Alteraciones de los genes de la vía RAS-MAPK en 200 pacientes españoles con síndrome de Noonan y otros síndromes neurocardiofaciocutáneos. Genotipo y cardiopatía / Alterations in RAS-MAPK genes in 200 spanish patients with noonan and other neuro-cardio-facio-cutaneous syndromes. Genotype and cardiopathy

Introducción y objetivos. La caracterización molecular de cardiopatías incluye una entidad congénita no infrecuente, el síndrome de Noonan. Presentamos el estudio de seis genes de la vía RAS-MAPK en pacientes españoles: perfil genotípico, impacto de la cardiopatía y expresividad clínica. Métodos. Compusieron la población en estudio 643 pacientes (y 182 familiares) diagnosticados por dismorfólogos, cardiólogos y endocrinopediatras de 74 hospitales (11 comunidades). Estudio primario de PTPN11 y complementario de SOS1, RAF1, BRAF, KRAS y HRAS, estratificado y orientado por signos clínicos, mediante secuenciación de exones recurrentes (un 80-95% de mutaciones descritas). Resultados. Se documentó mutación en 230 pacientes (91 mujeres, 139 varones) de 200 familias (31%), 172 PTPN11 +, 14 SOS1 +, 9 RAF1 + y 5 BRAF +, con referencia explícita a la cardiopatía padecida en 156 casos índice; 103 presentaban estenosis de la válvula pulmonar; 12, estenosis de la válvula pulmonar y miocardiopatía hipertrófica; 18, miocardiopatía hipertrófica y 14, otra cardiopatía; en sólo 9 casos se encontraba ausente. En 23/30 familiares positivos no había o no constaba cardiopatía. El rendimiento diagnóstico fue superior (p = 0,016) para las muestras de algunos centros (53%; 14/32), y alcanzó el 64% (9/14; p = 0,019) en profesionales concretos. El rendimiento cayó al 18% en los pacientes sin datos clínicos facilitados. El dato genotípico reorientó el diagnóstico clínico en 26 pacientes. Conclusiones. El 94% de los pacientes portadores de mutación presentaban cardiopatía, el 79% estenosis de la válvula pulmonar y el 12% miocardiopatía hipertrófica. En el 76% de los familiares positivos con rasgos clínicos compatibles, no se había documentado la cardiopatía. El estudio molecular es una herramienta útil en estos síndromes, aunque debe progresarse en la objetivación del diagnóstico clínico (AU)

Introduction and objectives. Molecular characterization of congenital heart diseases now includes the not infrequent dysmorphic Noonan syndrome. A study of 6 genes of the RAS-MAPK pathway in Spanish patients is presented: the impact of heart disease, clinical expressivity, and diagnostic yield are investigated. Methods. The study included 643 patients (and 182 family members) diagnosed by dysmorphologists, cardiologists, and pediatric endocrinologists from 74 tertiary hospitals. Bidirectional sequencing analysis of PTPN11, SOS1, RAF1, BRAF, KRAS and HRAS focused on exons carrying recurrent mutations accounting for 80% to 95% of previously described mutations. Results. Mutations were detected in 230 patients (91 women and 139 men) in 200 (31%) families (172 PTPN11+, 14 SOS1+, 9 RAF1+, 5 BRAF+). There was specific reference to the heart defect suffered in 156 index cases: 103 patients had shown pulmonary stenosis, 12 pulmonary stenosis with hyperthrophic cardiomyopathy, 18 hypertrophic cardiomiopathy, and 14 other cardiopathies; heart disease was absent in 9 index cases. Heart disease had not been documented in 23 of 30 family members with positive genotype and compatible clinical signs. Diagnostic yield was higher (P=.016) for samples from some centers (53%; 14/32) and even from certain professionals (64%; 9/14; P=.019). Characterization rate was 18% in patients for whom clinical data were not available. Genotyping led to a more precise diagnosis in 26 patients. Conclusions. Most patients (94%) with a positive genotype had known congenital heart disease, 79% pulmonary stenosis and 12% hyperthrophic cardiomyopathy. Cardiopathy had not been documented in 76% of family members carrying the mutation. Molecular study is a useful tool in these syndromes but a more rigorous clinical diagnosis should be intended as well (AU)

Alterations in RAS-MAPK genes in 200 Spanish patients with Noonan and other neuro-cardio-facio-cutaneous syndromes. Genotype and cardiopathy.

INTRODUCTION AND OBJECTIVES: Molecular characterization of congenital heart diseases now includes the not infrequent dysmorphic Noonan syndrome. A study of 6 genes of the RAS-MAPK pathway in Spanish patients is presented: the impact of heart disease, clinical expressivity, and diagnostic yield are investigated. METHODS: The study included 643 patients (and 182 family members) diagnosed by dysmorphologists, cardiologists, and pediatric endocrinologists from 74 tertiary hospitals. Bidirectional sequencing analysis of PTPN11, SOS1, RAF1, BRAF, KRAS and HRAS focused on exons carrying recurrent mutations accounting for 80% to 95% of previously described mutations. RESULTS: Mutations were detected in 230 patients (91 women and 139 men) in 200 (31%) families (172 PTPN11+, 14 SOS1+, 9 RAF1+, 5 BRAF+). There was specific reference to the heart defect suffered in 156 index cases: 103 patients had shown pulmonary stenosis, 12 pulmonary stenosis with hyperthrophic cardiomyopathy, 18 hypertrophic cardiomiopathy, and 14 other cardiopathies; heart disease was absent in 9 index cases. Heart disease had not been documented in 23 of 30 family members with positive genotype and compatible clinical signs. Diagnostic yield was higher (P=.016) for samples from some centers (53%; 14/32) and even from certain professionals (64%; 9/14; P=.019). Characterization rate was 18% in patients for whom clinical data were not available. Genotyping led to a more precise diagnosis in 26 patients. CONCLUSIONS: Most patients (94%) with a positive genotype had known congenital heart disease, 79% pulmonary stenosis and 12% hyperthrophic cardiomyopathy. Cardiopathy had not been documented in 76% of family members carrying the mutation. Molecular study is a useful tool in these syndromes but a more rigorous clinical diagnosis should be intended as well.

Mitochondrial DNA polymorphisms/haplogroups in hereditary spastic paraplegia.

Mitochondrial dysfunction could contribute to the development of spastic paraplegia. Among others, two of the genes implicated in hereditary spastic paraplegia encoded mitochondrial proteins and some of the clinical features frequently found in these patients resemble those observed in patients with mitochondrial DNA (mtDNA) mutations. We investigated the association between common mtDNA polymorphisms and spastic paraplegia. The ten mtDNA polymorphisms that defined the common European haplogroups were determined in 424 patients, 19% with a complicated phenotype. A rare haplogroup was associated with the disease in patients without a SPG3A, SPG4, or SPG7 mutation. Allele 10398G was more frequent among patients with a pure versus complicated phenotype. This mtDNA polymorphism was previously associated with the risk of developing other neurodegenerative diseases. In conclusion, some mtDNA polymorphisms could contribute to the development of spastic paraplegia or act as modifiers of the phenotype.

Mutational spectrum of the SPG4 (SPAST) and SPG3A (ATL1) genes in Spanish patients with hereditary spastic paraplegia.

BACKGROUND: Hereditary Spastic Paraplegias (HSP) are characterized by progressive spasticity and weakness of the lower limbs. At least 45 loci have been identified in families with autosomal dominant (AD), autosomal recessive (AR), or X-linked hereditary patterns. Mutations in the SPAST (SPG4) and ATL1 (SPG3A) genes would account for about 50% of the ADHSP cases. METHODS: We defined the SPAST and ATL1 mutational spectrum in a total of 370 unrelated HSP index cases from Spain (83% with a pure phenotype). RESULTS: We found 50 SPAST mutations (including two large deletions) in 54 patients and 7 ATL1 mutations in 11 patients. A total of 33 of the SPAST and 3 of the ATL1 were new mutations. A total of 141 (31%) were familial cases, and we found a higher frequency of mutation carriers among these compared to apparently sporadic cases (38% vs. 5%). Five of the SPAST mutations were predicted to affect the pre-mRNA splicing, and in 4 of them we demonstrated this effect at the cDNA level. In addition to large deletions, splicing, frameshifting, and missense mutations, we also found a nucleotide change in the stop codon that would result in a larger ORF. CONCLUSIONS: In a large cohort of Spanish patients with spastic paraplegia, SPAST and ATL1 mutations were found in 15% of the cases. These mutations were more frequent in familial cases (compared to sporadic), and were associated with heterogeneous clinical manifestations.

Genetic study of SMA patients without homozygous SMN1 deletions: identification of compound heterozygotes and characterisation of novel intragenic SMN1 mutations.

Autosomal recessive spinal muscular atrophy (SMA) is a disease resulting from mutations in the telomeric survival motor neuron gene ( SMN1). In our sample of 150 Spanish SMA families, 87% of patients had homozygous deletions of SMN1. To identify patients who retained a single SMN1 copy, SMN dosage analysis was performed by a fluorescent quantitative PCR assay. In five out of 19 patients tested we detected one SMN1 copy. An extensive SMN gene analysis in these patients led to identification of four intragenic mutations, including two novel ones: a frameshift mutation in exon 6 (773insC) and a splice site mutation in intron 6 (c.867+2T-->G). Two previously described mutations were also found: a deletion in exon 3 (430del4), identified in several Spanish patients, and a frequently occurring mutation in exon 6 (813ins/dup11), reported in several populations. Although the spectrum of intragenic mutations is small, only 27 reported up to now, identification of three mutations found exclusively in the Spanish population indicates that the occurrence of different intragenic mutations depends on the ethnic origin of SMA patients. In the remaining patient, who had a single SMN1 copy and three SMN2 copies, we found that the SMN1 allele was non-functional; the patient did not show any SMN1 transcript. Sequencing of the SMN promoter regions revealed various differences between promoters of the patient's four SMN genes, in particular a change in the length of a polyA run removing a putative YY1 binding site, which may affect the expression of SMN genes.

Propuesta técnica-económica planes de sostenibilidad para ocho casas materna componente de atención primaria en salud / Proposal technique-economic sostenibility plans for eight houses maternal component of primary attention in health

Presenta informe de propuesta técnica-económica de consultoria del Programa de Modernización del Sector Salud del Ministerio de Salud (MINSA). El propósito principal tienen como fin presentar Planes de Sostenibilidad para ocho (8) casas Maternas. Resalta la metodología de la consultoría que constará de tres etapas en las que se utilizarán diferentes métodos y técnicas. Se realizará un análisis financiero de cómo se han venido sosteniendo económicamente las casas maternas, mediante utilización de entrevistas, revisión de registros y reuniones con actores sociales. Se identificarán las principales debilidades y fortalezas y alternativas de sostenibilidad, teniendo conclusiones muy importantes, contenidas en ocho planes de sostenibilidad. Para medir el impacto de los planes,será elaborada la metodología de sosteniblidad, todo este proceso acompañado de un programa de capacitación y taller de trabajo...

Convulsiones y lesión frontoparietal izquierda en una mujer de 20 años / Convulsions and left frontotemporal lesion in a 20-yars-old woman

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Tolerabilidad y eficacia evacuante de una preparación del colon para el enema opaco / Tolerability and cleansing efficacy of an approach to bowel preparation for barium enema

Objetivo: Valorar la tolerabilidad y la eficacia evacuante de una pauta ambulatoria de preparación del colon previa a su examen radiológico.Material y métodos: Estudio observacional, prospectivo, unicéntrico, no controlado, abierto, fase IV. La preparación está constituida por una dieta pobre en residuos (tres días), senósidos A+B, hidratación del paciente y un enema de limpieza. Ciento cincuenta sujetos realizaron, total o parcialmente, la preparación ambulatoriamente y se les practicó un enema opaco. La eficacia evacuante se valoró por la calidad de la limpieza del colon en el enema opaco. La evaluación de la tolerabilidad se llevó a cabo mediante la descripción de los acontecimientos adversos y la valoración de la aceptabilidad de esta preparación por parte del paciente.Resultados: El grado de limpieza global fue excelente en el 36,7 por ciento, bueno en el 34 por ciento, deficiente en el 26 por ciento e incorrecto en el 3,3 por ciento. En el grupo que realizaron totalmente la preparación fue excelente en el 42,2 por ciento, buena en el 33,9 por ciento, deficiente en el 21,1 por ciento e incorrecta en el 2,8 por ciento. En los sujetos que la realizaron inadecuadamente fue excelente en el 22 por ciento, buena en el 34,1 por ciento, deficiente en el 39 por ciento e incorrecta en el 4,9 por ciento. Las pruebas estadísticas que comparan los resultados de eficacia entre estos dos grupos muestran diferencias significativas (p = 0,028).Se recogieron acontecimientos adversos en el 69,3 por ciento de pacientes, todos no serios y el 78 por ciento de ellos con intensidad leve. La aceptabilidad de la preparación por parte de los pacientes fue buena.Conclusiones: La pauta descrita de limpieza del colon para realizar enemas opacos ambulatoriamente presenta una buena tolerabilidad y eficacia evacuante (AU)