Efficacy and safety of fluoroless ureteroscopy and retrograde intrarenal surgery for the treatment of urolithiasis: A comparative study

INTRODUCTION

Ureteroscopy (URS) and retrograde intrarenal surgery (RIRS) are traditionally guided by fluoroscopy, but the risks of exposure to ionizing radiation may present a matter of concern for patients and urologists. The aim of this study was to evaluate the efficacy and safety of fluoroless URS and RIRS compared with conventional fluoroscopy-guided procedures for the treatment of ureteral and renal stones.

MATERIAL AND METHODS

Patients treated with URS or RIRS for urolithiasis between August 2018 and December 2019 were retrospectively evaluated and grouped according to the use of fluoroscopy. Data was collected from individual patient records. The main outcomes were stone-free rate (SFR) and complications, compared between the fluoroscopy and fluoroless groups. A subgroup analysis by type of procedure (URS and RIRS) and a multivariate analysis to identify predictors of residual stones were conducted.

RESULTS

A total of 231 patients met the inclusion criteria: 120 (51.9%) in the conventional fluoroscopy group and 111 (48.1%) in the fluoroless group. No significant differences were found between groups regarding SFR (82.5% vs 90.1%, p=.127) or postoperative complication rate (35.0% vs 31.5%, p=.675). In the subgroup analysis these variables did not present significant differences, regardless of the procedure considered. In the multivariate analysis the fluoroless technique was not an independent predictor of residual lithiasis (OR 0.991; 95% IC 0.407-2.411; p=.983), when adjusted for procedure type, stone size and stone number.

CONCLUSION

URS and RIRS can be done without fluoroscopic guidance in selected cases, without affecting the efficacy or safety of the procedure.

Screening for myeloid mutations in patients with myelodysplastic syndromes and AML with myelodysplasia-related changes

INTRODUCTION

One of the most critical complications in myelodysplastic syndromes (MDS) is the progression to acute myeloid leukemia (AML). The dynamics of clonal evolution in MDS and how acquired mutations can be used as biomarkers to track disease progression remains under investigation.

OBJECTIVE AND METHOD

Herein, we investigated the frequency of common myeloid clonal mutations (FLT3, NPM1, JAK2, IDH1 and IDH2) in 88 patients with MDS and 35 AML patients with myelodysplasia-related changes, followed at a single reference center in northeastern Brazil.

RESULTS

Overall, 9/88 (10%) of the MDS patients and 9/35 (26%) of the secondary AML patients had at least one mutation. While the JAK2 V617F mutation was the most frequent in the MDS patients, the FLT3, NPM1, IDH1 and IDH2 mutations were more frequently found in the secondary AML group. Furthermore, there was a higher frequency of FLT3, NPM1, IDH1 and IDH2 mutations in MDS patients classified as high-risk subtypes than in those of lower risk.

CONCLUSION

Despite the limited sample size, our data suggest that mutations in FLT3, NPM1, IDH1 and IDH2 genes could be potential biomarkers to detect early disease progression in MDS.

Endothelial Nitric Oxide Synthase (eNOS) Gene Polymorphisms and Markers of Hemolysis, Inflammation and Endothelial Dysfunction in Brazilian Sickle Cell Anemia Patients

The impaired bioavailability of endogenous nitric oxide (NO) in sickle cell anemia (SCA) may be influenced by polymorphisms in the endothelial nitric oxide synthase gene (eNOS). We compared allelic/genotypic frequencies of the eNOS polymorphisms T-786C, VNTR4a/b and G894T between 89 adult SCA patients and 100 healthy controls, and investigated the relationship between these SNPs and markers of hemolysis [lactate dehydrogenase (LDH), indirect bilirubin (IB) and reticulocyte counts], inflammation [interleukins IL-1β, IL-6, IL-8, Tumor Necrosis Factor (TNF-α) and C-reactive protein (CRP)] and endothelial dysfunction (ED) [soluble vascular cell adhesion molecule-1 (sVCAM-1), soluble intercellular adhesion molecule-1 (sICAM-1), soluble L-selectin (sL-selectin), von Willebrand Factor (vWF) antigen and D-dimers] in the patients. The frequencies of the mutant -786C allele and -786C/C genotype were significantly higher in patients (p = 0.02 and p = 0.04, respectively) but not significantly correlated with the markers. For VNTR4a/b and G894T, the allelic/genotypic frequencies did not statistically differ between patient and control groups. Patients carrying the 4a allele and those with the 894G/G genotype showed a significant decrease in IB (p = 0.02 and p = 0.04, respectively), and only patients with the 4a allele exhibited reduced IL-1β (p = 0.01). The correlation profiles between markers of inflammation and ED significantly differed between patients carrying the mutant alleles and those with wild-type genotypes. This appears to be the first report on the relationship between eNOS gene polymorphisms and markers of hemolysis, inflammation and ED in Brazilian SCA patients. Our results indicate that the SNPs analyzed may influence the phenotypic variability of these patients.

Genetic comparison of sickle cell anaemia cohorts from Brazil and the United States reveals high levels of divergence

Genetic analysis of admixed populations raises special concerns with regard to study design and data processing, particularly to avoid population stratification biases. The point mutation responsible for sickle cell anaemia codes for a variant hemoglobin, sickle hemoglobin or HbS, whose presence drives the pathophysiology of disease. Here we propose to explore ancestry and population structure in a genome-wide study with particular emphasis on chromosome 11 in two SCA admixed cohorts obtained from urban populations of Brazil (Pernambuco and São Paulo) and the United States (Pennsylvania). Ancestry inference showed different proportions of European, African and American backgrounds in the composition of our samples. Brazilians were more admixed, had a lower African background (43% vs. 78% on the genomic level and 44% vs. 76% on chromosome 11) and presented a signature of positive selection and Iberian introgression in the HbS region, driving a high differentiation of this locus between the two cohorts. The genetic structures of the SCA cohorts from Brazil and US differ considerably on the genome-wide, chromosome 11 and HbS mutation locus levels.

Adverse clinical and obstetric outcomes among pregnant women with different sickle cell disease genotypes

OBJECTIVE

To compare clinical and obstetric adverse events among pregnant women with sickle cell disease (SCD) according to genotype.

METHODS

The present cross-sectional study enrolled women aged 15-49 years with SCD and prior pregnancy attending a hematology center in Recife, Brazil, between September 1, 2015, and April 30, 2016. Associations between sickle cell genotype (HbSS, HbSC, Sβ-thalassemia) and adverse events were evaluated.

RESULTS

Overall, 89 women were included; 74 (83%) had HbSS genotype, 8 (9%) had HbSC genotype, and 7 (8%) had Sβ-thalassemia genotype. Fifty-three (60%) self-reported being of mixed race, and 27 (30%) self-reported they were black. Blood transfusion was observed more frequently among women with HbSS than among those with HbSC genotype (P=0.007). Postpartum adverse events were more frequent in the Sβ-thalassemia than in the HbSS group (P=0.030). Fetal intrauterine death occurred only among women with the HbSS genotype (11 [15%]). In the HbSS group, there was a higher frequency of blood transfusion (P=0.004) and lower rate of spontaneous abortion (P=0.001) among women with six or more consultations.

CONCLUSION

The HbSS genotype was associated with a higher frequency of blood transfusion. Sβ-thalassemia was associated with a higher frequency of postpartum adverse events. Prenatal care was associated with a lower rate of spontaneous abortion in the HbSS group.

Reduced rate of sickle-related complications in Brazilian patients carrying HbF-promoting alleles at the BCL11A and HMIP-2 loci

The presence of high levels of fetal haemoglobin (HbF) provides well-validated clinical benefits to patients with sickle cell anaemia (SCA). Nevertheless it has been difficult to show clear direct effects of the known genetic HbF modifiers, such as the enhancer polymorphisms for haematopoietic transcription factors BCL11A and MYB, on SCA severity. Investigating SCA patients from Brazil, with a high degree of European genetic admixture, we have detected strong effects of these variants on HbF levels. Critically, we have shown, for the first time, that the presence of such HbF-promoting variants leads to a reduced rate of SCA complications, especially stroke.

HLA-A, HLA-B and HLA-DRB1 haplotype frequencies in Piauí's volunteer bone marrow donors enrolled at the Brazilian registry

This study aimed to report the antigen and haplotype frequencies (HFs) of volunteer bone marrow donors (VBMDs) from the state of Piauí who were enrolled in the National Volunteer Bone Marrow Donor Registry (REDOME). The research subjects were 21,943 volunteer bone marrow donors, predominantly young adult women (53.3%). The most frequent allelic group was HLA-A2, followed by -DRB1*13, -DRB1*04, -DRB1*07, -B*15, -B∗35, -B*44, -A*24 and -A*03. Of the 2,704 haplotypes observed, the three most frequent haplotypes were A*29 B*44 DRB1*07 (1.45%), A*01 B*08 DRB1*03 (1.4%) and A*03 B*07 DRB1*15 (0.92%). These three haplotypes were in linkage disequilibrium. PCA showed that 98% of the VBMDs have HLA allele frequencies that are very similar to those from Teresina, the capital city of Piauí. According to the PCA results, these municipalities are distributed with a close proximity to Teresina, which in turn has a close genetic proximity to the Hispanic ethnicity, intermediate proximity to Caucasians and Africans and a distant kinship to Amerindians. The hierarchical proximity of the population of Piauí to the Portuguese and Hispanic populations to shows the strong influence of the latter on the former.

Association of variant alleles of MBL2 gene with vasoocclusive crisis in children with sickle cell anemia

Vasoocclusive crisis (VOC) is the major cause of morbidity and mortality in sickle cell anemia (SCA), which is caused by the occlusion of blood vessels, followed by ischemia or infarct, resulting in progressive damage to organs. However, this clinical manifestation is variable, indicating that this process could be influenced by modifier genes. The gene MBL2 which codes for mannose-binding lectin (MBL) has been associated with modifications in the progression of infectious and inflammatory vascular diseases. The aim of this study was to determine the frequency of the polymorphisms of exon 1 (alleles A/O) and promoter region -221 (alleles Y/X) of MBL2 in children with SCA and to verify their association with VOC. The determination of the polymorphism of exon 1 and the promoter region of MBL2 was performed by SYBR GREEN((R)) and Taqman((R)) system, respectively. In the patients with SCA, the frequency of the genotype related to high production of MBL was 0.46 (YA/YA) and for intermediate/low production was 0.54 (YA/XA, XA/XA, YA/YO, XA/YO, YO/YO). The frequency of the genotypes and haplotypes of MBL2 in patients with SCA did not differ from control individuals. The populations were in Hardy-Weinberg equilibrium. The patients were divided into two groups. The groups were separated by the frequency of VOC, which was defined by the total of VOC episodes divided by the age of the children at the end of this study. Since, we choose a cut point in FVOC <1 (n=48) (which we considered of mild presentation of disease) and FVOC >or=1 (n=39) (higher severity). In children with SCA, the frequency of the genotypes of MBL2 of intermediate/low expression for MBL was associated with FVOC >or=1 (p=0.0188 OR=3.15 CI=1.19-8.50). The results suggest that MBL2 polymorphism at promoter and first exon of MBL2 associated with low serum levels and structural alterations of MBL could modify the phenotype of the child with SCA related to VOC.

Brazilian IgY-Bothrops antivenom: Studies on the development of a process in chicken egg yolk

The aims of this study were to devise a process for raising antibodies against Brazilian Bothrops venom in chicken egg yolks, to determine the best delipidation method for the preparation of the aqueous extract and to define the best purification conditions for IgY bothropic antivenom produced in eggs from hens immunized with Brazilian standard bothropic antigen. A group of nine Single Comb White Leghorn laying hens were immunized with venom from five different species of pit vipers of the genus Bothrops. The immunization process was carried out in three cycles, each performed six weeks apart. For extraction, the egg yolk was diluted 1:10 in distilled water, adjusted to a pH of 5.0, subjected to a freeze-thaw cycle, centrifuged and filtered before being precipitated with 20%(w/v) ammonium sulfate salt. This methodology retrieved 2.57 mg of IgY/ml of yolk from eggs. This preparation yielded antibodies capable of neutralizing lethal toxic activity of the pool of Bothrops sp venoms from five species, with an effective dose (ED50) of 365 microL/2 LD50 and, 1.0 mL of IgY antivenom neutralized 0.154 mg of venom.

A Different Molecular Pattern of β‐Thalassemia Mutations in Northeast Brazil

The main hereditary hemoglobin (Hb) disorders of clinical significance in Brazil are sickle cell disease and beta-thalassemia (thal). The sickle gene was introduced by the slave trade, whereas beta-thal was introduced later, due to a massive immigration (mostly by Italians) between 1870 and 1953, mainly to the southeast region of Brazil. Molecular studies performed in the southeast of the country showed a marked prevalence of the nonsense mutation at codon 39 (C --> T) (47-54%), leading to severe forms of beta0-thal. However, the northeast region of the country has a different demographic history, characterized by the absence of the massive Italian immigration. Owing to this and since the majority of cases of beta-thal in Pernambuco, a state located in the northeast of the country, have mild or intermediate clinical and laboratory features, we would predict a different spectrum of beta-thal mutations in this region. We examined 60 unrelated patients (86 beta-thal chromosomes) under regular clinical follow-up in Pernambuco: 6 were regularly transfused beta-thal major subjects, 20 had beta-thal intermedia, 20 had Hb S/beta-thal and 14 were beta-thal trait individuals. The following mutations were found: IVS-I-6 (T --> C) 62.8%, IVS-I-1 (G -->A) 15.1%, IVS-I-5 (G --> C) 9.3%, IVS-I-110 (G --> A) 8.2%, codon 39 (C --> T) 3.5%, and codon 30 (AGG --> AGC) 1.1%. These data show different patterns of beta-thal mutations in two regions of Brazil, demonstrating a thus far unrevealed heterogeneity of the disease in the country.

Two new unstable haemoglobins leading to chronic haemolytic anaemia: Hb Caruaru [beta122 (GH5) Phe-->Ser], a probable case of germ line mutation, and Hb Olinda [beta22 (B4) - 25 (B7)], a deletion of a 12 base-pair sequence

We describe here two new unstable beta-globin variants, Hb Caruaru and Hb Olinda, found in northeastern Brazil, both associated with chronic haemolytic anaemia. Haemoglobin Caruaru is caused by a single base substitution at codon 122 (TTC-->TCC), possibly originating from the germ line cells of the patient's grandmother. Haemoglobin Olinda is also a de novo mutation, caused by a 12 bp deletion leading to the removal of the 22nd to the 25th residues of the normal beta-globin chain.

Molecular variations linked to the grouping of beta- and alpha-globin genes in neonatal patients with sickle cell disease in the State of Pernambuco, Brazil

Various factors have been described as phenotypic modulators of sickle cell disease, such as levels of fetal hemoglobin (Hb F), presence of alpha-thalassemia (thal), and haplotypes of the beta-globin genes. In order to characterize and determine the frequency of the betaS and betaC mutations and the prevalence of -alpha3.7-thal, 74 patients with sickle cell disease detected during neonatal screening in the State of Pernambuco, Brazil, were studied. The haplotypes of the beta gene and -alpha3.7-thal were determined using polymerase chain reaction (PCR), and specific restriction endonucleases were used to establish the polymorphic sites of the haplotypes. The results showed the high frequency of the Central African Republic (CAR) or Bantu haplotype in the State of Pernambuco, Brazil. The low frequency of the Benin haplotype recorded in this study, in comparison with other states in northeast Brazil, suggests the diversity of origins of Afro-Brazilians in this region.

Anatomical description of the facet joint innervation and its implication in the treatment of recurrent back pain

AIM

Many techniques are used in the back pain treatment, standing out the facet denervation as a therapeutic option for pain that originates in the facet joints. It's known that the facet joint is an abundant area of nocireceptor innervation, although the distribution and the location of the involved branches have not being well demonstrated. A good comprehension about the affected innervation is very important to get an effective treatment. Purpose of study was to describe innervation of the lumbar facet joints, potentially used in the diagnosis and treatment of painful pictures of the lumbar region by facet syndrome.

STUDY DESIGN

anatomical study of nerve roots distribution of the facet joint 3 human corpses. The determination of the neurotomy s point was carried out by direct visualization and the radiological study in human parts.

METHODS

Three anatomical pieces of the human lumbar spine were dissected. In those 3 pieces, the facet joint innervation distribution was studied thoroughly using surgical microscope and microsurgical technique. In one of the pieces the needles positioning was first made to test through the radiological study the possible application of the precise denervation in low back pain treatment.

RESULTS

The L1 to L4 segments, each dorsal branch of root emits a medial branch that emerges from intertransversal ligament. This branch crosses the superior margin of the medial termination of transverse process, passing through the root of the superior articulate process. Each branch innerves the anterior region of the inferior facet and the inferior portion of articulation which one spins around. The L5 dorsal branch was larger than the superior branches. It emerges dorsally and in the inferior region on top of the sacrum wing. This nerve is in the bone fissure of the junction between the wing and the posterior region of the sacrum articular process. Near the inferior portion of the articular process, the nerve ramifies itself in lateral and medial branch. The medial branch comes back around the inferior portion of the lumbar-sacrum articulation that it innervates.

CONCLUSIONS

We didn't note great variations in the anatomy from L1 do L4. The L5 segment has a different distribution of the branches that should be considered when we do a percutaneous denervation procedure. The approach of the needle must touch the transverse process and feels the resistance of the articular joint . The determination of the neurotomy s point tends to become more precise denervation procedure.

Hepatitis C virus infection in a Brazilian population with sickle-cell anemia

Patients with sickle-cell anemia submitted to frequent blood transfusions are at risk of contamination with hepatitis C virus (HCV). Determination of HCV RNA and genotype characterization are parameters that are relevant for the treatment of the viral infection. The objective of the present study was to determine the frequency of HCV infection and the positivity for HCV RNA and to identify the HCV genotype in patients with sickle-cell anemia with a history of blood transfusion who had been treated at the Hospital of the HEMOPE Foundation. Sera from 291 patients were tested for anti-HCV antibodies by ELISA 3.0 and RIBA 3.0 Chiron and for the presence of HCV RNA by RT-PCR. HCV genotyping was performed in 19 serum samples. Forty-one of 291 patients (14.1%) were anti-HCV positive by ELISA and RIBA. Both univariate and multivariate analysis showed a greater risk of anti-HCV positivity in those who had started a transfusion regime before 1992 and received more than 10 units of blood. Thirty-four of the anti-HCV-positive patients (34/41, 82.9%) were also HCV RNA positive. Univariate analysis, used to compare HCV RNA-negative and -positive patients, did not indicate a higher risk of HCV RNA positivity for any of the variables evaluated. The genotypes identified were 1b (63%), 1a (21%) and 3a (16%). A high prevalence of HCV infection was observed in our patients with sickle-cell anemia (14.1%) compared to the population in general (3%). In the literature, the frequency of HCV infection in sickle-cell anemia ranges from 2 to 30%. The serological screening for anti-HCV at blood banks after 1992 has contributed to a better control of the dissemination of HCV infection. Because of the predominance of genotype 1, these patients belong to a group requiring special treatment, with a probable indication of new therapeutic options against HCV.