Novel WWOX deleterious variants cause early infantile epileptic encephalopathy, severe developmental delay and dysmorphism among Yemenite Jews.

The human WW Domain Containing Oxidoreductase (WWOX) gene was originally described as a tumor suppressor gene. However, recent reports have demonstrated its cardinal role in the pathogenesis of central nervous systems disorders such as epileptic encephalopathy, intellectual disability, and spinocerebellar ataxia. We report on six patients from three unrelated families of full or partial Yemenite Jewish ancestry exhibiting early infantile epileptic encephalopathy and profound developmental delay. Importantly, four patients demonstrated facial dysmorphism. Exome sequencing revealed that four of the patients were homozygous for a novel WWOX c.517-2A > G splice-site variant and two were compound heterozygous for this variant and a novel c.689A > C, p.Gln230Pro missense variant. Complementary DNA sequencing demonstrated that the WWOX c.517-2A > G splice-site variant causes skipping of exon six. A carrier rate of 1:177 was found among Yemenite Jews. We provide the first detailed description of patients harboring a splice-site variant in the WWOX gene and propose that the clinical synopsis of WWOX related epileptic encephalopathy should be broadened to include facial dysmorphism. The increased frequency of the c.517-2A > G splice-site variant among Yemenite Jews coupled with the severity of the phenotype makes it a candidate for inclusion in expanded preconception screening programs.

A role for TENM1 mutations in congenital general anosmia.

Congenital general anosmia (CGA) is a neurological disorder entailing a complete innate inability to sense odors. While the mechanisms underlying vertebrate olfaction have been studied in detail, there are still gaps in our understanding of the molecular genetic basis of innate olfactory disorders. Applying whole-exome sequencing to a family multiply affected with CGA, we identified three members with a rare X-linked missense mutation in the TENM1 (teneurin 1) gene (ENST00000422452:c.C4829T). In Drosophila melanogaster, TENM1 functions in synaptic-partner-matching between axons of olfactory sensory neurons and target projection neurons and is involved in synapse organization in the olfactory system. We used CRISPR-Cas9 system to generate a Tenm1 disrupted mouse model. Tenm1(-/-) and point-mutated Tenm1(A) (/A) adult mice were shown to have an altered ability to locate a buried food pellet. Tenm1(A) (/A) mice also displayed an altered ability to sense aversive odors. Results of our study, that describes a new Tenm1 mouse, agree with the hypothesis that TENM1 has a role in olfaction. However, additional studies should be done in larger CGA cohorts, to provide statistical evidence that loss-of-function mutations in TENM1 can solely cause the disease in our and other CGA cases.

Functional variant of KLOTHO: a breast cancer risk modifier among BRCA1 mutation carriers of Ashkenazi origin.

Klotho is a transmembrane protein that can be shed and act as a circulating hormone and is a putative tumor suppressor in breast cancer. A functional variant of KLOTHO (KL-VS) contains two amino acid substitutions F352V and C370S and shows reduced activity. Germ-line mutations in BRCA1 and BRCA2 substantially increase lifetime risk of breast and ovarian cancers. Yet, penetrance of deleterious BRCA1 and BRCA2 mutations is incomplete even among carriers of identical mutations. We examined the association between KL-VS and cancer risk among 1115 Ashkenazi Jewish women: 236 non-carriers, 631 BRCA1 (185delAG, 5382insC) carriers and 248 BRCA2 (6174delT) carriers. Among BRCA1 carriers, heterozygosity for the KL-VS allele was associated with increased breast and ovarian cancer risk (hazard ratio 1.40, 95% confidence intervals 1.08-1.83, P=0.01) and younger age at breast cancer diagnosis (median age 48 vs 43 P=0.04). KLOTHO and BRCA2 are located on 13q12, and we identified linkage disequilibrium between KL-VS and BRCA2 6174delT mutation. Studies in breast cancer cells showed reduced growth inhibitory activity and reduced secretion of klotho F352V compared with wild-type klotho. These data suggest KL-VS as a breast and ovarian cancer risk modifier among BRCA1 mutation carriers. If validated in additional cohorts, the presence of KL-VS may serve as a predictor of cancer risk among BRCA1 mutation carriers.

Transgenic acetylcholinesterase induces enlargement of murine neuromuscular junctions but leaves spinal cord synapses intact.

Acetylcholinesterase (AChE) produced by spinal cord motoneurons accumulates within axo-dendritic spinal cord synapses. It is also secreted from motoneuron cell bodies, through their axons, into the region of neuromuscular junctions, where it terminates cholinergic neurotransmission. Here we show that transgenic mice expressing human AChE in their spinal cord motoneurons display primarily normal axo-dendritic spinal cord cholinergic synapses in spite of the clear excess of transgenic over host AChE within these synapses. This is in contrast to our recent observation that a modest excess of AChE drastically affects the structure and long-term functioning of neuromuscular junctions in these mice although they express human AChE in their spinal cord, but not muscle. Enlarged muscle endplates with either exaggerated or drastically shortened post-synaptic folds then lead to a progressive neuromotor decline and massive amyotrophy (Andres et al., 1997). These findings demonstrate that excess neuronal AChE may cause distinct effects on spinal cord and neuromuscular synapses and attribute the late-onset neuromotor deterioration observed in AChE transgenic mice to neuromuscular junction abnormalities.

Pituitary apoplexy as a first manifestation of pituitary adenomas following intensive thrombolytic and antithrombotic therapy.

Apoplexy of a previously asymptomatic pituitary macroadenoma may occur in the setting of intensive thrombolytic, antithrombotic, or anticoagulant therapy for acute myocardial infarction. Classic clinical findings may initially be nonspecific and a high index of suspicion is therefore required for early diagnosis.

Frequent apoptosis in human kidneys after acute renal hypoperfusion.

BACKGROUND/AIMS: Apoptosis, a form of cell death characterized by DNA fragmentation and minimal inflammation, is induced by intrarenal hypoxia in rats. The objective of this study was to test whether apoptosis participates in human acute renal injury. METHODS: We examined kidneys obtained from autopsies of 40 patients following hemodynamic compromise and from 9 controls following sudden death. Nuclear DNA fragmentation was assayed by in situ 3' end labeling (TUNEL stain) and compared to histological findings. RESULTS: DNA fragmentation along renal tubular cells was observed in 23 (57%) of the study patients but in none of the controls (p < 0.005). Acute tubular necrosis was seen by formal histology in 27% of the patients and correlated with clinical acute renal dysfunction, while DNA fragmentation did not. CONCLUSION: DNA fragmentation often occurs after renal hypoperfusion and does not imply renal failure. Apoptosis may participate in the adaptive response of the kidney to hypoxia.

Enhanced hemicholinium binding and attenuated dendrite branching in cognitively impaired acetylcholinesterase-transgenic mice.

In a search for behavioral, neuroanatomical, and metabolic characteristics of Alzheimer's disease that may result from cholinergic malfunction, we used transgenic mice overexpressing acetylcholinesterase (AChE) mRNA and active enzyme in brain neurons. Mapping by in situ hybridization revealed that transgenic and host AChE mRNAs were distributed similarly. In a Morris water maze working memory paradigm, adult transgenic mice did not display the characteristic improvement found in control mice either between or within test days and spent less time than control mice in the platform zone. In 5-week-old transgenic mice, the basilar dendritic trees of layer 5 pyramidal neurons from the frontoparietal cortex were essentially as developed as in age-matched controls. However, branching totally ceased after this age, whereas in control adults it continued up to at least 7 months. Therefore, dendritic arbors became smaller in adult transgenic mice than those of controls. Furthermore, the average number of spines was significantly lower on dendritic branches of 7-month-old but not 5-week-old transgenics as compared with controls. Binding of tritiated hemicholinium-3, a blocker of the high-affinity choline uptake characteristic of active cholinergic terminals, was over twofold enhanced in the brain of transgenic mice. In contrast, no differences were observed in the mRNA and ligand binding levels of several different subtypes of nicotinic and muscarinic acetylcholine receptors. These findings suggest that three different hallmarks associated with Alzheimer's disease--namely, progressive cognitive failure, cessation of dendrite branching and spine formation, and enhanced high-affinity choline uptake--are outcomes of cholinergic malfunction.

Acetylcholinesterase-transgenic mice display embryonic modulations in spinal cord choline acetyltransferase and neurexin Ibeta gene expression followed by late-onset neuromotor deterioration.

To explore the possibility that overproduction of neuronal acetylcholinesterase (AChE) confers changes in both cholinergic and morphogenic intercellular interactions, we studied developmental responses to neuronal AChE overexpression in motoneurons and neuromuscular junctions of AChE-transgenic mice. Perikarya of spinal cord motoneurons were consistently enlarged from embryonic through adult stages in AChE-transgenic mice. Atypical motoneuron development was accompanied by premature enhancement in the embryonic spinal cord expression of choline acetyltransferase mRNA, encoding the acetylcholine-synthesizing enzyme choline acetyltransferase. In contrast, the mRNA encoding for neurexin-Ibeta, the heterophilic ligand of the AChE-homologous neuronal cell surface protein neuroligin, was drastically lower in embryonic transgenic spinal cord than in controls. Postnatal cessation of these dual transcriptional responses was followed by late-onset deterioration in neuromotor performance that was associated with gross aberrations in neuromuscular ultrastructure and with pronounced amyotrophy. These findings demonstrate embryonic feedback mechanisms to neuronal AChE overexpression that are attributable to both cholinergic and cell-cell interaction pathways, suggesting that embryonic neurexin Ibeta expression is concerted in vivo with AChE levels and indicating that postnatal changes in neuronal AChE-associated proteins may be involved in late-onset neuromotor pathologies.

Failure of insulin-like growth factor 1 to improve radiocontrast nephropathy.

Exogenous insulin-like growth factor 1 (IGF-1) has been reported to improve experimental ischemic acute renal failure. We investigated a possible beneficial role of IGF-1 in a model of radiocontrast nephropathy induced by indomethacin, nitro-L-arginine ester and iothalamate. Multiple injections of recombinant human IGF-1 (or its vehicle) at 150 microg/100 g body weight/day were given for 24 h starting 1 h after radiocontrast, or initiated 1 day after the insults and continued for 48 h. IGF-1 prevented neither the fall in creatinine clearance nor medullary thick ascending limb necrosis observed at 24 h. Similarly IGF-1, given for 2 days after renal failure had been established, did not accelerate functional recovery at 72 h, did not ameliorate catabolism and did not alter the morphological evolution of intrarenal damage. In conclusion, IGF-1 had no beneficial effects in this model of radiocontrast nephropathy.

Left ventricular free wall rupture as the presenting manifestation of acute myocardial infarction in diabetic patients.

We present 5 diabetic patients with acute myocardial infarction in whom left ventricular free wall rupture was the presenting manifestation. Echocardiography may be indicated in diabetic patients with acute myocardial infarction and in shock, prior to thrombolysis.

Transgenic expression of human acetylcholinesterase induces progressive cognitive deterioration in mice.

BACKGROUND: Cognitive deterioration is a characteristic symptom of Alzheimer's disease. This deterioration is notably associated with structural changes and subsequent cell death which occur, primarily, in acetylcholine-producing neurons, progressively damaging cholinergic neurotransmission. We have reported previously that excess acetylcholinesterase (AChE) alters structural features of neuromuscular junctions in transgenic Xenopus tadpoles. However, the potential of cholinergic imbalance to induce progressive decline of memory and learning in mammals has not been explored. RESULTS: To approach the molecular mechanisms underlying the progressive memory deficiencies associated with impaired cholinergic neurotransmission, we created transgenic mice that express human AChE in brain neurons. With enzyme levels up to two-fold higher than in control mice, transgenic mice displayed an age-independent resistance to the hypothermic effects of the AChE inhibitor, paraoxon. In addition to this improved scavenging capacity for anti-AChEs, however, these transgenic mice also resisted muscarinic, nicotinic and serotonergic agonists, indicating that secondary pharmacological changes had occurred. The transgenic mice also developed progressive learning and memory impairments, although their locomotor activities and open-field behaviour remained similar to those of matched control mice. By six months of age, transgenic mice lost their ability to respond to training in a spatial learning water maze test, whereas they performed normally in this test at the age of four weeks. This animal model is therefore suitable for investigating the transcriptional changes associated with cognitive deterioration and for testing drugs that may attenuate progressive damage. CONCLUSION: We conclude that upsetting cholinergic balance may by itself cause progressive memory decline in mammals, suggesting that congenital and/or acquired changes in this vulnerable balance may contribute to the physiopathology of Alzheimer's disease.

Rapid DNA fragmentation from hypoxia along the thick ascending limb of rat kidneys.

Extensive DNA fragmentation, a marker for programmed cell death, was selectively and rapidly induced by hypoxia in the thick ascending limbs of rat kidneys. In isolated perfused kidneys, DNA breaks were present in medullary tubules as early as after 10 minutes of local hypoxia and were prevented by reduction of metabolic work. In a model of radiocontrast-induced acute renal failure, DNA breaks were detected selectively along thick ascending limbs as early as 15 minutes following insult, preceding overt morphological damage. Hypoxia induces rapid DNA fragmentation along thick ascending limbs, where programmed cell death could play an important role in nephron injury and kidney failure.

Predictors of mortality in patients admitted to hospital for acute upper gastrointestinal hemorrhage.

BACKGROUND: We wanted to identify features of prognostic significance in patients admitted to hospital because of acute upper gastrointestinal (UGI) hemorrhage. METHODS: A prospective, longitudinal study of 321 consecutive cases admitted during 1988-91 was carried out. The relative risk of mortality associated with each of the background, laboratory, and endoscopic features and the hospital course was calculated. Multiple stepwise logistic regression was used to define factors independently associated with mortality. Two models were evaluated, the first based on the data at presentation (history, physical findings, initial laboratory data) and the second based on the first, plus the endoscopic and follow-up data. RESULTS: The overall mortality was 7.8%. At presentation the features associated with a significantly (p < 0.05) increased risk of mortality were (adjusted odds ratios in parentheses) age > or = 75 years (11.2), a history of cancer (12.1), blood in the gastric aspirate (9.6), and a systolic blood pressure < or = 90 mm Hg (6.4). The overall predictors of mortality were age > or = 75 years (12.7), blood in the gastric aspirate (18.9), serum creatinine level > or = 150 mumol/l (14.8), increased serum aminotransferase level (20.2), and persistent or recurrent bleeding (57.3). CONCLUSIONS: In patients admitted to hospital because of UGI hemorrhage the prognosis depends on age, underlying diseases, hemodynamic status, and the persistence or recurrence of bleeding. The causes of bleeding were not relevant to the prognosis.

Testicular amplification and impaired transmission of human butyrylcholinesterase cDNA in transgenic mice.

Gene amplification occurs frequently in tumour tissues yet is, in general, non-inheritable. To study the molecular mechanisms conferring this restraint, we created transgenic mice carrying a human butyrylcholinesterase (BCHE) coding sequence, previously found to be amplified in a father and son. Blot hybridization of tail DNA samples revealed somatic transgene amplifications with variable restriction patterns and intensities, suggesting the occurrence of independent amplification events, in 31% (11/35) of mice from the FII generation but in only 3.5% (2/58) of the FIII and FIV generations. In contrast, > 10-fold amplifications of the BCHE transgene and the endogenous acetylcholinesterase and c-raf genes appeared in both testis and epididymis DNA from > 80% of FIII mice. Drastic, selective reductions in testis BCHEmRNA but not in actin mRNA were detected by the PCR amplification of testis cDNA from the transgenic mice, and apparently resulted in the limited transmission of amplified genes. The testicular amplification of the BCHE transgene may potentially represent a general phenomenon with clinical implications in human infertility.

Acute upper gastrointestinal bleeding in Jerusalem 1988-91: causes, characteristics and relation to nonsteroidal anti-inflammatory drugs.

We analyzed 321 consecutive episodes of community-based acute upper gastrointestinal bleeding admitted to the Hadassah University Hospital in Jerusalem during 1988-91. Of these 71% were in males aged 56.2 +/- 1.2 years (mean +/- SE) and 29% were in females (67.9 +/- 1.7 years, P < 0.001). The main diagnoses were duodenal ulcer (39.5%), gastric ulcer (16.9%), esophageal varices (10.0%), erosive gastritis (8.2%) and esophagitis (7.5%). The distribution of these diagnoses differed significantly between the genders (P = 0.0003). In males the prevalence of duodenal ulcer and of esophageal varices was higher, and that of gastric ulcer and esophagitis lower, than in females. Gastric ulcer patients were oldest, were the least likely to have received anti-ulcer medications prior to admission, and had the highest levels of urea and the lowest levels of hemoglobin on admission. Use of nonsteroidal anti-inflammatory drugs increased significantly with age and was reported in 35% of the cases (aspirin in doses < 1.0 g/day in 21%, nonsalicylate anti-inflammatory agents in 11%, aspirin plus other anti-inflammatory drugs in 3%). Use of systemic corticosteroids was reported in 4%. The most distinctive features of the population with acute upper gastrointestinal bleeding in the present study compared to other series were the significantly higher proportion of duodenal ulcers and the lower proportion of Mallory-Weiss tears.

Seasonal fluctuations in acute upper gastrointestinal bleeding: lack of effect of nonsteroidal anti-inflammatory drugs.

The seasonal pattern of community-based acute bleeding from the upper gastrointestinal (UGI) tract was studied prospectively in 1988-1991. Out of 3343 emergency admissions to the Departments of General Surgery, 321 (9.6%) were due to acute UGI bleeding. There was a significant monthly variation in the total number of admissions, as well as in the number of admissions due to acute UGI bleeding (p < 0.0001). However, there was no correlation between the two. Significant seasonal fluctuations were noted both in the absolute number of admissions due to acute UGI bleeding and in the percentage of UGI bleeding admissions of the total number of admissions to the Departments of General Surgery (p = 0.0002). During summer (July through September), the incidence declined significantly to a nadir of 5.5% of total number of admissions in July. The seasonal fluctuation correlated closely with the incidence of duodenal ulcer, but not with that of gastric ulcer. The seasonal pattern was consistent both in patients who had used aspirin or other nonsteroidal anti-inflammatory drugs as well as in those who had not.