Pronostic à long terme des patients ayant bénéficié d'une thrombolyse au stade aigu de l'infarctus du myocarde [Long-term prognosis for patients undergoing thrombolysis during the acute phase of myocardial infarction]

OBJECTIVE: The objective of this study was to analyse the long-term mortality and morbidity of a group of patients undergoing thrombolysis during the acute phase of myocardial infarction and to determine the factors influencing the prognosis. One hundred and seventy five patients (149 mean and 26 women, mean age: 54 years) were included in a randomized study, comparing the efficacy of 2 thrombolytic substances administered during the acute phase of myocardial infarction. A standard questionnaire was sent to the various attending physicians to follow-up of these 175 patients. RESULTS: The hospital mortality was 5% (9 patients) and 14 patients (9%) died after a mean follow-up of 4.3 +/- 2.1 years. The 5-year actuarial survival was 81%. Fourteen patients (8%) were lost to follow-up and 49 patients (32%) underwent surgical or percutaneous revascularization during follow-up. Revascularized patients had a significantly better survival than non-revascularized patients. The mean left ventricular ejection fraction of patients who died was lower (48% versus 71%) than that of survivors. Patients with an ejection fraction < 40% also had a significantly lower survival (p = 0.01). Patency of the vessel after thrombolysis was associated with a slightly better survival; this difference was not significant. The ejection fraction at 6 month was also significantly higher (60 +/- 10% versus 49 +/- 11%) for patients with a patent artery. Three risk factors for death or reinfarction were identified: age > 65 years at the time of infarction, disease in more than one coronary vessel and absence of angina pectoris before infarction. The probability of a coronary accident varied from 2 to 88% according to the number of risk factors present. At the time of follow-up, 60% of patients presented hypercholesterolaemia versus only 7% before infarction 73% of patients received anticoagulant or antiaggregant treatment and 81% of patients were asymptomatic. CONCLUSION: The mortality and the acute and long-term morbidity of myocardial infarction remain high, as only 34% of our patients did not develop any events during follow-up, despite serious medical management and follow-up. The ejection fraction has an important prognostic value. Patient management should take the abovementioned risk factors into account.

Effects of enteral carbohydrates on de novo lipogenesis in critically ill patients.

BACKGROUND: Conversion of glucose into lipid (de novo lipogenesis; DNL) is a possible fate of carbohydrate administered during nutritional support. It cannot be detected by conventional methods such as indirect calorimetry if it does not exceed lipid oxidation. OBJECTIVE: The objective was to evaluate the effects of carbohydrate administered as part of continuous enteral nutrition in critically ill patients. DESIGN: This was a prospective, open study including 25 patients nonconsecutively admitted to a medicosurgical intensive care unit. Glucose metabolism and hepatic DNL were measured in the fasting state or after 3 d of continuous isoenergetic enteral feeding providing 28%, 53%, or 75% carbohydrate. RESULTS: DNL increased with increasing carbohydrate intake (f1.gif" BORDER="0"> +/- SEM: 7.5 +/- 1.2% with 28% carbohydrate, 9.2 +/- 1.5% with 53% carbohydrate, and 19.4 +/- 3.8% with 75% carbohydrate) and was nearly zero in a group of patients who had fasted for an average of 28 h (1.0 +/- 0.2%). In multiple regression analysis, DNL was correlated with carbohydrate intake, but not with body weight or plasma insulin concentrations. Endogenous glucose production, assessed with a dual-isotope technique, was not significantly different between the 3 groups of patients (13.7-15.3 micromol * kg(-1) * min(-1)), indicating impaired suppression by carbohydrate feeding. Gluconeogenesis was measured with [(13)C]bicarbonate, and increased as the carbohydrate intake increased (from 2.1 +/- 0.5 micromol * kg(-1) * min(-1) with 28% carbohydrate intake to 3.7 +/- 0.3 micromol * kg(-1) * min(-1) with 75% carbohydrate intake, P: < 0. 05). CONCLUSION: Carbohydrate feeding fails to suppress endogenous glucose production and gluconeogenesis, but stimulates DNL in critically ill patients.

Genetic variation in GIPR influences the glucose and insulin responses to an oral glucose challenge.

Glucose levels 2 h after an oral glucose challenge are a clinical measure of glucose tolerance used in the diagnosis of type 2 diabetes. We report a meta-analysis of nine genome-wide association studies (n = 15,234 nondiabetic individuals) and a follow-up of 29 independent loci (n = 6,958-30,620). We identify variants at the GIPR locus associated with 2-h glucose level (rs10423928, beta (s.e.m.) = 0.09 (0.01) mmol/l per A allele, P = 2.0 x 10(-15)). The GIPR A-allele carriers also showed decreased insulin secretion (n = 22,492; insulinogenic index, P = 1.0 x 10(-17); ratio of insulin to glucose area under the curve, P = 1.3 x 10(-16)) and diminished incretin effect (n = 804; P = 4.3 x 10(-4)). We also identified variants at ADCY5 (rs2877716, P = 4.2 x 10(-16)), VPS13C (rs17271305, P = 4.1 x 10(-8)), GCKR (rs1260326, P = 7.1 x 10(-11)) and TCF7L2 (rs7903146, P = 4.2 x 10(-10)) associated with 2-h glucose. Of the three newly implicated loci (GIPR, ADCY5 and VPS13C), only ADCY5 was found to be associated with type 2 diabetes in collaborating studies (n = 35,869 cases, 89,798 controls, OR = 1.12, 95% CI 1.09-1.15, P = 4.8 x 10(-18)).

T cell receptor-ligand interactions: a conformational preequilibrium or an induced fit.

Kinetic parameters of T cell receptor (TCR) interactions with its ligand have been proposed to control T cell activation. Analysis of kinetic data obtained has so far produced conflicting insights; here, we offer a consideration of this problem. As a model system, association and dissociation of a soluble TCR (sT1) and its specific ligand, an azidobenzoic acid derivative of the peptide SYIPSAEK-(ABA)I (residues 252-260 from Plasmodium berghei circumsporozoite protein), bound to class I MHC H-2K(d)-encoded molecule (MHCp) were studied by surface plasmon resonance. The association time courses exhibited biphasic patterns. The fast and dominant phase was assigned to ligand association with the major fraction of TCR molecules, whereas the slow component was attributed to the presence of traces of TCR dimers. The association rate constant derived for the fast phase, assuming a reversible, single-step reaction mechanism, was relatively slow and markedly temperature-dependent, decreasing from 7.0 x 10(3) at 25 degrees C to 1.8 x 10(2) M(-1).s(-1) at 4 degrees C. Hence, it is suggested that these observed slow rate constants are the result of unresolved elementary steps of the process. Indeed, our analysis of the kinetic data shows that the time courses of TCR-MHCp interaction fit well to two different, yet closely related mechanisms, where an induced fit or a preequilibrium of two unbound TCR conformers are operational. These mechanisms may provide a rationale for the reported conformational flexibility of the TCR and its unusual ligand recognition properties, which combine high specificity with considerable crossreactivity.

Interferon-gamma release assays for the diagnosis of tuberculosis and tuberculosis infection in HIV-infected adults: a systematic review and meta-analysis.

Background: Despite the widespread use of interferon-gamma release assays (IGRAs), their role in diagnosing tuberculosis and targeting preventive therapy in HIV-infected patients remains unclear. We conducted a comprehensive systematic review to contribute to the evidence-based practice in HIV-infected people. Methodology/Principal Findings: We searched MEDLINE, Cochrane, and Biomedicine databases to identify articles published between January 2005 and July 2011 that assessed QuantiFERON H -TB Gold In-Tube (QFT-GIT) and T-SPOT H .TB (T-SPOT.TB) in HIV-infected adults. We assessed their accuracy for the diagnosis of tuberculosis and incident active tuberculosis, and the proportion of indeterminate results. The search identified 38 evaluable studies covering a total of 6514 HIV-infected participants. The pooled sensitivity and specificity for tuberculosis were 61% and 72% for QFT-GIT, and 65% and 70% for T-SPOT.TB. The cumulative incidence of subsequent active tuberculosis was 8.3% for QFT-GIT and 10% for T-SPOT.TB in patients tested positive (one study each), and 0% for QFT-GIT (two studies) and T-SPOT.TB (one study) respectively in those tested negative. Pooled indeterminate rates were 8.2% for QFT-GIT and 5.9% for T-SPOT.TB. Rates were higher in high burden settings (12.0% for QFT-GIT and 7.7% for T-SPOT.TB) than in low-intermediate burden settings (3.9% for QFT-GIT and 4.3% for T-SPOT.TB). They were also higher in patients with CD4 + T-cell count, 200 (11.6% for QFT-GIT and 11.4% for T-SPOT.TB) than in those with CD4 + T-cell count $ 200 (3.1% for QFT-GIT and 7.9% for T-SPOT.TB). Conclusions/Significance: IGRAs have suboptimal accuracy for confirming or ruling out active tuberculosis disease in HIV-infected adults. While their predictive value for incident active tuberculosis is modest, a negative QFT-GIT implies a very low short- to medium-term risk. Identifying the factors associated with indeterminate results will help to optimize the use of IGRAs in clinical practice, particularly in resource-limited countries with a high prevalence of HIV-coinfection.

The Advocate vol. 4, 2015

This communication tool comes from the Office of the State Long-Term Care Ombudsman to long-term care facilities administrators and directors. The Office's objective is to share information regarding various topics of long term care.

Mineral zoning and geochemistry of epithermal polymetallic Zn-Pb-Ag-Cu-Bi mineralization at Cerro de Pasco, Peru

The large Cerro de Pasco Cordilleran base metal deposit in central Peru is located on the eastern margin of a middle Miocene diatreme-dome complex and comprises two mineralization stages. The first stage consists of a large pyrite-quartz body replacing Lower Mesozoic Pucara carbonate rocks and, to a lesser extent, diatreme breccia. This body is composed of pyrite with pyrrhotite inclusions, quartz, and black and red chalcedony (containing hypogene hematite). At the contact with the pyrite-quartz body, the diatreme breccia is altered to pyrite-quartz-sericite-pyrite. This body was, in part, replaced by pipelike pyrrhotite bodies zoned outward to carbonate-replacement Zn-Pb ores hearing Fe-rich sphalerite (up to 24 mol % Fes). The second mineralization stage is partly superimposed on the first and consists of zoned east-west-trending Cu-Ag-(Au-Zn-Pb) enargite-pyrite veins hosted in the diatreme breccia in the western part of the deposit and well-zoned Zn-Pb-(Bi-Ag-Cu) carbonate-replacement orebodies; in both cases, sphalerite is Fe poor and the inner parts of the orebodies show typically advanced argillic alteration assemblages, including aluminum phosphate Sulfate (APS) minerals. The zoned enargite-pyrite veins display mineral zoning, from a core of enargite-pyrite +/- alunite with traces of Au, through an intermediate zone of tennantite, chalcopyrite, and Bi minerals to a poorly developed Outer zone hearing sphalerite-galena +/- kaolinite. The carbonate-hosted replacement ores are controlled along N 35 degrees E, N 90 degrees E, N 120 degrees E, and N 170 degrees E faults. They form well-zoned upward-flaring pipelike orebodies with a core of famatinite-pyrite and alunite, an intermediate zone with tetrahedrite-pyrite, chalcopyrite, matildite, cuprobismutite, emplectite, and other Bi minerals accompanied by APS minerals, kaolinite, and dickite, and an outer zone composed of Fe-poor sphalerite (in the range of 0.05-3.5 mol % Fes) and galena. The outermost zone consists of hematite, magnetite, and Fe-Mn-Zn-Ca-Mg carbonates. Most of the second-stage carbonate-replacement orebodies plunge between 25 degrees and 60 degrees to the west, suggesting that the hydrothermal fluids ascended from deeper levels and that no lateral feeding from the veins to the carbonate-replacement orebodies took place. In the Venencocha and Santa Rosa areas, located 2.5 km northwest of the Cerro de Pasco open pit and in the southern part of the deposit, respectively, advanced argillic altered dacitic domes and oxidized veins with advanced argillic alteration halos occur. The latter veins are possibly the oxidized equivalent of the second-stage enargite-pyrite veins located in the western part of the deposit. The alteration assemblage quartz-muscovite-pyrite associated with the pyrite-quartz body suggests that the first stage precipitated at slightly, acidic fin. The sulfide mineral assemblages define an evolutionary path close to the pyrite-pyrrhotite boundary and are characteristic of low-sulfidation states; they suggest that the oxidizing slightly acidic hydrothermal fluid was buffered by phyllite, shale, and carbonate host rock. However, the presence in the pyrite-quartz body of hematite within quartz suggests that, locally, the fluids were less buffered by the host rock. The mineral assemblages of the second mineralization stage are characteristic of high- to intermediate-sulfidation states. High-sulfidation states and oxidizing conditions were achieved and maintained in the cores of the second-stage orebodies, even in those replacing carbonate rocks. The observation that, in places, second-stage mineral assemblages are found in the inner and outer zones is explained in terms of the hydrothermal fluid advancing and waning. Microthermometric data from fluid inclusions in quartz indicate that the different ores of the first mineralization stage formed at similar temperatures and moderate salinities (200 degrees-275 degrees C and 0.2-6.8 wt % NaCl equiv in the pyrite-quartz body; 192 degrees-250 degrees C and 1.1-4.3 wt % NaCl equiv in the pyrrhotite bodies; and 183 degrees-212 degrees C and 3.2-4.0 wt % NaCl equiv in the Zn-Pb ores). These values are similar to those obtained for fluid inclusions in quartz and sphalerite from the second-stage ores (187 degrees-293 degrees C and 0.2-5.2 wt % NaCl equiv in the enargite-pyrite veins: 178 degrees-265 degrees C and 0.2-7.5 wt % NaCl equiv in quartz of carbonate-replacement orebodies; 168 degrees-999 degrees C and 3-11.8 wt % NaCl equiv in sphalerite of carbonate-replacement orebodies; and 245 degrees-261 degrees C and 3.2-7.7 wt % NaCl equiv in quartz from Venencocha). Oxygen and hydrogen isotope compositions oil kaolinite from carbonate-replacement orebodies (delta(18)O = 5.3-11.5%o, delta D = -82 to -114%o) and on alunite from the Venencocha and Santa Rosa areas (delta(18)O = 1.9-6.9%o, delta D = -56 to -73%o). Oxygen isotope compositions of quartz from the first and second stages have 6180 values from 9.1 to 1.7.8 per mil. Calculated fluids in equilibrium with kaolinite have delta(18)O values of 2.0 to 8.2 and delta D values of -69 to -97 per mil; values in equilibrium with alunite are -1.4 to -6.4 and -62 to -79 per mil. Sulfur isotope compositions of sulfides from both stages have a narrow range of delta(34)S values, between -3.7 and +4.2 per mil; values for sulfates from the second stage are between 4.2 and 31.2 per mil. These results define two mixing trends for the ore-forming fluids. The first trend reflects mixing between a moderately saline (similar to 10 wt % NaCl equiv) magmatic end member that had degassed (as indicated by the low delta D values) and meteoric water. The second mixing indicates condensation of magmatic vapor with HCl and SO(2) into meteoric water, which formed alunite. The hydrothermal system at Cerro de Pasco was emplaced at a shallow depth (similar to 500 m) in the epithermal and upper part of a porphyry environment. The similar temperatures and salinities obtained for the first stage and second stages, together with the stable isotope data, indicate that both stages are linked and represent successive stages of epithermal polymetallic mineralization in the upper part of a porphyry system.

Vitamin B12 Deficiency in the aged: Laboratory Diagnosis, Prevalence and Clinical Profile

B₁₂-vitamiinin puute iäkkäillä: laboratoriodiagnostiikka, yleisyys ja yhteys sairastavuuteen Tausta: B12-vitamiinin puute on yleistä iäkkäillä ja se tulisi todeta riittävän varhaisessa vaiheessa palautumattomien vaurioiden estämiseksi. On epäselvää pitäisikö diagnostiikka kohdistaa tiettyihin riskiryhmiin vai mahdollisesti seuloa valikoimatonta vanhusväestöä. Myöskään yksimielisyyttä laboratoriotutkimusten valinnasta ei ole. Tavoitteet: Tutkimuksen tarkoituksena oli evaluoida uutta HoloTC RIA menetelmää ja tuottaa viitearvot sille, selvittää B12-vitamiinin puutteen yleisyys, yhteys sairastavuuteen ja mahdolliset riskitekijät suomalaisessa vanhusväestössä, arvioida munuaisfunktion vaikusta B12-vitamiinin puutteen laboratoriotutkimuksiin ja näiden perusteella ehdottaa suomalaiseen terveydenhuoltoon sopivaa laboratoriotutkimusstrategiaa. Aineisto ja menetelmät: Liedon iäkkäät -tutkimuksen vanhusaineisto on edustava otos yhden kunnan yli 65-vuotiaasta väestöstä, yhteensä 1260 henkilöä. Tutkittavat kävivät lääkärintarkastuksessa, ja heistä on käytettävissä runsaasti laboratoriotutkimuksia sekä tiedot sairauksista, ruokavaliosta, lääkkeiden ja vitamiinivalmisteiden käytöstä, dementiaseula ja depressiokysely. Viitearvoaineistoa varten kerättiin näytteet 84 vapaaehtoisesta terveestä aikuisesta ja menetelmäevaluaatiota varten 107 sairaalapotilaasta. Tulokset: HoloTC RIA menetelmän toistettavuus oli hyvä manuaalimenetelmäksi. 95%:n viiteväli holotranskobalamiinille oli 37-171 pmol/l. Kaikilla tutkittavilla, joilla oli muilla laboratoriotutkimuksilla osoitettu todennäköinen B12-vitamiinin puute, myös holotranskobalamiini oli viitealueen alarajaa pienempi. Suurentuneella kystatiini C-pitoisuudella osoitettu munuaisten vajaatoiminta korreloi voimakkaasti homokysteiinin (rs=0.53, p<0.001) ja metyylimalonihapon (rs=0.27, p<0.001) pitoisuuksiin, mutta ei kokonais-B12-vitamiinin (rs=- 0.04, p=0.227) tai holotranskobamiinin (rs=-0.01, p=0.817) pitoisuuksiin. Suomalaisessa vanhusväestössä B12-vitamiinin puutteen prevalenssi oli 12%. Kokonais- B12-vitamiinin pitoisuus oli matala (<150 pmol/l) 6%:lla. Miessukupuoli (OR 1.9, 95% CI 1.2-2.9), ikä ≥75 (OR 2.2, 95% CI 1.4-3.4) ja maitotuotteiden välttäminen (OR 2.3, 95% CI 1.2-4.4) lisäsivät B12-vitamiinin puutteen riskiä, mutta anemia (OR 1.3, 95% CI 0.7-2.3) tai makrosytoosi (OR 1.2, 95% CI 0.6-2.7) eivät. Päätelmät: Diagnosoimaton B12-vitamiinin puute on yleistä iäkkäillä, mutta kliinisesti merkityksellistä spesifistä riskiryhmää ei löydy. Koska anemian ja makrosytoosin puuttuminen ei poissulje B12-vitamiinin puutetta ja munuaisten vajaatoiminta heikentää metabolisten merkkiaineiden käyttökelpoisuutta, kokonais-B12-vitamiinia suositellaan ensisijaiseksi laboratoriotutkimukseksi epäiltäessä B12-vitamiinin puutetta ja tarvittaessa varmentavina tutkimuksina käytetään homokysteiiniä ja holotranskobalamiinia.

Development of an activity index for adult eosinophilic esophagitis: international experts propose dysphagia, withish exudates on endoscopy and peripheral eosinophilia as items with closest association to EoE activity

Background and Aims: Eosinophilic Esophagitis (EoE) is reported with increasing frequency over the last two decades. However, it is still unknown whether this reflects a true increase in incidence or just an increased awareness by gastroenterologists. Therefore, we evaluated the incidence and cumulative prevalence of EoE in Olten county over the last 20 years. Methods: Olten county is an area of approximately 91,000 inhabitants without pronounced demographic changes in the last two decades. EoE evaluation is based upon two gastroenterology centers and one pathology center. No public programs for increased EoE awareness were implemented in this region. All EoE patients diagnosed from 1989 to 2009 were entered prospectively into the Olten county database. Results: Fourty-six patients (76% males, mean age 41±16 yrs) were diagnosed with EoE from 1989 to 2009. Ninety-four percent presented with dysphagia. In 70% of the patients concomitant allergies were found. The number of upper endoscopies per year was stable during the entire observation period. An average annual incidence rate of 2/100,000 was found (range 0-8) with a marked increase in the period from 2001 to 2009. A current cumulative EoE prevalence of 43/100,000 inhabitants was calculated. The mean diagnostic delay (time from first symptoms to diagnosis) was 4.3 years from 1989 to 1998 and 4.8 years from 1999 to 2009. Conclusions: Over the last 20 years, a significant increase in EoE incidence was found in a stable indicator region of Switzerland. The constant rate of upper endoscopies, the constant diagnostic delay, as well as the lack of EoE awareness programs in Olten county indicate a true increase in EoE incidence.

EFEITO DO ESTÁGIO DE DESENVOLVIMENTO DAS FLORES E DA APLICAÇÃO DE FUNGICIDAS NO CONTROLE DA PODRIDÃO FLORAL DOS CITROS

O presente trabalho teve por objetivo determinar os melhores estágios do desenvolvimento das flores de laranja-doce para o controle da Podridão Floral dos Citros (PFC), avaliando-se diversas épocas de aplicação e doses de fungicidas. Os estudos foram realizados em pomares de laranjas-'Natal' e 'Pêra' (Citrus sinensis [L.] Osbeck), onde foram marcados aleatoriamente ramos florais pertencentes à florada temporã (janeiro de 1994), caracterizando as fases de desenvolvimento de cada botão floral. Em um primeiro ensaio, avaliou-se o controle da doença através de pulverizações manuais, onde foram aplicados os seguintes tratamentos (doses por 1 L): a) testemunha; b) benomyl 0,5 g, no dia de marcação dos ramos (aplicação normal); c) benomyl 0,5 g, 3 a 4 dias depois da marcação (aplicação tardia); e d) benomyl 0,5 g em 2 aplicações, uma na marcação dos botões e outra uma semana depois. As aplicações foram feitas com pulverizadores manuais, molhando-se apenas os ramos com flores marcados. Em um segundo ensaio, avaliou-se o controle da doença através de pulverizações tratorizadas. Na laranja-'Natal', estudaram-se os seguintes tratamentos (doses por 2.000 L): a) testemunha; b) benomyl 1 kg em 4/jan; c) benomyl 1 kg em 4 e 11/jan; e d) benomyl 1 kg em 8/jan. Na laranja-'Pêra', os seguintes tratamentos foram aplicados (doses por 2.000 L): a) testemunha; b) benomyl 1 kg, 4/jan; c) benomyl 1 kg, 4 e 10/jan; d) benomyl 1 kg + captan 3,5 kg, 4/jan; e) benomyl 0,75 kg + captan 2,5 kg, 4/jan; f) benomyl 1 kg + captan 2,5 kg, 4/jan; g) benomyl 1 kg + captan 2,5 kg, 4/jan + benomyl 1 kg, 10/jan; h) benomyl 1,5 kg, 4/jan; e i) benomyl 1,5 kg, 4 e 10/jan. Avaliaram-se, em intervalos de dois dias, a freqüência e a época de ocorrência das lesões nas pétalas dos botões florais, a porcentagem de pegamento e o índice de cálices retidos de cada parcela. Pelos resultados, pôde-se concluir que o benomyl é eficiente no controle da PFC em doses de 0,5-0,75 g.L-1, e sua resposta podem ser obtida em floradas temporãs tratadas nos estágios de predominância de botões redondos brancos até o período anterior à antese.

Escurecimento interno de pêra asiática 'Ya Li' durante o armazenamento refrigerado

A pêra 'Ya Li' apresenta escurecimento da polpa poucos dias após o armazenamento refrigerado. Este trabalho objetivou avaliar condições de armazenamento visando a diminuir os danos pela baixa temperatura inicial em peras 'Ya Li'. As condições iniciais estabelecidas foram: 1) 0ºC; 2) 5ºC, nos 10 primeiros dias, com redução de 0,7ºC por dia, durante sete dias; 3) 10ºC nos 10 primeiros dias, com redução de 1,4ºC por dia, durante sete dias; 4) 10º C nos 10 primeiros dias, com redução de 1,4ºC por dia, durante sete dias, sempre em atmosfera controlada (2,0kPa de O2 e < 1,0kPa de CO2); 5) 10ºC nos 10 dias iniciais, com posterior exposição direta dos frutos a 0ºC. Em seqüência aos tratamentos iniciais, os frutos foram submetidos ao armazenamento refrigerado a 0ºC, com exceção do tratamento "4" que foi mantido continuamente em atmosfera controlada. Após 52 dias de armazenamento, verificou-se escurecimento interno, superior a 68% em todos os tratamentos. As temperaturas mais elevadas, no início, não evitaram a ocorrência do escurecimento durante o armazenamento.