Promoter -817C>T variant of B lymphocyte stimulator gene (BLyS) and susceptibility to endometriosis-related infertility and idiopathic infertility in Brazilian population.

Many theories have been proposed to explain the development of endometriosis, and recently, autoimmune aetiology has been suggested. Besides, it is well known that endometriosis, especially the advanced disease, may impair fertility. B lymphocyte stimulator (BLyS) is a cytokine produced by macrophages and is necessary for normal B cell development. One of the most studied polymorphisms is the -817C/T in the promoter region of the gene. We aimed to assess the association between endometriosis-related infertility and idiopathic infertility and the BLyS -817C/T polymorphism in a Brazilian population. We performed a case-control study comprising 165 infertile women with endometriosis, 83 with idiopathic infertility and 145 fertile and assessed the association with BLys -817C/T polymorphism. BLyS -817C/T polymorphism was detected using TaqMan PCR. The results were analysed statistically, and a P-value < 0.05 was considered significant. The results disclosed similar genotype and allelic frequencies between endometriosis-related infertility (P = 0.225) and control group, regardless of the disease stage (P = 0.213 and P = 0.462, respectively). However, a statistically significant difference was observed regarding idiopathic infertile group (P = 0.048) compared with controls. Considering the dominant and recessive inheritance models, no significant differences in both endometriosis and idiopathic infertility group were found. The genotype frequencies were in Hardy-Weinberg equilibrium in all studied groups. The results point to a possible association between BLyS -817C/T polymorphism and idiopathic infertility in Brazilian population.

Analysis of CTLA4 gene variant in infertile Brazilian women with and without endometriosis.

An autoimmune aetiology has been suggested for endometriosis mostly on the basis of an increased prevalence of autoimmune diseases in affected women. Cytotoxic T lymphocyte antigen (CTLA) 4 gene is recognized as a primary determinant for autoimmunity, since specific polymorphisms have been associated with predisposition to most autoimmune disorders. Thus, the objective of the study was to evaluate CTLA4 polymorphism (+49A/G) in a group of infertile women with and without endometriosis and controls. Case-control study comprising 244 infertile women (177 with endometriosis and 67 without endometriosis) and 172 fertile women as controls. CTLA4 polymorphism was identified by qPCR. The results were analysed statistically and a P-value <0.05 was considered significant. We found relatively similar CTLA4 polymorphisms genotype frequencies in women with and without endometriosis and controls (P=0.158 and P=0.262, respectively). When the patients with minimal/mild endometriosis and moderate/severe endometriosis were studied separately, no difference was also found related to controls (P=0.560 and P=0.11, respectively). The data suggest that the CTLA4 polymorphism is not associated with endometriosis and/or infertility in Brazilian women.

[Selective fusion of idiopathic scoliosis with respect to the Lenke classification]. / Selektive Fusionsmöglichkeiten der idiopathischen Skoliose unter kritischer Würdigung der Lenke-Klassifikation.

Indications for surgical treatment of idiopathic scoliosis are progressive curves greater than 40-50 degrees. In most cases, fusion of only the primary (structural) curve(s) is sufficient due to the flexibility and spontaneous correction of the secondary curves. Therefore, it is crucial to identify both primary and secondary curves. According to the Lenke classification, all curves with a residual curve of more than 25 degrees on the bending films and those with a pathological kyphosis are regarded as structural and should be fused, whereas the nonstructural curves can be left unfused. However, according to reports in the literature and to the author's experience, clinical parameters such as shoulder level and rib or lumbar hump as well as radiometric criteria such as rotation are relevant as well. In summary, the Lenke classification is an important and helpful tool for analysing idiopathic curves and determining fusion length, even though each scoliosis case needs to be evaluated individually, especially taking clinical parameters into account.

[Bone substitutes in scoliosis surgery]. / Knochenersatzstoffe in der Skoliosechirurgie.

In spinal fusion procedures, the local bone that is resected serves as the base bone graft for attaining biological fusion. The local bone is frequently not sufficient and requires supplementary grafting. Autologous bone transplantation is still regarded as the gold standard but might cause additional complications; also, autograft resources are limited. Alternatively, allografts and a wide variety of different bone substitutes are available.The bone substitutes currently used in scoliosis surgery are presented, and their clinical significance is elucidated by a review of the literature. Furthermore, our own experiences and clinical practice are compared with those in the literature and are critically discussed. The recently growing number of scientific publications reporting on bone substitutes reflects the immense interest and relevance of this issue. In scoliosis surgery, calcium phosphate ceramics together with bone marrow aspirate are increasingly applied.Although harvesting of autologous bone continues to be the accepted standard to extend the local autograft in scoliosis surgery, there is a clear trend toward the use of bone substitutes.

[En-bloc spondylectomy and reconstruction for primary tumors and solitary metastasis of the spine]. / En-bloc-Spondylektomie und Defektrekonstruktion bei Primärtumoren und Solitärmetastasen der Wirbelsäule.

In primary tumors of the spine and, with limitations, solitary metastasis, the surgical approach should aim for curative treatment of the disease. Because the prognosis of malignant bone tumors is extremely limited, if an intralesional approach is performed, an extralesional en bloc resection is the treatment of choice. Therefore, it is mandatory to use an appropriate staging system. For the spine, the WBB staging system has been approved, which transfers the principles of the Enneking classification for treating primary malignant tumors of the limb to the spine. After en bloc spondylectomy, rigid and primary stable instrumented dorsoventral reconstruction must be performed - posteriorly with a dual-rod system using pedicle screws, and anteriorly in the ideal case by means of a vertebral body replacement cage. The possibility of extralesional (wide or marginal) resection of spinal tumors depends on tumor size and location. Extralesional resection and, if indicated, other neoadjuvant, adjuvant, or local therapeutic modalities have a strong positive influence on long-term survival rates. A good prognosis for primary tumors is associated with a good response to chemotherapy and extralesional resection. Solitary metastases have a much worse quod vitam prognosis. Therefore, local control of the disease in en bloc resections of solitary metastasis is a second relevant goal, although curative treatment is the primary aim.

[Surgical treatment of idiopathic scoliosis with anterior dual rod instrumentation]. / Operative Therapie der idiopathischen Skoliose mittels ventraler Doppelstabinstrumentation.

BACKGROUND: In the surgical treatment of idiopathic scoliosis both anterior and posterior correction and instrumentation techniques are available. The aim of the present study was to analyse the results of a new anterior dual rod instrumentation. PATIENTS AND METHODS: Prospective analysis of radiometric and clinical parameters of 93 patients operated on between 1996 and 2004 using the Münster Anterior Dual Rod System. RESULTS: The average curve correction was 65% (fusion length usually Cobb levels) with a preoperative Cobb angle of 59 degrees. Postoperative loss of correction amounted to 1.5 degrees (average follow-up of 36 months). Apical vertebral derotation averaged 45% in the thoracic and 53% in the lumbar spine with a subsequent correction of the rib hump of 66% and the lumbar hump of 81%. There were no revisions or neurological complications. CONCLUSION: Anterior dual rod instrumentation enables an effective and safe three-dimensional curve correction in single structural curves with only minimal loss of correction.

[Lumbar spinal stenosis]. / Lumbale Spinalkanalstenose.

Lumbal spinal stenosis is gaining more and more clinical relevance because of changing population structure and increasing demand on lifequality in the elderly. Current treatment recommendations are based on clinical experience, expert opinions and single studies rather than on proven evidence. The radiologic degree of stenosis does not correlate with the patients' clinical situation. It is not the main factor indicating surgery but rather the typical history and spinal claudication. Symptomatic patients with light to moderate complaints should undergo multimodal conservative treatment. Epidural injections, delordosating physiotherapy and medication are useful. In patients with severe symptomatic stenosis surgery is indicated after a conservative treatment of 3 months. Relevant pareses or a cauda equina syndrome are absolute indications for surgery. The general aim is to decompress sufficiently while maintaining or restoring segmental stability. A laminectomy is not necessarily required. In patients with accompanying degenerative Meyerding grade I-II spondylolisthesis or instability in functional radiographs, fusion or dynamic stabilisation are recommended in addition to decompression, depending on the patient's age and activity level.

[Lumbar disc arthroplasty. Established technique or experimental procedure?]. / Lumbale Bandscheibenprothesen. Etablierte Technik oder experimentelles Vorgehen?

Lumbar interbody fusion used to be the most common surgical treatment for painful lumbar disc degeneration. With the technical development of total disc prostheses, replacement of the degenerated disc by a motion preserving implant has become a widely discussed alternative. The advantages of such replacement appear to include the prevention of adjacent segment disease as well as less perioperative morbidity. Three types of total disc prostheses are currently in common use. Although numerous studies have been made, a review of the literature reveals only two multicenter randomized studies comparing the outcome of disc prostheses with a control group of fusion patients. After 2 years, the available results show similar improvement after both types of surgery without significant differences. However, there is a trend towards faster recovery and improvement in disc arthroplasty patients. The long-term results of current and future randomized studies, including studies comparing results after disc arthroplasty, with results of standardized conservative therapies will determine the fate of lumbar disc prostheses.

[Surgical therapy of unspecific and specific Spondylodiscitis]. / Operative Therapie der unspezifischen und spezifischen Spondylodiszitis.

AIM: The aim of this study was to evaluate the clinical and radiological results of surgical treatment of thoracic and lumbar vertebral osteomyelitis by means of one-stage extrafocal posterior stabilisation, anterior debridement, and anterior column reconstruction. METHOD: A retrospective analysis of the peri- and postoperative parameters of 62 patients with a clinical and radiographic follow-up of 2.6 years that were available for 46 patients was performed. In 42 cases, the anterior column was restored with structural bone grafts, in 20 patients, expandable titanium cages filled with morsellised autologous bone and antibiotic collagen sponges were used. To assess the course of spinal alignment a radiometric analysis was undertaken. Furthermore, the Roland-Morris score (RMS) was applied to evaluate the back pain-related disability. RESULTS: The diagnosis was made no earlier than 2.7 months after the first symptoms. Preoperatively, 40 % of the patients presented with neurological impairment, of these 76 % improved after surgery. Staphylococcus aureus was the most common pathogen isolated (32 %), Mycobacterium tuberculosis was found in 11 % of the patients. Except for one patient with revision for persistent infection and consecutive failure of the bone graft, primary eradication of the infection was achieved in all cases. At follow-up, bony fusion was radiographically observed in all patients. When using cages, the segmental loss of correction was significantly lower than when using bone grafts (1.0 vs. 4.1 degrees ). At follow-up the RMS averaged 6.6. CONCLUSION: One-stage extrafocal posterior stabilisation combined with anterior debridement and anterior column reconstruction with bone grafts or titanium cages is a safe and effective strategy for patients with vertebral osteomyelitis in need of surgery. Titanium cages have proven to be biomechanically advantageous, especially in cases of extensive destruction and are not associated with higher rates of persistence or recurrence of infection compared to autologous bone grafts.

[Prospective evaluation of braces as treatment in idiopathic scoliosis]. / Prospektive Untersuchung zur Korsettbehandlung bei idiopathischen Skoliosen.

AIM: To prospectively evaluate the results of brace treatment in idiopathic scoliosis and to define risk factors of treatment failure. METHOD: Fifty-two patients with a Cobb angle of between 25 and 40 degrees were included in the study. Prior to initiation of brace treatment with the Chêneau-Toulouse-Muenster orthesis, skeletal age and flexibility of the curve (bending films) were evaluated. The average follow-up after weaning of the brace was 42 months (36-78 months). RESULTS: An average initial Cobb angle of 31 degrees was corrected to 18 degrees (43 %) under brace treatment with a flexibility to 6 degrees Cobb angle on bending films. Three years after weaning there was an overall increase of the Cobb angle to 37 degrees on average. The apical vertebral rotation was corrected from 16 degrees to 11 degrees (31 %) and increased to 20 degrees during follow-up. Thoracic kyphosis changed from 24 degrees to 18 degrees during treatment. At the latest follow-up kyphosis had returned to the pre-treatment angle again. Twenty-two patients had a curve progression during or after brace treatment of more than 5 degrees. In 14 patients surgical correction and fusion have been indicated. There was a positive correlation between flexibility and Cobb angle correction during brace treatment and a negative correlation between Cobb angle correction during brace treatment and curve progression (p < 0.05). CONCLUSIONS: Curve progression was prevented in 58 %. Prognostic risk factors are a young age at initiation of brace treatment, a thoracic curve, unsatisfactory curve correction in the brace and a male gender.

Titanium cages in the surgical treatment of severe vertebral osteomyelitis.

The role of spinal implants in the presence of infection is critically discussed. In this study 20 patients with destructive vertebral osteomyelitis were surgically treated with one-stage posterior instrumentation and fusion and anterior debridement, decompression and anterior column reconstruction using an expandable titanium cage filled with morsellised autologous bone graft. The patients' records and radiographs were retrospectively analysed and follow-up clinical and radiographic data obtained. At a mean follow-up of 23 months (range 12-56 months) all cages were radiographically fused and all infections eradicated. There were no cases of cage dislocation, migration or subsidence. Local kyphosis was corrected from 9.2 degrees (range -20 degrees to 64 degrees ) by 9.4 degrees to -0.2 degrees (range -32 degrees to 40 degrees ) postoperatively and lost 0.9 degrees during follow-up. All five patients with preoperative neurological deficits improved to Frankel score D or E. Patient-perceived disability caused by back pain averaged 7.9 (range 0-22) in the Roland-Morris score at follow-up. In cases of vertebral osteomyelitis with severe anterior column destruction the use of titanium cages in combination with posterior instrumentation is effective and safe and offers a good alternative to structural bone grafts. Further follow-up is necessary to confirm these early results.

Quantitative sensory nerve conduction threshold (sNCT) evaluation of the trigeminal nerve at the mental foramen area.

STATEMENT OF PROBLEM: There is a need for a quick, objective, quantitative sensory test of the mandibular inferior alveolar nerve to assess sensory dysfunction due to trauma, infection, or disease. PURPOSE: This study evaluated the reliability and reproducibility of a commercially available electrodiagnostic quantitative sensory nerve conduction threshold (sNCT) evaluation testing method and established normative values for future evaluation of nerve dysfunction. MATERIAL AND METHODS: Rapid current perception threshold (R-CPT) values were obtained with Neurometer CPT/C, an electrodiagnostic sNCT device that administers an alternating constant-current sinusoid waveform stimulus at either 2000 Hz (H) (Hertz [cycles/second]), 250 Hz (M), or 5 Hz (L) at intensity levels ranging from 0.001 to 10 mA. Thirty-four healthy subjects were tested then retested by the same operator from 7 days to 153 days. R-CPT evaluation was performed over the mental foramen bilaterally with dual disposable gold-plated electrodes and a hypoallergenic electrode gel held in place using nonconductive adhesive tape. Two consecutive identical R-CPT measures were obtained for each stimulation frequency for determination of the final R-CPT value. RESULTS: On the left side, there was no difference between the first and second test (P > .05). On the right side, there was a statistical difference between the first and second test for L, M, and H, but the confidence interval is very narrow and the differences are not clinically significant. CONCLUSION: From the values obtained, R-CPT testing was reliable for the quantification of sensory function in healthy individuals.

Mutational analysis of the defective protease in classic late-infantile neuronal ceroid lipofuscinosis, a neurodegenerative lysosomal storage disorder.

The late-infantile form of neuronal ceroid lipofuscinosis (LINCL) is a progressive and ultimately fatal neurodegenerative disease of childhood. The defective gene in this hereditary disorder, CLN2, encodes a recently identified lysosomal pepstatin-insensitive acid protease. To better understand the molecular pathology of LINCL, we conducted a genetic survey of CLN2 in 74 LINCL families. In 14 patients, CLN2 protease activities were normal and no mutations were identified, suggesting other forms of NCL. Both pathogenic alleles were identified in 57 of the other 60 LINCL families studied. In total, 24 mutations were associated with LINCL, comprising six splice-junction mutations, 11 missense mutations, 3 nonsense mutations, 3 small deletions, and 1 single-nucleotide insertion. Two mutations were particularly common: an intronic G-->C transversion in the invariant AG of a 3' splice junction, found in 38 of 115 alleles, and a C-->T transition in 32 of 115 alleles, which prematurely terminates translation at amino acid 208 of 563. An Arg-->His substitution was identified, which was associated with a late age at onset and protracted clinical phenotype, in a number of other patients originally diagnosed with juvenile NCL.

Progress toward the cloning of CLN6, the gene underlying a variant LINCL.

Marked clinical heterogeneity is seen in the late-infantile subtype of NCL (LINCL), complicating genetic analysis. In addition to the classical subtype, encoded by CLN2 on chromosome 11p15.5, several variant subtypes have also been described. In this paper, we report our progress in cloning a variant LINCL gene mapped in a small group of Costa Rican families. Clinically, these patients appear similar to classical LINCL patients, except onset of the disease is delayed and the course is milder. Extended haplotype analysis confirms the localization of this gene to chromosome 15q21-22, where CLN6 has also been mapped. Using now-standard positional cloning techniques, we have developed a physical map of our candidate region. These clones have been used to order genetic markers, STSs, and ESTs in this region and will be used for the identification of the disease gene transcript.

Chromosomal localization of two genes underlying late-infantile neuronal ceroid lipofuscinosis.

Classical late-infantile neuronal ceroid lipofuscinosis (LINCL; CLN2) is an inherited neurodegenerative disorder of childhood characterized by seizures, loss of vision, and progressive motor and mental deterioration. The hallmark of this disease is the accumulation of enlarged, secondary lysosomes packed with curvilinear bodies in cells of affected individuals. The biochemical basis of LINCL remains unknown and there is no treatment effective in delaying the progression of this fatal disorder. During a genome-wide search using a set of highly polymorphic markers and 15 affected individuals from 7 multi-affected families, we obtained evidence for linkage of the LINCL gene CLN2 with markers on chromosome 11p15.5. We then genotyped patients and all available family members, including 8 single-affected families, for markers spanning 15 cM of 11p15.5. We obtained a maximum two-point LOD score of 6.16 at 0 = 0.00 at the marker locus D11S2362. Multipoint analysis yielded a maximum LOD score of 6.90 localized to the same marker. Using haplotype analysis, we localized CLN2 to a minimum candidate region of 11 cM flanked by marker loci D11S4046 on the telomeric side and D11S1996 on the centromeric side. Additionally, we present data suggesting that the gene underlying a variant LINCL subtype found in Costa Rica maps to the region defined by the CLN6 locus on chromosome 15q21-23. The mapping of these two LINCL loci provides a genetic basis for understanding the clinical heterogeneity observed in this group of diseases.

Spectrum of mutations in the Batten disease gene, CLN3.

Batten disease (juvenile-onset neuronal ceroid lipofuscinosis [JNCL]) is an autosomal recessive condition characterized by accumulation of lipopigments (lipofuscin and ceroid) in neurons and other cell types. The Batten disease gene, CLN3, was recently isolated, and four disease-causing mutations were identified, including a 1.02-kb deletion that is present in the majority of patients (The International Batten Disease Consortium 1995). One hundred eighty-eight unrelated patients with JNCL were screened in this study to determine how many disease chromosomes carried the 1.02-kb deletion and how many carried other mutations in CLN3. One hundred thirty-nine patients (74%) were found to have the 1.02-kb deletion on both chromosomes, whereas 49 patients (41 heterozygous for the 1.02-kb deletion) had mutations other than the 1.02-kb deletion. SSCP analysis and direct sequencing were used to screen for new mutations in these individuals. Nineteen novel mutations were found: six missense mutations, five nonsense mutations, three small deletions, three small insertions, one intronic mutation, and one splice-site mutation. This report brings the total number of disease-associated mutations in CLN3 to 23. All patients homozygous for mutations predicted to give rise to truncated proteins were found to have classical JNCL. However, a proportion of the patients (n = 4) who were compound heterozygotes for a missense mutation and the 1.02-kb deletion were found to display an atypical phenotype that was dominated by visual failure rather than by severe neurodegeneration. All missense mutations were found to affect residues conserved between the human protein and homologues in diverse species.

Genomic structure and complete nucleotide sequence of the Batten disease gene, CLN3.

We recently cloned a cDNA for CLN3, the gene for juvenile-onset neuronal ceroid lipofuscinosis or Batten disease. To resolve the genomic organization we used a cosmid clone containing CLN3 to sequence the entire gene in addition to 1.1 kb 5' of the start of the published CLN3 cDNA and 0.3 kb 3' to the polyadenylation site. CLN3 is organized into at least 15 exons spanning 15 kb and ranging from 47 to 356 bp. The 14 introns vary from 80 to 4227 bp, and all exon/intron junction sequences conform to the GT/AG rule. Numerous repetitive Alu elements are present within the introns and 5'- and 3'-untranslated regions. The 5' region of the CLN3 gene contains several potential transcription regulatory elements but no consensus TATA-1 box was identified. CLN3 is homologous to 27 deposited human ESTs, and sequence comparisons suggest alternative splicing of the gene and the existence of transcribed sequences upstream to the start of the published CLN3 cDNA.

Strategy for mutation detection in CLN3: characterisation of two Finnish mutations.

A strategy for detection of mutations in CLN3, the gene for Batten disease or juvenile onset neuronal ceroid lipofuscinosis, has been devised using a technique which detects conformation polymorphisms and direct sequencing of genomic DNA fragments. We define two mutations found uniquely in Finnish patients, one a large deletion (2.8 kb), the other a point mutation affecting the 5'splice donor site of an intron.