Design and Development of a Web-Based Prospective Nationwide Registry for Ocular Inflammatory Diseases: UVEITE.PT - The Portuguese Ocular Inflammation Registry

Uveitis is a heterogeneous collection of infrequent diseases, which poses significant challenges to cost-effective research in the field. Medical registries are being increasingly recognized as crucial tools to provide high-quality data, thus enabling prospective clinical research. This paper describes the design and technical structure development of an innovative countrywide electronic medical record for uveitis, Uveite.pt, and gives an overview of the cohort registered since its foundation, March 2020.Uveite.pt is an electronic medical record platform developed by the Portuguese Ocular Inflammation Group (POIG), a scientific committee of the Portuguese Ophthalmology Society. This is a nationwide customized web-based platform for uveitis patients useful for both clinical practice and real-world-based research, working as a central repository and reporting tool for uveitis. This paper describes the technical principles, the design and the development of a web-based interoperable registry for uveitis in Portugal and provides an overview of more than 400 patients registered in the first 18 months since inception.In infrequent diseases, the existence of registries enables to gather evidence and increase research possibilities to clinicians. The adoption of this platform enables standardization and improvement of clinical practice in uveitis. It is useful to apprehend the repercussion of medical and surgical treatments in uveitis and scleritis, supporting clinicians in the strict monitoring of drug adverse reactions and surgical outcomes.

Combination Therapy With CD147-Targeted Nanoparticles Carrying Phenformin Decreases Lung Cancer Growth

Lung cancer is one of the most fatal cancers worldwide. Resistance to conventional therapies remains a hindrance to patient treatment. Therefore, the development of more effective anti-cancer therapeutic strategies is imperative. Solid tumors exhibit a hyperglycolytic phenotype, leading to enhanced lactate production; and, consequently, its extrusion to the tumor microenvironment. Previous data reveals that inhibition of CD147, the chaperone of lactate transporters (MCTs), decreases lactate export in lung cancer cells and sensitizes them to phenformin, leading to a drastic decrease in cell growth. In this study, the development of anti-CD147 targeted liposomes (LUVs) carrying phenformin is envisioned, and their efficacy is evaluated to eliminate lung cancer cells. Herein, the therapeutic effect of free phenformin and anti-CD147 antibody, as well as the efficacy of anti-CD147 LUVs carrying phenformin on A549, H292, and PC-9 cell growth, metabolism, and invasion, are evaluated. Data reveals that phenformin decreases 2D and 3D-cancer cell growth and that the anti-CD147 antibody reduces cell invasion. Importantly, anti-CD147 LUVs carrying phenformin are internalized by cancer cells and impaired lung cancer cell growth in vitro and in vivo. Overall, these results provide evidence for the effectiveness of anti-CD147 LUVs carrying phenformin in compromising lung cancer cell aggressiveness.

Aquatic wild meat consumption of cetaceans in São Tomé and Príncipe (Gulf of Guinea)

Relatively little is known about cetaceans in São Tomé and Príncipe and in recent years, some episodes of cetacean bycatch and human consumption have been described. Aiming to provide insight into the reliance upon cetaceans as a source of meat, we present findings from complementary studies conducted in the islands of São Tomé and Príncipe from 2012 to 2021. Based on interviews with local residents, we assessed the prevalence of human consumption of cetaceans and identified potential sociodemographic drivers. This study provides the first comprehensive assessment of harvest (direct remove or incidental take) and consumption of cetaceans (mainly the family Delphinidae) in the country. These findings will be useful in the development of regional conservation measures and contribute to our understanding of anthropogenic activities affecting cetacean populations in the Gulf of Guinea.

The 2021 Portuguese Society of Ophthalmology joint guidelines with Paediatric Rheumatology on the screening, monitoring and medical treatment of juvenile idiopathic arthritis-associated uveitis

AIM

To develop the first Ophthalmology joint guidelines with Paediatric Rheumatology with recommendations on the screening, monitoring and medical treatment of juvenile idiopathic arthritis-associated uveitis (JIA-U), endorsed by the Portuguese Society of Ophthalmology (SPO).

METHODS

A systematic literature review was conducted to include publications up to July 14th 2020, with no language restrictions, in order to include all the international position papers/guidelines concerning the medical management of JIA-U and randomised clinical trials assessing the efficacy and safety of medical treatment in this field. We searched through MEDLINE (PubMed), Scopus, Web of Science and Cochrane Library. The Delphi modified technique to generate consensus was used. Preliminary evidence statements were subject to an anonymous agreement assessment and discussion process using an online survey, followed by further discussion and update at a national meeting. A draft of the manuscript with all recommendations was then circulated among all participants and suggestions were incorporated. The final version was again circulated before publication.

RESULTS

Twenty-six recommendations were developed focusing on the following topics: general management (3), screening and follow-up of uveitis (4), treatment (17) and health education in JIA-U among patients and families (2).

CONCLUSION

These guidelines were designed to support the shared medical management of patients with JIA-U and emphasize the need for a multidisciplinary approach between Ophthalmology and Paediatric Rheumatology regarding the comprehensive care of JIA-U. We acknowledge that updating these recommendations will be warranted in the future, as more evidence becomes available.

KEY-WORDS

juvenile idiopathic arthritis, uveitis, biological treatment, conventional immunosuppressive treatment, multidisciplinary management, guidelines, consensus, review, Delphi Technique.

Fishroesomes as carriers with antioxidant and anti-inflammatory bioactivities

The great diversity of marine habitats and organisms renders them a high-value source to find/develop novel drugs and formulations. Therefore, herein, sardine (Sardina pilchardus) roe was used as a lipidic source to produce liposomes. This fish product presents high nutritional value, being its lipidic content associated with important health benefits. Consequently, it can be advantageously used to produce therapeutically active delivery devices. Roe lipids were extracted using the Matyash method. After lipid film hydration and extrusion, sardine roe-derived large unilamellar liposomes (LUVs), designated as fishroesomes, presented a size of ≈330 nm and a significant negative surface charge (≈-27 mV). Radical scavenging assays demonstrated that fishroesomes efficiently neutralized peroxyl, hydroxyl and nitric oxide radicals. Moreover, fishroesomes significantly reduced the expression of pro-inflammatory cytokines and chemokines by LPS-stimulated macrophages at non-toxic concentrations for L929 and THP-1 cells. Consequently, the developed liposomes exhibit unique properties as bioactive drug carriers for inflammatory diseases treatment.

Radiotherapy as Salvage Treatment in Intraocular Lymphoma: A Case Report

A 67-year-old previously healthy woman presented with progressive visual impairment including bitemporal hemianopsia. A brain magnetic resonance imaging revealed a contrast-enhancing mass in the optic chiasm, spreading along the left optic tract. The patient underwent a transcranial biopsy of the left optical tract that yielded a diagnosis of diffuse large B-cell lymphoma. CT scans of the chest, abdomen, and pelvis, PET-CT, and bone marrow biopsy revealed no evidence of systemic lymphoma. Thus, the final diagnosis was of primary central nervous system lymphoma of the optic chiasm. Systemic treatment was initiated with full response. Six months after the end of the treatment, recurrence at cerebellum parenchyma and left tentorium was recorded. A new systemic treatment achieved full response. A second recurrence was noted in an optical coherence tomography of the right eye, 2 years after the initial diagnosis. The patient was treated with intravitreal methotrexate with initial success, but eventual failure after 10 months. Intravitreal rituximab was used with no effect. The patient was then referred to radiotherapy and underwent external beam radiotherapy with VMAT. There were no acute toxicities to report. After the radiotherapy treatment, at 1-year follow-up, the patient has no evidence of disease. Long-term toxicities were recorded and are considered manageable. The present case emphasizes the role of ocular irradiation as an option in the management of intraocular lymphoma patients, including in the salvage setting, with an acceptable ocular toxicity profile.

Morphological and mechanical characterization of 3D printed PLA scaffolds with controlled porosity for trabecular bone tissue replacement

Bone transplant is still the gold standard approach when dealing with orthopedic trauma or disease. When this solution is not possible, scaffolding is a possibility provided by bone tissue engineering. To support the regeneration process, damaged bone tissue is removed and replaced by porous scaffold structures. In recent years, additive manufacturing has shown huge potential to produce scaffold structures with the required performance. In the current work, PLA scaffolds with different designs were 3D printed, using optimal manufacturing parameters. Scaffolds with three different porosity values were obtained by changing the filament offset from 571 to 1333 μm. A total of twelve designs were tested under monotonic and dynamic compression conditions. Numerical analysis showed good correlation with experimental results, allowing for a better assessment of scaffold mechanical behavior. Stress relaxation was measured on four different strain levels, assessing scaffold's behavior after implantation and consequent static response over time. Overall, orthogonal design provided better performance, due to improved material deposition. With lower porosity scaffolds equilibrium stress reached 24 MPa after 300 s relaxation time under 4% deformation, and the obtained equilibrium modulus was 428 MPa. Overall, attained results show that 3D printing with PLA can be applied in the manufacture of scaffolds for trabecular bone replacement.

Prevalence of enteroparasitic infections and related hormonal and immunological repercussions that may compromise students' physical performance

The aim of this study was to evaluate the prevalence of enteroparasitic infections in students and their hormonal and immunological repercussions on physical development. Students of basic education of both sexes were evaluated. Parasitological stool tests were performed using the Hoffman and Kato-Katz methods. The students were divided into two groups: a control group (negative parasitological examination, N=25) and an infected group (positive parasitological test, N=25). Anthropometric variables (height, weight, and BMI), concentrations of hormones (melatonin and cortisol), cytokine/chemokine levels (IL-1β, IL-6, IL-8, IL-10, IL-12, IL-17 and TNF-α) and physical performance (aerobic capacity, upper- and lower-limb muscle strength and abdominal performance) were evaluated. The prevalence of parasitic infection among the students was 7.98%. No anthropometric differences were observed among the groups. IL-2 and TNF-α levels were higher and IL-8 levels were lower in serum from students who were positive for parasitic infection. Serum from students who were positive for parasitic infection showed higher levels of melatonin than that from parasitenegative students. No differences were observed in cortisol levels. Students who were positive for parasitic infection presented greater lower-limb strength and lower abdominal performance than parasite-negative students. In the parasitic infection group, IL-12 was positively correlated with melatonin. In the parasitic infection group, IL-8 showed a positive correlation with aerobic capacity, while IL-17 and TNF-α showed a positive correlation with abdominal performance. These data suggest that parasitic infections determine the profile of inflammatory cytokines and that melatonin may be involved in the control of this process to minimize tissue damage. Additionally, students' difficulty in practising physical exercises can be an indication of enteroparasitic infection.

Tet3 regulates cellular identity and DNA methylation in neural progenitor cells

TET enzymes oxidize 5-methylcytosine (5mC) into 5-hydroxymethylcytosine (5hmC), a process thought to be intermediary in an active DNA demethylation mechanism. Notably, 5hmC is highly abundant in the brain and in neuronal cells. Here, we interrogated the function of Tet3 in neural precursor cells (NPCs), using a stable and inducible knockdown system and an in vitro neural differentiation protocol. We show that Tet3 is upregulated during neural differentiation, whereas Tet1 is downregulated. Surprisingly, Tet3 knockdown led to a de-repression of pluripotency-associated genes such as Oct4, Nanog or Tcl1, with concomitant hypomethylation. Moreover, in Tet3 knockdown NPCs, we observed the appearance of OCT4-positive cells forming cellular aggregates, suggesting de-differentiation of the cells. Notably, Tet3 KD led to a genome-scale loss of DNA methylation and hypermethylation of a smaller number of CpGs that are located at neurogenesis-related genes and at imprinting control regions (ICRs) of Peg10, Zrsr1 and Mcts2 imprinted genes. Overall, our results suggest that TET3 is necessary to maintain silencing of pluripotency genes and consequently neural stem cell identity, possibly through regulation of DNA methylation levels in neural precursor cells.

Correction to: Tet3 regulates cellular identity and DNA methylation in neural progenitor cells

The article Tet3 regulates cellular identity and DNA methylation in neural progenitor cells, written by Miguel R. Branco and C. Joana Marques, was originally published electronically on the publisher's internet portal.

Phospholipid-induced silk fibroin hydrogels and their potential as cell carriers for tissue regeneration

Silk fibroin (SF) hydrogels can be obtained via self-assembly, but this process takes several days or weeks, being unfeasible to produce cell carrier hydrogels. In this work, a phospholipid, namely, 1,2-dimyristoyl-sn-glycero-3-phospho-(1'-rac-glycerol) sodium salt (DMPG), was used to induce and accelerate the gelation process of SF solutions. Due to the amphipathic nature and negative charge of DMPG, electrostatic and hydrophobic interactions between the phospholipids and SF chains will occur, inducing the structural transition of SF chains to the beta sheet and consequently a rapid gel formation is observed (less than 50 min). Moreover, the gelation time can be controlled by varying the lipid concentration. To assess the potential of the hydrogels as cell carriers, several mammalian cell lines, including L929, NIH/3T3, SaOS-2, and CaSki, were encapsulated into the hydrogel. The silk-based hydrogels supported the normal growth of fibroblasts, corroborating their cytocompatibility. Interestingly, an inhibition in the growth of cancer-derived cell lines was observed. Therefore, DMPG-induced SF hydrogels can be successfully used as a 3D platform for in situ cell encapsulation, opening promising opportunities in biomedical applications, such as in cell therapies and tissue regeneration.

Uveíte Heterocrómica de Fuchs

Doente do género masculino, 51 anos, recorreu à consulta por olho direito (OD) vermelho e doloroso. Referia alguns episódios semelhantes desde há alguns anos, sempre no mesmo olho. [...] Recebido: 24/04/2016 - Aceite: 25/05/2016

Steroid-responsive painful ophthalmoplegia: Tolosa–Hunt syndrome, Eales disease, or both?

Introduction

Tolosa–Hunt syndrome (THS) is one of the most common ‘benign’ causes of painful ophthalmoplegia. Diagnosis is based on clinical and imaging findings and the exclusion of other causes because there is no specific biomarker for the syndrome. Eales disease, an idiopathic inflammatory venous disease that primarily affects the eye, can also affect the central (as stroke or myelitis) and peripheral nervous system.

Case report

We report the case of a 32-year-old woman with a subacute left ophthalmoplegia and evidence of a gadolinium-enhanced lesion suggesting an inflammatory granuloma that resolved within 48 hours after treatment with steroids. A diagnosis of THS was considered at this time. On a follow-up ophthalmological examination, a diagnosis of Eales disease with involvement of the left eye was made. The patient was treated successfully.

Conclusion

Eales disease could be a cause of painful ophthalmoplegia and may mimic THS. Long-term follow-up of patients diagnosed with THS may be necessary to exclude other diagnoses.

2016 update of the Portuguese recommendations for the use of biological therapies in children and adolescents with Juvenile Idiopathic Arthritis

OBJECTIVE

To provide evidence-based guidance for the rational and safe prescription of biological therapies in children and adolescents with juvenile idiopathic arthritis (JIAs) considering the latest available evidence and the new licensed biologics.

METHODS

Rheumatologists and Pediatricians with expertise in Pediatric Rheumatology updated the recommendations endorsed by the Portuguese Society of Rheumatology and the Portuguese Society of Pediatrics based on published evidence and expert opinion. The level of agreement with final propositions was voted using an online survey.

RESULTS

In total, 20 recommendations to guide the use of biological therapy in children and adolescents with JIAs are issued, comprising 4 general principles and 16 specific recommendations. A consensus was achieved regarding the eligibility and response criteria, maintenance of biological therapy, and procedures in case of non-response, for each JIA category. Specific recommendations concerning safety procedures were also updated.

CONCLUSIONS

These recommendations take into account the specificities of each JIA category and are intended to continuously improve the management of JIA patients.

Effect of polyphenols on glucose and lactate transport by breast cancer cells

One of the cancer molecular hallmarks is a deviant energetic metabolism, known as the Warburg effect, whereby the rate of glucose uptake is significantly increased and a high rate of glycolysis and lactic acid production occurs even when oxygen is present-"aerobic lactatogenesis". Accordingly, GLUT1 and MCT1, which are the main glucose and lactate transporters in cancer cells, respectively, have been proposed as oncogenes and are currently seen as potential therapeutic targets in cancer treatment. Polyphenols, commonly contained in fruits and vegetables, have long been associated with a protective role against cancer. Generally considered as nontoxic, dietary polyphenols are considered ideal chemopreventive and possibly chemotherapeutic agents. Several mechanisms of action of polyphenols in breast cancer cells have been proposed including modulation of intracellular signaling, induction of apoptosis through redox regulation or modulation of epigenetic alterations. Additionally, in vitro studies have shown that several polyphenols act as specific inhibitors of glucose transport in breast cancer cell lines and an association between their anticarcinogenic effect and inhibition of glucose cellular uptake has been described. Also, some polyphenols were found to inhibit lactate transport. Importantly, some polyphenols behave as inhibitors of both glucose and lactate cellular uptake by breast cancer cells and these compounds are thus very interesting in the context of a chemopreventive effect, because they deplete breast cancer cells of their two most important energy suppliers. So, the antimetabolic effect of polyphenols should be regarded as a mechanism of action contributing to their chemopreventive/chemotherapeutic potential in relation to breast cancer.

Recommendations for Vaccination in Adult Patients with Systemic Inflammatory Rheumatic Diseases from the Portuguese Society of Rheumatology

BACKGROUND

Serious infections are a major cause of morbidity and mortality in systemic inflammatory rheumatic disease (SIRD) patients. Although vaccination may prevent numerous infections, vaccination uptake rates are low in this group of patients.

OBJECTIVES

To develop evidence-based recommendations for vaccination in SIRD patients.

METHODS

We searched MEDLINE (until 31 October 2014) and EMBASE (until 14 December 2014) databases, as well as the ACR and EULAR congress abstracts (2011-2014). Patients with any systemic inflammatory rheumatic disease were included and all vaccines were considered. Any safety and efficacy outcomes were admitted. Search results were submitted to title and abstract selection, followed by detailed review of suitable studies. Data were subsequently pooled according to the type of vaccine and the SIRD considered. Results were presented and discussed by a multidisciplinary panel and systematic literature review (SLR)-derived recommendations were voted according to the Delphi method. The level of agreement among rheumatologists was assessed using an online survey.

RESULTS

Eight general and seven vaccine-specific recommendations were formulated. Briefly, immunization status should routinely be assessed in all SIRD patients. The National Vaccination Program should be followed and some additional vaccines are recommended. To maximize the efficacy of vaccination, vaccines should preferably be administered 4 weeks before starting immunosuppression or, if possible when disease activity is controlled. Non-live vaccines are safe in SIRD, including immunosuppressed patients. The safety of live attenuated vaccines in immunosuppressed patients deserves further ascertainment, but might be considered in particular situations.

DISCUSSION

The present recommendations combine scientific evidence with the multidisciplinary expertise of our taskforce panel and attained desirable agreement among Portuguese rheumatologists. Vaccination recommendations need to be updated on a regular basis, as more scientific data regarding vaccination efficacy and safety, emergent infectious threats, new vaccines as well as new immunomodulatory therapies become available.

[X-linked agammaglobulinemia: experience in a Portuguese hospital]

INTRODUCTION

X-Linked agammaglobulinemia (XLA) is characterized by an arrest of B cell differentiation, leading to recurrent bacterial infections. Lifelong immunoglobulin replacement therapy (IRT) is indicated to prevent infections and their complications.

MATERIAL AND METHODS

A retrospective study of patients with XLA followed in a level three hospital was performed; data was collected retrospectively by review of clinical files.

RESULTS

XLA was diagnosed in 9 children. One (11%) had a positive family history with a prenatal diagnosis. Infection was the clinical presentation in all the others (89%), at an average age of 13 months; diagnosis was established at a mean age of 3.4 years. Acute otitis media (7/9) and pneumonia (5/9) were the most frequently observed. Seven (78%) presented serum immunoglobulin G (IgG) levels below 200mg/dL and all of them had CD19(+) B cells below 2%. Neutropenia was present at diagnosis in three patients (33%). Bruton tyrosine kinase (BTK) mutations were identified in all cases. Intravenous IRT was initiated, switched later to subcutaneous administration, in all. The mean time of follow-up was 10.7 years with cumulative time of 97 years. Eight children (89%) achieved IgG serum levels above 800 mg/dL. One presented lower values due to renal loss. No deaths occurred. After diagnosis the most frequent infections were acute otitis media (6/9). In spite of stable adequate IgG levels on IRT, two patients developed bronchiectasis.

CONCLUSIONS

XLA overall prognosis is good, as long as patients have an early and adequate treatment. However, bronchiectasis can occur even on adequate immunoglobulin replacement therapy.

TET enzymes and DNA hydroxymethylation in neural development and function - how critical are they?

Epigenetic modifications of the genome play important roles in controlling gene transcription thus regulating several molecular and cellular processes. A novel epigenetic modification - 5-hydroxymethylcytosine (5hmC) - has been recently described and attracted a lot of attention due to its possible involvement in the active DNA demethylation mechanism. TET enzymes are dioxygenases capable of oxidizing the methyl group of 5-methylcytosines (5mC) and thus converting 5mC into 5hmC. Although most of the work on TET enzymes and 5hmC has been carried out in embryonic stem (ES) cells, the highest levels of 5hmC occur in the brain and in neurons, pointing to a role for this epigenetic modification in the control of neuronal differentiation, neural plasticity and brain functions. Here we review the most recent advances on the role of TET enzymes and DNA hydroxymethylation in neuronal differentiation and function.

Autologous stem cell transplantation in a patient with severe systemic sclerosis

Systemic Sclerosis (SSc) is a chronic disease of the connective tissue, whose pathogenesis involves abnormalities of the immunological system. It has a variable course and there is a subgroup of patients with rapidly progressive disease or unresponsive to conventional treatment. These patients can benefit from intensive immunosuppression and autologous hematopoietic stem cell transplant.

CLINICAL CASE

19-year-old (y.o.) woman diagnosed with SSc at the age of 13 y.o. with cutaneous, vascular and articular involvement with initial response to methotrexate. Three years later the disease progressed with severe digestive involvement (dysphagia, delayed gastric emptying and weight loss) needing gastrostomy for nutritional support. She was treated with cyclophosphamide without improvement In May 2012 she had an autologous transplant with myeloablative regimen (BEAM): carmustine 300 mg/m2x1 day; etoposido 120 mg/kgx4 days; cytarabine 120 mg/kg 12/12:hx4 days; melphalan 140 mg/m2x1 day. A year and a half after transplantation she is asymptomatic, without any signs or symptoms of the disease, feeds by mouth and the gastric emptying study is normal. Currently she is free of medication.

Concurrent training with different aerobic exercises

The aim of the present study was to compare the effects of using different intensities and types of aerobic exercise (i. e., cycle ergometer or running) during concurrent training on neuromuscular adaptations. A total of 44 young women were randomly assigned to 1 of 4 groups: concurrent strength and continuous running training (SCR, n=10), concurrent strength and interval running training (SIR, n=11), concurrent strength and continuous cycle ergometer training (SCE, n=11), or strength training only (STO, n=12). Each group trained twice a week during 11 weeks. The following strength measurements were made on all subjects before and after training period: maximal strength (1RM) in knee extension, bench press and leg press exercises; local muscular endurance (number of repetitions at 70% of 1 RM) in knee extension and bench press exercises; and isometric and isokinetic peak torque of knee extension. There were significant increases in the upper and lower-body 1 RM, isometric and isokinetic peak torque in all training groups (p<0.001), with no differences between groups. The present results suggest that in young women, concurrent training performed twice a week promotes similar neuromuscular adaptations to strength training alone, regardless of the type and the intensity in which the aerobic training is performed.

[How our pediatric services work]

The results of a questionnaire sent by the College of Pediatrics of the Portuguese Doctors Association (Ordem dos Médicos) to the pediatric departments all over the country are presented. From the answers of fifty-one services, physical conditions, equipment, human resources, assistancial and scientific activities developed are characterized.

[Comparative study of the lepromin reaction performed on medical students and on a control group]

The lepromin test was studied in 64 medical students and in a control group consisted of 40 patients from the orthopedic clinic. Both groups matched with respect to age and sex, but differed with regard to socio-economical conditions. The Fernandez reaction showed low frequency of positive results in both groups: 10% in the first group and 5,6% in the second one. This difference was not significant. The Mitsuda reaction showed high frequency of positive results: 98,4% in the medical students and 85,0% in the control group. This difference was significant. The authors discuss the factors that might have caused the high positivity of the lepromin test among the medical students.

[Comparative study of the intradermal reaction performed with whole lepromin and ultrasonic-treated lepromin in normal subjects]

A comparative study on the Fernandez and on the Mitsuda reaction was made in 104 normal people employing whole and sonicated lepromin. Both types of lepromin can induce a good early reaction, and there was no significant difference in the results of the Fernandez reaction. The sonicated lepromin, though it contains all of the components of the original preparation, gives weaker late skin reactions. The results of the Mitsuda reaction were statistically significant.