[Recommendations to develop Care Models for patients with Heart Failure (MAIC Project) from macromanagement]

BACKGROUND

The general objective of the study was to reflect on the key factors to advance in optimal models of care for Heart Failure (HF) and specifically, on the macromanagement elements most necessary for the development of comprehensive HF management models.

MATERIAL AND METHODS

An Advisory Committee, composed of 15 experts and a multidisciplinary group of 31 additional experts, was appointed, together forming a Delphi panel of 46 experts. Based on a systematic bibliographic review and the analysis of the care course of the patient with HF, an initial battery of key factors for the development of HF care models was identified by the Advisory Committee. This proposal was adjusted and prioritized by the Delphi panel applying Delphi Rand/UCLA methodology.

RESULTS

After two Delphi rounds, 75 key factors grouped into 7 challenges were defined. In the first of the challenges, related to the development of HF management models, 16 key factors were identified, 7 of which were valued as high priority and related to the establishment of common objectives, resources for the continuity of care and improving the measurement of health outcomes.

CONCLUSIONS

The definition of management elements at the macro level was considered a priority to advance in the development of optimal models of assistance to HF.

Cardiovascular risk in the elderly population of Spain. The EPICARDIAN risk score

BACKGROUND AND OBJECTIVES

Cardiovascular risk estimation in people over 70 years of age is problematic. Most scores have been created based on cohorts of middle-aged people, with an underrepresentation of older adults. The predictive power of classical cardiovascular risk factors declines with age. The aim of this work is to develop a specific score for estimating cardiovascular risk among the elderly population in Spain.

METHODS

This work is a population-based cohort established in 1995.

SETTING

Three geographical areas of Spain (Madrid, Ávila, and Lugo).

PARTICIPANTS

3,729 people older than 64 years with no cardiovascular diseases (CVD) at baseline.

MEASUREMENTS

Suspected fatal and nonfatal CVD (both coronary heart disease and stroke) were investigated annually and confirmed using the WHO-MONICA criteria. All participants were followed-up on until occurrence of a first CVD event, until death, or until December 31, 2015.

RESULTS

Age was the strongest predictor of CVD at 10 years in both men and women. In men, variables associated with CVD were high blood pressure treatment (HR: 1.35; 95% CI: 1.067-1.710), diabetes (HR: 1.359; 95% CI: 0.997-1.852), and smoking (HR: 1.207; 95% CI: 0.945-1.541) and in women, the variables were smoking (HR: 1.881; 95% CI: 1.356-2.609) and diabetes (HR: 1.285; 95% CI: 0.967-1.707). Total cholesterol did not increase the risk of CVD in men or women. However, total cholesterol levels >200 mg/dL were inversely associated with 10-year risk of CVD in men and women.

CONCLUSIONS

In elderly Spanish men, total CVD at 10 years is significantly increased by age, diabetes, and antihypertensive treatment and in elderly Spanish women by diabetes and smoking. Total cholesterol levels did not increase the risk of CVD, particularly in males.

Multi-isotope evidence of population aggregation in the Natufian and scant migration during the early Neolithic of the Southern Levant

Human mobility and migration are thought to have played essential roles in the consolidation and expansion of sedentary villages, long-distance exchanges and transmission of ideas and practices during the Neolithic transition of the Near East. Few isotopic studies of human remains dating to this early complex transition offer direct evidence of mobility and migration. The aim of this study is to identify first-generation non-local individuals from Natufian to Pre-Pottery Neolithic C periods to explore the scope of human mobility and migration during the Neolithic transition in the Southern Levant, an area that is central to this historical process. The study adopted a multi-approach resorting to strontium (⁸⁷Sr/⁸⁶Sr), oxygen (δ18O_VSMOW) and carbon (δ¹³C) isotope ratio analyses of tooth enamel of 67 human individuals from five sites in Jordan, Syria, and Israel. The isotope ratios point both to a significant level of human migration and/or mobility in the Final Natufian which is compatible with early sedentarism and seasonal mobility and with population aggregation in early sedentary hamlets. The current findings, in turn, offer evidence that most individuals dating to the Pre-Pottery Neolithic were local to their respective settlements despite certain evidence of non-locals. Interestingly, isotopic data suggest that two possible non-local individuals benefitted from particular burial practices. The results underscore a decrease in human mobility and migration as farming became increasingly dominant among the subsistence strategies throughout the Neolithic transition of the Southern Levant.

The structure of schizotypal personality traits: a cross-national study

BACKGROUND

Schizotypal traits are considered a phenotypic-indicator of schizotypy, a latent personality organization reflecting a putative liability for psychosis. To date, no previous study has examined the comparability of factorial structures across samples originating from different countries and cultures. The main goal was to evaluate the factorial structure and reliability of the Schizotypal Personality Questionnaire (SPQ) scores by amalgamating data from studies conducted in 12 countries and across 21 sites.

METHOD

The overall sample consisted of 27 001 participants (37.5% males, n = 4251 drawn from the general population). The mean age was 22.12 years (s.d. = 6.28, range 16-55 years). The SPQ was used. Confirmatory factor analysis (CFA) and Multilevel CFA (ML-CFA) were used to evaluate the factor structure underlying the SPQ scores.

RESULTS

At the SPQ item level, the nine factor and second-order factor models showed adequate goodness-of-fit. At the SPQ subscale level, three- and four-factor models displayed better goodness-of-fit indices than other CFA models. ML-CFA showed that the intraclass correlation coefficients values were lower than 0.106. The three-factor model showed adequate goodness of fit indices in multilevel analysis. The ordinal α coefficients were high, ranging from 0.73 to 0.94 across individual samples, and from 0.84 to 0.91 for the combined sample.

CONCLUSIONS

The results are consistent with the conceptual notion that schizotypal personality is a multifaceted construct and support the validity and utility of SPQ in cross-cultural research. We discuss theoretical and clinical implications of our results for diagnostic systems, psychosis models and cross-national mental health strategies.

Cancer Incidence in Heart Transplant Recipients With Previous Neoplasia History

Neoplasm history increases morbidity and mortality after solid organ transplantation and has disqualified patients from transplantation. Studies are needed to identify factors to be considered when deciding on the suitability of a patient with previous tumor for heart transplantation. A retrospective epidemiological study was conducted in heart transplant (HT) recipients (Spanish Post-Heart Transplant Tumor Registry) comparing the epidemiological data, immu-nosuppressive treatments and incidence of post-HT tumors between patients with previous malignant noncardiac tumor and with no previous tumor (NPT). The impact of previous tumor (PT) on overall survival (OS) was also assessed. A total of 4561 patients, 77 PT and 4484 NPT, were evaluated. The NPT group had a higher proportion of men than the PT group (p < 0.001). The incidence of post-HT tumors was 1.8 times greater in the PT group (95% confidence interval [CI] 1.2-2.6; p < 0.001), mainly due to the increased risk in patients with a previous hematologic tumor (rate ratio 2.3, 95% CI 1.3-4.0, p < 0.004). OS during the 10-year posttransplant period was significantly lower in the PT than the NPT group (p = 0.048) but similar when the analysis was conducted after a first post-HT tumor was diagnosed. In conclusion, a history of PT increases the incidence of post-HT tumors and should be taken into account when considering a patient for HT.

Multiplex detection of nine food-borne pathogens by mPCR and capillary electrophoresis after using a universal pre-enrichment medium

Routine microbiological quality analyses in food samples require, in some cases, an initial incubation in pre-enrichment medium. This is necessary in order to ensure that small amounts of pathogenic strains are going to be detected. In this work, a universal pre-enrichment medium has been developed for the simultaneous growth of Bacillus cereus, Campylobacter jejuni, Clostridium perfringens, Cronobacter sakazakii, Escherichia coli, Enterobacteriaceae family (38 species, 27 genera), Listeria monocytogenes, Staphylococcus aureus, Salmonella spp. (two species, 13 strains). Growth confirmation for all these species was achieved in all cases, with excellent enrichments. This was confirmed by plating on the corresponding selective agar media for each bacterium. This GVUM universal pre-enrichment medium could be useful in food microbiological analyses, where different pathogenic bacteria must be detected after a pre-enrichment step. Following, a mPCR reaction for detection of all these pathogens was developed, after designing a set of nine oligonucleotide pairs from specific genetic targets on gDNA from each of these bacteria, covering all available strains already sequenced in GenBank for each pathogen type. The detection limits have been 1 Genome Equivalent (GE), with the exception of the Fam. Enterobacteriaceae (5 GEs). We obtained amplification for all targets (from 70 to 251 bp, depending on the bacteria type), showing the capability of this method to detect the most important industrial and sanitary food-borne pathogens from a universal pre-enrichment medium. This method includes an initial pre-enrichment step (18 h), followed by a mPCR (2 h) and a capillary electrophoresis (30 min); avoiding the tedious and long lasting growing on solid media required in traditional analysis (1–4 days, depending on the specific pathogen and verification procedure). An external testing of this method was conducted in order to compare classical and mPCR methods. This evaluation was carried out on five types of food matrices (meat, dairy products, prepared foods, canned fish, and pastry products), which were artificially contaminated with each one of the microorganisms, demonstrating the equivalence between both methods (coincidence percentages between both methods ranged from 78 to 92%).

Dual role of astrocytes in perinatal asphyxia injury and neuroprotection

Perinatal asphyxia represents an important cause of severe neurological deficits including delayed mental and motor development, epilepsy, major cognitive deficits and blindness. However, at the moment, most of the therapeutic strategies were not well targeted toward the processes that induced the brain injury during perinatal asphyxia. Traditionally, experimental research focused on neurons, whereas astrocytes have been more related with the damage mechanisms of perinatal asphyxia. In this work, we propose to review possible protective as well as deleterious roles of astrocytes in the asphyctic brain with the aim to stimulate further research in this area of perinatal asphyxia still not well studied.

Effect of an educational intervention in primary care physicians on the compliance of indicators of good clinical practice in the treatment of type 2 diabetes mellitus [OBTEDIGA project]

AIM

To evaluate the effect of an educational intervention among primary care physicians on several indicators of good clinical practice in diabetes care.

METHODS

Two groups of physicians were randomly assigned to the intervention or control group (IG and CG). Every physician randomly selected two samples of patients from all type 2 diabetic patients aged 40 years and above and diagnosed more than a year ago. Baseline and final information were collected cross-sectionally 12 months apart, in two independent samples of 30 patients per physician. The educational intervention comprised: distribution of educational materials and physicians' specific bench-marking information, an on-line course and three on-site educational workshops on diabetes. External observers collected information directly from the physicians and from the medical records of the patients on personal and family history of disease and on the evolution and treatment of their disease. Baseline information was collected retrospectively in the control group.

RESULTS

Intervention group comprised 53 physicians who included a total of 3018 patients in the baseline and final evaluations. CG comprised 50 physicians who included 2868 patients in the same evaluations. Measurement of micro-albuminuria in the last 12 months (OR = 1.6, 95% CI: 1.1-2.4) and foot examination in the last year (OR = 2.0, 95% CI: 1.1-3.6) were the indicators for which greater improvement was found in the IG. No other indicator considered showed statistically significant improvement between groups.

CONCLUSIONS

The identification of indicators with very low level of compliance and the implementation of a simple intervention in physicians to correct them is effective in improving the quality of care of diabetic patients.

Systemic blockade of TNF-α does not improve insulin resistance in humans

The purpose of this study was to determine whether long-term modulation of inflammatory activity by tumor necrosis factor (TNF)-α inhibitors has some influence on insulin resistance (IR). 16 active rheumatoid arthritis (RA) patients without CV risk factors treated with anti-TNF-α agents were included in this study. RA activity by disease activity score 28, IR by HOMA2-IR, body composition by impedance analysis, physical activity by accelerometry, abdominal fat distribution by magnetic resonance imaging, and serum level of key adipokines by ELISA were measured at baseline and during a 1-year follow-up period. Patient body mass index increased significantly (26.94 ± 3.88 vs. 28.06 ± 4.57 kg/m2, p=0.02) after 1 year of treatment. Body composition, in terms of fat and fat-free mass, remained unchanged except for a significant elevation in body cell mass (25.50 ± 4.60 vs. 26.60 ± 3.17 kg, p=0.02). Basal levels of IR in the RA patients included in this study were significantly higher than healthy controls (1.6 ± 0.8 vs. 1.11 ± 0.56, p=0.011) but did not change during the follow-up. Nor did basal concentrations of adiponectin, visfatin, leptin, ghrelin, resistin, and apelin in response to anti-TNF-α treatment; only retinol-binding protein 4, showed a significant increase (51.7 ± 32.7 vs. 64.9 ± 28.4 μg/ml, p=0.03) at the end of the study. IR, adiposity distribution, and serum levels of most adipokines are not significantly affected by long-term inhibition of TNF-α in RA patients. Our data suggest that although systemic blockade of TNF-α exerts an anticachectic effect in RA patients, it does not seem to play a major role in IR.

Quality of care of patients with type-2 diabetes in Galicia (NW Spain) [OBTEDIGA project]

AIMS

The aim of this study was to describe the degree of compliance of agreed practices with reference to primary care patients with Type 2 diabetes of 40 years old and older in Galicia (NW Spain).

METHODS

A total of 108 primary care physicians were selected at random from the totality of doctors. Each physician selected 30 patients at random from their patients suffering from diabetes of 40 years old or older. External observers gathered information from each patient's medical record regarding their characteristics, condition and degree of compliance of selected indicators of good practice.

RESULTS

Group of physicians participated in this study had a mean age of 50 years (standard deviation = 3.9); 48% of them were females; and 17.5% involved in medical residents training. A total of 3078 diabetic patients were included in the study: mean age = 69 years (SD = 10.9), 47.6% women, presence of high blood pressure (72%), hypercholesterolaemia (56%), and regular smokers (10.3%). Compliance with selected indicators such as foot examination (14%), ophthalmological examination (30.6%), abdominal circumference measurement (6.1%), measurement of total or LDL-cholesterol (78.1), blood pressure measurement (84.8), glycosylated haemoglobin measurement < 7% (54.3%) was observed. Adequate monitoring in cases of high blood pressure and hypercholesterolaemia were 34.2% and 27.4%, respectively. Variability between physicians differs according to the different indicators, with interquartile range for compliance of between 16.4 and 66%.

CONCLUSIONS

There is a wide margin for improvement in the adaptation of clinical practice to recommendations for diabetic patients. The large variation existing in certain indicators would suggest that certain control objectives are less demanding than advisable in those that comply least, while low compliance and low variability in other indicators point to structural problems or unsatisfactory training of doctors.

Lung cancer after heart transplantation: results from a large multicenter registry

In this study we analyzed Spanish Post-Heart-Transplant Tumour Registry data for adult heart transplantation (HT) patients since 1984. Median post-HT follow-up of 4357 patients was 6.7 years. Lung cancer (mainly squamous cell or adenocarcinoma) was diagnosed in 102 (14.0% of patients developing cancers) a mean 6.4 years post-HT. Incidence increased with age at HT from 149 per 100 000 person-years among under-45s to 542 among over-64s; was 4.6 times greater among men than women; and was four times greater among pre-HT smokers (2169 patients) than nonsmokers (2188). The incidence rates in age-at-diagnosis groups with more than one case were significantly greater than GLOBOCAN 2002 estimates for the general Spanish population, and comparison with published data on smoking and lung cancer in the general population suggests that this increase was not due to a greater prevalence of smokers or former smokers among HT patients. Curative surgery, performed in 21 of the 28 operable cases, increased Kaplan-Meier 2-year survival to 70% versus 16% among inoperable patients.

Passive mechanical properties of cardiac tissues in heart hypertrophy during pregnancy

We evaluated changes in passive mechanical properties in cardiac tissues during rat pregnancy. Left and right ventricular free walls were dissected from hearts of nonpregnant, late-pregnant, and postpartum rats. Mechanical experiments in ventricular strips were done by stretch-release cycles using a step motor. The results show that during pregnancy, there is cardiac hypertrophy associated with (1) an increase in myocyte size, particularly of augmented myocyte length, (2) a decrease in passive tension developed by the myocardial walls, and (3) a decrease in both elastic modulus and hysteresis. All changes observed during rat pregnancy were reversed during postpartum. In conclusion, a heart with less ventricular rigidity could contribute to facilitating the ventricular filling in conditions of a greater circulating volume characteristic of pregnancy.

Homeostatic control of slow vacuolar channels by luminal cations and evaluation of the channel-mediated tonoplast Ca2+ fluxes in situ

Ca(2+), Mg(2+), and K(+) activities in red beet (Beta vulgaris L.) vacuoles were evaluated using conventional ion-selective microelectrodes and, in the case of Ca(2+), by non-invasive ion flux measurements (MIFE) as well. The mean vacuolar Ca(2+) activity was approximately 0.2 mM. Modulation of the slow vacuolar (SV) channel voltage dependence by Ca(2+) in the absence and presence of other cations at their physiological concentrations was studied by patch-clamp in excised tonoplast patches. Lowering pH at the vacuolar side from 7.5 to 5.5 (at zero vacuolar Ca(2+)) did not affect the channel voltage dependence, but abolished sensitivity to luminal Ca(2+) within a physiological range of concentrations (0.1-1.0 mM). Aggregation of the physiological vacuolar Na(+) (60 mM) and Mg(2+) (8 mM) concentrations also results in the SV channel becoming almost insensitive to vacuolar Ca(2+) variation in a range from nanomoles to 0.1 mM. At physiological cation concentrations at the vacuolar side, cytosolic Ca(2+) activates the SV channel in a voltage-independent manner with K(d)=0.7-1.5 microM. Comparison of the vacuolar Ca(2+) fluxes measured by both the MIFE technique and from estimating the SV channel activity in attached patches, suggests that, at resting membrane potentials, even at elevated (20 microM) cytosolic Ca(2+), only 0.5% of SV channels are open. This mediates a Ca(2+) release of only a few pA per vacuole (approximately 0.1 pA per single SV channel). Overall, our data suggest that the release of Ca(2+) through SV channels makes little contribution to a global cytosolic Ca(2+) signal.

Malignancy after heart transplantation: incidence, prognosis and risk factors

The Spanish Post-Heart-Transplant Tumour Registry comprises data on neoplasia following heart transplantation (HT) for all Spanish HT patients (1984-2003). This retrospective analysis of 3393 patients investigated the incidence and prognosis of neoplasia, and the influence of antiviral prophylaxis. About 50% of post-HT neoplasias were cutaneous, and 10% lymphomas. The cumulative incidence of skin cancers and other nonlymphoma cancers increased with age at HT and with time post-HT (from respectively 5.2 and 8.9 per 1000 person-years in the first year to 14.8 and 12.6 after 10 years), and was greater among men than women. None of these trends held for lymphomas. Induction therapy other than with IL2R-blockers generally increased the risk of neoplasia except when acyclovir was administered prophylactically during the first 3 months post-HT; prophylactic acyclovir halved the risk of lymphoma, regardless of other therapies. Institution of MMF during the first 3 months post-HT reduced the incidence of skin cancer independently of the effects of sex, age group, pre-HT smoking, use of tacrolimus in the first 3 months, induction treatment and antiviral treatment. Five-year survival rates after first tumor diagnosis were 74% for skin cancer, 20% for lymphoma and 32% for other tumors.

[Blood pressure and lipid control and coronary risk in the hypertensive population attended in Primary Care setting in Spain. The PRESCOT study]

OBJECTIVES AND METHODS

The aim of this cross-sectional and multicenter study was to determine the coronary risk of hypertensive patients attended in Spanish Primary Care and to evaluate whether blood pressure and LDL-cholesterol (LDL-c) control rates could change according to the ATP-III risk groups. Good blood pressure control was considered <140/90 mmHg (<130/80 mmHg for diabetics) and LDL-c according to the established by ATP-III for every risk group.

RESULTS

A total of 12,954 patients were included in the study (49.9 % women, mean age 62.1+/-10.7 years). Of these, 12.6% belonged to the group of low risk, 45% to the medium risk group and 42.4% to the high risk group. The control rates were different according to the risk group (p <0.0001). Blood pressure control: 37.5 % in low risk, 30.2 % in medium and 15.4 % in high risk group. LDL-c control: 65.6 % in low risk group, 28 % in medium risk group and 12.3 % in high risk group. Only 25.8 % of the patients of low risk were controlled for both blood pressure and LDL-c, 9.6 % of medium risk group and 2.7 % of high risk group.

CONCLUSIONS

The majority of hypertensive patients daily attended in Primary Care setting in Spain belongs to the medium or high coronary risk groups. Blood pressure and LDL-c controls rates in hypertensive population are low, and very few patients have both risk factors controlled. The control rates decline when the risk increases. In fact, less than 3% of high-risk patients have both parameters well controlled, what may result in significant clinical implications.

Long-Term Results of Heart Transplant in Recipients Older and Younger Than 65 Years: A Comparative Study of Mortality, Rejections, and Neoplasia in a Cohort of 445 Patients

BACKGROUND

Whether being older than 65 years should be considered an absolute counterindication to heart transplant (HT), as it is in some centers, is controversial. In our centre, patients older than 65 years are accepted for HT if they satisfy stringent conditions. The aim of this study was to examine whether heart recipients older than 65 years have a greater risk of rejection, neoplasia, or mortality than younger ones.

METHODS

We studied 445 patients who underwent HT between April 1991 and December 2003, 42 of whom were older than 65 years and 403 who were 65 years or younger. The parameters evaluated were the cumulative incidences of neoplasias and rejections (ISHLT grade > or = 3A), and the survival rates 1 month, 1 year, and 5 years post-HT.

RESULTS

The two groups had similar percentages of patients with at least one rejection episode (< or =65 years 56.9%, >65 years 51.3%; P > .05), and although there were proportionally almost twice as many tumors in the older group (14.2%) as in the younger (7.9%), this difference was not statistically significant either. Nor were there any significant differences in survival, the 1-month, 1-year, and 5-year rates being 87.8%, 82.1%, and 68.8%, respectively, in the younger group and 85.7%, 78.6%, and 73.4%, respectively, in the older.

CONCLUSIONS

Among carefully selected patients aged more than 65 years, HT can be performed without incurring greater risk of rejection, malignancy, or death than is found among recipients younger than 65 years.

Independent Predictors of Renal Dysfunction After Heart Transplantation in Patients With Normal Pretransplant Renal Function

BACKGROUND

Renal dysfunction (RD) is a common complication after heart transplantation (HT), but predictors of post-HT RD have not been clearly identified.

METHODS

We studied 262 HT patients (mean age 54 years, 221 men) with normal baseline renal function. Potential risk factors examined were age, sex, pre-HT ischemic cardiomyopathy, pre- and post-HT diabetes mellitus, pre- and post-HT arterial hypertension, initial immunosuppressive protocol (before 1998 [high cyclosporine, azathioprine, and prednisone] vs after 1998 [low cyclosporine, mycophenolate mofetil, and prednisone]), occurrence of rejection episodes > or =ISHLT Grade 3A, and creatinine level 1 month after HT. RD was considered mild if creatinine level was 1.5 to 2.5 mg/dl, moderate if creatinine level was >2.5 mg/dl, and severe if dialysis or kidney transplant was required.

RESULTS

The cumulative incidence of RD (creatinine >1.5 mg/dl) was 35% at 12 months, 42% at 24 months, and 47% at 60 months (mean follow-up 59 +/- 31 months). Only 1% of patients had severe RD 60 months after HT. Independent predictors of RD 24 months after HT were older age (odds ratio [OR] 1.1 [95% confidence interval (95% CI) 1.0-1.1]; p = 0.001), male sex (OR 3.3 [95% CI 1.3-8.1]; p = 0.008), pre-1998 immunosuppressive protocol (OR 2.8 [95% CI 1.4-5.4]; p = 0.003), and creatinine level 1 month after HT (OR 3.2 [95% CI 1.0-5.4]; p < 0.0001).

CONCLUSIONS

The cumulative incidence of RD in HT patients treated with calcineurin inhibitors increased with time after HT. Age, male sex, an immunosuppressive protocol with relatively high cyclosporine levels and creatinine level 1 month after HT were independent predictors of the presence of RD 24 months after HT.

Regulation of the Slow Vacuolar Channel by Luminal Potassium: Role of Surface Charge

Voltage-dependent activation of slow vacuolar (SV) channels has been studied on isolated patches from red beet (Beta vulgaris L.) vacuoles. Isoosmotic variation of vacuolar K(+) from 10 to 400 mM in Ca(2+)-free solutions at the vacuolar side shifted the SV channel activation threshold to more positive voltages. The effect of K(+) could be mimicked by additions of choline or N-methyl D-glucamine and could be explained by unspecific screening of the negative surface charge. Fitting the dependence of voltage shift on K(+) concentration to the Gouy-Chapman model yields a surface charge density of 0.36 +/- 0.05 e(-)/nm(2). Negative surface potential also tended to increase the local concentration of permeable ions (K(+)), resulting in anomalously high single-channel conductance, approximately 200 pS in 10 mM KCl. An increase of ionic strength due to addition of impermeable cations greatly reduced the unitary conductance. Large positive shift of the SV channel voltage dependence, caused by physiological (0.5 mM) free vacuolar Ca(2+), was partly ameliorated by increasing luminal K(+). We interpreted these results as follows: K(+)induced a reduction of surface potential, hence i) causing a positive shift of the voltage dependence and ii) a dilution of Ca(2+) in the membrane vicinity, thus reducing the inhibitory effect of vacuolar Ca(2+) and causing a negative shift of the SV channel voltage dependence, with a sum of the two shifts being negative.

Fast-activating channel controls cation fluxes across the native chloroplast envelope

A prerequisite for photosynthetic CO(2) fixation is the maintenance of alkaline pH in the stroma. This is achieved by H(+) pumping from the stroma to the cytosol, electrically balanced by an influx of cations through some unidentified non-selective envelope channels. In this study, the patch-clamp technique was applied to isolated Pisum sativum L. (pea) chloroplasts, and a fast-activating chloroplast cation (FACC) channel was discovered in the native envelope. This channel opens within a few milliseconds upon voltage steps to large positive or negative potentials. Remarkably, the single-channel conductance increased fivefold, from approximately 40 pS to approximately 200 pS (symmetric 250 mM KCl), upon a potential change from zero to +/- 200 mV. The FACC channel conducts all physiologically essential inorganic cations (K(+), Na(+), Ca(2+), Mg(2+)) with little preference. An increase of stromal pH from 7.3 to 8.0, mimicking dark-light transition, caused about a 2-fold decrease of the FACC channel activity within a physiologically relevant potential range. The FACC channel was completely and irreversibly blocked by Gd(3+). Based on the estimated transport capacity of the whole chloroplast population of FACC channels together with the envelope H(+)-ATPases, these channels can mediate electroneutral K(+)/H(+) exchange across the envelope, enabling stroma alkalinization, thereby allowing an optimal photosynthetic performance.

Cytotoxin and pyrogenic toxin superantigen gene profiles of Staphylococcus aureus associated with subclinical mastitis in dairy cows and relationships with macrorestriction genomic profiles

A set of 84 Staphylococcus aureus isolates collected from the milk of cows with subclinical mastitis in Asturias (a cattle region of Spain) and six control strains were tested for sequences of genes encoding hemolysins (hla, hlb, hld, hlg, and hlg-2), leukotoxins (lukPV, lukM, and lukED), toxic shock syndrome toxin (tst), and enterotoxins (sea to see, seg to ser, and seu) by conventional and multiplex PCR. It was found that 84, 83, 11, and 39 isolates carried some type of hl, luk, tst, or se gene, respectively, which were arranged in 14 exotoxin genotypes. All of the isolates were negative for lukPV, hlg, sea, sed, see, sej, sek, sep, seq, and ser. Two gene groupings could be related with pathogenicity islands-[lukED, seg, sei, sem, sen, seo +/- seu] with Sabeta-1 and [tst, sec, sel] with SaPIbov, present in 45 and 13.1% of the isolates, respectively-while 11.9% of them carried both islands. Only one contained seb (together with upsilonSabeta-1), and another contained seh (together with lukED). The isolates were also analyzed by pulsed-field gel electrophoresis performed with SmaI. Thirty-nine SmaI profiles (similarity coefficient [S] = 0.94 to 0.21) were differentiated; 12, 1, and 10 of these, respectively, were generated by isolates presumptively carrying Sabeta-1, SaPIbov, or both. Five SmaI profiles (S > or = 0.8) formed a cluster, which contained 20 and 10 isolates carrying one (upsilonSabeta-1) or both islands. These data show the high frequency of genes encoding cytotoxins and pyrogenic toxin superantigens, their relationship with pathogenicity islands, and their distribution among a diversity of genetic types of S. aureus related to subclinical mastitis.

Folding-unfolding of FN-III domains in tenascin: an elastically coupled two-state system

In a single-molecule atomic force microscopy (AFM) experiment, the tenascin molecule is stretched by an external force causing an elongation which is due to the unfolding of the FN-III modules. The features of the force-extension curves depend on the pulling speed and show a saw-tooth pattern (lower speeds) or a smooth pattern (higher speeds). In any case, the unfolded domains are elastically coupled to the unfolded modules, acting as transmitters of the external force. In this communication, the folding-unfolding process of the FN-III domains in tenascin is studied using reaction rate theory and a simple two-state model. The main hypothesis of the study is that, at microscopic level, the force needed to unfold a domain and the unfolding rate (unfolding velocity) can mimic the macroscopic process of measurement by AFM. As the external force is applied, the probability of unfolding increases as dictated by the reaction rate theory. Within this context, a relationship between the unfolding force and the unfolding velocity is obtained. The latter relation will describe microscopically the process in a phenomenological fashion. Moreover, while relating the results of this study with other experimental (AFM measurements) and theoretical (Monte Carlo simulations) data, we found that the graph of unfolding force-unfolding velocity is similar to that of external force-pulling velocity. The refolding process can also be studied within this model and the results show similar trends. The latter suggests a generic and universal behavior of such kind of molecular domains at least in the light of the proposed model.

Neuropsychological, Psychophysiological, and Personality Assessment of DSM-IV Clusters of Personality Disorders

Testing the construct validity of the three DSM-IV cluster groupings of personality disorders, in terms of neuropsychological, psychophysiological, and personality traits measures, was the purpose of this study. The results hardly confirm significant differences between B and C cluster groups in their neuropsychological functioning, but, instead, suggest that Cluster A could have some empirical validity based on executive prefrontal deficits (concept formation and sustained attention tasks) and clinical features. Similarly, no consistent differences among groups emerge when psychophysiological measures are compared. With regard to the Big-Five personality dimensions, the results also indicate that clusters may be more heterogeneous than the DSM-IV suggests. It appears, therefore, that the categorical division of DSM personality disorders into three discrete clusters may not be empirically justified.

Hypotension, acidosis and vasodilation syndrome after heart transplant: incidence, risk factors, and prognosis

BACKGROUND

HAV syndrome, the combination of hypotension, acidosis and vasodilation (HAV), is a serious postoperative complication after heart transplantation (HT). Its etiology and prognosis are poorly understood.

AIM

To determine the incidence and prognosis of post-HT HAV syndrome and examine possible risk factors.

METHODS

Retrospective examination of the records of 85 consecutive patients who underwent HT between December 1999 and June 2002 sought the HAV criteria: systolic BP <85 mm Hg plus HCO3 <19 mEq/l whole excluding cardiogenic, hypovolemic and septic shock. Donor variables included sex, age, weight, height, cause of death, time in ICU, and ischemic time; while recipient variables, sex, age, weight, height, etiology of cardiopathy, previous cardiopulmonary bypass surgery, preoperative amiodarone, beta-blockers, catecholamines, mechanical ventilation or intra aortic balloon pump (IABP), RVP, time on waiting list, pump time, reoperations, polytransfusion, preoperative creatinine, GOT, GPT and GGT, induction with OKT3 or anti-CD25, bypass-to-HAV time, duration of catecholamine treatment, and 1 month survival after HT.

RESULTS

The 11 HAV cases (13%) appeared between 1 and 72 h after HT (75% in the first hour). Catecholamines were used for 1 to 6 days; control was achieved within 48 h in 58% of cases. Two HAV patients (18%) died within the first month versus six non-HAV patients (8.1%) (P=.275). Only polytransfusion showed more than a borderline value to predict HAV syndrome.

CONCLUSIONS

HAV syndrome has an incidence of 13% and a mortality of 18% within 1 month post-HT. The only likely risk factor is polytransfusion.

Renal dysfunction after orthotopic heart transplantation: incidence, natural history, and risk factors

BACKGROUND

Renal dysfunction is a common complication after orthotopic heart transplantation (HT). The importance of factors other than exposure to immunosuppressive drugs is unclear. The purpose of this study was to determine the incidence and natural history of renal dysfunction following heart transplantation, and to evaluate a number of variables as risk factors for this condition.

METHODS

We examined the creatinine levels at 1, 6, 12, 24, and 60 months in 262 consecutive heart transplant patients who survived at least 1 year. The potential risk factors included pre- and posttransplantation diabetes mellitus, arterial hypertension, and drugs used to control arterial hypertension.

RESULTS

17.2% of patients showed mild renal dysfunction (creatinine 1.5-2.5 mg/dL) and 1.9% moderate dysfunction (creatinine >2.5 mg/dL) at 1 month; 29.8% showed mild and 1.1% moderate dysfunction at 6 months; 33.2% showed mild and 1.9% moderate dysfunction at 1 year; 40% showed mild, 0.9% moderate and 0.4% severe dysfunction (requiring dialysis or renal transplantation) at 2 years; and 43.6% showed mild, 1.7% moderate and 0.9% severe dysfunction at 5 years. None of the conditions analyzed as possible risk factors showed a significant association with renal dysfunction except the use of diuretics.

CONCLUSION

The incidence of renal dysfunction after orthotopic heart transplantation was 33.6% within the first year after transplant and 44% within the first five years, although more than 95% of cases were mild. The incidence increased with time after transplantation. Renal dysfunction seems likely to be multifactorial in origin, but no individual risk factors were identified.

Neither acute rejection nor immunosuppressant drug therapy (cyclosporine or tacrolimus) correlates with expression of either CD40 or CD154 on peripheral blood cells among human cardiac transplant patients

Acute allograft rejection (AAR) is an important cause of graft loss following heart transplantation (HT). Increasing evidence shows that CD40-CD154 interactions play a central role in the immune processes leading to AAR. In this study we investigated the expression of CD40 and CD154 on peripheral blood cells from HT patients so as to determine possible association with AAR. Using two-color flow cytometry, we determined the expression of CD40 and CD154 in 102 samples of peripheral blood taken from 53 adult HT patients and in 17 samples from healthy adult volunteers. Samples from patients were obtained at the same time as endomyocardial biopsy was performed. We analyzed the relationships between the expression of these molecules and the following parameters: immunosuppressive treatment (cyclosporine vs tacrolimus), gender, age, time post-HT, and AAR (indicated by an ISHLT rating > or =3A). The percentages of HT patients' blood samples showing above-normal CD40 or CD154 expression did not differ significantly from those of controls. The percentage of patients' samples showing above-normal CD40 expression decreased with time after HT. Expression of these molecules was not above normal during rejection episodes, and for neither was there any statistically significant correlation between expression level and the immunosuppressor drug.

Effect of exogenous melatonin on hepatic energetic status during ischemia/reperfusion: possible role of tumor necrosis factor-alpha and nitric oxide

BACKGROUND

This study was designed to determine if the very potent antioxidant melatonin is able to reduce organ damage and improve energetic status in an in situ liver ischemia/reperfusion model.

MATERIALS AND METHODS

Total hepatic ischemia was induced in rats by occlusion of the hepatic artery, portal vein, and bile duct. A portojugular shunt was inserted. After 60 min of ischemia, reperfusion was established for a period of 120 min. Rats were assigned to one group receiving systemic melatonin administration or to another receiving only normal saline. Variables were observed at preischemia, after 60 min of ischemia, and at 30, 60, and 120 min of reperfusion.

RESULTS

Energy charge, measured as the arterial ketone body ratio, showed higher values in the melatonin group during the first 60 min of reperfusion. Rises in plasma nitrite, tumor necrosis factor (TNF)-alpha, aspartate aminotransferase, alanine aminotransferase, lipid peroxidation products, and inducible nitric oxide synthase (iNOS) expression were less severe with melatonin. Linear regression analysis demonstrated a significant correlation between nitrites and arterial ketone body ratio (R(2) = 0.2454). Bile production was higher with melatonin. Seven-day survival rates were 52% for control, 80% for melatonin, and 100% for sham groups.

CONCLUSIONS

Exogenous melatonin is capable of preserving the functional and energetic status during ischemia/reperfusion which is associated with reduced concentrations of TNF-alpha and inhibited expression of iNOS and NO production. This improvement may be due to an adequate preservation of the hepatic mitochondrial redox status.

Effects of sprint and endurance training on passive stress-strain relation of fast- and slow-twitch skeletal muscle in Wistar rat

We investigated the effects of endurance and sprint training on the passive mechanical properties of fast-twitch (FT) and slow-twitch (ST) skeletal muscles. Eight-week-old male Wistar rats (n=18) were divided into three groups: control (C), sprint-trained (S) and endurance-trained (E). The trained animals exercised for 10 weeks on a treadmill. Under anaesthesia, Plantaris and Soleus muscles were deformed cyclically in vivo at 0.33 mm x s(-1) with length increments of 1 mm in successive cycles until rupture. The rupture of muscle occurs at belly. Stress-strain relation were constructed using the maximum stress and maximum strain in each cycle. The data were fitted to an S-shaped curve. The curve-fitting parameters for trained and untrained muscles showed significant statistical differences. Stress and strain at rupture and maximum deformation energy were statistically greater for trained ST muscles (both groups) than for the controls. The changes induced by the present training protocols were not significant in Plantaris. The above results suggest the plasticity of passive structure caused by activity-demands.

Processing and representation of meta-data for sleep apnea diagnosis with an artificial intelligence approach

In this article, we revise and try to resolve some of the problems inherent in questionnaire screening of sleep apnea cases and apnea diagnosis based on attributes which are relevant and reliable. We present a way of learning information about the relevance of the data, comparing this with the definition of the information by the medical expert. We generate a predictive data model using a data aggregation operator which takes relevance and reliability information about the data into account to produce a diagnosis for each case. We also introduce a grade of membership for each question response which allows the patient to indicate a level of confidence or doubt in their own judgement. The method is tested with data collected from patients in a Sleep Clinic using questionnaires specially designed for the study. Other artificial intelligence predictive modeling algorithms are also tested on the same data and their predictive accuracy compared to that of the aggregation operator.

Conduction of monovalent and divalent cations in the slow vacuolar channel

The conduction properties of individual physiologically important cations Na+, K+, Mg2+, and Ca2+ were determined in the slowly activating (SV) channel of sugar beet vacuoles. Current-voltage relationships of the open channel were measured on excised tonoplast patches in a continuous manner by applying a +/-140 mV ramp-wave protocol. Applying KCl gradients of either direction across the patch we have determined that the relative Cl- to K+ permeability was < or =1%. Symmetrical increase of the concentration of tested cation caused an increase of the single channel conductance followed by saturation. Fitting of binding isotherms at zero voltage to the Michaelis-Menten equation resulted in values of maximal conductance of 300, 385, 18, and 13 pS, and of apparent dissociation constants of 64, 103, 0.04, and 0.08 mm for Na+, K+, Mg2+, and Ca2+, respectively. Deviations from the single-ion occupancy mechanism are documented, and alternative models of permeation are discussed. The magnitude of currents carried by divalent cations at low concentrations can be explained by an unrealistically wide (approximately 140 A) radius of the pore entrance. We propose instead a fixed negative charge in the pore vestibules, which concentrates the cations in their proximity. The conduction properties of the SV channel are compared with reported characteristics of voltage-dependent Ca2+-permeable channels, and consequences for a possible reduction of postulated multiplicity of Ca2+ pathways across the tonoplast are drawn.

[Variability in the in-hospital management of acute myocardial infarction in Spain. IBERICA Study (Investigación, Búsqueda Específica y Registro de Isquemia Coronaria Aguda)]

Introduction and objective. Although some in-hospital studies have described the management of acute myocardial infarction (MI) patients in Spain, none has been able to guarantee the exhaustiveness of patient registry. This study sought to determine the clinical characteristics and in-hospital management of patients with MI in eight Spanish population registries.Methods. The IBERICA study is a population-based MI registry carried out in the 25 to 74 year-old population, in eight Spanish regions in 1997. A standardized methodology was used to register and investigate all MI arriving alive to a hospital. Clinical characteristics, cardiovascular risk factors prevalence, pharmacological treatment, invasive and non-invasive procedures performed and complications at 28 days of evolution were recorded. A descriptive analysis was performed and the variation coefficient (VC) was calculated.Results. In 1997, 4,041 MI patients were registered, 79.9% were men with a mean age of 61.1 years. Although 10.9% (95% CI: 9.9-11.9%) were not admitted to the coronary care unit, a large variability existed among different areas (VC = 53%). There was a high variability in the utilization and performance of non-invasive and invasive procedures among regions, as well as in the use of pharmacological treatment. Only the use of antiaggregants (91.5%) and thrombolytic therapy (41.8%) showed a low variability (VC < 10%). Twenty-eight day mortality was 16.2% (95% CI: 15.1-17.4%) with a high variability being observed among the different regions (VC = 20.6%).Conclusion. Patient characteristics vary among the different Spanish regions. The differences in management and prognosis suggest a lack of equality in the health care provided to MI patients in the different regions in Spain.

[Guidelines of the Spanish Society of Cardiology for cardiovascular disease prevention and cardiac rehabilitation]

The priorities for the prevention of cardiovascular diseases should be focused on patients with established disease and high risk subjects, with individual global risk always being taken into account. The current evidence on the influence of the main risk factors are unanimous (dyslipemia, tobacco, hypertension and diabetes mellitus), being somewhat less so in cases of sedentarism, obesity and the metabolic syndrome. The evidence concerning other risk factors still remains controversial. Guidelines for the control of the different risk factors should be based on the evidence derived from both epidemiological or clinical trials. The recommendations published by several scientific societies should also be followed. There are, at present, important evidence on the efficacy of smoking cessation, the treatment of arterial hypertension and particularly on the successful control of lipid levels with lipid-lowering drugs, especially with statins. There is also evidence on the need for rigorous control of diabetic patients not only in relation to the glucose levels but also to dyslipemia. The most efficient measures for a reduction in morbidity and mortality are cessation of smoking, appropriate hypertensive therapy, a comprehensive program of cardiac rehabilitation and overall the successful control of lipid levels with statins.

[Dermatologic complications after heart transplantation: incidence and prognosis]

BACKGROUND

This study was conducted to analyze the type, incidence, predisposing factors and prognosis of cutaneous complications (CC) occurring in heart transplant recipients (HTR).

PATIENTS AND METHODS

A retrospective study was carried out among 192 HTR with a survival > 1 month. The following variables were recorded: age, sex, place of residence, post-transplant diabetes, glucocorticoid dose, prophylaxis with acyclovir/itraconazole and CC.

RESULTS

One hundred sixty three CC were diagnosed in 93 patients. The major types were infectious complications (n = 115; 70.5%) and tumors (n = 20; 12.3%). The most common infections were viral (herpes zoster; n = 22) and fungal (pityriasis versicolor; n = 53). Out the 20 tumors, 3 were malignant: 2 squamous cell carcinomas (SCC) and 1 Kaposi sarcoma. None of the CC caused mortality or prolonged hospital stay. No relationship was found between CC and the variables studied.

CONCLUSIONS

Skin infections were the most common CC in this cohort of HTR. The incidence of SCC was very low and its prognosis was good due to early diagnosis and surgical excision.