Placental telomere length decreases with gestational age and is influenced by parity: a study of third trimester live-born twins.

BACKGROUND: In contrast to the postnatal period, little is known about telomere length (TL) during prenatal life. The decrease in placental TL remains unknown, although intra uterine growth retardation and preeclampsia are associated with shorter placental TL. The aim of this study is to assess the decrease of placental TL during the third trimester of gestation and to explore the role of potential "growth influencing factors". METHODS: The study sample consisted of 329 live-born twins from the East Flanders Prospective Twin Survey. TL was determined using a multiplex quantitative PCR method. Gestational age, sex, birth order, placental characteristics, parity, maternal and paternal age, diabetes, hypertension, smoking, alcohol use, and socio economic status (SES) were considered "growth influencing factors". Bivariable multilevel regression analysis with "growth influencing factors" was performed. RESULTS: Placental TL ranged from 4.3 kbp to 84.4 kbp with a median of 10.8 kbp. Ln(TL) decreased in a linear fashion with an estimated TL decreasing from 13.98 kbp at 28 weeks to 10.56 kbp at 42 weeks. The regression coefficient of gestational age became smaller if considered together with SES (b = -0.017; p = 0.08) or diabetes (b = -0.018; p = 0.07) and bigger if considered together with parity (b = -0.022; p = 0.02), indicating that part of the association between gestational age and telomere length is explained by these three confounding factors. CONCLUSION: Placental TL decreases during the third trimester of gestation of live-born twins with approximately 25% indicating that telomere shortening may play a role in aging of the placenta.

Vagus nerve stimulation for epilepsy activates the vocal folds maximally at therapeutic levels.

PURPOSE: Vagus nerve stimulation (VNS) for medically refractory epilepsy can give hoarseness due to stimulation of the recurrent laryngeal nerve. For a group of VNS-therapy users this side-effect interferes severely with their daily activities. Our goal was to investigate the severity of intra-operative VNS-related vocal fold contraction at different pulse widths and current output parameters. We investigated electromyographic and morphometric alterations on the vocal folds during VNS. METHODS: Vocal fold EMG experiments were conducted intra-operatively during the implantation of a VNS system. During surgery the VNS pulse generator was programmed to stimulate at different pulse durations. At each pulse width the EMG-threshold current was determined by electrical stimulation of the vagus nerve with increasing stimulation currents. Laryngostroboscopic examination was performed after surgery to analyze the effects of spontaneous stimulation on the larynx. RESULTS: The vocal fold EMG and morphodynamic changes in the larynx have been analyzed in eight patients. In all patients left vocal fold EMG-threshold was between 0.25 and 0.50 mA. Pulse duration had little influence on the EMG-threshold level. Vocal fold EMG saturation levels were reached between 0.75 and 1.00 mA. Video stroboscopic monitoring showed that stimulation induced an adductory spasm of either the ipsilateral vocal fold or the vestibular fold, and was present remarkably irrespective of the presence of hoarseness. CONCLUSIONS: VNS causes pronounced effects on the vocal folds even at low stimulation amplitudes. At therapeutic levels even at the lowest stimulation pulse durations, the vocal fold contract, however, this does not necessarily give hoarseness.

Variations in the complement regulatory genes factor H (CFH) and factor H related 5 (CFHR5) are associated with membranoproliferative glomerulonephritis type II (dense deposit disease).

INTRODUCTION: Membranoproliferative glomerulonephritis type II or dense deposit disease (MPGN II/DDD) causes chronic renal dysfunction that progresses to end stage renal disease in about half of patients within 10 years of diagnosis. Deficiency of and mutations in the complement factor H (CFH) gene are associated with the development of MPGN II/DDD, suggesting that dysregulation of the alternative pathway of the complement cascade is important in disease pathophysiology. SUBJECTS: Patients with MPGN II/DDD were studied to determine whether specific allele variants of CFH and CFHR5 segregate preferentially with the MPGN II/DDD disease phenotype. The control group was compromised of 131 people in whom age related macular degeneration had been excluded. RESULTS: Allele frequencies of four single nucleotide polymorphisms in CFH and three in CFHR5 were significantly different between MPGN II/DDD patients and controls. CONCLUSION: We have identified specific allele variants of CFH and CFHR5 associated with the MPGN II/DDD disease phenotype. While our data can be interpreted to further implicate complement in the pathogenesis of MPGN II/DDD, these associations could also be unrelated to disease pathophysiology. Functional studies are required to resolve this question.

[Meningitis due to Listeria monocytogenes as a complication of infliximab therapy]. / Meningitis door Listeria monocytogenes als complicatie van behandeling met infliximab.

A 41-year-old woman was admitted to the hospital with meningitis caused by Listeria monocytogenes. Because of her Crohn's disease she used prednisolone and azathioprine. Two weeks before presenting with meningitis, infliximab had been given as the other immunosuppressant drugs had no effect. This tumour necrosis factor alpha (TNF alpha) blocking agent is known to increase the risk of opportunistic infections. This is the first Dutch patient described with meningitis caused by L. monocytogenes after treatment with infliximab. She recovered after antibiotic therapy. When antibiotic treatment is chosen, the possibility of opportunistic infections in patients who use infliximab concurrently with other immunosuppressant drugs should be taken into account.

Optic disc, foveal, and extrafoveal damage due to surgical separation of the vitreous.

OBJECTIVE: To evaluate the morphologic outcomes resulting from surgical vitreoretinal separation in young adult primates. MATERIALS AND METHODS: Vitrectomy and mechanical separation of the vitreous from the internal limiting lamina (ILL) of the posterior retina and surface of the optic disc were performed on 25 young adult cynomolgus monkey eyes in vivo. Lectin histochemical studies were used to evaluate the vitreoretinal interface. Morphologic outcomes were tabulated. RESULTS: In 11 of 25 eye regions, residual vitreous remained attached to the ILL in some of the regions. Localized ILL breaks or separation of the ILL from the neural retina was noted in 9 eyes. Retinal tissue loss, including avulsion of the ganglion cell, inner plexiform, or inner nuclear layers, was observed in 7 eyes. Avulsion of axon bundles in the optic disc was noted in 9 eyes. Significantly, partial- or full-thickness foveal tears were noted in 11 eyes. Based on the surgeons' intraoperative observations, small superficial optic disc or retinal hemorrhages were observed in 3 of 25 eyes. None of the eyes on which a vitrectomy alone was performed showed ILL damage, or retinal or optic disc tissue loss. CONCLUSION: Damage may occur to the optic disc, fovea, and extrafoveal retina as a result of surgical separation of the vitreous from the retina in young adult primates. CLINICAL RELEVANCE: These data support the contention that surgically induced damage at the level of the vitreoretinal interface may help explain the visual field defects noted after surgery to close full-thickness macular holes. These data also support the need for developing additional modalities to assist in vitreous separation, thereby reducing the risk of traumatic complications associated with purely mechanical procedures.

Biomonitoring the intake of garlic via urinary excretion of allyl mercapturic acid.

Allium vegetables (onions, leeks, chives) and in particular garlic have been claimed to have health-promoting potential. This study was conducted to get insight into the perspectives for monitoring the intake of garlic by a biomarker approach. Chemically, the biomarker results from exposure to gamma-glutamyl-S-allyl-l-cysteine, which is first hydrolysed by gamma-glutamine-transpeptidase resulting in the formation of S-allyl-l-cysteine. The latter compound is subsequently N-acetylated by N-acetyltransferase into S-allyl-mercapturic acid (ALMA) and excreted into urine. The mercapturic acid was measured in urine using gaschromatography with mass spectrometry. Thus the intake of garlic was determined to check the compliance of garlic intake in a placebo-controlled intervention study. Results indicate that S-allyl-mercapturic acid could be detected in 15 out of 16 urine samples of garlic supplement takers, indicating good compliance. In addition, the intake of garlic was also monitored in a cross-section study of vegans versus controls in Finland, in which no differences in garlic consumption nor in ALMA output were recorded between vegans and controls. These data indicate good possibilities for further studies in the field of biomarkers to investigate the putative chemopreventive effects of garlic and garlic-containing products.

Niacin, poly(ADP-ribose) polymerase-1 and genomic stability.

Nicotinic acid (NA) and nicotinamide (NAM), commonly called niacin, are the dietary precursors for NAD(+) (nicotinamide adenine dinucleotide), which is required for DNA synthesis, as well as for the activity of the enzyme poly(ADP-ribose) polymerase-1 (PARP-1; EC 2.4.2.30) for which NAD(+) is the sole substrate. The enzyme PARP-1 is highly activated by DNA strand breaks during the cellular genotoxic stress response, is involved in base excision repair, plays a role in p53 expression and activation, and hence, is thought to be important for genomic stability. In this review, first the absorption, metabolism of niacin to NAD(+), as well as the assessment of niacin status are discussed. Since NAD(+) is important for PARP-1 activity, various aspects of PARP-1 in relation to DNA synthesis and repair, and regulation of gene expression are addressed. This is followed by a discussion on interactions between dietary methyl donor deficiency, niacin status, PARP-1 activity and genomic stability. In vitro studies show that PARP-1 function is impaired and genomic stability decreased when cells are either depleted from NAD(+) or incubated with high concentrations of NAM which is a PARP-1 inhibitor. In vitro as well as animal studies indicate that niacin deficiency increases genomic instability especially in combination with genotoxic and oxidative stress. Niacin deficiency may also increase the risk for certain tumors. Preliminary data suggest that niacin supplementation may protect against UV-induced tumors of the skin in mice, but data on similar preventive effects in humans are not available. NAM has been shown in vitro to have an antioxidant activity comparable to that of ascorbic acid. Data on niacin status and genomic stability in vivo in humans are limited and yield ambiguous results. Therefore, no firm conclusions with respect to optimal niacin intake are possible. As a consequence of oral niacin supplementation, however, NAM levels in the body may increase, which may result in inhibition of PARP-1 and increased genomic instability. More studies are needed to define an optimal level of niacin nutriture in relation to genomic stability and tumorigenesis.

Non-secretion of mutant proteins of the glaucoma gene myocilin in cultured trabecular meshwork cells and in aqueous humor.

Until recently, very little was known about the molecular mechanisms responsible for the development of glaucoma, a leading cause of blindness worldwide. Mutations in the glaucoma gene myocilin (MYOC, GLC1A) are associated with elevated intraocular pressure and the development of autosomal dominant juvenile glaucoma and a subset of adult-onset glaucoma. MYOC is expressed in the trabecular meshwork (TM), a tissue responsible for drainage of aqueous humor from the eye, and the tissue involved in elevated intraocular pressure associated with glaucoma. To better understand the role of MYOC in glaucoma pathogenesis, we examined the expression of normal and mutant myocilin in cultured ocular (TM) and non-ocular cells as well as in the aqueous humor of patients with and without MYOC glaucoma. Normal myocilin was secreted from cultured cells, but very little to no myocilin was secreted from cells expressing five different mutant forms of MYOC. In addition, no mutant myocilin was detected in the aqueous humor of patients harboring a nonsense MYOC mutation (Q368X). Co-transfection of cultured cells with normal and mutant myocilin led to suppression of normal myocilin secretion. These studies suggest that MYOC glaucoma is due either to insufficient levels of secreted myocilin or to compromised TM cell function caused by congestion of the TM secretory pathway.

Similarities and differences in the phenotype, genotype and pathogenesis of different spinocerebellar ataxias.

Historically, the differential diagnosis of the autosomal ataxias (ADCAs) has been difficult. In 1983 Harding proposed a useful clinical classification. Since 1983 ADCAs have been increasingly characterized in terms of their genetic locus and are referred to as spinocerebeller ataxia (SCA). The overlap between the SCA phenotypes and the high variability within SCA subgroups means that, for individual patients, the underlying mutation cannot be predicted reliable purely on the basis of clinical symptoms and so diagnosis should be made on the genotype. However, for executing DNA analyses in order of clinical likelihood, neurologists may try to deduce the underlying mutation by using a clinical algorithm. In this article we not only describe such an algorithm but also plot the pathway from clinical presentation, genetic classification and mutation, abnormal protein to common neuropathology in these disorders.

Expression of the protein tyrosine phosphatase, phosphatase of regenerating liver 1, in the outer segments of primate cone photoreceptors.

Foveal cone photoreceptors are morphologically distinct and, presumably, express unique transcripts. We have identified a cDNA clone encoding the protein tyrosine phosphatase (PTP), phosphatase of regenerating liver 1 (PRL-1) in a screen for genes that are enriched in monkey fovea. PRL-1 was originally isolated as an immediate early gene in regenerating liver [R.H. Diamond, D.E. Cressman, T.M. Laz, C.S. Abrams, R. Taub, PRL-1, a unique nuclear protein tyrosine phosphatase, affects cell growth, Mol. Cell Biol. 14 (1994) 3752-3762]. On cDNA Southern blots of human and monkey retina, radiolabeled PRL-1 cDNA hybridized to a single mRNA species of about 2.5 kb that was most intense in fovea-enriched samples. The monkey PRL-1 deduced amino acid sequence is identical to human, rat and mouse PRL-1. Affinity-purified antibodies directed against PRL-1 preferentially labeled cone photoreceptor cells and a subpopulation of bipolar cells in monkey retina. Immunoreactivity in cones was confined to red and green, but not to blue, cones and was restricted to the outer segments. Immunolocalization also revealed that PRL-1 protein expression was non-nuclear, suggesting that its function in the retina may be unrelated to its role in other tissues where it is expressed primarily in nuclei. Although both foveal and extrafoveal cones were PRL-1 reactive, the high abundance of PRL-1 mRNAs detected in monkey fovea correlates with the high concentration of cones in the fovea. The PRL-1 gene is located on chromosome 6q within an interval that also contains the genes that cause two hereditary retinal dystrophies. These studies demonstrate novel expression of the PRL-1 gene in the neural retina and suggest the phosphatase activity of PRL-1 may modulate normal cone photoreceptor cell function.

Drusen associated with aging and age-related macular degeneration contain proteins common to extracellular deposits associated with atherosclerosis, elastosis, amyloidosis, and dense deposit disease.

Age-related macular degeneration (AMD), a blinding disorder that compromises central vision, is characterized by the accumulation of extracellular deposits, termed drusen, between the retinal pigmented epithelium and the choroid. Recent studies in this laboratory revealed that vitronectin is a major component of drusen. Because vitronectin is also a constituent of abnormal deposits associated with a variety of diseases, drusen from human donor eyes were examined for compositional similarities with other extracellular disease deposits. Thirty-four antibodies to 29 different proteins or protein complexes were tested for immunoreactivity with hard and soft drusen phenotypes. These analyses provide a partial profile of the molecular composition of drusen. Serum amyloid P component, apolipoprotein E, immunoglobulin light chains, Factor X, and complement proteins (C5 and C5b-9 complex) were identified in all drusen phenotypes. Transcripts encoding some of these molecules were also found to be synthesized by the retina, retinal pigmented epithelium, and/or choroid. The compositional similarity between drusen and other disease deposits may be significant in view of the recently established correlation between AMD and atherosclerosis. This study suggests that similar pathways may be involved in the etiologies of AMD and other age-related diseases.

Location, substructure, and composition of basal laminar drusen compared with drusen associated with aging and age-related macular degeneration.

PURPOSE: To determine whether basal laminar drusen differ in their location, ultrastructure, or composition from drusen associated with aging and age-related macular degeneration. METHODS: A paraffin-embedded block from an eye of a patient with basal laminar drusen was obtained. Sections were examined immunohistochemically using a battery of antibodies and lectins directed against drusen-associated proteins and glycoconjugates, respectively. Thin sections were examined by electron microscopy and compared with eyes with age-related macular degeneration. RESULTS: Drusen in the eye with basal laminar drusen are located between the basal lamina of the retinal pigment epithelium and the inner collagenous layer of Bruch membrane, just as they are in age-related macular degeneration. Two distinct ultrastructural phenotypes are observed in the eye with basal laminar drusen; their substructure is indistinguishable from drusen phenotypes in age-related macular degeneration. Both basal laminar drusen and drusen associated with age-related macular degeneration are bound by the lectins Ricinis communis agglutinin and Arachis hypogea agglutinin (after neuraminidase digestion) and by antivitronectin, anti-HLA-DR, anti-serum amyloid P, and anti-C5 antibodies, but not by antibodies directed against basement membrane-associated heparan sulfate proteoglycan, laminin, fibrinogen, or collagen type IV. CONCLUSIONS: These data support the notion that cuticular or basal laminar drusen are similar to, and perhaps indistinguishable from, drusen associated with age-related macular degeneration and are not nodular or diffuse thickenings of Bruch membrane, as previously suggested. Thus, we suggest basal laminar drusen is a misnomer. This clinical phenotype should be identified as "early adult onset, grouped drusen" or by the eponym "Gass syndrome." Features of basal laminar drusen, such as uniform drusen size, clustered distribution, and angiographic features, do not appear to be related to differences in drusen location, composition, or substructure.

Meningioma presenting as Tolosa-Hunt syndrome.

A 23-year-old woman was admitted with headache, nausea, vomiting and blurred vision on the left side. Neurological examination showed ptosis with a complete internal and external ophthalmoplegia and a red fullness around the left orbita. Computed tomographic scanning of the brain revealed no abnormalities. As she improved on high doses of steroids a diagnosis of Tolosa-Hunt syndrome (THS) seemed to be indicated. However, magnetic resonance imaging (MRI) showed a lesion with intermediate signal intensity in the left cavernous sinus. Craniotomy was performed when symptoms of THS recurred. Histopathological examination revealed a meningioma with a papillary aspect and some mitoses. This case illustrates that: (1) THS is still a diagnosis by exclusion; (2) MRI and histopathological examination are important if there is any doubt about the diagnosis; and (3) also when there is no doubt, improvement after steroid therapy may be a diagnostic pitfall. Therefore, not only MRI but also orbital phlebography and angiography should seriously be considered.

Parkinsonism, pyramidal signs, polyneuropathy, and cognitive decline after long-term occupational solvent exposure.

It is well known that exposure to manganese, solvents, or carbon monoxide in an occupational setting may lead to central nervous system damage and parkinsonism. The most important solvents in this respect are methanol, toluene, carbon disulfide, and n-hexane. We describe three patients who had been exposed to various solvents for more than 20 years (25, 34, and 46 years). They presented with parkinsonism, pyramidal signs, mild cognitive decline, and unresponsiveness to levodopa. Two patients had a predominantly axonal and sensory polyneuropathy of the lower legs with fasciculations in one of them. Parkinsonian features were progressive, even after the patients had stopped work. We present clinical data, neuropsychological findings, and results of brain computed tomography or magnetic resonance imaging, electroneuromyography, evoked potentials, single photon emission computed tomography, and positron-emission tomography. There is growing evidence that various organic solvents give rise to a parkinsonism syndrome with pyramidal features in susceptible individuals.

The assessment of genetic risk of breast cancer: a set of GP guidelines.

BACKGROUND: Assessing a genetic risk for developing breast cancer is not an easy task for a GP. Current expert guidelines for referring and counselling women with a family history positive for breast cancer are complex and difficult to apply in general practice, and have only two strategies (to refer or not to refer for genetic counselling), giving no guidance for the GP on the management of women with a moderately increased risk of familial breast cancer. OBJECTIVES: We aimed to develop a set of simple practical guidelines for use in primary care for assessing risk and advising women with a positive family history in general practice and aimed to explore its performance. METHODS: Based on a consensus meeting of the Leiden working party of hereditary tumours, the GPs of a university-related health care centre developed a set of GP guidelines to assess risk and advise women with a family history positive for breast cancer in general practice. The GP guidelines include four therapeutic strategies (reassuring, starting surveillance, starting surveillance and contacting a family cancer clinic, referring to a family cancer clinic). Its performance was tested in 67 patients whose pedigrees were available together with the risk assessment of a clinical geneticist using Claus' tables as a gold standard. The gold standard was dichotomized regarding (i) referral to a family cancer clinic and (ii) surveillance. Two existing expert guidelines were similarly compared. RESULTS: Regarding referral to a family cancer clinic, the GP guidelines were very specific, whereas the expert guidelines were more sensitive. Regarding surveillance, the GP guidelines were very sensitive, whereas the expert guidelines were very specific. The total number of misclassified patients was lowest when using the GP guidelines, and higher when using the expert guidelines. CONCLUSIONS: The GP guidelines provide a simplification of current guidelines. Before using them on a larger scale, more testing and refining are needed to increase their sensitivity regarding a referral to a family cancer clinic and their specificity regarding surveillance. They incorporate a role for the GP in the care for women with a family history positive for breast cancer with a moderately increased risk.

Extended extradural spinal arachnoid cyst: an unusual cause of progressive spastic paraparesis.

A 15-year old girl presented with a slowly progressive spastic paraparesis since the age of 12. Creatine kinase was slightly increased. Muscle biopsy carried out during tendon surgery for severe toe-walking showed 'myopathic' changes. Subsequent neurological evaluation and radiological studies revealed a large extradural arachnoid cyst extending from the 11th thoracic vertebra to the first lumbar vertebra. Her condition improved after operation. The 'myopathic' features turned out to be the result of chronic spinal compression. MRI is the method of choice to examine patients with non-hereditary progressive spastic paraparesis. Muscle biopsy and tendon surgery should not be performed, without careful neurological examination.

Analysis of urinary caffeine metabolites to assess biotransformation enzyme activities by reversed-phase high-performance liquid chromatography.

An isocratic high-performance liquid chromatography procedure was developed for the analysis of five urinary metabolites of caffeine; caffeine or 1,3,7-trimethylxanthine (137X), paraxanthine or 1,7-dimethylxanthine (17X), 1,7-dimethylurate (17U), 1-methylxanthine (1X), 1-methylurate (1U) and 5-acetylamino-6-formylamino-3-methyluracil (AFMU). A standardized procedure was used for oral intake of caffeine and for urine collection. Conditions for sample storage and preparation were optimized, resulting in no detectable loss of caffeine metabolites after storage of the urine samples for four months. Urine samples were extracted with chloroform-2-propanol (4:1, v/v) and separated on a reversed-phase column with acetic acid (33%)-tetrahydrofuran-acetonitrile-water (1:2.5:44:925.5, v/v) as the eluent. Peaks were monitored at 280 nm. Peak heights were measured and the five metabolites were quantified using calibration curves. Cytochrome P4501A2 (CYP1A2) activity was calculated from the molar ratio (AFMU+1X+1U)/17U, N-acetyltransferase (NAT) from the ratio AFMU/1X, XO from the ratio 1U/1X+1U and cytochrome P4502A6 (CYP2A6) from the ratio 17U/(17U+17X+1U+ 1X+AFMU). The inter-assay coefficients of variation ranged from 1.7% for 17U to 5.7% for IX. The intra-individual variation in metabolite ratios determined in two people, with intervals of a few days to several weeks between measurements, ranged from 2. 1% for XO to 11.0% for CYP2A6. Using this procedure, metabolic ratios were determined for four groups of subjects; healthy, non-smoking females using oral contraceptives (OC users, n=5) and non-users (n=5), healthy nonsmoking males (n=9) and children (n=7). Results found in this study were comparable to results reported in the literature for subjects with similar characteristics. A significantly higher CYP1A2 ratio was found for males (4.87+/-0.47) compared to females (3.62+/-0.91: p=0.005, Mann-Whitney). For the other enzyme activities, no significant differences were found between the groups of subjects in this study.