Serum urea increase during hospital stay is associated with worse outcomes after in-hospital cardiac arrest

BACKGROUND

Evaluate the association between serum urea at admission and during hospital stay with return of spontaneous circulation (ROSC) and in-hospital mortality in patients with in-hospital cardiac arrest (IHCA).

METHODS

This retrospective study included patients over 18 years with IHCA attended from May 2018 to December 2022. The exclusion criteria were the absence of exams to calculate delta urea and the express order of "do-not-resuscitate". Data were collected from the electronic medical records. Serum admission urea and urea 24 hours before IHCA were also collected and used to calculate delta urea.

RESULTS

A total of 504 patients were evaluated; 125 patients were excluded due to the absence of variables to calculate delta urea and 5 due to "do-not-resuscitate" order. Thus, we included 374 patients in the analysis. The mean age was 65.0 ± 14.5 years, 48.9% were male, 45.5% had ROSC, and in-hospital mortality was 91.7%. In logistic regression models, ROSC was associated with lower urea levels 24 hours before IHCA (OR: 0.996; CI95%: 0.992-1.000; p: 0.032). In addition, increased levels of urea 24 hours before IHCA (OR: 1.020; CI95%: 1.008-1.033; p: 0.002) and of delta urea (OR: 1.001; CI95%: 1.001-1.019; p: 0.023) were associated with in-hospital mortality. ROC curve analysis showed that the area under the ROC curve for mortality prediction was higher for urea 24 hours before IHCA (Cutoff > 120.1 mg/dL) than for delta urea (Cutoff > 34.83 mg/dL).

CONCLUSIONS

In conclusion, increased serum urea levels during hospital stay were associated with worse prognosis in IHCA.

Reduced mobility is associated with adverse outcomes after in-hospital cardiac arrest

OBJECTIVE

In-hospital cardiac arrest is a critical medical emergency. Knowledge of prognostic factors could assist in cardiopulmonary resuscitation decision-making. Frailty and functional status are emerging risk factors and may play a role in prognostication. The objective was to evaluate the association between reduced mobility and in-hospital cardiac arrest outcomes.

METHODS

This retrospective cohort study included patients over 18 years of age with in-hospital cardiac arrest in Botucatu, Brazil, from April 2018 to December 2021. Exclusion criteria were patients with a do-not-resuscitate order or patients with recurrent in-hospital cardiac arrest. Reduced mobility was defined as the need for a bed bath 48 h before in-hospital cardiac arrest. The outcomes of no return of spontaneous circulation and in-hospital mortality were evaluated.

RESULTS

A total of 387 patients were included in the analysis. The mean age was 65.4±14.8 years; 53.7% were males and 75.4% had reduced mobility. Among the evaluated outcomes, the no return of spontaneous circulation rate was 57.1%, and in-hospital mortality was 94.3%. In multivariate analysis, reduced mobility was associated with no return of spontaneous circulation when adjusted by age, gender, initial shockable rhythm, duration of cardiopulmonary resuscitation, and epinephrine administration. However, in multiple logistic regression, there was no association between reduced mobility and in-hospital mortality.

CONCLUSION

In patients with in-hospital cardiac arrest, reduced mobility is associated with no return of spontaneous circulation. However, there is no relation to in-hospital mortality.

Beans comsumption can contribute to the prevention of cardiovascular disease

Cardiovascular diseases (CVD) are the major cause of global mortality, accounting for 31% of deaths worldwide. Healthy eating habits based on the consumption of bioactive molecules present in plant-based diets can contribute to the prevention of CVD. In this context, the consumption of common beans (Phaseolus vulgaris L.) is relevant. There are several species of beans, all of which provide proteins, carbohydrates, dietary fiber, vitamins, minerals, and phenolic compounds. More recently, the complexity of phytochemical components has expanded, including the role of antinutritional factors in nutrient bioavailability and immune responses. Experimental and clinical studies have shown that the consumption of beans results in less food consumption, control of body weight, and improvement of metabolic biochemical parameters. Thus, the consumption of beans is associated with a decrease in CVD risk factors. To date, there have been no interventional studies assessing CVD outcomes, such as hospitalization, infarction, and mortality, in the context of bean consumption. Furthermore, studies on the effect of bean consumption on metabolomics and intestinal microbiota are lacking. The purpose of this review is to explore the nutritional properties of beans and discuss the main effects of the consumption of beans on cardiovascular health. In conclusion, eating habits based on the consumption of bioactive molecules present in beans can contribute to the prevention of cardiovascular disease. Furthermore, there is a large gap in the literature regarding the consumption of beans associated with clinical outcomes, such as hospitalization and mortality.

Post-Cardiac Arrest: Mechanisms, Management, and Future Perspectives

Cardiac arrest is an important public health issue, with a survival rate of approximately 15 to 22%. A great proportion of these deaths occur after resuscitation due to post-cardiac arrest syndrome, which is characterized by the ischemia-reperfusion injury that affects the role body. Understanding physiopathology is mandatory to discover new treatment strategies and obtain better results. Besides improvements in cardiopulmonary resuscitation maneuvers, the great increase in survival rates observed in recent decades is due to new approaches to post-cardiac arrest care. In this review, we will discuss physiopathology, etiologies, and post-resuscitation care, emphasizing targeted temperature management, early coronary angiography, and rehabilitation.

Oxidative Stress as a Therapeutic Target of Cardiac Remodeling

Cardiac remodeling is defined as a group of molecular, cellular, and interstitial changes that clinically manifest as changes in the heart's size, mass, geometry, and function after different stimuli. It is important to emphasize that remodeling plays a pathophysiological role in the onset and progression of ventricular dysfunction and subsequent heart failure. Therefore, strategies to mitigate this process are critical. Different factors, including neurohormonal activation, can regulate the remodeling process and increase cell death, alterations in contractile and regulatory proteins, alterations in energy metabolism, changes in genomics, inflammation, changes in calcium transit, metalloproteases activation, fibrosis, alterations in matricellular proteins, and changes in left ventricular geometry, among other mechanisms. More recently, the role of reactive oxygen species and oxidative stress as modulators of remodeling has been gaining attention. Therefore, this review assesses the role of oxidative stress as a therapeutic target of cardiac remodeling.

A Review of Current Clinical Concepts in the Pathophysiology, Etiology, Diagnosis, and Management of Hypercalcemia

Calcium is the most abundant extracellular cation in the body, and it is responsible for structural and enzymatic functions. Calcium homeostasis is regulated by 3 factors: calcitonin, vitamin D, and parathyroid hormone (PTH). Hypercalcemia is defined by a serum calcium concentration >10.5 mg/dL, and it is classified into mild, moderate, and severe, depending on calcium values. Most cases are caused by primary hyperparathyroidism and malignancies. Various mechanisms are involved in the pathophysiology of hypercalcemia, such as excessive PTH production, production of parathyroid hormone-related protein (PTHrp), bone metastasis, extrarenal activation of vitamin D, and ectopic PTH secretion. The initial approach is similar in most cases, but a definitive treatment depends on etiology, that is why etiological investigation is mandatory in all cases. The majority of patients are asymptomatic and diagnosed during routine exams; only a small percentage of patients present with severe manifestations which can affect neurological, muscular, gastrointestinal, renal, and cardiovascular systems. Clinical manifestations are related to calcium levels, with higher values leading to more pronounced symptoms. Critically ill patients should receive treatment as soon as diagnosis is made. Initial treatment involves vigorous intravenous hydration and drugs to reduce bone resorption such as bisphosphonates and, more recently, denosumab, in refractory cases; also, corticosteroids and calcitonin can be used in specific cases. This review aims to provide a clinical update on current concepts of the pathophysiology of calcium homeostasis, epidemiology, screening, clinical presentation, diagnosis, and management of hypercalcemia.

Semi-automated data collection from electronic health records in a stroke unit in Brazil

BACKGROUND

There is a high demand for stroke patient data in the public health systems of middle and low-income countries.

OBJECTIVE

To develop a stroke databank for integrating clinical or functional data and benchmarks from stroke patients.

METHODS

This was an observational, cross-sectional, prospective study. A tool was developed to collect all clinical data during hospitalizations due to stroke, using an electronic editor of structured forms that was integrated with electronic medical records. Validation of fields in the electronic editor was programmed using a structured query language (SQL). To store the results from SQL, a virtual table was created and programmed to update daily. To develop an interface between the data and user, the Embarcadero Delphi software and the DevExpress component were used to generate the information displayed on the screen. The data were extracted from the fields of the form and also from cross-referencing of other information from the computerized system, including patients who were admitted to the stroke unit.

RESULTS

The database was created and integrated with the hospital electronic system, thus allowing daily data collection. Quality indicators (benchmarks) were created in the database for the system to track and perform decision-making in conjunction with healthcare service managers, which resulted in improved processes and patient care after a stroke. An intelligent portal was created, in which the information referring to the patients was accessible.

CONCLUSIONS

Based on semi-automated data collection, it was possible to create a dynamic and optimized Brazilian stroke databank.

Urea to albumin ratio is a predictor of mortality in patients with septic shock

BACKGROUND

The purpose of this study was to evaluate urea to albumin ratio (UAR) as predictor of mortality in patients with septic shock.

METHODS

We included all individuals aged ≥ 18 years, with the diagnosis of septic shock at Intensive Care Unit (ICU) admission. Laboratorial and clinical data was recorded within the first 24 h of the patient's admission. Serum urea and albumin concentration were used for UAR calculation. All patients were followed during their ICU stay and the mortality rate was recorded.

RESULTS

222 patients were included in the analysis; the mean age was 62.3 ± 15.1 years and 66% were male. Mortality rate during the ICU stay was 59.9% and the median UAR was 40.7 (24.5-66.1). The UAR was also higher in patients who died in the ICU and was positively correlated with APACHE II, SOFA score and CRP. The ROC ICU mortality development (AUC: 0.617; CI 95%: 0.541-0.693; p: 0.003) at the cutoff of ≥47.25. Furthermore, UAR values were associated with ICU mortality when adjusted by age, sex and APACHE II (OR: 1.011; CI95%:1.000-1.022; p = 0.043) and when adjusted by lactate (OR: 1.014; CI95%:1.003-1.024; p = 0.009).

CONCLUSIONS

Our data suggest that UAR could play a role as predictor of ICU mortality in patients with septic shock.

Different Clusters in Patients with Chronic Obstructive Pulmonary Disease (COPD): A Two-Center Study in Brazil

Background

Chronic obstructive pulmonary disease (COPD) has a functional definition. However, differences in clinical characteristics and systemic manifestations make COPD a heterogeneous disease and some manifestations have been associated with different risks of acute exacerbations, hospitalizations, and death.

Objective

Therefore, the objective of the study was to evaluate possible clinical clusters in COPD at two study centers in Brazil and identify the associated exacerbation and mortality rate during 1 year of follow-up.

Methods

We included patients with COPD and all underwent an evaluation composed of the Charlson Index, body mass index (BMI), current pharmacological treatment, smoking history (packs-year), history of exacerbations/hospitalizations in the last year, spirometry, six-minute walking test (6MWT), quality of life questionnaires, dyspnea, and hospital anxiety and depression scale. Blood samples were also collected for measurements of C-reactive protein (CRP), blood gases, laboratory analysis, and blood count. For the construction of the clusters, 13 continuous variables of clinical importance were considered: hematocrit, CRP, triglycerides, low density lipoprotein, absolute number of peripheral eosinophils, age, pulse oximetry, BMI, forced expiratory volume in the first second, dyspnea, 6MWD, total score of the Saint George Respiratory Questionnaire and packs-year of smoking. We used the Ward and K-means methods and determined the best silhouette value to identify similarities of individuals within the cluster (cohesion) in relation to the other clusters (separation). The number of clusters was determined by the heterogeneity values of the cluster, which in this case was determined as four clusters.

Results

We evaluated 301 COPD patients and identified four different groups of COPD patients. The first cluster (203 patients) was characterized by fewer symptoms and lower functional severity of the disease, the second cluster by higher values of peripheral eosinophils, the third cluster by more systemic inflammation and the fourth cluster by greater obstructive severity and worse gas exchange. Cluster 2 had an average of 959±3 peripheral eosinophils, cluster 3 had a higher prevalence of nutritional depletion (46.1%), and cluster 4 had a higher BODE index. Regarding the associated comorbidities, we found that only obstructive sleep apnea syndrome and pulmonary thromboembolism were more prevalent in cluster 4. Almost 50% of all patients presented an exacerbation during 1 year of follow-up. However, it was higher in cluster 4, with 65% of all patients having at least one exacerbation. The mortality rate was statistically higher in cluster 4, with 26.9%, vs 9.6% in cluster 1.

Conclusion

We could identify four clinical different clusters in these COPD populations, that were related to different clinical manifestations, comorbidities, exacerbation, and mortality rate. We also identified a specific cluster with higher values of peripheral eosinophils.

Spondias mombin L. attenuates ventricular remodelling after myocardial infarction associated with oxidative stress and inflammatory modulation

The objective of this study was to evaluate Spondias mombin L. (SM) pulp and its influence on cardiac remodelling after myocardial infarction (MI). Male Wistar rats were assigned to four groups: a sham group (animals underwent simulated surgery) that received standard chow (S; n = 20), an infarcted group that received standard chow (MI; n = 24), an infarcted group supplemented with 100 mg of SM/kg bodyweight/d, (MIS100; n = 23) and an infarcted group supplemented with 250 mg of SM/kg bodyweight/d (MIS250; n = 22). After 3 months of treatment, morphological, functional and biochemical analyses were performed. MI induced structural and functional changes in the left ventricle with worsening systolic and diastolic function, and SM supplementation at different doses did not influence these variables as analysed by echocardiography and an isolated heart study (P > .05). However, SM supplementation attenuated cardiac remodelling after MI, reducing fibrosis (P = .047) and hypertrophy (P = .006). Biomarkers of oxidative stress, inflammatory processes and energy metabolism were further investigated in the myocardial tissue. SM supplementation improved the efficiency of energy metabolism and decreased lipid hydroperoxide in the myocardium [group S (n = 8): 267.26 ± 20.7; group MI (n = 8): 330.14 ± 47.3; group MIS100 (n = 8): 313.8 ± 46.2; group MIS250: 294.3 ± 38.0 nmol/mg tissue; P = .032], as well as decreased the activation of the inflammatory pathway after MI. In conclusion, SM supplementation attenuated cardiac remodelling processes after MI. We also found that energy metabolism, oxidative stress and inflammation are associated with this effect. In addition, SM supplementation at the highest dose is more effective.

Cardiovascular Risk in Individuals with Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) patients present a higher risk of developing cardiovascular diseases due to the presence of chronic inflammation, which plays an essential role in atherogenesis. Therefore, the aim of the study was to evaluate the cardiovascular risk between patients with IBD and healthy control individuals.

MATERIALS AND METHODS

A total of 52 consecutive IBD outpatients from a tertiary hospital and 37 healthy controls were enrolled. Data collected included age, sex, smoking status, presence of comorbidities, disease activity, ongoing medical treatment, body mass index, arterial blood pressure, and cardiovascular risk. The cardiovascular risk was based on the Framingham risk score and ultrasonography variables, such as the carotid intima-media thickness and the presence of atherosclerotic plaque in the carotid. Multivariate logistic regression or multiple linear regression analysis was performed at a significance level of 5%.

RESULTS

No differences were observed between groups with regard to age, sex, smoking status, comorbidities, blood pressure, body mass index, lipid profile, and Framingham risk score. In the IBD group, fasting glucose [95 (86.2-107.3) mg/dL vs 86 (79-100) mg/dL, p=0.041], carotid intima-media thickness (0.69±0.12 mm vs 0.63±0.12 mm, p=0.031), and atherosclerotic carotid plaque (25% vs 5.4%, p=0.032) were higher compared with those in the control group. Multivariate logistic regression analysis showed that patients with IBD presented a 6.45-fold higher risk of carotid atherosclerotic plaque (odds ratio: 6.45; 95% confidence interval: 1.035-40.216; p<0.046).

CONCLUSION

Patients with IBD are at an increased risk of atherosclerosis and, consequently, an increased risk for cardiovascular diseases.

Comparison of morphometry and ventricular function of healthy and smoking young people

Background

Tobacco smoke is one of the most significant risk factors for cardiovascular diseases and damages in the myocardial tissue directly. Cardiac magnetic resonance (CMR) has been used and is a promising tool to evaluate morphometry and cardiac function in humans. The objective of this study was to evaluate associations of smoking with morphometry and cardiac function by CMR technique in young adult smokers.

Methods

Altogether, 49 volunteers (22 smokers and 27 non-smokers) were included in the study. The comparisons between groups were performed by multiple linear regression adjusting for body mass index and gender.

Results

In the morphometric and functional evaluation of the left ventricle, we observed statistical significant lower values of end-diastolic volume (EDV) (p = 0.02), ejection volume (EV) (p = 0.001) and indexed ejection volume (IEV) (p = 0.007) in smokers when compared to no-smoker group. Right ventricle showed statistical significant lower values of EDV (p = < 0.001), end-systolic volume (p = 0.01), EV (p = < 0.001), IEV (p = 0.001), indexed end-diastolic volume (p = 0.001) and major axis (p = 0.01) in smokers when compared to non-smokers group.

Conclusions

There is a strongly association of smoking in young adult and cardiac function decline, even adjusted by cofounders, which compromises the proper functioning of the heart. Evidence confirms that smoking can directly influence the cardiac function, even without atherosclerosis or other chronic comorbidities, associated with increased risk of cardiovascular diseases.

Performance of cardiovascular risk scores in mortality prediction ten years after Acute Coronary Syndromes

SUMMARY BACKGROUND The objective of this study was to evaluate the performance of the Framingham risk score (FRS) and risk score by the American College of Cardiology/American Heart Association (SR ACC/AHA) in predicting mortality of patients ten years after acute coronary syndrome (ACS). METHODS This is a retrospective cohort study that included patients aged ≥ 18 years with ACS who were hospitalized at the Coronary Intensive Care Unit (ICU) of the Botucatu Medical School Hospital from January 2005 to December of 2006. RESULTS A total of 447 patients were evaluated. Of these, 118 were excluded because the mortality in 10 years was not obtained. Thus, 329 patients aged 62.9 ± 13.0 years were studied. Among them, 58.4% were men, and 44.4% died within ten years of hospitalization. The median FRS was 16 (14-18) %, and the ACC/AHA RS was 18.5 (9.1-31.6). Patients who died had higher values of both scores. However, when we classified patients at high cardiovascular risk, only the ACC/AHA RS was associated with mortality (p <0.001). In the logistic regression analysis, both scores were associated with mortality at ten years (p <0.001). CONCLUSIONS Both FRS and SR ACC/AHA were associated with mortality. However, for patients classified as high risk, only the ACC/AHA RS was associated with mortality within ten years.

Lipid damage is the best marker of oxidative injury during the cardiac remodeling process induced by tobacco smoke

BACKGROUND

Oxidative stress is one potential mechanism that explain the direct effects of smoking on cardiac remodeling process. However, no study has compared different myocardial products of macromolecule oxidation after tobacco smoke exposure. Thus, the aim of this study was to investigate the lipid hydroperoxide (LH) levels, protein carbonyl concentrations and DNA damage in cardiac tissue of rats exposed to tobacco smoke.

METHODS

Male Wistar rats were divided into two groups: group C (control, n = 14) composed of animals not exposed to cigarette smoke; group ETS (exposed to tobacco smoke, n = 14) composed by animals exposed to cigarette smoke. The animals were exposed to 2 month of ETS and morphological, biochemical and functional analyses were performed.

RESULTS

Cardiac cotinine levels were elevated in the ETS group. In addition, the myocyte cross-sectional area was higher in the ETS group. (C = 266.6 ± 23.2 μm2 and ETS = 347.5 ± 15.1 μm2, p <  0.001). Cardiac LH was higher in the ETS group than in group C (C = 196.4 ± 51.5 nmol/g and ETS = 331.9 ± 52.9 nmol/g, p <  0.001). However, there were no between-group differences in cardiac protein carbonyl concentration or DNA damage.

CONCLUSIONS

Therefore, our results suggest that, in this model, lipid damage is a good marker of oxidative damage during the cardiac remodeling process induced by 2 months of exposure to tobacco smoke.

Erythrocyte SOD1 activity, but not SOD1 polymorphisms, is associated with ICU mortality in patients with septic shock

The objective of our study was to evaluate the influence of the superoxide dismutase 1 (SOD1) polymorphisms on erythrocyte SOD1 activity and the mortality of patients with septic shock. We prospectively evaluated 175 patients aged over 18 years with septic shock upon ICU admission. However, 38 patients were excluded. Thus, 137 patients were enrolled in the study. Blood samples were taken within the first 24 h of the patient's admission to determine erythrocyte SOD1 activity and nine SOD1 gene polymorphisms. The mean patient age was 63 ± 16 years, 58% were men, and ICU mortality rate was 66%. The patients who died were older and more severely ill, with higher Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, as well as higher lactate, urea, and protein carbonyl levels. In the logistic regression model, erythrocyte SOD1 activity was associated with ICU mortality. This relationship was also maintained in the highest tertile of SOD1 activity (odds ratio [OR]: 0.02; 95% confidence interval [CI]: 0.00-0.78; p = 0.037). Only SNP rs2070424 of the SOD1 gene influenced erythrocyte SOD1 activity. For patients with the AA allele, the activity of SOD1 was lower in relation to G-carriers (A/G+G/G genotype) (p = 0.019). None of the nine SOD1 SNPs were associated with ICU mortality. In conclusion, the SNP rs2070424 of the SOD1 gene interferes with erythrocyte SOD1 activity, and higher activity of SOD1 was associated with decreased mortality in patients with septic shock.

Peptidylarginine deiminase 4 concentration, but not PADI4 polymorphisms, is associated with ICU mortality in septic shock patients

The objective of our study was to evaluate the association between peptidylarginine deiminase 4 (PAD4) concentration and its polymorphisms with mortality in patients with septic shock. We prospectively evaluated 175 patients aged over 18 years with septic shock upon intensive care unit (ICU) admission. However, 48 patients were excluded. Thus, 127 patients were enrolled in the study. At the time of the patients’ enrollment, demographic information was recorded. Blood samples were taken within the first 24 hours of the patient's admission to determine serum PAD4 concentrations and its polymorphism PADI4_89 [rs11203366], PADI4_94 [rs2240340] and PADI4_104 [rs1748033]. The mean age was 63.3 ± 15.2 years, 56.7% were male, PAD4 concentration was 4.62 (2.48‐6.20) ng/mL and the ICU mortality rate was 67.7%. The patients who died in the ICU had higher APACHE II and Sequential Organ Failure Assessment (SOFA) scores. In addition, PAD4 concentration was higher in patients who died during ICU stay. However, there were no differences regarding PADI4 polymorphisms and ICU mortality. In the logistic regression models, PAD4 concentrations were associated with ICU mortality when adjusted for APACHE II score and lactate (OR: 1.477; CI 95%: 1.186‐1.839; P < .001), and when adjusted for age, gender and APACHE II score (OR: 1.392; CI 95%: 1.145‐1.692; P < .001). In conclusion, PAD4 concentration, but not PADI4_89, PADI4_94 and PADI4_104 polymorphisms, is associated with ICU mortality in septic shock patients.

Spondias mombin supplementation attenuated cardiac remodelling process induced by tobacco smoke

The objective of this study was to investigate the influence of Spondias mombin (SM) supplementation on the cardiac remodelling process induced by exposure to tobacco smoke (ETS) in rats. Male Wistar rats were divided into 4 groups: group C (control, n = 20) comprised animals not exposed to cigarette smoke and received standard chow; group ETS (n = 20) comprised animals exposed to cigarette smoke and received standard chow; group ETS100 (n = 20) received standard chow supplemented with 100 mg/kg body weight/d of SM; and group ETS250 (n = 20) received standard chow supplemented with 250 mg/kg body weight/d of SM. The observation period was 2 months. The ETS animals had higher values of left cardiac chamber diameters and of left ventricular mass index. SM supplementation attenuated these changes. In addition, the myocyte cross‐sectional area (CSA) was lower in group C compared with the ETS groups; however, the ETS250 group had lower values of CSA compared with the ETS group. The ETS group also showed higher cardiac levels of lipid hydroperoxide (LH) compared with group C; and, groups ETS100 and ETS250 had lower concentrations of LH compared with the ETS group. Regarding energy metabolism, SM supplementation decreased glycolysis and increased the β‐oxidation and the oxidative phosphorylation. There were no differences in the expression of Nrf‐2, SIRT‐1, NF‐κB, interferon‐gamma and interleukin 10. In conclusion, our results suggest that ETS induced the cardiac remodelling process. In addition, SM supplementation attenuated this process, along with oxidative stress reduction and energy metabolism modulation.

Protein Carbonyl, But Not Malondialdehyde, Is Associated With ICU Mortality in Patients With Septic Shock

Background:

The objective of our study was to evaluate the association of serum malondialdehyde (MDA) and protein carbonyl concentration with intensive care unit (ICU) mortality in patients with septic shock.

Methods:

We prospectively evaluated 175 patients aged over 18 years with septic shock upon ICU admission. However, 16 patients were excluded. Thus, 159 patients were enrolled in the study. In addition, we evaluated 16 control patients. At the time of the patients’ enrollment, demographic information was recorded. Blood samples were taken within the first 24 hours of the patient’s admission to determine serum MDA and protein carbonyl concentrations.

Results:

The mean age was 67.3 ± 15.9 years, 44% were males, and the ICU mortality rate was 67.9%. Median MDA concentration was 1.53 (0.83-2.22) µmol/L, and median protein carbonyl concentration was 24.0 (12.7-32.8) nmol/mL. Patients who died during ICU stay had higher protein carbonyl concentration. However, there was no difference in MDA levels between these patients. Receiver operating characteristic curve analysis showed that higher levels of protein carbonyl were associated with ICU mortality (area under the curve: 0.955; 95% confidence interval [CI]: 0.918-0.992; P < .001) at the cutoff of >22.83 nmol/mL (sensibility: 80.4% and specificity: 98.1%). In the logistic regression models, protein carbonyl concentrations (odds ratio [OR]: 1.424; 95% CI: 1.268-1.600; P < .001), but not MDA concentrations (OR: 1.087; 95% CI: 0.805-1.467; P = .59), were associated with ICU mortality when adjusted for age, gender, and Acute Physiology and Chronic Health Evaluation (APACHE) II score; and when adjusted by APACHE II score, lactate, and urea; protein carbonyl concentrations (OR: 1.394; 95% CI: 1.242-1.564; P < .001); and MDA (OR: 1.054; 95% CI: 0.776-1.432; P = .73).

Conclusion:

In conclusion, protein carbonyl, but not MDA, concentration is associated with ICU mortality in patients with septic shock.

Rosemary supplementation (Rosmarinus oficinallis L.) attenuates cardiac remodeling after myocardial infarction in rats

BACKGROUND

Myocardial infarction (MI) is one of the leading causes of morbidity and mortality worldwide. Dietary intervention on adverse cardiac remodeling after MI has significant clinical relevance. Rosemary leaves are a natural product with antioxidant/anti-inflammatory properties, but its effect on morphology and ventricular function after MI is unknown.

METHODS AND RESULTS

To determine the effect of the dietary supplementation of rosemary leaves on cardiac remodeling after MI, male Wistar rats were divided into 6 groups after sham procedure or experimental induced MI: 1) Sham group fed standard chow (SR0, n = 23); 2) Sham group fed standard chow supplemented with 0.02% rosemary (R002) (SR002, n = 23); 3) Sham group fed standard chow supplemented with 0.2% rosemary (R02) (SR02, n = 22); 4) group submitted to MI and fed standard chow (IR0, n = 13); 5) group submitted to MI and fed standard chow supplemented with R002 (IR002, n = 8); and 6) group submitted to MI and fed standard chow supplemented with R02 (IR02, n = 9). After 3 months of the treatment, systolic pressure evaluation, echocardiography and euthanasia were performed. Left ventricular samples were evaluated for: fibrosis, cytokine levels, apoptosis, energy metabolism enzymes, and oxidative stress. Rosemary dietary supplementation attenuated cardiac remodeling by improving energy metabolism and decreasing oxidative stress. Rosemary supplementation of 0.02% improved diastolic function and reduced hypertrophy after MI. Regarding rosemary dose, 0.02% and 0.2% for rats are equivalent to 11 mg and 110 mg for humans, respectively.

CONCLUSION

Our findings support further investigations of the rosemary use as adjuvant therapy in adverse cardiac remodeling.

Goldman score, but not Detsky or Lee indices, predicts mortality 6 months after hip fracture

Background

Over the past years, several cardiac risk indices were evaluated and modified, including Goldman, Detsky, and Lee scores. The predictive capacity of these scores in hip fracture patients is lacking. Thus, our objective was to compare the Goldman, Detsky, and Lee scores as predictors of mortality in 6 months after hip fracture.

Methods

We prospectively evaluated 80 consecutive patients with hip fractures, over the age of 65 admitted to an orthopedic ward at Botucatu Medical School. Patient demographic information, Goldman, Detsky and Lee scores were recorded. All patients were followed for 6 months after hip fracture, and mortality was recorded. Multiple logistic regression analyses were performed for mortality prediction.

Results

The mortality rate was 23% after a 6-month follow-up period. Patients who died had advanced age and the majority of them were male. They also had lower values of handgrip strength, and higher values of creatinine and urea. In the multiple logistic regression models when adjusted by age, gender, handgrip strength and creatinine, Goldman’s score (OR:3.025; 95%CI:1.022-8.953; p:0.046), but not Detsky (OR:2.328; 95%CI:0.422-12.835; p:0.332) and Lee (OR:1.262; 95%CI:0.649-2.454; p:0.494), was associated with mortality 6 months after hip fracture. Each 1 category increase in Goldman score increased the mortality to more than 3-fold.

Conclusions

In conclusion, our data suggest that Goldman score, but not Detsky or Lee indices, predicts mortality associated with hip fracture at up to 6 months post-injury.

Erythrocyte superoxide dismutase as a biomarker of septic acute kidney injury

Background

Oxidative stress is a key feature of sepsis and could be a common pathophysiological pathway between septic shock and acute kidney injury (AKI) Our objective was to evaluate the erythrocyte superoxide dismutase (SOD1) activity as predictor of AKI in patients with septic shock.

Methods

This is a prospective observational study that evaluated 175 consecutive patients over the age of 18 years with septic shock upon intensive care unit (ICU) admission. However, 43 patients were excluded (27 due to AKI at ICU admission). Thus, 132 patients were enrolled in the study. At the time of the patients’ enrollment, demographic information was recorded. Blood samples were taken within the first 24 h of the patient’s admission to determine the erythrocyte SOD1 activity. All patients were followed throughout the ICU stay, and the development of AKI was evaluated. In addition, we also evaluated 17 control subjects.

Results

The mean age of patients with septic shock was 63.2 ± 15.7 years, 53 % were male and the median ICU stay was 8 days (4–16). Approximately 50.7 % developed AKI during the ICU stay. The median erythrocyte SOD1 activity was 2.92 (2.19–3.92) U/mg Hb. When compared to control subjects, septic shock patients had a higher serum malondialdehyde concentration and lower erythrocyte SOD1 activity. In univariate analysis, erythrocyte SOD1 activity was lower in patients who developed AKI. The ROC curve analysis revealed that lower erythrocyte SOD1 activity was associated with AKI development (AUC 0.686; CI 95 % 0.595–0.777; p < 0.001) at the cutoff of <3.32 U/mg Hb. In the logistic regression models, SOD1 activity higher than 3.32 U/mg Hb was associated with protection of AKI development when adjusted by hemoglobin, phosphorus and APACHE II score (OR 0.309; CI 95 % 0.137–0.695; p = 0.005) and when adjusted by age, gender, chronic kidney disease, admission category (medical or surgery) and APACHE II score (OR 0.129; CI 95 % 0.033–0.508; p = 0.003).

Conclusions

In conclusion, our data suggest that erythrocyte SOD1 activity could play a role as an early marker of septic AKI and could be seen as a new research avenue in the field of biomarker in AKI. However, our study did not show a strong correlation between SOD activity and AKI. Nevertheless, these original data do warrant further research in order to confirm or not this hypothesis.

Phase angle is associated with advanced fibrosis in patients chronically infected with hepatitis C virus

AIMS

The objective of this study was to evaluate the association of phase angle (PhA) with advanced liver fibrosis in patients chronically infected with hepatitis C virus (HCV).

MAIN METHODS

One hundred sixty consecutive patients chronically infected with HCV were treated at the Hepatitis C outpatient care setting of our hospital from April 2010 to May 2011 and prospectively evaluated. Bioelectrical impedance analysis measurements were performed during the first hospital visit. Biochemical measurements and liver biopsy data were collected from the patients' medical records and included in the analysis only if they were performed within three months of the inclusion of the patient in the study.

KEY FINDINGS

One hundred sixty consecutive patients were evaluated and 25 patients were excluded. A total of 135 patients with 49.8±11.4years old were studied. Among these patients, 60% were male and the PhA was 6.5±0.8°. Regarding the stage of fibrosis, patients with advanced fibrosis were older and had more insulin resistance and more inflammation compared with patients that had mild fibrosis. Logistic regression analysis revealed that PhA was a predictor of advanced fibrosis even when adjusted for gender, age, HOMA-IR, HDL-cholesterol and AST (OR: 0.227; CI 95%: 0.090-0.569; p: 0.013). The best PhA cut-off points associated with advanced fibrosis for the combined data, for females and for males were 6.43°, 5.94° and 6.72°, respectively.

SIGNIFICANCE

PhA was predictor of advanced liver fibrosis in patients chronically infected with HCV. In the sample evaluated, for each one-degree decrease in PhA, the risk of advanced fibrosis increased more than four-fold.

Vitamin D serum levels are associated with handgrip strength but not with muscle mass or length of hospital stay after hip fracture

OBJECTIVES

The aim of this study was to evaluate the association between serum levels of 25(OH) vitamin D3 with midupper arm muscle circumference (MUAMC), handgrip strength and length of hospital stay (LOS) after hip fracture.

METHODS

In total, 102 consecutive patients with hip fracture over the age of 65 were admitted to the orthopedic unit and prospectively evaluated. All of the patients were treated according to specific protocols depending on the type of fracture. Anthropometric measurements and handgrip strength were performed, and blood samples were taken for serum biochemistry and 25(OH) vitamin D3 analysis within the first 72 h of admission. All of the patients were followed during their hospital stay, and the length of stay was recorded.

RESULTS

Of the patients, two were excluded because of pathologic fractures. In total, 100 patients with a mean age of 80 ± 7 y were included in the analysis. Among these patients, 73% were female, and 37% had vitamin D deficiency. The median LOS was 7 (5-11) d. Patients with vitamin D deficiency had lower handgrip strength in univariate analysis. In the multiple linear regression analysis with robust standard error, serum vitamin D levels adjusted by age and sex were associated with handgrip strength but not with MUAMC and LOS after hip fracture.

CONCLUSIONS

In conclusion, vitamin D serum levels were associated with handgrip strength but not with muscle mass or length of hospital stay after hip fracture.

Vitamin D induces increased systolic arterial pressure via vascular reactivity and mechanical properties

Background/Aims

The aim of this study was to evaluate whether supplementation of high doses of cholecalciferol for two months in normotensive rats results in increased systolic arterial pressure and which are the mechanisms involved. Specifically, this study assesses the potential effect on cardiac output as well as the changes in aortic structure and functional properties.

Methods

Male Wistar rats were divided into three groups: 1) Control group (C, n = 20), with no supplementation of vitamin D, 2) VD3 (n = 19), supplemented with 3,000 IU vitamin D/kg of chow; 3) VD10 (n = 21), supplemented with 10,000 IU vitamin D/kg of chow. After two months, echocardiographic analyses, measurements of systolic arterial pressure (SAP), vascular reactivity, reactive oxygen species (ROS) generation, mechanical properties, histological analysis and metalloproteinase-2 and -9 activity were performed.

Results

SAP was higher in VD3 and VD10 than in C rats (p = 0.001). Echocardiographic variables were not different among groups. Responses to phenylephrine in endothelium-denuded aortas was higher in VD3 compared to the C group (p = 0.041). Vascular relaxation induced by acetylcholine (p = 0.023) and sodium nitroprusside (p = 0.005) was impaired in both supplemented groups compared to the C group and apocynin treatment reversed impaired vasodilation. Collagen volume fraction (<0.001) and MMP-2 activity (p = 0.025) was higher in VD10 group compared to the VD3 group. Elastin volume fraction was lower in VD10 than in C and yield point was lower in VD3 than in C.

Conclusion

Our findings support the view that vitamin D supplementation increases arterial pressure in normotensive rats and this is associated with structural and functional vascular changes, modulated by NADPH oxidase, nitric oxide, and extracellular matrix components.

Serum thiamine concentration and oxidative stress as predictors of mortality in patients with septic shock

PURPOSE

The purpose of the study is to determine the influence of serum thiamine, glutathione peroxidase (GPx) activity, and serum protein carbonyl concentrations in hospital mortality in patients with septic shock.

MATERIALS AND METHODS

This prospective study included all patients with septic shock on admission or during intensive care unit (ICU) stay, older than 18 years, admitted to 1 of the 3 ICUs of the Botucatu Medical School, from January to August 2012. Demographic information, clinical evaluation, and blood sample were taken within the first 72 hours of the patient's admission or within 72 hours after septic shock diagnosis for serum thiamine, GPx activity, and protein carbonyl determination.

RESULTS

One hundred eight consecutive patients were evaluated. The mean age was 57.5 ± 16.0 years, 63% were male, 54.6% died in the ICU, and 71.3% had thiamine deficiency. Thiamine was not associated with oxidative stress. Neither vitamin B1 levels nor the GPx activity was associated with outcomes in these patients. However, protein carbonyl concentration was associated with increased mortality.

CONCLUSIONS

In patients with septic shock, oxidative stress was associated with mortality. On the other hand, thiamine was not associated with oxidative stress or mortality in these patients.

Association between phase angle, anthropometric measurements, and lipid profile in HCV-infected patients

OBJECTIVE

The objective of this study was to investigate the associations between phase angle, anthropometric measurements, and lipid profile in patients chronically infected with the hepatitis C virus.

METHODS

A total of 160 consecutive patients chronically infected with the hepatitis C virus and who received treatment at the hepatitis C outpatient unit of our hospital from April 2010 to May 2011 were prospectively evaluated. Bioelectrical impedance analysis, anthropometric measurements, and serum lipid profile analysis were performed.

RESULTS

Twenty-five patients were excluded. A total of 135 patients with a mean age of 49.8±11.4 years were studied. Among these patients, 60% were male. The phase angle and BMI means were 6.5±0.8° and 26.5±4.8 kg/m2, respectively. Regarding anthropometric variables, mid-arm circumference, mid-arm muscle circumference, and arm muscle area had a positive correlation with phase angle. In contrast, when analyzing the lipid profile, only HDL was inversely correlated with phase angle. However, in multiple regression models adjusted for age and gender, only mid-arm circumference (p = 0.005), mid-arm muscle circumference (p = 0.003), and arm muscle circumference (p = 0.001) were associated with phase angle in hepatitis C virus-infected patients.

CONCLUSIONS

In conclusion, phase angle is positively correlated with anthropometric measures in our study. However, there is no association between phase angle and lipid profile in these patients. Our results suggest that phase angle is related to lean body mass in patients chronically infected with hepatitis C virus.

Impact of the length of vitamin D deficiency on cardiac remodeling

BACKGROUND

This study was aimed to evaluate the influence of vitamin D (VD) deficiency on cardiac metabolism, morphology, and function. Thus, we investigated the relationship of these changes with the length of the nutrient restriction.

METHODS AND RESULTS

Male weanling Wistar rats were allocated into 4 groups: C2 (n=24), animals were fed an AIN-93G diet with 1000 IU VD/kg of chow and were kept under fluorescent light for 2 months; D2 (n=22), animals were fed a VD-deficient AIN-93G diet and were kept under incandescent light for 2 months; C4 (n=21) animals were kept in the same conditions of C2 for 4 months; and D4 (n=23) animals were kept in the same conditions of D2 for 4 months. Biochemical analyses showed lower β-hydroxyacyl coenzyme-A dehydrogenase activity and higher lactate dehydrogenase activity in VD-deficient animals. Furthermore, VD deficiency was related to increased cytokines release, oxidative stress, apoptosis, and fibrosis. Echocardiographic data showed left ventricular hypertrophy and lower fractional shortening and ejection fraction in VD-deficient animals. Difference became evident in the lactate dehydrogenase activity, left ventricular weight, right ventricle weight, and left ventricular mass after 4 months of VD deficiency.

CONCLUSIONS

Our data indicate that VD deficiency is associated with energetic metabolic changes, cardiac inflammation, oxidative stress, fibrosis and apoptosis, cardiac hypertrophy, left chambers alterations, and systolic dysfunction. Furthermore, length of the restriction influenced these cardiac changes.

[Adverse events: analysis of a notification instrument used in nursing management]

The nursing management board of a tertiary university hospital located in Central-South São Paulo state implemented an Adverse Events Notification Instrument in January 2004 aiming at patient safety and at establishing a means of communication between the team and the administration board. The aim of this study was to analyze the use of the referred communication instrument and identify the frequency, type, nature and period of the incident/adverse events. A descriptive data analysis was performed on 826 instruments completed between January 2004 and June 2006. There was compliance to using the instrument. There was predominance of notifications regarding health care services, although there was an increase in reports on administrative issues in the referred period. The most frequent adverse events concerned medications, falls, catheters, probes and drains, and skin integrity. The practicality of the instrument made it feasible for use among nursing aides and technicians. Systematic analysis and follow-up of the adverse events associated with this means of communication appeared as fundamental issues for patient safety.

[Characterization of patient falls according to the notification in adverse event reports]

The objective of this study was to observe the characteristics of falls occurring in the inpatient population at a tertiary hospital. Eight hundred and twenty-six Adverse Events Notification Reports were analyzed over a 30 months period, and 0.30 falls per 1000 patients/day were reported. Falls from beds were the most frequent (55%), showing the highest occurrence in the neurology ward. A higher frequency of falls was observed at night time (63.7%), during the first five hospitalization days (61.7%), in male patients (57.5%) over 60 years old (50%). In cases of falls from a bed, the diagnoses were related to infectious and parasitic diseases (18.2%), diseases affecting the nervous system (18.2%) and those affecting the circulatory system (13.7%). In cases of falls from one's own height, they were related to neoplasms (19.4%) and diseases affecting the genitourinary system (16.1%). It is concluded that high importance should be placed on studying the population to characterize those at high risk for falls to assist in the implementation of preventive measures.

Relationship of Upper-Limb and Thoracic Muscle Strength to 6-min Walk Distance in COPD Patients

STUDY OBJECTIVES

This study was developed to investigate the influence of thoracic and upper-limb muscle function on 6-min walk distance (6MWD) in patients with COPD.

DESIGN

A prospective, cross-sectional study.

SETTING

The pulmonary rehabilitation center of a university hospital.

PATIENTS

Thirty-eight patients with mild to very severe COPD were evaluated.

MEASUREMENTS AND RESULTS

Pulmonary function and baseline dyspnea index (BDI) were assessed, handgrip strength, maximal inspiratory pressure (Pimax), and 6MWD were measured, and the one-repetition maximum (1RM) was determined for each of four exercises (bench press, lat pull down, leg extension, and leg press) performed on gymnasium equipment. Quality of life was assessed using the St. George Respiratory Questionnaire (SGRQ). We found statistically significant positive correlations between 6MWD and body weight (r = 0.32; p < 0.05), BDI (r = 0.50; p < 0.01), FEV(1) (r = 0.33; p < 0.05), Pimax (r = 0.53; p < 0.01), and all values of 1RM. A statistically significant negative correlation was observed between 6MWD and dyspnea at the end of the 6-min walk test (r = - 0.29; p < 0.05), as well as between 6MWD and the SGRQ activity domain (r = - 0.45; p < 0.01) and impact domain (r = - 0.34; p < 0.05) and total score (r = - 0.40; p < 0.01). Multiple regression analysis selected body weight, BDI, Pimax, and lat pull down 1RM as predictive factors for 6MWD (R(2) = 0.589).

CONCLUSIONS

The results of this study showed the importance of the skeletal musculature of the thorax and upper limbs in submaximal exercise tolerance and could open new perspectives for training programs designed to improve functional activity in COPD patients.

Remodelação miocárdica na sobrecarga crônica de pressão ou de volume no coração de ratos

OBJECTIVE

To compare cardiac structural changes in experimental pressure and volume overload models.

METHODS

The study analysis included renovascular hypertensive rats (RVH, n = 8), normotensive rats with volume overload caused by an aortocaval fistula (ACF, n = 10) and control rats (CONT, n = 8). After four weeks, tail cuff blood pressure (SBP) was recorded. Rats were killed, the hearts were excised and the right and left ventricles (RV&LV) were weighed (RVW&LVW). Using histological sections, myocyte cross sectional areas (MA). LV wall thickness (LVWT) LV cavity diameter (LVD), normalized LVWT (LVWT/LVD) and collagen volume fraction (CVF) were measured. The comparisons were made using the ANOVA and Tukey test for a significance level of 5%.

RESULTS

Tail cuff blood pressure (mmHg) was higher in the RVH group (RVH = 187 +/- 22; CONT = 125 +/- 10; ACF = 122 +/- 6, p < 0.05). LV hypertrophy was observed in the RVH and ACF groups. The ACF group presented a significant increase in size of LVD, compared to CONT and RVH. The absolute and normalized ventricular wall thickness were similar among the groups. The RVH group presented a significant increase in CVF compared to CONT group and ACF group.

CONCLUSION

Cardiac remodeling patterns following volume or pressure overload are distinct, suggesting that their implications on ventricular dysfunction are not interchangeable.

O uso da gastrostomia percutânea endoscópica

A gastrostomia percutânea endoscópica foi introduzida na prática clínica como via alternativa de alimentação enteral. É procedimento que não necessita de anestesia ou laparotomia, como a gastrostomia cirúrgica. A gastrostomia percutânea endoscópica tem como objetivos a manutenção do aporte nutricional e a melhoria da qualidade de vida e sobrevida dos pacientes. É indicada quando o paciente necessita de dieta enteral por período superior a um mês. A freqüência de complicações varia de 1,0% a 10,0% e a mortalidade de 0,3% a 1,0%. É propósito deste trabalho abordar aspectos relevantes desse método de alimentação enteral, aprimorar seu manejo, bem como facilitar o manejo pelos pacientes que dele se utilizam. Para isso, vamos comentar as indicações e contra-indicações da gastrostomia percutânea endoscópica, técnica de colocação, material das sondas, antibiótico profilático, início de utilização, custo do procedimento, além de suas complicações, aspectos legais e éticos.

Behavior of cardiac variables in animals exposed to cigarette smoke

OBJECTIVE

To assess the behavior of cardiac variables in animals exposed to cigarette smoke.

METHODS

Two groups of Wistar rats were studied as follows: control group (C), comprising 28 animals; and smoking group (S), comprising 23 animals exposed to cigarette smoke for 30 days. Left ventricular cardiac function was assessed in vivo with transthoracic echocardiography, and myocardial performance was analyzed in vitro in preparations of isolated left ventricular papillary muscle. The cardiac muscle was assessed in isometric contractions with an extracellular calcium concentration of 2.5 mmol/L.

RESULTS

No statistical difference was observed in the values of the body variables of the rats and in the mechanical data obtained from the papillary muscle between the control and smoking groups. The values of left ventricular systolic diameter were significantly greater in the smoking animals than in the control animals (C=3.39 +/- 0.4 mm and S=3.71 +/- 0.51 mm, P=0.02). A significant reduction was observed in systolic shortening fraction (C=56.7 +/- 4.2% and S=53.5 +/- 5.3%, P=0.02) and in ejection fraction (C=0.92 +/- 0.02 and S=0.89 +/- 0.04, P=0.01).

CONCLUSION

The rats exposed to cigarette smoke had a reduction in left ventricular systolic function, although their myocardial function was preserved.

Ventricular remodeling induced by retinoic acid supplementation in adult rats

Retinoic acid (RA) plays a role in regulating cardiac geometry and function throughout life. The aim of this study was to analyze the cardiac effects of RA in adult rats. Wistar rats were randomly allocated to a control group (n = 18) receiving standard rat chow and a group treated with RA (n = 14) receiving standard rat chow supplemented with RA for 90 days. All animals were evaluated by echocardiography, isolated papillary muscle function, and morphological studies. Whereas the RA-treated group developed an increase in both left ventricular (LV) mass and LV end-diastolic diameter, the ratio of LV wall thickness to LV end-diastolic diameter remained unchanged when compared with the control group. In the isolated papillary muscle preparation, RA treatment decreased the time to peak developed tension and increased the maximum velocity of isometric relengthening, indicating that systolic and diastolic function was improved. Although RA treatment produced an increase in myocyte cross-sectional area, the myocardial collagen volume fraction was similar to controls. Thus our study demonstrates that small physiological doses of RA induce ventricular remodeling resembling compensated volume-overload hypertrophy in rats.