Deep intronic NIPBL de novo mutations and differential diagnoses revealed by whole genome and RNA sequencing in Cornelia de Lange syndrome patients

Cornelia de Lange syndrome (CdLS; MIM# 122470) is a rare developmental disorder. Pathogenic variants in 5 genes explain approximately 50% cases, leaving the other 50% unsolved. We performed whole genome sequencing (WGS) ± RNA sequencing (RNA-seq) in 5 unsolved trios fulfilling the following criteria: (i) clinical diagnosis of classic CdLS, (ii) negative gene panel sequencing from blood and saliva-isolated DNA, (iii) unaffected parents' DNA samples available and (iv) proband's blood-isolated RNA available. A pathogenic de novo mutation (DNM) was observed in a CdLS differential diagnosis gene in 3/5 patients, namely POU3F3, SPEN, and TAF1. In the other two, we identified two distinct deep intronic DNM in NIPBL predicted to create a novel splice site. RT-PCRs and RNA-Seq showed aberrant transcripts leading to the creation of a novel frameshift exon. Our findings suggest the relevance of WGS in unsolved suspected CdLS cases and that deep intronic variants may account for a proportion of them.

POS0474 ACTIVATION AND HYPERSENSITIZATION OF THE ANGIOTENSIN II TYPE 1 AND ENDOTHELIN-1 TYPE A RECEPTORS BY AGONISTIC AUTOANTIBODIES CONTRIBUTES TO VASCULAR INJURY IN SCLERODERMA RENAL CRISIS

Background

Scleroderma renal crisis (SRC) is a vascular complication of systemic sclerosis (SSc) with substantial risks for end-stage renal disease and death. Activating autoantibodies (Abs) targeting the angiotensin II type 1 (AT1R) and the endothelin-1 type A receptor (ETAR) are suggested to contribute to the vasculopathy in SSc (1, 2).

Objectives

Here, we sought to determine their pathogenic significance for acute renal vascular injury.

Methods

IgG from patients with SRC was studied for AT1R and ETAR dependent biologic effects on isolated rat renal interlobar arteries and vascular cells including contraction, signaling, and mechanisms of receptor activation. A cohort of ten patients with refractory SRC received multimodal treatment including AT1R and ETAR inhibition and plasma exchange and was followed for improvement of kidney function.

Results

In myography experiments, patient IgG exerted vasoconstriction (mean 6.5% of KCl induced contraction [95% confidence interval (95 CI) 5.0-8.1]) whereas control IgG did not (0.6% [95 CI 0.3-1.0]). The response was sensitive to inhibition of AT1R (3.0% [95% CI 1.4-4.7]) and ETAR (1.0% [95 CI 0.6-1.3]) and relied on MEK-ERK signaling. Contraction induced by angiotensin II and endothelin-1 was amplified by anti-AT1R and anti-ETAR Abs with substantial crosstalk between both receptors implicating autoimmune receptor hypersensitization. Co-immunoprecipitation experiments indicated heterodimerization between both receptor types enabling functional interrelation by structural interactions. 30% of patients with refractory SRC had improved kidney function after multimodal therapy.

Conclusion

We provide experimental and clinical evidence that agonistic Abs may contribute to SRC. Novel therapies targeted at autoimmune hyperactivation of AT1R and ETAR might improve outcomes in severe cases of SRC.

References

[1]Riemekasten, G. et al. Involvement of functional autoantibodies against vascular receptors in systemic sclerosis. Ann. Rheum. Dis. 70, 530–536 (2011).

[2]Becker, M. O. et al. Vascular receptor autoantibodies in pulmonary arterial hypertension associated with systemic sclerosis. Am. J. Respir. Crit. Care Med. 190, 808–817 (2014).

Figure 1.

Contraction of isolated rat renal interlobar arteries in response to IgG isolated from patients with scleroderma renal crisis (SRC) is dependent on angiotensin II typ 1 (AT1R) and endothelin-1 type A receptors (ETAR). Small vessel myography of artery rings exposed to (a) different concentrations of IgG isolated from healthy controls (Control IgG) or patients with SRC (SRC IgG). n = 12. *P<0.001 for SRC IgG versus Control IgG, #P<0.01 for 1.0 mg/mL versus 0.25 mg/mL and P<0.05 for 1.0 mg/mL versus 0.5 mg/mL. (b) Myography of vessels exposed to 1.0 mg/mL Control IgG or SRC IgG after pretreatment with an AT1R blocker (AT1RB, valsartan), an ETAR blocker (ETARB, sitaxsentan) or a dual endothelin-1 type A and type B receptor blocker (ETA/BRB, bosentan). n = 12. **P<0.01, ***P<0.001. Contraction is expressed as % of the maximal contraction in response to 60 mM KCl of each individual vessel. Mean±SEM.

Figure 2.

Interdependence of the angiotensin II (AngII) type 1 receptor (AT1R) and endothelin-1 (ET-1) receptors (ETA/BR) in the contractile response of isolated rat renal interlobar arteries to AngII and ET-1 in the presence of anti- AT1R and anti-ETAR activating autoantibodies.

Small vessel myography of artery rings exposed to 1.0 mg/mL IgG isolated from healthy controls (Control IgG) or patients with scleroderma renal crisis (SRC IgG) and natural ligands with and without pretreatment with receptor blockers as indicated. (a) Additional stimulation with 1000 nM AngII ± ETA/BR blocker (ETA/BRB) bosentan. n = 11-18. (b) Additional stimulation with 100 nM ET-1 ± AT1R blocker (AT1RB) valsartan. n = 6-12. Contraction is expressed as % of the maximal contraction in response to 60 mM KCl of each individual vessel. Mean±SEM. **P<0.01, ***P<0.001.

Disclosure of Interests

None declared.

Study of the influence of alcohol on the photostability of four UV filters

OBJECTIVE

Spray formulations are currently under development in the field of topical photoprotection. Such forms are characterized by their high fluidity, a property that is obtained by the presence of alcohol in the formula. The purpose of this work was to study the influence of ethanol in sunscreens on the photoprotective efficacy as well as the photostability of UV filters.

MATERIALS AND METHODS

The filters tested were octyl methoxycinnamate (OMC), PEG-25 PABA, octyl salicylate and butyl methoxydibenzoylmethane (BMDBM) at their maximum concentration authorized by European regulations and in the presence of increasing amounts of alcohol, up to 15% (w/w).

RESULTS

The effect of the presence of alcohol on the efficacy of the filters and their photostability varies depending on the molecule considered. Alcohol has no effect on octyl salicylate, either on its efficacy or its photostability. However, filter stabilization is seen for BMDBM and PEG-25 PABA.

CONCLUSIONS

Although these differences are significant, they are not great enough to justify large-scale use of ethanol in sunscreen products due to some of its properties, such as flammability.

Type I interferon response and vascular alteration in chilblain-like lesions during the COVID-19 outbreak

Background

The outbreak of chilblain‐like lesions (CLL) during the COVID‐19 pandemic has been reported extensively, potentially related to SARS‐CoV‐2 infection, yet its underlying pathophysiology is unclear.

Objectives

To study skin and blood endothelial and immune system activation in CLL in comparison with healthy controls and seasonal chilblains (SC), defined as cold‐induced sporadic chilblains occurring during 2015 and 2019 with exclusion of chilblain lupus.

Methods

This observational study was conducted during 9–16 April 2020 at Saint‐Louis Hospital, Paris, France. All patients referred with CLL seen during this period of the COVID‐19 pandemic were included in this study. We excluded patients with a history of chilblains or chilblain lupus. Fifty patients were included.

Results

Histological patterns were similar and transcriptomic signatures overlapped in both the CLL and SC groups, with type I interferon polarization and a cytotoxic–natural killer gene signature. CLL were characterized by higher IgA tissue deposition and more significant transcriptomic activation of complement and angiogenesis factors compared with SC. We observed in CLL a systemic immune response associated with IgA antineutrophil cytoplasmic antibodies in 73% of patients, and elevated type I interferon blood signature in comparison with healthy controls. Finally, using blood biomarkers related to endothelial dysfunction and activation, and to angiogenesis or endothelial progenitor cell mobilization, we confirmed endothelial dysfunction in CLL.

Conclusions

Our findings support an activation loop in the skin in CLL associated with endothelial alteration and immune infiltration of cytotoxic and type I IFN‐polarized cells leading to clinical manifestations.

Impact à long terme du COVID-19 chez les patients dialysés

Introduction

Les patients dialysés présentent un risque important de forme sévère de COVID-19 avec une mortalité élevée à la phase initiale. Cependant, les conséquences à long terme de cette pathologie dans cette population sont peu décrites. Nous rapportons ici le suivi à long terme des patients en hémodialyse, touchés par le COVID-19.

Description

Il s’agit d’une étude rétrospective sur patients dialysés affectés par le COVID-19 dans 19 centres de la région parisienne.

Méthodes

L’analyse concerne la description de la présentation clinique et du suivi à long terme de ces patients.

Résultats

Dans cette cohorte de 248 patients avec un taux de mortalité initial de 18 %, l’âge, les comorbidités, la dyspnée et un traitement immunosuppresseur antérieur étaient associés au décès dans les 30 premiers jours. Parmi les 203 patients survivants après la phase aiguë, le suivi à long terme (médiane 180 jours) était disponible pour 189 (93 %) patients. Des complications majeurs (cardiovasculaires, infections sévères ou tout autre événement menant à une hospitalisation) sont survenues chez 30 (16 %) patients au cours du suivi, dont 12 décès (6 %) après une médiane de 78 jours à compter de l’apparition des symptômes. Un âge plus avancé, un taux d’albumine plus faible au moment du diagnostic et des comorbidités cardiovasculaires présentaient des tendances d’association avec le décès à long terme. Dans l’ensemble, les événements cardiovasculaires, les infections et les hémorragies gastro-intestinales ont été les principales complications. Une cachexie post-COVID-19 a été observée chez 25/189 (13 %) patients. Une albuminémie initiale plus faible était significativement associée à ce syndrome. Aucune réinfection par le SARS-CoV-2 n’a été observée sur la période de 6 mois.

Conclusion

Ce travail montre les conséquences à long terme du COVID-19 chez les patients dialysés, mettant en évidence la sévérité initiale et à long terme de la maladie, associé notamment à une cachexie chez 13 % des patients.

Bi-allelic variants in IPO8 cause a connective tissue disorder associated with cardiovascular defects, skeletal abnormalities, and immune dysregulation

Dysregulated transforming growth factor TGF-β signaling underlies the pathogenesis of genetic disorders affecting the connective tissue such as Loeys-Dietz syndrome. Here, we report 12 individuals with bi-allelic loss-of-function variants in IPO8 who presented with a syndromic association characterized by cardio-vascular anomalies, joint hyperlaxity, and various degree of dysmorphic features and developmental delay as well as immune dysregulation; the individuals were from nine unrelated families. Importin 8 belongs to the karyopherin family of nuclear transport receptors and was previously shown to mediate TGF-β-dependent SMADs trafficking to the nucleus in vitro. The important in vivo role of IPO8 in pSMAD nuclear translocation was demonstrated by CRISPR/Cas9-mediated inactivation in zebrafish. Consistent with IPO8’s role in BMP/TGF-β signaling, ipo8^−/− zebrafish presented mild to severe dorso-ventral patterning defects during early embryonic development. Moreover, ipo8^−/− zebrafish displayed severe cardiovascular and skeletal defects that mirrored the human phenotype. Our work thus provides evidence that IPO8 plays a critical and non-redundant role in TGF-β signaling during development and reinforces the existing link between TGF-β signaling and connective tissue defects.

Data on diabetes from the French cohort study in schizophrenia

To establish the impact of antipsychotic medication on the incidence of diabetes, we have analysed data from the prospective French Cohort study of mortality in schizophrenia. This generated a large database of 3470 patients with schizophrenia initially enrolled in 1993 for which data collection on comorbidity has been collected systematically every three years since. The primary objective of the study was to evaluate the mortality rate in the study cohort. From this database, the prevalence and incidence of diabetes can be studied. In 1993, nine patients in 10 were prescribed conventional antipsychotics and the remainder amisulpride and clozapine. Since the introduction of risperidone and olanzapine, atypical antipsychotics are now used in one-third of patients. Multiple antipsychotic medications are used in many patients, with the exception of those receiving clozapine. At inclusion, 2.2% of patients in the study cohort had a diagnosis of diabetes. Morbidity rates were higher in females than in males (3.4% and 1.6%, respectively) and it was only in females that the standard morbidity ratio with respect to the general population was significantly elevated (2.2; 95% confidence intervals: 1.6 and 2.9). The prevalence of diabetes in the study cohort rose over the course of the study. Multivariate regression analysis was performed in order to identify potential determinants of diabetes. For pre-existing diabetes, four factors were identified: age at first hospitalisation, age, obesity and duration of schizophrenia. The same factors with the exception of length of illness were identified for the incident cases. There was no evidence for an interaction between the class and type of antipsychotic medication and risk of treatment emergent diabetes. However, the use of multiple antipsychotic treatments makes the individualisation of specific risks associated with any other antipsychotic drug impossible.

Schizophrenic patients: physical health and access to somatic care

This study concerns the state of physical health and the availability of somatic care for 3,470 adult patients diagnosed as schizophrenic according to the research criteria established by the International Classification of Diseases (ICD-10 F20) and treated in public institutions. These institutions volunteered to participate in the study, whereas the patients were selected at random. Data concerning demographic characteristics, physical health, and access to somatic care are compared to that of a public health survey of a sample of the French population. The present study allows the estimation of ratios for a large number of diseases and of some risk factors among the target group. Heavy smokers and overweight individuals are more numerous among schizophrenics. Pathologies such as epilepsy, diabetes and AIDS infection are overrepresented. Patients' access to somatic care is more prevalent than that of the general population overall, similar to that of the less qualified workers or unemployed group. In this study, gender does not appear to allow prediction of care use for schizophrenics in contrast to the general population.

Study of the influence of substrate and spectrophotometer characteristics on the in vitro measurement of sunscreens efficiency

All the methods used for the in vitro measurement of the SPF, the universal indicator of sunscreens efficiency, rely on a spectrophotometric analysis. What can vary about the experimental protocol used is mainly the substrate and the type of spectrophotometer chosen. We decided to work with polymethylmetacrylate plates that we analyzed using two spectrophotometers equipped with integrating spheres, the UV1000S and the UV2000 apparatus. Two marketed products were such tested, after spreading 2 mg/cm² on the plates, using one apparatus after another. We applied a non-parametric Wilcoxon test for paired data to the measures realized on 10 plates (as we systematically used the 2 apparatus), in order to compare the series of measures obtained with the two machines. This way, we were able to show a significant difference between the SPF values respectively obtained with the UV1000S and the UV2000 spectrophotometers. This difference could be explained by the decrease of the stray light in the case of the UV2000 apparatus.

PDD-NOS, psychotic features and executive function deficits in a boy with proximal 22q11.2 microduplication: Evolution of the psychiatric symptom profile from childhood to adolescence

22q11.2 microduplication (22q11.2DupS) is associated with a broad spectrum of phenotypes, including normality. Psychiatric disorders are described in 13% of these patients, including Attention Deficit and Hyperactivity Disorder (ADHD), Intellectual Deficiency (ID), and Autism Spectrum Disorder (ASD), but not schizophrenia. We report changes in the psychiatric symptom profile in the course of development of a young boy with a 22q11.2DupS syndrome, from early childhood to adolescence. The boy's psychiatric presentation was characterized by features of Pervasive Developmental Disorder (PDD), with ADHD in early childhood, a single psychotic episode in mid-infancy, and executive impairment in adolescence. We discuss the importance of an in-depth assessment of cognitive functions in children with22q11.2DupS throughout their development.

[Left temporal arachnoid cyst and specific learning disorders associated with Pervasive Developmental Disorders - Not Otherwise Specified (PDD-NOS): contributions of an integrative neuropsychomotor, neuropsychological, psychopathological and neurosurgical approach about a case report in a child (François)]

Left temporal arachnoid cyst and specific learning disorders associated with pervasive developmental disorders - not otherwise specified (PDD-NOS): contributions of an integrative neuro-psychomotor, neuropsychological, psychopathological and neurosurgical approach about a case report in a child (François). With DSM-IV and DSM-IV-TR, the terminology of pervasive developmental disorders (PDD) covers two main categories of infantile disorders: disorders of "strictly" autistic nature and pervasive developmental disorders - not otherwise specified (PDD-NOS). Under the terminology of multiple complex developmental disorder (MCDD), it is proposed to classify children presenting symptoms approaching the psychotic disharmonies and usually diagnosed as PDD-NOS. Such a category of developmental disorders is now included without nosographic distinction in the autistic spectrum in the Diagnostic and Statistical Manual of mental disorders (DSM-V).

CASE REPORT

We are reporting a case report of a 6-year-old boy which shows a PDD-NoS/MCDD complex symptomatology type. This child presents multiple disorders: minor neurological signs (soft signs), neuro-psychomotor disorders, developmental coordination disorder (DCD), communication, thought, and regulation of emotions disorders, attention deficit disorders (ADD); in the presence of a high verbal intellectual potential, which makes it difficult to establish a clear diagnosis. A cerebral magnetic resonance imaging (MRI) was carried out due to the presence of minor neurological signs (soft signs) and of neurodevelopmental multiple disorders. The MRI revealed a voluminous arachnoid temporo-polar left cyst with a marked mass effect on the left temporal lobe.

DISCUSSION

A neurosurgical intervention allowed to observe the gradual disappearance of the specific symptomatology (in particular soft signs, neuro-psychomotor functions and autistic symptoms) secondary to the interference of the cyst's pressure with intracranial areas involving neurological and psychopathological abnormalities, underlying at the same time the reversibility of the disorders after decompression as demonstrated in some studies. There are always, with a quantitative and qualitative decrease, an emotional dysregulation, a DCD, an ADD as well as impairments in the executive functions.

CONCLUSION

This clinical case underlines the necessity of an evaluation in a transdisciplinary way and to follow the developmental evolution of the child in order to focus adapted therapeutics. Furthermore, with neurodevelopmental disorders not specified, it is important to examine the presence of soft signs with standardized neuro-psychomotor assessment, and then, to propose an MRI investigation. To our knowledge, this is the first report in the literature with a school age child of an unusual association between a temporal arachnoid cyst associated with PDD-NOS/MCDD.

On the peeling procedure applied to a Poisson point process

In this paper we focus on the asymptotic properties of the sequence of convex hulls which arise as a result of a peeling procedure applied to the convex hull generated by a Poisson point process. Processes of the considered type are tightly connected with empirical point processes and stable random vectors. Results are given about the limit shape of the convex hulls in the case of a discrete spectral measure. We give some numerical experiments to illustrate the peeling procedure for a larger class of Poisson point processes.

An efficient scheme for sampling fast dynamics at a low average data acquisition rate

We introduce a temporal scheme for data sampling, based on a variable delay between two successive data acquisitions. The scheme is designed so as to reduce the average data flow rate, while still retaining the information on the data evolution on fast time scales. The practical implementation of the scheme is discussed and demonstrated in light scattering and microscopy experiments that probe the dynamics of colloidal suspensions using CMOS or CCD cameras as detectors.

Genetic counselling difficulties and ethical implications of incidental findings from array-CGH: a 7-year national survey

Microarray-based comparative genomic hybridization (aCGH) is commonly used in diagnosing patients with intellectual disability (ID) with or without congenital malformation. Because aCGH interrogates with the whole genome, there is a risk of being confronted with incidental findings (IF). In order to anticipate the ethical issues of IF with the generalization of new genome-wide analysis technologies, we questioned French clinicians and cytogeneticists about the situations they have faced regarding IF from aCGH. Sixty-five IF were reported. Forty corresponded to autosomal dominant diseases with incomplete penetrance, 7 to autosomal dominant diseases with complete penetrance, 14 to X-linked diseases, and 4 were heterozygotes for autosomal recessive diseases with a high prevalence of heterozygotes in the population. Therapeutic/preventive measures or genetic counselling could be argued for all cases except four. These four IF were intentionally not returned to the patients. Clinicians reported difficulties in returning the results in 29% of the cases, mainly when the question of IF had not been anticipated. Indeed, at the time of the investigation, only 48% of the clinicians used consents mentioning the risk of IF. With the emergence of new technologies, there is a need to report such national experiences; they show the importance of pre-test information on IF.

Autisme, TED, TSA : faut-il sauver Kanner ?

Un chercheur qui se destine aujourd’hui à travailler sur l’autisme peut rapidement être dérouté par les données de la littérature. Qu’il s’agisse de l’évolution nosologique depuis Kanner jusqu’aux TSA du DSM V, de la flambée épidémiologique multipliant la prévalence par 20 en 20 ans ou des multiples hypothèses étio-pathogéniques, tous les ingrédients sont réunis pour décourager les meilleures volontés en dépit d’un nombre de publications toujours croissant autour de cette pathologie dont les contours cliniques fluctuants n’en suscitent pas moins un engouement, une médiatisation, et des investissements financiers importants. Les progrès des techniques d’analyse du génome permettent d’identifier de plus en plus d’anomalies génétiques, mais leur signification clinique ne va pas toujours de soi et suppose de nouvelles façons d’appréhender notre connaissance du génome. Si les études de grands groupes d’enfants autistes ne sont pas parvenues à identifier quelques gènes « majeurs », c’est soit qu’il n’en existe pas, soit que ces groupes comportent une hétérogénéité sous-jacente à leur apparente homogénéité clinique qui conduit à s’interroger sur les outils cliniques d’inclusion utilisés dans ces études. On peut aussi aborder le problème différemment. Plusieurs gènes impliqués dans des pathologies neurodéveloppementales ont été découverts à partir de familles informatives ou de quelques cas étudiés de façon approfondie. Cette démarche restitue au clinicien un rôle capital dans l’observation des manifestations cliniques qui aident progressivement à dessiner des configurations pertinentes. Lorsque un gène est identifié (SHANK3, SLC6A8…), l’observation minutieuse des patients rend accessible la description d’un « phénotype développemental » spécifique. Lorsque ce n’est pas le cas, l’exploration d’une famille informative est l’occasion de tester des hypothèses quant aux contours cliniques du trouble exploré et sa présentation sous la forme de phénotypes mineurs chez des apparentés. Si les constructions cliniques comportent une part d’illusion nécessaire pour orienter le travail de recherche, le tableau proposé par Kanner, distinct des nombreux TED non spécifiés rencontrés dans nos consultations, mérite probablement d’être encore étudié comme tel.

Skin necrosis due to fluindione treatment: a rare but serious complication

In the setting of protein C deficiency, skin necrosis, which occurs most often at the initial phase of oral anticoagulants therapy, is a rare side effect. Six cases have previously been reported in the literature. In this case report, we present a protein C deficient 42-year-old woman who was being treated for venous thrombosis. Five days after the initiation of oral anticoagulant treatment, she developed extensive skin necrosis on her left calf, followed by a painful leg ulcer. The pathogenesis underlying skin necrosis caused by anticoagulation therapy is still not clear. Despite only a few cases being reported in the literature, it is important to recognise this complication since adequate therapeutic approaches leading to a stable anticoagulation state may prevent it.

Pretransplant sensitization against angiotensin II type 1 receptor is a risk factor for acute rejection and graft loss

The angiotensin II type 1 receptor (AT1R) is an emerging target of functional non-HLA antibodies (Ab). We examined the potential of determining the degree of presensitization against AT1R as a risk factor for graft survival and acute rejection (AR). The study included 599 kidney recipients between 1998 and 2007. Serum samples were analyzed in a blinded fashion for anti-AT1R antibodies (AT1R-Abs) using a quantitative solid-phase assay. A threshold of AT1R-Ab levels was statistically determined at 10 U based on the time to graft failure. An extended Cox model determined risk factors for occurrence of graft failure and a first AR episode. AT1R-Abs >10 U were detected in 283 patients (47.2%) before transplantation. Patients who had a level of AT1R-Abs >10 U had a 2.6-fold higher risk of graft failure from 3 years posttransplantation onwards (p = 0.0005) and a 1.9-fold higher risk of experiencing an AR episode within the first 4 months of transplantation (p = 0.0393). Antibody-mediated rejection (AMR) accounted for 1/3 of AR, whereby 71.4% of them were associated with >10 U of pretransplant AT1R-Abs. Pretransplant anti-AT1R-Abs are an independent risk factor for long-term graft loss in association with a higher risk of early AR episodes.

fMRI investigation of visual change detection in adults with autism

People with autism spectrum disorders (ASD) may show unusual reactions to unexpected changes that appear in their environment. Although several studies have highlighted atypical auditory change processing in ASD, little is known in this disorder about the brain processes involved in visual automatic change detection. The present fMRI study was designed to localize brain activity elicited by unexpected visual changing stimuli in adults with ASD compared to controls. Twelve patients with ASD and 17 healthy adults participated in the experiment in which subjects were presented with a visual oddball sequence while performing a concurrent target detection task. Combined results across participants highlight the involvement of both occipital (BA 18/19) and frontal (BA 6/8) regions during visual change detection. However, adults with ASD display greater activity in the bilateral occipital cortex and in the anterior cingulate cortex (ACC) associated with smaller activation in the superior and middle frontal gyri than controls. A psychophysiological interaction (PPI) analysis was performed with ACC as the seed region and revealed greater functionally connectivity to sensory regions in ASD than in controls, but less connectivity to prefrontal and orbito-frontal cortices. Thus, compared to controls, larger sensory activation associated with reduced frontal activation was seen in ASD during automatic visual change detection. Atypical psychophysiological interactions between frontal and occipital regions were also found, congruent with the idea of atypical connectivity between these regions in ASD. The atypical involvement of the ACC in visual change detection can be related to abnormalities previously observed in the auditory modality, thus supporting the hypothesis of an altered general mechanism of change detection in patients with ASD that would underlie their unusual reaction to change.

Array-based comparative genomic hybridisation identifies high frequency of cryptic chromosomal rearrangements in patients with syndromic autism spectrum disorders

BACKGROUND

Autism spectrum disorders (ASD) refer to a broader group of neurobiological conditions, pervasive developmental disorders. They are characterised by a symptomatic triad associated with qualitative changes in social interactions, defect in communication abilities, and repetitive and stereotyped interests and activities. ASD is prevalent in 1 to 3 per 1000 people. Despite several arguments for a strong genetic contribution, the molecular basis of a most cases remains unexplained. About 5% of patients with autism have a chromosome abnormality visible with cytogenetic methods. The most frequent are 15q11-q13 duplication, 2q37 and 22q13.3 deletions. Many other chromosomal imbalances have been described. However, most of them remain undetectable using routine karyotype analysis, thus impeding diagnosis and genetic counselling.

METHODS AND RESULTS

29 patients presenting with syndromic ASD were investigated using a DNA microarray constructed from large insert clones spaced at approximately 1 Mb intervals across the genome. Eight clinically relevant rearrangements were identified in 8 (27.5%) patients: six deletions and two duplications. Altered segments ranged in size from 1.4 to 16 Mb (2-19 clones). No recurrent abnormality was identified.

CONCLUSION

These results clearly show that array comparative genomic hybridisation should be considered to be an essential aspect of the genetic analysis of patients with syndromic ASD. Moreover, besides their importance for diagnosis and genetic counselling, they may allow the delineation of new contiguous gene syndromes associated with ASD. Finally, the detailed molecular analysis of the rearranged regions may pave the way for the identification of new ASD genes.

Molecular cytogenetic analysis of five 2q37 deletions: refining the brachydactyly candidate region

Deletions of the 2q37 region are associated with a recognizable pattern of MCA/MR so-called the AHO-like syndrome. Brachydactyly is a variable but characteristic feature of this clinical entity. Here we report on five cases of cytogenetically visible de novo deletions of this 2q37 chromosome region. Using FISH, we characterized at the molecular level the breakpoints of these deletions using a set of 15 BACs, PACs and YACs. In four patients, terminal deletions of variable size ranged between 6.2 and 10 Mb. The fifth patient had an interstitial deletion with an AHO-like phenotype including brachydactyly. These findings when compared to previous observations allowed us to narrow down the brachydactyly critical region between BACs RP11-585E12 and RP11-351E10. It contains HDAC4 and STK25 candidate genes loci.

Analyse coût-efficacité des stratégies de prise en charge des patients schizophrènes : place d’un antipsychotique atypique sous forme injectable à libération prolongée

Schizophrenia is a disease affecting the young adults and amounts to approximately 300,000 people in France. The French public psychiatric sector takes care of approximately 150,000 adults schizophrenics: 50% benefit from ambulatory care, 50% are in partial or full-time hospitalization care. Schizophrenia represents the first diagnosis that psychiatric sectors take in charge. The costs associated with schizophrenia, mainly hospital costs, are important and were estimated at 2% of the total medical costs in France. In the French social welfare system, the social costs (pensions, allowances, managements of custody or guardianship by social workers) are also to be taken into account: it amounts to a third of the global direct cost. Schizophrenia also generates indirect costs (losses of productivity and premature deaths) which would be at least equal, or even more important, than direct medical costs. The non-compliance to the antipsychotic treatment is a major problem with people suffering from schizophrenia. Indeed the lack of compliance to the treatment, estimated at 20 to 40%, is a major handicap for schizophrenic patient stabilization. The poor level of compliance is due to many various causes: adverse effects that are considered unbearable, medicine viewed as persecutory, negation of the disease, nostalgia for the productive phases of the disease, lack of social support, complexity of the prescription, relapse itself. Compliance is thus influenced by the patient's clinical features, local provision of health care and the specific nature of the drug (adverse effects, pharmaceutical formulation). The atypical antipsychotics present fewer extrapyramidal side effects and reduce the cognitive deficits associated with the disease, which results in improved compliance. Long-acting injectable antipsychotics allow a better therapeutic compliance and thus better efficacy of the treatment. Several studies have shown a significant improvement in compliance related to the pharmaceutical formulation of antipsychotics. Hospitalization and relapse risks are lower in compliant than in non-compliant patients.

OBJECTIVES

The main objective of this pharmacoeconomic analysis is to evaluate the impact in terms of medical benefits and costs of the following strategies: 1. Risperidone long-acting injection: first long-acting injectable atypical antipsychotic; 2. Haloperidol depot: long-acting injectable conventional neuroleptic; 3. Olanzapine: atypical antipsychotic available commercially in oral formulation.

METHODS

The target population defined for the study are young schizophrenic patients treated for at least 1 year and whose disorder has not been diagnosed for longer than 5 years. The time horizon is 2 years. A cost-effectiveness analysis is performed. The perspective adopted is the French Health System. The main hypothesis of the model is that an increase in compliance linked to the use of long-acting injectable formulation could lead to an increased efficacy and a modification of the cost-effectiveness ratio. A decision tree was built. Six periods of follow-up are identified with a duration of 4-months per period. The tree contains 3 principal arms, each one corresponding to a specific treatment: risperidone LA injection, haloperidol decanoate and olanzapine. For each arm, at the chance node, two health states are identified: either the patient responds favourably to the treatment or does not respond favourably and requires a switch to another drug treatment. After a period of response, the patient can either remain in the same state or experiences a clinical deterioration. If the patient presents a clinical deterioration, he can either go back to a positive response state after a period of intensive follow-up or remain in an insufficient response state; in this case, a change of antipsychotic treatment is necessary. In the model, a patient should receive four different treatments before a long-term hospitalization takes put in place. According to the market authorization labelling, clozapine is proposed only as a 2nd or 3rd line therapeutic option, so when at least one or two successive neuroleptics have failed. The efficacy data used in the model are provided by clinical research recently published. These studies estimate the efficacy of oral risperidone, LA risperidone, olanzapine, and treatment by haloperidol. When available data in the literature were insufficient, the opinion of experts was sought. The effectiveness criteria is the rate of patients treated successfully: patients responding to the initial treatment with the possibility of experiencing one or two episodes of clinical deterioration but without requiring a switch to another drug during 2 years of follow-up. The base case is as follows: efficacy for oral risperidone is used for the LA risperidone strategy, increased by 10% within the first 4 months of follow-up; efficacy for oral haloperidol is used for haloperidol depot, increased by 5% within the first 4 months of follow-up; for olanzapine, observed data in clinical trials were applied. The hypotheses for long acting forms are rather conservative because the increase of efficacy which can be expected for the long-acting injectable formulations varies between 5% to more than 30% according to the literature data. The analysis of sensibility includes three scenarios: scenario 1: for LA risperidone, 5% of patients treated successfully improvement in regard to oral risperidone instead of 10% in the base case; scenario 2: for haloperidol depot, 10% of patients treated successfully improvement in regard of oral haloperidol instead of 5% in the base case; scenario 3: the results of an open trial conducted within the framework of the LA risperidone license are used, leading to an increase of up to 13,3% of the rate of successfully treated patients, compared to oral risperidone literature data. As for the side effects, only extrapyramidal symptoms were considered. Other side effects are described in the literature such as the obesity or the occurrence of a diabetes; these effects were not taken into account in the model, their impact on the cove-rage of schizophrenic patients and on resources utilisation being poorly known. Only direct medical costs were considered in the pharmaco-economic analysis. Two types of costs were identified: hospital costs and community care costs. The stays in overnight hospitalisation and day hospitalisation were derived from the Disease Related Groups (DRG) and valued from the data of the National Cost Study (Etude Nationale de Coûts; 1999). The DRGs corresponding to the diagnosis of schizophrenia are the DRG 627 (complete hospitalization) and DRG 819 (day hospitalisation). Ambulatory care: procedures and visits, were valued in euros in reference with the tariffs for reimbursement issued in the Naming General of the Professional Acts (NGAP) and published by the French National Health Insurance (Year 2001). Medication consumption was quantified by using the daily dosage specified in the the MAA and the French prescription database IMS-Dorema. The cost of medicines was valued from tariffs 2001 (SEMPEX). LA risperidone price being not fixed to date, the reserved hypothesis is a 141,62 Euro retail price. As schizophrenia is listed among the diseases reimbursed at a 100% rate by the Health insurance, out of pocket expenses by patient are not considered in the analysis. The cost for the extrapyramidal effects was attributed to all the strategies. This cost was calculated according to the rates of extrapyramidal effects occurrence collected in the literature. Globally, in the published studies, the incidence of the side effects for the patients treated by olanzapine or risperidone is similar. It was thus decided by the experts to use the same rate of occurrence for extrapyramidal effects for olanzapine and risperidone (20%). This rate is 40% for haloperidol decanoate, 10% for oral clozapine. For the cost estimation, the expenses for treating a schizophrenic patient for two years were taken into account.

RESULTS

The results show that in two years, LA risperidone is more effective than the two other antipsychotics. After 2 years, the rate of patients treated successfully is 82,7% for LA risperidone, 74,8% for olanzapine and 57,3% for haloperidol depot. The 2 year-cost per patient treated by LA risperidone is 14,055 Euro. This cost is 14,351 Euro and 17,203 Euro respectively for the strategies olanzapine and haloperidol depot. The cost-efficacy ratios per patient successfully treated are 16,995 Euro for the strategy LA risperidone, 19,186 Euro for olanzapine and 30,023 Euro for haloperidol depot. LA risperidone is a dominant strategy compared with both olanzapine and haloperidol depot. Scenario 1 shows that LA risperidone strategy remains the most effective. Indeed, this strategy allows a response increase of 3,5% regarding olanzapine strategy and of 21% regarding haloperidol depot strategy. Under the hypothesis tested in scenario 1, LA risperidone is a partial dominant strategy against olanzapine and a total dominant strategy against haloperidol depot. In scenario 2, as efficacy is improved for haloperidol decanoate (61,10%), a decrease of 1,763 Euro in the cost per patient treated is observed for this strategy. Cost per patient treated successfully and efficacy for LA risperidone and olanzapine are the same than in the base case. LA risperidone is a total dominant strategy against olanzapine and haloperidol decanoate. In scenario 3, the rate of patients treated successfully at 2 years is 88,6% for LA risperidone with a cost per patient of 12,347 Euro. LA risperidone is dominant against olanzapine and haloperidol depot.

DISCUSSION AND CONCLUSION

The schizophrenia is a relatively frequent disease. (ABSTRACT TRUNCATED)

Neurodevelopmental pattern of succinic semialdehyde dehydrogenase deficiency (gamma-hydroxybutyric aciduria)

Succinic semialdehyde dehydrogenase (SSADH deficiency) (MIM 271980) is a defect in gamma-aminobutyric acid catabolism, resulting in the accumulation of gamma-hydroxybutyric acid (GHB) and causing neurological and cognitive disorders of varying severity. The non-specific nature and the difficulties in detection of urinary GHB explain why this disorder is largely underdiagnosed. Of 350 patients identified worldwide, to date only six adults with SSADH deficiency have been reported in the literature. Here we describe two additional cases in brothers up to ages 26 and 28 years. This retrospective report sheds light on the clinical features of SSADH deficiency in relation to the physiopathological involvement of GHB, and tries to identify the specific neurodevelopmental pattern of this learning disability.* Features of this are: early impaired psychomotor development with hypotonia and disturbances in motor coordination; impaired development of language, mainly due to poor auditory perception; and seizures and psychotic features in late adolescence or adulthood. Moreover, narcolepsy-like symptoms could be a consistent feature of the disease.

Pharmaco-épidémiologie des pratiques de prescription d’antipsychotiques chez les patients schizophrènes (coupes transversales 1995 et 1998)

OBJECTIVE

The two cross-sectional surveys reported here concern the field of pharmaco-epidemiology of prescription practices. The objective is to describe and understand these practices in regard to antipsychotics and their evolution in all indications which go beyond the field of psychotic pathology. The research presented here only concerns schizophrenic pathology.

METHODOLOGY

These 2 cross-sectional surveys were carried out in public psychiatric sectors in 1995 and 1998 applying the same methodology in the same services. On a given day, in each sector, they concern all patients aged from 18 to 64 and receiving an antipsychotic prescription. A hospital unit and a consultation unit were included to take into account practices which could be different in these two places of care. A comparison was made between the 1995 stage and the 1998 one for a better understanding of evolution in practical terms. An unvaried analysis was carried out to test the differences observed between 1995 and 1998 as well as a correlation test to evaluate evolution according to age and duration.

RESULTS

The main results were as follows: the number of antipsychotics slightly decreased significantly from 1.74 (+/- 0.02) in the 1995 survey to 1.69 (+/- 0.04) in the 1998 one (p<0.05); the number of patients receiving antiparkinsonian medicines, correcting extra pyramidal effects, decreased from 60% in 1995 to 50% in 1998. The following associated factors were noted concerning prescription of antipsychotics. Women received a mean number of antipsychotics significantly lower than that of men. For each sex the mean number was lower in the 1998 survey, but not significantly so. In the two surveys, there was a positive correlation between the mean number of antipsychotics and age; it increased as the patient grew older. The mean number of antipsychotics tended to increase significantly with length of illness, in 1995 as well as in 1998. It was for the shortest periods that the mean number of antipsychotics was lowest. The mean number of antipsychotics was significantly higher in the hospital field as compared to the ambulatory. The greater was the mean number of antipsychotics, the greater was the proportion of patients who received antiparkinsonian medication. Firstly, these surveys shed light on what may underlie prescription practices such as sex and age of the patient, length of illness and the place of care. Secondly, the evolution of practices in time can be followed, taking into account the increase of knowledge concerning this subject.

[Suicide in the elderly at home and in retirement homes in France]

BACKGROUND

Suicide in the elderly attracts less attention that in the young. However it is more frequent among the former. The retirement home receives the populations most isolated from their families and those most vulnerable from a psychological and physical point of view. The aim of this research is to provide information concerning suicide in the elderly in France, to specify the means employed and to compare suicide rates at home and in retirement homes

METHODS

The statistics utilized are those of population size (censuses) and medical causes of death. With these latter causes a relation cannot be made between place of residence and place where the death by suicide is registered. They therefore underestimate suicide rates which are only considered at the home or retirement home. Consequently different estimations have been made.

RESULTS

Suicide rates are higher in the retirement home than at home for both sexes. However, for men, the suicide rates in retirement homes are similar to those recorded for isolated men living at home. On the contrary, for women, the retirement home seems to constitute a specific risk in itself with suicide rates quite distinct from the other situations studied. In the retirement homes, conversely to men, it is the youngest women, (65 to 74 years) who have the highest rates. Hanging is the most prevalent mean of suicide both at home and in the retirement homes. Jumping from a high place is the second mean utilized in the retirement homes where fire arms and consumption of substances are less represented

CONCLUSIONS

There are few studies in France concerning suicide in the elderly. Due to the demographic evolution, the number of suicides among the aged may well increase considerably in the years to come.

[Pharmaco-epidemiological study on antipsychotic drug prescription in French Psychiatry: Patient characteristics, antipsychotic treatment, and care management for schizophrenia]

In 2000, a one week national survey was conducted among 202 psychiatrists (129 participants) in France, from hospitals and clinics, private or public. The first 20 inpatients and 10 outpatients prescribed at least one antipsychotic drug (age range 18-65), were included. The diagnostic procedure was standardized with a structured interview: the Mini International Neuropsychiatric Interview (MINI). A total 2 068 patients were included, among whom 892 (43.1%) reached the criteria of schizophrenia according ICD-10. We present here data on these latter patients. Mean age was 38.8 years; with 38.8% females. Median duration of current antipsychotic treatment was 0.5 year in inpatients and 2 years in outpatients. Median duration of any antipsychotic treatment was 10 years, without difference between groups. Comorbid situations (anxiety disorder, depression and suicidal risk) were found in 33.1% of schizophrenic patients, with higher frequency among inpatients in private hospitals (54.8%) than in other groups. 46.8% patients were prescribed at least 2 neuroleptics, and 73.6% at least one non-neuroleptic drugs. Cyamemazine accounted for 16.6% of all neuroleptics drugs, and 56% of patients were prescribed an atypical antipsychotic (risperidone, olanzapine, amisulpride or clozapine). Atypical drugs accounted for 59.4% of patients who were prescribed only one neuroleptic drug. Inpatients had more neuroleptics coprescription than outpatients (mean 1.8 vs 1.4 drugs), with higher daily dose. In addition, inpatients had more other psychotropics prescribed (mean 1.5 vs 1.1 drugs). Overall, more other psychotropic drugs were prescribed among patients with -, than those without - comorbid situations (1.7 vs 1.2 drugs). Median time since admission, at the time of the study, were similar in private and public hospitals (107 vs 99 days) but maximal time since admission was respectively 2.8 and 48.9 years. Visit frequency for outpatients was more than one every two weeks for 43.1% in private and 24.7% in public clinics. Among inpatients only we found a difference between private and public hospitals for polypharmacy of non neuroleptics psychotropics, (mean 1.9 vs 1.5). In outpatients, long acting depot accounted for 26.6% of neuroleptics treatments in public clinics and 15.4% in private clinics. Finally, we found that polypharmacy among outpatients increased with duration of antipsychotic treatment.

CONCLUSION

in France, important differences are reported in antipsychotic prescription for schizophrenia between in- and outpatients. Current antipsychotic prescription is more recent in inpatients than in outpatients, with similar duration of overall antipsychotic treatment. Inpatients have more drug prescription, antipsychotics and other psychotropics, than outpatients. Differences are less important between private and public providers. Inpatients in private hospitals receive more non neuroleptic drugs than in public hospitals, and depot antipsychotics are more used among patients of public clinics. Long term inpatients are found in public hospitals only. Outpatients follow up is more intensive in private than in public clinics.

Serotonin transporter gene polymorphisms and hyperserotonemia in autistic disorder

Previous studies have provided conflicting evidence regarding the association of the serotonin transporter (5-HTT) gene with autism. Two polymorphisms have been identified in the human 5-HTT gene, a VNTR in intron 2 and a functional deletion/insertion in the promoter region (5-HTTLPR) with short and long variants. Positive associations of the 5-HTTLPR polymorphism with autism have been reported by two family-based studies, but one found preferential transmission of the short allele and the other of the long allele. Two subsequent studies failed to find evidence of transmission disequilibrium at the 5-HTTLPR locus. These conflicting results could be due to heterogeneity of clinical samples with regard to serotonin (5-HT) blood levels, which have been found to be elevated in some autistic subjects. Thus, we examined the association of the 5-HTTLPR and VNTR polymorphisms of the 5-HTT gene with autism, and we investigated the relationship between 5-HTT variants and whole-blood 5-HT. The transmission/disequilibrium test (TDT) revealed no linkage disequilibrium at either loci in a sample of 96 families comprising 43 trios and 53 sib pairs. Furthermore, no significant relationship between 5-HT blood levels and 5-HTT gene polymorphisms was found. Our results suggest that the 5-HTT gene is unlikely to play a major role as a susceptibility factor in autism.

Assessing the impact of a consensus conference on long-term therapy for schizophrenia

OBJECTIVE

Our aim was to assess the impact of six recommendations regarding drug prescription on the clinical practices of French psychiatrists. The recommendations were part of the conclusions of a consensus conference entitled "Long-term therapy of schizophrenia" (Paris, January 1994).

METHODS

The impact of the conference was assessed on the basis of awareness of the existence of the conference, knowledge of its conclusions, and actual changes in clinical practice. We performed: a) a survey of a representative sample of 396 psychiatrists 2 years after the conference; and b) an analysis of changes in drug prescriptions in a cohort of 2,407 patients with schizophrenia under treatment at the time of the conference.

RESULTS

Overall, 78% of interviewed psychiatrists were aware of the existence of the conference and 70% of its conclusions. Declared prescription practices conformed with conference conclusions about 60% (10%-95%) of the time. No difference in practices was noted between psychiatrists who were aware of the recommendations and those who were not. Single neuroleptic prescriptions increased in the cohort study in line with the main conference recommendation. The increase was small, but significant from 51.1% to 56.4%, and mainly concerned patients recently put on treatment. Contrary to recommendations, prescriptions of anticholinergics plus neuroleptics inexplicably rose from 48.2% to 54.3%.

CONCLUSION

Small changes in prescription habits occurred in the wake of the consensus conference, but we cannot really ascribe them to a direct impact of the conference. Despite the great pains we took in disseminating the conclusions of the conference as widely as possible, it is clear that a more forceful action plan (e.g., including continuous medical education) is required.