Applying a modified metabarcoding approach for the sequencing of macrofungal specimens from fungarium collections.

Premise: Fungaria are an underutilized resource for understanding fungal biodiversity. The effort and cost of producing DNA barcode sequence data for large numbers of fungal specimens can be prohibitive. This study applies a modified metabarcoding approach that provides a labor-efficient and cost-effective solution for sequencing the fungal DNA barcodes of hundreds of specimens at once. Methods: We applied a two-step PCR approach using nested, barcoded primers to sequence the fungal nrITS2 region of 766 macrofungal specimens using the Illumina platform. The specimens represent a broad taxonomic sampling of the Dikarya. Of these, 382 Lactarius specimens were analyzed to identify molecular operational taxonomic units (MOTUs) using a phylogenetic approach. The raw sequences were trimmed, filtered, assessed, and analyzed using the DADA2 amplicon de-noising toolkit and Biopython. The sequences were compared to the NCBI and UNITE databases and Sanger nrITS sequences from the same specimens. Results: The taxonomic identities derived from the nrITS2 sequence data were >90% accurate across all specimens sampled. A phylogenetic analysis of the Lactarius sequences identified 20 MOTUs. Discussion: The results demonstrate the capacity of these methods to produce nrITS2 sequences from large numbers of fungarium specimens. This provides an opportunity to more effectively use fungarium collections to advance fungal diversity identification and documentation.

Efficacy Outcome Measures for Clinical Trials of USH2A Caused by the Common c.2299delG Mutation.

PURPOSE: To determine the change in vision and retinal structure in patients with the common c.2299delG mutation in the USH2A gene in anticipation of clinical trials of therapy. DESIGN: Retrospective observational case series. METHODS: Eighteen patients, homozygotes or compound heterozygotes with the c.2299delG mutation in USH2A, were studied with regard to visual acuity, kinetic perimetry, dark- and light-adapted static perimetry, optical coherence tomography (OCT), and autofluorescence (AF) imaging. Serial data were available for at least half of the patients, depending on the parameter analyzed. RESULTS: The kinetics of disease progression in this specific molecular form of USH2A differed between the measured parameters. Visual acuity could remain normal for decades. Kinetic and light-adapted static perimetry across the entire visual field had similar rates of decline that were slower than those of rod-based perimetry. Horizontal OCT scans through the macula showed that inner segment/outer segment line width had a similar rate of constriction as co-localized AF imaging and cone-based light-adapted sensitivity extent. The rate of constriction of rod-based sensitivity extent across this same region was twice as rapid as that of cones. CONCLUSIONS: In patients with the c.2299delG mutation in USH2A, rod photoreceptors are the cells that express disease early and more aggressively than cones. Rod-based vision measurements in central or extracentral-peripheral retinal regions warrant monitoring in order to complete a clinical trial in a timely manner.

TRENDS IN GROWTH HORMONE STIMULATION TESTING AND GROWTH HORMONE DOSING IN ADULT GROWTH HORMONE DEFICIENCY PATIENTS: RESULTS FROM THE ANSWER PROGRAM.

OBJECTIVE: Adult growth hormone deficiency (AGHD) results in physiologic impairments that may reduce quality of life and negatively impact body composition. AGHD can be treated with recombinant human growth hormone (GH). This study analyzes AGHD patients enrolled in the American Norditropin(®) STUDIES: Web-Enabled-Research (ANSWER) Program/NovoNet, a U.S. observational noninterventional study of patients treated with Norditropin(®) (somatropin [recombinant DNA origin] injection) at the discretion of their physicians. METHODS: Data were evaluated for GH stimulation test (GHST) usage and Norditropin(®) doses over 4 years. RESULTS: Adults (N = 468) with isolated GHD (IGHD) or multiple pituitary hormone deficiency (MPHD) were evaluated. The most commonly used GHSTs were arginine + L-dopa (27%; mostly a single center) and glucagon (25%; most frequent test after 2009). The percent of patients meeting recommended test-specific cut points varied from 32 to 100%, depending on the GHST used. Mean baseline GH doses were higher for MPHD patients and for younger patients in both IGHD and MPHD groups. CONCLUSION: MPHD was more common than IGHD. Mean GH doses were higher in younger patients, consistent with a transition from higher pediatric to lower adult dosing. Over time, glucagon became the most popular GHST. The use, in some patients, of other GHSTs with cut points, as well as starting doses not consistent with current recommendations, highlights the need for continued education regarding treatment guidelines for AGHD.

Hypothalamic-pituitary-adrenal axis suppression related to topical glucocorticoid therapy in a child with psoriatic exfoliative erythroderma.

Exfoliative erythroderma is a rare presentation of psoriasis in children and adults. We report a 9-year-old girl with exfoliative erythroderma secondary to plaque-type psoriasis who developed hypothalamic-pituitary-adrenal axis suppression resulting from topical treatment with a medium-potency glucocorticoid. This case emphasizes the need for awareness of this potentially life-threatening complication of topical glucocorticoid use, particularly in patients who have significant compromise of barrier function secondary to widespread skin disease.

Transition care of patients with growth hormone deficiency from pediatric endocrinologists to adult endocrinologists.

OBJECTIVE: To review whether growth hormone (GH) therapy should be continued into young adulthood, beyond achievement of final height, when GH deficiency persists, to summarize the recent evidence of the benefits of GH treatment during the transition period, and to address currently debated issues involving diagnosis, treatment, and transition of care. METHODS: Primary literature was reviewed in the following areas: the benefits and risks of GH therapy during the transition period, the diagnostic criteria for GH deficiency and recommended testing procedures during transition, the optimal dose of GH therapy during transition, and the factors to consider in the transition of care from the pediatric to the adult endocrinologist. RESULTS: Studies support the continuation of GH therapy through the transition period until accrual of peak bone mass, rather than cessation of GH treatment when adult height has been achieved. Continued GH treatment in patients with persistent GH deficiency after achieving final height has been associated with significant additional bone maturation and improved overall metabolic profile. The selection of the most appropriate methods and cutoff values for retesting GH deficiency during the transition period remains a challenge. Reassessment of the optimal GH dose is a key component of transition care. CONCLUSION: For patients with GH deficiency that will likely persist into adulthood, it is important to begin discussing possible continuation of GH treatment early in the management of GH deficiency. Clear communication between pediatric and adult endocrinologists will be needed to determine the timing of the patient-care transition and to minimize the interruption of GH therapy during the transition period.

Drug delivery systems improve pharmaceutical profile and facilitate medication adherence.

Innovations in dosage forms and dose delivery systems across a wide range of medications offer substantial clinical advantages, including reduced dosing frequency and improved patient adherence; minimized fluctuation of drug concentrations and maintenance of blood levels within a desired range; localized drug delivery; and the potential for reduced adverse effects and increased safety. The advent of new large-molecule drugs for previously untreatable or only partially treatable diseases is stimulating the development of suitable delivery systems for these agents. Although advanced formulations may be more expensive than conventional dosage forms, they often have a more favorable pharmacologic profile and can be cost-effective. Inclusion of these dosage forms on drug formulary lists may help patients remain on therapy and reduce the economic and social burden of care.

Diagnostic growth hormone deficiency testing practices among patients in the NCGS/NCSS databases.

This report describes the etiology and diagnostic testing of growth hormone deficiency (GHD) among pediatric patients enrolled in the National Cooperative Growth Study (NCGS) database and adult patients enrolled in the National Cooperative Somatropin Surveillance (NCSS) database. The etiologies of GHD within the two databases are defined and compared; the various GH-stimulation tests utilized by participating investigators are identified; and the contribution of insulin-like growth factor (IGF)-I measurement to diagnostic testing is assessed. Throughout the report, the diagnosis and classification of patients with organic GHD is highlighted.

Racial and ethnic differences in response to medicines: towards individualized pharmaceutical treatment.

It is now well documented that substantial disparities exist in the quality and quantity of medical care received by minority Americans, especially those of African, Asian and Hispanic heritage. In addition, the special needs and responses to pharmaceutical treatment of these groups have been undervalued or ignored. This article reviews the genetic factors that underlie varying responses to medicines observed among different ethnic and racial groups. Pharmacogenetic research in the past few decades has uncovered significant differences among racial and ethnic groups in the metabolism, clinical effectiveness, and side-effect profiles of many clinically important drugs. These differences must be taken into account in the design of cost management policies such as formulary implementation, therapeutic substitution and step-care protocols. These programs should be broad and flexible enough to enable rational choices and individualized treatment for all patients, regardless of race or ethnic origin.

Autotomy following limb denervation: effects of sparing selected afferents.

Lesions of the brachial plexus are often followed by inflammation, self-inflicted scratching and autotomy of the denervated extremity. If innervation of the shoulder girdle muscles was spared, this denervation syndrome was decreased in incidence and intensity as compared to a full brachial plexus section. Spared innervation increased the latency between the appearance of inflammation and autotomy, revealing a strong linkage between the site of inflammation and the site of autotomy attack. Plexus lesions, which spared one of the nerves of the distal limb, also decreased the incidence and intensity of autotomy and shifted self-attack from autotomy to scratching wounds. Subsequent section of this nerve produced a two-stage brachial plexus denervation, and the cumulated autotomy was markedly less than that produced by a single-stage brachial plexus denervation. Scratching wounds and autotomy exhibited similar latencies. Scratching was directed towards areas of partial innervation and autotomy towards areas of total denervation. The results are discussed in terms of the possible contributions of dysesthesia inflammation and ischemia in scratching behavior and autotomy.

Hypoalgesia following microinjection of noradrenergic antagonists in the nucleus raphe magnus.

The influence of the noradrenergic input to the nucleus raphe magnus (NRM) on the capacity of this nucleus to modulate nociceptive threshold was investigated in rat by microinjection of noradrenergic (NA) antagonists in the NRM. The distribution of NA terminals associated with the NRM was visualized histochemically using a glyoxylic acid-induced fluorescence technique. Microinjection of 5.0 and 10.0 micrograms phentolamine at sites within the NRM, which was found to be densely innervated by NA terminals, produced a dose-related hypoalgesia as assessed by both the tail flick and hot plate tests. Microinjection of these doses at sites close to yet outside the NRM, in areas less densely innervated with NA terminals, was either ineffective or produced hypoalgesia only after a substantial delay. Similar results were obtained following microinjection of 10.5 micrograms azapetine, another NA antagonist. The correspondence between the distribution of NA terminals associated with the NRM and the distribution of active sites for hypoalgesia in this area suggests that hypoalgesia was caused by blockade of the NA input to the NRM. These results indicate that those cells of the NRM involved in the modulation of nociceptive threshold are themselves subject to a tonic, inhibitory NA input, the suppression of which produces hypoalgesia.