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Baladron B, Mielu LM, López-Martín E, Barrero MJ, Lopez L, Alvarado JI, Monzón S, Varona S, Cuesta I, Cazorla R, Lara J, Iglesias G, Román E, Ros P, Gomez-Mariano G, Cubillo I, Miguel EHS, Rivera D, Alonso J, Bermejo-Sánchez E, Posada M, Martínez-Delgado B. Differences in Expression of IQSEC2 Transcript Isoforms in Male and Female Cases with Loss of Function Variants and Neurodevelopmental Disorder. Int J Mol Sci 2022; 23:ijms23169480. [PMID: 36012761 PMCID: PMC9409358 DOI: 10.3390/ijms23169480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 11/16/2022] Open
Abstract
Pathogenic hemizygous or heterozygous mutations in the IQSEC2 gene cause X-linked intellectual developmental disorder-1 (XLID1), characterized by a variable phenotype including developmental delay, intellectual disability, epilepsy, hypotonia, autism, microcephaly and stereotypies. It affects both males and females typically through loss of function in males and haploinsufficiency in heterozygous females. Females are generally less affected than males. Two novel unrelated cases, one male and one female, with de novo IQSEC2 variants were detected by trio-based whole exome sequencing. The female case had a previously undescribed frameshift mutation (NM_001111125:c.3300dup; p.Met1101Tyrfs*5), and the male showed an intronic variant in intron 6, with a previously unknown effect (NM_001111125:c.2459+21C>T). IQSEC2 gene expression study revealed that this intronic variant created an alternative donor splicing site and an aberrant product, with the inclusion of 19bp, confirming the pathogenic effect of the intron variant. Moreover, a strong reduction in the expression of the long, but also the short IQSEC2 isoforms, was detected in the male correlating with a more severe phenotype, while the female case showed no decreased expression of the short isoform, and milder effects of the disease. This suggests that the abnormal expression levels of the different IQSEC2 transcripts could be implicated in the severity of disease manifestations.
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Affiliation(s)
- Beatriz Baladron
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Lidia M. Mielu
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Estrella López-Martín
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Maria J. Barrero
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Lidia Lopez
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Jose I. Alvarado
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Sara Monzón
- Bioinformatics Unit, Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Sarai Varona
- Bioinformatics Unit, Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Isabel Cuesta
- Bioinformatics Unit, Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Rosario Cazorla
- Neuropediatrics Service, Hospital Puerta de Hierro, 28222 Madrid, Spain
| | - Julián Lara
- Neuropediatrics Service, Hospital Puerta de Hierro, 28222 Madrid, Spain
| | - Gemma Iglesias
- Neuropediatrics Service, Hospital Puerta de Hierro, 28222 Madrid, Spain
| | - Enriqueta Román
- Neuropediatrics Service, Hospital Puerta de Hierro, 28222 Madrid, Spain
| | - Purificación Ros
- Neuropediatrics Service, Hospital Puerta de Hierro, 28222 Madrid, Spain
| | - Gema Gomez-Mariano
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Isabel Cubillo
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Esther Hernandez-San Miguel
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Daniel Rivera
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Javier Alonso
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), U758, 28029 Madrid, Spain
| | - Eva Bermejo-Sánchez
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Manuel Posada
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
| | - Beatriz Martínez-Delgado
- Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), 28220 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), U758, 28029 Madrid, Spain
- Correspondence:
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8
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Mignot C, McMahon AC, Bar C, Campeau PM, Davidson C, Buratti J, Nava C, Jacquemont ML, Tallot M, Milh M, Edery P, Marzin P, Barcia G, Barnerias C, Besmond C, Bienvenu T, Bruel AL, Brunga L, Ceulemans B, Coubes C, Cristancho AG, Cunningham F, Dehouck MB, Donner EJ, Duban-Bedu B, Dubourg C, Gardella E, Gauthier J, Geneviève D, Gobin-Limballe S, Goldberg EM, Hagebeuk E, Hamdan FF, Hančárová M, Hubert L, Ioos C, Ichikawa S, Janssens S, Journel H, Kaminska A, Keren B, Koopmans M, Lacoste C, Laššuthová P, Lederer D, Lehalle D, Marjanovic D, Métreau J, Michaud JL, Miller K, Minassian BA, Morales J, Moutard ML, Munnich A, Ortiz-Gonzalez XR, Pinard JM, Prchalová D, Putoux A, Quelin C, Rosen AR, Roume J, Rossignol E, Simon MEH, Smol T, Shur N, Shelihan I, Štěrbová K, Vyhnálková E, Vilain C, Soblet J, Smits G, Yang SP, van der Smagt JJ, van Hasselt PM, van Kempen M, Weckhuysen S, Helbig I, Villard L, Héron D, Koeleman B, Møller RS, Lesca G, Helbig KL, Nabbout R, Verbeek NE, Depienne C. IQSEC2-related encephalopathy in males and females: a comparative study including 37 novel patients. Genet Med 2018; 21:837-849. [PMID: 30206421 PMCID: PMC6752297 DOI: 10.1038/s41436-018-0268-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/31/2018] [Indexed: 12/19/2022] Open
Abstract
Purpose Variants in IQSEC2, escaping X inactivation, cause X-linked intellectual disability with frequent epilepsy in males and females. We aimed to investigate sex-specific differences. Methods We collected the data of 37 unpublished patients (18 males and 19 females) with IQSEC2 pathogenic variants and 5 individuals with variants of unknown significance and reviewed published variants. We compared variant types and phenotypes in males and females and performed an analysis of IQSEC2 isoforms. Results IQSEC2 pathogenic variants mainly led to premature truncation and were scattered throughout the longest brain-specific isoform, encoding the synaptic IQSEC2/BRAG1 protein. Variants occurred de novo in females but were either de novo (2/3) or inherited (1/3) in males, with missense variants being predominantly inherited. Developmental delay and intellectual disability were overall more severe in males than in females. Likewise, seizures were more frequently observed and intractable, and started earlier in males than in females. No correlation was observed between the age at seizure onset and severity of intellectual disability or resistance to antiepileptic treatments. Conclusion This study provides a comprehensive overview of IQSEC2-related encephalopathy in males and females, and suggests that an accurate dosage of IQSEC2 at the synapse is crucial during normal brain development.
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Affiliation(s)
- Cyril Mignot
- INSERM, U 1127, CNRS UMR 7225, Sorbonne Universites, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle epiniere, ICM, Paris, France. .,APHP, Hôpital Pitie-Salpetriere, Departement de Genetique et de Cytogenetique; Centre de Reference Deficience Intellectuelle de Causes Rares; GRC UPMC «Deficience Intellectuelle et Autisme», Paris, France.
| | - Aoife C McMahon
- European Molecular Biology Laboratory, European Bioinformatics Institute, Wellcome Genome Campus, Hinxton, Cambridge, UK
| | - Claire Bar
- APHP, Reference Centre for Rare Epilepsies, Necker-Enfants Malades Hospital, Imagine Institute, Paris Descartes University, Paris, France.,INSERM U1163, Imagine Institute, Paris, France.,Paris Descartes University, Paris, France
| | - Philippe M Campeau
- Division of Medical Genetics, Department of Pediatrics, CHU Sainte-Justine and University of Montreal, Montreal, QC, Canada
| | - Claire Davidson
- European Molecular Biology Laboratory, European Bioinformatics Institute, Wellcome Genome Campus, Hinxton, Cambridge, UK
| | - Julien Buratti
- APHP, Hôpital Pitie-Salpetriere, Departement de Genetique et de Cytogenetique; Centre de Reference Deficience Intellectuelle de Causes Rares; GRC UPMC «Deficience Intellectuelle et Autisme», Paris, France
| | - Caroline Nava
- INSERM, U 1127, CNRS UMR 7225, Sorbonne Universites, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle epiniere, ICM, Paris, France.,APHP, Hôpital Pitie-Salpetriere, Departement de Genetique et de Cytogenetique; Centre de Reference Deficience Intellectuelle de Causes Rares; GRC UPMC «Deficience Intellectuelle et Autisme», Paris, France
| | | | - Marilyn Tallot
- CHU La Reunion-Groupe Hospitalier Sud Reunion, La Reunion, France
| | - Mathieu Milh
- APHM, Hôpital d'Enfants de La Timone, Service de Neurologie Pediatrique, centre de reference deficiences intellectuelles de cause rare, Marseille, France.,Aix Marseille University, INSERM, MMG, UMR-S 1251, Faculte de medecine, Marseille, France
| | - Patrick Edery
- Service de Genetique, Centre de Reference Anomalies du Developpement, Hospices Civils de Lyon, Bron, France.,INSERM U1028, CNRS UMR5292, Centre de Recherche en Neurosciences de Lyon, GENDEV Team, Universite Claude Bernard Lyon 1, Bron, France.,Claude Bernard Lyon I University, Lyon, France
| | - Pauline Marzin
- APHP, Hôpital Pitie-Salpetriere, Departement de Genetique et de Cytogenetique; Centre de Reference Deficience Intellectuelle de Causes Rares; GRC UPMC «Deficience Intellectuelle et Autisme», Paris, France
| | - Giulia Barcia
- INSERM U1163, Imagine Institute, Paris, France.,Paris Descartes University, Paris, France.,APHP, Service de genetique medicale, Necker-Enfants Malades Hospital, Imagine Institute, Paris Descartes University, Paris, France
| | - Christine Barnerias
- APHP, Unite fonctionnelle de Neurologie, Necker-Enfants Malades Hospital, Imagine Institute, Paris Descartes University, Paris, France
| | - Claude Besmond
- INSERM U1163, Imagine Institute, Paris, France.,Paris Descartes University, Paris, France
| | - Thierry Bienvenu
- APHP, Laboratoire de Genetique et Biologie Moleculaires, Hôpital Cochin, HUPC, Paris, France.,Universite Paris Descartes Paris, Institut de Psychiatrie et de Neurosciences de Paris, Inserm U894, Paris, France
| | - Ange-Line Bruel
- FHU-TRANSLAD, Universite de Bourgogne/CHU Dijon, Dijon, France.,INSERM UMR 1231 GAD team, Genetics of Developmental disorders, Universite de Bourgogne-Franche Comte, Dijon, France
| | - Ledia Brunga
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Berten Ceulemans
- Department of Pediatric Neurology, University Hospital and University of Antwerp, Antwerp, Belgium
| | - Christine Coubes
- Departement de Genetique Medicale, Maladies rares et Medecine Personnalisee, CHU de Montpellier, Montpellier, France
| | - Ana G Cristancho
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fiona Cunningham
- European Molecular Biology Laboratory, European Bioinformatics Institute, Wellcome Genome Campus, Hinxton, Cambridge, UK
| | | | - Elizabeth J Donner
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Bénédicte Duban-Bedu
- Centre de Genetique Chromosomique, Hôpital St-Vincent-de-Paul, GHICL, Lille, France
| | - Christèle Dubourg
- CHU Rennes, Service de Genetique Moleculaire et Genomique, Rennes, France
| | - Elena Gardella
- Danish Epilepsy Centre Filadelfia, Dianalund, Denmark.,Institute for Regional Health Services, University of Southern Denmark, Odense, Denmark
| | - Julie Gauthier
- Division of Medical Genetics, Department of Pediatrics, CHU Sainte-Justine and University of Montreal, Montreal, QC, Canada
| | - David Geneviève
- Departement de Genetique Medicale, Maladies rares et Medecine Personnalisee, CHU de Montpellier, Montpellier, France.,INSERM U1183, Montpellier, France
| | - Stéphanie Gobin-Limballe
- APHP, Service de genetique medicale, Necker-Enfants Malades Hospital, Imagine Institute, Paris Descartes University, Paris, France
| | - Ethan M Goldberg
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Eveline Hagebeuk
- Stichting Epilepsie Instellingen Nederland, SEIN, Zwolle, The Netherlands
| | - Fadi F Hamdan
- Division of Medical Genetics, Department of Pediatrics, CHU Sainte-Justine and University of Montreal, Montreal, QC, Canada
| | - Miroslava Hančárová
- Department of Biology and Medical Genetics, Charles University 2nd Faculty of Medicine and University Hospital Motol, Prague, Czech Republic
| | - Laurence Hubert
- INSERM U1163, Imagine Institute, Paris, France.,Paris Descartes University, Paris, France
| | - Christine Ioos
- APHP, University Hospital of Paris ïle-de-France ouest, Raymond Poincare Hospital, Garches, France
| | - Shoji Ichikawa
- Department of Clinical Diagnostics, Ambry Genetics, Aliso Viejo, CA, USA
| | - Sandra Janssens
- Centre for Medical Genetics Ghent, Ghent University Hospital, C. Heymanslaan 10, Ghent, Belgium
| | - Hubert Journel
- Service de Genetique Medicale, Hôpital Chubert, Vannes, France
| | - Anna Kaminska
- APHP, Department of Clinical Neurophysiology, Necker-Enfants Malades Hospital, Paris, France
| | - Boris Keren
- APHP, Hôpital Pitie-Salpetriere, Departement de Genetique et de Cytogenetique; Centre de Reference Deficience Intellectuelle de Causes Rares; GRC UPMC «Deficience Intellectuelle et Autisme», Paris, France
| | - Marije Koopmans
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Caroline Lacoste
- Departement de Genetique Medicale, APHM, Hopital d'Enfants de La Timone, Marseille, France
| | - Petra Laššuthová
- Child Neurology Department, 2nd Faculty of Medicine, Charles University and Motol Hospital, Prague, Czech Republic
| | - Damien Lederer
- Centre de Genetique Humaine, Institut de Pathologie et de Genetique, Gosselies, Belgium
| | - Daphné Lehalle
- FHU-TRANSLAD, Universite de Bourgogne/CHU Dijon, Dijon, France.,Unite fonctionnelle de genetique clinique, Centre Hospitalier Intercommunal de Creteil, Creteil, France
| | | | - Julia Métreau
- APHP, Service de neurologie pediatrique, Hôpital Universitaire Bicetre, Le Kremlin-Bicetre, France
| | - Jacques L Michaud
- Division of Medical Genetics, Department of Pediatrics, CHU Sainte-Justine and University of Montreal, Montreal, QC, Canada
| | - Kathryn Miller
- Department of Pediatrics, Albany Medical Center, Albany, NY, USA
| | - Berge A Minassian
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Joannella Morales
- European Molecular Biology Laboratory, European Bioinformatics Institute, Wellcome Genome Campus, Hinxton, Cambridge, UK
| | - Marie-Laure Moutard
- APHP, Hôpital Trousseau, service de neuropediatrie, Paris, France.,Sorbonne Universite, GRC n°19, pathologies Congenitales du Cervelet-LeucoDystrophies, APHP, Hôpital Armand Trousseau, Paris, France
| | - Arnold Munnich
- INSERM U1163, Imagine Institute, Paris, France.,Paris Descartes University, Paris, France.,APHP, Service de genetique medicale, Necker-Enfants Malades Hospital, Imagine Institute, Paris Descartes University, Paris, France
| | | | - Jean-Marc Pinard
- Division of Neuropediatrics, CHU Raymond Poincare (APHP), Garches, France
| | - Darina Prchalová
- Department of Biology and Medical Genetics, Charles University 2nd Faculty of Medicine and University Hospital Motol, Prague, Czech Republic
| | - Audrey Putoux
- Service de Genetique, Centre de Reference Anomalies du Developpement, Hospices Civils de Lyon, Bron, France.,INSERM U1028, CNRS UMR5292, Centre de Recherche en Neurosciences de Lyon, GENDEV Team, Universite Claude Bernard Lyon 1, Bron, France.,Claude Bernard Lyon I University, Lyon, France
| | - Chloé Quelin
- Service de Genetique Medicale, CLAD Ouest CHU Hôpital Sud, Rennes, France
| | - Alyssa R Rosen
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joelle Roume
- Unite de Genetique Medicale, Centre de Reference des Maladies rares du Developpement (AnD DI Rares), CHI Poissy-St Germain en Laye, Poissy, France
| | - Elsa Rossignol
- Departments of Pediatrics and Neurosciences, CHU Sainte-Justine and University of Montreal, Montreal, Canada
| | - Marleen E H Simon
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thomas Smol
- Institut de Genetique Medicale, CHRU Lille, Universite de Lille, Lille, France
| | - Natasha Shur
- Department of Pediatrics, Albany Medical Center, Albany, NY, USA
| | - Ivan Shelihan
- Division of Medical Genetics, Department of Pediatrics, CHU Sainte-Justine and University of Montreal, Montreal, QC, Canada
| | - Katalin Štěrbová
- Child Neurology Department, 2nd Faculty of Medicine, Charles University and Motol Hospital, Prague, Czech Republic
| | - Emílie Vyhnálková
- Department of Biology and Medical Genetics, Charles University 2nd Faculty of Medicine and University Hospital Motol, Prague, Czech Republic
| | - Catheline Vilain
- Department of Genetics, Hôpital Universitaire des Enfants Reine Fabiola, ULB Center of Human Genetics, Universite Libre de Bruxelles, Brussels, Belgium.,Department of Genetics, Hôpital Erasme, ULB Center of Human Genetics, Universite Libre de Bruxelles, Brussels, Belgium.,Interuniversity Institute of Bioinformatics in Brussels, Universite Libre de Bruxelles, Brussels, Belgium
| | - Julie Soblet
- Department of Genetics, Hôpital Universitaire des Enfants Reine Fabiola, ULB Center of Human Genetics, Universite Libre de Bruxelles, Brussels, Belgium.,Department of Genetics, Hôpital Erasme, ULB Center of Human Genetics, Universite Libre de Bruxelles, Brussels, Belgium.,Interuniversity Institute of Bioinformatics in Brussels, Universite Libre de Bruxelles, Brussels, Belgium
| | - Guillaume Smits
- Department of Genetics, Hôpital Universitaire des Enfants Reine Fabiola, ULB Center of Human Genetics, Universite Libre de Bruxelles, Brussels, Belgium.,Department of Genetics, Hôpital Erasme, ULB Center of Human Genetics, Universite Libre de Bruxelles, Brussels, Belgium.,Interuniversity Institute of Bioinformatics in Brussels, Universite Libre de Bruxelles, Brussels, Belgium
| | - Samuel P Yang
- Clinical Genomics & Predictive Medicine, Providence Medical Group, Dayton, WA, USA
| | | | - Peter M van Hasselt
- Department of Metabolic Diseases, Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands
| | - Marjan van Kempen
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sarah Weckhuysen
- Neurogenetics Group, Center of Molecular Neurology, VIB, Antwerp, Belgium.,Neurology Department, University Hospital Antwerp, Antwerp, Belgium
| | - Ingo Helbig
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Laurent Villard
- Aix Marseille University, INSERM, MMG, UMR-S 1251, Faculte de medecine, Marseille, France.,Departement de Genetique Medicale, APHM, Hopital d'Enfants de La Timone, Marseille, France
| | - Delphine Héron
- APHP, Hôpital Pitie-Salpetriere, Departement de Genetique et de Cytogenetique; Centre de Reference Deficience Intellectuelle de Causes Rares; GRC UPMC «Deficience Intellectuelle et Autisme», Paris, France
| | - Bobby Koeleman
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rikke S Møller
- CHU Rennes, Service de Genetique Moleculaire et Genomique, Rennes, France.,Danish Epilepsy Centre Filadelfia, Dianalund, Denmark
| | - Gaetan Lesca
- Service de Genetique, Centre de Reference Anomalies du Developpement, Hospices Civils de Lyon, Bron, France.,INSERM U1028, CNRS UMR5292, Centre de Recherche en Neurosciences de Lyon, GENDEV Team, Universite Claude Bernard Lyon 1, Bron, France.,Claude Bernard Lyon I University, Lyon, France
| | - Katherine L Helbig
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rima Nabbout
- APHP, Reference Centre for Rare Epilepsies, Necker-Enfants Malades Hospital, Imagine Institute, Paris Descartes University, Paris, France.,INSERM U1163, Imagine Institute, Paris, France.,Paris Descartes University, Paris, France
| | - Nienke E Verbeek
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christel Depienne
- INSERM, U 1127, CNRS UMR 7225, Sorbonne Universites, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle epiniere, ICM, Paris, France. .,IGBMC, CNRS UMR 7104/INSERM U964/Universite de Strasbourg, Illkirch, France. .,Institute of Human Genetics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
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