Congenital generalized lipodystrophy: identification of novel variants and expansion of clinical spectrum.

Congenital generalized lipodystrophy (CGL) is an autosomal recessive disorder with two major subtypes. Variants in AGPAT2 result in CGL type 1 with milder manifestations, whereas BSCL2 variants cause CGL type 2 with more severe features. Muscle hypertrophy caused by lack of adipose tissue is present early in life in CGL patients. Our aim was to investigate 10 CGL patients from 7 different countries and report genotype-phenotype relationships. Genetic analysis identified disease-causing variants in AGPAT2 (five patients) and in BSCL2 (five patients), including three novel variants; c.134C>A (p.Ser45*), c.216C>G (p.Tyr72*) in AGPAT2 and c.458C>A (p.Ser153*) in BSCL2. We also report possible novel clinical features such as anemia, breast enlargement, steatorrhea, intraventricular hemorrhage and nephrolithiasis in CGL patients. Generalized lipodystrophy and muscular hypertrophy were the only features in all of our patients. Hepatomegaly was the second common feature. Some manifestations were exclusively noticed in our CGL2 patients; hypertrichosis, high-pitched voice and umbilical hernia. Bone cysts and history of seizures were noticed only in CGL1 patients. The findings of this study expand our knowledge of genotype-phenotype correlations in CGL patients. These results have important clinical applications in diagnosis and management of the CGL patients as well as in genetic counseling in families at-risk.

[Trauma bay haemoglobin level. Predictor of coagulation disorder in major trauma]. / Schockraumhämoglobin. Prädiktor für eine Gerinnungsstörung beim Traumapatienten.

BACKGROUND: Trauma-induced coagulopathy is common in patients with major trauma and requires early and appropriate treatment for bleeding control. Even in emergency laboratory, the availability of standard coagulation tests is associated with certain latencies and devices for viscoelastic haemostasis diagnosis (thromboelastometry) are not routinely established in major trauma centres. PURPOSE: We searched for a laboratory parameter with fast availability by point of care blood gas analysis and reliable correlation with coagulation parameters. METHODS: We analyzed the trauma patients of a single level one trauma centre from 2005-2011 and particularly evaluated the correlation between haemoglobin (Hb) and coagulation parameters and the correlation of Hb and parameters indicating tissue perfusion. All patients who were directly admitted from the scene of an accident to the trauma centre had an injury severity score (ISS) > 9, had a complete revised injury severity classification (RISC) and blood samples that were taken in the emergency department (ED) immediately after admission were included. Correlations were tested using the Pearson test (r) with a two-tailed significance level of p < 0.05. RESULTS: A total of 425 patients met inclusion criteria presenting with a mean age of 43 years, 76% male gender and mean ISS of 30.4. Significant correlation (p < 0.01) between Hb and prothrombin time (Quick) (r = 0.652), Hb and partial thromboplastin time (PTT) (r = - 0.434), Hb and platelet count (r = 0.501) and Hb and base excess (BE) (0.408) was found. No significant correlation between Hb and lactate was found. CONCLUSION: We found a robust correlation of Hb and Quick in a single centre trauma population. These data suggest that especially severely injured trauma patients with persistent bleeding might benefit from an Hb-based algorithm for early correction of coagulation disorders. Further studies with larger trauma populations are required to confirm our findings.

[Anesthesia in a patient after endoscopic lung volume reduction. First anesthesiological experiences with implanted endobronchial valves]. / Narkose bei einem Patienten mit Zustand nach endoskopischer Lungenvolumenreduktion. Erste anästhesiologische Erfahrungen mit implantierten "Lungenventilen"

Chronic obstructive pulmonary disease (COPD) is a disease with a high incidence and extensive comorbidities that make COPD a key challenge for anesthesiologists. A new treatment strategy, such as endoscopic lung volume reduction (ELVR) with implantation of endobronchial valves is a rapidly developing area which is still unknown to many anesthesiologists. This article therefore describes first experiences in a patient with five endobronchial valves in the right upper lobe who needed urgent surgery due to lumbar disc herniation with neurological impairment. After preoperative evaluation of the patient's condition, the use of bronchodilating volatile anesthetics and adjusting the ventilatory settings with long expiration times and low peak pressure in a pressure controlled mode seems favorable in these patients. Intraoperatively, the patient should be assessed with modern physiological monitoring tools to titrate the administration of anesthetic agents, opioids and myorelaxant drugs. In conclusion the care of patients with implanted endobronchial valves after ELVR does not differ from COPD patients without ELVR. A close cooperation between surgeons, anesthesiologists and internists is mandatory in the care of these patients.

Genetic determinants of diastolic and pulse pressure map to different loci in Lyon hypertensive rats.

Several genetic loci involved in blood pressure regulation have recently been localized in experimental models of hypertension, but the manner in which they influence blood pressure remains unknown. Here, we report a study of the Lyon hypertensive rat strain showing that different loci are involved in the regulation of steady-state (diastolic pressure) and pulsatile (systolic-diastolic, or pulse pressure) components of blood pressure. Significant linkage was established between diastolic blood pressure and a microsatellite marker of the renin gene (REN) on rat chromosome 13, and between pulse pressure and the carboxypeptidase B gene (CPB) on chromosome 2. These findings show that two independent loci influence different haemodynamic components of blood pressure, and that pulse pressure has a specific genetic determination.

[Coagulation management of trauma patients with unstabile circulation : establishment of a hemoglobin-oriented standard operating procedure]. / Gerinnungsmanagement beim kreislaufinstabilen Polytraumapatienten : Erarbeitung einer hämoglobinorientierten "standard operating procedure"

INTRODUCTION: Massive hemorrhage is the leading cause of death in the first few hours following multiple trauma, therefore, early and aggressive treatment of clotting disorders and surgical intervention to stop the bleeding are of utmost importance. However, commonly performed clotting tests have a considerable latency of at least 30-45 min, whereas hemoglobin (Hb) levels can be tested very quickly. If a multiple trauma patient has already received fluid resuscitation, a certain relationship may be observed between the hemoglobin value and the development of clotting disturbances. Hence, hemoglobin may be a useful and rapidly available parameter for guiding the initial treatment of clotting disturbances in multiple trauma patients. METHODS: A Hb-guided algorithm has been developed to initiate initial clotting therapy. The algorithm contains three stages of different aggressive clotting therapy with fibrinogen, prothrombin complex concentrate (PCC), factor VIIa, tranexamic acid and desmopressin, depending on the first Hb value measured. For admission Hb levels > 5.5 mmol/l (≈8.8 g/dl) coagulation therapy is managed on the basis of the laboratory tests and if in doubt 2 g fibrinogen is administered. For admission Hb levels between 5.5 mmol/l (≈8.8 g/dl) and 4 mmol/l (≈6.5 g/dl) 2-4 g fibrinogen and 2,500-3,000 IU PCC are administered and tranexamic acid and desmopressin administration should be considered. For admission Hb levels < 4 mmol/l (≈6.5 g/dl) 4-6 g fibrinogen, 3,000-5,000 IU PCC and 1 mg factor VIIa should be administered and tranexamic acid and desmopression should be considered. All drugs mentioned should be stored in a special "coagulation box" in the hospital pharmacy and this box is brought immediately to the patient on demand. In addition to the use of clotting factors, infusions should be performed with balanced crystalloids and transfusions with an RBC/FFP ratio of 2:1-1:1. To assess the efficiency of the algorithm the routinely measured clotting parameters at trauma bay admission were compared with intensive care unit (ICU) admission and the standardized mortality ratio (SMR) was calculated. RESULTS: During a 6-month investigation period 71 severe multiple trauma patients were admitted to the trauma center and 19 patients were treated using the coagulation box of which 13 required massive transfusions. The routinely used clotting parameters markedly improved between admission to the trauma bay and ICU admission: Quick 61% versus 97% (p < 0.001), partial prothromboplastin time (PTT) 50 s versus 42 s (not significant), fibrinogen 1.7 g/l versus 2.15 g/l (not significant). Of the 19 patients 11 (58%) survived. The revised injury severity classification (RISC) predicted a survival rate of 40%, which corresponds to an SMR of 0.69, thus implying a higher survival rate than predicted. CONCLUSIONS: The Hb-driven algorithm, in combination with the coagulation box and the early use of clotting factors, may be a simple and effective tool for improving coagulopathy in multiple trauma patients.

[Methohexital for treatment of intracranial hypertension]. / Methohexital zur Therapie des erhöhten intrakraniellen Drucks.

BACKGROUND: Barbiturate coma therapy is a useful method to control increased intracranial pressure (ICP) in patients with severe brain damage if standard measures have failed to lower ICP. Pentobarbital (not available in Germany) and thiopental (in Germany only approved for induction of anesthesia) have frequently been used in patients with intracranial hypertension and the effects and side-effects are well-described. However, little is known about the effect of methohexital (the only barbiturate in Germany approved for maintaining anesthesia) in lowering increased ICP. Therefore, the effect of methohexital on ICP was studied in patients where standard measures had failed to control intracranial hypertension. METHOD: A retrospective observational study was carried out with the inclusion criteria of patient age ≥18 years and methohexital therapy for 12 h or more with ICP monitoring in place. Methohexital was administered following a standardized algorithm to patients for whom standard measures, such as deep anesthesia, normoventilation, cerebral perfusion pressure (CPP) >65 mmHg, osmotherapy, neurosurgical evacuation of mass lesions, had failed to lower ICP. Methohexital was used if the ICP had risen above 20-25 mmHg for more the 20-30 min and otherwise manageable causes for the ICP increase had been ruled out. Methohexital was given continuously in addition to standard analgesia and sedation in doses of 2-4-6 mg/kg body weight (BW), depending on the ICP lowering effect. The records of the patient data management system from the years 2008/2009 were used to compare the ICP and CPP before and during methohexital administration. For statistical analyses Student's t-test was applied for measured values and the χ(2)-test was applied for percentage values whereby p<0.05 was defined as being statistically significant. RESULTS: During the study period 36 patients required methohexital therapy and 30 fulfilled the inclusion criteria. In 26 out of 30 patients the data were complete and these 26 patients were included in the data analyses. Of the patients 6 (23%) died due to elevated intracranial hypertension and 20 patients (77%) survived. In all patients methohexital lowered the ICP from 25.2 mmHg (standard deviation, SD ±4.3 mmHg) to 19.8 mmHg (SD ±12.5 mmHg) within the first 24 h, this result closely failed to reach a level of significance. In the 20 survivors methohexital lowered the ICP from 25.88 mmHg (SD ±4.8 mmHg) to 14.25 mmHg (SD ±6.9 mmHg) within the first 24 h, which is statistically highly significant. In non-survivors the ICP had risen from 24 mmHg (SD ±2.6 mmHg) to 32 mmHg (SD ±16.3 mmHg) within the first 24 h despite all efforts. Due to the CPP driven volume and vasopressor therapy no significant changes in the CPP during methohexital administration were observed. No significant changes in brain temperature (as possible cause for the decrease of the ICP) were observed. Non-survivors received significantly more methohexital due to increased ICP and required significantly more vasopressor therapy to maintain a sufficient CPP. CONCLUSIONS: Methohexital showed a clear trend for decreasing ICP in patients with intracranial hypertension refractory to standard therapeutic measures. In survivors the effect was highly significant. Patients not responding to methohexital therapy seemed to have an unfavorable outcome.

[Different case fatality rates at German trauma centres : Critical analysis]. / Unterschiedliche Letalitätsraten an deutschen Traumazentren : Kritische Analyse.

OBJECTIVE: The level of trauma care in Germany belongs to one of the best worldwide. Nevertheless, previous studies have shown significant differences in the case fatality rates of multiple trauma patients in German trauma centres. The objective of this study was to indentify the reasons for the different outcomes based on data of the trauma registry of the German Society of Orthopaedic Surgery and Traumatology. METHODS: Due to the inadequacy of comparing only the case fataltiy rates in the different trauma centres, the data recorded in the trauma registry were analyzed in a retrospective, multicentre study to calculate the probability of survival, revised injury severity classification (RISC) and, additionally, the standardized mortality ratio (SMR) for ranking of the participating trauma centres. As a criterion for inclusion in the study, a minimum of 100 trauma patients admitted directly from the scene within a 4 year period was set. The ranking was carried out using the SMR (observed mortality divided by probability of survival). With the help of data from the trauma registry an attempt was made to find the differences in trauma management between the top 10 centres (lowest SMR), the 10 middle and the last 10 centres (highest SMR) in the ranking. RESULTS: The data of 6,522 patients were included in the study. There were significant differences in the pre-hospital time, the time spent in the emergency room (ER) and time until a CT scan had been performed. Pre-hospital time was longer in patients admitted to the top centres, whereas time in the ER was longer in the last centres of the ranking. Comparing the sum of pre-hospital time and time in the ER, there were no differences between the top and the last centres. At the scene of accident overall intubation rate and intubation rate in patients with traumatic brain injury were higher in patients admitted to the top centres. Regarding the transport modality, significantly more patients were transported by helicopter in the group of the top centres. In top centres CT scans, in particular whole-body CTs, were initiated sooner and used much more frequently so that the rate of missed injuries was much lower. The amount of fluid given at the scene of accident did not differ between the centres but the amount of fluid given in ER and the operating room until admission to the intensive care unit was significantly higher in the top centres. CONCLUSION: There are significant differences in the pre-hospital and clinical care of patients admitted to German trauma centres. Under clinical conditions a tight time management, an immediate and complete diagnostic approach, particularly by means of whole-body CT and a liberal fluid resuscitation seem to be favorable factors.

Recommendations for locus-specific databases and their curation.

Expert curation and complete collection of mutations in genes that affect human health is essential for proper genetic healthcare and research. Expert curation is given by the curators of gene-specific mutation databases or locus-specific databases (LSDBs). While there are over 700 such databases, they vary in their content, completeness, time available for curation, and the expertise of the curator. Curation and LSDBs have been discussed, written about, and protocols have been provided for over 10 years, but there have been no formal recommendations for the ideal form of these entities. This work initiates a discussion on this topic to assist future efforts in human genetics. Further discussion is welcome.

Congenital generalized lipodystrophy in an Indian patient with a novel mutation in BSCL2 gene.

Congenital generalized lipodystrophy (CGL) is an autosomal recessive metabolic syndrome with involvement of multiple organs. Mutations in BSCL2 are known to be associated with a severe form of CGL and mental retardation (MR). The genetic heterogeneity in CGL patients is accompanied by phenotypic heterogeneity in different ethnic groups. Studies in the Indian context are very few in this regard. We report here a detailed clinical analysis of a CGL case from infancy to adult hood. Interestingly, the patient was found to be homozygous for a novel BSCL2 mutation, but with normal intellectual development contrasting with the MR associated with BSCL2 mutation in CGL patients. The biochemical investigations at the time of diagnosis (9 months) included total cholesterol, total lipids, triglycerides, phospholipids, ß-lipoprotein and free fatty acids, which were above normal limits. The clinical phenotype, viz. lack of subcutaneous fat, hepatosplenomegaly, cardiomegaly, and advanced bone age was also documented. The patient was found to be insulin resistant and diabetes mellitus was diagnosed by age 13 years. Ultrasonography of the ovaries at age 22 showed polycystic features with elevated levels of gonadotropins and negligible levels of serum leptin. For genetic analysis, direct DNA sequencing of BSCL2 was carried out and disclosed an 11-base-pair deletion in exon 6 (H217fsX272) resulting in a truncated protein. This is a novel mutation that contributes to CGL formation in a family of Indian origin and adds to the array of variants reported in this disorder. Moreover, the novel mutation is found to be associated with normal intellectual ability.

A structured simple form for ordering genetic tests is needed to ensure coupling of clinical detail (phenotype) with DNA variants (genotype) to ensure utility in publication and databases.

Researchers and clinicians ideally need instant access to all the variation in their gene/locus of interest to efficiently conduct their research and genetic healthcare to the highest standards. Currently much key data resides in the laboratory books or patient records around the world, as there are many impediments to submitting this data. It would be ideal therefore if a semiautomated pathway was available, with a minimum of effort, to make the deidentified data publicly available for others to use. The Human Variome Project (HVP) meeting listed 96 recommendations to work toward this situation. This article is planned to initiate a strategy to enhance the collection of phenotype and genotype data from the clinician/diagnostic laboratory nexus. Thus, the aim is to develop universally applicable forms that people can use when investigating patients for each inherited disease, to assist in satisfying many of the recommendations of the HVP Meeting [Cotton et al., 2007]. We call for comment and collaboration in this article.

Rat gene mapping using PCR-analyzed microsatellites.

One hundred and seventy-four rat loci which contain short tandem repeat sequences were extracted from the GenBank or EMBL data bases and used to define primers for amplification by the polymerase chain reaction (PCR) of the microsatellite regions, creating PCR-formatted sequence-tagged microsatellite sites (STMSs). One hundred and thirty-four STMSs for 118 loci, including 6 randomly cloned STMSs, were characterized: (i) PCR-analyzed loci were assigned to specific chromosomes using a panel of rat x mouse somatic cell hybrid clones. (ii) Length variation of the STMSs among 8 inbred rat strains could be visualized at 85 of 107 loci examined (79.4%). (iii) A genetic map, integrating biochemical, coat color, mutant and restriction fragment length polymorphism loci, was constructed based on the segregation of 125 polymorphic markers in seven rat backcrosses and in two F2 crosses. Twenty four linkage groups were identified, all of which were assigned to a defined chromosome. As a reflection of the bias for coding sequences in the public data bases, the STMSs described herein are often associated with genes. Hence, the genetic map we report coincides with a gene map. The corresponding map locations of the homologous mouse and human genes are also listed for comparative mapping purposes.

Molecular genetics of the SA-gene: cosegregation with hypertension and mapping to rat chromosome 1.

OBJECTIVES: The SA-gene shows markedly higher levels of expression in the kidneys of spontaneously hypertensive rats (SHR) than in their non-hypertensive reference strain, the Wistar-Kyoto (WKY) rat. Based on the important role of the kidney in blood pressure regulation, the possibility has been raised that this gene, the translational product of which remains unknown, may participate in the pathogenesis of primary hypertension. The present study was conducted to test this hypothesis and to ascertain the chromosomal localization of the SA-gene. DESIGN: A cosegregation study was performed using an F2 intercross between stroke-prone SHR (SHRSP) and WKY rats, and a previously described restriction fragment length polymorphism of the SA-gene for characterization of genotype. Mapping of the SA-gene was accomplished by screening a somatic cell-hybrid panel and by linkage group analysis. RESULTS: A statistically significant difference in systolic blood pressure was found after sodium loading, but not under basal conditions between groups of rats defined by zygosity at the SA locus, consistent with a hypertensive effect of the SHRSP allele. No effect of SA genotype on diastolic blood pressure was observed. The SA-gene was localized on rat chromosome 1. CONCLUSIONS: This study establishes the SA locus on chromosome 1 as a region in which a gene or genes contributing to blood pressure regulation in this model are localized, and provides further evidence for a possible role of the SA-gene in the pathogenesis of hypertension.

Use of DNA bar codes to resolve a canine paternity dispute.

The DNA fingerprinting method was used to resolve a canine paternity dispute. During the same estrus, a Shih Tzu bitch was inseminated by 2 dogs--a Shih Tzu and a Coton de Tulear. Because both breeds are alike phenotypically, it was difficult to decide whether the pups were purebred or of mixed breeding. The DNA bar codes indicated unambiguously that the 2 sires had fathered one pup each, thus documenting superfecundation.

[Factor V Leiden and activated protein C resistance]. / Facteur V Leiden et résistance à la protéine C activée.

Factor V Leiden is characterised by a point mutation which prevents the physiologic inhibition of activated factor V by activated protein C (Activated Protein C Resistance). This mutation is now considered as the most frequent inherited thrombophilic disorder. It is found in about 20% of patients with venous thrombotic disease, far before ATIII, Protein C and S deficiency. Its prevalence (4% in the general belgian population, 1 to 15% in Europa) allows frequent associations with other thrombophilic disorders, inherited or acquired, such as contraceptive pill. Biological testing are now ready for screening, but the opportunity of a systematic evaluation in front of a risk situation remains a matter to discussion.

[Acute portal thrombosis revealing hereditary hemochromatosis: report of a case]. / Thrombose portale aiguë révélant une hémochromatose héréditaire: à propos d'un cas.

The authors report the case of a 49-year old man in whom an inaugural portal vein thrombosis led to the diagnosis of hereditary hemochromatosis. In this case, the increase in ferritinemia and the T2-weighted MRI hepatic segmental hyposignal were considered as consequences of tissular necrosis while they did probe a real iron overload. Genetic testing, revealing C282Y/H63D compound heterozygoty, provided evidence for a diagnosis of hereditary hemochromatosis. Weekly venesections induced a calculated iron depletion of 3.5 g without occurrence of anemia, further supporting the diagnosis. We suggest that hemochromatosis should be considered in the differential diagnosis of idiopathic portal vein thrombosis when signs of abnormal iron accumulation exist.

Li-Fraumeni syndrome: multiple distinct brain tumours in two brothers.

Li-Fraumeni syndrome is a rare autosomal dominant cancer-prone condition characterized by the occurrence of a large set of different types of cancer in a patient and their family. A germline disease-causing mutation of the gene encoding the p53 protein is associated with the syndrome. We report on a family in which segregation of a TP53 mutation in two generations was associated with two brain tumours, a leiomyosarcoma and a thyroid carcinoma in four male patients. The main patient presented with seizures revealing several primary brain tumours. We review recent views on its molecular basis and discuss management of the condition as well as a review of the literature.

[Desmopressin (Minirin) in multiple trauma--a case report]. / Desmopressin (Minirin) beim schweren Trauma--eine Fallbeschreibung.

Bleeding and clotting disturbances are not uncommon in trauma patients and require an early and consequent therapy. Under the prevalent pathophysiological circumstances of hypothermia, acidosis and clotting disturbances, desmopressin seems to be a possible option to control diffuse bleeding. We report about 2 trauma patients with diffuse bleeding and in whom desmopressin was used successfully to control bleeding from the point of view of the authors. We discuss the advantages and disadvantages of desmopressin in the 2 patients.