Fever and leukocytosis: Physical manifestations of bipolar affective disorder?

1. 1. Fever and leukocytosis are occasionally observed in patients with psychiatric disorders. A thorough medical evaluation does not always reveal the origin of these abnormalities.2. 2. We report the case histories of three patients with bipolar affective disorder and an abnormal DST who had fever and leukocytosis during the acute phase of their illness. No organic etiology could be found.3. 3. All three patients responded to ECT with resolution of the depression, the fever, and the leukocytosis, and normalization of the DST.4. 4. We propose that fever and leukocytosis may be rare physical manifestations of bipolar affective disorder, particularly in patients with abnormal DST.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/27598/1/0000642.pd

De Novo Mutations in SLC1A2 and CACNA1A Are Important Causes of Epileptic Encephalopathies

Epileptic encephalopathies (EEs) are the most clinically important group of severe early-onset epilepsies. Next-generation sequencing has highlighted the crucial contribution of de novo mutations to the genetic architecture of EEs as well as to their underlying genetic heterogeneity. Our previous whole-exome sequencing study of 264 parent-child trios revealed more than 290 candidate genes in which only a single individual had a de novo variant. We sought to identify additional pathogenic variants in a subset (n = 27) of these genes via targeted sequencing in an unsolved cohort of 531 individuals with a diverse range of EEs. We report 17 individuals with pathogenic variants in seven of the 27 genes, defining a genetic etiology in 3.2% of this unsolved cohort. Our results provide definitive evidence that de novo mutations in SLC1A2 and CACNA1A cause specific EEs and expand the compendium of clinically relevant genotypes for GABRB3. We also identified EEs caused by genetic variants in ALG13, DNM1, and GNAO1 and report a mutation in IQSEC2. Notably, recurrent mutations accounted for 7/17 of the pathogenic variants identified. As a result of high-depth coverage, parental mosaicism was identified in two out of 14 cases tested with mutant allelic fractions of 5%–6% in the unaffected parents, carrying significant reproductive counseling implications. These results confirm that dysregulation in diverse cellular neuronal pathways causes EEs, and they will inform the diagnosis and management of individuals with these devastating disorders

Deep learning-based prediction of deliverable adaptive plans for MR-guided adaptive radiotherapy: A feasibility study

PurposeFast and automated plan generation is desirable in radiation therapy (RT), in particular, for MR-guided online adaptive RT (MRgOART) or real-time (intrafractional) adaptive RT (MRgRART), to reduce replanning time. The purpose of this study is to investigate the feasibility of using deep learning to quickly predict deliverable adaptive plans based on a target dose distribution for MRgOART/MRgRART.MethodsA conditional generative adversarial network (cGAN) was trained to predict the MLC leaf sequence corresponding to a target dose distribution based on reference plan created prior to MRgOART using a 1.5T MR-Linac. The training dataset included 50 ground truth dose distributions and corresponding beam parameters (aperture shapes and weights) created during MRgOART for 10 pancreatic cancer patients (each with five fractions). The model input was the dose distribution from each individual beam and the output was the predicted corresponding field segments with specific shape and weight. Patient-based leave-one-out-cross-validation was employed and for each model trained, four (44 training beams) out of five fractionated plans of the left-out patient were set aside for testing purposes. We deliberately kept a single fractionated plan in the training dataset so that the model could learn to replan the patient based on a prior plan. The model performance was evaluated by calculating the gamma passing rate of the ground truth dose vs. the dose from the predicted adaptive plan and calculating max and mean dose metrics.ResultsThe average gamma passing rate (95%, 3mm/3%) among 10 test cases was 88%. In general, we observed 95% of the prescription dose to PTV achieved with an average 7.6% increase of max and mean dose, respectively, to OARs for predicted replans. Complete adaptive plans were predicted in ≤20 s using a GTX 1660TI GPU.ConclusionWe have proposed and demonstrated a deep learning method to generate adaptive plans automatically and rapidly for MRgOART. With further developments using large datasets and the inclusion of patient contours, the method may be implemented to accelerate MRgOART process or even to facilitate MRgRART

Tris[3,5-bis­(trifluoro­meth­yl)phen­yl]phosphine oxide

In the title compound, C24H9F18OP, an intra­molecular C—H⋯O short contact generates a five-membered ring, producing an S(5) ring motif. The dihedral angles between the benzene rings are 57.68 (10), 77.80 (11) and 79.48 (10)°. Each of the six trifluoro­methyl substituents shows rotational disorder over two positions with refined site-occupany ratios of 0.64 (3)/0.36 (3), 0.649 (14)/0.351 (14), 0.52 (2)/0.48 (2), 0.545 (16)/0.455 (16), 0.774 (9)/0.226 (9) and 0.63 (5)/0.37 (5). The crystal structure is stabilized by inter­molecular C—H⋯O and C—H⋯F inter­actions

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Rare mutations in N-methyl-D-aspartate glutamate receptors in autism spectrum disorders and schizophrenia

Pharmacological, genetic and expression studies implicate N-methyl-D-aspartate (NMDA) receptor hypofunction in schizophrenia (SCZ). Similarly, several lines of evidence suggest that autism spectrum disorders (ASD) could be due to an imbalance between excitatory and inhibitory neurotransmission. As part of a project aimed at exploring rare and/or de novo mutations in neurodevelopmental disorders, we have sequenced the seven genes encoding for NMDA receptor subunits (NMDARs) in a large cohort of individuals affected with SCZ or ASD (n=429 and 428, respectively), parents of these subjects and controls (n=568). Here, we identified two de novo mutations in patients with sporadic SCZ in GRIN2A and one de novo mutation in GRIN2B in a patient with ASD. Truncating mutations in GRIN2C, GRIN3A and GRIN3B were identified in both subjects and controls, but no truncating mutations were found in the GRIN1, GRIN2A, GRIN2B and GRIN2D genes, both in patients and controls, suggesting that these subunits are critical for neurodevelopment. The present results support the hypothesis that rare de novo mutations in GRIN2A or GRIN2B can be associated with cases of sporadic SCZ or ASD, just as it has recently been described for the related neurodevelopmental disease intellectual disability. The influence of genetic variants appears different, depending on NMDAR subunits. Functional compensation could occur to counteract the loss of one allele in GRIN2C and GRIN3 family genes, whereas GRIN1, GRIN2A, GRIN2B and GRIN2D appear instrumental to normal brain development and function

Insulin Therapy and Outcomes of Revascularization Procedures for Chronic Limb Threatening Ischemia in the Best-CLI Trial

ObjectivesDiabetes mellitus (DM) is a major risk factor for amputation in patients with chronic limb-threatening ischemia (CLTI) undergoing lower extremity revascularization (LER). Observational studies comparing patients with DM based on insulin therapy have reported inconsistent findings. This study compares the outcomes of patients with insulin-requiring DM (IRDM) and non-insulin requiring DM (NIRDM) based on high quality prospective data.MethodsCharacteristics and outcomes of patients with IRDM and NIRDM enrolled in the BEST-CLI trial were compared. Cox regression model was used to determine the association between insulin requirement and outcomes.ResultsThe analysis included 1,229 patients with DM among whom 67.7% (N=832) had IRDM. The mean age was 66.7 ± 9.9 years, with the IRDM group being younger (65.8 vs 68.6, P&lt;0.001) and more likely to be Hispanic (19% vs 13.1%, P=0.01). Patients with IRDM were more likely to have renal disease and prior minor amputation (20.9% vs 13.9%, P=0.003) but were less likely to be smokers (24.5% vs 38.3%, P&lt;0.001) compared to NIRDM. Overall, only 26.8% of the cohort had adequate glucose control at study entry with patients in the NIRDM more likely to have a hemoglobin A1C (HbA1c) level &lt; 7 (19.2% vs 44%, P&lt;0.001). Patients with IRDM had significantly higher wound grade and more advanced overall WIfI stage compared to patients with NIRDM. At three years, patients with NIRDM were more likely to achieve resolution of CLTI, but there were no differences in other outcomes. Two years after revascularization, glucose control continued to be suboptimal with only 37.3% of the cohort achieving HbA1c &lt; 7. Regression analysis showed that insulin requirement was associated with decreased CLTI resolution (HR=0.86[0.75-0.99]) but not with other outcomes. Compared to endovascular therapy, open revascularization was associated with a lower risk of major amputation (HR=0.65[0.48-0.88]), major reintervention (HR=0.41[0.30-0.56]) and MALE or death (HR=0.78 [0.66-0.91]), irrespective of insulin therapy. A spline model demonstrated that open revascularization was associated with a lower HR of MALE or death compared to endovascular regardless of baseline HbA1c level.ConclusionPatients with IRDM undergoing LER for CLTI present with worse glucose control and more advanced CLTI stage compared to NIRDM. Insulin requirement showed a modest association with the outcomes of revascularization in this cohort. Open revascularization was superior to endovascular in patients with DM, regardless of insulin therapy or HbA1c level

Global diversity and biogeography of deep-sea pelagic prokaryotes

The deep-sea is the largest biome of the biosphere, and contains more than half of the whole ocean/'s microbes. Uncovering their general patterns of diversity and community structure at a global scale remains a great challenge, as only fragmentary information of deep-sea microbial diversity exists based on regional-scale studies. Here we report the first globally comprehensive survey of the prokaryotic communities inhabiting the bathypelagic ocean using high-throughput sequencing of the 16S rRNA gene. This work identifies the dominant prokaryotes in the pelagic deep ocean and reveals that 50{\%} of the operational taxonomic units (OTUs) belong to previously unknown prokaryotic taxa, most of which are rare and appear in just a few samples. We show that whereas the local richness of communities is comparable to that observed in previous regional studies, the global pool of prokaryotic taxa detected is modest (\~{}3600 OTUs), as a high proportion of OTUs are shared among samples. The water masses appear to act as clear drivers of the geographical distribution of both particle-attached and free-living prokaryotes. In addition, we show that the deep-oceanic basins in which the bathypelagic realm is divided contain different particle-attached (but not free-living) microbial communities. The combination of the aging of the water masses and a lack of complete dispersal are identified as the main drivers for this biogeographical pattern. All together, we identify the potential of the deep ocean as a reservoir of still unknown biological diversity with a higher degree of spatial complexity than hitherto considered.En prensa8,951

A Population Genetic Approach to Mapping Neurological Disorder Genes Using Deep Resequencing

Deep resequencing of functional regions in human genomes is key to identifying potentially causal rare variants for complex disorders. Here, we present the results from a large-sample resequencing (n = 285 patients) study of candidate genes coupled with population genetics and statistical methods to identify rare variants associated with Autism Spectrum Disorder and Schizophrenia. Three genes, MAP1A, GRIN2B, and CACNA1F, were consistently identified by different methods as having significant excess of rare missense mutations in either one or both disease cohorts. In a broader context, we also found that the overall site frequency spectrum of variation in these cases is best explained by population models of both selection and complex demography rather than neutral models or models accounting for complex demography alone. Mutations in the three disease-associated genes explained much of the difference in the overall site frequency spectrum among the cases versus controls. This study demonstrates that genes associated with complex disorders can be mapped using resequencing and analytical methods with sample sizes far smaller than those required by genome-wide association studies. Additionally, our findings support the hypothesis that rare mutations account for a proportion of the phenotypic variance of these complex disorders