Association between socioeconomic status and hospitalisation requirement in older patients attended at the emergency department: A retrospective cohort study

INTRODUCTION AND OBJECTIVE

A low socioeconomic status (SES) has been associated with poor health results. The present study aimed to investigate if SES of older patients attending the emergency department is associated with the use of healthcare resources and outcomes.

PATIENTS AND METHODS

Observational, retrospective study including consecutive patients 65 years or older admitted to the emergency department. Variables at baseline, index episode, and follow-up were recorded. SES was measured using an indirect theoretical index and patients were categorised into two groups according to whether they lived in a neighbourhood with a low or high SES. Primary outcomes included hospitalisation after the emergency department visit and prolonged hospitalisation (>7 days) at index episode. Secondary outcomes included emergency department re-consultant and hospital admission in the following 3 months after the index episode, and all-cause mortality after long-term follow-up. Logistic regression and cumulative hazards regression models were used to investigate associations between SES and outcomes.

RESULTS

The cohort included 553 patients (80 years [73-85], 50.5% female, 55.9% with low SES). After the emergency department visit, 234 patients (42.3%) required hospital admission. A low SES was inversely associated with hospitalisation with an adjusted odds ratio=0.654 (95% CI 0.441-0.970). Among hospitalised patients, a low SES was associated with prolonged hospitalisation (adjusted odds ratio=2.739; 95% CI 1.470-5.104). Follow-up outcomes, including all-cause mortality, were not associated with SES.

CONCLUSIONS

Older patients living in more deprived urban areas were hospitalised less often after emergency department care, but hospital stays were longer. Understanding the effect of social determinants in healthcare use is mandatory to tailor resources to patient needs.

Proximal determinants of suboptimal early child development during the first three years of life in socially deprived Mexican contexts

Assessing the status and determinants of early child development (ECD) requires accurate and regularly updated measurements. Yet, little information has been published on the subject in low- and middle-income countries, particularly regarding the proximal determinants of childhood development in contexts of high social marginalization. This article analyzes the factors that favor or mitigate suboptimal ECD outcomes in Mexico. A cross-sectional study was conducted using recently collected data for 918 children aged 0-38 months from socially marginalized communities in 23 Mexican municipalities. The ECD outcomes of the children were estimated based on indicators of chronic undernutrition and neurodevelopment (normal, lagging and at risk of delay). The distribution of outcomes was described across the ECD proximal determinants analyzed, including the co-occurrence of chronic undernutrition and suboptimal neurodevelopment. Covariate-adjusted prevalence of the ECD outcomes and co-occurrences were calculated as post-estimations from a multiple multinomial logistic regression. The prevalence of chronic undernutrition was 23.5%; 45.9% of children were classified with neurodevelopmental lag, and 11% at risk of neurodevelopmental delay. The prevalence of stunting co-occurring with suboptimal neurodevelopment came to 15.4%. The results of the multinomial logistic regression model indicated that early gestational age, low birth weight, a low household socioeconomic level, being male and having numerous siblings were all associated with the co-occurrence of chronic undernutrition and suboptimal child neurodevelopment. This study identified important predictors of child development in the first three years of life, specifically in two of its principal indicators: nutritional and neurodevelopmental status. Most of the predictors observed can be improved by means of social programs and interventions. Trial registration: ClinicalTrials.gov ID: NCT04210362.

Discrepancies in infant feeding recommendations between grandmothers and healthcare providers in rural Mexico

BACKGROUND

Infant feeding practices are rapidly changing within rural areas in Mexico, including indigenous communities. The aim of this study was to compare infant feeding recommendations between grandmothers and healthcare providers, to better understand the factors that may influence these practices within these communities. This study builds on research that recognizes the legacy of colonization as an ongoing process that impacts the lives of people through many pathways, including the substandard healthcare systems available to them.

METHODS

Qualitative study based on secondary data analysis from interviews and focus groups guided by a socioecological framework conducted in 2018 in two rural, Indigenous communities in Central Mexico. Participants were purposively selected mothers (n = 25), grandmothers (n = 11), and healthcare providers (n = 24) who offered care to children up to two years of age and/or their mothers. Data were coded and thematically analyzed to contrast the different perspectives of infant feeding recommendations and practices between mother, grandmothers, and healthcare providers.

RESULTS

Grandmothers and healthcare providers differed in their beliefs regarding appropriate timing to introduce non-milk foods and duration of breastfeeding. Compared to grandmothers, healthcare providers tended to believe that their recommendations were superior to those from people in the communities and expressed stereotypes reflected in negative attitudes towards mothers who did not follow their recommendations. Grandmothers often passed down advice from previous generations and their own experiences with infant feeding but were also open to learning from healthcare providers through government programs and sharing their knowledge with their daughters and other women. Given the contradictory recommendations from grandmothers and healthcare providers, mothers often were unsure which advice to follow.

CONCLUSIONS

There are important differences between grandmothers and healthcare providers regarding infant feeding recommendations. Healthcare providers may perceive their recommendations as superior given the neocolonial structures of the medical system. Public health policies are needed to address the different recommendations mothers receive from different sources, by harmonizing them and following an evidence-informed approach. Breastfeeding programs need to value and to seek the participation of grandmothers.

A variant in GRN of Spanish origin presenting with heterogeneous phenotypes

INTRODUCTION

The variant c.1414-1G>T in the GRN gene has previously been reported as probably pathogenic in subjects of Hispanic origin in the American continent.

METHODS

We report 5 families of Spanish origin carrying this variant, including the clinical, neuroimaging, and laboratory findings.

RESULTS

Phenotypes were strikingly different, including cases presenting with behavioral variant frontotemporal dementia, semantic variant primary progressive aphasia, rapidly progressive motor neuron disease (pathologically documented), and tremor-dominant parkinsonism. Retinal degeneration has been found in homozygous carriers only. Ex vivo splicing assays confirmed that the mutation c.1414-1G>T affects the splicing of the exon, causing a loss of 20 amino acids in exon 11.

CONCLUSIONS

We conclude that variant c.1414-1G>T of the GRN gene is pathogenic, can lead to a variety of clinical presentations and to gene dosage effect, and probably has a Spanish founder effect.

Predictors of maternal knowledge on early childhood development in highly marginalized communities in Mexico: Implications for public policy

INTRODUCTION

Efforts to identify the predictors of maternal knowledge on Early Child Development (ECD) have proven inconclusive thus far, particularly with respect to socially deprived contexts in Low- and Middle-Income Countries (LMICs). We quantified the extent of ECD knowledge among mothers who were the primary caregivers of 0-38-month-old infants in marginalized communities in Mexico. We also explored the characteristics of the children, both individually and with regard to their households, given the influence of these factors on childhood development.

METHODS

We analyzed primary data obtained through a questionnaire administered to mothers who were the primary caregivers of 1045 girls and boys 0-38 months of age. The instrument was specifically designed for our study in order to explore the knowledge of participants about physical, neurological and psycho-affective development during childhood. We performed fractional regression analysis to assess the predictors of ECD knowledge.

RESULTS

The mean score of maternal ECD knowledge increased with their age and schooling as well as with their levels of cognitive ability and self-esteem. Irrespective of age at first birth, mean knowledge was relatively high for women with high school education and low for women with elementary or no formal education, a gradient with respect to age at fist birth was more marked among women with middle school education. ECD knowledge scores increased among mothers from households enjoying higher socioeconomic levels and from households with health insurance. Scores were lower for indigenous households regardless of their participation in social programs.

CONCLUSION

Public policies on ECD should promote programs that are not only adapted to specific contexts, but also designed to improve shared child-rearing, early childhood care and as well as psycho-emotional education skills as a pathway to healthier ECD. The participation of families and communities in sensitive childhood care should form part of multisectoral programs involving education, health and wellbeing.

Early neurological development and nutritional status in Mexican socially deprived contexts

Early childhood development (ECD) is a critical stage in the intergenerational process of human development. Targeted interventions depend on accurate and up-to-date ECD measurements. This paper presents estimates for the nutritional and neurodevelopmental status of socially marginalized children in Mexico. We performed a cross-sectional study based on data collected in 2019-2020 during home visits to 1,176 children aged 0-38 months across 24 highly marginalized locations in Oaxaca. We assessed nutritional status according to the World Health Organization 2006 child-growth standards and ECD status using the Child Development Evaluation Test, 2nd Edition. We stratified results by sex. Prevalence of stunting was 5.3 percentage points (p.p.) higher (p = 0.023) in males (25.3%; 95% CI: 20.2%, 31.1%) compared to females (20.0%; 95% CI: 15.0%, 26.1%). Overall prevalence rates stood at 5.7% (95% CI: 4.0%, 8.1%) for underweight, 1.5% (95% CI: 0.9%, 2.7%) for wasting and 3.6% (95% CI: 2.3%, 5.7%) for overweight/obesity, with no significant differences by sex. Prevalence of normal development was 8.3 p.p. lower (p = 0.001) in males (39.3%; 95% CI: 34.5%, 44.4%) compared to females (47.6%; 95% CI: 41.6%, 53.6%). By development area, the highest prevalence of suboptimal outcomes among children with developmental lag or at risk of delay was observed in their gross motor and language skills: 24.1% (95% CI: 20.0%, 28.8%) and 38.6% (95% CI: 34.0%, 43.3%), respectively. The largest difference between the sexes was found in the language area. Our results show that childhood development strategies have been insufficient thus far in the studied population. Programs specifically designed to prevent ECD lags and bridge inequality gaps are urgently needed. Trial registration: ClinicalTrials.gov ID: NCT04210362.

POS0270 DEVELOPMENT OF AORTIC ANEURYSM/DILATATION IN A PROSPECTIVE COHORT OF PATIENTS WITH BIOPSY-PROVEN GIANT-CELL ARTERITIS: EARLY IDENTIFICATION OF PATIENTS AT RISK

Background

Up to 10-33% of patients with giant-cell arteritis (GCA) develop aortic structural damage (ASD) (aneurysm or dilatation), typically involving the ascending aorta (1,2). Systematic use of imaging reveals radiological features of aortitis in 45-65% of patients at diagnosis (3). This finding has been associated with future aortic dilatation in retrospective studies (4).

Objectives

To investigate the prevalence of thoracic ASD in a large prospective cohort of patients with GCA subjected to periodic imaging. To evaluate the association between features at diagnosis with ASD development.

Methods

Patients were included in the study if consented, had biopsy-proven GCA and met the 1990 ACR criteria for GCA classification. Patients were prospectively followed and treated according to uniform criteria. Since 1995 patients were subjected to systematic imaging screening aimed to detect thoracic ASD. Until November 2006 it consisted of a chest X-ray that was performed at least 4 years after diagnosis and repeated every 4 years. When aortic dilatation was minimally suspected, patients underwent contrast-enhanced computed tomography (CT) scan. Since November 2006, most of patients were prospectively studied with CT angiography at diagnosis, after 1 year and every 4 years.

The diagnosis of ASD was confirmed by CT, defined as an aortic diameter > 4 cm at the ascending aorta or ≥4 cm at the aortic arch or the descending aorta.

Data regarding demographic characteristics, cardiovascular risk factors, GCA symptoms, laboratory tests, chronic medication at time of GCA diagnosis and corticosteroid tapering were recorded.

Kaplan-Meier survival plot was used to present the cumulated incidence of thoracic ASD over time and patients were censored at the time of ASD diagnosis or at the time of the last screening in those without ASD.

We also investigated which variables present at the time of GCA-diagnosis were associated with future development of ASD. Patients were classified in two groups according to whether they developed ASD or not during a follow-up period of 8 ± 1 years from the time of diagnosis.

Results

Thoracic ASD was confirmed by CT in 58 patients (21.6% of the patients with systematic screening diagnosed from 1994 to 2018) after a median follow-up of 4.7 years (0.05-7.5). Ascending aorta was involved in 56 patients (96.5%), followed by the aortic arch in 11 patients (18.9%), and descending aorta in 5 (8.6%). 14 patients (24.1%) had more than 1 aortic segment involved. Figure 1 shows the number of patients with thoracic ASD detected during follow-up.

Figure 1.

Thoracic ASD was detected within the first 4 years from GCA-diagnosis in 19 out of the 58 patients who developed ASD (32.7%) but was severe (≥ 50 mm) in only 3 (15.8% out of those 19 patients). Most ASD was detected between 5 and 9 years after GCA-diagnosis.

Patients who developed ASD during follow-up experienced less often cranial ischemic symptoms (14.8% vs 41.1%; p=0.003) or polymyalgia (33.3% vs 51.8%; p=0.057), and less frequently had a previous diagnosis of hypertension (66.7% vs 82.1%; p=0.081). Age, sex, clinical or laboratory findings or chronic therapies used at time of GCA-diagnosis were not significantly different between groups.

After multivariate analysis, the presence of cranial ischemic symptoms (HR 0.180, 95% CI 0.065-0.495, p=0.001) and polymyalgia rheumatica (HR 0.329, 95% CI 0.136-0.793, p=0.013) remained inversely associated with thoracic ASD development.

Conclusion

ASD is frequent and probably an underdiagnosed complication of GCA. There is no consensus yet regarding the optimal screening protocol during follow-up and early identification of patients at risk is crucial for this purpose. The presence of cranial ischemic symptoms or polymyalgia rheumatica were inversely associated with thoracic ASD development in our prospective cohort.

References

[1]García-Martínez A et al. Ann Rheum Dis 2014.

[2]Evans JM et al. Ann Intern Med 1995.

[3]Prieto-González S et al. Ann Rheum Dis 2012.

[4]Blockmans D et al. Rheumatology (Oxford) 2008.

Acknowledgements

Both first co-authors contributted equally to this work.

The research was supported MTV3 2014/20150730

Disclosure of Interests

None declared

A behavioral economics analysis of the participation in early childhood development social programs promoted by civil societies in Mexico

Based on a behavioral economics (BE) approach, we analyzed the decision to participate in an early childhood development (ECD) program implemented in Mexico by a non-governmental organization. We conducted a literature review and a qualitative study of four localities participating in the ECD program. Situated in the state of Oaxaca, these communities are characterized by high and very high levels of social marginalization. From May 20 to 30, 2019, we collected primary data through semi-structured interviews (n = 30) and focus groups (n = 7) with a total of 61 informants (51 women and 10 men). We then performed an inductive systematic analysis of the data to identify documented cognitive bias associated with the decisions of individuals to participate and remain in or abandon social programs. The interviewees were living in conditions of poverty, facing difficulties in meeting even their most basic needs including food. Program participants attached far greater weight to incentives such as the basic food basket than to the other benefits offered by the program. The four localities visited maintained traditional views of domestic roles and practices, particularly regarding child-rearing, where women were in charge of childcare, home care and food preparation. Problems linked to child malnutrition were a decisive factor in the decision of residents to participate and remain in the program. Testimonials gathered during the study demonstrated that the longer the mothers remained in the program, the more they understood and adopted the concepts promoted by the interventions. In contexts marked by economic vulnerability, it is essential that ECD programs create the necessary conditions for maximizing the benefits they offer. Our analysis suggests that cognitive load and present bias were the biases that most severely affected the decision-making capacity of beneficiaries. Therefore, considering loss aversion and improving the management of incentives can help policymakers design actions that "nudge" people into making the kinds of decisions that contribute to their well-being.

Assessing the effect of an educational intervention on early childhood development among Mexican preschool children in the state of Oaxaca: a study protocol of a cluster randomized stepped-wedge trial

Background

Early childhood development (ECD) is essential in human capacity building and a critical element in the intergenerational process of human development. In some countries, social programs targeted at improving ECD have proven to be successful. Oaxaca is one of the States with the greatest social inequities in Mexico. Therefore, children in Oaxaca are at a high risk of suboptimal ECD. In 2014, the non-governmental organization (NGO) Un Kilo de Ayuda started to implement the Neurological and Psycho-affective Early Childhood Development Program in eighty marginalized communities of Oaxaca. In this article, we present the impact evaluation design to estimate the effect of this program on ECD.

Methods

We will use a cluster randomized stepped-wedge design with an allocation ratio of 1:1. Communities will be randomly assigned to each study group: four groups of twenty communities each. We expect that children from intervened communities will show better ECD outcomes.

Discussion

This study is one of the few rigorous assessments of the effect of an ECD program on the neurodevelopment of Mexican children recruited in their first 3 years of life from communities of high social vulnerability. Our study design is recommended when the way in which outcomes are measured and assessed depends on age, self-selection is present, and assignment is performed at an aggregate level. Implementation research will be conducted prior to study launch and quality control measures will be in place to maximize the fidelity of study design implementation.

Trial registration

ClinicalTrials.gov NCT04210362

The silent variants of pituitary tumors: demographic, radiological and molecular characteristics

INTRODUCTION

Tumors of the anterior pituitary gland (PTs) are mostly benign tumors with a low prevalence, which has nevertheless increased with advances in brain radiology techniques. Nearly half of PTs are not associated with a clinical endocrine syndrome. These tumors have been indistinctly named non-functioning pituitary adenomas (NFPAs) or silent pituitary tumors (SPTs) and the mechanisms of silencing are not fully known.

AIM

To study the frequency and characterize the silent variant of PTs in a large local series, and to assess their pituitary adenohypophyseal gene expression.

METHODS

This observational, cross-sectional study was performed in a Pituitary Tumor Center of Excellence and involved 268 PTs. After identifying the different subtypes according to the immunohistochemical (IHC) expression of adenohypophyseal hormones, we studied their gene expression by RT-qPCR.

RESULTS

We found that silent tumors were larger and more invasive, but not more proliferative than their functional counterparts. The RT-qPCR complements the IHC typification of PTs, reducing the proportion of null-cell subtype. Finally, some silent PT subtype variants showed lower specific adenohypophyseal hormone gene expression than their functional counterparts, which may contribute to the absence of endocrine manifestations.

CONCLUSIONS

This paper highlights the importance of identifying the silent variant of the PTs subtypes. As expected, silent tumors were larger and more invasive than their functioning counterparts. However, there was no difference in the proliferation activity between them. Finally, the lower specific gene expression in the silent than in the functioning counterparts of some PTs subtypes gives insights into the silencing mechanisms of PTs.

Is Somatostatin Receptor and Dopamine Receptor profiling useful in the management of silent somatotroph tumors?

Silent somatotroph tumors (sSTs) are pituitary neuroendocrine tumors (PitNETs) which do not give rise to the clinical syndrome of acromegaly. Differently to their functioning counterparts, the adjuvant medical treatment with somatostatin analogues (SSAs) or dopamine receptors agonists (DAs) has been scarcely addressed in these tumors. As preliminary results of an ongoing research on silencing mechanisms involved in the pathogenesis of sSTs, we have characterized by qRT-PCR the expression of SSTRs and DRDs in a large series of 18 silent and 68 functioning STs. Although the expression of SSTR2 and SSTR5 was lower in sSTs than in functioning ones, we found a negative correlation between SSTR2 and the tumor size of the sSTs. Additionally, levels of expression of DRD2 were similar between the two subtypes suggesting a possible basis for the treatment of these tumors with SSAs and DAs.

Eficiencia técnica en sistemas de producción con bovinos de doble propósito

El sistema de producción con bovinos de doble propósito (SPDP) ha sido desarrollado en las zonas tropicales, caracterizado por bajos niveles de eficiencia, aspecto que requiere del análisis de los factores que la afectan. En el presente estudio se analizó la eficiencia técnica (ET) en 271 unidades de producción ubicadas en el estado Zulia, Venezuela, empleando una función de producción de frontera estocástica. Se utilizó como output los ingresos totales ($), y los inputs superficie (ha), unidades animales (UA), unidad trabajo hombre (UTH), y los costos totales ($). Se obtuvo un valor medio de eficiencia técnica de 66,63 %, con un rango de 19,74 a 99,62, lo que indica que existe un amplio margen de mejora. En el modelo de ineficiencia las variables carga animal (UA/ha), y los litros de leche por hectárea (L/ha) fueron significativas, el coeficiente presentó un signo positivo para la carga animal, lo que quiere decir que en la medida que aumenta este parámetro las explotaciones incrementan su ineficiencia, mientras que para los L/ha ocurrió lo contrario. Con base en estos resultados, se plantea la necesidad de determinar el efecto que ejercen las tecnologías de gestión del pastoreo sobre la ET, esto permitiría promover estrategias de manejo que tiendan a optimizar el uso del recurso forrajero, y de esta forma alcanzar mejores niveles de ET en los SPDP.

Why don't corticotroph tumors always produce Cushing's disease?

OBJECTIVE

Silent corticotroph tumors are a pituitary neuroendocrine tumor subtype of corticotroph lineage that do not clinically express Cushing's disease. The silencing of this type of tumor is not fully understood. The aim of the present study was to delve into the lack of secretory activity, studying the post-transcriptional and post-translational regulation of POMC/ACTH in a series of molecularly identified functioning and silent corticotroph tumors.

DESIGN

We analyzed 24 silent corticotroph, 23 functioning corticotroph and 25 silent gonadotroph tumors.

METHODS

We used Sanger sequencing, quantitative real-time PCR and Western blot to analyze genetic alterations in POMC, gene expression of TBX19, NEUROD1, POMC, PCSK1, PCSK2, CPE and PAM and protein expression of POMC, PC1/3, PC2, CPE and PAM.

RESULTS

We found different polymorphisms in the POMC gene of corticotroph tumors, some of them related to deficiency of proopiomelanocortin. Silent corticotroph tumors showed lower PC1/3 gene and protein expression than functioning ones, especially compared to micro-functioning corticotroph tumors (all P < 0.05). Moreover, we found a positive correlation between PC2 and CPE gene and protein expression (rho ≥ 0.670, P < 0.009) in silent corticotroph tumors compared with functioning ones.

CONCLUSIONS

By studying the post-transcriptional and post-translational processing of POMC and ACTH, respectively, in a large series of silent and functioning corticotroph tumors, we found that the lack of secretory activity of these tumors is related to an impaired processing of POMC and a high degradation of ACTH, with the macro-functioning corticotroph tumor behaving as an intermediate state between micro-functioning and silent corticotroph tumors.

Replacement of lucerne by Enterolobium cyclocarpum leaves in the diet of growing goats

Animal production in tropical regions is commonly limited by the low crude protein content and digestibility of pastures, particularly during the dry season. The objective of the present study was to evaluate the effect of including Enterolobium cyclocarpum leaves (ECL) (0%, 15% and 30%) in diets as a partial replacement for lucerne on dry-matter intake (DMI), weight gain and nitrogen (N) balance in growing Saanen goats (12.6 ± 3.2 kg at 3 months of age) and the digestibility of the diet. Daily weight gain, DMI and digestibility were analysed in a 3 × 3 Latin square design replicated three times. The inclusion of ECL did not affect daily weight gain or DMI (P &gt; 0.05). There were no significant (P &gt; 0.05) differences for N intake among the diets, but the inclusion of 30% ECL significantly (P = 0.01) increased N excreted in faeces. These results suggest that ECL can be used as a partial substitute of lucerne in diets for growing goats, without affecting animal performance.

Arsenic methylation capacity in relation to nutrient intake and genetic polymorphisms in one-carbon metabolism

BACKGROUND

Nutrients and genetic polymorphisms participating in one-carbon metabolism may explain interindividual differences in inorganic arsenic (iAs) methylation capacity, which in turn may account for variations in susceptibility to iAs-induced diseases.

OBJECTIVES

1) To evaluate the association between polymorphisms in five one-carbon metabolism genes (FOLH1 c.223 T > C, MTHFD1 c.1958 G > A, MTHFR c.665 C > T, MTR c.2756 A > G, and MTRR c.66 A > G) and iAs methylation capacity; 2) To assess if previously reported associations between nutrient intake and iAs methylation capacity are modified by those polymorphisms.

METHODS

Women (n = 1027) exposed to iAs in Northern Mexico were interviewed. Blood and urine samples were collected. Nutrient dietary intake was estimated using a validated food frequency questionnaire. iAs methylation capacity was calculated from urinary iAs species (iAs, monomethylarsonic acid [MMA] and dimethylarsinic acid [DMA]) measured by high performance liquid chromatography (HPLC-ICP-MS). One polymorphism in each of the five genes evaluated was genotyped by allelic discrimination. Multivariable linear regression models were used to evaluate if genetic polymorphisms modified the associations between iAs methylation capacity parameters and nutrient intake.

RESULTS

The median (min-max) concentration of total arsenic (TAs) was 20.2 (1.3-2776.0) µg/g creatinine in the study population. Significant interactions for iAs metabolism were only found with FOLH1 c.223 T > C polymorphism and vitamin B12 intake, so that CT and CC genotype carriers had significantly lower %iAs, and higher DMA/iAs with an increased vitamin B12 intake, as compared to carriers of wild-type TT.

CONCLUSION

Differences in dietary nutrient intake and genetic variants in one-carbon metabolism may jointly influence iAs methylation capacity. Confirmation of these interactions in other populations is warranted.

Phthalate exposure, flavonoid consumption and breast cancer risk among Mexican women

OBJECTIVE

To evaluate if selected phthalate exposure and flavonoid intake interact on breast cancer (BC) risk.

MATERIAL AND METHODS

Interviews and urine samples were obtained from 233 women with histologically confirmed BC and 221 healthy controls matched by age and place of residence, from various states of northern Mexico. Urinary metabolites concentrations of diethyl phthalate (DEP), butyl benzyl phthalate (BBzP) and dioctyl phthalate (DOP) were determined by solid-phase extraction coupled with high-performance liquid chromatography/isotope dilution/tandem mass spectrometry. Using a semiquantitative food frequency questionnaire, consumption of five types of flavonoids (anthocyanidins, flavan-3-ols, flavanones, flavones and flavonols) was estimated according to three food groups: vegetables, fruits and legumes-oil seeds.

RESULTS

A higher intake of anthocyanidins and flavan-3-ols (from vegetables), synergistically increased the negative association between BBzP and BC. No other significant flavonoid-phthalate multiplicative interactions on the risk for BC were found.

CONCLUSION

The consumption of some flavonoids may interact with exposure to phthalates on the risk of BC. Epidemiological and underlying mechanisms information is still insufficient and requires further investigations.

Increased expression of the endothelin system in arterial lesions from patients with giant-cell arteritis: association between elevated plasma endothelin levels and the development of ischaemic events

Objective:

Approximately 15–20% of patients with giant-cell arteritis (GCA) develop ischaemic complications often preceded by transient ischaemia. The expression of the endothelin (ET) system in GCA lesions was investigated to assess its relationship with the development of ischaemic complications.

Methods:

Plasma ET-1 was quantified by immunoassay in 61 patients with biopsy-confirmed GCA and 16 healthy donors. ET-1, endothelin-converting enzyme (ECE-1) and endothelin receptor (ETAR and ETBR) messenger RNA were measured by real-time quantitative reverse transcriptase–PCR in temporal arteries from 35 of these patients and 19 control arteries. Proteins were measured by immunoassay and Western blot.

Results:

ET-1 concentration was increased at the protein level in temporal artery samples from GCA patients compared with controls (0.98 (SEM 0.32) vs 0.28 (SEM 0.098) fmol/mg, p = 0.028). ECE-1, ETAR and ETBR/actin ratios (Western blot) were also significantly higher in GCA patients. Intriguingly, mRNA expression of ET-1, ECE-1 and both receptors was significantly reduced in GCA lesions compared with control arteries. When investigating mechanisms underlying these results, platelet-derived growth factor and IL-1β, present in GCA lesions, were found to downregulate ET-1 mRNA in cultured human temporal artery-derived smooth muscle cells. Glucocorticoid treatment for 8 days did not result in significantly decreased endothelin tissue concentration (0.87 (SEM 0.2) vs 0.52 (SEM 0.08); p = 0.6). Plasma endothelin concentrations were higher in patients with ischaemic complications (1.049 (SEM 0.48) vs 1.205 (SEM 0.63) pg/ml, p = 0.032).

Conclusions:

The endothelin system is increased at the protein level in GCA lesions creating a microenvironment prone to the development of ischaemic complications. Recovery induced by glucocorticoids is delayed, indicating persistent exposure to endothelin during initial treatment.

Imatinib mesylate inhibits in vitro and ex vivo biological responses related to vascular occlusion in giant cell arteritis

OBJECTIVES

Ischaemic complications occur in 15-20% of patients with giant cell arteritis (GCA). The aim of our study was to explore the effect of mesenchymal growth factors expressed in GCA lesions on myointimal cell responses related to the development of intimal hyperplasia and vessel occlusion.

METHODS

We developed a method to obtain primary human temporal artery derived myointimal cells (HTAMCs) based on the culture of temporal artery sections on Matrigel.

RESULTS

Among the factors tested (platelet-derived growth factor (PDGF)-AB, fibroblast growth factor (FGF)-2, vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), transforming growth factor (TGF)beta, chemokine (C-C motif) ligand (CCL)2, interleukin (IL)6 and IL1beta), PDGF exhibited the strongest activity in inducing HTAMC proliferation and migration. As assessed by protein array, immunoassay and quantitative real-time reverse transcriptase (RT)-PCR, PDGF stimulated matrix proteins (collagen I, collagen III and fibronectin) as well as CCL2 and angiogenin production by HTAMCs. Imatinib mesylate inhibited PDGF-mediated activation of signalling pathways (Src, extracellular signal-regulated kinase (ERK) and Akt phosphorylation) related to cell motility and survival, efficiently resulting in inhibition of PDGF-induced HTAMC responses. Myointimal cell outgrowth from cultured temporal artery sections from patients with GCA, where multiple interactions take place, was also efficiently reduced by imatinib.

CONCLUSION

Among several mediators produced in GCA, PDGF has the highest vaso-occlusive potential. PDGF may also contribute to disease perpetuation by stimulating the production of angiogenic factors (angiogenin) and chemoattractants (CCL2). Imatinib mesylate strongly inhibits PDGF-mediated responses, suggesting a therapeutic potential to limit vascular occlusion and ischaemic complications in large vessel vasculitis.

Association between increased CCL2 (MCP-1) expression in lesions and persistence of disease activity in giant-cell arteritis*

OBJECTIVE

Patients with giant-cell arteritis (GCA) usually respond dramatically to corticosteroid treatment. However, recurrences are frequent and corticosteroid requirements are highly variable among patients. The aim of our study was to identify genes potentially involved in disease persistence.

METHODS

Gene expression was explored with cDNA arrays in temporal artery biopsies from six GCA patients with relapsing disease and six patients who easily achieved sustained remission. Differentially expressed genes of interest were subsequently analysed by quantitative real-time polymerase chain reaction (PCR) and immunohistochemistry in temporal artery biopsies from 35 patients with biopsy-proven GCA and nine controls.

RESULTS

CCL2 (MCP-1) was up-regulated in temporal artery samples from relapsing individuals. In the extended series of patients, CCL2 mRNA concentration in lesions was significantly higher than in controls (31 +/- 15.6 vs 0.44 +/- 0.10, P = 0.0001). In addition, CCL2 was more abundant in patients who experienced two or more relapses during the first year compared with those who endured sustained remission (127 +/- 82 vs 11 +/- 5.5, P = 0.0233) and correlated with the cumulated prednisolone dose (R = 0.533, P = 0.0024). CCL2 mRNA concentration correlated with IL-1beta (R = 0.45, P = 0.02), tumour necrosis factor-alpha (TNF-alpha) (R = 0.47, P = 0.013) and IL-6 (R = 0.52, P = 0.0053) mRNA. However, circulating CCL2 determined by ELISA was decreased in patients with strong systemic inflammatory response, suggesting that reduction in circulating CCL2 may reinforce the local gradient in lesions.

CONCLUSION

Increased CCL2 (MCP-1) expression in lesions is associated with persistence of disease activity in GCA.

Tissue production of pro-inflammatory cytokines (IL-1 , TNF and IL-6) correlates with the intensity of the systemic inflammatory response and with corticosteroid requirements in giant-cell arteritis

OBJECTIVES

To investigate proinflammatory cytokine expression in temporal arteries from patients with giant-cell arteritis (GCA) and to analyse its relationship with the intensity of the initial systemic inflammatory reaction and response to corticosteroid therapy.

METHODS

Quantification of interleukin-1beta (IL-1beta), tumor necrosis factor alpha (TNFalpha), and interleukin-6 (IL-6) mRNA by real-time quantitative PCR in temporal artery samples from 36 patients with biopsy-proven GCA and 11 controls. Immunohistochemical detection of IL-1beta, TNFalpha, and IL-6 in temporal artery sections from 74 patients with GCA and 15 controls. Clinical and biochemical parameters of inflammation as well as the time (weeks) required to reach a maintenance prednisone dose <10 mg/day were recorded.

RESULTS

IL-1beta (13.8 +/- 2.5 vs 5.4 +/- 1.3 relative units, P = 0.012) and IL-6 transcripts (34 +/- 13.7 vs 7.8 +/- 4.5 relative units, P = 0.034) were significantly more abundant in patients with a strong systemic inflammatory response compared with those with no inflammatory parameters. Immunohistochemical scores for IL-1beta (2.7 +/- 0.3 vs 1.9 +/- 0.2, P = 0.018), TNFalpha (3.2 +/- 0.2 vs 2.4 +/- 0.3, P = 0.028) and IL-6 (3 +/- 0.2 vs 2.1 +/- 0.3, P = 0.023) were also significantly higher in patients with strong systemic inflammatory reaction. A significant correlation was found between the amount of tissue TNFalpha mRNA and the time required to reach a maintenance dose of prednisone <10 mg/day (r = 0.586, P = 0.001).

CONCLUSION

GCA patients with a strong systemic inflammatory response, who have been previously shown to be more resistant to corticosteroid therapy, have elevated tissue expression of proinflammatory cytokines IL-1beta, TNFalpha and IL-6. High production of TNFalpha is associated with longer corticosteroid requirements.

Feeding strategies for rearing replacement heifers in small-scale dairy production systems in the highlands of Central Mexico

The growth of Holstein heifers in the campesino dairy systems in the highlands of Mexico was evaluated in three feeding strategies. Thirty-three heifers from 11 farmers, grouped according to strategy, were weighed every 14 days for 28 weeks. The live weight change over each 14-day period was estimated by individually regressing live weight over period, taking the regression coefficient as an unbiased estimate of live weight change. Regression coefficients were analysed as a randomized design with feeding strategies as treatments. Strategies were as follows: S1: grazed or cut pasture all year, maize silage and maize straw in the dry season, and 1.0-1.5 kg concentrate/heifer per day. S2: maize straw in the dry season, cut pasture forage, grazing of native grass, weeds from maize fields, and 1.0-1.5 kg concentrate/heifer per day. S3: maize straw in the dry season, grazed native grasses and weeds in the rainy season. Live weight gains were: S1, 0.511 kg/heifer per day; S2, 0.271 kg/heifer per day; and S3, 0.252 kg/heifer per day. Despite the better gains in S1, they are 24% below recommendations, arriving to service at 20 months of age. Not rearing their replacements may be a better alternative for campesino farmers under current economic conditions.

Small-vessel vasculitis surrounding a spared temporal artery: clinical and pathological findings in a series of twenty-eight patients

OBJECTIVE

Occasionally, a temporal artery biopsy reveals small-vessel vasculitis (SVV) surrounding a spared temporal artery, the significance of which is unclear. We analyzed the final diagnosis in a series of patients with this condition and tried to identify histopathologic features with potential usefulness in predicting the ultimate diagnosis.

METHODS

We performed a clinical and histopathologic review of 28 patients in whom SVV surrounding a spared temporal artery was the first histologic finding that led to the diagnosis of vasculitis. For comparison purposes, we analyzed the pattern of small vessel involvement in 30 patients with biopsy-proven giant cell arteritis (GCA).

RESULTS

GCA was considered the most likely diagnosis in 12 patients, based on the absence of clinical evidence of additional organ involvement and normal findings on muscle biopsy and electrophysiologic study. Three patients had systemic necrotizing vasculitis (SNV), based on the demonstration of typical lesions on subsequent muscle, nerve, or kidney biopsy. After extensive evaluation, 4 patients remained unclassifiable. Nine patients were incompletely studied. Fibrinoid necrosis was significantly more frequent in patients with SNV (P = 0.0022), whereas involvement of vasa vasorum was more frequent in patients classified as having GCA (P = 0.022). No differences in the pattern of small vessel involvement were found in patients with SVV surrounding a spared temporal artery who were classified as having GCA compared with patients with biopsy-proven GCA. Granulocytes were observed at similar frequency in all conditions.

CONCLUSION

SVV may be the only abnormal feature in a temporal artery biopsy and the only histologic evidence of vasculitis. The diagnosis of GCA can be reasonably established in most of these patients when there is no apparent evidence of additional organ involvement. However, when fibrinoid necrosis is observed or the temporal artery vasa vasorum are not involved, SNV must be extensively excluded.