The burden of heat-related mortality attributable to recent human-induced climate change

Climate change affects human health; however, there have been no large-scale, systematic efforts to quantify the heat-related human health impacts that have already occurred due to climate change. Here, we use empirical data from 732 locations in 43 countries to estimate the mortality burdens associated with the additional heat exposure that has resulted from recent human-induced warming, during the period 1991-2018. Across all study countries, we find that 37.0% (range 20.5-76.3%) of warm-season heat-related deaths can be attributed to anthropogenic climate change and that increased mortality is evident on every continent. Burdens varied geographically but were of the order of dozens to hundreds of deaths per year in many locations. Our findings support the urgent need for more ambitious mitigation and adaptation strategies to minimize the public health impacts of climate change.

Response to belimumab among patients with systemic lupus erythematosus in clinical practice settings: 24-month results from the OBSErve study in the USA

Objective

To examine disease activity and clinical outcomes, and describe overall patterns of systemic lupus erythematosus (SLE) care in patients who received belimumab in a real-world clinical setting.

Methods

This observational cohort study was conducted in US clinical practices. Rheumatologists (n=92) identified adults with SLE who had received ≥8 infusions of belimumab plus standard of care (SoC). Physicians assessed disease outcomes at 6-month intervals using patient medical charts, for up to 24 months. The primary outcome was physician-assessed change in SLE disease. Other outcomes included change in steroid use, laboratory tests and healthcare resource utilisation (HCRU).

Results

Of 501 patients (intent-to-treat population (ITT)), 446 were female, mean age was 43.3 years and 98% had moderate/severe disease activity at baseline (first dose of belimumab). Data for 277 patients who completed 24 months of belimumab treatment were available. Among the ITT, a ≥50% improvement in overall clinical response between baseline and month 6 was reported for 48.7% of patients; continued improvement was seen at all subsequent 6-month intervals relative to the previous timepoint. The percentage of patients with moderate/severe disease also decreased at each timepoint. At baseline, 77.0% of patients received steroids at a mean (SD) prednisone equivalent dose of 19.9 (14.39) mg/day, which decreased to 8.4 (7.35) mg/day at month 6 and 6.1 (9.31) mg/day at month 24. Abnormal laboratory values typically associated with SLE also demonstrated improvements at month 6, which continued through 24 months. HCRU decreased over the duration of the study.

Conclusions

Patients with SLE who received belimumab plus SoC for up to 24 months demonstrated improvements in disease severity and laboratory values and a reduction in steroid use and HCRU as early as month 6. Improvements continued through 24 months, providing evidence of reduced disease activity among patients taking belimumab in real-world clinical practice.

Detection of vitamin K deficiency by use of an enzyme-linked immunosorbent assay for circulating abnormal prothrombin

A monoclonal antibody was raised against an abnormal decarboxylated prothrombin by a cell fusion technique. A cell line which produces an IgG1 murine antibody to the abnormal prothrombin, but not to prothrombin, was selected. Using this antibody we developed an enzyme-linked sandwich immunoassay for the abnormal prothrombin. The detection range was 0.5 X 10(-1) approximately 0.5 X 10(-3) micrograms protein of decarboxylated prothrombin and 0.5 approximately 0.5 X 10(-2) micrograms protein of abnormal prothrombin in vitamin K-deficient subjects. This discrepancy is attributable to a heterogeneity of decarboxylated prothrombin, depending on the number of gamma-carboxyglutamic acid residues. The antibody obtained had a higher affinity to a protein possessing less gamma-carboxyglutamic acid residues. The assay system developed may be useful for the detection of vitamin K deficiency, since a severe deficiency may result in less gamma-carboxyglutamic acid residues in the protein.

Dietary fiber, lung function, and chronic obstructive pulmonary disease in the atherosclerosis risk in communities study

Recent data suggest beneficial effects of fiber intake on chronic respiratory symptoms in adults that are independent of antioxidant vitamin intake, but little is known about fiber consumption in relation to lung function and chronic obstructive pulmonary disease (COPD). The authors investigated the association of fiber intake with lung function and COPD in 11,897 US men and women from the Atherosclerosis Risk in Communities study (1987-1989). After control for potential confounders, positive associations were found between lung function and fiber intake from all sources as well as from cereal or fruit alone. Compared with those in the lowest quintile, participants in the highest quintile of total fiber intake had a 60.2-ml higher forced expiratory volume in 1 second (FEV(1)) (p for trend < 0.001), 55.2-ml higher forced vital capacity (FVC) (p = 0.001), 0.4% higher FEV(1)/FVC ratio (p = 0.040), 1.8% higher percent predicted FEV(1) (p < 0.001), and 1.4% higher percent predicted FVC (p = 0.001). Adjusted odds ratios of COPD for the highest versus lowest quintiles of intake were 0.85 (p = 0.044) for total fiber, 0.83 (p = 0.021) for cereal fiber, and 0.72 (p = 0.005) for fruit fiber. This study provides the first known evidence that dietary fiber is independently associated with better lung function and reduced prevalence of COPD.

HIV gp120 enhances NO production by cardiac myocytes through p38 MAP kinase-mediated NF-kappaB activation

Human immunodeficiency virus (HIV) infection is associated with a surprisingly high frequency of myocardial dysfunction. Potential mechanisms include direct effects of HIV, indirect effects mediated by cytokines, or a combination. We have previously reported that interleukin-1beta (IL-1beta) (500 U/ml) alone induced nitric oxide (NO) production by neonatal rat cardiac myocytes (CM). Effects of the HIV-1 envelope, glycoprotein120 (gp120), on inducible NO synthase (iNOS) in CM have not been previously reported. Unlike IL-1beta, recombinant HIV-gp120 (1 microgram/ml) alone failed to enhance NO production in CM (0.5 +/- 0.4 vs. 0.4 +/- 0.5 micromol/1.25 x 10(5) cells/48 h, gp120 vs. control, respectively; n = 12, P = not significant). However, the addition of gp120 to IL-1beta significantly enhanced iNOS mRNA expression (70 +/- 1.5 vs. 26 +/- 2.4 optical units, IL-1beta + gp120 vs. IL-1beta, respectively; n = 3), iNOS protein synthesis (42 +/- 1.4 vs. 18 +/- 0.8 optical units, IL-1beta + gp120 vs. IL-1beta, respectively; n = 3), and NO production (NO(2)(-)) (6.6 +/- 0.6 vs. 4.1 +/- 0.8 micromol/1.25 x 10(5) cells/48 h, IL-1beta + gp120 vs. IL-1beta, respectively; n = 12, P </= 0.5). HIV-gp120 enhancement of IL-1beta-induced NO(2)(-) production was blocked by 10 microM of SB-203580 (SB), a selective p38 protein kinase inhibitor (3.6 +/- 0.2 vs. 6.6 +/- 0.6 micromol/1. 25 x 10(5) cells/48 h, IL-1beta + gp120 + SB vs. IL-1beta + gp120, respectively; n = 12, P </= 0.5). HIV-gp120-enhanced p38 protein kinase activity was associated with an increase in IL-1beta-stimulated NF-kappaB activity (184 +/- 12.7 vs. 92 +/- 10.7 optical units, IL-1beta + gp120 vs. IL-1beta, respectively; n = 3). None of these effects was seen with another recombinant HIV-1 protein, Tat. Thus HIV-gp120 enhancement of IL-1beta-induced NO production is associated with p38-mediated activation of NF-kappaB. Direct effects of HIV-gp120 on CM may provide a previously unrecognized mechanism contributing to HIV cardiomyopathy.

Understanding the inter-relationship between improved glycaemic control, hypoglycaemia and weight change within a long-term economic model

BACKGROUND

Current guidelines for the management of type 2 diabetes advocate the attainment of sustained near normal glycaemia levels. Metformin is widely accepted as the treatment of choice for the initiation of pharmacotherapy; however, secondary failure of oral monotherapy occurs in 60% of patients resulting in the need for multiple pharmacotherapies. Therapy-related consequences of treatment, such as weight gain and hypoglycaemia impact on the cost-effectiveness profile of various agents. We therefore sought to ascertain the respective contribution of hypoglycaemia, weight change and improved blood glucose control on second-line therapy options added to metformin.

METHODS

This study uses a simulation model designed to evaluate the cost utility of new therapies in a population of patients with type 2 diabetes mellitus. Standard model outputs include incidence of micro- and macrovascular complications and diabetes-specific and all-cause mortality.

RESULTS

The mean discounted quality-adjusted life year (QALY) predicted by the model was 12.31 years. Reducing Glycosylated haemoglobin (HbA1c) by 1% gave a predicted gain of 0.413 QALYs per patient. A 3-kg weight loss and 30% reduction in hypoglycaemia frequency produced a combined QALY gain of 0.355, whereas the reverse gave a QALY decrement of 0.356.

CONCLUSIONS

The results of this analysis quantify the QALY decrement that may result from adverse therapy effects. The beneficial effects of improved glycaemic control on QALYs may be offset by characteristic treatment-specific adverse effects, such as weight gain and hypoglycaemia frequency.

Burden of corticosteroid use in patients with systemic lupus erythematosus: results from a Delphi panel

Corticosteroid-related adverse events (AEs) are commonly reported in systemic lupus erythematosus (SLE), but are often under-represented in claims data. The most common corticosteroid-related AEs are not necessarily the most costly. The present study aimed to examine corticosteroid-related AE rates and identify the associated cost consequences in patients with SLE from the perspective of rheumatologists treating SLE in the United States (US). A modified Delphi process and RAND Appropriateness Method was used to estimate corticosteroid-related AEs and costs based on data from SLE-treating US rheumatologists and estimates from alternative sources. The panel (n=10) participated in two web-based questionnaires, covering disease severity, corticosteroid use, corticosteroid-related AEs, and resource utilization associated with treatment of the AEs. Eight members of the panel then participated in a guided discussion by interactive teleconference, in which the costs associated with specific corticosteroid-related AEs were also discussed. Consensus was achieved in the teleconference when a single response category (consensus values from 1 to 4 [4=strongly agree, 1=strongly disagree]) accounted for ≥80% of responses. Thirteen consensus statements were developed following two Delphi rounds. Costs were estimated for eight corticosteroid-associated AEs from the panel of rheumatologists. In the patients with SLE treated by these physicians, 41.5% were considered to have mild disease, 36.5% moderate disease, and 22.0% severe disease. The number of specialist visits, corticosteroid use, and corticosteroid dose increased with disease severity. The estimated rates of all AEs (except for cataracts) were at least doubled in patients receiving corticosteroid doses>20 mg/day compared with ≤20 mg/day. The highest estimated mean total costs of an event (for the required treatment duration for one patient) were for avascular necrosis ($14,460) and serious infection ($11,660). The costs of more common AEs, such as osteoporosis, obesity, diabetes, and fractures, ranged from $1190 to $8220. Ten rheumatologists concluded that as disease severity increases, corticosteroid doses increased. Greater utilization of resources is needed to manage patients and corticosteroid-related AEs.

Human elastic cartilage engineering from cartilage progenitor cells using rotating wall vessel bioreactor

Transplantation of bioengineered elastic cartilage is considered to be a promising approach for patients with craniofacial defects. We have previously shown that human ear perichondrium harbors a population of cartilage progenitor cells (CPCs). The aim of this study was to examine the use of a rotating wall vessel (RWV) bioreactor for CPCs to engineer 3-D elastic cartilage in vitro. Human CPCs isolated from ear perichondrium were expanded and differentiated into chondrocytes under 2-D culture conditions. Fully differentiated CPCs were seeded into recently developed pC-HAp/ChS (porous material consisted of collagen, hydroxyapatite, and chondroitinsulfate) scaffolds and 3-D cultivated utilizing a RWV bioreactor. 3-D engineered constructs appeared shiny with a yellowish, cartilage-like morphology. The shape of the molded scaffold was maintained after RWV cultivation. Hematoxylin and eosin staining showed engraftment of CPCs inside pC-HAp/ChS. Alcian blue and Elastica Van Gieson staining showed of proteoglycan and elastic fibers, which are unique extracellular matrices of elastic cartilage. Thus, human CPCs formed elastic cartilage-like tissue after 3-D cultivation in a RWV bioreactor. These techniques may assist future efforts to reconstruct complicate structures composed of elastic cartilage in vitro.

Physician-patient interactions and outcomes in systemic lupus erythematosus (SLE): a conceptual model

Objective

The objective was to develop a conceptual model illustrating the relationships between the physician-patient relationship and patient outcomes, including health status and regimen satisfaction, in systemic lupus erythematosus (SLE).

Methods

This was a cross-sectional survey of a geographically diverse sample of adults with SLE in the United States. Patients completed a Web-based survey that focused on physician interactions, clinical management, and patient outcomes, including patient perception of treatment regimen and health status. All survey variables related to physician interactions and patient perceptions of their health and satisfaction were evaluated for incorporation into a patient-centered model using cluster analysis. Structural equation modeling (SEM) was conducted to assess the inter-relationships observed among the variables to inform the development of a conceptual model of SLE patient-centered care.

Results

A total of 302 SLE patients completed the survey. The majority of patients were female (94.3%) with a mean age of 46 years. The cluster analysis resulted in six main factors: 1) physician interactions, 2) current health and hope, 3) satisfaction with treatment, 4) bedside manner, 5) discussion of lupus impacts during physician visits, and 6) steroid treatment. The significant relationships among the factors showed that positive physician interactions, such as including the patient in treatment decisions, were associated with higher satisfaction with treatment regimen and patients feeling that SLE was well controlled, a more favorable perception of current health, and being more hopeful about future health. Among the components of physician interactions, setting goals with patients is particularly important, as this was significantly associated with the patient being more hopeful about future health. Being steroid free was significantly related to higher treatment satisfaction.

Conclusion

The study findings informed a conceptual model of SLE patient-centered care that may be used to create more targeted education programs in the management of SLE, with the goal to improve patient outcomes.

Effects of cytokines and nitric oxide on myocardial E-C coupling

Compelling evidence now exists that pro-inflammatory cytokines and nitric oxide (NO) are newly identified endogenous regulators of myocardial contractility. The mechanism(s) responsible for the inotropic and chronotropic effects of these novel mediators can be explained on the basis of recently established principles of myocardial excitation contraction coupling (E-C). A novel hypothesis is proposed that cytokines and NO-mediated alterations in E-C coupling contribute to the reversible myocardial depression and beta-adrenergic desensitization observed in a diverse group of clinical conditions that activate host inflammatory responses, including congestive heart failure. The results of in vitro studies indicate that cytokines and NO have both immediate, short-term, as well as long-term effects on cardiac performance. Basic studies into these cytokine signaling pathways in cardiac myocytes have the potential to provide important new insights relevant to the design of new management strategies for the treatment of congestive heart failure patients.

Engineered nanoparticle exposure and cardiovascular effects: the role of a neuronal-regulated pathway

Human and animal studies have confirmed that inhalation of particles from ambient air or occupational settings not only causes pathophysiological changes in the respiratory system, but causes cardiovascular effects as well. At an equal mass lung burden, nanoparticles are more potent in causing systemic microvascular dysfunction than fine particles of similar composition. Thus, accumulated evidence from animal studies has led to heightened concerns about the potential short- and long-term deleterious effects of inhalation of engineered nanoparticles on the cardiovascular system. This review highlights the new observations from animal studies, which document the adverse effects of pulmonary exposure to engineered nanoparticles on the cardiovascular system and elucidate the potential mechanisms involved in regulation of cardiovascular function, in particular, how the neuronal system plays a role and reacts to pulmonary nanoparticle exposure based on both in vivo and in vitro studies. In addition, this review also discusses the possible influence of altered autonomic nervous activity on preexisting cardiovascular conditions. Whether engineered nanoparticle exposure serves as a risk factor in the development of cardiovascular diseases warrants further investigation.

TNF-alpha enhances cardiac myocyte NO production through MAP kinase-mediated NF-kappaB activation

We have previously reported that interleukin-1beta (IL-1beta) alone induced nitric oxide (NO) production by neonatal rat cardiac myocytes (CM). The effects of tumor necrosis factor-alpha (TNF-alpha) on inducible NO synthase (iNOS) were not characterized. Unlike IL-1beta, TNF-alpha alone failed to enhance NO production in CM. However, the addition of TNF-alpha to IL-1beta significantly enhanced iNOS mRNA expression, iNOS protein synthesis, and NO production (NO(-)(2)). TNF-alpha enhancement of IL-1beta-induced NO(-)(2) production was blocked by PD-98059, a selective mitogen-activated protein (MAP) kinase kinase inhibitor, but not calphostin C (Cal C), a protein kinase C inhibitor. TNF-alpha-enhanced MAP kinase activity was associated with an increase in IL-1beta-stimulated NF-kappaB activity. PD-98059, but not Cal C, inhibited both TNF-alpha-enhanced MAP kinase and NF-kappaB activities. Thus TNF-alpha enhancement of IL-1beta-induced NO production is associated with MAP kinase-mediated activation of NF-kappaB.

Incidental extra-cardiac findings on 13N-ammonia myocardial perfusion PET/CT

BACKGROUND

The objective of this study was to describe the prevalence of incidental extra-cardiac findings (IECFs) on myocardial perfusion PET/CTs and the prevalence of potentially clinically relevant and clinically irrelevant IECFs, as well as detection rate of previously unknown malignancies.

METHODS AND RESULTS

From September 2013 until February 2016, a total of 1397 consecutive patients referred for the evaluation of possible ischemia by 13NH3 PET/CT were prospectively included in a database. IECFs were categorized into three groups: potentially clinically relevant IECFs, IECFs that could potentially cause chest pain, and clinically irrelevant IECFs. Additionally, the prevalence of previously unknown malignancies was determined. In 717 (51%) of these patients, 775 IECFs were reported and 115 IECFs were categorized as potentially clinically relevant in 109 (8%) patients. A total of 145 IECFs that could potentially cause chest pain were detected in 139 (10%) patients and 515 clinically irrelevant IECFs were detected in 469 (34%) of the patients. An unknown primary malignancy was histologically proven in 19 patients (1.4%).

CONCLUSIONS

IECFs are detected on myocardial perfusion PET/CT in approximately half of the patients. In the present study, IECFs were potentially clinically relevant in 8% of the patients and in 1.4% an unknown malignancy was found, most of which were lung cancers.

Interactions between cytokines and neurohormonal systems in the failing heart

The prognosis for patients with congestive heart failure (CHF) has been improved as a result of the use of angiotensin converting enzyme inhibitors and beta-adrenergic receptor blockers. The success of these therapies underscores the pathogenic role of neurohormonal activation in CHF. Clinical and experimental evidence supports a pathophysiologic role for pro-inflammatory cytokines and nitric oxide (NO) in the effects of angiotensin II and norepinephrine in CHF. Potential mechanism(s) responsible for the effects of these immunomodulators can be explained on the basis of established principles of myocardial excitation contraction coupling (E-C). A novel hypothesis is proposed that cytokines and NO-mediated alterations in E-C coupling contribute to the reversible myocardial depression and beta-adrenergic desensitization observed in a diverse group of clinical conditions that activate host inflammatory responses, including CHF. Basic studies into cytokine signaling pathways in cardiac myocytes have the potential to provide important new insights relevant to the design of new management strategies for the treatment of congestive heart failure patients.

The influence of inhaled multi-walled carbon nanotubes on the autonomic nervous system

Background

Heart rate and cardiovascular function are regulated by the autonomic nervous system. Heart rate variability (HRV) as a marker reflects the activity of autonomic nervous system. The prognostic significance of HRV in cardiovascular disease has been reported in clinical and epidemiological studies. The present study focused on the influence of inhaled multi-walled carbon nanotubes (MWCNTs) on autonomic nervous system by HRV analysis.

Methods

Male Sprague–Dawley rats were pre-implanted with a telemetry device and kept in the individual cages for recovery. At week four after device implantation, rats were exposed to MWCNTs for 5 h at a concentration of 5 mg/m³. The real-time EKGs were recorded by a telemetry system at pre-exposure, during exposure, 1 day and 7 days post-exposure. HRV was measured by root mean square of successive differences (RMSSD); the standard deviation of inter-beat (RR) interval (SDNN); the percentage of successive RR interval differences greater than 5 ms (pNN5) and 10 ms (pNN10); low frequency (LF) and high frequency (HF).

Results

Exposure to MWCNTs increased the percentage of differences between adjacent R-R intervals over 10 ms (pNN10) (p < 0.01), RMSSD (p < 0.01), LF (p < 0.05) and HF (p < 0.01).

Conclusions

Inhalation of MWCNTs significantly alters the balance between sympathetic and parasympathetic nervous system. Whether such transient alterations in autonomic nervous performance would alter cardiovascular function and raise the risk of cardiovascular events in people with pre-existing cardiovascular conditions warrants further study.

[Effect of green tea polyphenol fraction on 1,2-dimethylhydrazine (DMH)-induced colorectal carcinogenesis in the rat]

We studied the anti-tumor effect of green tea polyphenol fraction (Sunphenon, SF: provided by Taiyo Kagaku Inc., Mie, Japan) on DMH-induced colorectal carcinogenesis in male Wistar rats. DMH was subcutaneously administered weekly at 20 mg/kg for 14 weeks. The rats in group I (20 rats) were given tap water for the whole of the study period. The rats in group II (15 rats) were given tap water from weeks 0-14, and 0.1% SF from weeks 15-35. The rats in group III (21 rats) were given 0.1% SF during the whole period. The rats were sacrificed at week 35. The cecal contents were aseptically removed and examined microbiologically to obtain the counts of four bacteria species (including Clostridium perfringens) per 1 g of cecal contents. The incidence of tumors production was significantly decreased (Group I: 100% vs Group II: 57.1%, Group III: 62.5%, p < 0.05), and the frequency of occurrence of C. perfringens (which is thought to yield harmful products which may be carcinogenic) was decreased in the SF-treated groups. These results suggest that SF prevents DMH-induced carcinogenesis in rats, and that its effect may be somehow related to its ability to preserve the composition of the colonic microflora.

Human acute myeloid leukemias may be etiologically associated with new human retroviral infection

The etiology of human acute myeloid leukemias (AML) remains uncertain. In order to examine the possibility of retroviral etiology in AML, we determined retroviral antigens related to HTLV-I in leukemic cell samples from 32 AML cases and peripheral blood mononuclear cells (PBMNCs) from 20 healthy donors by D-IGSS with high sensitivity and specificity, reverse transcriptase (RT) activity by a simple and sensitive non-radioisotopic RT assay, and retroviral particles by electron microscopy. The HTLV-I-related antigens were detected in 50.0% (16/32) of fresh leukemic cell samples and 87.5% (28/32) of cultured leukemic cell samples. The HTLV-I-related antigen-positive cells in fresh and cultured leukemic samples were 10.2% and 52.8%, respectively. Both frequency and level of HTLV-I-related antigens in cultured samples were much higher than in fresh samples. In contrast, no HTLV-I-related antigens were found in normal hematopoietic cells from 20 healthy donors. Further study results show that RT activity was detected not only in HTLV-I-related antigen-positive samples, but was also well correlated with the level of HTLV-I-related antigens in these samples, and preferred Mn+2 to Mg+2 as a cation. Moreover, typical retroviral particles were localized in most cultured HTLV-I-related antigen-positive samples by immunoelectron microscope. These data suggest that human acute myeloid leukemias may be etiologically associated with new human retroviral infection.