The effect of Yakson and Gentle Human Touch methods on pain and physiological parameters in preterm infants during heel lancing

BACKGROUND

Various non-pharmacologic methods are used to alleviate pain in preterm infants who spend their first days in neonatal intensive care units (NICU) because they are exposed to numerous painful interventions.

OBJECTIVE

To determine the effects of Yakson and Gentle Human Touch (GHT) methods on pain and physiologic parameters during heel lancing procedures in preterm infants.

DESIGN AND METHODS

This was a randomised controlled trial. The study was conducted in a NICU between June 2018 and June 2019. A total of 90 preterm infants were divided into three groups: 30 infants in the Yakson group, 30 infants in the GHT group, and 30 infants in the control group. All preterm infants were randomly divided into groups. Pain responses were evaluated using the Neonatal Infant Pain Scale.

RESULTS

It was found that pain scores and heart rates were significantly lower during and after heel lancing in preterm infants in the Yakson and GHT groups than in the control group, the difference was statistically significant (p < .001).

PRACTICAL IMPLICATIONS

Yakson and GHT applied to preterm infants during heel lancing has positive effects on pain and physiologic parameters.

The effectiveness of serum amyloid A for prediction of neonatal cholestasis associated with parenteral nutrition in premature infants

Özkan H, Köksal N, Doğan P, Güney-Varal İ, Bağcı O, Özgür T. The effectiveness of serum amyloid A for prediction of neonatal cholestasis associated with parenteral nutrition in premature infants. Turk J Pediatr 2019; 61: 26-33. Parenteral nutrition (PN) has been widely used in premature infants untill enteral feeding can be tolerated. Cholestasis is an important complication of PN. The objective of this study was to evaluate the role of serial measurements of serum amyloid A (SAA) during PN and compare its` effectiveness with C-reactive protein (CRP) and procalcitonin (PCT). We also aimed to determine the risk factors for PN associated cholestasis (PNAC). Premature infants ( < 34 weeks` gestational age) who were started on PN during hospitalization were included in this prospective study. SAA, CRP and PCT levels were measured on days 0, 3, 7, 14, and 21 of PN in all infants. Infants who had PN for less than 2 weeks, who developed sepsis and/or necrotizing enterocolitis were excluded. A total of 85 infants were included. The mean birth weight was 1226±329 g, and the mean gestational age was 29.4±1.8 weeks. The birth weight of infants who developed cholestasis were significantly lower. Enteral nutrition was started significantly later in infants with cholestasis. CRP and PCT did not correlate with conjugated bilirubin levels at any time point. SAA levels on days 7 and 14 showed a significant correlation with conjugated bilirubin levels. SAA levels on day 7 was found to have the highest sensitivity for prediction of PNAC. Low birth weight, late commencement of enteral feeding, and prolonged PN were the main risk factors for PNAC development. This is the first study that shows the predictive value of SAA for PNAC development. We suggest that SAA may be used as an accurate and useful biomarker for prediction of PNAC in high risk premature infants receiving PN.

The effect of early administration of combined multi-strain and multi-species probiotics on gastrointestinal morbidities and mortality in preterm infants: A randomized controlled trial in a tertiary care unit

Güney-Varal İ, Köksal N, Özkan H, Bağcı O, Doğan P. The effect of early administration of combined multi-strain and multi-species probiotics on gastrointestinal morbidities and mortality in preterm infants: A randomized controlled trial in a tertiary care unit. Turk J Pediatr 2017; 59: 13-19. Necrotizing enterocolitis (NEC) is a gastrointestinal emergency of the neonatal period. The aim of this study was to demonstrate the use of multistrain and multispecies probiotic on gastrointestinal morbidities and mortality. The study was organized as a randomized controlled, prospective study in premature infants (≤32 week and ≤1500 gram). The ready commercial preparations which contain multi-combined probiotics of Lactobacillus rhamnosus (4.1x10⁸ cfu) + Lactobacillus casei (8.2x10⁸ cfu) + Lactobacillus plantorum (4.1x10⁸ cfu) + Bifidobacterium animalis (4.1x10⁸ cfu) together with 383 mg of fructooligosaccharides and 100 mg of galactooligosaccharides as the prebiotic content, was administered enterally to the probiotic group (n=70); control group constituted of 40 preterms. Primary outcomes of the present study were ≥ Stage 2 NEC and the mortality. Secondary outcomes were culture-proven sepsis and days to reach full enteral feeding. All cases of NEC were seen in group 2 as 3.6% (n=4) of all infants. The mortality was found to be 1.4% (n=1) in Group 1 and 22.5% (n=9) in Group 2. The incidence of NEC and the mortality rate were found to be significantly lower in Group 1 (p=0.016, p=0.001, respectively). In Group 1, the NEC-related mortality rate and sepsis-related mortality rate were significantly lower than that of the control group (p=0.046, p=0.023). In this study, we showed that using probiotic strains in combined multistrain and multispecies forms at higher doses and for prolonged duration had positive effects on gastrointestinal complications, sepsis and mortality in premature infants.

Short-term graft patency of sequential and Y-graft in open heart surgery with transit time flow measurement

AIM

In this prospective study, we aimed to compare flow characteristics and the short term patency of sequential and y-grafts by intraoperative transit time flow measurement.

METHODS

Sixty patients were selected from 1374 isolated coronary bypass operations. Group 1 (N.=36) consisted of sequential grafted, Group 2 (N.=24) consisted of y-grafted patients. Intraoperative graft flow measurement was done with a transit time flow meter at stable hemodynamic conditions. We follow up the groups at the 30th day of the operation.

RESULTS

The mean flows at measurement set up were 43.2±19.7 mL/min in Group 1 and 43.6±21.7 mL/min in Group 2. After distal graft clamp removal the same values were 63.4±20.9 mL/min in Group 1 and 67.3±35.3 ml/mins in Group 2. At the 30th day of the operation no patients died, and none of them had an acute myocardial infarction.

CONCLUSION

The percent of flow increase in sequential graft group was higher but the difference of the percent of flow increase between groups was not statistically significant.

Very Low Birth Weight Infant Necessitating Nissen Fundoplication for Weaning off the Mechanical Ventilator

Gastro-esophageal reflux (GER) is one of the common problems of neonatal intensive care units. Although this condition does not always need to be treated, it occasionally causes clinically serious consequences. Initial management is medical; however, in some cases surgery might be required. A premature neonate with birth weight of 1370 grams was managed in our ICU. The patient was mechanical ventilator dependent due to GER. The patient needed Nissen fundoplication for successfully weaning off the ventilator.

Diagnostic implications of telomerase activity in pleural effusions

The aim of the present study was to investigate the diagnostic efficacy of telomerase activity for discrimination of malignant and benign pleural effusions. Pleural effusions were collected from 109 consecutive patients in whom the diagnosis was confirmed with cytological and/or histological examinations. Cytological samples were classified as malignant (n=63) and benign (n=46). Telomerase activity was determined with the polymerase chain reaction-based telomeric repeat amplification protocol assay. Telomerase activity was detected in 52 (82.5%) and nine (19.6%) samples from the malignant and benign groups, respectively, which was a significant difference. The sensitivity rate of cytological examination when combined with telomerase activity (92.1%) was significantly greater than that of cytological examination alone (53.9%). The sensitivity and specificity of telomerase activity were 82.5 and 80.4%, respectively. Diagnostic accuracy of telomerase activity was 81.6%. Telomerase activity is a highly sensitive diagnostic biomarker for malignancy and may be used as an adjunct to cytological findings in determining malignant pleural effusions.

Oxidative stress in hemodialyzed patients and the long-term effects of dialyzer reuse practice

OBJECTIVES

To investigate the existence of an altered oxidant/ antioxidant balance in patients on regular hemodialysis treatment (RHT) and whether there is any effect of dialyzer reuse on oxidative damage and antioxidative mechanism.

DESIGN AND METHODS

Malondialdehyde (MDA) levels and glutathione peroxidase (GPx) activities in both plasma and erythrocytes, plasma selenium (Se) levels, and erythrocyte superoxide dismutase (SOD) activities of RHT patients were determined at the beginning and end of 4-month reuse period.

RESULTS

When compared to healthy controls, both plasma and erythrocyte MDA levels were found to be significantly higher in RHT patients before the dialyzer reuse practice; whereas both plasma and erythrocyte GPx activities, erythrocyte SOD activity, and also plasma Se levels were lower in the same patient group than those of controls. When statistical comparison was made on RHT patients between before and after the reuse period, the decreases in MDA levels but increases in the enzyme activities and also an increase in plasma Se levels were observed after the reuse period. However, erythrocyte SOD activities and plasma Se levels measured after the reuse period were not found to be statistically different from the control values; MDA levels still remained elevated above the control values, and GPx activities were not attained to those of controls, after the reuse practice. In addition, positive correlations were found between activities of erythrocyte SOD and GPx enzymes, between GPx and Se levels and negative correlations between the activities of both enzymes and MDA levels in erythrocytes of patients on RHT.

CONCLUSION

These findings may indicate that dialyzer reuse may provide, at least partly, an improvement on oxidative stress in patients on RHT.

In vitro antioxidant effect of Ginkgo biloba extract (EGb 761) on lipoperoxidation induced by hydrogen peroxide in erythrocytes of Behçet's patients

Excessive superoxide radical production and an impaired antioxidant mechanism in both the neutrophils and plasma of patients with Behçet's disease (BD) have been reported. To provide clinical support for the earlier data, erythrocyte membrane integrity was investigated by measuring malondialdehyde (MDA, a marker of lipid peroxidation) levels in the erythrocytes of BD patients. In addition, the antioxidant effect of Ginkgo biloba extract (EGb 761) at 25 and 250 microg/ml concentrations on lipoperoxidation induced by hydrogen peroxide (H2O2) in erythrocyte obtained from BD patients was examined in in vitro conditions. When compared to healthy controls, basal erythrocyte MDA levels were found to be higher in BD patients. In the in vitro study, there was also a significant increase in H2O2-induced MDA production in the medium containing no EGb 761 in the patient group, whereas significant decreases in MDA levels were observed in the mediums containing EGb 761 both in the patient and control groups. The decrease in MDA production was found to be related to EGb 761 concentration. These data indicate that an oxidative damage is present in erythrocytes obtained from Behçet's patients, and EGb 761, which may strengthen the antioxidant defense system, may contribute to the treatment of BD.

A model of hypoxia-induced necrotizing enterocolitis: the role of distension

BACKGROUND/PURPOSE

This study was performed to investigate additional effects of intestinal distension in the damage to the gut caused by hypoxia-reperfusion.

METHODS

Five groups each consisting of ten 1-day-old Wistar albino rat pups were studied; Group 1, hypoxia-reoxygenation; Group 2, hypoxia-reoxygenation and distension; Group 3, distension and hypoxia-reoxygenation; Group 4, distension; and Group 5, control. Hypoxia was induced by placing the rat pups in a 100% carbon dioxide chamber for 5 minutes. After the hypoxia, the pups were exposed to 100% oxygen for reoxygenation for 5 minutes. The intestinal distension was carried out with a fine 21-gauge SILASTIC cannula via rectal route. The rats were killed on the third day, and all the intestine were harvested from duodenum to sigmoid colon. Malondialdehyde (MDA) levels were determined as an index of lipid peroxidation related to free radical reaction in the intestine. The histopathologic investigation was carried out by light microscopy in a blinded fashion.

RESULTS

The MDA levels of Group 3 animals were significantly higher than those in Group 1, 4, and the control group (P < .05). The MDA level of Group 2 did not differ significantly from that of the Group 3 (P > .05). All MDA levels of the study groups also were significantly higher than the control group (P < .05).

CONCLUSION

The results demonstrated that intestinal distension increased the damaging effects of hypoxia-reoxygenation in the gut.

The effect of vitamin E on ipsilateral and contralateral testis following unilateral testicular torsion in rats

An experimental study was conducted to investigate the role of lipid peroxidation in ipsilateral and contralateral testicular reperfusion injury following unilateral testicular torsion (TT) and the effect of vitamin E in the management of this injury. Fifty adult male Sprague-Dawley rats were divided into five equal groups. Bilateral orchiectomy was performed immediately in group 1, and 3 h after unilateral TT in group 2. In group 3, both testes were harvested 3 h after a sham operation. In groups 4 and 5, unilateral TT, detorsion after 3 h and bilateral orchiectomy after 6 h were performed. Vitamin E was given before detorsion in group 4 and after detorsion in group 5. The levels of malondialdehyde (MDA) were measured as an index of lipid peroxidation in all testes. There were no significant differences between right and left testes within groups or between right or left testicular MDA values in different groups. The results suggest that lipid peroxidation does not play an important role in ipsilateral and contralateral testicular injury following unilateral TT and that vitamin E given before or after detorsion of testes is not useful in preventing testicular reperfusion injury.

The effects of dialyzer reuse on plasma antioxidative mechanisms in patients on regular hemodialysis treatment

The effects of antioxidative mechanism are known to be reduced in patients on regular hemodialysis treatment (RHT). The data about the effects of reuse on antioxidative mechanisms are limited. Twelve patients on RHT (age range: 16-50 years) were included in the study. The basal and after 4 months of dialyzer reuse period, plasma antioxidant activity (AOA), myeloperoxidase (MPO) activity, ceruloplasmin (Cp), copper (Cu), transferrin (TF), and sulphydryl group (SH) levels were detected. The basal plasma AOA (110.92 +/- 17.19 microliters), TF (1.23 +/- 0.23 g/l), and SH (307.11 +/- 51.81 mumol/l) levels were lower than the levels of the control subjects (73.75 +/- 9.07 microliters, 2.38 +/- 0.25 g/l, 690.59 +/- 84.18 mumol/l) (p < .001). The basal Cp (0.47 +/- 0.08 g/l) and MPO activity (86.31 +/- 9.57 U/l) levels were higher than the levels of the control subjects (0.34 +/- 0.07 g/l and 65.90 +/- 7.28 U/l) (p < .001). The basal Cu levels (1.19 +/- 0.24 mg/l) were similar to the levels of the control subjects (1.11 +/- 0.13 mg/l) (p > .05). The difference between plasma AOA (83.33 +/- 14.71 microliters), Cp (0.38 +/- 0.08 g/l), and MPO activity (64.43 +/- 10.01 U/l) after the reuse period and the control values were not statistically significant (p > .05). The TF (1.87 +/- 0.15 g/l) levels after the reuse period were significantly lower than the control values (p < .001), although the levels were increased after the reuse period. Our findings may indicate some beneficial effects of hemodialyzer reuse process on plasma antioxidative mechanisms in patients on RHT.

Plasma selenium levels in rheumatoid arthritis

The plasma selenium (Se) levels were determined in patients with rheumatoid arthritis (RA) and healthy controls. Plasma Se levels in 60 patients were found to be significantly lower than those in 60 normal, healthy controls (p < 0.001). Similar significant differences were determined in sex-matched comparisons between patients and controls (p < 0.001) but there was no significant difference in plasma Se levels in sex-matched comparisons in both groups (p > 0.05). Our results suggest that Se is an important factor in RA.

Changes in platelet monoamine oxidase and plasma dopamine-beta-hydroxylase activities in lithium-treated bipolar patients

The activity of monoamine oxidase (MAO) and dopamine-beta-hydroxylase (DBH), enzymes involved in monoamine metabolism, were studied in 29 bipolar patients (mean age = 33.12 years, SD = 7.27) who were treated with lithium carbonate and in 20 healthy volunteers (mean age = 30.05 years, SD = 6.04). Platelet MAO activity was higher after lithium withdrawal, whereas plasma DBH activity was lower in remitted euthymic bipolar patients compared with normal volunteers. During lithium treatment, platelet MAO activity decreased and plasma DBH activity increased compared with the lithium-withdrawal values. It was also observed that the activities of these enzymes in the bipolar patients during lithium treatment did not differ from those in the volunteers. Thus, platelet MAO and plasma DBH activities differed in unmedicated patients with bipolar affective disorder from those of healthy subjects. Treatment with lithium appeared to have a normalizing effect on MAO and DBH activity levels.

Oxidative stress and antioxidant defenses in plasma of patients with Behçet's disease

Plasma myeloperoxidase (MPO) and glutathione peroxidase (GSH-Px) activities, and malondialdehyde (MDA), ceruloplasmin (Cp), transferrin (TF), thiol (SH), selenium (Se) and copper (Cu) levels were determined in patients with Behçet's disease (BD), in order to investigate whether the plasma antioxidant defense system is impaired in BD. When compared to controls, plasma MDA, Cp, Cu levels and also plasma MPO activity were significantly higher in patients, whereas plasma TF, SH and Se levels, and also plasma GSH-Px activity were lower in BD patients than those in controls. In addition, there were significant and positive correlations between MDA-Cp, MDA-Cu, MDA-MPO, MPO-Cp, GSH-Px-Se, Cp-Cu, and TF-SH parameters, but negative correlations between MPO-TF and Cp-TF parameters in BD patients. Based on these findings, it is concluded that plasma antioxidant defense system is insufficient and impaired in BD.

Lipoperoxidation induced by hydrogen peroxide in human erythrocyte membranes. 2. Comparison of the antioxidant effect of Ginkgo biloba extract (EGb 761) with those of water-soluble and lipid-soluble antioxidants

An in vitro model using healthy human erythrocyte suspensions was used to compare the antioxidant effect of standardized Ginkgo biloba extract (EGb 761) with those of water-soluble (ascorbic acid, glutathione and uric acid) and lipid-soluble (alpha-tocopherol and retinol acetate) antioxidants. Lipid peroxidation was induced by hydrogen peroxide in the absence (control) and presence of antioxidants at low (25 micrograms/ml) and high (250 micrograms/ml) concentrations. Malondialdehyde production was determined as the indicator of lipid peroxidation during the incubation period. The results suggest that all of the antioxidants, except ascorbic acid, have antioxidant potential in this system in a concentration-dependent manner. When the antioxidants were compared, EGb 761 was found to be more effective than water-soluble antioxidants, and as effective as lipid-soluble antioxidants. Among the lipid-soluble antioxidants there was no significant difference in potency between alpha-tocopherol and retinol acetate, but uric acid was the most potent of the water-soluble antioxidants. The antioxidant potency of EGb 761 appears to be comparable with that of the well-known antioxidants alpha-tocopherol and retinol acetate.

Lipoperoxidation induced by hydrogen peroxide in human erythrocyte membranes. 1. Protective effect of Ginkgo biloba extract (EGb 761)

The antioxidant potential of Ginkgo biloba extract (EGb 761) on healthy human erythrocyte membranes was investigated. Lipoperoxidation was induced in erythrocyte suspensions using hydrogen peroxide, in the presence of EGb 761 at 37 degrees C; malondialdehyde production was determined as the indicator of lipoperoxidation during the incubation period. The results for EGb 761 at concentrations of 0, 25, 50, 125, 250 and 500 micrograms/ml suggest that the antioxidant potential of EGb 761 in erythrocyte membranes increases with dose. Similarly, using different incubation periods (0, 15, 30, 45 or 60 min) indicated that the antioxidant effect of EGb 761 increased by the incubation time.

Oxidative enzymes of polymorphonuclear leucocytes and plasma fibrinogen, ceruloplasmin, and copper levels in Behçet's disease

This study was performed to investigate the antioxidant mechanisms of polymorphonuclear leucocytes (PMN) in active stage of Behçet's Disease. PMN activities of myeloperoxidase (p < 0.02), superoxide dismutase (p < 0.001), catalase (p < 0.005), and glutathione peroxidase (p < 0.005) were significantly lower in the patients: the NADPH oxidase activity was significantly higher (p < 0.001) than those in controls. The plasma levels of ceruloplasmin (Cp), fibrinogen, and copper (Cu) were also significantly higher in the patients group (p < 0.001). Significant and positive correlations were found between the glutathione peroxidase and catalase activities (p < 0.001) and also between the plasma Cp and Cu levels (p < 0.001) in the patients group. However, no correlation was observed among the other enzyme activities. In the control group, a significantly positive correlation was present only between the plasma ceruloplasmin and Cu levels (p < 0.001). It was concluded that (impaired PMN functions) decreased enzyme activities in the antioxidant system and increased levels of oxygen free radicals may play a role in tissue damage in Behçet's disease.

The effect of contraceptive steroids on plasma lipoprotein metabolism in female rats (II)

In order to investigate the effects of two contraceptive steroids given orally, which contain ethinyl estradiol in combination with different types and doses of progestins, on plasma lipoprotein metabolism, rat groups named according to progestin components were designated as short-and long-term groups of norethisterone acetate and levonorgestrel at low-and high-doses. At the end of the experiments, plasma triglyceride, phospholipid, apolipoprotein A1 and B, LDL-, HDL-, HDL2- and HDL3-cholesterol levels and hepatic lipase activity were measured. When compared to controls, phospholipid and LDL-cholesterol were increased in all groups; triglyceride levels were also increased in all short-term groups, but only in low-dose norethisterone and high-dose levonorgestrel of long-term groups. HDL- and HDL3- cholesterol were decreased in all groups, except in low-dose levonorgestrel groups, but HDL2-cholesterol were lower only at high doses and long period. In short-term, an increase in apolipoprotein A1 levels was significantly important at high doses; in long-term apolipoprotein A1 was increased at low doses, while decreased at high doses. Apolipoprotein B was elevated only in long-term high dose of norethisterone acetate group. Hepatic lipase activity was increased in long-term high-dose of levonorgestrel group, whereas decreased in all other groups. In conclusion, the data presented was interpreted that the effects of these combinations used in the study on plasma lipoprotein metabolism may be related to the changes observed in hepatic lipase activity.

The effect of contraceptive steroids on hepatic cholesterol metabolism in female rats (I)

In order to determine effects of contraceptive steroids with respect to dose, progestin type and duration of administration, on hepatic cholesterol metabolism, rats were treated with two different (ethinyl estradiol/norethisterone acetate and ethinyl estradiol/levonorgestrel) combinations orally at two different-low and high-doses and- short and long-terms. At the end of the experiments, total cholesterol and acetoacetate levels in plasma samples and HMG-CoA synthase and AcAc-CoA thiolase activities in the livers of rats were measured. In all groups, acetoacetate was found to be higher than in controls, and except in low dose- ethinyl estradiol/levonorgestrel treated groups, total cholesterol was also increased. In the short period treatments HMG-CoA synthase and AcAc-CoA thiolase (except in low dose-ethinyl estradiol/levonorgestrel group) activities were increased. But enzyme activities were either decreased or not changed in long period treatments. It is suggested that increased enzyme activities in short period treatments may increase total cholesterol levels, and that in time, these levels may lead to a suppression of enzyme activities.

Contraceptive steroids increase erythrocyte lipid peroxidation in female rats

In order to investigate the effects of contraceptive steroid combinations on lipid peroxidation in the erythrocyte membranes, adult female rats were divided into 2 groups for short- and long-term investigations; each group was then subdivided into 5 subgroups according to orally given low and high doses of EE/NEA (ethinyl estradiol/norethisterone acetate) and EE/LNG (ethinyl estradiol/levonorgestrel) combinations and control group. Since EE was included in each combination, the groups were named according to the progestin (NEA, LNG) components. At the end of the experiment periods, lipid peroxidation in the erythrocyte membranes from rats was measured. When compared to the controls, except low-dose LNG groups, lipid peroxidation levels were increased in all study groups. It was seen that the effect of NEA and LNG combinations on lipid peroxidation was not time-, but dose-dependent. When these combinations were compared to each other, different effects of NEA and LNG on lipid peroxidation were not detected in the experiment period. As a result, the increased lipid peroxidation following the administration of contraceptive steroid combinations is a very important finding that should be taken into account, in addition to the effects of these steroids on lipid and lipoprotein metabolism.

The effects of immobilization stress on electrodermal activity and brain catecholamine levels in rats

The effects of immobilization stress on electrodermal activity (EDA); skin conductance response magnitude and rate, skin conductance level and habituation number, and brain catecholamine levels; norepinephrine (NE) and dopamine (DA) were investigated in rats. Electrodermal activity was recorded using constant current method. Brain catecholamine levels were determined by a spectrophotophlorometric method. Electrodermal activity parameters (except skin conductance level) increased during immobilization. It was observed that, during immobilization stress, the alteration of norepinephrine and dopamine levels in rat brain was related to cerebral region and the duration of immobilization stress. It was concluded that these electrodermal activity alterations can be attributed to the changes in central norepinephrine metabolism induced by immobilization.

Superoxide dismutase and myeloperoxidase activity in polymorphonuclear leukocytes, and serum ceruloplasmin and copper levels, in psoriasis

The levels of superoxide dismutase (SOD) and myeloperoxidase (MPO) in polymorphonuclear leukocytes (PMN), and serum ceruloplasmin activity and copper content, were measured in 60 patients with psoriasis and 33 healthy controls. There were no significant differences in the activity of MPO between the patients and the controls. However, SOD activity in PMN was significantly lower in the patients than in the controls. Serum ceruloplasmin activity and copper levels were significantly higher in the psoriatics than in the controls.