Adult Plant Leaf Rust Resistance in AC Taber Wheat Maps to Chromosomes 2BS and 3BS.

AC Taber is a hard red spring wheat cultivar that has had long-lasting resistance to the leaf rust fungus Puccinia triticina. The objective of this study was to determine the chromosome location of the leaf rust resistance genes in AC Taber. The leaf rust-susceptible cultivar Thatcher was crossed with AC Taber to develop an F6 recombinant inbred line (RIL) population. The RILs and parents were evaluated for segregation of leaf rust resistance in five field plot tests and in two seedling tests to race BBBDB of P. triticina. A genetic map of the RIL population was developed using 90,000 single nucleotide polymorphism markers with the Illumina Infinium iSelect 90K wheat bead array. Quantitative trait loci (QTLs) with significant effects for lower leaf rust severity in the field plot tests were found on chromosomes 2BS and 3BS. The same QTLs also had significant effects for lower infection type in seedlings to leaf rust race BBBDB. The gene on 2BS was the adult plant resistance gene Lr13, and the gene on 3BS mapped to the same region as the adult plant resistance gene Lr74 and other QTLs for leaf rust resistance. Kompetitive allele-specific PCR assay markers linked to the 2BS and 3BS regions were developed and should be useful for marker-based selection of these genes.

Thatcher wheat line RL6149 carries Lr64 and a second leaf rust resistance gene on chromosome 1DS.

KEY MESSAGE: The leaf rust resistance gene Lr64 in the Thatcher wheat RL6149 was mapped to chromosome 6AL with SNP and KASP markers and a second leaf rust resistance gene was mapped to chromosome 1DS. RL6149, a near-isogenic line of Thatcher wheat, carries leaf rust resistance gene Lr64 on chromosome arm 6AL. The objective of this study was to develop molecular markers that can be easily used to select wheat lines with Lr64. RL6149 was crossed with Thatcher and F2 plants derived from a single F1 plant were advanced to F6 lines by single seed descent. The 100 F7 recombinant inbred lines (RIL) were inoculated with two races of P.triticina that differed widely for virulence in order to identify resistant and susceptible RIL. Thirty RIL that differed for resistance and the parental lines were genotyped with the 90 K Infinium iSelect single nucleotide polymorphism (SNP) array to find closely linked markers with Lr64. Seven linked SNPs on chromosome arm 6AL were converted into Kompetitive Allele Specific PCR (KASP) markers that were genotyped on the 100 RIL. A genetic linkage map for the seven KASP markers spanned 19.1 cM on chromosome arm 6AL. KASP marker K-IWB59855 was tightly linked to Lr64. A second unexpected gene for leaf rust resistance also segregated in the F7 lines. Four KASP markers that spanned 18.6 cM located the gene on chromosome 1DS. The KASP marker K-IWB38437 was tightly linked to the second leaf rust resistance gene.

Clinical outcomes and patient satisfaction following total hip and knee arthroplasty in patients with inherited bleeding disorders: A 20-year single-surgeon cohort.

INTRODUCTION: Persons with haemophilia and other inherited bleeding disorders are prone to disabling joint arthropathy frequently requiring arthroplasty for end-stage joint disease. Higher complication rates and more modest post-operative functional outcomes have previously been described. AIM: To evaluate the clinical outcomes and patient satisfaction of persons with inherited bleeding disorders (predominantly haemophilia) undergoing total hip and knee replacement. METHODS: Retrospective, single-centre cohort study with longitudinal assessment of patients with inherited bleeding disorders who underwent total hip and knee replacement over a 20-year period. Eligible patients were clinically assessed with Harris Hip Score (HHS), Knee Society Score (KSS), pain visual analogue scale (VAS) and a patient satisfaction questionnaire. RESULTS: Thirty-one patients (48 joints) met the inclusion criteria. Mean age at surgery was 49.3 years (SD: 13.1, range 21-75 years) with a mean follow-up of 9.33 years (1.7-19.3). The majority (26/31) of patients had haemophilia A, predominantly severe haemophilia A (22/26). Reported pain levels were low, and patient satisfaction was high. Joint-specific outcome scores were "good" to "excellent" in 67% of total hip replacement patients and 92% of total knee replacement patients. A low complication rate was observed, with 2 patients requiring revision surgery and 4 patients requiring re-operation without implant revision. CONCLUSION: Arthroplasty is a reliable procedure in patients with inherited bleeding disorders with end-stage hip or knee arthropathy. The overall complexity of this group is highlighted, and the need for multidisciplinary care is emphasised.

Hydrocarbon-degrading bacteria in deep-water subarctic sediments (Faroe-Shetland Channel).

AIMS: The aim of this study was the baseline description of oil-degrading sediment bacteria along a depth transect in the Faroe-Shetland Channel (FSC) and the identification of biomarker taxa for the detection of oil contamination in FSC sediments. METHODS AND RESULTS: Oil-degrading sediment bacteria from 135, 500 and 1000 m were enriched in cultures with crude oil as the sole carbon source (at 12, 5 and 0°C respectively). The enriched communities were studied using culture-dependent and culture-independent (clone libraries) techniques. Isolated bacterial strains were tested for hydrocarbon degradation capability. Bacterial isolates included well-known oil-degrading taxa and several that are reported in that capacity for the first time (Sulfitobacter, Ahrensia, Belliella, Chryseobacterium). The orders Oceanospirillales and Alteromonadales dominated clone libraries in all stations but significant differences occurred at genus level particularly between the shallow and the deep, cold-water stations. Alcanivorax constituted 64% of clones at FSC135 but was absent at deeper stations. Pseudoalteromonas and Oleispira dominated the bacterial community at 500 and 1000 m. CONCLUSIONS: The genus Oleispira emerged as a major player in the early stages of crude oil degradation in deep-sea sediments of the FSC particularly at subzero temperatures. This finding is offering a direction for future research into biomonitoring tools for the detection of low levels of crude oil contamination in the deep FSC, and possibly high latitude cold waters in general. SIGNIFICANCE AND IMPACT OF THE STUDY: Oil and gas exploration in the FSC occurs at depths >1000 m but baseline environmental data necessary for the assessment of ecosystem recovery to prespill conditions in the event of an oil spill are lacking. This study will contribute to our ability to assess the impact of oil release in the FSC and guide the direction of bioremediation strategies tailored to the area.

Parents perspectives on whole genome sequencing for their children: qualified enthusiasm?

OBJECTIVE: To better understand the consequences of returning whole genome sequencing (WGS) results in paediatrics and facilitate its evidence-based clinical implementation, we studied parents' experiences with WGS and their preferences for the return of adult-onset secondary variants (SVs)-medically actionable genomic variants unrelated to their child's current medical condition that predict adult-onset disease. METHODS: We conducted qualitative interviews with parents whose children were undergoing WGS as part of the SickKids Genome Clinic, a research project that studies the impact of clinical WGS on patients, families, and the healthcare system. Interviews probed parents' experience with and motivation for WGS as well as their preferences related to SVs. Interviews were analysed thematically. RESULTS: Of 83 invited, 23 parents from 18 families participated. These parents supported WGS as a diagnostic test, perceiving clear intrinsic and instrumental value. However, many parents were ambivalent about receiving SVs, conveying a sense of self-imposed obligation to take on the 'weight' of knowing their child's SVs, however unpleasant. Some parents chose to learn about adult-onset SVs for their child but not for themselves. CONCLUSIONS: Despite general enthusiasm for WGS as a diagnostic test, many parents felt a duty to learn adult-onset SVs. Analogous to 'inflicted insight', we call this phenomenon 'inflicted ought'. Importantly, not all parents of children undergoing WGS view the best interests of their child in relational terms, thereby challenging an underlying justification for current ACMG guidelines for reporting incidental secondary findings from whole exome and WGS.

Association mapping of North American spring wheat breeding germplasm reveals loci conferring resistance to Ug99 and other African stem rust races.

BACKGROUND: The recently identified Puccinia graminis f. sp. tritici (Pgt) race TTKSK (Ug99) poses a severe threat to global wheat production because of its broad virulence on several widely deployed resistance genes. Additional virulences have been detected in the Ug99 group of races, and the spread of this race group has been documented across wheat growing regions in Africa, the Middle East (Yemen), and West Asia (Iran). Other broadly virulent Pgt races, such as TRTTF and TKTTF, present further difficulties in maintaining abundant genetic resistance for their effective use in wheat breeding against this destructive fungal disease of wheat. In an effort to identify loci conferring resistance to these races, a genome-wide association study was carried out on a panel of 250 spring wheat breeding lines from the International Maize and Wheat Improvement Center (CIMMYT), six wheat breeding programs in the United States and three wheat breeding programs in Canada. RESULTS: The lines included in this study were grouped into two major clusters, based on the results of principal component analysis using 23,976 SNP markers. Upon screening for adult plant resistance (APR) to Ug99 during 2013 and 2014 in artificial stem rust screening nurseries at Njoro, Kenya and at Debre Zeit, Ethiopia, several wheat lines were found to exhibit APR. The lines were also screened for resistance at the seedling stage against races TTKSK, TRTTF, and TKTTF at USDA-ARS Cereal Disease Laboratory in St. Paul, Minnesota; and only 9 of the 250 lines displayed seedling resistance to all the races. Using a mixed linear model, 27 SNP markers associated with APR against Ug99 were detected, including markers linked with the known APR gene Sr2. Using the same model, 23, 86, and 111 SNP markers associated with seedling resistance against races TTKSK, TRTTF, and TKTTF were identified, respectively. These included markers linked to the genes Sr8a and Sr11 providing seedling resistance to races TRTTF and TKTTF, respectively. We also identified putatively novel Sr resistance genes on chromosomes 3B, 4D, 5A, 5B, 6A, 7A, and 7B. CONCLUSION: Our results demonstrate that the North American wheat breeding lines have several resistance loci that provide APR and seedling resistance to highly virulent Pgt races. Using the resistant lines and the SNP markers identified in this study, marker-assisted resistance breeding can assist in development of varieties with elevated levels of resistance to virulent stem rust races including TTKSK.

Predictive genetic testing for adult-onset disorders in minors: a critical analysis of the arguments for and against the 2013 ACMG guidelines.

The publication of the ACMG recommendations has reignited the debate over predictive testing for adult-onset disorders in minors. Response has been polarized. With this in mind, we review and critically analyze this debate. First, we identify long-standing inconsistencies between consensus guidelines and clinical practice regarding risk assessment for adult-onset genetic disorders in children using family history and molecular analysis. Second, we discuss the disparate assumptions regarding the nature of whole genome and exome sequencing underlying arguments of both supporters and critics, and the role these assumptions play in the arguments for and against reporting. Third, we suggest that implicit differences regarding the definition of best interests of the child underlie disparate conclusions as to the best interests of children in this context. We conclude by calling for clarity and consensus concerning the central foci of this debate.

Infection and Colonization of Several Bermudagrasses by Ophiosphaerella korrae.

Bermudagrass (Cynodon spp.) is the most commonly used turfgrass in the southern United States where it is severely affected by spring dead spot (SDS) caused by Ophiosphaerella herpotricha, O. korrae, and O. narmari. In this study, infection of bermudagrass roots and stolons by O. korrae was characterized using a transformant that expressed the red fluorescent protein tdTomato. Roots of interspecific hybrid cultivars Midlawn and Tifway 419, C. transvaalensis accessions Uganda and 3200, and C. dactylon cultivar U3 were inoculated and observed from 2 to 14 days postinoculation (DPI) while stolons were observed from 2 to 22 DPI. For all five cultivars tested, a similar level of root colonization was observed; however, differences were observed in the rate of necrosis development. Necrosis of Tifway 419 and Midlawn tissues was evident at 2 DPI, in Uganda and 3200 at 8 DPI, and in U3 necrosis was often absent as late as 14 DPI. The fungus rapidly penetrated the root epidermis and colonized the cortex of all cultivars by 4 DPI. Colonization of stele tissues by O. korrae was rare in hybrid cultivars but common in C. transvaalensis and C. dactylon accessions. On intact stolons, the fungus did not penetrate the epidermis 22 DPI though epidermal necrosis was evident on the surface of only the hybrid bermudagrasses. Wounded stolons became necrotic in all cultivars. Infection and colonization of various bermudagrasses by O. korrae was found to be similar to that by O. herpotricha, suggesting that host genetic resistance may be used for effective management of SDS caused by both species.

Seasonality and determinants of moderate and severe COPD exacerbations in the TORCH study.

We investigated the impact of season relative to other determinants of chronic obstructive pulmonary disease (COPD) exacerbation frequency in a long-term international study of patients with forced expiratory volume in 1 s (FEV(1)) <60% predicted. COPD exacerbations were defined by worsening symptoms requiring systemic corticosteroids and/or antibiotics (moderate) or hospital admission (severe). Seasonality effect was calculated as the proportion of patients experiencing an exacerbation each month. Exacerbations in the northern and southern regions showed an almost two-fold increase in the winter months. No seasonal pattern occurred in the tropics. Overall, 38% of exacerbations were treated with antibiotics only, 19% with systemic corticosteroids only and 43% with both, while 20% required hospital admission irrespective of the season. Exacerbation frequency was associated with older age, lower body mass index, lower FEV(1) % pred and history of prior exacerbations. Females and patients with worse baseline breathlessness, assessed using the Medical Research Council (MRC) dyspnoea scale, exacerbated more often (rate ratio (RR) for male versus female 0.7, 95% CI 0.7-0.8 (p<0.001); RR for MRC dyspnoea score 3 versus 1 and 2 combined 1.1, 95% CI 1.1-1.2 (p<0.001)). The effect of season was independent of these risk factors. COPD exacerbations and hospitalisations were more frequent in winter.

Operando DRIFTS study of the redox and catalytic properties of CuO/Ce(1-x)Tb(x)O(2-δ) (x = 0-0.5) catalysts: evidence of an induction step during CO oxidation.

Catalysts of 1 wt% copper oxide supported on cerium oxide or cerium-terbium mixed oxides are comparatively examined with respect to their redox and catalytic properties for CO oxidation. Characterization of the catalysts had shown that they contain highly dispersed CuO-type entities on the corresponding nanostructured fluorite supports with copper dispersion increasing with increasing amounts of terbium in the support. In contrast, the CO oxidation catalytic activity decreases with increasing amounts of terbium in the support. On the basis of operando-DRIFTS experiments, one of the factors that could explain such behaviour is related to the greater difficulty in generating reduced copper sites active for the reaction in the presence of terbium, which in turn is evidenced to constitute an induction stage. Analysis of the redox properties is complemented by XPS which confirms the greater resistance to copper reduction in the presence of terbium.

Genome comparisons reveal a dominant mechanism of chromosome number reduction in grasses and accelerated genome evolution in Triticeae.

Single-nucleotide polymorphism was used in the construction of an expressed sequence tag map of Aegilops tauschii, the diploid source of the wheat D genome. Comparisons of the map with the rice and sorghum genome sequences revealed 50 inversions and translocations; 2, 8, and 40 were assigned respectively to the rice, sorghum, and Ae. tauschii lineages, showing greatly accelerated genome evolution in the large Triticeae genomes. The reduction of the basic chromosome number from 12 to 7 in the Triticeae has taken place by a process during which an entire chromosome is inserted by its telomeres into a break in the centromeric region of another chromosome. The original centromere-telomere polarity of the chromosome arms is maintained in the new chromosome. An intrachromosomal telomere-telomere fusion resulting in a pericentric translocation of a chromosome segment or an entire arm accompanied or preceded the chromosome insertion in some instances. Insertional dysploidy has been recorded in three grass subfamilies and appears to be the dominant mechanism of basic chromosome number reduction in grasses. A total of 64% and 66% of Ae. tauschii genes were syntenic with sorghum and rice genes, respectively. Synteny was reduced in the vicinity of the termini of modern Ae. tauschii chromosomes but not in the vicinity of the ancient termini embedded in the Ae. tauschii chromosomes, suggesting that the dependence of synteny erosion on gene location along the centromere-telomere axis either evolved recently in the Triticeae phylogenetic lineage or its evolution was recently accelerated.

Plasma microparticles are not elevated in fresh plasma from patients with gynaecological malignancy--an observational study.

OBJECTIVES: Gynaecological cancer is common. It is highly amenable to effective treatment, but thrombosis remains a common complication. There is controversy about whether microparticles (MPs), particularly tissue factor (TF) positive MPs, are increased in patients with malignancy and/or thrombosis. We therefore set out to investigate the relationship between MPs of different cellular origins, in patients with gynaecological malignancy. We hypothesised that patients with gynaecological malignancy have increased numbers of MPs. We measured MPs released by different cell types in these patients, and correlated the results with measures of haemostatic activation. METHODS: We measured the number of platelet-derived MPs (PMPs), endothelial cell-derived MPs (EMPs), leucocyte-derived MPs (LMPs), TF+ve MPs and annexin V (AV) binding MPs in fresh plasma by flow cytometry in patients with gynaecological malignancy and a control group. We also measured D-dimers, prothrombin fragments 1 and 2 (PF1&2) and thrombin-antithrombin (TAT) complexes as indirect markers of haemostatic activation. RESULTS: The number of MPs (from all cell types) was similar in the two patient groups, with no significant differences. The number of circulating TF+ve MPs was also similar between the two groups. D-dimers (p<0.001) and PF1&2 (p=0.009) were significantly higher in the malignant group reflecting haemostatic activation, but there was no correlation between the level of D-dimers, PF1&2 and TAT and MP numbers. CONCLUSION: Using fresh samples, MPs were not significantly increased in patients with gynaecological malignancy. There was, however, evidence of haemostatic activation in the patients with malignancy, but no correlation between the number of MPs and haemostatic activation.

Mapping QTL in the porcine MHC region affecting fatness and growth traits in a Meishan/Large White composite population.

A number of studies have mapped QTL regulating porcine fatness and growth traits to the region of the major histocompatibility complex (MHC) on porcine chromosome 7 using various experimental crosses. The QTL results from crosses using the Chinese Meishan (MS) (slow growing and fat) are particularly interesting because the MS alleles have been found to be associated with increased growth rate and reduced backfat depth. We investigated these QTL further in a composite population derived previously over eight generations by intercrossing Meishan and the European Large White breeds. Genotype information from 32 markers in a 15cM target region was used in linkage and association analyses. A two-step variance component analysis identified QTL for three growth-related traits, explaining 19 ∼ 24% of the phenotypic variance with a confidence interval of 4 cM in the target region. SNP association analyses found that ss181128966 and ss181128924 within the QTL interval were strongly associated with the growth traits. Only weak signals for an effect on backfat depth were found in the association and linkage analyses, possibly because of past directional selection in the composite population.

First Detection in North America of Virulence in Wheat Leaf Rust (Puccinia triticina) to Seedling Plants of Wheat with Lr21.

Leaf rust resistance gene Lr21 is present in hard red spring wheat (Triticum aestivum) cultivars grown in Minnesota, North Dakota, South Dakota, Manitoba, and Saskatchewan. Isolates of Puccinia triticina, the causal organism of wheat leaf rust, with virulence to this gene have not been previously detected in annual virulence surveys in the United States. (2). In 2010, hard red spring wheat cvs. Faller, RB07 (1), and Glenn, all with Lr21, had 0 to 5% levels of leaf rust severity, which was higher than in previous years in research plots in North Dakota and Minnesota. Leaf rust collections from wheat cultivars and germplasm lines with Lr21 at three locations in Minnesota and North Dakota were increased on plants of the leaf rust susceptible wheat Thatcher and the Thatcher line with Lr21. Single uredinia from the collections were isolated and increased on seedlings of Thatcher. The single uredinial isolates were inoculated to 7- to 8-day-old seedling plants of the set of 19 differential lines that are currently used in the leaf rust virulence surveys (2). Thatcher lines with Lr3bg, Lr14b, Lr20, and Lr23 were also tested. The isolates were also inoculated to seedling plants of hard red spring wheat cultivars with Lr21: Glenn, Steele-ND, Faller, RB07, Amidon, AC Cora, and McKenzie (3). Previous standardized methods for growing seedling plants, increase of rust isolates, inoculation, incubation, and evaluation of infection types (IT) were used (2). All tests with the Thatcher differential lines and the cultivars with Lr21 were repeated at least twice. Virulence phenotypes were described based on virulence to the 19 differentials in the P. triticina virulence nomenclature system used in the United States. (2). Two virulence phenotypes, TFBJQ and TFBGQ, with virulence to Lr21 were found at the three locations. TFBJQ is virulent (IT 3 to 4) to genes Lr1, 2a, 2c, 3, 10, 14a, 14b, 20, 21, 24, 26, 28, and avirulent (IT 0 to 2+) to genes Lr3ka, Lr3bg, Lr9, Lr11, Lr17, Lr18, Lr30, LrB, and Lr39/41. TFBGQ was avirulent to Lr14a and Lr20, but identical to TFBJQ for virulence and avirulence to the other resistance genes. Isolates of both phenotypes were virulent on seedlings of Faller, Glenn, RB07 (1), Steele-ND, AC Cora, and Amidon. McKenzie had IT of 2+ due to the additional presence of Lr16 (3). Both TFBJQ and TFBGQ have intermediate IT of 2+ to Lr16; IT 2+3 to Lr23, and are completely virulent to Lr1, Lr2a, and Lr10 that are present in hard red spring wheat cultivars. Both phenotypes have high IT to Lr24 and Lr26 that are present in soft red winter wheat and hard red winter wheat cultivars. The Lr21 virulent phenotypes likely arose by mutation from the group of P. triticina genotypes in the simple sequence repeat group NA-5 (4) that have intermediate IT of ;2- to ;2+ to the Thatcher line with Lr21. P. triticina isolates with virulence to Lr21 are a new threat to wheat production since in 2010 more than 50% of the hard red spring wheat acreage in Minnesota and North Dakota relied on Lr21 for effective resistance to leaf rust. References: (1) J. A. Anderson et al. J. Plant Regist. 3:175, 2009. (2) J. A. Kolmer et al. Plant Dis. 94:775, 2010. (3) B. McCallum and P. Seto-Goh. Can. J. Plant Pathol. 32:387, 2010. (4) M. E. Ordoñez and J. A. Kolmer. Phytopathology 99:750, 2009.

Revised recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic - what a difference a year makes.

BACKGROUND: During the early part of the COVID-19 pandemic, the Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force published recommendations on performance of tracheotomy. Since then, our understanding of the virus has evolved with ongoing intensive research efforts. New literature has helped us better understand various aspects including patient outcomes and health care worker (HCW) risks associated with tracheotomy during the COVID-19 pandemic. Accordingly, the task force has re-evaluated and revised some of the previous recommendations. MAIN BODY: Based on recent evidence, a negative reverse transcription polymerase chain reaction (RT-PCR) COVID-19 swab status is no longer the main deciding factor in the timing of tracheotomy. Instead, tracheotomy may be considered as soon as COVID-19 swab positive patients are greater than 20 days beyond initial symptoms and 2 weeks of mechanical ventilation. Furthermore, both open and percutaneous surgical techniques may be considered with both techniques showing similar safety and outcome profiles. Additional recommendations with discussion of current evidence are presented. CONCLUSION: These revised recommendations apply new evidence in optimizing patient and health care system outcomes as well as minimizing risks of COVID-19 transmission during aerosol-generating tracheotomy procedures. As previously noted, additional evidence may lead to further evolution of these and other similar recommendations.

Quantitating the multiplicity of infection with human immunodeficiency virus type 1 subtype C reveals a non-poisson distribution of transmitted variants.

Identifying the specific genetic characteristics of successfully transmitted variants may prove central to the development of effective vaccine and microbicide interventions. Although human immunodeficiency virus transmission is associated with a population bottleneck, the extent to which different factors influence the diversity of transmitted viruses is unclear. We estimate here the number of transmitted variants in 69 heterosexual men and women with primary subtype C infections. From 1,505 env sequences obtained using a single genome amplification approach we show that 78% of infections involved single variant transmission and 22% involved multiple variant transmissions (median of 3). We found evidence for mutations selected for cytotoxic-T-lymphocyte or antibody escape and a high prevalence of recombination in individuals infected with multiple variants representing another potential escape pathway in these individuals. In a combined analysis of 171 subtype B and C transmission events, we found that infection with more than one variant does not follow a Poisson distribution, indicating that transmission of individual virions cannot be seen as independent events, each occurring with low probability. While most transmissions resulted from a single infectious unit, multiple variant transmissions represent a significant fraction of transmission events, suggesting that there may be important mechanistic differences between these groups that are not yet understood.

Mutations in LAMB2 causing a severe form of synaptic congenital myasthenic syndrome.

BACKGROUND: We describe a severe form of congenital myasthenic syndrome (CMS) associated with congenital nephrosis and ocular malformations caused by two truncating mutations in the gene encoding the laminin beta2 subunit (LAMB2). METHODS AND RESULTS: Mutational analysis in the affected patient, who has a history of a serious untoward reaction to treatment with acetylcholinesterase inhibition, revealed two frame-shifting heteroallelic mutations, a maternally inherited 1478delG and a paternally inherited 4804delC. An anconeus muscle biopsy demonstrated a profound distortion of the architecture and function of the neuromuscular junction, which was strikingly similar to that seen in mice lacking laminin beta2 subunit. The findings included: pronounced reduction of the axon terminal size with encasement of the nerve endings by Schwann cells, severe widening of the primary synaptic cleft and invasion of the synaptic space by the processes of Schwann cells, and moderate simplification of postsynaptic folds and intact expression of the endplate acetylcholinesterase. The endplate potential quantal content was notably reduced, while the frequencies and amplitudes of miniature endplate potentials were only moderately diminished and the decay phases of miniature endplate potentials were normal. Western blot analysis of muscle and kidney tissue and immunohistochemistry of kidney tissue showed no laminin beta2 expression. CONCLUSION: This case, which represents a new type of synaptic CMS, exemplifies the wide variability of phenotypes associated with LAMB2 mutations and underscores the fundamental role that laminin beta2 plays in the development of the human neuromuscular junction.

Adherence to inhaled therapy, mortality and hospital admission in COPD.

BACKGROUND: Little is known about adherence to inhaled medication in chronic obstructive pulmonary disease (COPD) and the impact on mortality and morbidity. METHODS: Data on drug adherence from a randomised double-blind trial comparing inhaled salmeterol 50 microg + fluticasone propionate 500 microg twice daily with placebo and each drug individually in 6112 patients with moderate to severe COPD over 3 years in the TORCH study were used. All-cause mortality and exacerbations leading to hospital admission were primary and secondary end points. The study of adherence was not specified a priori as an ancillary study. RESULTS: Of the 4880 patients (79.8%) with good adherence defined as >80% use of study medication, 11.3% died compared with 26.4% of the 1232 patients (20.2%) with poor adherence. The annual rates of hospital admission for exacerbations were 0.15 and 0.27, respectively. The association between adherence and mortality remained unchanged and statistically significant after adjusting for other factors related to prognosis (hazard ratio 0.40 (95% CI 0.35 to 0.46), p<0.001). The association was even stronger when analysing on-treatment deaths only. Similarly, the association between adherence and hospital admission remained unchanged and significant in a multivariate analysis (rate ratio 0.58 (95% CI 0.44 to 0.73, p<0.001). The association between increased adherence and improved mortality and reduction in hospital admission was independent of study treatment. The effect of treatment was more pronounced in patients with good adherence than in those with poor adherence. CONCLUSION: Adherence to inhaled medication is significantly associated with reduced risk of death and admission to hospital due to exacerbations in COPD. Further research is needed to understand these strong associations.

Pneumonia risk in COPD patients receiving inhaled corticosteroids alone or in combination: TORCH study results.

Inhaled corticosteroids (ICS) are important in reducing exacerbation frequency associated with chronic obstructive pulmonary disease (COPD). However, little is known about the risk of associated infections. In a post hoc analysis of the TOwards a Revolution in COPD Health (TORCH) study, we analysed and identified potential risk factors for adverse event reports of pneumonia in this randomised, double-blind trial comparing twice-daily inhaled salmeterol (SAL) 50 microg, fluticasone propionate (FP) 500 microg, and the combination (SFC) with placebo in 6,184 patients with moderate-to-severe COPD over 3 yrs. Despite a higher withdrawal rate in the placebo arm, after adjusting for time on treatment, a greater rate of pneumonia was reported in the FP and SFC treatment arms (84 and 88 per 1,000 treatment-yrs, respectively) compared with SAL and placebo (52 and 52 per 1,000 treatment-yrs, respectively). Risk factors for pneumonia were age > or =55 yrs, forced expiratory volume in 1 s <50% predicted, COPD exacerbations in the year prior to the study, worse Medical Research Council dyspnoea scores and body mass index <25 kg.m(-2). No increase in pneumonia deaths with SFC was observed; this could not be concluded for FP. Despite the benefits of ICS-containing regimens in COPD management, healthcare providers should remain vigilant regarding the possible development of pneumonia as a complication in COPD patients receiving such therapies.