Importance of Depression and Active Coping in Liver Transplant Candidates' Quality of Life

Objective

To investigate the importance of psychiatric and psychological factors such as depression, anxiety, personality traits, and coping strategies in liver transplant candidates' quality of life.

Methods

A total of 131 consecutive liver transplant candidates attending outpatient clinics at a liver transplantation central unit were assessed by means of the Medical Outcomes Study Short Form quality-of-life questionnaire, psychiatric diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, a personality inventory (NEO Five-Factor Inventory), the Hospital Anxiety and Depression Scale, and the Brief COPE scale.

Results and Conclusions

Both physical and mental components of quality of life are far more correlated with depression and active coping strategy than with clinical and sociodemographic factors. Neuroticism was also strongly correlated with the mental component of quality of life, and employment was correlated with the physical component of quality of life.

Psychiatric differences between liver transplant candidates with familial amyloid polyneuropathy and those with alcoholic liver disease

BACKGROUND

Psychiatric diagnoses are very common in liver transplant candidates, and such diagnoses are predictive of a poor clinical evolution and quality of life after transplantation. Also, nonadherence before the transplant is predictive of nonadherence after the transplant.

METHODS

We studied the psychiatric and psychosocial profiles of 85 liver transplant candidates, comprising consecutive patients attending outpatient clinics of a liver transplantation unit at a public hospital. Interviews and questionnaires were used to measure personality traits, symptoms of anxiety and depression, social support, and adherence. These patients were broken into 3 groups: patients with familial amyloid polyneuropathy (n = 20), patients with alcoholic liver disease (n = 33), and patients with other liver diseases (n = 32).

RESULTS

About 58% of patients had a current psychiatric diagnosis (24.8%, major depressive disorder, 22.3% generalized anxiety disorder, 8.3% adaptive disorder, 2.3% abuse of or dependence on substances other than alcohol). Current psychiatric diagnosis did not differ between patients with familial amyloid polyneuropathy and patients with alcoholic liver disease. Patients with alcoholic liver disease showed lower scores for 2 protective personality traits, social support and adherence to medication, than other patients. Patients with familial amyloid polyneuropathy showed higher scores for those traits.

CONCLUSIONS

All patients waiting for a liver transplant should undergo psychiatric and psychological assessment. Some psychological characteristics such as personality traits and social support differ between clinical groups, so it may be useful to design different approaches for each group. Patients with alcoholic liver disease may require a special approach to improve adherence to medication.

Psychiatric Differences between Liver Transplant Candidates with Familial Amyloid Polyneuropathy and Those with Alcoholic Liver Disease

Background

Psychiatric diagnoses are very common in liver transplant candidates, and such diagnoses are predictive of a poor clinical evolution and quality of life after transplantation. Also, nonadherence before the transplant is predictive of nonadherence after the transplant.

Methods

We studied the psychiatric and psychosocial profiles of 85 liver transplant candidates, comprising consecutive patients attending outpatient clinics of a liver transplantation unit at a public hospital. Interviews and questionnaires were used to measure personality traits, symptoms of anxiety and depression, social support, and adherence. These patients were broken into 3 groups: patients with familial amyloid polyneuropathy (n=20), patients with alcoholic liver disease (n=33), and patients with other liver diseases (n=32).

Results

About 58% of patients had a current psychiatric diagnosis (24.8%, major depressive disorder, 22.3% generalized anxiety disorder, 8.3% adaptive disorder, 2.3% abuse of or dependence on substances other than alcohol). Current psychiatric diagnosis did not differ between patients with familial amyloid polyneuropathy and patients with alcoholic liver disease. Patients with alcoholic liver disease showed lower scores for 2 protective personality traits, social support and adherence to medication, than other patients. Patients with familial amyloid polyneuropathy showed higher scores for those traits.

Conclusions

All patients waiting for a liver transplant should undergo psychiatric and psychological assessment. Some psychological characteristics such as personality traits and social support differ between clinical groups, so it may be useful to design different approaches for each group. Patients with alcoholic liver disease may require a special approach to improve adherence to medication.

[Transhyoid bucopharyngectomy: a new surgical approach to oropharyngeal tumours]

OBJECTIVES

To present a new surgical technique for oropharyngeal tumours. We describe the technique together with the indications, limits and pitfalls.

SURGICAL TECHNIQUE

Transverse cervical collar incision. Bilateral neck dissection according to patient's nodal status. Infrahyoide muscles dissection from the posterior-inferior surface of the hyoid bone body. Division of this structure bilateraly at it junction with greater corns. Push back and up of the hyoid bone together with its suprahyoid muscles upon the mandible. Incision of the mouth floor Push down of the tongue to the cervical region. Tumour bloc resection with optimal exposure. Wound closure with or without reconstruction according to the size of surgical defect. Reposition of the hyoid bone and suprahyoid muscles in place, and suture of infrahyiod muscles to hyoid bone. Neck closure. Transitory tracheotomy. MAIN INDICATIONS: T2-3 of tongue base and vallecula, T2-3 of tonsil.

DISCUSSION

Surgical therapy, alone or integrated in a multimodality program, maintains an essential role in the management of patients with oropharyngeal tumours. In locally advanced tumours transmandibular approach is the method usually employed. Despite the wide surgical exposure, this approach may cause significant morbidity secondary to mandibular interruption. To avoid this, mandible-sparing procedures as suprahyoid, transhyoid and transpharyngeal approaches are advocated, but usually need complex manoeuvres and don't allow a large field for resection. These problems can be solved with the described technique we called transhyoid bucopharyngectomy.

CONCLUSION

Transhyoid bucopharyngectomy is an easy and safe procedure for head and neck surgeons, offers an acceptable level of postoperative swallowing and speech function, without the morbidity associated with transmandibular approaches, besides providing a good and wide exposure of the tumour to be removed. Bone invasion is the most important limit for this technique.

Crohn's disease: increased mortality 10 years after diagnosis in a Europe-wide population based cohort

BACKGROUND

No previous correlation between phenotype at diagnosis of Crohn's disease (CD) and mortality has been performed. We assessed the predictive value of phenotype at diagnosis on overall and disease related mortality in a European cohort of CD patients.

METHODS

Overall and disease related mortality were recorded 10 years after diagnosis in a prospectively assembled, uniformly diagnosed European population based inception cohort of 380 CD patients diagnosed between 1991 and 1993. Standardised mortality ratios (SMRs) were calculated for geographic and phenotypic subgroups at diagnosis.

RESULTS

Thirty seven deaths were observed in the entire cohort whereas 21.5 deaths were expected (SMR 1.85 (95% CI 1.30-2.55)). Mortality risk was significantly increased in both females (SMR 1.93 (95% CI 1.10-3.14)) and males (SMR 1.79 (95% CI 1.11-2.73)). Patients from northern European centres had a significant overall increased mortality risk (SMR 2.04 (95% CI 1.32-3.01)) whereas a tendency towards increased overall mortality risk was also observed in the south (SMR 1.55 (95% CI 0.80-2.70)). Mortality risk was increased in patients with colonic disease location and with inflammatory disease behaviour at diagnosis. Mortality risk was also increased in the age group above 40 years at diagnosis for both total and CD related causes. Excess mortality was mainly due to gastrointestinal causes that were related to CD.

CONCLUSIONS

This European multinational population based study revealed an increased overall mortality risk in CD patients 10 years after diagnosis, and age above 40 years at diagnosis was found to be the sole factor associated with increased mortality risk.

Severe leukopenia and liver biochemistry changes in adult rabbits after calicivirus infection

Calicivirus infection is the major cause of the severe decrease in the stocks of wild and farm rabbits that has occurred worldwide during the last two decades. Adult rabbits (10-weeks-old) were experimentally infected with a calicivirus inoculum that killed all animals by causing rabbit haemorrhagic disease (RHD) within 24-62 h of infection. The rabbits were used to evaluate blood cell numbers and serum biochemistry every 6h, starting 12h after the inoculation of the caliciviruses. No significant changes in blood parameters were observed in most of the rabbits up to 18 h of infection. Severe leukopenia was seen 6h before death of the infected rabbits; both heterophils and lymphocytes contributed to the decrease in circulating white blood cells. Platelets were also severely decreased in number. Marked enhancement in liver enzymes was seen 6-12 h before death of the infected rabbits. There was also evidence both for cholestasis, as expressed by the elevated levels of direct (conjugated) bilirubin, and for hypoglycemia, an alteration that it is likely to contribute for the seizures that rabbits show during the late stages of RHD. Liver ultrastructure of rabbits that died from RHD revealed extensive hepatocyte vacuolization, severe changes in mitochondrial structure, and depletion of glycogen granules. We conclude that: (i) severe leukopenia characterizes the final hours of calicivirus-induced RHD; (ii) hypoglycemia and cholestasis precede death of rabbits from RHD; (iii) the kinetics of liver enzymes allows an accurate prediction of the time of death of rabbits from calicivirus-induced RHD.

Liver enzymes and ultrastructure in rabbit haemorrhagic disease (RHD)

Rabbit haemorrhagic disease (RHD) is caused by a calicivirus infection that kills most adult rabbits 24-72 h after viral inoculation. Two liver enzymes (AST, aspartate aminotransferase, and ALT, alanine aminotransferase) were monitored in blood samples of calicivirus-infected rabbits during the short course of RHD. Values of AST were used to differentiate three stages of hepatocellular degeneration in RHD: mild (up to 20-fold increase in AST), moderate (150-200-fold elevation of AST) and severe (more than 1000-fold elevation in AST). Liver samples of rabbits from these three biochemical stages of hepatocellular degeneration of RHD were studied by transmission electron microscopy to define the fine structure of the hepatocytes. In the mild hepatocellular degeneration there was proliferation (microvesiculation) of the smooth endoplasmic reticulum and swelling of mitochondria into spheroid bodies with loss of cristae. In moderate hepatocellular degeneration, vacuolization of cytoplasm and mitochondrial damage continued to be present, and there was also formation of autophagic vesicles. In the severe hepatocellular degeneration of RHD, the altered mitochondria also showed loss of density of their matrix; rupture of cytoplasmic vacuoles led to the formation of large vesicles. Marked depletion of liver glycogen was also found in this late stage of RHD. These data offer a correlation between biochemical and cytological features of the liver during the hepatocellular degeneration of RHD.

Leukocyte-hepatocyte interaction in calicivirus infection: differences between rabbits that are resistant or susceptible to rabbit haemorrhagic disease (RHD)

Calicivirus infection is lethal for adult rabbits, whereas young rabbits (less than 8-weeks-old) are resistant to the same infectious agent. The virus replicates in the liver and causes a fulminant hepatitis in adult rabbits leading to rabbit haemorrhagic disease (RHD); this is in contrast with the mild and transient hepatitis observed in infected young rabbits. We have used electron microscopy to compare liver leukocyte infiltrates between young (resistant) and adult (susceptible) rabbits, 36-48 h after inoculation of the animals with caliciviruses. In adult rabbits, liver infiltrates were made up mostly of heterophils, and they were located near hepatocytes showing severe cellular damage. In contrast, liver leukocyte infiltrates of RHD-resistant young rabbits were dominated by lymphocytes that depicted membrane contacts with the cell surface of undamaged hepatocytes. We conclude that: (i) the cellular inflammatory response of the liver to calicivirus infection is different in rabbits that are susceptible (adult) or resistant (young) to RHD; (ii) leukocyte infiltration of the adult liver by heterophils is probably directed at the removal of dead hepatocytes, whereas the liver lymphocytic infiltration of young rabbits suggests the expression of viral antigens on the surface of liver cells of the RHD-resistant animals.

Polymorphisms of the human OGG1 gene in laryngeal cancer: implications in radiotherapy response and survival

The human OGG1 (hOGG1) gene encodes a DNA glycosylase involved in the excision repair of 8-hydroxy-2'-deoxyguanine (8-OH-dG) from oxidatively-damaged DNA. Ser326Cys polymorphism in the hOGG1 gene is involved in the repair of 8-hydroxyguanine in oxidatively damaged DNA, and appears to be related to susceptibility to certain smoking and alcohol-related orolaryngeal cancers.

OBJECTIVE

To analyse if hOGG1 Ser326Cys (exon 7: m6) polymorphism is associated with tumour localization, T, stage and histologic differentiation, and if radiotherapy results were influenced by this polymorphism.

MATERIAL AND METHOD

Blood samples were obtained before treatment from seventy one patients with laryngeal cancer and screened by a PCR-RFLP method.

RESULTS

Although hOGG1 gene is important in DNA repair mechanisms, no significant association was observed between hOGG1 Ser326Cys (exon 7: m6) polymorphism, tumour characteristics and radiotherapy results.

CONCLUSION

So the analysis of this polymorphism is not important for treatment decision in laryngeal cancer patients.

Transient decrease in blood heterophils and sustained liver damage caused by calicivirus infection of young rabbits that are naturally resistant to rabbit haemorrhagic disease

Young rabbits are naturally resistant to rabbit haemorrhagic disease (RHD) caused by the same calicivirus that kills, within 3 days, nearly all adult animals. We have investigated changes in blood leukocytes, and in the morphology and biochemistry of the liver (the organ where caliciviruses replicate) of young rabbits undergoing benign infection by the RHD virus. Four-week-old rabbits were infected with a calicivirus inoculum having a titre of 2(12) haemagglutination units either sacrificed 18, 24, 48 and 72 h later, or kept for follow-up studies up to 21 days after inoculation. The infection caused an acute and transient decrease in blood heterophils, and sustained enhancement in hepatic transaminases. Inflammatory infiltrates of the liver were seen in all animals after 24 h of infection; they had a predominant midlobular location. Hepatocytes could present different degrees of cell damage, including cell death; these lesions were limited to the liver cells located around the inflammatory infiltrates. Liver transaminases peaked 24-48 h after calicivirus infection; this was the same timing when liver infiltration and hepatocyte damage were more evident. No alterations of other parameters of liver biochemistry were observed. We conclude that calicivirus infection of young rabbits causes a subclinical disorder characterised by an acute and transient decrease in circulating heterophils, and focal liver damage that is expressed by intralobular infiltration by heterophils, initially, and, later on, by mononuclear cells. Our finding of persistence of increased values of liver transaminases suggests chronicity of the infection in young rabbits. We propose that, although resistant to RHD, young rabbits infected by calicivirus may be long-term carriers of the infectious agent and, thus, become a major source of transmission of the virus.

CYP1A1 and XRCC1 gene polymorphisms in SCC of the larynx

The present study was undertaken to examine CYP1A1 and XRCC1 polymorphisms as potential genetic susceptibility markers for laryngeal squamous cell carcinoma (SCC). Eighty-eight patients with laryngeal SCC and 178 randomly selected healthy blood donors from the same Caucasian population (Porto, Northern Portugal) were analysed for CYP1A1 (MspI and NcoI) and XRCC1 (Arg194Trp and Arg399Gln) polymorphisms, using PCR-RFLP techniques. CYP1A1 MspI MH (mutant homozygous) and CYP1A1 NcoI HT (heterozygous) genotypes were more frequent in patients than in controls, with those carrying a CYP1A1 NcoI HT genotype having a 2.3-fold higher risk for tumour development. On the other hand, polymorphisms in XRCC1 codon 399 and codon 194 do not seem to play a role in the aetiology of smoking-related laryngeal SCC, once its distribution was similar in both analysed groups. All the significant associations observed were exclusively due to differences between controls and larynx glottic cancer patient subgroup. Furthermore, lower lifetime tobacco consumption was observed in laryngeal SCC patients carrying the MspI and NcoI polymorphisms, than in those who did not show the polymorphic variants. This investigation seems to support the importance of CYP1A1 gene polymorphism as a potential genetic marker of laryngeal cancer development, specially concerning smokers who have inherited the at-risk genotypes CYP1A1 MspI MH or CYP1A1 NcoI HT, who do appear to be more susceptible to the development of SCC of the glottic larynx.

Tumour morphology and radiotherapy immediate response in laryngeal tumours

Laryngeal cancer is relatively frequent in South Europe countries and its incidence suffered variations in last decades. Treatment options are usually based on histology, T category and stage. Tumors unchain in neighbour tissues the presence of cells that normally are associated to inflammatory response. A possible association between tumour inflammatory response and radiotherapy efficacy is focused in occasional papers. Several histological parameters (histologic type, nuclear grade, desmoplasia, necrosis, and cells normally involved in inflammatory response) were analysed in biopsy material obtained from 67 patients with laryngeal cancer treated with primary radiotherapy in our department. Statistical analyses were made in order to assess a possible association between tumour morphology and radiotherapy response.

Cyfra 21.1, TPS and SCC in squamous cell carcinoma of larynx

BACKGROUND

Serologic tumor markers are actually a valuable tool for diagnosis, management and follow up in some cancer types. The concentrations of Cyfra 21.1, SCC and TPS has been analysed in several groups of head and neck tumors, but exclusively in larynx there are no studies concerning this subject.

AIMS

The purpose of the present study was to assess the expression of serum fragments of cytokeratins (CK's) 18/19, and squamous cell carcinoma antigen (SCCA) in a same group of patients with squamous cell carcinoma of larynx, and correlate the results with tumor localisation, T, stage, histology, presence of regional metastasis, and smoking habits.

METHODS

Forty six patients treated at the Department of Otorhinolaryngology, Porto Center of the Portuguese Institute of Oncology were enrolled in the study. Blood samples were obtained before treatment, and determinations effectuated using standard commercial available kits.

RESULTS

Although serum concentrations of Cyfra 21.1, TPS and SCC were not significantly elevated in patients with laryngeal cancer, more expressive levels namely for TPS were observed in advanced supraglotic and metastasis tumors independent of the differentiation degree.

Big is beautiful: electronic patient records in large Norwegian hospitals 1980s-2001

OBJECTIVES

This paper aims to describe and analyze the prolonged efforts - spanning close to two decades - of developing and using electronic patient records in the large, university-based hospitals in Norway.

METHODS

This study belongs to an interpretative approach to the development and use of information systems.

RESULTS

The increase in organizational, institutional, political and technological complexity has been seriously underestimated. This paper describes and analyses the prolonged efforts - spanning close to two decades - of developing and using EPRs in the large, university-based hospitals in Norway. The investments involved were considerable, implying that a crucial aspect of these efforts has been the way alliances have been forged with public institutions and agendas.

CONCLUSIONS

The conditions for small-scale, bottom-up and evolutionary approaches never succeeded in constructing themselves as a viable alternative to the larger, more sweeping electronic patient record initiative, reiterating a more general tendency to privilege the more comprehensive and daring projects.

Integrating health information systems: a critical appraisal

OBJECTIVES

The aim of this paper is to critically assess some of the underlying assumptions behind these initiatives and analyze the dominant expressions, forms and mechanisms of integration.

METHODS

This paper employs a discourse analysis to elicit the notion of integration of information systems and its consequences for electronic patient record systems.

RESULTS AND CONCLUSIONS

An alternative strategy is outlined, encouraging a more decentralized, multi-vocal approach acknowledging the productive role of related and duplicated information and preserving the existing variety of information systems.

[Hemichorea induced by diabetic ketoacidosis and striatal hyperdensity on computerized axial tomography]

INTRODUCTION

Hyperglycaemia, usually not ketotic, may cause hemichorea hemiballism. The mechanism of this physiopathological syndrome is still not clear. It usually occurs in elderly ladies and is associated with hyperdensity in the striate area contralateral to the affected side, on CT and MR potentiated in T1.

CLINICAL CASE

Three days before hospital admission, and 86 year old woman presented with the acute onset of choreiform movements of her left limbs, particularly her left arm. She had not taken neuroleptic drugs and there was no family history of chorea. On neurological examination there were no other unusual findings. Laboratory tests showed hyperglycemia with metabolic acidosis and ketone bodies in the urine. On the CT scan there was a hyperdense lesion in the right striate area, but this did not act as a space occupying lesion. Treatment was started with intravenous insulin and the symptoms disappeared 48 hours later.

CONCLUSIONS

We emphasize the rarity of the association of hemichorea and diabetic ketoacidosis. From the histological studies done in some of these patients, it seems that the hyperdensity of the striate area may be due to the proliferation of hypertrophic astrocytes secondary to small ischemic lesions. When the hyperglycaemia is treated, the chorea disappears within a few days and it is unusual for neuroleptic treatment to be required. In cases of hemichorea, hyperglycaemia should be ruled out, as should structural causes (tumors, infarcts, hematomas, traumatic lesions, etc.).

Prognosis in patients with heart failure and preserved left ventricular systolic function

BACKGROUND

It is recognized that heart failure patients with preserved left ventricular systolic function have better prognosis; nevertheless, there are some studies with conflicting results. Also, there is a paucity of data concerning the prognostic factors in this group of patients.

OBJECTIVES

To determine possible variables with prognostic relevance in heart failure patients with preserved left ventricular systolic function (ejection fraction > 40%).

METHODS

157 consecutive ambulatory patients with heart failure were assessed; those patients with ejection fraction > 40% were included in the study (n = 46). All patients were evaluated by clinical interview and physical examination, ECG, echocardiogram (M-mode, 2D and pulsed Doppler of mitral flow), biochemical study and determination of type B natriuretic peptide (BNP). The patients were grouped according to the rhythm presented on ECG: Group I--patients with atrial fibrillation; Group II--patients in sinus rhythm Group II was further subdivided in two groups according to the presence or absence of restrictive left ventricular filling pattern. All patients had a clinical follow-up, with recording of events (death or hospitalization from cardiac cause). The mean follow-up time was 682.2 +/- 55 days.

RESULTS

The mean age of the patients was 70.4 +/- 1.2 years; 54.3% were women; mean ejection fraction was 49.6 +/- 1%; mean BNP levels were 202.9 +/- 41.3 pg/ml. Mortality was 19.6% and the combined event death or hospitalization from cardiac cause) occurred in 26.1% of the patients. Among the clinical, demographic, biochemical, echocardiographic and neurohumoral parameters, only BNP levels had prognostic significance in the whole population. In Group II patients, BNP levels, heart rate and restrictive left ventricular filling pattern were identified as having prognostic significance. Kaplan-Meyer curve analysis showed that both BNP and restrictive left ventricular filling pattern seemed to be important prognostic markers.

CONCLUSIONS

This preliminary study suggests thar neurohumoral activity (determined by plasma BNP levels) and a restrictive ventricular filling pattern may be important factors in prognostic stratification of heart failure patients with preserved left ventricular systolic function.

Echocardiographic patterns and prognosis in heart failure

BACKGROUND

There are many variables with prognostic value in patients with heart failure (HF). Those related to left ventricular function are among the most important. Recently, the evaluation of the patterns of ventricular filling by pulsed Doppler echocardiography has been studied as a variable with prognostic value.

OBJECTIVES

To evaluate the prognostic value of echocardiography variables (diastolic and systolic) in patients with HF. These variables were analysed in respect to hospital admission for cardiovascular reasons or death.

MATERIAL AND METHODS

We evaluated 157 consecutive patients with HF and included 110 patients who were in sinus rhythm. The mean age was 68.2 +/- 0.9 years. HF was ischemic in 52.7%. Patients underwent echocardiography examination within the week of reference. The patients were grouped according to left ventricular (LV) systolic dysfunction (LV ejection fraction < 40%). We also classified patients in two groups according to the presence of a restrictive pattern in diastolic transmitral flow profile. Finally, we classified all patients in four groups according to their systolic function and diastolic pattern: Group I--systolic dysfunction and restrictive ventricular filling pattern. Group II--systolic dysfunction without restrictive ventricular filling pattern. Group III--without systolic dysfunction with restrictive ventricular filling pattern. Group IV--without systolic dysfunction without restrictive ventricular filling pattern. The events were death or hospital admission. The mean follow up time was 625 +/- 55 days. We did a statistical analysis and for all tests a p value < 0.05 was considered statistically significant.

RESULTS

We found impaired LV systolic function (systolic HF) in 73.6% and restrictive ventricular filling pattern in 45.5%. During the follow-up 41.8% died or were admitted to hospital. Patients with systolic HF had lower admission free survival rate. Patients with restrictive ventricular filling pattern had lower admission free survival rate than those without. Group I had lower admission free survival rate than Group II and Group IV. Group IV had a higher admission free survival than all other Groups.

CONCLUSIONS

These results support and expand previous observations that diastolic function variables, such as the pattern of ventricular filling (namely the restrictive) have independent prognostic value in patients with HF.

Tracheal Transplantation: Cytological Changes Studied by Scanning and Transmission Electron Microscopy in the Rabbit

OBJECTIVES

Our goal was to offer a comprehensive cytological study of the changes in the trachea after experimental transplantation of the organ.

STUDY DESIGN

Autografting of four tracheal rings was done in rabbits and tracheal samples were observed by electron microscopy from 1 week to 6 months after the surgery was performed.

METHODS

Transmission and scanning electron microscopy were used to investigate the fine structure of tracheal samples of rabbits submitted to autotransplantation, and quantitative methods were used to compare several cytological parameters of the different groups of animals.

RESULTS

We found that tracheal autografting was associated with acute injury of ciliated cells expressed by loss of more than 90% of cilia density on the tracheal epithelium 1 week after the transplantation was performed. The loss of cilia was balanced by an increase in mucous cells present on the tracheal lumen. Recovery of ciliated cells was observed 1 month after the tracheal autografting was performed. In contrast, only mild cytological modifications were seen in the cartilage tissue of the autografted trachea during the first weeks of transplantation; the structural alterations of the cartilage progressed up to the third month after transplantation, resulting in a moderate tracheal stenosis.

CONCLUSIONS

The data indicate that 1) autotransplantation of four tracheal rings is a viable surgical procedure; 2) tracheal grafting causes severe acute changes of the epithelium that are, however, reversible in nature; whereas 3) the initial mild alterations induced by the autografting in the cartilage may evolve into tracheal stenosis.

PCR template preparation for capillary DNA sequencing

Fluorescence-based capillary DNA sequencing has facilitated the early completion of several complex sequencing projects. While capillary systems offer great benefits in terms of ease of use and automation, we find that they are sufficiently different from slab gel separation methodologies, demanding re-examination of the protocols used to generate and use DNA sequencing templates. We have recently initiated a large-scale Human Open Reading Frame EST project involving 30 laboratories feeding 11 MegaBace 1000 capillary sequencers. The group has already produced more than 300,000 valid sequences. The most successful template preparation protocol we have found is described here. We have found that a crucial step is the standardization of the quantity and quality of the templates, which have been achieved by overnight bacterial culture followed by PCR using limiting amounts of primers. Using this protocol, there is no need for post-PCR purification, and the final preparation cost is US $0.09/template. After sequencing 10,848 templates using this protocol, 78% of the reads were accepted (after discarding vectors without inserts and inserts smaller than 100 nucleotides), and 85% of the total number of bases had Phred scores of 15 or above.

Disease outcome in inflammatory bowel disease: mortality, morbidity and therapeutic management of a 796-person inception cohort in the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD)

BACKGROUND

The course of inflammatory bowel diseases (IBD) has mainly been studied using different methods in single patient cohorts. The aim of the present study was to assess clinical aspects of disease outcome in a population-based cohort of IBD patients over a 4-year period in multiple centres across Europe.

METHODS

A total of 796 patients with IBD diagnosed in 10 centres between October 1991 and October 1993, registered at the EC IBD study centre (98% of the original cohort), participated in the study. Investigators filled out a standard follow-up form containing questions on the method of follow-up, vital status of the patient, change in diagnosis, extraintestinal manifestations, medical and surgical treatment, and physician's global assessment of disease activity.

RESULTS

Complete relief of the complaints was reported in 255 (48%) patients with ulcerative colitis (UC), 9 (50%) with indeterminate colitis (IC), but only in 87 (35%) of patients with Crohn disease (CD). Improvement was reported in 195 (37%) patients with UC, 113 (45%) with CD and 6 (33%) with IC. During the 4-year follow-up period, 23 patients died (14 UC, 8 CD. and 1 IC). The mean age at death was 69.3 years (s, 14.9 years). The deaths of three patients were recorded as directly due to IBD.

CONCLUSIONS

With the present approach to therapeutic management the short-term outcome of patients with IBD seems to be favourable in 10 medical centres in the north and south of Europe. However, more detailed studies including both objective and subjective measures are necessary.

Phylogenetic relationships among Brazilian Biomphalaria species (Mollusca: Planorbidae) based upon analysis of ribosomal ITS2 sequences

In spite of their abundance, widespread distribution and medical importance, the phylogenetic relationships among Biomphalaria snails have received relatively little attention. We have collected and studied 29 populations of snails obtained from different localities from Brazil. We have sequenced the ribosomal DNA second internal transcribed spacer (ITS2) from the following Biomphalaria species: B. glabrata, B. tenagophila tenagophila, B. occidentalis, B. straminea, B. peregrina, B. kuhniana, B. schrammi, B. amazonica, B. oligoza, B. intermedia and an outgroup species Helisoma duryi. The sequence from each species is unique. Three different methods of phylogenetic reconstruction were used (distance, maximum parsimony and maximum likelihood). The resulting phylogenetic trees obtained by these methods basically support current systematic relationships based on morphological characters alone. This study demonstrates that the ITS2 region contains markers useful for identification and determination of relationships among Biomphalaria species.

The human pericardium in vibroacoustic disease

INTRODUCTION

One of the main features of vibroacoustic disease (VAD) is the proliferation of the extra-cellular matrix which induces cardiovascular morphological and dynamic changes, and has been evaluated through echo-Doppler. While all subjects exposed to large pressure amplitude (> or =90 dB SPL) and low frequency (< or =500 Hz) (LPALF) for at least 15 yr have thickening of some cardiac structure, most frequently the pericardium, no significant diastolic changes accompany these observations. Echocardiography has become the diagnostic method of choice for the VAD. However, there have been no studies relating the echo-images of pericardial thickening to gross anatomy.

METHODS

We present the histology and ultrastructure of the pericardia of four patients who underwent cardiac surgery.

RESULTS

The most important findings concern the real thickening of the pericardium (values: 1.11, 1.35, 2.19, and 2.33 mm vs. norm: < or = 0.5 mm), the dynamic arrangements of mesothelial cells in the serosa layer, and the plasticity of the cells found among the multifascicular waveform collagen fibers. We found that the fibrosa of VAD patients has three layers: sandwiched between two thickened layers of normal fibrosa there is a loose tissue layer with vascular, nervous, and adipose structures.

CONCLUSION

These features may partially explain why no important diastolic changes are observed in VAD patients in spite of the pericardium thickening.

Effects of low frequency noise upon the reaction of pleural milky spots to mycobacterial infection

INTRODUCTION

Milky Spots (m.s.), also known as Kampmeier's foci, are confined to the parietal leaflet and act as a barrier to mediastinum infections, having very important phagocytic functions. Previous studies have made clear that large pressure amplitude and low frequency (LPALF) noise (> or = 90 dB, < or = 500 Hz) induces morphofunctional changes on the pleural mesothelium. The purpose of this study was to investigate the dynamics of m.s., namely the response to infectious agents reaching the pleural space under noise stress.

METHODS

Wistar rats (n = 20) were used; 5 as control and sham operated, 5 exposed to infection but not to noise, 5 exposed to 1696 cumulative hours of LPALF noise, and 5 exposed to 2184 cumulative hours. Following noise exposures, all rats except the 5 controls were injected with 0.2 ml of saline solution containing 2 x 10(8) viable mycobacterium avium bacilli (ATCC-25291 strain, sereotype 2). The rats were sacrificed 21 d after infection and sections of the retrocardiac pleural leaflets were observed with a light microscope using the Ziehl-Neelsen staining method.

RESULTS

There was an increase in the number and diameter of the m.s. due to hypercellularity, mainly caused by the increase of mononuclear cells, and there was formation of large granulomas containing many mycobacteria. Rats submitted to noise also presented alterations of the standard morphological changes, namely partial necrosis of the m.s.

CONCLUSION

The data suggest that exposure to LPALF noise can interfere with the normal immune response to bacterial infection in rats. This can be an important contribution to the understanding of the disorders in the pleural space of vibroacoustic disease patients.

The effect of chronic exposure to low frequency noise on rat tracheal epithelia

INTRODUCTION

Vibroacoustic Disease (VAD) is a multi-systemic entity caused by occupational or chronic exposure to large pressure amplitude and low frequency (LPALF) noise (> or = 90 dB SPL, < or = 500 Hz). The clinical picture involves extra-auditory pathology, such as neurological disturbances, respiratory disorders and cardiovascular problems. Among the first complaints of VAD patients are coughing, bronchitis, and inflammation or infection of the oral cavity and the upper respiratory pathways. The goal of ths study was to investigate the effects of occupationally simulated LPALF noise exposure on rat tracheal epithelium to determine if they could explain the symptoms found in VAD patients.

METHODS

We exposed 20 Wistar rats to occupationally simulated (8 h x d(-1), 5d x wk(-1)) LPALF noise for an accumulated total of 1236 h. The control group consisted of 10 age-matched rats, kept in equal conditions but in silence. Histological and ultrastructural studies were performed on the tracheal epithelia of both populations.

RESULTS

The most dramatic changes were identified in the ciliated cells of the exposed rats. There were frequent images of shaggy or necrotic cilia as well as regularly to partially sheared cilia. Also, there were frequent images of different stages of cilia recovery.

CONCLUSION

Occupationally simulated exposure to LPALF noise can cause important changes in ciliated cells rat tracheal epithelia. This may partially explain the clinical findings observed in VAD patients.

Increase in CD8+ and CD4+ T lymphocytes in patients with vibroacoustic disease

INTRODUCTION

Some workers employed by the aviation industry are exposed to large pressure amplitude and low frequency (LPALF) noise (> or =90 dB SPL, < or = 500 Hz) and have developed vibroacoustic disease (VAD), a whole-body noise-induced pathology. Since VAD patients have an increased prevalence of respiratory and skin infections, we investigated whether these individuals had any quantitative changes in the number of peripheral blood cell populations. Also, we investigated whether different types of noise environments are related to cell quantification.

METHODS

Quantification of peripheral blood cell populations was performed in venous blood samples of 34 VAD-diagnosed patients, and 41 controls. Leukocytes, monocytes, granulocytes, and surface phenotypes of CD8+ and CD4+ T lymphocytes were considered.

RESULTS

We found that VAD patients showed a statistically significant elevation in the number of circulating CD8+ and CD4+ T lymphocytes when compared with the control population, but not when compared among different noise-environments. Monocyte and granulocyte populations did not register significant differences.

CONCLUSION

VAD patients present enhancement in the number of circulating cytotoxic T lymphocytes (CD8+ and CD4+ T cells) thus indicating that this environmental disease is associated with quantitative changes in immune cells.

Morphofunctional study of rat pleural mesothelial cells exposed to low frequency noise

BACKGROUND

Vibroacoustic disease (VAD) is a noise-induced pathology occurring in workers occupationally exposed to large pressure amplitude (> or =90 dB SPL) and low frequency (< or = 500 Hz) (LPALF) noise, over long periods of time (> or = 10 yr). Patient complaints frequently involve the respiratory tract. There have been three cases of pleural effusion of unknown etiology and with unusually long recovery times. To better understand what may be occurring we studied the effects of LPALF noise on the morphological and functional characteristics of pleural mesothelial cells of Wistar rats.

METHODS

The animals were exposed to LPALF noise for periods ranging from 24-600 h. An intrapleural instillation of calcium tungstate was performed, and after sacrifice the pleural visceral and parietal leaflets were studied by scanning electron microscopy.

RESULTS

Acute exposure to LPALF noise caused a temporary decrease in the number of mesothelial microvilli, and prolonged exposure resulted in a definite decrease in their number as well as an impairment of their capacity to absorb particles within in the pleural space.

CONCLUSION

These results explain the pleural pathology found in human patients with VAD and confirm the deleterious effect of LPALF noise on the respiratory system.

Morphological changes in rat lung parenchyma exposed to low frequency noise

BACKGROUND

Airway flow limitation is has been identified in nonsmoker aeronautical technicians who are exposed to long term (> or =10 yr) large pressure amplitude and low frequency (LPALF) noise (> or =90 dB, < or =500 Hz). Considering this work environment, some kind of pulmonary impairment would be expected, given the probable, but not de facto, existence of fuel exhausts and vapors. In the course of morphofunctional studies of rat pleura exposed to LPALF noise environments, intense subpleural fibrosis was identified. Thus, we decided to study the deep lung parenchyma of these noise-exposed rodents.

METHODS

One group of five Wistar rats was exposed to LPALF noise for a cumulative 4000 h, and another of five rats were exposed for a cumulative of 5000 h. The control group consisted of 10, age-matched, Wistar rats that were kept in the same conditions, but in silence. Fragments of lung parenchyma were extracted after sacrifice, and processed for light microscopy, and for scanning and transmission electron microscopy.

RESULTS

Focal interstitial fibrosis of the deep lung parenchyma were identified as well as changes in the small bronchial cilia. The amount of brush cells was increased in the locations where microvilli were abnormal. An obvious increase of alveolar type II pneumocyte cells was observed with numerous, large and confluent lamellar bodies.

DISCUSSION

In contrast with the normal lung morphology observed in the control group, changes in the extra-cellular matrix and epithelial cells were identified in the exposed rats. No fuel exhaust, vapors or dust were present in the environment of the noise-exposed rats. These results, linked with the respiratory disorders identified in noise-exposed humans, strongly suggest that LPALF noise is an agent of pulmonary fibrosis.

Detection of point mutations by non-isotopic single strand conformation polymorphism

We have developed a procedure for nonradioactive single strand conformation polymorphism analysis and applied it to the detection of point mutations in the human tumor suppressor gene p53. The protocol does not require any particular facilities or equipment, such as radioactive handling, large gel units for sequencing, or a semiautomated electrophoresis system. This technique consists of amplification of DNA fragments by PCR with specific oligonucleotide primers, denaturation, and electrophoresis on small neutral polyacrylamide gels, followed by silver staining. The sensitivity of this procedure is comparable to other described techniques and the method is easy to perform and applicable to a variety of tissue specimens.

Liver transplantation for familial amyloid polyneuropathy

Familiar Amyloid Polyneuropathy (FAP), an autosomal dominant inherited multisystemic disorder was first observed by Corino de Andrade, a Portuguese neurologist, in 1939. This disease of Portuguese origin was probably spread by fishermen, mainly to Sweden and Japan. It is characterized by a progressive peripheral polyneuropathy and autonomic neuropathy (erectile sexual disfunction, gastrointestinal disfunction, bladder dysfunction and cardio vascular disease) and malnutrition. There are neural and systemic amiloid deposits. Type I FAP, of Portuguese origin, is the most common variety. The amyloid protein is the variant transthyretin (TTR) in which methionine (MET) is a substitute for valine in position 30 (TTR MET 30). It is mainly produced by the liver (90%) and, in small amounts, by the choroidal plexus. Symptoms usually start in the 3rd and 4th decade of life and the patients usually die within 10-15 years. From the therapeutic options--plasmapheresis, immunoadsorption and liver transplantation; the latter seems to be the only one, which stops the production of TTR MET 30 in a permanent way, by means of the liver. The lack of any other effective therapy and the success of the first liver transplantation performed in Sweden arouse great hope. So far, around 300 patients have been transplanted all over the world. A hundred and thirty of them were transplanted in Portugal. A Kaplan Meier survival curve of the Portuguese patients shows a survival rate of 78% at 5 years. However, in spite of the progression of the disease being halted, the irreversibility of some neurological lesions seems to persist. This fact raises the problem of the timing of the transplantation. It seems that the patients should be transplanted as soon as the symptoms start, since mortality and severe morbidity seems to mainly involve those in whom symptomatic disease has lasted longer than six years. As the explanted liver is a morphologic normal liver, a sequential (domino) transplant has been carried out in 16 cases so far done--by one of the authors (ALF) on patients with either hepatocellular carcinoma or liver metastatic disease.

Carcinoma of the penis: A cluster of cases in young men

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