Preliminary data from a 4-year mirror-image and multicentre study of patients initiating paliperidone palmitate 6-monthly long-acting injectable antipsychotic: the Paliperidone 2 per Year study

Background

Paliperidone palmitate 6-monthly (PP6M) is the first long-acting antipsychotic injectable (LAI) to allow for only two medication administrations per year, though there is presently limited insight into its effectiveness and potential added value in real clinical practice conditions.

Objectives

To present our ongoing study and draw its preliminary data on patient characteristics initiating PP6M and adherence during the first year of treatment.

Methods

The paliperidone 2 per year (P2Y) study is a 4-year, multicentre, prospective mirror-image pragmatic study taking place at over 20 different sites in Europe. The mirror period covers 2 years either side of the PP6M LAI initiation. Retrospective data for the previous 2 years are collected for each patient from the electronic health records. Prospective data are recorded at baseline, 6, 12, 18 and 24 months of drug administration and also cover information on concomitant psychiatric medication, relapses, hospital admissions, side effects, discontinuation and its reasons. Meanwhile, here we present preliminary data from the P2Y study at basal and 6-month period (first and second PP6M administration).

Results

At the point of PP6M initiation, the most frequent diagnosis was schizophrenia (69%), the clinical global impression scale mean score was 3.5 (moderately markedly ill) and the rate of previous hospital admissions per patient and year was 0.21. PP6M was initiated after a median of 3-4 years on previous treatment: 146 (73%) from paliperidone palmitate 3-monthly, 37 (19%) from paliperidone palmitate 1-monthly and 17 (9%) from other antipsychotics. The mean dose of the first PP6M was 1098.9 mg. The retention rate at 6 months and 1 year of treatment on PP6M in our cohort was 94%.

Conclusion

Patient and clinician preference for LAIs with longer dosing intervals was the main reason for PP6M initiation/switching resulting in high treatment persistence. Future data are needed to evaluate the full impact of PP6M in clinical practice.

Impact of diseases of the hard tissues of teeth on oral health-related quality of life of schoolchildren in area with a high concentration of fluoride in drinking water

OBJECTIVE

To assess the impact of caries, Molar Incisor Hypomineralization (MIH), and fluorosis on the Oral Health-Related Quality of Life (OHRQoL) of schoolchildren aged 8-10 years living in area with different fluoride levels in the drinking water.

SUBJECT AND METHODS

The prevalence of caries and fluorosis were assessed among 663 Mexican schoolchildren using the International Caries Detection and Assessment System (ICDAS II) and the Thylstrup and Fejerskov Index (TFI), respectively. MIH was recorded using the European Academy of Pediatric Dentistry (EAPD) criteria and OHRQoL using the Child Perceptions Questionnaire (CPQ8-10). Poisson regression models were used in data analysis.

RESULTS

Schoolchildren presenting two of the three conditions (cavitated lesions and TFI≥4, cavitated lesions and MIH or TFI≥4 and MIH) experienced worse quality of life than children who did not [RR=4.18; (95% CI 3.83, 4.56)]. Children with all three conditions had worse quality of life than children who did not [RR=5.64; (95% CI 5.13, 6.20)].

CONCLUSIONS

Fluorosis, MIH, and caries have a negative impact on the OHRQoL of schoolchildren living in area with a high concentration of fluoride in their drinking water.

Contingency management for smoking cessation among individuals with substance use disorders: In-treatment and post-treatment effects

INTRODUCTION

Smokers with substance use disorders (SUDs) show elevated tobacco prevalence, and smoking abstinence rates are considerably low. This randomized controlled trial sought to compare the effect of a cognitive behavioral treatment (CBT) that includes an episodic future thinking (EFT) component with the same treatment protocol plus contingency management (CM). This study aims to examine the effect of CM on smoking outcomes and in-treatment behaviors (i.e., retention, session attendance and adherence to nicotine use reduction guidelines), and to analyze whether these in-treatment variables predicted days of continuous abstinence at end-of-treatment.

METHOD

A total of 54 treatment-seeking participants (75.9% males, M = 46.19 years old) were allocated to CBT + EFT (n = 30) or CBT + EFT + CM (n = 24). Intervention consisted of eight weeks of group-based sessions. Tobacco abstinence was verified biochemically by testing levels of carbon monoxide (≤4ppm) and urine cotinine (≤80 ng/ml).

RESULTS

CM intervention increased 24-hour tobacco abstinence (50% vs. 20%, χ²(1) = 5.4; p = .021) and days of continuous abstinence (M = 5.92 ± 7.67 vs. 5.53 ± 12.42; t(52) = -0.132; p = 0.89) at end-of-treatment in comparison with CBT + EFT intervention. Although not statistically significant, CBT + EFT + CM enhanced in-treatment behaviors, in terms of retention (83.3% vs. 70%; χ²(1) = 0.255; p = .208), sessions attended (12.29 ± 3.22 vs. 10.93 ± 3.26; t(52) = -1.527; p = .133) and adherence to weekly nicotine use reduction targets (41.07% ± 31.96 vs. 35% ±2 6.28; t(52) = -0.766; p = .447). A higher percentage of samples meeting reduction guidelines (β = 0.609; p<.001) predicted days of continuous abstinence at end-of-treatment.

CONCLUSION

Combining CM with CBT + EFT improves short-term quitting rates. Findings suggest the need to incorporate strategies for improving adherence to nicotine reduction guidelines.

Marginalization and fluorosis its relationship with dental caries in rural children in Mexico: A cross-sectional study

OBJECTIVE

Examine the association between marginalization and fluorosis with caries experience in Mexican rural children aged 8-12, in Oaxaca, Mexico.

METHODS

Cross-sectional study of 283 rural schoolchildren selected from two locations with high and medium levels of marginalization where the water fluoride concentration ranged from 2.0 to 2.5 ppm/F. Caries was evaluated using the DMFT index and dental fluorosis with the Thylstrup-Fejerskov Index (TFI). Socioeconomic data were collected from participants' parents, with data on the children's characteristics collected from them via a questionnaire.

RESULTS

The prevalence of caries was 72.4% (DMFT ≥1) in the permanent dentition. The prevalence of fluorosis was 98.0% (TFI ≥4=71.4%). 54.8% of the children brushed their teeth two or more times daily. In logistic regression children living in high levels of marginalization were more likely to present caries (OR=2.11, 95% CI 1.13 - 3.93) than children living in medium levels. Children with severe fluorosis (TFI ≥4) (OR=1.93, 95% CI 1.06 - 3.53) were more likely have caries than those with TFI ⟨3.

CONCLUSION

Rural children with a high level of marginalization and fluorosis (TFI ≥4) were more likely to present caries. Poor oral hygiene and low dental service levels were found in both marginalized areas. Populations with medium/high marginalization are more susceptible to caries.

Mapping radon-prone areas using γ-radiation dose rate and geological information

Identifying radon-prone areas is key to policies on the control of this environmental carcinogen. In the current paper, we present the methodology followed to delineate radon-prone areas in Spain. It combines information from indoor radon measurements with γ-radiation and geological maps. The advantage of the proposed approach is that it lessens the requirement for a high density of measurements by making use of commonly available information. It can be applied for an initial definition of radon-prone areas in countries committed to introducing a national radon policy or to improving existing radon maps in low population regions.

Levetiracetam as an alternative therapy for Tourette syndrome

Tourette syndrome is a common childhood-onset neuropsychiatric disorder characterized by chronic tics and frequent comorbid conditions such as attention deficit disorder. Most currently used tic-suppressing drugs are frequently associated with serious adverse events. Thus, alternative therapeutic agents with more favorable side-effect profiles are being evaluated. New hypotheses and recent studies involving GABAergic system in the pathophysiology of Tourette syndrome suppose a reason for the evaluation of GABAergic drugs. Levetiracetam is a drug with an atypical GABAergic mechanism of action that might be expected to improve tics. Although trials performed to evaluate the efficacy of levetiracetam in the treatment of Tourette syndrome have provided conflicting results, it may be useful in some patients. The established safe profile of levetiracetam makes this drug an alternative for treatment if intolerance to currently used drugs appears, but additional evaluation with larger and longer duration controlled studies are necessary to assess the real efficacy in patients with Tourette syndrome.

[Carpal tunnel syndrome in childhood.]

Introduction. Carpal tunnel syndrome (CTS) has usually a different clinical presentation in children compared to adults. On top of this, its rarity in childhood makes it difficult to diagnose. It has also different etiologies at this age, the majority of cases occur in children with lysosomal storage diseases (mucopolysaccharidosis and mucolipidosis) which may be the first manifestation of this disease in some cases. Clinical case. In this article we describe 3 cases of children aged between 4 and 10 years, 2 with idiopathic CTS and 1 with primary familial origin. The symptoms of the former were intermittent paresthesias and handling difficulty, while the familial case presented with a more typical paresthesias and pain. The neurophysiological study confirmed the diagnosis. Concerning the patient with a history of CTS in the family, MRI showed a compression of the nerve due to the thickening of the flexor retinaculum. In all cases, lysosomal storage disease was ruled out and a conservative treatment was initiated. Evolution was favorable in the idiopathic cases, one of them with an almost complete remission of symptoms, while the patient with a familial CTS follows a progressive course and is waiting for the surgical assessment. Discussion. The CTS in pediatric age presents milder and more unspecific symptoms than in adults, and the results of the exploration and provocation tests are often unclear. Surgical treatment is almost always necessary, although some idiopathic cases, particularly if they are not associated to the thickening of the flexor retinaculum, may improve with a conservative treatment.

[Coding in neuropediatrics based on the International Classification Diseases, 9th revision (ICD-9), 5th edition (2006)]

AIMS

To analyze International Classification Diseases, 9th revision (ICD-9) coding and adapt it, on a consensus basis, to 'reasons for medical consultation', 'diagnoses' and 'procedures' in child neurology.

MATERIALS AND METHODS

The most frequent reasons for medical consultation, diagnoses and procedures in neuropediatrics were selected and assigned the most appropriate ICD-9, Clinical Modification (5th ed.) (ICD-9-CM) codes in accordance with this system's coding rules. Disorders were grouped by sections, and allocated to the various members of the working group (13 child neurologists from 10 hospitals in Madrid and environs).

RESULTS

Available on the web www.neurologia.com/cie-9. ICD-9-CM codes were assigned to: 158 reasons for medical consultation; 886 diagnoses; 73 diagnostic procedures; and 53 therapeutic procedures. In every case, the most appropriate ICD-9 code was sought for the respective diagnosis. No codes were invented but the working group did take certain liberties with interpretation, which nevertheless showed respect for general ICD-9-CM philosophy and are described in full in the text.

CONCLUSIONS

The creation of this ICD-9 adaptation will not only enhance diagnostic coding in child neurology departments, but will also provide them with a useful tool for setting up databases to enable information to be retrospectively analyzed and shared by the different health centers.

[The clinical semiology of attention deficit hyperactivity disorder according to age, and the effectiveness of treatments at different ages]

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is the most important cause of poor academic performance and is also usually associated with behavioural, emotional and sociability disorders.

AIM

To analyse the different clinical features and the response to psychostimulant therapy, according to the age.

SUBJECTS AND METHODS

We reviewed the cases of 152 children referred to Neuropaediatrics owing to suspected ADHD over a 6-year period. Diagnosis and comorbidity were investigated by the looking at their case history, by examination and observation, as well as by interviewing the parents (DSM-IV criteria), and by applying Conners' Rating Scale for parents and teachers, in addition to neuropsychological tests. In order to improve data processing, we established four groups according to the patient's age at diagnosis and when treatment was started: G1: 3-5; G2: 6-8; G3: 9-11; and G4: 12-15 years.

RESULTS

ADHD was diagnosed in 102 of the 152 children; 53% had the combined type, 26% were of the inattentional type, and 20% were hyperactive/impulsive. Poor school performance increased with age and reached 75% in G4. The same occurred with conduct disorders: at 6 years of age, 23% were found to have oppositional defiant disorder, and from the age of 9 onwards over 60% of them had conduct disorders. Up until 12 years of age they showed some improvement with psychostimulants and later the rate of dropouts from medical clinical controls and from treatment was over 40%.

CONCLUSIONS

The older patients are and the later ADHD is attended, the more problems they have. If successful preventive measures are to be implemented, it would be advisable to begin treatment even before children start primary education (5 years old), so as to try and avoid the pedagogical and behavioural repercussions observed in these children at the age of 6.

[Clinical progress of neonatal non-ketotic hyperglycinemia under treatment]

INTRODUCTION

Non-ketotic hyperglycinemia is a congenital error in the breakdown of glycine. The most common type is the classical neonatal form, which begins at the age of a few days with symptoms of lethargy, hypotonia, myoclonia, convulsions, apneas and, frequently, ends in death. Survivors usually develop intractable epilepsy and mental retardation. There is no effective treatment for this condition, but trials have been carried out with a therapy that diminishes the levels of glycine, benzoate (BZ), and another that blocks the excitatory effect in N-methyl-D-aspartate receptors: dextromethorphan (DTM).

CASE REPORT

We report on the progress of a classical neonatal case, which began at the age of a few hours with hypotonia and stupor, without myoclonias or seizures, but with a suppression wave trace on the electroencephalogram (EEG). Cerebrospinal fluid (CSF) showed glycine levels of 141 micromol/L (the normal level is 6.66 +/- 2.66 micromol/L), with a CSF/plasma ratio of 0.19 (the normal ratio is < 0.02). Treatment was started on the thirteenth day with BZ and DTM, and alertness and eye fixation improved in just three days; at the same time the EEG readings become normal. The glycine level in plasma returned to normal at two months and that in CSF was considerably reduced, although with CSF/plasma levels that were still high. At present the patient is 4 years old, has never had convulsions, EEG results have always been normal, and continues with BZ, DTM, carnitine and diet. The patient has presented a high degree of hypermotoric behaviour, but is currently more attentive and more sociable, has been walking from the age of 35 months and has a quotient in the different areas of development of 40-50.

CONCLUSIONS

The clinical progress made by our patient could be said to be anything but negligible, and we therefore recommend that treatment should be started as early as possible after diagnosis.

[Growth charts for the Spanish population with neurofibromatosis type 1]

OBJECTIVE

To make the charts of stature and head circumference of Spanish pediatric patients affected with neurofibromatosis type 1 (NF1), to compare them with the ones from a healthy population and to review the possible causes of its alterations.

PATIENTS AND METHODS

We obtained the data from 251 Spanish patients (122 women and 129 men) with NF1 seen in seven hospitals between the years 2000 and 2002, with ages between 1 month and 18 years old. The calculation of the 50th centile or median was done using the method of mobile variables, and the 3rd and 97th centiles where calculated from this median.

RESULTS

Girls with NF1 have a shorter stature than the healthy ones, which becomes evident after 10 years of age. We have not found differences in the stature between boys with the disease and those without it. In regards to head circumference, in boys and girls we have observed that it is bigger throughout life in patients affected with NF1, and that the 50th centile of healthy people correlates with the 3rd centile of those affected, the 97th centile of the healthy ones with the 50th centile of those affected, being the 3rd centile of the healthy people well below the 3rd centile of the affected ones, and the 97th centile of the affected ones well above the 97th of the healthy people.

CONCLUSIONS

The short stature in postpuberal girls and the macrocephaly in both sexes at all ages, are primary characteristics in the NF1 and they are not usually related with other alterations, although they are not specific for this illness.

Presence of granulocytic ehrlichia in ticks and serological evidence of human infection in La Rioja, Spain

In order to estimate the risks of human granulocytic ehrlichiosis (HGE) in an endemic area for Lyme disease in the North of Spain (La Rioja), we collected and investigated by PCR specific to the E. phagocytophila group DNA, a total of 6870 Ixodes ricinus ticks. We also used an indirect immunofluorescence (IFI) test to study the presence of antibodies to the HGE agent in 147 human serum samples including patients with Lyme disease (LD), forestry workers, and persons with history of previous tick bite. Fifty serum samples from healthy people resident in urban areas and with no history of tick-bite disorder and without tick exposure were used as controls. Four of 76 adults and 49 of 203 nymphs pools carried E. phagocytophila DNA. This result, and the finding of 1.4% of sera reacting in the IFI test confirms that this tick-borne agent is present in La Rioja, and that humans show evidence of contact with it. HGE should be considered in the differential diagnosis of flu-like syndromes in the study area in the north of Spain.

[Pseudotumor cerebri associated with maxillary sinusitis: clinico-pathological study]

INTRODUCTION

The pseudotumor cerebri is characterized by increased intracranial pressure in the absence of a space occupying lesions or obstruction to the circulation of cerebrospinal fluid (CSF). Increased pressure but normal composition of the CSF is the diagnostic criterion. Ear infections and other infections such as sinusitis have been cited as possible, but rare, causes.

CLINICAL CASE

A 12 year old girl presented with diplopia 10 days after starting treatment for sinusitis. On examination there was paresia of the VI cranial nerve to the left eye and marked bilateral papilledema. She had normal visual acuity with visual field measurements showing increased blind spot field in both eyes. Resonance studies only showed maxillary sinusitis. CSF pressure was 35 cm H2O, with 40 lymphomonocytes and normal biochemical findings. After 15 cm of CSF had been removed treatment was started with acetazolamide, dexamethasone and cefotaxime. A week later the diplopia had disappeared and the CSF pressure was 25, with no cells present. Two months later the visual fields and fundus oculi were normal. After follow-up for one year there was no recurrence.

CONCLUSIONS

We describe a case of pseudotumor cerebri associated with maxillary sinusitis. We do not know whether this is a chance association or whether there was a pathophysiological basis. The possibility should be considered so as to treat the cause or predisposing factor. The initial CSF pleocytosis would support the possibility of a relationship of the pseudotumor with an infectious condition (meningeal irritation or para-infectious pleocytosis meningeal irritation or para-infections pleocytosis in the context of an ENT infection), which might have precipitated the problem by interfering with the reabsorption of CSF.

[Non-dystonic torticollis. A report of a case secondary to retropharyngeal abscess]

INTRODUCTION

There are many causes of acquired non-dystonic torticollis: cervical bony anomalies, nasopharyngeal infections, tumours of the spinal cord, and posterior fossa, ocular, vestibular and gastrointestinal disorders. In children, non-dystonic is commoner than dystonic torticollis, except for in adverse reactions to drugs. Palatopharyngeal lesions due to a rigid object being impacted in the mouth (pencil-injury) are common in childhood. Many are not dangerous and require no specific treatment, although there is a risk of perforation of the pharyngeal wall and of a retropharyngeal abscess.

CLINICAL CASE

We report the case of a 9 year old boy who was seen in the Emergency Department complaining of fever present for four days and progressive cervical rigidity for the past two days which did not improve with myorelaxant drugs. A lateral X-ray of the spine showed prevertebral air and on the oesophagogram a fistula tract was seen. On further questioning the boy admitted that a stick he had had in his mouth had caused damage the day before his fever started. CT showed the extent of the abscess. After a week of treatment with antibiotics and corticosteroids the clinical features disappeared, and on CT after two weeks it was seen that the abscess had resolved.

CONCLUSIONS

We suggest that a lateral radiograph of the neck should be done in cases of acquired torticollis, even though there is no suspicious clinical history. Early diagnosis and treatment of retropharyngeal abscesses is essential to prevent extension to adjacent structures, and atlanto-axoid subluxation secondary to the oedema and tension of the ligaments caused by the abscess (Grisel's syndrome).

Functional consensus for mammalian osmotic response elements

The molecular mechanisms underlying adaptation to hyperosmotic stress through the accumulation of organic osmolytes are largely unknown. Yet, among organisms, this is an almost universal phenomenon. In mammals, the cells of the renal medulla are uniquely exposed to high and variable salt concentrations; in response, renal cells accumulate the osmolyte sorbitol through increased transcription of the aldose reductase (AR) gene. In cloning the rabbit AR gene, we found the first evidence of an osmotic response region in a eukaryotic gene. More recently, we functionally defined a minimal essential osmotic response element (ORE) having the sequence CGGAAAATCAC(C) (bp -1105 to -1094). In the present study, we systematically replaced each base with every other possible nucleotide and tested the resulting sequences individually in reporter gene constructs. Additionally, we categorized hyperosmotic response by electrophoretic mobility shift assays of a 17-bp sequence (-1108 to -1092) containing the native ORE as a probe against which the test constructs would compete for binding. In this manner, binding activity was assessed for the full range of osmotic responses obtained. Thus we have arrived at a functional consensus for the mammalian ORE, NGGAAAWDHMC(N). This finding should accelerate the discovery of genes previously unrecognized as being osmotically regulated.

ORE, a eukaryotic minimal essential osmotic response element. The aldose reductase gene in hyperosmotic stress

Organisms, almost universally, adapt to hyperosmotic stress through increased accumulation of organic osmolytes but the molecular mechanisms have only begun to be addressed. Among mammalian tissues, renal medullary cells are uniquely exposed to extreme hyperosmotic stress. Sorbitol, synthesized through aldose reductase, is a predominant osmolyte induced under hyperosmotic conditions in renal cells. Using a rabbit renal cell line, we originally demonstrated that hyperosmotic stress induces transcription of the aldose reductase gene. Recently, we cloned the rabbit aldose reductase gene, characterized its structure, and found the first evidence of an osmotic response region in a eukaryotic gene. Now, we have progressively subdivided this 3221-base pair (bp) region into discrete fragments in reporter gene constructs. Thereby, we have functionally defined the smallest sequence able to confer hyperosmotic response on a downstream gene independent of other putative cis-elements, that is, a minimal essential osmotic response element (ORE). The sequence of the ORE is CGGAAAATCAC(C) (bp -1105/-1094). A 17-bp fragment (-1108/-1092) containing the ORE used as a probe in electrophoretic mobility shift assays suggests hyperosmotic induction of a slowly migrating band. Isolation of trans-acting factor(s) and characterization of their interaction with the ORE should elucidate the basic mechanisms for regulation of gene expression by hyperosmotic stress.

Organic osmolyte distribution and levels in the mammalian urinary bladder in diuresis and antidiuresis

Inositol, sorbitol, glycerophosphocholine (GPC), and betaine are organic osmolytes that are accumulated by renal medullary cells in response to hyperosmotic stress. Previous screening studies, using nuclear magnetic resonance spectroscopy, have shown some of these same compounds to be present in extracts of whole urinary bladder from rabbits and rats. In the present study, we used high-performance liquid chromatography to quantify levels of these compounds in the separated epithelium and muscle of bladders taken from normal rabbits as well as diuretic and thirsted rats. We find that 1) high concentrations of organic osmolytes, namely inositol, GPC, and sorbitol, are present in urinary bladder; 2) levels of these osmolytes in the bladder epithelium are higher than in the muscle; 3) increased urinary osmolality due to antidiuresis is associated with a 2.4-fold increase in total osmolyte levels in rat bladder epithelium and a lesser (1.5-fold) increase in the muscle, compared with corresponding levels in tissues from diuretic animals; and 4) these increases in total osmolyte amounts in the epithelium are due to increased levels of GPC, sorbitol, and perhaps inositol (P = 0.07), whereas only GPC increases in the bladder muscle.

Betaine transporter cDNA cloning and effect of osmolytes on its mRNA induction

Cells generally adapt to long-term hyperosmolality by accumulating compatible organic osmolytes, thereby helping to normalize both volume and intracellular inorganic ion concentration. When organic osmolytes are accumulated, as in renal inner medullary cells, it is the sum of their concentrations that is theoretically important. In effect, when one organic osmolyte rises, the others generally fall to maintain their sum approximately constant. The present study addresses the mechanism controlling betaine accumulation. Hypertonicity induces accumulation of betaine, sorbitol, inositol, and other organic osmolytes in PAP-HT25 cells, a line derived from rabbit renal papilla. Hypertonicity increases the betaine transporter expression in these cells. To obtain a specific probe for betaine transporter mRNA, we cloned from PAP-HT25 cells a cDNA that encodes the full protein. We then examined the effect of betaine, sorbitol, and inositol on betaine transporter mRNA abundance. Increased accumulation of any of these three organic osmolytes reduces betaine transporter mRNA. We previously observed similar results for aldose reductase, the enzyme responsible for osmotically regulated sorbitol accumulation. We conclude that the accumulation of organic osmolytes regulates betaine transporter gene expression. Because the aldose reductase gene is controlled in a similar fashion, we surmise that the two genes share a common signal for induction.

CD9 antigen mRNA is induced by hypertonicity in two renal epithelial cell lines

In diverse organisms, cells adapt to hyperosmotic stress by accumulating organic osmolytes. Mammalian renal medullary cells are routinely under osmotic stress. Two renal cell lines, Madin-Darby canine kidney (MDCK) and PAP-HT25, have been widely used to study mammalian osmotic regulation. In these epithelial cells, extracellular hypertonicity induces gene transcription of proteins directly involved in the metabolism and transport of organic osmolytes. This induction is relatively specific and not part of a generalized stress response. Little is known about the signal transduction pathway between cellular detection of extracellular osmolality and increased specific gene transcription. Here, using differential mRNA display polymerase chain reaction on MDCK cells in isotonic vs. hypertonic medium, we identify a cDNA product corresponding to CD9 antigen mRNA. CD9 antigen is a cell surface glycoprotein originally found in cells of the immune system. Although CD9 antigen has been structurally characterized, its function is unclear. We further demonstrate that CD9 antigen mRNA is present in MDCK and PAP-HT25 cells and that its mRNA abundance is induced by extracellular hypertonicity, but not by heat stress. Also, we show that accumulation of organic osmolytes markedly attenuates the CD9 mRNA induction, as only recently demonstrated with genes involved in the hyperosmotic stress response. This suggests a role for CD9 antigen in this response.

Betaine and inositol reduce MDCK cell glycerophosphocholine by stimulating its degradation

The amount of glycerophosphocholine (GPC) in renal medullary cells in vivo and in cultured renal [Madin-Darby canine kidney (MDCK)] cells varies with extracellular NaCl and urea. We previously showed that this is largely due to modulation of GPC degradation catalyzed by GPC:choline phosphodiesterase (GPC: PDE). GPC also varies inversely with the levels of other compatible osmolytes, the accumulation of which is induced by high tonicity. We tested whether GPC:PDE activity and GPC degradation are affected by accumulation of compatible osmolytes other than GPC. We find that MDCK cell GPC content decreases when the cells take up betaine and/or inositol from the medium. The effect is considerably greater for cells in isosmotic or high-NaCl medium than in high-urea medium. This difference is associated with suppression of betaine and inositol accumulation with high urea. We then measured GPC:PDE activity with a novel chemiluminescent assay. Addition of inositol and/or betaine to the medium greatly increases GPC:PDE activity in cells in isosmotic or high-NaCl media, but the increase is much less in high-urea medium. The increases in GPC:PDE activity, associated with the presence of betaine, are accompanied by commensurate increases in absolute rates of endogenous GPC degradation by cells in isosmotic or high-NaCl medium. We found previously that, in MDCK cells incubated for 2 days in high-NaCl medium, the rate of GPC synthesis from phosphatidylcholine is increased, correlated with an increase in phospholipase activity. However, in the present experiments, betaine accumulation has no effect on phospholipase activity under those conditions and, thus, presumably does not affect GPC synthesis. Collectively, these data support the conclusion that betaine and/or inositol reduces GPC by increasing GPC degradation catalyzed by GPC:PDE. This mechanism enables GPC to be reciprocally regulated relative to other compatible osmolytes, thus maintaining an appropriate total osmolyte content.

Osmoregulation of GPC:choline phosphodiesterase in MDCK cells: different effects of urea and NaCl

The organic osmolyte, glycerophosphocholine (GPC), accumulates in renal cells in response to high concentrations of either NaCl or urea, despite the very different effects of these solutes on cell function and volume. Together, high levels of these solutes increase GPC amount in Madin-Darby canine kidney cells by inhibiting its enzymatic degradation. The present study tests the effects of NaCl and urea, individually, on GPC accumulation and its degradation. A technique was developed to determine the absolute rate of GPC degradation by measuring the initial rate of disappearance of [3H]GPC (pulsed into the cells by hypotonic shock) and the specific activity of GPC in the cells. The mass of GPC in the cells was measured by another newly developed method, a sensitive chemiluminescent assay. We find that exposure to high NaCl or urea decreases the absolute rate of cellular GPC degradation by approximately one-half during the first 20.5 h. Reductions in GPC degradation are accompanied by commensurate decreases in the activity of GPC:choline phosphodiesterase (GPC:PDE; EC 3.1.4.2), an enzyme that catalyzes degradation of GPC. Activity of GPC:PDE falls > 50% in cells exposed for 2 h to high osmolality. Inhibition is sustained for 7 days with high urea alone. In contrast, with high NaCl alone, GPC:PDE activity reverts to control values by 7 days, by which time synthesis of GPC is increased, accounting for sustained GPC accumulation. Collectively, these data suggest that GPC accumulation in response to either high NaCl or urea occurs initially by inhibition of its degradation but that the effect of NaCl on degradation differs, in that it is transient, while that of urea is sustained.

Osmotic regulation of synthesis of glycerophosphocholine from phosphatidylcholine in MDCK cells

Glycerophosphocholine (GPC) is osmotically regulated in renal medullary cells and in cultured Madin-Darby canine kidney (MDCK) cells. Previously, it was shown that a high extracellular concentration of urea or NaCl causes these cells to accumulate large amounts of GPC. GPC is known to be a product of phosphatidylcholine (PC) catabolism. The purpose of the present experiments was to examine the role of changes in the rate of GPC synthesis from PC in hyperosmotically induced GPC accumulation. When 1-palmitoyl-2-lysophosphatidyl-[methyl-3H]choline ([3H]LPC) is added to the medium, it is taken up by the cells and most of it is rapidly converted to PC. During a chase, 3H lost from PC appears almost exclusively in GPC and sphingomyelin. The rate of catabolism of PC is twofold greater in cells exposed to high NaCl (200 mosmol/kgH2O, added for 2 days) than in control or high-urea medium. Increased PC catabolism in NaCl-treated cells is associated with a 2.6-fold increase in GPC synthesis from PC; sphingomyelin synthesis decreases, and total cell PC does not change. Also, neither total mass nor specific radioactivity of lysophosphatidylcholine changes. PC catabolism is unaffected by short (2 h) exposure to high NaCl or urea. To investigate the enzymatic basis for the increased PC catabolism in response to high NaCl, phospholipase activity was measured in cell homogenates with 1-palmitoyl-2-[1-14C]palmitoyl-PC as a substrate. Exposure of cells to high NaCl for 2 days (but not 2 h) increases activity 2.8-fold compared with control or high-urea medium. Lysophospholipase activity (measured with [3H]LPC as the substrate) is unchanged. The increased phospholipase activity occurs with dipalmitoyl PC, but not sn-2-arachidonyl PC, as a substrate. Collectively, these data suggest a role for a phospholipase, unrelated to the arachidonyl-selective enzyme, in the regulation of PC catabolism during accumulation of GPC induced by prolonged exposure to high extracellular NaCl.

Cloning, genomic organization, and osmotic response of the aldose reductase gene

Diverse organisms accumulate organic osmolytes to adapt to hyperosmotic stress. The molecular basis of eukaryotic gene osmoregulation remains obscure. Aldose reductase [AR; alditol:NAD(P)+ 1-oxidoreductase, EC 1.1.1.21], which catalyzes the conversion of glucose to sorbitol (an organic osmolyte), is induced in renal medullary cells under hyperosmotic conditions. Elevated extracellular NaCl increases AR mRNA transcription in PAP-HT25 cells, a cell line derived from the rabbit renal papilla. We have cloned and characterized the rabbit AR gene to determine how it is regulated by hyperosmolality. The length of the gene, not including 5' or 3' flanking regions, is approximately 14.7 kilobases (kb) organized into 10 exons and 9 introns. The transcription start site is 36 base pairs upstream of the initiator methionine codon. A 5-kb fragment containing approximately 3.5 kb of 5' flanking region was isolated. The 3.5-kb sequence was examined for basal promoter activity and hyperosmotic response in luciferase reporter gene constructs. A 235-base-pair fragment (base pairs -208 to +27) was able to drive the downstream reporter gene in transfected PAP-HT25 cells under isoosmotic conditions (300 mosmol/kg of H2O). When this fragment plus the remaining upstream sequence (from approximately base pair -3429 to base pair +27) was used, cells in hyperosmotic medium (500 mosmol/kg of H2O) showed about 40-fold induction of luciferase expression compared with cells in isoosmotic medium. The upstream fragment (from approximately base pair -3429 to base pair -192) also conferred osmotic response to a heterologous promoter (B19). This finding evidences putative osmotic response element(s) (OREs) within a specific DNA fragment in a eukaryotic genome. Identification and characterization of OREs within this fragment and their associated trans-acting factors should reveal the molecular mechanisms of gene regulation in osmotic stress.

Induction of gene expression by heat shock versus osmotic stress

Elevated temperature rapidly increases expression of genes for heat shock proteins (HSP), including HSP-70. The response is presumably triggered by denaturation of cell proteins and helps in their renaturation. Hypertonicity may also denature proteins, but the protective response, which is accumulation of compatible organic osmolytes [including betaine and inositol in Madin-Darby canine kidney (MDCK) cells], apparently differs and is slow. Recently, hypertonicity was found also to increase expression of HSP-70 in MDCK cells, a response proposed to provide protection until organic osmolytes can accumulate. Our purpose was to examine whether 1) a gene involved in accumulation of organic osmolytes also responds to heat stress and 2) whether accumulation of organic osmolytes affects expression of HSP-70. We find that 1) the betaine transporter mRNA, which is greatly increased by hypertonicity (515 vs. 315 mosmol), is unaffected by high temperature (42 degrees C vs. 37 degrees C); 2) hypertonicity-induced increases in HSP-70 and betaine transporter mRNA are much greater when the medium (and cell) contain no betaine and no inositol than when high concentrations of these are present; and 3) high betaine greatly inhibits the increase in HSP-70 mRNA at high temperature. We conclude the following. 1) Although heat shock and betaine transporter genes both respond to hypertonicity, the betaine transporter is not a HSP. 2) Accumulation of organic osmolytes attenuates the HSP-70 response to hypertonicity, as it might if the HSP-70 expression were a temporizing response. 3) Betaine inhibits HSP-70 response to elevated temperature, presumably by its known effect of stabilizing proteins.

Neuropsychological evaluation of children with intracranial tumors: impact of treatment modalities

Antineoplastic treatment has a deleterious effect on intellectual functions, which is mainly attributable to radiotherapy. With the object of determining the neuropsychological disturbances associated with brain irradiation in the child, and to try to differentiate them from the effects caused by the other types of treatment (surgical and chemotherapy) as well as from the effects of the tumor itself, a cross-sectional study was carried out in 25 survivors of medial edge intracranial tumors. In order to monitor the effect of systemic chemotherapy on the cognitive functions, and the effect of prolonged absence from school, two control groups were formed, one made up of subjects treated with chemotherapy for extracranial tumors, and the other of patients with non-malignant chronic disease. Neuropsychological functions were measured using the Spanish version of the Wechsler scale, as well as the following tests: Spreen-Benton, ITPA and TALE scales, Yuste Memory Test, Thurstone Attention Test, and the Rey Complex Figure. In addition to a progressive decline found in the full scale intelligence quotient in children irradiated for intracranial tumors, variance analysis showed that these patients deteriorate mainly in visual attention and memory, but also significantly in verbal fluency and in the Performance Intelligence Quotient and all its subtests, when compared to the control groups. Visual attention and the Wechsler Picture Arrangement and Block Designs, were the tests whose decline correlated with the total radiation administered. The article relates this specific neuropsychological injury with the total brain irradiation dose but also with the structures located in the cone-down fields of irradiation to boost regions in the middle edge intracranial content.

Self-inflicted tongue ulcer: an unusual form of factitious disorder

Factitious disorders in the buccal cavity are infrequent. A 9-year-old boy with a 5-year history of an artefact ulcer of the tongue is described. Psychiatric evaluation revealed an altered personality structure with a background of psychotic traits. Complete remission was observed with psychiatric management.

[Familial chronic mucocutaneous candidiasis. Study of 2 families]

Four cases of familial mucocutaneous candidiasis corresponding to two families were studied. In two of the cases (Family I), there were lesions in the mouth, vaginal mucosa, nails, palms and soles, with no other associated infections. In the other two cases (Family II) there were oral (glossitis with macroglossia), genital and inguinal folds lesions, associated to frequent bacterial infections (recurring forunculosis , pneumonia). The immunological study in the four cases showed overlapping results: anti-candida circulating antibodies at high dilutions, a negative or weakly positive candidine a negative TTL to candida in some of the cases, and not other abnormalities in T. lymphocytes. All of the cases became sensitive to DNCB. In two of them, there were low figures of ferritin (Family II); however, no improvement was obtained with an iron treatment. There were no endocrinological abnormalities in any case. All of the cases were cured with ketoconazole in a few months, and no relapse was found six months after the end of the treatment in one of them. A follow up could not be performed on the other three cases.

Pretibial epidermolysis bullosa: report of two families and review of the literature

Two pretibial epidermolysis bullosa families, with a total of four cases directly examined and another eight cases known from references, were studied. Both families showed an autosomal dominant inheritance. In one family there was a case of "bullous epidermolysis albo-papular of Pasini". All cases were compared with those of the literature.