P11.13.B Long-term outcome of patients with WHO grade 3 glioma treated with radiotherapy and temozolomide or radiotherapy alone

Background

For a long time, for patients with WHO grade 3 glioma the gold-standard after surgical treatment has been radiotherapy (RT). Since the combined radio-chemotherapy became the standard as a postoperative therapy for patients with glioblastoma in 2005, the role of radio-chemotherapy with temozolomide (RT/TMZ) for patients with WHO grade 3 glioma has long been controversial. Evidence is growing that RT/TMZ provides advantages in progression-free survival (PFS) and overall survival (OS) in WHO grade 3 gliomas as well. The aim of this study was to compare RT/TMZ (after 2005) and RT alone (before or after 2005) for patients with WHO grade 3 glioma in the long term.

Material and Methods

167 adult patients with first diagnosis of a WHO grade 3 glioma between 1994 and 2019 and treatment with surgery and either RT/TMZ (after 2005) or RT (before or after 2005) were included. Clinical and sociodemographic parameters as well as IDH1/2-mutation-, MGMT-promotor methylation- and 1p/19q-codeletion-status of the patient’s FFPE-tumor-tissue have been retrospectively investigated. Primary outcome was PFS and OS depending on postoperative treatment with RT before 2005 (n = 75) vs. RT after 2005 (n = 33) vs. RT/TMZ after 2005 (n = 48). Therefore, Kaplan-Meier analysis has been performed.

Results

RT before 2005 showed a significant advantage over RT/TMZ after 2005 and RT after 2005 regarding the PFS (p < 0.05) and OS (p < 0.001). Median PFS was 3.34 years (95%-CI = 1.08 - 5.59) for RT before 2005 vs. 1.96 years (95%-CI = 0.89 - 3.02) for RT/TMZ after 2005 and 1.22 years (95%-CI = 0.00 - 2.50) for RT after 2005. RT/TMZ after 2005 showed a significant advantage over RT after 2005 regarding the OS (p < 0.05). Median OS was not reached for RT before 2005 vs. 4.90 years (95%-CI = 2.14 - 7.66) for RT/TMZ after 2005 and 1.60 years (95%CI = 0.43 - 2.78) for RT after 2005. To measure the variability of the therapy groups, a stratified risk analysis of risk factors including IDH1/2-mutation-, MGMT-promotor-methylation- and 1p/19q-codeletion-status, extent of resection, initial Karnofsky Performance Score, Ki67-score, age, gender, tumor entity and dose in gray has been performed by using the Kruskal-Wallis test and Fisher-Freeman-Halton test. There has been a significant difference in IDH1/2-mutation- and MGMT-promotor-methylation-status and dose in gray. Single risk analysis of that parameters resulted in superiority of the RT before 2005 over RT/TMZ after 2005 and RT after 2005 regarding the OS.

Conclusion

There have been several limitations in this study, for example the retrospective setting or the missing randomization of the patients. RT before 2005 resulted in the best long-term outcome, what has to be further investigated. However, RT/TMZ after 2005 showed a significant benefit for the OS in the long term vs. RT after 2005, supporting recent findings regarding the role of RT/TMZ in the therapy of WHO grade 3 gliomas.

Normal values for paediatric atrial volumes assessed by steady-state free-precession cardiovascular magnetic resonance

Background

Measurement of atrial volumes by steady-state free precession (SSFP)cardiovascular magnetic resonance (CMR) is becoming increasingly important in the treatment and follow-up of paediatric congenital heart disease. It has prognostic value in terms of heart failure and cardiovascular death. However, CMR normal values for the clinically often used mono- and biplane area-length method in children are lacking.

Aims

We sought to create paediatric normal values for atrial volumes using the mono- and biplane area-length method.

Methods

In a retrospective study design, CMR data sets of 157 healthy children with an age range between 4 and 18 years from two centers in the UK and Germany were evaluated. In a four-chamber (4ch-) view, left and right atrial (LA, RA) endocardial borders were segmented during end-diastole and end-systole to calculate minimal and maximal atrial volumes (LAmin, LAmax, RAmin, RAmax) using the monoplane area-length method. Additionally, end-diastolic and end-systolic LA endocardial borders were segmented in a two-chamber (2ch-) view. Using the measurements from the 2ch- and 4ch-views, minimal and maximal LA volumes were calculated using the biplane area-length method. Atrial volumes were normalized for body surface area (BSA in m2). Sex-specific reference curves were created using the lambda mu sigma method.

Results

The median age was 13.8±2.81 years (53 girls).

In children from 4–10 years average atrial volumes measured: monoplane 4ch: LAmin 10.2±3.5 ml/m2, LAmax 28.8±7.4 ml/m2, RAmin 14.1±6.3 ml/m2, RAmax 27.0±11.4 ml/m2; monoplane 2ch: LAmin 10.9±4.1 ml/m2, LAmax 27.0±6.1 ml/m2; biplane: LAmin 10.2±3.3 ml/m2, LAmax 27.4±5.7 ml/m2.

In children from 11–18 years average atrial volumes measured: monoplane 4ch: LAmin 13.6±4.9 ml/m2, LAmax 34.1±9.1 ml/m2, RAmin 19.2±6.8 ml/m2, RAmax 34.2±9.6 ml/m2; monoplane 2ch: LAmin 13.2±4.9 ml/m2, LAmax 31.4±9.7 ml/m2; biplane: LAmin 12.9±4.4 ml/m2, LAmax 31.8±8.8 ml/m2.

Separate centile charts and centile tables for boys and girls for all volumetric parameters were created.

Conclusion

We provide paediatric CMR reference values for atrial volumes. They can be used in the diagnosis and follow-up of congenital or acquired heart disease in children and for research purposes.

Funding Acknowledgement

Type of funding sources: None.

Normal values for paediatric biventricular volumes, ejection fraction and mass – influence of cardiovascular magnetic resonance analysis techniques

Background

Measurement of ventricular volumes and function by steady-state free precession (SSFP) cardiovascular magnetic resonance (CMR) is an important diagnostic tool in the treatment and follow-up of paediatric congenital heart disease. However, normal values are rare and the CMR analysis methods are inconsistent.

Aims

We sought to create two sets of ventricular normal values for different CMR analysis (contouring) methods.

Methods

In a retrospective study design, CMR data sets of 154 healthy children with an age range between 4 and 18 years from two centers in the UK and Germany were evaluated. Left and right ventricular end-diastolic and end-systolic volumes (LVEDV, LVESV, RVEDV, RVESV), ejection fraction (RVEF, LVEF) and myocardial mass (LVMM, RVMM) were analysed from short axis steady-state free precession images by using two different analysis techniques: 1) papillary muscles, myocardial trabeculations and the moderator band were included in the ventricular volume and excluded from the ventricular mass (Figure 1), 2) papillary muscles, myocardial trabeculations and the moderator band were excluded from the ventricular volume and included in the ventricular mass (Figure 2). Sex-specific reference curves were created separately for both ventricular contouring methods using the lambda mu sigma method. Correlations between variables were analyzed with the Spearman's rank correlation. Contouring methods were compared through Bland-Altman analysis.

Results

The mean age was 13.85±2.8 years (53 girls).

In children from 4 to 10 years average ventricular volumes and mass normalized for body surface area (BSA) measured:

In children from 11 to 18 years average ventricular volumes and mass measured:

Separate centile charts and centile tables for boys and girls for all cardiac parameters were created.

Conclusion

We provide paediatric CMR reference values for biventricular volumes, ejection and masses for two different CMR contouring methods. They can be used in the diagnosis and follow-up of congenital or acquired heart disease in children and for research purposes.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Cardiovascular magnetic resonance (CMR) normal values for pulmonary arteries in healthy children and adolescents

Funding Acknowledgements

Type of funding sources: None.

Background

Changes in the right ventricular outflow tract (RVOT) and pulmonary arteries (PAs) are often seen in paediatric patients with congenital heart disease (CHD), pulmonary hypertension or genetic disorders (e.g. Marfan syndrome, Loeys-Dietz syndrome, Williams syndrome, DiGeorge syndrome). Cardiovascular magnetic resonance (CMR) imaging is an excellent method to visualize the RVOT and PAs without the use of ionizing radiation and contrast media but for the interpretation of CMR data in the paediatric population the knowledge of normal values is crucial. However, normal values for pulmonary arteries from contrast-free cine CMR images are lacking.

Purpose

The aim of this retrospective multicentre study was to establish reference ranges for the diameters of the mean PA (MPA), right PA (RPA) and left PA (LPA).

Methods

163 CMR scans of healthy children and adolescents (mean age 13.8 ± 2.9 years; range 5-18 years) from two centres in the UK and Germany were included. The diameter of the MPA was measured in sagittal-oblique RVOT cine images and transaxial cine stacks, whereas the diameter of the RPA and LPA were measured from transaxial stacks and specific pulmonary artery branch cine images.

Results

Mean systolic and diastolic diameters for the MPA were 22.1 ± 2.8 mm (14.4 ± 2.2 mm/m²)/ 17.2 ± 2.3 mm (11.3 ± 1.9 mm/m²) measured in RVOT cine stacks. Mean systolic and diastolic diameters for the RPA and LPA were:  1) RPA, 12.4 ± 1.7 mm (7,9 ± 1,6 mm/m²)/ 9.8 ± 1.6 mm (5.9 ± 1.8 mm/m²) and 2) LPA, 13.3 ± 1.5 mm (8.3 ± 2.1 mm/m²)/ 10.8 ± 1.5 mm (6.8 ± 1.8 mm/m²). Separate centile charts for boys and girls for the MPA were created.

Conclusions

We established CMR normal values for the MPA, RPA and LPA for children and adolescents. Our data might be useful for the detection of PA stenosis and dilatation and may serve as a reference in future studies.

Cardiovascular magnetic resonance normal values for pulmonary arteries and ventricular volumes in paediatric patients with transposition of the great arteries after arterial switch operation

Funding Acknowledgements

Type of funding sources: None.

Background

The anatomy of the pulmonary arteries (PA) in patients with transposition of the great arteries (TGA) after arterial switch operation (ASO) with Lecompte manoeuvre is different compared to healthy subjects and stenoses of the PA are known to occur. Cardiovascular magnetic resonance (CMR) imaging is an excellent imaging modality to assess PA anatomy in TGA patients. However, disease specific normal values for PA size do not exist. Furthermore, the impact of pulmonary artery size, age and gender on ventricular volumes and function is unknown. Therefore, we sought to establish disease specific normative ranges for PA dimensions as well as biventricular volumes and function.

Methods

70 CMR scans of paediatric patients with TGA after ASO with Lecompte manoeuvre (mean age 12.3 ± 3.6 years; range 5-18 years; 57 males) were included. Cine CMR sequences as well as contrast-enhanced magnetic resonance angiography (CE-MRA) data were used to measure pulmonary artery dimensions. Right and left PA were each measured at three locations during its course around the aorta. Ventricular volumes, mass and ejection fraction were measured from a stack of short axis cine images.

Results

Mean systolic and diastolic diameters of the MPA were 15.0 ± 2.3 mm (10.5 ± 2.7 mm/m²) / 13.2 ± 2.9 mm (9.2 ± 2.9 mm/m²) and mean cross-sectional MPA area was 286.7 ± 81.7 mm². Mean systolic and diastolic diameters for the RPA and LPA at the narrowest point were: RPA 10.5 ± 2.8 mm (7.8 ± 2.4 mm/m²)  / 8.1 ± 2.2 mm (6.0 ± 1.9 mm/m²); LPA 8.4 ± 2.8 mm (6.2 ± 2.1 mm/m²) / 7.4 ± 2.3 mm (5.4 ± 1.6 mm/m²). Mean values for biventricular volumes, ejection fraction and mass were as follows: 1) left  ventricular (LV) end-diastolic volume (EDV) 89.0 ± 20.3 ml/m² and end-systolic volume (ESV) 35.1 ± 11.7 ml/m², 2) right ventricular (RV) EDV 76.4 ± 15.4 ml/m² and ESV 32.4 ± 9.1 ml/m², 3) LV and RV ejection fraction 61.1 ± 6.5 % / 58.9 ± 6.1 % and 4) LV and RV mass 59.6 ± 15.2 g/m² / 23.3 ± 7.4 g/m². Separate centile charts for boys and girls for PA dimensions as well as biventricular volumes, mass and ejection fraction were created.

Conclusion

We established disease specific CMR normal values for the PA dimensions as well as for ventricular volumes, mass and ejection fraction in paediatric patients with TGA after ASO. Our data will improve CMR image interpretation and may serve as a reference in future studies.

Low copy numbers of complement C4 and homozygous deficiency of C4A may predispose to severe disease and earlier disease onset in patients with systemic lupus erythematosus

Objectives Low copy numbers and deletion of complement C4 genes are potent risk factors for systemic lupus erythematosus (SLE). However, it is not known whether this genetic association affects the clinical outcome. We investigated C4 copy number variation and its relationship to clinical and serological features in a Northern European lupus cohort. Methods We genotyped the C4 gene locus using polymerase chain reaction (PCR)-based TaqMan assays in 169 patients with SLE classified according to the 1997 revised American College of Rheumatology (ACR) criteria and in 520 matched controls. In the patient group the mean C4 serum protein concentrations nephelometrically measured during a 12-month period prior to genetic analysis were compared to C4 gene copy numbers. Severity of disease was classified according to the intensity of the immunosuppressive regimens applied and compared to C4 gene copy numbers, too. In addition, we performed a TaqMan based analysis of three lupus-associated single-nucleotide polymorphisms (SNPs) located inside the major histocompatibility complex (MHC) to investigate the independence of complement C4 in association with SLE. Results Homozygous deficiency of the C4A isotype was identified as the strongest risk factor for SLE (odds ratio (OR) = 5.329; p = 7.7 × 10^-3) in the case-control comparison. Moreover, two copies of total C4 were associated with SLE (OR = 3.699; p = 6.8 × 10^-3). C4 serum levels were strongly related to C4 gene copy numbers in patients, the mean concentration ranging from 0.110 g/l (two copies) to 0.256 g/l (five to six copies; p = 4.9 × 10^-6). Two copies of total C4 and homozygous deletion of C4A were associated with a disease course requiring cyclophosphamide therapy (OR = 4.044; p = 0.040 and OR = 5.798; p = 0.034, respectively). Homozygous deletion of C4A was associated with earlier onset of SLE (median 24 vs. 34 years; p = 0.019) but not significant after correction for multiple testing. SNP analysis revealed a significant association of HLA-DRB1*0301 with SLE (OR = 2.231; p = 1.33 × 10^-5). Conclusions Our findings confirm the important role of complement C4 genes in the development of SLE. Beyond the impact on the susceptibility for lupus, C4 copy numbers may be related to earlier onset and a more severe course of the disease. The association of homozygous deletion of C4A and SLE is accompanied by the presence of HLA-DRB1*0301 without a proven pathophysiological mechanism.

SPAG7 is a candidate gene for the periodic fever, aphthous stomatitis, pharyngitis and adenopathy (PFAPA) syndrome

Periodic fever, aphthous stomatitis, pharyngitis and adenopathy (PFAPA) syndrome is an auto-inflammatory disease for which a genetic basis has been postulated. Nevertheless, in contrast to the other periodic fever syndromes, no candidate genes have yet been identified. By cloning, following long insert size paired-end sequencing, of a de novo chromosomal translocation t(10;17)(q11.2;p13) in a patient with typical PFAPA syndrome lacking mutations in genes associated with other periodic fever syndromes we identified SPAG7 as a candidate gene for PFAPA. SPAG7 protein is expressed in tissues affected by PFAPA and has been functionally linked to antiviral and inflammatory responses. Haploinsufficiency of SPAG7 due to a microdeletion at the translocation breakpoint leading to loss of exons 2-7 from one allele was associated with PFAPA in the index. Sequence analyses of SPAG7 in additional patients with PFAPA point to genetic heterogeneity or alternative mechanisms of SPAG7 deregulation, such as somatic or epigenetic changes.

[Pediatric fracture diagnosis--ultra-low-dose CT with an effective dose equal to that of radiographs]

PURPOSE

Computed tomography (CT) plays an important role in trauma diagnosis in children, especially for complex fractures. The aim of this study was to examine the diagnostic value of ultra-low-dose-CT (ULD-CT) with an effective dose equal to that of radiographs in an experimental study and to compare its results with those of radiographs.

MATERIALS AND METHODS

Limb bones of dead young pigs served as a model for pediatric bones. A total of 51 fractured and non-fractured bones were examined with a 64 multislice-CT with a standard dose protocol as gold standard, with two ultra-low-dose-protocols, and with standard radiographs with different exposures.

RESULTS

In spite of high background noise the examinations of ULD-CT were not adequate only in 2 of 204 cases. ULD-CT was slightly superior to radiographs in detection of fractures. ULD-CT could significantly better characterize the fractures than radiographs. The overall result of ULD-CT was significantly better than that of radiographs with standard exposure.

CONCLUSION

ULD-CT with the effective dose of radiographs is successfully applicable in pediatric fracture diagnosis, and its overall result is significantly better than that of radiographs.

Novel Tandem Duplication in Exon 1 of the SNURF/SNRPN Gene in a Child with Transient Excessive Eating Behaviour and Weight Gain

A deletion in 15q11.2 involving the SNURF/SNRPN gene is the typical finding in patients with Prader-Willi syndrome. Apart from translocations disrupting this gene, no other mutation types have been described so far. We report a patient in whom a small duplication in exon 1 of the SNURF/SNRPN gene was diagnosed which is predicted to interrupt only SNURF expression. The patient was investigated due to overgrowth, increased appetite and developmental delay in childhood. This duplication was inherited from her father who carries the duplication on his paternal chromosome 15 and also had transient excessive eating behaviour as an adolescent. RNA studies showed that the duplication introduces a premature stop codon in SNURF.

Transienter neonataler Diabetes und Hypomethylierungssyndrome

Der transiente neonatale Diabetes (TNDM) ist definiert als Manifestation einer diabetogenen Stoffwechsellage in den ersten Lebenswochen und Normalisierung des Glukosestoffwechsels bis zum 18. Lebensmonat. Zu den klinischen Kardinalsymptomen zählen intrauterine Wachstumsverzögerung, Hyperglykämie und Dehydratation bei fehlender Ketoazidose. Die Ätiologie des TNDM ist sehr heterogen. In 70% der Fälle ist die Erkrankung mit Aberrationen in der Chromosomenregion 6q24 assoziiert. Diese Chromosomenregion enthält die genomisch geprägten Gene PLAGL1/ZAC und HYMAI. Durch eine paternale uniparentale Disomie 6 (upd(6)pat), eine paternale Duplikation der geprägten Region in 6q24 oder durch Imprintingdefekte des maternalen Allels kommt es zu einer Überexpression des paternal exprimierten Gens PLAGL1. Imprintingdefekte können isoliert oder im Rahmen eines Hypomethylierungssyndroms mit Beteiligung mehrerer geprägter Loci des Genoms auftreten. Hypomethylierung an multiplen Loci wurde bis jetzt bei Patienten mit TNDM, Silver-Russell-Syndrom (SRS) und Beckwith-Wiedemann-Syndrom (BWS) beobachtet. Das Wiederholungsrisiko hängt wesentlich von der Ursache des TNDM an. Chromosomale Aberrationen der Eltern unter Beteiligung des Chromosoms 6 erhöhen das Risiko sowohl für eine UPD des geprägten Bereichs in 6q24 als auch für eine paternale Duplikation. Jedoch entstehen sowohl UPD als auch Duplikationen zumeist de novo.

Malignant melanoma and Wiedemann-Beckwith syndrome in childhood

Patients with Wiedemann-Beckwith syndrome (WBS, MIM 130650), a congenital overgrowth syndrome, have a known increased tumor risk especially for embryonic tumors. WBS belongs to the "imprinting" syndromes caused by overexpression of IGF2 and/or loss of CDKN1C on chromosome 11p15.5. A 13-year-old boy with WBS developed a spitzoid malignant melanoma (Clark level V, Breslow index 4.8 mm) on the right cheek. Genetic analyses of the patient's blood showed hypermethylation at the H19 locus on chromosome 11p. The (epi)genetic changes of the WBS locus might have played a role in the pathogenesis of melanoma development.

[Is ultrasound equal to X-ray in pediatric fracture diagnosis?]

PURPOSE

Ultrasound is currently not established for the diagnosis of fractures. The aim of this study was to compare ultrasound and X-ray beyond their use solely for the identification of fractures, i. e., for the detection of fracture type and dislocation for pediatric fracture diagnosis.

MATERIALS AND METHODS

Limb bones of dead young pigs served as a model for pediatric bones. The fractured bones were examined with ultrasound, X-ray, and CT, which served as the gold standard.

RESULTS

162 of 248 bones were fractured. 130 fractures were identified using ultrasound, and 148 using X-ray. There were some advantages of X-ray over ultrasound in the detection of fracture type (80 correct results using X-ray, 66 correct results using ultrasound). Ultrasound, however, was superior to X-ray for dislocation identification (41 correct results using X-ray, 51 correct results using ultrasound). Both findings were not statistically significant after adjustment for multiple testing.

CONCLUSION

Ultrasound not only has comparable sensitivity to that of X-ray for the identification of limb fractures but is also equally effective for the diagnosis of fracture type and dislocation. Thus, ultrasound can be used as an adequate alternative method to X-ray for pediatric fracture diagnosis.

CYP3A5 genotype markedly influences the pharmacokinetics of tacrolimus and sirolimus in kidney transplant recipients

It is currently not clear whether the concentration-time curves of the immunosuppressants differ with respect to the CYP3A5, MDR1, or MRP2 genotype in dose-adapted stable kidney transplant patients. Dose/trough concentration ratios were obtained in 134 tacrolimus and 20 sirolimus-treated patients, and plasma concentration-time profiles were obtained from 16 (tacrolimus) and 10 (sirolimus) patients. Genotyping was carried out for CYP3A5 6986A>G; ABCB1 2677G>T/A, 3435C>T and ABCC2 -24C>T; 1249G>A; 3972C>T. Dose/trough concentration ratios were 0.67+/-0.3 and 1.36+/-0.73 x 10(3) l (P<0.00001) for tacrolimus and 0.42+/-0.17 and 0.84+/-0.46 x 10(3) l (P=0.18) for sirolimus in CYP3A5 non-expressors and expressors. The unadjusted tacrolimus area under curve (AUC)(0-12) was 106.8+/-17.5 ng/ml x h compared with 133.3+/-42.2 ng/ml x h (P=0.37) without affecting serum creatinine. Mean unadjusted AUC(0-24) of sirolimus did not differ significantly either. Therefore, CYP3A5 expressor status and not transporter variants is a main determinant of oral clearance, particularly for tacrolimus. Dose adaptation according to trough levels, however, appears to be sufficient to maintain similar concentration-time profiles.

Open versus laparoscopic appendicectomy: a critical review

BACKGROUND

The benefit of laparoscopic appendicectomy remains unclear. We have analysed available randomised studies comparing laparoscopic and open appendicectomy regarding their clinical pitfalls and statistical relevance.

METHODS

Thirty eight studies were analysed in terms of the following aspects: A. clinical problems (e.g., expertise of the surgeons, pre- and postoperative antibiotic treatment, definition of complications, blinding of outcomes) and B. statistical problems (e.g., definition of primary and secondary outcomes, power and sample size, statistical methods, confidence intervals, comparability of groups and studies).

RESULTS

Most of the studies have clinical and statistical pitfalls. The most important pitfalls are the uncertain expertise of the operating surgeons, blinding, and the exploratory nature of the studies. Our analysis aims at giving useful information for the appraisal of existing studies and the conduct of further studies. It also gives some preliminary results.

CONCLUSIONS

More than twenty years after Semm performed the first laparoscopic appendicectomy, it is necessary to clarify the superiority of laparoscopic or open appendectomy with well-defined, carefully designed randomised studies.

Sigmoid diverticulitis in patients with Williams-Beuren syndrome: relatively high prevalence and high complication rate in young adults with the syndrome

In a retrospective survey of 128 adults with Williams-Beuren syndrome (age range 18-62 years) sigmoid diverticulitis was reported in 10 patients (2 f, 8 m). The diagnosis of diverticulitis had been made between the ages of 17.1 and 39.6 years. An additional four patients (age range 23.5-32.2 years) had presented with sigmoid diverticulosis. In eight patients the course of the disease was complicated, some of them having to undergo multiple surgery. Conservative therapy was successful in only one female and one male patient with diverticulitis. Thus, we conclude that there is an increased prevalence of sigmoid diverticulitis in adult patients with Williams-Beuren syndrome (8% vs. 2% in the normal population in the age group below 40 years).

Phenotypical variation in cousins with the identical partial trisomy 9 (pter-q22.2) and 7 (q35-qter) at 16 and 23 weeks gestation

From the study of numerical and structural chromosomal abnormalities, there is convincing evidence and accumulating information of a direct karyotype to phenotype correlation. Knowledge of phenotypic consequences of a specific chromosomal imbalance is important for genetic counseling and prenatal diagnosis. However, for unbalanced non-Robertsonian translocations a precise karyotype to phenotype correlation is difficult to predict for several reasons: (I) unbalanced non-Robertsonian translocations are rare, (II) the published case reports are often not age-matched, (III) varying breakpoints result in different lengths of the monosomic and trisomic segments and therefore the phenotype will depend on additional genes present or the loss of coding regions, and (IV) the combination of the same trisomy with different monosomies, or vice versa, can result in diverging phenotypes. Therefore, the study of the karyotype to phenotype correlation in affected relatives of the same age and the identical unbalanced translocation provides a good model to investigate phenotypic consequences of a specific genetic imbalance. We report of two second trimester fetuses with the identical major partial trisomy 9 (9pter-9q22.2) and minor partial trisomy 7 (q35-qter) resulting from a familial translocation (7;9)(q35;q22.2)mat. One fetus presented with a Dandy-Walker malformation, polymicrogyria, and mild dysmorphic features, whereas the other fetus showed unilateral cleft lip and palate without cerebral anomalies. Potential mechanisms for this different phenotypic expression of the same unbalanced translocation resulting in partial trisomy 9 and 7 in the two cousins and possible consequences for genetic counseling and prenatal diagnosis are discussed.

A new level detector for ion channel analysis

The algorithm proposed here for automatic level detection in noisy time series of patch-clamp current is based on the detection of jump-free sections in the time series. The detector moves along the time series and uses a chi(2) test for the detection of jumps. When a jump is detected, the mean value, the variance and the length of the preceding jump-free section are stored. A Student's t-test was employed for the assignment of detected jump-free sections to discrete levels of the Markov model and for rejection of all sections with multiple assignments. The choice of the two significance levels is based on a 3-D diagram displaying the average number of detected levels from several time series vs. the significance levels of jump detection and of level assignment. The correct one is selected out of several plateaus with integer number of levels by means of the criterion of minimum scatter or other plausibility considerations. The test has been applied to simulated data obtained from a 2-state model and a 5-state aggregated Markov model, and the influences of SNR and of gating frequency are shown. Finally, the performance of the level detector is compared with a fit-by-eye and with a fit of the amplitude histogram by a sum of gaussians. At high noise, the fit of amplitude histograms failed, whereas the other two approaches were about equal.

[Molecular variants of fibrinogen]

In the final step of blood coagulation, fibrin monomers polymerize spontaneously and are covalently linked by factor XIIIa. Mutations in one of the three genes coding for the fibrinogen peptides may disturb this process and lead to diseases such as afibrinogenemia or dysfibrinogenemia, or may even cause hereditary renal amyloidosis. In the brief overview presented here we summarize some of the molecular aspects of these diseases.

Molekulare Varianten des Fibrinogens

Im letzten Schritt der Blutgerinnung lagern sich Fibrinmonomere aneinander und werden durch Faktor XIIIa kovalent verbunden. Mutationen in einem der drei Gene, die für die Fibrinogenpeptide kodieren, können diesen Prozess stören und zu Afibrinogenämie oder Dysfibrinogenämie führen. Sie können sogar Ursache der hereditären renalen Amyloidose sein. In dieser kurzen Übersicht beschreiben wir einige molekulare Aspekte dieser Erkrankungen.

A chi(2) test for model determination and sublevel detection in ion channel analysis

A chi(2) test is proposed that provides a means of discriminating between different Markov models used for the description of a measured (patch clamp) time series. It is based on a test statistic constructed from the measured and the predicted number of transitions between the current levels. With a certain probability, this test statistic is below a threshold if the model with a reduced number of degrees of freedom is compatible with the data. A second criterion is provided by the dependence of the test statistic on the number of data points. For data generated by the alternative model it increases linearly. The applicability of this test for verifying and rejecting models is illustrated by means of time series generated by two distinct channels with different conductances and by time series generated by one channel with two conductance levels. For noisy data, a noise correction is proposed, which eliminates noise-induced false jumps that would interfere with the test. It is shown that the test can also be extended to aggregated Markov models.

Absence of 9q22-9qter in trisomy 9 does not prevent a Dandy-Walker phenotype

We report on a female fetus with partial trisomy 9 due to a reciprocal translocation in the mother. Routine ultrasound examination at 23 weeks showed hypoplasia of the cerebellar vermis, dilated foramen Magendii, and dilatation of the cisterna magna. Due to the poor prognosis, the parents opted for termination of pregnancy. A postmortem examination confirmed caudal hypoplasia and dysplasia of the cerebellar vermis, resulting in a massively dilated foramen Magendii through which the enlarged cisterna magna communicated with the fourth ventricle. There was also micropolygyria indicating migration disorder. Cytogenetic studies showed a 47,XX,+der(9)t(7;9) (q35;q22.2)mat karyotype. Investigation of the parents revealed a translocation (7;9) (q35;q22.2) in the mother and a normal male karyotype in the father. We systematically searched the chromosome 9 gene map for genes that were trisomic in our fetus and genes that were located on the regions that had the normal two copies of genes. Genes that could potentially be involved in the formation of the Dandy-Walker phenotype are transcription factors or genes responsible for the regulation of normal in particular cerebral development but also adhesion molecules. We conclude that one cause for Dandy-Walker malformation could be a gene dosage effect of genes located on 9pter-9q22. In addition, it seems that absence of trisomy 9 in q22-pter does not prevent abnormal cerebellar development.

Low molecular thymic peptides stimulate human blood dendritic cells

Dendritic cells are considered to be the most potent antigen-presenting cells and are thus promising new tools for the immunotherapy of cancer. They respond to various stimuli by differentiation (expression of CD83) and up-regulation of costimulatory surface molecules. Thymic peptides have immunostimulatory and immunomodulating properties. Their therapeutic potential in immunotherapy of cancer has been discussed. To test whether thymic peptides act on dendritic cells, we examined the effects of a standardized thymic peptide preparation on cultured human monocyte-derived dendritic cells. Addition of thymic peptides resulted in enhanced expression of the specific differentiation marker CD83 in a dose dependent manner. Moreover, thymic peptides induced the up-regulation of costimulatory molecules including CD86, CD80, HLA-DR and HLA-ABC. After priming with thymic peptides dendritic cells showed an enhanced expression of IL-8 and TNF-alpha mRNA and protein release. Dendritic cells stimulated with thymic peptides were able to induce proliferation of autologous T cells as measured by 3H-thymidine incorporation in mixed Lymphocyte reaction. In combination with a low dosage of keyhole limpet hemocyanin, thymic peptides showed additive effects in the up-regulation of CD83 and costimulatory surface markers. Our findings indicate that thymic peptides per se act on professional antigen-presenting cells in a stimulatory manner and were presented by these cells. Furthermore, thymic peptides enhance the response of dendritic cells to low dosages of a standard nominal antigen. Therefore, thymic peptides could improve the immunological activity especially against low amounts of endogenous antigens.

The recombinant human histones H1 zero and H1.2 cause different toxicity profiles on the human leukemia cell line K562

The human histones H1 zero and H1.2 were expressed in E. coli and purified to homogenity. Their cytotoxicity on the human leukemia cell line K562 and on PBMC from healthy volunteers was compared with the cytotoxic effect of a bovine histone H1 preparation. In this preparation, histone H1.2 was identified as the main compound. All three histone preparations induced a significant dose-dependent toxicity on the leukemia cell line. Compared with the recombinant histone H1 zero, the bovine preparation and recombinant H1.2 showed stronger cytotoxicities. Cytotoxic effects on K562 cells were observed immediately after addition of the histones, whereas the histone preparations failed to induce significant cytotoxicity on PBMC during the first hour of incubation. However, after 24 hours all three histone preparations induced toxic effects on PBMC which were comparable to those observed on the leukemia cell line.

The wide spectrum of clinical expression in Adams-Oliver syndrome: a report of two cases

Two children are described with the combination of aplasia cutis congenita (ACC) and transverse limb defects known as Adams-Oliver syndrome. Whereas in the first child the typical features of ACC, syndactyly and transverse nail dystrophy were only mildly expressed and associated defects of the central nervous system and cardiac malformations were absent, the second child suffered from a very severe expression of the syndrome, with a combination of ACC, syndactyly, cutis marmorata telangiectatica congenita and multiple cardiac and central nervous system malformations which resulted in fatal central respiratory insufficiency.

Sonographically detected fetal and placental abnormalities associated with trisomy 16 confined to the placenta. A case report and review of the literature

Trisomy 16 is the most frequent autosomal anomaly seen in early spontaneous abortions, accounting for 15 per cent of all chromosomally abnormal early spontaneous abortions. This trisomy is thought to be lethal in the non-mosaic state and incompatible with full fetal development. We report a case of placental trisomy 16 mosaicism detected after chorionic villus sampling (CVS). The patient was referred at 18 weeks of gestation on account of moderate intra-uterine growth restriction (IUGR). Detailed sonography showed a thickened and enlarged placenta with multiple 'cysts', polyhydramnios, a single umbilical artery and a small ventricular septal defect (VSD). CVS, amniocentesis (AC) and fetal blood sampling (FBS) were performed. After direct preparation of chorionic villi only 47,XX,+16 cells were seen. However, chromosomal analysis of cultivated amniotic fluid cells and fetal lymphocytes only showed a normal karyotype 46,XX. After direct preparation of a second CVS at 19 + 4 weeks of gestation the karyotype 47,XX+16 was confirmed in the contralateral part of the placenta and near the insertion of the umbilical cord. A normal female karyotype 46,XX was demonstrated by extensive karyotyping of various sites of the placenta, the neonatal skin fibroblasts and lymphocytes postnatally. In accordance with this observation the multiple 'cysts' of the placenta disappeared in the third trimester. We speculate that the sonographic findings of multiple round placental 'cysts' without a hyperreflective border may be caused by the trisomic cell lineages and therefore may be a sonographic marker of trisomy 16.

Prenatal diagnosis of ductus venosus agenesis: a report of two cases and review of the literature

Anomalies of venous return due to absence of the ductus venosus have been described in the literature. This is a report of the prenatal diagnosis of two cases of isolated ductus venosus agenesis occurring at 20 and 37 weeks' gestation, confirmed postnatally by color-coded Doppler sonography. In both cases the hepatic veins assumed the function of the ductus venosus without compromising fetal hemodynamics or causing hydrops. In the first case, a healthy female infant was delivered at term. In the second case, a 46,XY,dup(8) (q21.1q22)[35]/47,idem, + r(8)[15] karyotype was diagnosed by amniocentesis. The male newborn showed facial anomalies, a bell-shaped thorax and increased intermamillary distance. There was muscular hypotonia, delayed psychomotor development and an inspiratory stridor leading to obstructive nocturnal dyspnea. On the basis of our observations in these two cases and previous reports from animal studies, we conclude that absence of the ductus venosus may be compatible with normal fetal development without relevant disturbance of circulation and oxygenation.

The chloroplastic protein import machinery contains a Rieske-type iron-sulfur cluster and a mononuclear iron-binding protein

Transport of precursor proteins across the chloroplastic envelope membranes requires the interaction of protein translocons localized in both the outer and inner envelope membranes. Analysis by blue native gel electrophoresis revealed that the translocon of the inner envelope membranes consisted of at least six proteins with molecular weights of 36, 45, 52, 60, 100 and 110 kDa, respectively. Tic110 and ClpC, identified as components of the protein import apparatus of the inner envelope membrane, were prominent constituents of this complex. The amino acid sequence of the 52 kDa protein, deduced from the cDNA, contains a predicted Rieske-type iron-sulfur cluster and a mononuclear iron-binding site. Diethylpyrocarbonate, a Rieske-type protein-modifying reagent, inhibits the translocation of precursor protein across the inner envelope membrane, whereas binding of the precursor to the outer envelope membrane is still possible. In another independent experimental approach, the 52 kDa protein could be co-purified with a trapped precursor protein in association with the chloroplast protein translocon subunits Toc86, Toc75, Toc34 and Tic110. Together, these results strongly suggest that the 52 kDa protein, named Tic55 due to its calculated molecular weight, is a member of the chloroplastic inner envelope protein translocon.

Mild phenotypic manifestations of terminal deletion of the long arm of chromosome 4: clinical description of a new patient

We present clinical and developmental data on a patient with a de novo terminal deletion of the long arm of chromosome 4. Cytogenetic studies after G-banding revealed the karyotype 46,XY,del(4)(q34). The 4-year-old male showed mild facial dysmorphism, moderate mental retardation with speech retardation, and marked deficits in gross motor skills. Our patient is the second with this deletion described in the literature. In both patients the phenotype was characterized by mild to moderate mental retardation, abnormalities of the pinnae, and nonspecific facial dysmorphism. The mild phenotype might explain why only two patients with this deletion have been described so far.

Periodontal manifestation of hypophosphatasia. A family case report

Hypophosphatasia is a rare inherited disease, the 1st clinical sign of which is often a premature loss of deciduous teeth. We describe clinical, histological and SEM findings of 2 cases of hypophosphatasia from a single family and discuss the pathological mechanisms with reference to the literature.

Transmission of a ring chromosome 18 from a mother with 46,XX/47,XX, + r(18) mosaicism to her daughter, resulting in a 46,XX,r(18) karyotype

A 6 month old patient is reported with a ring chromosome 18 confirmed by cytogenetic studies and in situ hybridisation. Her clinical features were similar to previous cases of ring chromosome 18 syndrome. The ring chromosome was inherited from the phenotypically and mentally normal mother with a mos 46,XX/47,XX, + r(18) karyotype.