Gavialis gangeticus is the sole survivor of the group, thus providing unique evidence on the distinctive biology of its fossil kin. Yet phylogenetic relationships and evolutionary ecology spanning ~70 million-years of longirostrine crocodylian diversification remain unclear. Analysis of cranial anatomy of a new proto-Amazonian gavialoid, Gryposuchus pachakamue sp. nov., from the Miocene lakes and swamps of the Pebas Mega-Wetland System reveals that acquisition of both widely separated and protruding eyes (telescoped orbits) and riverine ecology within South American and Indian gavialoids is the result of parallel evolution. Phylogenetic and morphometric analyses show that, in association with longirostry, circumorbital bone configuration can evolve rapidly for coping with trends in environmental conditions and may reflect shifts in feeding strategy. Our results support a long-term radiation of the South American forms, with taxa occupying either extreme of the gavialoid morphospace showing preferences for coastal marine versus fluvial environments. The early biogeographic history of South American gavialoids was strongly linked to the northward drainage system connecting proto-Amazonian wetlands to the Caribbean region.Gavialoid crocodylians are the archetypal longirostrine archosaurs and, as such, understanding their patterns of evolution is fundamental to recognizing cranial rearrangements and reconstructing adaptive pathways associated with elongation of the rostrum (longirostry). The living Indian gharial  Gavialis gangeticus and the Indonesian false gharial Tomistoma schlegelii, morphological phylogenies suggest that: 1) these two extant longirostrine species are much more distantly related, 2) their elongated skulls evolved convergently, and 3) the oldest fossil gavialoid dates back to the Cretaceous Period in North America, Europe, and Africa ..28].MUSM 987, right mandible, Locality IQ101 MZ6; ; MUSM 90Gryposuchus pachakamue is a long-snouted gavialoid crocodylian diagnosed by the following unique combination of characters: 22 maxillary and 22 mandibular teeth; ventral margin of postorbital bar inset from lateral jugal surface; frontoparietal suture between supratemporal fenestrae strongly concavoconvex; splenial with anterior perforation for mandibular ramus of cranial nerve V posterior to symphysis; splenial constricted within symphysis; surangular-dentary suture intersecting external mandibular fenestra at posterodorsal corner; surangular-articular suture bowed strongly laterally within glenoid fossa. Differs from Gr. croizati and Gr. colombianus in having nasals and premaxillae in extensive contact (character 82–2), narial opening longer than wide (character 83–0), posterior orbital margin not upturned (character 137–1), ventral margin of the orbit gently circular (character 138–0), and interorbital bridge width equivalent to orbit width (character 190–0).Gryposuchus pachakamue  and the rostral width/postorbital width index is 0.27 (0.25 in G. gangeticus). In front of the orbits, the initial lateral expansion of the skull occurs at the level of the sixteenth maxillary alveolus and continues to widen gradually posteriorly. In dorsal view, the post-rostral skull outline is roughly triangular and the skull table is wide, trapezoidal in shape, and perforated by large supratemporal fenestrae. The supratemporal fenestrae are irregular in outline and widest posteriorly. The orbits are slightly wider than long and markedly smaller than the supratemporal fenestrae. The infratemporal fenestra is roughly ellipsoid in shape. The narial opening is heart-shaped, and its narial rim surface is interrupted anteriorly and anterolaterally by distinctive grooves, but no plateau-like shelf typical of adult males of Gavialis is observed in any specimen. The incisive foramen forms a slender, elongated isosceles triangle. The occipital plate is posteriorly inclined but appears to be at a lesser degree than in other South American gavialoids. Suborbital fenestrae are proportionally longer than those of Gryposuchus colombianus and Gavialis gangeticus, with the anterior end acute and the posterior margin broadly rounded. Pterygoid bullae are located laterodorsal to the posterior half of the palatine bridge.Gavialis or Gryposuchus colombianus Gavialis  alveoli . VentralEogavialis, and not dorsoventrally flattened as in Gryposuchus colombianus and Piscogavialis. Dorsally, the maxillae are not in contact due to the forward projecting nasals that contact the slender posterior processes of the premaxillae. As in other Gryposuchus species, modest alveolar salients are observed along most of the maxillary margins. Each maxilla bears 22 tooth positions, all of them subequal in size, exclusive of the last two maxillary alveoli that are the only significantly smaller alveoli . Maxillae have no contact with the prefrontals.The maxillae are long and tubular resembling those of  alveoli . VentralEogavialis and Gryposuchus colombianus, and in distinction from Piscogavialis and Ikanogavialis in which the posterior end of the nasals is located far anterior to this position. The condition in Gavialis is intermediate in this aspect. Whereas the posterior process of the nasal is pointed in all South American gavialoids where this area is known, including Gryposuchus pachakamue, in Gavialis it is strongly denticulate.The nasals are extremely long, slender bones with close and extensive anterolateral contact with the premaxillae. Additionally, the nasals contact the maxillae and lacrimals laterally, the prefrontals posteriorly, and the frontal posteromedially. The nasals are in contact with each other along the sagittal axis for most of their length. Posteriorly, they are separated by the pointed anterior process of the frontal, almost at the level of the anterior extension of the jugals. The lateral margins of the nasals slightly diverge posteriorly, reaching their greatest transverse diameter just ahead of the anterior processes of the prefrontals. The posterior end of the nasals reach the level of the anterior margins of the orbits, resembling in this aspect The lacrimals are large and roughly triangular in shape. They contact the maxillae and jugals laterally and the nasals and prefrontals medially. Posteriorly, they form the anterior margin of the orbits. The anterior process of the lacrimal exceeds in length that of both the frontal and prefrontal. A small, discrete knob occurs at the orbital margin, lateral to the prefrontal-lacrimal suture.Gryposuchus pachakamue this bone differs from other Gryposuchus species and most other gavialoids, and it more closely resembles the general pattern observed in non-gavialoid crocodylians. Gavialoids, such as Gryposuchus colombianus, Gr. croizati, Ikanogavialis, Gavialis, and to a lesser degree Siquisiquesuchus, present a deep notch immediately anterior to the postorbital pillar. However, in non-gavialoid crocodylians as well as some gavialoids such as Gryposuchus pachakamue, Eothoracosaurus, Eosuchus, and Piscogavialis, the jugal orbital rim progressively descends lateral to the postorbital pillar, thus the ventral margin of the orbit is gently circular. Additionally, in these latter gavialoid taxa and in Siquisiquesuchus, the postorbital pillar reaches the horizontal bar of the jugal medially and a longitudinal sulcus is present between these structures. This latter condition also differs from the distinctive feature observed in gavialoids such as Gavialis and Gryposuchus species other than Gr. pachakamue, in which the postorbital bar lies flush with the lateral surface of the jugal.The jugals form the ventral margins of the orbits and infratemporal fenestrae. In Gavialis and Gryposuchus colombianus this suture is sharply angulated, a condition associated with their possession of fully “telescoped orbits” (see below).The prefrontals are short and rhomboid in shape. They are separated from each other by the frontal and nasals and form part of the anterodorsal orbital margin. From the orbit, the prefrontal-frontal suture follows a gentle semicircular path. In contrast, in Gryposuchus colombianus. In MUSM 900 the suture runs along the dorsal surface of the skull table, just grazing the margin of the fenestra. The frontal bone and skull table are not elevated relative to the rostrum. The skull table presents an uneven surface, being depressed between the orbits but higher along the postorbital-frontal suture and parietal-supraoccipital region.The frontal bears a long anterior process that largely exceeds the anterior end of the prefrontal and that of the orbit too. Posteriorly, the main surface of the frontal is slightly concave and weakly sculptured . LateralGavialis, Gryposuchus colombianus, and Gr. neogaeus. The development of this anterolateral process is variable in Gryposuchus croizati and is small in Siquisiquesuchus and Piscogavialis. The postorbital medially contacts the frontal and slightly contacts the parietal, at the rim of the supratemporal fenestra. The postorbital bone forms part of the dorsal portion of the postorbital bar. As in other gavialoids, the postorbital bar is robust and longer than wide in cross section. On the lateral side of the postorbital bar, lying entirely on the postorbital bone, there is an anteroposteriorly-oriented, crest-like bump, similar to that of Gryposuchus colombianus and Piscogavialis. In MUSM 900, the largest specimen, the bump presents an anterolateral spine similar to that of Gavialis [The postorbital bones on the skull table are relatively flat and lightly built. They form the anterior corner of the skull table and lack the anterolateral postorbital process characteristic of Gavialis . The sutGryposuchus pachakamue exhibits prong-like posterior extensions of the squamosal, but they are comparatively shorter than those of most South American gavialoids and Argochampsa . The postemporal fenestrae are hardly discernable in any of the specimens, and they seem to be small. Available specimens show asymmetrical development of the postoccipital processes   and surrPiscogavialis.The quadratojugal forms the posterior margin and corner of the infratemporal fenestra. The anterior process of the quadratojugal comprises a robust spine, as is usually observed in gavialoids. Dorsomedially, the ascending process that bounds most of the posterior margins of the infratemporal fenestra is very thin and long; its dorsal end is not discernible. Sutural contacts of the quadratojugal with the jugal and the quadrate are not parallel, in contrast with the condition in Piscogavialis, Siquisiquesuchus, and Gryposuchus croizati.The quadrates are robust and short. The quadrate ventrally bounds the otic aperture and, although incomplete, it seems to occupy part of its posterior margin; thus the quadrate-squamosal suture might have reached the otic aperture along the posterior wall. The small foramen aëreum is located on the mediodorsal surface of the quadrate. The axis of the mandibular condyles is oblique, as it generally is in gavialoids. Medial and lateral condyles are clearly discernable, with the medial one deflected ventrally as in South American gharials, where known, such as in The laterosphenoids are partially preserved in the holotype, as well as in MUSM 2032 and MUSM 1681. The anterior dorsal margin of the laterosphenoid, as well as the capitate process, is oriented lateromedially. The dorsal capitate process is massive, and its whole anterior portion is relatively flat.The palatine bones cover the entire ventral surface of the bridge between the suborbital fenestrae. They are roughly parallel-sided and transversely convex along this bridge. From the anterior limit of the suborbital fenestrae, the lateral margins of the palatine bones converge to a point approximately at the level of the fifteenth maxillary alveolus. The anterior limit of the suborbital fenestra is located at the level of the nineteenth maxillary alveolus . The palPiscogavialis, and comprises the posterior half of the margin of the suborbital fenestra. The anterior tip runs medially to the maxillary tooth row until the level of the anterior limit of the penultimate alveolus, as in Piscogavialis. The distance between the tooth row and the anterior process of the ectopterygoid is less than in Gavialis. In ventral view, Gryposuchus pachakamue and Piscogavialis display a substantial contact between the ectopterygoid and jugal, whereas this contact is smaller in the extant gharial Gavialis gangeticus. Available evidence from the same anatomical area is not clear in other South American fossil gharials. Eogavialis specimens do not preserve details of this region, other than in exhibiting a large ectopterygoid-jugal contact. Differing from all other gavialoids, in Argochampsa the ectopterygoid stops far behind the tooth row [Gryposuchus pachakamue; thus contact with the pterygoid flanges is reduced relative to the condition in other gavialoids.The ectopterygoids are incomplete and badly damaged, but preserved regions are informative. The anterior process of the ectopterygoid is thin and long, resembling that of ooth row . The posGryposuchus pachakamue, pterygoid bullae in intimate contact with the palatines are observed dorsal to the posterior portion of the palatal bridge. The bullae are neither ovoid in shape nor smooth-surfaced, as in other gavialoids; instead they are kidney-like in shape with irregular prominences and depressions. They are relatively small, flat, and project slightly laterally into the suborbital fenestrae, as in the type specimen of Gryposuchus colombianus. The choana is distorted in MUSM 900 but is not preserved at all in any other specimen.The pterygoid widely separates the ectopterygoids from the palatines. In the holotype of Piscogavialis, Gryposuchus colombianus, and Gr. croizati. The paraoccipital processes are long and encompass a ventral plate-like expansion that completely covers the cranioquadrate foramen. Dorsal to the foramen magnum, the exoccipitals and the supraoccipital are collapsed by deformation, thus positional relationships of these bones are obscured. The ventral processes of the exoccipitals laterally embrace the basioccipital tubera. These processes are robust and anteroposteriorly extended.The exoccipitals are best preserved in MUSM 1681. As in most gavialoids, they are visible in dorsal view, but not as much as in The basioccipital is typically gavialoid in being low and laterally expanded ventral to the condyle, producing two pendulous tuberae. The bassioccipital plate is smooth, exclusive of the lateral and ventral margins, in which tuberosities are well developed. Medially, the ventral margin of the plate is excavated. The basisphenoid is anteroposteriorly broad anterior to the basioccipital. The medial eustachian foramen is wider than long.The braincase region is badly damaged around the prootic in all of the specimens.Gavialis, Ikanogavialis, Siquisiquesuchus, and Piscogavialis. The mandible is low along the symphysis; and its height progressively increases posteriorly until the level of the glenoid fossa. The external mandibular fenestra is small, eye-shaped and occurs comparatively closer to the articular region than in Gavialis.The mandibular rami  and the same general dental pattern described above. Differences in Gr. pachakamue relative to these other Gryposuchus species include: proportionally higher and more tubular dentary, stronger alveolar salients, and no constriction between the fourth and fifth alveoli (this last character only pertains to comparisons with Gr. colombianus). There are at least four tooth positions located posterior to the level of the mandibular symphysis, as in Piscogavialis, whereas other gavialoids generally possess no more than three. These alveoli are located along the medial limit of the dentary and their lingual wall is formed either by the splenial  or the surangular .The dentary bone is long, transversely expanded at the level of the second alveolus and restricted to the lateral wall of the mandibular ramus between the end of the tooth series and the external mandibular fenestra. Posteriorly, the dentary reaches the rear margin of the external mandibular fenestra (EMF). The first 15 alveoli are implanted within salients along the lateral border of the dentary, providing a sinuous profile to this margin. The dentary (MUSM 987) bears 22 alveoli, all of them sub-equal in size, exclusive of the first and fourth, which are of greater diameter: the second and third are the smallest of the whole series. Tomistoma schlegeli, this foramen occurs within the symphysis of Gavialis gangeticus at the level of the twenty-second alveolus [Gryposuchus pachakamue (MUSM 987 and MUSM1428) and Eogavialis africanus (AMNH 5069)–probably homologous to that of Gavialis–situated just behind the symphysis, within the medially divergent walls of the splenial, at the level of the twentieth alveolus . Just behind this foramen, the surangular covers the postglenoid process of the articular; therefore this process is hardly seen in lateral view as in Gavialis  defines the separation between the orbits. Brevirostrine crocodylians, Eogavialis, Piscogavialis, and Ikanogavialis generally bear a narrow interorbital bridge diameter  compared to Gryposuchus pachakamue, in which the width of the frontal bone is essentially equivalent to the width of the orbit and this ratio is consistently higher  than that of adult Gavialis and other species of Gryposuchus  of Eogavialis, Gr. pachakamue, and Piscogavialis lies flush with the rostral surface contrasting with the raised anterior margins of other gavialoids. The jugals of Gr. pachakamue differ from those of other Gryposuchus species and most other gavialoids, more closely resembling the general pattern of non-gavialoid crocodylians. Gavialoids such as Gryposuchus colombianus, Gr. croizati, Ikanogavialis, Gavialis, and to a lesser degree Siquisiquesuchus, present a deep notch immediately anterior to the postorbital pillar. However, in non-gavialoid crocodylians and some gavialoids such as Gryposuchus pachakamue, Eothoracosaurus, Eosuchus, and Piscogavialis, the jugal orbital rim progressively descends lateral to the postorbital pillar, thus in those taxa the ventral margin of the orbit is gently circular. Additionally, in those taxa as well as in Siquisiquesuchus, the postorbital pillar reaches the horizontal bar of the jugal medially and a longitudinal sulcus is present between these structures. This latter condition also differs from a distinctive feature observed in many other gavialoids, such as Gavialis and other Gryposuchus species, in which the postorbital bar lies flush with the lateral surface of the jugal  characterized by association with riverine and lacustrine-tidal paleoenvironments. On the other hand, relationships among South American taxa usually associated with coastal marine paleoenvironments show no resolution: Siquisiquesuchus, Piscogavialis, and Ikanogavialis lie in a polytomy together with Amazonian Gryposuchus and Indo-Asian Gavialis. As a consequence, this first analysis finds no support for the monophyly of a clade comprising South American gavialoids, as had been suggested by previous studies [Argochampsa [Argochampsa and the Caribbean taxon Aktiogavialis. This clade is supported by the presence of long supratemporal fenestrae (character 191–0), a character state that implies a reversal within these gavialoids. This might be considered problematic since Argochampsa, as an early representative of the clade, could have retained the ancestral condition for Crocodylia if character polarization based on the phylogenetic position of “thoracosaurs” is erroneous. Nevertheless, further comparisons between Argochampsa and Aktiogavialis allows us to recognize other similarities not yet included in phylogenetic analyses, but potentially supporting their close relationship, such as the relative proportions of the skull table in dorsal view and the presence of a distinctive shallow fossa in the anterior margin of the supratemporal fenestra. This fossa has not been identified in any other crocodylian species at any ontogenetic stage [Argochampsa and Aktiogavialis, although barely discernable in other individuals of the African taxon Argochampsa . The Argochampsa + Aktiogavialis group is found as most closely related to the clade of South American gavialoids plus Indo-Asian Gavialis, and with Eogavialis as the nearest outgroup to all of these taxa. Therefore, African Argochampsa is more closely related to Indo-Asian Gavialis as was previously suggested by others [Eogavialis. In fact, both Paleogene African taxa, Argochampsa and Eogavialis, share key characters with more anatomically-derived gavialoids like Gavialis. The clade encompassing this subset of late-diverging gavialoids is here termed “gharials”  and anteriorly flaring squamosal groove (character 147–1), also are observed in the tomistomine Thecachampsa americana and might represent independent, convergent acquisitions. As in most crocodylians, the infratemporal fenestra is triangular in Gavialis (character 147–0), and is most parsimoniously regarded as a reversal in this latter taxon. Paleocene Eosuchus and Cretaceous “thoracosaurs” from the northern hemisphere are identified in this analysis as the first and second basalmost diverging branches among the gavialoids, respectively.The new Pebasian species,  studies ,39,49. Ty others ,9, than harials”  and it iGryposuchus and Gavialis. In addition, this analysis collapsed states of character 138 (as they may not be independent) and deleted state 2 from character 137, both of which describe morphology of the orbital margin associated with “telescoped” orbits, which the all-data parsimony analysis indicate clearly evolved multiple times independently within gavialoids , lack of exposure of the prootic on external braincase wall (character 164–1), a quadrate with ventromedially projected medial hemicondyle (character 181–4), and a retroarticular longitudinal crest (character 203–1). This last character is present in all South American gharials preserving this region [Argochampsa also clearly possesses this feature [Ikanogavialis, Siquisiquesuchus, and Piscogavialis. Other gavialoid relationships were unaffected relative to the initial analysis. Discussions below are based on this second phylogenetic analysis, unless otherwise noted.Compared to the first analysis, this approach substantially increased resolution of South American gavialoid relationships. The monophyly of gryposuchines, exclusive of the Caribbean taxon s region ,10, incls region . The disGryposuchus pachakamue inhabited the heart of the proto-Amazonian mega-wetlands ecosystem during the Middle Miocene, from around 16 to 13 Ma, and it represents the oldest known record of a gavialoid from this area. Remains belonging to this new taxon were consistently recovered from deposits depicting shallow lacustrine paleoenvironments. As the basalmost species of the Gryposuchus clade, it provides essential evidence for accurately reconstructing the ancestral anatomy and ecology of this clade and provides evidence of parallel evolution of distinctive rostral and orbital anatomy in gavialoids. Our phylogenetic analyses reconstruct the acquisition of widely separated orbits as independent evolutionary events in Asian Gavialis and later-diverging Gryposuchus species (Gr. colombianus + Gr. croizati) in South America. As a consequence, the comparatively slender interorbital bridge of Gr. pachakamue is primitive for all gavialoids  include: postorbital bar flush with lateral jugal surface (character 135–1), upturned dorsal and posterior orbital margins (character 137–2), and ventral orbital margin with a prominent notch (character 138–1). Parsimony analyses also suggest parallel development for two of these character states, indicating that the “telescoped” orbit condition is homoplastic in gavialoids and occurred independently in advanced South American Gryposuchus and Asian Gavialis species.vialoids . A wide Piscogavialis and Argochampsa, whereas lower scores along these PC axes correspond to the morphospace including taxa with fully “telescoped” orbits. Lacustrine Gryposuchus pachakamue and Eogavialis africanus, the latter lacking definitive data on its paleoenvironmental provenance, exemplify the intermediate morphospace. The fully “telescoped” orbit morphospace is represented by Gavialis and Gryposuchus colombianus; since they are distantly related, this morphospace depicts the parallel evolution of this distinctive cranial anatomy, apparently associated with convergent specialization in a freshwater habitat and similar visually enhanced feeding strategies. Distinct features of this morphotype include: upturned anterior, dorsal, and posterior orbital margins; ventral orbital margin with a prominent notch; postorbital pillar laterally displaced; and orbits widely separated. Gavialoids display different degrees of the “telescoped” condition.By mapping the phylogenetic tree onto the first two axes of the PCA axes, we examined ecological associations of circumorbital bone arrangements throughout gavialoid evolution . Higher Gavialis gangeticus involve active use of the telescoped eyes and integumentary sense organs in capturing fishes in streams [Gavialis species inhabited, and might have dispersed geographically via, fluvial systems then occurring between Indo-Pakistan and Southeast Asia [Gryposuchus colombianus is restricted to fluvial-influenced settings of the Pebas Mega-Wetland System at La Venta (Colombia) [Gryposuchus pachakamue consistently occurs. This latter species not only is the sole gavialoid in the Iquitos fauna, but the sole longirostrine crocodylian within a highly diversified community dominated by small caimans with crushing dentitions reflecting a specialized malacophagous diet [The feeding strategy of the extant gharial  streams , as its  streams . Fossil ast Asia . In Soutolombia) ,54 and Folombia) ,55,56, cous diet . In younous diet , at a tious diet .Gryposuchus croizati, most likely a dweller in fluvial settings. Based on its paleoenvironmental preference in the Iquitos fauna, Gryposuchus cf. pachakamue from Urumaco instead might have occupied relicts of the brackish lacustrine ecosystems once widely distributed in proto-Amazonia [Within a wider environmental context, the demise of the Pebas Mega-Wetland System and subsequent establishment of the fluvio-tidal Acre Phase in the Amazonian Basin at around 10.5 Ma seems to have promoted diversification, size increase, and specialization in gharials  comparedAmazonia . TherefoAmazonia ,58.Siquisiquesuchus was an early Miocene Caribbean inhabitant of present-day Venezuelan coasts [Gryposuchus pachakamue from both Urumaco and Iquitos, as well as other biotic indicators [Inasmuch as gharials were inhabitants in the Caribbean region at least since the Late Oligocene , the Carn coasts . Other mn coasts ,34,62,63n coasts ,32,61. Tdicators ,64–68. SAktiogavialis and African Argochampsa Click here for additional data file.S1 FigLandmarks are labeled from 1 to 20. Gray area symbolizes orbits defined by landmarks 5-7-9-11 and 6-8-10-12 on the right and left sides, respectively.(TIF)Click here for additional data file.S2 FigSecond approach after removing character state 137–2 and character 138. Numbers at nodes indicate Bremer support values.(TIF)Click here for additional data file.


Endogenous Cushing's syndrome (CS), a rare endocrine disorder characterized by cortisol hypersecretion, is associated with psychiatric and neurocognitive disorders. Major depression, mania, anxiety, and neurocognitive impairment are the most important clinical abnormalities. Moreover, patients most often complain of impairment in quality of life, interference with family life, social, and work performance. Surprisingly, after hypercortisolism resolution, despite the improvement of the overall prevalence of psychiatric and neurocognitive disorders, the brain volume loss at least partially persists and it should be noted that some patients may still display depression, anxiety, panic disorders, and neurocognitive impairment. This brief review aimed at describing the prevalence of psychiatric and neurocognitive disorders and their characterization both during the active and remission phases of CS. The last section of this review is dedicated to quality of life, impaired during active CS and only partially resolved after resolution of hypercortisolism. Chronic glucocorticoid (GC) overproduction by the adrenal glands represents the cause of endogenous Cushing's syndrome (CS), a rare but serious endocrine disorder. In approximately 80% of cases, endogenous CS is consequence of an ACTH hypersecretion (ACTH-dependent CS), generally due to a corticotroph pituitary tumor , and rarely due to an ACTH-secreting or CRH-secreting extra-pituitary tumor , whereas in the remaining 20% of cases CS is independent from ACTH hypersecretion (ACTH-independent CS) and GC excess is direct consequence of autonomous overproduction by the adrenal glands, because of unilateral adrenocortical tumors or bilateral adrenal hyperplasia, or dysplasia , mainly in the hippocampus; therefore, it is not surprising that chronic GC excess can lead to structural and functional changes in CNS, which are mainly based on brain atrophy  major depression, which include alterations in mood, affective, vegetative, and cognitive functions; and (2) mania and anxiety. Major depression represents the most frequent and severe psychiatric disorder associated with chronic endogenous hypercortisolism. The prevalence of major depression in patients with CS is reported to be about 50–81%, as summarized in Table  major deA significant percentage (66%) of CS patients reported generalized anxiety or panic disorders more frequently described in the chronic and advanced stage of active hypercortisolism (Starkman et al., Neurocognitive impairment has been reported in about two thirds of CS patients with variable degrees from mild to severe (Whelan et al., Several studies have reported that, after disease remission, the resolution of hypercortisolism, namely the normalization of cortisol secretion, is not constantly followed by the complete recovery of many clinical complications developed during the active disease; in particular, metabolic syndrome and the consequent cardiovascular risk have been found to partially persist after disease remission (Colao et al., To date, the issue of whether remission of CS may completely resolve psychiatric and neurocognitive disorders remains controversial. Several studies demonstrated a significant improvement of psychiatric and neurocognitive disorders after resolution of hypercortisolism (Jeffcoate et al., Overall these data highlight the importance of a long-term follow-up and careful periodic investigation of neuropsychiatric symptoms in patients with CS also after hypercortisolism resolution, and the importance to consider the management of these disorders as one of the essential outcomes of CS patients.Considering the systemic and neuropsychiatric complications associated with hypercortisolism it is expected that CS patients have impairment in QoL (Colao et al., In conclusion, CS is frequently associated with an high prevalence of psychiatric and neurocognitive disorders and with a significant impairment in QoL. Major depression represents the most important and life-threatening psychiatric complication, occurring in approximately 50–60% of patients, but mania and anxiety are also reported in many cases. Additionally, neurocognitive disorders may occur both as a manifestation within the depressive syndrome clinical frame, and separately as isolated neurological disorder. It should be highlighted that psychiatric and mainly neurocognitive disorders, even long-term after CS remission, although generally improve, may persist, or even worsen, contributing to the persistent impairment of QoL registered also in patients treated for CS. Therefore, long-term follow-up and careful periodical investigation of psychiatric and neurocognitive symptoms should be always considered in the management of CS both in the active phase and after disease remission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The primary focus of research into the pathophysiology of the acute respiratory distress syndrome (ARDS) has been on the interaction between the lung, underlying causes of ARDS, and the role of white blood cells and platelets in contributing to lung injury. Given a lack of specific therapies for this common complication of critical illness, further insight into the pathophysiology of this syndrome is greatly needed to develop targeted interventions. The red blood cell (RBC) has been reported to undergo deleterious changes in critical illness and be present in the alveoli of patients with ARDS. Release of RBC contents is known to be injurious in other conditions but has only recently been studied in critical illness and ARDS. The contribution of the RBC to ARDS represents a new avenue of research that may produce new, targeted therapies for this deadly syndrome. The acute respiratory distress syndrome (ARDS) frequently complicates critical illness from a variety of underlying causes ,2. This Since the first description of ARDS in 1967 , investiThe purpose of this review is to examine the changes that occur to the RBC in critical illness, the contribution of the RBC to alveolar injury in ARDS, and potential interventions for future study.It was first reported over 20 years ago that the RBC cell membrane undergoes changes and is damaged as a result of sepsis, even in the absence of an associated hemolytic condition . The RBCSepsis, the most common cause of indirect ARDS , has recIn addition to occlusion of capillary beds, decreased deformability of RBCs in critical illness also leads to RBC lysis and release of intracellular contents into the circulation. In an experimental model , plasma via binding of hemoglobin to haptoglobin leading to CD163 receptor-mediated uptake into the macrophage where hemoglobin is converted to bilirubin by heme oxygenase-1 (HO-1) and ultimately excreted by the liver [Hemoglobin exists in the red blood cell as a tetramer of globin molecules with ferrous (2+) iron bound to each of the four porphyrin-ring heme groups . During he liver . Free hehe liver . Of the he liver . Changeshe liver .via the NF-κB pathway, and this inflammatory response is independent of iron oxidation [2-Isoprostanes, and an increase in plasma creatinine [2-Isoprostanes, and plasma creatinine.These processes of cell-free hemoglobin (CFH) clearance protect against the four main mechanisms of CFH-mediated organ injury: nitric oxide (NO) consumption, endothelial damage, inflammation, and oxidative injury Figure . Nitric xidation . Finallyxidation . In an aeatinine . SupplemA number of disease states are characterized by the release of CFH from the RBC and include sickle cell anemia , hemodiavia peroxidation of lipid membranes. Products of lipid peroxidation, including F2-Isoprostanes and Isofurans, can be detected in critically ill patients and are associated with organ dysfunction [Compared to other disease states associated with CFH release from RBCs, critically ill patients with sepsis have a unique physiologic state that creates an environment where CFH can induce organ injury due to a “two-hit” set of conditions. First, critically ill patients, including those with sepsis, are known to have a reduced capacity to detoxify CFH. Decreased levels of haptoglobin, hemopexin, and heme oxygenase-1 occur in critical illness, including patients with sepsis and ARDS, and decreased levels have been associated with poor clinical outcomes ,43. Secofunction ,44.Alveolar hemorrhage was noted in the first description of ARDS ; howeverin vitro study of human alveolar epithelial cells [via activation of the NF-κB pathway. The supplementation of antioxidants or iron chelators did not alter the effects of methemoglobin, suggesting that CFH can mediate alveolar epithelial injury independent of iron and oxidative pathways.An additional mechanism of injury by CFH in ARDS may be mediated specifically by targeted cell surface receptor binding on the alveolar epithelium rather than oxidative injury by the ferryl hemoglobin radical. In an al cells , exposurvia endotracheal tube suctioning. Patients with ARDS had significantly higher levels of CFH compared with control patients with hydrostatic pulmonary edema. Also, in patients with diffuse alveolar hemorrhage, alveolar fluid obtained via bronchoalveolar lavage showed increasing levels of biomarkers of oxidative injury as the lavage became progressively bloodier. Pulmonary arterial hypertension (PAH) is known to occur during ARDS and is associated with poor outcomes [Several lines of evidence suggest that CFH also plays a role in human ARDS. In an observational study of 41 patients with ARDS or hydrostatic pulmonary edema , undilutoutcomes ,52. In houtcomes . Whetheroutcomes ,53,54 anoutcomes .Figure 2Although we still have a limited understanding of the role of RBCs and CFH in the pathogenesis of ARDS, in other disease states associated with release of CFH, there are therapeutic interventions being developed to improve clinical outcomes. Preliminary studies support a potential benefit of targeting CFH in sickle cell anemia, malaria, sepsis, and other conditions associated with release of CFH. These conditions are more common than ARDS and have some preliminary data regarding the benefit of CFH-inhibition and outcomes. As previously discussed, there are a number of processing proteins required to detoxify CFH to bilirubin including haptoglobin, hemopexin, and heme oxygenase-1 . Animal Small studies of haptoglobin as a therapeutic CFH scavenger have been conducted in humans with a variety of conditions . In pati2 synthase and cyclooxygenase inhibition, that are used to treat pain and fever [2-Isoprostanes and improved renal function compared with placebo [Acetaminophen has a number of pharmacologic mechanisms, including prostaglandin Hnd fever ,66. In and fever ,66. In a placebo . As prev placebo ,67. In a placebo . In a ra placebo . As sepsNo studies to date have examined the efficacy and safety of CFH-targeted therapies such as haptoglobin, hemopexin, heme oxygenase-1, or acetaminophen in humans with ARDS. As we continue to make further insights into the role of the RBC and CFH in the pathogenesis of ARDS, we are likely to see these and other therapies tested in patients with ARDS.ARDS is a common and incompletely understood syndrome without targeted therapies. Until recently, investigation into the pathophysiology of ARDS focused on the interaction between white blood cells, platelets, and the pulmonary endothelium and epithelium. The red blood cell, known to be present in the alveoli of patients with ARDS, has previously been viewed as an innocent bystander rather than a major driver of the pathogenesis of ARDS. New insights into the changes that occur in the RBC membrane during critical illness and the role of cell-free hemoglobin in oxidative and endothelial injury have renewed interest in the RBC as a pathologic mediator in ARDS. Further study is needed to better characterize the red blood cell’s role in the pathogenesis of ARDS; however, this line of research is already producing investigation into new therapeutic approaches in ARDS.


Viruses on HCV drug resistance, mechanisms of antiviral resistance for different classes of antiviral drugs are described. Furthermore, the detection and monitoring of resistance in clinical practice, the clinical impact of resistance in different patient groups and strategies to prevent and address resistance and treatment failure using complementary antiviral strategies are reviewed.Chronic hepatitis C is a major cause of chronic liver disease, including liver cirrhosis and hepatocellular carcinoma. The development of direct-acting antivirals (DAAs) revolutionized hepatitis C virus (HCV) treatment by offering genuine prospects for the first comprehensive cure of a chronic viral infection in humans. While antiviral resistance is a significant limitation for interferon-based therapies, resistance and treatment failure still appear to be present in a small fraction of patients even in state-of-the-art DAA combination therapies. Therefore, treatment failure and resistance still remain a clinical challenge for the management of patients not responding to DAAs. In this special issue of  Viruses, mechanisms of antiviral resistance for different classes of antiviral drugs are described. Furthermore, the detection and monitoring of resistance in clinical practice, the clinical impact of resistance in different patient groups and strategies to prevent and address resistance using complementary antiviral strategies are reviewed.Chronic hepatitis C is a major global cause of liver disease, including liver cirrhosis and hepatocellular carcinoma. More than 130 million persons, approximately 3% of the global population, are chronically infected with the hepatitis C virus (HCV). In the USA, chronic hepatitis C infection, the most common cause of liver-related death and liver transplantation, recently surpassed human immunodeficiency virus (HIV) infection as a cause of mortality . While aResistant variants are seen in most patients who do not achieve a sustained virological response (SVR) , highligGiven that the outcome of DAA-based therapies may be affected by the selection of resistant variants, virological tools to monitor drug resistance both in the drug development stage as well as in the clinic are of critical importance. Fourati and Pawlotsky  describeDespite the remarkable cure rates of DAAs, the pursuit of complementary antiviral strategies is still warranted for patient groups who do not respond to therapy, due to DAA resistance or other factors. For example, a substantial fraction 10%–20%) of patients with decompensated cirrhosis do not respond to current DAAs, and treatment is associated with adverse effects %–20% of . Roche aZeisel and colleagues  describeFinally, Mesalam and colleagues  describeViruses will help to bring the goal of global HCV eradication yet closer to reality.The development of DAAs markedly improved the outlook for HCV patients and provides the first real opportunity for global cure of a chronic viral infection. The novel strategies to prevent and address the challenges of DAA resistance described in this special issue of


Platelets are small, oval, circulating, anucleate cells that upon endothelial damage form a haemostatic plug and stop blood leakage. Circulating platelets derive from bone-marrow-resident megakaryocytes that daily produce and release approximately 100 billions of new platelets into the blood stream , the CNS is not free from the action of platelets, particularly, in response to injury. As expected, after their adherence to endothelial cells, platelets activate, and recruit leukocytes into the damaged CNS tissue Simon, , thus, pBesides their role in pathogenesis, platelets might also be involved in the regulation of regenerative processes by interacting with CNS stem/progenitor cells. Adult neural stem cells (NSCs) are undifferentiated self-renewing multipotent cells that reside in the subgranular zone (SGZ) in the dentate gyrus of the hippocampus and in the subventricular zone (SVZ) of the wall of the lateral ventricles Altman, . OligodeSupporting the previous hypothesis, a series of findings suggest that platelets directly exert CNS-regenerative activities and might contribute to neuroregeneration (see Table There is accumulating evidence that the role of platelets is not restricted to haemostasis, but it also involves the regulation of inflammation, angiogenesis and tissue repair. The CNS contains NSCs and OPCs that contribute to cellular turnover and CNS repair. In light of the accumulating evidence that associates platelets to neuroinflammation, especially under pathological conditions, their potential role in CNS repair has to be further investigated. Recent findings indicate that neuroinflammation is also relevant for CNS repair as it contributes to debris clearance and controls CNS-resident stem/progenitor cells function, suggesting a potential role for platelets by linking inflammation to regeneration. This hypothesis is supported by the facts that circulating platelets react to CNS injury and accumulate within the adult stem cell niche and that activated platelets release a plethora of bioactive molecules that not only regulate immune cells activity but also directly modulates NSC and OPC respond to injury. It is, therefore, likely that platelets might modulate CNS repair. Prospectively, this specific lesion-induced accumulation of circulating platelets at sites of tissue damage, inflammation, and even stem/progenitor cell activity (as in Kazanis et al., FR wrote the manuscript. IK, CG, and LA critically reviewed the manuscript. All authors read and approved the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Graft versus host disease (GVHD) is one of the most frequent and serious complications of hematopoietic stem cell transplantation, and is regarded as the leading cause of late mortality unrelated to the underlying malignant disease. GVHD is an autoimmune and alloimmune disorder that usually affects multiple organs and tissues, and exhibits a variable clinical course. It can manifest in either acute or chronic form. The acute presentation of GVHD is potentially fatal and typically affects the skin, gastrointestinal tract and liver. The chronic form is characterized by the involvement of a number of organs, including the oral cavity. Indeed, the oral cavity may be the only affected location in chronic GVHD. The clinical manifestations of chronic oral GVHD comprise lichenoid lesions, hyperkeratotic plaques and limited oral aperture secondary to sclerosis. The oral condition is usually mild, though moderate to severe erosive and ulcerated lesions may also be seen. The diagnosis is established from the clinical characteristics, though confirmation through biopsy study is sometimes needed. Local corticosteroids are the treatment of choice, offering overall response rates of close to 50%. Extracorporeal photopheresis and systemic corticosteroids in turn constitute second line treatment. Oral chronic GVHD is not considered a determinant factor for patient survival, which is close to 52% five years after diagnosis of the condition. Key words:Chronic graft-versus-host disease, oral chronic graft-versus-host disease, pathogenics, management, survival. Before transplantation, the recipient is subjected to myelosuppressive and immunosuppressive conditioning treatments in order to ensure that the recipient (host) immune system is reconstructed after grafting from the donor (graft) cells, thereby avoiding rejection problems. Following transplantation, however, the immunocompetent T lymphocytes of the donor may recognize as foreign the antigens expressed by the recipient cells - thereby triggering an immune reaction accompanied by intense inflammatory responses that result in damage to different organs and tissues of the recipient. This condition is known as graft versus host disease (GVHD), and is a consequence of the incompatibility between the HLA system antigens of the donor and recipient .Allogenic hematopoietic stem cell transplantation (HSCT) is widely used for the treatment of different benign and malignant hematological diseases. In this context, GVHD is one of the most frequent and serious complications of HSCT, and is regarded as the leading cause of late mortality unrelated to the underlying disease process -4. IndeeThe acute form of GVHD is observed in 50-70% of all allogenic transplant patients, while chronic GVHD is seen in 30-50% . At presThe aim of the present study is to offer a practical update on oral chronic GVHD, fundamented on what we consider to be five key concerns in relation to this disease: (a) What are the risk factors for cGVHD and what is the pathogenic role of the T cells? (b) How often is the oral cavity affected in cGVHD? (c) In what cases would a biopsy be indicated to confirm the diagnosis of oral cGVHD? (d) Is the treatment of oral cGVHD effective? Does it depend on any known factor? (e) How does oral cGVHD evolve?A Medline-PubMed and Cochrane Collaboration literature search (latest consultation: May 2014) was conducted to clarify these issues. The search comprised publications in English and Spanish, corresponding to studies conducted in humans, without time restrictions, and with the exclusion of isolated clinical cases.The described risk factors for cGVHD are HLA incompatibility or the absence of blood ties between the donor and recipient; advanced age of the donor and recipient; a female donor and male recipient; childbirth (parity) in female donors ; the transplantation of mobilized peripheral blood cells; the infusion of donor lymphocytes; and antecedents of aGVHD -16. AdvaThe immunopathogenic mechanism of the disease is not entirely clear, though it is known that donor T cell reactivity against the recipient tissues, in the form of exacerbated direct or indirect inflammatory responses, is the main triggering factor of GVHD ,17. AlthBoth the T cells and B lymphocytes are implicated in the loss of general immune tolerance. The role of the B lymphocytes in the pathogenesis of GVHD has been explored in recent publications, due to the capacity of these cells to produce antibodies, and the good response obtained with anti-CD20 drugs in other autoimmune disease processes with characteristics similar to those of GVHD . PatientThe criteria that define and characterize the different forms of presentation of GVHD are shown in figure Although the epidemiological information referred to GVHD is not homogeneous, it has been estimated that almost one-half of all patients subjected to hematopoietic stem cell transplantation will develop the disease ,7. The pThe prevalence of oral cGVHD ranges between 45-83% , and theThe oral cavity, together with the skin, is one of the target organs of cGVHD, though manifestations are also commonly seen in the lungs, liver, genitals and gastrointestinal tract .The consensus document published in 2005 by the American Society for Blood and Marrow Transplantation  defines In the presence only of the abovementioned distinctive clinical features, the diagnosis of oral cGVHD could be established without the need for a biopsy provided we have radiological, histological or serological confirmation of the presence of cGVHD in other body organs. However, in the presence only of the distinctive clinical features without disease involvement in other organs, or if malignancy is suspected, an oral biopsy would be indicated with the purpose of establishing the diagnosis ,20.Histologically, cGVHD of the oral mucosa is characterized by the presence of dyskeratotic epithelial cells, apoptosis and an inflammatory infiltrate of lichenoid appearance beneath the epithelial basal lamina, consisting of CD3+ and CD68+ T cells ,21. FibrOther oral manifestations that can appear in both the acute and chronic presentation of the disease are mucositis, gingivitis, erythema and pain ,22.According to some authors and cGVHD study groups, the disease has similarities with other immune-mediated disorders such as lichen planus, lupus erythematosus, systemic sclerosis and Sjögren’s syndrome. In relation to this latter syndrome, and in the context of cGVHD, it has been reported that hyposalivation and xerostomia can manifest with some frequency as a consequence of progressive salivary gland atrophy. This in turn is associated to a worsening of patient quality of life referred to the oral cavity, a diminished body mass index, and more serious manifestations such as lung involvement .The pediatric presentation of oral cGVHD is rarely characterized by dry mouth, dysgeusia or dysphagia . In contWith a view to standardizing the clinical, diagnostic and therapeutic criteria of oral cGVHD, the United States National Institutes of Health (NIH) in 2006 published a consensus document including a scale comprising a series of parameters that score the severity of cGVHD  and the response to treatment in the different affected areas of the oral cavity . The NIHConsidering that no specific drug therapy for GVHD has yet been approved by the United States Food and Drug Administration (FDA), the effSystemic therapy is indicated in severe cases where cGVHD affects a number of organs. Such treatment in turn can be complemented by local measures in patients with accessible lesions such as those of the skin and oral cavity.The drugs of choice for the treatment of cGVHD are corticosteroids  with or without calcineurin inhibitors ,14,17,18When cGVHD is found to progress despite treatment with prednisone 1 mg/kg/day during two weeks; remains stable with ≥ 0.5 mg/kg/day of prednisone during 4-8 weeks; or when it is not possible to lower the dose to under 0.5 mg/kg of prednisone a day, the disease is considered to be refractory to corticosteroids and the second- and third-line treatment options are then used. Specifically, the second-line treatment options comprise extracorporeal photopheresis  and drugs such as sirolimus, everolimus, pentostatin, rituximab and imatinib. Third-line treatment in turn comprises mofetil mycophenolate, methotrexate and corticosteroid pulses. Other described treatments for cGVHD have been less widely used and include hydroxychlo-roquine, clofazimine, cyclophosphamide, alemtuzumab, anti-TNFα drugs , thoraco-abdominal irradiation, thalidomide, alefacept, daclizumab/basiliximab, retinoids, azathioprine and mesenchymal stem cells .et al. ; moet al.  is described as effective and safe, with very acceptable overall response rates, though its main inconvenience is the appearance of side effects. The pre- or peri-transplant administration of rituximab offers prevention against aGVHD but not against cGVHD. In this regard, it is believed that the early administration of rituximab could resolve cGVHD and moreover prevent the appearance of other manifestations inherent to the disease, though this is still only a hypothesis . Gutiérret al.  analyzed . Other influencing factors are the involvement of multiple body organs or regions, hyperbilirubinemia, and extensive skin involvement at the time of the diagnosis , impliesHematological malignancies and lymphoproliferative disorders can be seen with some frequency and in early phases after HSCT. Secondary solid tumors are less common, though they increase over time after transplantation , with inThe use of biomarkers in cGVHD is the subject of different investigations and clinical trials. Unfortunately, no biomarker panel applicable to cGVHD has been developed to date. The similarities between the normal immune response and cGVHD possibly complicate the identification and application of such markers ,35.Oral cGVHD is a frequent complication of HSCT. The diagnosis is usually established from the clinical findings, though a biopsy is sometimes required. The disorder manifests as lichenoid lesions, hyperkeratotic plaques and limited oral aperture secondary to sclerosis, and is usually mild. Locally applied corticosteroids are the treatment of choice and oral cGVHD is not regarded as a determinant factor for patient survival.


Small ruminants are valuable assets for the Mediterranean, African, and Southeast Asian countries with the potential for providing meat, milk, and wool. These animals are highly susceptible to respiratory diseases, which account for almost 50% mortality amongst them. Irrespective of the etiology, the infectious respiratory diseases of sheep and goats contribute to 5.6 percent of the total diseases of small ruminants. The infectious respiratory disorders are classified into two groups: the diseases of upper respiratory tract including sinusitis caused by the larvae of parasites, nasal foreign bodies, gaseous irritation, and enzootic nasal tumors and the diseases of lower respiratory tract comprising mainly pneumonia. Often these are of infectious origin . However, the role of the environmental pollutants, toxicants, and mechanical induction of respiratory distress may also be the cause of these abnormal conditions. Depending upon the environmental, physiological, and etiological factors, respiratory conditions might be acute, chronic, and/or progressive in nature. Mycoplasma agalactiae, a causal agent of classical contagious agalactia (CA). CA is a serious, economically important but neglected enzootic disease of small ruminants. Both reviews would certainly assist in designing appropriate prevention protocols and devising suitable control strategies to overcome such important respiratory diseases, thus alleviating the economic losses. The cross-reactivity and differential immunogenicity between Mycoplasma agalactiae and Mycoplasma bovis, two often confusing pathogens causing contagious agalactia, have also been elaborated in the research article authored by Kumar et al.To overcome such important disease conditions, information on their identification, prevention, cure, and control can improve the economic status and sustainability of holders of small ruminants. Thus an early, rapid, and specific diagnosis of such diseases holds great importance to reduce the losses. The advanced enzyme-linked immunosorbent assays (ELISAs) for the detection of antigens as well as antibodies directly from the samples are primarily available for all the disease conditions with specificity and sensitivity. Similarly, molecular diagnostic assays along with microsatellites comprehensively assist in diagnosis as well as treatment and epidemiological studies. The two reviews written by Chakraborty et al. and Kumar et al. discuss the advancements made in the diagnosis of common infectious respiratory diseases of sheep and goats, in general, and also the management ofThe research article by P. Scott details the antibiotic treatment response in sheep with chronic lung diseases where the diagnosis was based upon ultrasonographic examination of the lungs using 5 MHz linear and sector scanners with no consideration to the auscultation findings. The lung pathological examinations were considered a basis for comparison between sonographic findings and pathological changes.Rahal et al. described in detail how a number of pathogenic microorganisms have been implicated in the development of respiratory diseases but the importance of environmental factors in the initiation and progress of the disease can never be overlooked. These environmental factors irritate the respiratory track producing stress in the microenvironment causing a decline in the immune status of the small ruminants and thereby assisting bacterial, viral, and parasitic infections in breaking down the tissue defense barriers. Environmental pollutants cause acute or chronic reactions as they deposit on the alveolar surface, which are characterized by inflammation or fibrosis and the exhibition of transitory or persistent tissue manifestation.The disease development can be portrayed as three sets of two-way communications among pathogen, environment, and host but the interactions are highly variable. Moreover, the environmental scenario is never static; new compounds are introduced daily making a precise evaluation of the disease burden almost impossible. The last article in the issue presents a detailed overview of these interactions and the ultimate effect on the respiratory health of sheep and goat.


Case Report. An 8-year-old girl with amelogenesis imperfecta (AI) reported unsatisfactory aesthetics, difficulty in mastication, and dental hypersensitivity. The intraoral examination observed mixed dentition, malocclusion in anteroposterior relationships, anterior open bite, and dental asymmetry. A hypoplastic form of AI was diagnosed in the permanent dentition. A multidisciplinary planning was performed and divided into preventive, orthopedic, and rehabilitation stages. Initially, preventive treatment was implemented, with fluoride varnish applications, in order to protect the fragile enamel and reduce the dental sensitivity. In the second stage, the patient received an interceptive orthopedic treatment to improve cross-relationship of the arches during six months. Finally, the rehabilitation treatment was executed to establish the vertical dimension. In the posterior teeth, indirect composite resin crowns were performed with minimally invasive dental preparation. Direct composite resin restorations were used to improve the appearance of anterior teeth. Follow-Up. The follow-up was carried out after 3, 6, 12, and 18 months. After 18 months of follow-up, The restoration of integrity, oral hygiene, and patient satisfaction were observed . Conclusion. Successful reduction of the dental hypersensitivity and improvement of the aesthetic and functional aspects as well as quality of life were observed. Amelogenesis imperfecta (AI) is a disorder group of hereditary development that affects the dental enamel structure which is marked by clinical alterations without association with systemic abnormalities and diseases . Apart oAccording to Aldred et al., , AI is aClinically, AI is under dependence of disturbance types and presents with a thin enamel layer (hypoplastic), roughness texture (hypomature), a mottled appearance, opaque white to yellow-brown , or association with one or two characteristics. To determine the presence of AI, an accurate diagnosis with other enamel defects and verification of alteration symmetric pattern linked to genetic inheritance are mandatory .The main sequel to patients with AI is represented by dental sensitivity and breakdown of hard tissues due to weak mechanical properties of affected teeth . Still, Some cases of AI need orthodontic/orthopedic correction aiming at the improvement of function and aesthetic aspects, constituting an interdependent approach between a good alignment and restorative features . In thesTherefore, this paper aims to demonstrate, through a case report, a rehabilitation treatment by a noninvasive and multidisciplinary approach of a pediatric patient with hypoplastic form of AI.An 8-year-old girl was referred to the Paediatric Dentistry Clinic, Araraquara Dental School (UNESP), for evaluation and treatment. Detailed medical and dental history was obtained from parent's speech. At intraoral examination, mixed dentition, congenitally missing of right upper lateral incisor (number 12), posterior cross-bite malocclusion, anterior open bite, dental asymmetry, and absence of caries activity were present. A thin enamel layer covering all teeth was verified, which resulted in painful sensitivity to mastication and decrease of aesthetics of anterior region stated by patient. Dental family history revealed that relatives suffered from similar dental conditions. The clinical and radiographic features were consistent with a possible diagnosis of hypoplastic AI .The treatment planning was based on priorities related to dental sensitivity, masticatory function, cross-bite malocclusion, and aesthetics of patient. After discussion among professionals, parents, and patient, the treatment was planned in three different phases. The first phase was based on preventive approach with weekly application of 22,600 ppm of sodium fluoride  for four consecutive weeks to reduce dental sensitivity, to protect and prevent remaining structures from future loss, and, at the same time, to avoid caries development . ReinforThe second phase consisted of orthopedic treatment to minimize posterior bilateral cross-bite and anterior open bite by the use of an intraoral interceptive device for 6 months . For ortA model cast of upper and lower teeth was done aiming to guide the position of posterior composite temporary crowns. After wax-up planning, models determined the need of 1 mm increase of occlusal vertical dimension .The upper and lower posterior teeth were minimally prepared to receive composite crowns. Tooth preparation involved only the smoothing of surface irregularities as well as the removal of unsupported enamel. After impressions of the preparations, composite resins crowns were obtained indirectly by VITA VM LC system  , due to Subsequently, direct anterior restorations were performed with the support of a silicone guide (Express XT - 3M ESPE) directly, since it was easier to isolate and develop the anterior anatomy. An adhesive system was applied according to the manufacturer's instructions . A thin layer of dentin shade (A2D)  was first inserted to simulate the opacity of the dentin. The enamel shade was applied in the cervical third (A2E) and in the middle third. The enamel A1E was applied in the incisal third. Finishing and polishing procedures of the restorations were performed using sequential Sof-Lex discs  .After the rehabilitation treatment, the patient and her relatives related satisfaction to the esthetics aspects as well as to the relief of the dental sensitivity, improving her masticatory function and quality of life. A follow-up after 18 months was performed to verify the condition of the treatment. The 6-month follow-up can be observed in The rehabilitation treatment is indicated in paediatric patients with AI. It is important to ensure the development of the craniofacial as well as psychology aspects of the children. The main goal of this treatment is to improve the quality of life, which includes improving the function, protecting the enamel structure, and reducing the sensitivity . AdditioNowadays, there are several different materials and techniques available to restorative procedures, which have made it both exciting and confusing for dental practitioners. The treatment planning for AI is complex and varies according to the patient's age, symptoms, type and severity of the defect, and the intraoral situation at the time the treatment. Thus, a multidisciplinary approach, which includes pediatric, orthopedic, and operative dentistry, plays an important role in the final result of AI patients. For the ideal treatment, children affected by AI must be analyzed by individual case and in accordance with specialist from different expertise taking into account the limitations and the application of techniques , as demoDifferent treatment options for the treatment of AI-affected teeth have been proposed in the literature. A number of cases have given the predictability and high aesthetics achieved with complete crowns. However, this approach requires the removal of substantial amount of dental structure . The tre2) and fluorapatite (FAp) [Patients affected by enamel hypoplasia present a thinner enamel, dental sensitivity, and more fragile structure, resulting in a more susceptibility to enamel breakdown and fractures during the masticatory function. To improve this condition, the first step for this case report was the preventive approach with 22,600 ppm of sodium fluoride. After four weeks, the patient related relief of the sensitivity. It was in accordance with data of the literature as stated by Petersson  that havte (FAp) .Regarding the orthopedics treatment, the fragile structure affected by AI did not permit the placement of fixed orthodontic devices due to the shape and size of the affected teeth. Then, the orthopedics device aimed to expand the upper arch to treat the posterior cross-bite malocclusion; a retentive removable appliance with screw, used as palatal expanders, was applied that was activated once or twice a week . This trThe composite resins crowns for posterior teeth allowed a better relationship between the upper and lower arches, protected the enamel structure, and promoted an adequate vertical dimension for the patient, improving the masticatory function. This is an adequate treatment until the ideal age and development of the dental structure for a definitive rehabilitation. Cost-effective restorative techniques involving these composite-resin crowns were previously shown for the restoration of a young patient with amelogenesis imperfecta . AnotherThe use of direct composite resin restorations to AI patient presented a favorable result as demonstrated at the 6-month follow-up. Papilla accommodation illustrates good interaction of the restorations with the soft tissue ; therefoBased upon the complexity of this condition and considering the complications encountered during the treatment, the use of proper direct-bonded resin composite restorations associated with temporary composite crowns provided an excellent conservative provisional treatment for protection of teeth affected by AI and, at same time, the reestablishment of the quality of life and self-esteem of the patient.


We report the diagnostic and successful therapeutic images of an acute occlusion of the abdominal and suprarenal aorta. This lesion is a rare but catastrophic pathology which can cause severe ischemic manifestations, depending on the site of obstruction, with high rate of mortality even after treatment. In the majority of cases it represents a surgical emergency. Although the mechanism of the thrombosis has not been delineated, the proposed etiologies include propagation of thrombus from distal artery occlusion, cardiac thromboembolism, dislodgment of a mural thrombus, or coagulation disorders. Frequent risk factors include advanced atherosclerosis combined with a low flow state because of poor cardiac performance. The management of this condition includes immediate intervention with systemic heparinization, improvement of the cardiac condition, and surgical revascularization based on the clinical and anatomical presentation. In this case the authors highlight the importance of an early detection and early intervention to enhance survival rates and reduce morbidity. A 71-year-old white male, with a history of heart failure, hypertension, hypercholesterolemia, and major abdominal surgery, was admitted to the emergency room hemodynamically stable with complaint of sudden and severe pain in the lower back and both lower limbs, which was accompanied by lower limb cyanosis, paresthesia, numbness, and progressively paralysis. No recent trauma was reported. Computed tomography (CT) scan revealed occlusion of the infrarenal abdominal aorta and bilateral iliac  arteries with retrograde partial propagation of the aortic thrombus along the aortic posterior wall up to the level of the patent celiac trunk . No aneuAcute aortic occlusion is a rare but catastrophic pathology with high hospital mortality and morbidity even after early recognition and intervention . It may


A 16-year-old adolescent boy presented to our clinic with an extensive hyperpigmented lesion on the left side of the scalp, neck, and face involving the entire left ear. The lesion was present at birth, increasing proportionally in size and developing nodules and coarse hair follicles as the patient advanced in age. Excision of part of the lesion on the neck in a peripheral hospital 4 years earlier resulted in a hard, nodular, and itchy lesion that has continued to increase in size beyond the original surgical scar.Discuss the diagnosis of the primary lesion.Discuss the diagnosis of the secondary lesion.What are the differential diagnoses of the primary lesion?What are the goals of treatment of the primary lesion?,3,4This rare and disfiguring skin lesion is a giant congenital melanocytic nevus (GCMN). It is characterized by variability in size and shape, dark pigmentation, and verrucous hair-bearing surfaces.1The secondary lesion on the neck resulting from surgical excision is a keloid, resulting from a fibroproliferative disorder of wound healing with unsavory reputation for recurrence. Occurring in genetically predisposed individuals, the etiopathogenesis of keloids is as uncertain as is its protean manifestations. Keloid formation has remained the bane of plastic surgical practice in sub-Saharan Africa. The bedrock of management has included intramarginal excision, intralesional injection of steroids, and radiotherapy, either individually or in any combination, yet control rather than cure remains the measure of success.The differential diagnosis of GCMN in the early stages includes other epidermal pigmented skin lesions such as hemangiomas, nevus psoriasis, verruca vulgaris, inflammatory linear verrucous epidermal nevus, and hamartomas. In its advanced stages, lesions such as cylindroma presenting as the turban tumor, malignant melanoma, pigmented basal cell carcinoma, dermatofibroma, and dermatofibrosarcoma deserve due consideration.,6The goals of treatment of GCMN are 2-fold: reducing nevocytic density albeit risk of malignancy and providing cosmetic relief for the disfigurement. Full-thickness surgical excision with reconstruction of the resultant defect is therefore the mainstay of treatment. Lesions in the head and neck region often constitute significant reconstructive challenges requiring the deployment of the full armamentarium in the plastic surgeon's arsenal—from skin grafts through tissue expansion to microvascular free flap reconstruction.5,Experience with hypertrophic scarring and keloid formation continues to play a major role in the choice of reconstructive techniques in our patient population.7


A 75-year-old woman presented with six months history of progressing lagophthalmos and immobility of the left eye. Magnetic resonance imaging (MRI) of the orbit demonstrated infiltration of orbital fat and the extra-ocular muscles. We performed transverse blepharotomy of the left eyelid to correct lagophthalmos; and during surgery, we took a biopsy sample from levator muscle and orbital fat. After the operation, the patient was able to close her eyelids, and epithelial problems were resolved. Biopsy revealed fibro-vascular, muscle and fat tissue infiltrated with minimally differentiated carcinoma cells. Breast examination revealed a nodule in the left breast. Biopsy of the mass confirmed the diagnosis of invasive breast carcinoma. Orbital manifestation of metastases, such as diplopia, lagophthalmos or pain may reduce life quality of the patients and must be evaluated on a multidisciplinary basis. One of the most common cancers to metastasize to the orbit is breast carcinoma . OrbitalA 75-year-old woman presented with six-month history of worsening lagophthalmos  and immoWe performed transverse blepharotomy of the left eyelid to correct lagophthalmos and during surgery, we performed a biopsy from levator muscle and orbital fat. After the operation, the patient was able to close her eyelids, and epitheliopathy was solved . Biopsy Orbital metastases may manifest with a palpable mass, proptosis, displacement of the globe, pain, chemosis, inflammation, or eyelid swelling  and the Ocular metastases can be treated with systemic chemotherapy and hormonal therapy with or without orbital radiation . ExtensiThe mean survival time of the patients with orbital metastases is reported to be between 18 and 22 months . Orbital


The carotid body (CB) plays a main role in the maintenance of the oxygen homeostasis. The hypoxic stimulation of the CB increases the chemosensory discharge, which in turn elicits reflex sympathetic, cardiovascular, and ventilatory adjustments. An exacerbate carotid chemosensory activity has been associated with human sympathetic-mediated diseases such as hypertension, insulin resistance, heart failure, and obstructive sleep apnea (OSA). Indeed, the CB chemosensory discharge becomes tonically hypereactive in experimental models of OSA and heart failure. Chronic intermittent hypoxia (CIH), a main feature of OSA, enhances CB chemosensory baseline discharges in normoxia and in response to hypoxia, inducing sympathetic overactivity and hypertension. Oxidative stress, increased levels of ET-1, Angiotensin II and pro-inflammatory cytokines, along with a reduced production of NO in the CB, have been associated with the enhanced carotid chemosensory activity. In this review, we will discuss new evidence supporting a main role for the CB chemoreceptor in the autonomic and cardiorespiratory alterations induced by intermittent hypoxia, as well as the molecular mechanisms involved in the CB chemosensory potentiation. Also, changes in blood flow, temperature, osmolarity and glucose are able to elicit CB chemosensory excitation , which in turn increases the discharge in the nerve endings of the chemosensory neurons  located in the bifurcation of the carotid arteries is the main peripheral chemoreceptor sensing arterial levels of POThe OSA syndrome elicited by repeated upper airways occlusion, is usually associated with daytime sleepiness, fatigue, and deficits in attention and executive function  have been proposed as mediators of the cardiovascular alterations in OSA patients  and macrophage infiltration in the CB. Thus, the unregulated RAS expression may play a role in the enhanced CB chemosensory activity and local inflammation via AT1 receptor activation during CIH.The role of Angiotensin II on the enhanced CB chemosensory responses induced by CIH has been extensively reviewed by Fung . The CB Among the molecules up regulated in the CB by CIH, such as ET-1, Ang II, VEGF and iNOS  could act at multiple sites to contribute to CIH-induced arterial blood pressure rise . The chemosensory petrosal neurons that innervate the CB glomus cells project to the NTS in the brainstem, which is the main integrative nucleus for visceral inputs. The NTS send projections to the RVLM that contain the pre-sympathetic neurons projecting to the pre-ganglionar neurons in the spinal cord. RVLM neurons participate in the control of BP, and in the CB-mediated activation of the sympathetic responses (Guyenet et al., The pathophysiological mechanisms involved in the development of hypertension in OSA are not fully understood. It is widely accepted that the CIH-induced oxidative stress contributes to enhance the CB chemosensory reactivity to oxygen and to the progression of the hypertension Figure . SeveralThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The normal liver milieu is characterized by an intricate network of hepatocytes and non-parenchymal cells including Kupffer cells, stellate cells, and sinusoidal endothelial cells, which can secrete anti-viral cytokines, provide a platform for non-specific uptake, and form a barrier to efficient viral spread. In addition, natural killer cells are greatly enriched in the liver, contributing to the innate defense against viruses. The situation is further complicated when HCC arises in the setting of underlying hepatitis virus infection and/or hepatic cirrhosis, which occurs in more than 90% of clinical cases. These conditions pose further inhibitory effects on oncolytic virus (OV) therapy due to the presence of chronic inflammation, constitutive cytokine expression, altered hepatic blood flow, and extracellular matrix deposition. In addition, OVs can modulate the hepatic microenvironment, resulting in a complex interplay between virus and host. The immune system undoubtedly plays a substantial role in the outcome of OV therapy, both as an inhibitor of viral replication, and as a potent mechanism of virus-mediated tumor cell killing. This review will discuss the particular challenges of oncolytic viral therapy for HCC, as well as some potential strategies for modulating the immune system and synergizing with the hepatic microenvironment to improve therapeutic outcome.Oncolytic viral therapies have recently found their way into clinical application for hepatocellular carcinoma (HCC), a disease with limited treatment options and poor prognosis. Adding to the many intrinsic challenges of  Hepatocellular carcinoma (HCC), representing over 90% of all cases of primary liver cancer, is the sixth most common form of cancer and the third leading cause of cancer-related mortality worldwide , 2. Due We have previously demonstrated in a preclinical rat model that oncolytic vesicular stomatitis virus (VSV) and Newcastle disease virus (NDV) both replicate well and cause significant tumor-specific cell lysis in orthotopic HCC, leading to substantial survival prolongation –7. Basedin vivo.Although these challenges are universal to OVs regardless of the tumor target, the dynamic setting of the liver presents a unique set of hurdles, which viruses must surpass in order to exert their therapeutic effects against HCC. The liver microenvironment consists of a complex network of hepatocytes, stromal cells, inflammatory cells, and extracellular matrix (ECM). HCC is an inflammation-driven cancer , and theWhen HCC arises as a consequence of chronic hepatitis virus infection and in the setting of hepatic fibrosis, the liver milieu is distorted and provides a platform for dynamic interactions between OVs and the liver microenvironment. In Greek mythology, Pandora’s box was actually a large and beautiful jar, which contained all the evils of the world. At first glance, the diseased liver can resemble a Pandora’s box of sorts, filled with a variety of “evils” that present unique challenges to conventional therapies. As we learn more about the pathogenesis of liver disease, we can actually exploit the unique features of the local microenvironment to synergize with OV therapy and thereby transform Pandora’s box from a vessel of evil into a platform of hope for new therapeutic targets. In this review, we will discuss the complex interactions between OVs and the liver milieu and present novel strategies for improving the therapeutic outcome.The liver is arguably one of the most vital organs of the body, due to its diverse roles in metabolism, nutrient uptake, detoxification, and immune modulation. Because of the complexity of functions, the liver architecture is composed of an intricate network of cells and ECM to ensure that each task can be performed efficiently. Although this system is crucial for the proper functioning of the liver, it poses various barriers to the ability of OVs to infect and replicate well in hepatic tumors. In this section, the various aspects of the liver microenvironment, which challenge the fate of OVs in HCC therapy . These transdifferentiated HSCs promote ECM remodeling by deregulating the balance of matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) and resulting in the degradation of the normal basement membrane and replacement with interstitial collagen (primarily type I and III) and scar matrix. In addition, HSCs migrate and proliferate in response to a variety of cytokines and growth factors elicited during hepatic injury to further promote the progression of fibrosis, resulting in the distortion of the normal liver architecture and leading to decompensated liver function.The implication of the presence of hepatic fibrosis on the outcome of OV therapy for HCC is complex, due to the multifaceted nature of the interactions between OVs and the microenvironment of the chronically injured liver. The presence of fibrotic tissue throughout the liver likely provides a physical barrier to trap OVs and prevent efficient delivery of viruses to tumor beds, and altered patterns of blood flow limit the ability of systemically applied viruses to reach their tumor targets. The aberrant microenvironment within HCC, consisting of activated HSCs, inflammatory cells, and extensive ECM deposition, not only further promotes HCC growth, invasion, and metastasis, but also challenges viral infection and spread among HCC cells. Although HCC is not conventionally considered to be a fibrotic cancer, evidence has shown a correlation between poor differentiation of HCC and degree of ECM remodeling . FurtherThe inflammatory milieu associated with chronic liver injury, most often induced by hepatitis B or C virus infection, not only contributes to the pathogenesis of fibrosis and HCC, but it also threatens the ability of OVs to replicate and destroy tumor cells. The acute response to liver injury involves the activation of resident liver immune cells, followed by the recruitment of non-resident immune cells to launch a potent cytokine response in the liver in an attempt to lyse the infected or injured cells , 49. HepParapoxvirus ovis (Orf virus), it was shown that viral therapy inhibited human HBV and HCV, as well as herpes simplex virus infection, without any signs of toxicity, in preclinical mouse models  is a cytokine with strong immunostimulatory properties that is secreted by macrophages, T-cells, fibroblasts, mast cells, and endothelial cells. GM-CSF promotes progenitor cell differentiation into DCs and can generate tumor-reactive CTL . Gene trAlong the same lines, other cytokines, such as IL-12, IL-24, IL-2, and IFN-β , 99, 100in vitro via patient-derived DCs that were transduced with an adenoviral vector encoding α-fetoprotein, a TAA often expressed in HCC, and co-cultured with autologous cytokine-induced killer (CIK) cells  cells . StrategK) cells , and wilBecause of the rapid clearance of viruses in immune-competent hosts, the therapeutic window during which OVs have the opportunity to replicate and cause their cytopathic effect in tumor cells is relatively short. In the context of the liver microenvironment, where myriad other barriers to OV propagation exist, we believe that the immune system represents an essential tool, which must be harnessed in order to destroy the remaining tumor cells that have escaped viral infection. The combination of viral-mediated cytolysis with tumor-directed immune stimulation creates a potent arsenal against hepatic tumors. Although two immunotherapeutic OVs are already in clinical trials for HCC, there are many other strategies for utilizing OVs to break immune tolerance and/or stimulate anti-tumor immune responses, which have shown efficacy in other tumor models but have not yet been tested in the context of HCC.One such strategy involves the exciting new concept of incorporating new molecules called “T-cell engagers” into oncolytic viral vectors . In thisAlternatively, a prime-boost approach has been investigated, in which two different recombinant OVs are sequentially administered, the first one priming the immune response through expression of a TAA, followed by a boosted secondary response produced by a subsequent TAA-encoding virus, leading to a robust tumor-specific immunity , 111. A A ubiquitous problem in the field of OV therapy is the relative inefficiency of systemic application, due to virus inactivation by blood components, non-specific uptake by off-target cells, and sequestration by the liver and spleen. To address this issue, various approaches using synthetic polymers or cell carrier systems for viral shielding have been investigated . The innAs an alternative to the cell carrier approach for virus delivery, strategies involving the surface modification of OVs using synthetic polymers have been developed to shield oncolytic vectors from inactivation and non-specific uptake. VSV shielding via covalent modification with polyethylene glycol (PEG) has resulted in increased circulation times and a reduction of neutralizing antibody responses . PolymerThe complex liver milieu underlying HCC presents innumerable challenges to the development of effective therapeutic agents to produce significant tumor responses and prolongation of patient survival. However, by gaining a greater understanding of the dynamic roles of the hepatic microenvironment and the pathogenesis of liver disease and carcinogenesis, we can actually exploit the properties of the local liver setting to synergize with therapeutic agents. Because OVs exert their therapeutic effects via multiple mechanisms, including direct cytopathic effects, anti-angiogenesis, and anti-tumor immune stimulation, they represent ideal agents for contending with the liver microenvironment. This is evidenced by recent reports, which demonstrate that OVs not only provide potent anti-tumor effects, but they also possess antifibrotic and anti-viral properties, allowing them to provide therapeutic benefits against the underlying liver injury. Therefore, by discerning the complexities of the liver microenvironment and their roles in the pathogenesis of HCC, Pandora’s box of evil is converted to a vessel of hope, for which OVs will surely play an important role in providing synergistic therapeutic outcomes.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.