Generalized myasthenia gravis with acetylcholine receptor antibodies: A guidance for treatment.

BACKGROUND: Generalized myasthenia gravis (MG) with antibodies against the acetylcholine receptor is a chronic disease causing muscle weakness. Access to novel treatments warrants authoritative treatment recommendations. The Nordic countries have similar, comprehensive health systems, mandatory health registers, and extensive MG research. METHODS: MG experts and patient representatives from the five Nordic countries formed a working group to prepare treatment guidance for MG based on a systematic literature search and consensus meetings. RESULTS: Pyridostigmine represents the first-line symptomatic treatment, while ambenonium and beta adrenergic agonists are second-line options. Early thymectomy should be undertaken if a thymoma, and in non-thymoma patients up to the age of 50-65 years if not obtaining remission on symptomatic treatment. Most patients need immunosuppressive drug treatment. Combining corticosteroids at the lowest possible dose with azathioprine is recommended, rituximab being an alternative first-line option. Mycophenolate, methotrexate, and tacrolimus represent second-line immunosuppression. Plasma exchange and intravenous immunoglobulin are used for myasthenic crises and acute exacerbations. Novel complement inhibitors and FcRn blockers are effective and fast-acting treatments with promising safety profiles. Their use depends on local availability, refunding policies, and cost-benefit analyses. Adapted physical training is recommended. Planning of pregnancies with optimal treatment, information, and awareness of neonatal MG is necessary. Social support and adaptation of work and daily life activities are recommended. CONCLUSIONS: Successful treatment of MG rests on timely combination of different interventions. Due to spontaneous disease fluctuations, comorbidities, and changes in life conditions, regular long-term specialized follow-up is needed. Most patients do reasonably well but there is room for further improvement. Novel treatments are promising, though subject to restricted access due to costs.

Fatigue and associated factors in 172 patients with McArdle disease: An international web-based survey.

McArdle disease is an autosomal recessive inherited disease caused by pathogenic variants in the PYGM gene, resulting in virtual absence of the myophosphorylase enzyme in skeletal muscle. Patients experience physical activity intolerance, muscle pain, and muscle fatigue. This study aimed to investigate other fatigue domains with the Multidimensional Fatigue Inventory (MFI-20) along with an investigation of potential contributing factors, including relevant disease and lifestyle-related factors. We conducted a survey in an international cohort of patients with McArdle disease. The survey included questions on demographics and McArdle disease-related symptoms, and the questionnaires: MFI-20, Insomnia Severity Index (ISI), and International Physical Activity Questionnaire Short-Form (IPAQ-SF). One hundred seventy-four responses were included in the data analyses. We found relatively high fatigue scores in all five domains (general fatigue (12.9 ± 2.2), mental fatigue (10.1 ± 4.1), physical fatigue (13.7 ± 4.1), reduced activity (12.1 ± 4.1), and reduced motivation (10.4 ± 3.4)). Fatigue associated with McArdle symptom severity (p < 0.005), lower levels of physical activity (assessed by IPAQ-SF) (p < 0.05), and poor sleep (assessed by ISI) (p < 0.05). These findings call for clinical focus and future research into fatigue, sleep and mental health in patients with McArdle disease.

Growth characteristics and morphology of Paramoeba perurans from Atlantic salmon Salmo salar L. and ballan wrasse Labrus bergylta in Norway.

BACKGROUND: Paramoeba perurans is the causative agent of amoebic gill disease (AGD) in Atlantic salmon Salmo salar L. and many other farmed marine fish species worldwide. The first cases of AGD in Norway were reported in 2006, and it has subsequently become established as a significant gill disease that affects the country's salmonid aquaculture industry. Despite several decades of research on AGD, there is still a lack of knowledge of the biology of P. perurans and its interactions with its hosts and the environment. METHODS: The growth and morphology of 10 clonal isolates of P. perurans were studied. The isolates were from farmed Atlantic salmon and ballan wrasse that had been obtained from different sites along the Norwegian coast between 2013 and 2015. The morphology and population growth patterns of these clonal amoeba isolates were examined in vitro using light microscopy and real-time reverse transcription polymerase chain reaction under a range of temperatures (4, 12, 15 and 21 °C) and salinities (20, 25, 30 and 34 ‰). RESULTS: We found distinct morphological differences between both locomotive and floating forms of the amoeba isolates. The locomotive amoebae of the clonal isolates varied in size (area) from 453 µm2 to 802 µm2. There were differences in the growth patterns of the clonal amoeba isolates under similar conditions, and in their responses to variations in temperature and salinity. While most of the isolates grew well at salinities of 25-34 ‰, a significant reduction in growth was seen at 20 ‰. Most of the amoeba isolates grew well at 12 °C and 15 °C. At 4 °C, amoebae grew slower and, in contrast to the other temperatures, no extended pseudopodia could be seen in their floating form. The isolates seemed to reach a plateau phase faster at 21 °C, with a higher number of smaller, rounded amoebae. CONCLUSIONS: The differences observed here between clonal isolates of P. perurans should be further examined in experimental in vivo challenge studies, as they may be of relevance to the virulence and proliferation potential of this amoeba on gills. Potential differences in virulence within P. perurans could have implications for management strategies for AGD.

Patient-Reported Experiences with a Low-Carbohydrate Ketogenic Diet: An International Survey in Patients with McArdle Disease.

The low-carbohydrate ketogenic diet (LCKD) has attracted increased attention in recent years as a potential treatment option for individuals with McArdle disease (glycogen storage disease type V), and despite the absence of strong scientific evidence of the LCKD's benefits, increased numbers of individuals with McArdle disease have tried a LCKD. The objective of this study was to collect patient-reported experiences with a LCKD. We aimed to estimate the immediate prevalence of individuals that had tried a LCKD in an international McArdle disease cohort, and we aimed to report on the patient-reported experiences with the diet, both positive and negative. A total of 183 responses were collected from individuals with McArdle disease from 18 countries. We found that one-third of the cohort had tried a LCKD, and almost 90% experienced some degree of positive effect, with the most prominent effects on McArdle disease-related core symptoms (e.g., activity intolerance, muscle pain, and muscle fatigue). Adverse effects were rare and generally rated as mild to moderate. These patient-reported findings underline the need for randomized clinical trials to decisively determine if a LCKD is a suitable nutritional strategy for patients with McArdle disease. The results from this study can prompt and contribute to the design of such a clinical trial.

Registered nurse mentors' experiences from co-creation in higher education targeting enhancement of mentorship practices in nursing homes: A qualitative study.

AIM: To explore registered nurse (RN) mentors' experiences of participating in the co-creation of a digital educational resource intended to enhance mentorship practices of first-year nursing students in clinical placement in nursing homes. DESIGN: An interpretive, descriptive qualitative study design. METHODS: Data were collected through two focus group interviews with 15 RN mentors (n = 15) participating in co-creative workshops. The co-creative process entailed four co-creative workshops conducted over a 17-month period (June 2019 to end of Oct 2020). Focus group interviews were conducted following the second and third workshops (i.e., in Dec 2019 and in Oct 2020) and data were analysed using thematic analysis. The consolidated criteria for reporting qualitative research (COREQ) checklist was used to report the findings. RESULTS: The analysis identified three themes: (1) co-creative reflective dialogues contributed to knowledge development and increased motivation among mentors; (2) the co-creative approach facilitated and validated the nursing academic-practice tripartite partnership; and (3) effectiveness of workshop structure in facilitating collaboration and mitigating power inequities. CONCLUSION: A co-creative process provides notable opportunities to advocate for mentorship needs and to enhance mentorship practices in nursing homes. IMPACT: Our study adds to the evidence on co-creation in nursing education, providing insights on the co-creative process and methodology. Higher Education Institutions are uniquely positioned to act as a co-creative arena for the academic-practice collaboration and for the development of educational resources within nursing education. Co-creation may facilitate stronger academic-practice partnership that may more effectively impact mentorship practices in nursing homes and health care system effectiveness. PUBLIC CONTRIBUTIONS: The RNs included in the study were involved in the co-creative process as active contributors informing the digital educational resource content and design.

Efficacy and safety profile of a subtilisin protease produced by fermentation in Bacillus licheniformis to be used as a feed additive.

The efficacy and safety of a novel Subtilisin protease from a Bacillus sp. produced in Bacillus licheniformis was investigated in broiler chickens, and a range of toxicological tests, respectively. The B. licheniformis production strain culture supernatant was not found cytotoxic in a Vero cell assay. Subtilisin was non-mutagenic and non-clastogenic in in-vitro tests, and did not exhibit irritating potential to the eye or skin in ex-vivo/in-vitro models. Oral administration of Subtilisin to rats did not cause any adverse effects in a 13-week sub-chronic toxicity study. In addition, a 35-day dose response broiler performance trial conducted with Subtilisin (30,000 and 60,000 NFP/kg diet), showed a significant linear improvement in both body weight gain and feed conversion ratio up to 35 days of protease supplementation. In conclusion, there are no safety concerns using this novel Subtilisin as a feed additive, and the protease is efficient in improving broiler growth performance, making it a good candidate for use as a feed additive.

Habitual Physical Activity in Patients with Myasthenia Gravis Assessed by Accelerometry and Questionnaire.

BACKGROUND: Physical activity (PA) in patients with myasthenia gravis (MG) is considered safe and beneficial, and an active lifestyle is required to obtain the health benefits of exercise. However, as the disease leads to physical impairments an insight into the overall PA habits in this patient population is relevant but lacking. OBJECTIVE: To measure habitual physical activity in a Danish cohort of patients with MG measured by accelerometer and questionnaire, and to determine relevant predictors for PA intensities. METHODS: Habitual physical activity was assessed by; 1) the accelerometer ActiGraph in a cohort of patients recruited from our neuromuscular clinic, 2) the International Physical Activity Questionnaire (IPAQ) in a web-based survey. PA levels were compared to international recommendations. Predictors for PA (age, sex, body mass index, disease severity and duration) were included in the regression analyses. RESULTS: Habitual physical activity was measured by accelerometer for 7 days in 69 patients and by questionnaire in 691 patients. Measured by the accelerometer, 46%of the patients did not meet the international recommendations for PA at moderate/vigorous intensity and 57%were below the recommendations for steps per day. Measured by the IPAQ, 48%did not meet the recommendations. Disease severity and age were predictors for PA intensities. CONCLUSIONS: This study found that around half of the included patients did not meet the recommendations for PA. This is a concern, as it increases the risk of life-style related diseases. Disease severity and age may be taking into consideration when counseling the patients about PA.

Causes of symptom dissatisfaction in patients with generalized myasthenia gravis.

BACKGROUND: Patient-centered assessments have attracted increasing attention in the last decade in clinics and research. The purpose of this study was to examine the association between patients' satisfaction with symptoms and several disease-specific and generic outcome measures in 100 patients with generalized myasthenia gravis (gMG). METHODS: In this cross-sectional study, patients with gMG followed at the Copenhagen Neuromuscular Center from October 2019 to June 2020 participated in one test. The patients completed commonly used MG-specific outcome measures and generic questionnaires for depression (Major Depression Inventory), comorbidities (Charlson Comorbidity Index), fatigue (Multidimensional Fatigue Inventory), overall health state (EQ-5D-3L), and satisfaction with MG treatment. The analyses were anchored in the Patient Acceptable Symptom State (PASS). RESULTS: N = 190 patients were screened for the study, and 100 patients were included. One-third of the patients reported dissatisfaction (negative PASS status) with the current symptom state. Increasing MG symptoms, fatigue, depression, low MG-related quality of life, and shorter disease duration were associated with negative PASS status. Age, sex, BMI, MG treatment, and comorbidity did not influence PASS status. CONCLUSIONS: This study shows that dissatisfaction with the current symptom level is high in patients with gMG and that dissatisfaction is associated with disease severity, disease length, depression, fatigue, and lower MG-related quality of life. The results emphasize the importance of a patient-centered approach to MG treatment to optimize patient satisfaction. The PASS question was useful in this study to investigate the causes of symptom dissatisfaction in gMG.

Extraction of a vascular function for a fully automated dynamic contrast-enhanced magnetic resonance brain image processing pipeline.

PURPOSE: To develop a deep-learning model that leverages the spatial and temporal information from dynamic contrast-enhanced magnetic resonance (DCE MR) brain imaging in order to automatically estimate a vascular function (VF) for quantitative pharmacokinetic (PK) modeling. METHODS: Patients with glioblastoma multiforme were scanned post-resection approximately every 2 months using a high spatial and temporal resolution DCE MR imaging sequence ( ≈5 s and ≈2 cm3 ). A region over the transverse sinus was manually drawn in the dynamic T1-weighted images to provide a ground truth VF. The manual regions and their resulting VF curves were used to train a deep-learning model based on a 3D U-net architecture. The model concurrently utilized the spatial and temporal information in DCE MR images to predict the VF. In order to analyze the contribution of the spatial and temporal terms, different weighted combinations were examined. The manual and deep-learning predicted regions and VF curves were compared. RESULTS: Forty-three patients were enrolled in this study and 155 DCE MR scans were processed. The 3D U-net was trained using a loss function that combined the spatial and temporal information with different weightings. The best VF curves were obtained when both spatial and temporal information were considered. The predicted VF curve was similar to the manual ground truth VF curves. CONCLUSION: The use of spatial and temporal information improved VF curve prediction relative to when only the spatial information is used. The method generalized well for unseen data and can be used to automatically estimate a VF curve suitable for quantitative PK modeling. This method allows for a more efficient clinical pipeline and may improve automation of permeability mapping.

Dying for change: A roadmap to refine the fish acute toxicity test after 40 years of applying a lethal endpoint.

The fish acute toxicity test (TG203; OECD, 2019) is frequently used and highly embedded in hazard and risk assessment globally. The test estimates the concentration of a chemical that kills 50% of the fish (LC50) over a 96 h exposure and is considered one of the most severe scientific procedures undertaken. Over the years, discussions at the Organisation for Economic Co-operation and Development (OECD) have resulted in changes to the test which reduce the number of fish used, as well as the development of a (potential) replacement test (TG236, OECD, 2013). However, refinement of the mortality endpoint with an earlier (moribundity) endpoint was not considered feasible during the Test Guideline's (TG) last update in 2019. Several stakeholders met at a UK-based workshop to discuss how TG203 can be refined, and identified two key opportunities to reduce fish suffering: (1) application of clinical signs that predict mortality and (2) shortening the test duration. However, several aspects need to be addressed before these refinements can be adopted. TG203 has required recording of major categories of sublethal clinical signs since its conception, with the option to record more detailed signs introduced in the 2019 update. However, in the absence of guidance, differences in identification, recording and reporting of clinical signs between technicians and laboratories is likely to have generated piecemeal data of varying quality. Harmonisation of reporting templates, and training in clinical sign recognition and recording are needed to standardise clinical sign data. This is critical to enable robust data-driven detection of clinical signs that predict mortality. Discussions suggested that the 96 h duration of TG203 cannot stand up to scientific scrutiny. Feedback and data from UK contract research organisations (CROs) conducting the test were that a substantial proportion of mortalities occur in the first 24 h. Refinement of TG203 by shortening the test duration would reduce suffering (and test failure rate) but requires a mechanism to correct new results to previous 96 h LC50 data. The actions needed to implement both refinement opportunities are summarised here within a roadmap. A shift in regulatory assessment, where the 96 h LC50 is a familiar base for decisions, will also be critical.

Fatigue, physical activity and associated factors in 779 patients with myasthenia gravis.

The objective of the study was to examine the association between fatigue (measured by the Multidimensional Fatigue Inventory; MFI-20) and physical activity (measured by the Saltin-Grimby Physical Activity Level Scale; SGPALS) in a large cohort of patients (≥18 years) with myasthenia gravis (MG) including relevant disease - and lifestyle-related factors. A total of 1463 persons, registered at the Danish National Registry of Patients with a MG diagnosis, according to the International Classification of Diseases, received a web-based survey. A total of 779 patients (53% women, mean [SD] age 60.8 [15.5]) responded. The remaining persons were either non-responders (n = 390) or could not confirm the MG diagnosis (n = 294). The most prominent MFI-20 fatigue domains were general fatigue (median [inter-quartile ranges, IQR], 13 [10-16]) and physical fatigue (median [IQR], 13 [9-15]), and 386 (53%) patients reported low levels of physical activity. All fatigue domains were associated with physical activity (p<.01). Higher level of physical activity was associated with lower levels of fatigue. Important factors for the association were myasthenia gravis disease severity (measured by the Myasthenia Gravis Activities of Daily Living profile), body mass index, insomnia (measured by the Insomnia Severity Index) job-status, comorbidity, and cohabitation.

Safety and efficacy profile of a phytase produced by fermentation and used as a feed additive.

Enzymes can aid in optimal feed stock utilization when used as feed additives. A range of toxicological studies were performed to evaluate the safety profile of a novel phytase (phytase HM) from Citrobacter b raakii produced in Aspergillus oryzae. Phytase HM was found to be non-mutagenic and non-clastogenic in in vitro tests. Further, the phytase HM preparation did not exhibit irritative potential to the eye and skin when applied in in vitro models. A 13-week subchronic toxicity study with oral administration of phytase HM to rats did not show any adverse effects. Efficacy studies showed that the dietary supplementation of this phytase significantly improved growth performance and bone mineralization in broiler chickens and piglets fed P-deficient diets, and increased retention of phosphorus (P) and calcium (Ca), and phytate-P degradation in excreta of broiler chickens in a dose-dependent manner. In conclusion, there are no safety concerns using phytase HM as a feed additive and the phytase is well tolerated by broiler chickens and pigs. Further, phytase HM improves with high efficacy the growth performance in both broiler chickens and pigs.

Experimental challenge of Atlantic salmon Salmo salar using clones of Paramoeba perurans, P. pemaquidensis and Tetramitus sp.

Salmon gill disease in Norway is in most cases associated with a range of different pathogens, stress and environmental factors. Paramoeba perurans and other amoebae have been isolated during such disease outbreaks. Other amoebae isolated from salmon with gill disease in Norway include P. pemaquidensis, Tetramitus sp. and Vannella sp. Here we tested the pathogenicity of the first 2 species in challenge experiments. We found that even when clonal cultures of P. pemaquidensis established an infection on the gills of salmon, it failed to cause gill disease, while Tetramitus sp. appeared to be unable to establish a lasting infection on the gills of healthy salmon. The result of the challenge with P. pemaquidensis confirms the results of similar studies performed in the USA and in Australia. Tetramitus sp. is probably a common amoeba in the marine environment, and its presence on the gills of farmed salmon may just be accidental. Based on this study, we conclude that P. perurans is the only known amoeba in marine salmon farming associated with amoebic gill disease in Norway.

Method for cryopreservation of Paramoeba perurans.

Paramoeba perurans causes amoebic gill disease (AGD), which is a major problem in aquaculture worldwide. The parasite can be cultured in vitro, but to this date, no method for long-term storage of the clones exists. In this study, we describe a method for cryopreservation of Paramoeba perurans. The method was successfully employed on four out the five clones we tested. The thawing success rate, that is the percentage of successfully thawed vials relative to the total number of vials that were thawed, differed for the clones and ranged from 25% to 100%. The age of the clones seemed to have a negative impact on the ability to survive cryopreservation.

Calgary Normative Study: design of a prospective longitudinal study to characterise potential quantitative MR biomarkers of neurodegeneration over the adult lifespan.

INTRODUCTION: A number of MRI methods have been proposed to be useful, quantitative biomarkers of neurodegeneration in ageing. The Calgary Normative Study (CNS) is an ongoing single-centre, prospective, longitudinal study that seeks to develop, test and assess quantitative magnetic resonance (MR) methods as potential biomarkers of neurodegeneration. The CNS has three objectives: first and foremost, to evaluate and characterise the dependence of the selected quantitative neuroimaging biomarkers on age over the adult lifespan; second, to evaluate the precision, variability and repeatability of quantitative neuroimaging biomarkers as part of biomarker validation providing proof-of-concept and proof-of-principle; and third, provide a shared repository of normative data for comparison to various disease cohorts. METHODS AND ANALYSIS: Quantitative MR mapping of the brain including longitudinal relaxation time (T1), transverse relaxation time (T2), T2*, magnetic susceptibility (QSM), diffusion and perfusion measurements, as well as morphological assessments are performed. The Montreal Cognitive Assessment (MoCA) and a brief, self-report medical history will be collected. Mixed regression models will be used to characterise changes in quantitative MR biomarker measures over the adult lifespan. In this report, we describe the study design, strategies to recruit and perform changes to the acquisition protocol from inception to 31 December 2018, planned statistical approach and data sharing procedures for the study. ETHICS AND DISSEMINATION: Participants provide signed informed consent. Changes in quantitative MR biomarkers measured over the adult lifespan as well as estimates of measurement variance and repeatability will be disseminated through peer-reviewed scientific publication.

Contractile properties are impaired in congenital myopathies.

The ratio between muscle strength and muscle cross-sectional area is called the specific force. Fatty replacement of muscles is seen in many myopathies, affecting the specific force, without necessarily affecting the ability of the remaining muscle fibers to contract. This ability is called the contractility and is the ratio between muscle strength and the lean muscle cross-sectional area, i.e. the contractile cross-sectional area. We hypothesized that contractility is disrupted in patients with congenital myopathy, because of defects in contractile proteins of the sarcomere. Peak torque across ankle and knee joints was measured by isokinetic dynamometry in 16 patients with congenital myopathy and 13 healthy controls. Five patients only participated partially in the dynamometer measurements due to severe muscle weakness. Dixon MRI technique was used to quantify muscle fat fractions and calculate cross-sectional area. Patients with congenital myopathy had lower cross-sectional area in all muscle groups (P<0.01), higher fat fraction (P<0.01) and less strength (P<0.005) in all studied muscle groups. Their fat content was more than doubled and peak torque lower than half that in healthy controls. Muscle contractility was reduced (P<0.01) in three of four patient muscle groups. In conclusion, muscle contractility was reduced in patients with congenital myopathy, across different diagnoses, and was independent of the level of muscle fat fraction, suggesting that intrinsic defects of the myocyte are responsible for reduced contractility.

A novel glucuronoxylan hydrolase produced by fermentation is safe as feed additive: toxicology and tolerance in broiler chickens.

The current study presents a safety evaluation of a novel glucuronoxylan hydrolase (EC 3.2.1.136) from Bacillus subtilis produced in Bacillus licheniformis. The glucuronoxylan hydrolase preparation did not exhibit irritative potential to the eye and skin when applied in in vitro models. The glucuronoxylan hydrolase preparation was non-mutagenic and non-clastogenic in in vitro tests. Oral administration of the glucuronoxylan hydrolase preparation to rats did not cause any adverse effect in a 90-days subchronic toxicity study. A tolerance study was performed with broiler chickens and confirmed that this glucuronoxylan hydrolase is safe for broiler chickens when fed at the maximum recommended dose, as well as at the 10 times higher dose. In conclusion, there are no safety concerns with using this novel glucuronoxylan hydrolase as a feed additive as it is toxicologically inert and the glucuronoxylan hydrolase is well tolerated by broiler chickens. The beneficial safety evaluation of glucuronoxylan hydrolase is consistent with the fact that this type of enzyme is ubiquitous in nature.

Does grip strength reflect isokinetic muscle strength in lower limbs in patients with chronic inflammatory demyelinating polyneuropathy?

INTRODUCTION: Grip strength (GS) is a common measure of general muscle strength in patients with chronic inflammatory demyelinating polyneuropathy (CIDP). However, it is important to investigate the correlation and responsiveness of GS compared with isokinetic muscle strength (IKS) and function of the lower limbs. METHODS: Seventy patients with CIDP were evaluated with GS, IKS, and functional measures of the lower limbs. Reevaluation was performed after 2 and 10/12 weeks. Correlation and response analyses were performed. RESULTS: GS correlated with IKS at the ankle (IKSankle ; maximum Spearman's rank-order correlation [RS ] = 0.58) and with walking performance (maximum RS = -0.38). IKSankle was more responsive to detect change (standardized response mean [SRM] = 0.57) than GS (SRM = 0.27). DISCUSSION: GS does not seem to be an appropriate surrogate measure of IKS and function of the lower limbs in patients with CIDP. Muscle Nerve 58: 449-452, 2018.

Progressive fat replacement of muscle contributes to the disease mechanism of patients with single, large-scale deletions of mitochondrial DNA.

Muscle dysfunction in mitochondrial myopathy is predominantly caused by insufficient generation of energy. We hypothesise that structural changes in muscles could also contribute to their pathophysiology. The aims of this study were to determine fat fractions and strength in selected muscles in patients with chronic progressive external ophthalmoplegia (CPEO), and compare progression of muscle fat fraction with age in individuals with CPEO vs. healthy controls and patients with the m.3243A>G mutation of mitochondrial DNA (mtDNA). Seventeen patients with CPEO and single large-scale deletions of mtDNA, 52 healthy controls, and 12 patients carrying the m.3243A>G mtDNA mutation were included. Muscle fat fractions were measured from cross-sections of paraspinal and leg muscles. Peak muscle strength was assessed from a static dynamometer. There was a direct correlation between age and fat fraction in all muscle groups in CPEO patients and healthy controls (p < 0.05). Analysis of covariance showed a higher progression rate of fat replacement in CPEO patients vs. healthy controls in studied muscle groups (p < 0.05). Patients with the m.3243A>G mutation had slower progression rates of fat replacement. Muscle strength decreased with increasing muscular fat fraction in CPEO patients, no correlation was seen in other groups. This indicates that structural muscle changes contribute to the phenotype of older patients affected by CPEO and large-scale deletions. It should therefore be considered, along with known energy deficiencies, as the cause of exercise intolerance.

Genotyping of Candidatus Syngnamydia salmonis (chlamydiales; Simkaniaceae) co-cultured in Paramoeba perurans (amoebozoa; Paramoebidae).

Candidatus Syngnamydia salmonis (Chlamydiales, Simkaniaceae) was described as an epitheliocystis-causing bacterium from the gills of Atlantic salmon (Salmo salar) in Norway. A bacterium showing 99.2% 16S rRNA identity to Cand. S. salmonis is able to multiply in Paramoeba perurans and based on the classification criteria this bacterium could represent the same species as Cand. S. salmonis. Sequencing the genome of the cultured bacterium has made it possible to fulfill the minimal standards for genetic characterization of species within the order Chlamydiales. The complete rRNA genes, the amino acid sequences of SucA, PepF, Adk, HemL, DnaA, FtsK and FabI, are presented in addition to the morphology of the Chlamydia-like morphs in the cytoplasm of P. perurans.