Chemical Constituents and Antioxidant Potential of Red Guava (Psidium cattleianum Sabine) from Southern Brazil in Different Edible Ripening Stages.

Ripening and growing location are important factors that can impact fruit quality characteristics. In this study, the influence of these factors on physicochemical characteristics, carbohydrates, aliphatic organic acids, phenolic compounds, and antioxidant capacity of red guava (Psidium cattleianum Sabine) was evaluated. Fruit ripening increased fructose and glucose (up to 22.83 and 16.42 g 100 g- 1 dry matter (DM), respectively), and decreased citric acid, the major organic acid (up to 135.35 mg g- 1 DM). Ripening and growing location also influenced the concentration of phenolic compounds and antioxidant capacity of red guava, in which a dependency between both factors was observed in most cases. Apigenin, galangin, isoquercitrin, among other phenolic compounds were quantified for the first time in red guava, in which isoquercitrin was the major (up to 13409.81 mg kg- 1 DM). The antioxidant potential of red guava was also confirmed by ferric reducing antioxidant power assay (up to 82.63 µmol Fe+ 2 g- 1 DM), Folin-Ciocalteu reducing capacity assay (up to 17.79 mg gallic acid equivalent g- 1 DM), and DPPH free radical scavenging assay (up to 25.36 mg ascorbic acid equivalent g- 1 DM). These results especially demonstrated the bioactive potential of red guava and provided knowledge regarding the influence of ripening and growing location on chemical and bioactive components encouraging its industrial exploitation.

Antioxidant and antifungal activity of phenolic compounds and their relation to aflatoxin B1 occurrence in soybeans (Glycine max L.).

BACKGROUND: Soybean is widely used in food formulations; however, few studies on fungal or mycotoxin contamination have been undertaken. Free, conjugated, and bound phenolic compounds, and their antioxidant and antifungal potential, were therefore evaluated together with the occurrence of aflatoxin B1 (AFB1 ) in soybeans. RESULTS: The conjugated and bound phenolic soybean extracts were more efficient for the inhibition of the 2,2 diphenyl-1-picryl-hydrazyl (DPPH) radical, the peroxidase enzyme, and the fungal α-amylase enzyme. Aflatoxin B1, detected at low levels (0.96 to 1.67 ng g-1 ), confirmed the protective effect of soybean phenolic compounds against mycotoxigenic contamination. Principal component analysis confirmed that syringic, p-hydroxybenzoic, p-coumaric acids and vanillin were essential for antioxidant and antifungal activities. CONCLUSION: This study presented new insights into the functionality of phenolic compounds in soybeans, regarding their potential to protect the crops naturally against fungal contamination, avoiding aflatoxin production, as attested by the correlations between phenolic compounds and antioxidant mechanisms. © 2019 Society of Chemical Industry.

Free phenolic compounds extraction from Brazilian halophytes, soybean and rice bran by ultrasound-assisted and orbital shaker methods.

In several countries halophytes are commercially cultivated in low saline or even irrigated with seawater, as well as with saline aquaculture effluent, like a sea asparagus Sarcocornia ambigua, that show a biotechnological potential for bioactive compounds production. However, their recovery from matrix is sometimes inefficient because the lignocellulosic materials difficult the solvent action when drastic conditions are not applied. The ultrasound-assisted extraction (UAE) was optimized by a central composite rotational design for recovery free phenolic compounds (FPC) from the sea asparagus S. ambigua. Optimum conditions were validated and compared with orbital shaker extraction for S. ambigua, other Brazilian halophytes (Apium graveolens, Myrsine parvifolia, Paspalum vaginatum, and Schinus terebinthifolius), soybean and rice bran. Except for P. vaginatum, soybean and rice bran, UAE yielded 18-29% higher FPC than that of the orbital shaker. Besides this analytical performance UAE method optimized is faster than the orbital shaker, providing shorter exposure of the analyst to the extractor solvent and applicable in matrices with different compositions. It was also demonstrated that halophytes species showed to be good natural sources of FPC in a better way as soybean and rice bran. This work was the first to report FPC in M. parvifolia and P. vaginatum.

Phenolic profile and in vitro anti-inflammatory activity of Mimosa scabrella Bentham honeydew honey in RAW 264.7 murine macrophages.

The anti-inflammatory activity is mainly attributed to the phenolic compounds. Once the geographical location affects the phenolic content of honeys, a relationship between the collection spot and the anti-inflammatory effect of bracatinga (Mimosa scabrella Bentham) honeydew honeys was hypothesized. The inhibitory effect of 14 honey samples on NOx, TNF-α, IL-6, IL-12p70, MCP-1, INF-γ, and IL-10 in RAW 264.7 macrophages inflamed by LPS was evaluated. Fourteen phenolic compounds were identified, mainly syringic acid and rutin. Ten honeys inhibited nitrite production; at least six downregulated TNF-α, IL-12p70, MCP-1, and IFN-γ; only four honey samples inhibited IL-6; and one honey sample inhibited IL-10 levels, showing their variable effects on the inflammatory markers. Principal component analysis grouped samples according to the phenolic content and downregulation of specific inflammatory markers. The bracatinga honeydew honey effectiveness was associated with geographical location, as samples from areas with higher density and diversity of plants had a more significant anti-inflammatory effect. PRACTICAL APPLICATIONS: The present research study investigated the anti-inflammatory potential of bracatinga honeydew honey samples collected from regions with different vegetation coverages. Honey samples collected from locations presenting greater forest diversity and density inhibited inflammatory markers more efficiently. This study reinforces the role of the bracatinga honeydew honey in preventing inflammatory processes and the importance of preserving forests so that products with a greater diversity of compounds and consequently more active can be obtained.

Quality, composition and health-protective properties of citrus honey: A review.

Citrus honey is one of the most important monofloral honeys produced and consumed worldwide. This honey has pleasant sensorial characteristics, which include light color and typical aroma and flavor. Besides that, several constituents such as minerals, phenolic and volatile compounds, amino acids, sugars, enzymes, vitamins, methylglyoxal and organic acids are found in citrus honey. Moreover, potential biological properties have been associated with citrus honey. All these factors make it highly desired by consumers, increasing its market value, which can stimulates the practice of fraud. Also, citrus honey is susceptible to contamination and to inadequate processing. All these factors can compromise the quality, safety and authenticity of citrus honey. In this sense, this review aims to update and to discuss, for the first time, the data available in the literature about the physicochemical and the sensorial characteristics, composition, health properties, contamination, authenticity and adulteration of citrus honey. With this background, we aim to provide data that can guide future researches related to this honey.

In vitro anti-inflammatory properties of honey flavonoids: A review.

Honey is a natural ready-to-eat product rich in flavonoids, which is known by the wound healing properties due to both antibacterial and antioxidant activity. Flavonoids mitigate inflammatory processes, and thus it could currently support studies of anti-inflammatory potential of honeys. In this review, in vitro anti-inflammatory properties of flavonoids found in honey were prioritized. Mechanistic information of specific isolated flavonoids as modulators of inflammatory processes are summarized aiming to stimulate studies regarding the action of honey in inflammatory events. Lastly, a structure-activity relationship (SAR) of flavonoids was also included. Flavonoids found in honey have demonstrated antioxidant properties and ability to inhibit pro-inflammatory enzymes such as COX, LOX, iNOS, and pro-inflammatory mediators, including nitric oxide, cytokines and chemokines. Transcriptional factors such as NF-κB are also modulated by flavonoids, controlling the expression of several inflammatory mediators. SAR studies demonstrate the effect of flavonoids in the prevention of inflammatory cascades. Despite the promising reports of in vitro anti-inflammatory activity, well-designed clinical trials need yet to be performed to confirm the benefits of honeys from different botanical sources in diseases that include episodes of inflammation.

Comparative quantification and differentiation of bracatinga (Mimosa scabrella Bentham) honeydew honey proteins using targeted peptide markers identified by high-resolution mass spectrometry.

Honey traceability is an important topic, especially for honeydew honeys, due to the increased incidence of adulteration. This study aimed to establish specific markers to quantify proteins in honey. A proteomics strategy to identify marker peptides from bracatinga honeydew honey was therefore developed. The proteomics approach was based on initial untargeted identification of honey proteins and peptides by LC-ESI-Triple-TOF-MS/MS, which identified the major royal jelly proteins (MRJP) presence. Afterwards, the peptides were selected by the in silico digestion. The marker peptides were quantified by the developed targeted LC-QqQ-MS/MS method, which provided good linearity and specificity, besides recoveries between 92 and 100% to quantify peptides from bracatinga honeydew honey. The uniqueness and high response in mass spectrometry were backed by further complementary protein analysis (SDS-PAGE). The selected marker peptides EALPHVPIFDR (MRJP 1), ILGANVK (MRJP 2), TFVTIER (MRJP 3), QNIDVVAR (MRJP 4), FINNDYNFNEVNFR (MRJP 5) and LLQPYPDWSWTK (MRJP 7), quantified by LC-QqQ-MS/MS, highlighted that the content of QNIDVVAR from MRJP 4 could be used to differentiate bracatinga honeydew honey from floral honeys (p < 0.05) as a potential marker for its authentication. Finally, principal components analysis highlighted the QNIDVVAR content as a good descriptor of the analyzed bracatinga honeydew honey samples.

Investigation of phenolic compounds, antioxidant and anti-inflammatory activities in stingless bee honey (Meliponinae).

The objective of this study was to investigate and quantify the composition phenolic, reducing capacity, the free radical scavenging activity, as well as, the anti-inflammatory effect evaluated against lipopolysaccharides-stimulated RAW264.7 macrophages through modulation of inflammatory mediators, in eight stingless bee honey types (Meliponinae) from southern Brazil. Stingless bee honey did not show to be cytotoxic at the tested concentrations (1-100 µM) and also reduced nitric oxide and the secretion of the pro-inflammatory cytokine in the inflamed macrophages. Two honey samples showed the ability to increase the secretion of anti-inflammatory cytokine (interleukin-10), suggesting a significant anti-inflammatory effect. All these findings indicate that stingless bee honey could be an important source of natural compounds presenting anti-inflammatory and antioxidant effect, which could would provide health benefits when included in the diet.

Takotsubo Multicenter Registry (REMUTA) - Clinical Aspects, In-Hospital Outcomes, and Long-Term Mortality. / Registro Multicêntrico de Takotsubo (REMUTA) ­ Aspectos Clínicos, Desfechos Intra-Hospitalares e Mortalidade a Longo Prazo.

BACKGROUND: Takotsubo syndrome (TTS) is an acquired form of cardiomyopathy. National Brazilian data on this condition are scarce. The Takotsubo Multicenter Registry (REMUTA) is the first to include multicenter data on this condition in Brazil. OBJECTIVE: To describe the clinical characteristics, prognosis, in-hospital treatment, in-hospital mortality, and mortality during 1 year of follow-up. METHODS: This is an observational, retrospective registry study including patients admitted to the hospital with diagnosis of TTS and patients admitted for other reasons who developed this condition. Evaluated outcomes included triggering factor, analysis of exams, use of medications, complications, in-hospital mortality, and mortality during 1 year of follow-up. A significance level of 5% was adopted. RESULTS: The registry included 169 patients from 12 centers in the state of Rio de Janeiro, Brazil. Mean age was 70.9 ± 14.1 years, and 90.5% of patients were female; 63% of cases were primary TTS, and 37% were secondary. Troponin I was positive in 92.5% of patients, and median BNP was 395 (176.5; 1725). ST-segment elevation was present in 28% of patients. Median left ventricular ejection fraction was 40 (35; 48)%. We observed invasive mechanical ventilation in 25.7% of cases and shock in 17.4%. Mechanical circulatory support was used in 7.7%. In-hospital mortality was 10.6%, and mortality at 1 year of follow-up was 16.5%. Secondary TTS and cardiogenic shock were independent predictors of mortality. CONCLUSION: The results of the REMUTA show that TTS is not a benign pathology, as was once thought, especially regarding the secondary TTS group, which has a high rate of complications and mortality. (Arq Bras Cardiol. 2020; 115(2):207-216).

FUNDAMENTO: A síndrome de takotsubo (takotsubo) é uma forma de cardiomiopatia adquirida. Dados nacionais sobre essa condição são escassos. O Registro REMUTA é o primeiro a incluir dados multicêntricos dessa condição no nosso país. OBJETIVO: Descrever as características clínicas, prognóstico, tratamento intra-hospitalar e mortalidade hospitalar e em 1 ano de seguimento. MÉTODOS: Estudo observacional, retrospectivo, tipo registro. Incluídos pacientes internados com diagnóstico de takotsubo ou que desenvolveram esta condição durante internação por outra causa. Os desfechos avaliados incluíram fator desencadeador, análise dos exames, uso de medicações, complicações e óbito intra-hospitalar e em 1 ano de seguimento. O nível de significância adotado foi de 5%. RESULTADOS: Foram incluídos 169 pacientes, em 12 centros no Estado do Rio de Janeiro. A idade média foi de 70,9 ± 14,1 anos e 90,5% eram do sexo feminino; 63% dos casos foram de takotsubo primário e 37% secundário. Troponina I foi positiva em 92,5% dos pacientes e a mediana de BNP foi de 395 (176,5; 1725). Supradesnivelamento do segmento ST esteve presente em 28% dos pacientes. A fração de ejeção do ventrículo esquerdo teve mediana de 40 (35; 48)%. Observamos taxa de 25,7% de ventilação mecânica invasiva e 17,4% de choque. Suporte circulatório mecânico foi utilizado em 7,7%. A mortalidade intra-hospitalar foi de 10,6% e a mortalidade ao final de 1 ano foi de 16,5%. Takotsubo secundário e choque cardiogênico foram preditores independentes de mortalidade. CONCLUSÃO: Os resultados do REMUTA mostram que takotsubo não se trata de patologia benigna como se pensava, especialmente no grupo de takotsubo secundário que acarreta elevada taxa de complicações e de mortalidade. (Arq Bras Cardiol. 2020; 115(2):207-216).

Simplex-centroid design and Derringer's desirability function approach for simultaneous separation of phenolic compounds from Mimosa scabrella Bentham honeydew honeys by HPLC/DAD.

Honeydew honeys have been under-evaluated about their major phenolic compounds, especially Mimosa scabrella Bentham (bracatinga) honeydew honey. In this work, a fast and robust chromatographic method was optimized for simultaneous separation and quantification by HPLC/DAD of 18 phenolic compounds detected in bracatinga honeydew honey. A simplex-centroid design, central composite rotatable design and response surface-desirability function simultaneous optimization of Derringer and Suich were used, evaluating the mobile phase composition, flow rate and oven temperature to separate all the peaks. These multivariate procedures were efficient in determining the optimal separation conditions, using peak pair resolutions and run time as responses. The 18 peaks were separated in 25 min and the mobile phase gradient started with 1.6% MeOH, 3.3% ACN, 1.0% THF and 94.1% formic acid 0.1% changing to 10.0% MeOH, 33.3% ACN, 6.0% THF and 50.7% formic acid 0.1%, oven temperature of 33 °C and flow rate of 0.73 mL min-1. The method was validated according to Eurachem guidelines and considered accurate and robust. It was applied to 18 bracatinga honeydew honey samples in which 9 phenolic compounds were identified and quantified.

An overview of physicochemical characteristics and health-promoting properties of honeydew honey.

Honeydew honey has differentiated chemical and physicochemical characteristics besides potential functional properties such as antimicrobial, anti-inflammatory and antioxidant. In this sense, the interest and consumption of this honey as a functional product by the food industry and consumers have increased. Honeydew honeys usually present dark color, a lower content of monosaccharides and higher values of pH, acidity, electric conductivity, proteins, minerals, phenolic compounds, and oligosaccharides compared to blossom honeys, which contribute to its outstanding biological activities. Consequently, contaminations and adulterations of this honey can occur and compromise the quality, safety and authenticity of honeydew honey. Thus, detailed knowledge of the composition and properties of honeydew honeys is of great importance, especially considering that honeydew honeys are still few studied and therefore underestimated. Therefore, in this review, the physicochemical characteristics, chemical and bioactive composition, functional and health-promoting properties of honeydew honey as well as contamination, adulteration and authenticity of this honey are summarized.

Depressive Symptoms and Associated Factors among People Living with HIV/AIDS.

The purpose of this study was to evaluate the prevalence of depressive symptoms and associated variables among people living with HIV/AIDS (PLWHA) in a specialized treatment center in a city located in southern Brazil. A cross-sectional study was conducted using the Beck Depression Inventory to assess the presence of depressive symptoms. The prevalence of depressive symptoms was 53.5% among the surveyed population, which supports the idea that depressive symptoms are more common among PLWHA, mainly if compared with the general population. It was observed that 57.7% of the study participants were with depressive symptoms and did not take any psychiatric medication and 100% did not undergo psychotherapy, which indicates undertreatment. There was no statistically significant difference in the mean CD4 count between patients with depressive symptoms (484.1  ±  353) and patients without depressive symptoms (528.4  ±  263). Further actions should be taken to improve the care for PLWHA. The interface between psychology, psychiatry, and internal medicine is of utmost importance to provide a more humanized care, in which the psychosocial, psychological, and psychiatric aspects are not neglected.

Registro Multicêntrico de Takotsubo (REMUTA) - Aspectos Clínicos, Desfechos Intra-Hospitalares e Mortalidade a Longo Prazo / Takotsubo Multicenter Registry (REMUTA) - Clinical Aspects, In-Hospital Outcomes, and Long-Term Mortality

Resumo Fundamento A síndrome de takotsubo (takotsubo) é uma forma de cardiomiopatia adquirida. Dados nacionais sobre essa condição são escassos. O Registro REMUTA é o primeiro a incluir dados multicêntricos dessa condição no nosso país. Objetivo Descrever as características clínicas, prognóstico, tratamento intra-hospitalar e mortalidade hospitalar e em 1 ano de seguimento. Métodos Estudo observacional, retrospectivo, tipo registro. Incluídos pacientes internados com diagnóstico de takotsubo ou que desenvolveram esta condição durante internação por outra causa. Os desfechos avaliados incluíram fator desencadeador, análise dos exames, uso de medicações, complicações e óbito intra-hospitalar e em 1 ano de seguimento. O nível de significância adotado foi de 5%. Resultados Foram incluídos 169 pacientes, em 12 centros no Estado do Rio de Janeiro. A idade média foi de 70,9 ± 14,1 anos e 90,5% eram do sexo feminino; 63% dos casos foram de takotsubo primário e 37% secundário. Troponina I foi positiva em 92,5% dos pacientes e a mediana de BNP foi de 395 (176,5; 1725). Supradesnivelamento do segmento ST esteve presente em 28% dos pacientes. A fração de ejeção do ventrículo esquerdo teve mediana de 40 (35; 48)%. Observamos taxa de 25,7% de ventilação mecânica invasiva e 17,4% de choque. Suporte circulatório mecânico foi utilizado em 7,7%. A mortalidade intra-hospitalar foi de 10,6% e a mortalidade ao final de 1 ano foi de 16,5%. Takotsubo secundário e choque cardiogênico foram preditores independentes de mortalidade. Conclusão Os resultados do REMUTA mostram que takotsubo não se trata de patologia benigna como se pensava, especialmente no grupo de takotsubo secundário que acarreta elevada taxa de complicações e de mortalidade. (Arq Bras Cardiol. 2020; 115(2):207-216)

Abstract Background Takotsubo syndrome (TTS) is an acquired form of cardiomyopathy. National Brazilian data on this condition are scarce. The Takotsubo Multicenter Registry (REMUTA) is the first to include multicenter data on this condition in Brazil. Objective To describe the clinical characteristics, prognosis, in-hospital treatment, in-hospital mortality, and mortality during 1 year of follow-up. Methods This is an observational, retrospective registry study including patients admitted to the hospital with diagnosis of TTS and patients admitted for other reasons who developed this condition. Evaluated outcomes included triggering factor, analysis of exams, use of medications, complications, in-hospital mortality, and mortality during 1 year of follow-up. A significance level of 5% was adopted. Results The registry included 169 patients from 12 centers in the state of Rio de Janeiro, Brazil. Mean age was 70.9 ± 14.1 years, and 90.5% of patients were female; 63% of cases were primary TTS, and 37% were secondary. Troponin I was positive in 92.5% of patients, and median BNP was 395 (176.5; 1725). ST-segment elevation was present in 28% of patients. Median left ventricular ejection fraction was 40 (35; 48)%. We observed invasive mechanical ventilation in 25.7% of cases and shock in 17.4%. Mechanical circulatory support was used in 7.7%. In-hospital mortality was 10.6%, and mortality at 1 year of follow-up was 16.5%. Secondary TTS and cardiogenic shock were independent predictors of mortality. Conclusion The results of the REMUTA show that TTS is not a benign pathology, as was once thought, especially regarding the secondary TTS group, which has a high rate of complications and mortality. (Arq Bras Cardiol. 2020; 115(2):207-216)

Qualidade de vida em pacientes com doença de Machado-Joseph sob acompanhamento fonoaudiológico para disfagia / Therapy speech impact in quality of life in patients with Machado-Joseph disease

RESUMO A doença de Machado-Joseph é uma doença degenerativa e atualmente considerada a ataxia espinocerebelar mais frequente. O processo degenerativo da doença afeta diferentes regiões e funções do sistema nervoso central e/ou periférico. A disfagia é um dos sintomas presentes na doença de Machado-Joseph, sendo responsável pelas complicações clínicas e pela pneumonia aspirativa, sua principal causa de morte. O objetivo deste trabalho é verificar o impacto da terapia fonoaudiológica na qualidade de vida em pacientes com doença de Machado-Joseph. Participaram da pesquisa quatro pacientes diagnosticados com a doença, três do sexo feminino e um do sexo masculino, com média de idade de 46,5 anos (±18) e queixa de disfagia. Na primeira sessão, todos os pacientes responderam ao questionário de Avaliação da Qualidade de Vida em Disfagia, SWAL-QOL, foram avaliados quanto aos aspectos estruturais e funcionais da deglutição e classificados de acordo com a Escala Funcional de Ingestão por Via Oral (FOIS). Após seis sessões de tratamento fonoaudiológico, realizaram nova avaliação clínica da deglutição, novamente classificados de acordo com a escala FOIS e responderam o SWAL-QOL. Conclusões: Após a intervenção fonoaudiológica, todos os pacientes apresentaram melhor conceito nos domínios medo de alimentar-se, alimentação como um fardo e fadiga, podendo-se inferir que houve uma melhora na satisfação com o processo alimentar e, consequentemente, qualidade de vida dos sujeitos acompanhados.

ABSTRACT The Machado-Joseph disease is a degenerative disease, currently considered the most frequent spinocerebellar ataxia. The degenerative process of the disease affects several regions and functions of the central and/or peripheral nervous system. The dysphagia is one of the symptoms of Machado-Joseph disease, being responsible for the clinical complications and for the aspiration pneumonia, its main cause of death. The goal of this paper is to verify the impact of the speech-language therapy in the quality of life of the Machado-Joseph disease patients. Four patients diagnosed with Machado-Joseph disease attended to the research, three female and one male, with age average in 46,5 years-old (± 18), and complaining about dysphagia. In the first session, all patients answered the protocol of quality of life in dysphagia assessment of Quality of Life in Dysphagia, SWAL -QOL were assessed for structural and functional aspects of swallowing and classified according to Functional Intake Scale for Oral (FOIS). After six speech therapy sessions conducted a new clinical evaluation of swallowing, again classified according to FOIS and answered the SWAL -QOL. Conclusions: After speech therapy, all patients showed better concept in the field fear of eating, food as a burden and fatigue, which can be inferred that there was an improvement in satisfaction with food processes and hence the quality of life accompanied subjects.

Aneurismas coronarianos, cerebral e de aorta abdominal: uma rara associação / Coronary, cerebral and abdominal aortic aneurysms: a rare association

Relata-se caso de associação de aneurismas coronariano, cerebral e de aorta abdominal em paciente idoso do sexo masculino, admitido por dispneia, cuja investigação mostrou insuficiência mitral grave. Apresentava história pregressa de aneurismas cerebral e de aorta abdominal, este corrigido por endoprótese, e diversas comorbidades. Foi submetido à cineangiocoronariografia em avaliação pré-operatória para possível correção valvar, que revelou aterosclerose coronariana severa e grandes formações aneurismáticas nos principais ramos coronarianos. Tendo em vista a complexidade para correção das alterações coronarianas e as outras comorbidades associadas, paciente, família e médico assistente optaram por tratamento clínico.

This case study describes an association of coronary,cerebral and abdominal aortic aneurysms in na elderly male patient hospitalized for dyspnea,whose investigation showed severe mitral regurgitation. His previous history included brain and abdominal aortic aneurysms, the later corrected by a stent, as well as several comorbidities. Coronary angiography during a pre-operative assessment for possible valve repair disclosed severe coronary atherosclerosis and large aneurysm formations in major coronary branches. Due to the complexity of correcting the coronary aneurysms and other associated comorbidities, the patient, his family and his attending physician opted for clinical treatment.