Muscular dystrophies: diagnostic approaches in Hungary.

Muscular dystrophies are a genetically heterogeneous group of degenerative muscle disorders. This article focuses on two severe forms of muscular dystrophies and provides genetic data for a large cohort of Hungarian patients diagnosed within the last few years by the authors. The Duchenne/Becker muscular dystrophy (DMD/BMD) is caused by mutations in the dystrophin gene, which is located on chromosome Xp21. The genetic analysis of dystrophin is usually performed by multiplex polymerase chain reaction (PCR), which detects approximately 95% of all deletions but does not distinguish between one and two copies of the exons investigated. The present work, therefore, concentrates on the improvement of the diagnostic panel for the analysis of DMD/BMD in Hungary. Radioactively labelled cDNA probes, encompassing the whole dystrophin gene detect all the deletions and the analysis is quantitative. In addition, the new multiple ligation-dependent probe amplification (MLPA) technique was recently introduced that enabled more reliable and faster quantitative detection of the entire dystrophin gene. The genomic basis of facioscapulohumeral muscular dystrophy (FSHD) is associated with contraction of the D4Z4 repeat region in the subtelomere of chromosome 4q. In case of FSHD, molecular genetic criteria still have to be improved because of the complexity of the disorder.

[Prevalence of methylenetetrahydrofolate reductase (MTHFR) gene polymorphism (C677T) in the Hungarian population]. / A metiléntetrahidrofolát-reduktáz (MTHFR) gén polimorfizmusának (C677T) magyarországi gyakorisága.

MTHFR encodes a critical enzyme in folate and homocysteine metabolism and the C677T allele of the MTHFR gene has some association with an increased risk for neural-tube defects and for adult cardiovascular diseases. As part of an international collaborative study the prevalence of C677T homozygous genotype was 11.1% while the frequency of C677T heterozygous condition was 45.2% in the Hungarian neonate sample. These findings underscore the clinical importance of the C677T variant in the Hungarian population and urge population-based prevention of conditions related to such gene.

Influence of mutation type and X chromosome inactivation on Rett syndrome phenotypes.

We screened 71 sporadic and 7 familial Rett syndrome (RTT) patients for MECP2 mutations by direct sequencing and determined the pattern of X chromosome inactivation (XCI) in 39 RTT patients. We identified 23 different disease-causing MECP2 mutations in 54 of 71 (76%) sporadic patients and in 2 of 7 (29%) familial cases. We compared electrophysiological findings, cerebrospinal fluid neurochemistry, and 13 clinical characteristics between patients carrying missense mutations and those carrying truncating mutations. Thirty-one of 34 patients (91%) with classic RTT had random XCI. Nonrandom XCI was associated with milder phenotypes, including a mitigated classic RTT caused by a rare early truncating mutation. Patients with truncating mutations have a higher incidence of awake respiratory dysfunction and lower levels of cerebrospinal fluid homovanillic acid. Scoliosis is more common in patients with missense mutations. These data indicate that different MECP2 mutations have similar phenotypic consequences, and random XCI plays an important role in producing the full phenotypic spectrum of classic RTT. The association of early truncating mutations with nonrandom XCI, along with the fact that chimeric mice lacking methyl-CpG-binding protein 2 (MeCP2) function die during embryogenesis, supports the notion that RTT is caused by partial loss of MeCP2 function.

Dose-dependent effect of folic acid on the prevention of orofacial clefts.

OBJECTIVE: In 1982, Tolarova(4) found a reduction in the recurrence rate of isolated cleft lip (CL) with or without cleft palate (CP; CL +/- CP) after periconceptional supplementation with a multivitamin including a very high dose (10 mg) of folic acid. The Hungarian randomized, double-blind, controlled trial of periconceptional supplementation with a multivitamin including a physiologic dose (.8 mg) of folic acid did not show any preventive effect on the first occurrence of isolated CL +/- CP and CP. However, the general evaluation of congenital abnormalities in the Hungarian Case-Control Surveillance of Congenital Abnormalities indicated, among others, a reduction of isolated CL +/- CP and CP after the use of high doses of folic acid in the critical period for the development of these congenital abnormalities in the 12-year dataset between 1980 and 1991. We hypothesized that the prevention of orofacial clefts by folic acid has a dose-dependent effect, and this hypothesis was tested in 2 recent Hungarian datasets. DESIGN: In a prospective cohort study, the occurrence of isolated CL +/- CP and CP was studied in the newborn infants born to mothers with or without periconceptional folic acid-containing (.8 mg) multivitamin supplementation. Supplemented women with confirmed pregnancy were recruited from the participants of the periconceptional service. Unsupplemented women were invited to take part in the study after the first visit between the 8th and 12th week of gestation in the antenatal care. Supplemented and unsupplemented women were matched based on age, socioeconomic status, and residence. In contrast, the occurrence of high-dose (in general daily 6 mg) folic acid supplementation was evaluated in the case-control pairs of CL +/- CP and CP, particularly during the critical period of these 2 types of orofacial clefts in the 17 years dataset of the Case-Control Surveillance of Congenital Abnormalities, between 1980 and 1996. Cases were selected from the population-based Hungarian Congenital Abnormality Registry, whereas population controls without congenital abnormality were ascertained from the national birth registry. Two population controls were matched to every case according to sex, week of birth, and district of parental residence. The drug uses, including pregnancy supplements as folic acid, were evaluated based on retrospective self-reported maternal questionnaire and prospective medically documented data of antenatal care logbook. RESULTS: In the prospective cohort study, of 3019 informative offspring (termination of pregnancies in the second and third trimesters because of fetal defect, stillborn fetuses, and liveborn infants) in the supplemented group, 3 had CL +/- CP and 1 was affected with CP, whereas of 3432 informative offspring in the unsupplemented group, 2 had CL +/- CP and 1 had CP. The lack of preventive effect was in agreement with the result of the previous Hungarian randomized double-blind controlled trial; thus, these 2 datasets were combined. The preventive effect of a folic acid containing multivitamin used in the periconceptional period for the first occurrence of isolated CL +/- CP and CP was estimated by the Mantel-Haenszel test. Of 5488 supplemented women, 6 had CL +/- CP, and of 5821 unsupplemented women, 4 had CL +/- CP. Of 5489 supplemented women, 1 had CP, and of 5823 unsupplemented pregnant women, 3 had CP. The Hungarian Case-Control Surveillance of Congenital Abnormalities, 1980-1996, included 38 151 population controls (1.8% of the Hungarian births) and 22 865 cases with congenital abnormalities. Within the latter group, 1368 had isolated CL +/- CP, and 596 had CP. A significantly more frequent use of high-dose folic acid (in general daily 6 mg) supplementation was found in controls than in cases of 1246 case-control pairs of CL +/- CP group and of 537 case-control pairs of CP group, respectively. (ABSTRACT TRUNCATED)

Timing of suicide attempts by self-poisoning during pregnancy and pregnancy outcomes.

OBJECTIVE: The purpose of this study was to examine the timing and consequences of suicide attempts by self-poisoning during pregnancy. METHODS: A population-based prospective study was organised in the toxicological in-patient hospital in Budapest which is responsible for health services for adult inhabitants poisoned by ingesting chemicals in Budapest and the surrounding area involving 3 million people between 1985 and 1993. All women aged between 16 and 50 years (22969) who were admitted to the study hospital due to suicide attempts by drug ingestion were examined by a sensitive serum pregnancy test. RESULTS: Of 559 self-poisoned pregnant women, two died. The peak period of suicide attempts was found to be in the first postconceptual month and its majority resulted in a very early fetal loss. The second highest figure was recorded in the second postconceptual month. Thus, 61% of suicide attempts occurred before the third postconceptual month. Later pregnancies had a significantly lower proportion of attempting suicide parallel with advanced fetal development. CONCLUSIONS: Most suicide attempts by self-poisoning occurred after the early recognition of unwanted pregnancies and most resulted in a very early fetal loss. Pregnancies with advanced gestation months had a significantly lower proportion of attempting suicide.

Congenital abnormalities and indicators of germinal mutations in the vicinity of an acrylonitrile producing factory.

The results of an environmental mutation and teratologic epidemiological study are presented which was performed in inhabitants living in the surrounding region of an acrylonitrile factory in Nyergesújfalu. The endpoint of the study was congenital abnormalities in 46,326 infants born to mothers living in the 30 settlements of the study region within a 25 km radius of the acrylonitrile factory between 1980 and 1996. The ascertainment of cases with congenital abnormalities was based on the dataset of the Hungarian Congenital Abnormality Registry complemented with the review of pediatric, pathology and cytogenetic records. A particular attention was paid to the indicators of germinal mutations as sentinel anomalies, Down syndrome and unidentified multiple congenital abnormalities and the indicators of teratogens as the specific pattern of multiple congenital abnormalities. Three congenital abnormalities: pectus excavatum in Tata, 1990-1992 (OR with 95%CI: 78.5, 8.4-729.6), undescended testis in Nyergesújfalu between 1980 and 1983 (8.6, 1.4-54.3) and in Esztergom, 1981-1982 (4. 2, 1.3-13.5) and clubfoot in Tata, 1980-1981 (5.5, 1.5-20.3) showed significant time-space clusters in the study region. There was a decrease in risk of undescended testis with increasing distance from the acrylonitrile factory. An unusual increase was found in the combination of oral cleft and cardiac septal defects in multimalformed babies in Tatabánya, 1990. The detailed analysis of congenital abnormalities in all settlements of a given territory may help to detect clusters of congenital abnormalities and their possible relation to the environmental hazards.

The deltaccr5 mutation conferring protection against HIV-1 in Caucasian populations has a single and recent origin in Northeastern Europe.

The chemokine receptor CCR5 is encoded by the CMKBR5 gene located on the p21.3 region of human chromosome 3, and constitutes the major co-receptor for the macrophage-tropic strains of HIV-1. A mutant allele of the CCR5 gene, Delta ccr5 , was shown to provide to homozygotes with a strong resistance against infection by HIV. The frequency of the Delta ccr5 allele was investigated in 18 European populations. A North to South gradient was found, with the highest allele frequencies in Finnish and Mordvinian populations (16%), and the lowest in Sardinia (4%). Highly polymorphic microsatellites (IRI3.1, D3S4579 and IRI3.2, D3S4580 ) located respectively 11 kb upstream and 68 kb downstream of the CCR5 gene deletion were used to determine the haplotype of the chromosomes carrying the Delta ccr5 variant. A strong linkage disequilibrium was found between Delta ccr5 and specific alleles of the IRI3.1 and IRI3.2 microsatellites: >95% of the Delta ccr5 chromosomes carried the IRI3.1-0 allele, while 88% carried the IRI3.2-0 allele. These alleles were found respectively in only 2 or 1.5% of the chromosomes carrying a wild-type CCR5 gene. From these data, it was inferred that most, if not all Delta ccr5 alleles originate from a single mutation event, and that this mutation event probably took place a few thousand years ago in Northeastern Europe. The high frequency of the Delta ccr5 allele in Caucasian populations cannot be explained easily by random genetic drift, suggesting that a selection advantage is or has been associated with homo- or heterozygous carriers of the Delta ccr5 allele.

Bone marrow transplantation in non-malignant disorders.

From January 1992 to December 1997, 21 consecutive patients (14 SAA, 3 SCID, 1 Fanconi anemia, 1 Diamond-Blackfan anemia, 1 mucolipidosis and 1 mucopolysaccharidosis type I.) were transplanted (16 HLA-id. family, 2 MUD and 3 haploidentical family donors) in a single center. The median follow up period is 41 months (range 7-76). The probability of 3.5 year overall disease free survival is 14/21 (67%), the transplant related mortality is 4/21 (19%). All the SCID patients are alive and disease free. 3 SAA patients had signs of fungal infection prior to transplant. They died in spite of intensive antifungal treatment resulting reduced DFS for SAA to 71%. Two patients with lysosomal storage disorders (mucolipidosis and MPS I.) rejected the haploidentical T-cell depleted graft 1 and 11 months after transplant, respectively. In 2 cases non-engraftment occured, both patients were retransplanted successfully.

Teratologic evaluation of 178 infants born to mothers who attempted suicide by drugs during pregnancy.

OBJECTIVE: To identify the teratogenic risk of large doses of various drugs taken by women in attempting suicide. METHODS: This population-based, prospective, epidemiologic study involved 559 women with pregnancy verified by a serum pregnancy test who were admitted to the toxicologic inpatient clinic in Budapest responsible for providing health services to chemically poisoned individuals from a population of 3 million. Each self-poisoned woman was matched for age and gestational age with a control selected from among participants in periconceptional care. RESULTS: Two of 559 self-poisoned pregnant women died. One hundred seventy-eight infants born to mothers who poisoned themselves during pregnancy either were examined personally or had appropriate medical data available. After excluding eight infants with fetal alcohol syndrome born to heavy-drinking mothers, the rate of congenital abnormalities in study infants (9.0%) did not significantly exceed the rate of control infants (6.1%). Thus, no teratogenic effect of drugs used for self-poisoning could be identified, even though large doses of drugs were used in 27 cases between the 3rd and 8th weeks of fetal development. This sample was not large enough to evaluate single drugs separately. CONCLUSION: Drugs taken by women in attempting suicide do not seem to pose a risk for structural birth defects in the offspring.

[The importance of molecular genetic diagnosis of Martin-Bell disease in genetic counseling]. / A Martin-Bell-kór molekuláris genetikai kórismézésének jelentösége a genetikai tanácsadásban.

The female consultant had two mentally retarded boys from her two marriages. The clinical symptoms and Fra-X chromosomes indicated their Martin-Bell disease. The daughter of the consultant is healthy and Fra-X negative. She is pregnant and insisted on her molecular genetic diagnosis due to an international collaboration. Both affected brothers had FRAXA genes with a full mutation including more than 200 CGG methylated repeats. The consultant female was in the phase of premutation, however, her healthy daughter had two normal 50% methylated genes with 19 and 26 CGG repeats. Thus there is no recurrence risk for Martin-Bell disease in her fetus.

Birth weight and congenital anomalies following poisonous mushroom intoxication during pregnancy.

A series of 22 women who suffered from mushroom poisoning while pregnant have been identified among adults receiving treatment between 1960 and 1993 in a specialist clinic in Budapest, Hungary. In most cases, the poisonings were attributed to Amanita phalloides, verna, and related species. Of these, 20 went to term, and data were collected on gestational age, birth weight, and both major and minor congenital anomalies. Mean birth weight (but not gestational age) was lower than in the control series, suggesting that maternal poisoning may have led to intrauterine growth retardation. Two children were identified with major abnormalities (one of whom had fetal alcohol syndrome related to alcohol abuse by the mother). The prevalences of both major and minor anomalies were similar to the prevalence in the matched control group and to the rate in a more recent control series examined according to the same protocols. However, the statistical power to detect teratogenic effects is limited, especially as only five of the mothers suffered the poisoning episode during the first trimester.

[Timing of attempted suicide by drug poisoning during pregnancy and pregnancy outcome]. / A terhesség alatti gyógyszeres öngyilkosságok idöpontja és a terhességek kimenetele.

Suicide attempts by drug ingestion during pregnancy provides an opportunity to study the teratogenicity of large doses of drugs in human beings. Data of a population-based prospective study of all pregnant women admitted to the toxicological inpatient hospital in Budapest which is responsible for the health provision of chemical poisoned persons from a 3 million study population. Of 22,969 self-poisoned women, 645 were pregnant and 559 attempted suicide by drug ingestion during pregnancy during the study period (1985-1993). Two died. The peak of suicide attempts was found in the first month of fetal development, and its great majority resulted in a very early fetal death, the so-called chemical pregnancy. Thus 61% of suicide attempts occurred before the third month. Later pregnancies had a protective effect against suicide parallel with advanced months of fetal development.

[The bone-marrow transplantation program in Hungary: report from the period 1990-1995]. / Csontveló-transzplantációs program Magyarországon: beszámoló az 1990-1995 közötti idószakról.

The article summarises the statistical data of bone marrow transplantation (BMT) carried out in Hungary between 1990-1995 in yearly distribution. Since the first BMT up to the end of 1995, 168 BMT were performed. The number of transplantations since 1990 to our days was gradually increasing. As a result of this activity in the three transplantation centers (National Institute of Haematology and Immunology, St. László Hospital and County Hospital in Miskolc) 36 allogeneic and 12 autologous BMT were performed in 1995. Out of the allogeneic BMT cases, 14% of them were completed with unrelated, donors in the last three years. The most frequent indications for allogenic BMT are: chronic myeloid leukaemia (CML), acute lymphoid leukaemia (ALL), acute myeloid leukaemia (AML), myelodysplasia, severe aplastic anaemia. Child allogenic BMTs are carried out on pediatric patients in St. László Hospital in leukaemia, severe aplastic anaemia cases and children born with immunodeficiency. Autologous BMTs started in an organised way in 1995 for adult patients in cases of non-Hodgkin lymphoma, Hodgkin lymphoma and for children with solid tumour indication in the Miskolc Centre. BMT activity in Hungary compared with international data, especially within Europe, shows a significant drop behind. To calculate for ten million inhabitants, the optimal BMT activity should be between 100-200 transplantations (allogeneic and autologous BMT together) in 1994. Among the Central European countries Hungary and Poland fall most behind. Autologous BMTs in most countries of Europe are above of allogeneic BMTs in numbers as indication in cases of lymphoma and solid tumours (first of all mamma carcinoma) comes into focus. This summary emphasises the most important difficulties in connection with the development of the National BMT program.

[Cases of diseases registered with the Genetic Counseling Service during the past 20 years, in the light of their etiology]. / Genetikai Tanácsadónk eseteinek alakulása a kóreredet tükrében az elmúlt 20 évben.

The authors analyse the experiences of their Genetic Counseling Clinic between 1979-1992. They show the formation of the motives of presenting and consulting. They range the consultants in three etiological categories (genetical, teratological and clinical entities). The proportion of new consultants increased fourfold and this tendency documents unambiguously the claim of family planners for this very important medical service. The proportion of Mendelian disorders, mutagen risk and consanguinity are relatively continuous. Because of teratogen risk the rate of presenting decreased moderately. The proportion of consultants shows a definite increase of multifactorial frequent disorders, which they value as a favorable tendency. For decreasing of unjustified cases they suggest the necessity of pre-screening.

[Prophylactic and therapeutic use of immunoglobulins in patients with bone marrow transplantation]. / Immunglobulinok profilaktikus és terápiás alkalmazása csontvelötranszplantált betegekben.

Eleven children were transplanted in our BMT Unit. All but one received standard IVIG preparations in doses of 100 mg/kg b. w. regularly on days before and after transplantation -1, +14, +28, +60 and +90, respectively, and anti-CMV hyperimmune globulin (Cytotect) was given to six patients in the same doses, respectively. In spite of the severe immunodeficiency bacterial infections were verified only in four patients, and CMV infection in three. New infection only occurred in two of the three patients, who hadn't been given CMV prophylaxis, while in the group of six children having been given Cytotect prophylaxis only one became infected from endogenous reactivation of CMV. Therapeutic application of immunoglobulin compounds were used in four of our transplanted patients. Two of them suffered from sepsis during transplantation, one from protracted immunoneutropenia and one from CMV antigenaemia after the transplantation, respectively. Our conclusion is that the administration of immunoglobulins may contribute to the prevention of infections and to the treatment of some complications in BMT recipients. Anti-CMV immune globulin seems to be more effective than standard IVIG in the prevention of CMV infection.

An assessment of simple referee methods for the prediction of lean in pig carcasses.

A study was carried out in which carcass characteristics of 36 gilts were evaluated: 18 originated from the Hungarian 'Hungahyb' cross-breed, another 18, with undefined genetic background, from small private household plots. Two, rather simple substitute reference methods, called referee methods, were evaluated: measurement of carcass weight without skin and subcutaneous fat ('meat + bone'), and measurement of carcass weight without skin, subcutaneous fat and bone ('boneless meat'). Both methods gave a rather close relationship with the Kulmbach reference lean; however, removal of bone had presumably a beneficial effect on stability of prediction. The importance of preliminary information in quantitative form, giving a theoretical background for prediction equations, was presented as an example. Simple material balances could be formulated between reference lean and 'meat + bone' or 'boneless meat' content. Such material balances could not be set up with the indirect, rapid surrogate methods using mainly linear measurements (e.g. fat and muscle thickness, etc.) For this reason, as several other publications demonstrated, these latter methods seem to be more susceptible to bias than the referee methods. By determining the lipid content of the homogenised 'boneless meat' component, a 'lean' value adjusted to 3% fat content could be calculated from data which was compared to the dissected reference lean standardised also to contain 3% fat. These relationships, for several reasons discussed in this paper, were not as close as expected. So, further studies are needed to reveal these discrepancies.

Ecogenetic and pharmacogenetic studies in Hungary.

12 population groups of Hungary, 1514 individuals altogether, have been studied for polymorphisms of alpha 1antitrypsin, serum cholinesterase, paraoxonase and delta-aminolevulinic acid dehydrase, N-acetyltransferase variation and aldehyde dehydrogenase deficiency. A possible relationship between their allele frequencies and environmental factors in the context of ecogenetic and pharmacogenetic phenomena in Hungary is discussed.

Association of Shokeir syndrome (congenital universal alopecia, epilepsy, mental subnormality and pyorrhea) and giant pigmented nevus.

The second case of Shokeir syndrome (congenital total permanent alopecia, psychomotor epilepsy, mental retardation and pyorrhea) is described in a Hungarian boy. This syndrome was associated with a giant pigmented nevus in this case.