Lessons learnt from a case of missed central hypothyroidism.

We present the case of a 57-year-old lady who had a delayed diagnosis of central hypothyroidism on a background of Grave's thyrotoxicosis and a partial thyroidectomy. During the twenty years following her partial thyroidectomy, the patient developed a constellation of symptoms and new diagnoses, which were investigated by numerous specialists from various fields, namely rheumatology, renal and respiratory. She developed significantly impaired renal function and raised creatine kinase (CK). She was also referred to a tertiary neurology service for investigation of myositis, which resulted in inconclusive muscle biopsies. Recurrently normal TSH results reassured clinicians that this did not relate to previous thyroid dysfunction. In 2015, she developed increased shortness of breath and was found to have a significant pericardial effusion. The clinical biochemist reviewed this lady's blood results and elected to add on a free T4 (fT4) and free T3 (fT3), which were found to be <0.4 pmol/L (normal range (NR): 12-22 pmol/L) and 0.3 pmol/L (NR: 3.1-6.8 pmol/L), respectively. She was referred urgently to the endocrine services and commenced on Levothyroxine replacement for profound central hypothyroidism. Her other pituitary hormones and MRI were normal. In the following year, her eGFR and CK normalised, and her myositis symptoms, breathlessness and pericardial effusion resolved. One year following initiation of Levothyroxine, her fT4 and fT3 were in the normal range for the first time. This case highlights the pitfalls of relying purely on TSH for excluding hypothyroidism and the devastating effect the delay in diagnosis had upon this patient. LEARNING POINTS: Isolated central hypothyroidism is very rare, but should be considered irrespective of previous thyroid disorders.If clinicians have a strong suspicion that a patient may have hypothyroidism despite normal TSH, they should ensure they measure fT3 and fT4.Laboratories that do not perform fT3 and fT4 routinely should review advice sent to requesting clinicians to include a statement explaining that a normal TSH excludes primary but not secondary hypothyroidism.Thyroid function tests should be performed routinely in patients presenting with renal impairment or a raised CK.

Investigating the beneficial traits of Trichoderma hamatum GD12 for sustainable agriculture-insights from genomics.

Trichoderma hamatum strain GD12 is unique in that it can promote plant growth, activate biocontrol against pre- and post-emergence soil pathogens and can induce systemic resistance to foliar pathogens. This study extends previous work in lettuce to demonstrate that GD12 can confer beneficial agronomic traits to other plants, providing examples of plant growth promotion in the model dicot, Arabidopsis thaliana and induced foliar resistance to Magnaporthe oryzae in the model monocot rice. We further characterize the lettuce-T. hamatum interaction to show that bran extracts from GD12 and an N-acetyl-ß-D-glucosamindase-deficient mutant differentially promote growth in a concentration dependent manner, and these differences correlate with differences in the small molecule secretome. We show that GD12 mycoparasitises a range of isolates of the pre-emergence soil pathogen Sclerotinia sclerotiorum and that this interaction induces a further increase in plant growth promotion above that conferred by GD12. To understand the genetic potential encoded by T. hamatum GD12 and to facilitate its use as a model beneficial organism to study plant growth promotion, induced systemic resistance and mycoparasitism we present de novo genome sequence data. We compare GD12 with other published Trichoderma genomes and show that T. hamatum GD12 contains unique genomic regions with the potential to encode novel bioactive metabolites that may contribute to GD12's agrochemically important traits.

Saprotrophic competitiveness and biocontrol fitness of a genetically modified strain of the plant-growth-promoting fungus Trichoderma hamatum GD12.

Trichoderma species are ubiquitous soil fungi that hold enormous potential for the development of credible alternatives to agrochemicals and synthetic fertilizers in sustainable crop production. In this paper, we show that substantial improvements in plant productivity can be met by genetic modification of a plant-growth-promoting and biocontrol strain of Trichoderma hamatum, but that these improvements are obtained in the absence of disease pressure only. Using a quantitative monoclonal antibody-based ELISA, we show that an N-acetyl-ß-d-glucosaminidase-deficient mutant of T. hamatum, generated by insertional mutagenesis of the corresponding gene, has impaired saprotrophic competitiveness during antagonistic interactions with Rhizoctonia solani in soil. Furthermore, its fitness as a biocontrol agent of the pre-emergence damping-off pathogen Sclerotinia sclerotiorum is significantly reduced, and its ability to promote plant growth is constrained by the presence of both pathogens. This work shows that while gains in T. hamatum-mediated plant-growth-promotion can be met through genetic manipulation of a single beneficial trait, such a modification has negative impacts on other aspects of its biology and ecology that contribute to its success as a saprotrophic competitor and antagonist of soil-borne pathogens. The work has important implications for fungal morphogenesis, demonstrating a clear link between hyphal architecture and secretory potential. Furthermore, it highlights the need for a holistic approach to the development of genetically modified Trichoderma strains for use as crop stimulants and biocontrol agents in plant agriculture.

False-positive polyethylene glycol precipitation tests for macroprolactin due to increased serum globulins.

BACKGROUND: The polyethylene glycol (PEG) precipitation test is widely used to detect hyperprolactinaemia caused by macroprolactin. We report two cases of hyperprolactinaemia in which a low recovery of serum prolactin (PRL) after PEG precipitation indicated the presence of macroprolactin, but no macroprolactin was detected by gel filtration chromatography (GFC). Both cases had elevated concentrations of serum globulin (IgG myeloma and polyclonal hypergammaglobulinaemia due to human immunodeficiency virus [HIV] infection), which prompted us to investigate further the effect of serum globulin on the specificity of the PEG precipitation procedure. METHODS: The effect of increasing concentrations of gamma globulin on the precipitation of PRL by PEG was studied by adding purified human gamma globulin to serum. Ten samples from HIV-infected patients, which showed a low recovery of PRL after PEG precipitation (<60%) were studied with GFC. RESULTS: Addition of gamma globulin decreased the recovery of PRL following precipitation with PEG and gamma globulin concentrations correlated inversely with PRL concentrations (r = 0.9429, P < 0.0167) and percentage recovery of PRL (r = -1.000, P < 0.005). Only one out of 10 samples from HIV-infected patients with PRL recoveries of <60% following PEG precipitation showed a substantial macroprolactin component on GFC. CONCLUSIONS: Monomeric PRL is co-precipitated with serum globulins by PEG. Increased serum globulin concentrations can increase the amount of monomeric PRL precipitated by PEG giving a false estimate of the monomeric PRL and the erroneous impression that macroprolactin is present. The results of the PEG precipitation test should be interpreted with caution in patients with elevated serum globulin concentrations.

Direct stenting may limit myocardial injury during percutaneous coronary intervention.

BACKGROUND: Direct coronary stenting has been shown to be safe and feasible, with a demonstrable reduction in cost, procedural time and radiation exposure. Direct stenting may limit distal embolization of atherosclerotic plaque and consequently reduce myocardial cell injury following percutaneous coronary intervention, which may have important prognostic implications. METHODS AND RESULTS: We assessed cardiac troponin I (cTnI) release in the 24 hours following direct coronary stenting (DS) as compared to stenting with balloon predilatation (PD) in a total of 311 patients and 440 vessels/lesions (vessel to lesion ratio = 1:1) (DS: n = 107 patients and 149 vessels/lesions; PD: n = 204 patients and 291 vessels/lesions). The 2 groups were well matched except for a greater proportion of diabetic patients in the PD group (21%) compared to the DS group (11%) (p < 0.05). There were no significant differences in the distribution of target lesion site or angiographic complexity between the 2 groups. Primary angiographic success was achieved in 97% of vessels in the DS group and 98% of vessels in the PD group (p = NS). DS failed in 7/114 patients (6%) deemed suitable for DS by the operator, but all stents were subsequently successfully deployed following balloon predilatation. Abciximab (ReoPro , Eli Lilly Company, Indianapolis, Indiana) was used in 11 patients (10%) in the DS group and 24 patients (12%) in the PD group ( p = 0.68). The post-procedural median (IQR) peak cTnI concentrations were 0.2 0.1 g/L in the DS group and 0.5 0.3 g/L in the PD group (p = 0.02). Post-procedural cTnI concentrations were > 0.2 g/L in 11 patients (10%) in the DS group and in 53 patients (26%) in the PD group (X2 = 58.6; p < 0.0001). The rate of major adverse cardiac events at 6 18 month follow-up was 8% in the DS group and 15% in the PD group (X2 = 38.5; p = 0.02). CONCLUSION: Direct stenting without balloon predilatation is associated with lower post-procedural cTnI concentrations and lower incidence of major adverse events compared to traditional stenting with predilatation.

Cardiac troponin I for risk stratification following percutaneous coronary artery intervention in acute coronary syndromes.

The cardiac troponins have been shown to provide prognostic information allowing risk stratification of patients with acute coronary syndromes (ACS). The benefit of early percutaneous coronary intervention (PCI) in this setting has been highlighted by the FRISC II study. We assessed the pattern of release of cardiac troponin I (cTnI) following PCI in patients with ACS and evaluated its prognostic value for major adverse cardiac events (MACE): death, Q-wave myocardial infarction (QWMI), and repeat revascularization at follow-up. cTnI was sampled at baseline and 6, 14, and 24 hr following PCI in 73 patients presenting with unstable and post-MI angina. Clinical follow-up was obtained in all 73 patients at a mean period of 43 +/- 19.9 weeks (range, 11-68 weeks). Patients were stratified into two groups according to whether cTnI remained unchanged or fell below baseline 24 hr post-PCI (group 1, n = 47) or increased above baseline 24 hr following PCI (group 2, n = 26). MACE occurred in 4 (8.5%) of patients in group 1 (QWMI = 1, CABG = 1, re-PCI = 2) and in 19 (73%) of patients in group 2 (death = 1, QWMI = 2, CABG = 2, re-PCI = 14; chi-square = 32.34, P < 0.0001). The positive predictive value of rising cTnI within 24 hr following PCI for MACE at follow-up was 0.73 and the negative predictive value was 0.92 (specificity = 83%, sensitivity = 86%; odds ratio = 29.18, 95% CI = 7.62-110.64, P < 0.0001). cTnI is an inexpensive and widely applicable tool that offers reliable prognostic information for the risk stratification of patients undergoing coronary revascularization in the setting of acute coronary syndromes and may identify a group of patients at particular risk of repeat PCI.