Developing a Natural History Model for Duchenne Muscular Dystrophy.

BACKGROUND: The aim of this study was to pool multiple data sets to build a patient-centric, data-informed, natural history model (NHM) for Duchenne muscular dystrophy (DMD) to estimate disease trajectory across patient lifetime under current standard of care in future economic evaluations. The study was conducted as part of Project HERCULES, a multi-stakeholder collaboration to develop tools to support health technology assessments of new treatments for DMD. METHODS: Health states were informed by a review of NHMs for DMD and input from clinicians, patients and caregivers, and defined using common outcomes in clinical trials and real-world practice. The primary source informing the NHM was the Critical Path Institute Duchenne Regulatory Science Consortium (D-RSC) database. This was supplemented with expert input obtained via an elicitation exercise, and a systematic literature review and meta-analysis of mortality data. RESULTS: The NHM includes ambulatory, transfer and non-ambulatory phases, which capture loss of ambulation, ability to weight bear and upper body and respiratory function, respectively. The NHM estimates patients spend approximately 9.5 years in ambulatory states, 1.5 years in the transfer state and the remainder of their lives in non-ambulatory states. Median predicted survival is 34.8 years (95% CI 34.1-35.8). CONCLUSION: The model includes a detailed disease pathway for DMD, including the clinically and economically important transfer state. The NHM may be used to estimate the current trajectory of DMD in economic evaluations of new treatments, facilitating inclusion of a lifetime time horizon, and will help identify areas for further research.

Point-of-Care Ultrasound by Nonexpert Operators Demonstrates High Sensitivity and Specificity in Detecting Gallstones: Data from the Samoa Typhoid Fever Control Program.

Approximately 90% of chronic typhoid carriers with persistent Salmonella enterica serovar Typhi (S. Typhi) gallbladder infection have gallstones. In Samoa, where typhoid fever has been endemic for many decades, risk factors predisposing to the development of gallstones are increasing among adults. The Samoa Typhoid Fever Control Program dispatches a "Typhoid Epidemiologic SWAT Team" to perform a household investigation of every blood culture-confirmed case of acute typhoid fever. Investigations include screening household contacts to detect chronic carriers. Following limited training, two nonexpert ultrasound operators performed point-of-care ultrasound (POCUS) on 120 Samoan adults from August to September 2019 to explore the feasibility of POCUS to detect individuals with gallstones during household investigations and community screenings. POCUS scans from 120 Samoan adults in three cohorts (28 food handlers, two typhoid cases and their 18 household contacts, and 72 attendees at an ambulatory clinic) were reviewed by a board-certified radiologist who deemed 96/120 scans (80%) to be interpretable. Compared with the radiologist (gold standard), the nonexpert operators successfully detected 6/7 Samoans with gallstones (85.7% sensitivity) and correctly identified 85/89 without gallstones (95.5% specificity). The proportion (24/120) of uninterpretable scans from this pilot that used minimally trained clinicians (who are neither radiologists nor ultrasound technicians) indicates the need for additional training of POCUS operators. Nevertheless, this pilot feasibility study engenders optimism that in the Samoan setting nonexperts can be trained to use POCUS to diagnose cholelithiasis, thereby helping (along with stool cultures and Vi serology) to identify possible chronic S. Typhi carriers.

The Relationship Between Developmental Coordination Disorder and Concurrent Deficits in Social Communication and Repetitive Behaviors Among Children with Autism Spectrum Disorder.

Children with Autism Spectrum Disorder (ASD), characterized by core deficits in social communication and restrictive behaviors, can exhibit concurrent motor incoordination and/or intellectual disability (ID). While pervasive delays in motor behavior are common, formal diagnosis of Development Coordination Disorder (DCD) is uncommon. It is not clear how DCD and ID impact core deficits in ASD. This study utilized the Simons Foundation SPARK cohort to describe the scope of motor incoordination among children with ASD and examine the interrelationships between DCD risk, ID, and ASD core deficits. 10,234 children with ASD, between the ages of 5 and 15 years, were included in the analysis. Parents completed online versions of the DCD Questionnaire (DCD-Q), Social Communication Questionnaire (SCQ) and Restrictive Behavior Scale (RBS-R). 85% of children with ASD had DCD-Q scores consistent with being at-risk for DCD, but only 14% reported a formal diagnosis. Children with ID exhibited significantly greater motor incoordination compared to children without ID (P < 0.001). Significantly, greater core deficits were identified in both children at-risk for DCD (P < 0.001) and with ID (P < 0.001). However, the effects of DCD risk were independent of ID and exhibited a medium effect size for SCQ (η2p = 0.063) and a small effect size for RBS-R (η2p = 0.04) scores. Collectively, study outcomes reinforce the pervasiveness of motor incoordination among children with ASD, both with and without concurrent ID, and provide further justification for the inclusion of motor behavior in the early intervention and prescription for children with ASD. LAY SUMMARY: This secondary data analysis of the Simons Foundation SPARK cohort found high rates (85%) of DCD risk among children with ASD. Deficits in motor coordination were greater among children with ASD with concurrent ID diagnoses. Meaningful differences in ASD core deficits (social communication and repetitive behaviors) were independently found in children at risk for DCD, both with and without ID. Autism Res 2021, 14: 804-816. © 2021 International Society for Autism Research and Wiley Periodicals LLC.

An enzootic transmission cycle of Lyme borreliosis spirochetes in the southeastern United States.

Lyme borreliosis, or Lyme disease (LD), is a tick-borne zoonotic infection of biomedical significance, caused by Borrelia burgdorferi sensu lato (s.l.) spirochetes and transmitted by Ixodes species ticks. It usually circulates among wildlife vertebrate reservoirs and vector ticks but may infect humans, causing multisystem problems. In far western and northern North America, the host reservoirs, tick vectors, and genospecies of Borrelia are well known but not so in the southern U.S., where there is controversy as to the presence of "true" LD. Here we report the presence of the LD spirochete B. burgdorferi sensu stricto (s.s.) and Borrelia bissettii, three main reservoir hosts, and two enzootic tick vectors in the southeastern U.S. The two enzootic tick vectors, Ixodes affinis and Ixodes minor, rarely bite humans but are more important than the human biting "bridge" vector, Ixodes scapularis, in maintaining the enzootic spirochete cycle in nature. We also report extraordinary longevities and infections in the reservoir rodents Peromyscus gossypinus, Sigmodon hispidus, and Neotoma floridana.

White grain mycetoma caused by a Cylindrocarpon sp. in India.

We describe a case of white grain eumycetoma of the foot of an Indian male caused by a slow-growing, poorly sporulating fungus that does not match any known agent of this infection. Histologic examination of a biopsy tissue specimen showed oval, lobular, white granules composed of hyaline, septate hyphae, and thick-walled chlamydospores. Culture of granules from a draining sinus yielded compact, very-slow-growing, poorly sporulating colonies producing a strong reddish brown pigment that diffused into the medium. The fungus was identified as a Cylindrocarpon sp. based on the development of rare cylindrical conidia borne from solitary phialides lacking collarettes, in addition to chlamydospores formed singly or in short chains.

Isolation, cultivation, and characterization of Borrelia burgdorferi from rodents and ticks in the Charleston area of South Carolina.

Twenty-eight Borrelia burgdorferi isolates from the Charleston, S.C., area are described. This represents the first report and characterization of the Lyme disease spirochete from that state. The isolates were obtained from December 1994 through December 1995 from the tick Ixodes scapularis, collected from vegetation, and from the rodents Peromyscus gossypinus (cotton mouse), Neotoma floridana (eastern wood rat), and Sigmodon hispidus (cotton rat). All isolates were screened immunologically by indirect immunofluorescence with monoclonal antibodies to B. burgdorferi-specific outer surface protein A (OspA) (antibodies H5332 and H3TS) and B. burgdorferi-specific OspB (antibodies H6831 and H614), a Borrelia (genus)-specific antiflagellin antibody (H9724), Borrelia hermsii-specific antibodies (H9826 and H4825), and two polyclonal antibodies (one to Borrelia species and another to B. burgdorferi). Six of the isolates were analyzed by exposing Western blots to monoclonal antibodies H5332, H3TS, H6831, and H9724. All isolates were also analyzed by PCR with five pairs of primers known to amplify selected DNA target sequences specifically reported to be present in the reference strain, B. burgdorferi B-31. The protein profiles of six of the isolates (two from ticks, one from a cotton mouse, two from wood rats, and one from a cotton rat) also were compared by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. We conclude that the 28 Charleston isolates are B. burgdorferi sensu stricto based on their similarities to the B. burgdorferi B-31 reference strain.

Solitary erythema migrans in Georgia and South Carolina.

OBJECTIVE: To evaluate the incidence of Borrelia burgdorferi infection in humans with erythema migrans (EM) in 2 southeastern states. DESIGN: Prospective case series. SETTING: Family medicine practice at academic center. PATIENTS: Twenty-three patients with solitary EM lesions meeting Centers for Disease Control and Prevention (CDC) criteria for Lyme disease. INTERVENTIONS: Patients underwent clinical and serologic evaluation for evidence of B burgdorferi infection. All lesions underwent photography, biopsy, culture and histopathologic and polymerase chain reaction analysis for B burgdorferi infection. Patients were treated with doxycycline hyclate and followed up clinically and serologically. MAIN OUTCOME MEASURES: Disappearance of EM lesions and associated clinical symptoms in response to antibiotic therapy; short-term and follow-up serologic assays for diagnostic antibody; growth of spirochetes from tissue biopsy specimens in Barbour-Stoenner-Kelly II media; special histopathologic stains of tissue for spirochetes; and polymerase chain reaction assays of tissue biopsy specimens for established DNA sequences of B burgdorferi. RESULTS: The EM lesions ranged from 5 to 20 cm (average, 9.6 cm). Five patients (22%) had mild systemic symptoms. All lesions and associated symptoms resolved with antibiotic therapy. Overall, 7 patients (30%) had some evidence of B burgdorferi infection. Cultures from 1 patient (4%) yielded spirochetes, characterized as Borrelia garinii, a European strain not known to occur in the United States; 3 patients (13%) demonstrated spirochetallike forms on special histologic stains; 5 patients (22%) had positive polymerase chain reaction findings with primers for flagellin DNA sequences; and 2 patients (9%) were seropositive for B burgdorferi infection using recommended 2-step CDC methods. No late clinical sequelae were observed after treatment. CONCLUSIONS: The EM lesions we observed are consistent with early Lyme disease occurring elsewhere, but laboratory confirmation of B burgdorferi infection is lacking in at least 16 cases (70%) analyzed using available methods. Genetically variable strains of B burgdorferi, alternative Borrelia species, or novel, uncharacterized infectious agents may account for most of the observed EM lesions.

Immunohistochemical evaluation of bcl-2 oncoprotein in oral dysplasia and carcinoma.

The proto-oncogene bcl-2 is associated with follicular lymphoma involving translocation t(14;18)(q32;q21) and is also overexpressed in various neoplasms. We report deregulation of bcl-2 expression during progression from oral epithelial dysplasia to squamous cell carcinoma. Immunohistochemical analysis with monoclonal antibodies to bcl-2 oncoprotein in formalin-fixed paraffin-embedded tissue sections revealed that severe epithelial dysplasias had a higher percentage of immunoreactivity than did mild and moderate dysplasias and squamous cell carcinomas. Expression of this oncoprotein was directly proportional to the degree of epithelial dysplasia, and nondysplastic basal cells contiguous to neoplastic lesions also expressed bcl-2. These findings, along with down-regulation of bcl-2 in differentiating carcinomas, suggest a role for this oncoprotein in relatively early stages of oral tumor progression. Differentiating neoplastic cells with marginal or no bcl-2 reactivity showed heterogeneous cell labeling of varying intensity for differentiation-associated cytokeratin (CK13), indicating their inverse topographic relationship.

First isolation and cultivation of Borrelia burgdorferi sensu lato from Missouri.

Five Borrelia burgdorferi sensu lato isolates from Missouri are described. This represents the first report and characterization of such isolates from that state. The isolates were obtained from either Ixodes dentatus or Amblyomma americanum ticks that had been feeding on cottontail rabbits (Sylvilagus floridanus) from a farm in Bollinger County, Mo., where a human case of Lyme disease had been reported. All isolates were screened immunologically by indirect immunofluorescence by using monoclonal antibodies to B. burgdorferi-specific outer surface protein A (OspA) (antibodies H3TS and H5332), B. burgdorferi-specific OspB (antibody H6831), Borrelia (genus)-specific antiflagellin (antibody H9724), and Borrelia hermsii-specific antibody (antibody H9826). Analysis of the isolates also involved a comparison of their protein profiles by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Finally, the isolates were analyzed by PCR with six pairs of primers known to amplify selected DNA target sequences specifically found in the reference strain B. burgdorferi B-31. Although some genetic variability was detected among the five isolates as well as between them and the B-31 strain, enough similarities were found to classify them as B. burgdorferi sensu lato.

Molecular detection of JC virus in embalmed, formalin-fixed, paraffin-embedded brain tissue.

Embalmed tissues are adequate for the detection of JC virus in lesions of progressive multifocal leukoencephalopathy (PML) by immunohistologic and molecular methods. JC virus was readily detected in embalmed brain tissue using immunohistochemistry (IHC), in situ hybridization (ISH), and the polymerase chain reaction (PCR). Two brains were removed from bodies that had been embalmed at least 24 h prior to autopsy. They were subsequently post fixed in 10% buffered formalin for 10-14 days before dissection and molecular studies were performed. Though these techniques are not novel, their use in embalmed tissues is. Routine embalming should not eliminate these diagnostic procedures from consideration.

p16 (CDKN2/MTS1) gene deletions are rare in prostatic carcinomas in the United States and Japan.

PURPOSE: The incidence of clinically apparent prostatic carcinoma is much higher in the United States than in Japan. Alterations in the p16 tumor suppressor gene have been identified in various tumor types, including cultured prostatic carcinoma cell lines. We studied the possible deletions of either exon 2 or 3 of this gene in primary clinical prostatic carcinomas from Japan and the United States. MATERIALS AND METHODS: Genomic DNA was extracted from 36 formalin-fixed, paraffin-embedded clinical prostatic carcinomas from Japan and 27 carcinomas from the United States. Exons 2 and 3 of the p16 gene were amplified using comparative multiplex polymerase chain reactions (PCR) and then analyzed for possible deletions of either exon. RESULTS: Two out of 36 (5.6%) carcinomas from Japan clearly demonstrated deletion of p16 exon 2, but this deletion was not detected in any of the 27 carcinomas from the United States. CONCLUSIONS: Although slightly higher in Japan than in the United States, the frequency of p16 exon deletions in clinical prostatic carcinomas is very low, and probably is not important in the development of this neoplasm.

Unusual strain of Borrelia burgdorferi isolated from Ixodes dentatus in central Georgia.

A new, unusual spirochete was cultured in Barbour-Stoenner-Kelly (BSK II) medium from the midgut and other tissues of the tick Ixodes dentatus. The tick was collected from leaf litter in an oak-pine wood lot in Bibb County approximately 7.2 km from Macon in central Georgia during February 1993. Characterization by indirect immunofluorescence using 5 murine monoclonal antibodies, by sodium dodecyl sulfate-polyacrylamide gel electrophoresis of whole spirochetal lysates, and by polymerase chain reaction assay for several known DNA target sequences indicates that the spirochete is Borrelia burgdorferi sensu lato. It is genetically different from the B-31 reference strain of B. burgdorferi sensu stricto that is typical of strains causing Lyme borreliosis in North America. Range of infectivity and pathogenesis of the Bibb County isolate (BC-1) are unknown but being investigated. The BC-1 strain is the first B. burgdorferi isolate from I. dentatus in the southeastern United States (I. dentatus is not the common vector for Lyme borreliosis in humans). Additionally, the collection site was approximately 322 km from the Atlantic coast, far distant from where most B. burgdorferi isolates have been obtained.

Rhinosporidiosis: three domestic cases.

Three cases of rhinosporidiosis in Americans who had not traveled abroad are reported. We believe this is the largest cluster of indigenous cases reported in the United States. The three patients had lived in rural northeast Georgia all of their lives. One had a polypoid conjunctival lesion, and the two others had nasal polyps. In each case, the diagnosis was made by demonstrating morphologically distinctive fungal elements in histopathologic sections. Clinically, rhinosporidiosis had not been suspected.

Opportunistic infections of the central nervous system in children with HIV infection: report of 9 autopsy cases and review of literature.

Central nervous system (CNS) abnormalities attributed to direct effects of HIV infection are seen in most of children with acquired immunodeficiency syndrome (AIDS). Secondary CNS infections with opportunistic and common pathogens are infrequent in this age group. We report 9 cases of opportunistic infection of the CNS found among 65 autopsy cases of pediatric AIDS. These included 4 cases of cytomegalovirus (CMV) infection, 1 of which was associated with aspergillosis, and 2 cases of candidiasis, 1 of which coexisted with Mycobacterium avium intracellulare (MAI) infection. There were also 2 cases of leptomeningitis, 1 due to Mycobacterium tuberculosis (MTB) and the other to Cryptococcus neoformans. In 1 child progressive multifocal leukoencephalopathy (PML) coexisted with mycotic encephalitis caused by an Aspergillus sp.

Natural occurrence and characterization of the Lyme disease spirochete, Borrelia burgdorferi, in cotton rats (Sigmodon hispidus) from Georgia and Florida.

This is the first report of natural infection by Borrelia burgdorferi in the cotton rat Sigmodon hispidus. Nine B. burgdorferi isolates were obtained from ear tissues, urinary bladders, or both, by culturing tissues in BSKII medium. The rat from which the SI-3 isolate was cultured was from the same site (Sapelo Island, Georgia) as an infected cotton mouse Peromyscus gossypinus and Ixodes scapularis tick reported previously. The 8 B. burgdorferi isolates from rats in Florida included 1 (AI-1) from Amelia Island, 1 (FD-1) from Faver-Dykes State Park, and 6 (MI-3 through MI-8) from Merritt Island. The distance between Sapelo Island and Merritt Island is approximately 400 km. All B. burgdorferi isolates were characterized by indirect immunofluorescence using monoclonal antibodies to OspA (H3TS, H5332) and OspB (H5TS, H6831), polymerase chain reaction detection of specific B. burgdorferi B-31 DNA target sequences (ospA, fla, and a random chromosomal sequence), and sodium dodecyl sulfate-polyacrylamide gel electrophoresis of spirochetal proteins. The phenotypic and genotypic characteristics of the isolates are discussed, as well as the probable importance of the cotton rat as a reservoir for B. burgdorferi in the southern United States.