Leishmania and HIV co-infection: first naturally Leishmania strain presenting decreased susceptibility to miltefosine, recovered from a patient in Portugal.

BACKGROUND: In Europe, up to 70% of visceral leishmaniasis (VL) cases occurring in adults living with HIV. People living with HIV with VL co-infection often display persistent parasitemia, requiring chronic intermittent anti-Leishmania therapies. Consequently, frequent VL relapses and higher mortality rates are common in these individuals. As such, it is of paramount importance to understand the reasons for parasite persistence to improve infection management. METHODS: To outline possible causes for treatment failure in the context of HIV-VL, we followed a person living with HIV-VL co-infection for nine years in a 12-month period. We characterized: HIV-related clinicopathological alterations (CD4+ T counts and viremia) and Leishmania-specific seroreactivity, parasitemia, quantification of pro-inflammatory cytokines upon stimulation and studied a Leishmania clinical isolate recovered during this period. RESULTS: The subject presented controlled viremia and low CD4+ counts. The subject remained PCR positive for Leishmania and also seropositive. The cellular response to parasite antigens was erratic. The isolate was identified as the first Leishmania infantum case with evidence of decreased miltefosine susceptibility in Portugal. CONCLUSION: Treatment failure is a multifactorial process driven by host and parasite determinants. Still, the real-time determination of drug susceptibility profiles in clinical isolates is an unexplored resource in the monitoring of VL.

Visceral Dissemination of Mucocutaneous Leishmaniasis in a Kidney Transplant Recipient.

Intracellular protozoan of the genus Leishmania, endemic in the Mediterranean basin, are the cause of cutaneous (CL), mucocutaneous (MCL), and visceral leishmaniasis (VL). A 75-year-old woman was admitted nine years after a second kidney transplant (KT), due to persistent pancytopenia and fever. She presented edema and erythema of the nose in the last two years and an exophytic nodular lesion located on the left arm, with areas of peripheral necrosis and central ulceration in the last 18 months. A bone marrow biopsy revealed features compatible with Leishmania amastigotes, and polymerase chain reaction test (PCR) for Leishmania infantum was positive. Moreover, biopsy and PCR for L. infantum of the cutaneous lesion on the patient's left arm and nose and PCR from peripheral blood were positive. Thus, a diagnosis of CL, MCL, and VL was made, and liposomal amphotericin B was initiated, but the patient had an unfavorable outcome and died. This is the first report of a KT recipient presenting with the entire spectrum of leishmaniasis. In Portugal, this infection is rare-so a high degree of clinical suspicion is required for its diagnosis, especially in endemic regions, as visceral leishmaniasis is a potentially life-threatening infection.

Thymic B Cell-Mediated Attack of Thymic Stroma Precedes Type 1 Diabetes Development.

Type 1 diabetes (T1D) results from a coordinated autoimmune attack of insulin producing beta cells in the pancreas by the innate and adaptive immune systems, beta cell death being predominantly T cell-mediated. In addition to T cells, peripheral B cells are important in T1D progression. The thymus of mice and man also contains B cells, and lately they have been linked to central tolerance of T cells. The role of thymic B cells in T1D is undefined. Here, we show there are abnormalities in the thymic B cell compartment before beta cell destruction and T1D manifestation. Using non-obese diabetic (NOD) mice, we document that preceding T1D development, there is significant accumulation of thymic B cells-partly through in situ development- and the putative formation of ectopic germinal centers. In addition, in NOD mice we quantify thymic plasma cells and observe in situ binding of immunoglobulins to undefined antigens on a proportion of medullary thymic epithelial cells (mTECs). By contrast, no ectopic germinal centers or pronounced intrathymic autoantibodies are detectable in animals not genetically predisposed to developing T1D. Binding of autoantibodies to thymic stroma correlates with apoptosis of mTECs, including insulin-expressing cells. By contrast, apoptosis of mTECs was decreased by 50% in B cell-deficient NOD mice suggesting intrathymic autoantibodies may selectively target certain mTECs for destruction. Furthermore, we observe that these thymic B cell-associated events correlated with an increased prevalence of premature thymic emigration of T cells. Together, our data suggest that the thymus may be a principal autoimmune target in T1D and contributes to disease progression.

CD4+ T Cells Alter the Stromal Microenvironment and Repress Medullary Erythropoiesis in Murine Visceral Leishmaniasis.

Human visceral leishmaniasis, a parasitic disease of major public health importance in developing countries, is characterized by variable degrees of severity of anemia, but the mechanisms underlying this change in peripheral blood have not been thoroughly explored. Here, we used an experimental model of visceral leishmaniasis in C57BL/6 mice to explore the basis of anemia following infection with Leishmania donovani. 28 days post-infection, mice showed bone marrow dyserythropoiesis by myelogram, with a reduction of TER119+ CD71-/+ erythroblasts. Reduction of medullary erythropoiesis coincided with loss of CD169high bone marrow stromal macrophages and a reduction of CXCL12-expressing stromal cells. Although the spleen is a site of extramedullary erythropoiesis and erythrophagocytosis, splenectomy did not impact the extent of anemia or affect the repression of medullary hematopoiesis that was observed in infected mice. In contrast, these changes in bone marrow erythropoiesis were not evident in B6.Rag2-/- mice, but could be fully reconstituted by adoptive transfer of IFNγ-producing but not IFNγ-deficient CD4+ T cells, mimicking the expansion of IFNγ-producing CD4+ T cells that occurs during infection in wild type mice. Collectively, these data indicate that anemia during experimental murine visceral leishmaniasis can be driven by defects associated with the bone marrow erythropoietic niche, and that this represents a further example of CD4+ T cell-mediated immunopathology affecting hematopoietic competence.

Transição para a creche e bem-estar emocional dos bebês em Portugal / Transition to childcare and infants' well-being in Portugal / Transición a la guardería y bienestar emocional de los bebés en Portugal

O presente estudo analisa a relação entre a implementação de práticas de transição do contexto familiar para a creche e o bem-estar emocional dos bebês durante o primeiro de mês de frequência neste contexto extrafamiliar. Foram recolhidos dados, antes e após a entrada do bebê na creche, junto das mães e das educadoras de 90 bebês.Os resultados indicaram que o número de práticas de transição reportadas pelas educadoras se revela positivamente associado ao bem-estar emocional dos bebês durante o primeiro mês de frequência da creche. Estes resultados recomendam a implementação de um conjunto diversificado de práticas de transição, antes e após a entrada na creche, no sentido de facilitar a adaptação dos bebês ao novo contexto desenvolvimental.

The present study analyzes the relationship between the implementation of transition practices from home to day care center and the emotional well-being of the infants during the first month of attendance in this extrafamiliar environment. Data were collected, before and after the infant entered the day care center, with the mothers and teachers of 90 infants. The results indicated that the number of transition practices reported by teachers is positively associated with the emotional well-being of infants during the first month of day care attendance. These results recommend the implementation of a diversified set of transition practices, before and after entry into the day care center, to facilitate the infants' adaptation to the new developmental setting.

En el presente estudio se analiza la relación entre la implementación de prácticas de transición del contexto familiar a la guardería y el bienestar emocional de los bebés, durante el primer mes de frecuencia de este contexto extra-familiar. Se recolectaron datos, antes y tras la entrada del bebé en la guardería, por intermedio de las madres y de las educadoras de 90 bebés. Los resultados indicaron que el número de prácticas de transición reportadas por las educadoras se revela positivamente asociado al bienestar emocional de los bebés durante el primer mes de frecuencia a la guardería. Estos resultados recomiendan la implementación de un conjunto diversificado de prácticas de transición, antes y tras la entrada en la guardería, en el sentido de facilitar la adaptación de los bebés al nuevo contexto de desarrollo.

TNF signalling drives expansion of bone marrow CD4+ T cells responsible for HSC exhaustion in experimental visceral leishmaniasis.

Visceral leishmaniasis is associated with significant changes in hematological function but the mechanisms underlying these changes are largely unknown. In contrast to naïve mice, where most long-term hematopoietic stem cells (LT-HSCs; LSK CD150+ CD34- CD48- cells) in bone marrow (BM) are quiescent, we found that during Leishmania donovani infection most LT-HSCs had entered cell cycle. Loss of quiescence correlated with a reduced self-renewal capacity and functional exhaustion, as measured by serial transfer. Quiescent LT-HSCs were maintained in infected RAG2 KO mice, but lost following adoptive transfer of IFNγ-sufficient but not IFNγ-deficient CD4+ T cells. Using mixed BM chimeras, we established that IFNγ and TNF signalling pathways converge at the level of CD4+ T cells. Critically, intrinsic TNF signalling is required for the expansion and/or differentiation of pathogenic IFNγ+CD4+ T cells that promote the irreversible loss of BM function. These findings provide new insights into the pathogenic potential of CD4+ T cells that target hematopoietic function in leishmaniasis and perhaps other infectious diseases where TNF expression and BM dysfunction also occur simultaneously.

Linking autism measures with the ICF-CY: functionality beyond the borders of diagnosis and interrater agreement issues.

PURPOSE: This study aims to: (1) link measurements used in the diagnosis of children with autism spectrum disorders (ASDs) with the International Classification of Functioning, Disability and Health - Children and Youth Version (ICF-CY) and (2) analyse issues relating with interrater agreement within this process. METHOD: Three instruments for ASD diagnosis were linked with the ICF-CY using deductive content analysis. RESULTS: Correspondences between items' content and ICF-CY dimensions were identified for all ICF-CY components, except for environmental factors. Interrater agreement varied with the content of the units analyzed. CONCLUSION: The linkage between the ICF-CY and the analyzed measures provides a way to document assessment-intervention outcomes using a common language, as well as to integrate diagnostic and functional data. Diagnostic measurements provide functional information beyond the diagnostic criteria defined for autism. A functional perspective is added to diagnostic outcomes, thus better informing educational and rehabilitation practices for children with ASD.

Identification of core functioning features for assessment and intervention in Autism Spectrum Disorders.

PURPOSE: Framed within a biopsychosocial approach, this study aimed to identify the main functionality dimensions that experts in the field of child development and child psychopathology considered as essential in the assessment-intervention process with young children with Autism Spectrum Disorders (ASD), using the International Classification of Functionality, Disability and Health for Children and Youth. METHOD: The Delphi method was used to obtain consensus among experts regarding the essential functionality features for the rehabilitation of young children with ASD. Therefore, web-based three-round survey was developed. RESULTS: There are more functionality features identified as more essential for the age group 3-6 than from the group birth-2 years of age. 49.4% of activities and participation dimensions were regarded as essential by experts, while only 13.9% of body functions were selected. 39.9% of environmental factors were also marked by experts as essential. CONCLUSIONS: Pervasive Developmental Disorders (PDD) are classified in diagnostic manuals-DSM-IV-TR and ICD-10. These classifications are valuable to detect signs/symptoms of health conditions; however, they are often not sufficient to develop individualized interventions. More functional information is needed to complement diagnostic data. The identified functionality dimensions of the ICF-CY complement diagnosis by differentiating relevant functioning aspects in all life domains, according to the biopsychosocial model and should always be addressed in the process of rehabilitation of young children with ASD.

Estilos interactivos de educadoras do Ensino Especial em contexto de educação-de-infância / Special Education teachers' interactive styles in early education

Este estudo pretendeu caracterizar os estilos interactivos das educadoras do Ensino Especial ao se relacionarem com crianças com Necessidades Educativas Especiais (NEE) integradas em creches/jardins-de-infância do Porto. Participaram 50 educadoras e 50 crianças. Os comportamentos interactivos foram avaliados utilizando a Escala de Avaliação dos Estilos de Ensino. O envolvimento das crianças foi codificado por meio do EQUAL-III. A análise de clusters identificou dois sub-grupos: (i) educadoras que utilizam mais frequentemente comportamentos directivos; (ii) educadoras nas quais predominam comportamentos elaborativos e responsivos. Os subgrupos distinguiram-se em características de qualidade estrutural da sala, da educadora e do envolvimento da criança. As crianças com NEE parecem se beneficiar de interacções baixas em directividade. Interacções elaborativas-responsivas tendem a promover níveis mais sofisticados de envolvimento, pelo que são recomendadas.

This study intended to characterize special education teachers' interactive styles while interacting with children with disabilities, in day care/preschool contexts in Porto. Fifty special education teachers and 50 children with disabilities participated in the study. Interactive behaviours were rated based on the Teaching Styles Rating Scale. Child engagement was coded by means of the E-QUAL III. Using cluster analysis, two subgroups of teachers were identified: (i) teachers using more frequently directive behaviours; (ii) teachers with predominance of elaborative and responsive behaviours. Subgroups differences were found for classroom structural quality, teachers' characteristics and children's observed engagement. Children with disabilities seem to benefit from low directive interactions. Elaborative-responsive teacher's interactions tend to promote more sophisticated levels of children's engagement, and are thus recommended.

Estilos interactivos de educadoras do Ensino Especial em contexto de educação-de-infância / Special Education teachers' interactive styles in early education

Este estudo pretendeu caracterizar os estilos interactivos das educadoras do Ensino Especial ao se relacionarem com crianças com Necessidades Educativas Especiais (NEE) integradas em creches/jardins-de-infância do Porto. Participaram 50 educadoras e 50 crianças. Os comportamentos interactivos foram avaliados utilizando a Escala de Avaliação dos Estilos de Ensino. O envolvimento das crianças foi codificado por meio do EQUAL-III. A análise de clusters identificou dois sub-grupos: (i) educadoras que utilizam mais frequentemente comportamentos directivos; (ii) educadoras nas quais predominam comportamentos elaborativos e responsivos. Os subgrupos distinguiram-se em características de qualidade estrutural da sala, da educadora e do envolvimento da criança. As crianças com NEE parecem se beneficiar de interacções baixas em directividade. Interacções elaborativas-responsivas tendem a promover níveis mais sofisticados de envolvimento, pelo que são recomendadas.(AU)

This study intended to characterize special education teachers' interactive styles while interacting with children with disabilities, in day care/preschool contexts in Porto. Fifty special education teachers and 50 children with disabilities participated in the study. Interactive behaviours were rated based on the Teaching Styles Rating Scale. Child engagement was coded by means of the E-QUAL III. Using cluster analysis, two subgroups of teachers were identified: (i) teachers using more frequently directive behaviours; (ii) teachers with predominance of elaborative and responsive behaviours. Subgroups differences were found for classroom structural quality, teachers' characteristics and children's observed engagement. Children with disabilities seem to benefit from low directive interactions. Elaborative-responsive teacher's interactions tend to promote more sophisticated levels of children's engagement, and are thus recommended.(AU)