Severity Of Patient Symptoms Research Articles

B-059 Allergen-specific IgE Measurement for Peanut Ara h 2*

Abstract Background Legumes such as peanuts are a major source of food allergies among children and adults. Ingestion is the primary route of exposure, although inhalation may also trigger an allergic response in patients with known hypersensitivity. Allergic reactions to peanut can include atopic dermatitis, angioedema, vomiting, diarrhea, and anaphylaxis. Several allergenic peanut proteins have been identified and linked with variable severity of patient symptoms. Ara h 2 is one of the proteins uniquely associated with severe peanut allergy. In this study, we evaluate the analytical performance of the Ara h 2 allergen containing reagent for use in the IMMULITE® 2000 3gAllergy® Specific IgE assay. Methods Serum samples were collected from 13 patient samples with documented histories of tree nut or legume-related allergies. The samples were analyzed for specific IgE reactivity to a commercially available recombinant Ara h 2 (rAra h 2) using the IMMULITE 2000 3gAllergy Specific IgE assay (Siemens Healthcare Diagnostics Inc., Tarrytown, NY). Precision, linearity, limit of detection, and endogenous interference were assessed. Results Repeatability and within-lab precision at all levels tested were less than 10% over a 20-day study. Regression analysis was performed following linearity assessment and resulted in a slope 95% CI of 0.9251–1.0492 (range 0.3–24 kU/L). Limit of blank and limit of detection were 0.02 kU/L and 0.08 kU/L, respectively. Endogenous interference testing showed <10% difference when spiked with hemoglobin (1000 mg/dL), intralipid (3000 mg/dL), and unconjugated bilirubin (40 mg/dL). Conclusion rAra h 2 allergen containing reagent for use in the IMMULITE 2000 3gAllergy Specific IgE assay is sensitive and capable of quantitatively measuring IgE in patients with clinical history of nut allergy. *Assay under development. Not available for sale. Future availability cannot be guaranteed.

Use of Silicon T-Tube for Subglottic Stenosis and Tracheal Stenosis.

The management of subglottic and tracheal stenosis is challenging for any ENT surgeon. The treatment choice depends on the site, severity of stenosis, patient symptoms, and surgeon preferences. The various options for the management include endoscopic balloon dilatation, various types of laryngotracheoplasty, resection anastomosis, and insertion of a silicon T-tube. Compared to the above, silicon T-tube stenting is a better alternative, as it is a onetime procedure, easy to perform with fewer chances of complications. Shiann Yann lee technique is a form of laryngotracheoplasty with long-term stenting using silicon T-tube. This article analyzed our silicon T-Tube insertion result in patients with subglottic and tracheal stenosis using this technique. In this retrospective study, we included a total of 21 patients with subglottic and tracheal stenosis who underwent silicon T-Tube insertion. Data regarding the site of stenosis, procedure, complications, and outcome were analyzed. Out of 21 patients, nine patients had subglottic stenosis (42.8%), 8 had cervical tracheal stenosis (38.09%), 3 had thoracic tracheal stenosis (14.28%), and 1 (4.7%) had combined subglottic and cervical tracheal stenosis. Out of 21 patients,7 (33.3%) have undergone successful removal of silicon T-Tube so far, one death due to medical reasons, and 13 patients (61.9%) are still on Silicon tube on regular follow-up. They are comfortable with the tube in situ. Silicon T-Tube for benign acquired laryngotracheal stenosis with Shiann Yann Lee's technique is effective, safe with less complication, and good acceptability and tolerance by the patient.

Supraglottoplasty- cold technique

Supraglottoplasty is the mainstay surgical treatment for severe laryngomalacia. The decision to operate is based on the severity of patient symptoms. High-pitched inspiratory stridor is the classic finding, but severity of symptoms is based on a spectrum of feeding and respiratory findings. The cold-steel technique was first described in the 1980s and has remained the primary technique for many pediatric otolaryngologists. This article reviews etiology of laryngomalacia, indications for operation, and cold-steel technique for the treatment of laryngomalacia.

Applicability of the Thrombin Generation Test to Evaluate the Hemostatic Status of Hemophilia A Patients in Daily Clinical Practice.

Hemophilia A (HA) is a rare bleeding disorder caused by factor VIII (FVIII) deficiency due to various genetic mutations in the F8 gene. The disease severity inversely correlates with the plasma levels of functional FVIII. The treatment of HA patients is based on FVIII replacement therapy, either following a prophylactic or on-demand regime, depending on the severity of the disease at diagnosis and the patient’s clinical manifestations. The hemorrhagic manifestations are widely variable amongst HA patients, who may require monitoring and treatment re-adjustment to minimize bleeding symptoms. Notably, laboratory monitoring of the FVIII activity is difficult due to a lack of sensitivity to various FVIII-related molecules, including non-factor replacement therapies. Hence, patient management is determined mainly based on clinical manifestations and patient–clinician history. Our goal was to validate the ST Genesia® automated thrombin generation analyzer to quantify the relative hemostatic status in HA patients. We recruited a cohort of HA patients from the Principality of Asturias (Spain), following treatment and at a stable non-bleeding phase. The entire cohort (57 patients) had been comprehensively studied at diagnosis, including FVIII and VWF activity assays and F8 genetic screening, and then clinically monitored until the Thrombin Generation Test (TGT) was performed. All patients were recruited prior to treatment administration, at the maximum time-window following the previous dose. Interestingly, the severe/moderate patients had a similar TGT compared to the mild patients, reflecting the non-bleeding phase of our patient cohort, regardless of the initial diagnosis (i.e., the severity of the disease), treatment regime, and FVIII activity measured at the time of the TGT. Thus, TGT parameters, especially the peak height (Peak), may reflect the actual hemostatic status of a patient more accurately compared to FVIII activity assays, which may be compromised by non-factor replacement therapies. Furthermore, our data supports the utilization of combined TGT variables, together with the severity of patient symptoms, along with the F8 mutation type to augment the prognostic capacity of TGT. The results from this observational study suggest that TGT parameters measured with ST Genesia® may represent a suitable tool to monitor the hemostatic status of patients requiring a closer follow-up and a tailored therapeutic adjustment, including other hemophilia subtypes or bleeding disorders.

Management of Isolated, Congenital Anterior Mitral Valve Cleft.

Background: Isolated anterior mitral valve clefts (MVC) are rare congenital heart defects, and data are limited regarding the natural history and surgical outcomes for such isolated MVCs. Methods: We conducted a retrospective review of patients with congenital MVC who were evaluated at Mayo Clinic in Rochester, Minnesota between 1993 and 2020. Patients were separated into two cohorts: those who underwent surgical repair of the MVC and those who had not yet undergone repair. Baseline and postoperative clinical and echocardiographic data were analyzed. Results: Fourteen patients were included in the nonsurgical cohort and eight patients in the surgical cohort. Surgical repair was via primary median sternotomy (n = 6) or robot-assisted, minimally invasive (n = 2). All cleft repairs were performed by simple suture closure. Intraoperative evaluation of the clefts did not reveal additional structural factors that could account for the mitral regurgitation (MR). At latest follow-up of the surgical cohort, the median grade of MR was 1 (range 0-1), and median left ventricular ejection fraction was 65% (IQR 59%-67%), both similar to the immediate postoperative result. At latest follow-up, all patients in the nonsurgical cohort were NYHA Class 1, and median MR grade was 1. All patients were asymptomatic (NYHA Class 1). Conclusions: Our findings corroborate prior reports that MVC repair is safe and successful and is followed by a low rate of recurrent mitral valve dysfunction. Durable surgical repair of isolated, congenital MVC can be performed safely in select patients. The decision to intervene should be based on the severity of mitral regurgitation and patient symptoms rather than the presence of the MVC alone.

Hemophilia: The Past, the Present, and the Future.

Hemophilia: The Past, the Present, and the Future.

A method for assaying peptide: N-glycanase/N-glycanase 1 activities in crude extracts using an N-glycosylated cyclopeptide.

Cytosolic peptide: N-glycanase (PNGase; NGLY1), an enzyme responsible for de-glycosylation of N-glycans on glycoproteins, is known to play pivotal roles in a variety of biological processes. In 2012, NGLY1 deficiency, a rare genetic disorder, was reported and since then, more than 100 patients have now been identified worldwide. Patients with this disease exhibit several common symptoms that are caused by the dysfunction of NGLY1. However, correlation between the severity of patient symptoms and the extent of the reduction in NGLY1 activity in these patients remains to be clarified, mainly due to the absence of a facile quantitative assay system for this enzyme, especially in a crude extract as an enzyme source. In this study, a quantitative, non-radioisotope (RI)-based assay method for measuring recombinant NGLY1 activity was established using a BODIPY-labeled asialoglycopeptide (BODIPY-ASGP) derived from hen eggs. With this assay, the activities of 27 recombinant NGLY1 mutants that are associated with the deficiency were examined. It was found that the activities of three (R469X, R458fs and H494fs) out of the 27 recombinant mutant proteins were 30–70% of the activities of wild-type NGLY1. We further developed a method for measuring endogenous NGLY1 activity in crude extracts derived from cultured cells, patients’ fibroblasts, iPS cells or peripheral blood mononuclear cells (PBMCs), using a glycosylated cyclopeptide (GCP) that exhibited resistance to the endogenous proteases in the extract. Our methods will not only provide new insights into the molecular mechanism responsible for this disease but also promises to be applicable for its diagnosis.

Is It Time for Artificial Intelligence to Invade Personal Privacy, for Pandemic Control?

Artificial intelligence (AI), specifically machine-learning, provides techniques to uncover complex associations that would normally not be resolved from simple computer algorithms/equations. In medicine, the introduction of AI systems have allowed for an unprecedented analysis of clinical presentations – systems are now able to systematically weigh pieces of information to reach logical conclusions, mimicking a clinician’s thought process [1]. In fact, AI systems have evolved to the point where in some clinical settings, their diagnostic accuracy surpasses those of clinicians: AI has been able to out-perform dermatologists in assessing suspicious skin lesions, and more effective at identifying pulmonary tuberculosis on chest radiographs than radiologists [2-3]. AI systems have even been given the responsibility of triaging severity of patient symptoms; the National Health Services in the United Kingdom recently employed AI to tend to medical questions from a population of 1.2 million residents, and assess the urgency of medical conditions to subsequently advise of appropriate action (i.e. advising rest, or recommending for immediate emergency room consult) [4]. There has been an increased interest in the use of artificial intelligence (AI) in public health, specifically to assist with health promotion and health protection. For example, personalized and targeted health advice can be provided to different members of the population based on personal health profiles, as identified through electronic medical records. AI can also be used to rapidly analyze data and anticipate subsequent data modulation with respect to disease surveillance and health protection; for example, AI can utilize GPS data from cellular phones to predict areas at risk of outbreak, based on the temporal exposure of a region to the origin/person harbouring an outbreak [5]. AI may not only allow for personalized public health but may allow for expedited assessments of complex public health scenarios.

Endoscopic ultrasound-measured muscular thickness of the lower esophageal sphincter and long-term prognosis after peroral endoscopic myotomy for achalasia.

BACKGROUNDPeople with achalasia typically have a thick lower esophageal muscularis propria (LEMP), and peroral endoscopic myotomy (POEM) has been effective in treating most patients. LEMP thickness may be associated with the outcomes and prognosis after POEM. However, more evidence is needed regarding the relationship between LEMP thickness and patient prognosis after POEM.AIMTo assess the association between LEMP thickness, measured using endoscopic ultrasound (EUS), and long-term prognosis, especially relapse, after POEM for achalasia.METHODSAll medical records, including EUS data, of patients who underwent POEM to treat achalasia at Shengjing Hospital of China Medical University from January 2012 to September 2018 were retrospectively reviewed. LEMP thickness was measured by EUS, and a thickness of ≥ 3 mm was defined as thickened. The severity of patient symptoms was evaluated using the Eckardt score. Relapse was defined as a 3-point rise in the Eckardt score after a period of clinical remission. The relationship between patient characteristics, muscle thickness, and recurrence was analyzed.RESULTSEighty-two patients (32 males and 50 females, aged 17-78 years) and 85 POEM procedures were included. In total, 76.8% (63/82 patients) of patients had a thickened muscularis propria. Older age and longer disease course were associated with muscularis propria thickening (P < 0.05). The mean postoperative follow-up time was 35.4 ± 17.2 mo (range, 8-87.5 mo) in 60 patients. Five patients with Eckardt scores > 3 refused further management after their symptoms were relieved. The relapse rate was 12.73% (7/55 cases). Five patients, four of whom had muscularis propria thickening, had disease recurrence within 12 mo after the procedure. Achalasia relapsed in one patient who had a thickened muscularis propria after 24 mo and in another patient who did not have a thickened muscularis propria after 30 mo. Patients with recurrence were typically younger and had a shorter disease course (P < 0.05). The relapse rate in patients with a non-thickened muscularis propria tended to be higher (18.2%, 2/11 patients) than that in patients with a thickened muscularis propria (11.4%, 5/44 patients), although no significant difference was found. Age (hazard ratio = 0.92; 95% confidence interval: 0.865-0.979; P < 0.05) and being male (hazard ratio = 7.173; 95% confidence interval: 1.277-40.286; P < 0.05) were identified as risk factors for symptomatic recurrence by multivariable analysis using the Cox model.CONCLUSIONPatients with a thickened muscularis are typically older and have a longer disease course. Younger age and the male sex are associated with increased recurrence. Patients with a thin muscularis propria may be prone to relapse, although further validation is needed.

Air Pollution and Covid-19: The Role of Particulate Matter in the Spread and Increase of Covid-19's Morbidity and Mortality.

Sars-Cov-2 virus (COVID-19) is a member of the coronavirus family and is responsible for the pandemic recently declared by the World Health Organization. A positive correlation has been observed between the spread of the virus and air pollution, one of the greatest challenges of our millennium. COVID-19 could have an air transmission and atmospheric particulate matter (PM) could create a suitable environment for transporting the virus at greater distances than those considered for close contact. Moreover, PM induces inflammation in lung cells and exposure to PM could increase the susceptibility and severity of the COVID-19 patient symptoms. The new coronavirus has been shown to trigger an inflammatory storm that would be sustained in the case of pre-exposure to polluting agents. In this review, we highlight the potential role of PM in the spread of COVID-19, focusing on Italian cities whose PM daily concentrations were found to be higher than the annual average allowed during the months preceding the epidemic. Furthermore, we analyze the positive correlation between the virus spread, PM, and angiotensin-converting enzyme 2 (ACE2), a receptor involved in the entry of the virus into pulmonary cells and inflammation.

Mucosal inflammation predicts response to systemic steroids in immune checkpoint inhibitor colitis

BackgroundImmune-related colitis is a common, often serious complication of immune checkpoint inhibition (ICI). Although endoscopy is not strictly recommended for any grade of diarrhea/colitis, emerging evidence suggests that endoscopic evaluation...

Impact of alcohol and substabce use by patients with schizophrenia on burden, quality of life, anxiety and depression levels of primary caregivers

Aim: Alcohol and substance use are the most common comorbidities among patients with schizophrenia, with significantly higher levels of burden reported among primary caregivers. In this study, we aimed to assess the impact of alcohol and substance use on caregivers, and the effects of the severity of disease symptoms and certain attributes of patients and their primary caregivers on the burden, depressive symptoms, quality of life, and anxiety levels of caregivers. Methods: We recruited 100 patients with schizophrenia according to DSM-IV TR from inpatient clinics of Bakirkoy Research and Training Hospital for Psychiatry, Neurology, and Neurosurgery and their primary caregivers from September 2010 to March 2011. The severity of patient symptoms was assessed using the Positive and Negative Syndrome Scale (PANSS). All caregivers completed the Sociodemographic and Clinical data form, The Zarit Burden Scale, Beck Depression Inventory, State-Trait Anxiety Inventory, and WHO Quality of life-BREF. Results: The ages of caregivers and patients were 23–68 and 20–65 years, respectively. The primary caregiver was the patient’s mother in 53% of cases. We found levels of burden that were significantly higher for caregivers of patients with alcohol or substance use, and these were positively correlated with the positive psychotic subscale of PANSS. Caregivers of patients without alcohol and substance use had significantly higher scores for psychological and social relationship domains of WHOQOL-BREF. Discussion: Alcohol and substance use disorder which causing more complicated and severe needs of schizophrenia patients is associated with increased level of caregiver burden, depression and anxiety levels and decreased quality of life. Our findings suggest that there is a significant relationship between caregiver burden and alcohol and substance use by patients with schizophrenia.

Fibrochondrocyte Growth and Functionality on TiO₂ Nanothin Films.

Disorders affecting the temporomandibular joint (TMJ) are a long-standing health concern. TMJ disorders (TMJD) are often associated with an internal disc derangement accompanied by a suite of symptoms including joint noises, jaw dysfunction, and severe pain. The severity of patient symptoms and their reoccurrence can be alleviated to some extent with conservative therapy; however, refractory cases often require surgery that has shown only limited success. Bioengineered scaffolds with cell supportive surfaces an d nanoarchitectures that mimic TMJ tissue structure may offer an alternative treatment modality. In this study, titanium dioxide (TiO2) nanothin films, fabricated by layer-by-layer assembly, were examined as means for creating such a scaffold. The viability and growth of TMJ discal fibrochondrocytes (FCs) were assessed through MTT and DNA assays and total protein content over a 14-day experimental period. ELISA was also used to measure expression of types I and II collagen, decorin and aggrecan. Quantitative analyses demonstrated that FCs synthesized characteristic discal matrix proteins, with an increased production of type I collagen and decorin as opposed to collagen type II and aggrecan. A stimulatory effect on discal FC proliferation and extracellular matrix (ECM) expression with thicker nanofilms was also observed. The cumulative results suggest that TiO2 nanofilms may have potential as a TMJ scaffolding material.

Cesarean scar pregnancy: a systematic review of treatment studies

To study treatment modalities for cesarean scar pregnancies (CSPs), focusing on efficacy and complications in relation to study quality. Systematic review. Not applicable. A total of 2,037 women with CSP. Review of MEDLINE, EMBASE, and Cochrane Library to find studies including five or more women. Data were extracted on primary treatment modality/efficacy, complications, and future fertility. The level of evidence was categorized according to Oxford Centre for Evidence-based Medicine guidelines. Quality was assessed using The Cochrane Collaboration's Risk of Bias Tools for Randomized Controlled Trials and the modified Delphi techniques for case series. Meta-analysis was impossible owing to multifarious treatments. Successful first-line treatment. Complications were hysterectomy, laparotomy, bleeding >1,000mL, or blood transfusion. Fifty-two studies were included: four randomized, controlled trials and 48 case series. Fifteen of the 52 analyzed studies were scored as high quality. Treatment modalities were condensed to 14 different approaches. Combining study quality, level of evidence, efficacy, and safety, five approaches for treating CSP are recommended, depending on availability, severity of patient symptoms, and surgical skills: [1] resection through a transvaginal approach, [2] laparoscopy, [3] uterine artery embolization in combination with dilatation and curettage and hysteroscopy, [4] uterine artery embolization in combination with dilatation and curettage, and [5] hysteroscopy. This review recommends treatment options for CSP in clinical practice, based on efficacy and safety. The literature supports an interventional rather than medical approach. Present recommendations are primarily based on case series. Multicenter, well-designed studies are needed to draw definite conclusions on how to treat CSP.

The Reliability of the Reflux Finding Score Among General Otolaryngologists

The reflux finding score (RFS) is a validated clinical severity scale for findings of laryngopharyngeal reflux (LPR) on fiberoptic laryngoscopy. To our knowledge, there have been no studies to determine whether severity of patient symptoms influence the RFS; in addition, the reliability of the RFS has not been tested for general otolaryngologists. The objectives of this study were (1) to determine whether the RFS for LPR is influenced by symptoms of reflux and (2) to determine the inter-rater reliability for general otolaryngologists in diagnosing LPR using the RFS. Ten general otolaryngologists were selected to participate. Participants were asked to complete an Internet survey consisting of flexible endoscopic videos of larynges with varying physical findings of reflux and grade the severity of reflux using the RFS. The videos were randomly shown with and without accompanying patient symptoms. Our data suggest that patient symptoms influence the RFS. Inter-rater reliability for general otolaryngologists using the RFS is fair. Among general otolaryngologists in our study, the reliability and objectivity of the RFS in diagnosing reflux cannot be demonstrated.

Individualized management of umbilical endometriosis: A report of seven cases

The aim of this study was to review diagnostic/therapeutic strategies of umbilical endometriosis managed in our department and evaluate the effectiveness of these strategies. Medical records for patients with diagnosis of endometriosis managed from 1999 through 2011 in the University of Tokyo Hospital were retrospectively reviewed. Cases with diagnosis of umbilical endometriosis were identified. Clinical information of age, gravida, parity, histories of surgery and oral contraceptive (OC), management for the disease prior to the first visit, symptoms, patients' desire for pregnancy, diagnostic/therapeutic methods and prognosis were reviewed and summarized. During the period, 2530 patients with diagnosis of endometriosis were identified. Seven patients had diagnosis of umbilical endometriosis, giving an incidence of 0.29% of all endometriosis cases and 5.6% of extragenital endometriosis cases. A definitive diagnosis was made by histological examination following a biopsy (two cases) or a resection (three cases). A clinical diagnosis was made by empirical treatment with OC (one case) or dienogest (one case). With regard to therapy, three patients chose expectant management and did not require therapeutic intervention. Three patients began OC and symptoms were well controlled in all patients. One patient who wished to conceive chose a wide resection followed by umbilical reconstruction. She became pregnant afterwards and recurrence was not reported. There are various options of diagnostic/therapeutic strategies, such as empirical treatments and OC that can provide individualized management of umbilical endometriosis, congruent with the severity of patient symptoms, age and desire for pregnancy.

Septal perforation repair: mucosal regeneration technique

A novel method for repair of septal perforations. Fifteen volunteers with symptomatic septal perforations were recruited. Open technique rhinoplasty approach was preferred: auricular conchal cartilage graft with intact perichondrium on both sides was harvested and shaped to fit the perforated site and attached to the septum with absorbable sutures. All margins of the graft were covered with nasal mucosa. The severity of patient symptoms was assessed at preoperation, 3 and 6 months postoperatively via visual analogue scale (VAS). Crust formation, whistling, nasal blockage, epistaxis and overall comfort were evaluated. Mucosal physiology was assessed by nasal mucociliary clearance time. The mean age of the patients was 47.3 years. Average perforation size was 1.86 ± 0.78 cm. 14/15 (93.3%) perforations were repaired, and only one patient required revision surgery. VAS scores improved significantly (p < 0.001). Mean mucociliary clearance time improved from 17.6 ± 3.83 to 10.3 ± 3.30 min and 9.3 ± 3.36 min at 3 and 6 months, respectively. This is a novel, simple and safe method for repairing the deficient mucosal area in septal perforations up to 25 mm in diameter.

WITHDRAWN: Interventions for treating acute and chronic Achilles tendinitis.

Achilles tendinitis is one of the most common of all sports injuries. There is no consensus on treatment. To assess the effectiveness of various treatment interventions for acute and chronic Achilles tendinitis in adults. The Cochrane Bone, Joint and Muscle Trauma Group specialised register (December 2000), Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2000), MEDLINE (1966 to December 2000), EMBASE (1980 to 2001 wk 04), CINAHL (1982 to December 2000), and reference lists of identified trials were searched. Randomised or quasi-randomised trials of treatment interventions for acute and chronic Achilles tendinitis in adults. Studies focusing on pathological tendinitis were excluded. Excluded were those trials that compared different dosages of the same drug or drugs within the same class of drugs, for example different non-steroidal anti-inflammatory drugs (NSAIDs). Three reviewers independently assessed trial quality, by use of a ten item check list, and extracted data. Requests were sent for separate data for Achilles tendinitis patients in studies within trials of mixed patient populations. Where possible, quantitative analysis and limited pooling of data were undertaken. Nine trials, involving 697 patients, met the inclusion criteria of the review. Methodological quality was adequate in most of the trials with regards to blinding but the assessment of outcome was incomplete and short-term.There was weak but not robust evidence from three trials of a modest benefit of NSAIDs for the alleviation of acute symptoms. There was some weak evidence of no difference compared with no treatment of low dose heparin, heel pads, topical laser therapy and peritendonous steroid injection, but this could not be fully evaluated from the reports of four trials. The results of an experimental preparation of a calf-derived deproteinized haemodialysate, Actovegin, were promising but the severity of patient symptoms was questionable in the single small trial testing this comparison. The results of a comparison of glycosaminoglycan sulfate with a NSAID were inconclusive. There is insufficient evidence from randomised controlled trials to determine which method of treatment is the most appropriate for the treatment of acute or chronic Achilles tendinitis. Further research is warranted.

Rett Syndrome-causing Mutations in Human MeCP2 Result in Diverse Structural Changes That Impact Folding and DNA Interactions

Most cases of Rett syndrome (RTT) are caused by mutations in the methylated DNA-binding protein, MeCP2. Here, we have shown that frequent RTT-causing missense mutations (R106W, R133C, F155S, T158M) located in the methylated DNA-binding domain (MBD) of MeCP2 have profound and diverse effects on its structure, stability, and DNA-binding properties. Fluorescence spectroscopy, which reports on the single tryptophan in the MBD, indicated that this residue is strongly protected from the aqueous environment in the wild type but is more exposed in the R133C and F155S mutations. In the mutant proteins R133C, F155S, and T158M, the thermal stability of the domain was strongly reduced. Thermal stability of the wild-type protein was increased in the presence of unmethylated DNA and was further enhanced by DNA methylation. DNA-induced thermal stability was also seen, but to a lesser extent, in each of the mutant proteins. Circular dichroism (CD) of the MBD revealed differences in the secondary structure of the four mutants. Upon binding to methylated DNA, the wild type showed a subtle but reproducible increase in alpha-helical structure, whereas the F155S and R106W did not acquire secondary structure with DNA. Each of the mutant proteins studied is unique in terms of the properties of the MBD and the structural changes induced by DNA binding. For each mutation, we examined the extent to which the magnitude of these differences correlated with the severity of RTT patient symptoms.

Can Family Caregivers of Terminally Ill Patients Be a Reliable Source of Information About the Severity of Patient Symptoms?

This study examines the reliability of family caregivers' assessments of a terminally ill patient's symptoms and identifies patient and caregiver characteristics that affect the reliability of caregiver reports. It compares the reports of 143 patients in home hospice units with those of their family caregiver about patient symptoms during the 3 days preceding the interview (Edmonton scale). Correlation coefficients between the patients' and proxies' reports were 0.5 to 0.8, indicating moderate-to-high agreement. Characteristics that had an independent effect on identical reporting were the patient being fully disabled, the care-giver being a woman in good health, the caregiver living with the patient, and the caregiver providing assistance with activities of daily living and medical care. These results suggest that primary caregivers can be a good source of information about a patient's symptoms, although their reports should be used with caution.