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Microcephaly is characterized by an occipitofrontal circumference at least two standard deviations below the mean for age and sex. Neurodevelopmental disorders (NDD) are commonly associated with microcephaly, due to perturbations in brain development and functioning. Given the extensive genetic heterogeneity of microcephaly, managing patients is hindered by the broad spectrum of diagnostic possibilities that exist before conducting molecular testing. We investigated the genetic basis of syndromic microcephaly accompanied by NDD in a Brazilian cohort of 45 individuals and characterized associated clinical features, as well as evaluated the effectiveness of whole-exome sequencing (WES) as a diagnostic tool for this condition. Patients previously negative for pathogenic copy number variants underwent WES, which was performed using a trio approach for isolated index cases (n = 31), only the index in isolated cases with parental consanguinity (n = 8) or affected siblings in familial cases (n = 3). Pathogenic/likely pathogenic variants were identified in 19 families (18 genes) with a diagnostic yield of approximately 45%. Nearly 86% of the individuals had global developmental delay/intellectual disability and 51% presented with behavioral disturbances. Additional frequent clinical features included facial dysmorphisms (80%), brain malformations (67%), musculoskeletal (71%) or cardiovascular (47%) defects, and short stature (54%). Our findings unraveled the underlying genetic basis of microcephaly in half of the patients, demonstrating a high diagnostic yield of WES for microcephaly and reinforcing its genetic heterogeneity. We expanded the phenotypic spectrum associated with the condition and identified a potentially novel gene (CCDC17) for congenital microcephaly., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Childhood cancer has a poorly known etiology, and investigating the underlying genetic background may provide novel insights. A recognized association exists between non-chromosomal birth defects and childhood cancer susceptibility., Methods: We performed whole-exome sequencing and chromosomal microarray analysis in a cohort of childhood cancer (22 individuals, 50% with congenital anomalies) to unravel deleterious germline variants., Results: A diagnostic yield of 14% was found, encompassing heterozygous variants in bona fide dominant Cancer Predisposition Genes (CPGs). Considering candidate and recessive CPGs harboring monoallelic variants, which were also deemed to play a role in the phenotype, the yield escalated to 45%. Most of the deleterious variants were mapped in genes not conventionally linked to the patient's tumor type. Relevant findings were detected in 55% of the syndromic individuals, mostly variants potentially underlying both phenotypes., Conclusion: We uncovered a remarkable prevalence of germline deleterious CPG variants, highlighting the significance of a comprehensive genetic analysis in pediatric cancer, especially when coupled with additional clinical signs. Moreover, our findings emphasized the potential for oligogenic inheritance, wherein multiple genes synergistically increase cancer risk. Lastly, our investigation unveiled potentially novel genotype-phenotype associations, such as SETD5 in neuroblastoma, KAT6A in gliomas, JAG1 in hepatoblastomas, and TNFRSF13B in Langerhans cell histiocytosis., Impact: Novel gene-phenotype associations and candidate genes for pediatric cancer were unraveled, such as KAT6A in gliomas, SETD5 in neuroblastoma, JAG1 in hepatoblastomas, and TNFRSF13B in Langerhans cell histiocytosis. Our analysis revealed a high frequency of deleterious germline variants, particularly in cases accompanied by additional clinical signs, highlighting the importance of a comprehensive genetic evaluation in childhood cancer. Our findings also underscored the potential for oligogenic inheritance in pediatric cancer risk. Understanding the cancer etiology is crucial for genetic counseling, often influencing therapeutic decisions and offering valuable insights into molecular targets for the development of oncological therapies., (© 2024. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Structural variants (SVs) pose a challenge to detect and interpret, but their study provides novel biological insights and molecular diagnosis underlying rare diseases. The aim of this study was to resolve a 9p24 rearrangement segregating in a family through five generations with a congenital heart defect (congenital pulmonary and aortic valvular stenosis and pulmonary artery stenosis), by applying a combined genomic analysis. The analysis involved multiple techniques, including karyotype, chromosomal microarray analysis (CMA), FISH, genome sequencing (GS), RNA-seq, and optical genome mapping (OGM). A complex 9p24 SV was hinted at by CMA results, showing three interspersed duplicated segments. Combined GS and OGM analyses revealed that the 9p24 duplications constitute a complex SV, on which a set of breakpoints matches the boundaries of the CMA duplicated sequences. The proposed structure for this complex rearrangement implies three duplications associated with an inversion of ~ 2 Mb region on chromosome 9 and a SINE element insertion at the more distal breakpoint. Interestingly, this genomic structure of rearrangement forms a chimeric transcript of the KANK1/DMRT1 loci, which was confirmed by both RNA-seq and Sanger sequencing on blood samples from 9p24 rearrangement carriers. Altogether with breakpoint amplification and FISH analysis, this combined approach allowed a deep characterization of this complex rearrangement. Although the genotype-phenotype correlation remains elusive from the molecular mechanism point of view, this study identified a large genomic rearrangement at 9p24 segregating with a familial congenital heart defect, revealing a genetic biomarker that was successfully applied for embryo selection, changing the reproductive perspective of affected individuals., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Introduction: Next generation sequencing technology has greatly reduced the cost and time required for sequencing a genome. An approach that is rapidly being adopted as an alternative method for CNV analysis is the low-pass whole genome sequencing (LP-WGS). Here, we evaluated the performance of LP-WGS to detect copy number variants (CNVs) in clinical cytogenetics., Materials and Methods: DNA samples with known CNVs detected by chromosomal microarray analyses (CMA) were selected for comparison and used as positive controls; our panel included 44 DNA samples (12 prenatal and 32 postnatal), comprising a total of 55 chromosome imbalances. The selected cases were chosen to provide a wide range of clinically relevant CNVs, the vast majority being associated with intellectual disability or recognizable syndromes. The chromosome imbalances ranged in size from 75 kb to 90.3 Mb, including aneuploidies and two cases of mosaicism., Results: All CNVs were successfully detected by LP-WGS, showing a high level of consistency and robust performance of the sequencing method. Notably, the size of chromosome imbalances detected by CMA and LP-WGS were compatible between the two different platforms, which indicates that the resolution and sensitivity of the LP-WGS approach are at least similar to those provided by CMA., Discussion: Our data show the potential use of LP-WGS to detect CNVs in clinical diagnosis and confirm the method as an alternative for chromosome imbalances detection. The diagnostic effectiveness and feasibility of LP-WGS, in this technical validation study, were evidenced by a clinically representative dataset of CNVs that allowed a systematic assessment of the detection power and the accuracy of the sequencing approach. Further, since the software used in this study is commercially available, the method can easily be tested and implemented in a routine diagnostic setting., (© 2023 University College London (UCL) and John Wiley & Sons Ltd.)

Microcephaly presents heterogeneous genetic etiology linked to several neurodevelopmental disorders (NDD). Copy number variants (CNVs) are a causal mechanism of microcephaly whose investigation is a crucial step for unraveling its molecular basis. Our purpose was to investigate the burden of rare CNVs in microcephalic individuals and to review genes and CNV syndromes associated with microcephaly. We performed chromosomal microarray analysis (CMA) in 185 Brazilian patients with microcephaly and evaluated microcephalic patients carrying < 200 kb CNVs documented in the DECIPHER database. Additionally, we reviewed known genes and CNV syndromes causally linked to microcephaly through the PubMed, OMIM, DECIPHER, and ClinGen databases. Rare clinically relevant CNVs were detected in 39 out of the 185 Brazilian patients investigated by CMA (21%). In 31 among the 60 DECIPHER patients carrying < 200 kb CNVs, at least one known microcephaly gene was observed. Overall, four gene sets implicated in microcephaly were disclosed: known microcephaly genes; genes with supporting evidence of association with microcephaly; known macrocephaly genes; and novel candidates, including OTUD7A, BBC3, CNTN6, and NAA15. In the review, we compiled 957 known microcephaly genes and 58 genomic CNV loci, comprising 13 duplications and 50 deletions, which have already been associated with clinical findings including microcephaly. We reviewed genes and CNV syndromes previously associated with microcephaly, reinforced the high CMA diagnostic yield for this condition, pinpointed novel candidate loci linked to microcephaly deserving further evaluation, and provided a useful resource for future research on the field of neurodevelopment., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Waardenburg syndrome (WS) is characterized by hearing loss and pigmentary abnormalities of the eyes, hair, and skin. The condition is genetically heterogeneous, and is classified into four clinical types differentiated by the presence of dystopia canthorum in type 1 and its absence in type 2. Additionally, limb musculoskeletal abnormalities and Hirschsprung disease differentiate types 3 and 4, respectively. Genes PAX3 , MITF , SOX10 , KITLG , EDNRB , and EDN3 are already known to be associated with WS. In WS, a certain degree of molecularly undetected patients remains, especially in type 2. This study aims to pinpoint causative variants using different NGS approaches in a cohort of 26 Brazilian probands with possible/probable diagnosis of WS1 (8) or WS2 (18). DNA from the patients was first analyzed by exome sequencing. Seven of these families were submitted to trio analysis. For inconclusive cases, we applied a targeted NGS panel targeting WS/neurocristopathies genes. Causative variants were detected in 20 of the 26 probands analyzed, these being five in PAX3 , eight in MITF , two in SOX10 , four in EDNRB , and one in ACTG1 (type 2 Baraitser-Winter syndrome, BWS2). In conclusion, in our cohort of patients, the detection rate of the causative variant was 77%, confirming the superior detection power of NGS in genetically heterogeneous diseases.

Xia-Gibbs syndrome (XGS) is a syndromic form of intellectual disability caused by heterozygous AHDC1 variants, but the pathophysiological mechanisms underlying this syndrome are still unclear. In this manuscript, we describe the development of two different functional models: three induced pluripotent stem cell (iPSC) lines with different loss-of-function (LoF) AHDC1 variants, derived by reprogramming peripheral blood mononuclear cells from XGS patients, and a zebrafish strain with a LoF variant in the ortholog gene (ahdc1) obtained through CRISPR/Cas9-mediated editing. The three iPSC lines showed expression of pluripotency factors (SOX2, SSEA-4, OCT3/4, and NANOG). To verify the capacity of iPSC to differentiate into the three germ layers, we obtained embryoid bodies (EBs), induced their differentiation, and confirmed the mRNA expression of ectodermal, mesodermal, and endodermal markers using the TaqMan hPSC Scorecard. The iPSC lines were also approved for the following quality tests: chromosomal microarray analysis (CMA), mycoplasma testing, and short tandem repeat (STR) DNA profiling. The zebrafish model has an insertion of four base pairs in the ahdc1 gene, is fertile, and breeding between heterozygous and wild-type (WT) animals generated offspring in a genotypic proportion in agreement with Mendelian law. The established iPSC and zebrafish lines were deposited on the hpscreg.eu and zfin.org platforms, respectively. These biological models are the first for XGS and will be used in future studies that investigate the pathophysiology of this syndrome, unraveling its underlying molecular mechanisms., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

DNA methylation may be involved in the development of osteosarcomas. Osteosarcomas commonly arise during the bone growth and remodeling in puberty, making it plausible to infer the involvement of epigenetic alterations in their development. As a highly studied epigenetic mechanism, we investigated DNA methylation and related genetic variants in 28 primary osteosarcomas aiming to identify deregulated driver alterations. Methylation and genomic data were obtained using the Illumina HM450K beadchips and the TruSight One sequencing panel, respectively. Aberrant DNA methylation was spread throughout the osteosarcomas genomes. We identified 3146 differentially methylated CpGs comparing osteosarcomas and bone tissue samples, with high methylation heterogeneity, global hypomethylation and focal hypermethylation at CpG islands. Differentially methylated regions (DMR) were detected in 585 loci (319 hypomethylated and 266 hypermethylated), mapped to the promoter regions of 350 genes. These DMR genes were enriched for biological processes related to skeletal system morphogenesis, proliferation, inflammatory response, and signal transduction. Both methylation and expression data were validated in independent groups of cases. Six tumor suppressor genes harbored deletions or promoter hypermethylation (DLEC1, GJB2, HIC1, MIR149, PAX6, and WNT5A), and four oncogenes presented gains or hypomethylation (ASPSCR1, NOTCH4, PRDM16, and RUNX3). Our analysis also revealed hypomethylation at 6p22, a region that contains several histone genes. Copy-number changes in DNMT3B (gain) and TET1 (loss), as well as overexpression of DNMT3B in osteosarcomas provide a possible explanation for the observed phenotype of CpG island hypermethylation. While the detected open-sea hypomethylation likely contributes to the well-known osteosarcoma genomic instability, enriched CpG island hypermethylation suggests an underlying mechanism possibly driven by overexpression of DNMT3B likely resulting in silencing of tumor suppressors and DNA repair genes., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

From the 15th to the 19th century, the Trans-Atlantic Slave-Trade (TAST) influenced the genetic and cultural diversity of numerous populations. We explore genomic and linguistic data from the nine islands of Cabo Verde, the earliest European colony of the era in Africa, a major Slave-Trade platform between the 16th and 19th centuries, and a previously uninhabited location ideal for investigating early admixture events between Europeans and Africans. Using local-ancestry inference approaches, we find that genetic admixture in Cabo Verde occurred primarily between Iberian and certain Senegambian populations, although forced and voluntary migrations to the archipelago involved numerous other populations. Inter-individual genetic and linguistic variation recapitulates the geographic distribution of individuals' birth-places across Cabo Verdean islands, following an isolation-by-distance model with reduced genetic and linguistic effective dispersals within the archipelago, and suggesting that Kriolu language variants have developed together with genetic divergences at very reduced geographical scales. Furthermore, based on approximate bayesian computation inferences of highly complex admixture histories, we find that admixture occurred early on each island, long before the 18 th -century massive TAST deportations triggered by the expansion of the plantation economy in Africa and the Americas, and after this era mostly during the abolition of the TAST and of slavery in European colonial empires. Our results illustrate how shifting socio-cultural relationships between enslaved and non-enslaved communities during and after the TAST, shaped enslaved-African descendants' genomic diversity and structure on both sides of the Atlantic., Competing Interests: RL, ZS, Sd, VT, CF, FD, LL, JU, NR, MB, PV No competing interests declared, (© 2023, Laurent et al.)

Chromosomal microarray analysis (CMA) has been recommended and practiced routinely since 2010 both in the USA and Europe as the first-tier cytogenetic test for patients with unexplained neurodevelopmental delay/intellectual disability, autism spectrum disorders, and/or multiple congenital anomalies. However, in Brazil, the use of CMA is still limited, due to its high cost and complexity in integrating the results from both the private and public health systems. Although Brazil has one of the world's largest single-payer public healthcare systems, nearly all patients referred for CMA come from the private sector, resulting in only a small number of CMA studies in Brazilian cohorts. To date, this study is by far the largest Brazilian cohort (n = 5788) studied by CMA and is derived from a joint collaboration formed by the University of São Paulo and three private genetic diagnostic centers to investigate the genetic bases of neurodevelopmental disorders and congenital abnormalities. We identified 2,279 clinically relevant CNVs in 1886 patients, not including the 26 cases of UPD found. Among detected CNVs, the corresponding frequency of each category was 55.6% Pathogenic, 4.4% Likely Pathogenic and 40% VUS. The diagnostic yield, by taking into account Pathogenic, Likely Pathogenic and UPDs, was 19.7%. Since the rational for the classification is mostly based on Mendelian or highly penetrant variants, it was not surprising that a second event was detected in 26% of those cases of predisposition syndromes. Although it is common practice to investigate the inheritance of VUS in most laboratories around the world to determine the inheritance of the variant, our results indicate an extremely low cost-benefit of this approach, and strongly suggest that in cases of a limited budget, investigation of the parents of VUS carriers using CMA should not be prioritized., (© 2022. The Author(s).)

Background: Syndromic obesity (SO) refers to obesity with additional phenotypes, including intellectual disability (ID)/developmental delay (DD), dysmorphic features, or organ-specific abnormalities. SO is rare, has high phenotypic variability, and frequently follows a monogenic pattern of inheritance. However, the genetic etiology of most cases of SO has not been elucidated., Subjects and Methods: In this study, we investigated 20 SO patients by whole-exome sequencing (WES) trios to identify causal genetic variants., Results: 4/20 patients had negative results for array comparative genomic hybridization (aCGH) analyses. In the remaining 15 patients, in addition to SNVs and indels, CNVs were also evaluated. Pathogenic/likely pathogenic (P/LP) SNVs/indels were detected in 6/20 patients (involving MED13L, AHDC1, EHMT1, MYT1L, GRIA3, and SETD1A), while two patients carried an inherited VUS. In addition, P/LP CNVs were observed in 3/15 patients (involving SATG2, KIAA0442, and MEIS2)., Conclusions: All nine detected P/LP variants involved genes already known to lead to syndromic ID/DD; however, for only two genes (EHMT1 and MYT1L) is the link with obesity well established. This is the first study applying a comprehensive genomic investigation of an SO cohort, showing a high diagnostic yield (~47%). Additionally, our findings suggested that several known ID/DD genes may also predispose individuals to SO., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Purpose: To present a large series ears with tympanic membrane perforations (TMP), to describe their characteristics, and to propose a new classification system based on the pathogenesis of TMP., Methods: This cross-sectional study was conducted at a tertiary university hospital with 1003 ears (792 consecutive patients with TMP in at least 1 ear). Otoendoscopy and audiometry were performed. Perforation measurements and their locations were digitally assessed. TMP with no suggestive signs of previous retraction were classified as Group 1, and those with possible previous retraction were classified as Group 2. Signs of retraction previous to the TMP, symptom length, perforation size and location, status of the contralateral ear, and hearing status were compared., Results: Group 1 comprised 63.5% of the included ears. Compared to Group 2, Group 1 presented a higher rate of central perforations (99% vs. 53%), a shorter duration of symptoms, smaller perforations (mean area: 18.5% vs. 41.4%), a higher rate of perforations in the anterior quadrants, better hearing levels (mean tritonal gap: 23.9 dB vs. 29.2 dB), and a lower rate of abnormal contralateral ears (28% vs. 66%)., Conclusion: The classification of TMP into two groups based on signs of previous retractions is feasible and indicates two different levels of disease severity. While the group without previous signs of retraction comprises ears with more limited disease, membranes with previous retraction seem to show more severe disease and, consequently, a less functional middle ear., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Copy number variations of several genes involved in the process of gonadal determination have been identified as a cause of 46,XY differences of sex development. We report a non-syndromic 14-year-old female patient who was referred with primary amenorrhea, absence of breast development, and atypical genitalia. Her karyotype was 47,XY,+mar/46,XY, and FISH analysis revealed the X chromosome origin of the marker chromosome. Array-CGH data identified a pathogenic 2.0-Mb gain of an Xp21.2 segment containing NR0B1/DAX1 and a 1.9-Mb variant of unknown significance from the Xp11.21p11.1 region. This is the first report of a chromosomal microarray analysis to reveal the genetic content of a small supernumerary marker chromosome detected in a 47,XY,+der(X)/46,XY karyotype in a non-syndromic girl with partial gonadal dysgenesis and gonadoblastoma. Our findings indicate that the mosaic presence of the small supernumerary Xp marker, encompassing the NR0B1/DAX1 gene, may have been the main cause of dysgenetic testes development, although the role of MAGEB and other genes mapped to the Xp21 segment could not be completely ruled out., (© 2021 S. Karger AG, Basel.)

Prediction of pathogenicity of rare copy number variations (CNVs), a genomic alteration known to contribute to the etiology of autism spectrum disorder (ASD), represents a serious limitation to interpreting genetic tests, particularly for genetic counseling purposes. Chromosomal microarray analysis (CMA) was conducted in a unique collection of 144 Brazilian individuals with ASD of strong European and African ancestries. Rare CNVs were detected in 39 patients: 41 of unknown significance (VUS), four pathogenic and one likely pathogenic CNVs (clinical yield of 4.1%; 5/122). Based on gene content and recurrence in three large cohorts [a Brazilian neurodevelopmental disorder cohort, the autism MSSNG cohort, and the Canadian-based Centre for Applied Genomics microarray database], this work strengthened the pathogenicity of 14 genes (FAT1, CAMK4, BIRC6, DPP6, CSMD1, CTNNA3, CDH8/CDH11, CDH13, OR1C1, CNTN6, CNTNAP4, FGF2 and PTPRN2) within 14 CNVs. Notably, enrichment of cell adhesion proteins to ASD etiology was identified (p < 0.05), highlighting the importance of these gene families in the etiology of ASD., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Genetic variants involving the MED13L gene can lead to an autosomal dominant syndrome characterised by intellectual disability/developmental delay and facial dysmorphism., Methods: We investigated two cases (one familial and one isolated) of intellectual disability with speech delay and dysmorphic facial features by whole-exome sequencing analyses. Further, we performed a literature review about clinical and molecular aspects of MED13L gene and syndrome., Results: Two MED13L variants have been identified [MED13L(NM&#95;015335.5):c.4417C>T and MED13L(NM&#95;015335.5):c.2318delC] and were classified as pathogenic according to the ACMG (American College of Medical Genetics and Genomics) guidelines. One of the variants was present in sibs., Conclusions: The two pathogenic variants identified have not been previously reported. Importantly, this is the first report of a familial case of MED13L nonsense mutation. Although the parents of the affected children were no longer available for analysis, their apparently normal phenotypes were surmised from familial verbal descriptions corresponding to normal mental behaviour and phenotype. In this situation, the familial component of mutation transmission might be caused by gonadal mosaicism of a MED13L mutation in a gonad from either the father or the mother. The case reports and the literature review presented in this manuscript can be useful for genetic counselling., (© 2021 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.)

Introduction  The treatment of cholesteatoma is generally surgical, and the major obstacle is the high prevalence of recidivism. The endoscopic ear surgery technique is proposed to minimize this problem. Objectives  To utilize endoscopes to visualize and manipulate cholesteatoma residues after microscopic removal Methods  Cross-sectional study. Thirty-two patients with cholesteatoma underwent microscopic wall-up mastoidectomy combined with the endoscopic approach. The subjects were assessed for the presence and location of covert disease. Results  Of the 32 cases, 17 (53.12%) had residual cholesteatoma in the endoscopic phase. Minimal disease was found, usually fragments of the cholesteatoma matrix. Pars tensa cholesteatomas had more covert disease than pars flaccida cholesteatomas (62.50% vs 43.75%). Posterior recesses (47.05%) and tegmen tympani (41.17%) were the locations with more covert disease ( p  < 0.05). Conclusion  Cholesteatomas of the pars tensa presented more residual disease and were significantly more common in the posterior recesses and tegmen tympani., Competing Interests: Conflict of Interests The authors have no conflict of interests to declare., (Fundação Otorrinolaringologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Chromosomal microarray analyses (CMA) have greatly increased both the yield and diagnostic accuracy of postnatal analysis; it has been used as a first-tier cytogenetic test in patients with intellectual disability, autism spectrum disorder, and multiple congenital abnormalities. During the last 15 years, we performed CMA in approximately 8,000 patients with neurodevelopmental and/or congenital disorders, of which 13 (0.16%) genetically catastrophic complex chromosomal rearrangements were identified. These ultrarare rearrangements showed clustering of breakpoints, characteristic of chromoanagenesis events. Al1 13 complex events display underlying formation mechanisms, originating either by a synchronization of the shattering of clustered chromosome regions in which regional asynchrony of DNA replication may be one of the main causes of disruption. We provide an overview of the copy number profiling in these patients. Although several previous studies have suggested that chromoanagenesis is often a genetic disease source in postnatal diagnostic screening, due to either the challenge of clinical interpretation of these complex rearrangements or the limitation of microarray resolution relative to the small size and complexity of chromogenic induced chromosome abnormalities, bringing further attention and to study its occurrence in the clinical setting is extremely important., (© 2021 Wiley Periodicals LLC.)

Objective: To evaluate the audiometric pattern in moderate/severe retractions of the tympanic membrane and correlate it with the severity of the otoscopy findings., Study Design: Cross-sectional study., Setting: Tertiary hospital., Patients: Consecutive patients with moderate or severe tympanic membrane retraction in at least one ear (451 ears) between August 2000 and January 2019, and no surgical history or effusion (mean [standard deviation] age, 32.8 [20.2] yr; 54% female and 42.4% children)., Intervention: Pure-tone audiometry., Main Outcome Measures: Air conduction (AC) and bone conduction thresholds, and air-bone gap (ABG) measured at the four-frequency pure-tone average., Results: The median in decibel hearing level (dB HL) (minimum-maximum) of the AC, BC, and ABG were 25 dB HL (0-120 dB HL), 10 dB HL (0-75 dB HL), and 12.5 dB HL (0-55 dB HL), respectively. Seventy-two percent of the ears had an ABG ≤ 20 dB HL. For severity of the retraction of pars flaccida (PF), the AC, bone conduction, and ABG were similar across groups, with a weak correlation. For the pars tensa (PT), there was a global difference in the medians of AC and ABG in terms of the degree of severity, with a moderate correlation. Retraction in PF and PT at the same time was observed in 6 4% of the ears. ABG median was lower in ears with PF retraction (6.25 dB HL) than PT retraction, isolated (15 dB HL) or not (13.75 dB HL; p < 0.05)., Conclusion: The ABG pure-tone average median was higher when PT was involved. We found a significant correlation between the retraction severity and worsening of AC and ABG thresholds, only for PT., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2021, Otology & Neurotology, Inc.)

Mosaic segmental and whole chromosome copy number alterations are postzygotic variations known to be associated with several disorders. We have previously presented an efficient targeted sequencing approach to simultaneously detect point mutations and copy number variations (CNVs). In this study, we evaluated the efficiency of this approach to detect mosaic CNVs, using seven postnatal and 19 tumor samples, previously characterized by chromosomal microarray analyses (CMA). These samples harbored a total of 28 genomic imbalances ranging in size from 0.68 to 171 Mb, and present in 10-80% of the cells. All CNV regions covered by the platform were correctly identified in postnatal samples, and only seven out of 19 CNVs from tumor samples were not identified either because of a lack of target probes in the affected genomic regions or an absence of minimum reads for an alteration call. These results demonstrate that, in a research setting, this is a robust approach for detecting mosaicism in cases of segmental and whole chromosome alterations. Although the current sequencing platform presented a resolution similar to genomic microarrays, it is still necessary to further validate this approach in a clinical setting in order to replace CMA and sequencing analyses by a single test., (© 2020 John Wiley & Sons Ltd/University College London.)

Objective: To analyze the modulation of the phenotype in manifesting carriers of recessive X-linked myotubular myopathy (XLMTM), searching for possible genetic modifiers., Methods: Twelve Brazilian families with XLMTM were molecularly and clinically evaluated. In 2 families, 4 of 6 and 2 of 5 manifesting female carriers were identified. These females were studied for X chromosome inactivation. In addition, whole-exome sequencing was performed, looking for possible modifier variants. We also determined the penetrance rate among carriers of the mutations responsible for the condition., Results: Mutations in the MTM1 gene were identified in all index patients from the 12 families, being 4 of them novel. In the heterozygotes, X chromosome inactivation was random in 3 of 4 informative manifesting carriers. The disease penetrance rate was estimated to be 30%, compatible with incomplete penetrance. Exome comparative analyses identified variants within a segment of 4.2 Mb on chromosome 19, containing the killer cell immunoglobulin-like receptor cluster of genes that were present in all nonmanifesting carriers and absent in all manifesting carriers. We hypothesized that these killer cell immunoglobulin-like receptor variants may modulate the phenotype, acting as a protective factor in the nonmanifesting carriers., Conclusions: Affected XLMTM female carriers have been described with a surprisingly high frequency for a recessive X-linked disease, raising the question about the pattern of inheritance or the role of modifier factors acting on the disease phenotype. We demonstrated the possible existence of genetic mechanisms and variants accountable for the clinical manifestation in these women, which can become future targets for therapies., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.)

17p13.3 microduplications are rare copy number variations (CNVs) associated with variable phenotypes, including facial dysmorphism, developmental delay, intellectual disability, and autism. Typically, when a recognized pathogenic CNV is identified, other genetic factors are not considered. We investigated via whole-exome sequencing the presence of additional variants in four carriers of class I 17p13.3 microduplications. A 730 kb 17p13.3 microduplication was identified in two half-brothers with intellectual disability, but not in a third affected half-brother or blood cells from their normal mother (Family A), thus leading to the hypothesis of maternal germline mosaicism. No additional pathogenic variants were detected in Family A. Two affected siblings carried maternally inherited 450 kb 17p13.3 microduplication (Family B); the three carriers of the microduplication exhibited microcephaly and learning disability/speech impairment of variable degrees. Exome analysis revealed a variant of uncertain significance in RORA , a gene already linked to autism, in the autistic boy; his sister was heterozygous for a CYP1B1 pathogenic variant that could be related to her congenital glaucoma. Besides, both siblings carried a loss-of-function variant in DIP2B , a candidate gene for intellectual disability, which was inherited from their father, who also exhibited learning disability in childhood. In conclusion, additional pathogenic variants were revealed in two affected carriers of class I 17p13.3 microduplication (Family B), probably adding to their phenotypes. These results provided new evidence regarding the contribution of RORA and DIP2B to neurocognitive deficits, and highlighted the importance of full genetic investigation in carriers of CNV syndromes with variable expressivity. Finally, we suggest that microcephaly may be a rare clinical feature also related to the presence of the class I 17p13.3 microduplication.

Objective: To characterize the audiological findings of a sample of patients with osteogenesis imperfecta (OI) in southern Brazil., Methods: This was a cross-sectional, observational, quantitative study. Research was carried out at a hospital which is considered to offer benchmark treatment for patients with OI in southern Brazil. Seventy-seven patients were recruited, at ages between 5 and 55 years; the mean age was 21.9 ± 14.3 years. Patients were divided into three age groups: 10 and under, 10-19 and over 19. During our study, peripheral audiological assessments were performed (pure tone testing and acoustic immittance measurements). The main outcome measures taken into account were airway thresholds, bone conduction, air-bone gap and compliance values between compared frequencies. Data were analyzed per ear., Results: Normal hearing thresholds were found in 96 (64.4%) ears of the total sample. When analysis was stratified into age groups, normal hearing thresholds were found in 81.3%, 65%, and 54.4%, of the children, adolescent and adult groups, respectively. Concerning hearing impairments, there was a predominance of mixed type hearing loss in adults (21.1%) whereas adolescents presented conductive hearing loss or a conductive loss factor, while maintaining airway thresholds within the bounds of normality (30%). Ears with hearing loss showed superior compliance means than ears without hearing loss (p = 0.002)., Conclusions: Overall, the majority of the subjects in this patient sample presented normal hearing thresholds. When present, hearing impairments were more prevalent in the adult group than in the adolescent or children's groups.

Ubiquitin-conjugating enzymes (E2) enable protein ubiquitination by conjugating ubiquitin to their catalytic cysteine for subsequent transfer to a target lysine side chain. Deprotonation of the incoming lysine enables its nucleophilicity, but determinants of lysine activation remain poorly understood. We report a novel pathogenic mutation in the E2 UBE2A, identified in two brothers with mild intellectual disability. The pathogenic Q93E mutation yields UBE2A with impaired aminolysis activity but no loss of the ability to be conjugated with ubiquitin. Importantly, the low intrinsic reactivity of UBE2A Q93E was not overcome by a cognate ubiquitin E3 ligase, RAD18, with the UBE2A target PCNA. However, UBE2A Q93E was reactive at high pH or with a low-pK a amine as the nucleophile, thus providing the first evidence of reversion of a defective UBE2A mutation. We propose that Q93E substitution perturbs the UBE2A catalytic microenvironment essential for lysine deprotonation during ubiquitin transfer, thus generating an enzyme that is disabled but not dead.

Auditory deprivation associated with early otitis media with effusion has been considered a risk factor for central auditory processing (CAP), as well as for the development of a number of cognitive functions., Objective: To study the neuropsychological functions of attention, working memory and executive function in adolescents with and without non-cholesteatomatous chronic otitis media (NCCOM) and analyze their interrelationships with the behavioral evaluation of CAP., Methods: Sixty-eight adolescents were recruited, 34 were diagnosed with NCCOM (study group - SG), and 34 had no otological history (control group - CG). The Neupsilin Brief Neuropsychological Assessment Instrument was used. CAP was assessed by: Masking Level Difference, Synthetic Sentence Identification, Random Gap Detection Test, Duration Pattern Sequence Test and Dichotic Digits Test., Results: The results of Neupsilin showed lower scores in the study group when compared to the control group on the following tests: digit sequence repetition, ascending digit ordering, auditory sentence span, and phonemic verbal fluency. An association was found between central auditory processing tests and Neupsilin subtests., Conclusion: The effects of NCCOM on attention, memory and executive function related to central auditory processing disorder in adolescents seem to be enhanced by the severity of the disease., Competing Interests: Disclosure: The authors report no conflicts of interest.

Purpose of Review: Effective hearing rehabilitation with cochlear implantation is challenging in developing countries, and this review focuses on strategies for childhood profound sensorineural hearing loss care in South America., Recent Findings: Most global hearing loss exists in developing countries; optimal cost-effective management strategies are essential in these environments. This review aims to assess and discuss the challenges of cochlear implantation effectiveness in South America. The authors searched electronic databases, bibliographies, and references for published and unpublished studies. Sensitivity analysis was performed to evaluate the effect of device cost, professional salaries, annual number of implants, and failure rate. Costs were obtained from experts in South America using known costs and estimations whenever necessary. Recent studies reported several challenges in unilateral or bilateral cochlear implants: cochlear implant costs, deaf education costs, increasing need for cochlear implant capacity, and training and increasing longevity., Summary: Cochlear implantation was very cost-effective in all South American countries. Despite inconsistencies in the quality of available evidence, the robustness of systematic review methods substantiates the positive findings of the included studies, demonstrating that unilateral cochlear implantation is clinically effective and likely to be cost-effective in developing countries.

Objective: To analyze the contralateral ear (CLE) of patients with cholesteatoma and to correlate the cholesteatoma growth pattern in the affected ear with the findings in the CLE., Methods: Videotoscopy of both ears in 432 patients with cholesteatomas classified as posterior epitympanic (PEC), posterior mesotympanic (PMC), two routes, or undetermined. Tympanic membrane (TM) retractions were classified by location and severity and TM perforations according to signs of previous TM retraction., Results: TM retraction was the most prevalent alteration in the CLE (42.6%). Cholesteatoma was observed in 17.4%. In patients with PEC, the retraction in the CLE was more frequent in the PF (66.7%) than in the PT (1.4%), and in those with two-route cholesteatoma, the retraction in the CLE most frequently involved both the PT and PF (65.6%; p < 0.0001)., Conclusion: Our results confirm the essential role of TM retraction at least in the earlier phases of cholesteatoma pathogenesis.

Introduction: Cholesteatoma is a destructive lesion that can result in life-threatening complications. Typically, it presents with hypoacusis and continuous otorrhea as symptoms. Because it is a rare disease, there are few studies in Brazil describing the characteristics of patients with the disease., Objective: This study aimed to determine the prevalence of cholesteatoma in patients with chronic otitis media and describe clinical, audiological and surgical characteristics of patients with acquired middle ear cholesteatoma treated at a referral hospital in the public health system., Methods: Cross-sectional and prospective cohort study, including 1710 patients with chronic otitis media, treated between August 2000 and June 2015, without prior surgery. Detailed clinical history, videotoscopy, and audiometry were performed, in addition to review of medical records to search for surgical data. Cholesteatomas were classified according to their route of formation., Results: Of the patients with chronic otitis media, 419 (24.5%) had cholesteatoma; mean age of 34.49 years; 53.5% female and 63.8% adults. Bilateral cholesteatoma was observed in 17.1%. Anterior epitympanic cholesteatoma corresponded to 1.9%; posterior epitympanic, 32.9%; posterior mesotympanic, 33.7%; two routes, 14.8%; and indeterminate, 16.7%. The mean air-bone gap was 29.84dB and did not differ between routes of formation. There were no correlations between gap size and patient age or duration of symptoms. Of the surgical cases, 16.8% underwent closed tympanomastoidectomy and 75.2% open tympanomastoidectomy., Conclusion: The prevalence of cholesteatoma in patients with chronic otitis media was 24.5% and it was more common in adults than in children. Posterior mesotympanic cholesteatoma was more frequent, with no difference in mean air-bone gap between the different routes of formation. In patients undergoing surgery, open tympanomastoidectomy was the procedure most frequently chosen., (Copyright © 2016 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.)

The objective of this is to verify whether the hearing impairment caused by posterior epitympanic differed from that caused by posterior mesotympanic cholesteatomas by a cross-sectional study. We evaluated 264 ears of patients with cholesteatoma, who had not been subjected to ear surgery. Otoendoscopy and pure-tone audiometry were performed. Analyzed route involved in cholesteatoma formation: posterior epitympanic or posterior mesotympanic, air-bone gaps at 512-4000 Hz and pure-tone averages. The mean age of the patients enrolled in this study was 33.8 years, and 51.8 % of them was male. Posterior epitympanic cholesteatoma was found in 50.4 % of the study population. When the air-bone gaps were compared, the mesotympanic group had greater thresholds at 500, 2000 Hz, and a greater pure-tone average (P = 0.003, P = 0.03, and P = 0.02, respectively). Posterior mesotympanic cholesteatoma showed greater air-bone gaps thresholds at the speech frequencies than posterior epitympanic cholesteatoma did. Moreover, the two growth patterns were very similar with regard to all other audiometric parameters analyzed in this study.

Naturally occurring myringostapediopexy frequently results in minimal hearing loss and is asymptomatic. Management decisions in such ears, however, often hinge on an appraisal of evolution toward cholesteatoma. The study of the contralateral ear has been used by our research team to infer the progression of chronic otitis media. This cross-sectional, comparative study describes the clinical findings of the contralateral ear in a series of patients with myringostapediopexy. This study included a historical and current sample of 46 patients divided into a pediatric (≤18 years) and an adult group. Patient distribution according to sex was similar (52.2% male), and 56.5% were adults. Mean conductive hearing loss ranged from 14.1 to 21.2 dB in ears with myringostapediopexy and from 16.0 to 26.6 dB in the contralateral ears according to the frequency assessed. The contralateral ear was normal in only 19.6% of the cases of myringostapediopexy. Central tympanic membrane perforation was found in 6.5% of the cases; perforation-retraction, in 17.4%; moderate or severe retraction, in 28.3%; and cholesteatoma, in 28.3%. The prevalence of cholesteatoma in the contralateral ear in the pediatric and adult groups was not significantly different (p = 0.5; χ(2) test). The presence of significant abnormalities, particularly cholesteatoma, in the contralateral ears suggests a probable unfavorable progression in cases of myringostapediopexy and may influence management decisions.

We report on a 16-year-old boy with a maternally inherited ~ 18.3 Mb Xq13.2-q21.31 duplication delimited by aCGH. As previously described in patients with similar duplications, his clinical features included intellectual disability, developmental delay, speech delay, generalized hypotonia, infantile feeding difficulties, self-injurious behavior, short stature and endocrine problems. As additional findings, he presented recurrent seizures and pubertal gynecomastia. His mother was phenotypically normal and had completely skewed inactivation of the duplicated X chromosome, as most female carriers of such duplications. Five previously reported patients with partial Xq duplications presented duplication breakpoints similar to those of our patient. One of them, a fetus with multiple congenital abnormalities, had the same cytogenetic duplication breakpoint. Three of the reported patients shared many features with our proband but the other had some clinical features of the Prader-Willi syndrome. It was suggested that ATRX overexpression could be involved in the major clinical features of patients with partial Xq duplications. We propose that this gene could also be involved with the obesity of the patient with the Prader-Willi-like phenotype. Additionally, we suggest that the PCDH11X gene could be a candidate for our patient's recurrent seizures. In males, the Xq13-q21 duplication should be considered in the differential diagnosis of Prader-Willi syndrome, as previously suggested, and neuromuscular diseases, particularly mitochondriopathies.

Middle ear cholesteatoma has been extensively studied. Theories of cholesteatoma pathogenesis involving previous tympanic membrane retraction are the most widely accepted, but the contralateral ear in patients with cholesteatoma remains unstudied. This study aimed to investigate the contralateral ear in patients with cholesteatoma, and to determine whether the characteristics of it differ according to patient age and cholesteatoma growth patterns. This study was cross sectional. We evaluated 356 patients with middle ear cholesteatoma in at least one ear, and no history of surgery, between August 2000 and March 2013. Otoendoscopy was conducted on both the affected and the contralateral ear. They were classified as normal, tympanic membrane perforation, moderate to severe tympanic membrane retraction and cholesteatoma. The mean age of the patients was 32.77 years, and 53.1 % of the cohort were female. Only 34.8 % of the contralateral ears were normal. The most common abnormality was moderate to severe tympanic membrane retraction (41.6 %). Cholesteatoma was identified in 16 %. Children exhibited a greater frequency of tympanic membrane retractions, whereas adults exhibited a greater frequency of cholesteatoma. All of the contralateral ears in the anterior epitympanic group were normal, but otherwise there were no differences in the contralateral ear when we compared the cholesteatoma growth patterns. We conclude that patients diagnosed with acquired cholesteatoma of one ear are significantly more likely to exhibit abnormalities of the contralateral ear.

Objective: To determine whether middle ear cholesteatoma is associated with, sensorineural hearing loss, and whether patient age, cholesteatoma growth pattern, or, air bone gap size contribute to inner ear impairment., Study Design: Cross-sectional comparative., Setting: A tertiary hospital., Patients: The subjects were 115 patients with middle ear cholesteatoma in one ear, and normal video-otoscopy in the contralateral ear (CLE)., Interventions: Otoendoscopy, pure-tone audiometry., Main Outcome Measures: Bone conduction (BC) threshold differences between the normal CLE and the cholesteatoma ear. Comparisons of these differences between different cholesteatoma growth patterns. Correlation between the air bone gap size in the ear with cholesteatoma and the difference in bone conduction thresholds between both ears., Results: The cholesteatoma ear was associated with greater BC thresholds than the CLE. With regard to different cholesteatoma growth patterns, the differences between associated BC thresholds were also significant in all groups at all frequencies, with the exception of the two routes of cholesteatoma group at 500  Hz. Comparing BC threshold differences, they were greater in the adult group at 500  Hz. The correlation between the air bone gap media in the ear with cholesteatoma and the difference in bone conduction thresholds between both ears was direct and moderate., Conclusion: Cholesteatoma was associated with greater BC thresholds at all frequencies tested. The differences were independent of cholesteatoma growth patterns. As bigger the air bone gap in the ear with cholesteatoma, greater the inner ear damage.

Importance: Several classifications of cholesteatoma exist, but there are controversies about their clinical application., Objective: To classify cholesteatomas and describe the prevalence of the subtypes., Design, Setting, and Participants: A cross-sectional comparative study of 414 ears in 356 consecutive patients with middle ear cholesteatoma and no history of ear surgery treated at a tertiary hospital was conducted from March 8, 2000, to March 30, 2015. Data analysis was conducted from March 30, 2014, to March 30, 2015., Intervention: Otoendoscopy was conducted, and findings for both ears were recorded., Main Outcomes and Measures: Cholesteatoma growth patterns were classified as anterior epitympanic, posterior epitympanic, posterior mesotympanic, 2 routes (both the pars flaccida and the pars tensa are involved), and undetermined., Results: Among the 356 patients in this study, mean (SD) patient age was 33.23 (19.81) years (range, 4-82 years), and 125 patients (35.1%) were female. The right ear was identified as the affected ear in 220 patients (61.8%). A total of 272 (65.7%) ears were from adults. Of the 414 ears that underwent otoendoscopy, posterior epitympanic (142 [34.3%]) and posterior mesotympanic (140 [33.8%]) were the most frequent types of cholesteatoma observed, followed by undetermined (67 [16.2%]) and 2 routes (57 [13.8%]). Anterior epitympanic type was the least frequent (8 [1.9%]). Posterior epitympanic cholesteatoma was more prevalent in adults (111 [40.8%]), whereas posterior mesotympanic cholesteatoma was more frequent in children (43.0%) (P < .001). Anterior epitympanic cholesteatoma was observed only in children., Conclusions and Relevance: Classifying cholesteatomas according to the growth pattern (anterior epitympanic, posterior epitympanic, posterior mesotympanic, 2 routes, and undetermined) includes all existing types of cholesteatomas of the middle ear. In general, the prevalence of posterior epitympanic and posterior mesotympanic cholesteatoma were similar. Whereas anterior epitympanic and posterior mesotympanic cholesteatomas were more prevalent in children, posterior epitympanic cholesteatoma was more frequent in adults.

Objective: Evaluate hearing impairment in acquired middle ear cholesteatoma and investigate audiometric differences between children and adults., Study Design: Cross-sectional comparative study., Setting: Tertiary hospital., Patients: Three hundred twenty-three consecutive patients diagnosed as having acquired middle ear cholesteatoma in at least one ear (385 ears) between August 2000 and March 2013 and no surgical history (mean [standard deviation {SD}] age, 32.8 [19.4] yr; 54.3% men and 34.8% children)., Intervention: Pure-tone audiometry., Main Outcome Measures: Air-conduction (AC) and bone conduction (BC) thresholds and air-bone gaps (ABGs) measured at the pure-tone average (PTA) and individual frequencies., Results: The mean (SD) AC and BC thresholds at the PTA were 46.8 (22.7) and 17.7 (17.5) dB, respectively. The mean (SD) ABG at the PTA was 29.6 (13.4) dB, and that at 500 Hz was significantly greater than the ABGs at the other frequencies. Only 3.6% of the ears had profound hearing loss, without a significant difference between children and adults. The AC and BC thresholds were significantly greater in adults at all the frequencies (p ≤ 0.05), but the ABGs were not significantly different between the age groups., Conclusion: Acquired middle ear cholesteatoma is associated with significant hearing impairment, although profound hearing loss is rare. Adults have greater AC and BC thresholds than those in children but similar ABGs to children.

Conclusion: There were no changes in the function of the six semicircular canals in active fighter pilots, through the use of the video head impulse test (vHIT). These results suggest that the vestibuloocular reflex (VOR) works well at the high frequencies related to the natural head movements in this population., Objectives/hypothesis: The vestibular function in pilots has been reported as being different from that of other normal subjects. These differences are attributed to adaptation of the vestibuloocular reflex (VOR) or by habituation. These studies were conducted with caloric and/or rotatory tests and were limited to the lateral semicircular canals. The aim of the present study was to verify the occurrence of high frequency changes in the function of the six semicircular canals in active fighter pilots, through the use of the video head impulse test (vHIT)., Study Design: Cross-sectional design., Methods: The subjects participating in this study were divided in three groups, according to their flight experience. The control group (Group 1) consisted of 20 soldiers with no experience of in-flight training. For the test subjects 14 fighter pilots were selected and divided into two groups. Group 2 included the pilots with 1000-2000 hours of flight experience and Group 3 included pilots with 2001-3000 hours of flight experience. They were all submitted to a video head impulse test and the gains of the six semicircular canals were analysed., Results: There were significantly low gain values (p < 0,013) only in the left posterior semicircular canal in the control group as compared with the subject groups. However, there were no significant differences in gain values between the two groups of the active pilots.

Objective: Assessing the adequacy of knowledge, attitude and practice of women regarding male and female condoms as STI/HIV preventive measures., Method: An evaluative Knowledge, Attitude and Practice (KAP) household survey with a quantitative approach, involving 300 women. Data collection took place between June and August 2013, in an informal urban settlement within the municipality of João Pessoa, Paraiba, Northeast Brazil., Results: Regarding the male condom, most women showed inadequate knowledge and practice, and an adequate attitude. Regarding the female condom, knowledge, attitude and practice variables were unsatisfactory. Significant associations between knowledge/religious orientation and attitude/education regarding the male condom were observed., Conclusion: A multidisciplinary team should be committed to the development of educational practices as care promotion tools in order to improve adherence of condom use.

Objective: To characterise the trend of leprosy according to epidemiological and operational indicators in the state of Paraíba in the period of 2001-2011 with projections for the years 2012-2014., Methods: An epidemiological, retrospective, documentary study of a temporal sequence conducted with 10,476 reported cases of leprosy diagnosed in adults between 2001 and 2011 in 223 municipalities in the state of Paraiba, Brazil. The results were composed and analysed using two epidemiological indicators, an operational indicator and statistical software., Results: The annual detection rate of new cases showed an upward slope between 2001 and 2005 and a declining trend from 2006. Disability showed a cyclic variation with a downward tendency and a medium level of efficiency., Conclusion: The results show that the disease continues to be a problem in the state and reveal the need for shorter assessments that focus on health programmes and strategies that are used to fight leprosy.

Studies in mice demonstrated that the Shh gene is crucial for normal development of both incisors and molars, causing a severe retardation in tooth growth, which leads to abnormal placement of the tooth in the jaw and disrupted tooth morphogenesis. In humans the SHH gene is located on chromosome 7q36. Defects in its protein or signaling pathway may cause holoprosencephaly spectrum, a disorder in which the developing forebrain fails to correctly separate into right and left hemispheres and that can be manifested in microforms such as single maxillary central incisor. A novel role for this gene in the developing human primary dentition was recently demonstrated. We report a 12-year old boy with a de novo 7q36.1-qter deletion characterized by high-resolution karyotyping, oligonucleotide aCGH and FISH. His phenotype includes intellectual disability, non-verbal communication, hypospadia, partial sacral agenesis and absence of coccyx, which are distinctive features of the syndrome and mainly correlated with the MNX1, HTR5A and EN2 genes. No microforms of holoprosencephaly spectrum were observed; but the patient had diastema and dental developmental abnormalities, such as conical, asymmetric and tapered inferior central incisors. The dental anomalies are reported herein for the first time in subtelomeric 7q36 deletion syndrome and may confirm clinically a novel role for the SHH gene in dental development.

In the attempt to prevent cervical cancer, various preventive measures have been instituted, notable among which is the pap smear test, which fulfills the function of early detection of cancer cells or their precursors. Therefore, the objective was to investigate the discourse on the knowledge, feelings and expectations of women regarding the pap smear test. This is an exploratory qualitative approach, conducted with ten users of a Integrated Family Health Unit in the city of João Pessoa in the State of Paraíba. Data collection was conducted through recorded interviews in April 2011. Eight core ideas were identified: prevention of disease; self-motivated search, search recommended by another person; sense of shame and embarrassment, sensation of pain, feeling of satisfaction; conversations during the examination and exchange of knowledge about women's health. Based on the reports, there are many difficulties to be overcome to ensure greater adherence of women to the pap smear test.

Experimental design methodology was used to optimize an analytical method for determination of the mineral element composition (Al, Ca, Cd, Cr, Cu, Ba, Fe, K, Mg, Mn, P, S, Sr and Zn) of dog and cat foods. Two-level full factorial design was applied to define the optimal proportions of the reagents used for microwave-assisted sample digestion (2.0 mol L(-1) HNO3 and 6% m/v H2O2). A three-level factorial design for two variables was used to optimize the operational conditions of the inductively coupled plasma optical emission spectrometer, employed for analysis of the extracts. A radiofrequency power of 1.2 kW and a nebulizer argon flow of 1.0 L min(-1) were selected. The limits of quantification (LOQ) were between 0.03 μg g(-1) (Cr, 267.716 nm) and 87 μg g(-1) (Ca, 373.690 nm). The trueness of the optimized method was evaluated by analysis of five certified reference materials (CRMs): wheat flour (NIST 1567a), bovine liver (NIST 1577), peach leaves (NIST 1547), oyster tissue (NIST 1566b), and fish protein (DORM-3). The recovery values obtained for the CRMs were between 80 ± 4% (Cr) and 117 ± 5% (Cd), with relative standard deviations (RSDs) better than 5%, demonstrating that the proposed method offered good trueness and precision. Ten samples of pet food (five each of cat and dog food) were acquired at supermarkets in Aracaju city (Sergipe State, Brazil). Concentrations in the dog food ranged between 7.1 mg kg(-1) (Ba) and 2.7 g kg(-1) (Ca), while for cat food the values were between 3.7 mg kg(-1) (Ba) and 3.0 g kg(-1) (Ca). The concentrations of Ca, K, Mg, P, Cu, Fe, Mn, and Zn in the food were compared with the guidelines of the United States' Association of American Feed Control Officials (AAFCO) and the Brazilian Ministry of Agriculture, Livestock, and Food Supply (Ministério da Agricultura, Pecuária e Abastecimento-MAPA)., (Copyright © 2013 Elsevier B.V. All rights reserved.)

This study was performed in six Long-Term Care Institutions for the Elderly (LTCIEs) that helped low-income senior citizens in three regions of the country. Its aim is to examine how LTCIEs' internal organizational system maintained structural coupling with surrounding systems. The data were collected through interviews and observation. The analysis was based on concepts of Luhmann's Social Systems Theory. As a result, the rules of belonging did not encourage aid proposals that stimulated independent life and the individuality of residents. The structural couplings with the external environment generated negative resonance within LTCIEs, such as the lack of links to programmatic actions of public primary health care, inability to maintain a multiprofessional staff, inability to fully adapt the infrastructure, and inability to bring reçatives closer to the institution's daily routine. As a positive aspect, the staff was empowered by the presence of students and their professors.

Objective: Cleft palates are strongly associated with the development of otitis media due to the anatomic and functional defect of the soft palate musculature and the associated alterations of velopharyngeal muscle insertion on tubal cartilage, or even intrinsic alterations of the cartilage, which affects eustachian tube function. This study will assess velopharyngeal muscle adequacy after palatoplasty through videonasoendoscopy and verify if there is a correlation with otologic status., Design: Transversal study., Setting: Otorhinolaryngology and cleft palate outpatient service of the Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil., Patients: Seventy-three patients with cleft palate or cleft lip and palate between the ages of 6 and 12 years who had already undergone palatoplasty., Interventions: Videonasoendoscopy for evaluation of velopharyngeal function and videotoscopy to assess middle ear status., Main Outcome Measures: Severity scale for videonasoendoscopic and videotoscopic findings., Results: There was no significant correlation between the videonasoendoscopic and the videotoscopic scores in the population studied., Discussion and Conclusions: Intrinsic defects of the eustachian tube cartilage and of the insertion of the velopharyngeal muscles seem to contribute to the evolution of otitis media in patients with cleft palate, in addition to the actual defect of the soft palate. There was no correlation between the severity of the otoscopic findings and the degree of velopharyngeal dysfunction.

Objective: Otitis media is the most common otological condition during childhood which compromises sound conduction in the middle ear. In chronic cases, it is estimated that the degree to which hearing is compromised is directly proportional to the damage caused to the middle ear's structures. It means that hearing thresholds may be influenced by factors such as the size and location of the tympanic perforation, the presence of ossicular chain erosion or disarticulation as well as the presence of cholesteatoma and its growth patterns. The goals of this study were to compare air conduction, bone conduction thresholds and air-bone gaps of children and teenagers between those with chronic suppurative otitis media with cholesteatoma and those without cholesteatoma. To compare air-bone gap values for different cholesteatoma growth patterns. To verify the relationship between the number of perforated quadrants and the size of the air-bone gap. To compare air-bone gap values between tympanic perforations in posterior quadrants with those in anterior quadrants., Methods: A transversal study involving 202 children and teenagers (287 ears), aged between 6 and 18, with chronic suppurative otitis media with and without cholesteatoma, submitted to digital videotoscopy and pure tone audiometry (PTA) was conducted., Results and Conclusions: Air conduction, bone conduction thresholds and air-bone gaps in children and teenagers with CCOM are significantly greater. There were no significative differences between air-bone gaps in epitympanic and posterior mesotympanic cholesteatomas. In NCCOM, the gap value is positively correlated with the number of quadrants with tympanic perforation. There was no significative difference between the air-bone gaps in tympanic perforations affecting the posterior and anterior quadrants.

The quantification of angiogenesis and metalloproteinases may be useful in cholesteatoma behavior assessment as markers of its aggressiveness. The objective of this study is to compare markers CD31, MMP2 and MMP9 in pediatric and adult patients. This study is based on cross-sectional studies of pediatric (or=19 years old). Samples of 120 cholesteatomas were fixed in 10% formol, prepared on five slides of each sample through habitual histological techniques, and number of blood vessels (CD31), marking with MMP2 and MMP9, number of matrix cells and thickness at perimatrix cell were observed. Data were analyzed through SPSS using Spearman and Mann-Whitney coefficients. Cholesteatomas were equally distributed: 60 in pediatric patients (11.77 +/- 3.57 years); 60 in adult patients (38.29 +/- 14.51 years). When correlating the number of blood vessels and metalloproteinases with perimatrix thickness, we obtained the following values: pediatric CD31, 7 (4-11); adult CD31, 4 (0-10) (P = 0.044); pediatric cytoplasmatic MMP2, 1 (0-3); adult cytoplasmatic MMP2, 0 (0-1) (P = 0.006); pediatric nuclear MMP2, 0 (0-1); adult nuclear MMP2, 0 (0-1) (P = 0.056); pediatric MMP9, 2 (0-4); adult MMP9, 0 (0-4) (P = 0.049). In conclusion, pediatric cholesteatomas present a more exacerbated inflammatory degree, produce more metalloproteinases, factors that, when combined, could characterize pediatric cholesteatomas as more aggressive than adult cholesteatomas.

Unlabelled: Chronic otitis media is generally associated with some degree of hearing loss, which is often the patient's chief complaint. This hearing loss is usually conductive, resulting from tympanic membrane rupture and/or changes in the ossicular chain due to fixation or erosion caused by the chronic inflammatory process. When cholesteatoma or granulation tissue is present in the middle ear cleft, the degree of ossicular destruction is even greater. An issue that has recently gained attention is additional sensorineural hearing loss due to chronic otitis media. While the conductive loss can be minimized through surgery, sensorineural hearing loss constitutes a permanent after effect, attenuated only through the use of a hearing aid. However, a few groups have reported a decrease in sensorineural function in these patients as well. This survey study performed at a referral center evaluates the occurrence of sensorineural hearing loss in ambulatory patients with this disease. We reviewed the files of patients with unilateral chronic otitis media. One hundred and fifty patients met the inclusion criteria: normal otoscopy and normal hearing in the contralateral ear., Main Outcome Measure: bone-conduction threshold averages were calculated for frequencies of 500, 1,000, 2,000, 3,000 and 4,000 Hz, with comparison between the normal ear and the ear with chronic otitis media. Thresholds were examined separately for each frequency. The bone-conduction threshold averages for the normal side were lower than those for the ear with chronic otitis media. The threshold shift was statistically significant for each frequency (P<0.0001, Student's t test). There were differences between the groups when analyzed for age (500 and 1,000 Hz) or the presence of cholesteatoma (1,000 Hz). This study shows that chronic otitis media is associated with a decrease in cochlear function.

Unlabelled: Chronic otitis media is hystopathologycaly defined as the presence of irreversible inflammatory tissue changes in the middle ear. Ossicular lesions represent the most prevalent change., Aim: to correlate the degree of ossicular chain changes seen during surgery with the inflammatory histological degree and the thickness of the cholesteatoma perimatrix., Study Design: Cross-sectional study., Methods: Seventy-one descriptions of surgeries done in patients submitted to tympanomastoydectomy were reviewed. Cholesteatoma were collected and fixed in 10% formaldehyde. Two slides were made for each cholesteatoma, one stained with HE and another with picrossirius. Images were obtained from light microscopy and digitally processed and "blindly" analyzed using Image Pro-Plus Software. For statistical analysis we used Spearman's coefficient. Differences were considered statistically significant if P< or =0.05., Results: the ossicular chain was involved in 65 cases. The incus was the most frequently affected bone, followed by the stapes and the malleus. When the Spearman's coefficient was employed considering ossicular chain change degree with patient's age by the time of surgery, perimatrix thickness and histological degree of inflammation, correlations were not established., Conclusion: Our findings indicate that ossicular chain changes are practically universal when a cholesteatoma is present. We didn't find correlations related with bone erosion and cholesteatoma's histological findings.