Over-blending effect of lubricants on capsules manufacturing: a simple and fast wettability technique to predict batch dissolution performance

Mixing/blending is a crucial operation in the manufacturing of solid drug products in the pharmaceutical industry. Although usually described and controlled in specific steps, blending is also inherent to other operations such as transference of materials and equipment feeding systems. This study aimed to investigate a simple and fast wettability testing procedure capable to foresee potential over-blending effects of lubricants occurring during manufacturing of solid dosage forms. An industrial batch blend was submitted to two mixing mechanisms studies (diffusion and shear) during increasing time periods, and the developed wettability testing procedure was applied to assess their impact on blend water uptake. Capsules filled with these blends were tested for dissolution and disintegration. The method was applied to capsules with known dissolution results manufactured at industrial scale. Results demonstrated that processes inducing shear stress led to less permeable blends with consequent retardation on capsules dissolution of at least 35% in the tested timepoints and obtained study metrics above 500 s. Moreover, disintegration testing was not able to detect non-compliant dissolutions, while the proposed wettability testing procedure proved to be able to identify performance failures. Wettability results correlate the effect of mixing mechanisms to capsules dissolution performance, evidencing that this technique can be applied in pharmaceutical industry to evaluate possible over-blending effects.

Influence of the SGLT2 inhibitor empagliflozin on post myocardial infarction rat hearts

 

Studies have shown that inhibition of the sodium glucose transporter protein 2 (SGLT2) reduces cardiovascular death in patients with heart failure and reduced ejection fraction. However, the mechanisms involved in the benefits of SGLT2 inhibitors are poorly understood.

Objective

To evaluate the effects of empagliflozin (EMP) on normal and post-myocardial infarction (MI) rat hearts.

Methods

Male Wistar rats (n=80) were assigned into four groups: Sham; Sham treated with EMP (Sham-EMP); myocardial infarction (MI); and MI treated with EMP (MI-EMP). EMP added to rat chow (5 mg/kg/day) was initiated 10 days after MI induction and maintained for 12 weeks. Echocardiogram was performed at the end of the experimental period. Markers of oxidative stress, energy metabolism, and respiratory complex activity were analyzed in left ventricular myocardium. Statistical analysis: ANOVA.

Results

Histological evaluation showed that EMP did not change infarct size. Cardiac structural and functional parameters did not differ between MI-EMP and MI groups. Myocardial oxidative stress, evaluated by lipid hydroperoxide concentration, was lower in MI-EMP than MI group (Sham 143±26; Sham-EMP 123±20; MI 183±29; MI-EMP 137±11 nmol/g tissue). Glutathione peroxidase was lower in the infarcted groups and did not differ between MI-EMP and MI (Sham 37.6±6.14; Sham-EMP 40.8±10.1; MI 27.7±6.61; MI-EMP 26.5±6.80 μmol/g tissue). Activity of the energy metabolism enzymes lactate dehydrogenase (Sham 45.2±6.65; Sham-EMP 41.1±9.33; MI 58.4±14.4; MI-EMP 55.7±10.1 nmol/mg protein) and citrate synthase (Sham 30.4±4.25; Sham-EMP 37.2±4.85; MI 45.8±8.47; MI-EMP 46.5±9.95 nmol/mg protein) was higher, and β-hydroxyacyl-CoA dehydrogenase (Sham 24.0±3.12; Sham-EMP 20.4±4.84; MI 16.9±4.81; MI-EMP 14.4±4.58 nmol/mg protein) lower in the infarcted groups with no differences between MI-EMP and MI. Respiratory complexes I and II, and ATP synthase did not differ between the infarcted groups.

Conclusion

Empagliflozin reduces myocardial oxidative stress independent of changes in antioxidant enzymes activity, energy metabolism, and respiratory complex activity in the myocardium of infarcted rats.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Fapesp, CNPq

Effects of resistance exercise in the cardiac remodeling of myocardial infarction rats

Introduction

Exercise is an important therapeutic strategy for heart failure (HF). However, the myocardial effects of resistance exercise during HF are not completely understood. In this study, we investigated the influence of resistance exercise on cardiac remodeling and molecular myocardial changes of rats with myocardial infarction (MI)-induced HF.

Methods

Three months after MI induction or simulated surgery, Wistar rats were divided into three groups: Sham (n=14); MI (n=9); and MI subjected to resistance exercise (MI-R, n=13). Exercised rats trained 3 times a week during 12 weeks performing four climbs in a ladder with progressive loads. Cardiac structure and left ventricular function were assessed by echocardiogram. Myocyte diameters were measured in histological sections. Energy metabolism, lipid hydroperoxide, antioxidant enzymes activity, malondialdehyde, and protein carbonylation were evaluated by spectrophotometry. NADPH oxidase subunits (Nox2, Nox4, p22phox and p47phox) gene expression was assessed by RT-PCR. Statistical analysis: ANOVA and Tukey test or Dunn's test.

Results

Mortality did not differ between MI-R and MI groups. MI-R and MI presented dilated left atrium and left ventricle with systolic and diastolic dysfunction. Exercise improved maximum carrying load with no changes in cardiac structure or left ventricle function. Myocyte diameter was lower in MI than Sham and MI-R. Lactate dehydrogenase and creatine kinase activities were lower in MI than Sham. Activity of citrate synthase and catalase was lower in MI and MI-R than Sham. Lipid hydroperoxide concentration was lower in MI-R than MI. Nox2 and p22phox gene expression was higher in MI-R than Sham. Gene expression of Nox4 was higher in both infarcted groups and gene expression of p47phox was lower in MI than Sham.

Conclusion

Resistance exercise is safe and well tolerated by infarcted rats. Exercise increases maximum carrying load and reduces myocardial oxidative stress with no changes in cardiac structure or left ventricle function of infarcted rats.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): CNPq - National Council for Scientific and Technological Development

Influence of resistance exercise on cardiac remodeling and soleus muscle of infarcted rats

Introduction

Resistance exercise (RE) provides several benefits for healthy individuals. However, its effects during heart failure are unclear. The aim of this study was to evaluate the effects of RE on functional capacity, cardiac remodeling, and soleus muscle molecular and biochemical features in rats with myocardial infarction (MI).

Methods

Three months after MI or simulated surgery (Sham), Wistar rats were divided into three groups: Sham (n=14), MI (n=13), and MI subjected to RE (RE-MI, n=14). Exercised rats trained 3 times a week performing four climbs with progressive loads on a ladder over 12 weeks. Functional capacity was assessed by maximum carrying capacity test in the ladder and exercise tolerance test in treadmill. Echocardiogram was performed at the end of the study. Energy metabolism and antioxidant enzyme activities were assessed by spectrophotometry in the soleus muscle. Oxidative stress markers were analyzed in soleus muscle (lipid hydroperoxide) or serum (malondialdehyde and protein carbonylation). Protein expression of insulin type-1 growth factor-like pathway, protein kinase B, and rapamycin target complex was analyzed by Western-blot. Statistical analysis: ANOVA and Bonferroni or Dunn, Student's t and Goodman tests; p<0.05.

Results

Mortality was higher in MI than Sham. Infarction size did not differ between groups. Resistance exercise increased maximum load carrying capacity, without changing functional capacity or cardiac remodeling. Catalase activity was lower in MI than Sham and glutathione peroxidase activity was lower in MI than Sham and RE-MI. Protein carbonylation was higher in RE-MI than MI. Energy metabolism did not differ between groups, except for lower phosphofructokinase activity in RE-MI than MI. Expression of p70s6K, p-FoxO3a, and p-FoxO3a-to-FoxO3a ratio was lower, and p-p70s6K-to-p70s6K ratio was higher in MI than Sham.

Conclusion

The practice of resistance exercise is safe, attenuates mortality, and improves maximum load carrying capacity regardless of changes in cardiac remodeling in infarcted rats. In soleus muscle, resistance exercise preserves phosphofructokinase and antioxidant enzyme activity and expression of the proteins involved in muscle trophism.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): CNPq UNESP

Osler-Weber-Rendu Syndrome with Severe Hepatic Manifestations: A Rare Clinical Case

Rendu-Osler-Weber syndrome is a rare inherited syndrome with autosomal dominant transmission characterized by systemic arteriovenous malformations (AVMs) with multi-organ involvement. Its incidence is 1-2/100,000 and it is predominant in females (the male/female ratio varies from 1:2 to 1:4.5). Clinical manifestations and complications are related to recurrent bleeding and, in some cases, the development of end-organ failure. Management is mostly supportive care and it is essential to promote control of the disease as much as possible and screen eventual complications. We describe the case of a 67-year-old male patient with Rendu-Osler-Weber syndrome admitted to the emergency department with decompensated heart failure due to acute anaemia because of severe epistaxis. During hospitalization, the patient progressed to acute-on-chronic liver failure with hepatic encephalopathy and an abdominal computed tomography scan showed multiple hepatic AVMs considered to be the cause of the chronic liver disease.

LEARNING POINTS

Rendu-Osler-Weber syndrome is a rare autosomal dominant syndrome characterized by systemic arteriovenous malformations (AVMs) with multi-organ involvement, in which the most common manifestation is recurrent epistaxis.In more severe cases the prognosis is determined by organ dysfunction caused by AVMs, including hepatic involvement, which happens in 74-79% of cases, leading to poor outcomes.The treatment is mainly supportive care so early recognition of major organ involvement is fundamental to prevent severe complications.

Body-Packing: A Rare Diagnosis to Keep in Mind

Body packing was first described in 1973 and refers to the intracorporeal concealment of illegal drugs, which are swallowed or placed in anatomical cavities and/or body orifices. The body packer can be asymptomatic or can have signs of systemic drug toxicity (neurological, cardiac, abdominal, renal and cutaneous) due to rupture of the packet(s) or symptoms of gastrointestinal obstruction or perforation. The diagnosis is established based on a suggestive history, findings on physical examination and laboratory findings and/or imaging. The vast majority of patients are asymptomatic and are treated conservatively. However, complex situations may require surgical intervention. We present a case of a 50-year-old man who was admitted in the emergency department with a generalized tonic-clonic seizure and vomiting with plastic film, which raised the suspicion of foreign body ingestion, confirmed by imaging and laboratory tests. He underwent exploratory laparotomy to remove the packages.

LEARNING POINTS

Body packing is a potentially lethal activity.Body-packers can be asymptomatic, or have signs/symptoms of systemic drug toxicity or gastrointestinal obstruction or perforation.It is essential to recognize this condition so that the correct clinical approach, diagnosis and management can be established.

Características Clínicas de Doentes com COVID-19 num Internamento Dedicado do Hospital CUF Infante Santo: Série de Casos

INTRODUÇÃO: A Rede CUF em 18 de março, disponibilizou o Hospital CUF Infante Santo (HCIS) como hospital de referência para os doentes com COVID-19 na área da grande Lisboa. O internamento do doente não crítico (IDNC) ficou a cargo de uma equipa médica dedicada (EMD) constituída por médicos do Cluster Tejo, sob coordenação da Medicina Interna. Este estudo reporta as principais características demográficas e clínicas da população internada no IDNC.MATERIAL E MÉTODOS: Estudo retrospetivo analisando os doentes admitidos entre 27 de março e 7 de maio de 2020, no IDNC. Os critérios para diagnóstico de COVID-19 basearam-se na confirmação laboratorial e/ou critérios de diagnóstico imagiológicos. Excluíram-se da análise os doentes inicialmente suspeitos, mas cujo diagnóstico final encontrado foi outro. Clinicamente, o doente não crítico foi definido como tendo um Modified Early Warning Score (MEWS) entre 0-2. Os dados foram coletados do processo clínico eletrónico e da base de dados criada para seguimento destes doentes. Apresentam-se as características demográficas, clínicas, exames complementares, terapêutica e resultados.RESULTADOS: Incluíram-se 44 doentes, média de idades 67 anos, 52,3% homens. Divididos em grupos de acordo com a apresentação, com pneumonia em 75%, os restantes com outra apresentação. Proveniência: domicílio 81,8%, residência sénior 11,4% e outro hospital 8%.Fatores de risco para doença mais grave foram: Idade > 65 anos, 56,8%, hipertensão arterial 59%, doença respiratória crónica 15,9%, obesidade 15,9%, neoplasia ativa 13,6%, diabetes 11,4%, cardiopatia isquémica 11,4%, insuficiência cardíaca 6,8%, imunossupressão 6,8%, com índice de comorbilidades de Charlson média de 3.6. Agravamento clínico significativo com necessidade de escalar cuidados em três doentes (6,8%), em dois (4,5%) com ventilação mecânica invasiva, adicionalmente registado um óbito (2,3%). Demora média de internamento 10 dias, três (6,8%) doentes foram transferidos para outro hospital e 40 (91%) tiveram alta.DISCUSSÃO: A casuística apresentada representa o primeiro grupo de doentes não críticos internados com COVID-19 na Rede CUF da Região de Lisboa. Houve evolução e mortalidade intra-hospitalar abaixo do expectável para as características desta população, nomeadamenteperante a presença de fatores de risco para doença mais grave e elevado índice de comorbilidades. CONCLUSÃO: A interpretação dos resultados obtidos fica condicionada ao pequeno tamanho da amostra e às incertezas ainda existentes nesta nova doença.

In vivo biodistribution of venlafaxine-PLGA nanoparticles for brain delivery: plain vs. functionalized nanoparticles

Background: Actually, no drugs provide therapeutic benefit to approximately one-third of depressed patients. Depression is predicted to become the first global disease by 2030. So, new therapeutic interventions are imperative.Research design and methods: Venlafaxine-loaded poly(lactic-co-glycolic acid) (PLGA) nanoparticles (NPs) were surface functionalized with two ligands against transferrin receptor to enhance access to brain. An in vitro blood-brain barrier model using hCMEC/D3 cell line was developed to evaluate permeability. In vivo biodistribution studies were performed using C57/bl6 mice. Particles were administered intranasal and main organs were analyzed.Results: Particles were obtained as a lyophilized powder easily to re-suspend. Internalization and permeability studies showed the following cell association sequence: TfRp-NPs>Tf-NPs>plain NPs. Permeability studies also showed that encapsulated VLF was not affected by P-gP pump efflux increasing its concentration in the basolateral side after 24 h. In vivo studies showed that 25% of plain NPs reach the brain after 30 min of one intranasal administration while less than 5% of functionalized NPs get the target.Conclusions: Plain NPs showed the highest ability to reach the brain vs. functionalized NPs after 30 min by intranasal administration. We suggest plain NPs probably travel via direct nose-to-brian route whereas functionalized NPs reach the brain by receptor-mediated endocytosis.

P2499Effects of aerobic and resistance exercise on skeletal muscle of infarcted rats

Background

Skeletal muscle changes contribute to reduced physical performance after myocardial infarction (MI). Exercise has been recommended to stable patients. However, the effects of resistance exercise after MI are not clear. We compared the effects of aerobic and resistance exercise initiated during compensated cardiac remodeling in infarcted rat gastrocnemius muscle.

Methods

Three months after MI induction, Wistar rats were divided into four groups: Sham (n=20); sedentary MI (MI-S, n=9); aerobic exercised MI (MI-A, n=9); and resistance exercised MI (MI-R, n=13). Exercised rats trained three times a week for 12 weeks on a treadmill or ladder. Energy metabolism, oxidative stress markers, and antioxidant enzyme activities were assessed by spectrophotometry. Satellite cells activation markers (MyoD, NCAM, and myosin heavy chain neonatal isoform) were assessed by immunofluorescence or Western blot (Pax-7). Statistical analysis: ANOVA or Mann Whitney.

Results

Physical aerobic capacity was greater in MI-A and strength gain higher in MI-R. Cardiac structures and left ventricular function evaluated by echocardiogram did not differ between infarcted groups. Histological analysis showed that MI size and gastrocnemius cross sectional area did not differ between infarcted groups. Oxygen reactive species production was higher in MI-S than Sham and lipid hydroperoxide concentration was lower in MI-A than the other groups. Catalase activity was higher and glutathione peroxidase lower in infarcted groups than Sham. Superoxide dismutase activity was higher in Sham and MI-R than MI-S. Skeletal muscle metabolism enzyme activity did not differ between groups, except for increase pyruvate kinase in MI-S against the other groups, and β-hydroxyacyl CoA dehydrogenase in MI-S against Sham. Satellite cell activation and protein expression of MAPK and NF-kB did not differ between groups.

Conclusion

Aerobic and resistance exercise respectively improves physical capacity and muscle strength without changing echocardiographic parameters of infarcted rats. Myocardial infarction increases oxygen reactive species production and changes antioxidant enzyme activity and glucose and fatty acid metabolism. Aerobic exercise is superior to resistance exercise against oxidative stress reducing muscle lipid hydroperoxide concentration and attenuating change in glutathione peroxidase activity.

Acknowledgement/Funding

Financial support: Fapesp, CNPq, Capes, and UNESP

P4428Physical exercise during uncontrolled systemic arterial hypertension

Introduction

Physical exercise reduces systemic arterial blood pressure and improves cardiac remodeling. However, the effects of exercise during uncontrolled arterial hypertension remains poorly understood. This study evaluated the influence of physical training on cardiac remodeling in untreated spontaneously hypertensive rats (SHR).

Methods

Four experimental groups were used: sedentary (W-SED n=27) and trained (W-EX, n=31) normotensive Wistar rats, and sedentary (SHR-SED, n=27) and exercised (SHR-EX, n=32) hypertensive rats. At 13 months old, the exercise groups underwent treadmill exercise five days a week, for four months. Echocardiogram was performed to evaluate cardiac structures and function. In vitro myocardial function was analyzed in left ventricular (LV) papillary muscle preparations. Myocardial collagen was quantified by histology and hydroxyproline concentration and antioxidant enzyme activity was assessed by spectrophotometry. NADPH oxidase activity was analyzed by lucigenin reduction. Protein expression was quantified by Western blot. Matrix metalloproteinases (MMP) activity was evaluated by zymography. Statistical analyzes: two factor ANOVA and Bonferroni or Kruskal-Wallis and Dunn tests.

Results

Systolic blood pressure was higher in SHR groups. Exercised groups had greater physical capacity. Frequency of heart failure features was higher in hypertensive groups than controls; SHR-EX had a lower frequency of pleural effusion and tachypnea than SHR-SED. Echocardiogram showed lower LV wall thickness, LV relative wall thickness, left atrium diameter, and relaxation time in SHR-EX than SHR-SED. Myocardial function was better in SHR-EX (positive derivative of developed tension) than SHR-SED. SHR-EX had higher antioxidant enzyme activity than SHR-SED. Lipid hydroperoxide concentration, myocyte diameters, and phosphorylated JNK and total IkB protein expression were higher in hypertensive than control groups. Hydroxyproline, malondialdehyde, NADPH oxidase activity, and protein expression of collagen III, lysyl oxidase, TIMP-1, total JNK, phosphorylated p38, phosphorylated and total p65, and phosphorylated IkB did not differ between groups. Interstitial collagen fraction, MMP-2 activity, and protein expression of total p38, and total and phosphorylated ERK were higher in SHR-SED than W-SED. Exercise reduced MMP-2 activity and phosphorylated ERK in hypertensive rats.

Conclusion

Physical exercise improves physical capacity, reduces the frequency of heart failure features, and attenuates cardiac remodeling in spontaneously hypertensive rats. In addition, exercise increases antioxidant enzyme activity, decreases ERK phosphorylation and MMP-2 activity, and attenuates total ERK protein expression.

Acknowledgement/Funding

Fapesp, CNPq, Capes and UNESP

A Rare Presentation of Ogilvie's Syndrome

Ogilvie’s syndrome or acute colonic pseudo-obstruction is characterized by massive colon dilation in the absence of mechanical obstruction or toxic megacolon. The phenotype associated with secretory diarrhoea is rare and is related to increased potassium channel activity in the colon, inducing excessive potassium loss, with increased sensitivity to normal serum aldosterone levels. The recommended therapy is potassium-sparing agents.

We present the case of an 85-year-old patient who was admitted at the emergency department with prostration, abdominal distension and diarrhoea, corresponding to functional colonic dilation precipitated by severe hypokalaemia. Resolution of the condition only occurred after spironolactone was administered for suspected primary hyperaldosteronism, which was not proved as the patient showed normal aldosterone serum levels. The pathophysiological mechanism of abnormal potassium secretion in this scenario corresponds to ‘relative hyperaldosteronism’ caused by increased sensitivity of colonocytes to aldosterone.

Intravascular Coagulation in Liver Transplantation – Is It Present or Not?

It is still not clear whether disseminated intravascular coagulation (DIC) contributes to the hemostatic disturbances in orthotopic liver transplantation (OLT). Theoretically the lack of hepatic clearance of procoagulant factors during the anhepatic period and the release of thromboplastic material from the graft might trigger DIC. During heterotopic liver transplantation (HLT) the host liver is left in situ and procoagulant factors may still be cleared; DIC, if present, may not occur until after reperfusion. The aim of the present study was to gain more insight into the underlying mechanism of the coagulation changes during liver transplantation by comparison of OLT and HLT. Thrombin-antithrombin-III complexes (TAT), and indicator of thrombin generation, fibrin degradation products (FbDP) and routine clotting times were assayed in 12 OLTs, 18 HLTs and in a control group of 10 partial hepatic resections (PHR).

TAT increased dramatically after reperfusion to 136 μg/l in OLT and to 94 μg/l in HLT (p n.s.). In contrast, FbDP levels increased only in OLT, to a maximum of 13.8 μg/ml. Routine clotting times changed mildly and similarly in both OLT and HLT.

Conclusions: Graft reperfusion triggers excessive thrombin formation, but there are no other signs of subsequent DIC. Any thrombin formed is probably rapidly inhibited by antithrombin-III. The rise in FbDP during OLT is the result of increased fibrinolysis, which occurred only in OLT and not in HLT.

Mild Haemostatic Problems Associated with Congenital Heterozygous α2-Antiplasmin Deficiency

A Dutch family, of which 13 members are heterozygotes, deficient for α2-antiplasmin (α2-AP) is reported. Clinical studies showed that 2 heterozygotes had a mild bleeding tendency, which presented as bleeding episodes after tooth extraction and after surgery and, in one patient, also as excessive menstruation. Laboratory investigations revealed an α2-AP activity of 62% (51-71) (median and range) and an antigen level of 60% (60-66). The plasminogen binding as well as the fibrin binding properties of α2-AP were normal. Plasminogen concentrations were significantly higher in the heterozygotes compared to the other family members. However, free plasminogen not bound to histidine-rich glycoprotein was not significantly different between these two groups. We propose that in this family the deficiency of α2-AP is due to a decreased synthesis of a normal α2-AP molecule. This present study brings the frequency of heterozygous α2-AP deficient patients with a bleeding tendency to 13 out of 59 heterozygotes reported in the literature.

Using microfluidic platforms to develop CNS-targeted polymeric nanoparticles for HIV therapy

The human immunodeficiency virus (HIV) uses the brain as reservoir, which turns it as a promising target to fight this pathology. Nanoparticles (NPs) of poly(lactic-co-glycolic) acid (PLGA) are potential carriers of anti-HIV drugs to the brain, since most of these antiretrovirals, as efavirenz (EFV), cannot surpass the blood-brain barrier (BBB). Forasmuch as the conventional production methods lack precise control over the final properties of particles, microfluidics emerged as a prospective alternative. This study aimed at developing EFV-loaded PLGA NPs through a conventional and microfluidic method, targeted to the BBB, in order to treat HIV neuropathology. Compared to the conventional method, NPs produced through microfluidics presented reduced size (73 nm versus 133 nm), comparable polydispersity (around 0.090), less negative zeta-potential (-14.1 mV versus -28.0 mV), higher EFV association efficiency (80.7% versus 32.7%) and higher drug loading (10.8% versus 3.2%). The microfluidics-produced NPs also demonstrated a sustained in vitro EFV release (50% released within the first 24 h). NPs functionalization with a transferrin receptor-binding peptide, envisaging BBB targeting, proved to be effective concerning nuclear magnetic resonance analysis (δ = -0.008 ppm; δ = -0.017 ppm). NPs demonstrated to be safe to BBB endothelial and neuron cells (metabolic activity above 70%), as well as non-hemolytic (1-2% of hemolysis, no morphological alterations on erythrocytes). Finally, functionalized nanosystems were able to interact more efficiently with BBB cells, and permeability of EFV associated with NPs through a BBB in vitro model was around 1.3-fold higher than the free drug.

“Viagem ao mundo das sílabas”: Intervenção na consciência fonológica

Jogo interativo “Viagem ao mundo das sílabas”, composto por duas atividades: “Visita aos animais” e “Ida ao supermercado”, cujo objetivo consiste na promoção da aquisição das competências fonológicas e no aumento da qualidade e quantidade de vocabulário. As atividades destinam-se a suprimir a sílaba inicial e detetar sílabas iniciais. Pretende-se demonstrar que, com ferramentas acessíveis, é possível criar um jogo para ser utilizado, com eficácia em sala de aula ou em casa, com crianças com dificuldades da linguagem. Tendo em conta que o processamento e as competências fonológicas específicas são altos preditores das futuras competências linguísticas.

Desenvolvimento e aplicação do jogo interativo “Vogais Saltitantes”: Intervenção no âmbito da Disnomia

O jogo interativo designado por “Vogais Saltitantes” é um jogo onde o principal objetivo consiste na intervenção junto de alunos com necessidades educativas especiais (NEE) que apresentam problemas de linguagem em geral, e/ou especificamente alunos com disnomia.Este jogo foi construído e desenvolvido em cinco partes, onde cada uma delas pretende trabalhar cada vogal individualmente. O aluno é levado a associar palavras iniciadas por cada vogal com a imagem correspondente.

Desenho Universal para Aprendizagem, Acessibilidade Web, Usabilidade no e-Learning e Usabilidade Pedagógica

Este artigo analisou os conceitos – “Desenho Universal para Aprendizagem”; “Acessibilidade na Web”; “Usabilidade no e-learning”; e “Usabilidade Pedagógica” – com o objetivo de identificar a articulação destes conceitos no contexto do Ensino a Distância (EaD) notadamente no e-learning destinadas ao aperfeiçoamento de Ambientes Virtuais de Aprendizagem. Para lograr este intento utilizou-se a metodologia de revisão sistemática da literatura fundamentada em Tranfield, et. al (2002). A pesquisa usou como lócus as bases científicas: Scopus, Web of Science e Google Scholar, no intervalo de 2012 a 2017. Nas pesquisas identificaram-se inicialmente 96 artigos em que foram selecionados, após uma análise preliminar, 14 artigos cujo conteúdo constituiu o corpus de suporte a este texto.

As tecnologias de informação e comunicação na comunicação aumentativa e alternativa: um estudo quantitativo exploratório

As tecnologias de apoio podem ser um interface de comunicação para muitas crianças e jovens com necessidades educativas especiais. Nesta investigação recorremos ao inquérito por questionário como instrumento de recolha de dados. A amostra foi constituída por 85 professores especializados a lecionar em unidades de educação especial. O objetivo foi conhecer a perspetiva dos professores quanto à utilização, potencialidades e condicionantes das tecnologias na comunicação. Concluímos que os professores se preocupam em fazer formação regular na área das tecnologias. Conhecem as soluções tecnológicas apresentadas e utilizam tecnologias de apoio para a comunicação aumentativa e alternativa na sala de aula.

As abordagens pedagogicas e o papel do professor de educação básica em processo de formação continuada no Brasil

Importa para este artigo conhecer quais as abordagens formativas que se fazem presentes na composição das propostas de formação continuada em TIC no Brasil. Compreende-se que as mesmas exercem um diferencial importante e repercutem na ação, na reflexão e no compromisso docente com as Tecnologias Digitais. Neste Sentido, busca-se por meio de uma Revisão Sistemática da Literatura encontrar evidências capazes de nos levar a perceber as influências da abordagem pedagógica no papel do professor enquanto aprendiz de TIC. Este estudo ressalta a formação docente como o espaço de diálogo entre as demandas do Século XXI e a situacionalidade em TIC.

O compromisso do professor e a situacionalidade docente em TIC

Este artigo visa discutir os termos profissionalização, profissionalismo e profissionalidade docente em paralelo com as reflexões de Freire (1979) sobre o compromisso do homem com a realidade. Neste propósito ressalta a necessidade de reflexão da relação do professor com a tecnologia, levando em consideração os termos profissionais que compõe a identidade docente a partir do cenário da formação. Abarcado em uma Revisão Bibliográfica, este trabalho almeja compor um quadro de conceitos capaz de evidenciar a arena de conflitos que é estabelecida entre as demandas do Século XXI e a situacionalidade docente em TIC.

Delivery of siRNA silencing P-gp in peptide-functionalized nanoparticles causes efflux modulation at the blood–brain barrier

Aim: Explore the use of transferrin-receptor peptide-functionalized nanoparticles (NPs) targeting blood–brain barrier (BBB) as siRNA carriers to silence P-glycoprotein (P-gp). Materials & methods: Permeability experiments were assessed through a developed BBB cell-based model; P-gp mRNA expression was evaluated in vitro; rhodamine 123 permeability was assessed after cell monolayer treatment with siRNA NPs. Results: Beyond their ability to improve siRNA permeability through the BBB by twofold, 96-h post-transfection, functionalized polymeric NPs successfully reduced P-gp mRNA expression up to 52%, compared with nonfunctionalized systems. Subsequently, the permeability of rhodamine 123 through the human BBB model increased up to 27%. Conclusion: Developed BBB-targeted NPs induced P-gp downregulation and consequent increase on P-gp substrate permeability, revealing their ability to modulate drug efflux at the BBB.

Web 2.0 Tools in Biomedical and Pharmaceutical Education

Web 2.0 technologies are being rapidly integrated in higher education, which dramatically influences the ways learners approach and use information. Knowledge transfer has evolved into a two-way process. Users no longer simply consume and download information from the web; they create and interact with it. Several theoretical works were developed in order to discuss the possibilities of integration of Web 2.0 tools in Pharmacy, Medicine, Allied Health, Nursing and many other Biomedical Areas. Other works have started gathering qualitative and quantitative evidence of the importance of Web 2.0 tools in the learning process. By performing this integrative review, this paper will provide an overview of what is being done in biomedical and pharmaceutical education, and elaborate some of the potential opportunities and challenges that these applications present. With this updated review we hope to give our contribution to consolidate research in this promising area.

Tailoring Lipid and Polymeric Nanoparticles as siRNA Carriers towards the Blood-Brain Barrier - from Targeting to Safe Administration

Blood-brain barrier is a tightly packed layer of endothelial cells surrounding the brain that acts as the main obstacle for drugs enter the central nervous system (CNS), due to its unique features, as tight junctions and drug efflux systems. Therefore, since the incidence of CNS disorders is increasing worldwide, medical therapeutics need to be improved. Consequently, aiming to surpass blood-brain barrier and overcome CNS disabilities, silencing P-glycoprotein as a drug efflux transporter at brain endothelial cells through siRNA is considered a promising approach. For siRNA enzymatic protection and efficient delivery to its target, two different nanoparticles platforms, solid lipid (SLN) and poly-lactic-co-glycolic (PLGA) nanoparticles were used in this study. Polymeric PLGA nanoparticles were around 115 nm in size and had 50 % of siRNA association efficiency, while SLN presented 150 nm and association efficiency close to 52 %. Their surface was functionalized with a peptide-binding transferrin receptor, in a site-oriented manner confirmed by NMR, and their targeting ability against human brain endothelial cells was successfully demonstrated by fluorescence microscopy and flow cytometry. The interaction of modified nanoparticles with brain endothelial cells increased 3-fold compared to non-modified lipid nanoparticles, and 4-fold compared to non-modified PLGA nanoparticles, respectively. These nanosystems, which were also demonstrated to be safe for human brain endothelial cells, without significant cytotoxicity, bring a new hopeful breath to the future of brain diseases therapies.

In vivo dual-delivery of glucagon like peptide-1 (GLP-1) and dipeptidyl peptidase-4 (DPP4) inhibitor through composites prepared by microfluidics for diabetes therapy

Oral delivery of proteins is still a challenge in the pharmaceutical field. Nanoparticles are among the most promising carrier systems for the oral delivery of proteins by increasing their oral bioavailability. However, most of the existent data regarding nanosystems for oral protein delivery is from in vitro studies, lacking in vivo experiments to evaluate the efficacy of these systems. Herein, a multifunctional composite system, tailored by droplet microfluidics, was used for dual delivery of glucagon like peptide-1 (GLP-1) and dipeptidyl peptidase-4 inhibitor (iDPP4) in vivo. Oral delivery of GLP-1 with nano- or micro-systems has been studied before, but the simultaneous nanodelivery of GLP-1 with iDPP4 is a novel strategy presented here. The type 2 diabetes mellitus (T2DM) rat model, induced through the combined administration of streptozotocin and nicotinamide, a non-obese model of T2DM, was used. The combination of both drugs resulted in an increase in the hypoglycemic effects in a sustained, but prolonged manner, where the iDPP4 improved the therapeutic efficacy of GLP-1. Four hours after the oral administration of the system, blood glucose levels were decreased by 44%, and were constant for another 4 h, representing half of the glucose area under the curve when compared to the control. An enhancement of the plasmatic insulin levels was also observed 6 h after the oral administration of the dual-drug composite system and, although no statistically significant differences existed, the amount of pancreatic insulin was also higher. These are promising results for the oral delivery of GLP-1 to be pursued further in a chronic diabetic model study.

Desafios da computação móvel e usabilidade em sala de aula

Este artigo relata a experiência em sala de aula na Universidade do Minho - Braga – Portugal, na disciplina de Sistemas Móveis e Ubíquos no Mestrado em Engenharia de Sistemas. Realizou-se a avaliação heurística de usabilidade de Nielsen  nas aplicações desenvolvidas para dispositivos móveis por grupos. A metodologia embasou-se na aplicação de 3 projetos de 7 alunos; bem como, aos 9 usuários externos a sala de aula; fundou-se ainda na observação direta por uma especialista. Validou-se com questionário de perguntas fechadas no intuito de confirmar os dados coletados. Ao final descreveu-se o grau de usabilidade das aplicações e sugestões.

Dos dispositivos móveis à aprendizagem ubíqua – Da usabilidade técnica à usabilidade pedagógica

A ampla disseminação e crescente disponibilidade das tecnologias digitais, sem fios, de comunicação, informação e colaboração a distância vêm sendo incorporadas nos contextos de ensino e formação, ampliando o espetro de ação das ofertas educativas. Este movimento veio renovar e modificar substancialmente, quer os contextos de ensino e formação presencial, quer os contextos de ensino e formação a distância, reduzindo aliás os elementos distintivos entre ambos. Numa sociedade crescentemente digital e wireless,  conceitos como “aprendizagem móvel” e “aprendizagem ubíqua” tornam-se cada vez mais presentes nos cenários educativos, configurando o ideal da “aprendizagem em qualquer momento e em qualquer lugar”, e expandindo-o, nomeadamente do espaço físico para o ciberespaço. Embora as primeiras pesquisas acerca da aprendizagem móvel tenham sido publicadas a partir de 2001, há ainda notável escassez de trabalhos e experiências que diminuam o hiato entre aprendizagem móvel e usabilidade pedagógica no intuito de aprimorar a tecnologia educativa em sala de aula. Este artigo pretende apresentar e discutir o conceito de usabilidade e as suas articulações com o conceito de usabilidade técnica na aprendizagem móvel e ubíqua. A investigação enquadra-se na linha Development Research que se aplicam a variadíssimas situações de pesquisa educativa, em geral, e à investigação do domínio da Tecnologia Educativa, em particular. Trata-se de um modelo de investigação multi-metodológico, na medida em que permite ao investigador a possibilidade de combinar métodos quantitativos e qualitativos. Porquanto, a análise documental, a observação, estudo de caso, inquérito por questionário ou por entrevista e registros automáticos. Situa-se o locus deste trabalho nos  cursos a distância do Instituto Federal da Amazônia (Manaus-Amazonas-Brasil). O presente trabalho consiste no projeto de tese em construção (Dos Dispositivos Móveis à Aprendizagem Ubíqua – Da Usabilidade Técnica à Usabilidade Pedagógica) que apresenta, portanto, resultados parciais e não conclusivos. Há presente nas atividades de EAD do IFAM aspectos de usabilidade técnica que permanecem distanciados da usabilidade pedagógica identificados no AVA-Moodle para dispositivos móveis. Umas das contribuições apresentada neste trabalho baseia-se na indicação de que os processos voltados ao EAD devem considerar não somente a usabilidade técnica mas sim, e de forma consistente,  a usabilidade pedagógica a fim o aprimoramento de sistemas educacionais contemporâneos.

Aprendizagens ressignificadas pelas TIC: uma investigação-ação com os professores da educação básica paranaense

O presente trabalho apresenta o enredo de um projeto de investigação de doutoramento em Ciências da Educação que vem trabalhar a questão da democratização das TIC ao saber docente. Nesta perspetiva, traz a compreensão de que o distanciamento entre as iniciativas de integração da Tecnologia Educativa ao saber docente, reúne questões de ordem social, política e econômica. Dado o fundamento, busca implementar um curso de formação continuada que possa trazer essa tecnologia educativa ao conhecimento do professor, levando-o para uma reflexão do processo formativo como fenómeno de integração das práticas pedagógicas à Sociedade da Informação e do Conhecimento. Para tanto, esta tarefa reforça a Investigação-Ação como metodologia que evidencia um trabalho prático, moral e crítico, intervindo, possivelmente, no desempenho profissional dos docentes, na intenção de uma melhoria do processo pedagógico. Desse modo, reconhece a escola e seus professores como fonte direta de dados, onde a descrição dos mesmos considera o processo e os resultados de forma indutiva, permitindo que os participantes possam significar a chave para o desfecho do trabalho. Neste contexto, esta produção enfatiza uma leitura em relação ao processo cultural escolar e a organização das políticas educativas em TIC no estado do Paraná, Brasil, visualizando a questão da disseminação das TIC junto ao sistema público de Educação Básica. Na mesma ação, ressalta os pontos de ligação entre as estruturas macro e micro, como forma de conhecimento e fundamentação teórica de base para a compreensão da relação entre as políticas públicas e o chão da escola. Numa operacionalização das variáveis busca encontrar a relação entre os professores de educação Básica do Estado do Paraná e as TIC pretendendo averiguar: as condições encontradas dentro das escolas para a viabilização do uso das TIC, a perceção e a recetividade dos professores para com as TIC e suas práticas pedagógicas, o grau de participação dos professores na capacitação online junto ao reconhecimento do potencial das TIC e os impactos desse fenómeno nas suas práticas de ensino. Dado o marco situacional, e com a recolha de dados a ser sistematizada e analisada, partir-se-á para o desenvolvimento do curso online, estruturando-o de acordo com os anseios e dificuldades demonstradas pelos participantes da pesquisa, considerando as TIC e a gama de possibilidades de sua democratização e integração aos saberes docentes. Acredita-se que esta pesquisa vai de encontro às necessidades de maior informação científica sobre o processo de formação continuada dos professores junto às TIC e seus impactos. No mesmo segmento, pretende contribuir para a mudança de práticas pedagógicas, esperando a repercussão social e intelectual do curso de capacitação online ao ato educativo, numa possível imersão docente de sustentabilidade,  atualização e mobilidade pedagógica em TIC.

siRNA as a tool to improve the treatment of brain diseases: Mechanism, targets and delivery

As the population ages, brain pathologies such as neurodegenerative diseases and brain cancer increase their incidence, being the need to find successful treatments of upmost importance. Drug delivery to the central nervous system (CNS) is required in order to reach diseases causes and treat them. However, biological barriers, mainly blood-brain barrier (BBB), are the key obstacles that prevent the effectiveness of possible treatments due to their ability to strongly limit the perfusion of compounds into the brain. Over the past decades, new approaches towards overcoming BBB and its efflux transporters had been proposed. One of these approaches here reviewed is through small interfering RNA (siRNA), which is capable to specifically target one gene and silence it in a post-transcriptional way. There are different possible functional proteins at the BBB, as the ones responsible for transport or just for its tightness, which could be a siRNA target. As important as the effective silence is the way to delivery siRNA to its anatomical site of action. This is where nanotechnology-based systems may help, by protecting siRNA circulation and providing cell/tissue-targeting and intracellular siRNA delivery. After an initial overview on incidence of brain diseases and basic features of the CNS, BBB and its efflux pumps, this review focuses on recent strategies to reach brain based on siRNA, and how to specifically target these approaches in order to treat brain diseases.

Nanoparticle-based drug delivery to improve the efficacy of antiretroviral therapy in the central nervous system

Antiretroviral drug therapy plays a cornerstone role in the treatment of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome patients. Despite obvious advances over the past 3 decades, new approaches toward improved management of infected individuals are still required. Drug distribution to the central nervous system (CNS) is required in order to limit and control viral infection, but the presence of natural barrier structures, in particular the blood-brain barrier, strongly limits the perfusion of anti-HIV compounds into this anatomical site. Nanotechnology-based approaches may help providing solutions for antiretroviral drug delivery to the CNS by potentially prolonging systemic drug circulation, increasing the crossing and reducing the efflux of active compounds at the blood-brain barrier, and providing cell/tissue-targeting and intracellular drug delivery. After an initial overview on the basic features of HIV infection of the CNS and barriers to active compound delivery to this anatomical site, this review focuses on recent strategies based on antiretroviral drug-loaded solid nanoparticles and drug nanosuspensions for the potential management of HIV infection of the CNS.

Lipid nanoparticles for topical and transdermal application for alopecia treatment: development, physicochemical characterization, and in vitro release and penetration studies

Alopecia is a dermatological disorder, commonly known as hair loss, which affects up to half of the Caucasian male population by middle age, and almost all (95%) Caucasian men by old age. Considering that alopecia affects so many people and that there is currently no scientifically proven treatment with few side effects, new drug-delivery systems able to improve alopecia therapy are urgently required. With this purpose in mind, the present study aimed to develop lipid nanoparticles (nanostructured lipid carriers) with the ability to incorporate and deliver anti-alopecia active compounds (minoxidil and finasteride) into the dermis and hair follicles. Lipid nanoparticles, prepared by ultrasonication method, showed mean particle sizes around 200 nm, which is sufficient for reaching the dermis and hair follicles, and zeta potential values around −30 mV, which indicates good physical stability. Over 28 days of storage, no significant variations in these parameters were observed, which indicates that all nanoformulations are stable in storage over that period. Cryo-scanning electron microscope measurements showed that all the lipid nanoparticles exhibited a spherical shape and a smooth surface regardless of their composition. Differential scanning calorimetry studies allowed the determination of phase transition temperatures and confirmed the recrystallization of the lipid nanoparticles (recrystallization index between 11% and 86%). A high loading efficiency was achieved for finasteride (between 70% and 90%), while less than 30% was achieved for minoxidil nanoparticles, over 28 days. Controlled release assays in physiological conditions demonstrated that nanoparticles loaded with minoxidil yielded a prolonged release, as desired. Penetration assays through pig ear skin demonstrated that nanoparticles loaded with minoxidil and finasteride had low levels of penetration. These results suggest that the proposed novel formulation presents several good characteristics indicating their suitability for dermal delivery of anti-alopecia active compounds.

A Case Based Learning Model in Therapeutics

Nowadays, learning a Pharmaceutical Profession is an increasing challenge. Apart from traditional texts, lectures and self-guided individual learning, pharmaceutical educators are encouraged to find and implement ways to promote higher order thinking, collaborative learning and to increase students' motivation. One way of achieving these objectives is to complement traditional learning methods with the development and implementation of Case Based Learning (CBL), supported in real life situations. Methods regarding real problems stand in contrast to a more traditional approach to learning and instruction. They promote learner-centered, small group, interactive learning experiences, instead of large group, didactic, teacher-centered instruction. Developing such a learning approach can be a challenge. In this sense, it becomes relevant to promote and share experiences already underway and by doing so, disseminate knowledge in this field. It is our goal with this text to share our experience in the design and implementation of a Case Based Approach to Therapeutics.   Type: Idea Paper

Intravenous immunoglobulin in lupus panniculitis

Systemic lupus erythematosus (SLE) is a disease of unknown cause that may involve one or many organ or systems. Skin involvement is a major feature in this disease, and a wide variety of skin conditions may be present. Lupus erythematosus panniculitis (LEP) constitutes a rare form of cutaneous lupus characterized by recurrent nodular or plaque lesions that can vary from a benign and mild course to a more disfiguring disease. Initial therapy includes corticosteroids, antimalarials, and azathioprine and, in refractory cases, two antimalarials in association, mycophenolate mofetil, or other immunomodulators. Intravenous immuglobulin (IVIG) is used in many autoimmune disorders, like in SLE, although clinical trials have not yet taken place. In this report, we review skin manifestations of SLE and their treatment, IVIG, and finally a case of LEP successfully treated with IVIG when other therapy modalities failed.

Rituximab therapy in primary Sjögren's syndrome

Primary Sjögren's syndrome is an autoimmune disease characterized by lymphocytic infiltration of glandular tissues leading to sicca symptoms, namely, dry eyes and dry mouth. In the majority of cases, the disease course is benign, albeit with considerable patient discomfort. Some patients, however, have systemic symptoms with arthritis, cutaneous vasculitis, low complement levels, and cryoglobulinemia. A small but not insignificant percentage of those patients evolve to B cell lymphoma. The increased expression of B cell survival factors, such as B cell activating factor, may promote the perpetuation of a B cell clone and precede the lymphoproliferative disease. Rituximab, a chimeric monoclonal antibody to CD20, leads to B cell depletion and may have a role in Sjögren systemic manifestations as well as in preventing and treating Sjögren-associated lymphoma.

Combination therapy with single inhaler budesonide/formoterol compared with high dose of fluticasone propionate alone in patients with moderate persistent asthma

BACKGROUND

The efficacy and safety of Symbicort (budesonide and formoterol in a single inhaler) were compared with those of a high dose of the commonly used corticosteroid fluticasone propionate in patients with moderate persistent asthma.

METHODS

This randomized, double-blind, double-dummy, parallel-group study involved 373 patients with asthma (mean age 42 years; FEV(1) 78% of predicted; reversibility 21%). After a 2-week run-in period, during which patients received budesonide 200 microg twice daily, they were randomly assigned to treatment with either Symbicort Turbuhaler (budesonide/formoterol 160/4.5 microg, one inhalation twice daily) or Flovent/Flixotide Diskus (fluticasone propionate 250 microg twice daily) for 12 weeks.

RESULTS

Significantly greater increases in morning PEF, the primary efficacy variable, were observed in patients treated with budesonide/formoterol compared with fluticasone propionate (27.4 L/min vs 7.7 L/min; p < 0.001). Evening PEF and clinic FEV(1) also favored budesonide/formoterol compared with fluticasone propionate (p < 0.001), as did use of reliever medication (p = 0.04) and the proportion of reliever-free days (p < 0.001). There were also numerical improvements in symptom-free days (60.4% vs 55.5%), night-time awakenings (7.9% vs 9.6%) and asthma-control days (57.8% vs 52.4%) in favor of budesonide/formoterol. The risk of an exacerbation was reduced by 32% in the budesonide/formoterol group compared with the fluticasone propionate group (p < 0.05). Both treatments were well tolerated.

CONCLUSION

Symbicort (budesonide/formoterol in a single inhaler) was more effective than a high dose of fluticasone propionate in improving lung function, reducing use of reliever medication and improving control of moderate persistent asthma.

[Diagnosis of illiteracy in patients hospitalized at a nursing service. Prospective study]

When, at the end of a medical visit, a doctor prescribes medication, he may be unaware that writing is unknown to the patient. This fact compromises the patient's understanding of disease and therapeutics and thus the importance of diagnosing illiteracy. The A.A studied prospectively 200 consecutive patients admitted to a Medical Ward at Santa Maria Hospital in Lisbon, from 13/3/1997 to 8/7/1998. The study included age, gender, social environment, evaluation of the ability to read and write, years of scholarship and the principal diagnosis. The results were to chi 2 (Yates) and Student's T-tests.

RESULTS

94 patients were male and 106 female, aged between 18 and 95 years (mean 62.3), 106 from an urban environment, 54 from a rural environment and 37 had lived their adult life in a rural environment but were at present living in an urban environment. The percentage of illiteracy was 30.5%, being considerably higher in the females (43.4%) than in the males (15.96%), in patients above 65 years (49%) compared to patients from 15 to 64 years old (12%), in non-urban patients (55%) opposed to urban born patients (10.4%). Any of these variables, gender, age and social environments had statistical significance to P < 0.001 when associated to illiteracy.

CONCLUSIONS

The comparative analysis of the official results for the general Portuguese Population study, Census 91, shows an important analogy. In both studies illiteracy was worst in females and in those above 65 years of age. Today illiteracy is still days a serious National problem, with important medical implications, a troublesome obstacle to the understanding of the disease and compliance with therapy.

Control of endophagic Anopheles mosquitoes and human malaria in Guinea Bissau, West Africa by permethrin-treated bed nets

We compared the anti-mosquito and antimalarial potentialities of placebo-treated versus permethrin-impregnated bed nets in north-western Guinea Bissau. Baseline, pre-intervention entomological and parasitological data were collected during the rainy season of 1990 and bed nets were distributed shortly before the rainy season of 1991. Pairs of 3 ethnically different villages were investigated. The villages in each pair were at least 2 km apart but belonged to the same ethnic group in an ecologically similar area. After one year permethrin-treated bed nets were provided to all people in one village of each pair and placebo-treated bed nets to the other villages. About 98% of mosquitoes caught in bedrooms belonged to Anopheles gambiae and A. melas, which we consider to be the main malaria vectors in the study villages. Mean Plasmodium falciparum sporozoite rate in A. gambiae (9.6%) and A. melas (12.4%) was highest during October-November. The Plasmodium index in children 2-9 years old in the 6 villages, at the end of the rainy season 1990, ranged between 44% and 79%. Of these, 98% were identified as P. falciparum, 1% as P. malariae and 1% as mixed infections of these species. Significant reductions of Anopheles indoor resting densities and malaria parasite rates in humans were recorded in villages which had received permethrin-treated nets, but not in the control villages. The mean number of P. falciparum-infective mosquito bites received indoors in untreated villages during the rainy season was estimated to be about 4 per child and 20 per adult. This inoculation rate was reduced by at least 78% by the use of permethrin-impregnated bed nets. The malaria parasite rates and proportions of people experiencing 'disease with fever' decreased significantly in villages provided with permethrin-treated nets but not in the control villages. Impregnated nets may be an important tool to reduce disease and death due to malaria in Guinea Bissau.

[Pulmonary lymphangioleiomyomatosis]

The authors present a clinical case of Lymphangioleiomyomatosis of the lung. They analyse the clinical, radiological and functional features and comment on the evolution and therapeutic approach of this rare disorder. To the authors, lung involvement as well as therapeutic decision are important features that affect the prognosis.

The effects of long-term graft preservation on intraoperative hemostatic changes in liver transplantation. A comparison between orthotopic and heterotopic transplantation in the pig

We compared hemostatic changes during OLT and HLT after various periods of graft storage, to investigate whether the host liver in HLT protects the recipient from hemostatic deterioration induced by severe graft storage damage. In particular, the mechanism of fibrinolytic deterioration was investigated. The effect of prostaglandin E1 (PGE1) on these parameters was also studied.

MATERIAL AND METHODS

69 pigs underwent either OLT (N = 32) or HLT (N = 37) with a graft stored for 2 hr (N = 31), 24 hr (N = 16), 48 hr (N = 7), or 72 hr (N = 15). PGE1 was given intravenously to both donor and recipient animals and was added to the preservation and flushing solutions. Fibrinolysis (euglobulin clot lysis time, t-PA activity and alpha 2-antiplasmin) and coagulation parameters (activated partial thromboplasmin time, prothrombin time, fibrinogen and platelet count) were measured at several intervals during transplantation.

STATISTICS

Univariate non-parametric tests were used for analysis of coagulation and fibrinolysis parameters. For the three main variables- i.e., the type of transplantation, the use of PGE1, and the preservation time, multiple regression analysis was performed.

RESULTS

Fibrinolytic activity increased during the anhepatic period of OLT. Graft reperfusion was followed by a rise in t-PA in both OLT and HLT. In HLT, t-PA quickly returned to normal, whereas a continuous increase was found in OLT. The coagulation parameters, in turn, remained unchanged during the anhepatic period and deteriorated in OLT compared to HLT. The duration of graft storage was directly related to the severity of the hemostatic changes, although this effect was more apparent in OLT than in HLT.

CONCLUSIONS

Changes in hemostasis are more pronounced in OLT than in HLT. This suggests that the host liver protects the recipient from the effects of graft storage damage, even after long preservation times. Early postreperfusion fibrinolytic activity was presumably due to t-PA release from the graft both in OLT and HLT. The further rise t-PA in OLT might be caused by the release of cytokines from the graft, that subsequently evoke endothelial t-PA release. In HLT, t-PA and cytokines may be cleared by the native liver. No positive or negative effect of PGE1 on coagulation or fibrinolysis parameters was noticed.

The appearance of donor heparin in the recipient after reperfusion of a liver graft

The release of heparin has been mentioned as one of the causes of hypocoagulability after reperfusion of the liver graft. It has been ascribed to endogenous heparin released from the donor liver or to exogenous heparin in the preservation fluid that is released into the recipient after sequestration into the graft during preservation. The aim of this study was to investigate whether systemic administration of heparin to the donor before the hepatectomy contributes to the appearance of heparin in the recipient after reperfusion. We studied 20 patients undergoing an auxiliary heterotopic liver transplantation; 15 donors had received heparin immediately before circulation arrest (median 300 IU/kg body weight), but 5 had not. The thrombin time (TT), activated partial thromboplastin time (aPTT), and heparin neutralization test were determined at several intervals during the transplantation.

[Extrapulmonary tuberculosis]

Although the respiratory tract is the major site for tuberculous lesions, all organs can be affected. The authors review the clinical files of 25 patients admitted to our Department with lung and/or pleural tuberculous disease, confirmed by bacteriology or histopathology, who simultaneously suffered from tuberculosis in other organs. We included 20 men and 5 women, aged from 10 to 74 years (mean: 37.12 years); 6 patients had pleural tuberculosis, 19 had pulmonary tuberculosis, 4 of them having miliary tuberculosis. Lymph node tuberculosis was diagnosed in 14 patients, tuberculosis of the bones in 4, laryngeal tuberculosis in 3 patients, tuberculous pericarditis in 2 patients, epididymitis in 1 and intestinal in another patient. Several clinical aspects are discussed, namely diagnostic procedures, M. tuberculosis identification in inflammatory exudates in 6 patients, in urine in 1, and in histopathology in 9 patients; in the 9 remaining patients extrapulmonary tuberculosis was accepted considering clinical and radiological findings in patients with respiratory tract tuberculosis. We concluded that tuberculosis may still assume severe clinical forms and that patients with tuberculosis should be globally evaluated.

Intravascular coagulation in liver transplantation--is it present or not? A comparison between orthotopic and heterotopic liver transplantation

It is still not clear whether disseminated intravascular coagulation (DIC) contributes to the hemostatic disturbances in orthotopic liver transplantation (OLT). Theoretically the lack of hepatic clearance of procoagulant factors during the anhepatic period and the release of thromboplastic material from the graft might trigger DIC. During heterotopic liver transplantation (HLT) the host liver is left in situ and procoagulant factors may still be cleared; DIC, if present, may not occur until after reperfusion. The aim of the present study was to gain more insight into the underlying mechanism of the coagulation changes during liver transplantation by comparison of OLT and HLT. Thrombin-antithrombin-III complexes (TAT), and indicator of thrombin generation, fibrin degradation products (FbDP) and routine clotting times were assayed in 12 OLTs, 18 HLTs and in a control group of 10 partial hepatic resections (PHR). TAT increased dramatically after reperfusion to 136 micrograms/l in OLT and to 94 micrograms/l in HLT (p n.s.). In contrast, FbDP levels increased only in OLT, to a maximum of 13.8 micrograms/ml. Routine clotting times changed mildly and similarly in both OLT and HLT.

CONCLUSIONS

Graft reperfusion triggers excessive thrombin formation, but there are no other signs of subsequent DIC. Any thrombin formed is probably rapidly inhibited by antithrombin-III. The rise in FbDP during OLT is the result of increased fibrinolysis, which occurred only in OLT and not in HLT.

Increased tissue-type plasminogen activator activity in orthotopic but not heterotopic liver transplantation: the role of the anhepatic period

The major cause of the increased tissue-type plasminogen activator activity during orthotopic liver transplantation is still unclear. Both the lack of hepatic clearance of tissue-type plasminogen activator in the anhepatic period and increased endothelial release from the graft on reperfusion have been proposed as the major causes. Heterotopic liver transplantation avoids the resection of the host liver and is a useful model to help differentiate between these two possibilities. In this study the fibrinolytic system was evaluated in 10 orthotopic liver transplantations, 18 heterotopic liver transplantations and a control group of 10 partial hepatic resections. A marked increment in tissue-type plasminogen activator activity, from 0.2 to 5.2 IU/ml (p less than 0.02), was observed during the anhepatic period of orthotopic liver transplantation, which rapidly normalized after reperfusion. In contrast, tissue-type plasminogen activator activity levels remained normal in heterotopic liver transplantation and partial hepatic resections. In orthotopic liver transplantation and in heterotopic liver transplantation no increase occurred in tissue-type plasminogen activator activity after reperfusion. The first venous hepatic outflow after reperfusion did not contain elevated tissue-type plasminogen activator activity levels. Plasma degradation products of fibrin and fibrinogen increased during the anhepatic period of orthotopic liver transplantation (from 2.60 to 8.80 micrograms/ml [p less than 0.008] and from 0.40 to 1.60 micrograms/ml [p less than 0.04], respectively) and remained elevated thereafter. In heterotopic liver transplantation and partial hepatic resections these levels remained low. In conclusion, the lack of hepatic clearance during the anhepatic period is probably the most important factor in the evolution of increased tissue-type plasminogen activator activity during orthotopic liver transplantation.

Mild haemostatic problems associated with congenital heterozygous alpha 2-antiplasmin deficiency

A Dutch family, of which 13 members are heterozygotes, deficient for alpha 2-antiplasmin (alpha 2-AP) is reported. Clinical studies showed that 2 heterozygotes had a mild bleeding tendency, which presented as bleeding episodes after tooth extraction and after surgery and, in one patient, also as excessive menstruation. Laboratory investigations revealed an alpha 2-AP activity of 62% (51-71) (median and range) and an antigen level of 60% (60-66). The plasminogen binding as well as the fibrin binding properties of alpha 2-AP were normal. Plasminogen concentrations were significantly higher in the heterozygotes compared to the other family members. However, free plasminogen not bound to histidine-rich glycoprotein was not significantly different between these two groups. We propose that in this family the deficiency of alpha 2-AP is due to a decreased synthesis of a normal alpha 2-AP molecule. This present study brings the frequency of heterozygous alpha 2-AP deficient patients with a bleeding tendency to 13 out of 59 heterozygotes reported in the literature.

Our experience with acetylsalicylic acid hypersensitivity

Results of a study carried out in 21 patients with acetylsalicylic acid (Aspirin), hypersensitivity, 17 females and 4 males, aged 16 to 69 years (mean 45.7) are presented. Some patients suffered from several types of allergic symptoms - 11 from Asthma, 3 Rhinitis, 3 Quinke edema, 5 Urticaria and 2 Anaphylactic Shock. Concomitant drug allergies, route of administration and composition of the ingested drug, familiar complaints of drug allergy, nasopharyngeal examination and lung function by spirometry and Acetylcholine tests were evaluated. Blood, sputum and nasal mucous eosinophil count, as well as secretory IgA and its secretory piece identification in saliva and nasal mucous, serotonin and histaminopexic power of serum and immunoelectrophoresis of serum proteins were performed in all patients. Human basophil degranulation test to Aspirin were evaluated in 12 patients. Skin prick tests with one standard range of 21 common allergens were done in all patients and intradermal skin tests with 1 lysine acetyl-salicylate (1/100 and 1/1000) were performed in all patients as well as in a selected control group of 12 healthy subjects.