Hospital Universitário Clementino Fraga Filho

The flagellum is an important virulence factor for bacteria pathogenic to animals and plants. Here we demonstrate that plants have a highly sensitive chemoperception system for eubacterial flagellins, specifically targeted to the most highly conserved domain within its N terminus. Synthetic peptides comprising 15-22 amino acids of this domain acted as elicitors of defence responses at sub-nanomolar concentrations in cells of tomato and several other plant species. Peptides comprising only the central 8 to 11 amino acids of the active domain had no elicitor activity but acted as specific, competitive inhibitors in tomato cells. These antagonists suppressed the plant's response to flagellin, crude bacterial extracts and living bacterial cells. Thus, plants have a highly sensitive and selective perception system for the flagellin of motile eubacteria.

OBJECTIVES: To evaluate the efficacy and safety of 18 months of tafamidis treatment in patients with early-stage V30M transthyretin familial amyloid polyneuropathy (TTR-FAP). METHODS: In this randomized, double-blind trial, patients received tafamidis 20 mg QD or placebo. Coprimary endpoints were the Neuropathy Impairment Score-Lower Limbs (NIS-LL) responder analysis (<2-point worsening) and treatment-group difference in the mean change from baseline in Norfolk Quality of Life-Diabetic Neuropathy total score (TQOL) in the intent-to-treat (ITT) population (n = 125). These endpoints were also evaluated in the efficacy-evaluable (EE; n = 87) population. Secondary endpoints, including changes in neurologic function, nutritional status, and TTR stabilization, were analyzed in the ITT population. RESULTS: There was a higher-than-anticipated liver transplantation dropout rate. No differences were observed between the tafamidis and placebo groups for the coprimary endpoints, NIS-LL responder analysis (45.3% vs 29.5% responders; p = 0.068) and change in TQOL (2.0 vs 7.2; p = 0.116) in the ITT population. In the EE population, significantly more tafamidis patients than placebo patients were NIS-LL responders (60.0% vs 38.1%; p = 0.041), and tafamidis patients had better-preserved TQOL (0.1 vs 8.9; p = 0.045). Significant differences in most secondary endpoints favored tafamidis. TTR was stabilized in 98% of tafamidis and 0% of placebo patients (p < 0.0001). Adverse events were similar between groups. CONCLUSIONS: Although the coprimary endpoints were not met in the ITT population, tafamidis was associated with no trend toward more NIS-LL responders and a significant reduction in worsening of most neurologic variables, supporting the hypothesis that preventing TTR dissociation can delay peripheral neurologic impairment. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that 20 mg tafamidis QD was associated with no difference in clinical progression in patients with TTR-FAP, as measured by the NIS-LL and the Norfolk QOL-DN score. Secondary outcomes demonstrated a significant delay in peripheral neurologic impairment with tafamidis, which was well tolerated over 18 months.

INTRODUCTION: The current shortage of accurate and readily available, validated biomarkers of disease severity in sepsis is an important limitation when attempting to stratify patients into homogeneous groups, in order to study pathogenesis or develop therapeutic interventions. The aim of the present study was to determine the cytokine profile in plasma of patients with severe sepsis by using a multiplex system for simultaneous detection of 17 cytokines. METHODS: This was a prospective cohort study conducted in four tertiary hospitals. A total of 60 patients with a recent diagnosis of severe sepsis were included. Plasma samples were collected for measurement of cytokine concentrations. A multiplex analysis was performed to evaluate levels of 17 cytokines (IL-1 beta, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-17, interferon-gamma, granulocyte colony-stimulating factor [G-CSF], granulocyte-macrophage colony-stimulating factor, monocyte chemoattractant protein [MCP]-1, macrophage inflammatory protein-1 and tumour necrosis factor-alpha). Cytokine concentrations were related to the presence of severe sepsis or septic shock, the severity and evolution of organ failure, and early and late mortality. RESULTS: Concentrations of IL-1 beta, IL-6, IL-7, IL-8, IL-10, IL-13, interferon-gamma, MCP-1 and tumour necrosis factor-alpha were significantly higher in septic shock patients than in those with severe sepsis. Cytokine concentrations were associated with severity and evolution of organ dysfunction. With regard to the severity of organ dysfunction on day 1, IL-8 and MCP-1 exhibited the best correlation with Sequential Organ Failure Assessment score. In addition, IL-6, IL-8 and G-CSF concentrations during the first 24 hours were predictive of worsening organ dysfunction or failure of organ dysfunction to improve on day three. In terms of predicting mortality, the cytokines IL-1 beta, IL-4, IL-6, IL-8, MCP-1 and G-CSF had good accuracy for predicting early mortality (< 48 hours), and IL-8 and MCP-1 had the best accuracy for predicting mortality at 28 days. In multivariate analysis, only MCP-1 was independently associated with prognosis. CONCLUSION: In this exploratory analysis we demonstrated that use of a multiple cytokine assay platform allowed identification of distinct cytokine profiles associated with sepsis severity, evolution of organ failure and death.

Transthyretin amyloidosis is a progressive and eventually fatal disease primarily characterized by sensory, motor, and autonomic neuropathy and/or cardiomyopathy. Given its phenotypic unpredictability and variability, transthyretin amyloidosis can be difficult to recognize and manage. Misdiagnosis is common, and patients may wait several years before accurate diagnosis, risking additional significant irreversible deterioration. This article aims to help physicians better understand transthyretin amyloidosis--and, specifically, familial amyloidotic polyneuropathy--so they can recognize and manage the disease more easily and discuss it with their patients. We provide guidance on making a definitive diagnosis, explain methods for disease staging and evaluation of disease progression, and discuss symptom mitigation and treatment strategies, including liver transplant and several pharmacotherapies that have shown promise in clinical trials.

The microbiology, epidemiology, diagnostics, and treatment of infective endocarditis (IE) have changed significantly since the Duke Criteria were published in 1994 and modified in 2000. The International Society for Cardiovascular Infectious Diseases (ISCVID) convened a multidisciplinary Working Group to update the diagnostic criteria for IE. The resulting 2023 Duke-ISCVID IE Criteria propose significant changes, including new microbiology diagnostics (enzyme immunoassay for Bartonella species, polymerase chain reaction, amplicon/metagenomic sequencing, in situ hybridization), imaging (positron emission computed tomography with 18F-fluorodeoxyglucose, cardiac computed tomography), and inclusion of intraoperative inspection as a new Major Clinical Criterion. The list of "typical" microorganisms causing IE was expanded and includes pathogens to be considered as typical only in the presence of intracardiac prostheses. The requirements for timing and separate venipunctures for blood cultures were removed. Last, additional predisposing conditions (transcatheter valve implants, endovascular cardiac implantable electronic devices, prior IE) were clarified. These diagnostic criteria should be updated periodically by making the Duke-ISCVID Criteria available online as a "Living Document."

RATIONALE: Bronchial thermoplasty (BT) is a bronchoscopic procedure in which controlled thermal energy is applied to the airway wall to decrease smooth muscle. OBJECTIVES: To evaluate the effectiveness and safety of BT versus a sham procedure in subjects with severe asthma who remain symptomatic despite treatment with high-dose inhaled corticosteroids and long-acting beta(2)-agonists. METHODS: A total of 288 adult subjects (Intent-to-Treat [ITT]) randomized to BT or sham control underwent three bronchoscopy procedures. Primary outcome was the difference in Asthma Quality of Life Questionnaire (AQLQ) scores from baseline to average of 6, 9, and 12 months (integrated AQLQ). Adverse events and health care use were collected to assess safety. Statistical design and analysis of the primary endpoint was Bayesian. Target posterior probability of superiority (PPS) of BT over sham was 95%, except for the primary endpoint (96.4%). MEASUREMENTS AND MAIN RESULTS: The improvement from baseline in the integrated AQLQ score was superior in the BT group compared with sham (BT, 1.35 +/- 1.10; sham, 1.16 +/- 1.23 [PPS, 96.0% ITT and 97.9% per protocol]). Seventy-nine percent of BT and 64% of sham subjects achieved changes in AQLQ of 0.5 or greater (PPS, 99.6%). Six percent more BT subjects were hospitalized in the treatment period (up to 6 wk after BT). In the posttreatment period (6-52 wk after BT), the BT group experienced fewer severe exacerbations, emergency department (ED) visits, and days missed from work/school compared with the sham group (PPS, 95.5, 99.9, and 99.3%, respectively). CONCLUSIONS: BT in subjects with severe asthma improves asthma-specific quality of life with a reduction in severe exacerbations and healthcare use in the posttreatment period. Clinical trial registered with www.clinialtrials.gov (NCT00231114).

BACKGROUND: Invasive candidiasis is an important cause of morbidity and mortality among patients with health care-associated infection. The echinocandins have potent fungicidal activity against most Candida species, but there are few data comparing the safety and efficacy of echinocandins in the treatment of invasive candidiasis. METHODS: This was an international, randomized, double-blind trial comparing micafungin (100 mg daily) and micafungin (150 mg daily) with a standard dosage of caspofungin (70 mg followed by 50 mg daily) in adults with candidemia and other forms of invasive candidiasis. The primary end point was treatment success, defined as clinical and mycological success at the end of blinded intravenous therapy. RESULTS: A total of 595 patients were randomized to one the treatment groups and received at least 1 dose of study drug. In the modified intent-to-treat population, 191 patients were assigned to the micafungin 100 mg group, 199 to the micafungin 150 mg group, and 188 to the caspofungin group. Demographic characteristics and underlying disorders were comparable across the groups. Approximately 85% of patients had candidemia; the remainder had noncandidemic invasive candidiasis. At the end of blinded intravenous therapy, treatment was considered successful for 76.4% of patients in the micafungin 100 mg group, 71.4% in the micafungin 150 mg group, and 72.3% in the caspofungin group. The median time to culture negativity was 2 days in the micafungin 100 mg group and the caspofungin group, compared with 3 days in the micafungin 150 mg groups. There were no significant differences in mortality, relapsing and emergent infections, or adverse events between the study arms. CONCLUSIONS: Dosages of micafungin 100 mg daily and 150 mg daily were noninferior to a standard dosage of caspofungin for the treatment of candidemia and other forms of invasive candidiasis.

UNLABELLED: Sustained virologic suppression is a primary goal of therapy for chronic hepatitis B (CHB). In study entecavir (ETV)-022, 48 weeks of entecavir 0.5 mg was superior to lamivudine for virologic suppression for hepatitis B e antigen (HBeAg)-positive CHB. A total of 183 entecavir-treated patients from ETV-022 subsequently enrolled in study ETV-901. We present the results after up to 5 years (240 weeks) of continuous entecavir therapy. The entecavir long-term cohort consists of patients who received >or=1 year of entecavir 0.5 mg in ETV-022 and then entered ETV-901 with a treatment gap <or=35 days. In ETV-901 the entecavir dose was 1.0 mg daily. For patients with samples available at Year 5, proportions with hepatitis B virus (HBV) DNA <300 copies/mL, normal alanine aminotransferase (ALT) levels, HBeAg loss, and HBeAg seroconversion were determined. In all, 146 patients met criteria for inclusion in the entecavir long-term cohort. At Year 5, 94% (88/94) had HBV DNA <300 copies/mL and 80% (78/98) had normal ALT levels. In addition to patients who achieved serologic responses during study ETV-022, 23% (33/141) achieved HBeAg seroconversion and 1.4% (2/145) lost hepatitis B surface antigen (HBsAg) during study ETV-901. Through 5 years, entecavir resistance emerged in one patient. The safety profile of entecavir was consistent with previous reports. CONCLUSION: Extended therapy with entecavir through 5 years maintained or increased rates of HBV DNA suppression and ALT normalization. Additional patients also achieved HBeAg loss and seroconversion. Entecavir provides sustained viral suppression with minimal resistance during long-term treatment of HBeAg-positive CHB.

Glycosaminoglycans are natural heteropolysaccharides that are present in every mammalian tissue. They are composed of repeating disaccharide units that consist of either sulfated or non-sulfated monosaccharides. Their molecular size and the sulfation type vary depending on the tissue, and their state either as part of proteoglycan or as free chains. In this regard, glycosaminoglycans play important roles in physiological and pathological conditions. During recent years, cell biology studies have revealed that glycosaminoglycans are among the key macromolecules that affect cell properties and functions, acting directly on cell receptors or via interactions with growth factors. The accumulated knowledge regarding the altered structure of glycosaminoglycans in several diseases indicates their importance as biomarkers for disease diagnosis and progression, as well as pharmacological targets. This review summarizes how the fine structural characteristics of glycosaminoglycans, and enzymes involved in their biosynthesis and degradation, are involved in cell signaling, cell function and cancer progression. Prospects for glycosaminoglycan-based therapeutic targeting in cancer are also discussed.

BACKGROUND/AIMS: Diabetic patients have an increased prevalence and severity of non-alcoholic fatty liver disease (NAFLD). We aimed to investigate the prevalence and the factors associated with the presence of ultrasonographic NAFLD in type-2 diabetic individuals. METHODS: In a cross-sectional design study, 180 type-2 diabetic patients were submitted to a complete clinical and laboratory evaluation and abdominal ultrasonography for NAFLD detection and grading. Statistical analysis included bivariate tests, analysis of variance (anova, for increasing severity of steatosis) and multivariate logistic regression. RESULTS: The prevalence of ultrasonographic NAFLD was 69.4% [95% confidence interval (CI): 58.3-82.7%]. Patients with NAFLD were more obese, had a higher waist circumference and serum triglyceride and alanine aminotransferase (ALT) levels than those without steatosis. Neither diabetic degenerative complication, nor glycaemic control was associated with liver steatosis. On multivariate analysis, a high serum triglycerides level [>2.82 mmol/L, odds ratio (OR): 3.7-4.1, 95% CI: 1.2-13.3] and a high-normal ALT level (> or =40 U/L, OR: 2.5-2.7, 95% CI: 1.2-5.9) were independently associated with hepatic steatosis, together with either the presence of obesity (OR: 7.1, 95% CI: 3.0-17.0) or of increased waist circumference (OR: 4.8, 95% CI: 1.9-12.2). CONCLUSIONS: Type-2 diabetic patients have a high prevalence of ultrasonographic NAFLD and its presence is associated with obesity, mainly abdominal, hypertriglyceridaemia and high-normal ALT levels. Non-alcoholic fatty liver disease in diabetic patients may develop and progress independent of the diabetes progression itself.

Myiasis is defined as the infestation of live vertebrates (humans and/or animals) with dipterous larvae. In mammals (including humans), dipterous larvae can feed on the host's living or dead tissue, liquid body substance, or ingested food and cause a broad range of infestations depending on the body location and the relationship of the larvae with the host. In this review, we deeply discuss myiasis as a worldwide infestation with different agents and with its broad scenario of clinical manifestations as well as diagnosis techniques and treatment.

Hedgehog (Hh) signaling pathway plays an essential role during vertebrate embryonic development and tumorigenesis. It is already known that Sonic hedgehog (Shh) pathway is important for the evolution of radio and chemo-resistance of several types of tumors. Most of the brain tumors are resistant to chemotherapeutic drugs, consequently, they have a poor prognosis. So, a better knowledge of the Shh pathway opens an opportunity for targeted therapies against brain tumors considering a multi-factorial molecular overview. Therefore, emerging studies are being conducted in order to find new inhibitors for Shh signaling pathway, which could be safely used in clinical trials. Shh can signal through a canonical and non-canonical way, and it also has important points of interaction with other pathways during brain tumorigenesis. So, a better knowledge of Shh signaling pathway opens an avenue of possibilities for the treatment of not only for brain tumors but also for other types of cancers. In this review, we will also highlight some clinical trials that use the Shh pathway as a target for treating brain cancer.

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CONTEXT: Biochemical control reduces morbidity and increases life expectancy in patients with acromegaly. With current medical therapies, including the gold standard octreotide long-acting-release (LAR), many patients do not achieve biochemical control. OBJECTIVE: Our objective was to demonstrate the superiority of pasireotide LAR over octreotide LAR in medically naive patients with acromegaly. DESIGN AND SETTING: We conducted a prospective, randomized, double-blind study at 84 sites in 27 countries. PATIENTS: A total of 358 patients with medically naive acromegaly (GH >5 μg/L or GH nadir ≥1 μg/L after an oral glucose tolerance test (OGTT) and IGF-1 above the upper limit of normal) were enrolled. Patients either had previous pituitary surgery but no medical treatment or were de novo with a visible pituitary adenoma on magnetic resonance imaging. INTERVENTIONS: Patients received pasireotide LAR 40 mg/28 days (n = 176) or octreotide LAR 20 mg/28 days (n = 182) for 12 months. At months 3 and 7, titration to pasireotide LAR 60 mg or octreotide LAR 30 mg was permitted, but not mandatory, if GH ≥2.5μg/L and/or IGF-1 was above the upper limit of normal. MAIN OUTCOME MEASURE: The main outcome measure was the proportion of patients in each treatment arm with biochemical control (GH <2.5 μg/L and normal IGF-1) at month 12. RESULTS: Biochemical control was achieved by significantly more pasireotide LAR patients than octreotide LAR patients (31.3% vs 19.2%; P = .007; 35.8% vs 20.9% when including patients with IGF-1 below the lower normal limit). In pasireotide LAR and octreotide LAR patients, respectively, 38.6% and 23.6% (P = .002) achieved normal IGF-1, and 48.3% and 51.6% achieved GH <2.5 μg/L. 31.0% of pasireotide LAR and 22.2% of octreotide LAR patients who did not achieve biochemical control did not receive the recommended dose increase. Hyperglycemia-related adverse events were more common with pasireotide LAR (57.3% vs 21.7%). CONCLUSIONS: Pasireotide LAR demonstrated superior efficacy over octreotide LAR and is a viable new treatment option for acromegaly.

BACKGROUND: The aim of this study is to evaluate the impact of diabetes, hypertension, cardiovascular disease and the use of angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB) with severity (invasive mechanical ventilation or intensive care unit admission or O2 saturation < 90%) and mortality of COVID-19 cases. METHODS: Systematic review of the PubMed, Cochrane Library and SciELO databases was performed to identify relevant articles published from December 2019 to 6th May 2020. Forty articles were included involving 18.012 COVID-19 patients. RESULTS: The random-effect meta-analysis showed that diabetes mellitus and hypertension were moderately associated respectively with severity and mortality for COVID-19: Diabetes [OR 2.35 95% CI 1.80-3.06 and OR 2.50 95% CI 1.74-3.59] Hypertension: [OR 2.98 95% CI 2.37-3.75 and OR 2.88 (2.22-3.74)]. Cardiovascular disease was strongly associated with both severity and mortality, respectively [OR 4.02 (2.76-5.86) and OR 6.34 (3.71-10.84)]. On the contrary, the use of ACEI/ARB, was not associate with severity of COVID-19. CONCLUSION: In conclusion, diabetes, hypertension and especially cardiovascular disease, are important risk factors for severity and mortality in COVID-19 infected people and are targets that must be intensively addressed in the management of this infection.

We have characterized the structure of a sulfatedd-galactan from the red algae Botryocladia occidentalis. The following repeating structure (-4-α-d-Galp-1→3-β-d-Galp-1→) was found for this polysaccharide, but with a variable sulfation pattern. Clearly one-third of the total α-units are 2,3-di-O-sulfated and another one-third are 2-O-sulfated. The algal sulfated d-galactan has a potent anticoagulant activity (similar potency as unfractionated heparin) due to enhanced inhibition of thrombin and factor Xa by antithrombin and/or heparin cofactor II. We also extended the experiments to several sulfated polysaccharides from marine invertebrates with simple structures, composed of a single repeating structure. A 2-O- or 3-O-sulfatedl-galactan (as well as a 2-O-sulfatedl-fucan) has a weak anticoagulant action when compared with the potent action of the algal sulfated d-galactan. Possibly, the addition of two sulfate esters to a single α-galactose residue has an “amplifying effect” on the anticoagulant action, which cannot be totally ascribed to the increased charge density of the polymer. These results indicate that the wide diversity of polysaccharides from marine alga and invertebrates is a useful tool to elucidate structure/anticoagulant activity relationships. We have characterized the structure of a sulfatedd-galactan from the red algae Botryocladia occidentalis. The following repeating structure (-4-α-d-Galp-1→3-β-d-Galp-1→) was found for this polysaccharide, but with a variable sulfation pattern. Clearly one-third of the total α-units are 2,3-di-O-sulfated and another one-third are 2-O-sulfated. The algal sulfated d-galactan has a potent anticoagulant activity (similar potency as unfractionated heparin) due to enhanced inhibition of thrombin and factor Xa by antithrombin and/or heparin cofactor II. We also extended the experiments to several sulfated polysaccharides from marine invertebrates with simple structures, composed of a single repeating structure. A 2-O- or 3-O-sulfatedl-galactan (as well as a 2-O-sulfatedl-fucan) has a weak anticoagulant action when compared with the potent action of the algal sulfated d-galactan. Possibly, the addition of two sulfate esters to a single α-galactose residue has an “amplifying effect” on the anticoagulant action, which cannot be totally ascribed to the increased charge density of the polymer. These results indicate that the wide diversity of polysaccharides from marine alga and invertebrates is a useful tool to elucidate structure/anticoagulant activity relationships. fast protein liquid chromatography activated partial thromboplastin time correlation spectroscopy total correlation spectroscopy nuclear Overhauser effect spectroscopy 1H/13C heteronuclear multiple quantum coherence spectra Sulfated polysaccharides comprise a complex group of macromolecules with a wide range of important biological properties. These anionic polymers are widespread in nature, occurring in a great variety of organisms. In marine algae, the carrageenans and fucoidans are composed mainly of sulfated galactose and fucose, respectively (1Painter T.J. Aspinall G.O. The Polysaccharides. Academic Press, New York1983: 195-285Crossref Google Scholar). Vertebrate tissues express abundant sulfated glycosaminoglycans (2Mathews M.B. Connective Tissue, Macromolecular Structure and Evolution. Springer-Verlag, Berlin1975: 93-206Google Scholar). Invertebrate species are also a rich source of sulfated polysaccharides with novel structures (3–16). We have isolated and characterized the structure of several sulfated galactans from marine invertebrates (3Albano R.M. Mourão P.A.S. J. Biol. Chem. 1986; 261: 758-765Abstract Full Text PDF PubMed Google Scholar, 4Mourão P.A.S. Perlin A.S. Eur. J. Biochem. 1987; 166: 431-436Crossref PubMed Scopus (75) Google Scholar, 6Pavão M.S.G. Albano R.M. Lawson A.M. Mourão P.A.S. J. Biol. Chem. 1989; 264: 9972-9979Abstract Full Text PDF PubMed Google Scholar, 7Albano R.M. Pavão M.S.G. Mourão P.A.S. Mulloy B. Carbohydr. Res. 1990; 208: 163-174Crossref PubMed Scopus (37) Google Scholar, 9Santos J.A. Mulloy B. Mourão P.A.S. Eur. J. Biochem. 1992; 204: 669-677Crossref PubMed Scopus (77) Google Scholar, 13Alves A.P. Mulloy B. Diniz J.A. Mourão P.A.S. J. Biol. Chem. 1977; 272: 6965-6971Abstract Full Text Full Text PDF Scopus (171) Google Scholar). In contrast with the algal polysaccharides, invertebrate galactans have simple structures, composed of a single repeating unit. The specific pattern of sulfation and the position of the glycosidic linkage varies among different species. The sea urchin (Echinodermata Echinoidea)Echinometra lucunter contains a linear polysaccharide composed of 2-O-sulfated, 3-linked α-l-galactose (Fig. 1 A) (13Alves A.P. Mulloy B. Diniz J.A. Mourão P.A.S. J. Biol. Chem. 1977; 272: 6965-6971Abstract Full Text Full Text PDF Scopus (171) Google Scholar), while in the tunicate (Chordata Ascidiacea) Herdmania monusa similar polysaccharide is composed of 3-O-sulfated, 4-linked α-l-galactose (Fig. 1 B) (9Santos J.A. Mulloy B. Mourão P.A.S. Eur. J. Biochem. 1992; 204: 669-677Crossref PubMed Scopus (77) Google Scholar). The sea urchin Strongylocentrotus franciscanus contains a related polysaccharide composed of 2-O-sulfated, 3-linked α-l-fucose units (Fig. 1 C) (15Vilela-Silva A.C.E.S. Alves A.P. Valente A.P. Vacquier V.D. Mourão P.A.S. Glycobiology. 1999; 9: 927-933Crossref PubMed Scopus (113) Google Scholar). In other species of tunicate, the sulfated l-galactans have more complex and branched structures (4Mourão P.A.S. Perlin A.S. Eur. J. Biochem. 1987; 166: 431-436Crossref PubMed Scopus (75) Google Scholar, 6Pavão M.S.G. Albano R.M. Lawson A.M. Mourão P.A.S. J. Biol. Chem. 1989; 264: 9972-9979Abstract Full Text PDF PubMed Google Scholar, 7Albano R.M. Pavão M.S.G. Mourão P.A.S. Mulloy B. Carbohydr. Res. 1990; 208: 163-174Crossref PubMed Scopus (37) Google Scholar, 9Santos J.A. Mulloy B. Mourão P.A.S. Eur. J. Biochem. 1992; 204: 669-677Crossref PubMed Scopus (77) Google Scholar). In Styela plicata, non-sulfated l-galactose occurs as branched units linked to position O-2 of the central core (Fig. 1 D) (6Pavão M.S.G. Albano R.M. Lawson A.M. Mourão P.A.S. J. Biol. Chem. 1989; 264: 9972-9979Abstract Full Text PDF PubMed Google Scholar, 7Albano R.M. Pavão M.S.G. Mourão P.A.S. Mulloy B. Carbohydr. Res. 1990; 208: 163-174Crossref PubMed Scopus (37) Google Scholar). One way to determine the relationship between structure and biological activity of sulfated polysaccharides is to compare their activity in various assays where the contributions of the polysaccharide backbone, and the extent and position of sulfation have been fully characterized. In this line of work, new sulfated galactans and the sulfated fucan from invertebrates constitute a valuable tool. Anticoagulant and antithrombotic activities are among the most widely studied properties of sulfated polysaccharides. The anticoagulant glycosaminoglycan heparin is an important therapeutic agent for prophylaxis and treatment of thrombosis (17Kakkar V.V. Hedges A.R. Lane D.A. Lindahl U. Heparin. Edward Arnold, London1989: 455-473Google Scholar); dermatan sulfate is also anticoagulant, although of lower potency than heparin (18Tollefsen D.M. Majerus D.W. Blank M.K. J. Biol. 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Haemostasis. 1995; 74: 1280-1285Crossref PubMed Scopus (106) Google Scholar) and red alga (24Carlucci M.J. Pujol C.A. Ciancia M. Noseda M.D. Matulewicz M.C. Damonte E.B. Cerezo A.S. Int. J. Biol. Macromol. 1997; 20: 97-105Crossref PubMed Scopus (201) Google Scholar, 25Yamada T. Ogamo A. Saito T. Uchiyama H. Nakagawa Y. Carbohydr. Polymer. 2000; 41: 115-120Crossref Scopus (91) Google Scholar), or obtained by chemical sulfation of natural polysaccharides (26Alban S. Jeske W. Welzel D. Franz G. Fareed J. Thromb. Res. 1995; 78 (210): 210Abstract Full Text PDF Scopus (43) Google Scholar), have been described as anticoagulant. In contrast with heparin and dermatan sulfate, the structural components of these algal sulfated polysaccharides have not been characterized for anticoagulant activity. Most of the difficulties arise from their heterogeneous chemical structures. In the present study we isolated and characterized the structure of a sulfated d-galactan from the red algae Botryocladia occidentalis. This polysaccharide has the following repeating structure (-4-α-d-Galp-1→3-β-d-Galp-1→). Besides its variable sulfation pattern, it clearly contains 2,3-di-O-sulfated d-galactose residues (approximately one-third of the total α-galactose units). This algal sulfated galactan has a potent anticoagulant activity. Its action was compared with the sulfated galactans and the sulfated fucan shown in Fig. 1. Our results suggest that the 2,3-di-O-sulfated galactose residues have an “amplifying effect” on the anticoagulant activity of sulfated galactans. Sulfated galactans were extracted from the tunics of the ascidians H. monus and S. plicata and from the egg jelly coat of the sea urchin E. lucunter. A sulfated fucan was extracted from the egg jelly coat of the sea urchinS. franciscanus. The sulfated polysaccharides were purified by anion exchange and/or gel filtration chromatography, as described (9Santos J.A. Mulloy B. Mourão P.A.S. Eur. J. Biochem. 1992; 204: 669-677Crossref PubMed Scopus (77) Google Scholar, 13Alves A.P. Mulloy B. Diniz J.A. Mourão P.A.S. J. Biol. Chem. 1977; 272: 6965-6971Abstract Full Text Full Text PDF Scopus (171) Google Scholar, 15Vilela-Silva A.C.E.S. Alves A.P. Valente A.P. Vacquier V.D. Mourão P.A.S. Glycobiology. 1999; 9: 927-933Crossref PubMed Scopus (113) Google Scholar). The marine red algae B. occidentaliswas collected at Pacheco beach, Caucaia, Ceará, Brazil, separated from other species and sun-dried. The dried tissue (5 g) was cut in small pieces, suspended in 250 ml of 0.1 m sodium acetate buffer (pH 6.0) containing 510 mg of papain (E. Merck, Darmstadt, Germany), 5 mm EDTA, and 5 mm cysteine, and incubated at 60 °C for 24 h. The incubation mixture was then filtrated and the supernatant saved. The residue was washed with 138 ml of distilled water, filtered again, and the two supernatants were combined. Sulfated polysaccharides in solution were precipitated with 16 ml of 10% cetylpyridinium chloride solution. After standing at room temperature for 24 h, the mixture was centrifuged at 2,560 × g, for 20 min, at 5 °C. The sulfated polysaccharides in the pellet were washed with 610 ml of 0.05% cetylpyridinium chloride solution, dissolved with 172 ml of a 2m NaCl, ethanol (100:15, v/v) solution, and precipitated with 305 ml of absolute ethanol. After 24 h at 4 °C, the precipitate was collected by centrifugation (2,560 × gfor 20 min at 5 °C), washed twice with 305 ml of 80% ethanol, and once with the same volume of absolute ethanol. The final precipitate was dried at 60 °C overnight and ∼200 mg (dry weight) of crude polysaccharide was obtained after these procedures. The crude polysaccharide (10 mg) was applied to a Mono Q column FPLC2 (HR 5/5) (Amersham Pharmacia Biotech), equilibrated with 20 mmTris-HCl buffer (pH 8.0). The column was developed by a linear gradient of 0–3.0 m NaCl in the same buffer. The flow rate of the column was 0.50 ml/min and fractions of 0.5 ml were collected and assayed by metachromasia using 1,9-dimethylmethylene blue (27Farndale R.W. Buttle D.J. Barret A.J. Biochim. Biophys. 1986; PubMed Scopus Google Scholar) and by the M. Chem. Scopus Google Scholar). Sulfated polysaccharides were by gel as described (9Santos J.A. Mulloy B. Mourão P.A.S. Eur. J. Biochem. 1992; 204: 669-677Crossref PubMed Scopus (77) Google A.P. Mulloy B. Diniz J.A. Mourão P.A.S. J. Biol. Chem. 1977; 272: 6965-6971Abstract Full Text Full Text PDF Scopus (171) Google Scholar). 20 of the polysaccharides were applied to a gel in mm buffer (pH and at for 1 h. were with solution for h, and with blue in was by the of M. Chem. Scopus Google Scholar). After °C for 5 of the polysaccharides, total sulfate was by the H. T. S. J. Biol. Chem. Full Text PDF PubMed Google Scholar). for and sulfate were from galactose and The in the was by chromatography of Chem. Scopus Google Scholar) and by chromatography in v/v) for 24 h on 1 by with The of the galactose was on of the as described Carbohydr. Res. Scopus Google Scholar). The polysaccharide from B. mg) was with 0.5 ml of 1 m After for h at °C, the solution was with the supernatant and dissolved in we of and the solution for min at room The and were on a The temperature was from to °C at The and were and °C, of and were the same of the sulfated galactan was as described (4Mourão P.A.S. Perlin A.S. Eur. J. Biochem. 1987; 166: 431-436Crossref PubMed Scopus (75) Google Scholar, Mulloy B. Mourão P.A.S. J. Biol. Chem. 1991; Full Text PDF PubMed Google Scholar). 20 mg of polysaccharide were dissolved in 5 ml of distilled and with 1 (dry weight) of After with were The were dissolved in ml of The were at °C for 4 h, and the were distilled and The extent of was by the of This to to a 5 mg of was The and galactans were to of as described J. Carbohydr. Res. Scopus Google Scholar) with the by M.S. S. T. J. Biol. Chem. Full Text PDF PubMed Google Scholar). The polysaccharides were with for 5 h at °C, with and the were with Chem. Scopus Google Scholar). The from the were dissolved in and in a was in the in a column m × The column was to at °C for min, then to °C at and for 5 and spectra were using a with a mg of was dissolved in 0.5 ml of spectra were at 60 °C with by heteronuclear correlation spectra were using for in the spectra were with × with a of and a time of were with × and for spectra were with a time of chemical were to and partial thromboplastin assays were by the of E. Thromb. Res. 9: Full Text PDF PubMed Scopus Google Scholar). was incubated with of a solution of polysaccharide 5 at °C for 1 of activated partial thromboplastin time were and incubated at °C. After min of incubation of were to the and the time in a The activity was as using a on the These were by the of activity of thrombin or factor Xa using as described U. M. Thromb. Res. Full Text PDF PubMed Scopus Google Scholar, U. Thromb. Res. Full Text PDF PubMed Scopus Google Scholar). Sulfated polysaccharide solution (10 and 5 of 1 purified antithrombin were with of purified thrombin in of m buffer (pH containing NaCl and 1 After a incubation of from was and the thrombin activity for min at This was as described that heparin cofactor from of antithrombin was to the incubation Sulfated polysaccharide solution (10 and 5 of 1 purified antithrombin were with of 4 purified factor Xa in of buffer (pH containing m NaCl and 1 After a incubation of mm from was and the factor Xa activity for min at In the incubation inhibition when thrombin or factor Xa was incubated at °C with the sulfated polysaccharides or with the or heparin cofactor exchange chromatography on Mono separated the sulfated polysaccharides from red algae and from the column with and NaCl, respectively fractions metachromasia with 1,9-dimethylmethylene blue and as by the of M. Chem. Scopus Google Scholar) gel an increased from to (Fig. of the purified fractions galactose as the and an sulfate from to The obtained from the algal polysaccharides have the same and on column as galactose occurs on galactan as a these results indicate that the red algae B. contains fractions of that in their sulfate specific and of NaCl for from the Mono column of the different fractions of sulfated galactans of the red alga B. Fig. was by its time on a of The of and sulfate on the obtained from the polysaccharides were by the and from Mono column shown in Fig. was by its time on a of The of and sulfate on the obtained from the polysaccharides were by the and shown in A. in a new the fractions of B. galactans were to of a variety of were mainly and The were not with polysaccharide structures. the that the of after an we have In of sulfated polysaccharides not of (4Mourão P.A.S. Perlin A.S. Eur. J. Biochem. 1987; 166: 431-436Crossref PubMed Scopus (75) Google M.S. S. T. J. Biol. Chem. Full Text PDF PubMed Google Scholar, H. A. A. J. Biol. Chem. Full Text PDF PubMed Google Scholar, P. Lawson A.M. H. T. Eur. J. Biochem. 1986; PubMed Scopus Google Scholar). This be a of due to the sulfate which not of these The more to sulfate esters also of the to the structure of these polymers is of the In of the and fractions similar of and 4-linked and 3-linked galactose respectively of were also from are not from an their after an these from structural components and/or from units which were not and and which are to the for of sulfate by the we as galactose obtained from and galactans from the red alga B. of was by time on column to of total The of was by time on column to in a new of a more complex mixture of which are not with polysaccharide structures. We several to this polysaccharide using different of the and a variety of to the of these of We cannot the in of from this be obtained the structure of this In contrast with the other two fractions in contains of the total of a branched similar to the other two it also and of and from and 3-linked galactose that and of 3-linked and 4-linked the other has a more complex and branched containing galactose at the We to the structure of fractions and and also to determine the sulfation pattern of these polysaccharides. This was not to by as The spectra of the and galactan from B. are shown in Fig. The chemical in and are on the of and chemical for residues of and in and chemical are to at in indicate sulfate and in indicate galactan from B. Fig. galactan galactan from galactan from galactan from E. lucunter galactan from E. lucunter galactan from C. not are to at in indicate sulfate and in indicate J. Carbohydr. Res. Scopus Google Pavão M.S.G. Mourão P.A.S. Mulloy B. Carbohydr. Res. 1990; 208: PubMed Scopus Google Alves (13Alves A.P. Mulloy B. Diniz J.A. Mourão P.A.S. J. Biol. Chem. 1977; 272: 6965-6971Abstract Full Text Full Text PDF Scopus (171) Google H. A. S. Carbohydr. Res. Scopus Google not in a new chemical for residues of and in and are to at in sulfated and in to galactan from B. galactan from B. galactan from galactan from galactan from E. lucunter galactan from E. lucunter galactan from C. are to at in sulfated and in to J. Carbohydr. Res. Scopus Google Pavão M.S.G. Mourão P.A.S. Mulloy B. Carbohydr. Res. 1990; 208: PubMed Scopus Google Alves (13Alves A.P. Mulloy B. Diniz J.A. Mourão P.A.S. J. Biol. Chem. 1977; 272: 6965-6971Abstract Full Text Full Text PDF Scopus (171) Google H. A. S. Carbohydr. Res. Scopus Google Scholar). in a new The galactan two at and another at (Fig. The and be on B) the in and and The of α-galactose and of residues that the two residues are and respectively was also obtained in the A is between and and from and as for and also from the that are in to the but their is These results are with a polysaccharide with the following repeating (Fig. spectra of and galactans from the red algae B. occidentalis. The was on and The of chemical in and are to at for and for The were by the chemical from the and spectra of the galactans from the red algae B. occidentalis. The of of galactan in with the the from the and of the unit. The to the the from and as for the and The and spectra were as described with a time of for the and for the structure of the sulfated d-galactan and from the red algae B. occidentalis. This polysaccharide has the following repeating structure with a variable sulfation pattern. the of 2,3-di-O-sulfated and residues as one-third of the total units in the The structure of was not to The polysaccharide has a complex (Fig. A) due to its heterogeneous sulfation pattern. were of and C) are between and in with while the other and are between and as for of the two of a and were to the but two of be A is and as by the in the (Fig. 4 and of residue A are from the in the and and sulfation in these two is also sulfated at position it a of The chemical are in and residues and be In this several the The of the in the suggest a of residues These are from and suggest that residues for one-third of the total α-units in the sulfated d-galactan from B. occidentalis. The of a of algal polysaccharides, was in the B. galactan due to the of of in this of residue for in with for and a similar to that obtained for but with in the of the various In has a more complex which not be with the In and indicate that fractions and obtained from B. are linear polysaccharides, containing residues of and A variable sulfation pattern to these polysaccharides. it is that 2,3-di-O-sulfated residues as of the total units of these galactans (Fig. was not to determine the structure of this polysaccharide is at the of its and was not Anticoagulant activities of the purified sulfated from the red algae B. were and compared with the same activities of sulfated l-galactans and a sulfated from marine which have well structures The in that crude B. polysaccharides have anticoagulant action of fractions and results in increased anticoagulant potency and with that of unfractionated heparin has a effect properties of the sulfated polysaccharides from red algae and compared to were as described The activity is as using a on the sulfated sulfated Sulfated Fig. 1 Fig. 1 Sulfated sulfate, sulfate, The were as described The activity is as using a on the in a new with sulfated polysaccharides from invertebrates sulfated galactans from red algae and from the marine invertebrates have similar as by gel that the sulfated from E. lucunter has a anticoagulant action of α-l-galactose by α-l-fucose (as in the of the polysaccharide from S. sulfation in a different or the position of the glycosidic linkage (as in H. anticoagulant potency by and of residues as branched units (as in S. the anticoagulant effect of the polysaccharide the sulfated galactans and are more potent as anticoagulant than sulfated from Possibly, this potent effect is related to the of 2,3-di-O-sulfated galactose this of is in the other The sulfate is important for anticoagulant action, the galactan the activity. it is not the sulfated polysaccharides as have lower anticoagulant activity than and and In fractions and in sulfate but have the same potency as anticoagulant. the in indicate in the anticoagulant effect of related sulfated galactans. This is not due to the sulfate but also to structure and/or sulfation of the polysaccharides. The sulfated d-galactan from B. thrombin inhibition by antithrombin with an similar to that of unfractionated heparin (Fig. of antithrombin by heparin cofactor results in a to the of the effect for thrombin but this polysaccharide has a lower than that of dermatan sulfate (Fig. of thrombin by factor Xa also the effect of compared with unfractionated heparin (Fig. experiments were with other fractions of from B. and fractions are potent thrombin in the of antithrombin and heparin cofactor II. is more for thrombin inhibition in the of In is a weak of sulfated galactans and sulfated fucan from red algae and and of for thrombin or factor Xa inhibition in the of antithrombin or heparin cofactor heparin cofactor Xa not Sulfated Sulfated dermatan not in a new thrombin inhibition by branched sulfated from the brown algae and was (15Vilela-Silva A.C.E.S. Alves A.P. Valente A.P. Vacquier V.D. Mourão P.A.S. Glycobiology. 1999; 9: 927-933Crossref PubMed Scopus (113) Google Scholar), but in this the assays were at °C. the same the sulfated galactans from B. also thrombin activity we extended this of experiments to the from invertebrates The sulfated from E. lucunter thrombin activity in the of either antithrombin or heparin cofactor but than fractions and from B. occidentalis. of α-l-galactose by α-l-fucose (as in the polysaccharide from S. sulfation in a different or the position of the glycosidic linkage (as in H. the effect on The structural B. is the of 2,3-di-O-sulfated d-galactose which are in the other galactans or fucan in the shown in Possibly, this of residue for the potent thrombin effect with these galactans. Our results indicate that the red algae B. two fractions and of composed of and but with a heterogeneous sulfation pattern. 2,3-di-O-sulfated and units for one-third of the total The structure of not be

OBJECTIVE: The aim of the Acromegaly Consensus Group was to revise and update the consensus on diagnosis and treatment of acromegaly comorbidities last published in 2013. PARTICIPANTS: The Consensus Group, convened by 11 Steering Committee members, consisted of 45 experts in the medical and surgical management of acromegaly. The authors received no corporate funding or remuneration. EVIDENCE: This evidence-based consensus was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence following critical discussion of the current literature on the diagnosis and treatment of acromegaly comorbidities. CONSENSUS PROCESS: Acromegaly Consensus Group participants conducted comprehensive literature searches for English-language papers on selected topics, reviewed brief presentations on each topic, and discussed current practice and recommendations in breakout groups. Consensus recommendations were developed based on all presentations and discussions. Members of the Scientific Committee graded the quality of the supporting evidence and the consensus recommendations using the GRADE system. CONCLUSIONS: Evidence-based approach consensus recommendations address important clinical issues regarding multidisciplinary management of acromegaly-related cardiovascular, endocrine, metabolic, and oncologic comorbidities, sleep apnea, and bone and joint disorders and their sequelae, as well as their effects on quality of life and mortality.

Acromegaly is a chronic systemic disease with many complications and is associated with increased mortality when not adequately treated. Substantial advances in acromegaly treatment, as well as in the treatment of many of its complications, mainly diabetes mellitus, heart failure, and arterial hypertension, were achieved in the last decades. These developments allowed change in both prevalence and severity of some acromegaly complications and furthermore resulted in a reduction of mortality. Currently, mortality seems to be similar to the general population in adequately treated patients with acromegaly. In this review, we update the knowledge in complications of acromegaly and detail the effects of different acromegaly treatment options on these complications. Incidence of mortality, its correlation with GH (cumulative exposure vs last value), and IGF-I levels and the shift in the main cause of mortality in patients with acromegaly are also addressed.

Sulfated fucans and galactans are strongly anionic polysaccharides found in marine organisms. Their structures vary among species, but their major features are conserved among phyla. Sulfated fucans are found in marine brown algae and echinoderms, whereas sulfated galactans occur in red and green algae, marine angiosperms, tunicates (ascidians), and sea urchins. Polysaccharides with 3-linked, beta-galactose units are highly conserved in some taxonomic groups of marine organisms and show a strong tendency toward 4-sulfation in algae and marine angiosperms, and 2-sulfation in invertebrates. Marine algae mainly express sulfated polysaccharides with complex, heterogeneous structures, whereas marine invertebrates synthesize sulfated fucans and sulfated galactans with regular repetitive structures. These polysaccharides are structural components of the extracellular matrix. Sulfated fucans and galactans are involved in sea urchin fertilization acting as species-specific inducers of the sperm acrosome reaction. Because of this function the structural evolution of sulfated fucans could be a component in the speciation process. The algal and invertebrate polysaccharides are also potent anticoagulant agents of mammalian blood and represent a potential source of compounds for antithrombotic therapies.

Tafamidis, a transthyretin (TTR) kinetic stabilizer, delayed neuropathic progression in patients with Val30Met TTR familial amyloid polyneuropathy (TTR-FAP) in an 18-month randomized controlled trial (study Fx-005). This 12-month, open-label extension study evaluated the long-term safety, tolerability, and efficacy of tafamidis 20 mg once daily in 86 patients who earlier received blinded treatment with tafamidis or placebo. Efficacy measures included the Neuropathy Impairment Score in the Lower Limbs (NIS-LL), Norfolk Quality of Life-Diabetic Neuropathy total quality of life (TQOL) score, and changes in neurologic function and nutritional status. We quantified the monthly rates of change in efficacy measures, and TTR stabilization, and monitored adverse events (AEs). Patients who continued on tafamidis had stable rates of change in NIS-LL (from 0.08 to 0.11/month; p = 0.60) and TQOL (from -0.03 to 0.25; p = 0.16). In patients switched from placebo, the monthly rate of change in NIS-LL declined (from 0.34 to 0.16/month; p = 0.01), as did TQOL score (from 0.61 to -0.16; p < 0.001). Patients treated with tafamidis for 30 months had 55.9 % greater preservation of neurologic function as measured by the NIS-LL than patients in whom tafamidis was initiated later. Plasma TTR was stabilized in 94.1 % of patients treated with tafamidis for 30 months. AEs were similar between groups; no patients discontinued because of an AE. Long-term tafamidis was well tolerated, with the reduced rate of neurologic deterioration sustained over 30 months. Tafamidis also slowed neurologic impairment in patients previously given placebo, but treatment benefits were greater when tafamidis was begun earlier.