Early recognition and treatment of OSA in hospitalized patients and its impact on health care utilization in rural population: a real-world study

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a highly prevalent, yet under-diagnosed condition. Due to its adverse impact on risk for cardiopulmonary disorders, there is interest in pro-active screening of OSA in hospitalized patients. We studied the long-term outcome of such screened patients who were initiated on positive airway pressure (PAP) therapy.

METHODS

Hospitalized patients who screened positive for OSA and were confirmed with post-discharge polysomnography (PSG) were dichotomized by PAP adherence and followed for a period of 12 months to evaluate for the composite endpoint of hospital readmissions and emergency room (ED) visits for cardiopulmonary reasons. Cost analysis between the two groups was also conducted.

RESULTS

2042 hospitalized patients were assessed for OSA as part of a hospital sleep medicine program from August 2019 to June 2023. Of these, 293 patients were diagnosed with OSA and prescribed PAP therapy. Of these 293 patients, 108 were adherent to therapy and 185 were non-adherent. The overall characteristics of the groups included a mean (SD) age: 58 years (12.82), mean BMI (kg/m2): 39.72 (10.71), male sex: 57%, and apnea-hypopnea index (AHI): 25.49 (26). 78%, 41% and 43% had hypertension, congestive heart failure, and diabetes mellitus, respectively.

The composite endpoint of hospital readmissions and ED visits for cardiovascular and pulmonary reasons was significantly higher in the non-adherent group as compared to the adherent group (HR: 1.24, 95% CI: 1-1.54) (p=0.03). The cost of care for both hospital billing (HB) as well as professional billing(PB) was higher for the non-adherent group ($1455.6 vs $1723.5, p = 0.004) in HB cost and $130.9 vs $144.7, p<0.001) in PB. Length of stay was higher for non-adherent patients (2.7 ± 5.1 days vs. 2.3 ± 5.9 days).

CONCLUSIONS

Hospitalized patients diagnosed with OSA and adherent to therapy have reduced readmissions and ED visits for cardiopulmonary reasons 12 months after discharge. Adherent patients have reduced cost of health care and length of stay during hospitalizations.

Characterization of PAHs bound to ambient ultrafine particles around runways at an international airport

The impact of airport activities on air quality, is not sufficiently documented. In order to better understand the magnitude and properly assess the sources of emissions in the sector, it is necessary to establish databases with real data on those pollutants that could have the greatest impact on both health and the environment. Particulate matter (PM), especially ultrafine particles, are a research priority, not only because of its physical properties, but also because of its ability to bind highly toxic compounds such as polycyclic aromatic hydrocarbons (PAHs). Samples of PM were collected in the ambient air around the runways at Barajas International Airport (Madrid, Spain) during October, November and December 2021. Samples were gathered using three different sampling systems and analysed to determine the concentration of PAHs bound to PM. A high-volume air sampler, a Berner low-pressure impactor, and an automated off-line sampler developed in-house were used. The agreement between the samplers was statistically verified from the PM and PAH results. The highest concentration of PM measured was 31 μg m-3, while the concentration of total PAH was 3 ng m-3, both comparable to those recorded in a semi-urban area of Madrid. The PAHs showed a similar profile to the particle size distribution, with a maximum in the 0.27-0.54 μm size range, being preferentially found in the submicron size fractions, with more than 84% and around 15-20% associated to UFPs. It was found that the ratio [PAHs(m)/PM(m)] was around 10-4 in the warmer period (October), whereas it more than doubled in the colder months (November-December). It is significant the shift in the relative distribution of compounds within these two periods, with a notable increase in the 5 and 6 ring proportions in the colder period. This increase was probably due to the additional contribution of other external sources, possibly thermal and related to combustion processes, as supported by the PAH diagnostic ratios.

High incidence of barotrauma in patients admitted with COVID-19 to ICU and associated mortality in rural Appalachia: An observational study

OBJECTIVES

To assess the incidence of barotrauma and its impact on mortality in COVID-19 patients admitted to ICU.

DESIGN

Single-center retrospective study of consecutive COVID-19 patients admitted to a rural tertiary-care ICU. The primary outcomes were incidence of barotrauma in COVID-19 patients and all-cause 30-day mortality. Secondary outcomes were the length of stay (LOS) in the hospital and ICU. Kaplan-Meier method and log-rank test were used in the survival data analysis.

SETTING

Medical ICU, West Virginia University Hospital (WVUH), USA.

PATIENTS

All adult patients were admitted to the ICU for acute hypoxic respiratory failure due to coronavirus disease 2019 between September 1, 2020, and December 31, 2020. Historical controls were ARDS patients admitted pre-COVID.

INTERVENTION

Not applicable.

MEASUREMENTS AND MAIN RESULTS

One hundred and sixty-five consecutive patients with COVID-19 were admitted to the ICU during the defined period, compared to 39 historical non-COVID controls. The overall incidence of barotrauma in COVID-19 patients was 37/165 (22.4%) compared to 4/39 (10.3%) in the control group. Patients with COVID-19 and barotrauma had a significantly worse survival (HR = 1.56, p = 0.047) compared to controls. In those requiring invasive mechanical ventilation, the COVID group also had significantly higher rates of barotrauma (OR 3.1, p = 0.03) and worse all-cause mortality (OR 2.21, p = 0.018). COVID-19 with barotrauma had significantly higher LOS in the ICU and the hospital.

CONCLUSIONS

Our data on critically ill COVID-19 patients admitted to the ICU shows a high incidence of barotrauma and mortality compared to the controls. Additionally, we report a high incidence of barotrauma even in non-ventilated ICU patients.

Right atrial structural remodeling predict worse outcomes in transcatheter mitral valve repair

BACKGROUND

In the current study, we assess the predictive role of right and left atrial volume indices (RAVI and LAVI) as well as the ratio of RAVI/LAVI (RLR) on mortality following transcatheter mitral valve repair (TMVr).

METHODS

Transthoracic echocardiograms of 158 patients who underwent TMVr at a single academic medical center from 2011 to 2018 were reviewed retrospectively. RAVI and LAVI were calculated using Simpson's method. Patients were stratified based on etiology of mitral regurgitation (MR). Cox proportional-hazard regression was created utilizing MR type, STS-score, and RLR to assess the independent association of RLR with survival. Kaplan-Meier analysis was used to analyze the association between RAVI and LAVI with all-cause mortality. Hemodynamic values from preprocedural right heart catheterization were also compared between RLR groups.

RESULTS

Among 123 patients included (median age 81.3 years; 52.5% female) there were 50 deaths during median follow-up of 3.0 years. Patients with a high RAVI and low LAVI had significantly higher all-cause mortality while patients with high LAVI and low RAVI had significantly improved all-cause mortality compared to other groups (p = 0.0032). RLR was significantly associated with mortality in patients with both functional and degenerative MR (p = 0.0038). Finally, Cox proportion-hazard modeling demonstrated that an elevated RLR above the median value was an independent predictor of all-cause mortality [HR = 2.304; 95% CI = 1.26-4.21, p = 0.006] when MR type and STS score were accounted for.

CONCLUSION

Patients with a high RAVI and low LAVI had significantly increased mortality than other groups following TMVr suggesting RA remodeling may predict worse outcomes following the procedure. Concordantly, RLR was predictive of mortality independent of MR type and preprocedural STS-score. These indices may provide additional risk stratification in patients undergoing evaluation for TMVr.

A Psycholgical Intervention Delivered by Automated Mobile Phone Messaging Stabilized Hip and Knee Function During the COVID-19 Pandemic: A Randomized Controlled Trial

BACKGROUND

We conducted a randomized controlled trial to evaluate the effectiveness of acceptance and commitment therapy (ACT) delivered via a mobile phone messaging robot to patients who had their total hip arthroplasty or total knee arthroplasty procedures postponed due to the COVID-19 pandemic.

METHODS

Ninety patients scheduled for total hip arthroplasty or total knee arthroplasty who experienced surgical delay due to the COVID-19 pandemic were randomized to the ACT group, receiving 14 days of twice daily automated mobile phone messages, or the control group, who received no messages. Minimal clinically important differences (MCIDs) in preintervention and postintervention patient-reported outcome measures were utilized to evaluate the intervention.

RESULTS

Thirty-eight percent of ACT group participants improved and achieved MCID on the Patient-Reported Outcome Measure Information System Physical Health compared to 17.5% in the control group (P = .038; number needed to treat [NNT] 5). For the joint-specific Hip Disability and Osteoarthritis Outcome Score Joint Replacement and Knee Disability and Osteoarthritis Outcome Score Joint Replacement (KOOS JR), 24% of the ACT group achieved MCID compared to 2.5% in the control group (P = .004; NNT 5). An improvement in the KOOS JR was found in 29% of the ACT group compared to 4.2% in the control group (P = .028; NNT 5). Fourteen percent of the ACT group participants experienced a clinical important decline in the KOOS JR compared to 41.7% in the control group (P = .027; NNT 4).

CONCLUSION

A psychological intervention delivered via a text messaging robot improved physical function and prevented decline in patient-reported outcome measures in patients who experienced an unexpected surgical delay during the COVID-19 pandemic.

LEVEL OF EVIDENCE

1.

Evaluation of a novel mechanical compression device for hematoma prevention and wound cosmesis after CIED implantation

BACKGROUND

An important complication of cardiac implantable electronic devices (CIED) is the development of hematoma and device infection.

OBJECTIVE

We aimed to evaluate a novel mechanical compression device for hematoma prevention and cosmetic outcomes following CIED.

METHODS

An open, prospective, randomized, single-center clinical trial was performed in patients undergoing CIED implantation. Patients were randomized to receive a novel mechanical compression device (PressRite, PR) or to receive the standard of care post device implantation. Skin pliability was measured with a calibrated durometer; the surgical site was evaluated using the Manchester Scar Scale (MSS) by a blinded plastic surgeon and the Patient and Observer Scar Scale (POSAS). Performance PR was assessed through pressure measurements, standardized scar scales and tolerability.

RESULTS

From the total of 114 patients evaluated for enrollment, 105 patients were eligible for analysis. Fifty-one patients were randomized to management group (PR) and 54 to the control group. No patients required early removal or experienced adverse effects from PR application. There were 11 hematomas (14.8% vs. 5.9% in the control and PR group respectively, p = NS). The control group had higher post procedure durometer readings in the surgical site when compared with the PR group (7.50 ± 3.45 vs. 5.37 ± 2.78; p = <0.01). There were lower MSS scores in the PR group after 2 weeks (p = 0.03).

CONCLUSION

We have demonstrated the safety of PR application and removal. In addition, PR appears to lower post-operative skin pliability, which could improve wound healing. This article is protected by copyright. All rights reserved.

The Sick Adipose Tissue: New Insights Into Defective Signaling and Crosstalk With the Myocardium

Adipose tissue (AT) biology is linked to cardiovascular health since obesity is associated with cardiovascular disease (CVD) and positively correlated with excessive visceral fat accumulation. AT signaling to myocardial cells through soluble factors known as adipokines, cardiokines, branched-chain amino acids and small molecules like microRNAs, undoubtedly influence myocardial cells and AT function via the endocrine-paracrine mechanisms of action. Unfortunately, abnormal total and visceral adiposity can alter this harmonious signaling network, resulting in tissue hypoxia and monocyte/macrophage adipose infiltration occurring alongside expanded intra-abdominal and epicardial fat depots seen in the human obese phenotype. These processes promote an abnormal adipocyte proteomic reprogramming, whereby these cells become a source of abnormal signals, affecting vascular and myocardial tissues, leading to meta-inflammation, atrial fibrillation, coronary artery disease, heart hypertrophy, heart failure and myocardial infarction. This review first discusses the pathophysiology and consequences of adipose tissue expansion, particularly their association with meta-inflammation and microbiota dysbiosis. We also explore the precise mechanisms involved in metabolic reprogramming in AT that represent plausible causative factors for CVD. Finally, we clarify how lifestyle changes could promote improvement in myocardiocyte function in the context of changes in AT proteomics and a better gut microbiome profile to develop effective, non-pharmacologic approaches to CVD.

AB0193 PRESENCE OF SUBLINICAL SYNOVITIS IN A ESTABLISHED RHEUMATOID ARTHRITIS COHORT

Background:

Some studies prove that a significant percentage of patients with rheumatoid arthritis (RA) in sustained clinical remission has radiological progression or joint damage, and the presence of residual activity objectified by imaging studies such as ultrasonography could be related to a relapse or flare of RA.(1,2)

Objectives:

To determine the presence of subclinical synovitis measured by ultrasonography in patients with RA on sustained clinical remission from the Rheumatology service at Hospital de Clínicas, San Lorenzo, Paraguay.

Materials and Methods:

Prospective, cross sectional, descriptive study, in RA patients meeting ACR/EULAR 2010 criteria, older than 18 years, on sustained clinical remission (≥6 months), measured by ESR-DAS28 (<2,6), doing follow-ups on our service. A healthy control group was included. All groups signed informed consent. Synovial hypertrophy (SH) and intraarticular vascularization grades on Power Doppler (PD) mode were determined according to EULAR recommendations and OMERACT 7 group definitions. Clinical data were obtained from the service’s registries.

SPSS 23rd version was used for data analysis. Quantitative variables were presented as means and qualitative as frequencies. Chi square test was performed for comparisons between dichotomous variables and t Student for continuous. For comparisons between variables the Spearman’s rank correlation coefficient was performed, and p≤0.05 for statistical significance. Factors predicting subclinical synovitis were analyzed with Odds Ratio (OR) CI 95%.

Results:

From 147 patients, 31 (21%) met remission criteria; 87.1% women, mean age 51.9±14.8 years. Mean disease duration was 9,06±10,81 years. 64,5% were RF and ACPA positive and 25,9% had erosions.

Ultrasonograms were made in 20 joints of both hands: radiocarpals (RC), metacarpophalangeals (MCP) and proximal interphalangeals (PIP). 12 patients (38.7%) presented subclinical synovitis (SH≥2+PD), more frequently on RC (29% right, 22.6% left), and MCP (9.7% on 2RMCP, 9.7% 4LMCP). These patients had greater CDAI (3.9±1.37 vs 2.89±1.15, p=0.03), HAQ (0.14±0.29 vs 0.00±0.00, p=0.04), CRP (9.90±7.46 vs 4.74±2.30, p=0.00) RF levels (502.67±275.66 vs 200.92±158.43, p=0,00), greater prednisone (16.5% vs 3.2%, p=0.04), and methotrexate use (20.16±5.54 vs 17.50±3.98, p=0.01). None of the healthy controls presented subclinical synovitis.

In binary logistic regression CRP levels, RF titers and methotrexate doses were associated to subclinical synovitis. This association is not found in multivariate logistic regression. Negative association was found between subclinical synovitis and two csDMARDs use.

Conclusion:

This is the first study of its type in Paraguayan patients, which clearly evidenced that an important part of RA patients in clinical remission still presented subclinical synovitis (HS≥2 + PD). It was associated with CRP, RF and methotrexate dose.

References:

[1]Płaza M, Nowakowska-Płaza A, Pracoń G, Sudoł-Szopińska I. Role of ultrasonography in the diagnosis of rheumatic diseases in light of ACR/EULAR guidelines. J Ultrason. marzo de 2016;16(64):55-64.

[2]Foltz V, Gandjbakhch F, Etchepare F, Rosenberg C, Tanguy ML, Rozenberg S, et al. Power Doppler ultrasound, but not low-field magnetic resonance imaging, predicts relapse and radiographic disease progression in rheumatoid arthritis patients with low levels of disease activity. Arthritis & Rheumatism. 2012;64(1):67-76.

Disclosure of Interests:

None declared

Electronic Cigarettes and Vaping-Associated Lung Injury (EVALI): A Rural Appalachian Experience

Background: Electronic cigarette use has increased dramatically since their introduction in 2007. Respiratory complications, particularly lipoid pneumonia, have been reported as early as 2012. An outbreak of pulmonary injury in 2019 has been reported in patients using vaping products.Research Question: To describe a rural Appalachian tertiary center's experience of EVALI and to identify novel mechanisms of pulmonary injury patterns.Study Design and Methods: We present a consecutive case series of 17 patients admitted to our rural, academic, tertiary care institution with EVALI from August 2019 to March 2020. Demographics, baseline characteristics, co-morbidities, vaping behavior, and hospital course were recorded. Broncho-alveolar lavage specimens were assessed for lipid-laden macrophages and hemosiderin-laden macrophages with stains for Oil-Red-O (n = 15) and Prussian Blue (n = 14) respectively.The patient volunteered e-liquid materials (n = 6), and vapors were analyzed using a proton transfer reaction time-of-flight mass spectrometer (PTR-TOF-MS) to describe the chemical profile. Post-discharge interviews were conducted.Results: The most common CT finding was bilateral ground-glass opacities with a predilection for lower lung zones. The most frequent pulmonary injury pattern was lipoid pneumonia. The majority of EVALI patients were critically ill requiring ventilation or ECMO. The most severely ill patients were noted to be positive for iron stains in macrophages and showed higher volatile organic compound (VOC) levels in chemical analysis.Interpretation: Based on our experience, EVALI in rural Appalachia presented with relatively severe respiratory failure. Worse outcomes appear to be correlated to high levels of VOCs, iron deposition in lungs, and concomitant infection.

Assessment of the Effect of the Go Red for Women Campaign on Search Engine Queries for Cardiovascular Disease in Women

Background

The Go Red for Women (GoRedW) campaign aims to increase awareness of cardiovascular disease (CVD) and stroke in women. However, assessing the effects of social campaigns on information-seeking behaviors may be challenging. The purpose of this study was to ascertain the effect of GoRedW using a large sample of unbiased real-world data from Google Trends (GTr) and evaluate the temporal correlation of online search queries for CVD and stroke in women with GoRedW.

Methods

We conducted a retrospective study using GTr, a public tool from the Google search engine to obtain relative search volumes (RSVs) related to CVD and stroke in women in the period January 2004 to April 2019 in the USA. In addition, trends of GoRedW were compared with those of the well-established Breast Cancer Awareness Month (BCAM) campaign.

Results

RSVs increased for queries of GoRedW and all searched terms for CVD but not for stroke in women during February compared to other months of the year without active campaign. The strong pattern with peaks of temporal increase was consistent over the 15-year study period. RSV of “Go Red for Women” in February increased on average 494% (range: 211% to 789%). The highest temporal increase on search queries for CVD was for the term “heart disease (in) women” with an average of 114% (24% to 182%). We found a positive correlation between RSVs of GoRedW and the term “heart disease (in) women” (r = 0.54, P < 0.001). RSVs for “Breast Cancer Awareness Month” had a higher increase during the active campaign month compared to GoRedW and showed a stronger positive correlation (r = 0.78, P < 0.001).

Conclusions

Search engines are a valuable resource to provide insights on information demand and to assess the effectiveness of social campaigns and interventions. Our study showed an increase in the RSVs for queries of GoRedW and all CVD terms which correlated with the active campaign months over a 15-year period.

Massive Pulmonary Embolism in a Recent Intracranial Hemorrhage: A Case Report of Inhaled Nitric Oxide to Improve Outcomes

Acute massive pulmonary embolism (PE) has a high mortality if left untreated. The mainstay of treatment is systemic thrombolysis which has some absolute contraindications like intracranial hemorrhage (ICH). Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator that decreases pulmonary artery pressure (PAP) and allows the right ventricle of the heart to pump against less resistance. We present a case of iNO use to improve hemodynamics in a patient with a recent ICH. We believe this to be the first such case reported.

A 70-year-old female with a history of PE on Eliquis initially presented for weakness and was found to have right-sided ICH. She was discharged with instructions to hold Eliquis given ICH but was readmitted eight days later in florid cardiogenic shock requiring vasopressors and hypoxic respiratory failure refractory to intubation. CT showed bilateral PE with evidence of right heart strain and IV heparin was started. Due to her history of a recent ICH, she had an absolute contraindication prohibiting the use of systemic tissue plasminogen activator (tPA). Interventional radiology (IR) consult determined that the patient was not a candidate for catheter-directed tPA due to the recent ICH, mechanical ventilation, and hemodynamic instability based on pressor requirement. Vascular surgery and extracorporeal membrane oxygenation (ECMO) consults deemed the patient not operable. The patient was then started on iNO with immediate improvement in her blood pressure. Once vitally stable, IR consult performed pulmonary angiogram and completed a thrombectomy. The patient was eventually extubated and she restarted her Eliquis. She continues to do well 16 months after discharge.

In patients with massive PE with contraindications to systemic thrombolytics, providers are left with very few therapeutic interventions. A handful of case reports show that iNO improves systemic hemodynamics in postoperative patients with massive PE. This case highlights the potential for iNO to be a potential adjuvant in patients with absolute contraindications to systemic thrombolysis.

Perirenal fat thickness is associated with metabolic risk factors in patients with chronic kidney disease

Background

Adipose tissue accumulation in specific body compartments has been associated with diabetes, hypertension and dyslipidemia. Perirenal fat (PRF) may lead to have direct lipotoxic effects on renal function and intrarenal hydrostatic pressure. This study was undertaken to explore the association of PRF with cardiovascular risk factors and different stages of chronic kidney disease (CKD).

Methods

We studied 103 patients with CKD of different stages (1 to 5). PRF was measured by B-mode renal ultrasonography in the distal third between the cortex and the hepatic border and/or spleen.

Results

The PRF thickness was greater in CKD patients with impaired fasting glucose than in those with normal glucose levels (1.10 ± 0.40 cm vs. 0.85 ± 0.39 cm, P < 0.01). Patients in CKD stages 4 and 5 (glomerular filtration rate [GFR] < 30 mL/min/1.73 m²) had the highest PRF thickness. Serum triglyceride levels correlated positively with the PRF thickness; the PRF thickness was greater in patients with triglyceride levels ≥ 150 mg/dL (1.09 ± 0.40 cm vs. 0.86 ± 0.36 cm, P < 0.01). In patients with a GFR < 60 mL/min/1.73 m², uric acid levels correlated positively with the PRF thickness (P < 0.05).

Conclusion

In CKD patients, the PRF thickness correlated significantly with metabolic risk factors that could affect kidney function.

Platypnea-orthodeoxia Syndrome in a Patient with Cryptogenic Liver Cirrhosis: An Elusive Cause of Hypoxemia

Platypnea-orthodeoxia syndrome (POS) has been defined as shortness of breath and hypoxemia in the upright position that improves with dorsal decubitus. This is a rare disorder caused by right-to-left shunts due to a persistent foramen ovale or pulmonary arteriovenous malformations. Hepatopulmonary syndrome can present with POS in the presence of pulmonary vasodilation and pulmonary arteriovenous communications in patients with liver disease. We report a case where the diagnosis of POS was made incidentally in a patient with cryptogenic liver cirrhosis. After other causes of hypoxemia were excluded, the diagnosis of right-to-left pulmonary shunt was confirmed by late opacification of the left heart chambers seen in a transthoracic echocardiogram. Interestingly, computerized tomography (CT) of the chest with contrast demonstrated a very prominent pulmonary vascular pattern extending to the periphery of the lungs. POS is a rare cause of hypoxemia that requires a high level of suspicion, and exclusion of more common causes of hypoxemia.

Myasthenia gravis crisis coinciding with asthma exacerbation in a patient with recent heroin use: three causes of acute hypercarbic respiratory failure

A 57-year-old woman with a history of asthma, hypertension and substance abuse disorder was admitted to the medical intensive care unit with hypercapnic respiratory failure. After the history was obtained, patient admitted heroin use earlier that day. The initial physical examination revealed right eye ptosis, diplopia, fatigability of neck flexion and extension. She also presented with wheezing and a prolonged expiratory phase. Pupils were 4 mm, with sluggish response to light bilaterally. CT chest with contrast showed a large mediastinal mass. Three different processes coexisted in this patient: simultaneous occurrence of a myasthenia gravis crisis, asthma exacerbation and a component of heroin use. This case highlights a series of overlapping clinical features that could lead to potential confounding and misdiagnosis. Respiratory symptoms improved after initial treatment for asthma exacerbation, but ptosis, diplopia and fatigability of neck muscles persisted.

Case of Missing Plastic: Foreign Body Bronchiectasis

Bronchiectasis is a well-known entity where the airways abnormally dilate losing their natural function. Most common causes of non-cytic fibrosis bronchiectasis in the middle age group include secondary immunodeficiency, aspiration, and allergic bronchopulmonary aspergillosis (ABPA). Obstructive foreign body is an uncommon cause of bronchiectasis and is often a missed diagnosis in a localized disease. Foreign bodies can be missed making the diagnosis and treatment more challenging and hence foreign body bronchiectasis should be considered in patients presenting with focal disease. Here we describe a patient with a retained foreign body that was discovered post lobectomy during gross pathological examination of the specimen with no significant aspiration history, non-diagnostic imaging of the chest and negative bronchoscopy.

Stevia rebaudiana Bertoni and Its Effects in Human Disease: Emphasizing Its Role in Inflammation, Atherosclerosis and Metabolic Syndrome

PURPOSE OF REVIEW

Stevia rebaudiana Bertoni is a perennial shrub with zero calorie content that has been increasing in popularity for its potential use as an adjuvant in the treatment of obesity. The level of evidence supporting general benefits to human health is insufficient. We conducted a review of the literature summarizing the current knowledge and role in human disease.

RECENT FINDINGS

Despite stevia's minimal systemic absorption, studies have been promising regarding its potential benefits against inflammation, carcinogenesis, atherosclerosis glucose control, and hypertension. On the other hand, the growing popularity of artificial sweeteners does not correlate with improved trends in obesity. An increased intake of artificial non-caloric sweeteners may not be associated with decreased intake of traditional sugar-sweetened beverages and foods. The effects of Stevia on weight change have been linked to bacteria in the intestinal microbiome, mainly by affecting Clostridium and Bacteroides sp.

POPULATIONS

A growing body of evidence indicates that Stevia rebaudiana Bertoni is protective against malignant conversion by inhibition of DNA replication in human cancer cell growth in vitro. Consumption of Stevia has demonstrated to be generally safe in most reports. Further clinical studies are warranted to determine if regular consumption brings sustained benefits for human health.

Blend design tools for Medium Combustion Plants (MCP) firing biomass wastes

A feasible alternative for agricultural or forestry waste management is the operation of a distributed network of sustainable Medium Combustion Plants (MCPs). However, one of the main factors that hinder its development is the propensity to operational problems derived from corrosion, slagging and fouling characteristics of both bottom and fly ashes. Therefore, a cost-effective approach for these multi-product MCP could be based on predictive tools for an optimal formulation of a fuel blend. This work focuses on the assessment of the ability of these methods to provide guidance for preventing ash-related operational problems and to provide fuel-blending rules. The more widespread tools pertain to two types: compositional classification based on chemical analysis of laboratory ashes, and thermodynamic prediction of the most likely species and phases. Both criterion numbers and compositional maps are ranking methods based on the chemical analysis at a given ashing temperature. Thermodynamic equilibrium modeling is not constrained by any difference in the physical conditions of the MCP compared to those in the laboratory. Both kind of prediction tools have been validated in an MCP firing olive tree pruning residues as well as its typical blends in order to mimic a plausible pattern of fuels along a full year operating campaign. An intensive experimental campaign encompasses plant monitoring and off-line analysis of the ashes along the process line. Interpretation of compositional plots has revealed to be potentially sensitive to ashing temperature. Here are presented examples showing how this variable could lead to either insignificant differences or to a substantial disparity in the a priori fuel diagnosis. Some inconsistencies have been observed between the predictions based on criterion numbers, even for the same fuel and for ranking rules specifically formulated for biomasses. Moreover, it does not match consistently with the information obtained from phase diagrams. Therefore, their use should be limited to the case of a well-established selection of a fuel index for a well-defined fuel provided empirical evidence of an enough good description of the ash behavior, which is not the most frequent case. Thermodynamic equilibrium calculations allow a more precise prediction of the main species in the condensed phase, without the constraint of the ashing temperature. Elemental closure of main ash-forming elements with the chemical analysis of the process ashes presents small differences, and their proximity localization on the phase diagrams denote similar prediction between predicted and process ashes.

Dyslipidemia: Genetics, lipoprotein lipase and HindIII polymorphism

The direct link between lipid metabolism alterations and the increase of cardiovascular risk are well documented. Dyslipidemias, including isolated high LDL-c or mixed dyslipidemia, such as those seen in diabetes (hypertriglyceridemia, high LDL-c or low HDL-c), correlate with a significant risk of cardiovascular and cerebrovascular disease worldwide.  This review analyzes the current knowledge concerning the genetic basis of lipid metabolism alterations, emphasizing lipoprotein lipase gene mutations and the HindIII polymorphism, which are associated with decreased levels of triglycerides and LDL-c, as well as higher levels of HDL-c. These patterns would be associated with decreased global morbidity and mortality, providing protection against cardiovascular and cerebrovascular diseases.

Dyslipidemia: Genetics, lipoprotein lipase and HindIII polymorphism

The direct link between lipid metabolism alterations and the increase of cardiovascular risk are well documented. Dyslipidemias, including isolated high LDL-c or mixed dyslipidemia, such as those seen in diabetes (hypertriglyceridemia, high LDL-c or low HDL-c), correlate with a significant risk of cardiovascular and cerebrovascular disease worldwide.  This review analyzes the current knowledge concerning the genetic basis of lipid metabolism alterations, emphasizing lipoprotein lipase gene mutations and the HindIII polymorphism, which are associated with decreased levels of triglycerides and LDL-c, as well as higher levels of HDL-c. These patterns would be associated with decreased global morbidity and mortality, providing protection against cardiovascular and cerebrovascular diseases.

Comparison of differential gene expression to water stress among bacteria with relevant pollutant-degradation properties

Resistance to semi-dry environments has been considered a crucial trait for superior growth and survival of strains used for bioaugmentation in contaminated soils. In order to compare water stress programmes, we analyse differential gene expression among three phylogenetically different strains capable of aromatic compound degradation: Arthrobacter chlorophenolicus A6, Sphingomonas wittichii RW1 and Pseudomonas veronii  1YdBTEX2. Standardized laboratory-induced water stress was imposed by shock exposure of liquid cultures to water potential decrease, induced either by addition of solutes (NaCl, solute stress) or by addition of polyethylene glycol (matric stress), both at absolute similar stress magnitudes and at those causing approximately similar decrease of growth rates. Genome-wide differential gene expression was recorded by micro-array hybridizations. Growth of P. veronii 1YdBTEX2 was the most sensitive to water potential decrease, followed by S. wittichii RW1 and A. chlorophenolicus A6. The number of genes differentially expressed under decreasing water potential was lowest for A. chlorophenolicus A6, increasing with increasing magnitude of the stress, followed by S. wittichii RW1 and P. veronii 1YdBTEX2. Gene inspection and gene ontology analysis under stress conditions causing similar growth rate reduction indicated that common reactions among the three strains included diminished expression of flagellar motility and increased expression of compatible solutes (which were strain-specific). Furthermore, a set of common genes with ill-defined function was found between all strains, including ABC transporters and aldehyde dehydrogenases, which may constitute a core conserved response to water stress. The data further suggest that stronger reduction of growth rate of P. veronii 1YdBTEX2 under water stress may be an indirect result of the response demanding heavy NADPH investment, rather than the presence or absence of a suitable stress defence mechanism per se.

The Potato Cryobank at The International Potato Center (Cip): A Model for Long Term Conservation of Clonal Plant Genetic Resources Collections of the Future

BACKGROUND

Cryobanks are a secure, efficient and low cost method for the long-term conservation of plant genetic resources for theoretically centuries or millennia with minimal maintenance.

OBJECTIVE

The present manuscript describes CIP's modified protocol for potato cryopreservation, its large-scale application, and the establishment of quality and operational standards, which included a viability reassessment of material entering the cryobank.

MATERIALS AND METHODS

In 2013, CIP established stricter quality and operational standards under which 1,028 potato accessions were cryopreserved with an improved PVS2-droplet protocol. In 2014 the viability of 114 accessions cryopreserved in 2013 accessions were reassessed.

RESULTS

The average recovery rate (full plant recovery after LN exposure) of 1028 cryopreserved Solanum species ranged from 34 to 59%, and 70% of the processed accessions showed a minimum recovery rate of ≥20% and were considered as successfully cryopreserved.

CONCLUSION

CIP has established a new high quality management system for cryobanking. Periodic viability reassessment, strict and clear recovery criteria and the monitoring of the percent of successful accessions meeting the criteria as well as contamination rates are metrics that need to be considered in cryobanks.

Evidence of population genetic effects in Peromyscus melanophrys chronically exposed to mine tailings in Morelos, Mexico

Effects of environmental chemical pollution can be observed at all levels of biological organization. At the population level, genetic structure and diversity may be affected by exposure to metal contamination. This study was conducted in Huautla, Morelos, Mexico in a mining district where the main contaminants are lead and arsenic. Peromyscus melanophrys is a small mammal species that inhabits Huautla mine tailings and has been considered as a sentinel species. Metal bioaccumulation levels were examined by inductively coupled plasma mass spectrometry and genetic analyses were performed using eight microsatellite loci in 100 P. melanophrys individuals from 3 mine tailings and 2 control sites. The effect of metal bioaccumulation levels on genetic parameters (population and individual genetic diversity, genetic structure) was analyzed. We found a tissue concentration gradient for each metal and for the bioaccumulation index. The highest values of genetic differentiation (Fst and Rst) and the lowest number of migrants per generation (Nm) were registered among the exposed populations. Genetic distance analyses showed that the most polluted population was the most genetically distant among the five populations examined. Moreover, a negative and significant relationship was detected between genetic diversity (expected heterozygosity and internal relatedness) and each metal concentration and for the bioaccumulation index in P. melanophrys. This study highlights that metal stress is a major factor affecting the distribution and genetic diversity levels of P. melanophrys populations living inside mine tailings. We suggest the use of genetic population changes at micro-geographical scales as a population level biomarker.

MRNA and miRNA expression patterns associated to pathways linked to metal mixture health effects

Metals are a threat to human health by increasing disease risk. Experimental data have linked altered miRNA expression with exposure to some metals. MiRNAs comprise a large family of non-coding single-stranded molecules that primarily function to negatively regulate gene expression post-transcriptionally. Although several human populations are exposed to low concentrations of As, Cd and Pb as a mixture, most toxicology research focuses on the individual effects that these metals exert. Thus, this study aims to evaluate global miRNA and mRNA expression changes induced by a metal mixture containing NaAsO2, CdCl2, Pb(C2H3O2)2·3H2O and to predict possible metal-associated disease development under these conditions. Our results show that this metal mixture results in a miRNA expression profile that may be responsible for the mRNA expression changes observed under experimental conditions in which coding proteins are involved in cellular processes, including cell death, growth and proliferation related to the metal-associated inflammatory response and cancer.

Generic sodium stibogluconate is as safe and effective as branded meglumine antimoniate, for the treatment of tegumentary leishmaniasis in Isiboro Secure Park, Bolivia

Human cutaneous leishmaniasis (CL) and mucous leishmaniasis (ML) are highly endemic in Isiboro Secure Park, which lies in the Bolivian department of Cochabamba--an area where branded meglumine antimoniate (Glucantime) is expensive and poorly distributed. The safety and efficacy of generic sodium stibogluconate (SSG), from Albert David Ltd, was therefore explored, in CL and ML cases from the park, who were treated with 20 mg/kg.day for 20 and 30 days, respectively. A questionnaire recording adverse effects was completed by a physician in each treatment centre. Efficacy of treatment was assessed at the end of treatment and at follow-ups 1 month and 3, 6 and 12 months later. Overall, 146 patients completed treatment with SSG in 2003-2004. No fatalities or severe adverse effects were reported but mild to moderate adverse effects were noted in 41 (28%) of the patients. The incidence of adverse effects was significantly higher among the cases of ML than among the cases of CL. Of the 86 patients with CL who completed 6 months of follow-up, 81 (94.2%) were considered to have been clinically cured; a comparable cohort of 69 CL cases who had been treated with Glucantime in 2001-2002 showed a similar frequency of clinical cure (90%). Generic SSG was shown to be safe and efficacious for the treatment of tegumentary leishmaniasis in Bolivia. Being several times cheaper than Glucantime, it could contribute to improving the access of CL and ML patients to treatment, not only in Bolivia but also in other countries of Latin America.

Targeting hypertension in patients with cardiorenal metabolic syndrome

Diabetes mellitus coexisting with hypertension is greater than chance alone would predict. Hypertensive patients have been shown to have altered composition of skeletal muscle tissue, decreased blood flow to skeletal muscle and post-receptor signaling alterations in the IRS insulin pathway, all inducing insulin resistance states, which partially explains why blood pressure goals in DM patients are lower than in normoglycemic patients. Although optimal first-step antihypertensive drug therapy in type 2 DM or impaired fasting glucose levels (IFG) should be individualized for each patient, converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) have been demonstrated in some but not all studies to decrease the rate of development of proteinuria and diabetic renal disease. According to the ACCF/AHA 2011 Expert Consensus, elderly persons with diabetes, hypertension, and nephropathy should be initially treated with ACEIs or ARBs, although the choice of a specific antihypertensive may also depend on other associated comorbidities.

Lipid/Polyelectrolyte coatings to control carbon nanotubes intracellular distribution

Carbon Nanotubes have been functionalized with a layer of poly (sulfopropyl methacrylate) synthesized from silane initiators attached to the walls of the Carbon nanotubes. On top of the poly sulfo propyl methacrylate, lipid vesicles composed of 75% 1,2-Dioleoyl-sn-Glycero-3-Phosphocholine and 25% 1,2-Dioleoyl-sn-Glycero-3-[Phospho-L-Serine] were assembled. The surface modification of the Carbon Nanotubes and lipid assembly were followed by TEM. Confocal Raman Microscopy was used to study the uptake and localization of the surface modified Carbon Nanotubes in the HepG2 cell line. The localization of the Carbon Nanotubes in the cells was affected by the surface coating. It was found that poly (sulfopropyl methacrylate) and lipid modified Carbon Nanotubes were present in the region of the lipid bodies in the cytoplasm.

Comparison of two wild rodent species as sentinels of environmental contamination by mine tailings

BACKGROUND

Contamination with heavy metals is among the most hazardous environmental concerns caused by mining activity. A valuable tool for monitoring these effects is the use of sentinel organisms. Particularly, small mammals living inside mine tailings are an excellent study system because their analysis represents a realistic approach of mixtures and concentrations of metal exposure.

PURPOSE

We analyzed metal tissue concentrations and DNA damage levels for comparison between genders of a sentinel (Peromyscus melanophrys) and a nonsentinel (Baiomys musculus) species. Also, the relationship between DNA damage and the distance from the contamination source was evaluated.

METHODS

This study was conducted in an abandoned mine tailing at Morelos, Mexico. Thirty-six individuals from both species at the exposed and reference sites were sampled. Metal concentrations in bone and liver of both species were analyzed by atomic absorption spectrophotometry, and DNA damage levels were assayed using the alkaline comet assay.

RESULTS

In general, concentrations of zinc, nickel, iron, and manganese were statistically higher in exposed individuals. A significant effect of the organ and the site on all metal tissue concentrations was detected. Significant DNA damage levels were registered in the exposed group, being higher in B. musculus. Females registered higher DNA damage levels than males. A negative relationship between distance from the mine tailing and DNA damage in B. musculus was observed.

CONCLUSIONS

We consider that B. musculus is a suitable species to assess environmental quality, especially for bioaccumulable pollutants--such as metals--and recommend that it may be considered as a sentinel species.

An elevated level of physical activity is associated with normal lipoprotein(a) levels in individuals from Maracaibo, Venezuela

Coronary artery disease is the main cause of death worldwide. Lipoprotein(a) [Lp(a)], is an independent risk factor for coronary artery disease in which concentrations are genetically regulated. Contradictory results have been published about physical activity influence on Lp(a) concentration. This research aimed to determine associations between different physical activity levels and Lp(a) concentration. A descriptive and cross-sectional study was made in 1340 randomly selected subjects (males = 598; females = 712) to whom a complete clinical history, the International Physical Activity Questionnaire, and Lp(a) level determination were made. Statistical analysis was carried out to assess qualitative variables relationship by chi2 and differences between means by one-way analysis of variance considering a P value <0.05 as statistically significant. Results are shown as absolute frequencies, percentages, and mean +/- standard deviation according to case. Physical activity levels were ordinal classified as follows: low activity with 24.3% (n = 318), moderate activity with 35.0% (n = 458), and high physical activity with 40.8% (n = 534). Lp(a) concentration in the studied sample was 26.28 +/- 12.64 (IC: 25.59-26.96) mg/dL. Lp(a) concentration according to low, moderate, and high physical activity levels were 29.22 +/- 13.74, 26.27 +/- 12.91, and 24.53 +/- 11.35 mg/dL, respectively, observing statistically significant differences between low and moderate level (P = 0.004) and low and high level (P < 0.001). A strong association (chi2 = 9.771; P = 0.002) was observed among a high physical activity level and a normal concentration of Lp(a) (less than 30 mg/dL). A lifestyle characterized by high physical activity is associated with normal Lp(a) levels.

Signaling pathways involved in the antiproliferative effect of molecular iodine in normal and tumoral breast cells: evidence that 6-iodolactone mediates apoptotic effects

Previous reports have documented the antiproliferative properties of I(2) and the arachidonic acid (AA) derivative 6-iodolactone (6-IL) in both thyroid and mammary glands. In this study, we characterized the cellular pathways activated by these molecules and their effects on cell cycle arrest and apoptosis in normal (MCF-12F) and cancerous (MCF-7) breast cells. Low-to-moderate concentrations of I(2) (10-20 microM) cause G1 and G2/M phase arrest in MCF-12F and caspase-dependent apoptosis in MCF-7 cells. In normal cells, only high doses of I(2) (40 microM) induced apoptosis, and this effect was mediated by poly (ADP-ribose) polymerase-1 (PARP1) and the apoptosis-induced factor, suggesting an oxidative influence of iodine at high concentrations. Our data indicate that both I(2) and 6-IL trigger the same intracellular pathways and suggest that the antineoplasic effect of I(2) in mammary cancer involves the intracellular formation of 6-IL. Mammary cancer cells are known to contain high concentrations of AA, which might explain why I(2) exerts apoptotic effects at lower concentrations only in tumoral cells.

Development of an edible rabies vaccine in maize using the Vnukovo strain

The objective of this study was to obtain transgenic maize expressing the rabies virus glycoprotein (G) of the Vnukovo strain and to evaluate its immunogenicity in mice, by the oral route. The ubiquitin maize promoter fused to the whole coding region of the rabies virus G gene, and a constitutive promoter from cauliflowermosaic virus (CaMV)were used. Maize embryogenic callus were transformed with the above construct by biolistics. Regenerated maize plants were recovered and grown in a greenhouse. The presence of the G gene and its product was detected by PCR and western blot, respectively. The amount of G protein detected in the grains was approximately 1% of the total soluble plant protein. Transformed kernels containing 50 microg of G protein were given once by the oral route in adult mice (BALB-C strain). Challenge was undertaken at 90-days post-vaccination using a lethal dose of a vampire bat rabies virus (100 LD 50% in mice); vampire bats are one of the main reservoirs in Latin America. The edible vaccine induced viral neutralizing antibodies (VNA) which, protected mice 100% against challenge. The control group did not survive. The G protein of the Vnukovo strain expressed in transgenic maize may be considered as an oral immunogen against rabies, conferring cross-protection.

Effects of a mixture of fatty acids from sugar cane (Saccharum officinarum L.) wax oil in two models of inflammation: zymosan-induced arthritis and mice tail test of psoriasis

A mixture of fatty acids obtained from sugar cane (Saccharum officinarum L.) wax oil (FAM), in which the main constituents are palmitic, oleic, linoleic, and linolenic acids, was evaluated in two models of inflammation: zymosan-induced arthritis and in the tail test for psoriasis, both on mice. In the first model, FAM significantly reduced zymozan-induced increase of beta glucuronidase (DE(50) 90+/-7 mg/kg). Histopathological studies showed inhibition in cellular infiltration and reduction of synovial hyperplasia and synovitis, whereas in the second test, histopathological and ultrastructural studies showed that topical application of FAM induced orthokeratosis with the presence of keratohyalin granules in the previously parakeratotic adult mouse tail, and without effects on epidermal thickness. The ED(50) of FAM in this model was 155+/-10 mg. The results of our studies showed that topical application of FAM exerts an important anti-inflammatory activity in both tests without evidence of irritant effects. The anti-inflamatory effects exerted by FAM may be due to its inhibitory effects on arachidonic acid metabolism. To our knowledge, this is the first report on the anti-inflammatory effect of sugar cane by-products in experimental models of arthritis and psoriasis.