Utility of whole-exome sequencing for those near the end of the diagnostic odyssey: time to address gaps in care.

An accurate diagnosis is an integral component of patient care for children with rare genetic disease. Recent advances in sequencing, in particular whole-exome sequencing (WES), are identifying the genetic basis of disease for 25-40% of patients. The diagnostic rate is probably influenced by when in the diagnostic process WES is used. The Finding Of Rare Disease GEnes (FORGE) Canada project was a nation-wide effort to identify mutations for childhood-onset disorders using WES. Most children enrolled in the FORGE project were toward the end of the diagnostic odyssey. The two primary outcomes of FORGE were novel gene discovery and the identification of mutations in genes known to cause disease. In the latter instance, WES identified mutations in known disease genes for 105 of 362 families studied (29%), thereby informing the impact of WES in the setting of the diagnostic odyssey. Our analysis of this dataset showed that these known disease genes were not identified prior to WES enrollment for two key reasons: genetic heterogeneity associated with a clinical diagnosis and atypical presentation of known, clinically recognized diseases. What is becoming increasingly clear is that WES will be paradigm altering for patients and families with rare genetic diseases.

Oxidation of sulfamethoxazole and related antimicrobial agents by TiO2 photocatalysis.

The widespread detection of pharmaceutically active compounds, including many synthetic antimicrobial agents, in aquatic environments is raising public health concerns. As a result, there is growing interest in the development of innovative technologies to efficiently transform these compounds to non-toxic and pharmaceutically inactive byproducts. This work examines the photocatalytic degradation of sulfamethoxazole (SMX) and related sulfonamide antimicrobial agents in aqueous suspensions of nanophase titanium dioxide (TiO(2)). Experimental results demonstrate that SMX is mineralized by TiO(2) irradiated with ultraviolet-A light (UVA: 324<

Severe laryngeal stenosis in newly born twins with 22q11.2 deletion syndrome: A case report.

Chromosome 22q11.2 deletion syndrome is common and presents with a range of clinical features from cardiac malformations to hypocalcemia. Laryngeal anomalies are not a common feature of this syndrome. We describe newly born twins who presented with unexpected severe birth depression secondary to severe type IV glottic webs requiring extensive resuscitation and emergency tracheostomy. They were diagnosed postnatally to have deletion of 22q11.2. The successful resuscitation of these infants at birth was only possible because they were born in a tertiary care hospital. This report shows the critical nature of prenatal diagnosis of 22q11.2 deletion syndrome.

17 beta-estradiol stimulation of uterine blood flow in oophorectomized rabbits with complete inhibition of uterine ribonucleic acid synthesis.

The 17 beta-estradiol-induced increase of uterine blood flow (UBF) was studied in 7- to 8-month-old oophorectomized rabbits 6-39 days after operation. Baseline blood flows were determined with 141Ce-labeled microspheres and 2-h flows with 85Sr-labeled microspheres. Mean UBF in control groups ranged from 0.11-0.26 mi/min . g. Mean UBF 2 h after 17 beta-estradiol (10 microgram/kg BW) was 1.51 ml/min . g. Utilizing [3H]uridine (100 microCi/kg 15 min before the 2-h flow study), 3H incorporation into uterine RNA was 2-fold higher than background. Estradiol treatment produced a 4-fold increase in 3H incorporation into uterine RNA. Estradiol-treated animals, pretreated with actinomycin D (4 mg/kg), increased UBF to 1.09 ml/min . g 2 h after estradiol but failed to increase uterine RNA synthesis. 3H incorporation into uterine RNA in this group was suppressed to undetectable (background) levels. These findings indicate that a mechanism other than accelerated transcription, whether induced directly or by translocation of a cytosolic receptor, underlies the increased UBF after estradiol administration to oophorectomized rabbits.

Partial purification and amino acid sequence analysis of endometriosis protein-II (ENDO-II) reveals homology with tissue inhibitor of metalloproteinases-1 (TIMP-1).

De novo synthesized endometriosis protein-II (ENDO-II; M(r) 28,000 to 32,000; pI 7.0 to 9.0) was partially purified from rat endometriotic tissue culture media using affinity chromatography and two-dimensional SDS-PAGE. The protein was electrophoretically transferred to polyvinyl difluoride membranes which were stained with Coomassie blue R-250. The stained protein corresponding to ENDO-II (M(r) 28,000 to 32,000; pI 7.0 to 9.0) was cut from the membranes for amino acid sequencing. Partial amino acid sequence was determined by automated Edman degradation using a gas phase sequencer and phenylthiohydantoin analyzer. Sequence analysis of ENDO-II yielded 25 residues: C S C A P T H P Q T A F C N S D L V I R K F M G. Comparison to sequence databanks demonstrated significant homology with rat (100%) and human (84%) tissue inhibitor of metalloproteinases-1 (TIMP-1). Western blot analysis using a TIMP-1 antibody confirmed amino acid sequence analysis. In conclusion, ENDO-II shares sequence homology with TIMP-1 and cross-reactivity with TIMP-1 antibody and subsequently identifies production of TIMP-1 by endometriotic tissues. The synthesis and secretion of TIMP-1 by endometriosis may derange the normal proteolytic milieu of the peritoneal cavity and contribute to the etiology and underlying physiological sequelae associated with the disease endometriosis.

Indium-111 oxine platelet survival in dogs: effect of doxorubicin and Dacron grafts.

The cytotoxic chemotherapeutic agent doxorubicin was found to acutely decrease platelet survival times in beagle dogs as determined using platelets labeled with [111In]oxine. Recovery was rapid, with platelet survival times returning to normal within 3 wk of cessation of treatment. Doxorubicin (1.5 mg/kg i.v. every 3 wk for a total of four doses) also delayed the return of platelet survival times to normal when given to beagle dogs following placement of thoracoabdominal aortic Dacron grafts. It is not known whether or not this may have clinical significance.

Corpus luteum formation in the fetus.

A well-developed corpus luteum was found at autopsy in a premature infant who died 26 hours post partum. Intrauterine pituitary-gonadal development and regulation are briefly reviewed and a possible mechanism of intrauterine fetal ovulation is presented.

Isolated gonadotropin deficiency in three sisters.

Three female siblings with isolated gonadotropin deficiency were studied. None demonstrated hyposmia or craniofacial abnormalities. Single doses of luteinizing hormone-releasing hormone and thyrotropin-releasing hormone (TRH) produced markedly different responses within the kindred. Following administration of TRH, one subject displayed a sharp rise in prolactin, but thyrotropin did not change.

Tuboplasty--comparison of the methodology.

A number of innovations have recently been made in the area of tubal surgery. This report summarizes our experience with these techniques. Microtechniques improved our results markedly with tubal anastomosis. Pregnancy rates were over 50% in reversal of fimbriectomy, but much lower with undilated tubes closed by inflammatory processes. Use of low molecular weight dextran was without benefit in improving pregnancy rates. Salpingolysis without steroids or hydrotubation resulted in a pregnancy rate of 69%.

Polypeptides synthesized and released by human endometriosis differ from those of the uterine endometrium in cell and tissue explant culture.

OBJECTIVE: To identify and compare the pattern of polypeptide synthesis and release of endometriosis with that of the normal endometrium in culture. DESIGN: Endometriosis and endometrial biopsy specimens were obtained from women presenting for a variety of diagnostic and therapeutic examinations. Specimens were cultured as isolated epithelial and stromal cells and tissue explants with L-[35S]methionine. De novo synthesized proteins were identified by two-dimensional sodium dodecyl sulfate-polyacrylamide gel electrophoresis, fluorography, and Western blot analysis. RESULTS: Five major deviations in protein synthesis and secretion were noted when comparing endometriotic and endometrial culture media. Endometriosis synthesized and secreted two proteins of stromal cell origin that were not produced by normal endometrium: endometriosis protein group I (M(r) 40,000 to 55,000; pI 4.0 to 5.2) and endometriosis protein group II (M(r) 30,000 to 32,000; pI 7.0 to 9.0). Conversely, endometriosis lacked the ability to secrete or asynchronously secreted three groups of secretory phase endometrial proteins in culture: endometrial protein group I (M(r) 25,000 to 27,000; pI 4.5 to 5.5) and endometrial protein group II (M(r) 68,000 to 72,000; pI 3.0 to 3.2) were endometrial epithelial cell products whereas endometrial protein group III (M(r) 70,000; pI 5.7) was of endometrial stromal cell origin. CONCLUSIONS: Unique characteristics in endometriosis protein synthesis and secretion as compared with the endometrium indicate biochemical dissimilarities between these tissues, which may be used to develop diagnostic markers and gain insight into the etiology and/or pathophysiology of the disease.

Proliferative and morphogenic changes induced by the coculture of rat uterine and peritoneal cells: a cell culture model for endometriosis.

OBJECTIVE: To evaluate the proliferative and morphogenic effects induced by the coculture of uterine and peritoneal cells to establish a cell culture model for endometriosis. DESIGN: Uterine epithelial and stromal cells and peritoneal mesothelial and subserosal cells were cocultured with homologous cell types, heterologous cell types, or as isolated populations using a bicameral chamber design. SETTING: Department of Obstetrics and Gynecology at the University of Missouri, Columbia, Missouri. ANIMALS: Cells isolated and purified from five mature female Sprague Dawley rats of normal reproductive status were used to establish cell cultures. MAIN OUTCOME MEASURES: Cell proliferation (deoxyribonucleic acid synthesis) was measured by the incorporation of 3H-thymidine, and cell morphology was assessed using inverted phase-contrast microscopy. RESULTS: Peritoneal mesothelial cells augmented proliferation and induced cellular aggregation of uterine stromal cell monolayers. Peritoneal subserosal cells amplified proliferation and induced an irregular, compacted morphology in uterine epithelial cells. The proliferation and morphology of the two peritoneal cell types was not altered by uterine cell coculture. CONCLUSIONS: The coculture of uterine and peritoneal cells in bicameral chambers provides a tool to study the paracrine interactions of cells that comprise the endometriotic lesion. The altered proliferation and morphology of the uterine cells may be related to the histologic and biochemical asynchrony observed between uterine endometrium and ectopic endometriotic tissue in vivo and offers insight into possible mechanisms of the histogenesis of endometriosis.

Predictors of psychological distress among infertility clinic patients.

One in every 6 couples is infertile, and the literature suggests that a number of individuals experience psychological distress associated with infertility. The purpose of this study was to investigate predictors of psychological distress among infertility clinic patients. Analyses indicated that infertile men (n = 86) and women (n = 120) reported greater psychological distress than normative data from the general population. Separate hierarchical multiple regressions revealed that self-blame and avoidance coping was the best predictor of psychological distress among men and women. Increased age and not already having biological children added to the prediction among men but not among women. The limitations and implications of the findings are presented.

Photoinduced degradation of carbaryl in a wetland surface water.

The photoinduced degradation of carbaryl (1-naphthyl-N-methyl carbamate) was studied in a wetland's surface water to examine the photochemical processes influencing its transformation. For this particular wetland water, at high pH, it was difficult to delineate the photolytic contribution to the overall degradation of carbaryl. At lower pH values, the extent of the degradation attributable to indirect pathways, that is, in the presence of naturally occurring photosensitizers, increased significantly. Moreover, the photoenhanced degradation at the lower pH values was found to be seasonally and spatially dependent. Analysis of water samples revealed two primary constituents responsible for the observed indirect photolytic processes: nitrate and dissolved natural organic matter (NOM). Nitrate in the wetland appears at high concentrations (> or =1 mM) seasonally after the application of fertilizers in the watershed and promotes contaminant destruction through the photochemical production of the hydroxyl radical (HO*). The extent of the observed indirect photolysis pathway appears to be dependent upon the concentration of nitrates and the presence of HO* scavengers such as dissolved NOM and carbonate alkalinity. Paradoxically, during low-nitrate events (<50 microM), NOM becomes the principal photosensitizer through either the production of HO*, direct energy transfer from the excited triplet state, and/or production of an unidentified transient species.

Pseudoaneurysm: diagnosis with color Doppler ultrasound.

Increasing numbers of interventional radiologic procedures, often with large arterial catheters, have led to increasing total numbers of complications. Pseudoaneurysm is not an infrequent complication. It is often difficult to differentiate pseudoaneurysm clinically from hematoma. In the past, we have used gray scale duplex scanning to aid in this differentiation. We have recently found color Doppler scanning to allow quicker, easier, and more accurate diagnosis. Color Doppler imaging also can often demonstrate the track between the artery and the aneurysm.

Ratio of unconjugated to total estriol in uncomplicated third-trimester pregnancy.

The serum unconjugated estriol, as a percent of total estriol, has been determined in third-trimester pregnancies studied longitudinally. The unconjugated fraction in any specific sample ranged from 4.1% to 21.6% of the total. The mean percent unconjugated estriol in 34 patients sampled 7 to 15 times each between 32 and 40 weeks of gestation ranged from 5.3% to 13.6%. Higher serum total estriol concentration correlates with a lower percent of unconjugated. The mean percent unconjugated decreases during the last eight weeks of gestation from 11.4% to 8.4%, with a calculated regression line of Y = 23.323--0.368X. Thus, the concentration of serum unconjugated estriol is relatively more constant. The majority of patients demonstrate a narrow range of percent serum unconjugated estriol. These circumstances, combined with ease of assay, support the use of serum unconjugated estriol in pregnancy estriol monitoring.

Uterus didelphys with obstructed hemivagina and pyocolpos, ipsilateral tubal occlusion and renal agenesis, and bilateral cervical hypoplasia. A case report.

The diagnosis of uterus didelphys with an obstructed hemivagina and ipsilateral renal agenesis is uncommon prior to menarche. The rarity and unusual presentation of the condition may contribute to a diagnostic delay for months to years after menarche. We encountered such a patient, who also had a microscopic communication between the uterine horns, hypertrophy of the right uterine horn, apparent ipsilateral occlusion of the fallopian tube and bilateral cervical hypoplasia, a finding not previously noted in similar cases. The inability to utilize the cervix as a landmark, associated findings and the presence of chronic inflammation precluded definitive treatment during initial hysteroscopy and laparoscopy. Laparotomy was performed to fully ascertain the status of the right uterine horn and to determine which structures to resect.

Multiple uterine rupture and crushing injury of the fetal skull after blunt maternal trauma. A case report.

Multiple pelvic fractures and explosive-type uterine lacerations occurred in a previously healthy 17-year-old primigravida involved in a motor vehicle accident. The fetus suffered a crushed skull and was completely extruded with the placenta from the uterus. Treatment was complicated by severe disseminated intravascular coagulation with secondary fibrinolysis. Thrombelastography enabled us to rapidly evaluate the patient's coagulation status and to monitor her response to goal-directed therapeutic interventions (surgery, specific blood product therapy and epsilon-aminocaproic acid).

Congenital lipodystrophy and polycystic ovarian disease.

A case is presented of congenital lipodystrophy and diabetes coexistent with severe polycystic ovarian disease characterized by primary amenorrhea and pronounced virilization. The relationship of these two disease entities is unknown. This case strengthens the suggestion that isochronia may not be coincidental.

Comparative study of operative laparoscopy versus laparotomy. Analysis of the financial impact.

A matched case study was performed comparing the financial impact of substituting laparoscopy for laparotomy. Laparoscopy was substantially less costly to the patient and her employer while more profitable for the hospital.

Sinusoidal fetal heart rate. Ominous or benign?

The perinatal prognosis associated with the sinusoidal heart rate pattern (SHR) remains controversial. Twenty-nine cases of SHR from 670 fetal heart rate tracings were correlated with narcotic analgesic use and perinatal outcome. Twenty-five of the SHR patterns followed either alphaprodine or demerol use; four were spontaneous. All neonates had Apgar scores of greater than 7 at five minutes. The prognosis of drug-related SHR is benign.