Cyclic-AMP dependent protein kinase A (PKA) regulates traffic of multiple proteins at different stages along the constitutive secretory pathway. PKA effects are regulated by protein phosphatases, which reverse the actions of PKA by dephosphorylation of PKA-substrates. Localization of specific PKA effects is mediated by the binding of A-kinase anchoring proteins (AKAPs). Apolipoprotein E (apoE) is an important regulator of lipid metabolism and atherosclerosis, and represents a large proportion of total protein constitutively secreted from macrophages. The signalling and trafficking pathways regulating secretion of apoE are unknown. Catalase is a peroxisomal enzyme which contributes to defence against hydrogen peroxide (H2O2). The primary hypothesis of this thesis is PKA and related protein phosphatase pathways are involved in the regulation of apoE secretion. The secondary hypothesis is that these pathways also regulate cellular clearance of H2O2. In Chapter Three, I have investigated the role of PKA in apoE secretion from primary human macrophages. Structurally distinct inhibitors of PKA (H89, KT5720, inhibitory peptide PKI14-22) all decreased basal secretion of apoE by between 50-80% whereas apoE mRNA or cellular protein are unaffected. Disruption of PKA-AKAP anchoring also significantly inhibited apoE secretion from human macrophages. Secretion of apoE was not immediately stimulated by PKA activity, suggesting that although PKA activity may be permissive for apoE secretion, it is in itself insufficient to stimulate apoE secretion above basal levels. Data from confocal microscopy and live cell imaging revealed PKA inhibition paralysed apoE vesicular movement from and to the plasma membrane. In Chapter Four, I investigated the effects of protein phosphatase 2B (PP2B) inhibition on apoE secretion by cyclosporin A (CsA). This was found to dose- and time-dependently inhibit secretion of apoE from primary human macrophages and increased cellular accumulation of apoE without affecting apoE mRNA levels. The role of PP2B in regulating apoE secretion was confirmed by using additional peptide and chemical inhibitors of PP2B. This effect was independent of the known inhibition of ABCA1 by CsA. Live cell imaging and confocal microscopy all demonstrated that inhibition of PP2B did not affect the apparent cellular distribution of apoE. Biochemical and microscopy studies indicated distinct mechanisms for PKA and PP2B regulation of apoE secretion. Chapter Five identified PKA-anchoring AKAPs in human macrophages, and investigated AKAP220 expression and its role in PKA-dependent processes relevant to atherosclerosis. AKAP220 protein was absent in human monocytes but was detectable after their differentiation into macrophages, with stable expression during late stages of maturation. It was also present in Chinese Hamster Ovary cells (CHO) cells. AKAP220 silencing had no effects on lipoprotein cholesteryl ester accumulation, total cellular apoE levels, apoE secretion or cholesterol efflux from human macrophages. Confocal microscopy in CHO cells revealed peroxisomal localisation of AKAP220. Catalase activity was confirmed to be PKA-regulated process, and AKAP220 was found to be a negative regulator of catalase activity, such that cell lysate catalase activity increased during AKAP220 silencing. AKAP220 silencing also decreased basal secretion of H2O2, detected using a sensitive and specific Amplex?? Red assay kit from intact CHO monolayers. In conclusion, this thesis has provided evidence that apoE secretion occurs via PKA- and PP2B-dependent pathways in human macrophages, and has identified the A-kinase anchoring protein AKAP220 as a regulator of cellular H2O2 clearance. These results will provide a basis for future investigations into the roles of PKA-related pathways in apoE secretion and catalase activity.

No description available.

La investigación se inscribe en el dominio de investigación de Didáctica de la Matemática y, en particular, del Pensamiento Matemático Avanzado, centrándose en el análisis de la comprensión del concepto de límite de una función. El marco teórico que fundamenta esta investigación es la teoría APOE y los elementos que lo configuran: las construcciones mentales y los mecanismos de las construcciones mentales, la descomposición genética, los niveles de desarrollo de un esquema y la tematización de un esquema. La investigación tiene por objetivos caracterizar los niveles de desarrollo del esquema de límite de una función, y analizar la influencia de los distintos modos de representación en la comprensión de la coordinación de los procesos de aproximación. Los participantes son estudiantes de bachillerato y del curso de nivelación en Ecuador (16 -18 años). Los resultados indican la influencia de los modos de representación en la coordinación de las aproximaciones en el dominio y el rango en la caracterización de los diferentes niveles de comprensión del concepto de límite de una función en un punto. En los resultados describimos las características de los esquemas INTER, INTRA y TRANS en términos de la coordinación de los diferentes tipos de aproximaciones, así como las características del esquema tematizado. Los resultados obtenidos se relacionan con el conocimiento proporcionado por otras investigaciones derivándose implicaciones para la enseñanza del concepto de límite en estos niveles educativos.

Every cell consists of carefully orchestrated biomolecules such as lipids, carbohydrates, and proteins. To maintain internal stability (homeostasis), cells maintain the right amount of these molecules at the right time and at the right place. This process is especially true for proteins since they are the foundation functional units within the cell. Proteins form structures and perform chemistry that bestows cells overarching functional roles. Cells maintain protein homeostasis (proteostasis) by modulating synthesis, folding, and degradation processes (turnover) to maintain the abundance levels for all proteins. This is the foundational kinetic model of proteostasis that is covered in this work, and it comprises protein abundance and turnover essential for protein homeostasis. When proteostasis is lost, cells may also fail to perform their internal cellular functions which will impact their external role. The sustained loss of proteostasis leads to disease. In the area of proteomics, we seek out the mechanisms of proteome change that result in the loss of normal proteostasis that are associated with disease states. As biochemists we explore the role of different proteins within biological systems and disease states. Predominantly, these studies involve isolating proteins (generally one at time) to measure abundance levels, function, and structure. In more recent years, technological advances in liquid chromatography and mass spectrometry (LC-MS) ushered in the golden age of proteomics. With LC-MS we can explore thousands of proteins in a single experiment to measure their expression levels. This work covers the fundamentals of this process as well as examples of LC-MS based proteomics for biomarker discovery and individual protein dynamics. In a sense, these experiments are like taking a snapshot of what proteins are found within a biological system at a given moment. However, cells are not static systems, rather they are dynamic systems in which proteins are being created and destroyed to maintain proteostasis. In this regard, LC-MS has recently become a powerful tool to explore protein turnover for thousands of proteins. Combined with protein abundance measurements, protein turnover yields a dynamic image of the internal state of the cell. This work applies the ideas within the kinetic model of proteostasis to explore the changes in protein homeostasis associated with Apolipoprotein E (ApoE) isoforms. ApoE isoforms are a genetic risk factor of ongoing research because of their role in disease and longevity. This work reviews some of the proposed mechanisms associated with ApoE genotype, and the LC-MS experiment we created to measure both proteome wide abundance and turnover changes associated with ApoE genotype. Our findings not only provide evidence that unifies previous ApoE studies, and it provides a benchmark for how to incorporate both quantitative and kinetic proteomics to monitor proteostasis.

Anti-inflammatory low-dose therapy is well established, whereas the immunomodulatory impact of doses below 0.1 Gy is much less clear. In this study, we investigated dose, dose rate and time-dependent effects in a dose range of 0.005 to 2 Gy on immune parameters after whole body irradiation (IR) using a pro-inflammatory (ApoE−/−) and a wild type mouse model. Long-term effects on spleen function (proliferation, monocyte expression) were analyzed 3 months, and short-term effects on immune plasma parameters (IL6, IL10, IL12p70, KC, MCP1, INFγ, TGFβ, fibrinogen, sICAM, sVCAM, sE-selectin/CD62) were analyzed 1, 7 and 28 days after Co60 γ-irradiation (IR) at low dose rate (LDR, 0.001 Gy/day) and at high dose rate (HDR). In vitro measurements of murine monocyte (WEHI-274.1) adhesion and cytokine release (KC, MCP1, IL6, TGFβ) after low-dose IR (150 kV X-ray unit) of murine endothelial cell (EC) lines (H5V, mlEND1, bEND3) supplement the data. RT-PCR revealed significant reduction of Ki67 and CD68 expression in the spleen of ApoE−/− mice after 0.025 to 2 Gy exposure at HDR, but only after 2 Gy at LDR. Plasma levels in wild type mice, showed non-linear time-dependent induction of proinflammatory cytokines and reduction of TGFβ at doses as low as 0.005 Gy at both dose rates, whereas sICAM and fibrinogen levels changed in a dose rate-specific manner. In ApoE−/− mice, levels of sICAM increased and fibrinogen decreased at both dose rates, whereas TGFβ increased mainly at HDR. Non-irradiated plasma samples revealed significant age-related enhancement of cytokines and adhesion molecules except for sICAM. In vitro data indicate that endothelial cells may contribute to systemic IR effects and confirm changes of adhesion properties suggested by altered sICAM plasma levels. The differential immunomodulatory effects shown here provide insights in inflammatory changes occurring at doses far below standard anti-inflammatory therapy and are of particular importance after diagnostic and chronic environmental exposures.

Made available in DSpace on 2016-01-26T12:51:43Z (GMT). No. of bitstreams: 1 sidneypinheirojunior_tese.pdf: 1185692 bytes, checksum: 2cae9b38515819abe487b6260ac74acc (MD5) Previous issue date: 2012-03-27 / Background Outstanding, among the factors associated to cholelithiasis after bariatric surgery, are those related to metabolism and synthesis of lipoproteins, such as apolipoprotein E (ApoE) and protein from cholesterol ester transfer protein (CETP). Methods - 220 patients have been part of the study, 114 (G1) with cholelithiasis postoperatively and 106 (G2) without cholelithiasis in over 8 months period, including the analysis of apoE-Hha I and CETP-TaqIB polymorphisms per PCR / RFLP and biochemical profile [total cholesterol (TC), lipoprotein cholesterol fraction of low (LDL), high (HDLc) and very low density (VLDLc), triglycerides (TG) and glucose levels. It was accepted level of significance for P <0.05. Results - Preoperatively, it was observed that in G1 54% of the patients with the APOE*4 allele had serum altered levels of LDL. Postoperatively, there was a decrease (P <0.001) of LDL with TG in G2 (85.3 ± 32.1 mg / dL, P <0.0001) and glucose (G1 = 83.2 ± 10.7 mg / dL; G2 = 84.7 ± 11.5 mg / dL, P <0.0001 for both), TC and LDL and HDL cholesterol increased only in G2 (P <0.0001). The B1 allele was related to decreased (P <0.01) of TC, LDLc and TG postoperatively in both groups, in addition to lowering glucose levels and increase HDL cholesterol only in G2 (P <0.0001). The genotype APOE*_/4 in G2 was associated with decreased levels of TC, LDL, TG and glucose levels and increased levels of HDL cholesterol (P<0.01) postoperatively. Conclusions - This study does not confirm the association of apoE-Hha-I and CETP-TaqIB with gallstones in the late postoperative period after bariatric surgery. However, B1 allele seems to enhance the action of bariatric surgery in the control of dyslipidemia effectively reducing levels of TC, LDL and TG, with additional benefit to those without gallstones by decreasing blood glucose levels and also increase HDL cholesterol. The relationship of APOE*4 with increased LDLc preoperatively only in G1 suggests its association with cholelithiasis in the late postoperative bariatric surgery, which should be evaluated in prospective studies. / Introdução- Destacam-se entre os fatores associados à colelitíase após cirurgia bariátrica, aqueles relacionados a metabolismo e síntese de lipoproteínas plasmáticas, como apolipoproteína E (apo E) e proteína de transferência do éster de colesterol (CETP). Objetivos-Avaliar a associação das variantes genéticas apoE-Hha I e CETP-TaqIB na colelitíase e sua influência no perfil bioquímico,além de perfil antropométrico e co-morbidades em pacientes com obesidade mórbida após cirurgia bariátrica. Métodos- Foram estudados 220 pacientes: 114 (G1) com colelitíase no pós-operatório e 106 (G2) sem colelitíase, em período >8 meses, incluindo a análise dos polimorfismos apoE-HhaI e CETP-TaqIB por PCR/RFLP e perfil bioquímico [colesterol total (CT), fração de colesterol de lipoproteína de baixa (LDLc), alta (HDLc) e muito baixa densidade (VLDLc), triglicérides (TG) e glicemia], além do índice de massa corporal (IMC), cintura abdominal (CA), hipertensão e diabete melito. Admitiu-se nível de significância para P<0,05. Resultados- Houve semelhança entre os grupos para os genótipos de apoE-HhaI e CETP-TaqIB. O genótipo APOE*3/3 prevaleceu em ambos os grupos (G1: 65% e G2:73%; P=0,204), enquanto genótipos APOE*_/4 destacaram-se em G1 (23% versus 16%; P=0,269). Para CETP o alelo B1 prevaleceu em G1 (0,59) e G2 (0,62; P=0,558). O perfil bioquímico, com valores recomendados já no pré-operatório em ambos os grupos, exceto para TG (141,4±75,4; 159,3±90,9mg/dL, respectivamente, P=0,123) e glicemia (113,0±53,2; 105,8±34,3mg/dL, respectivamente; P=0,262), mostrou decréscimo (P<0,001) no pós-operatório para todas as variáveis, incluindo TG (respectivamente, 89,0±34,6mg/dL; 85,3±32,1mg/dL; P<0,0001 para ambos) e glicemia (respectivamente, 83,2±10,7mg/dL; 84,7±11,5mg/dL; P<0,0001 para ambos). Níveis de HDLc mostraram acréscimo no pós-operatório apenas em G2 (52,5±14,7 versus 43,0±11,9; P<0,0001). Em G1, 54% dos pacientes portadores do alelo APOE*4 tinham níveis séricos alterados de LDLc no pré-operatório. O genótipo APOE*3/3, em G1, associou-se com decréscimo nos níveis de CT, LDLc, TG e glicemia e aumento nos níveis de HDLc (P<0,01). O mesmo ocorreu para genótipos APOE*_/4, em G2. O alelo B1 relacionou-se com decréscimo (P<0,01) de CT, LDLc e TG no pós-operatório em ambos os grupos, além de redução de glicemia e aumento de HDLc apenas em G2 (P<0,0001).Ambos os grupos mostraram redução nos valores de IMC e CA, além de hipertensão e diabete melito. Conclusões: Variantes de apoE-HhaI e CETP-TaqIB não diferenciam os grupos com e sem colelitíase no pós-operatório tardio de cirurgia bariátrica. Presença de APOE*4 relacionada com aumento de LDLc no pré-operatório, sugere sua influência no desenvolvimento de colelitíase no pós- operatório tardio, a ser confirmado em estudos prospectivos. CETP-Taq IB, representado pelo alelo B1 parece potencializar a ação da cirurgia bariátrica no controle do perfil bioquímico, particularmente em G2 com aumento de HDLc e decréscimo da glicemia. Além disso, independente da presença de colelitiase, a cirurgia bariátrica controla também doenças crônicas como diabete melito e hipertensão arterial.

A neuroimaging feature extraction model is designed to extract region-based image features whose values are predicted by base learners trained on raw neuroimaging morphological variables. The main objectives are to identify Alzheimer’s disease (AD) in its earliest manifestations, and be able to predict and gauge progression of the disease through the stages of mild cognitive impairment (EMCI), late MCI (LMCI) and AD. The model was evaluated on the ADNI database and showed 75.26% accuracy for the challenging EMCI diagnosis based on the 10-fold cross-validation. Our approach also performed well for the other binary classifications: EMCI vs. LMCI (72.3%), EMCI vs. AD (95%), LMCI vs. AD (84.3%), CN vs. LMCI (77.5%), and CN vs. AD (96.5%). By applying the model to the Genome-wide Association Study, along with the sparse Partial Least Squares regression method, we successfully detected risk genes such as the APOE, TOMM40, RVRL2 and APOC1 along with the new finding of rs917100. Moreover, the research aimed to investigate the relationship of different biomarkers; especially the imaging biomarkers to better understand the precise biologic changes that characterize Alzheimer’s disease. The unique and independent contribution of APOE4 allele status (E4+\E4-), amyloid (Aβ) load status (Amy+\Amy-) and combined APOE4 and Aβ status on regional cortical thickness (CTh) and cognition were evaluated via a series of two-way ANCOVAs with post-hoc Tukey HSD tests. Results showed that decreased CTh is independently associated with Amy+ status in many brain regions, but with E4+ status in very restricted number of brain regions. Among CN and EMCI participants, E4+ status is associated with increased CTh, in medial and inferior temporal regions. Diverging association patterns of global and regional Aβ load with cortical volume were found in the entorhinal, temporal pole and parahippocampal regions, which were positively associated with regional Aβ load, but with a negative correlation for global Aβ load in MCI stages. In addition, strong positive correlations were shown between baseline regional CTh and the difference of CTh in each region between the CN and AD, even after adjusting for the regional Aβ and APOE genotype (E4+: r = 0.521 and E4-: r = 0.694).

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Estudos demonstram a associação de alterações da apolipoproteína E (ApoE) e do receptor do LDL (RLDL) com a ocorrência de doenças cardiovasculares e dislipidemia. O objetivo principal deste trabalho foi investigar a associação entre genótipos diferenciais da ApoE e do RLDL com a persistência de alterações de variáveis lipídicas em indivíduos jovens acompanhados há 28 anos no Estudo do Rio de Janeiro (ERJ). Através de um estudo longitudinal, tipo coorte, investigou-se 56 indivíduos (35M) em três avaliações. Em A1 (13.301.53 anos), A2 (22.091.91 anos) e A3 (31.231.99). Nas três ocasiões foi realizada avaliação clínica. Em A2 e A3 foram dosados colesterol total, HDL, LDL e triglicerídeos. Em A3 acrescentou-se o estudo dos polimorfismos genéticos da ApoE e do RLDL. Os fragmentos de interesse neste estudo foram amplificados por PCR (polymerase chain reaction) e os genótipos foram identificados através de reações de restrição. As frequências genotípicas de ApoE foram &#949;3/&#949;3 (62,5%), &#949;3/&#949;4 (25%), &#949;2/&#949;3 (5,4%) ,&#949;2/&#949;4 (5,4%) e &#949;4/&#949;4 (1,8%) e para os genótipos de RLDL foram AA (85,7%), AT (12,5%) e TT (1,8%). O genótipo &#949;2/&#949;2 não foi observado. A análise da distribuição dos genótipos de ApoE segundo a permanência de dislipidemia mostrou que todos os indivíduos com genótipo de ApoE dos tipos &#949;2/&#949;4 e &#949;4/&#949;4 mantiveram pelo menos um lípide alterado em A2 e A3 entretanto, todos os indivíduos com genótipo de ApoE do tipo &#949;2/&#949;3 não apresentaram lípides alterados em A2 e A3. Para o genótipo do RLDL não houve diferença significativa. Quando analisadas isoladamente, não foi identificado nenhum resultado significativo em A2 e/ou A3 associado a estes genótipos. O polimorfismo do gene da ApoE esteve associado à permanência de dislipidemia em indivíduos jovens acompanhados em estudo de seguimento longitudinal / Studies have shown the association of changes in the apolipoprotein E (ApoE) and LDL receptor (LDLR) with the occurrence of cardiovascular diseases and dyslipidemia. The objective of this study was to investigate the association between different ApoE genotypes and LDLR with the persistence of changes in lipid variables in young individuals followed-up 28 years in the study of Rio de Janeiro (ERJ). Through a longitudinal study cohort, 56 subjects (35M) in A1(13.30 1.53 years), A2(22.09 1.91 years) and A3(31.23 1.99) were investigated. On all three occasions clinical evaluation was conducted. In A2 and A3: total cholesterol, HDL, LDL and triglycerides. In A3 was added to the study of genetic polymorphisms of the ApoE and LDLR. The fragments of interest in this study were amplified by PCR (polymerase chain reaction) and the genotypes were identified by reaction with the restriction enzyme HhaI and HaeIII for ApoE and LDLR polymorphisms, respectively. ApoE genotypes were identified as &#949;3/&#949;3 (62.5%), &#949;3/&#949;4 (25%), &#949;2/&#949;3 (5.4%), &#949;2/&#949;4 (5.4%) and &#949;4/&#949;4 (1.8%) and the LDLR genotypes identified as AA (85.7%), AT (12.5%) and TT (1.8%). &#949;2/&#949;2 genotype was not observed. The analysis of the distribution of ApoE and LDLR genotypes according to the permanence of the dyslipidemia in the study sample showed that all individuals with the ApoE genotype &#949;2/&#949;4 and &#949;4/&#949;4 kept at least one lipid changes in A2 and A3 and all individuals ApoE genotype &#949;2/&#949;3 had not altered lipids in A2 and A3, while for RLDL genotype no difference was found. When analyzed individually, no lipid variable altered in A2 and/or A3, associated with these genotypes, were found. The ApoE gene polymorphism was associated with the permanence of dyslipidemia in young individuals in a longitudinal follow-up study

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Estudos demonstram a associação de alterações da apolipoproteína E (ApoE) e do receptor do LDL (RLDL) com a ocorrência de doenças cardiovasculares e dislipidemia. O objetivo principal deste trabalho foi investigar a associação entre genótipos diferenciais da ApoE e do RLDL com a persistência de alterações de variáveis lipídicas em indivíduos jovens acompanhados há 28 anos no Estudo do Rio de Janeiro (ERJ). Através de um estudo longitudinal, tipo coorte, investigou-se 56 indivíduos (35M) em três avaliações. Em A1 (13.301.53 anos), A2 (22.091.91 anos) e A3 (31.231.99). Nas três ocasiões foi realizada avaliação clínica. Em A2 e A3 foram dosados colesterol total, HDL, LDL e triglicerídeos. Em A3 acrescentou-se o estudo dos polimorfismos genéticos da ApoE e do RLDL. Os fragmentos de interesse neste estudo foram amplificados por PCR (polymerase chain reaction) e os genótipos foram identificados através de reações de restrição. As frequências genotípicas de ApoE foram &#949;3/&#949;3 (62,5%), &#949;3/&#949;4 (25%), &#949;2/&#949;3 (5,4%) ,&#949;2/&#949;4 (5,4%) e &#949;4/&#949;4 (1,8%) e para os genótipos de RLDL foram AA (85,7%), AT (12,5%) e TT (1,8%). O genótipo &#949;2/&#949;2 não foi observado. A análise da distribuição dos genótipos de ApoE segundo a permanência de dislipidemia mostrou que todos os indivíduos com genótipo de ApoE dos tipos &#949;2/&#949;4 e &#949;4/&#949;4 mantiveram pelo menos um lípide alterado em A2 e A3 entretanto, todos os indivíduos com genótipo de ApoE do tipo &#949;2/&#949;3 não apresentaram lípides alterados em A2 e A3. Para o genótipo do RLDL não houve diferença significativa. Quando analisadas isoladamente, não foi identificado nenhum resultado significativo em A2 e/ou A3 associado a estes genótipos. O polimorfismo do gene da ApoE esteve associado à permanência de dislipidemia em indivíduos jovens acompanhados em estudo de seguimento longitudinal / Studies have shown the association of changes in the apolipoprotein E (ApoE) and LDL receptor (LDLR) with the occurrence of cardiovascular diseases and dyslipidemia. The objective of this study was to investigate the association between different ApoE genotypes and LDLR with the persistence of changes in lipid variables in young individuals followed-up 28 years in the study of Rio de Janeiro (ERJ). Through a longitudinal study cohort, 56 subjects (35M) in A1(13.30 1.53 years), A2(22.09 1.91 years) and A3(31.23 1.99) were investigated. On all three occasions clinical evaluation was conducted. In A2 and A3: total cholesterol, HDL, LDL and triglycerides. In A3 was added to the study of genetic polymorphisms of the ApoE and LDLR. The fragments of interest in this study were amplified by PCR (polymerase chain reaction) and the genotypes were identified by reaction with the restriction enzyme HhaI and HaeIII for ApoE and LDLR polymorphisms, respectively. ApoE genotypes were identified as &#949;3/&#949;3 (62.5%), &#949;3/&#949;4 (25%), &#949;2/&#949;3 (5.4%), &#949;2/&#949;4 (5.4%) and &#949;4/&#949;4 (1.8%) and the LDLR genotypes identified as AA (85.7%), AT (12.5%) and TT (1.8%). &#949;2/&#949;2 genotype was not observed. The analysis of the distribution of ApoE and LDLR genotypes according to the permanence of the dyslipidemia in the study sample showed that all individuals with the ApoE genotype &#949;2/&#949;4 and &#949;4/&#949;4 kept at least one lipid changes in A2 and A3 and all individuals ApoE genotype &#949;2/&#949;3 had not altered lipids in A2 and A3, while for RLDL genotype no difference was found. When analyzed individually, no lipid variable altered in A2 and/or A3, associated with these genotypes, were found. The ApoE gene polymorphism was associated with the permanence of dyslipidemia in young individuals in a longitudinal follow-up study

No description available.