Late-onset postoperative angioedema triggered by angiotensin-converting enzyme inhibitor: An emergent airway forethought

Angioedema is a potentially life-threatening condition due to the risk of airway compromise leading to deterioration of respiratory function, hypoxia, and ultimately, cardiopulmonary arrest. It can be either unprovoked or triggered by pharmaceutical agents, emotional or physiologic factors, upper airway trauma, or surgical stress. A 46-year-old man previously prescribed perindopril developed angioedema of the tongue 4 h after being discharged from the Post Anesthesia Care Unit (PACU). A multidisciplinary team was called and they outlined an airway management strategy to use in the event of worsening. The strategy consisted of either fiberoptic intubation by an anesthesiologist or surgical tracheostomy performed by the surgical team, both performed with the patient awake and in spontaneous ventilation. The aim of this case report is to raise awareness that angioedema is a potentially life-threatening condition. For optimal management, it is important to prepare in advance a detailed airway management strategy to be implemented by a multidisciplinary team.

Real-world EGFR testing practices for non-small-cell lung cancer by thoracic pathology laboratories across Europe

BACKGROUND

Testing for epidermal growth factor receptor (EGFR) mutations is an essential recommendation in guidelines for metastatic non-squamous non-small-cell lung cancer, and is considered mandatory in European countries. However, in practice, challenges are often faced when carrying out routine biomarker testing, including access to testing, inadequate tissue samples and long turnaround times (TATs).

MATERIALS AND METHODS

To evaluate the real-world EGFR testing practices of European pathology laboratories, an online survey was set up and validated by the Pulmonary Pathology Working Group of the European Society of Pathology and distributed to 64 expert testing laboratories. The retrospective survey focussed on laboratory organisation and daily EGFR testing practice of pathologists and molecular biologists between 2018 and 2021.

RESULTS

TATs varied greatly both between and within countries. These discrepancies may be partly due to reflex testing practices, as 20.8% of laboratories carried out EGFR testing only at the request of the clinician. Many laboratories across Europe still favour single-test sequencing as a primary method of EGFR mutation identification; 32.7% indicated that they only used targeted techniques and 45.1% used single-gene testing followed by next-generation sequencing (NGS), depending on the case. Reported testing rates were consistent over time with no significant decrease in the number of EGFR tests carried out in 2020, despite the increased pressure faced by testing facilities during the COVID-19 pandemic. ISO 15189 accreditation was reported by 42.0% of molecular biology laboratories for single-test sequencing, and by 42.3% for NGS. 92.5% of laboratories indicated they regularly participate in an external quality assessment scheme.

CONCLUSIONS

These results highlight the strong heterogeneity of EGFR testing that still occurs within thoracic pathology and molecular biology laboratories across Europe. Even among expert testing facilities there is variability in testing capabilities, TAT, reflex testing practice and laboratory accreditation, stressing the need to harmonise reimbursement technologies and decision-making algorithms in Europe.

Minimally invasive vessel-preservation spleen preserving distal pancreatectomy-how I do it, tips and tricks and clinical results

BACKGROUND

Minimally invasive spleen-preserving distal pancreatectomy (SPDP) has emerged as a parenchyma-preserving approach and has become the standard treatment for pancreatic benign and low-grade malignant lesions. Nevertheless, minimally invasive SPDP is still technically challenging, especially when vessel preservation is intended. This study aims to describe the technique and outcomes of laparoscopic (LSPDP) and robot-assisted spleen-preserving distal pancreatectomy (RSPDP) with intended vessel preservation, highlighting the important tips and tricks to overcome technical obstacles and optimize surgical outcomes.

METHODS

A retrospective observational study of consecutive patients undergoing LSPDP and RSPDP with intended vessel preservation by a single surgeon in two different centers. A video demonstrating both surgical techniques is attached.

RESULTS

A total of 50 patients who underwent minimally invasive SPDP were included of which 88% underwent LSPDP and 12% RSPDP. Splenic vessels were preserved in 37 patients (74%) while a salvage vessel-resecting technique was performed in 13 patients (26%). The average surgery time was 178 ± 74 min for the vessel-preserving and 188 ± 57 for the vessel-resecting technique (p = 0.706) with an estimated blood loss of 100 mL in both groups (p = 0.663). The overall complication rate was 46% (n = 23) with major complications (Clavien Dindo ≥ III) observed in 14% (n = 7) of the patients. No conversions occurred. The median length of hospital stay was 4 days.

CONCLUSION

This study presented the results after minimally invasive SPDP with intended vessel preservation by a highly experienced pancreatic surgeon. It provided tips and tricks to successfully accomplish a minimally invasive SPDP, which can contribute to quick patient rehabilitation and optimal postoperative results.

Radiotherapy skin marking with lancets versus electric marking pen - Comfort, satisfaction, effectiveness and cosmesis results from the randomized, double-blind COMFORTATTOO trial

INTRODUCTION

Set-up skin markings are performed, in several centers, for radiotherapy (RT) treatments. This study aimed to compare two permanent methods: lancets and an electric marking pen, the Comfort Marker 2.0® (CM).

METHODS

This was a prospective, unicentric, randomized study. Patients aged 18 years or older referred to our department to receive RT were recruited. Patients were randomly assigned, in a 1:1 ratio, to receive set-up markings using lancets or CM. The markings arrangement followed our departmental protocols. The coprimary endpoints were patients' comfort and effectiveness. Secondary endpoints included radiation therapists (RTTs) satisfaction and cosmesis.

RESULTS

Between October 2021 and January 2022, 100 patients were enrolled (50 received lancets and 50 CM) and assessed for the comfort and satisfaction outcomes. CM was significantly less painful than the lancets, with 44% and 16% of the patients, respectively, considering the tattooing process painless (RR = 2.75; 95% IC: 1.36 - 5.58). On the RTT-reported satisfaction, CM had significantly easier processes than lancets (98.0% vs. 78.0%, respectively; RR = 1.26; 95% CI: 1.08 - 1.46). For effectiveness and cosmesis assessment, 98 patients were analyzed (48 received lancets and 50 CM). Patients receiving CM had a significantly higher proportion of markings graded as good and excellent compared to those receiving lancets (98.0% and 50.0%, respectively, had ≥75% of the tattoos assessed as good/excellent, RR = 1.96; 95% CI: 1.47 - 2.61). On the cosmetic evaluation, patients receiving CM had significantly better cosmetic markings, with a median score of 4.4 (vs. 3.5 for lancets, p <0.001).

CONCLUSION

The trial results demonstrated that tattooing with the CM is significantly less painful, more effective, easier to apply, and cosmetically superior to tattooing with lancets.

IMPLICATIONS FOR PRACTICE

Tattooing with CM allows for better results regarding pain, quality, ease and cosmesis.

The production costs of Haemonchus contortus and other nematode parasites in pre-weaned beef calves in New Zealand

Haemonchus contortus can frequently be found infecting pre-weaned beef calves on sheep and beef farms around the North Island of New Zealand. The purpose of this study was to consider whether the presence of this parasite alone, or as part of a mixed infection, could be impacting growth rates of young animals, on three commercial farms in the North Island of New Zealand. Trials were conducted on commercial sheep and beef farms in each of the Northland, King Country and Gisborne regions, in late summer/autumn (February to April) of 2016 to measure the effect of treatment with narrow and broad spectrum anthelmintics on liveweight gain of spring-born calves pre-weaning. Each farm was chosen based on the presence of Haemonchus and that it was a beef cow/calf system with the cows and calves grazing the same pastures as sheep at some stage. Three sampling visits were made to each farm with the animals being weighed, faecal sampled and treated with one of two anthelmintics (Closantel alone to remove only Haemonchus or a triple combination containing moxidectin, levamisole and oxfendazole to remove all nematodes) or left untreated, on each of the first two visits. There was no significant difference in liveweight gain between any of the treatment groups, hence there was no evidence for an impact of Haemonchus alone, or a mixed nematode infection, on pre-weaned calf growth rates on these farms. It remains unclear whether there may be a justification to consider treatment of calves should they constitute a significant source of pasture larval infestation with H. contortus, in an integrated cattle-sheep system.

Laryngeal perforation during Sistrunk procedure

Thyroglossal duct cyst (TGDC) is the most common congenital neck anomaly in childhood, although it can be diagnosed at any age group. Ultrasound of the thyroid gland and the neck structures is an appropriate tool for diagnosis.

The authors aim to report a rare case of a 22-year-old male with a laryngeal perforation during a TGDC excision and raise awareness to this potentially life-threatening complication.

The Sistrunk procedure is the surgical treatment of choice with a low morbidity and recurrence rates.

The role of sheep (Ovis aries) in maintaining Theileria orientalis Ikeda type infection

Theileria orientalis is a tick‒borne intracellular parasite of red blood cells that causes severe and mild infections in various ruminants worldwide. To date there have been 11 types identified within this species, of which 4 types are presently found in New Zealand cattle. Since 2012, New Zealand has suffered a substantial epidemic of infectious bovine anaemia in both dairy and beef cattle associated with the Ikeda type. The speed at which the disease spread through the North Island suggested that other species could have been involved in transmission. The aim of a series of related experiments was to test the null hypothesis that sheep cannot maintain T. orientalis Ikeda type infection or infect ticks that feed on them. Several studies were conducted over 2 years to address this hypothesis which together showed that sheep can have detectable levels of T. orientalis Ikeda type infection in both the acute and chronic phase and that Haemaphysalis longicornis larvae can become infected when feeding on sheep. No anaemia, weight loss or clinical disease was recorded in the sheep in the acute phase of infection. The levels of infection recorded in the sheep were much lower than those found in cattle, consistent with the sheep being asymptomatic carriers of T. orientalis Ikeda type infection.

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

METHODS

This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

FINDINGS

Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

INTERPRETATION

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

FUNDING

National Institute for Health Research Global Health Research Unit.

Clinical and molecular practice of European thoracic pathology laboratories during the COVID-19 pandemic. The past and the near future

Background

This study evaluated the consequences in Europe of the COVID-19 outbreak on pathology laboratories orientated toward the diagnosis of thoracic diseases.

Materials and methods

A survey was sent to 71 pathology laboratories from 21 European countries. The questionnaire requested information concerning the organization of biosafety, the clinical and molecular pathology, the biobanking, the workload, the associated research into COVID-19, and the organization of education and training during the COVID-19 crisis, from 15 March to 31 May 2020, compared with the same period in 2019.

Results

Questionnaires were returned from 53/71 (75%) laboratories from 18 European countries. The biosafety procedures were heterogeneous. The workload in clinical and molecular pathology decreased dramatically by 31% (range, 3%-55%) and 26% (range, 7%-62%), respectively. According to the professional category, between 28% and 41% of the staff members were not present in the laboratories but did teleworking. A total of 70% of the laboratories developed virtual meetings for the training of residents and junior pathologists. During the period of study, none of the staff members with confirmed COVID-19 became infected as a result of handling samples.

Conclusions

The COVID-19 pandemic has had a strong impact on most of the European pathology laboratories included in this study. Urgent implementation of several changes to the organization of most of these laboratories, notably to better harmonize biosafety procedures, was noted at the onset of the pandemic and maintained in the event of a new wave of infection occurring in Europe.

•

Biosafety measures used in the first wave of the COVID-19 crisis were heterogeneous in 53 European pathology laboratories.

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A dramatic decrease of the workload in pathology laboratories was noted.

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No case of healthcare workers contaminated with SARS-CoV-2 associated with samples handling was identified.

Association between genetic polymorphisms in the promoter region of the defensin beta 1 gene and persistent apical periodontitis

AIM

To evaluate the association between the promoter region of defensin beta 1 (DEFB1) genetic polymorphisms and persistent apical periodontitis (PAP) in Brazilian patients.

METHODOLOGY

Seventy-three patients with post-treatment PAP (PAP group) and 89 patients with root filled teeth with healed and healthy periradicular tissues (healed group) were included (all teeth had apical periodontitis lesions at the beginning of the treatment). Patients who had undergone at least 1 year of follow-up after root canal treatment were recalled, and their genomic DNA was extracted from saliva. Two single nucleotide polymorphisms (SNPs) in DEFB1 at the g. -52G>A (rs1799946) and g. -20G>A (rs11362) positions were analysed using real-time polymerase chain reaction. The chi-squared test was performed, and the odds ratios were calculated using Epi Info 3.5.2. Logistic regression analysis in the codominant model, using the time of follow-up as a variable, was used to evaluate the SNP-SNP interaction. All tests were performed with an established alpha of 0.05 (P = 0.05).

RESULTS

For the rs11362 polymorphism in the codominant and recessive models, patients who carried two copies of the T allele had a significantly lower risk of developing PAP (P = 0.040 and P = 0.031, respectively). For the rs1799946 polymorphism in DEFB1 in the codominant and recessive models, carrying one copy of the T allele significantly increased the risk of developing PAP (P = 0.007 and P = 0.031, respectively). In the logistic regression, both polymorphisms were associated with PAP as well as the SNP-SNP interaction (P < 0.0001).

CONCLUSIONS

Polymorphisms in DEFB1 genes were associated with the development of post-treatment persistent apical periodontitis.

Validation of hair type diversification for recruiting shampoo panelists without losing data relevance

A sensory descriptive method is used by the industries to characterize their various products under development. The sensory panelists are recruited through some general criteria suggested in International Standard Sensory Analysis - General guidelines for the selection, training and monitoring of selected assessors and expert sensory assessors [5] but for hair product evaluation, some hair criteria should also be considered, as a major challenge lied in the difficulty to recruit panelists. Such an issue led us to find practical solutions to make this recruitment easier. Among others, one possible solution was to restrict some requirements in the characteristics of hair. This study aimed at checking if a hair type diversification on either sensitization or curliness could influence the sensory perception of shampoos, and, if so, to which extent. This study demonstrates that, for a shampoo trained panel, the evaluation is impacted by the hair curliness but is not impacted by the hair sensitization level.

Large mucinous cystic neoplasm of the pancreas during pregnancy: a case report

Mucinous cystic neoplasms (MCNs) of the pancreas occurring during pregnancy constitute a rare condition requiring special management due to its large size, malignant potential and the risk of fetal growth restriction. The key points to manage MCNs are to perform a correct diagnosis, accurately evaluate the grade of malignant potential in order to establish the right time for pancreatic surgery and to choose the most appropriate fetal mode of delivery. We describe a case of an incidental abdominal mass detected in a third-trimester pregnant woman. At surgery, a huge pancreatic cystic tumour was found and a distal pancreatectomy with splenic preservation was performed. The histopathological analysis revealed an MCN of the pancreas with low-grade dysplasia. To our knowledge, this is the largest pancreatic MCN detected in a pregnant woman reported in the literature and one of the few successfully resected after vaginal delivery.

Response to Comment on "Tropical forests are a net carbon source based on aboveground measurements of gain and loss"

The Hansen et al critique centers on the lack of spatial agreement between two very different datasets. Nonetheless, properly constructed comparisons designed to reconcile the two datasets yield up to 90% agreement (e.g., in South America).

Wooden-Breast, White Striping, and Spaghetti Meat: Causes, Consequences and Consumer Perception of Emerging Broiler Meat Abnormalities

Ten years ago, the occurrence of macroscopic defects in breasts muscles from fast-growing broilers challenged producers and animal scientists to label and characterize myopathies wholly unknown. The distinctive white striations in breasts affected by white striping disorder, the presence of out-bulging and pale areas of hardened consistency in the so-called wooden breast, and the separation of the fiber bundles in breasts labelled as spaghetti meat, made these myopathies easily identified in chicken carcasses. Yet, the high incidence of these myopathies and the increasing concern by producers and retailers led to an unprecedented flood of questions on the causes and consequences of these abnormal chicken breasts. This review comprehensively collects the most relevant information from studies aimed to understand the pathological mechanisms of these myopathies, their physicochemical and histological characterization and their impact on meat quality and consumer's preferences. Today, it is known that the occurrence is linked to fast-growth rates of the birds and their large breast muscles. The muscle hypertrophy along with an unbalanced growth of supportive connective tissue leads to a compromised blood supply and hypoxia. The occurrence of oxidative stress and mitochondrial dysfunction leads to lipidosis, fibrosis, and overall myodegeneration. Along with the altered appearance, breast muscles affected by the myopathies display poor technological properties, impaired texture properties, and reduced nutritional value. As consumer's awareness on the occurrence of these abnormalities and the concerns on animal welfare arise, efforts are made to inhibit the onset of the myopathies or alleviate the severity of the symptoms. The lack of fully effective dietary strategies leads scientists to propose whether "slow" production systems may alternatively provide with poultry meat free of these myopathies.

Improving outcome in congenital diaphragmatic hernia - experience of a tertiary center without ECMO

BACKGROUND

Congenital diaphragmatic hernia (CDH) has a high mortality rate, representing a therapeutic challenge. Prenatal diagnosis (PND) is essential in defining optimal perinatal strategy, particularly delivery planning. Hospital Pediátrico de Coimbra is the referral centre for all neonatal surgery, particularly CDH, for the central region of Portugal. The aim was to evaluate clinical management and outcome of newborns with CDH.

METHODS

An exploratory retrospective study made up of newborns admitted to PICU with CDH was undertaken between January 1995 and December 2014. Two groups were formed based on their year of admission: group A (1995- 2004) and group B (2005- 2014) and were compared.

RESULTS

The mean birth weight of the 69 newborns admitted was 2.762 ± 696 g; the median of the gestational age was 38 weeks. Associated malformations were observed in 28 (40.5%) and 15 (21.7%) had a right-sided diaphragm defect. The global mortality was 13.0%; in group A was significantly higher than in group B (22.2 vs 3.0%; p = 0.029). A reduction in mortality throughout the years was confirmed after adjusting for POS score (OR = 0.77; 95% CI: 0.62- 0.96, p = 0.021). PND was made in 30.6% of cases in the group A and 66.7% in the group B (p = 0.03). Tertiary perinatal hospital birth was achieved in 60% of newborns in the group A versus 84.8% in group B (p = 0.022). Maximum fraction of inspired oxygen showed a statistically significant difference between the two study groups (60% vs 40%; p = 0.009).

CONCLUSIONS

A significant decrease in mortality was observed throughout the study. The authors highlight the increase in prenatal diagnosis and an improvement in perinatal care with planning delivery as important contributors to these results.

Evaluation of a single extraction test to estimate the human oral bioaccessibility of potentially toxic elements in soils: Towards more robust risk assessment

Intake of soil by children and adults is a major exposure pathway to contaminants including potentially toxic elements (PTEs). However, only the fraction of PTEs released in stomach and intestine are considered as bioaccessible and results from routine analyses of the total PTE content in soils, therefore, are not necessarily related to the degree of bioaccessibility. Experimental methods to determine bioaccessibility usually are time-consuming and relatively complicated in terms of analytical procedures which limits application in first tier assessments. In this study we evaluated the potential suitability of a recently developed single extract method (ISO-17586:2016) using dilute (0.43M) nitric acid (HNO₃) to mimic the bioaccessible fraction of PTEs in soils. Results from 204 soils from Portugal, Brazil and the Netherlands including all major soil types and a wide range of PTEs' concentrations showed that the extraction efficiency using 0.43M HNO₃ of Ba, Cd, Cu, Ni, Pb and Zn in soils is related to that of in vitro methods including the Simple Bioaccessibility Extraction Test (SBET) and Unified BARGE Method (UBM). Also, differences in the degree of bioaccessibility resulting from differences in parent material, geology and climate conditions did not affect the response of the 0.43M HNO₃ extraction which is a prerequisite to be able to compare results from different soils. The use of 0.43M HNO₃ as a first screening of bioaccessibility therefore offers a robust and representative way to be included in first tier standard soil tests to estimate the oral bioaccessibility.

CAPSULE

The single dilute (0.43M) nitric acid extraction can be used in first tier soil risk assessment to assess both geochemical reactivity and oral bioaccessibility of PTEs.

Hepatitis C Virus Eradication in Kidney Transplant Recipients: A Single-Center Experience in Portugal

INTRODUCTION

Hepatitis C (HCV) is a major cause of liver impairment post-kidney transplantation (KT). Anti-HCV direct-acting antivirals (DAA) made viral eradication possible.

METHODS

We performed a retrospective review of KT patients (n = 23) who received DAA at our hospital. Sustained viral response (SVR) was defined as absence of viral detection 12 weeks after cessation of therapy.

RESULTS

From 1985 to September 2017, 1440 patients underwent transplantation at Hospital Santa Cruz. From a total of 32 HCV RNA+ KT recipients on follow-up, we describe the first 23 patients treated with DAA. They were 56.7 ± 9.1 years old; 22 were white, 52.2% were males, they underwent transplantation 18.8 ± 9.0 years ago, and 13 had genotype 1B, 21 were naïve, and 9 had stages F3/F4. All but 2 patients, treated with grazoprevir/elbasvir, received sofosbuvir (18 with ledispasvir, 2 with daclastavir, and 4 with simultaneous ribavirin). Pretreatment, intra-treatment, and post-treatment creatinine clearances were 61.4, 60.6, and 60.7 mL/min/1.73 m², respectively (not significant [NS]). Cyclosporine A was the basis of immunosuppression in the majority [(n = 14); pretreatment and intra-treatment levels were 79.5 ± 23.0 and 91.8 ± 26.0 ng/mL, respectively (P = .08)]; tacrolimus (n = 8) and mammalian target of rapamycin (mTOR) levels (n = 5) were also similar. One patient interrupted ribavirin after 7 weeks due to anemia; all other patients completed the treatment course without major side effects. Only 3 patients presented positive viral RNA at the fourth week of treatment and SVR was achieved in 100% of the patients 12 weeks after treatment.

CONCLUSIONS

DAA therapy was well tolerated and effective in 100% of our treated patients, without significant impact on the renal function or on the immunosuppression.

Proteostasis in epicardial versus subcutaneous adipose tissue in heart failure subjects with and without diabetes

BACKGROUND

Cardiovascular diseases (CVDs) are leading cause of death and primary cause of morbidity and mortality in diabetic population. Epicardial adipose tissue (EAT) covers the heart's surface and is a source of biomolecules regulating heart and blood vessel physiology. The protective activation of the unfolded protein response (UPR) and autophagy allows the cardiomyocyte reticular network to restore energy and/or nutrient homeostasis and to avoid cell death. However, an excessive or prolonged UPR activation can trigger cell death. UPR activation is an early event of diabetic cardiomyopathies and deregulated autophagy is associated with CVDs.

RESULTS

An upregulation of UPR markers (glucose-regulated protein 78 KDa, glucose-regulated protein 94 KDa, inositol-requiring enzyme 1α, protein kinase RNA-like ER kinase and CCAAT/-enhancer-binding protein homologous protein (CHOP) gene) in EAT compared to subcutaneous adipose tissue (SAT), was observed as well as the UPR-related apoptosis marker caspase-4/procaspase-4 ratio but not in CHOP protein levels. Additionally, levels of ubiquitin and ubiquitinated proteins were decreased in EAT. Moreover, upregulation of autophagy markers (5' adenosine monophosphate-activated protein kinase, mechanistic target of rapamycin, Beclin 1, microtubule-associated protein light chain 3-II, lysosome-associated membrane protein 2, and PTEN-induced putative kinase 1) was observed, as well as an increase in the apoptotic Bim but not the ratio between Bim and the anti-apoptotic Bcl-2 in EAT. Diabetic patients show alterations in UPR activation markers but not in autophagy or apoptosis markers.

CONCLUSION

UPR and autophagy are increased in EAT compared to SAT, opening doors to the identification of early biomarkers for cardiomyopathies and novel therapeutic targets.

Idiopathic pulmonary fibrosis in the era of antifibrotic therapy: Searching for new opportunities grounded in evidence

Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal lung disease that up to now has been associated with a poor prognosis. However, the results of the INPULSIS and ASCEND trials and the approval of nintedanib and pirfenidone have marked the beginning of a new era for IPF patients. Questions remain, however. Should these drugs be used earlier? What effect will they have on more severe disease? Will their effects last beyond the trial period? This manuscript is the outcome of a multidisciplinary meeting between pulmonology, radiology, and pathology clinicians on the use of antifibrotic agents in IPF. In our opinion, the existing data show that pirfenidone and nintedanib slow functional decline in early stages of disease. These drugs also appear to result in therapeutic benefits when administered to patients with advanced disease at diagnosis and maintain effective over time. The data also suggest that continuing antifibrotic therapy after disease progression may confer benefits, but more evidence is needed. Early diagnosis and treatment are crucial for reducing functional decline, slowing disease progression, and improving quality of life.

Identifying multiple stressor controls on phytoplankton dynamics in the River Thames (UK) using high-frequency water quality data

River phytoplankton blooms can pose a serious risk to water quality and the structure and function of aquatic ecosystems. Developing a greater understanding of the physical and chemical controls on the timing, magnitude and duration of blooms is essential for the effective management of phytoplankton development. Five years of weekly water quality monitoring data along the River Thames, southern England were combined with hourly chlorophyll concentration (a proxy for phytoplankton biomass), flow, temperature and daily sunlight data from the mid-Thames. Weekly chlorophyll data was of insufficient temporal resolution to identify the causes of short term variations in phytoplankton biomass. However, hourly chlorophyll data enabled identification of thresholds in water temperature (between 9 and 19°C) and flow (<30m(3)s(-1)) that explained the development of phytoplankton populations. Analysis showed that periods of high phytoplankton biomass and growth rate only occurred when these flow and temperature conditions were within these thresholds, and coincided with periods of long sunshine duration, indicating multiple stressor controls. Nutrient concentrations appeared to have no impact on the timing or magnitude of phytoplankton bloom development, but severe depletion of dissolved phosphorus and silicon during periods of high phytoplankton biomass may have contributed to some bloom collapses through nutrient limitation. This study indicates that for nutrient enriched rivers such as the Thames, manipulating residence time (through removing impoundments) and light/temperature (by increasing riparian tree shading) may offer more realistic solutions than reducing phosphorus concentrations for controlling excessive phytoplankton biomass.

Phytoplankton community responses in a shallow lake following lanthanum-bentonite application

The release of phosphorus (P) from bed sediments to the overlying water can delay the recovery of lakes for decades following reductions in catchment contributions, preventing water quality targets being met within timeframes set out by environmental legislation (e.g. EU Water Framework Directive: WFD). Therefore supplementary solutions for restoring lakes have been explored, including the capping of sediment P sources using a lanthanum (La)-modified bentonite clay to reduce internal P loading and enhance the recovery process. Here we present results from Loch Flemington where the first long-term field trial documenting responses of phytoplankton community structure and abundance, and the UK WFD phytoplankton metric to a La-bentonite application was performed. A Before-After-Control-Impact (BACI) analysis was used to distinguish natural variability from treatment effect and confirmed significant reductions in the magnitude of summer cyanobacterial blooms in Loch Flemington, relative to the control site, following La-bentonite application. However this initial cyanobacterial response was not sustained beyond two years after application, which implied that the reduction in internal P loading was short-lived; several possible explanations for this are discussed. One reason is that this ecological quality indicator is sensitive to inter-annual variability in weather patterns, particularly summer rainfall and water temperature. Over the monitoring period, the phytoplankton community structure of Loch Flemington became less dominated by cyanobacteria and more functionally diverse. This resulted in continual improvements in the phytoplankton compositional and abundance metrics, which were not observed at the control site, and may suggest an ecological response to the sustained reduction in filterable reactive phosphorus (FRP) concentration following La-bentonite application. Overall, phytoplankton classification indicated that the lake moved from poor to moderate ecological status but did not reach the proxy water quality target (i.e. WFD Good Ecological Status) within four years of the application. As for many other shallow lakes, the effective control of internal P loading in Loch Flemington will require further implementation of both in-lake and catchment-based measures. Our work emphasizes the need for appropriate experimental design and long-term monitoring programmes, to ascertain the efficacy of intervention measures in delivering environmental improvements at the field scale.

Sentidos da Saúde numa Perspectiva de Gênero: um Estudo com Homens da Cidade de Natal/RN

Resumo O presente trabalho objetivou investigar os sentidos atribuídos à saúde por homens da cidade de Natal/RN, em dois contextos: uma Unidade Básica de Saúde (UBS) de um bairro de classe média e uma Unidade de Saúde da Família (USF) de um bairro popular. Metodologicamente, realizamos entrevistas semiestruturadas junto a 24 homens, sendo 12 de cada serviço, com faixa etária de 25 a 59 anos, abordados nas unidades de saúde de cada bairro. A análise dos dados deu-se a partir da perspectiva de Spink (2000), e Spink e Frezza (2000) e Spink e Medrado (2000), no tocante às práticas discursivas e os estudos de gênero. Os dados encontrados acompanham a tendência de estudos já realizados no campo, especialmente ao identificar como as posições sociais de gênero conformam os sentidos que os homens investigados construíram em relação à saúde, atribuindo a esta a importância de proporcionar as condições de exercício de uma masculinidade voltada para o provimento do lar e da família. Houve diferença acerca dos sentidos sobre a resolução de problemas de saúde no tocante aos serviços investigados: a maioria do grupo da UBS apontou para pouca resolutividade, gerando sentidos de ineficácia do serviço. Na USF, os sentidos apresentaram uma positividade em relação ao serviço, que julgamos ter relação com a natureza da Estratégia de Saúde da Família. Finalmente, identificamos como a busca pelos serviços de saúde no nível de atenção básica é limitada, fato que segue os estudos de que os homens buscam os serviços de saúde quando esta se encontra demandando atenção especializada. Concluímos que a PNAISH pode ter uma importante contribuição na medida em que se efetive como política de saúde, sensibilizando a toda a rede de atores e serviços envolvidos na busca por novos sentidos e práticas em torno da relação gênero-saúde.

Influence of different mechanical stimuli in a multi-scale mechanobiological isotropic model for bone remodelling

This work represents a study of a mathematical model that describes the biological response to different mechanical stimuli in a cellular dynamics model for bone remodelling. The biological system discussed herein consists of three specialised cellular types, responsive osteoblasts, active osteoblasts and osteoclasts, three types of signalling molecules, transforming growth factor beta (TGF-β), receptor activator of nuclear factor kappa-b ligand (RANKL) and osteoprotegerin (OPG) and the parathyroid hormone (PTH). Three proposals for mechanical stimuli were tested: strain energy density (SED), hydrostatic and deviatoric parts of SED. The model was tested in a two-dimensional geometry of a standard human femur. The spatial discretization was performed by the finite element method while the temporal evolution of the variables was calculated by the 4th order Runge-Kutta method. The obtained results represent the temporal evolution of the apparent density distribution and the mean apparent density and thickness for the cortical bone after 600 days of remodelling simulation. The main contributions of this paper are the coupling of mechanical and biological models and the exploration of how the different mechanical stimuli affect the cellular activity in different types of physical activities. The results revealed that hydrostatic SED stimulus was able to form more cortical bone than deviatoric SED and total SED stimuli. The computational model confirms how different mechanical stimuli can impact in the balance of bone homeostasis.