Establishing a safe anesthesia concentration window for Nile tilapia (Oreochromis niloticus) (Linnaeus 1758) by monitoring cardiac activity in eugenol immersion baths.

Nile tilapia, Oreochromis niloticus, is the most cultivated fish species in the world, due to its low cost, high growth rate, environmental adaptability, and resistance to disease and stress. Anesthetics for fish become necessary in management because they minimize mortality during transport and maintenance of ponds, one of the most used anesthetics is clove oil, which has eugenol as the major substance, representing 90-95 % of clove oil. The present study evaluates the effect of eugenol on cardiac activity in Oreochromis niloticus specimens and relates it to behavioral data to determine a concentration window for safe anesthesia. For the comportamental analysis, was used five treatments (50, 75, 100, 125, and 150 µL·L-1) were evaluated and for the eletrocardiographic test was used seven groups (Control, Vehicle, 50, 75, 100, 125, and 150 µL·L-1), n = 9/treatment, totaling 108 animals. Behavioral and electrocardiographic tests were performed on all treatments during induction and recovery. The results of the behavioral tests demonstrated the reversibility of the effects with recovery of the posture reflex, varying according to the concentration. The ECG results showed a slow recovery because, at concentrations above 100 µL·L-1, there was no full reversibility of the cardiac effects in the observed experiment time, which could cause greater changes in the tilapia hemodynamics, which led us to identify a window for safe anesthesia. Eugenol is an effective anesthetic in Nile tilapia juveniles when used in concentrations ranging from 50 to 100 µL·L-1, if there is a need for anesthetic deepening, doses above 100 µL·L-1, however, the animals must be monitored due to hemodynamic changes.

Comparison between xCELLigence biosensor technology and conventional cell culture system for real-time monitoring human tenocytes proliferation and drugs cytotoxicity screening.

BACKGROUND: Local injections of anesthetics, NSAIDs, and corticosteroids for tendinopathies are empirically used. They are believed to have some cytotoxicity toward tenocytes. The maximal efficacy dosages of local injections should be determined. A commercial 2D microfluidic xCELLigence system had been developed to detect real-time cellular proliferation and their responses to different stimuli and had been used in several biomedical applications. The purpose of this study is to determine if human tenocytes can successfully proliferate inside xCELLigence system and the result has high correlation with conventional cell culture methods in the same condition. METHODS: First passage of human tenocytes was seeded in xCELLigence and conventional 24-well plates. Ketorolac tromethamine, bupivacaine, methylprednisolone, and betamethasone with different concentrations (100, 50, and 10% diluted of clinical usage) were exposed in both systems. Gene expression of type I collagen, type III collagen, tenascin-C, decorin, and scleraxis were compared between two systems. RESULTS: Human tenocytes could proliferate both in xCELLigence and conventional cell culture systems. Cytotoxicity of each drug revealed dose-dependency when exposed to tenocytes in both systems. Significance was found between groups. All the four drugs had comparable cytotoxicity in their 100% concentration. When 50% concentration was used, betamethasone had a relatively decreased cytotoxicity among them in xCELLigence but not in conventional culture. When 10% concentration was used, betamethasone had the least cytotoxicity. Strong and positive correlation was found between cell index of xCELLigence and result of WST-1 assay (Pearson's correlation [r] = 0.914). Positive correlation of gene expression between tenocytes in xCELLigence and conventional culture was also observed. Type I collagen: [r] = 0.823; type III collagen: [r] = 0.899; tenascin-C: [r] = 0.917; decorin: [r] = 0.874; and scleraxis: [r] = 0.965. CONCLUSIONS: Human tenocytes could proliferate inside xCELLigence system. These responses varied when tenocytes were exposed to different concentrations of ketorolac tromethamine, bupivacaine, methylprednisolone, and betamethasone. The result of cell proliferation and gene expression of tenocytes in both xCELLigence and conventional culture system is strongly correlated. CLINICAL RELEVANCE: xCELLigence culture system may replace conventional cell culture, which made real-time tenocyte proliferation monitoring possible.

Anesthetic propofol overdose causes vascular hyperpermeability by reducing endothelial glycocalyx and ATP production.

Prolonged treatment with a large dose of propofol may cause diffuse cellular cytotoxicity; however, the detailed underlying mechanism remains unclear, particularly in vascular endothelial cells. Previous studies showed that a propofol overdose induces endothelial injury and vascular barrier dysfunction. Regarding the important role of endothelial glycocalyx on the maintenance of vascular barrier integrity, we therefore hypothesized that a propofol overdose-induced endothelial barrier dysfunction is caused by impaired endothelial glycocalyx. In vivo, we intraperitoneally injected ICR mice with overdosed propofol, and the results showed that a propofol overdose significantly induced systemic vascular hyperpermeability and reduced the expression of endothelial glycocalyx, syndecan-1, syndecan-4, perlecan mRNA and heparan sulfate (HS) in the vessels of multiple organs. In vitro, a propofol overdose reduced the expression of syndecan-1, syndecan-4, perlecan, glypican-1 mRNA and HS and induced significant decreases in the nicotinamide adenine dinucleotide (NAD+)/NADH ratio and ATP concentrations in human microvascular endothelial cells (HMEC-1). Oligomycin treatment also induced significant decreases in the NAD+/NADH ratio, in ATP concentrations and in syndecan-4, perlecan and glypican-1 mRNA expression in HMEC-1 cells. These results demonstrate that a propofol overdose induces a partially ATP-dependent reduction of endothelial glycocalyx expression and consequently leads to vascular hyperpermeability due to the loss of endothelial barrier functions.

AV-block and conduction slowing prevail over TdP arrhythmias in the methoxamine-sensitized pro-arrhythmic rabbit model.

INTRODUCTION: The methoxamine-sensitized rabbit model is widely used to screen drugs for proarrhythmic properties, especially repolarization-dependent TdP arrhythmias. With the change of anesthesia and/or sensitizing agent, conduction disturbances have been reported as well. Therefore, we compared currently available in-house anesthetics in order to preserve arrhythmia sensitivity and preclude conduction disturbances. METHODS AND RESULTS: Rabbits were randomly assigned to 3 groups: (1) 35 mg/kg ketamine + 5 mg/kg xylazine; (2) 0.5 mL/kg hypnorm + 3 mg/kg midazolam; (3) 35 mg/kg ketamine + 20 mg/kg propofol. Anesthesia was maintained by 1.5% isoflurane. Concomitant infusion of methoxamine (17 µg/kg/min for 40 minutes) and dofetilide (10 µg/kg/min for 30 minutes) was used to induce arrhythmias. Sole methoxamine infusion exclusively decreased HR in groups 1 and 3. Dofetilide lengthened repolarization, followed in time by PQ/QRS prolongation, second-degree AV block, and subsequently TdP arrhythmias. TdP was seen in 80%, 0%, and 33% of the rabbits in groups 1, 2, and 3, respectively. Decreasing the dose of dofetilide to 5 µg/kg/min in ketamine/xylazine anesthetized rabbits resulted in a drop in TdP incidence (25%) while conduction disturbances persisted. Flunarizine (n = 6) suppressed all TdP arrhythmias while conduction disturbances remained present. CONCLUSION: TdP incidence in the methoxamine-sensitized rabbit could be dramatically influenced by anesthesia, drug dose, and flunarizine, while conduction slowing remained present. Thus, conduction slowing seems to be the integral outcome in this model.

Comparison of the effects of four anaesthetics on haematological and blood biochemical profiles in pikeperch (Sander lucioperca L.).

OBJECTIVES: The objectives of the study were to compare the effects of Propiscin, 2-phenoxyethanol, clove oil and tricaine methane sulphonate (MS 222), anaesthetics frequently used in aquaculture. DESIGN: The haematological and biochemical blood profiles of pikeperch (Sander lucioperca L.) anesthetized with Propiscin (1.5 ml L-1), 2-phenoxyethanol (0.3 ml L-1), clove oil (33 mg L-1), MS 222 (150 mg L-1) and non-anesthetized control group were tested. Each tested group was divided into two subgroups, the first subgroup was sampled in anaesthesia 10 min after application of the anaesthetic and the second one live on 24h. RESULTS: The erythrocyte count and haematocrit was significantly decreased in 2-phenoxyethanol (24 h) compared with control group (CG). The mean corpuscular haemoglobin concentration was significantly increased in 2-phenoxyethanol (10 min), Propiscin (10 min and 24 h) compared to CG. The 2-phenoxyethanol (10 min and 24 h), MS 222 (24 h), clove oil (24 h), and Propiscin (10 min and 24 h) showed significantly lower leukocyte count compared with CG. The level of glucose was significantly (p<0.05) elevated with MS 222 (10 min) and clove oil (10 min) compared with CG. The 2-phenoxyethanol (10 min and 24 h), MS 222 (24 h), clove oil (24 h), and Propiscin (24 h) showed significantly lower (p<0.01) ammonia levels compared with CG. The triacylglycerols was significantly decreased (p<0.01) with Propiscin (10 min and 24 h), MS 222 (24 h), clove oil (24 h) and with 2-phenoxyethanol (24 h) compared with CG. After 24 hours MS 222 (24 h) and Propiscin (24 h) anaesthesia, fish showed significantly lower (p<0.01) concentration of inorganic phosphate compared with CG. CONCLUSIONS: On the basis of this experiment, it appears that clove oil was associated with the lowest effects in pikeperch and therefore would be recommended as an alternative to MS 222, while Propiscin and 2-phenoxyethanol are not suitable for manipulation with pikeperch in aquaculture.

Evaluation of the toxicity of eugenol at anesthetic doses in African clawed frogs (Xenopus laevis).

Eugenol has been shown to induce anesthesia in African clawed frogs (Xenopus laevis). The toxicity of eugenol, administered at anesthetic doses, was evaluated in Xenopus frogs with an average body weight of 28.2 ± 13.7 g. Frogs were immersed in 250 mL of an aqueous solution containing 350 µl/L of eugenol for ten minutes and received a single administration (group 1, twelve animals) or three consecutive daily administrations (group 2, twelve animals). In each group, six frogs were scheduled to be euthanized the following day (subgroup A) and the other six were scheduled to be euthanized after a one-week recovery period (subgroup B). Morphologic changes consistent with renal tubular apoptosis affecting distal tubules in the medulla were observed in all subgroup A animals, ranging from mild to moderate in group 1, and from mild to severe in group 2. In subgroup B, renal tubular regeneration was present in all but one animal examined. These findings suggest that eugenol toxicity in amphibians is first manifested by renal tubular apoptosis. Other eugenol-related lesions were massive hepatic necrosis in group 2 (n = 6), hyaline membranes in the lung (n = 5), and adipose tissue hemorrhages in group/subgroup 2B (n = 4).

Daily rhythms of toxicity and effectiveness of anesthetics (MS222 and eugenol) in zebrafish (Danio rerio).

Although the chronotoxicity of xenobiotics is relatively well known in mammals, the existence of daily rhythms of drug toxicity and effectiveness in fish has been neglected to date. The aim of this research was to investigate the influence of the time (middle of the light phase [ML] versus middle of the dark phase [MD]) of exposure to two anesthetic substances (MS-222 or clove oil) commonly used with fish on the median lethal concentration (LC(50)) and swimming activity of zebrafish (Danio rerio). To this end, adult zebrafish were kept under a 12 h:12 h light-dark (LD) cycle and exposed to different concentrations of the anesthetics for 15 min at ML or MD. LC(50) calculations were performed using the Spearman-Karber program, whereas swimming activity was video-recorded and analyzed with specialized software. Zebrafish exhibited a mostly diurnal activity pattern (77.9% of activity occurring during daytime). The acute toxicity and mortality caused by MS-222 and eugenol varied with the time of exposure. For MS-222, the LC(50) was 170.6 ± 7.4 mg/L in fish exposed at ML and 215.6 ± 3.9 mg/L at MD, whereas for eugenol the LC(50) was 70.3 ± 3.1 mg/L at ML and 104.9 ± 5.4 mg/L at MD. Exposure to sublethal concentrations of MS-222 and eugenol altered the swimming patterns of zebrafish in a different manner depending on the time of exposure. Thus, the time required for decreasing swimming activity during exposure to anesthetics was shorter at ML than at MD, whereas the recovery period was longer during the day. In conclusion, these results revealed that the toxicity and effectiveness of both anesthetic substances is highest during daytime, the active phase of fish, thus suggesting a link between the daily rhythms of behavior and toxicity.

The effect of midazolam on mouse Leydig cell steroidogenesis and apoptosis.

The peripheral-type benzodiazepine receptor (PBR), a putative receptor in Leydig cells, modulates steroidogenesis. Since benzodiazepines are commonly used in regional anesthesia, their peripheral effects need to be defined. Therefore, this study set out to investigate in vitro effects of the benzodiazepine midazolam (MDZ) on Leydig cell steroidogenesis, and the possible underlying mechanisms. The effects of MDZ on steroidogenesis in primary mouse Leydig cells and MA-10 Leydig tumor cells were determined by radioimmunoassay. PBR, P450scc, 3beta-HSD and StAR protein expression induced by MDZ was determined by Western blotting. Inhibitors of the signal transduction pathway and a MDZ antagonist were used to investigate the intracellular cascades activated by MDZ. In both cell types, MDZ-stimulated steroidogenesis in dose- and time-dependent manners, and induced the expression of PBR and StAR proteins, but had no effect on P450scc and 3beta-HSD expressions. Moreover, H89 (PKA inhibitor) and GF109203X (PKC inhibitor) attenuated MDZ-stimulated steroid production. Interestingly, the MDZ antagonist (flumazenil) did not decrease MDZ-induced steroid production in both cell types. These results highly indicated that MDZ-induced steroidogenesis in mouse Leydig cells via PKA and PKC pathways, along with the expression of PBR and StAR proteins. In addition, MDZ at high dosages induced rounding-up, membrane blebbing, and then death in MA-10 cells. In conclusion, midazolam could induce Leydig tumor cell steroidogenesis, and high dose of midazolam could induce apoptosis in Leydig tumor cells.

Comparison of acute toxicity of 2-phenoxyethanol and clove oil to juvenile and embryonic stages of Danio rerio.

OBJECTIVES: Anaesthetics are used in aquaculture to prevent stress and mechanical damage to fish during handling or the treatment of fish in breeding, blood sampling and other veterinary interventions. Clove oil and 2-phenoxyethanol are used in the Czech Republic in a water bath for the short-term immobilization of the fish. DESIGN: Acute toxicity tests were performed on aquarium fish Danio rerio, which is considered to be one of the model organisms most commonly used in toxicity testing. The semi-static method according to OECD No. 203 (Fish acute toxicity test) was used for testing juvenile fish. Embryo toxicity tests were performed in zebrafish embryos (D. rerio) in compliance with the OECD No. 212 methodology (Fish, short-term toxicity test on embryo and sac-fry stages). The results obtained (the number of dead individuals at particular test concentrations) were subjected to a probit analysis using the EKO-TOX 5.2 programme in order to determine LC50 clove oil and 2-phenoxyethanol values. The statistical significance of the difference between LC50 values in juvenile and embryonic stages of D. rerio was tested using the Mann-Whitney non-parametric test implemented in the Unistat 5.1 programme. RESULTS: The LC50 clove oil mean value was 18.8 +/- 5.52 mg.L-1 in juvenile D. rerio, and 15.64 +/- 3.30 mg.L-1 in embryonic stages of D. rerio. The LC50 2-phenoxyethanol mean value was 338.22 +/- 15.22 mg.L-1 in juvenile D. rerio, whereas in embryonic stages of D. rerio it was 486.35 +/- 25.53 mg.L-1. CONCLUSIONS: The study proved statistically significantly higher (p<0.01) sensitivity in juvenile fish to 2-phenoxyethanol compared to the embryonic stages. Acute toxicity values of clove oil for juvenile and embryonic stages were comparable.

Strategies and experimental models for evaluating anesthetics: effects on the developing nervous system.

Advances in pediatric and obstetric surgery have resulted in an increase in the duration and complexity of procedures requiring anesthesia. It has been reported that anesthetic drugs cause widespread and dose-dependent apoptosis in the developing rat brain. The similarity of the physiology, pharmacology, metabolism, and reproductive systems of the nonhuman primate to that of the human, especially during pregnancy, make the monkey an exceptionally good animal model for assessing potential neurotoxic effects of anesthetics. The window of vulnerability to these neuronal effects of pediatric anesthetics is restricted to the period of rapid synaptogenesis, also known as the brain growth spurt period. To minimize the risks to children resulting from the use of anesthesia, the following questions should be addressed: 1. What is the relationship between exposure and brain cell loss for drugs commonly used in the practice of pediatric anesthesia (inhaled anesthetics, midazolam, ketamine, and nitrous oxide)? 2. Are there "class effects," or does each drug need to be considered independently? 3. Are there important interactions among the drugs used as anesthetics contributing to the risk of brain cell death? 4. What is the likely period of human vulnerability? Pharmacogenomic/system biology approaches have great potential for helping to advance the understanding of brain-related biological processes, including neuronal plasticity and neurotoxicity. Because of the complexity and temporal features of how developmental neurotoxicity is manifested, pharmacogenomic/systems biology approaches may prove to be useful tools for enhancing our understanding of the biological processes induced by anesthetics. Therefore, the main purpose of this review is to describe the application of these approaches and models, as well as protection strategies, especially as regards the issue of anesthetic-induced neuronal cell death during development. Much of the discussion that follows is based on experiments conducted with ketamine. This is due in part to the use of ketamine in the early studies and the volume of preclinical experimental work performed with this drug, as well as its use in anesthetic studies in developing rodents and nonhuman primates. Although ketamine use in pediatric anesthesia is relatively limited, the findings of the studies are sufficiently strong to merit concern about the N-methyl-d-aspartate antagonist drugs as a class. Our focus on ketamine should not be construed as implying that the risk of neurodegeneration with ketamine is greater, or less, than with other anesthetics. We are simply describing the effects where we have the most preclinical data.

Heme oxygenase-1 as a potential therapeutic target for hepatoprotection.

Heme oxygenase (HO), the rate limiting enzyme in the breakdown of heme into carbon monoxide (CO), iron and bilirubin, has recently received overwhelming research attention. To date three mammalian HO isozymes have been identified, and the only inducible form is HO-1 while HO-2 and HO-3 are constitutively expressed. Advances in unveiling signal transduction network indicate that a battery of redox-sensitive transcription factors, such as activator protein-1 (AP-1), nuclear factor-kappa B (NF-kappaB) and nuclear factor E2-related factor-2 (Nrf2), and their upstream kinases including mitogen-activated protein kinases play an important regulatory role in HO-1 gene induction. The products of the HO-catalyzed reaction, particularly CO and biliverdin/bilirubin have been shown to exert protective effects in several organs against oxidative and other noxious stimuli. In this context, it is interesting to note that induction of HO-1 expression contributes to protection against liver damage induced by several chemical compounds such as acetaminophen, carbon tetrachloride and heavy metals, suggesting HO-1 induction as an important cellular endeavor for hepatoprotection. The focus of this review is on the significance of targeted induction of HO-1 as a potential therapeutic strategy to protect against chemically-induced liver injury as well as hepatocarcinogenesis.

Anesthetic and nephrotoxic effects of Telazol in New Zealand white rabbits.

Telazol was evaluated as an anesthetic for rabbits. Two groups of five rabbits each were injected intramuscularly with 32 or 64 mg/kg of Telazol, and the depth and duration of anesthesia period monitored. At both doses, the righting reflex was lost within 2 minutes postinjection. Animals in both groups responded to noxious stimuli for the duration of the anesthesia. Hematology and urinalyses were performed daily for 7 days postinjection. Hematologic parameters remained unchanged in both groups. In the high-dose group, blood urea nitrogen and serum creatinine levels increased 1 day postinjection and continued steadily throughout the week. Elevations in urine protein and the presence of casts correlated with this increase. In the low-dose group, blood urea nitrogen and creatinine levels increased and protein was present in the urine of four of five rabbits beginning approximately 5 days postinjection. Histologically, severe renal tubular necrosis was evident 7 days postinjection in all high-dose rabbits and in three rabbits in the low-dose group. Our results indicate that Telazol does not produce analgesia in rabbits and is nephrotoxic at both 32 and 64 mg/kg. We conclude that Telazol is contraindicated for use in rabbits.

Cardiovascular dysfunction and hypersensitivity to sodium pentobarbital induced by chronic barium chloride ingestion.

Barium-supplemented Long-Evans hooded rats were characterized by a persistent hypertension that was evident after 1 month of barium (100 micrograms/ml mineral fortified water) treatment. Analysis of in vivo myocardial excitability, contractility, and metabolic characteristics at 16 months revealed other significant barium-induced disturbances within the cardiovascular system. The most distinctive aspect of the barium effect was a demonstrated hypersensitivity of the cardiovascular system to sodium pentobarbital. Under barbiturate anesthesia, virtually all of the myocardial contractile indices were depressed significantly in barium-exposed rats relative to the corresponding control-fed rats. The lack of a similar response to ketamine and xylazine anesthesia revealed that the cardiovascular actions of sodium pentobarbital in barium-treated rats were linked specifically to this anesthetic, and were not representative of a generalized anesthetic response. Other myocardial pathophysiologic and metabolic changes induced by barium were manifest, irrespective of the anesthetic employed. The contractile element shortening velocity of the cardiac muscle fibers was significantly slower in both groups of barium-treated rats relative to the control groups, irrespective of the anesthetic regimen. Similarly, significant disturbances in myocardial energy metabolism were detected in the barium-exposed rats which were consistent with the reduced contractile element shortening velocity. In addition, the excitability of the cardiac conduction system was depressed preferentially in the atrioventricular nodal region of hearts from barium-exposed rats. Overall, the altered cardiac contractility and excitability characteristics, the myocardial metabolic disturbances, and the hypersensitivity of the cardiovascular system to sodium pentobarbital suggest the existence of a heretofore undescribed cardiomyopathic disorder induced by chronic barium exposure. These experimental findings represent the first indication that life-long barium ingestion may have significant adverse effects on the mammalian cardiovascular system.

Variations in onset of porcine malignant hyperthermia.

Variations in the onset of malignant hyperthermia were observed in five Poland China swine. These pigs were equivalently susceptible to malignant hyperthermia, based on the rapid onset in response to mask inhalation induction with halothane (five pigs) or sevoflurane (two pigs). A moderate dose of thiopental delayed the response to sevoflurane 10 minutes (one pig) and larger doses delayed it more than 60 minutes (two pigs). Total paralysis with pancuronium in the absence of other drugs delayed the response to halothane 30 and 60 minutes (two pigs). The results suggest that drugs that decrease either neuromuscular transmission or reflex responsiveness can delay the onset of episodes of malignant hyperthermia. These data suggest pancuronium as a relaxant of choice in anesthesia for susceptible subjects. Correlation with other data suggests that malignant hyperthermia may be difficult to initiate in subjects paralyzed by non-depolarizing relaxants in the absence of exposure to potent volatile agents. Thus the use of relaxant-induced paralysis might aid in the care of patients who develop recurrent malignant hyperthermia.

[Suspension cultures of Ehrlich ascites tumor cells as a test system for the study of cytotoxic effects of anaesthetics (author's transl)]. / Suspensionskulturen von Ehrlich-Ascitestumorzellen als Arbeits-Modell zum Nachweis zelltoxischer Anaesthetikawirkungen.

Cultures of a permanently in suspension growing line of Ehrlich ascites tumor cells (EATC) were studied regarding their use as a test system for the determination of cytotoxic effects of anaesthetics. These cells, having a comparatively high reduplication rate, are cultured at 37 degrees C in vitro in a chemically defined liquid medium supplemented by 15% horse serum without agitation in a closed system. In order to detect drug effects on the cultures various cellular parameters can be determined due to the suspension character of the cultures without complicated preparatory measures, e.g. cell number or multiplication rate, cell volume, cell volume distribution. Moreover biochemical parameters, such as protein or nucleic acid content, may be estimated after centrifugation of the cultures separately in the cell sediment and the medium supernatant. Applying drugs of various pharmacological groups (cytostatic and anti-inflammatory drugs, local and general anaesthetics) the usefulness of some of these parameters for the detection of cytotoxic effects was studied.

Screening of certain anaesthetic agents for their ability to elicit acute porphyric phases in susceptible patients.

The activity of delta-aminolaevulinic acid synthetase (E.C. 2.3.1.37) (ALA-S) was measured in rat liver after the simultaneous administration of various anesthetic agents and 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC) in vivo. Flunitrazepam, Althesin and phenobarbitone caused a significant increase in the activity of the enzyme which was not observed with propanidid, etomidate and minaxolone. It is suggested that DDC-treated rat, which resembles latent human variegate porphyria, may be a more valid method of testing drugs for their ability to elicit acute porphyric phases in susceptible individuals. The anaesthetic agents which induced the activity of hepatic ALA-S in this model are not recommended in patients with genetic hepatic porphyria.