Generalized epilepsy with febrile seizures plus: further heterogeneity in a large family

BACKGROUND

Generalized epilepsy with febrile seizures plus (GEFS(+)) is a recently described benign childhood-onset epileptic syndrome with autosomal dominant inheritance. The most common phenotypes are febrile seizures (FS) often with accessory afebrile generalized tonic-clonic seizures (GTCS, FS(+)). In about one third, additional seizure types occur, such as absences, myoclonic, or atonic seizures. So far, three mutations within genes encoding subunits of neuronal voltage-gated Na(+) channels have been found in GEFS(+) families, one in SCN1B (beta(1)-subunit) and two in SCN1A (alpha-subunit).

METHODS

The authors examined the phenotypic variability of GEFS(+) in a five-generation German family with 18 affected individuals. Genetic linkage analysis was performed to exclude candidate loci.

RESULTS

Inheritance was autosomal dominant with a penetrance of about 80%. A variety of epilepsy phenotypes occurred predominantly during childhood. Only four individuals showed the FS or FS(+) phenotype. The others presented with different combinations of GTCS, tonic seizures, atonic seizures, and absences, only in part associated with fever. The age at onset was 2.8 +/- 1.3 years. Interictal EEG recordings showed rare, 1- to 2-second-long generalized, irregular spike-and-wave discharges of 2.5 to 5 Hz in eight cases and additional focal parietal discharges in one case. Linkage analysis excluded the previously described loci on chromosomes 2q21-33 and 19q13. All other chromosomal regions containing known genes encoding neuronal Na(+) channel subunits on chromosomes 3p21-24, 11q23, and 12q13 and described loci for febrile convulsions on chromosomes 5q14-15, 8q13-21, and 19p13.3 were also excluded.

CONCLUSION

These results indicate further clinical and genetic heterogeneity in GEFS(+).

Neonatal and neurodevelopmental outcome in infants born before 30 weeks of gestation with absent or reversed end-diastolic flow velocities in the umbilical artery

The objective of our study was to examine the outcome of infants born at a gestational age < 30 weeks with absent or reversed end-diastolic flow velocity (AREDFV) in the umbilical artery in comparison with gestational age-matched eutrophic controls. A group of 40 infants who had AREDFV were matched for gestational age and date of birth with 40 appropriate for gestational age infants. Perinatal outcome variables were retrospectively reviewed. In 16 out of the 40 matched pairs, a standardized neurological examination was done and, depending on age, the Kaufman Assessment Battery for Children or the Bayley Scales of Infant Development were applied at a corrected age of 13 to 100 months to assess neurodevelopmental outcome. The results were compared using Fisher's Exact Test or Mann Whitney U Tests as appropriate. In the AREDFV group, 26/40 (65%) survived until discharge compared to 39/40 (97.5%) in the control group (P < 0.001). AREDFV was associated with a higher rate of chronic lung disease, retinopathy of prematurity > or = grade III and impaired intestinal motility. More AREDFV infants suffered from permanent neurological sequelae compared with control infants: 44% versus 25% were mentally retarded (P = 0.033), and 38% versus 19% showed severe motor impairment (P = 0.073).

CONCLUSION

Absent or reversed end-diastolic flow velocity is not only associated with a higher mortality and morbidity during the neonatal period, but the surviving infants of this high risk group have an increased risk for mental retardation and severe motor impairment as compared with appropriate for gestational age preterm infants of the same gestational age.

Nutrient removal in the river basin of the Ruhr--a German case study

In the catchment area of the Ruhr, restructuring and upgrading measures in the domain of wastewater and stormwater treatment have been under way since 1990 to successively implement the currently applicable legal requirements for nutrient removal. With 2.1 million inhabitants and a design capacity of 3.7 million population equivalents (PE), it is expected that approximately DM 2 billion still have to be invested from 2000 onward. With this it will be possible to further cut the nutrient load in the Ruhr River, that has been declining consistently since the 1970s: by about 25% for Ntotal and about 10% for Ptotal. The anticipated decrease in ammonia-nitrogen in winter is particularly important for drinking water production from the river water (bank filtration). Whether and to what an extent the expected decline in phosphorus concentrations will curb eutrophication in the Ruhr with its several impounded stretches remains to be seen. Further nutrient load reductions cannot be achieved by sewage treatment-related measures. Load balances underline the adverse impact of diffuse or non-point sources, in particular, for nitrogen. Some potential to further improve the situation is seen in minimizing the nutrient releases from agricultural practices.

International product cost comparison in the field of water management

Comparing international costs in the field of water management is difficult. The frame conditions in the various countries are very different. They influence the costs and particularly the sewage charges in a complex way. Some of these conditions are outlined by analyzing the situation in Germany as a "case study". An objective comparison should deal with the in situ arising product costs as annual costs. The product costs consist of both the operating and the capital costs. The annual product costs of 34 wastewater treatment plants in six different European countries are presented. The observed differences in the quality of the construction and of the mechanical equipment of the plants were taken into account with different depreciation periods. The product costs in four of six countries, including Germany, were found to be nearly at the same level. Although the German frame conditions are demanding and difficult the expectation of outstanding high product costs was not confirmed.

A reduced K+ current due to a novel mutation in KCNQ2 causes neonatal convulsions

Benign familial neonatal convulsions (BFNC) is a rare dominantly inherited epileptic syndrome characterized by frequent brief seizures within the first days of life. The disease is caused by mutations in one of two recently identified voltage-gated potassium channel genes, KCNQ2 or KCNQ3. Here, we describe a four-generation BFNC family carrying a novel mutation within the distal, unconserved C-terminal domain of KCNQ2, a 1-bp deletion, 2513delG, in codon 838 predicting substitution of the last seven and extension by another 56 amino acids. Three family members suffering from febrile but not from neonatal convulsions do not carry the mutation, confirming that febrile convulsions and BFNC are of different pathogenesis. Functional expression of the mutant channel in Xenopus oocytes revealed a reduction of the potassium current to 5% of the wild-type current, but the voltage sensitivity and kinetics were not significantly changed. To find out whether the loss of the last seven amino acids or the C-terminal extension because of 2513delG causes the phenotype, a second, artificial mutation was constructed yielding a stop codon at position 838. This truncation increased the potassium current by twofold compared with the wild type, indicating that the pathological extension produces the phenotype, and suggesting an important role of the distal, unconserved C-terminal domain of this channel. Our results indicate that BFNC is caused by a decreased potassium current impairing repolarization of the neuronal cell membrane, which results in hyperexcitability of the central nervous system.

A microdeletion syndrome due to a 3-Mb deletion on 19q13.2--Diamond-Blackfan anemia associated with macrocephaly, hypotonia, and psychomotor retardation

We report on a boy with congenital pure red blood cell aplasia [Diamond Blackfan anemia (DBA)] and severe congenital hypotonia, macrocephaly, hypertelorism, a broad and tall forehead, medial epicanthus, and facial hypotonia with mouth-breathing and drooling, an affable and out-going personality, and a general psychomotor retardation. These features show similarity to the phenotype of the X-linked FG syndrome. DBA was diagnosed at the age of 4 months, and the boy underwent treatment with transfusion and with prednisolone. He had a normal 46, XY karyotype, but fluorescence in situ hybridization (FISH) analysis to metaphase chromosomes revealed a 3-Mb deletion on 19q13.2. This chromosomal region has previously been linked to the DBA phenotype and one 19q13 microdeletion has been identified in a patient with DBA. This deletion coincides with the deletion reported here. We suggest that the complex phenotype of our patient, including both DBA and the associated features, represent a microdeletion syndrome.

Tumor necrosis factor-alpha (TNFalpha) regulates the epithelial barrier in the human intestinal cell line HT-29/B6

Cytokines are supposed to be mediators in diarrhoeal diseases. The aim of this study is to characterize the effect of tumor necrosis factor-alpha (TNFalpha) on epithelial barrier function in the colonic epithelial cell line HT-29/B6. Active ion transport and barrier function were measured as short-circuit current and transepithelial electrical resistance (Rt), respectively. In parallel, freeze-fracture electron microscopy (EM) of tight junctions (TJ) and immunofluorescence microscopy of the zonula occludens protein-1 (ZO-1) were performed. Serosal addition of TNF(alpha) (100 ng/ml) decreased Rt by 81%. This effect was dose-dependent and could be mimicked by antibodies against the p55 form of the TNF receptor. Cytotoxic effects were excluded by a negative lactate dehydrogenase (LDH) assay. Immunofluorescence localization with anti-ZO-1 antibodies revealed no evidence for disruption of the monolayer after TNFalpha treatment. In freeze-fracture EM, TJ complexity was decreased by TNFalpha, as indicated by a decrease in the number of strands from 4.7 to 3.4. The tyrosine kinase blocker genistein and the protein kinase A inhibitor H-8 reduced the effect of TNFalpha. A combination of TNFalpha with interferon-gamma acted synergistically on the epithelial barrier. In conclusion, TNFalpha impairs epithelial barrier function by altering structure and function of the tight junction, which could be of pathogenic relevance in intestinal inflammation.

IL-1beta and TNF-alpha, but not IFN-alpha, IFN-gamma, IL-6 or IL-8, are secretory mediators in human distal colon

Inflammatory bowel disease (IBD) and HIV infection can cause diarrhoea which is accompanied by elevated cytokine levels. To elucidate a pathogenic role of cytokines, their effect on ion secretion was studied in human distal colon using the Ussing technique. Interluekin 1beta (IL-1beta) dose dependently increased short-circuit current (ISC). An ISC maximum of 2.5+/-0.3 micromol. h-1.cm-2 was reached at 20 ng/ml within 43+/-4 min. 22Na+ and 36Cl- fluxes were not altered and residual flux increased by 2.4+/-1.0 micromol.h-1.cm-2 indicating that the IL-1beta-induced ISC is based on electrogenic bicarbonate secretion. IL-1beta had no effect on HT-29/B6 epithlial monolayers suggesting that IL-1beta does not act directly on the epithelium. Furthermore, in human colon the effect was not attenuated by removal of the submucosa (total stripping) pointing to a mediation step via subepithlial cells in the lamina propria. While tetrodotoxin and the 5-lipoxygenase inhibitor ICI-230487 had no effect, indomethacin completely blocked IL-1beta action. Prostaglandin determination by RIA revealed an increased production of PGE2. At half maximum effective concentrations an additive action of tumour necrosis factor alpha (TNF-alpha) could be demonstrated on IL-1beta-induced secretion. Interferon alpha (IFN-alpha), IFN-gamma, IL-6, and IL-8 had no seretory effect in human distal colon. None of the investigated cytokines altered the intestinal barrier function. By their secretory effects IL-1beta and TNF-alpha, but not IFN-alpha, IFN-gamma, IL-6, and IL-8, may contribute to diarrhoea in IBD and AIDS.

Video-based documentation and rating system of the motor behaviour of handicapped children treated with physiotherapy--a new outcome measure

PURPOSE

Development of an instrument to measure modifications of motor quality in handicapped children receiving physiotherapy.

METHODS

A video-based documentation method of motor behaviour in children from 0 to 3 years receiving physiotherapy was elaborated, consisting of a standardized set of scenes (script) and a rating procedure concerning different categories of motor behaviour such as coordination, stability and effort.

RESULTS

The construction of the script and the rating system proved to be sensitive in documenting and evaluating the motor behaviour of handicapped children receiving physiotherapy. A good inter-rater reliability of 0.85 was obtained. The chosen rating categories represent two independent factors: One relating more to the motor functions (motor component) and the other relating to the psycho-social aspects of movement (interactive component).

CONCLUSION

The instrument allows to evaluate the quality aspects of movement. They can be observed in motor behaviour regardless of which function is being executed and may develop in a different pace and at different stages of therapy than specific motor functions such as turning, sitting or walking. The instrument is intended to complement a standard neurological examination and the application of motor function tests, especially, to evaluate therapeutic outcomes.

The Australian Multicenter Trial of Growth Hormone (GH) Treatment in GH-Deficient Adults

GH treatment in adults with GH deficiency has numerous beneficial effects, but most studies have been small. We report the results of an Australian multicenter, randomized, double-blind, placebo-controlled trial of the effects of recombinant human GH treatment in adults with GH deficiency. GH deficiency was defined as a peak serum GH of < 5 mU/liter in response to insulin-induced hypoglycemia. Patients were randomly assigned to receive either GH (0.125 U/kg per week for 1 month and 0.25 U/kg per week for 5 months) or placebo. After 6 months, all patients received GH. The primary end points were biochemical responses, body composition, quality of life, and safety. One hundred sixty-six patients (72 females and 91 males) with a mean age of 40 +/- 1 yr (+/- SEM; range 17-67 yr) were recruited. Serum insulin-like growth factor-I (IGF-I) increased from a standard deviation score of -2.64 +/- 0.27 (range -8.8 +3.82; n = 78) to +1.08 +/- 2.87 (range -7.21 to +6.42) at 6 months in the GH/GH group; 38% of the whole group were above the age-specific reference range following treatment [17.6% and 68.9% with subnormal (< 2 SD) or normal (+/- 2 SD) pretreatment levels, respectively]. Fasting total cholesterol (P = 0.042) and low-density lipoprotein cholesterol (P = 0.006) decreased over the first 6 months. Fat-free mass increased in the first 6 months whether measured by bioelectrical impedance (P < 0.001) or dual energy x-ray absorptiometry (DEXA; P < 0.001). Total-body water increased in the first 6 months whether measured by bioelectrical impedance (P < 0.001) or deuterium dilution (P = 0.002). Fat mass measured by DEXA (P < 0.001), skinfold thicknesses (P < 0.001), and waist/hip ratio (P = 0.001) decreased in the first 6 months. Most changes in body composition were complete by 3 months of treatment and maintained to 12 months. Whole-body bone mineral density (BMD) (by DEXA) was unaffected by GH treatment. Self-reported quality of life was considered good before treatment, and beneficial treatment effects were observed for energy, pain, and emotional reaction as assessed by the Nottingham Health Profile. In the initial 6 months, adverse effects were reported by 84% of patients in the GH and 75% in the placebo group, with more symptoms relating to fluid retention in the GH group (48% vs. 30%; P = 0.016). Such symptoms were mild and resolved in 70% of patients despite continued treatment. Resting blood pressure did not change over the initial 6 months. In summary, GH treatment in adults with GH deficiency resulted in 1) prominent increases in serum IGF-I at the doses employed, in some cases to supraphysiological levels; 2) modest decreases in total- and low-density lipoprotein cholesterol, together with substantial reductions in total-body and truncal fat mass consistent with an improved cardiovascular risk profile; 3) substantial increases in lean tissue mass; and 4) modest improvements in perceived quality of life. The excessive IGF-I response and side-effect profile suggests that lower doses of GH may be a required for prolonged GH treatment in adults with severe GH deficiency.

The second case of a t(17;22) in a family with neurofibromatosis type 1: sequence analysis of the breakpoint regions

A reciprocal t(17;22)(q11.2;q11.2) was found in a female patient with neurofibromatosis type 1 (NF1) and in her affected daughter. Sequence analysis of cloned junction fragments traversing the breakpoints allowed the identification of the structures involved in the rearrangement. Aberrant bands in Southern hybridizations of restriction enzyme-digested DNA of the patient pointed to the disruption of the NF1 gene in intron 31. Semispecific polymerase chain reaction analysis of the genomic DNA of the patient with the specific primer anchored at NF1 exon 31 was used to obtain the breakpoint-spanning fragment of the derivative chromosome 17. The intron 31 sequence turned out to be interrupted within a large irregular (AT) repeat. The chromosome 22-derived sequence of the der(17) junction fragment allowed us to identify cosmids of the corresponding region from a chromosome 22 specific cosmid library. With the support of the breakpoint-spanning cosmids, the chromosome 22 region upstream of the fragment carried by the der(17) was characterized. Primers deduced from the sequence of this upstream region were used in combination with a primer in NF1 intron 31 distal to the breakpoint on chromosome 17 to amplify the der(22) junction fragment. The structure of the junction sequences suggested that the translocation had arisen by unequal homologous recombination between (AT)-rich repeats on chromosome 22 and on chromosome 17 in intron 31 of the NF1 gene. However, our data support the assumption of additional rearrangements prior to, or in the course of, the recombination event, leading to a loss of the sequences between the involved (AT) repeats on chromosome 22. In the direct vicinity of these (AT) repeats, two members of a previously undescribed low-copy repetitive sequence have been found, copies of which are also present on human chromosome 13.

Tumor necrosis factor-alpha induces Cl- and K+ secretion in human distal colon driven by prostaglandin E2

Increased levels of tumor necrosis factor-alpha (TNF-alpha) have been found in, for example, inflammatory bowel disease (IBD) and human immunodeficiency virus (HIV) infection. To investigate a possible contribution of TNF-alpha to the pathogenesis of diarrhea in these diseases, ion transport of human distal colon was studied in the Ussing chamber in vitro. Serosal addition of TNF-alpha increased short-circuit current (Isc) of partially stripped tissues in a dose-dependent manner. Maximum Isc increase of 1.8 +/- 0.2 mumol.h-1.cm-2 was reached after 60 +/- 9 min at 200 ng/ml TNF-alpha. Bidirectional tracer flux measurements revealed that TNF-alpha induced an increase in 36 Cl serosal-to-mucosal flux, a decrease in 36Cl- mucosal-to-serosal flux, and a slight increase in K+ secretion indicated by an increased secretory 86Rb net flux. In the highly differentiated colonic epithelial cell line HT-29/B6, TNF-alpha had no effect on Isc, suggesting a mediation step located in the subepithelium. This supposition was supported by measurements on totally stripped human tissues, since removal of subepithelial layers by total stripping reduced the TNF-alpha effect by 40%. Experiments with tetrodotoxin (10(-6)M) indicated that the TNF-alpha effect was not mediated by the enteric nervous system. The specific 5-lipoxygenase blocker ICI-230487 (5 x 10(-8)M) also had no effect on TNF-alpha action. In contrast, inhibition of cyclooxygenase by indomethacin (10(-6)M inhibited the effect of TNF-alpha. Radioimmunoassay of prostaglandin E2 (PGE2) in the serosal bathing solution revealed an increase in PGE2 production/release after addition of TNF-alpha, which paralleled the Isc response. We conclude that TNF-alpha changed Cl- and K+ transport toward secretion in human colon. This effect was mediated by PGE2 produced by subepithelial cells. Thus TNF-alpha could be a mediator of diarrhea during intestinal inflammation, e.g., in IBD and HIV infection.

Investigation of nifedipine absorption in different regions of the human gastrointestinal (GI) tract after simultaneous administration of 13C- and 12C-nifedipine

OBJECTIVE

To evaluate the absorption of nifedipine in man from four different sites of the gastrointestinal tract.

METHODS

On separate occasions, nifedipine solution was administered locally to the stomach, the small intestine and two sites in the colon in 4 healthy male volunteers (age 29-34 y weight 73-82 kg, non-smokers) using a remote controlled drug delivery device (HF-capsule). In order to assess absolute and relative bioavailabilities, an intravenous infusion was given on a separate occasion and all treatments were accompanied by a simultaneous oral dose of a stable-isotope labelled nifedipine solution. This allowed to minimise the influence of intra-individual variability. Plasma samples were collected up to 24 h post dose and faeces for 72 h. A new method of analysis of nifedipine in plasma and faeces using gas chromatography with mass-selective detection (GCMS) was employed.

RESULTS

Dissolved nifedipine was found to enter the systemic circulation completely along the intestine, being absorbed from jejunum to colon. Absorption was less rapid from the colon than from the upper part of the gut, but this was not associated with a decrease in absorption and/or bioavailability: Absolute bioavailability, calculated from the normalised AUC values, ranged from 42 to 56%, and bioavailability relative to oral solution was 100 to 126% (medians of the application sites).

CONCLUSION

The absence of an absorption window in the intestinal tract suggests that nifedipine is well suited for use in controlled-release formulations.

Evidence for vacuolar-type proton pumps in nonmitochondrial and inositol 1,4,5-trisphosphate-sensitive calcium stores of insulin-secreting cells

This study examines whether acidic, vacuolar-type, proton-pump-carrying organelles of insulin-secreting cells (clonal endocrine pancreatic cell line INS-1) function as rapidly exchanging, inositol 1,4,5-trisphosphate-sensitive calcium stores. Calcium uptake into calcium stores will be modulated by the proton concentration within the stores, since calcium pumps in general appear to mediate a countertransport of calcium with protons. We therefore tested for sensitivity of calcium sequestration by nonmitochondrial stores (inhibition of mitochondrial calcium uptake by 2 microM ruthenium red) in saponin-permeabilized cells to proton-conducting ionophores and proton pump inhibition, using this as a marker for involvement of acidic organelles. Calcium sequestration was partially inhibited by the protonophores nigericin (10-50 microM) and carbonylcyanide m-chlorophenylhydrazone (CCCP; 20-50 microM), as well as by inclusion of 30 mM NH4Cl. Bafilomycin A1, a potent and selective inhibitor of vacuolar-type proton pumps, alone (1 - 500 nM) had no effect on calcium sequestration. however, it induced an inhibitory effect in the presence of nigericin or CCCP, even at low concentrations (5 microM) of these ionophores, lacking itself an inhibitory action on calcium sequestration. Bafilomycin A1 then was already maximally active at a concentration as low as 10 nM. Corres ponding to inhibition of total nonmitochondrial calcium sequestration, filling of inositol 1,4,5-trisphosphate-sensitive stores was decreased or even abolished by the protonophores alone or the protonophores combined with bafilomycin A1. We conclude that vacuolar-type proton pumps are present in at least a part of nonmitochondrial and inositol 1,4,5-trisphosphate-sensitive calcium stores in INS-1 cells. This assigns these stores to organelles such as secretory granules, the trans Golgi network, or endosomes. Luminal acidity of these stores will stimulate calcium sequestration by providing more protons for countertransport of calcium by calcium pumps. High concentrations of protonophores may be required for inhibitory effects because otherwise the proton pumps may be able to compensate sufficiently for ionophore-mediated proton loss. The lack of effect of bafilomycin A1 without protonophores may be due to a sufficient luminal buffering capacity or to preceding inhibition of the pump by an inside-positive transmembrane potential.

Mean input times of three oral chlorprothixene formulations assessed by an enhanced least-squares deconvolution method

The efficacy and quality of drug formulations are determined mainly by their bioavailability, which is defined by the rate and extent of drug absorption. The zero and first moments of the serum concentration time profile provide relevant information on the bioavailability. On the basis of the body residence time distributions, mean input times may be used as drug absorption rate parameters, but due to computational errors the statistical moments procedure is in some instances of limited value. To circumvent these problems we have developed a procedure to calculate mean input times from input profiles obtained by least-squares deconvolution. We enhanced the performance of the deconvolution method by directly generating initial estimates of one input rate for each sampling interval and compared the statistical properties of various input rate characteristics using data from a bioavailability study on four chlorprothixene preparations. The analysis of variance revealed that estimates of mean input times depended on the calculation procedure. Mean input times estimated by the least-squares deconvolution method were more reliable and less variable than those computed as differences of mean body residence times.

Calcifying arteriopathy in the basal ganglia in human immunodeficiency virus infection

Echogenic stripes in the basal ganglia were identified sonographically in a 4-month-old infant with human immunodeficiency virus (HIV) infection. This lenticulostriate arteriopathy correlated well with histologically identified early alterations of HIV encephalopathy in children. At 3 years and 5 months, CT examination performed after three seizures showed calcification in the area of the sonographically affected arteries but no signs of progressive encephalopathy. The child's mental and motor development have remained normal until now. Cerebral sonography performed in early infancy may allow identification of HIV encephalopathy even before its clinical manifestation.

Follow-up of optic pathway gliomas in children with neurofibromatosis type 1

Optic pathway gliomas (OPG) are found in about 15% of patients with neurofibromatosis Type 1 (NF-1). The natural history of OPG is not yet well documented. Treatment in cases with growing tumors is still controversial. Twenty-one patients with NF-1 and OPG, diagnosed over a 20-year period, and followed neuroradiologically and ophthalmologically for at least two years, were reevaluated. The diagnosis of OPG was made at a mean age of 7.1 years (range 0-14.5 years); six children were asymptomatic, 15 were symptomatic. The mean follow-up was 9.0 years (2.0-18.5 (years). In eight initially operated or biopsied patients (three optic nerve and five chiasmal gliomas) tumor regrowth was found in one patient without progression on subsequent follow-up. Improvement of visual acuity occurred in one child after operation of a large suprasellar tumor and deterioration in one patient after biopsy of a chiasmal glioma. The neuroradiological follow-up of the 13 not-operated and not-radiated patients (four optic nerve and nine chiasmal gliomas) was stable in 10, progressive in three, resulting in visual loss in one patient. In 11 children (52%) a second tumor outside the optic pathway was found at a mean age of 4.0 years after the diagnosis of an OPG. Until now they are mostly asymptomatic. Second site tumors were operated in two children because of rapid tumor growth, one child died of a brainstem tumor. OPG are a frequent complication in children with NF-1, appearing within the first decade.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of halothane anesthesia on cerebral blood flow velocity in children]

The effects of halothane on the cerebral circulation were studied in 23 children during general anaesthesia. Blood flow velocity in one middle cerebral artery was recorded continuously by transcranial Doppler sonography. Furthermore arterial blood pressure, pulse rate, endtidal CO2partial pressure and endtidal halothane concentration were recorded. Mean flow velocities/mean arterial blood pressures were 79 cm x s-1/65 mmHg; 86 cm x s-1/61 mmHg; 78 cm x s-1/54 mmHg and 67 cm x s-1/48 mmHg with 1; 1.5; 2 and 2.5 per cent endtidal halothane concentrations, respectively. Endtidal CO2-partial pressure and pulse rate remained constant throughout the study. The higher cerebral blood flow velocities seen with 1.5 per cent halothane compared with 1 per cent can be explained by an increase in cerebral blood flow. The lower cerebral blood flow velocities and arterial blood pressure with 2.5 per cent halothane compared with 1.5 per cent indicate impaired cerebral autoregulation. However, cerebral blood flow appeared to be sufficient even with low arterial blood pressures.

Congenital tetraplegia, respiratory insufficiency, and hypoplasia of medulla oblongata

A term infant with normal delivery presented with congenital tetraplegia and respiratory insufficiency just after birth. Magnetic resonance tomography on days 8 and 72 of life revealed an extreme thinning of the lower medulla oblongata. Endoscopy confirmed this and demonstrated the presence of vascular anomalies around the lesion which were not detectable by angiography. It is presumed that this is a malformation of the lower medulla oblongata.

Bioanalytics of nimodipine--an overview of methods

The analytical test procedures currently established for the determination of the dihydropyridine calcium antagonist nimodipine in biological fluids are presented. Method of choice which has been dominantly used in pharmacokinetic investigations and drug interaction studies is gas chromatography with electron-capture detection (GC-ECD) subsequent to simple toluene extraction. The limit of quantification of 0.1 ng/ml in plasma conveniently allows to follow concentration/time profiles in the nano/subnanogram per ml-range after therapeutic doses. If not restricted by its markedly higher limit of quantification of approx. 1-5 ng/ml, high-performance liquid chromatography with either UV- or amperometric detection may be an attractive alternative for therapeutic drug monitoring or compliance control. A combined approach of HPLC and GC--chiral stationary-phase HPLC with GC-MS as off-line detection mode--has proven adequate and efficient to obtain pharmacokinetic data for nimodipine enantiomers after administration of the racemic drug.

[EEG changes in type I and type II lissencephaly]

Lissencephaly syndromes are rare disturbances of the neuronal migration with agyria and/or pachygyria. Typical patterns in the EEG of 5 children with lissencephaly are presented. Rhythmic alpha- or beta-waves with high amplitudes of diffuse or fronto-precentral localisation are characteristic in type I lissencephaly. In type II lissencephaly initially theta- or delta-waves of somewhat lower amplitude are observed. Sharp and slow wave-complexes of very high amplitude are found more often in type I lissencephaly. They seem to correlate with the severity of the brain malformation and the epilepsy. In both types of lissencephaly the spatial organisation of the background activity and the sleep-wake differentiation are absent. The EEG of most type I lissencephalies show no reactivity to intravenous benzodiazepines. With increasing age the frequency of the background activity and of the high amplitude rhythmic waves decrease in type I and increase in type II lissencephaly. A complete dedifferentiation of the EEG tracings has been observed in the course of type I lissencephaly. Lissencephaly is diagnosed by imaging techniques. However, with a high probability lissencephaly can be suspected already by its EEG.

Effects of laryngoscopy and tracheal intubation on cerebral and systemic haemodynamics in children under different protocols of anaesthesia

The effects of laryngoscopy and tracheal intubation on cerebral and systemic haemodynamics were studied in 30 children. The objective was to identify conditions in which the alterations of cerebral and systemic haemodynamics were minimal. The children were intubated after muscular relaxation and following 10 min of mechanical ventilation with end-tidal halothane concentrations of 1.5%, 2.0% and 2.5%, respectively. With 1.5%, 2.0% and 2.5% end-tidal halothane, the mean flow velocity increased by 26%, 19% and 5%, the mean blood pressure by 14%, 10% and 1%, and the heart rate by 26%, 8% and 5% respectively after intubation. Adverse effects of laryngoscopy and tracheal intubation on cerebral haemodynamics in children can be avoided by adequate anaesthetic protocols.

[Acute spinal syndromes in children and adolescents]

23 children with acute spinal syndromes are presented. The clinical signs were caused by trauma in 11 patients, by extramedullary tumors in 6, by operations (coarctation of the aorta, scoliosis) in 4 and by encephalomyelitis in 2. Motor signs (flaccid paraplegia or paraparesis, monoplegia, bilateral weakness) and changes of reflex intensities were always observed. Most children presented with disturbances of sensory functions and micturition, some exhibited ataxia. In addition to the neurological signs, plain films of the spine were of diagnostic importance after trauma, for tumors myelography and/or computerized tomography were most useful. The unfavourable prognosis of posttraumatic paraplegia may be improved by early application of corticosteroids in very high doses. The value of GM1-ganglioside is controversial. In cases of external compression by tumors a decompression of the spinal cord is urgent. "Spinal cord monitoring" can be used intraoperatively in surgery of scoliosis and coarctation of the aorta to detect neurological complications early. Differential diagnosis and therapies of encephalomyelitis and Guillain-Barré-Syndrome are discussed.

[Lissencephalia syndromes]

Lissencephaly is in most cases a genetic anomaly of the brain development with agyria and/or pachygyria. It causes severe psychomotor retardation and epilepsy, which is often resistant to therapy. Some patients with type-I lissencephaly show cranial and facial dysmorphism and a deletion of chromosome 17p13.3 (Miller-Dieker syndrome). The isolated lissencephaly sequence occurs without these features. Patients with type-II lissencephaly present additional malformations of the posterior fossa and of the eyes (Walker-Warburg syndrome) and in some cases muscular dystrophy (cerebro-oculomuscular syndrome). Lissencephaly can be suspected with a high probability by its typical EEG. It is proved by imaging techniques. Therapeutic success is limited, the life expectancy is strongly reduced.

Intracranial blood flow velocities during seizures and generalized epileptic discharges

In 51 children with different types of epilepsy, blood flow velocities in the middle cerebral artery were recorded continuously by transcranial Doppler sonography during a standard electroencephalogram of 30 min duration. In 16 children 33 epileptic seizures were recorded. During tonic seizures, the mean flow velocity increased to a maximum of 133%-191% (median 160%) of the baseline values. Tonic-clonic seizures were also accompanied by a velocity increase. During absence seizures the mean flow velocity decreased to a minimum of 46%-82% (median 71%) of the baseline values. Changes in cerebral metabolism and arterial blood pressure in the presence of disturbed autoregulation are thought to be factors causing these alterations. No alteration of the flow velocities occurred in cases of petit-mal status, electrical status epilepticus and in 35 children with generalized epileptic discharges of up to 5 s duration without clinical manifestations.

Conservation of the prohormone convertase gene family in metazoa: analysis of cDNAs encoding a PC3-like protein from hydra

A subclass of proteolytic enzymes that correctly cleave precursor proteins at paired basic residues and are structurally related to the bacterial subtilisins has recently been identified. In yeast, a single membrane-bound proteolytic processing enzyme encoded by the kex2 gene has been found, whereas in higher vertebrates cDNAs encoding four distinct enzymes (PC2, PC3, furin, and PACE 4) have been identified. Like kex2, furin (also known as PACE) contains a hydrophobic transmembrane domain, but PC2, PC3, and PACE 4 lack this feature. All five enzymes exhibit striking similarities in their catalytic domains, and this suggests that they have arisen from a common ancestral subtilisin-like gene. We report here the identification of cDNAs encoding a protein that is similar in structure to PC3 from a simple metazoan, Hydra vulgaris (formerly Hydra attenuata). cDNAs encoding two isoforms of this PC3-like enzyme were obtained that differ only in their carboxyl-terminal sequences, probably due to alternative splicing of a common pre-mRNA. Neither form contains a transmembrane domain. Predicted amino acid sequence comparisons revealed that the hydra PC3-like enzyme is 55.4% and 56.7% identical in the catalytic domain to mouse PC3 and human furin, respectively. RNA blot analyses revealed that the PC3-like RNA is expressed predominantly in the hydra body column and not in the head region, although the hydra head contains a high density of nerve cells, which synthesize a variety of neuropeptides. For this reason, we suspect that another proprotein cleavage enzyme isoform may be expressed in head nerve cells. The isolation of a PC3-like cDNA from hydra is consistent with the presence of neuroendocrine cells and indicates that the PC/furin gene family has been well conserved in all metazoa. A simplified nomenclature for the group of mammalian processing proteases is proposed.

Abnormal cerebral hemodynamics during attacks of alternating hemiplegia

Frequent episodes of bilateral weakness and apathy, followed later by hemiplegia of alternating sides were observed in a now 32-month-old girl. Transcranial Doppler ultrasonography showed reduced flow velocities in the middle cerebral artery of the affected side during a hemiplegic attack and increased flow velocities at different sites of the basilar artery during a bilateral episode. These abnormal cerebral hemodynamics appear to indicate that alternating hemiplegia and some forms of migraine have a similar pathophysiology.

[Cerebral Doppler measurements in risk newborn infants do not have a prognostic value]

PROBLEM

The prognostic value of cerebral doppler for the neonatal and the developmental prognosis was studied.

METHODS

A prospective longitudinal study on 175 newborns at risk was performed. The blood flow velocities were recorded transcranially in the middle cerebral, posterior cerebral and internal carotid artery on day 1, 3-5 and 8-10 of life. Neonatal mortality and cerebral sonography gave the criteria for neonatal prognosis. Developmental prognosis was determined at a corrected age of 9 months by neurological examination and Griffth's test.

RESULTS

In 60 neonates abnormal flow velocities were obtained at least at one recording. Ultrasound revealed cerebral hemorrhage in 20, hypoxic-ischemic encephalopathy in 5 children. 14 infants died during the neonatal period, 5 in the following months. Premature babies with birth weights below 1501 g and abnormal flow velocities presented more cerebral hemorrhages and deaths than those with normal flow velocities. At the age of 9 months a slight handicap was observed in 10, a severe handicap in 6 of the surviving 156 infants. The majority of infants with abnormal neonatal doppler-recording had a normal neurodevelopmental status.

CONSEQUENCE

Cerebral doppler seems to be of little value to determine the prognosis of newborns at risk.

[Children of drug-dependent mothers--personal experiences and review of the literature]

The increasing incidence of drug abuse in central Europe leads to a growing number of children with intrauterine drug exposure. During pregnancy various risks affect these children. Postnatally severe symptoms of withdrawal are observed frequently. The psychosocial development is endangered. Between 1986 and 1990 30 drug dependent women attended the obstetric department of the University Hospital Basel during pregnancy. The data of 21 children born to mothers drug dependent at birth were evaluated. 11 children were born in 1990. 12 mothers received Methadon, 10 were polydrug abusers. Positive serology was found for hepatitis in 18, for HIV-infection in 9 women. 6 babies were premature, 8 were small for gestational age. 20 newborns presented withdrawal symptoms which required a mean hospitalization time of 45 days. Tonic and/or clonic seizures were observed in 6 neonates. In 9 other children some symptoms were suspicious of seizures. EEG recordings were pathological in 10 of 12 infants. For the control of withdrawal symptoms 16 children received pharmacological treatment for a mean duration of 61 days. Neurodevelopmental examinations were performed in 14 children at an average age of 22 months. Neurological findings were pathological in 2 children. 3 had mild, 2 had severe mental retardation, 5 presented with behavioural disturbances. Our data are compared with those of the literature. Therapeutic proposals for children of drug dependent mothers are presented. The impact of methadon programs on the exposed children is discussed.

[Successful multiple resuscitation in flecainide poisoning]

After a family quarrel a 37-year-old woman swallowed, with suicidal intent, a large number of flecainide tablets (exact amount unknown) together with alcohol. On admission to hospital some hours later her pupils were fully dilated, fixed and of irregular outline; she was unconscious and in cardiorespiratory failure. Nine hours after admission several episodes of ventricular fibrillation and asystole occurred, two of them lasting for 2 and 3 hours, respectively, before successful resuscitation (after defibrillation). The highest plasma flecainide level, between 3 and 10 hours after swallowing the drug, was 6160 ng/ml, i.e. six times the maximal therapeutic level. Under the influence of flecainide the ECG of the previously healthy woman had shown idioventricular rhythm with marked QRS widening and Q-T prolongation. The tachyarrhythmias, at times torsades de pointes, were successfully treated with high doses of lidocaine (4 g daily) after repeated defibrillations. As a late complication the patient went into acute left ventricular failure with pulmonary edema and pneumonia. There were no recognizable permanent sequelae on discharge 37 days after admission.

[Aspects of cerebral circulation in children]

Investigation of cerebral circulation represents an essential diagnostic adjunct to pediatric neurology. Doppler-sonography is presented as one of the diverse techniques to examine cerebral hemodynamics. The human cerebral circulation is controlled by autoregulatory mechanisms. Factors such as hematocrit, pulse, orthostasis and physical activity modulate the cerebral blood supply. The demand for blood depends essentially on arterial pCO2 but also on behavioural situations such as mental activity, effect of sensory stimuli or sleep. Bioelectric activity and perfusion of the central nervous system are closely linked. The cerebral perfusion in infants is characterized by a rapid increase in flow over the first couple of years to values exceeding those of adults. Disturbances of the cerebral perfusion are found in a variety of pediatric diseases. The patterns of perinatal brain damage depend on the maturity of the newborn. They are mainly sequels of impaired cerebral perfusion. In prematures periventricular leukomalacia and intracerebral hemorrhage are frequent whereas in infants at term cerebral edema and infarcts are more common. Acute hemiplegia in childhood can be of thromboembolic or vascular origin, however of etiologies different from those in adulthood. Prevention is the best treatment for disturbances of cerebral perfusion in childhood. Continuous monitoring techniques and pharmacotherapy need further clinical investigation.

Non calcific vasculopathy in the basal ganglia

Stripes of high echogenicity in the basal ganglia of infants have been rarely observed on cerebral ultrasound. These lesions, which appear to be due to a non calcific vasculopathy, are caused, in the majority of cases, by congenital infections and trisomy 13. We describe four infants with the characteristic ultrasonic appearance of this vasculopathy. Two children had cytomegalovirus (CMV) infection, one a human immunodeficiency virus (HIV) infection. The fourth child who presented a malformation of the skull and eye anomalies had no definitive diagnosis. Of the three surviving children one was developing normally. One had mild and one severe psychomotor retardation.

Cerebral blood flow velocities during orthostasis and physical exercise

The peak flow velocities in the middle cerebral artery were continuously recorded by transcranial Doppler sonography in 29 children. Arterial blood pressure and heart rates were measured every minute. The values observed during orthostasis and physical exercise were compared to baseline values obtained in the supine position. During orthostasis the velocities were, on average, reduced to 87%-94%, the minimal values being 75%-78% of the baseline values. The heart rate increased whereas blood pressure showed only minor alterations. Upon standing up the systolic peak flow velocity remained unchanged while the mean- and enddiastolic peak flow velocities decreased to 66% and 39% respectively. On average, the velocities increased to 103%-108% during physical exercise. Systolic blood pressure increased to the same extent, the heart rate even more. Continuous recording of cerebral blood flow velocities may be more useful than intermittent measurements of blood pressure to differentiate children with and without symptoms of orthostasis.

[Brain circulation in residual cerebral damage. A Doppler ultrasound study]

Transcranial Doppler recordings of flow velocities in 5 cerebral arteries were performed in children with cerebral palsy or with focal epileptic discharges. In 22 children with severe bilateral cerebral palsy as an average the flow velocities were 55% of the norm. In 8 of 10 children with spastic hemiplegia, the velocities were reduced at least in one artery of the affected side. 7 of 11 children with a mixed focus and 4 of 18 children with a pure epileptic focus in the EEG presented reduced velocities within the artery belonging to the focus. The results and other studies indicate a reduced cerebral blood flow in severe cerebral palsy with may be caused by vascular, metabolic, bioelectric or pharmacologic factors.

[Translocation trisomy 4q in 2 siblings as a sequela of paternal balanced reciprocal translocation: t(1;4)(q44;q31)]

In a sister and a brother with striking similarity of facial dysplasias, severe disturbance of expressive speech, and mild mental retardation a partial trisomy of the long arm of chromosome 4 was identified as cause of these anomalies. The partial trisomy 4q was due to a balanced translocation between the chromosomes 1 and 4 in the father of both children.

[An unusual "tumor-like finding" between the head of the pancreas and the duodenal wall]

A 48-year-old woman complained of right-sided upper abdominal pain and recurrent vomiting, and had lost 10 kg in 4 months. Ultrasound and computed tomography showed a solid, space-occupying lesion in the head of the pancreas, not separable from the duodenum. Despite thorough investigation the nature of the lesion remained obscure. Operation revealed a divided pancreas with stenosis of the accessory duct at the papilla. Histological examination showed pseudosarcomatous myofibroblastic proliferation within the duodenal wall in the vicinity of a duodenal wall cyst which had been destroyed by inflammation. In cases of divided pancreas it is the accessory duct which drains the main bulk of the pancreas, while the main duct carries little or no secretion; the stenosis of the accessory duct in this patient had therefore led to low-grade pancreatitis involving the head of the pancreas.

Origin of the left coronary artery from the right pulmonary artery and ventricular septal defect in a child of a mother with raised plasma phenylalanine concentrations throughout pregnancy

A child with anomalous origin of the left coronary artery from the right pulmonary artery, ventricular septal defect, fetal growth retardation, and facial abnormalities was born to a woman in whom plasma phenylalanine concentrations had been raised throughout pregnancy. The cardiac abnormalities were diagnosed by angiography when the child was eight months old. The anomalous coronary artery was imaged in a subsequent echocardiogram. Development retardation was caused by maternal phenylketonuria, which may also have been responsible for the development of the ventricular septal defect and the coronary anomaly. If dietary treatment of the mother had been started before pregnancy damage to the child might have been prevented.