[Neuroscience-Based Nomenclature for Psychotropic Drugs: Four Reasons to Use and Keep it in Portugal]

N/a.

On the concept, taxonomy, and transculturality of disordered grief

The enduring question of whether grief can ever be pathological (and, if so, when) has been shrouding mental health and psychiatric care over the last few years. While this discussion extends beyond the confines of psychiatry to encompass contributions from diverse disciplines such as Anthropology, Sociology, and Philosophy, scrutiny has been mainly directed toward psychiatry for its purported inclination to pathologize grief-an unavoidable facet of the human experience. This critique has gained particular salience considering the formal inclusion of prolonged grief disorder (PGD) in the 11th edition of the International Classification of Diseases (ICD-11) and the subsequent Text Revision 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This study contends that the inclusion of prolonged grief disorder as a diagnostic entity may be excessively rooted in Western cultural perspectives and empirical data, neglecting the nuanced variations in the expression and interpretation of grief across different cultural contexts. The formalization of this disorder not only raises questions about its universality and validity but also poses challenges to transcultural psychiatry, due to poor representation in empirical research and increased risk of misdiagnosis. Additionally, it exacerbates the ongoing concerns related to normativism and the lack of genuine cultural relativism within the DSM. Furthermore, the passionate discussion surrounding the existence, or not, of disordered forms of grief may actually impede effective care for individuals genuinely grappling with pathological forms of grief. In light of these considerations, this study proposes that prolonged grief disorder should be approached as a diagnostic category with potential Western cultural bias until comprehensive cross-cultural studies, conducted in diverse settings, can either substantiate or refute its broader applicability. This recalibration is imperative for advancing a more inclusive and culturally sensitive understanding of grief within the field of psychiatry.

Development of an online service for coping with spousal loss by means of human-centered and stakeholder-inclusive design: the case of LEAVES

To support older mourners after the loss of their partner, LEAVES, an online self-help service that delivers the LIVIA spousal bereavement intervention, was developed. It integrates an embodied conversational agent and an initial risk assessment. Based on an iterative, human-centered, and stakeholder inclusive approach, interviews with older mourners and focus groups with stakeholders were conducted to understand their perspective on grief and on using LEAVES. Subsequently, the resulting technology and service model were evaluated by means of interviews, focus groups, and an online survey. While digital literacy remains a challenge, LEAVES shows promise of being supportive to the targeted end-users.

A Web-Based Self-help Intervention for Coping With the Loss of a Partner: Protocol for Randomized Controlled Trials in 3 Countries

Background

The death of a partner is a critical life event in later life, which requires grief work as well as the development of a new perspective for the future. Cognitive behavioral web-based self-help interventions for coping with prolonged grief have established their efficacy in decreasing symptoms of grief, depression, and loneliness. However, no study has tested the efficacy for reducing grief after losses occurring less than 6 months ago and the role of self-tailoring of the content.

Objective

This study aims to evaluate the clinical efficacy and acceptance of a web-based self-help intervention to support the grief process of older adults who have lost their partner. It will compare the outcomes, adherence, and working alliance in a standardized format with those in a self-tailored delivery format and investigate the effects of age, time since loss, and severity of grief at baseline as predictors. Focus groups to understand user experience and a cost-effectiveness analysis will complement the study.

Methods

The study includes 3 different randomized control trials. The trial in Switzerland comprises a waitlist control group and 2 active arms consisting of 2 delivery formats, standardized and self-tailored. In the Netherlands and in Portugal, the trials follow a 2-arm design that will be, respectively, complemented with focus groups on technology acceptance and cost-effectiveness analysis. The main target group will consist of adults aged >60 years from the general population in Switzerland (n≥85), the Netherlands (n≥40), and Portugal (n≥80) who lost their partner and seek help for coping with grief symptoms, psychological distress, and adaptation problems in daily life. The trials will test the intervention’s clinical efficacy for reducing grief (primary outcome) and depression symptoms and loneliness (secondary outcomes) after the intervention. Measurements will take place at baseline (week 0), after the intervention (week 10), and at follow-up (week 20).

Results

The trials started in March 2022 and are expected to end in December 2022 or when the needed sample size is achieved. The first results are expected by January 2023.

Conclusions

The trials will provide insights into the efficacy and acceptance of a web-based self-help intervention among older adults who have recently lost a partner. Results will extend the knowledge on the role of self-tailoring, working alliance, and satisfaction in the effects of the intervention. Finally, the study will suggest adaptations to improve the acceptance of web-based self-help interventions for older mourners and explore the cost-effectiveness of this intervention. Limitations include a self-selective sample and the lack of cross-cultural comparisons.

Trial Registration

Switzerland: ClinicalTrials.gov NCT05280041; https://clinicaltrials.gov/ct2/show/NCT05280041; Portugal: ClinicalTrials.gov NCT05156346; https://clinicaltrials.gov/ct2/show/NCT05156346

International Registered Report Identifier (IRRID)

PRR1-10.2196/37827

[Excessive Alcohol Use in Women: An Underdiagnosed Problem?]

N/a.

Music and emotion

Introduction

Music has been said to be emotion’s language. Research confirms a link between music structure and triggered emotions.

Objectives

To assess the relationship between selected music excerpts and the emotions trigged, in order that the former will be used in future research.

Methods

An anonymous study was performed in April 2019 on 65 subjects of both sexes, aged 19- 33 (mean=21,09; SD=3,05).Subjects listened 4 excerpts of music, believed to be related either to excitement or to calmness, and answered to a questionary on emotion’s triggered by each exposure.

Results

Regarding to the music excerpts that were believed to induce excitement 80% of the subjects mentioned exciting emotions, 78% enjoyed the music while 78% didn’t knew them. For the ones that were believed to induce calmness 69% of the subjects mentioned calm emotions, 84% enjoyed the music and 62% didn’t knew the music. In an excerpt of music related to calmness, we observed association between knowing the music and the emotion trigged (p=0,027). The triggered emotion responses were independent of liking the music (P>0,05).

Conclusions

In our study, independent of liking the music, the participants reported to have perceived the expected emotions triggered by musical excerpts, showing this to be a phenomenon related to music structure. Calmness perception may be also influenced by previous knowledge of the music and related experiences. The role of individual perceptions will be looked for in following studies.

Disclosure

No significant relationships.

LEAVES (optimizing the mentaL health and resiliencE of older Adults that haVe lost thEir spouSe via blended, online therapy): Proposal for an Online Service Development and Evaluation

Background

Loss of a spouse is a frequent occurrence in later life. While most older adults successfully process this loss and will return to a normal life, about 10% of the individuals are unable to cope, and progress to prolonged grief (PG). PG, in turn, can result in mental and physical problems including poor sleep, cardiovascular problems, depression, and suicidal tendencies.

Objective

LEAVES (optimizing the mentaL health and resiliencE of older Adults that haVe lost thEir spouSe via blended, online therapy) is an online bereavement program that will support the prevention and treatment of PG, so that elderly mourners can continue to lead an active, meaningful, and dignified life. LEAVES will cater to secondary end users (eg, family, informal caregivers) by reducing stress.

Methods

LEAVES will help older adults to process the loss of a spouse in an online environment, which consists of (1) an existing online grief self-help program LIVIA, (2) the Before You Leave program that allows for storing personal memories, (3) a virtual agent platform, and (4) an accessible front-end design. LEAVES can detect persons at risk for complications, reveal negative trends in their emotional life, and act to counter such trends. The service relies on online support whenever possible but is blended with telephone or face-to-face counseling when necessary.

Results

The project will take place between February 2020 and January 2023 and includes a real-life evaluation in which 315 end users will use the service across 3 countries (the Netherlands, Portugal, and Switzerland). The evaluation of LEAVES will focus on clinical effect, its business case, and technology acceptance. The results will pave the way for smooth integration into existing care paths and reimbursement schemes.

Conclusions

The LEAVES service aims to soften the mourning process, prevents depression or social isolation, strengthens widow(er)s resilience and well-being, and quickens one’s return to societal participation.

International Registered Report Identifier (IRRID)

DERR1-10.2196/19344

The evaluation of compliance with iRefer guidelines for abdominal imaging and the impact of the normal abdominal radiograph on the clinical confidence and decision making of emergency clinicians

INTRODUCTION

Attendance of adult patients to the Emergency Department (ED) with acute abdominal pain is a frequent event. Abdominal X-ray imaging (AXR) is commonly the first line of investigation but previous studies have suggested that the AXR has no place in assessing acute abdominal pain because of its low diagnostic yield and limited contribution to direct clinical decision making. However, no evaluation of the impact of a negative AXR on the clinical confidence and decision making of emergency clinicians has been undertaken. This study aims to fill this gap.

METHOD

A self-designed paper questionnaire was distributed to medical clinicians on ED placement at a single NHS trust in the South of England. The survey sought to explore the impact of the negative AXR on clinical confidence and decision making and compliance with iRefer guidelines for referring to alternative imaging modalities (ultrasound and computed tomography) should the option to refer for AXR be restricted.

RESULTS

A total of 28 (n = 28/41; 68.3%) completed questionnaires were returned. Most clinicians (n = 18/28; 64.3%) indicated that negative AXR had little impact on their clinical decision making although a small majority (n = 10/18; 55.6%) acknowledged it provided greater clinical confidence in their decision making. Variable compliance with iRefer guidelines for referral to ultrasound and computed tomography was noted.

CONCLUSION

Whilst the negative AXR did not impact on the clinical decision making of most ED clinicians, it did increase clinical confidence. Consequently, the AXR should remain a referral option in the workup for adult patients presenting with acute abdominal pain to the emergency department.

Cognitive impairment and magnetic resonance imaging correlates in primary progressive multiple sclerosis

OBJECTIVES

To characterize cognitive impairment in primary progressive multiple sclerosis (PPMS) and to correlate the pattern of cognitive deficits with brain magnetic resonance imaging (MRI) volumetric data.

MATERIALS AND METHODS

In a multicenter cross-sectional study, we recruited consecutive patients with PPMS as well as age, sex, and education level-matched healthy controls (HC). All participants underwent neuropsychological (NP) assessment, and brain MRI was performed in patients with PPMS for analysis of lesion load, subcortical GM volumes, and regional cortical volumes.

RESULTS

We recruited 55 patients with PPMS and 36 HC. Thirty-six patients were included in the MRI analysis. Patients with PPMS performed significantly worse than HC in all NP tests. Subcortical GM volume was significantly correlated with all NP tests, except for Stroop Test, with the largest effect for the thalamus (r=-.516 [BVMT-R DR, P=.016 FDR-corrected] to r=.664 [SDMT, P<.001 FDR-corrected]). In the stepwise linear regression model, thalamic volume was the only predictor of performance in all NP tests.

CONCLUSION

Cognitive impairment is common in PPMS and affects all evaluated cognitive domains. Subcortical GM volume, particularly of the thalamus, is a strong predictor of cognitive performance, suggesting it has a central role in the pathophysiology of PPMS-related cognitive dysfunction.

The role of targeted BRCA1/BRCA2 mutation analysis in hereditary breast/ovarian cancer families of Portuguese ancestry

We report the analysis of altogether 1050 suspected hereditary breast/ovarian cancer (HBOC) families, 524 fully screened for BRCA1/BRCA2 mutations and 526 tested only for the most common mutations. Of the 119 families with pathogenic mutations, 40 (33.6%) had the BRCA2 c.156_157insAlu rearrangement and 15 (12.6%) the BRCA1 c.3331_3334del mutation, the former being specific of Portuguese ancestry and the latter showing a founder effect in Portugal. Interestingly, the two most common mutations were found in a significant proportion of the HBOC families with an a priori BRCAPRO mutation probability <10%. We recommend that all suspected HBOC families from Portugal or with Portuguese ancestry, even those fulfilling moderately stringent clinical-criteria for genetic testing, should be specifically analyzed for the two most common BRCA1/BRCA2 founder mutations, and we here present a simple method for this first tier test. Screening of the entire coding regions of BRCA1 and BRCA2 should subsequently be offered to those families with a mutation probability ≥10% if none of those founder mutations are found.

Final analysis and results of the Phase II SIMPLE dark matter search

We report the final results of the Phase II SIMPLE measurements, comprising two run stages of 15 superheated droplet detectors each, with the second stage including an improved neutron shielding. The analyses include a refined signal analysis, and revised nucleation efficiency based on a reanalysis of previously reported monochromatic neutron irradiations. The combined results yield a contour minimum of σp=5.7×10(-3)  pb at 35  GeV/c2 in the spin-dependent sector of weakly interacting massive particle (WIMP) proton interactions, the most restrictive to date for MW}≤60  GeV/c2 from a direct search experiment and overlapping, for the first time, with results previously obtained only indirectly. In the spin-independent sector, a minimum of 4.7×10(-6)  pb at 35  GeV/c2 is achieved, with the exclusion contour challenging a significant part of the light mass WIMP region of current interest.

Neoadjuvant radio chemotherapy in esophageal squamous cell carcinoma: Early results analysis of a 5-year experience

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Background: Optimized survival in oesophageal squamous cell carcinoma (OSCC) depends on complete surgical resection: prognostic impact of well-standardized techniques and per operative management in experienced groups has proven to be a key aspect. Multimodal treatment (MT) options are still controversial but particularly important in locally advanced disease apparently allowing better resectability. We perform an early evaluation of a MT protocol in locally advanced OSCC.

Methods: Survival and clinical response analysis of a cohort of pts selected between 01/01/2002 and 31/12/2007. Criteria: Locally advanced OSCC (T3/4); No distant metastases; Negative bronchoscopy; Age under 76y; No other known cancer; Surgical feasibility. Pts underwent a 5 week MT: Chemo – taxotere 20 mg/m2 IV, cysplatin 20 mg/m2 IV, 5-FU 425 mg/m2 iv (days 1,8,14,22 and 29); Radio- 40 Gy (days 1-5, 8-12, 14-19, 22-26 and 29-34) followed by surgery within 4 weeks.

Results: 57 pts (38% of all admitted) 8 fem and 49 male, aged < 50y = 11, 51-65y = 30 and > 65y = 16. Response: Complete pathological remission = 13; Partial clinical response with downstaging = 15; Minimal / no clinical response = 14; Disease progression / no surgery: 15. From the 42 pts operated, an “en bloc” osophagectomy with extended lymphadenectomy was possible in 36. The overall mean follow-up for resected pts was 16.9 months (CI 95%: 10.9-22.8). The median survival was 18 months for resected patients (CI 95%: 8.7-27.3) in contrast with 7 for all candidates to MT. There was a statistically significant difference in the survival of the 4 groups divided according to their response to MT, with clear advantage of the complete pathological remission achievers.

Conclusions: Short follow-up and series size does not allow definite conclusions. It seems nevertheless that only the group of full pathological remission and probably those that obtain a downstaging of their disease benefit from MT. Histopathological or molecular markers are required to identify target pts for neoadjuvant radio chemotherapy.

No significant financial relationships to disclose.

Real-time digital heterodyne interferometer for high resolution plasma density measurements at ISTTOK

With the implementation of alternating discharges (ac) at the ISTTOK tokamak, the typical duration of the discharges increased from 35 to 250 ms. This time increase created the need for a real-time electron density measurement in order to control the plasma fueling. The diagnostic chosen for the real-time calculation was the microwave interferometer. The ISTTOK microwave interferometer is a heterodyne system with quadrature detection and a probing frequency of 100 GHz (lambda(0)=3 mm). In this paper, a low-cost approach for real-time diagnostic using a digital signal programmable intelligent computer embedded system is presented, which allows the measurement of the phase with a 1% fringe accuracy in less than 6 micros. The system increases its accuracy by digitally correcting the offsets of the input signals and making use of a judicious lookup table optimized to improve the nonlinear behavior of the transfer curve. The electron density is determined at a rate of 82 kHz (limited by the analog to digital converter), and the data are transmitted for each millisecond although this last parameter could be much lower (around 12 micros--each value calculated is transmitted). In the future, this same system is expected to control plasma actuators, such as the piezoelectric valve of the hydrogen injection system responsible for the plasma fueling.

Molecular alterations of KIT and PDGFRA in GISTs: evaluation of a Portuguese series

AIM

To assess KIT and PDGFRA mutations frequencies in a Portuguese series of gastrointestinal stromal tumours (GISTs).

METHODS

78 GISTs were evaluated for CD117 expression and screened for mutations in KIT (exons 9, 11, 13, 14 and 17) and PDGFRA (exons 12, 14 and 18) genes.

RESULTS

KIT activating mutations were identified in 44 (56%) of the 78 GISTs. Forty cases (91%) presented a mutation in KIT exon 11, and 4 (9%) in exon 9. One case showed a 4 bp deletion in intron 14. PDGFRA mutations were observed in 5 cases (6%): 2 (3%) in exon 12 and 3 (4%) in exon 18. Survival analysis was performed in 63 of the 78 GISTs. The presence of mutated KIT was significantly correlated with shorter survival of patients (p = 0.0460), and inversely associated with epithelioid histological type of GISTs (p = 0.0064).

CONCLUSIONS

Overall, the incidence of both KIT and PDGFRA mutations in these Portuguese series was 63%, being in agreement with other studies, mainly of Iberian populations. The great majority of mutations were located in KIT exon 11, statistically associated with worse prognosis and indicative of favourable response to imatinib-based therapy in this Portuguese series of GISTs.

Effects of mercury intoxication on the response of horizontal cells of the retina of thraira fish (Hoplias malabaricus)

Methyl mercury (MeHg) is highly neurotoxic, affecting visual function in addition to other central nervous system functions. The effect of mercury intoxication on the amplitude of horizontal cell responses to light was studied in the retina of the fish Hoplias malabaricus. Intracellular responses were recorded from horizontal cells of fish previously intoxicated with MeHg by intraperitoneal injection (IP group) or by trophic exposure (T group). Only one retina per fish was used. The doses of MeHg chloride administered to the IP group were 0.01, 0.05, 0.1, 1.0, 2.0, and 6.0 mg/kg. The amplitudes of the horizontal cell responses were lower than control in individuals exposed to 0.01 (N = 4 retinas), 0.05 (N = 2 retinas) and 0.1 mg/kg (N = 1 retina), whereas no responses were recorded in the 1.0, 2.0, and 6.0 mg/kg groups. T group individuals were fed young specimens of Astyanax sp previously injected with MeHg corresponding to 0.75 (N = 1 retina), 0.075 (N = 8 retinas) or 0.0075 (N = 4 retinas) mg/kg fish body weight. After 14 doses, one every 5 days, the amplitude of the horizontal cell response was higher than control in individuals exposed to 0.075 and 0.0075 mg/kg, and lower in individuals exposed to 0.75 mg/kg. We conclude that intoxication with MeHg affects the electrophysiological response of the horizontal cells in the retina, either reducing or increasing its amplitude compared to control, and that these effects are related to the dose and/or to the mode of administration.

Investigation of the onset and development of forward scattering in an underdense plasma

We investigate the distortion of a spatial intensity modulation imposed on a 527 nm f/10 probe beam as it transmits through an underdense plasma characterized with Thomson scattering. Combining the measurements with full wave simulations of beam propagation through the entire plasma show that the key features of the data can be reproduced using the Kaiser thermal transport model.

K-shell spectroscopy of an independently diagnosed uniaxially expanding laser-produced aluminum plasma

We present detailed spectroscopic analysis of the primary K-shell emission lines from a uniaxially expanding laser-produced hydrogenic and heliumlike aluminum plasma. The spectroscopic measurements are found to be consistent with time-dependent hydrodynamic properties of the plasma, measured using Thomson scattering and shadowgraphy. The K-shell population kinetics code FLY with the measured hydrodynamic parameters is used to generate spectra that are compared to the experimental spectra. Excellent agreement is found between the measured and calculated spectra for a variety of experimental target widths employed to produce plasmas with different optical depths. The peak emission from the hydrogenic Lyman series is determined to be from a temporal and spatial region where the hydrodynamic parameters are essentially constant. This allows a single steady-state solution of FLY to be used to deduce the electron temperature and density, from the measured line ratios and linewidths, for comparison with the Thomson and shadowgraphy data. These measurements are found to agree well with time-dependent calculations, and provide further validation for the FLY calculations of the ionization and excitation balance for a K-shell aluminum plasma. We also discuss the possible application of this data as a benchmark for hydrodynamic simulations and ionization/excitation balance calculations.

Longitudinal left ventricular function in a population of healthy adults: a tissue Doppler imaging study

BACKGROUND

Longitudinal left ventricular function is a major determinant of global ventricular function and is probably more sensitive than radial function in the detection of disease. Tissue Doppler imaging of the mitral annulus allows the study of longitudinal left ventricular function.

METHODS

Forty-five healthy volunteers divided into two groups (younger and older than 45 years) were studied with pulsed tissue Doppler imaging of the 4 sides of the mitral annulus (septal, lateral, inferior, anterior) in 4 and 2 apical chamber views. In each wave (systolic-s, rapid filling-e, atrial contraction-a) we analyzed velocities, time intervals and velocity-time integrals, as well as heterogeneity and asynchrony indexes. Data were compared between the different sides in each group, between groups and with conventional Doppler data.

RESULTS

In contrast to the septal side, the lateral side of the annulus shows higher velocities and velocity-time integrals of the s and e waves, with non-significantly shorter isovolumic relaxation time and shorter time to peak e. There is functional agreement between the lateral and inferior sides versus the septal and anterior sides of the annulus. Most systolic parameters remained unchanged with aging; however, aging was associated with decreased e velocity, increased a velocity and inverted e/a ratio. The relation between s and fractional shortening also did not change with aging. Annular isovolumic contraction time and isovolumic relaxation time were shorter than their respective global time intervals.

CONCLUSIONS

This study shows that there are physiological differences in velocities, time intervals and velocity-time integrals between the 4 sides of the mitral annulus, reflecting physiological heterogeneity and asynchrony, and that some of these parameters are age dependent. These data also contribute to a better understanding of longitudinal left ventricular function and may be useful in future studies as reference values in control groups.

Role of myocardial ischemia and left ventricular wall motion abnormalities as contributory factors in the genesis of exercise-induced ST-segment elevation in Q-wave myocardial infarction

In patients with a previous myocardial infarction, controversy exists regarding the significance of postexercise ST-segment elevation in the infarct-related leads. Although usually admitted to be a sign of left ventricular dysfunction or myocardial aneurysm, other studies however have related this finding to transient myocardial ischemia and to the presence of jeopardized but viable myocardium in the infarct area. The aim of the present study was to assess the significance of postexercise ST-segment elevation in Q-wave leads as a marker of transmural ischemia or left ventricular dysfunction in 36 consecutive patients, 16 with exercise-induced ST-segment elevation in infarct-related leads. Patients were evaluated by treadmill exercise testing, coronary angiography and ventriculography, thallium-201 tomographic scintigraphy and radionuclide ventriculography within 3 months of the first myocardial infarction. Sixteen patients (group I) had exercise-induced ST segment elevation and 20 (group II) postexercise inversion, no change or pseudonormalization of the T wave in infarct-related leads. The study showed no difference in infarct-related artery, vessel disease or luminal diameter stenosis in groups I and II. The overall agreement between ST shifts and myocardial perfusion in the infarct area was 30.56% with a kappa coefficient of -0.33 (p = NS). The overall agreement between ST shifts and wall motion abnormalities was 69.44% with a kappa coefficient of 0.39 (p < 0.01), stress-induced ST-segment elevation being associated with severe wall contractile disorders in 85% of the patients. In conclusion stress-induced ST-segment elevation in Q wave leads, although not a marker of wall motion abnormalities, is associated with akinesia or dyskinesia of the left ventricular wall.

Conserved sequence motifs involving the tat reading frame of Brazilian caprine lentiviruses indicate affiliations to both caprine arthritis-encephalitis virus and visna-maedi virus

The sequence variation in small ruminant lentiviruses from Brazilian herds of milking goats was sampled in a representative region of the pol gene and in a region including the entire tat open reading frame. Clones were amplified from cDNA derived from virus produced in vitro using primers targetting conserved sequences of the pol gene. Iterative sequencing of clones indicated that animals from two herds in the Minas Gerais area were infected by a caprine arthritis-encephalitis virus (CAEV)-like virus and that individual animals carried variant virus populations. Sequences derived from an infected goat from a herd in Pernambuco showed no nucleic acid variation and were distant from the CAEV-type sequence but marginally closer to ovine visna-maedi virus (VMV) sequences. Sequences amplified from a region including the tat gene, amplified with a common upstream primer within the vif coding region and different downstream primers because of the local divergence between CAEV- and VMV-type sequences, confirmed the affiliation of the Minas Gerais sequences to CAEV and indicated that the Pernambuco isolate was indeed related to VMV, which had not previously been reported to cause natural caprine infection. The overlap between the vif and tat open reading frames clearly distinguished between CAEV-like small ruminant lentiviruses, which shared eight common nucleotides, and the VMV group, where the overlap was reduced to a single base; the final adenine of the vif terminator (TAA) is the initial adenine of the presumptive tat initiator codon. This may be useful for epizoological tracing of the origin of outbreaks.

Esophageal inflammatory pseudotumor associated with a pseudodiverticulosis cyst: two inter-related lesions?

There are some unusual esophageal lesions, which by their rarity, and location or etiology raise difficult therapeutic decisions for surgeons. In this report, we describe an esophageal inflammatory pseudotumor (IPT) associated with a pseudodiverticulosis cyst in an adult male. We discuss the pathogenic and the anatomopathological aspects of these uncommon associated lesions as well as the treatment of ITP.

Plasma homovanillic acid and prolactin in systemic lupus erythematosus

Prolactin (PRL) is an important immunoregulator and might have a role in the pathogenesis of systemic lupus erythematosus (SLE). The regulation of pituitary prolactin secretion is complex and involves a negative feedback process in the hypothalamus, in which dopamine plays the principal role. However, the main source of serum prolactin in lupus patients is still not clearly established. Since homovanillic acid (HVA), the principal metabolite of dopamine (DA), is removed from the brain into the blood, it would indirectly reflect DA metabolism. It is assumed that the turnover of a neurotransmitter can be determined through an analysis of its metabolites. The objective of this study was to analyse plasma samples from SLE patients to see if there were any alterations in neurally functioning DA through its principal metabolite, HVA. We also measured the levels of PRL and compared HVA and PRL with the clinical activity of the disease. Twenty-four SLE patients and fifteen healthy controls were studied. The investigation was done over a period of 3 months. The results of this study show significantly low levels of HVA in lupus patients compared to controls (P < 0.0001). This corresponds to a decrease in dopamine turnover. Hyperprolactinemia was observed in nine patients, and the average level of prolactin in lupus patients was higher than in healthy controls (P < 0.001). For the duration of the study, a significant percentage of variation was observed in the levels of HVA in the clinically active patients (P < 0.05) compared to inactive patients. When PRL was compared in these groups, throughout the study, no significant percentage of variation was observed. The relationship between HVA and PRL in healthy controls was r = 0.47, P = 0.08, and in patients was r = 0.04, P = 0.84. It is suggested that there is a probable association between plasma levels of HVA and PRL in the healthy controls and not in the SLE patients.

Post-exercise electrocardiographic alterations, ST-segment elevation and QTc changes in patients with recent myocardial infarction

Stress-induced ST-segment elevation and a prolongation or no change of the QTc ratio (corrected QT interval for heart rate) at maximal exercise in the infarct leads have been associated with the presence of residual myocardial ischemia in the infarct zone. The aim of this study was to test the agreement between stress-induced ST-segment elevation and post-exercise QTc changes in infarct leads, in 36 consecutive patients, studied by coronariography, radionuclide ventriculography and thallium-201 scintigraphy, within 3 months of the acute myocardial infarction. Sixteen patients (Group I) had exercise-induced ST-segment elevation in the infarct leads and 20 did not (Group II). The study showed no significant difference between severity of vessel disease and occlusion, prevalence of the infarct related artery or left ventricular dysfunction in Group I and II. No agreement between ST-segment shifts and myocardial perfusion in the infarct zone was found. Resting wall motion abnormalities were more severe in Group I than in Group II (p < 0.01). In the total of the 36 patients there was no agreement between ST-segment shifts and QTc-variations. The study showed agreement between QTc changes and myocardial perfusion in the infarct area (K = 0.64) (p < 0.001).

CONCLUSION

This study showed no relation between post-exercise ST elevation and post-exercise QTc variations in Q wave leads. QTc variations at the end of exercise in the infarct related leads identified residual ischemia. Exercise ST segment elevation, although not a marker of ischemia, is associated with more severe wall motion abnormalities in the infarct zone.

[Cardiac troponin-T. Diagnostic efficacy in acute myocardial infarction. Clinical and laboratory assessment]

Cardiac troponin-T is a subunit of the myofibrillar regulatory troponintropomiosin complex, with sufficient specificity to myocardium. In normal conditions it is absent from serum and its presence indicates lesion of the cardiac cells. The authors evaluated the analytical and clinical performance of an immunoassay for cardiac troponin-T, before its introduction in their own laboratory routine. They concluded that the test had good analytical performance, with some difficulties in practicability that can be surpassed by using a rapid bedside test for troponin-T in urgency departments, already approved by FDA in USA and available in Portugal. The diagnostic specificity and sensitivity was better than the one of the classic enzymatic markers for Acute Myocardial Infarction (AMI) but it is necessary to establish clear clinical protocols that allow its use in AMI.

[The risk of seroconversion in surgeons of the hepatitis B, hepatitis C and human immunodeficiency viruses (in a specific surgical population)]

The prevalence of hepatitis B surface antigen (HBs Ag) and antibody to hepatitis C virus (HCV) and human immunodeficiency virus (HIV) was determined in the serum specimens of 288 patients treated surgically in the orthopaedic department of an urban public teaching hospital. The cumulative risk of HBV, HCV and HIV seroconversion for an orthopaedic surgeon during the surgical career span was calculated. We found that 1.4%, 3.1% and 1.7% of patients were seropositive for HBsAg, HCV antibody and HIV antibody, respectively. Seropositivity was neither associated with age nor with trauma, whereas male patients had a greater likelihood of seropositivity. Risk factor assessment did not prove to be discriminating in identifying which patients may pose a potential exposure risk. This study supports the concept of universal infection control precautions for orthopaedic surgeons regardless of the patients' risk factor or serologic status.

[Coronary artery disease, myocardial perfusion and ventricular function in Q-wave and non-Q-wave myocardial infarcts]

Controversy remains in considering non-Q wave myocardial infarction (NQMI) a distinct pathophysiological entity of Q wave myocardial infarction (QMI). In order to analyze the severity of coronary artery disease, extension of myocardial scar or myocardial ischemia and ventricular function, 78 consecutive patients with QMI and 32 with NQMI, mean age 55.4 +/- 8.5, not submitted to thrombolytic therapy, were studied. Coronary angiography, exercise thallium scintigraphy and radionuclide ventriculography were performed in all at least within 3 months of a prior myocardial infarction. In the present study the occurrence of QMI was significantly more frequent in older patients than NQMI. There was no prevalence of occlusion either in the right, left circumflex or left anterior descending coronary arteries in both groups. Ejection fraction, degree of occlusion and presence of collateral circulation showed an equal prevalence in QMI and NQMI patients. A higher incidence of multivessel disease was found in NQMI that had less necrosis than QMI patients. The prevalence of exercise induced thallium-201 redistribution defects within the infarct zone was substantially higher and involved more scar segments in NQMI patients. Physiological and clinical consequences of coronary thrombosis depends on the size and the number of diseased arteries, the approach the pathophysiologic consequences of coronary disease in terms of fractal structure has been suggested. A pronounced heterogeneity in regional myocardial blood flow in a fractal branching arterial network may be responsible for the pathophysiologic differences of coronary thrombosis between Q-wave and non Q-wave infarction.

Comparison between dobutamine echocardiography and thallium-201 scintigraphy in detecting residual stenosis, ischemia, and necrosis in patients with prior myocardial infarction

BACKGROUND

Following the first attempts to detect myocardial ischemia with two-dimensional echocardiography stress testing, pharmacologic stress using dobutamine infusion has become an alternative to echocardiography exercise testing for evaluation of coronary artery disease. It has been shown that stress echocardiography has a diagnostic accuracy similar to that of an exercise thallium test. Other studies, however, indicated that radionuclide myocardial perfusion imaging was more sensitive than exercise or pharmacologic stress echocardiography for detection of ischemia or jeopardized myocardium.

HYPOTHESIS

The aim of the present study was to determine the ability of dobutamine stress echocardiography in comparison with thallium-201 scintigraphy to identify multivessel disease and the presence of myocardial scar and ischemia in 60 consecutive patients who suffered a first myocardial infarction (MI).

METHODS

Patients were evaluated by coronary angiography and ventriculography, thallium-201 (201TI) tomographic scintigraphy, and dobutamine echocardiography within 3 months of a first MI. Forty-seven had Q-wave MI and 13 had non-Q-wave MI. Eleven patients were excluded from final analysis-7 because of failure to achieve target heart rate in spite of the use of atropine, and 4 because of high blood pressure following the infusion of dobutamine.

RESULTS

Dobutamine echocardiography showed an overall sensitivity of 43% for detection of coronary artery lesions of 50-74% diameter stenosis and 201TI scintigraphy showed a sensitivity of 71%. For detection of lesions of > or = 75% diameter stenosis, dobutamine echocardiography showed a sensitivity of 52% and 201TI a sensitivity of 70%. Overall agreement between wall motion and myocardial perfusion for detection of necrosis and/or ischemia in the infarct area was 40.4% with a kappa coefficient of 0.09 (p = 0.13). For detection of ischemic myocardium outside the infarct zone, overall agreement was 78.6% with a kappa coefficient of 0.49 (p < 0.0001).

CONCLUSION

Dobutamine echocardiography results showed a lower sensitivity than myocardial perfusion images in predicting multivessel coronary artery disease, and there was poor agreement between both methods in identifying necrosis or ischemia.

[Prevalence of chronic hepatic disease in Portugal. Apropos of a review carried out in a hepatology unit]

The chronic elevation of Aminotransferases is one of the most frequent indications for percutaneous Liver Biopsy (LB). From a retrospective study of LB performed in the Hepatology liver Unit of Santa Maria Hospital, between 1989 and 1993, we correlated the histologic diagnosis with the etiology of liver disease, sex, age and the Aspartate aminotransferase/Alanine aminotransferase (AST/ALT) and Gama-Glutamyl transpeptidase (gamma GT) index in patients with chronic liver test abnormalities. 790 LB were reviewed retrospectively, of patients aged between 11 and 78 years, 68% males and 32% females. The most common etiology was Hepatitis C (34.6%), followed by Hepatitis B (20.1%) and alcohol (15.8%). Autoimmune diseases (Primary Biliary Cirrhosis and Autoimmune Hepatitis) were present in 3% of cases, and metabolic liver diseases in 1.4%. The distribution by sex revealed a predominance of Hepatitis C in both, alcoholic liver disease being more frequent in males (21.5% vs 3.9%). The main histological diagnoses were Chronic Active Hepatitis (27.2%), Liver Cirrhosis (19.5%), Steatohepatitis (9.5%) and minor lesions (24.6%). In alcoholic liver disease, 47.2% had Liver Cirrhosis and 16% Steatohepatitis; in Hepatitis B, Liver Cirrhosis was found in 12.6% and in Hepatitis C in 11.4%. Liver Cirrhosis had a prevalence between the 4th and 6th decade of life (82%) with a peak incidence in the 5th, and appeared earlier in Hepatitis B and later in Hepatitis C. The prevalence between sexes was similar. The main etiology of Liver Cirrhosis was alcohol (38.3%). The gamma GT index was greater in alcoholic liver disease (average 4.1) and was nearly twice in Hepatitis C than in Hepatitis B (1.7 vs 0.8).

CONCLUSIONS

1) Hepatitis C in our Hepatology Unit was the main indication for Liver biopsy. 2) The prevalence of alcoholic liver disease is greater in males, being the main etiology of Liver Cirrhosis. 3) The progression to Liver Cirrhosis seems to be similar in Hepatitis B and C. 4) The progression to Liver Cirrhosis is similar in both sexes, being dominant in the 5th decade of life. 5) The progression to Liver Cirrhosis is earlier in Hepatitis B than in Hepatitis C. 6) A gamma GT index elevation, without alcohol abuse, is suggestive of Hepatitis C. 7) Autoimmune and metabolic liver diseases seem to be rare in Portugal.

[Prospective study of duodenal ulcer. Analysis of prognostic factors]

We conducted a prospective clinical trial of 154 patients with duodenal ulcer disease, which was divided in two different steps: healing phase and post-healing phase. In the first phase, the patients were randomly assigned to treatment with H2 blockers (Ranitidine 300 mg or Famotidine 40 mg), in a single bedtime dose. Endoscopy was performed after 4 and 12 weeks of treatment and the healing rate was 70% and 90%. There were no significant differences between the two drugs. After 12 weeks of treatment there were sixteen patients with non-healed duodenal ulcer, considered as refractory duodenal ulcer disease, in which we started therapy with a double dose of H2 receptor antagonists or sucralfate (4 gr/day). Endoscopic follow-up after 12 weeks of this regimen revealed ulcer healing in about half of them; the cummulative healing rate in 6 months was 96.4%. Persistent lesions after 6 months of follow-up were found in 5 patients. Omeprazole 40 mg, single dose, was given and all of them were healed during the first 4 weeks of treatment. In the second phase, 137 patients healed during the first 3 months of treatment, were followed for 12 months and randomized in two groups: 61, with maintenance therapy--ranitidine 150 mg or famotidine 20 mg; 76, without treatment. In the patients without maintenance therapy, the recurrence rate was significantly higher (p less than 0.55), than in the group with maintenance therapy. In this group several parameters were evaluated--clinical, biochemical and psychosocial--to try to identify some prognostic markers of healing, relapse.(ABSTRACT TRUNCATED AT 250 WORDS)

[Large trials in hypertension]

Arterial Hypertension is an important public health problem due to its high prevalence, and consequences in terms of strokes, particularly in Portugal. The benefits of medical treatment of moderate and severe arterial hypertension are well documented. Some doubt persist in relationship to the indications to treat mild hypertension. This arises from the contradictory results of the great clinical trials. Some recent data suggests that the use of thiazide in low dosage, and cardioselective betablockers, in smokers, offers some hope.