Moduladores cronobiológicos en la efectividad de la trombolisis prehospitalaria / Circadian modulation of effectiveness in prehospital thrombolysis

Objetivo: Investigar si la hora del día influye en la efectividad de la terapia trombolítica prehospitalaria en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST). Método: Estudio observacional de cohortes retrospectivo con pacientes diagnosticados de IAMCEST a quienes se les realizó trombolisis precoz prehospitalaria. Se analizaron, como variables predictoras independientes de la efectividad de la terapia trombolítica, la hora del día de administración de la terapia trombolítica (variable principal), divididos en periodos horarios de 6 h y de 12 h, la edad, el sexo, la hora inicio del dolor torácico, tiempo de evolución del infarto, los factores de riesgo cardiovascular y el área de localización del infarto. Los datos se obtuvieron de la historia clínica y del seguimiento de preavisos hospitalarios a las 24 h. Resultados: Se incluyó a 206 pacientes. Dos variables se muestran como predictores independientes de la efectividad de la trombolisis prehospitalaria: la hora del día de administración de la terapia trombolítica, en el rango de cronorriesgo cardiovascular de 6a 12 h, con respecto al resto de franjas horarias (0-6 h, 12-18 h, 18-24 h) [p = 0,005odds ratio (OR) = 2,46; intervalo de confianza (IC) del 95%, 1,30-4,64] y presentar cardiopatía isquémica previa) (p = 0,003, OR = 5,30; IC del 95%, 1,74-16,15).Conclusiones: Encontramos variaciones circadianas clínicamente significativas en la efectividad del tratamiento trombolítico prehospitalario administrado a los pacientes con IAMCEST, independientemente del agente trombolítico empleado, de manera que existe una tromborresistencia matinal (6-12 am) al tratamiento y una mayor efectividad de reperfusión coronaria cuando se administra en el resto de franjas horarias diurnas ,especialmente en la de tarde (12-18 h) (AU)

Objective: To study whether time of day influences the effectiveness of prehospital thrombolysis in patients who have had acute myocardial infarction with ST-segment elevation (STEMI).Methods: Observational study of retrospective cohorts. We included patients diagnosed with STEMI who received early application of prehospital thrombolytic therapy. The main variable studied as an independent predictor of effectiveness was the time of day the thrombolytic agent was administered; this variable was studied in 6-hour periods and 12-hourperiods. Additional independent variables were patient age and sex, onset of chest pain, duration of pain from onset until administration of the thrombolytic agent, cardiovascular risk factors, and location of infarction. Data were extracted from patient records and ambulance pre-alert calls in the next 24 hours. Results: Two hundred six patients were studied. The 2 independent variables that predicted the effectiveness of prehospital thrombolysis were administration of the thrombolytic agent at a time of day within the period of greatest cardiovascular risk (6 AM to 12 noon) in comparison with the other time frames (12 midnight to 6 AM, 12 noon to 6 PM and 6 PM to midnight) (odds ratio [OR], 2.46; 95% CI, 1.30-4.64; P=.005) and history of ischemic heart disease (OR,5.30; 95% CI, 1.74-16.15; P=.003).Conclusions: We found that circadian rhythm had a clinically significant effect on the effectiveness of prehospital thrombolysis in STEMI patients. The effect was present regardless of which thrombolytic agent was used. The greatest resistance to therapy was observed in the morning hours between 6 AM and 12 noon. The response was greater in the remaining time frames and greatest in the hours between noon and 6 PM (AU)

Two new patients bearing mutations in the fukutin gene confirm the relevance of this gene in Walker-Warburg syndrome.

Walker-Warburg syndrome (WWS) is an autosomal recessive disorder characterized by congenital muscular dystrophy, brain malformations and structural abnormalities of the eye. We have studied two WWS patients born to non-consanguineous parents, and in both cases, we identified mutations in the fukutin gene responsible for this syndrome. One of the patients carries a homozygous-single nucleotide insertion that produces a frameshift, being this the first time that this insertion has been described in homozygosis and causing a WWS phenotype. The other patient carries two novel mutations, one being a point mutation that produces an amino acid substitution, while the other is a deletion in the 3'UTR that affects the polyadenylation signal of the fukutin gene. This deletion would probably result in the complete loss of the fukutin transcripts from this allele. This is the first time a mutation localized outside of the fukutin coding region has been identified as a cause of WWS.

[Drug therapy for corneo-conjunctival neoplasm]. / Tratamiento farmacológico de la neoplasia corneal y conjuntival.

BACKGROUND: The goal of therapy for corneo-conjunctival neoplasm is lesion removal, with the most widespread procedure being complete tumor resection with or without associated chemotherapy lines. As this sort of procedure entails a high relapse rate (9-52%) the use of adjuvant therapies to reduce the occurence of relapse becomes a need. The administration of a number of topically administered drugs has been used for adjuvant therapy, including mitomycin C, 5-fluorouracil and interferon a 2b. OBJECTIVE: To determine the clinical experience published regarding the effectiveness of the various drug therapies for cor-neo-conjunctival neoplasm. SEARCH STRATEGY: Information reported on this topic in the Medline database (1966-2004) was searched using corneo-conjunctival neoplasm, 5-fluorouracil, mitomycin C, and interferon ca2b as key words. SELECTION CRITERIA: All papers quoting dosage for drugs used,treatment length, adverse effect development, and clinical response obtained were included. PRIMARY RESULTS: Papers reporting the use of 5-fluorouracil re few when compared to those quoting other drugs, with a response rate of 88% and a relapse rate of 20%. The use of mitomycin C is widely described in the medical literature with a response rate of 90% and a relapse rate of 13%, but in association with the development of adverse effects in a high percentage of patients. Interferon ca 2b is the last drug to be incorporated in the treatment of these ocular lesions, with a response rate of 100% and a low incidence of adverse effects, with a relapse rate of 4%. CONCLUSIONS: Mitomycin C is an effective drug, but its use is associated with a high number of adverse events, some of which may lead to therapy discontinuation. Interferon ct 2b has efficacy outcomes comparable to mitomycin C and a lower incidence of adverse effects, which are mostly mild in nature. The use of 5-fluorouracil is relegated to a second-tier status.

Tratamiento farmacológico de la neoplasia corneal conjuntival / Drug therapy for corneo-conjunctival neoplasm

Antecedentes: El objetivo del tratamiento de la neoplasia córneo- conjuntival es la eliminación de la lesión, siendo el más extendido la resección quirúrgica completa del tumor asociado o no a varias hileras de crioterapia. Debido a la elevada tasa de recidivas de este tipo de intervención (9-52%), se hace necesaria la utilización de tratamientos adyuvantes que la reduzcan. Para el tratamiento adyuvante se ha empleado la administración de varios fármacos por vía tópica tales como: la mitomicina-C, el 5-fluorouracilo y el interferón alfa 2b. Objetivo: Conocer la experiencia clínica publicada sobre la efectividad de los diferentes tratamientos farmacológicos de la neoplasia córneo-conjuntival. Estrategia de la búsqueda: Se revisó la información publicada sobre este tema en la base de datos Medline (1966-2004), utilizando como palabras clave neoplasia córneo conjuntival, 5- fluorouracilo, mitomicina C e interferón alfa 2b. Criterios de selección: Se incluyeron todos los trabajos en los que se expresaba la dosis de fármaco utilizado, la duración del tratamiento, la aparición de efectos adversos y la respuesta clínica obtenida. Resultados principales: Los artículos publicados en los que se ha utilizado el 5-fluorouracilo son escasos en comparación con los publicados con los otros dos fármacos, presentando una tasa de respuesta del 88% y una tasa de recidivas del 20%. La utilización de mitomicina-C está ampliamente descrita en la literatura médica con una tasa de respuesta del 90% y tasa de recidivas del 13%, pero está asociada a la aparición de efectos adversos en un porcentaje elevado de pacientes. El interferón alfa 2b, ha sido el último fármaco incorporado para el tratamiento de estas lesiones oculares obteniendo unos resultados en cuanto a respuesta del 100% y un bajo número de efectos adversos, con un tasa de recidivas del 4%. Conclusiones: La mitomicina C es un fármaco eficaz, pero que se asocia a la aparición de un gran número de efectos adversos, que en algunos casos obligan a suspender el tratamiento. El interferón alfa 2b presenta unos resultados de eficacia comparables a la mitomicina-C y con un menor número de reacciones adversas, siendo en su mayoría de carácter leve. Queda en un segundo plano la utilización del 5-fluorouracilo

Background: The goal of therapy for corneo-conjunctival neoplasm is lesion removal, with the most widespread procedure being complete tumor resection with or without associated chemotherapy lines. As this sort of procedure entails a high relapse rate (9-52%) the use of adjuvant therapies to reduce the occurence of relapse becomes a need. The administration of a number of topically administered drugs has been used for adjuvant therapy, including mitomycin C, 5-fluorouracil and interferon alpha 2b. Objective: To determine the clinical experience published regarding the effectiveness of the various drug therapies for corneo- conjunctival neoplasm. Search strategy: Information reported on this topic in the Medline database (1966-2004) was searched using corneo-conjunctival neoplasm, 5-fluorouracil, mitomycin C, and interferon alpha 2b as key words. Selection criteria: All papers quoting dosage for drugs used, treatment length, adverse effect development, and clinical response obtained were included. Primary results: Papers reporting the use of 5-fluorouracil are few when compared to those quoting other drugs, with a response rate of 88% and a relapse rate of 20%. The use of mitomycin C is widely described in the medical literature with a response rate of 90% and a relapse rate of 13%, but in association with the development of adverse effects in a high percentage of patients. Interferon alpha 2b is the last drug to be incorporated in the treatment of these ocular lesions, with a response rate of 100% and a low incidence of adverse effects, with a relapse rate of 4%. Conclusions: Mitomycin C is an effective drug, but its use is associated with a high number of adverse events, some of which may lead to therapy discontinuation. Interferon alpha 2b has efficacy outcomes comparable to mitomycin C and a lower incidence of adverse effects, which are mostly mild in nature. The use of 5-fluorouracil is relegated to a second-tier status

[Treatment of persistent epithelial defects using autologous serum application]. / Tratamiento de defectos epiteliales persistentes mediante suero autólogo.

PURPOSE: To study the impact of topical treatment with autologous serum on the clinical evolution of persistent corneal epithelial defects (PED) and to observe its effect on squamous metaplasia in 7 cases of dry eye. PATIENTS AND METHODS: In this prospective, clinical, non-comparative case series study we evaluated a total of 17 eyes (14 patients). We analized the clinical evolution (fluorescein staining, Schirmer's I and II tests and photographic control) of PED in these patients, to whom 20% autologous serum eyedrops were applied for 28 days. Using impression cytology technique (Tseng's method) we evaluated the involution of squamous metaplasia in 7 eyes of 4 patients with ocular cicatricial pemphigoid and dry eye who were treated with autologous serum. The Wilconxon test was used for the statistical treatment of the data. RESULTS: The epithelial defect healed within 2 weeks in 6 eyes (35.2%). Eight eyes (47%) healed within 2-4 weeks and 3 eyes (17.6%) did not heal after week 4. The duration of PED, before serum therapy was 36 days. Six of seven eyes treated with autologous serum presented an involution of squamous metaplasia 28 days after initiation of the serum drops. CONCLUSIONS: Autologous serum treatment accelerates PED healing. Autologous serum application causes an involution of squamous metaplasia.

[Bioadhesives in ocular surgery]. / Bioadhesivos en cirugía ocular.

PURPOSE: To evaluate the histological inflammatory activity that bioadhesives such as fibrin, cyanoacrylate, unsutured valved closure and suturing, generate when applied on scleral tissue. METHODS: We used a total of 80 eyes of 80 white rabbits which we divided into 8 groups of ten eyes each and distributed according to the two periods of time (1 week and 30 days) and four technique used for closure: 10/0 nylon suture, sutureless self-sealing, cyanoacrylate glue (Histoacryl), and fibrin glue (Tissucol). ANOVA was used for the statistical study of histological inflammation. Descriptive statistical analysis was used for the study of the degree of healing. RESULTS: After 7 days, the fibrin bioadhesive led to greater inflammatory response than did the other techniques (p<0.001). The cyanoacrylate adhesive caused less inflammatory activity than did suturing material (p<0.005). On day 30, the inflammatory reaction generated by the fibrin and cyanoacrylate adhesives was greater than of the suturing and self valved closure technique (p<0.005). After 7 days, the degree of healing with the suture, sutureless technique and cyanoacrylate adhesive was incomplete, while healing was moderate with the fibrin glue. After 30 days the degree of healing with cyanoacrylate glue was incomplete. At this time the degree of healing, with the suture, sutureless technique and fibrin adhesive was complete. CONCLUSIONS: Fibrin causes greater inflammatory reaction than do the other techniques. The cyanoacrylate adhesive shows a biological tolerance identical to the suture technique. This shows that cyanoacrylate bioadhesives are a viable alternative to suturing in scleral surgery.

Bioadhesivos en cirugía ocular / Bioadhesives in ocular surgery

Objetivo: Evaluar la actividad inflamatoria histológica que los bioadhesivos de fibrina, cianoacrilato, cierre valvulado sin sutura y material de sutura generan al ser aplicados en el tejido escleral. Métodos: Utilizamos un total de 80 ojos de 80 conejos albinos, que clasificamos en 8 grupos de 10 ojos cada uno, distribuidos según los dos tiempos (1semana y 30 días) y las cuatro técnicas utilizadas: sutura de nylon 10/0, cierre autovalvulado sin sutura, adhesivo de cianoacrilato (Histoacryl®) y de f¦brina (Tissucol®). El análisis estadístico del grado de inflamación histológica fue realizado con el test del análisis factorial de la Varianza (ANOVA). El estudio sobre el grado de cicatrización se realizó mediante análisis estadístico descriptivo. Resultados: A los 7 días, el bioadhesivo de fibrina indujo una respuesta inflamatoria superior al resto de técnicas (p<0,001). El adhesivo de cianoacrilato demostró una actividad inflamatoria inferior a la sutura (p<0,005). A los 30 días la reacción inflamatoria generada por los adhesivos de fibrina y cianoacrilato superó a la presentada por las técnicas con sutura y cierre autovalvulado (p<0,005). A los 7 días, se observa una respuesta cicatricial incompleta con las técnicas con sutura, sin sutura y con cianoacrilato, y moderada con la técnica de fibrina. El grado de cicatrización observado con la técnica con cianoacrilato es incompleto al cabo de los 30 días. En este tiempo, el grado de cicatrización con las técnicas sin sutura, con sutura y con fibrina es completo. Conclusiones: El bioadhesivo de fibrina demuestra ser una sustancia más inflamatoria que el resto de técnicas. El adhesivo de cianoacrilato presenta una tolerancia biológica semejante a la sutura. Según esto, los bioadhesivos de cianoacrilato pueden constituir una alternativa al material de sutura en cirugía escleral (AU)

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Fine-scale comparative mapping of the human 7q11.23 region and the orthologous region on mouse chromosome 5G: the low-copy repeats that flank the Williams-Beuren syndrome deletion arose at breakpoint sites of an evolutionary inversion(s).

Williams-Beuren syndrome (WBS) is a developmental disorder caused by haploinsufficiency for genes deleted in chromosome band 7q11.23. A common deletion including at least 16-17 genes has been defined in the great majority of patients. We have completed a physical and transcription map of the WBS region based on analysis of high-throughput genome sequence data and assembly of a BAC/PAC/YAC contig, including the characterization of large blocks of gene-containing low-copy-number repeat elements that flank the commonly deleted interval. The WBS deletions arise as a consequence of unequal crossing over between these highly homologous sequences, which confer susceptibility to local chromosome rearrangements. We have also completed a clone contig, genetic, and long-range restriction map of the mouse homologous region, including the orthologues of all identified genes in the human map. The order of the intradeletion genes appears to be conserved in mouse, and no low-copy-number repeats are found in the region. However, the deletion region is inverted relative to the human map, exactly at the flanking regions. Thus, we have identified an evolutionary inversion with chromosomal breakpoints at the sites where the human 7q11.23 low-copy-number repeats are located. Additional comparative mapping suggests a model for human chromosome 7 evolution due to serial inversions leading to genomic duplications. This high-resolution mouse map provides the framework required for the generation of mouse models for WBS mimicking the human molecular defect.

WBSCR14, a putative transcription factor gene deleted in Williams-Beuren syndrome: complete characterisation of the human gene and the mouse ortholog.

Williams-Beuren syndrome (WBS) is a neurodevelopmental disorder affecting several systems caused by a heterozygous deletion in the chromosomal region 7q11.23. A common interval that includes up to 17 genes reported so far is deleted in the great majority of patients. Elastin haploinsufficiency is responsible for the cardiovascular features, but the specific contribution of other deleted genes to the WBS phenotype remains unknown. We have fully characterised a gene commonly deleted in WBS, WBSCR14, previously reported in a truncated form as WS-bHLH. The WBSCR14 cDNA encodes an 852amino acid protein with a basic helix-loop-helix-leucine-zipper motif (bHLHZip) and a bipartite nuclear localisation signal (BNLS), suggesting a function as a transcription factor. WBSCR14 is expressed as a 4.2kb transcript predominantly in adult liver and at late stages of foetal development. The WBSCR14 locus encompasses 33 kb of genomic DNA with 17 exons. Two intragenic polymorphic dinucleotide repeats have been identified and used to verify hemizygosity in WBS patients. We have also cloned the mouse ortholog and mapped its locus to mouse chromosome 5, in a region of conserved synteny with human 7q11.23. Given that other bHLHZip proteins are dosage sensitive and based on the putative function of WBSCR14 as a transcription factor, hemizygosity at this locus could be involved in some features of WBS.

Identification of de novo deletions at the NF1 gene: no preferential paternal origin and phenotypic analysis of patients.

Neurofibromatosis type 1 (NF1) is a common autosomal dominant disorder. To date, a relatively small number of NF1 mutations have been characterized, thus precluding genotype-phenotype correlations. By genotyping 75 NF1 families, we have detected six hemizygous patients (two of whom are members of the same family). The five presumed deletions were confirmed by two quantitative methods of analysis of NF1 copy number: Southern hybridization with cDNA probes and a single-strand conformation polymorphism analysis that discriminates between the NF1 gene and the pseudogene sequences. The five deletions remove most of the NF1 gene, at least 225 kb, from exon 9 to the 3' end of the coding sequence. The origin of de novo mutations in the NF1 gene has been reported to be mainly paternal but we have determined that four of the de novo deletions involved the maternal chromosome and one the paternal chromosome. The six patients with deletions exhibited precocious, multiple clinical features of the disease. The incidence of tumor complications, particularly plexiform neurofibromas and intracranial tumors, among this group of patients is higher than the observed incidence in our NF1 population, suggesting that NF1 haploinsufficiency may cause a more severe phenotype with regard to tumor development. In contrast to other reports that associated large deletions with mildly dysmorphic facies, mental retardation and a large number of cutaneous neurofibromas, only one out of our six patients presented this phenotype.

[McArdle's disease in adults: clinical and genetic study]. / Enfermedad de McArdle en adultos: estudio clínico y genético.

McArdle's disease is a rare metabolic myopathy resulting from an absence of functional muscle glycogen phosphorylase that is inherited as an autosomal recessive condition. Recent molecular genetic studies have identified more than ten different mutations in patients with McArdle's disease, although a nonsense point mutation at codon 49 in exon 1 (R49X) accounts for approximately 85% of mutant alleles in American and British patients. We describe clinical, biochemical and genetic characteristics of five adults patients with McArdle's disease studied at our hospital during the last 10 years.

Linkage disequilibrium between four intragenic polymorphic microsatellites of the NF1 gene and its implications for genetic counselling.

Four intragenic polymorphic microsatellite markers, AAAT Alu repeat, IVS27AC28.4, ACI27.2, and IVS38GT53.0, located along a 65 kb DNA region of the NF1 gene, were used to genotype 64 Spanish families with neurofibromatosis type 1 (NF1). Linkage disequilirium between each pair of markers was evaluated. Three of these markers, AAAT Alu repeat, ACI27.2, and IVS38GT53.0, exhibit linkage disequilibrium between each other. Analysis of extended haplotypes provides further evidence of the disequilibrium within this region since only 11 haplotypes account for 52% of the total chromosomes. Because of linkage disequilibrium, the informativeness of marker combinations for genotyping of NF1 families is diminished. There was no difference in the overall distribution of alleles between affected and normal chromosomes. An at risk haplotype was not found, as expected for a disease with at least 50% of cases being sporadic.

Characterization of four mutations in the neurofibromatosis type 1 gene by denaturing gradient gel electrophoresis (DGGE).

Neurofibromatosis type 1 (NF1) is one of the most common inherited disorders. The gene responsible for the disease has a very high mutation rate, approximately fifty per cent of NF1 patients appear to have a de novo mutation. The search for mutations is hampered by the large size of the NF1 gene and up to date, relatively few mutations have been characterized. In the present work, we report the results of screening seventy unrelated NF1 patients for mutations in NF1 exons 29 and 31 by using an experimental approach that combines the polymerase chain reaction (PCR) with denaturing gradient gel electrophoresis (DGGE). Four mutations were identified and characterized. Three of them consist of C-T transitions resulting in nonsense mutations, two in exon 29, C5242T and C5260T, and one in exon 31, C5839T. The fourth mutation consists of a two-base pair deletion in exon 31, 5843delAA, also resulting in a premature stop codon. The finding in our patients of mutation C5839T, previously reported in three independent studies, supports that this position is a hotspot within the NF1 gene.