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The benefit of antenatal corticosteroid (ACS) administration for the prevention of neonatal morbidity and mortality has been well described for preterm infants. Some studies have demonstrated a benefit for infants born by elective caesarean section (CS) at late preterm or term gestations. However, the neonatal benefits of ACS are not well described when given to pregnant women with diabetes.The aim of this study was to evaluate the neonatal outcomes following ACS administration in women with pre-gestational diabetes mellitus (PGDM) when administered prior to elective CS after 36 weeks gestation.This retrospective observational study included all women with PGDM who gave birth by elective CS between 36Of the 306 women identified, 65 (21.2%) were exposed to ACS within seven days prior to birth and 241 (78.8%) were not. Although not statistically significant, ACS-exposed infants born prior to 38This study did not demonstrate any statistically significant beneficial or harmful effects of ACS in neonates of women with PGDM who are born by elective CS. While it is plausible that ACS could reduce neonatal respiratory morbidity in this population, further prospective studies evaluating the benefits and harms are required before recommending this practice.

Women with substance abuse disorders have lower use of contraception. Unplanned pregnancies increase risk of fetal exposure to addictive and teratogenic substances. Postpartum inpatient periods for these women can be challenging times to facilitate contraception planning. To explore postnatal contraceptive planning practices, patient preferences for contraception, and supply challenges, and to identify how clinical pharmacists may best provide care in this context. A tertiary maternity referral hospital in metropolitan Victoria, Australia (January 2015—December 2018). A retrospective cohort study was conducted on postnatal women with substance abuse disorders. Patients were excluded if they had delivered at another health service, had inadequate documented evidence of a substance abuse disorder, or had incomplete or unavailable medical records. Records were reviewed for demographic data, admission details, and documented contraceptive planning. Documented contraceptive planning, patient contraception preferences and identified supply challenges. Ninety-three women were included. Seventy-one (76.3%) had psychiatric disorders or impairments, and 92 (98.9%) had identifiable follow-up challenges (eg. Homelessness). Nine (9.7%) self-discharged/absconded. Eighty-seven (93.5%) had documented postnatal contraception discussions. Sixty-two of 87 (71.3%) considered a medicine/device, three (3.4%) preferred condoms, 10 (11.5%) considered sterilisation, 2 (2.3%) preferred no contraception, and 16 (18.4%) undecided. Etonogestral 68 mg implants were most commonly prescribed (28 of 42; 66.7%). Inpatient postpartum periods for this cohort were characterised by psycho-social complexities, inconsistent contraceptive planning documentation, and patients seemingly unprepared to consider contraception. This study highlights a need for an earlier decision-making process and pragmatic counselling with antenatal pharmacists.

Background: The literature has demonstrated the efficacy of lumbar epidural blood patch (LEBP) in the management of spontaneous intracranial hypotension (SIH). However, the underlying pathophysiology of such management remains unclear. In this study, we aim to evaluate the utility of LEBP injections in the management of SIH and develop a potential management algorithm used in the triage and management of SIH patients. Methods: We retrospectively examined the clinical case notes of 14 patients with SIH (age: 25–69 years) who were managed with LEBP injections during the year of 2016–2021. We evaluated the presenting symptoms of each selected patient and radiological findings as well as treatment outcomes. Our aim is to evaluate the effectiveness of LEBP in the treatment of SIH patients through follow-up clinical and imaging assessment. Results: About 93% of patients describe the presence of headache at presentation, while 43% describe it as being of an orthostatic nature. All patients demonstrated typical findings on magnetic resonance imaging brain. Treatment success assessed through symptomatic improvement and radiological resolution was found in 85% of our patients at a 2-month interval. Conclusion: LEBP injection is an effective method of management in patients with a diagnosis of SIH. It should be considered in all SIH patients irrespective of whether a “dural leak” can be localized through radiological investigations.

BACKGROUND Hepatitis B virus (HBV) immunisation is the first vaccine of infant life and one of the most commonly refused immunisations on the Australian Immunisation Schedule. AIMS To quantify the frequency of declined HBV immunisation birth-doses, investigate reasons for refusal, and determine information sources used by parents. MATERIALS AND METHODS A cross-sectional study using a questionnaire was conducted on postnatal women who declined their newborn's HBV birth-dose immunisation during December 2016-July 2017 at an Australian tertiary referral hospital. Mothers who were non-English-speaking, unwell or medically unstable, or otherwise unavailable were excluded. RESULTS One hundred and thirty-seven of the 1574 (8.7%) eligible reviewed infants had HBV immunisation birth-doses documented as declined; 113 mothers consented to complete the questionnaire. The most common reasons for declining the dose were: 'baby too young' (55.8%); preference for two, four and six-month HBV immunisations only (56.6%); perceived low risk of contracting HBV (45.1%); and a fear of 'overloading' their baby's immune system (42.5%). General practitioners or nurses/midwives (43.3%) and the internet/media (33.6%) were the predominant information sources consulted, and 58.4% felt satisfied with the information they received antenatally. Eighty-eight of 113 mothers (77.9%) would still consider future immunisations for their infant. CONCLUSIONS The majority of postnatal women decline HBV birth-dose immunisation for their newborns citing age-related safety concerns and vaccine misconceptions. Informal information sources such as the internet and media are often consulted. Addressing the need for antenatal and health professional education toward the birth-dose may be instrumental in improving uptake.

Diffusion MRI (dMRI) tractography has been successfully used to study the trigeminal nerves (TGNs) in many clinical and research applications. Currently, identification of the TGN in tractography data requires expert nerve selection using manually drawn regions of interest (ROIs), which is prone to inter-observer variability, time-consuming and carries high clinical and labor costs. To overcome these issues, we propose to create a novel anatomically curated TGN tractography atlas that enables automated identification of the TGN from dMRI tractography. In this paper, we first illustrate the creation of a trigeminal tractography atlas. Leveraging a well-established computational pipeline and expert neuroanatomical knowledge, we generate a data-driven TGN fiber clustering atlas using tractography data from 50 subjects from the Human Connectome Project. Then, we demonstrate the application of the proposed atlas for automated TGN identification in new subjects, without relying on expert ROI placement. Quantitative and visual experiments are performed with comparison to expert TGN identification using dMRI data from two different acquisition sites. We show highly comparable results between the automatically and manually identified TGNs in terms of spatial overlap and visualization, while our proposed method has several advantages. First, our method performs automated TGN identification, and thus it provides an efficient tool to reduce expert labor costs and inter-operator bias relative to expert manual selection. Second, our method is robust to potential imaging artifacts and/or noise that can prevent successful manual ROI placement for TGN selection and hence yields a higher successful TGN identification rate.

Highlights • Investigation of the performance of multiple dMRI acquisitions and fiber models for trigeminal nerve (TGN) identification. • Expert rating study of over 1000 TGN visualizations using seven proposed expert rating anatomical criteria. • The two-tensor tractography method had better performance on identifying true positive structures, while generating more false positive streamlines in comparison to the single-tensor tractography method. • TGN tracking performance was significantly different across the three b-values for almost all structures studied., Background The trigeminal nerve (TGN) is the largest cranial nerve and can be involved in multiple inflammatory, compressive, ischemic or other pathologies. Currently, imaging-based approaches to identify the TGN mostly rely on T2-weighted magnetic resonance imaging (MRI), which provides localization of the cisternal portion of the TGN where the contrast between nerve and cerebrospinal fluid (CSF) is high enough to allow differentiation. The course of the TGN within the brainstem as well as anterior to the cisternal portion, however, is more difficult to display on traditional imaging sequences. An advanced imaging technique, diffusion MRI (dMRI), enables tracking of the trajectory of TGN fibers and has the potential to visualize anatomical regions of the TGN not seen on T2-weighted imaging. This may allow a more comprehensive assessment of the nerve in the context of pathology. To date, most work in TGN tracking has used clinical dMRI acquisitions with a b-value of 1000 s/mm2 and conventional diffusion tensor MRI (DTI) tractography methods. Though higher b-value acquisitions and multi-tensor tractography methods are known to be beneficial for tracking brain white matter fiber tracts, there have been no studies conducted to evaluate the performance of these advanced approaches on nerve tracking of the TGN, in particular on tracking different anatomical regions of the TGN. Objective We compare TGN tracking performance using dMRI data with different b-values, in combination with both single- and multi-tensor tractography methods. Our goal is to assess the advantages and limitations of these different strategies for identifying the anatomical regions of the TGN. Methods We proposed seven anatomical rating criteria including true and false positive structures, and we performed an expert rating study of over 1000 TGN visualizations, as follows. We tracked the TGN using high-quality dMRI data from 100 healthy adult subjects from the Human Connectome Project (HCP). TGN tracking performance was compared across dMRI acquisitions with b = 1000 s/mm2, b = 2000 s/mm2 and b = 3000 s/mm2, using single-tensor (1T) and two-tensor (2T) unscented Kalman filter (UKF) tractography. This resulted in a total of six tracking strategies. The TGN was identified using an anatomical region-of-interest (ROI) selection approach. First, in a subset of the dataset we identified ROIs that provided good TGN tracking performance across all tracking strategies. Using these ROIs, the TGN was then tracked in all subjects using the six tracking strategies. An expert rater (GX) visually assessed and scored each TGN based on seven anatomical judgment criteria. These criteria included the presence of multiple expected anatomical segments of the TGN (true positive structures), specifically branch-like structures, cisternal portion, mesencephalic trigeminal tract, and spinal cord tract of the TGN. False positive criteria included the presence of any fibers entering the temporal lobe, the inferior cerebellar peduncle, or the middle cerebellar peduncle. Expert rating scores were analyzed to compare TGN tracking performance across the six tracking strategies. Intra- and inter-rater validation was performed to assess the reliability of the expert TGN rating result. Results The TGN was selected using two anatomical ROIs (Meckel's Cave and cisternal portion of the TGN). The two-tensor tractography method had significantly better performance on identifying true positive structures, while generating more false positive streamlines in comparison to the single-tensor tractography method. TGN tracking performance was significantly different across the three b-values for almost all structures studied. Tracking performance was reported in terms of the percentage of subjects achieving each anatomical rating criterion. Tracking of the cisternal portion and branching structure of the TGN was generally successful, with the highest performance of over 98% using two-tensor tractography and b = 1000 or b = 2000. However, tracking the smaller mesencephalic and spinal cord tracts of the TGN was quite challenging (highest performance of 37.5% and 57.07%, using two-tensor tractography with b = 1000 and b = 2000, respectively). False positive connections to the temporal lobe (over 38% of subjects for all strategies) and cerebellar peduncles (100% of subjects for all strategies) were prevalent. High joint probability of agreement was obtained in the inter-rater (on average 83%) and intra-rater validation (on average 90%), showing a highly reliable expert rating result. Conclusions Overall, the results of the study suggest that researchers and clinicians may benefit from tailoring their acquisition and tracking methodology to the specific anatomical portion of the TGN that is of the greatest interest. For example, tracking of branching structures and TGN-T2 overlap can be best achieved with a two-tensor model and an acquisition using b = 1000 or b = 2000. In general, b = 1000 and b = 2000 acquisitions provided the best-rated tracking results. Further research is needed to improve both sensitivity and specificity of the depiction of the TGN anatomy using dMRI.

BACKGROUND AND PURPOSE: Previous literature has demonstrated disparity in the post-operative recovery of first and second language function of bilingual neurosurgical patients. However, it is unclear to whether pre-operative brain mapping of both languages is needed. In this study, we aimed to evaluate the clinical utility of language task functional MRI (fMRI) implemented in both languages in bilingual patients. METHODS: We retrospectively examined fMRI data of thirteen bilingual brain tumor patients (age: 23 to 59 years) who performed antonym generation task-based fMRIs in English and non-English language. The usefulness of bilingual language mapping was evaluated using a structured survey administered to five neurosurgeons. Additionally, quantitative comparison between the brain activation maps of both languages was performed. RESULTS: Survey responses revealed differences in raters’ surgical approach, including asleep vs. awake surgery and extent of resection, after viewing the language fMRI maps. Additional non-English fMRI led to changes in surgical decision-making and bettered localization of language areas. Quantitative analysis revealed an increase in laterality index (LI) in non-English fMRI compared to English fMRI. The Dice coefficient demonstrated fair overlap (0.458 +/− 0.160) between the activation maps. CONCLUSION: Bilingual fMRI mapping of bilingual patients allows to better appreciate functionally active language areas that may be neglected in single language mapping. Utility of bilingual mapping was supported by changes in both surgical approach and LI measurements, suggesting its benefit on pre-operative language mapping.

Epigenetic gene-regulation abnormalities have been implicated in various neuropsychiatric disorders including schizophrenia and depression, as well as in the regulation of mood and anxiety. In addition, epigenetic mechanisms are involved in the actions of psychiatric drugs. Current anxiolytic drugs have significant shortcomings, and development of new medications is warranted. Two proteins, G9a (also known as EHMT2 or KMT1C) and GLP (G9a-like protein, also known as EHMT1 or KMT1D), which methylate lysine 9 of histone H3 (H3K9), could be promising anxiolytic targets. Postnatal genetic knock-out of G9a reduces anxiety-related behavior, consistent with the reduction of G9a levels by some medications used to treat anxiety (amitriptyline, imipramine and paroxetine). Conversely, there is increased anxiety-like behavior in mice with GLP haplodeficiency. We sought to determine whether two pharmacological inhibitors of G9a/GLP, UNC0642 and A-366, would have similar effects to genetic G9a/GLP insufficiency. We found that G9a/GLP inhibition with either compound reduced anxiety-like behaviors when administered to adult mice, in conjunction with decreased H3K9 methylation in the brain. In contrast, exposure to these compounds from embryonic day 9.5 (E9.5) until birth increased anxiety-like behaviors and decreased social interaction in adulthood, while H3K9 methylation was at normal levels in the brains of the adult mice. These findings reinforce genetic evidence that G9a/GLP has different effects on anxiety-like behavior at different stages of brain development, and suggest that targeting this histone methyltransferase pathway could be useful for developing new anxiolytic drugs. These data also suggest that antidepressant exposure in utero could have negative effects in adulthood, and further investigation of these effects is warranted.

Aim The aim of this study was to evaluate dextrose gel in the management of neonatal hypoglycaemia in the postnatal wards at an Australian tertiary level perinatal centre. Methods An audit was performed before and after implementation of dextrose gel. Pre-implementation, neonatal hypoglycaemia was managed with feed supplementation alone, and dextrose gel was used in addition to feed supplementation in the post-implementation phase. Outcomes included admission to neonatal intensive care unit (NICU) for management of hypoglycaemia, proportion of neonates who achieved normoglycaemia (defined as blood glucose ≥2.6 mmol/L, with no clinical signs after one or two treatment attempts) and proportion of neonates with hypoglycaemia recurrence after normoglycaemia and one or two treatment attempts. Results NICU admission for treatment of hypoglycaemia reduced significantly post-implementation of dextrose gel (29/100 (29%) vs. 14/100 (14%), P = 0.01). No significant difference was seen in the proportion of neonates achieving normoglycaemia (71/100 (71%) vs. 75/100 (75%), P = 0.52), but hypoglycaemia recurrence was higher in the post-implementation group (22/71 (31%) vs. 37/75 (49%), P = 0.02). Conclusions Dextrose gel is effective in the management of neonatal hypoglycaemia in the postnatal ward setting, reducing admission to NICU and mother–infant separation.

Prescription medications, including opioid analgesics, are increasingly prescribed in Australia and internationally. More women are presenting in pregnancy with prescription opioid use which can potentially cause harm to the mother and fetus. This article outlines the different types of prescription opioids, defines how prescription opioid use disorder presents clinically and suggests a rational clinical approach to assess and manage patients in the context of pregnancy and their infants.

OBJECTIVE To examine the adverse drug reactions (ADRs) and the efficacy of intravenous iron polymaltose and ferric carboxymaltose (FCM) among gynecology/obstetric patients with anemia. METHODS The present retrospective observational study examined data from anemic obstetrics and gynecology patients who received either iron polymaltose or FCM between January 1, 2011, and April 30, 2015, at The Royal Women's Hospital, Victoria, Australia. Patient demographic data, dosage, ADR documentation, and hemoglobin levels were collected from medical records and compared. RESULTS The study included 221 patients; 111 and 110 received iron polymaltose and FCM, respectively. ADRs were documented for 18 (16.2%) patients in the iron polymaltose group and 2 (1.8%) in the FCM group (P

Background The use of oral complementary and alternative medicines, including herbal supplements, has been increasing in pregnant women worldwide despite limited safety data. The decision of healthcare professionals to recommend these products to pregnant patients is controversial and not well documented. Objective To explore the recommendations and information sources that healthcare professionals use to determine the safety of oral non-prescribed supplements during pregnancy. Setting An Australian metropolitan maternity hospital. Method An electronic survey was distributed to doctors, midwives, pharmacists, dietitians, lactation consultants and physiotherapists. Main outcome measure The nature of recommendations and information sources that healthcare professionals use to determine the safety of oral non-prescribed supplements during pregnancy. Results Responses were received from 54 healthcare professionals. Forty of 54 (74.1%) were concerned about the safety of their patients' supplements, while 35 of 54 (64.8%) felt that they had access to trustworthy safety information. Supplements most commonly recommended as safe to use were ginger (40.7%), probiotics (29.6%) and raspberry leaf (22.2%). Participants specifically requested further safety information for raspberry leaf, evening primrose oil, fish oil, probiotics, ginger, vitamin C, valerian, turmeric, blue cohosh and colloidal silver. Written resources most frequently consulted included MIMS® (61.1%) and 'Google Searches' (29.6%), and healthcare professionals most referred to were pharmacists (74.1%), doctors (22.2%), and naturopaths or herbalists (3.7%). Conclusion The recommendations of maternity heath care professionals and quality of information sources used varied. Further education and access to unbiased safety information is required to empower healthcare professionals to provide informed recommendations to pregnant patients.

Programs have recently been established in Australia and internationally to allow wider access to naloxone to people at risk of opioid overdose yet there are no guidelines relating to the administration of naloxone to pregnant women, particularly regarding dose requirements and resuscitative measures peculiar to pregnancy. This paper provides practical guidelines to health workers in relation to any complications that may arise during opioid overdose response (including the administration of naloxone) for pregnant women and the follow up required ensuring best possible outcomes for mother and baby.

Summary Tauopathies represent a group of neurodegenerative disorders characterized by the accumulation of pathological TAU protein in brains. We report a human neuronal model of tauopathy derived from induced pluripotent stem cells (iPSCs) carrying a TAU-A152T mutation. Using zinc-finger nuclease-mediated gene editing, we generated two isogenic iPSC lines: one with the mutation corrected, and another with the homozygous mutation engineered. The A152T mutation increased TAU fragmentation and phosphorylation, leading to neurodegeneration and especially axonal degeneration. These cellular phenotypes were consistent with those observed in a patient with TAU-A152T. Upon mutation correction, normal neuronal and axonal morphologies were restored, accompanied by decreases in TAU fragmentation and phosphorylation, whereas the severity of tauopathy was intensified in neurons with the homozygous mutation. These isogenic TAU-iPSC lines represent a critical advancement toward the accurate modeling and mechanistic study of tauopathies with human neurons and will be invaluable for drug-screening efforts and future cell-based therapies., Highlights • A human neuron model of tauopathy using TAU-A152T-iPSCs • Correction of TAU-A152T mutation eliminates tauopathy • Engineered homozygous TAU-A152T mutation intensifies tauopathy • A152T mutation increases TAU proteolysis, leading to tauopathy

The aim of this study was to evaluate dextrose gel in the management of neonatal hypoglycaemia in the postnatal wards at an Australian tertiary level perinatal centre.An audit was performed before and after implementation of dextrose gel. Pre-implementation, neonatal hypoglycaemia was managed with feed supplementation alone, and dextrose gel was used in addition to feed supplementation in the post-implementation phase. Outcomes included admission to neonatal intensive care unit (NICU) for management of hypoglycaemia, proportion of neonates who achieved normoglycaemia (defined as blood glucose ≥2.6 mmol/L, with no clinical signs after one or two treatment attempts) and proportion of neonates with hypoglycaemia recurrence after normoglycaemia and one or two treatment attempts.NICU admission for treatment of hypoglycaemia reduced significantly post-implementation of dextrose gel (29/100 (29%) vs. 14/100 (14%), P = 0.01). No significant difference was seen in the proportion of neonates achieving normoglycaemia (71/100 (71%) vs. 75/100 (75%), P = 0.52), but hypoglycaemia recurrence was higher in the post-implementation group (22/71 (31%) vs. 37/75 (49%), P = 0.02).Dextrose gel is effective in the management of neonatal hypoglycaemia in the postnatal ward setting, reducing admission to NICU and mother-infant separation.

Chronic exposure to JAK2 inhibitors leads to reactivation of downstream signalling through the formation of heterodimers between JAK2 and other JAK kinases in myeloproliferative neoplasms, which can be overcome with Hsp90 inhibitors. Mutations in JAK kinases, in particular JAK2, are frequent in some malignancies and JAK inhibitors have been trialled for example in patients with myeloproliferative neoplasms (MPNs). Here, Ross Levine and colleagues demonstrate that MPN cells can persist under conditions of chronic JAK2 inhibition, because JAK2 forms a heterodimer with other JAK kinases, leading to persistent JAK2 activation. This mode of drug 'persistence' seems to occur in patients treated with JAK2 inhibitor. Therapeutic approaches that induce JAK2 degradation may therefore be more effective than treatment with JAK2 inhibitors alone. The identification of somatic activating mutations in JAK2 (refs 1–4) and in the thrombopoietin receptor gene (MPL)5 in most patients with myeloproliferative neoplasm (MPN) led to the clinical development of JAK2 kinase inhibitors6,7. JAK2 inhibitor therapy improves MPN-associated splenomegaly and systemic symptoms but does not significantly decrease or eliminate the MPN clone in most patients with MPN. We therefore sought to characterize mechanisms by which MPN cells persist despite chronic inhibition of JAK2. Here we show that JAK2 inhibitor persistence is associated with reactivation of JAK–STAT signalling and with heterodimerization between activated JAK2 and JAK1 or TYK2, consistent with activation of JAK2 in trans by other JAK kinases. Further, this phenomenon is reversible: JAK2 inhibitor withdrawal is associated with resensitization to JAK2 kinase inhibitors and with reversible changes in JAK2 expression. We saw increased JAK2 heterodimerization and sustained JAK2 activation in cell lines, in murine models and in patients treated with JAK2 inhibitors. RNA interference and pharmacological studies show that JAK2-inhibitor-persistent cells remain dependent on JAK2 protein expression. Consequently, therapies that result in JAK2 degradation retain efficacy in persistent cells and may provide additional benefit to patients with JAK2-dependent malignancies treated with JAK2 inhibitors.

Aims: The safety of preventive asthma medicines during pregnancy has already been established. The aim of this study was to assess asthma management by women during pregnancy. Methods: Pregnant women attending the out-patient clinics of an Australian maternity hospital completed a questionnaire about their asthma medication use and symptoms. Parameters associated with changes in asthma medicine use are presented as odds ratio with a 95% confidence level. P-values

Background: Most women use medications at some stage in their pregnancy. Medication nonadherence during pregnancy could be detrimental to both mother and fetus. Aims: To study the extent and nature of the use of prescribed medications during pregnancy and factors associated with medication nonadherence. Methods: All women ≥18 years presenting for their 36th week antenatal visit at the pregnancy clinic of a maternity hospital were invited to complete an anonymous questionnaire that contained 61 items, including the Morisky scale. Factors associated with nonadherence were identified in univariate analysis; factors with P

Nuclear factor E2-related factor 2 (Nrf2) is a cap-n-collar basic leucine zipper (CNC-bZIP) transcription factor that is well established as a master regulator of phase II detoxification and antioxidant gene expression and is strongly expressed in tissues involved in xenobiotic metabolism including liver and kidney. Nrf2 is also abundantly expressed in adipose tissue; however, the exact function of Nrf2 in adipocyte biology is unclear. In the current study we show that targeted knock-out of Nrf2 in mice decreases adipose tissue mass, promotes formation of small adipocytes, and protects against weight gain and obesity otherwise induced by a high fat diet. In mouse embryonic fibroblasts, 3T3-L1 cells, and human subcutaneous preadipocytes, selective deficiency of Nrf2 impairs adipocyte differentiation. Deficiency of Nrf2 also leads to decreased expression of peroxisome proliferator-activated receptor gamma (PPARgamma), CCAAT enhancer-binding protein alpha (C/EBPalpha), and their downstream targets during adipocyte differentiation. Conversely, activation of Nrf2 in 3T3-L1 cells by stable knockdown of its negative regulator Keap1 enhances and accelerates hormone-induced adipocyte differentiation. Transfection of Nrf2 stimulates Ppargamma promoter activity, and stable knockdown of Keap1 enhances PPARgamma expression in 3T3-L1 cells. In addition, chromatin immunoprecipitation studies show that Nrf2 associates with consensus binding sites for Nrf2 in the Ppargamma promoter. These findings demonstrate a novel biologic role for Nrf2 beyond its participation in detoxification and antioxidant pathways and place Nrf2 within the limited network of transcription factors that control adipocyte differentiation by regulating expression of PPARgamma.

The development of the dual Janus kinase 1/2 (JAK1/2) inhibitor ruxolitinib for the treatment of myeloproliferative neoplasms (MPNs) has led to studies of ruxolitinib in other clinical contexts, including JAK-mutated acute lymphoblastic leukemia (ALL). However, the limited ability of JAK inhibition to induce molecular or clinicopathological responses in MPNs suggests a need for development of better therapies for JAK kinase-dependent malignancies. Here, we demonstrate that heat shock protein 90 (HSP90) inhibition using a purine-scaffold HSP90 inhibitor in early clinical development is an effective therapeutic approach in JAK-dependent ALL and can overcome persistence to JAK-inhibitor therapy in ALL cells.

Knockout studies have shown that the transcription factor Nrf1 is essential for embryonic development. Nrf1 has been implicated to play a role in mediating activation of oxidative stress response genes through the antioxidant response element (ARE). Because of embryonic lethality in knockout mice, analysis of this function in the adult knockout mouse was not possible. We report here that mice with somatic inactivation of nrf1 in the liver developed hepatic cancer. Before cancer development, mutant livers exhibited steatosis, apoptosis, necrosis, inflammation, and fibrosis. In addition, hepatocytes lacking Nrf1 showed oxidative stress, and gene expression analysis showed decreased expression of various ARE-containing genes, and up-regulation of CYP4A genes. These results suggest that reactive oxygen species generated from CYP4A-mediated fatty acid oxidation work synergistically with diminished expression of ARE-responsive genes to cause oxidative stress in mutant hepatocytes. Thus, Nrf1 has a protective function against oxidative stress and, potentially, a function in lipid homeostasis in the liver. Because the phenotype is similar to nonalcoholic steatohepatitis, these animals may prove useful as a model for investigating molecular mechanisms of nonalcoholic steatohepatitis and liver cancer.

Apolipoprotein (apo) E4 is the leading genetic risk factor for Alzheimer's disease (AD), and it has a gene dose-dependent effect on the risk and age of onset of AD. Although apoE4 is primarily produced by astrocytes in the brain, neurons can also produce apoE4 under stress conditions. ApoE4 is known to inhibit neurite outgrowth and spine development in vitro and in vivo, but the potential influence of apoE4's cellular source on dendritic arborization and spine development has not yet been investigated. In this study, we report impairments in dendritic arborization and a loss of spines, especially thin (learning) and mushroom (memory) spines, in the hippocampus and entorhinal cortex of 19-21-month-old female neuron-specific-enolase (NSE)-apoE4 and apoE4-knockin (KI) mice compared to their respective apoE3-expressing counterparts. In general, NSE-apoE4 mice had more severe and widespread deficits in dendritic arborization as well as spine density and morphology than apoE4-KI mice. The loss of dendritic spines, especially mushroom spines, occurred in NSE-apoE4 mice as early as 7-8 months of age. In contrast, glial fibrillary acidic protein (GFAP)-apoE4 mice, which express apoE4 solely in astrocytes, did not have impairments in their dendrite arborization or spine density and morphology compared to GFAP-apoE3 mice at both ages. These results indicate that the effects of apoE4 on dendrite arborization, spine density, and spine morphology depend critically on its cellular source, with neuronal apoE4 having more detrimental effects than astrocytic apoE4. © 2013 Jain et al.

The safety of preventive asthma medicines during pregnancy has already been established. The aim of this study was to assess asthma management by women during pregnancy.Pregnant women attending the out-patient clinics of an Australian maternity hospital completed a questionnaire about their asthma medication use and symptoms. Parameters associated with changes in asthma medicine use are presented as odds ratio with a 95% confidence level. P-values0.05 indicated statistical significance.Participants (n = 102) self-reported worsening of their asthma symptoms during pregnancy compared with the pre-pregnancy period, both during the day (P = 0.003) and night (P = 0.044). The number of participants whose asthma was treated by a medical professional decreased from 81 (79.4%) before pregnancy to 67 (65.7%) during pregnancy (P = 0.008). The use of regular asthma medicines (preventers and symptom controllers alone or in combination) decreased during pregnancy (P0.001 and P = 0.012, respectively), while the use of intermittent therapies (relievers) increased (P = 0.004) during pregnancy. Being treated by a medical professional during pregnancy (P = 0.033), a history of asthma medicine use before pregnancy (P = 0.015) and younger age of first asthma diagnosis (P = 0.046) were associated with the use of asthma medicines during pregnancy.Despite worsening of asthma symptoms, many pregnant women do not take regular preventive asthma medicines. Ongoing assessment of asthma control during pregnancy, medication review and adjustments in therapy by health professionals might facilitate asthma management.

Most women use medications at some stage in their pregnancy. Medication nonadherence during pregnancy could be detrimental to both mother and fetus.To study the extent and nature of the use of prescribed medications during pregnancy and factors associated with medication nonadherence.All women≥18 years presenting for their 36th week antenatal visit at the pregnancy clinic of a maternity hospital were invited to complete an anonymous questionnaire that contained 61 items, including the Morisky scale. Factors associated with nonadherence were identified in univariate analysis; factors with P0.1 were further analysed in a binary logistic regression model.The participants (n=819) had a mean age of 30.8±5.3 years. Most participants were born in Australia, lived with a partner, had university education, were nulliparous, carried one fetus and were nonsmokers. Of these participants, 322 (39.3%) reported a chronic health condition during pregnancy, the most common being asthma (104; 12.7%). Two hundred and seventeen (26.5%) were using prescribed medications, which included anti-anaemics (68; 8.3%), medicines for chronic airway conditions (64; 7.8%), vitamins and minerals (59; 7.2%) and anti-diabetics (43; 5.2%). Nonadherence was reported by 107 (59.1%) participants, mainly because of forgetting (79; 43.6%). Factors associated with nonadherence were having asthma (OR 0.26 (95% CI 0.095-0.72), P=0.009) and using nonprescription dietary minerals (0.30 (0.10-0.87), P=0.027).Adherence to prescribed medicines during pregnancy is alarmingly low. Health professionals should be more proactive in promoting adherence and assisting women avoid potential fetal harm because of nonadherence.

Nrf1 is a basic leucine zipper protein (bZIP) in the Cap'n'Collar (CNC) transcription factor family characterized by the presence of a 45-amino-acid homology region referred to as the CNC domain (9). The primary structures of members of the CNC-bZIP subfamily are also well conserved in the basic DNA-binding and protein dimerization domains, and at this time in mice this family includes p45NFE2, Nrf1, Nrf2, Nrf3, Bach1, and Bach2 (3, 8, 9, 35, 50, 51). Some are expressed in a tissue-specific manner. For example, the expression of p45NFE2 is restricted to hematopoietic cells (3), and Bach2 is expressed in the brain and B-cell compartment (51). In contrast, Nrf1, Nrf2, and Nrf3 are expressed in a wide variety of cell lines and mouse tissues, and Bach1 transcripts are found in various tissues and expressed at high levels in the spleen and intestine (9, 35, 43, 51). CNC-bZIP factors control transcription from an extended AP-1-like site [TGCTGA(G/C)TCA(T/C)] called the NFE2 site and form heterodimers with other bZIP proteins (30, 33, 36). One class of bZIP proteins that dimerizes with CNC-bZIP factors is the small Maf proteins (7, 44). Gene targeting experiments in embryonic stem (ES) cells to generate knockout mice have been performed to determine the biological requirements for CNC-bZIP proteins. Knockout mice revealed an important role for p45NFE2 in platelet production (60). Nrf2 knockout mice were found to be viable (11). While Nrf2 is dispensable for development, it is important in regulating antioxidant gene expression and expression of xenobiotic-metabolizing enzymes in multiple tissues (31, 32). In contrast, the biological function of Nrf1 is less well understood. While Nrf1 has been shown to play a role in the oxidative stress response pathway in fibroblasts, the importance of Nrf1 in this function in vivo compared to Nrf2 is not known (37). In our previous gene knockout study, we found that Nrf1 is required for development (10). Death at midgestation in nrf1−/− embryos is thought to be the result of anemia due to a presumed developmental arrest in fetal liver erythropoiesis. Because nrf1−/− erythropoietic cells grew normally in vitro and nrf1−/− ES cells contributed efficiently to erythroid cells of chimeric mice, it was suggested that the liver microenvironment in mutants failed to sustain erythropoiesis. Nrf1 is broadly expressed during development, but with the exception of anemia, discernible defects in other tissues were not readily apparent in mutants. Therefore, it was difficult to establish whether other tissue compartments were also affected by the loss of Nrf1 function in development. Moreover, the embryonic lethality precludes further analysis of the potential role of Nrf1 in fetal liver function and development. To gain more insight into the function of Nrf1, we utilized nrf1−/− ES cells in an analysis of chimeric mice to determine in which cell type is Nrf1 important during development. We describe here rescue of embryonic lethality in chimeric mice generated with ES cells bearing two inactive nrf1 alleles. Characterization of these chimeric mice indicated that ES cells deficient in Nrf1 contributed to most tissues in adult animals, including the lung, kidney, muscle, and heart where Nrf1 is normally expressed at high levels. However, deficiency in Nrf1 is associated with impaired contribution of ES cells to adult, but not fetal, hepatocytes. While Nrf1 function is not required for normal fetal liver ontogeny, liver cells in chimeric embryos undergo apoptosis late in gestation. Our results also indicate that oxidative stress and impaired antioxidant gene expression in the fetal liver correlated with loss of Nrf1 function. Primary mutant fetal hepatocytes in cultures demonstrated increased sensitivity to tert-butyl hydroperoxide (tBHP) and died, indicating that the loss of Nrf1 sensitizes hepatocytes to oxidative stress. Mouse embryonic fibroblasts isolated from nrf1−/− embryos were very sensitive to tumor necrosis factor (TNF) cytotoxicity, suggesting that Nrf1 may be required to protect fetal liver cells from endogenous TNF-induced apoptosis. Together, these findings suggest that Nrf1 plays an important role in maintaining redox balance in the fetal liver cells and indicate a cell-specific and developmental stage-specific function of Nrf1 in protecting liver cells from apoptosis during development.

Apolipoprotein (apo) E4 is the major genetic risk factor for Alzheimer's disease (AD). ApoE4 has sex-dependent effects, whereby the risk of developing AD is higher in apoE4-expressing females than males. However, the mechanism underlying the sex difference, in relation to apoE4, is unknown. Previous findings indicate that apoE4 causes age-dependent impairments of hilar GABAergic interneurons in female mice, leading to learning and memory deficits. Here, we investigate whether the detrimental effects of apoE4 on hilar GABAergic interneurons are sex-dependent using apoE knock-in (KI) mice across different ages. We found that in female apoE-KI mice, there was an age-dependent depletion of hilar GABAergic interneurons, whereby GAD67- or somatostatin-positive-but not NPY- or parvalbumin-positive-interneuron loss was exacerbated by apoE4. Loss of these neuronal populations was correlated with the severity of spatial learning deficits at 16 months of age in female apoE4-KI mice; however, this effect was not observed in female apoE3-KI mice. In contrast, we found an increase in the numbers of hilar GABAergic interneurons with advancing age in male apoE-KI mice, regardless of apoE genotype. Moreover, male apoE-KI mice showed a consistent ratio of hilar inhibitory GABAergic interneurons to excitatory mossy cells approximating 1.5 that is independent of apoE genotype and age, whereas female apoE-KI mice exhibited an age-dependent decrease in this ratio, which was exacerbated by apoE4. Interestingly, there are no apoE genotype effects on GABAergic interneurons in the CA1 and CA3 subregions of the hippocampus as well as the entorhinal and auditory cortexes. These findings suggest that the sex-dependent effects of apoE4 on developing AD is in part attributable to inherent sex-based differences in the numbers of hilar GABAergic interneurons, which is further modulated by apoE genotype. © 2012 Leung et al.

Abstract 122 Although JAK2 inhibitor therapy improves MPN-associated splenomegaly and systemic symptoms, JAK2 inhibitor treatment does not significantly reduce or eliminate the MPN clone in most MPN patients. We therefore sought to characterize mechanisms by which MPN cells can persist despite chronic JAK2 inhibition. We performed saturation mutagenesis followed by next-generation sequencing in JAK2 mutant cells exposed to two different JAK2 inhibitors, INCB18424, a dual JAK1/JAK2 inhibitor, and JAK Inhibitor I, a pan-JAK inhibitor. Although we were able to identify candidate resistance alleles, these alleles were present in less than 50% of the total population. These data and the clinical experience with JAK2 inhibitors suggest that the failure of JAK2 inhibitors to reduce disease burden is not due to acquired drug resistance but rather due to persistent growth and signaling in the setting of chronic JAK2 kinase inhibition. We therefore generated JAK2/MPL mutant JAK2-inhibitor persistent (JAKper) cell lines (SET-2, UKE-1, Ba/F3-MPLW515L). JAKper cell lines are able to survive and proliferate in the presence of JAK2 inhibitors including JAK Inhibitor I, INCB18424 and TG101348 without acquiring second-site resistance alleles and are also insensitive to other JAK inhibitors. Signaling studies revealed JAK-STAT signaling was reactivated in persistent cells at concentrations of inhibitor that completely abrogated signaling in naïve cells, and JAK2 phosphorylation was reactivated in JAK inhibitor persistent cells consistent with reactivation of the JAK-STAT pathway in JAKper cells despite inhibitor exposure. We hypothesized that JAK2 may be activated in trans by other JAK kinases, and found an increased association between activated JAK2 and JAK1/TYK2 consistent with activation of JAK2 in trans by other JAK kinases in JAKper cells. We next assessed whether JAK inhibitor persistence was reversible. Withdrawal of JAK2 inhibitors from JAKper cells for 2 weeks led to resensitization such that JAKper resensitized cells were now sensitive to different JAK2 inhibitors regardless of previous exposure. Resensitization was associated with reversal of heterodimerization and loss of transactivation of JAK2 by JAK1 and TYK2. The reversible nature of JAK inhibitor persistence led us to hypothesize epigenetic alterations are responsible for JAK inhibitor insensitivity in JAKper cells; we observed increased expression of JAK2 at the mRNA and protein level in JAK2 inhibitor persistent cells compared to parental as well as resensitized cells. ChIP-PCR analysis of the JAK2 locus revealed a significant increase in H3K4-trimethylation and a reduction in H3K9 trimethylation in persistent cells compared to parental cells consistent with a change to a more active chromatin state at the JAK2 locus and increased JAK2 mRNA expression in persistent cells. We next assessed whether the same phenomenon of JAK2 inhibitor persistence was observed in vivo. In a MPLW515L-mutant murine bone marrow transplant model of primary myelofibrosis, we observed increased JAK2 expression, increased JAK2 phosphorylation and JAK-inhibitor induced association between JAK1 and JAK2 in hematopoietic cells from INCB18424 treated mice. We next extended our findings to samples from patients treated with INCB18424. We identified 5 patients who had a significant clinical response and 5 patients without a significant clinical response as assessed by spleen size and JAK2V617F allele burden responses and measured JAK2 granulocyte mRNA expression before and during INCB18424 treatment. We found that JAK2 mRNA levels significantly increased in INCB18424 nonresponders compared to responders (p=0.05) suggesting this phenomenon is observed in cell lines, mouse models and primary samples. Finally, we investigated whether JAKper cells remain JAK2 dependent. Studies with shRNA targeting JAK2 and pharmacologic studies using Hsp90 inhibitors that degrade JAK2 protein demonstrate that JAK2 inhibitor persistent cells remain dependent on JAK2 protein expression. Our data indicate that JAK2/MPL mutant cells persist in the presence of JAK2 kinase inhibitors through epigenetic alterations which reactivate signaling in persistent cells, and that therapies which lead to JAK2 degradation can be used to inhibit signaling and improve outcomes in patients with persistent disease despite chronic JAK2 inhibition. Disclosures: Verstovsek: Incyte Corporation: Research Funding.