International practice of corticosteroid replacement therapy in congenital adrenal hyperplasia - data from the I-CAH registry.

OBJECTIVE: Despite published guidelines no unified approach to hormone replacement in congenital adrenal hyperplasia (CAH) exists. We aimed to explore geographical and temporal variations in the treatment with glucocorticoids and mineralocorticoids in CAH. DESIGN: This retrospective multi-center study, including 31 centers (16 countries), analyzed data from the International-CAH Registry. METHODS: Data was collected from 461 patients aged 0-18 years with classic 21-hydroxylase deficiency (54.9% females) under follow-up between 1982 - 2018. Type, dose and timing of glucocorticoid and mineralocorticoid replacement was analyzed from 4174 patient visits. RESULTS: The most frequently used glucocorticoid was hydrocortisone (87.6%). Overall, there were significant differences between age groups with regards to daily hydrocortisone-equivalent dose for body surface, with the lowest dose (median with interquartile range) of 12.0 (10.0 - 14.5) mg/ m2/ day at age 1 - 8 years and the highest dose of 14.0 (11.6 - 17.4) mg/ m2/ day at age 12-18 years. Glucocorticoid doses decreased after 2010 in patients 0-8 years (p<0.001) and remained unchanged in patients aged 8-18 years. Fludrocortisone was used in 92% of patients, with relative doses decreasing with age. A wide variation was observed among countries with regards to all aspects of steroid hormone replacement. CONCLUSIONS: Data from the I-CAH Registry suggests international variations in hormone replacement therapy, with a tendency to treatment with high doses in children

High Frequency of Copy Number Variations and Sequence Variants at CYP21A2 Locus: Implication for the Genetic Diagnosis of 21-Hydroxylase Deficiency

BACKGROUND: The systematic study of the human genome indicates that the inter-individual variability is greater than expected and it is not only related to sequence polymorphisms but also to gene copy number variants (CNVs). Congenital Adrenal Hyperplasia due to 21-hydroxylase deficiency (21OHD) is the most common autosomal recessive disorder with a carrier frequency of 1:25 to 1:10. The gene that encodes 21-hydroxylase enzyme, CYP21A2, is considered to be one of the most polymorphic human genes. Copy number variations, such as deletions, which are severe mutations common in 21OHD patients, or gene duplications, which have been reported as rare events, have also been described. The correct characterization of 21OHD alleles is important for disease carrier detection and genetic counselling METHODOLOGY AND FINDINGS: CYP21A2 genotyping by sequencing has been performed in a random sample of the Spanish population, where 144 individuals recruited from university students and employees of the hospital were studied. The frequency of CYP21A2 mutated alleles in our sample was 15.3% (77.3% were mild mutations, 9% were severe mutations and 13.6% were novel variants). Gene dosage assessment was also performed when CYP21A2 gene duplication was suspected. This analysis showed that 7% of individuals bore a chromosome with a duplicated CYP21A2 gene, where one of the copies was mutated. CONCLUSIONS: As far as we know, the present study has shown the highest frequency of 21OHD carriers reported by a genotyping analysis. In addition, a high frequency of alleles with CYP21A2 duplications, which could be misinterpreted as 21OHD alleles, was found. Moreover, a high frequency of novel genetic variations with an unknown effect on 21-hydroxylase activity was also found. The high frequency of gene duplications, as well as novel variations, should be considered since they have an important involvement in carrier testing and genetic counseling

Structure-Based Analysis of Five Novel Disease-Causing Mutations in 21-Hydroxylase-Deficient Patients

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is the most frequent inborn error of metabolism, and accounts for 90–95% of CAH cases. The affected enzyme, P450C21, is encoded by the CYP21A2 gene, located together with a 98% nucleotide sequence identity CYP21A1P pseudogene, on chromosome 6p21.3. Even though most patients carry CYP21A1P-derived mutations, an increasing number of novel and rare mutations in disease causing alleles were found in the last years. In the present work, we describe five CYP21A2 novel mutations, p.R132C, p.149C, p.M283V, p.E431K and a frameshift g.2511_2512delGG, in four non-classical and one salt wasting patients from Argentina. All novel point mutations are located in CYP21 protein residues that are conserved throughout mammalian species, and none of them were found in control individuals. The putative pathogenic mechanisms of the novel variants were analyzed in silico. A three-dimensional CYP21 structure was generated by homology modeling and the protein design algorithm FoldX was used to calculate changes in stability of CYP21A2 protein. Our analysis revealed changes in protein stability or in the surface charge of the mutant enzymes, which could be related to the clinical manifestation found in patients

Iron Behaving Badly: Inappropriate Iron Chelation as a Major Contributor to the Aetiology of Vascular and Other Progressive Inflammatory and Degenerative Diseases

The production of peroxide and superoxide is an inevitable consequence of aerobic metabolism, and while these particular "reactive oxygen species" (ROSs) can exhibit a number of biological effects, they are not of themselves excessively reactive and thus they are not especially damaging at physiological concentrations. However, their reactions with poorly liganded iron species can lead to the catalytic production of the very reactive and dangerous hydroxyl radical, which is exceptionally damaging, and a major cause of chronic inflammation. We review the considerable and wide-ranging evidence for the involvement of this combination of (su)peroxide and poorly liganded iron in a large number of physiological and indeed pathological processes and inflammatory disorders, especially those involving the progressive degradation of cellular and organismal performance. These diseases share a great many similarities and thus might be considered to have a common cause (i.e. iron-catalysed free radical and especially hydroxyl radical generation). The studies reviewed include those focused on a series of cardiovascular, metabolic and neurological diseases, where iron can be found at the sites of plaques and lesions, as well as studies showing the significance of iron to aging and longevity. The effective chelation of iron by natural or synthetic ligands is thus of major physiological (and potentially therapeutic) importance. As systems properties, we need to recognise that physiological observables have multiple molecular causes, and studying them in isolation leads to inconsistent patterns of apparent causality when it is the simultaneous combination of multiple factors that is responsible. This explains, for instance, the decidedly mixed effects of antioxidants that have been observed, etc...Comment: 159 pages, including 9 Figs and 2184 reference

Is implicit motor learning preserved after stroke? A systematic review with meta-analysis

© 2016 Kal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Many stroke patients experience difficulty with performing dual-tasks. A promising intervention to target this issue is implicit motor learning, as it should enhance patients' automaticity of movement. Yet, although it is often thought that implicit motor learning is preserved poststroke, evidence for this claim has not been systematically analysed yet. Therefore, we systematically reviewed whether implicit motor learning is preserved post-stroke, and whether patients benefit more from implicit than from explicit motor learning. We comprehensively searched conventional (MEDLINE, Cochrane, Embase, PEDro, PsycINFO) and grey literature databases (BIOSIS, Web of Science, OpenGrey, British Library, trial registries) for relevant reports. Two independent reviewers screened reports, extracted data, and performed a risk of bias assessment. Overall, we included 20 out of the 2177 identified reports that allow for a succinct evaluation of implicit motor learning. Of these, only 1 study investigated learning on a relatively complex, whole-body (balance board) task. All 19 other studies concerned variants of the serial-reaction time paradigm, with most of these focusing on learning with the unaffected hand (N = 13) rather than the affected hand or both hands (both: N = 4). Four of the 20 studies compared explicit and implicit motor learning post-stroke. Meta-analyses suggest that patients with stroke can learn implicitly with their unaffected side (mean difference (MD) = 69 ms, 95% CI[45.1, 92.9], p < .00001), but not with their affected side (standardized MD = -.11, 95% CI[-.45, .25], p = .56). Finally, implicit motor learning seemed equally effective as explicit motor learning post-stroke (SMD = -.54, 95% CI[-1.37, .29], p = .20). However, overall, the high risk of bias, small samples, and limited clinical relevance of most studies make it impossible to draw reliable conclusions regarding the effect of implicit motor learning strategies post-stroke. High quality studies with larger samples are warranted to test implicit motor learning in clinically relevant contexts

Neonatal screening for congenital adrenal hyperplasia

Het doel van deze studie was te onderzoeken of neonatale screening op adrenogenitaal syndroom (AGS) in Nederland haalbaar was en of dit kon worden ingepast in de bestaande screeningsprogramma's voor congenitale hypothyreoidie (CHT) en phenylketonurie (PKU), en verder om de prevalentie van AGS en de sensitiviteit en specificiteit van de gebruikte methode vast te stellen. Op 1 januari 1998 werd met financiele ondersteuning van ZonMw een tweejarig pilotonderzoek gestart in twee van de vijf screeningsregio's, waarbij iets minder dan de helft van alle pasgeborenen gescreend werden. De concentratie van het steroid 17alpha-hydroxyprogesteron werd gemeten in de monsters hielprikbloed, afgenomen voor de CHT/PKU screening. De afkapgrenzen waren in 1998 gebaseerd op het geboortegewicht, en vanaf 1999 op de zwangerschapsduur. Om fout-negatieve resultaten op te sporen en om de prevalentie van AGS vast te stellen in de screeningsregio en de controle regio werden alle kinderartsen verzocht om ziektegevallen te melden aan het Nederlands Signaleringscentrum Kindergeneeskunde (NSCK). De gebruikte meetmethode kende een binnen- en tussenmeetsessiespreiding van ca. 10 %. De prevalentie in de screeningsregio (221.418 pasgeborenen, 18 patienten; 9F,9M) was 1:12301 en in de controle regio (281.166 pasgeborenen, 25 patienten:12F,13M) 1:11247. De sensitiviteit was 100%, specificiteit 99.9% en positief voorspellende waarde 6.2%. Drie van de 9 meisjes en alle jongens waren klinisch niet verdacht. Alle AGS-patienten in de screeningsregio konden worden behandeld voordat de zoutcrisis intrad (natrium:133.6 plus of min 3.2 mmol/l serum) terwijl in de controle regio de meeste patienten ernstige hyponatrienemie vertoonden (natrium: 119.9 plus of min 10.5 mmol/l serum). Ook de opnameduur in het ziekenhuis was voor jongens in de screeningsregio gemiddeld 6 dagen korter. Op basis van deze gunstige resultaten van het pilotonderzoek werd door het Ministerie van VWS besloten om de proefscreening uit te breiden tot het gehele land gedurende 2 jaar, d.w.z. 2000 en 2001. Door aanloopproblemen met de financiering via het College van Zorgverzekeringen kon deze uitbreiding echter pas per 1 juli 2000 worden geeffectueerd. Nadat ook deze periode succesvol was afgesloten heeft de Minister van VWS besloten om de screening op AGS per 1 januari 2002 in het reguliere neonatale screeningprogramma op te nemen.Objectives: To evaluate the feasibility of newborn screening on congenital adrenal hyperplasia (CAH) in the Netherlands and possibilities for incorporation into the existing screening programme on congenital hyperplasia (CH) and phenylketonuria (PKU). To determine the sensitivity, specificity and prevalence of CAH. Methods: A 24 year pilot screening programme started on 1 January 1998 in 2 out of the 5 regions (45% of a total 200,000 newborns per year). With AutoDelfia,17alpha-OHP was measured in dried blood spots in the same heelstick sample as for CH/PKU-screening taken on day 4-7 after birth (day 0). Cut-off levels in 1998 were primarily based on birth weight and from 1 January 1999 on gestational age; the minimum cut-off level in 1998 was 60 nmol/l serum and from 1 January 1999, 80 nmol/l serum. All newly diagnosed CAH patients were reported to the Dutch Paediatric Surveillance Unit to detect false negatives and to determine the prevalence in the region with and without screening. Results: Intra- and interassay variance with the AutoDelfia method was (221,418 newborns, 18 patients: 9F,9M) and without screening (281,166 newborns, 25 patients:12F,13M) was 1:12,301 and 1:11,247, respectively. Sensitivity was 100%, specificity 99.9% and positive predictive value 6.2%. Three out of the 9 females and all males with CAH in the screening region were clinically not suspected. All CAH patients in the region with screening were treated before severe salt wasting was apparent (sodium:133.6 plus or minus 3.2 mmol/l serum; mean plus or minus SD), while in the region without screening most patients had severe hyponatraemia (sodium: 119.9 plus or minus 10.5 mmol/l serum; mean plus or minus SD). The mean period of hospitalization for male patients detected through screening was 6 days less than for male patients in the region without screening. Conclusion: Screening on CAH in the Netherlands is effective and can be incorporated into the existing screening programme for CH/PKU.IG

Neonatal screening for congenital adrenal hyperplasia

Objectives: To evaluate the feasibility of newborn screening on congenital adrenal hyperplasia (CAH) in the Netherlands and possibilities for incorporation into the existing screening programme on congenital hyperplasia (CH) and phenylketonuria (PKU). To determine the sensitivity, specificity and prevalence of CAH. Methods: A 24 year pilot screening programme started on 1 January 1998 in 2 out of the 5 regions (45% of a total 200,000 newborns per year). With AutoDelfia,17alpha-OHP was measured in dried blood spots in the same heelstick sample as for CH/PKU-screening taken on day 4-7 after birth (day 0). Cut-off levels in 1998 were primarily based on birth weight and from 1 January 1999 on gestational age; the minimum cut-off level in 1998 was 60 nmol/l serum and from 1 January 1999, 80 nmol/l serum. All newly diagnosed CAH patients were reported to the Dutch Paediatric Surveillance Unit to detect false negatives and to determine the prevalence in the region with and without screening. Results: Intra- and interassay variance with the AutoDelfia method was (221,418 newborns, 18 patients: 9F,9M) and without screening (281,166 newborns, 25 patients:12F,13M) was 1:12,301 and 1:11,247, respectively. Sensitivity was 100%, specificity 99.9% and positive predictive value 6.2%. Three out of the 9 females and all males with CAH in the screening region were clinically not suspected. All CAH patients in the region with screening were treated before severe salt wasting was apparent (sodium:133.6 plus or minus 3.2 mmol/l serum; mean plus or minus SD), while in the region without screening most patients had severe hyponatraemia (sodium: 119.9 plus or minus 10.5 mmol/l serum; mean plus or minus SD). The mean period of hospitalization for male patients detected through screening was 6 days less than for male patients in the region without screening. Conclusion: Screening on CAH in the Netherlands is effective and can be incorporated into the existing screening programme for CH/PKU.Het doel van deze studie was te onderzoeken of neonatale screening op adrenogenitaal syndroom (AGS) in Nederland haalbaar was en of dit kon worden ingepast in de bestaande screeningsprogramma's voor congenitale hypothyreoidie (CHT) en phenylketonurie (PKU), en verder om de prevalentie van AGS en de sensitiviteit en specificiteit van de gebruikte methode vast te stellen. Op 1 januari 1998 werd met financiele ondersteuning van ZonMw een tweejarig pilotonderzoek gestart in twee van de vijf screeningsregio's, waarbij iets minder dan de helft van alle pasgeborenen gescreend werden. De concentratie van het steroid 17alpha-hydroxyprogesteron werd gemeten in de monsters hielprikbloed, afgenomen voor de CHT/PKU screening. De afkapgrenzen waren in 1998 gebaseerd op het geboortegewicht, en vanaf 1999 op de zwangerschapsduur. Om fout-negatieve resultaten op te sporen en om de prevalentie van AGS vast te stellen in de screeningsregio en de controle regio werden alle kinderartsen verzocht om ziektegevallen te melden aan het Nederlands Signaleringscentrum Kindergeneeskunde (NSCK). De gebruikte meetmethode kende een binnen- en tussenmeetsessiespreiding van ca. 10 %. De prevalentie in de screeningsregio (221.418 pasgeborenen, 18 patienten; 9F,9M) was 1:12301 en in de controle regio (281.166 pasgeborenen, 25 patienten:12F,13M) 1:11247. De sensitiviteit was 100%, specificiteit 99.9% en positief voorspellende waarde 6.2%. Drie van de 9 meisjes en alle jongens waren klinisch niet verdacht. Alle AGS-patienten in de screeningsregio konden worden behandeld voordat de zoutcrisis intrad (natrium:133.6 plus of min 3.2 mmol/l serum) terwijl in de controle regio de meeste patienten ernstige hyponatrienemie vertoonden (natrium: 119.9 plus of min 10.5 mmol/l serum). Ook de opnameduur in het ziekenhuis was voor jongens in de screeningsregio gemiddeld 6 dagen korter. Op basis van deze gunstige resultaten van het pilotonderzoek werd door het Ministerie van VWS besloten om de proefscreening uit te breiden tot het gehele land gedurende 2 jaar, d.w.z. 2000 en 2001. Door aanloopproblemen met de financiering via het College van Zorgverzekeringen kon deze uitbreiding echter pas per 1 juli 2000 worden geeffectueerd. Nadat ook deze periode succesvol was afgesloten heeft de Minister van VWS besloten om de screening op AGS per 1 januari 2002 in het reguliere neonatale screeningprogramma op te nemen