Factor XIII deficiency diagnosis: Challenges and tools

Factor XIII deficiency (FXIIID) is a rare hereditary bleeding disorder arising from heterogeneous mutations, which can lead to life-threatening hemorrhage. The diagnosis of FXIIID is challenging due to normal standard coagulation assays requiring specific FXIII assays for diagnosis, which is especially difficult in developing countries. This report presents an overview of FXIIID diagnosis and laboratory methods and suggests an algorithm to improve diagnostic efficiency and prevent missed or delayed FXIIID diagnosis. Assays measuring FXIII activity: The currently available assays utilized to diagnose FXIIID, including an overview of their complexity, reliability, sensitivity, and specificity, as well as mutational analysis are reviewed. The use of a FXIII inhibitor assay is described. Diagnostic tools in FXIIID: Many laboratories are not equipped with quantitative FXIII activity assays, and if available, limitations in lower activity ranges are important to consider. Clot solubility tests are not standardized, have a low sensitivity, and are therefore not recommended as routine screening test; however, they are the first screening test in almost all coagulation laboratories in developing countries. To minimize the number of patients with undiagnosed FXIIID, test quality should be improved in less well-equipped laboratories. Common country-specific mutations may facilitate diagnosis through targeted genetic analysis in reference laboratories in suspected cases. However, genetic analysis may not be feasible in every country and may miss spontaneous mutations. Centralized FXIII activity measurements should also be considered. An algorithm for diagnosis of FXIIID including different approaches dependent upon laboratory capability is proposed.

Mixed-level orthogonal array design for the optimization of solid-phase extraction of some pesticides from surface water

An orthogonal array design (OAD), OA32(4(1) x 2(28)), was employed as a chemometric method for the optimization of the solid-phase extraction (SPE) of atrazine, diazinon, ametryn and fenthion in surface water. Seven parameters: the type of eluting solvent, type of sorbent, flow-rate of eluting solvent, sample pH, sample volume, elution volume, addition of modifier and flow-rate of water sample were studied and optimized by a mixed-level OAD. The effects of these factors and some two-variable interactions on the recovery of the pesticides were quantitatively evaluated by the analysis of variance and percentage contribution techniques. The final optimized condition was employed for the SPE of selected micro-organic pollutants from Karoun river water, south of Iran. Atrazine and ametryn were tentatively identified and determined at the 0.7 and 0.9 microg l(-1) level, respectively.

Association of CTSZ rs34069356 and MC3R rs6127698 gene polymorphisms with pulmonary tuberculosis

OBJECTIVE

To evaluate the possible association between cathepsin Z (CTSZ) rs34069356 C/T (Ala286Thr) and melanocortin-3 receptor (MC3R) rs6127698 G>T (-484 G/T) gene polymorphisms and pulmonary tuberculosis (PTB) in an Iranian sample population.

DESIGN

This case-control study included 150 PTB patients and 177 healthy subjects. Tetra amplification refractory mutation system-polymerase chain reaction was used to detect polymorphisms.

RESULTS

Our findings revealed that the MC3R rs6127698 TT genotype increased the risk of PTB compared with GG (additive model: OR 2.24, 95%CI 1.13-4.64, P = 0.021) as well as GG+GT (recessive model: OR 1.89, 95%CI 1.13-3.18, P = 0.016). The rs6127698 T allele increased the risk of PTB (OR 1.56, 95%CI 1.14-2.13, P = 0.005) compared to the G allele. The CTSZ rs34069356 polymorphism was not associated with PTB in additive-, dominant- and recessive-tested inheritance models (P > 0.05).

CONCLUSION

Our data suggest that MC3R rs6127698, but not CTSZ rs34069356 polymorphism, is associated with PTB in a sample Iranian population.

R620W functional polymorphism of protein tyrosine phosphatase non-receptor type 22 is not associated with pulmonary tuberculosis in Zahedan, southeast Iran

The protein tyrosine phosphatase non-receptor type 22 (PTPN22) gene, which encodes an intracellular lymphoid-specific phosphatase, is considered an important regulator of T-cell activation. We investigated a possible association between the PTPN22 C1858T (R620W) polymorphism and pulmonary tuberculosis in an Iranian population. Single nucleotide polymorphisms of PTPN22 C1858T (rs2476601) were genotyped in 172 pulmonary tuberculosis cases and 204 normal subjects from Zaheden, Iran. Frequencies of genotypes CC, CT and TT of the PTPN22 C1858T polymorphism were 98.3, 1.7 and 0% in the pulmonary tuberculosis patients, and 96.1, 3.9 and 0% in the control group, respectively (P = 0.239). The frequency of the minor (T) allele was 0.8% in pulmonary tuberculosis patients and 2.0% in controls. Significant differences were not observed in genotype or allele frequencies of PTPN22 C1858T in the comparison between pulmonary tuberculosis patients and healthy subjects in our Iranian population sample.

Diabetes as the cause of end-stage renal disease affects the pattern of post kidney transplant rehospitalizations

INTRODUCTION

Although there are reports that link diabetes-induced end-stage renal disease (ESRD) with several post renal transplantation complications and conditions, few studies have directly focused on this issue. This study compared the pattern of rehospitalizations after renal transplantation among diabetic versus nondiabetic ESRD patients, measuring causes, length of stay, outcomes and costs.

METHODS

We retrospectively reviewed 366 randomly selected rehospitalization records of kidney transplant recipients between 1994 and 2006, including 69 who underwent renal transplantation due to diabetic nephropathy and 297, due to nondiabetic ESRD. We compared the two groups with respect to demographic and clinical variables: donor source, readmission pattern, rehospitalization cause, time interval between transplantation and hospitalization (T-H time), length of hospital stay (LOS), and intensive care unit (ICU) admission, hospital charges, and inpatient outcomes of graft loss and mortality.

RESULTS

The diabetes group, compared with nondiabetic group, had a greater mean age (53 +/- SD vs. 39 +/- SD years), proportion of admissions due to infections (44.9% vs. 32%) or renal dysfunction (14.5% vs. 29.6%), mean hospital charges ($5056 vs. $3046), and hospital mortality (18% vs. 4.3%; P<.05). Diabetic patients were readmitted sooner after transplantation than nondiabetic patients (11 vs. 18 months; P<.05). There was no difference between the groups with regard to gender, donor source, LOS, ICU admission, and graft loss.

CONCLUSION

The etiology of ESRD should be considered for scheduling post renal transplantation follow-up. Renal transplant recipients with diabetes-induced ESRD need further attention in follow-up programs.

Molecular basis and prenatal diagnosis of β-thalassemia among Balouch population in Iran

OBJECTIVE

To determine the molecular spectrum of β-thalassemia mutations among at-risk Balouch couples in Iran.

METHODS

Mutations' detection in DNAs extracted from the blood of partners of at-risk couples was characterized, and chorion villus sampling by amplification refractory mutation system and DNA sequencing was performed. Fetal diagnosis was also confirmed by linkage analysis.

RESULTS

Out of a total of 1234 at-risk Balouch couples referred to the center for prenatal diagnosis (PND) from June 2002 to June 2010, a high percentage of '67.4%' were from consanguineous marriages and 37.4% had between one and four affected children. The trend in referring gradually increased from 34 cases in 2002 to 357 cases in 2010. The astonishing finding was that, unlike most previous studies, only IVS 1-5 with an unusual frequency of 87.20% along with codon 8/9 (+G) with 4% constitutes about 91% of mutations. Altogether, 729 PNDs were made in 583 couples, 25% of whom had over one PND, and surprisingly five PNDs were made in the same woman within just 8 years.

CONCLUSION

Regarding the limited types of frequent mutations among Balouch population, it is hopefully believed that the incidence of β-thalassemia could be controlled by a correct diagnosis in the due time.

Effect of processing route on the surface properties of amorphous indomethacin measured by inverse gas chromatography

The aim of this study was to investigate the effect of processing route (i.e., quench cooling and ball milling) on the surface energy heterogeneity and surface chemistry of indomethacin (IMC). Recently developed inverse gas chromatography (IGC) methodology at finite concentrations was employed to determine the surface energy distributions of crystalline, quench cooled and milled IMC samples. Surface properties of crystalline and processed IMC were measurably different as determined by the IGC and other conventional characterization techniques: differential scanning calorimetry and powder X-ray diffraction. Quench cooled IMC was in fully amorphous form. Milled IMC showed no amorphous character by calorimetric or X-ray diffraction studies. It was demonstrated that both processed IMC samples were energetically more active than the crystalline IMC. In particular, milled IMC exhibited a relatively higher dispersive surface energy and higher surface basicity (electron donor capability). This may be attributed to the creation of surface defect sites or exposure of higher energy crystal facets during the milling process. This study confirms that processing route has notable influence on the surface energy distribution and surface acid-base character. IGC was demonstrated as a powerful technique for investigating surface properties of real-world, heterogeneous pharmaceutical materials.

Prolonged rehospitalizations following renal transplantation: causes, risk factors, and outcomes

BACKGROUND

Although some studies have described rehospitalization after transplantation, few have focused on risk factors and consequences of prolonged hospital stay. Our goal was to determine the causes, risk factors, and outcomes of prolonged rehospitalizations after renal transplantation.

PATIENTS AND METHODS

In this retrospective study, 574 randomly selected rehospitalization records of kidney transplant recipients were reviewed from 1994 to 2006. Admissions were divided into group 1, prolonged stay (length of stay >14 days, n=149), and group II, short stay (length of stay <or=14 days, n=425). Demographic data, cause of end-stage renal disease (ESRD), cause of readmission, ICU admission, time interval between transplantation and rehospitalization, costs, and in-patient mortality were compared between the two groups.

RESULTS

Mean (+/-SD) hospital stay was 10.6 +/- 9.8 days. Median hospital stay was 5 days for renal stones, 7 days for surgical complications, 8 days for malignancy, 9 days for infection, and 10 days for renal dysfunction. We found higher rates of ESRD due to diabetes in group I (28% vs. 15.4%; P=.006). Admissions due to infections (56.4% vs 42.4%; P=.003) or renal dysfunctions (55% vs 41.4%; P=.004) were the cause of higher proportions of total hospitalizations with prolonged stay. Prolonged stay also correlated with higher ICU admissions (8.8% vs 2.8%; P=.002) and mortality (6.7% vs 3.05%; P=.001). Mean total hospital cost for short versus prolonged hospitalizations were US$ 586 versus US$ 2750, respectively.

CONCLUSION

In this study, we found that prolonged hospital stays accounted for >62% of all hospital costs; however, they comprised only 26% of the patients. High-risk kidney transplant recipients for prolonged hospitalizations should be closely observed for infections and graft rejection.

Burden of musculoskeletal disorders in Iran during 1990-2017: estimates from the Global Burden of Disease Study 2017

Musculoskeletal diseases (MSDs) are the leading cause of disability and facing them demands updated reports on their burden for efficient policymaking. We showed Iran had the highest female-to-male ratio and highest increase in the burden of musculoskeletal diseases, in the past three decades, worldwide. We further confirmed the role of population aging as the main cause.

PURPOSE

MSDs comprise most of the top causes of years lived with disability (YLDs) worldwide and are rapidly increasing in lower- and middle-income countries. Here, we present disability and mortality due to MSDs in Iran at the national level from 1990 to 2017.

METHODS

We used Global Burden of Disease (GBD) 2017 Study data and standard methodology and presented the burden of MSDs in rates of years of life lost (YLLs), YLDs, and disability-adjusted life years (DALYs) during 1990-2017, for population aged ≥ 5 years old. We further explored attributable risk factors and decomposed the changing trend in DALYs to assess underlying causes.

RESULTS

In Iran, MSDs were responsible for 1.82 million (95%uncertainty interval [UI] 1.3-2.4) DALYs, in 2017. During the past 28 years, with 1.75% annualized percentage change (APC), Iran had the highest percentage increase in the all-ages MSD DALYs rate worldwide, while the age-standardized DALYs APC was negligible. Low back pain was the greatest contributor to DALYs and caused 4.5% of total DALYs. The female population is experiencing considerably higher burden of MSDs, with 115% and 48% higher all-ages YLLs and YLDs rates per 100,000, respectively (YLLs 28.7; YLDs 2629.1), than males (YLLs 13.2; YLDs 1766.1). However, due to wide UIs, difference was not significant. Only 17.6% of MSD YLDs are attributable to assessed risk factors.

CONCLUSION

Despite that MSDs are rising as an important cause of disability in Iran, these conditions are not sufficiently addressed in health policies. There is urgent need for cross-sectoral engagement, especially addressing the MSDs in females.

Prenatal diagnosis in rare bleeding disorders-An unresolved issue?

Intracranial haemorrhage (ICH) is the most dreadful complication, and the main cause of death among patients with rare bleeding disorders (RBD) and prenatal diagnosis (PND) is a preventative lifesaving program. A total of 39 PNDs were reported in the literature through a search on PubMed, EMBASE, SCOPUS and Web of Science databases, most often for congenital factor (F) XIII and FVII deficiencies and rarely in FX, FV deficiencies and afibrinogenemia. The main cause to request a PND is ICH and related morbidity and mortality. Different molecular methods including direct sequencing and linkage analysis as well as polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) for a specific mutation are the most common used methods for PND, while factor assay and combination of molecular and factor assay also were used. In this research, 7 severely affected foetuses were identified during PND including 3 foetuses with FXIII deficiency, 3 with FVII deficiency and 1 with FX deficiency. Out of these 7 cases, intrauterine ICH occurred in 1 case with FXIII deficiency, 1 was electively aborted and 1 case with severe FVII deficiency received intrauterine factor transfusion. Postdelivery ICH was reported for 1 patient with severe FVII deficiency within the first month of life. All other pregnancies were uneventful.

Phenotypic characterization of a tobacco mutant impaired in auxin polar transport

A mutation in tobacco (Nicotiana tabacum L. cv `Xanthi') called lat (low auxin transport) that changes many morphogenic features throughout the life of the plant has been isolated. Abnormalities were observed in seed development, embryogenesis, cotyledon formation, leaf initiation and development, leaf veination pattern, and flower development. Selfed R₂ lat mutant plants set between 60% and 90% fewer seeds than wild-type tobacco, and about 10% of these seeds did not germinate. Non-germinating seeds contained either abnormal embryos or abnormal endosperm tissues. There was no uniformity in the stage at which embryonic development ceased in the aberrant seeds. Seedlings often revealed abnormal and highly varied phenotypes after germination. In some of these cases, cotyledons were heart-shaped, fused, cup-shaped, or cylindrical. Leaf morphology ranged from normal to cup-shaped, and some leaves occasionally produced shoots from the leaf midvein. Flowers ranged from normal to compound with occasional fused floral parts or split petals. Stamens were sometimes petal-like. This unusual assortment of phenotypic changes suggested that the mutation might affect a basic component of plant metabolism. We found that polar transport of indole-3-acetic acid (IAA) was reduced to about 9-19% of the wild-type level in the inflorescence axis of selfed R₂ lat mutants. In addition, supplementation of 1-naphthaleneacetic acid (NAA) to sterile media suppressed some of the abnormalities of the lat mutation so long as the plants grew there. Similarities in the phenotype of embryos, cotyledon and leaf shapes, translocation of labeled IAA, and response to applied NAA indicate that the lat locus of tobacco may be analogous to the pin locus of Arabidopsis, or produce a protein that functions in the same auxin-transport pathway.

Hospitalization Databases: A Tool for Transplantation Monitoring

INTRODUCTION

We sought to account for changes in posttransplant hospitalization patterns in terms of the changes in demographic and transplantation-related variables.

METHODS AND MATERIALS

We retrospectively analyzed 1860 cases of kidney transplantation performed between 1992 and 2004 in terms of demographic and transplantation-related variables. Of the 1860 cases, rehospitalization records in the first year posttransplantation were available for 1152 cases, which were assessed for causes of admission, mortality, graft loss, length of stay, and hospital charges.

RESULTS

The pattern of rehospitalizations showed the following trends: (1) Increased rate of infection; (2) Decreased rate of graft rejection; and (3) Peak costs of rehospitalization between 1999 and 2000.

CONCLUSION

We believed that the increased infection rate and decreased rejection rate may have been related at least partly to the shift in the treatment protocol from azathioprine-based to mycophenolate mofetil regimens in 2000. Furthermore, the peak in the relative frequency of diabetes mellitus and hypertension as the etiology of end-stage renal disease among those having undergone transplantation between 1999 and 2000 may have been responsible for the peak in rehospitalization costs and length of hospital stay. We are strongly of the opinion that hospital statistics are a valuable tool for health care policymakers to monitor transplantation outcomes.

A large case series on surgical outcomes in congenital factor XIII deficiency patients in Iran

Essentials Data on surgery in factor XIII (FXIII) deficiency patients are scarce and lack standardized guidelines. Variable dosage of 10-50 U kg-1 was given to FXIII deficiency patients undergoing surgery. Surgical outcomes showed excellent hemostasis with a minimal risk of post-operative complications. Surgery can be performed safely in FXIII deficiency patients following FXIII administration.

SUMMARY

Background The lack of accepted standardized surgical guidelines leads to dependence on the treating physicians' and centers' experiences. Aim Our aim is to evaluate the surgical outcomes of a large group of congenital factor XIII deficiency (FXIIID) patients. Methods A case series study was conducted prior to surgery on congenital FXIIID patients in two major referral centers located in Iran from 2010 to 2016. All patients were on prophylaxis using plasma factor XIII concentrate (10 U kg-1 , every 28 days) except for three patients. Single doses of 10 U kg-1 or 30 U kg-1 plasma factor XIII concentrate were given before a minor procedure and circumcision, respectively. Two doses of plasma factor XIII concentrate, one 30 U kg-1 prior to the procedure and the second dose of 30 U kg-1 on postoperative day 3, were given for major surgery. The dose was 50 U kg-1 both before and after neurosurgical procedures. Results One hundred and sixty-two FXIIID patients underwent minor, major and obstetrical/gynecological surgeries. Median age of the patients was 14 years (ages ranged 15 days to 47 years). The male-to-female ratio was 89/73. Five postoperative complications, two bleeding and three thrombosis, were recorded. Conclusion Our study showed excellent hemostasis in FXIIID patients undergoing surgeries. During the period of these surgeries, we observed only 1.8% postoperative complications. Surgery can be performed safely in FXIIID patients, and our proposed treatment regimens lead to adequate hemostatic coverage with minimal risk, for both minor and major surgeries.

Current understanding in diagnosis and management of factor XIII deficiency

Factor XIII or "fibrin-stabilizing factor," is a transglutaminase circulates in the blood circulation as a hetero tetramer with two catalytic A subunits and two carrier B subunits. This important coagulation factor has a crucial role in clotting cascade and produces strong covalent bonds between soluble formed fibrin monomers during coagulation. This stable cross linked fibrin strands are resistanttodegradationby thefibrinolyticsystem that enablesthe bodyto stoppotential bleeding episodes. In the absence or severe decrease of factor XIII, although the clot is formed, but is rapidly degraded by the fibrinolytic system, and delayed bleedingoccurs.Factor XIII deficiency is an extremely rare bleeding disorder with estimated incidence of 1/2-3000, 000 in the general population. Presumptive diagnosis of factor XIII deficiency was by clot solubility test in 5M urea or 1% monochloroacetic acid environments. In patients with abnormal screening clot solubility test, the disease can be confirmedbymore specifictestssuch as quantitative factor XIII activity assay andFXIIIAgassay.After diagnosis of disease all patients with severe factor XIII deficiency(<1 U/dl) shouldreceive prophylactic substitution therapywith fresh frozen plasma (FFP) and cryoprecipitate as traditional choices or purified concentrateof blood coagulation factor XIII (Fibrogammin P) inorder to control severe and life-threatening clinical complications of factor XIII deficiency.

Glutaraldehyde test for rapid diagnosis of pulmonary tuberculosis

OBJECTIVE

To determine the diagnostic value of blood glutaraldehyde gelification time in pulmonary tuberculosis (PTB).

DESIGN

We analysed the blood gelification time using 2.5% glutaraldehyde in 83 PTB patients, 46 patients with non-tuberculosis pulmonary disease and 43 healthy subjects.

RESULTS

The mean gelification time of PTB patients (556.9 +/- 122.4) is significantly less than non-tuberculosis pulmonary disease (708.0 +/- 100.5) and healthy subjects (821.2 +/- 138.3; P < 0.0001). The optimum cut-off point was 615 seconds by receiver operating characteristic curve analysis. The sensitivity, specificity, positive predictive value and negative predictive value were respectively 85.5%, 89.1%, 93.4% and 77.3% in distinguishing TB from non-PTB patients; and respectively 85.5%, 93.3%, 92.2% and 87.4% in distinguishing PTB patients from controls (non-PTB patients and healthy subjects).

CONCLUSION

Because many centres lack sputum culture capacity and sophisticated radiology facilities, the glutaraldehyde test in conjunction with other conventional methods of diagnosis (sputum smear for acid-fast bacilli and frontal chest X-ray) could be a rapid, easy, cost-effective and reliable test for the diagnosis of PTB.