The TALE homeodomain of PBX1 is involved in human primary testis-determination.

Human sex-determination is a poorly understood genetic process, where gonad development depends on a cell fate decision that occurs in a somatic cell to commit to Sertoli (male) or granulosa (female) cells. A lack of testis-determination in the human results in 46,XY gonadal dysgenesis. A minority of these cases is explained by mutations in genes known to be involved in sex-determination. Here, we identified a de novo missense mutation, p.Arg235Gln in the highly conserved TALE homeodomain of the transcription factor Pre-B-Cell Leukemia Transcription Factor 1 (PBX1) in a child with 46,XY gonadal dysgenesis and radiocubital synostosis. This mutation, within the nuclear localization signal of the protein, modifies the ability of the PBX1 protein to localize to the nucleus. The mutation abolishes the physical interaction of PBX1 with two proteins known to be involved in testis-determination, CBX2 and EMX2. These results provide a mechanism whereby this mutation results specifically in the absence of testis-determination.

Mutations involving the SRY-related gene SOX8 are associated with a spectrum of human reproductive anomalies.

SOX8 is an HMG-box transcription factor closely related to SRY and SOX9. Deletion of the gene encoding Sox8 in mice causes reproductive dysfunction but the role of SOX8 in humans is unknown. Here, we show that SOX8 is expressed in the somatic cells of the early developing gonad in the human and influences human sex determination. We identified two individuals with 46, XY disorders/differences in sex development (DSD) and chromosomal rearrangements encompassing the SOX8 locus and a third individual with 46, XY DSD and a missense mutation in the HMG-box of SOX8. In vitro functional assays indicate that this mutation alters the biological activity of the protein. As an emerging body of evidence suggests that DSDs and infertility can have common etiologies, we also analysed SOX8 in a cohort of infertile men (n = 274) and two independent cohorts of women with primary ovarian insufficiency (POI; n = 153 and n = 104). SOX8 mutations were found at increased frequency in oligozoospermic men (3.5%; P < 0.05) and POI (5.06%; P = 4.5 × 10-5) as compared with fertile/normospermic control populations (0.74%). The mutant proteins identified altered SOX8 biological activity as compared with the wild-type protein. These data demonstrate that SOX8 plays an important role in human reproduction and SOX8 mutations contribute to a spectrum of phenotypes including 46, XY DSD, male infertility and 46, XX POI.

Experiencia temprana en la aplicación de un programa ERAS en hepatectomías abiertas menores por metástasis de origen colorrectal, con resecciones simultáneas de colon o sin ellas / Early experience in the application of an ERAS program in minor open hepatectomies for metatstases of colorectal cancer, with or without simultaneous colon resection

Introducción. La aplicación de programas de tipo vía rápida (fast track) en cirugía abdominal mayor fue inicialmente implementada en cirugía abierta de colon con resultados comparables a los del abordaje laparoscópico. La disminución de la estancia hospitalaria y de los costos hospitalarios fueron las principales ventajas. Recientemente, se trasladó la aplicación de protocolos de recuperación posquirúrgica rápida (Enhanced Recovery After Surgery, ERAS) a la cirugía hepática con resultados aparentemente alentadores. El objetivo de este trabajo fue valorar los resultados iniciales obtenidos en un grupo de pacientes sometidos a hepatectomías menores por metástasis hepáticas, con resección simultánea de colon o sin ella. Métodos. Se evaluaron los datos de 13 resecciones hepáticas menores por metástasis hepáticas de origen colorrectal con resección simultánea del tumor primario o sin ella, las cuales se incorporaron a un protocolo ERAS. Se evaluaron los datos demográficos, de las hepatectomías, de la observancia del protocolo y de algunos factores que pueden afectar los resultados de una recuperación rápida, así como también lo que se considera recuperación total al momento del egreso. Resultados. En las 13 resecciones se pudo llevar adelante la aplicación del protocolo. Como resultado principal, se logró una corta estancia hospitalaria (3,69 días), el cumplimiento del protocolo fue alto y la recuperación total al egreso fue de 46,2 %. Conclusión. La aplicación de este protocolo ha sido exitosa en cuanto a una franca disminución de la estancia hospitalaria. El número de pacientes es pequeño, pero los resultados son esperanzadores

Introduction: The application of fast track programs in major abdominal surgery was initially implemented in open colonic surgery with comparable results to the laparoscopic approach. The decreases in hospital stay and in hospital costs were the main advantages. Recently the application of ERAS programs to liver surgery was transferred with apparently encouraging results. The aim of this study was to evaluate the initial results obtained in a group of patients undergoing hepatectomies due to hepatic metastases with or without simultaneous colon resection. Methods: Data from 13 minor liver resections for colorectal liver metastases with or without simultaneous resection of the primary tumor incorporated into an ERAS protocol were evaluated. Demographic data, hepatectomies, adherence to the protocol, and some factors that may affect the results of a rapid recovery, as well as what is considered full recovery at discharge, were evaluated. Results: in the 13 resections the application of the protocol could be carried out. As a main result, a short hospital stay (3.69 days) was achieved, adherence to the protocol was high and the total recovery at discharge was 46.2%. Conclusion: the application of this protocol has been successful in terms of a frank reduction of the hospital stay. The number of patients is small but the results are encouraging. Key words: Colonic neoplasms; neoplasm metastasis; hepatectomy; clinical protocols; learning curve; clinical evolution; cost-effectiveness evaluation

Sobreexpresión de C-MET en carcinoma de vesícula y del tracto biliar: prevalencia y correlación clínico-molecular / Overexpression of C-MET in gallbladder and biliary tract carcinoma: prevalence and clinical-molecular correlation

El objetivo fue determinar la sobreexpresión de c-MET en pacientes con cáncer biliar y analizar asociaciones con parámetros clínicos. Este es un estudio descriptivo, longitudinal, retrospectivo y prospectivo. Se determinó la sobreexpresión por inmunohistoquímica en 58 pacientes con resultados: positivo fuerte, positivo débil y negativo. Se construyeron curvas de supervivencia global con el método de KaplanMeier en todos los pacientes y en subgrupos según estadío, género, origen tumoral y grado de diferenciación histológica. La diferencia en supervivencia global entre subgrupos se analizó por el método log-rank. La asociación entre sobreexpresión y grado de diferenciación se estudió por el método chi cuadrado. Las pruebas estadísticas se realizaron a dos colas con un valor de p 0.05. Veintinueve muestras (50%) fueron negativas, 24 (41%) positivas débiles y 5 (9%) positivas fuertes. La mediana de supervivencia fue 18.2, 11.3 y 11.7 meses en pacientes con sobreexpresión negativa, positiva débil y positiva fuerte, respectivamente. Sin embargo, la diferencia en supervivencia global entre pacientes c-MET negativos y positivos (fuerte y débil) no alcanzó significancia estadística (p 0.068). En los subgrupos los resultados fueron similares. La sobreexpresión se asoció al grado de diferenciación (p 0.015), mostrando una relación inversa; y no se correlacionó con tasa de respuesta a la quimioterapia y tiempo a la progresión. La sobreexpresión de c-MET es frecuente en cáncer biliar, se asocia al grado de diferenciación tumoral y podría tener valor pronóstico. Si la vía c-MET es importante, los fármacos inhibidores tendrían impacto en la supervivencia global (AU)

The objective was to determine the overexpression of c-MET in patients with biliary cancer and to analyze associations with clinical parameters. This is a descriptive, longitudinal, retrospective and prospective study. Overexpression was obtained by immunohistochemistry in 58 patients, with the following results: strong positive, weak positive and negative. Overall survival curves were constructed using the Kaplan-Meier method in all patients and in subgroups according to stage, gender, tumor origin and grade of histological differentiation. The difference in overall survival between groups was analyzed by the log-rank test. The association between overexpression and grade of differentiation was studied using the chisquare method. Statistical tests were two-tailed with a p value 0.05. Twenty nine samples (50%) were negative, 24 (41%) weak positive and 5 (9%) strong positive. Median survival was 18.2, 11.3 and 11.7 months in patients with negative, weak positive and strong positive overexpression, respectively. However, the difference in overall survival between negative and positive (strong and weak together) c-MET patients did not reach statistical significance (p 0.068). In the subgroup analyses the results were similar. Overexpression correlated with tumor grade (p 0.015), showing an inverse association; and was not associated neither with chemotherapy response rate nor with time to progression. Overexpression of c-MET is common in biliary cancer, is associated with grade of tumor differentiation and could have prognostic value. If the c-MET pathway is important, the inhibitory drugs would have an impact on overall survival (AU)

A recurrent p.Arg92Trp variant in steroidogenic factor-1 (NR5A1) can act as a molecular switch in human sex development.

Cell lineages of the early human gonad commit to one of the two mutually antagonistic organogenetic fates, the testis or the ovary. Some individuals with a 46,XX karyotype develop testes or ovotestes (testicular or ovotesticular disorder of sex development; TDSD/OTDSD), due to the presence of the testis-determining gene, SRY Other rare complex syndromic forms of TDSD/OTDSD are associated with mutations in pro-ovarian genes that repress testis development (e.g. WNT4); however, the genetic cause of the more common non-syndromic forms is unknown. Steroidogenic factor-1 (known as NR5A1) is a key regulator of reproductive development and function. Loss-of-function changes in NR5A1 in 46,XY individuals are associated with a spectrum of phenotypes in humans ranging from a lack of testis formation to male infertility. Mutations in NR5A1 in 46,XX women are associated with primary ovarian insufficiency, which includes a lack of ovary formation, primary and secondary amenorrhoea as well as early menopause. Here, we show that a specific recurrent heterozygous missense mutation (p.Arg92Trp) in the accessory DNA-binding region of NR5A1 is associated with variable degree of testis development in 46,XX children and adults from four unrelated families. Remarkably, in one family a sibling raised as a girl and carrying this NR5A1 mutation was found to have a 46,XY karyotype with partial testicular dysgenesis. These unique findings highlight how a specific variant in a developmental transcription factor can switch organ fate from the ovary to testis in mammals and represents the first missense mutation causing isolated, non-syndromic 46,XX testicular/ovotesticular DSD in humans.

An ancient protein-DNA interaction underlying metazoan sex determination.

DMRT transcription factors are deeply conserved regulators of metazoan sexual development. They share the DM DNA-binding domain, a unique intertwined double zinc-binding module followed by a C-terminal recognition helix, which binds a pseudopalindromic target DNA. Here we show that DMRT proteins use a unique binding interaction, inserting two adjacent antiparallel recognition helices into a widened DNA major groove to make base-specific contacts. Versatility in how specific base contacts are made allows human DMRT1 to use multiple DNA binding modes (tetramer, trimer and dimer). Chromatin immunoprecipitation with exonuclease treatment (ChIP-exo) indicates that multiple DNA binding modes also are used in vivo. We show that mutations affecting residues crucial for DNA recognition are associated with an intersex phenotype in flies and with male-to-female sex reversal in humans. Our results illuminate an ancient molecular interaction underlying much of metazoan sexual development.

Refining the regulatory region upstream of SOX9 associated with 46,XX testicular disorders of Sex Development (DSD).

Disorders of Sex Development (DSD) are a heterogeneous group of disorders affecting gonad and/or genito-urinary tract development and usually the endocrine-reproductive system. A genetic diagnosis is made in only around 20% of these cases. The genetic causes of 46,XX-SRY negative testicular DSD as well as ovotesticular DSD are poorly defined. Duplications involving a region located ∼600 kb upstream of SOX9, a key gene in testis development, were reported in several cases of 46,XX DSD. Recent studies have narrowed this region down to a 78 kb interval that is duplicated or deleted respectively in 46,XX or 46,XY DSD. We identified three phenotypically normal patients presenting with azoospermia and 46,XX testicular DSD. Two brothers carried a 83.8 kb duplication located ∼600 kb upstream of SOX9 that overlapped with the previously reported rearrangements. This duplication refines the minimal region associated with 46,XX-SRY negative DSD to a 40.7-41.9 kb element located ∼600 kb upstream of SOX9. Predicted enhancer elements and evolutionary-conserved binding sites for proteins known to be involved in testis determination are located within this region.

Assessment of early response to imatinib 800 mg after 400 mg progression by ¹8F-fluorodeoxyglucose PET in patients with metastatic gastrointestinal stromal tumors.

INTRODUCTION: Imatinib is the standard first-line therapy for advanced gastrointestinal stromal tumor. (18)F-fluorodeoxyglucose PET computed tomography (FDG PET/CT) shows a faster response than computed tomography in nonpretreated patients. PATIENTS & METHODS: After disease progression on imatinib 400 mg, 16 patients were exposed to 800 mg. Tumor response was evaluated by FDG PET/CT on days 7 and 37. Primary objective was to correlate early metabolic response (EMR) with progression-free survival (PFS). RESULTS: EMR by FDG PET/CT scan was not predictive of PFS. Median PFS in these patients was 3 months. Overall survival was influenced by gastric primary site (p = 0.05). CONCLUSION: The assessment of EMR by FDG PET/CT in patients with advanced gastrointestinal stromal tumor exposed to imatinib 800 mg was not predictive of PFS or overall survival.

Terapeutica con tuberculostaticos: cumplimiento en un hospital general / Treatment with tuberculostatic drugs: compliance in a general hospital

El objetivo de este trabajo fue evaluar el grado de cumplimiento de la terapéutica con tuberculostáticos en pacientes controlados en el Hospital Nacional de Clínicas de Córdoba y estabelecer las causas del abandono del tratamiento. Para ello, fueron incluidos todos los pacientes a los que se indicó tratamiento con tuberculostáticos desde enero de 1991 hasta diciembre de 1994 en nuestra institución, porhaberse realizado diagnóstico presuntivo o confirmado de tuberculosis. En el período citado se inició tratamiento con tuberculostáticos a 45 pacientes, 18 mujeres (40 por ciento) y 27 varones. Dieciseis pacientes (35,6 por ciento) no cumplieron en su totalidad el tiempo de tratamiento indicado. Nueve (56,3 por ciento) abandonaron antes de transcurridos 2 meses de iniciada la terapéutica y 7 luego de ese lapso. Se observóun porcentaje mayor de pacientes de sexo feminino en el grupo que no completó el tratamiento (62,5 por ciento) en relación al que lo completó (27,6 por ciento), p=0,02. Entre ambos grupos no hubo diferenciais estadísticamente significativas en la edad, la proporción de casos con TBC pulmonar y extrapulmonar o el promedio en meses de duración de los tratamientos indicados. Se logró estabelecer la causa de abandono en 14 casos. El 35,7 por ciento refiró haber interrumpido la terapéutica por negligencia propia, conociendo los riesgos de tal conducta; el 35,7 por ciento presentó intolerancia y no regresó a consultar; el 21,4 por ciento relató haber acudido a otro facultativo quien le indicó suspender la medicación sin realizar otros estudios y el 7,1 por ciento malentendió las indicaciones. Se concluye que en un hospital general de Córdoba la tasa de abandono del tratamiento con tuberculostáticos es elevada. En la mayoria de los casos la causa de dicho abandono tiene relación con diferencias potencialmente corregibles en la conducta del médico, el paciente o ambos.

Monodosis de fleroxacina para el tratamiento de la diarrea aguda estival en el adulto / Silgle dose of fleroxacine for the treatment of adult acute diarrhea

El propósito de este trabajo fue evaluar la eficacia y seguridad de fleroxacina en monodosis de 400 mg para la terapéutica antibiótica empirica de pacientes adultos con diarrea aguda. Se diseño un estudio prospectivo, randomizado, doble ciego, controlado con placebo, incluyéndose los pacientes adultos que concurrieron al hospital por diarrea aguda. Valores de p <0,05 fueron considerados estadísticamente significativos, 72 casos fueron asignados a fleroxacina y 73 a placebo. Se logró evaluar la respuesta al tratamiento en 38 casos de cada grupo, no habiendo entre los mismos diferencias significativas en relación a edad, sexo, deposiciones diarias al momentos de la inclusión, días transcurridos desde el inicio del cuadro y la consulta, otros síntomas además de diarrea, porcentaje de casos con copro y parasitológico positivo y utilización de tratamiento sintomático. Al tercer día desde la inclusión presentó criterios de curación el 72,2 por ciento de los pacientes del grupo fleroxacina y el 36,4 por ciento del grupo placebo; p=0,002. Entre los que recibieron fleroxacina y placebo, los promedios + DE de duración del cuadro fueron 2,2 + 1,2 y 3,2 + 2,0 días respectivamente, p=0,01. El porcentaje de pacientes que refirieron efectos adversos fue de 28 por ciento en el grupo fleroxacina y 16,7 por ciento en el grupo placebo; p=0,3. Se concluye que fleroxacina en monodosis de 400 mg es una alternativa eficaz y segura para el tratamiento antibiótico empírico de la diarrea aguda en el adulto.