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Fiziologia-- Physiologysupplement
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Fiziologia- Physiology 2011.21.1(69)
Fiziologia- Physiology 2010supplement

CONTENTS
1. REVIEW - From Prostaglandins to Resolvins and Protectins - A New Perspective on Eicosanoids Involvement in Inflammation......................................................................... 5
Mihai Nechifor
2. Prevalence of Ovarian Autoantibodies in Women with Unexplained Recurrent Pregnancy Loss....................................................................................................................... 10
Manole Cojocaru, Inimioara Mihaela Cojocaru, Camelia Doina Vrabie, Isabela Silosi, Camelia Vidita Gurban, Felicia Sfrijan, Mihai Popa
3. Central Nervous System Effects of Combined Nanoparticulate Lead Exposure.................................................................................................................................................. 13
Edina Horváth, Zsuzsanna Máté, Gábor Oszlánczi, Leila Sárközi, Gábor Kozma, András Sápi, Edit Paulik, András Papp, Andrea Szabó
4. Experimental Neurophysiological Alterations Caused by Combined Nano-Manganese Exposure..................................................................................................................... 17
Zsuzsanna Máté, Andrea Szabó, Edit Paulik, András Papp
5. Effect of Body Temperature on The Electrical Activity of the Brain in Anaesthetised Rats................................................................................................................................. 21
Viktória Nagy, Edit Paulik, András Papp
6. Incidence, Risk Factors and Complications of White Coat Hypertension in Family Medicine Practice................................................................................................................ 26
Elena Ardeleanu, Ioana Popa, Adrian Gruici, Eleonora Burcă, Ioana Puricel, Adriana Râmneanţu, Delia Grigorescu
7. Surveillance of Nosocomial Infections in a Cardiac Surgery/Intensive Care Unit in Timisoara........................................................................................................................... 30
C. Piluţ, Monica Licker, Carmen Tatu, Dorina Dugăeşescu, Delia Berceanu-Văduva, Mihaela Crăciunescu, Liliana Dragomirescu, Elena Hogea, Delia Muntean, Roxana Zugravu,
F. Horhat, Matilda Rădulescu, Marcela Adămuţ, Ramona Pârvan, D. Şerban, Angela Adam, Roxana Moldovan
8. Psychological Characteristics and Personality Traits in Prodromal Stages of Body Dysmorphic Disorder........................................................................................................... 33
Diana Jivănescu, Iulia Crişan, Mircea Lăzărescu

CUPRINS
1. REVIEW - De la prostaglandine la resolvine si protectine - o noua viziune asupra implicarii eicosanoizilor in inflamatie..................................................................................5
Mihai Nechifor
2. Prevalenta autoanticorpilor anti-ovarieni la femeile cu avorturi spontane repetate........................................................................................................................................ 10
Manole Cojocaru, Inimioara Mihaela Cojocaru, Camelia Doina Vrabie, Isabela Silosi, Camelia Vidita Gurban, Felicia Sfrijan, Mihai Popa
3. Efectele induse la nivelul sistemului nervos central de expunerea combinata la nanoparticule de plumb...................................................................................................... 13
Edina Horváth, Zsuzsanna Máté, Gábor Oszlánczi, Leila Sárközi, Gábor Kozma, András Sápi, Edit Paulik, András Papp, Andrea Szabó
4. Alterari neurofiziologice experimentale determinate de expunerea combinata la nanoparticule si mangan.................................................................................................. 17
Zsuzsanna Máté, Andrea Szabó, Edit Paulik, András Papp
5. Efectele temperaturii corporale asupra activitatii electrice cerebrale la sobolanii anesteziati.......................................................................................................................... 21
Viktória Nagy, Edit Paulik, András Papp
6. Incidenţa, factorii de risc şi complicaţiile „hipertensiunii de halat alb” în practica medicinei de familie........................................................................................................... 26
Elena Ardeleanu, Ioana Popa, Adrian Gruici, Eleonora Burcă, Ioana Puricel, Adriana Râmneanţu, Delia Grigorescu
7. Supravegherea infectiilor nosocomiale in sectiile de chirurgie cardiace din Timisoara..................................................................................................................................... 30
C. Piluţ, Monica Licker, Carmen Tatu, Dorina Dugăeşescu, Delia Berceanu-Văduva, Mihaela Crăciunescu, Liliana Dragomirescu, Elena Hogea, Delia Muntean, Roxana Zugravu,
F. Horhat, Matilda Rădulescu, Marcela Adămuţ, Ramona Pârvan, D. Şerban, Angela Adam, Roxana Moldovan
8. Caracteristici psihologice şi trăsături de personalitate în stadiul prodromal al tulburării dismorfice corporale................................................................................................ 33
Diana Jivănescu, Iulia Crişan, Mircea Lăzărescu

2011.21.1 (69)  Fiziologia - Physiology

3

FIZIOLOGIA-PHYSIOLOGY – 20 YEARS OF PUBLICATION

Twenty years have been passed since the first issue of“Fiziologia-Physiology” journal, the successor of the “Revista deFiziologie”, published for the first time in 1959 under the editorship of Daniel Danielopolu, and then of “Fiziologia Normală şi
Patologică”, under the editorship of Grigore Benetato, and of
Petru Groza more recently. The journal of the Romanian Society of Physiological Sciences ceased to be published in 1973
out of economic reasons. Until that fatidic day, the Society ofPhysiological Sciences was also publishing “Studii şi Cercetări
de Fiziologie” and “Revue Roumaine de Physiologie”.
That’s the way it was…
Barely one year had passed from the December 1989
events when Timişoara undertook the issuing of this scientificjournal. It was the initiative of the head of the Physiology Department at the time, with the approval of the Medical Sciences
Society and the Romanian Society of Physiological Sciences
represented by Petru Groza and Valeriu Neştianu and with thesupport of the academicians Nicolae Simionescu, Pius Brinzeu,
Ion Baciu and Ion Haulică. We remind the active contribution
4

to the editorship of Aurelian Vlad and Ana Petroiu, later Ioana
Siska, Mihai Nechifor, Carmen Tatu and Florina Bojin. From
the first issue we mention: Physiology and Surgery (Pius Brînzeu), Current Cardiovascular Physiology Data (Ion Haulică),Radioisotope Ventriculography (Geza Deutsch), Computer
Molecular Modeling (Tudor Oprea) and Informational Stress(Adrian Restian). After several years with articles publishedin Romanian in 2-3 issues yearly, as the interest overseas
increased, it has been decided to have four issues per year.
The articles are published in English, while the abstracts areboth in English and Romanian and there are also contributors
from other countries.
We mention particularly the actual and financial support of theteams in Timişoara, Cluj and Arad. From outside Romania, we pointout the physiology societies in Hungary and Republic of Moldova.
The recognition of the scientific value of our journal is confirmed by
the CNCSIS B+ accreditation and indexing in EBSCO’s Academic
Research Complete database and Index Copernicus.
Francisc Schneider
Chief Editor
Fiziologia - Physiology  2011.21.1 (69)REVIEW

FROM PROSTAGLANDINS TO RESOLVINS AND PROTECTINS- A NEW PERSPECTIVE ON EICOSANOIDS INVOLVEMENT IN
INFLAMMATIONMIHAI NECHIFOR
Department of Pharmacology, Gr. T. Popa University of Medicine and Pharmacy

ABSTRACT

Eicosanoids are one of the most large and complex biologically active substance groups. Inflammation is an intensely studied
pathologic process, regarding eicosanoids involvement. The eicosanoids derived from arachidonic acid (prostaglandins, tromboxans, prostacycline, intermediary endoperoxydes, leukotriens, izoprostans) are important pro-inflammatory factors. In the last years
some data have appeared which show that biologically active lipids derived from eicosapentaenoic (EPA) and docosahexaenoic(DHA) acids, lipids such as resolvins, protectins, docosatrienes, epoxy-derived substances (EETS), lipoxins and aspirin-triggered
lipoxins have an important anti-inflammatory and protective role and contribute at acute inflammation resolution. The rate between
the arachidonic acid and omega acids from the cells, especially from membrane phospholipids is proved to be essential for the bodyreactivity at pro-inflammatory stimulants. Because the brain is very rich in DHA acid we consider that is possible that the interrelations
between the biologically active lipids derived from arachidonic acid and those derived from EPA and DHA acids to play a modulatorrole not only in the inflammation process but also in some brain activities.
Key words: inflammation, prostaglandins, leucotrienes, isoprostans, resolvins, protectins, lipoxin

INTRODUCTION
Eicosanoids such as local acting active lipids are wellestablished regulators of key events in the host defense incancer, platelet aggregation, bronhoconstriction, inflammationand others. The inflammation is the early response in a lot of
pathological situations. The eicosanoids derived from arahidonic,
linoleic and eicosapentaenoic acids, and the lipids derived fromdocosahexaenoic acid are potent bioactive mediators for inflammation and also for resolution (Hong S. and al.) (10). Participationof each group of eicosanoids in the inflammatory process differs.
Between the eicosanoids synthesized by different enzymatic
pathways there are complex interactions in the process of generation and evolution of the inflammation with major differences
between acute and chronic inflammation. There were numerous
experimental and clinical data about the involvement of someeicosanoids derived from the arachidonic acid as important proinflammatory agents. Actually is obvious that eicosanoids canbe divided in two major groups according to their involvementin the inflammation pathogenic mechanism:a) pro-inflammatory eicosanoids:
prostaglandins
thromboxanes
prostacyclines
leukotrienes
isoprostanesb) anti-inflammatory and pro-resolving compounds
lipoxins and aspirin-triggered lipoxins
resolvins(resolution phase interaction products)
protectins
epoxiderivatives(EETs)
docosatrienes

Prostaglandins E (PGEs) are considered as major proinflammatory mediators. Recent data showed that EP4 agonists
as well as genetic deletion of EP2 significantly reduced spinal
TNFα release in knock-out mice(Brenneis et al)(1). There aredata which suggest a different role of various EP receptors in
pro-inflammatory action of PGEs and indicate that the receptor expression at the level of various cell types is essential for
prostaglandin mediated inflammatory action. Regarding theaction of PGE2 and PGI2 in the development of inflammation,
the vasodilatation, increasing the endothelium permeability andincreasing the cytokine synthesis in macrophages are importantelements in inflammation pathogenesis. Shinomiya S. et al (35)showed that IP, EP2 and EP4 receptors but not EP1 and EP3
are involved in this process. EP4 agonists increased several
fold IL-10 production.
Both leukotrienes synthesized by 5-LO pathway but also
the prostaglandins produced by COX-2 action promote theacute inflammation. The inflammation is the early reaction tobone fracture (14) showed that in absence of COX-2 activity theexcess of leukotrienes synthesized by 5-LO will impair fracture
healing.
Between the pro-inflammatory eicosanoids there arealso the isoprostanes, lipids with a less studied involvementin the pathogenesis of acute inflammation. Isoprostanes areprostaglandin-like compounds synthesized by non-enzymatic
free-radical catalyzed peroxidation of arachidonic acid. There
are numerous isoprostanes. The first series of isoprostanes
containing PGF2α ring was termed F2 isoprostanes. But there
are also E2, D2, A2 and J2 isoprostanes. The intermediates in theisoprostans synthesis are PGH2 –like lipids that become reduced
to isoprostans (15). For example, F2 isoprostanes group are a

Received 15 February 2011. Accepted 20 March 2011. Address for correspondence: Mihai Nechifor, Department of Pharmacology, Gr. T. Popa University of Medicine
and Pharmacy, Universitatii 16 Iasi 700115, Romania, e-mail: mnechif@yahoo.com

2011.21.1 (69)  Fiziologia - Physiology

5group of 64 isomers compounds but there are also E2, D2, A2,
and J2 isoprostanes (2). Although, initially that was consideredthat isoprostanes are synthesized only from arachidonic acid, it
was proved, that at least in the brain, are generated isoprostaneslike compounds derived from DHA by oxidation (22).
Isoprostanes have a lot of involvements in human pathology. F2-isoprostanes promote mutagenesis in vascular smoothmuscles and atheromatosis, increase platelet aggregation andhave a pro-adhesive effect, induce bronchoconstriction and havea pro-inflammatory action. The isoprostanes are considered as
markers for the level of oxidative stress. The pro-inflammatory
mechanism of action of isoprostanes is complex:- this group of lipids directly stimulate FP receptors(receptors
for PGF2α)- a part of action is produced by stimulation of TXA2 formation because some effects of F-isoprostanes are suppressed by
TP receptors antagonist- is possible to exist a F-isoprostanes receptor in the membrane of some cells
D2/E2 isoprostanes are produced in vivo also from arachidonic acid by the free radical-catalyzed peroxidation of arachidonic acid. From DHA, the most abundant unsaturated fatty acidin the brain derives D4/E4 nemoprostanes. The basal levels of
D4/E4 nemoprostanes were 3.8±0.6 ng/mg and increased 54 foldafter oxidative stress in rat brain (21). In the human brain thebasal level is 9.2±4.1 ng/g.
There are F4, D4, E4, A4 and J4 docosahexaenoic derived
neuroprostanes (22). A new pathway of lipid proxidation which
generate new groups of neuroketals and isofurans were recently discovered (25). The concentration of oxygen is important
for the synthesis of the new groups of bioactive lipids. At highoxygen concentration the isofurans synthesis is favored and theisoprostanes synthesis decreases (25).
It was gradually observed that the actions and the biological roles of eicosanoids derived from omega-3 polyunsaturated
fatty acids (PUFAs) such as eicosapentaenoic acid (EPA) anddocosahexaenoic acid (DHA) are very different and frequently opposed to the actions of arachidonic acid and linoleic acid derived
eicosanoids (25). An important discovery was the identificationof novel mediators generated from omega-3 PUFA that display
a potent anti-inflammatory and pro-resolving action. Theseantiinflammatory compounds derived from EPA are designatedE series resolvins and similar compounds derived from DHA
are called D series resolvins (RVD) (4). The aspirin (a COX-1
inhibitor) initiates a related epimeric series of resolvins triggering
endogenous formation of 17R-RVD. These compounds have an
important anti-inflammatory action (26).
The first observed anti-inflammatory effect of some eicosanoids was the lipoxine’s effect. These anti-inflammatory lipids
appear to facilitate the resolution of the acute inflammatory response. Lipoxine branch of eicosanoid system generates specifictetraene-products which serve as “stop signals” for neutrophils.
By this way lipoxins prevent neutrophil-mediated inflammatory
response. Lipoxins synthesis has an important impact on the
resolution of acute inflammation.
6

DHA and EPA are converted each by an independent way
in active local lipids mediators. The new group di and tri-hydroxy
lipids derived from ω-3 fatty acids as EPA and DHA were termed“resolvins” because they are formed in the resolution phaseof acute inflammation and are involved in the resolution. These
compounds are synthesized at least in part as cell-cell interaction
products. DHA is the precursor of a potent family of bioactive lipids
DOCOSANOIDS that include the docosatrienes as well as 17s
epimer RESOLVINS series. The resolvins are generated in:leukocytes
glial cells and other cells and these compounds display
a potent action on leukocyte trafficking as well as on glial cellfunctions down-regulating cytokines expression
The synthesis of 10,17s and 16,17s docosatrienes from DHA
can occur in a single cell type and involve the activity of a lipoxygenase like 15-lipoxygenase (which transforms arachidonic acidin lipoxines). In this pathway for the synthesis of docosatrienes
the initial step is the formation of a 16(17s) epoxide intermediate. On the other side DHA is transformed via 17-hydroperoxy
17s-HDHA and 4s-hydroperoxy 17s-HDHA in 7s,16,17-Resolvin
and 4s,5,17s-Resolvin ,a new group of bioactive docosanoids
related to eicosanoids but different from them.
From DHA in the presence of aspirin (which inhibits COX-1)
is produced 17R series resolvins. Referring to the biologicalpotency the 17s series of resolvins appears to be equally potent
as 17R series. It is very interesting the fact that aspirin triggers theformation of some resolvins. This fact is very close to what wasobserved in the lipoxines synthesis from arachdionic acid under
15-lipoxygenase action when aspirin triggered 15-epi-lipoxin
synthesis (27). Although there isn’t available for the moment
a complete picture of the actions of different resolvins andprotectins groups there were noticed a series of involvementsfrom which we mention (after Serhan et al.)(33).
Resolvin E1:- promotes resolution of inflammation- regulates PMN infiltration- regulates dendritic cell function and IL-12 production- protects from osteoclast-mediated bone destruction
Resolvin E2 appears to be involved in the regulation of
PMN infiltration.
Protectin D1:- blocks T-cell and PMN migration- inhibits TNF secretion- promotes T-cell apoptosis- reduces PMN influx and infiltration- dampens NFβB expression and COX-2 induction- antifibrotic actions
Resolution of the inflammation is essential for the returnto the normal physiological state of the tissues. There was
longtime a unilateral image regarding the involvement of someeicosanoids only in the acute inflammation development and its
symptoms production mechanism. The discovery of resolvins
and protectins as new families of chemical lipid mediators with
Fiziologia - Physiology  2011.21.1 (69)Fig.1. The synthesis of resolvins and docosatrienes from DHA (after Serhan 2008) (33)potent anti-inflammatory activity clearly showed the existenceof a lipid control of the duration and magnitude of inflammation(32). It occurred an important change of view regarding the way
by which the non-steroidal anti-inflammatory drugs, aspirin andaspirin-like drugs COX-1 inhibitors induce the anti-inflammatory
effects in tissues in which COX-2 expression is higher (stimulated
by pro-inflammatory agents). Aspirin has a dual anti-inflammatory
mechanism of action:a) by direct inhibition of COX-1b) by triggering the biosynthesis of specific epimers, new
pro-resolving lipid mediators
We consider that this fact is important for the explanation
the anti-inflammatory action of aspirin.
A special group of lipids autacoids was constituted, specialized pro-resolving mediators (SPM), including:- ω-3 fatty acids:
- EPA
- DHA
- lipoxins- derived from arachidonic acid- resolvins- protectins
It is possible to complete this group with maresins-a newgroup of proresolving lipids (30,34).
Pro-resolving mediators have two big way of action:a) anti-inflammatory action-limiting PMN infiltrationb) pro-resolving action:- clearance of apoptotic PMN- clearance of microbial particles- stimulation of antimicrobial mucosal response
The analysis of the actions of these new lipid mediatorsgroups gives argues to consider anti-inflammatory action andpro-resolution activity as different responses of the host by lipid
synthesis pathway. The protectins comprise the docosatrienes and2011.21.1 (69)  Fiziologia - Physiology

resolvins of the D series. All these compounds (docosatrienes, D
resolvins, R resolvins) have a powerful anti-inflammatory action
and also a protective action in some tissues especially CNS (30).
From EPA derived also very active biological compounds which
possess a potent anti-inflammatory action: the E series of resolvins.
There are five distinct series of resolvins (28,29,33):- 18R resolvins synthesized from EPA- 17R resolvins produced from DHA (AT resolvins RvD1)- 17s series resolvins from DHA (RvD1 through RvD4)- docosatrienes from DHA- 17R (aspirin triggered) docosatrienes from DHA
The synthesis of some resolvins is presented in Fig. 1.
Besides resolvins and protectins the lipoxins and aspirin triggered lipoxins are eicosanoids that act as anti-inflammatory agentsand promote the resolution ( 30,31). Oposite to resolvins andprotectins which derive from ω-3 fatty acids, lipoxins derive fromarachidonic acid via 15-LO activity (25). Aspirin has an unexpected
involvement in the synthesis of the anti-inflammatory and proresolving lipids because it influences the evolution of inflammation
by triggering the formation of epimeric 17R-series of D resolvins(17R-RvDs) which are bioactive compounds (25). There wereisolated some new receptors on which these anti-inflammatory
and pro-resolving lipids are acting. This way the lipoxins LXA4and LXB4, synthesized by transcellular biosynthesis via interaction between leukocytes and endothelium, act at the level of ATL
receptors (20). Lipoxins plays some roles in immunomodulation
by regulation of T-lymphocytes and macrophage function (13).The
action of LXA4 is not sensitive to inhibitors of COX-1 or COX-2 andof 5-LO.The PMN migration across epithelia in the physiologicaldirection is significantly influenced by lipoxins (5).
It was identified a Resolvin E receptor (ResoER1 or RER1)
and a neuroprotectin D receptor (NPDR).The aspirin triggered
epimers (AT-RvDs) and docotrienes act also as RER1 (29).
LXA4 has a high affinity for receptors ALX. The epi- lipoxin(aspirin triggered epimers) acts on the same receptors. Because7the PMN migration is influenced both by LTB4 (acting on LTB4
receptors) and by LXA4 (by ATL receptor stimulation) it is probable that the number of each receptor type expressed on PMN
membrane is very important for PMN activity modulation during
the inflammatory process (7).
Another group of anti-inflammatory eicosanoids is a numberof epoxyeicosatrienoic acids (EETS) synthesized from arachidonic
acid by cytochrome P450-epoxygenase pathway (24). EETS are
involved in various pathological processes as myocardial infarct,
inflammation and others (3,9, 11 ). Because the most importantdegradation way of EETS is EETS-hydrolase (sEH) the inhibitorsof soluble epoxyde hydrolase such as DUDA and DUDA-buthyl
ester have anti-inflammatory action. EETS-hydrolase is now a
new target for the treatment of inflammation.
Cythochrome P450 converts arachidonic acid to four epoxyeicosatrienoic acid (EETs) isomers, which have anti-inflammatory
effects (37). In addition, they promote angiogenesis and protect
the ischemic brain (12) and myocardium. EETs act by binding
to a membrane receptor but EETS are also taken up by cells
and bound to cytosolic proteins and nuclear receptors (37). The
membrane receptor of EETS is not enough characterized. EETS
produce the anti-inflammatory effects by activation the peroxisome
proliferator-activated receptor alpha (PPAR alpha) and PPAR
gamma (38).Because the anti-inflammatory action and otherbeneficial effects are suppressed after the EETS inactivation bysoluble epoxidehydrolase (SHE), the inhibition of this enzyme is a
future important target for anti-inflammatory drugs. The 20-HETE
produced by action of CYP4A omega-hydroxylase is an antiinflammatory eicosanoid and a potent activator of PPAR alpha(19).
This lipid also decreases by 70% the expression of apolipoprotein
A1. The peroxisome-proliferator-activated receptors (PPARs)
are a family of transcription factors involved in the developmentof some pathological processes including inflammation (6).The
agonists of PPAR alpha are substances which inhibits or reduces
the acute inflammation and have a role in the regulation of the immune response of the host. The inhibitors of PPARs enhance theinflammatory reaction. The most important targets for PPAR alphaanti-inflammatory effect appear to be T cells and dendritic cells.
PPARs are nuclear hormone receptors and following activation
by an appropriate ligand stimulate transcription of specific genes
from DNA (8).The lack of PPAR alpha enhances the inflammationin PPARα-null mice. Activation of PPAR by EETS is not only a
new anti-inflammatory mechanism but also a new possibility for
immunomodulatory action of eicosanoids. The activators of PPARs
are involved in inhibiting the proliferation of activated T cells andinhibit the IL-2 secretion (6). PPAR is expressed in many tissues
which makes its stimulation by EETS a valid anti-inflammatory
mechanism in the whole body. The transcellular synthesis isimportant for these eicosanoids production. Endothelial cells withupregulated COX-2 treated with aspirin converted EPA in 18Rhydroxyeicosapentaenoic acid(18R-HEPE) and 15R-HEPE.In
leukocytes 15R-HEPE and 12-R HEPE are used for the synthesisof 15R-LX5 and 5,12,12R-triHEPE.Both compounds proved to
be inhibitors of PMN leukocyte trans-endothelial migration andinfiltration. It is interesting that not only aspirin but also other8

non-steroidal anti-inflammatory drugs such as indomethacin andacethaminophen also favors 18R-HEPE and 15R-HEPE from EPA
in the presence of COX-2.
In some diseases the resolution of inflammation appears
as a new paradigm to understand the pathogenesis and forthe therapeutic strategy.
The periodontal disease is produced by the host response
to bacterial aggression. The role of the pro-inflammatory eicosanoids as prostaglandins and leukotrienes produced by hosttissues is clear, but the role of lipoxins in inflammation resolution
reveals the possibility of the development of new drugs used
for the control and prevention of neutrophil-mediated tissue
injury and for the therapy of the periodontal disease (39).EETS
in models of vascular inflammation attenuate inflammatory signaling pathways both in endothelium and blood vessels. There
are data which show that the inhibition of epoxidehydrolaseattenuates the tobacco smoke-induced lung inflammation (36).
The variable ratio between the eicosanoids synthetizedfrom arachidonic acid and the lipids synthetized from eicosapentaenoic and docosahexaenoic acids is very important tohighlight the development of inflammation and to produce
the resolution of the acute inflammation.
In our opinion, because the brain is very rich in DHA (40)
it is possible to exist a relationship between the involvement ofarachidonic derived eicosanoids (leukotrienes, prostaglandins)
and docosahexaenoic lipids not only in inflammation but also inother important pathological processes located in the brain (pharmacodependence, convulsion, and others) (16,17,18).
These new data show the essential modulatory role ofthe eicosanoids according to the body reaction to various
normal and pathological factors.
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4. Chiang N, Serhan CN. Cell-cell interaction in the transcellular biosynthesis of novel omega-3-derived lipid mediators. Methods Mol Biol,
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6. Clark RB: The role of PPARs in inflammation and immunity. J Leukoc
Biol, 2002; 71: 388-400.
7. Devchand PR, Arita M, Hong S, et al. Human ALX receptor regulates
neutrophil recruitment in transgenic mice: roles in inflammation and hostdefense. FASEB J, 2003; 17: 652-659.
8. Galuppo M, Di Paola R, Mazzon E, et al. Role of PPAR-delta in thedevelopment of zymosan-induced multiple organ failure: an experimentmice study. J Inflamm (Lond), 2010; 18: 7-12.
9. Gross GJ, Nithipatikom K: Soluble epoxide hydrolase. a new target for

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cardioprotection. Curr Opin Investig Drugs, 2009; 10: 253-258.
10. Hong S, Gronert K, Devchand PR, et al:Novel docosatrienes and
17S-resolvins generated from docosahexaenoic acid in murine brain,human blood, and glial cells. Autacoids in anti-inflammation. J Biol Chem,
2003; 278: 14677-87.
11. Hutchens MP, Nakano T, Dunlap J, et al. Soluble epoxide hydrolase
gene deletion reduces survival after cardiac arrest and cardiopulmonary
resuscitation. Resuscitation, 2008; 76: 89-94.
12. Iliff JJ, Jia J, Nelson J, et al. Epoxyeicosanoid signaling in CNS function
and disease. Prostaglandins Other Lipid Mediat, 2010; 91: 68-84.
13. Kantarci A, Van Dyke TE. Lipoxins in chronic inflammation. Crit Rev
Oral Biol Med, 2003; 14: 4-12.
14. Manigrasso MB, O’Connor JP. Accelerated fracture healing in micelacking the 5-lipoxygenase gene. Acta Orthop., 2010; 81: 748-755.
15. Montuschi P, Barnes PJ, Roberts LJ. Isoprostanes: markers andmediators of oxidative stress. FASEB J, 2004; 18: 1791-800.
16. Nechifor M. Leukotriens in pathology and therapeutics. Bucharest,
Medical Publishing House, 1987.
17. Nechifor M. Lipoxines, hepoxilins and isoprostanes. Iasi, Polirom,
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18. Nechifor M, Cuciureanu M, Chelarescu D, et al. Magnesium and otherbivalent cations influence upon sodium montelukast effect in experimentalinduced thermoalgesia. Magnes Res, 2008; 21: 38-42.
19. Ng VY, Huang Y, Reddy LM, et al. Cytochrome P450 eicosanoids
are activators of peroxisome proliferator-activated receptor alpha. Drug
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20. Parkinson JF. Lipoxin and synthetic lipoxin analogs: an overview ofanti-inflammatory functions and new concepts in immunomodulation.
Inflamm Allergy Drug Targets, 2006; 5: 91-106.
21. Reich EE, Zackert WE, Brame CJ, et al. Formation of novel D-ringand E-ring isoprostane-like compounds (D4/E4-neuroprostanes) in vivo
from docosahexaenoic acid. Biochemistry, 2000; 39: 2376-83.
22. Roberts LJ 2nd, Montine TJ, Markesbery WR, et al. Formation of
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5: 149-157.

DE LA PROSTAGLANDINE LA RESOLVINE SI PROTECTINE - O NOUAVIZIUNE ASUPRA IMPLICARII EICOSANOIZILOR IN INFLAMATIE
REZUMAT

Eicosanoizii sunt unul dintre cele mai mari si complexe grupuri de substante biologic active. Inflamatia este un process patologic
foarte mult studiat sub aspectul implicarii eicosanoizilor. Eicosanoizii derivati din acidul arahidonic (prostaglandine, tromboxani,
prostaciclina, endoperoxizi intermediari, leucotriene, izoprostani) sunt factori proinflamatori importanti. In ultimii ani au aparut datece arata ca lipide biologic active derivate din acizii eicosapentaenoic (EPA) si docosahexaenoic (DHA), lipide, cum sunt resolvinele,
protectinele, docosatrienele dar si epoxiderivatii (EETS), lipoxinele si aspirin-triggered lipoxinele au un rol antiinflamator si protector
si contribuie la rezolutia inflamatiei acute. Raportul dintre acidul arahidonic si acizii omega din celula si indeosebi din fosfolipidele
membranare se dovedeste a fi essential pentru reactivitatea organismului la stimuli proinflamatori. Deoarece creierul este deosebit
de bogat in acid DHA, consideram ca este posibil ca interrelatiile dintre lipidele biologic active derivate din acidul arahidonic si cele
derivate din acizii EPA si DHA sa joace un rol modulator, nu numai in procesul inflamator, ci si in cazul unor activitati cerebrale.
Cuvinte cheie: inflamatie, prostaglandine, leucotriene, isoprostani, resolvine, protectine, lipoxine
2011.21.1 (69)  Fiziologia - Physiology

9PREVALENCE OF OVARIAN AUTOANTIBODIES IN WOMENWITH UNEXPLAINED RECURRENT PREGNANCY LOSSMANOLE COJOCARU1, INIMIOARA MIHAELA COJOCARU2, CAMELIA DOINA VRABIE2,
ISABELA SILOSI3, CAMELIA VIDITA GURBAN4, FELICIA SFRIJAN4, MIHAI POPA5
1“Titu Maiorescu” University, Faculty of Medicine, Bucharest,2“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
3
University of Medicine and Pharmacy, Craiova, Romania
4“Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
5
Clinical Hospital “Dr. I. Cantacuzino”, Deptartment of Obstetrics and Gynaecology

ABSTRACTThe involvement of autoimmune mechanisms in premature ovarian failure (POF) has been put forward by numerous investigators.
The aim of this study was to assess the prevalence of ovarian autoantibodies in women with unexplained recurrent pregnancy
loss. We studied the prevalence of ovarian autoantibodies in the 107 sera from women with unexplained recurrent pregnancy loss
as compared to 100 pregnant controls, and 68 non-pregnant controls matched for age. Ovarian autoantibodies are detected byindirect immunofluorescence (substrate-monkey ovary, conjugate polyvalent fluorescein isothiocyanate special monkey). Ovarian
autoantibodies produce a characteristic pattern of immunofluorescence staining. The prevalence of ovarian autoantibodies among
women with unexplained recurrent pregnancy loss was 46/107 (43%) vs. 4/100 (4%) in pregnant controls and 1/68 in nonpregnant
controls. Positive sera were those with the titer greater than 1:5. Ovarian autoantibodies may play an important role in recurrent
pregnancy loss, and may be useful for the elucidation of unexplained recurrent pregnancy loss.
Keywords: unexplained recurrent pregnancy loss, ovarian autoantibodies

INTRODUCTION
Clinically, the ensuing ovarian dysfunction often results inpremature ovarian failure (POF). Clinical studies also suggestthat pregnancy may affect the immune system. Both cellularand humoral immunity may be altered during pregnancy.
Reproduction is intricately involved with the immune system.
The maternal immunity system must tolerate foreign (paternal)
antigens. The relationship between the maternal and fetal
immune systems, acknowledged for many years, is now being
explored in couples who are unable to achieve a pregnancy
or carry a pregnancy to term. However, reports concerningchanges in the immune system during pregnancy are not inagreement (1).
The effects of pregnancy on humoral immunity are less clear,but immunoglobulin levels have been reported to be unchanged
or slightly increased. The investigations of causes of infertility andfetal loss are beginning to deal increasingly with immunologicalfactors, and in particular, with the autoimmunity (2,3).
Autoimmune diseases are suspected of causing somecases of recurrent pregnancy loss. The mechanism of pregnancy
loss is hypothesized to involve ovarian autoantibodies. Ovarian
failure may be an immune disorder causing reproductive failure.
There is no evidence of a direct immunologic attack on the conceptus. Lymphocytic infiltrates are often seen in ovarian biopsy
specimens from these patients. Clinically, the ensuing ovariandysfunction often results in POF and unexplained infertility. The
frequency of ovarian autoantibodies among women with premature ovarian failure varies between 35% and 69% dependingon the patient population studied. Controversies exist regarding
association of ovarian autoantibodies IgM with patients of firsttrimester recurrent abortions. The lack of consensus on ovary
specific antibodies as a marker for ovarian autoimmunity has
clinical and research consequences (4).
The objective of our study was to assess the prevalenceof ovarian autoantibodies in women with unexplained recurrent
pregnancy loss.
MATERIAL AND METHOD
We studied the prevalence of ovarian autoantibodies in the
107 sera from women with unexplained recurrent pregnancy
loss as compared to 100 pregnant controls, and 68 nonpregnant
controls matched for age. This retrospective study of the anamnestic data revealed that women presented at Clinical Hospital“Dr. I. Cantacuzino” Department of Obstetrics and Gynaecology,
between January 2010 and December 2010, had unexplained
recurrent pregnancy loss in the first trimester.
For all eligible patients the informed consent was given for
use their blood in this study. The research received approval by
ethical committee of the institution.
Ovarian autoantibodies are detected by indirect immuno-

Received 10 February 2011. Accepted 20 March 2011. Address for correspondence: Assoc. Prof. Manole Cojocaru MD, PhD, EurClinChem, “Titu Maiorescu” University, Faculty of Medicine, Bucharest, e-mail: manole_cojocar@yahoo.com

10

Fiziologia - Physiology  2011.21.1 (69)

fluorescence (substrate-monkey ovary, conjugate polyvalent fluorescein isothiocyanate special monkey). Ovarian autoantibodies
produce a characteristic pattern of immunofluorescence staining.
Positive sera were those with the titer greater than 1:5.
RESULTS
Total number of patients with unexplained recurrent pregnancy loss investigated for presence of ovarian autoantibodies
IgM was 107. In our study prevalence of increased ovarian
autoantibodies among women with unexplained recurrent pregnancy loss was 46/107 (43%) vs. 4/100 (4%) in pregnant controls.
This shows that raised levels of ovarian autoantibodies IgM are
responsible for recurrent pregnancy loss. (Fig 1).

Fig.1. Ovarian autoantibodies(substrate-monkey ovary, sample screening dilution-1/5,
conjugate-polyvalent fluorescein isothiocyanate special monkey), 400x

We would like to emphasize the fact that ovarian
autoantibodies may be present even in the healthy population.
In non-pregnant controls we found only one ovarian
autoantibodies positive result.
DISCUSSIONSPremature ovarian failure is characterized by the loss ofovarian functions before the age of 40 years. The diagnosis
of autoimmune ovarian disease relies on several clinical,
biological and histological findings, but special interest
has been focused on antiovarian autoantibodies. Ovarian
autoantibodies have reported in women with POF andunexplained infertility. Indirect immunofluorescence is the firstdescribed and most common method used for the detectionof antiovarian antibodies in serum. It is usually performed bytrained laboratory staff on frozen sections of human or, more
often, animal ovaries. Data presented in literature showedthat the incidence of ovarian autoantibodies in the healthy
population is about 4.8% (4).
The detection of autoantibodies directed against various
ovarian targets strongly supports the hypothesis of an autoimmune aetiology of POF. The ovary can be the target of an
autoimmune attack in various circumstances, including several
organ-specific or systemic autoimmune diseases. It has become
increasingly clear that immunologic factors and reproductive
2011.21.1 (69)  Fiziologia - Physiology

disorders interact at many levels (5).
It is now believed that 62% of conceptuses will be lost prior
to12 weeks’gestation. Current information implies that a sizable
proportion of pregnancy losses may be due to immunologic
factors (6).
Current information implies that a sizable proportion ofpregnancy losses may be due to immunologic factors. The fetus
is an immunogenic allograft and evokes a protective immune
response from the mother, which is necessary for implantationand growth. Recent evidence suggests that maternal autoimmune or alloimmune aberrations may be involved in pregnancy
rejection (7).
Autoimmune processes could be one of the causes of premature ovarian failure. Autoimmune processes are considered
as contributing factors in some cases of unexplained recurrent
pregnancy loss (8).
The involvement of autoimmune mechanisms in premature
ovarian failure has been put forward by numerous investigators.
The search for ovarian autoantibodies has been undertaken innumerous studies, especially in patients with POF (9).
The human ovary can be the target of an autoimmune attack in various circumstances, including several organ-specificor systemic autoimmune diseases. However, the exact role ofautoimmunity in the pathophysiology of premature ovarian failure
still remains controversial. For example, an increased rate ofabortion is observed in patients with systemic lupus erythematosus or subclinical autoimmune disorders (10).
Classically, POF has a genetic, enzymatic, infectious, or
iatrogenic aetiology. In most cases, however, no precise cause
can be identified, and these forms are reffered to as idiopathic(11).
Ovarian autoantibodies are associated primarily with POF
and unexplained infertility. The investigations of recurrent pregnancy loss are beginning to deal increasingly with immunologicalfactors, and in particular, with the autoimmunity (12).
Concept of autoimmune basis of infertility is still controversial, particularly regarding the presence of non-organ specificautoantibodies. Presence of organ-specific autoantibodies wasimportant for acceptance of autoimmunity as a possible causeof recurrent pregnancy loss (13).
Recent evidence suggests that maternal autoimmune may
be involved in pregnancy rejection (14).
Autoantibodies to the ovary are measured in many womenwith polyendocrinopathies. If these results are confirmed infurther studies, these antibodies might be assessed routinely in
reproductive failure (15).
There is still a lack of information on the specific featuresof autoimmune POF (3).
The possibility of an autoimmune mechanism in some casesof POF relies on clinical and therapeutic observations as well as
on immunological and histological findings (6).
The results of our study and mapping of the ovarian autoantibodies positivity support our hypothesis that the ovarian
autoantibodies positivity corresponds with the clinical symptoms(7).
11

Diagnostic and therapeutic approaches are being developed
for recurrent pregnancy losses due to immunologic causes.
Appropriate treatment with hormonal replacement therapy
minimizes ovarian destruction, preserves ovarian hormonal
functions and saves healthy ovarian tissue necessary for future
fertility (6).
Indirect immunofluorescence is the first described and mostcommon method used for the detection of ovarian autoantibodies inserum. It is usually performed by trained laboratory staff on sectionsof monkey ovary. It shows the localization of the antibodies in thevarious histological compartments of the ovary (16).
Among women with infertility, those with evidence of ovarian
autoimmunity appear to have poorer in vitro fertilization (IVT) treatment outcomes than women without ovarian autoantibodies (17).
If these results are confirmed in further studies, these
antibodies might be assessed routinely in recurrent pregnancy
loss. Larger studies will be necessary to determine if an association
exists. The next decade may bring more precision in diagnosis
and treatment of unexplained recurrent pregnancy loss. Our
study proves the importance of early diagnosis and treatment of
autoimmune ovarian damage that saves patient’s fertility.
CONCLUSIONS
Ovarian autoantibodies have been reported in womenwith premature ovarian failure and unexplained infertility.
Increased incidence of ovarian autoantibodies supports thecontention that these autoantibodies contribute to the recurrent pregnancy loss. Ovarian autoantibodies may play animportant role in recurrent pregnancy loss, and may be usefulfor the elucidation of unexplained recurrent pregnancy loss.
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PREVALENTA AUTOANTICORPILOR ANTI-OVARIENI LA FEMEILE CU
AVORTURI SPONTANE REPETATEREZUMAT
Implicarea mecanismelor autoimmune în insuficienţa ovariană prematură a constituit un obiect de studiu pentru numeroşi
investigatori. Scopul acestui studiu a fost să evaluăm prevalenţa anticorpilor antiovar la femei cu avorturi spontane repetate. S-astudiat prevalenţa anticorpilor antiovar în serul recoltat de la 107 femei cu avorturi spontane repetate comparativ cu lotul martor
format din 100 femei însărcinate şi 68 femei neînsărcinate cu vârste asemănătoare. Anticorpii antiovar au fost determinaţi folosind
tehnica imunofluorescenţei indirecte (substrat-ovar de maimuţă, conjugat fluorescent antigammaglobulină maimuţă). Anticorpii
antiovar prezintă un pattern caracteristic pe preparatul colorat fluorescent. Prevalenţa anticorpilor antiovar la femei cu avorturi
spontane repetate a fost 46/107 (43%), faţă de 4/100 (4%) la femei însărcinate şi respectiv 1/68 la cele neînsărcinate din lotul
martor. Serurile cu titrul peste 1:5 au fost considerate pozitive. Anticorpii antiovar ar putea să joace un rol important şi ar putea fi ocauză în cazul femeilor cu avorturi spontane repetate.
Cuvinte cheie: avorturi spontane repetate, anticorpi antiovar

12

Fiziologia - Physiology  2011.21.1 (69)CENTRAL NERVOUS SYSTEM EFFECTS OF COMBINEDNANOPARTICULATE LEAD EXPOSUREEDINA HORVÁTH1, ZSUZSANNA MÁTÉ1, GÁBOR OSZLÁNCZI1, LEILA SÁRKÖZI1, GÁBOR
KOZMA2, ANDRÁS SÁPI2, EDIT PAULIK1, ANDRÁS PAPP1, ANDREA SZABÓ1
1
Department of Public Health, Faculty of Medicine, University of Szeged
2
Department of Applied Chemistry, University of Szeged Faculty of Science and Informatics

ABSTRACT
Occupational lead exposure occurs mostly by inhalation while the general population can is exposed by ingestion. In the experiment
presented, the two exposure routes were modelled in rats using different physicochemical forms of lead. To mimic airborne exposure,PbO nanoparticles (mean diameter ca. 20 nm) were instilled into the trachea of the rats (2 or 4 mg/kg b. w.) five times a week for 6
weeks. In per os treatment, 80 or 320 mg/kg b. w. Pb-acetate was given to the rats by gavage (also five times a week for 6 weeks).
To combine the two routes of exposure, rats were treated per os with Pb acetate for 3 weeks, followed by intra-tracheal instillationof Pb-oxide nanoparticles for another 3 weeks, with the same timing and doses as above. After the 3 or 6 weeks of exposure, theeffects of lead on the central nervous system of the rats were investigated by behavioural and electrophysiological methods. Bothchemical forms and routes of exposure affected differently the outcome of central nervous system investigations.
Key words: lead, nanoparticle, behavioural toxicity, electrophysiology, rat

Introduction
Lead is one of the oldest known metals. The Romans
widely used this metal in everyday life by face powder, lipstick,mask, wine, dishes, coins or water pipes. Today, the popularityof lead has changed; it is mainly used in metallurgy, glassindustry, corrosion protection, for manufacturing battery, as fueladditives, or applied in older paints and ceramics. Lead is oneof the most common environmental xenobiotics, is present in thesoil, groundwater, air, and foodstuffs. The general population is
exposed mainly by contaminated drinking water or food: roots,
leafy vegetables, meats, dairy products or fishes. Tobacco smoke
is another notable source of Pb exposure (1).
By per os exposure, 20-70% of lead is absorbed; byinhalation route, almost all can be absorbed. Absorbed lead istransported to various organs (liver, kidneys, lungs and brain)
and finally mineralized in certain tissues like bones, teeth (2).
Lead is useless to the human body; it is one of the heavy metals
notoriously harmful for human health. The main target of leadis the nervous system, with consequences like occupational
neuropathy and delayed mental development of children. In
children, acute exposure to 70-80 µg/dL levels of lead may
cause encephalopathy with different degree symptoms such as
hyperirritability, ataxia, convulsion, stupor, and coma. Chronic
low level exposure of lead may produce decrement in intelligencequotient; hearing, balance, or peripheral functional impairment
in childhood. In adulthood, acute exposure to lead (460 µg/dL) results in encephalopathy with initiative sings as dullness,
irritability, poor attention, muscular tremor, loss of memory,
hallucination. In workers with chronic lead exposure less severe

neurologic effects were documented with headache, lethargy,
dizziness, diminished reaction time, cognitive and visual motor
performance and slowed nerve conduction (3).
Industrial high-temperature processes (smelting, casting,welding, cutting, grinding etc.) generate airborne metalcontaining particles, including those in the submicron range (socalled nanoparticles, NPs). Compared to microscopic particles,
NPs have higher mobility within the organism, including directaccess to the CNS by penetrating tissue boundaries like thealveolar and capillary wall, and the blood-brain barrier (4).
In this work, the above mentioned general (food-borne)
and occupational (inhalation) exposure was modelled by giving
lead to rats in two different chemical forms, and combining
exposure via the airways and the gastrointestinal tract. Our aim
was to study the adverse effects caused by lead in different
physico-chemical forms by behavioural and electrophysiologicalmethods.
Materials and methods
Young adult male Wistar rats (200±20 g, 9 groups of 8 ratseach) were obtained from the university’s breeding centre andwere housed in a GLP-rated animal house (22±1 ºC, 30-60 %relative humidity, 12-h light/dark cycle with light on at 06:00) withfree access to tap water and standard pellet. Body weight of theanimals was measured before every treatment. Treatments were
performed once daily, 5 times a week, and lasted 6 weeks (seeTable I). For modelling airborne exposure, PbO nanoparticles (2or 4 mg/kg b. w.) were suspended in 1% hydroxy ethyl cellulose(HEC, pH 7.4) vehicle and instilled into the trachea (1 ml/kg

Received 30 January 2011. Accepted 17 March 2011. Address for correspondence: Edina Horvath, University of Szeged, Faculty of Medicine, Department of Public
Health, Dóm tér 10., Szeged, Hungary, Tel. +36-65-545-119, Fax. +36-62-545-120

2011.21.1 (69)  Fiziologia - Physiology

13

b. w.) of the rats (5). Intratracheal instillation was carried out
in brief diethyl-ether anaesthesia. In per os treatment, 80 or
320 mg/kg b. w. Pb-acetate (dissolved in distilled water) was
given to the rats by gavage (6). To combine the two routes of
exposure, rats were treated per os with Pb acetate for 3 weeks,
followed by intratracheal instillation of Pb-oxide nanoparticles foranother 3 weeks, with the same timing and doses as above. For
intratracheal application, NPs of PbO2 with 20±12.4 nm diameter
were synthesized at the Department of Applied Chemistry,
University of Szeged.
The rats’ spontaneous locomotor behaviour pattern wasassessed in an open field (OF) instrument at the end of thetreatment period, 2 days after the last Pb administration. The
OF box used was of 48x48x40 cm size and was equipped with
two arrays of infrared beam gates at floor level and at 12 cm
height (Conducta 1.0 System; Experimetria Ltd., Budapest,
Hungary). After 20–30 min accommodation in the test room,
the animals were put into the centre of the box one by one fora 10 min session. From the beam interruptions, counts andtime of the horizontal (running), vertical (rearing) and local(grooming etc.) activity as well as horizontal run length were
calculated.
Electrophysiological recording was done on the day
following the OF test. Preparation for recording, and therecording itself, was performed in urethane anaesthesia (1000mg/kg ip). The left hemisphere was exposed, and spontaneouselectrical activity (electrocorticogram, ECoG) was recorded
from the primary somatosensory, visual and auditory areas for
6 minutes. From this, band spectrum according to the standard
human EEG bands (delta to gamma: Kandel and Schwartz,
1985) was calculated. Then, evoked potentials (somatosensory,
visual and auditory) were recorded from the same sites byapplying the stimuli in trains of 50. Somatosensory stimulation(SS) was done by square pulses (3-4 V; 0.05 ms; 1, 2 and 10
Hz frequency) delivered through a pair of needles inserted
into the contralateral whiskery skin. Visual stimulation (VIS)
was performed by flashes (1 Hz) of a high-luminance white
LED placed to the contralateral eye of the rat. For acoustic
stimulation (AUD), clicks (1 Hz) were applied to the contralateral
ear through the hollow ear bar of the stereotaxic frame. Latency
and duration of the EPs was measured after averaging. The
complete electrophysiological work was performed by meansof the software Neurosys 1.11 (Experimetria Ltd., Budapest,
Hungary). Finally, the rats were sacrificed by an overdoseof urethane, dissected, and organ weights were measured.
Relative organ weights, on the basis of 1/100 body weight, were
calculated. During the whole procedure, the principles of the
Ethical Committee for the Protection of Animals in Researchof the University were strictly followed.
The distribution of data was checked for normality
by means of the Kolmogorov-Smirnov test. Data analysis
was done by one-way ANOVA. Post hoc analysis of groupdifferences was performed by LSD test, setting the probability
level at p>0.05.
14

Table I. Treatment scheme with group codes, doses and treatment time

Group
code

Treatment

VC6 po. 6 weeks, distilled water, per os
PL6 po. 6 weeks 80 mg/b.w. kg lead(II)acetate, per os
PH6 po. 6 weeks 320 mg/b.w. kg lead(II)acetate, per os
VC33

3 weeks, distilled water, per os +3 weeks HEC intra-tracheal

PL33

3 weeks 80 mg/b.w. kg lead(II)acetate, per os +3 weeks lead(II) oxide NPs 2 mg/b.w.kg intratracheal

PH33

3 weeks 320 mg/b.w. kg lead(II)acetate, per os+
3 weeks lead(II) oxide NPs 2 mg/b.w.kg intratracheal

VC6 it. 6 weeks HEC intra-tracheal
PL6 it.

6 weeks lead(II) oxide NPs 2 mg/b.w.kg intratracheal

PH6 it.

6 weeks lead(II) oxide NPs 4 mg/b.w.kg intratracheal
VC: vehicle control, PL: low dose lead PH: high dose lead
HEC: 1% hydroxyethyl cellulose (HEC) dissolved in PBS

Results
Fig. 1 shows the body weight change seen on the 6th week.
The weight decrease was mainly observed in the high dosetreated groups, and most significantly in the single orally andintra-tracheal treated groups.
Among the relative organ weights, that of the lung, brain
thymus, heart, spleen kidney and liver showed significant
changes (Table II). The weight increase of the lungs was
significant vs. the corresponding control both in the combined
and intra-tracheal treated group. The relative liver, thymus weight
was strongly raised in only orally treated group vs. own control.
The relative kidney weight was significantly raised in oral andintra-tracheal groups

Fig.1. Average body weight on the 6th weeks Mean+SD, n=8, *: p<0.05 vs.
own control; #: p<0.05, PH6 po vs PL6 po.

Fiziologia - Physiology  2011.21.1 (69)Table II. Relative organ weights (related to 1/100 body weight). Mean± SD, n=8. *;**, ***: p<0.05, 0.01; 0.001 vs. own control;#
p<0.05, PH 6 po vs.PL6 po; PH6 it vs PL6 it; PH33 vs. PL33

Total spontaneous locomotors activity decreased dosedependently in the three experimental schemes, however without
significance. The decline of locomotors activity resulted mainly
from the reduced ambulation, and rearing time, and the increased
local activity and immobility.
In the spectral distribution of the spontaneous cortical activity,
slow waves increased and fast waves decreased (most significantly
in visual and auditory spontaneous cortical activity) after per os
treatment, and to a lesser extent also after the combined treatment.
Intra-tracheal treatment also showed significance, but only in caseof high dose nano-lead treatment (Fig. 2).

Fig. 2. Frequency spectrum of the spontaneous cortical activity after the treatment.
A: somatosensory area B: visual area C: auditory area Mean+SD, n=8.
*;**,: p<0.05, 0.01 vs. own control;#,##: p<0.05, PH6 po vs PL6 po. ; PH6 it vs PL6 it

2011.21.1 (69)  Fiziologia - Physiology

The cortical sensory evoked potentials showed mostly
dose dependently and significantly increased latency, which
was seen in all experimental schemes (Fig. 3).

Fig. 3. Latency of the cortical evoked potentials. A, somatosensory response
evoked with 10 Hz stimulation; B, visual and C auditory response. Mean+SD,
n=8. *;**, ***: p<0.05, 0.01; 0.001 vs. own control; #,##: p<0.05, PH6 po vs PL6
po. ; PH6 it vs PL6 it; PH33 vs.PL33

15

Conclusion
Electrophysiological results seemed more sensitive to theeffects of lead exposure than the behavioural investigations.
Comparing the different exposure routes it can be concluded,that per os administration resulted in more marked alterations,which is reflected in the cortical evoked potentials. Comparing
results of the combined vs. individual per os or intratracheal
administration, it can be seen, that changes in cortical evoked
potentials reveal some influence due to combined exposure, but
not as notable as in case of the other two treatment schemes,
moreover in body weight and spontaneous cortical activity
almost any alteration can be observed by combined treatment.
The differences indicated that chemical form and route of exposure may have their own influence on the functional alterations
seen in the CNS.

REFERENCES

1. Agency for Toxic Subtances and Disease Registery. Toxicological
profile forlead. Atlanta: US Department of Health and Human Services,
1999.
2. Gerhadsson L,Endlyst V, Lundstrom NG, et al. Lead in tissuesof deceased lead smelter workers. J Trace Elem Med Biol., 1995;
9:136-143.
3. Kehoe RA. The metabolism of lead in man in health and disease:present hygienic problems relating to the absorption of lead: the Harben
lectures. J R Inst Public Health Hyg., 1961; 24:177-233.
4. Oberdörster G, Finkelstein JN, Johnston C, Gelein R, Cox C, Baggs
R, Elder AC. Acute pulmonary effects of ultrafine particles in rats andmice. Res. Rep. Health Eff. Inst., 2000; (96): 5-74; 75-86.
5. Sárközi L, Horváth E, Kónya Z, Kiricsi I, Szalay B, Vezér T, Papp, A.
Subacute intratracheal exposure of rats to manganese nanoparticles:
Behavioral, electrophysiological and general toxicological effects. Inhal.
Toxicol., 2009; 21(S1): 83-91.

EFECTELE INDUSE LA NIVELUL SISTEMULUI NERVOS CENTRAL DE
EXPUNEREA COMBINATA LA NANOPARTICULE DE PLUMBREZUMAT
Expunerea ocupationala la plumb apare cel mai adesea prin inhalare, in timp ce populatia generala poate fi expusa prin ingestie.
In experimentul prezentat, au fost evidentiate cele doua cai de expunere la animalul de laborator (sobolan), folosind forme fizicochimice ale plumbului. Pentru a mima expunerea la particulele din aer, nanoparticulele de PbO (iametrul mediu de 20 nm) au fostinstilate la nivelul traheei de sobolan (2 sau 4 mg/kg corp), de cinci ori pe saptamana, timp de 6 saptamani. In tratamentul per os,
au fost administrate prin gavaj 80 or 320 mg/kg corp acetate de Pb (de asemenea, de 5 ori pe saptamana, timp de 6 saptamani).
Pentru a combina cele doua cai de expunere, sobolanii au fost tratati per os cu acetat de Pb timp de 3 saptamani, urmat de instilarea
intra-traheala a nanoparticulelor de oxid de Pb, pentru inca 3 saptamani, cu aceeasi frecventa si pentru aceasi perioada de timp.
Dupa expunere timp de 3 sau 6 saptamani, efectele plumbului asupra sistemului nervos central au fost investigate prin metodecomportamentale si electrofiziologice. Ambele forme chimice si cai de administrare au influentat diferit rezultatele investigatiilor la
nivelul sistemului nervos central.
Cuvinte cheie: plumb, nanoparticule, toxicitate comportamentala, electrofiziologie, sobolan

16

Fiziologia - Physiology  2011.21.1 (69)

EXPERIMENTAL NEUROPHYSIOLOGICAL ALTERATIONSCAUSED BY COMBINED NANO-MANGANESE EXPOSUREZSUZSANNA MÁTÉ*, ANDREA SZABÓ, EDIT PAULIK, ANDRÁS PAPP
Department of Public Health, University of Szeged, Hungary

ABSTRACTManganese (Mn) is a well known heavy metal, causing central nervous system damage after chronic exposure. To model inhalational
Mn exposure, we used an animal model system in which male Wistar rats were intratracheally instilled daily with MnCl2 (2.5 or 5.0
mg/kg bw.) dissolved in distilled water; or with nanosuspension of MnO2 (2.5 or 5.0 mg/kg bw.); or with the combination of 2.5 mg/kg
solute MnCl2 and 2.5 mg/kg nanosized MnO2, administered with a short delay. After the 5 weeks treatment period open field activityof the rats was tested and electrophysiological investigation was performed; spontaneous and stimulus evoked action potentials wererecorded from somatosensory, visual and auditory areas of the cortex. Mn could reach the CNS and caused significant alterationsin the spectral distribution of the ECoG bands, increased the latency of the evoked potentials and influenced the locomotor activityof the rats. The observed effects showed a kind of additive effect in case of the combined exposure.
Keywords: manganese, nanoparticle, intratracheal instillation, evoked potentials, rat

INTRODUCTION
Manganese (Mn) is an essential micronutrient, cofactorof enzymes (Mn-SOD, GS), but has toxic effects after chronic
overexposure. It is often used in industry: in dry cells, coatedwelding rods, steel alloys, chemical fertilizers or pesticides.
Technical applications of manganese (Mn) often results in human exposure, mostly due to inhalation of metal dust and fumes(ATSDR, 2008) causing mitochondrial dysfunction and leading
to oxidative stress and excitotoxicity in the neurons (Taylor etal., 2006). Inhibition of voltage-gated Ca-channels and disturbed
release of neurotransmitters are also typical of Mn intoxication.
Mn evolves its deteriorating effects manly on the central nervous system. Manganism, a chronic human neurological disorder
resembling Parkinson’s disease (Bowler et al., 2006) often occurs
among welders and miners exposed to Mn-containing aerosols(Dobson et al., 2004). These dusts and fumes, arising fromsoldering and welding contain Mn nanoparticles as well.
Inhalational Mn exposure may result in massive internal
doses, depending on the size of the inhaled particles. Microscopic
particles cannot pass the blood-brain barrier, but submicroscopic
particles (that is, nanoparticles, with dimension 100 nm andbelow) have high mobility within the organism, so these canhave direct access to the CNS (Oberdörster et al., 2000, 2005).
According to this, it is worth to pay more attention on the effects
of inhaled Mn on the nervous system and its dependence on
the different physicochemical forms. In this study we aimed to
explore the alterations in the CNS caused by solute and nanosized and their combinations.
MATERIALS AND METHODS
Adult male Wistar rats obtained from the Breeding Centre of

the University (300-320 g body weight at start) were housed in
an air conditioned room maintained at 22 ºC, with 12-hour light/
dark cycle (light on at 06:00) and free access to tap water andstandard rodent chow.
Animals were divided into seven groups (with 8 animalseach) and were treated intratracheally with MnCl2 dissolved
in distilled water (LD: 2.5 mg/kg b.w. MnCl2; HD: 5 mg/kg b.w.
MnCl2) or with MnO2 nanoparticles (nLD: 2.5 mg/kg b.w. MnO2;
nHD: 5 mg/kg b.w. MnO2). In Comb group, rats received 2.5 mg/
kg b.w. MnCl2 and the same dose of MnO2 with a short delay.
The MnO2 nanoparticles (NPs) were synthesized by a technique
combining ultrasonic and hydrothermal treatment (for details,
see Sárközi et al., 2009) at the Department of Applied Chemistry, University of Szeged Faculty of Science and Informatics.
MnO2 NPs were suspended in hydroxyethyl cellulose (swollen
in phosphate buffered saline) which was used as vehicle andthat the rats in vehicle control (VC) group were treated with. An
untreated control (Cont) group was also applied.
Intratracheal instillation (1 ml/kg b. w.) was carried out inbrief diethyl ether anaesthesia. The treatment lasted for 5 weeks,
performed once a day, 5 days per week.
Before the beginning of the treatment period and on the day
following the last instillation, the rats were put into an open field(OF) box to test their spontaneous horizontal and vertical motor
activity in 10 min sessions.
Electrophysiological measurement was done after anesthetizing the animals with urethane (1000 mg/kg b. w., i.p.). The
left hemisphere was exposed, the animals were put in a stereotaxic device, and silver electrodes were placed on the primarysomatosensory (SS), visual (VIS) and auditory (AUD) areas.
Spontaneous electrical activity (electrocorticogram, ECoG) was

Received 15 February 2011. Accepted 20 March 2011. Address for correspondence: Zsuzsanna Máté, University of Szeged, Faculty of Medicine, Department of
Public Health, Dóm tér 10., Szeged, Hungary, Tel. +36-65-545-119, Fax. +36-62-545-120, email: matezs@puhe.szote.u-szeged.hu

2011.21.1 (69)  Fiziologia - Physiology

17

recorded from these sites simultaneously for 6 min, and therelative spectral power of the frequency bands was determined(Kandel and Schwartz, 1985).
Stimulus-evoked activity was then recorded via thesame electrodes. Somatosensory stimulation was done byelectric pulses given trough a pair of needles inserted into thewhiskery skin (3-4 V; 1000, 500, 100 ms repetition time). Visual
stimulation was performed by flashes (1 Hz) delivered by a highluminescence white LED directly into the contralateral eye of therat. For acoustic stimulation, clicks (1 Hz, 40 dB), were applied
into the ear of the rat. Fifty stimuli of each modality per rat wereapplied and the evoked activity recorded. After averaging, latency
and duration of the evoked responses was measured.
The body weight of the animals was regularly measured
during the 5 weeks of the experiment.
Statistical analysis was done by two-sample t-test.
During the whole procedure, the principles of the EthicalCommittee for the Protection of Animals in Research of the
University were strictly followed.
RESULTS
Mn administration caused significantly slowed body weightgain in all treated groups (vs. Cont), from the first week on (Fig.
1).

180
160

**

140
120
100

**

#

*

**

*

##

immobility

*

60

**

*

ambulation

40
20

*

0
Cont

VC

LD

HD

nLD

nHD

Comb

Fig. 2 Effect of MnCl2 and MnO2 treatment on the OF activity of the rats after
the treatment. (A:time B:count) *,**;*** p<0.05, 0.01, 0.001 vs. Cont; #, ##,### p<0.05, 0.01, 0.001 vs. VC.

Intratracheal instillation of MnCl2 and MnO2 significantly
altered the spectral distribution of the electrocorticogram. The
general trend of the ECoG band spectrum change was different
in each modality depending on the treatment type (solute or nanosized Mn). MnCl2 treatment had a strong effect on theta band andthe increase was significant in each cortical area (vs. VC). Effect ofhigh dose MnO2 treatment was mainly seen on the VIS and AUD
ECoGs. On the VIS ECoG, the proportion of the fast frequency
bands increased and that of the slow bands decreased. On thecontrary, spectral distribution of the AUD ECoG showed decreasein fast bands, and increase in slow bands. These changes weresignificant in case of gamma and delta bands (Fig. 3).
SS

#

90%

160

80%

140

**

120

**

***

100

#

#

***

***

***

70%

gamma

60%

80

40%

60

30%

beta2

**

*

50%

beta1
alfa
theta

#

delta

20%

40

10%

20

0%

0

Cont

Cont

VC

LD

HD

nLD

nHD

VC

LD

HD

nLD

nHD

Comb

Comb
100%

Fig. 1 Body weight gain. *,**;*** p<0.05, 0.01, 0.001 vs. Cont; #, ##, ###p<0.05, 0.01, 0.001 vs. VC.

VIS

#

90%
80%
70%
gamma

60%

The open field test after the 5 weeks treatment period
showed decreased motor activity in all the treated rats. Increased
immobility and decreased rearing was observed both in the MnCl2
and MnO2 treated groups. The time spent with local activity
increased and showed mild significance in HD, nHD and Combgroups (Fig. 2a). Changes in activity counts were similar to theabove mentioned alterations, confirming that the OF activity of
the rats shifted to hypomotility, especially in MnCl2 treated andComb groups (Fig. 2b).

beta2

50%

beta1

40%

###

##

alfa

##

theta

30%

delta

20%
10%

**

0%
Cont

VC

LD

HD

nLD

nHD

100%

Comb

AUD

#

80%

gamma

60%

beta2

A

100%

*

90%
80%

#

*

70%

**

*
*

60%

*

50%

*

rearing

#

*

20%

*

10%
0%
Cont

VC

LD

HD

nLD

nHD

Comb

alfa

###

theta
delta

*

20%

immobility

ambulation

30%

beta1

*

40%

local activity

40%

18

rearing

local activity

80

100%

180

g

B

200

0%
Cont

VC

LD

HD

nLD

nHD

Comb

Fig. 3 Frequency spectrum of the spontaneous cortical activity. (SS-somatosensory, VIS-visual, AUD-auditory area) *,**;*** p<0.05, 0.01, 0.001 vs. Cont;#, ##, ### p<0.05, 0.01, 0.001 vs. VC.

Fiziologia - Physiology  2011.21.1 (69)From the parameters of the cortical evoked potentials,
lengthening of the SS latency, caused by MnCl 2 treatment,
was the most prominent. MnO2 treatment did not significantly
affect the SS latency, but in Comb group a combined effectof the two forms of Mn was seen (lower, but significant
increase; Fig. 4). SS amplitude was only affected in nLD
group, where the increase was significant. In case of fast
stimulation (10 Hz), the same trend was discovered, but
the effect of the combined treatment – strong decrease –appeared to be significant (Fig. 5). Between VIS and AUD
latency there was an opposite alteration, similarly to the
ECoG findings (Fig. 6).
12

**

**

**

10

#

#

#

##

##

##

**

*

**

8

#

Cont
VC
LD

6

HD
nLD

4

nHD
2
Comb
0
SS-1000 latency

SS-500 latency

SS-100 latency

Fig. 4 Comparison of the latency of somatosensory evoked potentials of thetreated groups. *,**;*** p<0.05, 0.01, 0.001 vs. Cont; #, ##, ### p<0.05, 0.01,
0.001 vs. VC.
7000
6000

###

##

**

***

Cont
VC

5000
LD
4000
HD
3000
nLD
2000

**

nHD

1000
Comb
0
SS - 1000 amplitude

SS - 500 apmlitude

SS - 100 amplitudeFig. 5 Comparison of the amplitude of somatosensory evoked potentials of
the treated groups. *,**;*** p<0.05, 0.01, 0.001 vs. Cont; #, ##, ### p<0.05,
0.01, 0.001 vs. VC.
##

70

***

Cont

60
50

VC

#

**
LD

40
HD
30

#

20

**

**

**

**

nLD
nHD

10
Comb
0
VIS latency

AUD latency

Fig. 6 Comparison of the latency of visual and auditory evoked potentials of
the treated groups. *,**;*** p<0.05, 0.01, 0.001 vs. Cont; #, ##, ### p<0.05,
0.01, 0.001 vs. VC.

2011.21.1 (69)  Fiziologia - Physiology

DISCUSSION
According to the observed changes in the electrophysiological parameters the applied animal model proved to be suitablefor intratracheal Mn intoxication follow up. As it was indicated inprevious experiments (9), Mn had access to the CNS and theobserved electrophysiological alterations were caused by Mn
accumulation in the brain.
In the regulation of OF activity, which is known to be affectedby Mn (Normandin et al., 2004), dopaminergic structures play
important role (Alexander et al., 1990). Alterations in corticalevoked activity due to Mn can be explained by Mn-dependent
inhibition of astrocytic glutamine synthetase (10). Desensitization and slowed action of the thalamocortical afferents (due toenhanced glutamatergic transmission) might cause lengtheningof the latency of the cortical evoked potentials. On the otherside, nerve conduction can be damaged as well. Mn might alsointerfere with Ca channels (11) and with mitochondrial energy
production (12).
Decrease of slow (delta, theta) and increase of fast (beta,
gamma) bands of the ECoG (or the opposite in VIS-AUD ECoG)
in the same rats might have resulted from impaired collateral
input of the glutamatergic afferents. Altered EEG and eventrealated potentials, which was found in this experiment in VIS
and AUD recordings, were also described in case of humanoccupational Mn exposure.
The results further suggested that electrophysiological tests
might be more sensitive to the effects of Mn than general toxicological or neurobehavioral ones, which is potentially relevant
both in experimental work and in hygienic toxicology.
REFERENCES

1. ATSDR. Toxicological profile for manganese. US Department of Healthand Human Services, Atlanta, GA USA, 2008.
2. Taylor MD, Erikson KM, Dobson AW, Fitsanakis VA, Dorman DC,
Aschner M. Effects of inhaled manganese on biomarkers of oxidative
stress in the rat brain. NeuroToxicol., 2006; 27: 788-797.
3. Bowler RM, Koller W, Schulz PE. Parkinsonism due to manganism inwelder: Neurological and neuropsychological sequelae. NeuroToxicol.,2006; 27: 327-332.
4. Dobson AW, Erikson KM, Aschner M. Manganese neurotoxicity. Ann.
NY Acad. Sci., 2004; 1012: 115-29.
5. Oberdörster G, Finkelstein JN, Johnston C, Gelein R, Cox C, Baggs
R, Elder AC. Acute pulmonary effects of ultrafine particles in rats andmice. Res. Rep. Health Eff. Inst., 2000; 96: 75-86.
6. Oberdörster G, Oberdörster E, Oberdörster J. Nanotoxicology: An
Emerging discipline evolving from studies of ultrafine particles. Environ.
Health Persp., 2005; 7: 823-39.
7. Sárközi L, Horváth E, Kónya Z, Kiricsi I, Szalay B, Vezér T, Papp A.
Subacute intratracheal exposure of rats to manganese nanoparticles:
Behavioral, electrophysiological and general toxicological effects. Inhal.
Toxicol., 2009; 21(S1): 83-91.
8. Kandel ER, Schwartz JH. Principles of Neural Science, 1995, Elsevier,
New York, 643-644.
9. Oszlánczi G, Vezér T, Sárközi L, Horváth E, Kónya Z, Papp A. Functional neurotoxicity of Mn-containing nanoparticles in rats. Ecotoxicol.
and Environm. Safety, 2010; 73: 2004-9.
10. Aschner M, Vrana KE, Zheng W. Manganese uptake and distribu-

19

tion in the central nervous system (CNS). NeuroToxicol., 1999; 20:
173-180.
11. Büsselberg D. Calcium channels as target sites of heavy metals.
Toxicol. Lett., 1995; 82/83: 255-261.

12. Malecki EA. Manganese toxicity is associated with mitochondrial
dysfunction and DNA fragmention in rat primary striatal neurons. Brain
Res. Bull., 2001; 15: 225-228.

ALTERARI NEUROFIZIOLOGICE EXPERIMENTALE DETERMINATE DEEXPUNEREA COMBINATA LA NANOPARTICULE SI MANGANREZUMAT
Manganul (Mn) este un metal greu bine cunoscut, care determina injurii la nivelul sistemului nervos dupa expunerea cronica. Pentru
a crea un model de expunere inhalatorie la Mn, am folosit un model animal, in care sobolanii masculi Wistar au fost instilati zilnic
intra-traheal cu MnCl2 (2,5 sau 5,0 mg/kg corp), dizolvata in apa distilata, sau cu nanosuspensie de MnO2 (2,5 sau 5,0 mg/kg corp);
au fost folosite si combinatii de 2,5 mg/kg solutie MnCl2 si 2,5 mg/kg MnO2 in suspensie de nanoparticule, care au fost administrateconsecutive, intr-un interval de timp scurt. Dupa o perioada de 5 saptamani de tratament, animalele au fost testate din punct devedere al activitatii si s-au efectuat investigatii electrofiziologice; au fost inregistrate potentiale de actiune evocate si spontane la
nivelul ariilor corticale somato-senzoriale, vizuale si auditorii. Mn a ajuns la nivelul SNC si a determinat alterarea semnificativa aspectrului de distributie al benzilor ECoG, a indus latenta potentialelor evocate si a influentat activitatea locomotorie la sobolani.
Efectele observate au aratat un efect aditiv in cazul expunerii combinate la ambele solutii.
Cuvinte cheie: mangan, nanoparticlule, instilare intra-traheala, potentiale evocate, sobolan

20

Fiziologia - Physiology  2011.21.1 (69)EFFECT OF BODY TEMPERATURE ON THE ELECRTICAL
ACTIVITY OF THE BRAIN IN ANAESTHETISED RATS
VIKTÓRIA NAGY, EDIT PAULIK, ANDRÁS PAPP
Department of Public Health, University of Szeged, Szeged, Hungary

ABSTRACTThe animal experiments with anaesthetise is very widespread in the world. In this stage the sensory function is turned out. During
anaesthetise the vegetative thermoregulation is failed; the body temperature is decreased, so it is important that the body temperatureof experimental animals is kept around on 37 oC. Using of two narcotics (urethane, ketamine-xilazine) we examined the effect ofvariable temperature on the central nervous system, as well as the different effect of narcotics in this stage. It was definable thatthe tail temperature change in different way as the core temperature. This knowledge is important to use in physio- pharmocoltoxicological experiments.
Key words: rat, anaesthesia, thermoregulation, central nervous system activity, peripheral nervous system activity

INTRODUCTION
In animal experiments general anaesthesia evolve a
sleeping-like stage caused by the effect of the narcotic on
the central nervous system. However, during anaesthesia thevegetative thermoregulation is failed and the body temperatureis reduced quickly, particularly in small-sized animals. It leads
to alteration of physiological processes and central nervous
functions, which is affected by narcotics. Usually, it is establishedto maintain the temperature of the animals - by any technicalway - on 37 oC, which is the normal body temperature in warmblooded species.
The artificial sleeping causes not only anaesthetised stage but
also influence, among others, the thermoregulation, too (Sessler,
1993; Kurz, 2001). During sleeping the temperature decreases,
but it remains within the normal range. It is the part of the circadianalteration of body temperature. In anaesthetised stage the agent
has influence for several functions of the brain, so it can retard
the vegetative system. Thus, the thermoregulation became more
imprecise. In waking stage vasomotor refund is started up by thechange of core temperature with ±0.2°C, while in anaesthetised
stage this refund is started up by ±3°C (Sessler, 1993). In case ofsmall-sized animals the heat loss can be rapid if the body surface
is big compared to body weight, therefore it is important to maintainthe normal temperature during the whole experiment. (Karwacki etal., 2001). In the course of our experiments we wanted to establish
if that the body temperature of experimental animals is changed
what alteration is caused on the nervous system recordings
particularly on certain electrophysiological parameters. On theother hands we wanted to see weather this effect is depended on
the type of narcotics.
MATERIALS AND METHODS
Male Wistar rats were anaesthetised with urethane(1000mg/kg b.w. ip.; Mook, 2006) or ketamine-xilazine compound(100+8 mg/kg b.w. ip.; Farkas et al 1999). The left hemisphereof the anesthetised rats was disclosed and the parietal bone
was removed. For recovery from the surgery the animal was
put aside for at least 30 min. After that, ball-tipped silver
recording electrodes were placed on the dura over the primarysomatosensory (SS) area of the whisker pad (barrel field; Tracey
and Waite, 1995) and a pair of needle electrodes inserted at thebase of tail to deliver electric stimuli, and another pair 50 mm
distally to record. SS stimulation was done by electric pulses
delivered to the contralateral whisker pad. The regulation oftemperature was controlled by the water of the thermostate
which held warm the plate. At the beginning of the experiment
the temperature was 36.5-37 oC. The core temperature wasmeasured by rectal thermometer about 6 cm from the anus.
One recording session consisted of six minutes recordingof ECoG then, evoked potentials (EPs) were recorded from thecortical areas and from the tail nerve, too. One period lasted 20
minutes, after two control record the temperature of the water
was reduced to 15 oC by an ice-cube. After three recordings thetemperature was increased to 37 oC by thermostate then werecorded 3-4 measurements.
In case of both narcotics 10-10 successful experiences wereanalysed. The ECoG records were processed by NEUROSYS
1.11 (Experimetria Ltd., Budapest) program. From the ECoG
records, the relative spectral power by the standard frequency
bands, delta to gamma, (delta, 0,5–4 Hz; theta, 4–7 Hz; alfa, 8–13
Hz; beta1, 13–20 Hz; beta2, 20–30 Hz; gamma, 30–50 Hz; Kandel and Schwartz, 1985) was determined. For characterization of
the base activity on the cortex was calculated the ECoG-index(Dési et al, 1998), which is the rate of the slow and the fast waves.
ECoG index = [delta + théta] / [béta1 + béta2]
On the recorded and averaged SS action potentials, latency andpeak-to-peak amplitude was measured. The data from the different
animals was normalized to the self control data to be comparable.
Statistical analysis was done by two-sample t-test andF-probe.

Received February 5, 2011. Accepted March 10, 2011. Address for correspondence: Viktoria Nagy, University of Szeged, Faculty of Medicine, Department of Public
Health, Dóm tér 10., Szeged, Hungary, Tel. +36-65-545-119, Fax. +36-62-545-120

2011.21.1 (69)  Fiziologia - Physiology

21

The rats were housed under standard conditions (22–24°C;
12-h light:12-h dark cycle with light starting at 06:00 a.m.) withfree access to food and water. During the whole study, theprinciples of the Ethical Committee for the Protection of Animals
in Research of the University were strictly followed.
RESULTS
1. Alteration of the temperature during theexperience.
The temperature of the animals altered along with thetemperature of the water, responded with short delay. The time
lag was similar in the phase of the refrigeration and of the warming
up. The alteration of the body temperature was for the most partsignificant. The alteration was bigger in the case of ketamine-xilazine
and in general the initial body temperature was lower, too (Fig. 1).
Fig.2. Right: The temporal alteration of the body temperature and ECoG index
during the experiments.
*; **; ***: p<0.05; 0.01; 0.001 vs. control values. Left: Correlation diagram, relativechange of the temperature and ECoG index.

In the temporal parameters, the onset latency changed the mostsignificantly while the duration did not show unequivocal changes.
It can be seen on figure 3 that all parameters of the cortical evoked
potentials change parallel with that of the temperature.

Fig.1. The temporal alteration of the body temperature and the temperatureof the water of the thermostate during the experiments. *; **; ***: p<0.05; 0.01;
0.001 vs. control values.

2. The alteration of the body temperature and theelectrophysiological parameters, and their coherence inanimals anesthetised by urethane
The change of the ECoG’s spectral compound followed
closely the change of the body temperature. The ECoG index
reduced with decreasing temperature, it means that in the baseactivity on the cortex the relative weight of fast activity increased.
It can be seen on Fig. 2. As the left diagram shows, there is highcorrelation between the temperature and the ECoG index. The
high R2 value shows that the changes of base activity firmly
depend on the temperature. The coherence was significant.

Fig.3. Right: The temporal alteration of the temperature and cortical evoked
potential’s latency and duration.
*; **; ***: p<0.05; 0.01; 0.001 vs. control values. Left: Correlation diagram, relativechange of the temperature and latency.

22

Fiziologia - Physiology  2011.21.1 (69)In case of the tail nerve action potentials also the latencychanged the most significantly. The rise of amplitude was lessunequivocal which appeared with a short delay. The correlation
between latency and rectal temperature was not as strong
as in the case of cortical evoked potential. It can mean thatthe temperature of the tail can change different as the coretemperature (Fig. 4).

Fig.5. Right: The temporal change of the body temperature and ECoG index
during the experiments.
*; **; ***: p<0.05; 0.01; 0.001 vs. control values. Left: Correlation diagram,
relative change of the temperature and ECoG index.

Fig.4. Right: The temporal change of latency and amplitude in the action
potential of the tail nerve*; **; ***: p<0.05; 0.01; 0.001 vs. control values. Left: Correlation diagram,
relative change of the temperature and latency.

Regarding the temporal parameters the alterations weresimilar as in case of urethane anaesthesia. The onset latency
increased significantly, but duration did not show significantly
increase (Fig. 6).

3. The alteration of the body temperature and theparameters of electrophysiology, and their coherence inanimals anesthetised by ketamine-xilazine
The change of ECoG index was similar to that of urethane;
however the degree of the alteration was bigger. If the 2nd andthe 5th correlation diagram is compared, it can be seen, thatthe value of gradient is bigger here, which refers to the bigger
alteration (Fig. 5).

2011.21.1 (69)  Fiziologia - Physiology

23

appointed the dependence of the latency of the action potentialsof the tail and of the cortex on the temperature of the plate
and/or that of the body. It can be seen on Figure 8 that thetrend-lines and R2-value show that the evoked potential on
the cortex coherent with the core temperature and the action
potentials on the tail coherent with own temperature, which is
the temperature of the plate.

Fig.6. Right: The temporal change of latency and duration in the corticalevoked potential.
*; **; ***: p<0.05; 0.01; 0.001 vs. control values. Left: Correlation diagram,
relative change of the temperature and latency.

In case of tail nerve action potential the temperaturedependence of latency was significant. In this case it can be seen
too, that the latency of cortical evoked potential and tail nerve
action potential showed different coherence with the temperature.
R2 value is bigger here (Fig. 7).

Fig.8. Right: Coherence of latency’s cortical evoked potential and tail nerve
action potential with body temperature. Left: Coherence of latency’s corticalevoked potential and tail nerve action potential with thermostat temperature.
Fig.7. Right: The temporal change of latency and amplitude in the action
potential of the tail nerve, KEX anaesthesia. *; **; ***: p<0.05; 0.01; 0.001 vs.
control values. Left: Correlation diagram, relative change of the temperatureand latency.

4. Conformation of the temperature on the cortex andon the tail and its effect of the evoked potentials
The abdominal temperature reacted for the refrigeration
and warming up with delay, as it can be seen on Figure 1. The
tail consorts with the big surface of the plate, so the temperatureof the tail can be different from the body temperature. However,
we did not measure the own temperature of the tail, but we
24

CONCLUSION
According to our results it can be concluded, that slight decreasein the temperature of an anaesthetised rat – the level of anaesthesia
that does not cause irreversible damage – can significantly alter themeasurable parameters of central or peripheral nervous activity.
Along with findings of our laboratory, it can be stated, that thesefunctional nervous system alterations are comparable in magnitudewith those gained by xenobiotic exposure.
Thermoregulation differently extends to different partsof the body even if non-anaesthetised, pharmacologically
non-exposed animals. Investigating the tail, results show that
Fiziologia - Physiology  2011.21.1 (69)temperature of the tail changes independently from the otherparts of the body in response to heating-cooling the holding
plate. This can be of importance when examining tail nerve
activity (or of other peripheral parts) and if the body temperature
is stabilized.
To summarize it can be said that in experimental studies it isessential to know, to monitor and to stabilize the temperature of
the animals, in order to reveal every disturbing factors of animal
experiments to achieve more precise and explainable results
reflecting only the effects of the xenobiotics.
REFERENCES

1. Dési I, Nagymajtényi L, Schulz H, Papp A. Experimental model studies
of pesticide exposure. NeuroToxicology, 1988; 19: 611-16.
2. Farkas T, Kiss Zs, Toldi J, Wolff JR. Activation of the primary motor

cortex by somatosensory stimulation in adult rats is mediated by associational connections from the somatosensory cortex. Neuroscience,
1999; 90: 353-61.
3. Kandel ER, Schwartz JH. Principles of Neural Science. Elsevier, New
York, 1985; 643-644.
4. Karwacki Z, Kowiański P, Moryś J. General anaesthesia in rats
undergoing experiments on the central nervous system. Folia Morphol.,
2001; 60: 235-42.
5. Kurz, F. 2001. Effects of anaesthesia on thermoregulation. Curr.
Anaesth. Crit. Care 12:72-78.
6. Mook, D. 2006. Anesthetic Management of Rodents and Rabbits.
http://www.dar.emory.edu/vet_drug_anesthetic.htm#inj
7. Sessler DI. Perianesthetic thermoregulation and heat balance inhumans. FASEB J., 1993; 7:638-644.
8. Tracey DJ, Waite PM. Somatosensory system. In: Paxinos, G. (Ed.):
The Rat Nervous System. Academic Press, 1995, San Diego, 689-704.

EFECTELE TEMPERATURII CORPORALE ASUPRA ACTIVITATII ELECTRICE
CEREBRALE LA SOBOLANII ANESTEZIATIREZUMAT

Experimentele animale care implica anestezia sunt foart larg raspandite in lume. In acest stadiu, functia senzoriala este
intrerupta. In timpul anesteziei, termoregalrea vegetativa este ineficienta; temperature corpului scade, astfel incat este
important ca temperatura corpului la animalele experimentale sa fie mentinuta in jurul valorii de 37 oC. Utilizand doua
substante narcotice (uretan, ketamina-xilazina), am examinat efectul variatiei temperaturii asupra sistemului nervos
central, precum si efectul narcoticelor in acest stadiu. A fost demonstrat ca temperatura la nivelul cozii variaza diferit
comparativ cu temperatura la nivel central. Aceasta observatie este importanta pentru a putea fi folosita in experimentele
psiho-farmaco-toxicologice.
Cuvinte cheie: sobolan, anestezie, termoreglare, sistem nervos central, activitatele sistemului nervos periferic

2011.21.1 (69)  Fiziologia - Physiology

25

INCIDENCE, RISK FACTORS AND COMPLICATIONS OF WHITECOAT HYPERTENSION IN FAMILY MEDICINE PRACTICEELENA ARDELEANU1, IOANA POPA2, ADRIAN GRUICI2, ELEONORA BURCĂ2, IOANA PURICEL2,ADRIANA RÂMNEANŢU2, DELIA GRIGORESCU2
1
Family Medicine Department, University of Medicine and Farmacy “Victor Babeş” Timişoara
2
Family medicine offices, Timiş County

ABSTRACTThe objective of the study was to asses the incidence, risk factors and complications of white coat hypertension in medicine family
practice.
Methods: Ambulatory blood pressure monitoring (ABPM) was applied between 2005 and 2010 on a number of 932 hypertensive
patients, of which 863 ABPM were validated. A number of 449 (52%) patients were female and 414 (48%) male, mean age 51±14
years, with limits between 37 and 65 years. The average follow-up time of the patients was 58±7 months. The study evaluated thepatient’s cardiovascular risk factors and cardiovascular events, current medications, demographic and anthropometric data andlaboratory analysis. Variables found between the groups were compared based on interview, clinical data and laboratory exams.
ANOVA and Student t test were used for statistical data. Results were expressed as means ± standard deviation, p<0.05 wasconsidered statistically significant.
Results: White coat hypertension was detected in 179 patients (20.7%), resistant hypertension in 215 (25%), nocturnal hypertension
in 90 (10.4%), masked hypertension in 71 (8.2%), orthostatic hypotension in 67 (7.75%), paroxysmal hypertension in 65 (7.5%)
and preeclampsia in 18 cases (2.1%). Females and smokers were predominant in the WCH group; the mean age in this group was
45.3±14 years. No correlation was found between white coat hypertension and demographic variable, increased body mass index,
plasma glucose, cholesterol, triglycerides and urea level. Complications occurred during the follow up time at a small number ofpatients with WCH. Seven patients (4%) developed coronary heart disease and 11 patients (6.2%) developed permanent hypertension. No sudden cardiac death or stroke occurred in the WCH group.
Conclusion: White coat hypertension was statistically more frequent in female and smokers and presented in evolution less complications compared to permanent hypertension. The differences found between the study groups concerning clinical and biochemicalvariables demonstrates that WCH is a condition that should be investigated distinctively in hypertensive patients.
Key words: hypertension, ambulatory blood pressure monitoring, white coat hypertension

INTRODUCTION
Blood pressure (BP) level is the most powerful sign for hypertension, although the inherent variability of BP levels must be taken
into account in association with clinical measurements. There isevidence showing that in hospital environment BP levels are usuallydifferent from measures at other settings. Therefore, ambulatory BP
is expected to allow the identification of a subgroup of white coat
hypertension patients.
White coat hypertension is understood as a persistent BP
increase at the doctor’s office or clinic, with normal BP levels whenassessed by blood pressure ambulatory monitoring (ABPM). Thismethod of BP measuring has been increasingly used in medical
practice, since it provides additional information to those obtained
usually from traditional methods of blood pressure measurement,
acting as a tool to eliminate error factors related to measuring as wellas permitting a wider reaching of diagnosis and therapeutic goals.
Many studies confirmed that ambulatory blood pressure monitoring reflect more accurately a patient’s blood pressure and correlate
more closely with organ complications, than blood pressure values
measured in the physician’s office.
White coat hypertension is definite by blood pressure values

more than 140/90 mmHg, when measured in the doctor’s officeand by normal blood pressure values (< 130/85 mmHg) during
APBM. None of the clinical characteristics help to diagnose WCH
better than by ABPM. Because of this reasons, ABPM should beconsidered before the prescription of a medical treatment, avoiding
so unnecessary drug prescription in WCH.
The objective of the study was to identify and establish infamily medicine practice the incidence, risk factors and associatedcomplications of white coat hypertension.
MATERIAL AND METHODS
Between 2005 and 2010 we evaluated and included in ourstudy a number of 4652 hypertensive from 14 family medicine offices of Timiş County. Of these 2428 patients were men (52.1%) and
2224 were women (47.9%). The average follow-up time was 58±7
months. The study evaluated the patients’ cardiovascular risk factors
and cardiovascular events, current medications, demographic andanthropometric data. Complete laboratory analysis, an electrocardiogram and echocardiogram were performed for each patient at thetime of enrolment. 863 patients, respectively 18.5% had an accurate
ambulatory blood pressure monitoring (ABPM).
Hypertension was documented by elevated blood pressure

Received 15 February 2011. Accepted 20 March 2011. Address for correspondence: Elena Ardelean, MD, PhD, Family Medicine Department, University of Medicine andFarmacy “Victor Babeş” Timişoara, eftimie Murgu Square No. 2A, 300041, Timisoara, Romania, e-mail: medicinafamiliei@umft.ro26

Fiziologia - Physiology  2011.21.1 (69)

at least at two separate visits, within 1 month (DBP>90 mmHg,
SBP≥145 mmHg), measured in standard conditions, as recommended by the international hypertension guidelines.
Ambulatory blood pressure monitoring was performed with a
BTL device, while the patient worked normally and was continuing
the drug therapy, if under antihypertensive medication.
Subjects were identified as presenting WCH if the office bloodpressure was ≥145/90 mmHg, but the average systolic and diastolicblood pressure on ABPM was ≤130/80 mmHg/24h or if the valuesof systolic/diastolic BP were at least 20 or 15 mmHg lower than at
the office.
The patients’ records were analyzed, previous history of morbidities, family history of heart diseases, exposure to risk factors,
anthropometry and blood pressure measures were collected. The
next step was to submit the patients to: ABPM exam and bloodcollection for the investigation of biochemical changes.
Variables found between the two groups were compared basedon interview, data measurements and laboratory exams. ABPM was
performed with intermittent measuring, with 30 minute intervals for
day time and 60 minute intervals for the night period. Exams wereconsidered valid when their minimum duration was 22 hours, with
2 measurements/hours in vigil status and 1 measurement/hour
during sleep.
For statistical data, the following variables were submitted
by analysis of variance (ANOVA) for repeated measures: bodymass index (BMI), glucose levels, total cholesterol, triglycerides,
sodium, potassium, urea and creatinine. Results were expressed
as means± standard deviations. p>0.05 was considered statisticallysignificant.
RESULTSWhite coat hypertension was detected in 179 patients of 863(20.7%), resistant hypertension in 215 (25%), nocturnal hypertension in 90 (10.4%), masked hypertension in 71 (8.2%), orthostatic
hypotension in 67 (7.75%), paroxysmal hypertension in 65 (7.5%)
and preeclampsia in 18 (2.1%). Of these 141 WCH (78.7%) werefemale, compared with a 47.9% female in the hypertensive group(p<0.001).
Hypertensive patients predominantly belonged to the50-59-year-old range (33.3%), with a mean age of 49.26 ± 2.7
years. As for WCH, the highest prevalence (27.8%) was found in
the 40-49-year-old range (mean age 45.28 ± 2.9 years).

.

Fig.1. Types of HT detected at ABPM

2011.21.1 (69)  Fiziologia - Physiology

Fig. 2.WCH profile on ABPM

There was no statistical significant difference concerning body mass index between the two study groups (29±8compared with 30±6). There was a significant difference concerning smoking between the groups: 84% in the WCH were
smokers, compared with only 53% in the total hypertensive
group (p<0.001). A family history of hypertension was present
in 5% WCH, but in 14% of the total hypertensive group. We
observed a statistical important difference concerning target
organ damage, that was present only in 3 patients (2%) with
WCH, but in 250 patients (29%) of the hypertensive study
group (p <0.001).
There were no important statistical differences concerning
biological data, as cholesterol levels (mean values 239 vs. 240
mg/dl), sodium (139.9 vs.139.7 mEq/ml), potassium (4.47 vs.
4.5 mEq/ml) and urea (28.5 vs. 30.6 mg/dl). Creatinine levels
were greater in the hypertensive group (0.9 vs. 0.7mg/dl),
with p<0.01.

Fig. 3. Characteristics of WCH comparedwith the total study group27the hypertensive group, where the patients presented one oreven more cardiovascular events: coronary heart disease andmyocardial infarction in 8%, heart failure in 5%, hypertensive
emergencies in 2%, sudden cardiac death in 0.2% and strokein 8.3%. The incidence of WCH complications was greater inthe presence of higher BP values, higher cholesterol levels andat older age.

Fig. 4. Biological data of WCT comparedwith the total study group

Office mean BP values in the white coat hypertension
group were 153±7 mmHg for systolic blood pressure and 94±4mmHg for diastolic blood pressure. ABPM for systolic bloodpressure/24h was 125±8 mmHg and diastolic blood pressure/24
h was 81±7 mmHg. During daytime mean systolic blood pressure was 127±6 mmHg and mean diastolic blood pressure 82±4mmHg. On night time mean systolic blood pressure was 110±10mmHg and mean diastolic blood pressure 71±6 mmHg.
Cardiovascular events were better predicted by ambulatory
blood pressure measurement than by simple office measurements. Complications occurred during the follow up time at asmall number of patients with WCH: seven patients (4%) developed coronary heart disease and 11 patients (6.2%) developed
permanent hypertension. No sudden cardiac death or stroke
occurred in the WCH group.

Fig. 5. Values of office BP and ABPM

The incidence of complications was statistically greater in28

Fig.6. Complications of WCH

DISCUSSIONS
WCH may vary between 15 to 30%, depending on the study
criteria. Significant difference between BP values - both systolicand diastolic, at the doctor’s office and on ABPM could be foundamong individuals in both groups. If we consider that BP increaseis a major risk predictor for cardiovascular diseases, such finding
suggests that white coat hypertensive are under higher risk forevents, if compared to individuals whose BP is under control.
In regard to gender, a predominance of female patients wasfound in the WCH subgroup, thus confirming the results brought
by a number of researchers (1, 3, 6), who pointed out that womenreport a higher prevalence of the phenomenon.
Smoking habit is a marked risk factor in both study groups
and alcohol drinking was frequent reported in essential hypertension patients’ history. Concerning the analysis of BMI, both study
groups were more obese, with no significant difference between
WCH and essential hypertension.
When detecting the risk of metabolic and cardiovascular diseases (6,10), the hypertensive group was found to report higher
prevalence, as compared to WCH, which was less exposed tothese complications.
Hypertension related metabolic risks contribute to the development of target organ lesions and atherosclerotic diseases (7,9). Many studies showed metabolic disorders in WCH, but results
are not consistent (2, 4, 8). The present study has shown that
total cholesterol levels and plasma glucose in both groups wereequal. When plasma creatinine was assessed, WCH with meancreatinine level of 0.8 mg/dl was not similar to the hypertensive
group (with creatinine level of 0.9 mg/dl), but the difference was
not statistically significant.
Our results showed that complications of WCH are less freFiziologia - Physiology  2011.21.1 (69)quent than those reported by essential hypertension, WCH being
in the intermediate risk category between essential hypertension
and individuals with no change of blood pressure condition. Literature shows controversial results about the analysis of thesevariables (2, 4, 5,10).
The difference found between the two groups in regard toclinical, biochemical variables and target organ damage, demonstrate that WCH is a condition that must be assessed distinctively
in regard to normal BP and essential hypertension. Although wehave not found any correlation between white coat hypertension
and the demographic variables investigated, we are aware that
our sample is not large enough for more solid conclusions.
Further studies are needed to help to measure the prevalence
and the risks associated to the WCH phenomenon. We believe thatnew strategies are to be raised in regard to control the BP in thesepatients. The likelihood of an association between WCH and risk
factors and co morbidities is also important and needs to be further
investigated. Additionally, the need for further studies to reassess
and possibly define the best conduct for WCH will be useful.
CONCLUSIONSThe present study demonstrates that ABPM is an importantand necessary investigation method, providing more conclusive
data about the blood pressure values than the measurement of
BP in the doctor’s office. The incidence of WCH was 20.7% in
our study, being higher in women and smokers. It is important
to introduce on a larger scale ABPM, even in hypertensive

patients which have high BP values in spite of an optimal
antihypertensive treatment, because the “white coat” effectcan not be predicted otherwise with accuracy. We noted theassociation of WCH with a low rate of cardiovascular events
during the follow up, compared with the higher events rate in
the hypertensive group.
REFERENCES

1. Björklund K, Lind L, Vessby B, et al: Different metabolic predictors of white-coatand sustained hypertension over a 20-year follow-up period: a population-based
study of elderly men. Circulation. 2002; 106 (1): 63-68.
2. Celis H, Fagard RH: White-coat hypertension: a clinical review. Eur J Intern
Med. 2004; 15 (6): 348-357.
3. Cerasola G, Cottone S, Nardi E, et al: White coat hypertension and cardiovascular risk. J Cardiovasc Risk. 1995; 2 (6): 545-549.
4. Kotsis V, Stabouli S, Bouldin M, et al: Impact of obesity on 24-hour ambulatory
blood pressure and hypertension. Hypertension. 2005; 45 (4): 602-607.
5. Papademetriou V: Comparative prognostic value of systolic, diastolic, andpulse pressure. Am J Cardiol. 2003; 91 (4): 433-435.
6. Parvulescu N V: Pacientul hipertensiv în practica medicală..E. Helios,
Craiova, 1999
7. Pickering TG: White coat hypertension – should it be treated or not? Cleve
Clin J Med. 2002; 69 (8): 584-585.
8. Smith PA, Graham LN, Mackintosh AF, et al: Sympathetic neural mechanisms
in white coat hypertension. J Am Coll Cardiol. 2002; 40 (1): 126-132.
9. Tobe SW, Kiss A, Perkins N, et al: Impact of job and marital strain on ambulatory blood pressure results from the double exposure study. Am J Hypertens.
2005; 18 (8): 1046-1051.
10. Tsai P. White coat hypertension: understanding the concept and examining
the significance. J Clin Nurs. 2002; 11 (6): 715-22.

INCIDENŢA, FACTORII DE RISC ŞI COMPLICAŢIILE „HIPERTENSIUNII DE
HALAT ALB” ÎN PRACTICA MEDICINEI DE FAMILIEREZUMAT
Obiectivul studiului a constat în evaluarea incidenţei, a factorilor de risc şi a complicaţiilor hipertensiunii „de halat alb” la nivel demedicină de familie în judeţul Timiş.
Metodă: Între anii 2005 şi 2010 la 14 cabinete de medicina familiei s-au efectuat 932 monitorizări ambulatorii ale tensiunii arteriale(MATA),
fiind validate un număr de 863, care au fost introduse în studiu. Din acestea 449 (52%) au fost efectuate la pacienţi de sex feminin şi
414 (48%) la sex masculin, având o vârstă medie de 51 ± 14 şi limite între 37 şi 65 de ani. Media de urmărire a pacienţilor în studiu
a fost de 58 ± 7 luni. Cercetarea a evaluat factorii de risc şi evenimentele cardiovasculare apărute, medicaţia administrată, datele
demografice şi antropometrice ale pacienţilor şi cele de laborator. Pentru analiza statistică au fost utilizate testul Student şi metoda
ANOVA. Rezultatele au fost exprimate ca medie ± deviaţia standard, p <0,05 a fost considerat semnificativ statistic.
Rezultate: hipertensiunea „de halat alb” a fost depistată la 179 de pacienţi (20,7%), hipertensiunea arterială rezistentă la tratament la
215 pacienţi (25%), hipertensiunea arterială nocturnă în 90 de cazuri (10,4%), hipertensiunea arterială mascată la 71 pacienţi (8,2%),
hipotensiunea ortostatică la 67 (7,75%), hipertensiunea paroxistică în 65 cazuri (7,5%) şi preeclampsia la 18 (2,1%). În grupul celor
cu „hipertensiune de halat alb” au predominat femeile şi fumătorii, vârsta medie fiind de 45,3 ± 14 ani. Nu s-au constatat corelaţii
între HTA „de halat alb” şi variabilele demografice, indexul crescut de masă corporală, glicemie, colesterolemie, trigliceridemie şiureea plasmatică. Complicaţiile s-au întâlnit în perioada de urmărire la un număr mic de pacienţi cu hipertensiune “de halat alb”.
Au dezvoltat boală coronariană şapte bolnavi ( 4%), HTA permanentă unsprezece (6,2%) şi nu s-a produs nici o moarte subită sau
accident vascular cerebral.
Concluzii: HTA „de halat alb” s-a întâlnit statistic semnificat mai frecvent la sexul feminin şi fumători, ea dezvoltând în evoluţie maipuţine complicaţii faţă de hipertensiunea arterială permanentă.. Diferenţele constatate la grupele de studiu din punct de vedere clinic,
biochimic şi evolutiv demonstrează că HTA „de halat alb” necesită depistare şi monitorizare individualizată.
Cuvinte cheie: HTA, monitorizarea ambulatorie a tensiunii arteriale, hipertensiunea „de halat alb”.
2011.21.1 (69)  Fiziologia - Physiology

29

Surveillance of nosocomial infections in a cardiac
surgery/Intensive Care unit in tIMISOARA
C. PILUŢ1, MONICA LICKER1, CARMEN TATU2, DORINA DUGĂEŞESCU1, DELIA BERCEANUVĂDUVA1, MIHAELA CRĂCIUNESCU1, LILIANA DRAGOMIRESCU1,3, ELENA HOGEA1, DELIA MUNTEAN1, ROXANA ZUGRAVU1, F. HORHAT1,3, MATILDA RĂDULESCU1, MARCELAADĂMUŢ1, RAMONA PÂRVAN1, D. ŞERBAN1, ANGELA ADAM4, ROXANA MOLDOVAN1
1Timisoara “Victor Babes” University of Medicine and Pharmacy, Microbiology Department
2
Timisoara “Victor Babes” University of Medicine and Pharmacy, Physiology Department
3
Timisoara Clinical Emergency County Hospital, Microbiology Department
4
Timisoara Institute of Cardiovascular Disease, Epidemiology Department

ABSTRACT
Nosocomial infections, which are common following cardiac surgery, are associated with prolonged lengths of hospitalization, thedevelopment of multiorgan dysfunction, and increased hospital mortality.
We isolated from IBCV (Timisoara Cardiovascular Institute Disease) between January 2009- November 2009 a number of 49
microbial strains from a total of 123 samples (48 blood, 45 wound secretions, 9 bronchoalveolar aspirates, 6 catheter-related
bloodstream infections, 6 biopsy fragment, 5 urines, 3 pericardic fluid, 1 pleural fluid).
Isolation and identification of germs were performed at the level of the University Microbiology Department laboratory. All the samples
were cultured on Columbia 5% sheep blood agar (bioMerieux) and selective media, like Chapmann, Mac Conkey agar (Bio-Rad).
Identification was generally based on morpho-tinctorial characteristics, cultural and biochemical tests and phenotyping, with the helpof automatic VITEK 2 compact system.
From the total of 49 microbial strains with nosocomial potential, 9 strains were multidrug resistant (MDR). The highest percentage
was reported for ESBL producing enterobacteria, followed by MRSA (Methicilin-Resistant S.aureus)
Keywords: ESBL, MRSA, MDR

INTRODUCTION
Surgical Site Infection (SSI) continues to be a major sourceof morbidity following operative procedures. The aging of the
population means that not only will the number of operations likely
increase, but the National Nosocomial Infections Surveillance(NNIS) Risk Index, which standardizes the risk of SSI for an
aging population, will be greater. The NNIS report for 1986-1996
described an SSI rate of 2.6% for all operations at the level of thereporting hospitals. It seems likely that overall SSI rates are likely
to be greater than reported. All surgical wounds are contaminatedby bacteria, but only a minority actually demonstrates clinicalinfection (1).
Mortality related to nosocomial infection was high (21.7%),
and at least one third of those deaths was directly related tothe infection. In hospital stay and cost were also increase withnosocomial infections (2).
The types of nosocomial infections are addressed, including
post-surgical wound infections, catheter-related bloodstream infections, urinary tract infections, ventilator-associated pneumonia
and gastrointestinal infections.
This retrospective review was conducted to evaluate the microbiologic spectrum and susceptibility pattern in the cardiology
surgery/ intensive care unit from January - November 2009.

MATERIAL AND METHOD
We collected from IBCV (Timisoara Cardiovascular
Institute Disease) between January 2009- November 2009
a number of 123 samples (48 blood, 45 wound secretions,
9 bronchoalveolar aspirates, 6 catheter-related bloodstream
infections, 6 biopsy fragment, 5 urines, 3 pericardic fluid, 1
pleural fluid)
Isolation and identification of germs were performed at
the level of the University Microbiology Department laboratory.
All the samples were cultured on Columbia 5% sheep blood
agar (bioMerieux) and selective media, like Chapmann, Mac
Conkey agar (Bio-Rad). Identification was generally based onmorpho-tinctorial characteristics, cultural and biochemical tests
and phenotyping, with the help of automatic VITEK 2 compact
system.
Blood samples were isolated and identificated at the level ofthe Microbiology laboratory of the Timisoara Clinical Emergency
County Hospital.
RESULTS AND DISCUSSIONS
From 123 samples (wound secretions, blood, urines, bronchoalveolar aspirates, etc.) we isolated 49 microbial strains withnosocomial potential (Tables I and II).

Received 20 February 2011. Accepted 10 March 2011. Address for correspondence: C. Pilut, Microbiology Department, “Victor Babes” University of Medicine andPharmacy Timisoara, Eftimie Murgu Square No. 2A, 300041, Timisoara, Romania

30

Fiziologia - Physiology  2011.21.1 (69)Table I. Positive pathological samples

Pathological samples

Total

blood
wound secretions
bronchoalveolar aspirates
catheter infections
biopsy fragments
urinespericardic fluids
pleural fluid

48
45
9
6
6
5
3
1
123

Positivesamples
15
26
5
2
1
0
0
0
49

Table II. Isolated germs from cardiology
surgery/ intensive care unit department

Strains
No.
%

isolated germs
S. aureus

23

MDR strains
No.
%

46.93

MRSA
17.39
4
Coagulase negative
5
10.20
MRSCN
20
staphylococcus
1
Streptococcus spp.
E.coli
5
10.20
ESBL
20
1
Klebsiella pneumoniae
5
10.20
ESBL
40
2
Klebsiella oxytoca
1
2.04
ESBL
0
Pseudomonas aeruginosa
6
12.24 Carbapenems
resistant0
Pseudomonas fluorescens
1
2.04
Carbapenems
resistant0
Acinetobacter baumannii
Serratia marcescens
1
2.04
ESBL
100
1
Proteus mirabilis
2
4.11
ESBL
0
Legend: ESBLextended spectrum beta-lactamase, MRSA Methicilin-Resistant S.aureus, MRSCN Methicilin Resistant Staphylococcus coagulase - negativ

From the total of 49 microbial strains with nosocomial potential, 9 strains were multidrug resistante (MDR). The highest
percentage was reported for ESBL producing enterobacteria,
followed by MRSA (Methicilin-Resistant S.aureus) (Figure 1). The
majority of these strains were involved in blood, wound secretions
and catheter-related bloodstream infections (Figure 2).

carbapenem0%
resistant nonnonresistantEnterobacteriaceae
Enterobacteriaceae

ESBL

28.57%

MRSCN

20%

MRSA

17.39%
0

5

10

15

20

Fig.1. Repartitions of multidrug resistance strains

2011.21.1 (69)  Fiziologia - Physiology

25

30

60
MDR strains 40
20
Total samples 0

48
4

45
3

9
0

6
2

5

6

0

0

3

0

1
0

od ns
nt es id uid.
...
blo etio lar . . ted gme urin ic flu al fl
a
r
a
l
o
r
c
r d eurs e alve e r-re sy f
ica pl
r
d
t
p
o
e
p
un ch he bio
wo ron catbFig. 2. Distribution of MDR strains

The ESBLs are frequently plasmid encoded. Plasmids
responsible for ESBL production frequently carry genes encoding resistance to other antimicrobial agents classes (forexample, aminoglycosides)(3). In this study, all ESBLs havebeen associated with other resistance patterns like: quinolones
or aminoglycosides resistance to (Table III).
Table III: Resistance phenotypes of ESBL producing enterobacteria

Isolated germs

phenotypes

No.

Klebsiella pneumoniae

ESBL + TGANt +cross resistance Fq

1

ESBL + cross resistance Fq

1E.coli

ESBL + TGANt +cross resistance Fq

1Serratia marcescens

ESBL +KTGANt

1

Legend: ESBL-extended spectrum beta-lactamase, G-resistance to gentamycine, T- resistance to tobramycine, A-resistance to amikacin, Nt-resistanceto netilmicin, Fq-fluoroquinolone

There is a considerable geographical difference in theoccurrence of ESBLs in the European countries. Withincountries, hospital-to-hospital variability in occurrence may
also be marked (4). In a SENTRY worldwide surveillance
program report, ESBL phenotypes were detected in 45% of K.
pneumoniae strains from Latin America, 23% from the western
Pacific, 23% from Europe, 8% from the United States, and 5%
from Canada (5).
CONCLUSIONS
1. ESBL-producing enterobacteria and MRSA were themajor concerns in this study. Good hand hygiene and strict
aseptic procedures remain the most important key factors for
infection control.
2. Knowledge of the factors associated with hospitalacquired infections is essential to reduce human and social
costs related to such infections, with simultaneously improving
the quality of health care.
3. We need a more effective hospital acquired infections
surveillance system to prevent and eliminate nosocomial infec31

tions and epidemic outbreak emergence.
4. It is obligatory to evaluate the relationship between nosocomial infections and clinical outcomes following cardiac surgery,and to identify risk factors for the development of nosocomial
infections in this patient population.
ACKNOWLEDGMENTS
These data are part of the PNII 42121 project: “Molecularcharacterization of multidrug resistant strains, hospital orcommunity acquired, collected from south-west Romania”.
REFERENCES

1. Fabiano G, Pezzolla A, Filograna MA, Ferrarese F. Risk factors ofsurgical wound infection. Ann Ital Chir., 2004 Jan-Feb; 75(1): 11-6.

2. Molina-Gamboa JD, Garza-Moreno H. Surveillance of nosocomial
infections in a cardiology hospital. Salud Publica Mex., 1999; 41 Suppl
1:S26-31.
3. Paterson DL, Bonomo RA. Extended-spectrum beta-lactamases: aclinical update. Clin Microbiol Rev., 2005 Oct; 18(4): 657-86.
4. Babini G S, Livermore D M. Antimicrobial resistance amongst
Klebsiella spp. collected from intensive care units in Southern andWestern Europe in 1997-1998. J. Antimicrob. Chemother., 2000;
45:183-189.
5. Winokur PL, Canton R, Casellas JM, et al. Variations in the prevalence of strains expressing an extended-spectrum-beta-lactamase
phenotype and characterization of isolates from Europe, the Americas,
and the Western Pacific region. Clin Infect Dis., 2001; 32(Suppl 2):
S94-S103.

Supravegherea infectiilor nosocomiale in sectiile dechirurgie cardiace din tIMISOARA
REZUMAT
Infecţiile nosocomiale, frecvente în secţiile de chirurgie cardiacă, sunt adesea asociate cu creşterea perioadei de spitalizare, cu
disfuncţii de organe şi cu creşterea mortalităţii în spital.
În perioada ianuarie – noiembrie 2009 am izolat 49 de tulpini microbiene dintr-un total de 123 probe recoltate(48 hemoculturi, 45
secreţii plagă, 9 aspirat bronşic, 6 vârf de cateter, 6 fragmente de biopsie, 5 urini, 3 lichid pericardic, 1 lichid pleural).
Izolarea şi identificarea tulpinilor microbiene s-a efectuat în laboratorul de microbiologie din cadrul Universităţii de Medicină şi Farmacie. Toate probele au fost însămânţate pe geloză sânge Colombia şi pe medii selective ca de exemplu Chapmann, Mac Conkey.
Identificarea s-a bazat pe caracterele morfotinctoriale, culturale şi pe baza testelor biochimice, iar fenotiparea cu ajutorul sistemului
VITEK 2.
Din totalul de 49 tulpini microbiene cu potenţial nososcomial izolate, 9 au fost tulpini microbiene multirezistente la antibiotice(MDR).
Procentul cel mai mare de tulpini microbiene multirezistente la antibiotice(MDR) a fost pentru enterobacteriile cu spectrul extins labeta lactamaze urmat de Staphilococcus aureus meticilino-rezistent.
Cuvinte cheie: ESBL, MRSA, MDR

32

Fiziologia - Physiology  2011.21.1 (69)PSYCHOLOGICAL CHARACTERISTICS AND PERSONALITYTRAITS IN PRODROMAL STAGES OF BODY DYSMORPHICDISORDER
DIANA JIVĂNESCU1, IULIA CRIŞAN2, MIRCEA LĂZĂRESCU1
1
Psychiatry Department, University of Medicine and Pharmacy Victor Babes Timisoara, Romania
2
Gataia Psychiatric Hospital, Romania

ABSTRACT
Objective: In a preliminary study on Romanian population, the authors examined the prevalence and correlates of certain psychological characteristics and personality traits regarding the prodrome of body dysmorphic disorder, a debilitating and chronic condition
characterized by an imagined defect in appearance. Method: Levels of anxiety and depression were investigated, as well as theprevalence of certain personality traits, similar to personality disorders as described in the DSM-IV-TR and ICD-10. This study usedthe Hamilton Anxiety Scale, Beck Depression Inventory, and the Altered Personality Questionnaire to characterize the diagnostic
status of a population-based sample of 30 cosmetic surgery patients who repeatedly requested surgical intervention. Results:
The presence of possible prodrome symptoms for body dysmorphic disorder was significantly associated with the presence of mild
depression and moderate or severe anxiety symptoms. Research subjects also exhibited certain personality features, similar to theobsessive-compulsive, paranoid and borderline personality disorders. Conclusions: The authors found that the presence of pre-onset
body dysmorphic disorder characteristics was linked to the presence of depression and anxiety symptoms, which is similar to findings
in other clinical studies. Their estimate of the personality trait prevalence is consistent with data from other studies and suggests
prevalence similar to that of other serious psychiatric disorders (e.g., BDD comorbidity with personality disorders). These prevalence
data encourage the further research and development of treatment options for this debilitating condition.
Key words: BDD, prodrome, anxiety, depression, altered personality traits, cosmetic surgery

INTRODUCTION
Body dysmorphic disorder is a somatoform disorder definedby the Diagnostic and Statistical Manual of Mental Disordersof the American Psychiatric Association (DSM-IV-TR) in Axis
I, alongside other somatoform disorders, such as: conversion
disorder, somatization disorder, hypochondriasis, pain disorder,and undifferentiated somatoform disorder. According to the DSM
IV to be diagnosed with BDD a person must fulfil the following
criteria:
First criteria: “Preoccupation with an imagined or slight
defect in appearance. If a slight physical anomaly is present,
the person’s concern is markedly excessive.”
Second criteria: “The preoccupation causes clinically significant distress or impairment in social, occupational, or otherimportant areas of functioning.”
Third criteria: “The preoccupation is not better accounted
for by another mental disorder (e.g., dissatisfaction with body
shape and size in Anorexia Nervosa)” (1).
BDD is a chronic illness which usually develops in teenagers, but with long-term evolution its symptoms are likely topersist or worsen, as in most cases BDD is under-recognizedor misdiagnosed. Research findings indicate that BDD affects
men and women equally, with different locations of perceived
defects as gender differences. In other words, women tend to
be concerned mostly about their body weight and their thighs,

whereas men tend to be preoccupied by head shape, hair orhair loss, and genitals. People with BDD often have more than
one area of concern.
People with BDD are excessively concerned with andpreoccupied by a perceived defect in their physical features,
given that this defect is minimal, even nonexistent. The sufferer
may complain of several specific features or a single feature, ora vague feature or general appearance. Whatever the case, theso-called defect exists only for the sufferer who believes himself/
herself to be so unspeakably hideous that he/she is unable tointeract with others, while others typically disagree that thereeven is a defect thus not being able to understand the sufferer’s
preoccupation and distress.
Any body location or area, including the whole body may
become target of this intense preoccupation, concerning body
shape, size, and symmetry, facial expression, skin tone, muscle
size and shape. Most common locations refer to the person’s
face/skin, hair, nose, but they can also include the person’shead, chin, cheekbones, eyes, lids, eyebrows, lips, facial hair,chest/breasts, belly, waist, buttocks, thighs, legs, genitals, handor fingers. Individuals with BDD may have one or more areasof concern or features that they perceive as defective, either simultaneously or sequentially, consequently performing countlessassociated behaviors. Many individuals with BDD seem to be
preoccupied by weight, whereas women are mostly concerned

Received 15 February 2011. Accepted 20 March 2011. Address for correspondence: Diana Jivanescu, MD, Psychiatry Department, “Victor Babes” University of Medicine
and Pharmacy Timisoara, Eftimie Murgu Square No. 2A, Timisoara 300041, Romania; e-mail: dianajivanescu@yahoo.com

2011.21.1 (69)  Fiziologia - Physiology

33

with being oversized and/or overweight. Some people with BDD
link the perceived defect to certain negative aspects such as oldage, and/or lack of femininity or masculinity, while considering theso-called defect not only obvious to others but also essential for
their appearance, thus seeing themselves as totally unattractive.
These individuals don’t just occasionally think about the defect,
they are preoccupied by it and tend to have obsessive thoughts
about it, while most of them find it difficult not to think about their„problem”. Consequently the time they actually spend thinking
about their perceived defect may vary between a few minutes
and the whole day, though 3 to 8 hours a day is considered the
maximum frequency. Most of these people admit to spending too
much time thinking about their appearance, nonetheless there
are some who lack this realization, obsessive thoughts being
part of their identities and their lives. These thoughts generally
refer to the following topics: the person’s body image with theperceived defect, the so-called defect alone, or the way others
perceive it. Individuals with BDD often experience delusional
thoughts and beliefs, such as the delusion of reference related
to other people’s attitude towards the perceived defect. (2)In addition, people with BDD find it difficult to oppose orcontrol these thoughts, which also tend to be time consuming.
Some of them try to ignore the thoughts or focus on somethingelse, while others feel a drive so intense that they give up on all
attempts to either oppose or control them. This partial or total
loss of control represents one of the main characteristics of
BDD, and it is generally regarded as the centre of this disorder.
The degrees of psychological distress vary according to the following aspects: repetitive thoughts over a long period of time,inability to control these thoughts, the negative thought content,
inability to improve the perceived defect which generates despair,feelings of worthlessness, shame, guilt, low self esteem, fear of
rejection, other people mistakenly believing them to be selfish
or vain because of the excessive concern which they consider„coarse”, even immoral. Strong feelings of shame are also
common symptoms of BDD which P. Janet described as „theobsession about body related embarrassment”.
Individuals with BDD exhibit variable degrees of insight:
some overrate the perceived defect due to poor insight, whileothers have delusional thoughts due to lack of insight. However,efficient treatment has proven helpful in gaining insight.
The excessive preoccupation for the perceived defectleads to common behaviors, generally regarded as compulsive
or reassuring, with an aim to: examine the perceived defect,camouflage it, improve the defective appearance, and seek
constant reassurance from others. Most common compulsive
behaviors include:• Compulsive mirror checking, glancing in reflective doors,
windows and other reflective surfaces.
• Attempting to camouflage the imagined defect (for example, using cosmetic camouflage, wearing baggy clothing,
maintaining specific body posture or wearing hats).
• Use of distraction techniques: an attempt to divert attention away from the person’s perceived defect, e.g. wearing
extravagant clothing or excessive jewelers.
34• Excessive grooming behaviors: skin-picking, combing
hair, plucking eyebrows, shaving, etc.
• Compulsive skin-touching, especially to measure or feelthe perceived defect.
• Seeking reassurance from loved ones.
• Excessive dieting or exercising, working on outside appearance.
• Self-harm• Comparing appearance/body parts with that/those of others, or obsessive viewing of favorite celebrities or models withwhom the person suffering from BDD wishes to resemble.
• Compulsive information-seeking: reading books, newspaper articles and websites that relate to the person’s perceived
defect, e.g. hair loss or being overweight.
• Obsession with and recurrent use of plastic surgery or dermatological procedures, often with little satisfactory results. (3)These behaviors are typically repetitive; in some cases thisis due to the individual’s doubt concerning his/her appearance,
while in other cases individuals become dissatisfied with theoutcome of certain interventions or with their previous actions,as their aim is to prevent a so-called „catastrophe”, in the eventthat others should notice the imagined defect. These activities
are generally time consuming, with different time frames whichvary between several minutes and more than 8 hours a day,according to the nature of the intervention, and the presence/
absence of satisfaction. Usually people with BDD find it extremely
hard to resist and even control the urge of taking action; some ofthem try to resist these behaviors, others fail and resort to taking
action, while others see these actions as „automatic”, given that
only a very small percentage report complete control. Feelingsof fear, distress, or pressure enhance the need to take action; inthe event that this proves to be impossible, psychological distressgradually intensifies. Sometimes specific reassuring behaviors
actually diminish distress and anxiety, such being the case inwhich individuals realize they don’t look as bad as they expected
to; however, in most cases after having checked the outcomeof the intervention, individuals feel a higher degree of anxiety
and distress, realizing they look bad, worse than expected or„as they feared it would be”.
BDD causes significant impairment in all areas of functioning, according to different levels on a continuum, from efficiency
to disability. Most individuals with BDD are faced with various
degrees of impairment in social, interpersonal and professional
functioning. Also, it is believed that most persons with BDD
experience social anxiety and tend to become homebound (notleaving their home for weeks) at some point during the courseof the disorder. BDD is linked to significantly diminished qualityof life to the extent to which people with BDD are listed among
those patients who report poorest quality of life.
In terms of co-morbidity with other psychological disorders,
BDD has often been misdiagnosed due to its association withother disorders, such as: depressive disorder, obsessivecompulsive disorder, social phobia, substance-related disorders, and personality disorders representing few of possible
co-morbidities.
Fiziologia - Physiology  2011.21.1 (69)Both BDD and its associated disorders usually require extensive medical assistance, without having a real somatic basis.
BDD is usually a time consuming activity, as it evolves
according to some excessive preoccupation coming from anoverrated idea, and it may lead to relational issues and low levelsof social performance. Due to the perception dependency many
people with BDD repeatedly seek treatment from dermatologists
and cosmetic surgeons before finally accepting psychiatric or
psychological help. Most common treatment methods range
from using various forms of alternative therapy or diet without
consulting a physician to various surgical procedures. Patientswith BDD rarely accept the idea that mental health treatment
could prove effective in decreasing emotional distress, so they
don’t usually address a psychiatrist or a psychologist. Thus, very
few cases of BDD actually receive an official diagnosis of BDD;
moreover, in most cases BDD is often in advanced stages by
the time the patient receives an official diagnosis.
ture

1. Research on BDD – study findings and relevant litera-

Current BDD research is generally focused on the prevalence, psychopathologic aspects, co-morbidity, and treatmentof BDD, as well as on providing an update on BDD and otherrelated aspects. Here are a few recent studies with the correspondent findings:
In a 2005 study on American population (3) the authors
examined various characteristics of BDD, indicating that: BDD
occurs in 0.7%-13% community samples; 13% of 122 psychiatricpatients (other than BDD diagnosis) met the criteria of an official
BDD diagnosis; 81% of the recently diagnosed patients identified
BDD as their main issue; of these patients, 9%-12% admitted torequesting dermatological assistance, while 6%-15% reported
seeking cosmetic surgery (3).
Another socio-demographic, phenomenological, and longterm follow-up study of patients with BDD in Brazil (4) found that:
12% of 166 patients had clinically significant BDD; the mean age
was 29.9 years, and most of the subjects were women (55%) of
the patients with BDD 13% exhibited a chronic condition, andkept the same concerns during the course of the disorder. Unlike
the results found by Gunstad and Phillips (5) in a 2003 study,
Fontenelle’s findings show high co-morbidity rates of BDD withobsessive-compulsive disorder; in addition to this, the same
study found significant resemblances between patients with
BDD in Brazil and those in the USA, UK, and Italy, concerning
the clinical features of the disorder (4).
One study from the University of Texas Medical Branch
surveyed over 2200 men and women of various body types
regarding their self-perceptions related to weight and body
image (6). The study found that only 13% of the womenparticipants who were evaluated as having a “healthy” weight
for their height (BMI) were satisfied with their overall appearance. More disturbing was the finding that only 6% of these
women saw themselves as being “slim”. Conversely, only
6% of the male participants who were evaluated as having
a healthy BMI saw themselves as “fat”. Furthermore, of the2011.21.1 (69)  Fiziologia - Physiology

study participants who were actually overweight, twice as many
women as men described themselves as being “ashamed” oftheir bodies. The most obvious conclusion we can draw fromthese data is that men and women see themselves in startlingly
different ways, and have very different emotional reactions totheir weight (6).
Another study, published in the Journal of the American
Academy of Dermatology (7), looked at the rate of BDD in patients presenting for dermatology treatment. The study comparedpatients who had come to treatment for general dermatology
procedures with those who were specifically seeking cosmetic
procedures. The study found that 6.7% of those requesting
general dermatology cares met the diagnostic criteria for BDD.
On the other hand, 14% of those seeking cosmetic procedures
met the criteria for BDD. A control group (individuals not seeking dermatological care of either type) had a 2% prevalence of
BDD, roughly matching the rate of BDD in the general population (7).
Finally, a study published in the Annals of Plastic Surgery(8), investigated how 200 individuals diagnosed with BDD
responded psychologically to their surgeries. Unfortunately,
the results exposed the flaw with using surgical approaches
to this condition. The first noteworthy finding was that 21% of
the participants had resorted to surgery in an effort to address
their body image concerns. More importantly, of those who had
undergone surgery, only 25% reported long-term feelings of satisfaction about the outcome of their cosmetic procedures. And
only 2.3% reported long-term reduction in their BDD symptoms
after surgery. The message from these two studies is that a highnumber of people with BDD seek out surgical solutions to theirbody image obsessions, but only a small percentage of those
who do so see any appreciable decline in their BDD symptoms.
In other words, plastic surgery should not be seen as a viablemeans of treating BDD (8).
2. Several considerations regarding cosmetic surgery andmental health in Romania
In Romania, the somewhat rapid development in the fieldof cosmetic surgery as well as the increasing number of surgicalservices determined most people to request and seek cosmetic
procedures and surgical interventions which are usually ineffective, and in some cases quite damaging.
What mental health is concerned, one must take into account not only clinical cases, but more importantly those cases
in which individuals are highly vulnerable and/or prone to BDD
onset.
Thus, I decided to include in this category patients who
frequently seek and request cosmetic and surgical procedures.
The present study focuses on investigating the prodromal stagefor BDD (early symptoms), whereas the main target remains
the early identification of those individuals exposed to risk ofdeveloping BDD.
MATERIALS AND METHODS
The present study asserts that, even though some people
may not exhibit the necessary criteria for an official BDD diag35

nosis, there are still enough psychological features which, once
examined, could outline the so-called prodromal stage for BDD(with either specific or non-specific symptoms); also, by investigating these features one could decide if a certain individual iscurrently experiencing BDD onset, or is likely to develop BDD
in the near future. These objectives are consistent with current
research, focusing on identifying and defining the prodromal
stage for BDD, so as to provide treatment methods that prove
effective in preventing rather than in curing BDD and to support
less aggressive, non-invasive treatment procedures.
The subjects involved in the present study consisted of 60
persons, who were divided into two samples, as follows: theresearch sample consisted of 30 persons who willingly underwent
at least two cosmetic surgical interventions in the last 2 years
with the specific intention of fixing or improving their perceived
defect(s). All participants had their interventions in the same
private medical facility. All interventions which might have beencaused by accidents or occurred despite the patient’s will were
excluded from the study. The second sample, the so-called control sample, consisted also of 30 individuals who were selectedfollowing certain sample criteria, such as: gender, age, marital,and professional status.
All 60 subjects were submitted to the same procedure: they
were interviewed prior to the desired surgical intervention, as partof the mandatory psychiatric evaluation. Both samples had to fillout the following standard questionnaires: the Hamilton Anxiety
Rating Scale, the Beck Depression Inventory, and the Altered
Personality Questionnaire (H. Schmiescheck). Regardless whatsample they belonged to, all subjects had to fill out each of thequestionnaires.
RESULTS
1. Comparative sample analysis. Socio-demographic
features
Sample distribution according to gender proved to be symmetric, both samples consisting of 1 male and 29 female participant. The mean age of the control sample was 36.77 years (witha standard deviation of 12.32), while for the research sample themean age was 38.90 years (with a standard deviation of 13.64).
Comparative sample distribution is shown below:
Age category

Control sample
Subjects
no.

%Research sample
Subjects
no.

%<21 years old

1

3.33

1

3.33

21-30 years old

8

26.67

8

26.67

31- 40 years old

10

33.34

10

33.34

41-50 years old

4

13.33

4

13.33

51-60 years old

7

23.33

7

23.33

According to stratified sampling, the percent distribution ofage categories is the same in both the control and the researchsample.
36

Due to the fact that both the population mean and thestandard deviations are unknown variables, associated with theclinical nature of the research sample, and the construction of
the control sample using quote sampling, the Liliefors test had
to be used in order to estimate data variance. As a result thenormal distribution hypothesis proves false, thus requesting theuse of non-parametric tests for data analysis.
2. Clinical parameters analysis
Levels of anxiety, as measured with Hamilton Anxiety
Scale
The Hamilton Anxiety Scale consists of 14 items that quantify several anxiety related features, such as: anxious mood,fear, insomnia, cognitive symptoms, depression, various physical behaviours and symptoms, and muscular strain. Each item
is scored on a scale of 0-5 (0 = lack of symptoms, 5 – severe
and impairing symptoms). The scores range from 0 to 56, anyscore higher than 14 indicate clinically significant anxiety, dividing the remaining categories as follows: 14-17 for mild anxiety
levels, 18-24 for moderate anxiety levels, and 25-30 for severe
anxiety levels.
a) Case distribution in the research sample depending on
anxiety levels is shown below:
Anxiety level

Research sample

Subject Cumulative Percent(%)
no.
frequency
Minimal or no anxi- 24
2480.0
ety (score < 14)
Mild anxiety level 000.0(scores 14-17)
Moderate anxiety 529
16.7
level (scores 18-24)
Severe anxiety levels 130
3.3(scores 25-30)

Cumulative
percent (%)
80.0
80.0
96.7
100.0

Up to this point research data show that 20% of the subjects
included in the research sample exhibit moderate and severe
levels of anxiety.
b) Case distribution in the control sample depending on
anxiety levels is shown below:
Anxiety level

Control sample

Subjects Cumulative Percent(%)
no.
frequency
Minimal or no anxi- 24
2480.0
ety (score < 14)
Mild anxiety level 428
13.3(scores 14-17)
Moderate anxiety 230
6.7level (scores 18-24)
Severe anxiety levels 030
0.0(scores 25-30)

Cumulative
percent (%)
80.0
93.3
100.0
100.0

13.3% of the subjects in the control group exhibit mild
anxiety, while 6.7% report moderate anxiety; although clinicallysignificant severe anxiety has not been reported in any of the
Fiziologia - Physiology  2011.21.1 (69)

two samples, a significant percentage of subjects in the researchgroup exhibit moderate (16.7%) and severe levels of anxiety(3.3%), unlike subjects in the research sample who report much
lower levels of anxiety (6.7% - moderate anxiety) and severe
anxiety (0.0%).
By comparing the mean values between the two samples,
we get the following results which are shown below:

Comparison between mean gradient values of the two
samples - Beck Depression Inventory

Median Minimal Maximum Standard
Value
value
value
deviation
6.50
0.00
24.00
6.30

Control sample

Research sample 4.00

0.00

26.00

8.11

Thus, in spite of the small number of subjects in both
samples, subjects in the research sample tend to display moderate and severe anxiety in a greater proportion than the control
sample, keeping in mind that this is not the case of a normal
distribution of variables. We believe that by including more casesin the analysis we could get more significant results, concerning
differences between the two samples.
Results of the non-parametric Mann-Whitney U test are
as follows:
Sum of ranks
in the control
sampleSum of ranks
in the researchsample

880.0

950.0

U

Z

p-level415.00 -0.519 p=0.612>0.05(not significant)Sample differences are not statistically significant, showingthat all in all there are no notable differences between the two
samples concerning anxiety levels.
Levels of depression, as measured with Beck Depression
Inventory
The inventory contains 21 questions, each answer beingscored on a scale value of 0 to 3. The cutoffs used differ fromthe original: 0–13: minimal depression; 14–19: mild depression;
20–28: moderate depression; and 29–63: severe depression.
Higher total scores indicate more severe depressive symptoms.
Level categories are as follows:
0.5 – 1.2: Mild depression
1.2 – 2: Moderate depression
2 - 2.5: Severe depression
2.5 – 3: Severe depression, risk of suicide
The sample situation is as follows:
SampleMedianvalue

Minimum

MaximumStandard
deviation

Control sample

0.214

0.00

0.904

0.264

Research sample

0.524

0.00

1.38

0.450

Results show the fact that the mean value in the researchsample indicates mild levels of depression, unlike the absence
2011.21.1 (69)  Fiziologia - Physiology

0.6
mean
gradient
value

Sampleof depression in the control sample.
A chart showing these differences is shown below:

0.4

0.524

0.2
0

0.214

Lot de control
Lot de studiu

Valoarea medie scor
ponderat pe scala Beck

Samples

To determine whether the above mentioned differences
are of statistic significance, we used the non-parametric MannWhitney U test. Results are shown below:
Sum ofranks inthe control
sample1059.5Sum of ranks
in the researchsample770.5

UZ

p-level305.5 2.1425 p = 0 . 0 3 1 9 < 0 . 0 5(significant)

There is a statistically significant difference concerning depression between the two samples, namely general depression
level is higher in the research sample than in the control sample,
corresponding to a mild depression level (0.524).
3. Comparing frequencies of altered personality traits inthe two samples
Considering the particular way of scoring and interpreting
the Altered Personality Questionnaire, we compared frequencies
in the two samples, concerning the prevalence of all 10 personality types and their corresponding features.
Generally a particular personality feature is taken into consideration if subjects report at least 50% of its characteristics (oscore of 50% or more). Results are shown below:
Personality features

Research sample
Subjects no. %Control sample
S u b j e c ts %no.

I – Histrionic

15

50.0

16

53.3

II – Obsessive-compulsive

19

63.3

12

40.0

III – Paranoid

20

66.7

18

60.0

IV – Borderline

8

26.7

9

30.0

37

Personality features

Research sample
Subjects no. %Control sample
S u b j e c t s%no.

V – Manic

20

66.7

21

70.0

VI – Low mood

8

26.7

7

23.3

VII – Emotionally unstable

16

53.3

13

43.3

VIII – Elated

14

46.7

11

36.7

IX – Anxious

7

23.3

7

23.3

X - Emotional

25

83.3

23

76.7

Nonetheless, taken the following graph into account, allfeatures corresponding to these personality types are lessfrequent than those exhibited by research subjects, with the„manic” personality type as the sole exception.
The χ2 test does not show significant differences between
frequencies.
Frequency of altered personality features - comparing the research andcontrol sample

IX – ANXIOSSample profiles are shown below:

VII – CICLOTIM

Frequency of altered personality features in the researchsampleV – HIPERTIM

III – HIPERPERSEVERENTI – DEMONSTRATIV

Research sample

0

I - Histrionic

II - Obsessive-compulssive
10
15
20

III25- Paranoid

IV - Borderline

V - Manic

VI - Low moodVII - Emotionally unstable

VIII - Elated

IX - Anxious

05

X - Emotional

5

10

15

Research sample

20

25

30

Control sample

What the intensity level of each personality feature isconcerned, differences between the research and the control
sample are shown below:

Thus, in the research sample there is a prevalence of
personality traits corresponding to following personality types:
emotional (83.3%), paranoid and manic (66.7%), and obsessivecompulsive (63.3%). These are common features in 60% of thecontrol subjects.
Frequency of altered personality features in control sample

25
20
15
10
5
0

Control sample
I - Histrionic

II - Obsessive-compulssive

III - Paranoid

IV - Borderline

V - Manic

VI - Low moodVII - Emotionally unstable

VIII - Elated

IX - Anxious

X - Emotional

38

According to the scoring procedure of the questionnaire,the intensity of each personality feature is shown in percents.
Thus, what the research sample is concerned we have identified following features, related to several personality types,
such as : emotional, paranoid, and manic personality types ;subjects in the control study exhibit intense personality features regarding the emotional, manic, paranoid and histrionictypes.
Fiziologia - Physiology  2011.21.1 (69)Level of altered personality features - comparing the researchand control sample

90
80
70
60

58,3
54,2

58,3
41,7

50

81,2
75

68,7
62,5

66,6
58,3

62,5

50
43,7

50

50 50

37,537,5

40

37,537,5

30
20
10
-E
MO
TI
V
X

NX
IO
S
–A
IX

EX
AL
TA
T
VI
II –

CI
CL
OT
IM
VI
I–

M
IP
ER
TI

DI
ST
IM
IC
VI
–

–H
V

HI
PE
RE
XA
CT
IP
ER
PE
RS
EV
ER
EN
T
III

–H

II –

I–

DE

M
ON
ST
RA
TI
V

0

Research sample

Control sample

All in all, evidence in both samples show high intensityof features concerning obsessive-compulsive and paranoid
personality types (58.3% vs. 41.7%, and 66.6% vs. 58.3%), as
well as emotionally unstable and emotional types (62.5% vs.
50.0% vs. 81.2% vs. 75.0%); in addition to this, certain alteredpersonality features, corresponding to the obsessive-compulsive
and paranoid types prove more common for subjects in the
research sample than those in the control sample (63.3% vs.
40.0%, and 66.7% vs. 60.0%).
DISCUSSION
Following data analysis up to now, several conclusions canbe drawn, regarding the existence and possibility of identifying
certain characteristics (possibly risk factors) of the prodromal
stage of BDD.
Thus, the general level of distress involved in perceiving
one’s body image is to be understood from a clinical viewpoint
through higher anxiety and depression severity; although generally these values are not considered of clinical importance,
results show that sample subjects have reported significantly
higher levels than the general (control) population. Of thepatients who requested cosmetic and surgical intervention,
16.7% reported moderate anxiety, while 3.3% reported mild
levels of anxiety. What specific symptoms of depression areconcerned, the general depression level proved to be higher
in the research sample than the control sample, with the meanvalue in the research sample corresponding to a mild depression level. Thus, of the patients who repeatedly seek surgicalprocedures, 30% exhibit anxiety symptoms in a moderate
even severe degree; this fact can be seen as a consequenceof excessive preoccupations with physical appearance, oneof the diagnostic criteria of BDD. At the same time, there is amuch lower prevalence of depression symptoms, both in thecontrol and the research sample. These results are consistent
with previous research on the efficiency of surgical intervention in BDD: high anxiety levels in research patients, as well2011.21.1 (69)  Fiziologia - Physiology

as their recurrent need of surgical procedures suggest how
important concern with their physical appearance still is. This
could indicate a favorable onset for BDD.
In addition to this, the prevalence of certain personality
traits, such as obsessive-compulsive, paranoid and manic,
could be regarded as a risk factor in future development ofexcessive concerns regarding body image. In other words,
people who repeatedly requested surgical procedures exhibit certain personality features of obsessive-compulsive
nature, such as: conscientiousness, perfectionism, seriousness, drive for performance, lack of sociability, restrain fromhuman interaction; these features are similar to cluster B
obsessive-compulsive personality disorder, as it is describedby DSM-IV-TR (2) and ICD-10 (9). In addition to his, researchsubjects exhibit certain features related to the paranoid type(similar to cluster A paranoid personality disorder), such as:
susceptibility, distrust of others, sensitivity to real or imagined
offences, pride, drive for success and maintaining personalprestige, ambition, rigid life principles. Features corresponding to manic personality type generally consist of irritability,
unthoughtful acting, difficulty in maintaining the course ofaction; these features correspond either to emotionally unstable personality disorder (ICD-10) or to cluster B borderline
personality disorder (DSM-IV-TR).
As shown above, results are consistent with otherresearch findings on people with BDD, even if our samples
lack a consistent number of subjects, and our study variables
indicate the prevalence of certain aspects only at a sub-clinicallevel. In this case this preliminary study allows us to extend
our research and investigation, by adding a larger number ofparticipants, more complex evaluation measures, as well as
by sample diversification according to the nature of intervention (e.g. dermatologic treatment, fitness clubs, and cosmetic
procedures). Future research will be conducted according tothese findings.
REFERENCES

1. Cash TF, Pruzinsky T. Body Image. The Guilford Press, NewYork London, 2002.
2. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorder, 4th edition, Text Revision. APA Press,
Washington, D.C, 2000.
3. Phillips KA. The Broken Mirror. Oxford University Press, 2005.
4. Fontenelle LF, Telles LL, Nazar BP, Mendlowicz MV, Versiani M.
A socio-demographic, phenomenological and long-term study ofBrazilian Patients with Body Dysmorphic Disorder. Int J Psychiatry
Med, 2006; 36(2):243-59.
5. Gunstad J, Phillips KA. Axis I Comorbidity in Body Dysmorphic
Disorder. Comprehensive Psychiatry, 2003; 44:270-276.
6. Rahman M, Berenson AB. Self-Perception of Weight and Its
Association with Weight-Related Behaviors in Young, Reproductive-Aged Women. Obstetrics & Gynecology, December 2010;
116(6):1274-1280.
7. Archetti Conrado L, Hounie AG, Belo Diniz J, Fossaluza V. Body
dysmorphic disorder among dermatologic patients: Prevalence andclinical features. Journal of the American Academy of Dermatology,
2010; Volume 63, Issue 2:235-243.

39

8. Crerand A, Phillips KA. Does cosmetic surgery help body dysmorphic disorder?. ScienceDaily. Retrieved March 8, 2011.
9. WHO ICD-10. The ICD-10 Classification of Mental and Behav-

ioural Disorders: Clinical Descriptions and Diagnostic Guidelines.
Geneva: Word Health Organization; 1992.

CARACTERISTICI PSIHOLOGICE ŞI TRĂSĂTURI DE PERSONALITATE ÎNSTADIUL PRODROMAL AL TULBURĂRII DISMORFICE CORPORALEREZUMAT
Obiective: În acest studiu preliminar pe populaţie românească, autorii au investigat prevalenţa şi corelaţiile între anumite aspecte
psihologice şi trăsături de personalitate implicate în stadiul prodromal al tulburării dismorfice corporale. Metodă: Au fost analizate
nivelele de anxietate şi depresie, precum şi prevalenţa anumitor trăsături accentuate de personalitate, similare celor descrise la nivelul
tulburărilor de personalitate din DSM-IV-TR şi ICD-10. Studiul a utilizat Scala de Anxietate Hamilton, Inventarul de Depresie Beckşi Chestionarul pentru Personalităţi accentuate pentru a caracteriza lotul de studiu, alcătuit din 30 de pacienţi de chirurgie estetică
care au solicitat intervenţii repetate pentru a-şi corecta un presupus defect. Rezultate: Prezenţa posibilelor simptome prodromale
specifice dismorfiei corporale a fost asociată cu nivele uşoare respectiv moderate ale anxietăţii, respectiv cu simptome uşoare ale
depresiei. La nivelul lotului de studiu s-au înregistrat anumite trăsături accentuate de personalitate, corespondente tulburărilor depersonalitate obsesiv-compulsivă, paranoidă şi borderline. Concluzii: Rezultate studiului permit asocierea anumitor caracteristici
atribuite fazei prodromale a dismorfiei corporale cu indici de depresie şi anxietate la nivel subclinic. Aceste rezultate sunt similare cu
alte studii. Prevalenţa trăsăturilor de personalitate se încadrează pe direcţia cercetărilor anterioare, sugerând comorbiditatea tulburării
dismorfice corporale cu anumite tulburări de personalitate. Aceste concluzii permit efectuarea de cercetări viitoare cu scopul de ainstitui noi metode de tratament mai puţin invazive şi mai eficiente pentru pacienţii cu tulburare dismorfică corporală.
Cuvinte cheie: tulburare dismorfică corporală, fază prodromală, anxietate, depresie, personalitate accentuată, chirurgie estetică

40

Fiziologia - Physiology  2011.21.1 (69)