Patient characteristics and predictors of mortality in 470 adults admitted to a district general hospital in England with Covid-19.

Understanding risk factors for death from Covid-19 is key to providing good quality clinical care. We assessed the presenting characteristics of the 'first wave' of patients with Covid-19 at Royal Oldham Hospital, UK and undertook logistic regression modelling to investigate factors associated with death. Of 470 patients admitted, 169 (36%) died. The median age was 71 years (interquartile range 57-82), and 255 (54.3%) were men. The most common comorbidities were hypertension (n = 218, 46.4%), diabetes (n = 143, 30.4%) and chronic neurological disease (n = 123, 26.1%). The most frequent complications were acute kidney injury (AKI) (n = 157, 33.4%) and myocardial injury (n = 21, 4.5%). Forty-three (9.1%) patients required intubation and ventilation, and 39 (8.3%) received non-invasive ventilation. Independent risk factors for death were increasing age (odds ratio (OR) per 10 year increase above 40 years 1.87, 95% confidence interval (CI) 1.57-2.27), hypertension (OR 1.72, 95% CI 1.10-2.70), cancer (OR 2.20, 95% CI 1.27-3.81), platelets <150 × 103/µl (OR 1.93, 95% CI 1.13-3.30), C-reactive protein ≥100 µg/ml (OR 1.68, 95% CI 1.05-2.68), >50% chest radiograph infiltrates (OR 2.09, 95% CI 1.16-3.77) and AKI (OR 2.60, 95% CI 1.64-4.13). There was no independent association between death and gender, ethnicity, deprivation level, fever, SpO2/FiO2, lymphopoenia or other comorbidities. These findings will inform clinical and shared decision making, including use of respiratory support and therapeutic agents.

Ectopic Hedgehog Signaling Causes Cleft Palate and Defective Osteogenesis.

Cleft palate is a common birth defect that frequently occurs in human congenital malformations caused by mutations in components of the Sonic Hedgehog (S HH) signaling cascade. Shh is expressed in dynamic, spatiotemporal domains within epithelial rugae and plays a key role in driving epithelial-mesenchymal interactions that are central to development of the secondary palate. However, the gene regulatory networks downstream of Hedgehog (Hh) signaling are incompletely characterized. Here, we show that ectopic Hh signaling in the palatal mesenchyme disrupts oral-nasal patterning of the neural crest cell-derived ectomesenchyme of the palatal shelves, leading to defective palatine bone formation and fully penetrant cleft palate. We show that a series of Fox transcription factors, including the novel direct target Foxl1, function downstream of Hh signaling in the secondary palate. Furthermore, we demonstrate that Wnt/bone morphogenetic protein (BMP) antagonists, in particular Sostdc1, are positively regulated by Hh signaling, concomitant with downregulation of key regulators of osteogenesis and BMP signaling effectors. Our data demonstrate that ectopic Hh-Smo signaling downregulates Wnt/BMP pathways, at least in part by upregulating Sostdc1, resulting in cleft palate and defective osteogenesis.

Candidate Genes for Nonsyndromic Cleft Palate Detected by Exome Sequencing.

Nonsyndromic cleft palate only (nsCPO) is a facial malformation that has a livebirth prevalence of 1 in 2,500. Research suggests that the etiology of nsCPO is multifactorial, with a clear genetic component. To date, genome-wide association studies have identified only 1 conclusive common variant for nsCPO, that is, a missense variant in the gene grainyhead-like-3 ( GRHL3). Thus, the underlying genetic causes of nsCPO remain largely unknown. The present study aimed at identifying rare variants that might contribute to nsCPO risk, via whole-exome sequencing (WES), in multiply affected Central European nsCPO pedigrees. WES was performed in 2 affected first-degree relatives from each family. Variants shared between both individuals were analyzed for their potential deleterious nature and a low frequency in the general population. Genes carrying promising variants were annotated for 1) reported associations with facial development, 2) multiple occurrence of variants, and 3) expression in mouse embryonic palatal shelves. This strategy resulted in the identification of a set of 26 candidate genes that were resequenced in 132 independent nsCPO cases and 623 independent controls of 2 different ethnicities, using molecular inversion probes. No rare loss-of-function mutation was identified in either WES or resequencing step. However, we identified 2 or more missense variants predicted to be deleterious in each of 3 genes ( ACACB, PTPRS, MIB1) in individuals from independent families. In addition, the analyses identified a novel variant in GRHL3 in 1 patient and a variant in CREBBP in 2 siblings. Both genes underlie different syndromic forms of CPO. A plausible hypothesis is that the apparently nonsyndromic clefts in these 3 patients might represent hypomorphic forms of the respective syndromes. In summary, the present study identified rare variants that might contribute to nsCPO risk and suggests candidate genes for further investigation.

Refinement of a thermal threshold probe to prevent burns.

Thermal threshold testing is commonly used for pain research. The stimulus may cause burning and merits prevention. Thermal probe modifications hypothesized to reduce burning were evaluated for practicality and effect. Studies were conducted on two humans and eight cats. Unmodified probe 0 was tested on two humans and promising modifications were also evaluated on cats. Probe 1 incorporated rapid cooling after threshold was reached: probe 1a used a Peltier system and probe 1b used water cooling. Probe 2 released skin contact immediately after threshold. Probe 3 (developed in the light of evidence of 'hot spots' in probe 0) incorporated reduced thermal mass and even heating across the skin contact area. Human skin was heated to 48℃ (6℃ above threshold) and the resulting burn was evaluated using area of injury and a simple descriptive scale (SDS). Probe 1a cooled the skin but required further heat dissipation, excessive power, was not 'fail-safe' and was inappropriate for animal mounting. Probe 1b caused less damage than no cooling (27 ± 13 and 38 ± 11 mm(2) respectively, P = 0.0266; median SDS 1.5 and 4 respectively, P = 0.0317) but was cumbersome. Probe 2 was unwieldy and was not evaluated further. Probe 3 produced even heating without blistering in humans. With probe 3 in cats, after opioid treatment, thermal threshold reached cut-out (55℃) on 24 occasions, exceeded 50℃ in a further 32 tests and exceeded 48℃ in the remainder. No skin damage was evident immediately after testing and mild hyperaemia in three cats at 2-3 days resolved rapidly. Probe 3 appeared to be suitable for thermal threshold testing.

The effects of a resistive warming mattress during caesarean section: a randomised, controlled trial.

BACKGROUND: The adverse effects of inadvertent perioperative hypothermia in the surgical population are well established. The aim of this study was to investigate whether a resistive warming mattress would reduce the incidence of inadvertent perioperative hypothermia in patients undergoing elective caesarean section. METHODS: A total of 116 pregnant women booked for elective caesarean section were randomised to either intraoperative warming with a mattress or control. The primary outcome was the incidence of inadvertent perioperative hypothermia, defined as a temperature <36.0 °C on admission to the recovery room. Shivering in the perioperative period, severity of shivering and the need for treatment, total blood loss, fall in haemoglobin, incidence of blood transfusion, immediate health of baby, and length of hospital stay were also recorded. RESULTS: The incidence of inadvertent perioperative hypothermia in the mattress-warmed group was significantly lower than in the control group (5.2% vs. 19.0%, P=0.043); mean temperatures differed between the two groups, 36.5 °C and 36.3 °C, respectively (P=0.046). There was also a significantly lower mean (± SD) haemoglobin change in the mattress-warmed group at -1.1±0.9 g/dL versus -1.6±0.9 g/dL in the control group (P=0.007). There was no difference in shivering (P=0.798). CONCLUSIONS: A resistive warming mattress reduced the incidence of inadvertent perioperative hypothermia and attenuated the fall in haemoglobin. The use of resistive mattress warming should be considered during caesarean section.

The pro-metastatic protein anterior gradient-2 predicts poor prognosis in tamoxifen-treated breast cancers.

Transcriptomic screens in breast cancer cell lines have identified a protein named anterior gradient-2 (AGR2) as a potentially novel oncogene overexpressed in estrogen receptor (ER) positive tumours. As targeting the ER is responsible for major improvements in cure rates and prevention of breast cancers, we have evaluated the pro-oncogenic function of AGR2 in anti-hormone therapeutic responses. We show that AGR2 expression promotes cancer cell survival in clonogenic assays and increases cell proliferation and viability in a range of cancer cell lines. Chromatin immunoprecipitation and reporter assays indicate that AGR2 is transcriptionally activated by estrogen through ERalpha. However, we also found that AGR2 expression is elevated rather than inhibited in response to tamoxifen, thus identifying a novel mechanism to account for an agonistic effect of the drug on a specific pro-oncogenic pathway. Consistent with these data, clinical analysis indicates that AGR2 expression is related to treatment failure in ERalpha-positive breast cancers treated with tamoxifen. In contrast, AGR2 is one of the most highly suppressed genes in cancers of responding patients treated with the anti-hormonal drug letrozole. These data indicate that the AGR2 pathway represents a novel pro-oncogenic pathway for evaluation as anti-cancer drug developments, especially therapies that by-pass the agonist effects of tamoxifen.

A small, silent, low friction, linear actuator for mechanical nociceptive testing in veterinary research.

Air pressure is commonly used to drive a mechanical stimulus for nociceptive threshold testing. This may be bulky, noisy, non-linear and suffer from friction, hence development of a better system is described. A novel, light (14 g) rolling diaphragm actuator was constructed, which supplied 20 N force via a constant actuation area irrespective of the pressure and position in the stroke. Three round-ended pins, 2.5 mm diameter, mounted in a triangle on the piston, provided the stimulus. Pressure was increased manually using a syringe with the rate of rise of force controlled at 0.8 N/s by warning lights. The pressure/force relationship was calibrated using a static force transducer and mercury column. Data were collected with the actuator attached to the antero-medial radius of 12 cats and four dogs. Mechanical threshold was recorded when the animal withdrew the limb and/or turned towards the actuator. Safety cut-off was 20 N. The pressure/force relationship was linear and independent of the start point in the actuator stroke. Baseline feline thresholds were 10.0 +/- 2.5 N (mean +/- SD), which increased significantly 30 min after butorphanol administration. Baseline canine thresholds were 5.5 +/- 1.4 N and increased significantly between 15 and 45 min after administration of fentanyl or butorphanol. The system overcame the problems of earlier devices and detected an opioid-induced increase in threshold. It has considerable advantages over previous systems for research in analgesia.

Novel mutations in GJA1 cause oculodentodigital syndrome.

Oculodentodigital syndrome (ODD) is a rare, usually autosomal-dominant disorder that is characterized by developmental abnormalities of the face, eyes, teeth, and limbs. The most common clinical findings include a long, narrow nose, short palpebral fissures, type III syndactyly, and dental abnormalities including generalized microdontia and enamel hypoplasia. Recently, it has been shown that mutations in the gene GJA1, which encodes the gap junction protein connexin 43, underlie oculodentodigital syndrome. Gap junction communication between adjacent cells is known to be vital during embryogenesis and subsequently for normal tissue homeostasis. Here, we report 8 missense mutations in the coding region of GJA1, 6 of which have not been described previously, in ten unrelated families diagnosed with ODD. In addition, immunofluorescence analyses of a developmental series of mouse embryos and adult tissue demonstrates a strong correlation between the sites of connexin 43 expression and the clinical phenotype displayed by individuals affected by ODD.

Histopathology of breast carcinoma following neoadjuvant systemic therapy: a common association between letrozole therapy and central scarring.

AIMS: Neoadjuvant systemic therapy of large and locally advanced breast cancers may, through shrinkage, enable breast conservation surgery. Letrozole, an aromatase inhibitor, is used frequently in the treatment of oestrogen receptor-positive breast cancer. The aim was to examine the response patterns in a letrozole-treated group compared with a chemotherapy-treated group. MATERIALS AND METHODS: Fifty patients with primary breast cancer were treated with 3 months of chemotherapy and 53 with 3 months of neoadjuvant letrozole. Excised tumours were compared with preoperative core biopsy specimens. Volume calculations before and after therapy were used to calculate clinical response in the letrozole group. RESULTS: Response patterns were significantly different between the two therapies (P < 0.0005). Chemotherapy produced more complete pathological responses (P = 0.008) and a scattered cell pattern was also seen more frequently (P = 0.035). Letrozole produced substantially more central scars - 31 cases as opposed to two cases in the chemotherapy group (P = 0.0001) - and there was a statistically significant correlation with central scarring and clinical tumour volume reduction (P = 0.034). CONCLUSIONS: There are significantly different histological responses between cancers treated with chemotherapy and endocrine therapy, particularly central scarring. This has not been documented previously and may be an important factor in down-sizing tumours with letrozole, enabling subsequent conservation surgery.

Carprofen and buprenorphine prevent hyperalgesia in a model of inflammatory pain in cats.

A model of nociceptive threshold determination was developed for evaluation of NSAID analgesia in cats. In a crossover study, eight cats received carprofen (4 mg/kg), buprenorphine (0.01 mg/kg) or saline (0.3 ml) subcutaneously before intradermal kaolin injection on the antebrachium to induce mild inflammation. Pressure thresholds were measured at the injected site using blunt-ended pins advanced by manual inflation of a bladder within a bracelet. Bladder pressure was recorded as threshold (PT) at the behavioural end point. Baseline PT were recorded before kaolin injection (time 0). PT was measured at 2-10 h intervals for 52 h. PT below the lower 95% confidence interval (CI) of baseline values indicated hyperalgesia. After saline, hyperalgesia was detected from 2-6 h, 22-26 h, and at 30 and 36 h. After carprofen, PT remained within the 95% CI. After buprenorphine, PT remained within the 95% CI except at 2h. Carprofen and to some extent buprenorphine, prevented inflammatory hyperalgesia.

Development of a pressure nociceptive threshold testing device for evaluation of analgesics in cats.

A pressure analgesiometric device was developed for unrestrained cats. Eleven cats were studied. Stimulation was via three rounded pins within a bracelet on the forearm. The pins were advanced by manual bladder inflation. Bladder pressure was measured using a strain gauge pressure transducer. The threshold was recorded at the behavioural end point. Thresholds were measured at 5 and 15min intervals for 2-4h, after removal/replacement of the cuff, for 120min after SC butorphanol (0.4mg/kg), and with mild skin inflammation at the testing site. Data were analysed using ANOVA. Pressure thresholds in untreated cats were around 150mmHg. The minimum interval for testing was established as 15min. Data were reproducible over 4h and beyond 24h. Thresholds in 5 cats increased (P<0.05) above baseline for 45min after butorphanol with a maximum increase of 270+/-182mmHg at 10min. Thresholds decreased with inflammation. The method appears suitable for feline analgesia investigations.

A nonsense mutation in the first transmembrane domain of connexin 43 underlies autosomal recessive oculodentodigital syndrome.

BACKGROUND: Oculodentodigital syndrome (ODD) is a pleiotropic congenital disorder characterised by abnormalities of the face, eyes, dentition, and limbs. ODD, which is inherited as an autosomal dominant trait, results from missense mutations in the gap junction protein connexin 43. OBJECTIVE: To analyse a family with a history of ODD which is inherited in an autosomal recessive manner RESULTS: ODD in this family resulted from the homozygous mutation R33X in the first transmembrane domain of connexin 43. CONCLUSIONS: The findings provide clear genetic evidence that ODD can be inherited in an autosomal recessive manner and that a dominant negative mechanism underlies autosomal dominant ODD.

Changes in thermal threshold response in eight cats after administration of buprenorphine, butorphanol and morphine.

Thermal thresholds were measured in eight cats after the intramuscular administration of morphine (0.2 mg/kg), buprenorphine (0.01 mg/kg) or butorphanol (0.2 mg/kg), doses commonly used in clinical practice; 0.9 per cent saline (0.3 ml) was injected as a control. Groups of six cats were used and each cat participated in at least two treatments, according to a randomised design. The investigator was blinded to the treatments. The thermal thresholds were measured with a testing device developed specifically for cats, and measurements were made before and five, 30, 45 and 60 minutes and two, four, six, 12 and 24 hours after the injections. There was no significant change in thermal threshold after the injection of saline. With butorphanol, the threshold was increased only at five minutes after the injection and was decreased two hours after the injection; with morphine it was increased from between four and six hours after the injection, and with buprenorphine it was increased from between four and 12 hours after the injection.

Mutation testing in Treacher Collins Syndrome.

OBJECTIVE: To report on a study where 97 subjects were screened for mutations in the Treacher Collins syndrome (TCS) gene TCOF1. METHOD: Ninety-seven subjects with a clinical diagnosis of TCS were screened for potential mutations in TCOF1, by means of single strand conformation polymorphism (SSCP) analysis. In those subjects where potential mutations were detected, sequence analysis was performed to determine the site and type of mutation present. RESULTS: Thirty-six TCS-specific mutations are reported including 27 deletions, six point mutations, two splice junction mutations, and one insertion/deletion. This brings the total number of mutations reported to date to 105. CONCLUSION: The importance of detection of these mutations is mainly in postnatal diagnosis and genetic counselling. Knowledge of the family specific mutation may also be used in prenatal diagnosis to confirm whether the foetus is affected or not, and give the parents the choice of whether to continue with the pregnancy.

Synaesthesia: a case study of discordant monozygotic twins.

We describe a study of 11-year-old twin sisters who are physically identical in appearance but who have considerably different conscious experiences. One twin appears to be a synaesthete in that she states that she has specific colour experiences (i.e. photisms) whenever she views, hears or thinks of digits. The other twin does not report such conscious experiences when viewing, hearing or thinking about digits. A genotypic analysis using eight microsatellite loci plus the gender of the twins and their parents confirmed that the twins are monozygotic. A phenotypic analysis using a modification of the Stroop task confirmed that only one twin is a synaesthete. We suggest that the discordance in synaesthesia may be due to either an epigenetic event, X chromosome inactivation, or a mutation of a synaesthesia gene.

A thermal threshold testing device for evaluation of analgesics in cats.

A thermal analgesiometric device was developed for unrestrained cats. Heat was provided by an electrical element potted together with a temperature sensor in thermally conductive epoxy in a 5 gm probe. This was attached to an elasticated band round the cat's thorax with an inflated bladder maintaining constant pressure between probe and skin. A safety cut-off was set at 60 degrees C. End point was a skin flick, turning, or jumping. Threshold temperatures in untreated cats were around 40 degrees C and repeatable to 4 degrees C with 5, 10 or 15 minutes between tests. Threshold temperature was stable in tests at 15 minutes intervals without false positives or negatives. Tests repeated at weekly intervals were repeatable to within 4 degrees C. Treatment with the opioid analgesic pethidine increased the threshold temperatures 10.2 (6.7) degrees C 45 minutes after treatment. The device was well tolerated for at least 24 hours and the analgesic effect of an opioid was detected. The system appears suitable for use in investigations into analgesic pharmacology in cats.

Colored photisms prevent object-substitution masking in digit-color synesthesia.

For C, a digit-color synesthete, viewing a digit elicits a photism (an experience of a highly specific color), which is perceived as externally projected onto the digit. We used an object substitution paradigm to demonstrate the influence of C's photisms on her perception of digits. Object substitution refers to a form of masking that depends upon two critical factors: attention must be taxed (e.g., distributed among numerous distracters), and the mask must remain on-screen for a sufficient duration after the target has been removed. Results showed that for C, even under conditions that produced maximal object substitution in control participants, her endogenous coloring of target digits prevented object substitution. Thus, the present study clearly showed that C's photisms influence her ability to detect digits.