A multi-enhancer RET regulatory code is disrupted in Hirschsprung disease.

The major genetic risk factors for Hirschsprung disease (HSCR) are three common polymorphisms within cis-regulatory elements (CREs) of the receptor tyrosine kinase gene RET, which reduce its expression during enteric nervous system (ENS) development. These risk variants attenuate binding of the transcription factors RARB, GATA2, and SOX10 to their cognate CREs, reduce RET gene expression, and dysregulate other ENS and HSCR genes in the RET-EDNRB gene regulatory network (GRN). Here, we use siRNA, ChIP, and CRISPR-Cas9 deletion analyses in the SK-N-SH cell line to ask how many additional HSCR-associated risk variants reside in RET CREs that affect its gene expression. We identify 22 HSCR-associated variants in candidate RET CREs, of which seven have differential allele-specific in vitro enhancer activity, and four of these seven affect RET gene expression; of these, two enhancers are bound by the transcription factor PAX3. We also show that deleting multiple variant-containing enhancers leads to synergistic effects on RET gene expression. These, coupled with our prior results, show that common sequence variants in at least 10 RET enhancers affect HSCR risk, seven with experimental evidence of affecting RET gene expression, extending the known RET-EDNRB GRN to reveal an extensive regulatory code modulating disease risk at a single gene.

The Use of Gene Expression Profiling and Biomarkers in Melanoma Diagnosis and Predicting Recurrence: Implications for Surveillance and Treatment.

Cutaneous melanoma is becoming more prevalent in the United States and has the highest mortality among cutaneous malignancies. The majority of melanomas are diagnosed at an early stage and, as such, survival is generally favorable. However, there remains prognostic uncertainty among subsets of early- and intermediate-stage melanoma patients, some of whom go on to develop advanced disease while others remain disease-free. Melanoma gene expression profiling (GEP) has evolved with the notion to help bridge this gap and identify higher- or lower-risk patients to better tailor treatment and surveillance protocols. These tests seek to prognosticate melanomas independently of established AJCC 8 cancer staging and clinicopathologic features (sex, age, primary tumor location, thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and/or SLNB status). While there is a significant opportunity to improve the accuracy of melanoma prognostication and diagnosis, it is equally important to understand the current landscape of molecular profiling for melanoma treatment. Society guidelines currently do not recommend molecular testing outside of clinical trials for melanoma clinical decision making, citing insufficient high-quality evidence guiding indications for the testing and interpretation of results. The goal of this chapter is to review the available literature for GEP testing for melanoma diagnosis and prognostication and understand their place in current treatment paradigms.

The Effect of Energy Devices, Nerve Monitors, and Drains on Thyroidectomy Outcomes: An American College of Surgeons National Surgical Quality Improvement Project Database Analysis.

The effect of energy devices, nerve monitors, and drains on thyroidectomy outcomes has been examined for each tool independently. Current literature supports the routine use of energy devices and nerve monitors and does not support the routine use of drains. The effect of these operative tools is interrelated and should be examined concurrently. The aim of this study was to describe the risk-adjusted effect of each of these tools on thyroidectomy outcomes. A retrospective analysis of 17 985 open thyroidectomy procedures was conducted using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) 2016-2018 thyroidectomy targeted procedure database. All open thyroidectomies were included. The risk-adjusted effect of energy devices, nerve monitors, and drains on 30-day outcomes was calculated by multiple logistic regression. Energy devices were associated with a decreased risk of hematoma and decreased extended length of stay without increased risk of hypocalcemia or recurrent laryngeal nerve injury. Nerve monitors were associated with a decreased risk of overall morbidity, decreased recurrent laryngeal nerve injury, and decreased extended length of stay without an increased risk of adverse outcomes. Drains were associated with an increased risk of bleeding, reoperation, and extended length of stay without decreasing hematoma. Our results support the routine use of energy devices and nerve monitors for thyroidectomy and do not support the routine use of drains for thyroidectomy.

Presence of antideoxyribonucleic acid antibody in patients with hyperthyroidism of Graves' disease.

In 16 untreated patients with hyperthyroidism due to Graves' disease, serum antidouble stranded DNA antibody, measured by RIA, was positive (greater than 20 U/ml) in 14. In methimazole-treated patients with T3-suppressible thyroid uptake, anti-DNA antibody was found in 9% (3 of 35). The frequency of positive tests in methimazole-treated patients with T3-nonsuppressible thyroid uptake and in surgically treated patients was 24% (5 of 21) and 57% (4 of 7), respectively. Among anti-DNA antibody-negative (less than 9 U/ml) and weakly positive (10-19 U/ml) patients, those with T3-suppressible thyroid uptake had lower anti-DNA antibody titers than those with T3-nonsuppressible thyroid uptake. Among 32 patients with Hashimoto's thyroiditis, anti-DNA antibody was positive in 7. None of the patients with simple goiter had positive or weakly positive anti-DNA antibody results. Although the quantity of antibodies did not correlate well in individual patients, the rates of positive TSH binding-inhibiting immunoglobulin and anti-DNA antibody tests were roughly comparable in these patient groups. None of these patients with thyroid disease associated with anti-DNA antibody had clinical or other serological evidence suggestive of systemic lupus erythematosus or related collagen vascular disorders. The finding of anti-DNA antibody provides a new aspect of immunological abnormality associated with hyperthyroidism of Graves' disease.

Immunologic and immunohistochemical study of familial amyloid polyneuropathy.

Amyloid fibril protein was purified from postmortem organs of patients with familial amyloid polyneuropathy. In immunodiffusion tests, the protein reacted with antihuman prealbumin antibody but not with antihuman retinol-binding protein or antihuman immunoglobulin G (IgG). In immunoelectrophoresis, the amyloid fibril protein gave a single line with a slightly faster mobility than prealbumin. Immunohistochemical analysis, using fluorescent and peroxidase-antiperoxidase methods, showed that the amyloid deposits contained antigenic determinants of human retinol-binding protein and IgG but not prealbumin.

Inflammatory cytokine cascade released by leukocytes in cerebrospinal fluid after subarachnoid hemorrhage.

Subarachnoid hemorrhage (SAH) elicits an inflammatory response in the subarachnoid space, which is mediated by the release of various cytokines. To assess their involvement in post-hemorrhagic complications, we determined the source and time-course of the release of inflammatory cytokines and acute-phase proteins in cerebrospinal fluid (CSF) following SAH. Concentrations of interleukin (IL)- 1beta, IL-6, transforming growth factor-beta1 (TGF-beta1) and C-reactive protein (CRP) in CSF of 36 patients with SAH were measured by enzyme-linked immunoabsorbent assay (ELISA). Floating cells collected from the CSF were centrifuged four to six days after SAH, and examined immunohistochemically. Intracellular IL-1beta and IL-6 were examined by flow cytometric analysis. The molecular weight of TGF-beta1 in CSF of 30 patients was examined by Western blot analysis. The TGF-beta1 levels of patients who had undergone ventriculoperitoneal (VP) shunt (n = 19) was significantly higher than nonshunt group (n = 16). The CRP levels of VP shunt group was significantly higher than nonshunt group. IL-6 concentration was maximal within day 0-1 and it was secreted by neutrophils and monocytes. ELISA showed consistently low levels of IL-1beta, whereas a proportion of monocytes and lymphcytes were IL- 1beta-positive by flow cytometric analysis. TGF-beta1 levels were also maximal on day 0-1 according to ELISA, although it tended to be in the inactive form derived from platelets. A 25 kDa band of TGF-1 was detectable for at least 13 days after SAH, which may have been secreted in part by neutrophils and monocytes. CRP levels in CSF peaked on day 2-3. The present results suggest that leukocytes induced by SAH play an important role in post-hemorrhagic inflammation in the subarachnoid space by releasing IL-6 and TGF-beta1. The CRP and TGF-beta1 levels in CSF are strongly concerned with communicating hydrocephalus after SAH.

[A case of IgG4-lambda type monoclonal immunoglobulin that interfered with determinations for albumin, direct bilirubin and iron in serum].

We report a human IgG4-lambda type M-protein that reacts with reagents of albumin, direct bilirubin and iron. Blood chemistry findings by an automated analyzer were: total protein 8.8 g/dl; albumin(ALB) 9.2 g/dl; direct bilirubin(D-Bil) -6.2 mg/dl; and iron(Fe) 25 micrograms/dl. The white precipitates were formed by the interaction of the patient's serum with reagents of ALB, D-Bil, and Fe. Immunofixation electrophoresis revealed that these precipitates were the IgG4-lambda type M-protein. Western blotting analysis showed that the IgG4 molecules were composed of two 55 kDa gamma 4 chains and two 24 kDa lambda chains.

[The clinical usefulness of a new (the second generation) antibody to hepatitis C virus].

To clarify the clinical usefulness of a second generation antibody to hepatitis C virus (anti-HCV-2), we tested the anti-HCV-2 by enzyme immunosorbent assay (Imucheck HCV Ab) in comparison to the first generation antibody (anti-HCV-1). Serum samples were obtained from the patients with acute hepatitis, chronic liver diseases, alcoholic liver disease and autoimmune liver diseases. Furthermore, both antibodies were tested in serum samples from individuals in a hyperendemic area of non-A, non-B hepatitis. Anti-HCV-2 was detected earlier than anti-HCV-1 in acute type C hepatitis. The prevalence of anti-HCV-2 was higher than that of anti-HCV-1 in acute and chronic non-A, non-B liver diseases. However, prevalence of anti-HCV-2 was not increased in patients with non-viral liver disease such as pure alcoholic liver disease and autoimmune liver diseases. The HCV-infection rate was increased to about 40% by detection of anti-HCV-2 in individuals in hyperendemic area of non-A, non-B hepatitis. Thus, the assay of anti-HCV-2 is very useful to detect actual HCV infection. The accuracy and sensitivity of anti-HCV-2 were higher than those of anti-HCV-1.

[Analysis of cross-linked fibrin and fibrinogen degradation products with SDS-PAGE and immunoblot].

SDS-PAGE and immunoblot technique with anti-FDP-D, -FDP-E, -fibrinogen antibody or anti-FDP-DD monoclonal antibody were applied to analyze FDP fragments prepared from cross-linked fibrin and fibrinogen with plasmic digestion in vitro. FDP fragments of DY(260K), DD(187K), X(245K), Y(166K), D(77K, 97K), E1(58K), E2(46K) and E3(40K) were identified from data of molecular weight and reactivity to four antibodies referred to reports of other investigators. Serum FDP fragments from five DIC suspected patients were analyzed by the same methods. In two patients' sera, DD fragment was a main component, and in the other three patients' sera, D fragment was a main fraction. Proportions of high molecular weight fragments of FDP were considerably different in patients' sera. Appearance of D fragment in our cases was considered to be derived from unstable fibrin (fibrin monomer and dimer) rather than from fibrinogen. Molecular weight of DD fragments from patients' sera had heterogeneity (160 approximately 180K), and the values were different from that (187K) prepared from cross-linked fibrin. In conclusion, SDS-PAGE and immunoblot analysis of serum fragments of FDP will be an useful technique to investigate the clinical and pathological condition of DIC.

[Studies on the blood coagulation factor XIII in patients with increased levels of FDP D-dimer].

Antigen levels of blood coagulation factor XIII (XIII) were determined in plasmas from patients with increased levels of fibrin degradation products-D-dimer (FDP-DD), including disseminated intravascular coagulation (DIC), by latex photometric immunoassay using polyclonal anti-XIII a subunit antibody-coated latex reagent. Since stable fibrin is directly degradated by plasmin and FDP-DD is produced, plasma FDP-DD levels correlate with plasmin-alpha 2-plasmin inhibitor complex levels, but not with thrombin-antithrombin III complex (TAT) or XIII levels. In order to clarify other causes of discordant relationships among the related three parameters, we studied the changes in plasma XIII, TAT and FDP-DD levels in fourteen DIC patients induced by various primary disorders. Only in two cases, XIII levels changed up and down irrelevant to the fluctuating levels of TAT and FDP-DD. In seven cases, plasma XIII levels remained low during the clinical courses, indicating possibilities that elevated condition of XIII consumption continued and/or production of XIII was low. On the other hand, in four patients, including two patients with nephrosis, XIII might be produced at higher rate than that of consumption. Same phenomenon was observed in one of eight recipients with living-related liver transplantation who showed remarkably increased levels of FDP-DD without DIC. In conclusion, plasma XIII level in patients with elevated FDP-DD may be influenced by the balance between consumption of XIII by unstable fibrin and/or surgical stress and the following tissue recovery etc. and production of XIII in liver, megakaryocytes and monocytes.

[Detection of anti-granulocyte antibodies using flow cytometry].

To detect anti-granulocyte antibodies (AGAs) in the sera of granulocytopenic patients is important to study the mechanism of the disease. In this report, we studied neutrophil associated immunoglobulin (NAIg) and neutrophil binding immunoglobulin (NBIg) in patients' sera using flow cytometry (FCM). We investigated the interference of circulating immune complexes (CIC) on measuring the NAIg and NBIg. No apparent effect of CIC was observed at concentrations up to 140 micrograms/ml. NAIg and NBIg were semiquantitated by determining the relative fluorescence intensity (RFI) on a flow cytometer and the normal ranges of NAIg and NBIg were less than 15 RFI and less than 10 RFI, respectively. Of 100 sera from patients with neutropenia, 5 were positive for NBIg and 3 of them were positive for granulocyte-specific antibodies. One serum of a patient with benign chronic neutropenia showed clear specificity for NA1 alloantigen but the other 4 AGAs were not specific for NA alloantigen system. Our NAIg, NBIg screening procedure, including NA specificity testing of NBIg and detection of reactivity with normal lymphocytes using FCM, is simple and useful for measuring and studying serological and immunological characteristics of AGAs.

[Anti-HCV and long-term prognosis in patients with non-A, non-B post-transfusion hepatitis].

Anti-HCV was tested in serial serum samples of 20 patients with non-A, non-B post-transfusion hepatitis (NANB-PTH) who had been followed for more than 3 years after the onset. The rate of chronicity of disease was significantly higher in anti-HCV positive patients (12 out of 14, 85.7%) than in anti-HCV negative patients (group 1) (1 out of 6 patients, 14.3%). Among 14 anti-HCV positive patients, 7 lost anti-HCV during the follow-up period (group 2) and 6 of these 7 patients revealed normalization of liver dysfunction before or after the disappearance of anti-HCV. To the contrary, remaining 7 patients whose anti-HCV sustained positive (group 3) did show persistent abnormal liver function tests. Anti-HCV titer was significantly higher in group 3 than in group 2 at the point of 1 year after PTH. The titration of anti-HCV at 1 year after the onset of PTH was thought to be useful for estimating the prognosis of patients with post-transfusion hepatitis type C.