Biochemical signatures of disease severity in multiple sulfatase deficiency

Sulfatases catalyze essential cellular reactions, including degradation of glycosaminoglycans (GAGs). All sulfatases are post-translationally activated by the formylglycine generating enzyme (FGE) which is deficient in multiple sulfatase deficiency (MSD), a neurodegenerative lysosomal storage disease. Historically, patients were presumed to be deficient of all sulfatase activities; however, a more nuanced relationship is emerging. Each sulfatase may differ in their degree of post-translational modification by FGE, which may influence the phenotypic spectrum of MSD. Here, we evaluate if residual sulfatase activity and accumulating GAG patterns distinguish cases from controls and stratify clinical severity groups in MSD. We quantify sulfatase activities and GAG accumulation using three complementary methods in MSD participants. Sulfatases differed greatly in their tolerance of reduction in FGE-mediated activation. Enzymes that degrade heparan sulfate (HS) demonstrated lower residual activities than those that act on other GAGs. Similarly, HS-derived urinary GAG subspecies preferentially accumulated, distinguished cases from controls, and correlated with disease severity. Accumulation patterns of specific sulfatase substrates in MSD provide fundamental insights into sulfatase regulation and will serve as much-needed biomakers for upcoming clinical trials. This work highlights that biomarker investigation of an ultra-rare disease can simultaneously inform our understanding of fundamental biology and advance clinical trial readiness efforts.

Assessing Clinical Utility of Pharmacogenetic Testing in the Military Health System

INTRODUCTION

Response to medications can differ widely among individual patients. Adverse drug reactions can lead to serious morbidity and mortality. Pharmacogenetic (PGx) testing can predict responses to medications and increased risks of adverse events where the genetic basis is understood. Several published manuscripts suggest positive impacts of systematic preemptive PGx testing. However, few studies have been conducted on PGx implementation in the Military Health System (MHS).

MATERIAL AND METHODS

A cross-sectional study of adult beneficiaries in a primary care clinic at a large military treatment facility was conducted in 2022. Participants underwent PGx genotyping of CYP2C19 and CYP2D6 genes at the Defense Health Agency Genetics Reference Laboratory. Participant medication lists were compared to the current Clinical Pharmacogenetic Implementation Consortium (CPIC) PGx gene-drug guidelines to assess potential actionability of these results.

RESULTS

Genotyping of CYP2C19 and CYP2D6 in 165 MHS beneficiaries (mean age: 65 years) revealed that 81.2% of participants had at least one abnormal PGx finding. Among those with an abnormal PGx result, 65% were taking a medication listed on the CPIC website with an association with the particular gene in which the finding was identified. In addition, 78% of all of the participants in the study were taking at least one medication that is metabolized by CYP2C19 or CYP2D6 with associated CPIC guidelines.

CONCLUSIONS

Pharmacogenetic testing for CYP2C19 and CYP2D6 identified a substantial proportion of MHS patients at a single center who could benefit from evaluation of current medication regimens based on the CPIC guidelines. Individualized medical management may be warranted to a greater degree than previously recognized based on the findings given possible differences in medication metabolism. Many MHS beneficiaries already take medications metabolized by CYP2C19 and CYP2D6, and a substantial proportion may be at risk for preventable adverse events for medications metabolized by these enzymes. While preliminary, a large number of actionable polymorphisms among a relatively small set of individuals taking at-risk medications suggest that implementing PGx testing in clinical practice may be beneficial in the MHS with appropriate clinical infrastructure.

Airmen and health-care providers' attitudes toward the use of genomic sequencing in the US Air Force: findings from the MilSeq Project

PURPOSE

The use of genomic sequencing (GS) in military settings poses unique considerations, including the potential for GS to impact service members' careers. The MilSeq Project investigated the use of GS in clinical care of active duty Airmen in the United States Air Force (USAF).

METHODS

We assessed perceived risks, benefits, and attitudes toward use of GS in the USAF among patient participants (n = 93) and health-care provider participants (HCPs) (n = 12) prior to receiving or disclosing GS results.

RESULTS

Participants agreed that there are health benefits associated with GS (90% patients, 75% HCPs), though more HCPs (75%) than patients (40%) agreed that there are risks (p = 0.048). The majority of both groups (67% HCPs, 77% patients) agreed that they trust the USAF with genetic information, but far fewer agreed that genetic information should be used to make decisions about deployment (5% patients, 17% HCPs) or duty assignments (3% patients, 17% HCPs). Despite their hesitancy, patients were supportive of the USAF testing for nondisease traits that could impact their duty performance. Eighty-seven percent of patients did not think their GS results would influence their career.

CONCLUSION

Results suggest favorable attitudes toward the use of GS in the USAF when not used for deployment or assignment decisions.

Natural history of multiple sulfatase deficiency: Retrospective phenotyping and functional variant analysis to characterize an ultra-rare disease

Multiple sulfatase deficiency (MSD) is an ultra-rare neurodegenerative disorder caused by pathogenic variants in SUMF1. This gene encodes formylglycine-generating enzyme (FGE), a protein required for sulfatase activation. The clinical course of MSD results from additive effect of each sulfatase deficiency, including metachromatic leukodystrophy (MLD), several mucopolysaccharidoses (MPS II, IIIA, IIID, IIIE, IVA, VI), chondrodysplasia punctata, and X-linked ichthyosis. While it is known that affected individuals demonstrate a complex and severe phenotype, the genotype-phenotype relationship and detailed clinical course is unknown. We report on 35 cases enrolled in our retrospective natural history study, n = 32 with detailed histories. Neurologic function was longitudinally assessed with retrospective scales. Biochemical and computational modeling of novel SUMF1 variants was performed. Genotypes were classified based on predicted functional change, and each individual was assigned a genotype severity score. The median age at symptom onset was 0.25 years; median age at diagnosis was 2.7 years; and median age at death was 13 years. All individuals demonstrated developmental delay, and only a subset of individuals attained ambulation and verbal communication. All subjects experienced an accumulating systemic symptom burden. Earlier age at symptom onset and severe variant pathogenicity correlated with poor neurologic outcomes. Using retrospective deep phenotyping and detailed variant analysis, we defined the natural history of MSD. We found that attenuated cases can be distinguished from severe cases by age of onset, attainment of ambulation, and genotype. Results from this study can help inform prognosis and facilitate future study design.

Educating military primary health-care providers in genomic medicine: lessons learned from the MilSeq Project

PURPOSE

With few trained genetics professionals, the Military Health System is ill-equipped to manage the rapid expansion of genomic medicine. The MilSeq Project introduces an alternative service delivery model (ASDM) in which primary health-care providers (HCPs) provide post-test counseling (PTC) to healthy Airmen who have undergone exome sequencing. We describe HCP performance after a prerequisite educational intervention (EI).

METHODS

After a brief EI and pre-/posteducation surveys, HCPs were eligible to provide PTC with a genetic counselor available for consult. PTC was recorded, transcribed, and reviewed. Opportunities for improvement were organized into four error adjustment categories: (1) knowledge limitation, (2) minor, (3) moderate, and (4) critical. Thematic analysis was also performed.

RESULTS

Pre-/posteducation survey responses revealed statistically significant improvements in all domains. Minor error adjustments were most represented (n = 93), followed by knowledge limitation (n = 39) and moderate (n = 19). No critical errors were identified, and 17 transcripts required no adjustment. Thematic analysis revealed four themes that would benefit from more focused education: (1) family-centered care, (2) conveying risk, (3) disease knowledge, and (4) assay knowledge.

CONCLUSION

HCPs demonstrated competence in basic PTC after a brief EI. This ASDM may be a viable interim response to the shortage of genetics professionals in some systems.

Automated typing of red blood cell and platelet antigens from whole exome sequences

BACKGROUND

Genotyping has expanded the number red blood cell (RBC) and platelet (PLT) antigens that can readily be typed, but often represents an additional testing cost. The analysis of existing genomic data offers a cost-effective approach. We recently developed automated software (bloodTyper) for determination of RBC and PLT antigens from whole genome sequencing. Here we extend the algorithm to whole exome sequencing (WES).

STUDY DESIGN AND METHODS

Whole exome sequencing was performed on samples from 75 individuals. WES-based bloodTyper RBC and PLT typing was compared to conventional polymerase chain reaction (PCR) RHD zygosity testing and serologic and single-nucleotide polymorphism (SNP) typing for 38 RBC antigens in 12 systems (17 serologic and 35 SNPs) and 22 PLT antigens (22 SNPs). Samples from the first 20 individuals were used to modify bloodTyper to interpret WES followed by blinded typing of 55 samples.

RESULTS

Over the first 20 samples, discordances were noted for C, M, and N antigens, which were due to WES-specific biases. After modification, bloodTyper was 100% accurate on blinded evaluation of the last 55 samples and outperformed both serologic (99.67% accurate) and SNP typing (99.97% accurate) reflected by two Fy^b and one N serologic typing errors and one undetected SNP encoding a Jk_null phenotype. RHD zygosity testing by bloodTyper was 100% concordant with a combination of hybrid Rhesus box PCR and PCR-restriction fragment length polymorphism for all samples.

CONCLUSION

The automated bloodTyper software was modified for WES biases to allow for accurate RBC and PLT antigen typing. Such analysis could become a routing part of future WES efforts.

Complex care of individuals with multiple sulfatase deficiency: Clinical cases and consensus statement

Multiple sulfatase deficiency (MSD) is an ultra-rare neurodegenerative disorder that results in defective sulfatase post-translational modification. Sulfatases in the body are activated by a unique protein, formylglycine-generating enzyme (FGE) that is encoded by SUMF1. When FGE is absent or insufficient, all 17 known human sulfatases are affected, including the enzymes associated with metachromatic leukodystrophy (MLD), several mucopolysaccharidoses (MPS II, IIIA, IIID, IVA, VI), chondrodysplasia punctata, and X-linked ichthyosis. As such, individuals demonstrate a complex and severe clinical phenotype that has not been fully characterized to date. In this report, we describe two individuals with distinct clinical presentations of MSD. Also, we detail a comprehensive systems-based approach to the management of individuals with MSD, from the initial diagnostic evaluation to unique multisystem issues and potential management options. As there have been no natural history studies to date, the recommendations within this report are based on published studies and consensus opinion and underscore the need for future research on evidence-based outcomes to improve management of children with MSD.

Johann Gregor Mendel: paragon of experimental science

This is a foreword on the life and work of one of the greatest minds of the 20th century, the father of modern genetics, Johann Gregor Mendel.

Determining the prevalence of McArdle disease from gene frequency by analysis of next-generation sequencing data

Purpose

McArdle disease is one of the most common glycogen storage disorders. Although the exact prevalence is not known, it has been estimated to be 1 in 100,000 patients in the United States. More than 100 mutations in PYGM have been associated with this disorder. McArdle disease has significant clinical variability with some patients presenting with severe muscle pain and weakness while others have only mild, exercise-related symptoms.

Methods

Next-Generation sequencing data allow estimation of disease prevalence with minimal ascertainment bias. We analyzed gene frequencies in two cohorts of patients from exome sequencing results. We categorized variants into three groups: a curated set of published mutations, variants of uncertain significance, and likely benign variants.

Results

An initial estimate based on the frequency of six common mutations predicts a disease prevalence of 1/7,650 (95% CI 1/5,362 to 1/11,108), which greatly deviates from published estimates. A second method using the two most common mutations predicts a prevalence of 1/42,355 (95% CI 1/24,536 - 1/76,310) in Caucasians.

Conclusions

These results suggest that the currently accepted prevalence of McArdle disease is an underestimate and that some of the currently considered pathogenic variants are likely benign.

Cultural aspects related to the health of Andean women in Latin America: a key issue for progress toward the attainment of the Millennium Development Goals

International declarations have affirmed that health is a universal right. In order for people to exercise their right to health, their social and cultural contexts need to be acknowledged. However, due to a number of barriers encountered at different levels of society and geographically this right is not yet fully exercised by a considerable number of women in Latin America. During the last decade progress has been made in the development of public health policies and programs that integrate and recognize the differences in culture that should be considered when addressing indigenous women's health issues. However, a biomedical health model, which discounts cultural influences, prevails globally over a more integrated approach. This leads to a lack of access and use of quality reproductive health services and care among indigenous people and is one of several important factors contributing to high levels of maternal mortality and poor reproductive health among indigenous women. It is important to ensure that an intercultural approach is included in health policies, programs and services. An intercultural strategy fosters dialogue and respect among women, men, and decision-makers and can contribute to the realization of reproductive health rights and improvement of health outcomes. The debate continues on how to accelerate progress in public policies, health programs and health services. An intercultural approach to assure the health of indigenous women should be a key part of this discussion. Specific efforts are critical for obtaining better health outcomes for indigenous women and other vulnerable populations, if not progress will stagnate in the middle of the 21st century, jeopardizing the attainment of the Millennium Development Goal (MDGs).

Prestroke dementia

OBJECTIVE

To determine the frequency, associated factors and outcome of dementia previous to a stroke.

DESIGN

Cross-sectional study of a cohort of 324 consecutive unselected stroke patients (mean age 70.9 years, range 20-98; 255 ischaemic, 46 haemorrhagic and 25 indefinite).

METHODS

Cognitive and functional status prior to stroke were assessed by means of an interview to a relative, a short version of the Informant Questionnaire on Cognitive Decline in the Elderly and the Barthel Index. The DSM-III-R criteria were used to establish the diagnosis of prestroke dementia. Clinical and CT features of patients with and without prestroke dementia were compared.

RESULTS

Forty-nine patients (15%) were demented before stroke; they were significantly older, less well educated, they had more frequently female gender, prior cerebrovascular disease, cerebral and medial temporal lobe atrophy and leukoaraiosis in the CT scan, and they had a higher mortality rate. Female sex (OR 3.7, CI 95% 1.2-12), low education (OR 2.1, CI 95% 1.1-4.2), previous stroke (OR 3.6, CI 95% 1.2-11), and cerebral atrophy (OR 3.8, CI 95% 1.7-8.3) were independently associated with prestroke dementia in the logistic regression analysis.

CONCLUSIONS

Fifteen percent of stroke patients have prestroke dementia and they have a worse outcome. Factors associated with prestroke dementia are reminiscent both of degenerative and vascular brain pathology.

Immunohistochemical study of constitutive neuronal and inducible nitric oxide synthase in the central nervous system of goat with natural listeriosis

The expression of both constitutive and inducible forms of nitric oxide synthase (NOS) was investigated by immunohistochemical staining of formalin-fixed paraffin-embedded sections in normal and Listeria monocytogenes-infected brains of goats. In normal control goats, a small number of neurons showed immunoreactivity of both iNOS and nNOS, and the number of iNOS-positive neurons was higher than the number of nNOS-positive neurons. In natural listeriosis, listeria antigens were easily immunostained in the inflammatory cells of microabscesses. In this lesion, the immunoreactivity of iNOS in neurons was more intense than the control, but nNOS was not. In microabscesses, nNOS was weakly visualized in macrophages and neutrophils, while iNOS was expressed in macrophages, but not in neutrophils. These findings suggest that normal caprine brain cells, including neurons, constitutively express iNOS and nNOS, and the expressions of these molecules is increased in Listeria monocytogenes infections. Furthermore, inflammatory cells, including macrophages, expressing both nNOS and iNOS may play important roles in the pathogenesis of bacterial meningoencephalitis in goat.

Production and evaluation criteria of specific monoclonal antibodies to the hemagglutinin of the H7N2 subtype of avian influenza virus

To enhance the rapidity in diagnosing the spread of avian influenza virus (AIV) in chicken layer flocks, studies were initiated to develop more sensitive and specific immunological and molecular methods for the detection of AIV. In this study, the purification of the hemagglutinin protein (H) from field isolates of H7N2, the production of monoclonal antibodies (MAbs), and their evaluation as diagnostic reagents are reported. Hybridomas were generated by fusion of SP2/0-Ag14 myelomas and spleen cells from immunized mice. Hybridomas secreting antibodies specific for the H protein were assayed by an ELISA and cloned using limiting dilution. The MAbs produced were characterized by hemagglutination inhibition (HI), immunohistochemistry (IHC), indirect fluorescent antibody assay (IFA), Western blots, and IFA flow cytometry using various AIV subtypes (i.e., H4N2, H5N3, H7N2). Of the various MAbs assayed, 6 had consistent and reproducible results in each of the assays used. The results obtained in this investigation enhanced the usage of the MAbs to viral H protein in the surveillance of AIV in chickens.

[Vasopressin and brain death]

Brain death results in the breakdown of effective central regulatory mechanisms of cardiocirculatory stability, even in patients with artificial mechanical ventilation, correction of electrolytic and acid-basic disorders and maximal conventional pharmacological support of the circulation. Recent evidences have shown that the fall of vasopressin levels in the blood circulation significantly influences the cardiocirculatory stability of patients with brain death, and its exogenous administration is defended by many authors for the management of multiorgan donor patients. In this brief review we analyse and discuss some experimental and clinical relevant studies about the role of vasopressin in the control of cardiocirculatory stability in brain death, and its potential usefulness in the management of multiorgan donor. We conclude that the role of vasopressin in the pathophysiology of brain death and its usefulness as a pharmacological agent in the management of multiorgan donor are not well elucidated, deserving further investigations.

[Blood pressure in school children and adolescents - The Belo Horizonte study]

OBJECTIVE: To investigate epidemiological aspects of blood pressure (BP) levels, and the prevalence of arterial hypertension in a representative sample of the whole elementary and high school population of the city of Belo Horizonte (state of Minas Gerais, southeastern Brazil). To describe the blood pressure levels found and the prevalence of BP levels above the 90th and 95th percentiles in the first and second measurements. To evaluate prevalence using four different normality references separately to assess the impact of choice of reference. To study the frequency at which the studentś blood pressure has been evaluated.METHODS: In an observational cross-sectional epidemiological study, we studied a sample of 1005 students, aged 6 to 18 year, randomized from an universe of 486,166 students from the 521 public and private elementary and high schools in the city. Each student was evaluated by means of a personal interview, anthropometric measurements, and two blood pressure measurements in a single visit and at a 10-minute interval.RESULTS: The systolic and diastolic blood pressure levels, by age and gender, were slightly lower than those described by the Task Force Report (1987) and by Rosner et al. (1993). The prevalence of BP levels (systolic or diastolic) over the 95th percentile were, according to the reference used: 8.7% - Task Force Report (1987); 5.5% - Rosner et al. (1993); 6.5% - Update on the Task Force Report (1996); and 9.8% - the 95th percentile from our own study. In the second measurement these prevalence rates dropped to 4.9%; 2.4%; 3.5% and 5.8%, respectively.CONCLUSIONS: We present a detailed description (mean values and standard deviations, and the 90th, 95th and 99th percentiles by age and gender) of the BP levels found in both measurements. Mean values and upper percentiles found in this study are very close to those found in the American references, which validates the current use of these references in Brazil. The prevalence of 9.0% of BP levels above the 90th percentile in two measurements made at random hints at the number of children who should be monitored for hypertension, and reinforces the importance of routine evaluation of blood pressure at every pediatric examination.

Skin and soft-tissue infections after injury in the ocean: culture methods and antibiotic therapy for marine bacteria

Isolated organisms from two common Indo-Pacific marine animals (Echinometra mathaei urchins and Acanthaster planci sea stars) likely to cause puncture wounds to recreational beachcombers, diverse, or operational military forces during amphibious assaults demonstrate why practitioners should consider their first choice for potential antibiotic therapy differently from their usual favorite antibiotics. The effects of thiosulfate-citrate-bile-sucrose (TCBS) agar, varying salt concentrations in the standard media, and comparison of room temperature incubation versus use of the 30 degrees C (86 degrees F) incubator are reviewed. The yield of pathogenic marine bacteria is increased if TCBS agar is used and more than one temperature is used for incubation. A potentially significant human pathogen, Vibrio vulnificus, appears to be ubiquitous.

Neosporosis-associated bovine abortion in Pennsylvania

Neospora caninum was found in fetal tissues of 34 of 688 cases of bovine abortion submitted to the Pennsylvania Animal Diagnostic Laboratory System during the period from May 1994 to November 1996. The aborted fetuses ranged in gestational age from 3 to 8 months. Microscopic lesions consisted primarily of encephalitis and myocarditis. A labeled (strept) avidin-biotin staining procedure using anti-N. caninum polyclonal rabbit serum revealed N. caninum organisms within the fetal brain (27 of 27), heart (10 of 13), placenta (5 of 6), kidney (2 of 2), liver (1 of 4) and skeletal muscle (1 of 1).

Aneurysmal bone cyst of the patella

Aneurysmal bone cysts are uncommon lesions accounting for less than 1% of reported primary bone tumors. This case study reports the ninth primary aneurysmal bone cyst of the patella, and the second to be reported in a white male patient. The scarcity of reports in this vulnerable site may refute trauma as the cause. If the articular surface is spared, this lesion can be treated successfully by curettage and bone grafting, once a definitive diagnosis is made.

Bovine platelets contain a 280 kDa microtubule-associated protein antigenically related to brain MAP 2

Resting bovine platelets contain a microtubule coil which reorganizes into linear arrays upon thrombin activation. Microtubule arrays in both resting and activated platelets are extensively cross-linked. In an effort to determine the proteins responsible for this cross-linking, we have developed a method to isolate taxol-stabilized microtubule coils directly from platelet-rich plasma. Negatively stained coils are still cross-linked, and fine filamentous projections are seen between adjacent microtubules. Critical-point-dried rotary shadowed replicas of these coils most clearly demonstrate the projections radiating from individual microtubules as well as along the microtubule coil. Sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) analysis of isolated coils shows many microtubule-associated proteins (MAPs) present in addition to tubulin. One of these proteins, a 280 kDa MAP, cross-reacts with an antibody to bovine brain MAP 2 by immunoblot analysis. Immunofluorescence localization of this protein with both monoclonal and polyclonal antibodies demonstrates that it is associated with the microtubule coil in resting platelets and with the linear microtubule array present after thrombin activation. Immunoelectron microscopic localization demonstrates that projections from individual microtubules are labeled by the antibodies. We suggest that this MAP, along with several other potential MAPs, is responsible for the cross-linking and stability of bovine platelet microtubules.

The application of Miller's elastic stain to glycol methacrylate tissue sections

The application of Miller's dilute elastic stain followed sequentially by Gill's III hematoxylin and a fast green counterstain produced a reliable and consistent method for differentially staining elastic fibers, nuclei, muscle and collagen in glycol methacrylate tissue sections. Evaluation of different methods of fixation and conditions of staining on animal tissue sections showed that elastic fibers in both perfusion and immersion fixed tissues can be intensely stained. The stability of Miller's elastic stain offers the potential of a commercially available histological stain reagent for coarse and fine elastic fibers in glycol methacrylate tissue sections.