Personalizable AI platform for universal access to research and diagnosis in digital pathology

BACKGROUND AND MOTIVATION

Digital pathology has been evolving over the last years, proposing significant workflow advantages that have fostered its adoption in professional environments. Patient clinical and image data are readily available in remote data banks that can be consumed efficiently over standard communication technologies. The appearance of new imaging techniques and advanced artificial intelligence algorithms has significantly reduced the burden on medical professionals by speeding up the screening process. Despite these advancements, the usage of digital pathology in professional environments has been slowed down by poor interoperability between services resulting from a lack of standard interfaces and integrative solutions. This work addresses this issue by proposing a cloud-based digital pathology platform built on standard and open interfaces.

METHODS

The work proposes and describes a vendor-neutral platform that provides interfaces for managing digital slides, and medical reports, and integrating digital image analysis services compatible with existing standards. The solution integrates the open-source plugin-based Dicoogle PACS for interoperability and extensibility, which grants the proposed solution great feature customization.

RESULTS

The solution was developed in collaboration with iPATH research project partners, including the validation by medical pathologists. The result is a pure Web collaborative framework that supports both research and production environments. A total of 566 digital slides from different pathologies were successfully uploaded to the platform. Using the integration interfaces, a mitosis detection algorithm was successfully installed into the platform, and it was trained with 2400 annotations collected from breast carcinoma images.

CONCLUSION

Interoperability is a key factor when discussing digital pathology solutions, as it facilitates their integration into existing institutions' information systems. Moreover, it improves data sharing and integration of third-party services such as image analysis services, which have become relevant in today's digital pathology workflow. The proposed solution fully embraces the DICOM standard for digital pathology, presenting an interoperable cloud-based solution that provides great feature customization thanks to its extensible architecture.

Microalgae biomass as an alternative source of biocompounds: New insights and future perspectives of extraction methodologies

Microalgae have characteristics that make them unique and full of potential. Their capacity to generate interesting bioactive molecules can add value to various industrial applications. However, most of these valuable compounds are intracellular, which makes their extraction a major bottleneck. Conventional extraction methodologies have some drawbacks, such as low eco-friendly character, high costs and energy demand, long treatment times, low selectivity and reduced extraction yields, as well as degradation of extracted compounds. The gaps found for these methods demonstrate that emergent approaches, such as ohmic heating, pulsed electric fields, ionic liquids, deep eutectic solvents, or high-pressure processing, show potential to overcome the current drawbacks in the release and extraction of added-value compounds from microalgae. These new processing techniques can potentially extract a variety of compounds, making the process more profitable and applicable to large scales. This review provides an overview of the most important and promising factors to consider in the extraction methodologies applied to microalgae. Additionally, it delivers broad knowledge of the present impact of these methods on biomass and its compounds, raising the possibility of applying them in an integrated manner within a biorefinery concept.

Differences in Trapezius Muscle H-Reflex between Asymptomatic Subjects and Symptomatic Shoulder Pain Subjects

In chronic shoulder pain, adaptations in the nervous system such as in motoneuron excitability, could contribute to impairments in scapular muscles, perpetuation and recurrence of pain and reduced improvements during rehabilitation. The present cross-sectional study aims to compare trapezius neural excitability between symptomatic and asymptomatic subjects. In 12 participants with chronic shoulder pain (symptomatic group) and 12 without shoulder pain (asymptomatic group), the H reflex was evoked in all trapezius muscle parts, through C3/4 nerve stimulation, and the M-wave through accessory nerve stimulation. The current intensity to evoke the maximum H reflex, the latency and the maximum peak-to-peak amplitude of both the H reflex and M-wave, as well as the ratio between these two variables, were calculated. The percentage of responses was considered. Overall, M-waves were elicited in most participants, while the H reflex was elicited only in 58-75% or in 42-58% of the asymptomatic and symptomatic participants, respectively. A comparison between groups revealed that the symptomatic group presented a smaller maximum H reflex as a percentage of M-wave from upper trapezius and longer maximal H reflex latency from the lower trapezius (p < 0.05). Subjects with chronic shoulder pain present changes in trapezius H reflex parameters, highlighting the need to consider trapezius neuromuscular control in these individuals' rehabilitation.

Leiomyoma with bizarre nuclei of the scrotum: a rare entity

Leiomyomas of the paratesticular region are a rare entity. A subtype of leiomyomas called bizarre nuclei leiomyoma is even rarer and histologically present some interesting features that are important to recognise to make the differential diagnosis with its malignant counterpart-leiomyosarcoma. We present a case of a man in his 60s, who presented with a painless mass on the right testicle. The clinical diagnosis was of an epidermoid cyst. The mass was excised and a diagnosis of leiomyoma of bizarre nuclei was made.

A Case of Acute Interstitial Nephritis After Two Doses of the BNT162b2 SARS-CoV-2 Vaccine

Background

The development of vaccines to prevent COVID-19 breakouts came with highly positive results but some unexpected side effects. Rare side effects have been seen with the BNT162b2 SARS-CoV 2 vaccine.

Case Presentation

We present the case of a 45-year-old female patient who developed an acute kidney injury needing urgent hemodialysis one week after the second administration of the BNT162b2 SARS-CoV 2 vaccine. She developed a macular rash on her lower limbs and palms as well. A kidney biopsy was performed 10 days after vaccine inoculation, diagnosing acute interstitial nephritis and acute tubular necrosis with cellular casts. The patient was treated with three corticosteroid pulses followed by daily prednisolone. We witnessed clinical improvement 4 days after the initial corticosteroid treatment with progressive recovery of kidney function and hemodialysis withdrawal. After 2 weeks, the patient had recovered her kidney function. Immunophenotyping was performed, diagnosing a hypersensitivity to the vaccine and the polyethylene glycol excipient.

Conclusion

Patients may develop acute reactions to vaccines. In this case, symptoms seem to correlate significantly with its inoculation and, although this case had a favourable outcome, these side effects must be made aware for clinicians and patients.

Patterns of subgingival microbiota in different periodontal phenotypes

OBJECTIVES

To compare the subgingival microbiota of patients with aggressive (AgP) or chronic periodontitis (CP) to healthy (H), non-periodontitis patients as well as to explore their relevant associations to different host genetic variants.

METHODS

Following clinical examination, blood and subgingival plaque sampling of 471 study participants (125 AgP, 121 CP, 225 H), subgingival community analysis was performed by next generation sequencing of the 16S rRNA. Microbial data from 266 participants (75 AgP, 95 CP, 98 H) were available for analysis. SNPs in the IL6, IL6R and FTO gene were selected for genetic marker analyses.

RESULTS

Combined periodontitis patients (AgP + CP), particularly those classified with AgP, exhibited lower alpha- and beta- diversity. Several genera (including Peptostreptococcaceae, Filifactor, Desulfobulbus, Tannerella and Lachnospiracee) and species were over-abundant in combined periodontitis vs. healthy individuals, while other genera such as Prevotella or Dialister were found to be more abundant in healthy cases. The only genus with difference in abundance between AgP and CP was Granulicatella. No associations between IL6, IL6RA and FTO genetic variants and microbial findings were detected.

CONCLUSION

This study suggests that limited microbial differences existed between AgP and CP and challenges the current notion that periodontitis is associated with increased subgingival microbial diversity compared with periodontal health.

CLINICAL SIGNIFICANCE

The findings of this study cast some doubts on the notion that the dysbiosis characteristic of periodontal disease is expressed as increased microbial diversity.

A structured methodology to understand municipal waste generation at local level with minimized effort: development and case study

Understanding municipal solid waste (MSW) generation is a key requirement for designing and optimizing MSW collection services. The present contribution proposes a statistical methodology to identify MSW generation patterns from MSW collection records. The methodology aims at finding statistically distinct household waste generation patterns within the days of the week and within months (seasonal variation). It is based on standard statistical methods (ANOVA complemented by non-parametric tests and cluster analysis). The methodology was applied to a Portuguese neighbourhood to assist in the definition of a waste sampling campaign to support the implementation of a pilot PAYT. The results showed the existence of groups with statistically distinct MSW generation patterns both at the weekly and monthly time scales. Three clusters of days of the week, with high, medium and low generation, and two clusters of months, with high and low generation, were identified. These results allowed to design and implement a customized field waste sampling campaign to estimate the MSW generated at the study site with minimal field work. Instead of implementing a homogeneous sampling campaign (equal number of samples for every day of the week and for every month), the samples were collected from the days and months that showed statistically distinct MSW generation pattern. The systematic procedure can be easily adapted to any given location, thus being a useful tool that combines statistical analysis with field collected data.

Staphylococcus-induced glomerulonephritis: potential role for corticosteroids

Staphylococcus aureus is a troublesome pathogen, responsible for a broad range of clinical manifestations, ranging from benign skin infections to life-threatening conditions such as endocarditis and osteomyelitis. The kidney can be affected through a rapidly progressive glomerulonephritis mediated by an inflammatory reaction against a superantigen deposited in the glomerulus during the infection's course. This glomerulopathy has a poor prognosis, often leading to chronically impaired kidney function, eventually progressing to end-stage renal disease. Treatment rests on antibiotherapy. Despite the inflammatory role in this disease's pathophysiology, most authors discourage a simultaneous immunosuppressive approach given the concomitant infection. However, there are some reports of success after administration of systemic corticosteroids in these patients. We present a 66-year-old man with a staphylococcus-induced glomerulonephritis brought on by a vascular graft infection, with rapidly deteriorating kidney function despite extraction of the infected graft and 3 weeks of antibiotherapy with achievement of infection control. Kidney function improved after the introduction of corticosteroids. This case highlights the potential role of corticosteroids in selected cases of staphylococcus-induced glomerulonephritis, particularly those in which the infection is under control.

Impact of Positive Surgical Margins After Partial Nephrectomy

Background

The impact of positive surgical margins (PSMs) after partial nephrectomy (PN) is controversial.

Objective

To evaluate the risk factors for a PSM and its impact on overall survival.

Design, setting, and participants

This is a retrospective study of 388 patients were submitted to PN between November 2005 and December 2016 in a single centre. Two groups were created: PSM and negative surgical margin (NSM) after PN. A p value of <0.05 was considered significant.

Outcome measurements and statistical analysis

Relationships with outcome were assessed using univariable and multivariable tests and log-rank analysis.

Results and limitations

The PSM rate was 3.8% (N = 16). The mean age at the time of surgery (PSM group: 64.1 ± 11.3 vs NSM group: 61.8 ± 12.8 yr, p =  0.5) and the mean radiological tumour size (4.0 ± 1.5 vs 3.4 ± 1.8 cm, p =  0.2) were similar. Lesion location (p =  0.3), surgical approach (p =  0.4), warm ischaemia time (p =  0.9), and surgery time (p =  0.06) had no association with PSM. However, higher surgeon experience was associated with a lower PSM incidence (2.6% if ≥30 PNs vs 9.6% if <30 PNs; p =  0.02). Higher operative blood loss (p =  0.02), higher-risk tumours (p =  0.03), and larger pathological size (p =  0.05) were associated with an increase in PSM. In the PSM group, recurrence rate (18.7% vs 4.2%, p =  0.007) and secondary total nephrectomy rate (25% vs 4.4%, p <  0.001) were higher. However, overall survival was similar. Multivariate analysis revealed that high-risk tumour (p =  0.05) and low experience (p =  0.03) could predict a PSM. Limitations include retrospective design and reduced follow-up time.

Conclusions

PSMs were mainly associated with high-risk pathological tumour (p =  0.05) and low-volume surgeon experience. Recurrence rate and need for total nephrectomy were higher in that group, but no impact on survival was noticed.

Patient summary

The impact of positive surgical margins (PSMs) after partial nephrectomy is a matter of debate. In this study, we found that PSMs were mainly associated with aggressive disease and low surgeon experience.

Are municipal waste utilities becoming sustainable? A framework to assess and communicate progress

A framework of indicators to assess the progress towards sustainability of municipal waste management utilities is developed. Its purpose is to fulfil the need for assessing the performance of municipal waste (MW) management in a simple but comprehensive way-unlike indicators based on individual aspects such as recycling-and including aspects not well considered before, such as waste prevention. The framework is composed of a set of six single indicators, concerning the three dimensions of sustainability: reduction of effectively landfilled MW and reduction of MW generation (environmental component), balance between expenses and revenues and reduction of costs (economic component), accessibility to separate collection and number of complaints (social component). Each indicator consists of an evaluation of the current status of the variable in contrast to a previous situation, with a positive value in case of improvement or negative in case of decline. Then, the values of the individual indicators are combined to obtain a global result. This approach focuses on dynamic progress towards sustainability, complementing the common static indicators. Contrarily to the existing performance indicator schemes, the proposed framework aims at measuring the progress and not the absolute or relative achievement of a waste management utility. The framework was tested on two Portuguese municipalities, proving to be a straightforward application and reliable in guiding stakeholders. Results for the case study showed good performance on economic sustainability, while environmental and social performance were lower due to a lack of strategies for waste prevention and low source separation, affected by poor accessibility to separate collection.

Granulomatous interstitial nephritis: a rare diagnosis with an overlooked culprit

Granulomatous interstitial nephritis (GIN) is a rare entity identified in <1% of native kidney biopsies. The most frequent aetiology is drug-related, followed by systemic granulomatous conditions. Among drugs implicated in GIN, antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs) are the most frequent. We report the case of a 45-year-old white man referred to a nephrology consult due to chronic kidney disease. He had a history of arterial hypertension with 10 years of evolution, hyperuricaemia, medicated with allopurinol and NSAID abuse for at least 20 years. Urine sediment was blunt, without proteinuria. Renal ultrasound was normal. A kidney biopsy revealed well-defined epithelioid granulomas with glomerular wrinkling and collapse. Infectious and systemic conditions were excluded, favouring the hypothesis of drug-induced GIN, probably related to NSAIDs. Kidney biopsy remains the gold standard for the diagnosis of GIN. Facing a patient with renal failure without significant proteinuria or active sediment, one should look for causes of tubulointerstitial injury.

Benchmarking operational efficiency in waste collection: Discussion of current approaches and possible alternatives

Efficiency assessment and benchmarking are crucial for managing any organization. However, especially from a regulatory perspective, such efficiency assessment and benchmarking must be unbiased from context-specific issues and should provide an absolute rating, rather than a relative one. The current work reviews the approaches used for performance assessment and benchmarking waste collection services, revealing that the majority are biased and are not absolute, and proposes two alternative context-unbiased and absolute performance indicators, the collection capacity use (CCU) and the segregated waste collection efficiency (SWE). The proposed indicators were calculated for 246 utilities operating in Portugal. The utilities were then ranked accordingly, and their position was compared with the position attained using the equivalent performance indicators in the system currently in use by the Portuguese service regulator. The results reveal ranking differences of over 50 positions and illustrate how misleading the results from context-biased and relative metrics can be.

Parvoviral infection with systemic impact and renal consequences

Parvovirus infection is usually asymptomatic especially in immunocompetent adults. When symptomatic it can range from mild to life threatening depending on the patient's age and comorbidities. We report a case of a 40-year-old male patient with parvovirus infection who presented a purpuric rash in distal extremities, acute kidney injury, type II mixed cryoglobulinaemia and hypocomplementaemia. His renal biopsy showed a mesangioproliferative glomerulonephritis with positive immunoreactivity to C3, IgM and C1q. Parvovirus B19 was detected in the biopsy tissue by PCR. He was treated with prednisolone with total remission after 1 month. We discuss the diagnosis of kidney lesion due to parvovirus in an immunocompetent person, which is a very rare condition and its association with the cryoglobulinaemia diagnosis.

Pretransplant Biopsy of Marginal Kidneys: Is It Necessary?

INTRODUCTION

Pretransplant kidney biopsy from marginal donors is used to guide the decision of whether to accept or discard organs for transplantation; however, there is controversy about this procedure, and the need for a pretransplant biopsy is still a debate. We sought to determine if histologic evaluation before implantation of marginal kidneys would influence the outcome.

METHODS

A retrospective observational cohort study of marginal donor transplants at Centro Hospitalar e Universitário de Coimbra was done. From 2009 to 2016, 650 marginal kidney transplants were analyzed. We evaluated long-term graft survival in a cohort of patients who received marginal kidneys. The recipients were divided into 2 groups based on whether a pretransplant donor biopsy was performed. Continuous variables were summarized by mean and standard deviation or median and range, as applicable. Categorical variables were summarized by relative and absolute frequencies. The survival analysis was obtained and plotted using the Kaplan-Meier method and compared with the log-rank test.

RESULTS

The median age of recipients and donors were statistically different between both groups (P < .001), with the donors and the recipients being younger in the group without a pretransplant biopsy. The median cold ischemia time was higher in the biopsy group (P = .01). The survival analysis showed that graft survival didn't differ between the groups (P = .2).

CONCLUSIONS

Selection of kidneys based on histological findings may not influence the graft survival and implies a higher cold ischemia time. More data are necessary to provide insight into which clinical, histologic, and biochemical parameters are necessary for decision making on kidney acceptance.

Mixed extragonadal germ cell tumour of the prostate

Extragonadal germ cell tumours (EGGCTs) originated in prostate are extremely rare, with <20 cases described in the literature. We report a case of a patient with a primary prostatic mixed EGGCT. A 47-year-old man presenting severe low urinary tract symptoms and signs of prostatic enlargement, with no malignancy suspicion, underwent transurethral resection of the prostate. The histopathological evaluation suggested the diagnosis of a retroperitoneal sarcoma. The patient underwent neoadjuvant chemotherapy and then was submitted to radical cystoprostatectomy. Histology revealed a mixed EGGCT of the prostate with yolk sac tumour and seminoma components. No testicular abnormalities were identified on the postoperative scrotal ultrasound. The patient went through four cycles of chemotherapy with bleomycin, etoposide and cisplatin. After 12 months of follow-up, the patient is alive and free of recurrence.

User preferences and water use savings owing to washbasin taps retrofit: a case study of the DECivil building of the University of Aveiro

During the last decades, achieving water efficiency in buildings has increasingly become an important challenge in the scope of sustainability. Water consumption is directly related to individual conduct. Despite the various technological improvements in fixtures and appliances, their performance will be influenced by human preferences and behavior. As a result, the potential for effective water consumption saving is influenced by behavior change as well as water-efficient fixtures and appliances. This work evaluates the impact of user preferences and behavior change on the water-efficient performance of tap aerators in a case study building: the Department of Civil Engineering building of the University of Aveiro, Portugal. Four aerators with different discharge reductions and types were installed in the toilet's washbasins and the user's preferences and behavior change measured through direct and online questionnaires. It was observed that the effective water consumption reduction (15 to 49%) was less than the discharge reduction (30 to 70%), confirming that user factors influence water savings. Water use reductions in the tested range (2.0 to 6.7 l/min) also varied according to gender, with male users using less water than their female counterparts. It was noted that an awareness of sustainability values prevailed amongst the users when confronted with the choice between comfort and water efficiency, although differences were observed in the user preferences regarding the various aerators. When confronted with the information that the lower discharge aerator would contribute to a reduction of about 70% on the water discharge, 25% of the users agreed with its use, even if it resulted in a certain degree of dissatisfaction. In comparison, only 8% of the users completely disagreed with its installation. On average, the water consumption reduction was 46% smaller than the discharge reduction achievable with the aerator alone. This further confirms the user factors inform the degree of water savings that is achievable from water-efficient fittings and fixtures.

Model for the separate collection of packaging waste in Portuguese low-performing recycling regions

Separate collection of packaging waste (glass; plastic/metals; paper/cardboard), is currently a widespread practice throughout Europe. It enables the recovery of good quality recyclable materials. However, separate collection performance are quite heterogeneous, with some countries reaching higher levels than others. In the present work, separate collection of packaging waste has been evaluated in a low-performance recycling region in Portugal in order to investigate which factors are most affecting the performance in bring-bank collection system. The variability of separate collection yields (kg per inhabitant per year) among 42 municipalities was scrutinized for the year 2015 against possible explanatory factors. A total of 14 possible explanatory factors were analysed, falling into two groups: socio-economic/demographic and waste collection service related. Regression models were built in an attempt to evaluate the individual effect of each factor on separate collection yields and predict changes on the collection yields by acting on those factors. The best model obtained is capable to explain 73% of the variation found in the separate collection yields. The model includes the following statistically significant indicators affecting the success of separate collection yields: i) inhabitants per bring-bank; ii) relative accessibility to bring-banks; iii) degree of urbanization; iv) number of school years attended; and v) area. The model presented in this work was developed specifically for the bring-bank system, has an explanatory power and quantifies the impact of each factor on separate collection yields. It can therefore be used as a support tool by local and regional waste management authorities in the definition of future strategies to increase collection of recyclables of good quality and to achieve national and regional targets.

Polyomavirus Nephropathy: Ten-Year Experience

BACKGROUND

Polyomavirus nephropathy (BKVN) is an important cause of chronic allograft dysfunction (CAD). Recipient determinants (male sex, white race, and older age), deceased donation, high-dose immunosuppression, diabetes, delayed graft function (DGF), cytomegalovirus infection, and acute rejection (AR) are risk factors. Reducing immunosuppression is the best strategy in BKVN. The objective of our study was to evaluate CAD progression after therapeutic strategies in BKVN and risk factors for graft loss (GL).

METHODS

Retrospective analysis of 23 biopsies, from patients with CAD and histological evidence of BKVN, conducted over a period of 10 years. Glomerular filtration rate was <30 mL/min in 16 patients at the time of the BKVN diagnosis.

RESULTS

BKVN was histologically diagnosed in 23 recipients (19 men, 4 women). All patients were white, with age of 51.2 ± 12.1 years (6 patients, age >60 years), and 22 had a deceased donor. Diabetes affected 4 patients, DGF occurred in 3, cytomegalovirus infection in 2, and AR in 15. All patients were medicated with calcineurin inhibitors (CNI) (95.7% tacrolimus) and corticoids, and 16 also received an antimetabolite. One year after antimetabolite reduction/discontinuation and/or CNI reduction/switching and/or antiviral agents, graft function was decreased in 11 patients, increased/stabilized in 10, and unknown in 2. GL occurred in 9 patients. Older age (hazard ratio, 1.76; 95% confidence interval, 0.94-3.28) and DGF (hazard ratio, 2.60; 95% confidence interval, 0.54-12.64) were the main risk factors for GL. The lower GFR at the time of the BKVN diagnosis was associated with an increased risk of initiation of dialysis.

CONCLUSIONS

GL occurred in 39.1% of patients with BKVN and DGF; older age and lower GFR at the time of diagnosis were important risk factors. Early diagnosis of BKVN is essential to prevent GL.

Birt-Hogg-Dubé syndrome: awareness is important!

Birt-Hogg-Dubé (BHD) is a rare syndrome of inherited renal cell carcinomas, characterised by cutaneous lesions and pulmonary cysts and pneumothorax in a vast majority of the patients. Awareness of this syndrome is important in order to refer patients for genetic counselling and personalised follow-up as soon as possible. We describe a case of a 30-year-old female referred to our institution due to incidental discovery of solid bilateral renal masses. Renal biopsies were consistent with chromophobe tumour, and bilateral nephrectomy was performed. Gross examination revealed deformed kidneys with 28 brown and solid lesions, size variable between 0.1 and 6 cm, histologically corresponding to renal cell carcinomas, chromophobe type. Genetic test was required that showed a c.573delGAinsT frameshift mutation in heterozigosity at the folliculin gene, consistent with BHD diagnosis.

Idiopathic pulmonary fibrosis in the era of antifibrotic therapy: Searching for new opportunities grounded in evidence

Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal lung disease that up to now has been associated with a poor prognosis. However, the results of the INPULSIS and ASCEND trials and the approval of nintedanib and pirfenidone have marked the beginning of a new era for IPF patients. Questions remain, however. Should these drugs be used earlier? What effect will they have on more severe disease? Will their effects last beyond the trial period? This manuscript is the outcome of a multidisciplinary meeting between pulmonology, radiology, and pathology clinicians on the use of antifibrotic agents in IPF. In our opinion, the existing data show that pirfenidone and nintedanib slow functional decline in early stages of disease. These drugs also appear to result in therapeutic benefits when administered to patients with advanced disease at diagnosis and maintain effective over time. The data also suggest that continuing antifibrotic therapy after disease progression may confer benefits, but more evidence is needed. Early diagnosis and treatment are crucial for reducing functional decline, slowing disease progression, and improving quality of life.

What Can We Do When All Collapses? Fatal Outcome of Collapsing Glomerulopathy and Systemic Lupus Erythematosus With Diffuse Alveolar Hemorrhage: Case Report

INTRODUCTION

Collapsing glomerulopathy (CG) is a rare form of glomerular injury. Although commonly associated with human immunodeficiency virus (HIV) infection, it can occur in association with systemic lupus erythematosus (SLE).

CASE REPORT

We present the case of a 50-year-old man, with chronic kidney disease secondary to focal and segmental glomerulosclerosis, who received a cadaveric kidney transplant in 2007. There were no relevant intercurrences until May 2015, when he presented with nephrotic range proteinuria (± 4 g/d). A graft biopsy was performed and it did not show any significant pathological changes. In September, he developed a full nephrotic syndrome (proteinuria 19 g/d) and a graft biopsy was repeated. CG features were evident with a rich immunofluorescence. Antinuclear antibodies (ANA) and anti-double-stranded DNA (anti-dsDNA) antibodies were positive; the remaining immunologic study was normal. Viral markers for HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) were negative. The patient was treated with corticosteroid pulses and plasmapheresis (seven treatments). A rapid deterioration of kidney function was seen and he became dialysis dependent. He was discharged with a low-dose immunosuppressive treatment. In October, he was hospitalized with diffuse alveolar hemorrhage (DAH). The auto-immune study was repeated, revealing complement consumption and positive titers of ANA and Anti-dsDNA antibodies. Anti-neutrophil cytoplasmic antibodies (ANCAs) and antiglomerular basement membrane antibody (anti-GBM) were negative. Treatment with intravenous corticosteroids, plasmapheresis, and human immunoglobulin was ineffective and the outcome was fatal.

CONCLUSION

This case report highlights the possible association of CG and SLE. To our knowledge, it is the first case of SLE presenting with CG and DAH, with the singularity of occurring in a kidney transplant recipient receiving immunosuppression.

Bronchial schwannoma: a singular lesion as a cause of obstructive pneumonia

Bronchial schwannomas are very rare pulmonary lesions, but its awareness is important to reach correct diagnosis and decide proper intervention. Clinical and radiological characteristics are mainly unspecific and pathological examination usually provides the definite diagnosis. In small lesions, endoscopic approach may be sufficient, but in large lesions associated with organising pneumonia surgical intervention may be required. Prognosis is typically favourable. We describe a case of a woman, aged 66 years, with productive cough and sporadic haemoptysis, dyspnoea, anorexia, excessive sweating and weight loss with 2 months evolution. CT scan showed a soft tissue dense lesion on the left hilum with 3.75 cm with 18-Fludeoxyglucose uptake. Left upper lobectomy was performed. Gross examination revealed a polypoid mass without necrosis, histologically showing cellular dense (Antoni A) and less dense (Antoni B) areas with Verocay bodies, slightly pleomorphic spindle cells, without mitotic activity and positive for S100 protein on immunohistochemistry.

Cast nephropathy: an extremely rare renal presentation of Waldenström's macroglobulinaemia

Renal involvement in Waldenström's macroglobulinaemia (WM) is very unusual when compared to multiple myeloma. We report a case of a patient who developed anuric acute kidney injury secondary to cast nephropathy, dependent on high-flux haemodialysis. Complementary study revealed the presence of blood IgM monoclonal gammopathy and a massive bone marrow lymphoplasmacytic infiltration. There were no osteolytic lesions and no clinical signs/symptoms of hyperviscosity syndrome. The diagnosis of WM was established and a dexamethasone plus cyclophosphamide regime was started, in addition to plasmapheresis. The patient partially recovered renal function allowing haemodialysis and plasmapheresis withdrawal. He remained asymptomatic with a good response to chemotherapy and 12 months after his renal function remained stable. This is a rare clinical case in which WM presented as an IgM cast nephropathy, which in turn is an extremely rare renal presentation of this equally rare haematological disorder.

Pretransplant biopsy in expanded criteria donors: do we really need it?

INTRODUCTION

Renal transplantation is the best treatment for end-stage renal disease, including when using expanded criteria donors (ECD) kidneys. However, these suboptimal kidneys should be evaluated rigorously to meet their usefulness. Opinions differ about the best way to evaluate them.

MATERIALS AND METHODS

We retrospectively reviewed kidneys from ECD harvested by a single academic institution between January 2008 and September 2013. Needle biopsies were performed at the time of the harvest when considered relevant by the transplant team. Two pathologists where responsible for their analysis; the Remuzzi classification has been used in all cases.

RESULTS

We evaluated 560 ECD kidneys. Biopsies were made in 197 (35.2%) organs, 20 of which were considered not usable and 36 good only for double transplantation. Sixty-three kidneys (11.3%) were discarded by the transplant team based on the biopsy result and clinical criteria. Donors who underwent a biopsy were older (P < .001) and had a worse glomerular filtration rate (GFR; P = .001). Comparing donors approved and rejected by the biopsy, the rejected donors were heavier (P = .003) and had a lower GFR (P = .002). Cold ischemia time was longer for the biopsy group (P < .001). Regarding graft function, the biopsy overall score correlated with the transplant outcome in the short and long term. Separately, glomeruli and interstitium scores were correlated with recipient's GFR in the earlier periods (3 months; P = .025 and .037), and the arteries and tubules correlated with GFR in the longer term (at 3 years P = .004 and .010).

CONCLUSION

The decision on the usability of ECD grafts is complex. At our center, we chose a mixed approach based on donor risk. Low-risk ECD do not require biopsy. In more complex situations, especially older donors or those with a lower GFR, prompted a pretransplant biopsy. The biopsy results proved to be useful as they relate to subsequent transplant outcomes, thereby allowing us to exclude grafts whose function would most probably be less than optimal.

Bronchial-pulmonary adenocarcinoma subtyping relates with different molecular pathways

Lung cancer is one of the most common cancers in the world with a high mortality rate. We analyzed 45 surgical samples of the adenocarcinoma, 13 with lymph node metastasis. APC, BCL2, chromogranin A, CK 5/6/18 (LP34), CK20, CK7, cyclin D1, EGFR, ERCC1, HER2, Ki67, LRP, MRP, P53, RB and TTF1 expressions were evaluated by immunohistochemistry (IHC). Higher Ki67, APC, ERCC1 expressions and lower TTF1 expression were identified in advanced stages (IIA and IIIA) of adenocarcinomas, which reflect a more aggressive, less differentiated, possibly a non-TRU adenocarcinoma. Acinar, micropapillary and BA/lepidic adenocarcinoma patterns were the most similar patterns and papillary was the most different pattern followed by solid pattern, according to expression of these markers. Different adenocarcinoma patterns are engaged with different molecular pathways for carcinogenesis, based on the differences of expression. Acinar, BA/lepidic and micropapillary showed higher TTF1 expression (type TRU), and papillary and solid patterns revealed less TTF1 expression, exhibiting a non-TRU/bronchial phenotype. Solid pattern revealed lower HER2 and higher EGFR and ERCC1 (this compared to papillary) expression; papillary higher HER2 and lower ERCC1 expressions; micropapillary higher RB expression; and acinar lower ERCC1 and higher EGFR expressions. Ciclin D1 seems to have more importance in acinar and BA/lepidic patterns than in micropapillary. ERCC1 protein expression in micropapillary, solid and BA/lepidic patterns may indicate DNA repair activation. Inhibition of apoptosis could be explained by BCL2 overexpression, present in all adenocarcinoma patterns. MRP-1 and LRP were overexpressed in all patterns, which may have implications for drug resistance. Further studies are needed to interpret these data regarding to therapy response in advanced staged bronchial-pulmonary carcinomas.

Endoscopic Endonasal Transphenoidal Approach for Pituitary Adenomas: Outcomes of Our Center

Objectives:

Report the results of a consecutive series of patients who underwent an endoscopic endonasal transphenoidal approach (EETA) for resection of a pituitary adenoma.

Methods:

A retrospective review of patients who underwent EETA at our center between 2010 and 2013, in a collaboration between head and neck surgeons and neurosurgeons, and a description of the technique used.

Results:

Nineteen patients underwent an EETA for removal of a pituitary adenoma. Decreased visual acuity or a visual field defect was the presenting complaint in 63.2% patients and headache in 26.3%. Nonfunctioning adenoma was the most frequent (52.6%). Sixteen (84.2%) patients had a macroadenoma (>1 cm) and 3 (15.8%) had a microadenoma (<1 cm). The overall postoperative cerebrospinal fluid leak rate was 5.3%. Other perioperative complications were epistaxis (5.3%), postsurgical hematoma (5.3%) with urgent evacuation, and meningitis (5.3%). The rate of gross total ressection was 70% in patients with nonfunctioning adenomas. The remission rate of secretory adenomas was 75%. Of the patients presenting with visual symptoms, 91.7% improved or normalized.

Conclusions:

EETA is an excellent alternative to other classic approaches for pituitary adenoma, providing similar results with less morbidity. It allows a better panoramic visualization of sellar and parasellar spaces and a better preservation of the normal anatomy and physiology of nasal cavity. This minimally invasive approach is now the standard of care in transasal pituitary surgery. Our outcomes, including remission and complication rates, are comparable with those reported in previous series of endoscopic and microscopic approaches.

Surgical Approaches to Cerebellopontine Angle: A 17-Year Experience of Our Skull Base Team

Objectives:

We give an overview of the current state of cerebellopontine angle (CPA) surgery, based on the recent evidence, and describe our center’s experience in surgical approaches to these lesions.

Methods:

Retrospective review of cases who underwent surgery for CPA lesions at our hospital during the past 17 years (1996-2013), with focus on the description of the currently most used technique-extended retrosigmoid. We also conducted a brief review of the literature on CPA surgery, comparing the different approaches, their indications and complications.

Results:

During this period, 203 patients underwent surgery for CPA. The most frequent indication was vestibular schwannoma (84.7%). Other indications were meningiomas (8.4%), epidermoids (1%), vestibular neurectomies (1.5%), arteriovenous malformations (1%), anterior inferior cerebellar artery–posterior inferior cerebellar artery aneurysms (1%), trigeminal microscopic decompression (0.5%), and other more rare tumors (2%). The most used approach was extended retrosigmoid (71.9%), followed by the translabyrinthine (26.1%) and middle fossa approach (2%). Until 2004, the most used approach was the translabyrinthine; after 2004, the most used was the extended retrosigmoid.

Conclusions:

Currently, the preferred surgical approach used by our team is the extended retrosigmoid, because it allows a complete exposition of sigmoid sinus from the transverse sinus to the jugular bulb, enhances CPA vision, avoids cerebellar retraction, and is a simple way to get a wide route to the CPA. It also allows good functional outcomes (hearing and facial nerve preservation) in most cases. However, indications for approaches depend on the size of the lesion, its location and the quality of preoperative hearing, as well as a necessary familiarity with all approaches.

WITHDRAWN: Bronchial-pulmonary adenocarcinoma subtyping relates with different molecular pathways

This article has been withdrawn for editorial reasons because the journal will be published only in English. In order to avoid duplicated records, this article can be found at http://dx.doi.org/10.1016/j.rppnen.2014.05.006. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

[Impact of early elective tracheotomy in critically ill patients]

INTRODUCTION

Tracheotomy is one of the most frequent surgical procedures performed in critically ill patients hospitalized at intensive care units. The ideal timing for a tracheotomy is still controversial, despite decades of experience.

OBJECTIVE

To determine the impact of performing early tracheotomies in critically ill patients on duration of mechanical ventilation, intensive care unit stay, overall hospital stay, morbidity, and mortality.

METHODS

Retrospective and observational study of cases subjected to elective tracheotomy at one of the intensive care units of this hospital during five consecutive years. The patients were stratified into two groups: early tracheotomy group (tracheotomy performed from day one up to and including day seven of mechanical ventilation) and late tracheotomy group (tracheotomy performed after day seven). The outcomes of the groups were compared.

RESULTS

In the early tracheotomy group, there was a statistically significant reduction in duration of mechanical ventilation (6 days vs. 19 days; p<0.001), duration of intensive care unit stay (10 days vs. 28 days; p=0.001), and incidence of ventilator-associated pneumonia (1 case vs. 44 cases; p=0.001).

CONCLUSION

Early tracheotomy has a significant positive impact on critically ill patients hospitalized at this intensive care unit. These results support the tendency to balance the risk-benefit analysis in favor of early tracheotomy.

Comparison of the inspector and rating protocol uncertainty influence in the condition rating of sewers

Wastewater drainage systems asset management decisions, in particular regarding rehabilitation interventions, are largely dependent on close-circuit television (CCTV) inspection results. However, the results of CCTV inspections are affected by several sources of uncertainty. Within the present communication, the inspector's uncertainty is quantified by comparing periodic inspection reports from three trunk sewers of a Portuguese sewer system. The inspections were carried out by the same experienced inspector using the same equipment. Therefore, the uncertainties from the lack of experience and the difference of the inspector and equipment were ruled out. The protocol uncertainty is also quantified comparing the results obtained with the Water Research Center (WRc) and the National Research Council of Canada (NRC) protocols condition ratings. Both operational and structural condition rating were analysed, but emphasis was given to the later since it dictates the repair and replacement interventions.

Risk assessment of sewer condition using artificial intelligence tools: application to the SANEST sewer system

Operation, maintenance and rehabilitation comprise the main concerns of wastewater infrastructure asset management. Given the nature of the service provided by a wastewater system and the characteristics of the supporting infrastructure, technical issues are relevant to support asset management decisions. In particular, in densely urbanized areas served by large, complex and aging sewer networks, the sustainability of the infrastructures largely depends on the implementation of an efficient asset management system. The efficiency of such a system may be enhanced with technical decision support tools. This paper describes the role of artificial intelligence tools such as artificial neural networks and support vector machines for assisting the planning of operation and maintenance activities of wastewater infrastructures. A case study of the application of this type of tool to the wastewater infrastructures of Sistema de Saneamento da Costa do Estoril is presented.

Role of the extracellular matrix in variations of invasive pathways in lung cancers

Among the most common features of highly invasive tumors, such as lung adenocarcinomas (AD) and squamous cell carcinomas (SqCC), is the massive degradation of the extracellular matrix. The remarkable qualitative and quantitative modifications of hyaluronidases (HAases), hyaluronan synthases (HAS), E-cadherin adhesion molecules, and the transforming growth factor β (TGF-β) may favor invasion, cellular motility, and proliferation. We examined HAase proteins (Hyal), HAS, E-cadherin, and TGF-β profiles in lung AD subtypes and SqCC obtained from smokers and non-smokers. Fifty-six patients, median age 64 years, who underwent lobectomy for AD (N = 31) and SqCC (N = 25) were included in the study. HAS-1, -2 and -3, and Hyal-1 and -3 were significantly more expressed by tumor cells than normal and stroma cells (P < 0.01). When stratified according to histologic types, HAS-3 and Hyal-1 immunoreactivity was significantly increased in tumor cells of AD (P = 0.01) and stroma of SqCC (P = 0.002), respectively. Tobacco history in patients with AD was significantly associated with increased HAS-3 immunoreactivity in tumor cells (P < 0.01). Stroma cells of SqCC from non-smokers presented a significant association with HAS-3 (P < 0.01). Hyal, HAS, E-cadherin, and TGF-β modulate a different tumor-induced invasive pathway in lung AD subgroups and SqCC. HAases in resected AD and SqCC were strongly related to the prognosis. Therefore, our findings suggest that strategies aimed at preventing high HAS-3 and Hyal-1 synthesis, or local responses to low TGF-β and E-cadherin, may have a greater impact in lung cancer prognosis.

Polysomy and amplification of chromosome 7 defined for EGFR gene in squamous cell carcinoma of the lung together with exons 19 and 21 wild type

PURPOSE

The epidermal growth factor receptor (EGFR) is overexpressed in the majority of nonsmall- cell lung cancers (NSCLC) and is a major target specific EGFR tyrosine kinase inhibitors (TKIs) developed and used for the treatment of advanced NSCLC. A number of biological factors are also associated with EGFR-TKIs responsiveness. This study was focused on EGFR somatic mutations and amplifications in squamous cell lung cancer.

MATERIAL AND METHODS

Representative sections of squamous cell carcinoma were selected from 54 surgical specimens from formalin-fixed paraffin-embedded tissues and submitted to TMA construction. Determination of EGFR protein expression was done by immunohistochemistry( IHC) (Zymed, Laboratories). Fluorescence in situ hybridization (FISH) was performed with LSI EGFR/CEP 7 (Vysis; Abbott Molecular, USA). Genomic DNA was extracted from 48 cases and exon 19 was amplified by polymerase chain reaction (PCR) for search deletions and point mutations for exon 21. All cases expressed high weigh cytokeratin and were observed negativity for CK7, CD56 and chromogranin.

RESULTS

EGFR protein overexpression was identified in 49 cases, by the application of Hirsh's scoring system. The chromosome 7 and EGFR gene were analyzed by FISH and scored according to Cappuzzo's method that showed high polysomy in 31 cases and amplification in 7 cases. Deletion in exon 19 of EGFR was detected in 3 cases of 48 samples; the exon 21 of EGFR was expressed in its wild type by RFLP in all cases.

CONCLUSIONS

Detection of common EGFR deletion and mutation showed to be a rare event in Squamous cell carcinoma of the lung. While EGFR mutation is the most effective molecular predictor or sensitivity in patients with advanced NSCLC submitted to EGFR-TKIs treatment, amplification and polysomy is the most effective molecular predictor for EGFR-TKIs responsiveness in squamous cell carcinoma, when validated isolated from the group of NSCLC.

SPAms: A user-friendly software to simulate population genetics data under complex demographic models

Patterns of genetic diversity can be used to reconstruct populations demographic history. Thus, it is crucial to understand the statistical properties of data sets generated under different scenarios. SPAms is a graphical application that allows the simulation of data under a set of demographic models of increasing complexity: (i) population size change (ii) admixture and (iii) population structure (n-island or stepping stone model). SPAms generates data under the infinite site and the stepwise mutation models and computes a set of commonly used statistics. It should thus be a useful tool for both research and teaching purposes.