A lethal phenotype associated with tissue plasminogen deficiency in humans.

The role of plasminogen in preventing thrombosis requires activation by tissue plasminogen activator (t-PA) encoded by PLAT. While case-control associations have been pursued for common variants in PLAT, no disease-causing mutations have been reported. We describe a consanguineous family with two children who died shortly after birth due to complications related to severe hydranencephaly and diaphragmatic hernia. A combined exome/autozygome analysis was carried out with informed consent. We identified a homozygous null mutation in PLAT that abrogated t-PA level in patient cells. This is the first reported human knockout mutation of PLAT. The apparent association with hydranencephaly, diaphragmatic hernia and postnatal lethality requires further validation.

Identification of a novel MKS locus defined by TMEM107 mutation.

Meckel-Gruber syndrome (MKS) is a perinatally lethal disorder characterized by the triad of occipital encephalocele, polydactyly and polycystic kidneys. Typical of other disorders related to defective primary cilium (ciliopathies), MKS is genetically heterogeneous with mutations in a dozen genes to date known to cause the disease. In an ongoing effort to characterize MKS clinically and genetically, we implemented a gene panel and next-generation sequencing approach to identify the causal mutation in 25 MKS families. Of the three families that did not harbor an identifiable causal mutation by this approach, two mapped to a novel disease locus in which whole-exome sequencing revealed the likely causal mutation as a homozygous splicing variant in TMEM107, which we confirm leads to aberrant splicing and nonsense-mediated decay. TMEM107 had been independently identified in two mouse models as a cilia-related protein and mutant mice display typical ciliopathy phenotypes. Our analysis of patient fibroblasts shows marked ciliogenesis defect with an accompanying perturbation of sonic hedgehog signaling, highly concordant with the cellular phenotype in Tmem107 mutants. This study shows that known MKS loci account for the overwhelming majority of MKS cases but additional loci exist including MKS13 caused by TMEM107 mutation.

Identification of embryonic lethal genes in humans by autozygosity mapping and exome sequencing in consanguineous families.

BACKGROUND: Identifying genetic variants that lead to discernible phenotypes is the core of Mendelian genetics. An approach that considers embryonic lethality as a bona fide Mendelian phenotype has the potential to reveal novel genetic causes, which will further our understanding of early human development at a molecular level. Consanguineous families in which embryonic lethality segregates as a recessive Mendelian phenotype offer a unique opportunity for high throughput novel gene discovery as has been established for other recessive postnatal phenotypes. RESULTS: We have studied 24 eligible families using autozygosity mapping and whole-exome sequencing. In addition to revealing mutations in genes previously linked to embryonic lethality in severe cases, our approach revealed seven novel candidate genes (THSD1, PIGC, UBN1, MYOM1, DNAH14, GALNT14, and FZD6). A founder mutation in one of these genes, THSD1, which has been linked to vascular permeability, accounted for embryonic lethality in three of the study families. Unlike the other six candidate genes, we were able to identify a second mutation in THSD1 in a family with a less severe phenotype consisting of hydrops fetalis and persistent postnatal edema, which provides further support for the proposed link between this gene and embryonic lethality. CONCLUSIONS: Our study represents an important step towards the systematic analysis of "embryonic lethal genes" in humans.

Accelerating novel candidate gene discovery in neurogenetic disorders via whole-exome sequencing of prescreened multiplex consanguineous families.

Our knowledge of disease genes in neurological disorders is incomplete. With the aim of closing this gap, we performed whole-exome sequencing on 143 multiplex consanguineous families in whom known disease genes had been excluded by autozygosity mapping and candidate gene analysis. This prescreening step led to the identification of 69 recessive genes not previously associated with disease, of which 33 are here described (SPDL1, TUBA3E, INO80, NID1, TSEN15, DMBX1, CLHC1, C12orf4, WDR93, ST7, MATN4, SEC24D, PCDHB4, PTPN23, TAF6, TBCK, FAM177A1, KIAA1109, MTSS1L, XIRP1, KCTD3, CHAF1B, ARV1, ISCA2, PTRH2, GEMIN4, MYOCD, PDPR, DPH1, NUP107, TMEM92, EPB41L4A, and FAM120AOS). We also encountered instances in which the phenotype departed significantly from the established clinical presentation of a known disease gene. Overall, a likely causal mutation was identified in >73% of our cases. This study contributes to the global effort toward a full compendium of disease genes affecting brain function.

The role of interleukin-6 promoter polymorphism -174G/C in Saudi women with hypertensive disorders of pregnancy.

OBJECTIVE: To study the relationship between -174 GC interleukin-6 single nucleotide polymorphism and hypertensive disorders of pregnancy (HDP) in Saudi women. METHODS: In this case-control study, 109 HDP patients and 100 women with normal pregnancy as a control group were studied. The HDP study group constituted of 60 women with gestational hypertension (GH) and 49 women with preeclampsia (PE). All women were randomly selected from the antenatal clinic and the prenatal and postnatal wards at the Antenatal Clinic and the Obstetric Ward of King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia from April 2010 to December 2011. The -174 GC of IL-6 SNP was determined using real time polymerase chain reaction, allele discrimination technique. RESULTS: Distribution of -174 GC of IL-6 genotype in HDP patients was GG (58.5%), GC (31.1%), and CC (10.4%), while in the control group was GG (67%), GC (30.9%), and CC (2.1%). The CC homozygosity was significantly associated with HDP (odds ratio [OR] = 5.76; 95% confidence interval [CI] 1.23-27.06, p=0.03). This association only manifested with GH (OR = 7.65; 95% CI = 1.54-38.03, p=0.01). However, no significant association was found with PE (OR = 3.48; 95% CI = 0.55-21.99, p=0.19). CONCLUSION: The results indicate a positive association between -174 GC of IL-6 genotype and the risk of HDP. Genotypes CC and GC are associated with increased risk of GH but not with PE, suggesting that they are of differing genetic predisposition/pathophysiology.

Ruptured spontaneous heterotopic pregnancy.

The coexistence of intrauterine and ectopic pregnancy (heterotopic pregnancy) occurs in 1/30,000 of spontaneous pregnancies, 1/900 in Clomiphene citrate induced pregnancies and rises to 1% in assisted reproduction. It is a life-threatening condition with diagnostic and therapeutic complexities. There is strong association between infertility and ectopic pregnancy. Risk factors for ectopic pregnancy are past history, assisted reproduction, and adhesions due to pelvic infection or surgery. Our patient was diagnosed initially as having an intrauterine singleton pregnancy, with urinary tract infection. At presentation pain out of proportion to primary diagnosis led to urgent ultrasonographic review that diagnosed heterotopic pregnancy. It was followed by laparoscopic salpingectomy. Human chorionic gonadotrophin (HCG) after laparoscopy in the subsequent days along with a sonographic evaluation revealed a viable intrauterine pregnancy. This ended in missed miscarriage and medical expulsion at 16 weeks of gestation. Issues discussed here are rarity, delayed, or misdiagnosis with its sequel.

Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postcesarean section delivery analgesia--a double-blind, placebo-controlled, randomized study.

BACKGROUND: Ultrasound-guided transversus abdominis plane (TAP) block has been used for intra-operative and postoperative analgesia. Here we evaluate the efficacy of TAP block for postoperative cesarean delivery analgesia. METHOD: A randomized, double-blind, placebo-controlled trial was performed at King Khalid University Hospital on 40 patients undergoing cesarean delivery under spinal anesthesia with bupivacaine and fentanyl. At the end of surgery they received bilateral ultrasound-guided TAP block either with bupivacaine 0.25% (B group) 20 patients, or saline (S group, or placebo group) 20 patients, followed by patient controlled analgesia with i.v. morphine only. Each patient was assessed 24 hours after delivery for pain, morphine consumption, nausea, vomiting, sedation, patient's satisfaction, and also pain relief during mobilization (24 hours post-cesarean section). RESULTS: All 40 participants completed the study. Total morphine consumption was reduced more than 60% in the bupivacaine group; the bupivacaine group also reported improved satisfaction with their pain relief over 24 hours after surgery, reduced morphine consumption, less nausea, vomiting, and better patient's satisfaction. CONCLUSION: Ultrasound-guided TAP block improved postoperative analgesia, reduced morphine consumption and improved patient's satisfaction regarding analgesia after cesarean delivery.

Leptin concentration during different trimesters of pregnancy and its relation to other pregnancy hormones.

OBJECTIVE: To determine the levels of leptin and other pregnancy hormones (progesterone, estradiol, folliculi stimulating hormone, luteinizing hormone and beta human chorionic gonadotropin) in pregnant females during different stages of pregnancy and to correlate these levels to maternal weight, body mass index (BMI), babies weight and babies BMI. METHODS: Leptin level and other pregnancy hormones were measured in 36 pregnant females and 30 non-pregnant females followed at King Khaled University Hospital, Riyadh, Kingdom of Saudi Arabia in the year 2001 in a prospective study. Blood samples were collected at the first, 2nd and 3rd trimester and after delivery. Correlation analysis between leptin level and pregnancy hormones, in addition to maternal weight, BMI, babies weight and BMI. RESULTS: The mean leptin levels during pregnancy and postnatally were significantly higher in pregnant females compared to the non-pregnant controls. Serum concentration of leptin increased significantly (p=0.01) in the pregnant females from 21.24 +/- 9 ng/ml during the first trimester to 26.3 +/- 8.69 ng/ml during the 2nd trimester, but insignificantly decreased to 23.29 +/- 8.62 ng/ml during the 3rd trimester (p=0.073). After delivery leptin concentration significantly decreased to 17.36 +/- 7.95 ng/ml (p=0.0025). The changes in levels of leptin during pregnancy were independent to other pregnancy hormones which showed a different pattern of variation. CONCLUSION: The changes in levels of leptin during pregnancy were independent to other pregnancy hormones which showed a different pattern of variation.

Age at menarche and the reproductive performance of Saudi women.

BACKGROUND: Saudi Arabia has undergone substantial development in the recent past with concomitant changes in living conditions, and economic and general health status that have affected the age at menarche in Saudi women. We evaluated the current age at menarche and reproductive events among Saudi women. SUBJECTS AND METHODS: Age, age at menarche, age at marriage, age of first pregnancy, number of children, and number of abortions were collected for Saudi women attending King Khalid University Hospital (KKUH) over a 3-month period in 2002. RESULTS: For 989 Saudi women, the mean age at menarche was 13.05 years. There was a decrease in the age of menarche over the past 20 years, an increase in the age of marriage, age of first pregnancy, and a decrease in the number of children and abortions. Compared with data from two decades, the age at menarche decreased significantly from 13.22 to 13.05 years. CONCLUSION: The decrease in the age of menarche among Saudi women indicates better socioeconomic status and improvements in health.

Prevalence of osteoporosis among postmenopausal females with diabetes mellitus.

OBJECTIVE: To assess the prevalence of osteopenia and osteoporosis among Saudi postmenopausal women with non-insulin dependent type 2 diabetes mellitus (T2DM). METHODS: The study was carried out at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia from February 2000 to September 2002. Bone mineral density (BMD) of the lumbar spine and femoral neck using dual x-ray absorptiometry (DXA; Lunar Wisconsin), were performed in 104 postmenopausal Saudi women with T2DM, and 101 postmenopausal non-diabetic women (control). Bone mineral density was measured in gm/cm2 and both T-score and Z-score were measured but only T-score was used for analysis based on World Health Organization criteria. Bone profile, 25(OH) Vitamin D, 1,25(OH)2 Vitamin D, parathyroid hormone and urine deoxypyridinoline (DPD) were measured in most patients and controls. Body fat measurement around the biceps muscles using Futrex (body composition analyzer) were performed in patients and controls. Years postmenopausal, duration of diabetes mellitus, parity, exercise, sun exposure and milk consumption were also recorded. RESULTS: In the diabetic group, the mean spine BMD was 0.928 gm/cm2 (T-score = -2.28 SD) and for femoral neck the mean BMD was 0.817 gm/cm2 (T-score = -1.21 SD). In control group, the mean spine BMD was 1.036 gm/cm2 (T-score = -1.2) and mean femoral neck BMD was 0.914 gm/cm2 (T-score = -0.608). In the diabetic group, there was 16 (16.64%) patients with normal BMD of the spine, 42 patients (43.68%) with osteopenia (mean T-score = -1.8 SD) and 45 (46.8%) with osteoporosis (mean T-score = -3.3 SD). CONCLUSION: Osteoporosis is more common among Type 2 postmenopausal females in this ethnic group. Since both groups are postmenopausal, having equal percentage of Vitamin D deficiency, multi-parity, non exposure to sun, lack of exercise and negligible milk intake, one can conclude that the low BMD can be attributed to DM in the absence of other causes of osteoporosis.

Leptin level in pregnant mothers at term and cord blood and the effect of newborns gender.

OBJECTIVE: To evaluate the leptin level in healthy pregnant mothers at term and in their newborns and its relationship to their body mass index (BMI) and gender of the newborn. METHODS: The leptin level was measured in serum of 187 pregnant women at term delivering at the King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia in July 2001 and their newborns. Correlation studies were made between leptin level and their growth parameters, and gender of the newborns. RESULTS: Leptin level of the mothers was significantly higher compared to their newborns. There was a significant correlation between leptin level in the pregnant women and their weight, BMI, and the newborns leptin level and weight, but not their height or BMI. A statistically significant difference was found between male and female newborns plasma leptin level. A significant correlation was found between male newborns leptin level and all their growth parameters, while in the female newborns there was no correlation between their leptin level and BMI. CONCLUSION: Leptin plays an important role in providing a growth promoting signal during pregnancy, but the fat mass does not seem to be the most important predictor of cord leptin level.

The prevalence of lupus anticoagulant in normal pregnancy and in women with recurrent fetal loss--recommendations for laboratory testing for lupus anticoagulant.

BACKGROUND: There is wide disagreement in the literature on the rate of detection of lupus anticoagulant (LA) in women with recurrent fetal loss (RFL). The aim of this study was to determine the prevalence of LA using four phospholipid-dependant coagulation tests in a large population of Saudi women. PATIENTS AND METHODS: We determined the prevalence of LA in women with RFL (n=925), normal pregnancy (n=663), and in healthy blood donors (n=204), at the King Khalid University Hospital, Riyadh. The following coagulation tests were employed: the activated partial thromboplastin time (APTT), platelet neutralization procedure (PNP), kaolin clotting time (KCT) and the dilute Russel's viper venom test (dRVVT). RESULTS: In RFL patients, positive APTT was 10.2%, APTT+PNP 3.6%, KCT 10.5%, and dRVVT 10.9%. In normal pregnancy, the corresponding figures were 12.8%, 3.1%, 10.8%, and 5.6%. Three positive tests occurred in 2.3% of RFL patients, including APTT+KCT 3.5%, APTT+dRVVT 3.9%, and KCT+dRWT 4.1%. The corresponding figures for normal pregnancy were 1.6% for three positive tests, and 3.0%, 1.8%, 2.4%, respectively. The dRVVT was the only test that showed a rate of positive results almost double that seen in normal pregnancy. CONCLUSIONS: If only one or even two screening tests were performed, a significant number of LA positive cases would have been missed. This could make a difference to treating physicians as to the possible etiology and management of RFL. It is therefore advisable to routinely use the three tests (APTT, KCT and dRRVT) when screening for LA.

The inter-relationship hematological parameters between Saudi newborns and parents.

OBJECTIVE: To determine the relationship of the hematological parameters between Saudi newborns and their parents. METHODS: This study was carried out at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia, over a one-year period. Venous blood samples were taken from 82 healthy Saudi pregnant women in labor at full term, their husbands, and umbilical cord blood after delivery. Estimation of the hematological indices, in addition to transferrin level were performed. RESULTS: A statistically significant correlation was found between parents and cord blood with regards to red blood count, mean corpuscular volume, mean corpuscular hemoglobulin, mean corpuscular hemoglobulin concentration and packed cell volume, while no correlation was found with hemoglobulin and transferrin. CONCLUSION: Some of the hematological indices could be mainly genetically determined including red blood count, mean corpuscular volume, mean corpuscular hemoglobulin concentration, and packed cell volume as significant correlation was found between parents and their newborns while hemoglobulin and transferrin levels were not as these variables are mainly affected by environmental factors.