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Background\ud Children with intellectual disability frequently have multiple co-morbid neuropsychiatric conditions and poor physical health. Genomic testing is increasingly recommended as a first-line investigation for these children. We aim to determine the effect of genomics, inheritance, and socioeconomic deprivation on neuropsychiatric risk in children with intellectual disability of genetic origin as compared with the general population.\ud Methods\ud IMAGINE is a prospective cohort study using online mental health and medical assessments in a cohort of 3407 UK participants with intellectual disability and pathogenic genomic variants as identified by the UK's National Health Service (NHS). Our study is on a subset of these participants, including all children aged 4–19 years. We collected diagnostic genomic reports from NHS records and asked primary caregivers to provide an assessment of their child using the Development and Well-Being Assessment (DAWBA), the Strengths and Difficulties Questionnaire (SDQ), the Adaptive Behaviour Assessment System 3 (ABAS-3), and a medical history questionnaire. Each child was assigned a rank based on their postcode using the index of multiple deprivation (IMD). We compared the IMAGINE cohort with the 2017 National Survey of Children's Mental Health in England. The main outcomes of interest were mental health and neurodevelopment according to the DAWBA and SDQ.\ud Findings\ud We recruited 2770 children from the IMAGINE study between Oct 1, 2014 and June 30, 2019, of whom 2397 (86·5%) had a basic assessment of their mental health completed by their families and 1277 (46·1%) completed a medical history questionnaire. The mean age of participants was 9·2 years (SD 3·9); 1339 (55·9%) were boys and 1058 (44·1%) were girls. 355 (27·8%) of 1277 reported a seizure disorder and 814 (63·7%) reported movement or co-ordination problems. 1771 (73·9%) of 2397 participants had a pathogenic copy number variant (CNV) and 626 (26·1%) had a pathogenic single nucleotide variant (SNV). Participants were representative of the socioeconomic spectrum of the UK general population. The relative risk (RR) of co-occurring neuropsychiatric diagnoses, compared with the English national population, was high: autism spectrum disorder RR 29·2 (95% CI 23·9–36·5), ADHD RR 13·5 (95% CI 11·1–16·3). In children with a CNV, those with a familial variant tended to live in more socioeconomically deprived areas than those with a de novo variant. Both inheritance and socioeconomic deprivation contributed to neuropsychiatric risk in those with a CNV.\ud Interpretation\ud Children with genomic variants and intellectual disability are at an increased risk of neuropsychiatric difficulties. CNV variant inheritance and socioeconomic deprivation also contribute to the risk. Early genomic investigations of children with intellectual disability could facilitate the identification of the most vulnerable children. Additionally, harnessing parental expertise using online DAWBA assessments could rapidly identify children with exceptional needs to child mental health services.

Ventricular longitudinal function measured as basal-apical atrioventricular plane displacement (AVPD) or global longitudinal strain (GLS) is a potent predictor of mortality and could potentially be a predictor of heart failure-associated morbidity. We hypothesized that low AVPD and GLS are associated with the combined endpoint of cardiovascular mortality and heart failure-associated morbidity.Two hundred eighty-seven patients (age 62 ± 12 years, 78% male) with heart failure with reduced (≤40%) ejection fraction (HFrEF) referred to a cardiovascular magnetic resonance exam were included. Ventricular longitudinal function, ventricular volume, and myocardial fibrosis or infarction were analysed from cine and late gadolinium enhancement images. National registries provided data on causes of cardiovascular hospitalizations and cardiovascular mortality for the combined endpoint. Time-to-event analysis capable of including reoccurring events was employed with a 5-year follow-up. HFrEF patients had EF 26.5 ± 8.0%, AVPD 7.8 ± 2.4 mm, and GLS -7.5 ± 3.0%. In contrast, ventricular longitudinal function was approximately twice as large in an age-matched control group (AVPD 15.3 ± 1.6 mm; GLS -20.6 ± 2.0%; P 0.001 for both). There were 578 events in total, and the majority were HF hospitalizations (n = 418). Other major events were revascularizations (n = 64), cardiovascular deaths (n = 40), and myocardial infarctions (n = 21). One hundred fifty-five (54%) patients experienced at least one event (mean 2.0, range 0-64). Of these patients, 119 (71%) had three events or fewer, and the first three events comprised 51% of all events (295 events). Patients in the bottom AVPD or GLS tertile (6.8 mm or-6.1%) overall experienced more than 3 times as many events as the top tertile (8.8 mm or-8.4%; P 0.001). Patients in this tertile also faced more cardiovascular deaths (P 0.05), HF hospitalizations (P = 0.001), myocardial infarctions (only GLS: P = 0.032), and accumulated longer in-hospital length-of-stay overall (AVPD 20.9 vs. 9.1 days; GLS 22.4 vs. 6.5 days; P = 0.001 for both), and from HF hospitalizations (AVPD 19.3 vs. 8.3 days; GLS 19.3 vs. 5.4 days; P = 0.001 for both). In multivariate analysis adjusted for significant covariates, AVPD and GLS remained independent predictors of events (hazard ratio 1.12 per-mm-decrease and 1.13 per-%-increase) alongside hyponatremia (135 mmol/L), aetiology of HF, and LV end-diastolic volume index.Low ventricular longitudinal function is associated with an increase in number of events as well as longer in-hospital stay from cardiovascular causes. In addition, AVPD and GLS have independent prognostic value for cardiovascular mortality and morbidity in HFrEF patients.

Background Lynch syndrome is an underdiagnosed hereditary condition carrying an increased lifetime risk for colorectal and endometrial cancer and affecting nearly 1 million people in the United States. Cascade screening, systematic screening through family members of affected patients, could improve identification of Lynch syndrome, but this strategy is underused due to multi-level barriers including low knowledge about Lynch syndrome, low access to genetics services, and challenging family dynamics. Methods We used intervention mapping, a 6-step methodology to create stakeholder-driven interventions that meet the needs of a target population, to develop an intervention to improve cascade screening for Lynch syndrome. The intervention development process was guided by input from key stakeholders in Lynch syndrome care and patients. We conducted usability testing on the intervention with Lynch syndrome patients using qualitative semi-structured interviewing and rapid qualitative analysis. Results We developed a workbook intervention named Let’s Talk that addresses gaps in knowledge, skills, self-efficacy, outcome expectancy and other perceived barriers to cascade screening for Lynch syndrome. Let’s Talk contained educational content, goal setting activities, communication planning prompts and supplemental resources for patients to plan family communication. Evidence-based methods used in the workbook included information chunking, guided practice, goal setting and gain-framing. We conducted usability testing focused on the complexity and relative advantage of the intervention through 45-min virtual interviews with 10 adult patients with Lynch syndrome recruited from a national advocacy organization in the United States. Usability testing results suggested the intervention was acceptable in terms of complexity and relative advantage to other available resources, but additional information for communication with young or distant family members and a web-based platform could enhance the intervention’s usability. Conclusions Intervention mapping provided a framework for intervention development that addressed the unique needs of Lynch syndrome patients in overcoming barriers to cascade screening. Future work is needed to transform Let’s Talk into a web-based tool and evaluate the effectiveness of the intervention in clinical practice with patients and genetic counselors. Intervention mapping can be useful to researchers as an evidence-based technique to develop stakeholder-centered interventions for addressing the needs of other unique populations.

Exergaming has been proposed as a promising alternative to traditional endurance training since many experience exergaming as more enjoyable. Therefore, the aim of this trial was to determine the exergaming-induced effect on cardiorespiratory fitness. This parallel-group randomised controlled trial, investigated the effects of regular exergaming among healthy adults (aged ≥ 18 years) who were not endurance-trained. Participants allocated to the exergaming group (n = 13) used the Playpulse exergaming platform for a minimum of 45 min twice weekly for eight weeks, whereas the control group (n = 17) received no intervention. The primary outcome measure was the between-group difference in peak oxygen uptake (V̇O2peak) after the intervention. V̇O2peak increased significantly from baseline (43.9 [SD 7.0]) to after the intervention (45.3 [SD 8.2] mL kg−1 min−1) in the exergaming group, compared to the control group (42.4 [SD 7.0] to 42.0 [SD 5.7] L·kg−1·min−1) with a between-group difference of 2.1 mL kg−1 min−1 (95% CI: 0.2–4.1; p = 0.04). The average score on the Feeling Scale reported during exergaming was 3.4 (95% CI 3.2–3.6), with 3 being “good” and 5 “very good” and was not related to the participants’ exergaming skills. There were no adverse events during this trial. Two weekly sessions using the Playpulse exergaming platform can improve V̇O2peak. This finding suggests that exergaming can be an efficient form of endurance training. Furthermore, our findings indicate that participants’ enjoyed exergaming irrespective of exergaming skills. Trial registration: ClinicalTrials.gov identifier: NCT04112329

ObjectivesThis study aimed to explore the experiences of parents caring for children with intellectual and developmental disabilities (IDD) during the UK national lockdown in spring 2020, resulting from the COVID-19 pandemic.DesignParticipants were identified using opportunity sampling from the IMAGINE-ID national (UK) cohort and completed an online survey followed by a semistructured interview. Interviews were analysed using thematic analysis.SettingInterviews were conducted over the telephone in July 2020 as the first UK lockdown was ending.Participants23 mothers of children with intellectual and developmental disabilities aged 5–15 years were recruited.ResultsThemes reported by parents included: managing pre-existing challenges during a time of extreme change, having mixed emotions about the benefits and difficulties that arose during the lockdown and the need for appropriate, individualised support.ConclusionsOur findings confirm observations previously found in UK parents of children with IDD and provide new insights on the use of technology during the pandemic for schooling and healthcare, as well as the need for regular check-ins.

Reduced ventricular longitudinal shortening measured by atrioventricular plane displacement (AVPD) and global longitudinal strain (GLS) are prognostic markers in heart disease. This study aims to determine if AVPD and GLS with cardiovascular magnetic resonance (CMR) are independent predictors of cardiovascular (CV) and all-cause death also in heart failure with reduced ejection fraction (HFrEF). Patients (n = 287) were examined with CMR and AVPD, GLS, ventricular volumes, myocardial fibrosis/scar were measured. Follow-up was 5 years with cause of death retrieved from a national registry. Forty CV and 60 all-cause deaths occurred and CV non-survivors had a lower AVPD (6.4 ± 2.0 vs 8.0 ± 2.4 mm, p

Undebakke, V, Berg, J, Tjønna, AE, and Sandbakk, Ø. Comparison of physiological and perceptual responses to upper-, lower-, and whole-body exercise in elite cross-country skiers. J Strength Cond Res 33(4): 1086–1094, 2019—The primary purpose of the present study was to compare physiological and perceptual responses to maximal and submaximal exercise between upper-, lower-, and whole-body exercise modes in elite cross-country (XC) skiers. Twelve elite XC skiers performed 5–7 submaximal 5-minute stages and an incremental test to exhaustion using upper-body poling (UP), running (RUN), and diagonal skiing (DIA), randomized on 3 separate days. Here, power output, cardiorespiratory variables, heart rate (HR), blood lactate concentration (BLa), and rating of perceived exertion (RPE) were determined. Peak power output increased gradually from UP to RUN and DIA, whereas peak oxygen uptake (V[Combining Dot Above]O2peak), peak HR, O2pulse, and total RPE were clearly lower in UP than RUN and DIA (p < 0.05). At submaximal workloads matched for either RPE, %HR, or BLa, the main pattern was that BLa was higher and V[Combining Dot Above]O2 and HR lower in UP compared with RUN and DIA (p < 0.05). DIA showed ∼10 and 35% higher V[Combining Dot Above]O2 than RUN and UP at RPE 10–13 and had lower muscular RPE values than UP and RUN at a given % of peak HR (p < 0.05). Most of the differences in cardiorespiratory variables between modes were eliminated when they were normalized to V[Combining Dot Above]O2peak or peak HR in the respective mode. Because of the low power production in UP, endurance training in this mode exhibits too low values of V[Combining Dot Above]O2 to tax the cardiovascular system sufficiently. In RUN and DIA, the similar V[Combining Dot Above]O2peak values indicate that both modes can be effectively used during high-intensity training and to determine V[Combining Dot Above]O2max in elite XC skiers. However, the relatively high V[Combining Dot Above]O2 values at low perceptual stress with submaximal DIA indicate that the large amount of power produced when combining upper- and lower-body work exhibits high oxidative flux even during low-intensity training. Overall, these findings should be taken into account when athletes and coaches are monitoring and prescribing training in future approaches, in particular in sports where athletes vary between training with upper-, lower-, and whole-body exercise modes. © 2019. This is the authors' accepted and refereed manuscript to the chapter. Locked until 30.4.2020 due to copyright restrictions. The final authenticated version is available online at: 10.1519/JSC.0000000000003078

Contains fulltext : 202928.pdf (Publisher’s version ) (Open Access) Acetylation of the lysine residues in histones and other DNA-binding proteins plays a major role in regulation of eukaryotic gene expression. This process is controlled by histone acetyltransferases (HATs/KATs) found in multiprotein complexes that are recruited to chromatin by the scaffolding subunit transformation/transcription domain-associated protein (TRRAP). TRRAP is evolutionarily conserved and is among the top five genes intolerant to missense variation. Through an international collaboration, 17 distinct de novo or apparently de novo variants were identified in TRRAP in 24 individuals. A strong genotype-phenotype correlation was observed with two distinct clinical spectra. The first is a complex, multi-systemic syndrome associated with various malformations of the brain, heart, kidneys, and genitourinary system and characterized by a wide range of intellectual functioning; a number of affected individuals have intellectual disability (ID) and markedly impaired basic life functions. Individuals with this phenotype had missense variants clustering around the c.3127G>A p.(Ala1043Thr) variant identified in five individuals. The second spectrum manifested with autism spectrum disorder (ASD) and/or ID and epilepsy. Facial dysmorphism was seen in both groups and included upslanted palpebral fissures, epicanthus, telecanthus, a wide nasal bridge and ridge, a broad and smooth philtrum, and a thin upper lip. RNA sequencing analysis of skin fibroblasts derived from affected individuals skin fibroblasts showed significant changes in the expression of several genes implicated in neuronal function and ion transport. Thus, we describe here the clinical spectrum associated with TRRAP pathogenic missense variants, and we suggest a genotype-phenotype correlation useful for clinical evaluation of the pathogenicity of the variants.

International audience; Purpose To investigate the effect of different DEAF1 variants on the phenotype of patients with autosomal dominant and recessive inheritance patterns and on DEAF1 activity in vitro. Methods We assembled a cohort of 23 patients with de novo and biallelic DEAF1 variants, described the genotype–phenotype correlation, and investigated the differential effect of de novo and recessive variants on transcription assays using DEAF1 and Eif4g3 promoter luciferase constructs. Results The proportion of the most prevalent phenotypic features, including intellectual disability, speech delay, motor delay, autism, sleep disturbances, and a high pain threshold, were not significantly different in patients with biallelic and pathogenic de novo DEAF1 variants. However, microcephaly was exclusively observed in patients with recessive variants (p < 0.0001). Conclusion We propose that different variants in the DEAF1 gene result in a phenotypic spectrum centered around neurodevelopmental delay. While a pathogenic de novo dominant variant would also incapacitate the product of the wild-type allele and result in a dominant-negative effect, a combination of two recessive variants would result in a partial loss of function. Because the clinical picture can be nonspecific, detailed phenotype information, segregation, and functional analysis are fundamental to determine the pathogenicity of novel variants and to improve the care of these patients. © 2019, American College of Medical Genetics and Genomics.

Biallelic loss of function variants in the TMCO1 gene have been previously demonstrated to result in cerebrofaciothoracic dysplasia (CFTD; MIM #213980). The phenotype of this condition includes severe intellectual disability, as well as distinctive craniofacial features, including brachycephaly, synophrys, arched eyebrows, "cupid's bow" upper lip, and microdontia. In addition, nonspecific skeletal anomalies are common, including bifid ribs, scoliosis, and spinal fusion. Only 19 molecularly confirmed patients have been previously described. Here, we present four patients with CFTD, including three brothers from a Pakistani background and an additional unrelated white Scottish patient. All share the characteristic craniofacial appearance, with severe intellectual disability and skeletal abnormalities. We further define the phenotype with comparison to the published literature, and present images to define the dysmorphic features in a previously unreported ethnic group. All of our patient series are homozygous for the same c.292_293del (p.Ser98*) TMCO1 pathogenic variant, which has been previously reported only in an isolated Amish population. Thus we provide evidence that CFTD may be more common than previously thought. The patients presented here further delineate the phenotypic spectrum of CFTD and provide evidence for a recurrent pathogenic variant in TMCO1.

Although a growing number of studies have demonstrated differences in responses to ADHD-like behaviours, very few studies have focused on theorizing diversity in the way ADHD is framed and approached globally. To contribute to the study of medicalization in a global context, this study examines the discursive field in which care professionals explain and treat ADHD among children in metropolitan India and addresses the need for an analytic framework to grasp the variations in the way ADHD is understood and approached. Building on the concepts of pragmatic medicalization and creolization, we study ADHD discourses in India asking ‘What is at stake’ and ‘What matters most’?In this mixed methods study, 64 care professionals regularly involved in assessing ADHD-like behaviour completed an online Q-sort, and 21 professionals participated in face-to-face interviews. The Q-data were subjected to factor analysis. The interviews were analyzed using qualitative content analyses.Our study identified six distinct ADHD discourses, which showed that care professionals combine explanatory and treatment models. Professionals adapt their explanations and treatments of ADHD to parents’ worries regarding academic performance, family prestige, stigma and side effects of allopathic medicine. Our findings indicate that an awareness of local concerns and adjustments to structural opportunities can diversify how ADHD-like behaviour is framed and responded to.This study demonstrates that medicalization operates between the emerging institutions of care and the everyday concerns of families and care professionals and reveals the need to examine conflicting stakes as drivers of diverse responses to ADHD diagnosis and treatment in India and the rest of the world.

Left ventricular (LV) stroke work (SW) is calculated from the pressure-volume (PV) loop. PV loops do not contain information on longitudinal and radial pumping, leaving their contributions to SW unknown. A conceptual framework is proposed to derive the longitudinal and radial contributions to SW, using ventricular force-length loops reflecting longitudinal and radial pumping. The aim of this study was to develop and validate this framework experimentally and to explore these contributions in healthy controls and heart failure patients. Thirteen swine underwent cardiovascular magnetic resonance (CMR) and LV pressure catheterization at baseline (n = 7) or 1 wk after myocardial infarction (n = 6). CMR and noninvasive PV loop quantification were performed on 26 human controls and 14 patients. Longitudinal and radial forces were calculated as LV pressure multiplied by the myocardial surface areas in the respective directions. Length components were defined as the atrioventricular plane and epicardial displacements, respectively. Contributions to SW were calculated as the area within the respective force-length loop. Summation of longitudinal and radial SW had excellent agreement with PV loop-derived SW (ICC = 0.95, R = 0.96, bias ± SD = −4.5 ± 5.4%) in swine. Longitudinal and radial contributions to SW were ~50/50% in swine and human controls, and 44/56% in patients. Longitudinal pumping required less work than radial to deliver stroke volume in swine (6.8 ± 0.8 vs. 8.7 ± 1.2 mJ/mL, P = 0.0002) and in humans (11 ± 2.1 vs. 17 ± 4.7 mJ/mL, P < 0.0001). In conclusion, longitudinal and radial pumping contribute ~50/50% to SW in swine and human controls and 44/56% in heart failure patients. Longitudinal pumping is more energy efficient than radial pumping in delivering stroke volume. NEW & NOTEWORTHY A novel method for quantifying the contributions of longitudinal and radial pumping to stroke work using global left ventricular force-length loops was proposed and validated, which can be quantified noninvasively using cardiovascular magnetic resonance and brachial cuff pressure. We found that longitudinal and radial pumping contributes equally to stroke work in controls and 44/56% in heart failure patients, and that the longitudinal pumping is more energy efficient in delivering stroke volume than radial pumping.

Background Irbesartan, a long acting selective angiotensin-1 receptor inhibitor, in Marfan syndrome might reduce aortic dilatation, which is associated with dissection and rupture. We aimed to determine the effects of irbesartan on the rate of aortic dilatation in children and adults with Marfan syndrome. Methods We did a placebo-controlled, double-blind randomised trial at 22 centres in the UK. Individuals aged 6–40 years with clinically confirmed Marfan syndrome were eligible for inclusion. Study participants were all given 75 mg open label irbesartan once daily, then randomly assigned to 150 mg of irbesartan (increased to 300 mg as tolerated) or matching placebo. Aortic diameter was measured by echocardiography at baseline and then annually. All images were analysed by a core laboratory blinded to treatment allocation. The primary endpoint was the rate of aortic root dilatation. This trial is registered with ISRCTN, number ISRCTN90011794. Findings Between March 14, 2012, and May 1, 2015, 192 participants were recruited and randomly assigned to irbesartan (n=104) or placebo (n=88), and all were followed for up to 5 years. Median age at recruitment was 18 years (IQR 12–28), 99 (52%) were female, mean blood pressure was 110/65 mm Hg (SDs 16 and 12), and 108 (56%) were taking β blockers. Mean baseline aortic root diameter was 34·4 mm in the irbesartan group (SD 5·8) and placebo group (5·5). The mean rate of aortic root dilatation was 0·53 mm per year (95% CI 0·39 to 0·67) in the irbesartan group compared with 0·74 mm per year (0·60 to 0·89) in the placebo group, with a difference in means of −0·22 mm per year (−0·41 to −0·02, p=0·030). The rate of change in aortic Z score was also reduced by irbesartan (difference in means −0·10 per year, 95% CI −0·19 to −0·01, p=0·035). Irbesartan was well tolerated with no observed differences in rates of serious adverse events. Interpretation Irbesartan is associated with a reduction in the rate of aortic dilatation in children and young adults with Marfan syndrome and could reduce the incidence of aortic complications. Funding British Heart Foundation, the UK Marfan Trust, the UK Marfan Association.

Introduction Novel psychotropic substances also known as legal highs are a major concern in UK prisons, fuelling violence and putting a strain on resources for inmates requiring medical treatment for adverse effects. We provide a clinical toxicology service including routine screening for novel psychoactive substances. In 2015, we were approached by Her Majesty Prison Service search dog training team to advise on which novel psychoactive substances to target, and again in 2016 to further provide analytical support to test five letters which the dogs positively identified for novel psychotropic substances during routine searches of prison mail rooms. Here we provide the first analytical confirmation that letters sent to inmates are being used to smuggle novel psychotropic substances into UK prisons. Results Novel psychotropic substances were detected on all five letters and these included the stimulants ethylphenidate, methiopropamine and methoxiphenidaine, the sedative etizolam and the third generation synthetic cannabinoids 5F-AKB-48, AB-FUBINACA, MDMB-CHMICA. Other compounds detected include the class A drug cocaine, class B drug methylphenidate and the cutting agents lignocaine, benzocaine and procaine. Conclusion Novel psychotropic substances smuggled into UK prisons is a major safety and security concern. By analytically confirming letters sent to inmates do contain novel psychotropic substances, we have produced categorical evidence to support anecdotal suggestions that novel psychotropic substances are entering UK prisons in this manner.

It is well documented that patients with human leucocyte antigen (HLA)-Cw6+ (type 1) psoriasis have increased severity and reduced age of onset of psoriasis. However, not much is known about any differential response of this genetic subgroup to various treatments. We set out to determine if there was any genetic association of the HLA-Cw6 allele with the first-line systemic treatment commonly used in psoriasis, methotrexate. A cohort of patients from Tayside in Scotland was recruited through a novel generic consenting process (GoShare); they were extensively phenotyped and analysed for an association of their HLA-Cw6 genotype status with treatment outcomes. HLA-Cw6+ patients showed notably improved response to methotrexate (P = 0.05), and further analysis demonstrated an even greater response in a subcohort of the HLA-Cw6+ patients, who did not have concomitant psoriatic arthritis (P = 0.01). HLA-Cw6+ patients also exhibited fewer treatment-limiting adverse events. In addition to these findings, the methodology and primary clinical outcome phenotype, which we validate here, will greatly facilitate replication of the present results in independent cohorts. Postprint Postprint

Contains fulltext : 206572.pdf (Publisher’s version ) (Open Access) We delineate a KMT2E-related neurodevelopmental disorder on the basis of 38 individuals in 36 families. This study includes 31 distinct heterozygous variants in KMT2E (28 ascertained from Matchmaker Exchange and three previously reported), and four individuals with chromosome 7q22.2-22.23 microdeletions encompassing KMT2E (one previously reported). Almost all variants occurred de novo, and most were truncating. Most affected individuals with protein-truncating variants presented with mild intellectual disability. One-quarter of individuals met criteria for autism. Additional common features include macrocephaly, hypotonia, functional gastrointestinal abnormalities, and a subtle facial gestalt. Epilepsy was present in about one-fifth of individuals with truncating variants and was responsive to treatment with anti-epileptic medications in almost all. More than 70% of the individuals were male, and expressivity was variable by sex; epilepsy was more common in females and autism more common in males. The four individuals with microdeletions encompassing KMT2E generally presented similarly to those with truncating variants, but the degree of developmental delay was greater. The group of four individuals with missense variants in KMT2E presented with the most severe developmental delays. Epilepsy was present in all individuals with missense variants, often manifesting as treatment-resistant infantile epileptic encephalopathy. Microcephaly was also common in this group. Haploinsufficiency versus gain-of-function or dominant-negative effects specific to these missense variants in KMT2E might explain this divergence in phenotype, but requires independent validation. Disruptive variants in KMT2E are an under-recognized cause of neurodevelopmental abnormalities.

© 2019 American Society of Human Genetics The occurrence of non-epileptic hyperkinetic movements in the context of developmental epileptic encephalopathies is an increasingly recognized phenomenon. Identification of causative mutations provides an important insight into common pathogenic mechanisms that cause both seizures and abnormal motor control. We report bi-allelic loss-of-function CACNA1B variants in six children from three unrelated families whose affected members present with a complex and progressive neurological syndrome. All affected individuals presented with epileptic encephalopathy, severe neurodevelopmental delay (often with regression), and a hyperkinetic movement disorder. Additional neurological features included postnatal microcephaly and hypotonia. Five children died in childhood or adolescence (mean age of death: 9 years), mainly as a result of secondary respiratory complications. CACNA1B encodes the pore-forming subunit of the pre-synaptic neuronal voltage-gated calcium channel Cav2.2/N-type, crucial for SNARE-mediated neurotransmission, particularly in the early postnatal period. Bi-allelic loss-of-function variants in CACNA1B are predicted to cause disruption of Ca2+ influx, leading to impaired synaptic neurotransmission. The resultant effect on neuronal function is likely to be important in the development of involuntary movements and epilepsy. Overall, our findings provide further evidence for the key role of Cav2.2 in normal human neurodevelopment.

IntroductionFetal anticonvulsant syndrome (FACS) describes the pattern of physical and developmental problems seen in those children exposed to certain antiepileptic drugs (AEDs) in utero. The diagnosis of FACS is a clinical one and so excluding alternative diagnoses such as genetic disorders is essential.MethodsWe reviewed the pathogenicity of reported variants identified on exome sequencing in the Deciphering Developmental Disorders (DDD) Study in 42 children exposed to AEDs in utero, but where a diagnosis other than FACS was suspected. In addition, we analysed chromosome microarray data from 10 patients with FACS seen in a Regional Genetics Service.ResultsSeven children (17%) from the DDD Study had a copy number variant or pathogenic variant in a developmental disorder gene which was considered to explain or partially explain their phenotype. Across the AED exposure types, variants were found in 2/15 (13%) valproate exposed cases and 3/14 (21%) carbamazepine exposed cases. No pathogenic copy number variants were identified in our local sample (n=10).ConclusionsThis study is the first of its kind to analyse the exomes of children with developmental disorders who were exposed to AEDs in utero. Though we acknowledge that the results are subject to bias, a significant number of children were identified with alternate diagnoses which had an impact on counselling and management. We suggest that consideration is given to performing whole exome sequencing as part of the diagnostic work-up for children exposed to AEDs in utero.

Introduction Legal highs also known as novel psychoactive substances mimic the effects of classic drugs of abuse. Challenges to developing screening services for novel psychoactive substances include identifying which novel psychoactive substances are available to target. Using new techniques such as exact mass time of flight can help identify common novel psychoactive substances to target for screening patient samples by routine methods such as tandem mass spectrometry. We demonstrate this strategy working in our own clinical toxicology laboratory after qualitative analysis of 98 suspect materials for novel psychoactive substances by ultra-performance liquid chromatography with time of flight mass spectrometry. Results From July 2014 to July 2015 we received 98 requests to test a range of different suspect materials for novel psychoactive substances including herbs, tobacco, liquids, pills and powders. Overall, 87% of the suspect materials tested positive for novel psychoactive substances, and 15% for controlled drugs. Three common novel psychoactive substances were present in 74% of the suspect materials: methiopropamine, a methamphetamine analogue; ethylphenidate, a cocaine mimic; and the third generation synthetic cannabinoid 5F-AKB-48. For the 55 branded products we tested only 24% of the stated contents matched exactly the compounds we detected. Conclusion Testing suspect materials using ultra-performance liquid chromatography with time of flight mass spectrometry has identified three common novel psychoactive substances in use in the UK, simplifying the development of a relevant novel psychoactive substances screening service to our population. By incorporating this into our routine liquid chromatography tandem mass spectrometry drugs of abuse screen, then offers a clinically relevant novel psychoactive substances service to our users. This strategy ensures our clinical toxicology service continues to remain effective to meet the challenges of the changing drug use in the UK.

ObjectivesTo assess the feasibility of delivering and evaluating a weight management (WM) programme for overweight patients with a family history (FH) of breast cancer (BC) or colorectal cancer (CRC).Study designA two-arm (intervention vs usual care) randomised controlled trial.SettingNational Health Service (NHS) Tayside and NHS Grampian.ParticipantsPeople with a FH of BC or CRC aged≥18 years and body mass index of ≥25 kg/m2referred to NHS genetic services.InterventionParticipants were randomised to a control (lifestyle booklet) or 12-week intervention arm where they were given one face-to-face counselling session, four telephone consultations and web-based support. A goal of 5% reduction in body weight was set, and a personalised diet and physical activity (PA) programme was provided. Behavioural change techniques (motivational interviewing, action and coping plans and implementation intentions) were used.Primary outcomeFeasibility measures: recruitment, programme implementation, fidelity measures, achieved measurements and retention, participant satisfaction assessed by questionnaire and qualitative interviews.Secondary outcomesMeasured changes in weight and PA and reported diet and psychosocial measures between baseline and 12-week follow-up.ResultsOf 480 patients approached, 196 (41%) expressed interest in the study, and of those, 78 (40%) patients were randomised. Implementation of the programme was challenging within the time allotted and fidelity to the intervention modest (62%). Qualitative findings indicated the programme was well received. Questionnaires and anthropometric data were completed by >98%. Accelerometer data were attained by 84% and 54% at baseline and follow-up, respectively. Retention at 12 weeks was 76%. Overall, 36% of the intervention group (vs 0% in control) achieved 5% weight loss. Favourable increases in PA and reduction in dietary fat were also reported.ConclusionsA lifestyle programme for people with a family history of cancer is feasible to conduct and acceptable to participants, and indicative results suggest favourable outcomes.Trial registration numberISRCTN13123470; Pre-results.

Histone lysine methyltransferases (KMTs) and demethylases (KDMs) underpin gene regulation. Here we demonstrate that variants causing haploinsufficiency of KMTs and KDMs are frequently encountered in individuals with developmental disorders. Using a combination of human variation databases and existing animal models, we determine 22 KMTs and KDMs as additional candidates for dominantly inherited developmental disorders. We show that KMTs and KDMs that are associated with, or are candidates for, dominant developmental disorders tend to have a higher level of transcription, longer canonical transcripts, more interactors, and a higher number and more types of post-translational modifications than other KMT and KDMs. We provide evidence to firmly associate KMT2C, ASH1L, and KMT5B haploinsufficiency with dominant developmental disorders. Whereas KMT2C or ASH1L haploinsufficiency results in a predominantly neurodevelopmental phenotype with occasional physical anomalies, KMT5B mutations cause an overgrowth syndrome with intellectual disability. We further expand the phenotypic spectrum of KMT2B-related disorders and show that some individuals can have severe developmental delay without dystonia at least until mid-childhood. Additionally, we describe a recessive histone lysine-methylation defect caused by homozygous or compound heterozygous KDM5B variants and resulting in a recognizable syndrome with developmental delay, facial dysmorphism, and camptodactyly. Collectively, these results emphasize the significance of histone lysine methylation in normal human development and the importance of this process in human developmental disorders. Our results demonstrate that systematic clinically oriented pathway-based analysis of genomic data can accelerate the discovery of rare genetic disorders.

Background We present a 5-year review of our UK service for plasma ethylene glycol and diethylene glycol determination in cases of acute poisoning. Methods Ethylene glycol and diethylene glycol have been measured on all samples received for screening for toxicity by gas chromatography-flame ionization detection over a five-year period. A detailed audit of the results has been undertaken. Results In this period, we received 811 requests, 56% were for first-time screening and 44% repeat analysis where a positive sample has already been received. Of the first-time screen samples, 33.5% screened positive for glycol poisoning. The mean positive ethylene glycol concentration was 1204 mg/L (range 31 to 8666 mg/L). Diethylene glycol was present in 14% of ethylene glycol positive samples but never found alone. Conclusions The data presented here suggest it is not essential to measure diethylene glycol since its inclusion is rarely likely to change patient management.

Background Infliximab, a monoclonal antibody directed against tumour necrosis factor, is widely used in the treatment of chronic inflammatory conditions including Crohn’s disease and rheumatoid arthritis. Its use is limited by development of anti-infliximab antibodies, which can lead to loss of therapeutic efficacy. Serum infliximab and anti-infliximab antibody measurements have recently become routinely available in the UK. The study aimed to assess the clinical utility of antibodies as an adjunct to trough infliximab. Methods Serum trough infliximab was measured in 201 samples from 108 gastroenterology and rheumatology patients on maintenance infliximab therapy. Results were correlated with C-reactive protein concentrations. Total anti-infliximab antibodies were measured in 164 samples. Results The median (25th–75th percentile) trough infliximab was 3.7 µg/mL (1.2–5.2 µg/mL) and 23% of samples had a concentration ≤1 µg/mL. A notable proportion had positive anti-infliximab antibodies: 84/164 (51%), which subdivided to 85% and 28% with infliximab ≤1 and >1 µg/mL, respectively. Serum C-reactive protein was found to be significantly higher where infliximab was ≤1 compared to >1 µg/mL (10 mg/L [Conclusion Our findings support measurement of anti-infliximab antibodies only in the context of low infliximab concentrations

On autopsy, a patient is found to have hypertrophic cardiomyopathy. The patient’s family pursues genetic testing that shows a “likely pathogenic” variant for the condition on the basis of a study in an original research publication. Given the dominant inheritance of the condition and the risk of sudden cardiac death, other family members are tested for the genetic variant to determine their risk. Several family members test negative and are told that they are not at risk for hypertrophic cardiomyopathy and sudden cardiac death, and those who test positive are told that they need to be regularly monitored for cardiomyopathy on echocardiography. Five years later, during a routine clinic visit of one of the genotype-positive family members, the cardiologist queries a database for current knowledge on the genetic variant and discovers that the variant is now interpreted as “likely benign” by another laboratory that uses more recently derived population-frequency data. A newly available testing panel for additional genes that are implicated in hypertrophic cardiomyopathy is initiated on an affected family member, and a different variant is found that is determined to be pathogenic. Family members are retested, and one member who previously tested negative is now found to be positive for this new variant. An immediate clinical workup detects evidence of cardiomyopathy, and an intracardiac defibrillator is implanted to reduce the risk of sudden cardiac death.

Background Germline mutations in the phosphatase PTEN are associated with diverse human pathologies, including tumour susceptibility, developmental abnormalities and autism, but any genotype-phenotype relationships are poorly understood. Methods We have studied the functional consequences of seven PTEN mutations identified in patients diagnosed with autism and macrocephaly and five mutations from severe tumour bearing sufferers of PTEN hamartoma tumour syndrome (PHTS). Results All seven autism-associated PTEN mutants investigated retained the ability to suppress cellular AKT signalling, although five were highly unstable. Observed effects on AKT also correlated with the ability to suppress soma size and the length and density of dendritic spines in primary neurons. Conversely, all five PTEN mutations from severe cases of PHTS appeared to directly and strongly disrupt the ability to inhibit AKT signalling. Conclusions Our work implies that alleles causing incomplete loss of PTEN function are more commonly linked to autism than to severe PHTS cases.

Context: At least a third of the patients with pheochromocytoma (PCC) or paraganglioma (PGL) harbor an underlying germline mutation in a known PCC/PGL gene. Mutations in genes (SDHB, SDHD, SDHC, and SDHA) encoding a component of the tricarboxylic acid cycle, succinate dehydrogenase (SDH), are a major cause of inherited PCC and PGL. SDHB mutations are also, albeit less frequently, associated with inherited renal cell carcinoma. Inactivation of SDH and another tricarboxylic acid cycle component, fumarate hydratase (FH), have both been associated with abnormalities of cellular metabolism, responsible for the activation of hypoxic gene response pathways and epigenetic alterations (eg, DNA methylation). However, the clinical phenotype of germline mutations in SDHx genes and FH is usually distinct, with FH mutations classically associated with hereditary cutaneous and uterine leiomyomatosis and renal cell carcinoma, although recently an association with PCC/PGL has been reported. Objective and Design: To identify potential novel PCC/PGL predisposition genes, we initially undertook exome resequencing studies in a case of childhood PCC, and subsequently FH mutation analysis in a further 71 patients with PCC, PGL, or head and neck PGL. Results: After identifying a candidate FH missense mutation in the exome study, we then detected a further candidate missense mutation (p.Glu53Lys) by candidate gene sequencing. In vitro analyses demonstrated that both missense mutations (p.Cys434Tyr and p.Glu53Lys) were catalytically inactive. Conclusions: These findings 1) confirm that germline FH mutations may present, albeit rarely with PCC or PGL; and 2) extend the clinical phenotype associated with FH mutations to pediatric PCC.

Breast cancer risk is a common indication for referral to clinical genetics services. UK National Institute of Health and Care Excellence (NICE) guidelines use family history (FH) to stratify by 10-year risk of breast cancer from age 40. Patients are stratified into population risk (PR, 10-year risk 8%). Women at increased risk are offered screening at or prior to age 40. To assess the clinical effectiveness of current risk stratification, FH data were obtained for all unaffected women with a FH of breast cancer aged

Colorectal cancer (CRC) risk is well defined for families of patients with classical familial adenomatous polyposis (FAP). However, the risk for those with an attenuated form of FAP is less well characterised. In this study, we estimated CRC risks for carriers of a novel germline mutation in the APC gene that causes attenuated FAP (AFAP). We performed genetic testing on 53 individuals from seven AFAP families harbouring an identical APC:c.288T>A mutation. Using a modified segregation analysis, we estimated relative and absolute CRC risks for mutation carriers. Twenty-three individuals harboured the disease causing mutation. CRC occurred in 28 individuals (mean 61.7 years, range 32–80 years). The estimated CRC relative risks for mutation carriers aged 60–69 and ≥70 years were 19 (95% CI: 1.77–204.08) and 45 (95% CI: 11.32–180.10), respectively, while the absolute CRC lifetime risk for men was 94% (95% CI: 67.5–99.9%), and for women, 84% (95% CI: 50.9–99.0%). This study shows that AFAP can manifest as autosomal dominant late-onset CRC. These findings highlight a subgroup of inherited CRCs that require new criteria for identification and surveillance.

Background Personal and family data forms, completed by women referred to breast cancer genetics clinics, are valuable tools for verification and extension of family history, crucial steps in accurate risk evaluation. A significant minority of women do not complete and return these forms, despite reminders, even when completion is a pre-requisite for a clinic appointment. Objective To facilitate access of women at increased familial risk of breast cancer to screening and counselling services by investigating reasons for non-return of the forms. Participants and Design Based on a single regional ‘breast cancer family’ service in the UK, Analysis of quantitative data comparing women who did not return forms (n = 55) with those who had done so (n = 59), together with qualitative evaluation of potential barriers to form-completion through semi-structured telephone interviews with a random subset of ‘non-returners’ (n = 23). Results Non-returners have higher proportions of the very young (below the age at which surveillance could be offered) and of women from lower social deprivation categories. Interviews revealed that the majority of non-returners are anxious, rather than unconcerned about their breast cancer risk and circumstances and attitudes contributed to non-compliance. Twenty-one participants confirmed that they would welcome an appointment at a ‘breast cancer family’ clinic, but nine did not attend for the appointment. They were significantly younger than those who attend, but were not at lower familial risk. Discussion and Conclusions Many women who fail to complete and return a family history form would benefit from risk assessment and genetic counselling. Several steps are suggested that might help them access the relevant services.

β2-Agonists are the most commonly prescribed asthma medication, and the β2-adrenergic receptor gene has been studied extensively. A single-nucleotide polymorphism causing the substitution of arginine (Arg) for glycine (Gly) at position 16 (Gly16Arg) of the β2-adrenergic receptor affects the response to β2-agonists. Regular exposure to β2-agonists results in down-regulation and uncoupling of β2-adrenoreceptors with associated subsensitivity or tachyphylaxis of response.1 Retrospective studies have reported an impaired therapeutic response in terms of peak expiratory flow in adults treated with long-acting β2-agonists (LABAs).

Introduction Our dried blood spot vitamin D testing service enables members of the public to assess their vitamin D status. Vitamin D has become popular with the media and the general public. We noticed that our direct access service had a higher rate of high to toxic 25-hydroxyvitamin D levels compared with our GP population and we wanted to know why. Methods Between January 2013 and September 2015 we contacted all direct access users who had 25-hydroxyvitamin D >220 nmol/L measured using LC/MS/MS. We investigated the amount, type and length of supplementation used and whether or not users were medically supervised. Results A total of 372 service users had 25-hydroxyvitamin D concentrations >220 nmol/L. Of 14,806 direct access samples received, 372 (2.5%) were from users with 25-hydroxyvitamin D concentrations ranging from 221 to 1235 nmol/L. Only 0.06% of GP patients had results >220 nmol/L over the same time frame. There were 361 direct access users regularly supplementing, taking between 1000 to 120,000 IU/day. Two users took bolus doses of 300,000 and 900,000 IU. Only 23 users taking supplements (6.4%) were under medical supervision. There were 28 users with levels >500 nmol/L, but only one was under medical supervision. The internet was the main source of supplements (74%). Conclusions The proportion of high to toxic concentrations of vitamin D was higher in direct access users than in the GP population. Many people were taking more than the Institute of Medicine's recommendation of 10,000 IU/day, yet only a few were being medically supervised. Clinicians should be aware that patients may be self-administering very high concentrations of vitamin D, especially when investigating unexplained hypercalcaemia.

The current work aimed to assess health behaviors, perceived risk and control over breast/colorectal cancer risk and views on lifestyle advice amongst attendees at cancer family history clinics. Participants attending the East of Scotland Genetics Service were invited to complete a questionnaire (demographic data, weight and height, health behaviors and psycho-social measures of risk and perceived control) and to participate in an in-depth interview. The questionnaire was completed by 237 (49 %) of attendees, ranging from 18 to 77 years (mean age 46 (±10) years). Reported smoking rates (11 %) were modest, most (54 %) had a BMI > 25 kg/m2, 55 % had low levels of physical activity, 58 % reported inappropriate alcohol intakes and 90 % had fiber intakes indicative of a low plant diet. Regression analysis indicated that belief in health professional control was associated with higher, and belief in fatalism with poorer health behavior. Qualitative findings highlighted doubts about the link between lifestyle and cancer, and few were familiar with the current evidence. Whilst lifestyle advice was considered interesting in general there was little appetite for non-tailored guidance. In conclusion, current health behaviors are incongruent with cancer risk reduction guidance amongst patients who have actively sought advice on disease risk. There are some indications that lifestyle advice would be welcomed but endorsement requires a sensitive and flexible approach, and the acceptability of lifestyle interventions remains to be explored.

BACKGROUND: The pathogenesis of sporadic brain arteriovenous malformations (BAVMs) remains unknown, but studies suggest a genetic component. We estimated the heritability of sporadic BAVM and performed a genome-wide association study (GWAS) to investigate association of common single nucleotide polymorphisms (SNPs) with risk of sporadic BAVM in the international, multicentre Genetics of Arteriovenous Malformation (GEN-AVM) consortium.METHODS: The Caucasian discovery cohort included 515 BAVM cases and 1191 controls genotyped using Affymetrix genome-wide SNP arrays. Genotype data were imputed to 1000 Genomes Project data, and well-imputed SNPs (>0.01 minor allele frequency) were analysed for association with BAVM. 57 top BAVM-associated SNPs (51 SNPs with pRESULTS: The estimated heritability of BAVM was 17.6% (SE 8.9%, age and sex-adjusted p=0.015). None of the SNPs were significantly associated with BAVM in the replication cohort after correction for multiple testing. 6 SNPs had a nominal pCONCLUSIONS: We performed the first GWAS of sporadic BAVM in the largest BAVM cohort assembled to date. No GWAS SNPs were replicated, suggesting that common SNPs do not contribute strongly to BAVM susceptibility. However, heritability estimates suggest a modest but significant genetic contribution.

Background Synthetic cannabinoids (NOIDS) are novel psychotropic drugs (NPS) currently freely sold in the United Kingdom as ‘research chemicals’. Detection of NOIDS use is not available in current routine methods. Here we describe a marker which helps determine which patients have used these substances. Methods In a test case, ultra-performance liquid chromatography mass spectrometry (UPLC-Tof) was used to screen the legal high Herbal Haze II, the contents of hand-rolled cigarettes and five patient samples for NOIDS and their metabolites. Results Analysis of legal high Herbal Haze II and cigarettes identified the third generation adamantyl-type NOIDS N-(1-adamantyl)-1-pentyl-1H-indazole-3-carboxamide (AKB-48), 5F-AKB-48 and N-adamantyl-1-fluoropentylindole-3-carboxamide (STS-135). Out of 18 potential metabolites, 1-adamantylamine (C10H17N) was detected in all five urine samples. This adamantyl-type NOID marker was incorporated into our routine LC-MS/MS urine screen. Out of 14,436 random urine samples screened over eight months, 296 (2.05%) tested positive for the adamantyl-type NOID marker. Conclusion We have discovered a urine marker for identifying patients smoking legal high products containing the third generation adamantyl-type NOIDS such as AKB-48 and its fluoropentyl analogue 5F-AKB-48, which are among the most popular NOIDS currently available in legal high products sold in UK. This marker can be incorporated into routine LC-MS/MS drug screening alongside classic drugs of abuse. Positive detection rates for this new legal high marker are greater than for established classic drugs that are routinely screened such as amphetamine. This work highlights the need for a flexible toxicology screening service capable of adapting to changes in drug use such as the growing popularity of legal highs/NPS.

Lifestyle influences breast cancer risk. Women at increased familial risk may benefit from modifying behaviour, but it is not known to what extent they do so. This study aims to measure changes that UK (Scottish) women make in response to increased familial risk of breast cancer and attitudes to a risk-reduction trial. A questionnaire, completed by 140 “breast cancer family” clinic patients, generated data on habitual diet, alcohol consumption and exercise, changes made after learning of breast cancer risk and attitudes to possible further changes. Subgroups of patients were defined by criteria likely to influence changes in behaviour. Between-group differences were analysed by Fisher's exact test and overall correlations by linear regression. Thirty-six subjects (26 %) reported no behavioural change but, overall, around 25 % of diet, exercise and alcohol items had been changed. Women perceiving their lifetime cancer risk to be high (>50 %) and those who were obese (BMI >25) had made significantly more changes than others. Younger women (

There have been few definitive examples of gene-gene interactions in humans. Through mutational analyses in 7325 individuals, we report four interactions (defined as departures from a multiplicative model) between mutations in the breast cancer susceptibility genes ATM and CHEK2 with BRCA1 and BRCA2 (case-only interaction between ATM and BRCA1/BRCA2 combined, P = 5.9 × 10 -4; ATM and BRCA1, P= 0.01; ATM and BRCA2, P= 0.02; CHEK2 and BRCA1/BRCA2 combined, P = 2.1 × 10 =4; CHEK2 and BRCA1, P= 0.01; CHEK2 and BRCA2, P= 0.01). The interactions are such that the resultant risk of breast cancer is lower than the multiplicative product of the constituent risks, and plausibly reflect the functional relationships of the encoded proteins in DNA repair. These findings have important implications for models of disease predisposition and clinical translation. © The Author 2011. Published by Oxford University Press. All rights reserved.

Mutations in TCF4 (basic helix-loop-helix transcription factor 4), a gene with complex organization and multiple transcription initiation sites, are usually associated with Pitt-Hopkins syndrome (PTHS). However, a translocation encompassing the 5' end of TCF4 and several point mutations have been linked to non-syndromic intellectual disability (NSID). Here we describe a family with autosomal dominantly inherited NSID in seven relatives with a partial deletion of TCF4, disrupting the 5' end of the gene, predicted to result in the reduction of the number of mRNAs that can be produced by alternative transcription initiation. Functional studies indicate that it leads to reduced levels of transcripts coding for TCF4 protein isoforms with a nuclear localization signal, which may be relevant to the phenotype. The findings in our family support the notion that the position of the mutation in TCF4 is relevant to the phenotype, with those mutations in the 5' region, cassette exons and regions not affecting the important functional domains being linked to NSID rather than PTHS. We suggest that screening for mutations in TCF4 could be considered in the investigation of NSID.

BackgroundThiopurine S-methyltransferase (TPMT) phenotype analysis, expressed as TPMT activity, is established as a routine pharmacogenomic test to screen patients prior to initiating thiopurine drug therapy. Conventionally measured TPMT activity is corrected for red blood cell (RBC) parameters. Here we present evidence that supports the simplification of the TPMT assay: by expressing TPMT activity in mU/L whole blood, without undertaking any haemoglobin (Hb) correction.MethodsHb concentrations were compared in consecutive samples that had been received for TPMT phenotype analysis and which were stratified into samples with high ( n = 111) and samples with normal ( n = 50) Hb-corrected enzyme activity. TPMT activity was also measured in samples received for full blood count determination, stratified into those with low ( n = 50) and normal ( n = 50) Hb. A reference interval for TPMT activity in mU/L was derived from a correlation between activity expressed in conventional units and that expressed in mU/L ( n = 1563), supported by comparison with associated genotype ( n = 201).ResultsIn the high TPMT activity group, 83% of specimens had a low Hb concentration compared with 14% of specimens in the normal TPMT group. Samples with a low Hb concentration were found to have significantly higher Hb-corrected TPMT activity than samples with a normal Hb concentration: 83 versus 44 nmol 6-methyl thioguanine /g Hb/h, P < 0.0001. These results strongly suggest that misleading high Hb-corrected TPMT activity is found in anaemic patients. Based on the reference interval for enzyme activity of 70–150 mU/L, phenotype–genotype concordance compared well with the conventional approach (88% versus 89%). Furthermore, distribution of TPMT phenotypes with activity expressed in mU/L was identical: 0.5% deficient, 11% low, 86% normal and 2.5% high, to when it was expressed in conventional units.ConclusionExpressing TPMT activity in mU/L can overcome misleading high Hb-corrected TPMT results occurring in patients with anaemia, which could lead to inappropriate treatment. Removing the need to measure RBC indices further simplifies TPMT phenotyping, leading to a more robust assay, with reduced turn-around time and cost.

The use of azathioprine (and its metabolite mercaptopurine) is limited by toxicity, especially myelosuppression, which is related to activity of the enzyme thiopurine S-methyltransferase (TPMT). TPMT activity varies between individuals and is considered deficient in one in 300 cases. Aims & methods: We identified TPMT activity within an ethnically diverse population of patients attending an inner-city hospital phlebotomy service. A total of 1000 subjects were recruited and analyzed with respect to age, sex and ethnicity. Results: Samples were analyzed from 456 Caucasians, 342 South Asians and 180 Afro–Caribbeans. Six subjects had deficient TPMT activity (0.6%: four women, two men; four Caucasians, one Afro–Caribbean, one South Asian). TPMT activity (nmol 6-methylthioguanine (6-MTG)/gHb/h) ranged 0–76 (median [interquartile range]: 33 [28–39]). Enzyme activity was lower in Afro–Caribbeans (30 [25–37.5]) than Caucasians (34 [29–40]) and South Asians (33 [29–38]), which was significant after adjustment for age and sex (p

To evaluate current guidelines criteria for inclusion of women in special ‘breast cancer family history' surveillance programmes, records were reviewed of women referred to Scottish breast cancer family clinics between January 1994 and December 2003 but discharged as at ‘less than ‘moderate' familial risk'. The Scottish Cancer Registry was then interrogated to determine subsequent age-specific incidence of breast cancer in this cohort and corresponding Scottish population figures. Among 2074 women, with an average follow-up of 4.0 years, 28 invasive breast cancers were recorded up to December 2003, where 14.4 were expected, a relative risk (RR) of 1.94. Eleven further breast cancers were recorded between January 2004 and February 2006 (ascertainment incomplete for this period). The overall RR for women in the study cohort exceeded the accepted ‘cutoff' level (RR=1.7) for provision of special counselling and surveillance. The highest RR was found for the age group 45–59 years and this group also generated the majority of breast cancers. The National Institute for Clinical Excellence (‘NICE') guidelines appear to be more accurate than those of the Scottish Intercollegiate Guidelines Network (‘SIGN') in defining ‘moderate' familial risk, and longer follow-up of this cohort could generate an evidence base for further modification of familial breast cancer services.

Background We have examined the effect of delayed sample separation on serum creatinine measurement using the kinetic Jaffe method and estimated glomerular filtration rate (eGFR), and the impact this can have on chronic kidney disease (CKD) staging. Methods In a preliminary study clotted samples were left at room temperature for up to 48 h prior to centrifugation and serum creatinine measurement on a Roche modular analyser. A larger study then used paired clotted samples separated at baseline (30 min) and after 24 h at room temperature. To determine the effect on CKD staging, eGFR was calculated using the simplified [4-v] Modification of Diet in Renal Disease formula. Results Preliminary study. A significant increase in creatinine concentration ( P < 0.001) occurred after a 16 h delay in sample separation. By 48 h the mean increase in creatinine was 29% (range 21–63%). Twenty-four hour delay study. The mean increase in creatinine for 113 outpatient samples after delaying sample separation by 24 h was 11%, and exhibited considerable individual variation (range 2–87%). CKD staging for 32% of the group changed, 26% from stage 1 to 2 and 6% from stage 2 to 3. Conclusions Delay in sample separation affects the creatinine measurement using the Roche kinetic Jaffe reaction, and can result in the misclassification of CKD staging. Laboratories using the kinetic Jaffe method should not report creatinine results where there has been a delay in separation. This advice should also be reflected in practice guidelines.

Matrix metalloproteinase 3 (MMP3), is over expressed in the wall of abdominal aortic aneurysms (AAA), while inactivation of the gene expressing this enzyme is associated with reduced aneurysm formation in an experimental model. The 5A allele of the 5A/6A polymorphism in the promoter region of the MMP3 gene is associated with enhanced MMP3 expression. This study aimed to determine whether the presence of the 5A allele in the MMP3 promoter is a risk factor for AAA, and if this allele is associated with an increased expression of MMP3 in the aneurysm wall. We compared the frequencies of the 5A and 6A alleles in AAA (n = 405), aortic occlusive disease (AOD) (n = 123) and controls (n = 405). The 5A allele frequency was higher in AAA compared with controls (odds ratio - OR 1.32, P = 0.005) and AOD (OR 1.684, P = 0.0004), but was similar in AOD compared to controls (OR 0.78, P = 0.1). The ORs of the 5A/6A and the 5A/5A genotypes were 1.35 and 1.79, compared with 6A homozygotes. Although wall from 5A homozygotes contained 17% more MMP3 mRNA than homozygotes (P = 0.049) the significance of this was lost when adjusted for age and sex (P = 0.069), and size (P = 0.30). Wall from 5A homozygotes did however contain over 45% more MMP3 protein than heterozygotes (P = 0.009 when corrected for age and sex and P = 0.043 when corrected for aneurysm size). It appears that an abnormality in the MMP3 gene is part of the genetic profile that predisposes to aneurysmal disease.

Individuals who have been treated for breast cancer have been reported to have increased lymphocyte chromosomal sensitivity to ionizing radiation and a significantly lower apoptotic response to irradiation compared to controls. We set out to test these findings using a substantial number of cases sampled before treatment (which could alter the parameters measured), compared to age-matched controls with normal mammograms.We used the G2 chromosome breakage, and apoptotic response assays of peripheral blood lymphocytes to ionizing radiation to compare 211 unselected newly diagnosed and untreated breast cancer patients, with 170 age, sex and ethnically matched controls.We found no significant differences between breast cancer patients and their matched controls in the G2 assay or apoptotic response. However, there was some evidence that both cases and controls with a strong family history of breast cancer had higher radiosensitivity than those without.This is the largest and best controlled study of its kind, but it has not replicated previous reports of differences between chromosome breakage or apoptotic response in breast cancer cases vs. controls. However there was a suggestion of increased radiosensitivity in patients with a strong family history, which may indicate a heritable cancer susceptibility trait, warranting further study.

Background: Vitamin D deficiency is still thought to be widespread in the UK and in recent years the number of cases of rickets reported in children has increased. In this study, the distribution of vitamin D and the prevalence of vitamin D deficiency have been determined for a multi-ethnic population from the inner-city area of Birmingham, UK, where a vitamin D testing service has been readily available for over 10 years. Methods: Serum 25-hydroxyvitamin D concentration was determined using an automated platform (Nichol's Advantage Speciality System) for 830 outpatient samples collected randomly at the end of summer (September). Results: In our total study population, prevalence of vitamin D deficiency, defined as a 25-hydroxyvitamin D concentration < 10 μg/L, was high (24%): one in eight Caucasians, one in four Black Afro-Caribbeans and one in three Asians were found to be deficient. Levels of deficiency were much higher in Asian women, with almost one in two individuals (43%) found to have a vitamin D level below 10 μg/L. Conclusion: Our study has shown that widespread vitamin D deficiency in a UK inner-city population remains an issue. In concordance with other studies, we found a high prevalence of vitamin D deficiency in Afro-Caribbean and Asians, and, in particular, women. It is clear that more routine screening of vitamin D is needed.

Background: If the lipid concentration is not taken into account, then in certain situations the vitamin E status of a patient may be wrongly assigned based on serum measurement alone. In this study, the utility of using the calculated vitamin E:cholesterol ratio to determine vitamin E status was compared to the measurement of vitamin E alone. Methods: The vitamin E:cholesterol ratio was measured in 457 patient samples received for routine vitamin E analysis. Serum vitamin E concentration was determined by high-performance liquid chromatography (HPLC) with UV detection and cholesterol concentration, using a Roche analyser and reagents. Results: The mean vitamin E concentration and vitamin E:cholesterol ratio for the total study population was 22.0 μmol/L and 5.9 μmol/mmol, respectively. Of the 457 patient samples analysed, 57 (12.5%) were found to have a low vitamin E concentration, but only 25 (47%) of these patients had a low vitamin E:cholesterol ratio as well. Two patients both with cholestasis had a normal vitamin E concentration but low vitamin E:cholesterol ratio. Conclusion: The determination of vitamin E:cholesterol ratios can be used to better define the vitamin E status of patients with disease states or disorders likely to raise LDL cholesterol, for example cholestasis. For the majority of samples, measurement of serum vitamin E concentration alone is sufficient to establish patient vitamin E status.

A non-extraction high-performance liquid chromatographic (HPLC) method has been developed for the determination of 6-methylthioguanine (6-MTG), as part of the determination of thiopurine S -methyltransferase activity (TPMT) in erythrocytes. Erythrocyte lysate is added to a glass vial containing substrates and incubation buffer, which is then sealed for the rest of the analysis. Enzyme incubation, sample preparation, and analysis are then undertaken without further sample-handling steps. The need for a solvent extraction step has been overcome by heating the incubate to 85 °C to stop the enzyme reaction. The heat inactivation step precipitates protein which upon centrifugation forms a thin film in the bottom of the glass vial enabling the supernatant to be injected directly onto the HPLC system. The assay shows excellent precision and recovery with a within-batch imprecision giving a co-efficient of variation of 2.9% (mean=41.5 nmol 6-MTG/g Hb/h, n =10) and 5.1% (mean=12.6 nmol 6-MTG/g Hb/h, n =10). The between-batch imprecision gives a co-efficient of variation of 8.2% (mean=11.1 nmol 6-MTG/g Hb/h, n =11) and 7.3% (mean=41.0 nmol 6-MTG/g Hb/h, n =16). Determination of the TPMT activity in 120 people shows a range of enzyme activity of 11.3–63.8 nmol 6-MTG/g Hb/h with a mean and median activity of 34.8 and 34.2 nmol 6-MTG/g Hb/h, respectively. TPMT is increasingly used in clinical practice to ensure optimisation of treatment with thioguanine drugs. This direct HPLC method minimises sample-handling, reduces inherent imprecision, the possibility of laboratory error and with the potential for further automation, makes it ideal for use in a regional referral laboratory.

Anophthalmia or microphthalmia occur in approximately one in 10 children who have severe visual impairment. These eye malformations are often of unknown aetiology, but can be inherited in autosomal dominant, recessive or X-linked forms, and can also occur in association with specific chromosome abnormalities. Four children are described in the medical literature with microphthalmia or anophthalmia in association with chromosome rearrangements involving distal 3q, suggesting the presence of a micro/anophthalmia gene in this region. We have identified two further patients with micro/anophthalmia and chromosome rearrangements involving 3q26-->3q27 and identified a 6.7 MB common deleted region. Patient 1 had multiple abnormalities including bilateral anophthalmia, abnormalities of the first and second cranial nerves and partial absence of the corpus callosum. His karyotype was 46,XY,del(3)(q26.33q28). Patient 2 had right anophthalmia and left extreme microphthalmia. Her karyotype was 46,XX,del(3)(q26.33q28)t(3;7)(q28;q21.1). Both patients had intrauterine growth retardation (IUGR) and strikingly similar dysmorphic facies consisting of bossed forehead, downward-slanting palpebral fissures, grooved bridge of the nose, prominent low-set ears, small down-turned mouth and small mandible. We identified BAC clones mapping to distal 3q from the ENSEMBL and NCBI Entrez databases. These BAC clones were used as fluorescence in situ hybridisation (FISH) probes to identify the minimum deleted region common to both patients. This interval, between clones RPC11-134F2 and RPC11-132N15, was estimated to be 6.7 MB. We conclude that there is an anophthalmia locus within this interval. Candidate genes mapping to this region include Chordin and DVL3, a homologue of the Drosophila Dishevelled gene.

BACKGROUND: Pontocerebellar hypoplasia (PCH) represents a group of neurodegenerative disorders with prenatal onset. Eight subtypes have been described thus far (PCH1-8) based on clinical and genetic features. Common characteristics include hypoplasia and atrophy of the cerebellum, variable pontine atrophy, and severe mental and motor impairments. PCH1 is distinctly characterized by the combination with degeneration of spinal motor neurons. Recently, mutations in the exosome component 3 gene (EXOSC3) have been identified in approximately half of the patients with PCH subtype 1.METHODS: We selected a cohort of 99 PCH patients (90 families) tested negative for mutations in the TSEN genes, RARS2, VRK1 and CASK. Patients in this cohort were referred with a tentative diagnose PCH type 1, 2, 4, 7 or unclassified PCH. Genetic analysis of the EXOSC3 gene was performed using Sanger sequencing. Clinical data, MR images and autopsy reports of patients positive for EXOSC3 mutations were analyzed.RESULTS: EXOSC3 mutations were found in twelve families with PCH subtype 1, and were not found in patients with other PCH subtypes. Identified mutations included a large deletion, nonsense and missense mutations. Examination of clinical data reveals a prolonged disease course in patients with a homozygous p.D132A mutation. MRI shows variable pontine hypoplasia in EXOSC3 mediated PCH, where the pons is largely preserved in patients with a homozygous p.D132A mutation, but attenuated in patients with other mutations. Additionally, bilateral cerebellar cysts were found in patients compound heterozygous for a p.D132A mutation and a nonsense allele.CONCLUSIONS: EXOSC3 mediated PCH shows clear genotype-phenotype correlations. A homozygous p.D132A mutation leads to PCH with possible survival into early puberty, and preservation of the pons. Compound heterozygosity for a p.D132A mutation and a nonsense or p.Y109N allele, a homozygous p.G31A mutation or a p.G135E mutation causes a more rapidly progressive course leading to death in infancy and attenuation of the ventral pons.Our findings imply a clear correlation between genetic mutation and clinical outcome in EXOSC3 mediated PCH, including variable involvement of the pons.