Improvement of the Pour Plate Method by Separate Sterilization of Agar and Other Medium Components and Reduction of the Agar Concentration.

Although the pour plate method is widely employed in microbiological quality control, it has certain drawbacks, including having to melt the culture medium before seeding. In this study, the preparation of the culture medium was modified by using a lower concentration of agar (10 g/L), which was separated from the nutrients during sterilization. The new protocol was assessed in media frequently used in microbiological quality control of food, cosmetics, and pharmaceutical products, with tryptic soy agar (TSA), Sabouraud 4% dextrose agar (SDA), and violet red bile glucose agar (VRBG). In comparison with the conventionally produced media, the modifications significantly improved the growth of Saccharomyces cerevisiae in SDA, Staphylococcus aureus, Salmonella enterica subsp. enterica serovar Typhimurium, and Candida albicans in TSA and Escherichia coli ATCC 8739 and ATCC 25922 and S. Typhimurium in VRBG. The modified VRBG was also more selective for Pseudomonas aeruginosa. Regarding physicochemical properties, a significantly lower pH was observed in TSA and VRBG and lower strength values in TSA. Sterilizing agar separately from the other components of the medium and reducing the agar concentration to 10 g/L can improve microorganism growth and enhance the selectivity of differential media in the pour plate method. These modifications could facilitate the automation of this culture technique. IMPORTANCE In the era of rapid microbiological methods, there is a need to improve long-established culture techniques. Drawbacks of the pour plate method include having to melt each medium separately before seeding. For this technique, we demonstrate that separating the agar from the other components of commonly used media during sterilization and reducing the agar concentration to 10 g/L can enhance microbial growth. The new protocol could have advantages in routine laboratory practice because less agar is required and the same molten agar suspension can be used to prepare different media. Moreover, these modifications could facilitate the automation of the pour plate method.

Improvement of Mueller-Kauffman Tetrathionate-Novobiocin (MKTTn) enrichment medium for the detection of Salmonella enterica by the addition of ex situ-generated tetrathionate.

The detection of Salmonella in food is based on the use of a selective enrichment broth such as Muller-Kauffman Tetrathionate-Novobiocin (MKTTn), in which tetrathionate plays a key role by providing Salmonella with a growth advantage. As sodium tetrathionate is unstable, it is generated in situ by the addition of iodine (Lugol's solution) before seeding. This step is cumbersome as the solution is easily spilled, compromising the performance of the medium and hindering the work of technicians. The aim of this study was to optimize MKTTn broth by generating tetrathionate ex situ through an external reaction between iodine and thiosulphate followed by lyophilization. Quality control procedures were performed to compare the modified and original media, testing pure productivity (enrichment with 50-120 CFU of Salmonella Thyphimurium ATCC 14028 and Salmonella Enteritidis ATCC 13076 and plating on Xylose Lysine Deoxycholate agar, XLD), mixed productivity (50-120 CFU of Salmonella strains and Pseudomonas aeruginosa and Escherichia coli at ≥104 CFU and XLD plating) and selectivity (≥104 CFU of P. aeruginosa and Enterococcus faecalis and plating on Tryptone Casein Soy agar, TSA). The modified MKTTn medium (S/L) performed comparably with the original medium in terms of growth of both Salmonella strains (>300 colonies in XLD), alone or with P. aeruginosa and E. coli. Quantitative assays showed no statistically significant differences in the number of colonies grown on XLD after 10-5 dilution (p = 0.7015 with S. Thyphimurium ATCC 14028 and p = 0.2387 with S. Enteritidis ATCC 13076; ANOVA test). MKTTn medium (S/L) was also selective against E. coli (≤100 colonies) and E. faecalis (<10 colonies). These results suggest that adding tetrathionate as a lyophilisate (S/L) is a feasible alternative to the use of Lugol's solution for the preparation of MKTTn enrichment broth and does not affect the properties of the medium.

Topological bound states in interacting Su-Schrieffer-Heeger rings.

We study two-particle states in a Su-Schrieffer-Heeger (SSH) chain with periodic boundary conditions and nearest-neighbor (NN) interactions. The system is mapped into a problem of a single particle in a two-dimensional (2D) SSH lattice with potential walls along specific edges. The 2D SSH model has a trivial Chern number but a non-trivial Zak's phase, the one-dimensional (1D) topological invariant, along specific directions of the lattice, which allow for the presence of topological edge states. Using center-of-mass and relative coordinates, we calculate the energy spectrum of these two-body states for strong interactions and find that, aside from the expected appearance of doublon bands, two extra in-gap bands are present. These are identified as bands of topological states localized at the edges of the internal coordinate, the relative distance between the two particles. As such, the topological states reported here are intrinsically many-body in what concerns their real space manifestation, having no counterpart in single-particle states derived from effective models. Finally, we compare the effect of Hubbard interactions with that of NN interactions to show how the presence of the topological bound states is specific to the latter case.

Viability qPCR, a new tool for Legionella risk management.

BACKGROUND: Viability quantitative Polymerase Chain Reaction (v-qPCR) is a recent analytical approach for only detecting live microorganisms by DNA amplification-based methods This approach is based on the use of a reagent that irreversibly fixes dead cells DNA. In this study, we evaluate the utility of v-qPCR versus culture method for Legionellosis risk management. METHODS: The present study was performed using 116 real samples. Water samples were simultaneously analysed by culture, v-qPCR and qPCR methods. Results were compared by means of a non-parametric test. RESULTS: In 11.6% of samples using both methods (culture method and v-qPCR) results were positive, in 50.0% of samples both methods gave rise to negative results. As expected, equivalence between methods was not observed in all cases, as in 32.1% of samples positive results were obtained by v-qPCR and all of them gave rise to negative results by culture. Only in 6.3% of samples, with very low Legionella levels, was culture positive and v-qPCR negative. In 3.5% of samples, overgrowth of other bacteria did not allow performing the culture. When comparing both methods, significant differences between culture and v-qPCR were in the samples belonging to the cooling towers-evaporative condensers group. The v-qPCR method detected greater presence and obtained higher concentrations of Legionella spp. (p<0.001). Otherwise, no significant differences between methods were found in the rest of the groups. CONCLUSIONS: The v-qPCR method can be used as a quick tool to evaluate Legionellosis risk, especially in cooling towers-evaporative condensers, where this technique can detect higher levels than culture. The combined interpretation of PCR results along with the ratio of live cells is proposed as a tool for understanding the sample context and estimating the Legionellosis risk potential according to 4 levels of hierarchy.

Amino acid­based surfactants: New antimicrobial agents.

The rapid increase of drug resistant bacteria makes necessary the development of new antimicrobial agents. Synthetic amino acid-based surfactants constitute a promising alternative to conventional antimicrobial compounds given that they can be prepared from renewable raw materials. In this review, we discuss the structural features that promote antimicrobial activity of amino acid-based surfactants. Monocatenary, dicatenary and gemini surfactants that contain different amino acids on the polar head and show activity against bacteria are revised. The synthesis and basic physico-chemical properties have also been included.

Optimizing the production of the biosurfactant lichenysin and its application in biofilm control.

AIMS: Apply response surface methodology (RSM) to develop and optimize an economical medium for lichenysin production, which is a surfactant produced by Bacillus licheniformis and evaluate the application of lichenysin in the prevention and disruption of pathogenic micro-organism biofilm that creates health problems in the food industry and hospitals. RESULTS: An economical medium containing molasses was optimized to enhance lichenysin production by RSM. A production of 3·2 g l(-1) of lichenysin was achieved with an optimum medium containing 107·82 g l(-1) of molasses, 6·47 g l(-1) of NaNO3 and 9·7 g l(-1) of K2 HPO4 /KH2 PO4 , in which molasses and phosphate salts had a significant effect on biosurfactant production. Lichenysin was effectively applied in a surface pre-treatment to avoid microbial biofilm development of methicillin-resistant Staphylococcus aureus (MRSA) (68·73%) and Candida albicans (74·35%), with ED50 values of 8·3 and 17·2 µg ml(-1) respectively. It was also very efficient in a surface post-treatment to remove biofilms of MRSA (55·74%) and Yersinia enterocolitica (51·51%), with an ED50 of 2·79 and 4·09 µg ml(-1) respectively. CONCLUSIONS: Lichenysin was found to have notable anti-adhesion activity, being able to prevent and eliminate the biofilm formation by pathogenic strains associated with foodborne illness. This new medium resulted in a four-fold increase in production compared with the nonoptimized medium. SIGNIFICANCE AND IMPACT OF THE STUDY: Molasses can be regarded as a useful resource for biotechnological applications, such as the production of lichenysin. The use of agro-industrial substrates has an important role in the sustainable and competitive development of several industrial sectors, as well as in industrial residues management. Additionally, lichenysin is particularly effective in preventing biofilm formation by strains problematic for the food industry and in the hospital environment. Lichenysin also efficiently disrupts biofilm.

Hypoglycemic Effect of the Methanol flower Extract of Piper Claussenianum and the Major Constituent 2',6'-dihydroxy-4'-methoxychalcone in Streptozotocin Diabetic Rats.

Piper claussenianum inflorescences crude methanol extract was tested for hypoglycemic effect in streptozotocin-induced diabetic rats. The blood glucose levels of rats treated with methanol extract were reduced from 318.4±28.1 mg/dl before treatment to 174.2±38.3 mg/dl after 12 days of treatment (P<0.05). Phytochemical studies were carried out on inflorescences methanol crude extract in order to investigate the possible metabolites responsible for the pharmacological properties of the extract. After chromatographic procedures, three flavonoids were isolated and characterized. The major compound 2',6'-dihydroxy-4'-methoxychalcone was also tested. Rats that received the chalcone content also displayed a reduction in blood glucose levels from 277.4±7.7 mg/dl before treatment to 158.8±9.2 mg/dl after 12 days of treatment (P<0.05). The results suggest this chalcone is one of the metabolite responsible for the blood glucose levels reduction in rats with streptozotocin-induced diabetes. The inflorescence crude extract of P. claussenianum was found to be composed mainly by flavonoids and may be a potential natural source of compounds with hypoglycemic properties.

Rhamnolipids as emulsifying agents for essential oil formulations: antimicrobial effect against Candida albicans and methicillin-resistant Staphylococcus aureus.

This work examines the influence of essential oil composition on emulsification with rhamnolipids and their use as therapeutic antimicrobial agents against two opportunistic pathogens, methicillin-resistant Staphylococcus aureus (MRSA) and Candida albicans. Rhamnolipids, produced by Pseudomonas aeruginosa, with waste frying oil as the carbon source, were composed of eight rhamnolipid homologues. The rhamnolipid mixture was used to produce emulsions containing essential oils (EOs) of Melaleuca alternifolia, Cinnamomum verum, Origanum compactum and Lavandula angustifolia using the titration method. Ternary phase diagrams were designed to evaluate emulsion stability, which differed depending on the essential oil. The in vitro antimicrobial activity of the EOs alone and the emulsions was evaluated. The antimicrobial activity presented by the essential oils alone increased with emulsification. The surface properties of rhamnolipids contribute to the positive dispersion of EOs and thus increase their availability and antimicrobial activity against C. albicans and S. aureus. Therefore, rhamnolipid-based emulsions represent a promising approach to the development of EO delivery systems.

A novel nerolidol-rich essential oil from Piper claussenianum modulates Candida albicans biofilm.

Candidiasis is a major opportunistic fungal infection in humans, and its incidence has increased steadily over the last two decades. Candida albicans, the main species of the genus, has a large arsenal of virulence attributes that contribute to successful infections, such as dimorphism and biofilm formation. The adverse effects of eukaryotic antimicrobial therapies associated with an increase in resistance to the compounds presently available have boosted efforts to improve the therapeutic arsenal against candidiasis with a newer and cheaper range of drugs. In this study, a novel nerolidol-rich essential oil (EO) derived from Piper claussenianum (Miq.) C. DC., Piperaceae, was tested on the growth, transition (yeast to hyphae), formation and stability of biofilms produced by C. albicans. Both inflorescence and leaf EOs were evaluated and revealed MIC values ranging from 0.04 to 0.1 % and 0.2 to 1.26 %, respectively. Furthermore, leaf EO managed to downregulate the yeast-to-hyphae transition by 81 %, as well as reducing biofilm formation by about 30 and 50 % after incubation for 24 and 48 h, respectively. The EO was also able to reduce the viability of pre-formed biofilm by 63.9 %. Finally, the association between the leaf EO and fluconazole was evaluated and revealed an interesting synergistic effect. Taken together, these results demonstrate that this novel compound could be a promising agent and could reinforce the arsenal of therapeutic alternatives for the treatment of candidiasis. Furthermore, it may represent a novel and natural source of nerolidol, which could be of interest pharmaceutically.

Congenital vesicovaginal fistula with or without menouria: a literature review.

Congenital vesicovaginal fistula (CVVF) is a rare, complex female genital malformation that is difficult to diagnose, classify and treat. Symptoms include menouria, cyclical haematuria and urinary incontinence from birth. The aim of this review was to highlight the importance of correct diagnosis and treatment of this congenital anomaly. A comprehensive literature review was conducted to identify articles on CVVF with and without menouria. Forty-one articles were found, of which 31 described 37 original cases of congenital fistula (30 CVVF, six uterovesical fistula and one urethrovaginal fistula): 14 in girls and 23 in adults. The cases were classified according to clinical, diagnostic and therapeutic parameters in order to unify concepts and terms. Menouria occurred in 21 of the 23 adults: 14 cases were CVVF, six cases were congenital uterovesical fistula, and one case was congenital urethrovaginal fistula in a young woman without congenital adrenal hyperplasia. Sixteen (53%) of the 30 patients with CVVF had urinary incontinence or hydrocolpometra, and 14 (47%) had menouria. There were associated anomalies in 91% of cases, 29 (48%) of which involved the urinary tract. Various diagnostic and therapeutic methods were used, and there was confusion surrounding the aetiopathogenesis in most cases. CVVF should be suspected in any girl with urinary incontinence, urinary tract infections from birth, vaginal swelling or hydrocolpometras, as well as in adults with menouria. Diagnosis should be based on physical examination and imaging (cystoscopy during menouria, ultrasound and magnetic resonance imaging). Surgical treatment should be based on correction of the vaginal defects (obstructive problem opening or vaginal reconstruction) and CVVF closure. The embryological origin of CVVF lies in the abnormal persistence of the urogenital sinus due to lack of formation and caudal growth of the urogenital wedge, combined with distinct degrees of agenesis or hypoplasia of the entire urogenital ridge or the mesonephric ducts (which affects development of the Müllerian ducts).

The production and physicochemical properties of a biosurfactant mixture obtained from Sphingobacterium detergens.

The commercial application of a new biosurfactant such as the one produced by Sphingobacteriumdetergens needs a cost-effective process and knowledge of its properties. In the present study, a specific medium and a downstream process have been developed to enhance biosurfactant production. Optimal concentrations of nutrients in MCA medium were (g/L) the following: KH(2)PO(4), 1; K(2)HPO(4), 2; CO(NH(2))(2) 0.88; CaCl(2) 0.01; FeSO(4)·7H(2)O, 0.01; MgSO(4)·7H(2)O 0.5; KCl, 1.0; trace elements 0.05 mL. Biosurfactant production in the MCA medium required a bacterial co-metabolism of glucose and an n-alkane. A fed-batch culture with supernatant lyophilization prior to organic extraction produced 466 mg/L of organic extract, which represents a 6.9-fold increase in production. The newly obtained biosurfactant was a complex mixture of molecules. The three characterized fractions consisted of the complete fraction and two second-level purification fractions with apolar and polar characteristics. The complete and apolar fractions have been shown to self-aggregate in the form of lamellar liquid crystals at a high concentration and bilayers at lower concentrations. Negatively charged particles were identified, which were neutralized at a low pH with a concomitant increase in size. The pH affected the surface tension of the solutions congruently with phosphate headgroups.

Manchester triage in acute pulmonary embolism: can it unmask the grand impersonator?

BACKGROUND: Acute pulmonary embolism (PE) is associated with high mortality risk. Early diagnosis is difficult because of non-specific clinical presentation and delay in imaging confirmation. Manchester Triage (MT) prioritises patients on the basis of illness severity and potentially recognises those with higher mortality risk. No studies of the role and impact of MT on rapid PE diagnosis and in-hospital mortality (IHM) have been carried out. OBJECTIVE: To assess the appropriateness of MT in this set of patients presenting acutely to the emergency department (ED), and to determine whether it assists in a rapid diagnosis, acts as a protective triage tool and affects short-term mortality. METHODS: Single-centre retrospective study of 176 consecutive patients with PE, assessed by MT in the ED between January 2006 and October 2010 (mean age 70.5±15.7 years, 38.6% men). The primary outcome measure was all-cause IHM. RESULTS: IHM was seen in 30 (17%) patients. More than half of the patients with PE (54%) were classified as target time for first medical observation (MOb) ≤10 min. 73.3% of IHM occurred in this group (p=0.020) with several increased markers of illness severity. MOb ≤10 min was not associated with faster PE imaging confirmation. The average door-to-diagnosis time (PEDx) was 26.8±36.8 h and PEDx >17.0 h was associated with higher IHM (p=0.017). On multivariate analysis, thrombolysis and MOb ≤10 min were included in an IHM predictor model. CONCLUSION: MT has high sensitivity in identifying patients with PE at risk. Those patients assigned as MOb ≤10 min have increased markers of illness severity and higher IHM. MT acts as a protective system in this challenging set and should be used as a patient's first assessment, aiding the emergency medical team to recognise those in need of urgent assessment and treatment.

[Prediction of cerebrovascular event risk following myocardial infarction]. / Predição do risco de evento cerebrovascular após um enfarte agudo do miocárdio.

INTRODUCTION: Patients with coronary artery disease (CAD) are at increased risk of stroke. The aim of this study was to analyze the prognostic accuracy of selected clinical and laboratory variables in stroke risk prediction following discharge after myocardial infarction (MI). METHODS: We analyzed 404 consecutive patients (aged 68.1±13.7 years; 63.4% male; 37.4% with diabetes) without previous stroke who were discharged in sinus rhythm after being admitted for MI. The following data were collected: cardiovascular risk factors, admission blood glucose (BG), HbA1c, creatinine, peak troponin levels; glomerular filtration rate (GFR) by the MDRD formula; maximum Killip class; GRACE score for in-hospital and 6-month mortality; and extent of CAD. Patients were followed for two years and each variable was tested as a possible predictor of cerebrovascular events (stroke or transient ischemic attack [TIA]). RESULTS: During follow-up, 27 patients were admitted for stroke or TIA. The presence of diabetes, hypertension, dyslipidemia and previously known CAD, type of MI (STEMI vs NSTEMI) and extent of CAD did not predict cerebrovascular risk. The following variables were associated with higher stroke risk: GFR <60ml/min/m(2) (p=0.029, OR 2.65, 95% CI 1.07-6.55); maximum Killip class >1 (p=0.025, OR 2.71, 95% CI 1.10-6.69); GRACE in-hospital mortality >180 (p=0.001, OR 4.09, 95% CI 1.64-10.22); admission BG >140 mg/dl (p=0.001, OR 5.74, 95% CI 1.87-17.58); GRACE 6-month mortality >150 (p=0.001, OR 4.50, 95% CI 1.80-6.27); and peak troponin >42ng/ml (p=0.032, OR 2.64, 95% CI 1.06-6.59). Logistic regression analysis produced a model with the predictors GRACE 6-month mortality >150 (OR 3.26; p=0.014) and admission BG >7.7mmol/l (OR 4.09; p=0.017) that fitted the data well (Hosmer-Lemeshow: p=0.916). DISCUSSION/CONCLUSIONS: In patients with MI, variables known to be predictors of in-hospital mortality, including admission BG, renal function, acute heart failure and GRACE score, were found to be useful predictors of stroke during 2-year follow-up. While both GRACE score for 6-month mortality >150 and admission BG >7.7 mmol/l were independent predictors of stroke, CV risk factors, previously known CAD, and extent of CAD assessed by coronary angiography did not improve stroke risk prediction. This study highlights the need for even more aggressive secondary prevention in patients most at risk.

[Blood pressure control after bilateral carotid angioplasty in a patient with severe hypertension--case report]. / Normalização da pressão arterial em hipertenso grave após angioplastia carotídea bilateral.

Carotid artery angioplasty with stenting is an effective treatment for carotid artery stenosis, but is frequently associated with acute transient hemodynamic changes. We present the case of a 73-year-old female patient with long-standing refractory hypertension who remained normotensive during a three-year follow-up after undergoing staged bilateral carotid angioplasty.

[Importance of different techniques in assessing the significance of coronary stenosis]. / Importância de diferentes técnicas na avaliação da significância de estenoses coronárias.

Atherosclerosis is a diffuse arterial disease, discontinuously distributed, that is not always linear in its pathophysiological significance. Starting with a paradigmatic clinical case, we review the hemodynamic techniques that are currently available for the assessment of this condition. We present the case of a male patient with known diffuse atherosclerotic disease, who had previously undergone angioplasty, in which angiography was repeated after acute pulmonary edema, with worsening left ventricular function and local ischemia documented by myocardial scintigraphy. The angiogram showed an intermediate lesion in the left anterior descending artery, not related to the ischemic territory. The significance of the lesion was evaluated anatomically with intravascular ultrasound, and functionally by determining fractional flow reserve with a pressure wire. We review the pathophysiology of the disease and the parameters used for overall evaluation, focusing on catheterization laboratory techniques and their indications and contribution to the diagnosis and treatment of coronary atherosclerosis.

Isolation and partial characterization of a biosurfactant mixture produced by Sphingobacterium sp. isolated from soil.

Strain 6.2S, isolated from soil and identified as a Sphingobacterium sp., is the first strain in this genus to be reported as a biosurfactant producer, being able to reduce the surface tension of its culture supernatant to 32 mN/m. In this work, biosurfactants from the culture supernatant were purified and partially characterized. The crude extract (10 g/L) was very effective in reducing surface tension (22 mN/m). Thin layer chromatography (TLC) indicated that a mixture of various biosurfactants was present in the 6.2S crude extract. After purification, Fraction A, a phospholipid mixture, reduced surface tension to 33 mN/m. Fraction B was a mixture of lipopetides and at least one glycolipid. The surface tension-concentration curve showed two plateaux, the first of which can be attributed to a critical aggregation concentration of the biosurfactant with a protein (2.7 g/L) and the second to the true cmc in water (6.3g/L).

Hereditary hemorrhagic telangiectasia: rare cause of pulmonary hypertension?

A 73-year-old woman was admitted to the emergency room with predominantly right-sided heart failure and anemia. Following clinical and imagiological evaluation, a diagnosis of pulmonary hypertension (PH) associated with Hereditary Hemorrhagic Telangiectasia (HHT) was confirmed. The initial response to bosentan plus sildenafil was good, including improvement in functional class and reduction of edema, allowing her to be discharged. Unfortunately, the patient died, due to her underlying condition, before the effects of the combination treatment could be fully assessed. PH should be considered in patients with HTT and screening for pulmonary hypertension should be performed in these patients and their relatives.

[Acute coronary syndrome, a rare complication of human immunoglobulin therapy]. / Síndrome coronário agudo, uma complicação rara da terapêutica com imunoglobulina humana.

Human immunoglobulin is being increasingly used in the treatment of autoimmune diseases. Despite being rare, thromboembolic complications like acute coronary syndrome (ACS) are possible and not reported in our country's literature. The authors present a case report of a 39 years old patient who developed an ACS after treatment of immune thrombocytopenic purpura with human immunoglobulin. A brief review of risk factors and mechanisms of this complication is performed.

Telangiectasia hereditária hemorrágica: causa rara de hipertensão pulmonar? / Hereditary hemorrhagic telangiectasia: rare cause of pulmonary hypertension?

Uma mulher de 73 anos foi admitida ao Pronto-Socorro com insuficiência cardíaca predominantemente direita e anemia. Após avaliação clínica e imagenológica, um diagnóstico de hipertensão pulmonar (HP) associado com telangiectasia hemorrágica hereditária (THH) foi confirmado. A resposta inicial à terapia com bosentan mais sildenafil foi boa, incluindo melhora na Classe Funcional e redução do edema, permitindo que ela recebesse alta hospitalar. Infelizmente, a paciente faleceu devido à sua condição básica, antes que o efeito do tratamento combinado pudesse ser completamente avaliado. A HP deve ser considerada em pacientes com THH e o screening para HP deve ser conduzido nesses pacientes e em seus familiares.

A 73-year-old woman was admitted to the emergency room with predominantly right-sided heart failure and anemia. Following clinical and imagiological evaluation, a diagnosis of pulmonary hypertension (PH) associated with Hereditary Hemorrhagic Telangiectasia (HHT) was confirmed. The initial response to bosentan plus sildenafil was good, including improvement in functional class and reduction of edema, allowing her to be discharged. Unfortunately, the patient died, due to her underlying condition, before the effects of the combination treatment could be fully assessed. PH should be considered in patients with HTT and screening for pulmonary hypertension should be performed in these patients and their relatives.