Loneliness impact on healthcare utilization in primary care: A retrospective study

BACKGROUND

An increased number of patients seek help for loneliness in primary care.

OBJECTIVE

To analyze whether loneliness was associated with a higher utilization of healthcare facilities.

METHODS

Observational, retrospective study based on the review of routinely coded data in the digital medical record system in a random sample of patients aged 65 or older, stratified by population size of their residence area. A minimum sample size was estimated at 892 medical records. Loneliness was defined as the negative feeling that arises when there is a mismatch between the quantity and quality of a person's social relationships and those, they desire. Thirty-three primary care nurses (30 females and 3 males) were reviewing the data.

RESULTS

A total of 932 medical records of patients were reviewed (72% belonged to female patients). Of these, 657 individuals were living alone (71.9%). DeJong Scale average scores was 8.9 points (SD 3.1, 95CI 8.6-9.1). The average annual attendance to primary care ranged from 12.2 visits per year in the case of family practice, 10.7 nurse, 0.7 social workers. The average number of home visits was 3.2, and the urgent consultations attended at health centers were 1.5 per year. Higher feelings of loneliness were associated with extreme values in the frequency of healthcare resource usage. Compared to their peers of the same age, the additional healthcare resource consumption amounted to €802.18 per patient per year.

CONCLUSION

Loneliness is linked to higher healthcare resource usage in primary care, with individuals experiencing poorer physical and mental health utilizing these resources up to twice as much as their peers of the same age.

Factors associated with unjustified chronic treatment with digoxin in patients with acute heart failure and relationship with short-term prognosis

OBJECTIVES

To analyze the factors related to inadequate chronic treatment with digoxin and whether the inadequacy of treatment has an impact on short-term outcome.

METHOD

Patients diagnosed with AHF who were in chronic treatment with digoxin, were selected. Digoxin treatment was classified as adequate or inadequate. We investigated factors associated to inadequacy and whether such inadequacy was associated with in-hospital and 30-day mortality, prolonged hospital stay (>7 days) and combined adverse event (re-consultation to the ED or hospitalization for AHF or death from any cause) during the 30 days after discharge.

RESULTS

We analyzed 2,366 patients on chronic digoxin treatment (median age = 83 years, women = 61%), which was considered adequate in 1,373 cases (58.0%) and inadequate in 993 (42.0%). The inadequacy was associated with older age, less comorbidity, less treatment with beta-blockers and renin-angiotensin inhibitors, better ventricular function, and worse Barthel index. In-hospital and 30-day mortality was higher in patients with inadequate digoxin treatment (9.9% versus 7.6%, p = 0.05; and 12.6% versus 9.1%, p < 0.001, respectively). No differences were recorded in prolonged stay (35.7% versus 33.8%) or post-discharge adverse events (32.9% versus 31.8%). In the model adjusted for baseline and decompensation episode differences, inadequate treatment with digoxin was not significantly associated with any outcome, with an odds ratio of 1.31 (95%CI = 0.85-2.03) for in-hospital mortality; 1.29 (0.74-2.25) for 30-day mortality; 1.07 (0.82-1.40) for prolonged stay; and 0.88 (0.65-1.19) for post-discharge adverse event.

CONCLUSION

There is a profile of patients with AHF who inadequately receive digoxin, although this inadequateness for chronic digitalis treatment was not associated with short-term adverse outcomes.

Relative apical sparing in severe aortic stenosis: does it mean concomitant amyloid cardiomyopathy?

Background

Relative apical sparing (RAS) of left ventricular (LV) longitudinal strain (LS) is a red flag marker for the suspicion of amyloid cardiomyopathy. However, it has also been described in patients with severe aortic stenosis (AS).

Aim

To assess the prevalence of RAS in patients with severe symptomatic AS referred for surgical aortic valve replacement (AVR), to evaluate its clinical significance and assess its presence after surgery.

Methods

We prospectively studied 135 consecutive patients (age: 73 y [IQR 68–77 y], 49% men) with severe symptomatic AS – mean transaortic pressure gradient (AVmean): 60.9±17.7 mmHg; mean aortic valve area: 0.7±0.2 cm2, referred for surgical AVR with no previous history of ischemic cardiomyopathy or other. Beyond 12 lead-ECG and transthoracic echocardiography (TTE), all patients underwent cardiac magnetic resonance (CMR) before surgery. RAS was defined by the ratio &gt;1 of average LS at apical segments/sum of the average basal and mid LS at speckle tracking analysis. AVR with septal myocardial biopsy, for investigational purposes, was performed in 80 patients. AS severity indexes, LV remodeling and tissue characterization parameters were compared in both groups of patients, with and without RAS. LS deformation pattern was reassessed at 3–6 months after AVR.

Results

RAS was present in 24 patients (18%). In the whole cohort there were neither pseudoinfarct pattern or low voltage ECG criteria, nor infiltration suspicion from CMR (native T1 value 1053 ms [IQR 1025–1071 ms] for institutional reference values: 972–1070 ms; ECV 24% [IQR 21–27%]). None of the patients had amyloid deposition at histopathology. Overall, mean CMR LV ejection fraction (LVEF) was 59.6±10.5% and 98 patients (74%) had non-ischemic delayed enhancement, with a median fibrosis fraction of 4.1% [IQR 1.6–7.8%]. RAS cohort had a significantly higher AVmean gradient, relative wall thickness, maximum septal thickness, peak systolic dispersion, with lower global LS at TTE, as well as higher LV mass and lower LVEF at CMR. RAS group has also higher NT-proBNP ambulatory values (Table 1). Follow-up evaluation after AVR revealed RAS disappearance in 19 patients (79.2%).

Conclusions

RAS occurs in almost one-fifth of the patients in this cohort despite the absence of signs of myocardial infiltration. This deformation pattern elapses with worse indexes of LV remodeling consistent with a more advanced stage of the disease, being reversible after AVR, which stands for the absence of concomitant myocardial infiltration.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular remodeling in aortic stenosis patients referred for surgical aortic valve replacement

Background

Left ventricular (LV) hypertrophy is a common expected finding in aortic stenosis (AS) patients. Cardiac magnetic resonance (CMR) plays an important role as a non-invasive method for determining LV mass and volume, and to characterize the LV remodeling response in AS.

Aim

To assess the prevalence, to describe the patterns and evolution of LV remodeling (by CMR) in AS patients referred for surgical aortic valve replacement (AVR).

Methods

Single-center prospective cohort of 132 consecutive patients (73 years [68–77 years], 49% men] with severe AS: mean transaortic pressure gradient (AVmean): 61±1.5 mmHg; aortic valve area (AVA): 0.7±0.1 cm2, referred for surgical AVR, with no previous history of ischemic cardiomyopathy. Before surgery, all patients underwent electrocardiogram, complete transthoracic echocardiogram (TTE) and CMR for LV assessment and tissue characterization (mean LV indexed mass [LVMi]: 80.3±26.5 g/m2; mean end-diastolic LV indexed volume [LVEDVi]: 84.4±24.5 mL/m2 and median geometric remodeling ratio [M/V]: 0.95 g/mL [IQR 0. 81–1.08 g/mL]). Patterns of LV remodeling were investigated before and after AVR by CMR measurements of LVMi, LVEDVi and M/V. Besides normal LV ventricular structure, four other patterns were considered: concentric remodeling, concentric hypertrophy, eccentric hypertrophy, and adverse remodeling (Figure 1).

Results

Overall, 43% (n=58) of the patients had concentric hypertrophy, 30% (n=40) concentric remodeling, 22% (n=29) normal ventricular geometry, 4% (n=5) eccentric hypertrophy and in two patients we observed an adverse remodeling pattern. AVR was performed in 80 patients. At the 3rd to 6th month post-AVR assessment, LV remodeling changed to: normal ventricular geometry in 46%, concentric remodeling in 31%, concentric hypertrophy in 19%, eccentric hypertrophy in 3% and adverse remodeling in only one patient (Figure 1).

Conclusions

In this group of patients with severe aortic stenosis, concentric hypertrophy was not the sole pattern of LV remodeling and two out of every five still presented a normal ventricular geometry and mass as assessed by CMR. LV response was dynamic after AVR which stands for complex and multifactorial interaction in these group of patients despite similar valvular pathophysiology and therapeutic intervention.

Funding Acknowledgement

Type of funding sources: None.

Cardiac magnetic resonance patterns of left ventricular hypertrophy in aortic stenosis patients

Background

Left ventricular (LV) hypertrophy is a known compensatory mechanism to pressure overload in aortic stenosis (AS) patients. However, by cardiac magnetic resonance (CMR) different patterns of LV adaptation are seen in this group of patients.

Aim

To describe the patterns of LV adaptation (by CMR) and to analyze its structure and function indexes in AS patients referred for surgical aortic valve replacement (AVR).

Methods

We prospectively studied 134 consecutive patients (age: 73y [IQR 68–77y], 49% men) with severe symptomatic AS - mean transaortic pressure gradient (AVmean): 61±1.5 mmHg; mean aortic valve area: AVA): 0.7±0.1 cm2, referred for surgical AVR with no previous history of ischemic cardiomyopathy or other. All patients underwent electrocardiogram, 2D transthoracic echocardiogram (TTE) and cardiac magnetic resonance (CMR) before surgery for LV assessment and tissue characterization. Five patterns of LV structure were considered: normal ventricular structure (normal LV mass/volume ratio [M/V], normal LVMi and normal indexed LV end-diastolic volume (LVEDVi); concentric remodeling: increased M/V, normal LVMi; concentric hypertrophy: increased M/V and LVMi; eccentric hypertrophy: increased LVMi and LVEDVi, normal M/V and ejection fraction; and adverse remodeling: dilated left ventricle, increased LVMi and normal M/V in the context of an impaired ejection fraction. Echocardiogram and CMR structural and functional indexes were compared between these groups.

Results

At baseline study, at CMR: mean LV indexed mass [LVMi]: 80.3±26.5 g/m2; mean end-diastolic LV indexed volume [LVEDVi]: 84.4±24.5 mL/m2 and median geometric remodeling ratio [M/V]: 0.95 g/mL [IQR 0. 81–1.08 g/mL]. Overall, 22% patients had normal LV structure, 30% concentric remodeling ventricular geometry, and two patients had an adverse remodeling pattern. LV hypertrophy was the most prevalent pattern and occurred in 48% of subjects (concentric 43%; eccentric 4%). In our cohort, the severity of AS (AVmean (p&lt;0.001), LV function (LV ejection fraction [p&lt;0.001] and Global longitudinal strain [p&lt;0.001]), LV loading conditions (indexed left atrial volume [p&lt;0.001] and E/e' ratio [p&lt;0.001]) and NT-proBNP (p&lt;0.001) were related to the pattern of LV structure (Table 1).

Conclusions

In our cohort, AS patients presented several distinct patterns of LV remodeling. Disease severity, functional repercussion and loading conditions are distinct between them.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular reverse remodeling in post operative aortic stenosis patients: prevalence and predictor(s)

Background

In patients with severe aortic stenosis (AS), left ventricular (LV) remodeling is believed to be a compensatory adaptive process which should reverse after aortic valve intervention. However, this is not always the rule and remodeling persistence may negatively impact post-procedural outcomes and survival.

Aim

To assess the prevalence and predictors of morphological LV reverse remodeling in severe symptomatic AS patients after surgical aortic valve replacement (AVR).

Methods

We prospectively studied 75 patients (72y [68–77y], 45% male) with severe symptomatic AS - mean gradient (AVM): 61±17mmHg; mean indexed aortic valve area (AVAi) 0.41±0.10 cm2/m2 with no previous history of ischemic cardiomyopathy, all with high gradient, 4 with low-flow, 81% with hypertension, 27% with type 2 diabetes mellitus and 35% patients with stage 3 chronic kidney disease: median MDR creat clearance: 70.4mL/min [40–102]. All patients performed pre-operative cardiac magnetic resonance (CMR) at a mean period of 3.4 months (0–17 months) before AVR and at the 3–6th months after AVR, for LV reverse remodeling assessment. It was defined as at least the occurrence of one of the following: &gt;15% reduction in LVEDVi; &gt;15% reduction in LVMi by CMR; &gt;10% reduction in geometric remodeling ratio. Clinical, AV severity data, preoperative functional LV and tissue characterization data were analyzed at multivariate regression to predict the occurrence of LV reverse remodeling.

Results

Overall, at pre-operative CMR: mean LV indexed mass (LVMi): 82±28.9 g/m2; mean end-diastolic LV indexed volume (LVEDVi): 87.4±26.6 mL/m2; mean geometric remodeling (LV mass/end-diastolic volume): 0.92±0.2 g/mL. After AVR, at echocardiographic evaluation, no patient had prosthetic obstruction or prosthetic patient mismatch: median LV-Ao gradient 12mmHg [9.1–14 mmHg]; 5 of them had mild paravalvular regurgitation. LV reverse remodeling occurred in 65 patients (88%) (Figure 1A) and these were younger, had significantly smaller preoperative AVAi and higher valvular gradients (Figure 1B). At multivariate analysis, only preoperative AVAi remained an independent predictor (odds ratio 0.85, 95% CI 0.735–0.984, p=0.029).

Conclusions

In this prospective cohort of patients LV reverse remodeling after surgical AVR was highly frequent, occurring in almost nine out of every ten patients.

Funding Acknowledgement

Type of funding sources: None.

Original articleAnalysis of the effectiveness and safety of short-stay units in the hospitalization of patients with acute heart failure. Propensity Score SSU-EAHFE

OBJECTIVES

This work aims to analyze if hospitalization in short-stay units (SSU) of patients diagnosed in the emergency department with acute heart failure (AHF) is effective in terms of the length of hospital stay and if it is associated with differences in short-term progress.

METHOD

Patients from the EAHFE registry diagnosed with AHF who were admitted to the SSU (SSU group) were included and compared to those hospitalized in other departments (non-SSU group) from all hospitals (comparison A) and, separately, those from hospitals with an SSU (comparison B) and without an SSU (comparison C). For each comparison, patients in the SSU/non-SSU groups were matched by propensity score. The length of hospital stay (efficacy), 30-day mortality, and post-discharge adverse events at 30 days (safety) were compared.

RESULTS

A total of 2,003 SSU patients and 12,193 non-SSU patients were identified. Of them, 674 pairs of patients were matched for comparison A, 634 for comparison B, and 588 for comparison C. The hospital stay was significantly shorter in the SSU group in all comparisons (A: median 4 days (IQR = 2-5) versus 8 (5-12) days, p < 0.001; B: 4 (2-5) versus 8 (5-12), p < 0.001; C: 4 (2-5) versus 8 (6-12), p < 0.001). Admission to the SSU was not associated with differences in mortality (A: HR = 1.027, 95%CI = 0.681-1.549; B: 0.976, 0.647-1.472; C: 0.818, 0.662-1.010) or post-discharge adverse events (A: HR = 1.002, 95%CI = 0.816-1.232; B: 0.983, 0.796-1.215; C: 1.135, 0.905-1.424).

CONCLUSION

The hospitalization of patients with AHF in the SSU is associated with shorter hospital stays but there were no differences in short-term progress.

Left ventricular myocardial work in patients with high gradient severe symptomatic aortic stenosis

Background

Left ventricular myocardial work (LVMW) is a novel method to evaluated left ventricular (LV) function using pressure-strain loops. It might correct global longitudinal strain (GLS) for afterload, being eventually useful to assess whether GLS reduction is due to reduced contractility (reflected as reduced myocardial work) or increased afterload (reflected as increased myocardial work).

Aim

To describe indices of LVMW in a group of patients with severe symptomatic aortic stenosis (AS).

Methods

We prospectively studied 104 consecutive patients (age: 71 years [IQR 66.5–75.5] years, 51% men) with severe symptomatic high gradient AS: mean transaortic pressure gradient: 56.5mmHg [IQR 46.8–67.8]; aortic valve area: 0.73cm2 [IQR 0.61–0.88]; indexed stroke volume: 47.7±1.3 mL/m2 (11 patients with low-flow AS), preserved LV ejection fraction (EV) (LVEF: 56.0% [51.0–61.3]; GLS: −14.5% [IQR −16.1 to −10.6]), with no previous coronary artery disease and no history of cardiomyopathy. Beyond complete transthoracic echocardiography, all patients underwent cardiac magnetic resonance for LV myocardium tissue characterization. As proposed for AS, LV systolic pressure was corrected adding the mean transaortic pressure gradient to non-invasive systolic blood pressure cuff measurement in the echocardiographic algorithm. Four LVMW indices were collected in 83 patients (patients excluded for atrial fibrillation, left bundle branch block or absence of non-invasive blood pressure registration) and correlated to LV function indexes, LV hypertrophy and remodeling, myocardial tissue characterization, BNP and troponin levels (Pearson or Spearman correlation). These same indexes were compared in patients with LV ejection fraction (EF) below and above 50%, normal and reduced flow and presence of replacement fibrosis.

Results

Global constructive work (GCW) (2658.6±76.4mmHg%), global myocardial work (GMW) (2218.7±74.9mmHg%) and global wasted work (GWE) (262.0mmHg% [198.8–339.5]) were high above normal with concomitant lower work efficiency (WE) (88.0% [83.2–91.8]. Weak correlations were found between LVMW indexes and parameters describing aortic valve severity, flow and LV function (table). Except for significant differences of LVMI in patients with reduced LV ejection fraction (GCW 2770.3±687.4 vs 2056.0±380.7mmHg%, p=0,014 and GMW 2362.5±657.9 vs 1621.3±319.9, p=0,021 in patients with LV EF&gt;50% vs. LV EF&lt;50%, respectively) work indexes were neither significantly different in low-flow patients nor in those with myocardial late gadolinium enhancement.

Conclusions

Global constructive and myocardial work are increased in these patients with severe aortic stenosis. This might reflect an increased afterload predominance rather than a LV functional impairment, particularly relevant in this group of patients with exclusive high gradient disease and preserved LVEF.

Funding Acknowledgement

Type of funding sources: None. Correlations between LVMI – LV function

Prevalence and determinants of right ventricular dysfunction in patients with severe symptomatic high gradient aortic stenosis

Background

Right ventricular (RV) function in aortic stenosis (AS) has been largely neglected. Recently it was demonstrated that right ventricular impairment may be influenced by left ventricular (LV) function and afterload, well before overt pulmonary hypertension development.

Aim

To describe the prevalence of RV dysfunction in a group of patients with severe symptomatic aortic stenosis (AS) and its relation to LV function parameters and afterload.

Methods

We prospectively studied 93 consecutive patients (age: 73 years [IQR 68–77] years, 55% women) with pure severe symptomatic high gradient aortic stenosis: mean transaortic pressure gradient: 57.0mmHg [IQR 46.9–71.1]; aortic valve area: 0.72cm2 [IQR 0.61–0.88]; indexed stroke volume: 48.8±1.5 mL/m2 (11 patients with low-flow AS), preserved LV ejection fraction (EV) (LVEF: 56.0% [51.0–61.3]; GLS: −14.5% [IQR −16.1 to −10.6]), with no previous coronary artery disease and no history of cardiomyopathy. Beyond complete transthoracic echocardiography, all patients underwent cardiac magnetic resonance (CMR) for LV myocardium tissue characterization (late gadolinium enhancement and extracellular volume). Normal RV function was defined according to TAPSE ≥17mm, tricuspid annular systolic velocity ≥12cm/s, mean free wall longitudinal strain ≤−20%. Patients were divided into four groups: (0) – all three RV parameters below normal (1.1%), (1) – 1 normal parameter (12.9%), (2) – 2 normal parameters (44.1%), (3) – 3 normal parameters (41.9%). Indexes of LV systolic and diastolic function, CMR derived LV geometric remodeling, hypertrophy and tissue characterization, aortic valve disease severity and afterload were compared across the 4 groups of patients. We tried to identify predictors of RV dysfunction (group 0, 1, 2 vs. group 3) at multivariate regression analysis.

Results

Left ventricular performance parameters, diastolic and myocardial work indexes were significantly different across the groups (Figure). Neither AV severity indexes nor LV tissue characterization were distinct. At multivariate analysis only global constructive work was an independent predictor of RV dysfunction.

Conclusion

RV dysfunction is common in this group of patients with severe high gradient aortic stenosis and preserved ejection fraction. RV impairment is significantly related to several LV systolic and diastolic parameters and also to LV afterload, probably accounting for RV-LV interdependence.

Funding Acknowledgement

Type of funding sources: None.

Prognostic implications of Anemia in patients with acute heart failure in emergency departments. ANEM-AHF Study

INTRODUCTION

The presence of anaemia leads to a worse prognosis in patients with heart failure (HF). There are few data on the impact of anaemia on mortality in patients with acute heart failure (AHF), and the studies available are mainly retrospective, and include hospitalised patients.

OBJECTIVE

Evaluate the role of anaemia on 30-day and 1-year mortality in patients with AHF attended in hospital emergency departments (HEDs).

METHODS

We performed a multicentre, observational study of prospective cohorts of patients with AHF. The study variables were: Anaemia (haemoglobin < 12g/dL in women and <13g/dL in men), mortality at 30 days and at 1 year, risk factors, comorbidity, functional impairment, basal functional grade for dyspnoea, chronic and acute treatment, clinical and analytical data of the episode, and patient destination.

STATISTICAL ANALYSIS

Bivariate analysis and survival analyses using Cox regression.

RESULTS

A total of 13 454 patients were included, 7662 (56.9%) of whom had anaemia. Those with anaemia were older, had more comorbidity, a worse functional status and New York Heart Association class, greater renal function impairment, and more hyponatraemia. The mortality was higher in patients with anaemia at 30 days and 1 year: 7.5% vs 10.7% (P < .001) and 21.2% vs 31.4% (P < .001), respectively. The crude and adjusted hazard ratios of anaemia for 30-day mortality were: 1.46 (confidence interval [CI] 95% 1.30-1.64); P < .001 and 1.20 (CI 95% 1.05-1.38); P = .009, respectively, and 1.57 (CI 95% 1.47-1.68) and 1.30 (CI 95% 1.20-1.40) for mortality at 1 year. The weight of anaemia on mortality was different in each follow-up period.

CONCLUSIONS

Anaemia is an independent predictor of mortality at 30 days and 1 year in patients with AHF attended in HEDs. It is important to study the aetiology of AHF since adequate treatment would reduce mortality.

Frequency, profile and results of patients with acute heart failure transferred directly to home hospitalisation from emergency departments

OBJECTIVE

To describe the frequency, clinical characteristics and outcomes of patients with acute heart failure (AHF) transferred directly from emergency departments to home hospitalisation (HH) and to compare them with those hospitalised in internal medicine (IM) or short-stay units (SSU).

METHOD

We included patients with AHF transferred to HH by hospitals that considered this option during the Epidemiology of Acute Heart Failure in Spanish Emergency Departments (EAHFE) 4-5-6 Registries and compared them with patients admitted to IM or SSU in these centres. We compared the adjusted all-cause mortality at 1 year and adverse events 30 days after discharge.

RESULTS

The study included 1473 patients (HH/IM/SSU: 68/979/384). The HH rate was 4.7% (95% CI, 3.8-6.0%). The patients in HH had few differences compared with those hospitalised in IM and SSUs. The HH mortality was 1.5%, and the HH median stay was 7.5 days (IQR, 4.5-12), similar to that of IM (median stay, 8 days; IQR, 5-13; p=.106) and longer than that of SSU (median stay, 4 days; IQR, 3-7; p<.001). The all-cause mortality at 1 year for HH did not differ from that of IM (HR, 0.91; 95% CI, 0.73-1.14) or SSU (HR, 0.77; 95% CI, 0.46-1.27); however, the emergency department readmission rate during the 30 days postdischarge was lower than that of IM (HR, 0.50; 95% CI, 0.25-0.97) and SSU (HR, 0.37; 95% CI, 0.19-0.74). There were no differences in the need for new hospitalisations or in the 30-day mortality rate.

CONCLUSIONS

Direct transfer from the emergency department to HH is infrequent despite being a safe option for a certain patient profile with AHF.

Frequency, profile, and outcomes of patients with acute heart failure transferred directly to home hospitalization from emergency departments

OBJECTIVE

To describe the frequency, clinical characteristics and outcomes of patients with acute heart failure (AHF) transferred directly from emergency departments to home hospitalisation (HH) and to compare them with those hospitalised in internal medicine (IM) or short-stay units (SSU).

METHOD

We included patients with AHF transferred to HH by hospitals that considered this option during the Epidemiology of Acute Heart Failure in Spanish Emergency Departments (EAHFE) 4-5-6 Registries and compared them with patients admitted to IM or SSU in these centres. We compared the adjusted all-cause mortality at 1 year and adverse events 30 days after discharge.

RESULTS

The study included 1473 patients (HH/IM/SSU:68/979/384). The HH rate was 4.7% (95% CI 3.8-6.0%). The patients in HH had few differences compared with those hospitalised in IM and SSUs. The HH mortality was 1.5%, and the HH median stay was 7.5 days (IQR, 4.5-12), similar to that of IM (median stay, 8 days; IQR, 5-13; p = .106) and longer than that of SSU (median stay, 4 days; IQR, 3-7; p < .001). The all-cause mortality at 1 year for HH did not differ from that of IM (HR, 0.91; 95% CI 0.73-1.14) or SSU (HR, 0.77; 95% CI 0.46-1.27); however, the emergency department readmission rate during the 30 days postdischarge was lower than that of IM (HR, 0.50; 95% CI 0.25-0.97) and SSU (HR, 0.37; 95% CI 0.19-0.74). There were no differences in the need for new hospitalisations or in the 30-day mortality rate.

CONCLUSIONS

Direct transfer from the emergency department to HH is infrequent despite being a safe option for a certain patient profile with AHF.

Relative apical sparing in patients with severe aortic stenosis: prevalence and significance

 

Relative apical sparing (RAS) of LV longitudinal strain (LS) is a red flag for diagnostic suspicion of amyloid cardiomyopathy (AC). However, it may present in pts with aortic stenosis (AS), where the prevalence of transthyretin AC is being increasingly reported.

Aim

To describe the prevalence of RAS deformation pattern in patients with AS and its clinical significance.

Methods

We prospectively studied 53 pts (71±8y, 54.7% men) with severe symptomatic AS - mean gradient (AVM): 54.6 mmHg; aortic valve area 0.74cm2, referred for surgical replacement with no previous history of ischemic cardiomyopathy. Beyond ECG and transthoracic echo (TTE), all pts underwent CMR, with tissue characterization before surgery. RAS was defined as average apical LS / average basal LS + average mid LS &gt;1 at 2D LV LS analysis. Aortic valve replacement and septal myocardial biopsy were already performed in 26 pts. AS severity indexes, LV remodelling and tissue characterization were compared in both groups, with and without RAS.

Results

RAS was present in 16 pts (30.8%). There were neither pseudoinfarct pattern or low voltage at ECG, nor infiltration suspicion from CMR study (native T1 value 1047ms [IQR 1028–1084]; ECV 22% [IQR 18–25]). Furthermore, none of the pts had suspicion of amyloid deposition at histopathology. Median CMR LVEF was 64.5% [IQR 51.3–70.8%] and 36 pts (67.9%) had non-ischemic DE, with a median fraction of 6.0% [IQR 4.9–12.7%] of LV mass. Comparing both groups, RAS cohort showed a significantly higher AVM, relative wall thickness, maximum septal thickness, peak systolic dispersion and higher LV indexed mass, DE and lower LVEF at CMR. RAS group has also higher NT pro BNP (Table).

Conclusions

RAS is common in this group of pts despite the absence of clinical and histological signs of myocardial infiltration. RAS occurs with worse indexes of LV remodeling and fibrosis consistent with a more advanced stage of the disease.

Funding Acknowledgement

Type of funding source: None

LV replacement fibrosis in aortic stenosis: prevalence and relation to LV remodelling and function

Background

Progressive myocardial fibrosis takes part in left ventricular (LV) remodeling in aortic stenosis (AS) and drives the transition from hypertrophy to heart failure. Replacement fibrosis may be characterized by late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR).

Aim

To assess the prevalence and association between LGE and indexes of LV function in patients with severe aortic stenosis.

Methods

We prospectively studied 53 consecutive patients (age: 71±8 years [min. 51–max. 84], 54.7% men) with severe symptomatic AS, referred for surgical aortic valve replacement with no previous history of ischemic cardiomyopathy. Aortic valve mean gradient was 54.6 mmHg [IQR 46.6–63.2] and aortic valve area 0.74cm2 [IQR 0.61–0.89]; all patients with high gradient, 4 with low-flow. CMR with tissue characterization (T1 mapping, LGE and extracellular volume by ECV quantification – using 5SD from remote myocardium as signal intensity cut-off), was performed before surgery. AS severity indexes, LV mass, systolic and diastolic LV function indexes including global longitudinal strain (GLS) and torsion were compared in both groups of patients, with and without LGE.

Results

Mid-wall LGE was present in 36 patients (67.9%) with a median fraction of 6.0% [IQR 4.9–12.7%] of LV mass. Native T1 value and ECV were within normal ranges (median values: 1047ms [IQR 1028–1084]; 22% [IQR 18–25], respectively). Median CMR LV ejection fraction and mass were 64.5% [IQR 51.3–70.8%] (11 patients with reduced EF) and 76.5g/m2 [IQR 57.4–94.8g/m2], respectively. Median GLS was −13.9% [IQR −11.4 to −17.0%] and torsion was 24.2° [IQR 19.8–32.5°]. Patients with LGE had significantly higher LV mass (87.1g/m2 vs 63.3 g/m2, p=0.001), worse GLS (−14.4% vs −16.9%, p=0.041) and higher NT-proBNP values (1333.7ng/mL vs 559.9ng/mL, p=0.004) (Figure).

Conclusions

Non-ischemic LGE is common in this group of patients with severe symptomatic high gradient aortic stenosis. As it is more prevalent in patients with more pronounced LVH, lower longitudinal deformation and higher NT-proBNP values, it probably represents a more advanced stage of the disease.

Funding Acknowledgement

Type of funding source: None

CHD1 loss sensitizes prostate cancer to DNA damaging therapy by promoting error-prone double-strand break repair

Background

Deletion of the chromatin remodeler chromodomain helicase DNA-binding protein 1 (CHD1) is a common genomic alteration found in human prostate cancers (PCas). CHD1 loss represents a distinct PCa subtype characterized by SPOP mutation and higher genomic instability. However, the role of CHD1 in PCa development in vivo and its clinical utility remain unclear.

Patients and methods

To study the role of CHD1 in PCa development and its loss in clinical management, we generated a genetically engineered mouse model with prostate-specific deletion of murine Chd1 as well as isogenic CHD1 wild-type and homozygous deleted human benign and PCa lines. We also developed patient-derived organoid cultures and screened patients with metastatic PCa for CHD1 loss.

Results

We demonstrate that CHD1 loss sensitizes cells to DNA damage and causes a synthetic lethal response to DNA damaging therapy in vitro, in vivo, ex vivo, in patient-derived organoid cultures and in a patient with metastatic PCa. Mechanistically, CHD1 regulates 53BP1 stability and CHD1 loss leads to decreased error-free homologous recombination (HR) repair, which is compensated by increased error-prone non-homologous end joining (NHEJ) repair for DNA double-strand break (DSB) repair.

Conclusions

Our study provides the first in vivo and in patient evidence supporting the role of CHD1 in DSB repair and in response to DNA damaging therapy. We uncover mechanistic insights that CHD1 modulates the choice between HR and NHEJ DSB repair and suggest that CHD1 loss may contribute to the genomic instability seen in this subset of PCas.

Hydrogen sulphide as a signalling molecule regulating physiopathological processes in gastrointestinal motility

The biology of H₂ S is a still developing area of research and several biological functions have been recently attributed to this gaseous molecule in many physiological systems, including the cardiovascular, urogenital, respiratory, digestive and central nervous system (CNS). H₂ S exerts anti-inflammatory effects and can be considered an endogenous mediator with potential effects on gastrointestinal motility. During the last few years, we have investigated the role of H₂ S as a regulator of gastrointestinal motility using both animal and human tissues. The aim of the present work is to review published data regarding the potential role of H₂ S as a signalling molecule regulating physiopathological processes in gastrointestinal motor function. H₂ S is endogenously produced by defined enzymic pathways in different cell types of the intestinal wall including neurons and smooth muscle. Inhibition of H₂ S biosynthesis increases motility and H₂ S donors cause smooth muscle relaxation and inhibition of propulsive motor patterns. Impaired H₂ S production has been described in animal models with gastrointestinal motor dysfunction. The mechanism(s) of action underlying these effects may include several ion channels, although no specific receptor has been identified. At this time, even though there is much experimental evidence for H₂ S as a modulator of gastrointestinal motility, we still do not have conclusive experimental evidence to definitively propose H₂ S as an inhibitory neurotransmitter in the gastrointestinal tract, causing nerve-mediated relaxation.

ID: 87: TRANSCRIPTION FACTOR CREB3L3 IS A NOVEL REGULATOR FOR ADIPOCYTE BIOLOGY AND METABOLISM

The presence of differential metabolic risks between the metabolically-protective subcutaneous adipose tissue (SAT) and the disease-associated visceral adipose tissue (VAT) is well established, but the mechanisms that cause these differences are not well understood. Cyclic AMP responsive element binding protein 3-like 3 (CREB3L3), a previously characterized liver-specific ER-bound transcription factor, was found to be expressed in murine SAT and VAT. In obese human subjects and an obese mouse model, we found that CREB3L3 is downregulated in SAT, but not in VAT. To examine the role of CREB3L3 in adipocyte biology and metabolism, we created a fat-specific CREB3L3 knockout (KO) mouse using the AdipoQ-Cre mouse. To establish a potential role for CREB3L3 in adipocytes, we examined in vitro differentiated adipocytes from isolated WT and KO primary stromal vascular fraction. We observed that ablation of CREB3L3 in SAT adipocytes significantly upregulated expression of both lipogenic and lipolytic markers. At the same time, we also observed significantly increased expression of thermogenic markers like PGC1α and Cox8b. Taken together our data suggest potential upregulation of the fat futile cycle in SAT upon deletion of CREB3L3. Surprisingly, we found that CREB3L3 KO tends to downregulate expression of markers of both lipogenesis and lipolysis in VAT adipocytes. This observation could potentially be contributed by the tendency of CREB3l3 KO VAT to have inhibited differentiation. To investigate the in vivo function of CREB3L3, we challenged WT and KO mice with high fat diet with weekly body weight assessment. We observed that CREB3L3 ablation in adipose tissues promotes significant weight gain in mice on HFD. Unexpectedly, despite being heavier, the KO mice are not more glucose intolerant or insulin resistant. These data together suggest that ablation of CREB3L3 could potentially promote fat storage in adipose tissues to prevent metabolic diseases caused by ectopic fat deposition.

Potential role of the gaseous mediator hydrogen sulphide (H2S) in inhibition of human colonic contractility

BACKGROUND

Hydrogen sulphide (H2S) is an endogenous signalling molecule that might play a physiologically relevant role in gastrointestinal motility. Cystathionine β-synthase (CBS) and cystathionine γ-lyase (CSE) are two enzymes responsible for H2S production. d,l-Propargylglycine (PAG) is a CSE inhibitor whereas both aminooxyacetic acid (AOAA) and hydroxylamine (HA) are CBS inhibitors. The characterization of H2S responses and its mechanism of action are crucial to define H2S function.

METHODS

Human colonic strips were used to investigate the role of H2S on contractility (muscle bath) and smooth muscle electrophysiology (microelectrodes). NaHS was used as a H2S donor.

RESULTS

Combination of PAG and AOAA depolarized the smooth muscle (5-6mV, n=4) and elicited a transient increase in tone (260.5±92.8mg, n=12). No effect was observed on neural mediated inhibitory junction potential or relaxation. In the presence of tetrodotoxin 1μM, NaHS concentration-dependently inhibited spontaneous contractions (EC50=329.2μM, n=18). This effect was partially reduced by the guanylyl cyclase inhibitor ODQ 10μM (EC50=2.6μM, n=12) and by l-NNA 1mM (EC50=1.4mM, n=8). NaHS reversibly blocked neural mediated cholinergic (EC50=2mM) and tachykinergic (EC50=5.7mM) contractions. NaHS concentration-dependently reduced the increase in spontaneous mechanical activity (AUC) induced by carbachol (EC50=1.9mM) and NKA (EC50=1.7mM AUC).

CONCLUSIONS

H2S might be an endogenous gasomediator regulating human colonic contractility. Its inhibitory effect is observed at high concentrations and could be mediated by a direct effect on smooth muscle with a possible synergistic effect with NO, as well as by an interaction with the cholinergic and tachykinergic neural mediated pathways.

Differential functional role of purinergic and nitrergic inhibitory cotransmitters in human colonic relaxation

AIM

ATP and nitric oxide (NO) are released from enteric inhibitory motor neurones and are responsible for colonic smooth muscle relaxation. However, how frequency of neural stimulation affects this cotransmission process and the post-junctional responses has not been systematically characterized in the human colon.

METHODS

The dynamics of inhibitory cotransmission were studied using different protocols of electrical field stimulation (EFS) to characterize the inhibitory junction potentials (IJP) and the corresponding relaxation in colonic strips obtained from 36 patients.

RESULTS

Single pulses elicited a fast IJP (IJPf(MAX) = -27.6 ± 1.6 mV), sensitive to the P2Y1 antagonist MRS2500 1 μm, that ran down with frequency increase leaving a residual hyperpolarization at high frequencies (IJPf∞ = -3.7 ± 0.6 mV). Accordingly, low frequencies of EFS caused purinergic transient relaxations that cannot be maintained at high frequencies. Addition of the P2Y1 agonist MRS2365 10 μm during the purinergic rundown did not cause any hyperpolarization. Protein kinase C (PKC), a putative P2Y1 desensitizator, was able to reduce the amplitude of the IJPf when activated, but the rundown was not modified by PKC inhibitors. Frequencies higher than 0.60 ± 0.15 Hz were needed to evoke a sustained nitrergic hyperpolarization that progressively increased reaching IJPs∞ = -13 ± 0.4 mV at high frequencies and leading to a sustained inhibition of spontaneous motility.

CONCLUSION

Changes in frequency of stimulation possibly mimicking neuronal firing will post-junctionally determine purinergic vs. nitrergic responses underlying different functional roles. NO will be responsible for sustained relaxations needed in physiological processes such as storage, while purinergic neurotransmission evoking sharp transient relaxations will be dominant in processes such as propulsion.

Effects of hydrogen sulphide on motility patterns in the rat colon

BACKGROUND AND PURPOSE

Hydrogen sulphide (H2 S) is an endogenous gaseous signalling molecule with putative functions in gastrointestinal motility regulation. Characterization of H2 S effects on colonic motility is crucial to establish its potential use as therapeutic agent in the treatment of colonic disorders.

EXPERIMENTAL APPROACH

H2 S effects on colonic motility were characterized using video recordings and construction of spatio-temporal maps. Microelectrode and muscle bath studies were performed to investigate the mechanisms underlying H2 S effects. NaHS was used as the source of H2 S.

KEY RESULTS

Rhythmic propulsive motor complexes (RPMCs) and ripples were observed in colonic spatio-temporal maps. Serosal addition of NaHS concentration-dependently inhibited RPMCs. In contrast, NaHS increased amplitude of the ripples without changing their frequency. Therefore, ripples became the predominant motor pattern. Neuronal blockade with lidocaine inhibited RPMCs, which were restored after administration of carbachol. Subsequent addition of NaHS inhibited RPMCs. Luminal addition of NaHS did not modify motility patterns. NaHS inhibited cholinergic excitatory junction potentials, carbachol-induced contractions and hyperpolarized smooth muscle cells, but did not modify slow wave activity.

CONCLUSIONS AND IMPLICATIONS

H2 S modulated colonic motility inhibiting propulsive contractile activity and enhancing the amplitude of ripples, promoting mixing. Muscle hyperpolarization and inhibition of neurally mediated cholinergic responses contributed to the inhibitory effect on propulsive activity. H2 S effects were not related to changes in the frequency of slow wave activity originating in the network of interstitial cells of Cajal located near the submuscular plexus. Luminal H2 S did not modify colonic motility probably because of epithelial detoxification.

Mechanisms of action of otilonium bromide (OB) in human cultured smooth muscle cells and rat colonic strips

BACKGROUND

The pharmacological properties of otilonium bromide (OB) have been investigated using different experimental models, techniques, and conditions, and consequently, the results are not always easy to compare. The aim of the present work was to investigate the pharmacological properties of OB in human cultured colonic smooth muscle cells (HCSMCs), which is the main target of the drug 'in vivo'. Rat colonic strips were used to confirm the pharmacological properties.

METHODS

Human cultured colonic smooth muscle cells were studied using the calcium imaging technique. Microelectrodes and muscle bath experiments were performed in rat colonic strips.

KEY RESULTS

Otilonium bromide (OB) concentration dependently inhibited nifedipine-sensitive calcium transients induced by KCl (EC50  = 3.6 μM) and BayK8644 (EC50  = 4.0 μM). All the following experiments were performed in the presence of nifedipine. In HCSMC, carbachol-induced calcium transients were inhibited by OB (EC50  = 8.4 μM). Carbachol evoked 1-a smooth muscle depolarization (10 mV) that was antagonized by 100 μM OB; and 2-a contraction that was inhibited by OB (EC50  = 13.0 μM). 'Non-nitrergic (L-NNA 1 mM) non-purinergic (MRS2500 1 μM)' conditions were used to elicit endogenous excitatory responses. Electrical field stimulation caused 1-an atropine-sensitive excitatory junction potential that was inhibited by OB (EC50  = 8.9 μM) and 2-an atropine-sensitive contraction that was inhibited by OB (EC50  = 7.3 μM). In HCSMC, neurokinin A (NKA) and CaCl2 induced calcium transients that were inhibited by OB (NKA: EC50  = 11.7 μM; CaCl2 : EC50  = 17.5 μM).

CONCLUSIONS & INFERENCES

Otilonium bromide causes inhibition of L-/T-type calcium channels, muscarinic, and tachykininergic responses that acting together explain the pharmacological properties of the compound.

[Correspondence between the fatty acids in healthy children serum and in membrane phospholipids]

INTRODUCTION

The diet is important in the supply of fatty acids in humans, especially those of the n-3 and n-6 families by its essentiality and related physiological function. It is important to have reference values in accessible biological samples: serum and erythrocyte membranes, in order to alleviate potential shortfalls. The objective is quantifying fatty acids present in these samples from C6 to C26.

MATERIAL AND METHODS

the determinations of the fatty acids of 30 healthy children in serum and its corresponding membrane phospholipids from blood cells by lipid extraction, methylation, separation and quantification in gas chromatography with detection of masses have been. It is comparing the values obtained in each serum and its partner of cell membranes.

RESULTS AND DISCUSSION

It is have obtained normal values in healthy children. The C16, which represent a quarter of all fatty acids, it is in the same proportion in both samples, in the rest of fatty acids, there is no clear correspondence between both values. In the n-6 family, the C18:2n6 is higher in serum against the C20:4n6 which is in the phospholipids. In the same way between the n-3 family, the C20:5n3 is higher in serum and the C22:6n3 is in membrane phospholipids. These values are cause of different processes, recent nutritional contribution to serum and with long-term implications and metabolic values in the phospholipids of membranes.

[High ratio of omega 6/omega 3 ratio children with neuropathies; cause or effect]

INTRODUCTION

The n-3 and n-6 fatty acids compete for the same elongases and desaturases, still highly deficient synthesis of polyunsaturated fatty acids from n-3 linolenic acid. The n-3 polyunsaturated prevent disease and are important in the development and maintenance of neuronal activities, necessitating a proper relationship with their antagonists n-6. This paper studies the proportion of these fatty acids.

MATERIAL AND METHODS

We analyzed the fatty acids of n- 3 and n-6 in sera and membrane phospholipid with 374 children neuropathies and 34 healthy children, using gas chromatography with mass detector. It has made the relevant statistical study.

RESULTS

The n-3 (EPA and DHA) in serum and their corresponding membrane phospholipids correlate better than the n-6 family. The major n-6 (LA and ARA) are equally in serum, being significantly higher in phospholipids of healthy children. The n-3 (EPA and DHA) have higher values in healthy children, both in serum and phospholipids, their sum is equal to the membrane phospholipids. The n-6/n-3 ratio is higher in children with neurological disorder in both samples.

CONCLUSION

Not being the cause of the high rate n-6/n- 3 neuropathy, however it is advisable to increase the intake of n-3, DHA particularly across the population, especially in children with neurological disorders.

P2Y(1) knockout mice lack purinergic neuromuscular transmission in the antrum and cecum

BACKGROUND

Pharmacological studies using selective P2Y(1) antagonists, such as MRS2500, and studies with P2Y(1)(-/-) knockout mice have demonstrated that purinergic neuromuscular transmission is mediated by P2Y(1) receptors in the colon. The aim of the present study was to test whether P2Y(1) receptors are involved in purinergic neurotransmission in the antrum and cecum.

METHODS

Microelectrode recordings were performed on strips from the antrum and cecum of wild type animals (WT) and P2Y(1)(-/-) mice.

KEY RESULTS

In the antrum, no differences in resting membrane potential and slow wave activity were observed between groups. In WT animals, electrical field stimulation elicited a MRS2500-sensitive inhibitory junction potential (IJP). In P2Y(1)(-/-) mice, a nitrergic IJP (N(ω) -nitro-l-arginine-sensitive), but not a purinergic IJP was recorded. This IJP was equivalent to the response obtained in strips from WT animals previously incubated with MRS2500. Similar results were obtained in the cecum: 1- the purinergic IJP (MRS2500-sensitive) recorded in WT animals was absent in P2Y(1)(-/-) mice 2- nitrergic neurotransmission was preserved in both groups. Moreover, 1- spontaneous IJP (MRS2500-sensitive) could be recorded in WT, but not in P2Y(1)(-/-) mice 2- MRS2365 a P2Y(1) agonist caused smooth muscle hyperpolarization in WT, but not in P2Y(1) (-/-) animals, and 3- β-NAD caused smooth muscle hyperpolarization both in WT and P2Y(1)(-/-) animals.

CONCLUSIONS & INFERENCES

1- P2Y(1) receptor is the general mechanism of purinergic inhibition in the gastrointestinal tract, 2- P2Y(1)(-/-) mouse is a useful animal model to study selective impairment of purinergic neurotransmission and 3- P2Y(1)(-/-) mouse might help in the identification of purinergic neurotransmitter(s).

Relative contribution of SKCa and TREK1 channels in purinergic and nitrergic neuromuscular transmission in the rat colon

Purinergic and nitrergic neurotransmission predominantly mediate inhibitory neuromuscular transmission in the rat colon. We studied the sensitivity of both purinergic and nitrergic pathways to spadin, a TWIK-related potassium channel 1 (TREK1) inhibitor, apamin, a small-conductance calcium-activated potassium channel blocker and 1H-[1,2,4]oxadiazolo[4,3-α]quinoxalin-1-one (ODQ), a specific inhibitor of soluble guanylate cyclase. TREK1 expression was detected by RT-PCR in the rat colon. Patch-clamp experiments were performed on cells expressing hTREK1 channels. Spadin (1 μM) reduced currents 1) in basal conditions 2) activated by stretch, and 3) with arachidonic acid (AA; 10 μM). l-Methionine (1 mM) or l-cysteine (1 mM) did not modify currents activated by AA. Microelectrode and muscle bath studies were performed on rat colon samples. l-Methionine (2 mM), apamin (1 μM), ODQ (10 μM), and N(ω)-nitro-l-arginine (l-NNA; 1 mM) depolarized smooth muscle cells and increased motility. These effects were not observed with spadin (1 μM). Purinergic and nitrergic inhibitory junction potentials (IJP) were studied by incubating the tissue with l-NNA (1 mM) or MRS2500 (1 μM). Both purinergic and nitrergic IJP were unaffected by spadin. Apamin reduced both IJP with a different potency and maximal effect for each. ODQ concentration dependently abolished nitrergic IJP without affecting purinergic IJP. Similar effects were observed in hyperpolarizations induced by sodium nitroprusside (1 μM) and nitrergic relaxations induced by electrical stimulation. We propose a pharmacological approach to characterize the pathways and function of purinergic and nitrergic neurotransmission. Nitrergic neurotransmission, which is mediated by cyclic guanosine monophosphate, is insensitive to spadin, an effective TREK1 channel inhibitor. Both purinergic and nitrergic neurotransmission are inhibited by apamin but with different relative sensitivity.

Effects of inhibitors of hydrogen sulphide synthesis on rat colonic motility

BACKGROUND AND PURPOSE

The role of hydrogen sulphide (H₂S) as a putative endogenous signalling molecule in the gastrointestinal tract has not yet been established. We investigated the effect of D,L-propargylglycine (PAG), an inhibitor of cystathionine γ-lyase (CSE), amino-oxyacetic acid (AOAA) and hydroxylamine (HA), inhibitors of cystathionine β-synthase (CBS) on rat colonic motility.

EXPERIMENTAL APPROACH

Immunohistochemistry, H₂S production, microelectrode and organ bath recordings were performed on rat colonic samples without mucosa and submucosa to investigate the role of endogenous H₂S in motility.

KEY RESULTS

CSE and CBS were immunolocalized in the colon. H₂S was endogenously produced (15.6 ± 0.7 nmol·min⁻¹·g⁻¹ tissue) and its production was strongly inhibited by PAG (2 mM) and AOAA (2 mM). PAG (2 mM) caused smooth muscle depolarization and increased spontaneous motility. The effect was still recorded after incubation with tetrodotoxin (TTX, 1 µM) or N(ω) -nitro-L-arginine (L-NNA, 1 mM). AOAA (2 mM) caused a transient (10 min) increase in motility. In contrast, HA (10 µM) caused a 'nitric oxide-like effect', smooth muscle hyperpolarization and relaxation, which were antagonized by 1H-[1,2,4]oxadiazolo[4,3-α]quinoxalin-1-one (ODQ, 10 µM). Neither spontaneous nor induced inhibitory junction potentials were modified by AOAA or PAG.

CONCLUSIONS AND IMPLICATIONS

We demonstrated that H₂S is endogenously produced in the rat colon. PAG and AOAA effectively blocked H₂S production. Our data suggest that enzymatic production of H₂S regulates colonic motility and therefore H₂S ight be a third gaseous inhibitory signalling molecule in the gastrointestinal tract. However, possible non-specific effects of the inhibitors should be considered.

Effects of inhibitors of hydrogen sulphide synthesis on rat colonic motility

BACKGROUND AND PURPOSE

The role of hydrogen sulphide (H₂S) as a putative endogenous signalling molecule in the gastrointestinal tract has not yet been established. We investigated the effect of D,L-propargylglycine (PAG), an inhibitor of cystathionine γ-lyase (CSE), amino-oxyacetic acid (AOAA) and hydroxylamine (HA), inhibitors of cystathionine β-synthase (CBS) on rat colonic motility.

EXPERIMENTAL APPROACH

Immunohistochemistry, H₂S production, microelectrode and organ bath recordings were performed on rat colonic samples without mucosa and submucosa to investigate the role of endogenous H₂S in motility.

KEY RESULTS

CSE and CBS were immunolocalized in the colon. H₂S was endogenously produced (15.6 ± 0.7 nmol·min⁻¹·g⁻¹ tissue) and its production was strongly inhibited by PAG (2 mM) and AOAA (2 mM). PAG (2 mM) caused smooth muscle depolarization and increased spontaneous motility. The effect was still recorded after incubation with tetrodotoxin (TTX, 1 µM) or N(ω) -nitro-L-arginine (L-NNA, 1 mM). AOAA (2 mM) caused a transient (10 min) increase in motility. In contrast, HA (10 µM) caused a 'nitric oxide-like effect', smooth muscle hyperpolarization and relaxation, which were antagonized by 1H-[1,2,4]oxadiazolo[4,3-α]quinoxalin-1-one (ODQ, 10 µM). Neither spontaneous nor induced inhibitory junction potentials were modified by AOAA or PAG.

CONCLUSIONS AND IMPLICATIONS

We demonstrated that H₂S is endogenously produced in the rat colon. PAG and AOAA effectively blocked H₂S production. Our data suggest that enzymatic production of H₂S regulates colonic motility and therefore H₂S ight be a third gaseous inhibitory signalling molecule in the gastrointestinal tract. However, possible non-specific effects of the inhibitors should be considered.

Pharmacological characterization of purinergic inhibitory neuromuscular transmission in the human colon

BACKGROUND

In the present study, we further characterize the purinergic receptors mediating the inhibitory junction potential (IJP) and smooth muscle relaxation in the human colon using a new, potent and selective agonist (MRS2365), and antagonists (MR2279 and MRS2500) of the P2Y(1) receptor. The P2Y(12) antagonist AR-C66096 was tested as well. Using this pharmacological approach, we tested whether β-nicotinamide adenine dinucleotide (β-NAD) fulfilled the criteria to be considered an inhibitory neurotransmitter in the human colon.

METHODS

We carried out muscle bath and microelectrode experiments on circular strips from the human colon and calcium imaging recordings on HEK293 cells, which constitutively express the human P2Y(1) receptor.

KEY RESULTS

Both the fast component of IJP and non-nitrergic relaxation was concentration-dependently inhibited by MRS2279 and MRS2500. This antagonism was confirmed in HEK293 cells. However, AR-C66096 did not modify either inhibitory response. Adenosine 5'-Ο-2-thiodiphosphate and MRS2365 caused a smooth muscle hyperpolarization and transient inhibition of spontaneous motility that was antagonized by MRS2279 and MRS2500. β-Nicotinamide adenine dinucleotide inhibited the spontaneous motility (IC(50) = 3.3 mmol L(-1) ). Nevertheless, this effect was not antagonized by high concentrations of P2Y(1) antagonists.

CONCLUSIONS & INFERENCES

Inhibitory purinergic neuromuscular transmission in the human colon was pharmacologically assessed by the use of new P2Y(1) receptor antagonists MRS2179, MRS2279, and MRS2500. The rank order of potency of the P2Y(1) antagonists is MRS2500 > MRS2279 > MRS2179. We found that β-NAD partially fulfills the criteria to be considered an inhibitory neurotransmitter in the human colon, but the relative contribution of each purine (ATP/ADP vsβ-NAD) requires further studies.

Body composition phenotypes in systemic lupus erythematosus and rheumatoid arthritis: a comparative study of Caucasian female patients

OBJECTIVES

The amount and distribution of fat and lean mass have important implications for health and systemic inflammation may represent a risk for altered body composition. The aim of this study was to analyse whether changes in body composition are similarly associated with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), two inflammatory conditions of different pathogenesis.

METHODS

Body mass index (BMI), waist circumference, fat mass (FM) and fat-free mass (FFM) were measured in 92 women with SLE, 89 with RA and 107 controls. Results were compared among the 3 groups and correlations of FM percentage were explored within SLE and RA.

RESULTS

Abnormal body composition was more frequent in women with SLE and RA than in non-inflammatory controls, despite having a similar BMI. RA diagnosis was significantly associated with overfat (OR=2.782, 95%CI 1.470-5.264; p=0.002) and central obesity (OR=2.998, 95%CI 1.016-8.841; p=0.04), while sarcopenia was more common among SLE (OR=3.003; 95%CI 1.178-7.676; p=0.01). Sarcopenic obesity, i.e. the coexistence of overfat with sarcopenia, was present in 6.5% of SLE and 5.6% of RA women, but no controls. Independent correlations of FM percentage in women with SLE included smoking, disease activity and CRP. In RA, education, disease activity and cumulative corticosteroid dose were identified as independent predictors of FM percentage.

CONCLUSIONS

Women with SLE or RA diagnosis are more likely to have abnormal body composition phenotype, with some differences existing between these two conditions. Changes in body composition are partly explained by the inflammatory burden of disease and its treatment.

Specific and complementary roles for nitric oxide and ATP in the inhibitory motor pathways to rat internal anal sphincter

BACKGROUND

The neurotransmitters mediating inhibitory pathways to internal anal sphincter (IAS) have not been fully characterized. Our aim was to assess the putative release of nitric oxide, purines and vasoactive intestinal peptide (VIP) from inhibitory motor neurons (MNs) and their role in the myogenic tone, resting membrane potential (RMP) of smooth muscle cells (SMC), spontaneous inhibitory junction potentials (sIJP), mechanical relaxation, and IJP induced by electrical field stimulation (EFS) or nicotine.

METHODS

Rat IAS strips were studied using organ baths, microelectrodes, and immunohistochemistry.

KEY RESULTS

Internal anal sphincter strips developed active myogenic tone (0.31 g), enhanced and stabilized by prostaglandin F(2α) (PGF2α). L-NNA (1 mmol L(-1)) depolarized SMC and increased tone but did not modify sIJP. In contrast, the specific P2Y(1) receptor antagonist MRS2500 (1 μmol L(-1)) did not modify the RMP or the basal tone but abolished sIJP. Electrical field stimulation and nicotine (10 μmol L(-1)) caused IAS relaxation (-45.9%VS-52.2%), partially antagonized by L-NNA (35%-45%, P ≤ 0.05) and fully abolished by MRS2500 (P ≤ 0.001). Electrical field stimulation induced a biphasic inhibitory junction potential (IJP), the initial fast component was selectively blocked by MRS2500 and the sustained slow component was blocked by L-NNA. Vasoactive intestinal peptide 6-28 (0.1 μmol L(-1)) or α-chymotrypsin (10 U mL(-1)) did not modify the RMP, sIJP, EFS-induced IJP, or relaxation. P2Y(1) receptors were immunolocalized in the circular SMC of IAS.

CONCLUSIONS & INFERENCES

The effects of inhibitory MNs on rat IAS are mediated by a functional co-transmission process involving nitrergic and purinergic pathways through P2Y(1) receptors with specific and complementary roles on the control of tone, sIJP, and hyperpolarization and relaxation of IAS following stimulation of inhibitory MNs.

Clinical pathways as a healthcare tool: design, implementation and assessment of a clinical pathway for lower-extremity deep venous thrombosis

OBJECTIVE

To design, implement and assess a clinical pathway for lower-extremity deep venous thrombosis, and to compare the length of hospital stay in two different periods.

DESIGN

Development of the care pathway by a multidisciplinary team, followed by a controlled intervention study to compare two non-concomitant cohorts of patients corresponding to the years 2002 (before the implementation of the critical pathway) and 2004 (year of the implementation).

SETTING

Academic tertiary care hospital.

PARTICIPANTS

90 patients, 42 corresponding to the year 2004 and 48 to 2002, admitted to hospital with a diagnosis of lower-extremity deep venous thrombosis (DVT).

MAIN OUTCOME MEASURES

Length of hospital stay, hospitalisation costs and care indicators.

RESULTS

The mean length of hospital stay was 6.78 days in 2002 and 4.72 days in 2004. This means a reduction of 2.06 days (p<0.012). The reduction in the length of hospital stay in 2004 situates the hospital 1.98 days below the mean stay of our community (6.7 days) for the same diagnosis and year. The impact of the clinical pathway was assessed using the following indicators: implementation indicator 92.2%, compliance indicator 65%, adverse events indicator 2.5% and satisfaction indicator 67%. In comparison with costs incurred in year 2002, implementation of the clinical pathway resulted in a saving of euro427.33 per patient and a total saving of euro17,093.20.

CONCLUSIONS

The implementation of a lower-extremity DVT clinical pathway in our institution has help to reduce hospitalisation costs, due to a decreased length of hospital stay.

Pharmacological compliance and acceptability of lansoprazole orally disintegrating tablets in primary care

OBJECTIVE

To evaluate the pharmacological compliance of patients treated with lansoprazole orally disintegrating tablets (LODT) in Primary Care (PC) and their acceptability of this formulation.

RESEARCH DESIGN AND METHODS

A multicenter, observational, cross-sectional study involving 433 PC physicians that included 433 patients aged at least 18 years, either diagnosed with gastroesophageal reflux disease (GERD) or taking LODT to prevent NSAID-induced gastric ulcers. Compliance with LODT treatment was assessed with the Haynes-Sackett self-reported test. Acceptability was based on global patient assessment, rating the drug's organoleptic characteristics and properties recorded with a self-administered 15-item ad hoc questionnaire with 2 and 5-point Likert-type scales.

RESULTS

423 patients (mean age 50.6 years, SD = 13.4) were evaluable for the main endpoint. Of these, 57.16% were men and 53.5% were treated with 30 mg doses of LODT for an average of 37.8 days (SD = 35.5). Compliance was achieved by 92.4% of the patients, mean percentage of compliance was 93.3. Demographical and clinical variables had no effect on compliance. Treatment with LODT was assessed as 'acceptable' or 'highly acceptable' by 91.7% of the sample. One adverse reaction, not serious, was reported by one patient (0.2%).

CONCLUSIONS

In this observational study, compliance with lansoprazole orally disintegrating tablets was very high. Patients reported that this formulation improved their compliance. LODT was clearly preferred to previous medication and the drug was well tolerated.