Coronal Repercussions of the Maxillary Central Incisor Torque in the First Set of Aligners: A Retrospective Study

Coronal torque is one of the key factors in orthodontic treatment. An adequate torque value has an impact on aesthetics and soft tissue profile. The aim of this quantitative, comparative and observational longitudinal cohort study was to analyze the efficacy of the maxillary central incisor coronal torque in the Invisalign® system and evaluate the relation between coronal torque movement and patient's facial biotype. In total, 27 patients were selected. The planned movements (TP) were obtained from the Invisalign Doctor Site® using mathematical formulas that consider the T0 measurements. Pre-treatment (T0) and after full use of the first set of aligners (T1) scanners were evaluated using Geomagic® Control X TM by superimposing T0 and T1 models using a transverse plane and the long axis of the tooth crown. IBM® SPSS® software was used for statistical purposes. We found statistically significant differences between T0 and T1 in pro-inclination and retro-inclination, as well as between achieved and planned values in pro-inclination (p = 0.011). We verified that hyperdivergent clinical cases presented higher mean values of coronal torque, and hypodivergent cases presented lower values. In pro-inclination, the differences between the planned and achieved values were greater in hypodivergent cases and smaller in hyperdivergent cases. In retro-inclination, the differences between the planned and achieved values were greater in normodivergent cases and smaller in hypodivergent cases. This study highlights that inefficacy is more accentuated in pro-inclination. Aligners are an effective tool for producing coronal repercussions of torque movement, being more effective in retro-inclination.

P–042 Impact of semen parameters, sperm DNA fragmentation and sperm aneuploidy in male infertility

Study question

Should sperm aneuploidies and sperm DNA fragmentation (sDNAfrag) be included as valid tests in the routine investigation of male infertility?

Summary answer

Sperm DNA fragmentation was associated with male age, oligozoospermia (OZ), oligoteratozoospermia (OT), astenoteratozoospermia (AT) and oligoastenoteratozoospermia (OAT). Sperm aneuploidies were associated with OT and OAT.

What is known already

Semen parameters assist male infertility diagnosis and treatment, but sDNAfrag and aneuploidy analysis could add useful information, as abnormal values compromise fertility. To include these tests in the routine diagnosis it should be determined if behave as informative parameter and add information regarding the fertility status. For that, further studies comparing these tests to semen parameters are needed, since previous results are not consensual. Additionally, standardization of a sDNAfrag cut-off is needed, as different sample sizes and techniques originate distinct results. Also, until a standardization of the protocol is missing, a cut-off value should be defined for each laboratory.

Study design, size, duration

A retrospective and prospective investigation was performed, within a 12 years period (April 2007-December 2019). A total of 835 infertile males with a normal karyotype (46,XY) were included. Karyotyping and evaluation of sDNAfrag and sperm aneuploidies were made at a public Genetic unit. All normozoospermic (NZ) patients with a born child and patients whose infertility treatments were done due to female factors were selected from our database and used as controls (60 individuals).

Participants/materials, setting, methods

Semen analysis followed WHO–2010 guidelines. sDNAfrag was evaluated using the TUNEL assay. Sperm aneuploidies were detected using FISH (chromosomes 13, 18, 21, X, Y). Several tests were applied: correlations for linear associations between numerical variables, ANOVA for comparisons between means, Dunn-test for post-hoc comparisons. To determine the sDNAfrag cut-off value, the area under the ROC curve, sensitivity and specificity, were calculated, with the Youden-Index used to find a threshold that maximizes both sensitivity and specificity.

Main results and the role of chance

Regarding male age, it was observed a positive correlation with sperm concentration, a negative correlation with sperm vitality (VT) and hypoosmolality, and a positive correlation with sDNAfrag. Regarding sDNAfrag, it was observed negative correlation with sperm concentration, total progressive motility (TPM), morphology, VT and hypoosmolality. Regarding sperm aneuploidies, both total sperm aneuploidy and total sperm disomy exhibited a negative association with sperm concentration, TPM and morphology. It was also investigated whose groups of individuals could be indicated for sDNAfrag or sperm aneuploidy testing. The NZ group evidenced significant lower sDNAfrag, total sperm aneuploidy and total sperm disomy in relation to the non-NZ group. In the NZ group, sDNAfrag was significantly lower in relation to the OZ, OT, AT and OAT groups. The NZ group presented significant lower percentages of sperm aneuploidy in relation to the OT and OAT groups, and significant lower percentages of sperm disomy in relation to the OAT group. Additionally, sDNAfrag was positively correlated with total sperm aneuploidy and total sperm disomy. From the present large population, ROC curve analysis allowed estimating a cut-off value of 18.8% for the TUNEL-assay (sDNAfrag), with 0.658 of area under the curve, 53.9% sensitivity and 76.7% specificity.

Limitations, reasons for caution

Although presenting a high number of cases and strict controls, the present study was unable to include as controls healthy men with proven fertility. Additionally, the present study did not take into account life-style factors and male associated pathologies besides infertility.

Wider implications of the findings: Semen parameters were shown to be negatively correlated with sDNAfrag and sperm aneuploidies. As sDNAfrag testing and sperm aneuploidy testing were associated with semen abnormalities and male age, it is suggested their inclusion in the routine evaluation of infertile men, thus adding important complementary information about the fertility status.

Trial registration number

Not Appliable

Dealing with COVID-19 Barriers to Care: Digital Platform to support and monitor chronic patients

The Covid-19 pandemic is causing a set of disruptions, especially at the delivery of healthcare services. The pandemic has shown subsidiary health effects like, chronic care, mental health, surgeries, and deadlock in the other diseases’ treatment.

A digital health platform (PrimaryCare@COVID-19) was implemented to be used by primary care physicians, and nurses, to address both chronic care and COVID-19-related patients at home or traveling. It has been piloted in three Health centers at Lisbon Health Region and it could be scale-up to all primary care in Portugal in the near future. This project was funded by the National Science Foundation to address Primary Care consultations and chronic care services shortage. The clinical primary care processes were studied and a digital workflow was defined using Design Science Research Methods.

This project‘s innovative digital platform is already covering several dozens of chronic patients while at home and addressing the communication with COVID-19-related patients.

The health professionals (physicians and nurses) are able to safely and rigorously communicate with chronic patients and prescribe the required medicines, as well as inform them about the COVID-19 measures. In case of patients either on quarantine or in isolation this platform also allows for the monitoring and health evaluation.

This eHealth Digital Platform is an opportunity to manage chronic care during epidemics, allowing to follow-up patients, preventing them from becoming uncontrolled and having to go to emergency. The digital platform uses smart algorithms to deal with both medication interactions and vital signs alerts while monitoring, chronic and COVID-19 infected, patients, allowing health professionals to remotely consult these patients at home/travelers (by default with phone, but also via digital videoconferencing) and manage all health information about patients in a secure way (and following GDPR rules).

eHealth solutions to regional shortages in the health workforce

Background

Healthcare systems are facing significant challenges, from demographics, shortage of health professionals to increasing costs that are associated with increasing demand. New technologies are thought to be a solution to these problems. However, the question is if the digitalization of healthcare will mitigate these problems and the shortage of health professionals in Europe.

Methods

This study provides a scoping review on existing health digital services aiming to cope with health professional shortage in Europe. The main challenges, from workforce performance, services quality, patient-interaction to technology use are addressed. The databases of Pubmed and Ebsco were searched.

Results

38 papers were selected and analysed addressing eHealth with impact on the workforce performance. It highlights the challenges associated with the digitalization of healthcare, the implementation of digital services, considering the design online service, and the impact of digitalization on healthcare workforce performance. An overview of the major effects of transformative technologies (e.g. eHealth services, Internet of Things solutions, Artificial Intelligence) on the healthcare workforce are addressed. Moreover, what are the major implications of technological change for future skill needs and competences of the public health workforce? Are there any reliable projections on how technologies will change the structure of the labour market for health professionals? And to what extent is the workforce equipped to adapt to the changes?

Conclusions

Proper digitalization of healthcare will enable changes in the paradigm of healthcare delivery as well as in the mechanism for patients’ participation and engagement. Sustainable implementation of eHealth is an important opportunity to address health workforce shortage but it is not enough.

Aspergillus species collected from environmental air samples in Portugal-molecular identification, antifungal susceptibility and sequencing of cyp51A gene on A. fumigatus sensu stricto itraconazole resistant

AIMS

Aspergillus sp. are ubiquitous saprophytic fungi and their conidia easily inhaled. This is particularly important in immunocompromised patients, more susceptible to developing invasive aspergillosis. In addition to A. fumigatus sensu stricto, cryptic species, many resistant to antifungal drugs, have been associated with invasive infections, making it important to assess their presence and diversity in different environments. Therefore, the aim of this study was to assess the presence, diversity and susceptibility to antifungal drugs of airborne fungi. Moreover, in azole-resistant A. fumigatus sensu stricto isolates the presence of underlying molecular mechanisms of resistance was investigated.

METHODS AND RESULTS

Eighty-four Aspergillus isolates were collected from the environment air in hospitals and the Water Treatment Plant. The use of molecular tools allowed to detect 12 different cryptic species, showing a prevalence of 21·4%. The majority of isolates (69·0%) belonged to A. fumigatus complex and 65·4% were A. fumigatus sensu stricto. Among these, 21·8% were resistant to itraconazole (ITZ), 38·2% to posaconazole and 87·3% to isavuconazole; none of them were resistant to voriconazole or amphotericin B. Sequencing of the cyp51A gene on the 12 A. fumigatus sensu stricto ITZ-resistant isolates revealed the presence of mutations.

CONCLUSION

Our study reports a large number of environmental-resistant Aspergillus species, including A. fumigatus sensu stricto that display an important role in invasive fungal infections. None of the environmental isolates showed mutations on cyp51A gene related to azole resistance.

SIGNIFICANT AND IMPACT OF THE STUDY

This study is the first assessment of molecular resistance mechanisms in A. fumigatus sensu stricto environmental isolates, in Portugal. Since TR34/L98H and TR46/Y121F/T289A cyp51A mutations were already reported in the clinical setting in Portugal (Monteiro et al. J Glob Antimicron Resist 13: 190-191, 2018; Pinto et al. Front Microbiol 9: 1656, 2018), and have been linked to environmental route, it is utmost importance to perform surveillance network for azole-resistant A. fumigatus.

The effect of comorbidities and complications on the mortality of burned patients

The World Health Organization has defined 'elderly' as 65 years or older. Age is a known major prognostic factor after burn injury. The objective of this study is to establish whether epidemiologic differences in the elderly contribute to higher mortality compared to younger patients. Patients admitted to the burn unit between 2011 and 2014 (229 patients) were included: 159 were under 65 years old and 70 (30.6%) were 65 or over. The elderly group had a higher mortality rate, 24.6% versus 8.2% (p=0.002). Patients over 65 presented more pre-existing co-morbidities (1.7 ± 1.1) than patients under 65 (1.1 ± 1.0), p<0.001, and COPD was significantly associated with higher mortality rate (p=0.014). Patients over and under 65 suffered similar TBSA, 15.7 versus 14.1, p=0.720. Regarding burn depth, deeper burns were significantly more prevalent in the over 65 group (17.1% vs. 5.0%, p=0.003). Patients over 65 developed more complications (0.9 ± 1.1) than the under 65s (0.5 ± 0.9), p=0.009, and sepsis was significantly associated with higher mortality rate (p=0.042). Over-65-year-old burn victims have a higher mortality risk than the under 65s. Elderly patients generally have more pre-existing comorbidities and develop more complications during hospital stay, which increase the mortality risk. Apparently, history of COPD or sepsis complication during hospital stay are independent risk factors for death in the elderly group. Although over-65-year-olds presented similar TBSA to the younger patients, the proportion of deep burns was higher, which suggests that burns might be more aggressive in the elderly.

Face and/or neck burns: a risk factor for respiratory infection?

Infections are a common cause of morbidity and mortality in burn patients, and almost 50% of infection-related deaths in burn patients are caused by pneumonia. The proportion of facial and/or neck burns (FNB) in burn centre admissions is high, and these patients have a well known respiratory risk. However, it is not well established in the literature if the occurrence of a FNB is a risk factor for respiratory infection during hospitalization. A retrospective, single-centre trial at the burn unit of the Prelada Hospital was conducted, including patients admitted between January 2011 and December 2014. The primary objective was to investigate the existence of a relation between face and/or neck burns and occurrence of respiratory infection. A total of 229 patients were included in the study, 126 with FNB and 103 without FNB. Higher total body surface area (TBSA) burned, inhalation injury and early endotracheal intubation were statistically more frequent in the FNB group. These variables were also more prevalent in the group that developed respiratory infection during the burn unit stay. Concerning FNB patients, the most frequent microbiological strains isolated in respiratory secretion cultures were Staphylococcus aureus, Pseudomonas aeruginosa and Streptococcus pneumonia, while in nFNB patients it was Klebsiella pneumoniae. In our population, only early ETI, inhalation injury and higher TBSA appear to be independent risk factors for respiratory infection in FNB patients, although age, male sex and co-morbidities are also known risk factors for respiratory infection in burn patients.

Pre-burn centre management of the airway in patients with face burns

Face burns expose patients to a higher respiratory risk, and early prophylactic intubation before they enter the burn unit might be life-saving. However, unnecessary intubation may compromise their clinical evolution. Hence, the decision to perform pre-burn centre endotracheal intubation remains a clinical challenge. A retrospective study was developed to characterize the experience of the tertiary burn unit of the Hospital da Prelada with face burn patients arriving endotracheally-intubated between January 2009 and September 2013. Specific goals included assessment of whether these intubations were clinically appropriate and if these procedures determined significant changes in clinical course and outcome. A total of 136 patients were admitted to our burn centre with facial burns. 38.2% (n=52) of them arrived endotracheally-intubated, with 75% (n=39) intubated at the scene of the burn injury and 25% (n=13) in the emergency room because of the suspicion of smoke inhalation injury. In only 23% of the cases (n=12) was the lesion confirmed by bronchoscopy. The overall mortality rate was 12.5% (n=17): 3.6% (n=3) were patients who had not been subjected to pre-burn centre intubation, and 27% (n=14) were in the group of patients arriving intubated. A face burn is a warning sign of a possible upper airway injury, and pre-burn centre prophylactic intubation might be life-saving. However, unnecessary intubation may impair clinical evolution. Therefore, it is imperative that updated practice guidelines for pre-burn centre airway management are adhered to, and that these guidelines are subject to revision in order to improve airway management in burn patients.

Muscle activity of the erector spinae during Pilates isometric exercises on and off Swiss Ball

BACKGROUND

The purpose of this study was to investigate the muscle activity of the Erector spinae (ES) during Pilates isometric exercises on and off Swiss ball.

METHODS

Fifteen women (22.9±2.1years, 171.7±4.7 cm, 65.7±5.3 kg and 11.2±3.2% of body fat) with previous Pilates experience (1±0.9 years) participated as subjects in this study. In the first test session, the anthropometric data and maximal voluntary contraction (MVC) was measured. In the second test session, three isometric exercises were conducted on and off the Swiss ball: back extension (BE), back extension with elbows flexed (BTF) and back extension with elbows extended (BTE). During all exercises, average integrated electromyography (IEMG) from ES muscle was collected and analyzed. A one-way ANOVA with repeated measures followed by Bonferroni post hoc was adopted to compare the muscle activity (P<0.05).

RESULTS

ES activity was higher for BT, BTF and BTE on stable surface than on Swiss ball, respectively. Significant differences were observed for the ES activity during BTE exercise when compared to BTF and BT on and off Swiss ball, respectively.

CONCLUSION

The Swiss ball may not provide a potential effect on ES activity during Pilates isometric exercises with similar posture when compared to stable surfaces. Therefore, the combination of BT, BTF and BTE exercises may be an interesting alternative to provide progressive increases in the ES activity.

Quantitative evaluation of experimental choroidal neovascularization by confocal scanning laser ophthalmoscopy: fluorescein angiogram parallels heparan sulfate proteoglycan expression

The objective of the present study was to develop a quantitative method to evaluate laser-induced choroidal neovascularization (CNV) in a rat model using Heidelberg Retina Angiograph 2 (HRA2) imaging. The expression of two heparan sulfate proteoglycans (HSPG) related to inflammation and angiogenesis was also investigated. CNV lesions were induced with argon laser in 21 heterozygous Zucker rats and after three weeks a fluorescein angiogram and autofluorescence exams were performed using HRA2. The area and greatest linear dimension were measured by two observers not aware of the protocol. Bland-Altman plots showed agreement between the observers, suggesting that the technique was reproducible. After fluorescein angiogram, HSPG (perlecan and syndecan-4) were analyzed by real-time RT-PCR and immunohistochemistry. There was a significant increase in the expression of perlecan and syndecan-4 (P < 0.0001) in retinas bearing CNV lesions compared to control retinas. The expression of these two HSPG increased with increasing CNV area. Immunohistochemistry demonstrated that the rat retina damaged with laser shots presented increased expression of perlecan and syndecan-4. Moreover, we observed that the overexpression occurred in the outer layer of the retina, which is related to choroidal damage. It was possible to develop a standardized quantitative method to evaluate CNV in a rat model using HRA2. In addition, we presented data indicating that the expression of HSPG parallels the area of CNV lesion. The understanding of these events offers opportunities for studies of new therapeutic interventions targeting these HSPG.

Thrombosed popliteal aneurysm - first manifestation of bilateral popliteal entrapment syndrome

Popliteal artery entrapment syndrome is a rare and underdiagnosed cause of claudication in the young adult. One of its rare and potentially limb threatening complications is aneurysmal degeneration. We present a case of a fifty years old man with a bilateral popliteal entrapment syndrome admitted with an acutely thrombosed aneurysm at the right inferior limb. An urgent bypass was required. The contralateral limb presented with a type III entrapment and an elective section of a musculotendinous structure was performed. This case suggests that an early diagnosis is mandatory to avoid a dramatic clinical outcome and to limit the surgical treatment to a myotomy.

Tractional retinal detachment following intravitreal bevacizumab (Avastin) in patients with severe proliferative diabetic retinopathy

AIMS

The aim of this study was to report the development or progression of tractional retinal detachment (TRD) after the injection of intravitreal bevacizumab (Avastin) used as an adjuvant to vitrectomy for the management of severe proliferative diabetic retinopathy (PDR).

METHODS

The clinical charts of patients who experienced the development or progression of TRD after an intravitreal injection of 1.25 mg bevacizumab before vitrectomy for the management of PDR were reviewed.

RESULTS

Eleven eyes (patients) out of 211 intravitreal injections (5.2%) that developed or had progression of TRD were identified. All eyes had PDR refractory to panretinal photocoagulation (PRP). Nine patients had type 1 diabetes mellitus (DM), and two patients had type 2 DM. Patients had a mean age of 39.5 years (range 22-62 years). In the current study, all patients used insulin administration and had poor glycaemic control (mean HbA(1c) 10.6%). Time from injection to TRD was a mean of 13 days (range 3-31 days). Mean best correct visual acuity (BCVA) at TRD development or progression was logarithm of the minimal angle of resolution (LogMAR) 2.2 (range 1.0-2.6) (mean Snellen equivalent hand motions; range 20/200 to light perception), a statistically significant worsening compared with baseline BCVA (p<0.0001). Eight eyes underwent vitrectomy and three patients refused or were unable to undergo surgery. The final mean BCVA after surgery was LogMAR 0.9 (range 0.2-2.0) (mean Snellen equivalent 20/160; range 20/32 to counting fingers), a statistically significant improvement compared with TRD BCVA (p = 0.002).

CONCLUSIONS

TRD may occur or progress shortly following administration of intravitreal bevacizumab in patients with severe PDR.

Intravitreal bevacizumab (Avastin) for proliferative diabetic retinopathy: 6-months follow-up

AIMS

To study the effects of intravitreal bevacizumab (Avastin) on retinal neovascularization (RN) in patients with proliferative diabetic retinopathy (PDR).

METHODS

Retrospective study of patients with RN due to PDR who were treated with at least one intravitreal injection of 1.25 or 2.5 mg of bevacizumab. Patients underwent ETDRS best-corrected visual acuity (BCVA) testing, ophthalmoscopic examination, optical coherence tomography (OCT), and fluorescein angiography (FA) at baseline and follow-up visits.

RESULTS

Forty-four eyes of 33 patients with PDR and a mean age of 57.2-years (range: 23-82 years) participated in the study. Thirty-three eyes (75%) had previous panretinal photocoagulation (PRP). Twenty-seven eyes (61.4%) showed total regression of RN on fundus examination with absence of fluorescein leakage, 15 eyes (34.1%) demonstrated partial regression of RN on fundus examination and FA. Follow-up had a mean of 28.4 weeks (range from 24 to 40 weeks). BCVA and OCT demonstrated improvement (P<0.0001). Three eyes without previous PRP ('naive' eyes) and with vitreous haemorrhage have avoided vitreo-retinal surgery. One eye (2.2%) had PDR progression to tractional retinal detachment requiring vitrectomy, and one eye (2.2%) had vitreous haemorrhage with increased intraocular pressure (ghost cell glaucoma). No systemic adverse events were observed.

CONCLUSIONS

Intravitreal bevacizumab resulted in marked regression of RN in patients with PDR and previous PRP, and rapid resolution of vitreous haemorrhage in three naive eyes. Six-months results of intravitreal bevacizumab at doses of 1.25 or 2.5 mg in patients with PDR do not reveal any safety concerns.

Interstitial high dose rate brachytherapy and cervical dissection the management of recurrent head and neck cancers

15529

Background: The literature is scarce regarding the use of interstitial high dose rate brachytherapy (I-HDR) in this setting, most reports are focused on primary tumors. We performed a retrospective analysis of a single institutional polity of treatment using salvage surgery associated to I-HDR at the Radiation Oncology Departments, Hospital do Cancer A.C. Camargo, São Paulo, Brazil. Methods: All patients with recurrent cervical cancer treated with combination of surgery and I-HDR, with or without the addition a new second course of EBRT, biopsy proven squamous cell carcinoma (SCC), Karnofsky performance status up to 60 and, no evidence of distant metastasis. Patients treated from October, 1994 to June, 2004, were retrospectively selected. Results: Twenty-one patients with median age of 53.5 years (range 31–73) were included in the study. The ratio male to female was 3.2:1 and the follow up time ranged from 6 months to 82 months (median - 36 months). Thirteen (61.9%) had a previous course of irradiation, in whom the median total I-HDR dose was 25.8 Gy, inferior when compared to the median dose of 40.7 Gy given to patients without a previous course of EBRT (p = 0.011), but with no influence in OS (p = 0.9436). The only predictive factor for an improved LFRS and OS was margin status, p = 0.0007 and p = 0.0002, respectively Conclusions: Recurrent HNC should have aggressive salvage procedures as they they are life threatening. Although the number of patients is small, our preliminary results are inspiring, leading to a relative high local control rate with acceptable morbidity,

No significant financial relationships to disclose.

Chemotherapy followed by low dose radiotherapy in childhood Hodgkin’s disease. Retrospective analysis of results and prognostic factors

9039

Background: To report on treatment results and prognostic factors of young patients with Hodgkin’s disease treated with chemotherapy (CT) followed by low dose radiotherapy (RT). Methods: This retrospective series analysed 166 patients under 18 years old, treated from January 1985 to December 2003. Median age was 10 years (range 2–18). The male to female ratio was 2,3:1. Adenomegalia was the most frequent complaint (68%), and the time of symptom duration was smaller than 6 months in 55% of the patients. In histological analysis Nodular Sclerosis was the most prevalent type (43%) followed by Mixed Celularity (41%). The disease was restricted to two nodal group ( stage II) in 60% and to adjacent groups in 55% (stage III). The most frequent site of metastasis ware the bone marrow (38%) and lungs (42%). Standard treatment consisted of chemotherapy (drug combination varied according to treatment protocols vigent). Radiotherapy consisted of 21 Gy dose in 17 fractions in most part of patients (90.2%), delivered to involved field or mantle field. 13,86% patients did not receive RT. Results: The OS and EFS in 10 years were 88.6% and 82.4%.Survival according to clinical stage as 94.4%, 94.25%, 90.6% and 71.5% for stages I to IV (p=0.0215). The OS in 90.5% of patients who received RT and in 75.6% of patients who did not (p=0.001). Multivariate analysis showed presence of B symptoms and low platelet count to be associated with a worse prognosis. Conclusions: This study shows that combining chemotherapy and low dose RT is an effective treatment for HL in childhood, providing high rates of cure and disease control (88.6% in 10 years), and that so far it is not possible to abdicar RT. And yet, attention to platelet count should be payed in order to improve survival. Also, B symptom presenting children may be involved in more aggressive protocols so survival can be improved. As the disease is highly curable, any data of long term follow-up should be presented in order to better direct therapy, improving outcome and lowering side effects.

No significant financial relationships to disclose.

Visual and electrical evoked response recorded from subdural electrodes implanted above the visual cortex in normal dogs under two methods of anesthesia

Sensitive methods are required to record electrical evoked potentials over the visual cortex to evaluate the efficacy and safety of a retinal prosthesis before it can be implanted on the retinal surface of patients afflicted by outer retinal diseases. This study was designed to examine subdural electrodes as a mean to evaluate cortical evoked potentials in response to light and electrical stimulation of the retina in three dogs under two methods of anesthesia-halothane and propofol. Results showed that subdural electrodes could be stabilized over the visual cortex for several (3-5) months, and that they were 6.95 times more sensitive than subdermal electrodes in recording cortical visual evoked potentials (VEPs) and 4.31 times more sensitive in recording cortical electrical evoked potentials under both methods of anesthesia. The waveforms' shape changed for each electrode in the subdural array during 6/6 (100%) and 20/38 (52%) multi-channel recording sessions under halothane and propofol, respectively. This change could point to a cortical retinotopic organization versus hierarchical organization of different cortical areas for a given retinal stimulus. In summary, subdural electrodes show promising results for recording visual and electrical evoked responses (EERs) and thus for evaluation of the retinal prosthesis.

Expression of the melanocortin receptors MC2-R (ACTH-receptor) and MC5-R during embryonic development of ovine adrenals

Two melanocortin receptors MC2-R (ACTH-receptor) and MC5-R are expressed in the adult lamb adrenal cortex. In this work, we have studied the time-course of expression of these two receptors during ovine fetal development. MC2-R expression progressively increases from day 60 to day 140 of gestation (x3), then more rapidly before parturition and remains constant in the newborn. In contrast, the pattern of MC5-R expression is totally different. A strong increase is observed between days 60 and 120 (x7) then followed by a decrease until parturition and after birth. This peak of MC5-R expression precedes that of MC2-R, suggesting that MC5-R might be involved in alpha-MSH- and/or ACTH-stimulated corticosteroid synthesis during early embryonic life.

[Fungal keratitis in the State of Paraná-Brazil: clinical, epidemiological and diagnostic findings]

Fungal keratites is more prevalent in tropical and subtropical regions, such as Brazil, and causes high morbidity. Usually, it is preceded by underlying conditions like ocular trauma or immunosuppression. The diagnosis is confirmed by the demonstration of the etiologic agent in the clinical specimen. Data were analysed from 49 patients with fungal keratitis observed in Ophthalmologic Division of Hospital de Clinicas, Federal University of Parana, from 1983 to 1997. The diagnosis was confirmed by culture and/ or direct examination. Of the cases studied, 22% were diagnosed only by direct examination; 50% by isolation in culture and 26% by the association of the both methods. The most prevalent etiologic agents were: Fusarium sp. (32%), Aspergillus sp. (16,5%) and Penicillium sp. (10%).

Macular translocation: unifying concepts, terminology, and classification

PURPOSE

To describe some unifying concepts, terminology, and classification of macular translocation so as to facilitate communication within the scientific community.

METHODS

A panel of ophthalmologists with expertise in macular translocation reviewed available data and developed some unifying concepts, terminology, and classification of macular translocation.

RESULTS

Macular translocation may be defined as any surgery that has a primary goal of relocating the central neurosensory retina or fovea intraoperatively or postoperatively specifically for the management of macular disease. It may be classified according to the size of the retinotomy and, where applicable, the technique of chorioscleral shortening used. The direction of macular translocation is denoted by the movement of the neurosensory macula relative to the underlying tissues. Effective macular translocation may be defined as successful intraoperative or postoperative relocation of the fovea overlying a subfoveal lesion to an area outside the border of the lesion. The concepts of minimum desired translocation and median postoperative foveal displacement can give some useful idea of the likelihood of effective macular translocation before surgery.

CONCLUSIONS

Use of a common standardized terminology for macular translocation will facilitate communication within the scientific community and enhance further research in this area. However, the definitions, terms, classification, and concepts concerning macular translocation are likely to continue to evolve as macular translocation undergoes further modifications and refinements.

Phase I trial of HuM291, a humanized anti-CD3 antibody, in patients receiving renal allografts from living donors

BACKGROUND

HuM291 is a humanized anti-CD3 monoclonal antibody engineered to reduce binding to Fcgamma receptors and complement fixation. HuM291 has a long serum half-life and mediated profound depletion of circulating T cells in chimpanzees; HuM291 also has significantly less mitogenic and cytokine-releasing activity than OKT3 in vitro.

METHODS

A phase I dose-escalation study was conducted in 15 end-stage renal disease patients scheduled for renal allografts from living donors. Patients received one i.v. HuM291 injection before transplantation. Five doses were tested: 0.015 microg/kg, 0.15 microg/kg, 0.0015 mg/kg, 0.0045 mg/kg, and 0.015 mg/kg. Patients were followed for adverse events, laboratory abnormalities, serum cytokine levels, pharmacokinetics, and CD2+, CD3+, CD4+, and CD8+ T cell counts.

RESULTS

HuM291 was well tolerated; most adverse events were mild to moderate in severity and included headache, nausea, chills, and fever. These occurred within the first few hours after HuM291 administration, resolved within 24 to 48 hr, and were likely related to cytokine release. In general, peak tumor necrosis factor-alpha, interferon-gamma, and interleukin-6 levels were detected 1 to 6 hr postdosing only at the three highest doses and were generally undetectable by 24-hr postdosing. Serious adverse events possibly related to HuM291 included clotting of a fistula (two patients), chemical cellulitis (one patient), and increased serum creatinine/decreased hematocrit (one patient). At doses > or = 0.0015 mg/kg (0.1 mg/70 kg), HuM291 induced rapid, marked depletion of peripheral T cells within 2 hr; duration of T cell depletion was dose dependent. At the two highest dose levels, T cells remained depleted for approximately 1 week.

CONCLUSIONS

A single HuM291 dose rapidly depleted circulating T cells in a dose-dependent manner and was associated with only mild to moderate symptoms of cytokine release.

Chronic stress effects on the rat adrenal cortex

Under the influence of a chronic permanent stress, the adrenal function as well as the entire hypothalamic-pituitary-adrenal axis (HPAA) suffered an adaptation process that resulted in the normalization of the studied stress hormones (ACTH, corticosterone and aldosterone) with the exception of plasma renin activity which first diminished and at the end increased. ACTH receptors exhibited a dual response since after 14 days of permanent stress MC2-R showed a slight reduction while MC5-R was still up-regulated.

The mitochondrial DNA A3243G mutation in Portugal: clinical and molecular studies in 5 families

Out of 90 Portuguese patients with mitochondrial cytopathy, six harbored the A3243G mutation in the mtDNA tRNA(Leu(UUR)) gene ('MELAS mutation'). They had heterogeneous clinical features, including myopathy with stroke-like episodes, progressive external ophthalmoparesis, diabetes mellitus, and subacute encephalopathy. Histochemical and biochemical analyses of muscle biopsies showed abundant ragged-red fibers reacting positively with the cytochrome oxidase stain, and decreased respiratory chain enzyme activities. On average, the proportion of mutated mtDNA was 67% (20-88%) in tissues from patients and 21% (0-49%) in blood from 20 maternal relatives. The proportion of mutated mitochondrial genomes in muscle did not correlate with clinical presentation or duration of disease. This study, the first in Portuguese patients, confirms the frequent occurrence of the A3243G mutation in patients with mitochondrial diseases, and emphasises the usefulness of genetic testing in reaching a correct diagnosis.

Ontogeny of 3beta-hydroxysteroid dehydrogenase expression in the rat adrenal gland as studied by immunohistochemistry

The enzyme 3beta-hydroxysteroid dehydrogenase plays a crucial role in the steroidogenic process in the adrenal gland. In the present study we tried to characterize its localization and developmental changes in the rat adrenal cortex during the postnatal period, using immunohistochemical methods. The development of the different zones evidenced specific particularities: the zona glomerulosa almost lacked 3beta-HSD in the first days after birth; then, 3beta-HSD increased, attaining a maximum around day 20 and afterwards it decreased again and remained less intense than the neighbouring zona fasciculata up until adulthood (65 days of age). The zona fasciculata was already intensely stained at birth and the expression of 3beta-HSD increased rapidly reaching a maximum after 2 weeks of life and that level was maintained from then on. The inner part of the zona fasciculata and the zona reticularis both of which develop postnatally were faintly immunostained before day 20. The expression of 3beta-HSD increased after that age to become approximately as intense as in the outer zona fasciculata and so remaining until day 90. The development of the zona glomerulosa was parallel to the secretion of aldosterone. The same did not occur with the zona fasciculata as the intensity of staining during the first 14 postnatal days was accompanied by very low levels of corticosterone.

DNA quantification and ploidy patterns in human adrenocortical neoplasms

The determination of DNA ploidy and the study of the cell cycle in adrenocortical tumoral cells could help in the distinction between benign and malignant lesions and also in the prediction of the biological behaviour of these tumors. We analysed 32 cases of adrenal tissue (8 normal adrenals--N, 12 benign adenomas--A and 12 carcinomas--C). DNA was quantified by image analysis of Feulgen stained sections (Ahrens System) employing ACAS3 software. The DNA content was considered to be diploid in 70% of the N and in 67% of the A groups and in none of C. In this latter group nearly 90% were triploid or tetraploid while this did not occur in any of the A cases. The percentage of cases with a 5c-exceeding rate (5cER) above 5% was nil in the N and A groups and 100% in C. In what concerns the distribution in the cell cycle we found a very distinctive pattern between the groups as the percentage of cases in which the S-phase fraction exceeded 33% was nil in the normals, 8% in A and 83% in the C cases. In conclusion, there was a good correlation between the analysed parameters and the clinically defined groups of adrenal cortex tumors.

L-2-Hydroxyglutaric aciduria: clinical, biochemical and magnetic resonance imaging in six Portuguese pediatric patients

We present clinical, biochemical and cranial magnetic resonance imaging data of six pediatric patients with L-2-hydroxyglutaric aciduria. All the children have the same ethic origin and lived in the northern area of Portugal. Our findings reinforce the described phenotype of this rare metabolic disease with mental deficiency, severe cerebellar dysfunction, mild extrapyramidal and pyramidal symptoms, progressive macrocephaly and seizures. Magnetic resonance imaging revealed subcortical leukoencephalopathy, cerebellar atrophy and signal changes in the putamina and dentate nuclei. These were similar to those of the previous reports in all patients. The urinary excretion of L-2-hydroxyglutaric acid was variably increased in all patients. The other persistent biochemical abnormality was hyperlysinemia. We have found a strong correlation between the severity of the clinical manifestations and the extension of the lesions in the neuroimaging studies. There was no correlation between the clinical findings and the amount of urinary excretion of L-2-hydroxyglutaric acid. We report the second case in the literature of a cerebral thalamic tumor in L-2-hydroxyglutaric aciduria; neuropathological examination of the surgical biopsy demonstrated a diffuse fibrillary astrocytoma.

Development of a two-site immuno-PCR assay for hepatitis B surface antigen

Hepatitis B virus (HBV) gene transcription may occur at very low levels resulting in HBsAg concentrations in serum and liver below the limit of detection by currently available immunoassays. An assay has been developed that combines the specificity of two high affinity anti-HBs monoclonal antibodies (MAb) directed against distinct and separate determinants in the 'a' domain of HBsAg with the highly sensitive polymerase chain reaction (PCR) detection method. Following capture of HBsAg present in serum samples, the second anti-HBs MAb, which is biotinylated, is added. Binding of the second antibody allows the subsequent specific binding of streptavidin and a biotinylated linear DNA molecule derived from a bluetongue virus (BTV) gene. Presence of this DNA is then detected by PCR using BTV-specific primers. The PCR product is quantified by a liquid-phase oligonucleotide enzymatic assay, which further increases the sensitivity of the technique. The use of a two-site MAb capture and PCR detection system for HBsAg was shown to greatly enhance the specificity and sensitivity of the assay and detect as little as 0.5 pg of HBsAg in serum samples. It is suggested that the principles of this technique could be applied to measure other low level viral antigens in serum and biological samples.

Risk factors for basal cell carcinoma: a case-control study

A controlled trial was performed with the purpose of investigating which factors could be considered of significant risk for the development of basal cell carcinoma. A total of 259 cases of basal cell carcinoma diagnosed from July 1991 to July 1992 were compared with 518 controls matched for age and sex. All subjects in both groups were white. Protocol data were submitted to statistical analysis by the chi-square test and by multiple conditional logistic regression analysis and the following conclusions were reached: 1) light skin color (types I and II of the Fitzpatrick classification), odds ratio of 2.8; outdoor work under constant sunlight, odds ratio of 5.0; the presence of actinic lesions due to exposure to the sun, odds ratio of 4.9, are risk factors per se. 2) Type III skin in the Fitzpatrick classification only represents a risk factor when the patient reports a history of intense sunburns, but not in the absence of such a history. 3) Sunburns per se do not represent a risk factor althorig the point made in item 2 of these conclusions is valid. 4) Other suspected risk factors whose significance was not confirmed by multiple conditioned logistic regression analysis were: residence in rural areas, light eyes and blond hair color, extent of the awareness of the "sun x skin cancer" relationship, familial occurrence of skin cancer, excessive exposure to the sun, and freckles appearing in childhood.

Expression of a full-length nonstructural protein NS1 of bluetongue virus serotype 17 in Escherichia coli

The relative abundance of the nonstructural protein NS1 in bluetongue virus (BTV)-infected cells, the existence of NS1 in the BTV particles and the highly conserved NS1 gene among BTV serotypes indicate the diagnostic potential of using NS1 in detecting BTV infections. In this study a NS1 gene was expressed with the T7 RNA polymerase expression system to produce a full-length NS1 protein. Sheep anti-NS1 antibodies were raised with the E. coli-produced NS1 and used to show that the NS1 proteins of the five BTV serotypes in the Unites States were immunologically indistinguishable.

GM2-gangliosidosis B1 variant: analysis of beta-hexosaminidase alpha gene mutations in 11 patients from a defined region in Portugal

The GM2-gangliosidosis B1 variant occurs at an exceptionally high frequency in the northern part of Portugal. In most patients, the disease manifests itself as a juvenile form, as opposed to the late-infantile form described for many patients from other parts of the world. We have analyzed the beta-hexosaminidase alpha gene in 11 patients, as well as in some relatives, in order to characterize the underlying abnormalities. They were screened for the two previously identified mutations responsible for the B1 variant phenotype (G533----A, also designated as the "DN allele," and C532---T) by PCR amplification of an 800-bp DNA fragment and subsequent dot-blot hybridization with allele-specific oligonucleotides. The fragment amplified from one patient was also subcloned and sequenced. Ten patients, constituting a clinically and biochemically homogeneous group, were found to be homozygous for the DN allele. The other, whose clinical profile more resembled the late-infantile phenotype often described in the literature, was a compound heterozygote carrying the DN allele and another, as yet unidentified, abnormal allele. Our results, corroborated by previously published data, suggest that homozygotes and compound heterozygotes for the DN allele may be distinguishable at the phenotypic level, depending on the nature of the abnormality in the other allele. A common ancestral origin for the DN allele can also be postulated.

Biochemical characterization of beta-hexosaminidase in different biological specimens from eleven patients with GM2-gangliosidosis B1 variant

GM2-gangliosidosis B1 variant is thought to be a rare disorder with a wide geographical and ethnic distribution. We report the biochemical findings obtained in different specimens from a group of 11 B1 variant patients originating from the north of Portugal. The biochemical data obtained seem to indicate that only one of these patients is a genetic compound presenting a clinical and biochemical pattern similar to the majority of B1 variant patients described in the literature, but somewhat different from the profile presented by the other patients reported here, who are homozygous for the 'DN-allele'.

Juvenile GM2 gangliosidosis variant B1: clinical and biochemical study in seven patients

We describe seven patients from five different families with GM2 gangliosidosis, variant B1. To our knowledge these are the first juvenile cases reported in the literature.