Differentiated Thyroid Cancer in Children and Adolescents: 12-year Experience in a Single Center

Objective

Differentiated thyroid cancer (DTC) is the most common pediatric endocrine cancer but studies are scarce. Latest recommendations advocate for an individualized risk-based approach to select patients for additional therapy. Lymphovascular invasion is not considered, despite being a well-known risk factor in the adult population. The aim of our study was to describe the outcomes of a cohort of DTC patients diagnosed at pediatric age and to evaluate the impact of lymphovascular invasion on the risk of persistence/recurrence.

Methods

We conducted a retrospective study of patients diagnosed with DTC at pediatric age from 2010 to 2022 at our center. All patients had total thyroidectomy. Radioactive iodine therapy (RAI) was used in selected patients. The response to therapy and occurrence of persistent/recurrent disease were evaluated.

Results

A total of 21 DTC were diagnosed, mostly papillary thyroid carcinoma (PTC) (81.0%, 17). Six patients (28.6%) had nodal involvement and one (4.8%) had lung metastasis at the time of the diagnosis. Lymphovascular invasion was present in 11 patients (52.4%). After surgery, 13 patients (61.9%) were submitted to RAI. The mean follow-up time was 5.7 ± 3.1 years. Overall, 6 patients (31.6%) experienced persistent/recurrent disease during the follow-up time. Among PTC patients, persistent/recurrent disease was more frequent in the presence of lymphovascular invasion [55.6% (5/9) vs 0.0% (0/6), p=0.031].

Conclusion

An individualized risk-based approach is recommended. Our study suggests that lymphovascular invasion may be associated with a higher risk of persistence/recurrence and should therefore be considered for decision making in children and adolescents with PTC.

Early Diagnosis of 46,XX Testicular Difference of Sexual Development: Unusual Presentation with Increased Nuchal Translucency

INTRODUCTION

46,XX testicular disorder of sexual development (DSD) may present prenatally as a mismatch between phenotype and karyotype. Enlarged nuchal translucency is an abnormal sign of many disorders. We present a first trimester fetus with increased nuchal translucency that was later determined to be a 46,XX testicular DSD.

CASE PRESENTATION

A first-trimester pregnancy ultrasound revealed enlarged nuchal translucency. Chorionic villous sampling documented a 46,XX karyotype. Subsequent ultrasounds identified male external genitalia. FISH analysis documented a SRY gene translocation. At birth, the infant had normal male internal and external genitalia.

CONCLUSIONS

46,XX testicular DSD may present in the first trimester with an enlarged nuchal translucency.

The Prevalence of Potentially Inappropriate Prescribing in Two Family Health Units in Portugal

OBJECTIVE

Polypharmacy and potentially inappropriate prescribing (PIP) are growing concerns in the ageing population. They carry the risk of increasing adverse effects, medical interactions, and difficulties managing the medication. Few studies in Portugal evaluate the prevalence of polypharmacy and PIP in primary care. No previous studies in the primary care setting in Portugal have been conducted using the European Union (EU)(7)-PIM (potentially inappropriate medication) list tool. In this study, we aimed to estimate the prevalence of polypharmacy and PIP in two family health units in Portugal.  Methods: To answer this question, we enrolled a sample of 361 elderly patients from two family health units in a descriptive observational transversal study. We randomly selected patients, consulted their prescription records in the previous 12 months, and applied the EU(7)-PIM list tool, validated for the Portuguese population. The data was then analyzed using descriptive and inferential statistics and the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 24.0, Armonk, NY).

RESULTS

Our results showed a prevalence of 79.8% of polypharmacy in the elderly population and 73.4% of PIP. These values are higher than predicted in the literature, but different screening tools have been used among papers. The mean number of prescribed drugs per patient was nine in one unit and seven in the other, and the mode was eleven per patient. The most identified PIP-associated drugs were proton pump inhibitors in 46.4% of the patients in one unit and 43.7% in the other. We also found a statistically significant higher prevalence of PIP and polypharmacy in females and patients over 75 years.

CONCLUSION

From a prevalence perspective, we found higher-than-expected prevalences of PIP and polypharmacy in our population. Contributing factors might be a higher ageing index in the Portuguese population, modern practices using combination therapy, and the use of a screening tool that does not take into account the personal clinical history of patients. Further limitations involve only including patients with follow-up in the units studied. Even so, it suggests both PIP and polypharmacy as concerns to address, and we will strive to educate both health teams on PIP, polypharmacy, and deprescribing. We also emphasize the need to widen the study to other family health units.

A prospective study on varicose veins surgery impact on systemic endothelial function evaluated by arterial brachial flow mediated dilation

OBJECTIVES

Chronic venous disease (CVD) is a prevalent pathology, and endothelial dysfunction is recognized as a core of its physiopathology. Flow-mediated dilation (FMD) is one of the most widely used tests for evaluating endothelial function. The aim of this study is to evaluate the influence of varicose vein (VV) surgery on FMD.

METHODS

A prospective study with patients with superficial CVD and saphenous incompetence on Doppler ultrasonography that were proposed for VV surgery. The FMD test was performed before and 6 months after the procedure. The operator performing the post-operative evaluation was blinded to the pre-operative result.

RESULTS

A total of 42 patients were included in the analysis. The median pre-operative percent change of FMD was 4.20% (±1.30) and the post-operative was 4.56% (±1.25) (p = 0.819).

CONCLUSIONS

Our findings do not corroborate the presence of an overall endothelial dysfunction prone to modulation by surgery. Nevertheless, further studies are needed to confirm our findings.

Rare Coexistence of Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency and Turner Syndrome: A Case Report and Brief Literature Review

The coexistence of congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency and Turner syndrome (TS) is rare. We report on a 6-year-old Portuguese girl with mosaic TS [45,XO(39)/47,XXX(21)] presenting with premature pubarche at the age of 5 years. Laboratory findings showed elevated 17-hydroxyprogesterone, dehydroepiandrosterone sulfate, androstenedione and total testosterone, and her sex-determining region Y (SRY) was negative. CYP21A2 gene analysis revealed two mutations (c.[844G>T]; [CYP21A2del]), consistent with the non-classical form of CAH. Complete deletion of CYP21A2 allele occurred de novo. At 6 years and 4 months, she presented with accelerated growth velocity and hydrocortisone at a dose of 5 mg/m²/day was initiated. This case highlights the need to perform global examinations looking for virilization signs in TS patients’ follow-ups. It also supports the reported genetic combination of TS and CAH. Therefore, CAH should be kept in mind in TS patients with SRY negative and virilization signs, even in the absence of short stature.

Knowledge translation in rehabilitation settings in low, lower-middle and upper-middle-income countries: a scoping review

PURPOSE

This review aims to identify the barriers and facilitators to knowledge use and Knowledge Translation (KT) strategies in rehabilitation in low, lower-middle, and upper-middle-income countries (LMICs).

MATERIALS AND METHODS

A scoping review of studies of KT in rehabilitation in LMICs contexts using the Arksey and O'Malley Framework was conducted. A comprehensive search of MEDLINE and 10 other databases was undertaken to identify studies conducted primarily in LMICs.

RESULTS

From the initial 15.606 titles identified; 27 articles were included for final analysis. Our analysis identified the following themes: Professional culture and context; KT interventions; and the conceptualization and application of KT and Evidence Based Practice (EBP). Individual-level barriers to KT included lack of skills, knowledge about EBP and English language, lack of motivation, and decision-making power. Facilitators to KT included positive attitudes and motivation. Organization-level barriers included lack of time, lack of financial resources, limited access to scientific journals, and applicability of research to rural settings. Facilitators included adequate financial and physical resources, a supportive management environment, and the existence of training and continuing education programs.

CONCLUSION

This review identified common and unique barriers and facilitators to KT in LMICs when compared to KT studies conducted in high-income settings.IMPLICATIONS FOR REHABILITATIONKnowledge Translation from academic institutions to rehabilitation clinical practice in low and upper-middle-income countries is important to support evidence-based practice and patient outcomes.Barriers at the individual level include professionals' ability to understand English and knowledge of the evidence-based practice.Organization-level barriers included lack of time to access and implement new practices, lack of financial and personal resources, limited access to scientific journals, and applicability of research to rural settings.Training and continuing education programs are needed to support rehabilitation professionals' efforts to achieve the application of evidence-based practice in clinical practice.

New-onset atrial fibrillation diagnosed by cardiac implantable devices in patients with hypertrophic cardiomyopathy: a systematic review and meta-analysis

Background

Atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM) is associated with high thromboembolic risk, morbidity, and mortality.

Purpose

We aimed to study the role of cardiac implantable devices (CID) for AF diagnosis in patients with HCM without prior AF history.

Methods

A comprehensive systematic review and meta-analysis was conducted using Pubmed, Embase, and ClinicalTrials.gov through November 2021 for studies reporting incidence of new-onset AF detected by CID including implantable cardioverter defibrillators, pacemakers, cardiac resynchronization therapy, and loop recorder devices in HCM patients. We used a Freeman-Tukey transformation to calculate the weighted summary proportion of the incidence of AF and stroke and pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model.

Results

Eight cohort studies were included, totalizing 910 patients with HCM and CID without baseline AF. Mean age was 54 years and 21% were female. Mean left ventricular wall thickness was 22.6 mm. Mean follow-up was 3.1 years. New-onset AF was detected in 27.6% (95% CI 18.7–37.5) of patients (Figure A) and 84% of the episodes were subclinical. Stroke occurred in 4.7% (95% CI 1.8–9.0) of patients without baseline AF (Figure B). There was no significant difference in the unadjusted risk of stroke between patients with newly diagnosed AF vs no AF detected at the end of follow-up (9.4% vs 4.7%, OR 1.93, 95% CI 0.83–4.48, p=0.13).

Conclusion

There is a high incidence of subclinical new-onset AF in patients with HCM, supporting the use of CID for early detection of AF in this population.

Funding Acknowledgement

Type of funding sources: None.

Omecamtiv mecarbil for the management of heart failure: a meta-analysis of randomized controlled trials

Background

Omecamtiv mecarbil (OM) is a selective cardiac myosin activator that promotes contractility in patients with Heart Failure with Reduced Ejection Fraction (HFrEF). We aimed to study the clinical outcomes of OM in this population.

Methods

PubMed, Cochrane CENTRAL Registry of Controlled Trials, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) that compared OM with placebo for the management of HFrEF. Efficacy and safety data were summarized with odds ratios (OR) and a 95% confidence interval (CI) using a fixed-effect model predicting low heterogeneity between studies.

Results

Four RCTs were included, totalizing 9,364 patients, 4,779 treated with OM and 4,585 with placebo. Mean age ranged from 63–66 years, 15–22% female, ejection fraction 26–29%, ischemic etiology 53–66%. Length of follow up ranged from 1 to 21 months. There was no difference in the outcomes all cause death (OR 0.99, 95% CI 0.9–1.1, p=0.91), cardiovascular death (OR 1.01, 95% CI 0.91–1.12, p=0.87) and heart failure events or hospitalizations (OR 0.96, 95% CI 0.87–1.05, p=0.35), Figure.

Conclusion

In a meta-analysis of 4 RCTs, OM showed no difference compared with placebo in the risk of all-cause death, cardiovascular death, or heart failure events among patients with HFrEF.

Funding Acknowledgement

Type of funding sources: None.

A serious and unusual presentation of congenital isolated ACTH deficiency due to TBX19 mutation, beyond the neonatal period

Summary

Congenital isolated adrenocorticotrophic hormone (ACTH) deficiency due to T-box transcription factor-19 (TBX19 mutation) (MIM 201400; ORPHA 199296) usually presents in the neonatal period with severe hypoglycemia, seizures, and sometimes prolonged cholestatic jaundice. We report a case with an unusual presentation that delayed the diagnosis. A 9-month-old female patient with no relevant personal history was admitted to the emergency department due to a hypoglycemic seizure in the context of acute gastroenteritis. There was rapid recovery after glucose administration. At age 4, she presented with tonic-clonic seizures, fever, and gastrointestinal symptoms and came to need support in an intensive care unit. Low serum cortisol was documented and hydrocortisone was initiated. After normalization of inflammatory parameters, the patient was discharged with hydrocortisone. The genetic investigation was requested and compound heterozygous mutations in TBX19 were detected. This is a rare case of presentation of TBX19 mutation outside the neonatal period and in the setting of acute disease, which presented a diagnostic challenge.

Learning points

Congenital isolated adrenocorticotrophic hormone deficiency due to TBX19 mutation usually presents with neonatal hypoglycemia and prolonged cholestatic jaundice. An uneventful neonatal period, however, does not exclude the diagnosis as the disease may be asymptomatic at this stage. In the context of idiopathic hypoglycemia, even in the context of acute disease, hypocortisolism must always be excluded. Genetic evaluation should be performed in cases of congenital central hypocortisolism to allow proper counselling.

Autoimmune Primary Adrenal Insufficiency in Children

Objective

Primary adrenal insufficiency (PAI) is a rare condition in children, and is potentially life-threatening. The most common cause is congenital adrenal hyperplasia, and autoimmune etiology is the most frequent acquired cause in this age group. Symptoms are usually non-specific and, when suspected, investigation should include adrenocorticotropin hormone (ACTH) and morning serum cortisol measurement and, in some cases, a cosyntropin test to confirm the diagnosis. Prompt treatment is essential to prevent an adverse outcome.

Methods

We retrospectively collected clinical and laboratory data from adrenal insufficiency due to autoimmune adrenalitis, observed from 2015 to 2020 in a pediatric endocrinology department of a tertiary care hospital.

Results

Eight patients were identified, seven males and one female, with age at diagnosis between 14 and 17 years. The symptoms at presentation ranged from non-specific symptoms, such as chronic fatigue and weight loss, to a severe presentation, with altered mental status and seizures. The median duration of symptoms was 4.5 months. The diagnosis was confirmed by serum cortisol and plasma ACTH measurement and all were confirmed to have autoimmune etiology (positive anti-adrenal antibodies). At diagnosis, the most common laboratory abnormality was hyponatremia. All patients were treated with hydrocortisone and fludrocortisone. One patient presented with evidence of type 2 autoimmune polyglandular syndrome.

Conclusion

PAI is a rare condition in the pediatric age group. Due to non-specific symptoms, a high index of suspicion is necessary to establish a prompt diagnosis. Once an autoimmune etiology is confirmed, it is important to initiate the appropriate treatment and search for signs and symptoms of other autoimmune diseases during follow-up.

Clinical characteristics of polyglandular autoimmune syndromes in pediatric age: an observational study

OBJECTIVES

Polyglandular autoimmune syndromes (PAS) are characterized by the association of two or more autoimmune diseases (AID) and are classified into four types. PAS type 1 is more frequently manifested in childhood, but the prevalence of other PAS in children, less described in the literature, seems to be underestimated.

METHODS

This study aimed to evaluate the prevalence of PAS in a selected pediatric population of 879 children with Diabetes mellitus type 1 (DM1), autoimmune thyroid disease (AITD), and Addison's disease (AD) followed in our hospital for 10 years and describe and classify the manifestations of different PAS.

RESULTS

We diagnosed 35 children with PAS, most fulfilled criteria for PAS type 3 (65.7%), and AITD was the AID more frequently detected (74.3%). PAS type 1 was not diagnosed in our sample. Patients with PAS manifested DM1 and AITD at a younger age than children with monoglandular pathology (7.7 vs. 9.3 years, p=0.04 and 7.7 vs. 13.1 years, p<0.01).

CONCLUSIONS

This is the first study that analyzes the prevalence of different types of PAS in a pediatric population followed by endocrine pathologies, namely DM1, AD, and AITD. As PAS manifestations are often preceded by a long latency period characterized by the presence of autoantibodies, we reinforce the need to value these markers for timely diagnosis and to screen PAS in patients with AD throughout their lives.

Effect of ultra-rapid insulin aspart on glycemic control in children with type 1 diabetes: the experience of a Portuguese tertiary centre

Background

Postprandial hyperglycemia is one of the biggest challenges in children with type 1 diabetes (T1D). Ultra-fast-acting aspartic insulin (faster aspart) has a quicker onset of action and an earlier maximum activity. The aim of this study is to analyze the impact of faster aspart in metabolic control of pediatric patients with T1D in a “real-world” setting.

Methods

Retrospective analysis of 60 pediatric patients with T1D who changed their insulin analogue to faster aspart. Anthropometric data, insulin doses, capillary and interstitial glucose recordings and average glycated hemoglobin before and after insulin analogue’s switch were obtained. After all population analyses, patients were analyzed separately according to the type of treatment, multiple daily injections (MDI) and continuous subcutaneous insulin infusion (CSII), and according to age group.

Results

Faster aspart significantly improved metabolic control, increasing time in range (TIR) (42 vs.54%, respectively; P = 0.007) and decreasing time above range (TAR) (52 vs.40%, respectively; P = 0.009), without an increased time in hypoglycemia (7% before and after faster aspart’s introduction; P = 0.933). This was reassured in the adolescent years (n = 45), with an increase in TIR (37 vs. 47%, respectively; P = 0.034) and decrease in TAR (51 vs. 45%, respectively; P = 0.022). Patients on CSII (n = 47), also demonstrated an increase in TIR (38 vs. 50%, respectively; P = 0.010). The reduction of A1c was not statistically significant.

Conclusion

Although the advantage of faster aspart had already been demonstrated in pediatric patients under MDI, “real-world” studies, including patients under CSII, are still lacking. This study highlights the important impact of faster aspart on metabolic control in children with T1D, particularly among adolescents under CSII.

A variant in the CASR gene (c.368T>C) causing hypocalcemia refractory to standard medical therapy

SUMMARY

Hypoparathyroidism is characterized by low or inappropriately normal parathormone production, hypocalcemia and hyperphosphatemia. Autosomal dominant hypocalcemia (ADH) type 1 is one of the genetic etiologies of hypoparathyroidism caused by heterozygous activating mutations in the calcium-sensing receptor (CASR) gene. Current treatments for ADH type 1 include supplementation with calcium and active vitamin D. We report a case of hypoparathyroidism in an adolescent affected by syncope without prodrome. The genetic testing revealed a variant in the CASR gene. Due to standard therapy ineffectiveness, the patient was treated with recombinant human parathyroid hormone (1-34), magnesium aspartate and calcitriol. He remained asymptomatic and without neurological sequelae until adulthood. Early diagnosis and treatment are important to achieve clinical stability.

LEARNING POINTS

Autosomal dominant hypocalcemia (ADH) type 1 is one of the genetic etiologies of hypoparathyroidism caused by heterozygous activating mutations in the calcium-sensing receptor (CASR) gene. The variant c.368T>C (p.Leu123Ser) in heterozygosity in the CASR gene is likely pathogenic and suggests the diagnosis of ADH type 1. Teriparatide (recombinant human parathyroid hormone 1-34) may be a valid treatment option to achieve clinical stability for those individuals whose condition is poorly controlled by current standard therapy.

A Novel Variant in the CASR Gene c.368T&gt;Cp.(Leu123Ser) in a Case of Hypocalcemia Refractory to Standard Medical Therapy

Introduction: Hypoparathyroidism is characterized by low or inappropriately normal PTH production, hypocalcemia and hyperphosphatemia. Autosomal dominant hypocalcemia (ADH) type 1 is one of the genetic etiologies of this, caused by heterozygous activating mutations in the CASR gene. Some individuals fail to meet treatment goals despite standard therapy. Clinical Case: A 13-year-old male patient was admitted in the emergency department due to syncope during physical activity. There was no reference to seizures or other complaints. Standard screening for metabolic diseases revealed no changes at the 7th day of life and family history was unremarkable. There was a history of febrile seizures up to 5 years of age with several hospitalizations for diagnosis investigation that were inconclusive. Physical examination showed a positive Chvostek signal, without other changes. A basic workup revealed hypocalcemia 1.67mmol/L (NR: 2.19-2.66), hyperphosphatemia 3.06mmol/L (NR: 0.95-1.75), hypomagnesemia 0.62mmol/L (NR: 0.7-1.0), low 25Hydroxyvitamin D 8.7ng/mL (NR: &gt;30ng/mL) and inappropriately low PTH 4.0pg/mL (NR: 16.0-87.0). Cranial computed tomography scan showed bilateral calcifications of the basal ganglia. Dual-energy x-ray absorptiometry revealed bone mineral density z-scores increased 15% in spine lumbar and decreased 7% in left femur. Cardiac ultrasound and electrocardiography were normal. The patient started therapy with intravenous calcium gluconate. During this treatment, he developed significant calcification of the peripheral veins at the site of administration, leading to intravenous therapy suspension. The dose of oral calcium, calcitriol and magnesium was gradually increased and sevelamer started to control hyperphosphatemia. Despite the optimization, the patient maintained hypocalcemia refractory to standard therapy. As a last resource strategy in therapeutic optimization, the patient started on rhPTH (1-34). Ever since, the patient has been clinically asymptomatic with biochemical stability and with a reasonable quality of life. At age 18, renal ultrasound revealed diffuse medullary nephrocalcinosis.

The genetic testing revealed a novel variant c.368T&gt;C p.(Leu123Ser) likely pathogenic in heterozygosity in the CASR gene, suggesting the diagnosis of ADH type 1. The patient′s mother did not give her consent for genetic study and patient’s father had already died with a diagnosis of acute leukemia. Conclusion: This case can be explained by the presence of a likely pathogenic variant in heterozygosity in the CASR gene that has been described in the medical literature that has not been identified in gnomAD population database, suggesting the diagnosis of ADH type 1. rhPTH (1-34) may be a treatment option for those individuals who are not well controlled on standard therapy, but long-term follow-up studies are needed to reinforce its safety.

Marketing of alcoholic beverages: what can be done to protect the adults of the future?

Issue

Marketing of alcoholic beverages can influence attitudes and intentions to drink including alcohol initiation in adolescents. Globally, alcohol is the leading cause of death among young people (15-49 years).

Description of the problem

Comprehensive restrictions or bans on alcohol advertising are considered 'best buys' to reduce the harmful use of alcohol and its consequences. We present a database with statutory, co- and self-regulatory alcohol-related marketing codes describing their characteristics, scope, target population groups, marketing techniques addressed, marketing restrictions, and information regarding implementation, monitoring and evaluation of such codes. We analysed these codes and asked: what are the critical aspects that an alcohol-related marketing code should include to be effective and protect public and children's health?

Results

Based on our analyses, we present a toolkit to support restrictions of marketing of alcoholic beverages (as well as of foods and non-alcoholic beverages). It includes a checklist for policy-makers to consider all important aspects during the design, implementation, evaluation or update of the code. We suggest specific actions for each point in the checklist and reflect on the implementation of some of these. Finally, the toolkit discusses digital marketing, the challenges it poses and offers potential solutions.

Lessons

Using a combined approach to address marketing to children of foods, non-alcoholic and alcoholic beverages may be more effective in protecting public and children's health than fragmented responses. The fields of nutrition and alcohol-related harm can learn from and complement each other. A code should cover all forms of marketing, including digital marketing. Our database, toolkit, checklist and inventory of actions support policy makers and others in designing or updating alcoholic beverage marketing regulations and codes of conduct.

Key messages

Our toolkit supports policy makers and others in designing or updating alcoholic beverage marketing regulations and codes of conduct. Practical technical guidance is provided in the form of a marketing code checklist and an inventory of specific actions.

Speech intelligibility of Parkinson's disease patients evaluated by different groups of healthcare professionals and naïve listeners

INTRODUCTION

Speech intelligibility, how well a listener comprehends the speaker's message, is related to the listener' expertise and type of the message conveyed. There is no evidence about speech intelligibility in different groups of healthcare professionals and naïve listeners.

OBJECTIVES

This study is the first to understand if there were differences in the speech intelligibility of Parkinson's Disease (PD) patients by different experienced and naïve listeners, according to the speech stimuli and dysarthria severity.

MATERIALS AND METHODS

Randomly digitised audio-files (50 words and 50 sentences) of 10 PD patients, one without dysarthria and 9 with different dysarthria severities (3 each: mild, moderate and severe dysarthria), were collected from a database of 60 PD patients' audio-files. A jury panel was formed by five different listeners groups including 10 speech and language therapists, 10 neurologists, 10 PD relatives, 12 PD patients, and 10 people from the general population. The jury panel transcribed single words and sentences from the audio recordings, the percentage correctly understood was calculated and the results were compared between the groups.

RESULTS

Multiple comparisons showed significant speech intelligibility differences between healthcare professionals and naïve listerners in words (highest effect size, η² = 0.7) and sentences (the highest effect size: η² = 0.6). Pairwise comparisons revealed that those significant differences were specifically in words with moderate and severe dysarthria and sentences with all severity levels of dysarthria.

CONCLUSION

The groups of healthcare professionals who work with dysarthria are more likely to understand the PD patients' speech than the groups of naïve listeners.

Neonates Born to Mothers with Graves' Disease: 15 Year Experience of a Pediatric Endocrinology Department

INTRODUCTION

Graves disease is characterized by the existence of autoantibodies directed to the thyrotropin receptor, which can have a stimulatory/inhibitory action, in women with the condition, their fetus or neonate. Our aim was to review the case series of these neonates in order to establish neonatal thyroid function predictors.

MATERIAL AND METHODS

Retrospective cohort study of the database of the Department of Pediatric Endocrinology, including patients born to mothers with Graves' disease, between 2002 and 2017. Clinical and biochemical data were collected from mothers and offspring.

RESULTS

Fifty newborns, from 46 women with a median of 3.5 years after diagnosis, were included. During all trimesters of pregnancy, more than half of women had positive autoantibodies directed to the thyrotropin receptor. Not every woman had a complete thyroid function evaluation every trimester. In 32 newborns, cord blood screening was done. During the neonatal period, there were three cases of hypothyroidism and two of hyperthyroidism. The mothers of these five newborns had higher levels of free thyroid hormones during the second trimester (p = 0.03). The level of antibodies directed to the thyrotropin receptor was significantly higher in the cord blood (p = 0.03) and in the first neonatal test (p = 0.03) of these dysthyroid newborns.

DISCUSSION

Our results reinforce the need for every pregnant woman with Graves' disease to be subject to thyroid function and autoantibodies evaluation during every trimester, as well as the importance of evaluating these antibodies in cord blood.

CONCLUSION

High levels of free thyroid hormones during the second trimester of pregnancy and antibodies directed to the thyrotropin receptor value in cord blood are predictors of dysthyroidism in neonates born from women with Grave's disease.

Novel Biomarkers for Evaluation of Endothelial Dysfunction

Endothelial dysfunction is one of the earliest indicators of cardiovascular (CV) dysfunction, and its evaluation would be of considerable importance to stratify CV risk of many diseases and to assess the efficacy of atheroprotective treatments. Flow-mediated dilation is the most widely used method to study endothelial function. However, it is operator-dependent and can be influenced by physiological variations. Circulating biomarkers are a promising alternative. Due to the complexity of endothelial function, many of the biomarkers studied do not provide consistent information about the endothelium when measured alone. New circulating markers are being explored and some of them are thought to be suitable for the clinical setting. In this review, we focus on novel biomarkers of endothelial dysfunction, particularly endothelial microparticles, endocan, and endoglin, and discuss whether they fulfill the criteria to be applied in clinical practice.

CYP21A2 Gene Pathogenic Variants: A Multicenter Study on Genotype-Phenotype Correlation from a Portuguese Pediatric Cohort

BACKGROUND

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21OHD) is an autosomal recessive disorder characterized by 3 overlapping phenotypes: salt-wasting (SW), simple virilizing (SV), and non-classic (NC). We aimed at conducting a nationwide genotype description of the CAH pediatric patients and to establish their genotype-phenotype correlation.

METHODS

CAH patients were recruited from Portuguese pediatric endocrinology centers and classified as SW, SV, or NC. Genetic analysis was performed by polymerase chain reaction (sequence specific primer, restriction fragment length polymorphism) or direct Sanger sequencing. Genotypes were categorized into 4 groups (0, A, B, and C), according to their predicted enzymatic activity. In each group, the expected phenotype was compared to the observed phenotype to assess the genotype-phenotype correlation.

RESULTS

Our cohort comprises 212 unrelated pediatric CAH patients (29% SW, 11% SV, 60% NC). The most common pathogenic variant was p.(Val282Leu; 41.3% of the 424 alleles analyzed). The p.(Val282Leu) variant, together with c.293-13A/C>G, p.(Ile173Asn), p.(Leu308Thr), p.(Gln319*), and large deletions/conversions were responsible for 86.4% of the mutated alleles. Patients' stratification by disease subtype revealed that the most frequent pathogenic variants were c.293-13A/C>G in SW (31.1%), p.(Ile173Asn) in SV (46.9%), and p.(Val282Leu) in NC (69.5%). The most common genotype was homozygosity for p.(Val282Leu; 33.0%). Moreover, we found 2 novel variants: p.(Ile161Thr) and p.(Trp202Arg), in exons 4 and 5, respectively. The global genotype-phenotype correlation was 92.4%. Group B (associated with the SV form) showed the lowest genotype-phenotype correlation (80%).

CONCLUSION

Our cohort has one of the largest NC CAH pediatric populations described. We emphasize the high frequency of the p.(Val282Leu) variant and the very high genotype-phenotype correlation observed.

P5237Continued financial benefits of LATIN telemedicine program from avoiding unnecessary transfer of patients

Background

Latin America Telemedicine Infarct Network (LATIN) employed telemedicine to construct a population-based AMI program in Brazil, Colombia, Mexico, and Argentina. It increased access, accuracy and guidelines-based care and addressed fiscal issues. Previously, we demonstrated a cost and benefit analysis (CBA) of LATIN based upon avoiding unnecessary transfers and hospitalization. We have performed a scrupulous follow up of this initial observation with a long-term follow up from all expanded LATIN sites.

Purpose

To demonstrate that telemedicine avoids unnecessary transfer of patients.

Methods

784,947 patients at LATIN spokes (small clinics in remote areas) were screened and CBA measured at hubs, spokes and telemedicine centers. Technology, transfer, inpatient, and procedure-related costs were included. A sensitivity analysis was performed for worst and best scenarios of costs, revenues, and savings. A comparison with Avera e-Emergency (Sioux Falls, SD) Telemedicine program, involving 85 rural hospitals in 7 states, is provided (13% transfer avoidance).

Results

Of 784,947 screened patients, 8,448 had STEMI (1.08%); 3,911 (46.3%) were urgently reperfused, 3,049 (78%) with PPCI. Time to Telemedicine Diagnosis was 3 min. With efficient triage, costs for non-AMI patients was controlled. LATIN expenses, including for IT and experts, were $272, and for transfer and indirect care, $1,068. Net savings/patient were $796. Savings, till date, range between $187.4 million and $62.4 million (Best scenario −30% transfer avoidance; Worse scenario −10% transfer avoidance).

Conclusions

Longitudinal analysis firms the trend of enormous cost savings with LATIN. Telemedicine avoids unnecessary transfers and hospitalization and it is a cost-effective strategy for population-based AMI programs.

P1741Hitting the wall in converting diagnosed ST-elevation myocardial infarction patients to treating them: a humbling analysis from LATIN telemedicine

Background

The behemoth telemedicine program, Latin America Telemedicine Infarct Network (LATIN) has exponentially grown in 4 countries in Central and South America. It has provided AMI coverage to >100 million patients and it has contributed to transforming AMI care in the continent by its “halo” effect. We continue our meticulous search in evaluating the impact of LATIN and in doing so, we have confronted a sobering reality.

Purpose

To make continued improvements in population-based AMI management, the continued success of the initiative requires participation from healthcare policy makers, health economists, and payers.

Methods

LATIN was created as a hub and spoke model to hugely increase access (>100 million population coverage) to quality AMI treatment primarily with short door to balloon time (D2B) PCI. Innovative telemedicine platforms were created and networked at all 350 centers that were located in small clinics and primary health centers in poor sections of the countries (spokes) and at 24/7 PCI capable institutions (hubs). Remote cardiologists, located in 3 central locations, provided immediate EKG diagnosis (time to telemedicine diagnosis, TTD <3.5 minutes) and they provided expert guidance for the entire STEMI process, Door in Door Out (DIDO), and transport times (TT). LATIN performance metrics, under its strict control, and including process metrics at the hubs, spokes, and at the command telemedicine sites, were measured and plotted. The macroeconomic variables of insurance approvals, ambulance structure, and availability of ICU beds were determined and incorporated into performance variables of the LATIN program.

Results

784,395 patients were screened at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). With expanded reach, 8,440 (1.08%) patients were diagnosed and 3,924 (46.5%) urgently reperfused, including 3,048 (77.7%) with PCI. Time to Telemedicine Diagnosis (TTD) was 3 min, tele-accuracy 98.9%, D2B 51 min, and in-hospital mortality 5.2%. Over 4 years of operation, the proportion of reperfused STEMI patients has ranged between 41–48% - the major reasons for non-treatment were insurance, lack of ICU beds and delayed presentation.

Conclusions

Sustained improvements, as a result of stringent QA processes and continuous education, have resulted in reduced D2B, TTD, DIDO, TT, and in overall mortality. However, LATIN remains constrained with a large proportion of patients that are diagnosed but not treated, largely because of payer denials. Although this metric is showing improvement from broad dissemination of LATIN benefits, further gains from LATIN will result mainly from improved reimbursements.

Should the Energy Contribution of Commercial Thickeners Be Considered in the Nutrition Plan of Patients With Dysphagia?

BACKGROUND

Clinical management options for dysphagia include the use of thickeners to increase the consistency of liquids. Health professionals may not be aware of the nutrition value of these products, since there are no such recommendation in clinical guidelines. Our aim was to estimate the added nutrition value of the 2 types of commercial thickeners (starch and xanthan gum) to daily nutrition intake and compare their nutrition value for nectar, honey, and pudding consistencies. Additionally, we compared the nutrition value of both thickeners with a high-energy powder, since they share the same main ingredients.

METHODS

We collected recommended dosages for obtaining the 3 different consistencies and nutrition content from the technical food labels. Daily intake of fluids was estimated from the Portuguese National Food, Nutrition and Physical Activity Survey. Total daily amount of thickener needed was estimated, as well as their correspondent nutrition contributions.

RESULTS

Estimated daily fluid intake was 2439 mL. Starch thickeners provide significantly more energy at all consistencies than xanthan gum provides (423-846 kcal, P < 0.05, and 103-308 kcal, P < 0.05, respectively). Significantly more fiber is provided by xanthan gum thickeners (9 g in nectar and 27 g in pudding consistencies, P < 0.05). Median energy and carbohydrate values per 100 g of high-energy powder modules and starch thickeners are similar.

CONCLUSION

The nutrition value of thickeners should be routinely considered in the nutrition assessment and planning of patients with dysphagia for liquids, since they contribute significantly with energy, carbohydrate, and fiber.

The spectrum of pediatric adrenal insufficiency: insights from 34 years of experience

Background Adrenal insufficiency (AI) is a life-threatening disease characterized by deficient production of glucocorticoids and/or mineralocorticoids. It is caused by primary or secondary/tertiary adrenal failure. Prompt diagnosis and management are essential and may even be life-saving. Methods We retrospectively collected clinical, laboratory and radiological data from AI patients observed over 34 years (1984-2017) in a pediatric endocrinology department of a tertiary care hospital. Results Seventy AI patients were identified: 59% with primary adrenal insufficiency (PAI) and 41% with central adrenal insufficiency (CAI). PAI patients were diagnosed at 1.5 ± 4.4 years and followed for 11.6 ± 6.2 years; 85% had classical congenital adrenal hyperplasia (CAH) and 7% had autoimmune PAI. At presentation, 73% had hyponatremia and more than half had mucocutaneous hyperpigmentation, asthenia, anorexia, weight loss, nausea and vomiting. All the patients were treated with hydrocortisone and 90% were also on fludrocortisone. Regarding CAI patients, they were diagnosed at 5.4 ± 5.0 years and they were followed for 9.6 ± 6.4 years; craniopharyngioma was present in 31% of the cases and 14% had pituitary hypoplasia. Besides corticotropin, thyrotropin (93%), growth hormone (63%) and antidiuretic hormone (52%) were the most common hormone insufficiencies. The most frequent manifestations were hypoglycemia (34.5%), nausea/vomiting (27.6%) and infectious diseases (27.6%); all the patients were treated with hydrocortisone. Conclusions Despite medical advances, the diagnosis and management of AI remains a challenge, particularly in the pediatric population. Raising awareness and knowledge in medical teams and population about the disease is of crucial importance to improve clinical outcomes and to reduce disease morbidity/mortality.

Congenital hyperreninemic hypoaldosteronism due to aldosterone synthase deficiency type I in a Portuguese patient - Case report and review of literature

Hyperreninemic hypoaldosteronism due to aldosterone synthase (AS) deficiency is a rare condition typically presenting as salt-wasting syndrome in the neonatal period. A one-month-old Portuguese boy born to non-consanguineous parents was examined for feeding difficulties and poor weight gain. A laboratory workup revealed severe hyponatremia, hyperkaliaemia and high plasma renin with unappropriated normal plasma aldosterone levels, raising the suspicion of AS deficiency. Genetic analysis showed double homozygous of two different mutations in the CYP11B2 gene: p.Glu198Asp in exon 3 and p.Val386Ala in exon 7. The patient maintains regular follow-up visits in endocrinology clinics and has demonstrated a favourable clinical and laboratory response to mineralocorticoid therapy. To our knowledge, this is the first Portuguese case of AS deficiency reported with confirmed genetic analysis.

Imbalance of Steroid Hormones in Hamsters Infected with Schistosoma mansoni

OBJECTIVE

Schistosomiasis is a debilitating disease that affects 200 million people worldwide. Schistosoma haematobium and Schistosoma mansoni are the major causative agents of this disease. Cancer-association and infertility-association in Schistosoma haematobium infection have already been described and it is known that the parasite produces a catechol-estrogen molecule that induces a hormonal imbalance in the host.

METHODS

In order to better understand the relation of hormonal imbalance in experimental Schistosoma mansoni infection, we investigated a serum panel of steroid hormones in Schistosoma mansoni infected hamsters.

RESULTS

We found a decrease in the serum levels of Estradiol (E2), Testosterone and Progesterone in infected females and an increase of Testosterone and a decrease in Progesterone in infected males in comparison with controls.

CONCLUSION

These results indicate that S. mansoni alters the levels of steroid hormones in infected males and females and it will increase the repertoire of data about the host-parasite molecular interplay and its relation with the endocrine system.

Dysphagia predicts poor outcome in late-stage Parkinson's disease

BACKGROUND

Few data exist on the rate of clinical progression for Parkinson's disease (PD) patients who have entered a late stage of the disease.

OBJECTIVE

Study the clinical progression of a late-stage PD (LSPD) population over one year follow-up.

METHODS

50 LSPD patients (Schwab and England ADL Scale <50 or Hoehn Yahr Stage >3 in MED ON) underwent an extensive clinical assessment at baseline and after one year and an acute levodopa test at baseline.

RESULTS

Mean age of LSPD patients (female 46%) was 77.5 ± 5.9 years and mean disease duration was 15.5 ± 6.5 years. At baseline, 76% had levodopa-induced motor complications (MC), usually non-troublesome, 68% were demented, 54% had psychosis and 68% depression. Caregiver distress was high. l-dopa responsiveness was mild (18% ± 12 of improvement on MDS-UPDRS-III). After one-year, 20% of the patients were dead, institutionalized or HY 5. MDS-UPDRS-motor mean score worsened 7.2 ± 10.3 points although there was heterogeneity between patients, and there was a global worsening of non-motor symptoms, mostly in cognition/mood, urinary and gastrointestinal domains. Nevertheless, MC improved despite similar levodopa equivalent dose. Functional independence and quality of life worsened. Dysphagia severity at baseline predicted a poor outcome (death, institutionalization or HY 5) (Hazard ratio 2.3, 95% CI 1.12-4.4; p = 0.01), whereas magnitude of l-dopa response of LSPD patients did not.

CONCLUSIONS

LSPD patients still present a significant, although heterogeneous, motor and non-motor progression over 1 year. Dysphagia severity predicts the occurrence of additional disease severity milestones and its management must be prioritized.

Parasites in Forensic Science: a historic perspective

Parasites show a great potential to Forensic Science. Forensic Science is the application of any science and methodology to the legal system. The forensic scientist collects and analyses the physical evidence and produce a report of the results to the court. A parasite is an organism that lives at the expense of another and they exist in any ecosystem. Parasites are the cause of many important diseases. The forensic scientists can use the parasites to identify a crime scene, to determine the murder weapon or simply identify an individual. The applications for parasites in the Forensic Science can be many and more studies should be made in Forensic Parasitology. The most important parasites in Forensic Science are helminths specifically schistosomes. Through history there are many cases where schistosomes were described in autopsies and it was related to the cause of death. Here we review the applications of parasites in Forensic Science and its importance to the forensic scientist.

Psychosocial impact of Parkinson's disease-associated dysarthria: Cross-cultural adaptation and validation of the Dysarthria Impact Profile into European Portuguese

AIM

The present study sought to make a cross-cultural adaptation of the Dysarthria Impact Profile (DIP) for European Portuguese (EP) and validate it for use in Parkinson's disease (PD) patients.

METHODS

The cross-cultural adaptation was carried out in accordance with the guidelines. The EP version of the DIP was administered to 80 people with PD, and 30 sex- and age-matched control participants. Psychometric properties, acceptability, feasibility reliability (internal consistency and intrarater agreement) and validity (construct, convergent and known-groups validity) were assessed using other assessment tools (motor disability and impairment, and voice impact).

RESULTS

Overall, the EP-DIP final version has the same conceptual meaning, semantics, idiomatic and score equivalences as the original version. Statistical analyses showed adequate feasibility (missing data <5%), good acceptability (ceiling or floor effects <15%; high requests of assistance to complete the questionnaire), satisfactory internal consistency (Cronbach's α = 0.9), weak-to-moderate intrarater reliability, good construct validity, strong convergent validity (with the Voice Handicap Index; Spearman's P = -0.8) and good known-groups validity (between those with PD and control participants).

CONCLUSIONS

The EP-DIP version displays the salient features of a valid patient-based assessment tool used to measure the psychosocial impact of slight-to-mild dysarthria in people with PD. Geriatr Gerontol Int 2018; 18: 767-774.

Modulation of cis- and trans- Golgi and the Rab9A-GTPase during infection by Besnoitia besnoiti, Toxoplasma gondii and Neospora caninum

Like most intracellular pathogens, the apicomplexan parasites Besnoitia besnoiti, Toxoplasma gondii and Neospora caninum scavenge metabolites from their host cells. Recruitment of the Golgi complex to the vicinity of the parasitophorous vacuole (PV) is likely to aid in this process. In this work, we comparatively assessed B. besnoiti, T. gondii and N. caninum infected human retinal pigmented epithelial (hTERT-RPE-1) cells at 24 h post-infection and used antibodies to confirm Golgi ribbon compaction in B. besnoiti, and Golgi ribbon dispersion in T. gondii, while no alteration in Golgi morphology was seen in N. caninum infected cells. In either case, the Golgi stacks of infected cells contained both cis- (GM130) and trans- (TGN46) Golgi proteins. The localization of Rab9A, an important regulator of endosomal trafficking, was also studied. GFP-tagged Rab9A was recruited to the vicinity of the PV of all three parasites. Toxoplasma-infected cells exhibited increased expression of Rab9A in comparison to non-infected cells. However, Rab9A expression levels remained unaltered upon infection with N. caninum and B. besnoiti tachyzoites. In contrast to Rab9A, a GFP-tagged dominant negative mutant form of Rab9A (Rab9A DN), was not recruited to the PV, and the expression of Rab9A DN did not affect host cell invasion nor replication by all three parasites. Thus, B. besnoiti, T. gondii and N. caninum show similarities but also differences in how they affect constituents of the endosomal/secretory pathways.

Speech and Voice Response to a Levodopa Challenge in Late-Stage Parkinson's Disease

BACKGROUND

Parkinson's disease (PD) patients are affected by hypokinetic dysarthria, characterized by hypophonia and dysprosody, which worsens with disease progression. Levodopa's (l-dopa) effect on quality of speech is inconclusive; no data are currently available for late-stage PD (LSPD).

OBJECTIVE

To assess the modifications of speech and voice in LSPD following an acute l-dopa challenge.

METHOD

LSPD patients [Schwab and England score <50/Hoehn and Yahr stage >3 (MED ON)] performed several vocal tasks before and after an acute l-dopa challenge. The following was assessed: respiratory support for speech, voice quality, stability and variability, speech rate, and motor performance (MDS-UPDRS-III). All voice samples were recorded and analyzed by a speech and language therapist blinded to patients' therapeutic condition using Praat 5.1 software.

RESULTS

24/27 (14 men) LSPD patients succeeded in performing voice tasks. Median age and disease duration of patients were 79 [IQR: 71.5-81.7] and 14.5 [IQR: 11-15.7] years, respectively. In MED OFF, respiratory breath support and pitch break time of LSPD patients were worse than the normative values of non-parkinsonian. A correlation was found between disease duration and voice quality (R = 0.51; p = 0.013) and speech rate (R = -0.55; p = 0.008). l-Dopa significantly improved MDS-UPDRS-III score (20%), with no effect on speech as assessed by clinical rating scales and automated analysis.

CONCLUSION

Speech is severely affected in LSPD. Although l-dopa had some effect on motor performance, including axial signs, speech and voice did not improve. The applicability and efficacy of non-pharmacological treatment for speech impairment should be considered for speech disorder management in PD.

Platelets Structure, Function and Modulator Capacity in Replacement Therapy

INTRODUCTION

Patients with severe thrombocytopenia are presumed to be at increased risk for bleeding, and consequently it has been a standard practice for the past four decades to give allogeneic platelet transfusions to severely thrombocytopenic patients as supportive care. Platelet transfusions may be given either prophylactically to reduce the risk of bleeding, in the absence of clinical hemorrhage (prophylactic transfusions), or to control active bleeding when present (therapeutic transfusions).

CONCLUSION

Here we review the structure and function of platelets and discuss the mechanisms of alloimmunization to platelet transfusion.

Dysarthria in individuals with Parkinson's disease: a protocol for a binational, cross-sectional, case-controlled study in French and European Portuguese (FraLusoPark)

INTRODUCTION

Individuals with Parkinson's disease (PD) have to deal with several aspects of voice and speech decline and thus alteration of communication ability during the course of the disease. Among these communication impairments, 3 major challenges include: (1) dysarthria, consisting of orofacial motor dysfunction and dysprosody, which is linked to the neurodegenerative processes; (2) effects of the pharmacological treatment, which vary according to the disease stage; and (3) particular speech modifications that may be language-specific, that is, dependent on the language spoken by the patients. The main objective of the FraLusoPark project is to provide a thorough evaluation of changes in PD speech as a result of pharmacological treatment and disease duration in 2 different languages (French vs European Portuguese).

METHODS AND ANALYSIS

Individuals with PD are enrolled in the study in France (N=60) and Portugal (N=60). Their global motor disability and orofacial motor functions is assessed with specific clinical rating scales, without (OFF) and with (ON) pharmacological treatment. 2 groups of 60 healthy age-matched volunteers provide the reference for between-group comparisons. Along with the clinical examinations, several speech tasks are recorded to obtain acoustic and perceptual measures. Patient-reported outcome measures are used to assess the psychosocial impact of dysarthria on quality of life.

ETHICS AND DISSEMINATION

The study has been approved by the local responsible committees on human experimentation and is conducted in accordance with the ethical standards. A valuable large-scale database of speech recordings and metadata from patients with PD in France and Portugal will be constructed. Results will be disseminated in several articles in peer-reviewed journals and in conference presentations. Recommendations on how to assess speech and voice disorders in individuals with PD to monitor the progression and management of symptoms will be provided.

TRIAL REGISTRATION NUMBER

NCT02753192, Pre-results.

Type 1 diabetes and GAD65 limbic encephalitis: a case report of a 10-year-old girl

Limbic encephalitis is a rare neurological disorder that may be difficult to recognize. Clinical features include memory impairment, temporal lobe seizures and affective disturbance. We report the case of a 10-year-old girl with type 1 diabetes mellitus that presented with seizures, depressed mood and memory changes. The diagnosis of glutamic acid decarboxylase 65 (GAD65) mediated limbic encephalitis relied on cerebral magnetic resonance imaging lesions and high serological and cerebrospinal fluid GAD65-antibodies titers. High-dose steroidal therapy was started with clinical improvement. Relapse led to a second high-dose steroid treatment followed by rituximab with remission. A correlation between serum GAD65-antibodies levels and symptoms was found, demonstrating GAD65-antibodies titers may be useful for clinical follow-up and immunotherapy guidance. This report raises awareness of this serious neurological condition that may be associated with type 1 diabetes, underlining the importance of an early diagnosis and prompt treatment for a better prognosis.

Autoimmune alternating hyper- and hypo-thyroidism: a rare condition in pediatrics

Alternating between hyper- and hypo-thyroidism may be explained by the simultaneous presence of both types of TSH receptor autoantibodies (TRAbs) – thyroid stimulating autoantibodies (TSAbs) and TSH blocking autoantibodies (TBAbs). It is a very rare condition, particulary in the pediatric age. The clinical state of these patients is determined by the balance between TSAbs and TBAbs and can change over time. Many mechanisms may be involved in fluctuating thyroid function: hormonal supplementation, antithyroid drugs and levels of TSAbs and TBAbs. Frequent dose adjustments are needed in order to achieve euthyroidism. A definitive therapy may be necessary to avoid switches in thyroid function and frequent need of therapeutic changes. We describe an immune-mediated case of oscillating thyroid function in a 13-year-old adolescent. After a short period of levothyroxine treatment, the patient switched to a hyperthyroid state that was only controlled by adding an antithyroid drug.

Rad54 and Mus81 cooperation promotes DNA damage repair and restrains chromosome missegregation

Rad54 and Mus81 mammalian proteins physically interact and are important for the homologous recombination DNA repair pathway; however, their functional interactions in vivo are poorly defined. Here, we show that combinatorial loss of Rad54 and Mus81 results in hypersensitivity to DNA-damaging agents, defects on both the homologous recombination and non-homologous DNA end joining repair pathways and reduced fertility. We also observed that while Mus81 deficiency diminished the cleavage of common fragile sites, very strikingly, Rad54 loss impaired this cleavage to even a greater extent. The inefficient repair of DNA double-strand breaks (DSBs) in Rad54(-/-)Mus81(-/-) cells was accompanied by elevated levels of chromosome missegregation and cell death. Perhaps as a consequence, tumor incidence in Rad54(-/-)Mus81(-/-) mice remained comparable to that in Mus81(-/-) mice. Our study highlights the importance of the cooperation between Rad54 and Mus81 for mediating DNA DSB repair and restraining chromosome missegregation.

Na, K, Ca, Mg, and U-series in fossil bone and the proposal of a radial diffusion-adsorption model of uranium uptake

Fossil bones are often the only materials available for chronological reconstruction of important archeological sites. However, since bone is an open system for uranium, it cannot be dated directly and therefore it is necessary to develop models for the U uptake. Hence, a radial diffusion-adsorption (RDA) model is described. Unlike the classic diffusion-adsorption (D-A) model, RDA uses a cylindrical geometry to describe the U uptake in fossil bones. The model was applied across a transverse section of a tibia of an extinct megamammal Macrauchenia patachonica from the La Paz Local Fauna, Montevideo State, Uruguay. Measurements of spatial distribution of Na, K, Ca, and Mg were also performed by neutron activation analysis (NAA). Gamma-ray spectrometric U-series dating was applied to determine the age of the bone sample. From U concentration profile, it was possible to observe the occurrence of a relatively slow and continuous uranium uptake under constant conditions that had not yet reached equilibrium, since the uranium distribution is a ∪-shaped closed-system. Predictions of the RDA model were obtained for a specific geochemical scenario, indicating that the effective diffusion coefficient D/R in this fossil bone is (2.4 ± 0.6)10(-12) cm(2)s(-1). Mean values of Na, K, Ca, and Mg contents along the radial line of the fossil tibia are consistent with the expected behavior for spatial distributions of these mineral elements across a modern bone section. This result indicates that the fossil tibia may have its mineral structure preserved.