Telomere capture as a frequent mechanism for stabilization of the terminal chromosomal deletion associated with inverted duplication

We report 4 interstitial inverted duplications with associated terminal deletions (inv dup del) involving the short arms of chromosomes 5 and 8, and the long arm of chromosome 13 by microarray-based comparative genomic hybridization (aCGH) combined with chromosome banding (GTG banding) and fluorescence in situ hybridization (FISH) analyses. Formation of the intermediate dicentric chromosomes in 3 of them occurred through breakage-fusion-bridge cycle mechanism (U-type exchange mechanism) and in the fourth one it occurred through the mediation of the inverted low-copy repeats on chromosome 8p23.1. Two of these 4 inv dup del were confirmed and a third one was suspected to be associated with telomere capture for the healing of the terminal deletions. These findings indicate that a telomere capture mechanism is frequently used for stabilizing the broken chromosome ends in this type of genomic rearrangements. In addition, the inv dup del(13) represents the first observation of inv dup del on chromosome 13 in humans, the inv dup del(5) represents the first observation of inv dup del(5p) with an associated telomere capture, and unique features of the remaining two inv dup del(8p) were also discussed.

Accelerated thymocyte maturation in IL-12Rβ2-deficient mice contributes to increased susceptibility to autoimmune inflammatory demyelination

IL-12Rβ2(-/-) mice, which are unresponsive to IL-12, develop severe experimental autoimmune encephalomyelitis (EAE). The mechanisms for enhanced autoimmunity are incompletely understood. We report that in IL-12Rβ2(-/-) mice, thymocytes undergo markedly accelerated maturation. This occurs at the transition from a double positive (DP) to a single positive (SP) phenotype, resulting in higher numbers of CD4 and CD8 SP cells, and to a lesser extent at the transition from double negative (DN) to DP cells. Accelerated maturation is observed in mice injected with anti-CD3 to mimic pre-T-cell receptor stimulation, and also in mice immunized with myelin oligodendrocyte glycoprotein (MOG) peptide to induce EAE.

Comparison of Bayesian network and support vector machine models for two-year survival prediction in lung cancer patients treated with radiotherapy

PURPOSE

Classic statistical and machine learning models such as support vector machines (SVMs) can be used to predict cancer outcome, but often only perform well if all the input variables are known, which is unlikely in the medical domain. Bayesian network (BN) models have a natural ability to reason under uncertainty and might handle missing data better. In this study, the authors hypothesize that a BN model can predict two-year survival in non-small cell lung cancer (NSCLC) patients as accurately as SVM, but will predict survival more accurately when data are missing.

METHODS

A BN and SVM model were trained on 322 inoperable NSCLC patients treated with radiotherapy from Maastricht and validated in three independent data sets of 35, 47, and 33 patients from Ghent, Leuven, and Toronto. Missing variables occurred in the data set with only 37, 28, and 24 patients having a complete data set.

RESULTS

The BN model structure and parameter learning identified gross tumor volume size, performance status, and number of positive lymph nodes on a PET as prognostic factors for two-year survival. When validated in the full validation set of Ghent, Leuven, and Toronto, the BN model had an AUC of 0.77, 0.72, and 0.70, respectively. A SVM model based on the same variables had an overall worse performance (AUC 0.71, 0.68, and 0.69) especially in the Ghent set, which had the highest percentage of missing the important GTV size data. When only patients with complete data sets were considered, the BN and SVM model performed more alike.

CONCLUSIONS

Within the limitations of this study, the hypothesis is supported that BN models are better at handling missing data than SVM models and are therefore more suitable for the medical domain. Future works have to focus on improving the BN performance by including more patients, more variables, and more diversity.

Risks and causes of musculoskeletal injuries among health care workers

BACKGROUND

Musculoskeletal injuries (MSIs) persist as the leading category of occupational injury in health care. Limited evidence exists regarding MSIs for occupations other than direct patient care providers. An evaluation of the risks, causes and activities associated with MSIs that includes non-patient care health care occupations is warranted.

AIMS

To examine the risks and causes of time-loss MSIs for all occupations in health care.

METHODS

Workers employed by a health region in British Columbia were followed from April 2007 to March 2008 using payroll data; injuries were followed using an incidence surveillance database. Frequency and rates were calculated for all occupational injuries and MSIs and relative risks (RRs) were computed using Poisson regression. Causes and occupational activities leading to MSIs were tabulated for direct care occupations and non-patient care occupations.

RESULTS

A total of 944 injuries resulting in time-loss from work were reported by 23 742 workers. Overall, 83% injuries were musculoskeletal. The two occupations showing highest RR of MSIs relative to registered nurses were facility support service workers [RR = 3.16 (2.38-4.18), respectively] and care aides [RR=3.76 (3.09-4.59)]. For direct patient care occupations, the leading causes of MSIs were awkward posture (25%) and force (23%); for non-patient care occupations were force (25%) and slip/fall (24%). Patient handling activities accounted for 60% of all MSIs for direct care occupations. For non-patient care occupations, 55% of MSIs were due to material/equipment handling activities.

CONCLUSIONS

Prevention efforts for MSIs should be directed to non-patient care occupations as well and consider their occupation-specific causes and activities.

Enumeration of Vibrio parahaemolyticus in oyster tissues following artificial contamination and depuration

AIMS

To evaluate enumeration of Vibrio parahaemolyticus in oyster tissues following artificial contamination and depuration.

METHODS AND RESULTS

After inoculating with V. parahaemolyticus (ATCC 17802) and incubating for 24 h, the contaminated oysters were depurated with artificial seawater for 14 days. At each step, the tissue homogenate supernatants of oysters were spread-plated onto thiosulfate-citrate-bile salt-sucrose agar, followed by colony confirmation by the polymerase chain reaction. The pathogen was detected in the gills, digestive glands (including stomach, digestive ducts and digestive diverticula), adductor muscle and mantle cilia. After a 48-h depuration period at 17-19 degrees C, the retention rate of V. parahaemolyticus in the gills (28.1%) and digestive glands (13.5%) was higher than that in adductor muscle and mantle cilia (1.4 and 2.4%, respectively).

CONCLUSIONS

The population of V. parahaemolyticus in the digestive glands was the highest among all tissues tested, followed by the gills. The data indicate that digestive glands and gills are good sample candidates for direct monitoring of V. parahaemolyticus contamination in oysters.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first report on the dynamics of V. parahaemolyticus in various oyster tissues following artificial contamination and depuration. This study provides information to help in monitoring for V. parahaemolyticus in commercial oysters.

Inhibition spectrum studies of microthecin and other anhydrofructose derivatives using selected strains of Gram-positive and -negative bacteria, yeasts and moulds, and investigation of the cytotoxicity of microthecin to malignant blood cell lines

AIMS

To prepare 1,5-anhydro-d-fructose (AF) derivatives, test their microbial inhibition spectrum, and to further examine the most effective AF derivative against Pseudomonas aeruginosa and malignant blood cell lines.

METHODS AND RESULTS

Microthecin and nine other AF derivatives were synthesized from AF. The 10 compounds were tested in vitro against Gram-positive (GP) and Gram-negative (GN) bacteria, yeasts and moulds using a well diffusion method and in a Bioscreen growth analyser. Of the test compounds, microthecin exhibited the most significant antibacterial activity at 100-2000 ppm against both GP and GN bacteria, including Ps. aeruginosa. Further tests with three malignant blood cell lines (Mutu, Ramos, Raji) and one normal cell line indicated that microthecin was a cell toxin, with a cell mortality >85% at 50 ppm. The other nine AF derivatives demonstrated low or no antimicrobial activity.

CONCLUSIONS

Microthecin was active 100-2000 ppm against GP and GN bacteria including Ps. aeruginosa, but was inactive against yeasts and moulds. Microthecin was also a cytotoxin to some mammalian cell lines.

SIGNIFICANCE AND IMPACT OF THE STUDY

Microthecin might have potential for development as a novel drug against Ps. aeruginosa and to target cancer cells. It might also be developed as a food processing aid to control bacterial growth.

Morphological analysis of the lung of neonatal yak

Although yaks play an important role as companion or pack and draught animals on Chinese plateaus in alpine and sub-alpine regions, morphological studies and anatomical data on the lung of yak are sparse. To provide anatomical descriptions and morphometric data, 10 one-day-old yaks were examined by means of dissection, light and electron microscopy. The measurements of lung were made on dissected specimens and histological sections. Unequal dichotomous branching was demonstrated in the dissected tracheobronchial tree. The diameters of bronchial airways and height of epithelium were measured, and showed that the variation of diameters in airways was always greater than that of height of epithelium. In addition, the thickness of muscularis, cartilage and adventitia was examined, as well as the number of goblet and Clara cells in airways. Ultrastructural studies showed that the surface epithelium was mainly composed of goblet, ciliated, Clara and basal cells, similar to that in other domestic animals. Under electron microscope, two distinctive types of ciliated cells could be seen in the tracheobronchial epithelium. The first type contained some mitochondria, distended smooth endoplasmic reticulum (SER), little rough endoplasmic reticulum (RER) and numerous vacuoles in electron-lucent cytoplasm. The second type had dense cytoplasm with abundant mitochondria, RER and no vacuoles. Both types were rich of glycogen granules. The goblet cells in neonatal yak lung had the following characteristic features: dentate nucleus in dense cytoplasm, with stacks of RER and numerous dense membrane-bounded mucous droplets, which were round or oval, often with an electron-lucent core. The droplets were not confluent. Glycogen granules were numerous, and Golgi complex was occasionally present. Clara cells were dome-shaped and usually protruded into the airway lumen. Large amounts of SER and many secretory droplets were found within the cytoplasm. Several typical 'clefts' were also found in the cytoplasm.

TAK-285, a Novel HER2/EGFR Inhibitor, Penetrates the CNS in Rats with an Intact Blood Brain Barrier (BBB)

Background: Approximately one third of patients with HER2-overexpressing (HER2+) metastatic breast cancer develop brain metastases. Treatment options for patients whose brain metastases have progressed after radiotherapy are urgently needed. The currently approved HER2-targeted therapies, trastuzumab and lapatinib, have generally shown limited activity against brain metastases, likely due to the limited brain penetration of these drugs. Brain penetration is mediated by multiple factors including drug permeability, tissue binding, and the expression of efflux transporters (P-gp and BCRP) and their interactions with the drug. TAK-285 is a novel, orally active, dual HER2/EGFR inhibitor currently under clinical development. In this nonclinical work, we evaluated the permeability, interactions with efflux transporters, and brain penetration of TAK-285, along with lapatinib and neratinib, using in vitro and animal models.Material and Methods: The first study evaluated the permeability of TAK-285, lapatinib, and neratinib and their interactions with efflux transporters using the Caco-2 cell monolayer system in the absence or presence of efflux pump inhibitors. The second study evaluated brain penetration of TAK-285, lapatinib and neratinib after a single oral administration in rats with an intact BBB.Results: In the Caco-2 cell model, TAK-285 showed high permeability with an efflux ratio of 1.7, indicating it is not a substrate for efflux pumps. The efflux pump inhibitors LY335979 (an inhibitor of P-gp), Ko143 (an inhibitor of BCRP), and GF120918 (an inhibitor of BCRP and P-gp) had no marked effect on the efflux ratio of TAK-285, further confirming that TAK-285 is not a substrate for P-gp and BCRP. Lapatinib and neratinib showed low to medium permeability and appeared to be substrates for P-gp/BCRP in this testing system. In the rat brain penetration study, the brain-to-plasma AUC ratio for total (free and bound) TAK-285, lapatinib, and neratinib was 0.202, 0.0243, and 0.0263, respectively.Discussion: These nonclinical studies showed that, unlike lapatinib and neratinib, TAK-285 is not a substrate for the efflux transporters, P-gp and BCRP. Based on published information, all of the approved receptor tyrosine kinase inhibitors are substrates for efflux transporters. Additionally, in rats with an intact BBB, the brain-to-plasma AUC ratio for TAK-285 was substantially higher than that of lapatinib and neratinib. The AUC ratios observed in this study for lapatinib and neratinib are similar to the proportion of blood volume in the rat brain (ie, outside the CNS) relative to the total rat brain volume. This suggests the actual brain-to-plasma AUC ratio for TAK-285 in rats may be much greater than 8-fold of that of lapatinib and neratinib calculated based on these measured AUC ratios. Consequently, TAK-285 may have a unique role in the treatment of brain lesions in patients with HER2- or EGFR-dependent tumors. Furthermore, TAK-285 may not be subject to drug resistance conferred by efflux transporters.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5098.

A miniature confocal Raman probe for endoscopic use

Raman spectroscopy is a powerful tool for studying biochemical changes in the human body. We describe a miniature, confocal fibre optic probe intended to fit within the instrument channel of a standard medical endoscope. This probe has been optimized for the study of the carcinogenesis process of oesophageal malignancy. The optical design and fabrication of this probe is described including the anisotropic wet etching technique used to make silicon motherboards and jigs. Example spectra of PTFE reference samples are shown. Spectra with acquisition times as low as 2 s from resected oesophageal tissue are presented showing identifiable biochemical changes from various pathologies.

Farm work-related injury among middle school students in rural China

Farm work-related injuries are considered an important issue facing rural area adolescents. However, little research has been done in developing countries, including China. This study evaluated agricultural work-related injuries among Chinese middle school adolescents, focusing on the potential association between farm work hours, sleep patterns, school-related stress, and farm work-related injuries. This cross-sectional study surveyed 1,551 middle school students in Hunan Province who reported working on farms. The surveys assessed their involvement in farm work, sleep patterns, school activities, and farm work-related injuries during a three-month recall period. The cumulative incidence of farm work-related injury was 15.6% among the 1187 students who reported working on a farm. Average days per month farming, number of pesticide applications per month, sleep disturbances, and school-related stress were significantly associated with farm work-related injuries (p < 0.05). Multivariable logistic regression analysis revealed that after adjusting for possible confounding effects of age, gender, and farm work days per month, sleep disturbance (less than 7 hours of sleep: OR = 2.36, 95% CI = 1.07-5.22; awakening at night and having trouble falling back to sleep: OR = 2.70, 95% CI = 1.36-5.37; having nightmares: OR = 2.24, 95% CI = 1.18-4.24) and school-related stress (difficult homework: OR = 2.45, 95% CI = 1.21-4.99; extra homework assigned often by parents: OR = 3.62, 95% CI = 1.88-6.97; and scolded/chastised by parents for poor school performance: OR = 2.53, 95% CI = 1.75-3.65) were statistically significant risk factors for farm work-related injuries (p < 0.05).

Reversible Cerebral Vasoconstriction Syndrome with Posterior Leucoencephalopathy after Oral Contraceptive Pills

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by sudden-onset recurrent ‘thunderclap’ headaches with reversible multifocal narrowing of the cerebral arteries, often associated with focal neurological deficits from ischaemic or haemorrhagic stroke. It has been associated with exposure to vasoconstrictive drugs, pregnancy, migraine, and a variety of other conditions. Whereas the pathophysiology of RCVS remains unclear, changes in the levels of female hormones are considered important because RCVS predominantly affects women and is frequently associated with pregnancy. We report a patient with angiographically confirmed RCVS whose MRI showed reversible brain oedema, suggesting an overlap between RCVS and the reversible posterior leucoencephalopathy syndrome. The only identified risk factor was oral contraceptive pills started 1 month prior to onset, supporting a role for female reproductive hormones in precipitating this overlap syndrome.

Condom-use skills checklist: a proxy for assessing condom-use knowledge and skills when direct observation is not possible

Because of the continued importance of correct condom-use in controlling the HIV epidemic and the limited availability of tools for assessing correct condom-use, methods for assessing condom-application skills, especially when direct observation is not feasible, are needed. Accordingly, in the context of a high-risk population (The Bahamas) for HIV, a 17-item scale--the Condom-use Skills Checklist (CUSC)--was developed for use among young adolescents and adults. The rationale and approach to developing the scale and some measures of internal consistency, construct validity, and criterion-related validity have been described. It is concluded that the scale offers a reasonable alternative to direct observation among older subjects and that further development may make it more useful among pre-adolescents.

Efficacy and safety of sorafenib in patients with advanced hepatocellular carcinoma (HCC): Asia-Pacific (AP) trial subgroup analyses by baseline transaminase (ALT/AST)/α-fetoprotein (AFP) levels

4590^

Background: Results of the phase III, randomized, double blind, placebo-controlled AP trial demonstrated that sorafenib is effective and safe for the treatment of advanced HCC in patients from the AP region (Cheng et al, Lancet Oncol, 2009). Hepatic function influences treatment as a measure of organ damage and tumor stage. We performed subset analyses of the AP study dataset according to baseline hepatic function, as indicated by levels of ALT/AST and AFP. Methods: Patients (N=226) with advanced HCC, ECOG PS 0–2, Child-Pugh class A, and no prior systemic therapy were randomized 2:1 to receive sorafenib 400 mg BID or placebo. Endpoints included overall survival (OS), disease-control rate (DCR; defined as complete/partial response or stable disease by RECIST, maintained for ≥28 days from first demonstration of response), time to progression (TTP) and safety. Patients were grouped by baseline levels of ALT/AST (normal, mild, or moderate) and AFP (normal or abnormal). Results: Median TTP, OS and DCR by subset are shown in the table . The most common grade 3/4 adverse events in the sorafenib populations were hand-foot skin reaction and diarrhea. Conclusions: Sorafenib was effective and safe in patients from the AP region with advanced HCC within a broad range of baseline hepatic enzyme and AFP levels. These results suggest that sorafenib is an effective treatment for HCC, irrespective of baseline ALT/AST or AFP levels.

[Table: see text]

[Table: see text]

ASCO Conflict of Interest Policy and Exceptions

In compliance with the guidelines established by the ASCO Conflict of Interest Policy (J Clin Oncol. 2006 Jan 20;24[3]:519–521) and the Accreditation Council for Continuing Medical Education (ACCME), ASCO strives to promote balance, independence, objectivity, and scientific rigor through disclosure of financial and other interests, and identification and management of potential conflicts. According to the ASCO Conflict of Interest Policy, the following financial and other relationships must be disclosed: employment or leadership position, consultant or advisory role, stock ownership, honoraria, research funding, expert testimony, and other remuneration (J Clin Oncol. 2006 Jan 20;24[3]:520). The ASCO Conflict of Interest Policy disclosure requirements apply to all authors who submit abstracts to the Annual Meeting.

For clinical trials that began accrual on or after April 29, 2004, ASCO's Policy places some restrictions on the financial relationships of principal investigators (J Clin Oncol. 2006 Jan 20;24[3]:521). If a principal investigator holds any restricted relationships, his or her abstract will be ineligible for placement in the 2009 Annual Meeting unless the ASCO Ethics Committee grants an exception. Among the circumstances that might justify an exception are that the principal investigator (1) is a widely acknowledged expert in a particular therapeutic area; (2) is the inventor of a unique technology or treatment being evaluated in the clinical trial; or (3) is involved in international clinical oncology research and has acted consistently with recognized international standards of ethics in the conduct of clinical research. NIH-sponsored trials are exempt from the Policy restrictions. Abstracts for which authors requested and have been granted an exception in accordance with ASCO's Policy are designated with a caret symbol (^) in the Annual Meeting Proceedings.

For more information about the ASCO Conflict of Interest Policy and the exceptions process, please visit www.asco.org/conflictofinterest .

Impact of prior surgical resection with curative intent on the efficacy and safety of sorafenib in patients with advanced hepatocellular carcinoma (HCC): Subset analysis of the Asia-Pacific (AP) study

e15518^

Background: The multinational, phase III, randomized, double-blind, placebo-controlled AP study demonstrated that sorafenib is effective and safe for the treatment of advanced HCC in patients from the AP region (Cheng, et al. Lancet Oncol, 2009). Surgical resection with curative intent is a commonly used procedure for the treatment of HCC; however, tumor recurrence occurs in the majority of patients. Hence, it is of interest to analyze the efficacy and safety of sorafenib in patients who had undergone prior partial hepatectomy. Methods: Patients (N=226) with advanced HCC, ECOG PS 0–2, Child-Pugh class A, and no prior systemic therapy were randomized 2:1 to receive either sorafenib 400 mg BID or placebo. End points included overall survival (OS), disease-control rate (DCR; defined as complete/partial response or stable disease by RECIST, maintained for ≥28 d from first demonstration of response), time-to-progression (TTP), and safety. Results: Of 226 patients enrolled, 70 had previously undergone partial hepatectomy. Median TTP, OS, and DCR by subset are shown in the table. The safety profile of sorafenib in patients with and without prior hepatectomy was similar to that reported for the total study population. The most common grade 3/4 adverse events in the sorafenib groups were hand-foot skin reaction and diarrhea. Conclusions: Sorafenib was safe for the treatment of advanced HCC in patients from the AP region, whether or not they had undergone prior surgical resection. Sorafenib treatment resulted in similar TTP in patients with and without a history of prior partial hepatectomy, and the magnitude of TTP was similar in both groups to that in the overall population. Due to small sample size, further study is warranted. [Table: see text]

[Table: see text]

ASCO Conflict of Interest Policy and Exceptions

In compliance with the guidelines established by the ASCO Conflict of Interest Policy (J Clin Oncol. 2006 Jan 20;24[3]:519–521) and the Accreditation Council for Continuing Medical Education (ACCME), ASCO strives to promote balance, independence, objectivity, and scientific rigor through disclosure of financial and other interests, and identification and management of potential conflicts. According to the ASCO Conflict of Interest Policy, the following financial and other relationships must be disclosed: employment or leadership position, consultant or advisory role, stock ownership, honoraria, research funding, expert testimony, and other remuneration (J Clin Oncol. 2006 Jan 20;24[3]:520). The ASCO Conflict of Interest Policy disclosure requirements apply to all authors who submit abstracts to the Annual Meeting.

For clinical trials that began accrual on or after April 29, 2004, ASCO's Policy places some restrictions on the financial relationships of principal investigators (J Clin Oncol. 2006 Jan 20;24[3]:521). If a principal investigator holds any restricted relationships, his or her abstract will be ineligible for placement in the 2009 Annual Meeting unless the ASCO Ethics Committee grants an exception. Among the circumstances that might justify an exception are that the principal investigator (1) is a widely acknowledged expert in a particular therapeutic area; (2) is the inventor of a unique technology or treatment being evaluated in the clinical trial; or (3) is involved in international clinical oncology research and has acted consistently with recognized international standards of ethics in the conduct of clinical research. NIH-sponsored trials are exempt from the Policy restrictions. Abstracts for which authors requested and have been granted an exception in accordance with ASCO's Policy are designated with a caret symbol (^) in the Annual Meeting Proceedings.

For more information about the ASCO Conflict of Interest Policy and the exceptions process, please visit www.asco.org/conflictofinterest .

Refining the 22q11.2 deletion breakpoints in DiGeorge syndrome by aCGH

Hemizygous deletions of the chromosome 22q11.2 region result in the 22q11.2 deletion syndrome also referred to as DiGeorge, Velocardiofacial or Shprintzen syndromes. The phenotype is variable but commonly includes conotruncal cardiac defects, palatal abnormalities, learning and behavioral problems, immune deficiency, and facial anomalies. Four distinct highly homologous blocks of low copy number repeat sequences (LCRs) flank the deletion region. Mispairing of LCRs during meiosis with unequal meiotic exchange is assumed to cause the recurrent and consistent deletions. The proximal LCR is reportedly located at 22q11.2 from 17.037 to 17.083 Mb while the distal LCR is located from 19.835 to 19.880 Mb. Although the chromosome breakpoints are thought to localize to the LCRs, the positions of the breakpoints have been investigated in only a few individuals. Therefore, we used high resolution oligonucleotide-based 244K microarray comparative genomic hybridization (aCGH) to resolve the breakpoints in a cohort of 20 subjects with known 22q11.2 deletions. We also investigated copy number variation (CNV) in the rest of the genome. The 22q11.2 breaks occurred on either side of the LCR in our subjects, although more commonly on the distal side of the reported proximal LCR. The proximal breakpoints in our subjects spanned the region from 17.036 to 17.398 Mb. This region includes the genes DGCR6 (DiGeorge syndrome critical region protein 6) and PRODH (proline dehydrogenase 1), along with three open reading frames that may encode proteins of unknown function. The distal breakpoints spanned the region from 19.788 to 20.122 Mb. This region includes the genes GGT2 (gamma-glutamyltransferase-like protein 2), HIC2 (hypermethylated in cancer 2), and multiple transcripts of unknown function. The genes in these two breakpoint regions are variably hemizygous depending on the location of the breakpoints. Our 20 subjects had 254 CNVs throughout the genome, 94 duplications and 160 deletions, ranging in size from 1 kb to 2.4 Mb. The presence or absence of genes at the breakpoints depending on the size of the deletion plus variation in the rest of the genome due to CNVs likely contribute to the variable phenotype associated with the 22q11.2 deletion or DiGeorge syndrome.