Reconstruction of femoro-acetabular offsets using a short-stem

PURPOSE Despite the fact that new and modern short-stems allow bone sparing and saving of soft-tissue and muscles, we still face the challenge of anatomically reconstructing the femoro-acetabular offset and leg length. Therefore a radiological and clinical analysis of a short-stem reconstruction of the femoro-acetabular offset and leg length was performed. METHODS Using an antero-lateral approach, the optimys short-stem (Mathys Ltd, Bettlach, Switzerland) was implanted in 114 consecutive patients in combination with a cementless cup (Fitmore, Zimmer, Indiana, USA; vitamys RM Pressfit, Mathys Ltd, Bettlach, Switzerland). Pre- and postoperative X-rays were done in a standardized technique. In order to better analyse and compare X-ray data a special double coordinate system was developed for measuring femoral- and acetabular offset. Harris hip score was assessed before and six weeks after surgery. Visual analogue scale (VAS) satisfaction, leg length difference and the existence of gluteal muscle insufficiency were also examined. RESULTS Postoperative femoral offset was significantly increased by a mean of 5.8 mm. At the same time cup implantation significantly decreased the acetabular offset by a mean of 3.7 mm, which resulted in an increased combined femoro-acetabular offset of 2.1 mm. Postoperatively, 81.7 % of patients presented with equal leg length. The maximum discrepancy was 10 mm. Clinically, there were no signs of gluteal insufficiency. No luxation occurred during hospitalization. The Harris hip score improved from 47.3 before to 90.1 points already at six weeks after surgery while the mean VAS satisfaction was 9.1. CONCLUSION The analysis showed that loss of femoro-acetabular offset can be reduced with an appropriate stem design. Consequently, a good reconstruction of anatomy and leg length can be achieved. In the early postoperative stage the clinical results are excellent.

Usability and Acceptability of ASSESS MS: Assessment of Motor Dysfunction in Multiple Sclerosis Using Depth-Sensing Computer Vision

Background: Sensor-based recordings of human movements are becoming increasingly important for the assessment of motor symptoms in neurological disorders beyond rehabilitative purposes. ASSESS MS is a movement recording and analysis system being developed to automate the classification of motor dysfunction in patients with multiple sclerosis (MS) using depth-sensing computer vision. It aims to provide a more consistent and finer-grained measurement of motor dysfunction than currently possible. Objective: To test the usability and acceptability of ASSESS MS with health professionals and patients with MS. Methods: A prospective, mixed-methods study was carried out at 3 centers. After a 1-hour training session, a convenience sample of 12 health professionals (6 neurologists and 6 nurses) used ASSESS MS to capture recordings of standardized movements performed by 51 volunteer patients. Metrics for effectiveness, efficiency, and acceptability were defined and used to analyze data captured by ASSESS MS, video recordings of each examination, feedback questionnaires, and follow-up interviews. Results: All health professionals were able to complete recordings using ASSESS MS, achieving high levels of standardization on 3 of 4 metrics (movement performance, lateral positioning, and clear camera view but not distance positioning). Results were unaffected by patients’ level of physical or cognitive disability. ASSESS MS was perceived as easy to use by both patients and health professionals with high scores on the Likert-scale questions and positive interview commentary. ASSESS MS was highly acceptable to patients on all dimensions considered, including attitudes to future use, interaction (with health professionals), and overall perceptions of ASSESS MS. Health professionals also accepted ASSESS MS, but with greater ambivalence arising from the need to alter patient interaction styles. There was little variation in results across participating centers, and no differences between neurologists and nurses. Conclusions: In typical clinical settings, ASSESS MS is usable and acceptable to both patients and health professionals, generating data of a quality suitable for clinical analysis. An iterative design process appears to have been successful in accounting for factors that permit ASSESS MS to be used by a range of health professionals in new settings with minimal training. The study shows the potential of shifting ubiquitous sensing technologies from research into the clinic through a design approach that gives appropriate attention to the clinic environment.

The growing spectrum of antibody-associated inflammatory brain diseases in children.

OBJECTIVE To describe the clinical spectrum, diagnostic evaluation, current management, and neurologic outcome of pediatric antibody-associated inflammatory brain diseases (AB-associated IBrainD). METHODS We performed a single-center retrospective cohort study of consecutive patients aged ≤18 years diagnosed with an AB-associated IBrainD at The Hospital for Sick Children, Toronto, Ontario, Canada, between January 2005 and June 2013. Standardized clinical data, laboratory test results, neuroimaging features, and treatment regimens were captured. RESULTS Of 169 children (93 female, 55%) diagnosed with an IBrainD, 16 (10%) had an AB-associated IBrainD. Median age at presentation was 13.3 years (range 3.1-17.9); 11 (69%) were female. Nine patients (56%) had anti-NMDA receptor encephalitis, 4 (25%) had aquaporin-4 autoimmunity, 2 (13%) had Hashimoto encephalitis, and 1 (6%) had anti-glutamic acid decarboxylase 65 (GAD65) encephalitis. The key presenting features in children with anti-NMDA receptor encephalitis, Hashimoto encephalopathy, and anti-GAD65 encephalitis included encephalopathy, behavioral symptoms, and seizures; patients with aquaporin-4 autoimmunity showed characteristic focal neurologic deficits. Six patients (38%) required intensive care unit admission at presentation. Median time from symptom onset to diagnosis was 55 days (range 6-358). All but 1 patient received immunosuppressive therapy. One child with anti-NMDA receptor encephalitis died due to multiorgan failure. At last follow-up, after a median follow-up time of 1.7 years (range 0.8-3.7), 27% of the children had function-limiting neurologic sequelae. CONCLUSIONS Children with AB-associated IBrainD represent an increasing subgroup among IBrainD; 1 in 4 children has function-limiting residual neurologic deficits. Awareness of the different clinical patterns is important in order to facilitate timely diagnosis and initiate immunosuppressive treatment.

South Asian immigrant cardiovascular risk assessment in Houston, Texas 2005

Background. Heart disease is the leading cause of death and stroke is the third leading cause of deaths for all people in the United States. South Asian Americans have a higher risk of developing cardiovascular diseases than native United States residents. ^ Purpose. This study examines the cardiovascular risk factors in the South Asian immigrant community residing in Southwest Houston. This study also explores the level of health insurance available to the South Asian in Houston. ^ Methods. One hundred sixty-two South Asian patients aged 18 years and older received cardiovascular screening from January 1 st, 2005 to March 31st, 2005 at Ibn Sina Community Clinic; blood pressure was measured twice in both arms after resting five minutes. Height and weight were also recorded. Demographic data was collected through personal interview (questionnaire) and blood samples were drawn to collect laboratory data. ^ Results. There were 162 eligible South Asian patients, among whom 127 (78%) participated in the study. There were no significant differences between the responders and the non-responders in terms of demographics and clinical characteristics. Laboratory data revealed a mean total cholesterol of 201 ± 34 mg/dl, 54 percent had high total cholesterol above 200 mg/dl. The mean fasting glucose was 108 ± 43 mg/dl, and body mass index (BMI) was 28 ± 4 kg/m2. The prevalence of hypertension was comparable with the general U.S. population; 38 percent of the South Asian males and 29 percent of females had hypertension. The prevalence of diabetes was also compared; 21 percent of SA males (3% for white American males) and 7 percent of SA females (2% for white American females) were found to have undiagnosed diabetes. Of the sample 12 percent had both hypertension and diabetes; 21 percent had both hypertension and high BMI, and 19 percent had hypertension and high total cholesterol levels. ^ Conclusion. The present study shows that the South Asians in this sample are at greater risk of developing cardiovascular diseases than other ethnicities. The high prevalence of hypertension, type 2 diabetes, higher total cholesterol levels with overweight and obesity, and less leisure time physical activity are important cardiovascular risk factors for South Asians population. ^

Safety, pharmacokinetics, and antiretroviral activity of multiple doses of ibalizumab (formerly TNX-355), an anti-CD4 monoclonal antibody in HIV-1 infected adults

Context: Despite tremendous strides in HIV treatment over the past decade, resistance remains a major problem. A growing number of patients develop resistance and require new therapies to suppress viral replication. ^ Objective: To assess the safety of multiple administrations of the anti-CD4 receptor (anti-CD4) monoclonal antibody ibalizumab given as intravenous (IV) infusions, in three dosage regimens, in subjects infected with human immunodeficiency virus (HIV-1). ^ Design: Phase 1, multi-center, open-label, randomized clinical trial comparing the safety, pharmacokinetics and antiviral activity of three dosages of ibalizumab. ^ Setting: Six clinical trial sites in the United States. ^ Participants: A total of twenty-two HIV-positive patients on no anti-retroviral therapy or a stable failing regimen. ^ Intervention: Randomized to one of two treatment groups in Arms A and B followed by non-randomized enrollment in Arm C. Patients randomized to Arm A received 10 mg/kg of ibalizumab every 7 days, for a total of 10 doses; patients randomized to Arm B received a total of six doses of ibalizumab; a single loading dose of 10 mg/kg on Day 1 followed by five maintenance doses of 6 mg/kg every 14 days, starting at Week 1. Patients assigned to Arm C received 25 mg/kg of ibalizumab every 14 days for a total of 5 doses. All patients were followed for safety for an additional 7 to 8 weeks. ^ Main Outcome Measures: Clinical and laboratory assessments of safety and tolerability of multiple administrations of ibalizumab in HIV-infected patients. Secondary measures of efficacy include HIV-1 RNA (viral load) measurements. ^ Results: 21 patients were treatment-experienced and 1 was naïve to HIV therapy. Six patients were failing despite therapy and 15 were on no current HIV treatment. Mean baseline viral load (4.78 log 10; range 3.7-5.9) and CD4+ cell counts (332/μL; range 89-494) were similar across cohorts. Mean peak decreases in viral load from baseline of 0.99 log10(1.11 log10, and 0.96 log 10 occurred by Wk 2 in Cohorts A, B and C, respectively. Viral loads decreased by >1.0 log10 in 64%; 4 patients viral loads were suppressed to < 400 copies/mL. Viral loads returned towards baseline by Week 9 with reduced susceptibility to ibalizumab. CD4+ cell counts rose transiently and returned toward baseline. Maximum median elevations above BL in CD4+ cell counts for Cohorts A, B and C were +257, +198 and +103 cells/μL, respectively and occurred within 3 Wks in 16 of 22 subjects. The half-life of ibalizumab was 3-3.5 days and elimination was characteristic of capacity-limited kinetics. Administration of ibalizumab was well tolerated. Four serious adverse events were reported during the study. None of these events were related to study drug. Headache, nausea and cough were the most frequently reported treatment emergent adverse events and there were no laboratory abnormalities related to study drug. ^ Conclusions: Ibalizumab administered either weekly or bi-weekly was safe, well tolerated, and demonstrated antiviral activity. Further studies with ibalizumab in combination with standard antiretroviral treatments are warranted.^

Case-control study of factors associated with virologic failure in HIV-infected children on HAART in Botswana, a developing African country

According to the United Nations Program on HIV/AIDS (UNAIDS, 2008), in 2007 about 67 per cent of all HIV-infected patients in the world were in Sub-Saharan Africa, with 35% of new infections and 38% of the AIDS deaths occurring in Southern Africa. Globally, the number of children younger than 15 years of age infected with HIV increased from 1.6 million in 2001 to 2.0 million in 2007 and almost 90% of these were in Sub-Saharan Africa. (UNAIDS, 2008).^ Both clinical and laboratory monitoring of children on Highly Active Anti-Retroviral Therapy (HAART) are important and necessary to optimize outcomes. Laboratory monitoring of HIV viral load and genotype resistance testing, which are important in patient follow-up to optimize treatment success, are both generally expensive and beyond the healthcare budgets of most developing countries. This is especially true for the impoverished Sub-Saharan African nations. It is therefore important to identify those factors that are associated with virologic failure in HIV-infected Sub-Saharan African children. This will inform practitioners in these countries so that they can predict which patients are more likely to develop virologic failure and therefore target the limited laboratory monitoring budgets towards these at-risk patients. The objective of this study was to examine those factors that are associated with virologic failure in HIV-infected children taking Highly Active Anti-retroviral Therapy in Botswana, a developing Sub-Saharan African country. We examined these factors in a Case-Control study using medical records of HIV-infected children and adolescents on HAART at the Botswana-Baylor Children's Clinical Center of Excellence (BBCCCOE) in Gaborone, Botswana. Univariate and Multivariate Regression Analyses were performed to identify predictors of virologic failure in these children.^ The study population comprised of 197 cases (those with virologic failure) and 544 controls (those with virologic success) with ages ranging from 3 months to 16 years at baseline. Poor adherence (pill count <95% on at least 3 consecutive occasions) was the strongest independent predictor of virologic failure (adjusted OR = 269.97, 95% CI = 104.13 to 699.92; P < 0.001). Other independent predictors of virologic failure identified were: First Line NNRTI with Nevirapine (OR = 2.99, 95% CI = 1.19 to7.54; P = 0.020), Baseline HIV-1 Viral Load >750,000/ml (OR = 257, 95% CI = 1.47 to 8.63; P = 0.005), Positive History of PMTCT (OR = 11.65, 95% CI = 3.04-44.57; P < 0.001), Multiple Care-givers (>=3) (OR = 2.56, 95% CI = 1.06 to 6.19; P = 0.036) and Residence in a Village (OR = 2.85, 95% CI = 1.36 to 5.97; P = 0.005).^ The results of this study may help to improve virologic outcomes and reduce the costs of caring for HIV-infected children in resource-limited settings. ^ Keywords: Virologic Failure, Highly Active Anti-Retroviral Therapy, Sub-Saharan Africa, Children, Adherence.^

Geotechnical properties of Lau Basin sediments

Distribution of pore space and degree of cementation appear to be the main factors controlling the permeability of sediments retrieved from the Lau Basin. The undisturbed microfabrics of two lithologies, nannofossil ooze and vitric sandy silt, commonly found at Holes 834A, 835A, 838A, and 839Aof Leg 135 were examined by scanning electron microscopy equipped with energy dispersive X-ray spectral analysis and image analysis systems. The results of these analyses were compared with laboratory determinations of porosity, grain-size distribution, and permeability on discrete samples from the same sediment depths. The permeability of the vitric sandy silt is 3-5 orders of magnitude higher than the nannofossil ooze samples. The porosity of nannofossil ooze ranges from 6% to 12% greater than the porosity of vitric sandy silt, which partially reflects the finer texture of nannofossil ooze. Although the correlation of higher porosity with lower permeability is not surprising, factors other than simply grain-size distribution must be invoked to explain the large differences in permeability found in these samples.

Fertilization Management: Assessing New Techniques and Key Interactions to Increase Crop Yields With Less N2O Emissions

El óxido nitroso (N2O) es un potente gas de efecto invernadero (GHG) proveniente mayoritariamente de la fertilización nitrogenada de los suelos agrícolas. Identificar estrategias de manejo de la fertilización que reduzcan estas emisiones sin suponer un descenso de los rendimientos es vital tanto a nivel económico como medioambiental. Con ese propósito, en esta Tesis se han evaluado: (i) estrategias de manejo directo de la fertilización (inhibidores de la nitrificación/ureasa); y (ii) interacciones de los fertilizantes con (1) el manejo del agua, (2) residuos de cosecha y (3) diferentes especies de plantas. Para conseguirlo se llevaron a cabo meta-análisis, incubaciones de laboratorio, ensayos en invernadero y experimentos de campo. Los inhibidores de la nitrificación y de la actividad ureasa se proponen habitualmente como medidas para reducir las pérdidas de nitrógeno (N), por lo que su aplicación estaría asociada al uso eficiente del N por parte de los cultivos (NUE). Sin embargo, su efecto sobre los rendimientos es variable. Con el objetivo de evaluar en una primera fase su efectividad para incrementar el NUE y la productividad de los cultivos, se llevó a cabo un meta-análisis. Los inhibidores de la nitrificación dicyandiamide (DCD) y 3,4-dimetilepyrazol phosphate (DMPP) y el inhibidor de la ureasa N-(n-butyl) thiophosphoric triamide (NBPT) fueron seleccionados para el análisis ya que generalmente son considerados las mejores opciones disponibles comercialmente. Nuestros resultados mostraron que su uso puede ser recomendado con el fin de incrementar tanto el rendimiento del cultivo como el NUE (incremento medio del 7.5% y 12.9%, respectivamente). Sin embargo, se observó que su efectividad depende en gran medida de los factores medioambientales y de manejo de los estudios evaluados. Una mayor respuesta fue encontrada en suelos de textura gruesa, sistemas irrigados y/o en cultivos que reciben altas tasas de fertilizante nitrogenado. En suelos alcalinos (pH ≥ 8), el inhibidor de la ureasa NBPT produjo el mayor efecto. Dado que su uso representa un coste adicional para los agricultores, entender las mejores prácticas que permitan maximizar su efectividad es necesario para posteriormente realizar comparaciones efectivas con otras prácticas que incrementen la productividad de los cultivos y el NUE. En base a los resultados del meta-análisis, se seleccionó el NBPT como un inhibidor con gran potencial. Inicialmente desarrollado para reducir la volatilización de amoniaco (NH3), en los últimos años algunos investigadores han demostrado en estudios de campo un efecto mitigador de este inhibidor sobre las pérdidas de N2O provenientes de suelos fertilizados bajo condiciones de baja humedad del suelo. Dada la alta variabilidad de los experimentos de campo, donde la humedad del suelo cambia rápidamente, ha sido imposible entender mecanísticamente el potencial de los inhibidores de la ureasa (UIs) para reducir emisiones de N2O y su dependencia con respecto al porcentaje de poros llenos de agua del suelo (WFPS). Por lo tanto se realizó una incubación en laboratorio con el propósito de evaluar cuál es el principal mecanismo biótico tras las emisiones de N2O cuando se aplican UIs bajo diferentes condiciones de humedad del suelo (40, 60 y 80% WFPS), y para analizar hasta qué punto el WFPS regula el efecto del inhibidor sobre las emisiones de N2O. Un segundo UI (i.e. PPDA) fue utilizado para comparar el efecto del NBPT con el de otro inhibidor de la ureasa disponible comercialmente; esto nos permitió comprobar si el efecto de NBPT es específico de ese inhibidor o no. Las emisiones de N2O al 40% WFPS fueron despreciables, siendo significativamente más bajas que las de todos los tratamientos fertilizantes al 60 y 80% WFPS. Comparado con la urea sin inhibidor, NBPT+U redujo las emisiones de N2O al 60% WFPS pero no tuvo efecto al 80% WFPS. La aplicación de PPDA incrementó significativamente las emisiones con respecto a la urea al 80% WFPS mientras que no se encontró un efecto significativo al 60% WFPS. Al 80% WFPS la desnitrificación fue la principal fuente de las emisiones de N2O en todos los tratamientos mientras que al 60% tanto la nitrificación como la desnitrificación tuvieron un papel relevante. Estos resultados muestran que un correcto manejo del NBPT puede suponer una estrategia efectiva para mitigar las emisiones de N2O. Con el objetivo de trasladar nuestros resultados de los estudios previos a condiciones de campo reales, se desarrolló un experimento en el que se evaluó la efectividad del NBPT para reducir pérdidas de N y aumentar la productividad durante un cultivo de cebada (Hordeum vulgare L.) en secano Mediterráneo. Se determinó el rendimiento del cultivo, las concentraciones de N mineral del suelo, el carbono orgánico disuelto (DOC), el potencial de desnitrificación, y los flujos de NH3, N2O y óxido nítrico (NO). La adición del inhibidor redujo las emisiones de NH3 durante los 30 días posteriores a la aplicación de urea en un 58% y las emisiones netas de N2O y NO durante los 95 días posteriores a la aplicación de urea en un 86 y 88%, respectivamente. El uso de NBPT también incrementó el rendimiento en grano en un 5% y el consumo de N en un 6%, aunque ninguno de estos incrementos fue estadísticamente significativo. Bajo las condiciones experimentales dadas, estos resultados demuestran el potencial del inhibidor de la ureasa NBPT para mitigar las emisiones de NH3, N2O y NO provenientes de suelos arables fertilizados con urea, mediante la ralentización de la hidrólisis de la urea y posterior liberación de menores concentraciones de NH4 + a la capa superior del suelo. El riego por goteo combinado con la aplicación dividida de fertilizante nitrogenado disuelto en el agua de riego (i.e. fertirriego por goteo) se considera normalmente una práctica eficiente para el uso del agua y de los nutrientes. Algunos de los principales factores (WFPS, NH4 + y NO3 -) que regulan las emisiones de GHGs (i.e. N2O, CO2 y CH4) y NO pueden ser fácilmente manipulados por medio del fertirriego por goteo sin que se generen disminuciones del rendimiento. Con ese propósito se evaluaron opciones de manejo para reducir estas emisiones en un experimento de campo durante un cultivo de melón (Cucumis melo L.). Los tratamientos incluyeron distintas frecuencias de riego (semanal/diario) y tipos de fertilizantes nitrogenados (urea/nitrato cálcico) aplicados por fertirriego. Fertirrigar con urea en lugar de nitrato cálcico aumentó las emisiones de N2O y NO por un factor de 2.4 y 2.9, respectivamente (P < 0.005). El riego diario redujo las emisiones de NO un 42% (P < 0.005) pero aumentó las emisiones de CO2 un 21% (P < 0.05) comparado con el riego semanal. Analizando el Poder de Calentamiento global en base al rendimiento así como los factores de emisión del NO, concluimos que el fertirriego semanal con un fertilizante de tipo nítrico es la mejor opción para combinar productividad agronómica con sostenibilidad medioambiental en este tipo de agroecosistemas. Los suelos agrícolas en las áreas semiáridas Mediterráneas se caracterizan por su bajo contenido en materia orgánica y bajos niveles de fertilidad. La aplicación de residuos de cosecha y/o abonos es una alternativa sostenible y eficiente desde el punto de vista económico para superar este problema. Sin embargo, estas prácticas podrían inducir cambios importantes en las emisiones de N2O de estos agroecosistemas, con impactos adicionales en las emisiones de CO2. En este contexto se llevó a cabo un experimento de campo durante un cultivo de cebada (Hordeum vulgare L.) bajo condiciones Mediterráneas para evaluar el efecto de combinar residuos de cosecha de maíz con distintos inputs de fertilizantes nitrogenados (purín de cerdo y/o urea) en estas emisiones. La incorporación de rastrojo de maíz incrementó las emisiones de N2O durante el periodo experimental un 105%. Sin embargo, las emisiones de NO se redujeron significativamente en las parcelas enmendadas con rastrojo. La sustitución parcial de urea por purín de cerdo redujo las emisiones netas de N2O un 46 y 39%, con y sin incorporación de residuo de cosecha respectivamente. Las emisiones netas de NO se redujeron un 38 y un 17% para estos mismos tratamientos. El ratio molar DOC:NO3 - demostró predecir consistentemente las emisiones de N2O y NO. El efecto principal de la interacción entre el fertilizante nitrogenado y el rastrojo de maíz se dio a los 4-6 meses de su aplicación, generando un aumento del N2O y una disminución del NO. La sustitución de urea por purín de cerdo puede considerarse una buena estrategia de manejo dado que el uso de este residuo orgánico redujo las emisiones de óxidos de N. Los pastos de todo el mundo proveen numerosos servicios ecosistémicos pero también suponen una importante fuente de emisión de N2O, especialmente en respuesta a la deposición de N proveniente del ganado mientras pasta. Para explorar el papel de las plantas como mediadoras de estas emisiones, se analizó si las emisiones de N2O dependen de la riqueza en especies herbáceas y/o de la composición específica de especies, en ausencia y presencia de una deposición de orina. Las hipótesis fueron: 1) las emisiones de N2O tienen una relación negativa con la productividad de las plantas; 2) mezclas de cuatro especies generan menores emisiones que monocultivos (dado que su productividad será mayor); 3) las emisiones son menores en combinaciones de especies con distinta morfología radicular y alta biomasa de raíz; y 4) la identidad de las especies clave para reducir el N2O depende de si hay orina o no. Se establecieron monocultivos y mezclas de dos y cuatro especies comunes en pastos con rasgos funcionales divergentes: Lolium perenne L. (Lp), Festuca arundinacea Schreb. (Fa), Phleum pratense L. (Php) y Poa trivialis L. (Pt), y se cuantificaron las emisiones de N2O durante 42 días. No se encontró relación entre la riqueza en especies y las emisiones de N2O. Sin embargo, estas emisiones fueron significativamente menores en ciertas combinaciones de especies. En ausencia de orina, las comunidades de plantas Fa+Php actuaron como un sumidero de N2O, mientras que los monocultivos de estas especies constituyeron una fuente de N2O. Con aplicación de orina la comunidad Lp+Pt redujo (P < 0.001) las emisiones de N2O un 44% comparado con los monocultivos de Lp. Las reducciones de N2O encontradas en ciertas combinaciones de especies pudieron explicarse por una productividad total mayor y por una complementariedad en la morfología radicular. Este estudio muestra que la composición de especies herbáceas es un componente clave que define las emisiones de N2O de los ecosistemas de pasto. La selección de combinaciones de plantas específicas en base a la deposición de N esperada puede, por lo tanto, ser clave para la mitigación de las emisiones de N2O. ABSTRACT Nitrous oxide (N2O) is a potent greenhouse gas (GHG) directly linked to applications of nitrogen (N) fertilizers to agricultural soils. Identifying mitigation strategies for these emissions based on fertilizer management without incurring in yield penalties is of economic and environmental concern. With that aim, this Thesis evaluated: (i) the use of nitrification and urease inhibitors; and (ii) interactions of N fertilizers with (1) water management, (2) crop residues and (3) plant species richness/identity. Meta-analysis, laboratory incubations, greenhouse mesocosm and field experiments were carried out in order to understand and develop effective mitigation strategies. Nitrification and urease inhibitors are proposed as means to reduce N losses, thereby increasing crop nitrogen use efficiency (NUE). However, their effect on crop yield is variable. A meta-analysis was initially conducted to evaluate their effectiveness at increasing NUE and crop productivity. Commonly used nitrification inhibitors (dicyandiamide (DCD) and 3,4-dimethylepyrazole phosphate (DMPP)) and the urease inhibitor N-(n-butyl) thiophosphoric triamide (NBPT) were selected for analysis as they are generally considered the best available options. Our results show that their use can be recommended in order to increase both crop yields and NUE (grand mean increase of 7.5% and 12.9%, respectively). However, their effectiveness was dependent on the environmental and management factors of the studies evaluated. Larger responses were found in coarse-textured soils, irrigated systems and/or crops receiving high nitrogen fertilizer rates. In alkaline soils (pH ≥ 8), the urease inhibitor NBPT produced the largest effect size. Given that their use represents an additional cost for farmers, understanding the best management practices to maximize their effectiveness is paramount to allow effective comparison with other practices that increase crop productivity and NUE. Based on the meta-analysis results, NBPT was identified as a mitigation option with large potential. Urease inhibitors (UIs) have shown to promote high N use efficiency by reducing ammonia (NH3) volatilization. In the last few years, however, some field researches have shown an effective mitigation of UIs over N2O losses from fertilized soils under conditions of low soil moisture. Given the inherent high variability of field experiments where soil moisture content changes rapidly, it has been impossible to mechanistically understand the potential of UIs to reduce N2O emissions and its dependency on the soil water-filled pore space (WFPS). An incubation experiment was carried out aiming to assess what is the main biotic mechanism behind N2O emission when UIs are applied under different soil moisture conditions (40, 60 and 80% WFPS), and to analyze to what extent the soil WFPS regulates the effect of the inhibitor over N2O emissions. A second UI (i.e. PPDA) was also used aiming to compare the effect of NBPT with that of another commercially available urease inhibitor; this allowed us to see if the effect of NBPT was inhibitor-specific or not. The N2O emissions at 40% WFPS were almost negligible, being significantly lower from all fertilized treatments than that produced at 60 and 80% WFPS. Compared to urea alone, NBPT+U reduced the N2O emissions at 60% WFPS but had no effect at 80% WFPS. The application of PPDA significantly increased the emissions with respect to U at 80% WFPS whereas no significant effect was found at 60% WFPS. At 80% WFPS denitrification was the main source of N2O emissions for all treatments. Both nitrification and denitrification had a determinant role on these emissions at 60% WFPS. These results suggest that adequate management of the UI NBPT can provide, under certain soil conditions, an opportunity for N2O mitigation. We translated our previous results to realistic field conditions by means of a field experiment with a barley crop (Hordeum vulgare L.) under rainfed Mediterranean conditions in which we evaluated the effectiveness of NBPT to reduce N losses and increase crop yields. Crop yield, soil mineral N concentrations, dissolved organic carbon (DOC), denitrification potential, NH3, N2O and nitric oxide (NO) fluxes were measured during the growing season. The inclusion of the inhibitor reduced NH3 emissions in the 30 d following urea application by 58% and net N2O and NO emissions in the 95 d following urea application by 86 and 88%, respectively. NBPT addition also increased grain yield by 5% and N uptake by 6%, although neither increase was statistically significant. Under the experimental conditions presented here, these results demonstrate the potential of the urease inhibitor NBPT in abating NH3, N2O and NO emissions from arable soils fertilized with urea, slowing urea hydrolysis and releasing lower concentrations of NH4 + to the upper soil layer. Drip irrigation combined with split application of N fertilizer dissolved in the irrigation water (i.e. drip fertigation) is commonly considered best management practice for water and nutrient efficiency. Some of the main factors (WFPS, NH4 + and NO3 -) regulating the emissions of GHGs (i.e. N2O, carbon dioxide (CO2) and methane (CH4)) and NO can easily be manipulated by drip fertigation without yield penalties. In this study, we tested management options to reduce these emissions in a field experiment with a melon (Cucumis melo L.) crop. Treatments included drip irrigation frequency (weekly/daily) and type of N fertilizer (urea/calcium nitrate) applied by fertigation. Crop yield, environmental parameters, soil mineral N concentrations, N2O, NO, CH4, and CO2 fluxes were measured during the growing season. Fertigation with urea instead of calcium nitrate increased N2O and NO emissions by a factor of 2.4 and 2.9, respectively (P < 0.005). Daily irrigation reduced NO emissions by 42% (P < 0.005) but increased CO2 emissions by 21% (P < 0.05) compared with weekly irrigation. Based on yield-scaled Global Warming Potential as well as NO emission factors, we conclude that weekly fertigation with a NO3 --based fertilizer is the best option to combine agronomic productivity with environmental sustainability. Agricultural soils in semiarid Mediterranean areas are characterized by low organic matter contents and low fertility levels. Application of crop residues and/or manures as amendments is a cost-effective and sustainable alternative to overcome this problem. However, these management practices may induce important changes in the nitrogen oxide emissions from these agroecosystems, with additional impacts on CO2 emissions. In this context, a field experiment was carried out with a barley (Hordeum vulgare L.) crop under Mediterranean conditions to evaluate the effect of combining maize (Zea mays L.) residues and N fertilizer inputs (organic and/or mineral) on these emissions. Crop yield and N uptake, soil mineral N concentrations, dissolved organic carbon (DOC), denitrification capacity, N2O, NO and CO2 fluxes were measured during the growing season. The incorporation of maize stover increased N2O emissions during the experimental period by c. 105 %. Conversely, NO emissions were significantly reduced in the plots amended with crop residues. The partial substitution of urea by pig slurry reduced net N2O emissions by 46 and 39 %, with and without the incorporation of crop residues respectively. Net emissions of NO were reduced 38 and 17 % for the same treatments. Molar DOC:NO3 - ratio was found to be a robust predictor of N2O and NO fluxes. The main effect of the interaction between crop residue and N fertilizer application occurred in the medium term (4-6 month after application), enhancing N2O emissions and decreasing NO emissions as consequence of residue incorporation. The substitution of urea by pig slurry can be considered a good management strategy since N2O and NO emissions were reduced by the use of the organic residue. Grassland ecosystems worldwide provide many important ecosystem services but they also function as a major source of N2O, especially in response to N deposition by grazing animals. In order to explore the role of plants as mediators of these emissions, we tested whether and how N2O emissions are dependent on grass species richness and/or specific grass species composition in the absence and presence of urine deposition. We hypothesized that: 1) N2O emissions relate negatively to plant productivity; 2) four-species mixtures have lower emissions than monocultures (as they are expected to be more productive); 3) emissions are lowest in combinations of species with diverging root morphology and high root biomass; and 4) the identity of the key species that reduce N2O emissions is dependent on urine deposition. We established monocultures and two- and four-species mixtures of common grass species with diverging functional traits: Lolium perenne L. (Lp), Festuca arundinacea Schreb. (Fa), Phleum pratense L. (Php) and Poa trivialis L. (Pt), and quantified N2O emissions for 42 days. We found no relation between plant species richness and N2O emissions. However, N2O emissions were significantly reduced in specific plant species combinations. In the absence of urine, plant communities of Fa+Php acted as a sink for N2O, whereas the monocultures of these species constituted a N2O source. With urine application Lp+Pt plant communities reduced (P < 0.001) N2O emissions by 44% compared to monocultures of Lp. Reductions in N2O emissions by species mixtures could be explained by total biomass productivity and by complementarity in root morphology. Our study shows that plant species composition is a key component underlying N2O emissions from grassland ecosystems. Selection of specific grass species combinations in the context of the expected nitrogen deposition regimes may therefore provide a key management practice for mitigation of N2O emissions.

Sobre la forma de garantizar la trazabilidad metrológica en los sistemas hospitalarios

Dentro del equipamiento que existen en los hospitales, se realizan muy diversas actuaciones para el correcto funcionamiento de los equipos que se destinan, tanto a medir sobre el paciente o para tratamiento sobre estos mismos, el abanico de equipos que existen es muy grande, sin contar con los que directamente se instalan o, más correctamente, se implantan en el paciente. Los hospitales tienen establecidas pautas de mantenimiento tanto correctivo como preventivo, también de verificación relativa a seguridad y, en algunos casos, acciones que van destinadas a comprobar las magnitudes en los equipos. Esto último no es lo normal, de hecho, en muchos casos, la mayoría, se desconoce cómo poder comprobar que las magnitudes de un equipo se pueden trazar a un patrón de medida nacional. La investigación se ha desarrollado para determinar, siendo algo que esta patente hasta en la normalización ISO, que no existen para muchos equipos principios establecidos para garantizar la trazabilidad metrológica da las magnitudes físicas en las que trabaja durante su vida útil. Debido a la amplitud de este campo, el desarrollo de investigación se ha llevado en un formato piramidal, desde las necesidades para poder llegar a un estudio concreto de equipos concretos (Termómetros Clínicos, Tensiómetros, Ultrasonidos y Onda Corta). Para llegar a estos se ha realizado un estudio de cómo se encuentra la trazabilidad metrológica en todo el espectro, desde la gestión hasta llegar a casos particulares. Estudiando la gran cantidad de documentación existente y llegando a determinar el campo de trabajo en la metrología hospitalaria, clasificando los equipos y determinando como se encuentran definidos los métodos que llevan a realidad la trazabilidad metrológica, en la normalización. Un grupo no muy trabajado de los equipos electromédicos son los que se encuentran dentro de los tratamientos de Rehabilitación de traumatología, siendo equipos de uso muy habitual en los centros de salud para las lesiones musculares y óseas. A este asunto se ha dedicado un esfuerzo extra, con un reporte histórico de su origen y en qué punto se encuentran ahora. Se han estudiado dentro de estos equipos los de tratamiento de ultrasonidos, de diatermia y onda corta, que son los más representativos de los equipos destinados a electro terapia, pero hay que tener en cuenta que hay campos que se han mencionado globalmente de la rehabilitación, como son la terapia o la biomecánica, de forma similar a otras tecnologías sanitarias de otras especialidades (radiología o análisis clínico). Hay, también, dentro de la terapia, todos esos tratamientos propios de gimnasio, como son poleas, pesas, mesas de masajes, balones, etc… Que su metrología es sencilla, son equipos que existen medios de comprobación de las magnitudes que utilizan por la existencia en otras actividades de la industria (balanzas, pesas, etc). La investigación realizada ha pretendido evaluar todo el global y llegar a casos concretos para determinar cómo está la situación. Llegando a desarrollar una clasificación de equipos y de normas, que permiten vislumbrar las necesidades metrológicas y permitiría establecer una Gestión de la Trazabilidad Metrológica, concluyendo en el estudio para los equipos que se han mencionado. ABSTRACT Within the equipment that exist in the hospitals, there are very diverse performances for the correct operation of the equipment that is intended both to measure on the patient or for treatment on these same, the range of equipment available is very large, without which directly are installed or, more correctly, are implanted in the patient. The hospitals have established patterns of maintenance both corrective and preventive, also of verification of security and, in some cases, actions which are intended to check the magnitudes in the equipment. This last is not normal, in fact, in many cases, the majority, it is not known as to be able to check that the magnitudes of a computer can be traced to a pattern of national measure. The research has been developed to determine, is something that this patent up to the International Organization for Standardization (ISO), that do not exist for many teams established principles to ensure the metrological traceability gives the physical quantities in which they work during its useful life. Due to the breadth of this field, the development of research has been conducted in a pyramid format, from the needs to be able to reach a specific study of specific equipment (Clinical Thermometers, Tensiometers, Ultrasound, and Short Wave). To reach theme, has been carried out a study of how is the metrological traceability across the entire spectrum, from the management to individuals cases. Considering the large amount of existing documentation and arriving to determine the labor camp in the metrology hospital, sorting equipment and determining how are defined the methods that lead to reality the metrological traceability, in the standardization. A group not too worked for medical electrical equipment are found within the rehabilitation treatment of traumatology, being equipment of very common use in the health centers for muscle injuries and bone. In this matter has been dedicated an extra effort, with a report history of its origin and where they are now. We have studied within these teams about the treatment of ultrasound, diathermy, short wave, which are the most representative of the equipment that is destined to electro therapy, but it must be borne in mind that there are fields that have been mentioned globally of rehabilitation, as are the therapy or the biomechanics, similar to other health technologies from other specialties (radiology or clinical analysis). There is, also, within the therapy, all these treatments own gym, such as pulleys, weights, tables of massages, balls, etc… that its metrology is simple, are computers that there are means of verification of the magnitudes that used by the existence in other activities of the industry (scales, weights, etc). The research carried out has tried to assess the entire global and reach specific cases to determine the situation as it is. Arriving in the development of a classification of equipment and standards, which give us a glimpse of the metrological needs and establish a Management of the Metrological Traceability, concluding in the study for computers that have been mentioned.

Estudo morfológico e eletrofisiológico dos efeitos da injeção intravítrea de ácido micofenólico em coelhos utilizando um modelo de uveíte crônica experimental

Uveítes são inflamações intra-oculares geralmente crônicas e constituem uma das principais causas de cegueira no mundo. Os corticosteroides são a droga de primeira escolha para o tratamento das uveítes não infecciosas, mas muitas vezes há necessidade do uso de outras drogas imunossupressoras. O micofenolato de mofetila (MMF) é um potente imunossupressor administrado por via oral que vem sendo utilizado com sucesso no tratamento das uveítes, mas cujos efeitos colaterais muitas vezes tornam necessária sua suspensão. O MMF é uma pró-droga, que é transformada no fígado em ácido micofenólico (MPA), o imunossupressor ativo. Para minimizar os efeitos colaterais do uso do MPA e permitir que o olho receba uma dose maior da droga, testamos os efeitos da injeção intravítrea do MPA em um modelo de uveíte crônica experimental (UCE) em olhos de coelhos. Os objetivos deste estudo foram: 1) reproduzir um modelo de UCE em coelhos através da injeção intravítrea de M. tuberculosis; 2) estabelecer uma dose segura de MPA a ser injetada no vítreo; e 3) analisar os efeitos morfológicos, clínicos e eletrofisiológicos da injeção intravítrea de MPA em coelhos utilizados como modelo de UCE. O modelo de UCE reproduzido apresentou uma inflamação autolimitada, possuindo um pico de inflamação no 17° dia após a indução da uveíte. As doses de MPA testadas (0,1 e 1mg) não foram toxicas para a retina do coelho. O modelo de UCE recebeu uma injeção intravítrea de 0,1mg de MPA e as análises clinicas demonstraram uma redução na inflamação. As análises realizadas com o eletrorretinograma (ERG) também apontaram uma melhora na inflamação através da recuperação da latência das ondas-a e b (fotópicas e escotópica) e recuperação da amplitude da onda-a (fotópica). As análises morfológicas com HE não apresentaram alterações na estrutura retinia, porem a imunohistoquimica para proteína GFAP evidenciou gliose das células de Müller, sinalizando um processo inflamatório. Concluímos que o modelo de UCE reproduziu uma uveíte anterior semelhante à uveíte causada em humanos e a dose de MPA utilizada apresentou efeitos terapêuticos durante o pico de inflamação, mostrando uma diminuição da inflamação e promovendo a recuperação de fotorreceptores e células bipolares-ON. Este resultado faz das injeções intravítreas de MPA um recurso promissor no tratamento de uveítes. Porém, novos experimentos são necessários para padronizar os resultados encontrados

Tumores indutores de osteomalácia: diagnóstico, caracterização tumoral e avaliação evolutiva em longo prazo de nove pacientes

INTRODUÇÃO: Tumores indutores de osteomalácia (TIOs) são raros, geralmente apresentam origem mesenquimal, têm produção excessiva de fosfatoninas sendo a mais comum o FGF23 (Fibroblast Growth Factor 23) que, em níveis elevados, provoca osteomalácia hipofosfatêmica. A cura dos TIOs envolve a remoção completa do tumor, o que torna essencial sua localização. OBJETIVOS: (1) caracterizar nove pacientes com TIO ao diagnóstico e avaliá-los evolutivamente em longo prazo; (2) avaliar a eficácia da cintilografia com Octreotida (Octreoscan®) e a da cintilografia de corpo inteiro com Mibi (MIBI) na detecção dos TIOs. MÉTODOS: O acompanhamento dos pacientes consistiu na avaliação clínica, na avaliação laboratorial com ênfase no metabolismo ósseo e na realização de exames de imagem para caracterização das deformidades esqueléticas. Para a localização dos TIOs, os pacientes foram submetidos a exames de Octreoscan®, MIBI, ressonância magnética (RM) e tomografia computadorizada (TC). RESULTADOS: O período de observação dos pacientes variou de dois a 25 anos. Ao diagnóstico, todos exibiam fraqueza muscular, dores ósseas e fraturas de fragilidade. Em relação à avaliação laboratorial, apresentavam: hipofosfatemia com taxa de reabsorção tubular de fosfato reduzida, fosfatase alcalina aumentada e níveis elevados de FGF23. O Octreoscan® permitiu a identificação dos TIOs nos nove pacientes e o MIBI possibilitou a localização dos TIOs em seis pacientes, sendo que ambos os exames foram concordantes entre si e com os exames topográficos (RM ou TC). Os achados histopatológicos das lesões dos nove pacientes confirmaram tratar-se de oito tumores mesenquimais fosfatúricos (PMTs) benignos e um PMT maligno. Após a primeira intervenção cirúrgica para a remoção dos TIOs, quatro pacientes encontram-se em remissão da doença e cinco evoluíram com persistência tumoral. Dos cinco, quatro foram reoperados e um aguarda nova cirurgia. Dos que foram reoperados, um paciente se mantém em remissão da doença, um foi a óbito por complicações clínicas, uma teve doença metastática e o último apresentou recidiva tumoral três anos após a segunda cirurgia. Deformidades ósseas graves foram observadas nos pacientes cujo diagnóstico e/ou tratamento clínico foram tardios. O tratamento da osteomalácia foi iniciado com fosfato e perdurou até a ressecção tumoral, tendo sido reintroduzido nos casos de persistência/recidiva tumoral. Quatro pacientes que fizerem uso regular desse medicamento por mais de seis anos evoluíram com hiperparatireoidismo terciário (HPT). CONCLUSÕES: O estudo revelou que tanto o Octreoscan® como o MIBI foram capazes de localizar os TIOs. Por isso, incentivamos a realização do MIBI nos locais onde o Octreoscan® não for disponível. Uma equipe experiente é indispensável para o sucesso cirúrgico visto que os tumores, embora benignos, costumam ser infiltrativos. Recomendamos o seguimento por tempo indeterminado em função do risco de recidiva tumoral. Assim como o FGF23, consideramos o fósforo um excelente marcador de remissão, persistência e recidiva dos TIOs. O diagnóstico e o tratamento precoce são fundamentais para a melhora dos sintomas podendo minimizar as deformidades esqueléticas e as sequelas ósseas. O uso prolongado do fosfato no tratamento da osteomalácia hipofosfatêmica foi associado ao desenvolvimento do HPT

Cistatina C : um marcador de função renal promissor em doentes com lúpus eritematoso sistémico?

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Manifestações extra-glandulares do síndrome de Sjögren primário - doença linfoproliferativa e vasculite : clínica, diagnóstico, tratamento e prognóstico : Caso clínico e revisão bibliográfica

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Suspected hexamine intoxication in a dog

An eight-month-old Labrador Retriever was presented with urinary incontinence and haematuria. Recent history suggested that the dog had access to solid fuel hexamine tablets, ingesting a dose of 6g/kg. Clinical signs, laboratory investigation and ultrasonographic findings were supportive of chemically-induced cystitis and a diagnosis of suspected hexamine intoxication was made. The dog recovered uneventfully and it is unlikely that the insult will be carcinogenic.

Active and passive immunization against oral Candida albicans infection in a murine model

Background/aims: Clinical and laboratory studies are consistent with a major role for cell-mediated immunity in recovery from oral infection with Candida albicans, but the role of humoral immunity remains controversial. The purpose of this study was to establish the relative contributions of cellular and humoral immunity to protection against oral candidiasis in a murine model, and to determine whether host responses could be enhanced by different immunization strategies. Results: Active oral immunization was protective in BALB/c and CBA/CaH mice, reducing both fungal burden and duration of infection after secondary challenge, whereas systemic immunization failed to protect against subsequent oral challenge. Candida-specific IgM was the predominant antibody detected in serum following both primary and secondary oral challenge; however, Candida-specific salivary IgA was not detectable. Immunization by passive transfer of either lymphocytes or immune serum did not confer any significant protection against oral infection in either susceptible or resistant mouse strain. Conclusion: The data demonstrate a possible role for mucosa-associated immunity following active immunization by the oral route, most likely exerted by local T lymphocytes resident in the oral mucosa, but there was no evidence to support a role for humoral immunity in protection against oral candidiasis.