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Souza F, Rochitte CE, Silva DC, Gomes AMR, Santos MR, Fonseca GWP, Battaglia ACBF, Correa KTS, Yonamine M, Pereira RMR, Negrao CE, Alves MJNN. Coronary inflammation by computed tomography pericoronary fat attenuation in young male anabolic androgenic steroid users. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The illicit use of anabolic androgenic steroids (AAS) has been associated with diminished cholesterol efflux mediated by HDL, remarkable decrease in high-density lipoprotein (HDL) plasma concentration and subclinical coronary artery disease (CAD). Inflammation is the key to the atherogenic process associated with atherosclerotic plaque vulnerability. The pericoronary mean fat attenuation (pFAM) has emerged as a marker of coronary inflammation and can predict future cardiovascular events, which is measurable from standard coronary computed tomography angiography (CCTA). However, whether AAS abuse has a role in pFAM in young male AAS users is unknown.
Purpose
The aim of this study was to evaluate whether AAS abuse could leads to higher pFAM and premature coronary inflammation in young male AAS users.
Methods
Twenty strength-trained AAS users (AASU) age 29±5 yr, 20 age-matched strength-trained AAS nonusers (AASNU), and 10 sedentary controls (SC) were enrolled in this study. Coronary inflammation was assessed by pFAM-CCTA in the right coronary artery (RCA), left anterior descending artery (LDA) and left circumflex coronary artery (Cx).
Results
pFAM in the RCA was significantly higher in AASU compared with AASNU and SC (−64.59±9.45 vs. −79.21±6.67 vs. −80.97±7,91 Hounsfield Units (HU), respectively, p<0.001]. Also, the pFAM in the LAD was higher in AASU compared with AASNU and SC (−72.83±7.21 vs. −79.41±6.72 vs. −80.97±7.72 HU, p=0.006). However, no difference to pFAM in the Cx between AASU, AASNU and SC (−74.30±5.85 vs. −79.77±7.13 vs. −78.19±5.82 HU, respectively, p=0.069) was found.
Conclusion
This study indicates that AAS abuse may be associated with higher pFAM and premature coronary inflammation in the RCA and LAD. The higher pFAM may be linked to early development of CAD in young AAS users.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): Fundação Zerbini
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Affiliation(s)
- F Souza
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - C E Rochitte
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - D C Silva
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - A M R Gomes
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - M R Santos
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - G W P Fonseca
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - A C B F Battaglia
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - K T S Correa
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - M Yonamine
- University of São Paulo, College of Pharmaceutical Sciences and Toxicology , Sao Paulo , Brazil
| | - R M R Pereira
- University of Sao Paulo, Bone Metabolism Laboratory, Rheumatology Division , Sao Paulo , Brazil
| | - C E Negrao
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
| | - M J N N Alves
- Heart Institute of the University of Sao Paulo (InCor) , Sao Paulo , Brazil
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Silva DC, Rabelo-da-Ponte FD, Salati LR, Lobato MIR. Heterogeneity in gender dysphoria in a Brazilian sample awaiting gender-affirming surgery: a data-driven analysis. BMC Psychiatry 2022; 22:79. [PMID: 35105327 PMCID: PMC8808968 DOI: 10.1186/s12888-022-03727-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/18/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Population heterogeneity and the lack of clinical and sociodemographic information in transgender individuals with gender dysphoria (GD) remains a challenge for specialized services in mental health and surgical procedures. It aimed to identify and describe profiles in a sample waiting for gender-affirming surgery. METHODS A sample of 100 outpatients with GD was assessed through a structured interview, Emotion Regulation Difficulty Scale (DERS), Ruminative Response Scale (RRS), Depression, Anxiety and Stress Scale (DASS-21) and Life Satisfaction scale (SWLS). Cluster analysis was used to identify different profile categories. RESULTS Two subgroups with different profiles were identified: with less clinical severity (LCS) and with high clinical severity (HCS) on emotional dysregulation, acute symptoms of depression, anxiety, stress and association with mental rumination. The HCS cluster had greater vulnerability in terms of psychiatric history, use of psychotropic drugs, HIV positive, child abuse and suicidal behavior. CONCLUSION Different profiles were found regarding the vulnerability to mental health in a sample of transgender people with GD who seek a public hospital service for the same clinical-surgical objective. Longitudinal studies are essential to monitor the impact of these contrasts and to target personalized therapeutic approaches in the prevention of psychiatric disorders.
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Affiliation(s)
- Dhiordan Cardoso Silva
- Transdisciplinary Gender Identity Program, Department of Psychiatry of Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil. .,Graduate Program in Psychiatry and Behavioral Sciences, Medical School of the Federal University of Rio Grande do Sul, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035-903, Brazil.
| | - Francisco Diego Rabelo-da-Ponte
- grid.8532.c0000 0001 2200 7498Graduate Program in Psychiatry and Behavioral Sciences, Medical School of the Federal University of Rio Grande do Sul, Rua Ramiro Barcelos, 2350, Porto Alegre, RS 90035-903 Brazil ,grid.414449.80000 0001 0125 3761Molecular Psychiatry Laboratory, Department of Psychiatry of Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Leonardo Romeira Salati
- grid.414449.80000 0001 0125 3761Transdisciplinary Gender Identity Program, Department of Psychiatry of Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Maria Inês Rodrigues Lobato
- grid.414449.80000 0001 0125 3761Transdisciplinary Gender Identity Program, Department of Psychiatry of Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil ,grid.8532.c0000 0001 2200 7498Graduate Program in Psychiatry and Behavioral Sciences, Medical School of the Federal University of Rio Grande do Sul, Rua Ramiro Barcelos, 2350, Porto Alegre, RS 90035-903 Brazil
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3
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Silva DC, Salati LR, Fontanari AMV, Schwarz K, Schneider MA, Soll BBM, Costa AB, Guadagnin F, Hirakata VN, Lobato MIR. Prevalence of Gender Dysphoria in Southern Brazil: A Retrospective Study. Arch Sex Behav 2021; 50:3517-3526. [PMID: 34697689 DOI: 10.1007/s10508-021-02036-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 05/01/2021] [Accepted: 05/04/2021] [Indexed: 06/13/2023]
Abstract
To ensure that public health services provide comprehensive and inclusive health care to the general population, it is important for countries to estimate how many of their citizens experience gender dysphoria and wish to receive specialized hormone treatment or gender-affirming surgery. The aim of this study was to estimate the prevalence of individuals with gender dysphoria seeking transgender health care in a public teaching hospital in southern Brazil. In this retrospective follow-up study, we analyzed the medical records and sociodemographic data of individuals aged > 15 years living in Rio Grande do Sul, Brazil, that enrolled in a specialized program to receive hormone therapy and gender-affirming surgery between 2000 and 2018. This study is the first to attempt estimating the prevalence of gender dysphoria in Rio Grande do Sul; it describes novel data on the clinical profile of individuals with gender dysphoria treated in a public hospital specialized in providing transgender health care. Prevalence estimates were calculated based on statewide annual population data in the study period. Of 934 identified individuals, 776 (601 trans women and 175 trans men) were included in this study. The overall prevalence of individuals with gender dysphoria was 9.3 per 100,000 individuals (95% CI: 8.6 to 9.8). Meanwhile, there were 15 trans women per 100,000 people (95% CI: 14 to 16) and 4.1 trans men per 100,000 people (95% CI: 3.5 to 4.8). There was a progressive increase in the number of people seeking hormone therapy and gender-affirming surgery during the study period. Future research is needed to determine the size of the trans population in other regions of Brazil and to expand the knowledge regarding gender dysphoria to allow for the development of effective public policies for people with gender dysphoria.
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Affiliation(s)
- Dhiordan Cardoso Silva
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
- Graduate Program in Psychiatry and Behavioral Sciences, Federal University of Rio Grande do Sul, Ramiro Barcelos, 2400, Porto Alegre, RS, 90035-003, Brazil.
| | - Leonardo Romeira Salati
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Karine Schwarz
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
- Graduate Program in Psychiatry and Behavioral Sciences, Federal University of Rio Grande do Sul, Ramiro Barcelos, 2400, Porto Alegre, RS, 90035-003, Brazil
| | - Maiko Abel Schneider
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada
- Youth Wellness Center, St. Joseph Healthcare Hamilton, Hamilton, ON, Canada
| | - Bianca Borba Machado Soll
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
- Graduate Program in Psychiatry and Behavioral Sciences, Federal University of Rio Grande do Sul, Ramiro Barcelos, 2400, Porto Alegre, RS, 90035-003, Brazil
| | - Angelo Brandelli Costa
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
- Graduate Program in Psychology, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Fernanda Guadagnin
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Vânia Naomi Hirakata
- Biostatistic Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Maria Inês Rodrigues Lobato
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
- Graduate Program in Psychiatry and Behavioral Sciences, Federal University of Rio Grande do Sul, Ramiro Barcelos, 2400, Porto Alegre, RS, 90035-003, Brazil
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Rupasinghe T, Silva DC, Balawardena J, Perera K, Gunasekera D, Weerasinghe S, Jeyakumaran N, Abeysinghe P, Skandarajah T, Choudhury A, Joseph N. Curative-Intent Radiotherapy for Squamous Cell Carcinoma of the Head and Neck in Sri Lanka: The Impact of Radiotherapy Technique on Survival. Clin Oncol (R Coll Radiol) 2021; 33:765-772. [PMID: 34642066 DOI: 10.1016/j.clon.2021.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 09/13/2021] [Accepted: 09/28/2021] [Indexed: 12/24/2022]
Abstract
AIMS We conducted a retrospective analysis of patients with squamous cell carcinoma of the head and neck (SCCHN) treated with curative-intent radiotherapy at the National Cancer Institute of Sri Lanka to determine the impact of the treatment technique on disease-free survival (DFS). MATERIALS AND METHODS SCCHN patients treated with radical radiotherapy or adjuvant postoperative radiotherapy from 2016 to 2017 were included in the study. Data on the following variables were collected by reviewing clinical and radiotherapy treatment records: age, gender, tumour site, stage, time to delivery of radiotherapy, use of neoadjuvant chemotherapy, use of concurrent radiosensitising chemotherapy and treatment technique. DFS, defined as the time to death, tumour recurrence or loss to follow-up, was the primary end point and outcomes were compared between patients treated with intensity-modulated radiotherapy (IMRT) in linear accelerators and those treated with conventional radiotherapy in cobalt teletherapy units. Univariate and multivariate analyses were carried out on known prognostic variables. RESULTS In total, 408 patients were included in the study, with 138 (34%) being treated with IMRT in the linear accelerator. More than 75% of patients were of stage III or IV at diagnosis. The 2-year DFS of the whole cohort was 25% (95% confidence interval 21-30%). Patients treated with IMRT in the linear accelerator had a superior DFS in comparison with those treated with conventional radiotherapy in the cobalt teletherapy units (P < 0.001, hazard ratio 0.64, 95% confidence interval 0.5-0.82). Higher stage, cobalt treatment and use of neoadjuvant chemotherapy were adversely associated with DFS on multivariate analysis. CONCLUSION A large proportion of patients with SCCHN treated with curative-intent radiotherapy in Sri Lanka had locally advanced disease and DFS was superior in patients treated with IMRT in the linear accelerator.
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Affiliation(s)
- T Rupasinghe
- National Cancer Institute, Maharagama, Sri Lanka; Sri Lanka Cancer Research Group, Sri Lanka College of Oncologists, Mahargama, Sri Lanka
| | - D C Silva
- Sri Lanka Cancer Research Group, Sri Lanka College of Oncologists, Mahargama, Sri Lanka
| | - J Balawardena
- Sri Lanka Cancer Research Group, Sri Lanka College of Oncologists, Mahargama, Sri Lanka; General Sir John Kotalawela Defence University, Kandawala, Sri Lanka
| | - K Perera
- National Cancer Institute, Maharagama, Sri Lanka; Sri Lanka Cancer Research Group, Sri Lanka College of Oncologists, Mahargama, Sri Lanka
| | - D Gunasekera
- National Cancer Institute, Maharagama, Sri Lanka; Sri Lanka Cancer Research Group, Sri Lanka College of Oncologists, Mahargama, Sri Lanka
| | - S Weerasinghe
- National Cancer Institute, Maharagama, Sri Lanka; Sri Lanka Cancer Research Group, Sri Lanka College of Oncologists, Mahargama, Sri Lanka
| | - N Jeyakumaran
- National Cancer Institute, Maharagama, Sri Lanka; Sri Lanka Cancer Research Group, Sri Lanka College of Oncologists, Mahargama, Sri Lanka
| | - P Abeysinghe
- National Cancer Institute, Maharagama, Sri Lanka; Sri Lanka Cancer Research Group, Sri Lanka College of Oncologists, Mahargama, Sri Lanka
| | - T Skandarajah
- National Cancer Institute, Maharagama, Sri Lanka; Sri Lanka Cancer Research Group, Sri Lanka College of Oncologists, Mahargama, Sri Lanka
| | - A Choudhury
- The Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK
| | - N Joseph
- Sri Lanka Cancer Research Group, Sri Lanka College of Oncologists, Mahargama, Sri Lanka; Teaching Hospital, Batticaloa, Sri Lanka.
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Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD, Rosito TE. Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front Surg 2021; 8:639430. [PMID: 34026813 PMCID: PMC8131861 DOI: 10.3389/fsurg.2021.639430] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/22/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty. Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18-61 years); the average of operative time was 3.3 h (range 2-5 h); the average duration of hormone therapy before surgery was 12 years (range 1-39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS. Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.
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Affiliation(s)
| | | | | | - Karine Schwarz
- Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Angelo Brandelli Costa
- Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | | | - Tiago Elias Rosito
- Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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Soll BMB, Fontanari AM, Brandelli Costa A, Chinazzo Í, Silva DC, Guadagnin F, Tramontina S, Lobato MIR. Descriptive Study of Transgender Youth Receiving Health Care in the Gender Identity Program in Southern Brazil. Front Psychiatry 2021; 12:627661. [PMID: 33746795 PMCID: PMC7969635 DOI: 10.3389/fpsyt.2021.627661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/22/2021] [Indexed: 11/13/2022] Open
Abstract
Since 2014, the Gender Identity Program (PROTIG) of Hospital de Clínicas de Porto Alegre (HCPA) has been assisting transgender youth seeking gender-affirmative treatment offered at a public health-care service specializing in gender in southern Brazil. This article aims to analyze sociodemographic and clinical data regarding the diagnoses of gender dysphoria and gender incongruence, psychiatric comorbidities, and clinical aspects of a sample of transgender youths seeking health care in the gender identity program. The research protocol consisted of a survey of the data collected in the global psychological evaluation performed at the health-care service for youths diagnosed with gender incongruence and their caretakers. Participating in this research were 24 transgender youths between 8 and 16 years old with diagnostic overlap of gender dysphoria [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)] and gender incongruence [International Classification of Diseases, 11th Revision (ICD-11)] and 34 of their caregivers. Of the young people, 45.8% were positive for some psychiatric comorbidity throughout their lives, with almost half (45.4%) having two or more psychiatric comorbidities in addition to gender dysphoria. The mental health professionals comprising affirmation care teams face the challenge of adapting the care protocols to the uniqueness of each demand by developing individualized forms to promote healthy development. This can be done by focusing not only on medical and physical interventions for gender affirmation but also on the promotion of mental health and general emotional well-being. Thus, the gender affirmation model, which advocates for global assessment and personalized guidance, proved to be adequate. Nevertheless, access to multidisciplinary health services specializing in gender is essential for promoting the general well-being of the population of transgender youth.
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Affiliation(s)
- Bianca Machado Borba Soll
- Programa de Identidade de Gênero, Departamento de Psiquiatria e Medicina Legal, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Anna Martha Fontanari
- Programa de Pós Graduação em Psicologia, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Angelo Brandelli Costa
- Programa de Pós Graduação em Psicologia, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Ítala Chinazzo
- Programa de Identidade de Gênero, Departamento de Psiquiatria e Medicina Legal, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Dhiordan Cardoso Silva
- Programa de Identidade de Gênero, Departamento de Psiquiatria e Medicina Legal, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Fernanda Guadagnin
- Programa de Identidade de Gênero, Departamento de Psiquiatria e Medicina Legal, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Silzá Tramontina
- Programa de Identidade de Gênero, Departamento de Psiquiatria e Medicina Legal, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Maria Inês Rodrigues Lobato
- Programa de Identidade de Gênero, Departamento de Psiquiatria e Medicina Legal, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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Silva DC, Salati LR, Villas-Bôas AP, Schwarz K, Fontanari AM, Soll B, Costa AB, Hirakata V, Schneider M, Lobato MIR. Factors Associated With Ruminative Thinking in Individuals With Gender Dysphoria. Front Psychiatry 2021; 12:602293. [PMID: 34113267 PMCID: PMC8185062 DOI: 10.3389/fpsyt.2021.602293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 04/30/2021] [Indexed: 12/11/2022] Open
Abstract
This study aimed to examine psychosocial factors and medical history as well as symptoms of depression, anxiety, and stress associated with ruminative thinking in transgender people with gender dysphoria (GD) before undergoing gender affirmation surgery (GAS). This study evaluated 189 participants with GD (111 trans women and 78 trans men) from a specialized service for GAS in southern Brazil. Semi-structured interviews were conducted, and participants were asked to complete self-report questionnaires. We recovered participants' sociodemographic and psychosocial data (e.g., history of sexual abuse, expulsion from home, and history of drug use) and data regarding their clinical history (e.g., medication, history of suicidal ideation and attempted suicide, and HIV status). Further, we implemented the Depression, Anxiety and Stress Scale (DASS-21) to examine participants' psychological state, as well as the Ruminative Response Scale (RRS) to assess ruminative thinking, which includes brooding and reflection. The predictor variables were those that exhibited a minimum level of significance of p ≤ 0.05 in multivariate linear regression. The ruminative thinking scores for trans women were higher than those of trans men (Brooding p = 0.014; Reflection p = 0.052).In the multivariate model, suicidal ideation, moderate depression, and severe/very severe anxiety were associated with both brooding and reflection. Feminine gender identity and stress symptoms moderated only brooding, while anxiety symptoms moderated only reflection. Our findings show that trans women had the highest ruminative thinking scores, and that depression, anxiety, stress, and suicidal ideation were associated with ruminative thinking in total sample. Psychological symptoms should be examined in the context of gender affirmation surgery to minimize the possibility of adverse mental health outcomes. Follow-up studies are required to measure ruminative thinking levels more accurately and to identify its predictors.
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Affiliation(s)
- Dhiordan Cardoso Silva
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Leonardo Romeira Salati
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Anna Paula Villas-Bôas
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Karine Schwarz
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Anna Martha Fontanari
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Bianca Soll
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Angelo Brandelli Costa
- Graduate Program in Psychology, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Vania Hirakata
- Biostatistic Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Maiko Schneider
- Departments of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada.,Youth Wellness Center, St Joseph Healthcare Hamilton, Hamilton, ON, Canada
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Soll BMB, Fontanari AM, Brandelli Costa A, Chinazzo Í, Silva DC, Guadagnin F, Tramontina S, Lobato MIR. Corrigendum: Descriptive Study of Transgender Youth Receiving Health Care in the Gender Identity Program in Southern Brazil. Front Psychiatry 2021; 12:722544. [PMID: 34349689 PMCID: PMC8327382 DOI: 10.3389/fpsyt.2021.722544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 11/24/2022] Open
Abstract
[This corrects the article DOI: 10.3389/fpsyt.2021.627661.].
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Affiliation(s)
- Bianca Machado Borba Soll
- Programa de Identidade de Gênero, Departamento de Psiquiatria e Medicina Legal, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Anna Martha Fontanari
- Programa de Pós Graduação em Psicologia, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Angelo Brandelli Costa
- Programa de Pós Graduação em Psicologia, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Ítala Chinazzo
- Programa de Identidade de Gênero, Departamento de Psiquiatria e Medicina Legal, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Dhiordan Cardoso Silva
- Programa de Identidade de Gênero, Departamento de Psiquiatria e Medicina Legal, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Fernanda Guadagnin
- Programa de Identidade de Gênero, Departamento de Psiquiatria e Medicina Legal, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Silzá Tramontina
- Programa de Identidade de Gênero, Departamento de Psiquiatria e Medicina Legal, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Maria Inês Rodrigues Lobato
- Programa de Identidade de Gênero, Departamento de Psiquiatria e Medicina Legal, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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9
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Ornelas LTC, Silva DC, Tomich TR, Campos MM, Machado FS, Ferreira AL, Maurício RM, Pereira LGR. Differences in methane production, yield and intensity and its effects on metabolism of dairy heifers. Sci Total Environ 2019; 689:1133-1140. [PMID: 31466153 DOI: 10.1016/j.scitotenv.2019.06.489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/24/2019] [Accepted: 06/28/2019] [Indexed: 06/10/2023]
Abstract
The effects of divergent phenotypic classification in crossbreed Holstein × Gyr dairy heifers for methane emissions in relation to performance, digestibility, energy and nitrogen partition, blood metabolites and temperature of body surface were evaluated. Thirty-five heifers were classified as high and low emission for CH4 production (g/day), yield (g/kg dry matter intake) and intensity (g/kg average daily gain). Digestibility was evaluated by total collection of feces and urine. Gas exchanges were obtained in open-circuit respiratory chambers. A completely randomized design was used and divergent groups were compared by Fisher's test. No differences were found in intake traits between groups of CH4 production and intensity. The low yield group had higher intake. For digestibility and temperature at different body sites were no differences between variables. High production group had higher energy losses as methane and heat production. Low intensity group had higher digestible energy, energy balance and ratio between metabolizable and digestible energy. Urinary nitrogen was 14.3% lower for low production group. There was a difference between methane yield divergent groups for nitrogen intake, digestible and retained. Energy and nitrogen partitioning traits are correlated to the animals divergent for methane production and yield. The low production group presented lower blood insulin concentration. It was not possible to identify divergent animals for CH4 emission using the infrared thermography technique.
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Affiliation(s)
- L T C Ornelas
- Department of Animal Science, State University of Southwestern Bahia (UESB), Bahia 45700-000, Brazil
| | - D C Silva
- Department of Animal Science, State University of Southwestern Bahia (UESB), Bahia 45700-000, Brazil
| | - T R Tomich
- Embrapa Dairy Cattle, Minas Gerais 36038-330, Brazil
| | - M M Campos
- Embrapa Dairy Cattle, Minas Gerais 36038-330, Brazil
| | - F S Machado
- Embrapa Dairy Cattle, Minas Gerais 36038-330, Brazil
| | - A L Ferreira
- Department of Agricultural Science, Federal University of São João del-Rei (UFSJ), Minas Gerais 36307-352, Brazil
| | - R M Maurício
- Department of Agricultural Science, Federal University of São João del-Rei (UFSJ), Minas Gerais 36307-352, Brazil
| | - L G R Pereira
- Embrapa Dairy Cattle, Minas Gerais 36038-330, Brazil.
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10
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Silva DC, Queiroz PJB, Caetano DBS, Assis BM, Rabelo RE, Silva LAF. Association between bovine digital dermatitis and annual periods of lower pluviometric precipitation in Central Brazil. Trop Anim Health Prod 2018; 50:1631-1636. [PMID: 29704090 DOI: 10.1007/s11250-018-1605-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 04/20/2018] [Indexed: 11/28/2022]
Abstract
We aimed to follow the epidemiologic evolution of bovine digital dermatitis (BDD) and other podal diseases grouped in a dairy farm in Central Brazil between the years 2010 and 2016. This study was carried out in a farm in Jataí, Goiás, Central Brazil, where the prevalence data of bovine digital dermatitis (BDD) and other podal diseases, as well as the composition, history, and management of the herd, was collected. We analyzed the collected data into the two annual pluviometric precipitation values in Central Brazil: rainy season and dry season. The cumulative frequency for comparison of prevalence between seasons throughout the years was calculated from 2011 to 2016. The comparison was carried out by post hoc chi-square test with the Bonferroni correction adopting a level of significance of 5% (p < 0.05). BDD was not diagnosed at the property in 2010; however, the disease became endemic from 2011, which coincides with the arrival of new animals to the herd. The comparison of the accumulated frequencies for prevalence of the diseases in the herd between 2011 and 2016 revealed BDD, as well as the grouped nutritional and metabolic foot diseases, has the highest prevalence in the period of lower annual precipitation in Central Brazil, which occurs between May and October. For a better control of BDD, we recommend greater attention in cattle management in the dry season of the year in Brazil, as well as in any other place in the world in which rainfall is seasonal.
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Affiliation(s)
- D C Silva
- Programa de Pós-Graduação em Ciência Animal, Escola de Veterinária e Zootecnia, Universidade Federal de Goiás, Goiânia, GO, CEP 74001-970, Brazil.
| | - P J B Queiroz
- Programa de Pós-Graduação em Ciência Animal, Escola de Veterinária e Zootecnia, Universidade Federal de Goiás, Goiânia, GO, CEP 74001-970, Brazil
| | - D B S Caetano
- Programa de Pós-Graduação em Ciência Animal, Escola de Veterinária e Zootecnia, Universidade Federal de Goiás, Goiânia, GO, CEP 74001-970, Brazil
| | - B M Assis
- Programa de Pós-Graduação em Ciência Animal, Escola de Veterinária e Zootecnia, Universidade Federal de Goiás, Goiânia, GO, CEP 74001-970, Brazil
| | - R E Rabelo
- Programa de Pós-Graduação em Ciência Animal, Escola de Veterinária e Zootecnia, Universidade Federal de Goiás, Goiânia, GO, CEP 74001-970, Brazil
| | - L A F Silva
- Programa de Pós-Graduação em Ciência Animal, Escola de Veterinária e Zootecnia, Universidade Federal de Goiás, Goiânia, GO, CEP 74001-970, Brazil
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11
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Piagentini M, Silva DC, Dell'Aqua CPF, Moya-Araujo CF, Codognoto VM, Ramos AA, Oba E. Effect of selenium supplementation on semen characteristics of Brazil's ram. Reprod Domest Anim 2017; 52:355-358. [DOI: 10.1111/rda.12903] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/02/2016] [Indexed: 11/28/2022]
Affiliation(s)
- M Piagentini
- School of Veterinary Medicine and Animal Science; Sao Paulo State University - UNESP; Botucatu SP Brazil
| | - DC Silva
- School of Veterinary Medicine and Animal Science; Sao Paulo State University - UNESP; Botucatu SP Brazil
| | - CPF Dell'Aqua
- School of Veterinary Medicine and Animal Science; Sao Paulo State University - UNESP; Botucatu SP Brazil
| | - CF Moya-Araujo
- School of Veterinary Medicine; State University Midwest - UNICENTRO; Guarapuava PR Brazil
| | - VM Codognoto
- School of Veterinary Medicine and Animal Science; Sao Paulo State University - UNESP; Botucatu SP Brazil
| | - AA Ramos
- School of Veterinary Medicine and Animal Science; Sao Paulo State University - UNESP; Botucatu SP Brazil
| | - E Oba
- School of Veterinary Medicine and Animal Science; Sao Paulo State University - UNESP; Botucatu SP Brazil
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12
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Silva DC, Machado LPB, Mateus RP. Migration rate and genetic diversity of two Drosophila maculifrons (Duda, 1927) populations from Highland Araucaria Forest Fragments in Southern Brazil. BRAZ J BIOL 2015; 75:254-5. [PMID: 25945646 DOI: 10.1590/1519-6984.09914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 06/30/2014] [Indexed: 11/22/2022] Open
Affiliation(s)
- D C Silva
- Programa de Pós-Graduação em Biologia Evolutiva, Universidade Estadual do Centro-Oeste, Guarapuava, PR, Brazil
| | - L P B Machado
- Programa de Pós-Graduação em Biologia Evolutiva, Universidade Estadual do Centro-Oeste, Guarapuava, PR, Brazil
| | - R P Mateus
- Programa de Pós-Graduação em Biologia Evolutiva, Universidade Estadual do Centro-Oeste, Guarapuava, PR, Brazil
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13
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Garcia TS, Silva DC, Gertrudes JC, Maltarollo VG, Honorio KM. Molecular features related to the binding mode of PPARδ agonists from QSAR and docking analyses. SAR QSAR Environ Res 2013; 24:157-173. [PMID: 23282254 DOI: 10.1080/1062936x.2012.751453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Diabetes affects approximately 4% of world's population and metabolic syndrome has been directly related to obesity. There is a class of nuclear receptors, peroxisome proliferator-activated receptors (PPARs), which controls the metabolism of carbohydrates and lipids. It has been considered an attractive target to treat diabetes and metabolic syndrome. Accordingly, the primary objective of this study was to employ molecular modelling techniques to understand the factors involved in PPARδ activation. The QSAR models obtained showed good internal and external consistency and presented good validation coefficients (QSAR: q(2) = 0.83, r(2) = 0.87; HQSAR: q(2) = 0.73, r(2) = 0.90; CoMFA: q(2) = 0.88, r(2) = 0.94). The selected properties and the contour maps described the possible interactions between the PPARδ receptor and its agonists. From these findings, it is possible to propose molecular modifications to design new compounds with improved biological properties.
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Affiliation(s)
- T S Garcia
- School of Arts, Sciences and Humanities, University of São Paulo, São Paulo, Brazil
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14
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Abstract
BACKGROUND Vision-threatening injury is a relatively rare but devastating complication of maxillofacial trauma. Identification is not always straightforward. The purpose of this study was to look at our experience of blindness after blunt facial injuries to see whether any useful patterns or risk factors were identified to assist in early recognition. METHODS This was a retrospective, qualitative study undertaken at the University Hospital of North Staffordshire. All case notes, plain radiographs, and computed tomographic scans were reviewed and the relevant data collated. RESULTS Over a 10-year period, 17 patients were identified in which loss of vision occurred secondary to blunt injury to the face. CONCLUSION It is important to maintain a high index of suspicion when dealing with maxillofacial trauma, particularly if the patient is not cooperative. We provide a list of salient features to look for in the examination and history to aid the clinician.
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Affiliation(s)
- Anne Dancey
- Birmingham Childrens' Hospital, Birmingham, United Kingdom
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15
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Vieira LAP, Freitas ALP, Feitosa JPA, Silva DC, Viana GSB. The alga Bryothamnion seaforthii contains carbohydrates with antinociceptive activity. Braz J Med Biol Res 2004; 37:1071-9. [PMID: 15264015 DOI: 10.1590/s0100-879x2004000700017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Bryothamnion seaforthii, a red alga common to the Northeastern coast of Brazil, was used to prepare the protein fraction F0/60 by ammonium sulfate precipitation. The chromatography of F0/60 on DEAE-Sephadel column resulted in two lectin fractions, PI and PII, which have antinociceptive properties in rodents. We determined the antinociceptive activity of the PII fraction and of a carbohydrate-containing fraction (CF) in mice. The CF was prepared from the dried algae, after digestion with 100 mM sodium acetate, pH 6.0, containing 5 mM cysteine, EDTA and 0.4% papain, at 60 masculine C. A 10% cetylpyridinium chloride was added to the filtrate, and the precipitate was dissolved with 2 M NaCl:ethanol (100:15, v/v) followed by the carbohydrate precipitation with ethanol. The final precipitate, in acetone, was dried at 25 masculine C. The PII fraction markedly inhibited acetic acid-induced abdominal writhing after ip administration (control: 27.1 +/- 2.20; PII 0.1 mg/kg: 5.5 +/- 1.85; 1 mg/kg: 1.6 +/- 0.72 writhes/20 min) and after oral administration (control: 32.0 +/- 3.32; PII 0.1 mg/kg: 13.1 +/- 2.50; 1 mg/kg: 9.4 +/- 3.96 writhes/20 min). PII was also effective against both phases of pain induced by 1% formalin (control, ip: 48.2 +/- 2.40 and 27.7 +/- 2.56 s; PII: 1 mg/kg, ip: 34.3 +/- 5.13 and 5.6 +/- 2.14 s; control, po: 44.5 +/- 3.52 and 25.6 +/- 2.39 s; PII 5 mg/kg, po: 26.5 +/- 4.67 and 15.3 +/- 3.54 s for the 1st and 2nd phases, respectively) and in the hot-plate test. The CF (ip) also displayed significant antinociceptive properties in all tests but at higher doses (1 and 5 mg/kg, ip and po). Thus, CF at the dose of 5 mg/kg significantly inhibited writhes (ip: 7.1 +/- 2.47 and po: 14.5 +/- 2.40 writhes/20 min) as well as the 1st (po: 19.6 +/- 1.74 s) and 2nd (po: 7.1 +/- 2.24 s) phases of the formalin test compared to controls ip and po. The antinociceptive effects of both the PII and CF in the formalin and hot-plate tests were prevented at least partially by pretreatment with the opioid receptor antagonist naloxone (2 mg/kg, sc). Moreover, both fractions retained antinociceptive activity in the acetic acid-induced writhing test following heating, a procedure which abolished the hemagglutinating activity of the fraction, presumably due to lectins also present. Finally, both fractions also prolonged the barbiturate-induced sleeping time. These results indicate that carbohydrate molecules present in the PII (26.8% carbohydrate) and CF (21% of the alga dried weight) obtained from B. seaforthii display pronounced antinociceptive activity which is resistant to heat denaturation and is mediated by an opioid mechanism, as indicated by naloxone inhibition.
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Affiliation(s)
- L A P Vieira
- Departamento de Bioquímica e Biologia Molecular, Universidade Federal do Ceará, Fortaleza, CE, Brazil
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16
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Abstract
OBJECTIVE: To correlate sweat conductivity by Wescor with quantitative sodium determination in the same sample. METHODS: We analyzed 206 sweat samples, being 31 obtained from patients with cystic fibrosis (CF). Sweat was collected by quantitative pilocarpine iontophoresis in the Macroduct system for 30 minutes. Samples were immediately determined by Sweat-Chek analyzer (Wescor) and sodium quantification with a flame photometer. RESULTS: In non-CF subjects sweat (n=175), mean conductivity and quantitative sodium were 41mmol/L (16-75mmol/l) and 36mEq/ l (12-75mEq/l) respectively. In CF subjects (n=31), mean values of conductivity and sodium were 119mmol/L (84-155mmol/l) and 113mEq/l (80 - 146mEq/l) respectively. None of CF patients showed values lower than 80mmol/L. There was a correlation between sweat conductivity and sodium determination (r= + 0.99; p<0.0001). CONCLUSION: Sweat conductivity by Wescor simplifies the analysis with lower volumes and is well correlated to sodium concentration.
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Affiliation(s)
- C A Riedi
- Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil
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17
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Silva DC, de Oliveira Filho RS, Bevilacqua RG, Falzoni R, Birolini D. [Multicentric myxoid, metachronous and synchronous and multifocal liposarcoma: report of a case]. Rev Hosp Clin Fac Med Sao Paulo 1994; 49:217-20. [PMID: 7716375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A case of a male patient, 66 years old, who exhibited in a period of six years many multicentric and multifocal synchronic and metachronic myxoid liposarcomas is reported. The authors made a revision of cytogenetics and DNA alterations recently identified in this type of tumor. The chromosomic alterations are represented by the translocation t(12;16) (q13;p11) and trisomy of the chromosome 8. The genic analysis revealed the presence of altered restriction fragments due to highly specific and reproducible methylation differences. In conclusion the authors suggest that the presence of the multiple tumors of this type in the same patient could be due to a common etiologic factor, not yet known, as being the initiator of this systemic illness of the fat tissue.
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Affiliation(s)
- D C Silva
- Serviço de Cirurgia Geral Eletiva, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
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18
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Silva DC, Falzoni R, de Oliveira Filho RS, Birolini D, Bevilacqua RG. [Gastric epithelioid leiomyosarcoma simulating pancreatic pseudocyst. Report of a case and review of the literature]. Rev Hosp Clin Fac Med Sao Paulo 1993; 48:98-102. [PMID: 8235282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The authors report a case of malignant gastric leiomyoblastoma (epithelioid leiomyosarcoma) which was mistaken for a pseudocyst of the pancreas. The patient was operated several times in another hospital. At one of the operations a cystogastrostomy was performed. In november, 1989, when operated again by us, a large tumoral mass arising from the posterior gastric wall was found. The histopathological diagnosis was leiomyoblastoma of the stomach. It is concluded that the wall of a pancreatic cystic lesion should always be submitted to histologic examination in order to be excluded the possibility of a malignant neoplasm.
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Affiliation(s)
- D C Silva
- Serviço de Cirurgia Geral Eletiva-Divisão da Terceira Clínica Cirúrgica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo
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