High dose cholecalciferol supplementation causing morning blood pressure reduction in patients with type 1 diabetes mellitus and cardiovascular autonomic neuropathy

We evaluated the association of cardiovascular autonomic neuropathy (CAN), blood pressure (BP) and Vitamin D (VD) levels before and after high-dose cholecalciferol supplementation (4000/10,000) UI/day) for 12 weeks in patients (N = 67) with type 1 diabetes mellitus (T1DM). Based on this prospective controlled pilot study, patients were divided into group 1 (N = 23 with CAN) and group 2 (N = 44 without CAN). At baseline, group 1 had higher systolic BP (SBP) during sleep (115 ± 14 vs. 107 ± 12 mmHg, p = 0.04) and lower nocturnal dipping (3 ± 5 vs. 8 ± 6%, p = 0.009). Among those with loss of nocturnal dipping, 45.4% (20/44) had CAN, while in normal nocturnal dipping group it occurred only in 13% (3/23) (p = 0.007). Non-dipper group had worse CAN parameters when compared to dipper group [Very low frequency (VLF) (2.5 ± 0.5vs.2.8 ± 0.4 s, p = 0.01), total power (TP) (2.9 ± 0.6 vs. 3.3 ± 0.4 s, p = 0.01), Valsalva coefficient (1.5 ± 0.4 vs. 1.8 ± 0.6, p = 0.06)]. After VD, only group 1 improved CAN parameters [TP (2.5 ± 0.4 vs. 2.8 ± 0.6, p = 0.01) and VLF (2.2 ± 0.4 vs. 2.4 ± 0.5, p = 0.03). Group 1 presented a reduction in morning SBP (120 ± 20 vs. 114 ± 17 mmHg, p = 0.038) and in morning SBP surge (13 ± 13 vs. 5 ± 14, p = 0.04). High-dose VD was associated with improved CAN parameters and reduced awake SBP and morning SBP surge. These findings suggest that VD may benefit patients with cardiovascular autonomic neuropathy. ISRCTN32601947, registration date: 31/07/2017.

A review: Circadian Rhythm Dysfunction and Bipolar Disorder

Introduction

Circadian rhythm (CR) dysfunction is a prominent feature in bipolar disorder (BD) and sleep disturbances are characteristic, although not essential to the diagnosis.

Objectives

To review the literature regarding the CR dysfunction and its impact on the onset and clinical course of BD.

Methods

We conducted a MEDLINE search using bipolar disorder, circadian rhythm and sleep as keywords, selecting studies written in English.

Results

CR dysfunction is a trait marker of BD. It’s known that during depressive episodes insomnia is present, with difficulty falling asleep/ maintaining sleep and early awakening. Regarding mania, decreased need for sleep is a critical marker. During the euthymic period significant alterations in sleep pattern have been described. It’s also known that changes in the sleep pattern occur prior to those in mood patterns, indicating that sleep dysregulation may trigger the onset of mood episodes or relapses. Therefore, CR disruption may be associated with the pathophysiology of BD and some factors have already been identified: irregularity of the sleep-wake rhythm, eveningness chronotype, abnormality of melatonin secretion, vulnerability of clock genes and the irregularity of social zeitgeber.

Conclusions

Disturbances of sleep are pervasive, and an essential feature of BD, worse during mood episodes, but still present during euthymic periods. It remains to determine whether circadian rhythm dysfunction is a trait marker or mood state dependent. Further studies are warranted to clarify this association.

Disclosure

No significant relationships.

Psychiatric manifestations of paraneoplastic syndromes

Introduction

Paraneoplastic syndromes (PS) result from indirect effects of neoplasms. In 50% of the cases the symptoms precede the diagnosis and run independently. PS may involve the peripheral or central nervous system, resulting in symptoms from sensory neuropathies to several neuropsychiatric manifestations.

Objectives

To review the psychiatric manifestations of paraneoplastic syndromes affecting the nervous system.

Methods

Selective literature review via PubMed search, using the keywords “paraneoplastic syndromes”, “endrocrine paraneoplastic syndromes”, “neuropsychiatric manifestations”, “limbic encephalitis”.

Results

The prevalence of PS varies with the type of cancer (<1% for breast and ovarian cancers; 3-5% for small cell lung cancer; 20% for thymomas). The general mechanisms behind PS are related to the production of substances by the tumor that directly or indirectly cause distant symptoms, the depletion of substances or the host response to the tumor. Frequently there are autoimmune phenomena involved, with the production of antineuronal antibodies that recognise various antigens at the nervous system. Paraneoplastic neurological disorders include limbic encephalits that can present subacutely with symptoms of depression, irritability, hallucinations, cognitive impairment associated with sleep alterations, confusion and seizures. Others include psoclonus-myoclonus ataxia syndrome, neuromyotonia and cramp fasciculation syndrome. Metabolic and endocrine paraneoplastic syndromes (hypercortisolism, carcinoid tumors, pancreatic cancer) can result from the production of cytokines and hormones by the tumor and produce mood disorders, confusional states and psychosis.

Conclusions

PS can be related to various neuropsychiatric manifestations affecting consciousness, cognition, mood and perception. The recognition of this association can alert for the possibility of a cancer diagnosis specially when facing a patient with unusual clinical presentation.

Disclosure

No significant relationships.

Global world, global hospitals. Ethnic differences and psychotic symptoms presentation – a review

Introduction

We live in a global world, where immigration is no longer just an escape, but also a demand and a desire. Globalization imposes the challenge of recognizing psychiatric illness in the most diverse of patients.

Objectives

To review the literature about the documentation of ethnic differences and the psychotic symptoms presentation.

Methods

We performed a MEDLINE search using the key words: ethnic differences and psychotic symptoms. We only included studies with full text published in English.

Results

Since the 1970s, some studies have shown that there are differences in the manifestation of psychiatric illness in ethnic minorities. Most recent studies confirm this statement, mainly with an increase in immigration in the 20th century, with the receiving countries having an increase in the number of cases of psychosis (affective and non-affective). Belonging to an ethnic minority increases the risk of psychotic symptoms and experiences, witch is related to the patients perception of discrimination, social differences, family separation and the stress associated with immigration. On the other hand, these groups also have less access to health care.

Conclusions

Currently, professionals are more aware of the global world and what this implies in the manifestations of psychiatric illnesses. However, more studies will be needed to identify these natural differences. In this way, we will be able to help our patients anywhere and support their families.

Disclosure

No significant relationships.

Levothyroxine supplementation among individuals with Subclinical Hypothyroidism and Depression | a review

Introduction

Depression is known to be associated with changes in the hypothalamic-pituitary-thyroid axis and the brain is a major target organ for thyroid hormone. Overt hypothyroidism can cause symptoms compatible with depression. However, its relationship with subclinical hypothyroidism (SCH) is not well established.

Objectives

To review the literature regarding the effect of levothyroxine therapy among patients with SCH and coexistent depression.

Methods

We conducted a MEDLINE search using depression, subclinical hypothyroidism and levothyroxine as keywords, selecting studies written in English.

Results

SCH is defined as an elevated thyroid stimulating hormone with normal peripheric hormone levels. The association between SCH and depression is controversial. Some studies indicate that SCH had the same propensity with overt hypothyroidism, while others report that major affective symptoms are not associated with SCH, but are likely due to independent psychiatric diagnoses, which are common in the general population and occur with similar frequency in patients with SCH. Individuals with SCH are recommended to initiate levothyroxine replacement therapy only when their TSH level is above 10 mIU/L or if symptoms are present. There is a lack of evidence supporting the use of levothyroxine therapy to improve mental health outcomes and the majority of meta-analysis do not show relief of affective symptoms after levothyroxine therapy, among individuals with SCH.

Conclusions

Routine screening for depressive symptoms among individuals with SCH is important to prevent morbidity. Nevertheless, there is no evidence enduring levothyroxine supplementation in these cases. Further studies, with larger sample sizes and longer follow-up periods are needed to enlighten the potential benefit of this therapy.

Disclosure

No significant relationships.

Hospital environment and patient recovery – a review

Introduction

Since the second half of the 20th century, studies have been carried out that prove the benefits of the hospital environment in the improvement and recovery of patients. In this way, it would be important to understand what has already been done within the reality of Psychiatry Department.

Objectives

To review the literature about the documentation of hospital environment influence in patients’ recovery.

Methods

We performed a MEDLINE search using the key words: hospital environment influence and patients’ recovery or patients healing. We only included studies with full text published in English.

Results

In the selected articles, we only found studies developed in the Surgery department; in one of them, the authors tested the presence of plants in the patients’ rooms and assessed lower blood pressure values, less pain and less anxiety than the control group; in another, they tested the presence of music and landscape, although there was no difference in terms of pain assessment, there was an improvement in the assessment of the postoperative experience. A review pointed some other aspects that patients linked with their recovery, such as: audio and visual environment; specifically, in anxiety, pain and stress. On the other hand, other studies address the influence of the hospital environment on the satisfaction of health care providers.

Conclusions

Although hospital environment has already demonstrated an impact on the patient recovery, none (in our review) was developed directly in a Psychiatric Department; further studies are needed to understand the impact on this kind of service.

Disclosure

No significant relationships.

Advanced echocardiographic function analysis in adolescents and young adults with corrected and residual coartation of the aorta

Funding Acknowledgements

Type of funding sources: None.

Introduction

This study aimed to assess systolic and diastolic heart function changes in patients with history of aortic coarctation using advanced echocardiographic imaging. Additionally, we sought to analyse which severity factors influenced these changes.

Methods

We performed a complete echocardiographic evaluation, with advanced functional analysis, including myocardial work analysis, to a random sample of 53 patients (age 12 to 40 years). These had a previous history of coarctation of the aorta (CoAo), which was either corrected (aortic transisthmic Doppler gradient (Dgrad) ≤20mmHg) or presented a significant residual gradient (Dgrad &gt;20mmHg). A control group of healthy individuals, matched for age, sex and BMI, was subjected to the same evaluation. Selected dependent variables were: E/A, E’, E/E’, atrial strain parameters, biplane ejection fraction, ventricular global longitudinal strain, and global myocardial work (GMW). One-way ANOVA with appropriate post-hoc tests was done to compare the distribution of dependent variables among controls (n = 31), patients with corrected coartation (cCOAO) (n = 36), and patients with residual coartation (rCOAO) (n = 17). Multivariable linear regression was used to evaluate the association, in the 53 patients, between the dependent variables and parameters of CoAo severity: systolic blood pressure (SBP), left ventricular indexed mass (LVmass), Dgrad, and the ratio of the narrowest diameter of the aortic arch to the aorta at the diaphragm level (Aoratio). Statistical significance was established as p &lt; 0.05.

Results

Patients with either cCOAO or rCOAO had lower E’ (p &lt; 0.001), higher E/E’ (p &lt; 0.001), lower atrial reservoir (p &lt; 0.001) and conduit (p &lt; 0.001) strain, when compared with controls (table 1). Patients with rCOAO had higher GMW when compared with either cCOAO or controls (p = 0.002). Multivariable regression analysis showed that both lower atrial reservoir and conduit strain were associated with a narrower aortic arch (lower Aoratio (p = 0.002 and p = 0.011, respectively); higher E/E’ with higher LVmass (p = 0.030); higher GMW with higher LVmass (p = 0.027) and Dgrad (p = 0.035). Patients subsequently submitted to an intervention for coartation treatment (n = 8) had lower atrial conduit (p = 0.007) and higher GMW (p = 0.015) when compared to all other patients (n = 45). Conclusion: Myocardial work emerged as a particularly useful tool as it was both significantly different between CoAo groups, and significantly higher in more severe patients, driven by the LV mass and residual gradient. This analysis may have a role in these patients’ clinical decision-making. Abstract Table 1

[Virtual palliative care : Pilot study of an electronic tool to test cognitive, psychomotor and affective palliative medical and pain therapeutic learning contents during medical training]

BACKGROUND

This article describes a first use of an electronic case-based assessment tool in undergraduate palliative care education. It describes the development of the tool presenting strengths and shortcomings in order to contribute to an innovative design of assessment tools in medical education.

DESIGN AND METHOD

An electronic (virtual) case-based assessment tool (the virtual palliative patient, vPp) was developed. Palliative care levels of knowledge, skills and attitude of students were tested at a computer workplace as a voluntary and non-performance-relevant pilot project at four faculties.

RESULTS

On average the students achieved 80% of the points using the vPp tool, which is below the average score of 91% achieved in the regular examination. In particular, the free text task on reflection of dealing with the patient's death wish caused uncertainty, while multiple choice questions and an interactive conversation sequence were perceived as relatively easy. Technical problems were also identified in the evaluation but overall the concept was evaluated positively and establishment as a regular examination or e‑learning tool was desired.

CONCLUSION

The implementation of an innovative assessment tool in medical education is technically challenging. A coordination with contents of the individual faculties is necessary in order that students do not have a feeling of a lack of preparation. The development of the vPp describes an innovative assessment format. In the long term, all interested faculties could receive a form of toolbox containing the technical framework of the assessment tool, which can then be fed with new contents.

Delirium in COVID-19: psychopharmacology considerations

Introduction

Delirium is characterized by fluctuating disturbance of consciousness, inattention, reduced awareness, hallucinations or delusions, occurring in 20% of hospital admissions. Central nervous system symptoms are the main form of neurologic injury in patients with COVID-19 and a significant portion of these patients presents with delirium. COVID-19 infection’s course and symptoms, as well as patient comorbidities can facilitate its onset, which is exacerbated by the frequent need for higher doses of sedation to suppress severe cough.

Objectives

To summarize the most recent practices for management of delirium in COVID-19 infected patients, with emphasis on the psychopharmacology approach.

Methods

Selective literature review via PubMed search, using the terms “delirium, neurological disorders, psychopharmacology and COVID-19”.

Results

COVID-19 associated delirium can be presented in its hyperactive type with exuberant agitation, but also with additional clinical features such as rigidity, akinetic mutism, abulia and alogia. Psychopharmacological approaches may be needed for patients with agitation when there’s intractable stress or risk to self or others. In this group of patients, melatonin, alfa-2 agonists and low potency antipsychotics have been used as first line treatment. Trazodone, valproate, dopamine agonists, amantadine can be used. Other approaches such as correction of vitamin deficiencies and remdesivir can also play a role.

Conclusions

Delirium remains frequently unrecognized. In the pandemic context of COVID-19 it is important to consider this infection as a cause of delirium and mind the misdiagnosis as a psychiatric condition. One should look for atypical features and be more thoughtful about the psychopharmacological approach.

What lies underneath: The genetics and neurobiology of psychopathy

Introduction

Psychopathy is a personality disorder characterized by lack of empathy, grandiosity, an impulsive lifestyle and antisociality. Anti-social personality disorder (ASPD) and psychopathy are distinct concepts presenting different criteria. Most people with a diagnosis of psychopathy also meet criteria for ASPD while the reverse is not true. Along the years there has been an increasing interest in investigating genetic and neurobiological factors.

Objectives

To analyze the neurobiological factors involved in psychopathy and anti-social personality disorder according to the scientific knowledge available.

Methods

Review of scientific literature via PubMed search, using the terms “anti-social personality disorder”, “biology or etiology or pathophysiology and psychopathy”.

Results

The strongest evidence base for a genetic pathway is associated with the low-expression variant of the Monoamine Oxidase-A (MAO-A) which is linked to the X chromosome. Other genetic factors involve the 5-HTT gene, dopamine receptor genes (DRD4 and DRD2) and genetic polimorfisms at SNAP25 t-snare protein, OXT gene and the CNR1 and FAAH cannabinoid receptor gene. Structural differences in the brain have been noticed such as reduced gray matter volume in the orbitofrontal cortex, gray matter volume reductions in the mid-anterior insula and left anterior temporal cortex, subtle reductions in gray matter volume across several paralimbic and limbic areas.

Conclusions

There is considerable evidence regarding various possible underlying neurobiological processes in psychopathy although it is insufficient to suggest a single biological etiology and environmental influences cannot be excluded from a complete understanding of this disorder. The neurobiological correlates found hold promise for new research and treatment.

Blended learning modules for lectures on oral and maxillofacial surgery

Over the last couple of years, new teaching methods have been developed and implemented in German universities, but only rarely in dental schools. The aim of this project therefore was to implement students' requests for such methods to be used in dental education. In 2012, based on an analysis of both quantitative and qualitative requirements, we designed a questionnaire for quantitative analysis, and evaluated a series of lectures on oral and maxillofacial surgery. Based on our findings, we then designed a blended learning module that was gradually integrated into the series. In 2017 we again evaluated the lectures, and rated the module. The two evaluations were then compared using a two-sample z-test. The results showed that students were very satisfied with the approach. They were particularly happy with the surgical videos, which were shown during the lectures and also included in the module, as they helped them to understand the surgical technique. Our survey showed that most of the students were using the online learning program and that it was the resource they preferred. Application of a blended learning approach could satisfy the requirements of the new generation of students, and transform traditional lectures into modern, sustainable, and technology-enhanced learning experiences.

The action of chemical and mechanical stresses on single and dual species biofilm removal of drinking water bacteria

The presence of biofilms in drinking water distribution systems (DWDS) is a global public health concern as they can harbor pathogenic microorganisms. Sodium hypochlorite (NaOCl) is the most commonly used disinfectant for microbial growth control in DWDS. However, its effect on biofilm removal is still unclear. This work aims to evaluate the effects of the combination of chemical (NaOCl) and mechanical stresses on the removal of single and dual species biofilms of two bacteria isolated from DWDS and considered opportunistic, Acinectobacter calcoaceticus and Stenotrophomonas maltophilia. A rotating cylinder reactor was successfully used for the first time in drinking water biofilm studies with polyvinyl chloride as substratum. The single and dual species biofilms presented different characteristics in terms of metabolic activity, mass, density, thickness and content of proteins and polysaccharides. Their complete removal was not achieved even when a high NaOCl concentrations and an increasing series of shear stresses (from 2 to 23Pa) were applied. In general, NaOCl pre-treatment did not improve the impact of mechanical stress on biofilm removal. Dual species biofilms were colonized mostly by S. maltophilia and were more susceptible to chemical and mechanical stresses than these single species. The most efficient treatment (93% biofilm removal) was the combination of NaOCl at 175mg·l^-1 with mechanical stress against dual species biofilms. Of concern was the high tolerance of S. maltophilia to chemical and mechanical stresses in both single and dual species biofilms. The overall results demonstrate the inefficacy of NaOCl on biofilm removal even when combined with high shear stresses.

Microbiological quality and biogenic amines in ready-to-eat grilled chicken fillets under vacuum packing, freezing, and high-dose irradiation

The combined effects of cooking, vacuum packing, freezing, and high-dose gamma irradiation in the microbiological conservation and in biogenic amine (BA) contents of ready-to-eat grilled breast chicken fillets are investigated in this work. After seasoning, cooking, and vacuum packing, one-third of the samples were stored at -25°C (T1). The remaining two-thirds were treated with 48 kGy, one-third being stored at -25°C (T2) and the other one-third kept at room temperature (T3). All samples were periodically analyzed to determine growth of heterotrophic aerobic mesophilic bacteria (HAMB) and levels of BA (tyramine, TYM; putrescine, PUT; cadaverine, CAD; spermidine, SPD; histamine, HYM; and spermine, SPM). Variance analysis was performed to determine significant changes in the measured data. Grilling caused HAMB counts in seasoned samples to drop from 5.3 log cfu/g to zero. In addition, no viable HAMB cells were detected in the samples throughout the 12-mo storage time. Regarding the BA analyses, the highest mean levels were measured for SPM and CAD with significantly higher levels (P < 0.05) being determined in nonirradiated samples (T1). Furthermore, significantly lower mean levels for the total content of BA were observed in the irradiated samples. Relative to T1 (7.5 ± 1.5 mg/kg), the figures were 47 ± 23% for T2 and 60 ± 25% for T3, mostly due to loss of CAD by radiolysis. Therefore, it can be concluded that the combination of grilling, vacuum packing, freezing, and high-dose gamma irradiation efficiently eliminated HAMB, while sustaining acceptable levels of BA in ready-to-eat chicken breast fillets throughout the 12 mo of storage at room temperature.

Isolation and in vitro culture of trypanosomes from Leptodactylus ocellatus from the Atlantic Forest in a new experimental culture medium

The purpose of this study was to verify the in vitro development of Trypanosoma sp. isolated from Leptodactylus ocellatus frogs under a new protocol using a biphasic medium composed of Novy, McNeal, and Nicolle (NNN) blood agar medium as a solid phase and liver infusion, brain heart infusion, and tryptose (LIBHIT) medium as a liquid phase. Blood forms, collected by cardiac puncture or after the maceration of different organs, were inoculated in culture tubes containing the biphasic medium composed by NNN and LIBHIT. Trypanosomes were observed 4 days postinoculation; most bloodstream trypomastigotes had differentiated into epimastigotes and amastigotes by this time. Trypomastigotes were again observed in older cultures (7 days). Parasites were successfully subcultured for 8 mo in this medium and successfully cryopreserved. The present study provides a new protocol medium for the isolation and culture of anuran trypanosomes.

High-resolution comprehensive radiation hybrid maps of the porcine chromosomes 2p and 9p compared with the human chromosome 11

We are constructing high-resolution, chromosomal 'test' maps for the entire pig genome using a 12,000-rad WG-RH panel (IMNpRH2(12,000-rad))to provide a scaffold for the rapid assembly of the porcine genome sequence. Here we present an initial, comparative map of human chromosome (HSA) 11 with pig chromosomes (SSC) 2p and 9p. Two sets of RH mapping vectors were used to construct the RH framework (FW) maps for SSC2p and SSC9p. One set of 590 markers, including 131 microsatellites (MSs), 364 genes/ESTs, and 95 BAC end sequences (BESs) was typed on the IMNpRH2(12,000-rad) panel. A second set of 271 markers (28 MSs, 138 genes/ESTs, and 105 BESs) was typed on the IMpRH(7,000-rad) panel. The two data sets were merged into a single data-set of 655 markers of which 206 markers were typed on both panels. Two large linkage groups of 72 and 194 markers were assigned to SSC2p, and two linkage groups of 84 and 168 markers to SSC9p at a two-point LOD score of 10. A total of 126 and 114 FW markers were ordered with a likelihood ratio of 1000:1 to the SSC2p and SSC9p RH(12,000-rad) FW maps, respectively, with an accumulated map distance of 4046.5 cR(12,000 )and 1355.2 cR(7,000 )for SSC2p, and 4244.1 cR(12,000) and 1802.5 cR(7,000) for SSC9p. The kb/cR ratio in the IMNpRH2(12,000-rad) FW maps was 15.8 for SSC2p, and 15.4 for SSC9p, while the ratio in the IMpRH(7,000-rad) FW maps was 47.1 and 36.3, respectively, or an approximately 3.0-fold increase in map resolution in the IMNpRH(12,000-rad) panel over the IMpRH(7,000-rad) panel. The integrated IMNpRH(12,000-rad) andIMpRH(7,000-rad) maps as well as the genetic and BAC FPC maps provide an inclusive comparative map between SSC2p, SSC9p and HSA11 to close potential gaps between contigs prior to sequencing, and to identify regions where potential problems may arise in sequence assembly.

Effects of an individually ventilated cage system on the airway integrity of rats (Rattus norvegicus) in a laboratory in Brazil

The ventilation method used in the management of laboratory rats is important in maintaining their health. Rats kept under general diluting ventilation (GDV) are exposed to high levels of pollutants present in the environment (dust, airborne bacteria, etc.) or those pollutants produced by animal metabolism and excretion inside the boxes (e.g. ammonia and carbon dioxide). These pollutants may contribute to respiratory pathologies. An alternative experimental ventilation system for laboratory animal housing using intracage ventilation technology (individually ventilated cage system, IVC) was developed. In this system, ammonia levels decreased and rats exhibited better reproductive performance and a lower incidence of pneumonia than rats maintained under GDV. Using two different levels of air speed (0.03-0.26 m/s: IVC(1); 0.27-0.80 m/s: IVC(2)), the effects of IVC were compared with GDV (control) in Wistar rats in terms of respiratory mucus properties, on the nasal epithelium (as measured by quantitative morphometry) and on the lungs (as determined by the cellular composition obtained by bronchoalveolar lavage). Mucus of the respiratory system was evaluated using the following techniques: rheology (viscoelasticity) by microrheometer, in vitro mucociliary transportability (frog palate) and contact angle (an indicator of adhesivity). Also, membrane transepithelial potential difference was measured as a biomarker of airway integrity. After bedding was changed, ammonia concentrations inside the cages on day 3 were significantly higher for GDV than for IVC(1) and IVC(2). The potential-difference values for IVC(1), IVC(2) and GDV in the epiglottis and in the trachea also showed differences. Although some significant differences were observed across the three groups in counts of some cell types, the intragroup results were highly variable among individuals and inconsistent between sexes. No significant differences in the other parameters were found across groups. These results establish that rats maintained under GDV in relatively unregulated conditions are exposed to factors that can lead to deleterious effects on the ciliated epithelium of the airways, and that these effects can be prevented by the use of IVC.

Prevalence of lysosomal storage diseases in Portugal

Lysosomal storage diseases (LSDs) are a group of inherited metabolic disorders individually considered as rare, and few data on its prevalence has been reported in the literature. The overall birth prevalence of the 29 different LSDs studied in the Portuguese population was calculated to be 25/100000 live births, twice the prevalence previously described in Australia and in The Netherlands. The comparison of the prevalence profile of the LSDs presenting a prevalence higher than 0.5/100000 in the Portuguese, Dutch and Australian populations showed, in the Portuguese, the existence of a higher prevalence of GM2 gangliosidoses (B variant), mucolipidoses (II and III), Niemman-Pick type C and metachromatic leukodystrophy (MLD), and a lower prevalence of Pompe and Fabry. The highest prevalence value for a single LSD is the one of GM2 gangliosidoses (B variant), corresponding to 3/100000, a value which is significantly higher than the prevalence of the most frequent LSD in Dutch, Pompe disease (2/100000) and Australians, Gaucher's disease (GD) (1.8/100000). It is worth noting that the highest prevalence of GM2 gangliosidoses found in the Portuguese is mainly due to the existence of a unique subtype, the rare juvenile B1 variant.

[Phenotypic evolution in adrenoleukodystrophy]

The X-linked adrenoleukodystrophy (ALD) is a genetic disease, caused by a defect mapped to Xq28. It is characterised by progressive demyelination of the cerebral white matter and adrenal insufficiency. The most important change that occurs is the accumulation of very long chain fatty acids (VLCFAs). The authors describe a patient whom the initial phenotype was Addison disease only (AO). With 21 years old he developed neurological complaints and the electrophysiological and neuroradiological studies performed, confirmed the phenotypic change from AO to pure Adrenomyeloneuropathy. Less than 2 years later, the clinical condition worsened and the magnetic resonance performed confirmed cerebral involvement by the disease. The authors point out the need to determine the levels of VLCFAs in all men with adrenal insufficiency. They also put much emphasis on the endocrinology and neurology following of any patient with ALD because of the possibility of a phenotypic change to occur.

Molecular characterization of 21 X-ALD Portuguese families: identification of eight novel mutations in the ABCD1 gene

X-linked adrenoleukodystrophy (X-ALD) is the most common inherited peroxisomal disorder. The gene associated with X-ALD, ABCD1, encodes a peroxisomal ATP-binding cassette half-transporter. In this study, we describe the molecular characterization of 21 affected Portuguese families. The complete coding region of the ABCD1 gene was amplified by reverse transcription polymerase chain reaction (RT-PCR) or genomic PCR. After conformation-sensitive gel electrophoresis analysis, fragments with a conformational heteroduplex pattern were sequenced. Using this strategy, we have identified 14 missense mutations, two nonsense mutations, two splicing site defects, and three small deletions, two of them resulting in frameshifts. Eight of the genetic alterations characterized in this study are novel. The levels of the ABCD1 transcript as well as the levels of ALDP in cultured skin fibroblasts of male probands were also determined in most cases. The levels of the ABCD1 transcript in one patient (corresponding to a nonsense mutation) were below the detection limit of Northern-blotting analysis. ALDP was found at normal levels in only three patients, absent in five (corresponding to a double missense, two nonsense, and two frameshift mutations), and decreased in all the others.

Characterisation of two mutations in the ABCD1 gene leading to low levels of normal ALDP

A variety of mutations have been identified in the X-linked adrenoleukodystrophy (X-ALD) gene, none of which is prevalent. In this work we describe a reverse transcription polymerase chain reaction (RT-PCR)-based strategy specially suited to the molecular characterisation of mutations in index cases. After RT-PCR amplification of the X-ALD transcript a conformation-sensitive gel electrophoresis analysis is performed followed by sequencing of the fragments with altered mobility. Two X-ALD patients were studied using this strategy. In both cases, splice site mutations were found. The first patient studied has a single base substitution at the first position of the invariant GT dinucleotide donor splice site of intron 8. In spite of this alteration, small quantities of correctly spliced mRNA molecules were easily detected. In agreement with these data, a small amount of ALDP was found by western blotting analysis. An alteration at the -1 position of the donor splice site of exon 1 was detected in the second patient. This mutation results in the utilisation of a cryptic 5' splice site within intron 1. Nevertheless, this transition also allows for some correct splicing. Western blotting analysis revealed the existence of normal-migrating ALDP. However, as expected, the levels of this protein were greatly decreased. Taken together, our data suggest that some less severe or late-onset forms of X-ALD associated with splice mutations result from the production of small amounts of normal ALDP. It is proposed that the quantification of ALDP levels in these patients could provide important insights concerning the correlation between clinical phenotype and amount of normal ALDP.

Fibrous capsule formation in response to ultrahigh molecular weight polyethylene treated with peptides that influence adhesion

A wide variety of hard tissue substitute materials for reconstruction have been designed for use in dental and orthopaedic procedures. Most of the literature provides information on the osteocompatibility of these materials, and not on soft tissue compatibility. The bone bonding strength of the materials is relatively high, but there seems to be a lack of bonding properties with soft tissue which results in the formation of fibrous encapsulation. This lack of soft tissue bonding can lead to implant failure. Therefore in order to study how artificial materials may remain in the body for long periods of time and remain functional, it is vital to understand the fibrous tissue encapsulation process. Ultrahigh molecular weight polyethylene coated with RGD, RGE, Poly-L-Lysine, or saline was implanted into Sprague Dawley rats either intraperitoneally or subcutaneously for 12 weeks. Aseptic surgical techniques were followed according to standard laboratory procedures. Blood was collected weekly for the first 8 weeks and at 12 weeks, and analyzed for lactate dehydrogenase activity to assess muscle wasting and compatibility. Lactate dehydrogenase activity was elevated at weeks one and two for groups implanted with materials, in comparison to control unoperated animals. From weeks 3-12, the LDH activity was similar in all groups indicating that there was no adverse response to the implanted material. The implants were harvested at the end of 12 weeks, and the fibrous capsule was screened histologically to determine thickness and cell types at the interface. The results clearly showed that the implants that were placed subcutaneously had a less extensive fibrous and vascular tissue formation, than those implanted intraperitoneally. The results also indicated that the location of the implant intraperitoneally, determined the extent of the fibrous tissue formation. The implanted materials coated with RGD and Poly-L-Lysine had thicker fibrous capsule formation than RGE coated implanted at both the subcutaneous and intraperitoneal sites. The results also suggest that the implant-interface contained fewer inflammatory cells when the implants were placed subcutaneously. The overall results indicate that more than surface charge or coating govern the formation of fibrous tissue in vivo.

Muscular herniation of the lower extremities

Fascial defects are encountered infrequently by physicians who manage disorders of the lower extremities. The correct diagnosis of this condition is important, because the treatment is forthright and will bring the patient relief from symptoms. This article reviews the literature and attempts to aid the clinician in understanding this condition and its treatment. Two illustrative cases are presented.

Differential distribution of elastic system fibers in control and bronchoconstricted intraparenchymatous airways in the guinea-pig lung

The elastic system fibers were studied at the light microscopic level by using Weigert's resorcin-fuchsin method after oxidation. This study was designed to describe the distribution of these fibers in intrapulmonary guinea-pig airways and to characterize their conformational changes during bronchoconstriction induced by methacholine aerosol. Airways present a palisade of elastic system fibers just beneath the epithelial basement membrane; these fibers are also present in the adventitial connective tissue. Thin fibers link the fibers located in the palisade among themselves and also connect them to those fibers located in the bronchial adventitial tissue, by traversing the airway smooth muscle. During bronchoconstriction, the fibers located beneath the epithelial basement membrane are divided into two components: one follows the epithelial invaginations towards airway lumen, while the other population remains attached through airway smooth muscle to the fibers located in the adventitial connective tissue. At the ultrastructural level, the findings corroborated those of the light microscopy and in addition, disclosed that typical mature elastic fibers and also elaunin fibers attach directly to the basal lamina, a feature that has not been reported previously in other tissues studied. This configuration is compatible with the idea that fibers of the elastic system restrict the mucosal folding during bronchoconstriction, and may also provide energy to restore airway configuration to its normal status after contraction.

Organization of collagen and elastic fibers studied in stretch preparations of whole mounts of human visceral pleura

Fibers of the collagenous and elastic systems are most relevant in the double mechanical action of visceral pleura (VP), i.e. volume limitation and the generation of elastic recoil pressure. In this work we studied the organization of these fibrous components of VP in two situations: normal lungs and bullous disease. We employed histochemical methods on conventional histological slides and on thin spreads of whole mounts of visceral pleura. In addition, the scanning electron microscope was also used. According to our results, pleural function is made possible by the combination of both the elastic and collagenous fiber systems, each one having as intrinsic organizational pattern. Marked alterations of pleural bullous structure are observed with changes in lung volume. Fibers of the elastic and collagenous systems are clearly interdependent elements. Collagenous fibers are interwoven in a plaited structure that closely resembles the osiers of a wicker basket, indicating that collagen fibers allow for lung volume increase up to a point of maximal stretching of the system. The pleural contribution to lung elastic recoil pressure originates from the elastic network which turns back to its resting position when inspiratory pressures are negligible. The pleural immobility in bullous disease is associated with an almost complete absence of elastic fibers and the presence of very thick collagen fibers, suggestive of a cicatricial process, devoid of any characteristic pattern of distribution.

Urban air pollution enhances the formation of urethane-induced lung tumors in mice

This paper investigates the association between air pollution and lung neoplasia in an animal model. The experimental exposures were done in two locations with different air pollution profiles: a polluted area (downtown São Paulo) and a "clean" environment (Atibaia). Swiss mice were employed and urethane (3 g/kg) was used as carcinogenic substance. Two experiments were performed: Experiment I was designed to verify whether air pollution acts as initiator and/or promoter of lung cancer, using 300 mice; Experiment II employed 250 animals and aimed to verify if the effects of air pollution on the development of lung tumors was dose dependent. A significant effect of air pollution in augmenting lung carcinogenecity induced by urethane was observed. This effect was shown to be dose-dependent and reproducible on two different occasions. In addition, morphometric studies revealed that pollution may influence tumor phenotype. These results support the hypothesis that air pollution plays a significant role in the development of lung tumors.

The role of the collagenous and elastic system fibers in modulating bronchoconstriction

The distribution and conformational changes of the fibers of the collagenous and elastic systems in guinea pig airways after a contractile agonist challenge are described. We observed a distinct pattern of behavior within the mucosal fibers during bronchoconstriction. Part of the fibers of the two systems tend to follow the epithelial invaginations towards the airway lumen, while the remaining ones seem to be attached to the internal smooth muscle. These layers of fibers in the mucosa are interconnected to one another and to the adventitial network by slender fibers. We suggest that the configuration and behavior of these fibers during bronchoconstriction may contribute to airway reopening after the contractile stimulus has ceased. The possible role of this mechanism in the pathophysiology of human asthma is discussed.

Prenatal diagnosis of GM2-gangliosidosis B1 variant

Prenatal diagnosis in a pregnancy at risk for a juvenile B1 variant of GM2-gangliosidosis was carried out. The biochemical study of the cultured amniocytes and the affected fetal brain is reported. The results obtained show that the sulphated artificial substrate can be used in the diagnosis of B1 variant, but not the neutral one. The accumulation of GM2-ganglioside in the fetal brain of the B1 juvenile form and an infantile form of GM2-gangliosidosis (0 variant) was compared.

Quantitative pathology of nasal passages in rats exposed to urban levels of air pollution

In order to assess the adverse effects of urban levels of air pollution, rats were used as biological indicators in a chronic exposure experiment. Animals were housed for 6 months in the center of São Paulo (the largest South American town) and compared to controls kept for the same period in a clean area. Pollution levels were obtained from a state air pollution monitoring station, 200 m distant from exposure location, which provided the levels of CO, SO2, particulates, and ozone. The nasal septum was submitted to quantitative analysis of morphological and histochemical parameters, comprising the measurement of volume of epithelium and lamina propria per unity of surface of basal lamina, the amount of mucus stored in the surface epithelium, the volume densities of neutral and acidic mucus in the lamina propria glands, and the densities of secretory and ciliated cells in the epithelium. The results obtained in the present investigation suggest that chronic exposure to urban levels of air pollution induces secretory hypertrophy, combined with a shift toward acidic mucus secretion and ciliary damage. The results are consistent with the idea that prolonged exposure to low levels of air pollution deteriorates respiratory defenses against infectious agents and may cause an increase in respiratory morbidity and perhaps mortality.

[Cellularity of distal pulmonary parenchyma in rats by the bronchoalveolar lavage method in acute pancreatitis]

The induction of pancreatitis by injecting the taurocholate acid 2.5% solution into the rat's hepatic duct. Ten rats formed the normal control group, nine rats the two hours pancreatitis group and eight rats the eight hours pancreatitis group. The comparison of the groups has shown a significant increase in the numbers of macrophages, neutrophils and lymphocytes in the broncho-alveolar lavage of pancreatitis group (p < 0.05) indicating an acute inflammatory pneumopathy.

Clinical evaluation of flexor tendon function in the small finger

Patients frequently present to the emergency department with hand injuries. Standard examination includes testing each digit for flexor function. The flexor digitorum superficialis (FDS) to the small finger has been shown to have variable anatomy and clinical examination. We prospectively examined 100 subjects (200 hands) for small finger FDS function by standard and modified testing. We found that 70 small flexors (35%) showed absent FDS by standard testing, whereas only eight fingers (4%) had absent FDS by modified testing. FDS function to the small finger is frequently unilateral. We conclude that modified testing is the only way to accurately test for small finger FDS function and that the use of this simple clinical examination may prevent unnecessary referral to a hand surgeon.

Regeneration of enzymatic activity after sodium dodecyl sulfate/polyacrylamide gel electrophoresis and zinc acetate staining: the example of inositol 1,4,5-trisphosphate 5-phosphatase

Regeneration of enzyme activity after sodium dodecyl sulfate-gel electrophoresis was investigated with a purified inositol 1,4,5-trisphosphate 5-phosphatase. In order to avoid silver or Coomassie blue staining, we have used zinc acetate. This staining procedure was sensitive, rapid, and reversible provided that zinc cations are chelated and activity is extracted after diffusion out of the gel. The method allows some gel lane staining and identification of the enzyme based on catalytic activity.

Rat brain inositol 1,4,5-trisphosphate 3-kinase. Ca2(+)-sensitivity, purification and antibody production

Inositol 1,4,5-trisphosphate (InsP3) 3-kinase catalyses the ATP-dependent phosphorylation of InsP3 to inositol 1,3,4,5-tetrakisphosphate (InsP4). InsP3 3-kinase was purified from rat brain by Blue-Sepharose, phosphocellulose and calmodulin (CaM)-Sepharose affinity chromatography. The purified enzyme was stimulated by Ca2+/CaM by 3-6-fold as compared with the activity measured in the presence of EGTA. Rat brain InsP3 3-kinase activity was associated with two silver-stained bands of about equal activity which migrated with an apparent Mr of 50,000 on SDS/polyacrylamide gels. InsP3 3-kinase activity from rat brain could be immunoprecipitated by an antiserum against the SDS/PAGE-purified 50,000-Mr protein doublet. InsP3 kinase activity from bovine brain and the InsP3 5-phosphatase activity from rat brain were not immunoprecipitated. On Western blot, the human brain crude InsP3 3-kinase reacted specifically, but less strongly than the rat brain enzyme, with the antiserum.

Identification of the bovine brain Ins(1,4,5)P3 5-phosphatase after SDS-polyacrylamide gel electrophoresis

Ins(1,4,5)P3 5-phosphatase catalyzes the dephosphorylation of Ins(1,4,5)P3 in the 5-position. In a high speed soluble fraction of bovine brain, there are two soluble 5-phosphatases: type I and type II. The purified Ins(1,4,5)P3 5-phosphatase type I exhibits a major silver-stained band of 43 kDa on denaturing (SDS) gels. It is possible to extract the 5-phosphatase activity form a duplicate lane after gel electrophoresis. The 43 kDa region contains the extractable Ins(1,4,5)P3 5-phosphatase activity.

Soluble and particulate Ins(1,4,5)P3/Ins(1,3,4,5)P4 5-phosphatase in bovine brain

Ins(1,4,5)P3 5-phosphatase catalyses the dephosphorylation of Ins(1,4,5)P3 in the 5 position. At 1 microM Ins(1,4,5)P3, 10-15% of total activity of a bovine brain homogenate was measured in the soluble fraction, whereas 85-90% was in the particulate fraction. Particulate activity could be solubilized by cholate or, to a lower extent, by 2 M KCl. Two soluble enzymes (type I and type II) could be fractionated by DEAE-Sephacel chromatography. Soluble activities have been further purified by blue-Sepharose, Sephacryl S-200 and phosphocellulose chromatography. Specific activities reached 10-30 mumol.min-1 mg protein-1 for type I and were 10-20 times lower for type II. Type I and type II Ins(1,4,5)P3 5-phosphatase displayed different Km values and molecular masses, as estimated by gel filtration. Type I dephosphorylated both Ins(1,4,5)P3 and Ins(1,3,4,5)P4; in contrast, type II specifically dephosphorylated Ins(1,4,5)P3 but not Ins(1,3,4,5)P4. Type I Ins(1,4,5)P3 5-phosphatase eluted as a single peak of activity with an apparent molecular mass of 51 kDa when gel filtration was performed in the presence of cholate. This molecular mass is identical to the molecular mass estimated for the particulate Ins(1,4,5)P3 5-phosphatase that was solubilized by cholate. Km values for Ins(1,4,5)P3 and Ins(1,3,4,5)P4 obtained with type I Ins(1,4,5)P3 5-phosphatase were 11 microM and 1 microM, respectively. Similar values were obtained with particulate Ins(1,4,5)P3 5-phosphatase. In conclusion, the catalytic domains of type I and particulate Ins(1,4,5)P3 5-phosphatase activity may be very similar, if not identical, but different from type II phosphatase.

Sodium taurocholate effect on beta-glucosidase activity: a new approach for identification of Gaucher disease using the synthetic substrate and leucocytes

In this work we have studied the leucocytes and sera of 3 Gaucher patients, 4 obligate heterozygotes, 11 brothers and sisters of patients and 11 controls. Beta-glucosidase activity with 4-M-U-beta-glucopyranoside has been assayed at different pH's, in the presence of pure sodium taurocholate. At pH 4.5 and 5.0 sodium taurocholate activates the beta-glucosidase of control leucocytes, but inhibits the residual enzyme present in Gaucher leucocytes. The ratio of beta-glucosidase activity in the presence and absence of this effector seems to be a good approach to the diagnosis of Gaucher disease and it has proved indispensible in one patient's diagnosis. The apparent Km of beta-glucosidase determined for the same substrate, at pH 4.5 and 5.5 in the presence of sodium taurocholate showed markedly lower values in the patients than in the controls. An increased serum acid phosphatase activity, previously described as a secondary alteration in Gaucher disease, has also been studied and seems to be a useful complementary test, particularly when its age dependence is taken into account.

Age dependency of serum acid phosphatase in controls and Gaucher patients

Serum acid phosphatase activity has been used as a complementary test for the diagnosis of Gaucher's disease. This study suggests that phosphatase activity is age dependent. The use of controls in the patients' age is strongly recommended.

[Gallbladder calculi: cholesterol concentration and its radiologic correlates]

Cholesterol concentration in the gallstones of 84 patients obtained by surgery is studied and radiologic correlation of the stones (lucency and opaqueness) is established with relation to cholesterol concentration. We conclude that 70% of gallstones in our population, contain greater than or equal to 80% of cholesterol and the radiographic appearance of stones in functioning gallbladder is a good method to predict cholesterol content in gallstones.