The effect of a novel intravenous fluid (Oxsealife®) on recovery from haemorrhagic shock in pigs.

Blood transfusion is given according to haemoglobin thresholds aimed at restoration of arterial oxygen-carrying capacity. Patient survival after severe haemorrhagic shock depends on restoration of microvascular perfusion, tissue oxygen delivery, endothelial function and organ integrity. We investigated a novel crystalloid fluid designed for tissue oxygen delivery, Oxsealife® , with components that generate microvascular nitric oxide and scavenge reactive oxygen species generated during ischaemia-reperfusion injury. The amount of dissolved oxygen in blood progressively increased during step-wise in vitro haemodilution with this fluid, suggesting that the oxygen solubility coefficient of blood is dynamic, not static. We performed a pilot safety and efficacy study to compare resuscitation with this novel crystalloid vs. whole blood transfusion in a swine haemorrhagic shock model with animals bled to an arterial lactate oxygen debt target. Despite contributing no haemoglobin, viscosity nor oncotic potential, resuscitation with Oxsealife after severe haemorrhagic shock restored central haemodynamic parameters comparable to stored allogeneic blood transfusion. Tissue perfusion, oxygenation and metabolic outcomes were equivalent between treatment groups. Increased consumption of bicarbonate in animals given Oxsealife suggested greater capillary recruitment and enhanced clearance of acidic tissue metabolites. Serum markers of organ function, animal activity during recovery and histological analysis of tissue morphology and endothelial glycocalyx integrity confirmed functional recovery from haemorrhagic shock. We conclude that recovery of tissue oxygen delivery and organ function after haemorrhagic shock may not be dependent on treatments that increase haemoglobin levels. Oxsealife shows promise for treatment of severe haemorrhagic shock and may reduce the requirement for allogeneic blood products.

[The prevalence of different types of epilepsy in clinical practice]. / Prevalencia de los distintos tipos de epilepsia en la práctica clínica.

INTRODUCTION: The author reviews the frequency with which different parameters are observed in the 7,500 patients included in his database, created in 1974 and last reviewed in June 2000. The objective of this review is not to do an epidemiological study, but exclusively for the evaluation of the characteristics of the patients who have attended the clinic in recent years. Since the population considered is not complete, but a particular transverse sector, strictly speaking it cannot be considered to be an epidemiological study. It is possible to make a hypothetical extrapolation from this data of a selected population to a general population. PATIENTS AND METHODS: We made a retrospective study of the database including 3,000 patients seen between 1974 and 1985. Between 1985 and 2000, 4,500 cases were analyzed prospectively. There were 7,500 patients altogether. RESULTS: Regarding the types of seizures and their associations, the commonest were the association of simple partial crises and secondarily generalized partial seizures as seen in 661 patients (8.81%). Rather less often there were complex partial crises associated with secondarily generalized partial crises, seen in 640 patients (8.53%). We thus show the frequency of seizures of partial epilepsy. With regard to the types of epilepsy, we point out that the commonest is partial epilepsy (40.86%), to which one should add the cases of so called unilateral epilepsy (398 patients, 5.3%) which was greater than those with generalized epilepsy (idiopathic and systemic and/or cryptogenic) (40.8%), with possible bias due to the origin of the cases. Finally, we mention the frequency of epileptic syndromes. The commonest syndrome seen we have labelled as partial, secondarily generalized epilepsy (6.57%). However, when the syndromes were strictly classified according to established criteria, this was only possible in 2,013 of the 7,500 patients (26.84%). We interpret this, as recently described by Lombroso, as indicating a need for extension of the current classification of epileptic syndromes.

Increased prevalence of polycystic kidney disease type 2 among elderly polycystic patients.

Autosomal dominant polycystic kidney disease (ADPKD) is genetically heterogeneous, with at least three chromosomal loci (PKD1, PKD2, and PKD3) accounting for the disease. Mutations in the PKD2 gene, on the long arm of chromosome 4, are estimated to be responsible for 15% of the cases of ADPKD, based on linkage studies. PKD2 is a milder form of the disease, with a mean age of end-stage renal disease (ESRD) approximately 20 years later than PKD1. The object of this study is to determine the proportion of elderly patients with ADPKD with ESRD who harbor mutations in the PKD2 gene. We analyzed all exons and intron-exon boundaries of the PKD2 gene by single-strand conformation polymorphism analysis and silver staining technique in 46 patients with ADPKD who reached ESRD after the age of 63 years or were not yet undergoing renal replacement therapy (RRT) by that age. We performed exactly the same studies in a control group of 40 patients with ADPKD with unknown gene status aged younger than 63 years. In 22 patients, a mutation in the PKD2 gene was defined: 18 of 46 patients from the elderly group and 4 of 40 patients from the control group. We identified 14 different mutations: 4 nonsense mutations, 1 missense mutation, 5 small deletions, 2 insertions, 1 deletion of the whole PKD2 gene, and 1 splicing mutation. Five of these mutations previously were described by our group. Three of the mutations reported in the present study are recurrent. The prevalence of PKD2 disease among elderly patients with ADPKD undergoing RRT is 39.1%, almost three times the prevalence of the disease in the general ADPKD population.

Loss of heterozygosity in renal and hepatic epithelial cystic cells from ADPKD1 patients.

Autosomal dominant polycystic kidney disease (ADPKD) is one of the commonest genetic diseases in man, affecting 1:1000 individuals in the Caucasian population. It is caused by mutations in the PKD1 or PKD2 genes. Recently, controversial data regarding the mutational mechanism underlying cyst initiation have been reported: genetic analyses have shown that second somatic mutations may lead to cyst formation (detected as microsatellite loss of heterozygosity, LOH, and point mutations), but immunohistochemical studies show strong immunoreactivity for polycystin in some cysts. In order to further characterise this matter we have analysed 211 cysts from seven different patients for LOH, we have detected a 13.3% LOH for PKD1. This loss was specific to PKD1 as no LOH was detected when other chromosomal regions were studied. Whenever linkage analysis has been possible, it has been proved that the lost allele corresponded to the wild-type. Our data supports previous results in the two-hit theory for ADPKD due to the large number of cysts studied. ADPKD would occur through a recessive cellular mechanism. The probability of cyst development would depend on the probability of mutation in the second allele. The different phenotypical expression of the same mutation reported in ADPKD could be due to the different tendency of inactivation in the second allele in each individual.

[Heterozygosity loss and somatic mutations in type I and II dominant autosomal renal polycystic kidney disease: evidence of a recessive mechanism at a cell level in cystogenesis]. / Estudio de pérdidas de heterozigosidad y mutaciones somáticas en la poliquistosis renal autosómica dominante tipos I y II: demostración de un mecanismo recesivo a nivel celular en la cistogénesis.

Autosomal dominant polycystic kidney disease (ADPKD) is a systemic disorder mainly characterized by renal cyst formation. Cysts in ADPKD are focal in nature, since only a small fraction of nephrons become cystic. The hypothesis that a second hit may be required for cyst formation has been proposed. This hypothesis suggests that inactivation of the inherited wild-type allele by a somatic mutation triggers cyst formation. In some cases, this second hit eliminates the normal allele and the affected cells remain with a single allele, which is the inherited mutated copy, and we only visualize one allele after the amplification by polymerase chain reaction; this is called loss of heterozygosity (LOH). In this study we have analysed the DNA isolated from epitehlial cells from 164 cysts of 8 kidneys affected by ADPKD type I and 30 cysts form a kidney affected by ADPKD type II. We have demonstrated the presence of LOH in 20.1% of PKD1 cysts and in 10% of PKD2 cysts. We have also found eight other different mutations in PKD2 cysts without LOH; so the percentage of somatic mutations in the PKD2 kidney reaches 36.6% of cysts. In conclusion, our data suggest that a recessive mechanism at the cellular level is implicated in cyst formation in the PKD1 and the PKD2 disease. The loss of both copies of the gene triggers the proliferation of a single cell, resulting in the cyst formation.

[Mutational analysis of the PKD1 and PKD2 (type 1 and 2 dominant autosomal polycystic kidney) genes]. / Estudio mutacional de los genes PKD1 y PKD2 (poliquistosis renal autosómica dominante tipo 1 y 2).

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease. It is caused by mutations in at least two different genes: PKD1 and PKD2. The study of mutations in these genes is very difficult nowadays. In this study we have analyzed the non reiterated region of the PKD1 gene and all the exons and intron exon boundaries of the PKD2 gene. The technique used to study these genes have been single strand conformation analysis and heteroduplex. We have found 25 differences within the DNA sequence of the PKD1 gene with respect to the published sequence. Seven of these changes correspond to nonsense, missense, frameshifting and splicing mutations. The rest of changes correspond to polymorphisms or rare DNA variants. In the PKD2 gene we have identified 8 new mutations and one polymorphism. Six of these mutations are frameshifting, one is missense and the other one is a large deletion of the PKD2 gene. The rate of mutation detection within the PKD1 gene has been 4% and the rate for PKD2 has been 100%. We have not observed any correlation between genotype and phenotype either in the PKD1 nor in the PKD2 gene. The mutation analysis of ADPKD genes is very difficult, specially for the PKD1 gene. The rate of mutation detection is higher in the PKD2 gene but the global efficacy of the technique is very low as PKD2 represents only 15% of ADPKD patients. Nowadays linkage analysis is still the most useful technique for the molecular diagnosis of ADPKD patients.

Estudio de pérdidas de heterozigosidady mutaciones somáticas en la poliquistosis renal autosómica dominante tipos I y II: demostración de un mecanismo recesivo a nivel celular en la cistogénesis / Loss of heterozygosity and somatic mutations in autosomal dominant polycystic kidney disease types I and II. Demonstration of a recessive mechanism at the cellular level in cyst formation

La poliquistosis renal autosómica dominante (PARAD) es una enfermedad sistémica caracterizada por la formación de quistes renales. La enfermedad muestra una expresión focal, dado que los quistes renales derivan de menos del 1 por ciento de todas las nefronas. Se ha propuesto un modelo de cistogénesis que se iniciaría con la inactivación del alelo normal del gen por una segunda mutación producida a nivel somático. Cuando esta segunda mutación es una deleción amplia que elimina la zona donde se encuentra el microsatélite utilizado como marcador, al amplificar el DNA por reacción en cadena de la polimerasa no obtenemos ningún producto y se visualizará una única banda correspondiente al alelo que contiene la mutación germinal; esto se conoce como pérdida de heterozigosidad (LOH, loss of heterozygosity).En este estudio hemos analizado el DNA extraído de células epiteliales procedentes de 164 quistes de ocho riñones de pacientes con PARAD tipo PKD1 y 30 quistes de un riñón procedente de un paciente con PARAD tipo PKD2. Se ha demostrado la presencia de LO¡'-1 en el 20,1 por ciento de los quistes PKD1 y en el 10 por ciento de los quistes PKD2. Asimismo, en el resto de quistes PKD2 hemos detectado ocho mutaciones diferentes que no cursan como LO,, con lo que el porcentaje total de mutaciones somáticas en el riñón PKD2 ha sido del 36,6 por ciento. En conclusión, estos datos sugieren que un mecanismo recesivo a nivel molecular está implicado en el proceso de cistogénesis tanto en PKD1 como en PKD2. La pérdida de ambas copias del gen provoca la proliferación a partir de una célula determinada resultando en la formación de un quiste (AU)

Estudio mutacional de los genes PKD1y PKD2 (poliquistosis renal autosómica dominante tipo 1 y 2) / Mutational analysis of PKD1 y PKD2 genes (autosomal dominant polycystic disease type 1 and 2)

La poliquistosis renal autosómica dominante (PQRAD) es la enfermedad renal hereditaria más frecuente. Es causada por mutaciones en al menos 2 genes: PKD1 y PKD2. El estudio molecular directo, mediante el análisis de mutaciones resulta actualmente complejo. En el presente trabajo hemos analizado una región de la zona no repetida del gen PKD1 y todos los exones y regiones intrónicas flanqueantes del gen PKD2. Las técnicas utilizadas han sido SSCA (single strand conformation analysis) y heteroduplex. Durante el presente estudio se han hallado 25 diferencias en la secuencia de ADN del gen PKD1 respecto a la secuencia publicada. Siete de ellas corresponden a mutaciones de tipo sin sentido, de sentido erróneo, cambio de pauta de lectura o de splicing y el resto son polimorfismos. Por lo que respecta al gen PKD2 hemos hallado 8 nuevas mutaciones y un polimorfismo, todos ellos no descritos previamente. Seis de las mutaciones modifican la pauta de lectura, una es de tipo sentido erróneo y otra es una gran deleción del gen PKD2. La tasa de detecciones para PKD1 ha sido del 4 por ciento mientras que para PKD2 ha sido del 100 por ciento. No se ha observado correlación genotipo-fenotipo para PKD1 ni para PKD2.El análisis mutación el de la PQRAD es complejo, sobre todo el del gen PKD1. El rendimiento del estudio de mutaciones es superior en el gen PKD2 pero la eficacia global es baja pues la prevalencia de la forma PKD2 es tan sólo de un 15 por ciento del total de poliquistosis. En la actualidad el análisis de ligamiento continúa sien-do la principal herramienta a utilizar para realizar el diagnóstico molecular de la enfermedad (AU)

Influence of the ACE gene polymorphism in the progression of renal failure in autosomal dominant polycystic kidney disease.

The recent description of a polymorphism in the gene for angiotensin-converting enzyme (ACE), with the D allele associated with greater plasma levels of ACE, allows us to perform studies of the relationship between this polymorphism and chronic renal diseases in which the renin-angiotensin system could be implicated. We examined 155 patients with autosomal dominant polycystic kidney disease (ADPKD) with linkage to the PKD1 locus. The ACE insertion/deletion (I/D) polymorphism was amplified with the previously published flanking primers, and the polymerase chain reaction product was separated, sized on a 2% agarose gel, and visualized by ultraviolet transillumination. The ACE genotype distributions were 11.6%, 63.8%, and 24.5% for II, ID, and DD, respectively. There were no significant differences among the three genotypes with respect to mean age, sex distribution, and prevalence of hypertension. The ACE genotype distribution in patients with end-stage renal failure at the time of data compilation was similar to that of the entire study population. In the subgroup of patients who received renal replacement therapy before the age of 50 years, we found a significant association between DD genotype and onset of end-stage renal disease (ESRD) before the age of 50 years compared with II and ID (P = 0.017). We calculated the estimated median renal survival time as 51 years for the II genotype, 53 years for the ID genotype, and 48 years for the DD genotype. There were statistically significant differences between DD and ID patients (P = 0.025). In conclusion, we found DD genotype implies a worse renal prognosis based on both the significantly lower median renal survival time and significantly greater percentage of patients who reach ESRD before the age of 50 years, without implying a greater prevalence of hypertension.

A loss-of-function model for cystogenesis in human autosomal dominant polycystic kidney disease type 2.

Autosomal dominant polycystic kidney disease (ADPKD) is genetically heterogeneous, with at least three chromosomal loci (PKD1, PKD2, and PKD3) that account for the disease. Mutations in the PKD2 gene, on the long arm of chromosome 4, are expected to be responsible for approximately 15% of cases of ADPKD. Although ADPKD is a systemic disease, it shows a focal expression, because <1% of nephrons become cystic. A feasible explanation for the focal nature of events in PKD1, proposed on the basis of the two-hit theory, suggests that cystogenesis results from the inactivation of the normal copy of the PKD1 gene by a second somatic mutation. The aim of this study is to demonstrate that somatic mutations are present in renal cysts from a PKD2 kidney. We have studied 30 renal cysts from a patient with PKD2 in which the germline mutation was shown to be a deletion that encompassed most of the disease gene. Loss-of-heterozygosity (LOH) studies showed loss of the wild-type allele in 10% of cysts. Screening of six exons of the gene by SSCP detected eight different somatic mutations, all of them expected to produce truncated proteins. Overall, >/=37% of the cysts studied presented somatic mutations. No LOH for the PKD1 gene or locus D3S1478 were observed in those cysts, which demonstrates that somatic alterations are specific. We have identified second-hit mutations in human PKD2 cysts, which suggests that this mechanism could be a crucial event in the development of cystogenesis in human ADPKD-type 2.

Autosomal recessive Alport syndrome: linkage analysis and clinical features in two families.

BACKGROUND: Genetic heterogeneity is a well-known feature of Alport syndrome (AS). Most families with AS show an X-linked dominant pattern of inheritance but about 15% of families show an autosomal inheritance of the disease. Autosomal recessive AS may account for 10% of the total number of cases and is caused by mutations in the COL4A3 and COL4A4 genes. The clinical spectrum of this rare disorder has not been well clarified. METHODS: We present two families with AS. Two affected members of these families have entered end-stage renal disease (ESRD) in their 30s, and the other three are older than 15 years and have normal serum creatinine. Four of the five patients have deafness but none have ocular abnormalities. Two have been transplanted and have not suffered from anti-GBM antibody nephritis. Men and women are equally affected. We have performed linkage analysis for chromosome 2 with the following markers: D2S279, COL4A3/4 DNTR, COL4A4 RFLP Hae III. RESULTS: We demonstrate that both families, one of them consanguineous, are linked to the COL4A3/4 locus. CONCLUSIONS: We can conclude that the only significant difference between the X-linked and the autosomal recessive forms of AS lies in the fact that in the latter females are as affected as males; thus the idea that autosomal recessive AS causes ESRD during childhood must be discarded. Other clinical features such as age of deafness or the presence of post-transplant anti-GBM antibody nephritis show no differences between the entities. Thus an accurate familial study is mandatory in patients with AS, as the identification of the different patterns of inheritance may cause a great difference in genetic counselling. Linkage analysis is the only effective molecular diagnosis that can be performed nowadays.

[A review of idiopathic generalized epilepsies: absence epilepsy]. / Revisión de la epilepsia generalizada idiopática: epilepsia ausencias.

We studied the clinical characteristics observed at diagnosis of the initial seizure in different types of epilepsy, particularly in idiopathic generalized epilepsy (IGE), and evaluated the importance of these in the classification of syndromes. The present study analyzes only those IGE initiated by absences leaving the cases initiated by GTC or myoclonic onset for a successive report. We observed differences between cases initiated by absences, those presenting simultaneously with absences and TCG, and those where TCG preceded the absences. Prognosis and evolution are considerably more favourable in cases initiated by absences than in cases with onset preceded by, or simultaneously with, other types of seizures. Besides this difference regarding evolution, it should also be emphasized that the form initiated by absences are more frequent in females, are generally pycnoleptic, appear more often in childhood with a second more moderate peak between 10 and 11 years of age, present more typical clinical-EEG characteristics, and the presence of previous febrile seizures is more notable.

[Prospective study of the differences between the syndromes of infantile absence epilepsy and syndromes of juvenile absence epilepsy]. / Estudio prospectivo acerca de las diferencias entre el síndrome epilepsia ausencias del niño y el síndrome epilepsia ausencias juvenil.

In this prospective study of the differences between the epileptic syndrome of absence attacks in the child (EAN) and the syndrome of juvenile absence attacks (EAJ), the author considers the characteristics of these syndromes in order to differentiate their various aspects, namely clinical features, complementary tests, course and prognosis. These cases are from a series of 6,299 epileptic patients. One of the objectives of a prospective study begun in 1970 was to evaluate the clinical course of all cases in which valproic acid was used. Valproic acid is known to be most effective in the basic crises of these two syndromes, namely the typical absence attacks. It is therefore an analysis of the clinical features and their subsequent course and prognosis when thus treated, since a retrospective study including a much larger number of patients would not be considered to be satisfactory in view of the 'bias' due to only some patients having access to treatment with this drug. The author analyzes 138 cases of EAN and 42 cases of EAJ seen between 1970 and the end of 1995. These syndromes, particularly EAN, have always been considered to have an excellent prognosis. The author tries to show from the point of view of long term follow-up, that absence attacks may not only persist into adult life but also be associated with other types of crises which worsen the prognosis. Thus, for instance, in EAN 50% of the cases show generalized tonic-clonic seizures on long-term follow-up. In EAJ the corresponding figure is 76.1%. This data modifies previous ideas as to the benign course of these syndromes when they are followed-up for a long period. The basic criteria were: a first visit after 1970 and an age of onset between 3 and 10 years for EAN and over 10 years for EAJ. In all cases there was the following conditions, onset by absence attacks, lack of permanent neurological or psychological disorders, and a video-EEG recording of a typical generalized EEG during an attack.

Abnormal local-circuit neurons in epilepsia partialis continua associated with focal cortical dysplasia.

A limited cortical resection including the rolandic fissure and the pre- and postcentral cortical regions was carried out in a patient suffering from epilepsia partialis continua resistant to antiepileptic drugs. The histological examination revealed several foci of very large neurons distributed with no laminar organization in the depth of the rolandic fissure and in the crown of the primary motor and primary somatosensory areas; these lesions were consistent with focal cortical dysplasia. In addition, decreased numbers of neurons, astrocytosis and proliferation of capillaries, compatible with chronic tissue necrosis, were found in the inferior regions of the banks of the rolandic fissure. Subpopulations of local-circuit neurons were examined with parvalbumin, calbindin D-28k and somatostatin immunocytochemistry. Focal areas of cortical dysplasia contained abnormal immunoreactive neurons. Huge parvalbumin-immunoreactive cells were distributed at random and resembled axo-axonic (chandelier) and basket neurons. Abnormal calbindin D-28k-immunoreactive cells were reminiscent of double-bouquet neurons and multipolar cells. Very large somatostatin-immunoreactive cells were seldom observed in the dysplastic foci. On the other hand, areas of tissue necrosis displayed massive reduction of immunoreactive cells and fibers. Abnormalities in the morphology and distribution of local-circuit (inhibitory) neurons observed here for the first time in focal cortical dysplasia may have a pivotal role in the appearance and prolongation of electrical discharges and continuous motor signs in human focal epilepsy.

Influence of the 'lost time' on the outcome of epilepsy.

A review of a series of epileptic patients revealed the importance of the 'lost time' in the future time course of a patient. The 'lost time' is regarded as the period of time elapsed since the onset of symptoms and the implementation of adequate treatment. An assessment of the follow-up of 3,529 epileptic patients showed that the shorter the 'lost time', the greater the efficacy of anticonvulsant treatment. Even the incidence of relapses after discontinuation of antiepileptic drugs correlates with the 'lost time' before diagnosis. These findings emphasize the importance of establishing an early diagnosis of the type of epilepsy and the prescription of adequate antiepileptic medication.

Partial epilepsy with seizures appearing in the first three years of life.

We reviewed records of 5,000 epileptic patients and identified 154 cases of partial epilepsy with seizure onset in the first 3 years of life. Of these, 35 patients had initial partial seizures. In 57 patients, partial seizures were preceded by a hemiclonic seizure, which manifested as status epilepticus in 70%. Generalized seizures were the initial manifestation in 62 patients: 17 grand mal, 14 clonic or myoclonic, and 31 tonic or atonic seizures. Of the 119 patients, 31 showed a seizure free-interval of several years between the initial seizure and the occurrence of partial epilepsy. The atypical initial clinical presentation and the seizure-free interval before occurrence of more characteristic partial seizures raise the possibility that the diagnosis of partial epilepsies in the first years of life may be missed.

Suppression of antiepileptic treatment.

The present report evaluates the suppression of antiepileptic drugs in a group of 608 epileptics. Conditions for the suppression of antiepileptic treatment included a previous seizure-free period of 5 years under medication, and a careful evaluation of individual social and work-related circumstances. The reduction of medication was realized during a minimum period of 1 year, passing from eventual polytherapy to monotherapy. Of the total 608 epileptics in whom treatment was suppressed, 144 relapses (23.7%) occurred, and 464 (76.3%) patients continued to be seizure-free. A complete remission of the epilepsy was achieved in 14.3% of 3,254 epileptics with an adequate follow-up. Significant risk factors for recurrence included a delay in starting anticonvulsant therapy; symptomatic generalized epilepsy; different types of combined seizures, or atypical absences and/or tonic crisis and/or atonic crisis; or partial complex associated with secondary generalized tonic-clonic seizures; the presence of status epilepticus in the course of the disease and permanent neurologic damage. With the patient's prior agreement, it was possible to suppress anticonvulsant medication in one fourth of nonselected epileptic patients with a possibility of relapse in about 25% of the cases (generally one isolated seizure).

Versive seizures of probable occipital origin in a case of posttraumatic epilepsy.

Oculoclonic versive elemental partial seizures developed in a 38-year-old male, who has suffered from a grave traumatism by impaling. Posttraumatic epileptic symptoms could be related to anatomical lesions at the exit orifice in the right occipitoparietal region.