The genetic landscape of mitochondrial diseases in the next-generation sequencing era: a Portuguese cohort study

Introduction: Rare disorders that are genetically and clinically heterogeneous, such as mitochondrial diseases (MDs), have a challenging diagnosis. Nuclear genes codify most proteins involved in mitochondrial biogenesis, despite all mitochondria having their own DNA. The development of next-generation sequencing (NGS) technologies has revolutionized the understanding of many genes involved in the pathogenesis of MDs. In this new genetic era, using the NGS approach, we aimed to identify the genetic etiology for a suspected MD in a cohort of 450 Portuguese patients. Methods: We examined 450 patients using a combined NGS strategy, starting with the analysis of a targeted mitochondrial panel of 213 nuclear genes, and then proceeding to analyze the whole mitochondrial DNA. Results and Discussion: In this study, we identified disease-related variants in 134 (30%) analyzed patients, 88 with nuclear DNA (nDNA) and 46 with mitochondrial DNA (mtDNA) variants, most of them being pediatric patients (66%), of which 77% were identified in nDNA and 23% in mtDNA. The molecular analysis of this cohort revealed 72 already described pathogenic and 20 novel, probably pathogenic, variants, as well as 62 variants of unknown significance. For this cohort of patients with suspected MDs, the use of a customized gene panel provided a molecular diagnosis in a timely and cost-effective manner. Patients who cannot be diagnosed after this initial approach will be further selected for whole-exome sequencing. Conclusion: As a national laboratory for the study and research of MDs, we demonstrated the power of NGS to achieve a molecular etiology, expanding the mutational spectrum and proposing accurate genetic counseling in this group of heterogeneous diseases without therapeutic options.

Herbivory and nutrients shape grassland soil seed banks

Anthropogenic nutrient enrichment and shifts in herbivory can lead to dramatic changes in the composition and diversity of aboveground plant communities. In turn, this can alter seed banks in the soil, which are cryptic reservoirs of plant diversity. Here, we use data from seven Nutrient Network grassland sites on four continents, encompassing a range of climatic and environmental conditions, to test the joint effects of fertilization and aboveground mammalian herbivory on seed banks and on the similarity between aboveground plant communities and seed banks. We find that fertilization decreases plant species richness and diversity in seed banks, and homogenizes composition between aboveground and seed bank communities. Fertilization increases seed bank abundance especially in the presence of herbivores, while this effect is smaller in the absence of herbivores. Our findings highlight that nutrient enrichment can weaken a diversity maintaining mechanism in grasslands, and that herbivory needs to be considered when assessing nutrient enrichment effects on seed bank abundance.

Brazilian guide to nutrition in bariatric and metabolic surgery

PURPOSE

Brazilian nutrition recommendations for bariatric and metabolic surgery aim to provide knowledge, based on scientific evidence, on nutritional practices related to different surgical techniques in the surgical treatment of obesity and metabolic diseases.

MATERIALS AND METHODS

A systematic literature search was carried out with the appropriate MeSH terms using Medline/Pubmed/LiLACS and the Cochrane database, with the established criteria being based on the inclusion of articles according to the degree of recommendation and strength of evidence of the Classification of Recommendations, Evaluation, Development, and Evaluation System (GRADE).

RESULTS

The recommendations that make up this guide were gathered to assist in the individualized clinical practice of nutritionists in the nutritional management of patients with obesity, including nutritional management in the intragastric balloon; pre and postoperative nutritional treatment and supplementation in bariatric and metabolic surgeries (adolescents, adults, elderly, pregnant women, and vegetarians); hypoglycemia and reactive hyperinsulinemia; and recurrence of obesity, gut microbiota, and inflammatory bowel diseases.

CONCLUSION

We believe that this guide of recommendations will play a decisive role in the clinical practice of nutritionists who work in bariatric and metabolic surgery, with its implementation in health services, thus promoting quality and safety in the treatment of patients with obesity. The concept of precision nutrition is expected to change the way we understand and treat these patients.

Transition from APAP to CPAP may be a cost-effective health intervention in OSA patients

OBJECTIVE

Obstructive sleep apnea (OSA) is a common disorder associated with a significant economic burden. Continuous positive airway pressure (CPAP) and auto-titrating positive airway pressure (APAP) are recognized therapeutic options in patients with OSA, although treatment costs are higher with APAP. We conducted a study aimed at evaluating the effectiveness and potential cost savings resulting from the implementation of a protocol guiding the transition to CPAP in OSA patients previously treated with APAP.

METHODS

This prospective study included patients with OSA under APAP who were followed up at the Sleep Medicine outpatient clinic of a tertiary referral hospital between January 2019 and January 2021. Treatment was switched to CPAP in patients who met the following criteria: satisfactory adaptation and adherence to APAP, residual apnea-hypopnea index (AHI) of < 5/hour, and no relevant air leaks. APAP and CPAP outcomes were compared and an estimate of the savings obtained by the transition from APAP to CPAP was calculated.

RESULTS

Ninety-three patients were included in the study. APAP and CPAP were both effective in correcting obstructive events and improving daytime sleepiness. No significant differences were found regarding treatment adherence and tolerance between both PAP modalities. The selection of fixed-pressure CPAP through 90th or 95th percentile APAP pressure proved to be effective and an alternative strategy to titration polysomnography. At the end of this two-year study, the transition from APAP to CPAP enabled savings of at least 10,353€.

CONCLUSION

The transition from APAP to CPAP may be an effective, well-tolerated, safe, and cost-saving strategy in patients with OSA.

Childbearing intentions after a very preterm delivery: a study among Portuguese mothers and fathers

Background

Adjustments to intended family size are strongly affected by life-course events, but data on childbearing plans after a very preterm delivery are lacking. This study intends to assess the childbearing intentions of mothers and fathers of very preterm infants, regarding the desired and intended number of children, the factors associated with the intention to have more children and the main reasons for not wanting to have more children.

Methods

Between May and July 2017, mothers and fathers of very preterm infants were invited to participate in a structured online questionnaire through the Portuguese association of parents for support to the premature baby, and 231 mothers and 21 fathers were included. The discrepancy between the ideal and intended number of children was assessed by the McNemar-Bowker test. To assess the main factors associated with the plan to have more children in the future, unconditional logistic regression models were fitted to compute odds ratios (OR) and 95% confidence intervals (95%CI), adjusted for age, number of children and time after the very preterm delivery.

Results

Participants intend to have fewer children than they ideally desired (p &lt; 0.001). Although 69.8% of parents would like to have more children, only 25% actually plan to conceive. After adjustment, participants aged above 34 years (OR = 0.27; 95%CI:0.08-0.86), with more than one offspring (OR = 0.34; 95%CI:0.14-0.69) and who experienced a very preterm delivery 5 or more years ago (OR = 0.28; 95%CI:0.09-0.90) were less likely to report the intention to have more children. The main reasons reported for not wanting to have more children were “having the desired number of children” (38.5%), “financial unavailability” (24.2%) and “being too old to have more children” (20.5%).

Conclusions

This study provides a comprehensive assessment of childbearing intentions after a very preterm delivery, advocating for reproductive counselling policies supportive of family planning.

Key messages

Discrepancy between the ideal and actual childbearing intentions support the enhancement of reproductive healthcare services for family planning. Socioeconomic and age-related constraints were the main motives presented by mothers and fathers of very preterm infants for not wanting to have more children.

Fertilized graminoids intensify negative drought effects on grassland productivity

Droughts can strongly affect grassland productivity and biodiversity, but responses differ widely. Nutrient availability may be a critical factor explaining this variation, but is often ignored in analyses of drought responses. Here, we used a standardized nutrient addition experiment covering 10 European grasslands to test if full-factorial nitrogen, phosphorus, and potassium addition affected plant community responses to inter-annual variation in drought stress and to the extreme summer drought of 2018 in Europe. We found that nutrient addition amplified detrimental drought effects on community aboveground biomass production. Drought effects also differed between functional groups, with a negative effect on graminoid but not forb biomass production. Our results imply that eutrophication in grasslands, which promotes dominance of drought-sensitive graminoids over forbs, amplifies detrimental drought effects. In terms of climate change adaptation, agricultural management would benefit from taking into account differential drought impacts on fertilized versus unfertilized grasslands, which differ in ecosystem services they provide to society.

Portuguese adaptation of the S3-non-invasive ventilation (S3-NIV) questionnaire for home mechanically ventilated patients

Short, valid and easy to use tools are needed to monitor non-invasive ventilation in clinical practice and for organization of home mechanical ventilation services. The aim of this study was to develop a professional translation and cultural adaptation of the Portuguese S³ non-invasive ventilation questionnaire. 234 stable patients (128 male patients, 53.8%) with a mean age of 69.3 years under long-term home non-invasive ventilation were recruited from a single-center outpatient clinic. The most frequent diagnostic groups were obesity hypoventilation syndrome, chronic obstructive pulmonary disease and restrictive chest wall disorders. The Portuguese version of the questionnaire was obtained using translation back-translation process with two professional translators. Internal consistency for the total score was good (Cronbach's α coefficient of 0.76) as well as for the "respiratory symptoms" and the "sleep and side effects" domains (Cronbach's α coefficient=0.68 and Cronbach's α coefficient=0.72, respectively). An exploratory factor analysis was performed leading to an explained variance of 54.6%, and resulted in 3 components. The Portuguese version of the S3-NIV questionnaire is a simple and valid tool for the routine clinical assessment of patients receiving home NIV.

Author Correction: Leaf nutrients, not specific leaf area, are consistent indicators of elevated nutrient inputs

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Assessment of microbiota present on a Portuguese historical stone convent using high-throughput sequencing approaches

The study performed on the stone materials from the Convent of Christ revealed the presence of a complex microbial ecosystem, emphasizing the determinant role of microorganisms on the biodecay of this built cultural heritage. In this case study, the presence of Rubrobacter sp., Arthrobacter sp., Roseomonas sp., and Marinobacter sp. seems to be responsible for colored stains and biofilm formation while Ulocladium sp., Cladosporium sp., and Dirina sp. may be related to structural damages. The implementation of high-throughput sequencing approaches on the Convent of Christ's biodecay assessment allowed us to explore, compare, and characterize the microbial communities, overcoming the limitations of culture-dependent techniques, which only identify the cultivable population. The application of these different tools and insights gave us a panoramic view of the microbiota thriving on the Convent of Christ and signalize the main biodeteriogenic agents acting on the biodecay of stone materials. This finding highlighted the importance of performing metagenomic studies due to the improvements and the reduced amount of sample DNA needed, promoting a deeper and more detailed knowledge of the microbiota present on these dynamic repositories that support microbial life. This will further enable us to perform prospective studies in quarry and applied stone context, monitoring biogenic and nonbiogenic agents, and also to define long-term mitigation strategies to prevent biodegradation/biodeterioration processes.

Short communication: Heat stress does not affect induced luteolysis in Holstein cows

Heat stress (HS) has deleterious effects on bovine reproduction, including prolongation of the luteal phase in Holstein cows, perhaps due to compromised luteolysis. The objective was to characterize effects of HS on luteolytic responses of nonlactating Holstein cows given 25 or 12.5 mg of PGF_2α on d 7 of the estrous cycle. Cows were randomly distributed into 2 environments: thermoneutral (n = 12; 25°C) or HS (n = 12; 36°C). In each environment, cows were treated with 2 mL of saline, 25 or 12.5 mg of PGF_2α (n = 4 cows per group). The HS environment induced a significant increase in rectal temperature and respiratory rate compared with the thermoneutral environment. Heat stress did not have significant effects on luteolytic responses or circulating progesterone concentrations. Rapid and complete luteolysis occurred in all cows given 25 mg of PGF_2α and in 4 of 8 cows given 12.5 mg; the other 4 cows given 12.5 mg had partial luteolysis, with circulating progesterone concentrations initially suppressed, but subsequently rebounding. Therefore, we conclude that HS does not change corpus luteum sensitivity to PGF_2α.

A prolonged dry season and nitrogen deposition interactively affect CO2 fluxes in an annual Mediterranean grassland

Mediterranean annual grasslands are species-diverse ecosystems of high economic and ecological value. CO₂ and water fluxes in these grasslands are triggered by the first rains in autumn, after a long hot and dry summer. Climate change scenarios project altered rainfall patterns, such as prolonged dry season into the autumn, while simultaneously nitrogen (N) deposition is increasing globally. However, how these global change drivers will interact to affect Mediterranean grassland CO₂, water fluxes and productivity is still unclear. In a greenhouse experiment, we subjected the seedbank of an annual Mediterranean grassland to a factorial treatment, by prolonging the dry season by 0 days (i.e. no autumn drought), 50 days and 100 days and crossing these drought treatments with two levels of N deposition: no N and N addition. A delayed onset of the rain season, i.e., a prolonged dry season, induced lower CO₂ and water fluxes throughout the growing season and a lower aboveground biomass by the end of the study period. However, N addition attenuated the effects on NEE, Reco and GPP, but did not affect aboveground biomass or functional group composition. A prolonged dry season also lowered the productivity of forbs, the dominant functional group in our grassland. Our results anticipate important effects of interacting global change drivers on Mediterranean grassland functioning.

Unravelling associations between tree-seedling performance, herbivory, competition, and facilitation in high nature value farmlands

Herbivory, plant facilitation, and competition have complex impacts on tree regeneration which are seldom investigated together. Grazing exclosure experiments have allowed quantification of the effects of large herbivores on tree regeneration dynamics but have often ignored the effect of herbivorous insects. We experimentally tested how folivory (percentage of leaf damaged by insects) and microenvironment (tree canopy cover and herbs) jointly alter performance (growth and survival) of seedlings of two dominant Mediterranean oak-species within ungulate exclosures in a 3-year field study. An agroforestry system dominated by cork oak (Quercus suber) and holm oak (Q. rotundifolia) was assessed in south-east Portugal. We aimed also to determine whether the two oak species differed in the interdependences between folivory, microenvironment, covaring factors, and seedling performance. Unexpectedly, under the low-moderate insect defoliation, growth and survival of cork and holm oak seedlings were positively associated with herbivore damage. Herb removal increased oak folivory by 1.4 times. Herb removal was also positively associated with growth, directly and indirectly through its negative effect on oak folivory. Tree canopy favored insect folivory upon cork oak seedlings directly and upon holm oak indirectly via decreasing light availability. Folivory was threefold greater upon cork than upon holm oak-seedlings. Our study shows that tree canopy, herbs, and covarying factors can affect cork and holm oak-seedling performances through complex pathways, which markedly differ for the two species. The combined effect of insect herbivory and positive and negative plant-plant interactions need to be integrated into future tree regeneration efforts toward tackling the regeneration crisis of oak agroforestry systems of the Mediterranean.

Long-Term Peritoneal Dialysis Experience in Portugal

Peritoneal dialysis (PD) penetration varies widely. Since the beginning of this therapy, indications have changed and outcomes have improved. In Portugal, PD still remains clearly underutilized.

The results of a 20 year PD programme were evaluated: 312 cumulative patients, 48±16 years, 27% >60 years old, 27% diabetic, 59% with prior hemodialysis (HD). The main reason for admission was vascular access failure (48.7%). Admission due to patient preference has increased significantly between first and second decades of the programme (33% vs 47% (P<0.001)); 98 patients (31.4%) were treated with automated PD but this prescription increased to 43% of the active patients.

A total of 376 Tenckhoff catheters were surgically implanted, recently by the Popovich-Moncrief technique (77 catheters): the cumulative survival was 82%, 64% and 50% at 1, 3 and 5 years, respectively. A better catheter survival was found in the last decade (85.7%, 69.6%, 54.8% versus 77.3%, 55.5%, 40.2%, at 1, 3 and 5 years, respectively (P=0.007).

The patient and technique cumulative survivals were 91, 74, 55% and 85, 67, 41%, at 1, 3, and 5 years, respectively.

The main drop-out was to hemodialysis (35.8%), followed by death (23.7%), and transplantation (21.5%). Peritonitis and access-related infections caused 35% of the transfer to HD. Cardiovascular events caused 58% of deaths. The median PD retention was 35.5 months. The rate of peritonitis has decreased to one episode /30 patient months. Hospital admission has also decreased to 4.8 days/patient year.

This is a first report on long-term PD experience in Portugal. It has been an effective modality of renal replacement therapy, reflected by the growing patient preference in our PD programme. Experience, knowledge and new technical solutions have improved the outcomes.

Molecular picture of cobalamin C/D defects before and after newborn screening era

Objective

Birth prevalence of Cobalamin (Cbl) C or D defects in Portugal is an estimated 1:85,000, one of the highest worldwide. We compared the genotype/phenotype of patients identified with CblC or CblD before and after the implementation of expanded newborn screening.

Methods

Twenty-five Portuguese CblC/D patients, 14 symptomatic and 11 identified through screening, were diagnosed using gas chromatography or tandem mass spectrometry. Molecular characterization was performed through the study of MMACHC and MMADHC genes.

Results

The most common MMACHC mutation, c.271dupA, was present in 100% of MMACHC alleles of all CblC screened patients, in contrast with the 61% identified before expanded newborn screening. All studied cases (except one, who presented a CblD deficiency) presented a CblC defect. More CblC late-onset patients were diagnosed before the introduction of newborn screening than in the post newborn screening era, probably because some early onset patients died without a definitive diagnosis.

Conclusion

The molecular data found in this cohort contribute to the improvement of screening and diagnosis of Cbl defects and would enable a confirmatory diagnosis of these patients, reducing the need for complex, costly, laborious, and time-consuming biochemical/enzymatic tests.

Preliminary safety assessment of C-8 xylitol monoester and xylitol phosphate esters

OBJECTIVES

Most of the cosmetic compounds with preservative properties available in the market pose some risks concerning safety, such as the possibility of causing sensitization. Due to the fact that there are few options, the proper development of new molecules with this purpose is needed. Xylitol is a natural sugar, and the antimicrobial properties of xylitol-derived compounds have already been described in the literature. C-8 xylitol monoester and xylitol phosphate esters may be useful for the development of skincare products. As an initial screen for safety of chemicals, the combination of in silico methods and in vitro testing can aid in prioritizing resources in toxicological investigations while reducing the ethical and monetary costs that are related to animal and human testing. This study was designed to evaluate the safety of C-8 xylitol monoester and xylitol phosphate esters regarding carcinogenicity, mutagenicity, skin and eye irritation/corrosion and sensitization through alternative methods.

METHODS

For the initial safety assessment, quantitative structure-activity relationship methodology was used. The prediction of the parameters carcinogenicity/mutagenicity, skin and eye irritation/corrosion and sensitization was generated from the chemical structure. The analysis also comprised physical-chemical properties, Cramer rules, threshold of toxicological concern and Michael reaction. In silico results of candidate molecules were compared to 19 compounds with preservative properties that are available in the market. Additionally, in vitro tests (Ames test for mutagenicity, cytotoxicity and phototoxicity tests and hen's egg test--chorioallantoic membrane for irritation) were performed to complement the evaluation.

RESULTS

In silico evaluation of both molecules presented no structural alerts related to eye and skin irritation, corrosion and sensitization, but some alerts for micronucleus and carcinogenicity were detected. However, by comparison, C-8 xylitol monoester, xylitol phosphate esters showed similar or better results than the compounds available in the market. Concerning experimental data, phototoxicity and mutagenicity results were negative. As expected for compounds with preservative activity, xylitol-derived substances presented positive result in cytotoxicity test. In hen's egg test, both molecules were irritants.

CONCLUSION

Our results suggested that xylitol-derived compounds appear to be suitable candidates for preservative systems in cosmetics.

Preliminary safety assessment of C-8 xylitol monoester and xylitol phosphate esters

OBJECTIVES

Most of the cosmetic compounds with preservative properties available in the market pose some risks concerning safety, such as the possibility of causing sensitization. Due to the fact that there are few options, the proper development of new molecules with this purpose is needed. Xylitol is a natural sugar, and the antimicrobial properties of xylitol-derived compounds have already been described in the literature. C-8 xylitol monoester and xylitol phosphate esters may be useful for the development of skincare products. As an initial screen for safety of chemicals, the combination of in silico methods and in vitro testing can aid in prioritizing resources in toxicological investigations while reducing the ethical and monetary costs that are related to animal and human testing. This study was designed to evaluate the safety of C-8 xylitol monoester and xylitol phosphate esters regarding carcinogenicity, mutagenicity, skin and eye irritation/corrosion and sensitization through alternative methods.

METHODS

For the initial safety assessment, quantitative structure-activity relationship methodology was used. The prediction of the parameters carcinogenicity/mutagenicity, skin and eye irritation/corrosion and sensitization was generated from the chemical structure. The analysis also comprised physical-chemical properties, Cramer rules, threshold of toxicological concern and Michael reaction. In silico results of candidate molecules were compared to 19 compounds with preservative properties that are available in the market. Additionally, in vitro tests (Ames test for mutagenicity, cytotoxicity and phototoxicity tests and hen's egg test--chorioallantoic membrane for irritation) were performed to complement the evaluation.

RESULTS

In silico evaluation of both molecules presented no structural alerts related to eye and skin irritation, corrosion and sensitization, but some alerts for micronucleus and carcinogenicity were detected. However, by comparison, C-8 xylitol monoester, xylitol phosphate esters showed similar or better results than the compounds available in the market. Concerning experimental data, phototoxicity and mutagenicity results were negative. As expected for compounds with preservative activity, xylitol-derived substances presented positive result in cytotoxicity test. In hen's egg test, both molecules were irritants.

CONCLUSION

Our results suggested that xylitol-derived compounds appear to be suitable candidates for preservative systems in cosmetics.

Vertebral osteoporotic fractures with height loss secondary to Cushing's disease

Cushing's disease is a rare condition which may present with a variety of signs and symptoms. In this report, we present a case of a 37-year-old man referred to our department due to osteoporosis complicated with vertebral and rib fractures and loss of six centimeters in height within the previous year. Study of secondary causes of osteoporosis led to the diagnosis of Cushing's disease. The patient was submitted to transsphenoidal surgery and histological findings confirmed the diagnosis. After surgery, the symptoms improved. Glucocorticoid induced osteoporosis may be reversible, but recovery of bone loss is gradual and may continue for as long as 10 years before bone mineral density normalizes. This case illustrates the need to consider secondary causes of osteoporosis in a young man with bone fractures, namely Cushing's syndrome.

Retinol, β-carotene and oxidative stress in systemic inflammatory response syndrome

OBJECTIVE

patients suffering systemic inflammatory response syndrome (SIRS) constitute a group susceptible to elevated levels of oxidative stress. This study's aim is to evaluate the state of oxidative stress and levels of serum retinol and β-carotene in these patients.

METHODS

forty-six patients were divided into 2 groups: those those without diet (G1; n=18) and those with enteral nutritional support (G2; n=28). Serum levels of retinol and total carotenoids were measured. C-reactive protein (CRP) levels and Apache scores were also calculated. Oxidative stress was estimated by measuring thiobarbituric acid reactive substance (TBARS) levels.

RESULTS

the patients' median age was 66.9 (SD=19.3) years. Lower concentrations of retinol and carotenoids were found in 68.6 and 66.7% of G1, respectively. In G2, despite average vitamin A levels being 8078 + 4035, retinol and β-carotene were considered insufficient (31.2 and 33.4%, respectively). No difference was noted between the 2 groups, according to the variables studied, with the exception being PCR and β-carotene (p=0.002; p=0.01).

CONCLUSION

the data presented in this study supports the need to establish/revise clinical practices in treating SIRS patients, in light of this micronutrient's role in the immune system and antioxidant defense without it interfering with its toxicity.

Luc's abscess as an unlucky complication of mastoiditis

Luc's abscess is a rare but important complication of acute otitis media (AOM), whereby infection spreads from the middle ear, resulting in a subperiosteal collection beneath the temporal muscle. Unlike other extracranial abscesses relating to AOM, Luc's abscess is not believed to involve the mastoid bone. We present the case of a patient with a Luc's abscess with mastoid involvement and discuss its successful management. We believe that patients presenting with a subperiosteal collection beneath the temporal muscle and mastoiditis may represent a different group of patients to those described originally by Luc. These individuals can be differentiated using computed tomography (CT) of the temporal bones. We advocate CT in patients with Luc's abscess and AOM; this aids preoperative surgical planning.

Diagnosis of sarcoidosis in the endobronchial ultrasound-guided transbronchial needle aspiration era

BACKGROUND

Sarcoidosis is a multisystemic disorder of unknown etiology. Its diagnosis is based on compatible clinical and radiological features and supported by histological demonstration of epithelioid cell noncaseating granulomas with exclusion of other causes. Endobronchial ultrasound combined with transbronchial needle aspiration (EBUS-TBNA) has been proposed as a valuable tool in obtaining suitable tissue sample. The aim of this study was to evaluate the contribution of EBUS-TBNA to the diagnosis of stages I and II thoracic sarcoidosis in a community-based hospital.

METHODS

A prospective study was conducted in patients with suspected stages I and II pulmonary sarcoidosis, based on clinical and radiological data, who were being followed in our Interstitial Lung Disorders Outpatient Clinic or sent from other hospitals to our Respiratory Endoscopy Unit for diagnostic procedures. All suitable and fit patients underwent EBUS-TBNA between March 2010 and June 2013. We assessed demographic characteristics, radiological stages, cytological/histological examination and diagnostic techniques performed.

RESULTS

In the period considered 39 patients underwent EBUS-TBNA for suspected stages I and II thoracic sarcoidosis and adequate samples were obtained in 38 (97.4%). Within this population, 33 (84.6%) patients had a definite diagnosis of sarcoidosis, of which 31 patients (93.9%) were confirmed to have epithelioid noncaseating granulomas by EBUS-TBNA. Four patients were submitted to surgical procedures (three to mediastinoscopy and one to open surgical lung biopsy). Data analysis allowed to calculate a sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of 93.9%, 100%, 100%, 75.0% and 94.8%, respectively. No complications were observed.

CONCLUSIONS

EBUS-TBNA is a valuable tool in the diagnostic workup of patients with suspected stages I and II thoracic sarcoidosis providing a substantial number of pathological confirmations and with few complications. Its high diagnostic accuracy precludes the need for more invasive procedures such as surgical biopsy.

The relationship between serum vitamin A and breast cancer staging before and after radiotherapy

INTRODUCTION

Several adverse effects of radiotherapy have been associated with the process of increased oxidative stress in the organism. In this context, vitamin A noteworthy for its important role in combating oxidative stress, in addition to its chemoprotective effect.

OBJECTIVE

To assess the serum levels of vitamin A (retinol and β-carotene) and their relationship to breast cancer staging in patients before and after radiotherapy.

METHODS

This is a prospective study of women with breast cancer who were evaluated from October 2011 to September 2012 before (T0) and after radiotherapy (T1-7 days). Serum retinol and β-carotene levels were analyzed using High Performance Liquid Chromatography. The assignment of breast cancer stages was based on the classification of malignant tumors that has been proposed by the International Union Against Cancer.

RESULTS

230 patients (mean age 63.6 years, SD ± 9.38) were evaluated. There was a significant reduction in the serum retinol (45.1 ± 18.2 μg/dL at T0 to 27.1 ± 11.7 μg/dL at T1, p < 0.001) and β-carotene (209.0 ± 153.6 μg/L at T0 to 47.7 ± 25.5 μg/L at T1, p < 0.001). There was also a significant difference in serum retinol (p < 0.001) and β-carotene (p = 0.003) levels based on the disease stage.

CONCLUSIONS

It is recommended the early establishment of adequation serum concentrations of retinol and beta-carotene, offering nutritional assistance for those patients with deficiencies, in order to minimize the harmful effects of radiation.

Dehiscence of the posterior and superior semicircular canal presenting in pregnancy

OBJECTIVE

We present an interesting case of superior and posterior semicircular canal dehiscence in pregnancy.

METHOD

We present a case report and a review of the world literature concerning semicircular canal dehiscence.

CASE REPORT

A 34-year-old woman presented with sound and pressure induced vertigo at 22 weeks gestation. A thinly sliced computed tomography (CT) scan of the petrous temporal bones viewed with coronal reconstructions was performed post-partum. This showed the presence of both left superior canal and posterior canal dehiscence.

CONCLUSION

To our knowledge this is the first reported case of semicircular canal dehiscence in pregnancy. The diagnosis of semicircular canal dehiscence should be suspected in pregnant patients with sound induced vertigo.

Commercial bee pollen with different geographical origins: a comprehensive approach

Since the primordial of humanity, pollen has been considered a good source of nutrients and energy. Its promising healing properties have also been referred to. The present study aimed to characterize, for the first time, eight commercial pollens from Portugal and Spain available on the market studying the legislation on labeling, pollinic origin, physicochemical and microbiological analyses and identification of yeasts. Eleven botanical families were found amongst the samples. The most abundant family and the most dominant pollen was Cistaceae. The moisture content, ash, a_w, pH, reducing sugars, carbohydrates, proteins, lipids and energy were analyzed and the specific parameters were within the specifications required by some countries with legislation regarding these parameters. Microbiologically commercial pollen showed acceptable safety for the commercial quality and hygiene. All samples showed negative results for toxigenic species. The microorganisms studied were aerobic mesophiles, yeasts and moulds, coliforms, Escherichia coli, Staphylococcus aureus, Salmonella and sulfite-reducing Clostridium. During the work, six yeasts species were isolated from pollen, with Rhodotorula mucilaginosa being the most abundant, as it was present in four samples.

Methionine Adenosyltransferase I/III Deficiency in Portugal: High Frequency of a Dominantly Inherited Form in a Small Area of Douro High Lands

Methionine adenosyltransferase deficiency (MAT I/III deficiency) is an inborn error of metabolism resulting in isolated hypermethioninemia, and usually inherited as an autosomal recessive trait, although a dominant form has been reported in several families.During the last 6 years, approximately 520,000 newborns were screened in the Portuguese Newborn Screening Laboratory by MS/MS, and 21 cases of persistent hypermethioninemia were found. One case was confirmed to be a deficiency of cystathionine β-synthase and 20 cases were confirmed by MAT1A gene analysis to have an elevation of methionine due to MAT I/III deficiency, which indicates an incidence for this condition of 1/26,000. Twelve of the MAT I/III deficient newborns, belonging to 11 families, were identified in the northern region of Portugal and sent to the same treatment center, where they are under follow-up. Clinical, biochemical, and genetic characteristics of individuals from these 11 families are presented. Plasma methionine and homocysteine concentrations were found to be moderately increased in all newborns, and molecular analysis revealed that they all were heterozygous for R264H mutation. Normal growth, development, and neurological examination were observed in all cases, and cerebral MRI performed in six cases revealed myelination abnormalities in one case. Plasma methionine concentration for all 12 cases was always below 300 μM, and they are all on a normal diet for their age.

Successful outcome of cochlear implantation in a patient with superficial siderosis

OBJECTIVE

To present the management of a rare case of progressive bilateral sensorineural hearing loss in a patient with superficial siderosis secondary to a cavernoma.

METHOD

A case report and a review of the literature concerning superficial siderosis.

RESULTS

The patient benefited significantly from a cochlear implantation.

CONCLUSIONS

Careful assessment and adequate counselling is necessary to determine the best approach to hearing rehabilitation in patients with superficial siderosis of the central nervous system. Cochlear implantation in patients with superficial siderosis is controversial due to the retrocochlear origin of the hearing loss and, although the case presented had a successful outcome, the results might deteriorate with time.

Prostatic carcinomas with neuroendocrine differentiation diagnosed in needle biopsies, a morphologic study of 7 cases among 465 sequential biopsies in a tertiary cancer center

PURPOSE

Neuroendocrine carcinomas (NEC) of the prostate are rare, with only a few series hitherto reported. The objective of this study was to assess in a single institution the clinical and morphologic characteristics of neuroendocrine carcinomas diagnosed in needle core biopsies.

MATERIALS AND METHODS

The current study analyses seven cases diagnosed in needle biopsies at a large tertiary regional cancer center from Northeastern Brazil. Two pathologists reviewed specimens retrospectively, and demographic and morphologic characteristics were compared to 458 acinar tumors diagnosed in the same period.

RESULTS

There were five small cell carcinomas and two low-grade neuroendocrine carcinomas (carcinoid). NEC were associated with an acinar component in 5/7 cases and the Gleason score of the acinar component was always > 6. The number of cores involved in prostates with NEC was greater (65% compared to 24% of acinar tumors, p < 0.05). The mean PSA at diagnosis was 417.7 (range 5.7-1593, SD 218.3), compared to 100.5 (p = 0.1) of acinar tumors (range 0.3-8545, SD 22.7). Prostates harboring NEC were bigger (p < 0.001, mean volume 240 mL vs. 53 mL of acinar tumors). Treatment of NEC included palliative surgery, chemotherapy, and hormonal therapy.

CONCLUSIONS

NEC of the prostate is rare and often associated with a high-grade acinar component. Prostates with NEC tend to be larger and involve a greater number of cores than acinar tumors. PSA at diagnosis does not seem to predict the presence of NE tumors in needle biopsy.

Micronutrientes com ação antioxidante em neonatos

OBJETIVO: Apresentar uma revisão atualizada e crítica sobre o estresse oxidativo em neonatos, bem como o efeito de micronutrientes com ação antioxidante direcionado ao grupo em questão. FONTES DE DADOS: Pesquisa bibliográfica nos bancos de dados Medline e LILACS (1997-2009), selecionando os artigos escritos em inglês, português ou espanhol, a partir dos descritores "neonato" e "micronutrientes", em combinação com "antioxidantes" e "estresse oxidativo". Foram examinados 90 artigos e 34 deles selecionados. SÍNTESE DOS DADOS: O nascimento, por si só, representa um estresse oxidativo para o recém-nascido, o que se agrava nos casos de prematuridade e quando existem doenças associadas. A agressão oxidativa sofrida pelo neonato a termo é contrabalançada pela maturação eficaz dos mecanismos antioxidantes; porém, no caso dos prematuros, isto não é evidente, uma vez que altas concentrações de antioxidantes só ocorrem no final da gestação. Diversos estudos foram realizados no intuito de avaliar as concentrações de antioxidantes em neonatos a termo e pré-termo, assim como propor doses de suplementação que possam ser eficazes em combater o estresse oxidativo. CONCLUSÕES: O estresse oxidativo está presente em neonatos, em especial nos prematuros, aumentando a demanda de nutrientes antioxidantes. É consenso que estes devem ser administrados de forma combinada, de modo a prevenir danos celulares. São necessários estudos longitudinais e com maiores casuísticas que avaliem as concentrações desses micronutrientes antioxidantes, com o intuito de traçar recomendações apropriadas para neonatos a termo e pré-termo.

Cooperative interactions of PTEN deficiency and RAS activation in melanoma metastasis

Mitogen-activated protein kinase (MAPK) and AKT pathways are frequently co-activated in melanoma through overexpression of receptor tyrosine kinases, mutations in their signaling surrogates, such as RAS and BRAF, or loss of negative regulators such as PTEN. As RAS can be a positive upstream regulator of PI3-K, it has been proposed that the loss of PTEN and the activation of RAS are redundant events in melanoma pathogenesis. Here, in genetically engineered mouse models of cutaneous melanomas, we sought to better understand the genetic interactions between HRAS activation and PTEN inactivation in melanoma genesis and progression in vivo. We showed that HRAS activation cooperates with Pten+/- and Ink4a/Arf-/- to increase melanoma penetrance and promote metastasis. Correspondingly, gain- and loss-of-function studies established that Pten loss increases invasion and migration of melanoma cells and non-transformed melanocytes, and such biological activity correlates with a shift to phosphorylation of AKT2 isoform and E-cadherin down-regulation. Thus, Pten inactivation can drive the genesis and promote the metastatic progression of RAS activated Ink4a/Arf deficient melanomas.

[Bronchoscopic dilation techniques and topical application of mitomycin-C in the treatment of tracheal stenosis post intubation - two case reports]

Tracheal stenosis follows any injury to the airway mucosa, such as ischaemic, traumatic and other injuries. The treatment of tracheal stenosis remains a challenging problem despite all the advances in endoscopic and surgical techniques. Scar formation and reestenosis are the main causes of treatment failure. The authors present two cases of successful treatment of a tracheal stenosis after tracheal injury from prolonged oro -tracheal intubation / tracheostomy following dilatation with rigid broncoscope and laser therapy, associated with topical application of mitomycin C as an adjuvant treatment.