Cdkn1c Boosts the Development of Brown Adipose Tissue in a Murine Model of Silver Russell Syndrome.

The accurate diagnosis and clinical management of the growth restriction disorder Silver Russell Syndrome (SRS) has confounded researchers and clinicians for many years due to the myriad of genetic and epigenetic alterations reported in these patients and the lack of suitable animal models to test the contribution of specific gene alterations. Some genetic alterations suggest a role for increased dosage of the imprinted CYCLIN DEPENDENT KINASE INHIBITOR 1C (CDKN1C) gene, often mutated in IMAGe Syndrome and Beckwith-Wiedemann Syndrome (BWS). Cdkn1c encodes a potent negative regulator of fetal growth that also regulates placental development, consistent with a proposed role for CDKN1C in these complex childhood growth disorders. Here, we report that a mouse modelling the rare microduplications present in some SRS patients exhibited phenotypes including low birth weight with relative head sparing, neonatal hypoglycemia, absence of catch-up growth and significantly reduced adiposity as adults, all defining features of SRS. Further investigation revealed the presence of substantially more brown adipose tissue in very young mice, of both the classical or canonical type exemplified by interscapular-type brown fat depot in mice (iBAT) and a second type of non-classic BAT that develops postnatally within white adipose tissue (WAT), genetically attributable to a double dose of Cdkn1c in vivo and ex-vivo. Conversely, loss-of-function of Cdkn1c resulted in the complete developmental failure of the brown adipocyte lineage with a loss of markers of both brown adipose fate and function. We further show that Cdkn1c is required for post-transcriptional accumulation of the brown fat determinant PR domain containing 16 (PRDM16) and that CDKN1C and PRDM16 co-localise to the nucleus of rare label-retaining cell within iBAT. This study reveals a key requirement for Cdkn1c in the early development of the brown adipose lineages. Importantly, active BAT consumes high amounts of energy to generate body heat, providing a valid explanation for the persistence of thinness in our model and supporting a major role for elevated CDKN1C in SRS

Willingness to pay for an mHealth anti-retroviral therapy adherence and information tool: Transitioning to sustainability, Call for life randomised study experience in Uganda.

Funder: Johnson & Johnson Corporate Citizenship TrustINTRODUCTION: Evidence shows benefit of digital technology for people living with human immunodeficiency virus on antiretroviral therapy adherence and retention in care, however, scalability and sustainability have scarcely been evaluated. We assessed participants' willingness to pay a fee for mHealth "Call for life Uganda" support, a mobile-phone based tool with the objective to assess sustainability and scalability. METHODS: "Call for Life study", approved by Makerere University, School of Public Health research & ethics committee, at 2 sites in Uganda, evaluated a MoTech based software "CONNECT FOR LIFE™" mHealth tool termed "Call for life Uganda". It provides short messages service or Interactive Voice Response functionalities, with a web-based interface, allows a computer to interact with humans through use of voice and tones input via keypad. Participants were randomized at 1:1 ratio to Standard of Care or standard of care plus Call for life Uganda. This sends pill reminders, visit reminders, voice messages and self-reported symptom support. At study visits 18 and 24 months, through mixed method approach we assessed mHealth sustainability and scalability. Participants were interviewed on desire to have or continue adherence support and willingness to pay a nominal fee for tool. We computed proportions willing to pay (± 95% confidence interval), stratified by study arm and predictors of willingness to continue and to pay using multivariate logistic regression model backed up by themes from qualitative interviews. RESULTS: 95% of participants were willing to continue using C4LU with 77.8% willing to pay for the service. Persons receiving care at the peri-urban clinic (OR 3.12, 95% CI 1.43-9.11.86) and those with exposure to the C4LU intervention (OR 4.2, 95% CI 1.55-11.84) were more likely to continue and pay for the service. Qualitative interviews revealed mixed feelings regarding amounts to pay, those willing to pay, argued that since they have been paying for personal phone calls/messages, they should not fail to pay for Call for life. CONCLUSIONS: Payment for the service offers opportunities to scale up and sustain mHealth interventions which may not be priorities for government funding. A co-pay model could be acceptable to PLHIV to access mHealth services in low resource settings. Clinical Trial Number NCT02953080

Multiple novel prostate cancer susceptibility signals identified by fine-mapping of known risk loci among Europeans

Genome-wide association studies (GWAS) have identified numerous common prostate cancer (PrCa) susceptibility loci. We have fine-mapped 64 GWAS regions known at the conclusion of the iCOGS study using large-scale genotyping and imputation in 25 723 PrCa cases and 26 274 controls of European ancestry. We detected evidence for multiple independent signals at 16 regions, 12 of which contained additional newly identified significant associations. A single signal comprising a spectrum of correlated variation was observed at 39 regions; 35 of which are now described by a novel more significantly associated lead SNP, while the originally reported variant remained as the lead SNP only in 4 regions. We also confirmed two association signals in Europeans that had been previously reported only in East-Asian GWAS. Based on statistical evidence and linkage disequilibrium (LD) structure, we have curated and narrowed down the list of the most likely candidate causal variants for each region. Functional annotation using data from ENCODE filtered for PrCa cell lines and eQTL analysis demonstrated significant enrichment for overlap with bio-features within this set. By incorporating the novel risk variants identified here alongside the refined data for existing association signals, we estimate that these loci now explain ∼38.9% of the familial relative risk of PrCa, an 8.9% improvement over the previously reported GWAS tag SNPs. This suggests that a significant fraction of the heritability of PrCa may have been hidden during the discovery phase of GWAS, in particular due to the presence of multiple independent signals within the same regio

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication

Designing, delivering and evaluating a specialty specific quality improvement course for the rheumatology multidisciplinary team

ObjectivesQuality improvement (QI) methodology aims to drive improvement in healthcare using a systematic approach. QI is an integral part of healthcare professional training curricula. However, many members of the rheumatology community have not accessed formal QI methodology training, including those expected to supervise QI activity. The BSR QI practical methodology workshop was created to address this knowledge gap in a specialty-specific course designed and delivered by, and for, the multidisciplinary team. MethodsCourse design centred on the Institute for Healthcare Improvement approach, ‘Model for improvement’, adapting materials from the well-established Trainees Improving Patient Safety through QI (TIPSQI) initiative. The course was delivered online (2021) and face-to-face (2022). Kolbs’ four stage experiential learning cycle informed course design utilising rheumatology-specific cases and facilitated breakout rooms to teach QI tools. Kirkpatrick’s four-stage model was used to design the course evaluation. Data from surveys completed before, immediately after, and six months’ following the courses were used to evaluate the course. ResultsBaseline knowledge of specific QI tools was limited. Post course evaluation demonstrated increased confidence to use and teach tools. Sustained confidence to contribute to and lead QI activity was reported. Course satisfaction was high; 100% of delegates would recommend the course to colleagues. ConclusionThis successful, rheumatology specific QI course led to improved delegate knowledge of QI methodology and confidence in leading and teaching QI initiatives. It has contributed to building momentum in a growing rheumatology QI community of practice and to embedding a sustainable culture of improvement across the rheumatology community. <br/

Willingness to pay for an mHealth anti-retroviral therapy adherence and information tool: Transitioning to sustainability, Call for life randomised study experience in Uganda

IntroductionEvidence shows benefit of digital technology for people living with human immunodeficiency virus on antiretroviral therapy adherence and retention in care, however, scalability and sustainability have scarcely been evaluated. We assessed participants' willingness to pay a fee for mHealth "Call for life Uganda" support, a mobile-phone based tool with the objective to assess sustainability and scalability.Methods"Call for Life study", approved by Makerere University, School of Public Health research &amp; ethics committee, at 2 sites in Uganda, evaluated a MoTech based software "CONNECT FOR LIFE™" mHealth tool termed "Call for life Uganda". It provides short messages service or Interactive Voice Response functionalities, with a web-based interface, allows a computer to interact with humans through use of voice and tones input via keypad. Participants were randomized at 1:1 ratio to Standard of Care or standard of care plus Call for life Uganda. This sends pill reminders, visit reminders, voice messages and self-reported symptom support. At study visits 18 and 24&nbsp;months, through mixed method approach we assessed mHealth sustainability and scalability. Participants were interviewed on desire to have or continue adherence support and willingness to pay a nominal fee for tool. We computed proportions willing to pay (± 95% confidence interval), stratified by study arm and predictors of willingness to continue and to pay using multivariate logistic regression model backed up by themes from qualitative interviews.Results95% of participants were willing to continue using C4LU with 77.8% willing to pay for the service. Persons receiving care at the peri-urban clinic (OR 3.12, 95% CI 1.43-9.11.86) and those with exposure to the C4LU intervention (OR 4.2, 95% CI 1.55-11.84) were more likely to continue and pay for the service. Qualitative interviews revealed mixed feelings regarding amounts to pay, those willing to pay, argued that since they have been paying for personal phone calls/messages, they should not fail to pay for Call for life.ConclusionsPayment for the service offers opportunities to scale up and sustain mHealth interventions which may not be priorities for government funding. A co-pay model could be acceptable to PLHIV to access mHealth services in low resource settings. Clinical Trial Number NCT02953080

<i>Cdkn1c</i> is expressed and imprinted in rpWAT and iBAT.

<p>(A) QPCR of <i>Cdkn1c</i> in P7 rpWAT, subcutaneous (sc) WAT, and iBAT relative to mesenteric (mes) WAT (n = 4 each depot taken from two litters). Data expres sed as mean ± SEM, <i>t</i> test. ** <i>P</i> <0.01.(B) E16.5 transverse sections through IBAT depots stained for <i>Cdkn1c</i> mRNA and protein. (C) WT, BACx1 and BACx2 P7 iBAT sections stained for <i>Cdkn1c</i>. -galactosidase staining of P7 BAC-lacZ iBAT depot (far right panel). <i>Cdkn1c</i>-positive cells indicated by arrows. (D) WT, BACx1 and BACx2 P7 rpWAT sections stained for <i>Cdkn1c</i>. -galactosidase staining of P7 BAC-lacZ rpWAT depot (far right panel). <i>Cdkn1c</i>-positive cells indicated by arrows. (E) <i>Cdkn1c</i> maternal allele-specific expression in P7 and adult iBAT and rpWAT from hybrid offspring from BL6 female mated with a BL6^spretus-chr7 male assessed by the presence (BL6; B) or absence (<i>spretus</i>; S) of an <i>AvaI</i> restriction enzyme site within the <i>Cdkn1c</i> PCR product. (F) Average methylated CpGs per sample with examples of differential methylation of <i>Cdkn1cDMR</i> in P7 and adult iBAT and rpWAT. Each row corresponds to an individual sequenced DNA clone. Each circle represents a CpG on the strand, filled circles and open circles indicate methylated and unmethylated sites, respectively. Percentage values given for n = 3 of each condition.</p

CDKN1C and PRDM16 co-localise to the nucleus of rare BrdU label-retaining cells in iBAT.

<p>(A) Confocal imaging of P7 iBAT co-stained for CDKN1C and PRDM16. DNA is stained with 4′,6-diamidino-2-phenylindole (DAPI, blue). (B) Western analysis of PRDM16 protein after siRNA-induced knock-down of <i>Cdkn1c</i> in the undifferentiated brown fat preadipocyte cell line HIB1.1. (C) Immunohistochemistry for CDKN1C (green), PRDM16 (red) and BRDU (purple) in WT iBAT 8 weeks after <i>in utero</i> pulsed exposure to BrdU. DNA (DAPI, blue).</p

<i>Cdkn1c</i> promotes the browning of WAT in young mice.

<p>(A) H&E of P7 WT, BACx1 and BACx2 rpWAT (WT from line BACx1). (B) Electron micrograph of WT and BACx1 P7 rpWAT (4000X). Mitochondria indicated by m and lipid by l. (C) QPCR analysis of <i>Cdkn1c</i> mRNA levels in P7 rpWAT from BACx1 and BACx2 relative to wild type controls. (D) QPCR of BAT-selective genes in WT, BACx1 and BACx2 P7 rpWAT. (E) Western blot analysis of UCP1, PRDM16 and β-ACTIN in P7 rpWAT from single litters of WT and BACx1 pups. Data expressed as mean ± SEM, <i>t</i> test. * <i>P</i> <0.05; ** <i>P</i> <0.01; *** <i>P</i> <0.005.</p

Elevated <i>Cdkn1c</i> drives thinness in adult mice.

<p>(A) Weights of WT and BAC transgenic male and female mice at 10 weeks. (B) Dissection of WT and BAC transgenic mice at 10 weeks to reveal adipose depots <i>in situ</i>. (C) Weights of adipose depots relative to body weights. (D) Food consumption per day, measurements taken over 5 days. (E) Rectal body temperature. (F) H&E sections of 10 week rpWAT depots from WT, BACx1 and BACx2 and BAClacZ (WT from line BACx1). (G) QPCR analysis of <i>Cdkn1c</i>, <i>Ucp1</i> and <i>Elovl3</i> in BACx1 female 10 week rpWAT depots (n = 4 per genotype). Data expressed as mean ± SEM, <i>t</i> test.</p