Genetic modulators of fetal hemoglobin expression and ischemic stroke occurrence in African descendant children with sickle cell anemia

Sickle cell anemia (SCA) is an autosomal recessive monogenic disease with significant clinical variability. Cerebrovascular disease, particularly ischemic stroke, is one of the most severe complications of SCA in children. This study aimed to investigate the influence of genetic variants on the levels of fetal hemoglobin (Hb F) and biochemical parameters related with chronic hemolysis, as well as on ischemic stroke risk, in ninety-one unrelated SCA patients, children of sub-Saharan progenitors. Our results show that a higher Hb F level has an inverse relationship with the occurrence of stroke, since the group of patients who suffered stroke presents a significantly lower mean Hb F level (5.34 ± 4.57% versus 9.36 ± 6.48%; p = 0.024). Furthermore, the co-inheritance of alpha-thalassemia improves the chronic hemolytic pattern, evidenced by a decreased reticulocyte count (8.61 ± 3.58% versus 12.85 ± 4.71%; p < 0.001). In addition, our findings have confirmed the importance of HBG2 and BCL11A loci in the regulation of Hb F expression in sub-Saharan African SCA patients, as rs7482144_A, rs11886868_C, and rs4671393_A alleles are significantly associated with a considerable increase in Hb F levels (p = 0.019, p = 0.026, and p = 0.028, respectively). Concerning KLF1, twelve different variants were identified, two of them novel. Seventy-three patients (80.2%) presented at least one variant in this gene. However, no correlation was observed between the presence of these variants and Hb F level, severity of hemolysis, or stroke occurrence, which is consistent with their in silico-predicted minor functional consequences. Thus, we conclude that the prevalence of functional KLF1 variants in a sub-Saharan African background does not seem to be relevant to SCA clinical modulation.

A Rare Manifestation of Tuberculosis in a Renal Transplant Patient: A Case Report

Cutaneous lesions in the presence of fever in patients undergoing immunosuppressive therapy are a diagnostic challenge and may represent manifestations of multiple diseases, such as fungal infections, nocardiosis, lymphoproliferative diseases, zoonosis, and tuberculosis. The authors report a case of a 66-year-old white man with chronic kidney disease since 2014 (chronic pyelonephritis) who had a renal transplant in the previous 6 months. Induction therapy was performed with thymoglobulin, and his current immunosuppression scheme included tacrolimus, mycophenolate mofetil, and prednisolone. The patient had no history of pulmonary tuberculosis. The patient presented with 2 cutaneous lesions, localized on the back and abdomen, that appeared to be firm, painful, subcutaneous, erythematous nodules with an approximately 5 cm diameter overlying an infected focus and purulent material inside. The patient also had a fever and fatigue. Blood analysis showed pancytopenia with an elevation of inflammatory markers and graft dysfunction. Tissue cultures and skin biopsy with histological analysis were performed. Histopathology of the lesion showed a nonspecific inflammatory infiltrate without granulomas, and acid-fast bacillus staining was negative. Nevertheless, serum QuantiFERON testing was positive. But polymerase chain reaction finally confirmed the presence of Mycobacterium tuberculosis, which confirmed the diagnosis of cutaneous tuberculosis. A chest computed tomography scan showed a lung pattern of miliary tuberculosis. The patient was treated with multidrug tuberculosis therapy, resulting in lesion clearance after 3 weeks. Tuberculosis is a serious infection, especially in high-risk patients, such as those in an immunocompromised state. The incidence of cutaneous tuberculosis is rare, but it should be considered in patients presenting with atypical skin lesions suggestive of an underlying infectious etiology.

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.

CLA-supplemented diet accelerates experimental colorectal cancer by inducing TGF-β-producing macrophages and T cells

Conjugated linoleic acid (CLA) has been shown to activate the nuclear receptor PPAR-γ and modulate metabolic and immune functions. Despite the worldwide use of CLA dietary supplementation, strong scientific evidence for its proposed beneficial actions are missing. We found that CLA-supplemented diet reduced mucosal damage and inflammatory infiltrate in the dextran sodium sulfate (DSS)-induced colitis model. Conditional deletion of PPAR-γ in macrophages from mice supplemented with CLA diet resulted in loss of this protective effect of CLA, suggesting a PPAR-γ-dependent mechanism mediated by macrophages. However, CLA supplementation significantly worsened colorectal tumor formation induced by azoxymethane and DSS by inducing macrophage and T-cell-producing TGF-β via PPAR-γ activation. Accordingly, either macrophage-specific deletion of PPAR-γ or in vivo neutralization of latency-associated peptide (LAP, a membrane-bound TGF-β)-expressing cells abrogated the protumorigenic effect of CLA. Thus, the anti-inflammatory properties of CLA are associated with prevention of colitis but also with development of colorectal cancer.

The two functionally distinct amino termini of chicken c-ets-1 products arise from alternative promoter usage

The chicken c-ets-1 locus gives rise to two distinct transcription factors differing by structurally and functionally unrelated N-termini. p54c-ets-1 shows a striking phylogenetic conservation from Xenopus to humans, while p68c-ets-1, the cellular counterpart of the E26-derived v-ets oncogene, is apparently restricted to avian and reptilian species. In the chick embryo, both mRNAs are expressed in a wide array of tissues of mesodermal origin; however, in the embryo and after hatching, p68c-ets-1 is excluded from lymphoid cells where p54c-ets-1 accumulates. In this report, we define the basis of the differential expression of the chicken c-ets-1 products to assess their different potentials as transcription factors. We demonstrate that the two distinct N-termini arise from alternative promoter usage within the chicken c-ets-1 locus. Examination of both promoters reveals that transcription initiates from multiple sites, consistent with the absence of TATA and CAAT elements. Of these two regulatory regions, only the one that initiates the p54c-ets-1 mRNA synthesis is of the G + C-rich type, and its organization is conserved in humans. The avian-specific p68c-ets-1 promoter activity was enhanced by its own product. In addition, we identify numerous potential binding sites for lymphoid-specific transcription factors that might contribute to a tight repressor effect in lymphoid tissues.

The cytosolic sensor STING is required for intestinal homeostasis and control of inflammation

STING (stimulator of interferon genes) is a cytosolic sensor for cyclic dinucleotides and also an adaptor molecule for intracellular DNA receptors. Although STING has important functions in the host defense against pathogens and in autoimmune diseases, its physiological relevance in intestinal homeostasis is largely unknown. In this study, we show that STING^-/- mice presented defective protective mechanisms of intestinal mucosa, including decreased number of goblet cells, diminished mucus production, and lower levels of secretory IgA, when compared with wild-type (WT) mice. Fecal content and microbiota DNA could activate STING, indicating a role of this molecule in gut. Microbiota composition was altered in STING^-/- mice toward a more inflammatory profile, evidencing a reduction in the Allobacolum and Bifidobacterium groups along with increase in Disulfovibrio bacteria. Absence of STING lead to decrease in induced intraepithelial lymphocytes (IEL) and to increase in group 1 innate lymphoid cell (ILC1) as well as ILC3 frequencies and decrease in ILC2 in the colon. Development and function of Foxp3+ and LAP+ regulatory T cells were also compromised in STING^-/- mice. Moreover, these mice were highly susceptible to dextran sodium sulfate-induced colitis, T-cell-induced colitis, and enteric Salmonella typhimurium infection when compared with WT animals. Therefore, our results identify an important role of STING in maintaining gut homeostasis and also a protective effect in controlling gut inflammation.

Harnessing extracellular vesicles to direct endochondral repair of large bone defects

Large bone defects remain a tremendous clinical challenge. There is growing evidence in support of treatment strategies that direct defect repair through an endochondral route, involving a cartilage intermediate. While culture-expanded stem/progenitor cells are being evaluated for this purpose, these cells would compete with endogenous repair cells for limited oxygen and nutrients within ischaemic defects. Alternatively, it may be possible to employ extracellular vesicles (EVs) secreted by culture-expanded cells for overcoming key bottlenecks to endochondral repair, such as defect vascularization, chondrogenesis, and osseous remodelling. While mesenchymal stromal/stem cells are a promising source of therapeutic EVs, other donor cells should also be considered. The efficacy of an EV-based therapeutic will likely depend on the design of companion scaffolds for controlled delivery to specific target cells. Ultimately, the knowledge gained from studies of EVs could one day inform the long-term development of synthetic, engineered nanovesicles. In the meantime, EVs harnessed from in vitro cell culture have near-term promise for use in bone regenerative medicine. This narrative review presents a rationale for using EVs to improve the repair of large bone defects, highlights promising cell sources and likely therapeutic targets for directing repair through an endochondral pathway, and discusses current barriers to clinical translation. Cite this article: E. Ferreira, R. M. Porter. Harnessing extracellular vesicles to direct endochondral repair of large bone defects. Bone Joint Res 2018;7:263-273. DOI: 10.1302/2046-3758.74.BJR-2018-0006.

Tuberculosis among the homeless: should we change the strategy?

BACKGROUND

Tuberculosis (TB) is a major concern among high-risk populations such as the homeless.

OBJECTIVES

To evaluate TB incidence and treatment outcomes among homeless patients in Portugal and to identify predictors of unsuccessful TB treatment outcomes among the homeless.

DESIGN

This was a retrospective cohort study of all TB patients notified in Portugal from 2008 to 2014. Characteristics of homeless TB patients were assessed and predictors of unsuccessful TB treatment were determined using logistic regression.

RESULTS

TB incidence among the homeless was 122/100,000 homeless persons and was positively correlated with TB incidence among non-homeless persons. Homeless TB patients had a higher prevalence of alcohol and/or drug use, human immunodeficiency virus (HIV) co-infection, cavitary TB and smear positivity. The rate of unsuccessful treatment outcomes among the homeless was 28.6%, and was significantly associated with increased age, injection drug use (IDU) and HIV co-infection.

CONCLUSION

TB incidence among homeless persons was five times that among the non-homeless, and higher in regions with greater TB incidence among non-homeless persons. The successful treatment outcome rate was lower. Predictors of unsuccessful treatment were age, IDU and HIV co-infection. Integrated TB programmes targeting homeless and non-homeless patients, with measures targeting specific characteristics, may contribute to TB elimination in Portugal.

Ultrasound Biomicroscopy Findings in Peripheral Vitreoretinal Toxocariasis

Purpose

To describe the morphologic alterations in ultrasound biomicroscopy (UBM) present in peripheral vitreoretinal toxocariasis.

METHODS

An observational prospective study of case series. Fifteen eyes of 15 patients with clinical and laboratory diagnosis of peripheral vitreoretinal toxocariasis were enrolled. The patients were submitted to UBM examination of the region corresponding to the pars plana of the affected eye.

Results

The most common morphologic alterations found by UBM in patients with peripheral vitreoretinal toxocariasis were as follows: vitreal membranes (13 cases), toxocara granuloma (11 cases), and pseudocysts (8 cases). Other less frequent findings were thickening of the ciliary body (6 cases), cystic formation (2 cases), peripheral retinal detachment (2 cases), rectification of the iris root (1 case), and posterior synechiae (1 case).

CONCLUSIONS

UBM allows detection of well-defined morphologic alterations associated with peripheral vitreoretinal toxocariasis, being useful to reinforce the clinical diagnosis

Long-Term Outcomes of Kidney Transplantation From Expanded-Criteria Deceased Donors: A Single-Center Experience

BACKGROUND

Organ shortage has prompted the use of expanded-criteria donors (ECDs). Our objective was to compare long-term outcomes of kidney transplants from ECDs with those from concurrent standard-criteria donors (SCDs). In addition, we evaluated variables associated with graft survival in both groups.

METHODS

We retrospectively reviewed all 617 deceased-donor kidney transplantations performed from 2005 to 2009 in our department. The population was divided according to donor status into ECD or SCD. Patients were followed until 5 years after transplantation, death, graft failure, or loss to follow-up.

RESULTS

We transplanted 150 deceased-donor kidneys from ECDs and 467 from SCDs. ECD were older, more frequently women, had a lower pre-retrieval glomerular filtration rate, and more frequently died due to cerebrovascular accident. ECD recipients were older, presented a lower proportion of black race, more frequently were on hemodialysis, and presented a higher rate of first kidney transplants. Mean glomerular filtration rate was consistently lower in the ECD group. Patient and graft survivals were lower in the ECD group, but statistical significance was present only in graft survival censored for death with a functioning graft at 3 years and graft survival noncensored for death with a functioning graft at 5 years. Younger recipient ages, longer time on dialysis, acute rejection episodes, and glomerular filtration rate at 1 year after transplantation were independent risk factors for lower graft survival.

CONCLUSIONS

Transplantation with the use of ECD kidneys provide quite satisfactory patient and graft survival rates despite their poorer long-term outcomes.

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.

Álcool para controle de cascudinho em cama de frangos de corte

O Brasil é o maior exportador e o terceiro maior produtor mundial de carne de frango, sendo a atividade geradora de grande quantidade de resíduo chamado de cama de frango. Este resíduo gera condições favoráveis para o desenvolvimento do besouro Alphitobius diaperinus (Panzer) (Coleoptera: Tenebrionidae), conhecido como cascudinho, sendo esse considerado a principal praga da avicultura, e afeta a produção avícola em todo o mundo. Seu controle é considerado difícil, sendo comumente empregadas substâncias piretróides e organofosforadas, apesar de não eficientes. Na busca pelo controle alternativo do inseto, vários métodos aditivos e inseticidas naturais vêm sendo testados. Contudo, na prática entomológica, substâncias com elevada pressão de vapor a fim de se produzir gases tóxicos são utilizadas para fixação dos insetos. Assim, em outubro de 2015, avaliou-se o álcool etílico PA para o controle de A. diaperinus em cama de frango. As unidades experimentais foram representadas por garrafas plásticas tipo “pet” cortadas, onde foram colocadas 100g de cama de frango, acrescidos de 20 insetos adultos e 135 larvas, cada uma. Os tratamentos foram constituídos pela aplicação de álcool no volume de 1, 2,5, 5, 7,5 e 10 mL e sua diluição com água (1:1) sendo aplicado igual volume. Simularam-se dois ambientes, sendo um aberto (com telas contendo os insetos) e um fechado (recipiente amostral fechado com a porção previamente cortada da garrafa “pet”). Nas parcelas foram mantidas a temperatura de 28,5 ± 2 ºC e UR de 51,0 ± 2%, feito seis repetições por tratamento. A quantidade de 2,5 mL (2,5% v/p) de álcool gerou 100% de mortalidade de adultos e larvas nas amostras fechadas, sendo necessário o dobro do volume no sistema aberto. Para a diluição álcool-água (1:1) o controle de 100% foi obtido com o dobro das quantidades relatadas anteriormente em relação aos respectivos tratamentos.

Risk factors that influence sexual and reproductive health in Portuguese university students

BACKGROUND

University students have unprotected sex and associate alcohol and/or drugs with sexual practices. These behaviours are risk factors for influencing sexual and reproductive health that can be targeted by nursing interventions.

AIM

The aim of this study was to determine the risk and protective factors influencing sexual and reproductive risk-taking behaviours in university students.

METHODS

We conducted a cross-sectional and correlational study in a sample of 1946 students. Data were collected using a self-report questionnaire on the individual, environmental, cognitive and psychosocial factors related to knowledge of sexually transmitted infections, attitude for sexual and reproductive health, subjective norms, Condom Use Self-Efficacy and Sexual Sensation Seeking scales.

RESULTS

Older male students were at higher risk for all risk behaviours studied. Students involved in committed relationships were at risk because of decreased condom use. Individuals who placed high importance on sexual sensation seeking were at increased risk. The higher the importance students placed on peers' opinion, the more protective their behaviours were.

CONCLUSION

The results of this study showed that university students are exposed to sexual risks. Individual, cognitive and psychosocial factors influence the risk-taking behaviours.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

The findings of this study should be further incorporated into health care with nurses' leadership, adapting healthcare services to the specific needs of this population and promoting educational programmes.

Polymorphism of mitochondrial DNA in the Brazilian Canindé goat breed

The success of the geographical distribution of goat populations around the world is a consequence of the adaptive potential of these breeds. Several relevant traits to the success of the species in colonizing different ecosystems (and use by man) evolved before domestication. These features were relevant for the selection of different breeds. Each breed represents a genetic heritage that may be unique and essential for maintaining the species. The objective of this study was to catalog the mtDNA haplotypes of the Brazilian autochthonous Canindé goat breed and to characterize the genetic diversity observed in subpopulations by sequencing a 481-bp fragment corresponding to the first portion of the control region in 178 individuals from 10 herds, sampled in six Brazilian states. The global population displays a total of 29 haplotypes and 56 polymorphic sites. About one-third (10) of the haplotypes were common to all subpopulations while the remaining (19) were exclusive to a single subpopulation. The population exhibited high average haplotype diversity (0.82), with maximum and minimum values of 0.90 and 0.56 in individual subpopulations, respectively. In contrast, nucleotide diversity was 0.014, with maximum and minimum values of 0.020 and 0.004, respectively. The spatial analysis of molecular variance did not detect structure within the Canindé goat breed, and analysis of molecular variance revealed that 88.4% of the variation observed in the population was due to differences among individuals in the same subpopulation. Only 11.4% of the genetic variation referred to differences among subpopulations. About one-third (33.1%) of the individuals within population shared the same haplotype, which may be due not only to the breed developing from a small number of matrilines. The Brazilian autochthonous Canindé breed was classified as haplogroup A, a haplotype predominant in the Europe region.

Demographic history, current expansion and future management challenges of wild boar populations in the Balkans and Europe

Wild boar (Sus scrofa), one of the most widespread wildlife species, has entered a stage of continuous growth in Europe, and could even be considered a pest species. We analysed microsatellite variability in 723 wild boars from across Europe, including the northern Dinaric Balkans. Our aims were: (1) to define the population structure of wild boars in the Balkans and its relation with other European populations; (2) to estimate effective populations sizes, levels of intra- and inter-population diversity, inbreeding migration and gene flow patterns; (3) to test subpopulations for bottlenecks; (4) to interpret these results in light of current knowledge about the demographic history of wild boars in Europe; and (5) to discuss the relevance of these findings for management and conservation. Strong population structuring was observed and 14 subpopulations were revealed. High genetic diversity was found, and besides the well-known identity of the Italian populations of Sardinia and Castelporziano, we bring new insights into other potential relevant, refugial populations such as Littoral Slovenia, South Portugal, North-western Iberia and an entire cluster in the Balkans. There was evidence of gene flow going from these refugial subpopulations towards less peripheral and more admixed subpopulations. Recent population bottlenecks and expansions were detected, mostly in the peninsular refuge subpopulations. The results are consistent with the fluctuations of wild boar numbers in Europe since the beginning of the twentieth century. These results should be taken into account in future conservation and management plans for wild boar populations in Europe.

Cytomegalic hepatitis in a patient receiving omalizumab

Cytomegalovirus is a double stranded DNA virus that can be present in nearly all organs and body fluids. The primary infection is usually asymptomatic in the immunocompetent host and it is common among adolescents and young adults. The symptomatic form appears, in the majority of cases, as a mononucleosis syndrome with full recovery without specific treatment. We report a case of a 25 years old woman who presented with hepatitis due to CMV infection and history of omalizumab administration one month earlier. This recombinant monoclonal antibody is used to control refractory asthma and chronic spontaneous urticarial as it inhibits human IgE. Despite that, the long course of the disease lead us to initiate treatment with valganciclovir. The improvement after that was rapid and complete.