Polystyrene nanoplastics in the marine mussel Mytilus galloprovincialis

Concerns about plastic pollution and its toxicity towards animals and people are growing. Polystyrene (PS) is a plastic polymer highly produced in Europe for packaging purposes and building insulation amongst others. Whatever their source-illegal dumping, improper waste management, or a lack of treatment for the removal of plastic debris from wastewater treatment plants-PS products ultimately end up in the marine environment. Nanoplastics (<1000 nm) are the new focus for plastic pollution, gaining broad interest. Whether primary or secondary, their small size permits nanoparticles to cross cellular boundaries, consequently leading to adverse toxic effects. An in vitro assay of Mytilus galloprovincialis haemocytes exposed to 10 μg/L of polystyrene nanoplastics (PS-NPs; 50 nm) for 24 h was used to test cellular viability along with the luminescence inhibition (LC50) of Aliivibrio fischeri bacteria to evaluate acute toxicity. Cellular viability of mussel haemocytes decreased significantly after a 24 h exposure and PS-NPs LC50 range from 180 to 217, μg/L. In addition, a 28-day exposure of the marine bivalve M. galloprovincialis to PS-NPs (10 μg/L; 50 nm) was performed to evaluate the neurotoxic effects and the uptake of these plastic particles in three bivalve tissues (gills, digestive gland, and gonads). The ingestion of PS-NPs was time- and tissue-specific, suggesting that PS-NPs are ingested through the gills and then translocated through the mussel bloodstream, to the digestive gland and gonads where the highest amount of ingested PS-NPs was reported. Ingested PS-NPs may compromise the digestive glands' key metabolic function and impair mussels' gametogenic and reproductive success. Data on acetylcholinesterase inhibition and those previously obtained on a wide range of cellular biomarkers were elaborated through weighted criteria providing a synthetic assessment of cellular hazard from PS-NPs.

Ecotoxicity of emerging contaminants in the reproductive organ of marine mussels Mytilus galloprovincialis

Contaminants of emerging concern (CECs) present a new threat to the marine environment, and it is vital to understand the interactions and possible toxicity of CEC mixtures once they reach the ocean. CECs-such as metal nanoparticles, nanoplastics, and pharmaceuticals-are groups of contaminants some of which have been individually evaluated, though their interactions as mixtures are still not fully understood. To ensure a healthy and prosperous future generation, successful reproduction is key: however, if hindered, population dynamics may be at danger leading to a negative impact on biodiversity. This study aimed to understand the effects of silver (20 nm nAg, 10 μg/L), polystyrene nanoparticles (50 nm nPS, 10 μg/L), and 5-fluorouracil (5FU, 10 ng/L) individually and as a mixture (10 μg/L of nPS + 10 μg/L of nAg +10 ng/L of 5FU) in the gonads of Mytilus galloprovincialis. A multibiomarker approach, namely the antioxidant defence system (ADS; superoxide dismutase, catalase, glutathione peroxidases, glutathione - S - transferases activities), and oxidative damage (OD; lipid peroxidation) were analysed in the gonads of mussels. All exposure treatments after 3 days led to an increase of enzymatic activity, followed by an inhibition after 14 and 21 days. Thus, ADS was overwhelmed due to the generation of ROS, resulting in OD, except for nPS exposed mussels. The OD in Mix exposed mussels increased exponentially by 57-fold. When CEC mixtures interact, they are potentially more hazardous than their individual components, posing a major threat to marine species. To understand synergistic and antagonistic interactions, a model was applied, and antagonistic interactions were observed in evaluated biomarkers at all time-points, apart from a synergistic interaction at day 3 relative to LPO. Results indicate that the effects observed in Mix-exposed mussel gonads are mainly due to the interaction of nAg and 5FU but not nPS.

New synthetic nano-immunotherapy (OncoTherad®) for non-muscle invasive bladder cancer: Its synthesis, characterization and anticancer property

Bacillus Calmette-Guérin (BCG)-based intravesical immunotherapy has been applied as gold standard treatment for high-risk non-muscle invasive bladder cancer (NMIBC) for almost half a century. However, several patients with high-risk disease experience relapse, including those whose condition has worsened and who failed to respond to BCG. Non-significant therapeutic options have been developed for these at-risk patients, for many years. Immunotherapies have shown promising outcomes for bladder cancer treatment. Accordingly, our research group developed the OncoTherad® (MRB-CFI-1) immunotherapy, which has shown positive outcomes in NMIBC treatment. The aim of the current study is to describe, in details, the physicochemical features and potential action mechanisms of OncoTherad® nano-immunotherapy, based on toll-like receptor 4 (TLR4)-mediated interferon and on RANK/RANKL signaling pathways, in animal model with NMIBC. Based on the current findings, OncoTherad® nano-immunotherapy did not have genotoxic effect on the investigated model and did not show signs of limiting local and/or systemic toxicity at therapeutic doses. OncoTherad® nano-immunotherapy was more effective than the BCG treatment, since it reduced by 70% the malignancy rate. Furthermore, it was possible identifying an important action mechanism of OncoTherad®, which was based on the modulation of TLR4-mediated interferon and RANK/RANKL signaling pathways that, altogether, were essential to reduce malignancy rate. OncoTherad® mechanisms in these pathways helped preventing tumor recurrence.

Assessing the effects of the cytostatic drug 5-Fluorouracil alone and in a mixture of emerging contaminants on the mussel Mytilus galloprovincialis

The assessment of contaminants of emerging concern, alone and in mixtures, and their effects on marine biota requires attention. 5-Fluorouracil is a cytostatic category 3 anti-cancer medication (IARC) that is used to treat a variety of cancers, including colon, pancreatic, and breast cancer. In the presence of other pollutants, this pharmaceutical can interact and form mixtures of contaminants, such as adhering to plastics and interaction with metal nanoparticles. This study aimed to comprehend the effects of 5-Fluorouracil (5FU; 10 ng/L) and a mixture of emerging contaminants (Mix): silver nanoparticles (nAg; 20 nm; 10 μg/L), polystyrene nanoparticles (nPS; 50 nm; 10 μg/L) and 5FU (10 ng/L), in an in vivo (21 days) exposure of the mussel Mytilus galloprovincialis. A multibiomarker approach namely genotoxicity, the antioxidant defence system (superoxide dismutase (SOD), catalase (CAT), glutathione peroxidases (GPx), glutathione - S - transferases (GST) activities), and oxidative damage (LPO) was used to assess the effects in gills and digestive gland of mussels. Both treatments cause genotoxicity in mussel's haemolymph, and antagonism between contaminants was observed in the Mix. Genotoxicity observed confirms 5FU's mode of action (MoA) by DNA damage. The antioxidant defence system of mussels exposed to 5FU kicked in and counter balanced ROS generated during the exposure, though the same was not seen in Mix-exposed mussels. Mussels were able to withstand the effects of the single compound but not the effects of the Mix. For oxidative stress and damage, the interactions of the components of the mixture have a synergistic effect.

Chronic toxicity of polystyrene nanoparticles in the marine mussel Mytilus galloprovincialis

Nanoplastics (NP) (1-100 nm) are a growing global concern, and their adverse effects in marine organisms are still scarce. This study evaluated the effects of polystyrene nanoplastics (10 μg/L; 50 nm nPS) in the marine mussel Mytilus galloprovincialis after a 21 - day exposure. The hydrodynamic diameter and zeta potential of nPS were analysed, over time, in seawater and ultrapure water. A multibiomarker approach (genotoxicity (the comet assay) was assessed in mussel haemocytes, and the antioxidant enzymes (superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx)), biotransformation enzyme (glutathione - S - transferase (GST)), and oxidative damage (LPO)) was assessed in gills and digestive glands to evaluate the toxicity of nPS towards mussels. In seawater, aggregation of nPS is favoured and consequently the hydrodynamic diameter increases. Genotoxicity was highly noticeable in mussels exposed to nPS, presenting a higher % tail DNA when compared to controls. Antioxidant enzymes are overwhelmed after nPS exposure, leading to oxidative damage in both tissues. Results showed that mussel tissues are incapable of dealing with the effects that this emerging stressor pursues towards the organism. The Integrated Biomarker Response index, used to summarise the biomarkers analysed into one index, shows that nPS toxicity towards mussels are both tissue and time dependent, being that gills are the tissue most compromised.

Perfluorooctane sulfonic acid (PFOS) adsorbed to polyethylene microplastics: Accumulation and ecotoxicological effects in the clam Scrobicularia plana

Microplastics are widespread in the marine environment, whereby the uptake of these tiny particles by organisms, can cause adverse biological responses. Plastic debris also act as a vector of many contaminants, herein depending on type, size, shape and chemical properties, possibly intensifying their effects on marine organisms. This study aimed to assess the accumulation and potential toxicity of different sizes of microplastics with and without adsorbed perfluorooctane sulfonic acid (PFOS) in the clam Scrobicularia plana. Clams were exposed to low-density polyethylene microplastics (1 mg L^-1) of two different sizes (4-6 and 20-25 μm) virgin and contaminated with PFOS (55.7 ± 5.3 and 46.1 ± 2.9 μg g^-1 respectively) over 14 days. Microplastic ingestion, PFOS accumulation and filtration rate were determined along with a multi biomarker approach to assess the biological effects of microplastics ingestion. Biomarkers include oxidative stress (superoxide dismutase, catalase, glutathione peroxidases), biotransformation enzymes (glutathione-S-transferases activity), neurotoxicity (acetylcholinesterase activity), oxidative damage and apoptosis. Microplastics ingestion and PFOS accumulation was microplastic size dependent but not PFOS dependent and filtration rate was reduced at the end of the exposure. Reactive oxygen species in gills and digestive gland were generated as a result of exposure to both types of microplastics, confirming the disturbance of the antioxidant system. Larger virgin microparticles lead to stronger impacts, when compared to smaller ones which was also supported by the Integrated Biomarker Responses index calculated for both tissues. An anti-apoptotic response was detected in digestive glands under exposure to any of the MPs treatments.

Nanoplastics impact on marine biota: A review

Emerging contaminants, such as nanoplastics, are gaining a vast interest within the scientific community. Most of the plastic debris found in the marine environment originates from land-based sources, and once in the marine environment, plastic can be degraded into smaller fragments. Nanoplastics are considered to fall within the definition of other nanoparticles (1-100 nm in size) and may be divided into primary or secondary nanoplastics. Primary nanoplastics are those that enter the environment in their original small size associated with specific applications and consumer products, whilst secondary nanoplastics are a consequence of macro/microplastic degradation. The formation of nanoplastics changes the physical-chemical characteristics of the particle, thus at a nanoscale, it is expected that the strength, conductivity, and reactivity of the nanoparticles will differ substantially from macro/micro-sized particles. To date, the toxicity nanoplastics may pursue on marine biota is still scarce. Herein, a review of the available data on the effects of different polymer types of nanoplastics specific to marine biota is accounted for.

Assessing cadmium-based quantum dots effect on the gonads of the marine mussel Mytilus galloprovincialis

This study assesses the sex-specific effects induced by CdTe QDs, on the marine mussel Mytilus galloprovincialis in comparison to its dissolved counterpart. A 14 days exposure to CdTe QDs and dissolved Cd was conducted (10 μg Cd L^-1), analysing Cd accumulation, oxidative stress, biotransformation, metallothionein and oxidative damage in the gonads. Both Cd forms caused significant antioxidant alterations, whereby QDs were more pro-oxidant, leading to oxidative damage, being females more affected. Overall, biochemical impairments on gonads of M. galloprovincialis demonstrate that the reproductive toxicity induced by CdTe QDs in mussels are sex-dependent and mediated by oxidative stress and lipid peroxidation. It is crucial to acknowledge how gametes are affected by metal-based nanoparticles, such as Cd-based QDs. As well as understanding the potential changes they may undergo at the cellular level during gametogenesis, embryogenesis and larval development potentially leading to serious impacts on population sustainability and ecosystem health.

Numerical simulation of lateral and transforaminal lumbar interbody fusion, two minimally invasive surgical approaches

The present study aims to compare spinal stability after two different minimally invasive techniques, the lateral lumbar interbody fusion (LLIF) and the transforaminal lumbar interbody fusion (TLIF) approaches. Two nonlinear three-dimensional finite element (FE) models of the L4-L5 functional spinal unit (FSU) were subjected to the loads that usually act on the lumbar spine. Findings show that the LLIF approach yields better results for torsion load case, due to the larger surface area of the implant. For extension, flexion and lateral bending loads, the TLIF approach presents smaller displacements probably due to the anterior placement of the cage and to the smaller damaged area of the annulus fibrosus.

Minimally invasive transforaminal and anterior lumbar interbody fusion surgery at level L5-S1

This paper presents a finite element analysis to investigate the biomechanical changes caused by transforaminal (TLIF) and anterior lumbar interbody fusion (ALIF) at the L5-S1 level, applying two different implants: T_PAL (TLIF) and SynFix (ALIF). The main objective is to determine which one is more stable for patients. Numerical simulations of segmental motion show that, in the early postoperative phase, displacements and rotation angles obtained in ALIF are greater than the corresponding ones obtained in TLIF, as well as the principal stress values on the ligaments. So, TLIF performed with T_PAL is more stable than ALIF, especially during the recovery phase.

Photodynamic inactivation of biofilms formed by Candida spp., Trichosporon mucoides, and Kodamaea ohmeri by cationic nanoemulsion of zinc 2,9,16,23-tetrakis(phenylthio)-29H, 31H-phthalocyanine (ZnPc)

The biofilms formed by opportunistic yeasts serve as a persistent reservoir of infection and impair the treatment of fungal diseases. The aim of this study was to evaluate photodynamic inactivation (PDI) of biofilms formed by Candida spp. and the emerging pathogens Trichosporon mucoides and Kodamaea ohmeri by a cationic nanoemulsion of zinc 2,9,16,23-tetrakis(phenylthio)-29H,31H-phthalocyanine (ZnPc). Biofilms formed by yeasts after 48 h in the bottom of 96-well microtiter plates were treated with the photosensitizer (ZnPc) and a GaAlAs laser (26.3 J cm(-2)). The biofilm cells were scraped off the well wall, homogenized, and seeded onto Sabouraud dextrose agar plates that were then incubated at 37°C for 48 h. Efficient PDI of biofilms was verified by counting colony-forming units (CFU/ml), and the data were submitted to analysis of variance and the Tukey test (p < 0.05). All biofilms studied were susceptible to PDI with statistically significant differences. The strains of Candida genus were more resistant to PDI than emerging pathogens T. mucoides and K. ohmeri. A mean reduction of 0.45 log was achieved for Candida spp. biofilms, and a reduction of 0.85 and 0.84, were achieved for biofilms formed by T. mucoides and K. ohmeri, respectively. Therefore, PDI by treatment with nanostructured formulations cationic zinc 2,9,16,23- tetrakis (phenylthio)- 29H, 31H- phthalocyanine (ZnPc) and a laser reduced the number of cells in the biofilms formed by strains of C. albicans and non-Candida albicans as well the emerging pathogens T. mucoides and K. ohmeri.

Outcome of endoscopic third ventriculostomy. Results from an unselected series with noncommunicating hydrocephalus

BACKGROUND

Endoscopic third ventriculostomy (ETV) has gained acceptance as the treatment of choice for noncommunicating hydrocephalus despite a relatively high failure rate and a higher surgical risk than the placement of a shunt. The benefits of shunt independence overcome both drawbacks. This argument also serves to consider candidates for ETV patients with a poor chance of success, a fact which may to a certain degree explain failure rates higher than 20% in most unselected series of patients with noncommunicating hydrocephalus.

METHOD

From 1997 to 2003 sixty-six patients with suspected noncommunicating hydrocephalus were treated with ETV. Male and female patients were equally distributed. It is an adult-based series (median age 53 years). The etiology of hydrocephalus was a space-occupying lesion in 39 patients (59%) and primary aqueductal stenosis in 27 (41%). Forty-seven patients presented an acute form of hydrocephalus (71%), the remainder presented a chronic form of hydrocephalus. The morbidity and outcome of the procedure were reviewed. Criteria for success was shunt independence and failure was considered when any surgical manoeuvre was further required for the treatment of hydrocephalus. The outcome was evaluated using the Kaplan-Meier survival method.

FINDINGS

The probability of remaining with a functioning ETV at 5.7 years (mean follow-up period) is 71.6% (95% confidence interval: 60.5-82.8). Failure occurred in 18 patients (27.3%). If failure occurs, there is a cumulative probability of 90% (95% confidence interval: 84-97) that the failure declares itself during the first 16 days after surgery. There were transient complications in five patients (7.5%), permanent in one (1.5%) and no mortality related to the procedure.

CONCLUSIONS

ETV had a 5-year success rate of 71.6% with a low rate of permanent complications. When ETV is successful, the result tends to hold up over time. Delayed failure is a rare event.

[Stereotactic brain biopsy: review of 80 cases. The need of ct-scan in the first hours]

OBJECTIVE

Evaluate the efficacy of the stereotactic brain biopsies performed in the Neurosurgery Department of the São João Hospital in order to diagnose intracerebral damage and to determine the existence of post-biopsy haemorrhage.

METHODS

The authors evaluated 80 consecutive cases of patients submitted to a stereotactic brain biopsy. 63 of them had a control CT-scan from 4 to 6 hours after the proceeding.

RESULTS

Stereotactic biopsy yield a conclusive diagnosis in 75 of the 80 patients which corresponds to 93.7% of the cases. Inconclusive results occurred in 5 patients (6.25%). Significant morbidity occurred in 4 cases (5%) and there was no mortality. Control CT-scan revealed no alterations in 25 patients and vestigial haemorrhage in 27. In the remaining 11 the haemorrhage was of little significance.

CONCLUSIONS

Stereotactic biopsy is a safe and effective method to diagnose brain lesions. The realization of a control CT-scan within few hours after biopsy allows the identification of a sub-group of patients without intracerebral haemorrhage that may be discharged from hospital on the same day.

Gains of chromosome 22 by fluorescence in situ hybridization in the context of an hyperdiploid karyotype are associated with aggressive clinical features in meningioma patients

BACKGROUND

Meningiomas usually are considered to be benign tumors; however, 10-20% of cases recur. Few disease characteristics have proved to have prognostic impact for predicting disease free survival. The objective of the current study was to explore the prognostic value of numeric abnormalities of chromosome 22 for meningioma patients.

METHODS

In this study, the authors prospectively analyzed the incidence of numeric chromosome abnormalities of chromosome 22 by interphase fluorescence in situ hybridization, using a specific probe for the bcr gene located in chromosome 22q11.2, on a total of 88 consecutive meningioma patients. The authors also analyzed its correlation with both the clinicobiologic characteristics at presentation and the patient's outcome.

RESULTS

The authors' results show that monosomy 22 was present in 49% of the cases and that this numeric chromosomal abnormality is not associated with other prognostic features of the disease. In contrast, gains (trisomy/tetrasomy) of chromosome 22 were detected in 8 (9%) cases who simultaneously showed gains for other chromosomes and represent an adverse prognostic factor regarding disease free survival (P = 0.001); in addition, trisomy/tetrasomy 22 was more frequently related to younger patients (P = 0.001), aggressive histopathologic features (P < 0.000), a greater incidence of DNA aneuploidy (P =0.006), and a higher proportion of S-phase tumor cells (P = 0.02).

CONCLUSIONS

In summary, the authors conclude that loss of a copy of chromosome 22 is a frequent finding in meningioma tumors, but it does not affect the clinical outcome of these patients. In contrast, gains (trisomy/tetrasomy) of chromosome 22, in the context of an hyperdiploid karyotype, although much less frequent, are associated with a more aggressive disease course.

[The use of Abciximab in patients with acute myocardial infarction undergoing direct percutaneous coronary revascularization]

OBJECTIVE

To evaluate the initial experience, in our Centre, with Abciximab in patients with acute myocardial infarction undergoing direct percutaneous transluminal coronary angioplasty (PTCA).

METHODS

Between October 1996 and May 1998, 65 patients (51 males, mean age 56.9 +/- 11 years) underwent direct PTCA for acute myocardial infarction. In thirty-seven patients the myocardial infarction was anterior and 40 had multivessels disease. Mainly to compare the incidence of bleeding complications we considered 2 groups: Group A--17 patients submitted to PTCA without the use of Abciximab, and Group B--48 patients submitted to PTCA and to a bolus followed by a 12 hour infusion of Abciximab. All the patients were treated with aspirin and heparin (5,000 to 15,000 U according to ACT) and ticlopidine in case of stent implantation.

RESULTS

Percutaneous coronary revascularization was successfully achieved in 92.3% of the patients. The total number of bleeding complications was ten cases (20.8%) in Group B and 1 case (5.8%) in Group A. Most of the bleeding complications in the Abciximab Group were minor and related to the femoral vascular access site (9 cases--18.7%) and were easily resolved with local measures (8 cases). There were also 3 cases of hematemesis and one of oral bleeding, all well tolerated. Major bleeding complications were identified in only one patient of the Abciximab Group related to the vascular access site, however there was an absolutely similar case in Group A (2% versus 5.8%).

CONCLUSIONS

Although bleeding complications were more frequent in patients receiving Abciximab, mostly related to the vascular access site, they were transient and well tolerated.

A rare cause of late infective endocarditis after heart surgery

A case is reported of a male patient with rheumatic mitral valve disease and open mitral valve commissurotomy, performed 13 years before, who had fever and multiple septic embolic events. Serial blood cultures were positive for Pseudomonas aeruginosa. Transthoracic and transesophageal echocardiography demonstrated the presence of an irregular, round, very mobile mass inserted in the fossa ovalis region of the interatrial septum. After resolution of the infectious process, surgery was performed. The structure previously described corresponded to a elongated suture material covered by fibrin. It had been secondarily infected and it was the cause of the entire process.

[Heart failure due to a postlaminectomy arteriovenous fistula]

The authors report a case of congestive heart failure as a consequence of traumatic postlumbar laminectomy arteriovenous fistula. A 49 years old female with the diagnosis of atrial septal defect was admitted at the hospital, complaining of dyspnea and peripheral edema. A hemodynamic study was performed and an arteriovenous fistula was detected between the iliac artery and vein, and arterial septal defect was excluded. Surgery for fistula closure was performed with great clinical improvement.

[Diagnosis of coronary disease using echocardiography with inotropic dobutamine stimulation]

PURPOSE

To evaluate dobutamine echocardiography capacity to diagnose coronary artery disease.

STUDY DESIGN

Prospective clinical study.

SETTING

Cardiology Department of Hospital Santa Marta.

PATIENTS

32 patients with suspected coronary artery disease, without myocardial infarction, have been studied.

METHODS

An intravenous perfusion of dobutamine with gradual doses, from 5 to 40 micrograms/kg/min, and increments of 5 to 10 micrograms/kg/min, in 3 minute stages, except the last stage which lasted only 1 minute with 40 micrograms/kg, was performed. Twelve-lead ECG were registered to detect ST changes and symptoms, namely chest pain. Basal and dobutamine bidimensional echocardiograms, in the end of each stage and during recovery, were registered in video. The segmental analysis was performed considering the left ventricle divided in 16 segments. It was considered positive the occurrence or aggravation of the contractility asynergy of the left ventricle with inotropic stress. All the patients were submitted to coronary arteriography.

RESULTS

Due to the bad quality of the echocardiographic images 2 patients were excluded. The stress dobutamine echocardiograms were positive in 14 P and negative in 16 P. The coronary arteriography showed coronary disease in 18 cases and absence of significant lesions in 12 cases. The values for sensitivity, specificity positive predictive value and negative predictive value obtained with dobutamine echocardiography were, 78% and 100% and 75% respectively. In Dobutamine-ECG, 7P had ST segment changes, 2 of them with chest pain values for sensitivity, specificity, positive and negative predictive value with dobutamine-ECG were, 39%, 100% and 52%, respectively. The occurrence of side-effects was observed in 8 P (27%): ventricular tachycardia (2 P-7%), complex ventricular ectopy (4 P-13%), chest pain (2 P-7%), headache (1 P-3%), nausea (1 P-3%) and palpitations (2 P-7%). There was no significant difference in the occurrence of side-effects in the two groups of patients, with and without coronary artery disease (33% vs 17%, respectively; p = ns). The reasons for early discontinuation of dobutamine infusion were: ventricular tachycardia (2 P), complex ventricular ectopy (2 P) and chest pain (1 P). Heart rate, systolic blood pressure and double-product did not differ significantly in patients with and without coronary artery disease. In dobutamine electrocardiography 7 P had ST segment changes, 2 of them with chest pain.

CONCLUSION

Dobutamine echocardiography showed in this study elevated values for sensitivity and specificity, however sensitivity can be increased with better technical conditions.

The prevalence of Parkinson's disease in Portugal. A population approach

Most of the epidemiological studies designed to determine the prevalence of Parkinson's disease (PD) in Portugal were hospital-based and the rates reported were around 1/1000. A sentinel network of general practitioners (GPs) has been in effect in the country since 1989, involving doctors with a relatively stable list of patients. This group of doctors notifies, every week, all the cases of certain selected diseases that may occur among the patients under their surveillance. On average, each doctor is responsible for 1500 to 1800 persons, of all ages and both sexes, whose main descriptive characteristics are known and updated every year. This led us to the idea of estimating the prevalence of Parkinson's disease in the community and to compare the estimated rates with hospital-based rates. One hundred and fifty general practitioners agreed to participate in a cross-sectional study which included a sample of 220,000 persons. The study took place between March and April 1992 and information on 291 PD patients was collected. Results show that among the study population, age-standardized rates were 1.4/1000 for males and 1.3/1000 for females. Sex-specific rates increase consistently with age in both sexes, reaching a level of 9/1000 in the oldest age group, '75 and more' years. These results estimate a higher prevalence of PD than was determined previously through hospital-based studies and allowed us to determine that patients aged 65 years and more are much likely to be followed by their own GP, either because the disease its already controlled and they are specifically seeking medication or because they find it difficult to attend neurology clinics.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiac involvement in dystrophia myotonica. Comments apropos a case]

Myotonic dystrophy may have several cardiovascular abnormalities. We report a case in which the cardiac changes that can be found in this disease. Finally, we make a revision of the cardiac changes that can be found in this disease.

[Myocardial infarct and coronary fistula. A rare combination]

We report an unusual case of a 39-years-old male patient, with previous inferior and anterior non Q wave myocardial infarctions, in whom the coronary arteriography showed an arteriovenous fistula between the left anterior descending coronary artery and the pulmonary artery, without any other coronary lesions. We make a revision of this disease and discuss the mechanisms of ischemia.

[Coronary fistula --clinical and angiographic review]

OBJECTIVE

To evaluate clinical and angiography date of patients (pts) in whom coronary arteriovenous fistula were detected.

STUDY DESIGN

Retrospective study of diagnostic coronary angiographies done between 1988 and 1993 in whom coronary arteriovenous fistula were detected.

SETTING

Patients submitted to cardiac catheterisation in the Cardiology Department of Santa Marta Hospital in whom coronary arteriovenous were detected.

PATIENTS

Fourteen pts, 10 male and 4 female, with a mean age of 49 years (21-72).

INTERVENTIONS

A retrospective analysis of clinical data and coronary artery anomalies was done. Whenever available, the Pulmonary Artery and the shunt (calculated through oximetries) were evaluated.

RESULTS

The following pathologies were associated: rheumatic valve heart disease (3 pts), Tetralogy of Fallot (2 pts), atrial septal defect--ostium primum (1 pt), dilated cardiomyopathy (1 pt), hypertrophic cardiomyopathy (1 pt), atherosclerotic coronary artery disease (2 pts). Four pts were in atrial fibrillation and the others in sinus rhythm. Four pts had normal ECG. In 6 pts there was cardiomegaly on the chest X-rays. The fistula was single in 11 pts, double in one and multiple in 2 other pts. The fistula originated from the right coronary artery in 6 pts, the left anterior descending coronary artery in 5 pts, the circumflex coronary artery in 3 pts and the left main coronary artery in one pt. Eight drained to the pulmonary artery (or its branches), 2 to the coronary sinus, one directly to the right atrium, one to the right ventricle and one to the left atrium. In only 2 pts the fistula was closed. In 6 pts the associated anomalies were corrected. With a mean follow up of 24 months (1-72), 8 pts are asymptomatic, 4 complain of slight heart failure, 3 of angina pectoris and the pt with dilated cardiomyopathy died 1 year after being studied.

CONCLUSION

A male predominance was found. Most fistulae were single. The artery mostly involved was the right coronary artery and the fistula drained more often to the pulmonary artery or its branches.

[The complications associated with the performance of heart catheterizations (diagnostic and therapeutic). The results in the Hemodynamics Laboratory of Hospital de Santa Marta]

OBJECTIVES

To evaluate the morbidity and mortality with cardiac catheterization (diagnostic and intervention).

DESIGN

Retrospective analysis of complications occurring within 24 h of a cardiac catheterization, in three consecutive years (1989-1991).

SETTING

Patients admitted to the Haemodynamic Laboratory of Santa Marta Hospital-Lisbon.

PATIENTS

4014 patients submitted to diagnostic and interventional procedures.

MATERIALS AND METHODS

Registry analyze in order to obtain the following data: pathology, age, vascular approach and complications of cardiac catheterization.

RESULTS

In three years there were 4014 cardiac procedures. 53.6% were performed in patients with coronary artery disease, 20% with valvular heart disease, 8.1% with congenital heart disease, 16.1% with others pathologies and 2.2% revealed normal vessels in coronary angiography. The incidence of ischemic heart disease was progressively higher in the studied years: 51.9% in 1989, 52.4% in 1990 and 55.2% in 1991. Data from population age showed the same tendency: mean age was 51, 53 and 55 years, respectively. Femoral approach was attempted in 95% of the studies, and the axillary in 2.15%. Complications of diagnostic and interventional cardiac procedures occurred in 3% of the patients. Dead occurred in 0.14%; arrhythmia, 0.37%; vascular, 0.14%; vasovagal/pyrogen reactions, 0.73%; myocardial infarction, 0.05%; and others, 1.58%.

CONCLUSION

The diagnostic and interventional cardiac catheterization in experienced laboratories are a safe procedure with a reduced incidence of major complications.

[The pulsed Doppler evaluation of patients with dilated cardiopathy]

OBJECTIVE

To evaluate, by 2D-Doppler echocardiography, the patterns of left ventricular filling in groups of patients with left ventricular systolic disfunction and different pulmonary wedge pressures.

STUDY DESIGN

perspective study of different indexes of left ventricular diastolic filling measured by Doppler echocardiography and compare them with a normal group.

SETTING

Patients studied in the Cardiology Department of the Santa Marta Hospital with a diagnosis of dilated cardiopathy and submitted to cardiac catheterisation.

PATIENTS

Twenty-four patients, aged 39 years old, submitted to hemodynamic study (group A) and nineteen subjects, aged 34 years old (group B). Pulmonary capillary wedge pressure (PWP) was determined in group A and the patients were divided in two groups: group A1 (with PWP < 16 mmHg) and group A2 (with PWP > or = 16 mmHg).

INTERVENTIONS

Every patient was submitted to cardiac catheterisation. The echocardiographic study showed global decrease of left ventricular systolic function. With pulsated Doppler left ventricular diastolic flow indexes were determined. The following parameters were studied: peak protodiastolic flow velocity (Vel E), peak telediastolic flow velocity (Vel A), E/A ratio, protodiastolic acceleration time (O-E) and diastolic flow time (O-C).

MEASUREMENTS AND RESULTS

There were no statistical differences between group A as a whole and group B. However in group A1, with a lower PWP there was a decrease of E flow velocity in relation to the control group (54.6 cm/sec +/- 14 vs 66.4 cm/seg +/- 12.8 p < 0.05) or to the group A2 (75.3 cm/sec +/- 29.9 p < 0.05). In the group A1 there was an increase of the flow velocity A in relation to group B (56.1 cm/sec +/- 15.9 vs 36.4 cm/sec +/- 7.3 p < 0.05) and to the group A2 (56.1 cm/sec +/- 15.5 vs 28.2 +/- 9.1 p < 0.05). The relation E/A in group A1 was deceased in relation to group B (1.0 +/- 0.4 m vs 1.8 +/- 0.6 p < 0.05) and in group A2 its increased in relation to B (2.6 +/- 0.9 vs 1.8 +/- 0.6 p < 0.05). The E-D time was increased in group A1 in relation to group B (162.1 +/- 8.7 cm/sec vs 140.5 +/- 42.0 cm/sec p < 0.05) and slightly reduced in group A2 (134.5 +/- 78 msec vs 140.5 +/- 42.0 msec NS). All the patients with mitral regurgitation belonged to group A2. There was only statistical difference in the velocity between the patients in group A with and without mitral regurgitation (29.6 +/- 17.4 cm/sec vs 26.4 +/- 8.5 cm/sec p < 0.05).

CONCLUSIONS

In spite of some limitations, Doppler echocardiography is useful in the evaluation of left ventricular filling of patients with dilated cardiomyopathy. It shows different patterns that vary according to the hemodynamic states of the patient.

[Multiple aneurysms of the coronary arteries. Report of a case]

Multiple coronary aneurysms are rare. We report a case of a 56 year-old patient and make a state of the art on this subject, discussing etiologic and pathogenic considerations versus clinical and therapeutic aspects.

[Successful operation of aortic abscess ruptured into left atrium. Diagnostic importance of color coded Doppler echocardiography]

Myocardial abscesses are a serious complication of infectious endocarditis. A 60 years old male patient with subaortic ring abscess is reported. A fistula developed between the left ventricular outflow tract and the left atrium. Doppler echocardiography was of outmost importance for diagnosis. Surgery was successfully performed.

[Contribution of Holter monitoring in the diagnosis of a case of Prinzmetal's angina]

Prinzmetal angina is a peculiar kind of angina pectoris, in which Holter monitoring has been particularly useful for diagnosis. In this paper it is reported a 56 years old male patient with coronary artery spasm induced during coronary arteriography in which the Holter electrocardiography was of most importance for decision making.

[Dilated myocardiopathies: the relationship between the degree of cardiac dysfunction and ventricular arrhythmias. A clinical follow-up]

STUDY OBJECTIVE

Characterization of the arrhythmic profile of idiopathic dilated cardiomyopathy (DMC); Evaluation of the relation of complex ventricular ectopy and cardiac dysfunction; Clinical outcome.

PATIENTS

We studied 20 patients (P) with idiopathic DCM, 15 males P and 5 female P, mean age 51.3 +/- 17.4 years (between 17 and 75 years).

MATERIAL AND METHODS

24-hours Holter study and left cardiac catheterization with ventriculography were performed. Patients were followed at the consults.

RESULTS

We detected in the Holter study the presence of ventricular ectopy in 19 P (95%). Nine P had complex ventricular arrhythmias (45%), 10 P had simple ventricular arrhythmias (50%) and 1 P had no ventricular arrhythmia (5%). The mean left ventricular ejection fraction was 28.6 +/- 14.1% (12 to 44%). Two groups were defined based on the severity of left ventricular dysfunction: Group I with 12 P and Group II with 8 P. In Group I, 8 P had complex ventricular ectopy and, in Group II, 1 P had complex ventricular ectopy (p < 0.05). Comparing mean left ventricular ejection fraction in the two groups of arrhythmias (simple and complex), 33.9 +/- 12.5% and 22.1 +/- 13.8%, we found out a statistically significant difference (p < 0.05). After an eight to thirty six months of follow-up, a greater number of cardiac events (mortality, transplant) were detected in the groups of complex arrhythmia and of more severe cardiac dysfunction.

CONCLUSIONS

We conclude that there is a high frequency of ventricular arrhythmias in this group of patients with idiopathic DCM. Complex ventricular arrhythmias were more frequently associated to more severe left ventricular dysfunction. The number of cardiac events at follow-up was higher in patients with complex ventricular arrhythmias and in those with more depressed cardiac function.

HM-PAO spect in head trauma

Single Photon Emission Computed Tomography (SPECT) after intravenous administration of Technetium-99m hexamethylpropylene-amine oxime (Tc-99m HM-PAO) makes possible the evaluation of cerebral perfusion. We have been assessing the diagnostic accuracy of SPECT in some groups of head trauma patients: the preliminary results of this study are presented. Fourteen patients have been selected, all of them showing some kind of focal neurological deficit; the Computed Tomography (CT) and Nuclear Magnetic Resonance (NMR) were normal, or showed lesions that could not be responsible for the neurological deficits. In all of the patients Tc-99m HM-PAO SPECT has been performed, showing changes in cerebral perfusion in areas correlated with the abnormalities elicited on clinical examination. These results show that Tc-99m HM-PAO SPECT is a better technique than CT or NMR in demonstrating the organic basis of some neurological deficits observed after head trauma.

[Changes in coronary angiography in young patients with myocardial infarction]

OBJECTIVE

To assess the coronariographic changes and left ventricular function of a group of young patients (pts) (less than 40 years) with myocardial infarction.

DESIGN

Retrospective analysis on clinical data and cineangiography.

SETTING

Patients studied in the Cardiology Department and Cardiothoracic Department of the Santa Marta Hospital in Lisbon.

PATIENTS AND INTERVENTIONS

Sequential sample of 40 pts 39 male and one female submitted to coronariography after an acute myocardial infarction (mean age--34 +/- 3 years).

MEASUREMENTS AND RESULTS

Twenty one pts had one vessel disease, 6 pts two vessel disease, 3 pts three vessel disease, 1 left main disease (2.5%) and 9 normal coronary arteries. More than a half (22) had a lesion on the left anterior descending artery (proximal in 12-30%), 13 a lesion on the right coronary artery (proximal in 3) and 8 on the circunflex coronary artery. There were 22 (55%) total occlusions (3 of the circunflex, 9 of the left anterior descending artery and 10 of the right coronary artery). Of these 8 were proximal. We divided the pts according to the regional contractility score in three groups. Most of them had a moderate decrease in contractility. Three pts had an apical aneurysm and 8 pts had apical discinesia. Three of these 11 pts had no significant coronary lesions, six had one vessel disease and 6 had a proximal lesion of the left anterior descending artery. The mean ejection was 53% and none was less than 30%. There was a statistical difference of score and ejection fraction between anterior and inferior myocardial infarctions (6.5 +/- 1.8 versus 7.8 +/- 1.6 e 48 +/- 11.6 versus 55.4 +/- 10.8), p less than 0.05 and between those with and without a proximal lesion of the anterior descending coronary artery (5.5 +/- 1.5 versus 7.9 +/- 1.5 and 41.4 +/- 7.9 versus 56.3 +/- 9.9), p less than 0.0005. Neverthless, when we tried to separate the pts with or without atherosclerotic lesions (6.9 +/- 1.7 versus 7.9 +/- 2.2 and 50.4 +/- 11 versus 54.8 +/- 14.3) or with and without multivessel disease (7.2 +/- 1.8 versus 6.7 +/- 1.9 and 52.9 +/- 12.2 versus 46.6 +/- 8.7), no statistical difference of score and ejection fraction was found.

CONCLUSION

Young patients with myocardial infarction are predominantly males; - There is an important number of one vessel disease and in many patients no coronary significant lesions were found; - The functional changes depended more on the proximal location than on the number of diseased vessels.

[Ebstein's anomaly. Clinical aspects and surgical therapy]

OBJECTIVE

We reviewed the clinical findings and surgical results of Ebstein's anomaly in adult and adolescent age.

DESIGN

Retrospective analysis on clinical data, surgery and follow up.

SETTING

Patients (pts) studied in the Cardiology and Cardiothoracic Surgery Departments of the Santa Marta Hospital, Lisbon.

PATIENTS

All pts in whom Ebstein's anomaly was diagnosed by cardiac catheterization or echocardiography or both, between 1875 and 1989 were included.

RESULTS

There were 8 cases (4 female and 4 male). The age varied from 15 and 53 years. Cyanosis and dyspnoea were the presenting features in 7 pts. One of the youngest pts had asymptomatic murmurs. Late appearance of cyanosis had no relation with prognosis. Three pts had pulmonary tuberculosis. One woman had no deterioration in cardiac function during two pregnancies. Clinical findings were variable and ranged from absent murmur with third and fourth sounds to systolic murmurs of high intensity. The ECG was abnormal in all pts. A case with delta wave and normal PQ interval was noted. On the chest X-ray we found cardiomegaly in all pts. Echocardiograms were recorded in 6 pts. The delay of tricuspid valve closure on mitral closure was not always diagnostic. Uncomplicated catheter studies were done in 6 pts. Two pts had associated cardiac lesions: ventricular septal defect (VSD) with pulmonary hypertension and mild pulmonary valve stenosis. Right ventricular angiographies were diagnostic in all cases. During medical follow up from 1 year to 10 years (mean-4) one death occurred in one pt with VSD. In the remaining 4 cases no deterioration in cardiac function or cyanosis was noted. Three pts were operated. The indications for surgery were: severe heart failure and/or increasing cyanosis. Two pts had tricuspid valve replacement with biological prosthesis. One pts had Danielson's tricuspid annuloplasty. During surgical follow up from 2 to 15 years (mean-7) functional class improved and cyanosis disappeared in 2 pts and it decreased in the other.

CONCLUSION

In our series of pts with Ebstein's anomaly clinical findings were variable. The indications for surgery were heart failure and cyanosis. The 3 pts operated are alive and have mild symptoms.

[Exercise test parameters after acute myocardial infarction. Relationship with coronary angiography]

OBJECTIVE

To analyze the relation between characteristics of symptom-limited treadmill exercise stress test, after acute myocardial infarction (MI) and coronariographic results (number of diseased vessels). Both tests were performed before hospital discharge.

DESIGN

Retrospective study with comparative analysis between variable defined groups.

POPULATION AND SETTING

From 232 patients interned in the department of Cardiology of Hospital de Santa Marta with a first acute MI, a population of 112 patients submitted to exercise stress test and coronary angiography before discharge were selected (aged 29 to 69 years).

METHODS

Symptom-limited treadmill exercise stress tests were performed according to Bruce protocol, with no heart-rate limitation. The following parameters were analyzed: Stress test duration (DUR); Double product variation (varDP); Metabolic equivalent units (METS); Maximal heart rate (FCmax); Percentage of the maximal reached heart rate (% FCmax); Incidence of ST segment depression (InfST); Maximal ST segment depression (Max-InfST); Onset minute of ST segment depression (MinInfST); Heart rate at the onset of ST segment depression (FCInfST); Double product at the onset of ST segment depression (DPInfST); Recovery minute of ST segment depression (MinRInfST); Onset minute of angina (MinAng); Heart rate at the onset of angina (FCAng); Double product at the onset of angina (DPAng).

RESULTS

Statistical significant differences were obtained between coronariographic groups concerning the following parameters: DUR: 1-vessel/3-vessel P = 0.02; VarDP: 1-vessel/3-vessel p = 0.008, 2-vessel/3-vessel p = 0.004; METS: 1-vessel/3-vessel p = 0.01. No differences were seen between anterior and inferior myocardial infarctions regarding all the stress test parameters. However in patients with anterior MI significant differences were obtained concerning the following variables: VarDP: 1-vessel/2-vessel p = 0.02; InfraST: 1-vessel/2-vessel p = 0.006, 1-vessel/3-vessel p = 0.03; MaxInfST: 1-vessel/2-vessel p = 0.01, 1-vessel/3-vessel p = 0.0006; Angina: 1-vessel/2-vessel p = 0.0005, 1-vessel/3-vessel p = .001. In inferior myocardial infarctions only the stress duration differed between 1-vessel and 3-vessel groups (p = 0.003).

CONCLUSIONS

Symptom-limited treadmill exercise stress tests, safely performed in our institution, were an important method for post MI evaluation and allowed the diagnosis of a great number of patients with residual ischemia. Statistical significant differences were found in ergometric parameters, between coronariographic groups (defined by the number of diseased vessels), emphasising the importance of stress tolerance analysis.

[Infective endocarditis of pulmonary valve. Considerations apropos of a case associated with interventricular communication and aortic insufficiency ]

We report the case of a 23 year old patient in whom heart disease was detected in childhood. He began to have suddenly fever and symptoms of right side heart failure. There were signs of aortic regurgitation, a systodiastolic murmur in the left parasternal region and a diastolic murmur in the left 4th intercostal space. The bidimensional and Doppler Echocardiogram showed a saccular dilatation in the right ventricular outflow tract. He was submitted to catheterisation which confirmed aortic regurgitation and detected ventricular septal defect and pulmonary hypertension. During surgery, a subaortic ventricular septal defect was seen as well as a dilatation of the right coronary aortic cusp which prolapsed through the defect to the right ventricular outflow tract. Vegetations were seen in the pulmonary valve. The aortic valve and a pulmonary cusp were excised and a Björk Shiley aortic prosthetic valve was inserted. The septal defect was closed. The patient is still alive, symptomless, with 40 months of follow up. We discuss some problems related to this case, particularly the surgical indication and the rarity of the morphology discovered.

[Isolated hypoplasia of the right ventricle--apropos of a case]

OBJECTIVE

To report one case of a rare heart disease (Isolated Hypoplasia of the Right Ventricle) and discuss the methodology used to propose surgery with goal. Good follow up results.

DESIGN

To report a case.

SETTING

One patient studied in the Cardiology Department of the Santa Marta Hospital, Lisbon, and submitted to surgery in the Cardiothoracic Surgery Department of the same Hospital.

PATIENT

A 22 years old woman, who had cyanosis since birth, normal cardiac auscultatory findings, pulmonary oligohemia in the chest Roentgenogram and right atrial strain on the Electrocardiogram.

INTERVENTIONS

She had an echocardiogram (M1 Mode and 2D) and catheterised, with pressure and oximetry measurements. During the latter procedure, the atrial septal defect was occluded for 20 minutes with a Fogarty catheter and pressure and oximetries were reevaluated. She was later operated.

MEASUREMENTS AND RESULTS

The Echocardiogram showed right ventricular hypoplasia, with a normally inserted tricuspid valve and a dilated right atrium. The hemodynamic study confirmed the presence of an atrial septal defect with right to left shunt, normal pulmonary artery pressure, no gradients and giant "a" wave in the right auriculogram. The right ventriculography showed right ventricular inflow hypoplasia. The occlusion of the atrial septal defect with the balloon catheter decreased the peripheral insaturation, without a significant increase in the right ventricular pressure. With this information, surgery was proposed (closure of the atrial septal defect), with good results (4 years of follow-up).

CONCLUSION

The interruption of the shunt with a balloon allows us to see if the right ventricle can handle properly the volume load. With this information surgery can be suggested. It may be rather simple as in this case.

Studies on the inactivation of vasoactive polypeptides by pyridoxal-5'-phosphate

The pharmacologically active peptides bradykinin (BK) lysylbradykinin or kallidin (LBK) and methionyl-lysylbradykinin (MLBK) were shown to react with pyridoxal-5'-phosphate (PLP) forming Schiff bases; upon reduction with sodium borohydride they were transformed into stable phosphopyridoxyl-kinins (PP-BK, PP-LBK and PP-MLBK). Amino acid analysis showed that the N-terminal alpha-aminogroup of the three kinins were efficiently blocked by phosphopyridoxyl groups: 98.8% for BK; 95.2% for LBK and 98.9% for MLBK. Guanidinium groups did not react with PLP. Estimated by guinea-pig ileum and the vascular permeability of rat skin assays respectively- the PP-kinins had the following average activities compared to the respective kinins: PP-BK, 0.20 and 0.16; PP-LBK, 0.05 and 0.17; PP-MLBK, 0.10 and 0.12. Isoleucyl5-angiotensin II and valyl5-angiotensin I were shown to be 50% inactivated (guinea-pig ileum assay) by reaction with PLP and reduction with borohydride.