Improving sudden cardiac death risk stratification in hypertrophic cardiomyopathy using established clinical variables and genetic information

BACKGROUND AND AIMS

The cardiac societies of Europe and the United States have established different risk models for preventing sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM). The aim of this study is to validate current SCD risk prediction methods in a German HCM cohort and to improve them by the addition of genotype information.

METHODS

HCM patients without prior SCD or equivalent arrhythmic events ≥ 18 years of age were enrolled in an expert cardiomyopathy center in Germany. The primary endpoint was defined as SCD/-equivalent within 5 years of baseline evaluation. 5-year SCD-risk estimates and recommendations for ICD implantations, as defined by the ESC and AHA/ACC guidelines, were analyzed. Multivariate cox proportional hazards analyses were integrated with genetic findings as additive SCD risk.

RESULTS

283 patients were included and followed for in median 5.77 years (2.92; 8.85). A disease-causing variant was found in 138 (49%) patients. 14 (5%) patients reached the SCD endpoint (5-year incidence 4.9%). Kaplan-Meier survival analysis shows significantly lower overall SCD event-free survival for patients with an identified disease-causing variant (p < 0.05). The ESC HCM Risk-SCD model showed an area-under-the-curve (AUC) of 0.74 (95% CI 0.68-0.79; p < 0.0001) with a sensitivity of 0.29 (95% CI 0.08-0.58) and specificity of 0.83 (95% CI 0.78-0.88) for a risk estimate ≥ 6%/5-years. By comparison, the AHA/ACC HCM SCD risk stratification model showed an AUC of 0.70 (95% CI 0.65-0.76; p = 0.003) with a sensitivity of 0.93 (95% CI, 0.66-0.998) and specificity of 0.28 (95% CI 0.23-0.34) at the respective cut-off. The modified SCD Risk Score with genetic information yielded an AUC of 0.76 (95% CI 0.71-0.81; p < 0.0001) with a sensitivity of 0.86 (95% CI 0.57-0.98) and specificity of 0.69 (95% CI 0.63-0.74). The number-needed-to-treat (NNT) to prevent 1 SCD event by prophylactic ICD-implantation is 13 for the ESC model, 28 for AHA/ACC and 9 for the modified Genotype-model.

CONCLUSION

This study confirms the performance of current risk models in clinical decision making. The integration of genetic findings into current SCD risk stratification methods seem feasible and can add in decision making, especially in borderline risk-groups. A subgroup of patients with high SCD risk remains unidentified by current risk scores.

Controlling my genome with my smartphone: first clinical experiences of the PROMISE system

Background

The development of Precision Medicine strategies requires high-dimensional phenotypic and genomic data, both of which are highly privacy-sensitive data types. Conventional data management systems lack the capabilities to sufficiently handle the expected large quantities of such sensitive data in a secure manner. PROMISE is a genetic data management concept that implements a highly secure platform for data exchange while preserving patient interests, privacy, and autonomy.

Methods

The concept of PROMISE to democratize genetic data was developed by an interdisciplinary team. It integrates a sophisticated cryptographic concept that allows only the patient to grant selective access to defined parts of his genetic information with single DNA base-pair resolution cryptography. The PROMISE system was developed for research purposes to evaluate the concept in a pilot study with nineteen cardiomyopathy patients undergoing genotyping, questionnaires, and longitudinal follow-up.

Results

The safety of genetic data was very important to 79%, and patients generally regarded the data as highly sensitive. More than half the patients reported that their attitude towards the handling of genetic data has changed after using the PROMISE app for 4 months (median). The patients reported higher confidence in data security and willingness to share their data with commercial third parties, including pharmaceutical companies (increase from 5 to 32%).

Conclusion

PROMISE democratizes genomic data by a transparent, secure, and patient-centric approach. This clinical pilot study evaluating a genetic data infrastructure is unique and shows that patient’s acceptance of data sharing can be increased by patient-centric decision-making.

Graphic abstract

Broad-Spectrum HDAC Inhibitors Promote Autophagy through FOXO Transcription Factors in Neuroblastoma

Depending on context and tumor stage, deregulation of autophagy can either suppress tumorigenesis or promote chemoresistance and tumor survival. Histone deacetylases (HDACs) can modulate autophagy; however, the exact mechanisms are not fully understood. Here, we analyze the effects of the broad-spectrum HDAC inhibitors (HDACi) panobinostat and vorinostat on the transcriptional regulation of autophagy with respect to autophagy transcription factor activity (Transcription factor EB-TFEB, forkhead boxO-FOXO) and autophagic flux in neuroblastoma cells. In combination with the late-stage autophagic flux inhibitor bafilomycin A1, HDACis increase the number of autophagic vesicles, indicating an increase in autophagic flux. Both HDACi induce nuclear translocation of the transcription factors FOXO1 and FOXO3a, but not TFEB and promote the expression of pro-autophagic FOXO1/3a target genes. Moreover, FOXO1/3a knockdown experiments impaired HDACi treatment mediated expression of autophagy related genes. Combination of panobinostat with the lysosomal inhibitor chloroquine, which blocks autophagic flux, enhances neuroblastoma cell death in culture and hampers tumor growth in vivo in a neuroblastoma zebrafish xenograft model. In conclusion, our results indicate that pan-HDACi treatment induces autophagy in neuroblastoma at a transcriptional level. Combining HDACis with autophagy modulating drugs suppresses tumor growth of high-risk neuroblastoma cells. These experimental data provide novel insights for optimization of treatment strategies in neuroblastoma.

Clinical genetics and outcome of left ventricular non-compaction cardiomyopathy

Aims

In this study, we aimed to clinically and genetically characterize LVNC patients and investigate the prevalence of variants in known and novel LVNC disease genes.

Introduction

Left ventricular non-compaction cardiomyopathy (LVNC) is an increasingly recognized cause of heart failure, arrhythmia, thromboembolism, and sudden cardiac death. We sought here to dissect its genetic causes, phenotypic presentation and outcome.

Methods and results

In our registry with follow-up of in the median 61 months, we analysed 95 LVNC patients (68 unrelated index patients and 27 affected relatives; definite familial LVNC = 23.5%) by cardiac phenotyping, molecular biomarkers and exome sequencing. Cardiovascular events were significantly more frequent in LVNC patients compared with an age-matched group of patients with non-ischaemic dilated cardiomyopathy (hazard ratio = 2.481, P = 0.002). Stringent genetic classification according to ACMG guidelines revealed that TTN, LMNA, and MYBPC3 are the most prevalent disease genes (13 patients are carrying a pathogenic truncating TTN variant, odds ratio = 40.7, Confidence interval = 21.6-76.6, P < 0.0001, percent spliced in 76-100%). We also identified novel candidate genes for LVNC. For RBM20, we were able to perform detailed familial, molecular and functional studies. We show that the novel variant p.R634L in the RS domain of RBM20 co-segregates with LVNC, leading to titin mis-splicing as revealed by RNA sequencing of heart tissue in mutation carriers, protein analysis, and functional splice-reporter assays.

Conclusion

Our data demonstrate that the clinical course of symptomatic LVNC can be severe. The identified pathogenic variants and distribution of disease genes-a titin-related pathomechanism is found in every fourth patient-should be considered in genetic counselling of patients. Pathogenic variants in the nuclear proteins Lamin A/C and RBM20 were associated with worse outcome.

Mutation of the Na+/K+-ATPase Atp1a1a.1 causes QT interval prolongation and bradycardia in zebrafish

The genetic underpinnings that orchestrate the vertebrate heart rate are not fully understood yet, but of high clinical importance, since diseases of cardiac impulse formation and propagation are common and severe human arrhythmias. To identify novel regulators of the vertebrate heart rate, we deciphered the pathogenesis of the bradycardia in the homozygous zebrafish mutant hiphop (hip) and identified a missense-mutation (N851K) in Na⁺/K⁺-ATPase α1-subunit (atp1a1a.1). N851K affects zebrafish Na⁺/K⁺-ATPase ion transport capacity, as revealed by in vitro pump current measurements. Inhibition of the Na⁺/K⁺-ATPase in vivo indicates that hip rather acts as a hypomorph than being a null allele. Consequently, reduced Na⁺/K⁺-ATPase function leads to prolonged QT interval and refractoriness in the hip mutant heart, as shown by electrocardiogram and in vivo electrical stimulation experiments. We here demonstrate for the first time that Na⁺/K⁺-ATPase plays an essential role in heart rate regulation by prolonging myocardial repolarization.

Epigenome-Wide Association Study Identifies Cardiac Gene Patterning and a Novel Class of Biomarkers for Heart Failure

BACKGROUND

Biochemical DNA modification resembles a crucial regulatory layer among genetic information, environmental factors, and the transcriptome. To identify epigenetic susceptibility regions and novel biomarkers linked to myocardial dysfunction and heart failure, we performed the first multi-omics study in myocardial tissue and blood of patients with dilated cardiomyopathy and controls.

METHODS

Infinium human methylation 450 was used for high-density epigenome-wide mapping of DNA methylation in left-ventricular biopsies and whole peripheral blood of living probands. RNA deep sequencing was performed on the same samples in parallel. Whole-genome sequencing of all patients allowed exclusion of promiscuous genotype-induced methylation calls.

RESULTS

In the screening stage, we detected 59 epigenetic loci that are significantly associated with dilated cardiomyopathy (false discovery corrected P≤0.05), with 3 of them reaching epigenome-wide significance at P≤5×10^-8. Twenty-seven (46%) of these loci could be replicated in independent cohorts, underlining the role of epigenetic regulation of key cardiac transcription regulators. Using a staged multi-omics study design, we link a subset of 517 epigenetic loci with dilated cardiomyopathy and cardiac gene expression. Furthermore, we identified distinct epigenetic methylation patterns that are conserved across tissues, rendering these CpGs novel epigenetic biomarkers for heart failure.

CONCLUSIONS

The present study provides to our knowledge the first epigenome-wide association study in living patients with heart failure using a multi-omics approach.

Spontaneous and Experimental Glycoprotein Storage Disease of Goats Induced by Ipomoea carnea subsp fistulosa (Convolvulaceae)

Spontaneous and experimental poisoning with the swainsonine-containing and calystegine-containing plant Ipomoea carnea subsp fistulosa is described. Three of 8 goats presenting with emaciation, weakness, symmetrical ataxia, posterior paresis, proprioceptive deficits, abnormal posture, abnormal postural reaction, and muscle hypertonia were necropsied. I fistulosa was suspected to be the cause of the neurologic disease in all cases. An experiment was conducted to confirm the diagnosis using 12 goats and diets containing 3 different concentrations of the plant. All goats fed I fistulosa developed neurological signs that were similar to those observed in the spontaneous intoxication. Muscle atrophy and pallor were the only macroscopic changes observed in spontaneous and in experimental intoxication. Histological lesions of spontaneous and experimental animals were similar. The most prominent lesion was cytoplasmic vacuolation in neurons of the central and the autonomous nervous system, pancreatic acinar cells, hepatocytes, Kupffer cells, follicular epithelial cells of the thyroid gland, and macrophages of the lymphatic tissues. Neuronal necrosis, axonal spheroids formation, and astrogliosis were additionally observed in the brain. Ultrastructurally, the cytoplasmic vacuoles consisted of distended lysosomes surrounded by a single-layered membrane. Nonreduced end-rests or sequence of α-Man, α-Glc, β(1–4)-GlcNAc, and NeuNAc on lysosomal membrane were revealed by lectin histochemistry. Samples of plants used in the experimental trial contained swainsonine and calystegine and their intermediary derivate. We conclude that I fistulosa induces a glycoprotein storage disease primarily based on the inhibition of the lysosomal α-mannosidase by the alkaloid swainsonine.

Bias in High-Throughput Analysis of miRNAs and Implications for Biomarker Studies

A certain degree of bias in high-throughput molecular technologies including microarrays and next-generation sequencing (NGS) is known. To quantify the actual impact of the biomarker discovery platform on miRNA profiles, we first performed a meta-analysis: raw data of 1 539 microarrays and 705 NGS blood-borne miRNomes were statistically evaluated, suggesting a substantial influence of the technology on biomarker profiles. We observed highly significant dependency of the miRNA nucleotide composition on the expression level. Higher expression in NGS was discovered for uracil-rich miRNAs (p = 7 × 10(-37)), while high expression in microarrays was found predominantly for guanine-rich miRNAs (p = 3 × 10(-33)). To verify the findings, 10 identical replicates of one individual were measured using NGS and microarrays (2 525 miRNAs from miRBase version 21). Overall, we calculated a correlation coefficient of 0.414 for both technologies. Detailed analysis however revealed that the correlation was observed only for miRNAs in the early miRBase versions (<8). The majority of miRNAs (2 013 from miRBase version 8 onward) was not correlated between microarray and NGS. Specifically, we observed 67 miRNAs with a median read count above 10 in NGS, while they were not detected in any of the 10 replicated array experiments. In contrast, 234 miRNAs were discovered in all 10 replicated array measurements but were not found in any of the NGS experiments of the same individual. While the first group had average guanine content of 22%, the latter group consisted of 41% of this nucleotide. Selected concordant and discordant miRNAs were tested in quantitative real-time-polymerase chain reaction (RT-qPCR) experiments again of the same individual, providing further evidence for the substantial bias depending on the base composition. As a consequence, biomarkers that have been discovered by specific high-throughout technologies have to be carefully considered. Especially for validation of the platform, the selection of reasonable candidates is essential.

miFRame: analysis and visualization of miRNA sequencing data in neurological disorders

Background

While in the past decades nucleic acid analysis has been predominantly carried out using quantitative low- and high-throughput approaches such as qRT-PCR and microarray technology, next-generation sequencing (NGS) with its single base resolution is now frequently applied in DNA and RNA testing. Especially for small non-coding RNAs such as microRNAs there is a need for analysis and visualization tools that facilitate interpretation of the results also for clinicians.

Methods

We developed miFRame, which supports the analysis of human small RNA NGS data. Our tool carries out different data analyses for known as well as predicted novel mature microRNAs from known precursors and presents the results in a well interpretable manner. Analyses include among others expression analysis of precursors and mature miRNAs, detection of novel precursors and detection of potential iso-microRNAs. Aggregation of results from different users moreover allows for evaluation whether remarkable results, such as novel mature miRNAs, are indeed specific for the respective experimental set-up or are frequently detected across a broad range of experiments.

Results

We demonstrate the capabilities of miFRame, which is freely available at http://www.ccb.uni-saarland.de/miframe on two studies, circulating biomarker screening for Multiple Sclerosis (cohort includes clinically isolated syndrome, relapse remitting MS, matched controls) as well as Alzheimer Disease (cohort includes Alzheimer Disease, Mild Cognitive Impairment, matched controls). Here, our tool allowed for an improved biomarker discovery by identifying likely false positive marker candidates.

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-015-0594-x) contains supplementary material, which is available to authorized users.

Systematic permutation testing in GWAS pathway analyses: identification of genetic networks in dilated cardiomyopathy and ulcerative colitis

Background

Genome wide association studies (GWAS) are applied to identify genetic loci, which are associated with complex traits and human diseases. Analogous to the evolution of gene expression analyses, pathway analyses have emerged as important tools to uncover functional networks of genome-wide association data. Usually, pathway analyses combine statistical methods with a priori available biological knowledge. To determine significance thresholds for associated pathways, correction for multiple testing and over-representation permutation testing is applied.

Results

We systematically investigated the impact of three different permutation test approaches for over-representation analysis to detect false positive pathway candidates and evaluate them on genome-wide association data of Dilated Cardiomyopathy (DCM) and Ulcerative Colitis (UC). Our results provide evidence that the gold standard - permuting the case–control status – effectively improves specificity of GWAS pathway analysis. Although permutation of SNPs does not maintain linkage disequilibrium (LD), these permutations represent an alternative for GWAS data when case–control permutations are not possible. Gene permutations, however, did not add significantly to the specificity. Finally, we provide estimates on the required number of permutations for the investigated approaches.

Conclusions

To discover potential false positive functional pathway candidates and to support the results from standard statistical tests such as the Hypergeometric test, permutation tests of case control data should be carried out. The most reasonable alternative was case–control permutation, if this is not possible, SNP permutations may be carried out. Our study also demonstrates that significance values converge rapidly with an increasing number of permutations. By applying the described statistical framework we were able to discover axon guidance, focal adhesion and calcium signaling as important DCM-related pathways and Intestinal immune network for IgA production as most significant UC pathway.

Influence of the confounding factors age and sex on microRNA profiles from peripheral blood

BACKGROUND

MicroRNAs (miRNAs) measured from blood samples are promising minimally invasive biomarker candidates that have been extensively studied in several case-control studies. However, the influence of age and sex as confounding variables remains largely unknown.

METHODS

We systematically explored the impact of age and sex on miRNAs in a cohort of 109 physiologically unaffected individuals whose blood was characterized by microarray technology (stage 1). We also investigated an independent cohort from a different institution consisting of 58 physiologically unaffected individuals having a similar mean age but with a smaller age distribution. These samples were measured by use of high-throughput sequencing (stage 2).

RESULTS

We detected 318 miRNAs that were significantly correlated with age in stage 1 and, after adjustment for multiple testing of 35 miRNAs, remained statistically significant. Regarding sex, 144 miRNAs showed significant dysregulation. Here, no miRNA remained significant after adjustment for multiple testing. In the high-throughput datasets of stage 2, we generally observed a smaller number of significant associations, mainly as an effect of the smaller cohort size and age distribution. Nevertheless, we found 7 miRNAs that were correlated with age, of which 5 were concordant with stage 1.

CONCLUSIONS

The age distribution of individuals recruited for case-control studies needs to be carefully considered, whereas sex may be less confounding. To support the translation of miRNAs into clinical application, we offer a web-based application (http://www.ccb.uni-saarland.de/mirnacon) to test individual miRNAs or miRNA signatures for their likelihood of being influenced.

A blood based 12-miRNA signature of Alzheimer disease patients

Background

Alzheimer disease (AD) is the most common form of dementia but the identification of reliable, early and non-invasive biomarkers remains a major challenge. We present a novel miRNA-based signature for detecting AD from blood samples.

Results

We apply next-generation sequencing to miRNAs from blood samples of 48 AD patients and 22 unaffected controls, yielding a total of 140 unique mature miRNAs with significantly changed expression levels. Of these, 82 have higher and 58 have lower abundance in AD patient samples. We selected a panel of 12 miRNAs for an RT-qPCR analysis on a larger cohort of 202 samples, comprising not only AD patients and healthy controls but also patients with other CNS illnesses. These included mild cognitive impairment, which is assumed to represent a transitional period before the development of AD, as well as multiple sclerosis, Parkinson disease, major depression, bipolar disorder and schizophrenia. miRNA target enrichment analysis of the selected 12 miRNAs indicates an involvement of miRNAs in nervous system development, neuron projection, neuron projection development and neuron projection morphogenesis. Using this 12-miRNA signature, we differentiate between AD and controls with an accuracy of 93%, a specificity of 95% and a sensitivity of 92%. The differentiation of AD from other neurological diseases is possible with accuracies between 74% and 78%. The differentiation of the other CNS disorders from controls yields even higher accuracies.

Conclusions

The data indicate that deregulated miRNAs in blood might be used as biomarkers in the diagnosis of AD or other neurological diseases.

A genome-wide association study identifies 6p21 as novel risk locus for dilated cardiomyopathy

AIMS

Dilated cardiomyopathy (DCM) is one of the leading causes for cardiac transplantations and accounts for up to one-third of all heart failure cases. Since extrinsic and monogenic causes explain only a fraction of all cases, common genetic variants are suspected to contribute to the pathogenesis of DCM, its age of onset, and clinical progression. By a large-scale case-control genome-wide association study we aimed here to identify novel genetic risk loci for DCM.

METHODS AND RESULTS

Applying a three-staged study design, we analysed more than 4100 DCM cases and 7600 controls. We identified and successfully replicated multiple single nucleotide polymorphism on chromosome 6p21. In the combined analysis, the most significant association signal was obtained for rs9262636 (P = 4.90 × 10(-9)) located in HCG22, which could again be replicated in an independent cohort. Taking advantage of expression quantitative trait loci (eQTL) as molecular phenotypes, we identified rs9262636 as an eQTL for several closely located genes encoding class I and class II major histocompatibility complex heavy chain receptors.

CONCLUSION

The present study reveals a novel genetic susceptibility locus that clearly underlines the role of genetically driven, inflammatory processes in the pathogenesis of idiopathic DCM.

Protein kinase D2 controls cardiac valve formation in zebrafish by regulating histone deacetylase 5 activity

BACKGROUND

The molecular mechanisms that guide heart valve formation are not well understood. However, elucidation of the genetic basis of congenital heart disease is one of the prerequisites for the development of tissue-engineered heart valves.

METHODS AND RESULTS

We isolated here a mutation in zebrafish, bungee (bng(jh177)), which selectively perturbs valve formation in the embryonic heart by abrogating endocardial Notch signaling in cardiac cushions. We found by positional cloning that the bng phenotype is caused by a missense mutation (Y849N) in zebrafish protein kinase D2 (pkd2). The bng mutation selectively impairs PKD2 kinase activity and hence Histone deacetylase 5 phosphorylation, nuclear export, and inactivation. As a result, the expression of Histone deacetylase 5 target genes Krüppel-like factor 2a and 4a, transcription factors known to be pivotal for heart valve formation and to act upstream of Notch signaling, is severely downregulated in bungee (bng) mutant embryos. Accordingly, the expression of Notch target genes, such as Hey1, Hey2, and HeyL, is severely decreased in bng mutant embryos. Remarkably, downregulation of Histone deacetylase 5 activity in homozygous bng mutant embryos can rescue the mutant phenotype and reconstitutes notch1b expression in atrioventricular endocardial cells.

CONCLUSIONS

We demonstrate for the first time that proper heart valve formation critically depends on Protein kinase D2-Histone deacetylase 5-Krüppel-like factor signaling.

Extraventricular neurocytoma of the spinal cord in a dog

Central neurocytoma is a rare, prognostically favorable neuronal tumor of the human central nervous system, typically located intraventricularly near the foramen of Monro. Extraventricular cerebral neurocytomas and spinal tumors have also been reported. To date, however, neurocytomas have not been documented in domestic animal species. In this report, we describe a spinal cord tumor in a dog. The microscopic examination revealed tumor cells forming loosely packed clusters in some areas and palisades in other areas. In addition, they showed fine fibrillary neuropil-like areas of different sizes, sometimes resembling the "rosettes" of pineocytomas, as well as ependymoma-like perivascular pseudorosettes. The tumor cells had scant eosinophilic cytoplasm, with perinuclear halos, closely resembling the appearance of oligodendroglioma. Immunohistochemical staining showed expression of synaptophysin and neuron-specific enolase by tumor cells and pronounced in fibrillary areas. On the basis of histomorphology and immunohistochemical reactivity, the present tumor was diagnosed as extraventricular neurocytoma.

Headache associated with sexual activity: demography, clinical features, and comorbidity

OBJECTIVE

S: To provide data on the demography, clinical features, and comorbidity of headache associated with sexual activity (HSA).

METHODS

Between 1996 and 2001, 51 patients with the diagnosis of HSA were questioned using a structured interview.

RESULTS

The mean age at onset was 39.2 (+/-11.1) years. There was a clear male preponderance (2.9:1). The age at onset had two peaks, with a first peak between the 20th and 24th (n = 13) years of life and a second peak between the 35th and 44th (n = 20) years of life. Eleven patients had HSA type 1 (dull subtype), which gradually increased with increasing sexual excitement. The remaining (n = 40) had HSA type 2 (explosive subtype). The pain was predominantly bilateral (67%), and diffuse or occipital (76%). The quality was nearly equally distributed among dull, throbbing, and stabbing. HSA was not dependent on specific sexual habits and most often occurred during sexual activity with the usual partner (94%) and during masturbation (35%). There was a high comorbidity with migraine (25%), benign exertional headache (29%), and tension-type headache (45%). HSA types 1 and 2 did not significantly differ in demography, clinical features, or comorbidity, except for a higher probability of stopping the attack by breaking off sexual activity in HSA type 1. There were no cases with HSA type 3 (postural subtype).

CONCLUSION

Mean age at onset, a male preponderance, a predominantly bilateral and occipital pain, and a high comorbidity with other primary headaches are in concordance with case reports in the literature. The authors found two peaks for the age at onset, however. There was no clinical evidence proving subtypes 1 and 2 to be distinct disorders. HSA types 1 and 2 may be different manifestations of the same disease rather than distinct entities.

Cognitive processing in headache associated with sexual activity

Cognitive processing in headache associated with sexual Cognitive processing as measured by event-related potentials (ERP) in patients suffering from the explosive subtype of headache associated with sexual activity (HSA type 2) was investigated. Visual ERP were measured in 24 patients with HSA type 2 outside the headache period. The differences of the first and the second part of measurement were evaluated separately to determine the amount of cognitive habituation. Twenty-four sex- and age-matched healthy subjects and 24 patients with migraine without aura served as controls. A missing increase of P3 latency during the second part of the measurement was found in 79% of patients with HSA type 2 and in 75% with migraine, but only in 17% of the healthy controls (P < 0.001). The P3 amplitude was increased during the second part in 71% of patients with HSA type 2 and in 79% with migraine, but only in 33% of the healthy controls (P = 0.02). Mean P3 latency was decreased and mean P3 amplitude was increased during the second part of the measurement in HSA type 2 and in migraine but not in the healthy control group. Patients with HSA type 2 have a loss of cognitive habituation as measured by ERP. This specific information processing is very similar to that in migraine observed in previous studies.

Evidence of infectious diseases in harbour porpoises (Phocoena phocoena) hunted in the waters of Greenland and by-caught in the German North Sea and Baltic Sea

The pathological, microbiological and serological findings in harbour porpoises hunted in Greenlandic waters were compared with the findings in animals accidentally caught in fishing gear in the German North Sea and Baltic Sea. The body condition of the Greenlandic animals was good, whereas nine of 23 German harbour porpoises were moderately to markedly emaciated. Both groups were infested with parasites. In the Greenlandic animals parasitism of the aural peribullar cavity with Stenurus minor, of the liver and pancreas with Orthosplanchnus mironovi, of the lungs with Halocercus species and of the subcutaneous and mammary tissue with Crassicauda species was generally associated with a mild inflammatory response. No diseases associated with bacteria were identified in any of the Greenlandic harbour porpoises. In the porpoises from the German North Sea and Baltic Sea, parasites were present in the aural peribullar cavity (S minor), liver (Campula oblonga), first and second gastric compartment (Anisakis simplex) and in the lungs (Pseudalius inflexus and Torynurus convolutus). Moderate to marked pulmonary parasitism and suppurative pneumonia, not observed in the Greenlandic porpoises, were present in 11 and 10, respectively, of the 23 German porpoises. The suppurative pneumonia was attributed to bacterial infection with beta-haemolytic streptococci and Escherichia coil var haemolytica. Four Greenlandic and 10 German porpoises had positive porpoise morbillivirus-specific antibody titres suggesting that the virus was circulating in both populations.

Post-mortem findings in harbour porpoises (Phocoena phocoena) from the German North and Baltic Seas

Between 1991 and 1996, necropsies were performed on 445 harbour porpoises (Phocoena phocoena), in various states of preservation, stranded on German coasts or accidentally caught by German fishermen. The animals originated from the North and Baltic Seas, and 133 were considered suitable for histopathological, immunohistochemical and microbiological examination. Most of the lesions in these 133 porpoises were caused by parasites, in particular in the respiratory tract, two-thirds of the animals exhibiting pneumonia associated with the parasites. Pneumonia was considered to be the cause of death in 46% of the stranded subadult and adult animals. The findings gave no evidence of any epidemic due to bacterial or viral infection. Bacteriological examination suggested that pneumonia was mainly caused by secondary bacterial infection and not by parasitic infestation alone. Beta-haemolytic streptococci were considered to be the main infectious agents. Morbillivirus antigen was not detected immunohistochemically.

Distribution of Borna disease virus in the brain of rats infected with an obesity-inducing virus strain

Experimental infection of Lewis rats with Borna disease virus (BDV), a nonsegmented, single-stranded RNA virus, usually causes an immune-mediated biphasic neurobehavioral disorder. Such animals develop a persistent infection of the CNS with viral antigen expression in all brain regions and a disseminated nonpurulent meningoencephalitis. Interestingly, intracerebral infection of Lewis rats with a BDV-variant (BDV-ob) causes a rapid increase of body weight with the development of an obesity syndrome without obvious neurological signs. The obese phenotype is correlated with a characteristic distribution of inflammatory lesions and BDV-antigen in the rat brain. Infiltration with mononuclear immune cells and viral antigen expression are restricted to the septum, hippocampus, amygdala and ventromedian tuberal hypothalamus. Therefore, infection with the obesity-inducing BDV-ob results most likely in neuroendocrine dysregulations leading to the development of an obesity syndrome. This might be due to the restriction of viral antigen expression and inflammatory lesions to brain areas which are involved in the regulation of body weight and food intake. The BDV-induced obesity syndrome represents a model for the study of immune-mediated neuroendocrine disorders caused by viral infections of the CNS.

Thymic cysts in harbor porpoises (Phocoena phocoena) from the German North Sea, Baltic Sea, and waters of Greenland

Thymic cysts have not been previously reported in harbor porpoises (Phocoena phocoena). Two hundred forty stranded or "by-caught" harbor porpoises originating from the German North Sea and Baltic Sea and 14 animals from the waters of Greenland were necropsied. Thymuses of 78 porpoises of the North Sea and Baltic Sea were considered suitable for histopathologic examination based on the extent of postmortem autolysis. Immunohistochemistry using an anti-cytokeratin antibody was employed to demonstrate thymic epithelial structures in selected cases. Thymic macrocysts were rare and were only found in animals > or =7 years of age. Thymic microcysts, lined by a single cytokeratin-positive cell layer, were common in involuting thymuses, and the prevalence increased with advancing age. Thymic cysts might have arisen from degenerating Hassall's corpuscles or condensed epithelial reticulum. Thymuses were easily identified macroscopically in most adult healthy harbor porpoises, suggesting that physiological thymic involution proceeds slowly in this species.

Expression of major histocompatibility complex class II antigen in neoplastic cells of canine cutaneous histiocytoma

Forty five cases of canine cutaneous histiocytoma (CCH) were examined by immunohistology for expression and distribution of major histocompatibility complex (MHC) class II antigen in neoplastic cells. In addition, expression of lysozyme and calprotectin (leucocyte protein L1) in neoplastic cells was investigated. Furthermore, B and T lymphocytes were demonstrated by antibodies against the CD3 antigen, IgG, and IgM. Neoplastic cells showed two staining patterns for MHC class II antigen: focal juxtanuclear cytoplasmic staining and/or rim-like staining along the cell periphery. In 24 cases, a predominant or exclusive focal juxtanuclear cytoplasmic MHC class II antigen reaction in neoplastic cells, and the presence of few diffusely distributed infiltrating CD3 antigen-positive T lymphocytes were observed. Tumors with numerous neoplastic cells exhibiting staining for MHC class II antigen along the cell periphery (n = 21) showed increased inflammatory alterations, represented by disseminated and nodular infiltrations of mainly CD3 antigen-positive T cells. B cells, plasma cells, exudate macrophages, and neutrophils were rarely seen disseminated between neoplastic cells whereas their number increased within focal inflammatory infiltrates. The focal cytoplasmic reaction for MHC class II antigen in neoplastic cells might represent newly synthesized MHC class II molecules stored in vesicles, whereas staining of the cell periphery might occur due to accumulation of MHC class II molecules along the plasma membrane. The increasing expression of MHC class II molecules on the cell surface might be the decisive factor for onset and progression of tumor regression. However, the exact mechanism of priming and activation of T cells by neoplastic cells and the nature of the presented antigen are not yet known.

[Cochlear implant for non-deaf patients?]

BACKGROUND

Cochlear implants have proven to be the method of choice for postlingually deafened adults. The great success of this application requires discussion of the degree in which the indication for cochlear implantation should be expanded to include patients with residual hearing.

METHOD AND PATIENTS

Following an initial discussion of the term deafness, we present the preoperative and postoperative results in five patients with residual hearing. These patients achieve a certain degree of speech recognition with their well fitted hearing aids. However, their aided speech intelligibility did not exceed 30% with the standardized Freiburg monosyllabic word test at 70 dB. In each case the worse hearing ear was treated with a cochlear implant. Speech discrimination in silence and noise are compared with the results of a group of postlingually deafened cochlear implant patients.

RESULTS

The five patients are very satisfied with the cochlear implant and use the telephone to communicate with unknown partners. They score 100% in the standardized four-syllable number test above 55 dB and they document a loss of speech discrimination between 0 and 25% within the open-set monosyllabic word test. The mean increase of best monosyllable intelligibility by the cochlear implant over the hearing aids is 65%. Using the innsbruck sentence test the patients score 100% at 70 dB; with the Göttingen sentence test, the mean result is 75%. Their mean results in noise are also very good, 76% at 10 dBS/N and 57% at 5 dBS/N respectively. None of these patients use the hearing aid on the untreated, better hearing ear.

CONCLUSION

A multichannel cochlear implant lead to a significant improvement of speech comprehension in these patients with residual hearing. We can successfully implant patients with minimal benefit of their well fitted hearing aids. Our group is too small to be able to define general selection criteria. For the time being we use as an audiological indication a open-set monosyllabic word intelligibility of not more than 30% at 70 dB with well fitted hearing aids.

Molecular characterization of Borna disease virus from naturally infected animals and possible links to human disorders

In this review data are presented which indicate a high degree of genetic stability of BDV in his natural host, the horse. Despite this high degree of sequence conservation, variation in antigenicity was found, which did not influence the pathogenic properties of the virus. In addition, the correlation between BDV-seropositivity and a variety of psychiatric and neurological disorders in humans is discussed. In diagnostically unselected psychiatric patients we found a similar distribution of psychiatric disorders in BDV seropositives compared to seronegatives. Investigations of cerebrospinal fluid revealed cases of BDV encephalitis in BDV seropositive psychiatric and neurological patients. In contrast to others, we have found no evidence for the presence of BDV-RNA or BDV in human peripheral blood leucocytes.

Detection of a novel Borna disease virus-encoded 10 kDa protein in infected cells and tissues

Borna disease (BD) is a transmissible, progressive polioencephalomyelitis primarily of horses and sheep. The genomes of two cell-adapted strains of Borna disease virus (BDV), the aetiological agent of BD, have been cloned and sequenced. According to the structural characterization achieved so far, BDV contains a non-segmented negative-sense 8.9 kb single-stranded RNA genome. In this paper we report the expression, purification and intracellular tracing of a novel non-glycosylated BDV-specific protein with a molecular mass of approximately 10 kDa (BDV p10 protein). The successful isolation of the corresponding mRNA from infected cells, amplification of the genetic region by RT-PCR and its efficient expression as a glutathione S-transferase (GST) fusion protein demonstrated that antibodies specific for the BDV p10 protein are induced in infected animals. In addition, we have produced monospecific antisera against the GST-p10 fusion protein in rabbits. This monospecific antiserum recognized the BDV p10 protein in brain cells of naturally and experimentally infected animals as well as in persistently BDV-infected cells. Antibody-mediated affinity-chromatography using the anti-p10 serum could successfully be applied to purify a ca. 10 kDa antigen from infected animal cells to such an extent that glycosylation of this component could be ruled out.

Borna disease virus infection in animals and humans

The geographic distribution and host range of Borna disease (BD), a fatal neurologic disease of horses and sheep, are larger than previously thought. The etiologic agent, Borna disease virus (BDV), has been identified as an enveloped nonsegmented negative-strand RNA virus with unique properties of replication. Data indicate a high degree of genetic stability of BDV in its natural host, the horse. Studies in the Lewis rat have shown that BDV replication does not directly influence vital functions; rather, the disease is caused by a virus-induced T-cell mediated immune reaction. Because antibodies reactive with BDV have been found in the sera of patients with neuropsychiatric disorders, this review examines the possible link between BDV and such disorders. Seroepidemiologic and cerebrospinal fluid investigations of psychiatric patients suggest a causal role of BDV infection in human psychiatric disorders. In diagnostically unselected psychiatric patients, the distribution of psychiatric disorders was found to be similar in BDV seropositive and seronegative patients. In addition, BDV-seropositive neurologic patients became ill with lymphocytic meningoencephalitis. In contrast to others, we found no evidence is reported for BDV RNA, BDV antigens, or infectious B DV in peripheral blood cells of psychiatric patients.

Lumbar range of motion: reliability and validity of the inclinometer technique in the clinical measurement of trunk flexibility

STUDY DESIGN

This study examines the reliability and validity of measuring lumbar range of motion with an inclinometer.

OBJECTIVES

To find out whether a manual determination of the reference points for measuring lumbar range of motion is as reliable as radiologic determination for positioning the inclinometers, lumbar range of motion was determined in degrees by evaluating radiographs and by using the inclinometer technique of Loebl.

SUMMARY OF BACKGROUND DATA

Reliability and validity of the inclinometer technique as a clinical measurement of trunk flexibility were investigated. Fifty-four patients participated in the study.

METHODS

Lumbar range of motion measurements were taken with and without radiologic control of the T12 and S1 vertebrae as reference points for positioning of the inclinometers. An interrater correlation was done of the inclinometer techniques of a physician and a physiotherapist. Functional radiographs were investigated in a standing position. Lumbar range of motion measurements based on radiographs and those taken using the inclinometer alone were correlated to validate the inclinometer technique.

RESULTS

Lumbar range of motion measurements taken with and without radiologic determination showed a very close correlation (r = 0.93; P < 0.001). Flexion alone also demonstrated a close correlation (r = 0.95; P < 0.001), whereas extension showed a somewhat smaller correlation (r = 0.82; P < 0.001). Total lumbar range of motion (r = 0.94; P < 0.001) and flexion (r = 0.88; P < 0.001) were closely related, as indicated by the interrater correlation, whereas extension (r = 0.42; P < 0.05) showed a lesser correlation. Correlation of the measurements taken radiographically and by inclinometer demonstrated an almost linear correlation for measurements of the total lumbar range of motion (r = 0.97; P < 0.001) and flexion (r = 0.98; P < 0.001), whereas extension (r = 0.75; P < 0.001) did not correlate as well.

CONCLUSIONS

The noninvasive inclinometer technique proved to be highly reliable and valid, but the measurement technique for extension needs further refinement.

Lumbar range of motion: influence of time of day and individual factors on measurements

STUDY DESIGN

Influence of time of day and individual factors on the measurements of the lumbar range of motion was investigated.

OBJECTIVES

To investigate factors that influence lumbar range of motion.

SUMMARY OF BACKGROUND DATA

Twenty-nine patients with chronic low back pain participated in the study.

METHODS

The lumbar range of motion was measured by inclinometer technique, Schober sign, modified-Schober sign, and fingertip-to-floor method in the morning, at noon, and in the afternoon. The lumbar range of motion was correlated with patients' gender, age, and body weight.

RESULTS

Total lumbar range of motion measured by the inclinometer technique and the modified-Schober sign increased significantly throughout the day from morning to afternoon. Extension lumbar range of motion was shown to be independent of the time of measurement. There were no significant correlations between lumbar range of motion and gender, age, and body weight of the patients.

CONCLUSION

For the reliability of a measurement, it is important to investigate lumbar range of motion at the same time of day.

[Intraosseous epidermoid cysts of the toe phalanx in dogs]

Out of 1057 amputated canine toes with tumours, tumour-like or other lesions, 17 cases were histopathologically diagnosed as epidermoid cysts of the terminal phalanx (EP). They were accompanied by osteolysis, reactive bone formation and chronic inflammation of phalanx 3. Extension of reactive changes to the phalangeal joint and phalanx 2 was less frequent. Various breeds were involved. There was no breed predisposition. The average age was 10.8 years; the male-female ratio 2.4:1. Nine EP were located on the forelimbs, 4 on the hindlimbs. In 4 cases location was unknown. Toes 4 and 5 were most frequently affected. A traumatic origin is suspected.

Borna disease virus-specific T cells protect against or cause immunopathological Borna disease

In this report we show that passive immunization of Lewis rats with viable CD4+, Borna disease virus (BDV)-specific T cells before infection with BDV resulted in protection against BD, whereas inoculation of these T cells after BDV infection induced clinical disease with more rapid onset than seen in BDV control animals. The protective as well as encephalitogenic effector functions of BDV-specific CD4+ T cells were mediated only by viable BDV-specific T cells. The protective situation was obtained by passive transfer of BDV-specific T cells into animals inoculated later with virus, whereas the immunopathological situation was observed when virus-specific T cells developed normally or after adoptive transfer, and appeared on the scene after considerable virus replication in the brain.

Borna disease, a possible hazard for man?

Evidence is presented that Borna disease (BD) virus, which is known to cause encephalopathy in horses, sheep, and a broad range of experimental animals, or a related agent, can infect man and may induce mental disorders. BD virus-specific antibodies could be demonstrated in 4-7% of sera (depending on origin) from more than 5000 psychiatric or neurological patients from Germany, U.S.A. and Japan. Antibodies from seropositive patients reacted with a BD virus-specific protein translated by RNAs which were transcribed from a cDNA clone obtained from BD virus-infected tissues. When the cerebrospinal fluid from three seropositive patients was inoculated into rabbits or rabbit embryonic brain cell cultures, evidence was obtained that suggests the presence of BD virus or a related agent.

Molecular and immunopathological studies of borna disease virus infection in rats

Borna disease virus is an agent distinct from all known viruses. Pathogenesis of its infection is also unique. This review highlights several aspects of the biology of this viral infection and the preliminary characterization of the agent. BDV can be used to answer important questions in neurobiology. These include neuroinvasiveness and neurotropism of viral agents, CD4+ T cell-mediated immunopathology and tolerance in newborn animals to a persistent viral infection in the CNS and behavioral diseases and eating disorders induced by neurotropic viruses. This review is dedicated to Prof. Dr. Rott on occasion of his 65th birthday in recognition of his immense contributions to studies on Borna disease and also for his success focusing the attention of the scientific community to this still evolving unique viral disease.