1例罕见Melnick-Needles综合征患者基因变异分析

摘要:目的研究 1例Melnick-Needles综合征家系的致病基因并为该家系提供遗传咨询依据。方法采集先证者即 1例不明原因骨骼发育异常、身材矮小的青年女性患者及其父母外周血标本,提取基因组DNA,采用家系全外显子组测序(Trio-WES)筛查先证者致病基因及突变位点，并通过Sanger测序进行验证。结果先证者位于 X染色体上的FLNA基因有一杂合变异位点:NM_ 001 110556.2: c.3562G>A(p.A1188T),父母均为野生型。根据ACMG指南,提示FLNA基因的c.3562G>A突变为1个致病突变位点,与X连锁显性遗传疾病Melnick-Needles综合征相关。国内未见该致病位点报道。结论确诊1 例罕见Melnick-Needles综合征,致病FLNA突变c.3562G>A在国内为首次报道,为患者及家属遺传咨询提供了依据。     

全外显子组测序鉴定汉族人群扩张型心肌病新的MYH7基因突变

目的：我们应用全外显子测序筛查一个扩张型心肌病患者家系的致病基因。方法：我们对一位在复旦大学附属中山医院就诊的扩张型心肌病患者及其家族成员采集临床资料,同时采集外周血做全外显子测序,寻找可能的致病基因突变,然后用sanger测序对患者及家系成员验证。结果：通过对家系患者及家族成员基因测序分析,经过多个数据库过滤,我们发现了致病基因突变位点MYH7 c.2458G>C (p.Ala820Pro),随后我们发现在家族成员中携带该突变位点的成员心功能异常。检索数据库发现该位点既往未在汉族人群中报道过,首次发现该突变位点与扩张型心肌病有关。结论：本研究通过全外测序发现了一个扩张型心肌病家系的致病基因,为新的汉族人群扩张型心肌病致病位点。     

一个戈谢病Ⅱ型中国家系GBA基因突变分析及文献复习

目的 鉴定一个戈谢病Ⅱ型中国家系中GBA基因的致病性突变。方法 收集1例戈谢病Ⅱ型10个月女性患儿的临床及家系资料,提取该先证者及其父母外周血DNA,采用PCR扩增GBA基因的11个外显子及剪接位点序列,对PCR产物进行直接测序;对先证者及其父亲的包含第6外显子变异位点的基因序列进行克隆测序。以 “Gaucher disease”“GBA” 和“mutation”为检索词对dbSNP、ClinVar、HGMD和PubMed等数据库进行检索,收集并分析检索到的携带GBA c.680_681delATinsGG突变的病例资料。结合该家系先证者的临床资料以及美国医学遗传学与基因组学学会和分子病理学协会（ACMG/AMP）的指南进行罕见突变的致病性鉴定。结果 该家系先证者GBA基因有2个复合杂合性突变：遗传自父亲的第6外显子的c.680_681delATinsGG（p.N227R）突变和遗传自母亲的第10外显子的c.1448T > C（p.L483P）突变。克隆测序验证了先证者及其父亲的c.680_681位点有2种单体型：突变的GG和正常的AT。c.680_681delATinsGG为罕见突变,尚未有研究对该突变进行致病性鉴定。随访显示先证者有运动、智力进行性减退以及惊厥发作和喂养困难,于出生后16个月因喂养时呛咳、窒息死亡。目前在数据库仅检索到2例患者携带该突变,其中1例患病资料缺乏,另外1例为中国戈谢病Ⅱ型患儿。根据ACMG/AMP的指南,该变异分类为“致病性的”。结论 GBA基因的c.680_681delATinsGG和c.1448T > C复合杂合性突变导致该家系的先证者患病,c.680_681delATinsGG为致病性突变,c.680_681delATinsGG/c.1448T > C基因型与戈谢病Ⅱ型相关。     

苯丙氨酸羟化酶缺乏症家系PAH基因新发突变分析

目的 对一个苯丙氨酸羟化酶缺乏症(phenylalanine hydroxylase deficiency,PAHD)家系苯丙氨酸羟化酶(phenylalanine hydroxylase,PAH)基因进行突变位点检测和分析,探讨此家系发病原因。方法 采用二代测序技术(next generation sequencing,NGS)和多重连接探针扩增技术(multiplex ligation-dependent probe amplification,MLPA)对先证者及其父母的静脉血进行PAH基因组测序和外显子缺失、重复分析。结果 先证者找到1个错义突变和1个剪接缺失,分别为:第6外显子c.630T>G和第2外显子c.61-1G>A,这两个变异在人类基因突变数据库(Human Gene Mutation Database,HGMD)中未见报道,根据美国医学遗传学与基因组学学会(America College of Medical Genetics and Genomics, ACMG)指南判定为临床意义未明和疑似致病性变异;信息软件REVEL预测结果为有害和未知。采用MLPA对先证者进行外显子缺失、重复分析显示PAH基因外显子拷贝数未发现异常。结论 PAH基因6号外显子c.630T>G和2号外显子c.61-1G>A可能是该PAHD家系的致病突变。     

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。     

Dravet综合征SCNIA基因新突变及遗传咨询

摘要:目的对2 例癫痫伴精神运动发育迟缓的患儿进行遗传学病因分析,旨在为患儿治疗及其家庭遗传咨询、生育指导提供依据。方法提取2例患儿及 其父母外周血基因组DNA并采用全外显子测序技术进行检测,按照美国医学遗传学与基因组 学学会(ACMG,2015)标准进行致病性分析,通过Sanger测序验证致病变异。结果全外显子测序结果发现,2例患儿电压门控性钠离子通道a1亚单位基因(SCNIA)基因存在c.5354T>C(p.11785T)和c.4380T>A(p.Y1460* )新发de novo杂合突变,分 别评估变异为可疑致病、致病突变位点,Sanger测序验证了该突变并确认双方父母相应位点均为野生型。结论结 合临床和基因诊断信息,2例患儿均被诊断为常染色体显性遺传病Dravet综合征,明确患儿的致病原因对于合理治疗方案的制定及其 家庭的优生优育、遗传咨询具有重要的意义。     

婴儿神经轴索营养不良患者PLA2G6基因的突变检测

目的辅助临床确诊1例婴儿神经轴索营养不良(infantile neuroaxonal dystrophy,INAD)家系,为患者家庭遗传咨询和产前诊断提供依据。方法收集患者临床资料,提取先证者及家系成员外周血基因组DNA,PCR扩增INAD致病基因PLA2G6编码序列并进行测序。对发现的突变位点在对照人群中进行验证及相关生物信息学分析。结果先证者表现为进行性智力发育及运动能力落后,头颅MRI显示小脑萎缩。测序结果发现患者PLA2G6基因存在复合性杂合突变,分别为父源性的c.668CT(p.Pro223Leu)和母源性的c.1534TA(p.Phe512Ile)突变,且二者在对照人群中未检测到。生物信息学分析显示两种突变均为致病性突变,可引起蛋白质二级结构和氨基酸亲水性改变。结论发现PLA2G6基因的新突变位点c.1534TA,该突变可与已知致病突变c.668CT共同导致常染色体隐性遗传病INAD的发生。     

应用全外显子组测序技术鉴定1个白化病家系致病基因HPS1

目的采用全外显子组测序鉴定1个常染色体隐性遗传白化病家系患者的致病基因,探讨其发病机制。方法采集先证者及其家系成员外周血并提取其基因组DNA,对先证者进行全基因外显子组测序,并结合序列变异生物信息学分析方法,鉴定其致病基因,利用Sanger测序对基因突变位点验证。结果全外显子组测序结果显示,先证者HPS1基因存在由c.1276_1279dupGGAG(p.Asp427fs)移码突变和c.398+5GA剪切位点变异组成的复合杂合突变,而其表型正常的父亲为c.1276_1279dupGGAG(p.Asp427fs)杂合突变,表型正常的母亲为c.398+5GA杂合突变。结论该白化病先证者由HPS1基因c.1276_1279dupGGAG和c.398+5GA复合杂合突变导致,此患者被诊断为Hermansky-Pudlak综合征1型。外显子测序技术可以快速准确地筛查白化病候选基因,并明确其具体临床亚型,有利于临床医师积极干预患者潜在并发症以及改善患者生存质量。     

1例肥厚型心肌病家系的产前诊断和遗传分析

目的对1例肥厚型心肌病(HCM)家系的孕妇进行产前诊断和遗传分析,探讨HCM致病基因突变与临床表型的联系。方法搜集该先证者及其家系成员临床资料,提取先证者外周血DNA、羊水细胞DNA、经培养的羊水细胞DNA,二代测序(NGS)筛查先证者的致病基因位点,PCR扩增产物直接测序验证HCM致病候选基因MYH7和MYBPC3的可疑致病突变序列,并检测羊水细胞潜在的致病突变。用遗传学数据资料和Mutation taster、PolyPhen-2、ANTHEPROT等生物信息学软件预测突变的致病性。结果测序结果显示先证者存在MYH7 c.1988GA(p.Arg663His)和MYBPC3 c.151GA (p.Ala51Thr)杂合突变,其父亲表型正常且未检出异常突变,其表型正常的母亲仅携带MYBPC3 c.151GA杂合突变。胎儿仅存在MYH7 c.1988GA杂合突变,而MYBPC3无异常变异。突变效应预测和蛋白质结构功能分析显示这2种错义突变分别影响蛋白质的疏水性和抗原性,且遗传学数据资料显示MYH7 c.1988GA为明确致病性突变。结论先证者MYH7 c.1988GA为新发致病性突变或由于其父母为生殖嵌合所致,MYBPC3 c.151GA突变可能促进HCM的发生。胎儿虽然仅携带MYH7 c.1988GA,但其表型可能仍为HCM。     

GCDH基因新变异致戊二酸血症Ⅰ型的遗传学分析及产前诊断

目的 寻找戊二酸血症Ⅰ型(GAⅠ)致病基因,为相关疾病的产前诊断提供依据。方法 对1例疑似GAⅠ家系先证者的DNA进行全外显子组测序,并对先证者及其父母进行DNA Sanger测序验证,确定变异位点,分析变异的致病性;随后对先证者孕18周母亲进行羊膜腔穿刺,获取胎儿羊水DNA进行戊二酰辅酶A脱氢酶(GCDH)基因测序分析。以“戊二酸血症Ⅰ型/ Glutarate disease type Ⅰ”“GCDH”以及“产前诊断/ Prenatal diagnosis”为检索词,检索PubMed、CNKI、万方数据知识服务平台、维普中文科技期刊数据库,收集并分析GAⅠ产前诊断的文献资料。结果 先证者外周血DNA中检测到GCDH基因(NM_000159.3)的2个变异：父源性c.206_207delAC (p.Thr70Leufs*117)和母源性c.892G>A(p.Ala298Thr)。父源的c.206_207delAC变异为未见报道的新变异,母源的c.892G>A变异为已知突变,致病性分析均判定为致病变异。先证者母亲羊水的基因检测提示GCDH基因复合杂合变异：c.206_207delAC和c.892G>A。先证者父母选择终止妊娠。文献共检索到GCDH基因测序分析产前诊断GAⅠ的9例家系,其中4例家系中5例胎儿的产前诊断为GAⅠ,4例胎儿家属选择终止妊娠,仅有1例胎儿家属要求继续妊娠并足月分娩。结论 在GAⅠ家系中发现了GCDH基因一个新的变异c.206_207delAC,明确了GAⅠ家系先证者的GCDH基因致病变异位点。     

Live a legacy or live a lie: a choice

This article is about the result of a choice to Live a Legacy or Live a Lie. The choice led to the development and implementation of a clinical practice model (CPM) designed to create a healthy, healing integrated practice culture. The focus is on the foundation of the model that is a unique ongoing process called the Core Belief Review. The purpose of the review is to uncover those things that matter most for both those who give and receive care. The ongoing open communication process provides insights and truths about reality and a sense of direction related to the nature of the work necessary to create and sustain the best places to give and receive care. The results of the review feedback from 2500 providers and recipients of care are correlated to the actions taken to address the complexities of the point-of-care reality and the clinical outcomes reached as a result of collaboration and lessons learned within an International Consortium.     

Intensive care use in a developing country: a comparison between a Tunisian and a French unit

Objectives: To compare the variations in intensive care (ICU) outcome in relation to variations in resources utilization and costs between a developed and a developing country with different medical and economical conditions. Design and setting: Prospective comparison between a 26-bed French ICU and an 8-bed Tunisian ICU, both in university hospitals. Patients: Four hundred thirty and 534 consecutive admissions, respectively, in the French and Tunisian ICUs. Measurements: We prospectively recorded demographic, physiologic, and treatment information for all patients, and collected data on the two ICU structures and facilities. Costs and ICU outcome were compared in the overall population, in three groups of severity indexes and among selected diagnostic groups. Results: Tunisian patients were significantly younger, were in better health previously and were less severely ill at ICU admission (p < 0.01). French patients had a lower overall mortality rate (17.2 vs 22.5 %; p < 0.01) and received more treatment (p < 0.01). In the low severity range, the outcome and costs were similar in the two countries. In the highest severity range, Tunisian and French patients had similar mortality rates, while the former received less therapy throughout their ICU stays (p < 0.05). Conversely, in the mid-range of severity, mortality was higher among Tunisian patients, and a difference in management was identified in COPD patients. Conclusion: Although the Tunisian ICU might appear more cost-effective than the French one in the highest severity group of patients, most of this difference appeared in relation to shorter lengths of ICU stay, and a poorer efficiency and cost-effectiveness was suggested in the mid-range severity group. Differences in economical constraints may partly explain differences in ICU performances. These results indicate where resource allocation could be directed to improve the efficiency of ICU care. Received: 15 December 1997 Accepted: 8 July 1998     

Fatal haemorrhage from a caput medusae: a differential to a stabbing

Fatal haemorrhage from caput medusae is reported once previously in the literature. We report the case of a 48-year-old man who presented to the ED in hypovolaemic shock, with a suspected stab wound to the abdomen. He was subsequently found to have exsanguinated from a cutaneous varix secondary to chronic liver disease.     

FXTAS: a bad RNA and a hope for a cure

Background: Fragile X-associated tremor/ataxia syndrome (FXTAS) is a newly identified neurodegenerative disorder due to intermediate expansion of trinucleotide CGG repeats (55 - 200 repeats) in the 5' untranslated region (UTR) of the Fragile X mental retardation 1 (FMR1) gene. FXTAS is now considered to be one of the most common inherited neurodegenerative disorders in males. Objective: To examine the future of potential therapies for this late-onset disease. Methods: Examination of relevent literature. Results/conclusions: Accumulating evidence indicates that overproduced riboCGG repeats in the 5' UTR of FMR1 mRNA are toxic. Recently, proteins that bind specifically to rCGG repeats were identified. Progress in understanding the molecular pathogenesis of FXTAS, plus the availability of different animal models are discussed.     

Caring for a patient with a urostomy in a community setting

Around 7500 people in the UK have a urostomy. A urostomy is normally performed if a person has bladder cancer, congenital bladder abnormalities. Many people who have a urostomy have long term conditions and may require the help and support of community nurses. This article examines common complications of urostomy including stomal complications, urinary tract infections and dermal complications. Although stoma complications are common and can affect quality of life, many people with a stoma tend not to seek help. Community nurses can provide care and support to optimize stoma management and enable the person with a urostomy to enjoy the best possible quality of life.