Evaluation of guideline implementation for dispensing driving-impairing medicines by National Pharmacy Organizations.

Background: In 2004, the International Pharmaceutical Federation (FIP) adopted a Statement of Professional Standard on the supply of medicines affecting driving performance, transformed to FIP guidelines in 2014. In 2011, the final report from the European initiative on Driving Under the Influence of Drugs, Alcohol and Medicines (DRUID) was published. Both documents provided recommendations for improving dispensing guidelines for driving-impairing medicines for patients who use psychoactive medicines. Objective: This study investigated the extent that European professional organizations of pharmacists (POPs) implemented existing guidelines and DRUID results. Methods: An online questionnaire survey was conducted in April-May 2022. Questionnaires were sent by e-mail to POPs in 46 European countries. The questionnaire addressed the following topics: awareness of FIP guidelines and DRUID outcomes (a), development of dispensing guidelines (b), target groups for information materials (c), evaluations of dispensing practices (d), examples of projects on medicines affecting driving fitness (e), development of ICT (Information and Communication Technology) -support (f), collaboration with organizations of physicians (g), and patients (h). The data were analyzed by indicating implementation initiatives in different countries. Open-ended questions were assessed qualitatively. Results: POPs in 23 European countries responded to the invitation (response rate: 50%). Guidelines for improving dispensing practices were available in 5 countries targeted at professionals, patients, and the general population. Patient and physician organizations were involved in 4 and 3 countries, respectively. Implementation was supported by computerized dispensing systems (5 countries) and public campaigns (5 countries). Conclusions: Twenty years after the introduction of FIP guidelines and ten years after the DRUID outcomes, only 5 European POPs have implemented this knowledge. Different activities were performed to support implementation, resulting in examples of successful use of recommendations for driving-impairing medicines in pharmacy practice. Implementation needs further attention. The successful practices that have been developed are an example for dissemination to other countries.

Gamma-ray sources imaging and test-beam results with MACACO III Compton camera.

Hadron therapy is a radiotherapy modality which offers a precise energy deposition to the tumors and a dose reduction to healthy tissue as compared to conventional methods. However, methods for real-time monitoring are required to ensure that the radiation dose is deposited on the target. The IRIS group of IFIC-Valencia developed a Compton camera prototype for this purpose, intending to image the Prompt Gammas emitted by the tissue during irradiation. The system detectors are composed of Lanthanum (III) bromide scintillator crystals coupled to silicon photomultipliers. After an initial characterization in the laboratory, in order to assess the system capabilities for future experiments in proton therapy centers, different tests were carried out in two facilities: PARTREC (Groningen, The Netherlands) and the CNA cyclotron (Sevilla, Spain). Characterization studies performed at PARTREC indicated that the detectors linearity was improved with respect to the previous version and an energy resolution of 5.2 % FWHM at 511 keV was achieved. Moreover, the imaging capabilities of the system were evaluated with a line source of 68Ge and a point-like source of 241Am-9Be. Images at 4.439 MeV were obtained from irradiation of a graphite target with an 18 MeV proton beam at CNA, to perform a study of the system potential to detect shifts at different intensities. In this sense, the system was able to distinguish 1 mm variations in the target position at different beam current intensities for measurement times of 1800 and 600 s.

Radiographic evaluation of the bicipital groove morphology does not predict intraarticular changes in the long head of biceps tendon.

INTRODUCTION AND OBJECTIVES: This study aimed to examine the clinical utility of the radiographic evaluation of the bicipital groove in predicting long head of biceps tendon (LHBT) pathology. MATERIAL AND METHODS: A prospective study was conducted, and sixty consecutive patients proposed to shoulder arthroscopic surgery were selected. Before surgery, a radiographic evaluation was performed with a supine and a Fisk radiograph. Most supine radiographs (>75%) were non-interpretable and were excluded from the study. As some Fisk radiographs (26.7%) were also non-interpretable, that left 44 interpretable radiographs in the study. These were measured for medial opening angle, total opening angle, width and depth of the bicipital groove. The radiographic measurements and the presence of LHBT pathology, as assessed at arthroscopy, were correlated. RESULTS: Radiographic evaluation of the bicipital groove showed a mean medial opening angle of 53 ±â€¯15° (23-90), a mean total opening angle of 80 ±â€¯26° (30-135), a mean width of 10.3 ±â€¯2.5 mm (6-19) and a mean depth of 4.1 ±â€¯1.5 mm (1-8). Men had higher medial opening angle (60 vs 50°, p = 0.044) and wider grooves (11.9 vs 9.7 mm, p = 0.019). Twenty-five patients (56.8%) were found to have an abnormal LHBT. No correlation was found between the radiographic measurements and LHBT pathology. Only age was correlated with a LHBT lesion (61.8 vs 46.3 years, p < 0.001). CONCLUSIONS: Our results show that there is no correlation between radiographic morphologic evaluation of the bicipital groove and LHBT pathology.

Influence of the background in Compton camera images for proton therapy treatment monitoring.

Objective. Background events are one of the most relevant contributions to image degradation in Compton camera imaging for hadron therapy treatment monitoring. A study of the background and its contribution to image degradation is important to define future strategies to reduce the background in the system.Approach. In this simulation study, the percentage of different kinds of events and their contribution to the reconstructed image in a two-layer Compton camera have been evaluated. To this end, GATE v8.2 simulations of a proton beam impinging on a PMMA phantom have been carried out, for different proton beam energies and at different beam intensities.Main results. For a simulated Compton camera made of Lanthanum (III) Bromide monolithic crystals, coincidences caused by neutrons arriving from the phantom are the most common type of background produced by secondary radiations in the Compton camera, causing between 13% and 33% of the detected coincidences, depending on the beam energy. Results also show that random coincidences are a significant cause of image degradation at high beam intensities, and their influence in the reconstructed images is studied for values of the time coincidence windows from 500 ps to 100 ns.Significance. Results indicate the timing capabilities required to retrieve the fall-off position with good precision. Still, the noise observed in the image when no randoms are considered make us consider further background rejection methods.

Joint image reconstruction algorithm in Compton cameras.

Objective.To demonstrate the benefits of using an joint image reconstruction algorithm based on the List Mode Maximum Likelihood Expectation Maximization that combines events measured in different channels of information of a Compton camera.Approach.Both simulations and experimental data are employed to show the algorithm performance.Main results.The obtained joint images present improved image quality and yield better estimates of displacements of high-energy gamma-ray emitting sources. The algorithm also provides images that are more stable than any individual channel against the noisy convergence that characterizes Maximum Likelihood based algorithms.Significance.The joint reconstruction algorithm can improve the quality and robustness of Compton camera images. It also has high versatility, as it can be easily adapted to any Compton camera geometry. It is thus expected to represent an important step in the optimization of Compton camera imaging.

Sub-millimeter precise photon interaction position determination in large monolithic scintillators via convolutional neural network algorithms.

In this work, we present the development and application of a convolutional neural network (CNN)-based algorithm to precisely determine the interaction position ofγ-quanta in large monolithic scintillators. Those are used as an absorber component of a Compton camera (CC) system under development for ion beam range verification via prompt-gamma imaging. We examined two scintillation crystals: LaBr3:Ce and CeBr3. Each crystal had dimensions of 50.8 mm × 50.8 mm × 30 mm and was coupled to a 64-fold segmented multi-anode photomultiplier tube (PMT) with an 8 × 8 pixel arrangement. We determined the spatial resolution for three photon energies of 662, 1.17 and 1.33 MeV obtained from 2D detector scans with tightly collimated137Cs and60Co photon sources. With the new algorithm we achieved a spatial resolution for the CeBr3 crystal below 1.11(8) mm and below 0.98(7) mm for the LaBr3:Ce detector for all investigated energies between 662 keV and 1.33 MeV. We thereby improved the performance by more than a factor of 2.5 compared to the previously used categorical average pattern algorithm, which is a variation of the well-established k-nearest neighbor algorithm. The trained CNN has a low memory footprint and enables the reconstruction of up to 104events per second with only one GPU. Those improvements are crucial on the way to future clinicalin vivoapplicability of the CC for ion beam range verification.

Radiographic evaluation of the bicipital groove morphology does not predict intraarticular changes in the long head of biceps tendon. / La evaluación radiográfica de la morfología del surco intertubercular no pronostica cambios intraarticulares en el tendón de la porción larga del bíceps.

INTRODUCTION AND OBJECTIVES: This study aimed to examine the clinical utility of the radiographic evaluation of the bicipital groove in predicting long head of biceps tendon (LHBT) pathology. MATERIAL AND METHODS: A prospective study was conducted, and sixty consecutive patients proposed to shoulder arthroscopic surgery were selected. Before surgery, a radiographic evaluation was performed with a supine and a Fisk radiograph. Most supine radiographs (>75%) were non-interpretable and were excluded from the study. As some Fisk radiographs (26.7%) were also non-interpretable, that left 44 interpretable radiographs in the study. These were measured for medial opening angle, total opening angle, width and depth of the bicipital groove. The radiographic measurements and the presence of LHBT pathology, as assessed at arthroscopy, were correlated. RESULTS: Radiographic evaluation of the bicipital groove showed a mean medial opening angle of 53±15o (23 - 90), a mean total opening angle of 80±26o (30 - 135), a mean width of 10.3±2.5mm (6 - 19) and a mean depth of 4.1±1.5mm (1 - 8). Men had higher medial opening angle (60 vs 50o, p=0.044) and wider grooves (11.9 vs 9.7mm, p=0.019). Twenty-five patients (56.8%) were found to have an abnormal LHBT. No correlation was found between the radiographic measurements and LHBT pathology. Only age was correlated with a LHBT lesion (61.8 vs 46.3 years, p <0.001). CONCLUSIONS: Our results show that there is no correlation between radiographic morphologic evaluation of the bicipital groove and LHBT pathology.

Eugenol as an efficient anesthetic for neotropical fish Prochilodus nigricans (Teleostei, Prochilodontidae) / [Eugenol como um anestésico eficaz para o peixe neotropical Prochilodus nigricans (Teleostei, Prochilodontidae)]

The use of anesthetics in fish farming is essential to reduce stress during management. The present study proposes to evaluate the effect of eugenol as an anesthetic for the management of curimatã (Prochilodus nigricans). Fifty specimens were used (221.34±9.0 g; 25.8 ±1.1 cm), submitted to five treatments with concentrations of 0, 25, 50, 100 and 200 mgL−1 eugenol for 10 min. The times required to reach each anesthetic stage and the recovery of each fish were recorded. To check bloodglucose levels individual blood samples were taken from the fish before immersion and after ten minutes of anesthetic exposure. Evaluation of the anesthetic effect ongills was performed by histopathological analysis. The concentration of 50 mgL−1 was within the ideal limit of three minutes recommended for surgical anesthesia induction and did not significantly increase glucose levels when compared to the control group (35.7±19.4 mg dL−1), besides not causing gill injuries. At this concentration the fish presented controlled blood glucose levels within the basal levels, besides not taking the risk to have later problems concernig mortality, because this concentration ensures the good health of the gills and good recovery of the animals.(AU)

O uso de anestésicos em pisciculturas é indispensável para reduzir o estresse durante o manejo. O presente trabalho propôs avaliar o efeito do eugenol como anestésico para manejo do curimatã (Prochilodus nigricans). Foram utilizados 50 espécimes (221,34±9,0 g; 25,8 ±1,1 cm), submetidos a cinco tratamentos com concentrações de 0, 25, 50, 100 e 200 mg L−1 de eugenol em exposição de 10 minutos. Foram registrados os tempos necessários para atingir cada estágio anestésico e a recuperação de cada peixe. Para verificação dos níveis de glicose sanguínea, foram realizadas coletas individuais de sangue dos peixes antes da imersão e após os 10 minutos de exposição ao anestésico. A avaliação do efeito do anestésico sobre as brânquias foi realizada por meio de análises histopatológicas. A concentração de 50 mg L−1 ficou dentro do limite ideal de três minutos preconizado para indução à anestesia cirúrgica e não elevou significativamente os níveis de glicose quando comparada ao grupo controle (35,7±19,4 mg dL−1), além de não provocar lesões branquiais. Nessa concentração, os peixes apresentaram níveis de glicose sanguínea controlada, dentro dos teores basais, além de não correrem o risco de apresentarem problemas posteriores em relação à mortalidade, pois essa concentração garante a boa saúde das brânquias e uma boa recuperação dos animais.(AU)

Image reconstruction for a multi-layer Compton telescope: an analytical model for three interaction events.

Compton Cameras are electronically collimated photon imagers suitable for sub-MeV to few MeV gamma-ray detection. Such features are desirable to enable in vivo range verification in hadron therapy, through the detection of secondary Prompt Gammas. A major concern with this technique is the poor image quality obtained when the incoming gamma-ray energy is unknown. Compton Cameras with more than two detector planes (multi-layer Compton Cameras) have been proposed as a solution, given that these devices incorporate more signal sequences of interactions to the conventional two interaction events. In particular, three interaction events convey more spectral information as they allow inferring directly the incident gamma-ray energy. A three-layer Compton Telescope based on continuous Lanthanum (III) Bromide crystals coupled to Silicon Photomultipliers is being developed at the IRIS group of IFIC-Valencia. In a previous work we proposed a spectral reconstruction algorithm for two interaction events based on an analytical model for the formation of the signal. To fully exploit the capabilities of our prototype, we present here an extension of the model for three interaction events. Analytical expressions of the sensitivity and the System Matrix are derived and validated against Monte Carlo simulations. Implemented in a List Mode Maximum Likelihood Expectation Maximization algorithm, the proposed model allows us to obtain four-dimensional (energy and position) images by using exclusively three interaction events. We are able to recover the correct spectrum and spatial distribution of gamma-ray sources when ideal data are employed. However, the uncertainties associated to experimental measurements result in a degradation when real data from complex structures are employed. Incorrect estimation of the incident gamma-ray interaction positions, and missing deposited energy associated with escaping secondaries, have been identified as the causes of such degradation by means of a detailed Monte Carlo study. As expected, our current experimental resolution and efficiency to three interaction events prevents us from correctly recovering complex structures of radioactive sources. However, given the better spectral information conveyed by three interaction events, we expect an improvement of the image quality of conventional Compton imaging when including such events. In this regard, future development includes the incorporation of the model assessed in this work to the two interaction events model in order to allow using simultaneously two and three interaction events in the image reconstruction.

Physiological adjustment to salt stress in Jatropha curcas is associated with accumulation of salt ions, transport and selectivity of K+, osmotic adjustment and K+/Na+ homeostasis.

This study assessed the capacity of Jatropha curcas to physiologically adjust to salinity. Seedlings were exposed to increasing NaCl concentrations (25, 50, 75 and 100 mm) for 15 days. Treatment without NaCl was adopted as control. Shoot dry weight was strongly reduced by NaCl, reaching values of 35% to 65% with 25 to 100 mm NaCl. The shoot/root ratio was only affected with 100 mm NaCl. Relative water content (RWC) increased only with 100 mm NaCl, while electrolyte leakage (EL) was much enhanced with 50 mm NaCl. The Na(+) transport rate to the shoot was more affected with 50 and 100 mm NaCl. In parallel, Cl(-) transport rate increased with 75 and 100 mm NaCl, while K(+) transport rate fell from 50 mm to 100 mm NaCl. In roots, Na(+) and Cl(-) transport rates fell slightly only in 50 mm (to Na(+)) and 50 and 100 mm (to Cl(-)) NaCl, while K(+) transport rate fell significantly with increasing NaCl. In general, our data demonstrate that J. curcas seedlings present changes in key physiological processes that allow this species to adjust to salinity. These responses are related to accumulation of Na(+) and Cl(-) in leaves and roots, K(+)/Na(+) homeostasis, transport of K(+) and selectivity (K-Na) in roots, and accumulation of organic solutes contributing to osmotic adjustment of the species.

Bioactive amines and internal quality of commercial eggs.

The physicochemical and microbiological qualities of commercial eggs produced by layer hens of different ages (approximately 30 and 60 wk old) were submitted to storage under room temperature or refrigeration for 28 d. A total of 600 eggs were subjected to microbiological analyses of their inner contents and another 600 to a determination of Haugh units (HU) and bioactive amine content. A decrease in the quality of the inner contents of the eggs was observed during the experiment, mainly in the eggs from the 60-wk-old layers, which presented the worst HU values when stored at room temperature (P < 0.05). Microbiological analyses showed an absence of Salmonella spp., Staphylococcus aureus, and coliforms, either total or thermal-tolerant; however, low counts of other Staphylococcus species, Enterobacter spp., Pseudomonas spp., mesophilic aerobic bacteria, and fungi were also recorded. The chromatographic analysis of bioactive amines detected the presence of phenylethylamine in all albumens (38.0 mg/kg) and spermidine in the yolks (1.02 mg/kg). It was concluded that the age of the hens and the time and temperature of storage influenced the quality parameters of the eggs (P < 0.05). Furthermore, despite the low levels of microbial contamination found, phenylethylamine was detected in the albumen. It was not possible to establish index of quality of eggs using bioactive amines present in the yolk and albumen of eggs.

Qualidade de ovos comerciais submetidos a diferentes condições de armazenamento / Quality of commercial eggs submitted to different storage conditions

Verificou-se a qualidade interna de 1440 ovos de consumo, provenientes de galinhas de linhagem comercial. O delineamento foi inteiramente ao acaso, em arranjo fatorial 2x2x15, com duas diferentes idades das galinhas (33 e 60 semanas), duas condições de armazenamento (ambiente e refrigerado) e 15 períodos de estocagem (um, dois, três, quatro, cinco, seis, sete, oito, nove, 10, 11, 12, 13, 14 e 15 dias). Os parâmetros de qualidade dos ovos avaliados foram Unidades Haugh (UH), pH do albúmen (pH), sólidos totais do albúmen (STA) e da gema (STG), e peso e porcentagem de albúmen, gema e casca. Foi observada diminuição da qualidade interna dos ovos durante o armazenamento. Os ovos produzidos por poedeiras velhas e armazenados em temperatura ambiente apresentaram os piores resultados de UH. O pH do albúmen aumentou no decorrer do armazenamento independentemente da idade da ave e da temperatura de estocagem, e os valores de STA aumentaram com o armazenamento em temperatura ambiente. Concluiu-se que a idade da ave, a temperatura e o tempo de armazenamento dos ovos exercem influência sobre os parâmetros de qualidade do ovo.

Physical-chemical egg qualities of 1440 egg from commercial layer hens of different ages (30 and 60-week-old) submitted to storage under room temperature or refrigeration conditions were evaluated according to the following traits: Haugh Unities (UH); pH of albumen (pH); total solids of albumen and yolk; and weight and percentage of albumen, yolk, and shell. Decrease of inner quality of the evaluated eggs was observed during the experiment, mainly eggs from old-layers, which presented the worst values of AA and HU when stored at room temperature. It was concluded that age, temperature and time of storage of eggs influenced egg quality.

Qualidade de leites fermentados funcionais elaborados a partir de bactérias ácido-lácticas isoladas de queijo de coalho / Quality of functional fermented milks produced by the use of lactic acid bacteria isolated from coalho cheese

Leites fermentados foram elaborados a partir de bactérias ácido-lácticas com propriedades funcionais, isoladas de queijo de coalho com e sem a adição de concentrado proteico de soro (CPS). Características físico-químicas, microbiológicas e sensoriais dos produtos elaborados foram analisadas durante 40 dias de estocagem sob refrigeração a 8-10ºC. Todos os leites fermentados elaborados, independentemente da adição de CPS e da cultura utilizada, apresentaram contagens adequadas de bactérias (>10(8)UFC/mL) durante todo o período de avaliação, o que garantiria seu possível potencial funcional. Leites fermentados por Lactobacillus acidophilus apresentaram melhor aceitação (P<0,05) pelos provadores aos 10 dias de estocagem; enquanto, aos 40 dias, o leite fermentado por Weissella confusa sem CPS resultou em pior aceitação (P<0,05). A associação de Lactobacillus acidophilus e Weissella confusa ou somente Lactobacillus acidophilus, independentemente da adição de CPS, seriam recomendados para elaboração industrial de novos leites fermentados potencialmente funcionais a partir de culturas lácticas brasileiras.

Fermented milks were produced using whey protein concentrate (WPC) and potentially functional lactic acid bacteria, which were isolated from coalho cheese produced in. Physical-chemical, microbiological, and sensorial characteristics of the fermented milks were analyzed during 40 days under refrigeration at 8-10ºC. All products, irrespectively of WPC adding or culture used, showed appropriated bacterial counts (>10(8)CFU/mL) throughout the evaluation time, which would guarantee their functional potential. Lactobacillus acidophilus fermented milks presented better sensorial approval (P<0.05) when evaluated at 10-day storage; while Weissella confusa fermented milks presented lower acceptance (P<0.05) at 40-day storage. The association of Lactobacillus acidophilus and Weissella confusa or Lactobacillus acidophilus isolatedly, irrespectively of WPC adding, should be recommended for the industrial elaboration of novel functional fermented milks using Brazilian lactic cultures as starters.

Eficiência dos testes COPAN (Microplate e Single) na detecção de resíduos de antimicrobianos no leite / Efficacy of COPAN (Microplate and Single kits) in detection of antimicrobials residues in milk

Avaliou-se a eficiência dos testes microbiológicos COPAN (Microplate e Single) para detecção de resíduos de 13 antimicrobianos inoculados em leite isento de resíduos. Foram utilizadas quatro concentrações, sendo a primeira equivalente à metade do limite de detecção declarado pelo fabricante (C1); a segunda equivalente ao limite máximo de resíduos (LMR) estabelecido pela legislação brasileira (C2); a terceira equivalente ao limite de detecção declarado pelo fabricante (C3); e a quarta equivalente ao dobro do limite de detecção declarado pelo fabricante (C4). Os testes apresentaram 100 por cento de sensibilidade na detecção de amoxicilina, ampicilina, cloxacilina, penicilina, tilosina, sulfadiazina, sulfametoxazol, e 96,7 por cento na detecção de oxacilina para as concentrações informadas pelo fabricante como limite de detecção. Em relação às concentrações estabelecidas pela legislação brasileira, verificou-se que os testes foram capazes de detectá-las para a maioria dos antimicrobianos avaliados. Os testes não se mostraram eficientes na detecção das concentrações estabelecidas pela legislação para eritromicina, oxitetraciclina, tetraciclina, trimetoprim e gentamicina (Microplate).

The efficacy of the microbiological kits COPAN (Microplate and Single) for detection of antimicrobials residues was tested. Thirteen drugs were inoculated into milk without residues at four concentration levels: C1 - half of the detection threshold declared by the manufacturer, C2 - the maximum residues threshold established by the Brazilian legislation, C3 - the detection threshold declared by the manufacturer, and C4 - two fold the detection threshold declared by the manufacturer. The tests showed 100 percent efficient in detection of amoxicillin, cloxacillin, penicillin, tilosin, sulfadiazine, and sulfa methoxazol; and 96.7 percent for oxacillin considering the concentration stated by the manufacturer as threshold level. Regarding the concentrations established by the Brazilian legislation, all tested kits were able to detect most of the evaluated antimicrobials. The kits were not efficient in detection of the concentration levels established by the Brazilian legislation for erythromycin, oxytetracyclin, tetracyclin, trimetoprim, and gentamycin (Microplate).

Nitrate reductase activity, distribution, and response to nitrate in two contrasting Phaseolus species inoculated with Rhizobium spp.

The nitrate reductase activity distribution and response of two nodulated species of Phaseolus (Phaseolus vulgaris-common bean, and Phaseolus lunatus-lima bean) to different exogenous nitrate levels were studied during the vegetative period. These Phaseolus species showed to be very contrasting in respect to the pattern of nitrate reductase (NR) activity distribution thought the plant. The highest level of NR activity in P. vulgaris was clearly shown to occur in leaves in contrast with the lowest one detected in roots and nodules as widely seen for other tropical species of the Phaseoleae tribe. Conversely, P. lunatus had higher NR activity in the nodules, whereas its leaves exhibited a steadily decrease during the plant development. Indeed, at 32 days after emergence (pre-flowering stage), the nodulated P. vulgaris had approximately 95% of the total NR activity localized in its leaves, whereas in P. lunatus it was equally distributed in the nodules and in the leaves. Under long-term exposure to increasing exogenous level of nitrate, the leaf-NR activity of nodulated P. vulgaris presented a positive response, whereas the enzyme activity was very low and unresponsive in P. lunatus. In contrast, the nodule-NR activity showed a reverse response to the increasing NO(3)(-) level. The nodule-NR activity of P. lunatus significantly increased whereas in the P. vulgaris nodules it was very low and unresponsive. This present study suggests that P. lunatus inoculated with Rhizobium tropici presents a singular pattern of nitrate reduction distribution among leaves and nodules during the vegetative development. It is speculated that the nodulated Phaseolus lunatus may have different NR isoforms in their leaves (at least a constitutive type) and an inducible form in their nodules, responsive to long-term exposure to nitrate.

Cardiac involvement in total generalized lipodystrophy (Berardinelli- Seip syndrome).

Total generalized lipodystrophy (Berardinelli - Seip Syndrome) is a rare hereditary disease characterized by insulin-resistant diabetes mellitus and a small quantity of adipose tissue and is of unknown origin. Common cardiovascular alterations related to this syndrome are cardiac hypertrophy and arterial hypertension. This article reports a case of Berardinelli - Seip syndrome and reviews the literature with special emphasis on the cardiovascular manifestations of this syndrome.