Autosomal dominant B-cell immunodeficiency, distal limb anomalies and urogenital malformations (BILU syndrome) - report of a second family

A family with an unusual combination of B-cell immunodeficiency, distal limb abnormalities, genitourinary malformations, and mild dysmorphic features has recently been described. Here, we report a second family with similar features, which also shows autosomal dominant inheritance. In affected individuals from both families, sequence analysis of candidate gene HOXA13 did not identify a mutation, and there was no evidence of a microdeletion involving either HOXA13 or the HOXA cluster as a whole. We further delineate the phenotype of this condition in females and add weight to the observation that this is a true syndromic association.

Chronic bronchitis in immunocompromised patients: association with a novel Mycoplasma species

Patients with primary antibody deficiency are prone to recurrent bronchitis, often caused by nonencapsulated Haemophilus influenzae and streptococcal infection. Productive cough often persists even after elimination of these organisms with antibiotics. During an investigation into the cause of unexplained chronic bronchitis in these patients, a novel Mycoplasma species (designated A39) was first isolated from the sputum of a man with X-linked agammaglobulinaemia. Screening of sputa from a further 45 patients with primary antibody deficiency showed that 10 were positive for a similar organism using culture and/or a polymerase chain reaction based on sequences within the 16S ribosomal RNA gene. A comparison of the sequence data showed that the organism was distinct from but similar to Mycoplasma pneumoniae and other closely related mycoplasmas found in humans and animals. Electron microscopy showed some unique morphological characteristics. Although respiratory symptoms improved after elimination of A39 from the sputum of the patient with X-linked agammaglobulinaemia, further work is needed to establish the organism as a pathogen.

Storage and use of residual dried blood spots

Newborn screening policy for Australia and New Zealand is developed by a committee of the Human Genetics Society of Australasia and the Royal Australasian College of Physicians Division of Pediatrics. Each program policy varies according to the local laws and customs. The residual dried blood spot policy recommends that each screening program develop its own policy taking into account the ownership of the material and the time of retention. Cards and associated records should be stored securely with regard to privacy issues. All uses of residual materials and access to stored material should be documented. Programs should state what permission and documentation is required for the use of samples in 1) investigation of cases missed by the screening program, 2) screening program development, method development and establishing normal ranges for new and existing tests, 3) requests from families for the return of samples, 4) requests from health professionals to use residual material for other health-related purposes, 5) research studies, and 6) coronial and forensic purposes. Storage of the samples must be appropriate to intended future uses and appropriate quality assurance material stored with the samples. Relevant privacy, legal and ethical issues should be considered when formulating storage and use policies. Use of dried blood spot samples for purposes other than newborn screening should also be covered.

Newborn screening in Australia and New Zealand

Newborn screening began in Australia and New Zealand in the mid-1960's as local and pilot programs and implemented as country or state-wide programs around 1970. There are five programs covering all Australia and one for New Zealand. All screening programs are fully government funded, as is treatment for the conditions found by the screening programs and newborn screening is a universally adopted policy funded by the government. Some have additional involvement in program advisory committees. There are no major problems sustaining existing screening, however, some programs have financial problems with funding for new equipment. Other problems include storage and other uses of residual dried blood samples; consent issues; protocols for action after screening and introduction of expanded (tandem mass spectrometry) screening. New activities vary from program to program--working towards expanded newborn screening and collaborative projects for the evaluation of this screening and development of screening for lysosomal storage disorders. All programs are working towards automation of punching and testing and increased automated data handling and reporting.

International developments in newborn screening quality assurance

The five dimensions of quality are Accessibility, Acceptability, Effectiveness, Efficiency and Safety. A newborn screening program consists of a number of interlinked parts, not usually managed by the same individual, and the quality of the program is dependent on the quality of program planning, specimen collection, laboratory testing and follow up, diagnosis and treatment. Outcome assessment and feedback into program planning complete the loop. Use of the quality parameters can quantify ongoing improvements to our screening programs.

The role of alcohol use in intimate partner femicide

The purpose of this study was to examine alcohol use by victims and perpetrators as a risk factor for intimate partner violence and femicide. A case control design was used to describe alcohol use among Femicide/Attempted Femicide victims (n = 380), Abused Controls (n = 384) and Non-Abused Controls (n = 376), and their intimate partners. Telephone interviews of proxies (family members or friends) of femicide victims and actual survivors of attempted femicide were conducted in 10 cities. The purpose of the interviews was to gather information about relationship violence and alcohol use by femicide victims, attempted femicide survivors, and their perpetrators. Telephone interviews of controls, recruited from the same cities by random digit dialing, were also conducted. Perpetrator problem drinking was associated with an eight fold increase in partner abuse (e beta = 8.24, p < .0001) and a two fold increased risk of femicide/attempted femicide (e beta = 2.39, p = .001), controlling for demographic differences.

Treatment of resistant mycoplasma infection in immunocompromised patients with a new pleuromutilin antibiotic

Patients with primary antibody deficiency (PAD) are prone to mycoplasma infection with unusual strains which may be resistant to conventional antibiotics. Mycoplasmas were isolated from the joint fluid (Ureaplasma urealyticum) of two PAD patients with arthritis and from the cerebral spinal fluid (Mycoplasma maculosum) in one with meningitis, the latter probably originating from the patient's dog. Combinations of doxycycline and quinolones or macrolides failed to clear the infections, but after demonstrating in-vitro sensitivity to the pleuromutilin, Econor, for two of the isolates, all three patients responded to oral treatment with Econor. The infection was completely eradicated in two patients, with the emergence of a resistant strain in the third. Mycoplasma infection should be considered in PAD patients with unexplained sepsis. Pleuromutilins such as Econor are powerful new anti-mycoplasmal agents which provide an additional therapeutic option when patients fail to respond to conventional antibiotics.

Does 77C-->G in PTPRC modify autoimmune disorders linked to the major histocompatibility locus?

A 77G allele of the gene encoding CD45, also known as the protein tyrosine phosphatase receptor-type C gene (PTPRC), has been associated with multiple sclerosis (MS). Here we determine allele frequencies in large numbers of MS patients, primary immunodeficiencies linked to major histocompatibility complex (MHC) locus and over 1,000 controls to assess whether aberrant splicing of PTPRC caused by the 77C-->G polymorphism results in increased susceptibility to these diseases. Our results show no difference in the frequency of the 77G allele in patients and controls and thus do not support a causative role for the polymorphism in the development of disorders with a strong autoimmune component in etiology.

Cochlear implantation of a patient with a previously undescribed mitochondrial DNA defect

Mitochondrial DNA (mtDNA) defects are responsible for symptom complexes that are characteristically heterogeneous but are typically represented by muscle weakness and neurological deficits. One common feature of mitochondrial disease is deafness. This report details the assessment and outcome of a patient with a previously undescribed mtDNA rearrangement who underwent cochlear implantation. The patient shows a marked improvement in sentence recognition tests and recognition of environmental sounds. Patients with profound sensorineural hearing loss due to mtDNA defects should be considered as candidates for cochlear implantation when they no longer benefit from conventional hearing aids.

Long term recovery of IgG and IgM production during HIV infection in a patient with common variable immunodeficiency (CVID)

AIMS

Common variable immunodeficiency (CVID) is the most common serious primary immunodeficiency. This paper describes the immunological consequences of human immunodeficiency virus (HIV) infection in a patient with familial CVID subsequently treated with highly active antiretroviral therapy (HAART).

METHODS

Serial measurements over 11 years of serum immunoglobulins, specific antibodies to tetanus toxoid and pneumococcal polysaccharides, lymphocyte phenotypes, and HIV viral load were made.

RESULTS

The patient recovered total serum IgG and IgM, but not IgA production, with adequate concentrations of specific antibodies, allowing withdrawal of intravenous immunoglobulin without an increase in infections. T cell numbers gradually declined and the patient developed a high grade B cell lymphoma. After successful chemotherapy, HAART was commenced, viral load fell from 472 000 to < 50 copies/ml, and CD4+ T cell numbers increased from 13 to 661 x 10(6)/litre. Antibody production was maintained after suppression of viral load.

CONCLUSIONS

This is the first definitive report of reversal of IgG and IgM deficiency in familial CVID after HIV infection. Failure to normalise IgA supports the concept of separate predisposing genetic factors for selective IgA deficiency, which when combined with others lead to CVID. Furthermore, a persistently high viraemia is not required to maintain the recovery of immunoglobulin values, suggesting this depends either on a transitory effect of a high viral load, or a persistence of low amounts of virus.

Using wound fluid analyses to identify trace element requirements for efficient healing

A series of wound fluid and blood plasma samples from 20 patients with breast cancer were analysed by Potentiometric Stripping Analysis and computer-aided chemical speciation to quantify the concentrations of the trace elements of copper and zinc in the samples and to investigate the individual species of copper and zinc present. Comparisons were made between total concentrations of copper and zinc in wound fluid, pre-operative blood plasma levels and reference values. A wound fluid model constructed using JESS identified the main copper and zinc species present. It was also used to investigate the effects of a change in pH and changes in the total concentrations of certain components on their predominance. The clinical significance of the research is discussed, together with suggestions for a continuation in the research.

Plant-derived measles virus hemagglutinin protein induces neutralizing antibodies in mice

Measles remains a significant problem in both the developed and developing world, and new measles vaccination strategies need to be developed. This paper examines the strategy of utilizing transgenic plants expressing a measles antigen for the development of an oral sub-unit measles vaccine. A 1.8 kb fragment encompassing the coding region of the measles virus hemagglutinin (H) protein was cloned into a plant expression cassette. Three different expression constructs were tested: pBinH (H gene alone), pBinH/KDEL (addition of a C-terminal endoplasmic reticulum-retention sequence SEKDEL) and pBinSP/H/KDEL (further addition of an authentic N-terminal plant signal peptide). The highest levels of recombinant H protein production were observed in plants transformed with pBinH/KDEL. Mice inoculated intraperitoneally with transgenic plant derived recombinant H protein produced serum anti-H protein antibodies that neutralized the measles virus (MV) in vitro. Mice gavaged with transgenic tobacco leaf extracts also developed serum H protein-specific antibodies with neutralizing activity against MV in vitro. These results indicate that the plant-derived measles H protein is immunogenic when administered orally and that, with further development, oral vaccination utilizing transgenic plants may become a viable approach to measles vaccine development.

Impaired antibody affinity maturation process characterizes a subset of patients with common variable immunodeficiency

Common variable immunodeficiency (CVID) is an heterogeneous syndrome characterized by decreased levels of serum Ig and recurrent bacterial infection. Here, we were interested to study whether a qualitative defect of the affinity Ab maturation process could be combined to the low level of serum Ig in a cohort of 38 CVID patients. For this, we designed a novel and rapid screening test for the detection of hypomutated V gene expressed by memory B cells. This test delineated a subset of 9/38 (23%) CVID patients with an abnormal pattern of Ig V gene mutation. The mean frequency of V gene mutation of this subset was significantly lower (1.74%) compared with other CVID patients (5.46%) and normal donors (6.5%) (p<0.0001). The mean age of this subgroup was significantly higher than other hypogammaglobulinemic patients with normal levels of V gene mutation (p<0.02), whereas no difference in the duration of symptoms was noted between the two groups. This suggests that hypomutation characterizes patients who began CVID late in life. Recently, it was shown that non-Ig sequences, such as the intronic BCL-6 gene, could be the target of the somatic hypermutation process in normal memory B cells. Our finding of a normal mutation frequency of the BCL-6 gene in two hypomutated CVID point to a defect of the Ig targeting of hypermutation machinery in these cases.

Brain abscess at the University Hospital of the West Indies

Surgical infections of the central nervous system are still attended by high rates of morbidity and mortality, although substantial progress has been made since the advent of computed tomography (CT) scanning technology. In this retrospective review of 25 surgically treated patients with either brain abscess or subdural empyema at the University Hospital of the West Indies, the majority of patients were male and between the ages of 10 and 30 years with a mean age of 16.9 years. Almost half the patients had a hemiparesis on presentation while 60% had fever. Subdural empyema was more common than a localized intracerebral abscess which was most frequently located in the frontal lobe. The most common predisposing factors were sinusitis and congenital heart disease. Streptococci spp and Staphylococci spp were the most frequently isolated organisms. All patients underwent CT scanning and surgical intervention. The mortality rate was 20%, and 21% of the survivors had late seizures. There must be a high index of clinical suspicion and early referral to specialist centres where neuroradiological investigation and prompt neurosurgical intervention can be carried out to minimize morbidity and mortality.

Placement stability for children in out-of-home care: a longitudinal analysis

This study examines the number of placement moves experienced over an eight-year period by 5,557 children in one state who first entered out-of-home care between birth and age six. This group comprised 28% of all young children who entered care during this period. Nearly 30% of children in kinship care and 52% of children in nonrelative care experienced placement instability (defined as three or more moves after the first year in care). Children in kinship care, regardless of age, had fewer placement moves than those in nonkinship care. A multivariate analysis found that children who had more than one placement move during their first year of care were more likely to experience placement instability in long-term out-of-home care than if they did not move or were moved only once during their first year in care.

Randomized trial of a specialist genetic assessment service for familial breast cancer

BACKGROUND

Because of the growing demand for genetic assessment, there is an urgent need for information about what services are appropriate for women with a family history of breast cancer. Our purpose was to compare the psychologic impact and costs of a multidisciplinary genetic and surgical assessment service with those of current service provisions.

METHODS

We carried out a prospective randomized trial of surgical consultation with (the trial group) and without (the control group) genetic assessment in 1000 women with a family history of breast cancer. All P: values are from two-sided tests.

RESULTS

Although statistically significantly greater improvement in knowledge about breast cancer was found in the trial group (P: =.05), differences between groups in other psychologic outcomes were not statistically significant. Women in both groups experienced statistically significant reductions in anxiety and found attending the clinics to be highly satisfying. An initial specialist genetic assessment cost pound 14.27 (U.S. $22.55) more than a consultation with a breast surgeon. Counseling and genetic testing of affected relatives, plus subsequent testing of family members of affected relatives identified as mutation carriers, raised the total extra direct and indirect costs per woman in the trial group to pound 60.98 (U.S. $96.35) over costs for the control subjects.

CONCLUSIONS

There may be little benefit in providing specialist genetics services to all women with a family history of breast cancer. Further investigation of factors that may mediate the impact of genetic assessment is in progress and may reveal subgroups of women who would benefit from specialist genetics services.

Morphological and biochemical evaluation of RAW 264.7 cells exposed to polychlorinated biphenyl

The effects of PCBs exposure, at low doses ranging between 10-100 mg PCB (Arclor-1254), on the viability of RAW 264.7 macrophage cells after 24, 48, and 72 hours of incubation was investigated. Furthermore, this study was designed to determine the interrelationship between PCBs and estrogen (E, 10 mg) and its role in the viability of RAW cells. Macrophages were cultured and plated in 24 well-plates according to standard protocols. The wells were divided into eight groups (n = 4 wells/group, 1 x 10(4) cells/well). The cells in groups 1-3 were treated with vehicle (serum-control for estrogen, DMSO-control for PCB, and media alone, respectively). Cells in groups 4 and 5 were treated with low (10 mg) and high (100 mg) doses of PCB. Cells in group 6 were treated with E, and cells in groups 7 and 8 were treated with low dose PCB + E and high dose PCB + E, respectively. Cell viability and damage (Malianodialdehyde, MDA level) were determined after 24, 48, and 72 hours, as well as, cell morphology. The results of this study showed that low and high doses of PCB depressed cell number by 52%. Estrogen treatment caused no effect on cell number in comparison to cells treated with serum alone. Cell number in response to E and low and high doses of PCB decreased cell number by 50%. Similar results were also observed at 48 hour time phase. In contrast, at the 72 hour phase, no significant changes were observed for cell count. Morphological evaluation of the cells revealed healthy spindle shaped multinucleated cells in the control group but, groups exposed to PCB induced morphological changes that included: cells became small, round, and increased evidence of cellular injury and debris. Estrogen treatment did not show changes from the control group. However E and PCB treatments caused the cells to become round, tightly compact nuclei with evidence of cell fragmentation. The results of this investigation showed that exposure to either 10 or 100 mg of PCB had detrimental effects on the RAW 264.7 macrophage cells as early as 24 hours. Combination treatment with E didn't provide any protective measures to the viability of RAW cells exposed to PCBs.