 2-methyleneoxetanes, dioxaspirohexanes, and oxaspirohexanes and on their reactivity. In contrast to simple oxetanes, reactions of 2-methyleneoxetanes with nucleophiles at C4 release an enolate rather than an alkoxide. Also, 2-methyleneoxetanes can be converted to homopropargyl alcohols or undergo a silicon accelerated isomerization/electrocyclic ring opening, processes accessible only because of the exocyclic double bond. In addition, oxetane oxocarbenium ions, derived from protonation of the enol ether, can react with nucleophiles to provide 2,2-disubstituted oxetanes. Oxaspirohexanes are readily prepared by Simmons-Smith cyclopropanation of 2-methyleneoxetanes. These unusual systems undergo a variety of substituent dependent rearrangements in the presence of the Lewis acid BF3·Et2O. In addition, upon treatment with Zeise's dimer, oxaspirohexanes are transformed to synthetically useful 3-methylenetetrahydrofurans. Dioxaspirohexanes are easily accessed by dimethyldioxirane oxidation of 2-methyleneoxetanes. Predictably, dioxaspirohexanes react with many nucleophiles to give α-functionalized-ß'-hydroxy ketones. Unexpectedly, 2,2-disubstituted oxetanes can also be selectively produced. This latter pathway has led to further unusual transformations, illuminating computational studies, and novel routes to biologically relevant molecules.

Easily accessible non-aromatic heterocycles with handles: 4-bromo-2,3-dihydrofurans from 1,2-dibromohomoallylic alcohols.

The first general preparation of 4-bromo-2,3-dihydrofurans is reported. These non-aromatic heterocycles containing a useful coupling handle are accessed via Cu-catalyzed intramolecular cyclization of 1,2-dibromohomoallylic alcohols, which are themselves available in just two steps from aromatic and aliphatic aldehydes and ketones. Molecular dynamics simulations using the simple substrates and key geometric parameters provide a rationale for the selectivities observed. The synthetic utility of the 4-bromodihydrofurans is also demonstrated.

Complete Hypokalemic Quadriparesis as a First Presentation of Sjögren Syndrome.

RATIONALE: We hope to increase awareness that hypokalemic paralysis may be the first presentation of Sjögren syndrome, for which potassium-sparing diuretics can be an effective adjunct to potassium replenishment. PRESENTING CONCERNS: A 73-year-old female presented to a peripheral hospital with quadriparesis and a critically low serum potassium of 1.6 mmol/L with U waves on the electrocardiogram (ECG). The initial arterial blood gas showed a pH of 7.19, bicarbonate of 13 mEq/L, and a CO2 of 35 mm Hg. Over the next 6 days, she was administered a total of 450 mEq of potassium supplements. Despite this, her potassium never increased above 2.9 mmol/L and was thus transferred to the University Hospital for further management. On arrival, her vital signs were within normal limits. Her only other symptoms were fatigue and ocular dryness. Physical exam showed slightly weakened quadriceps muscles bilaterally, graded 4/5. Examination was otherwise unremarkable. Admission investigations included a potassium of 2.8 mmol/L, chloride 118 mmol/L, sodium 136 mmol/L, and eGFR 48 mL/min/1.73 m2. Renin aldosterone ratio was normal. DIAGNOSES: Distal renal tubular acidosis (RTA) was diagnosed based on a normal anion gap metabolic acidosis, positive urine anion gap, and elevated urine potassium to creatinine ratio. Investigation of underlying causes revealed a positive Antinuclear antibody (ANA), elevated rheumatoid factor, and high anti-Ro/SSA titre which directed us toward a unifying diagnosis of Sjögren syndrome. A renal biopsy was undertaken as an outpatient and demonstrated severe interstitial nephritis with acute and chronic components, parenchymal scarring, atrophy, and small vessel arteriosclerosis. INTERVENTIONS: In the acute setting, the patient was treated with bicarbonate and amiloride in addition to potassium supplementation. OUTCOMES: The patient's hypokalemic paralysis and metabolic acidosis were corrected. LESSONS LEARNED: Severe hypokalemic paralysis in distal RTA associated with Sjögren syndrome can be successfully treated with amiloride in addition to potassium supplementation. We also review the literature on the aberrancies seen in H+ATPase, Band 3, Pendrin, and carbonic anhydrase that may underlie the pathogenesis of distal RTA in Sjögren syndrome.

JUSTIFICATION: La paralysie hypokaliémique pourrait être une des premières manifestations du syndrome de Sjögren; syndrome pour lequel les diurétiques épargneurs de potassium pourraient s'avérer un traitement d'appoint pour la régénération du potassium. PRÉSENTATION DU CAS: Nous présentons le cas d'une femme âgée de 73 ans qui s'est présentée dans un hôpital périphérique avec une quadriparésie et un taux de potassium alarmant de 1,6 mmol/L, en plus d'un tracé à l'ECG comportant des ondes U. Les analyses de gazométrie artérielle initiales montraient un pH sanguin à 7,19, un taux de bicarbonate à 13 mEq/L et un taux de CO2 à 35 mm Hg. Malgré l'administration d'un total de 450 mEq de potassium sous forme de suppléments au cours des six jours suivants, le taux de potassium sérique de la patiente n'a jamais dépassé 2,9 mmol/L; on a donc transféré la patiente à l'hôpital universitaire pour un suivi plus poussé. À son arrivée, les signes vitaux se situaient dans les limites normales et les seuls symptômes rapportés étaient de la fatigue et de la sècheresse oculaire. Mis à part une légère faiblesse bilatérale des quadriceps (score de 4/5), l'examen physique n'avait rien d'anormal. Les analyses faites à cette seconde admission ont révélé des taux de 2,8 mmol/L pour le potassium, de 118 mmol/L pour le chlore et de 136 mmol/L pour le sodium. Le DFGe de la patiente se situait à 48 mL/min/1,73 m2 et le rapport rénine/aldostérone était normal. DIAGNOSTIC: Une acidose rénale tubulaire distale (ARTd) a été diagnostiquée par le constat d'une acidose métabolique à trou anionique normale, d'un trou anionique urinaire positif et d'un rapport potassium/créatinine urinaire élevé. La recherche des causes sous-jacentes a révélé une détection d'anticorps antinucléaires ainsi que des valeurs élevées pour le facteur rhumatoïde et le titrage des anti-SSA/Ro, ce qui nous a directement aiguillés vers un diagnostic unificateur du syndrome de Sjögren. Une biopsie rénale pratiquée en consultation externe a révélé la présence d'une néphrite interstitielle grave avec composantes aiguës et chroniques, des lésions au parenchyme, une atrophie et une artériosclérose des artérioles. TRAITEMENT: Aux soins intensifs, la patiente a été traitée avec du bicarbonate et de l'amiloride en plus d'un apport supplémentaire en potassium. RÉSULTATS: La paralysie hypokaliémique et l'acidose métabolique ont été corrigées. CONCLUSION: La paralysie périodique hypokaliémique survenant en contexte d'une ARTd associée au syndrome de Sjögren peut être traitée par l'administration d'amiloride et d'un apport supplémentaire en potassium. Nous dressons également certains constats à la suite d'une revue de la littérature concernant des valeurs aberrantes (notamment dans l'activité de la H+ATPase et de l'anhydrase carbonique, de même que dans les taux de la protéine Band 3 et de la pendrine) qui expliquerait la pathogenèse d'une ARTd dans les cas de syndrome de Sjögren.

Label-free detection of carbohydrate-protein interactions using nanoscale field-effect transistor biosensors.

Carbohydrate-protein interactions play a significant role in cell communication, cell adhesion, cell trafficking, and immune responses. Many efforts have been made to demonstrate detection of carbohydrate-protein interactions. However, the existing methods are still tedious and expensive. Therefore, the detection of carbohydrate-protein interactions is of great significance, and new, efficient methods are required for fast and sensitive recognition testing. In this report, we, for the first time, developed the silicon nanowire (SiNW)-based biosensor capable of label-free electrical detection of carbohydrate-protein interactions with high selectivity and sensitivity by covalently immobilizing unmodified carbohydrates on the sensor surface. We fabricated new SiNW sensor chips with more SiNW arrays for potential detection of multiple analytes. In order to realize the immobilization of the unmodified carbohydrates on the SiNW surface, we used X-ray photoelectron spectra and fluorescence microscopy to verify the successful surface functionalization on the silicon surface. Furthermore, we demonstrated real-time detection of carbohydrate-protein interactions using the carbohydrate-modified SiNW sensor chips. The results show good specificity between galactose-lectin EC and mannose-Con A, which is in good agreement with that reported previously. Finally, the results also show that we are able to use the galactose-modified SiNW biosensor to detect lectin EC as low as 100 fg/mL, which is 4 orders of magnitude lower than that reported by other technologies. We believe that the developed SiNW biosensor paves a novel way for studying carbohydrate-protein interactions.

An integrated chip for rapid, sensitive, and multiplexed detection of cardiac biomarkers from fingerprick blood.

Cardiovascular diseases are the major cause of death among adults worldwide. Electrocardiogram (ECG) is a first test when a patient suffering from chest pain sees a doctor, however, it is lack of the required sensitivity. Standard assays to detect cardiac biomarkers, like enzyme-linked immunosorbent assay (ELISA) are sensitive, but suffer from important sample and reagent consumption in large-scale studies. Moreover they are performed in central laboratories of clinics and hospitals and take a long time, which is highly incompatible with the quick decisions needed to save a heart attack patient. Herein, we describe an integrated chip allowing rapid, sensitive, and simultaneous analysis of three cardiac biomarkers in fingerprick blood. The integrated chip is composed of a filtration chip for plasma separation from blood and a silicon nanowire (SiNW) array sensor chip for protein detection. These two chips are fabricated separately and bonded to form a single unit after alignment. The integrated chip is capable of reducing the dead volume of the sample by eliminating the tubing between the two chips. After the plasma is filtrated by the filtration chip, the SiNW sensor, spotted with three different antibodies, enabled us to detect three cardiac biomarkers, troponin T (cTnT), creatine kinase MM (CK-MM) and creatine kinase MB (CK-MB), simultaneously. The integrated chip is able to attain a low detection limit of 1 pg/ml for the three cardiac biomarkers from 2 µl blood in 45 min.

Self-assembled monolayer-assisted silicon nanowire biosensor for detection of protein-DNA interactions in nuclear extracts from breast cancer cell.

The large number of estrogen receptor (ER) binding sites of various sequence patterns requires a sensitive detection to differentiate between subtle differences in ER-DNA binding affinities. A self-assembled monolayer (SAM)-assisted silicon nanowire (SiNW) biosensor for specific and highly sensitive detection of protein-DNA interactions, remarkably in nuclear extracts prepared from breast cancer cells, is presented. As a typical model, estrogen receptor element (ERE, dsDNA) and estrogen receptor alpha (ERα, protein) binding was adopted in the work. The SiNW surface was coated with a vinyl-terminated SAM, and the termination of the surface was changed to carboxylic acid via oxidation. DNA modified with amine group was subsequently immobilized on the SiNW surface. Protein-DNA binding was finally investigated by the functionalized SiNW biosensor. X-ray photoelectron spectroscopy (XPS) and atomic force microscopy (AFM) were employed to characterize the stepwise functionalization of the SAM and DNA on bare silicon surface, and to visualize protein-DNA binding on the SiNW surface, respectively. We observed that ERα had high sequence specificity to the SiNW biosensor which was functionalized with three different EREs including wild-type, mutant and scrambled DNA sequences. We also demonstrate that the specific DNA-functionalized SiNW biosensor was capable of detecting ERα as low as 10 fM. Impressively, the developed SiNW biosensor was able to detect ERα-DNA interactions in nuclear extracts from breast cancer cells. The SAM-assisted SiNW biosensor, as a label-free and highly sensitive tool, shows a potential in studying protein-DNA interactions.