Expanding the landscape of oncogenic drivers and treatment options in acral and mucosal melanomas by targeted genomic profiling.

Despite advancements in treating cutaneous melanoma, patients with acral and mucosal (A/M) melanomas still have limited therapeutic options and poor prognoses. We analyzed 156 melanomas (101 cutaneous, 28 acral, and 27 mucosal) using the Foundation One cancer-gene specific clinical testing platform and identified new, potentially targetable genomic alterations (GAs) in specific anatomic sites of A/M melanomas. Using novel pre-clinical models of A/M melanoma, we demonstrate that several GAs and corresponding oncogenic pathways associated with cutaneous melanomas are similarly targetable in A/M melanomas. Other alterations, including MYC and CRKL amplifications, were unique to A/M melanomas and susceptible to indirect targeting using the BRD4 inhibitor JQ1 or Src/ABL inhibitor dasatinib, respectively. We further identified new, actionable A/M-specific alterations, including an inactivating NF2 fusion in a mucosal melanoma responsive to dasatinib in vivo. Our study highlights new molecular differences between cutaneous and A/M melanomas, and across different anatomic sites within A/M, which may change clinical testing and treatment paradigms for these rare melanomas.

Divergence in Cigarette Discontinuation Rates by Use of Electronic Nicotine Delivery Systems (ENDS): Longitudinal Findings From the United States PATH Study Waves 1-6.

INTRODUCTION: We compare real-world trends in population-level cigarette discontinuation rates among adults (ages ≥21) who smoked cigarettes, by electronic nicotine delivery systems (ENDS) use. AIMS AND METHODS: U.S nationally representative data from adults in the Population Assessment of Tobacco and Health (PATH) Study (2013/14-2021, Waves 1-6) who smoked cigarettes in the past 30 days (P30D) were analyzed (n = 13 640). The exposure was P30D ENDS use. The outcome was P30D cigarette discontinuation at biennial follow-up. Weighted trend analyses were conducted to test for differences in cigarette discontinuation trends by ENDS use. RESULTS: Between 2013/14 and 2015/16, cigarette discontinuation rates were both 16% for those who used ENDS and for those who did not; between 2018/19 and 2021, rates were ~30% for those who used ENDS and ~20% for those who did not; the time by ENDS use interaction was significant. CONCLUSIONS: The relationship between adults' ENDS use and cigarette discontinuation in the context of an expanded ENDS marketplace, new tobacco regulatory actions, and COVID-19 differs from the relationship in earlier years. IMPLICATIONS: It is important for public health decisions to be informed by research based on the contemporary ENDS marketplace and circumstances.

Respiratory symptoms and outcomes among cigar smokers: findings from the Population Assessment of Tobacco and Health (PATH) study waves 2-5 (2014-2019).

BACKGROUND: The mechanisms by which cigarette smoking increases the risk of respiratory disease have been studied. However, less is known about risks of respiratory symptoms and outcomes associated with smoking cigars, and risks by cigar types have not been previously explored. The aim of this study was to examine associations between cigar use, including traditional cigars, cigarillos, filtered cigars, and dual cigar and cigarette use, and functionally important respiratory symptoms (FIRS), lifetime asthma diagnosis, uncontrolled asthma, and new cases of FIRS. METHODS: Data from Waves 2-5 (2014-19) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative longitudinal study, were analyzed in two ways. For cross-sectional analysis, the analytic sample included adults 18 and older at each wave, resulting in 44,040 observations. Separately, longitudinal analyses were assessed among adults 18 and older at Wave 2, resulting in 7,930 individuals. Both analyses excluded adults with chronic obstructive pulmonary disease (COPD) or non-asthma respiratory disease. RESULTS: Current established cigarillo smokers had higher odds of having FIRS (Adjusted odds ratio (AOR): 1.72; 95% CI: 1.08, 2.74) compared to never smokers of cigarillos and cigarettes, after adjusting for covariates. Current established filtered cigar smokers had higher odds of asthma diagnosis (AOR: 1.35; 95% CI: 1.10, 1.66) while current established dual smokers of filtered cigars and cigarettes had higher odds of uncontrolled asthma (AOR: 5.13; 95% CI: 1.75, 15.02) compared to never smokers of filtered cigars or cigarettes. Both current established cigar smokers and current established dual smokers of cigarettes and cigars had higher odds of new FIRS compared to never cigar or cigarette smokers (AORs: 1.62; 95% CI: 1.02, 2.60 for exclusive cigars and 2.55; 95% CI 1.57, 4.14 for dual smokers). CONCLUSIONS: This study provides evidence that cigar smokers or dual smokers of cigars and cigarettes have greater odds of FIRS, asthma, and uncontrolled asthma and that new incidence of FIRS is higher among any cigar smokers compared to never cigar or cigarette smokers. Understanding health impacts associated with cigar use provides information for supporting policy development, as well as for designing clinical interventions focused on smoking cessation for cigars.

Support for cigarette filter waste policies among US adults.

INTRODUCTION: Little is known on whether cigarette filter-related knowledge or beliefs are associated with support for policies to reduce their environmental impact. METHODS: A cross-sectional, population-based sample of US adults aged 18-64 years (n=2979) was used to evaluate filter-related knowledge and beliefs by smoking status using data collected between 24 October 2018 and 17 December 2018. Multivariate logistic regression models explored whether these knowledge and belief items were associated with support for two policies, a US$0.75 litter fee and a ban on sales of filtered cigarettes, controlling for demographic characteristics and smoking status. RESULTS: Regardless of smoking status, 71% did not know plastic was a cigarette filter component and 20% believed filters were biodegradable. Overall, 23% believed filters reduce health harms and 60% believed filters make it easier to smoke; 90% believed cigarette butts are harmful to the environment. Individuals believing cigarette butts harmed the environment were more likely to support a litter fee (adjusted OR (aOR)=2.33, 95% CI: 1.71 to 3.17). Individuals believing that filters are not biodegradable had higher odds of supporting a litter fee (OR=1.47, 95% CI: 1.15 to 1.88). Respondents believing that filters do not make cigarettes less harmful were more likely to support a litter fee (aOR=1.50, 95% CI: 1.20 to 1.88) and filter ban (aOR=2.03, 95% CI: 1.64 to 2.50). Belief that filters make it easier to smoke was associated with decreased support for a filter ban (aOR=0.69, 95% CI: 0.58 to 0.83). CONCLUSIONS: Comprehensive efforts are needed to educate the public about the impact of cigarette filters in order to build support for effective tobacco product waste policy.

Measuring the impact of state and local Tobacco 21 policies in the United States: A longitudinal study of youth and young adults ages 15-21.

INTRODUCTION: Tobacco 21 (T21) policies, which prohibit tobacco sales to individuals under 21, aim to reduce youth tobacco use by limiting youth access to these products. Little, however, is known about the longitudinal effect of T21 policies on youth tobacco use behaviors at the national level. METHODS: Participants aged 15-21 years from a longitudinal study conducted between May 2014 and May 2019 (n = 13,990) were matched to geocoded T21 policies. Generalized linear mixed models examined the association of direct and bordering T21 policy exposure and cigarette and e-cigarette use and intention to use, accounting for individual characteristics. RESULTS: Controlling for sociodemographic and psychosocial covariates, there were statistically significant positive associations between T21 exposure and e-cigarette use (OR = 1.45 [1.03,2.06], p < .003) and intention to use e-cigarettes (OR = 1.54 [1.05,2.26], p < .027). We found no association between T21 policy exposure and cigarette use or intention to use cigarettes. Furthermore, exposure to T21 policies did not significantly modify the relationship between age and either cigarette outcome. CONCLUSIONS: This is the first longitudinal study to evaluate state and local T21 policies at the national level. Our analyses demonstrate that existing T21 policies are not sufficient to reduce youth tobacco use and intentions to use, and suggest that T21 policies need to be a part of a comprehensive tobacco policy landscape. Our findings suggest further research is warranted on state and local T21 policy enforcement and implementation, including how T21 may differentially impact cigarette and e-cigarette use, and may have implications for the federal T21 policy. IMPLICATIONS: This research evaluates state and local T21 policies in the United States longitudinally, finding that T21 policies are not sufficient to stem e-cigarette use among adolescents and young adults. These findings support further policy action and suggest that local and state T21 policies are not sufficient to reduce tobacco use and rather, need to be part of a broader, more comprehensive set of tobacco control policies. Further research on enforcement and implementation challenges of T21 policies and the impacts of the new federal T21 policy is warranted.

Image Processing for Public Health Surveillance of Tobacco Point-of-Sale Advertising: Machine Learning-Based Methodology.

BACKGROUND: With a rapidly evolving tobacco retail environment, it is increasingly necessary to understand the point-of-sale (POS) advertising environment as part of tobacco surveillance and control. Advances in machine learning and image processing suggest the ability for more efficient and nuanced data capture than previously available. OBJECTIVE: The study aims to use machine learning algorithms to discover the presence of tobacco advertising in photographs of tobacco POS advertising and their location in the photograph. METHODS: We first collected images of the interiors of tobacco retailers in West Virginia and the District of Columbia during 2016 and 2018. The clearest photographs were selected and used to create a training and test data set. We then used a pretrained image classification network model, Inception V3, to discover the presence of tobacco logos and a unified object detection system, You Only Look Once V3, to identify logo locations. RESULTS: Our model was successful in identifying the presence of advertising within images, with a classification accuracy of over 75% for 8 of the 42 brands. Discovering the location of logos within a given photograph was more challenging because of the relatively small training data set, resulting in a mean average precision score of 0.72 and an intersection over union score of 0.62. CONCLUSIONS: Our research provides preliminary evidence for a novel methodological approach that tobacco researchers and other public health practitioners can apply in the collection and processing of data for tobacco or other POS surveillance efforts. The resulting surveillance information can inform policy adoption, implementation, and enforcement. Limitations notwithstanding, our analysis shows the promise of using machine learning as part of a suite of tools to understand the tobacco retail environment, make policy recommendations, and design public health interventions at the municipal or other jurisdictional scale.

Modelling retailer-based exemptions in flavoured tobacco sales restrictions: national estimates on the impact of product availability.

OBJECTIVES: More than 250 US localities restrict sales of flavoured tobacco products (FTPs), but comprehensiveness varies, and many include retailer-based exemptions. The purpose of this study is to examine resulting changes in the US retail environment for FTPs if there was a hypothetical national tobacco control policy that would prohibit FTP sales in all retailers except (1) tobacco specialty stores or (2) tobacco specialty stores and alcohol outlets. DESIGN AND SETTING: A cross-sectional analysis of the FTP retail environment in every US Census tract (n=74 133). FTP retailers (n=3 10 090) were enumerated using nine unique codes from a national business directory (n=296 716) and a national vape shop directory (n=13 374). OUTCOME MEASURES: We assessed FTP availability using static-bandwidth and adaptive-bandwidth kernel density estimation. We then calculated the proportion of FTP stores remaining and the mean density of FTP retailers under each policy scenario for the overall population, as well as across populations vulnerable to FTP use. RESULTS: Exempting tobacco specialty stores alone would leave 25 276 (8.2%) FTP retailers nationwide, while exempting both tobacco specialty stores and alcohol outlets would leave 54 091 (17.4%) retailers. On average, the per cent remaining FTP availability per 100 000 total population was 7.1% for a tobacco specialty store exemption and 18.1% for a tobacco specialty store and alcohol outlet exemption. Overall, density estimate trends for remaining FTP availability among racial/ethnic populations averaged across Census tracts mirrored total population density. However, estimates varied when stratified by metropolitan status. Compared with the national average, FTP availability would remain 47%-49% higher for all racial/ethnic groups in large metropolitan areas. CONCLUSIONS: Retailer-based exemptions allow greater FTP availability compared with comprehensive policies which would reduce FTP availability to zero. Strong public policies have the greatest potential impact on reducing FTP availability, particularly among urban, and racial/ethnic minority populations.

Disparities in Distribution of Particulate Matter Emissions from US Coal-Fired Power Plants by Race and Poverty Status After Accounting for Reductions in Operations Between 2015 and 2017.

Objectives. To investigate potential changes in burdens from coal-fired electricity-generating units (EGUcfs) that emit fine particulate matter (PM2.5, defined as matter with a nominal mean aerodynamic diameter of ≤ 2.5 µm) among racial/ethnic and economic groups after reduction of operations in 92 US EGUcfs.Methods. PM2.5 burdens calculated for EGUs listed in the 2008, 2011, and 2014 National Emissions Inventory were recalculated for 2017 after omitting emissions from 92 EGUcfs. The combined influence of race/ethnicity and poverty on burden estimates was characterized.Results. Omission of 92 EGUcfs decreased PM2.5 burdens attributable to EGUs by 8.6% for the entire population and to varying degrees for every population subgroup. Although the burden decreased across all subgroups, the decline was not equitable. After omission of the 92 EGUcfs, burdens were highest for the below-poverty and non-White subgroups. Proportional disparities between White and non-White subgroups increased. In our combined analysis, the burden was highest for the non-White-high-poverty subgroup.Conclusions. Our results indicate that subgroups living in poverty experience the greatest absolute burdens from EGUcfs. Changes as a result of EGUcf closures suggest a shift in burden from White to non-White subgroups. Policymakers could use burden analyses to jointly promote equity and reduce emissions.

The availability of retail tobacco near federally qualified healthcare facilities and addiction treatment centers in New York State.

The effectiveness of tobacco control policies that create smoke-free healthcare facilities and encourage the delivery of tobacco dependence treatment may be undermined by the availability of retail tobacco in the surrounding environments. This study examined the availability of retail tobacco in relation to: federally qualified health centers and look-a-like (FQHC/LAL) healthcare facilities (n = 706) as well as substance abuse and addiction treatment centers (n = 953) across New York State (NYS) in 2018. A statewide tobacco retailer density surface using static-bandwidth kernel density estimation was constructed from geocoded licensed tobacco vendors (n = 21,314). For each healthcare facility, tobacco retailer density (retailers per square mile) was extracted from the underlying NYS density surface. Proximity from each healthcare facility to the nearest tobacco vendor was calculated in walkable miles. Across NYS, tobacco retailer density ranged from 0 to 41.02 retailers per square mile. The availability of retailer tobacco near FQHC/LAL healthcare facilities and substance abuse and addiction treatment centers was higher in metropolitan areas than less urban areas as expected. School-based FQHC/LAL healthcare facilities had higher density than all other FQHC/LAL healthcare facilities types (Mean = 20.82 vs. 17.04, p = 0.0042), while opioid abuse and addiction treatment centers had on average higher density (Mean = 20.42 vs. 9.81, p < 0.0001) and closer proximity to a tobacco vendor (Mean = 0.14 vs. 0.36, p < 0.0001) than other substance abuse and addiction treatment centers. State and local tobacco control retailer reduction policies should be considered to reduce the availability of retail tobacco surrounding these facilities.

Characteristics and Reach Equity of Policies Restricting Flavored Tobacco Product Sales in the United States.

In 2009, flavored cigarettes (except menthol) were banned in the United States, but other flavored tobacco products (FTPs) were allowed. Women, populations of color, youth, sexual minority, and low-socioeconomic status populations disproportionately use FTPs. Localities have passed sales restrictions on FTPs that may reduce disparities if vulnerable populations are reached. This study assessed the extent to which FTP restrictions reached these subgroups ("reach equity"). We identified 189 U.S. jurisdictions with FTP policies as of December 31, 2018. We linked jurisdictions with demographics of race/ethnicity, gender, age, partnered same-sex households and household poverty, and stratified by policy strength. We calculated Reach Ratios (ReRas) to assess reach equity among subgroups covered by FTP policies relative to their U.S. population representation. Flavor policies covered 6.3% of the U.S. population (20 million individuals) across seven states; 0.9% were covered by strong policies (12.7% of policies). ReRas indicated favorable reach equity to young adults, women, Hispanics, African Americans, Asians, partnered same-sex households, and those living below poverty. Youth, American Indians/Alaska Natives (AIAN) and Native Hawaiians/Pacific Islanders (NHPI) were underrepresented. Strong policies had favorable reach equity to young adults, those living below poverty, Asians, NHPIs, individuals of 2+ races, and partnered same-sex households, but unfavorable reach equity to women, youth, Hispanic, AIAN, and African American populations. U.S. flavor policies have greater reach to many, but not all, subgroups at risk of FTP use. Increased enactment of strong policies to populations not covered by flavor policies is warranted to ensure at-risk subgroups sufficiently benefit.

The Pan-Cancer Landscape of Coamplification of the Tyrosine Kinases KIT, KDR, and PDGFRA.

PURPOSE: Amplifications of receptor tyrosine kinases (RTKS) are therapeutic targets in multiple tumor types (e.g. HER2 in breast cancer), and amplification of the chromosome 4 segment harboring the three RTKs KIT, PDGFRA, and KDR (4q12amp) may be similarly targetable. The presence of 4q12amp has been sporadically reported in small tumor specific series but a large-scale analysis is lacking. We assess the pan-cancer landscape of 4q12amp and provide early clinical support for the feasibility of targeting this amplicon. EXPERIMENTAL DESIGN: Tumor specimens from 132,872 patients with advanced cancer were assayed with hybrid capture based comprehensive genomic profiling which assays 186-315 genes for all classes of genomic alterations, including amplifications. Baseline demographic data were abstracted, and presence of 4q12amp was defined as 6 or more copies of KIT/KDR/PDGFRA. Concurrent alterations and treatment outcomes with matched therapies were explored in a subset of cases. RESULTS: Overall 0.65% of cases harbored 4q12amp at a median copy number of 10 (range 6-344). Among cancers with >100 cases in this series, glioblastomas, angiosarcomas, and osteosarcomas were enriched for 4q12amp at 4.7%, 4.8%, and 6.4%, respectively (all p < 0.001), giving an overall sarcoma (n = 6,885) incidence of 1.9%. Among 99 pulmonary adenocarcinoma cases harboring 4q12amp, 50 (50%) lacked any other known driver of NSLCC. Four index cases plus a previously reported case on treatment with empirical TKIs monotherapy had stable disease on average exceeding 20 months. CONCLUSION: We define 4q12amp as a significant event across the pan-cancer landscape, comparable to known pan-cancer targets such as NTRK and microsatellite instability, with notable enrichment in several cancers such as osteosarcoma where standard treatment is limited. The responses to available TKIs observed in index cases strongly suggest 4q12amp is a druggable oncogenic target across cancers that warrants a focused drug development strategy. IMPLICATIONS FOR PRACTICE: Coamplification of the receptor tyrosine kinases (rtks) KIT/KDR/PDGFRA (4q12amp) is present broadly across cancers (0.65%), with enrichment in osteosarcoma and gliomas. Evidence for this amplicon having an oncogenic role is the mutual exclusivity of 4q12amp to other known drivers in 50% of pulmonary adenocarcinoma cases. Furthermore, preliminary clinical evidence for driver status comes from four index cases of patients empirically treated with commercially available tyrosine kinase inhibitors with activity against KIT/KDR/PDGFRA who had stable disease for 20 months on average. The sum of these lines of evidence suggests further clinical and preclinical investigation of 4q12amp is warranted as the possible basis for a pan-cancer drug development strategy.

Tissue Level Mechanical Properties and Extracellular Matrix Investigation of the Bovine Jugular Venous Valve Tissue.

Jugular venous valve incompetence has no long-term remedy and symptoms of transient global amnesia and/or intracranial hypertension continue to discomfort patients. During this study, we interrogate the synergy of the collagen and elastin microstructure that compose the bi-layer extracellular matrix (ECM) of the jugular venous valve. In this study, we investigate the jugular venous valve and relate it to tissue-level mechanical properties, fibril orientation and fibril composition to improve fundamental knowledge of the jugular venous valves toward the development of bioprosthetic venous valve replacements. Steps include: (1) multi loading biaxial mechanical tests; (2) isolation of the elastin microstructure; (3) imaging of the elastin microstructure; and (4) imaging of the collagen microstructure, including an experimental analysis of crimp. Results from this study show that, during a 3:1 loading ratio (circumferential direction: 900 mN and radial direction: 300 mN), elastin may have the ability to contribute to the circumferential mechanical properties at low strains, for example, shifting the inflection point toward lower strains in comparison to other loading ratios. After isolating the elastin microstructure, light microscopy revealed that the overall elastin orients in the radial direction while forming a crosslinked mesh. Collagen fibers were found undulated, aligning in parallel with neighboring fibers and orienting in the circumferential direction with an interquartile range of -10.38° to 7.58° from the circumferential axis (n = 20). Collagen crimp wavelength and amplitude was found to be 38.46 ± 8.06 µm and 4.51 ± 1.65 µm, respectively (n = 87). Analyzing collagen crimp shows that crimp permits about 12% true strain circumferentially, while straightening of the overall fibers accounts for more. To the best of the authors' knowledge, this is the first study of the jugular venous valve linking the composition and orientation of the ECM to its mechanical properties and this study will aid in forming a structure-based constitutive model.

Molecular profiling of cancer patients enables personalized combination therapy: the I-PREDICT study.

Cancer treatments have evolved from indiscriminate cytotoxic agents to selective genome- and immune-targeted drugs that have transformed the outcomes of some malignancies1. Tumor complexity and heterogeneity suggest that the 'precision medicine' paradigm of cancer therapy requires treatment to be personalized to the individual patient2-6. To date, precision oncology trials have been based on molecular matching with predetermined monotherapies7-14. Several of these trials have been hindered by very low matching rates, often in the 5-10% range15, and low response rates. Low matching rates may be due to the use of limited gene panels, restrictive molecular matching algorithms, lack of drug availability, or the deterioration and death of end-stage patients before therapy can be implemented. We hypothesized that personalized treatment with combination therapies would improve outcomes in patients with refractory malignancies. As a first test of this concept, we implemented a cross-institutional prospective study (I-PREDICT, NCT02534675 ) that used tumor DNA sequencing and timely recommendations for individualized treatment with combination therapies. We found that administration of customized multidrug regimens was feasible, with 49% of consented patients receiving personalized treatment. Targeting of a larger fraction of identified molecular alterations, yielding a higher 'matching score', was correlated with significantly improved disease control rates, as well as longer progression-free and overall survival rates, compared to targeting of fewer somatic alterations. Our findings suggest that the current clinical trial paradigm for precision oncology, which pairs one driver mutation with one drug, may be optimized by treating molecularly complex and heterogeneous cancers with combinations of customized agents.

Disparities in Distribution of Particulate Matter Emission Sources by Race and Poverty Status.

OBJECTIVES: To quantify nationwide disparities in the location of particulate matter (PM)-emitting facilities by the characteristics of the surrounding residential population and to illustrate various spatial scales at which to consider such disparities. METHODS: We assigned facilities emitting PM in the 2011 National Emissions Inventory to nearby block groups across the 2009 to 2013 American Community Survey population. We calculated the burden from these emissions for racial/ethnic groups and by poverty status. We quantified disparities nationally and for each state and county in the country. RESULTS: For PM of 2.5 micrometers in diameter or less, those in poverty had 1.35 times higher burden than did the overall population, and non-Whites had 1.28 times higher burden. Blacks, specifically, had 1.54 times higher burden than did the overall population. These patterns were relatively unaffected by sensitivity analyses, and disparities held not only nationally but within most states and counties as well. CONCLUSIONS: Disparities in burden from PM-emitting facilities exist at multiple geographic scales. Disparities for Blacks are more pronounced than are disparities on the basis of poverty status. Strictly socioeconomic considerations may be insufficient to reduce PM burdens equitably across populations.

Structural and functional small fiber abnormalities in the neuropathic postural tachycardia syndrome.

OBJECTIVE: To define the neuropathology, clinical phenotype, autonomic physiology and differentiating features in individuals with neuropathic and non-neuropathic postural tachycardia syndrome (POTS). METHODS: Twenty-four subjects with POTS and 10 healthy control subjects had skin biopsy analysis of intra-epidermal nerve fiber density (IENFD), quantitative sensory testing (QST) and autonomic testing. Subjects completed quality of life, fatigue and disability questionnaires. Subjects were divided into neuropathic and non-neuropathic POTS, defined by abnormal IENFD and abnormal small fiber and sudomotor function. RESULTS: Nine of 24 subjects had neuropathic POTS and had significantly lower resting and tilted heart rates; reduced parasympathetic function; and lower phase 4 valsalva maneuver overshoot compared with those with non-neuropathic POTS (P<0.05). Neuropathic POTS subjects also had less anxiety and depression and greater overall self-perceived health-related quality of life scores than non-neuropathic POTS subjects. A sub-group of POTS patients (cholinergic POTS) had abnormal proximal sudomotor function and symptoms that suggest gastrointestinal and genitourinary parasympathetic nervous system dysfunction. CONCLUSIONS AND RELEVANCE: POTS subtypes may be distinguished using small fiber and autonomic structural and functional criteria. Patients with non-neuropathic POTS have greater anxiety, greater depression and lower health-related quality of life scores compared to those with neuropathic POTS. These findings suggest different pathophysiological processes underlie the postural tachycardia in neuropathic and non-neuropathic POTS patients. The findings have implications for the therapeutic interventions to treat this disorder.

Diagnostic dilemmas in cardiology.

A 29-year-old pregnant woman presented in accident and emergency with severe acute left ventricular failure requiring admission to the intensive care unit. A nasal swab was found to be positive for H1N1 making peripartum and viral cardiomyopathies, the most likely differential diagnoses. CT coronary angiography and subsequent invasive angiography revealed an anomalous coronary system thus making ischaemic cardiomyopathy also a possibility. Cardiac MRI played a vital role in identifying the underlying cause, which in this case was that of H1N1 influenza cardiomyopathy. Correct diagnosis in such patients is paramount as this impinges on patients' overall prognosis. In this case aggressive initial therapy including inotropic support and invasive ventilation followed by standard antifailure treatment with ß-blockers and angiotensin-converting enzyme inhibitors led to restoration of the patient's left ventricular function and an associated marked improvement in symptoms.

Targeted single nucleotide polymorphism (SNP) discovery in a highly polyploid plant species using 454 sequencing.

Discovering single nucleotide polymorphisms (SNPs) in specific genes in a heterozygous polyploid plant species, such as sugarcane, is challenging because of the presence of a large number of homologues. To discover SNPs for mapping genes of interest, 454 sequencing of 307 polymerase chain reaction (PCR) amplicons (> 59 kb of sequence) was undertaken. One region of a four-gasket sequencing run, on a 454 Genome Sequencer FLX, was used for pooled PCR products amplified from each parent of a quantitative trait locus (QTL) mapping population (IJ76-514 x Q165). The sequencing yielded 96,755 (IJ76-514) and 86,241 (Q165) sequences with perfect matches to a PCR primer used in amplification, with an average sequence depth of approximately 300 and an average read length of 220 bases. Further analysis was carried out on amplicons whose sequences clustered into a single contig using an identity of 80% with the program cap3. In the more polymorphic sugarcane parent (Q165), 94% of amplicons (227/242) had evidence of a reliable SNP--an average of one every 35 bases. Significantly fewer SNPs were found in the pure Saccharum officinarum parent--with one SNP every 58 bases and SNPs in 86% (213/247) of amplicons. Using automatic SNP detection, 1632 SNPs were detected in Q165 sequences and 1013 in IJ76-514. From 225 candidate SNP sites tested, 209 (93%) were validated as polymorphic using the Sequenom MassARRAY system. Amplicon re-sequencing using the 454 system enables cost-effective SNP discovery that can be targeted to genes of interest and is able to perform in the highly challenging area of polyploid genomes.