A systematic study and literature review of parental somatic mosaicism of FBN1 pathogenic variants in Marfan syndrome.

BACKGROUND: A proportion of de novo variants in patients affected by genetic disorders, particularly those with autosomal dominant (AD) inheritance, could be the consequence of somatic mosaicism in one of the progenitors. There is growing evidence that germline and somatic mosaicism are more common and play a greater role in genetic disorders than previously acknowledged. In Marfan syndrome (MFS), caused by pathogenic variants in the fibrillin-1 gene (FBN1) gene, approximately 25% of the disease-causing variants are reported as de novo. Only a few cases of parental mosaicism have been reported in MFS. METHODS: Employing an amplicon-based deep sequencing (ADS) method, we carried out a systematic analysis of 60 parents of 30 FBN1 positive, consecutive patients with MFS with an apparently de novo pathogenic variant. RESULTS: Out of the 60 parents studied (30 families), the majority (n=51, 85%) had a systemic score of 0, seven had a score of 1 and two a score of 2, all due to minor criteria common in the normal population. We detected two families with somatic mosaicism in one of the progenitors, with a rate of 6.6% (2/30) of apparently de novo cases. CONCLUSIONS: The search for parental somatic mosaicism should be routinely implemented in de novo cases of MFS, to offer appropriate genetic and reproductive counselling as well as to reveal masked, isolated clinical signs of MFS in progenitors that may require specific follow-up.

Cap a la genètica assistencial interdisciplinària i transversal: evolució de cinquanta anys en un hospital terciari a partir de la pediatria / Hacia la genètica asistencial interdisciplinaria y transversal: evolución de cincuenta años en un hospital terciario a partir de la pediatría / Towards interdisciplinary and transversal clinical genetics: a 50-year evolution from pediatrics in a tertiary hospital

L’objectiu d’aquest treball és analitzar l’evolució de la demanda assistencial i les possibilitats diagnòstiques, en laconsulta de genètica clínica d’un hospital de tercer nivell durant els últims cinquanta anys i també a partir dels seus inicis com a consulta específica de Pediatria.S’hi analitzen tant els motius de consulta com les proves de laboratori disponibles per arribar al diagnòstic dels pacients valorats durant el període 1968-2018, a la consulta de Genètica Clínica i al Laboratori de Genètica. A partir de 200 consultes anuals, en els primers anys, arribem a l’actualitat, en què se’n fan al voltant de 8.000 (entre primeres, successives i interconsultes), distribuïdes en Genètica Clínica i Assessorament Genètic, fins a un total de més de 32.000 pacients visitats durant aquests cinquanta anys.Al Laboratori de Genètica, l’evolució abasta des de l’estudi del cariotip convencional fins a l’aplicació de les tecnologies genòmiques actuals, i s’hi fan més de 9.000 estudis anuals de pacients de l’Hospital. Amb la incorporació de noves tecnologies moleculars s’ha canviat el paradigma de l’estudi genètic i s’ha aconseguit un rendiment millor: s’han pogut incrementar els diagnòstics i també s’ha reduït el temps necessari per obtenir-los.A més de la transformació del genetista que col·labora en el seguiment multidisciplinari dels pacients, s’evidencia uncanvi i una diversificació del motiu de consulta i s’estableix el valor de la incorporació, a partir del 2010, de professionals especialitzats en assessorament genètic per donar resposta a aquesta demanda.Els canvis experimentats en els motius de consulta, els diagnòstics i les proves de laboratori fetes durant tots aquests anys reflecteixen la importància de la incorporació i la interacció, en una mateixa àrea o unitat assistencial, de professionals especialitzats en genètica clínica, assessorament genètic i laboratori de genètica integral (també ambbioinformàtics). (AU)

El objetivo de este trabajo es analizar la evolución de la demandaasistencial y las posibilidades diagnósticas en la consulta de genética clínica de un hospital de tercer nivel a lo largo de los últimos50 años a partir de sus inicios como una consulta específica dePediatría.Se analizan los motivos de consulta y las pruebas de laboratorio disponibles para llegar al diagnóstico de los pacientes valorados en el período 1968-2018 en la Consulta de Genética Clínica y el Laboratorio de Genética. A partir de 200 consultas anuales en los primeros años llegamos a la actualidad, en que se realizan alrededor de 8.000 visitas (primeras, sucesivas e interconsultas) distribuidas en Genética Clínica y Asesoramiento Genético (32.000pacientes visitados hasta la fecha).En el laboratorio de Genética la evolución abarca desde el estudio del cariotipo convencional hasta la aplicación de las tecnologías genómicas actuales realizando más de 9.000 estudios anuales de pacientes del Hospital. Además de la transformación del genetista clínico colaborando en el seguimiento multidisciplinar de los pacientes, se evidencia un cambio y diversificación del motivo de consulta y se establece el valor de la incorporación de profesionales especializados en asesoramiento genético (a partir de 2010) para dar respuesta a esta demanda. Con la incorporación de nuevas tecnologías moleculares se ha cambiado el paradigma del estudio genético con un incremento importante del rendimiento y mejoría en el tiempo en obtener resultados diagnósticos. Los cambios experimentados en los motivos de consulta, los diagnósticos y las pruebas de laboratorio realizadas a lo largo de estos años reflejan la importancia de la incorporación e interacción, en una misma área/unidad asistencial, de profesionales especializados en genética clínica, asesores genéticos y laboratorio de genética integral (incluyendo bioinformáticos). (AU)

The objective of this work is to analyze the evolution of the demand and the diagnostic capabilities in the clinical genetics service of a tertiary hospital over the last 50 years from its initiationas a specific pediatric consultation. The reasons for consultationare analyzed as well as the laboratory tests available to reach thediagnosis of the patients evaluated in the period 1968-2018 at the Clinical Genetics Service and the Genetics Laboratory. From 200 consultations/year in the first years, we have reachedaround 8,000 visits (first, follow-up, and internal consultations) distributed in Clinical Genetics and Genetic Counseling (32,000patients visited to date).The Genetics Laboratory evolved from the study of the conventional karyotype to the application of state of the art genomic technologies, carrying out more than 9,000 annual studies from patients followed–up in the hospital.In addition to the transformation of the role of the clinical geneticist into a member of the multidisciplinary care team, there isevidence of a change and diversification of the reasons for consultation and in the value of incorporating professionals specializedin genetic counseling (starting in 2010) to respond to this demand. With the incorporation of new molecular technologies, theparadigm of the genetic study has changed, with a significant increase in performance and improving time to diagnostic results.The changes experienced in the reasons for consultation, diagnosesand laboratory tests carried out throughout these years reflect theimportance of the incorporation and interaction, in the same healthcare area or unit, of professionals specialized in clinical geneticsand genetic counseling, with a comprehensive genetics laboratory(including bioinformatics). (AU)

Beyond the disease itself: A cross-cutting educational initiative for patients and families with rare diseases.

Rare diseases (RDs) as a whole affect a huge number of individuals although each specific condition comprises a low number of individuals. As a consequence, funds allocated to expand research to all conditions are often limited. Several initiatives have emerged to invest more resources for research in RDs, but patients express unmet needs regarding educational initiatives, awareness support, and psychosocial resources. We developed an educational training program in the format of weekly sessions covering basic medical scientific knowledge and psychosocial aspects of RDs. The aim of this initiative was to assess its overall impact regarding knowledge, psychological issues, and participant satisfaction. Items were evaluated through surveys before and after the sessions. Here, we report the experience and impact of two editions of this initiative with a total of 37 participants. Our results show improvements in knowledge and better management of the psychological impact. Moreover, participants were able to exchange experiences and concerns, most of which were shared even though the RDs were different. Overall, the program was evaluated by the participants as a highly beneficial experience and all of them were interested in attending advanced editions.

Further delineation of the phenotype caused by loss of function mutations in PRMT7.

PRMT7 encodes for an arginine methyltransferase that methylates arginine residues on various protein substrates and has been shown to play a role in various developmental processes. Mutations in PRMT7 have been recently shown to be implicated in a phenotype with intellectual disability, short stature and brachydactyly, and considered to be a phenocopy of pseudohypoparathyroidism. We report a patient with short stature, psychomotor delay, hearing loss and brachydactyly, for whom whole exome sequencing detected two mutations in PRMT7 and parental segregation studies detected biallelic mutation inheritance. Few patients with biallelic PRMT7 mutations have been reported so far in the literature. We report a new patient and review all reported cases to date to delineate the clinical manifestations that may help in diagnosis this disorder, known as Short Stature, Brachydactyly, Intellectual Developmental Disability, and Seizures syndrome, allowing appropriate management and genetic counselling.

Further delineation of the SOX18-related Hypotrichosis, Lymphedema, Telangiectasia syndrome (HTLS).

The transcription factor SOX18 has been shown to play a role in the development of hair, blood and lymphatic vessels. Mutations in SOX18 result in hereditary lymphedema, with the unique clinical association of hypotrichosis and telangiectasia (HLTS). Some patients present with additional disease features which may be explained by the location of SOX18 mutation. We report a patient with hypotrichosis-lymphedema-telangiectasia syndrome (HLTS) confirmed by detection of a novel mutation in the SOX18 gene. Few cases of HTLS have been reported in the literature. We reviewed all cases reported to date to delineate the clinical manifestations that allow us to prompt diagnosis of this syndrome for appropriate management and genetic counseling.

Arthrogryposis as neonatal presentation of Loeys-Dietz syndrome due to a novel TGFBR2 mutation.

Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized mainly by cardiovascular, craniofacial and skeletal features. We report on a patient with LDS, whose prenatal examination was compatible with the diagnosis of arthrogryposis multiplex congenita. Neonatal assessment showed craniofacial and cardiovascular findings suggestive of LDS whose diagnosis was confirmed by the detection of a novel mutation (HGVN: NM_003242.5 (TGFBR2): c.1381T > C (p.(Cys461Arg))) in the TGFBR2 gene. Few prenatal and neonatal cases of LDS have been reported in the literature. We reviewed all cases reported to date with perinatal onset to delineate the clinical manifestations that allow us to prompt diagnosis of this syndrome at an early stage to prevent fatal cardiovascular complications. Furthermore we discuss the multidisciplinary follow up required in these patients.

[PAIN MANAGEMENT IN PATIENTS OF RAPID RECOVERY (RR) PROGRAM IN TOTAL KNEE ARTHROPLASTY (TKA)]. / Gestión del dolor en pacientes del programa Rapid Recovery (RR) en artroplastia total de rodilla (ATR).

Total knee arthroplasty (TKA) is a surgery consisting on the artificial joint replacement, due to a traumatic injury or a degenerative process or arthrosis. This surgery causes an important pain to patients, and sometimes affects negatively on their recovery. The choice of the prostheses will depend on the anatomical features of the patient and the surgeon criterion. The concept of a "rapid recovery surgery" was introduced in 1997 by Khelet and meant the beginning of the Fast Track model or the Rapid Recovery (RR) linked to an accelerated rehabilitation, an early discharge and the optimization of all the aspects of pre, intra and post-operative patient experience. Fast recovery is a surgical process which aims to achieve maximum autonomy of the patient through education, pain control and early mobilization. The key of the rapid recovery is to get the involvement of the patient thanks to the empowerment, which means a preoperative patient education that will help to reduce anxiety and it will make easier to engage in their own recovery. Furthermore the patient will take part of an effective post-operative physical therapy, using all the necessary tools to increase their ability to manage their own health problems. The empowerment of these patients is part of the Nursing Model in the Hospital Clinic de Barcelona (HCB), adopted by the Nursing Management in December of 2012. In Catalonia, until the start of the RR surgery, 14,132 interventions in 2008 where done by TKA conventional surgery, needing subsequent conventional hospitalization. This article describes the care and outcomes of nurse interventions, defined in the RR of TKA clinical way, which is focused on the pain's minimization and the impact on patients' mobilization. It was performed in a monographic unit from a tertiary-level hospital in Barcelona in 2013.

A Novel Recurrent Breakpoint Responsible for Rearrangements in the Williams-Beuren Region.

Copy number variants (CNVs) of the Williams-Beuren syndrome (WBS) 7q11.23 region are responsible for neurodevelopmental disorders with multisystem involvement and variable expressivity. We found 2 patients with a deletion and 1 patient with a duplication in this region sharing a common breakpoint located between the LIMK1 and EIF4H(WBSCR1) genes. One patient had a WBS phenotype, although testing with a commercially available FISH assay was negative for the deletion. A further test using array CGH showed an atypical WBS region deletion. The second patient showed global developmental delay, speech delay and poor motor skills with a deletion outside the WBS region. The third patient had manifestations compatible with an autism spectrum disorder showing a duplication in the WBS region. Our findings point to the existence of a previously unrecognized recurrent breakpoint responsible for rearrangements in the WBS region. Given that most commercial FISH assays include probes flanking this novel breakpoint, further testing with array CGH should be performed in patients with WBS and negative FISH results.

Gestión del dolor en pacientes del programa Rapid Recovery (RR), en Artroplastia Total de Rodilla (ATR) / Pain management in patients of Rapid Recovery (Rr) Program in Total Knee Arthroplasty (TKA)

La artroplastia total de rodilla (ATR) es una cirugía consistente en la sustitución artificial de la articulación, debido a una lesión traumática o bien a un proceso degenerativo o de artrosis, con un dolor importante asociado que en ocasiones afecta de forma negativa a la recuperación del paciente. La elección de la prótesis dependerá de las características anatómicas del paciente y del criterio del cirujano. El concepto de «cirugía de recuperación rápida» fue introducido en 1997 por Khelet y significó el inicio del modelo Fast Track o de Rapid Recovery (RR), ligado a una rehabilitación acelerada, un alta precoz y la optimización de todos los aspectos de la experiencia del paciente pre, intra y posoperatoria. La recuperación rápida es un proceso quirúrgico que pretende conseguir la máxima autonomía del paciente mediante la educación, el control del dolor y la movilización precoz. El instrumento fundamental para la recuperación rápida es conseguir la implicación del paciente mediante el empoderamiento, es decir, por medio de la educación preoperatoria del paciente, que contribuirá a reducir la ansiedad y facilitará que se involucre en su propia recuperación. Así, será partícipe de una terapia física posoperatoria eficaz, utilizando todas aquellas herramientas necesarias para aumentar su capacidad de gestionar los problemas de salud. El empoderamiento del paciente forma parte del modelo de enfermería del Hospital Clínic de Barcelona (HCB) adoptado por la Dirección de Enfermería en diciembre del año 2012. La cirugía convencional de ATR en Cataluña hasta el inicio de la cirugía RR ocasionó 14 132 intervenciones en el año 2008, con hospitalización convencional posterior. Este artículo describe los cuidados y los resultados de las intervenciones enfermeras, definidas en la vía clínica RR de ATR dirigidas a la minimización del dolor, y las repercusiones sobre la movilización de los pacientes. Se efectuó en una unidad monográfica de un hospital terciario de Barcelona en el año 2013 (AU)

Total knee arthroplasty (TKA) is a surgery consisting on the artificial joint replacement, due to a traumatic injury or a degenerative process or arthrosis. This surgery causes an important pain to patients, and sometimes affects negatively on their recovery. The choice of the prostheses will depend on the anatomical features of the patient and the surgeon criterion. The concept of «rapid recovery surgery» was introduced in 1997 by Khelet and meant the beginning of the Fast Track model or the Rapid Recovery (RR) linked to an accelerated rehabilitation, an early discharge and the optimization of all the aspects of pre, intra and post-operative patient experience. Fast recovery is a surgical process which aims to achieve maximum autonomy of the patient through education, pain control and early mobilization. The key of the rapid recovery is to get the involvement of the patient thanks to the empowerment, which means a preoperative patient education that will help to reduce anxiety and it will make easier to engage in their own recovery. Furthermore the patient will take part of an effective post-operative physical therapy, using all the necessary tools to increase their ability to manage their own health problems. The empowerment of these patients is part of the Nursing Model in the Hospital Clinic de Barcelona (HCB), adopted by the Nursing Management in December of 2012. In Catalonia, until the start of the RR surgery, 14 132 interventions in 2008 where done by TKA conventional surgery, needing subsequent conventional hospitalization. This article describes the care and outcomes of nurse interventions, defined in the RR of TKA clinical way, which is focused on the pain’s minimization and the impact on patients’ mobilization. It was performed in a monographic unit from a tertiary-level hospital in Barcelona in 2013 (AU)

Síndrome cardiofaciocutáneo, un trastorno relacionado con el síndrome de Noonan: hallazgos clínicos y moleculares en 11 pacientes / Cardiofaciocutaneous syndrome, a Noonan syndrome related disorder: Clinical and molecular findings in 11 patients

Objetivos: Describir los hallazgos clínicos y moleculares de 11 pacientes españoles con síndrome cardiofaciocutáneo (CFC), y compararlos con una serie de 130 pacientes con otros trastornos neurocardiofaciocutáneos (111 pacientes con síndrome de Noonan [SN] y 19 con síndrome LEOPARD). Pacientes y métodos: Se obtuvieron datos clínicos de los pacientes remitidos para estudio genético. Se estudiaron los genesPTPN11, SOS1, RAF1, BRAF y MAP2K1 mediante secuenciación bidireccional de los exones donde se localizan las mutaciones más recurrentes, y todos los exones del gen KRAS. Resultados: Se identificaron 6 mutaciones en BRAF en 9 pacientes, y 2 mutaciones en MAP2K1. La talla baja, el retraso psicomotor, los trastornos del lenguaje y las anomalías ectodérmicas fueron más frecuentes en el CFC que en el resto de los síndromes (p < 0,05). En al menos 2 casos el estudio genético contribuyó a reorientar el diagnóstico. Discusión: Los pacientes con CFC muestran un fenotipo más grave, si bien se describe un paciente sin retraso psicomotor, lo que ilustra la variabilidad del espectro fenotípico asociado a las mutaciones en BRAF. El estudio genético es una herramienta útil en el diagnóstico diferencial del CFC y de los trastornos relacionados con el SN (AU)

Objectives: To describe 11 patients with cardiofaciocutaneous syndrome (CFC) and compare them with 130 patients with other RAS-MAPK syndromes (111 Noonan syndrome patients [NS] and 19 patients with LEOPARD syndrome). Patients and methods: Clinical data from patients submitted for genetic analysis were collected. Bidirectional sequencing analysis of PTPN11, SOS1, RAF1, BRAF, and MAP2K1 focused on exons carrying recurrent mutations, and of all KRAS exons were performed. Results: Six different mutations in BRAF were identified in 9 patients, as well as 2 MAP2K1 mutations. Short stature, developmental delay, language difficulties and ectodermal anomalies were more frequent in CFC patients when compared with other neuro-cardio-faciocutaneous syndromes (P < .05). In at least 2 cases molecular testing helped reconsider the diagnosis. Discussion: CFC patients showed a rather severe phenotype but at least one patient with BRAF mutation showed no developmental delay, which illustrates the variability of the phenotypic spectrum caused by BRAFmutations. Molecular genetic testing is a valuable tool for differential diagnosis of CFC and NS related disorders (AU)

[Cardiofaciocutaneous syndrome, a Noonan syndrome related disorder: clinical and molecular findings in 11 patients]. / Síndrome cardiofaciocutáneo, un trastorno relacionado con el síndrome de Noonan: hallazgos clínicos y moleculares en 11 pacientes.

OBJECTIVES: To describe 11 patients with cardiofaciocutaneous syndrome (CFC) and compare them with 130 patients with other RAS-MAPK syndromes (111 Noonan syndrome patients [NS] and 19 patients with LEOPARD syndrome). PATIENTS AND METHODS: Clinical data from patients submitted for genetic analysis were collected. Bidirectional sequencing analysis of PTPN11, SOS1, RAF1, BRAF, and MAP2K1 focused on exons carrying recurrent mutations, and of all KRAS exons were performed. RESULTS: Six different mutations in BRAF were identified in 9 patients, as well as 2 MAP2K1 mutations. Short stature, developmental delay, language difficulties and ectodermal anomalies were more frequent in CFC patients when compared with other neuro-cardio-faciocutaneous syndromes (P<.05). In at least 2 cases molecular testing helped reconsider the diagnosis. DISCUSSION: CFC patients showed a rather severe phenotype but at least one patient with BRAF mutation showed no developmental delay, which illustrates the variability of the phenotypic spectrum caused by BRAF mutations. Molecular genetic testing is a valuable tool for differential diagnosis of CFC and NS related disorders.

Mutation prevalence of cerebral cavernous malformation genes in Spanish patients.

OBJECTIVE: To study the molecular genetic and clinical features of cerebral cavernous malformations (CCM) in a cohort of Spanish patients. METHODS: We analyzed the CCM1, CCM2, and CCM3 genes by MLPA and direct sequencing of exons and intronic boundaries in 94 familial forms and 41 sporadic cases of CCM patients of Spanish extraction. When available, RNA studies were performed seeking for alternative or cryptic splicing. RESULTS: A total of 26 pathogenic mutations, 22 of which predict truncated proteins, were identified in 29 familial forms and in three sporadic cases. The repertoire includes six novel non-sense and frameshift mutations in CCM1 and CCM3. We also found four missense mutations, one of them located at the third NPXY motif of CCM1 and another one that leads to cryptic splicing of CCM1 exon 6. We found four genomic deletions with the loss of the whole CCM2 gene in one patient and a partial loss of CCM1and CCM2 genes in three other patients. Four families had mutations in CCM3. The results include a high frequency of intronic variants, although most of them localize out of consensus splicing sequences. The main symptoms associated to clinical debut consisted of cerebral haemorrhage, migraines and epileptic seizures. The rare co-occurrence of CCM with Noonan and Chiari syndromes and delayed menarche is reported. CONCLUSIONS: Analysis of CCM genes by sequencing and MLPA has detected mutations in almost 35% of a Spanish cohort (36% of familial cases and 10% of sporadic patients). The results include 13 new mutations of CCM genes and the main clinical symptoms that deserves consideration in molecular diagnosis and genetic counselling of cerebral cavernous malformations.

Cost-effective PKHD1 genetic testing for autosomal recessive polycystic kidney disease.

BACKGROUND: Genetic diagnosis of autosomal recessive polycystic kidney disease (ARPKD) is challenging due to the length and allelic heterogeneity of the PKHD1 gene. Mutations appear to be clustered at specific exons, depending on the geographic origin of the patient. We aimed to identify the PKHD1 exons most likely mutated in Spanish ARPKD patients. METHODS: Mutation analysis was performed in 50 ARPKD probands and nine ARPKD-suspicious patients by sequencing PKHD1 exons arranged by their reported mutation frequency. Haplotypes containing the most frequent mutations were analyzed. Other PKD genes (HNF1B, PKD1, PKD2) were sequenced in PKHD1-negative cases. RESULTS: Thirty-six different mutations (concentrated in 24 PKHD1 exons) were detected, giving a mutation detection rate of 86%. The screening of five exons (58, 32, 34, 36, 37) yielded a 54% chance of detecting one mutation; the screening of nine additional exons (3, 9, 39, 61, 5, 22, 26, 41, 57) increased the chance to 76%. The c.9689delA mutation was present in 17 (34%) patients, all of whom shared the same haplotype. Two HNF1B mutations and one PKD1 variant were detected in negative cases. CONCLUSIONS: Establishing a PKHD1 exon mutation profile in a specific population and starting the analysis with the most likely mutated exons might significantly enhance the efficacy of genetic testing in ARPKD. Analysis of other PKD genes might be considered, especially in suspicious cases.

Intrachromosomal 3p insertion as a cause of reciprocal pure interstitial deletion and duplication in two siblings: further delineation of the emerging proximal 3p deletion syndrome.

Very few cases of constitutional interstitial deletions of the proximal short arm of chromosome 3 have been reported; however, the proximal 3p deletion is emerging as a clinically recognizable syndrome. We present an intrachromosomal insertion of 3p12.3p14.1 in a phenotypic normal man (46,XY,ins(3)(p25p12.3p14.1)) which is responsible for the unbalanced karyotype in 2 affected offspring, one with a 3p12.3p14.1 interstitial deletion and the other with a reciprocal duplication. The exceptionality of these 2 reciprocal recombinants contributes to a better definition of the proximal 3p deletion syndrome and its duplication counterpart.

Contribution of rare copy number variants to isolated human malformations.

BACKGROUND: Congenital malformations are present in approximately 2-3% of liveborn babies and 20% of stillborn fetuses. The mechanisms underlying the majority of sporadic and isolated congenital malformations are poorly understood, although it is hypothesized that the accumulation of rare genetic, genomic and epigenetic variants converge to deregulate developmental networks. METHODOLOGY/PRINCIPAL FINDINGS: We selected samples from 95 fetuses with congenital malformations not ascribed to a specific syndrome (68 with isolated malformations, 27 with multiple malformations). Karyotyping and Multiplex Ligation-dependent Probe Amplification (MLPA) discarded recurrent genomic and cytogenetic rearrangements. DNA extracted from the affected tissue (46%) or from lung or liver (54%) was analyzed by molecular karyotyping. Validations and inheritance were obtained by MLPA. We identified 22 rare copy number variants (CNV) [>100 kb, either absent (n = 7) or very uncommon (n = 15, <1/2,000) in the control population] in 20/95 fetuses with congenital malformations (21%), including 11 deletions and 11 duplications. One of the 9 tested rearrangements was de novo while the remaining were inherited from a healthy parent. The highest frequency was observed in fetuses with heart hypoplasia (8/17, 62.5%), with two events previously related with the phenotype. Double events hitting candidate genes were detected in two samples with brain malformations. Globally, the burden of deletions was significantly higher in fetuses with malformations compared to controls. CONCLUSIONS/SIGNIFICANCE: Our data reveal a significant contribution of rare deletion-type CNV, mostly inherited but also de novo, to human congenital malformations, especially heart hypoplasia, and reinforce the hypothesis of a multifactorial etiology in most cases.

Alteraciones de los genes de la vía RAS-MAPK en 200 pacientes españoles con síndrome de Noonan y otros síndromes neurocardiofaciocutáneos. Genotipo y cardiopatía / Alterations in RAS-MAPK genes in 200 spanish patients with noonan and other neuro-cardio-facio-cutaneous syndromes. Genotype and cardiopathy

Introducción y objetivos. La caracterización molecular de cardiopatías incluye una entidad congénita no infrecuente, el síndrome de Noonan. Presentamos el estudio de seis genes de la vía RAS-MAPK en pacientes españoles: perfil genotípico, impacto de la cardiopatía y expresividad clínica. Métodos. Compusieron la población en estudio 643 pacientes (y 182 familiares) diagnosticados por dismorfólogos, cardiólogos y endocrinopediatras de 74 hospitales (11 comunidades). Estudio primario de PTPN11 y complementario de SOS1, RAF1, BRAF, KRAS y HRAS, estratificado y orientado por signos clínicos, mediante secuenciación de exones recurrentes (un 80-95% de mutaciones descritas). Resultados. Se documentó mutación en 230 pacientes (91 mujeres, 139 varones) de 200 familias (31%), 172 PTPN11 +, 14 SOS1 +, 9 RAF1 + y 5 BRAF +, con referencia explícita a la cardiopatía padecida en 156 casos índice; 103 presentaban estenosis de la válvula pulmonar; 12, estenosis de la válvula pulmonar y miocardiopatía hipertrófica; 18, miocardiopatía hipertrófica y 14, otra cardiopatía; en sólo 9 casos se encontraba ausente. En 23/30 familiares positivos no había o no constaba cardiopatía. El rendimiento diagnóstico fue superior (p = 0,016) para las muestras de algunos centros (53%; 14/32), y alcanzó el 64% (9/14; p = 0,019) en profesionales concretos. El rendimiento cayó al 18% en los pacientes sin datos clínicos facilitados. El dato genotípico reorientó el diagnóstico clínico en 26 pacientes. Conclusiones. El 94% de los pacientes portadores de mutación presentaban cardiopatía, el 79% estenosis de la válvula pulmonar y el 12% miocardiopatía hipertrófica. En el 76% de los familiares positivos con rasgos clínicos compatibles, no se había documentado la cardiopatía. El estudio molecular es una herramienta útil en estos síndromes, aunque debe progresarse en la objetivación del diagnóstico clínico (AU)

Introduction and objectives. Molecular characterization of congenital heart diseases now includes the not infrequent dysmorphic Noonan syndrome. A study of 6 genes of the RAS-MAPK pathway in Spanish patients is presented: the impact of heart disease, clinical expressivity, and diagnostic yield are investigated. Methods. The study included 643 patients (and 182 family members) diagnosed by dysmorphologists, cardiologists, and pediatric endocrinologists from 74 tertiary hospitals. Bidirectional sequencing analysis of PTPN11, SOS1, RAF1, BRAF, KRAS and HRAS focused on exons carrying recurrent mutations accounting for 80% to 95% of previously described mutations. Results. Mutations were detected in 230 patients (91 women and 139 men) in 200 (31%) families (172 PTPN11+, 14 SOS1+, 9 RAF1+, 5 BRAF+). There was specific reference to the heart defect suffered in 156 index cases: 103 patients had shown pulmonary stenosis, 12 pulmonary stenosis with hyperthrophic cardiomyopathy, 18 hypertrophic cardiomiopathy, and 14 other cardiopathies; heart disease was absent in 9 index cases. Heart disease had not been documented in 23 of 30 family members with positive genotype and compatible clinical signs. Diagnostic yield was higher (P=.016) for samples from some centers (53%; 14/32) and even from certain professionals (64%; 9/14; P=.019). Characterization rate was 18% in patients for whom clinical data were not available. Genotyping led to a more precise diagnosis in 26 patients. Conclusions. Most patients (94%) with a positive genotype had known congenital heart disease, 79% pulmonary stenosis and 12% hyperthrophic cardiomyopathy. Cardiopathy had not been documented in 76% of family members carrying the mutation. Molecular study is a useful tool in these syndromes but a more rigorous clinical diagnosis should be intended as well (AU)

Alterations in RAS-MAPK genes in 200 Spanish patients with Noonan and other neuro-cardio-facio-cutaneous syndromes. Genotype and cardiopathy.

INTRODUCTION AND OBJECTIVES: Molecular characterization of congenital heart diseases now includes the not infrequent dysmorphic Noonan syndrome. A study of 6 genes of the RAS-MAPK pathway in Spanish patients is presented: the impact of heart disease, clinical expressivity, and diagnostic yield are investigated. METHODS: The study included 643 patients (and 182 family members) diagnosed by dysmorphologists, cardiologists, and pediatric endocrinologists from 74 tertiary hospitals. Bidirectional sequencing analysis of PTPN11, SOS1, RAF1, BRAF, KRAS and HRAS focused on exons carrying recurrent mutations accounting for 80% to 95% of previously described mutations. RESULTS: Mutations were detected in 230 patients (91 women and 139 men) in 200 (31%) families (172 PTPN11+, 14 SOS1+, 9 RAF1+, 5 BRAF+). There was specific reference to the heart defect suffered in 156 index cases: 103 patients had shown pulmonary stenosis, 12 pulmonary stenosis with hyperthrophic cardiomyopathy, 18 hypertrophic cardiomiopathy, and 14 other cardiopathies; heart disease was absent in 9 index cases. Heart disease had not been documented in 23 of 30 family members with positive genotype and compatible clinical signs. Diagnostic yield was higher (P=.016) for samples from some centers (53%; 14/32) and even from certain professionals (64%; 9/14; P=.019). Characterization rate was 18% in patients for whom clinical data were not available. Genotyping led to a more precise diagnosis in 26 patients. CONCLUSIONS: Most patients (94%) with a positive genotype had known congenital heart disease, 79% pulmonary stenosis and 12% hyperthrophic cardiomyopathy. Cardiopathy had not been documented in 76% of family members carrying the mutation. Molecular study is a useful tool in these syndromes but a more rigorous clinical diagnosis should be intended as well.

Identification of a Gypsy SHOX mutation (p.A170P) in Léri-Weill dyschondrosteosis and Langer mesomelic dysplasia.

We report the clinical and molecular characteristics of 12 Spanish families with multiple members affected with Léri-Weill dyschondrosteosis (LWD) or Langer mesomelic dysplasia (LMD), who present the SHOX (short stature homeobox gene) mutation p.A170P (c.508G>C) in heterozygosity or homozygosity, respectively. In all studied families, the A170P mutation co-segregated with the fully penetrant phenotype of mesomelic limb shortening and Madelung deformity. A shared haplotype around SHOX was observed by microsatellite analysis, confirming the presence of a common ancestor, probably of Gypsy origin, as 11 of the families were of this ethnic group. Mutation screening in 359 Eastern-European Gypsies failed to identify any carriers. For the first time, we have shown SHOX expression in the human growth plate of a 22-week LMD fetus, homozygous for the A170P mutation. Although the mutant SHOX protein was expressed in all zones of the growth plate, the chondrocyte columns in the proliferative zone were disorganized with the chondrocytes occurring in smaller columnal clusters. We have also identified a novel mutation at the same residue, c. 509C>A (p.A170D), in two unrelated Spanish LWD families, which similar to A170P mutation impedes nuclear localization of SHOX. In conclusion, we have identified A170P as the first frequent SHOX mutation in Gypsy LWD and LMD individuals.

Pathological findings in the complete trisomy 9 syndrome: three case reports and review of the literature.

The term "complete trisomy 9" is used to indicate trisomy of the entire chromosome 9 without evidence of mosaicisms. It is a relatively rare chromosomal abnormality because the vast majority of affected pregnancies result in 1st trimester spontaneous abortions. The purpose of this paper is to delineate the complete trisomy 9 syndrome, based on autopsy findings. We performed an exhaustive review of the literature of complete forms of this trisomy with autopsy examination and added 3 new cases from our center with new findings not previously described.

Características y calidad de vida de los cuidadores informales de enfermos de sida / Characteristics and quality of life of informal caregivers of patients with AIDS

Objetivo. Conocer las características y la calidad de vida de los cuidadores informales de los enfermos de sida. Método. Estudio observacional, descriptivo y transversal, realizado en las unidades de referencia de atención a enfermos de sida de 3 hospitales públicos de Barcelona. Se observó a 221 cuidadores informales de estos enfermos, seleccionados de manera no probabilística consecutiva. Se estudiaron las características de las personas enfermas de sida y de sus cuidadores informales. Para identificar los cuidados que prestaba el cuidador y las repercusiones que esta labor tenía sobre su calidad de vida se ha utilizado el cuestionario ICUB97®, basado en el modelo de Virginia Henderson. Resultados. Los enfermos de sida tenían una media de edad de 37 años (desviación estándar = 9) y 153 eran varones (69%). El contagio había sido por vía parenteral en 108 casos (49%) y por vía sexual en 98 (44%). Sus cuidadores tenían una media de edad de 50 años (desviación estándar = 15) y 173 eran mujeres (78%). El 41% (n = 128) había dejado de trabajar o había adaptado su trabajo para cuidar al enfermo. Las necesidades alteradas más frecuentes fueron las de descanso y sueño (170 [77%] estaban más cansados) y la de recreación (156 [71%] tenían menos tiempo libre). Conclusiones. La mayoría de los cuidadores informales de enfermos de sida son mujeres de mediana edad que prestan un elevado número de cuidados y cuya calidad de vida se ve alterada a consecuencia de esta labor. Las necesidades que presentan más alteradas son la de descanso y sueño y la de recreación