Regulation of gliotoxin biosynthesis and protection in Aspergillus species

Aspergillus fumigatus causes a range of human and animal diseases collectively known as aspergillosis. A. fumigatus possesses and expresses a range of genetic determinants of virulence, which facilitate colonisation and disease progression, including the secretion of mycotoxins. Gliotoxin (GT) is the best studied A. fumigatus mycotoxin with a wide range of known toxic effects that impair human immune cell function. GT is also highly toxic to A. fumigatus and this fungus has evolved self-protection mechanisms that include (i) the GT efflux pump GliA, (ii) the GT neutralising enzyme GliT, and (iii) the negative regulation of GT biosynthesis by the bis-thiomethyltransferase GtmA. The transcription factor (TF) RglT is the main regulator of GliT and this GT protection mechanism also occurs in the non-GT producing fungus A. nidulans. However, the A. nidulans genome does not encode GtmA and GliA. This work aimed at analysing the transcriptional response to exogenous GT in A. fumigatus and A. nidulans, two distantly related Aspergillus species, and to identify additional components required for GT protection. RNA-sequencing shows a highly different transcriptional response to exogenous GT with the RglT-dependent regulon also significantly differing between A. fumigatus and A. nidulans. However, we were able to observe homologs whose expression pattern was similar in both species (43 RglT-independent and 11 RglT-dependent). Based on this approach, we identified a novel RglT-dependent methyltranferase, MtrA, involved in GT protection. Taking into consideration the occurrence of RglT-independent modulated genes, we screened an A. fumigatus deletion library of 484 transcription factors (TFs) for sensitivity to GT and identified 15 TFs important for GT self-protection. Of these, the TF KojR, which is essential for kojic acid biosynthesis in Aspergillus oryzae, was also essential for virulence and GT biosynthesis in A. fumigatus, and for GT protection in A. fumigatus, A. nidulans, and A. oryzae. KojR regulates rglT, gliT, gliJ expression and sulfur metabolism in Aspergillus species. Together, this study identified conserved components required for GT protection in Aspergillus species.

A. fumigatus secretes mycotoxins that are essential for its virulence and pathogenicity. Gliotoxin (GT) is a sulfur-containing mycotoxin, which is known to impair several aspects of the human immune response. GT is also toxic to different fungal species, which have evolved several GT protection strategies. To further decipher these responses, we used transcriptional profiling aiming to compare the response to GT in the GT producer A. fumigatus and the GT non-producer A. nidulans. This analysis allowed us to identify additional genes with a potential role in GT protection. We also identified 15 transcription factors (TFs) encoded in the A. fumigatus genome that are important for conferring resistance to exogenous gliotoxin. One of these TFs, KojR, which is essential for A. oryzae kojic acid production, is also important for virulence in A. fumigatus and GT protection in A. fumigatus, A. nidulans and A. oryzae. KojR regulates the expression of genes important for gliotoxin biosynthesis and protection, and sulfur metabolism. Together, this work identified conserved components required for gliotoxin protection in Aspergillus species.

IMPACTO DA PANDEMIA DE COVID-19 NO MOVIMENTO TRANSFUSIONAL DE HOSPITAL ONCOLÓGICO DE SÃO PAULO

Introdução

A pandemia de COVID-19 trouxe uma série de impactos sociais, econômicos, culturais e políticos para o país e o mundo. Na saúde, observamos a sobrecarga do sistema, com mudança do perfil epidemiológico dos pacientes e necessidade de reestruturação da rede de atendimento devido à alta transmissibilidade do vírus. No setor privado, observamos ainda redução das internações por doenças crônicas não transmissíveis e das cirurgias eletivas.

Objetivo

Avaliar o impacto da pandemia COVID-19 na demanda transfusional de um hospital privado de perfil oncológico na cidade de São Paulo.

Método

Realizada análise retrospectiva, a partir de dados dos sistemas informatizados, do número total de hemocomponentes transfundidos. O movimento médio transfusional foi correlacionado com a taxa de ocupação hospitalar e oscilações de fases da pandemia na cidade de São Paulo.

Resultados

Em 2019 tivemos um total de 7.869 transfusões e média mensal de 656 transfusões. Enquanto a taxa de ocupação média ficou em 86,04%. Em 2020 tivemos 6.618 transfusões, com média de 551 transfusões/mês e taxa de ocupação de 83,67%. No primeiro semestre de 2021 foram realizadas 3.472 transfusões, com média de 579 transfusões/mês e taxa média de ocupação de 83,07%. Analisando mês a mês, observamos as piores taxas transfusionais nos meses de maio, junho e julho de 2020 e todo período de 2021. As oscilações de fase da pandemia de covid-19 tiveram picos expressivos em julho e agosto de 2020 e março e abril de 2021.

Discussão

Pacientes oncológicos, principalmente onco-hematológicos, demandam um elevado suporte transfusional durante o tratamento, não podendo ser postergado em grande parte dos casos. Os pacientes oncológicos, devido a imunossupressão, fazem parte do grupo de risco para Covid-19. Com isso, foram implantadas rigorosas medidas para contenção da propagação do vírus, tornando seguros os ambientes e atendimento, reduzindo o risco de exposição para os pacientes e colaboradores, como a restrição de acesso para visitantes e acompanhantes, reagendamento de consultas e cirurgias, fechamento do pronto socorro e encaminhamento dos casos suspeitos para rede referenciada. Houve queda na procura de atendimento hospitalar, redução de agenda cirúrgica eletiva e diminuição das taxas de ocupação e rotatividade de leitos. Consecutivamente, a redução do volume transfusional no cenário de pandemia foi inevitável em comparação ao período anterior (2019). Os períodos com reduções expressivas estiveram em concordância com o agravamento do cenário pandêmico.

Conclusão

A redução do movimento transfusional está diretamente relacionada a queda da taxa de ocupação de leitos oncológicos e fases do cenário pandêmico na cidade de São Paulo. O movimento atual é de retomada no volume  de atendimento e aprimoramento das práticas de medidas  de proteção aos pacientes oncológicos em toda a linha de cuidado.

IMPACTO DA PANDEMIA DE COVID-19 NAS SOLICITAÇÕES DE RESERVAS CIRÚRGICAS EM HOSPITAL REFERÊNCIA PARA CIRURGIAS ORTOPÉDICAS EM SÃO PAULO

Introdução

A Covid-19 é uma infecção respiratória aguda causada pelo coronavírus SARS-CoV-2, de elevada transmissibilidade e distribuição global. A chegada da pandemia de Covid-19 ao Brasil ocorreu em fevereiro de 2020 impactando diretamente a vida dos brasileiros e das instituições de saúde, que tiveram de se adaptar diante de um vírus até então desconhecido e da mudança do perfil epidemiológico dos pacientes. No setor privado, observamos ainda redução das taxas de internações não relacionada ao COVID-19 e das cirurgias eletivas.

Objetivo

Avaliar o impacto nas taxas de solicitações de reservas de hemocomponentes para as cirurgias eletivas em hospital de referência ortopédica na cidade de São Paulo.

Método

Realizada análise retrospectiva, a partir de dados dos sistemas informatizados, através do número de reservas de hemocomponentes solicitados e utilizados, no período de janeiro de 2019 a junho de 2021. Os dados encontrados foram correlacionados com o número total de cirurgias e fases da pandemia na cidade de São Paulo.

Resultados

Em 2019 foram reservados 1.797 hemocomponentes, com uma média mensal de 150 reservas e taxa de utilização de 19,66%. Neste período a média mensal de cirurgias realizadas foi de 931. No ano de 2020 foram reservados 1.211 hemocomponentes, com média 101 reservas ao mês, com taxa de utilização de 18,58% e média mensal de 749 cirurgias. No primeiro semestre de 2021 foram solicitados 557 hemocomponentes para reservas cirúrgicas, com média de 93 reservas ao mês, consumo médio de 22,16% e a realização média de 7801 cirurgias por mês. Analisando o período, observamos uma queda significativa nas taxas de reserva de hemocomponentes segundo trimestre de 2020 e nos meses de março e abril de 2021. O decreto de pandemia no estado de São Paulo teve início no mês de março de 2020, com picos expressivos nos meses de julho e agosto de 2020 e março e abril de 2021.

Discussão

Segundo a Associação Nacional de Hospitais Privados (ANHP) em 2020 houve uma redução de 32% das cirurgias eletivas agendadas em todo o país. Em nosso serviço observamos uma queda importante do número de cirurgias, mais expressiva no segundo trimestre de 2020, com recuperação gradual ao longo do ano, contudo, com nova queda nos meses de março e abril de 2021. Esses períodos correspondem ao início da pandemia no país e a segunda onda de transmissão na cidade de São Paulo ocorreu em 2021, quando ocorreu a redução estratégica das cirurgias eletivas com objetivo reduzir a taxa de ocupação hospitalar e aguardar a melhora da taxa de giro de leito. Consecutivamente, observamos uma queda das solicitações de reservas de hemocomponentes para cirurgias, mais expressiva nos meses com menor número de cirurgias. Contudo, essa queda não foi observada na taxa de utilização de hemocomponentes reservados, sugerindo que não houve alteração do perfil dos pacientes cirúrgicos da instituição no período.

Conclusão

A pandemia de covid-19 teve um impacto negativo no número de cirurgias, de solicitações de reserva cirúrgica, assim como observado em diferentes hospitais durante o cenário de incertezas da pandemia. A retomada dos índices a valores pré-pandemia tem acontecido de forma gradual e ainda com baixa expressão.

Consumption of ultra-processed foods on free sugar intake of Portuguese infants: The Upper Project

Background

The dietary share of ultra-processed foods (UPF) has been associated with low diet quality, including high content of free sugar, mainly in adults' populations. We aim to assess the influence of UPF consumption on free sugar intake of Portuguese infants.

Methods

Cross-sectional representative study including 573 infants (6-23 months old) who participated in the 2015-2016 National Food, Nutrition and Physical Activity Survey. Dietary intake was collected by two non-consecutive food diaries (time interval 8-15 days). Food items were classified according food processing degree by the NOVA system. Total energy intake and percentage provided by each NOVA food groups as well as the free sugar content of the overall diet were assessed. Mean free sugar intake was evaluated across quintiles (Q) of UPF consumption by linear regression adjusted for socioeconomic covariates.

Results

Mean energy intake was 935 kcal/day, in which 49.1% was derived from unprocessed/minimally processed foods, 7.2% from processed culinary ingredients, 7.0% from processed foods and 36.6% from UPF. The mean dietary share of UPF ranged from 12.5% (Q1) to 65.5% (Q5) of total energy. Within UPF, infant formulas (19.3%), milk-based drinks (6.7%) and sweet snacks (4.8%) contributed the most to energy intake. Mean free sugar intake in the overall diet accounted for 8.1% of total energy intake, in which 92.5% came from UPF. As the UPF consumption increased, the dietary content of free sugar increased significantly (β = 0.77; p < 0.001). Contribution of free sugar in total energy intake raised from 2.9% to 12.7%, representing an increment of 338% from the lower to the upper quintile of the dietary share of UPF.

Conclusions

Portuguese infants had an important intake of free sugar. Nearly all of this intake came from UPF, which calls for public health efforts to avoid UPF consumption by this population group.

Funding

FAPESP 2018/07391-9, 2019/05972-7 (MCR), 2016/14302-7 (FR); POCI-01-0145-FEDER-032090.

Key messages

Ultra-processed foods contributed with 36.6% of total energy intake and 92.5% of free sugar in the diets of Portuguese infants. As the ultra-processed foods consumption increased, the dietary content of free sugar increased significantly from 2.9% (Q1) to 12.7% (Q5), representing an increment of 338%.

Influence of ultra-processed foods on prevalence of inadequacy in Portuguese adults and elderly

Background

Ultra-processed foods (UPF) consumption has been widely associated with low diet quality. We aim to investigate its energy contribution and influence on prevalence of nutrient inadequacy in Portugal.

Methods

Cross-sectional representative study involving 3102 adults and 750 elderly enrolled in the 2015-2016 National Food, Nutrition and Physical Activity Survey. Dietary intake was assessed by two non-consecutive 24h recalls. Food items were classified according to the NOVA system. Total energy intake and energy contribution provided by UPF group were determined. Inadequate intake was evaluated across quintiles (Q) of UPF consumption by adjusted Poisson regressions. We adjusted the usual intake estimate by Multiple Source Method and considered the World Health Organization (WHO) recommendations.

Results

UPF contributed with 24% and 16% of daily energy intake in adults (1904 kcal/day) and elderly (1603 kcal/day), respectively. In both age groups, practically all individuals had inadequate intake of sodium, while about a half or more of population had inadequate intake of fibre and potassium. As the dietary share of UPF increased, the prevalence of inadequacy of free sugars (PR = 1.53 for adults and 1.56 for elderly) and saturated fat (PR = 1.18 and 1.15, respectively) increased significantly. In adults, this same trend was also seen for fibre (PR = 1.03) and potassium (PR = 1.12). Particularly relevant was the increase in prevalence of inadequacy of free sugar from 10.5% (Q1) to 67.6% (Q5) in adults and 5.8% (Q1) to 41.8% (Q5) in elderly. Prevalence of inadequacy of saturated fat raised from 27.3% (Q1) to 68.9% (Q5) in adults and 29.4% (Q1) to 46.8% (Q5) in elderly.

Conclusions

Effective strategies are needed to reduce UPF consumption among Portuguese adults and elderly in order to prevent them from diet-related non-communicable diseases.

Funding

FAPESP 2018/07391-9, 2019/05972-7 (MCR), 2016/14302-7 (FR); POCI-01-0145-FEDER-032090.

Key messages

Ultra-processed food contributes with 24% and 16% of daily energy intake in Portuguese adults and elderly. As the ultra-processed food consumption increases, the prevalence of inadequacy of free sugars and saturated fat increases for both, while inadequacy of fiber and potassium also increases for adults.

Availability of ultra-processed food associated with health outcomes: a systematic review

Background

Ultra-processed food (UPF) consumption increases worldwide, which can be harm to population's health. To establish associations between UPF and health outcomes, food consumption can be assessed individually or by using availability data, such as purchase lists or household budget surveys. The aim of this review was to search for studies on the availability of UPF related with mortality and morbidity from noncommunicable diseases or their risk factors.

Methods

PRISMA guideline was used. Searches were performed on PubMED, EBSCO, Scopus and Web of Science on December 2019. Search strategy included terms related with exposure (UPF) and outcomes (mortality or morbidity from noncommunicable diseases and their risk factors). Studies were selected based on the title and abstracts. Full texts were screened for eligibility and the snowballing method was used to find other relevant studies. To be based on UPF availability data and its relation with health outcomes were the inclusion criteria. Studies that assessed only food consumption at an individual level and did not present health outcome were excluded. Selection was conducted by two reviewers and a third helped when disagreement occurred.

Results

After duplicates removal, 560 records were analyzed. From the 11 eligible studies, 55% were conducted in more than one country. Others were performed in Brazil (27%), Guatemala (9%) and Sweden (9%). Studies were ecological (64%), cross-sectional (27%) and longitudinal (9%). All had representative samples, 45.5% were national samples, and the others were from particular population subgroups. In all studies, the only health outcomes that showed positive association with UPF availability were overweight and obesity prevalence.

Conclusions

Studies relating ultra-processed food availability and health outcomes are mainly focused on overweight and obesity. It is thus necessary to further explore the relationship between UPF availability and other health outcomes.

Key messages

It is necessary to further research association between ultra-processed food availability and other health outcomes, such as morbidity and mortality from cardiovascular diseases, diabetes or cancer. Purchase lists or household budget surveys are an important source of food availability data and can be used to relate the consumption of ultra-processed foods to health outcomes.

The patterns of in vitro cell-death and inflammatory cytokines induced by distinct BCG vaccine strains are differentially induced in human mononuclear cells

Tuberculosis (TB) remains among the world's leading cause of mortality. For its control, studies of TB vaccines are needed. Since live-attenuated Mycobacterium bovis bacillus Calmette-Guérin (BCG) is the only TB vaccine currently in use, studies on the protective role of BCG are required. In this study, we analyzed host cells purified directly from whole blood of human immunodeficiency virus (HIV)-negative volunteers, comprising adult healthy donors (HD) and neonates (umbilical cord bloods, UCB), with the aim to directly compare in vitro immune responses with distinct BCG strains in human mononuclear cells. The Moreau, Pasteur, and Danish BCG strains were used to infect mononuclear cells in vitro for 48 h; bacilli viability and cell-death were subsequently detected by flow cytometry. In addition, cell culture supernatants were used in cytokine detection assays. Overall, the Moreau BCG strain induced higher levels of apoptosis than the Pasteur and Danish BCG strains in both the HD and UCB groups (p-value < 0.05), and a human monocytic cell-line mirrored those cell-death patterns after BCG infection. The Moreau BCG strain, exclusively, induced Th1 cytokines at the highest levels in cells from adults (p-value < 0.05) when compared with both Pasteur and Danish BCG strains, whereas TGF-β1 levels were reduced significantly (p-value < 0.01) in the HD group when cells were infected with the Moreau BCG vaccine. As expected, eight out of 22 pro-inflammatory cytokines were secreted at significant levels (p-value < 0.05) above the baseline rates in all BCG-infected cell cultures, in the HD group only. When analyzing these results, we excluded confounding factors related to storage and viability of the BCG strains used. These findings suggest that Moreau BCG is a more potent immunostimulating agent than the Pasteur and Danish BCG strains. Clinical trials will be needed to confirm these findings.

Diet and feeding daily rhythm of Pimelodella lateristriga (Osteichthyes, Siluriformes) in a coastal stream from Serra do Mar - RJ

The present study was carried out in Mato Grosso fluvial system, a costal drainage from Serra do Mar. We analysed the diet and the feeding daily rhythm of Pimelodella lateristriga from samples carried out during 24 hours over a 4 hour fishing interval, in June, July and September, 2006 as well as in January and February, 2007. Diet was described from the Feeding Index (IAi) and feeding daily rhythm was verified through the Gut Fullness Index (GFI). Pimelodella lateristriga diet was composed of 37 items, being aquatic insects the most important ones. IAi analysis revealed that Diptera, Trichoptera and Ephemeroptera amounted to 90% of the diet. Autochthonous invertebrates were the most important consumed items. Pimelodella lateristriga concentrated its feeding activities in the nocturnal period (10:00 PM to 2:00 AM) with marked significant differences (F = 16.11; gl = 5; p < 0.05) between each diurnal and nocturnal periods. Between 6:00 AM and 6:00 PM, foraging activity was gradually reduced. We concluded that P. lateristriga has an insectivorous diet and a nocturnal feeding habit with greater activity between 10:00 PM to 2:00 AM.

Tumor necrosis factor and interleukin-10 gene promoter polymorphisms in Brazilian population and in Terena Indians

The Terena Amerindians are located in the midwestern region of Brazil. We have previously reported a restricted polymorphism for HLA class I and class II in 99 unrelated Terena using PCR-SSO and more recently for MICA. There are single nucleotide polymorphisms (SNPs) that determine high or low production of certain cytokines. We have now studied the frequencies of mutant allele (A) at position -308 in the promoter of the gene tumor necrosis factor (TNF)-alpha (pro-inflammatory cytokine) and the alleles A and T, at position -1082 and -819, respectively, in the promoter of the interleukin (IL)-10 gene, in 51 of these subjects from the Terena tribe using PCR SSP and in 195 normal unrelated healthy Brazilians using PCR-RLFP. All 51 Terena Indians tested (100%) had the G/G genotype at position TNF-alpha -308, with no mutation found thus far. In contrast, among the Brazilian general population, the allelic frequency of A was 18.9%. When anti-inflammatory cytokine IL-10 was studied at two different positions, -1082 and -819, a high mutation rate was found when Terena were compared with the general Brazilian population (P <.05). The genetic cytokine profile may be required to balance the restricted HLA repertoire for peptide presentation in this native population.

Erectile dysfunction: prevalence and associated variables in patients with chronic renal failure

Patients with chronic renal failure (CRF) experience a significant decrease in quality of life, due both to the limitations imposed by the disease as well as the demands of the treatment that they receive. Some side effects of both illness and treatment contribute to increase the morbidity of these patients. Among them, erectile dysfunction (ED) is notable. One hundred and nineteen patients received clinical and laboratory evaluation. The following clinical data were observed: age, education, income, race, period of dialysis, period of complaints of ED, etiology of ED, use of erythropoietin, presence of arterial hypertension and/or diabetes mellitus, use of antihypertensive drugs, use of cigarettes, and psycho-emotional state of the patients. Assessment of complaints of ED was achieved using the International Index of Erectile Function (IIEF). The following laboratory data were analyzed: hemoglobin, hematocrit, free testosterone, gonadotrophin levels (FSH and LH), HDL-cholesterol, total cholesterol, prolactin, and parathyroid hormone. Statistical analysis of the means of continuous variables was performed through use of the Student's t-test. Analysis of significance of category variables was performed using the chi(2) test. Descriptive analysis was obtained through use of the clinical and socio-demographic data. A multivariate model was created and the odds ratio calculated. The average age of the patients was 47.3+/-15.9 y. The mean duration of erectile dysfunction complaints was 4 y. The average duration of dialysis was 66.2+/-58.9 months. Prevalence of erectile dysfunction in this population was 57.9%. The main known etiology of chronic renal failure was glomerulonephritis. The main variables associated with erectile dysfunction were age, psycho-emotional state, and levels of HDL-cholesterol. This study showed a high prevalence of erectile dysfunction in the group of patients examined. Factors such as age, anxiety and depressive complaints, and dyslipidemy seem to play an important role in the origin of erectile dysfunction in such patients.

Eradication of Helicobacter pylori infection in patients with duodenal ulcer and non-ulcer dyspepsia and analysis of one-year reinfection rates

Helicobacter pylori (HP) infection is endemic worldwide. The proposed treatment is expensive and there are few reports regarding reinfection rates in Brazil. The aim of this study was to compare the eradication rates obtained with two therapeutic options and to evaluate reinfection one year after treatment. This was a prospective randomized trial with 55 patients. Thirty-nine patients had active duodenal ulcer (DU) and 16 non-ulcer dyspepsia (NUD), and all tested positive for HP. Diagnosis was based on at least two positive tests: ultrarapid urease test, histology and/or culture. Patients were randomized to two groups: group OMC treated with 40 mg omeprazole (once a day), 500 mg metronidazole and 250 mg clarithromycin (twice daily) for 7 days, or group NA treated with 300 mg nizatidine (once a day) and 1000 mg amoxicillin (twice daily) for 14 days. Those patients in whom HP was eradicated were followed up for one year to evaluate reinfection. Twenty-five patients were randomized for OMC and 30 for NA. HP eradication occurred in 20/25 patients (80%) treated with OMC and 13/30 (43%) treated with NA (P = 0.01). After reallocation because of initial treatment failure, the overall eradication rate was 44/51 patients (86%). After an average follow-up of one year, we evaluated 34 patients (23 with DU and 11 with NUD). Reinfection occurred in 3/34 patients (7.6%). We conclude that OMC is effective for HP eradication, and that NA should not be used. Reinfection occurs in 7.6% of the patients in the first year after eradication.

Thalidomide and Its Dermatologic Uses

This article reviews how the drug thalidomide can be used for various dermatologic disorders. Also included is a short discussion of the chemistry and physiologic mechanisms of thalidomide. Thalidomide, now available again in the United States, is another drug that can be considered by dermatologists for some severe, unusual disorders.

A "bicycle-handlebar" type of incision for primary and secondary abdominoplasty

The authors register a revision of the literature regarding the types of low transversal pubic incisions used in abdominoplasty. Since 1987, the traditional open W-type incision changed to a new type called the bicycle handlebar. In this procedure, the pubic segment remains in a lower line at the level of the pubic hair, while the lateral limbs are in a high position. The anterior superior iliac spine is used as reference. Different types of procedures where the umbilical skin hole reaches the pubic incision are described and illustrated. This procedure is also used in secondary abdominoplasty. In all cases, the incision's new position should remain hidden under a bathing suit.

Philosophy, technical principles, selection, and indication in body contouring surgery

The experiences of almost three decades of performing various types of body contouring surgery, in both pre- and postlipoplasty periods, using many different techniques are described. Contouring surgery for such body areas as the abdomen, flanks, inner and outer thighs, and buttocks is discussed in detail.

Monocytic leukemoid reaction, glucocorticoid therapy, and myelodysplastic syndrome

A leukemoid reaction is a complex and poorly understood response by the bone marrow to a variety of stresses; although any peripheral blood cell line may be involved, it is rarely a purely monocytic event. A case is reported of a true monocytic leukemoid reaction in a patient with myelodysplastic syndrome related to the effect of corticosteroids on the underlying marrow disorder.