Cost-effectiveness analysis of a cardio-oncology rehabilitation framework compared to an exercise intervention for cancer survivors with high cardiovascular risk

BACKGROUND

A cardio-oncology rehabilitation model among cancer survivors showed superior results comparing to a community-based exercise intervention. However, questions remain about its cost-effectiveness.

AIMS

To assess the cost-effectiveness of a center-based cardiac rehabilitation (CBCR) program when compared to usual care encompassing a community-based exercise training (CBET), among cancer survivors with high cardiovascular risk.

METHODS

The CORE study was a single-center, prospective, randomized controlled trial; 80 adult cancer survivors with previous exposure to cardiotoxic cancer treatment and/or with previous cardiovascular disease were assigned (1:1 ratio) to an 8-week CBCR or CBET, twice/week. Cost-effectiveness was a pre-specified secondary endpoint. Outcomes included healthcare resource use and costs, quality-adjusted life-years (QALYs) and cost-effectiveness; incremental cost-effectiveness ratio (ICER) was computed from a societal perspective.

RESULTS

75 patients completed the study (CBCR N=38; CBET N=37). The CBCR had significantly higher cost per patient (477.76 ± 39.08€) compared to CBET group (339.32 ± 53.88€), with a significant between-group difference 138.44€ (95% CI, 116.82 to 160.05€, p<0.01). A between-group difference by 0.100 points in QALYs was observed, favouring the CBCR (95% CI, -0.163 to -0.037, p=0.002). When CBCR was compared with CBET, the ICER was €1,383.24 per QALY gained; at a willingness-to-pay threshold of €5,000 per QALY, the probability of CBCR being cost-effective was 99.9% (95% CI, 99.4 to 100.0).

CONCLUSION

The CORE trial shows that a CBCR is a cost-effective intervention in the management of cancer survivors with high cardiovascular risk, reinforcing the potential benefits of this multidisciplinary approach in supportive care of this specific subset of cancer patients.

Unilateral segmental presentation and a novel EPHB4 gene variant in capillary malformation-arteriovenous malformation type 2

Capillary malformation-arteriovenous malformation is a rare autosomal dominant disorder associated with EPHB4 loss-of-function mutations. We report the unique presentation of a 6-year-old girl with multiple capillary malformations in a unilateral segmental distribution affecting the right hemiface, right upper chest, and right arm associated with overgrowth. Targeted next-generation sequencing on a tissue sample revealed a novel heterozygotic variant in the EPHB4 gene (NM_004444.5 (EPHB4): c.715T>A, p.[Cys239Ser]). This case highlights a distinct presentation of CM-AVM type 2 and showcases a new variant in EPHB4 not previously reported in the literature.

Adherence, safety, and satisfaction of a cardio-oncology rehabilitation program framework versus community exercise training for cancer survivors: findings from the CORE trial

PURPOSE

To assess safety, satisfaction, and overall adherence of a center-based cardiac rehabilitation (CBCR) program for cancer survivors at increased cardiovascular (CV) risk, compared to community-based exercise training (CBET).

METHODS

The CORE study was a single-center, prospective, randomized controlled trial enrolling cancer survivors exposed to cardiotoxic cancer treatment and/or with previous CV disease. Participants were randomized to an 8-week CBCR program or CBET, twice a week. Overall feasibility (consent, retention, and completion rates), intervention adherence (percentage of exercise sessions attended), and safety were assessed. Adverse events (AEs) were registered, and participants' satisfaction was measured at the end of the study.

RESULTS

Eighty out of 116 potentially eligible individuals were included; consent rate was 72.4%, and 77 (96.2%) started the study (retention rate 100% in CBCR vs 92.5% in CBET); completion rate was 92.5%. Intervention adherence was higher in CBCR (90.3 ± 11.8% vs 68.4 ± 22.1%, p < 0.001). Exercise-related AEs were mainly related to musculoskeletal conditions in both groups (7 in CBCR vs 20 in CBET, p < 0.001), accounting for exercise prescription modification in 47 sessions (18 (3.3%) in CBCR vs 29 (7.2%) in CBET, p = 0.006), none motivating exercise discontinuation. No participants reported major CV events. Overall, the satisfaction with the different aspects of the programs (e.g., expectations, monitoring) was higher in the CBCR.

CONCLUSION

This exploratory analysis of the CORE trial suggests that both exercise-based interventions are feasible and safe in this setting. The higher intervention adherence and patient satisfaction in CBCR suggest that this comprehensive approach could be of interest in this population.

Pediatric Melanoma: Epidemiology, Pathogenesis, Diagnosis and Management

Pediatric melanoma is the most common skin cancer in children. However, it is extremely rare this population, being even rarer in younger than 10 years of age. Its diagnosis is often difficult, due to its rarity and atypical presentations. There are three main subtypes of pediatric melanoma: Spitzoid melanoma, melanoma arising in a congenital melanocytic nevus and conventional melanoma. Congenital melanomas exist and are exceptionally rare, although they do not constitute a different subtype of melanoma. Spitzoid melanoma is the most common subtype affecting children younger than 11 years. Despite presenting with local aggressive features and frequent nodal involvement, it encompasses an excellent prognosis. The risk of malignant transformation of congenital melanocytic nevi varies widely accordingly to the projected adult size, number, and concomitant abnormalities found in the central nervous system. The surveillance and treatment of melanoma arising in a congenital melanocytic nevus is challenging, enclosing poor outcomes. In adolescents, the most common subtype is the conventional (adult-type). Contrary to the adult population, the majority of conventional pediatric melanoma arises from previous nevi but follows the general adult epidemiology and risk factors. Specific guidelines for management of pediatric melanoma do not exist and it is treated similarly to melanoma in the adult.

Effects of community-based supervised exercise in the quality of life, physical fitness, and functioning of breast cancer survivors

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Background: Physical exercise is recommended to cancer patients. We aim to evaluate the efficacy of a low-cost community-based supervised exercise program in early breast cancer survivors after primary treatment. Methods: A single-arm clinical trial, controled by a run-in period, of a 16-weeks intervention consisting of 3 weekly sessions of combined aerobic and strength exercise at moderate to vigorous intensity in group classes of no more than 20 participants. Participants were evaluated at weeks 1, 8 and 16 (M1, M2 and M3) of the run-in period and 8 and 16 of the experimental phase (M4 and M5) for quality of life (QoL) (EORTC QLQ-C30), handgrip strength, sit-to-stand (STS) test and maximal aerobic capacity. Results: Of the 82 participants, 25 completed the program and evaluations. Median age was 58 years (39-73), 64% underwent mastectomy, 48% had axillary lymph node dissection, 80% was treated with radiotherapy, 80% with chemotherapy and 84% with hormonotherapy. Median time from surgery was 13 months (4-107). Physical functioning domain of QoL improved significantly following 8 (p = 0.04) and 16 weeks (p = 0.03) of exercise training. Handgrip strength in surgical and non-surgical limbs increased after 8 weeks and maintained after 16 weeks of control phase, further increasing after 8 weeks (p = 0.01) and 16 weeks of exercise (p = 0.00). Lower-limb strength also increased after 16 weeks of exercise (p = 0.01), and maintained during control (p = 0.09). Additionally, maximal aerobic capacity tended to further increase after exercise training (p = 0.06), after increasing during control phase (p = 0.02). Conclusions: A low-cost community-based supervised exercise program improves physical fitness and functioning in breast cancer survivors after primary treatment. Clinical trial information: NCT04024280 . [Table: see text]

Biological effects and bioaccumulation of gold in gilthead seabream (Sparus aurata) - Nano versus ionic form

The question of whether gold (Au) is more toxic as nanoparticles or in its ionic form remains unclear and controversial. The present work aimed to clarify the effects of 96 h exposure to 4, 80 and 1600 μg·L^-1 of 7 nm gold nanoparticles (AuNPs) - (citrate coated (cAuNPs) or polyvinylpyrrolidone coated (PVP-AuNPs)) - and ionic Au (iAu) on gilthead seabream (Sparus aurata). Effects at different levels of biological organization (behaviour, neurotransmission, biotransformation, oxidative stress/damage and genotoxicity) were assessed. cAuNPs induced oxidative stress and damage (lipid peroxidation increase), even at 4 μg·L^-1, and reduced the ability of S. aurata to swim against a water flow at 1600 μg·L^-1. Exposure to cAuNPs induced more adverse effects than exposure to PVP-AuNPs. All tested concentrations of Au (nano or ionic form) induced DNA breaks and cytogenetic damage in erythrocytes of S. aurata. Generally, iAu induced significantly more effects in fish than the nano form, probably associated with the significantly higher accumulation in the fish tissues. No fish mortality was observed following exposure to AuNPs, but mortality was observed in the group exposed to 1600 μg·L^-1 of iAu.

Predicting incomplete basal cell carcinoma excisions - a large multidisciplinary retrospective analysis in a tertiary center

Introduction: Surgical treatment of basal cell carcinomas is often performed by physicians with different surgical backgrounds. Collecting data from different surgical departments would better reflect their real-life surgical management.Objectives: To identify the rate, recurrence risk, and predictive factors accordingly to their relative contribution for an incomplete basal cell carcinoma excision in a large multidisciplinary real-life settingMethods: Retrospective cohort study of 2305 surgically treated lesions in different departments of a tertiary center.Results: There was a rate of incomplete excisions (15%) and a recurrence rate (35.5% vs. 6.8% in incomplete vs. complete excisions (p < .001)). A third of incompletely excised basal cell carcinoma (BCC) will recur over time. Stratified by relevancy, high-risk histological subtypes (micronodular (OR 5.10 - p < .001) and morpheaform (OR 5.42 - p < .001), smaller specimen sizes ( <0.5 cm or 0.5-1 cm, OR 3.99 and 2.49, respectively, p < .001) high-risk locations (OR 3.06 on the nose, OR 2.77 on the eyelids, p < .001), and recurrent BCCs (OR 1.72, p < .001). are the best predictors of an incomplete excision.Conclusions: Acknowledging the rate, recurrence risk and predictive factors for incomplete excisions may be beneficial for optimal preoperative planning and to prevent unwarranted re-interventions, morbidity, and healthcare costs.

Investigating the mechanisms underlying phytoprotection by plant growth-promoting rhizobacteria in Spartina densiflora under metal stress

Pollution of coasts by toxic metals and metalloids is a worldwide problem for which phytoremediation using halophytes and associated microbiomes is becoming relevant. Metal(loid) excess is a constraint for plant establishment and development, and plant growth promoting rhizobacteria (PGPR) mitigate plant stress under these conditions. However, mechanisms underlying this effect remain elusive. The effect of toxic metal(loid)s on activity and gene expression of ROS-scavenging enzymes in roots of the halophyte Spartina densiflora grown on real polluted sediments in a greenhouse experiment was investigated. Sediments of the metal-polluted joint estuary of Tinto and Odiel rivers and control, unpollutred samples from the Piedras estuary were collected and submitted to ICP-OES. Seeds of S. densiflora were collected from the polluted Odiel marshes and grown in polluted and unpolluted sediments. Rhizophere biofilm-forming bacteria were selected based on metal tolerance and inoculated to S. densiflora and grown for 4 months. Fresh or frozen harvested plants were used for enzyme assays and gene expression studies, respectively. Metal excess induced SOD (five-fold increase), whereas CAT and ascorbate peroxidase displayed minor induction (twofold). A twofold increase of TBARs indicated membrane damage. Our results showed that metal-resistant PGPR (P. agglomerans RSO6 and RSO7 and B. aryabhattai RSO25) contributed to alleviate metal stress, as deduced from lower levels of all antioxidant enzymes to levels below those of non-exposed plants. The oxidative stress index (OSI) decreased between 50 and 75% upon inoculation. The results also evidenced the important role of PAL, involved in secondary metabolism and/or lignin synthesis, as a pathway for metal stress management in this halophyte upon inoculation with appropriate PGPR, since the different inoculation treatments enhanced PAL expression between 3.75- and five-fold. Our data confirm, at the molecular level, the role of PGPR in alleviating metal stress in S. densiflora and evidence the difficulty of working with halophytes for which little genetic information is available.

Disentangling the photochemical salinity tolerance in Aster tripolium L.: connecting biophysical traits with changes in fatty acid composition

A profound analysis of A. tripolium photochemical traits under salinity exposure is lacking in the literature, with very few references focusing on its fatty acid profile role in photophysiology. To address this, the deep photochemical processes were evaluated by Pulse Amplitude Modulated (PAM) Fluorometry coupled with a discrimination of its leaf fatty acid profile. Plants exposed to 125-250 mm NaCl showed higher photochemical light harvesting efficiencies and lower energy dissipation rates. under higher NaCl exposure, there is evident damage of the oxygen evolving complexes (OECs). On the other hand, Reaction Centre (RC) closure net rate and density increased, improving the energy fluxes entering the PS II, in spite of the high amounts of energy dissipated and the loss of PS II antennae connectivity. Energy dissipation was mainly achieved through the auroxanthin pathway. Total fatty acid content displayed a similar trend, being also higher under 125-250 mm NaCl with high levels of omega-3 and omega-6 fatty acids. The increase in oleic acid and palmitic acid allows the maintenance of the good functioning of the PS II. Also relevant was the high concentration of chloroplastic C16:1t in the individuals subjected to 125-250 mm NaCl, related with a higher electron transport activity and with the organization of the Light Harvesting Complexes (LHC) and thus reducing the activation of energy dissipation mechanisms. All these new insights shed some light not only on the photophysiology of this potential cash-crop, but also highlight its important saline agriculture applications of this species as forage and potential source of essential fatty acids.

Ecophysiological constraints of Aster tripolium under extreme thermal events impacts: Merging biophysical, biochemical and genetic insights

Cold and heat waves are phenomenon that occurs in higher frequency and intensity due to global climate changes. Commonly cultivated crop species are crucially affected by extreme weather events, and therefore alternative crops - such as halophytes - gain in agricultural interest. While halophytes are potentially able to cope with temperature extremes on the long term exposure, effects of temporary events such as cold and heat waves are not yet described. In order to unveil the effects of these altered thermal environments, Aster tripolium plants were subjected to cold (9/5 °C) and heat (42/38 °C) waves regimes during 3 days and its photochemical and biochemical traits evaluated. In the potential cash crop A. tripolium cold waves induced the gene expression of dehydrins in order to counteract desiccation and thus to prevent oxidative stress. Regulatory proteins on the RNA maturation level (Maturase K) were highly expressed. Heat stress induced the gene expression of the cystein protease gene; most likely to degrade misfolded proteins temporary. Both thermal treatments decreased the photosynthetic efficiency and capacity, driven by a loss in the connectivity between PSII antennae. Nevertheless the light absorption capacity was unaffected due to an increased RC closure net rate. Cold wave-treated individuals showed a decrease in the carotenoid pigmentation, except auroxanthin. In cold wave treated individuals the overall peroxidase activity was significantly increased. Data suggest that exposure to both, cold and heat wave treatment decreased the ecophysiological capacity of A. tripolium.

Light-dark O2 dynamics in submerged leaves of C3 and C4 halophytes under increased dissolved CO2: clues for saltmarsh response to climate change

Waterlogging and submergence are the major constraints to which wetland plants are subjected, with inevitable impacts on their physiology and productivity. Global warming and climate change, as driving forces of sea level rise, tend to increase such submersion periods and also modify the carbonate chemistry of the water column due to the increased concentration of CO2 in the atmosphere. In the present work, the underwater O2 fluxes in the leaves of two abundant Mediterranean halophytes were evaluated at different levels of dissolved CO2. Photosynthetic enhancement due to increased dissolved CO2 was confirmed for both Halimione portulacoides and Spartina maritima, probably due to high tissue porosity, formation of leaf gas films and reduction of the oxygenase activity of Rubisco. Enhancement of the photosynthetic rates in H. portulacoides and S. maritima was concomitant with an increase in energy trapping and transfer, mostly due to enhancement of the carboxylation reaction of Rubisco, leading to a reduction of the energy costs for carbon fixation. Transposing these findings to the ecosystem, and assuming increased dissolved CO2 concentration scenarios, the halophyte community displays a new ecosystem function, increasing the water column oxygenation and thus reinforcing their role as principal primary producers of the estuarine system.

Photochemical and biophysical feedbacks of C₃ and C₄ Mediterranean halophytes to atmospheric CO₂ enrichment confirmed by their stable isotope signatures

According the latest predictions, an increase of about two times in atmospheric CO2 concentrations, is expected to occur by the end of this century. In order to understand the effects of this atmospheric composition changes on two abundant Mediterranean halophytes (Halimione portulacoides and Spartina maritima), mesocosmos trials were performed simulating two atmospheric CO2 environments (380 ppm and 760 ppm of CO2 respectively). The two chosen halophyte species present different metabolic characteristics: H. portulacoides, is a C3 specie while S. maritima is a C4 species. Distinct feedbacks were obtained for each of the studied species. Stable Isotope discrimination showed that both species showed an enhancement of the Rubisco carboxylation capacity and photosynthetic efficiency mostly due to an increase in intracellular [CO2]. In H. portulacoides CO2 fertilization induced an enhancement of ETR and a decrease in non-photochemical quenching and in dissipated energy fluxes. On the other hand the C4 grass S. maritima, already at full capacity, showed no photosynthetic enhancement. In fact this highly productive grass presented lower photosynthetic efficiencies accompanied by increases in dissipated energy fluxes mostly due to reductions in energy flux associated with the transport of reducing power throughout the quinone pool. The accumulation of reducing power led to oxidative stress, and thus the photosynthetic ability of this grass was greatly reduced. Both these feedbacks to realistic future CO2 concentrations are important consideration for in future primary productivity models, indicating a possible reduced abundance of the pioneer S. maritima and an increased biomass spreading of the sediment stabilizer H. portulacoides, inevitably affecting the morphology and function of the salt marshes imposed by these atmospheric changes, both in terms of ecosystem functioning and loss of biodiversity.

Biophysical probing of Spartina maritima photo-system II changes during prolonged tidal submersion periods

Submergence is one of the major constrains affecting wetland plants, with inevitable impacts on their physiology and productivity. Global warming as a driving force of sea level rise, tend to increase the submersion periods duration. Photosynthesis biophysical probing arise as an important tool to understand the energetics underlying plant feedback to these constrains. As in previous studies with Spartina maritima, there was no inhibition of photosynthetic activity in submerged individuals. Comparing both donor and acceptor sides of the PSII, the first was more severely affected during submersion, driven by the inactivation of the OEC with consequent impairment of the ETC. Although this apparent damage in the PSII donor side, the electron transport per active reaction centre was not substantially affected, indicating that this reduction in the electron flow is accompanied by a proportional increase in the number of active reaction centres. These conditions lead to the accumulation of excessive reducing power, source of damaging ROS, counteracted by efficient energy dissipation processes and anti-oxidant enzymatic defences. This way, S. maritima appears as a well-adapted species with an evident photochemical plasticity towards submersion, allowing it to maintain its photosynthetic activity even during prolonged submersion periods.

Ecophysiological adaptations of two halophytes to salt stress: photosynthesis, PS II photochemistry and anti-oxidant feedback--implications for resilience in climate change

Halimione portulacoides and Sarcocornia fruticosa commonly exhibit a reddish coloration especially in high evaporation periods, due to betacyanin production in response to stress. Although sharing the same area in salt marshes, they present different strategies to overcome salinity stress. While S. fruticosa present a dilution strategy, increasing succulence, H. portulacoides appears to have developed an ionic compartmentalization strategy. Nevertheless, there's still a decrease in the photosynthetic activity in different extents. While in S. fruticosa, the impairment of photosynthetic activity is due to a decrease in the flow from the electron transport chain to the quinone pool; in H. portulacoides the process is affected far more early, with high amounts of energy dissipated at the PSII light harvesting centers. This photosynthetic impairment leads to energy accumulation and consequently to the production of reactive oxygen species (ROS). SOD was particularly active in stressed individuals, although this increment is rather more significant in S. fruticosa than in H. portulacoides suggesting that H. portulacoides may have a maximum salt concentration at which can sustain cellular balance between ROS production and scavenging. These different ecophysiological responses have great importance while evaluating the impacts climate change driven increase of sediment salinity on halophyte physiology and on the marsh community and ecosystem services.

Particulate metal distribution in Tagus estuary (Portugal) during a flood episode

Particulate metal concentrations were assessed before, during and after a flood episode in the Tagus estuary. Particulate metal concentrations showed a decrease during the flood period and very similar values in the months before and after the flood event. Before this period, sampling station characteristics were verified to be homogenous during the peak of the flooding event, as all of the sampling stations assumed very specific characteristics. One of the main consequences from the flood, concurrent with a decrease in particulate metal concentrations, was the high input of SPM into the estuarine area. This finding indicates higher levels of heavy metals in fine-sized particles at low SPM concentration than those present in coarser particles at high SPM levels. These periodic flood events can be considered as estuarine contamination masks and should be interpreted as periods of dilution in heavy metal contamination rather than as an estuarine cleansing process.

Hexavalent chromium reduction, uptake and oxidative biomarkers in Halimione portulacoides

The in situ reduction of Cr (VI) to its less toxic form Cr (III) may be a useful detoxification mechanism for phytoremediation. Using a hydroponics mesocosmos approach, we evaluated the ability of Halimione portulacoides to reduce and uptake Cr (VI) and its anti-oxidative feedback and biomarkers. It was found that this specie can, not only reduce large amounts of Cr (VI) in the external medium, but also withdrawn and accumulate this element in its roots and aboveground organs. Both these mechanisms were found to be dose dependent. Jointly with this phytoremediative potential the oxidative feedback was also assessed. Chromium uptake had its major implications on the chlorophyll content and flavonoid content, with potential consequences in the photosynthetic and photo-protective mechanisms. Although the high Cr root accumulation in H. portulacoides, there were no inactivation of the enzymatic defenses, allowing a continuous defense against reactive oxygen species. In fact, GPX and specially SOD revealed to be an excellent dose-related biomarker of Cr induced stress. All these aspects make this specie suitable for Cr (VI) phytoremediation processes, either by phytoextraction or by reduction of Cr (VI) to Cr (III) and also for monitoring programs using SOD and GPX as biomarkers of Cr environmental contamination.

Scirpus maritimus leaf pigment profile and photochemistry during senescence: implications on carbon sequestration

Leaf senescence is the final phase of the leaf development, comprising several controlled complex physiological, biochemical and molecular events. From February to June it was possible to observe a rapid increase of Scirpus maritimus biomass accompanied by an increase in the overall pigment battery, photosynthetic efficiency and photoprotection capacity. With senescence progressing, the photosynthetic pigments decreased dramatically in a rather equal extent. With the exception of Zeaxanthin (90% decrease), all pigments suffered a 98-100% decreased during senescence. Overlooking the operational PSII quantum efficiency it was possible to observe that it suffered almost no changes during leaf maturation (with the exception of the senescent leaves), whilst the maximum quantum efficiency, showed more evident changes, decreasing with the leaf maturation. This observation coupled with the increased DES index may be an indication that the decrease in the PSII maximum yield may represent a mechanism to down-regulate the photosynthetic electron transport rate compensating the consequent decrease in CO(2) assimilation capacity. This fact allied with a decrease in the minimum light intensity for photosynthesis saturation in senescent leaves, suggest that the requirement for reducing power and photophosphorylation for the dark reaction is inevitably decreased and that photosynthesis in senescent leaves will be saturated.

Two novel recessive mutations in KRT14 identified in a cohort of 21 Spanish families with epidermolysis bullosa simplex

BACKGROUND

Basal epidermolysis bullosa simplex (EBS) is a group of blistering genodermatoses mostly caused by mutations in the keratin genes, KRT5 and KRT14. Recessive mutations represent about 5% of all EBS mutations, being common and specific in populations with high consanguinity, where affected patients show severe phenotypes.

OBJECTIVES

To accomplish the first mutational analysis in patients of Spanish origin with EBS and to delineate a comprehensive genotype-phenotype correlation.

METHODS

Twenty-one EBS families were analysed. Immunofluorescence mapping at the dermoepidermal junction level was performed on skin biopsies from patients. Mutation screening of the entire coding sequences of KRT5 and KRT14 in genomic DNA was assessed by polymerase chain reaction and direct sequencing.

RESULTS

KRT5 or KRT14 causative mutations were identified in 18 of the 21 EBS families. A total of 14 different mutations were disclosed, of which 12 were dominant missense mutations and two truncating recessive mutations. Five of the 14 mutations were novel including three dominant in KRT5 (p.V186E, p.T321P and p.A428T) and two recessive in KRT14 (p.K116X and p.K250RfsX8). The two patients with EBS carrying homozygous recessive mutations were affected by severe phenotypes and belonged to consanguineous families. All five families with the EBS Dowling-Meara subtype carried recurrent mutations affecting the highly conserved ends of the α-helical rod domain of K5 and K14. The seven mutations associated with the localized EBS subtype were widely distributed along the KRT5 and KRT14 genes. Two families with mottled pigmentation carried the P25L mutation in KRT5, commonly associated with this subtype.

CONCLUSIONS

This study further confirms the genotype-phenotype correlation established for EBS in other ethnic groups, and is the first in a Mediterranean country (excluding Israel). This study adds two novel recessive mutations to the worldwide record to date, which includes a total of 14 mutations. As in previous reports, the recessive mutations resulted in a lack of keratin K14, giving rise to a generalized and severe presentation.

Accumulation and biological cycling of heavy metal in four salt marsh species, from Tagus estuary (Portugal)

Pools of Zn, Cu, Cd and Co in leaf, stem and root tissues of Sarcocornia fruticosa, Sarcocornia perennis, Halimione portulacoides and Spartina maritima were analyzed on a bimonthly basis, in a Tagus estuary salt marsh. All the major concentrations were found in the root tissues, being the concentrations in the aboveground organs neglectable for sediment budget proposes, as seen by the low root-aboveground translocation. Metal annual accumulation, root turnovers and cycling coefficients were also assessed. S. maritima showed the higher root turnovers and cycling coefficients for most of the analyzed metals, making this a phytostabilizer specie. By contrast the low root turnover, cycling coefficient and low root necromass generation makes S. perennis the most suitable specie for phytoremediation processes. Although the high amounts of metal return to the sediments, due to root senescence, salt marshes can still be considered sinks of heavy metals, cycling heavy metals mostly between sediment and root.

The first COL7A1 mutation survey in a large Spanish dystrophic epidermolysis bullosa cohort: c.6527insC disclosed as an unusually recurrent mutation

BACKGROUND

Dystrophic epidermolysis bullosa (DEB) is a genodermatosis caused by mutations in COL7A1. The clinical manifestations are highly variable from nail dystrophy to life-threatening blistering, making early molecular diagnosis and prognosis of utmost importance for the affected families. Mutation identification is mandatory for prenatal testing.

OBJECTIVES

To conduct the first mutational analysis of COL7A1 in a Spanish cohort, to assess mutation consequences at protein/mRNA level and to establish genotype-phenotype correlations.

METHODS

Forty-nine Spanish patients with DEB were studied. Antigen mapping was performed on patient skin biopsies. COL7A1 mutation screening in genomic DNA was performed by polymerase chain reaction (PCR) and direct sequencing. Mutation consequences were determined by reverse transcriptase-PCR.

RESULTS

Eight patients belonged to three unrelated families with dominant DEB. Forty-one were affected with recessive DEB (RDEB). Specifically, 27 displayed the severe generalized subtype, eight the other generalized subtype and six a localized phenotype (two pretibial, three acral and one inversa). Thirty-five mutations were identified, 20 of which are novel. The pathogenic mutation c.6527insC accounted for 46.3% of Spanish RDEB alleles. A consistent genotype-phenotype correlation was established.

CONCLUSIONS

Although the COL7A1 database indicates that most DEB mutations are family specific, the pathogenic mutation c.6527insC was highly recurrent in our cohort. This level of recurrence for a single genetic defect has never previously been reported for COL7A1. Our findings are essential to the clinicians caring for patients with DEB in Spain and in the large population of Spanish descendants in Latin America. They also provide geneticists a molecular clue for a priority mutation screening strategy.

Avaliação do Projecto Integrado para a Prevenção do Abuso Sexual (PIPAS): Estudo preliminar

Neste artigo apresenta-se um programa de prevenção do abuso sexual implementado na Casa Pia de Lisboa e respectiva avaliação e discutem-se, ainda, critérios para a avaliação de programas. No estudo de avaliação utilizou-se um design longitudinal quantitativo, por questionário, com dois momentos, pré e pós-teste, com seis meses de intervalo entre si. Os participantes (N = 188), do 3º ao 6º ano, foram distribuídos aleatoriamente por grupos controlo e experimental, respondendo a um conjunto de questionários considerados adequados para a avaliação das principais competências treinadas no programa. Os grupos não se mostraram diferentes entre o início e o final da intervenção, mas o papel do colégio e o maior número de sessões contribuíram significativamente para o aumento das competências sócio-emocionais dos jovens. Por fim, discutem-se aspectos da aplicação do programa essenciais para a compreensão dos resultados encontrados e fazem-se recomendações sobre práticas de implementação do programa que optimizem a sua eficácia.

Skin gene therapy for acquired and inherited disorders

The rapid advances associated with the Human Genome Project combined with the development of proteomics technology set the bases to face the challenge of human gene therapy. Different strategies must be evaluated based on the genetic defect to be corrected. Therefore, the re-expression of the normal counterpart should be sufficient to reverse phenotype in single-gene inherited disorders. A growing number of candidate diseases are being evaluated since the ADA deficiency was selected for the first approved human gene therapy trial (Blaese et al., 1995). To cite some of them: sickle cell anemia, hemophilia, inherited immune deficiencies, hyper-cholesterolemia and cystic fibrosis. The approach does not seem to be so straightforward when a polygenic disorder is going to be treated. Many human traits like diabetes, hypertension, inflammatory diseases and cancer, appear to be due to the combined action of several genes and environment. For instance, several wizard gene therapy strategies have recently been proposed for cancer treatment, including the stimulation of the immune system of the patient (Xue et al., 2005), the targeting of particular signalling pathways to selectively kill cancer cells (Westphal and Melchner, 2002) and the modulation of the interactions with the stroma and the vasculature (Liotta, 2001; Liotta and Kohn, 2001).

[Syphilis in adolescent mothers in the city of Posadas, Province of Misiones]

During three months (April to June 1997) 1,238 consecutive pregnant women were studied at the time of delivery at the Madariaga public Hospital. Syphilis was confirmed in 26 (2.1%) women, and 15 cases (57.7%) of congenital syphilis were demonstrated in newborns one of whom was a stillborn. Of the syphilitic women 61.5% were 20 years old (average), 65.4% were single, 19.2% had a stable partner and 15.4% were married; 70% of them had finished elementary school (seven years), but despite this discrete level of instruction and that they were benefited with free health attention, 73% of them had not started or completed the pregnancy control. None of these women acted as sexual workers or were drug users; 57.7% were unemployed and the remainder worked as domestic servants or were still going to school. Menarca started at 13 (average) and the age of the first sexual activity was 15 (average). The distribution of the cases of syphilis within the city area shows four clusters that coincide with the lower income population, but not with marginal groups. The failure to submit to medical control during pregnancy among syphilitic women is directly linked with an increased risk for congenital syphilis. The specific prevalence of syphilis in women (20 years old or less) pregnant or not, shows an alarming hidden epidemic situation. An interinstitutional and communitary program, with direct interventions within the detected population clusters, is now underway in order to control syphilis. Undesired pregnancy and syphilis seem to be associated with adolescent unsafe sex conducts. A coordinated program between Public Health Service and National Misiones University is operating, visiting home by home, in order to decrease or eliminate congenital syphilis and is considered a priority health problem. Unfortunately, if sexual conducts do not undergo changes in the near future, at least by the correct use of condoms, HIV will replace syphilis.

A new method of creating an arteriovenous graft access

Since the initial description of the radial arteriovenous (AV) shunt, hemodialysis has played a primary role in the survival of patients with chronic renal failure. However, it is not unusual to be confronted with patients on chronic hemodialysis who have exhausted all superficial venous access sites. We describe a technique using the deep veins of the arms the outflow system during AV graft construction. By anastomosing the venous limb of the graft to the larger of the two brachial veins, we have been able to give patients AV access when the superficial veins have been exhausted. We have performed this technique with good success in 12 patients. Further experience and longer follow-up are needed.

Abdominal actinomycosis

PURPOSE

Actinomyces israelii are normal inhabitants in the oral cavity and upper intestinal tract of humans. They rarely cause disease and are seldom reported as pathogens. As a pathogen it causes fistulas, sinuses, and may appear as an abdominal mass and/or abscess. The abdominal mass can masquerade as a malignant process that is very difficult to differentiate, often requiring surgical intervention with resection. Because of difficulty in making a preoperative diagnosis, we undertook this review to determine if all patients require surgical intervention and whether other adjunctive modalities may improve preoperative diagnosis.

METHODS

We report two patients with abdominal actinomycosis, one affecting the sigmoid colon and the other the retroperitoneum, iliac crest region. Both simulated a malignant process and required operations for diagnosis and treatment.

RESULTS

As reported, actinomycotic abdominal masses and strictures can be treated by penicillin alone. Long-term medical treatment seems to be very successful and avoids surgical resection. The difficulty is obtaining a definitive diagnosis.

CONCLUSION

The computed tomographic scan is the most helpful diagnostic modality. Appearance of abdominal actinomycosis is usually a contrast enhancing multicystic lesion as was found in these two patients. Needle aspiration cytology can be fairly accurate in obtaining the diagnosis and is recommended for suspicious lesions.

Double-blind comparison of butorphanol and nalbuphine on the common bile duct by ultrasonography in man

Butorphanol and nalbuphine, narcotic agonist-antagonists were shown to cause no increase in biliary pressure in contrast to morphine in dogs or men. A non-invasive, ultrasonographic technique confirmed that morphine caused constriction of the common bile duct while placebo caused no effect. To prove the lack of constrictive effect of butorphanol and nalbuphine on the common bile duct, the changes in its diameter were measured following placebo or the two agonist-antagonists by ultrasonography. In a double-blind, randomized study, 17 patients undergoing open cholecystectomy were evaluated. No morphine or opioids were allowed for 12 hours prior to the study. After premedication with midazolam and glycopyrrolate, anesthesia was induced by midazolam, 50 micrograms.kg-1 and thiopental, 3.0-5.0 mg.kg-1. Tracheal intubation was facilitated by succinylcholine 1.0 mg.kg-1 and muscle relaxation was maintained with vecuronium. Anesthesia was maintained with isoflurane or enflurane and nitrous oxide in oxygen. After imaging the common bile duct by ultrasonography, placebo, nalbuphine 0.3 mg.kg-1 or butorphanol 40 micrograms.kg-1 were injected intravenously. The diameter of the common bile duct was measured before and at 4 and 8 minutes after drug administration. One-way analysis of variance and paired t-test were utilized for statistical analysis. P < 0.05 was considered significant. No significant changes in the common bile duct diameter was observed after placebo administration, nor was any change observed after either nalbuphine or butorphanol as compared to the baseline. The comparison of three groups of patients showed no statistically significant difference.(ABSTRACT TRUNCATED AT 250 WORDS)

Double-blind placebo-controlled ultrasonographic confirmation of constriction of the common bile duct by morphine

Although the increase in the common bile duct pressure in response to morphine has been repeatedly reported in experimental animals and humans, this is the first double-blind non-invasive, ultrasonographic study designed to demonstrate constriction of the common bile duct caused by i.v. administration of morphine in surgical patients. In a double-blind, placebo-controlled, randomized study, 12 patients undergoing open cholecystectomy were enrolled. No opioids were allowed for 12 hours prior to the study. After premedication with midazolam and glycopyrrolate, anesthesia was induced by midazolam, 50 micrograms/kg-1 and thiopental, 3.0-5.0 mg/kg-1. Tracheal intubation was facilitated by succinylcholine, 1.0 mg/kg-1 and muscle relaxation was maintained with vecuronium. Anesthesia was maintained with enflurane and nitrous oxide in oxygen. After imaging the common bile duct by ultrasonography, placebo or morphine, 0.2 mg/kg-1 was injected intravenously. The diameter of the common bile duct was measured before and 4 and 8 minutes after the drug. Student t-test was utilized for statistical analysis. P < 0.05 was considered significant. No significant change in common bile duct diameter was observed after placebo administration. Morphine caused a significant reduction in the diameter of the common bile duct. Before morphine, the mean +/- SD diameter was 9.5 +/- 3.3 mm; after morphine at 4 and 8 minutes, 7.2 +/- 2.1 and 5.8 +/- 2.1 mm, respectively. It is concluded that ultrasonography in a double-blind placebo-controlled design has proven to be a valid method for the evaluation of the effect of drugs on the common bile duct.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastrointestinal manifestations of amyloidosis: a case of diverticular perforation

Amyloidosis is an intriguing disorder. Its clinical presentation usually rests on the organ(s) infiltrated with the amyloid. We report a patient who presented with peritonitis secondary to a perforated large jejunal diverticulum and multiple small bowel diverticula. We believe the diverticula were a direct result of primary amyloid infiltration of the intestine in the antimesenteric location. This is the first reported case of small bowel diverticula caused by amyloidosis.

Perforated duodenal diverticulum

Duodenal diverticula are present in up to 20 per cent of the population but few patients require surgery for acute complications. Perforation is the rarest of these complications; only 101 affected patients have been reported in the world literature. These reports of perforated duodenal diverticulum are reviewed and strategies for the diagnosis and management of this unusual condition are discussed.