Body mass index is related to autonomic nervous system activity as measured by heart rate variability--a replication using short term measurements.

OBJECTIVES: The present analysis is a replication of previous findings presenting first evidence of an association between body mass index (BMI) and autonomic nervous system (ANS) activity as measured by heart rate variability (HRV), in healthy non-obese adults. DESIGN: A total of fifty-nine apparently healthy male (M) and female (F) individuals (M/F = 15/44) were included in the trial. HRV data for analysis was derived from 5 minutes of baseline recordings, while the subject was sitting on a comfortable chair. Subjects' body measures (weight and height) were taken and BMI was obtained according to common calculation (kg/m²). RESULTS: BMI was inversely related to pNN50 and RMSSD components of HRV. Statistically significant differences between stratified groups (BMI<20, BMI 20-25, BMI >25) only occurred for analysis of pNN50 components. The pNN50 components and RMSSD are strongly associated with cardiac vagal influence, and thus represents parasympathetic activity. CONCLUSIONS: The present data supports previous findings, that sympatho-vagal balance is related to BMI in non-obese, healthy individuals, providing evidence for a prominent role of the vagus nerve in the modulation of the energy expenditure of the human organism. Furthermore, this relation can be observed in short term recordings of HRV of 5 minutes in length.

Effect of air pollution on pediatric respiratory emergency room visits and hospital admissions.

In order to assess the effect of air pollution on pediatric respiratory morbidity, we carried out a time series study using daily levels of PM10, SO2, NO2, ozone, and CO and daily numbers of pediatric respiratory emergency room visits and hospital admissions at the Children's Institute of the University of Sao Paulo Medical School, from August 1996 to August 1997. In this period there were 43,635 hospital emergency room visits, 4534 of which were due to lower respiratory tract disease. The total number of hospital admissions was 6785, 1021 of which were due to lower respiratory tract infectious and/or obstructive diseases. The three health end-points under investigation were the daily number of emergency room visits due to lower respiratory tract diseases, hospital admissions due to pneumonia, and hospital admissions due to asthma or bronchiolitis. Generalized additive Poisson regression models were fitted, controlling for smooth functions of time, temperature and humidity, and an indicator of weekdays. NO2 was positively associated with all outcomes. Interquartile range increases (65.04 microg/m3) in NO2 moving averages were associated with an 18.4% increase (95% confidence interval, 95% CI = 12.5-24.3) in emergency room visits due to lower respiratory tract diseases (4-day moving average), a 17.6% increase (95% CI = 3.3-32.7) in hospital admissions due to pneumonia or bronchopneumonia (3-day moving average), and a 31.4% increase (95% CI = 7.2-55.7) in hospital admissions due to asthma or bronchiolitis (2-day moving average). The study showed that air pollution considerably affects children's respiratory morbidity, deserving attention from the health authorities.

Effect of air pollution on pediatric respiratory emergency room visits and hospital admissions

In order to assess the effect of air pollution on pediatric respiratory morbidity, we carried out a time series study using daily levels of PM10, SO2, NO2, ozone, and CO and daily numbers of pediatric respiratory emergency room visits and hospital admissions at the Children's Institute of the University of São Paulo Medical School, from August 1996 to August 1997. In this period there were 43,635 hospital emergency room visits, 4534 of which were due to lower respiratory tract disease. The total number of hospital admissions was 6785, 1021 of which were due to lower respiratory tract infectious and/or obstructive diseases. The three health end-points under investigation were the daily number of emergency room visits due to lower respiratory tract diseases, hospital admissions due to pneumonia, and hospital admissions due to asthma or bronchiolitis. Generalized additive Poisson regression models were fitted, controlling for smooth functions of time, temperature and humidity, and an indicator of weekdays. NO2 was positively associated with all outcomes. Interquartile range increases (65.04 æg/m ) in NO2 moving averages were associated with an 18.4 percent increase (95 percent confidence interval, 95 percent CI = 12.5-24.3) in emergency room visits due to lower respiratory tract diseases (4-day moving average), a 17.6 percent increase (95 percent CI = 3.3-32.7) in hospital admissions due to pneumonia or bronchopneumonia (3-day moving average), and a 31.4 percent increase (95 percent CI = 7.2-55.7) in hospital admissions due to asthma or bronchiolitis (2-day moving average). The study showed that air pollution considerably affects children's respiratory morbidity, deserving attention from the health authorities.

A kindred with a variant of multiple endocrine neoplasia type 1 demonstrating frequent expression of pituitary tumors but not linked to the multiple endocrine neoplasia type 1 locus at chromosome region 11q13.

Acromegaly is uncommon in kindreds with multiple endocrine neoplasia type 1 (MEN1), whereas primary hyperparathyroidism (PHP) has the highest penetrance of any endocrinopathy. We report an unusual MEN1 kindred with frequent expression of pituitary tumors and a low penetrance of PHP. Four members were found to have disease: PHP in generation I, acromegaly (2 cases) in generation II, and hyperprolactinemia associated with a pituitary tumor in generation III. There was no evidence for PHP in 1 patient with acromegaly (age 60 yr), the patient with hyperprolactinemia and the pituitary tumor (age 22 yr), and 1 asymptomatic obligate carrier (age 50 yr). Screening of 26 members revealed the possible diagnosis of PHP in 1 family member in generation II and possible early acromegaly in 2 members of generation III with elevated serum concentrations of insulin-like growth factor I and insulin-like growth factor-binding protein-3 but normal patterns of pulsatile GH release. Although the predisposing genetic defect in typical MEN1 families has previously been mapped to chromosome location 11q13 without evidence of heterogeneity among the 87 families analyzed, linkage of disease in this family to the MEN1 region is unlikely based on haplotype analysis. Localization of the gene(s) responsible for disease in such atypical families may aid in the understanding of the pathogenesis of MEN1. In addition, further study of the earliest changes in patterns of pulsatile GH release in familial acromegaly may allow more insight into the pathogenesis and natural history of this disease.

Airway responses to capsaicin in guinea pigs: role of NK-1 and NK-2 neurokinin receptors.

The role of NK-1 and NK-2 receptors on the pulmonary response to capsaicin in guinea pigs was evaluated using intravenous infusion of selective nonpeptide antagonists of NK 1 (CP 96345, 300 nmol/kg, and SR 140333, 300 nmol/kg) and NK-2 (SR 48968, 100 nmol/kg) neurokinin receptors. Maximal values of pulmonary dynamic elastance (Edyn) and pulmonary resistance (RL) after capsaicin infusion were significantly lower in the presence of SR 48968 (p < .005). Morphometric analysis of lungs obtained by quick-freezing showed significant attenuation of airway contraction and peribronchiolar edema formation in the presence of NK-2 antagonist (p < .001). When compared to guinea pigs that received only capsaicin, animals that received SR 140333 or CP 96345 showed lower values of Edyn, RL, airway contraction, and peribronchiolar edema, but only the difference in Edyn values was significant. The combination of NK-1 and NK-2 antagonists was not more effective than NK-2 antagonist alone in attenuating capsaicin effects. The results suggest that airway effects of capsaicin are mainly mediated by activation of NK-2 receptors although NK-1 receptors may also play a role.

Capsaicin-induced release of VIP-like immunoreactivity: modulation by enzyme inhibitors.

Vasoactive intestinal peptide (VIP) is a potent bronchial smooth muscle relaxant. In the present study we measured the release of VIP-like immunoreactivity (VIP-LI) after tracheal infusion of capsaicin, histamine, and methacholine in isolated guinea pig lungs superfused through the trachea. We also studied if inhibition of VIP enzymatic cleavage using a combination of an inhibitor of neutral endopeptidase [thiorphan (Thio)] and an inhibitor of serine proteases [soybean trypsin inhibitor (STI)] influenced the airway effects of capsaicin. Infusion of capsaicin resulted in a significant increase in VIP-LI in the perfusate (12.32 +/- 4.80 to 33.52 +/- 8.46 fmol/5 min fraction; P < 0.001). There was no increase in VIP-LI after infusion of methacholine or histamine. Maximal changes in airway opening pressure (Pao) observed 0-10 min after tracheal infusion of capsaicin were significantly greater in the Thio group than the control group and the groups of lungs that received STI or STI + Thio (P < 0.005). In addition, recovery of VIP-LI in the superfusate after infusion of capsaicin was significantly greater in the group of lungs that was superfused with Thio + STI compared with STI, Thio, and control groups. Our results suggest that a bronchodilator peptide with the profile of enzymatic cleavage of VIP also modulates capsaicin effects, since the increase in Pao in the presence of Thio + STI was significantly lower than Thio alone.

Neurokinin depletion attenuates pulmonary changes induced by antigen challenge in sensitized guinea pigs.

The role of neurokinins in the acute pulmonary response to antigen was studied in guinea pigs that received ovalbumin (50 mg/kg ip) on days 1 and 3 and capsaicin (50 mg/kg sc) on day 21 (OAC); ovalbumin on days 1 and 3 (OA1); capsaicin on day 1 and OA on days 8 and 10 (COA); and ovalbumin on days 8 and 10 (OA2). On day 28, guinea pigs were submitted to ovalbumin aerosol challenge. Maximal values of pulmonary dynamic elastance (Edyn) and pulmonary resistance (RL) were significantly lower in OAC and COA groups compared with OA1 and OA2 groups (P < 0.001). There was no difference between maximal Edyn and RL values obtained in OAC and COA groups. Morphometric analysis of lungs showed significantly (P < 0.05) lower values of contraction index of airways, peribronchial edema, and alveoli over inflation in guinea pigs that received capsaicin compared with intact guinea pigs. Capsaicin treatment did not influence the formation of specific IgG1 anaphylactic antibodies. We conclude that neurokinin depletion results in a decrease in the pulmonary mechanical and inflammatory responses to antigen challenge in sensitized guinea pigs. These effects are observed when capsaicin is given either before or after sensitization.

[Acute hemolytic crisis followed by fulminant hepatic failure with fatal outcome, as a first clinical manifestation of Wilson's disease]. / Crise hemolítica aguda seguida por insuficiência hepática fulminante com evolução fatal, como primeira manifestação clínica da doença de Wilson.

We describe in this work a clinical case of a female patient aged 21 years, bearer of Wilson's disease, a first clinical manifestation of the disease occurred as an acute hemolytic crisis followed by fulminant hepatic failure evolving to death after 26 days' internment. The definitive diagnosis was obtained only as a quantitative measurement of hepatic copper from the necropsy material. The search for Kayser-Fleischer ring was negative and the serum ceruloplasmin level was 9 mg/dl (15 to 60). No involvement of the central nervous system was noted from the pathologic analysis. The patient presented two Coombs negative hemolytic crises during the internment; the first on being admitted to hospital and the second after a transjugular hepatic biopsy carried out on the 16th day after internment. The last hemolytic crisis was accompanied by an increase of serum and urinary copper levels. On this occasion the patient evolved to a progressive hepatic failure with severe jaundice and hepatic encephalopathy. We are presenting the clinical-biochemical evolution of the patient and we shall discuss the existent hypotheses to the pathophysiology of this rare form for manifestation of the Wilson's disease as well the diagnostic difficulties.

[Two cases of severe cutaneous vasculitis with thrombocytopenia associated with hepatic cirrhosis: autoimmune and infective-inflammatory component with endothelial lesion and restrictive pulmonary pattern in one case]. / Dois casos de vasculite cutânea grave com plaquetopenia associada à cirrose hepática: componente autoimune e infecto-inflamatório com lesão endotelial e padrão restritivo pulmonar em um caso.

Two clinical cases of female patients with hepatic cirrhosis and autoimmune multisystemic involvement with infectious intercurrent are reported. Case 1 presented infective endocarditis and erysipelas on the left thigh. In the course of the clinical picture a cutaneous vasculitis developed in the same place together with autoimmune thrombocytopenia, leukopenia and pulmonary restrictive picture with inflammatory pattern. There are also elevate immune complexes and complement consumption. Case 2 presented erysipelas on the left thigh cutaneous vasculitis and complement consumption. In Case 1 the infective endocarditis was treated with antibiotic therapy during 4 weeks followed by 1 mg/kg corticoid (Prednisone) with thrombocytopenia and leukopenia reversion. Case 2 presented an improvement with antibiotic only. The relation between chronic liver diseases and systemic autoimmune phenomena is commented, special attention being paid to the cutaneous, hematological and pulmonary affection.

Massive infestation by Ascaris lumbricoides of the biliary tract: report of a successfully treated case.

This is a report of a 25 years old black woman from the city of São Paulo, Brazil, who developed acute obstructive cholangitis of Ascaris lumbricoides with septicemia and multiple hepatic abscesses. The patient had sickle cell trait and normal delivery 3 months ago. Massive infestation of the biliary tract by Ascaris lumbricoides was diagnosed by abdominal ultrasonography and endoscopic retrograde cholangiography. Sixty worms were removed from the common bile duct and hepatic abscesses were drained by surgery. The infectious process was polymicrobial. The patient's recovery was complete after a long evolution with a wide spectrum antibiotic therapy. New surgeries were needed to remove residual worms in the biliary tract. The diagnostic methods, clinical-biochemical features and also the clinical and surgical management are presented. The biliary ascariasis pathophysiology is commented.

[Lethal pulmonary involvement in neurofibromatosis]. / Comprometimento pulmonar letal na neurofibromatose.

A unusual case of a 61-year-old man who presented dyspnea and cough associated to skin and subcutaneous lesions typical of neurofibromatosis type 1 is reported. Chest roentgenograms and CT-scan showed emphysematous bullae. The patient underwent drainage of the greatest bulla, but death eventually ensured as a consequence of upper digestive bleeding. It can be expected that with the longer survival of neurofibromatosis patients with respiratory troubles, that are generally considered unusual will be recognized more frequently.

Lipoprotein metabolism in pregnancy, fat transport to the fetus, and the effects of diabetes.

The objective of this paper is to review the extent and mechanisms of lipoprotein alterations in pregnancy, present new data relating to placental lipid transport in normal humans and diabetic animals and consider possible effects on fetal growth and development in normal and diabetic pregnancy. The concentration of all lipoprotein fractions increases during pregnancy. VLDL cholesterol and triglyceride increase 2.5-fold over prepregnancy levels and LDL cholesterol increases 1.6-fold, all with peak levels at term. HDL cholesterol is maximally increased in midgestation by 1.45-fold and subsequently declines to 1.15-fold at term. The mechanisms of these lipoprotein changes have not been studied in humans but the hypertriglyceridemia in animal models is related to enhanced VLDL entry into the circulation. In addition, diminished adipose tissue lipoprotein lipase (LPL) activity in late gestation may cause a rerouting of triglyceride fatty acids to other tissues such as muscle and uterus for oxidation, rather than storage, since triglyceride transport is not reduced in pregnancy. All of these changes appear to be sex hormone mediated. In diabetic pregnancies, the available data indicate that triglyceride concentrations are increased and HDL cholesterol concentrations are decreased with reference to lipoproteins in nondiabetic pregnant women. Previously unpublished data show that a transplacental FFA gradient exists across the umbilical circulation in the direction of the fetus and is proportional to the maternal FFA concentration. No gradient is seen for triglyceride or total plasma cholesterol. However, transport of unmeasured amounts of triglyceride fatty acids may still occur via placental LPL and be exaggerated in diabetes where LPL declines in adipose tissue but not in placenta. The mechanism of transplacental cholesterol transport remains to be defined. Preliminary studies suggest that it depends on HDL as well as LDL since both can provide cholesterol for placental progesterone synthesis. In addition, fetal weight and length are associated with maternal apoproteins A-I and A-II, both major apoproteins of HDL. By lowering HDL in pregnancy, diabetes mellitus could negatively affect these relationships. In conclusion, sex hormone mediated modifications of lipoprotein physiology are described in pregnancy which may enhance triglyceride fatty acid transport to muscle for oxidation and LDL and HDL cholesterol delivery to growing maternal and fetal tissues, a process that diabetes could globally disrupt.

Relationships of lipoprotein lipids to mild fasting hyperglycemia and diabetes in pregnancy.

The available data have been examined to determine if plasma lipids or lipoproteins are altered in pregnant subjects with adult-onset (type II) diabetes, gestational diabetes, or the hyperglycemic extreme of a randomly selected group of pregnant women attending a prepaid health plan. In each of these groups, a trend is observed toward an increase in total plasma and very low density lipoprotein triglycerides and a decrease in high density lipoprotein (HDL) cholesterol. These observations indicate that measurements of plasma triglyceride and HDL cholesterol may be valuable in identifying and quantifying the metabolic abnormality in gestational diabetes and in prognosticating fetal outcome.

Dietary management of the pregnant diabetic.

The tendency of the pregnant diabetic to fasting ketosis limits the extent to which calorie restriction (particularly negative calorie balance) can be used in the treatment of the obese, adult-onset, pregnant diabetic. In addition, the vagaries of measuring excess weight gain and detecting extraneous sources of weight gain in diabetic pregnancy, and the difficulty of accurately enforcing a caloric prescription without forcing the subject to weigh her food, make the determination of an accurate degree of caloric limitation difficult at best. A greater reliance on the mother's appetite center may be more accurate and rewarding in most instances than any devices available to the clinician. Important considerations in the diet of the pregnant diabetic are adequate protein, minerals, and vitamins, an amount of carbohydrate that is constant from day to day but not necessarily restricted, carbohydrate intake in an unrefined form that maximizes the intake of associated fiber, and a reproducible meal and snack schedule which complements in insulin regimen. Insulin must remain the primary therapeutic tool if the effects of maternal diabetes on fetal morbidity and mortality are to be minimized.

Lipid metabolism in pregnancy. II. Altered lipid composition in intermediage, very low, low and high-density lipoprotein fractions.

The hyperlipidemia of pregnancy consists primarily of an increase in triglyceride with lesser rises in cholesterol and phospholipid. As a further characterization, we have analyzed all lipids in the major lipoprotein subfractions in fasting pregnant and non-pregnant women. An elevated triglyceride in the major lipoprotein fractions in pregnancy is confirmed. The triglyceride rises in VLDL and IDL (density 1.006-1.019 lipoprotein) are associated with proportional rises in cholesterol and phospholipid. The result is a 3-4-fold increase of compositionally unchanged lipoprotein lipid. Contrasting changes are seen in LDL, density 1.019-1.063 lipoprotein, and HDL. In these fractions, triglyceride rises more than cholesterol and phospholipid. As a result, an increase in triglyceride on a percentage basis tends to reduce the contribution of the other two lipids. Nonetheless, on an absolute basis HDL cholesterol is not significantly reduced. The proportional increases in all lipids of VLDL and IDL fractions are consistent with increased VLDL production in pregnancy as suggested by data from animal systems. However, alterations in removal are not rules out. Maintenance of the HDL cholesterol level distinguishes pregnancy from other endogenous hypertriglyceridemias where HDL cholesterol is reduced. One may speculate that these physiological adaptations in material lipid transport can serve the increased energy needs of the mother, supply steroid hormone precursors for the placenta, and provide cholesterol and essential fatty acids for the fetus.