Maternal Phenylketonuria Collaborative Study (MPKUCS)--the 'outliers'

Analysis of outcome data from 305 of the 414 offspring from the Maternal Phenylketonuria Collaborative Study (MPKUCS), plus 70 control offspring, revealed significant deficits in the IQ (intelligence quotient), as measured by the Wechsler Intelligence Scale for Children--Revised (WISC-R), when maternal metabolic control during pregnancy was delayed and/or inadequate. There were, however, 23 'outliers' (7.5% of the 305) in which the offspring's intellectual IQ was worse (n =10) or better (n =13) than expected. The aim of this study was to determine whether collection parameters were incomplete or whether these subjects were true biological variants influenced by other undetected factors or, perhaps, by modifier genes. Among the 10 offspring whose intellectual functioning was worse than expected, additional complications were uncovered that could explain the poor outcome. Four of the 13 offspring with higher than expected IQ had mothers with mild variants of PKU in which the insult to the fetus would not be expected to be as profound. For the other nine offspring whose intellectual performance was better than expected, there was no explanation, based on the parameters studied. We hypothesize that modifier genes will, at times, protect the fetus despite high maternal concentrations of phenylalanine. Not all offspring from the same (untreated) PKU mother may be similarly affected. Finding the source of these modifiers might effect the treatment of MPKU.

Neuropsychological outcome of subjects participating in the PKU adult collaborative study: a preliminary review

Adult subjects with classical phenylketonuria (PKU) who were diagnosed and treated neonatally participated in this long-term follow-up study. Twenty-four subjects received neuropsychological (NP) assessment and a subset received magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) to identify: (1) pattern of cognitive dysfunction; (2) effect of high blood phenylalanine (Phe) level at time of cognitive testing; and (3) treatment variables that may be associated with cognitive difficulties in adulthood. All subjects had average IQ except one subject in the borderline range. Diet was initiated by the 15th day of life. All subjects except one were on diet until age 6 years (mean years of treatment = 15). Blood Phe levels at cognitive testing ranged from 157 to 1713 micromol/L (mean = 1038); 11 subjects had levels < 1000 micromol/L and 13 subjects had levels >1000 micromol/L. Results suggest that adults with early-treated PKU demonstrate specific cognitive deficits, a number of which are associated with the frontal and temporal area of the brain. Deficits were noted in several domains including executive functioning, attention, verbal memory, expressive naming and verbal fluency. Self-report measures of depression and anxiety were generally in the normal/mild range. The group with a Phe level > 1000 micromol/L scored lower than the group with Phe level < 1000 micromol/L on measures of focused attention, verbal fluency, reaction time, verbal recognition memory, visual memory and naming. Tests of cognitive functioning were often correlated with measures of treatment during childhood rather than with Phe level at the time of cognitive testing. Subjects with abnormal MRI scored significantly lower on two cognitive tests (Trails A and CVLT Recognition Memory). We found no significant correlation between current brain Phe level obtained through MRS (n = 10) and neuropsychological functioning. Future longitudinal investigation with a larger sample size will assist in clarifying the aetiology of neuropsychological deficits and association with treatment history.

Ketene–acetylene [2 + 2] cycloadditions: cyclobutenone and/or oxete formation?

The [2 + 2] cycloaddition of monosubstituted acetylenes to ketene has been studied by ab initio(G2(MP2,SVP) and DFT (B3LYP/6-31Gd)) methods. The activation barrier decreases with increasing electron-donating ability of the acetylene substituent, and it can be roughly correlated with the energy of the acetylene HOMO. The addition to the C[double bond, length as m-dash]C bond of ketene (giving cyclobutenones) is preferred for the less electron-rich acetylenes, but for the most electron rich ones (X = NH(2) and NMe(2)) the addition to the C[double bond, length as m-dash]O bond (giving oxetes) becomes competitive, with activation barriers as low as ca. 45 (30) kJ mol(-1) for the two computational methods used. The cyclobutenones and oxetes can undergo ring opening to vinylketenes and acylallenes, respectively. Furthermore, the latter two compounds can interconvert by a 1,3-shift of the substituent X. The acylallenes become thermodynamically more stable than the vinylketenes for [small pi]-(lone pair) donating substituents X, and the 1,3-shift barrier also decreases, to ca. 130 kJ mol(-1) for X = NMe(2). In contrast, the 1,3-shifts of CH(3) and H have very high barriers.

Loss of BRCA2 correlates with reduced long-term survival of sporadic breast cancer patients

BACKGROUND

The present study was undertaken to analyze the prognostic value of loss of heterozygosity (LOH) at 13q12-13, 17q21 and 17p13, harboring BRCA2, BRCA1 and p53 to predict the clinical course of sporadic breast cancer patients.

MATERIALS AND METHODS

LOH analysis was performed by PCR amplification of genomic DNA using nine microsatellite markers. Fifty-three sporadic breast cancer patients were followed clinically for a median of 55 months. Disease-free and overall survival was documented as the endpoint for statistical evaluation.

RESULTS

Patients presenting with LOH in their tumor samples at at least one of the loci examined were found to have a reduced overall survival time compared to those retaining heterozygosity (61% versus 48%). Focusing on the three target regions, patients with LOH at the BRCA2 locus died earlier compared to patients retaining heterozygosity (69% versus 50%) and, in addition, BRCA2 LOH-positive patients showed a shorter metastasis-free interval (30 versus 37 months). In a multivariate analysis, LOH at the 13q12-13 locus was found to be a significant predictor for reduced long-term survival (risk ratio 2.33, 95% C.I., 1.0-5.3; p<0.05) and earlier metastases manifestation (risk ratio 2.32, 95% C.I., 1.0-5.3, p<0.05).

CONCLUSION

Allelic loss at the BRCA2 locus may be of use as a negative predictor for metastases-free and overall survival.

1H-1,3-Diazepines, 5H-1,3-diazepines, 1,3-diazepinones, and 2,4-diazabicyclo[3.2.0]heptenes,

Tetrazolo[1,5-a]pyridines/2-azidopyridines 1 undergo photochemical nitrogen elimination and ring expansion to 1,3-diazacyclohepta-1,2,4,6-tetraenes 3, which react with alcohols to afford 2-alkoxy-1H-1,3-diazepines 4 (5), with secondary amines to 2-dialkylamino-5H-1,3-diazepines 16, sometimes via isolable 2-dialkylamino-1H-1,3-diazepines 15, and with water to 1,3-diazepin-2-ones 19. The latter are also obtained by elimination of isobutene or propene from 2-tert-butoxy- or 2-isopropoxy-1H-1,3-diazepines 4 or 5. 1,3-Diazepin-2-one 22B and 1,3-diazepin-4-one 24 were obtained from hydrolysis of the corresponding 4-chlorodiazepines. Diazepinones 19 undergo photochemical ring closure to diazabicycloheptenones 25 in high yields. The 2-alkoxy-1H-1,3-diazepines 4 and 5 interconvert by rapid proton exchange between positions N1 and N3. The free energies of activation for the proton exchange were measured by the Forsén-Hoffman method as DeltaG([double dagger])298= 16.2 +/- 0.6 kcal mol(-1) as an average for 4a-c in CD2Cl2, acetone-d6, and methanol-d4, and 14.1 +/- 0.6 kcal mol(-1) for in 4c acetone/D2O. The structures of 2-methoxy-5,6-bis(trifluoromethyl)-1H-1,3-diazepine 4k, 1,2-dihydro-4-diethylamino-5H-1,3-diazepin-2-one 22bB, and diazabicycloheptanone were 26 determined by X-ray crystallography. The former represents the first reported X-ray crystal structure of any monocyclic N-unsubstituted 1H-azepine.

HLA typing and Parkinson's disease

Idiopathic Parkinson's disease (IPD) is a neurodegenerative disorder of unknown aetiology. Several antigens have been associated with IPD using serological methods. We systematically analysed HLA class I and II alleles in 45 German Caucasian IPD patients using sequence-specific oligonucleotides and sequence-specific primer technology. Applying Bonferroni adjusted p values, we demonstrate a statistically significant increase of the DQB1*06 allele (p = 0.002) in IPD which may indicate an association between IPD and the immune system. Alternatively, HLA alleles might be in linkage disequilibrium with genes located next to the HLA locus.

Comparison of the American Society of Anesthesiologists Physical Status classification with the Charlson score as predictors of survival after radical prostatectomy

OBJECTIVES

To compare the American Society of Anesthesiologists Physical Status (ASA) classification with the Charlson score in the radical prostatectomy setting. The ASA classification is a widely accepted way to evaluate perioperative risk. At present, the Charlson score is probably the most frequently used comorbidity measure to predict long-term survival after radical prostatectomy.

METHODS

A total of 444 consecutive patients were enrolled in this study. The ASA classification was obtained from the anesthesia chart, and the Charlson score was assigned based on conditions noted during the preoperative cardiopulmonary risk assessment or mentioned on the discharge document. Kaplan-Meier time-event curves and Mantel-Haenszel hazard ratios were estimated for comorbid (noncancer) and overall survival.

RESULTS

After a mean follow-up of 5.9 years, both classifications were able to predict comorbid and overall survival in dose-response patterns. The ASA classification was superior in terms of a clearer discrimination of the survival curves (lower P values, higher hazard ratios). Both classifications identified a high-risk group (ASA 3 and Charlson score 2 or more), but only the ASA classification sufficiently defined a low-risk group (ASA 1).

CONCLUSIONS

In experienced hands, the ASA classification is a promising tool to improve the classification of prognostic comorbidity in the radical prostatectomy setting and may be used as an alternative to the Charlson score.

Magnetologic with alpha-MnAs thin films

Taking advantage of the spin information in present day computing is expected to yield an enormous increase in efficiency. A promising ferromagnetic material compatible with semiconductors for room temperature applications is MnAs. By sensitive cantilever beam magnetometry, we discovered that alpha-MnAs films on GaAs(001) exhibit an additional small out-of-plane component of the magnetization which is magnetically coupled with the dominant in-plane magnetization. We demonstrate that by regarding the two components as independent inputs, the alpha-MnAs layer can be utilized as a logic gate with nonvolatile output. The logic functionality of the layer can be preselected to be AND or OR at run time, thus offering the perspective for programmable magnetologic devices.

CARD15 genotype and phenotype analysis in 55 pediatric patients with Crohn disease from Saxony, Germany

OBJECTIVES

Crohn disease is a chronic inflammatory bowel disorder that is caused by environmental and genetic factors. Mutations in the CARD15 gene have been recently identified to be associated with the disease. Until now no genetic study has focused directly on a pediatric population.

METHODS

The authors sequenced all 12 exons of the CARD15 gene in 55 pediatric patients with Crohn disease from Saxony. Their average age at onset was 11.2 years (1-17.5 years). The authors also evaluated the genotype-phenotype relationship in the patients.

RESULTS

Fourteen different polymorphic and/or disease-related nucleotide alterations have been identified in the patients. Sixty-five percent of their genomic DNA samples harbored at least one of six mutations within the CARD15 gene, which previously has been identified as being associated with Crohn disease. The authors found that the cytosine insertion mutation 3020insC was significantly more common in their pediatric population than in patients with Crohn disease (26% versus 11% of the alleles) whose results were reported in the literature. The genotype-phenotype analysis showed that the authors' patients with at least one of the six CARD15 disease-associated mutations had a high risk of inflammation located in the terminal ileum and ascending colon. In 10 of 19 patients with two mutations, intestinal resection surgery was necessary because of stricturing.

CONCLUSIONS

In the authors' pediatric patients, the genetic influence on Crohn disease was more pronounced than that reported in any other study, and it strongly affected the clinical phenotype.

Time course of the effect of a bolus dose of intrathecal baclofen on severe cerebral spasticity

Continuous intrathecal administration of baclofen with implanted programmable pump systems is recommended in the treatment of severe spasticity of cerebral origin. Prior to pump implantation, a baclofen bolus test (BBT) is used to assess the effectiveness of intrathecal baclofen using clinical scales such as the Modified Ashworth Scale (MAS). In the literature, the time and period of maximum effect of a bolus dose of intrathecally administered baclofen in patients with cerebral spasticity is variously reported. The aim of the study was, therefore, to reveal the time course of the effect of a BBT on severe cerebral spasticity by the use of a recently described spasticity measurement method. Spasticity in knee joints of 13 patients with severe cerebral spasticity was repeatedly assessed using the MAS and also continuously recorded by the measurement of force under circular fibreglass casts. Force was recorded as nettorque by multiplying the force by the distance between sensor and joint axis, thus allowing inter-individual comparison. Half-hour time integrals (TI) of net-torque were determined 9 hours before and 22 hours after intrathecal baclofen administration. Post-BBT half-hour time integrals (TI(+0), TI(+0.5), to TI(+22)) were compared with the mean of 17 pre-BBT half-hour time integrals. Significantly lower post-BBT half-hour time integrals compared with were found between TI(+2) and TI(+8) (Dunnett adjusted p < 0.05). The median lowest TI after BBT of the 13 patients was TI(+4). The lowest mean MAS scores were found 4 hours after BBT. The findings suggest that the greatest effect of BBT on cerebral spasticity occurs between 2 and 8.5 hours, with a maximal effect at 4 hours after intrathecal baclofen injection. Clinical scales used to determine the effect of BBT should thus be carried out during this period-ideally at 4 hours after baclofen injection.

Programmable computing with a single magnetoresistive element

The development of transistor-based integrated circuits for modern computing is a story of great success. However, the proved concept for enhancing computational power by continuous miniaturization is approaching its fundamental limits. Alternative approaches consider logic elements that are reconfigurable at run-time to overcome the rigid architecture of the present hardware systems. Implementation of parallel algorithms on such 'chameleon' processors has the potential to yield a dramatic increase of computational speed, competitive with that of supercomputers. Owing to their functional flexibility, 'chameleon' processors can be readily optimized with respect to any computer application. In conventional microprocessors, information must be transferred to a memory to prevent it from getting lost, because electrically processed information is volatile. Therefore the computational performance can be improved if the logic gate is additionally capable of storing the output. Here we describe a simple hardware concept for a programmable logic element that is based on a single magnetic random access memory (MRAM) cell. It combines the inherent advantage of a non-volatile output with flexible functionality which can be selected at run-time to operate as an AND, OR, NAND or NOR gate.

Neuro-Oncology Working Group 01 trial of nimustine plus teniposide versus nimustine plus cytarabine chemotherapy in addition to involved-field radiotherapy in the first-line treatment of malignant glioma

PURPOSE

The role of chemotherapy in the primary treatment of malignant glioma remains controversial. The results from the German-Austrian Glioma trial (GAG, 1983 to 1988) demonstrated a survival benefit for chemotherapy using carmustine (BCNU) plus teniposide (VM26) over BCNU alone in addition to radiotherapy in patients with a Karnofsky performance score (KPS) more than 60. The Neuro-Oncology Working Group (NOA) of the German Cancer Society therefore compared the efficacy of nimustine (ACNU) plus VM26 and ACNU plus cytarabine (Ara-C) chemotherapy in addition to standard radiotherapy in patients with newly diagnosed malignant glioma.

PATIENTS AND METHODS

From 1994 to 2000, 375 patients were randomly assigned to receive radiotherapy and cycles of ACNU 90 mg/m2 intravenously (IV) on day 1 and VM26 60 mg/m2 IV on days 1 to 3 (n = 183), or ACNU 90 mg/m2 IV on day 1 and Ara-C 120 mg/m2 IV on days 1 to 3 (n = 179), in 6-week intervals. Thirteen patients were not eligible after central neuropathology review. The remaining 362 patients had glioblastoma (n = 301) or anaplastic glioma (n = 61).

RESULTS

Median survival and 2-year survival rates were 17.3 months and 25% for ACNU plus VM26, and 15.7 months and 29% for ACNU plus Ara-C in glioblastoma, and 60 months and 88% for ACNU plus VM26 and 62.5 months and 72% for ACNU plus Ara-C in anaplastic glioma. Multivariate analysis revealed no survival advantage for either arm or for subpopulations defined by histology, age, or KPS. Hematologic toxicity was more prominent in the ACNU plus Ara-C arm.

CONCLUSION

The median survival times and 2-year survival rates for patients with anaplastic glioma and glioblastoma achieved in the NOA-01 trial compare favorably with historical trials and with the Radiation Therapy Oncology Group database. The toxicity profile favors ACNU plus VM26 for further evaluation.

Microbial ingrowth around single- and multi-component adhesives studied in vitro

The aim of this study was to compare the in vitro microbial leakage in 4 micro-hybrid composites in combination with 4 single-component dental adhesives (Scotchbond 1/Z100 MP = group 1; Syntac Single-Component/Tetric Flow = group 3; OptiBond Solo/XRV Herculite = group 5; Solobond M/Arabesk Top = group 7) and 4 multi-component dental adhesives (Scotchbond Multi-Purpose/Z100 MP = group 2; Syntac/Tetric Flow = group 4; OptiBond FL/XRV Herculite = group 6; Solobond Plus/Arabesk Top = group 8). Ninety-four mixed standardized Class V cavities of human caries-free extracted premolars were filled with eight different composite adhesive systems using a one-layer (groups 1-4) or a two-layer technique (groups 5-8). After thermocycling and incubation in a broth culture of Streptococcus mutans and Lactobacillus acidophilus, followed by decalcification and staining, the extent and the type of microbial leakage were measured histologically. The extent of microbial leakage in the composite restorations was very low in all groups and there were no significant differences between adhesives. Z100 MP in combination with single- and multi-component adhesives showed a significantly higher microbial leakage than Tetric Flow systems (U test: p=0.037). XRV Herculite adhesive systems showed significantly less extensive microbial leakage than Arabesk Top adhesive systems (U test: p<0.001). The single-component dental adhesives achieved a marginal adaptation of composites comparable to that of multi-component adhesives in vitro.

Ferromagnetism of MnAs studied by heteroepitaxial films on GaAs(001)

Thin epitaxial films of MnAs--promising candidates for the spin injection into semiconductors--are well known to undergo simultaneously a first-order structural and magnetic phase transition at 10-40 degrees C. The evolution of stress and magnetization of MnAs/GaAs(001), both measured quantitatively with our cantilever beam magnetometer at the coexistence region of alpha-MnAs and beta-MnAs, reveal an orthorhombically distorted unit cell of the ferromagnetic phase, which provides important clues on the origin of ferromagnetism in MnAs.

The use of small personal ultrasound devices by internists without formal training in echocardiography

AIMS

Hand-held ultrasound devices will probably be used for bedside cardiac diagnoses by internists without formal training in echocardiography. We compared the accuracy of hand-held ultrasound devices studies performed by expert echocardiographers vs internal medicine residents with brief training in echocardiography.

METHODS AND RESULTS

Three internal medicine residents participated in an organized training program in echocardiographic principles, image acquisition, and interpretation. Subsequently, these residents and three echocardiographers imaged 300 patients with a hand-held ultrasound device. Sensitivity, specificity, positive and negative predictive values for internist- and echocardiographer-performed studies for the detection of cardiac abnormalities were compared using a full-featured exam as the gold standard. Resident- and echocardiographer-performed scans had similar overall sensitivity and specificity. There was a higher positive predictive value for the echocardiographer-performed scans. For clinically important findings (likely to affect patient care), sensitivity was slightly but significantly higher for the echocardiographer-performed scans. Clinically important findings most often missed by residents included regional wall motion abnormalities, intra-cardiac thrombus, right ventricular dysfunction and non-trivial pericardial effusions.

CONCLUSION

Hand-held ultrasound devices provide useful screening tools for cardiac disease but should not replace a standard platform study. Training guidelines and competency evaluation are needed if these devices are to be used by non-echocardiographers for clinical decision-making.

The Kleine-Levin syndrome - effects of treatment with lithium -

Kleine-Levin syndrome (KLS) is a rare disorder which affects mainly adolescents. Periods of extreme somnolence alternate with megaphagia, psychomental changes and behavioural symptoms. The cause and pathogenesis of KLS remains unknown. Several treatments have been tried and recently lithium has been proposed for a prophylactic use in single cases. In view of the rarity of KLS, long-term results of lithium therapy have not been described yet. We report the clinical course of five adolescents with KLS who were treated with lithium. All patients showed significant EEG and polysomnographic changes during the episodes and had normal results in the interval. All patients had relapses while being treated with lithium. But episodes of hypersomnia under lithium therapy were shorter and monosymptomatic with lack of behavioural symptoms. Statistical modelling showed that the risk for a relapsing episode under maintenance of lithium drops per months of therapy from 100 % to 93 %, and furthermore that the maintenance of lithium shortens the mean duration of episodes to 19 %. No severe side effects were observed. In conclusion, in KLS with a high frequency of episodes and severe behavioural changes lithium may become a treatment option.

[Predictive value of thyrotropin receptor antibodies using the second generation TRAb human assay after radioiodine treatment in Graves' disease]

The detection of TSH-receptor antibodies (TRAb) in patients with Graves' disease is routinely used in nuclear medicine laboratories. This determination has been possible for approximately 3 years with a second generation human TRAb assay. Studies showed that this TRAb determination is diagnostically more sensitive compared to established, porcine TRAb assays.

OBJECTIVE

The aim of our study was to investigate, based on a ROC analysis, whether TRAb determination with the new, second generation assay allows a dependable statement about probability of occurrence of relapse after radioiodine therapy in patient suffering from Graves' disease.

METHODS

57 patients were examined with the DYNOtest TRAKhuman (BRAHMS Diagnostica AG, Hennigsdorf) directly before and six months after therapy with radioiodine (dose: 150 Gy). A ROC-analysis was performed to determine positive/negative predictive values depending on different cut-off values.

RESULTS

Whereas 21/57 patients became eu- or hypothyroid after six months, 36/57 patients relapsed. Non-relapsed patients showed a significant lower median TRAb titer (4.2 IU/l vs. 19.2 IU/l; p <0.05) compared to relapsed patients. But the positive predictive value conducted 63 and 66, 62 and 66 as well as 63 and 69% (before and after therapy) linked with the cut-offs 1.0, 1.5, and 2.0 IU/l. So it was in areas also achieved by the first generation porcine radio receptor assay.

CONCLUSION

An increased sensitivity is achieved undoubtedly with the new DYNOtest TRAKhuman in the diagnostic of Graves' disease. It is not held over the established radio receptor assay concerning the positive predictive value for relapsing patients.

Preoperative cardiopulmonary risk assessment as predictor of early noncancer and overall mortality after radical prostatectomy

OBJECTIVES

To evaluate the capability of the preoperative cardiopulmonary risk assessment to predict early noncancer and overall mortality after radical prostatectomy for clinically localized prostate cancer.

METHODS

In 444 consecutive radical prostatectomy patients, the American Society of Anesthesiologists Physical Status classification and the presence of cardiac insufficiency (New York Heart Association classification), angina pectoris (Canadian Cardiovascular Society classification), diabetes, hypertension, history of thromboembolism, and chronic obstructive or restrictive pulmonary disease were assessed. Kaplan-Meier time-event curves and Mantel-Haenszel hazard ratios were estimated for noncancer (other deaths were censored) and overall mortality. Cox proportional hazard models were used to analyze possible combined effects of risk factors.

RESULTS

During an average follow-up of 4.7 years, 36 patients died: 15 of noncancer causes, 14 of prostate cancer, 6 of other cancers, and 1 in a car accident. The comorbidity scores for American Society of Anesthesiologists Physical Status classification, New York Heart Association classification, and Canadian Cardiovascular Society classification and combinations between the latter two scores were significantly associated with early noncancer mortality in a dose-response pattern. Furthermore, patients with chronic obstructive pulmonary disease were at increased risk. The association with overall mortality was less strong.

CONCLUSIONS

The preoperative cardiopulmonary risk assessment may be used as a predictor of early noncancer and overall mortality after radical prostatectomy and should be evaluated further as a source of prognostic information in surgical oncology.