International Consensus Guidance for Management of Myasthenia Gravis

To update the 2016 formal consensus-based guidance for the management of myasthenia gravis (MG) based on the latest evidence in the literature. In October 2013, the Myasthenia Gravis Foundation of America appointed a Task Force to develop treatment guidance for MG, and a panel of 15 international experts was convened. The RAND/UCLA appropriateness method was used to develop consensus recommendations pertaining to 7 treatment topics. In February 2019, the international panel was reconvened with the addition of one member to represent South America. All previous recommendations were reviewed for currency, and new consensus recommendations were developed on topics that required inclusion or updates based on the recent literature. Up to 3 rounds of anonymous e-mail votes were used to reach consensus, with modifications to recommendations between rounds based on the panel input. A simple majority vote (80% of panel members voting "yes") was used to approve minor changes in grammar and syntax to improve clarity. The previous recommendations for thymectomy were updated. New recommendations were developed for the use of rituximab, eculizumab, and methotrexate as well as for the following topics: early immunosuppression in ocular MG and MG associated with immune checkpoint inhibitor treatment. This updated formal consensus guidance of international MG experts, based on new evidence, provides recommendations to clinicians caring for patients with MG worldwide

The Bern Birth Cohort (BeBiCo) to study the development of the infant intestinal microbiota in a high-resource setting in Switzerland: rationale, design, and methods.

BACKGROUND Microbiota composition is fundamental to human health with the intestinal microbiota undergoing critical changes within the first two years of life. The developing intestinal microbiota is shaped by maternal seeding, breast milk and its complex constituents, other nutrients, and the environment. Understanding microbiota-dependent pathologies requires a profound understanding of the early development of the healthy infant microbiota. METHODS Two hundred and fifty healthy pregnant women (≥20 weeks of gestation) from the greater Bern area will be enrolled at Bern University hospital's maternity department. Participants will be followed as mother-baby pairs at delivery, week(s) 1, 2, 6, 10, 14, 24, 36, 48, 96, and at years 5 and 10 after birth. Clinical parameters describing infant growth and development, morbidity, and allergic conditions as well as socio-economic, nutritional, and epidemiological data will be documented. Neuro-developmental outcomes and behavior will be assessed by child behavior checklists at and beyond 2 years of age. Maternal stool, milk, skin and vaginal swabs, infant stool, and skin swabs will be collected at enrolment and at follow-up visits. For the primary outcome, the trajectory of the infant intestinal microbiota will be characterized by 16S and metagenomic sequencing regarding composition, metabolic potential, and stability during the first 2 years of life. Secondary outcomes will assess the cellular and chemical composition of maternal milk, the impact of nutrition and environment on microbiota development, the maternal microbiome transfer at vaginal or caesarean birth and thereafter on the infant, and correlate parameters of microbiota and maternal milk on infant growth, development, health, and mental well-being. DISCUSSION The Bern birth cohort study will provide a detailed description and normal ranges of the trajectory of microbiota maturation in a high-resource setting. These data will be compared to data from low-resource settings such as from the Zimbabwe-College of Health-Sciences-Birth-Cohort study. Prospective bio-sampling and data collection will allow studying the association of the microbiota with common childhood conditions concerning allergies, obesity, neuro-developmental outcomes , and behaviour. Trial registration The trial has been registered at www. CLINICALTRIALS gov , Identifier: NCT04447742

Herramientas para el monitoreo y sistema de alerta de floraciones de cianobacterias nocivas: Río Uruguay y Río de la Plata = Monitoring tools and early warning system for harmful cyanobacterial blooms: Río Uruguay and Río de la Plata

Las floraciones de cianobacterias potencialmente tóxicas es uno de los problemas más difundidos en los sistemas acuáticos a nivel global. Sin embargo, no existen programas de monitoreo sensibles y directamente aplicables a la predicción de las floraciones y su gestión. Con este objetivo se combinaron conceptos ecológicos y genéticos para generar herramientas para el monitoreo de cianobacterias. Se utilizaron dos aproximaciones: agrupación de organismos en grupos funcionales basados en morfología y análisis moleculares (PCR cuantitativo en tiempo real) que indican presencia de genes que codifican para la expresión de cianotoxinas (mcy). Para evaluar las herramientas se realizaron seis campañas de muestreo bimensuales (2013-2014) en seis estaciones con dos sitios en cada una, a lo largo del Río Uruguay y del Estuario Río de la Plata, desde Salto Grande hasta Punta del Este. Se observó un gradiente marcado en las variables meteorológicas, físico-químicas, y mayores abundancias de organismos planctónicos en Salto Grande y Punta del Este. Se encontró la presencia en todo el gradiente de poblaciones tóxicas, con mayor abundancia en Salto, particularmente del complejo Microcystis aeruginosa (CMA). Las variables ambientales más importantes en determinar el gradiente ambiental y las variaciones en las variables biológicas fueron la salinidad, la temperatura, el viento y la turbidez. Los resultados de los nuevos indicadores (presencia en red del CMA y genes mcy) coincidieron con los tradicionales (ej. clorofila-a) en los casos de floraciones más severas, y ambos fueron sustantivamente más sensibles en situaciones de bajas abundancias. La conjunción de los resultados se aplicó a la construcción de un protocolo de monitoreo y un sistema de alerta

Update on worldwide regulations for mycotoxins. The Mercosur harmonization of limits on mycotoxins with the international regulations

Mycotoxins have been defined as "fungal metabolites which, when ingested, inhaled or absorbed through the skin, cause lowered performance, sickness or death in man or animals, including birds"( Pitt, 1996). The ability of some mycotoxins to compromise the immune system and, consequently, to reduce resistance to infectious disease, is widely considered to be their most important effect. The mycotoxins attract worldwide attention because of the significant economic losses associated with their impact on human health, animal production and both domestic and international trade. Those mycotoxins that are currently considered to be worldwide  importance are aflatoxins, trichothecenes, zearalenone, fumonisins, ochratoxin A, patulin (Coker, 2000). Mycotoxins can contaminate raw agricultural products before and or after harvest. As these commodities are subsequently incorporated into food and feed, concern exits regarding the fate of these toxins undergoing certain processes  and the possible concentration of mycotoxins or their derivatives in the end product. (Task Force Report N°139, 2003). The knowledge that mycotoxins can have serious effects on humans and animals has led many countries to establish regulations on mycotoxins in food and feed in the last decades to safeguard the health of humans, as well as the economical interests of producers and traders. In 2002, an international inquiry on mycotoxins was initiated by the National Institute for Public Health and the Environment. Data received were sorted by country and by economic community (Australia/New Zealand, EU, MERCOSUR). In addition, information was included about standards set by Codex Alimentarius. The available data were classified into the categories food, dairy and feed and then tabulated in alphabetic order of the countries. On a worldwide basis, at least 99 countries had mycotoxin regulations for food and/or feed in 2003, an increase of approximately 30 percent compared to 1995. The total population in these countries represents approximately 87 percent of the worlds inhabitants.  In 1995, 23 percent of the world's inhabitants were living in a region where no known mycotoxin regulations were in force. This percentage had decreased to 13 percent in 2003, due to a slight increase in coverage in Latin America and Europe, and more significant increases in Africa and Asia/Oceania. Comparing the situation in 1995 and 2003, it appears that in 2003 more mycotoxins are regulated in more commodities and products, whereas tolerance limits generally remain the same or tend to decrease. Regulations have become more diverse and detailed with newer requirements regarding official procedures for sampling and analytical methodology. At the same time, several regulations have been harmonized between countries belonging to economic communities (Australia/New Zealand, EU, MERCOSUR). In 2003, the number of countries that had specific regulations for mycotoxins in foodstuffs was significantly more than those that had specific regulations for feedstuffs. Chronic toxicity studies carried out under good laboratory practice conditions are time consuming, very expensive and not necessarily bound to certain regions. These studies should be carried out in internationally recognized centres of excellence and their results evaluated by international groups of experts such as JECFA. ( FAO, Food and Nutrition Paper 81, 2004

Update on worldwide regulations for mycotoxins. The Mercosur harmonization of limits on mycotoxins with the international regulations

Mycotoxins have been defined as "fungal metabolites which, when ingested, inhaled or absorbed through the skin, cause lowered performance, sickness or death in man or animals, including birds"( Pitt, 1996). The ability of some mycotoxins to compromise the immune system and, consequently, to reduce resistance to infectious disease, is widely considered to be their most important effect. The mycotoxins attract worldwide attention because of the significant economic losses associated with their impact on human health, animal production and both domestic and international trade. Those mycotoxins that are currently considered to be worldwide  importance are aflatoxins, trichothecenes, zearalenone, fumonisins, ochratoxin A, patulin (Coker, 2000). Mycotoxins can contaminate raw agricultural products before and or after harvest. As these commodities are subsequently incorporated into food and feed, concern exits regarding the fate of these toxins undergoing certain processes  and the possible concentration of mycotoxins or their derivatives in the end product. (Task Force Report N°139, 2003). The knowledge that mycotoxins can have serious effects on humans and animals has led many countries to establish regulations on mycotoxins in food and feed in the last decades to safeguard the health of humans, as well as the economical interests of producers and traders. In 2002, an international inquiry on mycotoxins was initiated by the National Institute for Public Health and the Environment. Data received were sorted by country and by economic community (Australia/New Zealand, EU, MERCOSUR). In addition, information was included about standards set by Codex Alimentarius. The available data were classified into the categories food, dairy and feed and then tabulated in alphabetic order of the countries. On a worldwide basis, at least 99 countries had mycotoxin regulations for food and/or feed in 2003, an increase of approximately 30 percent compared to 1995. The total population in these countries represents approximately 87 percent of the worlds inhabitants.  In 1995, 23 percent of the world's inhabitants were living in a region where no known mycotoxin regulations were in force. This percentage had decreased to 13 percent in 2003, due to a slight increase in coverage in Latin America and Europe, and more significant increases in Africa and Asia/Oceania. Comparing the situation in 1995 and 2003, it appears that in 2003 more mycotoxins are regulated in more commodities and products, whereas tolerance limits generally remain the same or tend to decrease. Regulations have become more diverse and detailed with newer requirements regarding official procedures for sampling and analytical methodology. At the same time, several regulations have been harmonized between countries belonging to economic communities (Australia/New Zealand, EU, MERCOSUR). In 2003, the number of countries that had specific regulations for mycotoxins in foodstuffs was significantly more than those that had specific regulations for feedstuffs. Chronic toxicity studies carried out under good laboratory practice conditions are time consuming, very expensive and not necessarily bound to certain regions. These studies should be carried out in internationally recognized centres of excellence and their results evaluated by international groups of experts such as JECFA. ( FAO, Food and Nutrition Paper 81, 2004

Latinamerican, Mercosur and imported countries regulations

Mycotoxins attract worldwide attention because of the significant economic losses associated with their impact on human health, animal production and both domestic and international trade. Those mycotoxins that are currently considered to be worldwide  importance are aflatoxins, trichothecenes, zearalenone, fumonisins, ochratoxin A, patulin (Coker, 2000). The knowledge that mycotoxins can have serious effects on humans and animals has led many countries to establish regulations on mycotoxins in food and feed in the last decades to safeguard the health of humans, as well as the economical interests of producers and traders. Setting mycotoxin regulations is a complex activity which involves many factors and interested parties. In 1995, 23 percent of the world's inhabitants were living in a region where no known mycotoxin regulations were in force. This percentage had decreased to 13 percent in 2003, due to a slight increase in coverage in Latin America and Europe, and more significant increases in Africa and Asia/Oceania.The major Latin American agricultural crops (maize, wheat, coffee, cotton, soybeans, barley, sunflower, groundnuts and tree nuts, cocoa and dairy products) are highly susceptible to fungal contamination and mycotoxin production (Pineiro, 2004). Nineteen countries, accounting for 91 percent of the population of the region, were known to have specific mycotoxin regulations. Uruguay has the most detailed regulations, including limits for ergot alkaloids in feeds, which is rather unique in the mycotoxin regulatory world. The same for deoxynivalenol in wheat products and barley products.MERCOSUR consists of Argentina, Brazil, Paraguay and Uruguay. These countries apply common limits for total aflatoxins in peanuts, maize and products thereof, and for aflatoxin M1 in fluid and powdered milk. The MERCOSUR regulations for mycotoxins also include official methods of sampling and analysis. In Europe, approximately 99 percent of the continent's population, were known to have specific mycotoxin regulations in 2003.Compared to other regions of the world, Europe has the most extensive and detailed regulations for mycotoxins in food. It is of interest to note that many of the EU candidate member countries have mycotoxin regulations, which are often more detailed than those currently in force in the EU. Comparing the situation in 1995 and 2003, it appears that in 2003 more mycotoxins are regulated in more commodities and products, whereas tolerance limits generally remain the same or tend to decrease.Whereas harmonized tolerance limits would be beneficial from the point of view of trade, this would not necessarily be the case from the point of view of (equal) human health protection around the world. Risks associated with mycotoxins depend on both hazard and exposure. The hazard of mycotoxins to individuals is probably more or less the same all over the world .Exposure is not the same because of differences in levels of contamination and dietary habits in various parts of the world. National governments or regional communities should encourage and fund activities that contribute to reliable exposure assessment of mycotoxins in their regions.(FAO Food and Nutrition paper 81

Relationship between the level of deoxynivalenol contamination in wheat and the fungal infection

Fusarium spp invades grain commodities in the field and during storage in Uruguay and produces Deoxynivalenol  as the main toxin.The Department of Natural Toxins of Technological Laboratory of Uruguay, as partner in the Project titled " The Development of a Food Quality Management System for the Control of Mycotoxins in Cereal Production and Proccesing Chains in Latin America South Cone Countries", INCO Project ICA4-CT-2002-10043 participates in two workpackages (WP). WP1 related to the development and standarisation of effective analytical tools for mycotoxin determination in cereal and by- products and WP4 related to hazard analysis on mycotoxins.Once DON results were obtained, the objective of this work was to evaluate a possible relationship between the level of deoxynivalenol contamination in wheat and the fungi infection.To reach the objective nine samples corresponding to four different levels of DON contamination were selected as representative of the 87 samples. One sample of 1379 ppb (Group A), four samples of 2536 ppb average (Group B), one sample of 7349 ppb (Group C) and three samples of 20076 ppb average (Group D) were used for the study. The water activity (aw) was measured previous DON content analysis and fungi contamination determination. The values recorded were lower than 0,7.The grains, before and after treatment with sodium hipocloride solution 5%, were placed in duplicate Petri dishes containing yeast glucose cloramphenicol agar (YGCA), twenty grains without treatment and fourty grains treated per dish. The colonies grown were isolated in potato dextrose agar (PDA) and malt extract agar (MEA) tubes. Cultures on Czapek Agar were made. Petri dishes and tubes were incubated at 25 ± 1 °C, 4 to 7 days. Cultures on Cazapek Agar were observed under microscope every 24 hours.After sodium hipocloride treatment Fusarium, Penicillium and Alternaria spp were found. The results obtained showed that Fusarium spp colonies were isolated from five samples: one of group A corresponding to three isolates, two of group B corresponding to two and three isolates and two of group D corresponding to five and eight isolates. Penicillium was recovered from three samples; one of group B corresponding to one isolate, one of group C corresponding to two isolate and one of  group D corresponding to two isolates.Alternaria spp was present in similar quantity of isolates, fifteen average, it didn´t matter the level of DON contamination except for group D, in which the number of isolates was lower than expected (seven). Without sodium hipocloride treatment too many species growed. Because of this Fusarium spp could not be recovered. The only species easily viewed and isolated was Aspergillus spp found in three samples. Aspergillus flavus colonies were isolated from one sample of group A corresponding to two isolates and one sample of group B corresponding to one isolate. Aspergillus niger colonies were isolated from two samples of group B corresponding to three and one isolates.The study focused in Fusarium contamination. Nevertheless other species of interest such as Penicillium, Alternaria and Aspergillus spp were isolated. Fusarium spp isolates apparently increased as the DON content became higher. This study should be continued analysing more samples of similar levels. Interaction between Fusarium , Penicillium, Alternaria and Aspergillus could be also studied

Study of clean up procedures using Charcoal-Alumina-Celite column, immunoaffinity column and strata x column to determine deoxynivalenol by high performance liquid chromatography in wheat

Fusarium graminearum is the most common toxic fungal species affecting grains in Uruguay. Since 1977, due to favorable climate conditions, there have been harvests with prominent Fusarium Head Blight in wheat. This were in 1984, 1990, 1993, 1996 and 2001.Natural Toxin Department of Technological Laboratory of Uruguay as National Reference Laboratory, is continuously improving the analytical methods in order to have a good response to the industry requirements and to the monitoring programs for import and exports commodities. The objective of this work was to compare different clean up methods in order to select the best one for routine determination of deoxynivalenol (DON) in wheat (grain and flour).  Charcoal-alumina-celite (7+5+3),  immunoaffinity columns DONPREP R-Biopharm Rhone and Strata X 33 m polymeric sorbent  Phenomenex columns were used to perform the study. Considering as reference analytical method the internal protocol  PEC.TOX.063 accredited by United Kingdom Accreditation Service (UKAS)  following the ISO 17025 requirements, and  based on AOAC method 986.17( chapter 49, 2002) for extraction and clean-up  and on J.AOAC 70(3), 1987:479-483 for the high performance liquid chromatography (HPLC) detection, two more clean up methods were evaluated. In all of them PEC.TOX.063 detection procedure was carried out. PEC.TOX.063 used for the clean up an in house column chromatography prepared with charcoal-alumina-celite (7+5+3) . Extraction was performed using acetonitrile- water (84+16) and an aliquot of the extract was passed through the column. Extract was dryed under vacuum and DON detected by HPLC using photodiode array detector. For the method that used immunoaffinity columns, water was the extraction solvent, and manufacture protocol was followed up. An aliquot of the extract was passed through the column. Column was washed using water and DON eluated using methanol 100%. For the method that used Strata X column for the clean up, the extraction solvent was acetonitrile- water (84+16). Column was conditioned with methanol 100% and water. Prior to pass an aliquot of the extract through the column it was necessary to reduce the acetonitrile to 10% using vacuum. Column was washed using methanol 15 %, and DON eluated using methanol 100%. An internal reference flour material (2010  g/kg) was analysed following the three procedures. For PEC.TOX.063 the historical recovery percentage of 91% was maintained, for immunoaffinity column protocol 84 % average was obtained, and for Strata X column 101% was obtained. Chromatograms and spectrums showed appropriated results. As the recoveries were acceptable it was decided to start with wheat samples analysis. Taking approval of the reference material and the IAC, the reuse of the columns was also estimated. Columns were regenerated with phosphate buffer solution (PBS) and storage in the fridge for 24 hours. At least three uses were undertaken with accepted recovery results (91, 69 and 104%) respectively. A total of 21 samples including wheat and reference internal material were analysed following PEC.TOX.063 (charcoal-alumina-celite) and immunoaffinity column method (first, second and third use) . Nine samples from the 21 were also analysed using Strata X columns. PEC.TOX 063 and the immunoaffinity method showed appropriate chromatograms. This didn't occur with Strata X columns method. Chromatograms presented interferences at DON retention time. Due to chromatograms and results obtained no more samples were passed through Strata X columns. As conclusion charcoal-alumina-celite (7+5+3), as well as immunoaffinity column would be a good option to analysed wheat samples by HPLC. For the Strata X Phenomenex columns more studies need to be done in order to optimize the elution solvent

Monitoreo de floraciones algales en el Río Negro, Uruguay

En este trabajo se presentan los resultados del monitoreo de uno de los sistemas lóticos que viene desarrollando el Departamento de Medio Ambiente del LATU. El Río Negro es el principal afluente del Río Uruguay, atraviesa al país en su zona media y pertenece a la cuenca del Plata. Sobre él se han construido tres importantes represas hidroeléctricas con el objetivo de satisfacer las demandas eléctricas del país. El monitoreo consiste en evaluaciones de calidad ambiental que incluye parámetros físico-químicos en agua, sedimentos y comunidades biológicas en dos tramos aguas abajo de la represa de Rincón de Bonete y de la Represa de Baygorria. En él se incluye el seguimiento de las Floraciones Algales Nocivas (FAN)