Effect of continuous positive airway pressure in very elderly with moderate-to-severe obstructive sleep apnea pooled results from two multicenter randomized controlled trials

STUDY OBJECTIVE

There is very limited information about the effect of continuous positive airway pressure (CPAP) in the very elderly. Here we aimed to analysed the effect of CPAP on a clinical cohort of patients with obstructive sleep apnea (OSA) ≥80 years old.

METHODS

Post-hoc pooled analysis of two open-label, multicenter clinical trials aimed to determine the effect of CPAP in a consecutive clinical cohort of elderly (≥70 years old) with moderate-to-severe OSA (apnea-hipopnea index ≥15 events/hour) randomized to receive CPAP or no CPAP for three months. Those consecutive patients ≥80 years old were included in the study. The primary endpoint was the change in Epworth Sleepiness scale (ESS). Secondary outcomes included sleep-related symptoms, quality of life, neurocognitive and mood status as well as office blood pressure measurements.

RESULTS

From the initial 369 randomized individuals with ≥70 years, 97 (26.3%) with ≥80 years old were included (47 in the CPAP group and 50 in the no-CPAP group). The mean (SD) age was 81.5 (2.4) years. Average use of CPAP was 4.3 (2.6) hours/night (53% with good adherence) Patients in the CPAP group significantly improved snoring and witnessed apneas as well as AHI (from 41.9 to 4.9 events/hour). However no clinical improvements were seen in ESS (-1.2 points, 95%CI, 0.2 to -2.6), any domain of QSQ, any neurocognitive test, OSA-related symptoms, depression/anxiety or blood pressure levels.

CONCLUSIONS

The present study does not support the use of CPAP in very elderly patients with moderate-to-severe OSA.

Specialist palliative and end-of-life care for patients with cancer and SARS-CoV-2 infection: a European perspective

BACKGROUND

Specialist palliative care team (SPCT) involvement has been shown to improve symptom control and end-of-life care for patients with cancer, but little is known as to how these have been impacted by the COVID-19 pandemic. Here, we report SPCT involvement during the first wave of the pandemic and compare outcomes for patients with cancer who received and did not receive SPCT input from multiple European cancer centres.

METHODS

From the OnCovid repository (N = 1318), we analysed cancer patients aged ⩾18 diagnosed with COVID-19 between 26 February and 22 June 2020 who had complete specialist palliative care team data (SPCT+ referred; SPCT- not referred).

RESULTS

Of 555 eligible patients, 317 were male (57.1%), with a median age of 70 years (IQR 20). At COVID-19 diagnosis, 44.7% were on anti-cancer therapy and 53.3% had ⩾1 co-morbidity. Two hundred and six patients received SPCT input for symptom control (80.1%), psychological support (54.4%) and/or advance care planning (51%). SPCT+ patients had more 'Do not attempt cardio-pulmonary resuscitation' orders completed prior to (12.6% versus 3.7%) and during admission (50% versus 22.1%, p < 0.001), with more SPCT+ patients deemed suitable for treatment escalation (50% versus 22.1%, p < 0.001). SPCT involvement was associated with higher discharge rates from hospital for end-of-life care (9.7% versus 0%, p < 0.001). End-of-life anticipatory prescribing was higher in SPCT+ patients, with opioids (96.3% versus 47.1%) and benzodiazepines (82.9% versus 41.2%) being used frequently for symptom control.

CONCLUSION

SPCT referral facilitated symptom control, emergency care and discharge planning, as well as high rates of referral for psychological support than previously reported. Our study highlighted the critical need of SPCTs for patients with cancer during the pandemic and should inform service planning for this population.

Acute kidney injury: prevention, detection, and management. Summary of updated NICE guidance for adults receiving iodine-based contrast media

The National Institute for Health and Care Excellence (NICE) has recently updated the guideline for Acute kidney injury: prevention, detection and management (NG148), providing new recommendations on preventing acute kidney injury (AKI) in adults receiving intravenous iodine-based contrast media. The association between intravenous iodinated contrast media and AKI is controversial, particularly with widespread use of iso-osmolar agents. Associations between contrast media administration and AKI are largely based on observational studies, with inherent heterogeneity in patient populations, definitions applied, and timing of laboratory investigations. In an attempt to mitigate risk, kidney protection has typically been employed using intravenous volume expansion and/or oral acetylcysteine. Such interventions are in widespread use, despite lacking high-quality evidence of benefit. In the non-emergency setting, glomerular filtration rate (GFR) measurements should be obtained within the preceding 3 months before offering intravenous iodine-based contrast media. In the acute setting, adults should also have their risk of AKI assessed before offering intravenous iodine-based contrast media; however, this should not delay emergency imaging. Based on the evidence available from randomised controlled trials, the NICE committee recommends that oral hydration should be encouraged in adults at increased risk of AKI and that volume expansion with intravenous V fluids should only be considered for inpatients at particularly high risk.

Presenting Features and Early Mortality from SARS-CoV-2 Infection in Cancer Patients during the Initial Stage of the COVID-19 Pandemic in Europe

We describe the outcomes in cancer patients during the initial outbreak of the COVID-19 in Europe from the retrospective, multi-center observational OnCovid study. We identified 204 cancer patients from eight centers in the United Kingdom, Italy, and Spain aged > 18 (mean = 69) and diagnosed with COVID-19 between February 26th and April 1st, 2020. A total of 127 (62%) were male, 184 (91%) had a diagnosis of solid malignancy, and 103 (51%) had non-metastatic disease. A total of 161 (79%) had > 1 co-morbidity. A total of 141 (69%) patients had > 1 COVID-19 complication. A total of 36 (19%) were escalated to high-dependency or intensive care. A total of 59 (29%) died, 53 (26%) were discharged, and 92 (45%) were in-hospital survivors. Mortality was higher in patients aged > 65 (36% versus 16%), in those with > 2 co-morbidities (40% versus 18%) and developing > 1 complication from COVID-19 (38% versus 4%, p = 0.004). Multi-variable analyses confirmed age > 65 and > 2 co-morbidities to predict for patient mortality independent of tumor stage, active malignancy, or anticancer therapy. During the early outbreak of SARS-CoV-2 infection in Europe co-morbid burden and advancing age predicted for adverse disease course in cancer patients. The ongoing OnCovid study will allow us to compare risks and outcomes in cancer patients between the initial and later stages of the COVID-19 pandemic.

Dietary management of maternal phenylketonuria with glycomacropeptide and amino acids supplements: A case report

BACKGROUND

In maternal PKU, protein substitute (PS) is provided by phenylalanine (PHE)-free l-amino acids (AA), but glycomacropeptide-based protein substitute (GMP) is an alternative consideration.

OBJECTIVE

To describe the first Portuguese Maternal Phenylketonuria (MPKU) partially managed with GMP.

CASE REPORT

A 31 year old MPKU female with classical PKU (mutations P281L/P281L), diagnosed by newborn screening, had a lifelong history of poor metabolic control. She has a history of partial bicornuate uterus and had a previous miscarriage in the first trimester. Pre-conception, her median blood PHE was 462 μmol/L but throughout pregnancy the median reduced to 258 μmol/L. GMP provided 30 g/day protein equivalent (46 mg/day PHE). Total protein equivalent from PS increased from 58 to 86 g/day during pregnancy but AA provided all additional protein equivalent intake. Both GMP and AA were well tolerated with no morning sickness. Normal morphologic evaluation and adequate fetal growth with cephalic biometry near the 5th percentile was determined. The infant was born at 39.3 weeks: weight 2570 g (3rd percentile), length 47.5 cm (10th percentile) and head circumference (HC) of 31.5 cm (1st percentile). In the neonatal period, the infant had craniofacial dimorphism with metopic suture prominence. Father also had bitemporal narrowing. By 12 months of age, the infant's weight (15th percentile), length (50th percentile) and HC (10th-50th percentile) were normal although bitemporal narrowing persisted.

CONCLUSIONS

This is the first case reporting the use of GMP in MPKU. Its PHE content did not adversely affect metabolic control although it only provided part of the PS intake. Some intrauterine development delay occurred in the last trimester, although we consider that this is unlikely to be associated with MPKU syndrome or the use of GMP. More published data is essential to examine the impact of using GMP in MPKU on morning sickness severity and aversion, maternal weight gain, blood amino acid concentrations and variability of blood PHE concentrations.

Changes over the last 15 years in the psychopharmacological management of persons with borderline personality disorder

OBJECTIVE

To describe the pharmacological management of borderline personality disorder (BPD) in Spain from 2001 through 2016, the factors associated with prescriptions, and changes in pharmacotherapy over this time period.

METHODS

Retrospective, cross-sectional, observational study conducted in a sample of 457 patients with BPD consecutively admitted to a specialist BPD Program between January 2001 and November 2016. Data on sociodemographic and clinical variables, as well as pharmacological treatment upon the admission to the programme, were used to describe pharmacological prescriptions, the factors associated with these medications, and changes in prescription over the last 15 years.

RESULTS

Most (88.4%) patients were on pharmacological treatment, with 53.8% of persons taking ≥3 medications. No significant changes in these percentages were observed over the study period. The use of tricyclic antidepressants and benzodiazepines decreased, while the use of atypical antipsychotics increased. Axis I comorbidity was the main factor associated with pharmacological treatment and polypharmacy.

CONCLUSIONS

This study provides further evidence confirming the worldwide overuse of prescription medications for BPD and shows that there has been a shift in the prescription pattern in the last 15 years. These results suggest that real clinical practice only partially adheres to clinical treatment guidelines.

Epidemiological updates and economic losses due to Taenia hydatigena in sheep from Sardinia, Italy

The aim of this study was to investigate the epidemiology and transmission of Taenia hydatigena in sheep and dogs from Sardinia and the economic estimation of losses due to this metacestodosis in lambs. A total of 7781 Sarda breed lambs were examined at abattoirs for the detection of Cysticercus tenuicollis or necrotic-haemorrhagic tracks of their migration. Morphological and molecular identification of parasites was carried out. Individual faecal samples from 300 dogs were examined for copromicroscopic investigations and coproELISA assay. An overall prevalence of 14.6% for T. hydatigena cysticercosis was found in the examined lambs. In total, 10,807 parasitary tracks were found, with an abundance of 1.39 and an average intensity of 9.52. The molecular analysis of the isolates showed an overall pairwise nucleotide divergence for the CO1 and ND1 was of 0-3.1 and 0-3.3%, respectively. Low intra- and interspecific variation was recorded for C. tenuicollis isolates used in this study which suggested the absence of differentiation. Microscopic examination of dog faeces showed a total prevalence of 31.3% for endoparasites in the examined samples (94/300). Taeniid eggs were found in 8.3% of the dogs. The results of the monoclonal antibody ATH4 ELISA test showed a prevalence of 11% (33/300) for T. hydatigena coproantigens. The total economic costs related to cysticercosis amounted to almost € 330,000. The prevalence of C. tenuicollis in 14.6% of 30-40-day-old lambs highlights the high parasitic pressure by T. hydatigena in the territory of Sardinia, Italy.

Discovery and validation of serum biomarkers expressed over the first twelve weeks of Fasciola hepatica infection in sheep

Serum biomarkers associated with Fasciola hepatica infection of Corriedale sheep were analysed during the first 12 weeks of infection using surface-enhanced laser desorption ionisation time of flight mass spectrometry (SELDI-TOF MS). In the discovery phase of analysis, pooled sera collected at week 0 and at each week p.i. to week 12 were fractionated by anion-exchange chromatography and the protein mass fingerprints obtained in individual fractions were in the M/z range 1.5-150 kDa. A total of 2302 protein clusters (peaks) were identified that varied between time-points following infection with peaks increasing or decreasing in intensity, or showing transient variation in intensity, during the 12 weeks of parasite challenge. In the validation phase, candidate biomarkers in sera of individual sheep at weeks 3 and 9 p.i. were analysed, identifying 100 protein peaks, many of which are small peptides <10 kDa in size: 54% of these peaks were up-regulated in intensity at week 3 or 9 p.i. Twenty-six biomarkers were chosen for further study, ranging in size from 1832 to 89,823 Da: six biomarkers were up-regulated at weeks 3 and 9 p.i., 16 biomarkers were up-regulated only at week 9 p.i. and four biomarkers were down-regulated at week 9 p.i. Two biomarkers up-regulated at week 9 were identified as transferrin (77.2 kDa) and Apolipoprotein A-IV (44.3 kDa), respectively. The results show that the interaction between the host and F. hepatica is complex, with changes in biomarker patterns beginning within 3 weeks of infection and either persisting to weeks 9-12 or showing transient changes during infection. Identification of biomarkers expressed during ovine fasciolosis may provide insights into mechanisms of pathogenesis and immunity to Fasciola and may assist in the rational development and delivery of vaccines.

A fluorescence study of the molecular interactions of harmane with the nucleobases, their nucleosides and mononucleotides

Fluorescence binding studies of harmane to the elemental components of the nucleic acids were undertaken to investigate the origin of the interaction between the drug and DNA. Most of the tested substrates have been found to induce hypochromism in the absorption spectrum of harmane and to quench its fluorescence. The quenching process induced by the nucleobases and their nucleosides is mainly due to the formation of ground state 1:1 complexes. However, in the case of the mononucleotides a dynamic quenching component is also observed. This quenching component is likely due to the excited state interaction of harmane with the phosphate group of the nucleotides. UV-vis spectral changes and quenching measurements have been used to quantify the ground state association constants of the complexes and the quenching rate constants.

Endobain E, a brain endogenous factor, is present and modulates NMDA receptor in ischemic conditions

We have isolated from rat cerebral cortex an endogenous Na(+), K(+)-ATPase inhibitor, termed endobain E, which modulates glutamatergic N-methyl-d-aspartate (NMDA) receptor. This endogenous factor allosterically decreases [(3)H]dizocilpine binding to NMDA receptor, most likely acting as a weak channel blocker. In the present study we investigated whether endobain E is present in the cerebral cortex of rats subjected to ischemia and modulates NMDA receptor exposed to the same conditions. Ischemia-reperfusion was carried out by bilateral occlusion of common carotid arteries followed by a 15-min reperfusion period. Elution profile of brain soluble fraction showed that endobain E is present in cerebral cortex of ischemia-reperfusion rats. On assaying its effect on synaptosomal membrane Na(+), K(+)-ATPase activity and [(3)H]dizocilpine binding to cerebral cortex membranes prepared from animals without treatment, it was found that the endogenous modulator isolated from ischemia-reperfusion rats was able to inhibit both enzyme activity and ligand binding. On the other hand, endobain E prepared from rats without treatment also decreased binding to cerebral cortex or hippocampal membranes obtained from animals exposed to ischemia-reperfusion. Since ischemia decreases tissue pH and NMDA receptor activity varies according to proton concentration, pH influence on endobain E effect was tested. Endobain E ( approximately 80 mg original tissue) decreased [(3)H]dizocilpine binding 25% at pH 7.4 or 8.0 but 90% at pH 6.5. These results demonstrate that endobain E is present and also able to modulate NMDA receptor in the short-term period that follows cerebral ischemia and that its effect depends on proton concentration, suggesting greater NMDA receptor modulation by endobain E at low pH, typical of ischemic tissues.

Hypoxia differentially reduces GABA(A) receptor density during embryonic chick optic lobe development

It has been demonstrated that the CNS is severely affected by hypoxic-ischemic insults during the prenatal-perinatal period, including imbalance in excitatory and inhibitory neurotransmitter release. Using a previously developed model of acute normobaric hypoxic hypoxia on chick embryos, we studied alterations observed both on [3H]GABA binding saturation parameters and on lactate concentration on successive embryonic days (ED). While maximal density of GABA binding sites (Bmax) from the low-affinity site was significantly reduced in an age-dependent manner, earlier stages of development (ED12 and 16) proving more vulnerable (ED12: control = 5.48 +/- 0.20, hypoxia = 3.90 +/- 0.39 pmol/mg prot, P < .05; ED16: control = 3.89 +/- 0.26, hypoxia = 2.80 +/- 0.28 pmol/mg prot, P < .05), ligand affinity (Kd) values and kinetic constants of the high-affinity site remained unaltered. Not unlikely, a physiological hypoxic state prevailing from ED17 up to hatching time rendered the whole embryo less sensitive to an externally induced hypoxic state (ED17: control = 2.93 +/- 0.06, hypoxia = 2.38 +/- 0.04 pmol/mg prot, P < .05; ED18: control = 2.97 +/- 0.12, hypoxia = 2.87 +/- 0.27 pmol/mg prot). Lactate levels in chick optic lobe homogenates were constant during development. The increase observed after hypoxic treatment compared to control value was significant at all stages studied, but increased percentage changes proved similar, indicating that all days of development equally perceive externally induced hypoxia. In conclusion, the present work demonstrates that after normobaric hypoxic hypoxia at different embryonic days, the embryo senses the externally induced hypoxic state as from ED12, but the GABA(A) receptor is differentially affected. It may be speculated that a different subunit composition of GABA(A) receptor is assembled in order to build a more stable receptor capable of resisting the physiological hypoxic state observed during the last few days before hatching.

Local and systemic immune responses to Echinococcus granulosus in experimentally infected dogs

Local and systemic immune responses were studied in six dogs experimentally infected with the dog/sheep tapeworm Echinococcus granulosus. All dogs developed similar IgG antibody response to parasite antigens. In contrast, IgE and IgA responses differed widely. No relationship between IgA responses and parasite burden at the end of the infection were observed. Further, clear differences in the anti-parasite IgA response in serum as compared with specific IgA forming cells in mesenteric lymph nodes were observed within the same dog. An inverse association of anti-parasite IgE and parasite load seemed to be present, with the strongest IgE response in the one dog that had no worms in the intestine at the end of the experiment. No differences were observed in the numbers of intestinal mast cells and goblet cells among all infected dogs. However, the dog with no detectable parasite load had a marked reduction of detected mast cells in the submuscular and muscular layer of the mucosa. Our data give new insight into the immune response of dogs during E. granulosus infection and provide information that may be useful for the rational design of vaccines for the control of hydatid disease.

Hydrogen bonding interactions between indole and benzenoid-pi-bases

The NH-pi interactions of indole with benzene, naphthalene, phenanthrene, toluene, m-xylene, and mesitilene, in carbon tetrachloride solutions, have been studied by Fourier transform infrared spectroscopy. The experiments, carried out on the NH stretching band of indole, prove the formation of 1:1 complexes in which the NH bond of indole is engaged. The NH frequency shifts are independent of the number of rings in the base, but they progressively increase as the electron density is enhanced by methylation. The association constants increase with the increase of both, the number of rings and the methyl groups on the base. At higher base concentrations, further shifts on the free NH and associated bands indicate the formation of 1:2 complexes, which suggest hybride NH-pi and van der Waals interactions between one indole ring and two benzene acceptor molecules.

Prevalence of sleep breathing disorders in outpatients on a heart transplant waiting list

Sleep related periodic breathing with recurrent episodes of apnea and hypopnea is known to occur in patients with heart failure. We investigated the prevalence of sleep related breathing disorders (SRBD) in 14 outpatients on a heart transplant waiting list. All were younger than 60 years and had severe stable heart failure. Three patients (21%) exhibited 10 or more apneas and hypopneas per hour of sleep; these apneas and hypopneas were predominantly of the central type and occurred during Cheyne-Stokes respiration. There were no statistically significant differences between the apneic and non-apneic group in terms of age, left ventricular ejection fraction or pulmonary function tests. The group with SRBD had worse quality of life and less tolerance to exercise.

Immunization with cathepsin L proteinases CL1 and CL2 secreted by Fasciola hepatica elicit a preferential type 1 response based on IgG2a antibodies in rats

Cathepsin L proteinases (CL1 and CL2), the major components of Fasciola hepatica excretion/secretion products (E/S) are considered potential antigens of a vaccine against fascioliasis. The humoral response elicited by CL1 and CL2 in rats either immunized with the enzymes or infected with F. hepatica has been analysed, examining specific IgE and IgG subclass dynamics. The experiment was continued for 10 weeks and peripheral blood eosinophilia was also determined. Infected rats presented peaks of eosinophilia at weeks 3 and 7 post-infection, while those immunized with CL1 and CL2 were no different from controls. Total IgE in infected rats increased up to week 5, reaching 30 microg(-1) in some cases, then decreased slowly and rising again towards the end of the experiment. Determination of specific IgE, carried out in sera previously absorbed with Protein G-Sepharose, reached a peak in infected rats between weeks 2 and 5, depending on the individual. In immunized rats both total and specific IgE levels remained around the pre-immunization values. With regard to the IgG subclass responses to E/S products, in infected rats IgG1 predominated over IgG2a, and the reverse was true in rats immunized with CL1 and CL2 and tested against the respective antigens. In all cases an increase in IgG1 and IgG2a antibody titres was seen, with maximum levels being reached later (weeks 6-7) in infected rats than in immunized ones (weeks 4-5). No IgG2b or IgG2c responses were detected in any of the groups studied.

Effectiveness of continuous positive airway pressure in mild sleep apnea-hypopnea syndrome

The aim of this trial was to evaluate the effectiveness of continuous positive airway pressure (CPAP) in patients with mild sleep apnea- hypopnea syndrome (SAHS). One hundred forty-two consecutive patients with mild SAHS (apnea-hypopnea index 10-30, without severe sleepiness) were randomly assigned to receive conservative treatment (CT)-sleep hygiene and weight loss-(65 patients) or CT plus CPAP (77 patients), and 125 patients (86% males, age: 54 +/- 9 yr, BMI: 29 +/- 4 kg/m(2), AHI: 20 +/- 6, ESS: 12 +/- 4) completed the follow-up. The following outcomes were assessed at inclusion and after 3 and 6 mo of treatment: sleepiness (Epworth scale, multiple sleep latency test [MSLT]), other symptoms related to SAHS, cognitive function, and perceived health status (Functional Outcomes of Sleep Questionnaire [FOSQ], Nottingham Health profile). The relief of SAHS-related clinical symptoms was significantly greater in the CPAP group than in the CT group; the Epworth scale and FOSQ also showed more improvement in the CPAP group but did not reach significance. There were no significant differences in the other tests performed probably because the baseline values were normal. CPAP compliance was 4.8 +/- 2.2 h and treatment continuation was accepted by 62% of the patients at the end of the study. These results suggest that CPAP can be considered in treating patients with mild SAHS on the basis of an improvement in symptoms.

Immunodiagnosis of fasciolosis using recombinant procathepsin L cystein proteinase

Cathepsin L1, a cysteine protease secreted by the gastrodermis of juvenile and adult Fasciola hepatica, was expressed in Escherichia coli as a fusion protein containing the proregion, supplied with six histidyl residues at the N-terminal end (rproCL1). In this study we tested its potential as antigen for the serologic diagnosis of F. hepatica infections by enzyme-linked immunosorbent assay (ELISA). The analyzed human sera included 16 positive samples, 99 negative controls and 111 from individuals affected by other parasitic and non parasitic diseases. The sensitivity and specificity of the rproCL1-ELISA were 100%. We also assessed the ability to detect antibodies in sera from 10 experimentally infected sheep, obtaining preliminary results that shown a response since the third week post infection in all the studied animals. Therefore, the recombinant rproCL1-based ELISA could be a standardized test for the accurate diagnosis of fasciolosis.

O-glycosylation in Echinococcus granulosus: identification and characterization of the carcinoma-associated Tn antigen

In the present work we demonstrate that the cancer-associated O-glycosylated Tn antigen (GalNAc-O-Ser/Thr) is expressed by the cestode Echinococcus granulosus. This antigen was detected in both larval and adult worm extracts, with the highest specific activity observed in the adult excretion/secretion preparation. Histochemical analysis showed that Tn is preferentially expressed in the parenchyma in both parasite stages and the external part of tegument in adult worms. A similar pattern was observed for sialyl-Tn, a related O-linked antigen. Tn glycoproteins from protoscoleces were resolved by SDS-PAGE in two main components of 43 and 49 kDa. After purification, this material was reactive with lectins which bind GlcNAc/sialic acid, GalNAc, and T antigen. In a preliminary evaluation, high levels of Tn antigen were detected in serum samples from patients with hydatid cyst, suggesting that the measure of Tn in serum could be a biomarker of this disease, although extensive work is necessary in order to determine the clinical usefulness of this assay. The results reported here, the first evidence of O-glycosylation pathways in E. granulosus and the presence of Tn antigen in cestodes, suggest that the evaluation of O-glycosylated antigens might give new insights in the host-parasite relationship.

Hydrogen bonding NH/pi interactions between betacarboline and methyl benzene derivatives

In the presence of benzene, toluene, m-xylene, mesitylene and durene, the pyrrolic NH stretching band of betacarboline, 9H-pyrido[3,4-b]indole, and its 1-methyl derivative, harmane, in tetrachloroethane diminishes in intensity while a new red-shifted band grows up. The shifts of the associated bands increase linearly with the pi-electron density of the substrates. These spectral changes are attributed to the formation of 1:1 molecular association complexes between the betacarbolines and the benzenoid substrates. The complexes are stabilized by the hydrogen-bonding interaction between the pyrrolic NH group of betacarboline and the pi-delocalized electrons of the benzene derivatives. The influence of these NH/pi hydrogen-bonding interactions in the fluorescence spectra of betacarboline is discussed.

Estimating the economic effects of cystic echinococcosis: Uruguay, a developing country with upper-middle income

Cost-benefit analyses, run before the commencement of a programme to control a parasitic disease, should include estimates of the economic losses attributable to the disease. Uruguay, a middle-income, developing country, has a recent history of persistent problems with cystic echinococcosis, in both its human population and livestock. The economic effects in Uruguay of this disease, caused by the larval stage of the canine tapeworm Echinococcus granulosus, have now been evaluated. Data on the incidence of the disease, in humans and livestock, were used to construct cost estimates. The estimated minimum cost (U.S.$2.9 million/year) was based on the condemnation costs of infected offal together with the actual costs of the hospital treatment of the human cases. The estimate of the maximum cost (U.S.$22.1 million/year) also included the production losses resulting from lower livestock efficiency and the reduced income of individuals with morbidity attributable to the disease.

The correlation of genotype and phenotype in Portuguese hyperphenylalaninemic patients

To understand the basis for the clinical heterogeneity of phenylalanine hydroxylase deficiency among Portuguese hyperphenylalaninemic patients, genotype-phenotype correlations were established. A group of 61 patients was completely genotyped, leading to the identification of 20 different mutant alleles in 36 different genotypic combinations, including a mutant allele not reported previously. The severity of those mutations found within this hyperphenylalaninemic population, which have not been previously expressed in vitro, were assessed. The results obtained by the present study exhibit a strong correlation between the predicted residual enzyme activity, as deduced from the genotype of the patients, and the biochemical phenotype represented by the diagnostic parameters (phenylalanine levels before the beginning of treatment and the dietary phenylalanine tolerance). It was observed that only a judicious follow-up and compliance with the appropriate diet permits the correct assessment of the clinical phenotype of the patients. Additionally, based upon the correlation observed between genotypes and diagnostic parameters, it was possible to predict the potential residual enzyme activity of those mutations (identified in our patients) which have not yet been studied in vitro.

Fasciola hepatica: parasite-secreted proteinases degrade all human IgG subclasses: determination of the specific cleavage sites and identification of the immunoglobulin fragments produced

The study was focused on the relationship of Fasciola hepatica-secreted proteinases and human IgG subclasses. Each IgG was incubated at different pH values and lengths of time with either the adult parasite excretion-secretion products or the purified cysteinyl proteinases cathepsin L1 and cathepsin L2. The Ig fragments produced were isolated and characterized by Western blot analysis, and the specific cleavage sites were determined by amino acid sequence analysis. Parasite excretion-secretion products and both cathepsins L produced similar degradation patterns and cleaved all human IgG subclasses at the hinge region, yielding at pH 7.3 and 37 degrees C Fab and Fc fragments in the case of IgG1 and IgG3 or Fab(2) and Fc in IgG2 and IgG4. While IgG1 and IgG3 were readily degraded by E/S products either in the presence or in the absence of reducing agents, IgG2 and IgG4 were resistant to proteolysis and were only digested in the presence of 0.1 M dithiothreitol. The cathepsins L needed the presence of dithiothreitol to digest IgG1, IgG2, and IgG4 whereas IgG3 was identically cleaved under both reducing and nonreducing conditions. The main cleavage sites produced by E/S products, CL1, or CL2 were located at the positions peptide bonds: His237-Thr238, Glu237-Cys239, Gly233-Asp234, and Ser241-Cys242 for gamma1, gamma2, gamma3, or gamma4, respectively. The enzymes gave additional splitting sites on the middle hinge of IgG3 to produce shorter Fc fragments and also produce Fd degradation of the IgG4. No cleavage specificity differences were found between CL1 and CL2, but they differed in the kinetics of IgG3 degradation. By lowering the pH, only the E/S products produced concomitant destruction of the Fc while preserving the Fab portion. Under all the conditions assayed the enzymes produced an Fc'-like fragment of 14-15 kDa corresponding to the whole CH3 domain of the immunoglobulin. Contrary to the extensive degradation produced by cathepsins on digested proteins, its actions on IgG subclasses were specific and restricted; thus, all the fragments produced could be potentially involved in the mechanisms used by the parasite to evade the host immune response.

A spectroscopic study of the molecular interactions of harmane with pyrimidine and other diazines

FTIR, UV-vis, steady state and time-resolved fluorescence measurements show that harmane (1-methyl-9H-pyrido/3,4-b/indole) interacts with pyrimidine and its isomers pyrazine and pyridazine in its ground and lowest singlet states. The mechanisms of interaction are dependent on both the structure of the diazine and the nature of the solvent. Thus, in a low polar solvent such as toluene, harmane forms ground state 1:1 hydrogen-bonded complexes with all the diazines. These complexes quench the fluorescence of harmane and diminish its fluorescence lifetime. Conversely, in buffered (pH 8.7) aqueous solutions, pyrimidine behaves differently from the other diazines. Thus, whereas pyrimidine only interacts with harmane in its ground state, pyrazine and pyridazine also interact in the excited state. The harmane-pyrimidine ground state interaction is an entropic controlled process. Therefore, we propose the formation of pi-pi stacked 1:1 complexes between these substrates. Association constants for the different types of complexes and quenching parameters are reported.

Vaccination with cathepsin L proteinases and with leucine aminopeptidase induces high levels of protection against fascioliasis in sheep

The potential of different parasite proteinases for use as vaccine candidates against fascioliasis in sheep was studied by vaccinating animals with the cathepsin L proteinases CL1 and CL2 and with leucine aminopeptidase (LAP) purified from adult flukes. In the first trial, sheep were immunized with CL1 or CL2 and the mean protection levels obtained were 33 and 34%, respectively. Furthermore, a significant reduction in egg output was observed in sheep vaccinated either with CL1 (71%) or with CL2 (81%). The second trial was performed to determine the protective potential of the two cathepsin L proteinases assayed together, as well as in combination with LAP, and of LAP alone. The combination of CL1 and CL2 induced higher levels of protection (60%) than those produced when these enzymes were administered separately. Those sheep that received the cocktail vaccine including CL1, CL2, and LAP were significantly protected (78%) against metacercarial challenge, but vaccination with LAP alone elicited the highest level of protection (89%). All vaccine preparations induced high immunoglobulin G titers which were boosted after the challenge infection, but no correlations between antibody titers and worm burdens were found. However, the sera of those animals vaccinated with LAP contained LAP-neutralizing antibodies. Reduced liver damage, as assessed by the level of the liver enzyme gamma-glutamyl transferase, was observed in the groups vaccinated with CL1, CL2, and LAP or with LAP alone.

CuZn superoxide dismutase activities from Fasciola hepatica

The levels of superoxide dismutase (SOD) were determined in detergent-soluble, somatic and excretion-secretion (E-S) preparations from adult Fasciola hepatica using the xanthine oxidase system and visualized in substrate gels. Compared to detergent-soluble and somatic extracts, E-S products showed the highest SOD activity (88.5 U/mg), indicating active release to the medium in which parasites were maintained. SOD specific activity was also detected at high levels in E-S products from 3-week-old and 5-week-old immature migrating flukes (25 and 143 U/mg, respectively). In all preparations except for the somatic extract, the activity was characterized as cyanide-sensitive CuZn SOD. Differences in SOD isoenzyme profiles between the extracts were observed in native polyacrylamide gel electrophoresis: the somatic and detergent-soluble extracts exhibited 1 band of activity while the E-S products from immature and adults flukes contained 2 and 3 migrating bands, respectively. SOD was purified from the detergent-soluble extract and E-S products of adult worms by a combination of ultrafiltration, gel filtration on Sephacryl S-200 HR and ion-exchange chromatography on QAE Sephadex A-50. The SOD from detergent-soluble extract showed, by SDS-PAGE analysis, 1 band of 16 kDa apparent molecular weight. The SOD from E-S products showed 2 bands of 16 and 60 kDa apparent molecular weight. N-terminal sequence analysis of the 16 kDa band from the detergent-soluble preparation showed some similarity with Schistosoma mansoni cytoplasmic SOD. These enzymes may have a potential role in the evasion of the oxidative burst killing mechanism by immune cells.

A spectroscopic study of the hydrogen bonding and pi-pi stacking interactions of harmane with quinoline

A spectroscopic (UV-vis, Fourier transform IR, steady state, and time-resolved fluorescence) study of the interactions of the ground and excited singlet states of harmane (1-methyl-9H-pyrido/3,4-b/indole) with quinoline has been carried out in cyclohexane, toluene, and buffered pH=8.7 aqueous solutions. To analyze how the number of rings in the substrate influences these interactions, pyridine and phenanthridine have also been included in this study. In cyclohexane and toluene 1:1 stoichiometric hydrogen-bonded complexes are formed in both the ground and the excited singlet states. As the number of rings of the benzopyridines and the solvent polarity increase hydrogen-bonding interactions weaken and pi-pi van der Waals interactions become apparent.

Risk factors associated with human cystic echinococcosis in Florida, Uruguay: results of a mass screening study using ultrasound and serology

Sonographic evidence of asymptomatic Echinococcus granulosus lesions in the liver was found in 156 of 9,515 persons in the Department of Florida, Uruguay. The sensitivity of ELISA and latex agglutination serology compared with ultrasound was 47.6% and 28.1%, respectively, and specificity was > 85%. There was a significant positive association between positive sonography and a personal history of previous but treated Echinococcus infection while those that were seropositive but ultrasound-negative were significantly more likely to have a personal history of infection or a history of infection in their family. Prevalence of infection increased significantly with age. There was no correlation between echinococcosis and dog ownership or home slaughter of sheep but offal disposal was important, with an increased prevalence of infection of 3.2%, 2.8%, and 3.1%, respectively, in persons feeding offal to dogs or burying or burning it compared with a prevalence of 0.8-1.5% in those using other methods of disposal. Almost half the population, when questioned, seemed to have sound knowledge about E. granulosus and described correct treatment of E. granulosus in dogs but this did not affect prevalence. There was a significant positive association between infection and the presence of a fenced fruit/vegetable garden and use of rural waters, particularly the cachimba (a small dam) and the aljibe (a cistern or tank) that collect rainwater from the ground surface and roofs, respectively.

Characterization and partial purification of a leucine aminopeptidase from Fasciola hepatica

An aminopeptidase activity capable of hydrolyzing different aminomethylcoumarin amino acids, but mainly leucine-7-amino-4-methylcoumarin (Leu-NHMc), was detected in deoxycholic soluble extracts from adult Fasciola hepatica. The enzyme (EC 3.4.11.1) was partially purified by gel filtration and EAH-Sepharose affinity chromatography using bestatin as a ligand. Results obtained by gel filtration, direct fluorogenic substrate analysis in polyacrylamide gel, and sodium dodecyl sulfate-polyacrylamide gel electrophoresis suggest that in a native form the enzyme might be aggregated as a high molecular weight complex. By affinity chromatography on concanavalin A Sepharose, the enzyme did not bond to the column showing that it lacks mannose residues. The F. hepatica aminopeptidase was characterized as a metalloproteinase based on its activation by Mn2+ and Mg2+, and its inhibition by EDTA, 1,10-phenanthroline, and bestatin. It has an optimal activity at a pH between 8.0 and 8.5. Histochemical localization revealed strong leucine naphthylamidase activity at the cells lining the gut epithelium of the parasite.

Proteinases secreted by Fasciola hepatica: time course of the inhibitory effect of serum from experimentally infected rabbits demonstrated by gelatin-substrate polyacrylamide gel electrophoresis

Fasciola hepatica secretes proteolytic enzymes to aid it to penetrate and migrate through the host tissues. Two of these proteinases have been purified and shown to be cathepsin L-like, and are termed, CL1 (27.5 kD) and CL2 (29 kD). The immunogenicity of these proteinases was investigated over the course of an experimental infection and following drug treatment. Four groups of rabbits were studied: group 1: orally infected with 50 metacercariae; group 2: infected and treated 8 weeks after infection; group 3: infected, treated at week 8 and reinfected at week 13 and group 4: non-infected control group. Sera were collected weekly from each group until week 20 postinfection. CL1 and CL2 were incubated with the different sera and then analysed by gelatin substrate polyacrylamide gel electrophoresis (GS-PAGE). Analysis of groups 1, 2 and 3 showed that CL1 and CL2 neutralizing antibodies appear at week 5 post-infection. In group 1, these remained throughout the 20 weeks of infection. In group 2, neutralizing antibodies disappeared at week 13, that is, 5 weeks after anti-Fasciola treatment. In group 3, CL1 and CL2 neutralizing antibodies disappeared at week 13 but reappeared by week 15, that is 2 weeks after reinfection. Pooled sera from group 4, showed no inhibitory capacity. ELISA results using CL1 and CL2 as antigen, correlate very well with the inhibitiory time course observed by GS-PAGE. These results suggest that purified cathepsin Ls are antigenic molecules recognized early in the infective process and capable of inducing a specific humoral response, strong enough to neutralize, at least partially, their enzymatic activity.

Coproantigen detection in dogs experimentally and naturally infected with Echinococcus granulosus by a monoclonal antibody-based enzyme-linked immunosorbent assay

A sandwich ELISA for the detection of Echinococcus granulosus coproantigen in formalin and heat-treated faecal supernatants of dogs was developed. The assay used affinity-purified polyclonal antibodies obtained from rabbits hyperimmunised with E. granulosus excretory/secretory antigens and biotinylated monoclonal antibody EmA9 produced against adult E. multilocularis somatic extract. The test was sensitive to 7 ng and 2.3 ng of E. granulosus protein and carbohydrate/ml of faecal supernatant, respectively. Thirteen helminth-free dogs were infected with different amounts of E. granulosus protoscoleces and the presence of coproantigen was monitored during the prepatent period until day 35 post-infection, when they were necropsied. Faecal antigen levels started to rise above the normal range between days 10 and 20 post-infection, and typically peaked at the end of the experiment. All the dogs, bearing from 3 to 67,700 worms, showed positive values in the ELISA during the prepatent period. One dog experimentally infected with Taenia hydatigena metacestode and harbouring three worms, tested positive only after the prepatent period at day 52. The test was applied to 98 stray dogs. The ELISA detected all of four dogs naturally infected with E. granulosus, two dogs with patent infections of T. hydatigena and two dogs with no cestode infections, showing a sensitivity of 100% and a specificity of 96%.

[Motor neuron disease and HIV]

Motor-neuron disease, in particular its commonest form (lateral amyotrophic sclerosis) is a degenerative disease of unknown aetiology and inexorable course with an estimated incidence of 0.4-1.8 per 100,000 inhabitants. In recent years great efforts have been made to discover the aetiopathogenesis of this disorder, studying genetic, viral, endocrine, toxic factors, etc. We present the case of a 30 year old man who started to develop a clinical condition compatible with motor-neuron disease 18 months after diagnosis of HIV. An extensive differential diagnosis was considered in view of this past history. Complementary tests considered necessary for diagnosis of motor-neurone disease and for exclusion of other neurological conditions related to HIV were done. After 16 months of follow-up the condition has become a clear case of ELA type motor neurone disease with no further HIV-related pathology. We discuss questions concerning the aetiopathology of the disease, based on the currently accepted viral hypothesis and describe recent findings related to both.

Principles of the surgical approach in human liver cystic echinococcosis

Ultrasonography (USG) has recently contributed much to the diagnostic of hepatic cystic echinococcosis (CE). The use of portable ultrasonograph allowed us to perform a community survey among 9482 people living in a high risk area for CE in the Florida Department (Uruguay). Positive USG results were found in 123 asymptomatic patients. 48 out of 51 USG positive cases were surgically confirmed and 3 were found to be false positive. The results of this survey allowed us to propose a new classification of the echographic imaging based on the parasite's various evolutive and involutive stages. The Echinococcus granulosus cyst size was compared with the parasite's evolutive stages. The cyst's segmentary topography and the related risk of CE is evaluated. The importance of cystic-biliary communication is pointed out and its rational surgical treatment described. Finally, an algorithm is presented facilitating the choice of a rational treatment.

Proteinases secreted by Fasciola hepatica degrade extracellular matrix and basement membrane components

The invasive stages of the parasitic trematode Fasciola hepatica release proteinases into the medium in which they are maintained. In this study, we investigated the interaction of F. hepatica excretory/secretory (E/S) products and 2 cysteine proteinases (CL1 and CL2) purified from these products with extracellular matrix and basement membrane macromolecules. Fasciola hepatica E/S products contained collagenolytic activity on fibrillar types I and III collagen as well as basement membrane type IV collagen. CL1 and CL2 were capable of degrading acid-soluble type III and type IV collagen but not insoluble type I collagen. In contrast, neither the E/S products nor the purified CL1 and CL2 showed elastinolytic activity. Fibronectin and laminin were degraded by E/S products and by CL1 and CL2. Sequence analysis of fibronectin degradation products showed that the fragments obtained corresponded to complete biologically active domains. These results indicate that the cysteine proteinases secreted by F. hepatica may be involved in the process of tissue invasion by the parasite.

Partition coefficients of indoles and betacarbolines

Partition coefficients for substituted indoles and betacarbolines were determined in octan-1-ol/water and cyclohexane/water. A comparative study of the results in both systems allows us to discuss the effects played by the different molecular structures, substituents, and aromaticity on the distribution properties of these compounds. In particular, the hydrogen-bond donor (HBD) and hydrogen-bond acceptor (HBA) properties of these solutes were characterized and compared with those of structurally related compounds. The Abraham solute descriptors were estimated and partition coefficients (log P) calculated and compared with the experimental values. The results show that the HBD properties are similar for indoles and betacarbolines, and the HBA capacity, as expected, is significantly enhanced by the contribution of the extra pyridinic or piperidinic ring in betacarbolines. The effects of the substituent groups are presented in relation to their contribution to the distribution properties of the compounds studied.