Paradoxical fall in proteinuria during pregnancy in an LCAT-deficient patient—A case report

A 29-year-old lady was diagnosed with lecithin:cholesterol acyltransferase (LCAT) deficiency having presented with bilateral corneal clouding, severely reduced high density lipoproteins cholesterol, and proteinuria. She is a compound heterozygote with two LCAT gene mutations, one of which is novel, c.321C>A in exon 3. Surprisingly, the level of proteinuria significantly improved during pregnancy, despite stopping the angiotensin-converting enzyme inhibitor. However, LCAT concentration and activity remained identical during pregnancy and postpartum. Her pregnancy was complicated by rising triglyceride levels from the second trimester requiring treatment with omega-3 fatty acid and fenofibrate. In the last trimester, a further complication arose when she became hypertensive and proteinuria worsened. She was diagnosed with pre-eclampsia and had an emergency cesarean section at 39 weeks delivering a healthy baby. This case adds to the knowledge of the pathophysiology of LCAT deficiency during pregnancy and will be useful in future patient management.     

Differential sensing for the regio- and stereoselective identification and quantitation of glycerides

Glycerides are of interest to the areas of food science and medicine because they are the main component of fat. From a chemical sensing perspective, glycerides are challenging analytes because they are structurally similar to one another and lack diversity in terms of functional groups. Furthermore, because animal and plant fat consists of a number of stereo- and regioisomeric acylglycerols, their components remain challenging analytes for chromatographic and mass spectrometric determination, particularly the quantitation of species in mixtures. In this study, we demonstrated the use of an array of cross-reactive serum albumins and fluorescent indicators with chemometric analysis to differentiate a panel of mono-, di-, and triglycerides. Due to the difficulties in identifying the regio- and stereochemistry of the unsaturated glycerides, a sample pretreatment consisting of olefin cross-metathesis with an allyl fluorescein species was used before array analysis. Using this simple assay, we successfully discriminated 20 glycerides via principal component analysis and linear discriminant analysis (PCA and LDA, respectively), including stereo- and regioisomeric pairs. The resulting chemometric patterns were used as a training space for which the structural characteristics of unknown glycerides were identified. In addition, by using our array to perform a standard addition analysis on a mixture of triglycerides and using a method introduced herein, we demonstrated the ability to quantitate glyceride components in a mixture.Glycerides are the primary component of animal fats and vegetable oils (1). They consist of one, two, or three fatty acids esterified on glycerol, and hence are referred to as mono-, di-, and triglycerides, respectively. The structural diversity of glycerides derives in part from their fatty acid alkyl groups, which can differ in carbon number (i.e., chain length), the degree of unsaturation, the position of olefins, and the configuration of the olefins (i.e., cis/trans). Furthermore, these fatty acid alkyl groups can be connected to the sn-1, -2, or -3 carbons on glycerol. Hence, a variety of regio- and stereoisomers can exist for glycerides, posing a challenge for mass spectrometry (2). Further, because the differences in chain length primarily result from the presence of greater or fewer methylene groups, NMR spectroscopy can be ambiguous (3).The analysis of glycerides is primarily important to the food and nutrition industries for tasks such as authenticating edible oils (4), designing foods with certain physical properties (5), and studying how fats are digested and absorbed (6). In particular, classifying all of the various kinds of regio- and stereoisomers of glycerides is biologically important because lipases, enzymes that catalyze the hydrolysis of glycerides into fatty acids and glycerol, exhibit selectivity based on these features of the glyceride substrates. As examples, the position and configuration of olefins, the identity of fatty acid alkyl groups, as well as their position on glycerol (i.e., sn-1,3 versus sn-2), all contribute to differing biological activity (7, 8). Studying the selectivity of these lipases has applications in understanding diseases, including fat malabsorption disorders, hypercholesterolemia, atherosclerosis, and diabetes (9, 10). Research on metabolic disorders has shown that fatty acid accumulation can exert a toxic or a protective effect on a tissue, depending on the specific tissue type (e.g., liver, cardiac, or skeletal muscle) (11, 12) and health state (e.g., diabetic) (13, 14) as well as on the fatty acids (e.g., saturated or unsaturated) (15). Sequestration of fatty acids by esterification to glycerides is one pathway by which these effects are regulated (16). Thus, a deeper understanding of the distinct roles of the cellular storage of structurally different glycerides in normal and disease states is a desirable avenue of research (17). However, currently only limited information is available about the composition of glycerides in adipose and nonadipose tissue.The most common method of glyceride identification is mass spectrometry (MS) (2, 18). However, as alluded to above, this approach has drawbacks. Because glycerides are neutral molecules, they must be ionized to be analyzed by MS. Saponification can be used to obtain the fatty acids, which are both volatile and charged, thereby facilitating MS analysis, but information about the glyceride structure is lost in this process (18). Electrospray ionization and atmospheric pressure chemical ionization are used to ionize glycerides directly; however, the ion yields are low compared with preionized lipids (19, 20). Furthermore, the ability of a glyceride to be ionized using these methods often varies. For example, ion abundance generally increases with increasing number of double bonds in the fatty acid alkyl chain and can also depend on fatty acid alkyl chain length (21). These significant variations in ion abundance mean that ionization methodologies must be developed and tailored to a specific application to satisfactorily detect each glyceride of interest (19). Finally, these variations render the quantification of glycerides, particularly in a complex mixture, quite challenging when using MS (22).Regio- and stereoisomers further confound the discrimination of glycerides by MS, because isomers share the same mass. Other techniques such as chemical derivitization of the glycerides, ion fragmentation, and specialized HPLC must be coupled with MS to effect differentiation of isomeric species. For example, ozonolysis has been used to cleave the double bonds in unsaturated glycerides before ionization to deduce the positions of double bonds (23). Nonaqueous reverse-phase (NARP)-HPLC can resolve cis/trans isomers of triacylglycerols and double-bond positional isomers after treatment of the olefins with bromine (24). Silver ion chromatography has been used to separate triacylglycerol positional isomers under specifically developed solvent and column temperature conditions (25). Silver cationization as a postcolumn treatment in conjunction with NARP-HPLC and ion fragmentation has also been used for triglyceride positional isomer determination (26, 27) Thus, although these current approaches to glyceride isomer analysis have been successful, they are complicated, labor intensive, time-consuming, and at times inconsistent in their results (26).Because glycerides are structurally very similar to one another, we believed that a differential sensing array-based approach would be most suitable for their classification. Our hypothesis was that if a cross-reactive array could be created that was responsive to the subtle structural differences inherent in glycerides, it could be used to pattern individual glycerides, identify structural features of unknown glycerides, and potentially quantitate glycerides in a mixture. Cross-reactive arrays have been successfully used in a number of sensing applications (28–33). Differential sensing mimics the mammalian senses of olfaction and gustation by detecting the pattern of response of an analyte to a collection of semiselective receptors (34, 35). In mammals, the characteristic pattern for a scent or taste is interpreted and stored by the brain (36). In the laboratory, chemometric routines such as principal component analysis (PCA) and linear discriminant analysis (LDA) are used to extract the relevant information from the array. Both PCA and LDA are multivariate methods that reduce the dimensionality of a data set. PCA does so by finding unbiased orthogonal axes that describe decreasing extents of variance in the data derived from different samples (classes) and repetitions of the samples (37). Any grouping of like samples represents intrinsic similarities between the sample datasets whereas separate classification represents differences in that variable space. LDA classifies samples by calculating discriminant functions that maximize the separation between predetermined classes and minimizes the separation within these classes (38, 39). Thus, LDA is a supervised method, meaning that the classes are provided as inputs into the algorithm. For this reason, a validation method called a leave-one-out cross-validation is used to test the predictive value of the model. Further, LDA can be used to predict the identity of unknowns by identifying which classes in the training set the unknowns most resemble.Therefore, the goal of this project was to develop an array of cross-reactive receptors that could discriminate glycerides. The glycerides selected are shown in Fig. 1. The panel includes commercially available mono-, di-, and triacylglycerols with fatty acid alkyl groups that are relevant to mammalian biology (40). Moreover, the panel consists of examples of each of the following stereo- and regioisomers: (i) cis/trans olefins (D1 and D2; T2 and T3), (ii) differing position of the olefin (T3 and T4), and (iii) differing position of the fatty acid alkyl groups on the glycerol (D5 and D6). Clearly, it would be extremely challenging to create highly selective receptors for each individual glyceride, and thus a differential sensing method seems the only reasonable approach to creating an optical sensing routine to identify and classify these structures.Open in a separate windowFig. 1.Glyceride panel with structures and names.Because glycerides are extremely hydrophobic analytes, we postulated that serum albumins (SAs) would be suitable cross-reactive receptors with which to test our hypothesis. SA is a common plasma protein that binds hydrophobic molecules to transport them through the hydrophilic environment of blood plasma (41). The protein binds a number of endogenous compounds: long-chain fatty acids (K_a = 10⁶–10⁷ M⁻¹) (42), bile acids (K_a = 10³–10⁵ M⁻¹) (43), and steroids (K_a = 10³–10⁵ M⁻¹) (44–46), as well as many drugs, toxins, and fluorophores (41). Despite being composed of fatty acid alkyl groups, glycerides bind less tightly to SAs and in a different location than their fatty acid counterparts (47). The primary sequence of SAs differs between species, which thus exhibit differences in ligand binding (41). Previously, we have used arrays of SAs for the differentiation of other hydrophobic analytes including fatty acids (48), terpenes (49), and plasticizers (50). However, none of these previous studies involved differences between the analyte structures as subtle as glycerides do, nor had we challenged our methods to identify structural aspects of an unknown. Furthermore, we had never implemented a quantitation assay in a complex mixture. Because the binding of ligands to SAs is known to depend on subtle differences in their structure (41), we anticipated that success could be achieved but would be highly dependent upon the signaling modality and potentially analyte prederivitization.Thus, herein we describe a method using SAs to fingerprint glycerides that classifies them as mono-, di-, or triglycerides. The glycerides were further classified based on fatty acid chain length, ester positions on glycerol, and olefin regio- and stereochemistry. For the unsaturated glycerides in the panel, differentiation based on olefin position and stereochemistry was achieved by the use of a pretreatment olefin metathesis. Using the protocols described herein, structural features of unknown glycerides could be identified. Furthermore, the quantitation of trilinolein in a mixture of triglycerides was achieved by application of the standard addition method using a net analyte signal technique (SANAS) presented herein.     

From the Cover: Contribution of cyanobacterial alkane production to the ocean hydrocarbon cycle

Hydrocarbons are ubiquitous in the ocean, where alkanes such as pentadecane and heptadecane can be found even in waters minimally polluted with crude oil. Populations of hydrocarbon-degrading bacteria, which are responsible for the turnover of these compounds, are also found throughout marine systems, including in unpolluted waters. These observations suggest the existence of an unknown and widespread source of hydrocarbons in the oceans. Here, we report that strains of the two most abundant marine cyanobacteria, Prochlorococcus and Synechococcus, produce and accumulate hydrocarbons, predominantly C15 and C17 alkanes, between 0.022 and 0.368% of dry cell weight. Based on global population sizes and turnover rates, we estimate that these species have the capacity to produce 2–540 pg alkanes per mL per day, which translates into a global ocean yield of ∼308–771 million tons of hydrocarbons annually. We also demonstrate that both obligate and facultative marine hydrocarbon-degrading bacteria can consume cyanobacterial alkanes, which likely prevents these hydrocarbons from accumulating in the environment. Our findings implicate cyanobacteria and hydrocarbon degraders as key players in a notable internal hydrocarbon cycle within the upper ocean, where alkanes are continually produced and subsequently consumed within days. Furthermore we show that cyanobacterial alkane production is likely sufficient to sustain populations of hydrocarbon-degrading bacteria, whose abundances can rapidly expand upon localized release of crude oil from natural seepage and human activities.Hydrocarbons are ubiquitous in the oceans, where natural seepage and human activities are estimated to release between 0.4 and 4.0 million tons of crude oil into the ocean ecosystem annually (1). Even in minimally polluted marine surface waters, alkanes such as pentadecane and heptadecane have been found at concentrations ranging from 2 to 130 pg/mL (2, 3), although their sources remain unclear. A small proportion of alkanes, from 1 to 60 fg/mL, is associated with particulate matter >0.7 µm in diameter (4). Larger amounts may be associated with particulate matter <0.7 µm in diameter, because ocean concentrations are higher than the solubility of pentadecane and heptadecane, which is ∼10 pg/mL and 1 pg/mL, respectively (2). Populations of hydrocarbon-degrading bacteria, referred to as hydrocarbonoclastic bacteria, including many species that cannot use other carbon sources, are present in marine systems and play an important role in turnover of these compounds (5–9). Because obligate hydrocarbon-degrading bacteria are found in waters without significant levels of crude oil pollution, these organisms must use an alternate hydrocarbon source (9–11).Here, we investigate the extent to which cyanobacteria may contribute to these marine hydrocarbon pools. Cyanobacteria (oxygenic photosynthetic bacteria) can synthesize C15 to C19 hydrocarbons via two separate pathways. The first produces alkanes, predominantly pentadecane, heptadecane, and methyl-heptadecane, in addition to smaller amounts of alkenes, via acyl-ACP reductase (FAR) and aldehyde deformylating oxygenase (FAD) enzymes (12). The second pathway generates alkenes, primarily nonadecene and 1,14-nonadecadiene, via a polyketide synthase enzyme (Ols) (13). The abundance and ubiquity of cyanobacteria in the marine environment suggests hydrocarbon production in the oceans could be considerable and broadly distributed geographically (14, 15).We focused our studies on the two most abundant marine cyanobacteria, Prochlorococcus and Synechococcus (16). These genera have estimated global population sizes of 2.9 ± 0.1 × 10²⁷ and 7.0 ± 0.3 × 10²⁶ cells, respectively (14), and are together responsible for approximately a quarter of marine net primary production (14). These are also the only cyanobacterial genera for which global population size estimates have been compiled (14). Although the distribution patterns of both genera overlap (14, 17), Prochlorococcus cells dominate low-nutrient open-ocean areas between 40°N and 40°S and can be found at depths of up to 200 m (16, 18). Synechococcus are more numerous in coastal and temperate regions where conditions and nutrient levels are more variable (14, 16) but are still widely distributed in high abundance.     

Small bowel obstruction via herniation through an iatrogenic defect of the falciform ligament following laparoscopic cholecystectomy

Internal herniation of the small bowel through a defect in the falciform ligament and subsequent small bowel obstruction is exceedingly rare with the majority of previous cases being attributed to congenital abnormalities. As laparoscopic techniques approach the forefront of modern surgery, an iatrogenic source for a falciform ligament defect has emerged over the last decade. In this case, a 50-year-old patient presented with signs of acute small bowel obstruction 10 days after a laparoscopic cholecystectomy. On diagnostic laparoscopy, part of the jejunum was found to have herniated through an opening in the falciform ligament. This was likely to have been caused by trauma during the cholecystectomy. Following relief of the obstruction, the defect was closed with polyglactin sutures.     

Major cardiothoracic trauma: Eleven-year review of outcomes in the North West of England

Introduction

Up to 15% of patients with cardiothoracic trauma require emergency surgery, and death can be prevented in a substantial proportion of this group. UK reports have emphasised the need for improvement in this field. We assessed major cardiothoracic trauma (MCT) outcomes in North West England over 11 years.

Methods

The database from the Trauma Audit and Research Network was used to retrieve data for all patients who had suffered MCT between 2000 and 2011 in North West England and the findings analysed. Trauma that led to thoracotomy/thoracoscopy or sternotomy was defined as MCT.

Results

A total of 146 patients were identified, and a considerable male predominance (88.4%) noted. A total of 54.1% had sustained penetrating cardiothoracic trauma. Also, 53.4% had been admitted to tertiary-care hospitals for trauma (TCHT) and 46.6% had been admitted to non-TCHT. Overall prevalence of mortality was 35.6%. No significant difference was found in mortality between TCHT vs non-TCHT. Prevalence of mortality was significantly higher in the subgroup of patients cared for exclusively in non-TCHT compared with patients transferred from non-TCHT to TCHT (41% vs 13.8%, p<0.05).

Conclusions

No significant difference was demonstrated in length of stay in hospital/length of stay in the intensive treatment unit and prevalence of mortality between patients originally presenting in TCHT and those presenting in non-TCHT. However, patients transferred from non-TCHT to TCHT had a lower prevalence of mortality. These findings may constitute a valuable benchmark for comparison with results arising after introduction of trauma centres in the UK.     

Pyoderma gangraenosum nach Marknagelosteosynthese bei Tibiaschaftfraktur

Die Unfallchirurgie - Das Pyoderma gangraenosum ist eine seltene nichtinfektiöse neutrophile Dermatitis, wohingegen die nekrotisierende Fasziitis eine lebensbedrohliche bakterielle...     

Technik der antegraden Femurmarknagelung in Seitenlage

Die Unfallchirurgie - Die Therapie der Wahl bei Femurschaftfrakturen ist die intramedulläre Marknagelung. Lagerungen auf dem Extensionstisch sind zeitaufwendig, freie Lagerungen setzen sich...