Large scale calcium channel gene rearrangements in episodic ataxia and hemiplegic migraine: implications for diagnostic testing.

BACKGROUND: Episodic ataxia type 2 (EA2) and familial hemiplegic migraine type 1 (FHM1) are autosomal dominant disorders characterised by paroxysmal ataxia and migraine, respectively. Point mutations in CACNA1A, which encodes the neuronal P/Q-type calcium channel, have been detected in many cases of EA2 and FHM1. The genetic basis of typical cases without CACNA1A point mutations is not fully known. Standard DNA sequencing methods may miss large scale genetic rearrangements such as deletions and duplications. The authors investigated whether large scale genetic rearrangements in CACNA1A can cause EA2 and FHM1. METHODS: The authors used multiplex ligation dependent probe amplification (MLPA) to screen for intragenic CACNA1A rearrangements. RESULTS: The authors identified five previously unreported large scale deletions in CACNA1A in seven families with episodic ataxia and in one case with hemiplegic migraine. One of the deletions (exon 6 of CACNA1A) segregated with episodic ataxia in a four generation family with eight affected individuals previously mapped to 19p13. In addition, the authors identified the first pathogenic duplication in CACNA1A in an index case with isolated episodic diplopia without ataxia and in a first degree relative with episodic ataxia. CONCLUSIONS: Large scale deletions and duplications can cause CACNA1A associated channelopathies. Direct DNA sequencing alone is not sufficient as a diagnostic screening test.

The phenotypic spectrum in patients with arginine to cysteine mutations in the COL2A1 gene.

BACKGROUND: The majority of COL2A1 missense mutations are substitutions of obligatory glycine residues in the triple helical domain. Only a few non-glycine missense mutations have been reported and among these, the arginine to cysteine substitutions predominate. OBJECTIVE: To investigate in more detail the phenotype resulting from arginine to cysteine mutations in the COL2A1 gene. METHODS: The clinical and radiographic phenotype of all patients in whom an arginine to cysteine mutation in the COL2A1 gene was identified in our laboratory, was studied and correlated with the abnormal genotype. The COL2A1 genotyping involved DHPLC analysis with subsequent sequencing of the abnormal fragments. RESULTS: Six different mutations (R75C, R365C, R519C, R704C, R789C, R1076C) were found in 11 unrelated probands. Each mutation resulted in a rather constant and site-specific phenotype, but a perinatally lethal disorder was never observed. Spondyloarthropathy with normal stature and no ocular involvement were features of patients with the R75C, R519C, or R1076C mutation. Short third and/or fourth toes was a distinguishing feature of the R75C mutation and brachydactyly with enlarged finger joints a key feature of the R1076C substitution. Stickler dysplasia with brachydactyly was observed in patients with the R704C mutation. The R365C and R789C mutations resulted in classic Stickler dysplasia and spondyloepiphyseal dysplasia congenita (SEDC), respectively. CONCLUSIONS: Arginine to cysteine mutations are rather infrequent COL2A1 mutations which cause a spectrum of phenotypes including classic SEDC and Stickler dysplasia, but also some unusual entities that have not yet been recognised and described as type II collagenopathies.

Assisted reproductive therapies and imprinting disorders--a preliminary British survey.

BACKGROUND: Recent reports have suggested a higher risk of Beckwith-Wiedemann syndrome (BWS) and Angelman syndrome (AS) after assisted reproductive technologies (ARTs), but it is unclear whether this might also apply to other disorders of genomic imprinting. METHODS: We contacted families of children with BWS, AS, Prader-Willi syndrome (PWS) and transient neonatal diabetes mellitus (TNDM) to determine use of ART. RESULTS: A statistically significant increased frequency of ART in children with BWS was confirmed [2.9%, 95% confidence interval (CI) 1.4-6.3% vs 0.8% expected] but there was no significant association with PWS or TNDM. Consideration of the molecular subgroup of BWS and AS suggested the feasibility of association with ART. CONCLUSIONS: These differences may relate to variations in (i) the molecular mechanisms for disordered imprinting in the different disorders and (ii) the susceptibility of specific imprinting control regions to ART-associated methylation alterations (epimutations).

Competence of new emergency medicine residents in the performance of lumbar punctures.

BACKGROUND: Medical students are taught some procedural skills during medical school, but there is no uniform set of procedures that all students learn before residency. OBJECTIVE: To determine the level of competence in the performance of a lumbar puncture (LP) by new postgraduate year 1 (PGY1) emergency medicine (EM) residents. METHODS: An observational study was conducted at three EM residencies with 42 PGY1 residents who recently graduated from 26 various medical schools. The LP procedure was divided into 26 major and 44 minor steps to create a scoring protocol. The model, procedure, and scoring protocol were validated by experienced emergency physicians. Subjects performed the procedure without interruption or feedback on an LP training model using a standard LP kit. A step was scored as "performed correctly" if two of the three evaluators concurred. Pre- and poststudy questionnaires assessed subjects' prior instruction and clinical experience with LP, self-confidence, sense of relevance, motivation, and fatigue. RESULTS: Subjects completed an average of 14.8 (57%; 95% confidence interval [95% CI] = 53% to 61%) of the major steps (range: 4-26) and 19.1 (43%; 95% CI = 42% to 45%) of the minor steps (range: 7-28) in 14.3 minutes (range: 3-22). Sixty-nine percent failed to obtain cerebrospinal fluid from the model. Subjects' levels of confidence changed slightly on a five-point scale from 2.8 ("little-to-some") before the test to 2.5 after the test. Eighty-three percent of the subjects previously performed LPs on patients during medical school (average attempts = 2.2; range: 0-10), but only 40% of those who did so were supervised by an attending during their first attempt. CONCLUSIONS: In the cohort studied, new PGY1 EM residents had not attained competence in performing LPs from training in medical school. Most new PGY1 residents probably require training, practice, and close, direct supervision of this procedure by attending physicians until the residents demonstrate competent performance.

Effects of nitrate on the tadpoles of two Ranids (Rana catesbeiana and R. clamitans).

Nitrate is a potential stressor of amphibian larvae. Previous research has shown variation in the effects of nitrate among species and even populations of amphibians. However, relatively few species and populations of amphibians have been examined for nitrate tolerance, especially from populations in the agricultural regions of the United States. Using a 15-day laboratory experiment, we investigated the effects of nitrate on the larvae of two species of anurans (Rana catesbeiana and R. clamitans) that are common throughout the agricultural Midwest. Survival of R. catesbeiana and R. clamitans tadpoles was negatively affected by higher concentrations of nitrate (20 mg L(-1)), with R. clamitans being more affected than R. catesbeiana. The final mass of R. catesbeiana tadpoles was affected by nitrate concentration, with tadpoles exposed to intermediate concentrations of nitrate (5 mg L(-1)) being the heaviest. The final mass of R. clamitans tadpoles was not affected by nitrate concentration. These experiments suggest that these two species differ in their responses to the toxic effects of nitrate and, along with previous results on Ranids, suggest there is a great deal of variation in nitrate tolerance in this family.

Supramolecular organometallic polymer chemistry: multiple morphologies and superstructures from the solution self-assembly of polyferrocene-block-polysiloxane-block-polyferrocene triblock copolymers.

The solution self-assembly of an organometallic-inorganic triblock copolymer, poly(ferrocenyldimethylsilane)-block-poly(dimethylsiloxane)-block-poly-(ferrocenyldimethylsilane) (PFDMS-b-PDMS-b-PFDMS, 3b; block ratio 1:13:1; Mn = 2.88 x 10(4) gmol(-1), polydispersity (PDI) 1.43 (gel permeation chromatography, GPC)) was studied in n-hexane, a PDMS block selective solvent. Transmission electron microscopy (TEM), atomic force microscopy (AFM), and TEM with negative staining analysis of these micellar solutions after solvent evaporation revealed the presence of multiple micellar morphologies including spheres, cylinders, and novel flower-like supramolecular aggregates. TEM analysis of samples fractionated by ultracentrifugation and preparative size-exclusion chromatography suggest that the formation of multiple morphologies is a consequence of compositional variations. When micellar solutions were prepared at 50 degrees C (above the glass transition of the PFDMS core-forming block) flower-like micellar aggregates similar to those present in micellar solutions prepared at room temperature also formed. However, after solvent evaporation, TEM analysis of micellar solutions prepared in decane at about 150 degrees C, above the melt temperature of the PFDMS core (ca. 120-145 degrees C), revealed the presence of spherical micelles (when decane solutions at 150 degrees C were rapidly cooled to room temperature) and rod-like cylindrical micelles (when decane solutions at 150 degrees C were slowly cooled to room temperature). In contrast, poly(ferrocenylmethylethylsilane)block-poly(dimethylsiloxane)-block-poly(ferrocenylmethylethylsilane) (PFMES-b-PDMS-b-PFMES, 4; block ratio 1:16:1; Mn=2.90x10(4)g mol(-1), PDI= 1.42 (GPC)) and poly(ferrocenylmethylphenylsilane)-block-poly(dimethylsiloxane)-block-poly(ferrocenylmethylphenylsilane) (PFMPS-b-PDMS-b-PFMPS, 5; block ratio 1:15:1; Mn=3.00 x 10(4) gmol(-1), PDI = 1.38 (GPC)), which possess completely amorphous organometallic core-forming blocks, formed only spherical micelles in hexane at room temperature. These observations indicate that crystallinity of the insoluble polyferrocenylsilane block is a critical factor in the formation of the nonspherical micelle morphologies.

Selenate-supplemented nutritional formula increases plasma selenium in hemodialysis patients.

OBJECTIVE: The purpose of this study was to determine the short-term effect of feeding selenium-supplemented formulas on the selenium status of end-stage renal disease patients on hemodialysis. DESIGN AND SETTING: The prospective, randomized, single-blind study of parallel design was conducted at three hemodialysis clinics. PATIENTS: A total of 79 hemodialysis patients were randomly assigned into one of three groups. INTERVENTION: Liquid nutritional formula supplemented with either selenite (28 microg Se/8 oz, n = 26), selenate (28 microg Se/8 oz, n = 26), or nonfortified (7 microg Se/8 oz, n = 27) was fed to hemodialysis patients as their sole source of nutrition for 14 days. MAIN OUTCOME MEASURE: Plasma and red blood cell (RBC) selenium and glutathione peroxidase (GPX) activities were measured in predialysis blood both before (day 1) and after (day 8) a 7-day baseline period, and after subjects received the formula as the sole source of nutrition (approximately 35 kcal/kg/d) for 14 days (day 22). RESULTS: Selenium intake (Mean +/- SEM, microg/d) was 134 +/- 9, 140 +/- 9, and 35 +/- 2 for patients receiving selenite-, selenate-, or non-supplemented formula, respectively. On day 22, plasma selenium (micromol/L) was greater (P <.032) in the selenate-supplemented group (1.5 +/- 0.1) compared with the nonsupplemented group (1.2 +/- 0.1), but not compared with the selenite-supplemented group (1.4 +/- 0.1). Plasma GPX activity was 44% to 60% that of healthy controls and not different among groups. RBC selenium and GPX activities were within the normal range and were not different among groups. CONCLUSION: The results of this study indicate that a liquid formula supplemented with selenium as selenate is successful at maintaining selenium concentrations within normal range, as well as significantly increasing plasma selenium levels compared with nonsupplementation.

Molecular confirmation of germ line mosaicism for a submicroscopic deletion of chromosome 22q11.

Submicroscopic deletions of chromosome 22q11 have been reported in a multiple anomaly syndrome variously labelled as velocardiofacial syndrome, conotruncal anomaly face syndrome, and Di George syndrome. Most 22q11 microdeletions occur sporadically, although in some cases the deletion may be transmitted. We describe two affected sibs with confirmed 22q11 deletions from unaffected parents who are not deleted. Haplotype analysis demonstrates that the deletion in the affected sibs has occurred on the same maternal chromosome 22. Furthermore, an unaffected sib was found to have inherited the same maternal haplotype at 22q11 in an undeleted form. This is the first molecular demonstration of germ line mosaicism for a microdeletion at chromosome 22q11 and highlights the need for caution in estimation of recurrence risks, even when constitutional deletions have been excluded on parental analysis.

X-linked spastic paraplegia (SPG1), MASA syndrome and X-linked hydrocephalus result from mutations in the L1 gene.

X-linked hydrocephalus, spastic paraplegia type I and MASA syndrome are related disorders with loci in subchromosomal region Xq28. We have previously shown that X-linked hydrocephalus is caused by mutations in the gene for neural cell adhesion molecule L1 (L1CAM), an axonal glycoprotein involved in neuronal migration and differentiation. Here we report mutations of the L1 gene in MASA syndrome and SPG1, in addition to HSAS families. Two of the HSAS mutations would abolish cell surface expression of L1 and represent the first functional null mutations in this disorder. Our results indicate that these three syndromes from part of a clinical spectrum resulting from a heterogeneous group of mutations in the L1 gene.

Antibody response to pneumococcal capsular polysaccharide vaccine in African children.

Antibody titers to six pneumococcal polysaccharides were measured by enzyme-linked immunosorbent assay in Gambian children before and 1 month after vaccination with a 23-valent pneumococcal capsular polysaccharide vaccine at the ages of 2, 4, 6 or 9 months or at 5 to 10 years of age. IgG responses to type 1, 3 and 5 polysaccharides were seen in children in all age groups. Responses to type 19F and 23F polysaccharides were seen only in the oldest children. Few children of any age responded to immunization with type 6A pneumococcal polysaccharide. The immune response of Gambian infants to immunization with six components of a polyvalent pneumococcal polysaccharide vaccine was comparable with that described previously in Finnish infants and would be unlikely to provide substantial protection against invasive pneumococcal disease.

Pitfalls in counselling: the craniosynostoses.

We describe three families to highlight the variability of expression and penetrance that can occur in the craniosynostoses. In two of the families, gene carriers were only identified in retrospect by looking at photographs of other family members. In the third family, identical twins were initially thought to be discordant for sagittal craniosynostosis until early skull x rays were examined and both were found to be affected. The dilemmas faced when counselling these families are discussed.

The iris in Williams syndrome.

Forty three children with Williams syndrome and 124 control subjects had their eyes photographed. The photographs were examined by three ophthalmologists and four geneticists of varying experience. A stellate pattern was noted more often in the irides of patients with Williams syndrome (51%) than in those of the control subjects (12%), and was more difficult to detect, or was absent, in heavily pigmented irides. We conclude that the stellate pattern is of diagnostic importance, particularly if the pattern is carefully defined and the clinician is experienced.

A case of atelosteogenesis.

Atelosteogenesis is a rare chondrodysplasia characterised by rhizomelic short limbed dwarfism, thoracic hypoplasia, multiple joint dislocations, talipes equinovarus, and early death. The diagnosis is confirmed radiologically: short, distally tapering humeri, absent or hypoplastic fibulae, deficient vertebral ossification with coronal clefting, and anarchic ossification of phalanges are characteristic findings. We report a male child with this condition born to first cousin Bengali parents.

Dominantly inherited cleft lip and palate in two families.

Two families with non-syndromic cleft lip and cleft palate are described. The linear pattern of inheritance through several generations is difficult to explain by conventional multifactorial models. The pedigrees strengthen the suggestion that a dominantly inherited mutation exists with a major influence on clefting of the lip and palate alone.

The prevalence of asthma in the South-Fore people of Papua New Guinea. A method for field studies of bronchial reactivity.

We studied the prevalence of asthma in a population of the South Fore linguistic group of the Eastern Highlands Province of Papua New Guinea, where a remarkable increase in the disease has been reported in the last decade. To make the study as objective as possible it was necessary to define the disease and to develop tests of bronchial reactivity for use in the field. Asthma was defined as symptoms of intermittent breathlessness plus bronchial hyperreactivity measured by a histamine inhalation test (HIT) or response to bronchodilator aerosol. Following a demographic study to define the symptomatic people in the population, all people with present or past breathlessness had a detailed history taken, their bronchial response measured with a HIT or with bronchodilator aerosol, and skin prick tests performed. Asthma was estimated to be present in at least 7.3% of the adult population and in 0.6% of children. The exact prevalence could not be determined because of difficulties in distinguishing asthma from chronic obstructive lung disease in patients with severe airflow limitation. In most subjects the asthma was severe and associated with allergy to house-dust mite. Control subjects matched for age, sex and village, who had no symptoms, had normal bronchial reactivity. The HIT, together with a history of breathlessness, may prove to be the simplest and most objective method for determining the prevalence of asthma in different populations.

Occurrence and activity of iron- and sulfur-oxidizing microorganisms in alkaline coal strip mine spoils.

Spoils samples collected from a coal strip mine in southeastern Montana were examined for populations and activities of iron- and sulfur-oxidizing bacteria. Spoils examined were of three types: (a) acidic pyrite-rich waste coal, (b) oxidation halo material, and (c) alkaline material, which was the most widespread type. Bacterial numbers, sulfur oxidation, and(14)CO2 uptake activity declined to low levels in the summer when spoils were dry. Even in wetter spring months pyritic spoils contained relatively low numbers of acidophilic iron- and sulfur-oxidizing bacteria, probably indicative of water stress since the same spoils incubated with excess water or dilute mineral salts showed considerably greater bacterial numbers and activity. Certain wells in coal and spoils aquifers contained substantial populations of iron-oxidizing acidophilic bacteria. However, these wells were always of alkaline or neutral pH, indicating that bacterial pyrite oxidation occurred where groundwaters contacted either replaced spoils or coal that contained pyrite or other metal sulfides. Bacterial activity may contribute to trace metal and sulfate leaching in the area.

Survival of two enterobacteria in feces buried in soil under field conditions.

Feces samples, inoculated with 10(6) Escherichia coli resistant to streptomycin and nalidixic acid and with 10(5) Salmonella typhimurium per g, were buried at five mountain field sites ranging from 2,005 to 2,730 m in elevation. Counts of each bacterium rose initially and then declined to 10(3) or 10(4) per g of feces in 8 weeks. The survival pattern was similar at all sites regardless of marked differences in elevation, soil, moisture, exposure, and vegetation. S. typhimurium numbers were consistently higher than E. coli numbers after week 3. The test encompassed most of the time that the area is snow-free and accessible for hiking. The results were judged to discredit the recommendation for shallow burial of feces and to indicate a potential health hazard under intensive use.