Distinguishing pathogenic mutations from background genetic noise in cardiology: The use of large genome databases for genetic interpretation.

Advances in clinical genetic testing have led to increased insight into the human genome, including how challenging it is to interpret rare genetic variation. In some cases, the ability to detect genetic mutations exceeds the ability to understand their clinical impact, limiting the advantage of these technologies. Obstacles in genomic medicine are many and include: understanding the level of certainty/uncertainty behind pathogenicity determination, the numerous different variant interpretation-guidelines used by clinical laboratories, delivering the certain or uncertain result to the patient, helping patients evaluate medical decisions in light of uncertainty regarding the consequence of the findings. Through publication of large publicly available exome/genome databases, researchers and physicians are now able to highlight dubious variants previously associated with different cardiac traits. Also, continuous efforts through data sharing, international collaborative efforts to develop disease-gene-specific guidelines, and computational analyses using large data, will indubitably assist in better variant interpretation and classification. This article discusses the current, and quickly changing, state of variant interpretation resources within cardiovascular genetic research, e.g., publicly available databases and ways of how cardiovascular genetic counselors and geneticists can aid in improving variant interpretation in cardiology.

Integration of 60,000 exomes and ACMG guidelines question the role of Catecholaminergic Polymorphic Ventricular Tachycardia-associated variants.

Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) is a highly lethal cardiac arrhythmia disease occurring during exercise or psychological stress. CPVT has an estimated prevalence of 1:10,000 and has mainly been associated with variants in calcium-regulating genes. Identification of potential false-positive pathogenic variants was conducted by searching the Exome Aggregation Consortium (ExAC) database (n = 60,706) for variants reported to be associated with CPVT. The pathogenicity of the interrogated variants was assessed using guidelines from the American College of Medical Genetics and Genomics (ACMG) and in silico prediction tools. Of 246 variants 38 (15%) variants previously associated with CPVT were identified in the ExAC database. We predicted the CPVT prevalence to be 1:132. The ACMG standards classified 29% of ExAC variants as pathogenic or likely pathogenic. The in silico predictions showed a reduced probability of disease-causing effect for the variants identified in the exome database (p < 0.001). We have observed a large overrepresentation of previously CPVT-associated variants in a large exome database. Based on the frequency of CPVT in the general population, it is less likely that the previously proposed variants are associated with a highly penetrant monogenic form of the disease.

Externally assessed psychosocial work characteristics and diagnoses of anxiety and depression.

BACKGROUND: Interpretations of relationships between work characteristics and psychiatric disorders may be biased by over-reporting of unfavourable work characteristics among those with psychiatric disorders. This study attempts to account for this bias by using external assessments of work characteristics. METHODS: Psychiatric symptoms were assessed in an interview and psychiatric diagnoses were established according to DSM-IV. Current work characteristics and work characteristics three years ago were assessed in an interview with predetermined criteria and included cognitive requirements, possibility of influence, and required conformance to schedule, time pressure, and hindrances concerning goals, resources and instrumental support. Deterioration in work characteristics during the study period was also assessed. The sample consisted of 672 employed men and women in different occupations. RESULTS: Lack of instrumental support from colleagues and supervisors (OR 6.4, 95% CI 2.6 to 15.8) assessed as a hindrance to work performance, and deterioration in work characteristics during the study period (OR 2.8, 95% CI 1.3 to 6.1) were associated with increased odds ratios for depression after adjustment for confounding factors, including symptoms of mental illness at baseline. Findings for anxiety were similar but not statistically significant. CONCLUSION: Externally assessed lack of instrumental social support at work and deteriorating work characteristics were associated with an increased risk for depression.

Leaching of metals from sewage sludge during one year and their relationship to particle size.

Leaching of metals from sewage sludge can lead to their accumulation in topsoil and can also contaminate groundwater. Our objectives were to document the metal leachates and the size distribution of leached particles from sewage sludge and to identify possible correlations with physical factors. Results from monthly lysimeter sampling showed an initial release followed by decline for most metals. Cadmium, Ca, Sr, Li, Mn, Ni and Zn showed a "cyclic" behaviour. Filtration revealed that this "cyclicity" had no correlation to the size of released particles, but Al, Cr, Fe, Cu, Ag and Pb were clearly related to release of coarser particles most of the year. Total metal amounts leached during one year, relative to original sludge content, had the order Na>Ca=Mg>Mn>Sr>Zn>K>Li=Ni>Cd>Co>Rb>Ag>Cr>Ba=Cu>Ga>Al=Pb=Fe. There were no simple correlations between monthly measured leachate concentrations and precipitation, temperature or pH of precipitation. Occasional leachate sampling might give misleading values for metals with "cyclic" behaviour.

Virtual reality colonoscopy simulation: a compulsory practice for the future colonoscopist?

BACKGROUND AND STUDY AIM: As for any manual procedure, the learning curves for medical interventions can have undesirable phases, occurring mostly in the early experience of applying a technique. There have been impressive advances in endoscopic procedures during recent years, and there is an emerging trend that the number of procedures is increasing in parallel with these. In addition, the introduction of screening programs for colorectal cancer will also increase the numbers of procedures needed. Recent developments in medical simulation seem promising with regard to the possibility of "training out" undesirable parts of the learning curve outside the operating room. The aim of this study was to investigate whether the use of the AccuTouch flexible endoscopy simulator improves the early part of the learning curve in colonoscopy training. METHOD: 12 endoscopy trainees, 10 surgeons and two medical gastroenterologists, all with experience in gastroscopy but with no specific colonoscopy experience, were randomly assigned to either simulator training or to a control group. They all received the same theoretical study package and the training group practiced with the AccuTouch colonoscopy simulator until a predefined expert level of performance was reached. All trainees performed their first ten individual colonoscopies described in detail in a separate protocol. RESULTS: Trainees in the simulator-trained group performed significantly better (P=0.0011) and managed to reach the cecum in 52% of their cases (vs. 19% in the control group), and were 4.53 times more likely to succeed compared with the controls. Additionally, there was a significantly shorter procedure time and less patient discomfort in the hands of the simulator-trained group. CONCLUSION: Skills acquired using the AccuTouch simulator transfer well into the clinical colonoscopy environment. The results of this trial clearly support the plan to integrate simulator training into endoscopic education curricula.

Sarcoplasmic body myopathy--a rare hereditary myopathy with characteristic inclusions.

OBJECTIVES: To characterise a Swedish family with a rare hereditary myopathy with unique sarcoplasmic inclusion bodies in the muscle biopsy. MATERIALS AND METHODS: Part of the pedigree was described in 1980. Nine new members of the included and the phenotype further characterised through clinical, neurophysiological and radiological investigations. RESULTS: Six of the nine subjects displayed clinical and/or laboratory evidence of myopathy with sarcoplasmic inclusions. CONCLUSIONS: Sarcoplasmic body myopathy is distinguished from other distal myopathies by a more malignant course and early involvement of thenar muscles and hand flexors. Five to ten years after onset the affected subjects develop distal, as well as proximal, weakness and atrophy and the majority require a wheelchair after ten to fifteen years of disease. The disorder is manifested through elevated creatine kinase levels and the presence of the pathognomonic sarcoplasmic inclusions prior to clinical signs and symptoms.

Identification of metal toxicity in sewage sludge leachate.

Sewage sludge is a source of organic matter and nutrients with the potential for being used as a fertilizer. However, metals in sewage sludge might accumulate in soil after repeated sludge applications, and metal concentrations might reach concentrations that are toxic to microorganisms, soil organisms and/or plants. This toxicity might change with time due to kinetic factors or abiotic factors such as freezing, drying or rainfall. The objective of this study was to determine toxicity of sewage sludge leachate from a lysimeter with 50 cm of sludge applied. Attempts were also made to identify the cause of toxicity of the sludge leachate by toxicity identification and evaluation (TIE) techniques. Sludge leachate was collected monthly during 1 experimental year (August 2001 to August 2002). Metal concentrations were analysed, and the toxicity was determined with Daphnia magna (48-h immobility). The effect of EDTA or sodium thiosulphate addition, filtration through a CM-resin or a Millex-resin on toxicity was also tested. The results showed that toxicity of the sludge leachate apparently varied during the year, and that filtration through the CM-resin reduced most of the toxicity followed by the addition of EDTA. None of the other treatments reduced the toxicity of the sludge leachate. This indicated that one or more metals were responsible for the observed toxicity. Further calculations of toxic units (TU) suggested that Zn contributed most to the toxicity. Results also indicated that Ca concentrations in the sludge leachate reduced the toxicity of Zn.

Does training in a virtual reality simulator improve surgical performance?

BACKGROUND: The development of computerized surgical simulators in a virtual reality environment demands models for proper validation. Recent investigations have shown that a virtual reality simulator (MIST-VR) is a reliable tool for the assessment of laparoscopic psychomotor skills and that it improves the automation of the so-called fulcrum effect. Therefore, we set out to determine whether training with the MIST-VR would improve the surgical performance of surgically inexperienced medical students and to see if results obtained in the simulator would correlate with surgical performance. METHODS: A total of 29 medical students were randomized into two groups. One group received preoperative MIST-VR training. Both groups then performed a simulated laparoscopic appendectomy in a pig. The operations were videotaped and examined by three independent observers. RESULTS: There was no significant difference in performance between the two groups. The performance with the MIST-VR correlated with the results in surgery. CONCLUSION: A method that can measure surgical skill, based on the scoring of independent observers who view videotaped performances, seems to be reliable. MIST-VR did not improve the surgical skills of the subjects, but the results with MIST-VR did predict surgical outcome.

Work environment and neck and shoulder pain: the influence of exposure time. Results from a population based case-control study.

OBJECTIVES: To study associations between long term and short term exposure to different work environmental conditions and the incidence of neck or shoulder pain. The results were obtained as part of the MUSIC-Norrtälje study, which is a population based case-control study conducted in Sweden in 1993-7. METHODS: The cases were people from the study base who sought medical care or treatment for neck or shoulder pain. Information on physical and psychosocial conditions in the work environment, currently and 5 years ago, and lifestyle factors, was obtained by self administered questionnaires from 310 cases and 1277 randomly selected referents. RESULTS: Associations between both physical and psychosocial exposures in the work environment and seeking care for neck or shoulder pain were found. The risk patterns differed for the sexes, and risk ratios exceeding 1.5 were more often found among women than among men. Generally, subjects who had experienced a recent increase of exposure were more likely (relative risk (RR) 2.1-3.7) to seek care than those who had been exposed long term (RR 1.5-1.8). Among women, an increased amount of visual display terminal (VDT) work, work above shoulder level, and reduced opportunities to acquire new knowledge, and among men, an increased amount of seated work were associated with neck or shoulder pain. This might indicate short induction periods for neck or shoulder pain for these exposures. However, for repetitive work with the hands and hindrance at work among women, and possibly also local vibrations among men, the induction periods seem to be longer. Interactive effects between factors, both at work and in the family, were found, but only among women. CONCLUSIONS: Associations between some exposures in the work environment and seeking care for neck or shoulder pain were found. The high RRs for short term exposure might indicate that for many factors the induction period for neck or shoulder pain is short.

Genetic linkage of Welander distal myopathy to chromosome 2p13.

Welander distal myopathy (WDM) is an autosomal dominant myopathy with late-adult onset characterized by slow progression of distal muscle weakness. The disorder is considered a model disease for hereditary distal myopathies and is almost only seen in Sweden and some parts of Finland. A genomewide screening has been performed in initially two Swedish families with 400 highly polymorphic microsatellite markers. We report here that the disease is linked to chromosome 2p13. Seven additional nonrelated families have subsequently been mapped to the same area where a maximum two-point LOD score of 17.97 was obtained with the marker D2S2113 at 0.0 recombination fraction. The region has been restricted by recombinations and the finding of a common shared haplotype through all analyzed families. This restricts the gene locus region to 2.4 cM. These findings provide evidence for the involvement of a single locus for WDM. The WDM region overlaps with the linkage region for Miyoshi myopathy and limb-girdle muscular dystrophy 2B. The dysferlin gene responsible for these disorders is considered a primary candidate gene for WDM.

Low molecular weight heparin (dalteparin) as adjuvant treatment of thrombolysis in acute myocardial infarction--a pilot study: biochemical markers in acute coronary syndromes (BIOMACS II).

OBJECTIVES: This randomized, double blind, placebo-controlled pilot trial evaluated the effect of dalteparin as an adjuvant to thrombolysis in patients with acute myocardial infarction regarding early reperfusion, recurrent ischemia and patency at 24 h. BACKGROUND: Low-molecular-weight heparin, given subcutaneously twice daily without monitoring, might be an attractive alternative to conventional intravenous heparin in the treatment of acute myocardial infarction. METHODS: In 101 patients dalteparin/placebo 100 IU/kg was given just before streptokinase and a second injection 120 IU/kg after 12 h. Monitoring with continuous vector-ECG was done to obtain signs of early reperfusion and later ischemic episodes. Blood samples for myoglobin were obtained at start and after 90 min to evaluate signs of reperfusion. Coronary angiography was performed after 20-28 h to evaluate TIMI-flow in the infarct-related artery. RESULTS: Dalteparin added to streptokinase tended to provide a higher rate of TIMI grade 3 flow in infarct-related artery compared to placebo, 68% versus 51% (p = 0.10). Dalteparin had no effects on noninvasive signs of early reperfusion. In patients with signs of early reperfusion, there seemed to be a higher rate of TIMI grade 3 flow, 74% versus 46% (myoglobin) (p = 0.04) and 73% versus 52% (vector-ECG) (p = 0.11). Ischemic episodes 6-24 h. after start of treatment were fewer in the dalteparin group, 16% versus 38% (p = 0.04). CONCLUSIONS: When dalteparin was added as an adjuvant to streptokinase and aspirin, there were tendencies for less ECG monitoring evidence of recurrent ischemia and better patency at 24 h, warranting further study.

Diagnostic laparoscopy in 1043 patients with suspected acute appendicitis.

OBJECTIVE: To evaluate the efficacy of diagnostic laparoscopy in patients with suspected acute appendicitis, the number of complications associated with the laparoscopic technique, and the effect of leaving a macroscopically normal-looking appendix in place. DESIGN: Three prospective protocols. SETTING: Three departments of surgery, one in Norway and two in Sweden. SUBJECTS: 1043 patients aged 15 years or over. INTERVENTIONS: Diagnostic laparoscopy in patients with signs and symptoms of acute appendicitis who were to be operated on. MAIN OUTCOME MEASURES: Morbidity, mortality, and histological appearance of removed appendices, and outcome whether or not the patient was operated on. RESULTS: 819 patients had appendectomies (61% laparoscopically and 39% by conversion to open operation) with a total complication rate of 10%. In 211 patients a diagnostic laparoscopy was done as a single procedure. There were 181 women in this group and 86 of them had gynaecological disorders. The complication rate was 2% among these 211 patients and after a follow up of two years no patients had been readmitted for appendicectomy. 13 patients were subjected to other open procedures. The overall mortality was 0.4%. CONCLUSION: Diagnostic laparoscopy is safe and can be recommended in patients with suspected acute appendicitis, particularly in women. A macroscopically normal-looking appendix can be left in place.

Welander hereditary distal myopathy, a molecular genetic comparison to hereditary myopathies with inclusion bodies.

Welander distal myopathy (WDM) is an autosomal dominant disorder with late onset predominantly affecting distal extensor muscles of the hands and the feet. The disorder is considered as the most common of the distal myopathies but is almost only seen in Sweden and some parts of Finland. The finding of rimmed vacuoles in muscle biopsies from patients with moderate and severe symptoms constitutes one similarity with hereditary inclusion body myopathy (HIBM) sparing the quadriceps as described by Argov and Yarom [Argov Z, Yarom R. J Neurol Sci 1984;64:33-43]. The question has been raised whether some of the different forms of distal myopathy might be allelic. In previous reports the gene defects for HIBM and autosomal recessive hereditary distal myopathy with rimmed vacuoles (DMRV) have been mapped to chromosome 9pl-q1. The Finnish tibial muscular dystrophy (TMD) that displays similar histopathological findings has recently been linked to chromosome 2q. We have investigated the regions of interest with dispersed microsatellite markers in four well-described pedigrees, and this study now excludes the regions on chromosome 9pl-q1 and 2q from linkage to WDM both by haplotype analysis and linkage analysis with the MLINK program. WDM, showing morphological similarities with HIBM, is clearly separated from the disorders mapped to chromosomes 9 and 2 on clinical and genetical grounds.

Welander distal myopathy--an overview.

Welander distal myopathy has an autosomal dominant inheritance and a late onset. The onset of symptoms is in the hands and gradually distal muscles of the lower extremities are involved. The most-affected muscles are the long extensors of the hands and feet. CK-values are normal or slightly elevated. There is never any cardiac involvement in Welander distal myopathy. Neurophysiological findings are of both myopathic and neuropathic character. Histopathological findings in muscle biopsies are mainly of myopathic type and include rimmed vacuoles which correspond to autophagic vacuoles on the ultrastructural level. Tubulo-filamentous inclusions with a diameter of 16-21 nm, i.e. of the same type as found in patients with Inclusion Body Myositis, are found in the sarcoplasm and in myofibre nuclei. A neurogenic component in Welander distal myopathy has been suggested, on the grounds of a sensory dysfunction, neuropathic findings on neurophysiology and muscle biopsy and a decrease of A-delta nerve fibres on sural nerve biopsy. Genetic analysis has excluded linkage to other defined distal myopathies and hereditary Inclusion Body Myopathy loci.

C4342T-mutation in the SCN4A gene on chromosome 17q in a Swedish family with paramyotonia congenita (Eulenburg)--correlations with clinical, neurophysiological and muscle biopsy data.

Genetic analysis of the adult muscle sodium channel alpha-subunit, SCN4A gene on chromosome 17q, was performed by means of PCR technique in a Swedish family with paramyotonia congenita (Eulenburg) (PMC). The mutation was found in four family members and consisted of a C to T transition affecting the fourth domain of the sodium channel protein. This mutation has earlier been described in other families with paramyotonia congenita. All family members carrying the mutation had cold-induced paradoxical myotonia, myotonic bursts on EMG, and a type IIB atrophy on muscle biopsy. Three of them had slight CK elevation and two had episodes of paralysis. On the basis of clinical findings in this family, persistent proximal muscle weakness, myopathic EMG abnormalities, a type IIB atrophy on muscle biopsy and no symptoms but other signs of muscle affection, were earlier suggested as clinical features of PMC. However, genetic analysis revealed that family members with these symptoms and findings did not have the mutation, indicating that these features are not due to PMC.

Welander distal myopathy is not linked to other defined distal myopathy gene loci.

Welander distal myopathy is an autosomal dominant disorder with late onset that affects extensor muscles of the hands and the feet. The disorder is considered as the most prevalent of the distal myopathies and is almost only seen in Sweden and in some parts of Finland. On clinical, morphological and genetical grounds the disorder is clearly separated from other distal myopathies. We have performed linkage analysis with the MLINK program in a total of six families with microsatellite markers dispersed throughout the genome and report exclusion for the localisation of the gene of 64% of the human genome. These studies have clearly separated Welander distal myopathy from previously mapped forms of distal myopathy such as the Miyoshi myopathy by excluding linkage to chromosome 2. The region on 14q that has been suggested to house the gene of the distal myopathy described by Laing et al. (Am J Hum Genet 1995;56:422-7), has as well been excluded by several markers.

Mechanical small-bowel obstruction after conventional appendectomy in children.

During the period May 1988 to August 1990, 871 children aged between 0 and 15 years were appendectomized by laparotomy because of suspected appendicitis at the department of pediatric surgery, St. Göran's Children's Hospital. The children were followed 4-6 years after appendectomy. 1.3 % (10/791) developed clinical symptoms consistent with mechanical small bowel obstruction (SBO) resulting in relaparotomy and confirmation of the diagnosis. The patients were divided into subgroups according to the degree of appendicitis. In the group with normal appendix 1.8% (3/170) developed mechanical SBO, simple appendicitis 0% (0/209), gangrenous appendicitis 0.4 % (1/236) and perforated appendicitis 3.4% (6/176). There was no mortality due to postoperative complications. Two patients died due to unrelated causes during the follow-up period.

Distribution of muscle degeneration in Welander distal myopathy--a magnetic resonance imaging and muscle biopsy study.

Seven patients with Welander distal myopathy were subjected to magnetic resonance imaging (MRI) of the lower extremity, and muscle biopsies of the tibialis anterior, soleus and vastus lateralis muscles. MRI revealed abnormalities in both the anterior and posterior compartments of the lower leg in three of the patients, and in only the posterior compartment in the rest of the patients. No MRI abnormalities were found in either the proximal muscles of the leg or in the peroneal or posterior tibial muscle groups. Affected muscles had T1- and T2-values indicating a replacement of muscle fibres with fat tissue. Muscle biopsies showed pathological changes varying from slight to severe in tibialis anterior and soleus muscles in all patients. No muscle fibre abnormalities were seen in the vastus lateralis muscle in any of the patients. In accordance with earlier reports from patients with Welander distal myopathy, there was muscle degeneration of tibialis anterior muscles corresponding to the weakness of dorsal extension of the feet, but also degeneration in the muscles of the posterior compartment. The patients did not, however, show any clinical signs of weakness related to posterior muscle groups. There is no evidence of involvement of proximal muscles of the leg clinically, with MRI or in muscle biopsies.

Larger expansions of the CTG repeat in muscle compared to lymphocytes from patients with myotonic dystrophy.

The discovery that there is an expansion of a CTG repeat underlying myotonic dystrophy has led to new approaches in diagnosis and genetic counselling for this disorder. The size of the expansion correlates to a reasonable degree with the clinical symptoms within a given family. We report comparisons of the length of the expansion seen in lymphocytes and muscle samples from eight patients. In all cases the length of the expansion seen in DNA isolated from muscle was larger than that seen in lymphocytes from the same patient. There was no progression of the expansion over a period of 10-15 years in muscle samples from two of these patients even though there had been significant progression of the severity of symptoms during that time.