Victor Evangelista de Faria Ferraz

Mucopolysaccharidoses in Brazil: what happens from birth to biochemical diagnosis?

Mucopolysaccharidoses (MPS) form a group of inherited metabolic disorders characterized by intralysosomal storage of glycosaminoglycans. This study aimed to investigate the path followed by Brazilian patients from birth to diagnosis. An interview was conducted with patients parents or guardians with subsequent review of patients medical records. One hundred thirteen patients with MPS were included (MPS I: 18, MPS II: 43, MPS IIIA: 2, MPS IIIB: 3, MPS IIIC: 1, MPS IVA: 15, MPS IVB: 1, MPS VI: 29, MPS VII: 1) from 97 families. Median age at the onset of signs/symptoms was 18 months (MPS I: 18, MPS II: 24, MPS IVA: 8, MPS VI: 8). Skeletal abnormalities (for MPS IVA and MPS VI), joint contractures (for MPS II), and typical facial features (for MPS I) were the most frequently reported first signs/symptoms. Several health professionals were involved in patients care as of the onset of symptoms until biochemical diagnosis was established. Median age at diagnosis was 76 months (MPS I: 75, MPS II: 95, MPS IVA: 75, MPS VI: 52). Considering the group as a whole, there was a 4.8‐year delay between the onset of signs/symptoms and the establishment of the diagnosis. Considering that specific therapies are available for some of these disorders and that early treatment is likely to change more favorably the natural history of the disease, efforts should be made to minimize this delay. We believe that this situation can be improved by measures that both increase awareness of health professionals about MPS and improve access to diagnostic tests.

Genetic services and testing in Brazil

The Federative Republic of Brazil is a country of continental dimensions, whose territory covers more than 8.5 million km2 and borders all the countries of South America except for Chile and Ecuador. After more than three centuries as a colony of Portugal, it became an independent monarchy in 1822 and a federal republic in 1889. It was under a 20-year long military dictatorship on the second half of last century, and today, after six presidential elections, the country has emerged as a consolidated democracy and as a political and economic leader in the region. The Brazilian economy also acquired a strong position in the global economy in recent years (IBGE 2010; United Nations 2010). It is defined as an upper middle-income country, but inequality remains significant, according to Human Development Report (UNDP 2009). Brazil is distinguished by an admirable national unity, based mainly in the Portuguese language, which is spoken in all regions, and by a magnificent biodiversity and natural resources. The agriculture is large and well-developed, while mining, manufacturing, and service sectors are having a significant growth. Notwithstanding, the country still faces economical, political, and social problems, whose paramount example is the highly unequal income distribution (IBGE 2010; United Nations 2010). In the past decades, with health improvement of the population in general, due to more effective sanitation and better control of infectious and nutritional diseases, it can be stated that Brazil has been living an epidemiological transition. Taking such statement into consideration, birth defects and genetic diseases are increasingly assuming a more important role in morbidity and mortality, especially in large centers and reference hospitals (Horovitz et al. 2005). This paper presents the background data on basic demographic statistics, health indicators and health expenditure, and information on the genetic services and genetic testing available in the country.

Clinical Genetics in Developing Countries: The Case of Brazil

There are many impediments to the progress of clinical and medical genetics in developing countries. Higher priorities concerning basic health care usually take precedence over genetic diseases and birth defects among medical professionals and public health officials. This is so in spite of the fact that the global prevalence of these conditions seems higher than in the developed world and that limited resources enhance the burden on individuals, families and populations. Furthermore, as a consequence of recent advances in medical genetics, demand for genetic services has increased, reinforcing the need for programs for the management and prevention of genetic diseases and birth defects, especially at primary health care level. An overview of these issues in Brazil is presented here, with information on the health system, the evolution of medical and clinical genetics in the country, and the situation of medical and clinical genetic services. We discuss proposals for implementing appropriate, ethically acceptable and equitable clinical genetic services for the Brazilian population.

Recurrent Mutations in the Basic Domain of TWIST2 Cause Ablepharon Macrostomia and Barber-Say Syndromes

Ablepharon macrostomia syndrome (AMS) and Barber-Say syndrome (BSS) are rare congenital ectodermal dysplasias characterized by similar clinical features. To establish the genetic basis of AMS and BSS, we performed extensive clinical phenotyping, whole exome and candidate gene sequencing, and functional validations. We identified a recurrent de novo mutation in TWIST2 in seven independent AMS-affected families, as well as another recurrent de novo mutation affecting the same amino acid in ten independent BSS-affected families. Moreover, a genotype-phenotype correlation was observed, because the two syndromes differed based solely upon the nature of the substituting amino acid: a lysine at TWIST2 residue 75 resulted in AMS, whereas a glutamine or alanine yielded BSS. TWIST2 encodes a basic helix-loop-helix transcription factor that regulates the development of mesenchymal tissues. All identified mutations fell in the basic domain of TWIST2 and altered the DNA-binding pattern of Flag-TWIST2 in HeLa cells. Comparison of wild-type and mutant TWIST2 expressed in zebrafish identified abnormal developmental phenotypes and widespread transcriptome changes. Our results suggest that autosomal-dominant TWIST2 mutations cause AMS or BSS by inducing protean effects on the transcription factors DNA binding.

Genetics and genomics in Brazil: a promising future.

Medical Genetics has a recent history in Brazil and started out as a research program in Human Genetics during the 1950s, mainly by a shift in work of Brazilian scientists from genetic studies conducted on drosophila melanogaster to this new emerging field of research, following a worldwide tendency (Otto and Frota-Pessoa 1975; Beiguelman 2000). The Department of Biology, currently Department of Genetics and Evolutionary Biology, at the Institute of Biosciences, University of Sao Paulo, was one of the main pioneers in this field, followed by other initiatives at the Federal Universities at Rio Grande do Sul and Parana (Otto and Frota-Pessoa 1975; Beiguelman 2000). The importance of genetics was recognized by the medical community only as of the 60 and onward, after the advent of human cytogenetics, and with the introduction of Genetics as a subject in a few medical schools (Beiguelman 2000). Nevertheless, Medical Genetics still is regarded as an optional discipline in many medical schools in Brazil. The Brazilian population is highly heterogeneous and admixed, as a result of five centuries of crossbreeding among native Amerindians, Europeans settlers and immigrants, and sub-Saharan Africans, who were mostly brought to this country during the slavery period. The countrys diverse regions underwent slightly different colonization processes: the North region had a larger preservation of indigenous people, the Northeast region had a stronger history of African influence, while Europeans colonized most of the South region (Alves-Silva et al. 2000; Pena et al. 2011). More recently, waves of Asian immigration reached mainly the Southeastern region. This trihybrid admixture process was strongly influenced by a directional mating between European males and African and Amerindian females during the colonization period, as demonstrated by the use of sexual and mitochondrial chromosome markers (Pena et al. 2009; Resque et al. 2010). In the last decade, the availability of genomic ancestry informative markers (AIMs) has encouraged a precise characterization of the contribution of each parental population. It has been shown that European ancestry is evenly preponderant across the country; the African contribution has reached the highest proportion in the Northeast (∼30.3%), followed in decreasing order by the Southeast (∼18.9%), South (∼12.7%), and North (∼10.9%) regions, while the Amerindian contribution is the highest in the North (∼19.4%) region, and relatively evenly spread across the other regions (Santos et al. 2010; Pena et al. 2011). An unexpected high Amerindian contribution is also found in semi-isolated communities founded by African-slaves refugees, the “quilombos” (Lopes Maciel et al. 2011; Kimura et al. 2013; Gontijo et al. 2014). Our colonization history also accounts for the high incidence of some diseases. For example, the autosomal recessive (AR) sickle cell disease (SCD), one of the most common monogenic disorder in Brazil (Cancado and Jesus 2007; Lobo et al. 2014, Table ​Table1),1), has been attributed to the intense African slave trade that occurred between the 16th and 19th centuries (Aygun and Odame 2012). Table 1 Genetic disorders under federal clinical protocols and guidelines for treatment including those from the newborn screening The Brazilian admixture, as briefly explained, constitutes a good example of a population characteristic boosting the research on Genetics in Brazil. Inbreeding in Brazil played a similar role within this field. The cultural diversity, socio-economic status, migration, population density, urbanization, and permissive laws have historically influenced the heterogeneous degree of consanguineous marriages across the country (Machado et al. 2013; Freire-Maia 1957, Fig. ​Fig.1A).1A). Even though inbreeding has been decreasing in all Brazilian regions in the past decades, large differences between Southern and Northeastern populations still remain, with the coefficient of inbreeding (f) 13 times higher in some Northeastern (f = 0.00395; proportion of consanguineous marriage from 6% to 12%) populations as compared to Southern (f = 0.0003) populations (Freire-Maia 1957, 1989; Brito et al. 2011; Weller et al. 2012; Machado et al. 2013), where the frequency of consanguineous marriage (<5%) is comparable to the estimates found for most of the other countries around the world (Hamamy et al. 2011). Figure 1 Inbreeding and Infant mortality rate across Brazil; (A) Inbreeding occurrence in Brazil, adapted from Salzano and Freire-Maia 1967. The diameter of black dots are proportional to the coefficient of inbreeding (f). According to that study, Brazil has a ... It is widely accepted that consanguineous marriage is a risk factor for AR and multifactorial inheritance disorders. Indeed, Brazilian consanguineous families have been useful study subjects for identifying pathogenic mutations underlying AR disorders, some of them originally described in Brazil, such as acheiropodia, Richieri-Costa-Pereira syndrome and Spastic paraplegia, optic atrophy, and neuropathy (SPOAN, Freire-Maia et al. 1975; Ianakiev et al. 2001; Macedo-Souza et al. 2005; Guion-Almeida et al. 2009; Lines et al. 2012; Favaro et al. 2014), in addition to others already described, such as Knobloch syndrome (Sertie et al. 2000). Still, high rates of inbreeding were recently reported to increase prevalence of some rare AR disorders, such as mucopolysaccharidoses and short stature, among others, in small Brazilian villages (Salvatori et al. 1999; Costa-Motta et al. 2011). Recently, National Institute of Populational Genetics (INAGEMP) has launched a census concerning clusters of genetic disorders in Brazil. Preliminary data list more than 100 small villages with a likely higher prevalence of a specific disorder. At a national level, however, the degree of inbreeding in Brazil has never been associated with increased overall prevalence of AR disorder. The impact of inbreeding rate in the etiology of complex disorders in the Brazilian population is still quite unexplored. Nevertheless, it has been shown to confer increased risk for hypertension in quilombos (Kimura et al. 2012), but not for nonsyndromic cleft lip and palate (Brito et al. 2011). The population admixture has always posed a challenge to the gene mapping studies of complex traits in Brazil, including pharmacogenomic studies, particularly when designing case–control studies, which are prone to produce spurious association in the presence of population structure. Accordingly, AIMs have proven to be useful for inferring the putative biogeographic ancestry of individuals, estimating the ancestry proportions of admixed individuals and populations (Shriver et al. 1997; Halder et al. 2008; Pena et al. 2011; Pereira et al. 2012; Suarez-Kurtz et al. 2012; Manta et al. 2013), correcting case–control studies for stratification bias (Brito et al. 2012a,b; Bagordakis et al. 2013), and performing admixture mapping approaches. Many of such studies have benefited from AIM panels built by Brazilian research groups, focused specifically on discriminating Brazilian parental populations (Bastos-Rodrigues et al. 2006; Santos et al. 2010; Brito et al. 2012a; Manta et al. 2013). In addition, in an ethnically admixed population, it is possible to evaluate the impact of certain at-risk alleles on the occurrence of some disorders or to drug response among different ethnicities simultaneously, under similar environmental and socio-economical conditions (Suarez-Kurtz et al. 2014). Brazil, with 26 states (Fig. ​(Fig.1A),1A), is the worlds 5th largest country in area (8,515,767 km2) and population (199,242,462 million individuals; IBGE, 2012). The age profile still remains as that of a young country, with 25% of the population under 15 years old and just 7% over 65 years old. Life expectancy at birth is estimated as 73.8 years old. Despite presenting the 7th largest gross domestic product (GDP), it ranks 61st and 85th in GDP per capita and in human development index (0.73), respectively (IBGE, 2012; reviewed in Acosta et al. 2013; World Bank, 2014, data.worldbank.org), reflecting an outstanding social inequality. As a related example, Brazil still has a high infant mortality rate, but it varies considerably across the country (Fig. ​(Fig.1B).1B). On behalf of policies with impact on sanitation and health, this rate has progressively decreased, and as part of the Millenium Development Goals from the United Nations (UN), Brazil reached the goal of decreasing the mortality rate to 2/3 of the one observed in 1990, 2 years before the deadline, set for 2015 (United Nation Development Programme, 2014). In this scenario, congenital malformations have become the second most common cause of death in children under 1 year of age surpassing infectious diseases, and represents more than 15% of the total number of infant deaths since 2000 (Fig. ​(Fig.2;2; DATASUS, tabnet.datasus.gov.br). This data highlight the increasing importance of Genetics for the health of the Brazilian population. Figure 2 Evolution of infant mortality (under 1 year old) by year, from 1980 to 2013. With the observed overall decrease in deaths caused by different conditions, congenital malformations became the second cause of infant mortality in Brazil (DATASUS). In this manuscript, we focus on describing the genetic services provided in the country, how they are working and some of our laws with direct impact on the quality of life of families with rare genetic disorders, as well as including Federal government support for treatment of some rare genetic disorders.

Congenital shortening of the anterior lamella of all eyelids : the so-called ablepharon macrostomia syndrome

Summary The so-called ablepharon macrostomia syndrome is an extremely rare congenital condition that includes abnormal ears, an enlarged, fishlike mouth, absence of lanugo, redundant skin, and vertical shortening of all eyelids. Only four cases have been described so far. In these cases the nature of the eyelid anomalies has not been clearly defined. We report one more case showing that the condition is better described as a severe microblepharon because only the anterior lamella of the eyelids is shortened. The literature about this condition is reviewed, and oculoplastic treatment is discussed.

Ablepharon-macrostomia syndrome: first report of familial occurrence.

Ablepharon-macrostomia syndrome (AMS) is a rare condition comprising severe deficiency of the anterior lamella of both eyelids, abnormal ears, macrostomia, anomalous genitalia, redundant skin, and absence of lanugo. There is no agreement about cause; some authors suggest autosomal recessive inheritance. We describe familial occurrence of AMS in a girl, sister of a previously reported patient. The father has facial anomalies that suggest autosomal dominant inheritance. Am. J. Med. Genet. 94:281-283, 2000.

TP53 p.R337H prevalence in a series of Brazilian hereditary breast cancer families.

BackgroundApproximately 5-10% of breast cancers are hereditary. Among hereditary syndromes, Hereditary Breast and Ovarian Cancer Syndrome (HBOC) and Li-Fraumeni Syndrome (LFS) have received the most attention. HBOC is due to mutations in the BRCA1 and BRCA2 genes and is characterized by breast adenocarcinoma and/or epithelial ovarian carcinoma. LFS is associated with germline mutations in TP53; the most frequent cancer types associated with this syndrome are sarcoma, breast cancer, leukemia, brain tumors and adrenocortical carcinomas. Other cancers related to LFS are found at lower frequencies. In Brazil, especially in the southern part of the country, a specific mutation in the TP53 gene, TP53 p.R337H, occurs at a high frequency in childhood adrenocortical tumors. It has been proposed that this mutation increases breast cancer risk in southern Brazilian women.MethodsWe carried out a case-control study to determine the prevalence of the TP53 p.R337H mutation in 28 female cancer patients attended at the Cancer Genetic Counseling Service of the General Hospital of the University of São Paulo Medical School of Ribeirão Preto who fulfilled Hereditary Breast and Ovary Cancer Syndrome genetic test criteria compared to healthy woman (controls). TP53 p.R337H mutation status was determined using the High Resolution Melting (HRM) method, followed by DNA sequencing. Fisher’s test was used to compare the prevalence of TP53 p.R337H in the patient and control groups.ResultsTwo of the breast cancer cases (7.1%) and none of the controls carried the TP53 p.R337H mutation. At the time of the investigation, both cases fulfilled testing criteria for Hereditary Breast and Ovary Cancer Syndrome but not Li-Fraumeni or Li-Fraumeni-like Syndrome, based on genetic testing criteria of NCCN Clinical Practice Guidelines in Oncology (v.1.2010).ConclusionsWe suggest that genetic screening of Brazilian breast cancer patients who fulfill Hereditary Breast and Ovary Cancer Syndrome criteria and have a family history that includes other tumors of the LFS/LFL spectrum be tested for the TP53 p.R337H mutation.

A further case of a Prader-Willi syndrome phenotype in a patient with Angelman syndrome molecular defect

Angelman syndrome (AS) and Prader-Willi syndrome (PWS) are distinct human neurogenetic disorders; however, a clinical overlap between AS and PWS has been identified. We report on a further case of a patient showing the PWS phenotype with the AS molecular defect. Despite the PWS phenotype, the DNA methylation analysis of SNRPN revealed an AS pattern. Cytogenetic and FISH analysis showed normal chromosomes 15 and microsatellite analysis showed heterozygous loci inside and outside the 15q11-13 region. The presence of these atypical cases could be more frequent than previously expected and we reinforce that the DNA methylation analysis is important for the correct diagnosis of severe mental deficiency, congenital hypotonia and obesity.

Genetic education, knowledge and experiences between nurses and physicians in primary care in Brazil: A cross‐sectional study

Recent advances in genomics and related technologies have the potential to improve health care throughout the world. In this cross-sectional study, we examine genetics education, knowledge, and genetics-related experiences among the nurses and physicians who provide primary care in a Brazilian city. Fifty-four healthcare professionals from family health units participated in the study (response rate: 90%). Data were collected using a structured 36-item questionnaire divided into five axes: sociodemographic data and academic background; genetics education; genetics knowledge; genetics-related experiences in family practice; and knowledge regarding the National Policy for Comprehensive Care in Clinical Genetics in the Unified Health System. Although most participants (85.2%) acknowledged receiving some genetic content during their undergraduate education, the majority (77.8%) advised that they did not feel prepared to deliver genomics-based health care in primary care. The results suggest that nurses and physicians often lack the knowledge to provide genomics-based health care in primary care. Therefore, continuing education in genetics/genomics should be provided to primary healthcare professionals in order to enhance family practice and compliance with national policies.