New insights into the genetic etiology of Alzheimer's disease and related dementias

Characterization of the genetic landscape of Alzheimer's disease (AD) and related dementias (ADD) provides a unique opportunity for a better understanding of the associated pathophysiological processes. We performed a two-stage genome-wide association study totaling 111,326 clinically diagnosed/'proxy' AD cases and 677,663 controls. We found 75 risk loci, of which 42 were new at the time of analysis. Pathway enrichment analyses confirmed the involvement of amyloid/tau pathways and highlighted microglia implication. Gene prioritization in the new loci identified 31 genes that were suggestive of new genetically associated processes, including the tumor necrosis factor alpha pathway through the linear ubiquitin chain assembly complex. We also built a new genetic risk score associated with the risk of future AD/dementia or progression from mild cognitive impairment to AD/dementia. The improvement in prediction led to a 1.6- to 1.9-fold increase in AD risk from the lowest to the highest decile, in addition to effects of age and the APOE ε4 allele

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

Background: In this study, we aimed to evaluate the effects of tocilizumab in adult patients admitted to hospital with COVID-19 with both hypoxia and systemic inflammation. Methods: This randomised, controlled, open-label, platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing several possible treatments in patients hospitalised with COVID-19 in the UK. Those trial participants with hypoxia (oxygen saturation <92% on air or requiring oxygen therapy) and evidence of systemic inflammation (C-reactive protein ≥75 mg/L) were eligible for random assignment in a 1:1 ratio to usual standard of care alone versus usual standard of care plus tocilizumab at a dose of 400 mg–800 mg (depending on weight) given intravenously. A second dose could be given 12–24 h later if the patient's condition had not improved. The primary outcome was 28-day mortality, assessed in the intention-to-treat population. The trial is registered with ISRCTN (50189673) and ClinicalTrials.gov (NCT04381936). Findings: Between April 23, 2020, and Jan 24, 2021, 4116 adults of 21 550 patients enrolled into the RECOVERY trial were included in the assessment of tocilizumab, including 3385 (82%) patients receiving systemic corticosteroids. Overall, 621 (31%) of the 2022 patients allocated tocilizumab and 729 (35%) of the 2094 patients allocated to usual care died within 28 days (rate ratio 0·85; 95% CI 0·76–0·94; p=0·0028). Consistent results were seen in all prespecified subgroups of patients, including those receiving systemic corticosteroids. Patients allocated to tocilizumab were more likely to be discharged from hospital within 28 days (57% vs 50%; rate ratio 1·22; 1·12–1·33; p<0·0001). Among those not receiving invasive mechanical ventilation at baseline, patients allocated tocilizumab were less likely to reach the composite endpoint of invasive mechanical ventilation or death (35% vs 42%; risk ratio 0·84; 95% CI 0·77–0·92; p<0·0001). Interpretation: In hospitalised COVID-19 patients with hypoxia and systemic inflammation, tocilizumab improved survival and other clinical outcomes. These benefits were seen regardless of the amount of respiratory support and were additional to the benefits of systemic corticosteroids. Funding: UK Research and Innovation (Medical Research Council) and National Institute of Health Research

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

Background: Many patients with COVID-19 have been treated with plasma containing anti-SARS-CoV-2 antibodies. We aimed to evaluate the safety and efficacy of convalescent plasma therapy in patients admitted to hospital with COVID-19. Methods: This randomised, controlled, open-label, platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]) is assessing several possible treatments in patients hospitalised with COVID-19 in the UK. The trial is underway at 177 NHS hospitals from across the UK. Eligible and consenting patients were randomly assigned (1:1) to receive either usual care alone (usual care group) or usual care plus high-titre convalescent plasma (convalescent plasma group). The primary outcome was 28-day mortality, analysed on an intention-to-treat basis. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936. Findings: Between May 28, 2020, and Jan 15, 2021, 11558 (71%) of 16287 patients enrolled in RECOVERY were eligible to receive convalescent plasma and were assigned to either the convalescent plasma group or the usual care group. There was no significant difference in 28-day mortality between the two groups: 1399 (24%) of 5795 patients in the convalescent plasma group and 1408 (24%) of 5763 patients in the usual care group died within 28 days (rate ratio 1·00, 95% CI 0·93–1·07; p=0·95). The 28-day mortality rate ratio was similar in all prespecified subgroups of patients, including in those patients without detectable SARS-CoV-2 antibodies at randomisation. Allocation to convalescent plasma had no significant effect on the proportion of patients discharged from hospital within 28 days (3832 [66%] patients in the convalescent plasma group vs 3822 [66%] patients in the usual care group; rate ratio 0·99, 95% CI 0·94–1·03; p=0·57). Among those not on invasive mechanical ventilation at randomisation, there was no significant difference in the proportion of patients meeting the composite endpoint of progression to invasive mechanical ventilation or death (1568 [29%] of 5493 patients in the convalescent plasma group vs 1568 [29%] of 5448 patients in the usual care group; rate ratio 0·99, 95% CI 0·93–1·05; p=0·79). Interpretation: In patients hospitalised with COVID-19, high-titre convalescent plasma did not improve survival or other prespecified clinical outcomes. Funding: UK Research and Innovation (Medical Research Council) and National Institute of Health Research

Accuracy of methods of sex steroid determination

Reproductive hormones (estrogenic and androgenic steroids) enter natural water bodies from various sources, e.g. human sewage, farmed livestock and vertebrate wildlife. A previous Defra research study (SF0241 Impacts of intensive in-river aquaculture on wild salmonids) reported very high concentrations of such steroids in two UK rivers (the River Test and R. Avon in Hampshire/Wiltshire) in the vicinity of trout farms. The mean reported concentrations of the natural steroids 11-ketotestosterone (11-KT), testosterone (T) and oestradiol (E2) ranged from 4 to 79 ng/L. The maximum level observed in an individual sample was 145 ng/L for 11-KT. Furthermore, the subject brown trout and rainbow trout farms were implicated as a source of the steroids, as mean levels reported “downstream” of the trout farms were 1.3 to 6 fold higher than those “upstream”. Nevertheless, the steroid concentrations reported both upstream and downstream of the trout farms would be of great concern for wild fish in these rivers due to potential for endocrine disruption, i.e. when exogenous substances negatively impact the endogenous hormone systems and reproductive function of the organism. The synthetic sex steroid ethinyl-estradiol (EE2) was also measured in the SF0241 study. EE2 originates from human prescription medicine (the contraceptive pill) via sewage treatment works, and has been studied in rivers due to its endocrine disruptive activity. Levels of EE2 reported in SF0241 were one to two orders of magnitude lower than the natural steroids. Mean values were in the range of 0.13 – 0.30 ng/L, and were not found to be elevated downstream of the trout farms. The very high levels of the natural sex steroids that were reported were not only of concern because of potential adverse effects on resident fish, but were also surprisingly high. In the SF0241 study, all steroid levels in acquired water samples had been measured using commercial Enzyme-ImmunoAssay (EIA) kits (also referred to as Enzyme-Linked Immuno-Sorbent Assay, ELISA kits). However, the kits used to measure the natural steroids used a different enzyme component in the assay to the EE2 kits. Environmental water samples are typically concentrated before assay, and it was speculated that other compounds in the river water may have interfered with the enzyme stage in the kits for the natural steroids. It was therefore hypothesised that the very high concentrations of the natural steroids reported in SF0241 were false positives due to interference in the EIAs. Due to concern over the possible inaccuracy of the EIA kits (and trout farms as a source of endocrine disrupting compounds), Defra’s Chemicals and Nanotechnology Division funded this project (CB0427) to examine the “Accuracy of methods of sex steroid determination”. The aim of the project was to test the above hypothesis by repeating the sampling and sample processing, and then assaying for the steroids using the EIA kits and an additional method – radioimmunoassay (RIA) - expected to be less susceptible to interference. Water samples were collected from the two trout farm sites, one on the R. Test and one on the R. Avon, between January and June 2010 and extracted (C18 solid phase extraction (SPE) followed by extract clean-up with aminopropyl SPE). Additional “spiked” and “blank” water samples were also prepared and processed. Four independent laboratories conducted EIAs and RIAs (3 laboratories per assay technique) for the four steroids (11-KT, T, E2, EE2) using replicate aliquots of the same 44 samples, each aliquot representing ca 1 L of river water. Participating laboratories (other than the lead laboratory) conducted the assays blind (i.e. were unaware of the sample details) and returned the calculated steroid concentrations to the project leaders for collation. A few anomalous results were questioned and, upon investigation, were found to be due to human errors and were subsequently corrected. There was broad agreement between the EIA and RIA measurements for all four steroids showing that the EIA kits did not generate erroneously high values. The base hypothesis for the project, i.e. that some EIA kits generate erroneously high values, was therefore rejected. The two assay methods were comparable for accuracy and precision. Recovery of steroids using the SPE methodology was examined using water samples spiked with known amounts of steroids. It was found that the recovery efficiency varied between samples and steroids. Higher recoveries were evident for the oestrogens (mean recovery 69% and 67% for E2 and EE2 respectively) than for the androgenic compounds (mean recovery 29% and 46% for 11KT and T respectively). Measured steroid concentrations in river water samples were all <0.6 ng/L. The measured concentrations cannot be considered definitive, as they are uncorrected for recovery efficiency. Nevertheless, they are considered low, unlikely to be of concern for endocrine disruption, and demonstrate that the water steroid levels reported in SF0241 were not typical of river steroid concentrations in 2010. The levels of 11KT, T, E2 and EE2 in the rivers were respectively 1300, 70, 90 and 3 times lower than reported in SF0241. In addition to the major difference in measured levels between the two studies: • the relative concentrations also differed, with 11KT being the lowest rather than highest as reported in SF0241. • river steroid levels were higher in Spring rather than the Winter period, being opposite to the seasonal effect reported in SF0241 • river EE2 levels in 2010 were too low to be detectable by EIA (equivalent to <0.05 ng/L). • the clear elevation in river water concentrations of the natural steroids associated with the fish farms reported in SF0241 was not evident in the present study. It was not possible to provide a definitive explanation for the differences found between the present results and those reported within SF0241. Eleven alternate hypotheses are discussed that could have contributed to the divergent results. The available evidence points towards miscalculation and assaying errors within SF0241 as the probable cause of differences. However, this hypothesis could not be definitively accepted because the raw assay data and the calculations from which the SF0241 results derived had not been retained. Published information on steroid output from fish farms is presented. It is suggested that there is no urgent requirement to further examine the steroid output from UK fish farms. Although the current research did indicate a possible 0.13 ng/L increase in testosterone in the immediate outflow of one farm, this was questionable and, if real, is below concentrations that cause endocrine disruption and would be further diluted in the receiving channel and then main river. During this project, a number of potential sources of error associated with the measurement of steroids from samples were identified and are discussed. It is suggested that guidance for quality control could be developed. Future research into river water steroids could also include: • comparisons of the recovery efficiencies of different steroids from water samples, and a full optimisation and validation of the most appropriate extraction methodology for the different steroids • a comparison of ‘modelled’ versus ‘measured’ river water steroid levels to examine whether the exclusion of other sources of steroids, e.g. agricultural livestock, is an important omission

Gliotoxin stimulates the apoptosis of human and rat hepatic stellate cells and enhances the resolution of liver fibrosis in rats

Background &amp; Aims: Hepatic stellate cells (HSCs) play a pivotal role in liver fibrosis and stimulating their apoptosis could be an effective treatment for liver fibrosis.Methods: Activated HSCs, hepatocytes, and rats with liver fibrosis were treated with gliotoxin.Results: Addition of gliotoxin to activated (-smooth muscle actin positive) rat and human HSCs resulted in morphologic alterations typical of apoptosis. Within 2–3 hours of incubation, caspase 3 activity was markedly induced and caspase inhibitor 1 (Z-VAD-FMK)-sensitive oligonucleosome-length DNA fragments were detectable by gel electrophoresis of low molecular weight DNA. Apoptosis was widespread as judged by fluorescence-activated cell sorter analysis and terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate nick-end labeling staining in both rat and human HSCs at concentrations that had no effect on the viability of rat hepatocytes. Gliotoxin treatment significantly reduced the number of activated stellate cells and mean thickness of bridging fibrotic septae in livers from rats treated with carbon tetrachloride.Conclusions: These data demonstrate proof-of-concept that by up-regulating HSC apoptosis, the extent of fibrosis can be decreased in inflammatory liver injury

Creating community‐based indicators of gender equity: A methodology

It appears that an almost unquestioned development pathway for achieving gender equity and women's empowerment has taken centre stage in mainstream development. This pathway focuses on economic outcomes that are assumed to be achieved by increasing women's access to material things, including cash income, loans, physical assets, and to markets. Gender equity indicators, which measure progress towards these outcomes, cannot escape reinforcing them. We argue that far from being neutral, indicators are embedded in political and ideological agendas that serve as guides to the appropriate conduct of those whose performance or behaviour is being measured. Drawing on participatory feminist, diverse economies and strengths based approaches, we outline a research methodology for developing community-based indicators that recognises women's and men's participation and relationships in all spheres of life, including the ‘non-economic’. If indicators are grounded in local meanings and realities, we propose that community members can use them to identify aspirational goals for gender equity, and measure progress towards these goals