Assessing Outcomes of Patients Subject to Intensive Care to Facilitate Organ Donation: A Spanish Multicenter Prospective Study

Intensive Care to facilitate Organ Donation (ICOD) consists of the initiation or continuation of intensive care measures in patients with a devastating brain injury (DBI) in whom curative treatment is deemed futile and death by neurological criteria (DNC) is foreseen, to incorporate organ donation into their end-of-life plans. In this study we evaluate the outcomes of patients subject to ICOD and identify radiological and clinical factors associated with progression to DNC. In this first prospective multicenter study we tested by multivariate regression the association of clinical and radiological severity features with progression to DNC. Of the 194 patients, 144 (74.2%) patients fulfilled DNC after a median of 25 h (95% IQR: 17-44) from ICOD onset. Two patients (1%) shifted from ICOD to curative treatment, both were alive at discharge. Factors associated with progression to DNC included: age below 70 years, clinical score consistent with severe brain injury, instability, intracranial hemorrhage, midline shift ≥5 mm and certain types of brain herniation. Overall 151 (77.8%) patients progressed to organ donation. Based on these results, we conclude that ICOD is a beneficial and efficient practice that can contribute to the pool of deceased donors.

Transplantation of organs from SARS-CoV-2-positive donors: Preliminary experience from Spain

BACKGROUND

The utilization of non-lung organs from deceased donors with a positive polymerase chain reaction (PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at the time of donation can be lifesaving, although the safety of this policy must be assessed.

METHODS

This is a nationwide, prospective study, reporting the experience on the utilization of non-lung organs from SARS-CoV-2-positive donors between December 15, 2020 and May 31, 2022 in Spain.

RESULTS

A total of 69 patients received a solid organ transplant (41 kidney, 18 liver, 8 heart, and 2 combined liver-kidney) obtained from 32 donors with a positive SARS-CoV-2 PCR at the time of donation (four of them with a cycle threshold value <30). All recipients tested negative for SARS-CoV-2 and were free of coronavirus disease 2019 (COVID-19) symptoms prior to transplantation. Nasopharyngeal swab turned positive for SARS-CoV-2 PCR in 4 (5.8%) recipients at 3, 8, 11, and 20 days after transplantation, though evidence did not support a donor-derived COVID-19. Four kidney recipients lost their grafts and two patients died: one heart recipient due to cardiogenic shock and one combined liver-kidney recipient due to lung hypertension and right heart failure. Graft losses and patient deaths were deemed unrelated to the donor SARS-CoV-2 status by the treating teams. No other adverse reactions were reported.

CONCLUSIONS

This preliminary experience supports the safety of the use of organs other than lungs from SARS-CoV-2 PCR-positive donors, in alignment with previous series. However, the impact of SARS-CoV-2 infection upon organ quality should be established in future research.

Temporal and spatial dynamics in the regulation of myocardial metabolism during the ischemia-reperfusion process

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (grant numbers PI20/00637 and CIBERCV16/11/00486) and Conselleria de Educación – Generalitat Valenciana (PROMETEO/2021/008).

Introduction

In the context of severe myocardial ischemia, cardiac metabolism shifts from beta oxidation to glycolisis. However, the temporal and spatial dynamics of the main regulators of myocardial metabolism during the ischemia-reperfusion process in the infarcted heart has not been fully characterized.

Methods

Myocardial infarction (MI) was induced in swine by means of 90 minutes occlusion of the mid left anterior descending coronary artery using angioplasty balloons. Tetrazolium staining and intracoronary infusion of thioflavin-S were used to define the infarcted, adjacent, and remote areas. mRNA and protein expression of PGC1a, PPARa, ERRa, GLUT1, and GLUT4 were quantified in controls and in MI groups submitted to 48 hours and 3 weeks of reperfusion.

Results

Compared to controls, a severe and generalized drop of PGC1a mRNA gene and protein levels occurred in the infarcted, adjacent and remote areas since ischemia onset until 48 hours reperfusion that persists at 1 month in the infarcted region. Similar dynamics occurred in the infarcted, adjacent, and remote areas in the case of PPARa gene expresion; PPARa protein significantly decreased only until 48 hours reperfusion in the infarcted area. ERRa gene and protein expression persistenly decreased only in the infarcted region since ischemia onset until 1 month. Incrases in GLUT1 (since ischemia onset) and GLUT4 (at 1 month) were detected.

Conclusions

Dynamics and generalized changes in metabolism regulation to a shift from beta oxidation to glycolisis occur in the infarcted heart since ischemia onset until late after reperfusion. Further research in this field can be helpful for a better understanding of pathophysiology of myocardial infarction and to explore new therapeutic options.

Improved short-term outcomes of kidney transplants in controlled donation after the circulatory determination of death with the use of normothermic regional perfusion

Normothermic regional perfusion (NRP) allows the in situ perfusion of organs with oxygenated blood in donation after the circulatory determination of death (DCDD). We aimed at evaluating the impact of NRP on the short-term outcomes of kidney transplants in controlled DCDD (cDCDD). This is a multicenter, nationwide, retrospective study comparing cDCDD kidneys obtained with NRP versus the standard rapid recovery (RR) technique. During 2012-2018, 2302 cDCDD adult kidney transplants were performed in Spain using NRP (n = 865) or RR (n = 1437). The study groups differed in donor and recipient age, warm, and cold ischemic time and use of ex situ machine perfusion. Transplants in the NRP group were more frequently performed in high-volume centers (≥90 transplants/year). Through matching by propensity score, two cohorts with a total of 770 patients were obtained. After the matching, no statistically significant differences were observed between the groups in terms of primary nonfunction (p = .261) and mortality at 1 year (p =  .111). However, the RR of kidneys was associated with a significantly increased odds of delayed graft function (OR 1.97 [95% CI 1.43-2.72]; p < .001) and 1-year graft loss (OR 1.77 [95% CI 1.01-3.17]; p = .034). In conclusion, compared with RR, NRP appears to improve the short-term outcomes of cDCDD kidney transplants.

Spanish version of the readiness for interprofessional learning scale (RIPLS) in an undergraduate health sciences student context

The Readiness for Interprofessional Learning Scale (RIPLS) has been widely used to measure students' and professionals' attitudes toward interprofessional learning. However, inconsistencies have been reported concerning its validity and reliability. This study aimed to translate, adapt, and validate the RIPLS questionnaire to be applied to Spanish-speaking health sciences students in Chile. Content and construct validity evidence of the newly created Spanish version of the RIPLS scale were analyzed. An exploratory (EFA) and confirmatory (CFA) analysis were conducted, determining goodness-of-fit indexes. Reliability was evaluated through Cronbach's Alpha Coefficient. We assessed sensitivity to change of the RIPLS scale by comparing pre- and post-interprofessional education workshop scores. The EFA showed that there were three factors. In the CFA, most of the standardized factor loadings were higher than 0.3. Regarding internal consistency, Cronbach's Alpha was 0.86. The differences between the total RIPLS scores before and after the workshops were statistically significant. The Spanish version of RIPLS showed evidence of validity and reliability for use amongst health sciences students. The construct was adequately measured and was shown that it could be used to assess the impact of interprofessional education workshops.

Health systems strengthening for noncommunicable disease control and healthy aging: integrated actions in Aruba and Curaçao

Caribbean countries are experiencing social, epidemiological, and demographic transitions shaped by the growing elderly population and the rise of noncommunicable diseases (NCDs)-now responsible for 78% of all deaths. These circumstances demand rethinking the model of care to improve health outcomes and build more sustainable health systems with new orientations in policy, service delivery, organization, training, technology, and financing. Policy must be aimed towards healthy living, leveraging interventions that ensure healthy aging. The health system must proactively structure interventions to reduce the incidence of new NCD cases and to prevent related complications. Interventions should be focused on optimizing the individual's capacity, functional ability, and autonomy within adapted environments, as well as with the necessary preventive, long-term care, self-care, community care, and health system support.

Adolescent characteristics of youth soccer players: do they vary with playing status in young adulthood?

Adolescent characteristics of young adult soccer players (n = 35) were compared with those of youth teammates (n = 124) no longer involved in soccer. Former U-13 players active in soccer as young adults were slightly later in maturation and performed better in several functional and soccer skills than youth teammates. Former U-15 players active in soccer as young adults did not differ in maturity status from youth teammates but were chronologically older and performed better in agility and ball control. Young adult regional and national players in both age groups were rated significantly higher on the potential for success by their youth coaches, and national players were rated significantly higher than regional players. The results highlight the need for study of interactions among coaches, youth training and playing environments and the growth, maturity, functional, skill and behavioural characteristics of youth players, and how these interactions may influence persistence in soccer and later playing status.

[Development of the Venezuela node of the Virtual Campus for Public HealthDesenvolvimento do núcleo Venezuela no Campus Virtual de Saúde Pública]

The objective of this document is to describe the steps in the development of the country node of the Virtual Campus for Public Health (VPHC) in Venezuela, with a view to enhancing continuing education in virtual learning environments and strengthening the abilities and knowledge of health workers, which was defined as a national priority. Eliminating geographical barriers, offering flexible schedules, and providing opportunities for real-time, low-cost interaction with experts were key aspects of the development of the Venezuela node. The VPHC nodes offered by the Pan American Health Organization (PAHO), both at the regional and country levels, allow for large-scale training of health workers. However, despite similarities in public health issues at the global and regional levels, each country has specific needs according to its epidemiological, political, social, and economic situation, and has to respond to needs identified at the local level. In Venezuela, the focus is on strengthening competencies and providing continuing education to the 13 921 basic health teams deployed in the country's 24 states. It was in this context that the PAHO country office supported the development of the Venezuela node of the VPHC.

Zika and Aedes aegypti: new and old challenges

Infection with the zika virus had a great impact not only on pregnant women and newborns, but also on public health, on popular ideas about Aedes aegypti and with respect to women's social rights. The objective of this paper is to identify this impact and the historical, social and health changes of the disease and the legacy of the zika virus. Interventions by researchers from different specialties foster conditions for more comprehensive investigations into future epidemic threats in Brazil and Latin America. This dialogue took place after the seminar "Aedes aegypti: past and future health emergencies," organized by the Casa de Oswaldo Cruz, when we talked with some speakers and other leading researchers about the history and challenges of Aedes aegypti and zika.

Neurotrophins role in depressive symptoms and executive function performance: Association analysis of NRN1 gene and its interaction with BDNF gene in a non-clinical sample

BACKGROUND

Neuritin-1 is a neurotrophic factor involved in synaptic plasticity that has been associated with depressive disorders, schizophrenia and cognitive performance. The study of genotype-phenotype relationships in healthy individuals is a useful framework to investigate the etiology of brain dysfunctions. We therefore aimed to investigate in a non-clinical sample whether NRN1 gene contributes to the psychopathological profile, with a particular focus on the clinical dimensions previously related to the NRN1 gene (i.e. depressive and psychotic). Furthermore, we aimed to analyze: i) the role of NRN1 on executive functions, ii) whether the association between either NRN1-psychopathological profile or NRN1-cognitive performance is moderated by the BDNF gene.

METHODS

The sample comprised 410 non-clinical subjects who filled in the self-reported Brief Symptom Inventory (BSI) and were assessed for executive performance (Verbal Fluency, Wisconsin Card Sorting Test (WCST) and Letter-Number subscale (WAIS-III)). Genotyping included nine SNPs in NRN1 and one in BDNF.

RESULTS

i) GG homozygotes (rs1475157-NRN1) showed higher scores on BSI depressive dimension and on total scores compared to A carriers (corrected p-values: 0.0004 and 0.0003, respectively). ii) a linear trend was detected between GG genotype of rs1475157 and a worse cognitive performance in WCST total correct responses (uncorrected p-value: 0.029). iii) Interaction between rs1475157-NRN1 and Val66Met-BDNF was found to modulate depressive symptoms (p=0.001, significant after correction).

LIMITATIONS

Moderate sample size; replication in a larger sample is needed.

CONCLUSIONS

NRN1 is associated with depressive symptoms and executive function in a non-clinical sample. Our results also suggest that the role of NRN1 seems to be modulated by BDNF.

Possible land management uses of common cypress to reduce wildfire initiation risk: a laboratory study

Accurate determination of flammability is required in order to improve knowledge about vegetation fire risk. Study of the flammability of different plant species is essential for the Mediterranean area, where most ecosystems are adapted to natural fire but vulnerable to recurrent human-induced fires, which are the main cause of forest degradation. However, the methods used to evaluate vegetation flammability have not yet been standardized. Cupressus sempervirens is a native or naturalized forest tree species in the Mediterranean area that is able to tolerate prolonged drought and high temperatures. The aim of this study was to characterize the flammability of C. sempervirens var. horizontalis at particle level by using different bench-scale calorimetry techniques (mass loss calorimeter, epiradiator and oxygen bomb) to determine the main flammability descriptors (ignitability, sustainability, combustibility and consumability) in live crown and litter samples. Our findings indicate that this variety of cypress is relatively resistant to ignition because of the high ash content, the high critical heat flux, the high time to ignition displayed by both crown and litter samples and the ability of the leaves to maintain a high water content during the summer. We also discuss the possibility of exploiting some morphological, functional and ecological traits of the species to construct a barrier system (with selected varieties of cypress) as a promising complementary land management tool to reduce the fire spread and intensity in a Mediterranean context.

Limitations of a Simplification Antiretroviral Strategy for HIV-Infected Patients with Decreasing Adherence to a Protease Inhibitor Regimen

PURPOSE

To determine the long-term efficacy of a simplification strategy in the clinical setting when used to improve adherence.

METHOD

Prospective study of 70 patients included in a regimen with ddI plus 3TC plus an NNRTI, after viral suppression with a PI-containing regimen, due to decreasing adherence. Adherence to PI was calculated as the percentage of doses taken last week before inclusion, and patients were stratified as high and low adherence (95% and <95% of doses).

RESULTS

Overall, 19 patients (27%) related adherence to PI <95% at inclusion (6 patients [9%], with adherence <80%). Mean adherence improved, with only 8% of patients presenting values <95%. At 104 weeks, 88% of patients on therapy had viral load suppression, but only 43% by ITT analysis. The main cause of therapy change or withdrawal was toxicity or drug interactions (26%). Notably, 16% of patients were lost to follow-up or left therapy, especially in the group of initially low adherent (26% vs. 12%, p = .02).

CONCLUSION

The use of a simplification strategy could be associated with long-term high risk of treatment failure, when used to improve adherence in the clinical setting.

[Chikungunya in the Dominican Republic: lessons learned in the first six months]

The chikungunya epidemic in the Dominican Republic began in February 2014. During the first six months 429 421 cases were recorded, representing 65% of all those notified to the Pan American Health Organization by 33 countries and territories of the Region of the Americas. This epidemic has spread quickly in the Dominican Republic, requiring a focused intersectoral response, led by the Ministry of Public Health and involving major efforts by the National Epidemiological System and the health services network. Given that the virus will affect thousands of people, this article seeks to describe the actions that have already been carried out, and to share the results and lessons learned during these first months with health ministries and professionals in the countries of the Region, in order to assist them to prepare an appropriate response to confront the epidemic effectively and efficiently.

[Chikungunya: a challenge for the Dominican Republic's health services]

The Region of the Americas has been affected since December 2013 by a chikungunya epidemic for the first time. Although the first cases were recorded in the French Caribbean, the epidemic quickly spread to the Dominican Republic due to trade and people movements. The Dominican Republic, which shares the island of Hispaniola with Haiti, has a population of 10 million. This article contains information from a range of different publications and official documents about the chikungunya virus infection and epidemic. These papers were extremely helpful for guiding the response to the epidemic in the Dominican Republic and may also be useful for enhancing knowledge of the virus and responses among health workers elsewhere in the region. Particular attention is drawn to the important research undertaken in countries and territories affected by the epidemic in the Indian Ocean area. This is the case, for example, of the island of La Réunion, where the epidemic had an attack rate of more than 30% between 2005 and 2007. Researchers were able to identify risk groups, severe and atypical forms of the infection, cases of vertical transmission, chronic disease causing recurrent pain over three years, and directly- or indirectly-related deaths from the virus. Given its high attack rate, the chikungunya virus has emerged as an exceptional challenge for health ministries and calls for appropriate organized responses from the health services, prioritization of care for risk groups and patients exhibiting severe forms of the disease, and effective social communication and intersectoral actions.

Phenotype gene expression differences between resistant and susceptible salmon families to IPNV

Infectious pancreatic necrosis virus (IPNV) is an economically important pathogen of the salmonid aquaculture industry. Selective breeding has been employed to improve resistance to this infectious disease, and it is of importance to investigate the expression profile of immune genes of Atlantic salmon with different genetic background in response to this virus. This study examined the immune modulation response of eight candidate genes in head kidney tissue in two families of Atlantic salmon with high and low mortalities, after challenge with IPNV. The results showed that the expression pattern of target genes differed in the two families. Generally, higher expression of antiviral, pro-inflammatory genes and transcription factors such as tripartite motif, NF-κB, IFNI, STAT1, protein kinase R, and Vig-2 in the resistant family were observed at the same time point. One may speculate the functional importance of these putative candidate genes in the characterization of the IPNV-resistant (low mortalities) immune phenotype. Therefore, on our findings, we suggest that future salmonids studies aiming to identify candidate genes/pathway or vaccines evaluation should consider validating detected genes/pathway across different genetic backgrounds or immune phenotype.

Psychosis-inducing effects of cannabis are related to both childhood abuse and COMT genotypes

OBJECTIVE

To test whether the association between childhood abuse, cannabis use and psychotic experiences (PEs) was moderated by the COMT (catechol-O-methyltransferase) gene.

METHOD

Psychotic experiences (PEs), childhood abuse, cannabis use and COMT Val158Met genotypes were assessed in 533 individuals from the general population. Data were analysed hierarchically by means of multiple linear regression models.

RESULTS

Childhood abuse showed a significant main effect on both positive (β = 0.09; SE = 0.04; P = 0.047) and negative PEs (β = 0.11; SE = 0.05; P = 0.038). A significant three-way interaction effect was found among childhood abuse, cannabis use and the COMT gene on positive PEs (β = -0.30; SE = 0.11; P = 0.006). This result suggests that COMT genotypes and cannabis use only influenced PE scores among individuals exposed to childhood abuse. Furthermore, exposure to childhood abuse and cannabis use increased PE scores in Val carriers. However, in individuals exposed to childhood abuse but who did not use cannabis, PEs increased as a function of the Met allele copies of the COMT gene.

CONCLUSION

Cannabis use after exposure to childhood abuse may have opposite effects on the risk of PEs, depending on the COMT genotypes providing evidence for a qualitative interaction. Val carriers exposed to childhood abuse are vulnerable to the psychosis-inducing effects of cannabis.

The role of genetic variability in the SLC6A4, BDNF and GABRA6 genes in anxiety-related traits

OBJECTIVE

The aims of this study were to test the individual association of the serotonin transporter gene (SLC6A4), the brain-derived neurotrophic factor gene (BDNF) and the GABA(A) α(6) receptor subunit gene (GABRA6) with anxiety-related traits and to explore putative gene-gene interactions in a Spanish healthy sample.

METHOD

A sample of 937 individuals from the general population completed the Temperament and Character Inventory questionnaire to explore Harm Avoidance (HA) dimension; a subsample of 553 individuals also filled in the Big Five Questionnaire to explore the Neuroticism dimension. The whole sample was genotyped for the 5-HTTLPR polymorphism (SLC6A4 gene), the Val66Met polymorphism (BDNF gene) and the T1521C polymorphism (GABRA6 gene).

RESULTS

Homozygous individuals for the T allele of the T1512C polymorphism presented slightly higher scores for HA than C allele carriers (F = 2.96, P = 0.019). In addition, there was a significant gene-gene interaction on HA between the 5-HTTLPR and Val66Met polymorphisms (F = 3.4, P = 0.009).

CONCLUSION

GABRA6 emerges as a candidate gene involved in the variability of HA. The effect of a significant gene-gene interaction between the SLC6A4 and BDNF genes on HA could explain part of the genetic basis underlying anxiety-related traits.

Childhood Abuse and the BDNF-Val66Met Polymorphism: Evidence for Gene-Environment Interaction in the Development of Adult Psychosis-Like Experiences

Introduction

The well-established relationship between childhood adversity and psychosis is likely to involve other factors such as genetic variants, which could help to understand why not everyone exposed to adverse events develops psychotic symptoms later in life (Van Winkel, et al. 2008; Simmons et al. 2009).

Aims

The present study investigated the influence of childhood abuse and neglect on positive and negative psychosis-like experiences in adulthood and the potential moderating effect of the BDNF-Val66Met polymorphism.

Method

Psychosis-like experiences and childhood adversity were assessed in 533 individuals from the general population.

Results

Childhood abuse showed a strong independent effect on the positive dimension of psychosis-like experiences (B = .16; SE = .05; p = .002). Furthermore, this association was moderated by the BDNF-Val66Met polymorphism (B = .17; SE = .09; p = .004).

Conclusions

Individuals exposed to childhood abuse are more likely to report positive psychosis-like experiences. Met carriers reported more positive psychosis-like experiences when exposed to childhood abuse than did individuals carrying the Val/Val genotype.

Therefore, the observed gene-environment interaction effect may be partially responsible for individual variation in response to childhood abuse.

Early adversity and 5-HTT/BDNF genes: new evidence of gene-environment interactions on depressive symptoms in a general population

BACKGROUND

Adverse childhood experiences have been described as one of the major environmental risk factors for depressive disorder. Similarly, the deleterious impact of early traumatic experiences on depression seems to be moderated by individual genetic variability. Serotonin transporter (5-HTT) and brain-derived neurotrophic factor (BDNF) modulate the effect of childhood adversity on adult depression, although inconsistencies across studies have been found. Moreover, the gene x environment (GxE) interaction concerning the different types of childhood adversity remains poorly understood. The aim of this study was to analyse the putative interaction between the 5-HTT gene (5-HTTLPR polymorphism), the BDNF gene (Val66Met polymorphism) and childhood adversity in accounting for adult depressive symptoms.

METHOD

A sample of 534 healthy individuals filled in self-report questionnaires of depressive symptomatology [the Symptom Check List 90 Revised (SCL-90-R)] and different types of childhood adversities [the Childhood Trauma Questionnaire (CTQ)]. The 5-HTTLPR polymorphism (5-HTT gene) and the Val66Met polymorphism (BDNF gene) were genotyped in the whole sample.

RESULTS

Total childhood adversity (beta=0.27, p<0.001), childhood sexual abuse (CSA; beta=0.17, p<0.001), childhood emotional abuse (beta=0.27, p<0.001) and childhood emotional neglect (beta=0.22, p<0.001) had an impact on adult depressive symptoms. CSA had a greater impact on depressive symptoms in Met allele carriers of the BDNF gene than in the Val/Val group (F=5.87, p<0.0001), and in S carriers of the 5-HTTLPR polymorphism (5-HTT gene) (F=5.80, p<0.0001).

CONCLUSIONS

Childhood adversity per se predicted higher levels of adult depressive symptoms. In addition, BDNF Val66Met and 5-HTTLPR polymorphisms seemed to moderate the effect of CSA on adult depressive symptoms.

Putative role of the COMT gene polymorphism (Val158Met) on verbal working memory functioning in a healthy population

Working memory has been described as a neurocognitive probe of prefrontal brain functioning. Genetic variability related with catechol-O-methyltransferase (COMT) gene (Val158Met polymorphism) has received increasing attention as a possible modulator of working memory tasks in both schizophrenic patients and healthy subjects, although inconsistencies across studies have been found. This may be related to the existence of different working memory components, processes and modalities, which may have different sensitivities to subtle changes in dopamine levels and, therefore, the effect of the underlying COMT Val158Met genetic variability. To test this out a large sample of 521 healthy individuals from the general population were tested on the WCST and three working memory tasks that cover the assessment of verbal and spatial working modalities as well as different components and processes (Letter and Number Sequencing, CPT-IP, Backwards Visual Span). All individuals were genotyped for the rs4680 (Val158Met) polymorphism at the COMT gene. Met carriers showed near-significant better performance in the LNS compared with Val/Val individuals (F = 3.9, df = 1, P = 0.046). Moreover, the analysis for linear trend found that Met allele carriers showed significantly better performance than Val/Val individuals (B = 0.58 P = 0.031), although evidence for a linear trend was not found. None of the WCST indices differed among genotypes. Consistent with the hypothesis that Val158Met polymorphism (COMT gene) might account for individual differences on dopamine-dependent prefrontally related neurocognitive functions, the Letter-Number Sequencing task, which requires not only maintenance but also active manipulation of information seemed to be more sensitive to the disadvantageous Val/Val genotype in a large non-clinical sample.

Anatomical redistribution of sweating after T2–T3 thoracoscopic sympathicolysis: a study of 210 patients

BACKGROUND

The cutaneous influence areas of the different sympathetic ganglia have not been fully established to date. The aim of this study was to define the cutaneous influence area of sympathetic ganglia T2-T3.

METHODS

A total of 210 patients with primary hyperhidrosis (PH) underwent 420 thoracoscopic sympathicolysis procedures of ganglia T2-T3 in a prospective study. All completed a preoperative questionnaire and a second questionnaire 12 months after the operation. The questionnaires evaluated perspiration in the different body areas. Only the zones of anhidrosis were considered in delimiting the cutaneous expression of sympathetic ganglia T2-T3.

RESULTS

Redistribution of perspiration as reported by the patients comprised significant reduction in the palms, axillas, and soles, and an increase in the abdomen, back, and gluteal and popliteal regions. Regarding the incidence of anhidrosis by anatomical location, statistically significant changes were recorded in the head, hands, axillas, and soles (p < 0.001).

CONCLUSIONS

Bilateral upper thoracic sympathicolysis is followed by redistribution of body perspiration, with a clear decrease in the zones regulated by mental or emotional stimuli, and an increase in the areas regulated by environmental stimuli, though we are unable to establish the etiology of this redistribution.

Safety and immunogenicity of a zoster vaccine in varicella-zoster virus seronegative and low-seropositive healthy adults

OBJECTIVE

To evaluate immunogenicity and tolerability of a live attenuated zoster vaccine in varicella-zoster virus (VZV) seronegative or low-seropositive adults > or = 30 years of age.

STUDY DESIGN

Double-blind, placebo-controlled, randomized, multicenter study. Subjects were enrolled in two stages by prescreened serostatus. Subjects with a low VZV antibody titer (< or = 5 gpELISA units/mL) were enrolled in Stage 1. Subjects with undetecable VZV antibodies and no safety issues identified during Stage 1 were enrolled in Stage 2. All enrolled subjects were randomized 4:1 to receive one dose (approximately 50,000 PFU) of zoster vaccine or placebo and were followed for safety for 42 days postvaccination. Primary objectives/hypotheses: (1) no vaccine-related serious adverse experiences (AE); (2) < or = 1 laboratory-confirmed varicella-like rash with > 50 lesions within 42 days postvaccination.

SECONDARY OBJECTIVE

summarize the VZV antibody response postvaccination.

RESULTS

Twenty-one subjects (age 27 to 69 years; median 34) enrolled (1148 prescreened); 18 (including 4 seronegative subjects) received vaccine and 3 (including 1 seronegative subject) received placebo. Twenty subjects completed the study; one subject withdrew for reasons unrelated to safety. No serious vaccine-related AE or laboratory-confirmed varicella-like rashes with > 50 lesions were reported. In the zoster vaccine group, all 4 of the initially seronegative subjects (age 32 to 36 years; median 33.5) seroconverted and 6 of the 13 (46.2%) initially seropositive subjects had a > or = 4-fold rise in VZV-specific antibody titer at 6 weeks postvaccination.

CONCLUSIONS

The zoster vaccine appears to be immunogenic and generally well tolerated in healthy adults > or = 30 years of age, regardless of initial VZV antibody serostatus.

Sperm morphology of the neotropical harvestman Iporangaia pustulosa (Arachnida: Opiliones): comparative morphology and functional aspects

We describe herein the sperm morphology of the harvestman Iporangaia pustulosa. Adult males were dissected, the reproductive tract was schematized and the seminal vesicle was processed by light, transmission and scanning electron microscopy. The male reproductive tract is composed of a tubular testis, two deferent ducts, a seminal vesicle, a propulsive organ and a penis, similar to that observed in other Opiliones. The spermatozoa from the seminal vesicle are oval, aflagellate and immotile, presenting a nucleus surrounding an invagination of the cytoplasm, as well as a complex acrosome and projections on the cell surface. In the testis, spermatozoa are devoid of projections. In the seminal vesicle, they gradually acquire the projections with tufts adhering to it. Consequently, spermatozoa in various distinct stages of projection development can be found in the seminal vesicle. We believe that these projections (1) could help transport sperm along the male and perhaps female reproductive tracts; (2) are used to anchor the spermatozoa inside the female spermatheca in order to avoid mechanical displacement by the genitalia of other males and (3) may play a role in oocyte recognition. We propose that the evolution of aflagellarity in Opiliones is related to the unique morphology of the female reproductive tract. Since eggs are fertilized on the tip of the ovipositor just prior to being laid, there is no advantage favoring sperm mobility. Additionally, female sperm receptacles are small and males that produced small spermatozoa would have a higher chance of fertilizing more eggs.

[Results of high bilateral endoscopic thoracic sympathectomy and sympatholysis in the treatment of primary hyperhidrosis: a study of 1016 procedures]

OBJECTIVE

Thoracic sympatholysis and sympathectomy are the current standard treatments for primary hyperhidrosis. In this study, we evaluated the incidence of peri- and postoperative complications associated with these procedures.

PATIENTS AND METHODS

From 1996 to 2004, 520 consecutive patients (364 women), with a mean age of 26.8 years, were treated for primary hyperhidrosis at our hospital. The procedure was bilateral in all but 24 cases. The 484 patients in the sympatholysis group underwent a single intervention while the 36 patients in the sympathectomy group underwent 2 separate interventions.

RESULTS

No deaths occurred. Anhidrosis of the target area was achieved in 97.6% of patients while 2.2% experienced hypohidrosis. In 0.2% of the cases, the procedure was initially unsuccessful and a second intervention was required. The mean duration of hospital stay was 72 hours for patients in the sympathectomy group and 17 hours for the sympatholysis group. Serious intraoperative complications requiring conversion to thoracotomy were recorded in 0.2% of patients. Postoperative complications--of which pneumothorax was the most common--occurred in 5.2% of the cases (in 22.5% of the sympathectomy group and 3.55% of the sympatholysis group). Compensatory hyperhidrosis occurred in 48.4% of the patients, excessive dryness of the hands and palpebral ptosis in 0.38%, and gustatory sweating in 0.9%. The degree of patient satisfaction was quite high (88.5%) and only 2.3% were very unsatisfied.

CONCLUSIONS

Given the results obtained, we can conclude that both sympatholysis and sympathectomy are appropriate treatments for hyperhidrosis. Nonetheless, because sympatholysis is both easier to perform and less aggressive, we consider it the treatment of choice for primary hyperhidrosis.

Thoracic sympathicolysis for primary hyperhidrosis: a review of 918 procedures

BACKGROUND

Bilateral upper thoracic sympathectomy or sympathicolysis, currently the standard treatment for palmar or axillary hyperhidrosis, is regarded as a safe procedure. This study evaluates the quantitative and qualitative incidence of intraoperative and postoperative complications resulting from bilateral thoracic sympathicolysis.

METHODS

From 1996 to 2004, 458 consecutive patients with primary hyperhidrosis underwent surgery. These patients comprised 143 men (31.2%) and 315 women (68.7%) with a mean age of 26 years (range, 14-52 years). In all but seven cases, the procedure was bilaterally synchronous.

RESULTS

No mortality was recorded. The anhydrosis rate was 97.4%, with a hypohidrosis rate of 2.4% and a failure rate of 0.2%. The latter was resolved with reintervention. The mean hospital stay was 17 h. The rate of major perioperative complications with conversion to thoracotomy was 0.4%. The overall rate of postoperative complications was 3.6%. The complications and rates observed were as follows: pneumothorax (2.06%), subcutaneous emphysema (1.08%), pleural bleeding (0.2%), hemothorax (0.1%), and atelectasis (0.1%). Compensatory hyperhidrosis was observed in 48.4% of the patients, but the sensation of compensatory hyperhidrosis was reported in 85.6% of the cases. Excessive dryness of the hands was reported in 0.38%, Horner's syndrome in 0.32%, and gustatory hyperhidrosis in 1.1% of the cases. The overall satisfaction rate was 88.5%.

CONCLUSIONS

The results suggest that endoscopic bilateral thoracic sympathicolysis is an effective method for managing primary hyperhidrosis, especially severe palmar hyperhidrosis, but it is necessary to inform patients fully concerning the undesirable effects.

[Primary hyperhidrosis and anxiety: a prospective preoperative survey of 158 patients]

OBJECTIVE

To determine the location of hyperhidrosis, the accompanying signs and symptoms, and patient anxiety assessed on 2 scales and standardized psychometric instruments.

PATIENTS AND METHODS

A prospective study of patients with hyperhidrosis was carried out between September 1, 2001 and June 30, 2003 with a self-administered preoperative questionnaire. The variables studied included the location of hyperhidrosis, the accompanying signs and symptoms, and the self-reported degree of anxiety and perception of its effect on daily life assessed by the State-Trait Anxiety Inventory (STAI) and a questionnaire designed in our department.

RESULTS

Palmar hyperhidrosis was reported by 93.6% of patients, plantar by 70.2%, axillary by 66.4%, facial by 12.1%, groin by 8.2%, chest by 5%, and abdominal by 2%. While more than 50% of the patients reported facial blushing and palpitations as accompanying signs and symptoms, approximately 30% experienced epigastric pain, trembling, and headaches. Over half of the patients reported that their anxiety was incapacitating, and a mere 1.2% experienced none at all. STAI scores were similar to those of the general population whereas scores on our department's questionnaire reflected those of the self-reported anxiety ratings.

CONCLUSIONS

Primary hyperhidrosis is a disorder in which excessive sweating occurs mainly, but not exclusively, on the palms. The condition is accompanied by signs and symptoms typical of autonomic nervous system hyperactivity and by a degree of anxiety that has an incapacitating effect on normal life, although that anxiety is not detected by the STAI questionnaire alone.

[Compensatory sweating after upper thoracic sympathectomy. Prospective study of 123 cases]

OBJECTIVE

The most unpleasant consequence of upper thoracic sympathectomy is compensatory sweating (CS). De-pending on the series, the incidence of CS ranges from 24% to 85%. The aim of this study was to determine the relation between CS and the following factors: distribution of hyperhidrosis, procedure performed (unilateral, synchronic bilateral, or sequential bilateral), and number of sympathetic ganglia eliminated. In addition, the degree of patient satisfaction was recorded as objectively as possible.

PATIENTS AND METHODS

Prospective study of 123 patients who underwent upper thoracic sympathectomy for palmar and/or axillary hyperhidrosis between 1 January, 1996 and 1 June, 2002 at our unit. All patients completed a questionnaire on symptoms 8 weeks before and after surgery to deter-mine postoperative changes in distribution of the hyperhidrosis and the overall degree of satisfaction on a scale of 0 to 4.

RESULTS

The sensation of CS was reported by 86.1% of the patients. When asked to relate this sensation to changes in sweating intensity in specific parts of the body, 46.54% reported CS and 48.37% no change. The trunk was the only region where statistically significant increases in CS occurred; in the feet, a decrease in sweating was noted. No differences in CS were observed with respect to the type of surgery or the number of sympathetic ganglia eliminated. The overall results were considered very satisfactory or quite satisfactory by 84.55% of the patients, while 4.88% were very dissatisfied.

CONCLUSIONS

Although CS is a side effect of upper thoracic sympathectomy, not all patients are affected by it. Significant CS occurs mainly in the back, chest, and abdomen. Neither the type of intervention nor the number of ganglia eliminated has an effect on CS. This side effect notwithstanding, overall satisfaction with the treatment is very satisfactory given that the palmar hyperhidrosis is eliminated.

[Histopathological changes in sympathetic ganglia of patients treated surgically for palmar-axillary hyperhidrosis. A study of 55 biopsies]

INTRODUCTION

Primary palmar hyperhidrosis (PPH) mainly affects the sympathetic ganglia. This study aims to analyze the histopathological changes in the sympathetic ganglia of patients with PPH.

MATERIAL AND METHOD

We studied 55 tissue samples from 35 patients with PPH who underwent T2-T3 gangliectomy for definitive treatment of their disease, analyzing the presence of inflammation, chromatolysis and lipofuscin accumulation. Findings were analyzed in relation to age, compensatory sweating and type of surgery: unilateral, synchronic bilateral or sequential bilateral.

RESULTS

We found inflammation in 5.5%, chromatolysis in 61.8% and lipofuscin accumulation in 41.8% of the samples. Chromatolysis and lipofuscin were found without inflammation in 32.1%. Chromatolysis and lipofuscin accumulation were each found in 60% of the samples from synchronic bilateral sympathectomies. However, those percentages decreased between the first and second sympathectomies in sequential procedures, such that chromatolysis was found in 71.4% of first-procedure samples and 42.8% of second-procedure samples; the rates for lipofuscin accumulation changed from 64.2% to 14.2%. Although findings were unrelated to age, they did correlate with compensatory sweating, which was found in 79.7% of patients undergoing synchronic bilateral sympathectomy, 78.5% of sequential bilateral sympathectomy patients and only 56.25% of unilateral sympathectomy patients.

CONCLUSIONS

Neuronal death and lipofuscin accumulation unrelated to inflammation are evident in sympathetic ganglia from patients with PPH. Such changes are atypical for a group of patients whose mean age is 29 years, unless such lesions are the result of functional hyperstimulation. Surgery performed sequentially does not lead to overloading of contralateral T2-T3 ganglia; on the contrary, decreased injury is evident.