Promoting networks between evidence-based medicine and values-based medicine in continuing medical education.

BACKGROUND: In recent years, medical practice has followed two different paradigms: evidence-based medicine (EBM) and values-based medicine (VBM). There is an urgent need to promote medical education that strengthens the relationship between these two paradigms. This work is designed to establish the foundations for a continuing medical education (CME) program aimed at encouraging the dialogue between EBM and VBM by determining the values relevant to everyday medical activities. METHODS: A quasi-experimental, observational, comparative, prospective and qualitative study was conducted by analyzing through a concurrent triangulation strategy the correlation between healthcare personnel-patient relationship, healthcare personnel's life history, and ethical judgments regarding dilemmas that arise in daily clinical practice.In 2009, healthcare personnel working in Mexico were invited to participate in a free, online clinical ethics course. Each participant responded to a set of online survey instruments before and after the CME program. Face-to-face semi-structured interviews were conducted with healthcare personnel, focusing on their views and representations of clinical practice. RESULTS: The healthcare personnel's core values were honesty and respect. There were significant differences in the clinical practice axiology before and after the course (P <0.001); notably, autonomy climbed from the 10th (order mean (OM) = 8.00) to the 3rd position (OM = 5.86). In ethical discernment, the CME program had an impact on autonomy (P ≤0.0001). Utilitarian autonomy was reinforced in the participants (P ≤0.0001). Regarding work values, significant differences due to the CME intervention were found in openness to change (OC) (P <0.000), self-transcendence (ST) (P <0.001), and self-enhancement (SE) (P <0.019). Predominant values in life history, ethical discernment and healthcare personnel-patient relation were beneficence, respect and compassion, respectively. CONCLUSIONS: The healthcare personnel participating in a CME intervention in clinical ethics improved high-order values: Openness to change (OC) and Self Transcendence (ST), which are essential to fulfilling the healing ends of medicine. The CME intervention strengthened the role of educators and advisors with respect to healthcare personnel. The ethical values developed by healthcare professionals arise from their life history and their professional formation.

Identification of two E-boxes that negatively modulate the activity of MyoD on the alpha-sarcoglycan core promoter.

The alpha-SG promoter is composed of a plethora of cis-regulatory elements, whose individual contribution to alpha-SG gene expression modulation remains unknown. We have identified a negative regulatory element in the alpha-SG distal promoter including two conserved E-boxes (E1 and E2), which interact with MyoD. We found that E1 and E2 negatively modulate the transactivation potential of MyoD on the alpha-SG core promoter. Moreover, such negative effect is mainly mediated by E2, which is surrounded by conserved nucleotides conferring MyoD binding capacity. Our results suggest that modulation of MyoD activity by E1, and particularly E2, contributes to the negative regulation of alpha-SG gene expression during myogenic differentiation.

pRB detection as a common event in human retinoblastomas: an immunohistochemical study.

Approximately 30% of the cases of retinoblastoma (RB), the childhood eye cancer, are inherited and are manifested by unilateral or bilateral tumor. In sporadic tumors, accounting for 70% of cases, only one eye is affected. RB has three histological features: undifferentiated anaplastic cells, retinoblast pattern, and differentiated pattern characterized by Flexner Wintersteiner rosettes (FWR). Currently, results concerning phosphoprotein RB (pRB) expression in RB tumors are contradictory. In this study we detected pRB immunohistochemically in 10 tumors from bilateral or unilateral RBs, which did not show gross chromosomal alterations in cytogenetic studies. Interestingly, pRB was undetectable in only one tumor where we found distinct histological features. Our results suggest that pRB immunopositivity may be common in these tumors. However, it does not rule out the possibility that pRB is functionally inactive in some cases. This may be due to the protein being present in phosphorylated form or being altered by point mutations not affecting its expression. Another possibility is that mechanisms other than RB1 gene changes may lead to retinoblastoma because not all cases of retinoblastoma show gene alterations. Together these findings may be useful in understanding the molecular mechanisms associated with this type of pediatric tumor.

Characterization of mtDNA haplogroups in 14 Mexican indigenous populations.

In this descriptive study we investigated the genetic structure of 513 Mexican indigenous subjects grouped in 14 populations (Mixteca-Alta, Mixteca-Baja, Otomi, Purépecha, Tzeltal, Tarahumara, Huichol, Nahua-Atocpan, Nahua-Xochimilco, Nahua-Zitlala, Nahua-Chilacachapa, Nahua-Ixhuatlancillo, Nahua-Necoxtla, and Nahua-Coyolillo) based on mtDNA haplogroups. These communities are geographically and culturally isolated; parents and grandparents were born in the community. Our data show that 98.6% of the mtDNA was distributed in haplogroups A1, A2, B1, B2, C1, C2, D1, and D2. Haplotype X6 was present in the Tarahumara (1/53) and Huichol (3/15), and haplotype L was present in the Nahua-Coyolillo (3/38). The first two principal components accounted for 95.9% of the total variation in the sample. The mtDNA haplogroup frequencies in the Purépecha and Zitlala were intermediate to cluster 1 (Otomi, Nahua-Ixhuatlancillo, Nahua-Xochimilco, Mixteca-Baja, and Tzeltal) and cluster 2 (Nahua-Necoxtla, Nahua-Atocpan, and Nahua-Chilacachapa). The Huichol, Tarahumara, Mixteca-Alta, and Nahua-Coyolillo were separated from the rest of the populations. According to these findings, the distribution of mtDNA haplogroups found in Mexican indigenous groups is similar to other Amerindian haplogroups, except for the African haplogroup found in one population.

WITHDRAWN: Identification of two E-boxes that negatively modulate the activity of MyoD on the alpha-sarcoglycan core promoter.

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Biochem. Biophys. Acta, doi:10.1016/j.bbagrm.2007.09.002. The duplicate article has therefore been withdrawn.

Molecular study of VWF gene from Mexican Mestizo patients with von Willebrand disease, and the finding of three new mutations.

To investigate the origin of von Willebrand disease in Mexican Mestizo population, we analyzed exons 18, 19, 20, 28, 45, and 52 of the VWF gene from 34 Mexican Mestizo index cases, 28 of them affected but not related, using DNA amplification by polymerase chain reaction and direct sequencing. We found three novel mutations: E1447Q in one patient with type 1; P2781S in one patient with type 2M; and P812L in another type 1/2N patient. These mutations were not found in 100 normal alleles. Moreover, we found other mutations previously reported in the literature; one of them (G1609R) was the most frequent (6/28) in patients with VWD type 2A. This is the first molecular study in a Mexican group that has a particular mixture of Indigenous, Caucasian, and African genes.

Expression and function of utrophin associated protein complex in stretched endothelial cells: dissociation and activation of eNOS.

Several studies have emphasized the relevance of dystrophin-associated protein complex (DAPC) to maintain the vascular function. Previously we postulated the presence of an utrophin associated protein complex (UAPC) in endothelium from umbilical cord vessels. In the present work, we demonstrate that utrophin (UTR) indeed forms a complex, with beta-dystroglycan (DG), epsilon-sarcoglycan (SG), caveolin-1 (cav-1), and endothelial nitric oxide synthase (eNOS) in human umbilical vein endothelial cells (HUVEC) by co-immunoprecipitation analysis. Additionally, we observed an increment in the protein levels of epsilon-SG, beta-DG, UTR and cav-1 after mechanical stretching. Interestingly, this stimulus also induced eNOS up-regulation, activation and release from the UAPC, and led to a significant increase in nitric oxide (NO) production. Finally, we propose that UAPC in HUVECs may play an important role in the regulation of vascular tone.

Partial characterization of the mouse alpha-sarcoglycan promoter and its responsiveness to MyoD.

The mouse alpha-sarcoglycan gene is expressed in muscle cells during differentiation, but its transcriptional regulation is not understood. We have characterized the promoter region of the mouse alpha-sarcoglycan gene. This region is composed of positive and negative regulatory elements that respond to the myogenic differentiation environment. Accordingly, MyoD transactivates the alpha-sarcoglycan full-length and the proximal promoter. Chromatin immunoprecipitation assays revealed that MyoD, TFIID, and TFIIB interact with the distal promoter in C2C12 myoblasts, a stage at which the alpha-SG promoter appears to drive basal activity. In myotubes, such factors are located concomitantly at the distal promoter and at a DNA region around the proximal promoter. In agreement with these results, TFIID and TFIIB co-immunoprecipitate with MyoD. We conclude that the alpha-SG promoter is activated by MyoD, which interacts with TFIID and TFIIB in a protein complex differentially located at the distal promoter and around the proximal promoter during myogenic cell differentiation.

A molecular analysis by gene expression profiling reveals Bik/NBK overexpression in sporadic breast tumor samples of Mexican females.

BACKGROUND: Breast cancer is one of the most frequent causes of death in Mexican women over 35 years of age. At molecular level, changes in many genetic networks have been reported as associated with this neoplasia. To analyze these changes, we determined gene expression profiles of tumors from Mexican women with breast cancer at different stages and compared these with those of normal breast tissue samples. METHODS: 32P-radiolabeled cDNA was synthesized by reverse transcription of mRNA from fresh sporadic breast tumor biopsies, as well as normal breast tissue. cDNA probes were hybridized to microarrays and expression levels registered using a phosphorimager. Expression levels of some genes were validated by real time RT-PCR and immunohistochemical assays. RESULTS: We identified two subgroups of tumors according to their expression profiles, probably related with cancer progression. Ten genes, unexpressed in normal tissue, were turned on in some tumors. We found consistent high expression of Bik gene in 14/15 tumors with predominant cytoplasmic distribution. CONCLUSION: Recently, the product of the Bik gene has been associated with tumoral reversion in different neoplasic cell lines, and was proposed as therapy to induce apoptosis in cancers, including breast tumors. Even though a relationship among genes, for example those from a particular pathway, can be observed through microarrays, this relationship might not be sufficient to assign a definitive role to Bik in development and progression of the neoplasia. The findings herein reported deserve further investigation.

Gene identification by cDNA arrays in HPV-positive cervical cancer.

BACKGROUND: One of the most frequent malignancies in women worldwide is carcinoma of the uterine cervix. High-risk human papillomavirus (HPV) infection is considered the most important etiological factor of uterine cervical cancer. Our aim was to identify novel cellular genes that could potentially act as predictive molecular markers for human cervical cancer by means of cDNA arrays. METHODS: We used cDNA arrays to examine the expression profiles of six cell lines derived from human cervical cancer, three HPV+ tumor samples and three normal (HPV-) epithelium tissues. Data normalization was performed and the top overexpressed genes were obtained. Hierarchical cluster was performed and, to validate some of the differentially expressed genes between normal and carcinogenic samples, semi-quantitative RT-PCR, in situ hybridization and immunohistochemistry were performed in tissue samples. RESULTS: Four genes were demonstrated to be consistently overexpressed in invasive cervical cancer biopsies; three novel genes not previously related to cervical cancer: MMP10, Lamc2 and Claudin 1. Moreover, overexpression of IL6 and VEGF was corroborated. CONCLUSIONS: The identification of characteristic molecular changes in cervical cells by carcinogenesis and HPV infection can lead to a better understanding of cervical cancer. cDNA arrays are beginning to provide new possible molecular markers for prognosis and diagnosis. This technology could eventually help to elucidate the biological differences of the particular mechanisms associated with each different HPV-type infection and those with a poor prognosis.

Glu298Asp endothelial nitric oxide synthase polymorphism is a risk factor for erectile dysfunction in the Mexican Mestizo population.

Penile erection depends on the balanced action between antagonist vasoactive molecules such as nitric oxide (NO) and angiotensin. Endothelial nitric oxide synthase (eNOS) and angiotensin-converting enzyme (ACE) polymorphisms have been associated with endothelial dysfunction, which is described as a cause of erectile dysfunction (ED). Endothelial NOS and ACE are both regulators of vascular and corporal smooth muscle tone, which are connected by interaction between the NO-cyclic guanosine monophosphate pathway and the renin-angiotensin system. We analyzed the frequencies of 894 G/T (Glu298Asp) eNOS and ACE I/D polymorphisms in Mexican patients with ED (n=53) and in an age-matched control group (n=62). The populations analyzed were in Hardy Weinberg equilibrium. We found significant differences in allelic (chi2=4.42; P=.03) and genotypic frequencies (chi2=3.96; P=.04) between patients and controls for the 894 G/T eNOS polymorphism. Presence of the 894T allele in carriers increased the risk of ED (odds ratio [TT + GT versus GG] = 2.37; 95% confidence interval, 1.08 to 5.21; P=.02). Multiple logistic regression analysis showed that the Glu298Asp polymorphism was an independent factor for ED, as was diabetes mellitus, hypertension, cardiac disease, and cigarette smoking. No association was found between ACE I/D polymorphism and ED in the population studied. Therefore, our results suggest that Glu298Asp eNOS polymorphism plays a role as a genetic susceptibility factor for ED.

Identification of chromosomal changes with comparative genomic hybridization in sporadic breast cancer in Mexican women.

Breast cancer is the second leading cause of death in women older than 35 years in Mexico. In this study, we used comparative genomic hybridization (CGH) to analyze sporadic breast cancers at stages II and III from untreated patients. We obtained 4.1 chromosomal alterations per sample, less than in previous reports. We identified a small region in Xq27 with high-level amplification in 3 of 16 samples. This amplification has been reported only in pancreatic and gastric cancer cell lines and in testis tumors; in addition, this amplification had been reported in one primary breast cancer, but in a more extended region that we identified. We also identified a loss in 2p13, not previously reported in this neoplasia. The most frequent alterations were amplifications in 4q, 5q, 8q, 12p, and 13q and losses in 1p, 8p, 16p, 19q, and Xp. CGH provides data for better understanding of molecular events in this neoplasia.

NFI-C2 negatively regulates alpha-sarcoglycan promoter activity in C2C12 myoblasts.

alpha-Sarcoglycan striated muscle-specific protein is a member of the sarcoglycan-sarcospan complex. Positive and negative transcriptional regulation of sarcoglycan genes are important in sarcoglycan's intracellular localization and sarcolemmal stability. In the present work we assessed the function of NFI transcription factors in the regulation of alpha-sarcoglycan promoter through the C2C12 cell line differentiation. NFI factors act alternatively as activators and negative modulators of alpha-sarcoglycan promoter activity. In myoblasts NFI-A1.1 and NFI-B2 are activators, whereas NFI-C2 and NFI-X2 are negative regulators. In myotubes, all NFI members are activators, being NFI-C2 the less potent. We identified the alpha-sarcoglycan promoter NFI-C2 response element by testing progressive deletion constructs and point mutations in C2C12 cells over-expressing NFI-C2. Gel-shift and chromatin immunoprecipitation experiments demonstrated that NFI factors are indeed interacting in vitro and in vivo with the binding sequence. These results suggest a NFI role in C2C12 cell differentiation.

Endothelial nitric oxide synthase gene polymorphism in the Indian and Mestizo populations of Mexico.

Endothelium-derived nitric oxide (NO) is an important factor in vasodilation synthesized by endothelial nitric oxide synthase (eNOS). A polymorphism (894 G to T) in exon 7 of the eNOS gene causes the conversion of Glu to Asp in position 298. The Glu298Asp polymorphism has been extensively associated with cardiovascular disease. We determined the Glu298Asp polymorphism frequency in healthy Mexican Mestizo, Huastec, Mayo, and Mayan populations by the endonuclease restriction method. The four populations analyzed were in Hardy-Weinberg equilibrium. Allele frequencies were similar among Mexican populations but different when compared with Caucasians. However, when compared with allele frequencies in Asian populations, Mestizo and Huastec allele frequencies were significantly different. Genotypically, only the Mestizos presented Asp298 homozygosity. The absence of double mutants in Indian populations resembles that in Asians. With these data, we conclude that the low frequency of the eNOS Glu298Asp polymorphism in Indian and Mestizo populations of Mexico is related to the Asian origin of Amerindian groups.

Severe congenital muscular dystrophy in a Mexican family with a new nonsense mutation (R2578X) in the laminin alpha-2 gene.

The congenital muscular dystrophies (CMDs) are a heterogeneous group of autosomal recessive disorders. Approximately one half of cases diagnosed with classic CMD show primary deficiency of the laminin alpha2 chain of merosin. Complete absence of this protein is usually associated with a severe phenotype characterized by drastic muscle weakness and characteristic changes in white matter in cerebral magnetic resonance imaging (MRI). Here we report an 8-month-old Mexican female infant, from a consanguineous family, with classical CMD. Serum creatine kinase was elevated, muscle biopsy showed dystrophic changes, and there were abnormalities in brain MRI. Immunofluorescence analysis demonstrated the complete absence of laminin alpha2. In contrast, expression of alpha-, beta-, gamma-, and delta-sarcoglycans and dystrophin, all components of the dystrophin-glycoprotein complex, appeared normal. A homozygous C long right arrow T substitution at position 7781 that generated a stop codon in the G domain of the protein was identified by mutation analysis of the laminin alpha2 gene ( LAMA2). Sequence analysis on available DNA samples of the family showed that parents and other relatives were carriers of the mutation.

Identification of novel mutations in the RB1 gene in Mexican patients with retinoblastoma.

Retinoblastoma (RB) is a childhood tumor of the eye with an average incidence of one case in every 15,000-20,000 live births and occurs in sporadic or hereditary form. This cancer results from loss or inactivation of the RB1 gene located at 13q14.1. This gene encodes for a 110 Kd nuclear phosphoprotein (pRB) that plays a major role in cell proliferation control. Different types of mutations in the RB1 gene have been reported, but point mutations are the most common. There are no molecular studies on RB1 gene mutation in Mexican patients. In this study, 19 patients with bilateral or unilateral RB were analyzed. Genetic and cytogenetic studies were carried out. Detection of RB1 gene mutations was done using single-strand conformational polymorphism (SSCP). Five conformational polymorphisms were identified in different exons. In all cases, SSCP sequence showed new non-described mutations that produced a frameshift on the open reading frame. The identification of mutations in the RB1 gene contributes to basic knowledge of this neoplasia and permits the possibility to offer adequate genetic counseling to relatives at risk.

Desarrollo de bancos de muestras para investigación en epidemiología molecular / Development of sample banks for research in molecular epidemiology

En los últimos años se ha implementado la metodología para el desarrollo de bancos de material genético, mediante el establecimiento de líneas celulares transformadas, la extracción directa del DNA, el almacenamiento de sangre u otros tejidos criopreservados y el estudio de muestras conservadas en bloques de parafina. Los propósitos principales para la creación de estos bancos pueden ser académicos y de investigación, principalmente relacionados con el mapeo génico o contemplar aspectos de servicio, tales como estudios familiares de ligamiento por riesgo genético, identificación en casos de medicina forense y tipificación para trasplantes. Estos desarrollos tienen muy importantes implicaciones éticas y legales y crean derechos y obligaciones por parte de los donadores y por quienes manejan los bancos de material biológico