Multisystemic RFC1-Related Disorder: Expanding the Phenotype Beyond Cerebellar Ataxia, Neuropathy, and Vestibular Areflexia Syndrome

Background and Objectives

The RFC1 spectrum has become considerably expanded as multisystemic features beyond the triad of cerebellar ataxia, neuropathy, and vestibular areflexia syndrome (CANVAS) have started to be unveiled, although many still require clinical replication. Here, we aimed to clinically characterize a cohort of RFC1-positive patients by addressing both classic and multisystemic features. In a second part of this study, we prospectively assessed small nerve fibers (SNF) and autonomic function in a subset of these RFC1-related patients.

Methods

We retrospectively enrolled 67 RFC1-positive patients from multiple neurologic centers in Portugal. All patients underwent full neurologic and vestibular evaluation, as well as neuroimaging and neurophysiologic studies. For SNF and autonomic testing (n = 15), we performed skin biopsies, quantitative sensory testing, sudoscan, sympathetic skin response, heart rate deep breathing, and tilt test.

Results

Multisystemic features beyond CANVAS were present in 82% of the patients, mainly chronic cough (66%) and dysautonomia (43%). Other features included motor neuron (MN) affection and motor neuropathy (18%), hyperkinetic movement disorders (16%), sleep apnea (6%), REM and non-REM sleep disorders (5%), and cranial neuropathy (5%). Ten patients reported an inverse association between cough and ataxia severity. A very severe epidermal denervation was found in skin biopsies of all patients. Autonomic dysfunction comprised cardiovascular (67%), cardiovagal (54%), and/or sudomotor (50%) systems.

Discussion

The presence of MN involvement, motor neuropathy, small fiber neuropathy, or extrapyramidal signs should not preclude RFC1 testing in cases of sensory neuronopathy. Indeed, the RFC1 spectrum can overlap not only with multiple system atrophy but also with hereditary motor and sensory neuropathy, hereditary sensory and autonomic neuropathy, and feeding dystonia phenotypes. Some clinical-paraclinical dissociations can pose diagnostic challenges, namely large and small fiber neuropathy and sudomotor dysfunction which are usually subclinical.

Home-based cardiac rehabilitation can reduce anxiety and depression in heart failure patients

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This work was financially supported by the project POCI-01-0145-FEDER-030011, funded by FEDER, through COMPETE2020-POCI, and by national funds, through FCT/MCTES (PTDC/MEC-CAR/30011/2017). CIAFEL, UnIC and UMIB are supported by national funds through Fundação para a Ciência e Tecnologia, I.P. [(UIDB/00617/2020), (UIDB/00051/2020 and UIDP/00051/2020), and (UIDB/00215/2020 and UIDP/00215/2020), respectively]. CS received an individual grant from CAPES [BEX 0554/14-6].

Introduction

The current COVID-19 pandemic has led to significant changes in physical and mental health and has become a major challenge for cardiac rehabilitation (CR) programs. CR is an essential component in the treatment of heart failure (HF), as it improves cardiorespiratory fitness and quality of life, as well as reducing hospitalization rates. COVID-19 pandemic increased social isolation, and the CR centers were closed. Center-based CR requires the patient to travel to the hospital, which increases the risk of SARS-CoV-2 infection in this high-risk population. In this context, home-based CR can be an excellent strategy to reduce the physical and mental consequences of the social isolation imposed by the COVID-19 pandemic.

Objective

To test the effectiveness of a home-based CR program on cardiorespiratory fitness and anxiety and depression levels in individuals with HF during covid-19 pandemic.

Methods

Forty-two individuals with HF (age: 61.3±12.0; LVEF: 37.5±11.2) were included in this study. The exercise training program consisted in 12 weeks of combined exercise training (2x/week; 60min/day, 60-80% VO2peak), with 4 supervised exercise sessions in the hospital context and the remaining at home. Patients were monitored using a heart rate monitor and weekly phone calls. The following parameters were evaluated: cardiorespiratory fitness through the 6-minute walk test (6MWT) and anxiety and depression levels through the Hospital Anxiety and Depression Scale (HADS).

Results

After the home-based CR program, there was a significant increase in the 6MWT of 49 meters (95%IC: 38 to 60; p<0.001) and a significant decrease in anxiety levels of -1.12 points (95%CI: - 2.163 to -0.075 p=0.036). No significant changes were found in depression levels (p=0.954). Furthermore, the improvements in cardiorespiratory fitness were significantly associated with the reduction in the levels of anxiety (r= -0.281; p=0.028) and depression (r=: -0.278; p=0.030).

Conclusions

The home-based CR program was able to improve cardiorespiratory fitness and this improvement was associated with a decrease in anxiety and depression levels in individuals with HF. The results suggest that home-based CR can be an important strategy to minimize the physical and mental impact induced by social isolation imposed by COVID-19 pandemic in HF patients.

Impact of a home-based cardiac rehabilitation program in heart failure during the COVID-19 pandemic

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This work was financially supported by the project POCI-01-0145-FEDER-030011, funded by FEDER, through COMPETE2020-POCI, and by national funds, through FCT/MCTES (PTDC/MEC-CAR/30011/2017). CIAFEL, UnIC and UMIB are supported by national funds through Fundação para a Ciência e Tecnologia, I.P. [(UIDB/00617/2020), (UIDB/00051/2020 and UIDP/00051/2020), and (UIDB/00215/2020 and UIDP/00215/2020), respectively]. CS received an individual grant from CAPES [BEX 0554/14-6].

Introduction

Cardiac rehabilitation (CR) is an evidence-based recommended treatment of heart failure (HF) patients. During the COVID-19 pandemic, the shutdown of CR centers was necessary to limit the infection risk among high-risk patients. The integration of a home-based CR (HBCR) program in CR units can help to improve the delivery of care and improve cardiovascular outcomes of HF patients.

Purpose

To assess the effectiveness of an HBCR program in HF patients.

Methods

This is a sub­study of the EXercise InTervention in Heart Failure trial (EXIT-HF), which include forty-nine HF patients (preserved and reduced ejection fraction). The HBCR program consisted in 12-week combined exercise program (60%-80% of peak oxygen consumption (VO2 peak)), 2 training sessions per week, for a total of 24 sessions. Patients performed 4 supervised training sessions and the remaining sessions at home. All patients performed a cardiopulmonary exercise test (VO2 peak), the 6-minute-walking test (6MWT), collected blood analysis (plasma NT-proBNP), and answered the Minnesota Living with Heart Failure Questionnaire.

Results

Forty-two patients (86%) complete at least 80% of prescribed training sessions (age: 61.1±12; FEVE: 37.1±10.8). The HBCR program improve VO2 peak from 18.3 to 20.1ml/kg/min (+1.8 ml/kg/min; 95%IC:1.4 to 2.4; p<0.001) and the walked distance at the 6MWT from 462 to 512 meters (+49 meters; 95%IC: 38 to 60; p<0.001). In addition, overall quality of life was improved (-13 points; 95%IC:-7.8 to -18.5; p<0.001), as well physical (-6.3 points; 95%IC:-3.5 to -9; p<0.001) and emotional dimension of quality of life (-2.8points ; 95%IC: -0.9 to -4.7; p=0.06). No significant change was found in NT-proBNP levels (820±1220 vs 674±903; p=0.285).

Conclusions

Our results showed that HBCR is feasible and can improve functional capacity and quality of life in HF patients.

Maternal and Child Health Pipeline Training Programs: A Description of Training Across 6 Funded Programs

Purpose

The HRSA-funded maternal and child health pipeline training programs (MCHPTPs) are a response to the critical need to diversify the MCH workforce, as a strategy to reduce health disparities in MCH populations. These MCHPTPs support students from undergraduate to graduate education and ultimately into the MCH workforce.

Description

The models and components of training across the six MCHPTPs funded in 2016–2021 are summarized, to examine the design and delivery of undergraduate pipeline training and the insights gained across programs.

Assessment

Strategies that emerged across training programs were organized into three themes: recruitment, support for student persistence (in education), and pipeline-to-workforce intentionality. Support for student persistence included financial support, mentoring, creating opportunity for students to develop a sense of belonging, and the use of research as a tool to promote learning and competitiveness for graduate education. Finally, the link to Maternal and Child Health Bureau (MCHB) long-term training and other MCHB opportunities for professional development contributed significant nuance to the pipeline-to-workforce objectives of these programs.

Conclusions

The MCHPTPs not only increase the diversity of the MCH workforce, they also actively prepare the next generation of MCH leaders. The intentional connection of undergraduates to the infrastructure and continuum of MCH training, underscores the comprehensive impact of this funding.

Impact of cardiac rehabilitation on inflammation in patients with ischaemic cardiomyopathy

Introduction

The benefits of cardiac rehabilitation (CR) in patients with ischaemic cardiomyopathy are well-known. However, inflammatory states have been associated to an increased risk of cardiovascular events.

Purpose

Evaluate the impact of CR in the serum levels of inflammatory biomarkers and identify potential predictors of that effect.

Methods

We retrospectively studied consecutive patients with ischaemic cardiomyopathy who completed a CR programme between 2011 and 2017. Patients underwent a supervised exercise training protocol, twice a week during a period of 8 to 12 weeks. Functional capacity was evaluated by metabolic equivalents assessed prior the beginning and 3 months after the programme with a symptom limited exercise treadmill test. Patients without levels of serum C-reactive protein at beginning and at the end of CR programme were excluded. Median variation of serum C-reactive protein was assessed and two groups were defined: one with levels above that and one with levels below.

Results

Of 250 patients (60.3±11.1 years, 84% male), 67% were admitted after an acute myocardial infarction. Left ventricular ejection fraction ≤40% before CR was present in 32% of individuals. Median levels of serum C-reactive protein before CR were 8.8 (3.1–21.7) mg/L and median variation after CRP was a decrease of 5.1 (0.9–17.7) mg/L (p&lt;0.001). Before CR, higher levels of serum C-reactive protein were seen in obese (15.7 [8–52.7] versus 8.8 [3.2–27.8], p=0.04) and those with higher NT-proBNP (p&lt;0.001). Patients with decrease of &gt;5.1mg/L of serum C-reactive protein had lower prevalence of hypertension (18% versus 30%, p=0.02), higher prevalence of obesity (16% versus 7%, p=0.03), lower levels of HDL cholesterol (38.3 [11.1] versus 43.2 [12.6], p&lt;0.001) and higher levels of NT-proBNP (1079 [610.3–1988] versus 488 [215–777], p&lt;0.001) at baseline. An increase of at least of 10% of functional capacity after CR was reached in 65% of patients, similar between groups. Patients with decrease of serum C-reactive protein &gt;5.1mg/L had also higher reduction of NT-proBNP after CR comparing to baseline (491.1 [142.7–948.5] versus 162.0 [30.9–295.2], p&lt;0.001).

Conclusions

Serum levels of inflammatory biomarkers decreased after CR in patients with ischaemic cardiomyopathy. Normotension, obesity, lower HDL and higher levels of natriuretic peptides are associated to a better response.

Funding Acknowledgement

Type of funding sources: None.

AB0754 THE INFLUENCE OF PHYSICAL ACTIVITY ON BODY COMPOSITION AND SELF-ESTEEM IN ADULTS WITH JUVENIL IDIOPATHIC ARTHRITIS

Background:

With improvement of treatment, long-term factors influencing quality of life have to be addressed in the care of juvenile idiopathic arthritis (JIA) patients.

Objectives:

To compare body composition, level of physical activity and self-esteem of adult patients with JIA with control group (CG).

Methods:

The levels of physical activity were analyzed using the International Physical Activity Questionnaire (IPAQ) short version. The body composition data were collected using the Omrom HBF 514 C vertical electric bioimpedance device. The Rosenberg Self-Esteem Scale was used to assess positive and negative attitude and feelings about themselves, where the lower the score, the higher the individual’s self-esteem. For the statistical analysis of the data, the IBM SPSS software was used with a significance index of p <0.05.

Results:

We included 81 individuals >18 years, 38 with JIA and 43 healthy people. The female sex was the largest participant in this research, being. There was no significant difference regarding sex [female =28 (73.7%) in JIA and 26 (60.5%) in CG] and age of the groups (29.39 ± 7.6 vs. 31.1 ± 3.1, p = 0.18). The CG showed greater height and body weight (163.5 ± 9.8 vs. 169.6 ± 8.0, p<0.001; 63.07 ± 16.65 vs. 69.33 ± 6.88, p = 0.003, respectively), but no difference in Body Mass Index (BMI) was observed (24.32 ± 4.9 vs. 24.12 ± 2.09, p = 0.8). JIA had a higher percentage of total fat mass (31.65 ± 10.20 vs. 28.47 ± 4.9, p = 0.07), while the CG had a higher percentage of total muscle mass (29.7 ± 6.5 vs. 35.86 ± 6.05, p<0.001). The self-esteem of JIA patients was lower than in the CG (21 ± 3.9 vs. 16.26 ± 4.3, p<0.001). In the IPAQ classifications, JIA patients were classified as less physically active than the CG (2.63% vs. 20.93%, p = 0.022), less irregularly active (5.26% vs. 23.25, p = 0.023) and a higher level of sedentary lifestyle (65.78% vs. 25.58%, p<0.001). A higher percentage of muscle mass was associated with greater self-esteem (r=-0.3; p=0.01).

Conclusion:

The low practice of physical activities by patients with JIA seems to directly influence both, their body composition and their self-esteem. These patients should be encouraged to increase physical activity from an early age by a multiprofessional healthcare team to seek improvement their quality of life.

Disclosure of Interests:

None declared

Clinical outcomes and trans-syndesmotic screw frequency after posterior malleolar fracture osteosynthesis

AIM

This study aimed to evaluate the clinical outcomes and the trans-syndesmotic screw frequency after trimalleolar ankle fractures with a posterior malleolus fracture involving <25% of the articular surface.

MATERIAL AND METHODS

Retrospective comparative study. Patients with trimalleolar ankle fracture who underwent surgery between January 2011 and January 2018 were identified within the departments' fracture database. General demographics, treatment details, and fracture specific details (CT-scans) were assessed. Patients were grouped per the posterior malleolus fragment treatment: osteosynthesis (group 1) and non-osteosynthesis (group 2).

RESULTS

64 patients, 58.6 ± 17.8 years (range: 23-75), 68.8% female were eligible and follow up time was 43.1 ± 22.2 (range 24-96) months. The mean size of the posterior malleolus fragment was 14.7 ± 5.3% (range: 5-24). Posterior malleolus fragment treatment distribution: osteosynthesis (group 1) 31.2% and non- osteosynthesis (group 2) 68.8%. Group 1 showed significantly better clinical outcomes (p<0.05), AOOS (93.9 ± 5.79 (range: 73-99), AOFAS (91.5 ± 6.22 (range: 72-100) and VAS (0.8 ± 1.22 (range: 0-5) compared to Group 2, AOOS (84.25±8.34 (range: 63-100); AOFAS (84.75±8.05 (range: 58-100) and VAS (1.7 ± 1.38 (range: 0-6). Osteosynthesis of the posterior malleolus fragment significantly reduced the frequency of trans-syndesmotic screw (0%) compared to non-osteosynthesis posterior malleolus fragment (15.9%) (p < 0.05). The EQ-5D score was better in group 1 (1.08±0.27 (range: 1-2.2) compared to group 2 (1.27 ± 0.27 (range: 1-2.4) but with no statistical significance (p> 0.15).

CONCLUSION

Posterior malleolus fragments (<25% of the articular surface) have significantly better clinical outcomes and significant decrease in trans-syndesmotic screw need following osteosynthesis.

Upgrading end-of-line residues of the red seaweed Gelidium sesquipedale to polyhydroxyalkanoates using Halomonas boliviensis

Agar extraction from Gelidium and Gracilaria red seaweed species produces hundred thousand ton of carbohydrate-rich residues annually. Gelidium sesquipedale waste biomass obtained after agar extraction, still contained 44.2 % w/w total carbohydrates (dry-weight basis). These residues were biologically up-graded to poly-3-hydroxybutyrate (P3HB) after saccharification of their carbohydrate fraction to simple sugars. A combined hydrolysis treatment using sulfamic acid followed by enzymatic hydrolysis with cellulases produced a glucose-rich hydrolysate with a negligible content of inhibitors. With this treatment a sugar yield of circa 30 % (g glucose/g biomass) was attained. The algal hydrolysates were assessed as carbon source for the production of P3HB by the halotolerant bacteria Halomonas boliviensis. A cell concentration of 8.3 g L-1 containing 41 % (w/w) of polymer and a yield (YP/S ) of 0.16 gpolymer/gglucose were attained in shake flask assays. In this work, cellulose-rich seaweed waste was shown to be an upgradable, sustainable source of carbohydrates.

P1349 POCUS by general and family physician - advancing physical examination

BACKGROUND

Alongside with the development of hand held equipment, echo is becoming more accessible to nontraditional settings. General and family medicine (GPs) are at the forefront of any health system, but the use of cardiac echo by GPs is still unexplored. PURPOSE: This study aims to evaluate the accuracy of echocardiography assessment performed as an extension of the physical exam by GPs. METHODS: Two GPs underwent standard echocardiography training for 6 months. Subsequently, patients with diabetes or arterial hypertension were submitted to an echocardiogram performed by their GPs using a pocket ultrasound. Views obtained (with and without color Doppler) were parasternal long and short axis, apical and subcostal, with measurements of the posterior wall (PW), interventricular septum (IVS), left ventricle (LV), left atrium (LA), aorta and inferior vena cava (IVC). Studies were reviewed at the workstation and measured by two experts who classified the exams according to the image quality. RESULTS: Sixty echocardiograms were analyzed (mean age of 61y, 42% females and 58% males). In 50% the image quality was considered sufficient, 42% considered good and 8% considered bad. There were statistically significant differences between the GPs and expert measurements on the sinus of Valsalva (30.3 ± 3 to 28.8 ± 3.1mm, p = 0.001), LV in systole (p &lt; 0.001, 28[24,31] for 31[29,34]mm), IVS (p = 0.001, 10.9 ± 1.7 for 10.1 ± 1.5mm), PW (p = 0.018, 8.7 ± 1.1 to 9.2 ± 1.6mm) and TAPSE (p = 0.021, 20.9 ± 2.3 to 20.1 ± 2.7mm). There were no significate differences in the measurements of the ascending aorta, LA, LV in diastole and IVC. Agreement between the GPs and the experts was moderate for the evaluation of LVH (k = 0.48). The concordance was substantial for evaluation of LV function (k = 0.66) and excellent for evaluation of pericardial effusion (k = 1) and right ventricular function (k = 1). Concordance was excellent for mitral insufficiency (k = 0.83) and substantial for aortic insufficiency (k = 0.68) and tricuspid insufficiency (k = 0.61). A case of mitral stenosis was identified by both. GPs signalized a case of mild aortic stenosis that the expert did not consider. CONCLUSION: GPs trained in echocardiography, using pocket ultrasound, can obtain cardiac images with sufficient quality for interpretation by experts in the majority of cases. In this study, differences in dimensions might be explained by interobserver variability and/or by the performance of measurements in different environments, mobile vs workstation. Overall the differences were minor and clinically meaningless.

Integrating road traffic externalities through a sustainability indicator

Road traffic poses negative externalities on society and represents a key challenge in sustainable transportation. However, the existing literature about the assessment of traffic externalities drawn on a common measure is scarce. This paper develops a sustainability indicator that integrates traffic-related externalities as means of traffic congestion, noise, greenhouse gases (GHG) and nitrogen oxides emissions, health impacts and road crash related costs, and adjusted to local contexts of vulnerability. Traffic, road crashes, acoustic and vehicle dynamic data were collected from one real-world intercity corridor pair comprising three alternative routes. The site-specific operations were characterized using a modeling platform of traffic, emissions, noise and air quality. A specific methodology is applied for each road traffic externality and translated in a single factor - external cost. The results indicated that road crashes presented the largest share in the partly rural/urban route while GHG emissions had the highest contribution in external costs for the highway routes. Also, the distribution of external cost component varied according to the type of road, mostly due to different levels of exposed inhabitants. This paper offers a line of research that produced a method for decision-makers with a reliable and flexible cost analysis aimed at reducing the negative impacts of road traffic. It also encourages the design of eco-traffic management policies considering the perspective of drivers, commuters and population.

Relationship between oro and nasopharynx permeability and the direction of facial growth

AIM

Most scientific literature relates vertical growth to individuals with decreased upper airway permeability. However, we often find subjects with a long face and a normal breathing pattern, most likely caused by other aetiological factors. And, frequently, we also find decreased upper airway permeability with horizontal growth. The aim of the study was to compare the cephalometric measurements of the oro and nasopharynx permeability with the facial growth direction and to identify the most common facial growth direction in individuals with decreased upper airway permeability.

MATERIALS AND METHODS

Cephalometric analysis was carried out in 158 pre-adolescent patients at the Orthodontic appointment, using facial profile teleradiographs. Parameters used were Jabarak's ratio and measurement of oro-nasopharynx space. Data collected were submitted to statistical treatment.

RESULTS

This study points to the presence of an intermediate growth in individuals with diminished oro and nasopharynx permeability, either simultaneous or separate. The number of individuals with diminished permeability and vertical growth is close to the number of individuals with horizontal growth.

CONCLUSIONS

The individuals with diminished permeability of the upper airway present an intermediate growth direction, representing the most frequent type. In the less common growth directions, there is a slight tendency to horizontal facial growth verified in individuals with diminished nasopharynx permeability. Also, a light tendency to vertical facial growth is present when oropharynx permeability is reduced.

Women Suffering through Their Bodies

This article is concerned with the nature of suffering as experienced by women struggling with problems related to the body. Since the body is viewed as integral in the formation of a woman's identity and self-concept, any illness, ailment, or deficiency associated with it may lead her to experience pain and suffering. To explore meanings of personal suffering, three contexts were chosen, namely familial breast cancer, eating disorders, and infertility. A qualitative approach, using the case study method, was adopted to provide rich descriptions of the different experiences of suffering. In-depth interviews were conducted with women living with familial breast cancer, eating disorders, and infertility. Two women were chosen for each context. The results show that for these women suffering manifested as loss, isolation, loneliness, anger, and emptiness. Suffering encompassed the physical, emotional, and social spheres, and entailed a deep and complex experience of pain. It was also evident that suffering remains a personal issue that depends on a person's life circumstances, personality, past and present experiences, the problem at hand, and the surrounding environment.

Hydrogen sensing via anomalous optical absorption of palladium-based metamaterials

A palladium (Pd)-based optical metamaterial has been designed, fabricated and characterized for its application in hydrogen sensing. The metamaterial can replace Pd thin films in optical transmission schemes for sensing with performances far superior to those of conventional sensors. This artificial material consists of a palladium-alumina metamaterial fabricated using inexpensive and industrial-friendly bottom-up techniques. During the exposure to hydrogen, the system exhibits anomalous optical absorption when compared to the well-known response of Pd thin films, this phenomenon being the key factor for the sensor sensitivity. The exposure to hydrogen produces a large variation in the light transmission through the metamembrane (more than 30% with 4% in volume hydrogen-nitrogen gas mixture at room temperature and atmospheric pressure), thus avoiding the need for sophisticated optical detection systems. An optical homogenization model is proposed to explain the metamaterial response. These results contribute to the development of reliable and low-cost hydrogen sensors with potential applications in the hydrogen economy and industrial processes to name a few, and also open the door to optically study the hydrogen diffusion processes in Pd nanostructures.

[Predictors of changes in functional capacity on a cardiac rehabilitation program]

INTRODUCTION

The effectiveness of cardiac rehabilitation programs (CRP) strongly influences the recovery of functional capacity (FC), resulting in improved prognosis and survival.

OBJECTIVE

To determine the cardiovascular risk factors that predict changes in FC in patients on CRP.

METHODS

We performed a cross-sectional descriptive retrospective study of patients who began a CRP between January 2008 and December 2013. The dependent variable was changes in FC estimated in metabolic equivalents (METs) achieved in stress testing at the beginning and end of the phase II program. The independent variables were age, gender, dyslipidemia, diabetes, smoking, body mass index, physical activity level and reason for referral to the CRP.

RESULTS

The sample included 1399 patients, of whom 1125 (80.4%) completed the program. FC improved in most patients (93%), with a mean gain of 1.45 ± 1.19 METs. Patients aged 45 -65 and over 65 years achieved a greater increase in FC compared with other age groups. Patients admitted to the CRP after coronary artery bypass graft surgery obtained a greater improvement in FC compared to patients with acute coronary syndrome. Non-diabetic patients benefited more than diabetic patients. No significant differences were seen between the groups in the other variables.

CONCLUSION

This study highlights the need for new and individualized approaches in certain subgroups of patients on CRP.

Differential expression of key regulators of Toll-like receptors in ulcerative colitis and Crohn's disease: a role for Tollip and peroxisome proliferator-activated receptor gamma?

The innate immune system is currently seen as the probable initiator of events which culminate in the development of inflammatory bowel disease (IBD) with Toll-like receptors (TLRs) known to be involved in this disease process. Many regulators of TLRs have been described, and dysregulation of these may also be important in the pathogenesis of IBD. The aim of this study was to perform a co-ordinated analysis of the expression levels of both key intestinal TLRs and their inhibitory proteins in the same IBD cohorts, both ulcerative colitis (UC) and Crohn's disease (CD), in order to evaluate the potential roles of these proteins in the pathogenesis of IBD. Of the six TLRs (TLRs 1, 2, 4, 5, 6 and 9) examined, only TLR-4 was increased significantly in IBD, specifically in active UC. In contrast, differential alterations in expression of TLR inhibitory proteins were observed. A20 and suppressor of cytokine signalling 1 (SOCS1) were increased only in active UC while interleukin-1 receptor-associated kinase 1 (IRAK-m) and B cell lymphoma 3 protein (Bcl-3) were increased in both active UC and CD. In contrast, expression of both peroxisome proliferator-activated receptor gamma (PPARγ) and Toll interacting protein (Tollip) was decreased in both active and inactive UC and CD and at both mRNA and protein levels. In addition, expression of both PPARγ and A20 expression was increased by stimulation of a colonic epithelial cell line Caco-2 with both TLR ligands and commensal bacterial strains. These data suggest that IBD may be associated with distinctive changes in TLR-4 and TLR inhibitory proteins, implying that alterations in these may contribute to the pathogenesis of IBD.

Surgical treatment of bronchiectasis: A review of 20 years of experience

BACKGROUND

Bronchiectasis is defined as an abnormal and irreversible dilation and distortion of the bronchi, which has numerous causes. Surgical treatment of this disease is usually reserved for focal disease and when the medical treatment is no longer effective. We report our center experience and outcomes in bronchiectasis surgery during the last 20 years.

METHODS

Between 1994 and 2014, sixty-nine patients underwent surgical resection for bronchiectasis. Patient demographics, presenting symptoms, indications for surgical treatment, type of lung resection, morbidity and mortality, as well as clinical follow-up and outcomes were analyzed.

RESULTS

From the 69 patients included, 31 (44.9%) were male and 38 (55.1%) were female. Surgery was indicated because of unsuccessful medical therapy in 33 patients (47.8%), haemoptysis in 22 patients (31.9%), nondiagnostic lung mass in 9 patients (13.0%) and lung abscess in 5 patients (7.3%). The surgical procedures were lobectomy in 45 (65.2%) patients, pneumonectomy in 10 (14.5%) patients, bilobectomy in 8 (11.6%) patients, lobectomy plus segmentectomy in 3 (4.3%) patients and only segmentectomy in 3 (4.3%) patients. Morbidity rate was 14.5% and there was no perioperative mortality. The follow-up was possible in 60 patients, with an outcome reported as excellent in 44 (73.3%) patients, as improved in 11 (18.3%) and as unchanged in 5 (8.3%).

CONCLUSION

Although the number of patients with bronchiectasis referred for surgical treatment has decreased, pulmonary resection still plays a significant role. Surgical resection of localized bronchiectasis is a safe procedure with proven improvement of quality of life for the majority of patients.

Increased titer and reduced lactate accumulation in recombinant retrovirus production through the down-regulation of HIF1 and PDK

Many mammalian cell lines used in the manufacturing of biopharmaceuticals exhibit high glycolytic flux predominantly channeled to the production of lactate. The accumulation of lactate in culture reduces cell viability and may also decrease product quality. In this work, we engineered a HEK 293 derived cell line producing a recombinant gene therapy retroviral vector, by down-regulating hypoxia inducible factor 1 (HIF1) and pyruvate dehydrogenase kinase (PDK). Specific productivity of infectious viral titers could be increased more than 20-fold for single gene knock-down (HIF1 or PDK) and more than 30-fold under combined down-regulation. Lactate production was reduced up to 4-fold. However, the reduction in lactate production, alone, was not sufficient to enhance the titer: high-titer clones also showed significant enrollment of metabolic routes not related to lactate production. Transcriptome analysis indicated activation of biological amines metabolism, detoxification routes, including glutathione metabolism, pentose phosphate pathway, glycogen biosynthesis and amino acid catabolism. The latter were validated by enzyme activity assays and metabolite profiling, respectively. High-titer clones also presented substantially increased transcript levels of the viral genes expression cassettes. The results herein presented demonstrate the impact of HIF1 and PDK down-regulation on the production performance of a mammalian cell line, reporting one of the highest fold-increase in specific productivity of infectious virus titers achieved by metabolic engineering. They additionally highlight the contribution of secondary pathways, beyond those related to lactate production, that can be also explored to pursue improved metabolic status favoring a high-producing phenotype.

Evaluation of helper-dependent canine adenovirus vectors in a 3D human CNS model

Gene therapy is a promising approach with enormous potential for treatment of neurodegenerative disorders. Viral vectors derived from canine adenovirus type 2 (CAV-2) present attractive features for gene delivery strategies in the human brain, by preferentially transducing neurons, are capable of efficient axonal transport to afferent brain structures, have a 30-kb cloning capacity and have low innate and induced immunogenicity in preclinical tests. For clinical translation, in-depth preclinical evaluation of efficacy and safety in a human setting is primordial. Stem cell-derived human neural cells have a great potential as complementary tools by bridging the gap between animal models, which often diverge considerably from human phenotype, and clinical trials. Herein, we explore helper-dependent CAV-2 (hd-CAV-2) efficacy and safety for gene delivery in a human stem cell-derived 3D neural in vitro model. Assessment of hd-CAV-2 vector efficacy was performed at different multiplicities of infection, by evaluating transgene expression and impact on cell viability, ultrastructural cellular organization and neuronal gene expression. Under optimized conditions, hd-CAV-2 transduction led to stable long-term transgene expression with minimal toxicity. hd-CAV-2 preferentially transduced neurons, whereas human adenovirus type 5 (HAdV5) showed increased tropism toward glial cells. This work demonstrates, in a physiologically relevant 3D model, that hd-CAV-2 vectors are efficient tools for gene delivery to human neurons, with stable long-term transgene expression and minimal cytotoxicity.

On-chip sample preparation and analyte quantification using a microfluidic aqueous two-phase extraction coupled with an immunoassay

Immunoassays are fast and sensitive techniques for analyte quantification, and their use in point-of-care devices for medical, environmental, and food safety applications has potential benefits of cost, portability, and multiplexing. However, immunoassays are often affected by matrix interference effects, requiring the use of complex laboratory extraction and concentration procedures in order to achieve the required sensitivity. In this paper we propose an integrated microfluidic device for the simultaneous matrix clean-up, concentration and detection. This device consists of two modules in series, the first performing an aqueous two-phase extraction (ATPE) for matrix extraction and analyte pre-concentration, and the second an immunoassay for quantification. The model analyte was the mycotoxin ochratoxin A (OTA) in a wine matrix. Using this strategy, a limit of detection (LoD) of 0.26 ng mL(-1) was obtained for red wine spiked with OTA, well below the regulatory limit for OTA in wines of 2 ng mL(-1) set by the European Union. Furthermore, the linear response on the logarithmic concentration scale was observed to span 3 orders of magnitude (0.1-100 ng mL(-1)). These results are comparable to those obtained for the quantification of OTA in plain buffer without an integrated ATPE (LoD = 0.15 ng mL(-1)). The proposed method was also found to provide similar results for markedly different matrices, such as red and white wines. This novel approach based on aqueous two-phase systems can help the development of point-of-care devices that can directly deal with real samples in complex matrices without the need for extra extraction processes and equipment.

Impact of adenovirus life cycle progression on the generation of canine helper-dependent vectors

Helper-dependent adenovirus vectors (HDVs) are safe and efficient tools for gene transfer with high cloning capacity. However, the multiple amplification steps needed to produce HDVs hamper a robust production process and in turn the availability of high-quality vectors. To understand the factors behind the low productivity, we analyzed the progression of HDV life cycle. Canine adenovirus (Ad) type 2 vectors, holding attractive features to overcome immunogenic concerns and treat neurobiological disorders, were the focus of this work. When compared with E1-deleted (ΔE1) vectors, we found a faster helper genome replication during HDV production. This was consistent with an upregulation of the Ad polymerase and pre-terminal protein and led to higher and earlier expression of structural proteins. Although genome packaging occurred similarly to ΔE1 vectors, more immature capsids were obtained during HDV production, which led to a ~4-fold increase in physical-to-infectious particles ratio. The higher viral protein content in HDV-producing cells was also consistent with an increased activation of autophagy and cell death, in which earlier cell death compromised volumetric productivity. The increased empty capsids and earlier cell death found in HDV production may partially contribute to the lower vector infectivity. However, an HDV-specific factor responsible for a defective maturation process should be also involved to fully explain the low infectious titers. This study showed how a deregulated Ad cycle progression affected cell line homeostasis and HDV propagation, highlighting the impact of vector genome design on virus-cell interaction.

Cardiac rehabilitation in patients with type 2 diabetes mellitus and coronary disease: a comparative study

INTRODUCTION AND AIMS

Diabetic patients have a 2-4 times higher risk of cardiovascular disease than non-diabetic individuals. The aims of this study are to evaluate the effects of a cardiac rehabilitation program (phase II) in patients with diabetes and coronary disease and to compare the results with regard to control of cardiovascular risk factors and improvement in functional capacity with coronary patients without diabetes.

METHODS

This was a prospective study of patients diagnosed with ischemic heart disease referred for a cardiac rehabilitation program between January 2009 and June 2013. The population was divided into two groups: diabetic and non-diabetic. Patients were assessed at the beginning of phase II and three months later and the following parameters were recorded: body mass index, waist circumference, lipid profile, blood glucose and glycated hemoglobin in diabetic patients, blood pressure, smoking, physical activity level (using the International Physical Activity Questionnaire) and functional capacity (on treadmill stress testing).

RESULTS

The study population consisted of 682 patients (253 diabetic and 429 non-diabetic). Diabetic patients were significantly older, had a worse cardiovascular risk profile (higher prevalence of overweight, dyslipidemia, hypertension and sedentary lifestyle) and lower functional capacity. At the end of phase II, there was a statistically significant improvement (p<0.05) in all risk factors and functional capacity, which was similar in both groups, except for body mass index, triglycerides and functional capacity.

CONCLUSIONS

Diabetic patients may benefit from a cardiac rehabilitation program and achieve comparable results to non-diabetic patients.

Successful use of extracorporeal membrane oxygenation for pulmonary embolism, prolonged cardiac arrest, post-partum: a cannulation dilemma

A 30-year-old female gravida 1 (37 weeks + 5 days gestation) underwent a crash Cesarean section for evidence of fetal distress, with the presumed diagnosis of placental abruption. Immediately post-op, the patient had a complete cardiovascular collapse with pulseless electrical activity, requiring cardiopulmonary resuscitation (CPR). Two doses of thrombolytics (Tenecteplase) were administered during the resuscitation, with a presumed diagnosis of a pulmonary embolism. After approximately 45 minutes into the resuscitation, the cardiac surgery team was called to initiate extracorporeal membrane oxygenation (ECMO).

CASE STUDY

Veno-arterial (V-A) ECMO was emergently attempted, with difficulty, through a left femoral cut-down approach and was successfully initiated 84 minutes into the resuscitation. Once the patient's blood pressure and oxygen saturations were stabilized, the cannulae were switched to the right groin, using a Dacron graft in an end-to-side fashion. The left groin vessels were small and spasmodic due to CPR, hypotension, hypovolemia and massive inotropes. The switch helped to facilitate repair of the left femoral vessels in order to restore perfusion to the left leg. Computer tomography (CT) demonstrated multiple pulmonary emboli at the sub-segmental branches bilaterally. The patient was transferred to the intensive care unit (ICU) with profound bleeding from all incisions and a massive transfusion protocol was instituted. ECMO flows varied, depending on the intravascular volume status of the patient. The patient was cooled to 33(o)C for cerebral protection. Initial blood work 5 minutes on from the initiation of ECMO revealed a pH of 7.10 and lactate >15 mmol/L. Over the next 12 hours, oxygen saturations in the right arm began to fall (29% right vs. 77% left); as the left ventricular ejection improved, the heart began to eject deoxygenated blood from the impaired pulmonary system. At the same time, the patient was developing an abdominal compartment syndrome from ongoing intraperitoneal bleeding. To avoid hypoxic cerebral and myocardial disruption of arterial ECMO flows from the femoral vessels during laparotomy, the decision was made to switch from the femoral to central right axillary artery cannulation in the hope of improving brain oxygenation for the procedure. The patient's hemodynamics and coagulation status stabilized, but, over the next few days, she developed a right arm compartment syndrome, requiring fasciotomies. At this time, her myocardial function improved and the patient was converted from V-A ECMO to a single, dual-lumen Avalon cannula for veno-venous (V-V) ECMO through the right internal jugular vein. It was felt that the lungs required more time to recover, therefore, V-V ECMO was used. The patient was weaned from V-V ECMO successfully on post-operative day (POD) 4. The duration of ECMO was 3.5 days (81 hours). The patient required 4 cannulation sites to optimize flow and perfusion with changing clinical conditions. On POD 46, the patient was discharged from hospital without any physical or neurological sequelae.