Blood Pressure Variability in Acute Ischemic Stroke: The Role of Early Recanalization.

We performed a retrospective study with the aim of investigating the association between blood pressure (BP) variability in the first 24 h after ischemic stroke and functional outcome, regarding arterial recanalization status. A total of 674 patients diagnosed with acute stroke and treated with revascularization therapies were enrolled. Systolic and diastolic BP values of the first 24 h after stroke were collected and their variation quantified through standard deviation. Recanalization state was evaluated at 6 h and clinical outcome at 3 months was assessed by modified Rankin Scale. In multivariate analyses systolic BP variability in the first 24 h post-stroke showed an association with 3 months clinical outcome in the whole population and non-recanalyzed patients. In recanalyzed patients, BP variability did not show a significant association with functional outcome.

Recanalization Modulates Association Between Blood Pressure and Functional Outcome in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Historical stroke cohorts reported a U- or J-shaped relationship between blood pressure (BP) and clinical outcome. However, these studies predated current revascularization strategies, disregarding the recanalization state of the affected arterial territory. We aimed to investigate the relationship between BP in the first 24 hours after ischemic stroke and clinical outcome in patients submitted to intravenous or intra-arterial recanalization treatments. METHODS: Consecutive patients with acute stroke treated with intravenous thrombolysis or intra-arterial therapies were enrolled in a retrospective cohort study. BP was measured on regular intervals throughout day and night during the first 24 hours after stroke onset. The mean systolic BP and diastolic BP during the first 24 hours post stroke were calculated. Recanalization was assessed at 6 hours by transcranial color-coded Doppler, angiography, or angio-computed tomography. Functional outcome was assessed at 3 months by modified Rankin Scale. Linear and quadratic multivariate regression models were performed to determine associations between BP and functional outcome for the whole population and recanalyzed and nonrecanalyzed patients. RESULTS: We included 674 patients; mean age was 73.28 (SD, 11.50) years. Arterial recanalization was documented in 355 (52.70%) patients. In multivariate analyses, systolic BP and diastolic BP in the first 24 hours post stroke show a J-shaped relationship with functional outcome in the total population and in the nonrecanalyzed patients. Recanalyzed patients show a linear association with functional outcome (systolic BP: odds ratio, 1.015; 95% confidence interval, 1.007-1.024; P=0.001; R(2) change=0.001; P=0.412 and diastolic BP: odds ratio, 1.019; 95% confidence interval, 1.004-1.033; P=0.012; R(2) change<0.001; P=0.635). CONCLUSIONS: Systemic BP in the first 24 hours after ischemic stroke influences 3-month clinical outcome. This association is dependent on the revascularization status.

Eosinophilic Colitis, an Uncommon Cause of Diarrhea: Case Report and Literature Review.

Eosinophilic colitis and hypereosinophilic syndrome with colic involvement are rare diagnosis that are characterized by wide-ranging gastrointestinal symptoms and idiopathic infiltration of eosinophils in the colon. The diagnostic workup is challenging since there are no standardized criteria. We report a case of a man admitted to the hospital with a history of nonbloody chronic diarrhea. The detailed workup demonstrated blood eosinophilia, and the colonic biopsies revealed extensive eosinophilic infiltration. He was treated with steroids with clinical and analytical improvement. Due to relapsing colitis after therapy withdrawal, he was chronically medicated with 10 mg of prednisolone with ultimate symptom control. This case report describes the diagnostic workup and highlights the most important features of this often underdiagnosed entity.

A colite eosinofílica e síndrome hipereosinofílico com atingimento gastrointestinal é um diagnóstico raro caracterizado por uma grande variedade de sintomas gastrointestinais e pela evidência de infiltração por eosinófilos na mucosa cólica. A marcha diagnóstica é desafiante dado não haver até à data critérios de diagnóstico. Os autores apresentam um caso de um homem hospitalizado com história de diarreia crónica não sanguinolenta. Durante a investigação etiológica foi identificada eosinofilia periférica e as biópsias cólicas realizadas evidenciaram predominante infiltração eosinofílica. Foi iniciado tratamento com corticoterapia tendo-se verificado normalização da contagem de eosinófilos e resolução do quadro clínico. Dado o carácter recidivante da colite que pode ocorrer com o desmame de corticoterapia, o doente ficou medicado cronicamente com 10 mg de prednisolona. Destaca-se este caso pela sua raridade na literatura de forma a realçar aspetos particulares desta entidade incomum.

Constitutional and somatic methylation status of DMRH19 and KvDMR in Wilms tumor patients.

The most frequent epigenetic alterations in Wilms tumor (WT) occur at WT2, assigned to 11p15. WT2 consists of two domains: telomeric domain 1 (DMRH19) that contains the IGF2 gene and an imprinted maternally expressed transcript (H19) and centromeric domain 2 (KvDMR) that contains the genes KCNQ1, KCNQ1OT1 and CDKN1C. In this work, we used pyrosequencing and MS-MLPA to compare the methylation patterns of DMRH19/KvDMR in blood and tumor samples from 40 WT patients. Normal constitutional KvDMR methylation indicated that most of the epigenetic alterations in WT occur at DMRH19. Constitutional DMRH19 hypermethylation (HM DMRH19) was observed in two patients with Beckwith-Wiedemann syndrome. Pyrosequencing and MS-MLPA showed HM DMRH19 in 28/34 tumor samples: 16/34 with isolated HM DMRH19 and 12/34 with concomitant HM DMRH19 and KvDMR hypomethylation, indicating paternal uniparental disomy. With the exception of one blood sample, the MS-MLPA and pyrosequencing findings were concordant. Diffuse or focal anaplasia was present in five tumor samples and was associated with isolated somatic HM DMRH19 in four of them. Constitutional 11p15 methylation abnormalities were present in 5% of the samples and somatic abnormalities in the majority of tumors. Combined analysis of DMRH19/KvDMR by pyrosequencing and MS-MLPA is beneficial for characterizing epigenetic anomalies in WT, and MS-MLPA is useful and reliable for estimation of DNA methylation in a clinical setting.

Peripheral T-Cell Lymphoma, Not Otherwise Specified - a case report and short literature review.

Peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS) is the most common subgroup of peripheral T-cell lymphomas (PTCL), and constitutes a diagnosis of exclusion. At presentation, most patients exhibit B symptoms and generalized lymphadenopathy, with or without concomitant extra-nodal involvement. We present a case of a man admitted to the hospital with B symptoms, generalized lymphadenopathy and a pruritic exanthema. Laboratory workup reveled persistent eosinophilia and malignant hypercalcemia. The excisional lymph node biopsy diagnosed PTCL-NOS, and the skin biopsy demonstrated a lichenoid dermatitis, compatible with the presumptive clinical diagnosis of a drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. The patient was treated with topical betamethasone with good overall response, and initiated the first cycle of chemotherapy before discharge. This case report describes a PTCL-NOS with a concomitant non-lymphoproliferative disease, the challenging diagnostic workup of the two diseases and reinforces the most important features of the lymphoproliferative neoplasm.

Clinical Spectrum and Tumour Risk Analysis in Patients with Beckwith-Wiedemann Syndrome Due to CDKN1C Pathogenic Variants.

Beckwith-Wiedemann syndrome spectrum (BWSp) is an overgrowth disorder caused by imprinting or genetic alterations at the 11p15.5 locus. Clinical features include overgrowth, macroglossia, neonatal hypoglycaemia, omphalocele, hemihyperplasia, cleft palate, and increased neoplasm incidence. The most common molecular defect observed is hypomethylation at the imprinting centre 2 (KCNQ1OT1:TSS DMR) in the maternal allele, which accounts for approximately 60% of cases, although CDKN1C pathogenic variants have been reported in 5-10% of patients, with a higher incidence in familial cases. In this study, we examined the clinical and molecular features of all cases of BWSp identified by the Spanish Overgrowth Registry Initiative with pathogenic or likely pathogenic CDKN1C variants, ascertained by Sanger sequencing or next-generation sequencing, with special focus on the neoplasm incidence, given that there is scarce knowledge of this feature in CDKN1C-associated BWSp. In total, we evaluated 21 cases of BWSp with CDKN1C variants; 19 were classified as classical BWS according to the BWSp scoring classification by Brioude et al. One of our patients developed a mediastinal ganglioneuroma. Our study adds evidence that tumour development in patients with BWSp and CDKN1C variants is infrequent, but it is extremely relevant to the patient's follow-up and supports the high heterogeneity of BWSp clinical features associated with CDKN1C variants.

Rhabdomyolysis Following Administration of Comirnaty®.

INTRODUCTION: Vaccination against COVID-19 is essential to control the pandemic. The vaccines developed so far have good safety profiles but full knowledge of adverse effects will only be acquired with time and through case reports. CASE DESCRIPTION: We present the case of a man admitted with rhabdomyolysis 3 days after receiving his first dose of the Pfizer coronavirus vaccine Comirnaty® Other traumatic, infectious, endocrine, electrolyte disturbance and autoimmune causes of rhabdomyolysis were excluded. The temporal relationship between vaccine administration and disease onset indicated possible causality. The patient had a favourable evolution after receiving fluids and completely recovered. To our knowledge, there have been only 69 reports of rhabdomyolysis following Comirnaty® administration in Europe, as stated by the European Medicines Agency, and this is the first case report in Portugal. DISCUSSION: When a patient presents with rhabdomyolysis without an obvious traumatic or exertional cause, other aetiologies need to be excluded. Drug use is one of the most common causes of rhabdomyolysis in adults. CONCLUSION: We present a case compatible with an adverse effect of Comirnaty® in order to raise awareness of this condition in vaccinated patients. LEARNING POINTS: Rhabdomyolysis is frequently due to pharmacological causes.COVID-19 vaccines are safe but their adverse effects have not yet been fully elucidated and more case reporting would be beneficial.Rhabdomyolysis secondary to administration the Pfizer anti-COVID-19 vaccine Comirnaty® can be a severe adverse effect and should be considered in the relevant clinical scenario.

Juvenile myelomonocytic leukemia in CBL syndrome associated with germline splice-site mutations: Two case reports and a literature review.

The clinical and laboratory criteria for hemophagocytic lymphohistiocytosis should be taken into account during the juvenile myelomonocytic leukemia diagnosis, specifically in CBL syndrome, to reveal the presence of primary rather than secondary associated hemophagocytosis.

Necrotizing Fasciitis Causing Acute Compartment Syndrome after Radial Artery Catheterization.

Necrotizing fasciitis is a rare but potentially fatal infection involving the subcutaneous tissue and fascia with the development of necrosis of these structures. Acute compartment syndrome occurs when increased pressure within a closed muscle compartment compromises the circulation and function of the tissues within that space. We report the case of a male patient who was admitted to the intensive care unit for the management of urosepsis due to an acute obstructive pyelonephritis complicated by cardiopulmonary arrest. A radial arterial catheter in the left arm was urgently inserted, under suboptimal aseptic technique. His clinical condition progressively deteriorated, and swelling of the left arm with extension to the forearm with incipient signs of compromised perfusion were observed. The diagnosis of necrotizing fasciitis with acute compartment syndrome was made and an emergency fasciectomy performed. Following this, the patient gradually improved, organ dysfunction resolved, and he was discharged without sequelae. LEARNING POINTS: Necrotizing fasciitis is a rare but potentially fatal infection that can cause substantial tissue destruction and lead to sepsis.In rare cases, it can cause acute compartment syndrome, which occurs when increased pressure within a closed muscle compartment compromises the circulation and function of the tissues within that space.Both necrotizing fasciitis and acute compartment syndrome can be a complication of an arterial catheterization performed under suboptimal aseptic technique; hence, rigorous daily physical examination of the site is crucial for timely diagnosis.

GMP-Compliant Manufacturing of NKG2D CAR Memory T Cells Using CliniMACS Prodigy.

Natural killer group 2D (NKG2D) is a natural killer (NK) cell-activating receptor that recognizes different stress-induced ligands that are overexpressed in a variety of childhood and adult tumors. NKG2D chimeric antigen receptor (CAR) T cells have shown potent anticancer effects against different cancer types. A second-generation NKG2D CAR was generated by fusing full-length human NKG2D to 4-1BB costimulatory molecule and CD3ζ signaling domain. Patient-derived CAR T cells show limitations including inability to manufacture CAR T cells from the patients' own T cells, disease progression, and death prior to return of engineered cells. The use of allogeneic T cells for CAR therapy could be an attractive alternative, although undesirable graft vs. host reactions may occur. To avoid such adverse effects, we used CD45RA- memory T cells, a T-cell subset with less alloreactivity, as effector cells to express NKG2D CAR. In this study, we developed a protocol to obtain large-scale NKG2D CAR memory T cells for clinical use by using CliniMACS Prodigy, an automated closed system compliant with Good Manufacturing Practice (GMP) guidelines. CD45RA+ fraction was depleted from healthy donors' non-mobilized apheresis using CliniMACS CD45RA Reagent and CliniMACS Plus device. A total of 108 CD45RA- cells were cultured in TexMACS media supplemented with 100 IU/mL IL-2 and activated at day 0 with T Cell TransAct. Then, we used NKG2D-CD8TM-4-1BB-CD3ζ lentiviral vector for cell transduction (MOI = 2). NKG2D CAR T cells expanded between 10 and 13 days. Final cell products were analyzed to comply with the specifications derived from the quality and complementary controls carried out in accordance with the instructions of the Spanish Regulatory Agency of Medicines and Medical Devices (AEMPS) for the manufacture of investigational advanced therapy medicinal products (ATMPs). We performed four validations. The manufacturing protocol here described achieved large numbers of viable NKG2D CAR memory T cells with elevated levels of NKG2D CAR expression and highly cytotoxic against Jurkat and 531MII tumor target cells. CAR T cell final products met release criteria, except for one showing myc overexpression and another with viral copy number higher than five. Manufacturing of clinical-grade NKG2D CAR memory T cells using CliniMACS Prodigy is feasible and reproducible, widening clinical application of CAR T cell therapies.

RPS6KA4/MIR1237 and AURKC promoter regions are differentially methylated in Wilms' tumor.

Wilms' tumor (WT) is the most frequent renal cancer in childhood, the occurrence of which is characterized by a relatively low frequency of associated mutations. While epigenetic alterations have been postulated to play a relevant role in the emergence of this tumor, the mechanisms involved in WT development remain largely unknown. In this study, the DNA methylation profile of WT was characterized with Beadchip array. Comparisons between WT with normal kidney identified 827 differentially methylated regions, most of which were attributable in hypermethylation in CpG islands. Among affected genes, WT1 and TP73 showed altered enhancers where hypermethylation was validaded by pyrosequencing. Thirty differentially methylated regions (DMRs) were identified in WT as compared to normal kidney, two of which were previously described. Two novel DMRs, located in RPS6KA4/MIR1237 and the AURKC promoter, were found to be hypermethylated in WT. Altogether, our data reinforced the relevance of alterations of DNA methylation in WT, highlighting the complex nature of these alterations that affect promoter regions as well as enhancers, UTRs and gene bodies.

[Autism spectrum disorder and parents' age: a case-control study in Brazil]. / Transtorno do espectro do autismo e idade dos genitores: estudo de caso-controle no Brasil.

Autism spectrum disorder (ASD) has become a public health problem with major family, social, and economic impacts. This study aimed to estimate the association between ASD and parents' age at the time of their child's birth. A case-control study was performed, consisting of 243 individuals with ASD (cases) and 886 neurotypical controls. A semi-structured questionnaire was applied, following by multiple logistic regression. Associations between ASD and paternal age (in years) from 25 to 34 (OR = 1.65; 95%CI: 1.01-2.71), 35 to 44 (OR = 1.62; 95%CI: 0.96-2.73), and ≥ 45 (OR = 2.44; 95%CI: 1.14-5.00); and maternal age from 25 to 34 (OR = 2.38; 95%CI: 1.54-3.37) and ≥ 35 (OR = 2.09; 95%CI: 1.29-3.39) were significant when assessed in independent models. However, when included in a single model, only maternal age from 25 to 34 (OR = 2.27; 95%CI: 1.45-3.55) and ≥ 35 years (OR = 2.15; 95%CI: 1.21-3.83) remained associated with ASD. The association was stronger when both parents were older (OR = 4.87; 95%CI: 1.71-13.80). The results have important implications for clinical psychiatry and public health, since parents' age at childbirth has increased. Emphasis is needed on the prevention of late childbearing and screening and follow-up of children born to these couples.

O transtorno do espectro do autismo (TEA) tem se tornado um problema de saúde pública, com grande impacto familiar, social e econômico. O objetivo deste trabalho foi estimar a associação entre o TEA e a idade dos genitores no momento do parto. Realizou-se um estudo de caso-controle constituído por 243 indivíduos com o TEA (casos) e 886 neurotípicos (controles). Foi aplicado um questionário semiestruturado e realizada a regressão logística múltipla. Associações entre o TEA e as idades paterna (em anos) entre 25 e 34 (OR = 1,65; IC95%: 1,01-2,71), 35 e 44 (OR = 1,62; IC95%: 0,96-2,73) e ≥ 45 (OR = 2,44; IC95%: 1,14-5,00); e materna entre 25 e 34 (OR = 2,38; IC95%: 1,54-3,37) e ≥ 35 (OR = 2,09; IC95%: 1,29-3,39) foram significativas quando avaliadas em modelos independentes. Porém, quando incluídas em um mesmo modelo apenas as idades maternas entre 25 e 34 (OR = 2,27; IC95%: 1,45-3,55) e ≥ 35 (OR = 2,15; IC95%: 1,21-3,83) se mantiveram associadas. A magnitude da associação foi maior quando ambos os genitores apresentavam idades avançadas (OR = 4,87; IC95%: 1,71-13,80). Os resultados encontrados podem ter importantes implicações para a psiquiatria clínica e a saúde pública, pois a idade dos genitores, no momento do parto, tem aumentado. Deve-se enfatizar a prevenção da idade reprodutiva tardia e o rastreamento e o acompanhamento das crianças geradas por estes casais.

El trastorno del espectro del autismo (TEA) se ha convertido en un problema de salud pública, con un gran impacto familiar, social y económico. El objetivo de este trabajo fue estimar la asociación entre el TEA y la edad de los progenitores en el momento del parto. Se realizó un estudio de caso-control constituido por 243 individuos con TEA (casos) y 886 neurotípicos (controles). Se aplicó un cuestionario semiestructurado y se realizó una regresión logística múltiple. Las asociaciones entre el TEA y las edades paterna (en años) entre 25 y 34 (OR = 1,65; IC95%: 1,01-2,71), 35 y 44 (OR = 1,62; IC95%: 0,96-2,73) y ≥ 45 (OR = 2,44; IC95%: 1,14-5,00); y materna entre 25 y 34 (OR = 2,38; IC95%: 1,54-3,37) y ≥ 35 (OR = 2,09; IC95%: 1,29-3,39) fueron significativas cuando se evaluaron en modelos independientes. No obstante, cuando se incluían en un mismo modelo, sólo las edades maternas entre 25 y 34 (OR = 2,27; IC95%: 1,45-3,55) y ≥ 35 (OR = 2,15; IC95%: 1,21-3,83) se mantuvieron asociadas. La magnitud de la asociación fue mayor cuando ambos progenitores presentaban edades avanzadas (OR = 4,87; IC95%: 1,71-13,80). Los resultados encontrados pueden tener importantes implicaciones para la psiquiatría clínica y la salud pública, puesto que la edad de los progenitores, en el momento del parto, ha aumentado. Se debe enfatizar la prevención de la edad reproductiva tardía y el rastreo, así como el seguimiento, de los niños generados por estas parejas.

Acute fibrinous and organising pneumonia.

Acute fibrinous and organising pneumonia (AFOP) is a rare histological pattern of interstitial lung disease. The authors describe a 60-year-old woman admitted to the hospital for sustained fever, presenting with an alveolar opacity on chest X-ray, with the presumed diagnosis of community-acquired pneumonia and the onset of antibiotics. Since serological results suggested that Legionella pneumophila was the infectious agent, she was discharged on levofloxacin. A week later, she was again admitted with fever. CT scan showed opacities with crescentic morphology and a central ground-glass area suggestive of cryptogenic organising pneumonia. Microbiological, serological and autoimmunity tests were negative. She underwent surgical lung biopsy that revealed inflammatory infiltrate, macrophage desquamation, fibroblasts proliferation and fibrin deposition in the alveolar spaces, consistent with AFOP. She started corticotherapy with good response. Disease relapsed after prednisolone discontinuation, 10 months later. Currently, the patient is on prednisolone 5 mg/day without clinical and radiological recurrence.

Array CGH Analysis of Paired Blood and Tumor Samples from Patients with Sporadic Wilms Tumor.

Wilms tumor (WT), the most common cancer of the kidney in infants and children, has a complex etiology that is still poorly understood. Identification of genomic copy number variants (CNV) in tumor genomes provides a better understanding of cancer development which may be useful for diagnosis and therapeutic targets. In paired blood and tumor DNA samples from 14 patients with sporadic WT, analyzed by aCGH, 22% of chromosome abnormalities were novel. All constitutional alterations identified in blood were segmental (in 28.6% of patients) and were also present in the paired tumor samples. Two segmental gains (2p21 and 20q13.3) and one loss (19q13.31) present in blood had not been previously described in WT. We also describe, for the first time, a small, constitutive partial gain of 3p22.1 comprising 2 exons of CTNNB1, a gene associated to WT. Among somatic alterations, novel structural chromosomal abnormalities were found, like gain of 19p13.3 and 20p12.3, and losses of 2p16.1-p15, 4q32.5-q35.1, 4q35.2-q28.1 and 19p13.3. Candidate genes included in these regions might be constitutively (SIX3, SALL4) or somatically (NEK1, PIAS4, BMP2) operational in the development and progression of WT. To our knowledge this is the first report of CNV in paired blood and tumor samples in sporadic WT.

Transtorno do espectro do autismo e idade dos genitores: estudo de caso-controle no Brasil / Autism spectrum disorder and parents' age: a case-control study in Brazil / Trastorno del espectro de autismo y edad de los progenitores: estudio de caso-control en Brasil

O transtorno do espectro do autismo (TEA) tem se tornado um problema de saúde pública, com grande impacto familiar, social e econômico. O objetivo deste trabalho foi estimar a associação entre o TEA e a idade dos genitores no momento do parto. Realizou-se um estudo de caso-controle constituído por 243 indivíduos com o TEA (casos) e 886 neurotípicos (controles). Foi aplicado um questionário semiestruturado e realizada a regressão logística múltipla. Associações entre o TEA e as idades paterna (em anos) entre 25 e 34 (OR = 1,65; IC95%: 1,01-2,71), 35 e 44 (OR = 1,62; IC95%: 0,96-2,73) e ≥ 45 (OR = 2,44; IC95%: 1,14-5,00); e materna entre 25 e 34 (OR = 2,38; IC95%: 1,54-3,37) e ≥ 35 (OR = 2,09; IC95%: 1,29-3,39) foram significativas quando avaliadas em modelos independentes. Porém, quando incluídas em um mesmo modelo apenas as idades maternas entre 25 e 34 (OR = 2,27; IC95%: 1,45-3,55) e ≥ 35 (OR = 2,15; IC95%: 1,21-3,83) se mantiveram associadas. A magnitude da associação foi maior quando ambos os genitores apresentavam idades avançadas (OR = 4,87; IC95%: 1,71-13,80). Os resultados encontrados podem ter importantes implicações para a psiquiatria clínica e a saúde pública, pois a idade dos genitores, no momento do parto, tem aumentado. Deve-se enfatizar a prevenção da idade reprodutiva tardia e o rastreamento e o acompanhamento das crianças geradas por estes casais.

Autism spectrum disorder (ASD) has become a public health problem with major family, social, and economic impacts. This study aimed to estimate the association between ASD and parents' age at the time of their child's birth. A case-control study was performed, consisting of 243 individuals with ASD (cases) and 886 neurotypical controls. A semi-structured questionnaire was applied, following by multiple logistic regression. Associations between ASD and paternal age (in years) from 25 to 34 (OR = 1.65; 95%CI: 1.01-2.71), 35 to 44 (OR = 1.62; 95%CI: 0.96-2.73), and ≥ 45 (OR = 2.44; 95%CI: 1.14-5.00); and maternal age from 25 to 34 (OR = 2.38; 95%CI: 1.54-3.37) and ≥ 35 (OR = 2.09; 95%CI: 1.29-3.39) were significant when assessed in independent models. However, when included in a single model, only maternal age from 25 to 34 (OR = 2.27; 95%CI: 1.45-3.55) and ≥ 35 years (OR = 2.15; 95%CI: 1.21-3.83) remained associated with ASD. The association was stronger when both parents were older (OR = 4.87; 95%CI: 1.71-13.80). The results have important implications for clinical psychiatry and public health, since parents' age at childbirth has increased. Emphasis is needed on the prevention of late childbearing and screening and follow-up of children born to these couples.

El trastorno del espectro del autismo (TEA) se ha convertido en un problema de salud pública, con un gran impacto familiar, social y económico. El objetivo de este trabajo fue estimar la asociación entre el TEA y la edad de los progenitores en el momento del parto. Se realizó un estudio de caso-control constituido por 243 individuos con TEA (casos) y 886 neurotípicos (controles). Se aplicó un cuestionario semiestructurado y se realizó una regresión logística múltiple. Las asociaciones entre el TEA y las edades paterna (en años) entre 25 y 34 (OR = 1,65; IC95%: 1,01-2,71), 35 y 44 (OR = 1,62; IC95%: 0,96-2,73) y ≥ 45 (OR = 2,44; IC95%: 1,14-5,00); y materna entre 25 y 34 (OR = 2,38; IC95%: 1,54-3,37) y ≥ 35 (OR = 2,09; IC95%: 1,29-3,39) fueron significativas cuando se evaluaron en modelos independientes. No obstante, cuando se incluían en un mismo modelo, sólo las edades maternas entre 25 y 34 (OR = 2,27; IC95%: 1,45-3,55) y ≥ 35 (OR = 2,15; IC95%: 1,21-3,83) se mantuvieron asociadas. La magnitud de la asociación fue mayor cuando ambos progenitores presentaban edades avanzadas (OR = 4,87; IC95%: 1,71-13,80). Los resultados encontrados pueden tener importantes implicaciones para la psiquiatría clínica y la salud pública, puesto que la edad de los progenitores, en el momento del parto, ha aumentado. Se debe enfatizar la prevención de la edad reproductiva tardía y el rastreo, así como el seguimiento, de los niños generados por estas parejas.

WT1, WTX and CTNNB1 mutation analysis in 43 patients with sporadic Wilms' tumor.

Wilms' tumor (WT) is a heterogeneous neoplasia characterized by a number of genetic abnormalities, involving tumor suppressor genes, oncogenes and genes related to the Wnt signaling pathway. Somatic biallelic inactivation of WT1 is observed in 5-10% of sporadic WT. Somatic mutations in exon 3 of CTNNB1, which encodes ß-catenin, were initially observed in 15% of WT. WTX encodes a protein that negatively regulates the Wnt/ß-catenin signaling pathway and mediates the binding of WT1. In this study, we screened germline and somatic mutations in selected regions of WT1, WTX and CTNNB1 in 43 WT patients. Mutation analysis of WT1 identified two single-nucleotide polymorphisms, one recurrent nonsense mutation (p.R458X) in a patient with proteinuria but without genitourinary findings of Denys-Drash syndrome (DDS) and one novel missense mutation, p.C428Y, in a patient with Denys-Drash syndrome phenotype. WT1 SNP rs16754A>G (R369R) was observed in 17/43 patients, and was not associated with significant difference in age at diagnosis distribution, or with 60-month overall survival rate. WTX mutation analysis identified five sequence variations, two synonymous substitutions (p.Q1019Q and p.D379D), a non-synonymous mutation (p.F159L), one frameshift mutation (p.157X) and a novel missense mutation, p.R560W. Two sequence variations in CTNNB1 were identified, p.T41A and p.S45C. Overall survival of bilateral cases was significantly lower (p=0.005). No difference was observed when survival was analyzed among patients with WT1 or with WTX mutations. On the other hand, the survival of two patients with the CTNNB1 p.T41A mutation was significantly lower (p=0.000517) than the average.

Detailed analysis of X chromosome inactivation in a 49,XXXXX pentasomy.

BACKGROUND: Pentasomy X (49,XXXXX) has been associated with a severe clinical condition, presumably resulting from failure or disruption of X chromosome inactivation. Here we report that some human X chromosomes from a patient with 49,XXXXX pentasomy were functionally active following isolation in inter-specific (human-rodent) cell hybrids. A comparison with cytogenetic and molecular findings provided evidence that more than one active X chromosome was likely to be present in the cells of this patient, accounting for her abnormal phenotype. RESULTS: 5-bromodeoxyuridine (BrdU)-pulsed cultures showed different patterns among late replicating X chromosomes suggesting that their replication was asynchronic and likely to result in irregular inactivation. Genotyping of the proband and her mother identified four maternal and one paternal X chromosomes in the proband. It also identified the paternal X chromosome haplotype (P), indicating that origin of this X pentasomy resulted from two maternal, meiotic non-disjunctions. Analysis of the HUMANDREC region of the androgen receptor (AR) gene in the patient's mother showed a skewed inactivation pattern, while a similar analysis in the proband showed an active paternal X chromosome and preferentially inactivated X chromosomes carrying the 173 AR allele. Analyses of 33 cell hybrid cell lines selected in medium containing hypoxanthine, aminopterin and thymidine (HAT) allowed for the identification of three maternal X haplotypes (M1, M2 and MR) and showed that X chromosomes with the M1, M2 and P haplotypes were functionally active. In 27 cell hybrids in which more than one X haplotype were detected, analysis of X inactivation patterns provided evidence of preferential inactivation. CONCLUSION: Our findings indicated that 12% of X chromosomes with the M1 haplotype, 43.5% of X chromosomes with the M2 haplotype, and 100% of the paternal X chromosome (with the P haplotype) were likely to be functionally active in the proband's cells, a finding indicating that disruption of X inactivation was associated to her severe phenotype.

Cytogenetic and molecular studies of an X;21 translocation previously diagnosed as complete monosomy 21.

We studied a child with apparent monosomy of chromosome 21. Cytogenetic, FISH and microsatellite analyses revealed a 45,X,-21,+der(X)t(X;21)(q25;q21.1) karyotype resulting from a de novo, unbalanced, X;21 non-reciprocal translocation of paternal origin, with partial monosomy of chromosomes 21 and X. An extreme, skewed X-inactivation pattern of the der(X) chromosome was demonstrated. Skewed inactivation probably accounted for a mild phenotype with respect to Xq25-->qter deletion while propagation of inactivation to the adjacent 21q region may account for mild clinical features associated to distal 21q monosomy.

Doença de Hirschsprung: experiência com uma série de 55 casos / Hirschsprung's disease: experiment with a serie of 55 cases

OBJETIVOS: analisar aspectos clínicos de pacientes com Doença de Hirschprung (DH). MÉTODOS: realizou-se estudo de caso institucional, retrospectivo, via revisão de prontuários de pacientes com DH atendidos no Instituto Fernandes Figueira entre 1993 e 2003. RESULTADOS: Em um total de 55 pacientes, 98 por cento apresentaram sintomas neonatais, sendo 47,2 por cento diagnosticados nesse período; em 88,9 por cento o enema baritado foi conclusivo; 69 por cento tinham DH de segmento curto; 16,3 por cento síndrome de Down; 15,2 por cento outras anomalias congênitas; 40 por cento foram rastreados para mutações RET associadas a neoplasias endócrinas múltiplas (MEN2A), não sendo detectada nenhuma; 63,6 por cento fizeram abaixamento estagiado do colon/íleo; 12,72 por cento abaixamento endoretal transanal primário; as principais complicações cirúrgicas foram sepse, enterocolite e obstrução intestinal; distúrbios da defecação foram detectados anos pós-cirurgia; a taxa de letalidade foi 9,25 por cento; os óbitos relacionaram-se a enterocolite e sepse pós-operatórias. CONCLUSÃO: embora apresentasse sintomas neonatais, a maioria dos pacientes foi diagnosticada tardiamente. Enterocolite foi a principal causa de morbimortalidade. Distúrbios da defecação ocorrem com frequência, demandando follow-up prolongado. Embora rara, a associação com MEN2A precisa ser investigada devido à agressividade da doença. A heterogeneidade clínica e genética da DH exige atuação de equipe multidisciplinar.

OBJECTIVES: to analyze clinical features of patients with Hirschprung's Disease (HD). METHODS: a retrospective institutional case study was carried out using the medical records of patients with HD attending the Fernandes Figueira Institute between 1993 and 2003. RESULTS: out of a total of 55 patients, 98 percent presented symptoms on birth, 47.2 percent of whom were diagnosed during the neonatal period; in 88.9 percent of cases the barium enema was conclusive; 69 percent had short segment HD; 16.3 percent Down's Syndrome; 15.2 percent other congenital anomalies; 40 percent were screened for RET mutations associated with multiple endocrine neoplasias (MEN2A), although none were detected; 63.6 percent had staged pull-through surgery on the colon or ileum; 12.72 percent primary transanal endorectal pull-through surgery; the main complications arising from surgery were sepsis, enterocolitis and obstruction of the intestines; abnormal bowel movements were detected years after the surgery; the mortality rate was 9.25 percent, the causes of death being post-operal enterocolitis and sepsis. CONCLUSION: although patients presented symptoms on birth, most were diagnosed at a later stage. Enterocolitis was the main cause of death. Abnormal bowel movements frequently occurred, requiring prolonged follow-up. Although rare, the association with MEN2A needs to be investigated owing to the highly aggressive nature of the disease. The clinical and genetic heterogeneity of HD necessitates the involvement of a multidisciplinary team.