Temporal change of DNA methylation subclasses between matched newly diagnosed and recurrent glioblastoma

The longitudinal transition of phenotypes is pivotal in glioblastoma treatment resistance and DNA methylation emerged as an important tool for classifying glioblastoma phenotypes. We aimed to characterize DNA methylation subclass heterogeneity during progression and assess its clinical impact. Matched tissues from 47 glioblastoma patients were subjected to DNA methylation profiling, including CpG-site alterations, tissue and serum deconvolution, mass spectrometry, and immunoassay. Effects of clinical characteristics on temporal changes and outcomes were studied. Among 47 patients, 8 (17.0%) had non-matching classifications at recurrence. In the remaining 39 cases, 28.2% showed dominant DNA methylation subclass transitions, with 72.7% being a mesenchymal subclass. In general, glioblastomas with a subclass transition showed upregulated metabolic processes. Newly diagnosed glioblastomas with mesenchymal transition displayed increased stem cell-like states and decreased immune components at diagnosis and exhibited elevated immune signatures and cytokine levels in serum. In contrast, tissue of recurrent glioblastomas with mesenchymal transition showed increased immune components but decreased stem cell-like states. Survival analyses revealed comparable outcomes for patients with and without subclass transitions. This study demonstrates a temporal heterogeneity of DNA methylation subclasses in 28.2% of glioblastomas, not impacting patient survival. Changes in cell state composition associated with subclass transition may be crucial for recurrent glioblastoma targeted therapies.

Unclassifiable CNS tumors in DNA methylation-based classification: clinical challenges and prognostic impact

DNA methylation analysis has become a powerful tool in neuropathology. Although DNA methylation-based classification usually shows high accuracy, certain samples cannot be classified and remain clinically challenging. We aimed to gain insight into these cases from a clinical perspective. To address, central nervous system (CNS) tumors were subjected to DNA methylation profiling and classified according to their calibrated score using the DKFZ brain tumor classifier (V11.4) as "≥ 0.84" (score ≥ 0.84), "0.3-0.84" (score 0.3-0.84), or "< 0.3" (score < 0.3). Histopathology, patient characteristics, DNA input amount, and tumor purity were correlated. Clinical outcome parameters were time to treatment decision, progression-free, and overall survival. In 1481 patients, the classifier identified 69 (4.6%) tumors with an unreliable score as "< 0.3". Younger age (P < 0.01) and lower tumor purity (P < 0.01) compromised accurate classification. A clinical impact was demonstrated as unclassifiable cases ("< 0.3") had a longer time to treatment decision (P < 0.0001). In a subset of glioblastomas, these cases experienced an increased time to adjuvant treatment start (P < 0.001) and unfavorable survival (P < 0.025). Although DNA methylation profiling adds an important contribution to CNS tumor diagnostics, clinicians should be aware of a potentially longer time to treatment initiation, especially in malignant brain tumors.

Molecular refinement of pilocytic astrocytoma in adult patients

AIM

Pilocytic astrocytomas (PA) in adults are rare and may be challenging to identify based only on histomorphology. Compared to their paediatric counterparts, they are reportedly molecularly more diverse and associated with a worse prognosis. We aimed to describe the characteristics of adult PAs more precisely by comprehensively profiling a series of 79 histologically diagnosed adult cases (≥18 years).

METHODS

We performed global DNA methylation profiling and DNA and RNA panel sequencing, and integrated the results with clinical data. We further compared the molecular characteristics of adult and paediatric PAs that had a significant match to one of the established PA methylation classes in the Heidelberg brain tumour classifier.

RESULTS

The mean age in our cohort was 33 years, and 43% of the tumours were located supratentorially. Based on methylation profiling, only 39% of the cases received a significant match to a PA methylation class. Sixteen per cent matched a different tumour type and 45% had a Heidelberg classifier score <0.9 with an affiliation to diverse established methylation classes in t-SNE analyses. Although the KIAA1549::BRAF fusion was found in 98% of paediatric PAs, this was true for only 27% of histologically defined and 55% of adult PAs defined by methylation profiling.

CONCLUSIONS

A particularly high fraction of adult tumours with histological features of PA do not match current PA methylation classes, indicating ambiguous histology and an urgent need for molecular profiling. Moreover, even in adult PAs with a match to a PA methylation class, the distribution of genetic drivers differs significantly from their paediatric counterparts (p<0.01).

Epigenetic profiling reveals a strong association between lack of 5-ALA fluorescence and EGFR amplification in IDH-wildtype glioblastoma

Background

5-aminolevulinic acid (5-ALA) fluorescence-guided resection increases the percentage of complete CNS tumor resections and improves the progression-free survival of IDH-wildtype glioblastoma patients. A small subset of IDH-wildtype glioblastoma shows no 5-ALA fluorescence. An explanation for these cases is missing. In this study, we used DNA methylation profiling to further characterize non-fluorescent glioblastomas.

Methods

Patients with newly diagnosed and recurrent IDH-wildtype glioblastoma that underwent surgery were analyzed. The intensity of intraoperative 5-ALA fluorescence was categorized as non-visible or visible. DNA was extracted from tumors and genome-wide DNA methylation patterns were analyzed using Illumina EPIC (850k) arrays. Furthermore, 5-ALA intensity was measured by flow cytometry on human gliomasphere lines (BT112 and BT145).

Results

Of 74 included patients, 12 (16.2%) patients had a non-fluorescent glioblastoma, which were compared to 62 glioblastomas with 5-ALA fluorescence. Clinical characteristics were equally distributed between both groups. We did not find significant differences between DNA methylation subclasses and 5-ALA fluorescence (P = .24). The distribution of cells of the tumor microenvironment was not significantly different between the non-fluorescent and fluorescent tumors. Copy number variations in EGFR and simultaneous EGFRvIII expression were strongly associated with 5-ALA fluorescence since all non-fluorescent glioblastomas were EGFR-amplified (P < .01). This finding was also demonstrated in recurrent tumors. Similarly, EGFR-amplified glioblastoma cell lines showed no 5-ALA fluorescence after 24 h of incubation.

Conclusions

Our study demonstrates an association between non-fluorescent IDH-wildtype glioblastomas and EGFR gene amplification which should be taken into consideration for recurrent surgery and future studies investigating EGFR-amplified gliomas.

Atypical neurofibromas reveal distinct epigenetic features with proximity to benign peripheral nerve sheath tumor entities

BACKGROUND

Plexiform neurofibromas can transform into atypical neurofibromas (ANF) and then further progress to aggressive malignant peripheral nerve sheath tumors (MPNST). ANF have been described to harbor distinct histological features and frequent loss of CDKN2A/B. However, histological evaluation may be rater-dependent, and detailed knowledge about the molecular mechanisms of malignant transformation is scarce. In general, malignant transformation can be accompanied by significant epigenetic changes, and global DNA methylation profiling is able to differentiate relevant tumor subgroups. Therefore, epigenetic profiling might provide a valuable tool to distinguish and characterize ANF with differing extent of histopathological atypia from neurofibromas and MPNST.

METHODS

We investigated 40 tumors histologically diagnosed as ANF and compared their global methylation profile to other peripheral nerve sheath tumors.

RESULTS

Unsupervised class discovery and t-SNE analysis indicated that 36/40 ANF cluster with benign peripheral nerve sheath tumors with clear separation from MPNST. 21 ANF formed a molecularly distinct cluster in proximity to schwannomas. Tumors in this cluster had a frequent heterozygous or homozygous loss of CDKN2A/B and significantly more lymphocyte infiltration than MPNST, schwannomas, and NF. Few ANF clustered closely with neurofibromas, schwannomas, or MPNST, raising the question, whether diagnosis based on histological features alone might pose a risk to both over- and underestimate the aggressiveness of these lesions.

CONCLUSIONS

Our data suggest that ANF with varying histological morphology show distinct epigenetic similarities and cluster in proximity to benign peripheral nerve sheath tumor entities. Future investigations should pay special respect to correlating this methylation pattern to clinical outcomes.

Epigenetic neural glioblastoma enhances synaptic integration and predicts therapeutic vulnerability

Neural-tumor interactions drive glioma growth as evidenced in preclinical models, but clinical validation is nascent. We present an epigenetically defined neural signature of glioblastoma that independently affects patients' survival. We use reference signatures of neural cells to deconvolve tumor DNA and classify samples into low- or high-neural tumors. High-neural glioblastomas exhibit hypomethylated CpG sites and upregulation of genes associated with synaptic integration. Single-cell transcriptomic analysis reveals high abundance of stem cell-like malignant cells classified as oligodendrocyte precursor and neural precursor cell-like in high-neural glioblastoma. High-neural glioblastoma cells engender neuron-to-glioma synapse formation in vitro and in vivo and show an unfavorable survival after xenografting. In patients, a high-neural signature associates with decreased survival as well as increased functional connectivity and can be detected via DNA analytes and brain-derived neurotrophic factor in plasma. Our study presents an epigenetically defined malignant neural signature in high-grade gliomas that is prognostically relevant.

BIOM-33. TEMPORAL HETEROGENEITY OF DNA METHYLATION SUBCLASSES BETWEEN MATCHED NEWLY DIAGNOSED AND RECURRENT IDH-WILDTYPE GLIOBLASTOMA

Spatiotemporal heterogeneity is a major factor contributing to the devastating prognosis of isocitrate-dehydrogenase (IDH)-wildtype glioblastoma. Genome-wide DNA methylation profiling allows the stratification into several DNA methylation subgroups of IDH-wildtype glioblastoma, which were shown to have a spatial heterogeneity in newly diagnosed tumors. However, the temporal heterogeneity and its clinical relevance of DNA methylation subgroups remains inconclusive. Tumor tissue obtained from first and recurrence surgery of 31 patients diagnosed with IDH-wildtype glioblastoma was subjected to DNA methylation profiling. DNA methylation profiles were analyzed for temporal heterogeneity and correlated with clinical data, survival outcome and copy number variations. In addition, deconvolution of immune cells and unsupervised hierarchical clustering using pairwise Pearson correlation coefficients of the 10.000 most variable CpG features was performed. Of all patients with matched tumor tissue, 4 (12.9%) patients had a non-matching brain tumor classifier output at recurrence. Within the remaining 27 patients, a transition of the dominant DNA methylation subclass was observed in 8 (29.6%) glioblastomas with a most frequent transition to the mesenchymal subclass (62.5%). A subclass transition was more likely after incomplete removal of contrast-enhanced tumor parts at first surgery (p = 0.04). Tumor location, adjuvant treatment, and time between primary and recurrence surgery did not influence the transition. Immune cell proportions from deconvolution data, tumor purity or specific CpG sites were not correlated with a subclass transition. Survival analyses revealed a comparable outcome for patients with or without subclass transition. Our findings demonstrate the temporal heterogeneity of DNA methylation subclasses in 29.6% of IDH-wildtype glioblastoma. We identified clinical factors and showed that a subclass transition did not impact the survival outcome. However, a possible DNA methylation subclass transition must be taken into consideration for future targeted therapies at recurrence.

PATH-47. THE CHALLENGE AND THERAPEUTIC RELEVANCE OF A NON-MATCHING CLASSIFIER OUTPUT USING GENOME-WIDE DNA METHYLATION FOR CLINICAL ROUTINE

DNA methylation-based classification of central nervous system tumours has been increasing in importance for routine clinical workups and offers novel opportunities in discriminating subtypes which could lead to a more customized therapy. However, there are still unclassifiable entities for which defining an effective therapeutic regimen is challenging. The aim of our study was to gain further insight in these challenging cases. We included 81 patients with a calibrated score below 0.9 in the classifier output, who underwent surgery for a tumour of the central nervous system (CNS). 47 patients had a different output using the classifier version v11b4 when compared to their histological diagnosis. Of these, 41 patients (87.2 %) did not have any diagnosis from the methylation classifier (“no matching methylation class”). Surgical and clinicopathological features as well as DNA input had no impact on the calibrated score. Cases with non-classifiable tumors had a significantly longer time until a decision for adjuvant therapy and these cases were presented more often in neurooncological tumor boards (p&lt; 0.01). Further analyses in 23 glioblastoma patients revealed comparable results for the overall survival, but a significantly shorter progression-free survival in cases with a discrepancy between the histological and classifier diagnosis. Application of the latest classifier version v12.5 enabled classification in 67.9% of cases, resulting in re-classification with a high calibrated score (&gt; 0.9) in 25.7% of the tumors. Taken together, our study presents unclassifiable cases and the possible clinical impact when waiting for the accurate diagnosis in these challenging cases. Even though DNA methylation profiling significantly contributes to advanced CNS tumour diagnostics, clinicians should be aware of a prolonged interval to treatment initiation, especially for highly malignant brain tumours. Therefore, we would recommend to schedule adjuvant treatment as early as possible if surgical and histological results are suspicious for this disease.

PATH-05 Challenge and clinical relevance of a non-matching classifier output in genome-wide DNA methylation analysis for CNS neoplasms in pediatric and adolescent patients

OBJECTIVE: The molecular classification of CNS tumors has revolutionized our understanding of the biological heterogeneity and diversity of tumor subtypes. DNA methylation-based classification allows to discriminate subtypes. Although DNA methylation-based classification can diagnose tumors with high specificity, there are tumors which cannot be classified. We aimed to gain further insight into these challenging cases. METHODS: Overall, 21 patients with a CNS tumor that was non-classifiable (confidence score <0.3), or had a low confidence score (<0.9) using the DNA methylation-based classifier version 11b4, were included. Tumors were re-classified using version (v12.3), and clinical data were analyzed. RESULTS: A total of 21 pediatric and adolescent brain tumors with a calibrated score below 0.9 in the classifier output were identified. Of these, 11 patients (52.4 %) were assigned to the “no matching methylation class” with a score below 0.3. IDH-wild type glioblastoma (23.8 %), ETMR (14.3 %), and DMG (14.3 %) were the most common histological diagnoses. Surgical and clinicopathological features as well as DNA input and tumor purity did not influence the confidence score. Cases with non-classifiable tumors had a significantly longer time until a decision for adjuvant therapy (p<0.01). Application of the latest classifier version v12.3 led to a re-classification of 9 (42.9 %) cases, of which 5 cases (55.6 %) had an improved calibrated score. CONCLUSION: Our study presents unclassifiable cases and the possible clinical impact when waiting for the accurate diagnosis in these challenging cases. Even though DNA methylation profiling significantly contributes to advanced CNS tumor diagnostics, clinicians should be aware of a prolonged interval to treatment initiation, especially for highly malignant brain tumors. Therefore, we would recommend to schedule adjuvant treatment as early as possible, if surgical and histological results are suspicious for this disease.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Novel homozygous RARS2 mutation in two siblings without pontocerebellar hypoplasia - further expansion of the phenotypic spectrum

BACKGROUND

Pontocerebellar hypoplasia type 6 (PCH6) is a mitochondrial disease caused by mutations in the RARS2 gene. RARS2 encodes mitochondrial arginyl transfer RNA synthetase, an enzyme involved in mitochondrial protein translation. A total of 27 patients from 14 families have been reported so far. Characteristic clinical features comprise neonatal lactic acidosis, severe encephalopathy, intractable seizures, feeding problems and profound developmental delay. Most patients show typical neuroradiologic abnormalities including cerebellar hypoplasia and progressive pontocerebellar atrophy.

METHODS

We describe the clinical, biochemical and molecular features of 2 siblings with a novel homozygous mutation in RARS2. Both patients presented neonatally with lactic acidosis. While the older sibling had severe neurological symptoms with microcephaly, seizures and developmental delay, the younger patient was still neurologically asymptomatic at the age of 2 months.

RESULTS

MRI studies in both children lacked pontocerebellar involvement. The expression of the OXPHOS complex proteins was decreased in both patients, whereas oxygen consumption was increased.

CONCLUSIONS

Characteristic neuroradiological abnormalities of PCH6 such as vermis and cerebellar hypoplasia and progressive pontocerebellar atrophy may be missing in patients with RARS2 mutations. RARS2 testing should therefore also be performed in patients without pontocerebellar hypoplasia but otherwise typical clinical symptoms.

[Neurodevelopmental outcome of very low birth weight infants born at the Perinatal Centre in Ulm, Germany]

BACKGROUND

Since 2006 an assessment of the neurodevelopmental outcome of very low birth weight infants (VLBWI) at a corrected age of 2 years is mandatory for every perinatal centre in Germany. The aim of our study was to check how complete these assessments were performed in our population of infants born at our perinatal centre and receiving treatment within our local neonatal network. Furthermore, the data obtained will be used for prenatal consultations. Another objective was to identify risk factors for adverse neurodevelopmental outcomes.

METHODS

All VLBWI were invited for a follow-up exam using the Bayley Scales of Infant Development II (BSID-II) or III (BSID-III), or Griffiths Mental Developmental Scales) at 2 years corrected age. The results of children assessed by other institutions were collected.

RESULTS

142 (69.3%) of the 205 VLBWI, born and finally discharged alive at the perinatal centre in Ulm were assessed at a median (minimum - maximum) corrected age of 23 (18-27) months. The BSID-II Psychomotor Development Index (PDI) 91 was (< 50-128) (n=115), the BSID-II Mental Development Index (MDI) was 87 (< 50-134) (n=96), BSID-III MDI 95 (60-112) (n=29) and the Griffiths Score was 93 (67-140) (n=17). Severe disability was diagnosed in 36 (25.4%) of the children studied. Gestational age and higher grade intraventricular haemorrhage were associated independently with severe disability.

CONCLUSIONS

It is very difficult to achieve a high rate of follow-up examinations in preterm infants <1,500 g in a neonatal network. Severe impairment in VLBWI is not rare. Improving neurodevelopmental outcome remains a challenge.

[Children with learning disabilities and handicaps in inclusive schools or in special schools? The view of parents and professionals]

BACKGROUND

To investigate the view of parents and professionals on sending children with special educational needs to inclusive schools.

PROBANDS

54 preschool children in the year before school entry and 155 school children attending a Social Pediatric Center. They displayed motor-, mental-, speech- or sensory handicaps, learning or behavioral disabilities.

METHODS

Questionnaires for parents of preschool- and of school children and questionnaires for the professional caring for the child were evaluated and compared. Parental expectations, experiences concerning school and the severity of disability were determined.

RESULTS

135 pupils attended special schools and 20 integrative schools. The parents were generally very content with both types of schools despite the fact that 33% of parents had not have a free choice of the school. They had a positive attitude to inclusive education. Preference for inclusive schooling decreased with increasing severity of the child's disability. The severity of disability was rated similar by parents and by professionals. Parents of preschool children tended more often and parents of school children less often than professionals towards sending the individual child to an inclusive school.

CONCLUSIONS

Some parents of children with special educational needs would like to send their child to a special school, others prefer inclusive schools. It is paramount to improve the professional advice and guidance to parents since parental options to choose the school for their child are increasing in Germany.

[Sexual and contraceptive behavior of teenagers and young adults. Selected results of the BZgA study "Youth Sexuality 2010"]

The BZgA study "Youth Sexuality 2010" clarifies the changes that have occurred in the sexual and contraceptive behavior of teenagers and young adults over the last 30 years. Among young Germans, there is now more gender similarity regarding both the age at which intercourse first takes place and contraceptive behavior. The proportion of German teenagers who take no contraceptive precautions when they have intercourse for the first time is now 8%, a lower figure than ever previously recorded. Communication about contraception, both at home and between the partners, is making a substantial contribution to responsible contraceptive behavior on the part of teenagers and young adults. Alongside education about sexuality in the family and at school, there are also structural influences on the positive developments witnessed in Germany. And yet there are still target groups that are inadequately reached. Many migrants are less well informed about bodily processes, their contraceptive practice is not as good, and their religious background tends to exclude them from access to information. Disabled teenagers and young adults constitute a target group about which to date we have insufficient knowledge. Education and social deprivation continue to be important factors in the differences seen in sexual and contraceptive behavior. In this area, proactive efforts are necessary.

Growth, neurological and cognitive development in infants with a birthweight <501 g at age 5 years

AIM

To determine growth, neurological and cognitive development at 5 years of preterm infants with birthweights <501 g born in three German tertiary perinatal centres between 1998 and 2001.

METHODS

Structured neurological examination, the Gross Motor Function Classification Scale and the Kaufman-Assessment-Battery Test for Children.

RESULTS

Of 107 infants, 48 received immediate life support (gestational age 25.2 weeks [21-30.7]; birth weight 435 g [290-500]) median [range]), 27 (56%) survived until follow-up [95% CI 39-69%], 19 (70%) could be tested. In few infants had catch-up growth taken place. Neurological test results were normal in five infants (26%) and mildly abnormal/severely abnormal in 11 (58%)/3 (16%) infants. Visual impairment was present in eight (42%), and hearing disability in three (16%). The mean mental processing composite (IQ) was 82 [50-104] (median [range]).

CONCLUSION

Of all resuscitated infants with a birthweight <501 g, 56% survived to school age. Of these, composite outcome score showed normal development or mild disability in one-half, and moderate or severe disability in the other half of them. Investigators should include such infants in studies and their reports should give specific information about them.

SOM230 (pasireotide) and temozolomide achieve sustained control of tumour progression and ACTH secretion in pituitary carcinoma with widespread metastases

Pituitary carcinomas are rare and neurosurgically challenging lesions, as they commonly relapse after surgical removal. Their prognosis is dismal due to their limited response to radiotherapy and chemotherapy. In recent studies, temozolomide was administered in very few patients with partial effects. We report a patient with an ACTH-secreting pituitary carcinoma and widespread intracranial, spinal and systemic metastases despite repeated surgical treatment, bilateral adrenalectomy, medical treatment and radiotherapy. Additionally to chemotherapy with temozolomide, the patient received SOM230 as salvage therapy with an improvement of the patient's clinical status, and a reduction of ACTH levels. After 12 months of combination therapy a sustained tumor control was achieved and persisted upon monotherapy with SOM230 for more than 9 months thereafter. Thus, temozolomide in combination with SOM230 seems to be promising in patients with ACTH-secreting metastasized pituitary carcinoma.

Comparative analysis of mononuclear cells isolated from mucosal lymphoid follicles of the human ileum and colon

Studies of human mucosal lymphoid follicles are rare and have been limited to children's Peyer's patches, which are visible at endoscopy. We investigated lymphoid follicles in ileum biopsies of 87 patients and surgical colon specimens from 66 cancer patients, and examined phenotype and function of isolated follicular immune cells. Two (0-10) and 12 (0-117) follicles per patient were found in ileum and colon samples respectively (P < 0.001). The number of lymphoid follicles mononuclear cells (LFMC) that could be isolated per patient was higher from colon compared with ileum specimens [725 000 (0-23 Mio) versus 100 000 (0-1.3 Mio), P < 0.001]. T cells were predominant in both LFMC and lamina propria mononuclear cells (LPMC), but B cells were more and plasma cells less frequent in LFMC. T cells from mucosal follicles were more frequently CD4-positive and CD62L-positive, but less frequently CD8-positive, CD103-positive and CD69-positive than lamina propria T cells. LFMC from ileum compared with colon showed no differences in mononuclear cell composition. Anti-CD3/CD28 stimulation induced similar proliferation of LFMC and LPMC from ileum and colon, as well as secretion of high levels of interferon-gamma, tumour necrosis factor-alpha and interleukin (IL)-2, but lower levels of IL-4, IL-6 and IL-10. LFMC from colon secreted more IL-2 than those from ileum. Our study shows that mucosal lymphoid follicles can be identified clearly in adult human colon and yield viable immune cells sufficient for phenotypical and functional analysis. The cellular composition of LFMC from ileum and colon is similar, and both secrete predominantly T helper type 1 cytokines.

Long-term treatment of central Cushing's syndrome with rosiglitazone

CONTEXT

Central Cushing's syndrome is not always curable by surgery or radiation of the pituitary. Medical treatment is often not possible or effective. Some studies revealed beneficial effects of the PPARgamma (Peroxisome-Proliferator-Activator- Receptor-gamma)-agonist rosiglitazone (RG) in in vitro studies, animal models and short term clinical studies.

OBJECTIVE

of this study was to observe the long-term effects of RG-treatment on cortisol- and ACTH -secretion, clinical outcomes and morphological changes of the pituitary in patients with persistent ACTH-overproduction despite previous operation and radiation.

DESIGN, SETTING AND PATIENTS

14 patients with persistent central ACTH -production were included and monitored over a period up to 12 months. RG was administered daily and increased to a maximum dosage of 24 mg daily, according to the response of ACTH and cortisol secretion. ACTH and cortisol were measured at least every 4 weeks during RG treatment.

RESULTS

Patients were treated between 4 and 12 months with RG (mean 6.8 months). Compared to baseline, ACTH- and cortisol levels dropped significantly (p<0.01) after 12, 16, 20, 24 and 28 weeks but thereafter rose again during the study period, despite continuous RG- treatment and dose increase up to the maximum dosage. This was paralleled by reocurrence of clinical symptoms. MRI-scans were performed in 6 patients because of persisting visible adenoma, but showed no morphological changes.

CONCLUSION

RG seems not to be a long-term treatment option for patients with persistent central ACTH-evcess. Though, in order to reduce perioperative complications, short term treatment of patients could be an alternative.

[Clinical impact of fetal MRI in addition to ultrasonography in brain anomalies--three case reports]

Fetal magnetic resonance imaging (MRI) is a reliable method to further evaluate brain anomalies detected on ultrasonography. MRI can reveal additional brain abnormalities which are consequential for counselling parents about the fetal prognosis and subsequently influence the decision about continuing the pregnancy. In case of fatal malformations, MRI can confirm a diagnosis established on ultrasonography, supplying more reliability.

Type of kindergarten and other potential determinants of overweight in pre-school children

OBJECTIVE

The study aimed to assess the relationship of various types of kindergarten differing in length of care and food availability with the development of overweight in pre-school children.

DESIGN, SETTING AND SUBJECTS

A cross-sectional study was carried out in 2002 in Stuttgart, Germany, as part of the school entrance examination. Height and weight of 2140 children (participation 70.2%) were measured and information on type of kindergarten and other potential determinants of overweight was collected by a parental questionnaire. Change in relative body mass index (BMI) position between the ages of 4 and 6 years was assessed using medical records.

RESULTS

The prevalence of overweight or change in relative BMI position did not differ according to the type of kindergarten. For the prevalence of overweight in German children, adjusted odds ratios (OR) comparing institutions that open only in the morning with those opening in the morning and afternoon or for the full day were 0.86 (95% confidence interval (CI) 0.40, 1.83) and 0.63 (95% CI 0.25, 1.58), respectively. Parental BMI and duration of television watching were positively associated, and maternal educational status and duration of breast-feeding were negatively associated, with overweight and/or change in relative BMI position. The prevalence of overweight was substantially higher among non-German than among German children (adjusted OR 2.17 (95% CI 1.53, 3.07)).

CONCLUSIONS

These data show no association between different types of kindergarten and the development of overweight in early childhood. Duration of television watching and breast-feeding, as well as the relatively high prevalence of overweight in ethnic minorities, deserve further attention.

The effect of public or private structures in wastewater treatment on the conditions for the design, construction and operation of wastewater treatment plants

Organised in public or private structures, wastewater services have to cope with different framework conditions as regards planning, construction, financing and operation. This leads quite often to different modes of management. In recent years there has been a push for privatisation on the water sector in general, the reasons for which are manifold, ranging from access to external know-how and capital to synergistic effects through integration of wastewater treatment into other tasks of similar or equal nature. Discussed are various models of public/private partnership (PPP) in wastewater treatment, encompassing for example the delegation of partial tasks or even the proportional or entire transfer of ownership of treatment facilities to private third parties. Decisive for high performance and efficiency is not the legal or organisational form, but rather the clear and unmistakable definition of tasks which are to be assigned to the different parties, customers and all other partners involved, as well as of clear-cut interfaces. On account of the (of course legitimate) profit-oriented perspective of the private sector, some decision-making processes in relation to project implementation (design and construction) and to operational aspects will differ from those typically found on the public sector. This does apply to decisions on investments, financing and on technical solutions too. On the other hand, core competencies in wastewater treatment should not be outsourced, but remain the public bodies' responsibility, even with 'far-reaching' privatisation models. Such core competencies are all efforts geared to sustainable wastewater treatment as life-supporting provision for the future or as contribution to the protection of health and the environment and to the development of infrastructure. Major areas of wastewater treatment and other related tasks are reviewed. The paper concludes with a list of questions on the issue of outsourcing.

Integrated water resources management in the Ruhr River Basin, Germany

The Ruhr, with an average flow of 80.5 m3/s at its mouth, is a comparatively small tributary to the Rhine River that has to perform an important task: to secure the water supply of more than 5 million people and of the industry in the densely populated region north of the river. The complex water management system and network applied by the Ruhrverband in the natural Ruhr River Basin has been developed step by step, over decades since 1913. And from the beginning, its major goal has been to achieve optimal conditions for the people living in the region. For this purpose, a functional water supply and wastewater disposal infrastructure has been built up. The development of these structures required and still requires multi-dimensional planning and performance. Since the river serves as receiving water and at the same time as a source of drinking water, the above-standard efforts of Ruhrverband for cleaner water also help to conserve nature and wildlife. Ruhrverband has summed up its environmental awareness in the slogan: "For the people and for the environment". This basic water philosophy, successfully applied to the Ruhr for more than 80 years, will be continued in accordance with the new European Water Framework Directive, enacted in 2000, which demands integrated water resources management in natural river basins, by including the good ecological status of surface waterbodies as an additional goal.

The influence of stormwater treatment on the hydraulic and pollution load--balance for an entire river basin

The installation of about 500 stormwater detention facilities (SDFs) led to a significant drop of the pollution originating from stormwater runoff in the river basin of the Ruhr which covers 4,488 km2. The German technical directives on the design of SDFs are briefly outlined and the specific costs for such plants are given. The average costs for one kilogram COD held back by SDFs in combined systems amount to Euro 3.73 (calculated without consideration of the subsequent removal in the municipal wastewater treatment plant (WWTP)). The tank volume for stormwater storage can be minimised by application of real-time management systems which allow a dynamic operation of all SDFs in a catchment area.

Late onset white matter disease in peroxisome biogenesis disorder

OBJECTIVE

To report late onset cerebral white matter disease as a distinctive phenotype in peroxisome biogenesis disorder (PBD).

BACKGROUND

There is phenotypic and genetic overlap among the PBD known as Zellweger syndrome (ZS), infantile Refsum disease (IRD), and neonatal adrenoleukodystrophy (NALD). Distinctive external features are variable among these three disorders, and neurologic deficit has its onset at birth or in infancy. In a structured follow-up cohort of 25 patients with PBD, not including ZS, three patients had an unusual pattern of cerebral white matter disease with onset past the age of 1, not conforming to any of the classic PBD phenotypes.

METHODS

Clinical phenotyping and follow-up, peroxisomal biochemical determinations in body fluids and fibroblasts, identification of affected PEX gene by genetic complementation in fibroblasts, and MRI studies.

RESULTS

Two unrelated patients with PBD without distinctive external features had normal neurodevelopmental milestones during their first year, followed by rapid deterioration including severe hypotonic pareses, seizures, retinopathy, and deafness. A third patient initially diagnosed with IRD developed cerebral white matter degeneration in the third year of life, complicating the original diagnosis. MRI in all three patients showed cerebral demyelination with sparing of subcortical fibers and pronounced central cerebellar demyelination.

CONCLUSIONS

Late-onset cerebral white matter disease may occur in PBD, either following IRD or following normal early development and in the absence of distinctive external features. Peroxisome biogenesis disorder should be included in the differential diagnosis of post-infantile onset of cerebral white matter disease

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(+).