Mutations in LRP2, which encodes the multiligand receptor megalin, cause Donnai-Barrow and facio-oculo-acoustico-renal syndromes.

Donnai-Barrow syndrome is associated with agenesis of the corpus callosum, congenital diaphragmatic hernia, facial dysmorphology, ocular anomalies, sensorineural hearing loss and developmental delay. By studying multiplex families, we mapped this disorder to chromosome 2q23.3-31.1 and identified LRP2 mutations in six families with Donnai-Barrow syndrome and one family with facio-oculo-acoustico-renal syndrome. LRP2 encodes megalin, a multiligand uptake receptor that regulates levels of diverse circulating compounds. This work implicates a pathway with potential pharmacological therapeutic targets.

An incidentally found mass on the remnant stomach after a Roux-en-Y gastric bypass.

BACKGROUND: Incidentally found masses are a widely discussed area of medicine, and there are conflicting opinions as to how to deal with these findings, particularly in the stomach-which has limited documentation in the literature. Here we present a middle-aged female who was found to have an incidentally found mass on her remnant stomach 10 years after a Roux-en-Y gastric bypass (RYGB) surgery. CASE PRESENTATION: We present the case of a 66-year-old female who is 10 years post-op from a RYGB. After a bout of self-resolving diarrheal illness prompted a computed tomography (CT) scan in the emergency department, she was diagnosed with a 9-cm mass on her remnant stomach that after resection was found to be a gastrointestinal stromal tumor (GIST) with the PDGRRA p.D842V gene mutation. CONCLUSION: The National Comprehensive Cancer Network (NCCN) outlines guidelines for the workup of abdominal masses. While endoscopic ultrasound is a common step in diagnosis of gastric masses, for a patient who has had a RYGB, access to the remnant stomach, which is no longer a part of the alimentary tract, is not possible. Thus, this patient's mass was surgically resected. Given the low risk of recurrence, her future care consists of follow-up with medical oncology in accordance with the NCCN guidelines.

Preoperative Opioid and Benzodiazepine Use: Influence on Abdominal Surgical Outcomes.

BACKGROUND: Preoperative opioid use has shown association with worse outcomes after surgery. However, little is known about the effect of preoperative benzodiazepines with and without opioids. The aim of this study was to determine the influence of preoperative substance use on outcomes after abdominal surgery. STUDY DESIGN: Patients undergoing abdominal operations including ventral hernia, colectomy, hysterectomy, cholecystectomy, appendectomy, nephrectomy, and hiatal hernia were identified in an opioid surgical steward program by a regional NSQIP consortium between 2019 and 2021. American College of Surgeons NSQIP data were linked with custom substance use variables created by the collaborative. Univariable and multivariable analyses were performed for 30-day outcomes. RESULTS: Of 4,439 patients, 64% (n = 2,847) were women, with a median age of 56 years. The most common operations performed were hysterectomy (22%), ventral hernia repair (22%), and colectomy (21%). Preoperative opioid use was present in 11% of patients (n = 472), 10% (n = 449) were on benzodiazepines, and 2.3% (n = 104) were on both. Serious morbidity was significantly (p < 0.001) increased in patients on preoperative opioids (16% vs 7.9%) and benzodiazepines (14% vs 8.3%) compared with their naïve counterpart and this effect was amplified in patients on both substances (20% vs 7.5%). Multivariable regression analyses reveal that preoperative substance use is an independent risk factor (p < 0.01) for overall morbidity and serious morbidity. CONCLUSIONS: Preoperative opioid and benzodiazepine use are independent risk factors that contribute to postoperative morbidity. This influence on surgical outcomes is exacerbated when patients are on both substances.

Congenital diaphragmatic hernia interval on chromosome 8p23.1 characterized by genetics and protein interaction networks.

Chromosome 8p23.1 is a common hotspot associated with major congenital malformations, including congenital diaphragmatic hernia (CDH) and cardiac defects. We present findings from high-resolution arrays in patients who carry a loss (n = 18) or a gain (n = 1) of sub-band 8p23.1. We confirm a region involved in both diaphragmatic and heart malformations. Results from a novel CNVConnect algorithm, prioritizing protein-protein interactions between products of genes in the 8p23.1 hotspot and products of previously known CDH causing genes, implicated GATA4, NEIL2, and SOX7 in diaphragmatic defects. Sequence analysis of these genes in 226 chromosomally normal CDH patients, as well as in a small number of deletion 8p23.1 patients, showed rare unreported variants in the coding region; these may be contributing to the diaphragmatic phenotype. We also demonstrated that two of these three genes were expressed in the E11.5-12.5 primordial mouse diaphragm, the developmental stage at which CDH is thought to occur. This combination of bioinformatics and expression studies can be applied to other chromosomal hotspots, as well as private microdeletions or microduplications, to identify causative genes and their interaction networks.

An Enhanced Recovery After Surgery Protocol Decreases the Use of Narcotics in Infrainguinal Bypass Patients.

OBJECTIVES: "Enhanced recovery after surgery" (ERAS) protocols use a multisystem approach to target homeostatic physiology via opioid-minimizing analgesia. The aim of this study is to determine if an ERAS protocol for lower extremity bypass surgery improves pain control and decreases narcotics. METHODS: From July 2020 through June 2021, all patients that underwent infrainguinal lower extremity bypass procedures were subject to the ERAS protocol and compared to a "pre-ERAS" group between June 2016 through May 2020. Preoperatively, ERAS patients were given celecoxib, gabapentin, and acetaminophen while postoperatively they were given standing acetaminophen, gabapentin, ketorolac, and tramadol with as needed use of oxycodone. Pain scores were recorded using a numerical rating pain scale. Demographics, length of stay, 30-day complications, and disposition metrics were recorded. RESULTS: There were 50 patients in the ERAS group, compared to 114 before its implementation. The mean age was 70.5 (ERAS group) versus 68.7 (pre-ERAS group) and a majority were male (P > .05). Enhanced recovery after surgery patients were less likely to have chronic kidney disease (P = .01). Enhanced recovery after surgery patients had improved length of stay (3.6 ± 2.3 days vs 4.8 ± 3.2 days, ERAS vs pre-ERAS, P = .01). There was no significant difference between groups for the remaining demographics (P > .05). One patient (2%) in the ERAS group used patient-controlled analgesia, compared to 30 patients (26%) in the pre-ERAS group (P < .001). Cumulative pain control in the first 12 hours was significantly better in the ERAS group (P = .05). Pain control at discharge was similar between the 2 groups (3 pain score vs 3 pain score, pre-ERAS vs ERAS, P > .05). CONCLUSION: Our study utilized a multisystem approach to optimize the physiologic stress response to vascular surgery while reducing high potency narcotic use. We show that an ERAS protocol provides noninferior pain control with less potent pain medication and improves the length of stay for patients undergoing infrainguinal bypass surgery.

Characterization of the chromosome 1q41q42.12 region, and the candidate gene DISP1, in patients with CDH.

Cytogenetic and molecular cytogenetic studies demonstrate association between congenital diaphragmatic hernia (CDH) and chromosome 1q41q42 deletions. In this study, we screened a large CDH cohort (N=179) for microdeletions in this interval by the multiplex ligation-dependent probe amplification (MLPA) technique, and also sequenced two candidate genes located therein, dispatched 1 (DISP1) and homo sapiens H2.0-like homeobox (HLX). MLPA analysis verified deletions of this region in two cases, an unreported patient with a 46,XY,del(1)(q41q42.13) karyotype and a previously reported patient with a Fryns syndrome phenotype [Kantarci et al., 2006]. HLX sequencing showed a novel but maternally inherited single nucleotide variant (c.27C>G) in a patient with isolated CDH, while DISP1 sequencing revealed a mosaic de novo heterozygous substitution (c.4412C>G; p.Ala1471Gly) in a male with a left-sided Bochdalek hernia plus multiple other anomalies. Pyrosequencing demonstrated the mutant allele was present in 43%, 12%, and 4.5% of the patient's lymphoblastoid, peripheral blood lymphocytes, and saliva cells, respectively. We examined Disp1 expression at day E11.5 of mouse diaphragm formation and confirmed its presence in the pleuroperitoneal fold, as well as the nearby lung which also expresses Sonic hedgehog (Shh). Our report describes the first de novo DISP1 point mutation in a patient with complex CDH. Combining this finding with Disp1 embryonic mouse diaphragm and lung tissue expression, as well as previously reported human chromosome 1q41q42 aberrations in patients with CDH, suggests that DISP1 may warrant further consideration as a CDH candidate gene.

A review of Donnai-Barrow and facio-oculo-acoustico-renal (DB/FOAR) syndrome: clinical features and differential diagnosis.

Mutations in the gene LRP2 have recently been identified as the cause of Donnai-Barrow and Facio-oculo-acoustico-renal (DB/FOAR) syndrome. More than two dozen cases, the first reported more than 30 years ago by Holmes, have been published. Summarizing available information, we highlight the cardinal features of the disorder found in >or=90% of published cases. These features include: agenesis of the corpus callosum, developmental delay, enlarged anterior fontanelle, high myopia, hypertelorism, proteinuria, and sensorineural hearing loss. Congenital diaphragmatic hernia and omphalocele are reported in only half of the patients. There is no evidence for genotype-phenotype correlation, though the sample size is too small to preclude this with certainty. Although several conditions to consider in the differential diagnosis are highlighted, the diagnosis of DB/FOAR syndrome should not be difficult to establish as its constellation of findings is strikingly characteristic.

Donnai-Barrow syndrome (DBS/FOAR) in a child with a homozygous LRP2 mutation due to complete chromosome 2 paternal isodisomy.

Donnai-Barrow syndrome [Faciooculoacousticorenal (FOAR) syndrome; DBS/FOAR] is a rare autosomal recessive disorder resulting from mutations in the LRP2 gene located on chromosome 2q31.1. We report a unique DBS/FOAR patient homozygous for a 4-bp LRP2 deletion secondary to paternal uniparental isodisomy for chromosome 2. The propositus inherited the mutation from his heterozygous carrier father, whereas the mother carried only wild-type LRP2 alleles. This is the first case of DBS/FOAR resulting from uniparental disomy (UPD) and the fourth published case of any paternal UPD 2 ascertained through unmasking of an autosomal recessive disorder. The absence of clinical symptoms above and beyond the classical phenotype in this and the other disorders suggests that paternal chromosome 2 is unlikely to contain imprinted genes notably affecting either growth or development. This report highlights the importance of parental genotyping in order to give accurate genetic counseling for autosomal recessive disorders.

Incidence of Surgical Site Infections after Thyroid and Parathyroid Surgery: No Role for Antimicrobial Prophylaxis.

To better define the value of antimicrobial prophylaxis (AMP) and antiseptic skin preparation (ASP) in thyroid and parathyroid surgery, we examined the rate of surgical site infections (SSIs) with and without AMP. Retrospective analysis was performed using the National Surgical Quality Improvement Program database at a single institution. Patients undergoing thyroid or parathyroid surgery with data entered into the National Surgical Quality Improvement Program database at our institution between November 2007 and June 2015 were studied, including patient demographics, wound classification, other risk factors for SSI, and wound outcome. Charts were retrospectively reviewed for AMP, ASP, and use of drains. Of the 534 patients who underwent thyroid (n = 358) or parathyroid (n = 176) surgery, 58 (10.9%) were diabetic, 54 (10.1%) used tobacco, and 14 (2.6%) were on steroids. Most wounds were classified as "clean" (99.6%). Betadine was used for ASP in 96 per cent. AMP was given to 141 patients (26%) using cefazolin, vancomycin, or clindamycin. The remaining 393 patients (74%) received no AMP. Zero infections occurred in the group who did not receive AMP. One (0.7%) superficial, nonpurulent SSI occurred in the group that received AMP which was not statistically significantly different (P = 0.319). The rates of SSI after thyroid and parathyroid surgery are extremely low, around two per 1000 cases, and do not decrease with AMP. Therefore, AMP is not necessary in thyroid and parathyroid surgery and should be avoided to reduce costs, adverse reactions, and antibiotic resistance.

Comprehensive assessment of array-based platforms and calling algorithms for detection of copy number variants.

We have systematically compared copy number variant (CNV) detection on eleven microarrays to evaluate data quality and CNV calling, reproducibility, concordance across array platforms and laboratory sites, breakpoint accuracy and analysis tool variability. Different analytic tools applied to the same raw data typically yield CNV calls with <50% concordance. Moreover, reproducibility in replicate experiments is <70% for most platforms. Nevertheless, these findings should not preclude detection of large CNVs for clinical diagnostic purposes because large CNVs with poor reproducibility are found primarily in complex genomic regions and would typically be removed by standard clinical data curation. The striking differences between CNV calls from different platforms and analytic tools highlight the importance of careful assessment of experimental design in discovery and association studies and of strict data curation and filtering in diagnostics. The CNV resource presented here allows independent data evaluation and provides a means to benchmark new algorithms.

Negative regulation of the SH2-homology containing protein-tyrosine phosphatase-1 (SHP-1) P2 promoter by the HTLV-1 Tax oncoprotein.

Expression of SH(2)-homology-containing protein-tyrosine phosphatase-1 (SHP-1), a candidate tumor suppressor, is repressed in human T-cell leukemia virus type-1 (HTLV-1)-transformed lymphocyte cell lines, adult T-cell leukemia (ATL) cells, and in other hematologic malignancies. However, the mechanisms underlying regulation and repression of SHP-1 remain unclear. Herein, we cloned the putative full-length, hematopoietic cell-specific SHP-1 P2 promoter and identified the "core" promoter regions. HTLV-1 Tax profoundly represses P2 promoter activity and histone deacetylase-1 (HDAC1) potentiates such inhibition. NF-kappaB was implicated as both a rate-limiting factor for basal P2 promoter activity and important for Tax-induced promoter silencing (TIPS). Chromatin immunoprecipitation studies demonstrated that NF-kappaB dissociates from the SHP-1 P2 promoter following the binding of Tax and HDAC1. This is in agreement with coimmunoprecipitation studies where NF-kappaB competed with HDAC1 for association with Tax protein. We propose that in TIPS, Tax recruits HDAC1 to the SHP-1 P2 promoter and forms an inhibitory complex that results in deacetylation and dissociation of NF-kappaB from the promoter and attenuation of SHP-1 expression. TIPS provides a possible first step toward HTLV-1 leukemogenesis through its down-modulation of this key immediate early negative regulator of IL-2 signaling.

Protective and therapeutic capacity of human single-chain Fv-Fc fusion proteins against West Nile virus.

West Nile virus has spread rapidly across the United States, and there is currently no approved human vaccine or therapy to prevent or treat disease. Passive immunization with antibodies against the envelope protein represents a promising means to provide short-term prophylaxis and treatment for West Nile virus infection. In this study, we identified a panel of 11 unique human single-chain variable region antibody fragments (scFvs) that bind the envelope protein of West Nile virus. Selected scFvs were converted to Fc fusion proteins (scFv-Fcs) and were tested in mice for their ability to prevent lethal West Nile virus infection. Five of these scFv-Fcs, 11, 15, 71, 85, and 95, protected 100% of mice from death when given prior to infection with virus. Two of them, 11 and 15, protected 80% of mice when given at days 1 and 4 after infection. In addition, four of the scFv-Fcs cross-neutralized dengue virus, serotype 2. Binding assays using yeast surface display demonstrated that all of our scFvs bind to sites within domains I and II of West Nile virus envelope protein. These recombinant human scFvs are potential candidates for immunoprophylaxis and therapy of flavivirus infections.

Herbal medication use in the pediatric surgical patient.

PURPOSE: The aim of this study was to determine the prevalence of herbal medication use in the pediatric surgical patient population, because herbal medications can cause major perioperative complications. METHODS: A questionnaire on all drug use before surgery was given to the parents of 1,100 consecutive pediatric surgical patients operated on at a metropolitan children's hospital between June 14, 2002 and August 14, 2002. RESULTS: Eighty-three percent of the surveys were returned. Twenty-one percent of the parents were herbal medication users, but only 4% of patients utilized herbal medications. An average of 2.4 different herbal medicines were in use by each child, and the most common herbal medications were echinacea, chamomile, and aloe. Forty-two percent of herbal medication-using patients were taking prescription medicines concurrently. Fifteen herbal medications-using patients underwent major surgery, and the average preoperative herbal cessation interval was 3.5 days. Children of parents who were herbal medication users and children reported to have chronic diseases were more likely to use herbal medicines (P <.05). Ten percent of parents reported that the surgeon inquired about patient herbal medication use. CONCLUSIONS: This is the first report on herbal medication use in the pediatric surgical patient. The prevalence of herbal medication use is significantly higher in children of parents who use herbal medications and children whose parents consider them to be chronically ill. Surgeons need to specifically inquire about the use of herbal medication in their patients to prevent possible harmful interactions and perioperative complications.

Nucleocapsid-RNA interactions are essential to structural stability but not to assembly of retroviruses.

The process of RNA incorporation into nascent virions is thought to be critical for efficient retroviral particle assembly and production. Here we show that human immunodeficiency virus type 1 mutant particles (which are highly unstable and break down soon after release from the cell) lacking nucleocapsid (NC) core protein-mediated RNA incorporation are produced efficiently and can be recovered at the normal density when viral protease function is abolished. These results demonstrate that RNA binding by Gag is not necessary for retroviral particle assembly. Rather, the RNA interaction with NC is critical for retroviral particle structural stability subsequent to release from the membrane and protease-mediated Gag cleavage. Thus, the NC-RNA interaction, and not simply the presence of RNA, provides the virus with a structural function that is critical for stable retroviral particle architecture.