1例植物固醇血症的家系调查及致病基因突变研究

目的探讨1例植物固醇血症家系及其致病基因突变。方法对1例诊断为植物固醇血症的患者及其家系成员进行家系调查;通过PCR扩增先证者及其家系成员基因组DNA中ABCG5及ABCG8基因的所有外显子及其侧翼序列,采用Sanger测序法对PCR产物进行基因测序;采用Polyphen2及Mutation Taster生物信息学软件预测突变的致病性。结果 Sanger测序法发现先症者及家系成员中存在多个基因突变,其中ABCG5基因发现3个突变,分别为外显子1 c.64CT(p.Q22X)杂合无义突变、外显子10 c.1336CT(p.R446X)杂合无义突变、外显子13 c.1810CG(p.Q604E)杂合错义突变;ABCG8基因发现4个突变,分别为(ATG前)-19TG纯合突变、外显子2 c.161AG(p.Y54C)纯合错义突变、外显子13 c.1895TC(p.V632A)纯合错义突变、外显子4和5间的内含子g.12902TC纯合突变。Polyphen2及Mutation Taster软件预测ABCG5基因中c.64CT及c.1336CT为致病突变,其他基因突变均为非致病性的多态性位点。结论 ABCG5基因c.64CT及c.1336CT复杂杂合突变是该植物固醇血症家系的基因发病机制。     

SERPINB7基因突变长岛型掌跖角化病一家系3例临床研究

目的总结一家系3例SERPINB7基因突变长岛型掌跖角化病患者及先证者父母SERPINB7基因突变情况。方法采集该家系3例掌跖角化病患者(先证者及其姐姐、叔叔)及先证者父母的外周血,提取基因组DNA,采用高通量测序法检测皮肤病相关基因各外显子编码区域的序列变异情况,对致病性变异经PCR-Sanger测序验证,并与100例健康者进行比较。结果先证者及其姐姐、叔叔临床表现为双手掌、双足足底红斑基础上角化过度。基因测序显示,先证者及其姐姐、叔叔SERPINB7基因携带c.336+2TG和c.522dupT位点复合杂合突变,先证者父亲携带c.522dupT(p.V175Cfs*45)杂合移码突变,先证者母亲携带c.336+2TG(splicing)杂合剪切突变;100例健康对照均未见c.336+2TG(splicing)杂合剪切突变和c.522dupT位点杂合移码突变。结论 SERPINB7基因c.336+2TG和c.522dupT位点的复合杂合突变可能是该家系3例长岛型掌跖角化病患者的致病原因。     

TMPRSS3基因的VUS变异在1个耳聋家系中的致病性分析

目的 针对一对耳聋夫妇和其胎儿进行家系全外显子组检测,为该家系遗传咨询提供参考和依据。方法 收集该家系的临床资料,采集孕妇和其配偶的外周血和孕妇羊水,并提取基因组DNA,应用家系全外显子组测序技术进行产前遗传学检测,发现疑似致病位点进行Sanger测序验证;通过Minigene技术针对可能导致异常选择性剪切突变位点进行分析。结果 孕妇携带跨膜丝氨酸蛋白酶3基因(transmembrane serine protease 3,TMPRSS3)的复合杂合疑似致病突变,孕妇配偶携带GJB2基因c.235delC的纯合致病突变。胎儿携带TMPRSS3基因复合杂合突变,分别来源于父亲的意义未明的c.323-8T>C杂合突变以及来源于母亲的c.325 C>T杂合突变;采用Minigene技术检测发现c.323-8T>C杂合突变未导致明显的剪切改变。结论 TMPRSS3基因的复合杂合突变可能是导致孕妇耳聋的原因,GJB2基因纯合突变是导致孕妇配偶耳聋的原因,胎儿携带的TMPRSS3基因复合杂合突变不会导致耳聋,夫妇再生聋儿的几率很小。     

一个MYSM1基因突变致骨髓衰竭综合征4型家系报道附文献复习

目的报道1例MYSM1基因复合杂合变异致骨髓衰竭综合征4型患儿临床表现及全外显子检测结果,同时报道其家系全外显子检测结果,为早期诊断此类骨髓衰竭综合征提供典型案例。方法报道1例1月龄骨髓衰竭综合征4型患儿临床诊断过程,并对患儿及其家系成员外周血DNA进行全外显子测序,使用BWA、GATK等软件对测序结果进行注释分析。结果本例1月龄骨髓衰竭综合征4型患儿,表现为全血细胞减少、多指畸形,影像学示非特异性脑白质改变及囊肿,淋巴细胞亚群分类示CD3-CD19+B细胞降低。通过家系全外显子测序检测,鉴定患儿携带分别遗传自父母的MYSM1基因复合杂合性变异NM001085487.2:c.1607c.1611delAAGAG和c.1432C>T。家系验证证实先证者父亲携带的c.1432C>T突变来源于先证者祖父,先证者母亲携带的c.1607c.1611delAAGAG突变来自于先证者外祖父,其他家系成员均不携带突变。结论本研究新发现MYSM1致病性变异c.1607c.1611delAAGAG,国内外尚未见报道。本例为BMFS4的早期诊断提供了典型案例,并扩展了MYSM1基因致病性变异谱和表型谱。     

复合杂合突变导致遗传性蛋白C缺陷症- -家系调查

摘要:目的调查复合 杂合突变导致遗传性蛋白C缺陷症家系的临床特征与基因突变情况,并分析其基因型与临床表型的关系。方法采集先证者及其家系成员(3代5人)外周静脉血，检测蛋白C活性、蛋白S活性和抗凝血酶活性等指标以明确表型 诊断。采用PCR对先证者PROC基因所有外显子及侧翼序列进行扩增,PCR产物纯化后进行直接测序。运用ClustalX-2. 1-win软件分析突变的保守性;使用在线生物信息学软件预测突变的致病性。结果家系中有4人 存在遗传性蛋白C缺陷症,先证 者临床表现为肺栓塞和下肢深静脉血栓栓塞,其他家系成员无明显的血栓形成事件表现。基因测序发现先证者PROC基因第7号外显子存在c.541T>G 杂合错义突变(p. Phe181Val)和c.577-579delAAG杂合缺失突变( p. Lys192deletion),其父亲为 c.541T>G突变杂合子，母亲和妹妹为c.577-579delAAG 突变杂合子。保守性分析显示Phe181和Lys192在同源物种间均高度保守,生物信息学软件预测该2个突变位点均为有害突变。结论该遗传性蛋白 C缺陷症家系存在c.541T>G杂合错义突变 和e.577-579delAAG 杂合缺失突变,该复合杂合突变可能引起先证者蛋白C活性明显降低,从而导致反复深静脉血栓栓塞和肺栓塞。     

SCN4A基因突变导致的一个先天性副肌强直家系研究

目的分析一个疑似先天性副肌强直家系致病突变,为产前分子诊断提供依据。方法针对该家系临床表型进行分析,确定待测基因。用PCR-直接测序法分析目标基因的外显子及其侧翼序列,寻找致病突变。对筛查出的突变用Poly Phen和NCBI网站进行致病性与保守性分析,同时结合家系分析评估突变位点的致病性。结果对目标基因SCN4A进行突变分析,发现家族中患者均存在c.3473CT杂合突变,健康成员均未发现该突变,属于常染色体显性遗传;生物信息学分析该突变位点编码氨基酸由脯氨酸变成亮氨酸,突变所在区域高度保守,该突变具有高度致病性。结论证实了一个先天性副肌强直家系中SCN4A基因的新致病突变c.3473CT,为患者选择胚胎植入前诊断健康婴儿提供了依据。     

FOXRED1基因新突变鉴定分析和产前诊断

目的 对1个线粒体复合体Ⅰ缺乏症家系进行全外显子组基因测序分析,探讨FOXRED1基因突变情况,并进行产前诊断。方法 采集表型正常、有3次不良生育史夫妻外周血,提取基因组DNA,进行全外显子组测序,筛选出致病性突变位点,采用Sanger测序法进行验证,对未报道的可疑致病突变进行生物信息学分析。明确致病突变后,于孕18周采集胎儿羊水进行产前诊断并随访。结果 患者存在FOXRED1基因c.811-1G>C(splicing)杂合突变,患者丈夫存在FOXRED1基因c.1052G>A(p.R351H)杂合突变。FOXRED1基因c.811-1G>C(splicing)杂合突变为未报道的致病性突变,c.1052G>A(p.R351H)杂合突变为未报道的疑似致病性突变。Sanger测序结果显示,胎儿FOXRED1基因c.811-1G>C、c.1052G>A位点均为野生型。出生后随访6个月,婴儿发育正常,未见相关异常表型。结论 FOXRED1基因c.811-1G>C(splicing)和c.1052G>A(p.R351H)复合杂合突变为患者多次不良生...     

COL2A1基因新发突变导致先天性脊柱骨骺发育不良的遗传分析及产前诊断

摘要:目的?对1例先天性脊柱骨骺发育不良(SEDC)患儿进行基因检测和蛋白质功能预测，确定其致病原因，为家系遗传咨询及产前诊断提供依据。方法?应用高通量测序法对先证者454个骨病相关基因进行检测，对检出的可疑基因突变进行Sanger测序检测，对父母进行验证并对胎儿进行产前诊断。结果?该患儿检出COL2A1基因c.3589G>A(p.Gly1197Ser)杂合错义突变，其父母均未携带该突变，先证者为新发变异，家系中胎儿产前诊断结果提示胎儿未携带与先证者相同的变异。Polyphen2、Mutation Taster软件对其蛋白质功能预测的结果为有害。结论?COL2A1基因c.3589G>A变异是该SEDC家系先证者的致病原因。     

新生儿耳聋基因联合听力筛查结果分析

目的调查耳聋基因热点突变位点在武汉地区新生儿中的携带率,探讨新生儿耳聋基因筛查联合听力筛查的临床应用价值和意义。方法回顾性分析2016年1月至2017年12月在武汉市出生的11 231例足月新生儿听力筛查与耳聋基因筛查结果。新生儿出生后3d采集足跟血,采用实时荧光定量PCR法对常见的3个基因4个位点进行筛查,包括GJB2c.235delC、SLC26A4c.919-2AG、12SrRNA m.1555AG及m.1494CT,同时利用耳声发射法于生后48～72h进行听力初筛,初筛未通过者在出生后42d行听力复筛,复筛未通过者于出生后6个月进行听力评估与诊断。基因突变阳性或听力确诊未通过的病例采用一代测序法进行验证。结果 11 231例新生儿中,59例未通过6月龄听力检测。耳聋基因检测检出346例(占3.08%)携带耳聋基因突变,包括GJB2c.235delC突变199例,c.176del16突变2例,c.427CT杂合突变1例;c.235delC/c.257CG复杂杂合突变1例,c.235delC/c.299delAT复杂杂合突变2例,c.235delC/c.427CT复杂杂合突变1例;SLC26A4c.919-2AG突变113例;线粒体12SrRNA m.1555AG突变20例及m.1494CT突变1例。GJB2基因突变合并SLC26A4基因突变2例;GJB2基因突变合并线粒体基因突变4例。结论部分类型的耳聋基因突变携带患儿出生时不表现出听力异常,单纯应用常规听力筛查会漏检部分耳聋高危患儿。新生儿常规听力筛查联合耳聋基因筛查,有助于提高耳聋患儿的检出率,有利于耳聋患儿的早期发现及早期干预。     

一个短肋骨窒息性胸廓发育不良3型伴多趾家系 DYNC2H1 基因新突变

目的对1例短肋骨窒息性胸廓发育不良3型伴多趾家系胎儿DYNC2H1基因突变检测和分析,探讨其发病的分子遗传学病因。方法采集第2胎胎儿皮肤和父母外周血进行外显子组测序,采用Polyphen-2,Sift和Provean等生物信息学软件对新的基因突变进行致病性分析,并用PCR-Sanger测序方法对可能的致病突变进行验证。结果先证者检测到DYNC2H1基因存在双杂合突变,分别为c.5984CT和c.10606CT,前者遗传于表型正常父亲,后者遗传于表型正常母亲。c.10606CT(rs562139820)为致病性变异,该变异可导致截断蛋白的产生。该变异在dbSNP数据库中基因频率是0.000 2。c.5984CT在OMIM、HGMD、Clinvar数据库中未发现相关报道,且正常人数据库(DYDF,dbSNP,千人基因组,千人南方,千人北方,Ex AC)中均未见收录,蛋白质结构预测可能有害(Polyphen-2,Sift和Provean),突变的氨基酸在不同的物种间高度保守。先证者携带的复合杂合突变符合常染色体隐性遗传(AR)复合杂合遗传疾病发病机制;先证者及其家系成员表型及基因型共分离。结论DYNC2H1基因的c.5984CT突变可能是导致该短肋骨窒息性胸廓发育不良3型伴多趾患者的致病原因。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.