Phase determination using chromosomal microarray and fluorescence in situ hybridization in a patient with early onset Parkinson disease and two deletions in PRKN.

BACKGROUND: Mutations in the parkin gene (PRKN) are the most commonly identified genetic factors in early onset Parkinson disease (EOPD), with biallelic mutations, resulting in a clinical phenotype. However, normal variation is also common in PRKN, particularly in the form of copy number variation (CNV), challenging interpretation of genetic testing results. Here we report a case of a 29-year-old male with EOPD and two deletions in PRKN detected by chromosomal microarray (CMA). METHODS: The proband was clinically examined by a neurologist for postural instability with frequent falls, bradykinesia, gait freezing with festination, and hypophonia. Chromosomal microarray analysis (CMA) was performed on the proband and his parents using the Affymetrix CytoScan HD microarray. Subsequent fluorescence in situ hybridization (FISH) was performed on the proband and both parents. RESULTS: Chromosomal microarray detected the presence of two deletions of PRKN in the proband. Parental CMA analysis was performed to determine the clinical significance of this finding, as well as to demonstrate phase of these deletions. Parental CMA revealed that one deletion was paternally inherited and one deletion was de novo. A custom FISH approach was then successfully used to phase the deletions. CONCLUSION: Chromosomal microarray and fluorescence in situ hybridization analysis of this trio identified two deletions in PRKN occurring in trans, providing a genetic etiology for the clinical diagnosis of EOPD. The determination of inheritance and phase of the deletions was critical to the proper interpretation of these results. These findings highlight the utility of CMA in the detection of clinically relevant CNVs in cases of EOPD, and also serve to emphasize the importance of follow-up FISH and parental testing.

A Novel Partial Duplication of ZEB2 and Review of ZEB2 Involvement in Mowat-Wilson Syndrome.

Mowat-Wilson syndrome is a rare genetic condition characterized by intellectual disability, structural anomalies, and dysmorphic features. It is caused by haploinsufficiency of the ZEB2 gene in chromosome 2q22.3. Over 180 distinct mutations in ZEB2 have been reported, including nonsense and missense point mutations, deletions, and large chromosomal rearrangements. We report on a 14-year-old female with a clinical diagnosis of Mowat-Wilson syndrome. Chromosomal microarray identified a novel de novo 69-kb duplication containing exons 1 and 2 of the ZEB2 gene. Sequence analysis identified no other variants in this gene. This is the first report of a partial duplication of the ZEB2 gene resulting in Mowat-Wilson syndrome.

A chimeric RNA characteristic of rhabdomyosarcoma in normal myogenesis process.

UNLABELLED: Gene fusions and their chimeric products are common features of neoplasia. Given that many cancers arise by the dysregulated recapitulation of processes in normal development, we hypothesized that comparable chimeric gene products may exist in normal cells. Here, we show that a chimeric RNA, PAX3-FOXO1, identical to that found in alveolar rhabdomyosarcoma, is transiently present in cells undergoing differentiation from pluripotent cells into skeletal muscle. Unlike cells of rhabdomyosarcoma, these cells do not seem to harbor the t(2;13) chromosomal translocation. Importantly, both PAX3-FOXO1 RNA and protein could be detected in the samples of normal fetal muscle. Overexpression of the chimera led to continuous expression of MYOD and MYOG-two myogenic markers that are overexpressed in rhabdomyosarcoma cells. Our results are consistent with a developmental role of a specific chimeric RNA generated in normal cells without the corresponding chromosomal rearrangement at the DNA level seen in neoplastic cells presumably of the same lineage. SIGNIFICANCE: A chimeric fusion RNA, PAX3-FOXO1, associated with alveolar rhabdomyosarcoma, is also present in normal non-cancer cells and tissues. Its transient expression nature and the absence of t(2;13) chromosomal translocation are consistent with a posttranscriptional mechanism. When constantly expressed, PAX3-FOXO1 interfered with the muscle differentiation process, which presumably contributes to tumorigenesis.

Spindle cell rhabdomyosarcoma of the neck with t(6;8) translocation: report of a case and literature review.

Spindle cell rhabdomyosarcoma is an uncommon subtype of embryonal rhabdomyosarcoma. Found almost exclusively in children, these tumors are classically located in the paratesticular and head and neck regions. Morphologically these lesions can resemble several other benign or malignant soft-tissue spindle cell lesions, especially smooth muscle or myofibroblastic tumors, and thus immunohistochemical staining is often needed to prove skeletal muscle differentiation. Although there is extensive literature reporting the genetics of embryonal rhabdomyosarcoma, little is reported specific to the spindle cell subtype. Below we present the case of a 7-month-old male presenting with a large posterior neck mass that was diagnosed as spindle cell rhabdomyosarcoma. Karyotype evaluation revealed a t(6;8) (p12;q11.2) chromosomal translocation within the lesion. We review the histologic and immunohistochemical diagnosis of these tumors and discuss the genetics of rhabdomyoscarcomas.

Development and characterization of xenograft model systems for adenoid cystic carcinoma.

Adenoid cystic carcinoma (ACC) is one of the most common malignancies to arise in human salivary glands, and it also arises in the glandular tissue of other organ systems. To address the paucity of experimental model systems for this tumor type, we have undertaken a program of transplanting tissue samples of human ACC into immunodeficient nu/nu mice to create xenograft model systems. In 17 of 23 attempts (74%), xenograft tumors were successfully grown. In all cases, the histologic appearance of the donating tumor was recapitulated in the subsequent xenograft. Characterization of a subset of xenograft models by immunohistochemical biomarkers and by RNA transcript microarray analysis showed good fidelity in the recapitulation of gene expression patterns in the xenograft tumors compared with the human donor tumors. As ACC is known to frequently contain a t(6;9) translocation that fuses the MYB and NFIB genes, fluorescence in situ hybridization (FISH) of 12 ACC xenograft models was performed that assayed MYB locus break-apart and MYB-NFIB locus fusion. Of 12 xenograft models, 11 (92%) revealed MYB locus rearrangement and 10 (83%) showed evidence of fusion of the MYB and NFIB loci. The two related xenograft models (derived from primary and metastatic tumors, respectively, of the same human subject) were karyotyped, showing a t(1;6) translocation, suggesting MYB translocation to a novel fusion partner gene. Overall, our results indicate that ACC is amenable to xenografting and that ACC xenograft models recapitulate the molecular and morphologic characteristics of human tumors, suggesting utility as valid experimental and preclinical model systems for this disease.

EuroQol (EQ-5D) health utility scores for patients with migraine.

PURPOSE: Previous studies have reported health utilities for migraine patients as generally measured between migraine attacks, but health utility data for within a migraine attack are unavailable. We evaluated within-attack health utilities among acute migraine patients experiencing different grades of headache severity. METHODS: We examined data for 330 20-65-year-old adults, in good physical health, who had 1-6 moderate/severe migraine attacks per month in the 2 months prior to the screening visit. Data were collected from a multicenter, double-blind study of a treatment for acute migraine in the United States. The EQ-5D system was used to measure generic health status at baseline and 24 h post-treatment within an acute migraine attack, and patients were also asked to rate their pain level at these time points (no, mild, moderate, or severe pain). The D1 time-trade-off scoring algorithm for the U.S. population was applied. Confidence intervals were estimated by bootstrap methods. RESULTS: The study population was 88% women and 78% white ethnicity, with 60% of subjects over age 40. The disutility of mild migraine pain was estimated to be 0.140 (95% CI: 0.0848, 0.1940), with a disutility for moderate migraine pain of 0.186 (95% CI: 0.1645, 0.2053) and for severe migraine pain of 0.493 (95% CI: 0.4100, 0.5654). CONCLUSIONS: Within-attack disutilities estimated for migraine in this study are much greater than those reported for migraine when evaluated as a chronic health condition (e.g., valuations collected at random time points). These data can be of value in adapting results from clinical trials of migraine interventions to cost-utility policy analyses.

Rates and predictors of starting a triptan: results from the American Migraine Prevalence and Prevention Study.

BACKGROUND: Although diagnostic rates for migraine have increased over the past 5 years, the proportion of migraine sufferers using triptans has remained essentially stable. OBJECTIVES: To assess the rate of onset of new triptan prescriptions among persons with migraine and the predictors of initiating therapy. METHODS: The American Migraine Prevalence and Prevention Study is a longitudinal study conducted in a representative sample of headache sufferers in the US population. Episodic migraineurs not using triptans in 2005 who continued to have migraine and provided treatment data in 2006 (n=6865) were included. We assessed predictors of triptan use in univariate and multivariate analyses, including 3 nested models. In Model 1, we adjusted for demographic variables. Model 2 added headache-related disability and cutaneous allodynia. Model 3 added depression and use of preventive headache medications. RESULTS: Among individuals not using triptans in 2005, triptan use in 2006 occurred in 4.9% of the sample. In unadjusted analyses, gender and race were not associated with use of triptan. Use was lower in those aged 60 years or more vs those 18-29 (odds ratio [OR]=0.4, 95% confidence interval [CI]=0.2-0.7, P=.001). Taking individuals with no disability as the reference, mild (OR=1.44, 95% CI=1.03-2.01, P=.03), moderate (OR=1.54, 95% CI=1.1-2.2, P=.01) and severe disability (OR=2.19, 95% CI=1.55-3.09, P<.0001) predicted triptan use. In the adjusted models, age, income, insurance, disability and preventive medication use were associated with triptan use. Gender, race, education and depression were not. CONCLUSIONS: New use of triptans is low in the population. Because adequacy of care was not assessed, future studies should focus on investigating whether this low rate of triptan start is proper or if it reflects an unmet treatment need.

Predictability of future attacks by migraineurs: a prospective observational study.

OBJECTIVE: To determine the predictability of future migraine attacks and to describe the effect of migraine on daily life during and between migraine attacks. BACKGROUND: Migraine is associated with substantial economic and humanistic burden. There is growing evidence that early intervention with triptans results in better treatment outcomes. However, this is dependent on a patient's preparedness for an attack including having abortive medications readily accessible at headache onset. METHODS: Physician-diagnosed adult migraine sufferers, who treat with prescription or over-the-counter medications, completed 2 self-reported, Internet-based questionnaires, administered at baseline and following the resolution of the next migraine attack. The baseline questionnaire included the Migraine Disability Assessment questionnaire (MIDAS), questions about experiences on days between attacks, predictions of the date, time of day (5 time windows), and sufferer's location (4 places) at the start of their next migraine. At follow-up, information was collected in the similar fashion about the date, time of day, and sufferer's location at the start of their most recent migraine. RESULTS: A total of 1519 migraine sufferers completed the baseline questionnaire and 877 (57.7%) completed the follow-up. At baseline, 58.7% experienced moderate to severe disability from headache, based on MIDAS. Only 4.0% were able to predict the exact date of their next migraine; 21.24% predicted next migraine within 3 days. Larger proportions (46.6%) were able to accurately predict time of day or location (70.7%) of their next migraine. In the past 3 months, 92.6% reported that they were forced to change daily plans because of migraine. Because of fear of getting a migraine, 20.2% had avoided and 27.0% had changed a work commitment, and 27.3% had avoided and 28.2% had changed social plans. CONCLUSIONS: Migraine sufferers are generally unable to predict onset of the next migraine. Lack of predictability heightens the importance of education and preparedness for a migraine attack which may also reduce fear and anxiety between attacks.

Triptan use as a function of cardiovascular risk. A population-based study.

AIM: To estimate the proportion of individuals with migraine using triptan therapy as a function of their cardiovascular (CV) profile and disease severity. METHODS: As a part of the American Migraine Prevalence and Prevention study, we identified migraineurs representative of the U.S. adult population. Triptan use was estimated as a function of presence of CV disease (CVD), of CV risk factors, and by level of migraine-related disability. RESULTS: Our sample consists of 6102 individuals with migraine. Compared with migraineurs without risk factors for CVD, triptans were significantly less likely to be used in individuals with diabetes (11.5% vs 18.3%, OR = 0.6, 95% CI = 0.5-0.7), hypertension (14.8%, OR = 0.8, 0.7-0.9) and by smokers (12.9%, OR = 0.7, 0.6-0.8). Similar findings were seen for individuals with established CVD. As contrasted to individuals without CVD, those with myocardial infarct (8.5% vs 18.5%, OR = 0.4, 0.3-0.7), stroke (7%, OR = 0.6, 0.3-0.9) and heart surgery (9.3%, OR = 0.5, 0.4-0.7) were less likely to use triptans. Use of triptan increased as a function of disability regardless of CVD status or presence of CV risk factors. CONCLUSION: Triptan use is lower in those with vs without CV risk, suggesting that doctors and/or patients fear using triptans in individuals at risk to CVD. Furthermore, triptan use in those with established CVD increases with headache-related disability, suggesting that patients and providers balance risks and benefits. Additional and analytical data are needed on the safety of triptans in the setting of CVD risk. This study has not assessed adequacy of care.

Migraine strikes study: factors in patients' decision to treat early.

To describe factors associated with early treatment of migraine, and to examine reasons patients do not treat early, this cross-sectional observational study email-recruited migraineurs >or= 18-years-old who were currently prescribed acute migraine medication. Within 24 h of migraine resolution, eligible patients completed an online migraine strikes questionnaire which addressed pain severity, associated symptoms, and other variables including reasons for not treating early. Results reported were descriptive. Among 1,044 evaluable patients, early treatment was significantly associated with several factors such as leisure activity at onset (OR 1.32, P=0.010), photophobia (OR 1.39, P=0.013), diagnosis of migraine with aura (OR 1.36, P=0.004), and other factors. Among 840 patients who reported wanting to treat earlier desire to reserve medication for a severe migraine was the most common reason given for not doing so (51.2%). Overcoming these factors may facilitate earlier migraine treatment.

GERD prevalence in migraine patients and the implication for acute migraine treatment.

The objective of this study is to estimate the prevalence of gastroesophageal reflux disease (GERD) and heartburn in migraine patients and examine their use of non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin-containing medications when treating acute migraine attacks. Responses from a web-based survey of migraine patients were matched to the same patient's responses on a general health survey. A total of 1,832 migraineurs (92.0%) were successfully matched. A total of 403 migraineurs (22.0%) reported having diagnosed GERD, 212 (11.6%) reported diagnosed heartburn, and 290 (15.8%) reported reflux symptoms but were undiagnosed. The most common prescription drugs used to treat migraines were triptans. First-line NSAID/aspirin medication use was 10.0% among diagnosed GERD and heartburn patients, 17.8% among undiagnosed patients, and 11.8% among GERD/heartburn-free migraineurs. In conclusion, almost half of migraineurs reported physician-diagnosed GERD and heartburn or symptoms of these conditions. Use of NSAID medications for migraine is fairly common among diagnosed GERD patients and more so for those with undiagnosed GERD symptoms. Physicians should minimize prescribing NSAIDs or NSAID-containing acute migraine medications in this population.

Single-dose rexinoid rapidly and specifically suppresses serum thyrotropin in normal subjects.

CONTEXT: Retinoid X receptor agonists (rexinoids) have demonstrated benefit in patients with certain malignancies but appear to cause central hypothyroidism in some patients with advanced cancer. The influence of rexinoids on thyroid function in healthy subjects is not clear. OBJECTIVE: The objective of this study was to determine the effect of a single dose of bexarotene on levels of TSH, T4, and T3 in healthy subjects. DESIGN: This study was a randomized, double-blind, placebo-controlled, crossover trial. SETTING: This study was conducted at the General Clinical Research Center (University of Colorado Health Sciences Center, Aurora, CO). SUBJECTS: Six healthy adults (>18 yr old) were studied. INTERVENTION: Single-dose rexinoid (bexarotene, 400 mg/m2) or placebo, with TSH measurements at 0, 1, 2, 4, 8, 12, 24, and 48 h, were used. MAIN OUTCOME MEASURE: The main outcome was the serum TSH level at 24 h. RESULTS: Single-dose bexarotene suppressed serum TSH (P < 0.001) over time. Compared with placebo, levels of TSH were significantly lower by 12 h (P = 0.043); the nadir of 0.32 +/- 0.02 mU/liter (P < 0.001) was seen at 24 h. Free T4 index and free T3 index were also significantly lower than placebo over time (48 h) (P = 0.029; P = 0.004, respectively). Serum prolactin, cortisol, and triglycerides were not affected (P > 0.05 for all). There was no significant effect of single-dose bexarotene on rT3 or T3/rT3 ratio at 24 h. CONCLUSION: A single dose of a rexinoid can rapidly and specifically suppress serum TSH levels in healthy subjects. These data provide insight into the mechanisms by which rexinoids cause central hypothyroidism and potential ways this effect can be used for treatment of disorders such as thyroid hormone resistance and TSH-secreting pituitary tumors.

Cardiac phenotypes in chromosome 4q- syndrome with and without a deletion of the dHAND gene.

PURPOSE: Terminal deletions of chromosome 4q are commonly associated with cardiovascular malformations (CVMs). The dHAND gene (HAND2 heart and neural crest derivative express 2), a basic helix-loop-helix transcription factor expressed in the developing heart, maps to 4q33. A targeted deletion in mouse shows that dHAND plays an important role in heart development, suggesting that haploinsufficiency of in patients with 4q deletions may be causal for CVMs. The purpose of this study is to examine the possible association between dHAND haploinsufficiency with the CVMs that occur in patients with 4q terminal deletions. METHODS: Fluorescence in situ hybridization (FISH) was performed with a dHAND human genomic probe on five patients with terminal deletion at 4q33 or 4q34. RESULTS: Of the three patients with a deletion of the dHAND locus, two had CVM (both valvar pulmonic stenosis). Of the two patients without a deletion of the dHAND gene, one had a small atrial septal defect noted on autopsy. In one of the patients with breakpoint on chromosome 4 assigned to 4q34.2 by GTG-banding, FISH revealed deletion of the dHAND gene. CONCLUSION: The results suggest that cardiac phenotypes are very variable in patients with the terminal deletion of chromosome 4q and that haploinsufficiency of the dHAND is not necessarily associated with CVMs. The correct cytogenetic interpretation of terminal chromosome deletions might be augmented by FISH.