MoS2 2D materials induce spinal cord neuroinflammation and neurotoxicity affecting locomotor performance in zebrafish

MoS2 nanosheets belong to an emerging family of nanomaterials named bidimensional transition metal dichalcogenides (2D TMDCs). The use of such promising materials, featuring outstanding chemical and physical properties, is expected to increase in several fields of science and technology, with an enhanced risk of environmental dispersion and associated wildlife and human exposures. In this framework, the assessment of MoS2 nanosheets toxicity is instrumental to safe industrial developments. Currently, the impact of the nanomaterial on the nervous tissue is unexplored. In this work, we use as in vivo experimental model the early-stage zebrafish, to investigate whether mechano-chemically exfoliated MoS2 nanosheets reach and affect, when added in the behavioral ambient, the nervous system. By high throughput screening of zebrafish larvae locomotor behavioral changes upon exposure to MoS2 nanosheets and whole organism live imaging of spinal neuronal and glial cell calcium activity, we report that sub-acute and prolonged ambient exposures to MoS2 nanosheets elicit locomotor abnormalities, dependent on dose and observation time. While 25 μg mL-1 concentration treatments exerted transient effects, 50 μg mL-1 ones induced long-lasting changes, correlated to neuroinflammation-driven alterations in the spinal cord, such as astrogliosis, glial intracellular calcium dysregulation, neuronal hyperactivity and motor axons retraction. By combining integrated technological approaches to zebrafish, we described that MoS2 2D nanomaterials can reach, upon water (i.e. ambient) exposure, the nervous system of larvae, resulting in a direct neurological damage.

A microphysiological system for handling graphene related materials under flow conditions

The field of nanotechnology has developed rapidly in recent decades due to its broad applications in many industrial and biomedical fields. Notably, 2D materials such as graphene-related materials (GRMs) have been extensively explored and, as such, their safety needs to be assessed. However, GRMs tend to deposit quickly, present low stability in aqueous solutions, and adsorb to plastic materials. Consequently, traditional approaches based on static assays facilitate their deposition and adsorption and fail to recreate human physiological conditions. Organ-on-a-chip (OOC) technology could, however, solve these drawbacks and lead to the development of microphysiological systems (MPSs) that mimic the microenvironment present in human tissues. In light of the above, in the present study a microfluidic system under flow conditions has been optimised to minimise graphene oxide (GO) and few-layer graphene (FLG) adsorption and deposition. For that purpose, a kidney-on-a-chip was developed and optimised to evaluate the effects of exposure to GO and FLG flakes at a sublethal dose under fluid flow conditions. In summary, MPSs are an innovative and precise tool for evaluating the effects of exposure to GRMs and other type of nanomaterials.

Fractional excretion of sodium and potassium and urinary strong ion difference in the evaluation of persistent AKI in sepsis

OBJECTIVE

To evaluate the diagnostic performance of FENa (Fractional excretion of sodium), FEK (fractional excretion of potassium) and uSID (urinary strong ion difference) in predicting pAKI in sepsis and septic shock.

DESIGN

Retrospective cohort study.

SETTING

Two intensive care units in Argentina.

PATIENTS

Adult patients with a confirmed diagnosis of sepsis or septic shock and AKI, and had a urinary biochemistry within 24h of the AKI diagnosis.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

We evaluated the diagnostic accuracy of FENa, FEK and uSID through a ROC (Receiver Operating Characteristic) curve analysis.

RESULTS

80 patients were included. 40 patients presented pAKI. pAKI group had higher APACHE, SOFA score, and mortality rate. In the ROC curve analysis, uSID had no diagnostic utility (AUC=0.52, p=0.69). FENa presented moderate accuracy showing an AUC of 0.71 (95% CI 0.60-0.83; p=0.001), while FEK presented low accuracy with an AUC of 0.69 (95% CI 0.57-0.80; p=0.04). The optimal Youden point for identifying pAKI was at a FENa higher than 0.51 % with a specificity of 72.5% and a sensitivity of 65.0%. In the case of FEK, a value higher than 21.9 % presented the best relation, with a specificity of 67.5% and a sensitivity of 65.0%.

CONCLUSIONS

urine biochemistry interpretation in septic patients must be revised. FENa and FEK are related to the severity of AKI and could be helpful complementary tools for diagnosing pAKI.

Evaluation of the discrimination and calibration of predictive scores of mortality in ECMO for patients with COVID-19

BACKGROUND

The criteria for the selection of COVID-19 patients that could benefit most from ECMO organ support are yet to be defined. In this study, we evaluated the predictive performance of ECMO mortality predictive models in patients with COVID-19. We also performed a cost-benefit analysis depending on the mortality predicted probability. We conducted a retrospective cohort study in COVID-19 patients who received ECMO at two tertiary care hospitals between March 2020 to July 2021.

MATERIALS AND METHODS

We evaluated the discrimination (C-statistic), calibration (Cox calibration), and accuracy of the prediction of death due to severe ARDS in V-V ECMO score (PRESERVE), the Respiratory Extracorporeal Membrane Oxygenation Survival Score (RESP) score, and the PREdiction of Survival on ECMO Therapy-Score (PRESET) score. In addition, we compared the RESP score with Plateau pressure instead of Peak pressure.

RESULTS

We included a total of 36 patients, 29 (80%) of them male and with a median (IQR) APACHE of 10 (8-15). The PRESET score had the highest discrimination (AUROCs 0.81 [95%CI 0.67-0.94]) and calibration (calibration-in-the-large 0.5 [95%CI -1.4 to 0.3]; calibration slope 2.2 [95%CI 0.7/3.7]). The RESP score with Plateau pressure had higher discrimination than the conventional RESP score. The cost per QALY in the USA, adjusted to life expectancy, was higher than USD 100 000 in patients older than 45 years with a PRESET > 10.

CONCLUSION

The PRESET score had the highest predictive performance and could help in the selection of patients that benefit most from this resource-demanding and highly invasive organ support.

Multicenter validation of Early Warning Scores for detection of clinical deterioration in COVID-19 hospitalized patients

Objective

Investigate the predictive value of NEWS2, NEWS-C, and COVID-19 Severity Index for predicting intensive care unit (ICU) transfer in the next 24 h.

Design

Retrospective multicenter study.

Setting

Two third-level hospitals in Argentina.

Patients

All adult patients with confirmed COVID-19, admitted on general wards, excluding patients with non-intubated orders.

Interventions

Patients were divided between those who were admitted to ICU and non-admitted. We calculated the three scores for each day of hospitalization.

Variables

We evaluate the calibration and discrimination of the three scores for the outcome ICU admission within 24, 48 h, and at hospital admission.

Results

We evaluate 13,768 days of hospitalizations on general medical wards of 1318 patients. Among these, 126 (9.5%) were transferred to ICU. The AUROC of NEWS2 was 0.73 (95%CI 0.68-0.78) 24 h before ICU admission, and 0.52 (95%CI 0.47-0.57) at hospital admission. The AUROC of NEWS-C was 0.73 (95%CI 0.68-0.78) and 0.52 (95%CI 0.47-0.57) respectively, and the AUROC of COVID-19 Severity Index was 0.80 (95%CI 0.77-0.84) and 0.61 (95%CI 0.58-0.66) respectively. COVID-19 Severity Index presented better calibration than NEWS2 and NEWS-C.

Conclusion

COVID-19 Severity index has better calibration and discrimination than NEWS2 and NEWS-C to predict ICU transfer during hospitalization.

Caffeine decreases ammonemia in athletes using a ketogenic diet during prolonged exercise

OBJECTIVES

Both exercise and a ketogenic (low-carbohydrate) diet favor glycogen depletion and increase ammonemia, which can impair physical performance. Caffeine supplementation has been routinely used to improve exercise performance. Herein, the effect of xanthine was evaluated on ammonemia in cyclists who were placed on a ketogenic diet and engaged in prolonged exercise.

METHODS

Fourteen male cyclists followed a ketogenic diet for 2 d before and during the experimental trial. The cyclists were assigned to either the caffeine- (CEx; n = 7) or placebo-supplemented (LEx; n = 7) group. Blood samples were obtained during cycling and the recovery periods.

RESULTS

The CEx group showed a significant decrease (up to 25%) in blood ammonia at 60, 90, and 120 min after beginning exercise compared with the LEx group. A higher concentration of apparent blood urea was observed in the LEx group than in the CEx group at 60 to 90 min of exercise (~10%). In addition, a significant increase in blood glucose levels was evident at 30 min of exercise (~28%), and an increase in blood lactate levels was visible during the first 30 to 60 min of exercise (~80%) in the CEx group.

CONCLUSIONS

Our results suggest that the consumption of caffeine might attenuate the increase in ammonemia that occurs during exercise.

Changes in the management and clinical outcomes of critically ill patients without COVID-19 during the pandemic

Objective

To analyze whether changes in medical care due to the application of COVID-19 protocols affected clinical outcomes in patients without COVID-19 during the pandemic.

Methods

This was a retrospective, observational cohort study carried out in a thirty-eight-bed surgical and medical intensive care unit of a high complexity private hospital. Patients with respiratory failure admitted to the intensive care unit during March and April 2020 and the same months in 2019 were selected. We compared interventions and outcomes of patients without COVID-19 during the pandemic with patients admitted in 2019. The main variables analyzed were intensive care unit respiratory management, number of chest tomography scans and bronchoalveolar lavages, intensive care unit complications, and status at hospital discharge.

Results

In 2020, a significant reduction in the use of a high-flow nasal cannula was observed: 14 (42%) in 2019 compared to 1 (3%) in 2020. Additionally, in 2020, a significant increase was observed in the number of patients under mechanical ventilation admitted to the intensive care unit from the emergency department, 23 (69%) compared to 11 (31%) in 2019. Nevertheless, the number of patients with mechanical ventilation after 5 days of admission was similar in both years: 24 (69%) in 2019 and 26 (79%) in 2020.

Conclusion

Intensive care unit protocols based on international recommendations for the COVID-19 pandemic have produced a change in non-COVID-19 patient management. We observed a reduction in the use of a high-flow nasal cannula and an increased number of tracheal intubations in the emergency department. However, no changes in the percentage of intubated patients in the intensive care unit, the number of mechanical ventilation days or the length of stay in intensive care unit.

Comparative analysis of Rhipicephalus tick salivary gland and cement elementome

Rhipicephalus spp. (Acari: Ixodidae) ticks are obligate hematophagous arthropods, which constitute a model for the study of vector-host interactions. The chemical composition or elementome of salivary glands (SG) and cement provides information relevant for the study of protein-based complex multifunctional tissues with a key role in tick biology. In this study, we characterized the elementome of cement cones in Rhipicephalus sanguineus collected from naturally infested dogs and in SG and cement of R. bursa collected from experimentally infested rabbits at different feeding stages. The elementome was characterized using scanning electron microscopy (SEM) combined with energy dispersive X-ray spectroscopy (EDS). The results showed the identification of up to 14 chemical elements in the cement, and suggested tick/host-driven differences in the cement elementome between tick species and between SG and cement within the same species. By still unknown mechanisms, ticks may regulate cement elementome during feeding to affect various biological processes. Although these analyses are preliminary, the results suggested that N is a key component of the cement elementome with a likely origin in SG/salivary proteins (i.e., Glycine (C2H5NO2)-rich superfamily member proteins; GRPs) and other tick/host-derived components (i.e. NAPDH). Future research should be focused on tick elementome and its functional implications to better understand cement structure and function.

Influenza season 2019. Analysis of 143 hospitalized patients

Influenza infection is a latent public health problem, affecting millions of people throughout the world, which imposes high morbidity and economic burden on the region. In Argentina, influenza-associated mortality is estimated at 6/100 000 person-years, and is higher among men = 65 years old. The knowledge of the baseline characteristics and outcomes of hospitalized patients is crucial for public health officials planning interventions to address local outbreaks. Thus, in this retrospective, single-center study, performed in a highcomplexity university hospital, we aimed to analyze clinical characteristics, image findings, and laboratory variables of patients with laboratory-confirmed influenza requiring hospitalization in our hospital during 2019. Cases were confirmed by real-time reverse transcription-polymerase chain reaction. One hundred and forty-three patients with influenza were hospitalized during the study period; 141 (98.6%) were infected with influenza virus type A, including 88 (61.5%) with the H1N1 subtype. The median age was 71 years (IQR 60- 82), 111 (77.6%) were older than 70 years, and 126 (88.1%) had at least one coexisting illness; 56 (39.1%) patients required intensive care unit, 16 (11.1%) invasive mechanical ventilation, and 6 (4.1%) died during hospitalization. In this study, in-hospital mortality was similar to that reported in previous series of non-pandemic influenza, even though the majority of the cases in this study were older than 70 years and had at least one coexisting illness.

Targeting the Exoskeleton Elementome to Track Tick Geographic Origins

Understanding the origin of ticks is essential for evaluating the risk of tick-borne disease introduction into new territories. However, when collecting engorged ticks from a host, it is virtually impossible to identify the geographical location where this tick was acquired. Recently, the elementome of tick exoskeleton was characterized by using scanning electron microscopy (SEM) and energy dispersive spectroscopy analysis (EDS). The objective of our preliminary proof-of-concept study was to evaluate the use of SEM-EDS for the analysis of tick exoskeleton elementome to gain insight into the tick geographic and host origin. For this preliminary analysis we used 10 samples of engorged ticks (larvae and nymphs of six species from three genera) collected from various resident hosts and locations. The elementome of the tick exoskeleton was characterized in dorsal and ventral parts with three scans on each part using an EDS 80 mm² detector at 15 kV in a field emission scanning electron microscope. We used principal component analysis (PCA) (varimax rotation) to reduce the redundancy of data under the premise of losing information as little as possible. The PCA was used to test whether the different variables (tick species, stages, hosts, or geographic locations) differ in the composition of exoskeleton elementome (C, O, P, Cl, and Na). Analyses were carried out using SPSS. The PCA analysis explained a high percentage of variance using the first two factors, C and O (86.13%). The first PC (PC-1; 63.12%) was positively related to P, Cl, and Na, and negatively related to C. The second principal component (23.01%) was mainly positively related to C. In the space defined by the two extracted PC (PC-1 and PC-2), the elementome of tick samples was clearly associated with tick species, but not with developmental stages, hosts or geographic locations. A differentiated elementome pattern was observed within Romanian regions (CJ and TL) for the same tick species. The use of the SEM-EDS methodological approach provided additional information about the tick exoskeleton elementome with possible applications to the identification of tick origin host and location.

Tick and Host Derived Compounds Detected in the Cement Complex Substance

Ticks are obligate hematophagous arthropods and vectors of pathogens affecting human and animal health worldwide. Cement is a complex protein polymerization substance secreted by ticks with antimicrobial properties and a possible role in host attachment, sealing the feeding lesion, facilitating feeding and pathogen transmission, and protection from host immune and inflammatory responses. The biochemical properties of tick cement during feeding have not been fully characterized. In this study, we characterized the proteome of Rhipicephalus microplus salivary glands (sialome) and cement (cementome) together with their physicochemical properties at different adult female parasitic stages. The results showed the combination of tick and host derived proteins and other biomolecules such as α-Gal in cement composition, which varied during the feeding process. We propose that these compounds may synergize in cement formation, solidification and maintenance to facilitate attachment, feeding, interference with host immune response and detachment. These results advanced our knowledge of the complex tick cement composition and suggested that tick and host derived compounds modulate cement properties throughout tick feeding.

Anaplasma pathogen infection alters chemical composition of the exoskeleton of hard ticks (Acari: Ixodidae)

Ticks are arthropod ectoparasites and vectors of pathogens affecting human and animal health worldwide. The exoskeleton is a structure that protect arthropods from natural threats such as predators and diseases. Both structural proteins and chemical elements are components of the exoskeleton. However, the chemical composition and effect of pathogen infection on tick exoskeleton properties has not been characterized. In this study, we characterized the chemical composition of tick exoskeleton and the effect of Anaplasma pathogen infection on the chemical elements of the exoskeleton and selected structural proteins. The chemical composition was characterized ventral, dorsal upper and dorsal lower regions of tick exoskeleton by scanning electron microscopy and energy dispersive spectroscopy and compared between infected and uninfected ticks. The levels of selected structural proteins were analyzed in infected and uninfected I. scapularis salivary glands by immunofluorescence analysis. The results showed that tick exoskeleton contains chemical elements also found in other arthropods. Some of the identified elements such as Mg and Al may be involved in tick exoskeleton stabilization through biomineralization of structural proteins that may be overrepresented in response to pathogen infection. These results suggested that pathogen infection alters the chemical composition of tick exoskeleton by mechanisms still to be characterized and with tick species and exoskeleton region-specific differences.

[Kinetics of procalcitonin in infections caused by multidrug-resistant bacteria]

Procalcitonin guidance stimulates a reduction in the duration of antibiotic treatment in critically ill patients with a presumed bacterial infection, but its role in infections caused by multidrug-resistant bacteria has not been sufficiently explored. In this retrospective observational study, we analyzed procalcitonin curves of 32 patients with culture-confirmed ventilation-associated pneumonia (VAP) and catheter-related bloodstream infections (CRBSI) occurred during the period 11/1/2016 to 7/1/2019. Sixteen infections were caused by multidrug-resistant bacteria (10 CRBSI and 6 VAP) and other 16 by sensitive bacteria (10 CRBSI and 6 VAP). CRBSI generated by multidrug-resistant bacteria elicited significantly higher procalcitonin levels than CRBSI infections caused by sensitive bacteria (39 ± 30 υg/l vs. 10.7 ± 11 υg/l, p = 0.02). Patients with VAP caused by sensitive and multidrug-resistant bacteria elicited similar procalcitonin levels. The time to a decrease in procalcitonin level to less than 80% of the peak value or less than 0.5 υg/l upon effective antibiotic treatment was 7.2 ± 2.9 days in multidrug-resistant bacteria vs. 5 ± 1.8 days in sensitive bacteria (p = 0.03). In multidrug-resistant bacteria, the inflammatory response measured by procalcitonin is stronger and longer, even with an effective antibiotic treatment. However, the decline occurs before the conventional antibiotic scheme is completed. The potential application of antibiotic protocols guided by procalcitonin to these groups of patients grants further studies aimed to reduce exposure to antibiotics in critical multidrug-resistant infections.

Reduction in Oviposition of Poultry Red Mite (Dermanyssus gallinae) in Hens Vaccinated with Recombinant Akirin

The poultry red mite (PRM), Dermanyssus gallinae, is a hematophagous ectoparasite of birds with worldwide distribution that causes economic losses in the egg-production sector of the poultry industry. Traditional control methods, mainly based on acaricides, have been only partially successful, and new vaccine-based interventions are required for the control of PRM. Vaccination with insect Akirin (AKR) and its homolog in ticks, Subolesin (SUB), have shown protective efficacy for the control of ectoparasite infestations and pathogen infection/transmission. The aim of this study was the identification of the akr gene from D. gallinae (Deg-akr), the production of the recombinant Deg-AKR protein, and evaluation of its efficacy as a vaccine candidate for the control of PRM. The anti-Deg-AKR serum IgY antibodies in hen sera and egg yolk were higher in vaccinated than control animals throughout the experiment. The results demonstrated the efficacy of the vaccination with Deg-AKR for the control of PRM by reducing mite oviposition by 42% following feeding on vaccinated hens. A negative correlation between the levels of serum anti-Deg-AKR IgY and mite oviposition was obtained. These results support Deg-AKR as a candidate protective antigen for the control of PRM population growth.

Notch3 signaling activation in smooth muscle cells promotes extrauterine growth restriction-induced pulmonary hypertension

BACKGROUND AND AIMS

Early postnatal life is a critical developmental period that affects health of the whole life. Extrauterine growth restriction (EUGR) causes cardiovascular development problems and diseases, including pulmonary arterial hypertension (PAH). PAH is characterized by proliferation, migration, and anti-apoptosis of pulmonary artery smooth muscle cells (PASMCs). However, the role of PASMCs in EUGR has not been studied. Thus, we hypothesized that PASMCs dysfunction played a role in EUGR-induced pulmonary hypertension.

METHODS AND RESULTS

Here we identified that postnatal nutritional restriction-induced EUGR rats exhibited an elevated mean pulmonary arterial pressure and vascular remodeling at 12 weeks old. PASMCs of EUGR rats showed increased cell proliferation and migration features. In EUGR-induced PAH rats, Notch3 signaling was activated. Relative mRNA and protein expression levels of Notch3 intracellular domain (Notch3 ICD), and Notch target gene Hey1 in PASMCs were upregulated. We further demonstrated that pharmacological inhibition of Notch3 activity by using a γ-secretase inhibitor DAPT, which blocked the cleavage of Notch proteins to ICD peptides, could effectively inhibit PASMC proliferation. Specifically knocked down of Notch3 in rat PASMCs by shRNA restored the abnormal PASMC phenotype in vitro. We found that administration of Notch signaling inhibitor DAPT could successfully reduce mean pulmonary arterial pressure in EUGR rats.

CONCLUSIONS

The present study demonstrated that upregulation of Notch3 signaling in PASMCs was crucial for the development of EUGR-induced PAH. Blocking Notch3-Hey1 signaling pathway in PASMCs provides a potential therapeutic target for PAH.

Programme de collaboration franco-suisse pour la création de nouvelles variétés de vigne durablement résistantes au mildiou et à l'oïdium

Une alternative aux traitements phytosanitaires pour lutter contre le mildiou et l'oïdium de la vigne est le développement de variétés résistantes. Leur création doit intégrer non seulement le niveau de résistance mais également sa durabilité, ainsi que les performances agronomiques notamment la productivité et la composition des baies qui doit convenir à la production de vins de haute qualité. L'Inra (France) a engagé le programme de sélection ResDur, basé sur le pyramidage des facteurs de résistance, en 2000. Il a conduit à l'inscription au catalogue français d'une première série de variétés à résistance polygénique – Artaban, Floreal, Vidoc, Voltis – en 2018. Agroscope (Suisse) a démarré la création de variétés résistantes en 1996, en mobilisant les résistances portées par des variétés allemandes, principalement Bronner. Un premier aboutissement a été l'homologation en Suisse de Divico et Divona, respectivement en 2013 et 2018. En 2009 l'Inra et Agroscope ont démarré un programme de sélection commun, visant à combiner les facteurs de résistance aux maladies présents de manière complémentaire dans leurs lignées respectives. Les croisements réalisés ont généré, après sélection assistée par marqueurs, 400 descendants porteurs des facteurs de résistanceRpv1, Rpv10 et/ou Rpv3 ; Run1, Ren3 et/ou Ren3.2. Leur phénotypage agronomique et œnologique est réalisé dans le cadre d'un réseau d'essais situés dans les deux Instituts à Colmar (FR) et à Pully (CH). Les premières observations pluriannuelles, portant sur 80 descendants, ont permis d'étudier leur stabilité phénotypique pour les caractères de résistance, les traits culturaux et la qualité des vins. A l'issue de cette étape, quinze variétés candidates ont été sélectionnées et installées en essais d'évaluation de leur valeur agronomique, technologique et environnementale (VATE) en Valais (CH), ainsi que dans trois régions françaises (Champagne, Val de Loire, Vallée du Rhône). L'inscription au catalogue des premières co-obtentions Inra/Agroscope est prévue à l'horizon 2024–2025.

Influence of the SPR Experimental Conditions on the G-Quadruplex DNA Recognition by Porphyrin Derivatives

Surface plasmon resonance (SPR) is a powerful technique to study the interactions of ligands with analytes and therefore a number of biosensor surfaces and injection methods have been developed so far. However, many experimental parameters can affect the interactions and consequently the affinity measurements. In particular, the interactions of positively charged analytes (often used for anionic nucleic acids targets) can be influenced by the sensing surfaces (e.g., negatively charged), leading to significant nonspecific interactions as well as regeneration problems. The aim of the present work is to investigate the effect of different parameters, including ionic strength, SPR biosensor (i.e., nature of the surfaces), and the injection method on the recognition of porphyrin G-quadruplex ligands. We demonstrate that the injection method does not influence the affinity whereas the ionic strength and the nature of the surface impact the recognition properties of the porphyrin for the G-quadruplex DNA. We also found that self-assembled monolayer coating surface presents many advantages in comparison with carboxymethylated dextran surface for SPR studies of G-quadruplex DNA/ligand interactions: (i) the electrostatic interaction with charged analytes is less important, (ii) its structure/composition is less sensitive to the ionic concentration and less prone to unspecific adsorption, (iii) it is easily homemade, and (iv) the cost is approximately 10 times cheaper.

Abstract P4-10-20: Breast cancer in Brazil: HER-2 testing and treatment patterns

BACKGROUND

Breast cancer is the most common cancer among Brazilian women. HER-2 targeted therapy improves overall survival in HER-2 overexpressing patients but immunohistochemistry testing for HER2 is not standardized in Brazil and is not available universally. In Brazil the health system includes a public and private sector. The aim of our study was to delineate the patterns of testing of HER-2 over time in Brazil in both of these settings and to determine if any disparities exist in testing and treatments received.

METHODS

Observational, retrospective study involving practice patterns of over 2000 cancer physicians in Brazil. We obtained de-identified data from a commercial database, which included 54,829 patients with breast cancer treated between 2012 and 2016. We analyzed the frequency of HER-2 testing, the percentage of positive results and the most common treatments used in the first line setting in both the private and public sector. The chi-squared test was used for proportions.

RESULTS

HER-2 testing was frequently performed in both the private and public sector (87% vs. 81%, p<0.0001. Between 2012 and 2016 most patients had HER-2 testing (88%, 73%, 79%, 90% and 88%, respectively) but coverage was not universal. The percentage of HER-2 positivity was 25%. The most common first line regimens used were docetaxel/trastuzumab, paclitaxel/trastuzumab and trastuzumab monotherapy. In the private sector trastuzumab/pertuzumab/docetaxel was the most commonly used regimen. In the public sector taxanes were frequently used as monotherapy without HER-2 targeted therapy.

CONCLUSIONS

To our knowledge this is the largest dataset assessing HER-2 testing and treatment patterns in Brazil. The frequency of testing has remained stable over the last 5 years, but is higher in the private sector and this finding was highly statistically significant. There are also differences in the regimens used in the private vs. public sector. Pertuzumab was approved in 2013 in the US and its use has increased in Brazil over the last two years. This trend however was only seen in the private sector. In the public sector there is still significant use of chemotherapy without HER-2 directed therapy despite HER-2 overexpression, which is possibly related to the restricted access of anti-HER2 therapy in the public health system for metastatic patients. Taxanes are used widely in both the public and private sector, which is possibly related to the availability of generics.

HER 2 Testing in the Public Sector20122013201420152016Tested4,2853,7114,5924,6884,126%92%76%80%94%91%Non Tested36211441134322428%8%24%20%6%9%Total4,6474,8555,7265,0104,554

HER 2 Testing in the Public Sector20122013201420152016Tested5,3913,9964,9175,2084,945%85%71%78%87%85%Non Tested9491,6611,367761842%15%29%22%13%15%Total6,3405,6576,2845,9695,787

Citation Format: Palacio S, Torres A, Prado E, Lopes G. Breast cancer in Brazil: HER-2 testing and treatment patterns [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-20.

N-acetylcysteine for therapy-resistant tobacco use disorder: a pilot study

INTRODUCTION

N-Acetylcysteine (NAC) may have efficacy in treating tobacco use disorder (TUD) by reducing craving and smoking reward. This study examines whether treatment with NAC may have a clinical efficacy in the treatment of TUD.

METHODS

A 12-week double blind randomized controlled trial was conducted to compare the clinical efficacy of NAC 3 g/day versus placebo. We recruited 34 outpatients with therapy resistant TUD concurrently treated with smoking-focused group behavioral therapy. Participants had assessments of daily cigarette use (primary outcome), exhaled carbon monoxide (CO(EXH)) (secondary outcome), and quit rates as defined by CO(EXH) < 6 ppm. Depression was measured with the Hamilton Depression Rating Scale (HDRS). Data were analyzed using conventional and modified intention-to-treat endpoint analyses.

RESULTS

NAC treatment significantly reduced the daily number of cigarettes used (Δ mean ± SD = -10.9 ± 7.9 in the NAC-treated versus -3.2 ± 6.1 in the placebo group) and CO(EXH) (Δ mean ± SD = -10.4 ± 8.6 ppm in the NAC-treated versus -1.5 ± 4.5 ppm in the placebo group); 47.1% of those treated with NAC versus 21.4% of placebo-treated patients were able to quit smoking as defined by CO(EXH) < 6 ppm. NAC treatment significantly reduced the HDRS score in patients with tobacco use disorder.

CONCLUSIONS

These data show that treatment with NAC may have a clinical efficacy in TUD. NAC combined with appropriate psychotherapy appears to be an efficient treatment option for TUD.

Agitation and psychosis associated with dementia with lewy bodies exacerbated by modafinil use

Dementia with Lewy bodies (DLB) is commonly associated with excessive daytime somnolence (EDS). Modafinil is a wakefulness-promoting agent that is considered to have limited interaction with the dopaminergic system. As individuals with DLB are predisposed to psychotic symptoms that might be exacerbated by dopaminergic stimulation, modafinil is considered to be an attractive option for the treatment of EDS in DLB. We describe 2 cases in which administration of modafinil exacerbated agitation and hallucinations in DLB, and we also review data that may explain the mechanisms underlying this effect. In both cases, psychotic symptoms emerged concomitantly with modafinil administration and remitted following its discontinuation. Although definitive data regarding the benefits and adverse effects of modafinil for the treatment of EDS in DLB await controlled prospective randomized studies, our observations warrant caution regarding its use in this context.

INFLUÊNCIA DA TEMPERATURA NA DISTRIBUIÇÃO VERTICAL DA COCHONILHA-BRANCA, PLANOCOCCUS CITRI (RISSO) (HEMIPTERA: PSEUDOCOCCIDAE) EM PLANTAS DE CAFÉ

RESUMO O conhecimento da distribuição vertical da cochonilha Planococcus citri em plantas de café faz-se necessário para tornar o seu monitoramento e controle mais eficientes. Assim, avaliou-se a distribuição de ninfas da cochonilha em diferentes partes da planta de café, Coffea arabica L., cv Mundo Novo em cinco temperaturas. A planta de café foi subdividida em porção superior (brotações, quarto e quinto pares de folhas e respectivo caule), porção mediana (folhas cotiledonares, segundo e terceiro pares de folhas e respectivo caule) e porção inferior (colo e raiz). As plantas, após a infestação de dez ninfas de 2°/3° instar na porção superior e colo, foram acondicionadas em câmaras climatizadas a 15, 20, 25, 30 e 35º C. As avaliações foram realizadas sete dias após, registrando-se o número de cochonilhas presentes em cada parte da planta. Constatou-se que a distribuição dos insetos variou de acordo com a temperatura. A 20 e 25° C, esses insetos encontra-ram-se distribuídos uniformemente nas três porções das plantas, porém a 15° C migraram para a porção inferior, e em maior número nas raízes. A 30° C houve predominância das ninfas na porção superior da planta, contudo, a 35° C deslocaram-se para a porção mediana.

ESTUDOS BIOLÓGICOS DE COCHONILHAS DO GÊNERO PLANOCOCCUS (HEMIPTERA: PSEUDOCOCCIDAE) EM DIFERENTES HOSPEDEIROS

RESUMO Este trabalho teve por objetivo estudar o desenvolvimento de populações de cochonilhas do gênero Planococcusem diferentes espécies vegetais, visando à verificação de especificidade hospedeira. A cochonilha Planococcus minorfoi obtida de plantas de cacau (Theobroma cacaoL.) e de café (Coffea canephoraPierre), enquanto Planococcus citrifoi obtida de plantas de citros (Citrus sinensisL. Osbeck). Ovos foram transferidos individualmente para placas de Petri contendo discos foliares de cacau (T. cacaocultivar Catongo), café (Coffea arabicaL. cultivar Mundo Novo) e citros (C. sinensiscultivar Pêra Rio), utilizando-se 60 repetições. Esses discos foliares foram mantidos sobre uma lâmina de ágar-água a 1%, com a superfície abaxial voltada para cima. As placas foram vedadas com filme plástico de PVC e mantidas em câmaras climatizadas reguladas a 25 ± 1º C, 70 ± 10% UR e 12 horas de fotofase. Para as cochonilhas oriundas de cacaueiro, o substrato citros prolongou o desenvolvimento ninfal dos machos (26,0 dias). Para os insetos provenientes de cafeeiro, o substrato café proporcionou o menor período ninfal de fêmeas e machos (19,2 e 21,3 dias, respectivamente) e maior longevidade das fêmeas (59,1 dias). Os maiores índices de mortalidade foram obtidos quando as cochonilhas foram criadas no substrato cacau, independente da planta hospedeira da qual foram originalmente coletadas, e quando mantidas em citros, a partir de espécimes coletados em plantas de café. Há maior preferência alimentar de P. citrie P. minorpara o substrato café, independente do hospedeiro de origem, o que indica uma especificidade hospedeira parcial.

Rentabilidade da exploração leiteira em uma propriedade durante cinco anos

Estudou-se a rentabilidade da atividade bovina leiteira em uma fazenda no município de Jaboticatubas-MG, durante cinco anos - 1996, 2000, 2001, 2002 e 2003. Os dados foram processados no Sistema de Administração Rural e Projetos Agropecuários da EMATER-MG. No cômputo global, conforme valores de dezembro de 2003, a margem líquida negativa atingiu R$ -201.091,89, embora a margem bruta fosse positiva (R$ 130.003,54). O custo da mão-de-obra foi o que mais onerou a produção (29,6%) e o que mais forçou a elevação dos custos fixos (47,8%). O custo unitário do litro de leite alcançou R$ 0,71, enquanto o preço recebido pelo produtor atingiu apenas R$ 0,50. Isso significa que durante o período analisado houve prejuízo de R$ 0,21 em cada litro de leite produzido.

[A new laparoscopic simulator]

BACKGROUND

Simulators are effective devices for the development of certain skills needed in laparoscopic surgery. Bench models with laparoscopy equipment, virtual reality and mirror boxes have been used; however, they have limitations such as the need for laparoscopy equipment, high cost or a considerable mismatch with reality.

METHODS

We undertook this study to test a simulator as a training device that allows the acquisition of eye-hand coordination and two-dimensional spatial orientation without the need of laparoscopic equipment. The simulator consists of a box with an internal light and a color video CCD connected to a television set. Quality of vision, illumination and adequacy as training equipment was assessed by experienced laparoscopic surgeons. Thereafter, 12 general surgeons without experience in laparoscopic surgery and 18 surgery trainees performed seven different drills after a short course on basic skills and knot-tying laparoscopic techniques. The time to completion of each task was recorded at the beginning and after 10 practices of 30-min each.

RESULTS

Ten experienced surgeons qualified with the simulator with a mean of 42 points (40-44 from a 44 total). There were significant reductions in the final times of all participants. Paired t-test was significant in all the measurements. The mean time decreased 31.8% (from 1108 +/- 96 to 755 +/- 107 sec) with a 95% confidence interval of 15.1-48.5%.

CONCLUSIONS

The simulator tested in this study helps to develop laparoscopic surgical skills economically and without the need for laparoscopic equipment. This laparoscopy training equipment is novel and original in its design.

Proton MR spectroscopy and imaging of a galactosemic patient before and after dietary treatment

We describe how proton MR spectroscopy ((1)H-MR spectroscopy) was useful in elucidating the diagnosis of galactosemia in an undiagnosed 6-month-old infant. In vivo (1)H-MR spectroscopy of the brain showed a doublet at 3.7 parts per million, which was identified as galactitol (Gal-ol) by in vitro (1)H-MR spectroscopy of the urine. Galactosemia was subsequently confirmed by laboratory tests and treatment was initiated. A follow-up brain MR imaging and (1)H-MR spectroscopy study revealed resolution of white matter lesions and disappearance of Gal-ol peaks.

Comparison of ceftibuten vs. amoxicillin/clavulanic acid as antibiotic prophylaxis in cholecystectomy and/or biliary tract surgery

A randomized, comparative, prospective clinical trial was carried out at a tertiary care center to compare the efficacy of two antibiotic regimens in the prophylaxis of postoperative infection in patients undergoing biliary tract surgery. One hundred patients undergoing cholecystectomy or biliary tract exploration were randomly allocated to one of the following antibiotic regimens: the standard regimen of three doses of amoxicillin/clavulanic acid (1000/200 mg) given by intravenous infusion, or a single dose of ceftibuten (400 mg) given orally. Patients were monitored during their stay in the hospital and over a 2 week period as outpatients. Fifty adult patients were included in each group. Mean age was 49 years, and sex distribution was 82 women and 18 men. The groups were comparable in terms of demographic characteristics and comorbidity. There were no cases of postoperative infection in the ceftibuten group, but five cases of infection occurred in the amoxicillin/clavulanic acid group (P < 0.05). No adverse effects were observed with either antibiotic. The treatment cost per patient was significantly lower for ceftibuten. The results indicate that ceftibuten is well tolerated and more effective than amoxicillin/clavulanic acid for prophylaxis following gallbladder and biliary tract surgery. In addition, ceftibuten has the advantage of being more cost-effective and easier to administer than amoxicillin/clavulanic acid so it could be considered as an alternative for antibiotic prophylaxis in these types of surgical procedures.

Enantioselective analysis of ketone bodies in patients with beta-ketothiolase deficiency, medium-chain acyl coenzyme A dehydrogenase deficiency and ketonemic vomiting

Enantioselective multidimensional gas chromatography-mass spectrometry (enantio-MDGC-MS) is a valuable tool for the differentiation of enantiomers from complex matrices when present in trace amounts. The separation of chiral compounds provides further information on the diagnosis of diseases, and on normal and abnormal biochemical pathways. The formation of the normal urinary metabolite 3-hydroxy-2-methylbutanoic acid (HMBA), excreted in abnormally high amounts in beta-ketothiolase deficiency, is not absolutely clarified. Metabolic pathways involving this metabolite are isoleucine catabolism, as well as presumably beta-oxidation of fatty acids and ketogenesis. The latter two pathways are distinguishable in their enantioselectivity. Enantioselective analysis gives further information on interfering metabolic pathways and the selectivity of the enzyme(s) forming HMBA. Different ratios of the stereoisomers of HMBA in control urine samples and patients with beta-ketothiolase deficiency were detected. Analogous to HMBA urinary 3-hydroxybutanoic acid (HBA) was investigated in several diseases. The formation of HBA and HMBA is expected to result from the same or similar metabolic pathways. Differences in the enantiomeric ratio of HMBA may originate from the enantioselectivity of different enzyme systems.

[Anaphylaxis and allergic reactions]

OBJECTIVE: To review the etiologic factors, pathophysiology and specially the therapeutic management of the anaphylactic reactions.METHODS: The bibliographic review included textbooks of allergy and intensive care and Medline references.RESULTS: Anaphylactic reactions that result from the rapid release of potent pharmacologically active mediators from mast cells or peripheral blood basophils may involve several organ systems with some risk of death.COMMENTS: Anaphylaxis is a clinical syndrome with significant mortality rate. There are several etiologic factors that trigger the process and multiple pathophysiologic mechanisms involved. Early diagnosis and an effective therapy lead to a better prognosis. In the majority of the cases prophylactic measures are needed to avoid other episodes.

[Comparative study of laparoscopic appendectomy vs open appendectomy]

Laparoscopy reduces the risk of performing unnecessary appendectomies and offers the advantages of minimal invasive surgery when appendectomy is needed. We report our experience comparing open (Group A) with laparoscopic (Group B) appendectomy.

PATIENTS AND METHODS

There were 20 patients in each group. Age, sex, signs, symptoms, evolution, laboratory, stage of disease, drains, duration of surgery, antibiotics, oral intake restart, postoperative pain at 24, 48 and 72 hours, complications, hospital stay, return to normal activities and cosmesis were reviewed. Statistical differences were determined using Student's t test (two tailed) or chi-square with Yates correction. Surgical technique is described.

RESULTS

In both groups most variables were similar (p = ns). Group B presented earlier oral intake restart (p < 0.001), and less postoperative pain at 24 (p < 0.001), 48 (p < 0.01) and 72 hours (p < 0.001). Hospitalization stay was shorter (p < 0.001) and return to normal activities was earlier (p < 0.001) in group B. Better cosmetical appearance was observed in Group B (16 vs. 0 "excellent" -p < 0.001).

CONCLUSIONS

Laparoscopic approach may reduce unnecessary appendectomies and it allows to perform appendectomy in a safe and effective way. In this study, laparoscopic was better than open appendectomy regarding early restart of oral intake, less postoperative pain, shorter hospitalization stay, earlier return to normal activities and better cosmetic appearance.

Angiographic evaluation after portal blood flow preserving operations

We carried out a prospective study comparing postoperative portal angiographic characteristics in patients with hemorrhagic portal hypertension treated electively by two different portal blood flow preserving procedures. Between 1986 and 1991, a total of 81 patients underwent operation: 38 selective shunts and 43 Sugiura-Futagawa procedures. Cirrhosis was shown by biopsy in 50 cases, 26 of them secondary to alcoholism. We found rebleeding in 5% of the patients, incapacitating postoperative encephalopathy in 8%, and an operative mortality of 7%. Fifty-two cases were evaluated in the postoperative period with angiography; 21 patients treated with a Sugiura-Futagawa operation were excluded due to portal vein thrombosis shown in the preoperative studies. Postoperative portal vein thrombosis was found in 11 cases (21%) [seven cases in the Warren group (21%) and four cases in the Sugiura-Futagawa group (20%)]. Decreased portal vein diameter was seen in eight cases (15%). The two procedures maintained hepatopedal portal blood flow, and no change was seen in relation to the preoperative state in 66% of the operated patients. We found no significant differences between the two procedures. Selection of procedure depends on the individual characteristics of each patient.

[Complications of splenectomy in the Sugiura-Futagawa procedure]

Evaluation of the complications of splenectomy in the Sugiura-Futawaga operation.

BACKGROUND

Splenectomy in portal hypertension is a more difficult procedure and probably has a higher morbidity and mortality.

METHOD

A retrospective study of 155 patients with hemorrhagic portal hypertension treated by means of the Sugiura-Futawaga operation was conducted to evaluate the complications related to splenectomy.

RESULTS

Mean age of the patients was 42 years: 81 patients were male and 74 female. In 87 cases liver cirrhosis was shown, 39 cases with portal fibrosis, 23 cases with primary biliary cirrhosis and 6 cases with normal liver (idiopathic portal hypertension). No patient received preoperative immunization against pneumococcus, but received antibiotic prophylaxis. Complications were found in 16 cases (10.3%): 13 of them related to the surgical procedure (peritonitis 3.9%, subphrenic collection 1.9%, pancreatic pseudocyst 1.9% and pancreatic fistula 0.6%) and three related to the absence of spleen (1.9%) with septic shock as manifestation.

CONCLUSIONS

The complications related to splenectomy in the Sugiura-Futagawa procedure are low, as well as the overwhelming post-splenectomy infection rate. Splenectomy in the Sugiura-Futagawa operation has no important role in the post-operative morbidity.

A comparative clinical study of idiopathic portal hypertension, extrahepatic portal vein thrombosis, and cirrhosis

The relationship between idiopathic portal hypertension (IPH) and extrahepatic portal vein thrombosis (EPVT) remains controversial. In a retrospective study, we compared the clinical features of 21 patients with IPH, 27 with EPVT, and 38 with liver cirrhosis (LC). The variables with statistical difference between IPH and EPVT were age (38 +/- 17 years versus 29 +/- 14, respectively; p < 0.05), and 5-year survival (72 versus 92%, respectively; p < 0.05). The other clinical and laboratory variables had similar distribution in IPH and EPVT. LC patients were older than those in the other groups (48 +/- 13 years, p < 0.05), and had a poorer 5-year survival (60%, p < 0.05). Furthermore, LC patients had clinical features of liver failure in a higher proportion than the other groups did. The results suggest that IPH, EPVT, and LC are separate clinical entities.

Long-term evolution of asymptomatic cholelithiasis diagnosed during abdominal operations for variceal bleeding in patients with cirrhosis

To define the risk of complications in cirrhotic patients with asymptomatic cholelithiasis and the possible benefit of incidental cholecystectomy during abdominal operations in these patients, a retrospective cohort of cirrhotic patients who had asymptomatic cholelithiasis and underwent abdominal operations for portal hypertension was analyzed. Of 338 patients operated on during the last 15 years, 34 patients were found with asymptomatic cholelithiasis, all of whom had long-term follow-up. At a mean follow-up of 70.5 +/- 8.6 months (SEM), 28 patients remained asymptomatic (82%), 6 patients have developed symptoms (18%), (4 patients had acute cholecystitis and 2 chronic cholecystitis), and 3 of these patients (8.8%) died due to complications of acute cholecystitis. The results suggest that the risk for the development of complications is low but that the mortality associated with acute episodes of cholecystitis is high. Incidental cholecystectomy is not justified in cirrhotic patients with asymptomatic cholelithiasis, but close follow-up with early elective operation when symptoms supervene should be recommended.

Inguinal herniorrhaphy under local anesthesia: a study of intraoperative tolerance

Tolerance to inguinal hernia repair under local anesthesia was prospectively evaluated in a consecutive series of 41 patients who underwent hernia repair with local infiltration of 0.75 per cent lidocaine. Intraoperative discomfort was measured by an analog visual scale. All complications were also recorded. Mean intraoperative pain was mild (1.6 +/- 1.4). There were two complications. Wound infection and wound hematoma occurred in one patient each. There was no operative mortality. Normal diet was tolerated the day of surgery in 39 patients, and 30 were discharged from the hospital on the same day. Our series supports good tolerance and a low complication rate when inguinal herniorrhaphy is performed under local anesthesia.

Surgical management of extrahepatic portal hypertension and variceal bleeding

Variceal bleeding remains an important complication in extrahepatic portal vein thrombosis (EPVT). As for portal hypertension due to other etiologies, an elective treatment to decrease the risk of subsequent rebleeding is warranted. The results of the Sugiura-Futagawa procedure (SP) in 38 patients with variceal bleeding secondary to EPVT are reported: 20 women and 18 men, with a mean age of 28 +/- 2 years (SEM). Thirty-seven patients were classified as Child-Pugh class A, and one patient as class B. In terms of diagnosis, 45% of patients had idiopathic EPVT, and 18% had associated hypercoagulability disorders; 52% of patients had associated splenic vein thrombosis. The SP was completed in two surgical stages in 18 patients and in one surgical stage in 14; 6 patients had only the abdominal stage. One patient had mild postoperative encephalopathy, and three patients rebled at long-term follow-up study. There were two operative deaths. Actuarial survival was 70% at 64 months. It is concluded that the SP is an excellent alternative for patients with variceal bleeding secondary to EPVT.