Clinical and genetic analysis of a patient with tyrosinemia type I but without elevated succinylacetone / 中华医学遗传学杂志

OBJECTIVE@#To analyze the clinical manifestation and genetic mutation of a child with tyrosinemia type I but without elevated succinylacetone.@*METHODS@#Clinical data of the patient was collected. Tandem mass spectrometry and gas chromatography mass spectrometry were used to analyze the blood amino acid and urine organic acid component of the proband. DNA was extracted from the child and his parents and used for mutation analysis.@*RESULTS@#The proband was of acute type, with features including hepatomegaly, jaundice, anemia and tendency of bleeding. Serum levels of Tyrosine, Methionine and Phenylalanine were 397.12 μmol/L, 896.16 μmol/L and 292.52 μmol/L, respectively, which all distinctly exceeded the normal levels. The level of phenyllactic acid and 4-hydroxyphenyl-lactic acid of proband's urine were 17.4 μmol/L and 417.0 μmol/L, respectively, which also exceeded the normal levels, but the level of succinylacetone was within the normal range. Compound heterozygous mutations of the FAH gene, namely c.634delT (p.L212Wfs*20) and c.455G>A (p.W152X), were detected in the proband, which were both predicted to be pathogenic and were inherited from her father and mother, respectively.@*CONCLUSION@#For children with tyrosinemia type I, detection of urine succinylacetone by gas phase mass spectrometry can be negative. The diagnosis of tyrosinemia type I must rely on genetic testing and/or enzymatic assaying.

Reference values of amino acids, acylcarnitines and succinylacetone by tandem mass spectrometry for use in newborn screening in southwest Colombia / Valores de referencia de aminoácidos, acilcarnitinas y succinilacetona por espectrometría de masas en tándem para su uso en el tamizaje neonatal en el suroccidente de Colombia

Abstract Introduction: Inborn errors of metabolism (IEM) represent an important public health problem due to current diagnosis and treatment limitations, poor life quality of affected patients, and consequent untimely child death. In contrast to classical methods, tandem mass spectrometry (MS/MS) has allowed simultaneous evaluation of multiple metabolites associated with IEM offering higher sensitivity, low false positive rates and high throughput. Aims: Determine concentration levels for amino acids and acylcarnitines in blood of newborns from Colombia, to establish reference values for further use in diagnosis of IEM. Methods: Implementation of a method to determine amino acids, acylcarnitines and succinylacetone in newborn dried blood spots using MS/MS, and its application in a cross-sectional study conducted in 891 healthy neonates from Cali and Quibdo cities is described. Results: fifty-seven analytes that allow the diagnosis of more than 40 different pathologies were tested. The method showed to be linear, precise and accurate. Healthy neonates 1-18 days of age were included, 523 from Cali and 368 from Quibdo; 52% male and 48% female. Age-related differences on the concentration levels of amino acids and acylcarnitines were observed whereas no significant differences by gender were found. Conclusion: The study has contributed to reveal the usual concentration levels of amino acids, acylcarnitines and succinylacetone that could be used as reference for the establishment of a newborn metabolic screening program in Colombia.

Resumen Introducción: Los Errores Innatos del metabolismo (EIM) representan un importante problema de salud pública debido a limitaciones en el tratamiento y diagnóstico oportuno, la pobre calidad de vida de los pacientes afectados, así como la muerte infantil prematura. Comparada con los métodos clásicos, la espectrometría de masas en tándem (MS/MS) ha permitido la evaluación simultánea de múltiples metabolitos asociados con EIM, con una alta sensibilidad, baja proporción de falsos positivos y alto rendimiento. Objetivos: Determinar los niveles de concentración de aminoácidos y acilcarnitinas en sangre de recién nacidos de Colombia, para establecer los valores normales para usarlos como referencia en el diagnóstico de EIM. Métodos: Aquí, se describe la implementación de un método para determinar aminoácidos, acilcarnitinas y succinilacetona en gotas de sangre seca de recién nacidos usando MS/MS, y su aplicación en un estudio de corte transversal realizado en 891 neonatos sanos de las ciudades de Cali y Quibdó. Resultados: Se evaluaron 57 analitos que permiten el diagnóstico de más de 40 patologías diferentes. El método mostró ser lineal, preciso y exacto. Se incluyeron neonatos sanos de 1-18 días de edad, 523 de Cali y 368 de Quibdó, 52% hombres y 48% mujeres. Se observaron diferencias en los niveles de concentración de aminoácidos y acilcarnitinas relacionadas con la edad, mientras que no se encontraron diferencias significativas por sexo. Conclusión: El estudio ha contribuido a revelar los niveles usuales de concentración de aminoácidos, acilcarnitinas y succinilacetona que pueden ser usados como referencia para el establecimiento del programa de tamizaje neonatal metabólico en Colombia.

El uso de placebo en ensayos clínicos de fase III en Brasil / The use of placebos in phase III clinical trials in Brazil

El Consejo Federal de Medicina de Brasil (CFM) -órgano normativo y fiscalizador del ejercicio ético de la medicina- prohibió, en 2008, la participación de médicos brasileños en investigaciones que utilizaran placebo para enfermedades con tratamiento eficaz y efectivo, en contraposición a la Declaración de Helsinki, que permite su uso en condiciones metodológicamente justificadas. Con el objetivo de verificar si la normativa ética del CFM modificó el uso de placebo en ensayos clínicos de fase III en Brasil, se analizaron varias características de sus registros en el ClinicalTrials.gov, en los períodos de 2003 a 2007 y de 2009 a 2013. Se concluye que: a) la normativa promulgada por el CFM en 2008 fue ineficaz y prevaleció la posición adoptada por la Declaración de Helsinki; b) el patrocinio de ensayos con placebo por parte de la industria farmacéutica multinacional fue significativo; c) predominaron las investigaciones de fármacos para enfermedades crónicas, y fueron poco significativas para las enfermedades postergadas, de importancia para Brasil.

In 2008, Brazil's Federal Council of Medicine [Conselho Federal de Medicina] (CFM) - regulatory and supervisory agency on the ethical practice of medicine - banned the participation of Brazilian doctors in studies using placebos for diseases with efficient and effective treatment. This position differs with the Helsinki Declaration, which allows the use of placebos in methodologically justified conditions. To ascertain whether the CMF's ethical regulation modified the use of placebos in phase III clinical trials in Brazil, characteristics of the records in ClinicalTrials.gov were researched in the periods from 2003 to 2007 and from 2009 to 2013. The conclusions reached were: a) the regulations issued by the CFM in 2008 were ineffective and the position adopted by the Helsinki Declaration prevails; b) there was significant sponsorship by the multinational pharmaceutical industry of trials with placebos; c) the research was predominantly on new drugs for chronic diseases, with little study done of the neglected diseases which are of great importance to Brazil.

Mutation analysis of FAH gene in patients with tyrosinemia type 1 / 中华儿科杂志

<p><b>OBJECTIVE</b>To investigate the clinical features and mutations of the FAH gene.</p><p><b>METHOD</b>Clinical records of two cases were collected, and diagnosis was made according to the diagnostic criteria of the International Organization for Rare Disorders (NORD). Genomic DNA was extracted from peripheral blood leukocytes with QIAamp DNA Mini Kit. The DNA extracts were subjected to direct sequencing for 14 exons together with adjacent fragments of FAH gene using ABI Prism 3730 Genetic Analyzer (Applied Biosystems, Foster City, CA) after PCR based on genomic DNA. The mutation source was verified by analyzing parents' exons corresponding to patients' mutation exons. The homology between human FAH enzyme and that of other species was surveyed using software Clustal X(European Bioinformatics Institute, Hinxton, Saffron Walde, UK). Polyphen (Polymorphism Phenotyping), available online, were used to predict possible impact of an amino acid substitution on structure and function of FAH enzyme. Polyphen calculates position-specific independent counts (PISC) scores for two amino acid variants in polymorphic position. A PISC scores that differ by > 2 were regarded as indicating the probability of damaging variants.</p><p><b>RESULT</b>Patient 1 was a 5 months and 21 days-old boy who suffered from persistent diarrhea, hepatomegaly, ascites; Alpha-fetoprotein > 1210 µg/L, levels of tyrosine in blood and succinylacetone in urine were 110.8 µmol/L and 83.7 µmol/L. His sister suffered from tyrosinemia type 1. Direct sequencing showed a G to A transition in CDS position 455 and 1027. He was compound heterozygous for the mutation c.455G > A/c.1027G > A, which predicts a change from tryptophan to a stop codon (TGG > TAG) at position 152 (W152X) and a change from glycine to arginine (GGG > AGG) at position 343 respectively. Patient 2 was a 6 year and 1 month-old girl with late-onset rickets who had signs of hepatosplenomegaly, rachitic rosary, windswept knees. Hypophosphatemia and alkaline phosphatase 1620 IU/L were detected. Alpha-fetoprotein 412.8 µg/L, levels of tyrosine in blood and succinylacetone in urine were 835.8 µmol/L and 27.48 µmol/L. Rickets did not improve after administration of calcium and vitamine D3. She is homozygous for the mutation c.1027G > A/c.1027G > A, which predicts G343R. The parents were mutation carriers. Analysis by Clustal X on the alignment of amino acids residual reservation among different species showed that the locative amino acid was highly conserved. Polyphen software predicted G343R was probably damaging (PISC score 3.235).</p><p><b>CONCLUSION</b>Children with tyrosinemia type 1 can have manifestations of persistent diarrhea or late-onset rickets. Physical examination can reveal hepatosplenomegaly, laboratory tests indicate markedly elevated serum concentration of alpha-fetoprotein and alkaline phosphatase in plasma and succinylacetone in urine, other members in family may have tyrosinemias or parents are consanguineous. Mutations c.455G > A and c.1027G > A can be detected in FAH gene of Chinese children.</p>

Application of succinylacetone levels measurement in the blood and urine in the diagnosis of tyrosinemia type 1 / 中华儿科杂志

<p><b>OBJECTIVE</b>To establish the diagnostic method of tyrosinemia type 1 and evaluate its value, the succinylacetone levels in the blood of suspected patients with tyrosinemia were tested by tandem mass spectrometry, and the succinylacetone in the urine was tested by gas chromatography-mass spectrometry.</p><p><b>METHOD</b>A total of 190 patients suspected of having tyrosinemia, were tested by tandem mass spectrometry for measurement of the level of succinylacetone in the blood, and detected by gas chromatography-mass spectrometry for measurement of the level of succinylacetone and organic acid in the urine. The method of measuring the level of succinylacetone in blood by tandem mass spectrometry as follows: After the diameter of 3 mm dry blood spots were punched into wells of 96-well plate, 100 µl 80% acetonitrile were added into each well, which contained hydrazine monohydrate and the internal standard of succinylacetone. The supernatant fluid were transferred to another 96-well plate and dried under heated nitrogen, after the plate was incubated for 30 min at 65°C. The residual hydrazine reagent was removed by addition of 100 µl methanol to each well and evaporated under heated nitrogen. The mobile phase (80% acetonitrile) was added to each well and 20 µl samples were tested by tandem mass spectrometry. The diagnostic terms were the clinical manifestation and the high level of succinylacetone in both blood and urine.</p><p><b>RESULT</b>Eleven patients were diagnosed as tyrosinemia type 1, with 9 males and 2 females. Their ages ranged from 2 months to 6 years. The succinylacetone levels in the blood of the patients were remarkably increased (7.26-31.09 µmol/L), with an average of (14.2 ± 7.8)µmol/L. Seven patients were tested for the level of succinylacetone in the urine by gas chromatography-mass spectrometry, and 4 were positive and 3 negative. Their tyrosine levels in the blood were 190-543 µmol/L(Normal: 20 - 100 µmol/L), with an average of (327.3 ± 125.8) µmol/L. All the patients presented the symptoms of hepatomegaly. Among them, 9 patients died and 2 patients were improved after treatment.</p><p><b>CONCLUSION</b>The higher levels of succinylacetone in the blood or urine is a remarkable evidence for the diagnosis of tyrosinemia type 1. Determination of succinylacetone in the dry blood spots using tandem mass spectrometry was a good method for diagnosis of tyrosinemia type 1. To test succinylacetone in urine by gas chromatography-mass spectrometry may yield a false-negative result for tyrosinemia type 1.</p>

Enzymatic resolution of (R, S)-ibuprofen and (R, S)-ketoprofen by microbial lipases from native and commercial sources

The enantioselectivity (E) of native lipases from Aspergillus niger, Aspergillus terreus, Fusarium oxysporum, Mucor javanicus, Penicillium solitum and Rhizopus javanicus in the resolution of (R,S)-ibuprofen and (R,S)-ketoprofenenantiomers by esterification reaction with 1-propanol in isooctane was compared with known commercial Candida rugosa (Sigma) and Candida antarctica (Novozym®435) lipases. In the resolution of (R,S)-ibuprofen, C. rugosa lipase showed good selectivity (E = 12) while Novozym®435 (E = 6.7) and A. niger (E = 4.8) lipases had intermediate selectivities. Other enzymes were much less selective (E around 2.3 and 1.5), under tested conditions. After preliminary optimization of reaction conditions (water content, enzyme concentration and presence of additives) the enantioselectivity of native A. niger lipase could be enhanced substantially (E = 15). All tested lipases showed low selectivity in the resolution of (R,S)-ketoprofen because poor ester yields and low enantiomeric excess of the acid remaining were achieved.

A enantioseletividade (E) das lipases nativas de Aspergillus niger, Aspergillus terreus, Fusarium oxysporum, Mucor javanicus, Penicillium solitum e Rhizopus javanicus na resolução dos enantiômeros do (R,S)-ibuprofeno e (R,S)-cetoprofeno na reação de esterificação com 1-propanol em isoctano foi comparada com as lipases comerciais de Candida rugosa (Sigma) e Candida antarctica (Novozym®435). A lipase de C. rugosa mostrou boa enantioseletividade (E = 12) comparada com as da Novozym®435 (E = 6.7), de A. niger (E=4.8) e com as outras lipases que foram muito menos seletivas (E por volta de 2.3 e 1.5) na resolução do (R,S)-ibuprofeno, dentro das condições testadas. Após uma otimização preliminar das condições da reação (conteúdo de água, concentração da enzima e presença de aditivos) a enantioseletividade da lipase de A. niger pôde ser substancialmente aumentada (E = 15). Todas as lipases testadas mostraram baixa seletividade na resolução de (R,S)-cetoprofeno, resultando baixos rendimentos de éster e de excesso enantiomérico do ácido não esterificado.

Validación histológica de un posible modelo de hiperplasia nodular prostática inducido con enantato de testosterona (100mg/ml) / Histological assessment of a possible model of nodular prostatic hyperplasia induced with testosterone enantate (100 mg/ml)

Estudio preclínico realizado en la Universidad Médica de Cienfuegos, Cuba, entre junio y diciembre de 2003, con el objetivo de validar desde el punto de vista histológico un posible modelo de hiperplasia prostática. Se utilizaron 15 ratas Sprague Dawley machos de 21 días de edad. El grupo I no se castró ni recibió, tratamiento con testosterona, mientras que los grupos II y III se orquiectomizaron y se les administró testosterona (25 mg/ml) a 3mg/kg subcutánea por veintiún días y enantato de testosterona (100 mg/ml) a 14 mg/kg en dosis única, respectivamente. La observación de los cortes histológicos se realizó en diez campos de 40X. La administración de enantato de testosterona causó una disminución del número de acinos e incrementó el número de capas epiteliales celulares, las aproximaciones interglandulares, las glándulas dilatadas y la presencia de pseudopapilas; el estroma se hizo más laxo y escaso. Los cambios histológicos hiperplásicos en estos animales fueron superiores cuantitativa y cualitativamente a los producidos por la administración de testosterona durante veintiún días.

Glucemia, insulinemia y secreción de insulina en ratas prepúberes hiperandrogenizadas e hiperestrogenizadas / Glycemia, insulinemia and insulin secretion in prepubescent rats receiving high doses of androgens and strogens

Se estudió el efecto de una sobredosis de enantato de testosterona y de benzoato de estradiol en ratas machos prepúberes, sobre el comportamiento de la glucemia y la insulinemia in vivo, durante una prueba de tolerancia a la glucosa. Adicionalmente se exploró, in vitro, la capacidad de secreción de insulina estimulada por glucosa de los islotes de Langerhans de estas ratas hiperandrogenizadas e hiperestrogenizadas. Se encontró que la hiperandrogenización se acompañaba de un deterioro de la sensibilidad a la insulina, con hiperinsulinemia, que no se corresponde con un aumento de la capacidad de secreción de insulina de los islotes de Langerhans. Sin embargo, se comprobó que la hiperestrogenización no indujo cambios en los perfiles de glucemia, ni de insulinemia, ni en la capacidad de secreción de insulina de los islotes de Langerhans de este grupo de ratas hiperestrogenizadas(AU)

The effect of an overdose of testosterone heptanoate and estradiol in male prepubescent rats on the behavior of glycemia and insulinemia was studied in vivo during a glucose tolerance test. The capacity of insulin secretion stimulated by glucose from the islets of Langerhans of these rats that were administered a high dose of androgens and estrogens was explored in vitro. It was found that the high level of circulating androgens was accompanied by a deterioration of sensitivity to insulin with hyperinsulinemia that does not correspond to an increase of the insulin secreting capacity of the islets of Langerhans. However, it was demonstrated that the high level of circulating estrogens did not produce changes either in the glycemia and insulinemia profiles or in the insulin secreting capacity of the islets of Langerhans in this group of rats that received an elevated dose of estrogens(AU)

Níveis séricos de HDL-C, LDL-C e correlaçäo LDL/HDL (índice de Castelli II) em adolescentes usuárias de contraceptivo injetável mensal / HDL-C, LDL-C Serum levels and the relation LDL/HDL (Castelli's II Index) in adolescents using monthly injectable contraceptive

OBJETIVO: Avaliar as possíveis alteraçöes no metabolismo lipoprotéico em adolescentes usuárias de contraceptivo injetável mensal após 12 ciclos de tratamento. PACIENTES E MÉTODOS: Foram avaliados os níveis séricos de lipoproteínas, em 30 adolescentes usuárias da associaçäo Acetofenido de Dihidroxiprogesterona 150mg e Enantato de Estradiol 10mg, por um período de 12 ciclos. Como grupo controle foram estudadas 31 adolescentes com as mesmas características, usuárias de dispositivo intra-uterino modelo T Cu200. foram tomadas amostras sangüíneas antes do início do tratamento em ambos os grupos e aos 60, 180 e 360 dias após iniciado o uso da medicaçäo ou do dispositivo intra-uterino e nestas ocasiöes dosadas as fraçöes HDL-C, LDL-C e calculada a relaçäo LDL/HDL. Os grupos estudados eram homogêneos em suas características físicas e também nos parâmetros lipoprotéicos pré-tratamento. RESULTADOS: Após 12 ciclos näo foram encontradas diferenças significativas nos parâmetros estudados, em ambos os grupos. As alteraçöes encontradas ao final do estudo foram semelhantes em ambos os grupos e devidas às características próprias do grupo estudado. CONCLUSÄo: Podemos concluir que o contraceptivo hormonal injetável mensal composto de 150mg de Acetofenido de Dihidroxiprogesterona e 10mg de Enantato de Estradiol se comporta como um contraceptivo näo hormonal no que concerne ao metabolismo de lipoproteínas, näo provocando alteraçöes significativas neste metabolismo.

Farmacocinética del anticonceptivo inyectable enantato de noretisterona / Pharmacokinetics of inyectable contraceptive norethisterone enantate

Se estudió la farmacocinética de una dosis de 200 mg de enantato de noretisterona por vía intramuscular en 11 pacientes, las muestras sanguíneas fueron extraídas durante 15 días y luego semanalmente durante 2 meses. Los níveles de noretisterona en plasma se determinaron por cromatografía líquida de alta presión (HPLC). A partir de las observaciones se determinó el modelo farmacocinético adecuado, este resultó ser el biocompartimental abierto con absorción de primer orden. Obtuvimos los parámetros farmacocinéticos en las diferentes fases y se correlacionaron entre sí. El tiempo de vida media de absorción se correlacionó positivamente con el tiempo de vida media de distribución, con el tiempo en que se alcanza la concentración máxima, y con índice de masa corporal. El volumen de distribución se correlacionó positivamente con el tiempo de vida media de eliminación y con el aclaramiento plasmático

Evaluación de la potencia hormonal del anticonceptivo inyectable mensual de dihidroxiprogesterona acetofenico 150 mg y estradiol enantato 10 mg, comparativamente con tratamientos anticonceptivos orales

Se realizó un estudio retrospectivo, comparativo, abierto en 58 mujeres voluntarias del Centro de Planificación Familiar, PROFAMILIA, de Santafé de Bogotá, Colombia. La potencia hormonal del anticonceptivo inyectable mensual constituido por Dihidrixiprogesterona Acetofénido (DHPA), 150 mg y Estradiol Enantato (EEn), 10 mg, fue comparada con la de otros anticonceptivos de uso habitual (píldoras de Etinilestradiol (EE), 0.050 mg y Levonorgestrel (LNG), 0.250 mg; EE, 0.030 mg, LNG, 0.150 mg y métodos no hormonales), mediante la determinación de triglicéridos, HDL/DL colesterol, cobre, ceruloplastia, cortisol total y libre, CBG, testosterona total y libre y SHBG en el suero de usuarias crónicas. Las usuarias de métodos no hormonales fueron el grupo de control. En los exámenes de laboratorio, los niveles de triglicéridos fueron más altos y los de testosterona total y libre más bajos en las mujeres que emplean DHPA 150 mg + EEn 10 mg y en las que utilizan píldoras. Tales modificaciones fueron levemente menores en el grupo que emplea el inyectable. Los efectos de DHPA 150 mg + EEn 10 mg sobre cobre, ceruloplasmina, CBG, cortisol libre y total y SHBG fueron escasos o nulos, en comparación con el grupo no hormonal. En cambio las píldoras, inclusive las microdosificadas, mostraron modificaciones de todas esas variables, altamente significativas frente al inyectable (p 0.01) y a los métodos no hormonales (p 0.01), sin que haya diferencias entre éstos últimos. Los resultados sugieren que la potencia hormonal de DHPA 150 mg + EEn 10 mg no es mayor que la de las microdosis orales habituales. Por otro lado, no ofrecen indicios de que ésta fórmula esté sobredosificada no produzca acumulación de efectos en el organismo. Estos hallazgos deben ser tenidos en cuenta al considerar la seguridad del inyectable a largo plazo

Estudo clínico multicêntrico sobre o efeito metabólico do contraceptivo mensal injetável contendo acetofenido de dihidroxiprogesterona 150 mg + enantato de estradiol 10 mg / A multicenter clinical trial on the metabolic effect of an injectable monthly contraceptive containing dihydroxyprogesterone acetophenide 150 mg + estradiol enanthate 10 mg

O efeito metabólico do contraceptivo mensal injetável contendo acetofenido de dihidroxiprogesterona (DHPA) 150 mg + enantato de estradiol (Een) 10 mg foi comparado ao de outros métodos anticoncepcionais comumente utilizados (pílulas contendo: etinilestradiol (EEn) 0,050 mg + levonogestrel (LNG) 0,250 mg, EE 0,030 + LNG 0,150 mg; e EE 0,030/0,040/0,030mmg + LNG 0,050/0,075/0,0125 mg; enantato de noretisterona (NEE) 200 mg via i.m.; e métodos nao-hormonais. Foram determinados os triglicerídeos séricos, colesterol HDL/LDL, cobre, ceruloplasmina, cortisol total e livre, CBG e testosterona total e livre e SHBG de usu rios crônicas. Este estudo contou com a participaçäo do total de 237 mulheres. As usuárias de métodos nao-hormonais utilizadas como controle apresentaram níveis mais altos de triglicerídeos. Os níveis de testosterona total e livre foram mais baixos em mulheres que utilizavam DHPA 150 mg + Een 10 mg e nas que tomavam pílulas anticoncepcionais (p<0,05 - 0,01). Tais alteraçöes foram levemente menores no grupo que utilizou o injetável. Os efeitos do DHPA 150 mg + EEn 10 mg sobre o colesterol HDL/LDL, cobre, ceruloplasmina, CBG, cortisol total e livre e SHBG foram raros ou inexistentes. Entretanto, com as pílulas anticoncepcionais (mesmo as de formulaçäo de baixa dosagem) ocorreram alteraçöes em todas essas vari eis, que foram altamente significativas na comparaçäo com o método injetável (p< 0,01) e com os métodos nao-hormonais (p<0,01); näo houve diferenças entre estes dois últimos métodos. Os resultados sugerem que o efeito metabólico da injeçäo mensal i.m. de DHPA 150 mg + Een 10 mg näo é superior aos dos anticoncepcionais orais comumente utilizados. Estes resultados também nao sugerem que a dose contida nesse injetável seja excessiva. Nao há qualquer evidência de que ele produza efeito cumulativo no organismo. Esses achados devem ser levados em consideraçäo com relaçäo à segurança do uso a longo prazo desse injetável.