Sensorineural Hearing Loss in a Child with Succinic Semialdehyde Dehydrogenase Deficiency.

Succinic semialdehyde dehydrogenase (SSADH) deficiency is a rare autosomal-recessive disorder of gamma-aminobutyric acid (GABA) metabolism, resulting in accumulation of GABA and gamma-hydroxybutyric acid (GHB) in physiological fluids. Approximately 450 patients have been diagnosed worldwide with this inherited neurotransmitter disorder. We report on a five-year-old male patient, homozygous for the pathogenic variant (NM_170740:c.1265G>A) in ALDH5A1 presenting with an unexpected association of typical SSADH deficiency manifestations with bilateral sensorineural hearing loss (SNHL). Brainstem evoked response audiometry (BERA) testing showed mid-frequency sensorineural hearing damage that suggested a hereditary component to SNHL. Whole exome sequencing (WES) failed to discern other genetic causes of deafness. Several variants of uncertain significance (VUS) detected in genes known for their role in hearing physiology could not be verified as the cause for the SNHL. It is known that central auditory processing depends on a delicate balance between excitatory and inhibitory neurotransmission, and GABA is known to play a significant role in this process. Additionally, excessive concentrations of accumulated GABA and GBH are known to cause a down-regulation of GABA receptors, which could have an adverse influence on hearing function. However, these mechanisms are very speculative in context of SNHL in a patient with inherited disorder of GABA metabolism. Injury of the globi pallidi, one of hallmarks of SSADH deficiency, could also be a contributory factor to SNHL, as was suspected in some other inborn errors in metabolism. We hope that this case will contribute to the understanding of phenotypic complexity of SSADH deficiency.

Expanding the Phenotypic Spectrum: Chronic Kidney Disease in a Patient with Combined Oxidative Phosphorylation Defect 21.

Introduction: Pathogenic variants in TARS2 are associated with combined oxidative phosphorylation deficiency 21 (COXPD21), an autosomal recessive disorder usually presenting as mitochondrial encephalomyopathy. Kidney impairment has been documented in a minority of COXPD21 patients, mostly with distal renal tubular acidosis. Case report: We report on the first COXPD21 patient with generalized tubular dysfunction and early childhood progression to chronic kidney disease (CKD). Thorough diagnostic evaluation was initiated at six months of age due to failure to thrive, muscular hypotonia, motor delay and recurrent bronchiolitis. The boy was lost to follow-up until the age of two years, when he was readmitted with elevated creatinine level, reduced estimated glomerular filtrate rate, normochromic anaemia, metabolic acidosis and hyperkalaemia. Urine abnormalities pointed to generalized tubular dysfunction. Two novel heterozygous missense variants in TARS2 gene were detected by the means of whole exome sequencing: c.1298T>G (p.Phe438Cys) of maternal origin and c.1931A>T (p.Asp644Val) of paternal origin. Currently, at 4.5 years of age, the boy has failure to thrive, severe motor and verbal delay and end stage of CKD. We referred the patient to paediatric centre that provides renal replacement therapy. Conclusion: The overall clinical course in the patient we report on corresponds well to the previously reported cases of TARS2 related COXPD21, especially in regard to neurological and developmental aspects of the disease. However, we point out the generalized tubulopathy and early occurrence of CKD in our patient as atypical renal involvement in COXPD21. Additionally, this is the first report of hypothyroidism and hypoparathyroidism in a COXPD21 patient.

Long lasting immunity in trichinellosis - insight from a small study group.

Trichinellosis in humans is most often caused by the parasite Trichinella spiralis. The clinical course of the disease is diverse and the symptoms can vary from mild to severe. Symptoms usually disappear within a few months, but encysted larvae in the muscles can cause myalgia and weakness that last for years. However, the existence of chronic trichinellosis as a disease is still debatable. This study presents the results obtained at the National Reference Laboratory for Trichinellosis - INEP, Serbia. The study was conducted to assess the immunoserological, biochemical and symptomatic disease parameters of twelve patients who acquired trichinellosis 13 and 18 years ago, respectively. They were involved in two T. spiralis outbreaks in Serbia, at the village of Kumane and the city of Belgrade (nine and three patients, respectively). Results indicated the presence of specific anti-Trichinella antibodies in 83% of the total number of patients. However, while the humoral immune response to Trichinella lasted for more than a decade reaching almost two decades after the acute infection phase (7/9 and 3/3 respectively, in two outbreaks), persistence of chronic muscular pain, as the most prolonged symptom of trichinellosis, could be found in the majority of patients from the Kumane outbreak (7/9). As a consequence, these patients suffered from limitations in daily living activities for the same period of time. The results presented in this paper are our contribution to the view that trichinellosis as a chronic disease with symptoms exists and may be related to the severity of the disease in the acute phase.

A competitive enzyme-linked immunosorbent assay for rapid detection of antibodies against Trichinella spiralis and T. britovi - one test for humans and swine.

Infection with parasites from the Trichinella genus occurs in many vertebrates but disease only occurs in humans (trichinellosis). Humans are infected after the consumption of raw or undercooked meat from infected wild or domestic animals (usually swine or horses). Using the monoclonal antibody (mAb) 7C2C5, specific for an epitope unique to the muscle larvae of the genus Trichinella, we have developed a competitive enzyme-linked immunosorbent assay (c-ELISA) that enables the rapid detection of Trichinella-specific antibodies in sera originating from two different host species (human, swine) infected with either Trichinella spiralis or Trichinella britovi. This novel c-ELISA exhibited 100% specificity and sensitivity, as confirmed by a Western blot test. The assay is easy to use (one incubation step), and the time required for the procedure (45 min) is shorter than in any other ELISA format. This test could be useful for both the detection and surveillance of Trichinella infections.

Morphologic predictors of in hospital mortality in acute type III aortic dissection. / Morfologicheskie prediktory gospital'noi smertnosti u bol'nykh s ostrym rassloeniem aorty III tipa.

INTRODUCTION: In-hospital mortality of acute aortic type III dissection ranged about 12%. Complicated dissections represent about 18% of all cases, and require open surgery or TEVAR. More morphological predictors of in hospital mortality are needed to differentiate patients who should be selected for immediate, surgical or endovascular intervention. METHODS: From January 2009 to December 2014, 74 patients with acute aortic type III dissection were enrolled at Clinic of Vascular and Endovascular Surgery in Belgrade Serbia and retrospectively analyzed. Every MSCT was observed in regard to morphologic characteristics of dissection. RESULTS: By analyzing morphologic parameters in patients between survival and non-survival group only localization of intimal tear showed statistical significance (p=0,020). The size of the intimal tear didn't reach statistical significance with the tendency of doing so in a larger sample of patients (p=0,063) with the cut-off value of 9.55mm. The shape of the true lumen was on the border of statistical significance (p=0,053). CONCLUSION: Inner curvature intimal tear localization, huge intimal tear as well as elliptic shape of the true lumen together should raise awareness to a subgroup at risk for in hospital mortality. More liberal endovascular treatment in this subgroup of patients is advocated.

Posterior approach for sciatic aneurysm repair - technical note.

Aneurysm of the persistent sciatic artery is a rare cause of limb ischemia, which is a challenge for both diagnosis and treatment. After successful diagnosis adequate treatment may require skills in open and endovascular surgery. We present a patient with the aneurysm of the persistent sciatic artery treated by bypass procedure with PTFE graft using posterior approach. We named this procedure "dorsal bypass". Detailed explanation of clinical presentation, diagnosis and the surgical procedure is given in this paper.

Application of dendritic cells stimulated with Trichinella spiralis excretory-secretory antigens alleviates experimental autoimmune encephalomyelitis.

The parasitic nematode, Trichinella spiralis (T. spiralis), exerts an immunomodulatory effect on the host immune response through excretory-secretory products (ES L1) released from encysted muscle larvae. Our model of combined T. spiralis infection and experimental autoimmune encephalomyelitis (EAE) in Dark Agouti (DA) rats demonstrated a significant reduction in EAE severity in infected animals. Recently, we have created an immune status characteristic for the live infection by in vivo application of dendritic cells (DCs) stimulated with ES L1 products of T. spiralis muscle larvae. Moreover, these cells were able to ameliorate EAE when applied 7 days before EAE induction. ES L1-stimulated DCs increased production of IL-4, IL-10 and TGF-ß, and decreased production of IFN-γ and IL-17, both at the systemic level and in target organs. A significant increase in the proportion of CD4+CD25+Foxp3+ T cells was found among spleen cells, and CNS infiltrates from DA rats treated with ES L1-stimulated DCs before EAE induction, compared to controls injected with unstimulated DCs. Regulatory T cells, together with elevated levels of IL-10 and TGF-ß, are most likely involved in restraining the production of Th1 and Th17 cytokines responsible for autoimmunity and thus are responsible for the beneficial effect of ES L1-educated DCs on the course of EAE. Our results show that ES L1 antigen-stimulated DCs are able not only to provoke, but also to sustain anti-inflammatory and regulatory responses regardless of EAE induction, with subsequent amelioration of EAE, or even protection from the disease.

Abdominal aortic aneurysm volume and relative intraluminal thrombus volume might be auxiliary predictors of rupture-an observational cross-sectional study.

Objectives: The study aimed to identify differences and compare anatomical and biomechanical features between elective and ruptured abdominal aortic aneurysms (AAAs). Methods: Data (clinical, anatomical, and biomechanical) of 98 patients with AAA, 75 (76.53%) asymptomatic (Group aAAA) and 23 (23.46%) ruptured AAA (Group rAAA), were prospectively collected and analyzed. Anatomical, morphological, and biomechanical imaging markers like peak wall stress (PWS) and rupture risk equivalent diameter (RRED), comorbid conditions, and demographics were compared between the groups. Biomechanical features were assessed by analysis of Digital Imaging and Communication in Medicine images by A4clinics (Vascops), and anatomical features were assessed by 3Surgery (Trimensio). Binary and multiple logistic regression analysis were used and adjusted for confounders. Accuracy was assessed using receiving operative characteristic (ROC) curve analysis. Results: In a multivariable model, including gender and age as confounder variables, maximal aneurysm diameter [MAD, odds ratio (OR) = 1.063], relative intraluminal thrombus (rILT, OR = 1.039), and total aneurysm volume (TAV, OR = 1.006) continued to be significant predictors of AAA rupture with PWS (OR = 1.010) and RRED (OR = 1.031). Area under the ROC curve values and correct classification (cc) for the same parameters and the model that combines MAD, TAV, and rILT were measured: MAD (0.790, cc = 75%), PWS (0.713, cc = 73%), RRED (0.717, cc = 55%), TAV (0.756, cc = 79%), rILT (0.656, cc = 60%), and MAD + TAV + rILT (0.797, cc = 82%). Conclusion: Based on our results, in addition to MAD, other important predictors of rupture that might be used during aneurysm surveillance are TAV and rILT. Biomechanical parameters (PWS, RRED) as valuable predictors should be assessed in prospective clinical trials. Similar studies on AAA smaller than 55 mm in diameter, even difficult to organize, would be of even greater clinical value.

Synchronous bilateral infiltrating syringomatous adenoma of the breast.

Infiltrating syringomatous breast adenoma is an uncommon mammary neoplasm composed of angulated glandular structures with a variable amount of epidermoid differentiation which proliferate in a background of dense collagenous stroma. The patient presented with bilateral hardness and oedema of the nipples. Ultrasound and mammography revealed microcalcifications in retromammilary regions of both nipples. Histological examination of the resected specimens showed angulated glands and solid cords, lined by an inner layer of epithelial cells and an outer layer of myoepithelial cells, immersed in desmoplastic stroma. Within the solid cords reminiscent of squamous cells, occasionally aggregated in keratinizing cysts were found. To the best of our knowledge this is the first described case of bilateral infiltrating syringomatous breast adenoma with synchronous presentation. Infiltrating syringomatous adenoma is a rare lesion. A finding of infiltrating syringomatous adenoma in one breast should prompt careful examination of the opposite breast with adequate follow-up.

Relationship between the incidence of idiopathic lower extremity deep vein thrombosis and the location of the thrombus depending on the changes in atmospheric pressure.

AIM: The study analysed the relationship between the incidence of idiopathic lower extremity deep vein thrombosis (DVT) and the location of the thrombus with changes in atmospheric pressure. MATERIAL AND METHOD: During the two year period between May 2009 and April 2011, inclusively, 124 consecutive patients were diagnosed as having idiopathic lower extremity DVT at the Vascular Surgical clinic "Clinical Center of Nis", Serbia. RESULTS: The increased average daily values of atmospheric pressure for 1 millibar on the day when the event took place and 7 days before, were associated (p < 0,05) with the increase of the total risk of the occurrence of lower extremity idiopathic DVT for 5,1% (0,7-9,8%), as well as with the occurrence of idiopathic DVT above the knees (p < 0,05) for 5,9% (0,9-11,0%). The increase in the average atmospheric pressure by 1 millibar on the day when the event took place and 7 days before this in the subgroup of patients under the age of 45 years, and on the day when the event took place and 3 days before it in the subgroup of patients of the age of 45 and above, was related with the increased risk of the occurrence of lower extremity idiopathic DVT. CONCLUSION: The increase of daily values of atmospheric pressure shows a significant relationship with the incidences of idiopathic lower extremity DVT and the location of the thrombus above the knee.

Trichinella spiralis antigens prime mixed Th1/Th2 response but do not induce de novo generation of Foxp3+ T cells in vitro.

Many parasitic helminth infections induce Th2-type immune responses and engage the regulatory network. In this study, we specifically investigated the influence of antigens derived from different life stages of the helminth Trichinella spiralis on the polarization of naive CD4(+) T cells by dendritic cells. Results obtained from C57BL/6 mice showed that T. spiralis derived antigens have the capacity to induce bone marrow-derived dendritic cells to acquire an incompletely mature phenotype that promotes a significant proliferation of naive CD4(+) T cells and a mixed Th1/Th2 cytokine profile with the predominance of Th2 cytokines. Increased production of IL-4, IL-9, IL-10 and IL-13 accompanied increased IFN-γ. Furthermore, dendritic cells pulsed with T. spiralis antigens did not induce an increase in the population of Foxp3(+) T regulatory cells. Although other helminth antigens have demonstrated the capacity to induce de novo generation of Foxp3(+) T regulatory cells, here our in vitro studies provide no evidence that T. spiralis antigens have this capacity.

Diagnosis of Fanconi's Anemia by Diepoxybutane Analysis in Children from Serbia.

The high sensitivity of Fanconi's anemia (FA) cells to drug induced DNA interstrand crosslinks (ICL) such as diepoxybutane (DEB) was used as a part of FA screening in the children with clinical suspicion of FA. The study considered a total of 66 children with the hematological and/or congenital phenotypic symptoms reminiscent of FA. Blood samples from patients with clinical suspicion of FA and controls were collected for chromosome fragility evaluation by the DEB test. According to the results of DEB test, the patients were divided into two subgroups: FA displaying typical DEB sensitive cellular response and non FA. In this study, 10 out of 66 patients were found to have a FA cellular phenotype. The percentage of DEB-induced aberrant cells was increased more than 26 times in FA patients (range 22.00-82.00% with a mean of 48.32%) when compared to non FA patients (range 0.00-12.00% with a mean of 1.84%). The number of DEB-induced breaks/cells was more than 68 times higher in FA patients (range 0.26-4.39 with a mean of 1.37 breaks/cell) when compared to non FA patients (range 0.00-0.20 with a mean of 0.02 breaks/cell). The spontaneous chromosome fragility values in FA patients were overlapping those in non FA patients. Our results indicate that the DEB sensitivity test is the most reliable in vitro method for verification of the FA cellular phenotype.

Mechanisms of modulation of experimental autoimmune encephalomyelitis by chronic Trichinella spiralis infection in Dark Agouti rats.

Trichinella spiralis is a helminth that provokes Th2 and anti-inflammatory type responses in an infected host. Our previous studies using Dark Agouti (DA) rats indicated that T. spiralis infection reduced experimental autoimmune encephalomyelitis (EAE) severity in rats. The aim of this study was to analyse the mechanisms underlying EAE suppression driven by T. spiralis infection. Reduced clinical and histological manifestations of the disease were accompanied by increased IL-4 and IL-10 production and decreased IFN-gamma and IL-17 production in draining lymph node cells. This indicates that T. spiralis infection successfully maintains a Th2 cytokine bias regardless of EAE induction. High IL-10 signifies parasite-induced anti-inflammatory and/or regulatory cell responses. Transfer of splenic T cell-enriched population of cells from T. spiralis-infected rats into EAE immunized rats caused amelioration of EAE and in some cases protection from disease development. This population of cells contained higher proportion of CD4(+) CD25(+) Foxp3(+) regulatory cells and produced high level of IL-10 when compared with uninfected rats.

Dacron or ePTFE graft for above-knee femoropopliteal bypass reconstruction. A bi-centre randomised study.

BACKGROUND: The objective of this study was to compare polyester (Dacron) and expanded polytetrafluorethilene (ePTFE) grafts for above-knee femoropopliteal bypass. PATIENTS AND METHODS: Eighty five patients with disabling claudications or limb threatening ischemia suitable for above-knee femoropopliteal reconstruction were randomized into two groups. In the first group the surgery was performed using 8 mm Dacron graft, whereas the patients in the second group were operated using ePTFE grafts. RESULTS: The primary patency rates for Dacron and ePTFE were 100 %, and 88.37 % (p < 0.05), while secondary patency rates were 83.3 % and 75 % (p > 0.05) respectively. The early limb salvage rates for Dacron and ePTFE were 100 % and 97.7 % (p > 0.05). Early (30-day) complications (bleeding 2.38 % and 2.32 %; wound infection 11.9 % and 11.63 %) occurred in both groups with similar frequency (p > 0.05). The patients were followed up over a period of 6 to 12 months (mean 8.3 +/- 3.6 months). The overall mortality rate in the follow-up period was 2.38 % (one patient) for Dacron and 6.98 % (three patients) for ePTFE group (p > 0.05). Late graft infection was noted in three patients (7.1 %) in Dacron, and two patients (4.65 %) in ePTFE group (p > 0.05). Primary patency rates were not significantly influenced by obesity, diabetes, hypertension, hyperlipidemia, cigarette smoking, (p > 0.05). However, poor run-off (only one crural artery patent on preoperative angiography) significantly decreased patency of both grafts and favored the use of ePTFE graft (p < 0.05). CONCLUSIONS: This study confirms that both materials are suitable for above-knee femoropopliteal reconstructions. Above-knee femoropopliteal bypass does not have a good long-term prognosis in the presence of poor run-off.

In vitro induction of apoptotic cell death in chronic lymphocytic leukemia by two natural products: preliminary study.

PURPOSE: B cell chronic lymphocytic leukemia (B-CLL) is an neoplastic disorder characterized by alterations in the pathways of programmed cell death (apoptosis). Deregulation of apoptosis pathways also contributes to chemoresistance of B-CLL cells. Therefore, it is not surprising that induction and acceleration of apoptosis represent key point in novel B-CLL therapeutic protocols. The present study was designed to investigate the effects of two natural products, Immunarc forte and Korbazol on the in vitro survival of leukemic cells. METHODS: peripheral blood mononuclear cells (PBMC) from 20 B-CLL patients and 20 healthy donors were used for cytotoxicity studies. Cytotoxic activity of the tested products were assessed by the MTT colorimetric assay and the type of cell death was determined by flow cytometry. RESULTS: we found that Korbazol was selectively cytotoxic against B-CLL cells, but the cytotoxic activity of Immunarc forte was much weaker. Of note, synergy was shown between these two drugs, and this effect was also selective, without affecting the normal mononuclear cells. According to Annexin-V binding, Korbazol and Immunarc forte induced apoptotic type of cell death in B-CLL cells. Moreover, treatment with Korbazol, but not with Immunarc forte, decreased spontaneous apoptosis in cultured normal polymorphonuclear cells. CONCLUSION: our findings imply that Korbazol is as potential therapeutic agent that induces apoptosis of B-CLL cells. The resistance of normal mononuclear cells and anti-apoptotic effects on normal polymorphonuclear cells, as well as its ability to synergize with Immunarc forte, warrants further investigation and supports their therapeutic application in the treatment of B-CLL.

Differential diagnosis of liver diseases using serum biomarkers.

PURPOSE: Many human blood proteins are synthesised in the liver. Their serum levels may decrease or increase due to liver disorders and some of them serve as useful biomarkers. Determination of serum concentration of different biomarkers has important role in diagnosis of liver diseases and in monitoring the course of disease. In this work 3 serum markers associated with liver disorders were compared. The aim was to assess whether these biomarkers exhibit specific distribution pattern in different types of liver disease: liver neoplasia (primary hepatocellular carcinoma [HC] or metastatic liver disease [MLD] from colon cancer), viral hepatitis C (HCV) and the parasitic infection echinococcosis. METHODS: Serum concentrations of alpha-fetoprotein (AFP), ferritin and insulin-like growth factor I (IGF-I) were determined in patients with liver disease and compared between patient groups and with healthy persons. RESULTS: Serum AFP and ferritin levels exhibited similar pattern of change in patients with liver neoplasia or HCV, and concentrations of these 2 markers were significantly increased compared to the control group (p < 0.01 in each case). On the other hand, the concentration of IGF-I was significantly decreased in patients with liver neoplasia or echinococcosis compared to the control group (p < 0.05 for both). The concentration of IGF-I was significantly lower and the concentration of ferritin significantly higher in patients with HC than in patients with MLD from colorectal cancer (p < 0.01 for both). CONCLUSION: The results have shown that each hepatic pathology studied exhibited specific profile of the analysed set of biomarkers. Therefore, the simultaneous determination of the 3 mentioned biomarkers may help in differential diagnosis of liver diseases.

Industrial use of pepper (Capsicum annum L.) derived products: Technological benefits and biological advantages.

The recovery of pepper phytochemicals present an interesting strategy in pursuit of new bioactive compounds and natural ingredients for agro-food, cosmetic and pharma industry uses, as replacements for the synthetic compounds and also in the valorisation of plant's by-products. Besides being used as a condiment, providing characteristic pungency, colour and flavour, the new pepper-derived ingredients could be used for the preservation and extension of industrial products' lifespan, as well as additives or technological ingredients with antioxidant and antimicrobial activities. Moreover, the application of the new products in pharmaceutical formulas for the treatment of inflammatory and pain-related conditions is also a possibility, since peppers contain capsaicinoids, carotenoids, phenolic compounds, vitamin C and A, and minerals, such as iron and calcium, which have a health-promoting potential. Further studies on appropriate extraction protocols, stability, safety and bioactivity are necessary to provide novel and promising pepper ingredients for food, cosmetic, and pharmaceutical applications.

Characterization of rat bone marrow dendritic cells initially primed by Trichinella spiralis antigens.

Pathogen-derived products have the capacity to induce maturation of bone marrow-derived dendritic cells (BMDCs)into populations of effectors cells that polarize Th cells toward Th1 or Th2 phenotype via different mechanisms. Since those mechanisms are not entirely clear for helminths, and almost completely unknown for Trichinella spiralis(TS), we started an investigation of the effects of TS antigens (four different antigens isolated from all three life-cycle stages of parasite)on maturation of BMDCs and their potential to present TS antigens. The expression of MHC class II, costimulatory molecules CD86, CD54, IL-10 and IL-12p70 cytokine production were measured after 2 days of BMDCs cultivation with TS antigens. While parasitic antigens did not significantly alter the expression of MHC II, most of them, except crude muscle larvae antigens, up-regulated the expression of costimulatory molecules. BMDCs, primed with all TS antigens, released increased amounts of IL-10 and decreased amounts of IL-12p70. BMDCs, primed with TS antigens, induced significant proliferation of syngeneic TS sensitized lymph nodes cells and also stimulated the production of IL-4 by T cells purified from of TS infected DA rats. The results indicate that TS stimulated BMDCs leads to the polarization of the immune response towards regulatory and Th2 type.