New pathologic mechanisms in nucleotide repeat expansion disorders.

Tandem microsatellite repeats are common throughout the human genome and intrinsically unstable, exhibiting expansions and contractions both somatically and across generations. Instability in a small subset of these repeats are currently linked to human disease, although recent findings suggest more disease-causing repeats await discovery. These nucleotide repeat expansion disorders (NREDs) primarily affect the nervous system and commonly lead to neurodegeneration through toxic protein gain-of-function, protein loss-of-function, and toxic RNA gain-of-function mechanisms. However, the lines between these categories have blurred with recent findings of unconventional Repeat Associated Non-AUG (RAN) translation from putatively non-coding regions of the genome. Here we review two emerging topics in NREDs: 1) The mechanisms by which RAN translation occurs and its role in disease pathogenesis and 2) How nucleotide repeats as RNA and translated proteins influence liquid-liquid phase separation, membraneless organelle dynamics, and nucleocytoplasmic transport. We examine these topics with a particular eye on two repeats: the CGG repeat expansion responsible for Fragile X syndrome and Fragile X-associated Tremor Ataxia Syndrome (FXTAS) and the intronic GGGGCC repeat expansion in C9orf72, the most common inherited cause of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). Our thesis is that these emerging disease mechanisms can inform a broader understanding of the native roles of microsatellites in cellular function and that aberrations in these native processes provide clues to novel therapeutic strategies for these currently untreatable disorders.

Effectiveness and safety of sofosbuvir-based regimens plus an NS5A inhibitor for patients with HCV genotype 3 infection and cirrhosis. Results of a multicenter real-life cohort.

Patients with HCV genotype 3 (GT3) infection and cirrhosis are currently the most difficult to cure. We report our experience with sofosbuvir+daclatasvir (SOF+DCV) or sofosbuvir/ledipasvir (SOF/LDV), with or without ribavirin (RBV) in clinical practice in this population. This was a multicenter observational study including cirrhotic patients infected by HCV GT3, treated with sofosbuvir plus an NS5A inhibitor (May 2014-October 2015). In total, 208 patients were included: 98 (47%) treatment-experienced, 42 (20%) decompensated and 55 (27%) MELD score >10. In 131 (63%), treatment was SOF+DCV and in 77 (37%), SOF/LDV. Overall, 86% received RBV. RBV addition and extension to 24 weeks was higher in the SOF/LDV group (95% vs 80%, P=.002 and 83% vs 72%, P=.044, respectively). A higher percentage of decompensated patients were treated with DCV than LDV (25% vs 12%, P=.013). Overall, SVR12 was 93.8% (195/208): 94% with SOF+DCV and 93.5% with SOF/LDV. SVR12 was achieved in 90.5% of decompensated patients. Eleven treatment failures: 10 relapses and one breakthrough. RBV addition did not improve SVR (RR: 1.08; P=.919). The single factor associated with failure to achieve SVR was platelet count <75×10E9/mL (RR: 3.50, P=.019). In patients with MELD <10, type of NS5A inhibitor did not impact on SVR12 (94% vs 97%; adjusted RR: 0.49). Thirteen patients (6.3%) had serious adverse events, including three deaths (1.4%) and one therapy discontinuation (0.5%), higher in decompensated patients (16.7% vs 3.6%, P<.006). In patients with GT3 infection and cirrhosis, SVR12 rates were high with both SOF+DCV and SOF/LDV, with few serious adverse events.

Longitudinal outcomes of obeticholic acid therapy in ursodiol-nonresponsive primary biliary cholangitis: Stratifying the impact of add-on fibrates in real-world practice.

BACKGROUND: Suboptimal response to ursodeoxycholic acid occurs in 40% of primary biliary cholangitis (PBC) patients, affecting survival. Achieving a deep response (normalisation of alkaline phosphatase [ALP] and bilirubin ≤0.6 upper limit of normal) improves survival. Yet, the long-term effectiveness of second-line treatments remains uncertain. AIMS: To evaluate the long-term effectiveness of obeticholic acid (OCA) ± fibrates. Focusing on biochemical response (ALP ≤1.67 times the upper limit of normal, with a decrease of at least 15% from baseline and normal bilirubin levels), normalisation of ALP, deep response and biochemical remission (deep response plus aminotransferase normalisation). METHODS: We conducted a longitudinal, observational, multicentre study involving ursodeoxyccholic acid non-responsive PBC patients (Paris-II criteria) from Spain and Portugal who received OCA ± fibrates. RESULTS: Of 255 patients, median follow-up was 35.1 months (IQR: 20.2-53). The biochemical response in the whole cohort was 47.2%, 61.4% and 68.6% at 12, 24 and 36 months. GLOBE-PBC and 5-year UK-PBC scores improved (p < 0.001). Triple therapy (ursodeoxycholic acid plus OCA plus fibrates) had significantly higher response rates than dual therapy (p = 0.001), including ALP normalisation, deep response and biochemical remission (p < 0.001). In multivariate analysis, triple therapy remained independently associated with biochemical response (p = 0.024), alkaline phosphatase normalisation, deep response and biochemical remission (p < 0.001). Adverse effects occurred in 41.2% of cases, leading to 18.8% discontinuing OCA. Out of 55 patients with cirrhosis, 12 developed decompensation. All with baseline portal hypertension. CONCLUSION: Triple therapy was superior in achieving therapeutic goals in UDCA-nonresponsive PBC. Decompensation was linked to pre-existing portal hypertension.

COVID-19 and the forgotten pandemic: follow-up of neurocognitive disorders during lockdown in Argentina. / COVID-19 y la pandemia olvidada: el seguimiento de las enfermedades neurocognitivas durante la cuarentena en Argentina.

INTRODUCTION: Health systems in numerous countries around the world are suffering a serious burden as a consequence of the COVID-19 pandemic. As a result of this situation, the follow-up of such chronic diseases as dementia may be at risk. Similarly, neuropsychiatric complications related to lockdown measures may also be neglected; Argentina's lockdown has been the longest implemented in Latin America. This study aims to determine the frequency of the different types of medical consultations for neurocognitive disorders and the predictors for requiring consultation since the beginning of the lockdown. METHODS: We performed a descriptive, observational, cross-sectional study based on data collected through an online survey. RESULTS: Data were collected on 324 participants, with 165 (50.9%) having had at least one medical consultation. Consultations were held by telephone in 109 cases (33.6%), by e-mail in 62 (19.1%), by video conference in 30 (9.3%), and at the emergency department in 23 (7.1%). Predictors of requiring consultation were Clinical Dementia Rating scores ≥1 (P<.001) and diagnosis of Alzheimer disease (P=.017). Higher Neuropsychiatric Inventory scores were found in the group of respondents who did require medical consultation (P<.001), but no significant differences were found between groups for Zarit Burden Interview scores. CONCLUSION: We identified a high prevalence of behavioural disorders and caregiver burden during lockdown. Nevertheless, only 50% of respondents had sought medical consultation (by telephone or email in 52.7% of cases). Care of people with dementia must be emphasised, guaranteeing follow-up of these patients.

Capnography is superior to pulse oximetry for the detection of respiratory depression during colonoscopy.

BACKGROUND: Pulse oximetry is a widely accepted procedure for ventilatory monitoring during gastrointestinal endoscopy, but this method provides an indirect measurement of the respiratory function. In addition, detection of abnormal ventilatory activity can be delayed, especially if supplemental oxygen is provided. Capnography offers continuous real-time measurement of expiratory carbon dioxide. OBJECTIVE: We aimed at prospectively examining the advantages of capnography over the standard pulse oximetry monitoring during sedated colonoscopies. PATIENTS AND METHODS: Fifty patients undergoing colonoscopy were simultaneously monitored with pulse oximetry and capnography by using two different devices in each patient. Several sedation regimens were administered. Episodes of apnea or hypoventilation detected by capnography were compared with the occurrence of hypoxemia. RESULTS: Twenty-nine episodes of disordered respiration occurred in 16 patients (mean duration 54.4 seconds). Only 38% of apnea or hypoventilation episodes were detected by pulse oximetry. A mean delay of 38.6 seconds was observed in the events detected by pulse oximetry (two episodes of disturbed ventilation were simultaneously detected by capnography and pulse oximetry). CONCLUSIONS: Apnea or hypoventilation commonly occurs during colonoscopy with sedation. Capnography is more reliable than pulse oximetry in early detection of respiratory depression in this setting.

Epidemiologic study on the current incidence of inflammatory bowel disease in Madrid.

INTRODUCTION: The incidence of inflammatory bowel disease (IBD) varies widely according to geographical area and has been reported to have increased in the last few years. No data are available on the current incidence of this disease in Madrid (Spain). AIM: to determine the incidence of inflammatory bowel disease in the area of influence of University Hospital Fundación Alcorcón (Madrid), and to compare our results with those from other Spanish and European series. PATIENTS AND METHODS: A prospective, population-based study was performed to determine the incidence of IBD in the area of University Hospital Fundación Alcorcón in Madrid between 2003 and 2005. Total population: 213,587 inhabitants (177,490 older than 14 years). Crude rates and age- and sex-specific rates adjusted to the European standard population were calculated. A retrospective study (1998-2003) was also performed. RESULTS: A total of 69 cases were diagnosed -Crohn s disease (CD): 35, ulcerative colitis (UC): 33, indeterminate colitis: 1- in the prospective period. Crude rates of CD and UC were 7.92 and 7.47 cases/100,000 inhabitants/year, respectively (the population aged 0-14 years). Specific rates were 8.0 (95% CI, 7.03-8.97) and 7.47 (95% CI, 6.5-8.4), respectively. Mean age at diagnosis was 31.02+/- 10.76 and 39.91+/-16.19 years for CD and UC, respectively. Incidence in the retrospective study was 7.13 and 6.22 cases/100,000 inhabitants/year, respectively for CD and UC. CONCLUSIONS: The incidence of CD and UC in Madrid has increased in the last decades, with rates close to those in northern European countries for CD, higher than those recently published in Spanish prospective studies and similar to those previously described in Spain and southern countries for UC. Rates were higher in the prospective period than in the retrospective one.

«Safety First¼: Design of an anesthetic checklist in pediatrics. / «Safety First¼: diseño de un checklist anestésico en pediatría.

INTRODUCTION: Quality improvement in health care entails the design of reliable processes which prevent and mitigate medical errors. Checklists are cognitive tools which reduce such errors. The primary objective of this study was to design an anesthetic checklist in Pediatrics to be implemented in our hospital. METHODS: Delphi technique was used, with 3 rounds of questionnaire surveys: a generic questionnaire to obtain dimensions and items; and 2 specific ones to score individual items and obtain an overall rating for the checklist (median), and to measure the level of consensus (relative interquartile range) and internal reliability (Wilcoxon signed-rank test). RESULTS: Final version of the checklist obtained a high overall score (Med 9) with a very high consensus (RIR 5%). Internal consensus was reached on all items (RIR ≤ 30%). Wilcoxon signed-rank test found no statistically significant differences, demonstrating reliability or consistency of responses between consecutive rounds. CONCLUSION: The Anesthetic checklist in Pediatrics has been methodically designed for implementation and use in our hospital.

First Report of Xylella fastidiosa in Nerium oleander in Costa Rica.

Oleander (Nerium oleander L.) shrubs presenting mottling, leaf tip and margin scorch, short internodes, defoliation, and branch dieback were observed at different localities in the Central Valley in Costa Rica. Severity of the symptoms ranged widely, and most plants showed both diseased and healthy branches. In severe cases, entire sections of the plant were defoliated. Symptoms resembled those described for oleander leaf scorch (OLS) caused by the bacterium Xylella fastidiosa in the United States (3). This bacterium has been reported in coffee and citrus plants in Costa Rica. Sixty plants from five different places were sampled and tested using ELISA (Agdia Inc., Elkhart, IN) against X. fastidiosa. Thirty-five plants showed absorbance mean value of duplicate wells greater than the mean of control wells plus three times the standard deviation, and therefore were considered positive. Thirty-three of the sixty samples were processed for an immunofluorescence assay modified from Carbajal et al. (1) with antibody to X. fastidiosa (Agdia Inc.). Thirteen samples showed fluorescent rod-shaped bacilli with morphology similar to those observed from a pure culture of X. fastidiosa obtained from coffee. Ten of these thirteen samples were positive by ELISA. DNA extracts (2) from three of the oleander plants with high ELISA absorbance values were tested by nested PCR with primer pair 272-1/272-2 followed by the pair 272-1 int/272-2 int (4). Two of the samples were positive for the bacterium and one of the PCR products was cloned and sequenced in both directions (GenBank Accession No. EU009615). The negative (PCR mix) and positive (pure culture of X. fastidiosa isolated from grapevine) controls for nested-PCR were indeed negative and positive, respectively. The BLAST program was used to compare the sequence to the nucleotide collection (nr/nt) and Microbe Assembled Genomes databases in GenBank. All matches corresponded to X. fastidiosa sequences. The sequence showed 97% similarity with strains Found-4 (coffee strain from Brazil) and Found-5 (citrus strain from Brazil) and 96% similarity with strain Ann-1 from oleander in California. On the basis of serological, microscopic, and molecular detection of X. fastidiosa from oleander exhibiting symptoms of OLS similar to those reported in the literature, this pathogen likely is causing the symptoms we observed in Costa Rica. References: (1) D. Carbajal et al. Curr. Microbiol. 49:372, 2004. (2) M. J. Green et al. Plant Dis. 83:482, 1999. (3) Q. Huang et al. Plant Dis. 88:1049, 2004. (4) M. R. Pooler and J. S. Hartung. Curr. Microbiol. 31:377, 1995.

[Effect of pentoxifylline on survival, cardiac function and both portal and systemic hemodynamics in advanced alcoholic cirrhosis--a randomized double-blind placebo-controlled trial]. / Effecto de la pentoxifilina en la supervivencia, la función cardiaca y en la hemodinámica portal y sistémica de la cirrosis alcohólica avanzada.

OBJECTIVE: To assess the effect of pentoxiphylline (a potent inhibitor of tumor necrosis factor alpha) on survival, on systemic and portal hemodynamics, and on cardiac function in patients with alcoholic cirrhosis. DESIGN: A randomized double-blind placebo-controlled trial. SETTING: A single center using parallel groups of patients to compare pentoxiphylline with placebo. PATIENTS: We recruited 24 patients with alcoholic cirrhosis (8 Child-Pugh B and 16 Child-Pugh C). INTERVENTIONS: Patients were randomly assigned to receive pentoxiphylline (400 mg tid; n = 12) or placebo (n = 12) over a 4-week period. OUTCOME MEASURES: The primary outcome was to extend short-term and long-term survival. Secondary outcomes included hemodynamic benefits (improvement in cardiac function and/or systemic vascular resistance index, or decrease in portal pressure). RESULTS: Portal pressure and cardiac function remained unchanged and there were no significant differences in short-term or long-term survival between treatment and placebo groups. The group on pentoxiphylline increased systemic vascular resistance and decreased cardiac indices (from 1,721 +/- 567 to 2,082 +/- 622 dyn.sec(-1) cm(-5) m(-2) and from 4.17 +/- 1.4 to 3.4 +/- 0.9 l.m(-2), p = 0.05). CONCLUSIONS: Although pentoxiphylline seems to provide some short-term hemodynamic benefits in patients with advanced alcoholic cirrhosis, this drug has no effect on survival or portal pressure in these patients.

Topical imiquimod 5% as an alternative therapy in periocular basal cell carcinoma in two patients with surgical contraindication. / Imiquimod 5% tópico como terapia alternativa en carcinoma basocelular periocular en 2 pacientes con contraindicación quirúrgica.

CLINICAL CASES: The cases are presented of two patients with periocular basal cell carcinoma of the eyelid who received topical imiquimod 5%, with a good response. Both had a functional state that contraindicated surgical treatment. CONCLUSION: Imiquimod cream 5% was shown to be an effective alternative to surgical treatment of periocular basal cell carcinoma, especially in those cases where surgery is not possible.

Susceptibility and PK/PD relationships of Staphylococcus aureus strains from ovine and caprine with clinical mastitis against five veterinary fluoroquinolones.

Minimum inhibitory concentration (MIC) and mutant prevention concentration (MPC) of veterinary fluoroquinolones as enrofloxacin, its metabolite ciprofloxacin, danofloxacin, difloxacin and marbofloxacin against Staphylococcus aureus strains (n=24) isolated from milk of sheep and goats affected by clinical mastitis were evaluated. The authors have used the MIC and MPC, as well as the pharmacokinetic-pharmacodynamic relationships in plasma and milk. MIC values were significantly different between drugs, unlike MPC values. Lower MIC values were obtained for danofloxacin and difloxacin, middle and higher values for enrofloxacin, ciprofloxacin and marbofloxacin. However, differences in MPC values were not found between drugs. At conventional doses, the AUC24/MIC and AUC24/MPC ratios were close to 30-80 hours and 5-30 hours, with exception of danofloxacin, in plasma and milk. The time inside the mutant selection window (TMSW) was close to 3-6 hours for enrofloxacin, ciprofloxacin and marbofloxacin, near to 8 hours for danofloxacin and 12-22 hours for difloxacin. From these data, the mutant selection window could be higher for danofloxacin and difloxacin compared with the other fluoroquinolones tested. The authors concluded that enrofloxacin and marbofloxacin, at conventional doses, could prevent the selection of bacterial subpopulations of S aureus, unlike danofloxacin and difloxacin, where higher doses could be used.

Long-term reversal of hypocholesterolaemia in patients with chronic hepatitis C is related to sustained viral response and viral genotype.

BACKGROUND: Genotype-3 of hepatitis C virus (HCV) has been associated with serum lipid changes (reversible with sustained viral response) and liver steatosis. AIM: To characterize the relationships among hepatic steatosis, cholesterol and sustained viral response in these patients. METHODS: Patients (n = 215) with chronic hepatitis C (157 with genotype-1 of HCV) had age, body mass index, gender, alcohol intake, glycaemia, serum lipids, transaminases, grade and stage (METAVIR and Scheuer), degree of liver steatosis, sustained viral response, insulinaemia, leptinaemia, beta-hydroxybutyrate and glycerol measured, and were compared with 32 hepatitis B virus (HBV)-infected subjects. RESULTS: Genotype-3 of HCV patients had age-adjusted hypocholesterolaemia and more frequent hepatic steatosis (P < 0.001). Steatosis was inversely correlated with serum cholesterol (P < 0.01) and directly with viral load (P < 0.03). In patients with genotype-3 of HCV and sustained viral response, serum cholesterol increased from 138 (95% CI: 120-151) to 180 mg/dL (95% CI: 171-199) 12 months after treatment conclusion (P < 0.0001). By contrast, cholesterol values were unchanged in genotype-3 of HCV non-responders and in patients with genotype-1 of HCV regardless of response. Rising cholesterol in sustained viral response did not parallel the changes in beta-hydroxybutyrate. CONCLUSIONS: Besides causing hepatic steatosis, genotype-3 specifically decreases serum cholesterol. This interference with the metabolic lipid pathway is related to viral load, is reversed with sustained viral response, and seems unrelated to mitochondrial dysfunction.

First Report of Xylella fastidiosa Infecting Citrus in Costa Rica.

Citrus variegated chlorosis (CVC) is an important disease mainly of sweet orange (Citrus sinensis (L.) Osbeck) cultivars. It was first described in Brazil in the state of Sa Paulo in 1987 (4). The disease has spread to all Brazilian states that grow citrus and is affecting more than one-third of the orange trees grown in Brazil. CVC is caused by Xylella fastidiousa, a xylem-limited, gram-negative bacterium. During the last 4 years, symptoms including leaf interveinal chlorosis, stunting, canopy dieback, and hard and undersized fruits, similar to those caused by CVC (3), appeared in sweet orange trees used as shade plants for coffee plantations and as fence posts in Costa Rica. Necrotic lesions on the abaxial side of the leaves as reported in Brazil were rarely observed. Leaf petiole samples from 25 symptomatic sweet orange trees reacted positively with a X fastidiosa-specific antiserum (AGDIA Inc., Elkart, IN) in a double-sandwich antibody enzyme-linked immunosorbent assay (DAS-ELISA). A fastidious, gram-negative bacterium identified as X. fastidiosa using DAS-ELISA was isolated on perwinkle wilt (PW) medium plates (1) from citrus stems showing CVC symptoms, but not from asymptomatic trees. The isolated colonies were circular and opalescent with diameters of 2 to 3 mm and were clearly visible within 6 to 7 days after streaking. Petiole sections from symptomatic plants observed with scanning electron microscopy showed rod-shaped bacteria with rippled cell walls tightly packed in xylem vessels, as described for X. fastidiosa previously (2), and with transmission electron microscopy, the bacteria were morphologically similar to those reported previously for CVC (2). To our knowledge, this is the first report of X. fastidiosa associated with citrus in Costa Rica. References: (1) M. J. Davis et al. Curr. Microbiol. 6:309, 1981. (2) J. S. Hartung et al. Phytopathology 84:591, 1994. (3) R. F. Lee et al. Summa Phytopathol. 19:123, 1993. (4) V. Rossetti et al. 1990, C.R. Acad. Sci. (Paris) 310:345-349.

Osteopontin gene expression in the Holstein bull reproductive tract.

The objective of this study was to localize gene expression of osteopontin in the Holstein bull reproductive tract using Northern blot analysis and in situ hybridization. For Northern blot analysis, a digoxigenin-labeled osteopontin complementary deoxyribonucleic acid (cDNA) was used to probe blots containing total ribonucleic acid (RNA) isolated from the testis, epididymis, vas deferens, ampulla, seminal vesicle, prostate, and bulbourethral glands. The digoxigenin-labeled cDNA for the bovine homologue of osteopontin was hybridized to a single band at approximately 1.6 kb to RNA samples from the ampulla and seminal vesicle. For in situ hybridization studies, antisense and sense riboprobes were synthesized and used to hybridize cryosections that had been obtained from bull reproductive tissues. In situ hybridization of the bull testis detected osteopontin messenger RNA in the developing germ cells. Osteopontin gene expression was detected only in seminiferous tubules that contained elongated spermatids, which suggests that expression varies with the stage of the seminiferous epithelium. Within the epididymis, silver grains were distributed over the sperm that were located within the lumen of the caput, corpus, and cauda epididymis. Osteopontin expression was primarily observed in the epithelial cells of the ampulla. Antisense riboprobes also hybridized to sperm that were located within the lumen of the ampulla, confirming the presence of osteopontin transcripts in the haploid male gamete.

Occurrence of Coffee ringspot virus, a Brevipalpus Miteborne Virus in Coffee in Costa Rica.

Coffee ringspot virus (CoRSV) (family Rhabdoviridae) is transmitted by Brevipalpus phoenicis (Geijskes) (Acari: Tenuipalpidae). Coffee ringspot disease was first reported in coffee plants from Brazil in 1939 (1). In August 2000, severe symptoms of concentric ringspots and "oak leaf" patterns on coffee leaves (Coffea arabica L. cv. Catuai) were observed during field inspections conducted in two areas of San Gabriel de Desamparados, Costa Rica. The disease caused premature fruit and leaf drop in the affected plants. Some areas within the ringspot lesions remained green on senescent leaves. Because CoRSV particles remain restricted to lesion areas (1), this virus has not been purified, and antiserum for virus detection is not available. Therefore, leaves with symptoms were collected and examined by transmission electron microscopy. In ultrathin sections of symptomatic leaves, arrays of rhabdovirus-like particles were associated with the nucleus as described for CoRSV (2). Healthy tissues did not contain similar arrays of bacilliform and bullet-shaped particles. Twenty mites collected from the infected plants at the same locations and time were slide-mounted and identified as B. phoenicis. High populations of this mite were also observed infesting plants of Cajanus cajan L. that were intercropped with coffee at the same location. Sweet orange trees growing in the same fields as shade for the coffee did not show symptoms of citrus leprosis, a disease caused by another Brevipalpus-transmitted virus that was recently reported in Panama (3). To our knowledge, this is the first report of a virus similar to CoRSV in Costa Rica. The spread of this virus, presumably CoRSV, could seriously affect the coffee industry throughout Central America by increasing production costs. It may be necessary to apply one or more foliar acaricides to effectively control the mite vector. References: (1) A. Bitancourt. O. Biol. 5:33, 1939. (2) C. M. Chagas et al. Phytopathol. Z. 102:100, 1981. (3) F. S. Dominguez et al. Plant Dis. 85:228, 2001.

First Report of Xylella fastidiosa Infecting Coffee in Costa Rica.

In 1995, severe symptoms were observed on 'Caturra' and 'Catuaí' coffee (Coffea arabica L.) varieties in farms in the southern part of the Central Valley in Costa Rica. Symptoms were reduced leaf size, malformation of leaves, curling of leaf edges, shortening of internodes, and severe leaf chlorotic mosaic, which sometimes became necrotic. Abortion of flowers and young beans was also observed, with a reduction in yield. Plants also showed irregular growth with an atypical curling appearance that gave rise to the Spanish name "crespera." Ten and three healthy plants were inoculated by grafting in the greenhouse, using infected and healthy budwoods, respectively. Approximately 6 months after inoculation, 3 of 10 grafted plants with infected budwoods showed symptoms of leaf chlorosis, curling, and malformation of leaves and bunched new flushes. Samples of 39 symptomatic plants collected from the field and samples of 3 healthy plants maintained in the greenhouse were tested by enzyme-linked immunosorbent assay (ELISA). All (100%) analyzed symptomatic samples were positive for X. fastidiosa, and all healthy controls were negative. The symptoms observed in Costa Rica are different from those described for coffee leaf scorch in Brazil (1,2), but the climatological conditions and soil type present in Costa Rica are also very different from the areas where X. fastidiosa occurs in Brazil. Leafhoppers were collected randomly in one of the most affected regions. Graphocephala permagna and Erythrogonia sonora were the most frequent insect species found associated with coffee. In ELISA, 34.5% (10 of 29) and 23.8% (5 of 21) of the collected specimens belonging to G. permagna and E. sonora, respectively, tested positive for X. fastidiosa. These positive ELISAs do not necessarily mean that the insect is a vector. The results presented here extend the known geographic distribution of X. fastidiosa. To our knowledge, this is the first report of X. fastidiosa in coffee in Costa Rica. References: (1) M. J. G. Beretta et al. Plant Dis. 80:821, 1996. (2) de Lima et al. Plant Dis. 82:94, 1998.

Parenting stress and anger expression as predictors of child abuse potential.

To explore one potential pathway to physical child abuse, the present investigation used hierarchical regression analysis using measures of parenting stress and anger expression to jointly predict child abuse potential. The Parenting Stress Index, State-Trait Anger Expression Inventory, and the Child Abuse Potential Inventory were administered to two different samples of New Zealand parents. As expected, both studies revealed parenting stress and anger expression and were individually positively correlated with child abuse potential: the major finding involved the strong point contribution of parenting stress and anger expression in predicting Child Abuse Potential Inventory scores. Application of findings for intervention and prevention are discussed.

Predictors of parents' physical disciplinary practices.

OBJECTIVE: This study examined how childhood history of discipline (1) related to ratings of how severe and typical punishments were; and (2) predicted parents' use of discipline techniques. The influence of child culpability on these ratings was also investigated. METHOD: Ninety-nine New Zealand parents rated 12 physical discipline scenarios varying in discipline severity and perceived child culpability. Parents judged how severe and typical they considered the disciplines depicted in the scenarios and reported on how often they had experienced such discipline as children and how often they had used them with their own children. RESULTS: When the child was perceived to be at fault, parents rated the discipline depicted as less severe, considered the technique more typical, reported they had been similarly disciplined more frequently, and applied such discipline to their child more frequently. Childhood history of a discipline was related to the parent's use of that method, and the parents judged techniques they used with their own children as less severe and more typical of methods of discipline. History of discipline and severity judgments were the best predictors of parents' disciplinary practices. CONCLUSIONS: Although the findings support the cycle of violence theory, more complex potential pathways to abusive parenting, including the variables in this study, are proposed.

Diagnostic and therapeutic approach to cholestatic liver disease.

When cholestatic liver disease is present, liver ultrasound should be performed to ascertain if cholestasis is extrahepatic or intrahepatic. If bile ducts appear dilated and the probability of interventional treatment is high, endoscopic retrograde cholagio-pancreatography (ERCP) or trans-hepatic cholangiography (THC) should be the next step. If the probability of interventional therapeutics is low, cholangio-MRI should be performed. Once bile duct dilation and space occupying lesions are excluded, a work up for intrahepatic cholestasis should be started. Some specific clinical situations may be helpful in the diagnostic strategy. If cholestasis occurs in the elderly, drug-induced cholestatic disease should be suspected, whereas if it occurs in young people with risk factors, cholestatic viral hepatitis is the most likely diagnosis. During the first trimester of pregnancy cholestasis may occur in hyperemesis gravidorum, and in the third trimester of gestation cholestasis of pregnancy should be suspected. A familial history of recurrent cholestasis points to benign recurrent intrahepatic cholestasis. The occurrence of intrahepatic cholestasis in a middle-aged woman is a frequent presentation of primary biliary cirrhosis, whereas primary sclerosing cholangitis should be suspected in young males with inflammatory bowel disease. The presence of vascular spider nevi, ascites, and a history of alcohol abuse should point to alcoholic hepatitis. Neonatal cholestasis syndromes include CMV, toxoplasma and rubinfections or metabolic defects such as cystic fibrosis, alpha1-antitrypsin deficiency, bile acid synthesis defects, or biliary atresia. The treatment of cholestasis should include a management of complications such as pruritus, osteopenia and correction of fat soluble vitamin deficiencies. When hepatocellular failure or portal hypertension-related complications occur, liver transplantation should be considered.