A regionally based precision medicine implementation initiative in North Africa:The PerMediNA consortium

Precision Medicine is being increasingly used in the developed world to improve health care. While several Precision Medicine (PM) initiatives have been launched worldwide, their implementations have proven to be more challenging particularly in low- and middle-income countries. To address this issue, the "Personalized Medicine in North Africa" initiative (PerMediNA) was launched in three North African countries namely Tunisia, Algeria and Morocco. PerMediNA is coordinated by Institut Pasteur de Tunis together with the French Ministry for Europe and Foreign Affairs, with the support of Institut Pasteur in France. The project is carried out along with Institut Pasteur d'Algérie and Institut Pasteur du Maroc in collaboration with national and international leading institutions in the field of PM including Institut Gustave Roussy in Paris. PerMediNA aims to assess the readiness level of PM implementation in North Africa, to strengthen PM infrastructure, to provide workforce training, to generate genomic data on North African populations, to implement cost effective, affordable and sustainable genetic testing for cancer patients and to inform policy makers on how to translate research knowledge into health products and services. Gender equity and involvement of young scientists in this implementation process are other key goals of the PerMediNA project. In this paper, we are describing PerMediNA as the first PM implementation initiative in North Africa. Such initiatives contribute significantly in shortening existing health disparities and inequities between developed and developing countries and accelerate access to innovative treatments for global health.

Insights from the SNP analysis of TYMP gene linking MNGIE

TYMP gene, which codes for thymidine phosphorylase (TP) is also known as platelet-derived endothelial cell growth factor (PD-ECGF). TP plays crucial roles in nucleotide metabolism and angiogenesis. Mutations in the TYMP gene can lead to Mitochondrial Neurogastrointestinal Encephalopathy (MNGIE) syndrome, a rare genetic disorder. Our main objective was to evaluate the impact of detrimental non-synonymous single nucleotide polymorphisms (nsSNPs) on TP protein structure and predict harmful variants in untranslated regions (UTR). We employed a combination of predictive algorithms to identify nsSNPs with potential deleterious effects, followed by molecular modeling analysis to understand their effects on protein structure and function. Using 13 algorithms, we identified 119 potentially deleterious nsSNPs, with 82 located in highly conserved regions. Of these, 53 nsSNPs were functional and exposed, while 79 nsSNPs reduced TP protein stability. Further analysis of 18 nsSNPs through 3D protein structure analysis revealed alterations in amino acid interactions, indicating their potential impact on protein function. This will help in the development of faster and more efficient genetic tests for detecting TYMP gene mutations.

Novel pathogenic WHRN variant causing hearing loss in a moroccan family

OBJECTIVES

The most prevalent sensory disease in humans is deafness. A variety of genes have been linked to hearing loss, which can either be isolated (non-syndromic) or associated with lesions in other organs (syndromic). It has been discovered that WHRN variants are responsible for non-syndromic hearing loss and Usher syndrome type II.

METHODS AND RESULTS

Exome sequencing in a consanguineous Moroccan patient with severe hearing loss identified a single homozygous mutation c.619G > T; p.Ala207Ser in WHRN, encoding a cytoskeletal scaffold protein that binds membrane protein complexes to the cytoskeleton in ocular photoreceptors and ear hair cell stereocilia. Bioinformatics methods and molecular dynamic modeling were able to predict the pathogenic implications of this variation.

CONCLUSION

We used whole exome sequencing to find a homozygous WHRN gene variant in a Moroccan family. Numerous bioinformatics methods predict that this modification might result in a change in the WHRN protein's structure.

Computational study of the potential impact of AURKC missense SNPs on AURKC-INCENP interaction and their correlation to macrozoospermia

Aurora Kinase C (AURKC) is considered an important element in Chromosome Passenger Complex (CPC), its interaction with Inner Centromere Protein (INCENP) plays a critical role in the establishment and the recruitment of a stable CPC during spermatogenesis. Genetic variations of AURKC gene are susceptible to impact AURKC-INCENP interaction, which may affect CPC stability and predispose male subjects to macrozoospermia. In this study, we systematically applied computational approaches using different bioinformatic tools to predict the effect of missense SNPs reported on AURKC gene, we selected the deleterious ones and we introduced their corresponding amino acid substitutions on AURKC protein structure. Then we did a protein-protein docking between AURKC variants and INCENP followed by a structural assessment of each resulting complex using PRODIGY server, Yassara view, Ligplot + and we choose the complexes of the most impactful variants for molecular dynamics (MD) simulation study. Seventeen missense SNPs of AURKC were identified as deleterious between all reported ones. All of them were located on relatively conserved positions on AURKC protein according to Consurf server. Only the four missense SNPs; E91K, D166V, D221Y and G235V were ranked as the most impactful ones and were chosen for MD simulation. D221Y and G235V were responsible for the most remarkable changes on AURKC-INCENP structural stability, therefore, they were selected as the most deleterious ones. Experimental studies are recommended to test the actual effect of these two variants and their actual impact on the morphology of sperm cells.Communicated by Ramaswamy H. Sarma.

RANDOMIZED COMPARATIVE STUDY OF DEFINITIVE EXTERNAL FIXATION VERSUS ORIF IN PILON FRACTURES: AN EARLY CLINICAL OUTCOME REPORT

Repairing Pilon fractures remains challenging. ORIF allows direct anatomical reduction, but at the expense of soft tissues dissection which are associated with recovery. On the other hand, External Fixation allows indirect reduction and causes less soft tissue damage. However, a few studies conclude that External Fixation is associated with high rates of malunion.The objectives were to evaluate and compare: primary outcome measure: ankle hindfoot function (AOFAS at 9 months) and secondary outcome measures: quality of reduction, bone union, arthritic changes, other potential complications and ultimately the optimum management for pilon fractures.A prospective randomized comparative clinical study. 40 Patients were included in the study with comminuted closed Pilon fracture. Patients were randomized by closed envelope technique into two groups: Group (1) Included 20 patients managed by external fixation with limited internal fixation. Group (2) Included 20 patients managed by open reduction and internal fixation. Skeletally immature, type 43A AO/OTA, Open fractures, compartment syndrome, Pathological fractures were excluded.There was no significant difference between External fixation and ORIF as methods of fixation for Pilon fracture in the functional activity of the patient after 9 months as evidenced by AOFAS score (P=0.547) and the development of complications (P=0.227). However, there was statistically significant difference (P<0.001) regarding the time to weight bearing between both groups, and statistically significant difference (P=0.042) regarding time to union.The best surgical modality to treat Pilon fractures is still debatable. While external fixation is used by many to avoid major complications, it has been associated with high rates of malunion, and osteoarthritis.

Homozygous Missense Variants in FOXI1 and TMPRSS3 Genes Associated with Non-syndromic Deafness in Moroccan Families

One of the most prevalent sensorineural disorders, autosomal recessive non-syndromic hearing loss (ARNSHL) which can affect all age groups, from the newborn (congenital) to the elderly (presbycusis). Important etiologic, phenotypic, and genotypic factors can cause deafness. So far, the high genetic variability that explains deafness makes molecular diagnosis challenging. In Morocco, the GJB2 gene is the primary cause of non-syndromic hereditary deafness, while the existence of a variant in the LRTOMT gene is the second cause of this condition. After excluding these two frequently occurring GJB2 and LRTOMT variants, whole-exome sequencing was carried out in two Moroccan consanguineous families with hearing loss. As a result, two novel variants in the TMPRSS3 (c.1078G>A, p. Ala 360Thr) and FOXI1 (c.6C>G, p. Ser 2Arg) genes have been discovered in deaf patients and the pathogenic effect has been anticipated by several bioinformatics and molecular modeling systems. For the first time, these variants are identified in the Moroccan population, showing the population heterogeneity and demonstrating the value of the WES in hearing loss diagnosis.

A case report of two Moroccan patients with hereditary neurological disorders and molecular modeling study on the S72L de novo PMP22 variant

Hereditary neurological disorders represent a wild group of hereditary illnesses affecting mainly the nervous system, the majority of which have a Mendelian inheritance pattern. Here we present the case of two Moroccan patients each affected by a different hereditary neurological disorder. In the first patient WES analysis revealed the presence of the p.Ser72Leu de novo mutation in the PMP22 gene reported for the first time in Africa, specifically in Morocco. This variant is predicted to be in a mutation "hot-spot" region causing Dejerine-Sottas syndrome called also Charcot-Marie-Tooth type 3. The molecular modeling study suggests an important alteration of hydrogen and hydrophobic interactions between the residue in position 72 of the PMP22 protein and its surrounding amino acids. On the other hand, the p.Ala177Thr mutation on the RNASEH2B gene, responsible of Aicardi-Goutières syndrome 2, was carried in a homozygous state by the second patient descending from a consanguineous family. This mutation is common among the Moroccan population as well as in other North African countries. The present results contributed to a better follow-up of both cases allowing better symptom management with convenient treatments.

Genetic Association of LEP Gene Polymorphisms with Obesity in Moroccan Individuals: Case-Control Study and Updated Meta-analysis

Obesity is a global epidemic disease representing the fifth leading cause of death in the world. It was shown that it is caused by the interaction between environmental factors and genes including leptin gene (LEP). This paper aimed to analyze the association between the LEP gene polymorphisms rs7799039 and rs11761556 with obesity in Moroccan individuals as well as to perform an update meta-analysis of this genetic association. Both polymorphisms were genotyped in 146 obesity patients and 104 controls using real-time PCR technique. The genetic association analysis and the comparison of quantitative parameters were carried out using the R language. Moreover, a meta-analysis including 20 genetic association studies was performed using Review Manager 5.3 software. No significant association was found between the polymorphisms rs7799039 and rs11761556 and the risk of obesity. The comparison of biochemical and clinical parameters between the genotypes of the rs7799039 polymorphism, showed a significant increased triglycerides levels in carriers of AA or GA genotypes (P value = 0.040). The meta-analysis showed no significant association between the rs7799039 polymorphism and obesity under all genetic models. In conclusion, the case-control study and meta-analysis demonstrated that the LEP gene polymorphisms rs7799039 and rs11761556 cannot be considered as genetic risk factors for obesity.

Exploring the impact of CYP11A1's missense SNPs on the interaction between CYP11A1 and cholesterol: A comprehensive structural analysis and MD simulation study

The process of steroidogenesis plays a vital role in human physiology as it governs the biosynthesis of mineralocorticoids, glucocorticoids, and androgens. These three classes of steroid hormones are primarily produced in the adrenal and gonadal glands through steroidogenesis pathways. Initiated by the side chain cleavage of cholesterol (CLR), this process leads to the conversion of cholesterol into pregnenolone and isocaproic aldehyde. The enzyme CYP11A1, encoded by the CYP11A1 gene, plays a key role in catalyzing the side chain cleavage of CLR. Several single nucleotide polymorphisms (SNPs) have been identified in the CYP11A1 gene, which may predispose carriers to disorders associated with abnormal steroidogenesis. Specifically, missense SNPs in the CYP11A1 gene have the potential to negatively impact the interaction between CYP11A1 and CLR, thus affecting the overall metabolome of steroid hormones. In this computational study, we focused on a specific set of missense SNPs reported in the CYP11A1 gene, aiming to identify variants that directly impact the interaction between CYP11A1 and CLR. The three-dimensional structure of the CYP11A1-CLR complex was obtained from the RCSB Protein Data Bank, while missense SNPs in the CYP11A1 gene were retrieved from Ensembl. To predict the most deleterious variants, we utilized the ConSurf server, SIFT, and PolyPhen. Furthermore, we assessed the impact of induced amino acid (AA) substitutions on the CYP11A1-CLR interaction using the PRODIGY server, PyMol, and Ligplot programs. Additionally, molecular dynamics (MD) simulations were conducted to analyze the effects of deleterious variants on the structural dynamics of the CYP11A1-CLR complex. Among the 8096 retrieved variants, we identified ten missense SNPs (E91K, W147G, R151W, R151Q, S391C, V392M, Q395K, Q416E, R460W, and R460Q) as deleterious for the interaction between CYP11A1 and CLR. MD simulations of the CYP11A1-CLR complexes carrying these deleterious AA substitutions revealed that Q416E, W147G, R460Q, and R460W had the most pronounced impacts on the structural dynamics of the complex. Consequently, these missense SNPs were considered the most deleterious ones. Further functional tests are recommended to assess the impact of these four missense SNPs on the enzymatic activity of CYP11A1. Moreover, Genome-Wide Association Studies (GWAS) should be conducted to determine the significance of their association with abnormal steroidogenesis diseases in various patient groups.

Molecular docking analysis of PPARγ with phytochemicals from Moroccan medicinal plants

PPARγ agonists play a crucial role in regulating metabolic homeostasis for treating type-2 diabetes (T2D). Due to the adverse side effects associated with thiazolidinediones, a class of PPARγ agonists, there is a growing interest in identifying natural compounds from medicinal plants that have the potential to bind PPARγ. In this study, we extensively investigated Moroccan phytochemicals using computational structure-based screening with the crystal structure of the PPARγ ligand-binding domain (PDB ID: 7awc) to discover novel phytochemicals targeting PPARγ. The docking results of 540 Moroccan phytochemicals were integrated into online databases for further exploitation through in-depth studies. Drug-likeness analysis was performed to assess the phytochemicals drug-like properties. Two promising phytochemicals, 3,4-dicaffeoylquinic acid and Chlorogenic acid, were identified, both exhibiting high docking affinity and unique binding site interactions compared to the established PPARγ full agonist, rosiglitazone. Molecular dynamics simulations of 100 ns were conducted to examine the stability of the complexes formed by both compounds within the PPARγ active site, and their dynamic behavior was compared to the reference structure of PPARγ alone and with rosiglitazone. Binding free energy calculations demonstrated that 3,4-dicaffeoylquinic acid and Chlorogenic acid exhibited higher binding free energy than the reference agonist, suggesting their potential as candidates for experimental validation in future drug discovery efforts targeting PPARγ for the treatment of T2D and metabolic syndrome.

Current concepts in the management of radial head fractures: a national survey and review of the literature

INTRODUCTION

This study aims to report on current practice in the management of radial head fractures (RHFs) in the United Kingdom and to review the literature to identify areas for future investigation.

METHODS

A 12-question online survey was sent to 500 surgeon members of the British Elbow and Shoulder Society in 2021. Questions focused on clinical assessment, indications for surgical treatment and willingness to participate in future studies. Descriptive statistical analysis summarised the responses.

RESULTS

The response rate was 20.4% (n = 102). For minimally displaced RHFs, non-operative management with immediate mobilisation was reported by 90.2% (n = 92) as opposed to 9.8% (n = 10) for initial immobilisation in plaster or brace. The most cited indication for radial head arthroplasty as opposed to fixation was increased patient age or low functional demand in 69.9% of responses (n = 71). In total, 41.2% (n = 42) indicated the need for a future randomised controlled trial (RCT) concerning the management of RHF. Only five RCTs were returned by the literature review.

DISCUSSION

There is considerable variability in the management of RHF among an experienced cohort of surgeons. With the interest declared by the participating surgeons, there is a call for a well-designed sufficiently powered RCT.

In silico exploration and molecular dynamics of deleterious SNPs on the human TERF1 protein triggering male infertility

By limiting chromosome erosion and end-to-end fusions, telomere integrity is critical for chromosome stability and cell survival. During mitotic cycles or due to environmental stresses, telomeres become progressively shorter and dysfunctional, thus triggering cellular senescence, genomic instability and cell death. To avoid such consequences, the telomerase action, as well as the Shelterin and CST complexes, assure the telomere's protection. Telomeric repeat binding factor 1 (TERF1), which is one of the primary components of the Shelterin complex, binds directly to the telomere and controls its length and function by regulating the telomerase activity. Several reports about TERF1 gene variations have been associated with different diseases, and some of them have linked these variations to male infertility. Hence, this paper can be advantageous to investigate the association between the missense variants of the TERF1 gene and the susceptibility to male infertility. The stepwise prediction of SNPs pathogenicity followed in this study was based on stability and conservation analysis, post-translational modification, secondary structure, functional interaction prediction, binding energy evaluation and finally molecular dynamic simulation. Prediction matching among the tools revealed that out of 18 SNPs, only four (rs1486407144, rs1259659354, rs1257022048 and rs1320180267) were predicted as the most damaging and highly deleterious SNPs affecting the TERF1 protein and its molecular dynamics when interacting with the TERB1 protein by influencing the function, structural stability, flexibility and compaction of the overall complex. Interestingly, these polymorphisms should be considered during genetic screening so they can be used effectively as genetic biomarkers for male infertility diagnosis.Communicated by Ramaswamy H. Sarma.

Use of photosensitizers activated by photodynamic therapy on the canal disinfection of radicular dentin bonded to Dimethacrylate-based glass fiber post: an assessment of pushout bond strength

OBJECTIVE

The present lab-based investigation aimed at evaluating the canal disinfectants using photodynamic therapy (PDT) using different photosensitizers, conventional NaOCl, a mixture of doxycycline, citric acid, and a detergent (MTAD) and their impact on the bond strength of glass fiber post to radicular dentin.

MATERIALS AND METHODS

Forty extracted human premolars were gathered and disinfected. The decoration was performed up to the cementoenamel junction. Using the crown down technique cleaning of the canal was done following rinse with distilled water. All canals were dried with paper points and obturated with gutta-percha. Post space was prepared using peso reamers and samples were randomly allocated into four groups following different disinfection regimes: Group 1 - Methylene blue photosensitizer (MBP) + MTAD; Group 2 - RBP (Rose Bengal photosensitizer) + MTAD; Group 3 - CP (curcumin photosensitizer) + MTAD and Group 4 - 2.25% NaOCl + MTAD (control). Following disinfection, the canals were dried and the post was placed and cemented within the canal. Samples were dissected at coronal, middle, and apical third and placed in a universal testing machine for push-out bond strength (PBS). Debonded surfaces were evaluated for failure modes. PBS was examined using a one-way analysis of variance (ANOVA). The means of PBS were compared using Tukey multiple comparison tests with a significance threshold of (p<0.05).

RESULTS

Group 3 canals disinfected with CP and MTAD had the highest PBS at two levels: cervical (9.57±1.21 MPa), middle (6.37±0.79 MPa), and group 2 canal space disinfected by RBP and MTAD had the maximum PBS in apical portion (5.35±0.42 MPa). No significant difference at all root levels between group 2 (RBP + MTAD) and group 3 (p>0.05). Canal irrigation with group 1 (MBP + MTAD) and group 4 control (2.25% NaOCl + MTAD) exhibited comparable PBS at all three levels of the root.

CONCLUSIONS

CP, MTAD, RBP and MTAD for canal disinfection and bonding of glass fiber post to radicular dentin demonstrated comparable bond values at all three root levels and can be recommended in clinical settings after further investigations.

Association between G2677T/A polymorphism in ABCB1 gene and the risk of drug resistance epilepsy: An updated systematic review and meta-analysis

PURPOSE

Epilepsy is a common serious brain condition characterized by the abnormal electrical activity of neurons. In most cases, epileptic patients respond to antiepileptic drugs. Approximately, one-third of patients prove medically intractable. The ABCB1 gene is a superfamily of ATP-binding cassette (ABC) transporters that encode a drug-transport protein, lead to cells and organs protects and eliminates toxic agents. We performed this meta-analysis to assess the association between G2677T/A in the ABCB1 gene and the risk of drug resistance in epileptic patients.

METHODS

Two online libraries (PubMed and Scopus) were used to identify studies that report the relationship between G2677T/A polymorphism in the MDR1 gene and the risk of antiepileptic drug resistance. The meta-analysis was performed using Review Manager 5.3 software. The pooled odds ratios and 95 % confidence intervals (CIs) were calculated using a random or fixed effects model according to the heterogeneity between studies.

RESULTS

A total of 33 eligible studies were included in this meta-analysis which 4192 patients were drug-resistant and 5079 patients were drug-responsive. As a result, a significant association was observed in overall population for the genetic model GG+GA vs AA (OR with 95 % CI = 0,56 [0.34,0.93]; P = 0.02). The subgroup ethnicity analysis showed a significant decrease in the risk of AEDs resistance in the Caucasian population.

CONCLUSION

In conclusion, our analysis demonstrates that G2677T/A polymorphism in the ABCB1 gene decreases the risk of drug resistance. More studies are needed in the different ethnic groups to clarify the role of polymorphism in AEDs resistance.

Clinical and genetic spectrums of 413 North African families with inherited retinal dystrophies and optic neuropathies

Background

Inherited retinal dystrophies (IRD) and optic neuropathies (ION) are the two major causes world-wide of early visual impairment, frequently leading to legal blindness. These two groups of pathologies are highly heterogeneous and require combined clinical and molecular diagnoses to be securely identified. Exact epidemiological studies are lacking in North Africa, and genetic studies of IRD and ION individuals are often limited to case reports or to some families that migrated to the rest of the world. In order to improve the knowledge of their clinical and genetic spectrums in North Africa, we reviewed published data, to illustrate the most prevalent pathologies, genes and mutations encountered in this geographical region, extending from Morocco to Egypt, comprising 200 million inhabitants.

Main body

We compiled data from 413 families with IRD or ION together with their available molecular diagnosis. The proportion of IRD represents 82.8% of index cases, while ION accounted for 17.8%. Non-syndromic IRD were more frequent than syndromic ones, with photoreceptor alterations being the main cause of non-syndromic IRD, represented by retinitis pigmentosa, Leber congenital amaurosis, and cone-rod dystrophies, while ciliopathies constitute the major part of syndromic-IRD, in which the Usher and Bardet Biedl syndromes occupy 41.2% and 31.1%, respectively. We identified 71 ION families, 84.5% with a syndromic presentation, while surprisingly, non-syndromic ION are scarcely reported, with only 11 families with autosomal recessive optic atrophies related to OPA7 and OPA10 variants, or with the mitochondrial related Leber ION. Overall, consanguinity is a major cause of these diseases within North African countries, as 76.1% of IRD and 78.8% of ION investigated families were consanguineous, explaining the high rate of autosomal recessive inheritance pattern compared to the dominant one. In addition, we identified many founder mutations in small endogamous communities.

Short conclusion

As both IRD and ION diseases constitute a real public health burden, their under-diagnosis in North Africa due to the absence of physicians trained to the identification of inherited ophthalmologic presentations, together with the scarcity of tools for the molecular diagnosis represent major political, economic and health challenges for the future, to first establish accurate clinical diagnoses and then treat patients with the emergent therapies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02340-7.

A homozygous nonsense HECW2 variant is associated with neurodevelopmental delay and intellectual disability

Intellectual disability is characterized by a significant impaired intellectual and adaptive functioning, affecting approximately 1-3% of the population, which can be caused by a variety of environmental and genetic factors. In this respect, de novo heterozygous HECW2 variants were associated recently with neurodevelopmental disorders associated to hypotonia, seizures, and absent language. HECW2 encodes an E3 ubiquitin-protein ligase that stabilizes and enhances transcriptional activity of p73, a key factor regulating proliferation, apoptosis, and neuronal differentiation, which are together essential for proper brain development. Here, using whole exome sequencing, we identified a homozygous nonsense HECW2 variant: c.736C > T; p.Arg246* in a proband from a Moroccan consanguineous family, with developmental delay, intellectual disability, hypotonia, generalized tonico-clonic seizures and a persistent tilted head. Thus this study describes the first homozygous HECW2 variant, inherited as an autosomal recessive pattern, contrasting with former reported de novo variants found in HECW2 patients.

The correlation between coronary artery disease and left ventricular filling pressure: which correlates more LVEDP or LV pre-A wave?

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital and Uneversity Heart Surgery Center, Damascus, Syrian Arab Republic.

Background

Coronary artery disease (CAD) affects left ventricular (LV) systolic and diastolic function. This  results in high filling pressure which expressed by different waves and may be assessed by invasive and noninvasive methods. Validation and comparing the correlation between CAD and different LV filling pressure waves may add a step forward in CAD diagnosis, prognosis and treatment.

Purpose

This study invasively validates the correlation between coronary artery disease (CAD) and left ventricular end-diastolic pressure (LVEDP) as well as left ventricular pre-A wave (LV pre-A wave) and compare the results.

Methods

124 patients who accepted to participate for this study underwent left heart catheterization for medical indications. This study obtained the results of LV filling pressures (LVEDP and LV pre-A wave), as well as, coronary angiography results with assessing the severity and extents (if CAD presents) by vessels number and Gensini Score (GS). Spearman r correlation were used for continuous/continuous or continuous/ordinal variables and Chi square test for nominal/nominal variables. Then we compared the results.

Results

CAD presence with elevated LVEDP incidence (OR = 4.29, relative risk = 1.85 P = 0.0123). Vessel number, plaque number and Gensini score correlations with LVEDP were (P = 0.0038 r = 0.34, P = 0.0002 r = 0.44, p = 0.0002 r = 0.43 and p = 0.0622 r = 0.22) respectively. In the same way, CAD presence with LV pre-a wave (OR = 2.75, relative risk = 1.5, P = 0.0447). Vessels number, plaque numbers and Gensini score relations with LV pre-A wave were (P = 0.0379 r = 0.23, P = 0.0004 r = 0.39, p = 0.0002 r = 0.40 and p = 0.0568 r = 0.21) respectively. All the results are summarized in Tables (1 + 2+3).

Conclusions

LV filling pressure had a significant correlation with CAD presence, vessel number and plaque number but it did not have a correlation with Gensini score. LVEDP had a stronger correlation with CAD presence, severity, sensitivity and extent but lower specificity than LV pre-A wave. Abstract Tables of results (1 + 2)  Abstract Table of result 3

A check of the grading system among the 2009 and 2016 EACVI/ASE left ventricular diastolic function guidelines statistically and invasively

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital and University Heart Surgery Center in Damascus, Syrian Arab Republic.

Background

Left ventricular diastolic function assessment undergoes continuous updates. EACVI/ASE 2016 guidelines handles with this case, which is an expert consensus and simplified update of the 2009 recommendations. As stated in the latest guidelines, studies need to check that the simplicity does not affect much the accuracy.

Aim

This study compares the corresponding subgroups between the 2009 and 2016 EACVI/ASE guidelines, for the assessment of left ventricular diastolic function statistically. Furthermore, it invasively validates of the relation between the grading results of each guidelines and  the measured LV filling pressure during catheterization lab.

Methods

124 patients underwent transthoracic echocardiography just before angiography. A trained echo cardiographer obtained E/A mitral flow, Av E/e", LAVI, TR, septal and lateral e" and other supportive parameters to assess LV diastolic function and filling pressure according to 2009 and 2016 EACVI/ASE guidelines algorithms and we compared the results with LV pre-a wave during catheterization with a cut-off &gt;12mmhg considered elevated.

Results

EACVI/ASE 2016 resulted in {normal (46.77%), Grade I (29.03%), Grade II (10.48%), Grade III  (7.26%) and indeterminate (6.45%)}, while EACVI/ASE 2009 resulted in {normal (39.52%), Grade I (25%), Grade II (13.71%), Grade III  (7.26%) and indeterminate (14.52%)} with no statically significant difference between subgroups. EACVI/ASE 2016 vs. 2009 in assessment LV filling pressure (odds ratio =0.51 and p value = 0.034. EACVI/ASE 2016 sensitivity and specificity were (0.36, 0.94 ) respectively and EACVI/ASE 2009 sensitivity and specificity were (0.63, 0.80) respectively. All results are summarized in (tables: 1 + 2+3 + 4+5 + 6).

Conclusion

This study found that the updated and simplified 2016 EACVI/ASE guidelines algorithm did not affect statistically the grading results of 2009 EACVI/ASE. Even more, 2016 had a higher relation between diastolic subgroups and invasively measured LV filling pressure which reflects the higher specificity than 2009. On the other hand 2016 was less able to detect elevated LV filling pressure which reflects a lower sensitivity than 2009. 2016 was more specific but less sensitive than 2009. There were no statistically significant difference between the means of invasively measured LV filling pressures among both guidelines. Abstract Figure.  Abstract Figure.

Invasive validation of the different echo parameters and cut-offs among the trilogy of left ventricular filling pressure assessment guidelines: EACVI/ASE 2016, ESC 2016, HFA 2019

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital and University Heart Surgery Center in Damascus, Syrian Arab Republic.

Background

Left ventricular filling pressure assessment is a challenge. Three guidelines concerned about this are: EACVI/ASE 2016, ESC 2016 and the HFA 2019 guidelines. Echo assessment is a corner stone in their algorithms with different cutoffs and different parameters used depending on expert consensus that should be validated in an invasive manner as the authors stated.

Aims

This study validates and tests the accuracy of the different cutoffs and parameters used in echo LV filling pressure assessment in the three guidelines: EACVI/ASE 2016, ESC 2016 and HFA 2019 by direct measure in the catheterization lab.

Methods

82 patients with EF ≥ 50%, signs and symptoms of HF underwent transthoracic echocardiography immediately before catheterization. Av E/e", TR, LAVI, LVMI, RWT, LV wall thickness, Septal, lateral and mean e" were used to assess LV filling pressure with respect to EACVI/ASE 2016, ESC 2016 and HFA guidelines algorithms" different cutoffs and  parameters used. This study used LV pre-A wave with a cutoff &gt;12mmhg defined high as a reference and then we compared the results.

Results

all the results of functional and structural echo parameters" diagnostic criteria (sensitivity, specificity, NPV, PPV and accuracy) are summarized in (Table:1 + 2).

Conclusion

From an echo view, each algorithm depends on  modest to high specific but low to modest sensitive echo parameters. There is no single parameter makes a guidelines superior to others. Although that the fact of combining more echo indices make the diagnosis and eventually the algorithm more reliable as in HFA 2019, that was for the cost of simplicity and ease of application. Av E/e"&gt;13 was the best cutoff (ESC 2016). Orientation for the cause of use (sensitivity, specificity, NPV or PPV) should employ the echo indices and cutoffs in best benefit, as for mitral (e"), although that septal &lt; 7 and lateral e"&lt;10 (EACVI/ASE 2016 and HFA 2019) had an overall more accuracy than mean e"&lt;9 (ESC 2016), sub analysis showed that the first is better used for specificity and NPV but the latter better for sensitivity and PPV. Same idea for LVMI≥145/122 (m/f)+RWT &gt; 0.42 (HFA 2019 major criteria) which had more specificity than LVMI≥115/95 (m/F) cutoffs (HFA2019 minor criteria and ESC2016) but in the cost of lower sensitivity, furthermore, sub analysis showed this LVMI high cutoffs were more benefit in female than in men after taking the NPV, PPV and accuracy in consideration. Abstract Figure.  Abstract Figure.

The correlation of ESC 2016 diastolic guidelines with invasively measured left ventricular filling pressure

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital, University Heart Surgery Center in Damascus, Syrian Arab Republic.

Background

left ventricular (LV) diastolic function and filling pressure assessment is a challenge. ESC 2016 diastolic guidelines handles with this issue. Validation of and comparing the correlation between this guidelines and invasively measured different waves may add a step forward in the assessment, prognosis and treatment of LV diastolic function by echo.

Purpose

this study validates of the correlation of ESC 2016 left ventricular filling pressure echo guidelines with invasively measured left ventricular end-diastolic pressure and left ventricular pre-a.

Methods

124 patients who accepted to participate for this study underwent transthoracic echocardiography immediately before left heart catheterization. This study obtained echo parameters to assess LV filling pressure according to ESC 2016 algorithms. It also obtained left ventricular end-diastolic pressure (LVEDP) and LV pre-a waves during catheterization. It analyzed the data and compared the results.

Results

Correlations of grading system (normal, abnormal parameters 1,2 and 3 present) with LV pre-a and LVEDP waves were (P= &lt; 0.0001 r = 0.47, P = 0.0027 r = 0.41), respectively. After excluding group of patients with only one abnormal parameter as indeterminate group, pressure assessment guidelines correlations with the presence of LV pre-a and LVEDP waves were (P = 0.0009 OR = 31.76, p= 0.0170 OR = 36.00), respectively. Means difference of LV pre-a and LVEDP waves between pressure guidelines presence and absence two groups were (LV pre-a: 12.72, 7.52, P &lt; 0.0001and LVEDP: 21.03 10.36, P = 0.0043), respectively. All results are summarized in (Table:1 + 2+3 + 4+5).

Conclusion

ESC 2016 guidelines pressure assessment correlated strongly with both LV pre-a and LVEDP waves which means that the higher the number of abnormal echo parameters is resulted by echo guidelines, the higher the LV pre-a or LVEDP is presented invasively. Different approaches had different diagnostic accuracy, the best specific was cutoff≥ 2 abnormal echo parameters and the best sensitive and overall accuracy was still cutoff≥2 but after excluding only one abnormal echo parameter group as indeterminate group. The difference between means between echo guidelines pressure assessment was more significant statistically in LV pre-a wave than in LVEDP. Abstract Figure. Abstract Figure.

A comparison between left ventricular filling pressure two waves: end-diastolic and pre-a for the correlation with echocardiographic parameters

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital, University Heart Surgery Center Damascus, Syrian Arab Republic.

Background

left ventricular (LV) filling pressure has an important prognostic and therapeutic role. Echocardiography plays an essential noninvasive role in its assessment and diagnosis. Checking of the correlation between echo parameters and different LV filling pressure wave invasively measure may add a step forward in its diagnosis, prognosis and treatment.

Purpose

this study invasively measures left end-diastolic pressure (LVEDP) and left ventricular pre-a wave (LV pre-a wave) and validates the correlation of each wave with echo parameters obtained immediately before angiography.

Methods

124 patients who accepted to participate for this study underwent transthoracic echocardiography just before catheterization. E/A, Av E/e", lateral and septal e", TR. LAVI, S/D, AR-A and other parameters were obtained to validate and compare the correlation with LVEDP and LV pre-a wave.

Results

  Correlation of different echo parameters with LVEDP and LV pre-a wave are summarized in table.

Conclusion

Among these echo parameters of this study, there was a significant correlation between LVEDP and E, E/A, TR, S velocity, S/D, AR duration, AR-A duration and LVMI. LV pre-a wave had a significant correlation with LAVI, EF, FS, Av E/e", E velocity, A velocity, E/A, TR, S velocity, S/D, AR duration, AR-A duration, LVDd, RWT, LVDs and LVMI. LVEDP correlated more than LV pre-a wave with S velocity, S/D, AR duration, AR-A duration and LVMI. LV pre-a wave correlated more than LVEDP with TR and E velocity. E/A was equally correlated with LVEDP and LV pre-a wave. Abstract Table of results 1  Abstract Table of results 2

An echocardiographic algorithm for predicting coronary artery disease: is it time to establish one?

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Al-mouwasat University Hospital and University Heart Surgery Center in Damascus, Syrian Arab Republic.

Background

Coronary artery disease (CAD) is a major clinical issue. CAD affects left ventricular systolic, diastolic function and LV filling pressure. Echocardiography has been known as the best noninvasive way for the assessment of systolic, diastolic function and LV filling pressure. Finding a correlation between CAD and echocardiographic parameters may help in the early assessment, prognosis and treatment of CAD.

Purpose

Finding a correlation between coronary artery disease and echocardiographic parameters with cutoffs to use in a diagnostic algorithm.

Methods

124 patients who accepted to participate for this study underwent transthoracic echocardiography immediately before their medically indicated left heart catheterization . An experienced echo cardiographer obtained mitral flow E velocity, A velocity, E/A, A duration, Av E/e", septal, lateral and mean e", pulmonary veins S velocity, D velocity, S/D, AR velocity, AR duration, AR-A duration, left atrial volume index (LAVI), tricuspid regurgitation (TR), inter ventricular septum (IVS), left inter ventricular diameter (LIVD), posterior wall diameter (PW) and some other echo parameters and assessed LV diastolic function and filling pressure according to EACVI/ASE 2016 guidelines. This study obtained angiography results and then analyzed and compared the results.

Results

Echo parameters that correlated with CAD were: EDT ≥ 160 (P = 0.0012 OR = 5.46), Av E/e" ≥ 7 (P = 0.0066 OR = 3.67), E ≥ 44 cm/s (P = 0.0026 OR = 10.00), A duration &gt; 140 (P = 0.0256 OR = 10.50), E/A ≥ 1 (P = 0.0036 OR = 4.17) and AR duration ≥ 210 (P = 0.0001 OR = 85.00). When Cutoffs ≥ 3 present, the correlation with CAD was (P= &lt; 0.0001 OR = 8.80) with diagnostic accuracy of (sensitivity = 0.76, specificity = 0.74, NPV = 0.68, PPV = 0.81). All the results are summarized in (Picture1:Tables 1 and 2).

Conclusion

Echo parameters (EDT, Av E/e", E velocity, A duration, E/A, AR duration) had strong correlations with the presence of coronary artery disease. The presence of three or more abnormal parameters had a significant diagnostic accuracy for CAD, and the more the abnormal parameters were positive, the higher the specificity and positive predictive value were for the diagnosis of CAD. The presence of only two abnormal parameters had a low specificity for CAD and the presence of 2016 EACVI/ASE diastolic dysfunction correlated with CAD with modest specificity which needs further assessment for the differential diagnosis. Furthermore, one or no abnormal parameters ruled out CAD with strong negative predictive value. Depending on the results of this study we kindly propose a resting echocardiographic algorithm for the diagnosis of CAD in (picture2: a proposed algorithm). Further studies should validate this algorithm and find other echo parameters especially strain echocardiography wether for resting or exercise algorithms. Abstract Tables of results  Abstract Figure. A proposed algorithm

Association of HNF1A gene variants and haplotypes with metabolic syndrome: a case-control study in the Tunisian population and a meta-analysis

BACKGROUND

Variants in the Hepatocyte Nuclear Factor 1 Alpha gene (HNF1A) are associated with lipoproteins levels and type 2 diabetes. In this study, we aimed to assess the association of HNF1A gene and haplotypes with the metabolic syndrome (MetS) and its components through an association study in the Tunisian population as well as by a meta-analysis.

METHODS

A total of 594 Tunisian individuals were genotyped for three variants (rs1169288, rs2464196 and rs735396) located in HNF1A gene using KASPar technology. Statistical analyses were performed with R software. The association was furthermore evaluated through a meta-analysis of our results with those obtained in a Moroccan population.

RESULTS

Our results showed no association between HNF1A variants and MetS in the Tunisian population. However, a significant association was observed between the variant rs735396 and a higher waist circumference. The stratified analysis according to the sex highlighted a significant association between the variant rs1169288 and high cholesterol levels only in women. Similarly, Haplotype analysis showed an association between the HNF1A minor haplotype and high total cholesterol mainly in women. Finally, our meta-analysis showed no association between HNF1A variants and MetS.

CONCLUSIONS

Our findings exclude the involvement of the three HNF1A variants rs1169288, rs2464196 and rs735396 in the susceptibility to MetS in our studied Tunisian population but emphasize the role of these variants in the cholesterol homeostasis with sex-specific differences, which may serve to rise clinical consideration to early statin therapy in women carrying these genetic variants.

Computational screening of potential drugs against COVID-19 disease: the Neuropilin-1 receptor as molecular target

The transmembrane receptor Neuropilin-1 (NRP-1) was reported to serve as a host cell entry factor for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causal agent of COVID-19 disease. Therefore, molecular compounds interfering with SARS-CoV-2 binding to NRP-1 seem to be potential candidates as new antiviral drugs. In this study, NRP-1 receptor was targeted using a library of 1167 compounds previously analyzed in COVID-19 related studies. The results show the effectiveness of Nafamostat, Y96, Selinexor, Ebastine and UGS, in binding to NRP-1 receptor, with docking scores lower than − 8.2 kcal/mol. These molecules interact with NRP-1 receptor key residues, which makes them promising drugs to pursue further biological assays to explore their potential use in the treatment of COVID-19.

Comparison between the British and the American/European guidelines for the assessment of left ventricular diastolic function with invasive validation of left ventricular filling pressure

Background

Left ventricle diastolic function and filling pressures assessment is still a major challenge to echocardiographer. There are two echo guidelines regarding this issue: the British Society of Echocardiography (BSE 2013) and the American Society of Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI 2016). The 2016 guidelines, which is an expert consensus and simplified update of 2009 guidelines, needs an invasive validation according to its authors. Recent studies raised questions about the diagnostic accuracy as sensitivity results varied very widely (34% to 87%) and also that of 2009 (43% to 79%). This study validated the diastolic pressure invasively in the cath lab and compared the results with the echo guidline algorithms were done immediately before the catheterization. When possible, it included additional assessment of S/D and Ar-A duration.

Purpose

Validation of the diagnostic accuracy of the 2009, the updated 2016 ASE/EACVI and 2013 BSE echocardiographic LV filling pressure predicting algorithms, as well as pulmonary veins flow (S/D) and (Ar-A) durations with invasively measured LV-pre-A wave.

Methods

124 patients (58.06% males) underwent transthoracic echocardiography immediately before left heart catheterization. A trained echocardiographer obtained E/A mitral flow, E/e', left atrial volume index, TR, EDT, lateral and septal e' to estimate LV filling pressure as normal, elevated or indeterminate using the 2009, 2016

ASE/EACVI algorithms and 2013 BSE algorithm. He also obtained Secondary parameters as (S/D) and (Ar-A) duration. Invasive LV pre-A pressure was the reference of this study, with &gt;12 mm Hg defined as elevated.

Results

Invasive LV pre-A pressure was elevated in 60 (48.38%) patients. When they could determine LV filling pressure, 2016 sensitivity was 0.36 and specificity 0.94, 2009 had 0.56 sensitivity and 0.90 specificity and 2013 resulted in 0.63 sensitivity and 0.80 specificity. Results of diagnostic accuracy of each algorithm as well as (S/D) and (Ar-A) summarized in tables associated in (picture 1: Tables of results). EDT≥150 msec raised NPV in normal, grade one diastolic dysfunction and indeterminate pressure.

Conclusion

2016 was the most specific but the least sensitive with modest NPV and PPV between the 2013 and 2009. 2013 was the most sensitive with the highest indeterminate pressure rate to execlude. Adding S/D or Ar-A duration markedly improved the sensitivity and reduced class indeterminate among all algorithms with more benefit when both combined. EDT had a rule out role in normal, grade one diastolic dysfunction and indeterminate pressure patients. We kindly propose a modification of 2016 algorithm by adding S/D, Ar-A and EDT as optional parameters to increase sensitivity and reduce indeterminate class without affecting simplicity or specificity (picture 2: Proposed algorithms A+B). We recommend future studies to validate the diagnostic accuracy of the proposed algorithms.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Al mouwasat University Hospital and University Heart Surgery Center at Damascus, Syrian Arab Republic. Tables of resultsProposed Algorithms A+B

First characterization of congenital myasthenic syndrome type 5 in North Africa

BACKGROUND

Congenital myasthenic syndromes (CMS) are associated with defects in the structure and the function of neuromuscular junctions. These rare disorders can result from mutations in the collagenic tail of endplate acetylcholinesterase (COLQ) essentially associated with autosomal recessive inheritance. With the lowered cost of genetic testing and increased access to next-generation sequencing, many mutations have been reported to date.

METHODS AND RESULTS

In this study we identified the first COLQ homozygous mutation c.1193T>A in the North African population. This study outlines the genetic and phenotypic features of a CMS patient in a Moroccan family. It also describes a novel COLQ missense mutation associated with CMS-5.

CONCLUSION

COLQ mutations are probably underdiagnosed in these North African populations, this is an issue as CMS-5 may be treated with ephedrine, and albuterol. Indeed, patients can seriously benefit and even recover after the treatment that should be planned according to genetic tests and clinical findings.

DSPECT-specific normal limits for LV measurements: a new approach to derivation

Funding Acknowledgements

Type of funding sources: None.

Background

Differences in spatial resolution and image filtering between the solid-state DSPECT and traditional Anger SPECT (A-SPECT) cameras are likely to result in differences in LV measurements. However, DSPECT- specific normal values have not been systematically derived. We used healthy organ-donor subjects from our high-volume solid organ transplant center for derivation of normal values.

Purpose

To report DSPECT-specific LV measurements normal limits derived from a unique cohort of donor subjects.

Methods

Subjects were 92 consecutive kidney or liver donors who underwent single day rest (5 mCi)- stress (15mCi) Tc-99m sestamibi gated SPECT myocardial perfusion imaging (MPI) on the DSPECT for pre-operative evaluation. Exclusion criteria included any cardiac disease or medications. LV measurements were made on the post-stress supine stress images using QGS®.

Results

Of 92 subjects (mean age 54.4 ± 15.0 and 39% men), mean EF for women and men were 77.2 ± 14.1% and 70.0 ± 14.7%, respectively. Mean end-diastolic volume for women and men were 67.0 ± 32.2 ml and 99.6 ± 51.6 ml (indexed 38.3 ± 17.2 ml/m2 and 48.1 ± 25.9 ml/m2), respectively. Mean LV wall volume for women and men were 95.9 ± 26.0 ml and 112.0 ± 48.8 ml (indexed 55.0 ± 13.8 ml/m2 and 54.1 ± 24.6 ml/m2), respectively.

Conclusion

We report DSPECT-specific LV measurements from normal subjects from which limits of normality can be derived for clinic use. Organ-donors who undergo pre-operative MPI are a suitable cohort for the derivation of normal values.

Thalamic versus midbrain tremor; two distinct types of Holmes' Tremor: a review of 17 cases

INTRODUCTION

Holmes Tremor (HT) is a unique and debilitating movement disorder. It usually results from lesions of the midbrain and its connection but can also result from posterior thalamic injury. Clinical examination can help lesion localization between these two areas. We studied the clinical features and their radiological correlations to distinguish midbrain HT (HT-m) from thalamic HT (HT-t).

METHODS

Retrospective review of 17 patients with a HT-type presentation was conducted. Tremor characteristics, associated clinical signs and radiological findings were studied.

RESULTS

Eleven patients had a myorythmic rest tremor, large amplitude proximal tremor with goal-directed worsening, with or without mild distal dystonic posturing, representing HT-m. Six patients had slow, large amplitude proximal tremors and distal choreathetoid movements, significant proximal/distal dystonic posturing, associated with proprioceptive sensory loss, representing HT-t. Haemorrhagic lesions were the predominant cause of HT-m; whereas, ischaemia was more commonly associated with HT-t.

CONCLUSION

When assessing patients with HT, attentiveness to the presence of associated signs in the affected limb, such as a proprioceptive sensory deficits and additional movement disorders, can aid lesion localisation, which can have implications for management.

Omenn syndrome caused by a novel homozygous mutation in recombination activating gene 1

Omenn syndrome (OS) is a type of severe combined immunodeficiency (SCID) that is distinguished by, lymphadenopathy, hepatosplenomegaly, erythroderma, alopecia with normal to elevated T-cell counts, eosinophilia, and elevated serum IgE levels. Recombination activation gene (RAG) 1 or RAG2 mutations that result in partial V(D)J recombination activity are known to be the main cause of OS. Other genes (DCLRE1C, LIG4, IL7RA, common gamma chain, ADA, RMRP, and CHD7) have also been linked to OS, although with low frequency. Here, we report a two-month-old Moroccan girl from consanguineous marriage with chronic diarrhea, recurrent and opportunistic infections, failure to thrive, desquamative erythroderma, hepatosplenomegaly, and axillary lymphadenitis. The immunological assessment showed normal lymphocyte and NK cell counts but an absence of B cells, agammaglobulinemia contrasting with a high level of IgE. On the other hand, Sanger sequencing of RAG1 and RAG2 exon 2 regions revealed a new homozygous deleterious mutation in the RAG1 gene. This c.1184C > T mutation caused a change from Proline to Leucine at position 395 of the protein, leading to a partial loss of function. Early and rapid diagnosis of the disease may facilitate urgent life-saving treatment.

Management of peri-prosthetic joint infection and severe bone loss after total hip arthroplasty using a long-stemmed cemented custom-made articulating spacer (CUMARS)

Background

There is little evidence on techniques for management of peri-prosthetic infection (PJI) in the context of severe proximal femoral bone loss. Custom-made articulating spacers (CUMARS) utilising cemented femoral stems as spacers was described providing better bone support and longer survival compared to conventional articulating spacers. We retrospectively report our experience managing PJI by adaptation of this technique using long cemented femoral stems where bone loss precludes use of standard stems.

Methods

Patients undergoing 1st stage revision for infected primary and revision THA using a cemented long stem (> 205 mm) and standard all-polyethylene acetabulum between 2011 and 2018 were identified. After excluding other causes of revision (fractures or aseptic loosening), Twenty-one patients remained out of total 721 revisions. Medical records were assessed for demographics, initial microbiological and operative treatment, complications, eradication of infection and subsequent operations. 2nd stage revision was undertaken in the presence of pain or subsidence.

Results

Twenty-one patients underwent 1st stage revision with a cemented long femoral stem. Mean follow up was 3.9 years (range 1.7–7.2). Infection was eradicated in 15 (71.4%) patients. Two patients (9.5%) required repeat 1st stage and subsequently cleared their infection. Three patients (14.3%) had chronic infection and are on long term suppressive antibiotics. One patient (4.8%) was lost to follow up before 2 years. Complications occurred in seven patients (33%) during or after 1st stage revision. Where infection was cleared, 2nd stage revision was undertaken in 12 patients (76.5%) at average of 9 months post 1st stage. Five (23.8%) CUMARS constructs remained in-situ at an average of 3.8 years post-op (range 2.6–5.1).

Conclusions

Our technique can be used in the most taxing of reconstructive scenarios allowing mobility, local antibiotic delivery, maintenance of leg length and preserves bone and soft tissue, factors not afforded by alternative spacer options.

Intensive home treatment in comparison with care as usual: Cost-utility analysis from a pre-randomized controlled trial in the netherlands

Introduction

The implementation of Intensive Home Treatment (IHT) aims to decrease the pressure on acute inpatient services that could lead to prevent hospitalization and reduce the number of hospitalization days and, ultimately, reduce cost in the mental health services. Although there are studies assessing the effectiveness of IHT, there is a shortage of research studying the cost-effectiveness.

Objectives

The aim of this study is to present an cost-utility analysis of IHT compared to care as usual (CAU)

Methods

Patients between 18 and 65 years of age whose mental health professionals considered hospitalization were included. These patients were pre-randomized in either IHT or CAU and followed up for 12-months. For this study, the base case analysis was performed from the societal and healthcare perspective. For the cost-utility analyses the Euroqol 5D was used to calculate quality adjusted life years (QALYs) as a generic measure of health gains.

Results

Data of 198 patients were used. From a sociatal perspective, the cost-utility analysis resulted in an incremental cost-effectiveness ratios (ICERs) of €58 730, and a 37% likelihood that IHT leads to higher QALYs at lower costs. The probability of IHT being cost-effective was >50% if there was no willingness to pay more for extra QALY than in the current situation under CAU.

Conclusions

Professionals working in crisis care are able to offer IHT with the same effect as other crisis care interventions at lower costs. IHT seem to be cost-effective compared with CAU over 52 weeks follow-up for patients who experience psychiatric crises.

Disclosure

No significant relationships.

Novel Mutation in AIFM1 Gene Associated with X-Linked Deafness in a Moroccan Family

INTRODUCTION

Auditory neuropathy is a hearing disorder where outer hair cell function within the cochlea is normal, but inner hair cell and/or the auditory nerve function is disrupted. It is a heterogeneous disorder, which can have either congenital or acquired causes.

METHODS

We found a disease-segregating mutation in the X-linked AIFM1 gene through whole-exome sequencing, encoding the apoptosis-inducing factor mitochondrion-associated 1.

RESULTS

The impact of the c.1045A>G; p.(Ser349Gly) mutation on the AIFM1 protein was predicted using different bioinformatics tools. The pedigree analysis in the examined family was consistent with X-linked dominant inheritance.

DISCUSSION/CONCLUSION

To our knowledge, this is the first study that identifies a mutation in the AIFM1 gene in Moroccan patients suffering from X-linked auditory neuropathy.

A homozygous MPZL2 deletion is associated with non syndromic hearing loss in a moroccan family

Adhesion glycoproteins are implicated in the pathophysiology of hearing loss, the most frequent inherited sensory disorder, affecting 1 in 1000 new-borns. Exome sequencing of a consanguineous Moroccan patient with mild hearing loss identified for the first time in a North African family a single homozygous mutation c.72delA in MPZL2 gene, encoding the Myelin Protein Zero-Like 2, reported as causing deafness in two other populations. Variable tandem repeat genotyping of this family revealed that the c.72delA MPZL2 allele shared a common haplotype with Turkish and Dutch families. These results confirm the pathogenicity of this MPZL2 mutation in recessive mild to moderate non-syndromic deafness.

Dominant ACO2 mutations are a frequent cause of isolated optic atrophy

Biallelic mutations in ACO2, encoding the mitochondrial aconitase 2, have been identified in individuals with neurodegenerative syndromes, including infantile cerebellar retinal degeneration and recessive optic neuropathies (locus OPA9). By screening European cohorts of individuals with genetically unsolved inherited optic neuropathies, we identified 61 cases harbouring variants in ACO2, among whom 50 carried dominant mutations, emphasizing for the first time the important contribution of ACO2 monoallelic pathogenic variants to dominant optic atrophy. Analysis of the ophthalmological and clinical data revealed that recessive cases are affected more severely than dominant cases, while not significantly earlier. In addition, 27% of the recessive cases and 11% of the dominant cases manifested with extraocular features in addition to optic atrophy. In silico analyses of ACO2 variants predicted their deleterious impacts on ACO2 biophysical properties. Skin derived fibroblasts from patients harbouring dominant and recessive ACO2 mutations revealed a reduction of ACO2 abundance and enzymatic activity, and the impairment of the mitochondrial respiration using citrate and pyruvate as substrates, while the addition of other Krebs cycle intermediates restored a normal respiration, suggesting a possible short-cut adaptation of the tricarboxylic citric acid cycle. Analysis of the mitochondrial genome abundance disclosed a significant reduction of the mitochondrial DNA amount in all ACO2 fibroblasts. Overall, our data position ACO2 as the third most frequently mutated gene in autosomal inherited optic neuropathies, after OPA1 and WFS1, and emphasize the crucial involvement of the first steps of the Krebs cycle in the maintenance and survival of retinal ganglion cells.

In vitro haemostatic efficacy of aqueous, methanol and ethanol plant extracts of three medicinal plant species in Palestine

Abstract The haemostatic efficacy of different extract types of Satureja thymbra L., Thymbra spicata L. (Lamiaceae) and Verbascum fruticulosum Post. (Scrophulariaceae) was evaluated in this study via the Prothrombin time (PT) and Activated partial thromboplastin time (aPTT) analysis. Aqueous, methanol and ethanol extracts of the examined plant species leaves were prepared to a final concentration 50 mg/mL. In vitro PT and aPTT assays were conducted on normal platelet poor plasma blood samples by a digital coagulation analyzer. The obtained results revealed anticoagulation activity of all investigated plant species with observed variations among them. The aqueous and ethanol extracts of T. spicata as well as the aqueous extract of S. thymbra prolonged PT values significantly (p < 0.05). While, all V. fruticulosum extract types have had no significant effect on the PT values. The recorded aPTT data showed that all aqueous extracts have had a significant effect on the blood haemostasis as they increased aPTT values in all plant species under study. Out of which, both the ethanol and methanol extracts of T. spicata and methanol extract of S. thymbra showed similar effect. Of great concern, it was clearly noticed that the aqueous and ethanol extract of T. spicata and the aqueous extract of S. thymbra possess the strongest anticoagulation effect as they increased both PT and aPTT values significantly relative to the control (p < 0.05). The variable anticoagulation bioactivity among the studied plant species could be referred to the various solvents degrees of solubility of different phyto-constituents. Thus, the efficacy of the plant species extracts evaluation as anticoagulants or coagulants were related to the plant species and to the solvent of extraction.

A Homozygous RAG1 Gene Mutation in a Case of Combined Immunodeficiency: Clinical, Molecular, and Computational Analysis

BACKGROUND

The recombination-activating gene 1 and 2 (RAG1/RAG2) proteins are essential to initiate the V(D)J recombination process, the result is a diverse repertoire of antigen receptor genes and the establishment of the adaptive immunity. RAG1 mutations can lead to multiple forms of combined immunodeficiency.

METHODS

In this report, whole exome sequencing was performed in a Moroccan child suffering from combined immunodeficiency, with T and B lymphopenia, autoimmune hemolytic anemia, and cytomegalovirus (CMV) infection.

RESULTS

After filtering data and Sanger sequencing validation, one homozygous mutation c.2446G>A (p.Gly816Arg) was identified in the RAG1 gene.

CONCLUSION

This finding expands the spectrum of immunological and genetic profiles linked to RAG1 mutation, it also illustrates the necessity to consider RAG1 immunodeficiency in the presence of autoimmune hemolytic anemia and CMV infection, even assuming the immunological phenotype appears more or less normal.

Potential inhibitors of SARS-cov-2 RNA dependent RNA polymerase protein: molecular docking, molecular dynamics simulations and MM-PBSA analyses

The SARS-cov-2 RNA dependent RNA polymerase (nsp12) is a crucial viral enzyme that catalyzes the replication of RNA from RNA templates. The fixation of some ligands in the active site may alter the viral life cycle. The aim of the present study is to identify the conservation level of nsp12 motifs (A-G), using consurf server, and discover their interactions with rifabutin, rifampicin, rifapentin, sorangicin A, streptolydigin, myxopyronin B, VXR and VRX using AutoDockTools-1.5.6, Gromacs 2018.2 and g-mmpbsa. Thus, the most of amino acids residues located in nsp12 protein Motifs (A-G) were predicted as highly conserved. The binding energies of streptolydigin, VXR, rifabutin, rifapentine, VRX, sorangicin A, myxopyronin B and rifampicin with nsp12 protein are -8.11, -8.23, -7.14, -6.94, -6.55, -5.46, -5.33 and -5.26 kcal/mol, respectively. In the other hand, the binding energies of ligand in the same order with nsp7-nsp8-nsp12 complex are -7.23, -7.08, -7.21, -7, -6.59, -8.73, -5.52, -5.87 kcal/mol, respectively. All ligands interact with at least two nsp12 motifs. The molecular dynamics simulation of nsp12-streptolydigin and nsp12-VXR complexes shows that these two complexes are stable and the number of hydrogen bonds as a function of time, after 30 ns of simulation, varies between 0 and 6 for nsp12-streptolydigin complex and between 0 and 4 for nsp12-VXR complex. The average of free binding energies obtained using g_mmpbsa, after 30 ns of simulation, is -191.982 Kj/mol for nsp12-streptolydigin complex and -153.583 Kj/mol for nsp12-VXR complex. Our results suggest that these ligands may be used as inhibitors of SARS-cov-2 nsp12 protein.Communicated by Ramaswamy H. Sarma.

Association of c.56C > G (rs3135506) Apolipoprotein A5 Gene Polymorphism with Coronary Artery Disease in Moroccan Subjects: A Case-Control Study and an Updated Meta-Analysis

PURPOSE

Coronary artery diseases (CAD) are clinical cardiovascular events associated with dyslipidemia in common. The interaction between environmental and genetic factors can be responsible for CAD. The present paper aimed to examine the association between c.56C > G (rs3135506) APOA5 gene polymorphism and CAD in Moroccan individuals and to perform an association update meta-analysis.

MATERIALS AND METHODS

The c.56C > G variant was genotyped in 122 patients with CAD and 134 unrelated controls. Genetic association analysis and comparison of biochemical parameters were performed using R statistical language. In addition, a comprehensive meta-analysis including eleven published studies in addition to our case-control study results was conducted using Review Manager 5.3. Publication bias was examined by Egger's test and funnel plot.

RESULTS

The case-control study data showed that the c.56C > G polymorphism was associated with CAD susceptibility under codominant (P-value = 0.001), recessive (P-value <0.001) and log-additive (P-value = 0.008) inheritance models. In addition, this polymorphism was significantly associated with increased levels of systolic and diastolic blood pressures, triglycerides, glycemia, and total cholesterol. Furthermore, meta-analysis showed a significant association between the c.56C > G gene polymorphism and increased risk of CAD under recessive (OR = 3.39[1.77-6.50], P value <0.001) and homozygote codominant (OR = 3.96[2.44-6.45], P value <0.001) models.

CONCLUSION

Our case-control study revealed a significant association between c.56C > G polymorphism and CAD in the Moroccan population. In addition, meta-analysis data supported the implication of this polymorphism in CAD susceptibility.

Are positive-pressure ventilation lobby rooms effective for protective and source isolation?

High-efficiency particulate air supplied to a positive-pressure ventilation lobby (PPVL) in isolation rooms offers the dual advantage of protective and source isolation. This study demonstrates the in-use validity of PPVL rooms for protective isolation of patients. Of the 48 PPVL air samples investigated, Aspergillus fumigatus was detected from only one (2%) sample. Local and remote monitoring of the PPVL rooms is essential for the safety of patients and healthcare workers. Remote and point-of-use engineering controls are essential for ongoing ventilation monitoring, but this should be complemented by visual inspection of the isolation suite. Periodic microbiological monitoring should also be considered with other control measures.

Further Evidence for the Implication of the MET Gene in Non-Syndromic Autosomal Recessive Deafness

Mutations in the mesenchymal epithelial transition factor (MET) gene are frequently associated with multiple human cancers but can also lead to human non-syndromic autosomal recessive deafness (DFNB97). In the present study, we identified a novel homozygous missense mutation in the METgene causing a non-syndromic hearing impairment DFNB97 form. Whole-exome sequencing was performed to determine the genetic causes of hearing loss in a Moroccan consanguineous family with an affected daughter. The structural analysis of native and mutant in the SEMA domain of the MET receptor was investigated using a molecular dynamics simulation (MDS) approach. We identified a novel pathogenic homozygous c.948A>G (p.Ile316Met) mutation in the MET gene in one deaf Moroccan young girl carrying a total bilateral non-syndromic hearing impairment. The results of the MDS approach show that an Ile316Met mutation in the SEMA domain leads to protein flexibility loss. This may produce a major impact on the structural conformation of the MET receptor, which also affects the function and binding site of the receptor. This is the first time that a mutation in the MET gene is described in a Moroccan family. Moreover, this study reports the second family in the world associating deafness and mutation in the MET gene.

Genetic Approaches for Definitive Diagnosis of Agammaglobulinemia in Consanguineous Families

Autosomal recessive agammaglobulinemia (ARA) is a primary immunodeficiency characterized by absent peripheral B cells, severe hypogammaglobulinemia, and absent BTK gene mutations. In ARA, mutations occur in genes encoding the pre-B cell receptor (pre-BCR) or downstream signaling proteins. In this work, we used candidate gene and whole-exome sequencing to investigate the molecular basis of ARA in 6 patients from 4 consanguineous North-African families. Sanger sequencing of candidate genes encoding the pre-BCR components (ΙGΗΜ, CD79A, CD79B, IGLL1, and VPREB1) was initially performed and determined the genetic defect in five patients. Two novel mutations in IGHM (p.Val378Alafs*1 and p.Ile184Serfs*21) were identified in three patients from two unrelated kindred and a novel nonsense mutation was identified in CD79A (p.Trp66*) in two siblings from a third kindred. Whole-exome sequencing (WES) was performed on the sixth patient who harbored a homozygous stop mutation at position 407 in the RAG2 gene (p.Glu407*). We concluded that conventional gene sequencing, especially when multiple genes are involved in the defect as is the case in ARA, is costly and time-consuming, resulting in delayed diagnosis that contributes to increased morbidity and mortality. In addition, it fails to identify the involvement of novel and unsuspected gene defects when the phenotype of the patients is atypical. WES has the potential to provide a rapid and more accurate genetic diagnosis in ARA, which is crucial for the treatment of the patients.