Idiopathic thrombocytopenic purpura: current concepts in pathophysiology and management.

Idiopathic thrombocytopenic purpura (ITP) is characterized by a low platelet count, which is the result of both increased pla- telet destruction and insufficient platelet production. Although the development of autoantibodies against platelet glycoproteins remains central in the pathophysiology of ITP, several abnormalities involving the cellular mechanisms of immune modu- lation have been identified. Conventional treatments for ITP aim at reducing platelet destruction, either by immunosuppression or splenectomy. Two new thrombopoietic agents,AMG 531 and eltrombopag, have been used in clinical trials to stimulate platelet production in ITP patients not responsive to standard treatments. These new molecules bear no structural resemblance to thrombopoietin, but still bind and activate the thrombopoietin receptor. This review will focus on the pathophysiology and treatment of ITP in adults, highlighting recent advances in both fields

A large-eddy simulation (LES) model for wind-farm-induced atmospheric gravity wave effects inside conventionally neutral boundary layers

The interaction of large wind farm clusters with the thermally stratified atmosphere has emerged as an important physical process that impacts the productivity of wind farms. Under stable conditions, this interaction triggers atmospheric gravity waves (AGWs) in the free atmosphere due to the vertical displacement of the atmospheric boundary layer (ABL) by the wind farm. AGWs induce horizontal pressure gradients within the ABL that alter the wind speed distribution within the farm, influencing both wind farm power generation and wake development. Additional factors, such as the growth of an internal boundary layer originating from the wind farm entrance and increased turbulence due to the wind turbines, further contribute to wake evolution. Recent studies have highlighted the considerable computational cost associated with simulating gravity wave effects within large-eddy simulations (LESs), as a significant portion of the free atmosphere must be resolved due to the large vertical spatial scales involved. Additionally, specialized boundary conditions are required to prevent wave reflections from contaminating the solution. In this study, we introduce a novel methodology to model the effects of AGWs without extending the LES computational domain into the free atmosphere. The proposed approach addresses the wave reflection problem inherently, eliminating the need for these specialized boundary conditions. We utilize the recently developed multi-scale coupled (MSC) model of Stipa et al. (2024b) to estimate the vertical ABL displacement triggered by the wind farm, and we apply the deformation to the domain of an LES that extends only to the inversion layer. The accuracy in predicting the AGW-induced pressure gradients is equivalent to the MSC model. The AGW modeling technique is verified for two distinct free-atmosphere stability conditions by comparing it to the traditional approach in which AGWs are fully resolved using a domain that extends several kilometers into the free atmosphere. The proposed approach accurately captures AGW effects on the row-averaged thrust and power distribution of wind farms while demanding 12.7 % of the computational resources needed for traditional methods. Moreover, when conventionally neutral boundary layers are studied, there is no longer a need to solve the potential temperature equation, as stability is neutral within the boundary layer. The developed approach is subsequently used to compare the global blockage and pressure disturbances obtained from the simulated cases against a solution characterized by zero boundary layer displacement, which represents the limiting case of very strong stratification above the boundary layer. This approximation, sometimes referred to as the “rigid lid”, is compared against the full AGW solution using the MSC model. This is done for different values of inversion strength and free atmosphere lapse rate, evaluating the ability of the “rigid lid” to predict blockage, wake effects, and overall wind farm performance.</p

Epilepsy with auditory features: A heterogeneous clinico-molecular disease

Objective: To identify novel genes implicated in epilepsy with auditory features (EAF) in phenotypically heterogeneous families with unknown molecular basis. Methods: We identified 15 probands with EAF in whom an LGI1 mutation had been excluded. We performed electroclinical phenotyping on all probands and available affected relatives. We used whole-exome sequencing (WES) in 20 individuals with EAF (including all the probands and 5 relatives) to identify single nucleotide variants, small insertions/deletions, and copy number variants. Results: WES revealed likely pathogenic variants in genes that had not been previously associated with EAF: a CNTNAP2 intragenic deletion, 2 truncating mutations of DEPDC5, and a missense SCN1A change. Conclusions: EAF is a clinically and molecularly heterogeneous disease. The association of EAF with CNTNAP2, DEPDC5, and SCN1A mutations widens the phenotypic spectrum related to these genes. CNTNAP2 encodes CASPR2, a member of the voltage-gated potassium channel complex in which LGI1 plays a role. The finding of a CNTNAP2 deletion emphasizes the importance of this complex in EAF and shows biological convergence

New records of rare species in the Mediterranean Sea (October 2021)

This Collective Article presents information about 27 taxa belonging to five Phyla (one Ochrophyta, one Cnidaria, three Arthropoda, two Mollusca and twenty Chordata) and extending from the Western Mediterranean Sea to the Levantine Sea and theBlack Sea (Sea of Marmara). The new records were reported from 11 countries as follows: Algeria: occurrence of the Africanstriped grunt Parapristipoma octolineatum; Spain: new records of eight uncommon fish species (Gadella maraldi, Hypleurochilusbananensis, Lobotes surinamensis, Parapristipoma octolineatum, Selene dorsalis, Sphoeroides marmoratus, Tetragonuruscuvieri, and Trachyrincus scabrus) from the Spanish Mediterranean; Italy: new record of the football octopus Ocythoe tuberculatafrom the Southern Tyrrhenian Sea; a rare sighting of a juvenile phase of a moray eel of the genus Gymnothorax, tentativelyidentified as Gymnothorax cf. unicolor in the Ligurian Sea; first record of adult Facciola’s sorcerer Facciolella oxyrhynchus inthe Adriatic Sea; occurrence of the tope shark Galeorhinus galeus in the Northern Adriatic Sea; Libya: first confirmed recordof the pen shell Pinna rudis; first documented record of the palaemonid shrimp Brachycarpus biunguiculatus; first record of thefish Sudis hyalina; Malta: new records of Grant’s rockling, Gaidropsarus granti; multiple concomitant reports of the rare hydromedusanspecies Aequorea forskalea; Croatia: a record of the skipjack tuna Katsuwonus pelamis in the Southern Adriatic Sea;Albania: new record of the bigeye thresher shark Alopias superciliosus; Greece: confirmation of the rare brown alga Sargassumflavifolium occurrence in the Eastern Mediterranean Sea; first record of the scaleless dragonfish Bathophilus nigerrimus; Turkey:first occurrence of the calanoid copepod Pteriacartia josephinae in the Aegean Sea; first documented record of the Cremona’s seaslug Placida cremoniana for the easternmost Mediterranean Sea; new record of the yellow-headed goby Gobius xanthocephalusin the Sea of Marmara; Cyprus: first record of the Liechtenstein’s goby Corcyrogobius liechtensteini; an individual of the Yellowfintuna Thunnus albacares captured with handline by an artisanal fisher; Lebanon: an individual of the Black marlin Istiompaxindica captured in a gill ne

Transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND-study)

Background: Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications. The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas. Methods/design. Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma 3 cm, located between 115 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane i

Polygenic burden in focal and generalized epilepsies

Rare genetic variants can cause epilepsy, and genetic testing has been widely adopted for severe, paediatric-onset epilepsies. The phenotypic consequences of common genetic risk burden for epilepsies and their potential future clinical applications have not yet been determined. Using polygenic risk scores (PRS) from a European-ancestry genome-wide association study in generalized and focal epilepsy, we quantified common genetic burden in patients with generalized epilepsy (GE-PRS) or focal epilepsy (FE-PRS) from two independent non-Finnish European cohorts (Epi25 Consortium, n = 5705; Cleveland Clinic Epilepsy Center, n = 620; both compared to 20 435 controls). One Finnish-ancestry population isolate (Finnish-ancestry Epi25, n = 449; compared to 1559 controls), two European-ancestry biobanks (UK Biobank, n = 383 656; Vanderbilt biorepository, n = 49 494), and one Japaneseancestry biobank (BioBank Japan, n = 168 680) were used for additional replications. Across 8386 patients with epilepsy and 622 212 population controls, we found and replicated significantly higher GE-PRS in patients with generalized epilepsy of European-ancestry compared to patients with focal epilepsy (Epi25: P = 1.64 710-15; Cleveland: P = 2.85 710-4; Finnish-ancestry Epi25: P = 1.80 710-4) or population controls (Epi25: P = 2.35 710-70; Cleveland: P = 1.43 710-7; Finnish-ancestry Epi25: P = 3.11 710-4; UK Biobank and Vanderbilt biorepository meta-analysis: P = 7.99 710-4). FE-PRS were significantly higher in patients with focal epilepsy compared to controls in the non-Finnish, non-biobank cohorts (Epi25: P = 5.74 710-19; Cleveland: P = 1.69 710-6). European ancestry-derived PRS did not predict generalized epilepsy or focal epilepsy in Japanese-ancestry individuals. Finally, we observed a significant 4.6-fold and a 4.5-fold enrichment of patients with generalized epilepsy compared to controls in the top 0.5% highest GE-PRS of the two non-Finnish European cohorts (Epi25: P = 2.60 710-15; Cleveland: P = 1.39 710-2). We conclude that common variant risk associated with epilepsy is significantly enriched in multiple cohorts of patients with epilepsy compared to controls-in particular for generalized epilepsy. As sample sizes and PRS accuracy continue to increase with further common variant discovery, PRS could complement established clinical biomarkers and augment genetic testing for patient classification, comorbidity research, and potentially targeted treatment

The CARTS study: Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery

Contains fulltext : 96401.pdf (publisher's version ) (Open Access

A Controversy That Has Been Tough to Swallow: Is the Treatment of Achalasia Now Digested?

Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux

Ultra-Rare Genetic Variation in the Epilepsies : A Whole-Exome Sequencing Study of 17,606 Individuals

Sequencing-based studies have identified novel risk genes associated with severe epilepsies and revealed an excess of rare deleterious variation in less-severe forms of epilepsy. To identify the shared and distinct ultra-rare genetic risk factors for different types of epilepsies, we performed a whole-exome sequencing (WES) analysis of 9,170 epilepsy-affected individuals and 8,436 controls of European ancestry. We focused on three phenotypic groups: severe developmental and epileptic encephalopathies (DEEs), genetic generalized epilepsy (GGE), and non-acquired focal epilepsy (NAFE). We observed that compared to controls, individuals with any type of epilepsy carried an excess of ultra-rare, deleterious variants in constrained genes and in genes previously associated with epilepsy; we saw the strongest enrichment in individuals with DEEs and the least strong in individuals with NAFE. Moreover, we found that inhibitory GABA(A) receptor genes were enriched for missense variants across all three classes of epilepsy, whereas no enrichment was seen in excitatory receptor genes. The larger gene groups for the GABAergic pathway or cation channels also showed a significant mutational burden in DEEs and GGE. Although no single gene surpassed exome-wide significance among individuals with GGE or NAFE, highly constrained genes and genes encoding ion channels were among the lead associations; such genes included CACNAIG, EEF1A2, and GABRG2 for GGE and LGI1, TRIM3, and GABRG2 for NAFE. Our study, the largest epilepsy WES study to date, confirms a convergence in the genetics of severe and less-severe epilepsies associated with ultra-rare coding variation, and it highlights a ubiquitous role for GABAergic inhibition in epilepsy etiology.Peer reviewe