Genome sequencing identify chromosome 9 inversions disrupting ENG in 2 unrelated HHT families

Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber disease, is a dominant inherited vascular disorder. The clinical diagnosis is based on the Curaçao criteria and pathogenic variants in the ENG and ACVRL1 genes are responsible for most cases of HHT. Four families with a negative targeted gene panel and selected by a multidisciplinary team were selected and whole-genome sequencing was performed according to the recommendations of the French National Plan for Genomic Medicine. Structural variations were confirmed by standard molecular cytogenetic analysis (FISH). In two families with a definite diagnosis of HHT, we identified two different paracentric inversions of chromosome 9, both disrupting the ENG gene. These inversions are considered as pathogenic and causative for the HHT phenotype of the patients. This is the first time structural variations are reported to cause HHT. As such balanced events are often missed by exon-based sequencing (panel, exome), structural variations may be an under-recognized cause of HHT. Genome sequencing for the detection of these events could be suggested for patients with a definite diagnosis of HHT and in whom no causative pathogenic variant was identified.

AB0375 EXTERNAL VALIDATION OF THE GIANT CELL ARTERITIS PROBABILITY SCORE IN THE NETHERLANDS

Background:

Severe complications of giant cell arteritis (GCA), such as blindness and ischemic stroke, can be prevented by timely treatment. This requires early and accurate diagnosis. In 2019, Laskou et al. developed a clinical GCA probability score (GCAPS) that allows physicians to assess the probability of GCA at initial assessment. The GCAPS is suitable for easy implementation in daily practice. It has a high sensitivity (95.7%) and specificity (86.7%) at a cut-off value of 9.5 as proposed by Laskou et al.

Objectives:

The aim of this study was to externally validate the GCAPS in a general hospital.

Methods:

A retrospective cohort of patients with suspected GCA between January 1st 2017 and October 1st 2019 at Ziekenhuisgroep Twente (the Netherlands) was used. As the parameter extra-cranial artery abnormality was not available in our cohort, a modified version of the GCAPS was used (m-GCAPS). The m-GCAPS was compared to clinical diagnosis of a rheumatologist after six months in accordance with Laskou et al. The validity of the m-GCAPS was assessed by plotting a receiver operating characteristic (ROC) curve and assessing sensitivity and specificity for multiple cut-off values. For practical purposes, risk stratifications as proposed by Sebastian et al. (2020) were applied to our data (low-risk <9; intermediate-risk 9-12; high-risk >12).

Results:

In our cohort, 40 GCA patients and 95 controls (suspected of GCA) had complete records and were therefore used for analysis. In the patient group, 29 (72.5%) were female and mean (SD) age was 73.3 (1.6). The area under the ROC curve (AUC) was 0.83 (95% CI 0.75 – 0.91). At our optimal cut-off value of 10.5, sensitivity was 80.0% and specificity was 75.8%. In total, 5 patients and 45 controls were stratified as low, 7 patients and 35 controls as intermediate and 28 patients and 15 controls as high-risk.

Conclusion:

The m-GCAPS showed good discrimination in our cohort. Risk stratification of patients looks promising, although cut-off values by Sebastian et al. might need optimization based on population and modification to the GCAPS. Colour Doppler ultrasound is recommended by EULAR as the first-choice diagnostic test to confirm GCA in case of high pre-test probability and exclude GCA for low pre-test probability. The (m-)GCAPS may aid in quantification of this pre-test probability.

References:

[1]Laskou F, Coath F, Mackie SL et al. A probability score to aid the diagnosis of suspected giant cell arteritis. Clin Exp Rheumatol. 2019;37 Suppl 1(2):104–8.

[2]Sebastian A, Tomelleri A, Kayani A et al. Probability-based algorithm using ultrasound and additional tests for suspected GCA in a fast-track clinic. RMD Open. 2020 Sep 1;6(3):e001297.

[3]Dejaco C, Ramiro S, Duftner C et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Ann Rheum Dis. 2018 May 1;77(5):636 LP – 643.

Table 1.

Cut-off values of the m-GCAPS stratified into risk categories as proposed by Sebastian et al. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) and the number of patients scoring above or below the cut-off values are described (optimal cut-off value in blue). The total number of patients with a score within low- (red), intermediate- (orange) and high- (green) risk categories are depicted.

GCA+ (N)N=40GCA- (N)N=95Scorem-GCAPSGCA+ (N)GCA- (N)Sens. (%)Spec. (%)PPV (%)NPV (%)Low-risk <95 (12.5%)45 (47.4%)5.5<5.501410014.733.1100>5.540818.5<8.554587.547.441.290>8.53550Intermediate-risk9-127 (17.5%)35 (36.8%)9.5<9.58568058.945.187.5>9.5323910.5<10.58728075.858.290>10.5322311.5<11.510747577.958.888.1>11.53021High-risk>928 (70.0%)15 (15.8%)12.5<12.512807084.265.187>12.5281514.5<14.518895593.778.683.2>14.522619.5<19.537957.510010072>19.530Figure 1.

ROC curve depicting sensitivity and (1-) specificity. The AUC was 0.83 (95.0% CI 0.75-0.91) with an optimal cut-off value of 10.5 (sensitivity 80.0%, specificity 75.8%).

Disclosure of Interests:

None declared

AB0367 DIAGNOSTIC DELAY IN PATIENTS WITH GIANT CELL ARTERITIS

Background:

Giant cell arteritis (GCA) is the most common systemic vasculitis in the elderly which can lead to severe complications when treatment is delayed. Therefore, timely diagnosis and start of treatment is essential. Several forms of delay (consultation, referral and diagnostic delay) can contribute to the total delay towards GCA diagnosis. In the Dutch healthcare system, treatment is not started by a general practitioner (GP). When GCA is suspected, GPs refer to specialists. In our hospital, a fast track clinic (FTC) is used to expedite diagnosis. However, information on factors contributing to delay is scarce.

Objectives:

The aim of this study was to describe the different components of delay towards diagnosis in GCA suspected patients in a general hospital, Ziekenhuisgroep Twente (the Netherlands).

Methods:

For this descriptive study, a retrospective cohort consisting of patients with suspected GCA between January 1st 2017 and October 1st 2019 was used to analyse components of delay in diagnosis, as suggested by Prior et al. Consultation delay was defined as the time between start of symptoms and a patient’s first consultation with a GP. Referral delay was defined as the time between a patient’s first consultation with a GP and first visit to the FTC. Diagnostic delay was defined as the time between the first visit to the FTC and treatment initiation. Total delay was defined as the time from symptom onset until start of treatment. Delays were described using the median and interquartile ranges (IQR).

Results:

In our cohort, 206 patients were included for analysis of whom 62 had GCA. Controls (n=144) were suspected of but did not have GCA. Comparing GCA patients with controls, 66.1% and 50.7% were female and the mean (SD) age was 74.2 (9.4) and 70.2 (11.0) years, respectively. In our cohort, the majority of patients (n=42, 67.7%) had cranial GCA (C-GCA). Furthermore, 8 (12.9%) had large vessel GCA (LV-GCA) and 12 (19.4%) had a combination of C-GCA and LV-GCA. For GCA patients, median consultation delay was 2.1 (IQR 0.8-5.8) weeks, referral delay 1.4 (IQR 0.4-4.6) weeks and diagnostic delay 0 (IQR 0-0.1) weeks (Figure 1). For delay regarding consultation and referral, results of controls were comparable to GCA patients. The median total delay was 4.4 weeks (IQR 1.57-10.14) for GCA patients.

Conclusion:

With a median total delay of 4.4 weeks, delay in our cohort is almost half the delay described in a review by Prior et al. This difference might be due to FTC implementation and subsequent awareness in our hospital and by local GPs. Patients generally received treatment within one day after FTC visit. Nevertheless, contribution of consultation and referral delay is not resolved by introduction of the FTC, as shown in our data. Timely diagnosis is essential as severe complications can develop instantly, which emphasizes the need to tackle consultation and referral delay.

References:

[1]Prior JA, Ranjbar H, Belcher J, et al. Diagnostic delay for giant cell arteritis – a systematic review and meta-analysis. BMC Med. 2017;15(1):120.

Table 1.

Baseline characteristics of GCA patients and controls in our retrospective cohort. *CDUS=Colour Doppler Ultrasound; **Temporal Artery Biopsy;***18-FDG-Positron Emission Tomography/Computed Tomography.

GCA patients (n=62)Controls (n=144)RangeRangeGender, % female (n)66.1 (41)50.7 (73)Age (years), mean (SD)74.2 (9.4)51 – 9170.2 (11.0)50 – 97ESR, mean (SD)Missing78.4 (30.3)322 – 12039.9 (32.4)92 – 124CRP, mean (SD)74.7 (60.0)2 - 28335.8 (52.9)0.4 -280Missing16Polymyalgia Rheumatica,% yes (n)21 (13)11.8 (17)Cranial symptoms,% yes (n)80.6 (50)75.0 (108)Vision loss, %yes (n)Compliant with GCA (i.e. AION, central retinal artery occlusion diplopia)27.4 (17)15.3 (22)Diagnostics CDUS* %yes (n)96.8 (60)96.5 (139) TAB** %yes (n)58.1 (36)18.8 (27) PET/CT***%yes (n)40.3 (25)16.0 (23)Figure 1.

Description of consultation (A); referral (B); diagnostic (C) and total (D) delay in weeks for controls (black) and GCA patients (green), stratified for C-GCA (red), LV-GCA (blue) and C/LV-GCA (purple). 1Not possible for controls as no GCA-indicated treatment was started.

Disclosure of Interests:

None declared

Re-focusing on Agnathia-Otocephaly complex

OBJECTIVES

Agnathia-otocephaly complex is a rare condition characterized by mandibular hypoplasia or agnathia, ear anomalies (melotia/synotia) and microstomia with aglossia. This severe anomaly of the first branchial arch is most often lethal. The estimated incidence is less than 1 in 70.000 births, with etiologies linked to both genetic and teratogenic factors. Most of the cases are sporadic. To date, two genes have been described in humans to be involved in this condition: OTX2 and PRRX1. Nevertheless, the overall proportion of mutated cases is unknown and a significant number of patients remain without molecular diagnosis. Thus, the involvement of other genes than OTX2 and PRRX1 in the agnathia-otocephaly complex is not unlikely. Heterozygous mutations in Cnbp in mice are responsible for mandibular and eye defects mimicking the agnathia-otocephaly complex in humans and appear as a good candidate. Therefore, in this study, we aimed (i) to collect patients presenting with agnathia-otocephaly complex for screening CNBP, in parallel with OTX2 and PRRX1, to check its possible implication in the human phenotype and (ii) to compare our results with the literature data to estimate the proportion of mutated cases after genetic testing.

MATERIALS AND METHODS

In this work, we describe 10 patients suffering from the agnathia-otocephaly complex. All of them benefited from array-CGH and Sanger sequencing of OTX2, PRRX1 and CNBP. A complete review of the literature was made using the Pubmed database to collect all the patients described with a phenotype of agnathia-otocephaly complex during the 20 last years (1998-2019) in order (i) to study etiology (genetic causes, iatrogenic causes…) and (ii), when genetic testing was performed, to study which genes were tested and by which type of technologies.

RESULTS

In our 10 patients' cohort, no point mutation in the three tested genes was detected by Sanger sequencing, while array-CGH has allowed identifying a 107-kb deletion encompassing OTX2 responsible for the agnathia-otocephaly complex phenotype in 1 of them. In 4 of the 70 cases described in the literature, a toxic cause was identified and 22 out the 66 remaining cases benefited from genetic testing. Among those 22 patients, 6 were carrying mutation or deletion in the OTX2 gene and 4 in the PRRX1 gene. Thus, when compiling results from our cohort and the literature, a total of 32 patients benefited from genetic testing, with only 34% (11/32) of patients having a mutation in one of the two known genes, OTX2 or PRRX1.

CONCLUSIONS

From our work and the literature review, only mutations in OTX2 and PRRX1 have been found to date in patients, explaining around one third of the etiologies after genetic testing. Thus, agnathia-otocephaly complex remains unexplained in the majority of the patients, which indicates that other factors might be involved. Although involved in first branchial arch defects, no mutation in the CNBP gene was found in this study. This suggests that mutations in CNBP might not be involved in such phenotype in humans or that, unlike in mice, a compensatory effect might exist in humans. Nevertheless, given that agnathia-otocephaly complex is a rare phenotype, more patients have to be screened for CNBP mutations before we definitively conclude about its potential implication. Therefore, this work presents the current state of knowledge on agnathia-otocephaly complex and underlines the need to expand further the understanding of the genetic bases of this disorder, which remains largely unknown.

CLINICAL RELEVANCE

We made here an update and focus on the clinical and genetic aspects of agnathia-otocephaly complex as well as a more general review of craniofacial development.

Defense strategies used by two sympatric vineyard moth pests

Natural enemies including parasitoids are the major biological cause of mortality among phytophagous insects. In response to parasitism, these insects have evolved a set of defenses to protect themselves, including behavioral, morphological, physiological and immunological barriers. According to life history theory, resources are partitioned to various functions including defense, implying trade-offs among defense mechanisms. In this study we characterized the relative investment in behavioral, physical and immunological defense systems in two sympatric species of Tortricidae (Eupoecilia ambiguella, Lobesia botrana) which are important grapevine moth pests. We also estimated the parasitism by parasitoids in natural populations of both species, to infer the relative success of the investment strategies used by each moth. We demonstrated that larvae invest differently in defense systems according to the species. Relative to L. botrana, E. ambiguella larvae invested more into morphological defenses and less into behavioral defenses, and exhibited lower basal levels of immune defense but strongly responded to immune challenge. L. botrana larvae in a natural population were more heavily parasitized by various parasitoid species than E. ambiguella, suggesting that the efficacy of defense strategies against parasitoids is not equal among species. These results have implications for understanding of regulation in communities, and in the development of biological control strategies for these two grapevine pests.

[Pain management in radiation oncology]

The goal of this article is to propose some practical means of pain management in radiation departments. Pain management in radiation oncology is difficult because of the high proportion of painful patients, underestimation by medical teams, and limited therapeutic options. Pain can cause mobilization difficulties, set-up errors, treatment interruption. According to procedure steps, a preventive attitude (for pre-radiation consultation) or an active attitude (for treatment) to quickly relieve the patient can be planned. This work is a brain storming about pain management. It is not a review about analgesic radiotherapy. The practical situations apply to patients to whom radiotherapy is indicated. Teamwork and anticipation are keywords to relieve patients. All proposed means are not always available for different reasons (time, finance, staff, training). The idea is to establish simple procedures that are appropriate to each center to fluidify acts, to optimize time for a successful irradiation.

Systematic molecular and cytogenetic screening of 100 patients with marfanoid syndromes and intellectual disability

The association of marfanoid habitus (MH) and intellectual disability (ID) has been reported in the literature, with overlapping presentations and genetic heterogeneity. A hundred patients (71 males and 29 females) with a MH and ID were recruited. Custom-designed 244K array-CGH (Agilent®; Agilent Technologies Inc., Santa Clara, CA) and MED12, ZDHHC9, UPF3B, FBN1, TGFBR1 and TGFBR2 sequencing analyses were performed. Eighty patients could be classified as isolated MH and ID: 12 chromosomal imbalances, 1 FBN1 mutation and 1 possibly pathogenic MED12 mutation were found (17%). Twenty patients could be classified as ID with other extra-skeletal features of the Marfan syndrome (MFS) spectrum: 4 pathogenic FBN1 mutations and 4 chromosomal imbalances were found (2 patients with both FBN1 mutation and chromosomal rearrangement) (29%). These results suggest either that there are more loci with genes yet to be discovered or that MH can also be a relatively non-specific feature of patients with ID. The search for aortic complications is mandatory even if MH is associated with ID since FBN1 mutations or rearrangements were found in some patients. The excess of males is in favour of the involvement of other X-linked genes. Although it was impossible to make a diagnosis in 80% of patients, these results will improve genetic counselling in families.

[Neonatal diarrhea due to congenital glucose-galactose malabsorption: report of seven cases]

Congenital glucose-galactose malabsorption (CGGM) is a rare autosomal recessive disorder, which presents as a protracted diarrhea in early neonatal life. We describe the clinical history, diagnostic evaluation, and management of 7 children with CGGM in western France. There were 4 girls and 3 boys from 5 families, born between 1984 and 2010. The principal complaint was a neonatal onset of watery and acidic severe diarrhea complicated by hypertonic dehydration. The diarrhea stopped with fasting. In 2 cases, the family history supported the diagnosis. In the other cases, elimination of glucose and galactose (lactose) from the diet resulted in the complete resolution of diarrhea symptoms. In 2 cases, the H2 breath tests were positive. In 2 cases, the HGPO or oral glucose tolerance test (OGTT) demonstrated an abnormal curve with glucose and a normal curve with fructose. DNA sequencing was not used. When glucose and galactose were eliminated from the diet, the infants had normal growth and development. In conclusion, CGGM is a rare etiology of neonatal diarrhea; however, the diagnosis is easy to make and the prognosis is excellent.

Binder phenotype in mothers affected with autoimmune disorders

OBJECTIVE

To report four foetal cases of the Binder phenotype associated with maternal autoimmune disorders.

PATIENTS AND METHODS

In three mothers with autoimmune diseases, 2D and 3D ultrasonographic measurements were made on four foetuses with the Binder profile, and were compared with postnatal phenotypes.

RESULTS

The Binder phenotype can be detected in early pregnancy (14.5 WG). All foetuses had verticalized nasal bones and midfacial hypoplasia. Punctuate calcifications were found in almost all the cases. No specific maternal auto-antibody has been associated with foetal Binder phenotype.

CONCLUSION

Since the Binder phenotype can be diagnosed at ultrasound examination during pregnancy, it is important to establish the underlying cause so as to assess the foetal prognosis. This study stresses the importance of systematic checks for maternal autoimmune disease in cases of prenatally diagnosed Binder phenotypes.

Late effects of cycle competition on arterial stiffness. A preliminary study

AIM

The purpose of this study was to examine the effects of a cycle competition on the large arteries stiffness, 24-hours after the end of the effort.

METHODS

Two males elite cyclists were studied before and after performing a stage-race. Their heart rate (HR) was measured continuously during the two competition days. The impact of the competition on their vascular system was determined using the measure of pulse wave velocity (PWV), an index of regional arterial stiffness. HR and blood pressure were also measured before and 24-hours postexercise.

RESULTS

During the race, mean cyclists HR were relatively similar. Changes in PWV and HR were found after competition: these measures increased for the offensive subject and decreased for the other.

CONCLUSIONS

Despite their involvement in the same cycling competition, we suggest that the long-term effects induced by effort on arterial stiffness were inverted according to the subject's comportment during the race. This study should be completed by others measures in order to precise our results and to precise the possible link between arteries stiffness and the recovery kinetic process, both depending on the cardiovascular autonomic nervous system control.

Balance of mass, momentum, and energy in splintering central collisions for 40Ar up to 115 MeV /Nucleon

For central collisions of (17-115)A MeV 40Ar+Cu, Ag, Au, an overall balance is determined for the average mass, energy, and longitudinal momentum. Light charged particles and fragments are separated into forward-focused and isotropic components in the frame of the heaviest fragment. Energy removal by the isotropic component reaches 1-2 GeV. For such high deposition energies, statistical multifragmentation models predict much more extensive nuclear disassembly than is observed.

[Pituitary tumors: clinical presentation and evaluation of transphenoidal surgical treatment]

The clinical manifestations and the surgical treatment results of 280 patients (179 female), undergoing a total of 319 operations at the Asenjo Institute of Neurosurgery were retrospectively analyzed. The surgical approach for the first operation was transphenoidal in 89.3% of patients and transcraneal in the rest. Tumors were non-secretory in 169 (60.4%) patients, prolactinomas in 75 (27.8%) and produced acromegalia in 29 (10.4%) and Cushing syndrome in 7 (2.5%) patients. There was extraselar extension in 42% of women and 71% of men. The surgical treatment of prolactinomas corrected endocrine alterations in 25 of 29 and visual alterations in 18 of 27 patients assessed. Surgical treatment of acromegalia improved endocrine alterations in 11 of 13 and visual alterations in 4 of 10 patients assessed. Treatment of non secretory tumors corrected visual alteratons in 38 of 64 patients assessed. The principal complication of transphenoidal surgery was transient diabetes insipidus in 6.8% of patients. Overall mortality was 2.3% for transphenoidal surgery and 5.6% for transcraneal surgery. It is concluded that transphenoidal surgery is effective for the management extraselar complications of pituitary tumors and endocrine management of selected cases.

The empty sella: results of treatment in 76 successive cases and high frequency of endocrine and neurological disturbances

OBJECTIVE

We assessed the frequency of endocrine or neurological disturbances and the results of surgery in patients with empty sella, diagnosed with cisternography and/or computerized tomography scanning.

DESIGN AND PATIENTS

Analysis of hospital records of 76 successive patients (73 primary, three secondary empty sella) from a single institution.

MEASUREMENTS

Clinical and neuro-ophthalmological evaluation. Serum PRL, GH, TSH, LH, FSH, T4, T3 by radioimmunoassay. Diagnosis of empty sella with cisternography and/or computerized tomography scanning (n = 69), or discovered at surgery (n = 7).

RESULTS

Patients with empty sella had: headache (69.7%), visual disturbances (34.2%), cerebrospinal fluid rhinorrhoea (11.8%), endocrine disturbances (51.4%, including hyperprolactinaemia, acromegaly, Cushing's syndrome). A pituitary tumour was discovered in two patients, in seven other ones it was suspected but not found at surgery. Transsphenoidal packing of empty sellas was done in 56 cases, with 7.1% post-operative complications. With surgery there was improvement of headache in 71%, of visual disturbances in 46%. Cerebrospinal fluid rhinorrhoea (discovered at surgery in four other patients) was not resolved by the first operation in six out of 13 patients. In 20 patients without surgery, headache improved in 64.6%.

CONCLUSIONS

The empty sella is frequently associated with a variety of neurological and endocrine disturbances, which is contrary to conventional belief. Cerebrospinal fluid rhinorrhoea is not a rare complication and it may be difficult to treat. Some cases of empty sella may be due to partial pituitary apoplexy. Autoimmunity may have existed in other cases. Surgery may be useful in many patients, but a judicious selection is needed because it entails complications and non-operated patients may improve spontaneously.