THE IMPACT OF NEUTROPHIL-TOLYMPHOCYTE RATIO AND PLATELETTO- LYMPHOCYTE RATIO IN CAROTID ARTERY DISEASE

INTRODUCTION

Inflammation is a common underlying feature of atherosclerosis. Several inflammatory biomarkers have been reported to have prognostic value, in several areas, including in vascular surgery. The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) may permit to identify patients at greater risk for cerebrovascular events, tailor patient management, improve preoperative status and possibly develop target anti-atherosclerotic therapy. However, studies reporting usefulness of these hematological biomarkers in the context of carotid artery disease are still scarce. The aim of this study was to review the literature concerning the prognostic ability of NLR and PLR in the subpopulation of vascular patients with carotid artery disease.

METHODS

A Medline search was performed in order to identify publications focused on the physiopathology of NLR and PLR and their impact in the management of patients with carotid artery disease.

RESULTS

The study identified 18 articles with a total of 5339 patients. NLR is associated with carotid intima-media thickness, carotid plaques, carotid stenosis, symptomatic stenosis and intra-stent restenosis after carotid artery stenting and cognitive dysfunction after carotid endarterectomy. PLR is associated with carotid stenosis, symptomatic stenosis and predicts post-operative outcomes after carotid artery revascularization, including post-operative stroke, acute coronary syndrome and all-cause mortality.

CONCLUSIONS

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have the ability to predict sub-clinic atherosclerosis, atherosclerosis progression in carotid artery disease and propensity for carotid stenosis to become symptomatic along with morbidity following CEA and carotid stenting. Consequently, these parameters may be considered to tailored therapy and improve patient management.

Red blood cell distribution width is associated with hypoperfusion in carotid endarterectomy under regional anesthesia

BACKGROUND

A subset of patients submitted to carotid endarterectomy under regional anesthesia develop intraoperative neurologic deficit during carotid artery crossclamping related to critical cerebral perfusion, which may be owing to low flow or embolic phenomena. This subgroup is deemed prone to worse outcomes, which highlights its clinical relevance. The main aim of this study was to identify clinical and hematological predictors for intraoperative neurologic deficit. The secondary aim was to evaluate the perioperative prognostic value of postcarotid artery crossclamping manifestations of cerebral ischemia.

METHODS

Between January 2012 to January 2020, patients submitted to carotid endarterectomy under regional anesthesia in a tertiary referral center who presented intraoperative neurologic deficit were prospectively and consecutively included. This group constituted 8% of the total carotid endarterectomy performed in the center during this timeframe. The control group of patients was the subsequent patient submitted to carotid endarterectomy without intraoperative neurologic deficit in a 1:1 ratio. Blood samples were collected before surgery (<2 weeks). Propensity score matching was used to identify well-matched pairs of patients.

RESULTS

A total of 180 patients were included, with 90 (50% of the cohort and 8% of total carotid endarterectomies) presenting intraoperative neurologic deficit associated to clamping. Mean age was 71.4 ± 9.27 years in the study group and 68.8 ± 8.36 years in the control group. The clinical variables presenting significance after multivariate analysis include: age (adjusted odds ratio: 1.04, 5-95% confidence interval, [1.003-1.078]; P = .034), obesity (adjusted odds ratio: 3.537 [1.445-8.658]; P = .006), lower ipsilateral carotid stenosis grade (adjusted odds ratio: 0.725 [0.525-0.997]; P = .049), and higher contralateral carotid stenosis grade (adjusted odds ratio: 1.266 [1.057-1.516]; P = .010). Red cell distribution width coefficient of variation demonstrated statistical significance in predicting intraoperative neurologic deficit with an adjusted odds ratio of 1.394 (1.076-1.805); P = .012. The 30-day stroke rate was significantly higher in the intraoperative neurologic deficit group, with an adjusted odds ratio of 5.13 (5-95% confidence interval [1.058-24.87]; P = .042) after propensity score matching. Postoperative complications (Clavien-Dindo ≥2) were also associated with intraoperative neurologic deficit (after propensity score matching adjusted odds ratio of 2.748 [5-95% confidence interval, 0.976-7.741]; P = .051).

CONCLUSION

In this study, increased red cell distribution width coefficient of variation demonstrated value to predict intraoperative neurologic deficit. Additionally, age, obesity, a lower degree of ipsilateral carotid stenosis, and a higher degree of contralateral carotid stenosis also demonstrated ability to predict intraoperative neurologic deficit. Moreover, intraoperative neurologic deficit was an independent risk factor for 30-day stroke and postoperative complications Clavien-Dindo ≥2.

Bioactive zinc-doped sol-gel coating modulates protein adsorption patterns and in vitro cell responses

Zinc is an essential element with an important role in stimulating the osteogenesis and mineralization and suppressing osteoclast differentiation. In this study, new bioactive ZnCl₂-doped sol-gel materials were designed to be applied as coatings onto titanium. The biomaterials were physicochemically characterized and the cellular responses evaluated in vitro using MC3T3-E1 osteoblasts and RAW264.7 macrophages. The effect of Zn on the adsorption of human serum proteins onto the material surface was evaluated through nLC-MS/MS. The incorporation of Zn did not affect the crosslinking of the sol-gel network. A controlled Zn²⁺ release was obtained, reaching values below 10 ppm after 21 days. The materials were no cytotoxic and lead to increased gene expression of ALP, TGF-β, and RUNX2 in the osteoblasts. In macrophages, an increase of IL-1β, TGF-β, and IL-4 gene expression was accompanied by a reduced TNF-α liberation. Proteomic results showed changes in the adsorption patterns of proteins associated with immunological, coagulative, and regenerative functions, in a Zn dose-dependent manner. The variations in protein adsorption might lead to the downregulation of the NF-κB pathway, thus explain the observed biological effects of Zn incorporation into biomaterials. Overall, these coatings demonstrated their potential to promote bone tissue regeneration.

Complex Aortoiliac Pelvic And Visceral Revascularization

Aortoiliac occlusive disease (AIOD) remains an area of debate concerning open and endovascular treatment options. A case of a 63-year old female is reported, with previous known vascular intermittent claudication, that presented in the emergency room with acute ischemia of the right lower limb with 24-hours of evolution. The computer tomographic angiography unveiled occlusion of the superior mesenteric artery, occlusion of left common iliac artery (CIA), subocclusive stenosis of right CIA, occlusion of distal runoffs vessels in the right lower limb and diffuse aorto-iliac disease. The first approach was to place the patient under catheter directed thrombolysis (48h) which led to right pedal pulse recovery but the occlusion of left CIA remained. The patient was then electively submitted to Covered Endovascular Repair of Aortic Bifurcation (CERAB) with chimney to inferior mesenteric artery and with an additional bailout left iliac sandwich due to dissection. Distal pulses are still present after 18 months of follow-up. Endovascular techniques provide a low morbimortality option with similar symptomatic improvement, challenging open surgery as the standard of care even in complex AIOD.

Validation of Anthropometric Measures Self-Reported in a Randomized Controlled Trial of a Web-Based Platform for Weight Loss

INTRODUCTION

A great number of weight loss interventions have been delivered through digital solutions. Analysis of the effectiveness in terms of weight loss is fundamental to understand the real potential of digital technologies as tools for delivery of weight loss interventions. For this, we need accurate and reliable anthropometric data. For reasons of convenience, self-reported weight and height often replace actual measurements in these interventions. This might lead to misclassification of BMI status during selection of participants and to bias in the assessment of the outcomes. Therefore, it is fundamental to have validation studies of self-reported web-based data.

OBJECTIVES

We aimed to validate online self-reported height, weight and BMI in a POEmaS trial subsample.

METHODS

We included 12.5% of the POEmaS' population (n=159). Anthropometric data reported on the web-platform were compared to measured data by paired T-tests. Agreement was assessed by Bland-Altman plots. Multinomial regression was used to investigate factors associated with self-reported weight validity.

RESULTS

There was no significant difference between reported and measured weight (0.4 kg, SD 1.7; p=0.13) and BMI (0.03 kg/m2, SD 0.87; p=0.06). Reported height was on average 0.4 cm (SD 1.2) higher than the measured ones (p<0.001). For all anthropometric data, >=95% of the cases were within the limits of agreement. Higher measured BMI was the only factor associated with low accuracy of weight report. Each unit increase in BMI increased the odds that the reported weight was lower than the one measured (OR 1.13; 95%CI 1.01-1.26).

DISCUSSION

Self-reported weight and BMI change showed good agreement with measured ones. Since these are the primary outcomes of the POEmaS trial, the findings of the validation study suggest that the outcomes' accuracy is high and that it does not vary across gender, age, study group. These findings are relevant to digital health researchers and assessors and suggest that digital health interventions for weight loss might rely on self-reported assessment of outcomes. This might be particularly useful when other modes of assessment, such as anthropometry and e-scales, are not feasible or not available. However, we acknowledge that these results might not be applicable to low educated populations.

Proteomic analysis of calcium-enriched sol-gel biomaterials

Calcium is an element widely used in the development of biomaterials for bone tissue engineering as it plays important roles in bone metabolism and blood coagulation. The Ca ions can condition the microenvironment at the tissue-material interface, affecting the protein deposition process and cell responses. The aim of this study was to analyze the changes in the patterns of protein adsorption on the silica hybrid biomaterials supplemented with different amounts of CaCl₂, which can function as release vehicles. This characterization was carried out by incubating the Ca-biomaterials with human serum. LC-MS/MS analysis was used to characterize the adsorbed protein layers and compile a list of proteins whose affinity for the surfaces might depend on the CaCl₂ content. The attachment of pro- and anti-clotting proteins, such as THRB, ANT3, and PROC, increased significantly on the Ca-materials. Similarly, VTNC and APOE, proteins directly involved on osteogenic processes, attached preferentially to these surfaces. To assess correlations with the proteomic data, these formulations were tested in vitro regarding their osteogenic and inflammatory potential, employing MC3T3-E1 and RAW 264.7 cell lines, respectively. The results confirmed a Ca dose-dependent osteogenic and inflammatory behavior of the materials employed, in accordance with the protein attachment patterns.

True Brachial Artery Aneurysm after Arteriovenous Fistula for Hemodialysis - Case Report

INTRODUCTION

Brachial artery aneurysms are relatively uncommon and generally due to infectious, post-traumatic or iatrogenic etiology. They seem to affect 4.5% of arteriovenous fistula. The usual manifestation is an accidental finding of a pulsatile, painless, and asymptomatic mass. Complications include sac thrombosis, thromboembolic ischaemic events, and disruption with profuse bleeding.

METHODS

The aim of this study is to present a case of true brachial artery aneurysm in end-stage renal disease patient after arteriovenous fistula creation.

RESULTS

Sixty-six-year-old men with a past medical history of hypertension, dyslipidemia, smoking and poliquistic renal disease. He started a hemodialysis program in March 2006, using a brachiocephalic fistula on the left upper limb, built in February 2005. Submitted to kidney transplant in June 2010 and subsequent fistula ligation in December 2012. He goes to the emergency service in June 2016 with a pulsatile mass on the medial aspect of the left arm. Pain, redness and heat were present. Radial pulse was palpable. Inflammatory parameters were high and ultrasound revealed a fusiform aneurysm of the brachial artery with partial thrombosis and triphasic flow. An MRI was performed, documenting a brachial artery aneurysm, with 44mm greatest diameter and an extension of 17.5cm. Patient was hospitalized under antibiotic therapy and submitted to a reversed great saphenous vein interposition graft. Discharge from hospital occurred on the 7th postoperative day, with no sensitive or motor deficits and a present radial pulse.

CONCLUSION

Arterial aneurysm is a rare, but significant complication long after the creation of a hemodialysis access. High flow, immunosuppression and increased resistance following ligation of the AV fistula may accelerate this process.

Renal transplantation in human immunodeficiency virus-positive patients: a report of four cases

INTRODUCTION

Renal transplantation (RT) in patients infected with human immunodeficiency virus (HIV) has significantly improved under the advent of combined antiretroviral therapy (cART). The authors describe their experience in RT in patients with HIV from September 2010 to June 2013.

CASES REPORT

Four patients underwent transplantation (3 with HIV-1 and 1 with HIV-2), three patients were male, and one was black. None were coinfected with hepatitis B virus (HBV) or hepatitis C virus (HCV). Etiology of kidney disease was HIV-associated nephropathy (2 patients), immunoglobulin (Ig)A nephropathy, and unknown. Average age at RT was 51 (range, 41-63) years. No patient was of high immunologic risk. Immunosuppression consisted of basiliximab for induction and prednisolone, tacrolimus (TAC), and mycophenolate mofetil for maintenance. TAC levels varied considerably in the early days (8.5-46 ng/mL), requiring major adjustments in TAC dose. Only the HIV-2 patient had delayed graft function. The follow-up of patients with HIV-1 was 37, 19, and 16 months, and 3 months for the HIV-2 patient. CD4+ T cells decreased in the early days after transplantation with subsequent improvement, along with persistent virological suppression. In the HIV-1 group there were no major infectious, cardiovascular, or neoplastic complications. Nevertheless, the HIV-2 patient died 3 months after RT due to H1N1 pneumonia complicated by pulmonary aspergillosis. Average estimated (CKD- EPI) glomerular filtration rate (eGFR) at 6 months was 85.6 mL/min/1.73 m(2).

CONCLUSION

Besides the difficulty in adjusting calcineurin inhibitors levels due to its interaction with antiretroviral therapy, namely with protease inhibitors, no patient had acute rejection. Furthermore, all patients presented an excellent control of viro-immunologic parameters. At the last follow-up neither cardiovascular events nor neoplastic complications were observed. Our results highlight the favorable outcome of RT in HIV-1-infected patients. The HIV-2 patient died due to severe infection, and the clinical management and potential benefit of RT in HIV-2-infected patients needs further study.

[Endovascular management of iatrogenic renal arteriovenous fistulas]

Renal arteriovenous fistulas are uncommon in clinical practice, however the higher frequency of percutaneous renal procedures led to an increase of iatrogenic renal vascular lesions and associated fistulas. Many of these lesions are asymptomatic, however in case of symptoms they can be indicated for treatment. With the emergence of new techniques and materials for embolization, this therapeutic option has been increasingly used to treat this type of injury. The authors present two clinical cases of iatrogenic renal arteriovenous fistulas successfully treated using percutaneous embolization. The percutaneous management of iatrogenic renal vascular lesions is a safe and effective procedure and should be considered as the first-line treatment.

[Occlusion of peripheral bypass--changing of an institutional paradigm]

OBJECTIVES

Compare the results of surgical thrombectomy (ST) and catheter directed thrombolysis (CDT) in the treatment of acute ischemia due to peripheral prosthetic bypass occlusion.

METHODS

Retrospective single center analysis of the electronic clinical data on two groups of patients with acute lower limb ischemia due to prosthetic bypass occlusion: in one ST was performed (data collected between June-2006 ahd September-2011) and the other was treated with CDT Qui2 test (categorical variables) and independent samples t test (continuous variables) were used for comparisons between groups. The Kaplan-Meier method was used to estimate rates of freedom from reintervention and limb salvage, with the Log Rank test used for comparisons.

RESULTS

Twenty-six bypass were included in the ST group and 11 bypass were included in the CDT group. There were no statistically significan differences between groups regarding gender age and type of occluded bypass. The median time for freedom from reintervention was 275 days for the CDT group and three days for the ST group (p = 0.0029 when comparing survival curves). The median time for limb salvage was 468 days for the CDT group and 17 days for the ST group (p = 0.03 when comparing survival curves).

CONCLUSION

These results support the choice for CDT as the local first line therapy for acute ischemia due to bypass occlusion, despite the limitations arising from the sample size. The results of ST need to be urgently addressed.

[Independent factors related to limb salvage and survival in distal angioplasty for critical ischemia]

INTRODUCTION

Infragenicular multisegmentar atherosclerotic disease is prevalent in diabetic and chronic renal failure (CRF) patients and associated with critical ischemia ulcera related. Distal angioplasty revascularization is an option allowing wound healing and improvement of life quality. Objectives Identification and impact determination of independent factors related to limb salvage and mortality in patients submitted to distal angioplasty.

METHODS

Between January 2010 and December 2012, 31 balloon angioplasties were performed in 25 patients with critical limb ischemia. Overall survival and limb salvage were determined by Kaplan- Meier analysis. Independent impact on the "primary endpoints" factors was evaluated using log rank test or Cox regression. The rate of complications and reintervention was analyzed.

RESULTS

Mean age was 68 ± 11 years, 17 diabetic patients (68%) and 9 patients on hemodialysis (36 %). Mean follow-up was 380 days. Mean C-reactive protein was 75 mg / L. Overall survival was 97, 88 and 74 % at 3, 6 and 12 months, and remained stable at last observation. The limb salvage was 67 % at 3 months, 55 % at 6 months and 30 % at last observation. Diabetic and ASA 2 patients had a more satisfactory last observation limb salvage, respectively 61 and 75%, p value close to significance. There was statistically significant relationship between mortality and CRF (p = 0.004). One non-succeded reintervention occurred and there was one transient post contrast renal acute failure.

CONCLUSION

In this sample, although survival is high, long term limb salvage is low justified by the very sick population and anatomical issues. ASA classification and diabetes can be an additional prognostic factor of limb salvage.

Paradoxical embolism and pulmonary embolism in a patient with patent foramen ovale: a case report

Paradoxical embolism may occur in patients with acute pulmonary thromboembolism, when a patent foramen ovale(PFO) coexists with a right to left shunt associated to pulmonary hypertension. We presented the case of a 83 year old woman with paradoxical embolism to both legs, in the setting of pulmonary embolism. She was successfully treated with peripheral thrombectomy and anticoagulation. Patent foramen ovale closure wasn't performed because of its small size and right to left shunt absence after clinical stability.

[Radiofrequency-powered segmental thermal ablation in chronic venous disorders: A single center experience]

BACKGROUND

In the last decade, endovascular radiofrequency obliteration has been used as a safe and feasible method, alternative to conventional vein-stripping surgery.

METHODS

Data were collected from our center between January 2009 and June 2011. Pretreatment examination included lower limb assessment using CEAP classification and VCSS (Vein Clinical Severity Score). Ultrasound examination was performed at first follow-up visit (one week to one month after surgery) and the last-one in September 2011.

RESULTS

The study enrolled 30 patients (33 legs), their mean age was 41.4 ± 10.4 and 76,7% (n=23) were female. Mean follow-up time was 240 days. Treated veins included 32 great saphenous vein above-knee segments, and one small saphenous vein. Only 8% of patients were free of pain before treatment and at last follow-up 61% reported no pain. Edema rate also improved from 52% (before surgery) to 9% at last control. During follow-up, two treated vessels were identified as patent, albeit competent: one a small saphenous vein and the other a segment of a great saphenous vein. Two cases of paresthesias and one of hyperpigmentation were observed at stab avulsion site. The mean VCSS score was 5,6 ±3.11before surgery and 1,4±1.34 at last follow-up.

CONCLUSION

Radiofrequency segmental thermal ablation effectively reduced symptoms of venous insufficiency, with a significant reduction at VCSS score, and was a well tolerated and safe method, with few complications.

[Carotid eversion endarterectomy: retrospective analysis]

The aim of this study was to report the initial experience with eversion carotid endarterectomy technique at our department. We undertook a retrospective analysis of prospectively collected data on all carotid endarterectomies performed since January 2004 to March 2006. A comparison between both groups - eversion endarterectomy (EE) and conventional endarterectomy (CE) - was done using a statistical software package. A total of 150 consecutive carotid endarterectomies were performed, 26 (17 %) of them being done using EE. Median age for all patients was 69 [52 - 89] years old with a clear male predominance (n=119; 79,3%). Cardiovascular risk factors were distributed as follows: hypertension, 126 (84%); diabetes, 40 (26,7%); dyslipidaemia, 105 (70%); tobacco smoking, 44 (29,3%). There were proportionately more patients on the EE group submitted to simultaneous CABG (30,8 % vs. 8,8 %; p=0,043) and asymptomatic for previous neurological events (53,9 %vs. 27,3%; p=0,05). There was one case of cervical haematoma reported for the EE technique. Neither neurological morbidity nor deaths were reported within this group. In the CE group the mortality was 0,8 % (1 patient) and the neurological morbidity (either stroke or TIA) was 2,4 % (3 patients). The overall stroke and death rate combining both groups was 2,7 %. Outcome differences between EE and CE patients were nonsignificant, even on multivariate analysis. Eversion carotid endarterectomy is a safe procedure that might be considered as a valid option to conventional endarterectomy.

[Rupture of venous bypass graft associated to infection of multiresistant bacteria]

We report two cases of severe trauma of the upper limb requiring arterial revascularization. A brachio-brachial inverted saphenous bypass graft was done in both cases. Graft rupture attributed to local infection occurred at fourth post-operative week. Pseudomonas aeruginosa was isolated from the surgical wound in the first case and Acinetobacter baumanni in the second. The first case ended up with arm amputation mostly owing to extensive destruction of soft tissue, the patient being discharged home without any other sequel. In the second case the patient was successfully resuscitated after cardiopulmonary arrest, secondary to hemorrhagic shock. He underwent new brachio-brachial venous bypass graft avoiding the contaminated area. Irreversible ischemic signs plus growing overt infection led to arm amputation later on. This patient developed multi-organ failure and died by the fifth post-operative week. Acinetobacter baumannii and Pseudomonas aeruginosa are gram-negative bacilli widely present in hospital environment. Most of them are resistant to commonly used antibiotics. Their association with vascular conduit infections might have dreadful consequences as it happened in these cases.

[Supra-genicular femoro-popliteal bypass: 5 years retrospectively analysis]

We report a retrospective study of patients submitted to supragenicular femoro-popliteal bypass surgery in our department between 1998 and 2002. A SPSS package was used for statistical analysis. Eighty bypasses were performed in 74 patients with a median follow up of 19,6 months [1-71 (+/- 22,5 months)]. Leriche-Fontaine stage IV chronic ischemia was the main indication for surgery accounting for 68,8% of cases, followed by stage III (25%) and stage IIb (6,2%). The most prevalent vascular conduit was PTFE (87,5%), with great saphenous vein and Dacron being used on 7,5 % and 5% of cases. Ten patients (12,5 %) later required major amputation and limb salvage at 12, 24 and 36 months was 91,6 %, 87,7 % and 82,8 %. The primary patency rates were 81,7 %, 78,9 % and 71 % at the end of the first, second and third year of follow up. Patient survival was 92,8 %, 92,8 % e 88,6 % at 12, 24 e 36 months of follow up. A large proportion of patients (61,7 %) required an accessory procedure. Our results might be considered acceptable in face of other published results, though care must be taken given the intrinsic limitations of this retrospective study.

One Living Donor and Two Donations: Sequential Kidney and Liver Donation With 20-Years Interval

The shortage of cadaveric donor organs remains the critical factor limiting the use of organ transplantation. In this environment of organ shortage, living donor transplantation has emerged as a reasonable therapeutic alternative. Simultaneous kidney-liver transplantation from the same donor has been described. We report a case of right liver lobe transplant from a living donor who had donated his kidney to the same recipient 20 years prior.

Asymptomatic carriers and gender differences in facioscapulohumeral muscular dystrophy (FSHD)

Facioscapulohumeral muscular dystrophy is an autosomal dominant muscle disorder, mapped to 4q35. It is characterized by remarkable inter- and intrafamilial clinical variability ranging from severe phenotype to asymptomatic carriers. The aim of the present study was to assess the size of the Eco RI fragment in a large sample of asymptomatic or minimally affected carriers as well as symptomatic patients, comparing both sexes, in order to verify if asymptomatic carriers are randomly distributed or concentrated in some particular families and if there is preferential parental transmission (maternal or paternal) resulting in non-penetrant carriers. We have analysed a total of 506 individuals from 106 unrelated families with at least one affected facioscapulohumeral muscular dystrophy proband. In all patients the molecular diagnosis was confirmed following double digestion (Eco RI/Bln I fragment <35 kb). About 20% among probands' relatives who were found to carry the small fragment were asymptomatic or minimally affected, without preferential parental transmission, but with a significantly higher proportion of females (n=37) than males (n=14). Although asymptomatic carriers were found in about 30% of the families, some genealogies seem to concentrate more non-penetrant cases. A significant correlation between the size of the Eco RI fragment and severity of the phenotype was observed in the total sample but surprisingly this correlation is significant only among affected females. The gender difference in clinical manifestation as well as the observation that asymptomatic carriers are not rare should be taken into consideration in genetic counseling of affected patients or 'at-risk' relatives.

Facioscapulohumeral (FSHD1) and other forms of muscular dystrophy in the same family: is there more in muscular dystrophy than meets the eye?

We report on two unrelated Brazilian families with members affected by two different forms of muscular dystrophy. In the first one, the 35-year-old male proband has limb-girdle muscular dystrophy with proximal weakness, elevated creatine kinase and a myopathic muscle biopsy. All the proteins known to be associated with limb-girdle muscular dystrophy were normal. Two of his sisters also complained of muscle weakness. The oldest sister showed clinical signs consistent with facioscapulohumeral muscular dystrophy, confirmed through molecular analysis. She presented a 30 kb EcoRI/BlnI fragment which was found in another six relatives, but surprisingly not in the affected proband or the other sister. In the second family, a 57-year-old male with a typical facioscapulohumeral muscular dystrophy phenotype has a 17 kb EcoRI/BlnI fragment, which was also present in other affected relatives. However in a 14-year-old severely affected male cousin, confined to a wheelchair since age 12, but without facial weakness, the small fragment was absent. These families illustrate the importance of testing all affected individuals in a family.

Clinical and molecular analysis of spinal muscular atrophy in Brazilian patients

Spinal muscular atrophy (SMA), the second most common lethal autosomal recessive disorder, has an incidence of 1:10,000 newborns. SMA is divided into acute (Werdnig-Hoffmann disease, type I), intermediate (type II) and juvenile forms (Kugelberg-Welander disease, type III). The gene of all three forms of SMA maps to chromosome 5q 11.2-13.3. Two candidate genes, the survival motor neuron (SMN) gene and the neuronal apoptosis inhibitory protein (NAIP) gene, have been identified; SMN is deleted in most SMA patients. We studied both genes in 87 Brazilian SMA patients (20 type I, 14 type II and 53 type III) from 74 unrelated families, by using PCR and single strand conformation polymorphism (SSCP). Deletions of exons 7 and/or 8 of the SMN gene were found in 69% of the families: 16/20 in type I, 9/12 in type II and 26/42 in type III. Among 51 families with deletions, 44 had both exons deleted while seven had deletions only of exon 7. Deletions of exon 5 of the NAIP gene were found in 7/20 of type I, 2/12 of type II and 1/42 of type III patients. No deletion of SMN and NAIP genes was found in 112 parents, 26 unaffected sibs and 104 normal controls. No correlation between deletions of one or both genes and phenotype severity was found.

Paternal inheritance or different mutations in maternally related patients occur in about 3% of Duchenne familial cases

Duchenne dystrophy (DMD) is an X-linked lethal condition which affects 1 in 3,500 boys. The DMD gene is deleted in about 60-65% of patients while in the remaining 35-40% the condition is caused by point mutations, small insertions, or duplications. We have ascertained 967 DMD families (680 isolated and 287 familial cases). Screening for deletions showed a molecular deletion in 383 among 615 (62.3%) analyzed cases. However, 10 families were unusual: In 7 of them, 2 or more DMD patients were related through paternal lines while in 3 others, affected boys related through maternal lines carried different mutations or originated through independent new mutation events. The finding of 10 atypical genealogies, which represent about 1% of the sample (10/967) or about 3% of familial cases (10/287) is higher than we would expect by chance. Even so, it is an underestimate because screening of mutations in all the affected DMD relatives from each genealogy is not done in many of the familial cases. It suggests that other mechanisms (such as transposon-like elements, for example) could be responsible for a higher genomic instability leading to novel mutations as reported previously by us and others in DMD and in other genetic disorders such as hemophilia and inherited peripheral neuropathies. On the other hand, it shows the importance of testing all affected patients within each genealogy to prevent possible mistakes in carrier detection, genetic counseling, and prenatal diagnosis.

The facioscapulohumeral muscular dystrophy (FSHD1) gene affects males more severely and more frequently than females

We investigated 52 families of patients with facioscapulohumeral muscular dystrophy (FSHD1), including 172 patients (104 males and 68 females). Among 273 DNA samples which were analyzed with probe p13E-11, 131 (67 males and 64 females) were shown to carry an EcoRI fragment smaller than 35 kb; 114 among them were examined clinically and neurologically. Results of the present investigation showed that: a) there is no molecular evidence for autosomal or X-linked recessive inheritance of FSHD1; b) an excess of affected males, which is explained by a significantly greater proportion of females than males among asymptomatic cases and a significantly greater proportion of affected sons than daughters observed in the offspring of asymptomatic mothers; c) the penetrance of the FSHD1 gene until age 30 was estimated as 83% for both sexes but was significantly greater for males (95%) than for females (69%); d) new mutations occur significantly more frequently in females than males among somatic/germinal mosaic cases; and e) severely affected cases originated more often through new mutations or were transmitted through maternal than through paternal lines including somatic/germinal mothers. These observations have important implications for understanding the molecular mechanisms responsible for FSHD1 and for genetic and prognostic counseling according to the gender of the affected patient.

CTG repeat length in muscle from patients affected with myotonic dystrophy (DM)

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Analysis of the CTG repeat in skeletal muscle of young and adult myotonic dystrophy patients: when does the expansion occur?

The purpose of this investigation was to analyze the CTG expansion in muscle as compared to lymphocytes DNA in a sample of selected myotonic dystrophy (DM) patients of different ages and degrees of clinical severity, ranging from severe congenital to minimally affected. Results from the present study showed that the size of the CTG repeat was markedly larger in skeletal muscle than in lymphocytes in all DM patients. In contrast to lymphocytes, no significant correlation was found between the size of the CTG expansion in muscle and age at onset. In addition, large expansions were observed in muscle from all adult symptomatic patients independently of the presence of muscle weakness, which raises the question of the value of analyzing CTG expansions in muscle for predicting the severity of the phenotype. Differences between the size of the CTG expansions in muscle as compared to lymphocytes were smaller in affected children suggesting an apparent tendency to increase with aging and reaching a plateau in adulthood.

High proportion of new mutations and possible anticipation in Brazilian facioscapulohumeral muscular dystrophy families

A gene responsible for facioscapulohumeral muscular dystrophy (FSHD) has been localized at 4q35. Subsequently, it was found that probe p13E-11 detects a polymorphic EcoRI fragment, usually > 28 kb, in normal individuals, whereas in sporadic and familial FSHD cases, an EcoRI fragment, usually < 28 kb, was found. Although these findings have been amply confirmed, several aspects are as yet either controversial or unsolved. In the present investigation, 34 Brazilian FSHD families were studied at the clinical and the molecular level for the following purposes: to assess the frequency of new mutations and their effect on estimates of biological fitness, to characterize FSHD-associated EcoRI fragments detected with probe p13E-11 in familial--as compared with isolated--FSHD cases, and to assess whether anticipation occurs in multigenerational families. Results from our study suggest that new mutations are apparently frequent for FSHD and may account for at least one-third of the cases, that somatic mosaicism may not be rare, and that biological fitness appeared to be reduced in FSHD, ranging from 0.6 to 0.82 by different estimates, with no difference in sexes. Interestingly, the size of the new EcoRI fragment is apparently smaller in more severely affected isolated patients. Moreover, the age at onset of clinical signs, as well as the age at ascertainment, in patients from multigenerational families suggests that anticipation occurs for FSHD in the majority of the families.

Myotonic dystrophy: genetic, clinical, and molecular analysis of patients from 41 Brazilian families

Results of genealogical, DNA, and clinical findings in 41 families with 235 patients affected with myotonic dystrophy (DM) led to the following observations. (1) The relative proportion of affected patients among blacks is apparently lower than among whites or orientals. (2) A significant excess of males was observed. (3) The frequency of DM patients who did not reproduce was similar for males and females; however, female patients had on average 25% fewer children than male patients. (4) There was a significant intergenerational increase in the mean length of the CTG repeat which was also correlated with the severity of the phenotype. (5) No significant difference was observed in the mean size of the CTG repeat in offspring of male as compared to female transmitters. (6) With the exception of the congenital cases of maternal origin, the largest expansions were paternally inherited, but did not lead to congenital DM.

[Myotonic dystrophy: study of clinico-genetic correlation in a pair of relatives (father-son)]

We report the case of a child with myotonic dystrophy (DM) with symptoms beginning at the age of seven, whose genetic study showed an additional DNA fragment, greater than of his father, an asymptomatic carrier. The clinical and molecular analysis of this parent-child pair are probably the first described in Brazil, since the recent discovery of genetic abnormality in DM by American and European researchers, that explained the long-debated phenomenon of "anticipation" in this disease. The main advances in molecular genetics in DM and its correlation with increasing severity and earlier onset of the symptoms in successive generations of a family are commented briefly.