Perfil imunológico de grávidas atópicas versus grávidas saudáveis

RESUMO: A prevalência das doenças atópicas tem vindo a aumentar, em especial ao nível dos países ocidentalizados. Vários fatores têm sido apontados para justificar este aumento de prevalência,destacando-se o reduzido tamanho das famílias, o elevado uso de antibióticos, a melhoria das condições sanitárias, bem como a diminuição quer das infeções de helmintas, quer da contaminação orofecal. Alguns estudos têm também avaliado a influência do ambiente pré-natal no desenvolvimento de atopia e asma. Da análise da literatura, parece inegável a importância deste período para o desenvolvimento do sistema imunitário. Neste âmbito, a transmissão de atopia à descendência em mulheres atópicas, e concretamente com asma alérgica, poderá ser moldada desde este período. A possibilidade de identificar marcadores de risco precoces para o desenvolvimento de atopia poderá ser o primeiro passo para o desenvolvimento de estratégias de prevenção para os indivíduos em risco. Este trabalho pretendeu abordar o sistema imunitário materno de forma a enriquecer a sua caraterização desde o terceiro trimestre da gravidez até ao fim do puerpério. Para além da exploração de perfis celulares e citocínicos maternos (nos quais se incluiu sobretudo a avaliação de diferentes populações de células T e B, com funções efetoras e reguladoras), foi também considerada a sua eventual relação com o desenvolvimento de atopia nas crianças. Foram recrutadas 135 mulheres com critérios para serem incluídas num dos 4 grupos do estudo: grávidas atópicas – GA (n=24), não grávidas atópicas – NGA (n=32), grávidas saudáveis – GS (n=44) e não grávidas saudáveis – NGS (n=35). Foram caraterizadas por Citometria de Fluxo populações de leucócitos e linfócitos, com particular interesse nos perfis maturativos de linfócitos T e B, bem como nas subpopulações de células T e B reguladoras. Foi ainda efetuada uma análise funcional, para avaliar a capacidade de produção de citocinas pelos linfócitos T e B. Foram igualmente avaliadas as concentrações de citocinas séricas por ensaios imunoenzimáticos. Estes parâmetros imunológicos maternos foram acompanhados desde o terceiro trimestre de gestação, até depois do puerpério (primeiras 6 semanas pós parto), e aos seis meses de idade, foi efetuada uma avaliação clínica das crianças. As mulheres não grávidas atópicas apresentaram contagens celulares mais elevadas para a generalidade das populações leucocitárias e linfocitárias (em relação a mulheres não grávidas saudáveis). Destaca-se ainda uma maior presença de eosinófilos nas mulheres NGA (p=0,0009; teste de Mann-Whitney U), que tinham igualmente os seus compartimentos linfocitários T e B mais ricos em células de memória, em relação às mulheres NGS. Para os perfis de regulação, verificou-se que as células T reguladoras se encontravam percentualmente aumentadas (p≤0,003; teste de Mann-Whitney U), tal omo as células T produtoras de IL10 após estimulação (p≤0,03; teste de Mann-Whitney U) em mulheres NGA. Também se observou uma maior expressão de Foxp3 (p=0,0002; teste de Mann-Whitney U), e ainda a diminuição dos níveis séricos de IFN-γ nas mulheres NGA (p=0,0019; teste de Mann-Whitney U), em relação a mulheres NGS. De um modo geral, as alterações verificadas nos parâmetros imunológicos de mulheres grávidas atópicas no terceiro trimestre da gravidez foram semelhantes às observadas em mulheres grávidas saudáveis. Comparadas com mulheres NGA, nas mulheres grávidas atópicas ocorreu uma alteração substancial da fórmula leucocitária, com um importante incremento de neutrófilos (p<0,0001; teste de Mann-Whitney U) e diminuição dos valores das restantes populações leucocitárias. A diminuição nas contagens de linfócitos totais estendeu-se a grande parte das subpopulações linfocitárias caraterizadas. Nos compartimentos linfocitários T e B foi possível observar uma diminuição das subpopulações de células de memória. Verificou-se igualmente na gravidez uma menor expressão de Foxp3 em mulheres GA (p<0,0001; teste de Mann-Whitney U) e ainda menos células B CD24HiCD38Hi circulantes (p=0,0012; teste de Mann-Whitney U). Ocrreu ainda uma diminuição relativa das células T CD4 produtoras de IFN-γ em mulheres GA (p≤0,024; teste de Mann-Whitney U), e uma maior presença de células T CD8 produtoras de IL17 (p=0,0172; teste de Mann-Whitney U), em relação ao observado em mulheres NGA. Depois do puerpério, no compartimento T de mulheres do grupo GA, verificou-se um aumento das populações de células de memória. Em comparação com a gravidez, após o puerpério o compartimento B, apresentou nas mulheres GA um aumento significativo da subpopulação de células B de transição (p<0,0001; teste de Wilcoxon). Verificou-se, igualmente em mulheres GA após o puerpério, uma maior expressão de Foxp3 nas células T reguladoras (p<0,0001; teste de Wilcoxon) e o aumento das populações de células T circulantes produtoras de IFN-γ (p≤0,0234; teste de Wilcoxon). As modulações das populações T e B desde a gravidez até depois do puerpério ocorreram de forma semelhante nas mulheres dos grupos GA e GS. Apesar de as mulheres GA manterem um perfil imunológico próximo do das mulheres GS depois do puerpério, aconteceu também neste período um processo de reaproximação ao perfil observado nas mulheres NGA. As mulheres GA com manifestações de risco para atopia na descendência (comparadas com mulheres GA sem manifestações de risco para atopia na descendência até aos 6 meses de vida) apresentaram uma maior proporção de células T e menor proporção de células B, percentagens mais elevadas de células T CD8 de memória efetoras, de células B de transição e de células B CD24HiCD38Hi, e contagens mais baixas de células B de memória. Na avaliação destes parâmetros como marcadores de risco para o desenvolvimento de atopia verificou-se que o parâmetro com melhor desempenho foi a percentagem de células B de transição, com uma Odds-Ratio de 54,0 [IC 95%: 4,2-692,9; (p=0,0005)], sensibilidade de 90,0% [IC 95%: 55,5 – 99,8] e especificidade de 85,7% [IC 95%: 57,2 – 98,2]. Este estudo foi pioneiro em Portugal, e no mundo, no que se refere ao acompanhamento do compartimento linfocitário B circulante, abordando o seu perfil de maturação, e em particular as células B com funções reguladoras, desde a gravidez até ao fim do puerpério, em mulheres atópicas e não atópicas. A este nível, encontram-se estudos na literatura a documentar a alteração do compartimento B durante a gravidez. O presente trabalho reporta agora que alterações, como a diminuição do número de células B em circulação, são impostas também na mulher atópica. Em suma, demonstrou-se a existência de um perfil imunológico caraterístico em mulheres atópicas, que sofre alterações significativas durante a gravidez, tendendo os parâmetros imunológicos a normalizar após o puerpério. O compartimento T, para o qual a literatura é mais rica em estudos e abordagens, demonstrou também neste trabalho oscilações caraterísticas entre o período pré e pós-natal. Verificaram-se sobretudo variações nos compartimentos de células T de memória, sem grandes alterações ao nível das células Treg no que se refere à sua presença em circulação. Apenas a registar a menor expressão de Foxp3 nas células Treg durante a gestação observada em mulheres atópicas, tal como em mulheres saudáveis (como também já foi relatado em estudos anteriores). Apesar de muitos dos dados se encontrarem em concordância com a literatura, quer no que se refere às subpopulações de células de memória, quer no que se refere às células Treg, também se encontram resultados discordantes, por exemplo documentando variações numéricas nas células Treg em circulação em mulheres atópicas e mulheres atópicas grávidas. A importância de harmonizar protocolos e fenótipos, parece crucial na abordagem de estudos futuros. Ao nível do risco para a atopia na descendência de mulheres atópicas, acrescentou-se ainda a possibilidade de definir marcadores não invasivos para a criança, em particular as células B de transição. Estas células, cuja maior presença em circulação no recém-nascido foi recentemente associada com manifestações alérgicas subsequentes, são agora apontadas já na mulher atópica, grávida do terceiro trimestre, como um elemento de risco para o desenvolvimento de atopia. Os marcadores de risco descritos, para além de facilmente poderem vir a ser englobados no âmbito dos normais rastreios maternos durante a gravidez, apresentam ainda a vantagem da precocidade do diagnóstico, permitindo não só a possibilidade de prevenção pós-natal, mas estendendo esta possibilidade ao período gestacional.----------------------------ABSTRACT: The prevalence of atopic diseases has been increasing, especially in Westernized countries. Several factors have been suggested to justify this increase in prevalence, as the small size of families, the high use of antibiotics, the improvement in sanitation conditions, as well as the reduction of both helminth infections, and orofecal contamination. A few studies have adressed the influence of prenatal environment on the development of atopy and asthma. From literature, it seems undeniable the importance of the prenatal period for the development of the immune system. In this context, the transmission of atopy to the progeny in atopic women, and specifically in women with allergic asthma, can be modulated from this period on. The ability to detect early risk markers for the development of atopic diseases may be the first step in the development of prevention strategies for individuals at risk. This study aimed to approach the maternal immune system in order to enrich its characterization from the third trimester of pregnancy until the end of the puerperium period. In addition to the evaluation of the maternal cellular profiles (in which, mostly, diferente populations of T and B cells with effector and regulatory functions were included) and citokines, the relation between these profiles and the development of atopy in the progeny was also assessed. 135 women were recruited for this study, and fullfiled the inclusion criteria necessary to be included in one of the four groups preset: atopic pregnant women - GA (n = 24), atopic nonpregnant women - NGA (n = 32), healthy pregnant women - GS (n = 44) and healthy nonpregnant women - NGS (n = 35). Populations of leukocytes and lymphocytes, and particularty maturation profiles of T and B lymphocytes, as well as subpopulations of T and B cells with regulatory functions, were characterized by flow cytometry. Functional assays were also performed, to assess the ability of cytokine production by T and B lymphocytes. Serum cytokine concentrations were assessed as well by enzymatic immunoassays. These maternal imune parameters were monitored since the third trimester of pregnancy until the end of the puerperium period (first six weeks after delivery). A clinical evaluation of all the newborn children was performed at the age of six months. Non-atopic pregnant women presented higher cell counts for most leukocyte and lymphocyte populations (compared to healthy non-pregnant women). We should also highlight the increased presence of eosinophils in NGA women (p = 0,0009; Mann-Whitney U test). Again compared to NGS women, NGA women showed increased memory cells within the circulating T and B lymphocyte compartments. Considering the regulatory profiles, NGA women presented higher percentages of regulatory T cells (p≤0,003; Mann-Whitney U test) and IL10 producing T cells after stimulation (p≤0,03; Mann Whitney U), as well as increased expression of Foxp3 (p = 0,0002; Mann-Whitney U test), and also decreased serum levels of IFN-γ (p = 0,0019; test Mann-Whitney U test) compared to NGS women. In general, the changes observed in immune parameters of atopic pregnant women in the third trimester of gestation were similar to those observed in healthy pregnant women. Comparing pregnant and non-pregnant atopic women, an important change in leukocyte subsets was observed, with a significant increase of neutrophils (p <0,0001; Mann-Whitney U test) and the consequent diminution of the remaining leukocyte populations in the GA group. The decrease in total lymphocyte counts was extended to most of the lymphocyte subsets characterized. It was possible to detect a decrease in memory cell subsets within the T and B lymphocyte compartments, also. During pregnancy, a lower expression of Foxp3 was reported in GA women (p <0,0001; Mann-Whitney U test) and, besides, lesser CD24HiCD38Hi B cells were present in circulation in these women, compared to NGA women (p = 0,0012; Mann-Whitney U test). There was still a decrease in the percentages of IFN-γ-producing CD4 T cells in GA women (p≤0,024; Mann-Whitney U test) and a greater presence of IL17-producing CD8 T cells (p = 0,0172; Mann-Whitney U test), compared to the levels observed in NGA women. At the end of the puerperium, there was an increase in memory cell subpopulations within the T cell compartment of GA women. Compared with the pregnancy evaluation, after puerperium, the B cell compartment showed a significant increase in the transitional subpopulation (p<0,0001; Wilcoxon test), in GA women. Moreover, after puerperium, GA women exhibited a greater expression of Foxp3 in Treg cells (p <0,0001; Wilcoxon test) and there was an increase in circulating IFN-γ-producing T cells (p≤0,0234; Test Wilcoxon). The modulations of T and B cell subpopulations from pregnancy until the end of puerperium were similar in women of GA and GS groups. Although at the end of puerperium, GA women still kept an immune profile close the one observed in GS women, at this time point, there were also signs of rapprochement between the immune profiles observed in women of GA and NGA groups. GA women with atopic manifestations in the offspring (compared to GA women without atopic manifestations in the offspring at the age of 6 months) presented higher proportions of T cells and lower proportions of B cells, higher percentages of effector memory CD8 T cells, transitional B cells and CD24HiCD38Hi B cells, and, finally, lower absolute counts of memory B cells. In the evaluation of these parameters as risk markers for the development of atopy, the parameter which presented the best performance was the percentage of transitional B cells, with an Oddsratio of 54,0 [95% CI: 4,2 to 692,9; (p = 0,0005)], sensitivity of 90,0% [95% CI: 55,5 to 99,8] and a specificity of 85,7% [95% CI: 57,2 to 98,2]. This study was a pioneer in Portugal, and in the world, in what concerns the monitoring of the circulating B cell compartment, addressing not only the maturation profile, but, in particular, B cells with regulatory functions, from pregnancy untill after puerperium, in atopic and non-atopic women. Literature presents evidence of a typical change in circulating B cells during pregnancy. This study now reports that changes, such as the decrease in the number of circulating B cells,/ are also imposed by pregnancy in atopic woman. In brief, it demonstrated the existence of a characteristic immune profile in atopic women, which undergoes significant alterations during pregnancy, tending to normalize after the puerperium. As for the T cell compartment, for which the literature is richer in studies and approaches, this study also showed characteristic fluctuations between the pre- and postnatal periods. There were variations mostly in the memory subsets within the T cell compartment, without major changes in regulatory T cells regarding their presence in circulation. Only the expression of Foxp3 in Treg cells presented lower levels during pregnancy, in both atopic and healthy women (as previously reported in other studies). Although much of the data now reported are in agreement with literature, regarding either memory cell subsets or regulatory T cells, there are also conflicting results, for example documenting changes in the numbers of regulatory T cells circulating in atopic pregnant and atopic non-pregnant women. The importance of harmonizing protocols and phenotypes seems crucial for the establishement of future studies. Considering the risk for atopy in the offspring of atopic women, this study added the possibility to define non-invasive markers for the child, in particular transitional B cells. These cells, whose greater presence in circulation in newborns has recently been associated with subsequent allergy development, are here identified in atopic pregnant women in the third trimester of gestation as a risk factor in the development of atopy in their progeny. The risk factors described, besides having the capacity to easily become integrated within the normal maternal screening protocols during pregnancy, also have the advantage of an early diagnosis, allowing not only the possibility of postnatal prevention but extending this possibility to the prenatal period.

Development of sandwich panels of customized functionalities for the rehabilitation of the built patrimony

Considering that the future of the construction sector in most European countries will mainly lie in the renovation of the existing building stock, in the next coming years thousands of energy inefficient buildings will need renovation to force EU member states to reach the EU 2020 targets and implement the Energy Performance of Buildings Directive (EPBD). Seeing the actual crisis in the construction sector as an opportunity, this work aims to develop a concept for prefabricated customizable sandwich panels for the multifunctional renovation of buildings, focusing also on technological innovation. More than a conventional solution, this proposal aims to combine sustainable and recycled building materials, available technologies and systems with advanced design and manufacturing tools within an integrated and mass-customizable approach of advanced building renovation prefabricated solutions. The adoption of these new proposed solutions would improve the living standards of the inhabitants of our cities, reducing energy inefficiency and other existing construction/renovation problems, while enabling some advanced features like the incorporation of technical modules that could even monitor the building performance during its full lifetime and the living conditions of its occupants.

Cross-language influences on new second language vocabulary acquisition: the effect of learning method

Dissertação de mestrado integrado em Psicologia

Cross-scale determinants of palm species distribution

We investigate palm species distribution, richness and abundance along the Mokoti, a seasonally-dry river of southeastern Amazon and compare it to the patterns observed at a large scale, comprising the entire Brazilian territory. A total of 694 palms belonging to 10 species were sampled at the Mokoti River basin. Although the species showed diverse distribution patterns, we found that local palm abundance, richness and tree basal area were significantly higher from the hills to the bottomlands of the study region, revealing a positive association of these measures with moisture. The analyses at the larger spatial scale also showed a strong influence of vapor pressure (a measure of moisture content of the air, in turn modulated by temperature) and seasonality in temperature: the richest regions were those where temperature and humidity were simultaneously high, and which also presented a lower degree of seasonality in temperature. These results indicate that the distribution of palms seems to be strongly associated with climatic variables, supporting the idea that, by 'putting all the eggs in one basket' (a consequence of survival depending on the preservation of a single irreplaceable bud), palms have become vulnerable to extreme environmental conditions. Hence, their distribution is concentrated in those tropical and sub-tropical regions with constant conditions of (mild to high) temperature and moisture all year round.

The role of deviant-letter position in cognate word processing

Dissertação de mestrado integrado em Psicologia

Thermal–mechanical behaviour of chitosan–cellulose derivative thermoreversible hydrogel films

CH, Chitosan; HPMC, (Hydroxypropyl)methyl cellulose; FT, Freeze-thaw; SC, Solvent casting; CH:HPMC (X:Y), pH Z, FT/SC, Chitosan and (hydroxypropyl)methyl cellulose hydrogel, at X and Y proportion (0-100), at Z pH (3.0-4.0) and prepared by freeze-thaw or solvent casting techniques; DSC, Differential scanning calorimetry; MDSC, Temperature modulated Differential scanning calorimetry; Tg, glass transition temperature; ΔH, enthalpy change; TGA, Thermogravimetric Analysis; TG, Thermogravimetry; DTG, Derivative or Differential thermogravimetry; σ, Tensile strength; ε, elongation at break; DMA, Dynamic mechanical analysis; X-Ray, X-radiation, FTIR-ATR, Attenuated total reflectance Fourier transform infrared spectroscopy; SEM, Scanning electron microscopy.

Erratum to: Thermal–mechanical behaviour of chitosan–cellulose derivative thermoreversible hydrogel films

CH, Chitosan; HPMC, (Hydroxypropyl)methyl cellulose; FT, Freeze-thaw; SC, Solvent casting; CH:HPMC (X:Y), pH Z, FT/SC, Chitosan and (hydroxypropyl)methyl cellulose hydrogel, at X and Y proportion (0-100), at Z pH (3.0-4.0) and prepared by freeze-thaw or solvent casting techniques; DSC, Differential scanning calorimetry; MDSC, Temperature modulated Differential scanning calorimetry; Tg, glass transition temperature; ΔH, enthalpy change; TGA, Thermogravimetric Analysis; TG, Thermogravimetry; DTG, Derivative or Differential thermogravimetry; σ, Tensile strength; ε, elongation at break; DMA, Dynamic mechanical analysis; X-Ray, X-radiation, FTIR-ATR, Attenuated total reflectance Fourier transform infrared spectroscopy; SEM, Scanning electron microscopy.

Enhancement of adhesion and promotion of osteogenic differentiation of human adipose stem cells by poled electroactive poly(vinylidene fluoride)

Poly(vinylidene fluoride) (PVDF) is a biocompatible material with excellent electroactive properties. Non-electroactive α-PVDF and electroactive β-PVDF were used to investigate the substrate polarization and polarity influence on the focal adhesion size and number as well as on human adipose stem cells (hASCs) differentiation. hASCs were cultured on different PVDF surfaces adsorbed with fibronectin and focal adhesion size and number, total adhesion area, cell size, cell aspect ratio and focal adhesion density were estimated using cells expressing EGFP-vinculin. Osteogenic differentiation was also determined using a quantitative alkaline phosphatase assay. The surface charge of the poled PVDF films (positive or negative) influenced the hydrophobicity of the samples, leading to variations in the conformation of adsorbed extracellular matrix (ECM) proteins, which ultimately modulated the stem cell adhesion on the films and induced their osteogenic differentiation.

Influência de filtros de ruído dinâmico na perceção das cores utilizando um novo teste de visão das cores

Dissertação de mestrado em Optometria Avançada

Atividade fotossintética do bago de uva (Vitis vinifera, cv. Alvarinho) ao longo do desenvolvimento dos cachos em diferentes microambientes de luz

Dissertação de mestrado em Biologia Molecular, Biotecnologia e Bioempreendedorismo em Plantas

Graphene-based nanostructures: Plasmonics in the THz range

The properties of surface plasmon-polaritons (SPPs) in graphene are discussed and several possible ways of coupling electromagnetic radiation in the terahertz (THz) spectral range to this type of surface waves are described: (i) the attenuated total reflection (ATR) method employing a prism, (ii) graphene-based gratings or graphene monolayers with modulated conductivity, (iii) a metal stripe on top of the graphene layer, and (iv) a nanoparticle located above it. Potentially interesting for applications SPP effects, such as switching, modulation and polarization of THz radiation, as well as its enhanced absorption in graphene, are considered. The discussion also concerns the impact of the nonlinear properties of graphene, such as optical bistability.

The influence of nitrogen and oxygen additions on the thermal characteristics of aluminium-based thin films

The ternary aluminium oxynitride (AlNxOy) system offers the possibility to obtain a wide range of properties by tailoring the ratio between pure Al, AlNx and AlOy and therefore opening a significant number of possible applications. In this work the thermal behaviour of AlNxOy thin films was analysed by modulated infrared radiometry (MIRR), taking as reference the binary AlOy and AlNx systems. MIRR is a non-contact and non-destructive thermal wave measurement technique based on the excitation, propagation and detection of temperature oscillations of very small amplitudes. The intended change of the partial pressure of the reactive gas (N2 and/or O2) influenced the target condition and hence the deposition characteristics which, altogether, affected the composition and microstructure of the films. Based on the MIRR measurements and their qualitative and quantitative interpretation, some correlations between the thermal transport properties of the films and their chemical/physical properties have been found. Furthermore, the potential of such technique applied in this oxynitride system, which present a wide range of different physical responses, is also discussed. The experimental results obtained are consistent with those reported in previous works and show a high potential to fulfil the demands needed for the possible applications of the systems studied. They are clearly indicative of an adequate thermal response if this particular thin film system is aimed to be applied in small sensor devices or in electrodes for biosignal acquisition, such as those for electroencephalography or electromyography as it is the case of the main research area that is being developed in the group.

Adipogenic cell sheets to recreate in vitro adipose tissue microenvironments

Cell sheet (CS) engineering, taking advantage of cellular self-matrix organized as in native tissue, has been largely explored, including by us, for different purposes [1â 3]. Herein we propose for the ï¬ rst time, the use of human adipose stem cells (hASCs)-derived CS to create adipose tissue analogues with different levels of maturation. hASCs were cultured on UpCellTM thermo-responsive dishes for 1, 3 and 5 days under basal conditions previously established by us [3]. The inï¬ uence of pre-differentiation time and respective cell number, over CS stability and differentiation was assessed. Mechanically robust CS were only obtained with 5 days pre-differentiation period. Adipogenesis was followed along the culture assessing the variation of expression of mesenchymal (CD73, CD105 but not CD90) and adipogenic (PPARg, FABP4 and LPL) markers by ï¬ ow cytometry, immunocytochemistry and RT-PCR. Increased ratio of differentiated cells was achieved for longer pre-differentiation periods, while maturation degree was modulated by the maintenance medium. Independently of the overall CS differentiation/maturation level, 3D constructs were fabricated by stacking and further culturing 3 CS. Thus, by varying the culture conditions, different 3D adipose tissue-like microenvironments were recreated, enabling future development of new tissue engineering strategies, as well as further study of adipose tissue role in the regeneration of different tissues.

Development of sandwich panels of customized functionalities for the rehabilitation of the built patrimony

Dissertação de International Master in Sustainable Built Environment

Antidepressant induced excessive yawning and indifference

Introduction Antidepressant induced excessive yawning has been described as a possible side effect of pharmacotherapy. A syndrome of indifference has also been described as another possible side effect. The frequency of those phenomena and their physiopathology are unknown. They are both considered benign and reversible after antidepressant discontinuation but severe cases with complications as temporomandibular lesions, have been described. Methods We report two unprecedented cases in which excessive yawning and indifference occurred simultaneously as side effects of antidepressant therapy, discussing possible physiopathological mechanisms for this co-occurrence. Case 1: A male patient presented excessive yawning (approximately 80/day) and apathy after venlafaxine XR treatment. Symptoms reduced after a switch to escitalopram, with a reduction to 50 yawns/day. Case 2: A female patient presented excessive yawning (approximately 25/day) and inability to react to environmental stressors with desvenlafaxine. Conclusion Induction of indifference and excessive yawning may be modulated by serotonergic and noradrenergic mechanisms. One proposal to unify these side effects would be enhancement of serotonin in midbrain, especially paraventricular and raphe nucleus.