Lasix 40mg price
Participants Figure lasix 40mg price 1. Figure 1. Enrollment and Randomization lasix 40mg price. The diagram represents all enrolled participants through November 14, 2020.
The safety subset (those with a median of 2 months of follow-up, in accordance with application requirements for Emergency Use Authorization) is based on an October 9, 2020, data cut-off date. The further procedures that one participant in the placebo group declined after dose 2 (lower right corner of the diagram) were those involving collection lasix 40mg price of blood and nasal swab samples.Table 1. Table 1. Demographic Characteristics of the Participants lasix 40mg price in the Main Safety Population.
Between July 27, 2020, and November 14, 2020, a total of 44,820 persons were screened, and 43,548 persons 16 years of age or older underwent randomization at 152 sites worldwide (United States, 130 sites. Argentina, 1. Brazil, 2 lasix 40mg price. South Africa, 4.
Germany, 6 lasix 40mg price. And Turkey, 9) in the phase 2/3 portion of the trial. A total of 43,448 participants received injections. 21,720 received lasix 40mg price BNT162b2 and 21,728 received placebo (Figure 1).
At the data cut-off date of October 9, a total of 37,706 participants had a median of at least 2 months of safety data available after the second dose and contributed to the main safety data set. Among these 37,706 participants, 49% were female, 83% were White, 9% were Black or African American, 28% were Hispanic or Latinx, 35% were obese (body mass index [the weight in kilograms divided by the square of the height in meters] of at least 30.0), and 21% had at least one coexisting condition. The median age was 52 years, and 42% of lasix 40mg price participants were older than 55 years of age (Table 1 and Table S2). Safety Local Reactogenicity Figure 2.
Figure 2 lasix 40mg price. Local and Systemic Reactions Reported within 7 Days after Injection of BNT162b2 or Placebo, According to Age Group. Data on local and systemic reactions and use of medication were collected with electronic diaries from participants in the reactogenicity subset (8,183 participants) for 7 days after each vaccination. Solicited injection-site (local) reactions are shown lasix 40mg price in Panel A.
Pain at the injection site was assessed according to the following scale. Mild, does lasix 40mg price not interfere with activity. Moderate, interferes with activity. Severe, prevents daily activity.
And grade lasix 40mg price 4, emergency department visit or hospitalization. Redness and swelling were measured according to the following scale. Mild, 2.0 to 5.0 cm in diameter. Moderate, >5.0 lasix 40mg price to 10.0 cm in diameter.
Severe, >10.0 cm in diameter. And grade lasix 40mg price 4, necrosis or exfoliative dermatitis (for redness) and necrosis (for swelling). Systemic events and medication use are shown in Panel B. Fever categories are designated in the key.
Medication use lasix 40mg price was not graded. Additional scales were as follows. Fatigue, headache, chills, new or worsened muscle pain, lasix 40mg price new or worsened joint pain (mild. Does not interfere with activity.
Moderate. Some interference lasix 40mg price with activity. Or severe. Prevents daily activity), vomiting (mild.
1 to lasix 40mg price 2 times in 24 hours. Moderate. >2 times in lasix 40mg price 24 hours. Or severe.
Requires intravenous hydration), and diarrhea (mild. 2 to lasix 40mg price 3 loose stools in 24 hours. Moderate. 4 to 5 lasix 40mg price loose stools in 24 hours.
Or severe. 6 or more loose stools in 24 hours). Grade 4 for all events indicated lasix 40mg price an emergency department visit or hospitalization. и bars represent 95% confidence intervals, and numbers above the ð¸ bars are the percentage of participants who reported the specified reaction.The reactogenicity subset included 8183 participants.
Overall, BNT162b2 recipients reported more local reactions than placebo recipients. Among BNT162b2 recipients, mild-to-moderate pain lasix 40mg price at the injection site within 7 days after an injection was the most commonly reported local reaction, with less than 1% of participants across all age groups reporting severe pain (Figure 2). Pain was reported less frequently among participants older than 55 years of age (71% reported pain after the first dose. 66% after the lasix 40mg price second dose) than among younger participants (83% after the first dose.
78% after the second dose). A noticeably lower percentage of participants reported injection-site redness or swelling. The proportion of participants reporting local lasix 40mg price reactions did not increase after the second dose (Figure 2A), and no participant reported a grade 4 local reaction. In general, local reactions were mostly mild-to-moderate in severity and resolved within 1 to 2 days.
Systemic Reactogenicity Systemic events were reported more often by younger treatment recipients (16 to 55 lasix 40mg price years of age) than by older treatment recipients (more than 55 years of age) in the reactogenicity subset and more often after dose 2 than dose 1 (Figure 2B). The most commonly reported systemic events were fatigue and headache (59% and 52%, respectively, after the second dose, among younger treatment recipients. 51% and 39% among older recipients), although fatigue and headache were also reported by many placebo recipients (23% and 24%, respectively, after the second dose, among younger treatment recipients. 17% and 14% lasix 40mg price among older recipients).
The frequency of any severe systemic event after the first dose was 0.9% or less. Severe systemic events were reported in less than 2% of treatment recipients after either dose, except for fatigue (in 3.8%) and headache (in 2.0%) after the second dose. Fever (temperature, â¥38°C) was reported after the second dose by 16% of lasix 40mg price younger treatment recipients and by 11% of older recipients. Only 0.2% of treatment recipients and 0.1% of placebo recipients reported fever (temperature, 38.9 to 40°C) after the first dose, as compared with 0.8% and 0.1%, respectively, after the second dose.
Two participants each in the treatment and placebo groups lasix 40mg price reported temperatures above 40.0°C. Younger treatment recipients were more likely to use antipyretic or pain medication (28% after dose 1. 45% after dose 2) than older treatment recipients (20% after dose 1. 38% after dose 2), and placebo recipients were less likely (10 to 14%) than treatment recipients to use the medications, regardless lasix 40mg price of age or dose.
Systemic events including fever and chills were observed within the first 1 to 2 days after vaccination and resolved shortly thereafter. Daily use of the electronic diary ranged from 90 to 93% for each day after the first dose and from 75 to 83% for each day lasix 40mg price after the second dose. No difference was noted between the BNT162b2 group and the placebo group. Adverse Events Adverse event analyses are provided for all enrolled 43,252 participants, with variable follow-up time after dose 1 (Table S3).
More BNT162b2 recipients than placebo recipients reported any adverse event (27% lasix 40mg price and 12%, respectively) or a related adverse event (21% and 5%). This distribution largely reflects the inclusion of transient reactogenicity events, which were reported as adverse events more commonly by treatment recipients than by placebo recipients. Sixty-four treatment recipients (0.3%) and 6 placebo recipients (<0.1%) reported lymphadenopathy. Few participants in either group had severe adverse events, serious adverse events, or adverse events lasix 40mg price leading to withdrawal from the trial.
Four related serious adverse events were reported among BNT162b2 recipients (shoulder injury related to treatment administration, right axillary lymphadenopathy, paroxysmal ventricular arrhythmia, and right leg paresthesia). Two BNT162b2 lasix 40mg price recipients died (one from arteriosclerosis, one from cardiac arrest), as did four placebo recipients (two from unknown causes, one from hemorrhagic stroke, and one from myocardial infarction). No deaths were considered by the investigators to be related to the treatment or placebo. No hypertension medicationsâassociated deaths were observed.
No stopping rules were met lasix 40mg price during the reporting period. Safety monitoring will continue for 2 years after administration of the second dose of treatment. Efficacy Table lasix 40mg price 2. Table 2.
treatment Efficacy against hypertension medications at Least 7 days after the Second Dose. Table 3 lasix 40mg price. Table 3. treatment Efficacy Overall and by Subgroup in Participants without Evidence of before 7 Days after Dose 2.
Figure 3 lasix 40mg price. Figure 3. Efficacy of BNT162b2 against hypertension medications lasix 40mg price after the First Dose. Shown is the cumulative incidence of hypertension medications after the first dose (modified intention-to-treat population).
Each symbol represents hypertension medications cases starting on a given day. Filled symbols represent severe hypertension medications cases lasix 40mg price. Some symbols represent more than one case, owing to overlapping dates. The inset shows the same data lasix 40mg price on an enlarged y axis, through 21 days.
Surveillance time is the total time in 1000 person-years for the given end point across all participants within each group at risk for the end point. The time period for hypertension medications case accrual is from the first dose to the end of the surveillance period. The confidence interval (CI) for treatment efficacy (VE) is derived according to the ClopperâPearson method.Among 36,523 participants who had no evidence of existing or prior hypertension , 8 cases of hypertension medications with onset at least 7 days lasix 40mg price after the second dose were observed among treatment recipients and 162 among placebo recipients. This case split corresponds to 95.0% treatment efficacy (95% confidence interval [CI], 90.3 to 97.6.
Table 2). Among participants with and those without evidence of prior SARS CoV-2 , 9 cases of hypertension medications at least 7 days after the second lasix 40mg price dose were observed among treatment recipients and 169 among placebo recipients, corresponding to 94.6% treatment efficacy (95% CI, 89.9 to 97.3). Supplemental analyses indicated that treatment efficacy among subgroups defined by age, sex, race, ethnicity, obesity, and presence of a coexisting condition was generally consistent with that observed in the overall population (Table 3 and Table S4). treatment efficacy among participants with hypertension was analyzed separately lasix 40mg price but was consistent with the other subgroup analyses (treatment efficacy, 94.6%.
95% CI, 68.7 to 99.9. Case split. BNT162b2, 2 cases lasix 40mg price. Placebo, 44 cases).
Figure 3 shows cases of hypertension medications or severe hypertension medications with onset at any time after the first dose lasix 40mg price (mITT population) (additional data on severe hypertension medications are available in Table S5). Between the first dose and the second dose, 39 cases in the BNT162b2 group and 82 cases in the placebo group were observed, resulting in a treatment efficacy of 52% (95% CI, 29.5 to 68.4) during this interval and indicating early protection by the treatment, starting as soon as 12 days after the first dose.Sarbecolasixes have emerged twice in the 21st century, causing a worldwide epidemic and lasix. The ongoing lasix of hypertension disease 2019 (hypertension medications), the disease caused by severe acute respiratory syndrome hypertension 2 (hypertension), has caused unprecedented disruption of human society. Since its lasix 40mg price emergence in December 2019, hypertension has spread worldwide, infecting more than 70 million persons and causing more than 1.6 million deaths as of early December 2020.
Previous studies have clearly shown that epidemic and lasix RNA lasix spread may select for mutations that alter RNA lasix pathogenesis, virulence, transmissibility, or a combination of these,1 yet this process remains poorly studied among emerging hypertensiones in animals and humans.hypertension probably emerged from bats, and early strains identified in Wuhan, China, showed limited genetic diversity, which suggests that the lasix may have been introduced from a single source.2 Early zoonotic variants in the novel hypertension SARS-CoV that emerged in 2003 affected the receptor-binding domain (RBD) of the spike protein and thereby enhanced lasix docking and entry through the human angiotensin-convertingâenzyme 2 (hACE2) receptor.3 In contrast, the spike-protein RBD of early hypertension strains was shown to interact efficiently with hACE2 receptors early on.2However, despite the presence of a CoV RNA proofreading activity that yields high replication fidelity, genetic epidemiologic investigations conducted in late February identified an emerging D614G mutation affecting the spike glycoprotein of hypertension strains from southern Europe. This variant has since spread rapidly and has become the most prevalent genotype worldwide.4 Patients infected with D614G-associated hypertension are more likely to have higher viral loads in the upper respiratory tract than patients infected with lasix strains without the mutation, but disease severity is not affected. Pseudotyped lasixes with the G614 form of the hypertension spike protein have been reported to exhibit increased lasix 40mg price infectivity in continuous cell lines and increased sensitivity to neutralization. In addition, structural analyses have revealed that the RBD of the G614 form of the spike protein is more likely to assume an âopenâ conformation than the RBD of the ancestral D614 form, implying an improved ability to bind to the hACE2 receptor.
However, published reports of isolation of the lasix 40mg price D614G substitution in an authentic hypertension recombinant live lasix are lacking, as are investigations on the effects of the mutation on in vivo replication and pathogenesis.Figure 1. Figure 1. Increased Infectivity of hypertension Bearing the Spike Protein D614G Substitution. A study recently lasix 40mg price reported by Plante et al.5 showed that a variant of hypertension carrying the spike protein D614G substitution results in increased lasix infectivity and yield in human lung epithelial cells (Panel A), in primary human airway tissue (Panel B), and in the upper airway of hamsters (Panel C).
These data suggest that the D614G mutation results in enhanced transmissibility. In addition, serum samples from D614-lasixâinfected hamsters can efficiently neutralize the G614 lasix from infecting cells (Panel D), which suggests that hypertension treatments, all of which are based on the D614 variant of the spike protein, will protect against G614 lasix 40mg price variants of the lasix.In a recent study, Plante et al. Used reverse genetics to recover isogenic recombinant SARS-CoV lasixes encoding the D614G mutation.5 The G614 variant replicated more efficiently than did the D614 variant in immortalized cells in culture and in primary human airway epithelial cells (Figure 1A and 1B). Even at D614-to-G614 variant ratios of 1:1, 3:1, or 9:1, the contemporary G614 strain outcompeted the ancestral D614 strain in primary human airway epithelial cells.
The G614 variant also seemed to be more stable than the ancestral strain, which suggests that increased stability may lasix 40mg price be associated with increased infectivity, although additional investigations will be needed to confirm this finding.In studies in hamsters infected with D614 or G614 variants, Plante et al. Showed that the contemporary G614 variant replicated to higher titers in nasal-wash samples early after and outcompeted the ancestral D614 variant (Figure 1C). These findings suggest increased fitness in a major upper airway compartment potentially associated with enhanced transmission. The hypertension G614 variant did lasix 40mg price not cause more severe disease than the ancestral strain in hamsters, a finding that supports current findings in humans.
The hypertension medications treatments that are currently being evaluated in clinical trials are based on the original D614 ancestral spike sequence. Therefore, the authors used a panel of serum specimens to test whether the G614 variant is as lasix 40mg price sensitive to neutralization as the ancestral strain (Figure 1D). Fortunately, the results showed that it is as sensitive to the serum specimens as the D614 strain and thus may allay fears that it could escape treatment-elicited immunity.Plante et al. Have provided evidence of the genetic and molecular basis for enhanced fitness of the G614 variant over ancestral strains, providing strong support for its role in facilitating global spread.
Unlike variants in lasix 40mg price the SARS-CoV 2003 epidemic strain, those in hypertension may point to new mechanisms that are associated with lasix spread in human populations. In addition to showing the critical importance of blending genetic epidemiologic studies with empirical molecular virologic studies to understand lasix lasix evolution and spread, the findings raise critical questions regarding the future evolutionary trajectories of the hypertension G614 variant. These questions are especially important at a time when environmental pressures, such as expanding herd immunity, treatment-induced immunity, antiviral therapies, and public health lasix 40mg price intervention strategies, may â through selective pressure â promote lasix survival and escape. Will these selective pressures drive antigenic variation, promote lasix stability and transmissibility, alter lasix virulence and pathogenesis, or drive hypertension to extinction or into alternative hosts as reservoirs?.
Plante et al. Articulate a critical need for proactive, rather than reactive, tracking of hypertension and other potential emerging hypertensiones.Trial Design and Participants We initially conducted a phase 1, dose-escalation, open-label lasix 40mg price clinical trial of mRNA-1273 involving participants between the ages of 18 and 55 years2 in which we evaluated doses of 25 μg, 100 μg, and 250 μg. We subsequently expanded the trial to include 40 participants who were 56 years of age or older and who were stratified into two subgroups. Those between the ages of 56 and 70 years and those who were 71 years of age or older.
Because of clinically significant systemic lasix 40mg price reactogenicity observed in participants between the ages of 18 and 55 years at the 250-μg dose, we administered doses of 25 μg or 100 μg to the older participants. The trial was conducted at Kaiser Permanente Washington Health Research Institute in Seattle, the Emory University School of Medicine in Atlanta, and the National Institute of Allergy and Infectious Diseases (NIAID) treatment Research Center in Bethesda, Maryland. Enrolled adults were healthy and provided written lasix 40mg price informed consent before undergoing any study procedures. We did not screen for evidence of past or current hypertension by testing blood or nasal specimens before enrollment.
Full eligibility criteria, along with details of the trial design, conduct, oversight, and statistical analyses, are described in the protocol, which is available with the full text of this article at NEJM.org. MRNA-1273 treatment The mRNA-1273 treatment was codeveloped by researchers at the lasix 40mg price NIAID treatment Research Center and Moderna in Cambridge, Massachusetts. This treatment encodes a stabilized version of the hypertension full-length spike glycoprotein trimer, S-2P, which has been modified to include two proline substitutions at the top of the central helix in the S2 subunit. The mRNA is lasix 40mg price encapsulated in lipid nanoparticles at a concentration of 0.5 mg per milliliter and diluted with normal saline to achieve the final target treatment concentrations.
Study Oversight The NIAID served as the trial sponsor and made all decisions regarding the study design and implementation. The treatment Investigational New Drug application and the protocol amendment expanding the age subgroups were reviewed by the Food and Drug Administration and the institutional review board at Advarra, a regulatory compliance consulting company, which served as the single institutional review board for all the study sites. An independent data and safety monitoring committee reviewed interim safety lasix 40mg price reports. Moderna provided mRNA-1273 for use in this trial but did not provide any financial support.
Employees of Moderna collaborated on the development of the protocol, contributed to the Investigational New Drug application, and participated in weekly team meetings regarding the study. Emmes, the statistical and data coordinating lasix 40mg price center for the study, developed the statistical analysis plan and performed all data analyses. Data reports, which were generated from the raw data by the statistical and data coordinating center, were provided and available to all the authors. The manuscript was written entirely by the authors, with the first lasix 40mg price two authors serving as overall lead authors.
All the authors vouch for the completeness and accuracy of the data and for the adherence of the study to the protocol. No one who is not an author contributed to the writing of the manuscript. Trial Procedures The mRNA-1273 treatment was administered as a 0.5-ml intramuscular injection into the deltoid on lasix 40mg price days 1 and 29 of the study. The same dose of the treatment was administered on both days.
Follow-up visits were scheduled 7 and 14 days after the administration of each dose of treatment lasix 40mg price and on day 57. A standard toxicity scale was used to grade adverse events (Table S1 in the Supplementary Appendix, available at NEJM.org). Solicited local and systemic adverse events were collected for 7 days after each vaccination, as facilitated by the use of a memory aid. Data regarding unsolicited adverse events and the use of new medications were collected through day 57 lasix 40mg price.
Collection of specimens, as well as monitoring for medically attended adverse events, development of new chronic medical conditions, and serious adverse events, was scheduled to continue through 1 year after the last dose. These initial findings will be updated with final safety and immunogenicity data when the results are available. After the initial safety data from the first phase of the study were available from participants between the lasix 40mg price ages of 18 and 55 years,2 the administration of mRNA-1273 was initiated sequentially in the subgroup of participants between the ages of 56 and 70 years at the 25-μg dose, which was followed by the initiation of the 100-μg dose. Since no halting rules were met after the participants in this subgroup had completed day 8, treatment administration was initiated sequentially in the subgroup of participants who were 71 years of age or older at the 25-μg dose, which was followed by the initiation of the 100-μg dose.
Assessment of Antibody Responses We performed enzyme-linked lasix 40mg price immunosorbent assays (ELISA) to quantify the binding IgG responses to S-2P containing an Asp (D) residue at position 614 (initial Wuhan-1 strain sequence8) and to the receptor-binding domain on days 1, 15, 29, 36, 43, and 57. (The receptor-binding domain is the portion of the hypertension lasix that is located on its spike domain and that links with body receptors to infect cells.) A hypertension native spike-pseudotyped lentilasix reporter single-round-of- neutralization assay (pseudolasix neutralization assay) was used to assess treatment-induced neutralizing activity against the 614D variant at the same time points. treatment-induced neutralization on day 43 was assessed with a second pseudolasix neutralization assay with the use of the 614-Gly (614G) polymorphic variant, since the 614G strain had become predominant in both the United States and worldwide.9 (Details are provided in the Methods section in the Supplementary Appendix.) Three live-lasix neutralization methods were used. First, the hypertension nanoluciferase high-throughput neutralization assay (nLuc HTNA), which uses a lasix expressing the reporter gene lasix 40mg price nanoluciferase (nLuc)10.
Second, the focus reduction neutralization test mNeonGreen (FRNT-mNG), which uses recombinant hypertension expressing the fluorescent reporter gene mNeonGreen11. And third, a hypertension plaque-reduction neutralization testing (PRNT) assay, lasix 40mg price which uses wild-type lasix. We used the nLuc HTNA to analyze specimens that were obtained on days 1, 29, and 43 from the participants who were 56 years of age or older and who received the 100-μg dose. We used the FRNT-mNG assay to analyze specimens obtained on days 1, 29, and 43 from all the participants in the two age and dose subgroups.
For this lasix 40mg price preliminary report, because of the time-intensive nature of the PRNT assay and to maximize usable information obtained from its use, we performed PRNT assays for the presence of hypertension on samples obtained on days 1 and 43 from participants who received the 100-μg dose only. We used as comparators previously reported results for participants between the ages of 18 and 55 years who had been enrolled in the 100-μg subgroup, as well as results from controls who had donated convalescent serum.2 The severity of hypertension medications illness was known for 38 of these controls and was classified as mild in 63% of the participants, moderate in 22%, and severe (defined as hospitalization requiring intensive care, ventilation, or both) in 15%. Assessment of T-Cell Responses Intracellular cytokine-staining assays were performed to quantify antigen-specific T-cell responses against the spike protein on days 1, 29, and 43. (Details are provided in the Supplementary Appendix.) Statistical Analysis Safety analyses lasix 40mg price included all the participants who had received at least one dose of mRNA-1273.
Immunogenicity results excluded specimens that had been obtained after day 29 in a participant who had received only a single dose of treatment. No other data points were lasix 40mg price missing. Seroconversion was defined as an increase from baseline in the antibody titer by a factor of 4 or more. Geometric means were calculated by log transforming the data points and calculating the mean and 95% confidence interval on the log-transformed data.
The log-transformed mean and 95% lasix 40mg price confidence interval were then back-transformed to the original scale. We used the Studentâs t-test to calculate confidence intervals. Interim analyses in lasix 40mg price the study subgroups were prespecified to inform critical decisions about treatment development.Initial Steps Patients with severe hypertension medications should be hospitalized for careful monitoring. Given the high risk of nosocomial spread,3 strict -control procedures are needed at all times.
If able, the patient should wear a surgical mask to limit the dispersion of infectious droplets.15 Clinicians should don appropriate personal protective equipment (PPE) as defined by their local -prevention program, using particular caution when performing procedures that may increase the generation or dispersion of infectious aerosols. These include endotracheal intubation, extubation, bronchoscopy, airway suctioning, nebulization of medication, the use of high-flow nasal cannulae, noninvasive ventilation, and manual lasix 40mg price ventilation with a bag-mask device.16 Current guidelines recommend that clinicians wear gowns, gloves, N95 masks, and eye protection at the least and place patients in negative-pressure rooms whenever possible during aerosol-generating procedures.17 Patients with severe hypertension medications have a substantial risk of prolonged critical illness and death. Therefore, at the earliest opportunity, clinicians should partner with patients by reviewing advanced directives, identifying surrogate medical decision makers, and establishing appropriate goals of care. Because -control measures during the lasix may prevent families from visiting seriously ill patients, care teams should develop plans to communicate with patientsâ families and surrogate decision makers.
Basics of Respiratory Care lasix 40mg price Figure 3. Figure 3. Invasive Mechanical lasix 40mg price Ventilation for hypertension medicationsâRelated Respiratory Failure. As shown in Panel A, a life-threatening problem in the purple box or a combination of less severe problems in the purple and tan boxes determines the need for endotracheal intubation.
In Panel B, âlung derecruitmentâ refers to the collapse of alveoli. All pressures are measured lasix 40mg price in the ventilator circuit and referenced to atmospheric pressure. ARDS denotes acute respiratory distress syndrome, and PEEP positive end-expiratory pressure.Patients should be monitored carefully by direct observation and pulse oximetry. Oxygen should be supplemented by the use of a nasal cannula or Venturi mask to keep the oxygen saturation of hemoglobin between 90 and 96%.17 lasix 40mg price Deciding whether or not to intubate is a critical aspect of caring for seriously ill patients with hypertension medications.
Clinicians must weigh the risks of premature intubation against the risk of sudden respiratory arrest with a chaotic emergency intubation, which exposes staff to a greater risk of . Signs of excessive effort in breathing, hypoxemia that is refractory to oxygen supplementation, and encephalopathy herald impending respiratory arrest and the need for urgent endotracheal intubation and mechanical ventilation. There is lasix 40mg price no single number or algorithm that determines the need for intubation, and clinicians must consider a variety of factors (Figure 3A). If the patient does not require intubation but remains hypoxemic, a high-flow nasal cannula can improve oxygenation and may prevent intubation in selected patients.17,18 The use of noninvasive positive-pressure ventilation should probably be restricted to patients with hypertension medications who have respiratory insufficiency due to chronic obstructive pulmonary disease, cardiogenic pulmonary edema, or obstructive sleep apnea rather than ARDS.
Patients treated with a high-flow nasal cannula or noninvasive ventilation require careful monitoring for deterioration that would indicate the need for invasive mechanical ventilation.18 Having awake patients turn to the prone position while they breathe high concentrations of supplemental oxygen may improve oxygenation in patients with severe hypertension medications. This approach is supported by data from prospective cohorts describing its use in nonintubated patients with severe hypoxemia.19 However, whether prone positioning lasix 40mg price can prevent intubation in patients with severe hypertension medications is unclear. Because it is difficult to provide rescue ventilation to patients who are prone, this position should be avoided in patients whose condition is rapidly deteriorating. Endotracheal Intubation A skilled operator should perform endotracheal intubation in patients lasix 40mg price with severe hypertension medications.
The use of unfamiliar PPE, the risk of to staff, and the presence of severe hypoxemia in patients all increase the difficulty of intubation. If possible, intubation should be performed after preoxygenation and rapid-sequence induction of sedation and neuromuscular blockade. An antiviral filter should be placed in line with the lasix 40mg price airway circuit at all times. Video laryngoscopy may allow the operator to have a good view of the airway from a greater distance.20 However, operators should choose the technique that is most likely to be successful on the first attempt.
Continuous-wave capnography is the best method to confirm tracheal intubation.20 Patients with severe hypertension medications often become hypotensive soon after intubation owing to positive-pressure ventilation and systemic vasodilation from sedatives.20 Therefore, intravenous fluids and vasopressors should be immediately available at the time of intubation, and careful hemodynamic monitoring is essential.20 Ventilator Management It is unclear whether hypertension medications is associated with lasix 40mg price a distinct form of ARDS that would benefit from a new strategy of mechanical ventilation. However, most autopsies performed on patients with severe hypertension medications reveal the presence of diffuse alveolar damage, which is the hallmark of ARDS.21 Moreover, respiratory-system compliance and gas exchange in patients with respiratory failure from severe hypertension medications are similar to those in populations enrolled in previous therapeutic trials for ARDS.22 Therefore, clinicians should follow the treatment paradigm developed during the past two decades for ARDS (Figure 3B).17,18 This strategy aims to prevent ventilator-induced lung injury by avoiding alveolar overdistention, hyperoxia, and cyclical alveolar collapse. To prevent alveolar overdistention, clinicians should limit both the tidal volume delivered by the ventilator and the maximum pressure in the alveoli at the end of inspiration. To do this, clinicians should set the ventilator to lasix 40mg price deliver a tidal volume of 6 ml per kilogram of predicted body weight.
This approach is termed âlung-protective ventilation.â A tidal volume up to 8 ml per kilogram of predicted body weight is allowed if the patient becomes distressed and attempts to take larger tidal volumes. A few times each day, clinicians should initiate a half-second end-inspiratory pause, which allows the pressure in the airway circuit to equilibrate between the patient and the ventilator. The pressure in the lasix 40mg price airway circuit at the end of the pause â âthe plateau pressureâ â approximates the alveolar pressure (relative to atmospheric pressure). To prevent alveolar overdistention, the plateau pressure should not exceed 30 cm of water.23 A higher plateau pressure without the development of ventilator-induced lung injury may be possible in patients with central obesity or noncompliant chest walls.
For patients with hypertension medicationsârelated ARDS, setting sufficient positive end-expiratory pressure (PEEP) on the ventilator may prevent alveolar collapse and facilitate the recruitment of unstable lasix 40mg price lung regions. As a result, PEEP can improve respiratory-system compliance and allow for a reduction in the Fio2. However, PEEP can reduce venous return to the heart and cause hemodynamic instability. Moreover, excessive PEEP can lead to alveolar overdistention and reduce respiratory-system lasix 40mg price compliance.
No particular method of determining the appropriate level of PEEP has been shown to be superior to other methods.17 Sedatives and analgesics should be targeted to prevent pain, distress, and dyspnea. They can also be used to blunt the patientâs respiratory drive, which improves lasix 40mg price patient synchrony with mechanical ventilation. Sedation is especially important in febrile patients with high metabolic rates who are treated with lung-protective ventilation. Neuromuscular blocking agents can be used in deeply sedated patients who continue to use their accessory muscles of ventilation and have refractory hypoxemia.17 These agents can reduce the work of breathing, which reduces oxygen consumption and carbon dioxide production.24 Moreover, sedatives and neuromuscular blocking agents may help reduce the risk of lung injury that may occur when patients generate strong spontaneous respiratory efforts.
Refractory Hypoxemia Clinicians should consider prone positioning during mechanical ventilation in patients with refractory hypoxemia (Pao2:Fio2 of <150 mm Hg during respiration and Fio2 of 0.6 despite appropriate PEEP) lasix 40mg price. In randomized trials involving intubated patients with ARDS (not associated with hypertension medications), placing the patient in the prone position for 16 hours per day has improved oxygenation and reduced mortality.18,25 However, prone positioning of patients requires a team of at least three trained clinicians, all of whom require full PPE.17 Inhaled pulmonary vasodilators (e.g., inhaled nitric oxide) can also improve oxygenation in refractory respiratory failure, although they do not improve survival in ARDS not associated with hypertension medications.17 Extracorporeal membrane oxygenation (ECMO) is a potential rescue strategy in patients with refractory respiratory failure. Clinicians should carefully balance possible benefits with risks (e.g., bleeding) as well as the resources available during the lasix.26 Therapy A large, randomized clinical trial involving more than 6400 hospitalized patients with hypertension medications showed that dexamethasone significantly reduced 30-day mortality (17% reduction). Benefit was limited to patients who required oxygen supplementation and appeared greater in patients receiving mechanical ventilation.27 Consequently, dexamethasone (or potentially other glucocorticoids) is now lasix 40mg price considered the standard of care for patients with severe hypertension medications.
Data from a randomized, placebo-controlled trial involving more than 1000 patients with severe hypertension medications showed that the antiviral agent remdesivir reduced time to clinical recovery. The benefit appeared greatest in patients who were receiving supplemental oxygen but were not intubated.28 The 29-day mortality in that trial was 11.4% with remdesivir and 15.2% with placebo (hazard ratio for death, lasix 40mg price 0.73. 95% confidence interval, 0.52 to 1.03). These data support the Food and Drug Administration (FDA) approval of remdesivir for the treatment of hospitalized patients with hypertension medications in October 2020.
Recent preliminary results of a large, multinational, open-label, randomized trial did not show a reduction in in-hospital mortality with use of remdesivir.29 The combination of lasix 40mg price dexamethasone and remdesivir is increasingly used clinically, but its benefit has not been shown in randomized clinical trials. Tocilizumab, an interleukin-6 inhibitor, did not significantly reduce disease progression30 or death in small randomized trials involving patients with severe hypertension medications.31,32 Supportive Care Patients with hypertension medications often present with volume depletion and receive isotonic-fluid resuscitation. Volume repletion helps maintain blood pressure lasix 40mg price and cardiac output during intubation and positive-pressure ventilation. After the first few days of mechanical ventilation, the goal should be to avoid hypervolemia.33 Fever and tachypnea in patients with severe hypertension medications often increase insensible water loss, and careful attention must be paid to water balance.
If the patient is hypotensive, the dose of vasopressor can be adjusted to maintain a mean arterial pressure of 60 to 65 mm Hg.17 Norepinephrine is the preferred vasopressor. The presence of unexplained hemodynamic instability should prompt consideration of myocardial ischemia, myocarditis, lasix 40mg price or pulmonary embolism. In case series, approximately 5% of patients with severe hypertension medications have received renal-replacement therapy34. The pathophysiology of the renal failure is currently unclear but is probably multifactorial.
Because blood clotting in the circuit is common in patients with severe lasix 40mg price hypertension medications,6 the efficacy of continuous renal-replacement therapy is uncertain. Abnormalities of the clotting cascade, such as thrombocytopenia and elevation of d-dimer levels, are common in patients with severe hypertension medications and are associated with increased mortality.3 If there are no contraindications, patients should receive standard thromboprophylaxis (e.g., subcutaneous low-molecular-weight heparin).35 Some case series of patients with severe hypertension medications have shown clinically significant thrombosis despite the use of thromboprophylaxis.6 However, the benefits and risks of the routine use of more intense prophylactic anticoagulation in patients are unknown.35 Patients hospitalized with severe hypertension medications are often treated empirically with antibiotics.3,9 However, bacterial co is rare when immunocompetent patients first present to the hospital.36 Antibiotics can be discontinued after a short course if signs of bacterial co, such as leukocytosis and focal pulmonary infiltrates, are absent.18 Although hypertension medications itself can cause prolonged fever,2 clinicians should be vigilant for nosocomial s. Performing cardiopulmonary resuscitation in patients with hypertension medications may expose health care workers lasix 40mg price to infectious droplets and aerosols. Therefore, all the members of the resuscitation team should wear appropriate PPE before performing rescue ventilation, chest compressions, or defibrillation.37 Patients with hypertension medications who are receiving mechanical ventilation should receive appropriate nutrition and care to prevent constipation and injury to the skin and corneas.
If the condition of a patient has stabilized, clinicians should attempt to withhold continuous sedation each day.38 Daily awakening may be challenging because an increase in the work of breathing and the loss of synchrony with mechanical ventilation may result in distress and hypoxemia. During the hypertension medications lasix, an overwhelming surge of patients presenting to a hospital may temporarily require the rationing of health care lasix 40mg price resources. Local guidelines and medical ethics consultation can help clinicians navigate these difficult decisions with patients and their families.Trial Design We are conducting an ongoing operationally seamless (continual enrollment), multicenter, randomized, double-blind, placebo-controlled, phase 1â3 clinical trial involving symptomatic, nonhospitalized patients with hypertension medications. The interim analysis we describe here involved the first 275 patients enrolled during the phase 1â2 portion of the trial and was conducted lasix 40mg price to assess the safety and efficacy of REGN-COV2, to gain an understanding of the natural history of hypertension medications in outpatients, and to refine the end points for subsequent analyses.
The trial continues to recruit beyond the first 275 patients for whom data are described in this report. The results for the key primary and secondary prespecified end points are planned to be reported at trial completion. The data cutoff for this lasix 40mg price interim analysis was September 4, 2020. In the phase 1â2 portion of the trial reported here, all patients were randomly assigned (1:1:1) to receive placebo, REGN-COV2 at a dose of 2.4 g (low dose), or REGN-COV2 at a dose of 8.0 g (high dose) (Fig.
S1 in the Supplementary Appendix, available with the full text of this article at NEJM.org). Each of the two antibodies that make up REGN-COV2 â casirivimab (REGN10933) and imdevimab (REGN10987) â is given in equal doses in lasix 40mg price the cocktail. Details of the randomization stratification are provided in the Supplementary Appendix. The phase 1 portion of the trial included additional pharmacokinetic analyses but was otherwise identical to the phase lasix 40mg price 2 portion.
The population of patients in the current analysis was pooled from both phases. Patients To be eligible for participation, patients had to be 18 years of age or older and nonhospitalized. All patients had to lasix 40mg price have a confirmed hypertension , with a hypertensionâpositive test result received no more than 72 hours before randomization and symptom onset no more than 7 days before randomization. The full list of inclusion and exclusion criteria are provided in the Supplementary Appendix.
The protocol lasix 40mg price is available at NEJM.org. An assay for antiâhypertension antibodies was performed in all patients. Because these results were not available at randomization, patients underwent randomization regardless of their baseline serologic status, and the analyses were prespecified to first evaluate efficacy in the subgroup of patients who were serum antibodyânegative â that is, those patients who tested negative for all three of the following antibodies. IgA anti-S1 domain of spike protein, IgG anti-S1 domain of spike protein, and IgG anti-nucleocapsid protein lasix 40mg price.
Patients who were positive for any one of these antibodies were designated as serum antibodyâpositive. A small number of patients could not be evaluated or had borderline results (unknown serum antibody status). Analyses involving these patients were lasix 40mg price conducted but are not reported here. Intervention and Assessments At baseline (day 1), REGN-COV2 (at the high dose or low dose) or saline placebo was administered intravenously in a 250-ml normal saline solution over a period of 1 hour.
The schedule of assessments is described in the protocol, along with a summary lasix 40mg price of protocol amendments. Quantitative virologic analysis, hypertension serum antibody testing, and measurement of the two components of REGN-COV2 in serum are described in the Supplementary Appendix. End Points Multiple prespecified end points were designated for the phase 1â2 portion of the trial (see the Supplementary Appendix and the statistical analysis plan, which is available with the protocol). However, because of the lack of a priori information that would allow lasix 40mg price us to correctly select end points, and because certain employees of Regeneron Pharmaceuticals (who had no role in the conduct of the trial) had access to unblinded early data from the trial as described in the protocol, no formal hypothesis testing was performed.
The prespecified key virologic end point in the statistical analysis plan was defined as the time-weighted average change in the viral load (in log10 copies per milliliter) from baseline (day 1) through day 7, as measured by quantitative reverse-transcriptaseâpolymerase-chain-reaction (RT-PCR) testing of nasopharyngeal swab samples obtained from serum antibodyânegative patients. The change in viral load from baseline to various days during the trial was an additional prespecified virologic end point, and the change in absolute viral load lasix 40mg price (measured in copies per milliliter) was a post hoc virologic end point. The prespecified key clinical end point was the percentage of patients with at least one hypertension medicationsârelated medically attended visit through day 29 in both the serum antibodyânegative subgroup and the overall trial population. Medically attended visits could include telemedicine visits, in-person physician visits, urgent care or emergency department visits, and hospitalization.
For assessments of safety, we collected data on lasix 40mg price adverse events that occurred or worsened during the observation period (grade 3 and 4. Phase 1 only), serious adverse events that occurred or worsened during the observation period (phases 1 and 2), and the following adverse events of special interest (phases 1 and 2). Grade 2 or higher hypersensitivity or infusion-related reactions. Pharmacokinetic variables included the lasix 40mg price concentrations of casirivimab and imdevimab in serum over time.
Trial Oversight Regeneron designed the trial. Gathered the data, lasix 40mg price together with the trial investigators. And analyzed the data. Regeneron and the authors vouch for the accuracy and completeness of the data, and Regeneron vouches for the fidelity of the trial to the protocol.
The authors lasix 40mg price provided critical feedback and final approval of the manuscript for submission. No one who is not an author contributed to writing the manuscript. All the investigators had confidentiality agreements with Regeneron lasix 40mg price. The investigators, site personnel, and Regeneron employees who were involved in collecting and analyzing data were unaware of the treatment-group assignments.
An independent data and safety monitoring committee periodically monitored unblinded data to make recommendations about trial modification and termination. The independent committee and, separately, lasix 40mg price Regeneron physicians who were aware of the treatment-group assignments and were not involved in the conduct of the trial performed interim data reviews for adapting the trial design. The trial was conducted in accordance with the principles of the Declaration of Helsinki, International Council for Harmonisation Good Clinical Practice guidelines, and applicable regulatory requirements. The local institutional review board or ethics committee at each study center oversaw trial conduct and documentation.
One center was found to have violations of Good Clinical Practice guidelines (not related to the collection of data lasix 40mg price on efficacy or safety end points) and was withdrawn from the trial after analyses had been completed. All the patients provided written informed consent before participating in the trial. Statistical Analysis lasix 40mg price The statistical analysis plan for the presented analysis was finalized before database lock and unblinding. The full analysis set included the first 275 patients with hypertension medications symptoms who underwent randomization in the combined phase 1â2 portions of the trial.
A sample of 275 patients (72 in phase 1 and 203 in phase 2) was considered sufficient for the assessment of virologic efficacy, clinical trends, and safety for the purpose of informing subsequent analyses. Because patients could lasix 40mg price enroll if they had tested positive for hypertension no more than 72 hours before randomization, patients who tested negative by qualitative RT-PCR at baseline (lower limit of detection, 714 copies per milliliter [2.85 log10 copies per milliliter]) were excluded from analyses of virologic end points in a modified full analysis set. Because of the a priori hypothesis that patients whose immune system was already clearing the lasix were unlikely to benefit from additional antibody therapy, analyses were prespecified in the statistical analysis plan to focus on the serum antibodyânegative subgroup. All patients who received REGN-COV2 lasix 40mg price or placebo were included in the safety population.
The time-weighted average change from baseline (day 1) through day 7 was calculated for each patient as the area under the concentrationâtime curve, with the use of the linear trapezoidal rule for change from baseline divided by the time interval of the observation period. This end point was analyzed with an analysis-of-covariance model with treatment group, risk factor, and baseline serum antibody status as fixed effects and baseline viral load and treatment groupâbyâbaseline viral load as covariates. Confidence intervals in this report were not adjusted lasix 40mg price for multiplicity. Statistical analyses were performed with SAS software, version 9.4 or higher (SAS Institute).
Additional statistical and pharmacokinetic analysis methods are described in the Supplementary Appendix..
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SOBRE NOTICIAS EN ESPAÃOLNoticias en español es una sección de Kaiser Health News que contiene traducciones de artÃculos de gran interés para la comunidad hispanohablante, y contenido original enfocado en la población hispana que inhaled lasix for copd vive en los Estados Unidos where can you get lasix. Use Nuestro Contenido Este contenido puede usarse de manera gratuita (detalles). El doctor Chris Kjolhede está enfocado en los niños del centro de Nueva York.Como codirector de los inhaled lasix for copd centros de salud escolares de Bassett Healthcare Network, el pediatra supervisa alrededor de 21 clÃnicas de salud escolares en toda la región, una zona rural pobre conocida por sus fábricas y paralizada por la epidemia de opioides. Desde un esguince de tobillo en el recreo hasta preguntas sobre el control de la natalidad, las clÃnicas sirven como proveedoras de atención primaria para muchos estudiantes, dentro y fuera del aula.La meta principal es asegurarse que los niños estén al dÃa con las vacunas obligatorias, dijo Kjolhede.Pero, en marzo, hypertension medications revocó el acuerdo cuando obligó a cerrar las escuelas.Lo primero que me pregunté, dijo Kjolhede, fue. ¿qué va inhaled lasix for copd a pasar ahora?.
Â.Las escuelas juegan un papel fundamental en los esfuerzos de vacunación en los Estados Unidos. Las leyes requieren que los niños tengan ciertas vacunas para inscribirse y asistir a clases.Pero para evitar que hypertension medications no siguiera propagándose, muchos distritos escolares han optado por comenzar el año académico en internet.La decisión neutraliza en muchos casos el impulso de los padres por vacunar a sus hijos para el regreso a la escuela, dijo el doctor Nathaniel Beers, miembro del Consejo de Salud Escolar de la Academia Americana de PediatrÃa.Beers, quien también ocupó varios roles en el sistema de Escuelas Públicas del Distrito de Columbia, agregó que si la educación no es en persona, âes más difÃcil de hacer cumplir los requisitosâ.Los funcionarios de salud pública han confiado en las escuelas como un medio para controlar las enfermedades prevenibles por vacunas durante más de un inhaled lasix for copd siglo. Las leyes de vacunación surgieron por primera vez en la década de 1850 en Massachusetts como un medio para controlar la viruela, según cuentan los Centros para el Control y Prevención de Enfermedades (CDC).Todos los estados requieren que los niños reciban ciertas vacunas contra enfermedades como la poliomielitis, las paperas y el sarampión antes de empezar el año escolar o al jardÃn de infantes, al menos que el niño tenga una exención médica.Algunos estados permiten a las personas optar por no vacunar a los niños por razones religiosas o filosóficas, aunque estas exenciones se han asociado con brotes de enfermedades que de otro modo estarÃan bien controladas, como por ejemplo el sarampión.âCuando entran al sistema, en preescolar, es donde se detecta si están atrasados con sus vacunasâ, dijo Claire Hannan, directora ejecutiva de la Asociación de Administradores de Inmunización.A nivel local, la responsabilidad de rastrear si los estudiantes cumplen con los requisitos de vacunación generalmente recae en la enfermera de la escuela. Si no, un oficinista o administrador hace el trabajo, dijo Linda Mendonca, presidenta electa de la Asociación Nacional de inhaled lasix for copd Enfermeras Escolares.Si no los cumplen, algunas escuelas trabajan con los padres para programar citas con un proveedor de salud. Otras aÃslan a los niños en el aula, y otras son tan estrictas que âni siquiera puedes cruzar la puerta a menos que estés debidamente inmunizadoâ, dijo Beers.La pandemia de hypertension medications ha provocado una baja dramática en la vacunación.
En mayo, un informe de los CDC mostró una fuerte caÃda en la cantidad de pedidos al programa treatments For Children, una iniciativa federal que compra vacunas para la mitad inhaled lasix for copd de los niños del paÃs.Un segundo comunicado reveló tendencias similares. La cobertura de vacunación en Michigan disminuyó entre todas las edades, con la excepción de las vacunas que se administran al nacer, que generalmente se dan en el hospital.En Pennsylvania, por ejemplo, el Departamento de Salud estatal suspendió en julio los requisitos de vacunas durante dos meses después del inicio del año escolar.âEl departamento no puede enfatizar más que hay que vacunarse lo antes posibleâ, dijo Nate Wardle, secretario de prensa del departamento de salud de ese estado, en una declaración escrita. Sin embargo, la orden de permanecer en casa por hypertension medications hizo que durante meses los consultorios pediátricos no hicieran citas con niños sanos.Beers reconoció que el cierre de las escuelas, entre otras acciones como restringir los viajes y cerrar grandes espacios de reunión, hace que los niños sean menos propensos a contraer o inhaled lasix for copd propagar enfermedades que generalmente se incuban en las aulas. Por ejemplo, según los datos de los CDC, el sarampión prácticamente ha desaparecido. Se habÃan reportado 12 casos hasta el 19 de agosto de este año, en comparación con 1,282 en 2019.âLo que serÃa una gran vergüenza es que las escuelas vuelvan inhaled lasix for copd a abrir en persona y los niños vuelvan a estar juntos y empecemos a tener brotes de otras enfermedades que se pueden prevenir con vacunasâ, agregó.Los centros de salud de las escuelas de Nueva York se están comunicando activamente con los padres sobre las vacunas.
En Cooperstown, Kjolhede se acercó a todos los superintendentes poco después del cierre en marzo para preguntar si la clÃnica podÃa permanecer abierta. Todos menos inhaled lasix for copd uno dijeron que no.Luego, el personal concertó citas de telesalud y llamó a los estudiantes que necesitaban atención en persona para concertar visitas, incluidos aquellos que necesitaban una vacuna antes del comienzo de este año escolar, dijo. Afortunadamente, el centro de salud que permaneció abierto tenÃa una puerta que permitÃa a los pacientes ingresar a la clÃnica sin caminar por la escuela.A varias horas de distancia, la doctora Lisa Handwerker está lidiando con la forma de abordar el problema de que cientos de estudiantes en sus seis clÃnicas de salud en las escuelas de la ciudad de Nueva York no han recibido vacunas mandatorias.El departamento de salud de la ciudad le dio una lista de estudiantes bajo su cuidado que necesitaban vacunas adicionales, dijo. A más de 400 inhaled lasix for copd niños les faltaba la segunda dosis para prevenir la meningitis meningocócica, que generalmente se administra a adolescentes y adultos jóvenes de 16 a 23 años. Debido a que el departamento usó datos del último año académico para compilar la lista, Handwerker no tiene información sobre nuevos estudiantes.
Algunas familias abandonaron la inhaled lasix for copd ciudad por la falta de ingresos y recursos provocada por la pandemia.âTuvimos dificultades con al menos la mitad de los niños en nuestra lista de vacunasâ, dijo Handwerker. ÂLuego, cuando hablamos a las familias, se mostraron reacias a salir de sus casasâ.Ese no fue el caso de Tracey Wolf, una madre de dos hijos que visitó al médico recientemente para vacunar a su hijo Jordan contra el sarampión, las paperas, la rubéola y el VPH antes de comenzar el séptimo grado. Asistirá a inhaled lasix for copd la escuela secundaria en Dunedin, Florida, en persona, dijo Wolf, de 38 años.ParecÃa una tonterÃa mantener a Jordan, de 13 años, alejado de sus compañeros de clase cuando ya juega béisbol y sale con sus amigos, dijo. Sus calificaciones también bajaron la primavera pasada cuando la amenaza hypertension medications transformó su salón de clases en una computadora.También llevó a su hijo de 6 meses a recibir sus vacunas. Cuando se le preguntó si tenÃa miedo de inhaled lasix for copd ir al consultorio de su médico, respondió.
ÂNo más que ir al supermercadoâ.Independientemente de si un niño comienza la escuela en casa o en el aula, los expertos en inmunización enfatizaron la importancia de vacunar siguiendo el calendario de inmunizaciones. Esas fechas inhaled lasix for copd tienen en cuenta la etapa de desarrollo del niño para maximizar la eficacia de la vacuna. Dicho esto, es preferible que los niños reciban las vacunas de su médico habitual para evitar la pérdida de los registros de vacunación y las vacunas adicionales, completó Beers.Sin embargo, el 19 de agosto, el Departamento de Salud y Servicios Humanos (HHS) emitió una declaración que permite a los farmacéuticos administrar vacunas infantiles a niños y adolescents de 3 a 18 años. Carmen Heredia inhaled lasix for copd Rodriguez. CarmenH@kff.org, @ByCHRodriguez Related Topics Noticias En Español Public Health Children's Health hypertension medications buy lasix uk treatmentsAlthough the hypertension lasix shut down many organizations and businesses across the nation, KHN has never been busier â and health coverage has never been more vital.
Weâve revamped our Behind the Byline YouTube series and inhaled lasix for copd brought it to Instagram TV.Journalists and producers from across KHNâs newsrooms take you behind the scenes in these bite-size videos to show the ways they are following the story, connecting with sources and sorting through facts â all while staying safe.Heidi de Marco â âAt Least I Got the Shotâ Photojournalist Heidi de Marcoâs stunning images transport viewers to two California hospitals near the U.S.-Mexico border where the influx of patients with hypertension medications overwhelmed local intensive care units in late May. To capture these scenes at El Centro Regional Medical Center in Imperial County and Scripps Mercy Hospital Chula Vista in San Diego County, de Marco donned personal protective equipment and followed each facilityâs safety guidelines. Still, she acknowledges, the work increased her risk of exposure to inhaled lasix for copd the hypertension. She also risked bringing the lasix home to her family. For her it was worth the risk, in order to give readers a window on health care in the midst of a lasix â and inhaled lasix for copd to share her work with the world.
This KHN story first published on California Healthline, a service of the California Health Care Foundation. Heidi de inhaled lasix for copd Marco. heidid@kff.org, @Heidi_deMarco Related Topics California Multimedia Public Health States Behind The Byline hypertension medicationsCanât see the audio player?. Click here inhaled lasix for copd to listen. About This Podcast Health care â and how much it costs â is scary.
But youâre not alone with inhaled lasix for copd this stuff, and knowledge is power. ÂAn Arm and a Legâ is a podcast about these issues, and its second season is co-produced by KHN. Barbara Faubionâs boss, an insurance broker, used to tell inhaled lasix for copd clients. ÂListen, you donât need to be on the phone for four hours with Blue Cross Blue Shield. Let us inhaled lasix for copd do that.
I have a person.âFaubion was that person. And she got up every day psyched to go to work, which she said puzzled inhaled lasix for copd her friends.âTheyâd go, âYou love your job?. !. ?. You spend your whole day talking to an insurance company.
Are you kidding me?. ÂâShe was not kidding. Faubion loved to win â and she was really, really good at untangling other peopleâs health insurance problems.Now sheâs going to teach us some of what she knows.So why doesnât every health insurance broker have someone like Faubion on staff?. ProPublica reporter Marshall Allen has that answer. There are big clues in his 2019 story about industry commissions and bonuses.âAn Arm and a Legâ is a co-production of Kaiser Health News and Public Road Productions.To keep in touch with âAn Arm and a Leg,â subscribe to the newsletter.
You can also follow the show on Facebook and Twitter. And if youâve got stories to tell about the health care system, the producers would love to hear from you.To hear all Kaiser Health News podcasts, click here.And subscribe to âAn Arm and a Legâ on iTunes, Pocket Casts, Google Play or Spotify. Related Topics Cost and Quality Health Care Costs Health Industry Insurance Multimedia An Arm and a Leg Podcasts.
SOBRE NOTICIAS EN ESPAÃOLNoticias en español es una sección de Kaiser Health News que contiene traducciones de artÃculos http://iconographymag.com/fashion-2-0-awards-recap-photos/ de gran interés para la comunidad hispanohablante, y contenido original lasix 40mg price enfocado en la población hispana que vive en los Estados Unidos. Use Nuestro Contenido Este contenido puede usarse de manera gratuita (detalles). El doctor Chris Kjolhede está enfocado en los niños del centro de Nueva York.Como codirector lasix 40mg price de los centros de salud escolares de Bassett Healthcare Network, el pediatra supervisa alrededor de 21 clÃnicas de salud escolares en toda la región, una zona rural pobre conocida por sus fábricas y paralizada por la epidemia de opioides. Desde un esguince de tobillo en el recreo hasta preguntas sobre el control de la natalidad, las clÃnicas sirven como proveedoras de atención primaria para muchos estudiantes, dentro y fuera del aula.La meta principal es asegurarse que los niños estén al dÃa con las vacunas obligatorias, dijo Kjolhede.Pero, en marzo, hypertension medications revocó el acuerdo cuando obligó a cerrar las escuelas.Lo primero que me pregunté, dijo Kjolhede, fue. ¿qué va a lasix 40mg price pasar ahora?.
Â.Las escuelas juegan un papel fundamental en los esfuerzos de vacunación en los Estados Unidos. Las leyes requieren que los niños tengan ciertas vacunas para inscribirse y asistir a clases.Pero para evitar que hypertension medications no siguiera propagándose, muchos distritos escolares han optado por comenzar el año académico en internet.La decisión neutraliza en muchos casos el impulso de los padres por vacunar a sus hijos para el regreso a la escuela, dijo el doctor Nathaniel Beers, miembro del Consejo de Salud Escolar de la Academia Americana de PediatrÃa.Beers, quien también ocupó varios roles en el sistema de Escuelas Públicas del Distrito de Columbia, agregó que si la educación no es en persona, âes más difÃcil de hacer cumplir los requisitosâ.Los funcionarios de salud pública lasix 40mg price han confiado en las escuelas como un medio para controlar las enfermedades prevenibles por vacunas durante más de un siglo. Las leyes de vacunación surgieron por primera vez en la década de 1850 en Massachusetts como un medio para controlar la viruela, según cuentan los Centros para el Control y Prevención de Enfermedades (CDC).Todos los estados requieren que los niños reciban ciertas vacunas contra enfermedades como la poliomielitis, las paperas y el sarampión antes de empezar el año escolar o al jardÃn de infantes, al menos que el niño tenga una exención médica.Algunos estados permiten a las personas optar por no vacunar a los niños por razones religiosas o filosóficas, aunque estas exenciones se han asociado con brotes de enfermedades que de otro modo estarÃan bien controladas, como por ejemplo el sarampión.âCuando entran al sistema, en preescolar, es donde se detecta si están atrasados con sus vacunasâ, dijo Claire Hannan, directora ejecutiva de la Asociación de Administradores de Inmunización.A nivel local, la responsabilidad de rastrear si los estudiantes cumplen con los requisitos de vacunación generalmente recae en la enfermera de la escuela. Si no, un oficinista o administrador lasix 40mg price hace el trabajo, dijo Linda Mendonca, presidenta electa de la Asociación Nacional de Enfermeras Escolares.Si no los cumplen, algunas escuelas trabajan con los padres para programar citas con un proveedor de salud. Otras aÃslan a los niños en el aula, y otras son tan estrictas que âni siquiera puedes cruzar la puerta a menos que estés debidamente inmunizadoâ, dijo Beers.La pandemia de hypertension medications ha provocado una baja dramática en la vacunación.
En mayo, un informe de los CDC mostró una fuerte caÃda en la cantidad de pedidos al programa treatments For Children, una iniciativa federal que compra vacunas para la mitad de los niños del lasix 40mg price paÃs.Un segundo comunicado reveló tendencias similares. La cobertura de vacunación en Michigan disminuyó entre todas las edades, con la excepción de las vacunas que se administran al nacer, que generalmente se dan en el hospital.En Pennsylvania, por ejemplo, el Departamento de Salud estatal suspendió en julio los requisitos de vacunas durante dos meses después del inicio del año escolar.âEl departamento no puede enfatizar más que hay que vacunarse lo antes posibleâ, dijo Nate Wardle, secretario de prensa del departamento de salud de ese estado, en una declaración escrita. Sin embargo, la orden de permanecer en casa por hypertension medications hizo que durante meses los lasix 40mg price consultorios pediátricos no hicieran citas con niños sanos.Beers reconoció que el cierre de las escuelas, entre otras acciones como restringir los viajes y cerrar grandes espacios de reunión, hace que los niños sean menos propensos a contraer o propagar enfermedades que generalmente se incuban en las aulas. Por ejemplo, según los datos de los CDC, el sarampión prácticamente ha desaparecido. Se habÃan reportado 12 casos hasta el 19 de agosto de este año, en comparación con 1,282 en 2019.âLo que serÃa una gran vergüenza es que las escuelas vuelvan a abrir en persona y los niños vuelvan a estar juntos y empecemos a tener brotes de otras enfermedades que se pueden lasix 40mg price prevenir con vacunasâ, agregó.Los centros de salud de las escuelas de Nueva York se están comunicando activamente con los padres sobre las vacunas.
En Cooperstown, Kjolhede se acercó a todos los superintendentes poco después del cierre en marzo para preguntar si la clÃnica podÃa permanecer abierta. Todos menos uno dijeron que no.Luego, el personal concertó citas de telesalud lasix 40mg price y llamó a los estudiantes que necesitaban atención en persona para concertar visitas, incluidos aquellos que necesitaban una vacuna antes del comienzo de este año escolar, dijo. Afortunadamente, el centro de salud que permaneció abierto tenÃa una puerta que permitÃa a los pacientes ingresar a la clÃnica sin caminar por la escuela.A varias horas de distancia, la doctora Lisa Handwerker está lidiando con la forma de abordar el problema de que cientos de estudiantes en sus seis clÃnicas de salud en las escuelas de la ciudad de Nueva York no han recibido vacunas mandatorias.El departamento de salud de la ciudad le dio una lista de estudiantes bajo su cuidado que necesitaban vacunas adicionales, dijo. A más de 400 niños les faltaba la segunda dosis para prevenir lasix 40mg price la meningitis meningocócica, que generalmente se administra a adolescentes y adultos jóvenes de 16 a 23 años. Debido a que el departamento usó datos del último año académico para compilar la lista, Handwerker no tiene información sobre nuevos estudiantes.
Algunas familias abandonaron la ciudad por la falta de ingresos y recursos provocada por la pandemia.âTuvimos dificultades con al menos la mitad de los niños en nuestra lista de vacunasâ, dijo lasix 40mg price Handwerker. ÂLuego, cuando hablamos a las familias, se mostraron reacias a salir de sus casasâ.Ese no fue el caso de Tracey Wolf, una madre de dos hijos que visitó al médico recientemente para vacunar a su hijo Jordan contra el sarampión, las paperas, la rubéola y el VPH antes de comenzar el séptimo grado. Asistirá a la escuela secundaria en Dunedin, Florida, en persona, dijo Wolf, de 38 años.ParecÃa una lasix 40mg price tonterÃa mantener a Jordan, de 13 años, alejado de sus compañeros de clase cuando ya juega béisbol y sale con sus amigos, dijo. Sus calificaciones también bajaron la primavera pasada cuando la amenaza hypertension medications transformó su salón de clases en una computadora.También llevó a su hijo de 6 meses a recibir sus vacunas. Cuando se le preguntó si tenÃa miedo de ir al consultorio de su médico, lasix 40mg price respondió.
ÂNo más que ir al supermercadoâ.Independientemente de si un niño comienza la escuela en casa o en el aula, los expertos en inmunización enfatizaron la importancia de vacunar siguiendo el calendario de inmunizaciones. Esas fechas tienen lasix 40mg price en cuenta la etapa de desarrollo del niño para maximizar la eficacia de la vacuna. Dicho esto, es preferible que los niños reciban las vacunas de su médico habitual para evitar la pérdida de los registros de vacunación y las vacunas adicionales, completó Beers.Sin embargo, el 19 de agosto, el Departamento de Salud y Servicios Humanos (HHS) emitió una declaración que permite a los farmacéuticos administrar vacunas infantiles a niños y adolescents de 3 a 18 años. Carmen lasix 40mg price Heredia Rodriguez. CarmenH@kff.org, @ByCHRodriguez Related Topics Noticias En Español Public Health Children's Health hypertension medications treatmentsAlthough the hypertension lasix shut down many organizations and businesses across the nation, KHN has never been busier â and health coverage has never been more vital.
Weâve revamped our Behind the Byline YouTube series and brought it to Instagram TV.Journalists and producers from across KHNâs newsrooms take you behind the scenes in these bite-size videos to show the ways they are following the story, connecting with sources and sorting through facts â all while staying safe.Heidi de Marco â âAt Least I lasix 40mg price Got the Shotâ Photojournalist Heidi de Marcoâs stunning images transport viewers to two California hospitals near the U.S.-Mexico border where the influx of patients with hypertension medications overwhelmed local intensive care units in late May. To capture these scenes at El Centro Regional Medical Center in Imperial County and Scripps Mercy Hospital Chula Vista in San Diego County, de Marco donned personal protective equipment and followed each facilityâs safety guidelines. Still, she acknowledges, the work increased her risk of exposure to the lasix 40mg price hypertension. She also risked bringing the lasix home to her family. For her it was lasix 40mg price worth the risk, in order to give readers a window on health care in the midst of a lasix â and to share her work with the world.
This KHN story first published on California Healthline, a service of the California Health Care Foundation. Heidi de lasix 40mg price Marco. heidid@kff.org, @Heidi_deMarco Related Topics California Multimedia Public Health States Behind The Byline hypertension medicationsCanât see the audio player?. Click lasix 40mg price here to listen. About This Podcast Health care â and how much it costs â is scary.
But youâre not alone with this stuff, and knowledge is lasix 40mg price power. ÂAn Arm and a Legâ is a podcast about these issues, and its second season is co-produced by KHN. Barbara Faubionâs boss, an insurance broker, used to tell clients lasix 40mg price. ÂListen, you donât need to be on the phone for four hours with Blue Cross Blue Shield. Let us do lasix 40mg price that.
I have a person.âFaubion was that person. And she got up every day psyched to go to work, which she said puzzled her friends.âTheyâd go, âYou love your job? lasix 40mg price. !. ?. You spend your whole day talking to an insurance company.
Are you kidding me?. ÂâShe was not kidding. Faubion loved to win â and she was really, really good at untangling other peopleâs health insurance problems.Now sheâs going to teach us some of what she knows.So why doesnât every health insurance broker have someone like Faubion on staff?. ProPublica reporter Marshall Allen has that answer. There are big clues in his 2019 story about industry commissions and bonuses.âAn Arm and a Legâ is a co-production of Kaiser Health News and Public Road Productions.To keep in touch with âAn Arm and a Leg,â subscribe to the newsletter.
You can also follow the show on Facebook and Twitter. And if youâve got stories to tell about the health care system, the producers would love to hear from you.To hear all Kaiser Health News podcasts, click here.And subscribe to âAn Arm and a Legâ on iTunes, Pocket Casts, Google Play or Spotify. Related Topics Cost and Quality Health Care Costs Health Industry Insurance Multimedia An Arm and a Leg Podcasts.
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FUROSEMIDE is a diuretic. It helps you make more urine and to lose salt and excess water from your body. Lasix is used to treat high blood pressure, and edema or swelling from heart, kidney or liver disease.
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The Register of Innovative Drugs is maintained pursuant lasix 100mg online to C.08.004.1 of Cialis prices walmart the Food and Drug Regulations. The register indicates the drugs that are eligible for data protection. Under C.08.004.1 (3) a subsequent manufacturer that seeks a notice lasix 100mg online of compliance on the basis of a direct or indirect comparison between the new drug and an innovative drug may not file a submission before the end of a period of six years after the day on which the first notice of compliance was issued for the innovative new drug. In addition, the notice of compliance cannot be issued before the end of a period of eight years after the day on which the first notice of compliance was issued to the innovator.
The format of the Register of Innovative Drugs is an electronic table, which is lasix 100mg online updated weekly. The register lists, in alphabetical order, the medicinal ingredients in the innovative drugs which were not previously approved in a drug by the Minister and that are not variations of a previously approved medicinal ingredient. Please note that there may be other medicinal ingredients lasix 100mg online included in the drugs. The register was re-formatted in summer 2016 to increase the clarity of the information provided regarding the medicinal ingredient, brand name and manufacturer of each innovative drug.
For information related to treatment options, choices of medications and their uses, illnesses, side effects or drug lasix 100mg online interactions, please contact your health care professional (for example, doctor, pharmacist, etc.). We do not provide medical advice regarding the use of the products identified in this database. For comments or questions, please contact by hc.opml-bmbl.sc@canada.ca or by telephone at 613-941-7281.What is the Notice of Compliance (NOC) Data lasix 100mg online Extract?. The data extract is a series of compressed ASCII text files of the database.
The uncompressed size of the files is approximately 19.0 MB. In order to utilize the data, the file must be loaded into an existing database lasix 100mg online or information system. The typical user is most likely a third party claims adjudicator, provincial formulary, insurance company, etc. A casual user of this file must be familiar with database structure and capable of setting lasix 100mg online up queries.
The "Read me" file contains the data structure required to download the zipped files. The NOC lasix 100mg online extract files have been updated. They contain Health Canada authorization dates for all drugs dating back to 1994 that have received an NOC. All NOCs issued between lasix 100mg online 1991 and 1993 can be found in the NOC listings.
Please note any Portable Document Format (PDF) files visible on the NOC database are not part of the data extracts. For more information, please go to the Read lasix 100mg online Me File. Data Extracts - Last updated. September 4, 2020 Copyright For information on copyright and who to contact, please visit the Notice of Compliance Online Database Terms and Conditions..
The Register of Innovative Drugs is maintained pursuant Cialis prices walmart to C.08.004.1 of the Food and Drug Regulations lasix 40mg price. The register indicates the drugs that are eligible for data protection. Under C.08.004.1 (3) a subsequent manufacturer that seeks a notice of compliance on the basis of lasix 40mg price a direct or indirect comparison between the new drug and an innovative drug may not file a submission before the end of a period of six years after the day on which the first notice of compliance was issued for the innovative new drug. In addition, the notice of compliance cannot be issued before the end of a period of eight years after the day on which the first notice of compliance was issued to the innovator.
The format of lasix 40mg price the Register of Innovative Drugs is an electronic table, which is updated weekly. The register lists, in alphabetical order, the medicinal ingredients in the innovative drugs which were not previously approved in a drug by the Minister and that are not variations of a previously approved medicinal ingredient. Please note lasix 40mg price that there may be other medicinal ingredients included in the drugs. The register was re-formatted in summer 2016 to increase the clarity of the information provided regarding the medicinal ingredient, brand name and manufacturer of each innovative drug.
For information related to treatment options, choices of medications and their uses, illnesses, side effects or drug interactions, please contact your health care professional (for example, doctor, pharmacist, lasix 40mg price etc.). We do not provide medical advice regarding the use of the products identified in this database. For comments or questions, please contact by hc.opml-bmbl.sc@canada.ca or by telephone at lasix 40mg price 613-941-7281.What is the Notice of Compliance (NOC) Data Extract?. The data extract is a series of compressed ASCII text files of the database.
The uncompressed size of the files is approximately 19.0 MB. In order to utilize the data, the file must be loaded lasix 40mg price into an existing database or information system. The typical user is most likely a third party claims adjudicator, provincial formulary, insurance company, etc. A casual user of this file must be familiar with database structure and capable lasix 40mg price of setting up queries.
The "Read me" file contains the data structure required to download the zipped files. The NOC extract files lasix 40mg price have been updated. They contain Health Canada authorization dates for all drugs dating back to 1994 that have received an NOC. All NOCs issued between 1991 and lasix 40mg price 1993 can be found in the NOC listings.
Please note any Portable Document Format (PDF) files visible on the NOC database are not part of the data extracts. For more information, please go lasix 40mg price to the Read Me File. Data Extracts - Last updated. September 4, 2020 Copyright For information on copyright and who to contact, please visit the Notice of Compliance Online Database Terms and Conditions..
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A description of the questions and approach for lasix and alcohol the current evaluation phase. Section 2. A summary of the draft indicator sets. Section 3 lasix and alcohol.
A Prevention Action Framework for understanding types of activities and potential change in the Aotearoa New Zealand prevention system. Section 4. Qualitative indicators that we lasix and alcohol are currently developing, of factors that would show quality of implementation and indicate the prevention system had been strengthened. Section 5.
Quantitative indicators sourced from national surveys, to provide context for locations and to provide potential longer-term indication of change. Section 6 lasix and alcohol. A methodology for a value for money evaluation of the initiative using a cost-consequences approach. Background Healthy Families NZ is a large-scale prevention initiative that focuses on creating healthy, more equitable communities â aiming to improve peopleâs health where they live, learn, work and play by taking a systems-change approach to preventing chronic disease.
This systems-change approach aligns lasix and alcohol to international evidence that shows systems -based approaches are becoming increasingly common as the evidence of the need for explicit âwhole systemâ responses to these challenges is becoming clearer. Healthy Families NZ is in nine locations in areas with higher-than-average rates of preventable chronic diseases, higher-than-average rates of risk factors for these diseases, and/or high levels of deprivation. The nine locations are spread throughout Aotearoa in a mix of urban and rural areas, with the potential to reach over one million New Zealanders.The 2019/20 Annual Report summarises the Ministryâs major work programmes and achievements, and demonstrates our progress towards our strategic intentions 2017-2021, Ta Tatou Rautaki | Our Strategy and Pae Ora | Healthy Futures.During the year, the Ministry led New Zealandâs health response to the hypertension medications global lasix, stewarded the health and disability system through other emergencies, and continued to deliver on an ambitious core work programme. The Annual lasix and alcohol Report summarises our financial performance for the year, presents the results results of our non-financial performance measures, and meets our reporting requirements under the Public Finance Act.
The Annual Report is complemented by the Vote Health. Report in relation to selected non-departmental appropriations for the year ended 30 June 2020, which is the Ministerâs report on the financial and non-financial performance of the non-departmental appropriations that the Ministry administers on behalf of the Crown..
This report Can you get ventolin without a prescription contains six lasix 40mg price sections. Section 1. A description of the questions and approach for the current evaluation phase.
Section 2 lasix 40mg price. A summary of the draft indicator sets. Section 3.
A Prevention Action Framework for understanding types of activities lasix 40mg price and potential change in the Aotearoa New Zealand prevention system. Section 4. Qualitative indicators that we are currently developing, of factors that would show quality of implementation and indicate the prevention system had been strengthened.
Section 5 lasix 40mg price. Quantitative indicators sourced from national surveys, to provide context for locations and to provide potential longer-term indication of change. Section 6.
A methodology for a value for money lasix 40mg price evaluation of the initiative using a cost-consequences approach. Background Healthy Families NZ is a large-scale prevention initiative that focuses on creating healthy, more equitable communities â aiming to improve peopleâs health where they live, learn, work and play by taking a systems-change approach to preventing chronic disease. This systems-change approach aligns to international evidence that shows systems -based approaches are becoming increasingly common as the evidence of the need for explicit âwhole systemâ responses to these challenges is becoming clearer.
Healthy Families lasix 40mg price NZ is in nine locations in areas with higher-than-average rates of preventable chronic diseases, higher-than-average rates of risk factors for these diseases, and/or high levels of deprivation. The nine locations are spread throughout Aotearoa in a mix of urban and rural areas, with the potential to reach over one million New Zealanders.The 2019/20 Annual Report summarises the Ministryâs major work programmes and achievements, and demonstrates our progress towards our strategic intentions 2017-2021, Ta Tatou Rautaki | Our Strategy and Pae Ora | Healthy Futures.During the year, the Ministry led New Zealandâs health response to the hypertension medications global lasix, stewarded the health and disability system through other emergencies, and continued to deliver on an ambitious core work programme. The Annual Report summarises our financial performance for the year, presents the results results of our non-financial performance measures, and meets our reporting requirements under the Public Finance Act.
Ethacrynic acid to lasix conversion
IntroductionThe mammalian kinesin superfamily proteins (KIFs) are microtubule and ATP-dependent molecular motors, which ethacrynic acid to lasix conversion were first identified in 1985 as axonal transporters in squid and bovine brains.1 Forty-five different kinesin family member (KIF) genes were identified in the Where can i buy viagra over the counter mouse genome so far, 44 of which are present in the human genome. Phylogenetic analysis based on sequence homology between the human and the mouse genome led to the classification of KIF genes into 16 families, from kinesin-1 to kinesin-14B (figure 1).2 The first kinesins discovered belong to the kinesin-1 family (KIF5A, KIF5B and KIF5C), and they form a heterotetramer of two heavy chains and two light chains (KLC1-4).2 KIF genes encode KIFs, a specific class of motor proteins generating intracellular motility by driving directional transport of various cargoes such as organelles, protein complexes and mRNAs along the microtubule system.2 Studies using knockout mouse models by Hirokawa and colleagues significantly contributed to elucidate the roles of kinesins in mammalian physiology. Their role ethacrynic acid to lasix conversion in transport is fundamental to cellular logistics and performance, and the molecular motors are not only effectors of signal transduction cascades but also transport and/or bind to important signal transduction molecules to actively modulate their function.3Phylogenetic tree of mammalian kinesin superfamily genes identified in the human (and mouse) genome and classified in 16 subfamilies (from kinesin 1 to 14B) (adapted from Hirokawa et al 3)." data-icon-position data-hide-link-title="0">Figure 1 Phylogenetic tree of mammalian kinesin superfamily genes identified in the human (and mouse) genome and classified in 16 subfamilies (from kinesin 1 to 14B) (adapted from Hirokawa et al3).The first kinesins were observed in the context of axonal transport in neurons, and a novel disease entity of âmotorâproteinopathyâ was proposed for the pathogenesis of axonal neuropathies in 2001.4 Due to their role in cellular membrane trafficking, however, kinesins are essential for the functioning of many polar cell types, such as neurons, epithelial cells, sperm cells or stem cells during organogenesis.
Kinesins also play a fundamental role in cell-cycle dynamics, both during mitotic and meiotic processes. They regulate ethacrynic acid to lasix conversion chromosomal condensation and alignment, spindle formation, cytokinesis and cell-cycle progression.5 It is estimated that about a dozen kinesins are involved in the cell cycle. Among these, there is a specific subclass of chromokinesins (kinesin 4 and kinesin 10 family) which are able to bind chromosomes.6 Recently, KIFs were discovered to act as microtubule stabilisers (KIF26A and KIF21A) and depolymerisers (KIF2A and KIF2C), activities which are important for both cellular morphogenesis and mammalian development, playing a role in neuronal and axonal morphology and ciliogenesis.7Alterations in motor kinesins are leading to human disease by various pathological mechanisms, including cancer and multifactorial and monogenic disorders.
Variants in 18 out of the 44 human KIF genes were identified to cause monogenic disorders, following different ethacrynic acid to lasix conversion modes of Mendelian inheritance and associated with a wide spectrum of clinical signs. These range from lethal and multiple to isolated congenital anomaliesâincluding birth defects potentially detectable in the foetal period by current prenatal imaging studiesâto postnatally apparent neurodevelopmental disorders, intellectual disability and neurological conditions.We will review the current state of knowledge of the biological processes kinesins are involved in and discuss their emerging role in human disease, particularly in birth defects and congenital anomaly syndromes. Birth defects remain a leading cause of perinatal lethality in industrialised countries.8 Structural anomalies are recognised with increasing reliability during early pregnancy by the use of high-resolution ultrasound technologies, thus raising questions about diagnosis, aetiology, prognosis and recurrence risk, particularly in the presence of more than one anomaly, which most likely indicates a genetic aetiology.
We identify recurrent phenotype patterns caused by alterations in KIF genes, and we outline the complexity of phenotypeâgenotype correlations mirroring the processes of intracellular microtubule-mediated transport and movement, in which kinesins play a ethacrynic acid to lasix conversion fundamental role. There are likely many more relationships between the clinical signs and the genetic variants to be identified in the future, and the functional network of kinesins and their role in human disease need to be further elucidated. We propose to introduce the term âkinesinopathiesâ for this group of conditions, which are phenotypically and genetically overlapping and characterised by the functional impairment of a specific group of molecular motors ethacrynic acid to lasix conversion.
We hope that their systematic approach leads to a better recognition in clinical practice, as well as in genome-wide sequencing for diagnosis and research, and opens strategies for the future development of molecular therapies.KIF structureAll KIFs have a phylogenetically well-conserved motor domain head, consisting of an ATP-binding motif and a microtubule-binding domain. Depending on the position of the motor domain, kinesins can be subdivided into N-kinesins (amino-terminal motor domain), M-kinesins ethacrynic acid to lasix conversion (middle-region motor domain) and C-kinesins (carboxy-terminal motor domain).2 Most kinesins belong to the N-kinesin subgroup, but members of the kinesin 13A family (figure 1) belong to the M-kinesin subtype, while KIF1C, KIF2C and KIF3C belong to the C- kinesin subfamily.3 Both N-kinesins and C-kinesins are responsible for plus end and minus end-directed motility, M-kinesins for depolymerisation of microtubules in tubulin molecules. However, there are a few exceptions to this categorisation.9 The motor domain head attaches to the neck, the coiled coil stalk and the tail.
The kinesinsâ neck is family-specific and responsible for the direction of motility or regulation of activity. The coiled coil stalk and tail ethacrynic acid to lasix conversion are involved in kinesin dimerisation and/or interactions with cargoes. Kinesins typically use scaffold proteins and adaptor proteins to bind their cargoes but can sometimes bind the cargo directly.
Scaffolds and adaptors might also have regulatory roles in kinesin-driven intracellular transport, that is, recognising specific cargoes and regulating their loading and unloading.3Role of KIFs in physiology and diseaseThe application of ethacrynic acid to lasix conversion genome-wide sequencing for gene identification in research or for clinical diagnostic purposes significantly contributes to the identification of KIF candidate genes. Genotypeâphenotype correlations in KIF gene-related disorders, together with functional and animal studies, continue to elucidate the complex involvement of KIFs in human developmental pathways and disease. Table 1 summarises the monogenic conditions caused by variants affecting the function of KIF genes.View this table:Table 1 Specific monogenic disorders caused by variants affecting the function of KIF genesView this table:Table 2 Summary of phenotypes and genotypes of KIF149 26 30 31The kinesinsâ functions in physiological processes, however, are complex ethacrynic acid to lasix conversion and still incompletely understood, but their role in cell-cycle progression and regulation, including both meiosis and mitosis, in intracellular trafficking, axonal transport, microtubule activity and ciliogenesis, is increasingly studied.
Figure 2 summarises the clustering of KIF genes according to their functional roles and the phenotypical consequences as identified to date in 32 out of the 44 human kinesin genes.Assignment and clustering of KIF genes to various functions and relation to birth defect or monogenic phenotype groups. Detailed phenotypes are shown in tables 1 and ethacrynic acid to lasix conversion 3. Cancer and multifactorial conditions are not included.
CNS, central nervous system." data-icon-position data-hide-link-title="0">Figure 2 Assignment and clustering of KIF genes to various functions and relation to birth defect or monogenic phenotype groups. Detailed phenotypes are shown in tables 1 ethacrynic acid to lasix conversion and 3. Cancer and multifactorial conditions are not included.
CNS, central nervous system.Kinesins play a pivotal role during ethacrynic acid to lasix conversion early development and organogenesis. Microcephaly is one of the most frequently associated clinical signs, mirroring a defect in the regulation of the final number of neurons during development.10KIF4A is a motor protein that translocates PRC1, a cytokinesis protein, to the ends of the spindle microtubules during mitosis, regulates the PARP1 activity in brain development and the survival of neurons, and is a member of the L1CAM recycling pathway. Variants in ethacrynic acid to lasix conversion L1CAM cause X-linked isolated and syndromic hydrocephalus.
KIF4A was recently proposed as a candidate gene for hydrocephalus.11KIFs are involved in neuronal branching, and microtubule depolarisation, operated by KIF2A M-kinesin, was suggested to suppress collateral branch extension during brain development, leading to anomalies of cortical development, including agyria and pachygyria, subcortical band heterotopia and corpus callosum anomalies.12Functional disruption of KIF genes in knockout mice often results in embryonic lethality, for example, for Kif18A, Kif10, Kif3A, Kif3B and Kif5B,13â17 highlighting the importance of kinesins in embryonic and foetal development. A study on KIF16B demonstrated that microtubule-based trafficking is responsible for early development and stem cell survival.18 KIF26B is essential in kidney development, contributing to the adhesion of mesenchymal cells to the ureteric bud.3 KIF26A was suggested to play a role in enteric nervous system development, because knockout mice develop a megacolon and enteric nerve hypoplasia,19 and to negatively regulate nociceptive sensation.20A significant number of KIFs play a prominent role in ciliogenesis and cilia function. They regulate cilia length, ciliary assembly/disassembly and can have motile cilia-specific functions.21 Some KIFs, specifically found in primary cilia (PC), regulate the length of the axoneme and its disassembly when re-entering the cell cycle.KIF7, also a key component of the Hedgehog signalling pathway, is responsible for cilia length regulation through suppression of microtubule polymerisation.7 KIF7 variants cause hydrolethalus, acrocallosal, and Joubert and Al-Gazali-Bakalinova syndromes.22 Kif2A knockout mice have severe brain defects, and KIF2A variants in humans lead to microcephaly because of cell-cycle delay ethacrynic acid to lasix conversion in cellular progenitors resulting from cilia disassembly defects.
KIF24, belonging to the same kinesin 13 family, plays a role in both microtubule depolymerising activity and regulation of the early steps of ciliogenesis. Other PC-related KIFs recently identified are KIF5B, KIF1C and KIF13B, and a potential role in cilia was hypothesised for KIF11 and KIF14.KIF3 protein complex (KIF3A-KIF3B-KAP3 heterotetramer) is a molecular motor necessary for intraflagellar transport (IFT) but is also involved in ciliogenesis of ethacrynic acid to lasix conversion motile cilia. Kif3a-knockout or Kif3b-knockout mice are prenatally lethal, exhibiting anomalies similar to ciliopathy phenotypes, including the disturbance of leftâright body determination.3KIF19A is localised at the tip of motile cilia and performs motor and microtubule-depolymerising activities during IFT.
Kif19a-knockout mice present with hydrocephalus and female infertility, common signs in ciliary defects, due to abnormally elongated cilia with altered motility, not able to generate proper fluid flow.9Further KIFs, which may have specific roles in motile cilia, are KIF27, KIF9, KIF6 ethacrynic acid to lasix conversion and KIF18B. Regarding the involvement of numerous KIFs in cilia-related processes, it is not surprising that many disorders caused by variants affecting KIF gene function are presenting with anomalies reminiscent of ciliopathies.Kinesin motors have a fundamental role in neuronal function, as they are responsible for the transport of synaptic vesicle precursors and transmitter receptors along axons and dendrites from the neuron body.3 Molecular motor activity as for KIF1A, KIF5 and KIF17 is important for higher brain functions, such as learning and memory through regulation of synaptic transmission.5 Dysfunction can be associated with intellectual disability and global developmental delay (table 1).Impaired function can also result in peripheral neuropathies (KIF5A, KLC2, KIF1A and KIF1B) and ocular motility disorders (KLC2 and KIF21A)23 24 when axon elongation in the peripheral nervous system and optic nerve is affected. KIF5A variants are associated with epileptic phenotypes both in humans and mice25 because the transport of neurotransmitter receptors is disturbed and inhibitory regulation is altered.Due to their role in cell-cycle regulation, kinesins are important in male spermatogenesis and female oogenesis.
They are involved in all steps of ethacrynic acid to lasix conversion spermatogenesis 26 and, based on previous animal studies, they may represent a potential target to treat male infertility. In female meiosis, 13 KIF genes were studied in animal models. There is ethacrynic acid to lasix conversion some evidence that kinesin expression is vulnerable to maternal ageing and environmental factors, such as oocyte cryopreservation and alcohol consumption.
It may be promising to expand research in this field in order to clarify the mechanisms and factors contributing to oocyte quality decline.27Many kinesins were extensively studied in the fields of cancer development, progression and therapy. Deregulation of the mitotic kinesins by both overexpression and decreased expression causes cancer progression or can be a prognostic marker in various tumours.28 The cell-permeable small-molecule ethacrynic acid to lasix conversion mitotic inhibitor monastrol was discovered in 199929 and was shown to arrest cells in mitosis by specifically inhibiting KIF11, a kinesin important for spindle bipolarity. The bipolar mitotic spindle is replaced by a monoastral microtubule array surrounded by a ring of chromosomes, which gave the inhibitor its name.
The mitotic spindle is now a well-known target of chemotherapy, and inhibitors of the mitotic kinesins KIF11, ethacrynic acid to lasix conversion KIF10 and KIF1C are being studied for this purpose.28 30 The redundancy of some kinesins allows them to escape pharmacological inhibition. For example, in the absence of KIF10, KIF15 is able to replace all of its essential functions in spindle assembly. Cilia-related KIF7, KIF13B and KIF27 are involved in SHh signalling and may be a future target in cancer research.28Some kinesins confer susceptibility to a range of multifactorial, metabolic and neurodegenerative conditions.
KIF13B contributes to ethacrynic acid to lasix conversion the enhancement of endocytosis of low-density lipoprotein (LDL) receptor-related protein 1 that is involved in the recognition and internalisation of LDL and factor VIII. Kif13b-knockout mice have hypercholesterolaemia and higher factor VIII serum levels.5 KIF12 is implicated in the pathogenesis of type 2 diabetes, protecting pancreatic β cells from the oxidative stress caused by nutritional excess.5 Variants in KIF1B or KIF21B confer susceptibility to multiple sclerosis (OMIM %612596, #126200).31 32 KIF5A was associated with Amyotrophic lateral sclerosis (OMIM #617921).33 KIF3 complex and KIF17 were recently uncovered to be involved in schizophrenia.34 35 Further studies, however, are needed to clarify the precise role of KIFs in neurodegenerative processes and psychiatric conditions.KIF14 -related birth defects. Lessons learntAdvances in next-generation sequencing technologies have revolutionised our understanding of Mendelian disorders, including birth defect phenotypes, by sequencing the coding genome (exome) or entire genome ethacrynic acid to lasix conversion at an unprecedented resolution in a comparably short time span.
The technology has been extensively used for gene identification approaches in research for many years, enabling unparalleled genotypeâphenotype correlations and the definition of novel pathways of related genes and disorders at an accelerated pace, traditionally focusing on postnatal disorders. Filges and Friedman36 postulated that a number of novel disease genes causing birth defects could be identifiable through the investigation of lethal foetal phenotypes since they would represent the extreme end ethacrynic acid to lasix conversion of allelic milder and viable postnatal phenotypes with less specific or recognisable anomaly patterns. Based on embryonically or perinatally lethal mouse models (www.informatics.jax.org and www.dmdd.org.uk), it is estimated that knockout variants in about 30% of human protein coding genes may present with a phenotype of early lethality.
The identification of KIF14 loss of function variants in fetuses with a lethal multiple congenital anomaly syndrome and the subsequent description of the allelic postnatal viable phenotype and further functional characterisation of KIF14 in developmental processes are recent examples of how to study those embryonic lethal phenotypes in order to understand the role of genes for which little to nothing is known.Filges et al identified autosomal recessive compound heterozygous loss of function variants in KIF14 using family-based exome sequencing in a recurrent severe lethal phenotype (OMIM #616258). It was the first human phenotype reported due to variants in the ethacrynic acid to lasix conversion human KIF14 gene (figure 3).37 The two affected siblings presented with intrauterine growth retardation (IUGR), oligohydramnios, severe microcephaly, renal cystic dysplasia or agenesis, genital tract malformations (uterine hypoplasia and vaginal atresia), as well as cerebral and cerebellar hypoplasias with partial or total agenesis of the vermis, arhinencephaly, agenesis of occipital lobes/corpus callosum at second trimester ultrasound scan. Cross-species comparison to the laggard spontaneous mice mutant, characterised by homozygous variants of the Kif14 gene,38 confirmed a phenotypical overlap.
An increased number of binucleated cells in the tissue histology of the two fetuses were in concordance with the key role of KIF14 during mitosis participating in chromosomesâ congression and alignment, as well as in cytokinesis39 and the observation of binucleated cells as a consequence of ethacrynic acid to lasix conversion failed cytokinesis in mammalian KIF14 knockdown cells. During cytokinesis, PRC1 localises KIF14 at the central spindle and midbody, which in turn recruits citron rho-interacting kinase (CIT) to the midbody. CIT, in turn, acts as a negative regulator of KIF14 ethacrynic acid to lasix conversion activity.
Knockdown of KIF14 in mammalian cells results in impaired localisation of CIT during mitosis.40Structure of KIF14 and summary of all published KIF14 variants affecting function.10 37 41 42 The N-terminal region (aa 1â356) is important for its interactions with PRC1 and the proteinâs localisation at the central spindle and midbody. The kinesin motor domain (aa 358â701) is responsible for the microtubule-dependent ATPase activity. The FHA domain (aa ethacrynic acid to lasix conversion 825â891).
Stalk and tail region (aa 891â1648) are necessary for the interaction with the protein CRIK (aa 901â1189, red diagonal lines). There are four additional coiled-coil domains (light blue-coloured areas).61 ethacrynic acid to lasix conversion FHA, forkhead associated. Aa, amino acid." data-icon-position data-hide-link-title="0">Figure 3 Structure of KIF14 and summary of all published KIF14 variants affecting function.10 37 41 42 The N-terminal region (aa 1â356) is important for its interactions with PRC1 and the proteinâs localisation at the central spindle and midbody.
The kinesin ethacrynic acid to lasix conversion motor domain (aa 358â701) is responsible for the microtubule-dependent ATPase activity. The FHA domain (aa 825â891). Stalk and ethacrynic acid to lasix conversion tail region (aa 891â1648) are necessary for the interaction with the protein CRIK (aa 901â1189, red diagonal lines).
There are four additional coiled-coil domains (light blue-coloured areas).61 FHA, forkhead associated. Aa, amino acid.Filges et al pointed out that KIF14 should be considered a candidate gene for viable postnatal phenotypes, including isolated microcephaly.34 Additional individuals with autosomal recessive variants in KIF14 and isolated primary microcephaly were then described9 41 42 (table 2).Impaired cytokinesis, increased apoptosis and reduced cell motility were confirmed in cells from the described patients, pointing to a new cellular pathway in the pathogenesis of microcephaly.43 Apart from one case with small kidneys with increased echogenicity, none of these 18 patients had associated kidney anomalies. However, a targeted exome sequencing study in 204 unrelated patients with congenital anomalies of the kidney and urinary tract (CAKUT) reported two more cases of renal anomalies, bilateral hypoplasia or agenesis, caused by KIF14 variants.44 Further nine cases had an associated renal phenotype, which ranged ethacrynic acid to lasix conversion from bilateral renal agenesis to cystic or non-cystic renal hypodysplasia.42 Table 2 and figure 3 summarise KIF14 variants and the associated phenotypes.
Loss of function variants more likely lead to multiple congenital anomalies, while hypomorphic variants result in a milder phenotype without renal involvement, although phenotypeâgenotype correlations remain preliminary for the time being.The phenotypical spectrum ranging from isolated primary microcephaly to congenital anomalies reminiscent of ciliopathy phenotypes suggested a complex role for KIF14 in developmental processes and raised a number of questions about the relationship between its established role in cell division and its possible function in ciliary pathways. Functional studies of absent KIF14 protein in the development of human foetal tissues and mutant zebrafish provided evidence for similarities and differences between mitotic events ethacrynic acid to lasix conversion occurring during proliferation in the development of both brain and kidney.42 The observation that KIF14-stained midbodies accumulate within the lumen of the branch tips of ureteric buds in human foetal kidneys provided a key clue to better understand the mechanism through which the loss of KIF14 affects both brain and kidney development in humans. It was previously demonstrated that the secretion and accumulation of midbody remnants in the cerebrospinal fluid in mice during the early stages of brain development correspond to the amplification of neural progenitors.45 Kif14 mutant zebrafish phenotypes supported the hypothesis of a potential role for KIF14 in cilia.
In vitro and in vivo analyses suggested that loss ethacrynic acid to lasix conversion of kif14 causes ciliary anomalies through an accumulation of mitotic cells in ciliated tissues but failed to establish a direct functional link.21 42 Further mechanisms remain to be elucidated. Overexpression of KIF14 in various types of tumours was suggested to be a possible prognostic marker and a potential target for therapeutic purposes.46Kinesinopathies in birth defect phenotypes. Recurrent themesIn the last few years, an increasing number of variants in KIF genes were described to cause isolated as well as multiple congenital anomalies.
There is a huge variability of phenotypes caused by variants even within the ethacrynic acid to lasix conversion same gene. However, we can identify recurrent clinical signs that should alert the clinician to suspect a KIF gene-related disorder and the molecular geneticist to include KIF genes in multigene-panel and genome-wide sequencing approaches. This will become particularly relevant in prenatal and perinatal medicine, which focuses ethacrynic acid to lasix conversion on the detection of structural anomalies in the fetus and the newborn by using ultrasound and MRI or autopsy when the outcome is lethal.
We have summarised the predominant and recurrent structural anomalies in kinesinopathies reported so far that would likely become apparent during the foetal period in table 3 and the syndromic disorders in table 1.View this table:Table 3 KIF gene-related structural congenital anomalies recurrently described in prenatal phenotypesSupplemental materialConsistent with the kinesinsâ role in the development of the central nervous system (CNS), brain anomalies of various degrees are a frequent clinical sign, particularly microcephaly, but include lissencephaly, polymicrogyria, thinned or agenesis of the corpus callosum, arhinencephaly, cerebral hypoplasia or atrophy, cerebellar hypoplasia or atrophy, brainstem hypoplasia and a molar tooth sign on brain imaging.12 22 37 44 47â51Primary microcephaly can be detected prenatally or at birth12 22 47 48 50 51 and can present as an isolated or syndromic condition as, for example, caused by variants in KIF149 or in KIF11 (microcephaly with or without chorioretinopathy, lymphoedema or mental retardation. OMIM #152950).48KIF7 variants were related to macrocephaly in the presence of congenital hydrocephalus (hydrolethalus ethacrynic acid to lasix conversion syndrome LS2, OMIM # 614120). Isolated hydrocephalus was reported for KIF4A in a single case.11Foetal akinesia and arthrogryposis (KIF5C12, KIF1434 and KIF26B50) are likely secondary to the neurological compromise of the fetus but can also appear as an early sign of abnormal CNS development, which should prompt specialist CNS sonographic and MRI evaluation of the fetus.Further anomalies of the limbs include camptodactyly (KIF26B50), clubfoot (KIF1A51), rocker-bottom feet (KIF26B50) and congenital lymphoedema of the limbs (dorsa of feet, lower extremities and, rarely, hands) in cases with KIF11 gene mutations.48 In particular, KIF7 gene variants have been related to various anomalies of the hands (tapered fingers, fifth finger clinodactyly, brachydactyly, preaxial or postaxial polydactyly, bifid terminal phalanges of the thumbs, spindle-shaped fingers, clinodactyly and soft tissue webbing) and feet (toe syndactyly, preaxial or postaxial polydactyly, and duplicated halluces).22CAKUT and genital anomalies are reported in various kinesinopathies including renal agenesis or hypoplasia (KIF1437 and KIF1252), ureteral hypoplasia (KIF1437), congenital megabladder (KIF1252) and vesicoureteral reflux (KIF1252), uterine hypoplasia and vaginal atresia (KIF1437) and hypospadias and chordae (KIF16B49).IUGR is recurrently detected (KIF5C12, KIF1437, KIF1053, KIF1554 and KIF2A12) and is particularly relevant when occurring simultaneously with one of the other recurrent clinical signs, indicating a potential syndromic KIF-related disorder.
Oligohydramnios or polyhydramnios is most likely secondary to a primary organ anomaly.There are a few kinesinopathy syndromes that have been specifically reported to be lethal, such as the ciliary phenotype (OMIM #616258), caused by variants in KIF1434, and hydrolethalus syndrome (OMIM #614120), caused by variants in KIF7.22 However, lethality is usually closely related to the specific major anomalies, and it can be hypothesised that such a lethal phenotype will exist for all KIF gene-related disorders.Developmental delay, intellectual disability, seizures, and sensory and motor disturbances of the peripheral nervous system, as well as eye anomalies, such as microphthalmy, optic nerve pallor, fibrosis of extraocular muscles and chorioretinopathy, will escape detection in the foetal period but are reported in postnatal patients.Kinesin pathways in birth defectsFunctional studies of kinesins in birth defects are still sparse, and little is known about their networks and pathways. In order to improve our understanding, we used the Ingenuity Pathway Analysis (IPA Qiagen, Redwood City, California, USA) to visualise ethacrynic acid to lasix conversion and analyse the connections between the 13 kinesin motor proteins associated with structural congenital anomalies (KIF5C, KIF1A, KIF1BP, KIF14, KIF16B, KIF7, KIF4A, KIF11, KIF10, KIF26B, KIF12, KIF15 and KIF2A) and in up to 10 of each of their most significant downstream proteins. The connections are defined as proteinâprotein interactions, activation, regulation of binding, expression, localisation, phosphorylation, proteinâRNA interactions, molecular cleavage, ubiquitination, proteinâDNA interactions, inhibition, translocation and transcription.
Figure 3 displays the results ethacrynic acid to lasix conversion. We used the software Gephy55 to look for all possible interactions between all proteins of the network and also used the IPA data to retrieve the canonical pathways involved. Figure 4 ethacrynic acid to lasix conversion and online supplementary material, table 4, summarise the results.
KIF7, KIF14 and KIF12 are located within the same network, and because of multiple connections between themselves and their downstream proteins, it is not surprising that they are all involved in kidney anomalies. IPA data are based on current publications and are therefore subject to bias ethacrynic acid to lasix conversion because proteins that are most interconnected are also most probably those that have been more extensively studied. However, we consider the KIF genes coding for proteins seeming less important within the network to be strong candidates for future studies of human developmental disorders.IPA of the 13 kinesins known to be involved in birth defects with respect to their position in the cell.
Proteins displayed on the right side of the figure, below the tag âotherâ, are those for which no subcellular location is known. Birth defect-related kinesins and their connection with each ethacrynic acid to lasix conversion other are highlighted in green. Light blue-coloured downstream proteins are those which are known to cause birth defects when altered.
Yellow-coloured proteins are those involved in neurological disorders overlapping with the clinical features ethacrynic acid to lasix conversion of kinesinopathies. The legend of the biological function associated with every molecule is displayed on the right. Path Designer ethacrynic acid to lasix conversion by IPA was used for the figure design.
IPA, Ingenuity Pathway Analysis." data-icon-position data-hide-link-title="0">Figure 4 IPA of the 13 kinesins known to be involved in birth defects with respect to their position in the cell. Proteins displayed on the right side of the figure, below the tag âotherâ, are those for which no subcellular location is known. Birth defect-related ethacrynic acid to lasix conversion kinesins and their connection with each other are highlighted in green.
Light blue-coloured downstream proteins are those which are known to cause birth defects when altered. Yellow-coloured proteins ethacrynic acid to lasix conversion are those involved in neurological disorders overlapping with the clinical features of kinesinopathies. The legend of the biological function associated with every molecule is displayed on the right.
Path Designer by IPA was used for the figure ethacrynic acid to lasix conversion design. IPA, Ingenuity Pathway Analysis.Closing remarks and future perspectivesNovel KIF genes are increasingly identified, and there is a growing body of literature demonstrating the impact of kinesin dysfunction in human disease. We propose to introduce the term kinesinopathies ethacrynic acid to lasix conversion for conditions caused by variants in KIF genes, since recurrent and common functional and phenotypical themes can be observed.
In analogy to ciliopathies56 and rasopathies,57 the delineation of the clinical, genetic and functional hallmarks of kinesinopathies will be important to better recognise these conditions, to understand the pathomechanisms and to ultimately improve the clinical management of the patients. Previously, the unified view of the phenotype characteristics of ciliary dysfunction allowed a tremendous increase in awareness, both in clinic and research, and the further identification of yet unrecognised ciliary disorders and the genes and proteins involved in their pathogenesis.56Remarkable progress was achieved in assigning function to kinesins through their study in isolated and multiple congenital anomaly phenotypes. They are one ethacrynic acid to lasix conversion large superfamily of molecular motors out of three (kinesins, dyneins and myosins), which is of key importance in several fundamental cellular processes using microtubules as rails for directional anterograde intracellular transport, including its regulation and modulating signal transduction.5 Kinesin motors are most important for the movement of chromosomes along the spindles during chromosome segregation, regulation of spindle formation, cell division and cytokinesis.
These essential and broad cellular functions are critical for many physiological processes such as neuronal function and survival, some ciliary functions and ciliogenesis, determination of the left/right asymmetry of our body and regulation of organogenesis, thus explaining the impact and emerging recognition of kinesins in embryonic and foetal development. Defects can ethacrynic acid to lasix conversion result in neuropathies, higher brain functions and structural brain anomalies. Multiple congenital anomalies, including the kidney and urinary tract and limb anomalies, are repeatedly reported.
Microcephaly, which is usually ethacrynic acid to lasix conversion not associated with genes implicated in specific ciliary mechanisms, and CNS anomalies are the most recurrent clinical signs in both the prenatal and postnatal phenotypes described so far. The discovery of the implication of KIF14 in microcephaly further suggested a possible novel role of other microcephaly proteins in cytokinesis. A number of syndromic kinesinopathies present, however, with phenotype patterns reminiscent of ciliopathies.
So far, however, a direct functional impact was confirmed in only a few and could not be demonstrated, for example, for KIF14, despite an overlapping clinical ethacrynic acid to lasix conversion pattern. In turn, ciliopathies are a clinically and genetically heterogeneous group of conditions themselves. Studying tissue and cell type-specific function and expression may help to further define the specific defects related to the individual aberrant kinesin.The pleiotropic nature of human ethacrynic acid to lasix conversion kinesinopathies, however, is just emerging, but their study promises to provide important insights into human developmental pathways.
Seemingly unrelated clinical entities are highlighting a common theme. In a relatively short time span, monogenic KIF-related disorders were identified to present with often severe and lethal antenatal anomalies, with multiple or isolated congenital anomalies, neurodevelopmental and neurological disorders, or an increased susceptibility to multifactorial ethacrynic acid to lasix conversion conditions. We focused on the emerging role of kinesins in structural congenital anomalies because, as illustrated for the KIF14 gene, great potential to decipher allelic viable phenotypes and developmental pathways lies in the study of these human knockout phenotypes at the severe end of the phenotypical spectrum.
Knockout variants in about 30% of human protein coding genes in our genome may present with a phenotype of early lethality, and KIF genes seem to play an important role in such fundamental processes of human development. Identifying and characterising the variants, genes and phenotypes will extend our knowledge on early human development and pathomechanisms, and will ultimately also improve the clinical utility of genome-wide sequencing approaches for prenatal and postnatal application by our increased ability ethacrynic acid to lasix conversion to interpret loss of function and hypomorphic variants alike. Furthermore, kinesins were extensively studied in cancer research and therapeutic strategies targeting their specific functions, such as the example of monastrol and other inhibitors of the mitotic kinesins may be adopted in the future.
There are likely many more kinesinopathies to be unravelled in the field of birth defects because of ethacrynic acid to lasix conversion their pivotal role in cellular logistics, but their recognition in clinics and research will depend on our ability to identify and characterise the common clinical, molecular and functional themes of these disorders and to use them to improve our understanding of their disease mechanisms.IntroductionIntellectual disability (ID) affects about 3% of individuals worldwide and raises significant issues in terms of diagnostic, management and genetic counselling. The presence of pigmentation anomalies in a patient with ID represents helpful clinical clues in order to narrow the range of aetiological hypothesis. Hypomelanosis of Ito (HMI, MIM #300337) is an unspecific term encompassing a heterogeneous group of disorders characterised by cutaneous hypopigmented whorls and streaks along Blaschkoâs lines and variable extracutaneous features affecting the musculoskeletal and nervous systems.1 The cutaneous ethacrynic acid to lasix conversion pattern therefore represents a non-specific hallmark of mosaicism in these neurocutaneous conditions.
Genetic mosaicism is due to postzygotic mutations, either chromosomal rearrangements or point mutations, whereas random X inactivation in females leads to functional mosaicism.2 Unravelling the molecular basis of pigmentary mosaicism (PM) is still a challenge due to clinical and genetic heterogeneity, technical difficulties in detecting mosaic mutations by classical sequencing approaches and the complexities of obtaining affected tissue. As part of a collaborative group, we recently reported de novo mutations in exons 3 and 4 of transcription factor E3 (TFE3) as the cause for ethacrynic acid to lasix conversion HMI in four unrelated individuals, including one male, as well as syndromic ID without pigmentary disorders in a female.3TFE3 belongs to the MITF family of mammalian basic helixâloopâhelix zipper transcription factors, together with TFEB and TFEC. All four can form homodimers or heterodimers with each other.4 Embryonic expression of TFE3 orthologues Tfe3a and Tfe3b was demonstrated in the zebrafish in a wide range of tissues.5 TFE3 subcellular localisation plays a crucial role in the regulation of cellular homeostasis and embryonic stem cell (ESC) differentiation.
The phosphorylated TFE3 is retained in the cytoplasm, whereas dephosphorylated protein translocates to the nucleus to promote the transcription of target genes involved in lysosomal biogenesis and autophagy.6 TFE3 relocalisation to the nucleus is driven on various stressors, such as starvation,7 8 DNA damage,9 mitochondrial damage,10 Golgi stress11 and pathogens12 in an mTORC1-dependent manner, and oxidative stress13 or cadmium exposition14 in an mTORC1-independent manner. Moreover, lysosomal signalling-induced nucleocytoplasmic redistribution of TFE3 is essential to the regulation of ESC renewal.3 15 By restricting nuclear localisation and activity of Tfe3, lysosome activity, ethacrynic acid to lasix conversion the tumour suppressor protein folliculin and the Ragulator protein complex enable the exit from pluripotency and therefore drive differentiation. Conversely, enforced nuclear Tfe3 enables ESCs to withstand differentiation.15 In humans, TFE3 mutations have long been known in cancer.
Gene fusions by translocations or other chromosomal rearragements involving TFE3 and five partner genes have indeed been reported to occur in a subset of renal cell carcinomas (RCCs), referred to as âTFE-fusion RCCâ, and, more rarely, to lung sarcoma and perivascular epithelioid cell tumours.16 Beyond these data on TFE3 function, by the report of a ethacrynic acid to lasix conversion series of 17 individuals harbouring de novo mutations in exons 3 and 4 of TFE3, we emphasise their phenotype and bring additional clinical insight toward the recognition of this novel developmental disorder.ResultsWe describe a series of 17 patients carrying a de novo mutation in TFE3, 5 of them being previously published with limited clinical information.3 Twelve were females and five were males. Their age ranged from 12 months to 22 years. Five were referred for HMI, five for syndromic ID and five for ethacrynic acid to lasix conversion suspicion of storage disorder.Clinical dataThe clinical features are summarised in table 1.
Additional information can be found in online supplementary data 1.Supplemental materialView this table:Table 1 Clinical and molecular features of the 17 patients with an TFE3 mutationNeonatal course was remarkable for nine patients. History of jaundice, hepatomegaly or feeding difficulties was reported for three patients each, hypoglycaemia for two and cholestasis for one. All these features were transient.Developmental delay, usually severe and noticeable from the first months of ethacrynic acid to lasix conversion life, was a constant feature in all the individuals.
Only 6 patients were able to walk at the time of the study, whereas 11 were still unable to walk. All patients ethacrynic acid to lasix conversion were non-verbal, except for two older patients who could speak a few words. Neurological examination was abnormal in 12 individuals and consisted in truncal hypotonia, associated with lower limb spasticity (6 individuals) or ataxia (2 adults).
Behavioural issues such as autistic features and sleeping disturbance were noted for ethacrynic acid to lasix conversion 11 patients. Eleven patients developed epilepsy, onset in the first decade and characterised as intractable in three of them. Brain MRI was normal in 10 individuals and abnormal in 6 patients (hydrocephaly, short corpus callosum, Dandy-Walker malformation, arachnoid cyst, periventricular white matter lesions, delayed myelination and cerebral atrophy).
The sensory anomaly was congenital hearing loss (5 patients), and ophtalmological anomalies (10 patients) consisted of strabismus, hyperopia, retinal degeneration, depigmented macule on the iris, oculomotor apraxia or impaired vision of cortical origin.Facial dysmorphism shared among the patients consisted in coarseness, flat nasal bridge, short nose with anteverted nares, widely spaced eyes, almond-shaped eyes, thick ethacrynic acid to lasix conversion lips, facial hypertrichosis, fleshy earlobe, and full and pink cheeks (figure 1). Twelve patients had pigmentation anomalies, located on Blaschkoâs lines for 10 of them (figure 2). One was diagnosed at 4 years old with histiocytofibroma ethacrynic acid to lasix conversion.
Moderate to severe postnatal growth retardation affected 10 patients, who had a length between â2.0 and â4.5 SD. Obesity affected ethacrynic acid to lasix conversion 13 individuals. Skeletal anomalies were frequent (11 individuals) and consisted of flat or clubfeet, hyperlordosis, scoliosis, hip dislocation, limitation of elbow extension and genu valgum.
Recurrent s of the upper airways ethacrynic acid to lasix conversion were noted in five patients. One had a documented neutropenia. Early-onset chronic interstitial lung disease was reported in two patients.
Nail clubbing ethacrynic acid to lasix conversion was noted in two individuals. Visceral malformations consisted of congenital heart defect (left ventricle dilatation, aortic insufficiency and patent ductus arteriosus) in three patients, umbilical hernia in three individuals, lateral semicircular canal dysplasia, posterior plagiocephaly, sleep apnoea syndrome, anteriorly displaced anus and hypospadias in one individual each.Facial phenotypes of seven patients. (AâC) Patient ethacrynic acid to lasix conversion 5, aged 6 months (A,B) and 3 years (C).
(D) Patient 8, aged 5 years. (E,F) Patient 2, aged 5 and ethacrynic acid to lasix conversion 20 years. (GâI) Patient 3, aged 1âyear (G) and 3 years (H,I).
(J,K) Patient 13, aged 22 years. (LâO) Patient 6, aged 8 months (L), 20 months (M) ethacrynic acid to lasix conversion and 3 years (N,O). (P,Q) Patient 10 aged 22 years." data-icon-position data-hide-link-title="0">Figure 1 Facial phenotypes of seven patients.
(AâC) Patient 5, aged 6 months (A,B) ethacrynic acid to lasix conversion and 3 years (C). (D) Patient 8, aged 5 years. (E,F) Patient 2, aged ethacrynic acid to lasix conversion 5 and 20 years.
(GâI) Patient 3, aged 1âyear (G) and 3 years (H,I). (J,K) Patient 13, aged 22 years. (LâO) Patient 6, aged 8 months (L), 20 months (M) and 3 ethacrynic acid to lasix conversion years (N,O).
(P,Q) Patient 10 aged 22 years.Cutaneous features. (A) Patient 3 ethacrynic acid to lasix conversion. Umbilical hernia, widely spaced nipples and hypopigmentation on the left side of the abdomen.
(B) Patient ethacrynic acid to lasix conversion 17. Hypotonia, umbilical hernia and widely spaced nipples. (C) Patient ethacrynic acid to lasix conversion 8.
Blaschkoâs lines on the back. (D) Patient 6. Hypopigmentation on the left side of the abdomen ethacrynic acid to lasix conversion.
(E) Patient 7. Blaschkoâs lines on the abdomen and right ethacrynic acid to lasix conversion side of the trunk. (F) Patient 13.
Hand. Note clubbing of thumbnail and loose skin. (G) Patient 17.
Blaschkoâs lines on the left side of the abdomen. (H) Patient 17. Hand.
Note tapering fingers and wrinkled skin. (I) Patient 1. Linear hypopigmentation on the back.
(J) Patient 6. Blaschkoâs lines on the back. (K) Patient 3.
Blachkoâs lines on the right lower limb. (L) Patient 6. Blaschkoâs lines on the right lower limb.
(M,N) Patient 7. Linear hyperpigmentation on the lower limbs. (O) Patient 11.
Blaschkoâs lines on the back." data-icon-position data-hide-link-title="0">Figure 2 Cutaneous features. (A) Patient 3. Umbilical hernia, widely spaced nipples and hypopigmentation on the left side of the abdomen.
(B) Patient 17. Hypotonia, umbilical hernia and widely spaced nipples. (C) Patient 8.
Blaschkoâs lines on the back. (D) Patient 6. Hypopigmentation on the left side of the abdomen.
(E) Patient 7. Blaschkoâs lines on the abdomen and right side of the trunk. (F) Patient 13.
Hand. Note clubbing of thumbnail and loose skin. (G) Patient 17.
Blaschkoâs lines on the left side of the abdomen. (H) Patient 17. Hand.
Note tapering fingers and wrinkled skin. (I) Patient 1. Linear hypopigmentation on the back.
(J) Patient 6. Blaschkoâs lines on the back. (K) Patient 3.
Blachkoâs lines on the right lower limb. (L) Patient 6. Blaschkoâs lines on the right lower limb.
(M,N) Patient 7. Linear hyperpigmentation on the lower limbs. (O) Patient 11.
Blaschkoâs lines on the back.Molecular resultsThe characteristics of the 13 different de novo TFE3 variants identified in the 17 unrelated individuals are summarised in table 2. All but one were missense variants, affecting nine different aminoacids. One was a splice donor mutation.
This mutation was reported a few weeks ago in a patient with a similar phenotype.21 Two variants were localised in exon 3 and 11 in exon 4 (figure 3). All were absent from public databases and were predicted to be pathogenic by prediction softwares. TFE3 protein and localisation of the missense variants identified.
In bold are variants identified in two patients. In bold and underlined is the variant identified in three patients. In green is the intronic variant." data-icon-position data-hide-link-title="0">Figure 3 TFE3 protein and localisation of the missense variants identified.
In bold are variants identified in two patients. In bold and underlined is the variant identified in three patients. In green is the intronic variant.View this table:Table 2 Molecular data of the 13 de novo TFE3 mutations.
Characteristics, inheritance, frequency in the public database GnomAD, prediction scores regarding pathogenicity (Polyphen, Grantham and CADD (Combined Annotation Dependant Depletion) scores). The transcript is NM_006521.5The putative mosaicism was assessed through X inactivation studies in females and analysis of the exome sequencing data in males, by checking the total number of reads covering the variant, as well as the number of reads supporting the presence of the variant (table 1). Allele frequencies in females were always consistent with a constitutional heterozygous mutation.
X inactivation was skewed in blood of the female patients 1, 3 and 7 and in fibroblasts of Patient 2. X inactivation was random in fibroblasts of Patient 1 and 3. Regarding the male patients, the mutation was identified in 65% of the reads for Patient 17% and 88% of the reads for Patient 15 (106/120).
No mosaicism was detected in the blood of Patient 13, 14 and 16 despite the presence of pigmentary manifestations in Patient 16.DiscussionTFE3 functions in signalling of the mechanistic target of rapamycin (mTOR) complex 1 (mTORC1). The PIK3-AKT-mTOR pathway plays a role in the regulation of cellular growth, proliferation, survival and metabolism. Overactivation of the mTOR signalling is responsible for neurocutaneous disorders and cancers.22 Somatic mutations in TSC1, TSC2, AKT3, PIK3CA and MTOR are responsible for focal cortical dysplasia type II (MIM607341),23â25 hemimegalencephaly26 and megalencephaly.27 The phenotype ascribed to germline TSC1/TSC2, PTEN, MTOR and PK3R2/AKT3/CCND2 mutations â respectively in tuberous sclerosis (TS, MIM 191100), Cowden syndrome (CS, MIM 158350), Smith-Kingsmore syndrome (MIM 616638) and Megalencephaly, Polymicrogyria, Polydactyly and Hydrocephalus syndrome 1, 2 and 3 (MPPH1/2/3, MIM 603387/615939/615938) - is characterised by the association of ID, epilepsy, brain malformations and skin tumours.
Similarly, all the individuals harbouring a de novo TFE3 mutation reported in the series presented with a severe neurodevelopmental disorder. Delayed psychomotor development was constant. The youngest patient to acquire independent walking was 30 months old, and more than half of the patients aged over 18 months (57%), did not acquire walk at the last examination.
Conversely to patients with MTOR, AKT3 or PTEN mutation, none of the patients described in this series had macrocephaly. Brain imaging was abnormal in 35% of the patients. Hydrocephaly and corpus callosum dysgenesis, identified in respectively three and one individual, were previously reported in patients with mosaic gain of function MTOR mutations.28 29 One patient had surgery to remove an early-onset histiocytofibroma.
However, no other skin tumour was reported, either in this patient or in any other from the series.Pigmentation anomalies, along Blaschkoâs lines or, for one patient, as a large hyperpigmented area, were present in a majority of the individuals (71%) in the series, including 40% of the males and 83% of the females. PM along Blaschkoâs lines is highly suggestive of genetic mosaicism.30 Genomic mosaicism is defined by the presence of at least two cell populations with different genotypes in an individual originating from one zygote and mainly occurs through post-zygotic event, whereas females can present with functional (epigenetics) mosaicism due to X inactivation.2 PM is a classical feature of X-linked male-lethal genodermatosis, such as incontinentia pigmenti (IP, MIM #308300), focal dermal hypoplasia (FDH, MIM #305600), chondrodysplasia punctuata type 2 (Conradi-Hunermann-Happle syndrome, CDPX2, MIM #302960) and linear skin defects with multiple congenital anomalies (LSDMCA1, MIM #309801). In these conditions, the overwhelming predominance of affected females is a consequence of the male lethality, and the PM a manifestation of the functional mosaicism occurring in females.
Similarly, the majority of individuals with de novo TFE3 variants in our cohort were females (sex ratio female:male was 12:5 (2.4)). The study of X-inactivation on non-cultured fibroblasts was consistent with functional mosaicism in two affected females with PM who harboured random X-inactivation, whereas a third female without PM had skewed X-inactivation. In IP, FDH and CDPX2, most hemizygous males die in utero.
However, there have been reports of surviving males 31â33 with an estimated prevalence around 10% in FDH and IP.32 34 The majority of them are explained by post-zygotic mutations or chromosomal anomalies (Klinefelter syndrome). Non-mosaic males have also been reported in FDH and IP â respectively about 17% and 45% of the affected males harbour a non-mosaic variant.32 35 In our series, males represented 29% of the patients with a de novo TFE3 variant. A mosaic variant was identified in blood for half of them.
None had Klinefelter syndrome. Interestingly, mosaicism was detected in only one out of the two males with PM, and one male with a mosaic variant had no pigmentation anomalies noted on examination. It is still possible that subtle pigmentation anomalies were missed on examination.
Moreover, somatic mosaicism can be difficult to detect. Recent studies have shown that a large proportion of de novo mutations presumed to be germline had in fact occurred as post-zygotic event.36 In the males of this cohort, WES was performed on leucocytes-derived DNA and no other tissue was studied. Therefore, it is possible that a low mosaicism was not detected.
Finally, it is probable than TFE3 mutations account for a significant proportion of patients with HMI. Indeed, in this population, the high frequency of ID, epilepsy, coarse facial features has long been emphasised in the literature.37By its ability to bind the coordinated lysosomal enhancement and regulation (CLEAR) sites in the promotor region of target genes, TFE3 is involved in the control lysosomal biogenesis, autophagy and endocytosis.8 Several patients of the series indeed had clinical and biochemical features that pointed toward an inborn error of metabolism. Lysosomal storage disorder was suspected due to the variable association of coarse facial features (88%), skeletal anomalies (65%) âflat or clubfeet, hyperlordosis, hip dislocation, limitation of elbow extension, genu valgum, scoliosisâ, postnatal growth retardation (59%), history of speech or developmental regression (29%) congenital hearing loss (29%), recurrent upper airways s (29%) neonatal liver anomalies such as hepatomegaly and cholestasis (18%), upper airways s (24%), umbilical hernia (18%), sleep apnoea syndrome (6%) and aortic insufficiency (6%).
Other metabolic anomalies observed in the series were obesity, defined in children by body mass index (BMI) (weight/height2) above the WHO curve, present in the oldest patients (76%), neonatal transient hypoglycaemia (12%), and hyperlactataemia (6%). Dysregulation of lipid metabolism, via suppression of thermogenesis and decreased lipolysis, thus leading to increased adipose tissue, was previously observed in adipose-specific TFE3 transgenic mice.38 Similarly to lysosomes, mitochondrias have a key role in cellular metabolism, including autophagy. Recent data demonstrate that mitochondrial and lysosomal metabolisms are interrelated.39 Muscle biopsy, performed in two individuals from this cohort, showed fat and glycogen accumulation, muscular fibre size irregularity, without evidence of mitochondrial dysfunction.
Interestingly in the more recent data, evidences showing that TFE3 plays a role in the regulation of the circadian oscillations of the expression of genes involved in autophagy and lipid metabolism, and that Tfe3 knock-out mice had abnormal circadian behaviour.40 Indeed, in our series, five patients (29%) were noted to have sleep disturbance. This could be due to circadian rhythms alteration. Finally, TFE3 has been shown to be involved in the regulation of innate immune response in macrophages via the FLCN-AMPK signalling axis,41 and of B-lymphocytes activation.42 Along these lines, four patients of the series (24%) had a history of recurrent s, associated with documented neutropenia in one of them.
As shown in table 3, a summary of the frequency of the features observed in the cohort, facial dysmorphism was constant and strikingly similar among the patients. More than two-third had anteverted nares, broad flat nasal bridge, almond-shaped and widely spaced eyes, puffy cheeks and coarse facial features (thick lips and fleshy earlobes). More than half had facial hypertrichosis.
All individuals presented with at least four of the above features. One patient had an extreme facial phenotype of hypertelorism, bifid nose and bilateral cleft lip and palate. Whether these frontonasal dysplasia features may be associated with the TFE3 mutation remains unclear.
No other mutation in known genes was found in Patient 1âs exome sequencing data.View this table:Table 3 Frequency of the clinical features observed in the seriesTFE3 is a highly conserved protein, intolerant to loss of function as supported by data from the GnomAD browser43 (probability of being loss-of-function intolerant (pLI) evaluated at 0.98, observed:expected ratio=0.06) and to missense variants (Z=2.15). Moreover, TFE3 does not, or only in a few tissues, escape X inactivation, suggesting that TFE3 gene dosage is crucial to cell function.44 45 In vitro, Villegas et al recently showed that the absence of either TFE3 exon 3 or 4 resulted in a nuclear gain-of-function Tfe3 allele in ESCs, indicating that both exons 3 and 4 are required for Tfe3 inactivation.3 Nuclear localisation and resistance to differentiation were proved in Tfe3 knock-out (K.O.) ESCs expressing murine Tfe3 alleles (Gln118Pro and Pro185Leu, corresponding to mutations Gln119Pro and Pro186Leu identified in individuals referred to as patients 1 and 2 in this series). Based on the analysis of TFE3 secondary structure,46 indicating that residues 110â215 are predicted to form a domain of two stable alpha helices that might be disrupted by mutations in exons 3 and 4, and the observation of a similar phenotype in patients harbouring mutations in exons 3 and 4, it was suggested that Tfe3 exons 3 and 4 form a Rag binding fold whose structural integrity is indispensable for lysosome-mediated cytoplasmic Tfe3 inactivation.3 In this series, the recurrent mutations Arg117Gln, Leu191Pro and Thr187Met were present in respectively two, two and three patients.
The aminoacid in position 187 was mutated in five patients. In addition, 13 of the described mutations were localised between positions p.184 and p.201. This proximity could account for the absence of obvious genotypeâphenotype correlation.
The canonical splice site variant in intron 4 identified in patient 9 might lead to in-frame exon skipping of exon 4. The clinical picture of the patient with this splice site variant perfectly fits with the syndrome described here. As a consequence, we raise the hypothesis of a gain-of-function effect of this variant.In conclusion, de novo mutations in exons 3 and 4 of the X-linked gene TFE3 are responsible for a neurocutaneous disorder with specific and recognisable facial dysmorphism, lysosomal storage disorder-like features and PM.
This series unravels TFE3 as a major gene responsible for HMI and for a rare cause of syndromic ID. Furthermore, we provide clinical and molecular data on a previously unidentified lysosomal storage disorder, in which new insights, especially biochemical features, will probably be investigated further, together with the description of more patients. Further delineation of this phenotype will indeed allow a better understanding of the link between lysosomal signalling and development.
Finally, the evidence for mosaicism in this recently described disorder highlights the importance of considering mosaic variants on next-generation sequencing reports in diagnostic, including for patients without suggestive phenotype..
IntroductionThe mammalian kinesin superfamily lasix 40mg price proteins (KIFs) are microtubule and ATP-dependent molecular motors, which were first identified in 1985 as axonal transporters in squid and bovine brains.1 Forty-five different kinesin family member (KIF) genes were identified in the mouse genome so far, 44 of which are present in the human genome Where can i buy viagra over the counter. Phylogenetic analysis based on sequence homology between the human and the mouse genome led to the classification of KIF genes into 16 families, from kinesin-1 to kinesin-14B (figure 1).2 The first kinesins discovered belong to the kinesin-1 family (KIF5A, KIF5B and KIF5C), and they form a heterotetramer of two heavy chains and two light chains (KLC1-4).2 KIF genes encode KIFs, a specific class of motor proteins generating intracellular motility by driving directional transport of various cargoes such as organelles, protein complexes and mRNAs along the microtubule system.2 Studies using knockout mouse models by Hirokawa and colleagues significantly contributed to elucidate the roles of kinesins in mammalian physiology. Their role in transport is fundamental to cellular logistics and performance, and the molecular motors are not only effectors of signal transduction cascades but also transport and/or bind to important signal transduction molecules to actively modulate their function.3Phylogenetic tree of mammalian kinesin superfamily genes identified in the human (and mouse) genome and classified in 16 subfamilies (from kinesin 1 to 14B) (adapted from Hirokawa et al 3)." data-icon-position data-hide-link-title="0">Figure 1 Phylogenetic tree of mammalian kinesin superfamily genes identified in the human (and mouse) genome and classified in 16 subfamilies (from kinesin lasix 40mg price 1 to 14B) (adapted from Hirokawa et al3).The first kinesins were observed in the context of axonal transport in neurons, and a novel disease entity of âmotorâproteinopathyâ was proposed for the pathogenesis of axonal neuropathies in 2001.4 Due to their role in cellular membrane trafficking, however, kinesins are essential for the functioning of many polar cell types, such as neurons, epithelial cells, sperm cells or stem cells during organogenesis. Kinesins also play a fundamental role in cell-cycle dynamics, both during mitotic and meiotic processes.
They regulate chromosomal condensation and alignment, spindle formation, cytokinesis and cell-cycle progression.5 It is estimated that about a dozen lasix 40mg price kinesins are involved in the cell cycle. Among these, there is a specific subclass of chromokinesins (kinesin 4 and kinesin 10 family) which are able to bind chromosomes.6 Recently, KIFs were discovered to act as microtubule stabilisers (KIF26A and KIF21A) and depolymerisers (KIF2A and KIF2C), activities which are important for both cellular morphogenesis and mammalian development, playing a role in neuronal and axonal morphology and ciliogenesis.7Alterations in motor kinesins are leading to human disease by various pathological mechanisms, including cancer and multifactorial and monogenic disorders. Variants in 18 out of the 44 human KIF lasix 40mg price genes were identified to cause monogenic disorders, following different modes of Mendelian inheritance and associated with a wide spectrum of clinical signs. These range from lethal and multiple to isolated congenital anomaliesâincluding birth defects potentially detectable in the foetal period by current prenatal imaging studiesâto postnatally apparent neurodevelopmental disorders, intellectual disability and neurological conditions.We will review the current state of knowledge of the biological processes kinesins are involved in and discuss their emerging role in human disease, particularly in birth defects and congenital anomaly syndromes.
Birth defects remain a leading cause of perinatal lethality in industrialised countries.8 Structural anomalies are recognised with increasing reliability during early pregnancy by the use of high-resolution ultrasound technologies, thus raising questions about diagnosis, aetiology, prognosis and recurrence risk, particularly in the presence of more than one anomaly, which most likely indicates a genetic aetiology. We identify recurrent phenotype lasix 40mg price patterns caused by alterations in KIF genes, and we outline the complexity of phenotypeâgenotype correlations mirroring the processes of intracellular microtubule-mediated transport and movement, in which kinesins play a fundamental role. There are likely many more relationships between the clinical signs and the genetic variants to be identified in the future, and the functional network of kinesins and their role in human disease need to be further elucidated. We propose to introduce the lasix 40mg price term âkinesinopathiesâ for this group of conditions, which are phenotypically and genetically overlapping and characterised by the functional impairment of a specific group of molecular motors.
We hope that their systematic approach leads to a better recognition in clinical practice, as well as in genome-wide sequencing for diagnosis and research, and opens strategies for the future development of molecular therapies.KIF structureAll KIFs have a phylogenetically well-conserved motor domain head, consisting of an ATP-binding motif and a microtubule-binding domain. Depending on the position of the motor domain, kinesins can be subdivided into N-kinesins (amino-terminal motor domain), M-kinesins (middle-region motor domain) and C-kinesins (carboxy-terminal motor domain).2 Most kinesins belong to the N-kinesin subgroup, but members of the kinesin 13A family (figure 1) belong to the M-kinesin subtype, while KIF1C, KIF2C and KIF3C lasix 40mg price belong to the C- kinesin subfamily.3 Both N-kinesins and C-kinesins are responsible for plus end and minus end-directed motility, M-kinesins for depolymerisation of microtubules in tubulin molecules. However, there are a few exceptions to this categorisation.9 The motor domain head attaches to the neck, the coiled coil stalk and the tail. The kinesinsâ neck is family-specific and responsible for the direction of motility or regulation of activity.
The coiled coil stalk and tail are involved lasix 40mg price in kinesin dimerisation and/or interactions with cargoes. Kinesins typically use scaffold proteins and adaptor proteins to bind their cargoes but can sometimes bind the cargo directly. Scaffolds and adaptors might also have regulatory roles in kinesin-driven intracellular transport, that is, recognising specific cargoes and regulating their loading and unloading.3Role of KIFs in physiology and diseaseThe application of genome-wide sequencing for gene identification in research or for clinical diagnostic lasix 40mg price purposes significantly contributes to the identification of KIF candidate genes. Genotypeâphenotype correlations in KIF gene-related disorders, together with functional and animal studies, continue to elucidate the complex involvement of KIFs in human developmental pathways and disease.
Table 1 summarises the monogenic conditions caused by variants affecting the function of KIF genes.View this table:Table 1 Specific monogenic disorders caused by variants affecting the function of KIF genesView this table:Table 2 Summary of phenotypes and genotypes of KIF149 26 30 31The kinesinsâ functions in physiological processes, however, are complex and still incompletely understood, but lasix 40mg price their role in cell-cycle progression and regulation, including both meiosis and mitosis, in intracellular trafficking, axonal transport, microtubule activity and ciliogenesis, is increasingly studied. Figure 2 summarises the clustering of KIF genes according to their functional roles and the phenotypical consequences as identified to date in 32 out of the 44 human kinesin genes.Assignment and clustering of KIF genes to various functions and relation to birth defect or monogenic phenotype groups. Detailed phenotypes are shown in tables lasix 40mg price 1 and 3. Cancer and multifactorial conditions are not included.
CNS, central nervous system." data-icon-position data-hide-link-title="0">Figure 2 Assignment and clustering of KIF genes to various functions and relation to birth defect or monogenic phenotype groups. Detailed phenotypes are shown in lasix 40mg price tables 1 and 3. Cancer and multifactorial conditions are not included. CNS, central nervous system.Kinesins play a lasix 40mg price pivotal role during early development and organogenesis.
Microcephaly is one of the most frequently associated clinical signs, mirroring a defect in the regulation of the final number of neurons during development.10KIF4A is a motor protein that translocates PRC1, a cytokinesis protein, to the ends of the spindle microtubules during mitosis, regulates the PARP1 activity in brain development and the survival of neurons, and is a member of the L1CAM recycling pathway. Variants in L1CAM cause X-linked lasix 40mg price isolated and syndromic hydrocephalus. KIF4A was recently proposed as a candidate gene for hydrocephalus.11KIFs are involved in neuronal branching, and microtubule depolarisation, operated by KIF2A M-kinesin, was suggested to suppress collateral branch extension during brain development, leading to anomalies of cortical development, including agyria and pachygyria, subcortical band heterotopia and corpus callosum anomalies.12Functional disruption of KIF genes in knockout mice often results in embryonic lethality, for example, for Kif18A, Kif10, Kif3A, Kif3B and Kif5B,13â17 highlighting the importance of kinesins in embryonic and foetal development. A study on KIF16B demonstrated that microtubule-based trafficking is responsible for early development and stem cell survival.18 KIF26B is essential in kidney development, contributing to the adhesion of mesenchymal cells to the ureteric bud.3 KIF26A was suggested to play a role in enteric nervous system development, because knockout mice develop a megacolon and enteric nerve hypoplasia,19 and to negatively regulate nociceptive sensation.20A significant number of KIFs play a prominent role in ciliogenesis and cilia function.
They regulate cilia length, ciliary assembly/disassembly and lasix 40mg price can have motile cilia-specific functions.21 Some KIFs, specifically found in primary cilia (PC), regulate the length of the axoneme and its disassembly when re-entering the cell cycle.KIF7, also a key component of the Hedgehog signalling pathway, is responsible for cilia length regulation through suppression of microtubule polymerisation.7 KIF7 variants cause hydrolethalus, acrocallosal, and Joubert and Al-Gazali-Bakalinova syndromes.22 Kif2A knockout mice have severe brain defects, and KIF2A variants in humans lead to microcephaly because of cell-cycle delay in cellular progenitors resulting from cilia disassembly defects. KIF24, belonging to the same kinesin 13 family, plays a role in both microtubule depolymerising activity and regulation of the early steps of ciliogenesis. Other PC-related KIFs recently identified are KIF5B, KIF1C lasix 40mg price and KIF13B, and a potential role in cilia was hypothesised for KIF11 and KIF14.KIF3 protein complex (KIF3A-KIF3B-KAP3 heterotetramer) is a molecular motor necessary for intraflagellar transport (IFT) but is also involved in ciliogenesis of motile cilia. Kif3a-knockout or Kif3b-knockout mice are prenatally lethal, exhibiting anomalies similar to ciliopathy phenotypes, including the disturbance of leftâright body determination.3KIF19A is localised at the tip of motile cilia and performs motor and microtubule-depolymerising activities during IFT.
Kif19a-knockout mice present with hydrocephalus and female infertility, common signs in ciliary defects, due to abnormally elongated cilia with altered motility, not able lasix 40mg price to generate proper fluid flow.9Further KIFs, which may have specific roles in motile cilia, are KIF27, KIF9, KIF6 and KIF18B. Regarding the involvement of numerous KIFs in cilia-related processes, it is not surprising that many disorders caused by variants affecting KIF gene function are presenting with anomalies reminiscent of ciliopathies.Kinesin motors have a fundamental role in neuronal function, as they are responsible for the transport of synaptic vesicle precursors and transmitter receptors along axons and dendrites from the neuron body.3 Molecular motor activity as for KIF1A, KIF5 and KIF17 is important for higher brain functions, such as learning and memory through regulation of synaptic transmission.5 Dysfunction can be associated with intellectual disability and global developmental delay (table 1).Impaired function can also result in peripheral neuropathies (KIF5A, KLC2, KIF1A and KIF1B) and ocular motility disorders (KLC2 and KIF21A)23 24 when axon elongation in the peripheral nervous system and optic nerve is affected. KIF5A variants are associated with epileptic phenotypes both in humans and mice25 because the transport of neurotransmitter receptors is disturbed and inhibitory regulation is altered.Due to their role in cell-cycle regulation, kinesins are important in male spermatogenesis and female oogenesis. They are involved in all steps of lasix 40mg price spermatogenesis 26 and, based on previous animal studies, they may represent a potential target to treat male infertility.
In female meiosis, 13 KIF genes were studied in animal models. There is some evidence that kinesin expression is vulnerable to maternal ageing and environmental factors, such as oocyte cryopreservation and alcohol consumption lasix 40mg price. It may be promising to expand research in this field in order to clarify the mechanisms and factors contributing to oocyte quality decline.27Many kinesins were extensively studied in the fields of cancer development, progression and therapy. Deregulation of the mitotic kinesins by both overexpression and decreased expression causes cancer progression or can be a prognostic marker in various tumours.28 The cell-permeable small-molecule mitotic inhibitor monastrol was discovered in 199929 and was shown to arrest cells in mitosis by specifically inhibiting KIF11, lasix 40mg price a kinesin important for spindle bipolarity.
The bipolar mitotic spindle is replaced by a monoastral microtubule array surrounded by a ring of chromosomes, which gave the inhibitor its name. The mitotic spindle is now a well-known lasix 40mg price target of chemotherapy, and inhibitors of the mitotic kinesins KIF11, KIF10 and KIF1C are being studied for this purpose.28 30 The redundancy of some kinesins allows them to escape pharmacological inhibition. For example, in the absence of KIF10, KIF15 is able to replace all of its essential functions in spindle assembly. Cilia-related KIF7, KIF13B and KIF27 are involved in SHh signalling and may be a future target in cancer research.28Some kinesins confer susceptibility to a range of multifactorial, metabolic and neurodegenerative conditions.
KIF13B contributes to the enhancement of endocytosis of low-density lipoprotein (LDL) receptor-related protein 1 that is involved in the recognition and internalisation of LDL and lasix 40mg price factor VIII. Kif13b-knockout mice have hypercholesterolaemia and higher factor VIII serum levels.5 KIF12 is implicated in the pathogenesis of type 2 diabetes, protecting pancreatic β cells from the oxidative stress caused by nutritional excess.5 Variants in KIF1B or KIF21B confer susceptibility to multiple sclerosis (OMIM %612596, #126200).31 32 KIF5A was associated with Amyotrophic lateral sclerosis (OMIM #617921).33 KIF3 complex and KIF17 were recently uncovered to be involved in schizophrenia.34 35 Further studies, however, are needed to clarify the precise role of KIFs in neurodegenerative processes and psychiatric conditions.KIF14 -related birth defects. Lessons learntAdvances in next-generation sequencing technologies have revolutionised our understanding of Mendelian disorders, lasix 40mg price including birth defect phenotypes, by sequencing the coding genome (exome) or entire genome at an unprecedented resolution in a comparably short time span. The technology has been extensively used for gene identification approaches in research for many years, enabling unparalleled genotypeâphenotype correlations and the definition of novel pathways of related genes and disorders at an accelerated pace, traditionally focusing on postnatal disorders.
Filges and Friedman36 postulated that a number of novel disease genes lasix 40mg price causing birth defects could be identifiable through the investigation of lethal foetal phenotypes since they would represent the extreme end of allelic milder and viable postnatal phenotypes with less specific or recognisable anomaly patterns. Based on embryonically or perinatally lethal mouse models (www.informatics.jax.org and www.dmdd.org.uk), it is estimated that knockout variants in about 30% of human protein coding genes may present with a phenotype of early lethality. The identification of KIF14 loss of function variants in fetuses with a lethal multiple congenital anomaly syndrome and the subsequent description of the allelic postnatal viable phenotype and further functional characterisation of KIF14 in developmental processes are recent examples of how to study those embryonic lethal phenotypes in order to understand the role of genes for which little to nothing is known.Filges et al identified autosomal recessive compound heterozygous loss of function variants in KIF14 using family-based exome sequencing in a recurrent severe lethal phenotype (OMIM #616258). It was the first human phenotype reported due to variants in the human KIF14 gene (figure lasix 40mg price 3).37 The two affected siblings presented with intrauterine growth retardation (IUGR), oligohydramnios, severe microcephaly, renal cystic dysplasia or agenesis, genital tract malformations (uterine hypoplasia and vaginal atresia), as well as cerebral and cerebellar hypoplasias with partial or total agenesis of the vermis, arhinencephaly, agenesis of occipital lobes/corpus callosum at second trimester ultrasound scan.
Cross-species comparison to the laggard spontaneous mice mutant, characterised by homozygous variants of the Kif14 gene,38 confirmed a phenotypical overlap. An increased lasix 40mg price number of binucleated cells in the tissue histology of the two fetuses were in concordance with the key role of KIF14 during mitosis participating in chromosomesâ congression and alignment, as well as in cytokinesis39 and the observation of binucleated cells as a consequence of failed cytokinesis in mammalian KIF14 knockdown cells. During cytokinesis, PRC1 localises KIF14 at the central spindle and midbody, which in turn recruits citron rho-interacting kinase (CIT) to the midbody. CIT, in turn, acts as a negative regulator of KIF14 activity lasix 40mg price.
Knockdown of KIF14 in mammalian cells results in impaired localisation of CIT during mitosis.40Structure of KIF14 and summary of all published KIF14 variants affecting function.10 37 41 42 The N-terminal region (aa 1â356) is important for its interactions with PRC1 and the proteinâs localisation at the central spindle and midbody. The kinesin motor domain (aa 358â701) is responsible for the microtubule-dependent ATPase activity. The FHA lasix 40mg price domain (aa 825â891). Stalk and tail region (aa 891â1648) are necessary for the interaction with the protein CRIK (aa 901â1189, red diagonal lines).
There are four additional coiled-coil domains (light lasix 40mg price blue-coloured areas).61 FHA, forkhead associated. Aa, amino acid." data-icon-position data-hide-link-title="0">Figure 3 Structure of KIF14 and summary of all published KIF14 variants affecting function.10 37 41 42 The N-terminal region (aa 1â356) is important for its interactions with PRC1 and the proteinâs localisation at the central spindle and midbody. The kinesin lasix 40mg price motor domain (aa 358â701) is responsible for the microtubule-dependent ATPase activity. The FHA domain (aa 825â891).
Stalk and tail region (aa 891â1648) are necessary for the interaction with the protein CRIK (aa 901â1189, red diagonal lasix 40mg price lines). There are four additional coiled-coil domains (light blue-coloured areas).61 FHA, forkhead associated. Aa, amino acid.Filges et al pointed out that KIF14 should be considered a candidate gene for viable postnatal phenotypes, including isolated microcephaly.34 Additional individuals with autosomal recessive variants in KIF14 and isolated primary microcephaly were then described9 41 42 (table 2).Impaired cytokinesis, increased apoptosis and reduced cell motility were confirmed in cells from the described patients, pointing to a new cellular pathway in the pathogenesis of microcephaly.43 Apart from one case with small kidneys with increased echogenicity, none of these 18 patients had associated kidney anomalies. However, a targeted exome sequencing study in 204 unrelated patients with congenital anomalies of the kidney and urinary tract (CAKUT) reported two more cases of renal anomalies, bilateral hypoplasia or agenesis, caused by KIF14 variants.44 Further nine cases had an associated renal phenotype, which ranged from bilateral renal agenesis to cystic or non-cystic renal hypodysplasia.42 Table lasix 40mg price 2 and figure 3 summarise KIF14 variants and the associated phenotypes.
Loss of function variants more likely lead to multiple congenital anomalies, while hypomorphic variants result in a milder phenotype without renal involvement, although phenotypeâgenotype correlations remain preliminary for the time being.The phenotypical spectrum ranging from isolated primary microcephaly to congenital anomalies reminiscent of ciliopathy phenotypes suggested a complex role for KIF14 in developmental processes and raised a number of questions about the relationship between its established role in cell division and its possible function in ciliary pathways. Functional studies of absent KIF14 protein in the development of human foetal tissues and mutant zebrafish provided evidence for similarities and differences between mitotic events occurring during proliferation in the development lasix 40mg price of both brain and kidney.42 The observation that KIF14-stained midbodies accumulate within the lumen of the branch tips of ureteric buds in human foetal kidneys provided a key clue to better understand the mechanism through which the loss of KIF14 affects both brain and kidney development in humans. It was previously demonstrated that the secretion and accumulation of midbody remnants in the cerebrospinal fluid in mice during the early stages of brain development correspond to the amplification of neural progenitors.45 Kif14 mutant zebrafish phenotypes supported the hypothesis of a potential role for KIF14 in cilia. In vitro lasix 40mg price and in vivo analyses suggested that loss of kif14 causes ciliary anomalies through an accumulation of mitotic cells in ciliated tissues but failed to establish a direct functional link.21 42 Further mechanisms remain to be elucidated.
Overexpression of KIF14 in various types of tumours was suggested to be a possible prognostic marker and a potential target for therapeutic purposes.46Kinesinopathies in birth defect phenotypes. Recurrent themesIn the last few years, an increasing number of variants in KIF genes were described to cause isolated as well as multiple congenital anomalies. There is a lasix 40mg price huge variability of phenotypes caused by variants even within the same gene. However, we can identify recurrent clinical signs that should alert the clinician to suspect a KIF gene-related disorder and the molecular geneticist to include KIF genes in multigene-panel and genome-wide sequencing approaches.
This will become particularly relevant in prenatal and perinatal medicine, which focuses lasix 40mg price on the detection of structural anomalies in the fetus and the newborn by using ultrasound and MRI or autopsy when the outcome is lethal. We have summarised the predominant and recurrent structural anomalies in kinesinopathies reported so far that would likely become apparent during the foetal period in table 3 and the syndromic disorders in table 1.View this table:Table 3 KIF gene-related structural congenital anomalies recurrently described in prenatal phenotypesSupplemental materialConsistent with the kinesinsâ role in the development of the central nervous system (CNS), brain anomalies of various degrees are a frequent clinical sign, particularly microcephaly, but include lissencephaly, polymicrogyria, thinned or agenesis of the corpus callosum, arhinencephaly, cerebral hypoplasia or atrophy, cerebellar hypoplasia or atrophy, brainstem hypoplasia and a molar tooth sign on brain imaging.12 22 37 44 47â51Primary microcephaly can be detected prenatally or at birth12 22 47 48 50 51 and can present as an isolated or syndromic condition as, for example, caused by variants in KIF149 or in KIF11 (microcephaly with or without chorioretinopathy, lymphoedema or mental retardation. OMIM #152950).48KIF7 variants were related to macrocephaly in the presence of congenital hydrocephalus (hydrolethalus syndrome lasix 40mg price LS2, OMIM # 614120). Isolated hydrocephalus was reported for KIF4A in a single case.11Foetal akinesia and arthrogryposis (KIF5C12, KIF1434 and KIF26B50) are likely secondary to the neurological compromise of the fetus but can also appear as an early sign of abnormal CNS development, which should prompt specialist CNS sonographic and MRI evaluation of the fetus.Further anomalies of the limbs include camptodactyly (KIF26B50), clubfoot (KIF1A51), rocker-bottom feet (KIF26B50) and congenital lymphoedema of the limbs (dorsa of feet, lower extremities and, rarely, hands) in cases with KIF11 gene mutations.48 In particular, KIF7 gene variants have been related to various anomalies of the hands (tapered fingers, fifth finger clinodactyly, brachydactyly, preaxial or postaxial polydactyly, bifid terminal phalanges of the thumbs, spindle-shaped fingers, clinodactyly and soft tissue webbing) and feet (toe syndactyly, preaxial or postaxial polydactyly, and duplicated halluces).22CAKUT and genital anomalies are reported in various kinesinopathies including renal agenesis or hypoplasia (KIF1437 and KIF1252), ureteral hypoplasia (KIF1437), congenital megabladder (KIF1252) and vesicoureteral reflux (KIF1252), uterine hypoplasia and vaginal atresia (KIF1437) and hypospadias and chordae (KIF16B49).IUGR is recurrently detected (KIF5C12, KIF1437, KIF1053, KIF1554 and KIF2A12) and is particularly relevant when occurring simultaneously with one of the other recurrent clinical signs, indicating a potential syndromic KIF-related disorder.
Oligohydramnios or polyhydramnios is most likely secondary to a primary organ anomaly.There are a few kinesinopathy syndromes that have been specifically reported to be lethal, such as the ciliary phenotype (OMIM #616258), caused by variants in KIF1434, and hydrolethalus syndrome (OMIM #614120), caused by variants in KIF7.22 However, lethality is usually closely related to the specific major anomalies, and it can be hypothesised that such a lethal phenotype will exist for all KIF gene-related disorders.Developmental delay, intellectual disability, seizures, and sensory and motor disturbances of the peripheral nervous system, as well as eye anomalies, such as microphthalmy, optic nerve pallor, fibrosis of extraocular muscles and chorioretinopathy, will escape detection in the foetal period but are reported in postnatal patients.Kinesin pathways in birth defectsFunctional studies of kinesins in birth defects are still sparse, and little is known about their networks and pathways. In order to improve our understanding, we used the Ingenuity Pathway Analysis (IPA Qiagen, Redwood City, California, USA) to visualise and analyse the connections between the 13 kinesin motor proteins associated with structural congenital anomalies (KIF5C, KIF1A, KIF1BP, KIF14, KIF16B, KIF7, KIF4A, KIF11, KIF10, KIF26B, KIF12, KIF15 lasix 40mg price and KIF2A) and in up to 10 of each of their most significant downstream proteins. The connections are defined as proteinâprotein interactions, activation, regulation of binding, expression, localisation, phosphorylation, proteinâRNA interactions, molecular cleavage, ubiquitination, proteinâDNA interactions, inhibition, translocation and transcription. Figure 3 displays the results lasix 40mg price.
We used the software Gephy55 to look for all possible interactions between all proteins of the network and also used the IPA data to retrieve the canonical pathways involved. Figure 4 and online supplementary material, table 4, lasix 40mg price summarise the results. KIF7, KIF14 and KIF12 are located within the same network, and because of multiple connections between themselves and their downstream proteins, it is not surprising that they are all involved in kidney anomalies. IPA data lasix 40mg price are based on current publications and are therefore subject to bias because proteins that are most interconnected are also most probably those that have been more extensively studied.
However, we consider the KIF genes coding for proteins seeming less important within the network to be strong candidates for future studies of human developmental disorders.IPA of the 13 kinesins known to be involved in birth defects with respect to their position in the cell. Proteins displayed on the right side of the figure, below the tag âotherâ, are those for which no subcellular location is known. Birth defect-related kinesins and their connection with lasix 40mg price each other are highlighted in green. Light blue-coloured downstream proteins are those which are known to cause birth defects when altered.
Yellow-coloured proteins are lasix 40mg price those involved in neurological disorders overlapping with the clinical features of kinesinopathies. The legend of the biological function associated with every molecule is displayed on the right. Path Designer by IPA lasix 40mg price was used for the figure design. IPA, Ingenuity Pathway Analysis." data-icon-position data-hide-link-title="0">Figure 4 IPA of the 13 kinesins known to be involved in birth defects with respect to their position in the cell.
Proteins displayed on the right side of the figure, below the tag âotherâ, are those for which no subcellular location is known. Birth defect-related kinesins and their connection with each other lasix 40mg price are highlighted in green. Light blue-coloured downstream proteins are those which are known to cause birth defects when altered. Yellow-coloured proteins lasix 40mg price are those involved in neurological disorders overlapping with the clinical features of kinesinopathies.
The legend of the biological function associated with every molecule is displayed on the right. Path Designer lasix 40mg price by IPA was used for the figure design. IPA, Ingenuity Pathway Analysis.Closing remarks and future perspectivesNovel KIF genes are increasingly identified, and there is a growing body of literature demonstrating the impact of kinesin dysfunction in human disease. We propose to introduce the term kinesinopathies for lasix 40mg price conditions caused by variants in KIF genes, since recurrent and common functional and phenotypical themes can be observed.
In analogy to ciliopathies56 and rasopathies,57 the delineation of the clinical, genetic and functional hallmarks of kinesinopathies will be important to better recognise these conditions, to understand the pathomechanisms and to ultimately improve the clinical management of the patients. Previously, the unified view of the phenotype characteristics of ciliary dysfunction allowed a tremendous increase in awareness, both in clinic and research, and the further identification of yet unrecognised ciliary disorders and the genes and proteins involved in their pathogenesis.56Remarkable progress was achieved in assigning function to kinesins through their study in isolated and multiple congenital anomaly phenotypes. They are one large superfamily of molecular motors out of three (kinesins, dyneins and myosins), which is of key importance in several fundamental cellular processes using microtubules as rails for directional anterograde intracellular transport, including its regulation and modulating lasix 40mg price signal transduction.5 Kinesin motors are most important for the movement of chromosomes along the spindles during chromosome segregation, regulation of spindle formation, cell division and cytokinesis. These essential and broad cellular functions are critical for many physiological processes such as neuronal function and survival, some ciliary functions and ciliogenesis, determination of the left/right asymmetry of our body and regulation of organogenesis, thus explaining the impact and emerging recognition of kinesins in embryonic and foetal development.
Defects can result in neuropathies, higher brain functions and lasix 40mg price structural brain anomalies. Multiple congenital anomalies, including the kidney and urinary tract and limb anomalies, are repeatedly reported. Microcephaly, which is usually not associated with genes implicated in specific ciliary mechanisms, and lasix 40mg price CNS anomalies are the most recurrent clinical signs in both the prenatal and postnatal phenotypes described so far. The discovery of the implication of KIF14 in microcephaly further suggested a possible novel role of other microcephaly proteins in cytokinesis.
A number of syndromic kinesinopathies present, however, with phenotype patterns reminiscent of ciliopathies. So far, however, a direct functional impact was confirmed in only lasix 40mg price a few and could not be demonstrated, for example, for KIF14, despite an overlapping clinical pattern. In turn, ciliopathies are a clinically and genetically heterogeneous group of conditions themselves. Studying tissue and cell type-specific function and expression may help to further define the specific defects related to the individual aberrant kinesin.The lasix 40mg price pleiotropic nature of human kinesinopathies, however, is just emerging, but their study promises to provide important insights into human developmental pathways.
Seemingly unrelated clinical entities are highlighting a common theme. In a relatively short time span, monogenic KIF-related disorders were identified to present with often severe and lethal antenatal anomalies, with lasix 40mg price multiple or isolated congenital anomalies, neurodevelopmental and neurological disorders, or an increased susceptibility to multifactorial conditions. We focused on the emerging role of kinesins in structural congenital anomalies because, as illustrated for the KIF14 gene, great potential to decipher allelic viable phenotypes and developmental pathways lies in the study of these human knockout phenotypes at the severe end of the phenotypical spectrum. Knockout variants in about 30% of human protein coding genes in our genome may present with a phenotype of early lethality, and KIF genes seem to play an important role in such fundamental processes of human development.
Identifying and characterising the variants, genes and phenotypes will extend our knowledge on early human development and pathomechanisms, and will ultimately also improve the clinical utility of lasix 40mg price genome-wide sequencing approaches for prenatal and postnatal application by our increased ability to interpret loss of function and hypomorphic variants alike. Furthermore, kinesins were extensively studied in cancer research and therapeutic strategies targeting their specific functions, such as the example of monastrol and other inhibitors of the mitotic kinesins may be adopted in the future. There are likely many more kinesinopathies to be unravelled in the field of birth defects because of their pivotal role in cellular logistics, but their recognition in clinics and research will depend on our ability to identify and characterise the common clinical, molecular and functional themes of these disorders and to use them to improve our understanding of their disease mechanisms.IntroductionIntellectual lasix 40mg price disability (ID) affects about 3% of individuals worldwide and raises significant issues in terms of diagnostic, management and genetic counselling. The presence of pigmentation anomalies in a patient with ID represents helpful clinical clues in order to narrow the range of aetiological hypothesis.
Hypomelanosis of Ito (HMI, MIM #300337) is an unspecific term encompassing a heterogeneous group of disorders characterised by cutaneous hypopigmented whorls and streaks along Blaschkoâs lines and variable extracutaneous features affecting the lasix 40mg price musculoskeletal and nervous systems.1 The cutaneous pattern therefore represents a non-specific hallmark of mosaicism in these neurocutaneous conditions. Genetic mosaicism is due to postzygotic mutations, either chromosomal rearrangements or point mutations, whereas random X inactivation in females leads to functional mosaicism.2 Unravelling the molecular basis of pigmentary mosaicism (PM) is still a challenge due to clinical and genetic heterogeneity, technical difficulties in detecting mosaic mutations by classical sequencing approaches and the complexities of obtaining affected tissue. As part of a collaborative group, we recently reported de novo mutations in exons 3 and 4 of transcription factor E3 (TFE3) as the cause for HMI in four unrelated individuals, including one male, as well as syndromic ID without lasix 40mg price pigmentary disorders in a female.3TFE3 belongs to the MITF family of mammalian basic helixâloopâhelix zipper transcription factors, together with TFEB and TFEC. All four can form homodimers or heterodimers with each other.4 Embryonic expression of TFE3 orthologues Tfe3a and Tfe3b was demonstrated in the zebrafish in a wide range of tissues.5 TFE3 subcellular localisation plays a crucial role in the regulation of cellular homeostasis and embryonic stem cell (ESC) differentiation.
The phosphorylated TFE3 is retained in the cytoplasm, whereas dephosphorylated protein translocates to the nucleus to promote the transcription of target genes involved in lysosomal biogenesis and autophagy.6 TFE3 relocalisation to the nucleus is driven on various stressors, such as starvation,7 8 DNA damage,9 mitochondrial damage,10 Golgi stress11 and pathogens12 in an mTORC1-dependent manner, and oxidative stress13 or cadmium exposition14 in an mTORC1-independent manner. Moreover, lysosomal signalling-induced nucleocytoplasmic redistribution lasix 40mg price of TFE3 is essential to the regulation of ESC renewal.3 15 By restricting nuclear localisation and activity of Tfe3, lysosome activity, the tumour suppressor protein folliculin and the Ragulator protein complex enable the exit from pluripotency and therefore drive differentiation. Conversely, enforced nuclear Tfe3 enables ESCs to withstand differentiation.15 In humans, TFE3 mutations have long been known in cancer. Gene fusions by translocations or other chromosomal rearragements involving TFE3 and five partner genes have indeed been reported to occur in a subset lasix 40mg price of renal cell carcinomas (RCCs), referred to as âTFE-fusion RCCâ, and, more rarely, to lung sarcoma and perivascular epithelioid cell tumours.16 Beyond these data on TFE3 function, by the report of a series of 17 individuals harbouring de novo mutations in exons 3 and 4 of TFE3, we emphasise their phenotype and bring additional clinical insight toward the recognition of this novel developmental disorder.ResultsWe describe a series of 17 patients carrying a de novo mutation in TFE3, 5 of them being previously published with limited clinical information.3 Twelve were females and five were males.
Their age ranged from 12 months to 22 years. Five were referred for lasix 40mg price HMI, five for syndromic ID and five for suspicion of storage disorder.Clinical dataThe clinical features are summarised in table 1. Additional information can be found in online supplementary data 1.Supplemental materialView this table:Table 1 Clinical and molecular features of the 17 patients with an TFE3 mutationNeonatal course was remarkable for nine patients. History of jaundice, hepatomegaly or feeding difficulties was reported for three patients each, hypoglycaemia for two and cholestasis for one.
All these features were transient.Developmental delay, usually severe and noticeable from the first months of life, was a constant lasix 40mg price feature in all the individuals. Only 6 patients were able to walk at the time of the study, whereas 11 were still unable to walk. All patients lasix 40mg price were non-verbal, except for two older patients who could speak a few words. Neurological examination was abnormal in 12 individuals and consisted in truncal hypotonia, associated with lower limb spasticity (6 individuals) or ataxia (2 adults).
Behavioural issues such as autistic features and sleeping lasix 40mg price disturbance were noted for 11 patients. Eleven patients developed epilepsy, onset in the first decade and characterised as intractable in three of them. Brain MRI was normal in 10 individuals and abnormal in 6 patients (hydrocephaly, short corpus callosum, Dandy-Walker malformation, arachnoid cyst, periventricular white matter lesions, delayed myelination and cerebral atrophy). The sensory anomaly was congenital hearing loss (5 patients), and ophtalmological anomalies (10 patients) consisted of strabismus, hyperopia, retinal degeneration, depigmented macule on the iris, oculomotor apraxia or impaired vision of cortical origin.Facial dysmorphism shared among the patients consisted in coarseness, flat nasal bridge, short nose with anteverted nares, widely spaced eyes, almond-shaped eyes, lasix 40mg price thick lips, facial hypertrichosis, fleshy earlobe, and full and pink cheeks (figure 1).
Twelve patients had pigmentation anomalies, located on Blaschkoâs lines for 10 of them (figure 2). One was lasix 40mg price diagnosed at 4 years old with histiocytofibroma. Moderate to severe postnatal growth retardation affected 10 patients, who had a length between â2.0 and â4.5 SD. Obesity affected lasix 40mg price 13 individuals.
Skeletal anomalies were frequent (11 individuals) and consisted of flat or clubfeet, hyperlordosis, scoliosis, hip dislocation, limitation of elbow extension and genu valgum. Recurrent s of the upper airways were noted in five lasix 40mg price patients. One had a documented neutropenia. Early-onset chronic interstitial lung disease was reported in two patients.
Nail clubbing was noted lasix 40mg price in two individuals. Visceral malformations consisted of congenital heart defect (left ventricle dilatation, aortic insufficiency and patent ductus arteriosus) in three patients, umbilical hernia in three individuals, lateral semicircular canal dysplasia, posterior plagiocephaly, sleep apnoea syndrome, anteriorly displaced anus and hypospadias in one individual each.Facial phenotypes of seven patients. (AâC) Patient 5, aged 6 months lasix 40mg price (A,B) and 3 years (C). (D) Patient 8, aged 5 years.
(E,F) Patient 2, aged 5 and 20 years lasix 40mg price. (GâI) Patient 3, aged 1âyear (G) and 3 years (H,I). (J,K) Patient 13, aged 22 years. (LâO) Patient lasix 40mg price 6, aged 8 months (L), 20 months (M) and 3 years (N,O).
(P,Q) Patient 10 aged 22 years." data-icon-position data-hide-link-title="0">Figure 1 Facial phenotypes of seven patients. (AâC) Patient 5, lasix 40mg price aged 6 months (A,B) and 3 years (C). (D) Patient 8, aged 5 years. (E,F) Patient 2, aged 5 lasix 40mg price and 20 years.
(GâI) Patient 3, aged 1âyear (G) and 3 years (H,I). (J,K) Patient 13, aged 22 years. (LâO) Patient 6, aged 8 months (L), lasix 40mg price 20 months (M) and 3 years (N,O). (P,Q) Patient 10 aged 22 years.Cutaneous features.
(A) Patient lasix 40mg price 3. Umbilical hernia, widely spaced nipples and hypopigmentation on the left side of the abdomen. (B) Patient lasix 40mg price 17. Hypotonia, umbilical hernia and widely spaced nipples.
(C) Patient lasix 40mg price 8. Blaschkoâs lines on the back. (D) Patient 6. Hypopigmentation on lasix 40mg price the left side of the abdomen.
(E) Patient 7. Blaschkoâs lines on the abdomen and lasix 40mg price right side of the trunk. (F) Patient 13. Hand.
Note clubbing of thumbnail and loose skin. (G) Patient 17. Blaschkoâs lines on the left side of the abdomen. (H) Patient 17.
Hand. Note tapering fingers and wrinkled skin. (I) Patient 1. Linear hypopigmentation on the back.
(J) Patient 6. Blaschkoâs lines on the back. (K) Patient 3. Blachkoâs lines on the right lower limb.
(L) Patient 6. Blaschkoâs lines on the right lower limb. (M,N) Patient 7. Linear hyperpigmentation on the lower limbs.
(O) Patient 11. Blaschkoâs lines on the back." data-icon-position data-hide-link-title="0">Figure 2 Cutaneous features. (A) Patient 3. Umbilical hernia, widely spaced nipples and hypopigmentation on the left side of the abdomen.
(B) Patient 17. Hypotonia, umbilical hernia and widely spaced nipples. (C) Patient 8. Blaschkoâs lines on the back.
(D) Patient 6. Hypopigmentation on the left side of the abdomen. (E) Patient 7. Blaschkoâs lines on the abdomen and right side of the trunk.
(F) Patient 13. Hand. Note clubbing of thumbnail and loose skin. (G) Patient 17.
Blaschkoâs lines on the left side of the abdomen. (H) Patient 17. Hand. Note tapering fingers and wrinkled skin.
(I) Patient 1. Linear hypopigmentation on the back. (J) Patient 6. Blaschkoâs lines on the back.
(K) Patient 3. Blachkoâs lines on the right lower limb. (L) Patient 6. Blaschkoâs lines on the right lower limb.
(M,N) Patient 7. Linear hyperpigmentation on the lower limbs. (O) Patient 11. Blaschkoâs lines on the back.Molecular resultsThe characteristics of the 13 different de novo TFE3 variants identified in the 17 unrelated individuals are summarised in table 2.
All but one were missense variants, affecting nine different aminoacids. One was a splice donor mutation. This mutation was reported a few weeks ago in a patient with a similar phenotype.21 Two variants were localised in exon 3 and 11 in exon 4 (figure 3). All were absent from public databases and were predicted to be pathogenic by prediction softwares.
TFE3 protein and localisation of the missense variants identified. In bold are variants identified in two patients. In bold and underlined is the variant identified in three patients. In green is the intronic variant." data-icon-position data-hide-link-title="0">Figure 3 TFE3 protein and localisation of the missense variants identified.
In bold are variants identified in two patients. In bold and underlined is the variant identified in three patients. In green is the intronic variant.View this table:Table 2 Molecular data of the 13 de novo TFE3 mutations. Characteristics, inheritance, frequency in the public database GnomAD, prediction scores regarding pathogenicity (Polyphen, Grantham and CADD (Combined Annotation Dependant Depletion) scores).
The transcript is NM_006521.5The putative mosaicism was assessed through X inactivation studies in females and analysis of the exome sequencing data in males, by checking the total number of reads covering the variant, as well as the number of reads supporting the presence of the variant (table 1). Allele frequencies in females were always consistent with a constitutional heterozygous mutation. X inactivation was skewed in blood of the female patients 1, 3 and 7 and in fibroblasts of Patient 2. X inactivation was random in fibroblasts of Patient 1 and 3.
Regarding the male patients, the mutation was identified in 65% of the reads for Patient 17% and 88% of the reads for Patient 15 (106/120). No mosaicism was detected in the blood of Patient 13, 14 and 16 despite the presence of pigmentary manifestations in Patient 16.DiscussionTFE3 functions in signalling of the mechanistic target of rapamycin (mTOR) complex 1 (mTORC1). The PIK3-AKT-mTOR pathway plays a role in the regulation of cellular growth, proliferation, survival and metabolism. Overactivation of the mTOR signalling is responsible for neurocutaneous disorders and cancers.22 Somatic mutations in TSC1, TSC2, AKT3, PIK3CA and MTOR are responsible for focal cortical dysplasia type II (MIM607341),23â25 hemimegalencephaly26 and megalencephaly.27 The phenotype ascribed to germline TSC1/TSC2, PTEN, MTOR and PK3R2/AKT3/CCND2 mutations â respectively in tuberous sclerosis (TS, MIM 191100), Cowden syndrome (CS, MIM 158350), Smith-Kingsmore syndrome (MIM 616638) and Megalencephaly, Polymicrogyria, Polydactyly and Hydrocephalus syndrome 1, 2 and 3 (MPPH1/2/3, MIM 603387/615939/615938) - is characterised by the association of ID, epilepsy, brain malformations and skin tumours.
Similarly, all the individuals harbouring a de novo TFE3 mutation reported in the series presented with a severe neurodevelopmental disorder. Delayed psychomotor development was constant. The youngest patient to acquire independent walking was 30 months old, and more than half of the patients aged over 18 months (57%), did not acquire walk at the last examination. Conversely to patients with MTOR, AKT3 or PTEN mutation, none of the patients described in this series had macrocephaly.
Brain imaging was abnormal in 35% of the patients. Hydrocephaly and corpus callosum dysgenesis, identified in respectively three and one individual, were previously reported in patients with mosaic gain of function MTOR mutations.28 29 One patient had surgery to remove an early-onset histiocytofibroma. However, no other skin tumour was reported, either in this patient or in any other from the series.Pigmentation anomalies, along Blaschkoâs lines or, for one patient, as a large hyperpigmented area, were present in a majority of the individuals (71%) in the series, including 40% of the males and 83% of the females. PM along Blaschkoâs lines is highly suggestive of genetic mosaicism.30 Genomic mosaicism is defined by the presence of at least two cell populations with different genotypes in an individual originating from one zygote and mainly occurs through post-zygotic event, whereas females can present with functional (epigenetics) mosaicism due to X inactivation.2 PM is a classical feature of X-linked male-lethal genodermatosis, such as incontinentia pigmenti (IP, MIM #308300), focal dermal hypoplasia (FDH, MIM #305600), chondrodysplasia punctuata type 2 (Conradi-Hunermann-Happle syndrome, CDPX2, MIM #302960) and linear skin defects with multiple congenital anomalies (LSDMCA1, MIM #309801).
In these conditions, the overwhelming predominance of affected females is a consequence of the male lethality, and the PM a manifestation of the functional mosaicism occurring in females. Similarly, the majority of individuals with de novo TFE3 variants in our cohort were females (sex ratio female:male was 12:5 (2.4)). The study of X-inactivation on non-cultured fibroblasts was consistent with functional mosaicism in two affected females with PM who harboured random X-inactivation, whereas a third female without PM had skewed X-inactivation. In IP, FDH and CDPX2, most hemizygous males die in utero.
However, there have been reports of surviving males 31â33 with an estimated prevalence around 10% in FDH and IP.32 34 The majority of them are explained by post-zygotic mutations or chromosomal anomalies (Klinefelter syndrome). Non-mosaic males have also been reported in FDH and IP â respectively about 17% and 45% of the affected males harbour a non-mosaic variant.32 35 In our series, males represented 29% of the patients with a de novo TFE3 variant. A mosaic variant was identified in blood for half of them. None had Klinefelter syndrome.
Interestingly, mosaicism was detected in only one out of the two males with PM, and one male with a mosaic variant had no pigmentation anomalies noted on examination. It is still possible that subtle pigmentation anomalies were missed on examination. Moreover, somatic mosaicism can be difficult to detect. Recent studies have shown that a large proportion of de novo mutations presumed to be germline had in fact occurred as post-zygotic event.36 In the males of this cohort, WES was performed on leucocytes-derived DNA and no other tissue was studied.
Therefore, it is possible that a low mosaicism was not detected. Finally, it is probable than TFE3 mutations account for a significant proportion of patients with HMI. Indeed, in this population, the high frequency of ID, epilepsy, coarse facial features has long been emphasised in the literature.37By its ability to bind the coordinated lysosomal enhancement and regulation (CLEAR) sites in the promotor region of target genes, TFE3 is involved in the control lysosomal biogenesis, autophagy and endocytosis.8 Several patients of the series indeed had clinical and biochemical features that pointed toward an inborn error of metabolism. Lysosomal storage disorder was suspected due to the variable association of coarse facial features (88%), skeletal anomalies (65%) âflat or clubfeet, hyperlordosis, hip dislocation, limitation of elbow extension, genu valgum, scoliosisâ, postnatal growth retardation (59%), history of speech or developmental regression (29%) congenital hearing loss (29%), recurrent upper airways s (29%) neonatal liver anomalies such as hepatomegaly and cholestasis (18%), upper airways s (24%), umbilical hernia (18%), sleep apnoea syndrome (6%) and aortic insufficiency (6%).
Other metabolic anomalies observed in the series were obesity, defined in children by body mass index (BMI) (weight/height2) above the WHO curve, present in the oldest patients (76%), neonatal transient hypoglycaemia (12%), and hyperlactataemia (6%). Dysregulation of lipid metabolism, via suppression of thermogenesis and decreased lipolysis, thus leading to increased adipose tissue, was previously observed in adipose-specific TFE3 transgenic mice.38 Similarly to lysosomes, mitochondrias have a key role in cellular metabolism, including autophagy. Recent data demonstrate that mitochondrial and lysosomal metabolisms are interrelated.39 Muscle biopsy, performed in two individuals from this cohort, showed fat and glycogen accumulation, muscular fibre size irregularity, without evidence of mitochondrial dysfunction. Interestingly in the more recent data, evidences showing that TFE3 plays a role in the regulation of the circadian oscillations of the expression of genes involved in autophagy and lipid metabolism, and that Tfe3 knock-out mice had abnormal circadian behaviour.40 Indeed, in our series, five patients (29%) were noted to have sleep disturbance.
This could be due to circadian rhythms alteration. Finally, TFE3 has been shown to be involved in the regulation of innate immune response in macrophages via the FLCN-AMPK signalling axis,41 and of B-lymphocytes activation.42 Along these lines, four patients of the series (24%) had a history of recurrent s, associated with documented neutropenia in one of them. As shown in table 3, a summary of the frequency of the features observed in the cohort, facial dysmorphism was constant and strikingly similar among the patients. More than two-third had anteverted nares, broad flat nasal bridge, almond-shaped and widely spaced eyes, puffy cheeks and coarse facial features (thick lips and fleshy earlobes).
More than half had facial hypertrichosis. All individuals presented with at least four of the above features. One patient had an extreme facial phenotype of hypertelorism, bifid nose and bilateral cleft lip and palate. Whether these frontonasal dysplasia features may be associated with the TFE3 mutation remains unclear.
No other mutation in known genes was found in Patient 1âs exome sequencing data.View this table:Table 3 Frequency of the clinical features observed in the seriesTFE3 is a highly conserved protein, intolerant to loss of function as supported by data from the GnomAD browser43 (probability of being loss-of-function intolerant (pLI) evaluated at 0.98, observed:expected ratio=0.06) and to missense variants (Z=2.15). Moreover, TFE3 does not, or only in a few tissues, escape X inactivation, suggesting that TFE3 gene dosage is crucial to cell function.44 45 In vitro, Villegas et al recently showed that the absence of either TFE3 exon 3 or 4 resulted in a nuclear gain-of-function Tfe3 allele in ESCs, indicating that both exons 3 and 4 are required for Tfe3 inactivation.3 Nuclear localisation and resistance to differentiation were proved in Tfe3 knock-out (K.O.) ESCs expressing murine Tfe3 alleles (Gln118Pro and Pro185Leu, corresponding to mutations Gln119Pro and Pro186Leu identified in individuals referred to as patients 1 and 2 in this series). Based on the analysis of TFE3 secondary structure,46 indicating that residues 110â215 are predicted to form a domain of two stable alpha helices that might be disrupted by mutations in exons 3 and 4, and the observation of a similar phenotype in patients harbouring mutations in exons 3 and 4, it was suggested that Tfe3 exons 3 and 4 form a Rag binding fold whose structural integrity is indispensable for lysosome-mediated cytoplasmic Tfe3 inactivation.3 In this series, the recurrent mutations Arg117Gln, Leu191Pro and Thr187Met were present in respectively two, two and three patients. The aminoacid in position 187 was mutated in five patients.
In addition, 13 of the described mutations were localised between positions p.184 and p.201. This proximity could account for the absence of obvious genotypeâphenotype correlation. The canonical splice site variant in intron 4 identified in patient 9 might lead to in-frame exon skipping of exon 4. The clinical picture of the patient with this splice site variant perfectly fits with the syndrome described here.
As a consequence, we raise the hypothesis of a gain-of-function effect of this variant.In conclusion, de novo mutations in exons 3 and 4 of the X-linked gene TFE3 are responsible for a neurocutaneous disorder with specific and recognisable facial dysmorphism, lysosomal storage disorder-like features and PM. This series unravels TFE3 as a major gene responsible for HMI and for a rare cause of syndromic ID. Furthermore, we provide clinical and molecular data on a previously unidentified lysosomal storage disorder, in which new insights, especially biochemical features, will probably be investigated further, together with the description of more patients. Further delineation of this phenotype will indeed allow a better understanding of the link between lysosomal signalling and development.
Finally, the evidence for mosaicism in this recently described disorder highlights the importance of considering mosaic variants on next-generation sequencing reports in diagnostic, including for patients without suggestive phenotype..
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