Early safety of tenofovir alafenamide in patients with a history of tubulopathy on tenofovir disoproxil fumarate: a randomized controlled clinical trial.

OBJECTIVES: The aim of the study was to assess the effect of tenofovir alafenamide (TAF) on kidney and bone biomarkers in patients who developed proximal renal tubulopathy (PRT) while receiving tenofovir disoproxil fumarate (TDF). METHODS: Individuals with a history of TDF-associated PRT and currently suppressed HIV infection on a tenofovir-sparing regimen were randomized 1:1 to continue current antiretroviral therapy or initiate emtricitabine (F)/TAF with discontinuation of nucleoside reverse transcriptase inhibitors (NRTIs) as appropriate. Renal and bone biomarkers were analysed at baseline, week 4 and week 12. The primary outcome was the mean difference between study arms in urine retinol-binding protein:creatinine ratio (RBPCR) change from baseline to week 12. Data were analysed using linear regression, with robust standard errors (primary outcome), and repeated measures mixed effects models (secondary outcomes). The trial was registered under European Union Drug Regulating Authorities Clinical Trials Database 2016-003345-29. RESULTS: We randomized 31 individuals [mean age 52.4 (standard deviation 0.3) years; 97% male; 90% white); all completed the study. At 12 weeks, there was no difference in change in RBPCR (ß 19.6; 95% confidence interval -35.3, 74.5; P = 0.47), and no difference in change in estimated glomerular filtration rate (eGFR) (based on creatinine or cystatin C), albuminuria, proteinuria, renal phosphate or urea handling, (fasting) urine osmolality, parathyroid hormone and bone turnover markers in the control versus the F/TAF exposed groups. No cases of PRT were observed. CONCLUSIONS: In people with a history of proximal renal tubulopathy while on TDF, 12-week exposure to TAF did not adversely affect renal tubular function. These data support continued evaluation of the long-term safety of TAF in this group of patients.

Impact of rare variants in ARHGAP29 to the etiology of oral clefts: role of loss-of-function vs missense variants.

Non-syndromic cleft lip with or without cleft palate (NSCL/P) is a prevalent, complex congenital malformation. Genome-wide association studies (GWAS) on NSCL/P have consistently identified association for the 1p22 region, in which ARHGAP29 has emerged as the main candidate gene. ARHGAP29 re-sequencing studies in NSCL/P patients have identified rare variants; however, their clinical impact is still unclear. In this study we identified 10 rare variants in ARHGAP29, including five missense, one in-frame deletion, and four loss-of-function (LoF) variants, in a cohort of 188 familial NSCL/P cases. A significant mutational burden was found for LoF (Sequence Kernel Association Test, p = 0.0005) but not for missense variants in ARHGAP29, suggesting that only LoF variants contribute to the etiology of NSCL/P. Penetrance was estimated as 59%, indicating that heterozygous LoF variants in ARHGAP29 confer a moderate risk to NSCL/P. The GWAS hits in IRF6 (rs642961) and 1p22 (rs560426 and rs4147811) do not seem to contribute to the penetrance of the phenotype, based on co-segregation analysis. Our data show that rare variants leading to haploinsufficiency of ARHGAP29 represent an important etiological clefting mechanism, and genetic testing for this gene might be taken into consideration in genetic counseling of familial cases.

Larval migration of the ascarid nematode Toxocara canis following infection and re-infection in the gerbil Meriones unguiculatus.

A morphological and immunohistochemical study of larval migration patterns was performed in gerbils that were infected once (primary infected group) or twice (secondary infected group) with 1500 eggs of Toxocara canis. Animals from the primary infected and the re-infected group were killed at different times after infection, and larvae were counted in the intestines, liver, lungs and brain. Fragments of all organs were formalin fixed and paraffin embedded for histology and immunohistochemistry analyses (using polyclonal anti-Toxocara serum raised in rabbits infected with T. canis). In the primary infected group, larvae were more abundant in the intestine at 24 h, in the liver and lungs between 24 and 72 h and in the brain after 96 h; larvae predominated in the brain for up to 60 days after infection. In the re-infected group, an increase in the number of larvae in the liver and a reduction in the number of larvae in the brain was observed up to 60 days after re-infection. Inflammatory reactions were absent or limited. Eosinophils and loose granulomata were observed around the larvae and their antigens in the primary infected group and were more severe. Many eosinophils and typical epithelioid granulomata were observed around larvae in the re-infected group. These results demonstrate that the migration pattern of T. canis larvae in gerbils is similar to that in mice and rats, exhibiting a late neurotropic stage. In the re-infected group, there was histological evidence of an adaptive T-helper 2 (Th-2) response, and larvae were apparently retained within granulomata in the liver, without obvious signs of destruction.

Protocol to cryopreserve and isolate nuclei from adipose tissue without dimethyl sulfoxide.

Cryopreservation injuries involve nuclear DNA damage. A protocol for cryopreserving and isolating adipocyte nuclei is proposed. Adipose tissue samples were directly analyzed (NoCRYO-0h), or stored at -196°C for 7 days without 10% dimethyl sulfoxide (DMSO) (CRYO-WO-DMSO) or with DMSO (CRYO-W-DMSO). To determine the effect of DMSO on cryopreservation treatment, adipose tissue samples were stored at 4°C for 24 h with 10% DMSO (NoCRYO-W-DMSO-24h) and without (NoCRYO-WO-DMSO-24h). Samples were processed in isolation buffer, and nuclear integrity was measured by flow cytometry. The coefficient of variation, forward scatter, side scatter, and number of nuclei analyzed were evaluated. Pea (Pisum sativum) was used to measure the amount of DNA. All groups contained similar amounts of DNA to previously reported values and a satisfactory number of nuclei were analyzed. CRYO-W-DMSO presented a higher coefficient of variation (3.19 ± 0.09) compared to NoCRYO-0h (1.85 ± 0.09) and CRYO-WO-DMSO (2.02 ± 0.02). The coefficient of variation was increased in NoCRYO-W-DMSO-24h (3.80 ± 0.01) compared to NoCRYO-WO-DMSO-24h (2.46 ± 0.03). These results relate DMSO presence to DNA damage independently of the cryopreservation process. CRYO-W-DMSO showed increased side scatter (93.46 ± 5.03) compared to NoCRYO-0h (41.13 ± 3.19) and CRYO-WO-DMSO (48.01 ± 2.28), indicating that cryopreservation with DMSO caused chromatin condensation and/or nuclear fragmentation. CRYO-W-DMSO and CRYO-WO-DMSO presented lower forward scatter (186.33 ± 9.33 and 196.89 ± 26.86, respectively) compared to NoCRYO-0h (322.80 ± 3.36), indicating that cryopreservation reduced nuclei size. Thus, a simple method for cryopreservation and isolation of adipocyte nuclei causing less damage to DNA integrity was proposed.

Constraints on tree seedling establishment after fires: passing the germination bottlenecks.

Persistence and colonization by tree species in an environment following a fire depends on the effects on seed germination and seedling development. We used seeds of Kielmeyera coriacea and Qualea parviflora as a model to test the effects of high temperatures on germination and initial development of tree seedlings. We exposed the seeds to heat flow (70, 100, 130, 150 or 170 °C) for 2 or 5 min and compared the germination with that of unheated seeds (control). Seedlings were then harvested after 3, 7 or 15 days to evaluate aerial and root mass, root:shoot ratio, presence of cotyledon opening, true leaves, and secondary roots. We found no effect on germination for seeds exposed to temperatures ≥150 °C. However, germination was significantly reduced for seeds exposed to 100 °C for both 2 and 5 min. The mass of 15-day-old K. coriacea seedlings was smaller when seeds were heated at 70 °C for 5 min or at temperatures higher or equal to 100 °C. Qualea parviflora seedlings did not show any difference in mass, but there were marginal differences in the presence of roots and the opening of cotyledons. Kielmeyera coriacea seedlings allocated biomass faster than Q. parviflora. High temperatures affect both quantity and quality of germinable seeds, as well as biomass allocation during initial seedling development. These factors may explain the decrease in seedlings observed after fire, suggesting a bottleneck effect that influences population dynamics and species persistence in systems with frequent fires.

Hyperinsulinemic hypoglycemia in adolescents: case report and systematic review.

BACKGROUND: Hyperinsulinemic hypoglycemia is the most common cause of severe and persistent hypoglycemia in neonates and children. It is a heterogeneous condition with dysregulated insulin secretion, which persists in the presence of low blood glucose levels. CASE PRESENTATION: We report a case of a 15 year-old male with hyperinsulinemic hypoglycemia, who underwent a subtotal pancreatectomy after inadequate response to medical therapy. Pathological examination was positive for nesidioblastosis (diffuse ß-cell hyperplasia by H-E and immunohistochemical techniques). The patient's blood glucose levels normalized after surgery and he remains asymptomatic after 1 year of follow-up. The systematic review allowed us to identify 41 adolescents from a total of 205 cases reported in 22 manuscripts, from a total of 454 found in the original search done in PubMed and Lilacs. CONCLUSIONS: Although very well reported in children, hyperinsulinemic hypoglycemia can occur in adolescents or young adults, as it happens in our reported case. These patients can be seen, treated and reported by pediatricians or adult teams either way due to the wide age range used to define adolescence. Most of them do not respond to medical treatment, and subtotal distal pancreatectomy has become the elected procedure with excellent long-term response in the vast majority.

Reset Osmostat: Facts and Controversies.

Reset osmostat (RO) consists of a change in the normal plasma osmolality threshold (reduction or increase), which consequently induces chronic dysnatremia (hyponatremia or hypernatremia). Although the early papers on RO state that hyponatremic patients with this condition are usually not symptomatic, the current view is that most patients with hyponatremia are symptomatic and should be treated. RO has been associated with a myriad of clinical conditions and has clear diagnostic criteria which are crucial to arrive at the correct diagnosis and treatment.

Fire-induced damage to Qualea multiflora Mart. seeds depends on fruit protection and the position in the tree crown.

Although the Cerrado vegetation is adapted to fire, anthropogenic fires may impair the reproduction of some species. This study aimed to test the role of fruits of Qualea multiflora and their position in the tree crown in protecting the seeds during fires. Ten trees were selected in an area protected from fire (NB) and ten in a biannually burned area (B). Fruits were counted before the 2008 fire and weekly thereafter for 5 weeks. Fruit dehiscence, damage and position in the tree crown were recorded. Seed germination was assessed for seeds from both areas. In NB, 5.7% of fruits were located higher than 2 m, while in B 49.5% were located at this height. One week after the fire, the proportion of dehiscent fruits was lower in NB (19.5%) than in B (34.5%). Five weeks after the fire, all fruits in NB had dispersed their seeds, whereas in B only 47% of the fruits had. Immediately before the fire, the germination rate of seeds collected in NB was 80% (0-1 m), 97% (1-2 m) and 92% (≥2 m). Fifteen days after the fire, the germination rate of seeds in the B area was 3% (0-1 m), 13% (1-2 m) and 78% (≥2 m). Protection of Q. multiflora seeds from high temperatures is related to the fruit position in the tree crown rather than to fruit protection. Therefore, the results suggest that fire may alter the recruitment of new individuals.

Pancreas Transplantation at a Single Latin-American Center; Overall Results with Type 1 and Type 2 Diabetes Mellitus.

BACKGROUND: Simultaneous pancreas-kidney transplantation (SPK) has become the treatment of choice for type 1 diabetes mellitus (T1DM) patients with chronic renal failure. Type 2 diabetes mellitus (T2DM), was once considered to be a contraindication for pancreas transplantation; however, it has been accepted as a new indication, under strict criteria. Although favorable results have increase the indication for T2DM in developed countries, there have been no reports of long-term results for this indication from Latin American centers. METHODS: From April 2008 to March 2016, patients receiving SPK or pancreas transplant alone (PTA) for T2DM were included and compared with T1DM recipients. Variables were compared between groups with the use of χ2 and t tests; Kaplan-Meier with log rank was used for patient and graft survivals; P < .05 was considered to be significant. RESULTS: A total of 45 SPK and 1 PTA were performed, 35 (76.1%) for T1DM and 11 (24.5%) for T2DM. Mean pre-transplantation C-peptide was significantly higher in the T2DM group (P = .01); HbA1c was higher in the T1DM group (P = .03). No differences were found in weight, body mass index, and pre-transplantation glycemia. Patient survivals for T1DM recipients were 88.2% and 84.8% at 1 and 5 years, respetively, versus 100% and 74.1% for T2DM recipients (P = .87). CONCLUSIONS: Our initial prospective experience in a single Latin American center showed that medium- and long-term outcomes for T1DM and T2DM individuals receiving pancreas transplants are similar, under strict selection criteria.

The Importance of Evaluating Frailty and Social-behavioral Factors for Managing Drugs and Dialysis Prescription in Elderly Patients.

Ageing is characterized by a progressive loss of complexity, which is an essential condition for making the organism capable of keeping homeostasis. Thus, senile loss of complexity makes old individuals frail: a syndrome characterized by the presence of shrinking (sarcopenia), weakness, poor endurance and energy, slowness, and low physical activity. Moreover, renal ageing progressively leads to a glomerular filtration rate (GFR) reduction, one of the main pharmacokinetic senile changes, which is not detectable by simply evaluating serum urea or creatinine values but measuring or calculating patient's GFR. Finally, current epidemiology has documented that detrimental social-behavioral factors such as low education level, poor financial-resource, depression, and isolation, also influence the onset and progression of chronic diseases, and even overall mortality, particularly in the elderly. Thus, we propose that these 3 variables: frailty phenotype, senile GFR, and detrimental social-behavioral factors, should be considered at time of prescribing drugs or medical procedures in the elderly. Additionally, they should also be considered for following patient's response to prescribed therapies in elderly patients suffering from chronic diseases (diabetes mellitus, chronic kidney disease, etc.), or on organ replacement treatments (dialysis and transplantation).

Renal potassium excretion: comparison between chronic renal disease patients and old people.

UNLABELLED: Senescence and chronic renal failure bring about a progressive glomerular filtration reduction. Moreover, a reduction in glomerular filtration usually modifies the potassium renal excretion. In the present study, we compared the renal potassium handling between old and chronic renal disease populations. MATERIALS AND METHODS: Fifty-five volunteers were studied, 43 of them were healthy old persons and 12 were predialysis chronic renal disease patients. Exclusion criteria were: presence of altered plasma potassium (Kp), diabetes mellitus, obstructive uropathy, drugs that could alter plasma potassium levels. All volunteers were on a diet with a potassium content around 50 mmol/day (3-day dietary register). We measured potassium, creatinine, urea in plasma and 24 hours urine. We also measured creatinine clearance (CrCl) and fractional excretion of potassium (FEK), and we studied the relationship between these parameters. Statistical analysis was made using Student's test. RESULTS: Slopes of the correlation curves between CrCl and FEK. [Table: see text]. CONCLUSION: The relationship between creatinine clearance and fractional excretion of potassium in old and chronic renal disease groups were different with the excretion of potassium being lower in the elderly.

Variations in regional cerebral blood flow investigated by single photon emission computed tomography with technetium-99m-d, l-hexamethylpropyleneamineoxime = l-h during temporary clipping in intracranial aneurysm surgery: preliminary results.

Single photon emission computed tomography with technetium-99m-d, l-hexamethylpropyleneamineoxime was used to assess variations in regional cerebral blood flow during temporary clipping in the course of intracranial aneurysm surgery and during the postoperative period in 20 patients, 14 of whom underwent temporary clipping. Of these 14 patients (Group A), 9 had aneurysms of the anterior communicating artery, 2 had aneurysms of the middle cerebral artery, and 3 had aneurysms of the carotid siphon. Temporary clips were applied, according to the site of the lesion, on A1, on the trunk of the middle cerebral artery, or on the trunk of the internal carotid artery. The occlusion time ranged from 2 to 31 minutes. The six patients who did not undergo temporary clipping served as controls (Group B), as follows: three had aneurysms of the posterior communicating artery, one of the anterior communicating artery, one of the middle cerebral artery, and one of the internal carotid artery. All patients were investigated with cerebral single photon emission computed tomography preoperatively, perioperatively, and postoperatively. In all the patients of Group A, the preliminary results of the study show a sharp fall in the perfusion of the territories of the temporarily clipped parent vessel and practically a complete recovery within 2 to 7 days of surgery, with no significant neurological symptoms. No similar disturbance of perfusion was found in the patients of Group B.

Acute brain swelling during removal of supratentorial cystic lesion caused by contralateral extradural hematoma: case report.

BACKGROUND: Protrusion of the cortex through a bone flap in the course of surgery is a very serious event and, if it persists, the procedure must be suspended, the cause sought, and the problem resolved. CASE DESCRIPTION: We report the case of a 13-year-old boy whose brain underwent sudden swelling during removal of a supratentorial cystic lesion. The operation was suspended at once and an emergency CT scan was performed. It revealed a large contralateral extradural hematoma, which was removed immediately. CONCLUSIONS: We considered the following possible mechanisms of the emergency: bleeding of bone at the site of the supposed piercing by the headrest pin and/or a vacuum mechanism consequent upon removal of the large cystic lesion. Our aims are to emphasize the importance of gauging the thickness of a child's skull before fixing the head in the headrest, especially when chronic intracranial hypertension is present, and the need to suspend the operation for CT scanning in the event of uncontrollable brain swelling.

Clinical and neuroradiological correlations in a patient with a wandering retained air gun pellet in the brain.

The authors present the case of a patient with an air gun pellet that moved from the ventricular system into the subarachnoid space of C2-C3, from where it was successfully removed by interlaminotomy.

Isolation and characterization of iridoviruses from the giant toad Bufo marinus in Venezuela.

In this communication we describe for the first time the isolation of 7 iridoviruses from the toad Bufo marinus and an unknown species of frog Leptodactylus in Venezuela, South America. The viruses are icosahedral with electron-dense cores, each of which is surrounded by an inner membrane, capsid and a cell-derived envelope. The virus(es) have an average vertex to vertex diameter of 160 nm and replicate in the cytoplasm of a range of cell lines. Within the cytoplasm of infected cells, rarefied areas could be observed; structures lacked cellular organelles and contained complete, empty and developing viruses. Results from antigen-capture enzyme-linked immunosorbent assays (ELISA) with polyclonal antibody raised against epizootic haematopoietic necrosis virus (EHNV) indicated cross-reactivity between these isolates, Bohle iridovirus (BIV) and frog virus 3 (FV3). Comparison of polypeptide and genomic profiles indicated that the Venezuelan viruses shared many polypeptides of equivalent molecular weight with type species FV3. There were, however, differences between the group of Venezuelan viruses and FV3 and BIV. The viruses belongs to the family Iridoviridae and the genus Ranavirus.

Labrea-like hepatitis in Vitoria, Espirito Santo State, Brazil: report of a case.

A case of fulminant hepatitis with microvesicular steatosis resembling Labrea's fever, diagnosed in Vitoria (ES) is reported. The 16 year old boy presented with severe epistaxis, agitation, jaundice and hemorrhagic vomiting and died two days after admission to the emergency unit of the University Hospital. The disease started five days before with fever, myalgias, dark urine and jaundice and progressed with psychic agitation, torpor and coma. The liver and spleen were not palpable. HBsAg was negative in the serum. The autopsy showed acute hepatitis with lytic necrosis confluent in the midzonal and periportal areas with massive microvesicular steatosis in the remaining hepatocytes. Mononuclear cells predominated in the exudate. The reticulum showed condensation in the necrotic areas without typical bands of collapse. The portal tracts were edematous with mononuclear infiltration and mild bile duct proliferation. Absence of cholestasis. Except for the confluent midzonal and periportal necrosis this case showed several clinical and morphological aspects of the Labrea fever described from the East Amazon, demonstrating that the anatomical picture of this disease probably is not in related to a factor peculiar to the Amazon region.

Ascaris lumbricoides: reinfection in children bearing an established worm burden.

To clarify the existence of reinfection in children bearing an established Ascaris lumbricoides infection, the authors evaluated the weight and the length of worms collected from ten cases of ascaridiasis. The worm burden was greater than 27 worms in nine cases. In seven cases the weight and the length of worms showed little variation, with unimodal distribution of values, suggesting that all the worms in each case belong to the same population, originated from a single brood infection or from successive infections over small time intervals. In three cases there was great variation in worm size indicated by the different values for the means and medians and by the high values for the standard deviation and coefficient of variation. In these three cases there was a bimodal distribution of worm's size suggesting the coexistence of two distinct populations: one, less numerous, composed of mature worms and the other, more numerous, composed of immature worms, in two cases, and two distinct populations of immature worms in one case. The existence of worms in different stages of maturation indicates that the less mature population was acquired when the mature worms were established in the gut. These results indicate that the reinfection with Ascaris in children bearing an established infection is not rare and resistance induced by a preexisting infection is not the rule.

[Pyogenic liver abscess and schistosomiasis mansoni in the state of Espírito Santo]. / Abscesso piogênico do fígado e esquistossomose mansônica: observações no Estado do Espírito Santo.

A possible association of the acute toxemic form of schistosomiasis and pyogenic liver abscess (PLA) has been recently suggested. As in the west of the Espírito Santo state schistosomiasis is endemic and PLA are frequently diagnosed in the Children's Hospital of Vitória we reviewed the records of the Hospital during the period from May 1991 to April 1993 to: a) identify all cases of PLA in which Schistosoma mansoni infection was present and b) annotate the procedence of each case to verify if there is an association of the two diseases. 65 cases of PLA were recorded and 39 had the result of a stool examination, being three positive for Schistosoma mansoni (7.6%) and 26 for other helminth (mainly Ascaris and Trichocephalus). The procedence of the patients showed that only 7 (10.7%) came from endemic areas. These results show that an association of Schistosoma mansoni infection and PLA was not significative in the country, where the acute toxemic form is not frequent. The great majority of PLA in this study came from the urban periphery of Vitória, where transmission of schistosomiasis does not occur but intestinal helminth infections are extremely frequent. The great majority of PLA in this study came from the urban periphery of Vitória, where transmission of schistosomiasis does not occur but intestinal helminth infections are extremely frequent. As 40% of these PLA were cryptogenetic it is possible that the immunomodulation induced by intestinal parasites and the liver granulomas produced by the larvae of these helminths would be predisposing factors for pyogenic liver abscess.

Plasma erythropoietin levels in the oldest old.

UNLABELLED: Erythropoietin (EPO) regulates erythrocytes production and is synthesized mainly by the kidney. Its production is reduced during chronic renal failure but is not altered by the senescence process in spite of the morphological changes that occur in the kidney. However, there is no information regarding what happens to erythropoietin synthesis during advanced ageing. Thus, we carried out an investigation to determine whether there was any significant difference in plasma erythropoietin between adults, old and very old people. MATERIAL AND METHODS: We studied 74 healthy volunteers: 22 adults, 30 old, and 22 very old. None of them were smokers or were suffering from any disease that may intefere with hemoglobin (Hb) levels or with EPO production. Hematocrit, Hb, plasma creatinine and plasma erythropoietin were measured, and creatinine clearance was calculated from serum creatinine using two different formulae. Statistical analysis was performed using ANOVA and Bonferroni tests. RESULTS AND CONCLUSION: Among the three groups we found a significant difference in creatinine clearance (p < 0.001), but not in plasma erythropoietin levels; we conclude that normal senescence does not alter plasma erythropoietin levels, even during advanced ageing.