Índice frágil-VGI y mortalidad a los 12 meses de seguimiento en el Hospital Central Fuerza Aérea del Perú

Objetivo: Conocer la relación entre mortalidad y nivel de fragilidad mediante los índices de fragilidad-valoración geriátrica integral (IF-VGI) a los 12 meses de seguimiento en adultos mayores. Materiales y métodos: Estudio descriptivo, observacional y prospectivo, con muestreo no probabilístico. Se incluyeron pacientes mayores de 60 años del Servicio de Geriatría. Se utilizaron los IF-VGI, y se diagnosticó la fragilidad si la puntuación era mayor o igual a 0,2 en los diferentes niveles de atención: unidad de agudos, hospital de día, consulta externa y consulta domiciliaria; se realizó un seguimiento de 12 meses después de su evaluación por vía telefónica. En caso de fallecimiento, se corroboró el suceso y la causa en el Sistema Informático Nacional de Defunciones (SINADEF) del Ministerio de Salud del Perú. Se excluyeron los pacientes que fallecieron por complicaciones de coronavirus. Para determinar la asociación entre IF-VGI y mortalidad se utilizaron las pruebas ji al cuadrado y t de Student, tanto para las variables cualitativas y cuantitativas, respectivamente. Resultados: Se incluyeron 241 sujetos, con una edad media de 85,08 años. De esta población, 222 (92,12 %) tenían fragilidad con un IF mayor-igual a 0,2. De ellos, 82 presentaron fragilidad leve (IF entre 0,2-0,36); 59, fragilidad moderada (IF entre 0,4-0,52), y 54, fragilidad severa (IF mayor 0,56). En el seguimiento de la población reevaluada a los 12 meses, 28 (11,61 %) fallecieron en este periodo. De los fallecidos, 23 (82,14 %) registraron un IF mayor igual a 0,56. Al analizar la asociación entre la mortalidad y el IF-VGI, se encontró que, a mayor índice de fragilidad, mayor mortalidad, con diferencias muy significativas (p = 0,001). No hubo asociación entre edad y mortalidad (p = 0,95). Conclusiones: El IF-VGI es una herramienta útil para predecir la mortalidad en los pacientes frágiles, según su severidad, a los 12 meses de seguimiento.

Objective: To determine the relationship between mortality and level of frailty using the Frailty Index-Comprehensive Geriatric Assessment (FI-CGA) among older adults at a 12-month follow-up. Materials and methods: A descriptive, observational and prospective study with non-probabilistic sampling conducted with patients over 60 years of age from the Geriatrics Service. Using the FI-CGA, frailty was diagnosed if the score was greater than or equal to 0.2 at the different levels of care: acute care unit, day hospital, outpatient clinic and house call. Moreover, a follow-up was conducted 12 months following their telephone consultation. In case of death, the event and cause were confirmed in the Sistema Informático Nacional de Defunciones (SINADEF, National Death Computer System) of the Ministry of Health of Peru. Patients who died from coronavirus complications were excluded. To determine the association between FI-CGA and mortality, chi-square and Student's t tests were used for the qualitative and quantitative variables, respectively. Results: A total of 241 subjects with an average age of 85.08 years were included in the research. Out of this population, 222 (92.12 %) were classed as frail (FI-CGA score ≥ 0.2), among which 82 were considered mildly frail (0.2-0.36), 59 moderately frail (0.4-0.52) and 54 severely frail (> 0.56). At the 12-month follow-up, 28 (11.61 %) older adults had died during that period. Out of the deceased, 23 (82.14 %) had a FI-CGA score greater than or equal to 0.56. When analyzing the association between mortality and the FI-CGA, it was found that the higher the FI, the higher the mortality, with very significant differences (p = 0.001). There was no association between age and mortality (p = 0.95). Conclusions: The FI-CGA is a useful tool to predict mortality in frail patients, according to their severity, at a 12-month follow-up.

Conocimientos de médicos geriatras respecto a la terminalidad de pacientes con demencia avanzada

Objetivo: Conocer las discrepancias entre los médicos del ámbito de la geriatría de un país latinoamericano (Perú) respecto al manejo paliativo de la demencia. Materiales y métodos: Estudio descriptivo y de corte transversal. La población estuvo conformada por médicos geriatras y residentes de geriatría peruanos encuestados en agosto del 2019. Se empleó un muestreo no probabilístico por conveniencia. Considerando una población total de 277 médicos geriatras en Perú y un efecto de diseño de 1,0, el tamaño mínimo de la muestra fue 162 médicos geriatras. La encuesta constó de diferentes preguntas enfocadas en las decisiones de la práctica clínica diaria del médico geriatra sobre la terminalidad de pacientes con demencia. Para asegurar un mejor entendimiento de las respuestas se presentó un caso típico de la enfermedad. Resultados: Se encuestaron 162 médicos, de los cuales la mayoría eran médicos geriatras (81,48 %). Con respecto al nivel global de actitudes y conocimientos de cuidados paliativos, el 89,61 % considera que la demencia es una enfermedad terminal no oncológica; el 69,18 % considera que la toma de muestras de laboratorio, vías periféricas, cateterismo urinario y sonda nasogástrica son medidas invasivas. Conclusiones: La encuesta mostró un nivel moderado respecto a actitudes y conocimientos; los puntos más débiles fueron la perspectiva práctica y la idoneidad en la toma de decisiones. Por consiguiente, deben realizarse capacitaciones dirigidas a establecer pronósticos y mejorar la toma de decisiones de los médicos involucrados en el tratamiento de los adultos mayores con demencia terminal, para evitar la implementación de medidas que no generen un impacto positivo y que le restarán calidad de vida al paciente.

Objective: To learn about the disagreements among geriatricians from a Latin American country (Peru) as to the palliative therapy for dementia. Materials and methods: A descriptive and cross-sectional study. The population consisted of Peruvian geriatricians and geriatrics residents surveyed during August 2019. A non-probability convenience sampling was used. Considering a total population of 277 geriatricians in Peru and a design effect of 1.0, the minimum sample size was 162 geriatricians. The survey included different questions focused on geriatricians' decisions on the daily clinical practice of terminal care in dementia. To ensure a better understanding of the answers, a typical case of the disease was presented. Results: One hundred sixty-two (162) doctors were surveyed, most of whom were geriatricians (81.48 %). Regarding the global level of attitudes and knowledge of palliative care, 89.61 % considered dementia as a non-oncological terminal illness, and 69.18 % considered laboratory sample collection, peripheral intravenous line insertion, urinary catheterization and nasogastric tube insertion as invasive measures. Conclusions: The survey showed a moderate level in attitudes and knowledge of palliative care. The weakest points were the practical perspective and suitability in decision-making. Therefore, training programs aimed at making adequate prognoses and improving decision-making of physicians involved in the care and support of older adults with late-stage dementia should be conducted to avoid implementing measures that will not generate a positive impact to and will harm the patient's quality of life.

Relación entre fragilidad en adultos mayores y fuerza de prensión disminuida

Objetivo: Conocer si la fuerza de prensión disminuida está asociada con fragilidad y resultados adversos a los 3 meses de seguimiento. Materiales y métodos: Estudio descriptivo, observacional, prospectivo. Se incluyeron pacientes mayores de 59 años que acudían al hospital de día. La fuerza de prensión de la mano dominante fue medida durante la visita clínica ambulatoria. La fragilidad fue evaluada mediante la escala de Edmonton. La asociación entre fuerza de prensión disminuida, fragilidad y resultados adversos a los 3 meses de seguimiento fueron evaluados mediante el test de Chi cuadrado y la prueba T de Student. Resultados: La fuerza de prensión fue medida en 82 adultos mayores (46 mujeres), cuya edad media era 83,68 años. Según la escala de fragilidad de Edmonton, estos adultos tuvieron fuerza de prensión disminuida: el 83,33 % de los sujetos presentó fragilidad severa; el 86,66 %, fragilidad leve, y el 46,66 % era vulnerable a fragilidad. Los adultos mayores "no frágiles", según Edmonton, no tuvieron fuerza de prensión disminuida. La disminución de la fuerza de prensión fue asociada con fragilidad (p = 0,002). Los resultados adversos a los 3 meses de seguimiento fueron frecuentes en los adultos mayores con disminución de la fuerza de prensión (p = 0,49), así como en aquellos con fragilidad (p = 0,48), aunque no fueron estadísticamente significativos. Conclusiones: La fuerza de prensión disminuida está asociada con fragilidad. A los 3 meses de seguimiento, todos los sujetos que murieron tuvieron fuerza de prensión disminuida.

Objective: To find out if decreased grip strength is associated with frailty and adverse outcomes at three-month follow-up. Materials and methods: A descriptive, observational and prospective study. Patients older than 59 years of age attending a day hospital were included in the research. The dominant hand grip strength was measured during an outpatient visit. Frailty was assessed using the Edmonton Frail Scale. The association between decreased grip strength, frailty and adverse outcomes at three-month follow-up was evaluated using the chi-square test and Student's t-test. Results: Grip strength was measured in 82 older adults (out of whom 46 were females) whose mean age was 83.68 years. Based on the Edmonton Frail Scale, 83.33 % of the study subjects were severely frail, 87.87 % were moderately frail, 86.66 % were mildly frail and 46.66 % were vulnerable to frailty. According to this scale, "not frail" older adults were those who did not show decreased grip strength. Decreased grip strength was associated with frailty (p = 0.002). Adverse outcomes at three-month follow-up were frequent in older adults with decreased grip strength (p = 0.49) and those with frailty (p = 0.48), although such outcomes were not statistically significant. Conclusions: Decreased grip strength is associated with frailty. At three-month follow-up, all the study participants who died had decreased grip strength.

Protective effect of N-acetyl-L-cysteine and rosuvastatin against oxidative stress in fibroblasts from asymptomatic patients with X-ALD: a preliminary study

Introduction: Several studies in the literature have evaluated the role of oxidative stress and adjuvant therapies for X-linked adrenoleukodystrophy (X-ALD). Here, we investigated whether n-acetyl-L-cysteine (NAC) and rosuvastatin (RSV) could influence the generation of reactive species, redox status and nitrative stress in fibroblasts from asymptomatic patients with X-ALD. Methods: Skin biopsy samples were cultured and treated for 2 hours (37 °C) with NAC and RSV. Results: X-ALD fibroblasts generated high levels of reactive oxygen species. These levels were significantly lower in fibroblasts treated with NAC and RSV relative to untreated samples. The X-ALD fibroblasts from asymptomatic patients also had higher catalase activity, and only NAC was able to increase enzyme activity in the samples. Conclusions: Our results indicated that NAC and RSV were able to improve oxidative stress parameters in fibroblasts from asymptomatic patients with X-ALD, showing that adjuvant antioxidant therapy may be a promising treatment strategy for asymptomatic patients with this disease. (AU)

Free carnitine and branched chain amino acids are not good biomarkers in Huntington's disease / Carnitina livre e aminoácidos de cadeia ramificada não são bons biomarcadores na doença de Huntington

ABSTRACT Background: Huntington's disease (HD), caused by an expanded CAG repeat at HTT, has no treatment, and biomarkers are needed for future clinical trials. Objective: The objective of this study was to verify if free carnitine and branched chain amino acids levels behave as potential biomarkers in HD. Methods: Symptomatic and asymptomatic HD carriers and controls were recruited. Age, sex, body mass index (BMI), age of onset, disease duration, UHDRS scores, and expanded CAG tract were obtained; valine, leucine, isoleucine, and free carnitine were measured. Baseline and longitudinal analysis were performed. Results: Seventy-four symptomatic carriers, 20 asymptomatic carriers, and 22 non-carriers were included. At baseline, valine levels were reduced in symptomatic and asymptomatic HD carriers when compared to non-carriers. No difference in free carnitine or isoleucine+leucine levels were observed between groups. BMI of symptomatic individuals was lower than those of non-carriers. Valine levels correlated with BMI. Follow-up evaluation was performed in 43 symptomatic individuals. UHDRS total motor score increased 4.8 points/year on average. No significant reductions in BMI or valine were observed, whereas free carnitine and isoleucine+leucine levels increased. Conclusions: Although valine levels were lower in HD carriers and were related to BMI losses observed in pre-symptomatic individuals, none of these metabolites seem to be biomarkers for HD.

RESUMO Introdução: A doença de Huntington (DH), causada por uma repetição CAG expandida no HTT, não possui tratamento e biomarcadores são necessários para futuros ensaios clínicos. Objetivo: Nosso objetivo foi verificar se os níveis de carnitina livre e aminoácidos de cadeia ramificada se comportam como potenciais biomarcadores na DH. Métodos: Portadores sintomáticos e assintomáticos e controles foram recrutados. Idade, sexo, índice de massa corporal (IMC), idade de início, duração da doença, escores UHDRS e trato CAG expandido foram obtidos; valina, leucina, isoleucina e carnitina livre foram medidas. Foram realizadas análises basal e longitudinal. Resultados: Setenta e quatro portadores sintomáticos, 20 portadores assintomáticos e 22 não portadores foram incluídos. No início do estudo, os níveis de valina estavam reduzidos em portadores de DH sintomáticos e assintomáticos quando comparados aos não portadores. Não foram observadas diferenças nos níveis de carnitina livre ou isoleucina + leucina entre os grupos. O IMC dos indivíduos sintomáticos foi menor que o dos não portadores. Níveis de valina correlacionaram-se com o IMC. Avaliação de acompanhamento foi realizada em 43 indivíduos sintomáticos. A pontuação do escore motor total da UHDRS aumentou 4,8 pontos/ano em média. Não foram observadas reduções significativas no IMC ou na valina, enquanto os níveis de carnitina livre e isoleucina+leucina aumentaram. Conclusões: Embora os níveis de valina tenham sido menores nos portadores de DH e estivessem relacionados às perdas de IMC observadas em indivíduos pré-sintomáticos, nenhum desses metabólitos parece ser biomarcador para a DH.

Increased levels of hexacosanoic acid in the brain of Winstar rats: a behavioral study

Introduction: X-linked adrenoleukodystrophy (X-ALD) is a peroxisomal metabolic disorder associated with mutations in the ATP-binding cassette sub-family D member1 (ABCD1) gene. Practically all male patients with X-ALD develop adrenocortical insufficiency during childhood and progressive myelopathy and peripheral neuropathy in adulthood. However, some male patients develop a fatal cerebral demyelinating disease named cerebral adrenoleukodystrophy. Although the exact mechanisms underlying brain damage in X-ALD are still poorly elucidated, it is known that hexacosanoic acid (C26:0) accumulation represents a hallmark in the pathogenesis of this disease. In this study, we examined whether an overload of C26:0 injected in Wistar rats was capable of causing behavioral changes in these animals. Methods: Egg lecithin in ethanol was dried under a nitrogen stream and mixed with C26:0 methyl ester. Male Wistar rats at 2-3 weeks of age were obtained from Universidade Federal do Rio Grande do Sul (UFRGS), divided into 8 groups, and submitted to an open field test. We then analyzed line crossings (locomotion and exploration), rearing (orienting and investigatory responses), grooming (anxiety manifestation), and latency to move for each animal. Results: Animals subjected to C26:0 administration presented fewer crossings and rearing episodes and a higher latency to move 45 minutes after C26:0 injection. The present work yields experimental evidence that C26:0, the main accumulated metabolite in X-ALD, can cause behavioral alterations in rats such as the impairment of locomotion and exploratory capabilities, as well as a reduction in orienting and investigatory responses. Conclusion: Although our results are preliminary, they are extremely important for future studies that investigate C26:0 accumulation and locomotor impairment in patients with X-ALD. (AU)

Monitoring of Phenylalanine Levels in Patients with Phenylketonuria Using Dried Blood Spots: a Comparison of Two Methods

Abstract Phenylketonuria (PKU) is caused by deficient activity of phenylalanine hydroxylase (PAH), responsible for the conversion of phenylalanine (Phe) to tyrosine (Tyr). Monitoring of patients with PKU requires the measurement of Phe in plasma using high-performance liquid chromatography (HPLC) or in dried blood spots (DBS) using different techniques to adjust treatment strategy. The objective of this study was to evaluate Phe levels in DBS measured by two different methods and compare them with Phe levels measured in plasma by HPLC. We analyzed 89 blood samples from 47 PKU patients by two different methods: fluorometric method developed in-house (method A) and the commercially available PerkinElmer® Neonatal Phenylalanine Kit (method B) and in plasma by HPLC. The mean Phe levels by method A, method B, and HPLC were 430.4±39.9μmol/L, 439.3±35.4μmol/L, and 442.2±41.6μmol/L, respectively. The correlation values between HPLC and methods A and B were 0.990 and 0.974, respectively (p < 0.001 for both). Our data suggest that methods A and B are useful alternatives for monitoring Phe levels in patients with PKU, with method A being in closer agreement with the reference standard (HPLC).

The value of fasting in the diagnosis of medium-chain acyl-CoA dehydrogenase deficiency / O valor do jejum no diagnóstico da deficiência de acil-CoA desidrogenase de cadeia média

ABSTRACT Female patient carrier of medium-chain acyl-CoA dehydrogenase deficiency (MCADD) with recurrent clinical episodes of hypoglycemia and altered level of consciousness, presented changes in blood acylcarnitine profile by tandem mass spectrometry and in the urinary organic acid analysis by gas chromatography/mass spectrometry (GC/MS). This case demonstrates the importance of fasting prior biological sample collection (when possible) when MCADD is suspected, and emphasizes that the time/momentum of biological sample collection is crucial to diagnosis, considering the possibility that MCADD is underdiagnosed in Brazil.

RESUMEN Paciente portadora de deficiencia de acil-CoA deshidrogenasa de cadena media (MCADD) con episodios clínicos recurrentes de hipoglucemia y alteración de consciencia presentó mudanzas en el perfil de acilcarnitinas en la sangre con técnicas de espectrometría de masas en tándem y en el análisis de ácidos orgánicos urinarios mediante cromatografía de gases acoplada a espectrometría de masas. Este caso demuestra la importancia de la toma de muestras biológicas en ayunas (se posible) cuando se sospecha de MCADD y destaca que el tiempo/momento de extracción de la muestra biológica es valioso para el diagnóstico, considerando la posibilidad de que la MCADD es subdiagnosticada en Brasil.

RESUMO Paciente portadora de deficiência de acil-CoA desidrogenase de cadeia média (MCADD), com episódios clínicos recorrentes de hipoglicemia e alteração de consciência, apresentou alterações no perfil de acilcarnitinas em sangue por espectrometria de massas em tandem e na análise de ácidos orgânicos urinários por cromatografia gasosa acoplada à espectrometria de massa. Este caso demonstra a importância da coleta de amostra biológica em jejum (se possível) quando há suspeita de MCADD e ressalta que o tempo/momento de coleta da amostra biológica é importante para o diagnóstico, considerando a possibilidade de a MCADD ser subdiagnosticada no Brasil.

DNA damage in homocystinuria: 8-oxo-, 8-dihydro-2'-deoxyguanosine levels in cystathionine-ß-synthase deficient patients and the in vitro protective effect of N-acetyl­L­cysteine

Introduction: Homocysteine (Hcy) tissue accumulation occurs in a metabolic disease characterized biochemically by cystathionine ß-synthase (CBS) deficiency and clinically by mental retardation, vascular problems, and skeletal abnormalities. Previous studies indicate the occurrence of DNA damage secondary to hyperhomocysteinemia and it was observed that DNA damage occurs in leukocytes from CBS-deficient patients. This study aimed to investigate whether an oxidative mechanism could be involved in DNA damage previously found and investigated the in vitro effect of N-acety-L-cysteine (NAC) on DNA damage caused by high Hcy levels. Methods: We evaluated a biomarker of oxidative DNA damage in the urine of CBS­deficient patients, as well as the in vitro effect of NAC on DNA damage caused by high levels of Hcy. Moreover, a biomarker of lipid oxidative damage was also measured in urine of CBS deficient patients. Results: There was an increase in parameters of DNA (8-oxo-7,8-dihydro-2'- deoxyguanosine) and lipid (15-F2t-isoprostanes levels) oxidative damage in CBS-deficient patients when compared to controls. In addition, a significant positive correlation was found between 15-F2t-isoprostanes levels and total Hcy concentrations. Besides, an in vitro protective effect of NAC at concentrations of 1 and 5 mM was observed on DNA damage caused by Hcy 50 µM and 200 µM. Additionally, we showed a decrease in sulfhydryl content in plasma from CBS-deficient patients when compared to controls. Discussion: These results demonstrated that DNA damage occurs by an oxidative mechanism in CBS deficiency together with lipid oxidative damage, highlighting the NAC beneficial action upon DNA oxidative process, contributing with a new treatment perspective of the patients affected by classic homocystinuria.

Acción Inmediata de los Enjuagues Orales en la Saliva / Immediate Action of Mouthwashes on Whole Saliva

RESUMEN: Numerosos estudios confirman la efectividad de los enjuagatorios orales sobre la viabilidad de los microorganismos que producen gingivitis y halitosis, pero poco se conoce sobre la influencia de los mismos en el medio ambiente oral. El objetivo del siguiente trabajo fue analizar In vivo e In vitro el efecto de enjuagatorios orales sobre la saliva total no estimulada. Se trabajó con saliva de individuos sanos. Para el estudio in vivo se recogieron las muestras antes y después del enjuague oral a diferentes tiempos (1, 5, 10, 15, 30, 45 y 60 minutos). Para el ensayo in vitro, se incubó la saliva con igual volumen de la solución enjuagatoria a 37 ºC con agitación a diferentes tiempos (1, 5, 10 y 15 minutos). Se determinó pH inmediatamente recogidas las muestras. Posteriormente fueron centrifugadas y determinados flujo salival y proteínas totales. La separación de proteínas por electroforesis en SDS-PAGE se realizó solo en el ensayo in vivo. Los resultados mostraron que los enjuagatorios fluorurados poco alteran la fisiología oral a través de flujo salival, pH y proteínas totales. La combinación fluoruro de sodio/xilitol produjo mayor estimulación del flujo salival. La mezcla de aceites esenciales provocó un incremento del flujo salival y de pH, redujo el contenido de proteínas totales, evidenciando por SDS-PAGE que las comprometidas fueron particularmente las de mediano y bajo peso molecular. Clorhexidina debido a su elevada sustantividad, incrementó significativamente flujo salival y pH in vivo. In vitro, fuera del medioambiente oral, los enjuagatorios estudiados ejercieron un efecto similar sobre proteínas totales. Los enjuagatorios de uso frecuente alteraron parámetros salivales, por lo que podría estudiarse la acción que ejercen sobre otros componentes de la saliva con actividad biológica importante en cavidad oral.

ABSTRACT: Numerous studies confirm the effectiveness of mouthwashes on the viability of microorganisms that produce gingivitis and halitosis, but little is known about their influence on the oral environment. The objective of the following work was to analyze In vivo and In vitro the effect of mouthwashes on total non-stimulated saliva. We worked with saliva from healthy individuals. For In vivo study, samples were collected before and after oral rinsing at different times (1, 5, 10, 15, 30, 45 and 60 minutes). For the In vitro assay, the saliva was incubated with equal volume of the rinse solution at 37 ° C with shaking at different times (1, 5, 10 and 15 minutes). PH was determined immediately collected samples. Subsequently they were centrifuged and determined salivary flow and total proteins. Separation of proteins by SDS-PAGE electrophoresis was performed only in the In vivo assay. The results showed that fluoridated rinses hardly alter oral physiology through salivary flow, pH and total proteins. The combination of sodium fluoride / xylitol produced greater stimulation of salivary flow. The mixture of essential oils caused an increase in salivary flow and pH, reduced the total protein content, evidencing by SDS-PAGE that those involved were particularly those of medium and low molecular weight. Chlorhexidine due to its high substantivity, significantly increased salivary flow and pH In vivo. In vitro, outside the oral environment, the rinses studied had a similar effect on total proteins. Rinses used frequently altered salivary parameters, so that the action they exert on other components of saliva with important biological activity in the oral cavity could be studied.

In vitro effect of N-acetyl-L-cysteine on glutathione and sulfhydryl levels in X-linked adrenoleukodystrophy patients

Introduction: Recent evidence shows that oxidative stress seems to be related with the pathophysiology of X-linked adrenoleukodystrophy (X-ALD), a neurodegenerative disorder. Methods: In the present study, the in vitro effect of N-acetyl-L-cysteine (NAC) on glutathione (GSH) and sulfhydryl levels in X-ALD patients was evaluated. Results: A significant reduction of GSH and sulfhydryl content was observed in X-ALD patients compared to the control group. Furthermore, 5 mM of NAC, in vitro, led to an increase in GSH content and sulfhydryl groups in these patients. Conclusion: These data probably indicate that an adjuvant therapy with the antioxidant NAC could improve the oxidative imbalance in X-ALD patients(AU)

Validation of a Multiplex Tandem Mass Spectrometry Method for the Detection of Selected Lysosomal Storage Diseases in Dried Blood Spots

Abstract Background: Interest in screening methods for lysosomal storage diseases (LSDs) has increased in recent years, since early diagnosis and treatment are essential to prevent or attenuate the onset of symptoms and the complications of these diseases. In the current work, we evaluated the performance of tandem mass spectrometry (MS/MS) for the detection of some LSDs, aiming the future use of this methodology for the screening of these disorders. Methods: Standard curves and quality control dried blood spots were assayed to evaluate the precision, linearity, and accuracy. A total of 150 controls were grouped according to age and subjected to measurement of lysosomal enzymes deficient in Niemann-Pick A/B, Krabbe, Gaucher, Fabry, Pompe, and Mucopolysaccharidosis type I diseases. Samples from 59 affected patients with a diagnosis of LSDs previously confirmed by fluorimetric methods were analyzed. Results: Data from standard calibration demonstrated good linearity and accuracy and the intra- and interassay precisions varied from 1.17% to 11.60% and 5.39% to 31.24%, respectively. Except for galactocerebrosidase and ?-l-iduronidase, enzyme activities were significantly higher in newborns compared to children and adult controls. Affected patients presented enzymatic activities significantly lower compared to all control participants. Conclusion: Our results show that MS/MS is a promising methodology, suitable for the screening of LSDs, but accurate diagnoses will depend on its correlation with other biochemical and/or molecular analyses.

Neurological outcomes after hematopoietic stem cell transplantation for cerebral X-linked adrenoleukodystrophy, late onset metachromatic leukodystrophy and Hurler syndrome / Desfechos neurológicos após transplante de células tronco hematopoiéticas na adrenoleucodistrofia ligada ao X, forma cerebral, na leucodistrofia metacromática de início tardio e na síndrome de Hurler

ABSTRACT Hematopoietic stem cell transplantation (HSCT) is the only available treatment for the neurological involvement of disorders such as late-onset metachromatic leukodystrophy (MLD), mucopolysaccharidosis type I-Hurler (MPS-IH), and X-linked cerebral adrenoleukodystrophy (CALD). Objective To describe survival and neurological outcomes after HSCT for these disorders. Methods Seven CALD, 2 MLD and 2 MPS-IH patients underwent HSCT between 2007 and 2014. Neurological examinations, magnetic resonance imaging, molecular and biochemical studies were obtained at baseline and repeated when appropriated. Results Favorable outcomes were obtained with 4/5 related and 3/6 unrelated donors. Two patients died from procedure-related complications. Nine transplanted patients were alive after a median of 3.7 years: neurological stabilization was obtained in 5/6 CALD, 1/2 MLD, and one MPS-IH patient. Brain lesions of the MPS-IH patient were reduced four years after HSCT. Conclusion Good outcomes were obtained when HSCT was performed before adulthood, early in the clinical course, and/or from a related donor.

RESUMO O transplante de células tronco hematopoiéticas (TCTH) é o único tratamento disponível para o envolvimento neurológico de doenças como a leucodistrofia metacromática (MLD), a mucopolissacaridose tipo I-Hurler (MPS-IH) e a adrenoleucodistrofia (CALD). Objetivos Descrever a sobrevida e os desfechos neurológicos após o TCTH nessas doenças. Métodos Sete pacientes CALD, 2 MLD e 2 MPS-IH realizaram TCTH entre 2007 e 2014. Avaliações neurológicas, ressonância nuclear magnética e estudos bioquímicos e moleculares foram feitos no baseline e repetidos quando apropriado. Resultados Desfechos favoráveis foram obtidos em 4/5 TCTH de doadores relacionados e em 3/6 não relacionados. Dois pacientes faleceram de complicações do procedimento. Nove transplantados sobreviveram após uma mediana de 3,7 anos: estabilização neurológica foi obtida em 5/6 CALD, ½ MLD e em um caso MPS-IH. As lesões encefálicas de um caso MPS-IH reduziram-se quatro anos após o TCTH. Conclusão Bons desfechos foram obtidos quando o TCTH foi feito antes da vida adulta, cedo no curso clínico e/ou a partir de um doador relacionado.

Caso Clínico: Pielonefritis Enfisematosa / Case Report: Emphysematous Pyelonephritis

INTRODUCCIÓN: La pielonefritis enfisematosa (PEN) es una infección aguda grave y en ocasiones fulminante, se manifiesta con necrosis y presencia de gas en el parénquima renal y tejido perirrenal. CASO CLÍNICO: Se trata de una paciente de sexo femenino de 60 años con antecedentes de diabetes mellitus tipo 2 e hipertensión arterial; ingresa por cuadro de dolor lumbar, malestar general, astenia y nausea que llevó al vómito. Al examen físico se evidenció puño percusión izquierda positiva e hiperglicemia. Se realizaron estudios complementarios que establecieron el diagnóstico de pielonefritis enfisematosa. EVOLUCIÓN: Se inició tratamiento antibiótico de amplio espectro para Escherichia coli, posteriormente fue necesario someter a la paciente a nefrectomía total por la imposibilidad de drenaje percutáneo de lesiones intra y perirrenales. La evolución fue favorable después de una nueva intervención y rotación del esquema antibiótico. CONCLUSIÓN: Se establece la necesidad de la sospecha clínica para determinar de forma precoz el diagnóstico, mismo que puede evitar la necesidad de terapias radicales como la nefrectomía.(au)

BACKGROUND: Emphysematous pyelonephritis is a severe acute infection and fulminant sometimes. Its manifestations include necrosis and presence of gas in the kidney parenchyma and around it. CASE REPORT: This is about a 60-years old female patient with precedent diagnosis of type 2 diabetes mellitus and arterial hypertension; she was admitted because of back pain, general malaise, asthenia, nausea and vomit. Physical examination revealed positive fist percussion at right back and hyperglycemia. Complementary exams were performed and emphysematous pyelonephritis diagnosis was established. EVOLUTION: Broad spectrum antibiotic therapy was used to treat Escherichia coli and a complete nephrectomy was performed lately due to impossibility to perform a percutaneous drainage of kidney injuries. Evolution was successful after another intervention and rotation of antibiotic scheme. CONCLUSION: Need of diagnostic suspicion was established to complete an early diagnosis, which may avoid radical therapies as nephrectomy.(au)

Acidúrias D-2-hidroxiglutárica e L-2-hidroxiglutárica: uma revisão da literatura / D-2-hydroxyglutaric and L-2-hydroxyglutaric acidurias:a literature review

As acidúrias D-2-hidroxiglutárica (D-2-HGA) e L-2-hidroxiglutárica (L-2-HGA) são raras doenças neurometabólicas que constituem um grupo de erros inatos do metabolismo. Essas doenças são causadas pela deficiência das atividades enzimáticas da D-2-hidroxiglutarato desidrogenase na D-2-HGA do tipo I ou isocitrato desidrogenase na D-2-HGA do tipo II, e da L-2-hidroxiglutarato desidrogenase na L-2-HGA. Os principais achados clínicos nos pacientes caracterizam-se por sintomas neurológicos, como convulsões, coma e atrofia cerebral. Também ocorrem lesões cerebrais nos gânglios da base (D-2-HGA, L-2-HGA) e cerebelo (L-2-HGA). Bioquimicamente, essas acidúrias caracterizam-se por acúmulo em tecidos e elevada excreção urinária dos ácidos D-2-hidroxiglutárico (na D-2-HGA) e L-2-hidroxiglutárico (na L-2-HGA). Ainda, uma terceira variante bioquímica da acidúria, a D,L-2-hidroxiglutárica (D,L-2-HGA), é caracterizada por excreção aumentada de ambos enantiômeros do ácido 2-hidroxiglutárico. Em modelo animal, estudos de toxicidade dos ácidos D e L-2-hidroxiglutárico mostraram injúria cerebral, mas não foi elucidado o mecanismo exato causador do dano. Além disso, altos níveis dos ácidos D e L-2-hidroxiglutárico foram encontrados em tumores cerebrais. No entanto, a relação entre a acidúria e o câncer ainda precisa ser esclarecida. Tendo em vista a gravidade da doença, este trabalho teve como objetivo fazer uma revisão bibliográfica acerca do tema, enfatizando as consequências do metabolismo, principalmente para o tecido cerebral, bem como apontar possíveis abordagens terapêuticas.

The D-2-hydroxyglutaric (D-2-HGA) and L-2-hydroxyglutaric acidurias (L-2-HGA) are rare neurometabolic diseases that form a group of inborn errors of metabolism. They are caused by a deficiency on the enzyme activities of D-2-hydroxyglutarate dehydrogenase in D-2-HGA type I or isocitrate dehydrogenase in D-2-HGA type II, and L-2-hydroxyglutarate dehydrogenase in L-2-HGA. The main clinical findings in affected patients are related to neurological symptoms, such as convulsions, coma and brain atrophy. Brain injuries also occur in the basal ganglia (D-2-HGA, L-2-HGA) and cerebellum (L-2-HGA). These acidurias are biochemically characterized by the accumulation in tissues and increased urinary excretion of D-2-hydroxyglutaric acid (in D-2-HGA) and L-2-hydroxyglutaric acid (in L-2-HGA). Still, a third biochemical variant of aciduria, called D,L-2-hydroxyglutaric (D,L-2-HGA), is characterized by increased excretion of both enantiomers of 2-hydroxyglutaric acid. In an animal model, toxicity studies on D- and L-2-hydroxyglutaric acids showed brain injury, but the exact mechanism of brain damage was not elucidated. Furthermore, high levels of D- and L-2-hydroxyglutaric acids were found in brain tumors. However, the relationship between cancer and aciduria still needs to be clarified. In view of the severity of the disease, this study aimed to do a literature review on the topic, emphasizing metabolic consequences, particularly for the brain tissue, as well as to identify possible therapeutic approaches.

Encefalopatia diabética e depressão: dano oxidativo no cérebro / Diabetic encephalopathy and depression: brain oxidative damage

O diabetes é um distúrbio complexo e heterogêneo caracterizado por hiperglicemia resultante de defeitos na secreção e ação da insulina. Tem sido reconhecido que, além do comprometimento de órgãos como rins, olhos, fígado e coração, o sistema nervoso central é suscetível aos efeitos deletérios da hiperglicemia em longo prazo. A encefalopatia diabética representa uma das complicações do diabetes, na qual os danos são caracterizados por alterações do funcionamento cognitivo, modificações estruturais e neurofisiológicas no cérebro. Existe uma associação bem reconhecida entre a depressão e o diabetes, uma vez que a prevalência de depressão é maior na população diabética comparada com a população geral. Porém, os mecanismos atribuídos a essa relação ainda estão em fase de investigação. O estresse oxidativo desempenha um papel importante nas complicações do diabetes e pode ser um mecanismo biológico envolvido na relação entre a depressão e o diabetes, relacionado à encefalopatia diabética. Neste artigo de revisão, apresentamos uma visão geral dos principais conceitos relacionados ao assunto, bem como dos dados clínicos e experimentais que suportam a relação entre o dano oxidativo no cérebro e a depressão relacionada com encefalopatia diabética...

Diabetes is a complex and heterogeneous disorder characterized by hyperglycemia resulting from defects in the secretion and action of insulin. It has been recognized that, in addition to the involvement of organs such as kidney, eye, liver, and heart, the central nervous system is susceptible to the deleterious effects of hyperglycemia in the long term. Diabetic encephalopathy is one of the complications of diabetes, in which the damage is characterized by changes in cognitive functioning, structural and neurophysiologic changes in the brain. There is a well-known association between depression and diabetes, since the prevalence of depression is higher in the diabetic population compared to the general population. However, the mechanisms assigned to this relationship are still under investigation. Oxidative stress plays an important role in the complications of diabetes and can be a biological mechanism involved in the relation between depression and diabetes related to diabetic encephalopathy. This review article is an overview of key concepts related to the subject, as well as of the clinical and experimental data supporting the relationship between oxidative damage in the brain and depression related to diabetic encephalopathy...

Homocysteine and other markers of cardiovascular risk during a manic episode in patients with bipolar disorder

Objective: To evaluate serum levels of different biomarkers associated with cardiovascular disease in patients with bipolar disorder (BD). Patients were prospectively evaluated in two separate instances: during acute mania and after remission of manic symptoms. All measurements were compared with those of healthy controls. Methods: The study included 30 patients with BD and 30 healthy controls, matched for gender and age. Biochemical parameters evaluated included homocysteine (Hcy), folic acid, vitamin B12, ferritin, creatine kinase (CK) and C-reactive protein (CRP). Results: Hcy levels were significantly higher in the BD patients, both during mania and after achieving euthymia. When Hcy was adjusted for body mass index, there was no significant difference between patients and controls. Ferritin was the only marker that showed a significant decrease during mania when compared to both euthymic patients and controls. There were no significant differences for folate, vitamin B12, CK and CRP. Conclusions: These findings do not show an association between alterations of markers of cardiovascular risk during manic episodes. Further studies are necessary to determine factors and mechanisms associated with cardiovascular risk in patients with BD. .

Responsividade à tetrahidrobiopterina em pacientes com deficiência de fenilalanina hidroxilase / Tetrahydrobiopterin responsiveness of patients with phenylalanine hydroxylase deficiency

OBJETIVO: Identificar indivíduos responsivos à tetrahibrobiopterina (BH4) em uma amostra de pacientes brasileiros com hiperfenilalaninemia por deficiência de fenilalanina-hidroxilase (HPA-PAH). MÉTODOS: Estudo intervencional, amostragem por conveniência. Para serem incluídos no estudo, os pacientes deveriam: possuir diagnóstico bioquímico de HPA-PAH; ter idade > 7 anos; estar em tratamento dietético; e apresentar níveis de fenilalanina (Phe) > 6 mg/dL em todas as medidas realizadas no ano anterior à inclusão no estudo. Os níveis de Phe foram determinados por meio de espectrometria de massas in tandem no dia anterior (dia 1) e nos pontos de hora 0, 4 e 8 h (dia 2) e 24 h (dia 3) após ingestão de BH4. Os critérios utilizados para definir responsividade ao BH4 foram: critério 1-redução > 30 por cento de Phe após 8 h da administração de BH4; e critério 2-redução > 30 por cento de Phe após 24 h da administração. RESULTADOS: Dezoito pacientes foram incluídos no estudo (mediana de idade = 14 anos, sexo masculino = 12). Cinco pacientes foram responsivos ao BH4, sendo três (forma clássica: um; forma leve: dois) de acordo com ambos os critérios, e dois (forma clássica: um; forma não definida: um) de acordo com o critério 2. Os níveis de Phe plasmáticos do dia 1 não demonstraram variação nos pontos de hora (p = 0,523). Entretanto, quando comparamos os níveis de Phe nos pontos de hora dos dias 1 e 2, encontramos uma variação significativa (p = 0,006). A análise da associação genótipo-fenótipo confirmou o caráter multifatorial da responsividade ao BH4. CONCLUSÃO: Os nossos achados estão de acordo com a literatura e indicam que um número relevante de pacientes brasileiros com HPA-PAH é responsivo à BH4.

OBJECTIVE: To identify patients responsive to tetrahydrobiopterin (BH4) in a sample of Brazilians with hyperphenylalaninemia due to phenylalanine hydroxylase deficiency (HPA-PAH). METHODS: Interventional study, convenience sampling. The inclusion criteria were: diagnosis of HPA-PAH; age > 7 years; phenylalanine-restricted diet and phenylalanine (Phe) levels > 6 mg/dL in all blood tests 1 year before inclusion. Blood samples were obtained the day before (day 1) and at 0, 4, 8 (day 2) and 24 h (day 3) after BH4 intake. Phe levels were measured using tandem mass spectrometry. The criteria used to define responsiveness to BH4 were: criterion 1- Phe reduction > 30 percent 8 h after BH4 administration; criterion 2 - Phe reduction > 30 percent 24 h after BH4 administration. RESULTS: Eighteen patients were enrolled (median age, 14 years; 12 boys). Five patients were responsive to BH4, 3 according to both criteria (one classical PKU, two mild PKU); and two according to criterion 2 (one classical PKU; one indefinite PKU type). There were no differences between Phe serum levels on day 1 and at the other time points (p = 0.523). However, Phe levels on days 1 and 2 were significantly different (p = 0.006). The analysis of the phenotype-genotype association confirmed its multifactorial character. CONCLUSION: A relevant number of Brazilian patients with HPA-PAH are responsive to BH4, in agreement with other studies in the literature.

Frecuencia de casos de úlceras de presión y factores asociados a su desarrollo en adultos mayores hospitalizados en servicios de Medicina de un hospital general / Frequency of pressure ulcers and its related factors in elderly patients admitted to the Medicine wards at a general hospital

Objetivo: Determinar la frecuencia de casos de úlcera de presión y los factores asociados más importantes para su aparición en pacientes adultos mayores hospitalizados en el servicio de medicina de un hospital general. Material y métodos: Estudio prospectivo, observacional. Se estudiaron a todos los pacientes mayores de 60 años, hospitalizados en el servicio de medicina del Hospital Nacional Cayetano Heredia, entre diciembre de 2006 y abril de 2007. Se evaluaron diferentes variables demográficas, clínicas, así como diversos síndromes geriátricos; en dos grupos de pacientes, quienes desarrollaron úlcera de presión y los que no desarrollaron úlcera de presión. Se utilizó chi cuadrado y el análisis multivariado para determinar asociación estadística. Resultados: Se incluyeron 463 adultos mayores, la frecuencia de casos de úlcera de presión fue 11,4 por ciento. Las variables que estuvieron asociadas con el desarrollo de úlcera de presión, con una significancia estadística en el análisis univariado fueron: edad mayor de 70 años, dependencia parcial o total, deterioro cognitivo moderado o severo, incontinencia urinaria, malnutrición, riesgo moderado y alto para desarrollar úlcera de presión según escala de Norton, neumonía y accidentecerebrovascular como diagnósticos de ingreso, uso de catéter vesical, sujeción mecánica, dispositivos externos locales en zonas de prominencias óseas, la presencia de cuidador y el desarrollo de infección pulmonar intrahospitalaria. Luego del análisis multivariado solo: malnutrición (OR =6,87; IC 95 por ciento, 1,38-34,06 p=0,01) y sujeción mecánica (OR=8,09; IC 95 por ciento, 2,47-26,41 p=0,001) fueron los factores de riesgo. Conclusiones: La úlcera de presión es una condición frecuente en el adulto mayor hospitalizado. Los factores asociados a su aparición fueron malnutrición y sujeción mecánica.

Objective: To assess the frequency of pressure ulcers and its related factors in elderly patients admitted to the Medicine wards at a national hospital. Material and methods: Prospective and observational study. We evaluated patients older than 60 years of age who were admitted to Medical wards of the Hospital Nacional Cayetano Herediabetween December 2006 and April 2007. We assess clinical and demographic variables and geriatrics syndromes in two groups of elderly patients according with the presence of pressure ulcers or not. We performed chi-square and multivariate analyses for detecting statistic association. Results: We studied 463 elderly patients, and the frequency of pressure ulcers was 11.4 per cent. The following variables were associated with pressure ulcers: patients older than 70 years old, partial or total dependency, moderate and severe cognitive dysfunction, urine incontinence, malnutrition, moderate risk and higher risk according Norton scale, pneumonia and stroke as entry diagnosis, use of bladder catheter, physical restraints, use of pressure-reducing cushions and heel protectors, caregiver support and the presence of in-hospital pneumonia. In the multivariable analyses, only malnutrition (OR= 6.87; IC 95 per cent, 1.38-34.06, p=0.01) and physical restraints (OR=8.09; IC 95 percent, 2.47-26.41, p=0.001) were significant associated factors. Conclusions: Pressure ulcers are frequent in hospitalized elderly patients. The associated factors for pressureulcers were malnutrition and physical restraints.