A new blood DNA methylation signature for Koolen-de Vries syndrome: Classification of missense KANSL1 variants and comparison to fibroblast cells

Pathogenic variants in KANSL1 and 17q21.31 microdeletions are causative of Koolen-de Vries syndrome (KdVS), a neurodevelopmental syndrome with characteristic facial dysmorphia. Our previous work has shown that syndromic conditions caused by pathogenic variants in epigenetic regulatory genes have identifiable patterns of DNA methylation (DNAm) change: DNAm signatures or episignatures. Given the role of KANSL1 in histone acetylation, we tested whether variants underlying KdVS are associated with a DNAm signature. We profiled whole-blood DNAm for 13 individuals with KANSL1 variants, four individuals with 17q21.31 microdeletions, and 21 typically developing individuals, using Illumina's Infinium EPIC array. In this study, we identified a robust DNAm signature of 456 significant CpG sites in 8 individuals with KdVS, a pattern independently validated in an additional 7 individuals with KdVS. We also demonstrate the diagnostic utility of the signature and classify two KANSL1 VUS as well as four variants in individuals with atypical clinical presentation. Lastly, we investigated tissue-specific DNAm changes in fibroblast cells from individuals with KdVS. Collectively, our findings contribute to the understanding of the epigenetic landscape related to KdVS and aid in the diagnosis and classification of variants in this structurally complex genomic region.

Seizures in children undergoing stem cell transplantation

BACKGROUND

Neurological complications (NCs) are of major concern following hematological stem cell transplantation (HSCT), most of which present with seizures.

PROCEDURES

We performed a retrospective study (2002-2018) of patients undergoing HSCT in order to analyze the incidence and aetiologies related to seizures.

RESULTS

Of 155 children undergoing HSCT, 27 (17.4%) developed seizures at some point in 2 years of follow-up. The most frequent etiologies were central nervous system (CNS) infection (n = 10), drug toxicity (n = 8), and vascular disease (n = 5). A statistically significant association was found between seizure and the HSCT type (lower risk for a related identical donor, p = .010), prophylactic or therapeutic mycophenolate use (p = .043 and .046, respectively), steroid use (p = .023), selective CD45RA+ depletion (p = .002), pre-engraftment syndrome (p = .007), and chronic graft-versus-host disease (GVHD) severity (p = .030). Seizures predicted evolution to life-threatening complications and admission to intensive care (p < .001) and higher mortality (p = .023). A statistically significant association was also found between seizures and sequelae in survivors (p = .029). Children who developed seizures had a higher risk of CNS infection and vascular disease (odds ratio 37.25 [95% CI: 7.45-186.05] and 12.95 [95% CI 2.24-74.80], respectively).

CONCLUSIONS

Neurological complications highly impact survival and outcomes and need to be addressed when facing an HSCT procedure.

Severe communication delays are independent of seizure burden and persist despite contemporary treatments in SCN1A+ Dravet syndrome: Insights from the ENVISION natural history study

OBJECTIVE

Dravet syndrome (DS) is a developmental and epileptic encephalopathy characterized by high seizure burden, treatment-resistant epilepsy, and developmental stagnation. Family members rate communication deficits among the most impactful disease manifestations. We evaluated seizure burden and language/communication development in children with DS.

METHODS

ENVISION was a prospective, observational study evaluating children with DS associated with SCN1A pathogenic variants (SCN1A+ DS) enrolled at age ≤5 years. Seizure burden and antiseizure medications were assessed every 3 months and communication and language every 6 months with the Bayley Scales of Infant and Toddler Development 3rd edition and the parent-reported Vineland Adaptive Behavior Scales 3rd edition. We report data from the first year of observation, including analyses stratified by age at Baseline: 0:6-2:0 years:months (Y:M; youngest), 2:1-3:6 Y:M (middle), and 3:7-5:0 Y:M (oldest).

RESULTS

Between December 2020 and March 2023, 58 children with DS enrolled at 16 sites internationally. Median follow-up was 17.5 months (range = .0-24.0), with 54 of 58 (93.1%) followed for at least 6 months and 51 of 58 (87.9%) for 12 months. Monthly countable seizure frequency (MCSF) increased with age (median [minimum-maximum] = 1.0 in the youngest [1.0-70.0] and middle [1.0-242.0] age groups and 4.5 [.0-2647.0] in the oldest age group), and remained high, despite use of currently approved antiseizure medications. Language/communication delays were observed early, and developmental stagnation occurred after age 2 years with both instruments. In predictive modeling, chronologic age was the only significant covariate of seizure frequency (effect size = .52, p = .024). MCSF, number of antiseizure medications, age at first seizure, and convulsive status epilepticus were not predictors of language/communication raw scores.

SIGNIFICANCE

In infants and young children with SCN1A+ DS, language/communication delay and stagnation were independent of seizure burden. Our findings emphasize that the optimal therapeutic window to prevent language/communication delay is before 3 years of age.

Inherited SCN1A missense mutation in a Dravet Syndrome family: Neuropathological correlation, family screening and implications for adult carriers

INTRODUCTION

Neuropathological findings in Dravet Syndrome (DS) are scarce, especially in adult patients, and often do not have a genetic confirmation. Additionally, the missense SCN1A pathogenic variant found has only been described as de novo mutation in previous literature.

METHODS

We describe the clinical and genetic findings of a family (including three sisters and his father), using Sanger sequencing in the three sisters and in postmortem brain tissue in the father. The present study also shows the neuropathological findings of the father.

RESULTS

Despite the presence of long term drug resistant epilepsy, starting with febrile seizures between 6 and 12 months of age, and intellectual disability (ID), the three sisters were diagnosed with DS in adulthood, identifying a missense SCN1A pathogenic variant in exon 20, previously described as de novo -p.Gly1332Glu (c .3995 G>A). The oldest sister had the most severe phenotype, with severe ID and wheel chair dependency, passing away at 52. The other two sisters had a moderate phenotype, being at the present seizure free, but with significant comorbidities, such as crouch gait and parkinsonism. Several relatives from the paternal path (including the father) presented epilepsy, but without ID. The father was diagnosed with Alzheimer´s Disease (AD) at 60, and because he donated his brain, the same variant was confirmed in postmortem study. Neither the MRI nor the histopathology showed specific morphological changes for DS, consistent with previous studies.

CONCLUSIONS

This work supports the need to review the clinical and genetic spectra of DS in adults with epilepsy and unknown ID. The clinical consequences of this syndrome seem to have a functional rather than a structural basis, supported by the absence of specific neuropathological findings.

Sclerotic Bone Lesions as a Clue in the Diagnosis of Three Generations of Tuberous Sclerosis Complex: Case Report and Review of Literature

Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disorder that can involve multiple organ systems. Diagnosis is based on independent clinical diagnostic criteria and genetic diagnostic criteria (pathogenic variants on TSC1 and TSC2 genes). To make a definitive diagnosis can be especially difficult in oligosymptomatic or asymptomatic patients and in those patients with genetic variants of uncertain significance (VUS). Early diagnosis and lifelong surveillance are paramount to avoid morbidity and potentially life-threatening complications. To increase diagnostic sensibility, less known manifestations of TSC can be helpful. Herein we show a case in which SBLs were used as a diagnostic clue to help diagnose three generations of oligosymptomatic TSC carrying a VUS in TSC1. SBLs are commonly detected in imaging studies of patients with TSC and have been recently included as a minor clinical diagnostic criterion. Clinicians and radiologists should be aware of their significance as they can be mistaken with osteoblastic metastases.

Arterial tortuosity syndrome: Phenotypic features and cardiovascular manifestations in 4 newly identified patients

Arterial tortuosity syndrome (ATS) is an autosomal recessive connective tissue disease caused by biallelic variants in the SLC2A10 gene (NG_016284.1) and characterised by tortuosity and elongation of the aorta and medium-sized arteries. It is considered an extremely rare disease; only 106 individuals with genetically confirmed ATS have been identified to date. Four cases of ATS from two families are described, contributing to the clinical delineation of this condition. A patient with microcephaly and a complex uropathy and two cases with diaphragmatic hernia are noticed. Regarding the vascular involvement, a predominant supra-aortic involvement stands out and only 1 patient with significant arterial stenoses was described. All presented severe tortuosity of the intracranial arteries. To reduce hemodynamic stress on the arterial wall, beta-adrenergic blocking treatment was prescribed. A not previously described variant (NM_030777.4:c.899T>G (p.Leu300Trp)) was detected in a proband; it has an allegedly deleterious effect in compound heterozygous state with the pathogenic variant c.417T>A (p.Tyr139Ter). The other 3 patients, siblings born to healthy consanguineous parents, had a variant in homozygous state: c.510G>A (p.Trp170Ter).

Case report: De novo pathogenic variant in WFS1 causes Wolfram-like syndrome debuting with congenital bilateral deafness

Background: Congenital deafness could be the first manifestation of a syndrome such as in Usher, Pendred, and Wolfram syndromes. Therefore, a genetic study is crucial in this deficiency to significantly improve its diagnostic efficiency, to predict the prognosis, to select the most adequate treatment required, and to anticipate the development of other associated clinical manifestations.

Case presentation: We describe a young girl with bilateral congenital profound deafness, who initially received a single cochlear implant. The genetic study of her DNA using a custom-designed next-generation sequencing (NGS) panel detected a de novo pathogenic heterozygous variant in the WFS1 gene related to Wolfram-like syndrome, which is characterized by the presence of other symptoms such as optic atrophy. Due to this diagnosis, a second implant was placed after the optic atrophy onset. The speech audiometric results obtained with both implants indicate that this work successfully allows the patient to develop normal speech. Deterioration of the auditory nerves has not been observed.

Conclusion: The next-generation sequencing technique allows a precise molecular diagnosis of diseases with high genetic heterogeneity, such as hereditary deafness, while this was the only symptom presented by the patient at the time of analysis. The NGS panel, in which genes responsible for both syndromic and non-syndromic hereditary deafness were included, was essential to reach the diagnosis in such a young patient. Early detection of the pathogenic variant in the WFS1 gene allowed us to anticipate the natural evolution of the disease and offer the most appropriate management to the patient.

The Charlotte Project: Recommendations for patient-reported outcomes and clinical parameters in Dravet syndrome through a qualitative and Delphi consensus study

Objective

The appropriate management of patients with Dravet Syndrome (DS) is challenging, given the severity of symptoms and the burden of the disease for patients and caregivers. This study aimed to identify, through a qualitative methodology and a Delphi consensus-driven process, a set of recommendations for the management of DS to guide clinicians in the assessment of the clinical condition and quality of life (QoL) of DS patients, with a special focus on patient- and caregiver-reported outcomes (PROs).

Methods

This study was conducted in five phases, led by a multidisciplinary scientific committee (SC) including pediatric neurologists, epileptologists, a neuropsychologist, an epilepsy nurse, and members of DS patient advocates. In phases 1 and 2, a questionnaire related to patients' QoL was prepared and answered by caregivers and the SC. In phase 3, the SC generated, based on these answers and on a focus group discussion, a 70-item Delphi questionnaire, covering six topic categories on a nine-point Likert scale. In phase 4, 32 panelists, from different Spanish institutions and with a multidisciplinary background, answered the questionnaire. Consensus was obtained and defined as strong or moderate if ≥80% and 67–79% of panelists, respectively, rated the statement with ≥7. Phase 5 consisted of the preparation of the manuscript.

Results

The panelists agreed on a total of 69 items (98.6%), 54 (77.14%), and 15 (21.43%) with strong and moderate consensus, respectively. The experts' recommendations included the need for frequent assessment of patient and caregivers QoL parameters. The experts agreed that QoL should be assessed through specific questionnaires covering different domains. Likewise, the results showed consensus regarding the regular evaluation of several clinical parameters related to neurodevelopment, attention, behavior, other comorbidities, and sudden unexpected death in epilepsy (SUDEP). A consensus was also reached on the instruments, specific parameters, and caregivers' education in the routine clinical management of patients with DS.

Conclusions

This consensus resulted in a set of recommendations for the assessment of clinical and QoL parameters, including PROs, related to the general evaluation of QoL, neurodevelopment, attention, behavior, other comorbidities affecting QoL, SUDEP, and QoL of caregivers/relatives and patients with DS.

AB1237 COMPARISON BETWEEN ENZYME IMMUNOASSAY AND CHEMILUMINESCENCE TO DETERMINE THE CONCENTRATION OF SERUM CALPROTECTIN AND ITS ASSOCIATION WITH CLINICAL VARIABLES IN PEDIATRIC RHEUMATOLOGY

Background

Serum calprotectin (SC) is an emerging biomarker in the measurement of inflammation. It can be determined by different techniques, such as enzyme immunoassay (EIA) or chemiluminescence (CLIA). However, there are no studies comparing whether there is a correlation between the two diagnostic methods in paediatric rheumatologic diseases.

Objectives

(i) To assess whether there are differences between serum calprotectin (SC) levels determined by EIA (Bühlmann) method and CLIA (QUANTA Flash) in pediatric age patients with systemic autoimmune rheumatic disease (SARD). (ii) To evaluate which clinical and analytical variables are associated with an increase of SC in each method.

Methods

Analytical cross-sectional study that included patients from a pediatric rheumatology specialized unit between 02/2017 and 05/2021. We included 41 patients with SARD who had at least one SC analysis determined by EIA in their routine controls (144 serum) and afterwards had SC determined again, this time using the CLIA method.

The collected variables were sex, age, remission according to clinical judgment, swollen joint count according to physical examination (PE Count) and ultrasound (US Count), Juvenile Arthritis Disease Activity Score according to physical examination (PE JADAS-27) and ultrasound (US JADAS-27), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).

As for the statistical analysis, intraclass correlation (ICC) and paired samples t-test were performed to compare the two methods. Univariate linear regression was performed to study the association between EIA, CLIA and both clinical and analytical variables.

Results

We included 41 patients, 50.1% were women with a mean age (± SD) of 13.1 (± 3.8) years. The details of their descriptive characteristics were: mean SC (EIA) of 3.1 (±1.8) µg/ml, mean SC (CLIA) of 2.5 (±1.6) µg/ml, mean CRP of 2.6 (± 6.5) mg/l, mean ESR of 10.1 (± 11) mm/h, and mean PE JADAS-27 of 2.8 (± 8). Most frequent diagnosis was oligoarticular juvenile idiopathic arthritis (JIA) (24.4%), followed by enthesitis-related (ERA) JIA (12.2%) and polyarticular JIA (12.2%), familial Mediterranean fever (FMF) (9.8%), psoriatic JIA (4.9%), systemic JIA (4.9%) and syndrome of periodic fever, aphtous stomatitis, pharyngitis, and cervical adenitis (PFAPA) (4.9%), vasculitis (4.8%), and undifferentiated JIA (2.4%). Clinical diagnosis was unspecific in 9.8% of the patients. In our sample, 66.7% were in clinical remission at the discretion of the specialist.

A statistically significant Pearson’s CCI of 0.77 (95%CI 0.70-0.83; p=0.00) was observed as a single measure between EIA and CLIA and with an average of 0.87 (95%CI=0.82-0.91; p=0.000). Figure 1 shows the dispersion of this correlation.

On the other hand, we observed a statistically significant difference in the mean between both methods of 0.58 (95%CI=0.40-0.77; p=0.000), observing a greater difference in SC (EIA) > 4 µg/ml.

A significant association was observed between EIA and clinical remission, joint count, JADAS and CRP; and also between CLIA and clinical remission, JADAS and CRP. The analysis performed is shown in Table 1.

Table 1.

Association between EIA and CLIA with clinical and analytical variables.

RemissionPE CountUS CountPE JADASUS JADASbpbpbpbpbpSC(EIA)0.430.0110.140.0270.080.0240.090.0000.060.000SC(CLIA)0.530.000-0.000.9450.310.3200.050.0210.040.015SexGenderESRCRPbpbpbpbpSC(EIA)0.000.9970.050.2070.000.4870.050.027SC(CLIA)-0.240.3620.010.7950.020.1050.080.000

b, regression coefficient; p, statistical significance.

Conclusion

There is a good correlation between EIA and CLIA methods to determine SC in pediatric patients with SARD. Significant differences were observed between both methods above the value of 4 µg/ml. This fact could be explained by methodological differences, since CLIA discriminates better at higher values than EIA.

An association was observed between both methods and variables of remission or disease activity.

Disclosure of Interests

None declared

[Epidemiology and characteristics of SARS-CoV-2 infection in the newborn and pregnant woman. Transplacemental transfer of immunoglobulins]

Introduction

SARS-CoV-2 infection during pregnancy and its impact on the newborn were, in the first months of the pandemic, unknown. Recent studies have provided information on the clinical involvement in the newborn and its evolution.This work shows how passive immunity varies in the newborn in relation to the moment of maternal SARS-CoV-2 infection during pregnancy.

Population and method

Observational, prospective and longitudinal study in a third level hospital. Epidemiological and clinical data from mothers and their newborns were collected from May 2020 to June 2021.

Results

A total of 109 mothers and 109 neonates have been included. 28.4% of maternal infections were in the first trimester, 24.8% during the second and 58.8% in the third. 56% of maternal infections were symptomatic and only one pregnant woman with severe respiratory infection was admitted to intensive care. The mean gestational age of the newborns was 39 weeks, with a mean weight of 3232 g and a head circumference of 35 cm. Eight newborns born from mothers with SARS-CoV-2 required admission to the neonatal ICU: 2 due to jaundice, 2 due to respiratory distress, 1 due to moderate prematurity, and 3 due to other causes unrelated to infection attributable to SARS-CoV-2. IgG-type antibodies were positive in 56.9% of newborns. Of the mothers infected during the 1 st trimester, IgG were positive in 32.2% of the newborns, in the second trimester 81.5% were positive and in the third 58.8%. No neonate had positive IgM.

Conclusions

SARS-CoV-2 infection during pregnancy provides IgG antibodies to half of newborns. The presence of antibodies in the newborn is more likely when the infection has occurred in the second trimester of pregnancy.

Neurologic Complications in Pediatric Allogeneic Stem Cell Transplantation: Analysis of Risk Factors and Outcome

Neurologic complications following stem cell transplantation are of utmost importance owing to their high morbimortality. Although many studies have been performed in the adult population, reports in children are scarce. Our objective was to determine the most common neurologic complications in a pediatric population and to analyze possible risk factors for their development. We performed an exploratory retrospective study of neurologic complications in pediatric patients who had allogeneic stem cell transplantation over the last 18 years. We identified 66 neurologic complications in 178 allogeneic stem cell transplantations. The most frequent neurologic complications were those involving the peripheral nervous system and those related to drug toxicity. Survival decreased significantly in the presence of neurologic complications. Multivariate logistic regression analysis showed that independent risk factors for developing neurologic complications were development of chronic extensive graft-vs-host disease requiring treatment, cytomegalovirus reactivation, and central nervous system radiation. Prompt diagnosis and preemptive treatment, if possible, are necessary to avoid long-term sequelae or mortality.

Long-term Efficacy of Perampanel in a Child with Dravet Syndrome

Dravet syndrome is a genetic developmental and epileptic encephalopathy (DEE) mostly due to mutations in SCN1A gene. Perampanel is a selective and non-competitive alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonist. There is increasing experience in the use of perampanel in this syndrome; however, there is still a lack of evidence of sustained benefit years after the beginning of the treatment.

We report a twelve-year-old girl who was diagnosed with Dravet Syndrome when she was 2 years old and has been on perampanel since she was 7. Her genetic test showed a de novo previously described heterozygous SCN1A mutation in the 24th exon (c.4547C>A, p.Ser1516*). She received previous antiseizure drug combinations with little benefit. When perampanel was started, there was a complete resolution of her spontaneous seizures that has continued five years later. More studies are needed to investigate if there is an association between this excellent response and the genotype of our patient.

Impact of COVID-19 on Spanish patients with Dravet syndrome and their caregivers: consequences of lockdown

INTRODUCTION

The COVID-19 pandemic caused a state of alarm in Spain in March 2020. The necessary approach to the care of patients with Dravet syndrome (DS) makes them and their caregivers a vulnerable group in emergency situations.

OBJECTIVES

To explore the impact of the COVID-19 pandemic on the management and condition of Spanish patients with DS and their caregivers and families.

MATERIALS AND METHODS

Analysis of data belonging to Spanish families taken from a European online survey (14 April-17 May 2020). It included data on DS patients, on the disease and on caregivers before and after lockdown during the state of alarm.

RESULTS

Sixty-nine Spanish families participated; average age of patients: 12.6 years. Except in 19% of the cases that were isolated, protective/isolation measures for patients were followed without increasing. Epilepsy remained stable, with no medication or resource/personnel availability issues. Sleep-wake pattern (61%) and behavior (41%) of patients changed. Behavior change was associated with seizures during lockdown and with caregiver emotional state (changes in 76%). Psychological support was offered to only 9% of caregivers. Thirty-eight per cent of patients did not receive remote care.

CONCLUSIONS

The experience gathered during the lockdown has allowed the detection of points of improvement to ensure the proper management of DS and to keep the situation of patients and caregivers stable. All of this with a prominent role of telemedicine.

A case report of PHF6 mosaicism: Beyond the classic Börjeson-Forssman-Lehmann syndrome

We report a 6-year-old female with linear skin hyperpigmentation on the axillae and groin, intellectual disability, dysplastic teeth and nails, and facial dysmorphism who was diagnosed with a novel PHF6 pathogenic splicing variant. Males with PHF6 mutations have been associated with the X-linked recessive disorder Börjeson-Forssman-Lehmann, but females have a distinct phenotype which is likely modulated by X-inactivation.

Neurologic Care of COVID-19 in Children

Most children with SARS-CoV-2 infection have relatively mild clinical symptoms without fever or pneumonia, although severe cases with multiple-organ failure have been reported. Neurological symptoms, which have been mainly reported in adults, are very rare in children. This article will review 2 different aspects of neurological involvement related to this infection in children. In the first part, we will review the neurological abnormalities reported in children caused by this viral infection. Adults frequently report muscle pain, headache, anosmia, dysgeusia, and occasionally more severe central or peripheral nervous system damage. Neurological involvement seems infrequent in children, although some cases have been reported. In the second part, we will discuss the COVID-19 pandemic impact on the healthcare system of some countries, causing collateral damage to general pediatric care and in particular to those children affected with chronic diseases, mainly neurological conditions, including autism, intellectual disability, attention deficit and hyperactivity disorder (ADHD), neuromuscular disorders, cerebral palsy, and epilepsy, and patients needing neurosurgical procedures.

[Neurological complications in haematopoietic stem cell transplant patients]

INTRODUCTION

Neurological complications are some of the most important complications that can occur in a patient undergoing haematopoietic stem cell transplantation (HSCT), not only because of the high mortality rate, but also because of the sequelae that appear in survivors. The causes of such complications are manifold and very often coexist in the same patient: toxicity of the conditioning regimen, graft-versus-host disease and its treatment, infections and their treatment, platelets and coagulation disorders, liver failure or arterial hypertension with low platelet count.

AIMS

The aim of the present study is to provide a clinical description and to describe the risk factors for complications involving the central nervous system that may occur during the course of HSCT, in order to assist in the early detection of these disorders that may have a negative influence on the morbidity and mortality of these patients.

DEVELOPMENT

The following types of neurological complications are described: central nervous system infections, vascular complications, pharmacological toxicity, metabolic complications, immune-mediated disorders and post-HSCT carcinogenesis, and effects of graft-versus-host disease and thrombotic microangiopathy on the nervous system.

CONCLUSIONS

The patient undergoing HSCT is at particular risk for the development of neurological complications. Early diagnosis and treatment are needed to try to reduce the high morbidity and mortality in these patients.

AB0997 IS HEIGHT ADJUSTMENT NECESSARY IN PEDIATRIC DENSITOMETRY IN ALL CHILDREN?

Background:

The current guidelines of the International Society for Clinical Densitometry (1) recommend that in children with linear growth or maturational delay, Z score results should be adjusted. Height for age Z score (HAZ) adjustment is valid and can be calculated using the formula the formula proposed by Zemmel et al(2).

It is possible that pediatric populations without linear growth or maturational delay, also benefit from HAZ, to prevent bone size from influencing the final Z score.

Objectives:

To evaluate Z score variability adjusted and without adjusting for height for age.

Methods:

We analysed data from densitometry performed on patients 2-20 years of age, from 2016 to 2018, assessed in the pediatric rheumatology office of our hospital for presenting risk factors for low bone mass/osteoporosis. The HAZ was calculated according to Zemel’s formula.

Results:

Data from 103 patients are presented. Its characteristics are summarized in Table 1

Table 1.Mean age9,8 yearsFemale52,4%Height Percentil ≤ 36,8%Height Percentil ≥ 974,9%LBM (Z score ≤ -2) spine8,2%LBM HAZ spine6,4%LBM whole body10,5%LBM HAZ whole body7,2%

The table shows that the proportion of patients with BMD decreases in both the spine region and the whole body when adjusting for HAZ.

When evaluating the relationship between densitometric measurements we found that spine Z score (ZsS) and whole body Z score (ZsWB) had a correlation coefficient of 0,73 (p<0,001). There were no differences between their averages (p=0,170).

At the LBM cut-off point (Z score ≤ -2) there were discrepancies in 7%, where 5% presented LBM in ZsWB but not in ZsS. The concordance index at this point was 0,557.

When comparing these measures with their HAZ adjusted equivalents, we observe:

Conclusion:

There are discrepancies at the LBM cut-off point depending on the HAZ adjustment.

The pediatric population without linear growth or maturational delay, can also benefit from HAZ adjustment, especially those with high height percentiles in which their size can hide a diagnosis of LBM.

References:

[1]Weber DR, Boyce A, Gordon C, Hogler W, Kecskemethy HH, Misra M, et al. The Utility of DXA Assessment at the Forearm, Proximal Femur, and Lateral Distal Femur, and Vertebral Fracture Assessment in the Pediatric Population: 2019 ISCD Official Position. Journal of clinical densitometry: the official journal of the International Society for Clinical Densitometry. 2019;22(4):567-89.

[2]Zemel BS, Leonard MB, Kelly A, Lappe JM, Gilsanz V, Oberfield S, et al. Height adjustment in assessing dual energy x-ray absorptiometry measurements of bone mass and density in children. The Journal of clinical endocrinology and metabolism. 2010;95(3):1265-73.

Disclosure of Interests:

None declared

AB0998 TRABECULAR BONE SCORE IN PEDIATRICS, IS IT USEFUL?

Background:

Bone fragility depends not only on bone mineral density (BMD), but also on bone microarchitecture. In adults, Trabecular Bone Score (TBS) is being used as an indirect marker of bone microarchitecture

It is a software that applicated to the vertebral image obtained by conventional densitometry, informs about the thickness of the trabeculae, the trabecular connectivity and the space between them. A high score indicates a better bone microstructure. In adults, a TBS equal to or greater than 1,350 is considered to represent a normal microarchitecture

Objectives:

To evaluate the usefulness of TBS in pediatric population with risk factors for Low Bone Mass (LBM)

Methods:

TBS was assessed by analyzing vertebral densitometries performed on patients from 4 to 20 years of age, assessed in the pediatric rheumatology office of our hospital for presenting risk factors for LBM, consecutively from 2016 until 2018

Data were compared with normal pediatric population

Results:

Data from 83 patients are shown, with an average age of 11.2 years, 62% female, 80% Caucasian

The main risk factors for LBM were (%): Insufficient calcium intake (84,5), medications with osteopenizing potential (31), corticosteroids (39), sedentary lifestyle (13,6), fractures of long or vertebral bones (12,6) and hypovitaminosis D (8,1)

Table 1.

TBS por age groups and in patients with and without LBM

Age groupsnMeanSDMinimum-MaximumScholars (4-9a)221,3210,0931,119-1,502Adolescence (10-17a)541,3090,0881,073-1,493Youth (18-20a)61,3590,0851,258-1,460Spine Z scorenMean (SD)pMinimum-Maximum ≤-281,270 (0,075)0,1261,419-1,162 >-2741,321 (0,090)1,502-1,073Whole Body Z score ≤-291,246 (0,060)0,0121,323-1,145 >-2731,324 (0,089)1,502-1,073Table 2.

TBS in healthy population and study population for age

Healthy girls (n=2535)Healthy boys (n=1459)Study girls (n=47)Study boys (n=36)Age (y)Spine BMDTBSSpine BMDTBSTBSTBS1-20,401,3250,371,2722-30,511,3630,461,2671,1273-40,521,3460,511,2641,2044-50,601,3460,601,2671,2371,2435-60,601,2880,561,2691,3301,3686-70,651,2800,601,2321,3181,4227-80,671,2680,641,2441,3391,3458-90,711,2660,681,2281,2449-100,751,2780,701,2081,2531,34110-110,81,2850,731,2311,2291,29211-120,841,3370,761,2501,3031,31512-130,991,3550,811,2481,3811,36813-141,061,3860,891,2731,3941,33814-151,101,3980,991,3031,4741,28515-161,141,4051,081,3111,3681,40616-171,171,4051,151,3341,3321,37117-181,171,4041,201,3281,3741,28518-191,171,4041,161,314

Conclusion:

TBS was lower in the patients with LBM by whole body Z score, but not in those with LBM by spine Z score. We observed a decrease in TBS in adolescence, not corresponding with a decrease in BMD, and that should not be interpreted as a pathological finding

Similar results have been described in other pediatric populations (1, 2), but larger studies are needed to evaluate this phenomenon. We hypothesize that it may be due to a higher rate of growth in adolescence, with a lower rate of calcium apposition into the osteoid material

References:

[1]Del Rio DS, Winthenrieth R. BONE MICROARCHITECTURE (TBS) AND BONE MASS DEVELOPMENT DURING CHILDHOOD AND ADOLESCENCE IN A SPANISH POPULATION GROUP. . WCO-IOF-ESCEO; Seville2014.

[2]Shawwa K, Arabi A, Nabulsi M, et al. Predictors of trabecular bone score in school children. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2016;27(2):703-10.

Disclosure of Interests:

None declared

Less common manifestations in TSC

Tuberous sclerosis complex (TSC) is due to pathogenic variants in TSC1 or TSC2 genes resulting in hyperactivation of the mTOR pathway. Many organ systems can be affected, such as brain, skin, eye, heart, bone, kidney, or lung. Typical lesions of TSC usually are those included as major criteria, including angiofibromas, hypomelanotic macules, tubers, subependymal nodules, angiomyolipomas, cardiac rhabdomyomas, and lymphangioleiomyomatosis. However, there are many other manifestations less frequent and/or less well known, many of them not included as clinical diagnostic criteria that are part of the clinical spectrum of TSC. The focus of this review will be on these less common and less well-known manifestations of TSC. Among the rare manifestations, we will discuss some clinical findings including arteriopathy, arachnoid cysts, lymphatic involvement, chordomas, gynecological, endocrine, and gastrointestinal findings. Among the manifestations that are very frequent but much less well known, we find the sclerotic bone lesions. Although they are very frequent in TSC they have been largely overlooked and not considered diagnostic criteria, mainly because they are asymptomatic. However, it is important to know their typical characteristics to avoid misdiagnosing them as metastasis.

Pediatric Klüver-Bucy Syndrome: Report of Two Cases and Review of the Literature

Klüver-Bucy syndrome (KBS) is a rare behavioral phenotype described in monkeys and humans that appears most often after bilateral temporal damage. The main features of KBS are compulsion to examine objects orally, increased sexual activity, placidity, hypermetamorphosis, visual agnosia, and amnesia. Cases in children are scarce, and the most frequently reported etiology is herpes encephalitis. Hyperorality (90%), hypersexuality (82%), and epilepsy (70%) were the most common features of the 51 cases reported in the literature to date. Carbamazepine, selective serotonin reuptake inhibitors (SSRIs), and neuroleptics have been used for symptomatic treatment with variable control. Corticosteroids or immunosupressive agents, such as rituximab, can be an option to use in some cases, according to etiology suspicion. Cognitive and behavioral disturbances after KBS are often severe, but improvement can occur over a long time and residual disabilities vary from major to fairly mild.We report two new encephalitis-associated pediatric patients and review all of the pediatric KBS cases in the literature to better describe the clinical features of this rare neurobehavioral condition.

Cerebellar lesions are associated with TSC2 mutations in tuberous sclerosis complex: a retrospective record review study

AIM

Cerebellar lesions are present in approximately 30% of patients with tuberous sclerosis complex. Although several prior studies have characterized these lesions, our study provides the first description of the specific distribution of these lesions within the cerebellum and the first genotype-phenotype correlation yet to be published.

METHOD

We retrospectively reviewed magnetic resonance images from 220 paediatric and adult patients with tuberous sclerosis complex (95 males, 125 females; mean age 22.7y, range 9mo-81y). Sex, age, and genotype of patients with cerebellar lesions were recorded and specific characteristics, including signal intensity, number, shape, presence of enhancement, calcification or haemorrhage, and location within the cerebellar lobules were noted.

RESULTS

Fifty-eight patients (26.4%) had 106 cerebellar lesions (62 right, 44 left). The mean number of cerebellar lesions per patient was 1.8 (range 1-6). Enhancement was present in 42.4% of lesions and folial retraction in 84%. Calcification was detected in 86.8% of lesions. Patients with calcified lesions were older (mean age 21.6y) than patients without calcification (11.5y). TSC2 mutations were detected in 41/42 (97.6%) of patients with cerebellar tubers who had genetic testing and one patient had no mutation identified. None of the patients had TSC1 mutation.

INTERPRETATION

We provide new information regarding cerebellar lesions in tuberous sclerosis complex: cerebellar lesions are significantly much more frequent in patients with TSC2 mutations than TSC1 mutations or patients with no mutation identified, and Crus II is the most frequent location of cerebellar lesions. New studies are needed to assess the clinical significance of these lesions.

Cerebral arteriopathy associated with heterozygous Arg179Cys mutation in the ACTA2 gene: Report in 2 newborn siblings

Mutations in the ACTA2 gene lead to a multisystemic smooth muscle dysfunction syndrome that causes vascular disease, congenital mydriasis, and variable presentation of urinary and gastrointestinal problems. The heterozygous Arg179 mutation is associated with a distinctive cerebrovascular phenotype. We report the cases of two newborn siblings with heterozygous ACTA2 Arg179Cys substitution and provide neuroimaging exams that demonstrate the distinctive cerebrovascular phenotype, also associated with variable degree of hypoplasia of the vertebro-basilar circulation as well as hypoxic-ischemic lesions.

Seizures and electroencephalography findings in 61 patients with fetal alcohol spectrum disorders

Fetal alcohol spectrum disorders (FASD) cause neurodevelopmental abnormalities. However, publications about epilepsy and electroencephalographic features are scarce. In this study, we prospectively performed electroencephalography (EEG) and brain magnetic resonance (MR) imaging in 61 patients with diagnosis of FASD. One patient had multiple febrile seizures with normal EEGs. Fourteen children showed EEG anomalies, including slow background activity and interictal epileptiform discharges, focal and/or generalized, and 3 of them had epilepsy. In one patient, seizures were first detected during the EEG recording and one case had an encephalopathy with electrical status epilepticus during slow sleep (ESES). Focal interictal discharges in our patients did not imply the presence of underlying visible focal brain lesions in the neuroimaging studies, such as cortical dysplasia or polymicrogyria. However, they had nonspecific brain MR abnormalities, including corpus callosum hypoplasia, vermis hypoplasia or cavum septum pellucidum. The latter was significantly more frequent in the group with EEG abnormal findings (p < 0.01).

Sclerotic bone lesions at abdominal magnetic resonance imaging in children with tuberous sclerosis complex

BACKGROUND

Sclerotic bone lesions are often seen on chest CT in adults with tuberous sclerosis complex.

OBJECTIVE

To characterize bone lesions at abdominal MRI in children with tuberous sclerosis complex.

MATERIALS AND METHODS

This retrospective review included 70 children with tuberous sclerosis complex who had undergone abdominal MRI for renal imaging. An additional longitudinal study was performed in 50 children who had had two or more MRI scans. Abdominal CT (eight children) and radiographs (three children) were reviewed and compared with MRI.

RESULTS

A total of 173 sclerotic bone lesions were detected in 51/70 children (73%; 95% confidence interval: 0.61-0.82) chiefly affecting vertebral pedicles. New lesions appeared in 20 children and growth of previous sclerotic bone lesions was documented in 14 children. Sclerotic bone lesions were more frequent in girls and in children with more extensive renal involvement.

CONCLUSION

Sclerotic bone lesions are commonly detected by abdominal MRI in children with tuberous sclerosis complex. They usually affect posterior vertebral elements and their number and size increase with age. As current recommendations for tuberous sclerosis complex surveillance include renal MR performed in childhood, recognition of these lesions is useful.

Electroencephalographic patterns during sleep in children with chromosome 15q11.2-13.1 duplications (Dup15q)

Our objective was to define the EEG features during sleep of children with neurodevelopmental disorders due to copy number gains of 15q11-q13 (Dup15q). We retrospectively reviewed continuous EEG recordings of 42 children with Dup15q (mean age: eight years, 32 with idic15), and data collected included background activity, interictal epileptiform discharges, sleep organization, and ictal activity. Three patterns were recognized: Pattern 1: Alpha–delta sleep was noted in 14 children (33%), not associated with any clinical changes. Pattern 2: Electrical status epilepticus in sleep was noted in 15 children (35%), all diagnosed with treatmentresistant epilepsy. Thirteen of the 15 children had clinical seizures. Pattern 3: Frequent bursts of high amplitude bifrontal predominant, paroxysmal fast activity (12–15 Hz) during non-REM sleep was noted in 15 children (35%). All 15 children had treatment-resistant epilepsy. This is the first report of electroencephalographic patterns during sleep of children with Dup15q reporting alpha-delta rhythms, CSWS, and high amplitude fast frequencies. Alpha-delta rhythms are described in children with dysautonomia and/or mood disorders and CSWS in children with developmental regression. The significance of these findings in cognitive function and epilepsy for the children in our cohort needs to be determined with follow-up studies.

Gel-free proteomic methodologies to study reversible cysteine oxidation and irreversible protein carbonyl formation

Oxidative modifications in proteins have been traditionally considered as hallmarks of damage by oxidative stress and aging. However, oxidants can generate a huge variety of reversible and irreversible modifications in amino acid side chains as well as in the protein backbones, and these post-translational modifications can contribute to the activation of signal transduction pathways, and also mediate the toxicity of oxidants. Among the reversible modifications, the most relevant ones are those arising from cysteine oxidation. Thus, formation of sulfenic acid or disulfide bonds is known to occur in many enzymes as part of their catalytic cycles, and it also participates in the activation of signaling cascades. Furthermore, these reversible modifications have been usually attributed with a protective role, since they may prevent the formation of irreversible damage by scavenging reactive oxygen species. Among irreversible modifications, protein carbonyl formation has been linked to damage and death, since it cannot be repaired and can lead to protein loss-of-function and to the formation of protein aggregates. This review is aimed at researchers interested on the biological consequences of oxidative stress, both at the level of signaling and toxicity. Here we are providing a concise overview on current mass-spectrometry-based methodologies to detect reversible cysteine oxidation and irreversible protein carbonyl formation in proteomes. We do not pretend to impose any of the different methodologies, but rather to provide an objective catwalk on published gel-free approaches to detect those two types of modifications, from a biologist's point of view.

Hippocampal abnormalities in magnetic resonance imaging (MRI) of 15q duplication syndromes

Patients with 15q duplication syndromes, including isodicentric chromosome 15 and interstitial duplications, usually present with autism spectrum disorder, intellectual disability, and frequently epilepsy. Neuroimaging studies in these patients are typically reported as normal, but nonspecific findings such as thinning of the corpus callosum and increased pericerebral spaces have been reported. A review of brain magnetic resonance imaging (MRI) studies of 11 individuals seen at the Massachusetts General Hospital Dup15q Center was performed. Hippocampus morphology was specifically reviewed, as a recent neuropathologic study has found frequent hippocampal heterotopias and dysplasias in these disorders. Two subjects had unilateral hippocampal sclerosis and 6 had bilateral hippocampal malformations. Hypoplasia of the corpus callosum was present in 2 subjects.

Gastrointestinal problems in 15q duplication syndrome

Chromosome 15q duplication syndrome (Dup15q syndrome) is a neurodevelopmental disorder involving copy number gains of the maternal chromosome 15q11.2-q13 region, characterized by intellectual disability, developmental delay, autism spectrum disorder (ASD), and epilepsy. Gastrointestinal (GI) problems in Dup15q syndrome have been reported only rarely, mostly focused on neonatal feeding difficulties. A retrospective review of the medical records of 46 patients with Dup15q syndrome was conducted to assess GI issues and their treatments in this population. GI symptoms were present in 76.7% of subjects with an isodicentric duplication and 87.5% with an interstitial duplication. There was no clear association between GI issues and ASD, with symptoms occurring in 78.9% of all subjects and 78.2% of ASD subjects. The most commonly reported symptoms were gastroesophageal reflux (56.7%) and constipation (60%), with 30% of subjects reporting both. The most common treatments were polyethylene glycol for constipation and proton pump inhibitors for reflux. Behaviors such as irritability and aggressiveness improved with treatment of GI symptoms in several subjects. The results indicate that GI symptoms are common in Dup15q syndrome and may have an atypical presentation. Diagnosis may be difficult, especially in individuals who are nonverbal or minimally verbal, so increased awareness is critical for early diagnosis and treatment.

Absence of subependymal nodules in patients with tubers suggests possible neuroectodermal mosaicism in tuberous sclerosis complex

AIM

Patients with tuberous sclerosis complex (TSC) with brain involvement usually have both tubers and subependymal nodules (SENs) and the occurrence of one lesion without the other seems to be rare. The aim of this study was to assess the specific clinical manifestations and genotype of patients with one type of lesion or the other but not both.

METHOD

The magnetic resonance images of 220 patients with TSC were reviewed, and patients with either tubers or SENs, but not both, were identified.

RESULTS

Out of a total of 220 patients (95 males, 125 females; mean age 22y 9mo, range 9mo-81y), six (3%) had tubers without SENs (two males; four females; mean age 34y 10mo, range 11-48y); however, no patients with SENs and without tubers were identified. No mutation was identified (NMI) in any of the six patients who underwent mutational analysis of TSC1 and TSC2. Five of the six patients had three or fewer tubers.

INTERPRETATION

We found no patients with SENs but without tubers among our cohort. In all patients with tubers but without SENs, mutational studies of TSC1/TSC2 were negative, and the majority of these had three or fewer tubers. A possible mechanism for patients with NMI and an absence of SENs is a mosaicism with a first postzygotic mutation in the neuroectoderm.

Arachnoid cysts in tuberous sclerosis complex

OBJECTIVE

Some clinical findings in tuberous sclerosis complex (TSC), such as hypomelanotic macules or angiofibromas are related to problems in development of the neural crest, which is also the origin of cranial leptomeninges. Arachnoid cysts have been reported in two TSC patients to date. The purpose of this study was to assess the prevalence and characteristics of arachnoid cysts in a large cohort of TSC.

MATERIALS AND METHOD

We performed a review of brain MRIs of 220 TSC patients searching for arachnoid cysts.

RESULTS

Arachnoid cysts were found in 12 (5.5%) (general population: 0.5%), including ten males (83.3%). Four patients (33.3%) had also autosomal dominant polycystic kidney disease (ADPKD) due to a contiguous deletion of the TSC2-PKD1 genes. Three patients (25%) had two or more arachnoid cysts, of whom two also had ADPKD. One patient with an arachnoid cyst did not have tubers, subependymal nodules or white matter migration lines.

CONCLUSION

Our study suggests that arachnoid cysts are part of the clinical spectrum of TSC and may be also present in TSC patients without other typical TSC brain lesions.

Intracranial arteriopathy in tuberous sclerosis complex

Arterial aneurysms, mostly aortic and intracranial, have been occasionally reported in patients with tuberous sclerosis complex. Brain magnetic resonance imaging reports of 404 patients with definite and 16 patients with either probable or possible tuberous sclerosis complex were revised for intracranial aneurysms. Among these patients, brain images of 220 patients with definite and 16 with probable or possible tuberous sclerosis complex were reviewed. Intracranial aneurysms were reported in 3 of 404 patients with a definite diagnosis (0.74%) (general population: 0.35%), including 2 children. A fourth intracranial aneurysm was found in a patient with probable tuberous sclerosis complex, who did not have tubers or subependymal nodules but had clinical manifestations related to neural crest derivatives, including lymphangioleiomyomatosis and extrarenal angiomyolipomas. The authors hypothesize that neural crest dysfunction can have a major role in intracranial arteriopathy in tuberous sclerosis complex, as smooth muscle cells in the forebrain vessels are of neural crest origin.

Lymphedema in tuberous sclerosis complex

Congenital lymphedema has been described as a possible rare association of tuberous sclerosis complex (TSC), with only six previous cases reported in the literature. TSC is an autosomal dominant, multisystem disorder connected to aberrant regulation of the mammalian target of rapamycin (mTOR) pathway. The aim of this study is to review cases of lymphedema in a large cohort of TSC patients. The medical records of 268 patients seen at The Herscot Center for Children and Adults with Tuberous Sclerosis Complex at the Massachusetts General Hospital from 2002 to 2012 were retrospectively reviewed for reports of lymphedema or edema of unknown etiology. Genotypic and phenotypic data were collected in accordance with institutional review board (IRB) approval. This cohort presents two new cases of congenital lymphedema in TSC patients and acquired lymphedema was found in eight additional cases. Thus, we report 10 new cases of lymphedema in TSC (4%). The two patients with congenital lymphedema were female, as were the previous six reported cases. The frequency of lymphedema reported here (4%) is higher than the estimated prevalence in the general population (0.133-0.144%), suggesting a higher frequency of lymphedema in TSC. This study shows that patients with TSC and lymphedema are more likely to be females with renal AMLs and suggests that congenital lymphedema is a gender-specific (female) manifestation of TSC. Exploration of the potential role of mTOR antagonists may be important in treatment of lymphedema in TSC patients.

Stressor-related disorders in tuberous sclerosis

BACKGROUND

Patients with tuberous sclerosis complex (TSC) have high rates of psychiatric comorbidity, including mood and anxiety disorders. The aim of this study is to identify patients with stressor-related disorders such as posttraumatic stress disorder (PTSD) or adjustment disorder (AD) and to describe their clinical picture in the setting of TSC.

METHODS

Retrospective review of medical charts of TSC patients referred for a stressor-related disorder to a TSC psychiatric clinic.

RESULTS

We identified 7 females and 2 males (3 PTSD, 6 AD), including 4 children. Two patients with severe intellectual disability presented with aggression and the remaining patients presented with avoidance. The mean duration of symptoms at the time of the study was 21 months (range: 7 to 48 months) and 7 of the 9 patients still were having trauma-related symptoms. All the patients who received an initial diagnosis of AD had their diagnosis changed to another category because their symptoms lasted >6 months. In most cases, selective serotonin reuptake inhibitors improved the symptoms.

CONCLUSIONS

Stressor-related disorders in TSC frequently linger beyond 6 months and may appear with triggering events that typically are not viewed as trauma in a normal population.

Tuberous sclerosis complex without tubers and subependymal nodules: a phenotype-genotype study

Tuberous sclerosis complex (TSC) is caused by a mutation in the TSC1 or TSC2 genes. However, 15% of patients have no mutation identified. Tubers and subependymal nodules (SENs) are the typical brain lesions in TSC and are present in 90-95% of patients. The objective of this study is to characterize the specific genotype-phenotype of patients without these lesions. We analyzed the features of 11 patients without typical TSC neuroanatomic features. Ten had TSC1/TSC2 mutational analysis, which was negative. Clinically they had lesions thought to be of neural crest (NC) origin, such as hypomelanotic macules, facial angiofibromas, cardiac rhabdomyomas, angiomyolipomas, and lymphangioleiomyomatosis. We hypothesize that patients without tubers and SENs reflect mosaicism caused by a mutation in TSC1 or TSC2 in a NC cell during embryonic development. This may explain the negative results in TSC1 and TSC2 testing in DNA from peripheral leukocytes.

Klüver-Bucy syndrome after unilateral frontotemporal resection in a child with tuberous sclerosis

Klüver-Bucy syndrome (KBS) is a behavioral phenotype that appears most often after bilateral temporal damage. The main features of KBS are compulsion to examine objects orally, increased sexual activity, placidity, hypermetamorphosis (irresistible impulse to notice and react to everything within sight), visual agnosia, and problems with memory. It is more rarely reported in children than in adults. We present a case of KBS in a 2-year-old boy with tuberous sclerosis complex (TSC) after left frontotemporal resection for refractory epilepsy. This is the first KBS after unilateral temporal resection in a child, although it has already been reported in two adult cases. It also is the first case reported in a TSC patient.

Two-stage case-control association study of dopamine-related genes and migraine

BACKGROUND

We previously reported risk haplotypes for two genes related with serotonin and dopamine metabolism: MAOA in migraine without aura and DDC in migraine with aura. Herein we investigate the contribution to migraine susceptibility of eight additional genes involved in dopamine neurotransmission.

METHODS

We performed a two-stage case-control association study of 50 tag single nucleotide polymorphisms (SNPs), selected according to genetic coverage parameters. The first analysis consisted of 263 patients and 274 controls and the replication study was composed by 259 cases and 287 controls. All cases were diagnosed according to ICHD-II criteria, were Spanish Caucasian, and were sex-matched with control subjects.

RESULTS

Single-marker analysis of the first population identified nominal associations of five genes with migraine. After applying a false discovery rate correction of 10%, the differences remained significant only for DRD2 (rs2283265) and TH (rs2070762). Multiple-marker analysis identified a five-marker T-C-G-C-G (rs12363125-rs2283265-rs2242592-rs1554929-rs2234689) risk haplotype in DRD2 and a two-marker A-C (rs6356-rs2070762) risk haplotype in TH that remained significant after correction by permutations. These results, however, were not replicated in the second independent cohort.

CONCLUSION

The present study does not support the involvement of the DRD1, DRD2, DRD3, DRD5, DBH, COMT, SLC6A3 and TH genes in the genetic predisposition to migraine in the Spanish population.

[Ectopic mediastinal parathyroid adenoma. Detection with a radioisotopic probe and resolution with videothoracoscopy]

We report a 66 years old woman with a diagnosis of primary hyperparathyroidism. Localization to mediastinum was obtained with parathyroid scintigraphy using 99mtc-methoxy-isobutyl-isonitrite (Tc99-MIBI). The patient was successfully operated upon by means of a videothora-coscopic approach. During the procedure serum parathormone was measured before and 10 minutes after adenomectomy, showing a more than 50% reduction from the basal level. An attempt to detect the precise site of the adenoma with a Tc99-MIBI probe was unsuccessful because of its proximity to the myocardium, but radioactivity was confirmed on the surgical specimen after resection. The patient's calcemia and parathormone levels became normal during the postoperative course and she remains normocalcemic 9 months after the procedure. In our case, preoperative localization and intraoperative parathormone measurements were both very useful for confirming surgical success; the intraoperative localization with a radioactive probe was not useful, but radioactivity was confirmed after resection on the surgical specimen. The endoscopic surgical procedure with videothoracoscopy was well tolerated, less painful than a thoracotomy, and it shortened the hospitalization period.

Specific deactivation of the mouse mammary tumor virus long terminal repeat promoter upon continuous hormone treatment

We have studied the transcriptional behavior of the mouse mammary tumor virus long repeat (MMTV-LTR) promoter during a prolonged exposure to glucocorticoids. When integrated into XC-derived cells, MMTV-LTR expression reached its maximum during the first day of dexamethasone treatment, but longer exposure to the hormone resulted in the deactivation of the promoter. In contrast, glucocorticoid-responsive resident genes or MMTV-based transiently transfected plasmids maintained or even increased their mRNA levels during the same period of hormone treatment. An integrated chimeric construct containing the hormone-responsive elements from MMTV-LTR but in different sequence context became also deactivated after a prolonged hormone treatment but with a deactivation kinetics significantly slower than constructs containing the entire, chromatin-positioning MMTV-LTR sequence. The decrease on MMTV-LTR-driven transcription was concomitant with a parallel closure of the MMTV-LTR chromatin and with a decrease in glucocorticoid receptor (GR) concentration in the cell. We concluded that the chromatin-organized MMTV-LTR promoter is particularly sensitive to any decrease on GR levels. We propose that chromatin structure may contribute decisively to the differential expression of MMTV-LTR by two mechanisms: limiting MMTV-LTR accessibility to activating transcription factors and accelerating its shutting down upon a decrease on GR levels.