Facioscapulohumeral muscular dystrophy (FSHD) is a common form of muscular dystrophy characterized by an asymmetric progressive weakness and wasting of the facial, shoulder and upper arm muscles, frequently accompanied by hearing loss and retinal vasculopathy. FSHD is an autosomal dominant disease linked to chromosome 4q35, but the causative gene remains controversial. DUX4 is a leading candidate gene as causative of FSHD. However, DUX4 expression is extremely low in FSHD muscle, and there is no DUX4 animal model that mirrors the pathology in human FSHD. Here, we show that the misexpression of very low levels of human DUX4 in zebrafish development recapitulates the phenotypes seen in human FSHD patients. Microinjection of small amounts of human full-length DUX4 (DUX4-fl) mRNA into fertilized zebrafish eggs caused asymmetric abnormalities such as less pigmentation of the eyes, altered morphology of ears, developmental abnormality of fin muscle, disorganization of facial musculature and/or degeneration of trunk muscle later in development. Moreover, DUX4-fl expression caused aberrant localization of myogenic cells marked with alpha-actin promoter-driven enhanced green fluorescent protein outside somite boundary, especially in head region. These abnormalities were rescued by coinjection of the short form of DUX4 (DUX4-s). Our results suggest that the misexpression of DUX4-fl, even at extremely low level, can recapitulate the phenotype observed in FSHD patients in a vertebrate model. These results strongly support the current hypothesis for a role of DUX4 in FSHD pathogenesis. We also propose that DUX4 expression during development is important for the pathogenesis of FSHD.
Algorithms designed to identify canonical yeast prions predict that around 250 human proteins, including several RNA-binding proteins associated with neurodegenerative disease, harbour a distinctive prion-like domain (PrLD) enriched in uncharged polar amino acids and glycine. PrLDs in RNA-binding proteins are essential for the assembly of ribonucleoprotein granules. However, the interplay between human PrLD function and disease is not understood. Here we define pathogenic mutations in PrLDs of heterogeneous nuclear ribonucleoproteins (hnRNPs) A2B1 and A1 in families with inherited degeneration affecting muscle, brain, motor neuron and bone, and in one case of familial amyotrophic lateral sclerosis. Wild-type hnRNPA2 (the most abundant isoform of hnRNPA2B1) and hnRNPA1 show an intrinsic tendency to assemble into self-seeding fibrils, which is exacerbated by the disease mutations. Indeed, the pathogenic mutations strengthen a 'steric zipper' motif in the PrLD, which accelerates the formation of self-seeding fibrils that cross-seed polymerization of wild-type hnRNP. Notably, the disease mutations promote excess incorporation of hnRNPA2 and hnRNPA1 into stress granules and drive the formation of cytoplasmic inclusions in animal models that recapitulate the human pathology. Thus, dysregulated polymerization caused by a potent mutant steric zipper motif in a PrLD can initiate degenerative disease. Related proteins with PrLDs should therefore be considered candidates for initiating and perhaps propagating proteinopathies of muscle, brain, motor neuron and bone.
Amyotrophic lateral sclerosis (ALS) is a fatal human neurodegenerative disease affecting primarily motor neurons. Two RNA-binding proteins, TDP-43 and FUS, aggregate in the degenerating motor neurons of ALS patients, and mutations in the genes encoding these proteins cause some forms of ALS. TDP-43 and FUS and several related RNA-binding proteins harbor aggregation-promoting prion-like domains that allow them to rapidly self-associate. This property is critical for the formation and dynamics of cellular ribonucleoprotein granules, the crucibles of RNA metabolism and homeostasis. Recent work connecting TDP-43 and FUS to stress granules has suggested how this cellular pathway, which involves protein aggregation as part of its normal function, might be coopted during disease pathogenesis.
Telomeres may regulate human disease by at least two independent mechanisms. First, replicative senescence occurs once short telomeres generate DNA-damage signals that produce a barrier to tumor progression. Second, telomere position effects (TPE) could change gene expression at intermediate telomere lengths in cultured human cells. Here we report that telomere length may contribute to the pathogenesis of facioscapulohumeral muscular dystrophy (FSHD). FSHD is a late-onset disease genetically residing only 25-60 kilobases from the end of chromosome 4q. We used a floxable telomerase to generate isogenic clones with different telomere lengths from affected patients and their unaffected siblings. DUX4, the primary candidate for FSHD pathogenesis, is upregulated over ten-fold in FSHD myoblasts and myotubes with short telomeres, and its expression is inversely proportional to telomere length. FSHD may be the first known human disease in which TPE contributes to age-related phenotype.
Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disease whose causes are still poorly understood. To identify additional genetic risk factors, we assessed the role of de novo mutations in ALS by sequencing the exomes of 47 ALS patients and both of their unaffected parents (n = 141 exomes). We found that amino acid-altering de novo mutations were enriched in genes encoding chromatin regulators, including the neuronal chromatin remodeling complex (nBAF) component SS18L1 (also known as CREST). CREST mutations inhibited activity-dependent neurite outgrowth in primary neurons, and CREST associated with the ALS protein FUS. These findings expand our understanding of the ALS genetic landscape and provide a resource for future studies into the pathogenic mechanisms contributing to sporadic ALS.
Profoundly different prion diseases in knock-in mice carrying single PrP codon substitutions associated with human diseases
In man, mutations in different regions of the prion protein (PrP) are associated with infectious neurodegenerative diseases that have remarkably different clinical signs and neuropathological lesions. To explore the roots of this phenomenon, we created a knock-in mouse model carrying the mutation associated with one of these diseases [Creutzfeldt-Jakob disease (CJD)] that was exactly analogous to a previous knock-in model of a different prion disease [fatal familial insomnia (FFI)]. Together with the WT parent, this created an allelic series of three lines, each expressing the same protein with a single amino acid difference, and with all native regulatory elements intact. The previously described FFI mice develop neuronal loss and intense reactive gliosis in the thalamus, as seen in humans with FFI. In contrast, CJD mice had the hallmark features of CJD, spongiosis and proteinase K-resistant PrP aggregates, initially developing in the hippocampus and cerebellum but absent from the thalamus. A molecular transmission barrier protected the mice from any infectious prion agents that might have been present in our mouse facility and allowed us to conclude that the diseases occurred spontaneously. Importantly, both models created agents that caused a transmissible neurodegenerative disease in WT mice. We conclude that single codon differences in a single gene in an otherwise normal genome can cause remarkably different neurodegenerative diseases and are sufficient to create distinct protein-based infectious elements.
A new approach for the study of lung smooth muscle phenotypes and its application in a murine model of allergic airway inflammation
Phenotypes of lung smooth muscle cells in health and disease are poorly characterized. This is due, in part, to a lack of methodologies that allow for the independent and direct isolation of bronchial smooth muscle cells (BSMCs) and vascular smooth muscle cells (VSMCs) from the lung. In this paper, we describe the development of a bi-fluorescent mouse that permits purification of these two cell populations by cell sorting. By subjecting this mouse to an acute allergen based-model of airway inflammation that exhibits many features of asthma, we utilized this tool to characterize the phenotype of so-called asthmatic BSMCs. First, we examined the biophysical properties of single BSMCs from allergen sensitized mice and found increases in basal tone and cell size that were sustained ex vivo. We then generated for the first time, a comprehensive characterization of the global gene expression changes in BSMCs isolated from the bi-fluorescent mice with allergic airway inflammation. Using statistical methods and pathway analysis, we identified a number of differentially expressed mRNAs in BSMCs from allergen sensitized mice that code for key candidate proteins underlying changes in matrix formation, contractility, and immune responses. Ultimately, this tool will provide direction and guidance for the logical development of new markers and approaches for studying human lung smooth muscle.
FSHD2 is a rare form of facioscapulohumeral muscular dystrophy (FSHD) characterized by the absence of a contraction in the D4Z4 macrosatellite repeat region on chromosome 4q35 that is the hallmark of FSHD1. However, hypomethylation of this region is common to both subtypes. Recently, mutations in SMCHD1 combined with a permissive 4q35 allele were reported to cause FSHD2. We identified a novel p.Lys275del SMCHD1 mutation in a family affected with FSHD2 using whole-exome sequencing and linkage analysis. This mutation alters a highly conserved amino acid in the ATPase domain of SMCHD1. Subject III-11 is a male who developed asymmetrical muscle weakness characteristic of FSHD at 13 years. Physical examination revealed marked bilateral atrophy at biceps brachii, bilateral scapular winging, some asymmetrical weakness at tibialis anterior and peroneal muscles, and mild lower facial weakness. Biopsy of biceps brachii in subject II-5, the father of III-11, demonstrated lobulated fibers and dystrophic changes. Endomysial and perivascular inflammation was found, which has been reported in FSHD1 but not FSHD2. Given the previous report of SMCHD1 mutations in FSHD2 and the clinical presentations consistent with the FSHD phenotype, we conclude that the SMCHD1 mutation is the likely cause of the disease in this family.
Evaluating current patterns of assessment for self-harm in emergency departments: a multicenter study
OBJECTIVES: The objective was to describe self-harm assessment practices in U.S. emergency departments (EDs) and to identify predictors of being assessed.
METHODS: This was a prospective observational cohort study of adults presenting to eight U.S. EDs. A convenience sample of adults presenting to the EDs during covered research shifts was entered into a study log. Self-harm assessment was defined as ED documentation of suicide attempt; suicidal ideation; or nonsuicidal self-injury thoughts, behaviors, or both. Institution characteristics were compared relative to percentage assessed. To identify predictive patient characteristics, multivariable generalized linear models were created controlling for weekend presentation, time of presentation, age, sex, and race and ethnicity.
RESULTS: Among 94,354 charts, self-harm assessment ranged from 3.5% to 31%, except for one outlying site at 95%. Overall, 26% were assessed (11% excluding the outlying site). Current self-harm was present in 2.7% of charts. Sites with specific self-harm assessment policies had higher assessment rates. In the complete model, adjusted risk ratios (aRR) for assessment included age >/= 65 years (0.56, 95% confidence interval [CI] = 0.35 to 0.92) and male sex (1.17, 95% CI = 1.10 to 1.26). There was an interaction between these variables in the smaller model (excluding outlying site), with males < 65 years of age being more likely to be assessed (aRR = 1.14, 95% CI = 1.02 to 1.37).
CONCLUSIONS: Emergency department assessment of self-harm was highly variable among institutions. Presence of specific assessment policies was associated with higher assessment rates. Assessment varied based upon patient characteristics. The identification of self-harm in 2.7% of ED patients indicates that a substantial proportion of current risk of self-harm may go unidentified, particularly in certain patient groups.
The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE): method and design considerations
BACKGROUND: Due to the concentration of individuals at-risk for suicide, an emergency department visit represents an opportune time for suicide risk screening and intervention.
PURPOSE: The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) uses a quasi-experimental, interrupted time series design to evaluate whether (1) a practical approach to universally screening ED patients for suicide risk leads to improved detection of suicide risk and (2) a multi-component intervention delivered during and after the ED visit improves suicide-related outcomes.
METHODS: This paper summarizes the ED-SAFE's study design and methods within the context of considerations relevant to effectiveness research in suicide prevention and pertinent human participants concerns. 1440 suicidal individuals, from 8 general ED's nationally will be enrolled during three sequential phases of data collection (480 individuals/phase): (1) Treatment as Usual; (2) Universal Screening; and (3) Intervention. Data from the three phases will inform two separate evaluations: Screening Outcome (Phases 1 and 2) and Intervention (Phases 2 and 3). Individuals will be followed for 12 months. The primary study outcome is a composite reflecting completed suicide, attempted suicide, aborted or interrupted attempts, and implementation of rescue procedures during an outcome assessment.
CONCLUSIONS: While 'classic' randomized control trials (RCT) are typically selected over quasi-experimental designs, ethical and methodological issues may make an RCT a poor fit for complex interventions in an applied setting, such as the ED. ED-SAFE represents an innovative approach to examining the complex public health issue of suicide prevention through a multi-phase, quasi-experimental design embedded in 'real world' clinical settings.
Objective: This study examined how smoking-related causal attributions, perceived illness severity, and event-related emotions relate to both intentions to quit and subsequent smoking behavior after an acute medical problem (sentinel event).
Methods: Three hundred and seventy-five patients were enrolled from 10 emergency departments (EDs) across the USA and followed for six months. Two saturated, manifest structural equation models were performed: one predicting quit attempts and the other predicting seven-day point prevalence abstinence at 14 days, three months, and six months after the index ED visit. Stage of change was regressed onto each of the other predictor variables (causal attribution, perceived illness severity, event-related emotions) and covariates, and tobacco cessation outcomes were regressed on all of the predictor variables and covariates.
Results: Non-White race, baseline stage of change, and an interaction between causal attribution and event-related fear were the strongest predictors of quit attempt. In contrast, abstinence at six months was most strongly predicted by baseline stage of change and nicotine dependence.
Conclusion: Predictors of smoking behavior after an acute medical illness are complex and dynamic. The relations vary depending on the outcome examined (quit attempts vs. abstinence), differ based on the time that has progressed since the event, and include significant interactions.
Audit studies represent an emerging method for examining disparities in access to care, like substance use treatment, whereby fake patients (i.e., actors) attempt to procure a service with one or more characteristics isolated across condition. This allows for manipulation of variables, like insurance status, that are normally fixed or impossible to standardize with precision when studying actual patients. This pilot study explored whether these methods were feasible for the examination of community-based substance use treatment access. Masked telephone calls (n=48) were made to providers (k=8) in a single city seeking an appointment. A male and female "patient" made calls in three insurance status conditions: no insurance, state-funded insurance, and private insurance. All other subject characteristics were held constant. Results showed an audit design to be a feasible method for examining disparities in access and demonstrated substantial barriers to voluntary treatment. Implications and future directions are discussed.
Objective: The National Network of Libraries of Medicine, New England Region’s Clear: Conversations project aimed to teach health literacy skills to help patients communicate better with their health care providers including how to: ask for simple language and slow down the provider, use teach-back, bring medications and supplements for a brown bag review, and get need-to-know information.
Methods: Five organizations were awarded with Clear: Conversations materials that were adapted from a program created by Health Literacy Missouri. A highlight of the workshop was a role play between a health care provider and patient. Awardees were required to offer the workshop at least once, meet regularly via teleconference to get support in planning their programs and to learn from each other’s experiences, and provide a brief post-project report. Awardees also created and used pre- and post-workshop tests.
Results: The program was offered at a variety of venues including a Healthy Start initiative, a senior center, a patient and family learning center, and a family life education center. A total of 109 individuals participated in the workshops. Pre- and post-workshop tests showed participants felt more comfortable to ask questions, slow down their doctor, and repeat back what the doctor said to make sure they understood.
Conclusions : The NN/LM NER’s Clear: Conversations project was offered by a cross-disciplinary group of health information providers. It empowered participants with practical health literacy skills for better health care visits.
Implications: The Clear: Conversations materials created by Health Literacy Missouri present an opportunity for librarians and other health information providers to empower patients with useful and essential health literacy skills.
Objective: Chronic hypertension, pregestational diabetes mellitus, history of prior preeclampsia and obese nulliparity are maternal conditions associated with increased preeclampsia risk. Whether altered maternal angiogenic factor levels allow for prediction of pending disease is unclear. Our objective was to evaluate angiogenic factors for early preeclampsia prediction in high-risk women.
Methods: Serial serum specimens were collected from 157 women at high preeclampsia risk and 50 low-risk controls between 23 and 36 weeks gestation in 3 windows (23-27.6, 28-31.6, and 32-35.6 weeks) in a two-center observational cohort. Soluble fms-like tyrosine kinase-1 (sFlt1), placental growth factor (PlGF) and soluble endoglin (sEng) were measured by ELISA.
Results: Multivariate parsimonious logistic regression analyses using backward elimination for prediction of early-preeclampsia (diagnosed < 34 weeks) found the best-fitting model included the predictors (1) sFlt1 measured in the second window (28-31.6 weeks) with AUC 0.85, sensitivity 67% and specificity 96% and (2) sFlt1 measured in the first window (23-27.6 weeks) and sEng change between first and second window with AUC 0.91, sensitivity 86% and specificity 96%.
Conclusions: Two-stage sampling screening protocol utilizing sFlt1 and sEng is promising for prediction of preeclampsia diagnosed before 34 weeks. Larger studies are needed to confirm these findings.
Evaluation of reproductive function in women treated for bipolar disorder compared to healthy controls
OBJECTIVES: The purpose of the present study was to investigate the reproductive function of women with bipolar disorder (BD) compared to healthy controls.
METHODS: Women diagnosed with BD and healthy controls with no psychiatric history, aged 18-45 years, were recruited from a university clinic and surrounding community. Participants completed a baseline reproductive health questionnaire, serum hormone assessment, and ovulation tracking for three consecutive cycles using urine luteinizing hormone (LH)-detecting strips with a confirmatory luteal-phase serum progesterone.
RESULTS: Women with BD (n = 103) did not differ from controls (n = 36) in demographics, rates of menstrual abnormalities (MAs), or number of ovulation-positive cycles. Of the women with BD, 17% reported a current MA and 39% reported a past MA. Dehydroepiandrosterone sulfate and 17-hydroxyprogesterone levels were higher in controls (p = 0.052 and 0.004, respectively), but there were no other differences in biochemical levels. Medication type, dose, or duration was not associated with MA or biochemical markers, although those currently taking an atypical antipsychotic agent indicated a greater rate of current or past MA (80% versus 55%, p = 0.013). In women with BD, 22% reported a period of amenorrhea associated with exercising or stress, versus 8% of controls (p = 0.064). Self-reported rates of bulimia and anorexia nervosa were 10% and 5%, respectively.
CONCLUSIONS: Rates of MA and biochemical levels did not significantly differ between women with BD and controls. Current atypical antipsychotic agent use was associated with a higher rate of current or past MA and should be further investigated. The incidence of stress-induced amenorrhea should be further investigated in this population, as should the comorbid incidence of eating disorders.
Tamoxifen (TMX) is a selective estrogen receptor modulator that is used as an estrogen receptor antagonist for the treatment and prevention of breast cancer. Whether TMX has antagonist activities in the human brain is less clear and its effects on cognitive function have not been experimentally explored. This study examined how TMX affected cognitive performance in older women using a model of anticholinergic drug-induced cognitive dysfunction. Twenty-one postmenopausal women were administered 20 mg of oral TMX or placebo for 3 months. Participants then took part in five drug challenges using the anticholinergic antinicotinic agent mecamylamine (MECA) and antimuscarinic agent scopolamine (SCOP) and were tested on a comprehensive battery including tasks of attention and psychomotor function, verbal episodic memory, and spatial navigation. After a 3-month placebo washout, participants were then crossed over to the alternate treatment and repeated the drug challenges after 3 months. Compared with placebo treatment, TMX significantly attenuated the impairment from cholinergic blockade on tasks of verbal episodic memory and spatial navigation, but effects on attentional/psychomotor tasks were more variable. Analysis by APOE genotype showed that APO varepsilon4+ women showed a greater beneficial effect of TMX on reversing the cholinergic impairment than APO varepsilon4- women on most tasks. This study provides evidence that TMX may act as an estrogen-like agonist to enhance cholinergic system activity and hippocampally mediated learning.
Institute of medicine 2009 gestational weight gain guideline knowledge: survey of obstetrics/gynecology and family medicine residents of the United States
BACKGROUND: In 2009, the Institute of Medicine revised gestational weight gain recommendations; revisions included body mass index (BMI) category cut-point changes and provision of range of gain for obese women. Our objective was to examine resident prenatal caregivers' knowledge of revised guidelines.
METHODS: Anonymous electronic survey of obstetrics/gynecology and family medicine residents across the United States from January to April 2010.
RESULTS: Overall, 660 completed the survey; 79 percent female and 69 percent aged between 21 and 30. When permitted to select >/= 1 response, 87.0 percent reported using BMI to assess weight status at initial visits, 44.4 percent reported using "clinical impression based on patient appearance," and 1.4 percent reported not using any parameters. When asked the most important baseline parameter for providing recommendations, 35.8 percent correctly identified prepregnancy BMI, 2.1 percent reported "I don't provide guidelines," and 4.5 percent reported "I do not discuss gestational weight gain." Among respondents, 57.6 percent reported not being aware of new guidelines. Only 7.6 percent selected correct BMI ranges for each category, and only 5.8 percent selected correct gestational weight gain ranges. Only 2.3 percent correctly identified both BMI cutoffs and recommended gestational weight gain ranges per 2009 guidelines.
CONCLUSIONS: Guideline knowledge is the foundation of accurate counseling, yet resident prenatal caregivers were minimally aware of the 2009 Institute of Medicine gestational weight gain guidelines almost a year after their publication. Inc.
Urinary Isoflavone Concentrations Are Inversely Associated with Cardiometabolic Risk Markers in Pregnant U.S. Women
Some evidence suggests that phytoestrogens, such as soy-derived isoflavones, may have beneficial effects on cardiovascular health and glycemic control. These data are mainly limited to postmenopausal women or individuals at elevated cardiometabolic risk. There is a lack of data for pregnant women who have elevated estrogen levels and physiologically altered glucose and lipid metabolism. We analyzed data from 299 pregnant women who participated in the NHANES 2001-2008 surveys. Multivariable linear regression analyses were used to examine the association between urinary concentrations of isoflavonoids and cardiometabolic risk markers, adjusted for body mass index, pregnancy trimester, total energy intake, dietary intake of protein, fiber, and cholesterol, and demographic and lifestyle factors. Cardiometabolic risk markers were log-transformed, and geometric means were calculated by quartiles of urinary concentrations of isoflavonoids. Comparing women in the highest vs. lowest quartiles of urine total isoflavone concentrations, we observed significant, inverse associations with circulating concentrations of fasting glucose (79 vs. 88 mg/dL, P-trend = 0.0009), insulin (8.2 vs. 12.8 muU/mL, P-trend = 0.03), and triglyceride (156 vs. 185 mg/dL, P-trend = 0.02), and the homeostasis model assessment of insulin resistance (1.6 vs. 2.8, P-trend = 0.01), but not for total, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol. The concentrations of individual isoflavonoids, daidzein, equol, and O-desmethylangolensin were inversely associated with some cardiometabolic risk markers, although no clear pattern emerged. These data suggest that there may be a relation between isoflavone intake and cardiometabolic risk markers in pregnant women.
The nucleolus is a plurifunctional organelle with dynamic protein exchange involved in diverse aspects of cell biology. Additionally, the nucleolus has been shown to have a role in the replication of numerous viruses, which includes HIV-1. Several groups have reported HIV-1 vRNA localization within the nucleolus. Moreover, it has been demonstrated the HIV-1 Rev protein localizes to the nucleolus and interacts with nucleolar proteins, including NPM1. Despite evidence for a nucleolar involvement during replication, a functional link has not been demonstrated. I investigated whether introncontaining vRNAs have a Rev-mediated nucleolar localization step prior to export. Furthermore, I examined whether NPM1 mediates Rev nucleolar localization, participates in Rev function, and/or post-transcriptional events during viral replication. I used coupled RNA fluorescence in situhybridization and indirect immunofluorescence to visualize intron-containing vRNA relative to the nucleolus in the absence or presence of Rev expression. An RNAi-based approach was used to examine the role of NPM1 in Rev function and viral replication in cell lines and primary human macrophages. My research findings support a model for a Rev-independent nucleolar localization step of introncontaining vRNA prior to export. Intriguingly, my results also suggest NPM1 does not participate in Rev nucleolar localization or Rev-mediated vRNA export, as previously proposed. Rather, my findings support a novel role for NPM1, the cytoplasmic localization and utilization of a select class of Rev-dependent vRNAs. Collectively, my findings provide novel insight for a functional role of the nucleolus and NPM1 in HIV-1 replication, which enhances our current understanding of HIV-1 biology.