Pivotal role of BCL11B in the immune, hematopoietic and nervous systems: a review of the BCL11B-associated phenotypes from the genetic perspective.

The transcription factor BCL11B plays an essential role in the development of central nervous system and T cell differentiation by regulating the expression of numerous genes involved in several pathways. Monoallelic defects in the BCL11B gene leading to loss-of-function are associated with a wide spectrum of phenotypes, including neurological disorders with or without immunological features and susceptibility to hematological malignancies. From the genetic point of view, the landscape of BCL11B mutations reported so far does not fully explain the genotype-phenotype correlation. In this review, we sought to compile the phenotypic and genotypic variables associated with previously reported mutations in this gene in order to provide a better understanding of the consequences of deleterious variants. We also highlight the importance of a careful evaluation of the mutation type, its location and the pattern of inheritance of the variants in order to assign the most accurate pathogenicity and actionability of the genetic findings.

Novel frameshift variants expand the map of the genetic defects in IRF2BP2.

Background: At present, the knowledge about disease-causing mutations in IRF2BP2 is very limited because only a few patients affected by this condition have been reported. As previous studies have described, the haploinsufficiency of this interferon transcriptional corepressors leads to the development of CVID. Very recently, a more accurate phenotype produced by truncating variants in this gene has been defined, manifesting CVID with gastrointestinal inflammatory symptoms and autoimmune manifestations. Methods: We analyzed 5 index cases with suspected primary immunodeficiency by high throughput sequencing. They were submitted for a genetic test with a panel of genes associated with immune system diseases, including IRF2BP2. The screening of SNVs, indels and CNVs fulfilling the criteria with very low allelic frequency and high protein impact, revealed five novel variants in IRF2BP2. In addition, we isolated both wild-type and mutated allele of the cDNA from one of the families. Results: In this study, we report five novel loss-of-function (LoF) mutations in IRF2BP2 that likely cause primary immunodeficiency, with CVID as more frequent phenotype, variable expression of inflammatory gastrointestinal features, and one patient with predisposition of viral infection. All identified variants were frameshift changes, and one of them was a large deletion located on chromosome 1q42, which includes the whole sequence of IRF2BP2, among other genes. Both de novo and dominant modes of inheritance were observed in the families here presented, as well as incomplete penetrance. Conclusions: We describe novel variants in a delimited low-complex region, which may be considered a hotspot in IRF2BP2. Moreover, this is the first time that a large CNV in IRF2BP2 has been reported to cause CVID. The distinct mechanisms than LoF in IRF2BP2 could cause different phenotype compared with the mainly described. Further investigations are necessary to comprehend the regulatory mechanisms of IRF2BP2, which could be under variable expression of the disease.

Incidence, Management Experience and Characteristics of Patients with Giardiasis and Common Variable Immunodeficiency.

Common variable immunodeficiency (CVID) is an antibody immunodeficiency with a wide variety of clinical and immunological manifestations, and whose genetic cause is found in about 25% of diagnosed cases. Giardia lamblia is one of the main causes of gastrointestinal infections in CVID. 5-Nitroimidazoles are the most used first-line treatment, but nitroimidazole-refractory giardiasis is increasing. Nevertheless, only a few cases of refractory giardiasis in CVID have been reported. This study aimed to determine the incidence of Giardia infection in our CVID cohort, shows our management experience and describes patients' phenotypic features. Clinical data collection, immunological, immunogenetics and microbiology assays were performed, and previous cases of giardiasis in CVID were reviewed. The incidence of symptomatic giardiasis was 12.9%. The main immunological features were undetectable or decreased IgA levels and reduced switched memory B cells. A probable PTEN pathogenic variant was detected in one. Three patients responded to metronidazole but suffered reinfections, and one was a refractory giardiasis eradicated with innovative quinacrine plus paromomycin combination. This work could contribute to the decision-making and therapeutic management of future patients with CVID and giardiasis, highlighting the importance of the early detection and treatment of infections in patients with CVID to ensure a good quality of life.

Mapping the genetic features of T-ALL cases through simplified NGS approach.

BACKGROUND: Despite the irruption of massive sequencing technologies in clinical routine, the genetic diagnosis of T-cell acute lymphoblastic leukemia (T-ALL) continues to be based on traditional techniques. The integration of old and new technologies with diagnostic and prognostic purposes represents a major challenge. METHODS: A High-Throughput Sequencing (HTS) approach was applied to analyze the genetic landscape of two patients diagnosed with T-ALL and one early T cell precursor acute leukemia. Orthogonal standard techniques were used to confirm the findings of NGS analysis. RESULTS: By using a single test, a complete genetic map including 2 previously unreported missense mutations in BCL11B gene are reported. Cooperating oncogenic lesions including CDKN2A/B deletions, SIL-TAL1 rearrangement and FLT3 amplification were also captured by using a single test. CONCLUSIONS: HTS is a useful approach that allows simultaneously analyzing mutations, CNVs and the clonal repertoire in T-ALL patients. This approach may simplify the genetic assessment of ALL.

New Insights into Renal Failure in a Cohort of 317 Patients with Autosomal Dominant Forms of Alport Syndrome: Report of Two Novel Heterozygous Mutations in COL4A3.

Alport syndrome (AS) is a clinically and genetically heterogeneous disorder with a wide phenotypic spectrum, onset, and progression. X-linked AS (XLAS) and autosomal recessive AS (ARAS) are severe conditions, whereas the severity of autosomal dominant AS (ADAS) may vary from benign familial hematuria to progressive renal disease with extra-renal manifestations. In this study, we collated information from the literature and analyzed a cohort of 317 patients with ADAS carrying heterozygous disease-causing mutations in COL4A3/4 including four patients from two unrelated families who carried two novel variants in COL4A3. Regarding the age of onset of the disease, 80% of patients presented urinalysis alterations (microhematuria, hematuria, and/or proteinuria) before the age of 40 years. The cumulative probability of suffering adverse renal events was mainly observed between 30 and 70 years, without statistical differences between COL4A3 and COL4A4. We observed statistically significant differences between the sexes in the age of developing ESKD in cases affected by mutations in COL4A3/4 (p value = 0.0097), suggesting that males begin experiencing earlier deterioration of renal function than women. This study supports the importance of follow-up in young patients who harbor pathogenic mutations in COL4A3/4. We update the knowledge of ADAS, highlighting differences in the progression of the disease between males and females.

Common Variable Immunodeficiency Associated with a De Novo IKZF1 Variant and a Low Humoral Immune Response to the SARS-CoV-2 Vaccine.

BACKGROUND AND AIMS: Common variable immunodeficiency (CVID) comprises a group of diseases with heterogeneous clinical and immunological manifestations. Several mutations have been identified in genes encoding proteins essential for immune function. Our aim was to phenotypically and genotypically characterize a patient diagnosed with CVID and study his response to the SARS-CoV-2 vaccine. METHODS: We performed a next-generation sequencing analysis, a CMIA, and an ELISA to analyze the humoral and cellular response to the SARS-CoV-2 vaccine, respectively. We also employed flow cytometry and immunoturbidimetry to assess the patient's global immune status. RESULTS: We found a low humoral but positive cellular response to the SARS-CoV-2 vaccine. NGS screening revealed a transition from guanine to adenine at position c.485 of the IKZF1 gene in heterozygosity, giving rise to the R162Q variant, which was not present in his parents. CONCLUSIONS: The R162Q variant of the IKZF1 gene has been associated with CVID type 13, but always with an autosomal dominant inheritance with high penetrance. Therefore, we present for the first time a case of CVID associated with a de novo heterozygous R162Q variant in the IKZF1 gene in a patient with a low humoral immune response to the complete COVID-19 vaccination program.

Whole Exome Sequencing Provides the Correct Diagnosis in a Case of Osteopathia Striata with Cranial Sclerosis: Case Report of a Novel Frameshift Mutation in AMER1.

The diagnosis of rare diseases with multisystem manifestations can constitute a difficult process that delays the determination of the underlying cause. Whole exome sequencing (WES) provides a suitable option to examine multiple target genes associated with several disorders that display common features. In this study, we report the case of a female patient suspected of having Sotos syndrome. Screening for the initially selected genes, considering Sotos syndrome and Sotos-like disorders, did not identify any pathogenic variants that could explain the phenotype. The extended analysis, which considered all genes in the exome associated with features consistent with those shown by the studied patient, revealed a novel frameshift variant in the AMER1 gene, responsible for osteopathia striata with cranial sclerosis. WES analysis and an updated revision of previously reported disease-causing mutations, proved useful to reach an accurate diagnosis and guide further examination to identify critical abnormalities.

Clinical exome sequencing: results from 2819 samples reflecting 1000 families.

We report our results of 1000 diagnostic WES cases based on 2819 sequenced samples from 54 countries with a wide phenotypic spectrum. Clinical information given by the requesting physicians was translated to HPO terms. WES processes were performed according to standardized settings. We identified the underlying pathogenic or likely pathogenic variants in 307 families (30.7%). In further 253 families (25.3%) a variant of unknown significance, possibly explaining the clinical symptoms of the index patient was identified. WES enabled timely diagnosing of genetic diseases, validation of causality of specific genetic disorders of PTPN23, KCTD3, SCN3A, PPOX, FRMPD4, and SCN1B, and setting dual diagnoses by detecting two causative variants in distinct genes in the same patient. We observed a better diagnostic yield in consanguineous families, in severe and in syndromic phenotypes. Our results suggest that WES has a better yield in patients that present with several symptoms, rather than an isolated abnormality. We also validate the clinical benefit of WES as an effective diagnostic tool, particularly in nonspecific or heterogeneous phenotypes. We recommend WES as a first-line diagnostic in all cases without a clear differential diagnosis, to facilitate personal medical care.

Influência das qualificações académicas e percurso curricular de comportamento violento / Influencia de las calificaciones académicas e itinerario curricular sobre conductas violentas / Influence of ratings and itinerary curriculum aggression and victimization behaviors

Esta pesquisa tem como objetivo analisar e estabelecer a incidência de qualificações, escolha de percursos curriculares e local de residência sobre comportamento violento e vitimização entre adolescentes de 13-17 anos de Granada (Espanha). A participação de um total de 2.273 adolescentes permitiu o registro e avaliação das variáveis ​​Acadêmicas, Família, Gênero, vitimização (Escala de Vitimização na Escola) e Comportamento Violento (medido com a Escala de Conduta Violenta na Escola). Os resultados mostraram que os adolescentes com qualificações mais baixas, que vivem em abrigos e que no itinerário curricular pretendiam inscrever-se na formação profissional ou inserir-se no mercado de trabalho apresentaram comportamentos mais agressivos e de vitimização do que os alunos com melhores notas médias (bons e excelentes), que procuravam continuar estudando no Ensino Superior e que residiam na casa da família.(AU)

En este trabajo de investigación se tiene como objetivo analizar y establecer la incidencia que tienen las calificaciones, elección de itinerarios curriculares y lugar de residencia sobre conductas violentas y de victimización en adolescentes de 13 a 17 años de Granada (España). La participación de un total de 2.273 adolescentes permitió el registro y evaluación de las variables Académicas, Residencia, Género, Victimización (Escala de Victimización en la Escuela) y Conducta Violenta (medida con la Escala de Conducta Violenta en la Escuela). Los resultados mostraron que los adolescentes con peores calificaciones, que vivían en régimen de acogimiento residencial y que como itinerario curricular pretendían matricularse en Formación Profesional o insertarse en el Mercado Laboral presentaban comportamientos más agresivos y de victimización que estudiantes con mejores notas medias (notable y sobresaliente), que pretendían seguir estudiando la opción de Bachillerato y que residían en el domicilio familiar.(AU)

This research work aims to analyze and establish the incidence who have the qualifications, election of curricular pathways and residence of violent behaviors and victimization in adolescents 13 to 17 years of Granada (Spain). The participation of a total of 2,273 adolescents allowed the recording and evaluation of variables Academic, Family, Gender, Victimization Scale (Victimization at School) and violent conduct (measured with the Scale of violent conduct in the School). Results showed that adolescents with lower qualifications, living in residential care and as curricular itinerary intended to enroll in vocational training or inserted into the job market showed more aggressive and victimization behaviors students with better average marks ( good and excellent) intended to continue studying the option of high school and residing in the family home .(AU)

Influência das qualificações académicas e percurso curricular de comportamento violento / Influencia de las calificaciones académicas e itinerario curricular sobre conductas violentas / Influence of ratings and itinerary curriculum aggression and victimization behaviors

Esta pesquisa tem como objetivo analisar e estabelecer a incidência de qualificações, escolha de percursos curriculares e local de residência sobre comportamento violento e vitimização entre adolescentes de 13-17 anos de Granada (Espanha). A participação de um total de 2.273 adolescentes permitiu o registro e avaliação das variáveis ​​Acadêmicas, Família, Gênero, vitimização (Escala de Vitimização na Escola) e Comportamento Violento (medido com a Escala de Conduta Violenta na Escola). Os resultados mostraram que os adolescentes com qualificações mais baixas, que vivem em abrigos e que no itinerário curricular pretendiam inscrever-se na formação profissional ou inserir-se no mercado de trabalho apresentaram comportamentos mais agressivos e de vitimização do que os alunos com melhores notas médias (bons e excelentes), que procuravam continuar estudando no Ensino Superior e que residiam na casa da família.

En este trabajo de investigación se tiene como objetivo analizar y establecer la incidencia que tienen las calificaciones, elección de itinerarios curriculares y lugar de residencia sobre conductas violentas y de victimización en adolescentes de 13 a 17 años de Granada (España). La participación de un total de 2.273 adolescentes permitió el registro y evaluación de las variables Académicas, Residencia, Género, Victimización (Escala de Victimización en la Escuela) y Conducta Violenta (medida con la Escala de Conducta Violenta en la Escuela). Los resultados mostraron que los adolescentes con peores calificaciones, que vivían en régimen de acogimiento residencial y que como itinerario curricular pretendían matricularse en Formación Profesional o insertarse en el Mercado Laboral presentaban comportamientos más agresivos y de victimización que estudiantes con mejores notas medias (notable y sobresaliente), que pretendían seguir estudiando la opción de Bachillerato y que residían en el domicilio familiar.

This research work aims to analyze and establish the incidence who have the qualifications, election of curricular pathways and residence of violent behaviors and victimization in adolescents 13 to 17 years of Granada (Spain). The participation of a total of 2,273 adolescents allowed the recording and evaluation of variables Academic, Family, Gender, Victimization Scale (Victimization at School) and violent conduct (measured with the Scale of violent conduct in the School). Results showed that adolescents with lower qualifications, living in residential care and as curricular itinerary intended to enroll in vocational training or inserted into the job market showed more aggressive and victimization behaviors students with better average marks ( good and excellent) intended to continue studying the option of high school and residing in the family home.

Violencia escolar en adolescentes: un análisis en función de la actividad física y lugar de residencia habitual / School violence in adolescents: A analysis based on physical activity and place of residence

Son variados y frecuentes los estudios que intentan establecer la relación directa entre variables de tipo psicosocial y deportivo en la conducta violenta y agresiva de los adolescentes, pero pocos incluyen la relación con residir fuera del contexto familiar. De esta manera en este estudio se evalúa la agresividad y componentes de la misma en jóvenes adolescentes, determinando los niveles de práctica de actividad físico-deportiva así como el lugar de residencia de alumnos de ESO de la ciudad de Granada (España) y dictaminando posibles relaciones entre la agresividad, lugar de residencia y realización de actividad física continua. La participación de un total de 2.273 adolescentes permitió el registro y evaluación de las variables de conducta violenta (medida con la escala de conducta violenta en la escuela), lugar de residencia y práctica de actividad física. Los resultados mostraron que los adolescentes no residentes en el hogar familiar tenían mayores índices de agresividad que los residentes y que los que practicaban deporte de manera regular presentaban índices de agresividad manifiesta mayores que los sedentarios. Como principal conclusión indicamos la necesidad de elaborar más estudios que intenten dilucidar más detalladamente aquellas variables que pueden inducir a comportamientos agresivos.

The studies attempting to establish the relationship directly between psychosocial variables and sporty type in violent behavior and aggressive adolescents are varied and frequent, but few include the relationship with reside outside the family context. The aim in this study is evaluated aggressiveness and components thereof in young adolescents, determining practice levels of physical and sporting activities as well as the residence of ESO students from the city of Granada (Spain) ruling and possible relationships between aggressiveness, place of residence and conducting continuous physical activity. The participation of a total 2,273 adolescents allowed the recording and evaluation of variables violent behavior (as measured by the scale of violent behavior at school) place of residence and physical activity. The results showed non-residents adolescents in the family home had higher aggressiveness indexes residents and practicing the sport regularly they had higher rates of aggression manifests that sedentary. The main conclusion indicated the need for develop more studies that attempt to elucidate in more detail those variables that can lead to aggressive behavior.

I-DNASE21 system: development and SWGDAM validation of a new STR 21-plex reaction.

I-DNASE21 is a new STR multiplex system that amplifies 21 STR autosomal loci, plus the amelogenin locus in one reaction. This system has been designed to analyze all the STR loci included in the Combined DNA Index System (CODIS), Interpol Standard Set of Loci (ISSL), Extended European Standard Set (ESS-Extended), UK National Criminal Intelligence DNA Database (NDNAD) and German Core loci (GCL). This manuscript presents the validation of the I-DNASE21 system according to the revised guidelines issued by the Scientific Working Group on DNA Analysis Methods (SWGDAM). The results of this validation, added to the extremely high discriminatory power showed, suggest that I-DNASE21 could be a potentially helpful tool for identification and kinship determination even in complex paternity cases.

Population genetic data for 10 X-STR loci in autochthonous Basques from Navarre (Spain).

Ten X chromosome markers (DXS6789, DXS6809, DXS7132, DXS7133, DXS7423, DXS8378, DXS9898, DXS9902, GATA172D05, and GATA31E08) were analyzed in a sample of 185 unrelated autochthonous Basques from Navarre. Deviations from Hardy-Weinberg equilibrium and linkage disequilibrium between markers were not observed at any loci. Combined power of discrimination was 0.999999999 (females) and 0.999998764 (males). Mean exclusion chance was 0.99999463 (trios) and 0.999761591 (duos). Pairwise genetic distances (Fst) of X-STR frequencies indicate significant differences in the allele frequency distribution between the autochthonous Basques from Navarre and American and Iberian populations except with the Basque Country.

Development and validation for identity testing of I-DNADuo, a combination of I-DNA1 and a new multiplex system, I-DNA2.

The I-DNADuo multiplex system combination is composed of previously validated I-DNA1 and a new short tandem repeat (STR) multiplex named I-DNA2 that analyses 11 STR loci plus amelogenin. I-DNADuo, with amplicon sizes ranging from 57 to 298 bp, is specifically designed to analyse amelogenin and 15 STR loci (ten of them plus amelogenin in duplicate), including all the STR loci of the CODIS, ISSL and ECL databases, and seven of the eight in GCL. The validation of I-DNADuo shows that it is a highly sensitive, robust multiplex system for obtaining individual genetic profiles and for detecting and preventing allelic dropouts.

Y-STR variation in the Basque diaspora in the Western USA: evolutionary and forensic perspectives.

Individuals of Basque origin migrated in large numbers to the Western USA in the second half of the nineteenth century, and the flow continued with less intensity during the last century. The European source population, that of the Basque Country, has long been a cultural and geographical isolate. Previous studies have demonstrated that Y-STR frequencies of Basques are different from those of other Spanish and European populations [1]. The Basque diaspora in the Western USA is a recent migration, but the founder effect and the incorporation of new American Y chromosomes into the paternal genetic pool of the Basque diaspora could have influenced its genetic structure and could thus have practical implications for forensic genetics. To check for genetic substructure among the European source and Basque diaspora populations and determine the most suitable population database for the Basque diaspora in the Western USA, we have analysed the haplotype distribution of 17 Y-STRs in both populations. We have found that the Basque diaspora in the Western USA largely conserve the Y chromosome lineage characteristic of the autochthonous European Basque population with no statistically significant differences. This implies that a common 17 Y-STR Basque population database could be used to calculate identification or kinship parameters regardless of whether the Basque individuals are from the European Basque Country or from the Basque diaspora in the Western USA.

[Poliostotic fibrous dysplasia with affectation of cervical rachis]. / Displasia fibrosa poliostótica con afectación de raquis cervical.

The fibrous dysplasia is a benign although progressive dysfunction, in which a gene mutation originates the production of fibrous disorganized bony matrix. The bony tissue is replaced by bony tissue in expansion (amorph conjuntival tissue) that produces bony deformities in some patients, pain, pathological fractures or deambulation disorders. The diagnosis is important since ocasionally the first symptom is the fracture. We show up the case of a 21 year-old patient with pain clinic in high cervical region. The complementary tests (radiology, bone scintigrraphy and MRI) and anatomo-pathology confirmed the diagnosis of polyostotic fibrous dysplasia with cranial (occipital, esfenoides and right frontal and temporal bone), iliac, femoral, tibial and cervical (apophysis of C2) affectation. Our attitude was of carrying out a narrow observation by means of periodical strict controls, advising to avoid hard activities or contact sports. To the five years the patient is free of symptomatology. Radiologically the injuries have been stabilized. The fibrous dysplasia can affect to a single bone (monostotic) or to several (polyostotic). In occasions it is associated to endocrine dysfunctions and skin pigmentations in McCune-Albright's syndrome. We confront a pathology that specifies an anatomo-pathologic diagnosis to be confirmed, an extension diagnosis to detect asymptomatic focuses and whose treatment is symptomatic in most of the cases only using surgery in frank deformities or when the fracture risk is considerable, although the recurrence is frequent. The malignization is exceptional but possible that's why continuous observation is needed. The radiation therapy is radically contraindicated.

Displasia fibrosa poliostótica con afectación de raquis cervical / Poliostotic fibrous dysplasia with affectation of cervical rachis

La displasia fibrosa es un trastorno benigno aunque progresivo, en el que una mutación genética origina la producción de matriz ósea fibrosa desorganizada. El tejido óseo se reemplaza por tejido óseo en expansión (tejido conjuntivo amorfo) que en algunos pacientes produce deformidades óseas, dolor, fracturas patológicas o problemas con la deambulación. Su diagnóstico es importante ya que ocasionalmente el primer síntoma es la fractura. (1-3) Presentamos el caso de un paciente de 21 años con clínica de dolor en región cervical alta. Las pruebas complementarias (radiologia, gammagrafia y RNM) y la anatomía patológica confirmaron el diagnóstico de displasia fibrosa poliostótica con afectación craneal (occipital, esfenoides y fronto-temporal derechas), iliaca, femoral, tibial y cervical (apófisis espinosa de C2). Nuestra actitud fue de realizar una observación estrecha mediante controles periódicos estrictos, aconsejando evitar actividades o deportes de contacto. A los cinco años el paciente está libre de sintomatología. Radiológicamentelas lesiones se han estabilizado. La displasia fibrosa puede afectar a un solo hueso (monostótica) o varis (poliostótica). En ocasiones se asocia a trastornos endocrinos y pigmentaciones cutáneas en el denominado síndrome de McCune-Albright. (7). Nos encontramos ante una patología que precisa un diagnóstico anatomopatológico para confirmarla, de extensión para detectar focos asintomáticos y cuyo tratamiento es sintomático en la mayoría de los casos recurriendo a la cirugía sólo en ocasión de deformidades francas o cuando el riesgo de fractura es considerable, ya que las recidivas son frecuentes. La malignización es excepcional pero posible por lo que necesita observación continuada. La radioterapia está radicalmente contraindicada (6).

The fibrous dysplasia is a benign although progressive dysfunction, in which a gene mutation originates the production of fibrous disorganized bony matrix. The bony tissue is replaced by bony tissue in expansion (amorph conjuntival tissue) that produces bony deformities in some patients, pain, pathological fractures or deambulation disorders. The diagnosis is important since ocasionally the first symptom is the fracture. We show up the case of a 21 year-old patient with pain clinic in high cervical region. The complementary tests (radiology, bone scintigrraphy and MRI) and anatomo-pathology confirmed the diagnosis of polyostotic fibrous dysplasia with cranial (occipital, esfenoides and right frontal and temporal bone), iliac, femoral, tibial and cervical (apophysis of C2) affectation. Our attitude was of carrying out a narrow observation by means of periodical strict controls, advising to avoid hard activities or contact sports. To the five years the patient is free of symptomatology. Radiologically the injuries have been stabilized. The fibrous dysplasia can affect to a single bone (monostotic) or to several (polyostotic). In occasions it is associated to endocrine dysfunctions and skin pigmentations in McCune-Albright's syndrome. We confront a pathology that specifies an anatomo-pathologic diagnosis to be confirmed, an extension diagnosis to detect asymptomatic focuses and whose treatment is symptomatic in most of the cases only using surgery in frank deformities or when the fracture risk is considerable, although the recurrence is frequent. The malignization is exceptional but possible that's why continuous observation is needed. The radiation therapy is radically contraindicated.