The Portuguese observatory on occupational psychosocial factors: contribution for public health

 

To achieve the goal of sustainable employment, considering the profile of the Portuguese working population (PWP), is needed a range of strategies to ensure long, productive, and sustainable careers allied with a better quality of working life, health, and wellbeing, but also with public health policies grounded on scientifically validated and reliable data. This is possible through a comprehensive working system approach that ensures workers will be mentally and physically able to remain at work by the balance between work demands and individual resources allied with public health policies transfer into the workplaces by organizations’ leadership and policy makers. The Portuguese Observatory on Occupational Factors (Popsy@Work) aims at addressing this global challenge by: i) digitally collecting psychosocial data on the PWP; ii) implementing and strengthening of a psychosocial occupational health surveillance digital system; iii) providing reference values for the PWP concerning Psychosocial Health; iv) Transferring to society knowledge and best practices; v) Raising awareness on the importance of psychosocial management in occupational settings based on science. Popsy@work is a digital platform that collects and aggregates psychosocial data analytically and creates a visualization hub adding value to data on the PWP and giving science back to society in a usable way, empowering workers, strengthening organizations and grounding public policies. Pospy@Work considers the development of strategic intelligence on levels and inequalities of psychosocial health and well-being in occupational settings by robust metrics and reference data. Creating opportunities for national policy dialogue on inequalities, including the psychosocial health of the PWP through collaboration with diverse sectors identifying and mapping subgroups of populations whose unmet needs require specific outreach measures.

Key messages

“It’s not only the bad side” - Experiences reported by health professionals working with women victims of sexual violence in a Brazilian university specialized outpatient service: A qualitative study

Introduction

Health Psychology is a scientific branch that studies interpersonal relationships in the field of emotions and behavior in clinical settings. Violence against women is a gender-based action that alarmingly affects the population, with sexual violence (SV) being one of its main phenomena. The complexity of the care offered to SV patients by clinical professionals impacts themselves, affecting their personal lives and the quality of their work.

Objectives

To explore symbolic emotional meanings attributed by health professionals to care and follow-up of women victims of SV in state service of reference of the Unified Health System.

Methods

Clinical-Qualitative design was used to guide semi-directed interviews with open-ended questions in-depth. Clinical-Qualitative Content Analysis was employed to treat data. Five participants make up the multi-professional team at the Hospital of the Woman of the State University of Campinas. Theoretical framework chosen to interpret categories was Balintian Medical Psychology.

Results

Three categories were selected for this presentation: The human anguishes as the main challenge and handling of working with sexual violence; “To see things progressing”: to the patient and together with the team, a facilitator of the work; and “I try to leave it on the three’s leaves”: the difficult attempt to separate work from personal life.

Conclusions

Taking care of SV is a very emotionally demanding task. Working with the team and see expected outcomes help clinical professionals deal with negative feelings, avoiding, for example, compensatory traumas. New research about social-cultural impacts of working with SV is important to develop institutional approaches of coping for health teams.

Disclosure

No significant relationships.

Eccrine Hidradenocarcinoma of the Scalp

Eccrine hidradenocarcinoma is a rare adnexal neoplasm arising from the eccrine sweat glands of the skin. Surgery and radiotherapy are the mainstay of treatment, and chemotherapy is reserved for unresectable or metastatic lesions. We present the case of a 60-year-old man, referred for treatment of an unresectable basal cell carcinoma of the scalp. He started Vismodegib in January of 2017 but progressed after three months. A new biopsy showed a poorly differentiated carcinoma. The patient started carboplatin/paclitaxel with a major response, enabling surgery in December of 2017. Pathology concluded on a hidradenocarcinoma, R1, and radiotherapy was not possible due to local infection. Four months later, he underwent radiotherapy due to local recurrence, and restarted carboplatin/paclitaxel, but with progressive disease. An exploratory surgery in October of 2018 revealed unresectable disease. Restaging showed lung metastasis and second-line chemotherapy was proposed. However, due to continued clinical deterioration, the patient died in February of 2019.

Impact of a cardio-oncology rehabilitation program in patients with breast cancer undergoing cardiotoxic treatment

Background

Cancer treatment–related cardiotoxicity (CTrCD) is commonly associated with anthracyclines and anti-HER2 agents which are widely used for the treatment of breast cancer. In order to mitgate CTrCD, exercise-based cardio-oncology rehabilitation (COR) involving a structured exercise program has been proposed.

Objectives

To evaluate the impact of a cardiac-rehabilitation program in breast cancer patients submitted to chemotherapy with known cardiotoxicity.

Methods

A systematic review was performed. Two databases were searched, PubMed and SCOPUS. All randomized or controlled trials and other prospective studies published between 2000 and March 2020 which evaluate the impact of an aerobic exercise program on cardiorespiratory fitness (CRF), health-related quality of life (QOL), vascular/endothelial function as well as cardiac assessment namely through the evaluation of left ventricular function and cardiac biomarkers in patients undergoing anthracycline and/or anti-HER2 treatments were included.

Main results

Fourteen studies were included enrolling 578 breast cancer patients with a mean age of 48.80 years. Regarding the impact of exercise in CRF, 5 studies (n=176) reported a significant improvement of VO2 max. and 4 studies of VO2max./kg (n=137). The peak power output was also improved in 4 studies (n=95) in the exercise-group. Considering the assessment of QOL, 3 studies (n=180) revealed significant differences favoring the exercise-group. The results regarding the evaluation of the LVEF were not clear: 2 studies (n=48) reported a significant decrease on LVEF when compared to baseline at the end of the intervention in both groups, despite the exercise program. However, 2 studies (n=97) showed a significant increase on LVEF in the exercise-group. Three studies (n=82) did not found significant differences in global longitudinal strain between groups. Limited evidence was found in vascular and endothelial functon. In 2 studies (n=50), endothelial function measured by brachial artery flow-mediated dilatation significantly improved in the exercise-group. Two studies (n=98) reported no significant impact of exercise on atenuating the increase of cTnI and BNP levels in the course of chemotherapy. On the other hand, when considering NT-proBNP, an increase in its levels was attenuated in the exercise-group.

Conclusions

This study confirms that exercise-based COR seems to be an effective approach to improve several cardiovascular outcomes and quality of life in breast cancer patients.

Funding Acknowledgement

Type of funding sources: None.

Disseminated Saprochaete capitata fungal infection in a patient with acute myeloid leukemia

The case highlights the importance of actively obtaining informative samples at an early stage and of prompt initiation of combination therapy with antifungal drugs.

Merkel cell carcinoma metastatic to the testis: report of a rare diagnosis and review of the literature

Merkel cell carcinoma is an aggressive malignancy that frequently recurs/disseminates, but metastases to the genitourinary tract are rare. Only eight cases of Merkel cell carcinoma metastatic to the testis are reported. We describe the ninth case of this event and provide a review of the literature. A 58-year-old man diagnosed with Merkel cell carcinoma of the wrist, presented, 37 months later, a recurrence in the form of a testicular metastasis. The tumor consisted of a monotonous proliferation of small, blue, round cells, with immunoexpression of neuroendocrine markers and the typical dot-like paranuclear immunostaining for cytokeratin 20, in the absence of immunostaining for cytokeratin 7. The patient is alive with no evidence of disease. Clinicians should be aware of the possibility of metastatic dissemination to the testis since genital examination/imaging is not part of routine follow-up for these patients, but timely orchiectomy may be curative.

Basal cell carcinoma: multimodal treatment and the role of neoadjuvant vismodegib

Basal cell carcinoma (BCC) is the most common skin cancer. It generally has an indolent course with low rates of metastasis and mortality. However, BCC is locally invasive and can cause significant morbidity due to destructive local spread. We report our experience with a patient who was referred to our skin cancer unit due to a previously neglected lesion on the parietal region of the scalp, which had developed for 7 years. The patient was prescribed vismodegib on the basis that surgery could cause excessive functional and aesthetic damage. The patient had an objective partial response after 20 months of treatment. He was then submitted to radical skin excision, leaving a large defect that was reconstructed using a free latissimus dorsi muscle flap. The patient recovered well, and at the 1-year follow-up there were no signs of local recurrence. Our case demonstrates the value of vismodegib treatment prior to surgery in a locally advanced, high-risk scalp BCC and highlights the importance of an individualized and specialized approach with these patients, within a multidisciplinary team.

Effects of di(2-etilhexil) phthalate on human umbilical artery

Di(2-etilhexil) phthalate (DEHP) is a compound used in plastic materials, which has endocrine disrupting properties. The human DEHP exposure depend on the use of plastics in toys, medical devices and food and beverage containers. The DEHP effects were studied in some physiological systems; nevertheless, the actions in human arteries were never described. We analysed the DEHP effect on endothelium denuded human umbilical artery (HUA), an important artery to ensure gases and nutrients exchange with fetus. We assessed DEHP short-term effects on contractility, occurring few minutes after DEHP is in contact with HUA in the organ bath receptacles. The long-term effects on HUA, observed after 24 h in presence of DEHP, were assessed in the organ bath system, and also through the analysis of receptors expression (5-HT_2A and H₁) and of cellular viability, by using HUA smooth muscle cells. DEHP (1 nM-100 μM) induced a short-term relaxing effect on HUA contracted by 5-HT, histamine or KCl. DEHP long-term exposure of arteries (1 nM, 10 μM and 100 μM) reduced its own relaxant effect on HUA contracted by 5-HT and histamine and, precisely, 24 h exposure to DEHP 1 nM reverted the relaxant effect on 5-HT contractility. Long-term exposure at more than 10 nM of DEHP decreased 5HT_2A receptors expression. In conclusion, DEHP short-term exposition elicit vasodilation of HUA contracted by different agents. DEHP long-term exposition reduced the expression of 5HT_2A receptors. The DEHP long-term exposition decrease the short-term relaxant effect and, at low concentrations can increase the contractile effect of 5-HT.

Mechanical Properties of Topical Anti-Psoriatic Medicines: Implications for Patient Satisfaction with Treatment

Different types of topical preparations are available as anti-psoriatic medicines, semisolid formulations being the preferred dosage forms for the treatment of body lesions. The mechanical characterization of these semisolid formulations is seldom reported, although mechanical features have been recognized to play an important role in treatment acceptability and adherence. The aim of this study was to characterize the mechanical properties of semisolid topical formulations commercially available for psoriasis treatment. One complementary aim was to evaluate patient satisfaction with topical treatment and discuss the results according to the mechanical features of the dosage form. Eight ointments (O 1-8), five creams (C 1-5), one oleogel (G1), and one excipient (E1-petrolatum) were characterized for textural properties (spreadability and penetration tests) and flow behavior. Power law model was fitted to the results. A questionnaire for the assessment of satisfaction with topical medicines used for psoriasis treatment over 6 months was developed and applied to 79 psoriasis patients. All the tested formulations presented a shear-thinning behavior with power law indexes (n) lower than 1. Ointments were distinct from the other dosage forms, since they presented higher consistency coefficients (K), firmness, and adhesiveness and this was evidenced by hierarchical cluster analysis, which identified two clusters based on the mechanical properties. Cluster 1 included the ointments and petrolatum and the cluster 2 enclosed the creams and the gel. The clusters were associated with several attributes classified by patients as analyzed with Fisher's exact test. In all cases, higher satisfaction was observed for cluster 2. The knowledge obtained regarding the influence of the dosage form on the degree of satisfaction with the treatment could be helpful in supporting the selection of the dosage form in clinical practice and thus improve treatment adherence and clinical outcomes. The differences observed between the mechanical properties of the formulations studied may be also relevant to the industry, as guidance to the development of new medicines.

A functional glycoproteomics approach identifies CD13 as a novel E-selectin ligand in breast cancer

BACKGROUND

The glycan moieties sialyl-Lewis-X and/or -A (sLe^X/A) are the primary ligands for E-selectin, regulating subsequent tumor cell extravasation into distant organs. However, the nature of the glycoprotein scaffolds displaying these glycans in breast cancer remains unclear and constitutes the focus of the present investigation.

METHODS

We isolated glycoproteins that bind E-selectin from the CF1_T breast cancer cell line, derived from a patient with ductal carcinoma. Proteins were identified using bottom-up proteomics approach by nanoLC-orbitrap LTQ-MS/MS. Data were curated using bioinformatics tools to highlight clinically relevant glycoproteins, which were validated by flow cytometry, Western blot, immunohistochemistry and in-situ proximity ligation assays in clinical samples.

RESULTS

We observed that the CF1_T cell line expressed sLe^X, but not sLe^A and the E-selectin reactivity was mainly on N-glycans. MS and bioinformatics analysis of the targeted glycoproteins, when narrowed down to the most clinically relevant species in breast cancer, identified CD44 glycoprotein (HCELL) and CD13 as key E-selectin ligands. Additionally, the co-expression of sLe^X-CD44 and sLe^X-CD13 was confirmed in clinical breast cancer tissue samples.

CONCLUSIONS

Both CD44 and CD13 glycoforms display sLe^X in breast cancer and bind E-selectin, suggesting a key role in metastasis development. Such observations provide a novel molecular rationale for developing targeted therapeutics.

GENERAL SIGNIFICANCE

While HCELL expression in breast cancer has been previously reported, this is the first study indicating that CD13 functions as an E-selectin ligand in breast cancer. This observation supports previous associations of CD13 with metastasis and draws attention to this glycoprotein as an anti-cancer target.

Nutrition in Chronic Liver Disease

Protein-calorie malnutrition is a transversal condition to all stages of chronic liver disease. Early recognition of micro or macronutrient deficiencies is essential, because the use of nutritional supplements reduces the risk of complications. The diet of patients with chronic liver disease is based on a standard diet with supplements addition as necessary. Restrictions may be harmful and should be individualized. Treatment management should aim to maintain an adequate protein and caloric intake and to correct nutrient deficiencies. The large majority of patients with grade I/II hepatic encephalopathy can tolerate a regular diet. Protein restriction can aggravate malnutrition and is not recommended, except in cases of hepatic encephalopathy unresponsive to optimized therapy.

Exposure to Cr(VI) induces organ dependent MSI in two loci related with photophosphorylation and with glutamine metabolism

Chromium (Cr), as a mutagenic agent in plants, has received less attention than other metal pollutants. To understand if Cr induces microsatellite instability (MSI), Pisum sativum seedlings were exposed for 28 days to different concentrations of Cr(VI) up to 2000mgL(-1), and the genetic instability of ten microsatellites (SSRs) was analyzed. In plants exposed to Cr(VI) up to 1000mg L(-1), MSI was never observed. However, roots exposed to 2000mgL(-1) displayed MSI in two of the loci analyzed, corresponding to a mutation rate of 8.3%. SSR2 (inserted in the locus for plastid photosystem I 24kDa light harvesting protein) and SSR6 (inserted in the locus for P. sativum glutamine synthetase) from Cr(VI)-treated roots presented alleles with, respectively, less 6bp and more 3bp than the corresponding controls. This report demonstrates that: (a) SSRs technique is sensitive to detect Cr-induced mutagenicity in plants, being Cr-induced-MSI dose and organ dependent (roots are more sensitive); (b) two Cr-sensitive loci are related with thylakoid photophosphorylation and with glutamine synthetase, respectively; (c) despite MSI is induced by Cr(VI), it only occurs in plants exposed to concentrations higher than 1000mgL(-1) (values rarely found in real scenarios). Considering these data, we also discuss the known functional changes induced by Cr(VI) in photosynthesis and in glutamine synthetase activity.

Pb2+ exposure induced microsatellite instability in Pisum sativum in a locus related with glutamine metabolism

Lead (Pb) is a toxic element, but its putative mutagenic effects in plant cells, using molecular markers, remain to unveil. To evaluate if Pb induces mutagenicity, Pisum sativum L. seedlings were exposed to Pb(2+) (up to 2000 mg L(-1)) for 28 days and the instability of microsatellites (or Simple Sequence Repeats, SSR) was analyzed in leaves and roots. The analysis of eight selected microsatellites (SSR1-SSR8) demonstrated that only at the highest dosage microsatellite instability (MSI) occurred, at a frequency of 4.2%. Changes were detected in one microsatellite (SSR6) that is inserted in the locus for glutamine synthetase. SSR6 products of roots exposed to the highest concentration of Pb were 3 bp larger than those of the control. Our data demonstrate that: (a) SSR technique is sensitive to detect Pb-induced mutagenicity in plants. MSI instability is Pb dose dependent and organ dependent (roots are more sensitive); (b) the Pb-sensitive SSR6 is inserted in the glutamine synthetase locus, with still unknown relation with functional changes of this enzyme; (c) Pb levels inducing MSI are much above the maximum admitted levels in some European Union countries for agricultural purpose waters. In conclusion, we propose here the potential use of SSR to evaluate Pb(2+)-induced mutagenicity, in combination with other genetic markers.

Aortic clamping in pancreas transplantation: is there any harm to the transplanted kidney graft?

INTRODUCTION

Some special situations may require aortic clamping during pancreas transplantation (PT). The most important problem is ischemic injury to a previous transplanted kidney. We sought to demonstrate experience with aortic clamping in PT without special kidney allograft protection measures and its impact on kidney function.

METHODS

Retrospective study that analyzed 6 patients who underwent PT (5 pancreas after kidney and 1 simultaneous pancreas-kidney) with aortic clamping. In all cases, the pancreas graft was placed on the right with retrocolic portal-enteric drainage. Serum creatinine was evaluated pre- and posttransplantation.

RESULTS

The average clamping time was 19 minutes. The mean serum creatinine was 1.1, 1.15, 0.95, and 1.0, respectively, at pre and postoperative days 1 and 7 and at hospital discharge. Patient, kidney, and pancreatic graft survivals were 100%, 100%, and 83%, respectively.

CONCLUSION

The need for aortic clamping in selected cases of PT did not seem to affect the transplanted kidney, even without protective measures, provided that the ischemic time was short.

The invasion route for an insect pest species: the tobacco aphid in the New World

Biological invasions are rapid evolutionary events in which populations are usually subject to a founder event during introduction followed by rapid adaptation to the new environment. Molecular tools and Bayesian approaches have shown their utility in exploring different evolutionary scenarios regarding the invasion routes of introduced species. We examined the situation for the tobacco aphid, Myzus persicae nicotianae, a recently introduced aphid species in Chile. Using seven microsatellite loci and approximate Bayesian computation, we studied populations of the tobacco aphid sampled from several American and European countries, identifying the most likely source populations and tracking the route of introduction to Chile. Our population genetic data are consistent with available historical information, pointing to an introduction route of the tobacco aphid from Europe and/or from other putative populations (e.g. Asia) with subsequent introduction through North America to South America. Evidence of multiple introductions to North America from different genetic pools, with successive loss of genetic diversity from Europe towards North America and a strong bottleneck during the southward introduction to South America, was also found. Additionally, we examined the special case of a widespread multilocus genotype that was found in all American countries examined. This case provides further evidence for the existence of highly successful genotypes or 'superclones' in asexually reproducing organisms.

Cutaneous mastocytosis: Two pediatric cases treated with topical pimecrolimus

Cutaneous mastocytosis is characterized by increased numbers of skin mast cells that release mediators causing pruritus, urticaria, and flushing. Most pediatric mastocytosis patients exhibit the pattern of urticaria pigmentosa, which typically appears during the first two years of life and resolves spontaneously in late adolescence. However, while the disease is active, patients are frequently symptomatic and uncomfortable, which justifies symptomatic treatment. We report 2 patients, a 14-month-old girl and a 26-month-old boy, with localized cutaneous erythematous lesions with a positive Darier sign. In each, a punch biopsy confirmed the diagnosis of mastocytosis. Treatment was instituted with pimecrolimus cream twice a day and oral antihistamine. An almost complete response was achieved after 4 months of therapy in both patients, with no clinical evidence of recurrence after 4 years and 2 years of follow-up, respectively. In children, the treatment of mastocytosis is directed primarily to avoiding potential mast cell degranulating agents and alleviating symptoms. Topical calcineurin inhibitors act by inhibiting T-cell activation and cytokine release; they may suppress mast cell- mediated reactions by reducing their degranulation. These two cases suggest that in localized cutaneous mastocytosis they are a safe and efficacious alternative to topical steroid therapy.

Low power laser in the prevention of induced oral mucositis in bone marrow transplantation patients

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Background: High-dose chemotherapy followed by bone marrow transplant produces undesirable effects in the oral cavity leading to oral mucositis (OM) that may be a painful and debilitating side-effect. Laser therapy has been used to improve the symptoms and duration of already established OM in this group of patients (pts). Recent data suggest the upfront use of laser therapy may decrease the incidence of OM. Methods: Through the use of upfront LPL as protecting and modulating therapy of the oral mucosa membrane, we evaluated the potential for a reduction in the incidence and/or severity of OM in pts submitted to autologous (AT) or allogeneic (AL) bone marrow transplant (BMT). Sample size was based on estimative of P0 control = 0.6 and a P1 LPL = 0.1, β = 0.1; α= 0.05. From Jan 2004 to May 2005, 38 pts treated at the National Bone Marrow Transplant Center in Rio de Janeiro were randomized into a group of 19 pts that received and a group of 19 that did not receive the application of the preventive LPL from the beginning of the conditioning. The irradiation was used an diode InGaAlP, emiting light at 660 nm wavelenght with output power of 50 mW, giving an energy density of 4 J/cm2. The tip of the laser device touched the oral mucosa. The evaluation of OM was done by different investigators both by WHO and OMAS scale. Results: The male to female ratio was 60.5/39.5%. The median age 37 (19–56). The frequency of AT and AL was 73.7 (15.8% non related) vs 26.3%. In the LPL group 94.8% of pts had OM WHO grade < 2 (including 63.2% with grade 0), whereas in the control group 68.4% of pts had OM grade III and IV (p<0,001). Remarkably the HR for grade II, III and IV OM was 0.41 (CI 95% 0.22–0.75, p = 0,002) and for grade III and IV was 0.07 (CI 95%0.11–0.53, p<0,000). Using OMAS scale by the calculation of ulcerous area, 73.6% of LPL pts presented lesions of 0 to 3 cm2, whereas 73.6% of the control group presented ulcers from 9.1 to 18 cm2 (p=0.003). An agreement was observed among investigators (index of 81.7%) and between WHO and OMAS scale (p<0,001). Conclusion: Our results indicate that the use of upfront LPL in bone marrow transplantation patients is a powerful instrument in reducing the incidence of OM and is now standard in our center.

No significant financial relationships to disclose.

Tirofiban (Aggrastat®) Protects Platelets and Decreases Platelet-Granulocyte Binding in an Extracorporeal Circulation Model

OBJECTIVES

Extracorporeal circulation (ECC) induces platelet activation and inflammation with potentially life-threatening organ dysfunction. Short-acting GP IIb/IIIa inhibitors like tirofiban and eptifibatide protect platelets during ECC without increasing bleeding complications and may reduce inflammation. This study investigates anti-thrombotic and anti-inflammatory effects of different platelet inhibitors.

METHODS

Control (untreated) and treated (using either 150 ng/mL tirofiban, 2.5 microg/mL eptifibatide, 0.7 microg/mL milrinone, 15 microg/mL dipyridamol, or 300 KIU/mL aprotinin) heparinized blood of healthy volunteers (n = 6) was recirculated in a well-established ECC model (Chandler loop). Percentage of platelet aggregates, P-selectin-expressing (activated) platelets, CD15-positive aggregates (indicating proinflammatory platelet-granulocyte binding), and platelet counts were determined before (baseline) and after 30 minutes recirculation in unstimulated and ADP-stimulated samples using flow cytometry. Statistical analysis was performed using multifactor ANOVA after transforming the data (logarithms for counts and log odds for percentages). Least square means were backtransformed to obtain appropriate means and their 95 % confidence intervals. Multiple post-hoc comparisons were performed by Tukey's HSD test with a global alpha of 5 %.

RESULTS

Significant inhibition was observed for: 1) ECC-induced platelet aggregation by tirofiban (unstimulated: 2.2-fold/stimulated: 2.46-fold), eptifibatide (unstimulated: 1.96-fold/stimulated: 2.65-fold), and milrinone (unstimulated: 1.87-fold/stimulated: 1.37-fold); 2) ECC-induced P-selectin expression by tirofiban (unstimulated: 3.95-fold/stimulated: 2.54-fold), and eptifibatide (unstimulated: 5.87-fold/stimulated: 3.28-fold); 3) ECC-induced platelet loss by tirofiban (1.27-fold), and eptifibatide (1.25-fold); 4) ECC-induced platelet-granulocyte binding by tirofiban (unstimulated: 2.25-fold/stimulated: 1.59-fold), but not by eptifibatide.

CONCLUSIONS

Amongst the investigated drugs only GP IIb/IIIa inhibitors decreased activation, aggregation, and loss of platelets during ECC but acted differently on platelet-granulocyte interaction. A short-acting GP IIb/IIIa inhibitor with the potential to inhibit platelet activation and platelet-leukocyte interaction should be considered both for platelet protection and inhibition of platelet-mediated inflammation during ECC.

Hypothermia-Induced Platelet Aggregation: No Effect of Aprotinin (Trasylol®) but Inhibition by Eptifibatide (Integrilin®)

OBJECTIVES

The serine-protease inhibitor aprotinin protects platelet function during cardiopulmonary bypass. However, its safety and efficacy during deep hypothermic circulatory arrest (DHCA) is controversial, and aprotinin is suspected to cause thrombosis especially during hypothermia. The platelet GP IIb/IIIa inhibitor eptifibatide has been assumed to preserve platelet function during cardiopulmonary bypass without increasing bleeding complications. The aim of this study was to compare the effect of aprotinin and eptifibatide on platelet function under conditions of DHCA.

METHODS

Heparinized blood from healthy volunteers (n = 10) was incubated in stasis for 30 minutes at 18 degrees C to simulate DHCA and compared to samples incubated at 37 degrees C. The effect of eptifibatide (2.5 microg/ml) and aprotinin (300 KIU/ml) on platelets under these conditions was analyzed by flow cytometry. Platelet aggregates were identified using CD41-antibody binding and size. GPIIb/IIIa function was evaluated with the activation-specific antibody PAC-1 after stimulation with 10 microM ADP. Aggregate numbers and antibody mean-fluorescence are reported as mean +/- standard deviation.

RESULTS

Hypothermia induced a 2.5-fold increase of aggregates ( p < 0.001) and a 2.6-fold increase of GPIIb/IIIa activation ( p < 0.001). This effect was not influenced by aprotinin but almost completely inhibited by eptifibatide ( p < 0.001).

CONCLUSIONS

Aprotinin has no procoagulatory effect on platelet function during hypothermia but is not protective either. Eptifibatide inhibits hypothermia-induced platelet aggregation in vitro and may prevent aggregate sequestration in the microvasculature and consecutive ischemic organ damage in vivo.

Squamous cell carcinoma of the breast

Squamous carcinoma of the breast (SCB) is a rare entity. For its diagnosis, the exclusion of squamous cell carcinoma of local cutaneous structures and metastasis of distant squamous carcinoma are mandatory. The aim was to retrospectively evaluate the prevalence, epidemiological and clinical characteristics of the cases of SCB, studied in our institution, between January 1985 and December 1996. The diagnosis was histopathological. We studied the patients' demographic data and tumour characteristics. In the 11-year study period, 5791 patients with breast carcinoma were admitted to our Institution, seven (0.1%) of which were SCB. All seven patients were female and Caucasian. Their average age was 63 years (range 24-82). The presentation was always a breast lump. Five patients were in Stage II-A and two in Stage II-B. All tumours were hormone-receptor negative. The initial treatment was surgery and four patients received adjuvant radiotherapy. The median follow-up was 64 months. No relapses were diagnosed. SCB is a rare entity. The initial therapeutic approach should be surgical. There is still no consensus regarding adjuvant therapy. The prognosis of this type of breast cancer is still the subject of controversy with some series, including the present study, suggesting an indolent clinical course and a relatively good prognosis.

CD8+ lymphocytes in the blister fluid of severe acute cutaneous graft-versus-host disease: further similarities with toxic epidermal necrolysis

BACKGROUND

Graft-versus-host disease (GvHD) remains the major toxicity of allogeneic bone marrow transplantation (BMT). In the acute form of the disease, the differential diagnosis includes viral rash and drug eruptions.

METHODS

We report two patients with chronic myeloid leukemia submitted to allogeneic BMT who developed a severe form of acute cutaneous GvHD, with clinical and histological pictures mimicking toxic epidermal necrolysis (TEN).

RESULTS

We found a predominance of peripheral CD8+ T lymphocytes and, at the same time, studying the cellular profile of the blister fluid, just in the beginning of blister eruption, we also found a high proportion of CD8+ T lymphocytes, mainly CD8+CD57-.

CONCLUSION

These data are in agreement with previous reports of the presence of CD8+ T cells in the blister fluid of patients with TEN, further emphasizing similar immunoinflammatory pathways in both diseases.

Biphasic effects of selegiline on striatal dopamine: lack of effect on methamphetamine-induced dopamine depletion

We tested the hypothesis that selegiline can attenuate dopamine depletion if administered following high doses of methamphetamine that cause neurotoxicity in the striatum. Methamphetamine produced decreases of 50% or greater in both striatal concentrations of dopamine and combined concentrations of homovanillic acid and DOPAC in mice. For animals not exposed to methamphetamine, chronic treatment with selegiline over 18 days caused biphasic effects on striatal dopamine content, with decreases, no effect, or increases observed for mice receiving treatment with 0.02, 0.2, and 2.0 mg/kg, respectively. Selegiline failed to modify methamphetamine-induced reductions in striatal dopamine content or combined concentrations of homovanillic acid and DOPAC. Significant increases in mortality following the onset of selegiline treatment (24 hours after the initial dose of methamphetamine) occurred in methamphetamine-treated mice that received saline or 2.0 mg/kg of selegiline, but not for mice treated with 0.02 or 0.2 mg/kg of selegiline. These results indicate that selegiline fails to attenuate dopamine depletion when administered chronically following exposure to methamphetamine, but may attenuate methamphetamine-induced mortality. In control animals that did not receive methamphetamine, low doses of selegiline produced decreases the concentration of striatal dopamine, while high dose treatment caused increases in striatal dopamine content.

Prognostic value of Ki-67 expression in localized cutaneous malignant melanoma

BACKGROUND

The proliferative activity of some tumors is related to the development of metastatic disease and survival. Thus it could be used as a potential prognostic variable.

OBJECTIVE

The purpose of this study was to determine the prognostic value of the Ki-67 index and of a "proliferation-based prognostic index" (PBPI, derived as tumor thickness x Ki-67 index/100) in localized cutaneous malignant melanoma (CMM).

METHODS

The Ki-67 index (percent of total tumor nuclei) was determined in a series of 84 localized CMMs, with the use of the alkaline phosphatase-antialkaline phosphatase labeling method in formalin-fixed, paraffin-embedded material, and was correlated with other prognostic variables. Survival analysis was performed to determine whether the Ki-67 index and the PBPI could be predictive of metastatic spread or recurrent disease. A stratified analysis of these two parameters according to the tumor thickness was done.

RESULTS

An association among the Ki-67 index and location, Clark level, tumor thickness and stage, and prognostic index was detected. Increased Ki-67 index and PBPI were associated with poorer overall survival (P =.03 and P <.0001, respectively) and disease-free survival (P =.01 and P <.0001, respectively). However, after stratification for thickness, only the PBPI showed independent prognostic significance, restricted to tumors thicker than 4 mm (P =. 03).

CONCLUSION

The determination of the PBPI in CMM conveys prognostic information for localized thick (>4 mm) CMM, identifying two groups of patients with distinct outcome.

Correlation between HIV and HCV in Brazilian prisoners: evidence for parenteral transmission inside prison

OBJECTIVE

It is an accepted fact that confinement conditions increase the risk of some infections related to sexual and/or injecting drugs practices. Mathematical techniques were applied to estimate time-dependent incidence densities of HIV infection among inmates.

METHODS

A total of 631 prisoners from a Brazilian prison with 4,900 inmates at that time were interviewed and their blood drawn. Risky behavior for HIV infection was analyzed, and serological tests for HIV, hepatitis C and syphilis were performed, intended as surrogates for parenteral and sexual HIV transmission, respectively. Mathematical techniques were used to estimate the incidence density ratio, as related to the time of imprisonment.

RESULTS

Prevalence were: HIV - 16%; HCV - 34%; and syphilis - 18%. The main risk behaviors related to HIV infection were HCV prevalence (OR=10.49) and the acknowledged use of injecting drugs (OR=3.36). Incidence density ratio derivation showed that the risk of acquiring HIV infection increases with the time of imprisonment, peaking around three years after incarceration.

CONCLUSIONS

The correlation between HIV and HCV seroprevalence and the results of the mathematical analysis suggest that HIV transmission in this population is predominantly due to parenteral exposure by injecting drug, and that it increases with time of imprisonment.

Gangrene of the fingertips after bleomycin and methotrexate

The increased use of cytostatic drugs, which are sometimes used in combination chemotherapy, may result in new and unusual cutaneous side effects. We describe a 57-year-old man with acral erythrocyanosis progressing to acute digital ischemia and gangrene that developed after combined chemotherapy (bleomycin and methotrexate) used to treat a metastatic squamous cell carcinoma of the hypopharynx. A leukocytoclastic vasculitis was found in both the acute phase and in the amputated fingertips. This supports the well-reported potential of bleomycin to trigger acral vascular toxicity.

[Clinical-epidemiologic indications for echocardiographic assessment in the neonatal period. Value of risk groups]

PURPOSE

An echocardiographic study was performed in newborns from risk groups, with the aim of to determining prevalence and to evaluate the indications for this test in the neonatal period.

METHODS

One hundred fifty six newborns were studied. They were admitted to the Newborn ward of the Department of Obstetric of the HC-FMUSP, in the period of November 91 to April 93, from mothers with congenital heart disease or diabetes, low birth weight newborns, with extracardiac malformations, cardiac signs and/or congenital infections.

RESULTS

The observed prevalence was 21.8%, greater than that of the general population (0.8-1.2%). The group composed by 27 children with extracardiac abnormalities presented the largest prevalence when compared with the other groups (40.7%). These data justify the use of echocardiography in high risk newborns for the detection of congenital heart disease.

Reliability of environmental, biological and health characteristics of infants from a developing country

BACKGROUND

Although most epidemiological data are gathered by interviews, few studies ascertain their reliability. This study quantified inter-observer reliability of environmental, biological and health characteristics of underprivileged children, in a southern Brazilian state.

METHODS

Five health care professionals who had received extensive standardized interview and observation training interviewed mothers and observed the home environments of a random sample of 102 children. A second interview was conducted by a sixth health professional who had received separate but identical training without the initial interviewer knowing a follow-up interview would be conducted. Data from the two independent interviews and observations were compared for agreement using the kappa statistic.

RESULTS

There was excellent agreement (kappa > 0.75) for most of the household characteristics, such as type of walls, ceiling, floor and windows in spite of the diversity of buildings. Presence of the parents, number of people in the house-hold, age of the mother and health assistance were reliable as well. However, information about skin colour of the mother and the number of cracks in the house only reached fair agreement.

CONCLUSIONS

These results showed that data gathered by observation and interviews generate accurate information about environmental, biological and health care characteristics. Those based on written information, such as birth date, were highly concordant.

Diagnosis of Wuchereria bancrofti filariasis by immunofluorescence using microfilariae as antigen

A new technique for the diagnosis of wuchereriasis is described. Microfilariae treated with proteolytic enzyme were used as antigen for the immunofluorescent reaction. The specificity of the reaction is demonstrated in sera from persons who have a microfilariaemia, individuals with clinical symptoms of the disease but no microfilariaemia, those who have no clinical symptoms, but harbour other parasites, and in persons living in France, where the Wuchereria bancrofti filariasis is absent.