Combined coagulation factor VIII and factor IX deficiency (CDF8F9) in a patient from Lithuania

Haemophilia A (FVIII deficiency) and haemophilia B (FIX deficiency) are X-linked inherited bleeding disorders. It is a very rare event to identify both haemophilias in the same patient. So far, only two families with such combination are reported in the literature worldwide supported by genetic background. Patients and methods: Evaluation of clinical data, determination of FVIII and FIX levels and genetic analysis of F8 and F9 genes by direct sequencing. Results: We report on a patient having severe haemophilia B (FIX:C <1 IU dl-1) and mild haemophilia A (FVIII:C 18 IU dl-1 ). FIX deficiency was known since childhood, whereas mild haemophilia A was confirmed at the age of 42 due to unexpected bleeding complications after dental extraction despite adequate substitution with plasma derived FIX concentrate. F9 gene analysis showed a point mutation in exon 2 (c.223C>T, p.R75X), whereas F8 gene analysis revealed a point mutation in exon 4 (c.545A>C, p.D182A). The mother of the patient was heterozygous for F8 mutation, but not for F9 mutation suggesting a de novo F9 mutation. Accidentally, further family from Germany with mild Haemophilia A was identified to have the same F8 mutation. F8 Haplo-type analysis revealed that the p.D182A mutation most likely represents a founder mutation with common ancestors of the German and the Lithuanian family. Conclusions: Our results confirm the rare event of Haemophilia A and haemophilia B in the same patient originating from two distinct genetic defects in F8 and F9 genes.

A novel fibrinogen γ chain frameshift deletion (c.637delT) in a patient with hypodysfibrinogenemia associated with thrombosis

Inherited fibrinogen (FG) disorders are rare and result in quantitative or/and qualitative FG deficiency. While the majority of patients with clinically relevant FG deficiencies demonstrate a bleeding phenotype, a subset of patients are at increased risk of thrombosis.

We report a 54-years old man presenting with a thrombophilic phenotype characterized by two episodes of unprovoked venous thrombosis and a deep vein thrombosis several weeks after myocardial infarction. Recently, he developed A. carotis communis thrombosis and died. Coagulation tests were done using standard procedures. FG genes were screened using direct sequencing. Effect on fibrin clot structure was analyzed by scanning electron microscopy (SEM) and FG chain polymerization was analysed using SDS-PAGE.

While thrombophilia testing was negative, we found a decreased concentration of clottable FG (126-148 mg/dl) compared to FG antigen (182-194 mg/dl of normal). The thrombin time was slightly prolonged, while aPTT and reptilase time were within the normal range. A novel deletion in FGG gene (c.637delT) resulting in a frameshift and the premature termination of the γ chain at amino acid position p.228 was identified. SDS-PAGE showed a time-shift in γ-γ and α-α cross linking. SEM showed no statistically significant differences between the patient´s and a healthy control´s fibrin clot structure.

In addition to the reduction of FG concentration expected by the nature of the mutation also a functional defect (hypodysfibrinogenemia) was found. Moreover this mutation seems to increase the risk of thrombosis warranting long term anticoagulation possibly in a combination with antiplatelet drugs.

A prospective study examining the influence of cardiac rehabilitation on the sedentary time of highly sedentary, physically inactive patients

OBJECTIVES

Prolonged sedentary time is recognized as a distinct health risk, and mortality risks are expected to be greatest for individuals with low exercise levels. It is unknown whether participation in exercise-based cardiac rehabilitation (CR) programs influences sedentary behaviour particularly among those patients expected to be at greatest mortality risk. This study examined the influence of CR participation on sedentary behaviour and identified the proportion and characteristics (socio-demographic and clinical) of patients who do not meet exercise recommendations and have prolonged sedentary times.

METHODS

A prospective study was conducted among patients of an exercise-based CR program and assessments performed at baseline and 3 months. Physical activity and sedentary behaviour information were collected by self-report, and convergent validity was examined on an accelerometer-wearing subsample.

RESULTS

Of 468 CR patients approached, 130 participants were recruited with an average sedentary time of 8hours/day. Sedentary behaviour remained consistent at follow-up (relative change= -2.4%, P=0.07) notwithstanding a greater proportion meeting exercise recommendations (relative change= 57.4%). 19.2% of participants were classified to have prolonged sedentary time and not meet exercise recommendations at baseline. No significant differences were found between the characteristics of high-risk individuals and lower risk subgroups. Findings were consistent among the accelerometer-derived subgroup and the overall sample despite poor to moderate convergent validity.

CONCLUSIONS

These results suggest that the exercise-focus of CR may not reduce sedentary behaviours. Future studies are needed to determine whether sedentary behaviour-specific reduction strategies are more effective than traditional exercise-based strategies and lead to meaningful improvements in clinical outcomes.

Acute thyroid swelling in renal transplant recipient

Tuberculosis (TB) of thyroid gland is rare entity even in solid organ transplant recipients who have a high risk of TB. Thyroid TB is easily diagnosed by fine needle aspiration cytology. The majority of cases require only antitubercular drugs for treatment, and surgical intervention is required only in few patients. We here describe a case of thyroid TB presenting as an acute abscess in postrenal transplant recipient with a background of acute rejection treated with steroid and antithymocyte globulin.

A novel missense mutation in the FGB gene (p.Gly302Arg) leading to afibrinogenemia. Predicted structure and function consequences

Afibrinogenemia represents the rarest form of fibrinogen deficiency. Causative missense mutations occur rarely and may improve the understanding of fibrinogen structure and function.

PATIENTS AND METHODS

The propositus was a 26-year-old Argentinian with afibrinogenemia. FGA, FGB and FGG exons and flanking regions were screened by sequencing and the mutant protein was analyzed in silico.

RESULTS

A novel missense mutation in the FGB gene (Bbeta Gly272Arg, p.Gly302Arg) was identified. In silico analysis revealed its location in a highly conserved region, which preserves the core fold of the C-terminal beta-chain and is important for proper secretion. A substitution by a positively charged large Arg residue in this area would most likely disturb the core fold by additional interactions with adjacent residues (p.Asp291, p.Asp297, p.Asp311), or by forming of non-native interactions with other proteins, thereby hindering the action of molecular chaperones. Both alternatives would disturb the regular secretion of the beta-chain.

CONCLUSIONS

The novel missense mutation in the FGB gene causes afibrinogenemia most probably by affecting the secretion of the fibrinogen beta-chain.

Combined coagulation factor VIII and factor IX deficiency (CDF8F9) in a patient from Lithuania

Haemophilia A (FVIII deficiency) and haemophilia B (FIX deficiency) are X-linked inherited bleeding disorders. It is a very rare event to identify both haemophilias in the same patient. So far, only two families with such combination are reported in the literature worldwide supported by genetic background.

PATIENTS AND METHODS

Evaluation of clinical data, determination of FVIII and FIX levels and genetic analysis of F8 and F9 genes by direct sequencing.

RESULTS

We report on a patient having severe haemophilia B (FIX:C <1 IU dl^-1) and mild haemophilia A (FVIII:C 18 IU dl^-1 ). FIX deficiency was known since childhood, whereas mild haemophilia A was confirmed at the age of 42 due to unexpected bleeding complications after dental extraction despite adequate substitution with plasma derived FIX concentrate. F9 gene analysis showed a point mutation in exon 2 (c.223C>T, p.R75X), whereas F8 gene analysis revealed a point mutation in exon 4 (c.545A>C, p.D182A). The mother of the patient was heterozygous for F8 mutation, but not for F9 mutation suggesting a de novo F9 mutation. Accidentally, further family from Germany with mild Haemophilia A was identified to have the same F8 mutation. F8 Haplotype analysis revealed that the p.D182A mutation most likely represents a founder mutation with common ancestors of the German and the Lithuanian family.

CONCLUSIONS

Our results confirm the rare event of Haemophilia A and haemophilia B in the same patient originating from two distinct genetic defects in F8 and F9 genes.

Chemoradiotherapy for squamous cell anal carcinoma: a review of prognostic factors

AIM

Previous literature has sought prognostic factors for the survival of anal cancer patients. The present study aimed to determine prognostic factors for local disease recurrence, distant metastasis and survival for patients treated with radical chemoradiotherapy (CRT) at the Rosemere Cancer Centre, Preston, UK.

METHOD

Patients treated with CRT for nonmetastatic squamous cell anal cancer between September 2000 and January 2013 were studied. Kaplan-Meier and Cox regression analysis assessed the prognostic value of age, sex, tumour size, the proportion of the anal canal circumference involved (ACCI), nodal disease, tumour location and pretreatment haemoglobin.

RESULTS

One hundred and 48 patients with a mean age of 63 years were studied, of whom 15% suffered local disease recurrence and 10% developed distant metastasis. The 5-year overall and cancer-specific survival rates were 84% and 86%, respectively. Predictors of local recurrence were tumour size >5 cm and over two-thirds ACCI (P < 0.01). Predictors of distant metastasis and poor survival were tumour size >5 cm (P < 0.01), node positive disease on imaging (P < 0.05), over two-thirds ACCI (P < 0.01) and a pretreatment haemoglobin level below 130 g/l (P < 0.05). Multivariate analysis found large tumour size to be the most significant factor for local recurrence (P = 0.002) and survival (P = 0.02) whilst over two-thirds ACCI was most predictive of distant metastasis (P < 0.001). Age, gender, palpable lymph nodes and tumour location were not of prognostic value for local disease recurrence, distant metastasis or survival.

CONCLUSION

Tumour size, nodal disease, over two-thirds ACCI and low pretreatment haemoglobin confer poorer prognostic and survival outcomes. Use of intensity-modulated radiation therapy may allow greater radiation doses to be given for locally advanced tumours, thus improving local control and survival and reducing morbidity.

Custom-made silicone hand prosthesis: A case study

Up to now, a cosmetic glove was the most common method for managing transmetacarpal (TMC) and carpometacarpal (CMC) amputations, but it is devoid of markings and body color. At this amputation level, it is very difficult to fit a functional prosthesis because of the short available length, unsightly shape, grafted skin, contracture and lack of functional prosthetic options. A 30-year-old male came to our clinic with amputation at the 1st to 4th carpometacarpal level and a 5th metacarpal that was projected laterally and fused with the carpal bone. The stump had grafted skin, redness, and an unhealed suture line. He complained of pain projected over the metacarpal and suture area. The clinical team members decided to fabricate a custom-made silicone hand prosthesis to accommodate the stump, protect the grafted skin, improve the hand's appearance and provide some passive function. The custom silicone hand prosthesis was fabricated with modified flexible wires to provide passive interphalangeal movement. Basic training, care and maintenance instructions for the prosthesis were given to the patient. The silicone hand prosthesis was able to restore the appearance of the lost digits and provide some passive function. His pain (VAS score) was reduced. Improvement in activities of daily living was found in the DASH questionnaire and Jebsen-Taylor Hand Function test. A silicone glove is a good option for more distal amputations, as it can accommodate any deformity, protect the skin, enhance the appearance and provide functional assistance. This case study provides a simple method to get passively movable fingers after proximal hand amputation.

Accuracy of ultrasound dating formulae in the late second-trimester in pregnancies conceived with in-vitro fertilization

Purpose: To investigate the accuracy of ultrasound dating formulae in the late second trimester of pregnancy.

Material and Methods: A dataset of 136 singleton pregnancies conceived by artificial reproductive techniques was studied to assess the accuracy of ultrasound dating formulae in the late second trimester, and compared with early second trimester. A total of 21 published ultrasound-dating formulae were tested.

Results: For most formulae, late second trimester scans yielded results that were marginally less accurate than the early second trimester. The best performance was obtained with dating formulae based on femur length, either alone or combined with the biparietal diameter. These formulae had mean absolute errors of 3–3.5 days. Combining two or more parameters did not result in any substantial gain in accuracy.

Conclusions: Pregnancy dating by ultrasound in the late second trimester is sufficiently accurate for routine clinical use. Formulae based on femur length appear to be at least as accurate as head measurements.

Composition dependence of charge and magnetic length scales in mixed valence manganite thin films

Mixed-valence manganese oxides present striking properties like the colossal magnetoresistance, metal-insulator transition (MIT) that may result from coexistence of ferromagnetic, metallic and insulating phases. Percolation of such phase coexistence in the vicinity of MIT leads to first-order transition in these manganites. However the length scales over which the electronic and magnetic phases are separated across MIT which appears compelling for bulk systems has been elusive in (La_1−yPr_y)_1−xCa_xMnO₃ films. Here we show the in-plane length scale over which charge and magnetism are correlated in (La_0.4Pr_0.6)_1−xCa_xMnO₃ films with x = 0.33 and 0.375, across the MIT temperature. We combine electrical transport (resistance) measurements, x-ray absorption spectroscopy (XAS), x-ray magnetic circular dichroism (XMCD), and specular/off-specular x-ray resonant magnetic scattering (XRMS) measurements as a function of temperature to elucidate relationships between electronic, magnetic and morphological structure of the thin films. Using off-specular XRMS we obtained the charge-charge and charge-magnetic correlation length of these LPCMO films across the MIT. We observed different charge-magnetic correlation length for two films which increases below the MIT. The different correlation length shown by two films may be responsible for different macroscopic (transport and magnetic) properties.