Le syndrome CACH/VWM et les leucodystrophies liées à des mutations EIF2B

A new leukoencephalopathy, the CACH syndrome (Childhood Ataxia with Central nervous system Hypomyelination) or VWM (Vanishing White Matter) was identified on clinical and MRI criteria. Classically, this disease is characterized by (1) an onset between 2 and 5 years of age, with a cerebello-spastic syndrome exacerbated by episodes of fever or head trauma leading to death after 5 to 10 years of disease evolution, (2) a diffuse involvement of the white matter on cerebral MRI with a CSF-like signal intensity (cavitation), (3) a recessive autosomal mode of inheritance, (4) neuropathologic findings consistent with a cavitating orthochromatic leukodystrophy with increased number of oligodendrocytes with sometimes "foamy" aspect. A total of 148 cases have been reported so far. This disease is linked to mutations in the five EIF2B genes encoding the five subunits of the eukaryotic initiation factor 2B (eIF2B), involved in the protein synthesis and its regulation under cellular stresses. Clinical symptoms are variable, from fatale infantile forms (Cree leukoencephalopathy) and congenital forms associated with extra-neurological affections, to juvenile and adult forms (ovarioleukodystrophy) characterized by cognitive and behaviour dysfunctions and by a slow progression of the disease, leading to the term of eIF2B-related leukoencephalopathies. Prevalence of these remains unknown. Diagnosis lays on the detection of EIF2B mutations, affecting predominantly the EIF2B5 gene. A decrease in the intrinsic activity of the eIF2B factor (the guanine exchange activity, GEF) in lymphoblasts from patients seems to have a diagnostic value. The patho-physiology of the disease would involve a deficiency in astrocytes maturation leading to an increased susceptibility of the white matter to cellular stress. No specific treatment exists except the "prevention" of cellular stress. Corticosteroids sometimes proved to be useful in acute phases. Prognosis seems to correlate with the age of onset, the earliest forms being more severe.

Impact of early central venous catheter removal on outcome in patients with candidaemia

Removal of central venous catheters (CVCs) from candidaemic patients is considered the reference standard of care, although this practice is not always possible. The impact of prompt catheter removal on outcome was investigated by analysing data from an active population-based surveillance study in Barcelona, Spain. Patients with candidaemia and a CVC were identified between January 2002 and December 2003. Cases with CVC removal within 2 days were classified as having early CVC removal. Outcome, defined as in-hospital mortality 2-30 days after diagnosis of candidaemia, was determined among hospitalised adults using univariate, Kaplan-Meier and multivariate logistic regression analysis. Outpatients, paediatric patients and those who died or were discharged within 2 days were excluded. The study identified 265 patients with candidaemia and a CVC. Median time from diagnosis of candidaemia to catheter removal was 1 day (range 0-29 days). Overall, 172 patients met the criteria for inclusion in the outcome study. Patients with early CVC removal differed significantly from those with delayed CVC removal. According to univariate, Kaplan-Meier and multivariate analysis, the marker most predictive of in-hospital mortality among candidaemic patients with CVCs was severity of illness. These data suggest that timing of CVC removal may best be determined after carefully considering the risks and benefits to individual patients.

Ostarine increases lean body mass and improves physical performance in healthy elderly subjects: Implications for cancer cachexia patients

9119

Background: Cancer cachexia results in selective loss of skeletal muscle resulting in weakness, reduced physical activity and a lower quality of life. Cancer cachexia also diminishes response to chemotherapy and survival. Anabolic steroids appear to increase weight and muscle mass in cancer patients, but have the potential for masculinization in women and prostate stimulation in men. A new class of non-steroidal selective androgen receptor modulators (SARMs) is being developed for use in cancer cachexia. SARMs are designed to have predominately anabolic activity in muscle and bone with minimal androgenic effects in most other tissues. We conducted a randomized phase II proof of concept study of ostarine, the first-in-class SARM, in healthy postmenopausal women and elderly men prior to intitiating a phase II study in cancer patients. Methods: Sixty elderly men (mean age 66 years) and 60 postmenopausal women (mean age 63 years) were randomly assigned to ostarine 0.1, 0.3, 1 mg, 3 mg or placebo for three months. The primary end point was change from baseline to three months in total lean body mass (LBM) measured by dual energy x-ray absorptiometry (DXA). The key secondary end point was a stair climb functional performance test that measured speed and power exerted. Evaluations included laboratory safety assessments and additional assessments of androgenic activity including PSA, sebum production and luteinizing hormone. Results: Ostarine treatment resulted in a dose dependent increase in total LBM, with an increase of 1.4 kg compared to placebo (p<0.001) at the 3 mg dose. Increased LBM translated to an improvement in the stair climb test in both speed (+15.5% ± 12.9 faster time, p=0.006) and power (+25.5% ± 20.3 watts, p=0.005). There were no serious adverse events reported. There were no significant changes in PSA, sebum production or luteinizing hormone. Conclusions: Ostarine improves LBM and physical performance in healthy older men and women. Ostarine had no unwanted androgenic side effects. A phase II study is planned to evaluate the safety and efficacy of ostarine in patients with cancer cachexia.

No significant financial relationships to disclose.

Effect of toremifene in lowering total cholesterol, LDL, and triglycerides and raising HDL in prostate cancer patients on androgen deprivation therapy

5124

Introduction: Androgen deprivation therapy (ADT) is the standard treatment for men with advanced prostate cancer. ADT has been shown to detrimentally affect lipids (average 9% increase in total cholesterol and 26% increase in triglycerides) and is associated with increased risk of coronary heart disease and myocardial infarction. Toremifene, a selective estrogen receptor modulator (SERM), improves bone mineral density and lipid profiles in women. An ongoing phase III trial will assess the safety and efficacy of toremifene in treating multiple side effects of ADT including osteoporosis, hot flashes, gynecomastia and lipid profiles. Given the emerging recognition of increased cardiovascular risk during ADT, an interim analysis was conducted to assess the effects of toremifene on lipid profiles in the ongoing phase III study. Methods: 1,392 men = 50 years old with histologically documented prostate cancer and receiving ADT were randomized to toremifene (80 mg/day) or placebo. An interim analysis evaluated changes in lipids from baseline to month 12 in the first 197 subjects to complete one-year follow up. The outcomes measured in this interim analysis were total cholesterol, LDL cholesterol, triglycerides, total cholesterol/HDL ratio, and HDL cholesterol. Results: Compared to treatment with placebo, toremifene decreased total cholesterol (7.1%; p=0.001 for between group comparison), LDL cholesterol (9.0%; p=0.003), and triglycerides (20.1%; p=0.009) levels, and the total cholesterol/HDL ratio (11.7%; p<0.001). Toremifene also significantly increased HDL levels (5.4%; p=0.018) compared to placebo. The effects of toremifene were observed in both statin users and nonusers. Conclusions: Toremifene decreases total cholesterol, LDL cholesterol, and triglycerides and increases HDL cholesterol in men receiving ADT for advanced prostate cancer compared to placebo. Conclusions regarding the clinical significance of these observations will be based on the full cohort of patients at the conclusion of the trial.

No significant financial relationships to disclose.

Prevalence of osteoporosis and osteopenia during androgen deprivation (ADT) for prostate cancer: Baseline data from a large randomized controlled trial

5116

Background: Androgen deprivation therapy (ADT) is the standard treatment for men with advanced prostate cancer. ADT decreases bone mineral density (BMD) and increases fracture risk although there is limited information about the prevalence of osteopenia and osteoporosis during ADT. We evaluated the baseline data from a large fracture prevention study to better characterize the prevalence of ostepenia and osteoporosis in men receiving ADT for prostate cancer. Methods: In an ongoing phase 3 fracture prevention study, 1,392 men = 50 years old with histologically documented prostate cancer and receiving ADT were randomized to placebo or toremifene 80 mg, a selective estrogen receptor modulator. The phase 3 study included men at increased risk of fracture based on age = 70 years or low baseline BMD of the hip or spine as assessed by dual energy x-ray absorptiometry. Subjects with metabolic bone disease or receiving treatment for osteoporosis were excluded. In the current analyses, we report the baseline BMD and prevalence of osteopenia (T score -1.0 to -2.5 total hip, femoral neck or spine) and osteoporosis (T score = -2.5 total hip, femoral neck or spine) for the 1,139 subjects older than 70 years. The analyses were restricted to subjects =70 years because these subjects were included in the study regardless of baseline BMD. Results: Mean (± standard deviation) age was 76 ± 7 years. Mean duration on ADT was 39 ± 36 months. For men 70 years of age or older, mean T scores for the total hip, femoral neck, and spine are -1.01 ± 1.14, -1.50 ± 1.06 and 0.37 ± 1.88 respectively. A total of 73% of subjects 70 years of age or older were classified with osteopenia (55%) or osteoporosis (18%). Conclusions: In this large cross- sectional analysis, the vast majority of older men receiving ADT for prostate cancer have either osteopenia or osteoporosis. These observations provide further evidence that close attention to skeletal health is warranted during ADT for prostate cancer.

No significant financial relationships to disclose.

[Human herpes virus type 6, etiology of an acute encephalitis in childhood: case report]

Primary infection with human herpesvirus-6 (HHV-6) causes the classical roseola infantum. Otherwise the infection is clinically silent but it may sometimes be responsible for central nervous system involvement. In order to illustrate such a type of lesions, we report on a 16-month-old girl with acute leucoencephalitis. The disease started with pyrexia 40 degrees C, followed by an episode of seizure, erythematous rash on the trunk and then coma. Brain MRI showed wide lesions on white matter. HHV-6 DNA was detected by PCR in the CSF and serum at the acute stage, and tests for HHV-6 antibody showed a significant increase of IgG antibody titre between acute and convalescent sera. One month later complete clinical recovery was observed while the MRI showed a partial disappearance of the lesions. The sero-conversion associated with the detection of the viral DNA in the serum identified a primary HHV-6 infection and the detection of viral nucleic acid in CSF gives arguments for the responsibility of the virus in the pathogenesis. When facing an acute leuco-encephalitis in infants, it is important to perform exhaustive virology investigations to rule out the implication of HHV-6 as well as other commonly incriminated pathogens (EBV, CMV, mycoplasma, enterovirus) to avoid accusing wrongly the vaccines.

The limit to wheat water-use efficiency in eastern Australia. I. Gradients in the radiation environment and atmospheric demand

In the wheatbelt of eastern Australia, rainfall shifts from winter dominated in the south (South Australia, Victoria) to summer dominated in the north (northern New South Wales, southern Queensland). The seasonality of rainfall, together with frost risk, drives the choice of cultivar and sowing date, resulting in a flowering time between October in the south and August in the north. In eastern Australia, crops are therefore exposed to contrasting climatic conditions during the critical period around flowering, which may affect yield potential, and the efficiency in the use of water (WUE) and radiation (RUE). In this work we analysed empirical and simulated data, to identify key climatic drivers of potential water- and radiation-use efficiency, derive a simple climatic index of environmental potentiality, and provide an example of how a simple climatic index could be used to quantify the spatial and temporal variability in resource-use efficiency and potential yield in eastern Australia. Around anthesis, from Horsham to Emerald, median vapour pressure deficit (VPD) increased from 0.92 to 1.28 kPa, average temperature increased from 12.9 to 15.2°C, and the fraction of diffuse radiation (FDR) decreased from 0.61 to 0.41. These spatial gradients in climatic drivers accounted for significant gradients in modelled efficiencies: median transpiration WUE (WUEB/T) increased southwards at a rate of 2.6% per degree latitude and median RUE increased southwards at a rate of 1.1% per degree latitude. Modelled and empirical data confirmed previously established relationships between WUEB/T and VPD, and between RUE and photosynthetically active radiation (PAR) and FDR. Our analysis also revealed a non-causal inverse relationship between VPD and radiation-use efficiency, and a previously unnoticed causal positive relationship between FDR and water-use efficiency. Grain yield (range 1–7 t/ha) measured in field experiments across South Australia, New South Wales, and Queensland (n = 55) was unrelated to the photothermal quotient (Pq = PAR/T) around anthesis, but was significantly associated (r2 = 0.41, P < 0.0001) with newly developed climatic index: a normalised photothermal quotient (NPq = Pq . FDR/VPD). This highlights the importance of diffuse radiation and vapour pressure deficit as sources of variation in yield in eastern Australia. Specific experiments designed to uncouple VPD and FDR and more mechanistic crop models might be required to further disentangle the relationships between efficiencies and climate drivers.

384 EFFECTS OF CONDITION SCORE ON OVARIAN RESPONSE AND TRANSFERABLE EMBRYOS IN SUPERSTIMULATED COWS IN ARGENTINA

The success of an embryo transfer program is influenced by ovarian response, number of ovulations, fertilization, and embryo viability (Armstrong 1993). It has been observed that over-conditioned, overweight donor females tend to produce fewer viable embryos per collection (Stroud and Hasler 2006 Theriogenology 65, 65–76). The condition score is one of the many intrinsic factors that affects cow reproduction. A retrospective analysis was done to compare the ovarian response, number of ovulations, fertilization, and total transferable embryos recovered of cows with different condition scores in Argentina. This research was carried out using different breed donors (n = 640; 82% Angus; 18% other) during the last 4 years in Buenos Aires province, Argentina. Donors at random stages of follicular wave with CL received an intravaginal progesterone device (DIB; Syntex, Buenos Aires, Argentina), 2 mg of estradiol benzoate, and 50 mg of progesterone (Syntex, Buenos Aires, Argentina) IM on the same day. On Day 4 after DIB insertion, superestimulatory treatment was initiated on a decreasing dose regimen of FSH (Pluset®; Callier, São Paulo, Brazil, or Folltropin®; Bioniche Animal Health, Inc., Belleville, Ontario, Canada) as IM injections every 12 h during 4 days. On Day 6, DIBs were removed, and cows received a double dose of 2 mL of cloprostenol within 12 h. At heat detection, all donors received a dose of 2 mL of GnRH (Dalmarelin; Von Franken, Buenos Aires, Argentina) by IM injection and were inseminated 12 and 24 h thereafter. Seven days later, embryo collection was performed and ovarian response was evaluated as number of CL + anovulatory follicles by transrectal ultrasound using a 7.5-MHz transducer (Pie Medical, Maastricht, The Netherlands). The condition score was determined at this time using a 1 to 5 scale. Embryos recovered were evaluated and classified according to the IETS manual. Kruskal–Wallis test was used to compare variables among score groups, and results are shown in Table 1. Ovarian response as the number of CL and anovulatory follicles was significantly different (P = 0.0001) among groups. There is a negative correlation (−0.2194) between condition score and ovarian response. At higher condition scores, ovarian response decreased. There is a significant difference (P = 0.0001) for the number of ovulations and total number of fertilized ova among groups. Finally, the total number of transferable embryos was no different for either score; however, there is a trend toward decrease when the condition score is higher. In conclusion, these results indicate that using donors with condition scores of 2 to 3 improves the results of a superstimulatory treatment. Controlling donors' condition score by nutrition management gives us the possibility to produce more embryos per donor treatment. Table 1. Condition score, ovarian response, fertilization, and transferable embryos in donor cows in Argentina

Heterogeneous reactions of HOI, ICl and IBr on sea salt and sea salt proxies

The heterogeneous chemistry of HOI, ICl and IBr on sea salt and sea salt proxies has been studied at 274 K using two experimental approaches: a wetted wall flow tube coupled to an electron impact mass spectrometer (WWFT-MS) and an aerosol flow tube (AFT) coupled to a differential mobility analyser (DMA) and a chemical ionisation mass spectrometer (CIMS). Uptake of all three title molecules into bulk aqueous halide salt films was rapid and controlled by gas phase diffusion. Uptake of HOI gave rise to gas-phase ICl and IBr, with the latter being the predominant product whenever Br(-) was present. Only partial release of IBr was observed due to high solubility of dihalogens in the film. ICl uptake gave the same yield of IBr as HOI uptake. Uptake of ICl on NaBr aerosol was accommodation limited with alpha = 0.018 +/- 0.004 and gas phase IBr product has a yield of 0.6 +/- 0.3. The results show that HOI can act as a catalyst for activation of bromine from sea-salt aerosols in the marine boundary layer, via the reactions: HOI(aq) + Cl + H--> ICl(aq) + H(2)O(l) and ICl(aq) + Br--> IBr(aq) + Cl.

The limit to wheat water-use efficiency in eastern Australia. II. Influence of rainfall patterns

We investigated the influence of rainfall patterns on the water-use efficiency of wheat in a transect between Horsham (36°S) and Emerald (23°S) in eastern Australia. Water-use efficiency was defined in terms of biomass and transpiration, WUEB/T, and grain yield and evapotranspiration, WUEY/ET. Our working hypothesis is that latitudinal trends in WUEY/ET of water-limited crops are the complex result of southward increasing WUEB/T and soil evaporation, and season-dependent trends in harvest index. Our approach included: (a) analysis of long-term records to establish latitudinal gradients of amount, seasonality, and size-structure of rainfall; and (b) modelling wheat development, growth, yield, water budget components, and derived variables including WUEB/T and WUEY/ET. Annual median rainfall declined from around 600 mm in northern locations to 380 mm in the south. Median seasonal rain (from sowing to harvest) doubled between Emerald and Horsham, whereas median off-season rainfall (harvest to sowing) ranged from 460 mm at Emerald to 156 mm at Horsham. The contribution of small events (≤ 5 mm) to seasonal rainfall was negligible at Emerald (median 15 mm) and substantial at Horsham (105 mm). Power law coefficients (τ), i.e. the slopes of the regression between size and number of events in a log-log scale, captured the latitudinal gradient characterised by an increasing dominance of small events from north to south during the growing season. Median modelled WUEB/T increased from 46 kg/ha.mm at Emerald to 73 kg/ha.mm at Horsham, in response to decreasing atmospheric demand. Median modelled soil evaporation during the growing season increased from 70 mm at Emerald to 172 mm at Horsham. This was explained by the size-structure of rainfall characterised with parameter τ, rather than by the total amount of rainfall. Median modelled harvest index ranged from 0.25 to 0.34 across locations, and had a season-dependent latitudinal pattern, i.e. it was greater in northern locations in dry seasons in association with wetter soil profiles at sowing. There was a season-dependent latitudinal pattern in modelled WUEY/ET. In drier seasons, high soil evaporation driven by a very strong dominance of small events, and lower harvest index override the putative advantage of low atmospheric demand and associated higher WUEB/T in southern locations, hence the significant southwards decrease in WUEY/ET. In wetter seasons, when large events contribute a significant proportion of seasonal rain, higher WUEB/T in southern locations may translate into high WUEY/ET. Linear boundary functions (French-Schultz type models) accounting for latitudinal gradients in its parameters, slope, and x-intercept, were fitted to scatter-plots of modelled yield v. evapotranspiration. The x-intercept of the model is re-interpreted in terms of rainfall size structure, and the slope or efficiency multiplier is described in terms of the radiation, temperature, and air humidity properties of the environment. Implications for crop management and breeding are discussed.

Golli-MBP copy number analysis by FISH, QMPSF and MAPH in 195 patients with hypomyelinating leukodystrophies

The inherited disorders of CNS myelin formation represent a heterogeneous group of leukodystrophies. The proteolipoprotein (PLP1) gene has been implicated in two X-linked forms, Pelizaeus-Merzbacher disease (PMD) and spastic paraplegia type 2, and the gap junction protein alpha12 (GJA12) gene in a recessive form of PMD. The myelin basic protein (MBP) gene, which encodes the second most abundant CNS myelin protein after PLP1, presents rearrangements in hypomyelinating murine mutants and is always included in the minimal region deleted in 18q- patients with an abnormal hypomyelination pattern on cerebral MRI. In this study, we looked at the genomic copy number at the Golli-MBP locus in 195 patients with cerebral MRI suggesting a myelin defect, who do not have PLP1 mutation. Although preliminary results obtained by FISH suggested the duplication of Golli-MBP in 3 out of 10 patients, no abnormal gene quantification was found using Quantitative Multiplex PCR of Short Fluorescent fragments (QMPSF), Multiplex Amplifiable Probe Hybridization (MAPH), or another FISH protocol using directly-labelled probes. Pitfalls and interest in these different techniques to detect duplication events are emphasised. Finally, the study of this large cohort of patients suggests that Golli-MBP deletion or duplication is rarely involved in inherited defects of myelin formation.

Phenotype at diagnosis predicts recurrence rates in Crohn's disease

BACKGROUND

In Crohn's disease (CD), studies associating phenotype at diagnosis and subsequent disease activity are important for patient counselling and health care planning.

AIMS

To calculate disease recurrence rates and to correlate these with phenotypic traits at diagnosis.

METHODS

A prospectively assembled uniformly diagnosed European population based inception cohort of CD patients was classified according to the Vienna classification for disease phenotype at diagnosis. Surgical and non-surgical recurrence rates throughout a 10 year follow up period were calculated. Multivariate analysis was performed to classify risk factors present at diagnosis for recurrent disease.

RESULTS

A total of 358 were classified for phenotype at diagnosis, of whom 262 (73.2%) had a first recurrence and 113 patients (31.6%) a first surgical recurrence during the first 10 years after diagnosis. Patients with upper gastrointestinal disease at diagnosis had an excess risk of recurrence (hazard ratio 1.54 (95% confidence interval (CI) 1.13-2.10)) whereas age >/=40 years at diagnosis was protective (hazard ratio 0.82 (95% CI 0.70-0.97)). Colonic disease was a protective characteristic for resective surgery (hazard ratio 0.38 (95% CI 0.21-0.69)). More frequent resective surgical recurrences were reported from Copenhagen (hazard ratio 3.23 (95% CI 1.32-7.89)).

CONCLUSIONS

A mild course of disease in terms of disease recurrence was observed in this European cohort. Phenotype at diagnosis had predictive value for disease recurrence with upper gastrointestinal disease being the most important positive predictor. A phenotypic North-South gradient in CD may be present, illustrated by higher surgery risks in some of the Northern European centres.

Impact of subsoil constraints on wheat yield and gross margin on fine-textured soils of the southern Victorian Mallee

The APSIM-Wheat module was used to investigate our present capacity to simulate wheat yields in a semi-arid region of eastern Australia (the Victorian Mallee), where hostile subsoils associated with salinity, sodicity, and boron toxicity are known to limit grain yield. In this study we tested whether the effects of subsoil constraints on wheat growth and production could be modelled with APSIM-Wheat by assuming that either: (a) root exploration within a particular soil layer was reduced by the presence of toxic concentrations of salts, or (b) soil water uptake from a particular soil layer was reduced by high concentration of salts through osmotic effects. After evaluating the improved predictive capacity of the model we applied it to study the interactions between subsoil constraints and seasonal conditions, and to estimate the economic effect that subsoil constraints have on wheat farming in the Victorian Mallee under different climatic scenarios. Although the soils had high levels of salinity, sodicity, and boron, the observed variability in root abundance at different soil layers was mainly related to soil salinity. We concluded that: (i) whether the effect of subsoil limitations on growth and yield of wheat in the Victorian Mallee is driven by toxic, osmotic, or both effects acting simultaneously still requires further research, (ii) at present, the performance of APSIM-Wheat in the region can be improved either by assuming increased values of lower limit for soil water extraction, or by modifying the pattern of root exploration in the soil profile, both as a function of soil salinity. The effect of subsoil constraints on wheat yield and gross margin can be expected to be higher during drier than wetter seasons. In this region the interaction between climate and soil properties makes rainfall information alone, of little use for risk management and farm planning when not integrated with cropping systems models.

Detection of nitrogen deficiency in wheat from spectral reflectance indices and basic crop eco-physiological concepts

We tested the capacity of several published multispectral indices to estimate the nitrogen nutrition of wheat canopies grown under different levels of water supply and plant density and derived a simple canopy reflectance index that is greatly independent of those factors. Planar domain geometry was used to account for mixed signals from the canopy and soil when the ground cover was low. A nitrogen stress index was developed, which adjusts shoot %N for plant biomass and area, thereby accounting for environmental conditions that affect growth, such as crop water status. The canopy chlorophyll content index (CCCi) and the modified spectral ratio planar index (mSRPi) could explain 68 and 69% of the observed variability in the nitrogen nutrition of the crop as early as Zadoks 33, irrespective of water status or ground cover. The CCCi was derived from the combination of 3 wavebands 670, 720 and 790 nm, and the mSRPi from 445, 705 and 750 nm, together with broader bands in the NIR and RED. The potential for their spatial application over large fields/paddocks is discussed.

Oligophrenin 1 mutations frequently cause X-linked mental retardation with cerebellar hypoplasia

BACKGROUND

Mutations of oligophrenin 1, one of the first genes identified in nonspecific X-linked mental retardation (MRX), have been described in patients with moderate to severe cognitive impairment and predominant cerebellar hypoplasia, in the vermis.

OBJECTIVE

To further delineate the phenotypic and mutational spectrum of the syndrome, by screening oligophrenin 1 in two cohorts of male patients with mental retardation (MR) with or without known posterior fossa anomalies.

METHODS

Clinical examination, cognitive testing, MRI studies, and mutational analysis (denaturing gradient gel electrophoresis and direct sequencing) on blood lymphocytes were performed in 213 unrelated affected individuals: 196 patients classified as MRX and 17 patients with MR and previously detected cerebellar anomalies.

RESULTS

Four novel oligophrenin 1 mutations were identified. In the MRX group, two nonsense mutations were detected. In the MR group, two mutations were found: a deletion of exons 16 to 17 and a splice site mutation. All patients shared characteristic clinical, radiologic, and distinctive features with a degree of intrafamilial variability in motor and cognitive deficits.

CONCLUSIONS

Oligophrenin 1 mutations were found in 12% (2/17) of individuals with mental retardatin and known cerebellar anomalies and in 1% (2/196) of the X-linked mental retardation group.

The use of B-type natriuretic peptide in the management of elderly patients with acute dyspnoea

OBJECTIVES

The aim of this study was to define the impact of B-type natriuretic peptide (BNP) levels on the management of elderly patients presenting with acute dyspnoea.

DESIGN

We performed a prospective randomized controlled study in 269 elderly patients at least 70 years of age included in the B-type natriuretic peptide for Acute Shortness of breath Evaluation (BASEL) study. Patients were randomly assigned to a diagnostic strategy with (n = 136, BNP group) or without (n = 133, control group) the use of BNP levels provided by a rapid bedside assay. The time to discharge and the total cost of treatment were the primary end-points.

RESULTS

Amongst elderly patients, baseline characteristics were well matched between both groups. The use of BNP levels significantly reduced the time to discharge (median 9.0 in the BNP group versus 11.0 days in the control group; P = 0.029). Total treatment cost was $5381 (95% CI, 4482-6280) in the BNP group when compared with $7411 (95% CI, 6180-8642; P = 0.009) in the control group. In addition, a significant reduction in 30-day mortality was observed (9% in the BNP group versus 17% in the control group; P = 0.039).

CONCLUSIONS

Used in conjunction with other clinical information, rapid measurement of BNP in the emergency department improved the management of elderly patients presenting with acute dyspnoea and thereby reduced the time to discharge and the total treatment cost. In addition, BNP testing seemed to reduce 30-day mortality.