RESUMO
The world's largest butterfly genus Delias, commonly known as Jezebels, comprises ca. 251 species found throughout Asia, Australia, and Melanesia. Most species are endemic to islands in the Indo-Australian Archipelago or to New Guinea and nearby islands in Melanesia, and many species are restricted to montane habitats over 1200 m. We inferred an extensively sampled and well-supported molecular phylogeny of the group to better understand the spatial and temporal dimensions of its diversification. The remarkable diversity of Delias evolved in just ca. 15-16 Myr (crown age). The most recent common ancestor of a clade with most of the species dispersed out of New Guinea ca. 14 Mya, but at least six subsequently diverging lineages dispersed back to the island. Diversification was associated with frequent dispersal of lineages among the islands of the Indo-Australian Archipelago, and the divergence of sister taxa on a single landmass was rare and occurred only on the largest islands, most notably on New Guinea. We conclude that frequent inter-island dispersal during the Neogene-likely facilitated by frequent sea level change-sparked much diversification during that period. Many extant New Guinea lineages started diversifying 5 Mya, suggesting that orogeny facilitated their diversification. Our results largely agree with the most recently proposed species group classification system, and we use our large taxon sample to extend this system to all described species. Finally, we summarize recent insights to speculate how wing pattern evolution, mimicry, and sexual selection might also contribute to these butterflies' rapid speciation and diversification.
Assuntos
Borboletas , Animais , Filogenia , Borboletas/genética , Nova Guiné , Austrália , EcossistemaRESUMO
Vasculitis is a complication of several infectious diseases affecting the central nervous system, which may result in ischemic and/or hemorrhagic stroke, transient ischemic attack, and aneurysm formation. The infectious agent may directly infect the endothelium, causing vasculitis, or indirectly affect the vessel wall through an immunological mechanism. The clinical manifestations of these complications usually overlap with those of non-infectious vascular diseases, making diagnosis challenging. Intracranial vessel wall magnetic resonance imaging (VWI) enables the evaluation of the vessel wall and the diseases that affect it, providing diagnostic data beyond luminal changes and enabling the identification of inflammatory changes in cerebral vasculitis. This technique demonstrates concentric vessel wall thickening and gadolinium enhancement, associated or not with adjacent brain parenchymal enhancement, in patients with vasculitis of any origin. It permits the detection of early alterations, even before a stenosis occurs. In this article, we review the intracranial vessel wall imaging features of infectious vasculitis of bacterial, viral, and fungal etiologies.
Assuntos
Doenças Transmissíveis , Vasculite do Sistema Nervoso Central , Humanos , Angiografia por Ressonância Magnética/métodos , Meios de Contraste , Angiografia Cerebral/métodos , Gadolínio , Imageamento por Ressonância Magnética , Vasculite do Sistema Nervoso Central/diagnóstico por imagem , Vasculite do Sistema Nervoso Central/patologiaRESUMO
Arterial spin labeling (ASL) is an emerging noninvasive MRI technique for assessing cerebral perfusion. An important advantage of ASL perfusion is the lack of a requirement for an exogenous tracer. ASL uses magnetically labeled water protons from arterial blood as an endogenous diffusible tracer. For this reason, ASL is an attractive perfusion imaging modality for children and for patients with contraindications or adverse reactions to gadolinium, patients with renal failure, and those who need repeated follow-up imaging. Another advantage of ASL is the possibility of quantifying cerebral blood flow, which provides an opportunity for comparative analysis among multiple longitudinal studies, unlike other MR perfusion techniques, which are semiquantitative and yield relative perfusion parameters. Advances in MRI technology and pulse sequence design have translated ASL beyond the research arena to successful clinical implementation. However, ASL is still underused in routine clinical practice. Some disadvantages of ASL include a lower signal-to-noise ratio and a longer acquisition time than those with dynamic susceptibility contrast-enhanced MRI. Additional factors limiting the use of ASL include variations in existing techniques and pulse sequence design, the complexity of implementation and postprocessing, insufficient experience with and/or knowledge of the potential clinical applications, and the absence of interpretation guidelines. The authors review the technical and physiologic basis of ASL perfusion, as well as artifacts, pitfalls, and its current clinical applications. A practical approach for interpreting ASL findings is also suggested.
Assuntos
Circulação Cerebrovascular , Angiografia por Ressonância Magnética , Criança , Humanos , Marcadores de Spin , Angiografia por Ressonância Magnética/métodos , Circulação Cerebrovascular/fisiologia , Imageamento por Ressonância Magnética/métodos , ArtefatosRESUMO
A decrease in brain volume (ie, brain atrophy) is a marker of cognitive health in older adults. Insufficient weekly accumulation of moderate and vigorous physical activity (MVPA) has been associated with lower brain volume. As this association has been established for a small number of brain areas and structures and atrophy rates seem to be nonuniform between them, more comprehensive analyses are warranted. We compared the volume of 71 brain areas and structures in 45 older adults who met and did not meet objectively measured MVPA recommendations. In addition, we used multiple regression models to determine whether cardiorespiratory fitness (VO2PEAK), MVPA, and health-related risk factors could affect the atrophy of brain areas and structures. An accelerometer (GT9-X ActiGraph) was worn for 7 days. Participants were then classified into 2 groups: <150 minutes MVPA (<150'MVPA; n = 20) and ≥150 minutes MVPA (≥150'MVPA; n = 25) per week. Older adults who accumulated ≥150'MVPA per week had significantly higher absolute and relative (% of intracranial volume) volumes of 39 and 9 brain areas and structures, respectively, than those who accumulated <150'MVPA per week. Higher VO2PEAK seems to be a key predictor of the atrophy of brain areas and structures. In conclusion, meeting weekly physical activity recommendations seems to have a widespread effect on preserving the volume of more than 30 brain areas and structures in older adults. VO2PEAK seems to be the most frequent and important predictor of brain volume preservation.
Assuntos
Encéfalo , Exercício Físico , Humanos , Idoso , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Imageamento por Ressonância Magnética , Atrofia , AcelerometriaRESUMO
Nucleic acid vaccines have become a revolutionary technology to give a fast, safe, cost-effective and efficient response against viral infections, such as SARS-CoV-2 or Human papillomavirus (HPV). However, to ensure their effectiveness, the development of adequate methods to protect, carry, and deliver nucleic acids is fundamental. In this work, nanoparticles (NPs) of chitosan (CS)-tripolyphosphate (TPP)-plasmid DNA (pDNA) were thoroughly modulated and characterized, by measuring the charge and size through dynamic light scattering (DLS) and morphology by scanning electron microscopy (SEM). Stability, cytotoxicity and cellular uptake of NPs were also evaluated. Finally, the effect of polyplexes on the expression of HPV E7 antigen in human fibroblast and RAW cells was investigated through polymerase chain reaction (PCR) and real-time PCR. The results showed NPs with a spherical/oval shape, narrow size distribution <180 nm and positive zeta potentials (>20 mV) and good stability after one month of storage at 4 °C in formulation buffer or when incubated in culture medium and trypsin. In vitro studies of NPs cytotoxicity revealed that the elimination of formulation buffers led to an improvement in the rate of cell viability. The E7 antigen transcription was also increased for NPs obtained with high pDNA concentration (60 µg/mL). The analyzed CS-TPP-pDNA polyplexes can offer a promising vehicle for nucleic acid vaccines, not only in the prevention or treatment of viral infections, but also to fight emergent and future pathogens.
RESUMO
In current times, DNA vaccines are seen as a promising approach to treat and prevent diseases, such as virus infections and cancer. Aiming at the production of a functional and effective plasmid DNA (pDNA) delivery system, four chitosan polymers, differing in the molecular weight, were studied using the design of experiments (DoE) tool. These gene delivery systems were formulated by ionotropic gelation and exploring the chitosan and TPP concentrations as DoE inputs to maximize the nanoparticle positive charge and minimize their size and polydispersity index (PDI) as DoE outputs. The obtained linear and quadratic models were statistically significant (p-value < 0.05) and non-significant lack of fit, with suitable coefficient of determination and the respective optimal points successfully validated. Furthermore, morphology, stability and cytotoxicity assays were performed to evaluate the endurance of these systems over time and their further potential for future in vitro studies. The subsequent optimization process was successful achieved for the delivery systems based on the four chitosan polymers, in which the smallest particle size was obtained for the carrier containing the 5 kDa chitosan (~82 nm), while the nanosystem prepared with the high molecular weight (HMW) chitosan displayed the highest zeta potential (~+26.8 mV). Delivery systems were stable in the formulation buffer after a month and did not exhibit toxicity for the cells. In this sense, DoE revealed to be a powerful tool to explore and tailor the characteristics of chitosan/pDNA nanosystems significantly contributing to unraveling an optimum carrier for advancing the DNA vaccines delivery field.
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ABSTRACT: One of the biggest challenges in intercropping of two or more crops is to maintain their productivity as that of their sole counterparts. In order to obtain sustainable intercropping systems in a semi-arid environment, this study evaluated the agro-economic advantage and sustainability of intercropped systems of carrot and cowpea, optimizing the green manuring and spatial arrangements. Experiments were conducted in the period from July to October 2017 and 2018, using a randomized complete block design with the treatments arranged in a 4 x 3 factorial scheme, with four replications. Treatments included four amounts of M. aegyptia incorporated into the soil (20, 35, 50, and 65 t ha-1 on dry basis) with three spatial arrangements (2:2, 3:3, and 4:4) between the components cultures formed from cowpea rows alternated with carrot rows. The agro-economic advantage indices evaluated in the intercropping systems were: land equivalent ratio (LER), area-time equivalent ratio (ATER), score of the canonical variable (Z), actual yield loss (AYL), intercropping advantage (IA), gross income (GI), net income (NI), rate of return (RR), and profit margin (PM). The highest agro-economic advantages of the carrot and cowpea intercropping were obtained for LER, ATER, NI, and RR of 2.60, 4.16, US$ 8,720.99 ha-1, and US$ 2.21, respectively, for M. aegyptia biomass amounts of 46.42, 47.82, 32.60 and 31.51t ha-1 added to the soil. The 2: 2 spatial arrangement was the one with the best productive performance, with higher net income and rate of return in the intercropping of carrot-cowpea.
RESUMO: Um dos maiores desafios no consórcio de duas ou mais culturas é manter sua produtividade como a de suas únicas contrapartes. Com o objetivo de obter sistemas de consórcio sustentáveis em ambiente semiárido, este estudo avaliou vantagem agroeconômica e a sustentabilidade de sistemas consorciados de cenoura e feijão-caupi, otimizando a adubação verde e os arranjos espaciais. Experimentos foram conduzidos no período de julho a outubro de 2017 e 2018, em delineamento de blocos ao acaso, com os tratamentos dispostos em esquema fatorial 4 x 3, com quatro repetições. Os tratamentos incluíram quatro quantidades de M. aegyptia incorporadas ao solo (20, 35, 50 e 65 t ha-1 em base seca) com três arranjos espaciais (2: 2, 3: 3 e 4: 4) entre as culturas componentes formadas a partir de fileiras de feijão-caupi alternadas com fileiras de cenoura. Os índices de vantagem agroeconômica avaliados nos sistemas de consorciação foram: índice de uso eficiente da terra (UET), razão de área equivalente no tempo (RAET), escore da variável canônica (Z), perda de rendimento real (PRR), vantagem do consórcio (VC), renda bruta (RB), renda líquida (RL), taxa de retorno (TR) e margem de lucro (ML). As maiores vantagens agroeconômicas do consórcio de cenoura e feijão-caupi foram obtidas para UET, RAET, RL e TR de 2,60, 4,16, US$ 8.720,99 ha-1 e US$ 2,21, respectivamente, para as quantidades de biomassa de M. aegyptia de 46,42, 47,82, 32,60 e 31,51 t ha-1, adicionadas ao solo. O arranjo espacial 2: 2 foi o de melhor desempenho produtivo, com maior receita líquida e taxa de retorno no consórcio entre feijão-caupi e cenoura.
RESUMO
Intracranial vessel wall imaging plays an increasing role in diagnosing intracranial vascular diseases. With the growing demand and subsequent increased use of this technique in clinical practice, radiologists and neurologists should be aware of the choices in imaging parameters and how they affect image quality, clinical indications, methods of assessment, and limitations in the interpretation of these images. Due to the improvement of the MRI techniques, the possibility of accurate and direct evaluation of the abnormalities in the arterial vascular wall (vessel wall imaging) has evolved, adding substantial data to diagnosis when compared to the indirect evaluation based on conventional flow analyses. Herein, the authors proposed a comprehensive approach of this technique reinforcing appropriated clinical settings to better use intracranial vessel wall imaging.
Assuntos
Transtornos Cerebrovasculares , Imageamento por Ressonância Magnética , Cabeça , Humanos , Angiografia por Ressonância Magnética/métodosRESUMO
ABSTRACT Intracranial vessel wall imaging plays an increasing role in diagnosing intracranial vascular diseases. With the growing demand and subsequent increased use of this technique in clinical practice, radiologists and neurologists should be aware of the choices in imaging parameters and how they affect image quality, clinical indications, methods of assessment, and limitations in the interpretation of these images. Due to the improvement of the MRI techniques, the possibility of accurate and direct evaluation of the abnormalities in the arterial vascular wall (vessel wall imaging) has evolved, adding substantial data to diagnosis when compared to the indirect evaluation based on conventional flow analyses. Herein, the authors proposed a comprehensive approach of this technique reinforcing appropriated clinical settings to better use intracranial vessel wall imaging.
RESUMO O estudo angiográfico intracraniano não invasivo está sendo amplamente utilizado no diagnóstico de doenças vasculares intracranianas. Com a crescente demanda e o aumento subsequente do uso dessa técnica na prática clínica, radiologistas e neurologistas devem estar cientes das opções nos parâmetros de imagem e como estes afetam a qualidade da imagem, as indicações clínicas, os métodos de avaliação e as limitações na interpretação dessas imagens. Devido ao aprimoramento das técnicas de imagem por RM, a possibilidade de avaliação precisa e direta das anormalidades na parede vascular arterial (vessel wall imaging) evoluiu, agregando dados substanciais ao diagnóstico quando comparados à avaliação indireta baseada em análises de fluxo convencionais. Neste artigo, os autores discorrem sobre a avaliação e interpretação dos achados de imagem desta nova técnica e suas aplicações clínicas.
Assuntos
Humanos , Imageamento por Ressonância Magnética , Transtornos Cerebrovasculares , Angiografia por Ressonância Magnética/métodos , CabeçaRESUMO
The use of amantadine in clinical practice still seems limited, despite its increasing evidence in the emergence of vegetative state after traumatic brain injury. We describe the case of an adolescent with severe traumatic brain injury after being run over by a car. After four months of hospitalization in a Central Hospital where he remained in a vegetative state, he was transferred to a Rehabilitation Center. He underwent a comprehensive rehabilitation program with physiotherapy, occupational therapy and speech therapy, including multisensory stimulation and intervention in the surrounding environment. He started amantadine, 50 mg/day, titrated up to 200 mg/day, with significant clinical and functional improvements, and emerged from vegetative state to minimally conscious state at week three and recovered consciousness at the sixth week of amantadine, maintaining progressive improvement, even after drug suspension. The case described underlines the importance of a holistic intervention and corroborates the literature in demonstrating the efficacy and safety of amantadine in the emergence from vegetative state.
A utilização da amantadina na prática clínica ainda parece pouco difundida, apesar da evidência crescente na emergência de alterações do estado de consciência após traumatismo cranioencefálico. Descrevemos o caso de um adolescente com traumatismo cranioencefálico grave por atropelamento. Após quatro meses de internamento num hospital central onde se manteve em estado vegetativo foi transferido para um centro de reabilitação. Iniciou um programa de reabilitação integral liderado por equipa médica, incluindo estimulação multissensorial e intervenção no meio envolvente. Iniciou amantadina, 50 mg/dia, titulada até 200 mg/dia, verificando-se melhoria clínica e funcional significativas, com emergência para estado de consciência mínima à terceira semana e recuperação da consciência à sexta semana de amantadina. Manteve melhoria progressiva mesmo após suspensão do fármaco. O caso descrito salienta a importância da intervenção holística e corrobora a literatura ao demonstrar a eficácia e segurança da amantadina na emergência do estado vegetativo.
Assuntos
Amantadina/administração & dosagem , Lesões Encefálicas Traumáticas/reabilitação , Estado Vegetativo Persistente , Adolescente , Lesões Encefálicas Traumáticas/tratamento farmacológico , Hospitalização , Humanos , Masculino , Resultado do TratamentoRESUMO
BACKGROUND: The New World Tropics has experienced a dynamic landscape across evolutionary history and harbors a high diversity of flora and fauna. While there are some studies addressing diversification in Neotropical vertebrates and plants, there is still a lack of knowledge in arthropods. Here we examine temporal and spatial diversification patterns in the damselfly family Polythoridae, which comprises seven genera with a total of 58 species distributed across much of Central and South America. RESULTS: Our time-calibrated phylogeny for 48 species suggests that this family radiated during the late Eocene (~ 33 Ma), diversifying during the Miocene. As with other neotropical groups, the Most Recent Common Ancestor (MRCA) of most of the Polythoridae genera has a primary origin in the Northern Andes though the MRCA of at least one genus may have appeared in the Amazon Basin. Our molecular clock suggests correlations with some major geographical events, and our biogeographical modeling (with BioGeoBEARS and RASP) found a significant influence of the formation of the Pebas and Acre systems on the early diversification of these damselflies, though evidence for the influence of the rise of the different Andean ranges was mixed. Diversification rates have been uniform in all genera except one-Polythore-where a significant increase in the late Pliocene (~ 3 mya) may have been influenced by recent Andean uplift. CONCLUSION: The biogeographical models implemented here suggest that the Pebas and Acre Systems were significant geological events associated with the diversification of this damselfly family; while diversification in the tree shows some correlation with mountain building events, it is possible that other abiotic and biotic changes during our study period have influenced diversification as well. The high diversification rate observed in Polythore could be explained by the late uplift of the Northern Andes. However, it is possible that other intrinsic factors like sexual and natural selection acting on color patterns could be involved in the diversification of this genus.
Assuntos
Evolução Biológica , Geografia , Odonatos , Animais , Filogenia , América do SulRESUMO
HistoryA 13-year-old girl was born to consanguineous parents. She presented with mild intellectual impairment, convergent strabismus, horizontal gaze palsy, and bilateral abducens palsy. Vertical gaze was preserved, and no abnormalities suggesting facial paralysis were noted. In addition, she reported progressive back pain since she was 5 years old. Other symptoms were denied. No medications or related drugs had been administered thus far. The patient underwent brain MRI for further evaluation. Current and previous spine radiographs were also reviewed.
Assuntos
Análise Mutacional de DNA , Oftalmoplegia Externa Progressiva Crônica/genética , Receptores de Superfície Celular/genética , Escoliose/genética , Adolescente , Consanguinidade , Feminino , Humanos , Imageamento por Ressonância Magnética , Oftalmoplegia Externa Progressiva Crônica/diagnóstico por imagem , Doenças Raras , Escoliose/diagnóstico por imagemRESUMO
Nutrient deficiency is one of the major problems of the human population today. Studies indicate that consumers consider that the price of food is more relevant than its nutritional value. Therefore, this work sought to compare the costs of nutrients provided by typical foods found in the Brazilian diet. Food prices available in virtual markets were collected, and the costs to meet 30% of the daily recommendations for a healthy adult were calculated for eight nutrients. Poultry was found to be the cheapest source of protein. Cereal fiber had the lowest cost for both fiber and iron. The cheapest sources of calcium were Ovaltine and dairy products, whereas cow`s liver was the best ranked food for vitamin A. Vitamin C was found to be the cheapest nutrient in the Brazilian diet, with acerola juice being the cheapest source of this nutrient. Dairy products occupied the first six positions in the ranking of vitamin D, while nuts and seeds were the cheapest sources of vitamin E. The results showed that Brazilian consumers can meet the recommended intake of critical nutrients at a low cost through the purchase of the best ranked foods. However, this ranking should be weighted according to the food quality, as recommended in the New Dietary Guidelines for the Brazilian Population.
Um dos maiores problemas atuais da população é a deficiência de nutrientes. Estudos indicam que consumidores consideram o preço dos alimentos mais relevante do que os valores nutricionais. Assim, este trabalho objetivou comparar o custo dos nutrientes de alimentos típicos da dieta brasileira, realizando coletas de preços em mercados virtuais e calculando o custo para se atingir 30% das necessidades diárias de um adulto saudável para oito nutrientes. A carne de frango foi a fonte mais barata de proteína. A fibra de cereal teve o menor custo para fibra e ferro. As fontes mais baratas de cálcio foram o Ovomaltine e os lácteos, e o fígado bovino foi o alimento melhor ranqueado para vitamina A. A vitamina C foi o nutriente mais barato na dieta brasileira, e o suco de acerola a fonte mais barata deste nutriente. Os lácteos ocuparam as seis primeiras posições no "ranking" da vitamina D, e nozes e sementes apresentaram o menor custo para vitamina E. Os resultados mostraram que os consumidores brasileiros podem alcançar a ingestão recomendada de nutrientes considerados críticos a um baixo custo por meio da aquisição dos alimentos melhor ranqueados. No entanto, esse ranqueamento deve ser ponderado em função da qualidade do alimento, conforme preconiza o Novo Guia Alimentar para a População Brasileira.
Assuntos
Análise Custo-Benefício , Alimentos/economia , Valor Nutritivo , Brasil , Humanos , Recomendações NutricionaisRESUMO
Resumo Um dos maiores problemas atuais da população é a deficiência de nutrientes. Estudos indicam que consumidores consideram o preço dos alimentos mais relevante do que os valores nutricionais. Assim, este trabalho objetivou comparar o custo dos nutrientes de alimentos típicos da dieta brasileira, realizando coletas de preços em mercados virtuais e calculando o custo para se atingir 30% das necessidades diárias de um adulto saudável para oito nutrientes. A carne de frango foi a fonte mais barata de proteína. A fibra de cereal teve o menor custo para fibra e ferro. As fontes mais baratas de cálcio foram o Ovomaltine e os lácteos, e o fígado bovino foi o alimento melhor ranqueado para vitamina A. A vitamina C foi o nutriente mais barato na dieta brasileira, e o suco de acerola a fonte mais barata deste nutriente. Os lácteos ocuparam as seis primeiras posições no "ranking" da vitamina D, e nozes e sementes apresentaram o menor custo para vitamina E. Os resultados mostraram que os consumidores brasileiros podem alcançar a ingestão recomendada de nutrientes considerados críticos a um baixo custo por meio da aquisição dos alimentos melhor ranqueados. No entanto, esse ranqueamento deve ser ponderado em função da qualidade do alimento, conforme preconiza o Novo Guia Alimentar para a População Brasileira.
Abstract Nutrient deficiency is one of the major problems of the human population today. Studies indicate that consumers consider that the price of food is more relevant than its nutritional value. Therefore, this work sought to compare the costs of nutrients provided by typical foods found in the Brazilian diet. Food prices available in virtual markets were collected, and the costs to meet 30% of the daily recommendations for a healthy adult were calculated for eight nutrients. Poultry was found to be the cheapest source of protein. Cereal fiber had the lowest cost for both fiber and iron. The cheapest sources of calcium were Ovaltine and dairy products, whereas cow`s liver was the best ranked food for vitamin A. Vitamin C was found to be the cheapest nutrient in the Brazilian diet, with acerola juice being the cheapest source of this nutrient. Dairy products occupied the first six positions in the ranking of vitamin D, while nuts and seeds were the cheapest sources of vitamin E. The results showed that Brazilian consumers can meet the recommended intake of critical nutrients at a low cost through the purchase of the best ranked foods. However, this ranking should be weighted according to the food quality, as recommended in the New Dietary Guidelines for the Brazilian Population.
Assuntos
Humanos , Análise Custo-Benefício , Alimentos/economia , Valor Nutritivo , Brasil , Recomendações NutricionaisRESUMO
Pediatric multiple sclerosis (MS) deserves special attention because of its impact on cognitive function and development. Although knowledge regarding pediatric MS has rapidly increased, understanding the peculiarities of this population remains crucial for disease management. There is limited expertise about the efficacy and safety of current disease-modifying agents. Although pathophysiology is not entirely understood, some risk factors and immunological features have been described and are discussed herein. While the revised International Pediatric MS Study Group diagnostic criteria have improved the accuracy of diagnosis, the recently revised McDonald criteria also offer some new insights into the pediatric population. It is fundamental that radiologists have strong knowledge about the vast spectrum of demyelinating disorders that can occur in childhood to ensure appropriate diagnosis and provide early treatment.
Assuntos
Esclerose Múltipla/diagnóstico por imagem , Idade de Início , Criança , Diagnóstico Diferencial , HumanosRESUMO
HistoryA 13-year-old girl was born to consanguineous parents. She presented with mild intellectual impairment, convergent strabismus, horizontal gaze palsy, and bilateral abducens palsy. Vertical gaze was preserved, and no abnormalities suggesting facial paralysis were noted. In addition, she reported progressive back pain since she was 5 years old. Other symptoms were denied. No medications or related drugs had been administered thus far.