Guía de actuación en las anomalías de la diferenciación sexual (ADS) / desarrollo sexual diferente (DSD)

Las anomalías de la diferenciación sexual (ADS) engloban un amplio espectro de discordancias entre los criterios cromosómico, gonadal y fenotípico (genital) que definen la diferenciación sexual; actualmente, se aboga por la denominación de «desarrollo sexual diferente» (DSD). Su origen es congénito; se clasifican en función de los cromosomas sexuales presentes en el cariotipo; las causas genéticas conocidas son muy diversas y heterogéneas, aunque algunos casos pueden ser secundarios a factores maternos o medioambientales. Su diagnóstico y tratamiento requieren siempre una atención médica y psicosocial multidisciplinar. El diagnóstico etiológico precisa la interacción entre las exploraciones clínicas, bioquímicas (hormonales), genéticas, de imagen y, eventualmente, quirúrgicas. El tratamiento debe abordar la asignación de género, la posible necesidad de tratamiento hormonal substitutivo (suprarrenal si hay insuficiencia suprarrenal y con esteroides sexuales si hay insuficiencia gonadal a partir de la edad puberal), la necesidad de intervenciones quirúrgicas sobre las estructuras genitales (actualmente se tiende a diferirlas) y/o sobre las gónadas (en función de los riesgos de malignización), la necesidad de apoyo psicosocial y, finalmente, una adecuada programación de la transición a la atención médica en las especialidades de adultos. Las asociaciones de personas afectadas tienen un papel fundamental en el apoyo a familias y la interacción con los medios profesionales y sociales. La utilización de Registros y la colaboración entre profesionales en Grupos de Trabajo de sociedades médicas nacionales e internacionales es fundamental para avanzar en mejorar los medios diagnósticos y terapéuticos que precisan los DSD.Disorders of Sex Development (DSD) include a wide range of anomalies among the chromosomal, gonadal, and phenotypic (genital) characteristics that define sexual differentiation. At present, a definition as Different Sexual Development (DSD) is currently preferred. They originate in the pre-natal stage, are classified according to the sex chromosomes present in the karyotype. The known genetic causes are numerous and heterogeneous, although, in some cases, they may be secondary to maternal factors and/or exposure to endocrine-disrupting chemicals (EDCs). The diagnosis and treatment of DSD always requires multidisciplinary medical and psychosocial care. An aetiological diagnosis needs the interaction of clinical, biochemical (hormonal), genetic, imaging and, sometimes, surgical examinations. The treatment should deal with sex assignment, the possible need for hormone replacement therapy (adrenal if adrenal function is impaired, and with sex steroids from pubertal age if gonadal function is impaired), as well as the need for surgery on genital structures (currently deferred when possible) and/or on gonads (depending on the risk of malignancy), the need of psychosocial support and, finally, an adequate organisation of the transition to adult medical specialties. Patient Support Groups have a fundamental role in the support of families, as well as the interaction with professional and social media. The use of Registries and the collaboration between professionals in Working Groups of national and international medical societies are crucial for improving the diagnostic and therapeutic tools required for the care of patients with DSD

c-LDL/Apo B-100 em crianças obesas insulino-resistentes como ferramenta clínica para avaliar o risco cardiovascular

Obesity is the most common( nutritional disease in children and adolescents in developed countries. It is a proinfammatory disease that implies a break in the transduction signal of insulin with subsequent insulin resistance. The aim of the study was to assess the presence of particles of small and dense c-LDL by calculating the c-LDL/ApoB-100 index in an insulin resistant obese children population. Children of both sexes aged between 2 and 12 attending the pediatric outpatient clinics of Hospital Universitario Virgen Macarena were included. It recruited a cohort of 200 children, with a total of 103 girls and 97 boys distributed in the following groups: Group 1: n=96 obese (P97) and IR and n=104 normal weight, Group 2 (P<80). BMI percentile for age and sex as well as lipid and biochemical profle were calculated. Both groups had informed consent from relatives before the extraction. The c-LDL/ApoB-100 achieved greater statistical significance and area under the curve (AUC) than other ratios measured with sensibil-ity (S)=87 and specificity (E)=0.585 for the value of 1.3 with an AUC of 0.78 and p<0.001. Besides, a negative correlation between the c-LDL/Apo-B-100 and HOMA (p<0.05), fbrinogen (p<0.05) and us-PCR (p<0.05) ratios is obtained. The LDL/ApoB-100 ratio is a determining parameter for presence of small and dense LDL particles with high sensitivity, statistical significance and positive predictive value in an insulin resistant obese children population as a clinical tool to assess cardiovascular risk.YesLa obesidad es la enfermedad nutricional más frecuente en niños y adolescentes en los países desarrollados. Se caracteriza por un estado proinflamatorio que supone una interrupción de las señales de traducción de la insulina con la consiguiente resistencia a la insulina. El objetivo del estudio fue valorar la presencia de factores de riesgo cardiovasculares y de partículas de c-LDL pequeñas y densas mediante el cálculo del índice c-LDL/ApoB-100 en una población infantil obesa insulinorresistente. Se incluyeron niños de ambos sexos con edades comprendidas entre 2 y 12 años que acudieron a las consultas de pediatría del Hospital Universitario Virgen Macarena. Se reclutó una cohorte de 200 niños correspondiente a un total de 97 niños y 103 niñas distribuidos en los siguientes grupos: Grupo 1: n=96 con obesidad (P97) y resistencia a la insulina (RI); y Grupo 2, n=104, con peso normal (P<80). Se calculó el percentilo del IMC para cada edad y sexo así como se analizó el perfil lipídico y bioquímico. Ambos grupos contaron con el consentimiento informado previo a la extracción de la muestra por parte de los familiares. El cociente c-LDL/ApoB- 100 alcanzó mayor significación estadística y área bajo la curva (AUC) que otros cocientes valorados, con una sensibilidad (S)=87 y especificidad (E)=0,585 para el valor de 1,3 y un AUC de 0,78 y p<0,001. Además, se obtuvo una correlación negativa entre el cociente c-LDL/ApoB-100 y el HOMA (p<0,05), el fibrinógeno (p<0,05) y us-PCR (p<0,05). El cociente c-LDL/ApoB-100 podría ser un parámetro determinante de la presencia de partículas pequeñas y densas con alta sensibilidad, significación estadística y valor predictivo positivo en una población infantil obesa e insulinorresistente como herramienta clínica para valorar el riesgo cardiovascular

Human MAMLD1 Gene Variations Seem Not Sufficient to Explain a 46,XY DSD Phenotype

MAMLD1 is thought to cause disordered sex development in 46,XY patients. But its role is controversial because some MAMLD1 variants are also detected in normal individuals, several MAMLD1 mutations have wild-type activity in functional tests, and the male Mamld1-knockout mouse has normal genitalia and reproduction. Our aim was to search for MAMLD1 variations in 108 46,XY patients with disordered sex development, and to test them functionally. We detected MAMDL1 variations and compared SNP frequencies in controls and patients. We tested MAMLD1 transcriptional activity on promoters involved in sex development and assessed the effect of MAMLD1 on androgen production. MAMLD1 expression in normal steroid-producing tissues and mutant MAMLD1 protein expression were also assessed. Nine MAMLD1 mutations (7 novel) were characterized. In vitro, most MAMLD1 variants acted similarly to wild type. Only the L210X mutation showed loss of function in all tests. We detected no effect of wild-type or MAMLD1 variants on CYP17A1 enzyme activity in our cell experiments, and Western blots revealed no significant differences for MAMLD1 protein expression. MAMLD1 was expressed in human adult testes and adrenals. In conclusion, our data support the notion that MAMLD1 sequence variations may not suffice to explain the phenotype in carriers and that MAMLD1 may also have a role in adult life

Human MAMLD1 Gene Variations Seem Not Sufficient to Explain a 46,XY DSD Phenotype

Ajuts: Swiss National Science Foundation (320030-146127), the Instituto de Salud Carlos III CIBERER U-712, i the University and Research Management and Evaluation Agency (2009SGR31)MAMLD1 is thought to cause disordered sex development in 46,XY patients. But its role is controversial because some MAMLD1 variants are also detected in normal individuals, several MAMLD1 mutations have wild-type activity in functional tests, and the male Mamld1-knockout mouse has normal genitalia and reproduction. Our aim was to search for MAMLD1 variations in 108 46,XY patients with disordered sex development, and to test them functionally. We detected MAMDL1 variations and compared SNP frequencies in controls and patients. We tested MAMLD1 transcriptional activity on promoters involved in sex development and assessed the effect of MAMLD1 on androgen production. MAMLD1 expression in normal steroid-producing tissues and mutant MAMLD1 protein expression were also assessed. Nine MAMLD1 mutations (7 novel) were characterized. In vitro, most MAMLD1 variants acted similarly to wild type. Only the L210X mutation showed loss of function in all tests. We detected no effect of wild-type or MAMLD1 variants on CYP17A1 enzyme activity in our cell experiments, and Western blots revealed no significant differences for MAMLD1 protein expression. MAMLD1 was expressed in human adult testes and adrenals. In conclusion, our data support the notion that MAMLD1 sequence variations may not suffice to explain the phenotype in carriers and that MAMLD1 may also have a role in adult life

Guía de actuación en las anomalías de la diferenciación sexual (ADS) / desarrollo sexual diferente (DSD).

Disorders of Sex Development (DSD) include a wide range of anomalies among the chromosomal, gonadal, and phenotypic (genital) characteristics that define sexual differentiation. At present, a definition as Different Sexual Development (DSD) is currently preferred. They originate in the pre-natal stage, are classified according to the sex chromosomes present in the karyotype. The known genetic causes are numerous and heterogeneous, although, in some cases, they may be secondary to maternal factors and/or exposure to endocrine-disrupting chemicals (EDCs). The diagnosis and treatment of DSD always requires multidisciplinary medical and psychosocial care. An aetiological diagnosis needs the interaction of clinical, biochemical (hormonal), genetic, imaging and, sometimes, surgical examinations. The treatment should deal with sex assignment, the possible need for hormone replacement therapy (adrenal if adrenal function is impaired, and with sex steroids from pubertal age if gonadal function is impaired), as well as the need for surgery on genital structures (currently deferred when possible) and/or on gonads (depending on the risk of malignancy), the need of psychosocial support and, finally, an adequate organisation of the transition to adult medical specialties. Patient Support Groups have a fundamental role in the support of families, as well as the interaction with professional and social media. The use of Registries and the collaboration between professionals in Working Groups of national and international medical societies are crucial for improving the diagnostic and therapeutic tools required for the care of patients with DSD

Summary of reported patients harboring sequence variations and deletions affecting <i>MAMLD1</i> gene ^a.

<p>^a the variants were named according to NM_005491.4.</p><p>N: normal sequence; NA: not analyzed; ?/-: unknown; GD: gonadal dysgenesis; GOF: gain of function.</p><p>Summary of reported patients harboring sequence variations and deletions affecting <i>MAMLD1</i> gene <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0142831#t003fn001" target="_blank">^a</a>.</p

Clinical, biochemical and genetic characteristics of the patients harboring mutations and polymorphisms in the <i>MAMLD1</i> gene.

<p>ND: not done. d: day(s), m: month(s), y: year(s).</p><p>Clinical, biochemical and genetic characteristics of the patients harboring mutations and polymorphisms in the <i>MAMLD1</i> gene.</p

Transactivation activity of MAMLD1 on the <i>Hes3</i> promoter.

<p>HEK293 cells were transiently transfected with wild-type (WT) and mutant MAMLD1 expression vectors and with a <i>Hes3</i> promoter luciferase reporter construct. Luciferase activity was measured with the Promega Dual Luciferase assay system. A. Comparison of the newly constructed MAMLD1 WT expression vector (WT (a), NM_005491.4) with the older WT (WT (b)), and ΔE5 (ΔE5 (b)) constructs [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0142831#pone.0142831.ref014" target="_blank">14</a>]. Similar transactivation activity on the <i>Hes3</i> promoter was found for all constructs. B. <i>Hes3</i> transactivation by WT and the 11 MAMLD1 mutants was assessed. Only the L210X MAMLD1 mutant showed an impaired activity on the <i>Hes3</i> promoter. Results are expressed in relative light units (RLU) and represent the mean and SEM of 3 independent experiments performed in duplicate. ΔE5: original WT (b) without exon 5 [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0142831#pone.0142831.ref014" target="_blank">14</a>]; * <i>p</i>≤0.05.</p

MAMLD1 transcripts, reported mutations and tissue expression.

<p>A. Schemes of the 3 MAMLD1 human transcripts are shown (<a href="http://www.ncbi.nlm.nih.gov/" target="_blank">http://www.ncbi.nlm.nih.gov/</a>; <a href="http://www.ensembl.org" target="_blank">http://www.ensembl.org</a>). B. Scheme showing all reported <i>MAMLD1</i> gene mutations. Mutations described in this study are shown in red and the novel ones are marked with an asterisk. C. Assessment of MAMLD1 expression in human fetal and adult adrenal and testis. Semiquantitative RT-PCRs were performed using specific primers (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0142831#pone.0142831.s005" target="_blank">S1 Table</a>). GAPDH was used as the internal control. A representative gel picture is shown (n = 3). For MAMLD1 the band at 581 bp corresponds to isoform 2 and the band at 506 bp to isoforms 1 and 3. Dashed red lines in A indicate the location of the PCR fragments amplified for the expression studies.</p

Effect of MAMLD1 on CYP17A1 promoter and enzyme activities.

<p>HEK293 cells or NCI-H295R cells were transiently transfected with MAMLD1 WT and mutant expression vectors. For promoter activation studies, the (-3.7kb) <i>CYP17A1</i> promoter luciferase reporter construct was co-transfected. A. <i>CYP17A1</i> promoter activation by MAMLD1 was assessed by the Promega Dual luciferase assay in HEK293 cells. Only for mutant MAMLD1 L210X and L724V an impaired <i>CYP17A1</i> activation was found. Results are expressed in RLU and represent the mean and SEM of 3 independent experiments performed in duplicate. B. The effect of WT and mutant MAMLD1 on CYP17A1 enzyme activity was assessed in transfected NCI-H295R, MA-10 and HEK293 cells by measuring the conversion of progesterone to 17-hydroxyprogesterone. Steroid production was labeled with [¹⁴C]progesterone for 60 min. Steroids were extracted and resolved by thin-layer chromatography, then quantified as % conversion. A representative steroid profile obtained from NCI-H295R cells is shown (n = 2). No effect of MAMLD1 on CYP17A1-hydroxylase activity was detected. P: progesterone; 17OHP: 17-hydroxyprogesterone; RLU: relative light units; Ve: empty vector; WT: wild type; NT: non-transfected; * <i>p</i>≤0.05.</p