Candidate Genes for Nonsyndromic Cleft Palate Detected by Exome Sequencing

Nonsyndromic cleft palate only (nsCPO) is a facial malformation that has a livebirth prevalence of 1 in 2,500. Research suggests that the etiology of nsCPO is multifactorial, with a clear genetic component. To date, genome-wide association studies have identified only 1 conclusive common variant for nsCPO, that is, a missense variant in the gene grainyhead-like-3 ( GRHL3). Thus, the underlying genetic causes of nsCPO remain largely unknown. The present study aimed at identifying rare variants that might contribute to nsCPO risk, via whole-exome sequencing (WES), in multiply affected Central European nsCPO pedigrees. WES was performed in 2 affected first-degree relatives from each family. Variants shared between both individuals were analyzed for their potential deleterious nature and a low frequency in the general population. Genes carrying promising variants were annotated for 1) reported associations with facial development, 2) multiple occurrence of variants, and 3) expression in mouse embryonic palatal shelves. This strategy resulted in the identification of a set of 26 candidate genes that were resequenced in 132 independent nsCPO cases and 623 independent controls of 2 different ethnicities, using molecular inversion probes. No rare loss-of-function mutation was identified in either WES or resequencing step. However, we identified 2 or more missense variants predicted to be deleterious in each of 3 genes ( ACACB, PTPRS, MIB1) in individuals from independent families. In addition, the analyses identified a novel variant in GRHL3 in 1 patient and a variant in CREBBP in 2 siblings. Both genes underlie different syndromic forms of CPO. A plausible hypothesis is that the apparently nonsyndromic clefts in these 3 patients might represent hypomorphic forms of the respective syndromes. In summary, the present study identified rare variants that might contribute to nsCPO risk and suggests candidate genes for further investigation.

Genome-wide analysis implicates microRNAs and their target genes in the development of bipolar disorder

Bipolar disorder (BD) is a severe and highly heritable neuropsychiatric disorder with a lifetime prevalence of 1%. Molecular genetic studies have identified the first BD susceptibility genes. However, the disease pathways remain largely unknown. Accumulating evidence suggests that microRNAs, a class of small noncoding RNAs, contribute to basic mechanisms underlying brain development and plasticity, suggesting their possible involvement in the pathogenesis of several psychiatric disorders, including BD. In the present study, gene-based analyses were performed for all known autosomal microRNAs using the largest genome-wide association data set of BD to date (9747 patients and 14 278 controls). Associated and brain-expressed microRNAs were then investigated in target gene and pathway analyses. Functional analyses of miR-499 and miR-708 were performed in rat hippocampal neurons. Ninety-eight of the six hundred nine investigated microRNAs showed nominally significant P-values, suggesting that BD-associated microRNAs might be enriched within known microRNA loci. After correction for multiple testing, nine microRNAs showed a significant association with BD. The most promising were miR-499, miR-708 and miR-1908. Target gene and pathway analyses revealed 18 significant canonical pathways, including brain development and neuron projection. For miR-499, four Bonferroni-corrected significant target genes were identified, including the genome-wide risk gene for psychiatric disorder CACNB2. First results of functional analyses in rat hippocampal neurons neither revealed nor excluded a major contribution of miR-499 or miR-708 to dendritic spine morphogenesis. The present results suggest that research is warranted to elucidate the precise involvement of microRNAs and their downstream pathways in BD.

Ethnicity is an independent determinant of age-specific PSA level: findings from a multiethnic Asian setting

Objectives

To study the baseline PSA profile and determine the factors influencing the PSA levels within a multiethnic Asian setting.

Materials and Methods

We conducted a cross-sectional study of 1054 men with no clinical evidence of prostate cancer, prostate surgery or 5α-reductase inhibitor treatment of known prostate conditions. The serum PSA concentration of each subject was assayed. Potential factors associated with PSA level including age, ethnicity, height, weight, family history of prostate cancer, lower urinary tract voiding symptoms (LUTS), prostate volume and digital rectal examination (DRE) were evaluated using univariable and multivariable analysis.

Results

There were 38 men (3.6%) found to have a PSA level above 4 ng/ml and 1016 (96.4%) with a healthy PSA (≤4 ng/ml). The median PSA level of Malay, Chinese and Indian men was 1.00 ng/ml, 1.16 ng/ml and 0.83 ng/ml, respectively. Indians had a relatively lower median PSA level and prostate volume than Malays and Chinese, who shared a comparable median PSA value across all 10-years age groups. The PSA density was fairly similar amongst all ethnicities. Further analysis showed that ethnicity, weight and prostate volume were independent factors associated with age specific PSA level in the multivariable analysis (p<0.05).

Conclusion

These findings support the concept that the baseline PSA level varies between different ethnicities across all age groups. In addition to age and prostate volume, ethnicity may also need to be taken into account when investigating serum PSA concentrations in the multiethnic Asian population.

Hook wire localization for testis sparing surgery

OBJECTIVE

To describe a novel technique for localizing small testicular mass during testicular-sparing surgery (TSS).

METHODS AND RESULTS

A 20-year-old man presented with bilateral testicular masses. Both alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (BHCG) levels were raised. Clinical and imaging studies revealed a 2.7 cm and 0.7 cm mass in the right and left testis, respectively. No metastatic disease was detected on staging scans. Right inguinal total orchiectomy was performed. For the left testis, the inguinal approach was used to deliver the testis to the surgical wound. Vascular clamping and cooling of the testis were performed. A hook wire (Ghiatas Beaded Breast Localization Wire, 20G) was then inserted through the small testicular tumor with the aid of on-table ultrasound imaging. Testicular-sparing surgery (TSS) was easily performed with the aid of the hook wire. Postoperative recovery was uneventful. The histology report revealed a mixed germ cell tumor with clear margin. Tumor markers returned to normal after surgery. Serum testosterone level was also within normal range. Follow-up ultrasound scan showed a viable left testis with normal vascularity.

CONCLUSION

Hook wire localization of a small testicular mass under ultrasound guidance is an easy-to-perform technique that facilitates TSS in selected patients. This technique allows TSS to be performed in a more controlled and confident manner.

Automatic conformal prescription of very selective saturation bands for in vivo 1H-MRSI of the prostate

An important step in the implementation of three-dimensional in vivo proton magnetic resonance spectroscopic imaging ((1)H-MRSI) of the prostate is the placement of spatial saturation pulses around the region of interest (ROI) for the removal of unwanted contaminating signals from peripheral tissue. The present study demonstrates the use of a technique called conformal voxel magnetic resonance spectroscopy (CV-MRS). This method automates the placement, orientation, timing and flip angle of very selective saturation (VSS) pulses around an irregularly-shaped, user-defined ROI. The method employs a user adjustable number of automatically positioned VSS pulses (20 used in the present study) which null the signal from periprostatic lipids while closely conforming the shape of the excitation voxel to the shape of the prostate. A standard endorectal coil in combination with a torso-phased array coil was used for all in vivo prostate studies. Three-dimensional in vivo prostate (1)H-MRSI data were obtained using the proposed semi-automated CV-MRS technique, and compared with a standard point resolved spectroscopy (PRESS) technique at TE = 130 ms using manual placement of saturation pulses. The in vivo prostate (1)H-MRSI data collected from 12 healthy subjects using the CV-MRS method showed significantly reduced lipid contamination throughout the prostate, and reduced baseline distortions. On average there was a 50 ± 17% (range 12% - 68%) reduction in lipids throughout the prostate. A voxel-by-voxel benchmark test of over 850 voxels showed that there were 63% more peaks fitted using the LCModel when using a Cramer-Rao Lower Bound (CRLB) cut-off of 40% when using the optimized conformal voxel technique in comparison to the manual placement approach. The evaluation of this CV-MRS technique has demonstrated the potential for easy automation of the graphical prescription of saturation bands for use in (1)H-MRSI.

Developing an algorithm of informative markers for evaluation of chimerism after allogeneic bone marrow transplantation

Analysis of chimerism by polymerase chain reaction amplification of STR or VNTR has become a routine procedure for the evaluation of engraftment after allogeneic stem cell transplantation. Knowledge of the frequency of different STR or VNTR alleles in unrelated individuals in a population is useful for forensic work. In the context of HLA identical sibling bone marrow transplantation the informativeness of these markers needs to be evaluated. We evaluated five STRs (THO1, VWA, FES, ACTBP2, and F13A1) and 1 VNTR (APOB) for informativeness in stem cell transplants from HLA identical sibling donors. All four markers used individually allowed us to discriminate 20-56% of the patient donor pairs. Using a combination of all these markers along with a polymorphic marker in the beta-globin gene and the sex chromosome specific amelogenin marker, we were able to discriminate 99% of the patient donor pairs. We have established an algorithm for evaluating chimerism following HLA identical sibling donor transplants in the Indian population using molecular markers in 310 patients. Analysis of heterozygote frequencies in different populations is similar suggesting that this algorithm can be used universally for transplant centers to evaluate chimerism following allogeneic bone marrow transplantation.

The value of a second transurethral resection for T1 bladder cancer

OBJECTIVE

To evaluate a series of repeat transurethral resections (TURs) of tumour in patients with T1 bladder cancer, usually used to ensure a complete resection and to exclude the possibility muscle-invasive disease.

PATIENTS AND METHODS

In all, 136 consecutive patients had a second TUR because of a histopathological diagnosis of T1 transitional cell carcinoma (TCC) after their initial TUR. Of the 136 patients, 101 were first presentations and 35 had recurrent tumours. The second TUR was done 4-6 weeks later. The evaluation included the presence of previously undetected residual tumour, changes to histopathological staging/grading, and tumour location.

RESULTS

In all, 71 patients (52%) had residual disease according to findings from specimens obtained during the second TUR. The staging was: no tumour, 65 (48%); Ta, 11 (8%); T1, 32 (24%); Tis, 15 (11%); and > or = T2, 13 (10%). Histopathological changes that worsened the prognosis (>T1 and or concomitant Tis) were found in 21% of patients. Residual malignant tissue was found in the same location as the first TUR in 86% of the patients, and at different locations in 14%. Overall, 28 patients (21% of the original 136) had a radical cystectomy as a consequence of the second TUR findings.

CONCLUSIONS

A routine second TUR should be advised in patients with T1 TCC of the bladder, to achieve a more complete tumour resection and to identify patients who should have a prompt cystectomy.

An Overview of the Diagnosis and Treatment of Erectile Dysfunction

Epidemiological studies have demonstrated an age-stratified increase in the incidence and prevalence of erectile dysfunction (ED). There is a greater degree of openness today when discussing sexual matters and more information on the treatment of ED is available to the public through the media. Quality-of-life issues are now a matter of great importance to the aging population. Men and their partners are no longer prepared to merely accept ED as a natural consequence of aging. The advent of a simple and effective oral therapy for ED has also indirectly fueled the increase in treatment-seeking behaviour among men. Despite great strides in research into ED, our knowledge and understanding of the pathophysiological mechanisms is still in its infancy. As a result, we are able to treat only the symptom of ED rather than prevent it. Common diseases found in the population, such as diabetes mellitus and coronary artery disease appear to be risk factors for the development of ED. Therefore, physicians need to identify any underlying co-existing organic diseases in their patients presenting with ED. Whenever possible, patients are encouraged to attend their consultation sessions with their partners because ED is a condition affecting 'the couple' and not just the man. Psychogenic aspects of ED should also be explored during the consultation. Efforts need to be made to uncover and address the presence of any psychological stressors, if necessary with the help of a psychosexual therapist. The first-line treatment of ED is oral phosphodiesterase-5 inhibitors. For those who do not respond to oral therapy, there is no defined 'step-ladder' escalation in alternative therapy. It is up to the physician to discuss the options with the patient or couple and reach a decision based on their preference.

The utility of Ki-67 and BrdU as proliferative markers of adult neurogenesis

Adult animals continue to produce new neurons in the dentate gyrus of hippocampus. Until now, the principal method of studying neurogenesis has been to inject either tritiated thymidine or 5'-Bromo-2-deoxyuridine (BrdU) intraperitoneally followed by autoradiographic or immunohistochemical detection methods respectively. However, such exogenous markers may produce toxic effects. Our objective was to determine whether Ki-67, a nuclear protein expressed in all phases of the cell cycle except the resting phase, can be used as an alternative, endogenous marker. Using immunohistochemistry, we examined Ki-67 and BrdU expression pattern in rats. Ki-67 was expressed within the proliferative zone of the dentate gyrus and its expression pattern mimicked that of BrdU when examined soon after exogenous BrdU administration. Quantitative comparison of BrdU and Ki-67-positive cells showed 50% higher numbers of the latter when examined 24 h after the BrdU injection. This was expected, since BrdU can be incorporated into DNA only during the S-phase of the mitotic process, whereas Ki-67 is expressed for its whole duration. Experimental increases (by ischemia) or reductions (by radiation) in the number of mitotic cells produced parallel changes in BrdU and Ki-67 signals. Thus, Ki-67 is an effective mitotic marker and has most of the benefits of BrdU and none of the costs. This study provides evidence for Ki-67 to be used as a marker of proliferation in the initial phase of adult neurogenesis.

Medical radiation exposures for diagnostic radiology in Malaysia

The medical radiation usage for diagnostic radiology in Malaysia (a Level II country) for 1990-1994 is reported, enabling a comparison to be made for the first time with the United Nations Scientific Committee on the Effects of Atomic Radiation Report. In 1994, the number of physicians, radiologists, x-ray units, and x-ray examinations per 1,000 population was 0.45, 0.005, 0.065, and 183, respectively. (Level I countries had averages of 2.6, 0.072, 0.35, and 860, respectively). In 1994, a total of 3.6 million x-ray examinations were performed; the annual effective dose per capita to the population was 0.05 mSv, and the collective effective dose was 1,000 person-Sv. Chest examinations contributed 63% of the total. Almost all examinations experienced increasing frequency from 1990 to 1994 except for barium studies, cholecystography, and intravenous urography (-23%, -36%, -51%). These decreases are related to the increasing use of ultrasound and greater availability of fiberoptic endoscopy. Notable increases during the same period were observed in computed tomography (161%), cardiac procedures (190%), and mammography (240%). In order to progress from Level II to Level I status Malaysia needs to expand and upgrade radiological service in tandem with the health care development of the country.

X-ray based radiological procedures in Malaysia--1990-1994

X-ray based radiological procedure statistics and trend in Malaysia for 1990-1994 is reported; this information allows comparisons to be made with the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) Report. Additionally it is essential information for health care planners and providers. Malaysia is categorised as a health care level II country based on the UNSCEAR definition. In 1994, the number of physicians, radiologists, x-ray units and x-ray examinations per 1000 population was 0.45, 0.005, 0.065 and 183 respectively. 3.6 million x-ray examinations were performed in 1994, with chest radiography being the commonest study (63%). Information on x-ray examinations, number of hospitals and x-ray units is reported for the Ministry of Health, private practice and teaching hospitals. Examination frequency increased in computed tomography (161%), cardiac procedures (190%), and mammography (240%); while a decrease in barium studies (-23%), cholecystography (-36%), and intravenous urography (-51%) was noted. There is a potential and need to expand and upgrade radiological services.

Renal papillary necrosis in the east coast of Peninsular Malaysia

Six hundred and one intravenous Urograms (IVU) done at the General Hospital, Kuala Trengganu from 1981 to 1985 were reviewed retrospectively for Renal Papillary Necrosis (RPN). It was found that 1.3% of IVUs had RPN. There was a higher incidence of RPN amongst males as compared to females. RPN occurred more commonly in the younger age groups.

Computer assisted ventriculography

Computed tomography was performed following iothalamate meglumine (Conray) ventriculography in two cases of colloid cyst of the third ventricle. The application of this technique in the diagnosis of intraventricular mass lesions is discussed.

Dose dependency of the post-insult protective effect of pentobarbital in the canine experimental stroke model

In a canine stroke model, dose dependent protection by postocclusion pentobarbital was suggested from 10--40 mg/kg. In 28 dogs investigated (10 from a previous study) a distinct, significant reduction in right cerebral hemisphere infarction occurred in animals given 15--20 mg/kg pentobarbital intramuscularly 1 hour postocclusion. Increased dosages did not alter statistically the infarct size and 2 dogs at the 50 mg/kg and 80 mg/kg levels died of barbiturate-induced respiratory failure.

Focal eosinophilic granuloma of the temporal lobe. Case report

The authors describe the clinical, pathological, and therapeutic aspects of a case of focal temporal lobe eosinophilic granuloma, presenting with otitis media and meningitis, and evolving subsequently into a temporal lobe mass. This triad, otitis media, meningitis, focal cerebral lesion with systemic manifestations of inflammation, eosinophilia of blood and cerebrospinal fluid, should suggest eosinophilic granuloma in the differential diagnosis. The lesion is sensitive to relatively small doses of radiation.

Treatment of hydrocephalus and bilateral subdural effusions in a patient with closed sutures. Case report

For management of bilateral subdural hematomas in a hydrocephalic child with fused sutures, a simple technique is described that involves minimal cranial procedures for modification of an already installed ventriculoperitoneal shunt system.

Failure of computerized axial tomography to demonstrate a chronic subdural hematoma

A chronic subdural hematoma may present in a computerized axial tomography (CAT) scan with the same density as normal brain tissue. The presence of a lesion may be suggested only by its mass effect. The lack of contrast enhancement or edema may help to differentiate a chronic subdural hematoma for a neoplasm or a cerebrovascular accident.

Hepatic manifestations during amoebic dysentery

A variety of hepatic manifestations may occur during attacks of acute amoebic dysentery, conforming to clearly defined clinical groups.

The incidence of definite hepatic involvement presenting as cases of hepatic amoebiasis with or without demonstrable pus or with tender hepatomegaly was 57·5%.

While it is possible that the cases presenting with hepatic manifestations without demonstrable pus are due to small deep-seated abscesses, the non-specific nature of the histological lesions observed in the study and the inability to demonstrate the presence of amoebae in the lesions support the contention that these hepatic manifestations may represent a non-specific reaction in the liver to amoebic ulceration of the colon.

Chest radiology may be helpful in confirming the clinical evidence of hepatic involvement but the leucocyte count, ESR, and the serum enzymes are of limited value in indicating both its presence and type.

Patients manifesting hepatic involvement during attacks of amoebic dysentery should be adequately treated with tissue amoebicidals. This therapeutic approach would be useful in reducing the incidence of hepatic amoebiasis.