Detecção de Bordetella bronchiseptica a partir de suabes nasais de suínos pela bacteriologia clássica e pela reação em cadeia pela polimerase

A Bordetella bronchiseptica é um dos agentes etiológicos da rinite atrófica e de pneumonia em suínos. Embora os prejuízos econômicos gerados por esses distúrbios respiratórios sejam amplamente reconhecidos, o impacto desse patógeno na sanidade dos rebanhos é freqüentemente subestimado. Isso se deve, em parte, à dificuldade de isolar a Bordetella bronchiseptica a partir dos espécimes clínicos que em muitos casos está presente em pequeno número na cavidade nasal. Este trabalho descreve a determinação do meio de transporte mais adequado, às nossas condições, que favoreçam sua detecção da Bordetella bronchiseptica e a comparação de três meios seletivos para o seu isolamento. Também foram comparadas as sensibilidades dos meios de isolamento e da técnica de reação em cadeia pela polimerase. O meio de transporte que apresentou melhor desempenho, avaliando as temperaturas testadas (10ºC e 27ºC) em conjunto, foi o meio Amies com carvão. De acordo com os resultados obtidos e a praticidade de seu uso na rotina clínica, a temperatura de 27ºC foi a eleita para o transporte dos espécimes. Os três meios seletivos empregados para o isolamento primário de Bordetella bronchiseptica a partir de suabes nasais mostraram semelhantes capacidades de recuperação da bactéria, mas o ágar MacConkey selecionou melhor os espécimes colhidos, recuperando um número maior de colônias. Mesmo usando o meio e a temperatura de transporte mais favoráveis para o transporte de suabes nasais e o meio seletivo mais sensível determinado neste estudo, a reação em cadeia pela polimerase apresentou uma capacidade de detecção da Bordetella bronchiseptica superior a do cultivo.

Estabelecimento de uma nova metodologia para o cálculo do índice de patoigenicidade em amostras de escherichia coli provenientes da produção de frango de corte

Essa dissertação possui como objetivo traçar, uma nova metodologia de classificação de patogenicidade da Escherichia.coli,.através de um índice no qual, além do número de animais mortos, também foi considerado o tempo de morte e a capacidade da cepa causar lesão compatível à colibacilose em pintos de 1 dia. Para gerar esse critério, foram utilizadas 300 amostras de E.coli oriundas de lotes com lesão de celulite, cama desses mesmos aviários e amostras de quadros respiratórios. Através desse experimento foi possível observar que as amostras de E.coli originadas das camas dos aviários, apresentavam índice de patogenicidade significativamente menor do que aquelas isoladas das lesões cutâneas e de quadros respiratórios.Também foi associado às cepas de E.coli a capacidade de causar lesões de: pericardite, perihepatite, aerossaculite, peritonite e celulite. Dentre as lesões citadas somente a celulite foi considerada de apresentação significativamente mais freqüente em comparação às outras.

Perfil de memória e ativação de linfócitos T na leishmaniose visceral

Visceral leishmaniasis (VL) in Brazil is a disease caused by Leishmania infantum chagasi (L.i.chagasi). The clinical evolution post-infection depends on the vertebrate host immune response, which is genetically mediated. This study aimed to evaluate the immune response of individuals living in endemic area for VL in the state of the Rio Grande do Norte, considering individuals with VL under treatment (n = 9), recovered VL <1 year post treatment (n = 10), > 10 years posttreatment (n = 9), uninfected individuals living in endemic areas (n = 7), individuals that lost DTH response (n=6) and asymptomatic individuals for VL (n=9). Peripheral blood cells were evaluated in the presence and absence of soluble Leishmania antigens (SLA) and ex vivo, to determine activation, presence of regulatory cells and memory cells. The Leishmania parasitemia and anti-Leishmania antibodies were determined respectively by qPCR and ELISA. Cells from individuals with VL under treatment showed less cell activation after stimulation with SLA for the markers CD4/CD69, CD8/CD69 and CD8/CD25 compared with VL post treatment treatment (p <0.001). Apparently uninfected individuals have a higher cell activation than symptomatic VL (p <0.001), with the exception of CD8/CD25 marker (p = 0.6662). On the other hand, in the ex-vivo group, significant differences were observed for CD4/CD69, CD8/CD69 and CD8/CD25 between the 4 groups due to increased cell activation present in cells of individuals symptomatic LV (p <0.001). VL cells under treatment, ex vivo, have a lower percentage of memory cells (CD4/CD45RO and CD8/CD45RO) than individuals VL post-treatment or control group (p = <0.01). Likewise, individuals with symptomatic VL have fewer regulatory cells when stimulated by SLA [CD4/CD25 (p = 0.0022) and CD4/FOXP3 (p = 0.0016)] and in the ex-vivo group (p = 0.0017). Finally, DNA isolated from recovered VL contained Leishmania DNA, supporting the hypothesis of non-sterile clinical cure for Leishmania infection. Recovered VL, even 10 years after treatment have high levels of memory cells, which may be due to the presence of stimulation, either by reexposure to Leishmania or non-sterile cure

Avaliação das atividades antioxidantes e citotóxicas de extratos ricos em polissacarídeos extraídos das hastes de mandacaru (Cereus Jamacaru de Candolle, Cactaceae)

The use of medicinal plants to cure and treat various diseases is a common practice in the world and in Brazil. In several regions of the Brazil´s Northeast, the cactus Cereus jamacaru, known as mandacaru, is used popularly as a treatment to many diseases, including those related to heart respiratory diseases, gastric ulcers, scurvy, and kidney diseases. However, there is a scarcity in the scientific literature that proves scientifically the popular application of this cactus. Like other plants, Cereus jamacaru synthesizes several potentially bioactive molecules, like as polysaccharides. In this work, three polysaccharides-rich aqueous extracts, MCA80, MPM and MCP60, were obtained from this plant and analyzed chemically, as well as their cytotoxic and antioxidant potential. The data showed that all extracts consist mainly of polysaccharides (89.42 to 95.76%), but also protein (> 2%) and phenolic (3 to 8.87%) contaminants were detected. All extracts are rich in galactose, glucose and mannose. In addition, glucuronic acid was found in MCA80 and MCP60. The extracts showed total antioxidant capacity ranged from 55.21 to 68.13 of ascorbic acid equivalents (AAE). Besides, they exhibited reducer power and cupric chelation in a dose-dependent manner. None of the extracts inhibited the MTT reduction in the presence of prostate tumor cells (PC-3). However, MCP60 was the most effective extract by preventing the reduction of MTT by about 80% in the presence of cells 786. Nuclear fragmentation tests showed that this extract induces cell death. The data indicated that mandacaru synthesizes bioactive polysaccharides with potential as antioxidant and antitumor agents. For future studies, it is intended to purify and characterize these polysaccharides and its antioxidant and antitumor mechanisms

Avaliação da efetividade de estratégias não farmacológicas para o alívio da dor de parturientes na fase ativa do período de dilatação no trabalho de parto

This study was aim to evaluate the effectiveness of strategies non pharmacological for the relief of the intensity of the parturient pain in the phase activates of the dilation period in the labor. Is a clinic rehearse of the type therapeutic intervention before and after" with a quantitative approach, accomplished in the Humanized Unit of Childbirth of the Maternity Januário Cicco School of the Federal University of Rio Grande do Norte, in Natal/RN, whit 130 parturient, being 30 in the pre-test of the strategies and 100 in the application of the strategies non pharmacological combined (breathing exercises, muscular relaxation and lombossacral massage) and isolated (shower bath in a normal temperature). We used the visual analogical scale to evaluate the intensity of the pain of the study parturient before and after" to the application of the strategies in the phases of acceleration, maximum inclination and desaceleration in the phase activates of dilation period in the labor. The principal results showed that the majority of the study parturient was between 20 to 30 years old (60%); with incomplete fundamental teaching (85%); family income until 2 minimum wages (74%); 78% had a companion and these, 44% were the own husband. The oxytocin was administered in the parturient during the phase activates of the labor in 81% of the cases and only 15% these women didn´t reciev anything medication. We verified significant relief (ρ=0.000) of intensity of the pain of the study parturient after application of the strategies non pharmacological combined and isolated. We concluded that the strategies non pharmacological combined and isolated were effective in the relief of the pain of the study parturient in the phase activates de labor

Distribuição regional da ventilação pulmonar em indivíduos com insuficiência cardíaca crônica após serem submetidos a um programa de treinamento da musculatura inspiratória e sua correlação com dados funcionais

Introduction: Chagas Disease is a serious public health problem, with 5 million infected individuals in Brazil. Of these, approximately 30% develop chronic Chagas cardiomyopathy (CCC), where the main symptoms are fatigue and dyspnea. Objective: To correlate maximal exercise capacity with pulmonary function, inspiratory muscle strength and quality of life in patients with CCC. Methodology: Twelve individuals suffering from CCC were evaluated (7 men), with a mean age of 54.91± 8.60 years and the following inclusion criteria: functional class II and III according to the New York Heart Association (NYHA); left ventricle ejection fraction below 45%; clinical stability (> 3 months); symptom duration > 1 year, body mass index (BMI) < 35Kg/m2 and non-smokers or ex-smokers with a history of smoking <10 packs/day. All subjects were submitted to spirometry, manometer testing, maximal cardiopulmonary exercise testing (CPX) and a quality of life questionnaire (Minnesota). Results: A negative correlation was observed between VO2máx and MLHFQ scores (r=-0.626; p=0.03) and a positive association with MIP (r=0.713; p=0.009). Positive correlations were also recorded between MIP and spirometric variables [FEV1(r=0.825;p=0.001 ), FVC(r=0.66;p=0.01 and FEF25-75%(r=0.639;p=0.02)]. Conclusion: The present study demonstrated that in patients with CCC: VO2MAX is directly related to inspiratory muscle strength and quality of life, while deteriorating lung function is directly associated with respiratory muscle weakness

Avaliação dos efeitos da reeducação postural global (rpg) em pacientes com espondilite anquilosante

The Ankylosing Spondylitis (AS) is a chronic inflammatory disease that primarily affects the axial skeleton, leading to limitation of spine mobility and functional disability. Physical therapy, especially exercise, is an important part in your treatment. The Global Postural Reeducation(GPR),a method that uses stretching based on evaluation of muscular chains, with significant interference in postural changes may be a complementary alternative for the treatment of this disease. The aim was to evaluate the effects of Global Postural Reeducation (GPR) in patients with Ankylosing Spondylitis (AS) and compare GPR with group conventional segmental self-stretching and breathing exercises. This is a controlled interventional study of 38 patients divided into 2 groups: a GPR group (n = 22) and a control group (n = 16). Both groups were treated over four months. With the GPR group patients, positions that stretched the shortened muscle chains were used. With the control group patients, conventional segmental self-stretching and breathing exercises were performed. The variables analyzed were: pain intensity, morning stiffness, spine mobility, chest expansion, functional capacity (Health Assessment Questionnaire - Spondyloarthropathies - HAQ-S), quality of life (Medical Outcome Study Short Form 36 Healthy Survey-SF-36), and disease activity (Bath Ankylosing Spondylitis Disease Activity Index - BASDAI). Statistical analysis was used with a significance level of p < 0.05. There was a statistically significant difference for all the parameters analyzed between pre and post-treatment in both groups. In the inter-group comparison the GPR group showed a statistically significant improvement in morning stiffness (p = 0.01), spine mobility parameters, except finger-floor distance (p = 0.11), in chest expansion (p = 0.02), and in the physical aspect component of the SF-36 (p = 0.00).Finally, we observed that this sample of patients with AS ,treatment with RPG 60 seems to have a better response in some clinical measures, than the conventional self stretching performed in groups. Further studies are needed to further evaluate this therapeutic alternative in the EA

Avaliação da eficácia analgésica no pós-operatório de revascularização do miocárdio: ensaio clínico randomizado controlado

A analgesia pós-operatória eficaz é especialmente importante após cirurgias torácicas, pois, além de aliviar a dor, facilita a retomada de atividades normais, incluindo a deambulação, a respiração e a tosse. Dessa forma, os objetivos deste estudo são: avaliar a eficácia analgésica da associação entre anestesia geral e raquianestesia com morfina e ropivacaína mais esquema multimodal em relação à anestesia geral e esquema multimodal em cirurgia de revascularização do miocárdio; analisar a eficácia analgésica da injeção subcutânea de lidocaína e analgesia multimodal na remoção de tubos torácicos em cirurgia de revascularização do miocárdio. A metodologia consiste em ensaio clínico randomizado, controlado, envolvendo 58 pacientes, de ambos os sexos, com idade média de 59,8  8,9 anos, estado físico ASA II e III. Os participantes foram alocados em dois grupos, sendo o GI composto por indivíduos submetidos à anestesia geral combinada à raquianestesia com morfina 400μg e 6 ml (30mg) a 8 ml (40mg) de ropivacaína a 0,5% e analgesia multimodal; já o GII foi composto por indivíduos submetidos à anestesia geral associada à analgesia multimodal. Foi avaliada a dor, ao despertar, nas primeiras 24 horas, e ao realizar exercício respiratório, ao retirar drenos de torácicos e o tempo para extubação. A análise estatística foi realizada pelos testes do Qui-quadrado e Teste t de Student e o teste de Fisher. O resultado obtido foi o seguinte: o GI apresentou menor intensidade de dor ao despertar (p= 0,001), nas primeiras 24 horas (p= 0,001) e durante a realização dos exercícios respiratórios (p= 0,004). Houve maior necessidade de analgesia complementar no grupo GII, com maior consumo de morfina (p= 0,05), e os efeitos colaterais leves, como náuseas (p= 0,001), vômito (p= 0,002), prurido (p= 0,030), predominaram no GI. Não houve diferença estatisticamente significante entre os grupos (P= 0,47), em relação à intensidade de dor na remoção dos drenos. Após as observações feitas, o estudo sugere que a anestesia geral combinada à raquianestesia com morfina associada à ropivacaína oferece melhor efeito analgésico no pós-operatório de cirurgia cardíaca. Adicionalmente, o estudo sugere que o efeito analgésico da injeção subcutânea de lidocaína 1% associado à analgesia multimodal não é eficaz

Diferentes frações inspiradas de oxigênio em coelhos hipovolêmicos anestesiados com propofol e submetidos à ventilação mecânica

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Estudo clínico e laboratorial da pneumonia de bezerros induzida pela inoculação intrabronquial de Mannheimia haemolytica

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Susceptibility of fruits of the 'Valência' and 'Natal' sweet orange varieties to Guignardia citricarpa and the influence of the coexistence of healthy and symptomatic fruits

Em pomar de laranjeiras 'Valência' e 'Natal' avaliou-se a importância da presença de frutos sintomáticos da mancha preta citros (MPC) na severidade da doença nos frutos cítricos da safra subseqüente. Adicionalmente, avaliou-se o estádio de suscetibilidade dos frutos dessas variedades. Frutos foram protegidos com sacos de papel cristal a partir do estádio de 75% de pétalas caídas em outubro de 2000, até abril de 2001. Frutos foram expostos, em intervalos semanais, da 1ª à 24ª semana. Esse processo se deu tanto em plantas onde os frutos da safra remanescente foram previamente colhidos, como naquelas cujos frutos sintomáticos da safra remanescente permaneceram até a sua queda natural. Avaliou-se a severidade da doença usando uma escala de notas que variou de 0 (ausência de sintomas) a 6 (sintomas severos). Observou-se que para as duas variedades os conídios de Phyllosticta citricarpa, formados nas lesões dos frutos da safra remanescente, não provocaram incremento significativo na severidade da doença dos frutos da safra subseqüente. A proteção dos frutos até 10ª semana após a queda de pétalas não influenciou na quantidade final de lesões, indicando que as descargas de ascósporos que ocorreram a partir desse momento foram, provavelmente, responsáveis pela severidade da doença. Frutos que ficaram expostos entre a 20ª a 24ª semanas após a queda de 75% de pétalas mostraram-se sintomáticos, indicando que nesse estádio frutos encontravam-se suscetíveis ao patógeno.

Identificação de crianças e adolescentes com suspeita de câncer: uma proposta de intervenção

Unlike adult cancer, where cells usually originate from epithelial tissue and is linked to environmental factors, malignant tumors in childhood are mostly of embryonic origin and have a phase of rapid proliferation. When not started chemotherapy at this stage, the tumor increases in size, reducing their growth rate, thus reducing the response to chemotherapy. Childhood cancer is in Brazil, the second cause of mortality among children and adolescents from one to nineteen. His impact on the ranking of diseases becomes significantly important to public health since the first issue is related to accidents and violence. Many children are still sent to the centers of high complexity for cancer treatment with advanced stage disease. The delay in referral to diagnosis can be family, or the difficulty of access to the health sector, or the characteristics of the disease and lack of health staff regarding theme of childhood cancer. Before this problem, we aimed to assess the performance of health teams in the identification of child and adolescent symptoms of cancer in primary care, through the action research methodology, which includes the teaching-learning, seminars, describing the actions of the group and discussing the activities after the training. This study involved thirty-seven health professionals who provide care for children and adolescents in the USF Felipe Shrimp II, the Support Center for Children with Cancer and the pediatric hospital UFRN during the period from March to December 2010. The data were analyzed simultaneously to evaluate actions, following the direction of the analysis of ideas Freires, having as theoretical reference the primary health care. The diagnosis of current reality, as knowledge of the health team targeted for early identification of signs and symptoms raised through questioning, presented as generative themes: resistance to change, awareness of the need for apprehension of knowledge; prior knowledge through the media, fragmentation of the healthcare network, interfering with the operation of the reference and counter, the stigma of death, among others. The selected themes enabled the choice of content for the preparation of four seminars, such as implementation of collective action for discussion problematical. The teaching-learning process has allowed the study participants awareness of the problem and work through the knowledge acquired by interfering in decreasing the time interval between the identification of signs and symptoms of cancer and early specialist treatment. Their difficulties we are faced with a diagnosis of terminal cancer and associated with delayed access to laboratory tests and imaging necessary for the diagnosis of neoplasms. Thus, we find that when the team is consciously involved in the education process from identification of the problem situation, there may be significant changes in daily activities through awareness of being. However, we also realize that acquisition of knowledge and interest of the team are not enough, since to be efficiency of our service, we need an organization of cancer care network operating in the state of Rio Grande do Norte

Força muscular respiratória e capacidade funcional em idosas hipertensas com sonolência diurna excessiva

The restriction of physical fitness is directly related with hypertension and sleep disorders, while the respiratory muscle strength is associated with hypertension, but the literature is scarce regarding its relationship with sleep disorders and particularly with excessive daytime sleepiness. Objectives: To compare physical fitness and strength of respiratory muscles between people with hypertension with excessive daytime sleepiness (EDS) and non EDS people, those who do not feel excessive daytime sleepiness, in addition to relate aerobics resistance and functional mobility of patients. Methods: An observational, analytical and transversal study, evaluated 32 elderly with hypertension, divided into two groups (EDS and non EDS), in which the following topics were measured; respiratory muscular strength, functional fitness, level of physical activity, level of excessive daytime sleepiness, quality of sleep and intensity of the patients snoring. Results: There was a significant difference in the level of EDS (P=0,00) and quality of sleep (p=0,03), however, the data related to snoring intensity (p=0,18), maximum inspiratory pressure PImax (p=0,39) and maximum expiratory pressure PEmax (p=0,98) did not show any difference. Also, no significant difference was observed concerning physical fitness, presenting p=0,08 for the sitting and getting up test on the chair in 30 ; p=0,54 for the extension and flexing of the elbow test in 30 ; p=0,38 for the walking test 6 ; p=0,38 for the parking gear test 2 , p=0,08 for the sitting and reaching test; p=0,42 for the scratching the back test; p=0,49 for the getting up and walking test; and p=0,62 for the global rate of activity limitation. There was moderate positive correlation between 6MWT and 2MST, r=0,54 (p=0,01) and negative moderate correlation between 6MWT and TUG, r=-0,61 (p=0,000) and between 2MST and TUG, r=-0,60 (p=0,000). Conclusion: The presence of EDS in the hypertension people studied, showed a bad quality of sleep, however this sleepiness did not influence the strength of the respiratory muscles. The physical fitness came out diminished in all hypertension people, regardless of the presence or non presence of sleep disturbance; and there is a close relationship between cardiovascular resistance and physical mobility, since when there is less cardiovascular resistance, there is precarious physical mobility and vice-versa

Avaliação da função pulmonar em obesos mórbidos com sonolência diurna excessiva

Background: Obesity impairment to the pulmonary function related to the magnitude of adiposity and is associated with excessive daytime sleepiness (EDS) and snoring, among others symptoms of respiratory disorders related to sleep. It is possible that obese individuals with excessive daytime sleepiness may make changes in lung function on spirometry monitored during the day as a consequence of fragmented sleep or episodes of nocturnal hypoventilation that cause respiratory and changes that can persist throughout the day. The combination of these findings alone sleepiness observed by subjective scales with pulmonary function in obese patients is unknown. Objective: To assess the influence of EDS and snoring on pulmonary function in morbidly obese and distinguish between different anthropometric markers, the snoring and sleepiness which the best predictors of spirometric function and respiratory muscle strength and endurance of these patients. Methods: We evaluated 40 morbidly obese markers on the anthropometric, spirometric respiratory variables, maximal inspiratory and expiratory pressures (MIP and MEP) and maximal voluntary ventilation (MVV) and the measured excessive daytime sleepiness (the Epworth sleepiness scale) and snoring (snoring scale of Stanford). The data were treated when the differences between the groups of obese patients with and without sleepiness, whereas the anthropometric variables, respiratory and snoring. Pearson's correlation was performed, and multiple regression analysis assessed the predictors of pulmonary function. For this we used the software SPSS 15.0 for windows and p <0.05. Results: 39 obese patients were included (28 women), age 36.92+11.97y, body mass index (BMI) 49.3+5.1kg/m², waist-hip ratio (WHR) 0.96+0.07 and neck circumference (NC) 44.1+4.2 cm. Spirometric values and respiratory pressures were up 80% of predicted values, except for endurance (MVV <80%). Obese with EDS have lower tidal volume. Positive correlation was observed between BMI and EDS, EDS and NC and between snoring and BMI, and negative correlation between EDS and tidal volume (TV), and between snoring and snoring FVC and FEV1. In linear regression the best predictor of pulmonary function was snoring, followed by NC. NC has more obese with higher strength (MEP, p = 0.031) and endurance (MVV p = 0.018) respiratory muscle. Conclusion: Obese with EDS tend to have lower TV. In addition, snoring and NC can better predict pulmonary function in obese when compared with other anthropometric markers or EDS. Obese patients with higher NC tend to have greater capacity for overall strength of respiratory muscles, but may have low muscle endurance

Força muscular respiratória, qualidade de vida e modulação autonômica da frequência cardíaca na distrofia miotônica

Background: The myotonic dystrophy (MD) is a multisystem neuromuscular disease that can affect the respiratory muscles and heart function, and cause impairment in quality of life. Objectives: Investigate the changes in respiratory muscle strength, health-related quality of life (HRQoL) and autonomic modulation heart rate (HR) in patients with MD. Methods: Twenty-three patients performed assessment of pulmonary function, sniff nasal inspiratory pressure (SNIP), the maximal inspiratory (MIP) and expiratory (MEP) pressure, and of HRQoL (SF-36 questionnaire). Of these patients, 17 underwent assessment of heart rate variability (HRV) at rest, in the supine and seated positions. Results: The values of respiratory muscle strength were 64, 70 and 80% of predicted for MEP, MIP, and SNIP, respectively. Significant differences were found in the SF-36 domains of physical functioning (58.7 ± 31,4 vs. 84.5 ± 23, p<0.01) and physical problems (43.4 ± 35.2 vs. 81.2 ± 34, p<0.001) when patients were compared with the reference values. Single linear regression analysis demonstrated that MIP explains 29% of the variance in physical functioning, 18% of physical problems and 20% of vitality. The HRV showed that from supine position to seated, HF decreased (0.43 x 0.30), and LF (0.57 x 0.70) and the LF/HF ratio (1.28 x 2.22) increased (p< 0.05). Compared to healthy persons, LF was lower in both male patients (2.68 x 2.99) and women (2.31 x 2.79) (p< 0.05). LF / HF ratio and LF were higher in men (5.52 x 1.5 and 0.8 x 0.6, p <0.05) and AF in women (0.43 x 0.21) (p< 0.05). There was positive correlation between the time of diagnosis and LF / HF ratio (r = 0.7, p <0.01). Conclusions: The expiratory muscle strength was reduced. The HRQoL was more impaired on the physical aspects and partly influenced by changes in inspiratory muscle strength. The HRV showed that may be sympathetic dysfunction in autonomic modulation of HR, although with normal adjustment of autonomic modulation during the change of posture. The parasympathetic modulation is higher in female patients and sympathetic tends to increase in patients with longer diagnosis