Toll-like receptor 3 L412F polymorphism promotes a persistent clinical phenotype in pulmonary sarcoidosis.

BACKGROUND/INTRODUCTION: Sarcoidosis is a multi-systemic disorder of unknown etiology, characterized by the presence of non-caseating granulomas in target organs. In 90% of cases, there is thoracic involvement. Fifty to seventy percent of pulmonary sarcoidosis patients will experience acute, self-limiting disease. For the subgroup of patients who develop persistent disease, no targeted therapy is currently available. AIM: To investigate the potential of the single nucleotide polymorphism (SNP), Toll-like receptor 3 Leu412Phe (TLR3 L412F; rs3775291), as a causative factor in the development of and in disease persistence in pulmonary sarcoidosis. To investigate the functionality of TLR3 L412F in vitro in primary human lung fibroblasts from pulmonary sarcoidosis patients. DESIGN: SNP-genotyping and cellular assays, respectively, were used to investigate the role of TLR3 L412F in the development of persistent pulmonary sarcoidosis. METHODS: Cohorts of Irish sarcoidosis patients (n = 228), healthy Irish controls (n = 263) and a secondary cohort of American sarcoidosis patients (n = 123) were genotyped for TLR3 L412F. Additionally, the effect of TLR3 L412F in primary lung fibroblasts from pulmonary sarcoidosis patients was quantitated following TLR3 activation in the context of cytokine and type I interferon production, TLR3 expression and apoptotic- and fibroproliferative-responses. RESULTS: We report a significant association between TLR3 L412F and persistent clinical disease in two cohorts of Irish and American Caucasians with pulmonary sarcoidosis. Furthermore, activation of TLR3 in primary lung fibroblasts from 412 F-homozygous pulmonary sarcoidosis patients resulted in reduced IFN-ß and TLR3 expression, reduced apoptosis- and dysregulated fibroproliferative-responses compared with TLR3 wild-type patients. DISCUSSION/CONCLUSION: This study identifies defective TLR3 function as a previously unidentified factor in persistent clinical disease in pulmonary sarcoidosis and reveals TLR3 L412F as a candidate biomarker.

Utilising magnetic resonance imaging as the gold-standard in management of suspected scaphoid fractures in the emergency department setting.

Scaphoid fractures are the most common carpal bone fracture. Up to 40% of scaphoid fractures can be missed at initial presentation and investigation. Follow-up plain film radiograph has overall poor sensitivity and reliability. MRI has been shown to have an almost 100% sensitivity and specificity and so is the gold standard in scaphoid fracture diagnosis. Additionally, early specialist involvement is recommended. We proposed that following a designated pathway, there would be no significant increase in MRI requests. Following implementation of a pathway for the management of suspected scaphoid fractures in St James's Hospital in 2012 re-auditing demonstrated that management changed to either MRI directly after initial x-ray (16/145, 11%), MRI after second x-ray (9/28, 32%) or orthopaedic follow-up (19/28, 68%). The number of MRIs requested was consistent with our predictors of demand. Thus, our new protocol maximises diagnostics, cost effectiveness and quality of patient care.

Socioeconomic deprivation does not affect prescribing of secondary prevention in patients with peripheral arterial disease.

AIM: Aim of the study was to assess the effect of socioeconomic deprivation on prescribing of cardiovascular secondary prevention medications in patients referred with peripheral arterial disease (PAD). METHODS: A retrospective review of vascular clinic referrals was performed. All patients referred from primary care with suspected PAD over a two month period were included. The deprivation score, prescription of cardiovascular secondary prevention medications, smoking status and the presence of cardiovascular co-morbidities (coronary artery or cerebrovascular disease--CAD/CVD) were assessed. Comparison was made between socioeconomic groups using the Carstairs Deprivation (DepCat) Score and between patients with and without a history of currently existing cardiovascular co-morbidities. RESULTS: The study included 391 patients. Almost two thirds of patients (253) were from the most deprived socioeconomic groups and were significantly younger at presentation (median age DepCat 7: 63 yrs, DepCat 1-2: 74.5 yrs, P<0.0001). The majority of patients with a prior history of CAD/CVD were prescribed secondary preventative medications at the time of referral with suspected PAD whereas those with no prior history of CAD/CVD, (212 patients, 54%) were significantly less likely to be prescribed antiplatelets (47% vs. 83%), statins (45% vs. 86%) or ACEi/ARBs (29% vs. 68%) (all P<0.05). Secondary prevention prescribing did not differ between socioeconomic groups. CONCLUSION: Secondary prevention prescribing is inadequate in patients with suspected PAD regardless of socioeconomic group and is significantly lower in those without previously diagnosed CAD/CVD. There remains a lack of appreciation of the high cardiovascular risk associated with PAD.

Iliopsoas abscess masquerading as 'sciatica'.

A 35-year-old woman of Indian origin presented with a 5-month history of lower back pain, radiating down the back of her right leg in distribution of the sciatic nerve. Referral was made to the spinal clinic querying sciatica, but a deterioration in her symptoms developed, and the patient presented to the Accident and Emergency department. She was significantly tender at right sacroiliac joint and had positive psoas sign. The MRI scan showed a large iliopsoas abscess causing bony destruction, and extended culture was positive for mycobacterium tuberculosis. The patient was initially diagnosed with sciatica yet had a positive psoas sign and a painful sacrum. It is important that primary physicians are aware of the relations the iliopsoas muscle and the potential effect an abscess can have here. A sinister underlying cause of a patient's sciatic distribution of pain should be excluded before accepting a diagnosis of mechanical back pain.

Iliopsoas abscess--a review and update on the literature.

Iliopsoas abscess is a rare condition with a varied symptomology and aetiology. Patients with this condition often present in different ways to different specialities leading to delays in diagnosis and management. Recent advances in the radiological diagnosis of this traditionally rare abscess have highlighted that there is a lack of evidence relating to its aetiology, symptomology, investigation and management. This article reviews the currently available literature to present a concise and systematic review of iliopsoas abscess.

Effect of supplementation with an electrolyte containing a Bacillus-based direct-fed microbial on immune development in dairy calves.

Immune characteristics in 65 calves were evaluated in response to a Bacillus-based direct-fed microbial (DFM) provided in electrolyte scour treatment. Blood samples were analyzed for cell surface markers and α(1)-acid glycoprotein (AGP) concentration. AGP increased in scouring calves given electrolyte containing Bacillus at day 7 post-placement compared to scouring calves administered electrolyte alone and non-scouring calves, enhancing the inflammatory response for pathogen clearance. The Bacillus promotes T cell subsets including greater proportions of activated, mature cells (CD8(-)CD25(+), CD8(-)CD45RO(+), CD8(-)TCR1(+)) in calves given electrolyte containing Bacillus than scouring calves administered electrolyte alone and non-scouring calves. Also, the Bacillus may be alleviating inflammation at day 3 post-placement as the proportion of monocytes and granulocytes lacking L-selectin (CD172a(+)CD62L(-)) was greater in scouring calves given electrolyte compared to the other groups. Electrolyte containing Bacillus administered at the onset of scours influences components of innate and adaptive immune development during and following the scouring event.

Oncogenic Ras/Src cooperativity in pancreatic neoplasia.

Pancreas cancer is one of the most lethal malignancies and is characterized by activating mutations of Kras, present in 95% of patients. More than 60% of pancreatic cancers also display increased c-Src activity, which is associated with poor prognosis. Although loss of tumor suppressor function (for example, p16, p53, Smad4) combined with oncogenic Kras signaling has been shown to accelerate pancreatic duct carcinogenesis, it is unclear whether elevated Src activity contributes to Kras-dependent tumorigenesis or is simply a biomarker of disease progression. Here, we demonstrate that in the context of oncogenic Kras, activation of c-Src through deletion of C-terminal Src kinase (CSK) results in the development of invasive pancreatic ductal adenocarcinoma (PDA) by 5-8 weeks. In contrast, deletion of CSK alone fails to induce neoplasia, while oncogenic Kras expression yields PDA at low frequency after a latency of 12 months. Analysis of cell lines derived from Ras/Src-induced PDA's indicates that oncogenic Ras/Src cooperativity may lead to genomic instability, yet Ras/Src-driven tumor cells remain dependent on Src signaling and as such, Src inhibition suppresses growth of Ras/Src-driven tumors. These findings demonstrate that oncogenic Ras/Src cooperate to accelerate PDA onset and support further studies of Src-directed therapies in pancreatic cancer.

G-protein beta3 subunit polymorphism and bleeding in the orbofiban in patients with unstable coronary syndromes-thrombolysis in myocardial infarction 16 trial.

SUMMARY BACKGROUND: Variability in platelet response to antiplatelet drugs is heritable. A common single base substitution (825C>T) in the G-protein beta polypeptide 3 (GNB3) gene leads to alternative splicing (41-amino-acid deletion) of the human G-protein beta3 (Gbeta3) subunit. This truncated protein carried by GNB3 T allele carriers is linked to coronary artery disease and implicated as a genetic marker of drug response. Large studies of Caucasians associate T allele carriage with lower platelet reactivity. OBJECTIVES: To evaluate whether the GNB3 genotype would predispose to bleeding in patients treated with a GPIIb/IIIa receptor antagonist. METHODS: GNB3 genotype distribution was determined in DNA samples from patients in the orbofiban in patients with unstable coronary syndromes-thrombolysis in myocardial infarction (OPUS-TIMI) 16 genetic sub-study. Impact of genotype on the bleeding endpoint and the composite primary endpoint of death, myocardial infarction (MI), re-hospitalization for ischemia and urgent revascularization was estimated in the treatment and placebo arm. RESULTS: Out of 887 patients, 45.1% carried the GNB3 CC genotype, 44.5% CT and 10.4% TT. Interaction between T allele carriership and treatment for bleeding was significant (P = 0.008). This reflects the fact that GNB3 non-T carriers treated with orbofiban had no bleeding effect compared with placebo (RR = 0.92, 95% CI 0.55-1.55) whereas T carriers did (RR = 2.62, 95% CI 1.58-4.35, P < 0.001). Interaction between T allele carriership and treatment was not significant for the primary endpoint (P = 0.18) or MI (P = 0.69). CONCLUSION: The GNB3 T allele significantly increased bleeding in patients treated with the platelet antagonist orbofiban. Our findings suggest that risk of bleeding associated with an antiplatelet agent is heritable and may be dissociated from risk of thrombosis.

Consideration of epilepsy surgery in adults should be independent of age.

OBJECTIVES: Epilepsy surgery is performed less frequently in persons over 45 years of age than in younger individuals, probably reflecting biases among patients, referring physicians and neurologists. METHODS: We report on a clinically heterogeneous cohort of patients aged 45 years or older who underwent epilepsy surgery for medically intractable epilepsy. RESULTS: Over a 15-year period, 42 patients with a mean duration of epilepsy of 27.3 years underwent elective surgery. The mean follow-up period was 48 months. Thirty-two patients had an Engel class I outcome, of which 23 were totally seizure-free (Ia). Six patients had a class II outcome (rare disabling seizures), one had a class III outcome (worthwhile improvement), and three had a class IV outcome (no worthwhile improvement). The majority of patients reported an improved quality of life and satisfaction with the epilepsy surgery. A subjective improvement in cognition was reported in 7 patients while a decline was reported in 10 patients. New neuropsychiatric difficulties were reported in three patients while three patients reported improved anxiety after surgery. Only one patient became newly employed after surgery while 23 returned to driving. Permanent complications occurred in four patients (thalamic infarct during a Wada test (n=1) and asymptomatic visual field defect (n=3)). CONCLUSIONS: We report a favorable outcome from epilepsy surgery in a large series of older adults and conclude that age per se is not a contraindication to epilepsy surgery. We emphasize the lack of correlation between outcome from surgery and pre-operative duration of epilepsy.

Genetic polymorphisms in platelet-related proteins and coronary artery disease: investigation of candidate genes, including N-acetylgalactosaminyltransferase 4 (GALNT4) and sulphotransferase 1A1/2 (SULT1A1/2).

BACKGROUND: Both platelet function and heart disease show strong genetic components, many of which remain to be elucidated. MATERIALS AND METHODS: The roles of candidate polymorphisms in ten platelet-associated genes were compared between 1,237 Acute Coronary Syndrome (ACS) cases (with myocardial infarction and unstable angina) and 386 controls, from an Irish Caucasian population. Additionally, 361 stable angina patients were investigated. Two genes of interest were followed up in a separate Irish study of 1,484 individuals (577 with IHD and 907 unaffected). RESULTS: The GALNT4 (N-acetyl galactosaminyl transferase 4) 506I allele was significantly underrepresented in ACS (OR = 0.66, CI = 0.52-0.84; P = 0.001; P = 0.01 after correction for multiple testing), while the SULT1A1 (Sulphotransferase 1A1) 213H allele was associated with risk of ACS (OR = 1.37, CI = 1.08-1.74; P = 0.01; P = 0.1 after correction for multiple testing). Subsequent genotyping of further SNPs in GALNT4 in the family-based (IHD) group revealed that the 506I allele showed the same trend towards protecting against ACS but the haplotypic test over the four commonest haplotypes was not significant (P = 0.55). In contrast, the SULT1A1/SULT1A2 gene complex showed suggestive haplotypic association in the family-based study (P = 0.07), with the greatest increase in risk conferred by the SULT1A2 235T allele (P = 0.025). CONCLUSION: We have identified two risk genes for cardiovascular disease, one of whose (GALNT4) effects may be on either platelet or endothelial function through modifications of PSGL1 or other important glycosylated proteins. The role of sulphotransferases (SULT1A1/2) in cardiovascular disease requires further exploration. Further validation of cardiovascular risks conferred by both genes in other populations (including gene copy number variation) is warranted.

Benefits of Supplementation of an Electrolyte Scour Treatment with a Bacillus-Based Direct-Fed Microbial for Calves.

A Bacillus-based direct-fed microbial (DFM), Omni-BosCB™, added to an electrolyte was evaluated as a therapy for scours. Fecal shedding of presumptive Clostridium perfringens at day 7 was reduced in scouring calves treated with electrolyte plus DFM compared to scouring calves treated with electrolyte alone. Total therapeutic treatment costs during the first 2 weeks were significantly reduced by supplementing the electrolyte with the DFM: $18.69 and $21.57 for electrolyte plus DFM and electrolyte treated calves, respectively. Electrolyte treated calves experienced more severe scours than electrolyte plus DFM treated calves as additional therapy with Lactated Ringer's Solution was only necessary for electrolyte treated calves. The DFM may have other ancillary benefits after supplementation has ended, as evidenced by decreased recurrence of a second scouring event. This is the first report demonstrating efficacy of a DFM used therapeutically for mitigating calf scours. These findings have implications as alternatives to chemical interventions for disease control.

Sources of nitrogen dioxide (NO2) in New Zealand homes: findings from a community randomized controlled trial of heater substitutions.

UNLABELLED: Houses in New Zealand have inadequate space heating and a third of households use unflued gas heaters. As part of a large community intervention trial to improve space heating, we replaced ineffective heaters with more effective, non-polluting heaters. This paper assesses the contribution of heating and household factors to indoor NO2 in almost 350 homes and reports on the reduction in NO2 levels due to heater replacement. Homes using unflued gas heaters had more than three times the level of NO2 in living rooms [geometric mean ratio (GMR) = 3.35, 95% CI: 2.83-3.96, P < 0.001] than homes without unflued gas heaters, whereas homes using gas stove-tops had significantly elevated living room NO2 levels (GMR = 1.42, 95% CI: 1.05-1.93, P = 0.02). Homes with heat pumps, flued gas heating, or enclosed wood burners had significantly lower levels of NO2 in living areas and bedrooms. In homes that used unflued gas heaters as their main form of heating at baseline, the intervention was associated with a two-third (67%) reduction in NO2 levels in living rooms, when compared with homes that continued to use unflued gas heaters. Reducing the use of unflued gas heating would substantially lower NO2 exposure in New Zealand homes. PRACTICAL IMPLICATIONS: Understanding the factors influencing indoor NO2 levels is critical for the assessment and control of indoor air pollution. This study found that homes that used unflued gas combustion appliances for heating and cooking had higher NO2 levels compared with homes where other fuels were used. These findings require institutional incentives to increase the use of more effective, less polluting fuels, particularly in the home environment.

Improved renal allograft survival with vitamin D receptor polymorphism.

BACKGROUND: Polymorphisms in genes, coding for proteins involved in immune response, or the pathogenesis of atherosclerosis may influence immunological and non-immunological mechanisms that lead to allograft loss. Vitamin D receptor (VDR) agonists reduce allograft rejection in animal models, and there are a number of functional polymorphisms in VDR. METHODS: In all, 379 renal transplant recipients were genotyped for VDR (FokI & ApaI) polymorphisms, and the association of each genotype with renal allograft survival and acute rejection was determined. RESULTS: There was significantly improved allograft survival for patients who were homozygous or heterozygous for the VDR FokI T allele (Hazard Ratio [HR] = 0.488, p < 0.001). CONCLUSION: The association of VDR FokI T allele with improved renal allograft survival is a unique observation. The finding is in keeping with data showing the prevention of chronic allograft rejection with the use of Vitamin D receptor agonists.

Stereotactic cortical resection in non-lesional extra-temporal partial epilepsy.

The presentation and treatment of a patient with extra-temporal non-lesional partial epilepsy is discussed herein. His clinical semiology was consistent with supplementary motor area seizures; however, MR imaging did not demonstrate a lesion. A region of stable cortical glucose hypermetabolism in the left frontal region was noted with 2-fluoro-2-deoxy-D-glucose (FDG)-PET. This was consistent with the frequent interictal discharges evident over the left fronto-temporal region and the stereotypic high amplitude ictal discharges arising with highest amplitude from the left frontal region. Epileptiform activity evident on an intracranial 64-point subdural recording grid placed over the left dorsolateral frontal cortex confirmed a distribution concordant with FDG-PET findings. The subsequent resection was guided by the PET and EEG findings rather than structural MR imaging, and a limited cortical resection led to an immediate and substantial reduction in seizure frequency.

An investigation of potential genetic determinants of propofol requirements and recovery from anaesthesia.

BACKGROUND AND OBJECTIVE: The objectives of this study were, firstly, to characterize the inter-patient variability in the dose of propofol required to achieve a bispectral index <70 and 'time to eye opening' following propofol infusion and, secondly, to determine if the pharmacodynamic parameter 'time to achieve bispectral index <70' was influenced by genotype of the sex-linked drug receptor gene GABRE or if pharmacokinetic parameters such as clearance and 'time to eye opening' were influenced by the genotype of the metabolizing enzyme CYP2B6. METHODS: One hundred and fifty patients received a standardized anaesthetic. Apparent systemic clearance values were estimated. Correlation was sought between carriers of different CYP2B6 and GABRE genotypes and apparent systemic clearance, 'time to achieve bispectral index <70' and 'time to eye opening'. RESULTS: Propofol induction/emergence characteristics varied, with slow recovery times in a subset of males. Time to loss of verbal contact and time to bispectral index <70 varied 6.6- and 4.3-fold, respectively. At emergence, there was a 15.5- to 111-fold variability in the measured time intervals. Clearance varied from 9.1 to 55.8 mL min-1 kg-1. The CYP2B6 C1459T (R487C) genotype frequencies were TT 1%, TC 22% and CC 67%. The three major haplotypes of CYP2B6 (R487C, K262R and Q172H variants) were not significantly associated with time to eye opening or clearance. Clearance was similar in 487C carriers and 487RR genotypes. There was no statistically significant correlation between the four major haplotypes of GABRE variants investigated ([mRNA358]G/T, 20118C/T, 20326C/T and 20502 A/T) and the observed anaesthesia induction time. CONCLUSIONS: Great inter-patient variability exists in the dose of propofol required to achieve bispectral index <70, apparent systemic propofol clearance and time to eye opening. Common haplotypic differences at the CYP2B6 and GABRE genes do not appear to account for the majority of the observed inter-patient variability.

Randomised clinical trial of the duration of compression therapy after varicose vein surgery.

OBJECTIVE: To determine whether a period of one or three weeks of compression following varicose vein surgery influenced the outcome. DESIGN: Randomised controlled trial. METHOD: 300 patients aged between 18-80 years underwent unilateral varicose vein surgery in a Day Procedure Unit. Compression bandaging was applied post-operatively for three days. Patients then wore graduated elastic compression stockings randomised to a period of either one or three weeks. Patients were assessed by questionnaire on pain scores at rest and during mobilisation for up to six weeks, total analgesic consumption, duration of time off work, any complications, and patient perception of cosmetic results at various periods up to 12 weeks following surgery. RESULTS: The mean pain score reported by patients over 6 weeks was similar in the two groups (1 week group: mean 2.18, three week group: mean 1.87). The 95% confidence interval (CI) for the mean difference in pain was (-0.05-0.66). Analysis of the pain curves at 1 week, 4 weeks and 6 weeks, showed equivalence at 4 and 6 weeks, but not for 1 week, with the group wearing stockings for only one week complaining of more pain for this period. A significant increase in the total number of analgesia tablets consumed was also found in the group wearing stockings for only one week. No significant differences were found in the other secondary endpoints - return to work (categorised as <2 weeks, 2-6 weeks or 6-12 weeks), patient satisfaction or post-operative complications. CONCLUSION: We found no benefit in wearing compression stockings for more than one week following uncomplicated high saphenous ligation with stripping of the great saphenous vein with respect to post-operative pain, number of complications, time to return to work, or patient satisfaction for up to 12 weeks following surgery.

The impact on coronary artery disease of common polymorphisms known to modulate responses to pathogens.

There are two distinct models to explain how genetic variants contributing to cardiovascular disease may have arisen. Firstly, variants may result from random, initially neutral, mutations whose effects are largely revealed in post-reproductive individuals in industrialized societies. Alternatively, the introduced variants may confer an adaptive advantage in certain circumstances. Resistance to pathogens is one of the strongest selection pressures on human proteins. To determine whether this evolutionary pressure has made a large contribution to heart disease we tested whether seventeen polymorphisms in fourteen innate-immunity genes, with documented evidence of modulating response to pathogens, had an impact on heart disease. Genotyping was performed in 1,598 CAD subjects (ACS or stable angina) and 332 controls. The TLR4 399Ile allele had the greatest impact on ACS risk (uncorrected p = 0.006); however there was no evidence overall that the resistance alleles cumulatively influenced the risk of ACS compared to controls or stable angina patients (p = 0.12, and p = 0.40, respectively). We did note a significant interaction between age at onset of disease and combined resistance allele carriership when the ACS and non-thrombotic, stable angina groups were compared (p = 0.04, 16 d.f.). This suggests that innate immunity factors could have a greater impact on thrombus formation among younger CAD patients.

Monitoring modulators of platelet aggregation in a microtiter plate assay.

Platelets play a central role in maintaining biological hemostasis. Inappropriate platelet activation is responsible for thrombotic diseases such as myocardial infarction and stroke. Therefore, novel agents that can inhibit platelet activation are necessary. However, assays that monitor platelet aggregation are generally time-consuming and require high volumes of blood and specialized equipment. Therefore, a medium- to high-throughput assay that can monitor platelet aggregation would be considered useful. Such an assay should be sensitive, comparable to the "gold standard" assay of platelet aggregometry, and able to monitor multiple samples simultaneously but with low assay volumes. We have developed such a microtiter assay. It can assay an average of 60 independent treatments per 60 ml blood donation and demonstrates greater sensitivity than the current gold standard assay, namely platelet aggregation in stirring conditions in a platelet aggregometer. The microtiter plate (MTP) assay can detect known inhibitors of platelet function such as indomethacin, aspirin, and ReoPro. It is highly reproducible when using standard doses of agonists such as thrombin receptor-activating peptide (20 microM) and collagen (0.19 mg/ml). Finally, the MTP assay is rapid and sensitive and can detect unknown platelet-modulating agents from a library of compounds.