Fibrinogen-erythrocyte binding and hemorheology measurements in the assessment of essential arterial hypertension patients

Some studies have reported a positive association between plasma fibrinogen levels, erythrocyte aggregation and essential arterial hypertension (EAH). The aim of this study was to understand how the interaction between fibrinogen and its erythrocyte membrane receptor is altered in EAH. EAH patients (n = 31) and healthy blood donors (n = 65) were enrolled in the study. EAH patients were therapeutically controlled for the disease, presenting a systolic blood pressure between 108 and 180 mmHg and a diastolic blood pressure between 66 and 123 mmHg. Clinical evaluation included blood pressure monitoring, electrocardiography, echocardiography and blood cell count. The hemorheological parameters were also analyzed. Fibrinogen-erythrocyte binding force and frequency were evaluated quantitatively, at the single-molecule level, using atomic force microscopy (AFM). Changes in erythrocyte elasticity were also evaluated. Force spectroscopy data showed that the average fibrinogen-erythrocyte binding forces increase from 40.4 ± 3.0 pN in healthy donors to 73.8 ± 8.1 pN in patients with EAH, despite a lower binding frequency for patients compared to the control group (7.9 ± 1.6% vs. 27.6 ± 4.2%, respectively). Elasticity studies revealed an increase of erythrocyte stiffness in the patients. The stronger fibrinogen binding to erythrocytes from EAH patients and alteration in cell elasticity may lead to changes in the whole blood flow. The patients' altered hemorheological parameters may also contribute to these blood flow perturbations. The transient bridging of two erythrocytes, by the simultaneous binding of fibrinogen to both of them, promoting erythrocyte aggregation, could represent an important cardiovascular risk factor.

The Externalities of Advocacy: The High Cost of Standing Up for Patients' Dignity in Senegal

Background and context: In Senegal, pediatric oncology patients arrive at the hospital at advanced stages of disease. Their large tumors, as well as the side effects of chemotherapy make children experience intense pain. In this low-resource setting, morphine supply was quite irregular. Doctors don´t prescribe morphine due to shortages; but few prescriptions also lead to limited orders. A vicious circle with only 1 victim: the patient. Hearing children in pain was agonizing for everyone: patients, caregivers and healthcare practitioners. Aim: This advocacy narrative illustrates how the fight for access to morphine in pediatric oncology has led to both positive and negative externalities. We will highlight ways in which this fight for morphine has provoked political tensions moving the issue forward, but has also affected the careers of health workers involved. Strategy/Tactics: Morphine is a cheap drug, yet it is extremely regulated by international laws. It takes political will to influence national morphine orders. This advocacy strategy was built on raising awareness and setting morphine shortage on the political agenda. Not providing morphine in oncology goes against international standards of care. But most importantly, letting patients suffer without “existing” relief is a breach of basic human right to live - and also die - in dignity. Program/Policy process: Conversations began within the pediatric oncology department. Focus groups highlighted caregivers' feelings of powerlessness before their suffering child. Interviews with key informants (doctor and nurses) were instrumental to a widely diffused Human Rights Watch report exploring the medical and political causes to morphine supply shortages, as well as its psychological repercussions on patient care. A BBC documentary was broadcasted soon after. Subsequently, meetings were held between the Ministry of Health, the National Supply Pharmacy and leading local oncologists. Outcomes: Morphine orders were multiplied by 10, leading to much improved pain management for patients. However, Senegal was portrayed negatively on the international scenes, much to the Health Minister´s dismay. The consequences were incurred by the health workers who contributed to the international publications/reports. What was learned: Health practices can inform policy just like policy can inform health practices. It is a cyclical process. Creating advocacy coalitions and rallying the help of the international community are effective strategies. However, in the political arena, health workers need more than commitment to human rights and quality care. Even in democratic republics, systems can penalise outspoken activists. We have learned that health care practitioners (especially working in public settings) who wish improvement for their patients must learn to be tactical and diplomatic. International partners will return to their home countries, but local actors will pay the high cost of advocacy.

Fruit, vegetable consumption and blood pressure in healthy adolescents: A longitudinal analysis from the LabMed study

BACKGROUND AND AIMS

The associations between fruit and vegetable consumption and high blood pressure among adults are well studied. Nonetheless, data on the influence of a low consumption of fruit and vegetables on cardiovascular disease risk, particularly blood pressure, among healthy adolescents are scarce. Therefore, we aim to analyse the associations between fruit and/or vegetable intake and blood pressure over a two-year period in healthy adolescents.

METHODS AND RESULTS

As part of a cohort, 606 adolescents from the LabMed Physical Activity study were evaluated in 2011 (baseline) and 2013 (follow-up). Blood pressure was measured according to standardized procedures and fruit and vegetable consumption was assessed with a food frequency questionnaire. Anthropometric variables, socioeconomic status, pubertal stage and lifestyle determinants were gathered and used as confounders. Prospective associations between fruit and/or vegetable intake and blood pressure were examined using generalized linear models. Girls who consumed more fruit at baseline had a significant decrease in diastolic blood pressure at follow-up [unstandardized beta: -0.005 mmHg (95%CI: -0.01; -0.0002) (p = 0.038)].

CONCLUSION

In apparently healthy adolescents, fruit intake may already start to have an effect in blood pressure. Girls who consumed more fruit exhibited lower levels of diastolic blood pressure.

Longitudinal association between ideal cardiovascular health status and muscular fitness in adolescents: The LabMed Physical Activity Study

BACKGROUND AND AIMS

Muscular fitness is an emerging predictor for cardiovascular disease mortality. The ideal cardiovascular health metrics has been inversely related to a subsequent cardiometabolic health in adulthood. However, evidence regarding muscular fitness and ideal cardiovascular health in adolescents is scarce. This study aimed to examine the longitudinal association between ideal cardiovascular health index and muscular fitness.

METHODS AND RESULTS

This study cohort consisted of 331 adolescents (183 girls) from the LabMed Physical Activity Study who were followed from 2011 to 2013. Ideal cardiovascular health, as defined by the American Heart Association, was determined as meeting ideal health factors (total cholesterol, blood pressure, and glucose) and behaviors (smoking status, body mass index, physical activity, and diet). Handgrip strength and standing long jump tests assessed muscular fitness and were transformed into standardized values according to age and sex. ANCOVA showed a significant association between the accumulation of ideal cardiovascular health metrics at baseline and muscular fitness indices at follow-up (F_{(4, 322)} = 2.280, p = 0.04). In addition, the higher the number of ideal cardiovascular health metrics accumulated, the higher the likelihood of having a high muscular fitness over a two-year period (p for trend = 0.01), after adjustments for age, sex, pubertal stage and socioeconomic status and muscular fitness at baseline.

CONCLUSION

The ideal cardiovascular health status during adolescence was associated with high muscular fitness levels over a two-year period.

Essential arterial hypertension patients present higher cell adhesion forces, contributing to fibrinogen-dependent cardiovascular risk

The increase of erythrocyte aggregation by high fibrinogen levels may be an indicator of cardiovascular risk. γ' fibrinogen variant has been considered as a possible player in enhancing aggregation. Here, we assessed, at the single-cell level, the influence of fibrinogen on erythrocyte aggregation in essential arterial hypertension. We also aimed at understanding how γ' fibrinogen is altered in this disease. Using atomic force microscopy (AFM), we show that the work and force necessary for erythrocyte-erythrocyte detachment is higher for patients than for healthy donors, with these parameters further increasing in both groups when higher fibrinogen concentrations are present. This can be associated with changes in blood flow, due to transient bridging of two erythrocytes by fibrinogen, representing an important cardiovascular risk factor. γ' fibrinogen can influence the increased risk in essential arterial hypertension, as we demonstrate that its levels are significantly increased in these patients' blood. Nevertheless, this cannot be the only cause for the changes observed in the AFM data.

[Fatal female genital mutilation in a 10-year-old girl]

Female genital mutilation (FGM) comprises all procedures involving partial or total removal of the external genitalia and/or any other procedures affecting the female genitalia, for cultural or religious reasons or for nontherapeutic purposes in general. FGM is responsible for a number of short-, medium-, and long-term complications that can engage the vital and functional prognosis, especially in African countries. We report on a case in a 10-year-old girl who underwent genital mutilation, a traditional type of total excision during the neonatal period. She was followed for urethral meatus stenosis, which then was complicated by obstructive chronic kidney failure and urinary sepsis, whose progression was fatal.

Muscular fitness, adherence to the Southern European Atlantic Diet and cardiometabolic risk factors in adolescents

BACKGROUND AND AIM

Muscular fitness and an adherence to the Southern European Atlantic Diet (SEADiet) have been inversely associated with cardiometabolic risk. Our aim was to assess the independent and combined associations of muscular fitness and adherence to the SEADiet on cardiometabolic risk in adolescents.

METHODS AND RESULTS

A total of 467 Portuguese adolescents (275 girls) participated in this cross-sectional study. Sum of the Z-Scores of Curl-Up and Push-Up tests was used to create a muscular fitness score. Adherence to SEADiet was obtained using a food frequency questionnaire. A cardiometabolic risk score was computed from sum of Z-score of triglycerides, systolic blood pressure, total cholesterol/HDL ratio, HOMA-IR and waist circumference. Adolescents with low muscular fitness and low adherence to the SEADiet had the poorest cardiovascular profile F_(5, 452) = 5.074 (p < 0.001) and the highest odds of having a high cardiometabolic risk score (OR = 4.5; 95% CI: 2.1-14) when compared to those with High muscular fitness/High adherence to the SEADiet after adjustments for age, sex, pubertal stage, socioeconomic status, total energy intake, low-energy reporter and cardiorespiratory fitness.

CONCLUSIONS

Our findings seem suggest that improving muscular fitness as well as an adherence to the SEADiet could be an important strategy to reduce clustered cardiometabolic risk in youth.

[Pathological profiles of retinoblastoma in Senegal]

OBJECTIVES

Describe the macroscopic and microscopic profiles of retinoblastoma (RB) in Senegal and correlate histological criteria with progression to establish severity factors.

METHODOLOGY

We realized a retrospective study over 10 years (January 2005-December 2014). Only patients (n=67) who underwent histological analysis of the enucleation specimen (n=68) were followed until the end of the study.

RESULTS

The tumor measured an average of 3.8cm (2/4.5). Endophytic tumor development was observed in 55 cases (80.8%), exophytic in 6 cases (8.9%) and mixed in 7 cases (10.3%). Retinal detachment was present in 13 cases (19.2%). The RB was well differentiated in 11 cases (16.2%), moderately differentiated in 31 cases (45.6%) and undifferentiated in 26 cases. Optic nerve (ON) invasion was present in 18 cases (26.5%). The tumor was extraretinal in 37 cases (54.4%). The anterior chamber was invaded in 6 cases (8.8%). The global survival at 2 years was 84% and 70% at 5 years. On multivariate analysis, well differentiated tumors and stage pT1 were associated with remission. Retrolaminar ON invasion, massive choroidal invasion and stage pT3 were risk factors for recurrence. Poor tumor differentiation, invasion of the ON resection margin, tumor invasion through the sclera, and stage pT4 were predictive of death.

CONCLUSION

The pathologist is a principal actor in the management of RB because his account guide the post-surgical management strategy.

Generalized Bullous Fixed Drug Eruption due to Bromhexine

We describe a patient with a generalized bullous form of Fixed Drug Eruption (FDE) induced by bromhexine, a commonly used drug for respiratory symptoms. This is a rare association and generalized bullous FDE is also very rare. We emphasize the importance of patch tests in identifying the culprit drug.

Association between serum adiponectin levels and muscular fitness in Portuguese adolescents: LabMed Physical Activity Study

BACKGROUND AND AIM

Paradoxically, recent investigations have showed that adiponectin levels are inversely associated with muscle strength. However, to date, there is a lack of knowledge on the relationship between muscular fitness (MF) and adiponectin levels in adolescents. We aimed to examine the independent associations between MF and adiponectin levels in adolescents, controlling for several potential confounders.

METHODS AND RESULTS

This is a cross-sectional analysis with 529 Portuguese adolescents aged 12-18 years. A MF score was computed as the mean of the handgrip strength and standing long jump standardized values by age and gender. We measured fasting glucose, insulin, HDL-cholesterol, C-reactive protein and adiponectin. Linear regression analysis showed a significant inverse association between adiponectin (Z-score by age and sex) and MF score, after adjustments for age, sex, pubertal stage, socioeconomic status, adherence to the Mediterranean diet, body mass index, HOMA-IR, HDL-cholesterol, C-reactive protein and cardiorespiratory fitness (unstandardized β = -0.176; p < 0.005). Analysis of covariance showed a significant difference between the Low MF/Non-overweight group and the High MF/Non-overweight Group (p < 0.05) and between the Low MF/Non-overweight and High MF/Overweight Group (p < 0.05) (F (5, 523) = 2.262, p = 0.047).

CONCLUSION

Adiponectin circulating levels are inversely and independently associated with MF. In non-overweight adolescents, those with high levels of MF presented lower levels of adiponectin compared to those with Low MF. Likewise, overweight adolescents with High MF presented lower levels of serum adiponectin than non-overweight adolescents with Low MF.

Why Portugal is pushing towards migration?

Background

International professional mobility is a reality, people have skills they can put in the global marketplace. The increasing migration of health professionals to wealthy countries is a phenomenon known as “brain drain”.

Objectives/Aims

This work aims to present the push factors that pressure people to migrate from Portugal.

Methods

A cross-sectional survey was carried out with the psychiatric trainees in Portugal. A self-administered structured questionnaire was distributed to collect psychiatry trainees’ demographic and educational characteristics.

Results

In Portugal, the majority of trainees have a Portuguese citizenship. Almost 2/3 did not have a short-mobility experience, and the majority never migrated to another country. Less than half consider staying in Portugal in the next years, and nearly 4/5 have considered leaving the country. Working conditions ranked first as the priority condition to be improved in psychiatry in Portugal, followed by financial conditions. In fact, an attractive job for psychiatry trainees in Portugal must have as the most important feature a pleasant work environment.

Conclusions

An alarming percentage of psychiatry trainees from Portugal intend to migrate. Impact on future career, financial conditions of doctors, job opportunities and better working conditions were some of the motivating factors behind the migration.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Boderline versus personality

Introduction

Latest classifications led to an inflamed debate urging for change or validation in the way personality disorders are classified. The placement in psychiatric classifications of several personality disorders, particularly Borderline Personality Disorder (BPD), is also a matter of discussion.

Objectives and aims

The present work aims to question BPDs place in classification alongside with other personality disorders, rather than focusing on the algorithms used to classify it. The authors review updated literature on core features of the disorder collected from online scientific databases.

Results

Studies reveal that the stability of the diagnosis of BPD over the longer term is less than what standard general definitions of personality disorders would appear to require. It is a chronic and debilitating syndrome with severe functional and psychosocial impairment that remain relevant when comparing to other personality disorders. Additionally, these measures show further declines over time in spite of improvement in psychopathology, in contrast to what happens with other personality disorders. Several misconceptions may have led to the placement of BPD on former axis II, namely being a direct consequence of trauma and merely explained by environmental factors. However, recent research on heritability shows the contrary and several neurobiological markers suggest it has got a nature of its own.

Conclusion

BPD is probably the most studied and validated personality disorder and has substantially greater empirical basis, clinical significance and public health implications, being both enduring and distinct from other personality disorders. We suggest the placement of BPD as major psychiatric disorder in classifications.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Gut Feeling

Introduction

There is growing evidence of the importance of nutrition in mental disorders. Gut microbiota, influenced by environmental factors such as diet and stress, has been proposed as one of the players on a dynamic called gut-brain axis, which is thought to have an influence on behaviour and mental health.

Objectives and aims

To summarize recent evidence on the topic, and its potential role in psychiatric interventions.

Methods

The authors review updated literature collected from online scientific databases.

Results

The development of the brain itself has been shown to be influenced by the gut microbiome. Research demonstrates that the composition of the microbiota has influence on behaviour through neuroendocrine and other neuroactive messengers production by the bacteria within the gut lumen. Studies in germ-free animals, animals exposed to bacterial infections, probiotic suplements or antibiotic drugs suggest a role for the gut microbiota in the regulation of anxiety, mood, cognition and pain. The gut microbiome has been implicated in brain disorders including anxiety and depression, multiple sclerosis, Alzheimer's disease, Parkinson's disease, and autism.

Conclusions

The treatment of mental disorders is usually based on pharmacological and psychotherapeutic interventions, and little attention is given to dietary interventions. The emerging field of research focused on the human microbiome suggests an important role for the gut microbiota in influencing brain development, behaviour and mood in humans, and points new strategies for developing novel therapeutics for mental disorders.

Disclosure of interest

The authors have not supplied their declaration of competing interest.