Krabbe disease: clinical, biochemical and molecular information on six new patients and successful retrospective diagnosis using stored newborn screening cards

PURPOSE

To present clinical, biochemical and molecular information on six new clinically diagnosed Krabbe disease patients and assess the sensitivity of retrospective galactocerebrosidase measurement in their newborn screening samples.

METHODS

Medical records were reviewed. Galactocerebrosidase activity was measured in leukocytes and, retrospectively, in the patients' newborn screening cards (stored for 1.4 to 13.5 years). GALC gene mutation analysis was performed.

RESULTS

Five patients with Krabbe disease, one of whom also had hydrocephalus, became symptomatic during infancy. A sixth patient presented with seizures and developmental regression at age two and had a protracted disease course. Galactocerebrosidase activity in leukocytes ranged from 0.00 to 0.20 nmol/h/mg protein. Low galactocerebrosidase activity (range: 3.2% to 11.1% of the daily mean), consistent with Krabbe disease, was detected in each of the newborn screening samples. GALC molecular analysis identified six previously unreported mutations and two novel sequence variants.

CONCLUSION

Our cases highlight the clinical variability of Krabbe disease. Galactocerebrosidase activity in newborn dried blood spots is a highly sensitive test, even when samples have been stored for many years. The high frequency of private mutations in the GALC gene may limit the use of genetic information for making treatment decisions in the newborn period.

Two visualization tools for analyzing agent-based simulations in political science

MDSVis (Multidimensional Scaling Visualization) lets analysts explore the simulation space of agent-based models, finding similar patterns at an aggregated level and finding the dominant factors affecting agent behavior. SocialVis lets analysts narrow their analysis to a single simulation run, exploring relationships between time steps and geographic regions.

Percutaneous Endoscopic Gastrostomy Prevents Gastroesophageal Reflux in Patients with Nasogastric Tube Feeding: A Prospective Study with 24-Hour pH Monitoring

Background/Aims

Percutaneous endoscopic gastrostomy (PEG) has been widely used for patients with swallowing dysfunction. However, its beneficial effects in the treatment of gastroesophageal reflux (GER) are controversial. The aim of this study was to evaluate the effect of PEG on the prevention of GER in patients with nasogastric tube (NGT) feeding.

Methods

Continuous 24-hour pH monitoring was performed prospectively in 21 patients receiving NGT feeding before and 7.3±2.2 days after PEG placement to compare the severity of GER.

Results

We studied 21 patients with a mean age of 59.8±14.1 years. The mean duration of NGT placement was 5.8±5.4 months. The causes of swallowing dysfunction included cerebral infarction, cerebral hemorrhage and other central nervous system (CNS) lesions. When all of the patients were considered, there were no significant differences in reflux parameters after PEG placement compared to before PEG placement. However, all seven patients who had preexisting GER showed significant improvement (p<0.05) of the reflux parameters, including the frequency of acid reflux, duration of acid reflux, total time with a pH below 4.0 and the fraction of time with a pH below 4.0, after PEG placement.

Conclusions

PEG might prevent GER in patients receiving NGT feeding, especially in those patients with GER.

Abstract P5-14-08: The Impact of Immediate Breast Reconstruction on Surgical Complications and the Delivery of Adjuvant Chemotherapy

Introduction: For women undergoing mastectomy immediate breast reconstruction (IBR) offers potential psychological benefits and increased quality of life. This study aimed to answer the question whether IBR might lead to higher complication rates and subsequently delay adjuvant chemotherapy (AdCT). Secondary aims included predictors for complications, and whether patients (pts) with worse tumour prognosis were less likely to undergo IBR.

Materials and Methods: Retrospective analysis was performed on 220 pts who underwent mastectomy ± IBR and received AdCT.

Results: Comparisons were made between the 107 pts who received IBR and 113 who had mastectomy alone (table 1). Women who were younger with less co-morbidity, lower BMI, and had better prognosis tumours were more likely to receive IBR. No statistically significant difference was found in the overall surgical wound complication rate between the groups. There was more return to surgery in the IBR group, resulting in a 9.8% (12/123) prosthesis loss rate. There was no significant difference in the average time to chemotherapy between the two groups. Conclusion: We found no evidence to suggest that IBR compromised the delivery of adjuvant chemotherapy, although there are significant risks of complications associated with reconstruction.

Table 1: Comparison between women who underwent mastectomy alone (no IBR) and women who

[Successful resection of locally advanced gastrointestinal stromal tumor of the ampulla of Vater after treatment with imatinib]

Gastrointestinal stromal tumor (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract arising from Cajal's cells, expressing CD 117. The standard treatment for primary GIST is complete surgical resection. Imatinib mesylate, a specific tyrosine kinase inhibitor, is effective against locally advanced and metastatic GIST. There are several reports of the effect of preoperative imatinib in patients with unresectable and locally advanced primary GIST. We report a case of unresectable primary GIST of the ampulla of Vater, which we were able to completely resect after treatment with a dosage of imatinib 400 mg daily for 5 months. Twelve months later, the patient was treated with imatinib and doing well with no evidence of recurrence.

Ratio-contrast imaging of dual-energy absorption for element mapping with a scanning transmission X-ray microscope

The detection of chemical mapping with a spatial resolution of 30 nm has been achieved with a scanning transmission X-ray microscope at the Shanghai Synchrotron Radiation Facility. For each specimen, two absorption images were scanned separately with energies E(1) and E(2): E(1) was focused on the absorption edge of the chosen element and E(2) was focused below the edge. A K-edge division method is proposed and applied to obtain the element mapping. Compared with the frequently used K-edge subtraction method, this ratio-contrast method is shown to be more accurate and sensitive in identifying the elements of interest, where the definition of the contrast threshold is simple and clear in physics. Several examples are presented to illustrate the effectiveness of the method.

Sacroiliitis is common in Crohn's disease patients with perianal or upper gastrointestinal involvement

BACKGROUND/AIMS

Sacroiliitis (SI) is one of the most frequent extraintestinal manifestations in inflammatory bowel disease (IBD) patients, but the exact prevalence has not been evaluated in Asia. There are few data on the association between SI and other clinical features of IBD. The prevalence of SI was evaluated using computed tomography (CT) and the phenotypic parameters associated with SI in Korean IBD patients were determined.

METHODS

Eighty-two patients with ulcerative colitis (UC) and 81 patients with Crohn's disease (CD) were evaluated clinically. The presence of SI was evaluated using bone window setting of abdomino-pelvic CT images by two radiologists.

RESULTS

The prevalence rates of SI were 12.2% and 21.0% in the UC and CD groups, respectively. There was no relationship between the localization or extent of intestinal inflammation and the presence of SI in the UC group. Multivariate analyses confirmed that perianal and upper-gastrointestinal (from the mouth through to the jejunum) diseases were associated with the occurrence of SI in the CD group (p=0.026 and p=0.047, respectively).

CONCLUSIONS

SI was as common among Korean IBD patients as among Western patients. Perianal or upper-gastrointestinal involvement is associated with SI in CD patients.

Targeted messenger RNA profiling of transfected breast cancer gene in a living cell

Selective messenger RNA (mRNA) profiling of transfected breast cancer gene expression in a living cell is demonstrated. Atomic force microscope (AFM) probe tips are structurally modified to create a dielectrophoretic force that attracts mRNA molecules within the cell nucleus. The tip end is chemically modified to hybridize only to the target mRNA from a pool of molecules within the nucleus. We successfully combined this scheme with standard assay techniques to develop an assay technology that can be used for early disease detection and basic studies in cell biology.

Maple syrup urine disease: further evidence that newborn screening may fail to identify variant forms

Newborn screening (NBS) by tandem mass spectrometry (MS/MS) has allowed for early detection and initiation of treatment in many patients with maple syrup urine disease (MSUD) (OMIM 248600), however, a recent report suggests that variants forms may be missed. Information on these patients is limited. We present clinical, biochemical and molecular information on patients with variant forms of MSUD not detected by the California Newborn Screening Program. Between July 2005 and July 2009, 2200,000 newborns were screened in California by MS/MS. Seventeen cases of MSUD were detected and three (two siblings) were missed. Additionally, the NBS cards of two siblings with late onset MSUD, who were born pre-expanded NBS, were retrospectively analyzed. None of the five patients met criteria to be considered presumptive positive for MSUD (leucine>200micromol/L and a ratio of leucine/alanine>or=1.5). Alloisoleucine (allo-ile) was subsequently analyzed in the NBS cards of all five patients, two of whom were found to have elevated levels. The proband in each family was diagnosed following symptoms triggered by an intercurrent illness or increased protein intake. At diagnosis, leucine levels ranged between 561 and >4528micromol/L, and allo-ile ranged from 137 to 239micromol/L. Two affected siblings had normal plasma amino acids when asymptomatic; however, their biochemical profiles were diagnostic of MSUD during intercurrent illnesses. The median age at diagnosis of all patients was one year (range 0.8-6.7). Heterozygous BCKDHB (E1beta) mutations (c.832G>A/c.970C>T) were identified in one family and a homozygous DBT (E2) sequence variant (c.1430 T>G) in another. The third family had one identifiable DBT mutation (c.827T>G), however, a second mutation was not detected. This report provides further evidence that NBS by MS/MS is unable to detect all cases of MSUD. Second-tier testing with allo-ile may improve sensitivity; however, some children with variant forms will invariably be missed.

The peroxisome proliferator-activated receptor gamma ligands, pioglitazone and 15-deoxy-Delta(12,14)-prostaglandin J(2), have antineoplastic effects against hepatitis B virus-associated hepatocellular carcinoma cells

Chronic hepatitis B virus (HBV) infection is the most common cause of hepatocellular carcinoma (HCC) worldwide. This study investigated the antineoplastic effects of intrinsic and extrinsic peroxisome proliferator-activated receptor gamma (PPARgamma) ligands against HBV-associated HCC cells in vitro. Four cell lines that were established from patients with HBV-associated HCC were used. The cells were cultured in various concentrations of the following PPARgamma ligands: troglitazone, pioglitazone, rosiglitazone and 15-deoxy-Delta(12,14)-prostaglandin J(2) (15d-PGJ(2)). Cell proliferation, cell cycle and apoptosis were analyzed. PPARgamma was expressed in all the cell lines studied. Among the PPARgamma ligands, pioglitazone and 15d-PGJ(2) clearly inhibited the HBV-associated HCC cell growth and increased the proportion of cells in the sub-G1 phase in the cell-cycle analysis. In apoptosis assays, DNA fragments increased significantly, and the activities of caspase-3 and -9 also increased. A pan-caspase inhibitor and a caspase-3 inhibitor suppressed the PPARgamma ligand-induced apoptosis in a dose-dependent manner. These two PPARgamma ligands decreased the expression of bcl-2 in most of the cell lines studied. The results suggest that pioglitazone and 15d-PGJ(2) have antineoplastic effects on HBV-associated HCC cells. Both of these PPARgamma ligands could be candidates for cancer prevention or the chemotherapy of HBV-associated HCC.

Recurrent massive bleeding due to dissecting intramural hematoma of the esophagus: Treatment with therapeutic angiography

Spontaneous or traumatic intramural bleeding of the esophagus, which is often associated with overlying mucosal dissection, constitutes a rare spectrum of esophageal injury called dissecting intramural hematoma of the esophagus (DIHE). Chest pain, swallowing difficulty, and minor hematemesis are common, which resolve spontaneously in most cases. This case report describes a patient with spontaneous DIHE with recurrent massive bleeding which required critical management and highlights a potential role for therapeutic angiography as an alternative to surgery.

Acute enterovirus infection followed by myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and viral persistence

AIMS

Enteroviruses are well-known causes of acute respiratory and/or gastrointestinal infections and non-specific flu-like illness. Although enterovirus protein, RNA and non-cytopathic viruses have been demonstrated in the stomach biopsies of patients with myalgia encephalomyelitis/chronic fatigue syndrome (ME/CFS), causality for chronic diseases is difficult to establish without having well-documented cases of acute enterovirus infections. The aim of this study was to link acute enteroviral infection to viral persistence in patients with ME/CFS.

METHOD

Patients admitted to the hospital with acute febrile illnesses were screened for enteroviral infections. Acutely infected patients were followed longitudinally, and those who developed symptoms of ME/CFS underwent oesophagogastroduodenoscopy and biopsies of the antrum to document viral persistence by immunoperoxidase staining for viral protein and viral RNA assay.

RESULTS

Three representative patients with different manifestations of acute enterovirus infections progressed to have chronic symptoms of ME/CFS. Persistent viral infection was demonstrated in the antrum years later.

CONCLUSION

After acute infections, enteroviruses can persist in patients resulting in manifestation of ME/CFS. Chronic enterovirus infection in an immunocompetent host may be an example of a stalemate between attenuated, intracellular viruses and an ineffective immune response.

Pancreatic beta cell function persists in many patients with chronic type 1 diabetes, but is not dramatically improved by prolonged immunosuppression and euglycaemia from a beta cell allograft

AIMS/HYPOTHESIS

We measured serum C-peptide (at least 0.167 nmol/l) in 54 of 141 (38%) patients with chronic type 1 diabetes and sought factors that might differentiate those with detectable C-peptide from those without it. Finding no differences, and in view of the persistent anti-beta cell autoimmunity in such patients, we speculated that the immunosuppression (to weaken autoimmune attack) and euglycaemia accompanying transplant-based treatments of type 1 diabetes might promote recovery of native pancreatic beta cell function.

METHODS

We performed arginine stimulation tests in three islet transplant and four whole-pancreas transplant recipients, and measured stimulated C-peptide in select venous sampling sites. On the basis of each sampling site's C-peptide concentration and kinetics, we differentiated insulin secreted from the individual's native pancreatic beta cells and that secreted from allografted beta cells.

RESULTS

Selective venous sampling demonstrated that despite long-standing type 1 diabetes, all seven beta cell allograft recipients displayed evidence that their native pancreas secreted C-peptide. Yet even if chronic immunosuppression coupled with near normal glycaemia did improve native pancreatic C-peptide production, the magnitude of the effect was quite small.

CONCLUSIONS/INTERPRETATION

Some native pancreatic beta cell function persists even years after disease onset in most type 1 diabetic patients. However, if prolonged euglycaemia plus anti-rejection immunosuppressive therapy improves native pancreatic insulin production, the effect in our participants was small. We may have underestimated pancreatic regenerative capacity by studying only a limited number of participants or by creating conditions (e.g. high circulating insulin concentrations or immunosuppressive agents toxic to beta cells) that impair beta cell function.