The development of a virtual learning environment in genetic syndromes

Objetivo: desenvolver um ambiente virtual de aprendizagem (AVA) para alunos do ensino \ud fundamental sobre síndromes genéticas. Método: o AVA, conhecido como Cybertutor, possibilita o \ud aprendizado do aluno pela internet de forma interativa. A metodologia deste estudo foi composta de \ud duas etapas, a de desenvolvimento e a de disponibilização do AVA. O desenvolvimento do conteúdo \ud educacional, gráfico e audiovisual do Cybertutor contou com o auxílio de um geneticista do HRAC/\ud USP e de informações científicas disponibilizadas em livros, artigos, teses e dissertações nacionais \ud e internacionais. O Cybertutor foi disponibilizado na plataforma do Projeto Jovem Doutor (http://www.\ud jovemdoutor.org.br/jdr/) pela equipe técnica da DTM/FMUSP. Resultados: o Cybertutor elaborado\ud possibilitou estruturar o conteúdo educacional, gráfico e audiovisual em tópicos, inserir questões de \ud reforço, lista de discussão e verificar o desempenho dos alunos. Conclusão: o AVA desenvolvido \ud pode ser uma importante ferramenta de educação em saúde em Síndromes Genéticas, abrangendo \ud as mais diversas regiões do país.Purpose: to develop a virtual learning environment (VLE) for elementary school students about \ud genetic syndromes. Method: VLE, known as Cybertutor enables student learning through the Internet \ud interactively. The methodology of this study consisted of two stages, the development and availability \ud of the VLE. The development of educational content, graphic and audiovisual Cybertutor’s counted \ud on the help of a geneticist at the HRAC/USP and scientific information available in books, articles, \ud thesis and national and international dissertations. The Cybertutor was available on the platform of \ud the Young Doctor Project (http://www.jovemdoutor.org.br/jdr/) by the technical staff of DTM/FMUSP. \ud Results: elaborated Cybertutor enabled the structure of educational content, graphics and audiovisual \ud topics, to insert reinforcing issues, mailing list and check the performance of students. Conclusion:\ud the VLE developed can be an important tool for health education in Genetic Syndromes, covering \ud various regions of the country.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Fetal alcohol spectrum disorders and communication abilities: family case report

Este estudo teve como objetivo caracterizar o perfil de habilidades comunicativas de cinco irmãos com Desordens do Espectro Alcoólico Fetal. O diagnóstico de Desordens do Espectro Alcoólico Fetal foi realizado a partir do histórico gestacional positivo para álcool e identificação de sinais clínicos. A avaliação fonoaudiológica constou da Observação do Comportamento Comunicativo, Escala de Desenvolvimento Comportamental de Gesell e Amatruda, Teste de Vocabulário por Imagens Peabody e avaliação audiológica. Todos os participantes apresentaram alterações nos comportamentos motor grosso, motor delicado, adaptativo, pessoal-social e de linguagem em graus variados. As habilidades comunicativas estavam comprometidas para todos os participantes e S4 apresentava comportamentos autísticos. As Desordens do Espectro Alcoólico Fetal foram confirmadas em S1, S2 e S5 e o diagnóstico de Síndrome Alcoólica Fetal foi confirmado para S3 e S4. Os resultados apresentaram variabilidade no desenvolvimento das habilidades de desenvolvimento dos irmãos com as Desordens do Espectro Alcoólico Fetal. A variabilidade dos achados, principalmente nas habilidades comunicativas e comportamentais, sugere a necessidade de acompanhar crianças com histórico de uso de álcool pela mãe, visto o impacto destas desordens no desenvolvimento global destes indivíduos, com impacto nas atividades de vida diária e escolaridade.The present study had the aim to characterize the communicative abilities profile of five siblings with Fetal Alcohol Spectrum Disorders. This diagnosis was carried out based on the positive report of prenatal alcohol exposure and identification of clinical signs. The Speech-Language Pathology evaluation consisted of the Communicative Behavior Observation, the Behavioral Development Scale of Gesell and Amatruda, the Peabody Picture Vocabulary Test, and hearing evaluation. Participants presented various degrees of alterations in gross motor, fine motor, adaptative, personal-social and language behaviors. The communicative abilities were altered for all the participants, and S4 presented autistic behaviors. Fetal Alcohol Spectrum Disorders were confirmed in S1, S2 and S5 and the diagnosis of Fetal Alcohol Syndrome was confirmed for S3 and S4. The results showed variability in the development of the studied abilities among the siblings with Fetal Alcohol Spectrum Disorders. The variability of the findings, especially in communicative abilities and behavior, suggests the need to follow-up children with reports of alcohol use by the mother, considering the impact of these disorders on these individuals' global development, including daily life activities and schooling

Attention deficit hyperactivity disorder in patients with velocardiofacial/del 22q11.2 syndrome

Objective: To investigate a frequency Attention Deficit Hyperactivity Disorder in children and adolescents with 22q11 deletion syndrome. Design/participants: 13 individuals, being 8 females and 5 males, aged 6 to 18 years, diagnosed with 22q11 deletion syndrome. The 13 subjects in the sample, 07 (54%) of patients had cleft palate or cleft Occult and 06 (46%), Velopharyngeal insufficiency (VPI). Setting: Instruments: (I) the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL) - Brazilian version (Brasil 2003) with semi-structured questions to identify affective disorders in the age range 6 to 18 years; and (II) Raven’s Progressive Matrices Test (1999) for 5 to 11 years, Progressive Matrices Test, General Scale Series, A, B, C, D and E, (Raven 2003), for Brazilian individuals aged more than 11 years. Results: Assess the Behavioral Phenotype (FC) in genetic syndromes becomes important, to the symptoms of Attention Deficit Disorder / Hyperactivity, 10 (77%) subjects punctuated, indicating research on ADHD Supplement analysis. Three (23%) of the subjects were classified as having Attention Deficit Disorder Hyperactivity (with a predominance of type inattentive), being a teenager and two female children, a son, who also had Oppositional Defiant Disorder. Conclusions: Subjects diagnosed with the syndrome should be investigated in childhood, because they may present signs of symptoms as Attention Deficit Hyperactivity Disorder and which may be parallel or associated to comorbidities. The treatment should be initiated as early as possible because of the possible evaluation to more severe mental health disorders

Acro-cardio-facial syndrome

Acro-cardio-facial syndrome (ACFS) is a rare genetic disorder characterized by split-hand/split-foot malformation (SHFM), facial anomalies, cleft lip/palate, congenital heart defect (CHD), genital anomalies, and mental retardation. Up to now, 9 patients have been described, and most of the reported cases were not surviving the first days or months of age. The spectrum of defects occurring in ACFS is wide, and both interindividual variability and clinical differences among sibs have been reported. The diagnosis is based on clinical criteria, since the genetic mechanism underlying ACFS is still unknown. The differential diagnosis includes other disorders with ectrodactyly, and clefting conditions associated with genital anomalies and heart defects. An autosomal recessive pattern of inheritance has been suggested, based on parental consanguinity and disease's recurrence in sibs in some families. The more appropriate recurrence risk of transmitting the disease for the parents of an affected child seems to be up to one in four. Management of affected patients includes treatment of cardiac, respiratory, and feeding problems by neonatal pediatricians and other specialists. Prognosis of ACFS is poor

Oral cleft prevention programa (OCPP)

Background: Oral clefts are one of the most common birth defects with significant medical, psychosocial, and economic ramifications. Oral clefts have a complex etiology with genetic and environmental risk factors. There are suggestive results for decreased risks of cleft occurrence and recurrence with folic acid supplements taken at preconception and during pregnancy with a stronger evidence for higher than lower doses in preventing recurrence. Yet previous studies have suffered from considerable design limitations particularly non-randomization into treatment. There is also well-documented effectiveness for folic acid in preventing neural tube defect occurrence at 0.4 mg and recurrence with 4 mg. Given the substantial burden of clefting on the individual and the family and the supportive data for the effectiveness of folic acid supplementation as well as its low cost, a randomized clinical trial of the effectiveness of high versus low dose folic acid for prevention of cleft recurrence is warranted. Methods/design: This study will assess the effect of 4 mg and 0.4 mg doses of folic acid, taken on a daily basis during preconception and up to 3 months of pregnancy by women who are at risk of having a child with nonsyndromic cleft lip with/without palate (NSCL/P), on the recurrence of NSCL/P. The total sample will include about 6,000 women (that either have NSCL/P or that have at least one child with NSCL/P) randomly assigned to the 4 mg and the 0.4 mg folic acid study groups. The study will also compare the recurrence rates of NSCL/P in the total sample of subjects, as well as the two study groups (4mg, 0.4 mg) to that of a historical control group. The study has been approved by IRBs (ethics committees) of all involved sites. Results will be disseminated through publications and presentations at scientific meetings. Discussion: The costs related to oral clefts are high, including long term psychological and socio-economic effects. This study provides an opportunity for huge savings in not only money but the overall quality of life. This may help establish more specific clinical guidelines for oral cleft prevention so that the intervention can be better tailored for at-risk women

Influência de diferentes intervalos de processamento de milho doce sobre características quantitativas e qualitativas

Sweet corn differs from common corn due to its lower concentrations of starch in relation to the sucrose in its endosperm, a characteristic that gives cultivars in this segment a unique sweet taste for this vegetable species. Because of this product’s high perishability, the interval between harvest and processing is recommended to be as short as possible so as to preserve both its quantitative and qualitative characteristics. The objective of this study was to observe the effects on the quantity and quality of sweet corn when it is harvested and subjected to late processing, i.e., periods that are not recommended. A randomized block design with five replications was adopted for the experiment. The following intervals were chosen for processing the ears of corn: 0, 4, 8, 12, 16, 20 and 24 hours after harvest. Characteristics such as the fresh weight of the ear with and without the husk, of only the cob, and of only the kernels from processing as well as the industrial yield were noted. The sample’s moisture, soluble solids content, titratable acidity, and sucrose and reducing sugar content were also evaluated. No quantitative gains or losses were verified during the postharvest storage and pre-processing periods for the ears of sweet corn. Depending on the interval before processing there was a 15.6% reduction in the concentration of soluble solids.O milho doce se diferencia do milho comum devido a menores concentrações de amido em relação à sacarose em seu endosperma, característica essa que confere a cultivares deste segmento um sabor adocicado único para essa espécie vegetal. Devido à alta perecibilidade deste produto, recomenda-se que o intervalo entre a colheita e seu processamento seja o menor possível, a fim de preservar tanto características quantitativas como as de ordem qualitativa. Portanto, objetivou-se com esse trabalho estudar os efeitos ocorridos em ordem quantitativa e qualitativa em milho doce quando este é colhido e submetido ao processamento tardio, ou seja, em períodos não recomendados. O experimento foi conduzido em delineamento experimental de blocos ao acaso, com cinco repetições. Adotou-se como períodos de processamento das espigas 0, 4, 8, 12, 16, 20 e 24 horas após a colheita. Características como peso fresco da espiga com palha, sem palha, somente do sabugo e somente dos grãos oriundos do processamento foram anotados bem como seu rendimento industrial. Também foram avaliados a umidade da amostra, teor de sólidos solúveis, acidez titulável, teor de sacarose e de açúcares redutores. Durante os períodos de armazenamento pós-colheita e pré-processamento das espigas de milho doce não foi verificado ganhos ou perdas em caráter quantitativo. Verificou-se uma redução de 15,6% na concentração de sólidos solúveis, em função do período de processamento

Waardenburg Syndrome: Clinical Differentiation Between Types I and II

Here we present the results of a study performed on 59 patients affected by Waardenburg syndrome (WS), 30 with the I variant, 21 having the type II, and 8 of them being isolated cases without telecanthus. These patients belong to 37 families; the main contributions and conclusions are based on the detailed study of 25 of these families, examined using standard procedures. All patients were examined as to the presence of eight cardinal signs important for the diagnosis of the condition; from each patient, from many of his/her normal relatives, and from a control sample of 300 normal individuals stratified by age and sex, 23 different craniofacial measurements were obtained. We also estimated, using our own data as well those collected from the literature, the frequencies of the cardinal signs, based on a total sample of 461 affected individuals with WSI and 121 with WSII. In order to originate discriminant functions to separate individuals affected by one of the two variants, both metric (from craniofacial measurements) as well as categoric data (based on the frequencies of the cardinal signs or symptoms) were used. Discriminant analysis based on the frequency of the eight cardinal signs can improve the separation of WSI patients without telecanthus from those presenting the variant II. We present also a Table with the conditional probabilities favoring the diagnosis of WSI for suspect subjects without telecanthus and any combination of the other seven signs/symptoms. The discriminant function based on the four ocular measurements (inner and outer intercanthal, interpupillary, and inferior lacrymal distances), on the other side, perfectly classifies patients affected by one of the variants of WS, the same taking place when the average values of the W index of all affected individuals per family are used. The discriminant function based solely in the individual W index values of patients correctly classifies 93% of WSII subjects, but only 60% of the patients with the I variant of WS. ß 2003 Wiley-Liss, Inc. KEY WORDS: Waardenburg syndrome; genetic heterogeneity; discriminant analysis INTRODUCTION The Waardenburg syndrome (WS), first comprehensively described in 1951, is a genetically heterogeneous condition, each of its forms having a wide clinical spectrum with a very high degree of phenotypic expressivity. In the present paper, we will consider only the two most frequent variants (WSI and WSII) out of the four described so far. These two forms, together accounting for a prevalence of 2 to 3 affected individuals/100,000 in the general population, are determined by non-allelic autosomal dominant mutant genes with a high penetrance. WS is characterized clinically by the association of craniofacial dysmorphim, pigmentation defects, and severe sensorineural congenital hearing impairment. The craniofacial dysmorphisms most commonly seen in affected individuals include telecanthus (in WSI only), broad and high nasal root, hypoplasia of the alae nasi, lower lacrimal dystopia, and synophrys. Telecanthus (dystopia canthorum lateroversa) is classically described as an increase of inner ocular intercantal distance (IID) with preservation of both interpupillary (IPD) and outer intercantal (OID) distances. WS patients with this sign, however, commonly present larger values of the other two measurements, so that they exhibit a certain degree of hypertelorism. Patients frequently display conspicuous pigmentary defects of the irides (totally or partially heterochromic and bright hypochromic blue irides), hypopigmented skin spots, and partial hair albinism (white forelock or early graying). The first variant (WSI), with telecanthus, is caused by mutations at the PAX3 gene located in 2q35, while the second (WSII) is determined by other non-allelic autosomal dominant mutations located in the region 3p12.3 ! 3p14.1 of the MITF gene. Many of these are point mutations involving single-base substitutions and the number of different mutations described so far for both loci is so large that the molecular screening for them in WS can not be routinely performed in most laboratories. Because of all this, the differential diagnosis between variants I and II still relies largely on classic clinical methods. Clinical signs and symptoms are similar in both conditions, but telecanthus is known to occur only in WSI; the other characteristics have contrasting frequencies in both forms, especially iris and hair pigmentary disturbances and deafness. The penetrance of the last trait is higher in the second variant of WS, which has therefore a poorer clinical prognosis. Telecanthus (sometimes hypertelorism) is the most important sign for the differentiation between both forms, because it is present in the vast majority (95-99%) of WSI patients and virtually absent in those with the WSII variant. The presence of conspicuous craniofacial dysmorphisms in WS explains why the condition has been widely studied anthropometrically. The first of these studies was performed on Waardenburg's original data by Since the penetrance of the telecanthus trait and consequently the efficiency of the W index-although generally high-are both incomplete In this paper, we describe 59 individuals affected by the Waardenburg syndromes WSI and WSII, belonging to 25 Brazilian families. A detailed craniofacial phenotypic description of all affected individuals is presented, as well as the values of several measurements taken in these patients. The relative frequencies of cardinal signs and the values of craniofacial measurements are used to compare, through discriminant analysis, WSI and WSII affected individuals. MATERIALS AND METHODS Out of the 25 families studied personally, 18 were ascertained in the Laboratory of Human Genetics (LGH, Departamento de Biologia, IB USP, São Paulo) and seven were examined at the Hospital de Reabilitação de Anomalias Cranio-Faciais (HRAC, Faculdade de Odontologia, USP, Bauru). For this, we used a standardized routine for physical examination that included the investigation, in all affected individuals (with the exception of a few instances in which one measurement could not be recorded and the corresponding feature could not be evaluated objectively), of the following eight cardinal signs and symptoms of WS: telecanthus, synophrys, iris pigmentation disturbances, localized albinism on hair (white forelock and early graying), hearing impairment, nasal root hyperplasia, hypopigmented skin spots, and lower lacrimal dystopia. We selected also, through review of the international literature, 44 different papers published from 1951 to 1995 with complete clinical presentation of cases of WS Waardenburg Syndrome 225 non-mentioned characteristic was absent, the estimate for its frequency is given by under the hypothesis (b) that the non-mentioned sign/ symptom was not investigated, its frequency estimate is given by x 00 ¼ X/(X þ Y) ¼ X/(N À Z), with expected binomial variance var(x 00 ) ¼ x 00 (1 À x 00 )/(N À Z). Obviously, the true estimate of the frequency is given by an unknown quantity within an interval with lower und upper limits given by x 0 and x 00 . If there is no additional information enabling us to choose one out of the two hypotheses above, an estimate of the true frequency x can be obtained by weighing the estimates x 0 and x 00 by the reciprocal of their expected binomial variances. This estimate will be used throughout this work to contrast the frequencies of the cardinal signs in a sample of WSI and WSII patients combining our data with those from the literature. We also determined-in random samples of Caucasian individuals stratified by sex and age (total of 300 individuals) and in affected individuals and in their relatives belonging to ten of our 25 families-23 different craniofacial measurements of interest in the diagnosis of WS. Some of these measurements were used for comparing controls and patients as well as types I and II of WS. 226 Pardono et al. We have classified as WSI all the patients, familial or isolated, that presented conspicuous telecanthus. In order to classify as WSI a case of WS without telecanthus, this affected individual should always belong to a family with at least one typical case of WSI (with telecanthus). Therefore, all cases of WSI without telecanthus presented here are familial, whereas all isolated cases of WS classified as WSI present with the sign. Inversely, all cases of WS classified as WSII are necessarily familial, that is, they belong strictly to families with at least one more affected individual, none of them presenting telecanthus. In the cases selected from literature, we applied the same classification criteria, systematically disregarding the classification of isolated cases of WS without telecanthus as being WSII. In the presentation of our cases in the Results and Discussion section, all isolated WS patients without telecanthus were grouped in a group labelled as WSII?, but their data were not used in the statistical analyses described below. For the study of cardinal characteristics, the application of the above-mentioned stringent criteria to the cases from literature enabled us to consider a total of 461 WSI patients (29 of them not presenting telecanthus) and 121 carriers of the WSII variant. With the addition of our own data to those from the literature, the discriminant analysis performed with categorical data was based, therefore, on totals of 491 WSI and 142 WSII patients, respectively. The techniques of statistical analysis used throughout this paper are detailed in standard textbooks (e.g., Zar [1999]). Those on linear and non-linear discriminant analysis in particular are detailed in Smith [1947, 1969], Penrose [1947], and Karn and Penrose [1951]. RESULTS AND DISCUSSION Description of Cases Using a modification of the genealogy symbols proposed by Discriminant Analysis Using the Frequencies of Cardinal Signs and Symptoms The estimated frequencies of the eight cardinal characteristics of WS were calculated from reliable case descriptions in the literature and are shown in Waardenburg Syndrome 227 Comparing the observed frequencies of each sign in the groups of WSI and WSII patients through chisquared tests in 2 Â 2 contingency tables, we obtained in all cases test figures that were significant at least at the 1% level. The elements necessary for performing a simplified categoric discriminant analysis, together with an application example, are summarized in Since there are only seven other possible signs besides telecanthus, all the possible combinations of these seven signs/symptoms (presence or absence) reduce to 2 7 ¼ 128. 38 out of these 128 combinations generate probability figures larger than 95% or less than 5% favoring the diagnosis of WSI and are shown in We could obtain, combining our data with those from the literature, complete individual phenotypic descriptions of 111 patients affected by WSII out of the 142 used for deriving the probabilities shown in Discriminant Analysis Based on Craniofacial Measurements First we compared the craniofacial measurements between WSI and WSII patients, and between WS patients and controls through t tests with allowance for variance heterogeneity. Using as selection criterion all variables that were statistically different between any of the two comparison groups at least at the 0.001 significance level, we chose the following variables to be used on discriminant analysis: inner intercanthal distance (IID); outer intercanthal distance (OID); interpupillary distance (IPD); lower interlacrimal distance (LID); nose interalar distance (IAD); mean length of ear (EML), obtained by averaging the longitudinal length of both auricles; and the W index (WI), a composite measure used in the literature for separating WSI and WSII patients and described in the introduction section. We decided to also include the variables facial length or morphological face height (MFH) and the mean width of ear (EMW), a measurement obtained by averaging the transversal length of both auricles. These two measurements, in spite of not showing statistical significance at the 0.001 level, exhibited differences at a critical level much less than 0.01. The statistical parameters of these nine measurements, estimated in the groups of WSI and WSII patients and controls, are shown i