Redefining migraine prevention: early treatment with anti-CGRP monoclonal antibodies enhances response in the real world.

BACKGROUND: Anti-CGRP monoclonal antibodies (anti-CGRP MAbs) are approved and available treatments for migraine prevention. Patients do not respond alike and many countries have reimbursement policies, which hinder treatments to those who might respond. This study aimed to investigate clinical factors associated with good and excellent response to anti-CGRP MAbs at 6 months. METHODS: European multicentre, prospective, real-world study, including high-frequency episodic or chronic migraine (CM) patients treated since March 2018 with anti-CGRP MAbs. We defined good and excellent responses as ≥50% and ≥75% reduction in monthly headache days (MHD) at 6 months, respectively. Generalised mixed-effect regression models (GLMMs) were used to identify variables independently associated with treatment response. RESULTS: Of the 5818 included patients, 82.3% were females and the median age was 48.0 (40.0-55.0) years. At baseline, the median of MHD was 20.0 (14.0-28.0) days/months and 72.2% had a diagnosis of CM. At 6 months (n=4963), 56.5% (2804/4963) were good responders and 26.7% (1324/4963) were excellent responders. In the GLMM model, older age (1.08 (95% CI 1.02 to 1.15), p=0.016), the presence of unilateral pain (1.39 (95% CI 1.21 to 1.60), p<0.001), the absence of depression (0.840 (95% CI 0.731 to 0.966), p=0.014), less monthly migraine days (0.923 (95% CI 0.862 to 0.989), p=0.023) and lower Migraine Disability Assessment at baseline (0.874 (95% CI 0.819 to 0.932), p<0.001) were predictors of good response (AUC of 0.648 (95% CI 0.616 to 0.680)). These variables were also significant predictors of excellent response (AUC of 0.691 (95% CI 0.651 to 0.731)). Sex was not significant in the GLMM models. CONCLUSIONS: This is the largest real-world study of migraine patients treated with anti-CGRP MAbs. It provides evidence that higher migraine frequency and greater disability at baseline reduce the likelihood of responding to anti-CGRP MAbs, informing physicians and policy-makers on the need for an earlier treatment in order to offer the best chance of treatment success.

Unconventional structure and mechanisms for membrane interaction and translocation of the NF-κB-targeting toxin AIP56.

Bacterial AB toxins are secreted key virulence factors that are internalized by target cells through receptor-mediated endocytosis, translocating their enzymatic domain to the cytosol from endosomes (short-trip) or the endoplasmic reticulum (long-trip). To accomplish this, bacterial AB toxins evolved a multidomain structure organized into either a single polypeptide chain or non-covalently associated polypeptide chains. The prototypical short-trip single-chain toxin is characterized by a receptor-binding domain that confers cellular specificity and a translocation domain responsible for pore formation whereby the catalytic domain translocates to the cytosol in an endosomal acidification-dependent way. In this work, the determination of the three-dimensional structure of AIP56 shows that, instead of a two-domain organization suggested by previous studies, AIP56 has three-domains: a non-LEE encoded effector C (NleC)-like catalytic domain associated with a small middle domain that contains the linker-peptide, followed by the receptor-binding domain. In contrast to prototypical single-chain AB toxins, AIP56 does not comprise a typical structurally complex translocation domain; instead, the elements involved in translocation are scattered across its domains. Thus, the catalytic domain contains a helical hairpin that serves as a molecular switch for triggering the conformational changes necessary for membrane insertion only upon endosomal acidification, whereas the middle and receptor-binding domains are required for pore formation.

Stabilization of Natural Pigments in Ethanolic Solutions for Food Applications: The Case Study of Chlorella vulgaris.

Chlorella vulgaris is a green microalga with a high chlorophyll content, representing a valuable source of green pigments for food applications. As the application of whole biomass can promote an unpleasant fish-like flavor, the use of chlorophyll extract can overcome this drawback. However, chlorophylls tend to easily degrade when out of the chloroplasts, decreasing their potential as a food ingredient. Thus, to study the suitable conditions for isolated chlorophylls preservation, in this work, the influence of temperature (4 to 60 °C), light (dark or 24 h photoperiod), alkaline conditions (with or without aqueous NaOH addition), and modified atmosphere (air or argon atmosphere) on the stability of the color in ethanolic solutions obtained from C. vulgaris were studied. The loss of green color with temperature followed the first-order kinetics, with an activation energy of 74 kJ/mol. Below 28 °C and dark conditions were suitable to preserve isolated chlorophylls. The addition of NaOH and an inert argon-rich atmosphere did not exhibit a statistically positive effect on color preservation. In the case study, cooked cold rice was colored to be used in sushi. The color remained stable for up to 3 days at 4 °C. Therefore, this work showed that C. vulgaris chlorophylls could be preserved in ethanolic solutions at room or lower temperatures when protected from light, allowing them to obtain a suitable natural food ingredient to color foodstuffs.

Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry.

BACKGROUND AND OBJECTIVES: COVID-19-related inflammation, endothelial dysfunction, and coagulopathy may increase the bleeding risk and lower the efficacy of revascularization treatments in patients with acute ischemic stroke (AIS). We aimed to evaluate the safety and outcomes of revascularization treatments in patients with AIS and COVID-19. METHODS: This was a retrospective multicenter cohort study of consecutive patients with AIS receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021 tested for severe acute respiratory syndrome coronavirus 2 infection. With a doubly robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT). RESULTS: Of a total of 15,128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19; of those, 5,848 (38.7%) patients received IVT-only and 9,280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted OR 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour mortality (OR 2.47; 95% CI 1.58-3.86), and 3-month mortality (OR 1.88; 95% CI 1.52-2.33). Patients with COVID-19 also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60). DISCUSSION: Patients with AIS and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 patients receiving treatment. Current available data do not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in patients with COVID-19 or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring, and establishing prognosis. TRIAL REGISTRATION INFORMATION: The study was registered under ClinicalTrials.gov identifier NCT04895462.

Headaches and the use of personal protective equipment in the general population during the COVID-19 pandemic.

INTRODUCTION: Headaches associated with personal protective equipment were reported in health-care workers in previous epidemiological studies. METHODS: National web-based survey advertised by the Portuguese Headache Society and National Headache and Migraine patient´s organization between September-December 2020 screening for personal protective equipment usage pattern, pre-existing and de novo headaches after the onset of the COVID-19 pandemic, and its relation to personal protective equipment use. RESULTS: Of 5064 participants, 90.6% (4562/5034) were women, mean age was 37.2 ± 11 years. Most questions had a completion rate above 87% (non-completion rate ranging from 0-12.7%). Twenty percent were health-care professionals (993/5046). Surgical and cloth masks were the most common personal protective equipment type, whereas protective eyewear and FFP2/FFP3 masks were mostly used by health-care professionals. About 97% (1814/1870) of migraine and headache participants reported aggravation of pre-existing headaches with personal protective equipment use, and 56% (2476/4420) had de novo headaches. Participants with de novo headaches had a higher frequency of pre-existing migraine (1118/1226, 91.2% vs 1408/1600, 88%, P = .042), and wore personal protective equipment for longer periods of time (7 ± 2 h 42 vs 6 ± 2 h 54 min per day, P < .001). In multivariate analysis longer mean duration of personal protective equipment use (OR of 1.1, 95% CI 1-1.2) and previous migraine (OR of 1.2, 95% CI 1-1.4) were predictors of developing de novo headaches. CONCLUSIONS: Almost all participants with pre-existing headache reported worsening of their headaches, and more than half of the study population developed de novo headaches following personal protective equipment use. Duration of personal protective equipment usage and pre-existing migraine were the strongest predictors of de novo headaches.

Nationwide Access to Endovascular Treatment for Acute Ischemic Stroke in Portugal.

INTRODUCTION: Since the publication of endovascular treatment trials and European Stroke Guidelines, Portugal has re-organized stroke healthcare. The nine centers performing endovascular treatment are not equally distributed within the country, which may lead to differential access to endovascular treatment. Our main aim was to perform a descriptive analysis of the main treatment metrics regarding endovascular treatment in mainland Portugal and its administrative districts. MATERIAL AND METHODS: A retrospective national multicentric cohort study was conducted, including all ischemic stroke patients treated with endovascular treatment in mainland Portugal over two years (July 2015 to June 2017). All endovascular treatment centers contributed to an anonymized database. Demographic, stroke-related and procedure-related variables were collected. Crude endovascular treatment rates were calculated per 100 000 inhabitants for mainland Portugal, and each district and endovascular treatment standardized ratios (indirect age-sex standardization) were also calculated. Patient time metrics were computed as the median time between stroke onset, first-door, and puncture. RESULTS: A total of 1625 endovascular treatment procedures were registered. The endovascular treatment rate was 8.27/100 000 inhabitants/year. We found regional heterogeneity in endovascular treatment rates (1.58 to 16.53/100 000/year), with higher rates in districts closer to endovascular treatment centers. When analyzed by district, the median time from stroke onset to puncture ranged from 212 to 432 minutes, reflecting regional heterogeneity. DISCUSSION: Overall endovascular treatment rates and procedural times in Portugal are comparable to other international registries. We found geographic heterogeneity, with lower endovascular treatment rates and longer onset-to-puncture time in southern and inner regions. CONCLUSION: The overall national rate of EVT in the first two years after the organization of EVT-capable centers is one of the highest among European countries, however, significant regional disparities were documented. Moreover, stroke-onset-to-first-door times and in-hospital procedural times in the EVT centers were comparable to those reported in the randomized controlled trials performed in high-volume tertiary hospitals.

Introdução: A aprovação do tratamento endovascular para o acidente vascular cerebral isquémico obrigou à reorganização dos cuidados de saúde em Portugal. Os nove centros que realizam tratamento endovascular não estão distribuídos equitativamente pelo território, o que poderá causar acesso diferencial a tratamento. O principal objetivo deste estudo é realizar uma análise descritiva da frequência e métricas temporais do tratamento endovascular em Portugal continental e seus distritos. Material e Métodos: Estudo de coorte nacional multicêntrico, incluindo todos os doentes com acidente vascular cerebral isquémico submetidos a tratamento endovascular em Portugal continental durante um período de dois anos (julho 2015 a junho 2017). Foram colhidos dados demográficos, relacionados com o acidente vascular cerebral e variáveis do procedimento. Taxas de tratamento endovascular brutas e ajustadas (ajuste indireto a idade e sexo) foram calculadas por 100 000 habitantes/ano para Portugal continental e cada distrito. Métricas de procedimento como tempo entre instalação, primeira porta e punção foram também analisadas. Resultados: Foram registados 1625 tratamentos endovasculares, indicando uma taxa bruta nacional de tratamento endovascular de 8,27/100 000 habitantes/ano. As taxas de tratamento endovascular entre distritos variaram entre 1,58 e 16,53/100 000/ano, com taxas mais elevadas nos distritos próximos a hospitais com tratamento endovascular. O tempo entre sintomas e punção femural entre distritos variou entre 212 e 432 minutos. Discussão: A análise nacional a taxas de tratamento endovascular e tempos de atuação é comparável a outros registos internacionais. Verificaram-se heterogeneidades geográficas, com taxas de tratamento endovascular menores e maior tempo para tratamento nos distritos do sul e interior. Conclusão: Portugal continental apresenta uma taxa nacional de tratamento endovascular elevada, apresentando, contudo, assimetrias regionais no acesso. As métricas temporais foram comparáveis com as observadas nos ensaios clínicos piloto.

Acute Myocardial Infarction after Intravenous Thrombolysis for Acute Ischemic Stroke: Case Series and Systematic Review.

BACKGROUND AND OBJECTIVES: Intravenous thrombolysis (IV-rtPA) has been suggested as a potential cause of myocardial infarction (MI) after acute ischemic stroke (AIS), with randomized clinical trials showing a higher number of cardiac events within the thrombolysis group. We assessed the prevalence and MI mechanisms after IV-rtPA for AIS. METHODS: Retrospective review of consecutive AIS patients admitted to six stroke units and systematic literature review searching for AIS patients who suffered a MI less than 24 h after IV-rtPA. In those with available coronary angiography, MI etiology was defined as atherosclerotic or embolic. Patients' characteristics were compared between groups. RESULTS: Fifty-two patients were included. Thirty-two patients (61.5%) derived from hospital cases, after reviewing 6958 patients treated with IV-rtPA [0.5% (95% CI 0.38-0.54) of total hospital cases]. After coronary angiography (n = 25, 48.1%), 14 (54%) patients were considered to have an atherosclerotic MI, and 11 (46%) due to coronary embolism. Patients with an embolic MI more frequently had a cardioembolic AIS (72.7% vs 28.6%; p-value = 0.047) and an intracardiac thrombus (27.3% vs 0.0%; p-value = 0.044). Although not statistically significant, patients with an embolic MI had apparent lower time intervals between starting IV-rtPA infusion and MI occurrence [2 h (0.2-3.0) vs 3 h (1.0-15.0); p-value = 0.134]. CONCLUSIONS: MI within the first 24 h after IV-rtPA for AIS is an infrequent event, and more frequently non-embolic. However, the prevalence of embolic MI was superior to what is found in the general population with MI. There was an association between the pathophysiology of AIS and MI. The low number of events and publication bias may have limited our conclusions.

Author Correction: Involvement of Hsp90 and cyclophilins in intoxication by AIP56, a metalloprotease toxin from Photobacterium damselae subsp. piscicida.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Role of AIP56 disulphide bond and its reduction by cytosolic redox systems for efficient intoxication.

Apoptosis-inducing protein of 56 kDa (AIP56) is a major virulence factor of Photobacterium damselae subsp. piscicida, a gram-negative pathogen that infects warm water fish species worldwide and causes serious economic losses in aquacultures. AIP56 is a single-chain AB toxin composed by two domains connected by an unstructured linker peptide flanked by two cysteine residues that form a disulphide bond. The A domain comprises a zinc-metalloprotease moiety that cleaves the NF-kB p65, and the B domain is involved in binding and internalisation of the toxin into susceptible cells. Previous experiments suggested that disruption of AIP56 disulphide bond partially compromised toxicity, but conclusive evidences supporting the importance of that bond in intoxication were lacking. Here, we show that although the disulphide bond of AIP56 is dispensable for receptor recognition, endocytosis, and membrane interaction, it needs to be intact for efficient translocation of the toxin into the cytosol. We also show that the host cell thioredoxin reductase-thioredoxin system is involved in AIP56 intoxication by reducing the disulphide bond of the toxin at the cytosol. The present study contributes to a better understanding of the molecular mechanisms operating during AIP56 intoxication and reveals common features shared with other AB toxins.

Involvement of Hsp90 and cyclophilins in intoxication by AIP56, a metalloprotease toxin from Photobacterium damselae subsp. piscicida.

AIP56 (apoptosis inducing protein of 56 kDa) is a key virulence factor secreted by virulent strains of Photobacterium damselae subsp. piscicida (Phdp), a Gram-negative bacterium that causes septicemic infections in several warm water marine fish species. AIP56 is systemically disseminated during infection and induces massive apoptosis of host macrophages and neutrophils, playing a decisive role in the disease outcome. AIP56 is a single-chain AB-type toxin, being composed by a metalloprotease A domain located at the N-terminal region connected to a C-terminal B domain, required for internalization of the toxin into susceptible cells. After binding to a still unidentified surface receptor, AIP56 is internalised through clathrin-mediated endocytosis, reaches early endosomes and translocates into the cytosol through a mechanism requiring endosomal acidification and involving low pH-induced unfolding of the toxin. At the cytosol, the catalytic domain of AIP56 cleaves NF-κB p65, leading to the apoptotic death of the intoxicated cells. It has been reported that host cytosolic factors, including host cell chaperones such as heat shock protein 90 (Hsp90) and peptidyl-prolyl cis/trans isomerases (PPIases), namely cyclophilin A/D (Cyp) and FK506-binding proteins (FKBP) are involved in the uptake of several bacterial AB toxins with ADP-ribosylating activity, but are dispensable for the uptake of other AB toxins with different enzymatic activities, such as Bacillus anthracis lethal toxin (a metalloprotease) or the large glycosylating toxins A and B of Clostridium difficile. Based on these findings, it has been proposed that the requirement for Hsp90/PPIases is a common and specific characteristic of ADP-ribosylating toxins. In the present work, we demonstrate that Hsp90 and the PPIases cyclophilin A/D are required for efficient intoxication by the metalloprotease toxin AIP56. We further show that those host cell factors interact with AIP56 in vitro and that the interactions increase when AIP56 is unfolded. The interaction with Hsp90 was also demonstrated in intact cells, at 30 min post-treatment with AIP56, suggesting that it occurs during or shortly after translocation of the toxin from endosomes into the cytosol. Based on these findings, we propose that the participation of Hsp90 and Cyp in bacterial toxin entry may be more disseminated than initially expected, and may include toxins with different catalytic activities.

Prevenção e monitorização do delirium na pessoa em situação crítica internada numa unidade de cuidados intensivos / Prevention and monitoring of delirium in critically ill patients admitted to an intensive care unit

O delirium é uma síndrome de disfunção de órgão aguda com elevada incidência e prevalência nas pessoas internadas numa unidade de cuidados intensivos. A presença de delirium na pessoa em situação crítica aumenta o tempo de internamento e as suas complicações (quedas, úlceras por pressão, infeção entre outras), a mortalidade hospitalar e pós-alta, declínio cognitivo e funcional (imediato e a longo prazo), a demência, a necessidade de admissão em lares/unidades de longa duração, os custos globais de saúde e sobretudo o stress para a pessoa, família e para os profissionais, considerada um determinante preditor de prognóstico. Por tudo isto pretendeu-se explorar e descrever o conhecimento que os enfermeiros têm acerca do delirium e que intervenções de enfermagem estes profissionais reconhecem como importantes para a sua prevenção e monitorização. Optou-se por um estudo exploratório e descritivo de natureza qualitativa, realizado numa unidade de cuidados intensivos de um hospital da região sul do país. Os dados foram obtidos por meio de entrevista semiestruturada na qual participaram onze enfermeiros do sexo feminino. Os resultados mostraram um conhecimento limitado relativamente ao delirium, designadamente no que diz respeito à identificação dos fatores de risco e às caraterísticas da manifestação da síndrome. Os participantes apenas destacaram a sintomatologia que se manifesta na sua forma hiperativa. O estudo revelou tratar-se de uma disfunção subdiagnosticada uma vez que não houve por parte dos participantes o recurso a instrumentos de avaliação validados, sendo o seu diagnóstico feito pela avaliação clínica. No entanto, as intervenções autónomas e interdependentes que os enfermeiros reconhecem como importantes para a prevenção desta disfunção vão de encontro à mais recente evidência científica. Apesar disso, as intervenções de enfermagem assumidas por estes participantes não foram aplicadas na prática, uma vez que o grupo de enfermeiros entrevistados revelou que foram escassas as intervenções no que respeita às ações prevenir, monitorizar ou tratar o delirium. Os resultados apontam para a importância de incluir o tema na formação contínua dos enfermeiros, sendo entendida pelos participantes do estudo como uma estratégia para melhorar a abordagem na pessoa em situação critica com, ou em risco de desenvolver delirium.

Delirium is an acute organ dysfunction syndrome with a high incidence and prevalence in people in an intensive care unit. The presence of delirium in the critically ill person increases hospitalization time and complications (falls, pressure ulcers, infection), hospital and post-discharge mortality, cognitive and functional decline (immediate and long term), dementia , the need for admission to long-term care homes / units, overall health costs, and especially stress for the individual, the family and the professionals, is considered a predictor of prognosis. Therefore, it was intended to explore and describe the knowledge that nurses have about delirium and what nursing interventions these professionals recognize as important for their prevention and monitoring. We chose an exploratory and descriptive study of a qualitative nature, carried out in an intensive care unit of a hospital in the southern region of the country. Data were obtained through a semi-structured interview in which eleven female nurses participated. The results showed a limited knowledge regarding delirium, namely regarding the identification of the risk factors and the characteristics of the manifestation of the syndrome. The participants only highlighted the symptomatology that manifests itself in its hyperactive form. The study revealed that it was an underdiagnosed dysfunction since the participants did not resort to validated evaluation instruments, and their diagnosis was made by clinical evaluation. However, the interventions (autonomous and interdependent) that nurses recognize as important for the prevention of this dysfunction go against the latest scientific evidence. Although the nursing interventions assumed by these participants were in agreement with the scientific evidence, they were not applied in practice, since the group of nurses interviewed revealed that there were few interventions with regard to preventing, monitoring or treating or delirium. The results point to the importance of continuous training, being understood by the nurses participating in the study as a strategy to improve the approach in the person in critical situation with or at risk of developing delirium.

Seguridad y efectividad del rtPA en el ictus isquémico agudo en pacientes con cáncer activo: estudio de casos y controles / Safety and outcome of rtPA in acute ischemic stroke in patients with active cancer: case-control study

Introducción. Los pacientes con cáncer tienen un mayor riesgo de ictus debido a los efectos malignos directos e indirectos. La trombólisis intravenosa con activador tisular del plasminógeno recombinante (rtPA) constituye un tratamiento médico estándar para el ictus isquémico agudo. Objetivo. Revisar el uso de rtPA en el ictus isquémico agudo en pacientes con cáncer activo. Sujetos y métodos. Estudio retrospectivo observacional de casos y controles para evaluar pacientes con ictus isquémico agudo y cáncer admitidos en la unidad de ictus entre enero de 2010 y junio de 2015. Resultados. Se identificaron siete casos (86% varones; mediana de edad: 76 años) y también se incluyeron 20 controles pareados por edad y clasificación del Oxfordshire Community Stroke Project. Un 29% de casos experimentó complicaciones directas del procedimiento frente a un 30% en el grupo control. Un 14% sufrió transformación hemorrágica (frente a un 20%). Un paciente (caso) sufrió una hemorragia sistémica grave, y otro (control), una hemorragia intracerebral grave. A los tres meses, un 43% era independiente (frente a un 25% de los controles) y un 29% había fallecido (frente a un 30%). Un subtipo etiológico indeterminado (clasificación TOAST) era más frecuente en pacientes con cáncer (71% frente a 20%). Conclusión. Complicaciones hemorrágicas graves, potenciadas por el rtPA, pueden incrementar el riesgo de morbilidad y mortalidad. Sin embargo, pacientes seleccionados con cáncer que padecen un ictus isquémico agudo pueden beneficiarse del tratamiento con rtPA. Un cáncer activo no debería considerarse una contraindicación de uso de rtPA, aunque debe evaluarse el riesgo de complicaciones y la esperanza de vida para tomar la decisión (AU)

Introduction. Cancer patients have increased stroke risk from direct and indirect malignancy effects. Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) is standard medical treatment for acute ischemic stroke (AIS). Aim. To review rtPA use in AIS patients with active cancer. Subjects and methods. Retrospective observational case-control study evaluating patients with AIS and cancer admitted to our stroke unit between January/2010 and June/2015. Results. Seven cases were identified (86% male; median age: 76), and 20 controls were included matched for age and Oxfordshire Community Stroke Project classification. 29% experienced direct procedure complications vs 30% within the control group, 14% suffered haemorrhagic transformation (vs 20%), one patient experienced serious systemic haemorrhage (case) and one patient experienced serious intracerebral haemorrhage (control). After three months’ follow-up, 43% were independent compared with 25% controls, and 29% had died (vs 30%). Undetermined aetiology subtype (TOAST classification) was more frequent in cancer patients when compared to controls (71% vs 20%). Conclusion. Severe haemorrhagic complications, potentiated by rtPA, carry increased risk of morbidity and mortality. Nevertheless, selected cancer patients with AIS may benefit from rtPA treatment. Active cancer should not be considered an absolute contraindication to rtPA use. Risk of complications and life expectancy should be assessed when making this decision (AU)

Portuguese Psychology: Placing the Professional Practice and Training in a Global Context / Psicología Portuguesa: Situando la Práctica Profesional y la Formación en un Contexto Global

Presently, the profession of psychologists has evolved greatly since the first psychology degree was created in 80's; however, in Portugal studies concerning the profession of psychologists are scarce. So there is a need to describe the situation of psychologists in Portugal, as well as to predict and comparing it with other countries in order to influence political and professional decisions regarding the practice. In this study official data from Government sources and from the professional national association (Order of Portuguese Psychologist) was collected. The sample consisted of 14140 psychologists, 85% females, and average age was 39. The results showed a great expansion both in academic and professional numbers: there are psychologists working in a wide spread of areas and locations.

En la actualidad, la profesión de psicólogo ha evolucionado mucho desde que ha sido creado el primer grado universitario de psicología en los años 80. Pero, sin embargo, en Portugal los estudios relativos a la profesión de psicólogos son reducidos. Entonces, es necesario describir la situación de los psicólogos en Portugal, así como compararla con otros países para influir en las decisiones políticas y profesionales relativas a la práctica. En este estudio se recogieron datos oficiales de fuentes gubernamentales y de la asociación profesional nacional. La muestra consistió en 14.140 psicólogos, 85% mujeres, y la edad media fue de 39 años. Los resultados mostraron una gran expansión tanto en el ámbito académico como profesional: hay psicólogos que trabajan en una amplia gama de áreas y lugares.

Dynamics of a haemodynamic headache: A case report and literature review of headache secondary to flow inversion of the internal jugular vein.

BACKGROUND: Haemodialysis arteriovenous fistulas have common local and regional complications, but are rarely associated with neurological symptoms. CASE REPORT: A 43-year-old woman presented with short acute episodes of unilateral, non-throbbing, severe headache, vertigo and left lateropulsion. She had undergone renal transplantation and had a still-functioning left brachial arteriovenous fistula. No abnormality was detected on neurological examination or on brain parenchymal imaging. Colour Doppler ultrasonography showed a subclavian steal syndrome of the left vertebral artery and reversed flow in the left internal jugular vein. Ligation of the arteriovenous fistula had to be delayed as a result of renal graft dysfunction. Six months later she developed a headache attributed to intracranial hypertension. All symptoms subsided after ligation of the arteriovenous fistula. LITERATURE REVIEW: We identified 16 case reports of central neurological complications attributed to haemodialysis brachial fistulas. Headache descriptions were scarce and were not fully detailed. CONCLUSIONS: The case of our patient suggests that unilateral, episodic, non-throbbing, non-postural headache with transient neurological symptoms can be caused by combined arterial and venous flow abnormalities secondary to a high-flow arteriovenous brachial fistula. In this setting, this pattern of headache may precede overt signs of intracranial hypertension and may be used as a warning sign of cerebral venous congestion.

Intracellular trafficking of AIP56, an NF-κB-cleaving toxin from Photobacterium damselae subsp. piscicida.

AIP56 (apoptosis-inducing protein of 56 kDa) is a metalloprotease AB toxin secreted by Photobacterium damselae subsp. piscicida that acts by cleaving NF-κB. During infection, AIP56 spreads systemically and depletes phagocytes by postapoptotic secondary necrosis, impairing the host phagocytic defense and contributing to the genesis of infection-associated necrotic lesions. Here we show that mouse bone marrow-derived macrophages (mBMDM) intoxicated by AIP56 undergo NF-κB p65 depletion and apoptosis. Similarly to what was reported for sea bass phagocytes, intoxication of mBMDM involves interaction of AIP56 C-terminal region with cell surface components, suggesting the existence of a conserved receptor. Biochemical approaches and confocal microscopy revealed that AIP56 undergoes clathrin-dependent endocytosis, reaches early endosomes, and follows the recycling pathway. Translocation of AIP56 into the cytosol requires endosome acidification, and an acidic pulse triggers translocation of cell surface-bound AIP56 into the cytosol. Accordingly, at acidic pH, AIP56 becomes more hydrophobic, interacting with artificial lipid bilayer membranes. Altogether, these data indicate that AIP56 is a short-trip toxin that reaches the cytosol using an acidic-pH-dependent mechanism, probably from early endosomes. Usually, for short-trip AB toxins, a minor pool reaches the cytosol by translocating from endosomes, whereas the rest is routed to lysosomes for degradation. Here we demonstrate that part of endocytosed AIP56 is recycled back and released extracellularly through a mechanism requiring phosphoinositide 3-kinase (PI3K) activity but independent of endosome acidification. So far, we have been unable to detect biological activity of recycled AIP56, thereby bringing into question its biological relevance as well as the importance of the recycling pathway.

A distensibilidade da aorta prediz o acidente vascular cerebral em pacientes hipertensos / Aortic stiffness is an independent predictor of stroke in hypertensive patients

FUNDAMENTO: A doença cardiovascular continua a ser principal causa de morte nos países desenvolvidos e não é inteiramente prevista por fatores de risco clássicos. O aumento da rigidez arterial constitui um importante determinante de morbidade e mortalidade cardiovascular. OBJETIVO: Avaliar se a velocidade da onda de pulso prediz a ocorrência de acidente vascular cerebral (AVC) em pacientes hipertensos. MÉTODOS: Estudo de coorte, observacional, prospetivo, multicêntrico, incluindo 1.133 pacientes hipertensos (586 homens), com uma média de idade de 51,05 ± 12,64 anos. Todos os pacientes foram submetidos à avaliação da VOP pelo método Complior, a uma avaliação clínica pormenorizada e à medição da pressão arterial. RESULTADOS: A incidência cumulativa de risco de AVC nos hipertensos com VOP aumentada foi de 3,25% (IC: 1,97%-5,25%), em comparação com 0,78% (IC: 0,28% - 1,87%) nos hipertensos com VOP normal (risco relativo (RR) = 4,15; IC: 1,53 - 11,26). Numa análise multivariável, ajustando o modelo aos fatores de risco cardiovasculares clássicos, a VOP foi um preditor independente de AVC, com um hazard ratio (HR) = 1,40 (IC: 1,13 - 1,73, p < 0,002), indicando um incremento de 40% no risco de AVC por cada incremento de 1 m/seg na VOP. A adição da VOP a um modelo composto pelos fatores de risco cardiovascular convencionais melhorou significativamente a sua capacidade discriminativa para o risco de AVC (C de Harrel aumentou de 0,68 para 0,71 após inclusão da VOP; p <0,01). CONCLUSÃO: A distensibilidade arterial aferida pela VOP aórtica é um fator de risco independente de AVC em pacientes hipertensos, sendo recomendável a sua integração em programas de follow-up de situações em que o risco cardiovascular é manifesto.

BACKGROUND: Cardiovascular disease remains the leading cause of death in developed countries and is not entirely predicted by classic risk factors. Increased arterial stiffness is an important determinant of cardiovascular morbidity and mortality. OBJECTIVE: To assess whether Aortic Pulse Wave Velocity (PWV) predicts the occurrence of stroke in hypertensive patients METHODS: A cohort, observational and prospective study, including 1133 hypertensive patients (586 men), with a mean age 51.05 ± 12.64 years, was designed. PWV with the Complior method was performed in all patients, as well as a detailed clinical evaluation and blood pressure measurement. RESULTS: The cumulative incidence of stroke in hypertensive patients with increased PWV was 3.25% (CI: 1.97% -5.25%), compared with 0.78% (CI: 0.28% -1.87%) in hypertensive patients with normal PWV (Risk Ratio (RR) =4.15; CI:1.53-11.26). In a multivariate analysis, adjusting the model to classical cardiovascular risk factors, PWV was an independent predictor of stroke, with a Hazard Ratio (HR) = 1.40 (CI:1.13-1.73, p<0.001), indicating a 40% increase in the risk of stroke per 1m/s increment in PWV. The addition of PWV to a model consisting of conventional cardiovascular risk factors significantly improved the discriminative capacity for stroke (Harrell's C increased from 0.68 to 0.71 after the inclusion of the PWV; p<0.01). CONCLUSION: Aortic PWV is a risk factor for stroke in hypertensive patients, and its integration into clinical follow-up programs in patients whose cardiovascular risk is manifest is strongly recommended.

Aortic stiffness is an independent predictor of stroke in hypertensive patients.

BACKGROUND: Cardiovascular disease remains the leading cause of death in developed countries and is not entirely predicted by classic risk factors. Increased arterial stiffness is an important determinant of cardiovascular morbidity and mortality. OBJECTIVE: To assess whether Aortic Pulse Wave Velocity (PWV) predicts the occurrence of stroke in hypertensive patients METHODS: A cohort, observational and prospective study, including 1133 hypertensive patients (586 men), with a mean age 51.05 ± 12.64 years, was designed. PWV with the Complior method was performed in all patients, as well as a detailed clinical evaluation and blood pressure measurement. RESULTS: The cumulative incidence of stroke in hypertensive patients with increased PWV was 3.25% (CI: 1.97% -5.25%), compared with 0.78% (CI: 0.28% -1.87%) in hypertensive patients with normal PWV (Risk Ratio (RR) =4.15; CI:1.53-11.26). In a multivariate analysis, adjusting the model to classical cardiovascular risk factors, PWV was an independent predictor of stroke, with a Hazard Ratio (HR) = 1.40 (CI:1.13-1.73, p<0.001), indicating a 40% increase in the risk of stroke per 1m/s increment in PWV. The addition of PWV to a model consisting of conventional cardiovascular risk factors significantly improved the discriminative capacity for stroke (Harrell's C increased from 0.68 to 0.71 after the inclusion of the PWV; p<0.01). CONCLUSION: Aortic PWV is a risk factor for stroke in hypertensive patients, and its integration into clinical follow-up programs in patients whose cardiovascular risk is manifest is strongly recommended.

The apoptogenic toxin AIP56 is a metalloprotease A-B toxin that cleaves NF-κb P65.

AIP56 (apoptosis-inducing protein of 56 kDa) is a major virulence factor of Photobacterium damselae piscicida (Phdp), a Gram-negative pathogen that causes septicemic infections, which are among the most threatening diseases in mariculture. The toxin triggers apoptosis of host macrophages and neutrophils through a process that, in vivo, culminates with secondary necrosis of the apoptotic cells contributing to the necrotic lesions observed in the diseased animals. Here, we show that AIP56 is a NF-κB p65-cleaving zinc-metalloprotease whose catalytic activity is required for the apoptogenic effect. Most of the bacterial effectors known to target NF-κB are type III secreted effectors. In contrast, we demonstrate that AIP56 is an A-B toxin capable of acting at distance, without requiring contact of the bacteria with the target cell. We also show that the N-terminal domain cleaves NF-κB at the Cys(39)-Glu(40) peptide bond and that the C-terminal domain is involved in binding and internalization into the cytosol.