Medium-Chain Acyl-CoA Dehydrogenase Deficiency (MCADD) is the most common inborn error of metabolism affecting the fatty acid oxidation pathway. The deficiency is caused by a defect in the medium-chain acyl-CoA dehydrogenase enzyme which catalyzes the first step in the oxidation of medium-chain fatty acids. Long-chain fatty acids, after being transported into the mitochondria and activated into long-chain acyl-CoAs, are sequentially broken down until they become medium-chain acyl-CoAs. Medium-chain acyl-CoAs are then broken down until they become short-chain acyl-CoAs. Short-chain acyl-CoAs are broken down until only acetyl-CoA remains. The block in the oxidation of fatty acids in those with MCADD happens once the long-chain acyl-CoAs have been oxidized to medium-chain acyl-CoAs. The medium-chain acyl-CoAs cannot be further oxidized and build up. Without the breakdown of fatty acids, individuals with MCADD cannot produce enough energy during times of increased metabolic demand. Thus, prolonged exercise, fasting, or fever can precipitate clinical symptoms once the body enters a hypoketotic hypoglycemic state. Those with MCADD typically present in the early months of life with fasting intolerance, vomiting, lethargy, and, in more serious cases, seizures. Adult presentation is rare, but should not be ruled out of a differential diagnosis, because early detection and intervention can prevent permanent brain damage and death. Because early detection can prevent the serious effects of metabolic decompensation, MCADD was added to the Newborn Screen and is tested through measuring levels of medium-chain acylcarnitines in dried blood smears by tandem mass spectrometry. Metabolic decompensation is manifested clinically through dehydration, vomiting, and acidosis. In serious cases, metabolic decompensation can progress to seizures, coma, and death. Introduction of the Newborn Screen has reduced the morbidity of the deficiency, but has not eliminated it. Those with MCADD need to be closely monitored and emergency glucose needs to be available to them in case of a hypoglycemic emergency. The Newborn Screen has been effective in finding mutations in the ACADM gene that produce a mild phenotype of MCADD. Before the Newborn Screen, the most common variant, K329E, was detected in clinically diagnosed patients. However, the screen has shown that there are about 150 variants leading to MCADD. The most common variant of the MCAD protein, K329E, has been studied and characterized in order to further understand the pathogenesis of MCADD. This mutation substitutes a lysine for a glutamic acid, introducing hindrance and the inability of the protein to form its fully functional tetrameric form. The mutant protein also has an increased sensitivity to heat denaturation. Currently, there are no pharmacological treatments for MCADD. The idea of pharmacological chaperones is explored by using the example of tetrahydrobiopterin and phenylketonuria. Future studies will need be done to find a treatment for MCADD that is curative rather than treating the symptoms of the deficiency; however, curative therapies which target the mutant enzyme may be problematic since there is a wide array of mutations that result in a defective enzyme in affected individuals.

The perception is that inborn errors of metabolism (IEM) are rare, but the reality is that more than 600 lEMs are now recognized. The organic aciduria, 3-methylcrotonyl-CoA carboxylase (MCC) deficiency arises when 3-methylcrotonyl-Coenzyme A (CoA) carboxylase that participates in the fourth step of the leucine catabolism is defective. Tandem mass spectrometry (MS/MS) based screening programmes in North America, Europe and Australia, showed that MCC deficiency is the most frequent organic aciduria detected, with an average frequency of 1:50 000. Therefore MCC deficiency is considered an emerging disease in these regions. The incidence of MCC deficiency in the Republic of South Africa (RSA) is not yet known. However, one 48 year old male Caucasian individual (HGS) was diagnosed suffering from mild MCC deficiency, since elevated levels of 3-hydroxyisovaleric acid, 3- hydroxyisovalerylcarnitine, 3-methylcrotonylglycine was present in his urine. Several groups are currently working on various aspects of this emerging disease with the focus on the molecular characterisation of MCC deficiency. In the RSA no molecular based diagnostic method which complements MS/MS screening programmes have yet been implemented. Therefore, the aim of this study was to implement the necessary techniques for the molecular characterisation of MCC deficiency, the determination of the sequence of the open reading frame (ORF) of mccA and mccB subunits to determine which mutation(s) are present in the South African MCC deficient patient. For the implementation of the molecular characterisation, a two-pronged approached was used to characterize MCC of a MCC non-deficient individual (CFC). This approach included the reverse transcriptase polymerase chain reaction (RT-PCR) amplification of the ORFs of the associated genes [mccA (19 exons) and mccB (17 exons] and the PCR amplification of selected (genomic deoxyribonucleic acid (gDNA) regions (exons mccA8, mccA11 , mccB5, mccB6 and mccB5-intron 5-6 exon 6 (mccB5-6) which have been found to have mutations associated with MCC deficiency in Caucasians. The sequence analyses produced surprising results of the amplified ORFs (CFCmccA and CFCmccB) of the MCC non-deficient individual CFC. A non-synonymous single nucleotide polymorphism (SNP) (1391C→A, H464P) associated with MCC deficiency (Gallardo et al., 2001) was identified in the CFCmccA subunit. Another SNP (1368G→A, A456A) recently listed in GenBank was observed in the amplified CFCmccB ORF. No significant novel variations or described mutations were identified in the amplified genomic regions mccA8, mccA11 ,mccB5, mccB6 and mccB5-6. The implemented molecular approach was used to characterise MCC of our MCC deficient patient (HGS). The patient did not have any mutation in the four selected exons mccA8, mccA11, mccB5, mccB6 or the genomic region mccB5-6. The RT-PCR amplification of both ORFs (HGSmccA and HGSmccB) resulted in multiple amplicons. Gel extracted amplicons of the expected size were sequenced. Of the 36 exons, 34 exons were sequenced. This includes all 19 exons of HGSmccA and 15 of 17 exons of HGSmccB (exons 1-6 and exons 9-17). The non-synonymous SNP (1391C→A, H464P) detected in CFCmccA (MCC non-deficient individual), seems to be present in the HGSmccA subunit of the MCC deficient individual, HGS. The HGSmccB amplicons could not be entirely sequenced. However, the region exon 1-6 and 9-17 was sequenced but no described or novel mutations were identified. The lack of sequence data of region exon 7-8 led to an incomplete molecular characterisation of the MCC deficiency in HGS. In conclusion, the basic methods and techniques for the molecular characterisation of MCC deficient patients have been implemented locally. A few additional sequencing primers need to be designed to cover mccB7 and mccB8 as well as the entire coding and non-coding strands of each MCC gene (mccA and mccB). The primers for RT-PCR of both mccA and mccB need to be further refined to ensure better specificity. / Thesis (M.Sc. (Biochemistry))--North-West University, Potchefstroom Campus, 2007.

The perception is that inborn errors of metabolism (IEM) are rare, but the reality is that more than 600 lEMs are now recognized. The organic aciduria, 3-methylcrotonyl-CoA carboxylase (MCC) deficiency arises when 3-methylcrotonyl-Coenzyme A (CoA) carboxylase that participates in the fourth step of the leucine catabolism is defective. Tandem mass spectrometry (MS/MS) based screening programmes in North America, Europe and Australia, showed that MCC deficiency is the most frequent organic aciduria detected, with an average frequency of 1:50 000. Therefore MCC deficiency is considered an emerging disease in these regions. The incidence of MCC deficiency in the Republic of South Africa (RSA) is not yet known. However, one 48 year old male Caucasian individual (HGS) was diagnosed suffering from mild MCC deficiency, since elevated levels of 3-hydroxyisovaleric acid, 3- hydroxyisovalerylcarnitine, 3-methylcrotonylglycine was present in his urine. Several groups are currently working on various aspects of this emerging disease with the focus on the molecular characterisation of MCC deficiency. In the RSA no molecular based diagnostic method which complements MS/MS screening programmes have yet been implemented. Therefore, the aim of this study was to implement the necessary techniques for the molecular characterisation of MCC deficiency, the determination of the sequence of the open reading frame (ORF) of mccA and mccB subunits to determine which mutation(s) are present in the South African MCC deficient patient. For the implementation of the molecular characterisation, a two-pronged approached was used to characterize MCC of a MCC non-deficient individual (CFC). This approach included the reverse transcriptase polymerase chain reaction (RT-PCR) amplification of the ORFs of the associated genes [mccA (19 exons) and mccB (17 exons] and the PCR amplification of selected (genomic deoxyribonucleic acid (gDNA) regions (exons mccA8, mccA11 , mccB5, mccB6 and mccB5-intron 5-6 exon 6 (mccB5-6) which have been found to have mutations associated with MCC deficiency in Caucasians. The sequence analyses produced surprising results of the amplified ORFs (CFCmccA and CFCmccB) of the MCC non-deficient individual CFC. A non-synonymous single nucleotide polymorphism (SNP) (1391C→A, H464P) associated with MCC deficiency (Gallardo et al., 2001) was identified in the CFCmccA subunit. Another SNP (1368G→A, A456A) recently listed in GenBank was observed in the amplified CFCmccB ORF. No significant novel variations or described mutations were identified in the amplified genomic regions mccA8, mccA11 ,mccB5, mccB6 and mccB5-6. The implemented molecular approach was used to characterise MCC of our MCC deficient patient (HGS). The patient did not have any mutation in the four selected exons mccA8, mccA11, mccB5, mccB6 or the genomic region mccB5-6. The RT-PCR amplification of both ORFs (HGSmccA and HGSmccB) resulted in multiple amplicons. Gel extracted amplicons of the expected size were sequenced. Of the 36 exons, 34 exons were sequenced. This includes all 19 exons of HGSmccA and 15 of 17 exons of HGSmccB (exons 1-6 and exons 9-17). The non-synonymous SNP (1391C→A, H464P) detected in CFCmccA (MCC non-deficient individual), seems to be present in the HGSmccA subunit of the MCC deficient individual, HGS. The HGSmccB amplicons could not be entirely sequenced. However, the region exon 1-6 and 9-17 was sequenced but no described or novel mutations were identified. The lack of sequence data of region exon 7-8 led to an incomplete molecular characterisation of the MCC deficiency in HGS. In conclusion, the basic methods and techniques for the molecular characterisation of MCC deficient patients have been implemented locally. A few additional sequencing primers need to be designed to cover mccB7 and mccB8 as well as the entire coding and non-coding strands of each MCC gene (mccA and mccB). The primers for RT-PCR of both mccA and mccB need to be further refined to ensure better specificity. / Thesis (M.Sc. (Biochemistry))--North-West University, Potchefstroom Campus, 2007.

Made available in DSpace on 2014-08-26T17:31:46Z (GMT). No. of bitstreams: 2 license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) 69585.pdf: 1181357 bytes, checksum: 50462d1ba789c7b199ee8460ca90f3b8 (MD5) / Fundação Oswaldo Cruz. Instituto Fernandes Figueira. Departamento de Ensino. Programa de Pós-Graduação em Saúde da Criança e da Mulher. Rio de Janeiro, RJ, Brasil / A Doença de Gaucher (DG) é uma Doença de Depósito Lisossômico (DDL) e seu tratamento baseia - se na terapia de reposição enzimática. Tal terapia foi um marco na vida de pacientes e especialistas, pois mudou a história da evolução da doença, caracterizando um a nova era na Genética Médica. Este trabalho tem como objeto de pesquisa as perspectivas trazidas por profissionais, com experiência em trata r a Doença de Gaucher no Sistema Único de Saúde no estado do Rio de Janeiro. Uma vez que a DG é a única condição d o grupo das DDL a ser contemplada por uma Política Ministerial, promovendo acesso a drogas de alto custo através de um Protocolo Clínico e Diretrizes Terapêuticas (PCDT). O o bjetivo geral foi a nalisar a prática da aplicação do protocolo oficial de tratame nto da DG e o seu entendimento a partir da ótica dos médicos tratadores, profissionais de saúde e gestores do Centro de Referência , o Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO). Os objetivos específicos foram primeiramente id entificar a formaçã o profissional dos envolvidos no programa, analisar a ótica desses profissionais sob re as recomendações do PCDT e como estes situam o Centro de Referência (CR) e m seu atual funcionamento , e d iscutir de maneira crítica a visão dos profiss i onais a respeito dos benefícios e de possíveis falhas do programa. Foram realizadas entrevistas temáticas semiestruturadas e a elas aplicou - se a análise de conteúdo. No que tange ao entendimento sobre o PCDT - DG e o seu viii funcionamento, os resultados apontam a importância da existência de um balizador, um programa robusto governamental, revisado por especialistas bem capacitados no tema. O PCDT - DG foi um avanço na saúde, oficializando e garantindo o acesso à medicação de maneira embasada, controlada por câmar as técnicas estaduais, permitindo a efetuação de pregões públicos, uma maneira transparente de aquisiçã o de drogas de alto custo comparada a medidas judiciais . Os sujeitos da pesquisa são favoráveis ao programa, no entanto possuem uma abordagem crítica ao sistema de saúde no que diz respeit o a entraves na rede de assistência cirúrgica e de reabilitação. Um grande gargalo atualmente no SUS não é exclusivo ao programa da DG: certos questionamentos éticos na fomentação do diagnóstico laboratorial por parte da indústria farmacêutica, apesar de haver relações amigáveis entre esses dois atores no CR. Concluímos que muitos avanços foram conquistados a partir da implementação do protocolo e que talvez este possa servir como modelo para garantir acesso ao tratamento de outras DDL. Algumas incongruências do siste ma são questionáveis e discutida s entre gestores, médicos e usuários, entretanto ainda são muito poucos os estudos publicados no Brasil sobre o tema . / Gaucher disease (GD) is a Lysosomal Storage Disease (LSD) and its treatment is based on enzyme replacement therapy. Such therapy was a milestone in patients `s lives and experts in the field, changing the disease natural history . This work aims at present ing the treatment of GD in the Unified Health System i n the state of Rio de Janeiro, as it is the only LSD to be covered by a Ministerial policy , which promotes access to high cost drugs through a Clinical Gui deline (CG) . The overall objective was to analyze the practical application of the CG protocol in the treatment of GD, and how this guideline was interpreted and used by the medical c haracters , health professionals and ma nagers of the Reference Center and the State Institute of Hematology Arthur de Siquei ra Cavalcanti (HEMORIO ). The specific objectives were to identify the training of those involved in the program, to analyze how professionals viewed the recommendations included in the CP, what they thought about the Reference Center for GD and to critical ly discuss the benefits and possi ble shortcomings of the program . Thematic semi - structured interviews were conducted, and the content analysis was applied. Regarding the understanding of the CP - GD and its op eration, the results point the importance of t he existence of a robust government program, reviewed by well - trained experts in the subject. The CP - GD was a health`s breakthrough , ensuring access to medication, controlled by state technical chambers, a llowing the practice of public auctions, a transpar ent way of purchasing high - cost drugs when compared to individual litigation. The steakeholder`s research were x favo rable to the program, although they criticized the health network constraints for specialized care, such as surgical services and rehabilitat ion. Another major bottleneck in the health system, not exclusive for G D is ethical issues regarding laboratory diagnosis by the pharmaceutical industry. We conclude d that many advances have been achieved from the implementation of the CP, and that hopeful ly this can serve as a model to ensure access t o treatment for other LSD. Managers, physicians and users point out some inconsistencies in the system although there is still limited published data on this subject in Brazil.