Identification of potentially pathogenic variants in patients with Genetic Epilepsy with Febrile Seizures Plus (GEFS+)

Orientador: Íscia Teresinha Lopes-CendesDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: Introdução. A epilepsia genética com crises febris plus - GEFS+ (do inglês: genetic epilepsy with febrile seizures plus) é uma síndrome epilética familiar, com um padrão de herança monogênico, com predomínio autossômico dominante, heterogeneidade fenotípica, penetrância incompleta, e prognóstico clínico variável. Tem como principal característica, mas não essencial, as crises tônico-clônicas generalizadas desencadeadas por febre. Cerca de 30% das famílias com GEFS+ têm o diagnóstico molecular realizado, entretanto, a maioria dos pacientes com GEFS+ permanece sem etiologia genética identificada. Objetivo. Investigar alterações moleculares e de número de cópias em pacientes com GEFS+. Métodos. Foram avaliados 19 pacientes com GEFS+. O sequenciamento completo do exoma (Whole Exome Sequencing ¿ WES) foi realizado em todos os pacientes, e a análise cromossômica por microarranjos ¿ (Chromosomal Microarray Analysis ¿ CMA) em 17 pacientes. No WES foi realizada uma análise focada em potenciais genes candidatos para GEFS+ e outras síndromes epilépticas relacionadas, por meio de painéis de bioinformática que abrangeram um total de 192 genes candidatos. Na CMA foram consideradas como relevantes todas as alterações observadas nos pacientes, e não observadas nos controles (339 indivíduos da população brasileira). A análise da patogenicidade das variantes foi conduzida segundo as diretrizes do Colégio Americano de Genética Médica e Genômica. Resultados. Os fenótipos identificados em nossa coorte de estudo foram: crises febris (FS) ou crises febris plus (FS+) com outros tipos de crises generalizadas (13/19 [68,4%]), FS+ (3/19 [15,8%]) e FS (3/19 [15,8%]). Foram encontradas alterações genéticas patogênicas ou provavelmente patogênicas em 36,8% (n=7/19) dos casos. Destes, em 42,9% (n=3/7) foram encontradas alterações genéticas nos genes candidatos já estabelecidos com o fenótipo GEFS+ (SCN1A e SCN2A); 42,9% (n=3/7) apresentaram alterações genéticas provavelmente patogênicas em genes que têm sido associados principalmente com outras formas de epilepsias genéticas generalizadas ¿ EGG (EFHC1, CLCN2 e SLC2A1); e 28,6% (n=2/7) dos casos tinham alterações genéticas provavelmente patogênicas em genes associados com fenótipos de encefalopatias epilépticas da infância (SCN3A, CACNA1E e MTOR). Um paciente com FS+ e com outros tipos de crises generalizadas e afasia, apresentou duas alterações genéticas concomitantes não relacionadas, sendo uma variante no gene SCN1A p.K1654R de significância incerta (VUS), mas não descrita na literatura; e a outra uma CNV (Copy Number Variation) patogênica (deleção "de novo" em 7q33q35) Conclusão. Utilizando o sequenciamento de exoma completo e uma análise focada em painéis de bioinformática abrangentes para múltiplos genes associados com o fenótipo GEFS+ e outras epilepsias na infância, foi possível encontrar alterações genéticas patogênicas ou provavelmente patogênicas em 36,8% (n=7/19) dos pacientes, o que é ligeiramente superior ao relatado na literatura (30%). Nossos achados apoiam o sugerido por outros autores quanto ao compartilhamento de determinantes genéticas entre os dois grandes grupos de epilepsias generalizadas (GEFS+ e EGG) e também das encefalopatias epilépticas da infância, e portanto, sugerimos a investigação de variantes, não apenas em genes associados ao fenótipo GEFS+, mas também que se estenda essa investigação, quando possível, para genes relacionados a outras epilepsias na infância, especialmente para síndromes de epilepsia genética generalizada e encefalopatias epilépticasAbstract: Introduction. Genetic epilepsy with febrile seizure plus (GEFS+) is a familial epileptic syndrome, with a monogenic inheritance pattern, predominantly autosomal dominant. It shows phenotypic heterogeneity, incomplete penetrance, and variable prognosis. GEFS+ has the main characteristic, but not essential, the presence of generalized tonic-clonic seizures triggered by fever. Molecular diagnosis in GEFS+ families occurs in around 30%, so most of the patients with GEFS+ remain without identified genetic changes. Objective. To investigate molecular and copy number alterations in patients with GEFS+. Methods. We included nineteen patients with GEFS+. Whole-exome sequencing - WES was performed in all patients and chromosomal microarray analysis - CMA in seventeen patients. The WES approach focused on potential candidate genes for GEFS+ and other related epileptic syndromes using a bioinformatics multi-gene panel containing 192 genes. In the CMA approach, all variants observed in patients but not observed in controls (339 individuals from the Brazilian population) were considered relevant. We characterized the putative pathogenicity of the variants of interest according to the American College of Medical Genetics and Genomics guidelines. Results. The clinical spectrum of the GEFS+ phenotypes identified in our study were distributed as follows: febrile seizures (FS) or FS+ with other generalized seizure type (13/19 [68.4%]), FS+ (3/19 [15.8%]) and FS (3/19 [15.8%]). We found pathogenic and likely pathogenic genetic variants in 36.8% (n=7/19) of the patients. Of these variants, mutations in genes known to be associated with the GEFS+ phenotypes (SCN1A and SCN2A) were found in 42.9% (n=3/7) of cases, 42.9% (n=3/7) in genes associated with genetic generalized epilepsies - GGEs (EFHC1, CLCN2, and SLC2A1), and 28.6%, (n=2/7) in genes associated with childhood epileptic encephalopathies - CEEs (SCN3A, CACNA1E, and MTOR). We identified a patient with FS+ with other generalized seizure types and aphasia, who presented two concomitant, unrelated genetic alterations: a variant classified as a variant of unknown significance (VUS) in the SCN1A p.K1654R, not yet described in the literature, and a pathogenic "de novo" CNV (7q33q35 deletion). Conclusion. Using WES combined with a focused analysis based on a bioinformatics multi-gene panel approach, which includes genes previously associated with the GEFS+ phenotype and other childhood epilepsies, we found pathogenic and likely pathogenic genetic variants in 36.8% of the patients tested. This is slightly higher than the 30% diagnostic yield reported in the literature. In addition, our findings support previous suggestions that genetic testing for GEFS+ should also include genes related to other generalized epilepsies and epileptic encephalopathies. Therefore, we suggested that the search for genetic variants in patients with GEFS+ should include genes related to other types of childhood epilepsiesMestradoFisiopatologia MédicaMestra em CiênciasCAPE

Sewage Gone Green

The Mbaracayu Forest Reserve School in Paraguay lacks an adequate sewage processing system. However, many modern techniques for producing clean effluent utilize expensive and environmentally damaging chemicals. A more sustainable alternative exists by using naturally occurring macrophytes and microbes to purify raw sewage. Through literary research and working with Martin Burt of the Fundacion Paraguaya, sponsor of this project, we designed a parallel lagoon system that uses water hyacinth and natural processes to create clean effluent which is discharged away from the community. Raw sewage enters the system at an elevated position and is slowly driven by gravity through a series of lagoons with different functions and processes that reduce nitrogen, phosphorus, TSS, BOD, and pathogens from the sewage to acceptable levels. The flow is controllable by manually operated gates. The parallel lagoons are interconnected by pipes and operable gates to allow parts of the system to be bypassed for maintenance or in case of malfunction. In addition to producing safe effluent, this system creates two sustainable agricultural resources for the school in sludge and water hyacinth. The sludge can be used as a fertilizer rich in organic material and nutrients including phosphorus and nitrogen. Water hyacinth can be utilized as compost, animal feed, rope, and for paper fabrication. This solution will provide the Mbaracayu school with necessary sewage treatment and two sustainable resources for agriculture while hopefully providing a template to other communities in developing countries across the world

Air Pollution and Blood Pressure: Evidence From Indonesia

Indonesia faces significant air quality issues due to multiple emissions sources, including rapid urbanization and peatland fires associated with agricultural land management. Limited prior research has estimated the episodic shock of intense fires on morbidity and mortality in Indonesia but has largely ignored the impact of poor air quality throughout the year on biomarkers of cardiovascular disease risk. We conducted a cross-sectional study of the association between particulate matter less than 2.5 microns in diameter (PM2.5) and blood pressure. Blood pressure measurements were obtained from the fifth wave of the Indonesian Family Life Survey (IFLS5), an ongoing population-based socioeconomic and health survey. We used the GEOS-Chem chemical transport model to simulate daily PM2.5 concentrations at 0.5° × 0.625° resolution across the IFLS domain. We assessed the association between PM2.5 and diastolic and systolic blood pressure, using mixed effects models with random intercepts for regency/municipality and household and adjusted for individual covariates. An interquartile range increase in monthly PM2.5 exposure was associated with a 0.234 (95% CI: 0.003, 0.464) higher diastolic blood pressure, with a greater association seen in participants age 65 and over (1.16 [95% CI: 0.24, 2.08]). For the same exposure metric, there was a 1.90 (95% CI: 0.43, 3.37) higher systolic blood pressure in participants 65 and older. Our assessment of fire-specific PM2.5 yielded null results, potentially due to the timing and locations of health data collection. To our knowledge, this is the first study to provide evidence for an association between PM2.5 and blood pressure in Indonesia

Mortality attributable to PM2.5 from wildland fires in California from 2008 to 2018

In California, wildfire risk and severity have grown substantially in the last several decades. Research has characterized extensive adverse health impacts from exposure to wildfire-attributable fine particulate matter (PM2.5), but few studies have quantified long-term outcomes, and none have used a wildfire-specific chronic dose-response mortality coefficient. Here, we quantified the mortality burden for PM2.5 exposure from California fires from 2008 to 2018 using Community Multiscale Air Quality modeling system wildland fire PM2.5 estimates. We used a concentration-response function for PM2.5, applying ZIP code-level mortality data and an estimated wildfire-specific dose-response coefficient accounting for the likely toxicity of wildfire smoke. We estimate a total of 52,480 to 55,710 premature deaths are attributable to wildland fire PM2.5 over the 11-year period with respect to two exposure scenarios, equating to an economic impact of $432 to$456 billion. These findings extend evidence on climate-related health impacts, suggesting that wildfires account for a greater mortality and economic burden than indicated by earlier studies