Pain site persistence and changes from childhood to adolescence: a prospective cohort study

BACKGROUND

Pain is a complex experience that interferes with the well-being of youth who experience it. We aimed to assess whether recurrent pain sites in childhood can predict later recurrent pain sites prospectively.

METHODS

Pain was assessed using the Luebeck Pain Screening Questionnaire at ages 7, 10, and 13 from the Generation XXI cohort. We used multinomial regression to assess the association of recurrent pain sites at ages 7 and 10 with those at age 13.

RESULTS

We included 3833 participants. Boys with recurrent abdominal/pelvic pain at age 7 were more likely to report headaches (OR 2.81; 95%CI 1.48-5.34), abdominal/pelvic (OR 2.92; 95%CI 1.46-5.84), and musculoskeletal pain (OR 1.55; 95%CI 1.02-2.34) at age 13. Girls with recurrent abdominal/pelvic pain at age 7 were more likely to report both musculoskeletal (OR 1.62; 95%CI 1.10-2.40) and abdominal/pelvic pain (OR 1.74; 95%CI 1.15-2.65). At age 10, all pain sites were associated with pain in the same site at age 13.

CONCLUSION

Recurrent abdominal/pelvic pain at age 7 may be related to the development of various pains in adolescence. Pain at a given site at age 10 can be associated with pain at that same site at age 13.

IMPACT

Recurrent abdominal or pelvic pain during childhood was distinctively associated with an increased risk of recurrent pain in other sites during adolescence. Recurrent pain during childhood was associated with pain in the same sites at age 13, and this persistence seemed to emerge between the ages of 7 and 10 for both boys and girls. Studying early pain sites may add to the understanding of the etiology of chronic pain.

Red and brown seaweeds extracts: A source of biologically active compounds

The biological activities of Porphyra sp., Gracilaria gracilis, Alaria esculenta and Saccharina latissima extracts prepared by enzymatic and ball milling-assisted methods and hot water were evaluated. Enzyme-assisted methods allowed the highest extraction yields. Alcalase-assisted extraction (EAA) was the most effective in the recovery of polyphenolic compounds and Porphyra sp. had the highest content. The efficiency of flavonoids extraction was highly dependent on the used method. Globally, Porphyra sp. and EAA extracts exhibited the highest antioxidant and chelating activities. The highest α-amylase inhibitory activity was determined in HW Porphyra sp. extract while EAA A. esculenta extract had the highest α-glucosidase inhibitory activity. The highest ACE inhibitory activity was obtained in EAA from S. latissima. None of the extracts showed antimicrobial activity against the tested bacteria. The results showed that Porphyra sp. and S. latissima are potentially useful as ingredient in functional foods and nutraceuticals.

ST-segment elevation myocardial infarction: are women being discriminated?

Background

Although outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary interventions (PCI) have improved, a gender disparity exists, with women showing higher mortality.

Objectives

To assess gender differences in presentation, management and in-hospital, at 30-days, 6-months and 1-year after STEMI mortality.

Methods

We collected data from 809 consecutive patients treated with primary PCI and compared the females versus males.

Results

Women were older than man (69,1±14,6 vs. 58,5±12,7 years; p<0.001) with higher prevalence of age over 75 years (36.7% vs. 11.7%; p<0.001), diabetes (30,6% vs. 18,5%; p=0.001), hypertension (60.5% vs. 45.9%; p=0.001), chronic kidney disease (3.4% vs. 0.6%; p=0.010) and acute ischemic stroke (6.8% vs. 3.0%; p=0.021). At presentation, women had more atypical symptoms, less chest pain (90.3% vs. 95.6%; p=0.014) and greater clinical severity (cardiogenic shock (10.7% vs. 5.4%; p=0.011). There were no differences in the symptom-first medical contact me (95.0 min vs. 80.5 min; p=0.215); however, women had longer time until reperfusion (264.0 min vs. 212.5 min; p=0.001) and were less likely to receive optimal medical therapy (aspirin-93.1% vs. 99.2%; p<0.001; P2Y12 inhibitors 91.9% vs. 98.2%; p<0.001; beta-blockers-90.8% vs. 95.1%; p=0.032; ACEIs- 88.1% vs. 94.8%; p=0.003). In-hospital mortality (9.6% vs. 3.5%; p=0.001), at 30-days (11.3% vs. 4.0%; p<0.001), 6-months (14.1% vs. 4.7%; p<0.001) and 1-year (16.4% vs. 6.3%; p<0.001) was significantly higher in women. The multivariate analysis identified age over 75 years (HR=4.25; 95% CI [1.67–10.77]; p=0.002), Killip class II (HR=8.80; 95% CI [2.72–28.41]; p<0.001), III (HR=5.88; 95% CI [0.99–34.80]; p=0.051) and IV (HR=9.60; 95% CI [1.86–48.59]; p=0.007), acute kidney injury (HR=2.47; 95% CI [1.00–6.13]; p=0.051) and days of hospitalization (HR=1.04; 95% CI [1.01–1.08]; p=0.030) but not female gender (HR=0.83; 95% CI [0.33–2.10]; p=0.690) as independent prognostic factors of mortality.

Conclusions

Compared to men, women with STEMI undergoing primary PCI have higher mortality rates. Our results suggest that this is not due to the gender itself, but due to the women worse risk profile, the higher reperfusion time related with system delays and the minor probability of receiving the recommended therapy. Efforts should be made to reduce these gender differences.

Funding Acknowledgement

Type of funding sources: None.

The Predictive role of speckle-tracking and left ventricular ejection fraction estimation using 2D and 3D echocardiography in the detection of chemotherapy related cardiotoxicity

Background

2D left ventricular ejection fraction (LVEF) estimation through echocardiography has been the classic parameter for cancer therapy–related cardiac dysfunction (CTrCD) detection. However, it is hypothesized that other parameters can be used in order to detect early stages of subclinical cardiotoxicity when LVEF is still preserved. Therefore, 3D LVEF and 2D and 3D strain parameters assessments have been evaluated in patients submitted to anthracyclines treatment.

Objectives

To compare 2D and 3D LVEF and strain parameters estimation using echocardiography regarding its ability to predict and detect subclinical and clinical cardiotoxicity during and after anthracyclines treatment.

Search methods and criteria

A systematic review was done and search was performed on PubMed and EMBASE from January 1st of 2000 to October 31th of 2020. Observational studies comparing 2D and 3D echocardiographic exams performed in adult patients submitted to anthracyclines were analyzed. Studies that evaluated survivors of pediatric cancer were excluded. 11 studies were included (n=844 patients).

Main results

2D and 3D LVEF decreased throughout the echocardiographic assessments of 7 studies, but 2D LVEF drops were not statistically significant in 4 studies and 3 studies showed that 3D LVEF detected a superior number of patients with abnormal LVEF. Compared to 3D LVEF,

2D GLS decreased at an earlier point of treatment and detected a superior number of patients with subclinical LV dysfunction. Despite 2D and 3D GLS decreased throughout treatment, 3D GLS measurements were consistently lower and had higher relative variation. All 3D strain parameters decreased during and after the treatment and have higher relative variations than 2D GLS, with the exception of 1 study. 3D GLS reference values are not yet recognized by guidelines, so subclinical LV dysfunction was not evaluated.

Conclusions

LVEF estimation through 3D proved to be a better parameter for CTrCD detection vs 2D imaging. GLS is superior to 3D LVEF in detecting earlier LV changes, even if calculated using 2D echocardiography. Moreover, GLS reduction can be a predictor of subsequent LVEF decrease. 3DE is a growing potential technique and may be superior to 2DE in detecting and predicting subclinical LVEF dysfunction and CTrCD, respectively. Though 3D strain parameters presented promising results, more studies are needed to prove its incremental value over 2D strain echocardiography

Funding Acknowledgement

Type of funding sources: None.

Managing bifurcations: are two stents better than one?

Introduction

Bifurcation percutaneous coronary intervention (PCI) is associated with a higher degree of complexity when compared with non-bifurcation procedures. Although 1-stent PCI remains the standard approach for most bifurcation lesions, data is constantly being published on 2-stent PCI.

Aim

To evaluate and compare the characteristics and outcomes of patients that underwent bifurcation PCI with one or two stents.

Methods

Single center, retrospective observational study including all patients who underwent bifurcation PCI between January 2015-December 2018. We defined two groups: 1-stent PCI group (1s-PCI) and 2-stent PCI group (2s-PCI). The 2s-PCI group included PCI patients with all the different techniques used in our center: provisional stenting with 2 stents, Cullote, crushing stent and DK Crush.

Results

1s-PCI group included 376 individuals and 2s-PCI group included 26. Overall baseline clinical characteristics were balanced between groups. There was no statistically significant difference in age (mean 64 vs 66; p=0.388), gender (79% vs 85% males; p=0.622) and comorbidities (hypertension, diabetes mellitus, hypercholesterolemia, chronic kidney disease, smoking and previous history of coronary artery disease). Also, there was no difference in clinical status (NSTEMI 36% vs 38%; stable disease 32% vs 42%; STEMI 28% vs 19%; unstable angina 5% vs 0%; p=0.419). Coronary angiography and lesion distribution were similar in both groups (p=0.367). However, radiation dose (median 90.5 [IQR=79] vs 156 [IQR=84] mGy cm2; p<0,001) and contrast volume (median 150 [IQR=100] vs 156 [IQR=83] ml; p<0,001) were significantly higher in 2s-PCI group. At 12-month follow-up, mortality rate was higher in 1s-PCI group, but without statistical significance (8% vs 4%; p=0.71); the same is true for acute myocardial infarction at 12 months (3% vs 0%; p=0.368). Target-lesion failure was only reported in 4 patients in the 1s-PCI group. Survival tests showed no significant difference between groups (χ2(1,n=402)=0.634; p=0.426).

Conclusion

Individuals that underwent 1s-PCI were overall similar to those who underwent 2s-PCI. Predictably, deploying more than 1 stent required more contrast volume and implied a higher radiation dose. We should note that our studied is greatly limited by the 2s-PCI group size, which may justify the lack of difference in the evaluated outcomes.

Funding Acknowledgement

Type of funding sources: None.

Impact of a cardio-oncology rehabilitation program in patients with breast cancer undergoing cardiotoxic treatment

Background

Cancer treatment–related cardiotoxicity (CTrCD) is commonly associated with anthracyclines and anti-HER2 agents which are widely used for the treatment of breast cancer. In order to mitgate CTrCD, exercise-based cardio-oncology rehabilitation (COR) involving a structured exercise program has been proposed.

Objectives

To evaluate the impact of a cardiac-rehabilitation program in breast cancer patients submitted to chemotherapy with known cardiotoxicity.

Methods

A systematic review was performed. Two databases were searched, PubMed and SCOPUS. All randomized or controlled trials and other prospective studies published between 2000 and March 2020 which evaluate the impact of an aerobic exercise program on cardiorespiratory fitness (CRF), health-related quality of life (QOL), vascular/endothelial function as well as cardiac assessment namely through the evaluation of left ventricular function and cardiac biomarkers in patients undergoing anthracycline and/or anti-HER2 treatments were included.

Main results

Fourteen studies were included enrolling 578 breast cancer patients with a mean age of 48.80 years. Regarding the impact of exercise in CRF, 5 studies (n=176) reported a significant improvement of VO2 max. and 4 studies of VO2max./kg (n=137). The peak power output was also improved in 4 studies (n=95) in the exercise-group. Considering the assessment of QOL, 3 studies (n=180) revealed significant differences favoring the exercise-group. The results regarding the evaluation of the LVEF were not clear: 2 studies (n=48) reported a significant decrease on LVEF when compared to baseline at the end of the intervention in both groups, despite the exercise program. However, 2 studies (n=97) showed a significant increase on LVEF in the exercise-group. Three studies (n=82) did not found significant differences in global longitudinal strain between groups. Limited evidence was found in vascular and endothelial functon. In 2 studies (n=50), endothelial function measured by brachial artery flow-mediated dilatation significantly improved in the exercise-group. Two studies (n=98) reported no significant impact of exercise on atenuating the increase of cTnI and BNP levels in the course of chemotherapy. On the other hand, when considering NT-proBNP, an increase in its levels was attenuated in the exercise-group.

Conclusions

This study confirms that exercise-based COR seems to be an effective approach to improve several cardiovascular outcomes and quality of life in breast cancer patients.

Funding Acknowledgement

Type of funding sources: None.

Syncope: call for the missed diagnosis

Funding Acknowledgements

Type of funding sources: None.

Background

Syncope is a common reason for emergency department attendance. This entity may be associated with significant morbidity and mortality and its differential diagnosis is not straightforward. Arrhythmic causes include tachycardia and bradycardia; the later may require pacemaker implantation. Many hospitals lack a dedicated syncope unit to approach these patients. So, patients’ triage may fall into medical or surgical (trauma) areas.

Purpose

To describe the population of patients that required permanent pacemaker implantation in the year of 2019, particularly those who had a previous visit to the emergency department with syncope or presyncope.

Methods

Single-center descriptive analysis of patients that implanted a permanent pacemaker in 2019 (inclusion criteria). Additional information was collected in patients with emergency department visits in the 365 days that preceded the device implantation.

Results

In 2019, a total of 398 patients were admitted for pacemaker implantation in 2019, 55% male (n = 218), 45% female (n = 180), with mean age of 79 years. Regarding indications for pacing, 41% (n= 156) had complete atrioventricular (AV) block, 26% (n = 105) had a second degree AV block, 16% (n = 64) had sinus node dysfunction, 13.5% (n = 53) had atrial fibrillation with slow ventricular conduction, and 3.5% (n = 14) had other indications.

Twenty-two percent (n = 88) of patients had a previous visit to the emergency department (other than the ones that triggered the pacemaker implantation) with complaints of syncope (60%) or presyncope (40%). Of these, 73% (n = 64) were referred to a medical area and 27% (n = 24) were referred to a surgical area; 40 patients presented with traumatic lesions (68% cranioencephalic trauma and 32% other traumas). Of the 88 patients, only 67% (n = 59) performed an ECG and only 23% (n = 20) were referred for observation by a cardiologist in the emergency department.

Comparing medical and surgical triage, we observe that patients referred to the surgical area were less likely to perform an ECG and to be observed by a cardiologist (with statistical significance).

Conclusions

Our work describes a common problem in hospitals without dedicated syncope evaluation units. As all the patients ended up implanting a pacemaker, it is interesting to observe that 22%of these had a "warning" visit to the emergency and 33% of the last did not get and ECG. Also, trauma-oriented approaches result in a lower likelihood of performing a complete evaluation of the cause of the syncopal event. This analysis highlights the need for a comprehensive and multidisciplinary approach of patients presenting with syncope and presyncope to promote early identification and treatment of arrhythmic causes, reducing patient morbidity and healthcare costs.

Prognostic impact of severe anemia (hemoglobin <10g/dL) during treatment with dual antiplatelet therapy after hospital discharge for acute coronary syndrome

Introduction

In recent years, the use of invasive strategies has become the generalized approach in the management of patients with acute coronary syndrome (ACS), justified by the associated prognostic benefit due to reduced mortality and the evolution of percutaneous coronary intervention (PCI). However, the benefits of an invasive approach in ACS are unclear in the population with significant anemia, as anemia is strongly associated with increased risk of morbidity and mortality in these patients.

Aim

To determine the ischaemic vs. bleeding risks from patients with severe anemia (hemoglobin <10 g/dL) during treatment with Dual Antiplatelet Therapy (DAPT) after an ACS undergoing PCI.

Methods

From a national multicentre registry, we analyzed 17 370 ACS pts. Pts were divided into two groups: group 1 - pts with severe anemia (hemoglobin <10g/dL) (n=557, 3.2%); group 2 - pts without severe anemia (hemoglobin 10g/dL) (n=16813, 96.8%). Primary endpoint was the occurrence of a composite of death and adverse cardiovascular events (stroke, reinfarction, and rehospitalization of cardiovascular etiology) at 1 year.

Results

The sample consisted in 73.4% men and 26.6% women, with mean age of 66±14 years. The incidence of severe anemia was 3.2%. Group 1 pts were older (75±12 vs 66±14, p<0.001), had a higher proportion of women (47.6% vs 25.9%, p<0.001), diabetes (55% vs 30.6%, p<0.001), hypertension (81.8% vs 68.2%, p<0.001) and chronic kidney disease (29.2% vs 5.2%, p<0.001). During hospitalization, group 1 had more heart failure (35.3% vs 15.1%, p<0.001), worst LVEF (27.3% vs 17.3%, p<0,001), bleeding (7.6%% vs 1.3%, p<0.001) and transfusion (23.4% vs 1%, p<0.001). During hospitalization, group 2 pts were more likely to undergo revascularization (82.9% vs 89.4%, p<0.001) and double antiaggregation (82.5% vs 95%, p<0.001). A multivariate analysis identified age [OR 1.48, 95% CI 1.32 to 1.89; p<0.001] and feminine sex [OR 2.21, 95% CI 1.89 to 3.61; p<0.001] as independent predictors of severe anemia during hospitalization. Patients with severe anemia had longer hospital stay (9 days vs 6 days; p<0.001), and higher 6-month mortality (8.7% vs. 2.9%; p<0.001). In multivariate analysis and after adjusting for different baseline characteristics, pts with severe anemia had higher occurrence of a composite of death and adverse cardiovascular events at 1-year compared to those without severe anemia [OR 3.04, 95% CI 1.21 to 5.04; p=0.029].

Conclusion

We objected a low prevalence of ACS patients with severe anemia undergoing PCI (52.2%) but the incidence of ICP in these complex patients has increased in recent years, mainly due to the evolution of PCI over the last 40 years. Severe anemia was strongly associated with increased risk of morbidity and mortality in ACS pts.

Funding Acknowledgement

Type of funding source: None

Self-Sampling as a Plausible Alternative to Screen Cervical Cancer Precursor Lesions in a Population with Low Adherence to Screening: A Systematic Review

BACKGROUND

Cervical cancer is the fourth most common cancer in the world. A raised incidence and mortality parallel a low participation rate in screening, namely screening in poor countries and among specific populations of developed countries. Cervical or vaginal self-sampling may increase adherence to screening due to its low costs and elevated sensibility and specificity. Our main goal was to compare self-sampling with physician sampling and to evaluate the participation rate of women formerly non-adherent to cervical cancer screening.

STUDY DESIGN

We identified relevant studies from PubMed. Studies were eligible for inclusion if they fulfilled the following criteria: women aged between 16 and 80 years, poor and developed countries that use self-sampling, women with a low participation rate in screening and studies published since 2013. After fully reading the articles, data were extracted to an Excel sheet to -display all relevant information in an organized manner. -Results: We identified 18 studies, which altogether enrolled 22,118 women. Self-sampling and physician sampling are quite similar regarding the HPV detection rate. Women have a low participation rate mainly because of limited access to health services, religious and culture beliefs, and lack of time due to several demanding tasks in daily life. Self-sampling shows a significant increase in acceptability and preference compared to physician sampling.

CONCLUSION

Self-sampling is a reliable method to involve women in opportunistic or organized screening programs for cervical cancer prevention.

Statin-related Lichenoid Dermatosis: An Uncommon Adverse Reaction to a Common Treatment

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are generally safe and well-tolerated drugs that are extensively used for the primary and secondary prevention of atherosclerotic cardiovascular events. Muscle and liver adverse reactions are the best recognized, while cutaneous side effects are exceedingly rare. We present the case of a 65-year-old woman with severe hypercholesterolemia, who developed generalized erythematous cutaneous lesions with pruritus, resembling lichen planus, months after starting treatment with simvastatin. The symptoms disappeared on withdrawal of simvastatin and reappeared within 3 months upon rechallenge with rosuvastatin. In addition to describing a rare adverse effect of statins, the authors also discuss the nutraceutical approach to the management of a statin-intolerant patient.

LEARNING POINTS

Lichenoid drug eruption is an uncommon cutaneous adverse effect of several drugs, with very few cases associated with statins.A temporal relationship, dechallenge/rechallenge information, and the lack of confounding factors or alternative explanations support the suggestion of causality.Due to the lack of optimized alternative treatment options for statin-intolerant patients, the nutraceutical approach should be considered.

Identification of bacterial pathogens and antimicrobial resistance directly from clinical urines by nanopore-based metagenomic sequencing

OBJECTIVES

The introduction of metagenomic sequencing to diagnostic microbiology has been hampered by slowness, cost and complexity. We explored whether MinION nanopore sequencing could accelerate diagnosis and resistance profiling, using complicated urinary tract infections as an exemplar.

METHODS

Bacterial DNA was enriched from clinical urines (n = 10) and from healthy urines 'spiked' with multiresistant Escherichia coli (n = 5), then sequenced by MinION. Sequences were analysed using external databases and bioinformatic pipelines or, ultimately, using integrated real-time analysis applications. Results were compared with Illumina data and resistance phenotypes.

RESULTS

MinION correctly identified pathogens without culture and, among 55 acquired resistance genes detected in the cultivated bacteria by Illumina sequencing, 51 were found by MinION sequencing directly from the urines; with three of the four failures in an early run with low genome coverage. Resistance-conferring mutations and allelic variants were not reliably identified.

CONCLUSIONS

MinION sequencing comprehensively identified pathogens and acquired resistance genes from urine in a timeframe similar to PCR (4 h from sample to result). Bioinformatic pipeline optimization is needed to better detect resistances conferred by point mutations. Metagenomic-sequencing-based diagnosis will enable clinicians to adjust antimicrobial therapy before the second dose of a typical (i.e. every 8 h) antibiotic.

Extraction of Sardine Proteins by Acidic and Alkaline Solubilisation

Muscle sardine ( Sardina pilchardus) proteins were extracted using acidic or alkaline-aided solubilisation followed by isoelectric protein precipitation and compared to the traditional surimi process. This work reports the results obtained with unwashed and washed sardine mince. The highest solubilisation of sardine miofibrillar proteins was recorded at pH 2.5 (85%) and 11.5—12 (80%) and the isoelectric point was around pH 5—5.5. The global yields achieved were 77% and 73% for the alkaline and acidic processes respectively, which are considerably higher than that of the traditional surimi process ( ca. 28%). The fat content reduction was 65.3% and 51.0% for the proteins recovered after alkaline and acidic solubilisation respectively. A reduction of 91.1% was obtained in the surimi process. However, higher fat elimination was achieved when washed mince was used (95.3% and 99.0% for acidic and alkaline processes, respectively). The protein recovered after both solubilisation processes showed poor gelling properties than surimi but the acidic recovered proteins had the lowest gel strength. The washing of mince did not influence the whiteness of acidic protein recovered but the proteins recovered in the alkaline-aided solubilisation process from the washed mince were whiter.

Time course of NT-proBNP levels after acute ischemic stroke

BACKGROUND

Studies suggest that N-terminal-pro-brain natriuretic peptide (NT-proBNP) can be a biomarker of cardioembolic stroke. However, the best time to measure it after stroke is unknown. We studied the time course of NT-proBNP in patients with ischemic stroke.

METHODS

Consecutive acute ischemic stroke patients were admitted over 10 months to a Stroke Unit. Stroke type was classified according to TOAST. Blood samples were drawn within 24, 48, and 72 hours after stroke. Friedman test was used to compare NT-proBNP values across the 3 times in all, cardioembolic and non-cardioembolic stroke patients. Post hoc analysis with Wilcoxon signed-rank tests was conducted with a Bonferroni correction. Mann-Whitney test was used to compare median values of NT-proBNP between cardioembolic and non-cardioembolic stroke patients. ROC curves were drawn to determine NT-proBNP accuracy to diagnose cardioembolic stroke at 24, 48, and 72 hours after stroke onset.

RESULTS

One hundred and one patients were included (29 cardioembolic) with a mean age of 64.5±12.3 years. NT-proBNP values for cardioembolic stroke were significantly higher (P < 0.001) than for non-cardioembolic stroke in the 3 time points. NT-proBNP was highest in the first 24-48 h after ischemic stroke and decreased significantly 72 h after stroke onset. The area under the curve for the three time points was similar.

CONCLUSION

NT-proBNP levels were highest in the first 2 days after ischemic stroke and declined significantly thereafter. However, the area under the curve for the three time points was similar. The first 72 hours after ischemic stroke have a similar diagnostic accuracy to diagnose cardioembolic stroke.

One year of Lamivudine therapy for portuguese patients with chronic hepatitis B

OBJECTIVE

To assess the efficacy of lamivudine treatment on hepatitis B e antigen (HBeAg) and/or hepatitis B surface antigen (HBsAg) seroconversion, on other virological and serological markers of response including hepatitis B virus (HBV) DNA and serum aminotransferases, and the safety of lamivudine treatment in hepatitis B patients.

PATIENTS

This phase III open-label study evaluated the virological and biochemical response to lamivudine in 70 Portuguese patients with HBeAg positive chronic hepatitis B. Patients were treated with lamivudine 100mg once daily for 12 months.

METHODS

Antiviral activity was assessed by measuring alanine aminotransferase (ALT)/aspartate aminotransferase (AST) levels at all protocol visits, and hepatitis B serology and HBV DNA were performed at baseline and at month 12 visits. Evaluation of safety and tolerance was based on clinical adverse events and laboratory analyses.

RESULTS

The primary endpoint was virological response at month 12, defined as loss of detectable HBeAg from serum with a reduction of HBV DNA to undetectable levels, and this was observed in 19/69 (27.5%) of patients. Almost half of the patients were HBV DNA negative by this time. Mean ALT values decreased steadily during treatment and by 12 months 61% of patients had values within the normal range. HBeAg seroconversion (HBeAg negative, HBeAb positive) was achieved in 27.9% of patients by 12 months, although all patients remained HBsAg positive.

CONCLUSION

Lamivudine was well tolerated and the incidence of adverse events was similar to those reported in previous studies. Lamivudine treatment resulted in virological and biochemical improvements in HBeAg positive chronic hepatitis B patients, with HBeAg seroconversion in one-third of patients.

Photosensitizers for photodynamic therapy: One-pot heterogeneous catalytic transfer reduction of porphyrins

A number of new porphyrin-based photosensitizers have been developed for Photodynamic Therapy (PDT) in recent years. Chlorins, which are a reduced form of porphyrins, show better potential of application since they have a stronger absorption band on the red region of the visible spectrum and, hence, a deeper penetration into tissues. We found that by using heterogeneous catalytic transfer reduction (CTR), meso-tetraphenylporphyrin (TPP) could be hydrogenated, although in modest yields, to meso-tetraphenylchlorin (TPC) in a single reaction step. Best reaction conditions were attained using formic acid or sodium phosphinate/water as hydrogen donors, tetrahydrofuran (THF) or toluene as solvent and 10% palladium on charcoal as catalyst.

Bacterial community dynamics in horizontal flow constructed wetlands with different plants for high salinity industrial wastewater polishing

This study is focused on the diversity of bacterial communities from two series of horizontal subsurface flow constructed wetlands (CW) polishing high salinity tannery wastewater. Each series was planted with Arundo donax or Sarcocornia sp. in a substrate composed by expanded clay and sand. Chemical and biochemical oxygen demand removal efficiencies were similar in each series, varying between 58 and 67% (inlet COD 218 ± 28 mg L(-1)) and 60 and 77% (inlet BOD(5) 37 ± 6 mg L(-1)), respectively. High numbers of culturable bacteria were obtained from substrate and root samples - 5.75 × 10(6)-3.95 × 10(8) CFU g(-1) recovered on marine agar and 1.72 × 10(7)-8.46 × 10(8) CFU g(-1) on nutrient agar. Fifty bacterial isolates were retrieved from the CW, related phylogenetically to Firmicutes, Actinobacteria, Bacteroidetes, α-, β-, and γ-Proteobacteria. Changes in the bacterial communities, from roots and substrate of each series, related to the plant species, hydraulic loading rates and along CW operation were examined using denaturating gradient gel electrophoresis (DGGE). The clustering analysis suggested that a diverse and distinct bacterial community inhabits each series, which was related to the type of plant present in each CW.

Wine wastes as carbon source for biological treatment of acid mine drainage

Possible use of wine wastes containing ethanol as carbon and energy source for sulphate-reducing bacteria (SRB) growth and activity in the treatment of acid mine drainage (AMD) is studied for the first time. The experiments were performed using anaerobic down-flow packed bed reactors in semi-continuous systems. The performance of two bioreactors fed with wine wastes or ethanol as carbon sources is compared in terms of sulphate reduction, metals removal and neutralization. The results show that efficient neutralization and high sulphate removal (>90%) were attained with the use of wine wastes as substrate allowing the production of effluents with concentrations below the required local legislation for irrigation waters. This is only possible provided that the AMD and wine wastes are contacted with calcite tailing, a waste material that neutralizes and provides buffer capacity to the medium. The removal of metals using wine wastes as carbon source was 61-91% for Fe and 97% for both Zn and Cu. The lower removal of iron, when wine waste is used instead of ethanol, may be due to the presence of iron-chelating compounds in the waste, which prevent the formation of iron sulphide, and partial unavailability of sulphide because of re-oxidation to elemental sulphur. However, that did not affect significantly the quality of the effluent for irrigation. This work demonstrates that wine wastes are a potential alternative to traditional SRB substrates. This finding has direct implication to sustainable operation of SRB bioreactors for AMD treatment.

[Effects by androgen suppression with luteinizing hormone on cognitive functions in men treated for cancer of prostate]

OBJECTIVE

To evaluate secondary effects on cognitive functions as memory and attention impairments in men treated by androgen suppression for cancer of prostate.

MATERIAL AND METHODS

A prospective study on men treated with luteinizing hormone-realising hormone analogues (LH-RH analogues) for cancer of prostate was designed. Eighteen men were evaluated with cognitive tests as Mini Mental State (MMS), memory evaluation (Grober-Buschke, Rey Test), attention and executive test (Trail Making Test and Montgomery Asberg Depression Rating Scale [MADRS]) before beginning androgen suppression. Base line pretreatment assessments of every patient were compared with similar tests after six and 12 months of hormone therapy.

RESULTS

On 18 patients, 14 were eligible with pretreatment-median PSA of 22ng/ml (13-659), testosterone of 477ng/dl (398-583), which decreased to 1 and 37ng/dl, respectively. Visual-memory test (Rey test) was significantly improved at M6 (p: 0,001) and M12 (p: 0,02) as was the inversed number-memory test (WAIS) after M6 of androgen suppression and (p: 0,03).

CONCLUSION

After 12 months of androgen suppression, global cognitive performances were preserved. Our results failed to observe impairment of cognitive function. This deserves more important prospective study.

Detection of nosocomial malnutrition is improved in Amazon region by a standard clinical nutrition education program

BACKGROUND

In Brazil hospital malnutrition is highly prevalent, physician awareness of malnutrition is low, and nutrition therapy is underprescribed. One alternative to approach this problem is to educate health care providers in clinical nutrition. The present study aims to evaluate the effect of an intensive education course given to health care professionals and students on the diagnosis ability concerning to hospital malnutrition.

MATERIALS AND METHODS

An intervention study, based on a clinical nutrition educational program, offered to medical and nursing students and professionals, was held in a hospital of the Amazon region. Participants were evaluated through improvement of diagnostic ability, according to agreement of malnutrition diagnosis using Subjective Global Assessment before and after the workshop, as compared to independent evaluations (Kappa Index, k). To evaluate the impact of the educational intervention on the hospital malnutrition diagnosis, medical records were reviewed for documentation of parameters associated with nutritional status of in-patients. The SPSS statistical software package was used for data analysis.

RESULTS

A total of 165 participants concluded the program. The majority (76.4%) were medical and nursing students. Malnutrition diagnosis improved after the course (before k = 0.5; after k = 0.64; p < 0.05). A reduction of false negatives from 50% to 33.3% was observed. During the course, concern of nutritional diagnosis was increased (chi2 = 17.57; p < 0.001) and even after the course, improvement on the height measurement was detected (chi2 = 12.87; p < 0.001).

CONCLUSIONS

Clinical nutrition education improved the ability of diagnosing malnutrition; however the primary impact was on medical and nursing students. To sustain diagnostic capacity a clinical nutrition program should be part of health professional curricula and be coupled with continuing education for health care providers.

Aseptic peritonitis in a peritoneal dialysis patient

INTRODUCTION

Patients who have repeatedly sterile peritoneal fluid cultures despite elevated peritoneal fluid white cell count should be evaluated for disorders other than usual bacterial peritonitis. Intra-abdominal pathology was responsible for less than 6 percent of cases of peritonitis. Still, the clinical outcome is these situations are much worse than in other commoner causes.

CASE REPORT

A 25-year-old male non-diabetic patient in PD started his complains with diffuse abdominal pain with spontaneous remissions and exacerbations, anorexia and vomiting with 3 days evolution. Laboratory results with persistent culture-negative peritoneal fluid results seemed compatible with the diagnosis of aseptic peritonitis. However, clinical status progression and peritoneal fluid amylase levels above 50 UI/L led to perform an abdominal ultrasound that showed a painful non-compressible tubular structure with a diameter of >6 mm at the base of the cecum. The patient was then submitted to a laparotomy with appendix removal.

DISCUSSION

When assessing a patient with abdominal pain and clear or cloudy but aseptic peritoneal liquid, causes other than peritonitis should be excluded. Under antibiotic therapy, their clinical picture and evolution may be masked, delaying surgical resolution. In appendicitis, this delay may lead to perforation and consequent faecal peritonitis. All patients should be screened for peritoneal fluid amylase levels in order to differentiate bacterial peritonitis from intra-abdominal pathology. In all cases similar to the present one, an abdominal US/CAT scan should be promptly made.

Renal tumor size: comparison between computed tomography and surgical measurements

OBJECTIVE

We studied the agreement between renal tumor size as assessed on computed tomography (CT) before surgery and that measured during histopathological examination on the radical nephrectomy specimen.

METHODS

We retrospectively analyzed the records of 100 consecutive patients treated with radical nephrectomy for a renal tumor. The tumor size was determined in all patients by the largest diameter shown within the month before surgery on contrast-enhanced CT and as measured postoperatively by the pathologist. A possible influence of the clinical and pathological parameters was assessed in a multivariate analysis.

RESULTS

CT estimate and surgical measurement of tumor size were highly correlated (r = 0.9; p<0.001). Median (range) tumor size was 70.0 mm (13-180) and 60.0 mm (10-180) as measured, respectively, on CT and in the specimen, with a significant difference (p = 0.005). Multiple regression did not reveal any significant influence of tumor side, location, type, nuclear grade as well as patient gender, body mass index and radiological center (p>0.3 in all cases). The extent of difference between CT and surgical measurements was significantly influenced by the surgical size of the tumor (p = 0.03): the smaller the tumor, the more the CT overestimated the tumor size. If nephron-sparing surgery had been planned for tumors equal to or less than 40 mm, 24 patients would have been selected following the CT estimate, while 27 patients would have met this criterion on the surgical measurement.

CONCLUSION

Renal tumors were statistically smaller than the estimate from CT, although this was not systematically the case. This should be kept in mind when issuing recommendations on the optimal cutoff size value under which nephron-sparing surgery is considered equivalent to radical nephrectomy.

Pain in the first stage of labor: relationship with the patient's position

This study was designed to evaluate the relationship between the parturient's position and her abdominal and lumbar (continuous and contraction) pain during the first stage of labor. A homogeneous group of 100 parturients was randomly assigned to alternately assume the horizontal or the vertical position for 15-min periods. Their pain was measured at 2-3, 4-5, 6-7, and 8-9 centimeters dilatation. To avoid "carry over" effect, these positions were preceded by a self-elected posture. Thus, the patient adopted (a) a self-elected position, (b) recumbent (or erect), (c) a self-elected position, (d) erect (or recumbent), and so on. Pain intensity was measured by the Argentine Pain Questionnaire's Present Pain Intensity and the Huskisson's visual analogue scale. Only the patients with at least one pain evaluation in both positions using both instruments were included in the study. The setting for the study was the obstetric department of a general hospital for people connected with public education (professors, teachers, or members of school administrative staffs). The analysis revealed that a majority of patients felt less abdominal and lumbar pain, either continuous or due to contractions, during recumbency. The effect was more remarkable when dilation exceeded 5 centimeters and less intense during the first half of the first stage of labor.

Low-dose (5 mg/kg) desferrioxamine treatment in acutely aluminium-intoxicated haemodialysis patients using two drug administration schedules

BACKGROUND

According to the recommendations proposed at The Consensus Conference on Diagnosis and Treatment of Aluminium Overload in End-Stage Renal Failure Patients, Paris, 1992 low-dose desferrioxamine (DFO) treatment was applied for the first time in 41 acutely aluminium-intoxicated patients.

METHODS AND RESULTS

DFO-related neurological/ophthalmological side-effects were observed in nine of 11 patients with a post-DFO serum aluminium level > 300 micrograms/litre and in two patients of 30 below this level after a single administration of a 5-mg/kg dose of the chelator in the conventional way (i.e. the last hour of a dialysis session). They were no longer observed after introducing an alternative DFO administration schedule (i.e. administration of the chelator 5 h prior to the start of a haemodialysis session; group I: n = 14). A significant decrease in the serum aluminium levels as well as in the post-DFO serum aluminium increment (delta s A1) was observed during the first 6 months, course of low-dose DFO treatment in group I as well as group II (which consisted of patients receiving DFO in the conventional way; n = 27). Low-dose DFO treatment was accompanied by a significant increase in the mean +/- SD serum iPTH levels (group I: 174 +/- 245 up to 286 +/- 285 ng/litre; group II: 206 +/- 272 up to 409 +/- 424 ng/litre; P < 0.005) and the mean corpuscular volume (group I: 80 +/- 6.4 up to 85 +/- 3.7 fL, P < 0.005; group II: 76 +/- 5.0 up to 87 +/- 4.3 fL, (P < 0.0001). Serum ferritin levels significantly decreased in both groups. No further side-effects were observed during the DFO course. Patients in which DFO treatment could be stopped (i.e. subjects in which both serum aluminium and delta sA1 were below 50 micrograms/litre at two successive occasions) before the end of the 6 months' treatment course had a significantly greater residual diuresis (700 +/- 682 ml/min vs 84 +/- 109 ml/24 h). Also, residual diuresis was found to protect against aluminium intoxication as reflected by the values noted in group I versus those in group II.

CONCLUSION

The 5-mg/kg DFO treatment provides a safe and adequate therapy for aluminium overload. In severely aluminium-intoxicated patients presenting post-DFO serum aluminium levels above 300 micrograms/litre DFO should be given once weekly 5 h prior to high-extraction dialysis ensuring (i) maximal chelation of aluminium (ii) limited exposure to circulating aluminium noxamine levels, and (iii) adequate removal of the latter compound. Finally, the necessity for a better communication between the local water distribution companies and the dialysis centres is a major lesson that can be drawn from this dramatic intoxication.

Persistence of antibodies to hepatitis C virus in a chronic hemodialysis population

In order to evaluate the persistence of antibodies against hepatitis C virus (HCV) in a chronic hemodialysis population, we studied 151 HBsAg-negative patients. Anti-HCV titers were evaluated every 3 months over 1 year, and the serum alanine aminotransferase/serum aspartate aminotransferase ratio monthly from the start of hemodialysis. The anti-HCV titers (ELISA C100-3) remained stable in 127 patients and fluctuated in 24, without an evident correlation with hepatic function. Using our criteria, we found 85 patients with non-A, non-B hepatitis, 57 of them with biochemical criteria of chronic hepatic disease. There was a strong correlation between antibodies to HCV and non-A, non-B hepatitis (chi 2; p < 0.05) which was more marked in those patients with biochemical criteria of chronic hepatic disease (chi 2; p < 0.001). We concluded that the anti-HCV titer is reliable as a long-term marker of hepatitis C virus infection.

[Significance of digestive hemorrhage in patients with chronic renal insufficiency in hemodialysis]

Gastrointestinal Bleeding (GIB) is a complication in patients with Chronic Renal Failure (CRF) on regular hemodialysis (HD). To analyse the importance of GIB we studied, retrospectively, the causes of hospitalization in 301 patients, all on HD in the same Unit in January 1990. The average age was 57.4 +/- 14.2 years (17 to 87), time on HD 58.3 +/- 44.9 months, male = 166, female = 135. Of a total of 169 hospitalizations, the infectious disease were the most frequent cause with 37 admissions (21.9%), followed by gastrointestinal diseases with 34 admissions (21.1%). Of these, 23 (13.6%) were due to GIB (Upper GIB = 19, Lower GIB = 4). The etiologies of Upper GIB were: Peptic Ulcer = 9, erosive Gastritis/Duodenitis = 7. Angiodysplasia = 1, Mallory Weiss = 1 and unknown = 1. The etiologies of Lower GIB were: Angiodysplasia of the colon = 3, Cancer of the colon = 1. Non-steroid anti-inflammatory drugs (NSAID) had a positive correlation (p less than 0.01) with Upper GIB due to erosive Gastritis/Duodenitis. Surgery was necessary in a 8 cases of GIB, 7 of them due to Peptic Ulcer. GIB is an important cause of morbidity in patients with CRF on HD. Peptic Ulcer and erosive Gastritis/Duodenitis were the most frequent causes of GIB in the population studied. Angiodysplasia of the colon was the most important cause of Lower GIB. NSAID appear to be a risk factor for GIB from erosive Gastritis and or Duodenitis.

Prevalence of non-A non-B hepatitis and anti-HCV antibodies in a Portuguese dialysis population

Non-A Non-B hepatitis (NANBH) is nowadays one of the most common causes of hepatic dysfunction in dialysis patients. We reviewed the records of 231 HBsAg-negative patients in our unit and found 119 patients with biochemical criteria of NANBH (51.5%), 88 of them (68.9%) with circulating antibodies against HCV (chi 2 P less than 0.0001). Such high prevalence of NANBH was due to an outbreak of NANBH in the late 70s and early 80s. Time on haemodialysis (HD) was the major risk factor of NANBH in this population, and no other risk factors were identified. Prevalence of anti-HCV was similar to reports from non-uraemic populations. Anti-HCV seems to be a reliable test to confirm NANBH, but not better than using common biochemical criteria of NANBH to manage these patients in dialysis units.