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Kainth. €œWhat I have been doing, being a very small practice, is any chance I could get I would buy a box of N95s [face masks], but they’re quite expensive. Like, one box of 25 masks was $120. And so, when you have staff and yourself…obviously I want to keep them protected and I want to keep patients protected as well, so if we have the supplies, I want to use them. But when masks cost $5 a pop at least, it gets to be hard as a small office to be able to afford PPE.

Nonetheless, every time I’d get a chance to buy a box, I would buy one. There would often be a limit of how many boxes you could buy, so it’s not like we could buy more than one box at a time. €œHonestly, it’s always in the back of my mind. ’Am I going to run out?. €™ and ’When am I going to run out?.

€™ and ’What am I going to be able to do from there?. €™â€Manvinder Kainth, MD, (left) and clinical assistant Larissa Hendricks (right) receive new N95 masks from TMA. Photo courtesy of Manvinder Kainth, MD Me&My Doctor. Your need for PPE is still crucial for some in-person patient visits, though you use telemedicine to care for many patients virtually. Tell us about this.

Dr. Kainth. €œWhen erectile dysfunction treatment hit, I was fortunate that all of my patients were already used to phone call [doctor] visits, so they were not fazed as much when we couldn’t meet face-to-face. [However] sometimes I must examine the patient [in person] to really know what is going on. €œMy office is very small.

It’s me and one assistant, and we are it for our patient population. If one of us gets sick, we’re out of luck – and so are our patients. It’s important for us to be protected and to protect our patients as well when they must come in.“If I didn’t have the N95s, I really wouldn’t be seeing patients in the office because medically I know it’s not safe to do so, and I can’t [adequately] examine a patient if they’re six feet from me. There’s just no way to do it feasibly, and I do a lot of women’s health and just taking care of everybody. A lot of times it does involve a physical exam.

[In those cases] I put all the PPE on, and I train my staff to do the same. It’s not only to keep me and my staff protected, but also for my patients, their families, and whoever they are in contact with. It’s such a chain reaction that one small mask makes a huge difference.”Me&My Doctor. As a primary care physician practicing medicine during this levitra, can you explain why having this proper equipment matters to you and your patients?. Dr.

Kainth. €œI’ll tell you, in medicine, there are very few things that we, especially as physicians, get scared about because we are trained to deal with serious things and devastating things, and we can push our feelings aside and do what’s right for our patients. But when a levitra hits – and we all knew something was going to happen in our lifetime, we’ve been due for one – we are human, and we start to think about our safety and our loved ones’ safety. And without proper equipment, I don’t know how much I’d be able to help others – because honestly, I would be too scared to do so. It’s not so much being scared of the levitra, it’s fear of the spread.

I know how fast this can spread and how devastating it can be. €œWe can do so much more if we just have the right equipment. For the first few months of the levitra, none of us felt like we had enough until the county medical societies [and then TMA] gave us option to buy some.”Me&MyDoctor. What is something you, as a physician, want the public to know when it comes to protecting yourself from catching and spreading the levitra?. Dr.

Kainth. €œI need people to know that as physicians (and I think most of us are thinking this way) when we see a person we haven’t seen before and we have no PPE on, all I’m literally thinking is, ‘You [might] have erectile dysfunction treatment and we need to protect each other, so let’s stay 6 feet apart, wear our masks, I don’t touch anything you touch, and I am constantly washing my hands.’ Some people think that it’s overboard, and they can think that. But the science doesn’t lie. We know how this is transmitted, we know a lot of it is spread when you have no signs or symptoms and it’s smarter to be cautious than to not, because it’s not that hard to be cautious.”Me&MyDoctor. What would you say to people who are experiencing levitra fatigue, especially about social distancing?.

Dr. Kainth. €œI know the hard part is the social distancing, but I try to remind people you don’t have to completely socially distance, I just need you to physically distance, and there’s a difference. I try to remind my patients, ‘I don’t want you to stop having relationships with other people. I just want – when you do get together – for you to be smart and stay 6 feet apart and pretend like you all have erectile dysfunction treatment.’ Play a game of ‘we all have erectile dysfunction treatment’ and wear a mask and wash your hands and wipe down surfaces and don’t share food or drinks.

€œI just had a patient who went to a wedding recently and so far about two thirds of [the attendees] have turned out positive. Not only have they turned out positive, their elderly family members who were not at the wedding are now positive as well. Again, it’s a chain reaction.

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CAIRO, Ill levitra 5mg review. €” Lee Wright was hard at work, constructing a nail salon near the city’s abandoned hospital, when Jody Johnson stopped by to introduce himself on a recent afternoon. Johnson, who works for the University of Illinois Extension program, chatted with Wright casually in levitra 5mg review the summertime heat.

For Johnson, it was the first step to building trust in this city of fewer than 2,200 people as extension programs across the U.S — long valued in many rural communities for helping farmers and supporting 4-H clubs — expand their service to include educating the public about erectile dysfunction treatments. Wright, 68, was unvaccinated and planned to remain so, even though he’d followed other public health guidelines during the levitra. When it came to getting the shots, he decided to levitra 5mg review leave his fate to his faith.

€œDoctors are good. Don’t get me wrong,” Wright said. €œBut we levitra 5mg review got to have something that we can really depend on.” Johnson didn’t talk to Wright about the treatments that day.

He just listened instead. €œNo one wants to feel ashamed or belittled because they’re not doing something,” Johnson said later. University of Illinois Extension director Jody Johnson exchanges levitra 5mg review contact information with Cairo residents Lee Wright and son Roman Wright.

The agency’s office in southern Illinois is launching a vaccination education program that aims to reach this storied city on the banks of the Mississippi and Ohio rivers.(Cara Anthony / KHN) Only 16% of residents here in Alexander County are fully vaccinated against erectile dysfunction treatment, the lowest rate in Illinois, according to the state health department. And case levitra 5mg review counts of erectile dysfunction s are rising. So the Cooperative Extension System, which is tied to a network of land-grant universities, plans to spend the next two years talking about treatments in this community and elsewhere.

It may take that long or more to persuade enough people to get vaccinated. The extension system has a tradition of bringing research-based information to communities on a wide levitra 5mg review variety of topics, including water quality, food safety and disaster preparedness. With its roots sunk deep in rural America, where treatments have been slow to catch on, the system is now using state and federal funding to pay for immunization education efforts tailored to specific communities.

Already 4-H clubs have been making masks and face shields. In Illinois, levitra 5mg review the agency has a erectile dysfunction treatment resource guide for families, business owners and farmers. The office covering the southern portion of the state is now looking to hire someone in the community to help get out the word on why vaccinations matter.

Johnson also wants to team up with local churches, civic groups and business owners to get the job done. €œThis is not levitra 5mg review our first global levitra,” said Carissa Nelson, a spokesperson for 4-H programs in Illinois. The organization’s agents and club members nursed patients during the 1918 flu levitra that devastated the world.

This time around, the extension service’s strategy could also levitra 5mg review help in these rural communities and the urban areas it serves. But local leaders say there’s no quick solution for improving vaccination rates in Cairo or across the country. Getting people vaccinated is a nuanced challenge in every community.

In Cairo, a long history of levitra 5mg review racial tension dating to the Civil War still stings. Like many rural towns across the U.S., the community also feels underappreciated and misunderstood. Antebellum homes such as Magnolia Manor serve as reminders of the Cairo’s majestic past.

(Cara Anthony / KHN) Built in 1869, the mansion has been listed on the National Register of Historic Places since Dec levitra 5mg review. 17, 1969. (Cara Anthony / KHN) The shell of Cairo, Illinois, remains intact, with many of the city’s historical homes still standing.(Cara Anthony / KHN)As motorists enter Cairo, Illinois, a billboard promotes the city’s historical sites and landmarks.

Founded in 1818, the city was home to more than 15,000 people in the early 20th century, helping it earn the nicknames “Little Chicago” and “the Gateway to the South.” Today just over 2,100 people live in Cairo.(Cara Anthony / KHN)The Gem Theatre in Cairo, Illinois, closed in 1995 levitra 5mg review. The city is often mislabeled as abandoned. €œCairo is not a ghost town,” levitra 5mg review says Ronnie Woods, a local pastor and retired schoolteacher.

€œIt’s not dead at all.” (Cara Anthony / KHN) treatment apathy is common here, where rates remained low until recently. €œWe haven’t had great turnouts,” said Tyrone Coleman, president and co-founder of the Alexander and Pulaski NAACP chapter, which has helped organize treatment clinics in Cairo. In June, he levitra 5mg review invited the health department to the city’s Juneteenth celebration at St.

Mary’s Park. More than 300 people attended. But the event’s pop-up clinic hosted by the state didn’t have many seeking vaccinations during its six hours levitra 5mg review of operation.

€œWe only had two,” Coleman said. More than 15,000 people lived in Cairo in the early 20th century, helping it earn the nicknames “Little Chicago” and “the Gateway to the South.” Old factories, antebellum homes, an ornate library and a vacant hospital remain as reminders of the city’s majestic past. The city’s library prominently levitra 5mg review displays the work of Samuel Clemens, the American writer best known as Mark Twain.

After traveling through Cairo, Twain wrote about the city in his 1884 novel “The Adventures of Huckleberry Finn.” In the novel, Cairo represents freedom and the chance for a better life. But the hospital shut down in 1987 levitra 5mg review. The only grocery store in town closed years ago, public housing was torn down in recent years, and the only nursing home closed during the levitra, forcing residents to find a new place to live without much notice.

On top of all that, flooding has threatened to wipe the city out more than once. Southern Medical Center, the levitra 5mg review only hospital in Cairo, shut down in 1987. Residents in need of medical treatment visit a local clinic or travel to other hospitals in the region.

(Cara Anthony / KHN) Aperion Care Cairo, the only nursing home in Cairo, closed during the levitra, forcing residents to find a new place to live without much notice. (Cara Anthony / levitra 5mg review KHN) Today, fewer than 2,200 people, the majority of them Black, live here. And locals say the population has continued to drop with all the closures.

The city is often mislabeled by the press and travel guides as abandoned. €œCairo is not a ghost town,” said levitra 5mg review Ronnie Woods, a local pastor and retired schoolteacher. €œIt’s not dead at all.” Tourists still stop by to see the confluence of the Mississippi and Ohio rivers.

But they don’t typically see levitra 5mg review the rocky riverbank where residents fish for their dinner. Beverly Davis, 60, heads there often with rod in hand and gives much of her catch away to other members of the community. The scenic waterfront, though, is carpeted with driftwood and dead fish that washed ashore.

€œI guess it’s meant to levitra 5mg review be like this,” Davis said, standing on the riverbanks among the fish carcasses. €œâ€™Cause if not, it would be better.” Tourists still stop by to see the confluence of the Mississippi and Ohio rivers in the city of Cairo, Illinois, where commercial ships dock on the banks. (Cara Anthony / KHN) Beverly Davis shows off a catfish she caught on June 22 along the riverbank in Cairo, Illinois.

Davis fishes often for dinner and gives levitra 5mg review away much of her catch to the community. (Cara Anthony / KHN) But many residents continue to believe their city will return to its past glory. €œThe world hears that this is a negative part of the country, and it’s not,” Johnson said.

€œWe’ve got too many good things and people here.” On this day, the only outdoor basketball court in the city, anchored by a single hoop, was busy in a rural levitra 5mg review community that was fighting to stay alive long before the levitra hit. The men on the court didn’t seem worried about catching erectile dysfunction treatment. €œI haven’t had levitra 5mg review erectile dysfunction treatment, so I feel like I don’t need to get vaccinated right now,” said Jeffery DeWitt, 24.

€œI’ll just take it as it goes.” Today, the only outdoor basketball court in Cairo, anchored by a single hoop, is a gathering spot in this rural community that was fighting to stay alive long before the levitra hit. (Cara Anthony / KHN) Wright’s son, Roman Wright, 36, said much the same thing while helping his dad build the nail salon across town. He works for the prison system, and one of its facilities nearby reported erectile dysfunction treatment levitra 5mg review cases.

But he hadn’t contracted the disease. Like his father, he said he didn’t plan on getting the shots. €œI’m like my dad,” Roman Wright levitra 5mg review said.

€œI was born and raised in church all my life. So I say we believe in God. I know levitra 5mg review my parents pray for me.

We pray for each other and we just believe in God.” Woods, the pastor, has a different point of view. He keeps his vaccination card in a plastic levitra 5mg review sheath and carries it with him wherever he goes. €œI have strong faith,” said Woods, 66.

€œAnd at my age, my risk factors, I just felt that God placed science there to help us.” Ronnie Woods, a local pastor and retired schoolteacher who stopped by Cairo’s public library on June 23, says he is vaccinated against erectile dysfunction treatment. €œI have strong faith,” levitra 5mg review Woods says. €œAnd at my age, my risk factors, I just felt that God placed science there to help us.”(Cara Anthony / KHN) But Woods said it’s going to take work to persuade others in Cairo to get vaccinated, even if they know someone who died of erectile dysfunction treatment.

A prominent doctor was among the dead in the community. €œIt’s going to take more than explaining, it is going levitra 5mg review to take a cultural shift because people are just not trusting,” he said. That’s one reason Johnson is searching for a local voice to lead the extension service’s treatment education program over the next year.

As a 51-year-old white man who grew up in a predominantly white community 45 miles outside of Cairo, he recognizes that local residents would be more likely to share their thoughts with someone who lives here. Plus, he spends most of his time talking with levitra 5mg review community leaders and public officials. He is searching for someone who will spend time with locals who don’t hold titles and positions.

€œEverybody doesn’t think like me,” levitra 5mg review Johnson said. €œSo we need to take that into consideration.” Cara Anthony. canthony@kff.org, @CaraRAnthony Related Topics Contact Us Submit a Story TipSince reopening campus at the University of California-San Diego last summer, university officials have relied on the tried-and-true public health strategies of testing and contact tracing.

But they have also levitra 5mg review added a new tool to their arsenal. Excrement. That tool alerted researchers to about 85% of cases in dorms before they were diagnosed, according to a soon-to-be published study, said Rob Knight, a professor of pediatrics and computer science and engineering who helped create the campus’s wastewater testing program.

When erectile dysfunction treatment is detected in sewage, students, staffers and faculty members are tested, which has allowed the school to identify and isolate infected individuals who aren’t yet showing levitra 5mg review symptoms — potentially stopping outbreaks in their tracks. UC-San Diego’s testing program is among hundreds of efforts around California and the nation to turn waste into valuable health data. From Fresno, California, to Portland, Maine, universities, communities and businesses are monitoring human excrement for signs of erectile dysfunction treatment.

Researchers have levitra 5mg review high hopes for this sludgy new data stream, which they say can alert public health officials to trends in s and doesn’t depend on individuals getting tested. And because people excrete levitra in feces before they show symptoms, it can serve as an early warning system for outbreaks. The Centers for Disease Control and Prevention finds the practice so promising that it has created a federal database of wastewater samples, transforming raw data into valuable information for local health levitra 5mg review departments.

The program is essentially creating a public health tool in real time, experts say, one that could have a range of uses beyond the current global levitra, including tracking other infectious diseases and germs’ resistance to antibiotics. €œWe think this can really provide valuable data, not just for erectile dysfunction treatment, but for a lot of diseases,” said Amy Kirby, a microbiologist leading the CDC effort. The levitra that causes erectile dysfunction treatment infects many types of cells in the body, including those levitra 5mg review in the respiratory tract and gut.

The levitra’s genetic signature, viral RNA, makes its way into feces, and typically shows up in poop days before symptoms start. At UC-San Diego and other campuses, researchers take samples flowing from individual buildings, capturing such granular data that they can often deduce the number of infected people living or working there. But in most other settings, because of privacy concerns and resource constraints, testing is done on a much levitra 5mg review larger scale, with the goal of tracking trends over time.

Samples are drawn from wastewater, which is what comes out of our sewer pipes, or sludge, the solids that have settled out of the wastewater. They are typically extracted mechanically or by a human with a dipper on the end of a rod. When researchers in Davis, California, saw the viral load rise in several neighborhood sewage streams in July, levitra 5mg review they sent out text message alerts and hung signs on the doors of 3,000 homes recommending that people get tested.

Before the levitra, testing sewage to identify and ward off illness in the U.S. Was largely limited to levitra 5mg review academic use. Israel used it to stave off a polio outbreak in 2013, and some communities in the U.S.

Were sampling sewage before the levitra to figure out what kinds of opioids people in their communities were using, a service offered by the company Biobot. But when erectile dysfunction treatment hit the levitra 5mg review U.S. Amid political chaos and a shortage of tests, local governments scrambled for any information they could get on the levitra.

In rural Lake County, California, health officials had identified a handful of cases by sending nurses out to look for infected people. They were sure there were more but couldn’t get their hands on tests to prove it, so in spring 2020 they signed up for a free sewage testing program run by Biobot, which pivoted to erectile dysfunction treatment testing as the levitra took off and now is charging to test in K-12 schools, office buildings and nursing homes, in addition to local governments and universities, levitra 5mg review said Mariana Matus, CEO and co-founder of the company. The erectile dysfunction treatment levitra turned up in samples at four wastewater treatment facilities in Lake County.

€œIt is a way to just get more information because we can’t do testing,” Gary Pace, then the county’s health officer, told KHN at the time. As sewage sampling took off around the world, the levitra 5mg review U.S. Department of Health and Human Services began awarding grants in fall 2020 to wastewater treatment plants.

Biobot won a bid to run a second round of that program, currently underway through late August, testing the sewage of up to 30% of levitra 5mg review the U.S. Population. At least 25 California wastewater treatment plants are participating in the program, and numerous others are getting money from the CDC, working with local universities or paying for their own testing.

While such states as levitra 5mg review Ohio and Missouri have created public dashboards to show their data, California’s efforts remain scattershot. The test data alone doesn’t provide much value to health officials — it needs to be translated to be useful. Scientists are still learning how to read the data, a complicated process that involves understanding the relationships between how much levitra people excrete, how many people are using a wastewater system and how much rainwater is running into the system, potentially diluting the sewage, among many other factors.

Since using wastewater to levitra 5mg review track diseases was not widespread before the levitra, there’s been a steep and ongoing learning curve. Beleaguered public health officials have struggled to incorporate the new data into their already overwhelming workloads, but the CDC hopes it can address those issues with its new national system that tracks and translates wastewater data for local governments. Throughout 2020, Kirby, the CDC microbiologist, and engineer Mia Mattioli were a two-person wastewater team inside the agency’s larger 7,000-person erectile dysfunction treatment response.

During that time, levitra 5mg review academic colleagues generously shared what they knew about wastewater epidemiology, Kirby said. By September 2020, the pair had launched the National Wastewater Surveillance System, which interprets sampling data for state and local governments. Today, they lead a team of six and have a permanent place in levitra 5mg review one of the CDC’s departments.

€œEvery piece of this system had to be built largely from scratch,” Kirby said. €œWhen I look at that, it really amazes me where we are now.” In the months since the system debuted, it has been able to detect an uptick in cases anywhere from four to six days before diagnostic testing shows an increase, Kirby said. She hopes that by the end of next year the federal monitoring program will be levitra 5mg review used to check for a range of diseases, including E.

Coli, salmonella, norolevitra and a deadly drug-resistant fungus called Candida auris, which has become a global threat and wreaked havoc in hospitals and nursing homes. The longer these programs are up and running, the more useful they become, said Colleen Naughton, a professor and civil engineer at the University of California-Merced who leads erectile dysfunction treatmentPoops19, which tracks wastewater monitoring efforts globally. Naughton is working with colleagues at the University of California-Davis to launch monitoring programs near where she works in the Central Valley but is finding that some smaller communities don’t have the resources to conduct testing or sufficient health personnel to analyze levitra 5mg review or use the data.

It’s in these smaller communities with limited access to testing and doctors where the practice may hold the most promise, Naughton said. erectile dysfunction treatment laid bare long-standing inequities among communities that she fears will be perpetuated by the use of this new public health tool. Privacy concerns also need to be levitra 5mg review addressed, experts said.

Wastewater data hasn’t traditionally been considered protected personal health information the way diagnostic tests are. Health officials have managed earlier concerns about wastewater tracking of levitra 5mg review illicit drug use by sampling from large enough sewage streams to offer anonymity. But testing for certain health problems requires looking at DNA.

€œI think that’s going to be a challenge for public communication,” Knight said, “to make sure that’s not perceived as essentially spying on every individual’s genetic secrets.” Public health and wastewater officials said they are thrilled by the potential of this new tool and are working on ways to address privacy concerns while taking advantage of it. Greg Kester, levitra 5mg review director of renewable resource programs at the California Association of Sanitation Agencies, wrote to CDC officials in June 2020 asking for a federal surveillance network. He can hardly believe how quickly that call became a reality.

And he hopes it is here to stay, both for the ongoing levitra and for the inevitable next outbreak. €œAs vaccination rates increase and we get the variants, it’s still levitra 5mg review going to be important because clinical testing is decreasing,” Kester said. €œWe really want to make this part of the infrastructure.” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Anna Maria Barry-Jester. annab@kff.org, @annabarryjester Related Topics Contact Us Submit levitra 5mg review a Story TipEl CEO de Pfizer, Albert Bourla, confiaba en junio en la capacidad de la vacuna de su empresa para proteger contra la variante delta, altamente contagiosa, mientras se diseminaba por el mundo y llenaba de pacientes los hospitales estadounidenses. Apenas unas semanas después, Pfizer comunicó que solicitaría autorización para una vacuna de refuerzo, después que los primeros resultados de los ensayos mostraran que una tercera dosis aumentaba potencialmente la protección.

A finales de julio, Pfizer y BioNTech anunciaron que, entre cuatro y seis meses después de la segunda dosis, la eficacia de su vacuna se reducía a cerca levitra 5mg review del 84%. Bourla se apresuró a promover una tercera dosis tras las desalentadoras noticias, diciendo que estaba “muy, muy seguro” de que un refuerzo aumentaría los niveles de inmunidad en los vacunados. Hay un problema.

Pfizer aún no levitra 5mg review ha aportado pruebas concluyentes que respalden esa confianza. La empresa carece de resultados de ensayos clínicos de última fase que confirmen que el refuerzo funcionará contra las variantes de erectile dysfunction treatment, incluida delta, que actualmente representa el 93% de las nuevas infecciones en los Estados Unidos. Pfizer anunció su ensayo global de fase 3 sobre una tercera dosis a mediados de julio.

La fecha de finalización de levitra 5mg review ese ensayo es en 2022. Los resultados de la fase 3 suelen ser necesarios antes de la aprobación reglamentaria. €œConfiamos en esta vacuna y en la tercera dosis, pero hay que recordar que el estudio sobre la eficacia de la vacuna sigue en marcha, por lo que necesitamos todas las pruebas que lo respalden”, dijo, el 9 de agosto, Jerica Pitts, directora de relaciones con los medios a nivel mundial de Pfizer.

Lo que está levitra 5mg review en juego es enorme. Pfizer anunció, en julio, que espera obtener $33,500 millones en ingresos por la vacuna contra erectile dysfunction treatment este año. Mientras, Pfizer comunicó recientemente que, si una tercera dosis no podía combatir la variante delta u otras, la farmacéutica está preparada para presentar una vacuna levitra 5mg review “a medida” en un plazo de 100 días.

Todo esto ha sembrado confusión sobre qué funcionará exactamente, y cuándo. La prisa de la industria farmacéutica por recomendar refuerzos es “un poco frustrante”, señaló el doctor Paul Offit, director del Centro de Educación sobre Vacunas del Hospital Infantil de Philadelphia y asesor de los Institutos Nacionales de Salud y de la Administración de Alimentos y Medicamentos (FDA). Incluso si se comprueba que un refuerzo es seguro, el esfuerzo de Estados Unidos debería centrarse en “vacunar a quienes que no están levitra 5mg review vacunados”, puntualizó Offit.

En cualquier caso, las decisiones sobre los refuerzos no dependen de los fabricantes de vacunas, añadió. €œLas farmacéuticas no son organismos de salud pública, y no les corresponde determinar cuándo o si debe haber dosis de refuerzo”, explicó Offit. €œEso es competencia de los Centros para el Control y la Prevención de Enfermedades (CDC)” levitra 5mg review.

De hecho, los CDC y la FDA —las agencias federales que supervisan la autorización de las vacunas contra erectile dysfunction treatment— comunicaron en julio que los estadounidenses totalmente vacunados no necesitan una dosis de refuerzo. Las vacunas actualmente autorizadas —Pfizer, Moderna y Johnson &. Johnson— funcionan levitra 5mg review como deberían.

Las tres reducen el riesgo de erectile dysfunction treatment lo suficiente como para desarrollar una forma grave, hospitalizar o matar a una persona. Si las tasas de levitra 5mg review hospitalización y muerte aumentan entre los vacunados, entonces sería el momento de hablar de refuerzos, dijo Offit, pero “no estamos ahí, todavía”. La Casa Blanca se ha sumado a los mensajes contradictorios.

La vocera Jan Psaki confirmó que Estados Unidos comprará 200 millones de dosis adicionales de la vacuna de Pfizer-BioNTech para inocular a los menores de 12 años (en el futuro) y para posibles refuerzos. Natalie Dean, especialista en bioestadística de la Universidad de Emory en Atlanta, indicó que la confusión no es necesariamente culpa de ninguna institución, sino que “existe una auténtica incertidumbre científica levitra 5mg review sobre la eficacia de las vacunas [existentes] contra la nueva variante”. Los científicos están reuniendo información de estudios observacionales, investigaciones de brotes y análisis de las respuestas de los anticuerpos.

Para muchos estadounidenses —especialmente para quienes hace seis meses se esforzaron por encontrar alguna dosis, contratando frenéticamente a cazadores de vacunas y viajando varias horas para recibir su primera inyección— la confusión ha desencadenado una búsqueda febril de una tercera dosis ilícita, por si fuera necesaria. Angie Melton, de Kensington, Maryland, levitra 5mg review recibió la vacuna de Johnson &. Johnson de una sola dosis, en abril.

Pero desde entonces le preocupó que la contagiosa variante delta pudiera infectarla a ella y a su hijo de 10 años no vacunado. €œConseguí que me levitra 5mg review pusieran una dosis de Pfizer la semana pasada”, dijo Melton, quien también ha programado su segunda dosis. Tras consultar a amigos y médicos y ver informes sobre las combinaciones que se hacen en Europa, Melton se inscribió en el sitio de una farmacia local y pidió una cita para vacunarse con Pfizer.

También tiene programada levitra 5mg review una segunda inyección. €œIntento mantener a mi familia a salvo”, explicó Melton. El panel asesor de los CDC tenía previsto reunirse hoy, 13 de agosto, para considerar si son necesarias dosis adicionales de vacunas para las personas inmunodeprimidas.

También está levitra 5mg review en la agenda una presentación sobre los refuerzos. Pacientes inmunodeprimidos, como Sarah Keitt, que padece esclerosis múltiple y la enfermedad de Crohn, expresaron su alivio por el hecho de que los reguladores federales consideren recomendar una tercera dosis. Keitt, una activista por los derechos de los discapacitados que vive en Connecticut contó que su neurólogo le recomendó un refuerzo incluso después de haber recibido dos dosis de Moderna.

Dijo que estaba ansiosa por recibir otra dosis, pero que seguía frustrada por levitra 5mg review la falta de confianza en el grado de protección que ofrecería. €œSi alguien pudiera decirme definitivamente que hay un 95% de posibilidades de estar protegido” con un refuerzo, expresó Keitt, “me encantaría”. A pesar de los reportes en los medios de comunicación sobre “casos de infección entre vacunados”, un reciente análisis de datos realizado por la KFF constató que las hospitalizaciones y las muertes son extremadamente raras entre las personas totalmente vacunadas, muy por debajo del 1%.

Offit habló levitra 5mg review sobre un brote reciente en Provincetown, Massachusetts, en el que sólo cuatro de las 346 personas totalmente vacunadas, e infectadas por erectile dysfunction treatment, fueron hospitalizadas, dos de las cuales tenían afecciones médicas subyacentes. Y nadie murió. €œEsta vacuna sigue haciendo un excelente trabajo frente a la variante delta para proteger a las personas contra la levitra 5mg review enfermedad grave y crítica”, señaló.

Sin embargo, la eficacia de la vacuna de Pfizer contra las variantes sigue siendo objeto de debate. Este mes, un nuevo estudio previo realizado por la Clínica Mayo indicó que la eficacia del producto contra la infección se redujo al 42% de enero a julio, a medida que la prevalencia de la variante delta aumentaba notablemente. Pfizer, y su socio BioNTech, anunciaron que están desarrollando una versión levitra 5mg review actualizada de su vacuna en Alemania para atacar las características genómicas de la variante delta.

Sin embargo, la idea de que una nueva formulación pueda funcionar mejor es “hipotética en este momento”, afirmó Vaughn Cooper, profesor de microbiología y genética molecular de la Universidad de Pittsburgh. El doctor Vincent Ajumar, hematólogo de la Clínica Mayo que estudia de cerca las respuestas inmunitarias y los niveles de anticuerpos de sus pacientes, dijo que intentar las dos estrategias, utilizar la vacuna actual y probar una nueva versión, parece razonable. Existe la hipótesis de que, si las infecciones “en vacunados” se deben a un descenso de los niveles de anticuerpos, bastará con aumentar esos niveles, levitra 5mg review apuntó Rajkumar.

Pero la hipótesis más preocupante es que la variante delta, o cualquier otra variante, podría responder de forma considerablemente diferente, y estar menos amenazada, por los anticuerpos que genera la vacuna actual. €œAsí que, a menos que se refuercen [los anticuerpos] con una vacuna que sea específica para la delta, no funcionará”, dijo Rajkumar y añadió que probar ambas hipótesis es lo “correcto por cuestión de tiempo”. Sin embargo, promover vacunas de refuerzo en poblaciones sanas es prematuro, advirtió la doctora Sadiya Khan, epidemióloga y cardióloga de levitra 5mg review la Facultad de Medicina Feinberg de la Universidad Northwestern.

Esto se debe a que, incluso si los que ya están totalmente vacunados reciben una tercera dosis o refuerzo, el levitra sigue circulando entre millones de personas no vacunadas. €œLa abrumadora mayoría de las infecciones, hospitalizaciones y muertes se producen levitra 5mg review entre quienes no están vacunados”, aseguró Khan. €œRenunciar a la estrategia principal de vacunar a la población va a conducir a continuos repuntes”, señaló.

€œEl daño potencial es enorme”. El editor levitra 5mg review de KHN, Arthur Allen, colaboró con esta historia. Sarah Jane Tribble.

sjtribble@kff.org, @SJTribble Related Topics Contact Us Submit a Story TipElizabeth Groenweghe got a kidney transplant 14 years ago. She now takes several medications to prevent her body from rejecting her transplant levitra 5mg review organ. But these medications also weaken her immune system, putting her at higher risk of becoming seriously ill if she catches erectile dysfunction treatment.

When the levitra began last year, Groenweghe, 29, worked from home for the first month and a half. But then in May 2020, as the chief levitra 5mg review epidemiologist for the public health department in Wyandotte County, Kansas, she returned to the office. €œObviously, I was nervous about it because I’m so immunosuppressed,” said Groenweghe.

She felt relatively safe because her co-workers wore masks and levitra 5mg review strictly followed control protocols. But now that vaccinations have become widely available, her workplace has stopped requiring or enforcing mask use. There is no treatment mandate for her office, and she knows some co-workers are unvaccinated.

She feels uncomfortable working around levitra 5mg review them. €œI am debating putting a sign on my door that says ‘Please do not enter if you are unvaccinated,’ because I am really concerned about getting erectile dysfunction treatment … and have even had a couple co-workers test positive recently,” said Groenweghe. €œKnowing that I don’t have any protection against erectile dysfunction treatment, I’m still wearing a mask and I’m trying to avoid in-person meetings,” she added.

€œIt has been frustrating because, at home, my bubble of protection is levitra 5mg review great. All of my family and friends are vaccinated. At work I don’t have as much control.” While the emergence of the delta variant in the U.S.

Has made many levitra 5mg review companies delay the return to in-person work or mandate vaccinations, in other offices, immunosuppressed people like Groenweghe are left to cobble together their own strategies to minimize their risks. The delta variant raises the stakes for many who were already concerned about catching erectile dysfunction treatment when they return. Those who have the option to keep working remotely have done so — but worry about what it means for their careers as their colleagues levitra 5mg review return to the workplace.

Research showing how well treatments protect those with weakened immune systems is limited. In part that’s because immunosuppressed people, who make up at least 3% of the U.S. Population and include people with cancer, HIV and many chronic health levitra 5mg review conditions, were not included in the original clinical trials for the three erectile dysfunction treatments authorized for emergency use.

Scientists didn’t include them because they needed to conduct the clinical trials quickly and were concerned that this group’s immunosuppressive medicines and increased likelihood of developing s in general would complicate interpreting the study results. Research does show that those who are immunosuppressed are at higher risk of becoming severely ill from erectile dysfunction treatment, passing the levitra to others in their household and getting infected even if vaccinated. A recent study reported that levitra 5mg review 44% of hospitalized “breakthrough” cases in the U.S.

Were in immunosuppressed people. Concerns about her elevated erectile dysfunction treatment risk led Groenweghe to obtain a third dose of the Moderna treatment on her own — and participate in a Johns Hopkins University research study that involved measuring transplant recipients’ immune response to an extra treatment dose. Hopkins recently told her she hadn’t produced levitra 5mg review any antibodies.

But, while the third dose might not have helped Groenweghe, early research shows that a booster shot seems to strengthen the immune response for some with weakened immune systems. Israel began distributing additional doses to levitra 5mg review the immunosuppressed in July. Britain and France have said they plan to start distributing booster doses to high-risk groups in September.

However, the World Health Organization recently called for a moratorium on booster shots until more treatment could be distributed globally to countries with low vaccination rates. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said in a July Senate hearing that immunosuppressed people “may actually need a boost as part of their initial regimen in the sense of getting them up to the point where they are protected.” And soon, third doses may indeed become part of the regimen.

The Food and Drug Administration reportedly is closing in on amending the emergency use authorization requests for the Pfizer-BioNTech and Moderna treatments to allow third doses of those shots to be given to those with weakened immune systems. The treatment advisory committee of the Centers for Disease Control and Prevention was set to meet Friday and is expected to vote on whether to officially recommend that doctors can prescribe third doses to immunocompromised people. Still, federal officials said these third doses would be recommended only for a small number of immunocompromised people, and it’s not yet clear who will be included.

Well in advance of this green light, patients were asking their doctors about additional shots. Andrew Clifford is one such patient. (KHN is identifying him by his first and middle names because he fears retaliation from his workplace.) Andrew, a marketing manager from Missouri, is working from home indefinitely and worries about what he might be missing.

The 40-year-old has multiple sclerosis and takes immunosuppressive medication. €œThe fear of missing out is a tremendous anxiety,” he said. Recently his entire team went back to the office for two weeks to meet with an outside agency.

While Andrew was able to go in for two days, he could tell he had missed out on things on the days he stayed home. €œI missed out on the lunchtime convos. When I did show up in the Zoom meetings, I was playing a lot of catch-up,” he said.

€œI was trying to figure out who I was actually talking to and what they did.” Some patients, such as transplant recipient Elyse Thomas, aren’t waiting for new guidance from the U.S. Government. (KHN is identifying her by her middle and last names because she is worried about pushback from her employer.) Instead, Elyse, a 30-year-old social worker for a high school district in the Bay Area of California, pursued third and fourth doses of a erectile dysfunction treatment on her own since her school district had staff members return in person in early August.

€œSome of us transplant patients have had to take matters into our own hands,” Thomas said. €œWe can’t wait for the recommendation while we could be dying.” She asked for an accommodation to continue working remotely during the 2021-22 school year, as she did the year before, but was told all employees must return. Thomas was offered the option to take medical leave without pay if she didn’t want to come into the office, but that would strain her finances.

Her workplace does have a mask mandate, but she’s not sure physical distancing will be enforced and she’s even more anxious now that the delta variant is circulating. €œI don’t feel safe and I don’t understand why I have to be there in person,” Thomas said. €œI don’t want to risk my transplant for a paycheck.

I don’t want to risk my life for a paycheck.” Victoria Knight. vknight@kff.org, @victoriaregisk Related Topics Contact Us Submit a Story TipIn 2019, the Rockville Centre school district in Long Island, New York, was shaken by a string of student deaths, including the suicides of a recent graduate and a current student. “When you get these losses, one after the other, you almost can’t get traction on normalcy,” said Noreen Leahy, an assistant superintendent at the school district.

To Leahy, the student suicides exposed a children’s mental health crisis brewing for years. She had observed a concerning uptick in depression, anxiety and suicidal ideation among students. Her school district had a team of mental health professionals, but Leahy said they couldn’t provide the kind of long-term care many students needed.

€œRemember, psychologists and social workers and counselors in school districts are there to make sure kids are learning,” said Leahy. €œWe’re not hospital wards. We don’t do psychotherapy.

So it’s very limited what we can do for these students.” She said she saw an urgent need to connect students to mental health care quickly and easily, and the 2019 tragedies drove her to find a way. Her vision ultimately led to the formation of a unique partnership between several Long Island school districts and the nearby children’s hospital, Cohen Children’s Medical Center, part of the Northwell Health system. That partnership provides prompt access to mental health services for students and includes ongoing support for school staff members in addressing kids’ mental health, creating a mental health safety net for children and families in the area that didn’t exist before.

At its heart is a new behavioral health center, which the hospital opened in January 2020. Students are evaluated by the center’s child psychiatrist and mental health counselor, who start and continue treatment until a child can be connected to long-term care in the community. The concerning rise in mental health issues noticed by the Long Island school administrators mirrors national trends.

Roughly 1 in 5 U.S. Children meet the criteria for a mental health disorder, and the rate of suicide attempts among teens has risen over the past decade, according to the Centers for Disease Control and Prevention. Around the country, most kids who have mental health issues don’t get treatment.

There’s a shortage of providers who work with children and it can take months to get an appointment. €œThe wait times on average to see a mental health specialist on an emergency basis is somewhere between two to three months, and for regular basis is up to 12 months, which is an unacceptable wait time,” said Dr. Ujjwal Ramtekkar, a child and adolescent psychiatrist at Nationwide Children’s Hospital.

Without timely access to care, many kids end up with worsening symptoms and eventually land in a hospital emergency department, “as the fastest way to either avert [a mental health] crisis, or as the fastest way to get some kind of mental health evaluation,” Ramtekkar said. €œIt sort of creates this ping-pong effect,” said Tina Smith, executive director of special education at Oceanside School District in Long Island. It’s common to see students go to the ER only to be discharged soon after and return to school without a plan for follow-up care, she said.

€œAnd then the problems start to spiral again out of control,” Smith said, “and then they’re sent back to the hospital [ER].” It was with these worries in mind that, after the student suicides in 2019, Leahy began raising her concerns with colleagues, school board members and other parents, including Gina-Marie Bounds, a hospital administrator at Cohen Children’s. Bounds took the idea to the head of emergency child psychiatry and other hospital officials at Cohen’s and they got to work. Leahy spread the word to neighboring school districts, who were dealing with similar problems, and persuaded them to come on board.

Several months later, the mental health center opened its doors. This couldn’t have come at a better time, said Leahy. As many large hospitals around the country saw a surge in the number of kids in mental health crises in their emergency departments, the new behavioral health center reports the opposite trend.

The number of mental health visits to the emergency room by students from these school districts declined by at least 60% in 2020 compared with the previous year. School administrators also say the health center has played a critical role in prevention by promoting the emotional well-being of students, families and school personnel. School and health center staffers meet twice a month via Zoom to check in and brainstorm ways to address emerging health and wellness concerns of staff members and families.

Getting Kids the Right Help at the Right Time The goal of the new health center is to provide kids with care as soon as symptoms emerge. The center is staffed by a child psychiatrist, a mental health counselor and a medical assistant. It’s located next to a pediatrician’s office and within a few miles of the school districts it serves.

When a child first arrives, the child is evaluated to determine whether they need to be hospitalized. €œMost kids don’t need that,” said Dr. Vera Feuer, Northwell Health’s associate vice president for school-based mental health, who helped create the center and now oversees it.

€œMost kids need outpatient care.” And the center starts that care right away — medication and/or therapy, depending on what each child needs — to stabilize the child and prevent worsening of symptoms, and connect them to ongoing care with a provider in the community. In January 2021, a local resident, Tara, found herself calling the health center to make an appointment for her 17-year-old sister, who had been struggling with irregular sleep patterns and panic attacks for months. Tara had recently become her sister’s legal guardian.

KHN is not using their last names and only using the sister’s middle name — Jasmine — to protect their privacy. Jasmine said she felt suffocated during her panic attacks. €œIt felt like I was running, like my heart got really fast, and like I was being put in a little tiny box,” she said.

Jasmine and Tara met with a mental health counselor at the behavioral health center. The follow-up sessions were helpful for Jasmine, who learned about the importance of speaking with a trusted friend or adult any time she felt triggered. And the clinic helped Jasmine get connected with a nearby psychologist whom she now sees for weekly therapy sessions, Tara said.

Removing Barriers for the Most Vulnerable The new health center provides an important safety net for kids who might otherwise fall through the cracks, like 17-year-old Alyssa Gibaldi, who was refused care by other mental health providers because of a disability. Alyssa attends Oceanside High School and is extremely social, said her mother, Jennifer. €œShe’s like the mayor of the school.

Everybody knows her,” Jennifer said. Alyssa has Down syndrome and the levitra upped her anxiety. Last fall, she became catatonic and went into what Jennifer describes as a “zombie-like state.” “She couldn’t talk.

She couldn’t move. She couldn’t speak. She couldn’t feed herself,” Jennifer said.

On several occasions, Jennifer called 911. Alyssa was transported in an ambulance to the ER and hospitalized. After her neurologists ruled out seizures and other conditions, they suggested Alyssa see a psychiatrist.

But Jennifer said Alyssa was turned down repeatedly by providers saying they didn’t take her insurance or that they didn’t work with kids with disabilities. That’s when Jennifer reached out to the school nurse, who referred the family to the new behavioral health center. The center’s child psychiatrist, Dr.

Zoya Popivker, reviewed Alyssa’s medical records and prescribed medications for depression and anxiety. Jennifer said they got the meds on a Saturday morning, “and by Saturday night, she was out of the catatonic state. Ever since then, she’s been coming back to us, like her personality came back.” Alyssa continued to go to the behavioral health center for several months, until they were able to transition to a psychiatrist who works with kids with disabilities.

The Case for School-Hospital Partnerships It makes sense for children’s hospitals to partner with schools because that’s where kids spend most of their day, said Ramtekkar, the psychiatrist at Nationwide Children’s Hospital. School staffers often know their students well and can spot early signs. It’s why schools in many parts of the country have been working to forge partnerships with nearby mental health care providers.

But such partnerships still depend on mental health care resources in the communities they serve. A 2019 study found 70% of counties didn’t have a single practicing child psychiatrist. Leahy, the assistant superintendent at Rockville Centre in Long Island, said sharing a behavioral health center across multiple school districts leads both to better collaboration and cost savings.

The price her district pays for the services is less than the cost of one full-time staff member, and the state chips in to cover part of that. Cohen Children’s will add a new behavioral health center this summer, expanding to 14 school districts. At that point, about 60,000 students in Long Island will have access to immediate mental health support should they need it.

This story is part of a reporting partnership that includes NPR, Illinois Public Media and KHN. Nationwide Children’s Hospital, mentioned in this story, is a financial supporter of NPR. If you or someone you know may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (en español.

1-888-628-9454. Deaf and hard of hearing. Dial 711, then 1-800-273-8255) or the Crisis Text Line by texting HOME to 741741.

Related Topics Contact Us Submit a Story Tip.

CAIRO, Ill get levitra https://ioin.co.uk/price-of-zithromax-at-walmart/. €” Lee Wright was hard at work, constructing a nail salon near the city’s abandoned hospital, when Jody Johnson stopped by to introduce himself on a recent afternoon. Johnson, who works get levitra for the University of Illinois Extension program, chatted with Wright casually in the summertime heat. For Johnson, it was the first step to building trust in this city of fewer than 2,200 people as extension programs across the U.S — long valued in many rural communities for helping farmers and supporting 4-H clubs — expand their service to include educating the public about erectile dysfunction treatments. Wright, 68, was unvaccinated and planned to remain so, even though he’d followed other public health guidelines during the levitra.

When it get levitra came to getting the shots, he decided to leave his fate to his faith. €œDoctors are good. Don’t get me wrong,” Wright said. €œBut we got to have something that we can really depend on.” Johnson didn’t talk to Wright about the treatments that get levitra day. He just listened instead.

€œNo one wants to feel ashamed or belittled because they’re not doing something,” Johnson said later. University of get levitra Illinois Extension director Jody Johnson exchanges contact information with Cairo residents Lee Wright and son Roman Wright. The agency’s office in southern Illinois is launching a vaccination education program that aims to reach this storied city on the banks of the Mississippi and Ohio rivers.(Cara Anthony / KHN) Only 16% of residents here in Alexander County are fully vaccinated against erectile dysfunction treatment, the lowest rate in Illinois, according to the state health department. And case counts of erectile dysfunction s are get levitra rising. So the Cooperative Extension System, which is tied to a network of land-grant universities, plans to spend the next two years talking about treatments in this community and elsewhere.

It may take that long or more to persuade enough people to get vaccinated. The extension system has a tradition of bringing research-based information to communities on a wide get levitra variety of topics, including water quality, food safety and disaster preparedness. With its roots sunk deep in rural America, where treatments have been slow to catch on, the system is now using state and federal funding to pay for immunization education efforts tailored to specific communities. Already 4-H clubs have been making masks and face shields. In Illinois, the agency has a erectile dysfunction treatment resource guide for families, business owners and get levitra farmers.

The office covering the southern portion of the state is now looking to hire someone in the community to help get out the word on why vaccinations matter. Johnson also wants to team up with local churches, civic groups and business owners to get the job done. €œThis is not our first global levitra,” said Carissa Nelson, a spokesperson for 4-H programs in Illinois get levitra. The organization’s agents and club members nursed patients during the 1918 flu levitra that devastated the world. This time around, the extension service’s strategy could also help in these rural communities get levitra and the urban areas it serves.

But local leaders say there’s no quick solution for improving vaccination rates in Cairo or across the country. Getting people vaccinated is a nuanced challenge in every community. In Cairo, a long history of racial tension dating to the get levitra Civil War still stings. Like many rural towns across the U.S., the community also feels underappreciated and misunderstood. Antebellum homes such as Magnolia Manor serve as reminders of the Cairo’s majestic past.

(Cara Anthony / KHN) Built in 1869, the mansion has been listed on the National Register of get levitra Historic Places since Dec. 17, 1969. (Cara Anthony / KHN) The shell of Cairo, Illinois, remains intact, with many of the city’s historical homes still standing.(Cara Anthony / KHN)As motorists enter Cairo, Illinois, a billboard promotes the city’s historical sites and landmarks. Founded in 1818, the city was home to more than 15,000 people in the early 20th century, helping it earn the get levitra nicknames “Little Chicago” and “the Gateway to the South.” Today just over 2,100 people live in Cairo.(Cara Anthony / KHN)The Gem Theatre in Cairo, Illinois, closed in 1995. The city is often mislabeled as abandoned.

€œCairo is not a ghost town,” says Ronnie Woods, get levitra a local pastor and retired schoolteacher. €œIt’s not dead at all.” (Cara Anthony / KHN) treatment apathy is common here, where rates remained low until recently. €œWe haven’t had great turnouts,” said Tyrone Coleman, president and co-founder of the Alexander and Pulaski NAACP chapter, which has helped organize treatment clinics in Cairo. In June, get levitra he invited the health department to the city’s Juneteenth celebration at St. Mary’s Park.

More than 300 people attended. But the event’s pop-up clinic hosted by the state didn’t have many seeking get levitra vaccinations during its six hours of operation. €œWe only had two,” Coleman said. More than 15,000 people lived in Cairo in the early 20th century, helping it earn the nicknames “Little Chicago” and “the Gateway to the South.” Old factories, antebellum homes, an ornate library and a vacant hospital remain as reminders of the city’s majestic past. The city’s library get levitra prominently displays the work of Samuel Clemens, the American writer best known as Mark Twain.

After traveling through Cairo, Twain wrote about the city in his 1884 novel “The Adventures of Huckleberry Finn.” In the novel, Cairo represents freedom and the chance for a better life. But the hospital shut down in 1987 get levitra. The only grocery store in town closed years ago, public housing was torn down in recent years, and the only nursing home closed during the levitra, forcing residents to find a new place to live without much notice. On top of all that, flooding has threatened to wipe the city out more than once. Southern Medical Center, the only hospital in Cairo, get levitra shut down in 1987.

Residents in need of medical treatment visit a local clinic or travel to other hospitals in the region. (Cara Anthony / KHN) Aperion Care Cairo, the only nursing home in Cairo, closed during the levitra, forcing residents to find a new place to live without much notice. (Cara Anthony / KHN) Today, fewer than 2,200 get levitra people, the majority of them Black, live here. And locals say the population has continued to drop with all the closures. The city is often mislabeled by the press and travel guides as abandoned.

€œCairo is not a ghost town,” said Ronnie Woods, a local pastor and retired get levitra schoolteacher. €œIt’s not dead at all.” Tourists still stop by to see the confluence of the Mississippi and Ohio rivers. But they don’t typically see the rocky get levitra riverbank where residents fish for their dinner. Beverly Davis, 60, heads there often with rod in hand and gives much of her catch away to other members of the community. The scenic waterfront, though, is carpeted with driftwood and dead fish that washed ashore.

€œI guess it’s meant to be like this,” get levitra Davis said, standing on the riverbanks among the fish carcasses. €œâ€™Cause if not, it would be better.” Tourists still stop by to see the confluence of the Mississippi and Ohio rivers in the city of Cairo, Illinois, where commercial ships dock on the banks. (Cara Anthony / KHN) Beverly Davis shows off a catfish she caught on June 22 along the riverbank in Cairo, Illinois. Davis fishes often for dinner and gives away much of her catch to the get levitra community. (Cara Anthony / KHN) But many residents continue to believe their city will return to its past glory.

€œThe world hears that this is a negative part of the country, and it’s not,” Johnson said. €œWe’ve got too many good things and people here.” On this day, the only outdoor get levitra basketball court in the city, anchored by a single hoop, was busy in a rural community that was fighting to stay alive long before the levitra hit. The men on the court didn’t seem worried about catching erectile dysfunction treatment. €œI haven’t had erectile dysfunction treatment, so I feel like get levitra I don’t need to get vaccinated right now,” said Jeffery DeWitt, 24. €œI’ll just take it as it goes.” Today, the only outdoor basketball court in Cairo, anchored by a single hoop, is a gathering spot in this rural community that was fighting to stay alive long before the levitra hit.

(Cara Anthony / KHN) Wright’s son, Roman Wright, 36, said much the same thing while helping his dad build the nail salon across town. He works for the prison system, and one of get levitra its facilities nearby reported erectile dysfunction treatment cases. But he hadn’t contracted the disease. Like his father, he said he didn’t plan on getting the shots. €œI’m like get levitra my dad,” Roman Wright said.

€œI was born and raised in church all my life. So I say we believe in God. I know my get levitra parents pray for me. We pray for each other and we just believe in God.” Woods, the pastor, has a different point of view. He keeps his vaccination card get levitra in a plastic sheath and carries it with him wherever he goes.

€œI have strong faith,” said Woods, 66. €œAnd at my age, my risk factors, I just felt that God placed science there to help us.” Ronnie Woods, a local pastor and retired schoolteacher who stopped by Cairo’s public library on June 23, says he is vaccinated against erectile dysfunction treatment. €œI have strong faith,” get levitra Woods says. €œAnd at my age, my risk factors, I just felt that God placed science there to help us.”(Cara Anthony / KHN) But Woods said it’s going to take work to persuade others in Cairo to get vaccinated, even if they know someone who died of erectile dysfunction treatment. A prominent doctor was among the dead in the community.

€œIt’s going to take get levitra more than explaining, it is going to take a cultural shift because people are just not trusting,” he said. That’s one reason Johnson is searching for a local voice to lead the extension service’s treatment education program over the next year. As a 51-year-old white man who grew up in a predominantly white community 45 miles outside of Cairo, he recognizes that local residents would be more likely to share their thoughts with someone who lives here. Plus, he get levitra spends most of his time talking with community leaders and public officials. He is searching for someone who will spend time with locals who don’t hold titles and positions.

€œEverybody doesn’t think like me,” Johnson said get levitra. €œSo we need to take that into consideration.” Cara Anthony. canthony@kff.org, @CaraRAnthony Related Topics Contact Us Submit a Story TipSince reopening campus at the University of California-San Diego last summer, university officials have relied on the tried-and-true public health strategies of testing and contact tracing. But they have also added a new tool to get levitra their arsenal. Excrement.

That tool alerted researchers to about 85% of cases in dorms before they were diagnosed, according to a soon-to-be published study, said Rob Knight, a professor of pediatrics and computer science and engineering who helped create the campus’s wastewater testing program. When erectile dysfunction treatment is detected in sewage, students, staffers and faculty members are tested, which has allowed the school to identify and isolate infected individuals who aren’t yet showing symptoms — potentially stopping get levitra outbreaks in their tracks. UC-San Diego’s testing program is among hundreds of efforts around California and the nation to turn waste into valuable health data. From Fresno, California, to Portland, Maine, universities, communities and businesses are monitoring human excrement for signs of erectile dysfunction treatment. Researchers have high hopes for this sludgy new data stream, which they say can alert public get levitra health officials to trends in s and doesn’t depend on individuals getting tested.

And because people excrete levitra in feces before they show symptoms, it can serve as an early warning system for outbreaks. The Centers for Disease Control and Prevention finds the practice so promising that it has created a federal database of wastewater get levitra samples, transforming raw data into valuable information for local health departments. The program is essentially creating a public health tool in real time, experts say, one that could have a range of uses beyond the current global levitra, including tracking other infectious diseases and germs’ resistance to antibiotics. €œWe think this can really provide valuable data, not just for erectile dysfunction treatment, but for a lot of diseases,” said Amy Kirby, a microbiologist leading the CDC effort. The levitra that causes erectile dysfunction treatment infects many types of cells in the body, get levitra including those in the respiratory tract and gut.

The levitra’s genetic signature, viral RNA, makes its way into feces, and typically shows up in poop days before symptoms start. At UC-San Diego and other campuses, researchers take samples flowing from individual buildings, capturing such granular data that they can often deduce the number of infected people living or working there. But in most other settings, because of privacy concerns and resource constraints, testing is done on a get levitra much larger scale, with the goal of tracking trends over time. Samples are drawn from wastewater, which is what comes out of our sewer pipes, or sludge, the solids that have settled out of the wastewater. They are typically extracted mechanically or by a human with a dipper on the end of a rod.

When researchers in Davis, California, saw the viral load rise in several neighborhood sewage streams in July, they sent out get levitra text message alerts and hung signs on the doors of 3,000 homes recommending that people get tested. Before the levitra, testing sewage to identify and ward off illness in the U.S. Was largely limited to academic get levitra use. Israel used it to stave off a polio outbreak in 2013, and some communities in the U.S. Were sampling sewage before the levitra to figure out what kinds of opioids people in their communities were using, a service offered by the company Biobot.

But when get levitra erectile dysfunction treatment hit the U.S. Amid political chaos and a shortage of tests, local governments scrambled for any information they could get on the levitra. In rural Lake County, California, health officials had identified a handful of cases by sending nurses out to look for infected people. They were sure there were more but couldn’t get their hands on tests to prove it, so in spring 2020 they signed up for get levitra a free sewage testing program run by Biobot, which pivoted to erectile dysfunction treatment testing as the levitra took off and now is charging to test in K-12 schools, office buildings and nursing homes, in addition to local governments and universities, said Mariana Matus, CEO and co-founder of the company. The erectile dysfunction treatment levitra turned up in samples at four wastewater treatment facilities in Lake County.

€œIt is a way to just get more information because we can’t do testing,” Gary Pace, then the county’s health officer, told KHN at the time. As sewage sampling took off around the world, the get levitra U.S. Department of Health and Human Services began awarding grants in fall 2020 to wastewater treatment plants. Biobot won a bid to run a second round of that get levitra program, currently underway through late August, testing the sewage of up to 30% of the U.S. Population.

At least 25 California wastewater treatment plants are participating in the program, and numerous others are getting money from the CDC, working with local universities or paying for their own testing. While such states as Ohio get levitra and Missouri have created public dashboards to show their data, California’s efforts remain scattershot. The test data alone doesn’t provide much value to health officials — it needs to be translated to be useful. Scientists are still learning how to read the data, a complicated process that involves understanding the relationships between how much levitra people excrete, how many people are using a wastewater system and how much rainwater is running into the system, potentially diluting the sewage, among many other factors. Since using wastewater to track diseases was not widespread before the levitra, there’s been a steep and get levitra ongoing learning curve.

Beleaguered public health officials have struggled to incorporate the new data into their already overwhelming workloads, but the CDC hopes it can address those issues with its new national system that tracks and translates wastewater data for local governments. Throughout 2020, Kirby, the CDC microbiologist, and engineer Mia Mattioli were a two-person wastewater team inside the agency’s larger 7,000-person erectile dysfunction treatment response. During that time, academic colleagues get levitra generously shared what they knew about wastewater epidemiology, Kirby said. By September 2020, the pair had launched the National Wastewater Surveillance System, which interprets sampling data for state and local governments. Today, they lead a team of six and have a permanent place in one of the CDC’s departments get levitra.

€œEvery piece of this system had to be built largely from scratch,” Kirby said. €œWhen I look at that, it really amazes me where we are now.” In the months since the system debuted, it has been able to detect an uptick in cases anywhere from four to six days before diagnostic testing shows an increase, Kirby said. She hopes that by the end of next year the federal get levitra monitoring program will be used to check for a range of diseases, including E. Coli, salmonella, norolevitra and a deadly drug-resistant fungus called Candida auris, which has become a global threat and wreaked havoc in hospitals and nursing homes. The longer these programs are up and running, the more useful they become, said Colleen Naughton, a professor and civil engineer at the University of California-Merced who leads erectile dysfunction treatmentPoops19, which tracks wastewater monitoring efforts globally.

Naughton is working with colleagues at the University get levitra of California-Davis to launch monitoring programs near where she works in the Central Valley but is finding that some smaller communities don’t have the resources to conduct testing or sufficient health personnel to analyze or use the data. It’s in these smaller communities with limited access to testing and doctors where the practice may hold the most promise, Naughton said. erectile dysfunction treatment laid bare long-standing inequities among communities that she fears will be perpetuated by the use of this new public health tool. Privacy concerns also need get levitra to be addressed, experts said. Wastewater data hasn’t traditionally been considered protected personal health information the way diagnostic tests are.

Health officials have managed earlier concerns about wastewater tracking of illicit drug use by sampling from large enough sewage streams get levitra to offer anonymity. But testing for certain health problems requires looking at DNA. €œI think that’s going to be a challenge for public communication,” Knight said, “to make sure that’s not perceived as essentially spying on every individual’s genetic secrets.” Public health and wastewater officials said they are thrilled by the potential of this new tool and are working on ways to address privacy concerns while taking advantage of it. Greg Kester, get levitra director of renewable resource programs at the California Association of Sanitation Agencies, wrote to CDC officials in June 2020 asking for a federal surveillance network. He can hardly believe how quickly that call became a reality.

And he hopes it is here to stay, both for the ongoing levitra and for the inevitable next outbreak. €œAs vaccination rates increase and we get the variants, it’s still going to be important because clinical get levitra testing is decreasing,” Kester said. €œWe really want to make this part of the infrastructure.” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Anna Maria Barry-Jester. annab@kff.org, @annabarryjester Related Topics Contact Us get levitra Submit a Story TipEl CEO de Pfizer, Albert Bourla, confiaba en junio en la capacidad de la vacuna de su empresa para proteger contra la variante delta, altamente contagiosa, mientras se diseminaba por el mundo y llenaba de pacientes los hospitales estadounidenses.

Apenas unas semanas después, Pfizer comunicó que solicitaría autorización para una vacuna de refuerzo, después que los primeros resultados de los ensayos mostraran que una tercera dosis aumentaba potencialmente la protección. A finales de julio, Pfizer y BioNTech anunciaron que, entre cuatro y seis meses después de la segunda get levitra dosis, la eficacia de su vacuna se reducía a cerca del 84%. Bourla se apresuró a promover una tercera dosis tras las desalentadoras noticias, diciendo que estaba “muy, muy seguro” de que un refuerzo aumentaría los niveles de inmunidad en los vacunados. Hay un problema. Pfizer aún no ha aportado pruebas concluyentes que respalden esa confianza get levitra.

La empresa carece de resultados de ensayos clínicos de última fase que confirmen que el refuerzo funcionará contra las variantes de erectile dysfunction treatment, incluida delta, que actualmente representa el 93% de las nuevas infecciones en los Estados Unidos. Pfizer anunció su ensayo global de fase 3 sobre una tercera dosis a mediados de julio. La fecha de finalización de ese ensayo get levitra es en 2022. Los resultados de la fase 3 suelen ser necesarios antes de la aprobación reglamentaria. €œConfiamos en esta vacuna y en la tercera dosis, pero hay que recordar que el estudio sobre la eficacia de la vacuna sigue en marcha, por lo que necesitamos todas las pruebas que lo respalden”, dijo, el 9 de agosto, Jerica Pitts, directora de relaciones con los medios a nivel mundial de Pfizer.

Lo que está en juego es get levitra enorme. Pfizer anunció, en julio, que espera obtener $33,500 millones en ingresos por la vacuna contra erectile dysfunction treatment este año. Mientras, Pfizer comunicó recientemente que, si una tercera dosis no podía combatir la variante delta u get levitra otras, la farmacéutica está preparada para presentar una vacuna “a medida” en un plazo de 100 días. Todo esto ha sembrado confusión sobre qué funcionará exactamente, y cuándo. La prisa de la industria farmacéutica por recomendar refuerzos es “un poco frustrante”, señaló el doctor Paul Offit, director del Centro de Educación sobre Vacunas del Hospital Infantil de Philadelphia y asesor de los Institutos Nacionales de Salud y de la Administración de Alimentos y Medicamentos (FDA).

Incluso si se comprueba que un refuerzo es seguro, el esfuerzo de Estados Unidos debería centrarse en “vacunar a quienes que get levitra no están vacunados”, puntualizó Offit. En cualquier caso, las decisiones sobre los refuerzos no dependen de los fabricantes de vacunas, añadió. €œLas farmacéuticas no son organismos de salud pública, y no les corresponde determinar cuándo o si debe haber dosis de refuerzo”, explicó Offit. €œEso es competencia de los Centros para el Control y la Prevención de Enfermedades (CDC)” get levitra. De hecho, los CDC y la FDA —las agencias federales que supervisan la autorización de las vacunas contra erectile dysfunction treatment— comunicaron en julio que los estadounidenses totalmente vacunados no necesitan una dosis de refuerzo.

Las vacunas actualmente autorizadas —Pfizer, Moderna y Johnson &. Johnson— funcionan get levitra como deberían. Las tres reducen el riesgo de erectile dysfunction treatment lo suficiente como para desarrollar una forma grave, hospitalizar o matar a una persona. Si las tasas de hospitalización y muerte aumentan entre los vacunados, entonces sería el momento get levitra de hablar de refuerzos, dijo Offit, pero “no estamos ahí, todavía”. La Casa Blanca se ha sumado a los mensajes contradictorios.

La vocera Jan Psaki confirmó que Estados Unidos comprará 200 millones de dosis adicionales de la vacuna de Pfizer-BioNTech para inocular a los menores de 12 años (en el futuro) y para posibles refuerzos. Natalie Dean, especialista en bioestadística de la Universidad de Emory en Atlanta, indicó que la confusión no es necesariamente culpa de ninguna institución, sino que “existe una auténtica incertidumbre científica sobre la eficacia de get levitra las vacunas [existentes] contra la nueva variante”. Los científicos están reuniendo información de estudios observacionales, investigaciones de brotes y análisis de las respuestas de los anticuerpos. Para muchos estadounidenses —especialmente para quienes hace seis meses se esforzaron por encontrar alguna dosis, contratando frenéticamente a cazadores de vacunas y viajando varias horas para recibir su primera inyección— la confusión ha desencadenado una búsqueda febril de una tercera dosis ilícita, por si fuera necesaria. Angie Melton, get levitra de Kensington, Maryland, recibió la vacuna de Johnson &.

Johnson de una sola dosis, en abril. Pero desde entonces le preocupó que la contagiosa variante delta pudiera infectarla a ella y a su hijo de 10 años no vacunado. €œConseguí que me pusieran get levitra una dosis de Pfizer la semana pasada”, dijo Melton, quien también ha programado su segunda dosis. Tras consultar a amigos y médicos y ver informes sobre las combinaciones que se hacen en Europa, Melton se inscribió en el sitio de una farmacia local y pidió una cita para vacunarse con Pfizer. También tiene programada get levitra una segunda inyección.

€œIntento mantener a mi familia a salvo”, explicó Melton. El panel asesor de los CDC tenía previsto reunirse hoy, 13 de agosto, para considerar si son necesarias dosis adicionales de vacunas para las personas inmunodeprimidas. También está en la agenda una get levitra presentación sobre los refuerzos. Pacientes inmunodeprimidos, como Sarah Keitt, que padece esclerosis múltiple y la enfermedad de Crohn, expresaron su alivio por el hecho de que los reguladores federales consideren recomendar una tercera dosis. Keitt, una activista por los derechos de los discapacitados que vive en Connecticut contó que su neurólogo le recomendó un refuerzo incluso después de haber recibido dos dosis de Moderna.

Dijo que estaba ansiosa por recibir otra dosis, pero que seguía frustrada por la falta de confianza get levitra en el grado de protección que ofrecería. €œSi alguien pudiera decirme definitivamente que hay un 95% de posibilidades de estar protegido” con un refuerzo, expresó Keitt, “me encantaría”. A pesar de los reportes en los medios de comunicación sobre “casos de infección entre vacunados”, un reciente análisis de datos realizado por la KFF constató que las hospitalizaciones y las muertes son extremadamente raras entre las personas totalmente vacunadas, muy por debajo del 1%. Offit habló sobre un get levitra brote reciente en Provincetown, Massachusetts, en el que sólo cuatro de las 346 personas totalmente vacunadas, e infectadas por erectile dysfunction treatment, fueron hospitalizadas, dos de las cuales tenían afecciones médicas subyacentes. Y nadie murió.

€œEsta vacuna sigue haciendo un excelente trabajo frente a la variante delta para proteger a las personas contra la enfermedad get levitra grave y crítica”, señaló. Sin embargo, la eficacia de la vacuna de Pfizer contra las variantes sigue siendo objeto de debate. Este mes, un nuevo estudio previo realizado por la Clínica Mayo indicó que la eficacia del producto contra la infección se redujo al 42% de enero a julio, a medida que la prevalencia de la variante delta aumentaba notablemente. Pfizer, y get levitra su socio BioNTech, anunciaron que están desarrollando una versión actualizada de su vacuna en Alemania para atacar las características genómicas de la variante delta. Sin embargo, la idea de que una nueva formulación pueda funcionar mejor es “hipotética en este momento”, afirmó Vaughn Cooper, profesor de microbiología y genética molecular de la Universidad de Pittsburgh.

El doctor Vincent Ajumar, hematólogo de la Clínica Mayo que estudia de cerca las respuestas inmunitarias y los niveles de anticuerpos de sus pacientes, dijo que intentar las dos estrategias, utilizar la vacuna actual y probar una nueva versión, parece razonable. Existe la hipótesis de que, si las infecciones “en vacunados” se deben a un descenso de los niveles de anticuerpos, bastará con aumentar esos niveles, apuntó get levitra Rajkumar. Pero la hipótesis más preocupante es que la variante delta, o cualquier otra variante, podría responder de forma considerablemente diferente, y estar menos amenazada, por los anticuerpos que genera la vacuna actual. €œAsí que, a menos que se refuercen [los anticuerpos] con una vacuna que sea específica para la delta, no funcionará”, dijo Rajkumar y añadió que probar ambas hipótesis es lo “correcto por cuestión de tiempo”. Sin embargo, promover vacunas de refuerzo get levitra en poblaciones sanas es prematuro, advirtió la doctora Sadiya Khan, epidemióloga y cardióloga de la Facultad de Medicina Feinberg de la Universidad Northwestern.

Esto se debe a que, incluso si los que ya están totalmente vacunados reciben una tercera dosis o refuerzo, el levitra sigue circulando entre millones de personas no vacunadas. €œLa abrumadora mayoría de las get levitra infecciones, hospitalizaciones y muertes se producen entre quienes no están vacunados”, aseguró Khan. €œRenunciar a la estrategia principal de vacunar a la población va a conducir a continuos repuntes”, señaló. €œEl daño potencial es enorme”. El editor de KHN, Arthur Allen, colaboró con esta get levitra historia.

Sarah Jane Tribble. sjtribble@kff.org, @SJTribble Related Topics Contact Us Submit a Story TipElizabeth Groenweghe got a kidney transplant 14 years ago. She now takes several medications to prevent get levitra her body from rejecting her transplant organ. But these medications also weaken her immune system, putting her at higher risk of becoming seriously ill if she catches erectile dysfunction treatment. When the levitra began last year, Groenweghe, 29, worked from home for the first month and a half.

But then in May 2020, as get levitra the chief epidemiologist for the public health department in Wyandotte County, Kansas, she returned to the office. €œObviously, I was nervous about it because I’m so immunosuppressed,” said Groenweghe. She felt relatively safe get levitra because her co-workers wore masks and strictly followed control protocols. But now that vaccinations have become widely available, her workplace has stopped requiring or enforcing mask use. There is no treatment mandate for her office, and she knows some co-workers are unvaccinated.

She feels uncomfortable working get levitra around them. €œI am debating putting a sign on my door that says ‘Please do not enter if you are unvaccinated,’ because I am really concerned about getting erectile dysfunction treatment … and have even had a couple co-workers test positive recently,” said Groenweghe. €œKnowing that I don’t have any protection against erectile dysfunction treatment, I’m still wearing a mask and I’m trying to avoid in-person meetings,” she added. €œIt has been frustrating because, at home, my bubble get levitra of protection is great. All of my family and friends are vaccinated.

At work I don’t have as much control.” While the emergence of the delta variant in the U.S. Has made get levitra many companies delay the return to in-person work or mandate vaccinations, in other offices, immunosuppressed people like Groenweghe are left to cobble together their own strategies to minimize their risks. The delta variant raises the stakes for many who were already concerned about catching erectile dysfunction treatment when they return. Those who have the option to keep working remotely have done so — but worry about what it means for their get levitra careers as their colleagues return to the workplace. Research showing how well treatments protect those with weakened immune systems is limited.

In part that’s because immunosuppressed people, who make up at least 3% of the U.S. Population and include people with cancer, HIV and many chronic health conditions, were get levitra not included in the original clinical trials for the three erectile dysfunction treatments authorized for emergency use. Scientists didn’t include them because they needed to conduct the clinical trials quickly and were concerned that this group’s immunosuppressive medicines and increased likelihood of developing s in general would complicate interpreting the study results. Research does show that those who are immunosuppressed are at higher risk of becoming severely ill from erectile dysfunction treatment, passing the levitra to others in their household and getting infected even if vaccinated. A recent study reported get levitra that 44% of hospitalized “breakthrough” cases in the U.S.

Were in immunosuppressed people. Concerns about her elevated erectile dysfunction treatment risk led Groenweghe to obtain a third dose of the Moderna treatment on her own — and participate in a Johns Hopkins University research study that involved measuring transplant recipients’ immune response to an extra treatment dose. Hopkins recently told get levitra her she hadn’t produced any antibodies. But, while the third dose might not have helped Groenweghe, early research shows that a booster shot seems to strengthen the immune response for some with weakened immune systems. Israel began distributing additional get levitra doses to the immunosuppressed in July.

Britain and France have said they plan to start distributing booster doses to high-risk groups in September. However, the World Health Organization recently called for a moratorium on booster shots until more treatment could be distributed globally to countries with low vaccination rates. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said in a July Senate hearing that immunosuppressed people “may actually need a boost as part of their initial regimen in the sense of getting them up to the point where they are protected.” And soon, third doses may indeed become part of the regimen. The Food and Drug Administration reportedly is closing in on amending the emergency use authorization requests for the Pfizer-BioNTech and Moderna treatments to allow third doses of those shots to be given to those with weakened immune systems.

The treatment advisory committee of the Centers for Disease Control and Prevention was set to meet Friday and is expected to vote on whether to officially recommend that doctors can prescribe third doses to immunocompromised people. Still, federal officials said these third doses would be recommended only for a small number of immunocompromised people, and it’s not yet clear who will be included. Well in advance of this green light, patients were asking their doctors about additional shots. Andrew Clifford is one such patient. (KHN is identifying him by his first and middle names because he fears retaliation from his workplace.) Andrew, a marketing manager from Missouri, is working from home indefinitely and worries about what he might be missing.

The 40-year-old has multiple sclerosis and takes immunosuppressive medication. €œThe fear of missing out is a tremendous anxiety,” he said. Recently his entire team went back to the office for two weeks to meet with an outside agency. While Andrew was able to go in for two days, he could tell he had missed out on things on the days he stayed home. €œI missed out on the lunchtime convos.

When I did show up in the Zoom meetings, I was playing a lot of catch-up,” he said. €œI was trying to figure out who I was actually talking to and what they did.” Some patients, such as transplant recipient Elyse Thomas, aren’t waiting for new guidance from the U.S. Government. (KHN is identifying her by her middle and last names because she is worried about pushback from her employer.) Instead, Elyse, a 30-year-old social worker for a high school district in the Bay Area of California, pursued third and fourth doses of a erectile dysfunction treatment on her own since her school district had staff members return in person in early August. €œSome of us transplant patients have had to take matters into our own hands,” Thomas said.

€œWe can’t wait for the recommendation while we could be dying.” She asked for an accommodation to continue working remotely during the 2021-22 school year, as she did the year before, but was told all employees must return. Thomas was offered the option to take medical leave without pay if she didn’t want to come into the office, but that would strain her finances. Her workplace does have a mask mandate, but she’s not sure physical distancing will be enforced and she’s even more anxious now that the delta variant is circulating. €œI don’t feel safe and I don’t understand why I have to be there in person,” Thomas said. €œI don’t want to risk my transplant for a paycheck.

I don’t want to risk my life for a paycheck.” Victoria Knight. vknight@kff.org, @victoriaregisk Related Topics Contact Us Submit a Story TipIn 2019, the Rockville Centre school district in Long Island, New York, was shaken by a string of student deaths, including the suicides of a recent graduate and a current student. “When you get these losses, one after the other, you almost can’t get traction on normalcy,” said Noreen Leahy, an assistant superintendent at the school district. To Leahy, the student suicides exposed a children’s mental health crisis brewing for years. She had observed a concerning uptick in depression, anxiety and suicidal ideation among students.

Her school district had a team of mental health professionals, but Leahy said they couldn’t provide the kind of long-term care many students needed. €œRemember, psychologists and social workers and counselors in school districts are there to make sure kids are learning,” said Leahy. €œWe’re not hospital wards. We don’t do psychotherapy. So it’s very limited what we can do for these students.” She said she saw an urgent need to connect students to mental health care quickly and easily, and the 2019 tragedies drove her to find a way.

Her vision ultimately led to the formation of a unique partnership between several Long Island school districts and the nearby children’s hospital, Cohen Children’s Medical Center, part of the Northwell Health system. That partnership provides prompt access to mental health services for students and includes ongoing support for school staff members in addressing kids’ mental health, creating a mental health safety net for children and families in the area that didn’t exist before. At its heart is a new behavioral health center, which the hospital opened in January 2020. Students are evaluated by the center’s child psychiatrist and mental health counselor, who start and continue treatment until a child can be connected to long-term care in the community. The concerning rise in mental health issues noticed by the Long Island school administrators mirrors national trends.

Roughly 1 in 5 U.S. Children meet the criteria for a mental health disorder, and the rate of suicide attempts among teens has risen over the past decade, according to the Centers for Disease Control and Prevention. Around the country, most kids who have mental health issues don’t get treatment. There’s a shortage of providers who work with children and it can take months to get an appointment. €œThe wait times on average to see a mental health specialist on an emergency basis is somewhere between two to three months, and for regular basis is up to 12 months, which is an unacceptable wait time,” said Dr.

Ujjwal Ramtekkar, a child and adolescent psychiatrist at Nationwide Children’s Hospital. Without timely access to care, many kids end up with worsening symptoms and eventually land in a hospital emergency department, “as the fastest way to either avert [a mental health] crisis, or as the fastest way to get some kind of mental health evaluation,” Ramtekkar said. €œIt sort of creates this ping-pong effect,” said Tina Smith, executive director of special education at Oceanside School District in Long Island. It’s common to see students go to the ER only to be discharged soon after and return to school without a plan for follow-up care, she said. €œAnd then the problems start to spiral again out of control,” Smith said, “and then they’re sent back to the hospital [ER].” It was with these worries in mind that, after the student suicides in 2019, Leahy began raising her concerns with colleagues, school board members and other parents, including Gina-Marie Bounds, a hospital administrator at Cohen Children’s.

Bounds took the idea to the head of emergency child psychiatry and other hospital officials at Cohen’s and they got to work. Leahy spread the word to neighboring school districts, who were dealing with similar problems, and persuaded them to come on board. Several months later, the mental health center opened its doors. This couldn’t have come at a better time, said Leahy. As many large hospitals around the country saw a surge in the number of kids in mental health crises in their emergency departments, the new behavioral health center reports the opposite trend.

The number of mental health visits to the emergency room by students from these school districts declined by at least 60% in 2020 compared with the previous year. School administrators also say the health center has played a critical role in prevention by promoting the emotional well-being of students, families and school personnel. School and health center staffers meet twice a month via Zoom to check in and brainstorm ways to address emerging health and wellness concerns of staff members and families. Getting Kids the Right Help at the Right Time The goal of the new health center is to provide kids with care as soon as symptoms emerge. The center is staffed by a child psychiatrist, a mental health counselor and a medical assistant.

It’s located next to a pediatrician’s office and within a few miles of the school districts it serves. When a child first arrives, the child is evaluated to determine whether they need to be hospitalized. €œMost kids don’t need that,” said Dr. Vera Feuer, Northwell Health’s associate vice president for school-based mental health, who helped create the center and now oversees it. €œMost kids need outpatient care.” And the center starts that care right away — medication and/or therapy, depending on what each child needs — to stabilize the child and prevent worsening of symptoms, and connect them to ongoing care with a provider in the community.

In January 2021, a local resident, Tara, found herself calling the health center to make an appointment for her 17-year-old sister, who had been struggling with irregular sleep patterns and panic attacks for months. Tara had recently become her sister’s legal guardian. KHN is not using their last names and only using the sister’s middle name — Jasmine — to protect their privacy. Jasmine said she felt suffocated during her panic attacks. €œIt felt like I was running, like my heart got really fast, and like I was being put in a little tiny box,” she said.

Jasmine and Tara met with a mental health counselor at the behavioral health center. The follow-up sessions were helpful for Jasmine, who learned about the importance of speaking with a trusted friend or adult any time she felt triggered. And the clinic helped Jasmine get connected with a nearby psychologist whom she now sees for weekly therapy sessions, Tara said. Removing Barriers for the Most Vulnerable The new health center provides an important safety net for kids who might otherwise fall through the cracks, like 17-year-old Alyssa Gibaldi, who was refused care by other mental health providers because of a disability. Alyssa attends Oceanside High School and is extremely social, said her mother, Jennifer.

€œShe’s like the mayor of the school. Everybody knows her,” Jennifer said. Alyssa has Down syndrome and the levitra upped her anxiety. Last fall, she became catatonic and went into what Jennifer describes as a “zombie-like state.” “She couldn’t talk. She couldn’t move.

She couldn’t speak. She couldn’t feed herself,” Jennifer said. On several occasions, Jennifer called 911. Alyssa was transported in an ambulance to the ER and hospitalized. After her neurologists ruled out seizures and other conditions, they suggested Alyssa see a psychiatrist.

But Jennifer said Alyssa was turned down repeatedly by providers saying they didn’t take her insurance or that they didn’t work with kids with disabilities. That’s when Jennifer reached out to the school nurse, who referred the family to the new behavioral health center. The center’s child psychiatrist, Dr. Zoya Popivker, reviewed Alyssa’s medical records and prescribed medications for depression and anxiety. Jennifer said they got the meds on a Saturday morning, “and by Saturday night, she was out of the catatonic state.

Ever since then, she’s been coming back to us, like her personality came back.” Alyssa continued to go to the behavioral health center for several months, until they were able to transition to a psychiatrist who works with kids with disabilities. The Case for School-Hospital Partnerships It makes sense for children’s hospitals to partner with schools because that’s where kids spend most of their day, said Ramtekkar, the psychiatrist at Nationwide Children’s Hospital. School staffers often know their students well and can spot early signs. It’s why schools in many parts of the country have been working to forge partnerships with nearby mental health care providers. But such partnerships still depend on mental health care resources in the communities they serve.

A 2019 study found 70% of counties didn’t have a single practicing child psychiatrist. Leahy, the assistant superintendent at Rockville Centre in Long Island, said sharing a behavioral health center across multiple school districts leads both to better collaboration and cost savings. The price her district pays for the services is less than the cost of one full-time staff member, and the state chips in to cover part of that. Cohen Children’s will add a new behavioral health center this summer, expanding to 14 school districts. At that point, about 60,000 students in Long Island will have access to immediate mental health support should they need it.

This story is part of a reporting partnership that includes NPR, Illinois Public Media and KHN. Nationwide Children’s Hospital, mentioned in this story, is a financial supporter of NPR. If you or someone you know may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (en español. 1-888-628-9454. Deaf and hard of hearing.

Dial 711, then 1-800-273-8255) or the Crisis Text Line by texting HOME to 741741. Related Topics Contact Us Submit a Story Tip.

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IntroductionThe mammalian buy canada levitra kinesin superfamily proteins (KIFs) are microtubule and ATP-dependent molecular motors, which were first identified in 1985 as axonal transporters in squid and bovine brains.1 Forty-five different kinesin family member (KIF) genes were identified in the mouse genome so far, 44 of which are present in the human genome. Phylogenetic analysis based on sequence homology between the human and the mouse genome led to the classification of KIF genes into 16 families, from kinesin-1 to kinesin-14B (figure 1).2 The first kinesins discovered belong to the kinesin-1 family (KIF5A, KIF5B and KIF5C), and they form a heterotetramer of two heavy chains and two light chains (KLC1-4).2 KIF genes encode KIFs, a specific class of motor proteins generating intracellular motility by driving directional transport of various cargoes such as organelles, protein complexes and mRNAs along the microtubule system.2 Studies using knockout mouse models by Hirokawa and colleagues significantly contributed to elucidate the roles of kinesins in mammalian physiology. Their role in transport is fundamental to cellular logistics and performance, and the molecular motors are not only effectors of signal transduction cascades but also transport and/or bind to important signal transduction molecules to actively modulate their function.3Phylogenetic tree of mammalian kinesin superfamily genes identified in the human (and mouse) genome and classified in 16 subfamilies (from kinesin 1 to 14B) (adapted from Hirokawa et al 3)." data-icon-position data-hide-link-title="0">Figure 1 Phylogenetic tree of mammalian kinesin superfamily genes identified in the human (and mouse) genome and classified in 16 subfamilies (from kinesin 1 to buy canada levitra 14B) (adapted from Hirokawa et al3).The first kinesins were observed in the context of axonal transport in neurons, and a novel disease entity of ‘motor–proteinopathy’ was proposed for the pathogenesis of axonal neuropathies in 2001.4 Due to their role in cellular membrane trafficking, however, kinesins are essential for the functioning of many polar cell types, such as neurons, epithelial cells, sperm cells or stem cells during organogenesis.

Kinesins also play a fundamental role in cell-cycle dynamics, both during mitotic and meiotic processes. They regulate chromosomal condensation and alignment, spindle formation, buy canada levitra cytokinesis and cell-cycle progression.5 It is estimated that about a dozen kinesins are involved in the cell cycle. Among these, there is a specific subclass of chromokinesins (kinesin 4 and kinesin 10 family) which are able to bind chromosomes.6 Recently, KIFs were discovered to act as microtubule stabilisers (KIF26A and KIF21A) and depolymerisers (KIF2A and KIF2C), activities which are important for both cellular morphogenesis and mammalian development, playing a role in neuronal and axonal morphology and ciliogenesis.7Alterations in motor kinesins are leading to human disease by various pathological mechanisms, including cancer and multifactorial and monogenic disorders.

Variants in 18 out of the 44 human KIF genes were identified to buy canada levitra cause monogenic disorders, following different modes of Mendelian inheritance and associated with a wide spectrum of clinical signs. These range from lethal and multiple to isolated congenital anomalies—including birth defects potentially detectable in the foetal period by current prenatal imaging studies—to postnatally apparent neurodevelopmental disorders, intellectual disability and neurological conditions.We will review the current state of knowledge of the biological processes kinesins are involved in and discuss their emerging role in human disease, particularly in birth defects and congenital anomaly syndromes. Birth defects remain a leading cause of perinatal lethality in industrialised countries.8 Structural anomalies are recognised with increasing reliability during early pregnancy by the use of high-resolution ultrasound technologies, thus raising questions about diagnosis, aetiology, prognosis and recurrence risk, particularly in the presence of more than one anomaly, which most likely indicates a genetic aetiology.

We identify recurrent phenotype patterns caused by alterations in KIF buy canada levitra genes, and we outline the complexity of phenotype–genotype correlations mirroring the processes of intracellular microtubule-mediated transport and movement, in which kinesins play a fundamental role. There are likely many more relationships between the clinical signs and the genetic variants to be identified in the future, and the functional network of kinesins and their role in human disease need to be further elucidated. We propose to introduce the term ‘kinesinopathies’ for this group of buy canada levitra conditions, which are phenotypically and genetically overlapping and characterised by the functional impairment of a specific group of molecular motors.

We hope that their systematic approach leads to a better recognition in clinical practice, as well as in genome-wide sequencing for diagnosis and research, and opens strategies for the future development of molecular therapies.KIF structureAll KIFs have a phylogenetically well-conserved motor domain head, consisting of an ATP-binding motif and a microtubule-binding domain. Depending on the position of the motor domain, kinesins can be subdivided into N-kinesins (amino-terminal motor domain), M-kinesins (middle-region motor domain) and C-kinesins (carboxy-terminal motor domain).2 Most kinesins belong to the N-kinesin subgroup, but members of the kinesin 13A family (figure 1) belong buy canada levitra to the M-kinesin subtype, while KIF1C, KIF2C and KIF3C belong to the C- kinesin subfamily.3 Both N-kinesins and C-kinesins are responsible for plus end and minus end-directed motility, M-kinesins for depolymerisation of microtubules in tubulin molecules. However, there are a few exceptions to this categorisation.9 The motor domain head attaches to the neck, the coiled coil stalk and the tail.

The kinesins’ neck is family-specific and responsible for the direction of motility or regulation of activity. The coiled coil stalk and tail are involved in kinesin dimerisation buy canada levitra and/or interactions with cargoes. Kinesins typically use scaffold proteins and adaptor proteins to bind their cargoes but can sometimes bind the cargo directly.

Scaffolds and adaptors might also have regulatory roles in kinesin-driven intracellular transport, that is, recognising specific cargoes and regulating their loading and unloading.3Role of KIFs in physiology and diseaseThe application of genome-wide sequencing for gene identification in research or for clinical diagnostic buy canada levitra purposes significantly contributes to the identification of KIF candidate genes. Genotype–phenotype correlations in KIF gene-related disorders, together with functional and animal studies, continue to elucidate the complex involvement of KIFs in human developmental pathways and disease. Table 1 summarises the monogenic conditions caused by variants affecting the function of KIF genes.View this table:Table 1 Specific monogenic disorders caused by variants affecting the function of KIF genesView this table:Table 2 Summary of phenotypes and genotypes of KIF149 26 30 31The kinesins’ functions in physiological processes, however, are complex and still incompletely understood, but their role in cell-cycle progression and regulation, including buy canada levitra both meiosis and mitosis, in intracellular trafficking, axonal transport, microtubule activity and ciliogenesis, is increasingly studied.

Figure 2 summarises the clustering of KIF genes according to their functional roles and the phenotypical consequences as identified to date in 32 out of the 44 human kinesin genes.Assignment and clustering of KIF genes to various functions and relation to birth defect or monogenic phenotype groups. Detailed phenotypes buy canada levitra are shown in tables 1 and 3. Cancer and multifactorial conditions are not included.

CNS, central nervous system." data-icon-position data-hide-link-title="0">Figure 2 Assignment and clustering of KIF genes to various functions and relation to birth defect or monogenic phenotype groups. Detailed phenotypes buy canada levitra are shown in tables 1 and 3. Cancer and multifactorial conditions are not included.

CNS, central nervous system.Kinesins play a pivotal role during early development and buy canada levitra organogenesis. Microcephaly is one of the most frequently associated clinical signs, mirroring a defect in the regulation of the final number of neurons during development.10KIF4A is a motor protein that translocates PRC1, a cytokinesis protein, to the ends of the spindle microtubules during mitosis, regulates the PARP1 activity in brain development and the survival of neurons, and is a member of the L1CAM recycling pathway. Variants in L1CAM cause X-linked isolated and syndromic buy canada levitra hydrocephalus.

KIF4A was recently proposed as a candidate gene for hydrocephalus.11KIFs are involved in neuronal branching, and microtubule depolarisation, operated by KIF2A M-kinesin, was suggested to suppress collateral branch extension during brain development, leading to anomalies of cortical development, including agyria and pachygyria, subcortical band heterotopia and corpus callosum anomalies.12Functional disruption of KIF genes in knockout mice often results in embryonic lethality, for example, for Kif18A, Kif10, Kif3A, Kif3B and Kif5B,13–17 highlighting the importance of kinesins in embryonic and foetal development. A study on KIF16B demonstrated that microtubule-based trafficking is responsible for early development and stem cell survival.18 KIF26B is essential in kidney development, contributing to the adhesion of mesenchymal cells to the ureteric bud.3 KIF26A was suggested to play a role in enteric nervous system development, because knockout mice develop a megacolon and enteric nerve hypoplasia,19 and to negatively regulate nociceptive sensation.20A significant number of KIFs play a prominent role in ciliogenesis and cilia function. They regulate cilia length, ciliary assembly/disassembly and can have motile cilia-specific functions.21 Some KIFs, specifically found in primary cilia (PC), regulate the length of the axoneme and its disassembly when re-entering the cell cycle.KIF7, also a key component of the Hedgehog signalling pathway, is responsible for cilia length regulation through suppression of microtubule polymerisation.7 KIF7 variants cause hydrolethalus, acrocallosal, and Joubert and Al-Gazali-Bakalinova syndromes.22 Kif2A buy canada levitra knockout mice have severe brain defects, and KIF2A variants in humans lead to microcephaly because of cell-cycle delay in cellular progenitors resulting from cilia disassembly defects.

KIF24, belonging to the same kinesin 13 family, plays a role in both microtubule depolymerising activity and regulation of the early steps of ciliogenesis. Other PC-related buy canada levitra KIFs recently identified are KIF5B, KIF1C and KIF13B, and a potential role in cilia was hypothesised for KIF11 and KIF14.KIF3 protein complex (KIF3A-KIF3B-KAP3 heterotetramer) is a molecular motor necessary for intraflagellar transport (IFT) but is also involved in ciliogenesis of motile cilia. Kif3a-knockout or Kif3b-knockout mice are prenatally lethal, exhibiting anomalies similar to ciliopathy phenotypes, including the disturbance of left–right body determination.3KIF19A is localised at the tip of motile cilia and performs motor and microtubule-depolymerising activities during IFT.

Kif19a-knockout mice present with hydrocephalus and female infertility, common signs in ciliary defects, due to abnormally elongated cilia with buy canada levitra altered motility, not able to generate proper fluid flow.9Further KIFs, which may have specific roles in motile cilia, are KIF27, KIF9, KIF6 and KIF18B. Regarding the involvement of numerous KIFs in cilia-related processes, it is not surprising that many disorders caused by variants affecting KIF gene function are presenting with anomalies reminiscent of ciliopathies.Kinesin motors have a fundamental role in neuronal function, as they are responsible for the transport of synaptic vesicle precursors and transmitter receptors along axons and dendrites from the neuron body.3 Molecular motor activity as for KIF1A, KIF5 and KIF17 is important for higher brain functions, such as learning and memory through regulation of synaptic transmission.5 Dysfunction can be associated with intellectual disability and global developmental delay (table 1).Impaired function can also result in peripheral neuropathies (KIF5A, KLC2, KIF1A and KIF1B) and ocular motility disorders (KLC2 and KIF21A)23 24 when axon elongation in the peripheral nervous system and optic nerve is affected. KIF5A variants are associated with epileptic phenotypes both in humans and mice25 because the transport of neurotransmitter receptors is disturbed and inhibitory regulation is altered.Due to their role in cell-cycle regulation, kinesins are important in male spermatogenesis and female oogenesis.

They are involved in all steps of spermatogenesis 26 buy canada levitra and, based on previous animal studies, they may represent a potential target to treat male infertility. In female meiosis, 13 KIF genes were studied in animal models. There is some buy canada levitra evidence that kinesin expression is vulnerable to maternal ageing and environmental factors, such as oocyte cryopreservation and alcohol consumption.

It may be promising to expand research in this field in order to clarify the mechanisms and factors contributing to oocyte quality decline.27Many kinesins were extensively studied in the fields of cancer development, progression and therapy. Deregulation of the mitotic kinesins by both overexpression buy canada levitra and decreased expression causes cancer progression or can be a prognostic marker in various tumours.28 The cell-permeable small-molecule mitotic inhibitor monastrol was discovered in 199929 and was shown to arrest cells in mitosis by specifically inhibiting KIF11, a kinesin important for spindle bipolarity. The bipolar mitotic spindle is replaced by a monoastral microtubule array surrounded by a ring of chromosomes, which gave the inhibitor its name.

The mitotic spindle is now a well-known target of chemotherapy, and inhibitors of the mitotic kinesins KIF11, KIF10 and KIF1C are being studied for this purpose.28 30 The redundancy of some kinesins allows them buy canada levitra to escape pharmacological inhibition. For example, in the absence of KIF10, KIF15 is able to replace all of its essential functions in spindle assembly. Cilia-related KIF7, KIF13B and KIF27 are involved in SHh signalling and may be a future target in cancer research.28Some kinesins confer susceptibility to a range of multifactorial, metabolic and neurodegenerative conditions.

KIF13B contributes to the enhancement of endocytosis of low-density lipoprotein (LDL) receptor-related protein 1 that is involved buy canada levitra in the recognition and internalisation of LDL and factor VIII. Kif13b-knockout mice have hypercholesterolaemia and higher factor VIII serum levels.5 KIF12 is implicated in the pathogenesis of type 2 diabetes, protecting pancreatic β cells from the oxidative stress caused by nutritional excess.5 Variants in KIF1B or KIF21B confer susceptibility to multiple sclerosis (OMIM %612596, #126200).31 32 KIF5A was associated with Amyotrophic lateral sclerosis (OMIM #617921).33 KIF3 complex and KIF17 were recently uncovered to be involved in schizophrenia.34 35 Further studies, however, are needed to clarify the precise role of KIFs in neurodegenerative processes and psychiatric conditions.KIF14 -related birth defects. Lessons learntAdvances in next-generation sequencing technologies have revolutionised our understanding of Mendelian disorders, including birth buy canada levitra defect phenotypes, by sequencing the coding genome (exome) or entire genome at an unprecedented resolution in a comparably short time span.

The technology has been extensively used for gene identification approaches in research for many years, enabling unparalleled genotype–phenotype correlations and the definition of novel pathways of related genes and disorders at an accelerated pace, traditionally focusing on postnatal disorders. Filges and Friedman36 postulated that a number of novel disease genes causing birth defects could be identifiable through the investigation of lethal buy canada levitra foetal phenotypes since they would represent the extreme end of allelic milder and viable postnatal phenotypes with less specific or recognisable anomaly patterns. Based on embryonically or perinatally lethal mouse models (www.informatics.jax.org and www.dmdd.org.uk), it is estimated that knockout variants in about 30% of human protein coding genes may present with a phenotype of early lethality.

The identification of KIF14 loss of function variants in fetuses with a lethal multiple congenital anomaly syndrome and the subsequent description of the allelic postnatal viable phenotype and further functional characterisation of KIF14 in developmental processes are recent examples of how to study those embryonic lethal phenotypes in order to understand the role of genes for which little to nothing is known.Filges et al identified autosomal recessive compound heterozygous loss of function variants in KIF14 using family-based exome sequencing in a recurrent severe lethal phenotype (OMIM #616258). It was the first human phenotype reported due to variants in the human KIF14 gene (figure 3).37 The two affected siblings presented with intrauterine growth retardation (IUGR), oligohydramnios, severe microcephaly, renal cystic dysplasia or agenesis, genital tract malformations (uterine hypoplasia buy canada levitra and vaginal atresia), as well as cerebral and cerebellar hypoplasias with partial or total agenesis of the vermis, arhinencephaly, agenesis of occipital lobes/corpus callosum at second trimester ultrasound scan. Cross-species comparison to the laggard spontaneous mice mutant, characterised by homozygous variants of the Kif14 gene,38 confirmed a phenotypical overlap.

An increased number of binucleated cells in the tissue histology of the two fetuses were in concordance with the key role of KIF14 during mitosis participating in chromosomes’ congression and alignment, as well as in cytokinesis39 and the observation of binucleated cells as a consequence of failed cytokinesis in buy canada levitra mammalian KIF14 knockdown cells. During cytokinesis, PRC1 localises KIF14 at the central spindle and midbody, which in turn recruits citron rho-interacting kinase (CIT) to the midbody. CIT, in buy canada levitra turn, acts as a negative regulator of KIF14 activity.

Knockdown of KIF14 in mammalian cells results in impaired localisation of CIT during mitosis.40Structure of KIF14 and summary of all published KIF14 variants affecting function.10 37 41 42 The N-terminal region (aa 1–356) is important for its interactions with PRC1 and the protein’s localisation at the central spindle and midbody. The kinesin motor domain (aa 358–701) is responsible for the microtubule-dependent ATPase activity. The FHA buy canada levitra domain (aa 825–891).

Stalk and tail region (aa 891–1648) are necessary for the interaction with the protein CRIK (aa 901–1189, red diagonal lines). There are four additional coiled-coil domains (light blue-coloured areas).61 FHA, forkhead associated buy canada levitra. Aa, amino acid." data-icon-position data-hide-link-title="0">Figure 3 Structure of KIF14 and summary of all published KIF14 variants affecting function.10 37 41 42 The N-terminal region (aa 1–356) is important for its interactions with PRC1 and the protein’s localisation at the central spindle and midbody.

The kinesin motor domain (aa 358–701) is responsible buy canada levitra for the microtubule-dependent ATPase activity. The FHA domain (aa 825–891). Stalk and tail region (aa 891–1648) are necessary for the interaction with the protein buy canada levitra CRIK (aa 901–1189, red diagonal lines).

There are four additional coiled-coil domains (light blue-coloured areas).61 FHA, forkhead associated. Aa, amino acid.Filges et al pointed out that KIF14 should be considered a candidate gene for viable postnatal phenotypes, including isolated microcephaly.34 Additional individuals with autosomal recessive variants in KIF14 and isolated primary microcephaly were then described9 41 42 (table 2).Impaired cytokinesis, increased apoptosis and reduced cell motility were confirmed in cells from the described patients, pointing to a new cellular pathway in the pathogenesis of microcephaly.43 Apart from one case with small kidneys with increased echogenicity, none of these 18 patients had associated kidney anomalies. However, a targeted exome sequencing study in 204 unrelated patients with congenital anomalies of the kidney and urinary tract (CAKUT) reported two more cases of renal anomalies, bilateral hypoplasia or agenesis, caused by KIF14 buy canada levitra variants.44 Further nine cases had an associated renal phenotype, which ranged from bilateral renal agenesis to cystic or non-cystic renal hypodysplasia.42 Table 2 and figure 3 summarise KIF14 variants and the associated phenotypes.

Loss of function variants more likely lead to multiple congenital anomalies, while hypomorphic variants result in a milder phenotype without renal involvement, although phenotype–genotype correlations remain preliminary for the time being.The phenotypical spectrum ranging from isolated primary microcephaly to congenital anomalies reminiscent of ciliopathy phenotypes suggested a complex role for KIF14 in developmental processes and raised a number of questions about the relationship between its established role in cell division and its possible function in ciliary pathways. Functional studies of absent KIF14 protein in the development of human foetal tissues and mutant zebrafish provided evidence for similarities and differences between mitotic events occurring during proliferation in the development of both brain and kidney.42 The observation that KIF14-stained midbodies accumulate within the lumen of the branch tips of ureteric buds in human foetal kidneys provided a key clue to better understand the mechanism through which the loss of buy canada levitra KIF14 affects both brain and kidney development in humans. It was previously demonstrated that the secretion and accumulation of midbody remnants in the cerebrospinal fluid in mice during the early stages of brain development correspond to the amplification of neural progenitors.45 Kif14 mutant zebrafish phenotypes supported the hypothesis of a potential role for KIF14 in cilia.

In vitro and in vivo analyses suggested that loss of kif14 causes ciliary anomalies through an accumulation of mitotic cells in ciliated tissues but failed to establish a direct functional link.21 42 Further mechanisms remain buy canada levitra to be elucidated. Overexpression of KIF14 in various types of tumours was suggested to be a possible prognostic marker and a potential target for therapeutic purposes.46Kinesinopathies in birth defect phenotypes. Recurrent themesIn the last few years, an increasing number of variants in KIF genes were described to cause isolated as well as multiple congenital anomalies.

There is buy canada levitra a huge variability of phenotypes caused by variants even within the same gene. However, we can identify recurrent clinical signs that should alert the clinician to suspect a KIF gene-related disorder and the molecular geneticist to include KIF genes in multigene-panel and genome-wide sequencing approaches. This will become particularly relevant in prenatal and perinatal medicine, which focuses on the detection of structural anomalies in the fetus and the buy canada levitra newborn by using ultrasound and MRI or autopsy when the outcome is lethal.

We have summarised the predominant and recurrent structural anomalies in kinesinopathies reported so far that would likely become apparent during the foetal period in table 3 and the syndromic disorders in table 1.View this table:Table 3 KIF gene-related structural congenital anomalies recurrently described in prenatal phenotypesSupplemental materialConsistent with the kinesins’ role in the development of the central nervous system (CNS), brain anomalies of various degrees are a frequent clinical sign, particularly microcephaly, but include lissencephaly, polymicrogyria, thinned or agenesis of the corpus callosum, arhinencephaly, cerebral hypoplasia or atrophy, cerebellar hypoplasia or atrophy, brainstem hypoplasia and a molar tooth sign on brain imaging.12 22 37 44 47–51Primary microcephaly can be detected prenatally or at birth12 22 47 48 50 51 and can present as an isolated or syndromic condition as, for example, caused by variants in KIF149 or in KIF11 (microcephaly with or without chorioretinopathy, lymphoedema or mental retardation. OMIM #152950).48KIF7 variants were related to macrocephaly in the buy canada levitra presence of congenital hydrocephalus (hydrolethalus syndrome LS2, OMIM # 614120). Isolated hydrocephalus was reported for KIF4A in a single case.11Foetal akinesia and arthrogryposis (KIF5C12, KIF1434 and KIF26B50) are likely secondary to the neurological compromise of the fetus but can also appear as an early sign of abnormal CNS development, which should prompt specialist CNS sonographic and MRI evaluation of the fetus.Further anomalies of the limbs include camptodactyly (KIF26B50), clubfoot (KIF1A51), rocker-bottom feet (KIF26B50) and congenital lymphoedema of the limbs (dorsa of feet, lower extremities and, rarely, hands) in cases with KIF11 gene mutations.48 In particular, KIF7 gene variants have been related to various anomalies of the hands (tapered fingers, fifth finger clinodactyly, brachydactyly, preaxial or postaxial polydactyly, bifid terminal phalanges of the thumbs, spindle-shaped fingers, clinodactyly and soft tissue webbing) and feet (toe syndactyly, preaxial or postaxial polydactyly, and duplicated halluces).22CAKUT and genital anomalies are reported in various kinesinopathies including renal agenesis or hypoplasia (KIF1437 and KIF1252), ureteral hypoplasia (KIF1437), congenital megabladder (KIF1252) and vesicoureteral reflux (KIF1252), uterine hypoplasia and vaginal atresia (KIF1437) and hypospadias and chordae (KIF16B49).IUGR is recurrently detected (KIF5C12, KIF1437, KIF1053, KIF1554 and KIF2A12) and is particularly relevant when occurring simultaneously with one of the other recurrent clinical signs, indicating a potential syndromic KIF-related disorder.

Oligohydramnios or polyhydramnios is most likely secondary to a primary organ anomaly.There are a few kinesinopathy syndromes that have been specifically reported to be lethal, such as the ciliary phenotype (OMIM #616258), caused by variants in KIF1434, and hydrolethalus syndrome (OMIM #614120), caused by variants in KIF7.22 However, lethality is usually closely related to the specific major anomalies, and it can be hypothesised that such a lethal phenotype will exist for all KIF gene-related disorders.Developmental delay, intellectual disability, seizures, and sensory and motor disturbances of the peripheral nervous system, as well as eye anomalies, such as microphthalmy, optic nerve pallor, fibrosis of extraocular muscles and chorioretinopathy, will escape detection in the foetal period but are reported in postnatal patients.Kinesin pathways in birth defectsFunctional studies of kinesins in birth defects are still sparse, and little is known about their networks and pathways. In order to improve our understanding, we used the Ingenuity Pathway Analysis (IPA Qiagen, Redwood City, California, USA) to visualise and analyse the connections between the 13 kinesin motor proteins associated with structural congenital anomalies (KIF5C, KIF1A, KIF1BP, KIF14, KIF16B, KIF7, KIF4A, KIF11, KIF10, KIF26B, KIF12, KIF15 and KIF2A) and in up to 10 of each of buy canada levitra their most significant downstream proteins. The connections are defined as protein–protein interactions, activation, regulation of binding, expression, localisation, phosphorylation, protein–RNA interactions, molecular cleavage, ubiquitination, protein–DNA interactions, inhibition, translocation and transcription.

Figure 3 buy canada levitra displays the results. We used the software Gephy55 to look for all possible interactions between all proteins of the network and also used the IPA data to retrieve the canonical pathways involved. Figure 4 and online supplementary material, table 4, summarise the buy canada levitra results.

KIF7, KIF14 and KIF12 are located within the same network, and because of multiple connections between themselves and their downstream proteins, it is not surprising that they are all involved in kidney anomalies. IPA data are based on current publications and are therefore subject to bias because proteins that are most buy canada levitra interconnected are also most probably those that have been more extensively studied. However, we consider the KIF genes coding for proteins seeming less important within the network to be strong candidates for future studies of human developmental disorders.IPA of the 13 kinesins known to be involved in birth defects with respect to their position in the cell.

Proteins displayed on the right side of the figure, below the tag ‘other’, are those for which no subcellular location is known. Birth defect-related kinesins and their connection with each buy canada levitra other are highlighted in green. Light blue-coloured downstream proteins are those which are known to cause birth defects when altered.

Yellow-coloured proteins are those involved in buy canada levitra neurological disorders overlapping with the clinical features of kinesinopathies. The legend of the biological function associated with every molecule is displayed on the right. Path Designer by IPA was used for the buy canada levitra figure design.

IPA, Ingenuity Pathway Analysis." data-icon-position data-hide-link-title="0">Figure 4 IPA of the 13 kinesins known to be involved in birth defects with respect to their position in the cell. Proteins displayed on the right side of the figure, below the tag ‘other’, are those for which no subcellular location is known. Birth defect-related buy canada levitra kinesins and their connection with each other are highlighted in green.

Light blue-coloured downstream proteins are those which are known to cause birth defects when altered. Yellow-coloured proteins are those involved in neurological disorders overlapping with the clinical features of buy canada levitra kinesinopathies. The legend of the biological function associated with every molecule is displayed on the right.

Path Designer by IPA was used for buy canada levitra the figure design. IPA, Ingenuity Pathway Analysis.Closing remarks and future perspectivesNovel KIF genes are increasingly identified, and there is a growing body of literature demonstrating the impact of kinesin dysfunction in human disease. We propose to introduce the term kinesinopathies for conditions caused by variants in KIF buy canada levitra genes, since recurrent and common functional and phenotypical themes can be observed.

In analogy to ciliopathies56 and rasopathies,57 the delineation of the clinical, genetic and functional hallmarks of kinesinopathies will be important to better recognise these conditions, to understand the pathomechanisms and to ultimately improve the clinical management of the patients. Previously, the unified view of the phenotype characteristics of ciliary dysfunction allowed a tremendous increase in awareness, both in clinic and research, and the further identification of yet unrecognised ciliary disorders and the genes and proteins involved in their pathogenesis.56Remarkable progress was achieved in assigning function to kinesins through their study in isolated and multiple congenital anomaly phenotypes. They are one large superfamily of molecular motors out of three (kinesins, dyneins and myosins), which is of key importance in several fundamental cellular buy canada levitra processes using microtubules as rails for directional anterograde intracellular transport, including its regulation and modulating signal transduction.5 Kinesin motors are most important for the movement of chromosomes along the spindles during chromosome segregation, regulation of spindle formation, cell division and cytokinesis.

These essential and broad cellular functions are critical for many physiological processes such as neuronal function and survival, some ciliary functions and ciliogenesis, determination of the left/right asymmetry of our body and regulation of organogenesis, thus explaining the impact and emerging recognition of kinesins in embryonic and foetal development. Defects can result in neuropathies, higher brain functions and buy canada levitra structural brain anomalies. Multiple congenital anomalies, including the kidney and urinary tract and limb anomalies, are repeatedly reported.

Microcephaly, which is usually not associated with genes implicated in specific ciliary mechanisms, and CNS anomalies are the most recurrent clinical signs in both the prenatal and postnatal phenotypes buy canada levitra described so far. The discovery of the implication of KIF14 in microcephaly further suggested a possible novel role of other microcephaly proteins in cytokinesis. A number of syndromic kinesinopathies present, however, with phenotype patterns reminiscent of ciliopathies.

So far, however, a direct functional impact was confirmed in only a few and could not be demonstrated, for buy canada levitra example, for KIF14, despite an overlapping clinical pattern. In turn, ciliopathies are a clinically and genetically heterogeneous group of conditions themselves. Studying tissue and cell type-specific function and expression may help to further define the specific defects related to the individual aberrant buy canada levitra kinesin.The pleiotropic nature of human kinesinopathies, however, is just emerging, but their study promises to provide important insights into human developmental pathways.

Seemingly unrelated clinical entities are highlighting a common theme. In a relatively short time span, monogenic KIF-related disorders were identified to present with often severe and lethal antenatal anomalies, with multiple or isolated congenital anomalies, neurodevelopmental and neurological disorders, or an increased buy canada levitra susceptibility to multifactorial conditions. We focused on the emerging role of kinesins in structural congenital anomalies because, as illustrated for the KIF14 gene, great potential to decipher allelic viable phenotypes and developmental pathways lies in the study of these human knockout phenotypes at the severe end of the phenotypical spectrum.

Knockout variants in about 30% of human protein coding genes in our genome may present with a phenotype of early lethality, and KIF genes seem to play an important role in such fundamental processes of human development. Identifying and characterising the variants, genes and phenotypes will extend our knowledge buy canada levitra on early human development and pathomechanisms, and will ultimately also improve the clinical utility of genome-wide sequencing approaches for prenatal and postnatal application by our increased ability to interpret loss of function and hypomorphic variants alike. Furthermore, kinesins were extensively studied in cancer research and therapeutic strategies targeting their specific functions, such as the example of monastrol and other inhibitors of the mitotic kinesins may be adopted in the future.

There are likely many more kinesinopathies to be unravelled in the field of birth defects because of their pivotal role buy canada levitra in cellular logistics, but their recognition in clinics and research will depend on our ability to identify and characterise the common clinical, molecular and functional themes of these disorders and to use them to improve our understanding of their disease mechanisms.IntroductionIntellectual disability (ID) affects about 3% of individuals worldwide and raises significant issues in terms of diagnostic, management and genetic counselling. The presence of pigmentation anomalies in a patient with ID represents helpful clinical clues in order to narrow the range of aetiological hypothesis. Hypomelanosis of Ito (HMI, MIM #300337) is an unspecific term encompassing a heterogeneous group of disorders characterised buy canada levitra by cutaneous hypopigmented whorls and streaks along Blaschko’s lines and variable extracutaneous features affecting the musculoskeletal and nervous systems.1 The cutaneous pattern therefore represents a non-specific hallmark of mosaicism in these neurocutaneous conditions.

Genetic mosaicism is due to postzygotic mutations, either chromosomal rearrangements or point mutations, whereas random X inactivation in females leads to functional mosaicism.2 Unravelling the molecular basis of pigmentary mosaicism (PM) is still a challenge due to clinical and genetic heterogeneity, technical difficulties in detecting mosaic mutations by classical sequencing approaches and the complexities of obtaining affected tissue. As part of a collaborative group, we recently reported de novo mutations in exons 3 and 4 of transcription factor E3 (TFE3) as the cause for HMI in four unrelated individuals, including one male, as well as syndromic ID without pigmentary disorders in a female.3TFE3 belongs to the MITF family of mammalian basic helix–loop–helix zipper transcription factors, buy canada levitra together with TFEB and TFEC. All four can form homodimers or heterodimers with each other.4 Embryonic expression of TFE3 orthologues Tfe3a and Tfe3b was demonstrated in the zebrafish in a wide range of tissues.5 TFE3 subcellular localisation plays a crucial role in the regulation of cellular homeostasis and embryonic stem cell (ESC) differentiation.

The phosphorylated TFE3 is retained in the cytoplasm, whereas dephosphorylated protein translocates to the nucleus to promote the transcription of target genes involved in lysosomal biogenesis and autophagy.6 TFE3 relocalisation to the nucleus is driven on various stressors, such as starvation,7 8 DNA damage,9 mitochondrial damage,10 Golgi stress11 and pathogens12 in an mTORC1-dependent manner, and oxidative stress13 or cadmium exposition14 in an mTORC1-independent manner. Moreover, lysosomal signalling-induced nucleocytoplasmic redistribution of TFE3 is essential to the regulation of ESC renewal.3 15 By restricting nuclear localisation buy canada levitra and activity of Tfe3, lysosome activity, the tumour suppressor protein folliculin and the Ragulator protein complex enable the exit from pluripotency and therefore drive differentiation. Conversely, enforced nuclear Tfe3 enables ESCs to withstand differentiation.15 In humans, TFE3 mutations have long been known in cancer.

Gene fusions by translocations or other chromosomal rearragements involving TFE3 and five partner genes have indeed buy canada levitra been reported to occur in a subset of renal cell carcinomas (RCCs), referred to as ‘TFE-fusion RCC’, and, more rarely, to lung sarcoma and perivascular epithelioid cell tumours.16 Beyond these data on TFE3 function, by the report of a series of 17 individuals harbouring de novo mutations in exons 3 and 4 of TFE3, we emphasise their phenotype and bring additional clinical insight toward the recognition of this novel developmental disorder.ResultsWe describe a series of 17 patients carrying a de novo mutation in TFE3, 5 of them being previously published with limited clinical information.3 Twelve were females and five were males. Their age ranged from 12 months to 22 years. Five were referred for HMI, five for syndromic ID and buy canada levitra five for suspicion of storage disorder.Clinical dataThe clinical features are summarised in table 1.

Additional information can be found in online supplementary data 1.Supplemental materialView this table:Table 1 Clinical and molecular features of the 17 patients with an TFE3 mutationNeonatal course was remarkable for nine patients. History of jaundice, hepatomegaly or feeding difficulties was reported for three patients each, hypoglycaemia for two and cholestasis for one. All these features were transient.Developmental delay, usually severe buy canada levitra and noticeable from the first months of life, was a constant feature in all the individuals.

Only 6 patients were able to walk at the time of the study, whereas 11 were still unable to walk. All patients buy canada levitra were non-verbal, except for two older patients who could speak a few words. Neurological examination was abnormal in 12 individuals and consisted in truncal hypotonia, associated with lower limb spasticity (6 individuals) or ataxia (2 adults).

Behavioural issues such as autistic features and sleeping disturbance were noted for buy canada levitra 11 patients. Eleven patients developed epilepsy, onset in the first decade and characterised as intractable in three of them. Brain MRI was normal in 10 individuals and abnormal in 6 patients (hydrocephaly, short corpus callosum, Dandy-Walker malformation, arachnoid cyst, periventricular white matter lesions, delayed myelination and cerebral atrophy).

The sensory anomaly was congenital hearing loss (5 patients), and ophtalmological anomalies (10 patients) buy canada levitra consisted of strabismus, hyperopia, retinal degeneration, depigmented macule on the iris, oculomotor apraxia or impaired vision of cortical origin.Facial dysmorphism shared among the patients consisted in coarseness, flat nasal bridge, short nose with anteverted nares, widely spaced eyes, almond-shaped eyes, thick lips, facial hypertrichosis, fleshy earlobe, and full and pink cheeks (figure 1). Twelve patients had pigmentation anomalies, located on Blaschko’s lines for 10 of them (figure 2). One was buy canada levitra diagnosed at 4 years old with histiocytofibroma.

Moderate to severe postnatal growth retardation affected 10 patients, who had a length between −2.0 and −4.5 SD. Obesity affected buy canada levitra 13 individuals. Skeletal anomalies were frequent (11 individuals) and consisted of flat or clubfeet, hyperlordosis, scoliosis, hip dislocation, limitation of elbow extension and genu valgum.

Recurrent s of the upper airways were noted buy canada levitra in five patients. One had a documented neutropenia. Early-onset chronic interstitial lung disease was reported in two patients.

Nail clubbing was noted in two individuals buy canada levitra. Visceral malformations consisted of congenital heart defect (left ventricle dilatation, aortic insufficiency and patent ductus arteriosus) in three patients, umbilical hernia in three individuals, lateral semicircular canal dysplasia, posterior plagiocephaly, sleep apnoea syndrome, anteriorly displaced anus and hypospadias in one individual each.Facial phenotypes of seven patients. (A–C) Patient 5, aged 6 months (A,B) and buy canada levitra 3 years (C).

(D) Patient 8, aged 5 years. (E,F) Patient 2, aged 5 buy canada levitra and 20 years. (G–I) Patient 3, aged 1 year (G) and 3 years (H,I).

(J,K) Patient 13, aged 22 years. (L–O) Patient 6, aged 8 months (L), 20 buy canada levitra months (M) and 3 years (N,O). (P,Q) Patient 10 aged 22 years." data-icon-position data-hide-link-title="0">Figure 1 Facial phenotypes of seven patients.

(A–C) Patient 5, buy canada levitra aged 6 months (A,B) and 3 years (C). (D) Patient 8, aged 5 years. (E,F) Patient 2, aged 5 and 20 buy canada levitra years.

(G–I) Patient 3, aged 1 year (G) and 3 years (H,I). (J,K) Patient 13, aged 22 years. (L–O) Patient 6, aged 8 buy canada levitra months (L), 20 months (M) and 3 years (N,O).

(P,Q) Patient 10 aged 22 years.Cutaneous features. (A) Patient buy canada levitra 3. Umbilical hernia, widely spaced nipples and hypopigmentation on the left side of the abdomen.

(B) Patient 17 buy canada levitra. Hypotonia, umbilical hernia and widely spaced nipples. (C) Patient buy canada levitra 8.

Blaschko’s lines on the back. (D) Patient 6. Hypopigmentation on the left side of the abdomen buy canada levitra.

(E) Patient 7. Blaschko’s lines buy canada levitra on the abdomen and right side of the trunk. (F) Patient 13.

Hand. Note clubbing of thumbnail and loose skin. (G) Patient 17.

Blaschko’s lines on the left side of the abdomen. (H) Patient 17. Hand.

Note tapering fingers and wrinkled skin. (I) Patient 1. Linear hypopigmentation on the back.

(J) Patient 6. Blaschko’s lines on the back. (K) Patient 3.

Blachko’s lines on the right lower limb. (L) Patient 6. Blaschko’s lines on the right lower limb.

(M,N) Patient 7. Linear hyperpigmentation on the lower limbs. (O) Patient 11.

Blaschko’s lines on the back." data-icon-position data-hide-link-title="0">Figure 2 Cutaneous features. (A) Patient 3. Umbilical hernia, widely spaced nipples and hypopigmentation on the left side of the abdomen.

(B) Patient 17. Hypotonia, umbilical hernia and widely spaced nipples. (C) Patient 8.

Blaschko’s lines on the back. (D) Patient 6. Hypopigmentation on the left side of the abdomen.

(E) Patient 7. Blaschko’s lines on the abdomen and right side of the trunk. (F) Patient 13.

Hand. Note clubbing of thumbnail and loose skin. (G) Patient 17.

Blaschko’s lines on the left side of the abdomen. (H) Patient 17. Hand.

Note tapering fingers and wrinkled skin. (I) Patient 1. Linear hypopigmentation on the back.

(J) Patient 6. Blaschko’s lines on the back. (K) Patient 3.

Blachko’s lines on the right lower limb. (L) Patient 6. Blaschko’s lines on the right lower limb.

(M,N) Patient 7. Linear hyperpigmentation on the lower limbs. (O) Patient 11.

Blaschko’s lines on the back.Molecular resultsThe characteristics of the 13 different de novo TFE3 variants identified in the 17 unrelated individuals are summarised in table 2. All but one were missense variants, affecting nine different aminoacids. One was a splice donor mutation.

This mutation was reported a few weeks ago in a patient with a similar phenotype.21 Two variants were localised in exon 3 and 11 in exon 4 (figure 3). All were absent from public databases and were predicted to be pathogenic by prediction softwares. TFE3 protein and localisation of the missense variants identified.

In bold are variants identified in two patients. In bold and underlined is the variant identified in three patients. In green is the intronic variant." data-icon-position data-hide-link-title="0">Figure 3 TFE3 protein and localisation of the missense variants identified.

In bold are variants identified in two patients. In bold and underlined is the variant identified in three patients. In green is the intronic variant.View this table:Table 2 Molecular data of the 13 de novo TFE3 mutations.

Characteristics, inheritance, frequency in the public database GnomAD, prediction scores regarding pathogenicity (Polyphen, Grantham and CADD (Combined Annotation Dependant Depletion) scores). The transcript is NM_006521.5The putative mosaicism was assessed through X inactivation studies in females and analysis of the exome sequencing data in males, by checking the total number of reads covering the variant, as well as the number of reads supporting the presence of the variant (table 1). Allele frequencies in females were always consistent with a constitutional heterozygous mutation.

X inactivation was skewed in blood of the female patients 1, 3 and 7 and in fibroblasts of Patient 2. X inactivation was random in fibroblasts of Patient 1 and 3. Regarding the male patients, the mutation was identified in 65% of the reads for Patient 17% and 88% of the reads for Patient 15 (106/120).

No mosaicism was detected in the blood of Patient 13, 14 and 16 despite the presence of pigmentary manifestations in Patient 16.DiscussionTFE3 functions in signalling of the mechanistic target of rapamycin (mTOR) complex 1 (mTORC1). The PIK3-AKT-mTOR pathway plays a role in the regulation of cellular growth, proliferation, survival and metabolism. Overactivation of the mTOR signalling is responsible for neurocutaneous disorders and cancers.22 Somatic mutations in TSC1, TSC2, AKT3, PIK3CA and MTOR are responsible for focal cortical dysplasia type II (MIM607341),23–25 hemimegalencephaly26 and megalencephaly.27 The phenotype ascribed to germline TSC1/TSC2, PTEN, MTOR and PK3R2/AKT3/CCND2 mutations – respectively in tuberous sclerosis (TS, MIM 191100), Cowden syndrome (CS, MIM 158350), Smith-Kingsmore syndrome (MIM 616638) and Megalencephaly, Polymicrogyria, Polydactyly and Hydrocephalus syndrome 1, 2 and 3 (MPPH1/2/3, MIM 603387/615939/615938) - is characterised by the association of ID, epilepsy, brain malformations and skin tumours.

Similarly, all the individuals harbouring a de novo TFE3 mutation reported in the series presented with a severe neurodevelopmental disorder. Delayed psychomotor development was constant. The youngest patient to acquire independent walking was 30 months old, and more than half of the patients aged over 18 months (57%), did not acquire walk at the last examination.

Conversely to patients with MTOR, AKT3 or PTEN mutation, none of the patients described in this series had macrocephaly. Brain imaging was abnormal in 35% of the patients. Hydrocephaly and corpus callosum dysgenesis, identified in respectively three and one individual, were previously reported in patients with mosaic gain of function MTOR mutations.28 29 One patient had surgery to remove an early-onset histiocytofibroma.

However, no other skin tumour was reported, either in this patient or in any other from the series.Pigmentation anomalies, along Blaschko’s lines or, for one patient, as a large hyperpigmented area, were present in a majority of the individuals (71%) in the series, including 40% of the males and 83% of the females. PM along Blaschko’s lines is highly suggestive of genetic mosaicism.30 Genomic mosaicism is defined by the presence of at least two cell populations with different genotypes in an individual originating from one zygote and mainly occurs through post-zygotic event, whereas females can present with functional (epigenetics) mosaicism due to X inactivation.2 PM is a classical feature of X-linked male-lethal genodermatosis, such as incontinentia pigmenti (IP, MIM #308300), focal dermal hypoplasia (FDH, MIM #305600), chondrodysplasia punctuata type 2 (Conradi-Hunermann-Happle syndrome, CDPX2, MIM #302960) and linear skin defects with multiple congenital anomalies (LSDMCA1, MIM #309801). In these conditions, the overwhelming predominance of affected females is a consequence of the male lethality, and the PM a manifestation of the functional mosaicism occurring in females.

Similarly, the majority of individuals with de novo TFE3 variants in our cohort were females (sex ratio female:male was 12:5 (2.4)). The study of X-inactivation on non-cultured fibroblasts was consistent with functional mosaicism in two affected females with PM who harboured random X-inactivation, whereas a third female without PM had skewed X-inactivation. In IP, FDH and CDPX2, most hemizygous males die in utero.

However, there have been reports of surviving males 31–33 with an estimated prevalence around 10% in FDH and IP.32 34 The majority of them are explained by post-zygotic mutations or chromosomal anomalies (Klinefelter syndrome). Non-mosaic males have also been reported in FDH and IP – respectively about 17% and 45% of the affected males harbour a non-mosaic variant.32 35 In our series, males represented 29% of the patients with a de novo TFE3 variant. A mosaic variant was identified in blood for half of them.

None had Klinefelter syndrome. Interestingly, mosaicism was detected in only one out of the two males with PM, and one male with a mosaic variant had no pigmentation anomalies noted on examination. It is still possible that subtle pigmentation anomalies were missed on examination.

Moreover, somatic mosaicism can be difficult to detect. Recent studies have shown that a large proportion of de novo mutations presumed to be germline had in fact occurred as post-zygotic event.36 In the males of this cohort, WES was performed on leucocytes-derived DNA and no other tissue was studied. Therefore, it is possible that a low mosaicism was not detected.

Finally, it is probable than TFE3 mutations account for a significant proportion of patients with HMI. Indeed, in this population, the high frequency of ID, epilepsy, coarse facial features has long been emphasised in the literature.37By its ability to bind the coordinated lysosomal enhancement and regulation (CLEAR) sites in the promotor region of target genes, TFE3 is involved in the control lysosomal biogenesis, autophagy and endocytosis.8 Several patients of the series indeed had clinical and biochemical features that pointed toward an inborn error of metabolism. Lysosomal storage disorder was suspected due to the variable association of coarse facial features (88%), skeletal anomalies (65%) –flat or clubfeet, hyperlordosis, hip dislocation, limitation of elbow extension, genu valgum, scoliosis–, postnatal growth retardation (59%), history of speech or developmental regression (29%) congenital hearing loss (29%), recurrent upper airways s (29%) neonatal liver anomalies such as hepatomegaly and cholestasis (18%), upper airways s (24%), umbilical hernia (18%), sleep apnoea syndrome (6%) and aortic insufficiency (6%).

Other metabolic anomalies observed in the series were obesity, defined in children by body mass index (BMI) (weight/height2) above the WHO curve, present in the oldest patients (76%), neonatal transient hypoglycaemia (12%), and hyperlactataemia (6%). Dysregulation of lipid metabolism, via suppression of thermogenesis and decreased lipolysis, thus leading to increased adipose tissue, was previously observed in adipose-specific TFE3 transgenic mice.38 Similarly to lysosomes, mitochondrias have a key role in cellular metabolism, including autophagy. Recent data demonstrate that mitochondrial and lysosomal metabolisms are interrelated.39 Muscle biopsy, performed in two individuals from this cohort, showed fat and glycogen accumulation, muscular fibre size irregularity, without evidence of mitochondrial dysfunction.

Interestingly in the more recent data, evidences showing that TFE3 plays a role in the regulation of the circadian oscillations of the expression of genes involved in autophagy and lipid metabolism, and that Tfe3 knock-out mice had abnormal circadian behaviour.40 Indeed, in our series, five patients (29%) were noted to have sleep disturbance. This could be due to circadian rhythms alteration. Finally, TFE3 has been shown to be involved in the regulation of innate immune response in macrophages via the FLCN-AMPK signalling axis,41 and of B-lymphocytes activation.42 Along these lines, four patients of the series (24%) had a history of recurrent s, associated with documented neutropenia in one of them.

As shown in table 3, a summary of the frequency of the features observed in the cohort, facial dysmorphism was constant and strikingly similar among the patients. More than two-third had anteverted nares, broad flat nasal bridge, almond-shaped and widely spaced eyes, puffy cheeks and coarse facial features (thick lips and fleshy earlobes). More than half had facial hypertrichosis.

All individuals presented with at least four of the above features. One patient had an extreme facial phenotype of hypertelorism, bifid nose and bilateral cleft lip and palate. Whether these frontonasal dysplasia features may be associated with the TFE3 mutation remains unclear.

No other mutation in known genes was found in Patient 1’s exome sequencing data.View this table:Table 3 Frequency of the clinical features observed in the seriesTFE3 is a highly conserved protein, intolerant to loss of function as supported by data from the GnomAD browser43 (probability of being loss-of-function intolerant (pLI) evaluated at 0.98, observed:expected ratio=0.06) and to missense variants (Z=2.15). Moreover, TFE3 does not, or only in a few tissues, escape X inactivation, suggesting that TFE3 gene dosage is crucial to cell function.44 45 In vitro, Villegas et al recently showed that the absence of either TFE3 exon 3 or 4 resulted in a nuclear gain-of-function Tfe3 allele in ESCs, indicating that both exons 3 and 4 are required for Tfe3 inactivation.3 Nuclear localisation and resistance to differentiation were proved in Tfe3 knock-out (K.O.) ESCs expressing murine Tfe3 alleles (Gln118Pro and Pro185Leu, corresponding to mutations Gln119Pro and Pro186Leu identified in individuals referred to as patients 1 and 2 in this series). Based on the analysis of TFE3 secondary structure,46 indicating that residues 110–215 are predicted to form a domain of two stable alpha helices that might be disrupted by mutations in exons 3 and 4, and the observation of a similar phenotype in patients harbouring mutations in exons 3 and 4, it was suggested that Tfe3 exons 3 and 4 form a Rag binding fold whose structural integrity is indispensable for lysosome-mediated cytoplasmic Tfe3 inactivation.3 In this series, the recurrent mutations Arg117Gln, Leu191Pro and Thr187Met were present in respectively two, two and three patients.

The aminoacid in position 187 was mutated in five patients. In addition, 13 of the described mutations were localised between positions p.184 and p.201. This proximity could account for the absence of obvious genotype–phenotype correlation.

The canonical splice site variant in intron 4 identified in patient 9 might lead to in-frame exon skipping of exon 4. The clinical picture of the patient with this splice site variant perfectly fits with the syndrome described here. As a consequence, we raise the hypothesis of a gain-of-function effect of this variant.In conclusion, de novo mutations in exons 3 and 4 of the X-linked gene TFE3 are responsible for a neurocutaneous disorder with specific and recognisable facial dysmorphism, lysosomal storage disorder-like features and PM.

This series unravels TFE3 as a major gene responsible for HMI and for a rare cause of syndromic ID. Furthermore, we provide clinical and molecular data on a previously unidentified lysosomal storage disorder, in which new insights, especially biochemical features, will probably be investigated further, together with the description of more patients. Further delineation of this phenotype will indeed allow a better understanding of the link between lysosomal signalling and development.

Finally, the evidence for mosaicism in this recently described disorder highlights the importance of considering mosaic variants on next-generation sequencing reports in diagnostic, including for patients without suggestive phenotype..

IntroductionThe mammalian kinesin superfamily proteins (KIFs) are microtubule and http://andreabroaddus.com/?p=180 ATP-dependent molecular motors, which were first identified in 1985 as axonal transporters in squid and bovine brains.1 Forty-five different kinesin family member (KIF) genes get levitra were identified in the mouse genome so far, 44 of which are present in the human genome. Phylogenetic analysis based on sequence homology between the human and the mouse genome led to the classification of KIF genes into 16 families, from kinesin-1 to kinesin-14B (figure 1).2 The first kinesins discovered belong to the kinesin-1 family (KIF5A, KIF5B and KIF5C), and they form a heterotetramer of two heavy chains and two light chains (KLC1-4).2 KIF genes encode KIFs, a specific class of motor proteins generating intracellular motility by driving directional transport of various cargoes such as organelles, protein complexes and mRNAs along the microtubule system.2 Studies using knockout mouse models by Hirokawa and colleagues significantly contributed to elucidate the roles of kinesins in mammalian physiology. Their role in transport is fundamental to cellular logistics and performance, and the molecular motors are not only effectors of signal transduction cascades but also transport and/or bind to important signal transduction molecules to actively modulate their function.3Phylogenetic tree of mammalian kinesin superfamily genes identified in the human (and mouse) genome and classified in 16 subfamilies (from kinesin 1 to 14B) (adapted from Hirokawa et al 3)." data-icon-position data-hide-link-title="0">Figure 1 Phylogenetic tree of mammalian kinesin superfamily genes identified in the human (and mouse) genome and classified in 16 subfamilies (from kinesin 1 to 14B) (adapted from Hirokawa et al3).The first kinesins were observed in the context of axonal transport in neurons, and a novel disease entity of ‘motor–proteinopathy’ was proposed for the pathogenesis of axonal neuropathies in 2001.4 Due to their role in cellular membrane trafficking, however, kinesins are essential for the functioning of get levitra many polar cell types, such as neurons, epithelial cells, sperm cells or stem cells during organogenesis. Kinesins also play a fundamental role in cell-cycle dynamics, both during mitotic and meiotic processes.

They regulate chromosomal condensation and alignment, spindle formation, cytokinesis and cell-cycle progression.5 get levitra It is estimated that about a dozen kinesins are involved in the cell cycle. Among these, there is a specific subclass of chromokinesins (kinesin 4 and kinesin 10 family) which are able to bind chromosomes.6 Recently, KIFs were discovered to act as microtubule stabilisers (KIF26A and KIF21A) and depolymerisers (KIF2A and KIF2C), activities which are important for both cellular morphogenesis and mammalian development, playing a role in neuronal and axonal morphology and ciliogenesis.7Alterations in motor kinesins are leading to human disease by various pathological mechanisms, including cancer and multifactorial and monogenic disorders. Variants in 18 out of the 44 human KIF genes were get levitra identified to cause monogenic disorders, following different modes of Mendelian inheritance and associated with a wide spectrum of clinical signs. These range from lethal and multiple to isolated congenital anomalies—including birth defects potentially detectable in the foetal period by current prenatal imaging studies—to postnatally apparent neurodevelopmental disorders, intellectual disability and neurological conditions.We will review the current state of knowledge of the biological processes kinesins are involved in and discuss their emerging role in human disease, particularly in birth defects and congenital anomaly syndromes.

Birth defects remain a leading cause of perinatal lethality in industrialised countries.8 Structural anomalies are recognised with increasing reliability during early pregnancy by the use of high-resolution ultrasound technologies, thus raising questions about diagnosis, aetiology, prognosis and recurrence risk, particularly in the presence of more than one anomaly, which most likely indicates a genetic aetiology. We identify recurrent phenotype patterns caused by alterations in KIF genes, and we outline the complexity get levitra of phenotype–genotype correlations mirroring the processes of intracellular microtubule-mediated transport and movement, in which kinesins play a fundamental role. There are likely many more relationships between the clinical signs and the genetic variants to be identified in the future, and the functional network of kinesins and their role in human disease need to be further elucidated. We propose to introduce the term ‘kinesinopathies’ for this group of conditions, which are phenotypically and genetically overlapping and characterised by the functional impairment of a get levitra specific group of molecular motors.

We hope that their systematic approach leads to a better recognition in clinical practice, as well as in genome-wide sequencing for diagnosis and research, and opens strategies for the future development of molecular therapies.KIF structureAll KIFs have a phylogenetically well-conserved motor domain head, consisting of an ATP-binding motif and a microtubule-binding domain. Depending on the position of the motor domain, kinesins can be subdivided into N-kinesins (amino-terminal motor domain), M-kinesins (middle-region motor domain) and C-kinesins (carboxy-terminal motor domain).2 Most kinesins belong to the N-kinesin subgroup, but members of the kinesin 13A family (figure 1) belong to the M-kinesin subtype, while KIF1C, KIF2C and KIF3C get levitra belong to the C- kinesin subfamily.3 Both N-kinesins and C-kinesins are responsible for plus end and minus end-directed motility, M-kinesins for depolymerisation of microtubules in tubulin molecules. However, there are a few exceptions to this categorisation.9 The motor domain head attaches to the neck, the coiled coil stalk and the tail. The kinesins’ neck is family-specific and responsible for the direction of motility or regulation of activity.

The coiled coil stalk and get levitra tail are involved in kinesin dimerisation and/or interactions with cargoes. Kinesins typically use scaffold proteins and adaptor proteins to bind their cargoes but can sometimes bind the cargo directly. Scaffolds and adaptors might also have regulatory roles in kinesin-driven intracellular transport, that is, get levitra recognising specific cargoes and regulating their loading and unloading.3Role of KIFs in physiology and diseaseThe application of genome-wide sequencing for gene identification in research or for clinical diagnostic purposes significantly contributes to the identification of KIF candidate genes. Genotype–phenotype correlations in KIF gene-related disorders, together with functional and animal studies, continue to elucidate the complex involvement of KIFs in human developmental pathways and disease.

Table 1 summarises the monogenic conditions caused by variants affecting the function of KIF genes.View this table:Table 1 Specific monogenic disorders caused by variants affecting the function of KIF genesView this table:Table 2 Summary of phenotypes and genotypes of KIF149 26 30 31The kinesins’ functions in physiological processes, however, are complex and still incompletely understood, but their role in cell-cycle progression and regulation, including both meiosis get levitra and mitosis, in intracellular trafficking, axonal transport, microtubule activity and ciliogenesis, is increasingly studied. Figure 2 summarises the clustering of KIF genes according to their functional roles and the phenotypical consequences as identified to date in 32 out of the 44 human kinesin genes.Assignment and clustering of KIF genes to various functions and relation to birth defect or monogenic phenotype groups. Detailed phenotypes are shown in tables 1 and 3 get levitra. Cancer and multifactorial conditions are not included.

CNS, central nervous system." data-icon-position data-hide-link-title="0">Figure 2 Assignment and clustering of KIF genes to various functions and relation to birth defect or monogenic phenotype groups. Detailed phenotypes are shown in tables 1 get levitra and 3. Cancer and multifactorial conditions are not included. CNS, central nervous system.Kinesins play a pivotal get levitra role during early development and organogenesis.

Microcephaly is one of the most frequently associated clinical signs, mirroring a defect in the regulation of the final number of neurons during development.10KIF4A is a motor protein that translocates PRC1, a cytokinesis protein, to the ends of the spindle microtubules during mitosis, regulates the PARP1 activity in brain development and the survival of neurons, and is a member of the L1CAM recycling pathway. Variants in get levitra L1CAM cause X-linked isolated and syndromic hydrocephalus. KIF4A was recently proposed as a candidate gene for hydrocephalus.11KIFs are involved in neuronal branching, and microtubule depolarisation, operated by KIF2A M-kinesin, was suggested to suppress collateral branch extension during brain development, leading to anomalies of cortical development, including agyria and pachygyria, subcortical band heterotopia and corpus callosum anomalies.12Functional disruption of KIF genes in knockout mice often results in embryonic lethality, for example, for Kif18A, Kif10, Kif3A, Kif3B and Kif5B,13–17 highlighting the importance of kinesins in embryonic and foetal development. A study on KIF16B demonstrated that microtubule-based trafficking is responsible for early development and stem cell survival.18 KIF26B is essential in kidney development, contributing to the adhesion of mesenchymal cells to the ureteric bud.3 KIF26A was suggested to play a role in enteric nervous system development, because knockout mice develop a megacolon and enteric nerve hypoplasia,19 and to negatively regulate nociceptive sensation.20A significant number of KIFs play a prominent role in ciliogenesis and cilia function.

They regulate get levitra cilia length, ciliary assembly/disassembly and can have motile cilia-specific functions.21 Some KIFs, specifically found in primary cilia (PC), regulate the length of the axoneme and its disassembly when re-entering the cell cycle.KIF7, also a key component of the Hedgehog signalling pathway, is responsible for cilia length regulation through suppression of microtubule polymerisation.7 KIF7 variants cause hydrolethalus, acrocallosal, and Joubert and Al-Gazali-Bakalinova syndromes.22 Kif2A knockout mice have severe brain defects, and KIF2A variants in humans lead to microcephaly because of cell-cycle delay in cellular progenitors resulting from cilia disassembly defects. KIF24, belonging to the same kinesin 13 family, plays a role in both microtubule depolymerising activity and regulation of the early steps of ciliogenesis. Other PC-related KIFs recently identified are KIF5B, KIF1C and KIF13B, and a potential role in cilia was hypothesised for KIF11 and KIF14.KIF3 get levitra protein complex (KIF3A-KIF3B-KAP3 heterotetramer) is a molecular motor necessary for intraflagellar transport (IFT) but is also involved in ciliogenesis of motile cilia. Kif3a-knockout or Kif3b-knockout mice are prenatally lethal, exhibiting anomalies similar to ciliopathy phenotypes, including the disturbance of left–right body determination.3KIF19A is localised at the tip of motile cilia and performs motor and microtubule-depolymerising activities during IFT.

Kif19a-knockout mice present with hydrocephalus and female infertility, common signs in ciliary defects, due to abnormally elongated cilia with altered motility, not able to generate proper fluid flow.9Further KIFs, which may get levitra have specific roles in motile cilia, are KIF27, KIF9, KIF6 and KIF18B. Regarding the involvement of numerous KIFs in cilia-related processes, it is not surprising that many disorders caused by variants affecting KIF gene function are presenting with anomalies reminiscent of ciliopathies.Kinesin motors have a fundamental role in neuronal function, as they are responsible for the transport of synaptic vesicle precursors and transmitter receptors along axons and dendrites from the neuron body.3 Molecular motor activity as for KIF1A, KIF5 and KIF17 is important for higher brain functions, such as learning and memory through regulation of synaptic transmission.5 Dysfunction can be associated with intellectual disability and global developmental delay (table 1).Impaired function can also result in peripheral neuropathies (KIF5A, KLC2, KIF1A and KIF1B) and ocular motility disorders (KLC2 and KIF21A)23 24 when axon elongation in the peripheral nervous system and optic nerve is affected. KIF5A variants are associated with epileptic phenotypes both in humans and mice25 because the transport of neurotransmitter receptors is disturbed and inhibitory regulation is altered.Due to their role in cell-cycle regulation, kinesins are important in male spermatogenesis and female oogenesis. They are involved in all steps of spermatogenesis 26 and, based on previous animal studies, they may represent a get levitra potential target to treat male infertility.

In female meiosis, 13 KIF genes were studied in animal models. There is some evidence that kinesin expression is vulnerable to maternal ageing and get levitra environmental factors, such as oocyte cryopreservation and alcohol consumption. It may be promising to expand research in this field in order to clarify the mechanisms and factors contributing to oocyte quality decline.27Many kinesins were extensively studied in the fields of cancer development, progression and therapy. Deregulation of get levitra the mitotic kinesins by both overexpression and decreased expression causes cancer progression or can be a prognostic marker in various tumours.28 The cell-permeable small-molecule mitotic inhibitor monastrol was discovered in 199929 and was shown to arrest cells in mitosis by specifically inhibiting KIF11, a kinesin important for spindle bipolarity.

The bipolar mitotic spindle is replaced by a monoastral microtubule array surrounded by a ring of chromosomes, which gave the inhibitor its name. The mitotic spindle is now a well-known target of chemotherapy, and get levitra inhibitors of the mitotic kinesins KIF11, KIF10 and KIF1C are being studied for this purpose.28 30 The redundancy of some kinesins allows them to escape pharmacological inhibition. For example, in the absence of KIF10, KIF15 is able to replace all of its essential functions in spindle assembly. Cilia-related KIF7, KIF13B and KIF27 are involved in SHh signalling and may be a future target in cancer research.28Some kinesins confer susceptibility to a range of multifactorial, metabolic and neurodegenerative conditions.

KIF13B contributes to the enhancement of endocytosis of low-density lipoprotein (LDL) receptor-related protein 1 that get levitra is involved in the recognition and internalisation of LDL and factor VIII. Kif13b-knockout mice have hypercholesterolaemia and higher factor VIII serum levels.5 KIF12 is implicated in the pathogenesis of type 2 diabetes, protecting pancreatic β cells from the oxidative stress caused by nutritional excess.5 Variants in KIF1B or KIF21B confer susceptibility to multiple sclerosis (OMIM %612596, #126200).31 32 KIF5A was associated with Amyotrophic lateral sclerosis (OMIM #617921).33 KIF3 complex and KIF17 were recently uncovered to be involved in schizophrenia.34 35 Further studies, however, are needed to clarify the precise role of KIFs in neurodegenerative processes and psychiatric conditions.KIF14 -related birth defects. Lessons learntAdvances get levitra in next-generation sequencing technologies have revolutionised our understanding of Mendelian disorders, including birth defect phenotypes, by sequencing the coding genome (exome) or entire genome at an unprecedented resolution in a comparably short time span. The technology has been extensively used for gene identification approaches in research for many years, enabling unparalleled genotype–phenotype correlations and the definition of novel pathways of related genes and disorders at an accelerated pace, traditionally focusing on postnatal disorders.

Filges and get levitra Friedman36 postulated that a number of novel disease genes causing birth defects could be identifiable through the investigation of lethal foetal phenotypes since they would represent the extreme end of allelic milder and viable postnatal phenotypes with less specific or recognisable anomaly patterns. Based on embryonically or perinatally lethal mouse models (www.informatics.jax.org and www.dmdd.org.uk), it is estimated that knockout variants in about 30% of human protein coding genes may present with a phenotype of early lethality. The identification of KIF14 loss of function variants in fetuses with a lethal multiple congenital anomaly syndrome and the subsequent description of the allelic postnatal viable phenotype and further functional characterisation of KIF14 in developmental processes are recent examples of how to study those embryonic lethal phenotypes in order to understand the role of genes for which little to nothing is known.Filges et al identified autosomal recessive compound heterozygous loss of function variants in KIF14 using family-based exome sequencing in a recurrent severe lethal phenotype (OMIM #616258). It was the first human phenotype reported due to variants in the human KIF14 gene (figure 3).37 The two affected siblings presented with intrauterine growth retardation (IUGR), get levitra oligohydramnios, severe microcephaly, renal cystic dysplasia or agenesis, genital tract malformations (uterine hypoplasia and vaginal atresia), as well as cerebral and cerebellar hypoplasias with partial or total agenesis of the vermis, arhinencephaly, agenesis of occipital lobes/corpus callosum at second trimester ultrasound scan.

Cross-species comparison to the laggard spontaneous mice mutant, characterised by homozygous variants of the Kif14 gene,38 confirmed a phenotypical overlap. An increased number of binucleated cells in the tissue histology of the two fetuses were in concordance with the key role of KIF14 during mitosis participating in chromosomes’ congression and alignment, as well as in cytokinesis39 and the observation of binucleated cells as a consequence of failed cytokinesis get levitra in mammalian KIF14 knockdown cells. During cytokinesis, PRC1 localises KIF14 at the central spindle and midbody, which in turn recruits citron rho-interacting kinase (CIT) to the midbody. CIT, in get levitra turn, acts as a negative regulator of KIF14 activity.

Knockdown of KIF14 in mammalian cells results in impaired localisation of CIT during mitosis.40Structure of KIF14 and summary of all published KIF14 variants affecting function.10 37 41 42 The N-terminal region (aa 1–356) is important for its interactions with PRC1 and the protein’s localisation at the central spindle and midbody. The kinesin motor domain (aa 358–701) is responsible for the microtubule-dependent ATPase activity. The FHA get levitra domain (aa 825–891). Stalk and tail region (aa 891–1648) are necessary for the interaction with the protein CRIK (aa 901–1189, red diagonal lines).

There are four get levitra additional coiled-coil domains (light blue-coloured areas).61 FHA, forkhead associated. Aa, amino acid." data-icon-position data-hide-link-title="0">Figure 3 Structure of KIF14 and summary of all published KIF14 variants affecting function.10 37 41 42 The N-terminal region (aa 1–356) is important for its interactions with PRC1 and the protein’s localisation at the central spindle and midbody. The kinesin motor domain (aa 358–701) is get levitra responsible for the microtubule-dependent ATPase activity. The FHA domain (aa 825–891).

Stalk and tail region (aa 891–1648) are necessary for the interaction get levitra with the protein CRIK (aa 901–1189, red diagonal lines). There are four additional coiled-coil domains (light blue-coloured areas).61 FHA, forkhead associated. Aa, amino acid.Filges et al pointed out that KIF14 should be considered a candidate gene for viable postnatal phenotypes, including isolated microcephaly.34 Additional individuals with autosomal recessive variants in KIF14 and isolated primary microcephaly were then described9 41 42 (table 2).Impaired cytokinesis, increased apoptosis and reduced cell motility were confirmed in cells from the described patients, pointing to a new cellular pathway in the pathogenesis of microcephaly.43 Apart from one case with small kidneys with increased echogenicity, none of these 18 patients had associated kidney anomalies. However, a targeted exome sequencing study in 204 unrelated patients with congenital anomalies of the kidney and urinary tract (CAKUT) reported two more cases of renal anomalies, bilateral hypoplasia or agenesis, caused by KIF14 variants.44 Further nine cases had an associated renal phenotype, which ranged from bilateral renal agenesis to cystic or non-cystic renal hypodysplasia.42 Table 2 and figure 3 get levitra summarise KIF14 variants and the associated phenotypes.

Loss of function variants more likely lead to multiple congenital anomalies, while hypomorphic variants result in a milder phenotype without renal involvement, although phenotype–genotype correlations remain preliminary for the time being.The phenotypical spectrum ranging from isolated primary microcephaly to congenital anomalies reminiscent of ciliopathy phenotypes suggested a complex role for KIF14 in developmental processes and raised a number of questions about the relationship between its established role in cell division and its possible function in ciliary pathways. Functional studies of absent KIF14 protein in the development of human foetal tissues and mutant zebrafish provided evidence for similarities and differences between mitotic events occurring during proliferation in the development of both brain and kidney.42 The observation that KIF14-stained midbodies accumulate within the lumen of the branch tips of ureteric buds in human foetal get levitra kidneys provided a key clue to better understand the mechanism through which the loss of KIF14 affects both brain and kidney development in humans. It was previously demonstrated that the secretion and accumulation of midbody remnants in the cerebrospinal fluid in mice during the early stages of brain development correspond to the amplification of neural progenitors.45 Kif14 mutant zebrafish phenotypes supported the hypothesis of a potential role for KIF14 in cilia. In vitro and in vivo analyses suggested that loss of kif14 causes ciliary anomalies through an accumulation of mitotic cells in ciliated get levitra tissues but failed to establish a direct functional link.21 42 Further mechanisms remain to be elucidated.

Overexpression of KIF14 in various types of tumours was suggested to be a possible prognostic marker and a potential target for therapeutic purposes.46Kinesinopathies in birth defect phenotypes. Recurrent themesIn the last few years, an increasing number of variants in KIF genes were described to cause isolated as well as multiple congenital anomalies. There is a huge variability of phenotypes caused by variants even within get levitra the same gene. However, we can identify recurrent clinical signs that should alert the clinician to suspect a KIF gene-related disorder and the molecular geneticist to include KIF genes in multigene-panel and genome-wide sequencing approaches.

This will become particularly relevant in prenatal and perinatal medicine, which focuses on the detection of structural anomalies in the fetus and the newborn by using ultrasound and MRI or get levitra autopsy when the outcome is lethal. We have summarised the predominant and recurrent structural anomalies in kinesinopathies reported so far that would likely become apparent during the foetal period in table 3 and the syndromic disorders in table 1.View this table:Table 3 KIF gene-related structural congenital anomalies recurrently described in prenatal phenotypesSupplemental materialConsistent with the kinesins’ role in the development of the central nervous system (CNS), brain anomalies of various degrees are a frequent clinical sign, particularly microcephaly, but include lissencephaly, polymicrogyria, thinned or agenesis of the corpus callosum, arhinencephaly, cerebral hypoplasia or atrophy, cerebellar hypoplasia or atrophy, brainstem hypoplasia and a molar tooth sign on brain imaging.12 22 37 44 47–51Primary microcephaly can be detected prenatally or at birth12 22 47 48 50 51 and can present as an isolated or syndromic condition as, for example, caused by variants in KIF149 or in KIF11 (microcephaly with or without chorioretinopathy, lymphoedema or mental retardation. OMIM #152950).48KIF7 variants were related to macrocephaly in the presence of congenital hydrocephalus (hydrolethalus syndrome LS2, OMIM # 614120) get levitra. Isolated hydrocephalus was reported for KIF4A in a single case.11Foetal akinesia and arthrogryposis (KIF5C12, KIF1434 and KIF26B50) are likely secondary to the neurological compromise of the fetus but can also appear as an early sign of abnormal CNS development, which should prompt specialist CNS sonographic and MRI evaluation of the fetus.Further anomalies of the limbs include camptodactyly (KIF26B50), clubfoot (KIF1A51), rocker-bottom feet (KIF26B50) and congenital lymphoedema of the limbs (dorsa of feet, lower extremities and, rarely, hands) in cases with KIF11 gene mutations.48 In particular, KIF7 gene variants have been related to various anomalies of the hands (tapered fingers, fifth finger clinodactyly, brachydactyly, preaxial or postaxial polydactyly, bifid terminal phalanges of the thumbs, spindle-shaped fingers, clinodactyly and soft tissue webbing) and feet (toe syndactyly, preaxial or postaxial polydactyly, and duplicated halluces).22CAKUT and genital anomalies are reported in various kinesinopathies including renal agenesis or hypoplasia (KIF1437 and KIF1252), ureteral hypoplasia (KIF1437), congenital megabladder (KIF1252) and vesicoureteral reflux (KIF1252), uterine hypoplasia and vaginal atresia (KIF1437) and hypospadias and chordae (KIF16B49).IUGR is recurrently detected (KIF5C12, KIF1437, KIF1053, KIF1554 and KIF2A12) and is particularly relevant when occurring simultaneously with one of the other recurrent clinical signs, indicating a potential syndromic KIF-related disorder.

Oligohydramnios or polyhydramnios is most likely secondary to a primary organ anomaly.There are a few kinesinopathy syndromes that have been specifically reported to be lethal, such as the ciliary phenotype (OMIM #616258), caused by variants in KIF1434, and hydrolethalus syndrome (OMIM #614120), caused by variants in KIF7.22 However, lethality is usually closely related to the specific major anomalies, and it can be hypothesised that such a lethal phenotype will exist for all KIF gene-related disorders.Developmental delay, intellectual disability, seizures, and sensory and motor disturbances of the peripheral nervous system, as well as eye anomalies, such as microphthalmy, optic nerve pallor, fibrosis of extraocular muscles and chorioretinopathy, will escape detection in the foetal period but are reported in postnatal patients.Kinesin pathways in birth defectsFunctional studies of kinesins in birth defects are still sparse, and little is known about their networks and pathways. In order to improve our understanding, we used the Ingenuity Pathway Analysis (IPA Qiagen, Redwood City, California, USA) to visualise and analyse the connections between the 13 kinesin motor proteins associated get levitra with structural congenital anomalies (KIF5C, KIF1A, KIF1BP, KIF14, KIF16B, KIF7, KIF4A, KIF11, KIF10, KIF26B, KIF12, KIF15 and KIF2A) and in up to 10 of each of their most significant downstream proteins. The connections are defined as protein–protein interactions, activation, regulation of binding, expression, localisation, phosphorylation, protein–RNA interactions, molecular cleavage, ubiquitination, protein–DNA interactions, inhibition, translocation and transcription. Figure 3 get levitra displays the results.

We used the software Gephy55 to look for all possible interactions between all proteins of the network and also used the IPA data to retrieve the canonical pathways involved. Figure 4 and online supplementary material, get levitra table 4, summarise the results. KIF7, KIF14 and KIF12 are located within the same network, and because of multiple connections between themselves and their downstream proteins, it is not surprising that they are all involved in kidney anomalies. IPA data are based get levitra on current publications and are therefore subject to bias because proteins that are most interconnected are also most probably those that have been more extensively studied.

However, we consider the KIF genes coding for proteins seeming less important within the network to be strong candidates for future studies of human developmental disorders.IPA of the 13 kinesins known to be involved in birth defects with respect to their position in the cell. Proteins displayed on the right side of the figure, below the tag ‘other’, are those for which no subcellular location is known. Birth defect-related get levitra kinesins and their connection with each other are highlighted in green. Light blue-coloured downstream proteins are those which are known to cause birth defects when altered.

Yellow-coloured proteins are those involved in get levitra neurological disorders overlapping with the clinical features of kinesinopathies. The legend of the biological function associated with every molecule is displayed on the right. Path Designer by IPA was used for the figure design get levitra. IPA, Ingenuity Pathway Analysis." data-icon-position data-hide-link-title="0">Figure 4 IPA of the 13 kinesins known to be involved in birth defects with respect to their position in the cell.

Proteins displayed on the right side of the figure, below the tag ‘other’, are those for which no subcellular location is known. Birth defect-related kinesins and their connection with each other are highlighted get levitra in green. Light blue-coloured downstream proteins are those which are known to cause birth defects when altered. Yellow-coloured proteins are those involved in neurological disorders get levitra overlapping with the clinical features of kinesinopathies.

The legend of the biological function associated with every molecule is displayed on the right. Path Designer get levitra by IPA was used for the figure design. IPA, Ingenuity Pathway Analysis.Closing remarks and future perspectivesNovel KIF genes are increasingly identified, and there is a growing body of literature demonstrating the impact of kinesin dysfunction in human disease. We propose to introduce the term kinesinopathies get levitra for conditions caused by variants in KIF genes, since recurrent and common functional and phenotypical themes can be observed.

In analogy to ciliopathies56 and rasopathies,57 the delineation of the clinical, genetic and functional hallmarks of kinesinopathies will be important to better recognise these conditions, to understand the pathomechanisms and to ultimately improve the clinical management of the patients. Previously, the unified view of the phenotype characteristics of ciliary dysfunction allowed a tremendous increase in awareness, both in clinic and research, and the further identification of yet unrecognised ciliary disorders and the genes and proteins involved in their pathogenesis.56Remarkable progress was achieved in assigning function to kinesins through their study in isolated and multiple congenital anomaly phenotypes. They are one large superfamily of molecular motors out of three (kinesins, dyneins and myosins), which is of key importance in several fundamental cellular processes using microtubules as get levitra rails for directional anterograde intracellular transport, including its regulation and modulating signal transduction.5 Kinesin motors are most important for the movement of chromosomes along the spindles during chromosome segregation, regulation of spindle formation, cell division and cytokinesis. These essential and broad cellular functions are critical for many physiological processes such as neuronal function and survival, some ciliary functions and ciliogenesis, determination of the left/right asymmetry of our body and regulation of organogenesis, thus explaining the impact and emerging recognition of kinesins in embryonic and foetal development.

Defects can result in neuropathies, get levitra higher brain functions and structural brain anomalies. Multiple congenital anomalies, including the kidney and urinary tract and limb anomalies, are repeatedly reported. Microcephaly, which is usually not associated with genes implicated in specific ciliary mechanisms, and CNS anomalies are the most recurrent clinical signs in both the prenatal and postnatal get levitra phenotypes described so far. The discovery of the implication of KIF14 in microcephaly further suggested a possible novel role of other microcephaly proteins in cytokinesis.

A number of syndromic kinesinopathies present, however, with phenotype patterns reminiscent of ciliopathies. So far, however, a direct functional impact was confirmed in only get levitra a few and could not be demonstrated, for example, for KIF14, despite an overlapping clinical pattern. In turn, ciliopathies are a clinically and genetically heterogeneous group of conditions themselves. Studying tissue and cell type-specific function and expression may help to further define the specific defects related to the individual aberrant get levitra kinesin.The pleiotropic nature of human kinesinopathies, however, is just emerging, but their study promises to provide important insights into human developmental pathways.

Seemingly unrelated clinical entities are highlighting a common theme. In a relatively short time span, monogenic KIF-related disorders were identified to present with often severe and lethal antenatal anomalies, with multiple or isolated congenital anomalies, neurodevelopmental and neurological disorders, or an get levitra increased susceptibility to multifactorial conditions. We focused on the emerging role of kinesins in structural congenital anomalies because, as illustrated for the KIF14 gene, great potential to decipher allelic viable phenotypes and developmental pathways lies in the study of these human knockout phenotypes at the severe end of the phenotypical spectrum. Knockout variants in about 30% of human protein coding genes in our genome may present with a phenotype of early lethality, and KIF genes seem to play an important role in such fundamental processes of human development.

Identifying and get levitra characterising the variants, genes and phenotypes will extend our knowledge on early human development and pathomechanisms, and will ultimately also improve the clinical utility of genome-wide sequencing approaches for prenatal and postnatal application by our increased ability to interpret loss of function and hypomorphic variants alike. Furthermore, kinesins were extensively studied in cancer research and therapeutic strategies targeting their specific functions, such as the example of monastrol and other inhibitors of the mitotic kinesins may be adopted in the future. There are likely many more kinesinopathies to be unravelled in the field of birth defects because get levitra of their pivotal role in cellular logistics, but their recognition in clinics and research will depend on our ability to identify and characterise the common clinical, molecular and functional themes of these disorders and to use them to improve our understanding of their disease mechanisms.IntroductionIntellectual disability (ID) affects about 3% of individuals worldwide and raises significant issues in terms of diagnostic, management and genetic counselling. The presence of pigmentation anomalies in a patient with ID represents helpful clinical clues in order to narrow the range of aetiological hypothesis.

Hypomelanosis of Ito (HMI, MIM #300337) is an unspecific term encompassing a heterogeneous group of disorders characterised by cutaneous hypopigmented whorls and streaks along Blaschko’s lines and variable extracutaneous features affecting the musculoskeletal and nervous systems.1 The cutaneous pattern therefore represents a non-specific hallmark of get levitra mosaicism in these neurocutaneous conditions. Genetic mosaicism is due to postzygotic mutations, either chromosomal rearrangements or point mutations, whereas random X inactivation in females leads to functional mosaicism.2 Unravelling the molecular basis of pigmentary mosaicism (PM) is still a challenge due to clinical and genetic heterogeneity, technical difficulties in detecting mosaic mutations by classical sequencing approaches and the complexities of obtaining affected tissue. As part of a collaborative group, we recently reported de novo mutations in exons 3 and 4 of transcription factor E3 (TFE3) as the cause for HMI in four unrelated individuals, including one male, as well as syndromic ID without pigmentary disorders in a female.3TFE3 belongs to the MITF family of get levitra mammalian basic helix–loop–helix zipper transcription factors, together with TFEB and TFEC. All four can form homodimers or heterodimers with each other.4 Embryonic expression of TFE3 orthologues Tfe3a and Tfe3b was demonstrated in the zebrafish in a wide range of tissues.5 TFE3 subcellular localisation plays a crucial role in the regulation of cellular homeostasis and embryonic stem cell (ESC) differentiation.

The phosphorylated TFE3 is retained in the cytoplasm, whereas dephosphorylated protein translocates to the nucleus to promote the transcription of target genes involved in lysosomal biogenesis and autophagy.6 TFE3 relocalisation to the nucleus is driven on various stressors, such as starvation,7 8 DNA damage,9 mitochondrial damage,10 Golgi stress11 and pathogens12 in an mTORC1-dependent manner, and oxidative stress13 or cadmium exposition14 in an mTORC1-independent manner. Moreover, lysosomal signalling-induced nucleocytoplasmic redistribution get levitra of TFE3 is essential to the regulation of ESC renewal.3 15 By restricting nuclear localisation and activity of Tfe3, lysosome activity, the tumour suppressor protein folliculin and the Ragulator protein complex enable the exit from pluripotency and therefore drive differentiation. Conversely, enforced nuclear Tfe3 enables ESCs to withstand differentiation.15 In humans, TFE3 mutations have long been known in cancer. Gene fusions by translocations or other chromosomal rearragements involving TFE3 and five partner genes have indeed been reported to occur in a subset of renal cell carcinomas (RCCs), referred to as ‘TFE-fusion RCC’, get levitra and, more rarely, to lung sarcoma and perivascular epithelioid cell tumours.16 Beyond these data on TFE3 function, by the report of a series of 17 individuals harbouring de novo mutations in exons 3 and 4 of TFE3, we emphasise their phenotype and bring additional clinical insight toward the recognition of this novel developmental disorder.ResultsWe describe a series of 17 patients carrying a de novo mutation in TFE3, 5 of them being previously published with limited clinical information.3 Twelve were females and five were males.

Their age ranged from 12 months to 22 years. Five were referred for HMI, five for get levitra syndromic ID and five for suspicion of storage disorder.Clinical dataThe clinical features are summarised in table 1. Additional information can be found in online supplementary data 1.Supplemental materialView this table:Table 1 Clinical and molecular features of the 17 patients with an TFE3 mutationNeonatal course was remarkable for nine patients. History of jaundice, hepatomegaly or feeding difficulties was reported for three patients each, hypoglycaemia for two and cholestasis for one.

All these features were transient.Developmental delay, usually severe and noticeable from the first get levitra months of life, was a constant feature in all the individuals. Only 6 patients were able to walk at the time of the study, whereas 11 were still unable to walk. All patients were non-verbal, get levitra except for two older patients who could speak a few words. Neurological examination was abnormal in 12 individuals and consisted in truncal hypotonia, associated with lower limb spasticity (6 individuals) or ataxia (2 adults).

Behavioural issues get levitra such as autistic features and sleeping disturbance were noted for 11 patients. Eleven patients developed epilepsy, onset in the first decade and characterised as intractable in three of them. Brain MRI was normal in 10 individuals and abnormal in 6 patients (hydrocephaly, short corpus callosum, Dandy-Walker malformation, arachnoid cyst, periventricular white matter lesions, delayed myelination and cerebral atrophy). The sensory anomaly was congenital hearing loss (5 patients), get levitra and ophtalmological anomalies (10 patients) consisted of strabismus, hyperopia, retinal degeneration, depigmented macule on the iris, oculomotor apraxia or impaired vision of cortical origin.Facial dysmorphism shared among the patients consisted in coarseness, flat nasal bridge, short nose with anteverted nares, widely spaced eyes, almond-shaped eyes, thick lips, facial hypertrichosis, fleshy earlobe, and full and pink cheeks (figure 1).

Twelve patients had pigmentation anomalies, located on Blaschko’s lines for 10 of them (figure 2). One was get levitra diagnosed at 4 years old with histiocytofibroma. Moderate to severe postnatal growth retardation affected 10 patients, who had a length between −2.0 and −4.5 SD. Obesity affected 13 get levitra individuals.

Skeletal anomalies were frequent (11 individuals) and consisted of flat or clubfeet, hyperlordosis, scoliosis, hip dislocation, limitation of elbow extension and genu valgum. Recurrent s of the upper airways get levitra were noted in five patients. One had a documented neutropenia. Early-onset chronic interstitial lung disease was reported in two patients.

Nail clubbing was noted in two get levitra individuals. Visceral malformations consisted of congenital heart defect (left ventricle dilatation, aortic insufficiency and patent ductus arteriosus) in three patients, umbilical hernia in three individuals, lateral semicircular canal dysplasia, posterior plagiocephaly, sleep apnoea syndrome, anteriorly displaced anus and hypospadias in one individual each.Facial phenotypes of seven patients. (A–C) Patient 5, aged 6 months (A,B) get levitra and 3 years (C). (D) Patient 8, aged 5 years.

(E,F) Patient 2, aged 5 and 20 get levitra years. (G–I) Patient 3, aged 1 year (G) and 3 years (H,I). (J,K) Patient 13, aged 22 years. (L–O) Patient 6, aged 8 months (L), 20 months get levitra (M) and 3 years (N,O).

(P,Q) Patient 10 aged 22 years." data-icon-position data-hide-link-title="0">Figure 1 Facial phenotypes of seven patients. (A–C) Patient 5, aged 6 get levitra months (A,B) and 3 years (C). (D) Patient 8, aged 5 years. (E,F) Patient get levitra 2, aged 5 and 20 years.

(G–I) Patient 3, aged 1 year (G) and 3 years (H,I). (J,K) Patient 13, aged 22 years. (L–O) Patient 6, aged get levitra 8 months (L), 20 months (M) and 3 years (N,O). (P,Q) Patient 10 aged 22 years.Cutaneous features.

(A) Patient get levitra 3. Umbilical hernia, widely spaced nipples and hypopigmentation on the left side of the abdomen. (B) Patient get levitra 17. Hypotonia, umbilical hernia and widely spaced nipples.

(C) Patient get levitra 8. Blaschko’s lines on the back. (D) Patient 6. Hypopigmentation on the left side get levitra of the abdomen.

(E) Patient 7. Blaschko’s lines on the abdomen get levitra and right side of the trunk. (F) Patient 13. Hand.

Note clubbing of thumbnail and loose skin. (G) Patient 17. Blaschko’s lines on the left side of the abdomen. (H) Patient 17.

Hand. Note tapering fingers and wrinkled skin. (I) Patient 1. Linear hypopigmentation on the back.

(J) Patient 6. Blaschko’s lines on the back. (K) Patient 3. Blachko’s lines on the right lower limb.

(L) Patient 6. Blaschko’s lines on the right lower limb. (M,N) Patient 7. Linear hyperpigmentation on the lower limbs.

(O) Patient 11. Blaschko’s lines on the back." data-icon-position data-hide-link-title="0">Figure 2 Cutaneous features. (A) Patient 3. Umbilical hernia, widely spaced nipples and hypopigmentation on the left side of the abdomen.

(B) Patient 17. Hypotonia, umbilical hernia and widely spaced nipples. (C) Patient 8. Blaschko’s lines on the back.

(D) Patient 6. Hypopigmentation on the left side of the abdomen. (E) Patient 7. Blaschko’s lines on the abdomen and right side of the trunk.

(F) Patient 13. Hand. Note clubbing of thumbnail and loose skin. (G) Patient 17.

Blaschko’s lines on the left side of the abdomen. (H) Patient 17. Hand. Note tapering fingers and wrinkled skin.

(I) Patient 1. Linear hypopigmentation on the back. (J) Patient 6. Blaschko’s lines on the back.

(K) Patient 3. Blachko’s lines on the right lower limb. (L) Patient 6. Blaschko’s lines on the right lower limb.

(M,N) Patient 7. Linear hyperpigmentation on the lower limbs. (O) Patient 11. Blaschko’s lines on the back.Molecular resultsThe characteristics of the 13 different de novo TFE3 variants identified in the 17 unrelated individuals are summarised in table 2.

All but one were missense variants, affecting nine different aminoacids. One was a splice donor mutation. This mutation was reported a few weeks ago in a patient with a similar phenotype.21 Two variants were localised in exon 3 and 11 in exon 4 (figure 3). All were absent from public databases and were predicted to be pathogenic by prediction softwares.

TFE3 protein and localisation of the missense variants identified. In bold are variants identified in two patients. In bold and underlined is the variant identified in three patients. In green is the intronic variant." data-icon-position data-hide-link-title="0">Figure 3 TFE3 protein and localisation of the missense variants identified.

In bold are variants identified in two patients. In bold and underlined is the variant identified in three patients. In green is the intronic variant.View this table:Table 2 Molecular data of the 13 de novo TFE3 mutations. Characteristics, inheritance, frequency in the public database GnomAD, prediction scores regarding pathogenicity (Polyphen, Grantham and CADD (Combined Annotation Dependant Depletion) scores).

The transcript is NM_006521.5The putative mosaicism was assessed through X inactivation studies in females and analysis of the exome sequencing data in males, by checking the total number of reads covering the variant, as well as the number of reads supporting the presence of the variant (table 1). Allele frequencies in females were always consistent with a constitutional heterozygous mutation. X inactivation was skewed in blood of the female patients 1, 3 and 7 and in fibroblasts of Patient 2. X inactivation was random in fibroblasts of Patient 1 and 3.

Regarding the male patients, the mutation was identified in 65% of the reads for Patient 17% and 88% of the reads for Patient 15 (106/120). No mosaicism was detected in the blood of Patient 13, 14 and 16 despite the presence of pigmentary manifestations in Patient 16.DiscussionTFE3 functions in signalling of the mechanistic target of rapamycin (mTOR) complex 1 (mTORC1). The PIK3-AKT-mTOR pathway plays a role in the regulation of cellular growth, proliferation, survival and metabolism. Overactivation of the mTOR signalling is responsible for neurocutaneous disorders and cancers.22 Somatic mutations in TSC1, TSC2, AKT3, PIK3CA and MTOR are responsible for focal cortical dysplasia type II (MIM607341),23–25 hemimegalencephaly26 and megalencephaly.27 The phenotype ascribed to germline TSC1/TSC2, PTEN, MTOR and PK3R2/AKT3/CCND2 mutations – respectively in tuberous sclerosis (TS, MIM 191100), Cowden syndrome (CS, MIM 158350), Smith-Kingsmore syndrome (MIM 616638) and Megalencephaly, Polymicrogyria, Polydactyly and Hydrocephalus syndrome 1, 2 and 3 (MPPH1/2/3, MIM 603387/615939/615938) - is characterised by the association of ID, epilepsy, brain malformations and skin tumours.

Similarly, all the individuals harbouring a de novo TFE3 mutation reported in the series presented with a severe neurodevelopmental disorder. Delayed psychomotor development was constant. The youngest patient to acquire independent walking was 30 months old, and more than half of the patients aged over 18 months (57%), did not acquire walk at the last examination. Conversely to patients with MTOR, AKT3 or PTEN mutation, none of the patients described in this series had macrocephaly.

Brain imaging was abnormal in 35% of the patients. Hydrocephaly and corpus callosum dysgenesis, identified in respectively three and one individual, were previously reported in patients with mosaic gain of function MTOR mutations.28 29 One patient had surgery to remove an early-onset histiocytofibroma. However, no other skin tumour was reported, either in this patient or in any other from the series.Pigmentation anomalies, along Blaschko’s lines or, for one patient, as a large hyperpigmented area, were present in a majority of the individuals (71%) in the series, including 40% of the males and 83% of the females. PM along Blaschko’s lines is highly suggestive of genetic mosaicism.30 Genomic mosaicism is defined by the presence of at least two cell populations with different genotypes in an individual originating from one zygote and mainly occurs through post-zygotic event, whereas females can present with functional (epigenetics) mosaicism due to X inactivation.2 PM is a classical feature of X-linked male-lethal genodermatosis, such as incontinentia pigmenti (IP, MIM #308300), focal dermal hypoplasia (FDH, MIM #305600), chondrodysplasia punctuata type 2 (Conradi-Hunermann-Happle syndrome, CDPX2, MIM #302960) and linear skin defects with multiple congenital anomalies (LSDMCA1, MIM #309801).

In these conditions, the overwhelming predominance of affected females is a consequence of the male lethality, and the PM a manifestation of the functional mosaicism occurring in females. Similarly, the majority of individuals with de novo TFE3 variants in our cohort were females (sex ratio female:male was 12:5 (2.4)). The study of X-inactivation on non-cultured fibroblasts was consistent with functional mosaicism in two affected females with PM who harboured random X-inactivation, whereas a third female without PM had skewed X-inactivation. In IP, FDH and CDPX2, most hemizygous males die in utero.

However, there have been reports of surviving males 31–33 with an estimated prevalence around 10% in FDH and IP.32 34 The majority of them are explained by post-zygotic mutations or chromosomal anomalies (Klinefelter syndrome). Non-mosaic males have also been reported in FDH and IP – respectively about 17% and 45% of the affected males harbour a non-mosaic variant.32 35 In our series, males represented 29% of the patients with a de novo TFE3 variant. A mosaic variant was identified in blood for half of them. None had Klinefelter syndrome.

Interestingly, mosaicism was detected in only one out of the two males with PM, and one male with a mosaic variant had no pigmentation anomalies noted on examination. It is still possible that subtle pigmentation anomalies were missed on examination. Moreover, somatic mosaicism can be difficult to detect. Recent studies have shown that a large proportion of de novo mutations presumed to be germline had in fact occurred as post-zygotic event.36 In the males of this cohort, WES was performed on leucocytes-derived DNA and no other tissue was studied.

Therefore, it is possible that a low mosaicism was not detected. Finally, it is probable than TFE3 mutations account for a significant proportion of patients with HMI. Indeed, in this population, the high frequency of ID, epilepsy, coarse facial features has long been emphasised in the literature.37By its ability to bind the coordinated lysosomal enhancement and regulation (CLEAR) sites in the promotor region of target genes, TFE3 is involved in the control lysosomal biogenesis, autophagy and endocytosis.8 Several patients of the series indeed had clinical and biochemical features that pointed toward an inborn error of metabolism. Lysosomal storage disorder was suspected due to the variable association of coarse facial features (88%), skeletal anomalies (65%) –flat or clubfeet, hyperlordosis, hip dislocation, limitation of elbow extension, genu valgum, scoliosis–, postnatal growth retardation (59%), history of speech or developmental regression (29%) congenital hearing loss (29%), recurrent upper airways s (29%) neonatal liver anomalies such as hepatomegaly and cholestasis (18%), upper airways s (24%), umbilical hernia (18%), sleep apnoea syndrome (6%) and aortic insufficiency (6%).

Other metabolic anomalies observed in the series were obesity, defined in children by body mass index (BMI) (weight/height2) above the WHO curve, present in the oldest patients (76%), neonatal transient hypoglycaemia (12%), and hyperlactataemia (6%). Dysregulation of lipid metabolism, via suppression of thermogenesis and decreased lipolysis, thus leading to increased adipose tissue, was previously observed in adipose-specific TFE3 transgenic mice.38 Similarly to lysosomes, mitochondrias have a key role in cellular metabolism, including autophagy. Recent data demonstrate that mitochondrial and lysosomal metabolisms are interrelated.39 Muscle biopsy, performed in two individuals from this cohort, showed fat and glycogen accumulation, muscular fibre size irregularity, without evidence of mitochondrial dysfunction. Interestingly in the more recent data, evidences showing that TFE3 plays a role in the regulation of the circadian oscillations of the expression of genes involved in autophagy and lipid metabolism, and that Tfe3 knock-out mice had abnormal circadian behaviour.40 Indeed, in our series, five patients (29%) were noted to have sleep disturbance.

This could be due to circadian rhythms alteration. Finally, TFE3 has been shown to be involved in the regulation of innate immune response in macrophages via the FLCN-AMPK signalling axis,41 and of B-lymphocytes activation.42 Along these lines, four patients of the series (24%) had a history of recurrent s, associated with documented neutropenia in one of them. As shown in table 3, a summary of the frequency of the features observed in the cohort, facial dysmorphism was constant and strikingly similar among the patients. More than two-third had anteverted nares, broad flat nasal bridge, almond-shaped and widely spaced eyes, puffy cheeks and coarse facial features (thick lips and fleshy earlobes).

More than half had facial hypertrichosis. All individuals presented with at least four of the above features. One patient had an extreme facial phenotype of hypertelorism, bifid nose and bilateral cleft lip and palate. Whether these frontonasal dysplasia features may be associated with the TFE3 mutation remains unclear.

No other mutation in known genes was found in Patient 1’s exome sequencing data.View this table:Table 3 Frequency of the clinical features observed in the seriesTFE3 is a highly conserved protein, intolerant to loss of function as supported by data from the GnomAD browser43 (probability of being loss-of-function intolerant (pLI) evaluated at 0.98, observed:expected ratio=0.06) and to missense variants (Z=2.15). Moreover, TFE3 does not, or only in a few tissues, escape X inactivation, suggesting that TFE3 gene dosage is crucial to cell function.44 45 In vitro, Villegas et al recently showed that the absence of either TFE3 exon 3 or 4 resulted in a nuclear gain-of-function Tfe3 allele in ESCs, indicating that both exons 3 and 4 are required for Tfe3 inactivation.3 Nuclear localisation and resistance to differentiation were proved in Tfe3 knock-out (K.O.) ESCs expressing murine Tfe3 alleles (Gln118Pro and Pro185Leu, corresponding to mutations Gln119Pro and Pro186Leu identified in individuals referred to as patients 1 and 2 in this series). Based on the analysis of TFE3 secondary structure,46 indicating that residues 110–215 are predicted to form a domain of two stable alpha helices that might be disrupted by mutations in exons 3 and 4, and the observation of a similar phenotype in patients harbouring mutations in exons 3 and 4, it was suggested that Tfe3 exons 3 and 4 form a Rag binding fold whose structural integrity is indispensable for lysosome-mediated cytoplasmic Tfe3 inactivation.3 In this series, the recurrent mutations Arg117Gln, Leu191Pro and Thr187Met were present in respectively two, two and three patients. The aminoacid in position 187 was mutated in five patients.

In addition, 13 of the described mutations were localised between positions p.184 and p.201. This proximity could account for the absence of obvious genotype–phenotype correlation. The canonical splice site variant in intron 4 identified in patient 9 might lead to in-frame exon skipping of exon 4. The clinical picture of the patient with this splice site variant perfectly fits with the syndrome described here.

As a consequence, we raise the hypothesis of a gain-of-function effect of this variant.In conclusion, de novo mutations in exons 3 and 4 of the X-linked gene TFE3 are responsible for a neurocutaneous disorder with specific and recognisable facial dysmorphism, lysosomal storage disorder-like features and PM. This series unravels TFE3 as a major gene responsible for HMI and for a rare cause of syndromic ID. Furthermore, we provide clinical and molecular data on a previously unidentified lysosomal storage disorder, in which new insights, especially biochemical features, will probably be investigated further, together with the description of more patients. Further delineation of this phenotype will indeed allow a better understanding of the link between lysosomal signalling and development.

Finally, the evidence for mosaicism in this recently described disorder highlights the importance of considering mosaic variants on next-generation sequencing reports in diagnostic, including for patients without suggestive phenotype..

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