Mastopexy for secretory carcinoma of breast in a young female: a case report.

Secretory carcinoma, a triple-negative benign tumor, is one of the rarest malignancies of the breast which rarely metastasizes. Surgical excision via lumpectomy or mastectomy is the mainstay of treatment, but in young patients, mastopexy can be a better option cosmetically. A 26-year-old woman presented with a lump in her right breast that, on ultrasonography, was revealed to be a multi lobulated solid lesion measuring 25 × 16 mm2 in the retro areolar region at a 4 o'clock position. It turned out to be secretory carcinoma of the breast in a tru-cut biopsy. Vertical Mastopexy was opted for the removal and simultaneous reconstruction of the breast, which was followed by adjuvant chemotherapy and radiotherapy. Vertical mastopexy showed that the tumor was removed, and the breast was restored to its original form simultaneously. This procedure gave better results clinically and cosmetically. The patient had an uneventful recovery and is on a regular follow-up.

A Recurrent Nonsense Mutation in NECTIN4 Underlying Ectodermal Dysplasia-Syndactyly Syndrome with a Novel Phenotype in a Consanguineous Kashmiri Family.

EDSS1, a syndrome characterized by ectodermal dysplasia-syndactyly, is inherited in an autosomal recessive manner due to mutations in the NECTIN4/PVRL4 gene. Clinical manifestations of the syndrome include defective nail plate, sparse to absent scalp and body hair, spaced teeth with enamel hypoplasia, and bilateral cutaneous syndactyly in the fingers and toes. Here, we report a consanguineous family of Kashmiri origin presenting features of EDSS1. Using whole exome sequencing, we found a recurrent nonsense mutation (NM_030916: c.181C > T, p.(Gln61 ∗)) in the NECTIN4 gene. The variant segregated perfectly with the disorder within the family. The candidate variant was absent in 50 in-house exomes pertaining to other disorders from the same population. In addition to the previously reported clinical phenotype, an upper lip cleft was found in one of the affected members as a novel phenotype that is not reported by previous studies in EDSS1 patients. Therefore, the study presented here, which was conducted on the Kashmiri population, is the first to document a NECTIN4 mutation associated with the upper lip cleft as a novel phenotype. This finding broadens the molecular and phenotypic spectrum of EDSS1.

A homozygous missense variant in the MLC1 gene underlies megalencephalic leukoencephalopathy with subcortical cysts in large kindred: Heterozygous carriers show seizure and mild motor function deterioration.

Megalencephalic leukoencephalopathy with subcortical cysts (MLC) is a rare type of leukodystrophy characterized by epileptic seizures, macrocephaly, and vacuolization of myelin and astrocyte. The magnetic resonance imaging of the brain of MLC patients shows diffuse white-matter anomalies and the occurrence of subcortical cysts. MLC features have been observed in individuals having mutations in the MLC1 or HEPACAM genes. In this study, we recruited a six generation large kindred with five affected individuals manifesting clinical features of epileptic seizures, macrocephaly, ataxia, and spasticity. In order to identify the underlying genetic cause of the clinical features, we performed whole-genome genotyping using Illumina microarray followed by detection of loss of heterozygosity (LOHs) regions. One affected individual was exome sequenced as well. Homozygosity mapping detected several LOH regions due to extensive consanguinity. An unbiased and hypothesis-free exome data analysis identified a homozygous missense variant (NM_015166.3:c.278C>T) in the exon 4 of the MLC1 gene. The variant is present in the LOH region on chromosome 22q (50 Mb) and segregates perfectly with the disorder within the family in an autosomal recessive manner. The variant is present in a highly conserved first cytoplasmic domain of the MLC1 protein (NM_015166.3:p.(Ser93Leu)). Interestingly, heterozygous individuals show seizure and mild motor function deterioration. We propose that the heterozygous variant in MLC1 might disrupt the functional interaction of MLC1 with GlialCAM resulting in mild clinical features in carriers of the variant.

A Profile of Colorectal Tumors Presenting as Emergency.

OBJECTIVE:  To determine the factors, management and outcome of colorectal tumors presenting at Emergency Department, Mayo Hospital, Lahore. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Accident & Emergency Department, Mayo Hospital, Lahore, from August 2017 to July 2019. METHODOLOGY: Conducted on 40 consecutive patients who presented in the Accident and Emergency Department, Mayo Hospital, Lahore; determined to have colon or rectal cancer as the cause of intestinal obstruction or perforation, were studied. Data was abstracted from patient charts. Studied variables included patient's demographic data, indication for admission, surgical procedure done, complications, histopathology and mortality rate. RESULTS: Forty patients underwent operations of colon and rectum during the study period. Mean age at presentation was 37.8 ± 16.7 years. Intestinal obstruction (75%) was the main presenting symptom. Ascending colon was the main site involved (50%), followed by recto-sigmoid mass (15%) and rectal mass (12.5%); 80% patients subjected to the stoma formation. Electrolyte imbalance and wound infection were the most common medical and surgical complications. Adenocarcinoma was the most common tumor on histopathology (92.5%). After surgery 87.5% patients survived and 12.5% patients expired. Factors significantly associated with worse outcome were greater ASA score (p=0.004), absence of screening colonoscopy in the past (p=0.013) and postoperative medical complications (p<0.001). CONCLUSION: Colorectal tumor cases continue to present in emergency in a high number. Male gender, young age and ascending colon cancers were more frequent among such cases. Most patients had to undergo stoma formation in emergency. Mortality is significantly associated with higher ASA score, absence of screening colonoscopy and postoperative medical complications. Key Words: Colorectal carcinoma, Adenocarcinoma, Ascending colon, Wound infection, Emergency, Young males, Screening colonoscopy, ASA score.

Surgical Outcome of Peripheral Vascular Injuries in Adults.

OBJECTIVE: To describe the management and outcome of adult patients after peripheral vascular injuries. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Accident & Emergency Department, Mayo Hospital Lahore, Pakistan, from January 2014 to December 2018. METHODOLOGY: All adult trauma patients (aged ≥13 years), who were admitted following injury to peripheral blood vessels regardless injuries, were included. Variables including patient data, mechanism of injury, vessel involved, injury severity score (ISS), surgical procedure etc. were retrospectively extracted from patient charts. Binary logistic and multinomial regression analyses were performed. The p-value <0.05 was considered significant for mortality and limb outcome. RESULTS: There were 117 patients, with mean age of 28.9±11.6 years. The commonest cause was blunt trauma (55.6%). The popliteal artery was most commonly involved (44.4%). Complete transection of artery was the most common type of injury (58.1%). The mean ISS was 17.2 ± 10. Reverse saphenous vein graft (RSVG) was the most common surgical repair (49.6%) procedure. Wound infection (17.1%) was the main complication. Limb salvage rate was 73.5% and mortality rate was 5.1%. Variables significantly influencing the limb outcome (amputated vs. salvaged) were duration of injury (p <0.001), concomitant body injury (p=0.009), ISS (p <0.001), surgical procedure (p <0.001), hemoglobin on presentation (p<0.001), number of blood transfusion (p=0.05) complications after surgery (p <0.001) and referral or not (p=0.001). Factors significantly associated with mortality were duration of injury (p=0.008), ISS (p = 0.002) and complications after surgery (p=0.011). CONCLUSION: Low hemoglobin on presentation, postoperative increased requirement of blood transfusions and having reverse saphenous graft as procedure were independent risk factors for amputation. ISS score and postoperative complications led to higher amputation and mortality rates after surgery. Key Words: Injury severity score (ISS), Glasgow coma scale (GCS), Reverse saphenous graft (RSVG), Fasciotomy, Popliteal artery, Mortality.

Identification of a recurrent nonsense mutation in HR gene responsible for atrichia with papular lesions in two Kashmiri families.

BACKGROUND: Congenital atrichia (CA) is a rare form of irreversible alopecia with an autosomal recessive mode of inheritance. This form of hair loss is mainly associated with mutations in the human hairless (HR) gene located at chromosome 8p21.3. An additional unique feature atrichia with papular lesions (APL) comprises keratin-filled cysts known as papules. The present study aimed to uncover the underlying genetic causes of APL in two consanguineous Kashmiri families. METHODS: In the present study, two consanguineous families of Kashmiri origin with APL displaying an autosomal recessive mode of inheritance were investigated. Whole exome and Sanger sequencing followed by bioinformatic studies, variant prioritization, Sanger validation and segregation analysis was performed to find the mutation. RESULTS: A recurrent nonsense (NM_005144: c.2818C > T:p.Arg940*) mutation was detected in exon 13 of the human HR gene. CONCLUSIONS: Whole exome sequencing analysis has widely been used in the screening of single gene disorders mutations, both in research and diagnostic laboratories. Sanger sequencing alone for genes such as HR becomes expensive and time consuming. Instead, it is recommended that a patient is to screen by whole exome sequencing and then special attention first focuses on known genes of the APL phenotype. This is helpful for intime diagnosis, being more efficient and economic. The results obtained in the present study may contribute to prenatal diagnosis, carrier secreening and the genetic counseling of families with the APL phenotype in Kashmiri poplution.

A recurrent missense mutation in the EDAR gene causes severe autosomal recessive hypohidrotic ectodermal dysplasia in two consanguineous Kashmiri families.

BACKGROUND: Hypohidrotic ectodermal dysplasia (HED) is a rare congenital disorder arising from the abnormal development of ectoderm derived structures, including skin, hair, nails, teeth and glands. These patients have sparse hair on the whole body, including the scalp, as well as hypoplastic teeth. They have no resistance to heat as a result of abnormal sweat glands. In total, four genes, namely ectodysplasin A (EDA), ectodysplasin A receptor (EDAR), EDAR-associated death domain protein (EDARADD) and Wnt family member 10A (WNT10A), are known to be involved in the etiology of HED. METHODS: In the present study, we investigated two consanguineous Kashmiri families (A &B) with an autosomal recessive form of HED. Using whole exome sequencing and different bioinformatics tools, we detected a recurrent mutation causing severe HED. RESULTS: We identified an already known rare homozygous missense (NM_022336 c.1300 T>C; p.W434R; minor allele frequency 0.00007) variant in exon 12 of the EDAR gene. This variant segregated with a homozygous form in all patients and their obligate carriers were heterozygous. A panel of > 100 unrelated ethnically matched controls was screened, and the mutation was not identified outside the families. Furthermore, the candidate variant is predicted to be damaging by in silico software giving a CADD (Combined Annotation Dependent Depletion) score of 25.5, which indicates that the variant is among the top 1% of the deleterious variants in the human genome. CONCLUSIONS: The identification of the same homozygous mutation segregating with disease in two different families supports the important role of the gene in the development of the disorder and this may contribute to novel approaches, prenatal diagnosis and genetic counseling of families with EDAR related disorders.

FAM92A Underlies Nonsyndromic Postaxial Polydactyly in Humans and an Abnormal Limb and Digit Skeletal Phenotype in Mice.

Polydactyly is a common congenital anomaly of the hand and foot. Postaxial polydactyly (PAP) is characterized by one or more posterior or postaxial digits. In a Pakistani family with autosomal recessive nonsyndromic postaxial polydactyly type A (PAPA), we performed genomewide genotyping, linkage analysis, and exome and Sanger sequencing. Exome sequencing revealed a homozygous nonsense variant (c.478C>T, p.[Arg160*]) in the FAM92A gene within the mapped region on 8q21.13-q24.12 that segregated with the PAPA phenotype. We found that FAM92A is expressed in the developing mouse limb and E11.5 limb bud including the progress zone and the apical ectodermal ridge, where it strongly localizes at the cilia level, suggesting an important role in limb patterning. The identified variant leads to a loss of the FAM92A/Chibby1 complex that is crucial for ciliogenesis and impairs the recruitment and the colocalization of FAM92A with Chibby1 at the base of the cilia. In addition, we show that Fam92a-/- homozygous mice also exhibit an abnormal digit morphology, including metatarsal osteomas and polysyndactyly, in addition to distinct abnormalities on the deltoid tuberosity of their humeri. In conclusion, we present a new nonsyndromic PAPA ciliopathy due to a loss-of-function variant in FAM92A. © 2018 American Society for Bone and Mineral Research.

Correction to: RF-ablation pattern shaping employing switching channels of dual bipolar needle electrodes: ex vivo results.

The original version of this article was published without funding note. The funding note is given below.

RF-ablation pattern shaping employing switching channels of dual bipolar needle electrodes: ex vivo results.

PURPOSE: Radiofrequency (RF) ablation with mono- or bipolar electrodes is a common procedure for hepatocellular carcinoma (HCC) with a low rate of recurrence for small size tumors. For larger lesions and/or non-round/ellipsoid shapes RF ablation has some limitations and generally does not achieve comparable success rates to microwave ablation or high-intensity focused ultrasound therapies. MATERIALS AND METHODS: To shape RF ablations for matching a tumor size and geometry, we have developed an electronic channel switch box for two bipolar needles that generates multiple selectable ablation patterns. The setup can be used with commercially available mono- or bipolar RF generators. The switch box provides ten selectable ablation procedures to generate different ablation patterns without a relocation of a needle. Five patterns were exemplary generated in ex vivo tissue of porcine liver and chicken breast and visually characterized. RESULTS: Different ablation patterns, e.g., in a L- or U-shape, were achieved. In chicken breast a maximum ablation with a diameter of [Formula: see text] was obtained and in porcine liver [Formula: see text] with electrodes of [Formula: see text] length. CONCLUSION: The resulting ablations with the electronic switch box and two bipolar needles show the potential ability to manage RF therapies of complex and large tumor geometries. Next steps would be to validate the actual tissue ablation volumes in further ex vivo and preclinical studies and against simulation results.

Expansion of the spectrum of ITGB6-related disorders to adolescent alopecia, dentogingival abnormalities and intellectual disability.

Alopecia with mental retardation (APMR) is a very rare disorder. In this study, we report on a consanguineous Pakistani family (AP91) with mild-to-moderate intellectual disability, adolescent alopecia and dentogingival abnormalities. Using homozygosity mapping, linkage analysis and exome sequencing, we identified a novel rare missense variant c.898G>A (p.(Glu300Lys)) in ITGB6, which co-segregates with the phenotype within the family and is predicted to be deleterious. Structural modeling shows that Glu300 lies in the ß-propeller domain, and is surrounded by several residues that are important for heterodimerization with α integrin. Previous studies showed that ITGB6 variants can cause amelogenesis imperfecta in humans, but patients from family AP91 who are homozygous for the c.898G>A variant present with neurological and dermatological features, indicating a role for ITGB6 beyond enamel formation. Our study demonstrates that a rare deleterious variant within ITGB6 causes not only dentogingival anomalies but also intellectual disability and alopecia.

A Novel Locus for Ectodermal Dysplasia of Hair, Nail and Skin Pigmentation Anomalies Maps to Chromosome 18p11.32-p11.31.

Ectodermal dysplasias (EDs) are a large heterogeneous group of inherited disorders exhibiting abnormalities in ectodermally derived appendages such as hair, nails, teeth and sweat glands. EDs associated with reticulated pigmentation phenotype are rare entities for which the genetic basis and pathophysiology are not well characterized. The present study describes a five generation consanguineous Pakistani family segregating an autosomal recessive form of a novel type of ectodermal dysplasia. The affected members present with sparse and woolly hair, severe nail dystrophy and reticulate skin pigmentation. After exclusion of known gene loci related with other skin disorders, genome-wide linkage analysis was performed using Illumina HumanOmniExpress beadchip SNP arrays. We linked this form of ED to human chromosome 18p11.32-p11.31 flanked by the SNPs rs9284390 (0.113Mb) and rs4797100 (3.14 Mb). A maximum two-point LOD score of 3.3 was obtained with several markers along the disease interval. The linkage interval of 3.03 Mb encompassed seventeen functional genes. However, sequence analysis of all these genes did not discover any potentially disease causing-variants. The identification of this novel locus provides additional information regarding the mapping of a rare form of ED. Further research, such as the use of whole-genome sequencing, would be expected to reveal any pathogenic mutation within the disease locus.

Cellular therapy in combination with cytokines improves survival in a xenograft mouse model of ovarian cancer.

Studies have shown enhanced survival of ovarian cancer patients in which the tumors are infiltrated with tumor infiltrating lymphocytes and natural killer cells showing the importance of immune surveillance and recognition in ovarian cancer. Therefore, in this study, we tested cellular immunotherapy and varying combinations of cytokines (IL-2 and/or pegylated-IFNα-2b) in a xenograft mouse model of ovarian cancer. SKOV3-AF2 ovarian cancer cells were injected intra-peritoneally (IP) into athymic nude mice. On day 7 post-tumor cell injection, mice were injected IP with peripheral blood mononuclear cells (PBMC; 5 × 10(6) PBMC) and cytokine combinations [IL-2 ± pegylated-IFNα-2b (IFN)]. Cytokine injections were continued weekly for IFN (12,000 U/injection) and thrice weekly for IL-2 (4000 U/injection). Mice were euthanized when they became moribund due to tumor burden at which time tumor and ascitic fluid were measured and collected. Treatment efficacy was measured by improved survival at 8 weeks and overall survival by Kaplan-Meier analysis. We observed that the mice tolerated all treatment combinations without significant weight loss or other apparent illness. Mice receiving PBMC plus IL-2 showed improved median survival (7.3 weeks) compared to mice with no treatment (4.2 weeks), IL-2 (3.5 weeks), PBMC (4.0 weeks), or PBMC plus IL-2 and IFN (4.3 weeks), although PBMC plus IL-2 was not statistically different than PBMC plus IFN (5.5 weeks, p > 0.05). We demonstrate that cytokine-stimulated cellular immune therapy with PBMC and IL-2 was well tolerated and resulted in survival advantage compared to untreated controls and other cytokine combinations in the nude-mouse model.

Report on influenza A and B viruses: their coinfection in a Saudi leukemia patient.

PURPOSE: Influenza A and B viruses are the leading cause of respiratory infections in children worldwide, particularly in developing countries. There is a lack of data on coinfection of influenza A and B viruses circulating in Saudi Arabia. In this study, we aimed to identify the circulation of influenza viruses that contribute to respiratory tract infections in Saudi children. METHODS: We collected 80 nasopharyngeal aspirates (NPAs) from hospitalized children with acute respiratory illness (ARI) at Riyadh during the period extended from October 2010 till April 2011. Samples were tested for the common respiratory viruses including influenza viruses by RT-PCR. RESULTS: Overall, 6 samples were found positive for influenza A and/or B viruses. Among these positive clinical samples, only one collected sample from a female one-year-old immunocompromised child with leukemia showed a coinfection with influenza A and B viruses. In present study coinfection was confirmed by inoculation of the clinical specimen in specific pathogenfree embryonating chicken eggs and identification of the virus isolates by hemagglutination and one-step RT-PCR. CONCLUSION: This study opens the scene for studying the role of influenza virus's coinfection in disease severity and virus evolution. Further studies are required to better understand the clinical importance of viral coinfection.

Use of vascularised free fibula in limb reconstruction (for non-malignant defects).

The case series was conducted at the Department of Plastic Surgery, Combined Military Hospital, Rawalpindi, from June 2009 to May 2011, and comprised 19 patients in whom free fibula flap was performed for upper and lower limb reconstruction, using SPSS 16. Results showed that flap survival was 100%. One (5.2%) flap was re-explored for venous congestion and was salvaged. One (5.2%) patient of congenital pseudoarthrosis of tibia had a fracture of the fibula and was treated with external fixation. Average follow up was 8 months. Mean union time and full weight-bearing was 6.5 +/- 1.34 months (range 3-8 months) and 9 months, respectively. No recurrence of pseudoathrosis was observed until the last follow up, with only a 1.5 cm length discrepancy in one patient. The results proved that a microvascular free fibular flap heals rapidly, causes early functional recovery and it can be raised as an osteocutaneous flap.

Mutation in NSUN2, which encodes an RNA methyltransferase, causes autosomal-recessive intellectual disability.

Causes of autosomal-recessive intellectual disability (ID) have, until very recently, been under researched because of the high degree of genetic heterogeneity. However, now that genome-wide approaches can be applied to single multiplex consanguineous families, the identification of genes harboring disease-causing mutations by autozygosity mapping is expanding rapidly. Here, we have mapped a disease locus in a consanguineous Pakistani family affected by ID and distal myopathy. We genotyped family members on genome-wide SNP microarrays and used the data to determine a single 2.5 Mb homozygosity-by-descent (HBD) locus in region 5p15.32-p15.31; we identified the missense change c.2035G>A (p.Gly679Arg) at a conserved residue within NSUN2. This gene encodes a methyltransferase that catalyzes formation of 5-methylcytosine at C34 of tRNA-leu(CAA) and plays a role in spindle assembly during mitosis as well as chromosome segregation. In mouse brains, we show that NSUN2 localizes to the nucleolus of Purkinje cells in the cerebellum. The effects of the mutation were confirmed by the transfection of wild-type and mutant constructs into cells and subsequent immunohistochemistry. We show that mutation to arginine at this residue causes NSUN2 to fail to localize within the nucleolus. The ID combined with a unique profile of comorbid features presented here makes this an important genetic discovery, and the involvement of NSUN2 highlights the role of RNA methyltransferase in human neurocognitive development.

Congenital atrichia with papular lesions resulting from novel mutations in human hairless gene in four consanguineous families.

Congenital atrichia with papular lesions (APL; Mendelian Inheritance in Man no. 209500) is a rare form of irreversible alopecia that follows an autosomal recessive mode of inheritance. Patients with this form of alopecia show hair loss soon after birth with the development of papular lesions of keratin-filled cysts over the body. Several studies have reported sequence variants in the human hairless (HR) gene as the underlying cause of this disorder. In the present study, we have reported four consanguineous families showing features of APL. Genotyping using microsatellite markers showed mapping of all four families to the hairless (HR) gene on chromosome 8p21.1. Further, DNA sequence analysis of the HR gene revealed three novel mutations including two nonsense (p.Cys690X, p.Arg819X) and a missense (p.Pro1157Arg) in the four families.

A novel deletion mutation in the TUSC3 gene in a consanguineous Pakistani family with autosomal recessive nonsyndromic intellectual disability.

BACKGROUND: Intellectual disability (ID) is a serious disorder of the central nervous system with a prevalence of 1-3% in a general population. In the past decades, the research focus has been predominantly on X-linked ID (68 loci and 19 genes for non syndromic X linked ID) while for autosomal recessive nonsyndromic ID (NSID) only 30 loci and 6 genes have been reported to date. METHODS: Genome-wide homozygosity mapping with 500 K Nsp1 array (Affymetrix), CNV analysis, PCR based breakpoint mapping and DNA sequencing was performed to explore the genetic basis of autosomal recessive nonsyndromic ID in a large Pakistani family. RESULTS: Data analysis showed linkage at 8p23 locus with common homozygous region between SNPs rs6989820 and rs2237834, spanning a region of 12.494 Mb. The subsequent CNV analysis of the data revealed a homozygous deletion of 170.673 Kb which encompassed the TUSC3 gene. CONCLUSION: We report a novel deletion mutation in TUSC3 gene which is the second gene after TRAPPC9 in which mutation has been identified in more than one family with autosomal recessive NSID. The study will aid in exploring the molecular pathway of cognition.

Genetic mapping of a novel hypotrichosis locus to chromosome 7p21.3-p22.3 in a Pakistani family and screening of the candidate genes.

Hereditary hypotrichosis is a heterogeneous group of inherited hair loss disorders characterized by diffused or localized thinning or absence of hair affecting scalp, eyebrows and eyelashes, and other body parts. Over the past few years, at least four autosomal dominant and six autosomal recessive forms of hypotrichosis have been described. All these ten forms of hypotrichosis have been mapped on different human chromosomes and the corresponding genes have been identified in most of these cases. In the present study, we have described a six-generation Pakistani consanguineous family with an autosomal recessive transmission of hereditary hypotrichosis. All the five affected individuals of the family showed complete absence of scalp hair and sparse eyebrows and eyelashes. They were born with complete absence of scalp hairs. Facial hair of beard and mustaches were present in all the affected adult male individuals. Papules were observed only on scalp of the affected individuals. A scalp biopsy from an affected individual showed markedly reduced number of hair follicles. Human genome scan using polymorphic microsatellite markers mapped the disease locus on chromosome 7p21.3-p22.3, flanked by markers D7S1532 and D7S3047. A maximum two-point LOD score of 4.74 (theta = 0.00) was obtained at marker D7S481. The linkage interval spans 15.69 cM, which corresponds to 6.59 Mb according to the sequence-based physical map (Build 36.2). Mutation analysis of five potential candidate genes (GNA12, FOXK1, DAGLB, ZNF12, ACTB), located in the linkage interval, did not reveal any functional sequence variant.