CCS e amiloide A do leite de quartos mamários tratados na secagem com plasma rico em plaquetas autólogo, associado ou não a antibiótico

RESUMO Este estudo teve como objetivo avaliar biomarcadores de mastite após terapia da secagem com plasma rico em plaquetas (PRP), associado ou não a antibiótico. Trinta e seis quartos mamários foram utilizados em três tratamentos (T): T1 - antibiótico (ATB), T2 - PRP e T3 - PRP + ATB. Amostras de leite foram coletadas antes da secagem (A1), no parto (D0) e 14, 30 e 60 dias pós-parto (D14, D30 e D60), para determinar contagem de células somáticas (CCS) e amiloide A (AA). O delineamento foi inteiramente ao acaso, com arranjo em parcelas subdivididas (SigmaPlot®). Dados de CCS foram transformados (log 10). As médias foram comparadas utilizando-se testes de Tukey ou Holm-Sidak (P<0,05). A CCS em A1 foi elevada em todos os grupos (P>0,05). No D30, CCS foi maior em T2 (P<0,05), igualando-se no D60. Não houve diferença na AA entre Ts em qualquer dia de coleta (P>0,05). Houve diferença nos momentos de coleta (P<0,05), A1 maior que D14 e D30. Houve uma correlação positiva fraca com CCS (0,280). Os tratamentos foram semelhantes em manter a saúde da glândula mamária na lactação subsequente. O PRP intramamário pode ser usado para terapia de vaca seca em casos de mastite subclínica.

AB0561 AUTOMATIC QUANTIFICATION OF INTERSTITIAL LUNG DISEASE FROM CHEST COMPUTED TOMOGRAPHY IN SYSTEMIC SCLERODERMA

Background:

Scleroderma-associated interstitial lung disease (SSc-ILD) is often observed in patients with systemic scleroderma (SSc) and its diagnosis contributes to early treatment decisions1,2.

Objectives:

The present study aims to automatically quantify SSc-ILD from high-resolution chest-computed tomography (HRCT) and to evaluate the association between interstitial lung disease (ILD) extension and lung function impairment.

Methods:

Ninety-four patients with SSc and 27 lung-healthy subjects matched for gender, weight, height, and age underwent HRCT, spirometry and carbon monoxide diffusion capacity (DLCO). SSc-ILD was determined as the tissue mass present between -500 and +100 Hounsfield Units normalized by the total lung tissue mass (TLM). Cut off was the highest value obtained in the control group (25% of TLM). All data are presented as mean and standard deviations (Table I). An ANOVA test followed by Bonferroni post-hoc correction was used for comparisons among groups.

Results:

From 94 patients with SSc, 64 were classified as having pulmonary involvement (SSc-ILD) and 30 as not having pulmonary involvement (SSc No-ILD). In SSc-ILD subjects, there was a significant reduction in forced vital capacity (FVC), carbon monoxide diffusion capacity (DLCO) and carbon monoxide diffusion capacity normalized by alveolar ventilation (DLCO/A) when compared with SSc No-ILD and control group.

Conclusion:

The proposed method allows the automatic quantification of SSc-ILD from HRCT and ILD extent is associated with pulmonary function impairment.

References:

[1]Doyle TJ, Dellaripa PF. Lung Manifestations in the Rheumatic Diseases. CHEST. 2017 Dec;152(6):1283–95.

[2]Saketkoo LA, Magnus JH, Doyle MK. The primary care physician in the early diagnosis of systemic sclerosis: the cornerstone of recognition and hope. The American Journal of the Medical Sciences. 2014 Jan;347(1):54–63.

Table 1.

Demographic variables, pulmonary function tests and densitovolumetry considering scleroderma patients with less or greater pulmonary involvement.

Control GroupN = 27SSc No-ILDN = 30SSc-ILDN = 64p-valueDemographic DataFemales16 (59.2)28 (93.3)58 (90.1)-Age (years)37.9 ± 14.851.2 ± 12.256 ± 14<0.011a,bBMI (kg/m2)26.7 ± 5.124.1 ± 5.025.9 ± 5.7-Lung Function FVC (% predicted)100.2 ± 9.299.9 ± 19.869.8 ± 16.7<0.001b,c DLco (% predicted)103 ± 13.383.8 ± 14.263.4 ± 20.3<0.002a,b,cDLco/A (% predicted)112.7 ± 17.485.7 ± 12.979.2 ± 20.6<0.001a,bDensitovolumetryTLV mL4675 ± 9864471 ± 9163492 ± 1120<0.001b,cLung Tissue Mass (g)793 ± 125756 ± 159731 ± 155- ILD Extent (% LTM)17 ± 222.9 ± 1.232.6 ± 8<0.003a,b,c

a: Statistically significant difference between No-ILD SSc and control group; b and c: Statistically significant difference between SSc-ILD vs control group and SSc No-ILD, respectively.

Disclosure of Interests:

None declared

Distraction osteogenesis in dog with a tooth-borne device: Histological and histomorphometric analysis

Background

The distraction osteogenesis (DO) is the biological process of new bone formation between the surfaces of bone segments gradually separated by incremental traction. However, the lack of solid experimental studies using the tooth-borne distractor does not allow comparing this technique with the classical procedures. This study aimed to establish the effect of two different activation protocols in new bone formation, with a new intraoral tooth-borne device for dog mandibular distraction osteogenesis.

Material and Methods

Nine beagle dogs were split into 3 similar groups, Group A the control, Group B subjected to two daily activations of 0.5 mm and Group C subjected to a single daily activation of 1 mm. The distraction period was 10 days followed by a 12 weeks consolidation period. Samples where then processed and embedded in methylmethacrylate and ground to a thickness of 20µm. Toluidine blue stains were done on all specimens and histological and histomorphometric evaluation of bone tissue formed within distraction gap was performed. The statistical analysis in this manuscript was performed with IBM®-SPSS® v.20 statistics software and R software version 3.1.0. The level of significance adopted was 5 % (α=0.05).

Results

No statistically significant difference was detected by histomorphometric evaluation between the two experimental groups in what concerns the bone volume. However, significant differences were found in the coefficients of variation between the medial and buccal areas, and the buccal and lingual areas.

Conclusions

This study shows that the mandible can be lengthened successfully using a tooth-borne distractor. Moreover, it suggested that a decrease from once to twice-daily activations might negatively change the quality and structure of newly formed bone and prompt it to instability.

Key words:Retrognathia, bone regeneration, osteogenesis, distraction.

64 Prediction of pregnancy and early embryo loss through OAS-1 expression, concentrations of pregnancy-associated glycoproteins, and Doppler ultrasonography in beef cattle

We aimed to compare three methods to detect pregnancy based on interferon-tau stimulated gene expression in peripheral blood polymorphonuclear cells and Doppler ultrasonography (Doppler-US) 20 days after timed AI and the concentrations of pregnancy associated glycoproteins (PAGs) 25 days after timed AI. Our second objective was to compare interferon-tau stimulated genes and PAGs as early embryo loss (EEL) predictors. Nelore cows (n=144) and heifers (n=103) were submitted to timed AI (Day (D) 0). On D20, polymorphonuclear cells were isolated from blood samples by Ficoll gradient (GE Healthcare), and the RNA was extracted. Expression of the interferon-tau stimulated gene (OAS-1) was quantified by qPCR and normalized to reference genes (GAPDH and ACTB). On D25, blood was collected from the jugular vein and PAG concentrations were measured by an in-house enzyme-linked immunosorbent assay. Pregnancy diagnoses were performed on D20 by luteolysis detection with Doppler-US and on D30 by detection of an embryo by heartbeat. Animals were classified as pregnant (P; fetus on D30), non-P (NP; no active corpus luteum on D20), and EEL (active corpus luteum on D20 but NP on D30). Expression of OAS-1 and PAG concentrations were analysed by analysis of variance using PROC MIXED of SAS considering the effects of group, category, and their interaction. Receiver operating characteristic curves were created, and the area under the curve (AUC), accuracy, specificity, and sensitivity were calculated for pregnancy predictions on D20 (OAS-1 and Doppler-US) and D25 (PAGs) compared with the standard diagnosis method on D30. Expression of OAS-1 and PAG concentrations were greater (P&lt;0.01) in the P (2.4±0.2 and 4.8±0.2ngmL−1, respectively) compared with the NP (0.50±0.1 and 1.2±0.2ngmL−1, respectively) and EEL (0.8±0.2 and 1.0±0.2ngmL−1, respectively) groups. Receiver operating characteristic analysis indicated that OAS-1, Doppler, and PAGs were significant (P&lt;0.01) predictors of pregnancy in heifers (AUC=0.86, 0.92, and 0.94, respectively) and cows (AUC=0.82, 0.94, and 0.95, respectively). The PAGs and Doppler-US presented higher accuracy on diagnosing pregnancy (92 and 89% for heifers, 94 and 93% for cows, respectively) than OAS-1 (81% for heifers and 75% for cows). Doppler-US was 100% sensitive to detect nonpregnant females, which avoided false negative results, whereas PAG concentrations presented a higher specificity (86% for heifers and cows) when compared with Doppler-US and OAS-1 (76 and 65% for heifers, 85 and 75% for cows, respectively). On D25, PAGs were 90% accurate to detect heifers and cows that would experience EEL, whereas on D20, OAS-1 was 50% accurate. In conclusion, Doppler-US can be used as early as D20 with high accuracy and sensitivity. Likely, the use of PAG concentrations on D25 is highly accurate and is more effective at detecting EEL. Pregnancy diagnosis through OAS-1 expression is not as accurate as the other methods and could not efficiently predict EEL. This research was supported by FAPESP (2015/106069; 2017/134729).

OR04-6 Predictors of Clinical Outcome after Adrenalectomy for Unilateral Primary Aldosteronism

Primary aldosteronism (PA) is the most common cause of endocrine hypertension (HT) with an estimated prevalence of 10% in referred populations and 15-20% in patients with resistant hypertension. The most common cause of unilateral PA is aldosterone-producing adenomas (APAs). HT and hypokalemia improve in nearly 100% of patients with unilateral PA after unilateral adrenalectomy. However, complete clinical success (defined as blood pressure ≤130x80 mmHg without anti-hypertensive drugs) has been reported in about 50% (range, 35-80%) of patients with unilateral PA after surgery. HT duration and severity have been associated with clinical outcome after adrenalectomy, but few reports with a limited number of cases evaluated the prognostic role of somatic KCNJ5 mutations. In this study, our aim was to determine clinical and molecular features associated with complete clinical success after unilateral adrenalectomy in unilateral PA patients. We retrospectively evaluated 103 PA patients (42 males; median age 49 yrs, 20-74) with a median follow-up of 25 months. Hypokalemia was present in 78% of the cases. Anatomopathological analysis revealed 94 APAs and 9 unilateral adrenal hyperplasias. All patients had biochemical cure after unilateral adrenalectomy. KCNJ5 mutations were identified in 27 out of 67 (40%) tumors: p.Gly151Arg (n= 13), p.Leu168Arg (n= 13) and p.Glu145Gln (n= 1). Complete clinical success was reported in 32 out of 103 (31%) patients. In univariate analysis, HT duration, body mass index (BMI kg/m²), female sex and somatic KCNJ5mutations were associated with HT resolution after adrenalectomy. Complete clinical success was reported in 50% of patients with HT duration ≤5 yrs (vs. 24% with HT duration >5 yrs; p= 0.011), in 40% of patients with BMI <25 (vs. 22% with BMI ≥25; p= 0.042), in 38% of women (vs. 21% of men; p= 0.079) and in 70% of the patients with tumors harboring KCNJ5 somatic mutations (vs. 30% with WT tumors; p= 0.003). According to a stepwise multivariate logistic regression analysis, only the presence of a somatic KCNJ5 mutation was an independent predictor of complete success after adrenalectomy (relative risk 4.8, 95% confidence interval 1.24 to 19.21; p= 0.023). In conclusion, the presence of a somatic KCNJ5 mutation was an independent predictor of complete clinical success after unilateral adrenalectomy in patients with unilateral PA.

Biomonitoring a human population inhabiting nearby a deactivated uranium mine

Environmental exposure to uranium and its daughter radionuclides, has been linked to several negative effects such as those related with important physiological processes, like hematopoiesis, and may also be associated with genotoxicity effects. Herein, genotoxic effects, immunotoxicity, trace elements and C reactive protein (CRP) analyses, were performed in peripheral blood samples collected from individuals of a population living near a deactivated uranium mine. C reactive protein analysis was performed to exclude candidates with active inflammatory processes from further evaluations. DNA damage and immunotoxicity (immunophenotyping and immune cell counts) were evaluated by comet assay and flow cytometry, respectively. Significant DNA damage was observed in the peripheral blood samples from volunteers living in the Cunha Baixa village. A significant decrease of NK and T lymphocytes counts were observed in the individuals from the Cunha Baixa village, when compared with individuals from the reference site. Uranium and manganese levels were significantly higher in the Cunha Baixa village inhabitants. On the other hand, zinc levels were significantly lower in those individuals when compared with the volunteers from the control village. Results suggest that inhabitants from Cunha Baixa have a higher risk of suffering from serious diseases such as cancer, since high DNA damages were observed in peripheral blood leukocytes and also decreased levels of NK and T cells, which play an essential role in the defense against tumor growth.

Usefulness of labial salivary gland biopsy in familial amyloid polyneuropathy Portuguese type

BACKGROUND

The diagnosis of amyloidosis of all types is definitively made by demonstration of Congo red binding material in the affected tissues. Nerve biopsy was classically used to diagnose amyloid polyneuropathy but less invasive alternative types of biopsies have been proposed including labial salivary gland (LSG) biopsy, a minimally invasive procedure.

METHOD

LSG biopsies were done in 87 subjects with molecular diagnosis of TTRVal30Met mutation. The group includes 76 patients in different stages of familial amyloid polyneuropathy and 11 asymptomatic carriers. They were all submitted to a stomatological and a neurological observation to evaluate oral health problems and to determine the neurological stage of the disease. No major oral health problems were found. Mean age of onset of the symptomatic disease was 32.8 years (+/-9.69 SD).

CONCLUSIONS

No significant side effects occurred after the surgical procedure, and adequate material for pathological analysis was always obtained. Amyloid deposition was found in 91% of the patients. Patients with negative biopsies (N = 7) were all in the earlier stage of the disease. Two asymptomatic carriers had biopsies with amyloid deposition. We conclude that LSG biopsy is a useful, sensitive and minimal invasive method to detect amyloid deposition.

CLN2/TPP1 deficiency: the novel mutation IVS7-10A>G causes intron retention and is associated with a mild disease phenotype

The classical form of late infantile neuronal ceroid lipofuscinosis (LINCL) is a childhood hereditary neurodegenerative disease usually fatal in the first decade of life. The underlying gene, CLN2, encodes the lysosomal soluble enzyme tripeptidyl-peptidase 1 (TPP1). In a Portuguese patient with juvenile form of the disease, the histochemical study revealed the presence of curvilinear inclusions typical of LINCL. In vitro TPP1 activity was deficient in patient's cells. CLN2 gene analysis revealed the transition IVS7-10A>G (g.4196A>G) in both alleles. In silico analysis suggested that A-to-G change in the A-rich region of intron 7 could cause aberrant splicing of exon 8 by creating a novel acceptor splice site. However, because the wild-type acceptor of intron 7 is weak and it was not apparently affected, the severity of this mutation could not be established through sequencing data of gDNA. Normal level of spliced CLN2/mRNA was observed in patient's fibroblasts. In the cDNA, the 9-nt retention of intronic sequence (c.886_887ins9) was observed. The mutation is predicted to result in a protein with three extra amino acids between proline 295 and glycine 296. In patient's fibroblasts the level of mutant CLN2p was reduced to about 60% but the migration pattern was similar to the wild-type protein, suggesting that it was correctly targeted to the lysosomes. Taken together, these findings suggest that the first "ag" is selected for splicing and the mutant protein must retain some residual catalytic activity, thus explaining the late onset and the delayed progression of the disease.

Congenital amegakaryocytic thrombocytopenia--report of a new c-mpl gene missense mutation

A 44-month old girl with congenital amegakaryocytic thrombocytopenia, already with pancytopenia, underwent an unrelated allogeneic cord blood transplantation with recovery of normal blood cell counts. The patient was a compound heterozygote for two c-mpl missense mutations inherited from both parents, one of them, a G578A exon 4 mutation leading to a cysteine to tyrosine replacement of codon 193, previously unreported.

Seasonal allergic dermatitis in sheep in southern Brazil caused by Culicoides insignis (Diptera: Ceratopogonidae)

The incidence of seasonal dermatitis was studied in a Hampshire Down flock on a farm in southern Brazil. Epidemiological data, clinical signs and macroscopic pathology were obtained by visiting the farm. Histological lesions were studied in skin biopsies of affected sheep. Biting insects were collected from January to April 2005 in an attempt to identify the etiological agent of the disease. Disease prevalence was 40%; the age of the affected animals was variable. Disease occurred from December to March, some animals had lesions for the entire year. Clinical signs include pruritus on the ears, around the eyes and ventral abdomen. Initially erythema and small red papules were seen, followed by alopecia and crust formation. Histologically the lesions were characterized by perivascular eosinophilic dermatitis. Hyperkeratosis and acanthosis were observed in the chronic lesions. Both Anopheles albitarsis and Culicoides insignis were captured during the study. C. insignis bites caused pruritus in sheep. Both types of insects were caught when they approached the sheep baits approximately 30min after sunset. Results suggested that the disease occurred as a result of an immediate hypersensitivity reaction to C. insignis.

Two novel CLN5 mutations in a Portuguese patient with vLINCL: insights into molecular mechanisms of CLN5 deficiency

The neuronal ceroid-lipofuscinoses are the most common neurodegenerative disorders in childhood characterized by progressive blindness, epilepsy, brain atrophy, and premature death. Based on the age at onset, disease progression and ultrastructural features three classical (infantile, late-infantile, and juvenile) and three variant late-infantile forms are generally distinguished (Finnish variant, Costa Rican variant, and epilepsy with progressive motor retardation). The Finnish variant late-infantile form has been associated with CLN5 gene defects, with only five mutations described to date. We report a patient with vLINCL/CLN5 who represents the first evidence of the disease in the Portuguese population. Mutational screening revealed the previously described missense mutation c.835G>A (D279N) inherited from the mother, and two novel mutations, c.565C>T (Q189X) and c.335G>C (R112P) from paternal and maternal inheritance, respectively. Based on data here reported: (i) the number of possible mutations in CLN5 gene is now 7; (ii) the CLN5 Portuguese case represents the third description of the disease outside northern Europe; (iii) the CLN5/mRNA expression level reduced to 45% supports the existence of one mRNA non-producing allele, further noticeable at the protein level; (iv) Western blotting data using a specific antibody to human CLN5p provided evidence for the presence of four integral membrane isoforms in human fibroblasts; (v) data from differential expression of CLN2, CLN3, and CLN5 suggest down-regulation of CLN3 gene expression in CLN2 and CLN5-deficient human patients and this observation strengths the hypothesis of functional redundancy of the CLN system.

Activation of ERK1/2 MAP kinases in Familial Amyloidotic Polyneuropathy

Familial amyloidotic polyneuropathy (FAP) is a neurodegenerative disorder characterized by the extracellular deposition of transthyretin (TTR), especially in the PNS. Given the invasiveness of nerve biopsy, salivary glands (SG) from FAP patients were used previously in microarray analysis; mitogen-activated protein (MAP) kinase phosphatase 1 (MKP-1) was down-regulated in FAP. Results were validated by RT-PCR and immunohistochemistry both in SG and in nerve biopsies of different stages of disease progression. MKP-3 was also down-regulated in FAP SG biopsies. Given the relationship between MKPs and MAPKs, the latter were investigated. Only extracellular signal-regulated kinases 1/2 (ERK1/2) displayed increased activation in FAP SG and nerves. ERK1/2 kinase (MEK1/2) activation was also up-regulated in FAP nerves. In addition, an FAP transgenic mouse model revealed increased ERK1/2 activation in peripheral nerve affected with TTR deposition when compared to control animals. Cultured rat Schwannoma cell line treatment with TTR aggregates stimulated ERK1/2 activation, which was partially mediated by the receptor for advanced glycation end-products (RAGE). Moreover, caspase-3 activation triggered by TTR aggregates was abrogated by U0126, a MEK1/2 inhibitor, indicating that ERK1/2 activation is essential for TTR aggregates-induced cytotoxicity. Taken together, these data suggest that abnormally sustained activation of ERK in FAP may represent an early signaling cascade leading to neurodegeneration.

Factors affecting reconstitution of the T cell compartment in allogeneic haematopoietic cell transplant recipients

The factors affecting T cell reconstitution post haematopoietic cell transplantation (HCT) are not well characterised. We carried out a longitudinal analysis of T cell reconstitution in 32 HCT recipients during the first 12 months post transplant. We analysed reconstitution of naïve, memory and effector T cells, their diversity and monitored thymic output using TCR rearrangement excision circles (TRECs). Thymic-independent pathways were responsible for the rapid reconstitution of memory and effector T cells less than 6 months post HCT. Thymic-dependent pathways were activated between 6 and 12 months in the majority of patients with naïve T cell numbers increasing in parallel with TREC levels. Increasing patient age, chronic GVHD and T cell depletion (with or without pretransplant Campath-1H) predicted low TREC levels and slow naïve T cell recovery. Furthermore, increasing patient age also predicted high memory and effector T cell numbers. The effects of post HCT immunosuppression, total body irradiation, donor leucocyte infusions, T cell dose and post HCT infections on T cell recovery were also analysed. However, no effects of these single variables across a variety of different age, GVHD and T cell depletion groups were apparent. This study suggests that future analysis of the factors affecting T cell reconstitution and studies aimed at reactivating the thymus through therapeutic intervention should be analysed in age-, GVHD- and TCD-matched patient groups.

Novel mutations in the CLN6 gene causing a variant late infantile neuronal ceroid lipofuscinosis

The neuronal ceroid lipofuscinoses (NCLs) are a heterogeneous group of autosomal recessive neurodegenerative diseases comprising Batten and other related diseases plus numerous variants. They are characterized by progressive neuronal cell death. The CLN6 gene was recently identified, mutations in which cause one of the variant late infantile forms of NCL (vLINCL). We describe four novel mutations in the CLN6 gene. This brings the total number of CLN6 mutations known to 11 in 38 families. This suggests that the CLN6 gene may be highly mutable. An American patient of Irish/French/Native American origin was heterozygous for a 4-bp insertion (c.267_268insAACG) in exon 3. The other allele had a point mutation (c.898T>C) in exon 7 resulting in a W300R amino acid change. Two Trinidadian siblings of Indian origin were homozygous for a mutation at the 5' donor splice site of exon 4 (IVS4+1G>T), affecting the first base of the invariant GT at the beginning of intron 4. The fourth novel mutation, a double deletion of 4 bp and 1 bp in exon 7 (c.829_832delGTCG;c.837delG), was identified in a Portuguese patient heterozygous for the I154del Portuguese CLN6 mutation. Four of the 11 mutations identified are in exon 4. Three Portuguese patients with clinical profiles similar to CLN6 patients without defects in CLN6 or other known NCL genes are described. We conclude the following: 1) the CLN6 gene may be a highly mutable gene; 2) exon 4 must code for a segment of the protein crucial for function; 3) vLINCL disease in Portugal is genetically heterogeneous; 4) the I154del accounts for 81.25% of affected CLN6 Portuguese alleles; and 5) three vLINCL Portuguese patients may have defects in a new NCL gene.

Deposition of transthyretin in early stages of familial amyloidotic polyneuropathy: evidence for toxicity of nonfibrillar aggregates

Familial amyloidotic polyneuropathy (FAP) is a neurodegenerative disorder characterized by extracellular deposition of transthyretin (TTR) amyloid fibrils, particularly in the peripheral nervous system. No systematic immunohistochemical data exists relating TTR deposition with FAP progression. We assessed nerves from FAP patients in different stages of disease progression (FAP 0 to FAP 3) for TTR deposition by immunohistochemistry, and for the presence of amyloid fibrils by Congo Red staining. The nature of the deposited material was further studied by electron microscopy. We observed that early in FAP (FAP 0), TTR is already deposited in an aggregated nonfibrillar form, negative by Congo Red staining. This suggested that in vivo, preamyloidogenic forms of TTR exist in the nerve, in a stage before fibril formation. Cytotoxicity of nonfibrillar TTR was assessed in nerves of different FAP stages by immunohistochemistry for macrophage colony-stimulating factor. FAP 0 patients already presented increased axonal expression of macrophage colony-stimulating factor that was maintained in all other stages, in sites related to TTR deposition. Toxicity of synthetic TTR fibrils formed in vitro at physiological pH was studied on a Schwannoma cell line by caspase-3 activation assays and showed that early aggregates but not mature fibrils are toxic to cells. Taken together, these results show that nonfibrillar cytotoxic deposits occur in early stages of FAP.

[Treatment of hypertension - answers of Brazilian physicians to a survey]

INTRODUCTION

The third Brazilian Consensus of Hypertension recomends the usage of pharmacological (PT) and non-pharmacological treatment (NPT). In Brazil, we don't know how if this recommedation has been followet by doctors.

OBJECTIVES

a) to characterize NPT regarding prescription and acceptability by hypertensive patients; b) characterize PT concerning the criterion used for choosing medication and medication prescribed; and c) identify doctors' opinions about patients' degree of acceptability to PT and NPT.

METHODS

37904 questionnaires with reply-paid envelopes were sent to Brazilian doctors and 2519 of those were replied (57% from the Southeast region, 41% were cardiologists, and 26% clinicians).

RESULTS

1- 62% of doctors recommend NPT to 25% of their patients. 2 - The most recommended NP treatments are: hyposodic diet (55%), weight reduction (29%) and physical exercises (8%), considering that doctors believe that 50% of their patients follow a hyposodic diet, 20% do physical exercises and 19% lose weight. 3 - Only one medication is prescribed at the beginning of a PT (88%) and when blood pressure isn't under control, 55% of the doctors associate other medications with it whereas 33% of them increase the dose. 4 - The most prescribed medications are: diuretics (53%) and ECA inhibitors (24%). 5 - The main criteria for choosing medication are: personal experience (32%) and characteristics of patients (31%). 6 - Doctors (60%) believe that acceptability to PT is better.

CONCLUSION

The recommendations of the Third Brazilian Consensus of Hypertension have been followed partially concerning NPT and as expected regarding PT.

Recessive ataxia with ocular apraxia: review of 22 Portuguese patients

BACKGROUND

The recessive ataxias are a heterogeneous group of neurodegenerative disorders characterized by cerebellar ataxia associated with a number of different neurologic, ophthalmologic, or general signs. They are often difficult to classify in clinical terms, except for Friedreich ataxia, ataxia-telangiectasia, and a relatively small group of rare conditions for which the molecular basis has already been defined.

OBJECTIVES

To study the clinical presentation and to define diagnostic criteria in a group of Portuguese patients with ataxia and ocular apraxia, an autosomal recessive form without the essential clinical and laboratory features of ataxia-telangiectasia.

PATIENTS AND METHODS

We reviewed 22 patients in 11 kindreds, identified through a systematic survey of hereditary ataxias being conducted in Portugal.

RESULTS

Age at onset ranged from 1 to 15 years, with a mean of 4.7 years. The duration of symptoms at the time of last examination varied from 5 to 58 years. All patients presented with progressive cerebellar ataxia, the characteristic ocular apraxia, and a peripheral neuropathy. Associated neurologic signs included dystonia, scoliosis, and pes cavus. Magnetic resonance imaging was performed in 16 patients, all of whom showed cerebellar atrophy.

CONCLUSIONS

Ataxia with ocular apraxia may be more frequent than postulated before, and may be identified clinically using the following criteria: (1) autosomal recessive transmission; (2) early onset (for most patients in early childhood); (3) combination of cerebellar ataxia, ocular apraxia, and early areflexia, with later appearance of the full picture of peripheral neuropathy; (4) absence of mental retardation, telangiectasia, and immunodeficiency; and (5) the possibility of a long survival, although with severe motor handicap.

Mitochondrial DNA analysis in ocular myopathy. Observations in 29 Portuguese patients

We analyzed 29 patients with progressive external ophthalmoparesis (PEO) either alone or as part of a multisystem disorder. Ragged-red fibers were very abundant (10-20%) in 15 patients, and many of them were also cytochrome c oxidase-negative. Biochemical analysis of the respiratory chain showed partial defects of single or multiple complexes in 18 patients (64%). Eleven PEO patients (38%) harbored single large-scale mtDNA deletions in muscle, which averaged 5.4 kb in size and 47% in relative abundance. One PEO patient harbored the A3243G mutation (MELAS mutation) in muscle (63%). Our findings, the first reported in Portuguese patients, confirm that single large-scale mtDNA deletions are a significant cause of PEO. Although ophthalmoparesis was the main clinical feature in the majority of patients, the clinical spectrum is broad, ranging from severe encephalopathy of childhood to a milder, though disabling, muscle weakness in adults.

[Cervical spondylodiscitis in an infant]

Spondylitis in childhood is rare, presenting a great variety of symptoms that are related to the child s age and to the site of the inflammatory process. We present the case of a nine-month-old infant, who presented to the emergency department with a torticollis of six weeks evolution. The diagnosis of spondylitis (C6-C7) was confirmed by MRI. Intravenous antibiotic therapy was administered. The patient showed complete regression of symptoms and imaging tests were normal. The rarity of this disease in patients in this age group, as well as the site and form of presentation are emphasised as is the importance of diagnosing this disease to prevent permanent neurological injuries or bone deformities.

Noval mutation (Y184C) in exon 4 of the beta-sarcoglycan gene identified in a Portuguese patient. Mutations in brief no. 177. Online

We report a novel beta-sarcoglycan gene mutation identified in a 21-year-old Portuguese male with a progressive myopathy of intermediate severity, who had been misdiagnosed as Becker Muscular Dystrophy (BMD) based on clinical observations and muscle immunocytochemical anaylsis with dystrophin antibodies only. Since no detectable deletions or duplications were found in the dystrophin gene, we screened for mutations in the sarcoglycan genes by PCR-SSCP. The patient's sample showed a band of increased mobility in exon 4 of the beta-sarcoglycan gene which, upon sequencing, was found to represent a homozygous A-->G transversion at nucleotide 551, resulting in a tyrosine to cysteine substitution at position 184 (Y184C). Carrier status was ascertained in both parents and a sister. These aberrant conformers were not detected in 85 unrelated control individuals screened by PCR-SSCP analysis. All seven beta-sarcoglycan mutations reported to date are associated with a severe phenotype and occur in exons 3 and 4, which correspond to the immediate extracellular domain of the protein. This region contains five conserved cysteine residues. In our patient, the presence of an extra cysteine residue could interefere with intra- and/or inter-molecular disulphide bond formation. The intermediate phenotype could perhaps result from the assembly of both normal and abnormal complexes, depending on the formation of the disulphide bonds.

Defibrotide as salvage therapy for refractory veno-occlusive disease of the liver complicating allogeneic bone marrow transplantation

A 30-year-old woman developed veno-occlusive disease of the liver during an allogeneic BMT for acute leukemia. Treatment with recombinant human tissue plasminogen activator and heparin resulted in an incomplete and transient response followed by progressive disease. The patient was then given defibrotide (DF), a mammalian tissue-derived polydeoxyribonucleotide developed for the treatment of a number of vascular disorders, which has thrombolytic and anti-thrombotic properties. No significant bleeding or other major toxicities were observed during treatment and she made a full recovery. At 6 months after the onset of VOD her liver function tests and color flow Doppler ultrasound scan are normal. Our experience supports the preliminary results already obtained with DF. Its efficacy should be evaluated in a prospective randomized fashion.

The mitochondrial DNA A3243G mutation in Portugal: clinical and molecular studies in 5 families

Out of 90 Portuguese patients with mitochondrial cytopathy, six harbored the A3243G mutation in the mtDNA tRNA(Leu(UUR)) gene ('MELAS mutation'). They had heterogeneous clinical features, including myopathy with stroke-like episodes, progressive external ophthalmoparesis, diabetes mellitus, and subacute encephalopathy. Histochemical and biochemical analyses of muscle biopsies showed abundant ragged-red fibers reacting positively with the cytochrome oxidase stain, and decreased respiratory chain enzyme activities. On average, the proportion of mutated mtDNA was 67% (20-88%) in tissues from patients and 21% (0-49%) in blood from 20 maternal relatives. The proportion of mutated mitochondrial genomes in muscle did not correlate with clinical presentation or duration of disease. This study, the first in Portuguese patients, confirms the frequent occurrence of the A3243G mutation in patients with mitochondrial diseases, and emphasises the usefulness of genetic testing in reaching a correct diagnosis.

Ultrastructure of familial amyloid polyneuropathy amyloid fibrils: examination with high-resolution electron microscopy

The ultrastructure of familial amyloid polyneuropathy (FAP) amyloid fibrils was examined with high-resolution electron microscopy and immunolabeling. Sural nerve biopsies from FAP (Met 30) patients as well as control tissues were prepared for thin-section observations. Extracellular spaces in the vicinity of myelinated and unmyelinated peripheral nerves were found to be filled with amyloid fibrils as well as with deposits of an "amorphous" material. The fibril was composed of a surface layer and a core. The surface layer was made up of heparan sulfate proteoglycan and was externally associated with a loose assembly of 0.5- to 1-nm-wide filaments. The core was a microfibril-like structure in which amyloid P component was enclosed in a tight helical structure by chondroitin sulfate proteoglycan. Immunogold labeling showed that the peripheral fine filaments were composed of transthyretin. The dimensions of the transthyretin filament suggest that its basic unit is a modified monomer. The deposited amorphous material was a mixture of individual components of the fibril. These results suggest that the main body of FAP amyloid fibrils is similar to that of recently observed fibrils of experimental murine AA and hemodialysis-associated amyloid as well as of connective tissue microfibrils. The differences in the fibrils of these various types of amyloid are in the peripheral filaments which are composed of a protein specific to each type of amyloid.

Diagnostic electrocardiography in epidemiological studies of Chagas' disease: multicenter evaluation of a standardized method

An electrocardiographic recording method with an associated reading guide, designed for epidemiological studies on Chagas' disease, was tested to assess its diagnostic reproducibility. Six cardiologists from five countries each read 100 electrocardiographic (ECG) tracings, including 30 from chronic chagasic patients, then reread them after an interval of 6 months. The readings were blind, with the tracings numbered randomly for the first reading and renumbered randomly for the second reading. The physicians, all experienced in interpreting ECGs from chagasic patients, followed printed instructions for reading the tracings. Reproducibility of the readings was evaluated using the kappa (kappa) index for concordance. The results showed a high degree of interobserver concordance with respect to the diagnosis of normal vs. abnormal tracings (kappa = 0.66; SE 0.02). While the interpretations of some categories of ECG abnormalities were highly reproducible, others, especially those having a low prevalence, showed lower levels of concordance. Intraobserver concordance was uniformly higher than interobserver concordance. The findings of this study justify the use by specialists of the recording of readings method proposed for epidemiological studies on Chagas' disease, but warrant caution in the interpretation of some categories of electrocardiographic alterations.

[Microsurgical reconstruction of the head and neck: experience of 63 free flaps]

The authors present the experience of 63 clinical cases of microsurgical reconstruction of the head and neck. These reconstructions were accomplished by different microvascular free flaps which were selected according to the type, size and location of the defects. Fasciocutaneous, osteofasciocutaneous, adipofascial, myo, myocutaneous, myosseous, jejunum and great omentum flaps were applied. The etiology was traumatic in 10 cases, tumoral in 41 cases, congenital in 7 cases, iatrogenic in 3 cases and infectious in 2 cases. The reconstructed anatomical regions were the scalp in 6 cases, the skull base in 1 case, the orbit in 3 cases, the nose in 1 case, the hemiface in 7 cases, the lips in 1 case, the intraoral cavity in 21 cases, the mandible in 8 cases, the intraoral cavity plus mandible in 11 cases and the cervical esophagus in 1 cases. An analysis was made of surgical times, selection and survival rate of the free flaps and the morphofunctional quality of the reconstructions. Considering the good quality of reconstructions, the amelioration of quality of life and the low morbidity in these patients, microvascular free flaps are considered a first choice technique for head and neck reconstruction when the size and location of the defect prevents the use of local flaps.

Relapsed chronic myeloid leukemia in accelerated phase 10 years after allogeneic bone marrow transplantation: full chimera reconversion with donor peripheral blood stem cells infusion

We report the case of a 44-year-old male who relapsed in accelerated phase chronic myeloid leukemia 10 years after a successful bone marrow transplantation from his HLA-identical brother, and 3 years after 12 months treatment with interferon-alpha (IFN-alpha) for chronic active hepatitis C (CAH). The patient was infused with G-CSF-primed peripheral blood cells (PBSC) from the original bone marrow donor and a full donor reconstitution, with no detectable molecular disease, was obtained within 4 months without clinical aplasia or GVHD, nor help from other forms of chemotherapy or use of biological response modifiers. We speculate that IFN-alpha for CAH delayed the onset of a clinical recurrence of chronic myeloid leukemia and that in advanced disease PBSCs can provide an advantageous alternative to donor lymphocyte infusion (DLI).

L-2-Hydroxyglutaric aciduria: clinical, biochemical and magnetic resonance imaging in six Portuguese pediatric patients

We present clinical, biochemical and cranial magnetic resonance imaging data of six pediatric patients with L-2-hydroxyglutaric aciduria. All the children have the same ethic origin and lived in the northern area of Portugal. Our findings reinforce the described phenotype of this rare metabolic disease with mental deficiency, severe cerebellar dysfunction, mild extrapyramidal and pyramidal symptoms, progressive macrocephaly and seizures. Magnetic resonance imaging revealed subcortical leukoencephalopathy, cerebellar atrophy and signal changes in the putamina and dentate nuclei. These were similar to those of the previous reports in all patients. The urinary excretion of L-2-hydroxyglutaric acid was variably increased in all patients. The other persistent biochemical abnormality was hyperlysinemia. We have found a strong correlation between the severity of the clinical manifestations and the extension of the lesions in the neuroimaging studies. There was no correlation between the clinical findings and the amount of urinary excretion of L-2-hydroxyglutaric acid. We report the second case in the literature of a cerebral thalamic tumor in L-2-hydroxyglutaric aciduria; neuropathological examination of the surgical biopsy demonstrated a diffuse fibrillary astrocytoma.

Transfontanelle ultrasonography in infants: comparative study with cranial computed tomography

The findings of transfontanelle ultrasonography, undertaken in 36 infants with clinical evidence of central nervous system (CNS) disorders, were compared with the findings of cranial computed tomography (CT). Considering the CT scan findings as gold standard, cranial ultrasonography had a sensitivity of 82 per cent and a specificity of 75 per cent in identifying cerebral pathology. The positive predictive value was 92 per cent and negative predictive value was 45 per cent.

Distinct T cell populations distinguish chronic myeloid leukaemia cells from lymphocytes in the same individual: a model for separating GVHD from GVL reactions

Donor lymphocyte responses to minor histocompatibility antigen (mHA) differences are involved in allo-responses between HLA matched pairs causing GVHD and graft-versus-leukaemia (GVL). Since some mHA are tissue-restricted, GVHD and GVL responses may be separable. We studied donor lymphocyte responses to patients with CML in a series of 10 HLA-matched sibling and 10 unrelated donor-recipient pairs comparing proliferation to recipient PHA blasts and CML cells and attempting to selectively deplete responses to PHA blasts in vitro. Responses in counts per min (c.p.m) to CML cells and PHA blasts were, respectively, 2809 +/- 2205 (SD) and 7376 +/- 1877 in related and 12,107 +/- 7191 and 26,136 +/- 22,479 in unrelated pairs. Autologous responses to PHA blasts were significantly lower (mean 779 +/- 735) (p < 0.001). Results correlated with clinical outcome: higher responses to recipient cells correlated with transplant-related death (p = 0.02 for CML and p = 0.06 for PHA blasts). Higher responses to CML correlated with GVHD grade > or = II (p = 0.025). Donor lymphocytes exposed to recipient PHA blasts for 5 days and treated with a ricin-conjugated anti-CD25 antibody retained over 75% of their response to CML but < 10% to PHA blasts. Similarly, depletion of response to CML but not to PHA blasts occurred when CML was the primary challenge. These results indicate that distinct populations of donor T cells respond to recipient leukaemic and non-leukaemic cells, and provide the basis for a clinically applicable technique to selectively deplete donor GVHD reacting cells while conserving GVL.

The galea frontalis myofascial flap in anterior fossa CSF leaks

We report the clinical use of galea frontalis myofascial flaps in the treatment of anterior fossa cerebrospinal fluid leaks after trauma. This flap provides an adequately sized and vascularised barrier between the cranial and nasal cavities through which the cells of the inflammatory response reach the target area. This technique was used in 9 cases with complete success; in 5 out of 9 patients, repair of an anterior cranial base bone defect was also performed with split calvarial bone grafts, harvested from the frontal craniotomy bone. In all patients, neither recurrence of the CSF leakage nor postoperative meningitis or its recurrence were observed.