La inflamación como el nexo entre la enfermedad periodontal y la enfermedad cardiovascular / Inflammation as a link between periodontal disease and cardiovascular disease

La periodontitis es una enfermedad no transmisible, con una alta prevalencia, que oscila entre el 45% y el 50% de la población mundial, ocupando el sexto lugar entre las enfermedades más frecuentes de la huma-nidad. Existe suficiente evidencia que avala la relación entre la enfermedad periodontal y la enfermedad car-diovascular, responsable de aproximadamente el 45% de las muertes en países desarrollados, compren-diendo en su causalidad al infarto de miocardio, el accidente cerebrovascular, la insuficiencia cardíaca y las arritmias, que causan alrededor del 95 % de las muertes relacionadas con la enfermedad cardiovas-cular. Ambas patologías presentan factores de riesgo comunes ampliamente reconocidos, como la diabetes y el tabaquismo, pero además manifiestan caracte-rísticas genéticas y epigenéticas que avalan distintos mecanismos etiopatológicos. Más allá de los factores de riesgo comunes, se han propuesto dos mecanis-mos para explicar la relación entre la enfermedad periodontal y las cardiovasculares. Uno de ellos, constituye la invasión directa de patógenos periodontales en las células endoteliales. El otro mecanismo sugerido (vía indirecta), ocasionado por la respuesta inflamatoria sistémica que resulta en niveles cróni-camente elevados de diferentes citoquinas, también relacionadas con la enfermedad vascular aterosclerotica como IL-1ß, IL-6, IL-8, TNF-α, PCR y la proteína quimioatrayente de monocitos, podría estar mediado por productos bacterianos, como los lipopolisacári-dos que alcanzarían la circulación induciendo una potente respuesta inmunitaria. Estos mecanismos pueden actuar inflamando las células endoteliales, modulando el metabolismo de los lípidos y aumentan-do el estrés oxidativo, favoreciendo la aterosclerosis, conformando la expresión de un fenotipo arterial in-flamatorio, generando el nexo entre la enfermedad periodontal y las patologías cardiovasculares (AU))

Periodontitis is a non-communicable disease which is highly prevalent worldwide. It was reported to range from 45% to 50% around the world and it was the sixth most prevalent condition of humanity. Consistent body of evidence explains the relationship between periodontal disease and other common systemic conditions such as cardiovascular disease. Periodontitis is likely to cause a 45% of deaths in developed countries, including myocardial infarction, stroke, heart failure and arrhythmias that cause about a 95% of deaths related to cardiovascular disease.Both diseases share many risk factors, such as diabetes and smoking; but also, genetic, and epigenetic characteristics support several etiopathological mechanisms. Beyond the common risk factors, two mechanisms have been proposed to elucidate the relationship between the periodontal disease and cardiovascular diseases. One of them supports the concept that periodontal pathogens are capable of the direct invasion of endothelial cells. The other mechanism suggested (indirect pathway), caused by the disease resulting in chronically elevation of CRP, inflammatory cytokines, the monocyte chemoattractant protein, could be mediated by bacterial products, such as lipopolysaccharides, wich induce a potent immune response and can accelerate endothelial dysfunction. These mechanisms may act by inflaming endothelial cells, modulating lipid metabolism and increasing oxidative stress, favoring atherosclerosis, determining the expression of an inflammatory arterial phenotype, generating the link between periodontal disease and cardiovascular pathologies (AU)

Pulmonary Artery Catheter Seemingly Entrapped in the Skull.

A pulmonary artery catheter is an important tool for the monitoring of hemodynamics in patients. Unfortunately, misplacement of a catheter tip may occur in the vasculature local to the intended placement. Misplacement of the catheter can be further complicated by entrapment at the unintended destination. We present a case of a misplaced and entrapped pulmonary artery catheter in a patient with worsening pulmonary disease. After multiple unsuccessful attempts to float the catheter, it was partially retracted and found to be stuck. Imaging showed the tip terminating in the right internal jugular vein at the level of the jugular foramen. It was initially suspected that the catheter had become looped, knotted, or otherwise entangled within the vasculature of the skull and surgical removal would be necessary. Before surgical removal was performed, it was instead determined that the catheter had become kinked and entrapped at the end of the introducer sheath, and noninvasive removal was accomplished by first removing the introducer sheath.

Body composition analysis by dual-energy X-ray absorptiometry in young preschool children.

BACKGROUND/OBJECTIVES: Dual-energy X-ray absorptiometry (DXA) is considered a specific method for measuring body composition to assess obesity and osteoporosis, although few studies have been conducted in preschool children. The aim of this study was to provide sex - and age-specific references for bone mineral density (BMD), bone mineral content (BMC), fat mass (FM) and fat-free mass (FFM) normative data for children aged 2 to <6 years. SUBJECTS/METHODS: One hundred and eighty seven healthy white children from Buenos Aires City suburbs, Argentina, were studied by the Lunar DPX-L DXA, pediatric software: BMC less head (g), BMD (g/cm2), FM (%) and FFM (g). RESULTS: BMD and BMC increased significantly with age (P<0.0001), but only BMD was significantly different between boys and girls of similar age, being greater for boys (P=0.013). FM was not significantly different among the various age groups of boys and girls. However, the FFM/height was higher in boys and the BMC/FFM was higher in girls. The Z-scores and centile curves were derived separately for each sex and age. Q-Q detrended plots and LMS curves produced robust, unbiased fits that generated references for the 3rd, 50th and 97th percentiles for BMD, BMC, FM and FFM data, respectively. CONCLUSIONS: These DXA scans add to the scarcity of accurate measurements of body composition of white young children. The data analyses provided greater accuracy, particularly at the upper and lower ends of the distribution, which is important in clinical settings for identification of children with impaired body composition.

Co-managed care for fragility hip fractures (Rochester model).

Hip fractures in older adults are a common event with a high risk of morbidity and mortality. Patients who sustain a hip fracture often present with multiple co-morbid conditions that can benefit from co-management by orthopedic surgeons and geriatricians. This manuscript describes a co-managed model of care for patients with hip fractures. This model of care will be explained, and the benefits and results will be described. Retrospective review of the care of all native non-pathological hip fracture patients aged 60 years and older admitted between April 2005 and March 2009 to a 261-bed community teaching hospital. The outcome measures include patient characteristics, length of stay, mortality, 30-day readmission, re-operation, and costs of care. Seven hundred fifty-eight patients were identified with an average age of 84.8 (SD 8.4); 77.8% of the patients were female, 94.7% Caucasian, and 37.3% from nursing homes, and the mean Charlson score is 2.9 (SD 2.1). The length of stay was 4.3 days, 30-day readmission rate was 10.4%, 17-month re-operation rate was 1.9%, and costs of care to the system were $15,188. The 1-year mortality rate was 21.2%. This model of care resulted in improvements in all measures studied. Previous studies have shown reduction in in-hospital complications. Additional studies are needed to show if this model of care can be translated to other systems or to other surgical conditions. Wide application of this model care could substantially improve the quality of care and cost of caring for frail elders with hip fractures.

Ortho-geriatric service--a literature review comparing different models.

In the fast-growing geriatric population, we are confronted with both osteoporosis, which makes fixation of fractures more and more challenging, and several comorbidities, which are most likely to cause postoperative complications. Several models of shared care for these patients are described, and the goal of our systematic literature research was to point out the differences of the individual models. A systematic electronic database search was performed, identifying articles that evaluate in a multidisciplinary approach the elderly hip fracture patients, including at least a geriatrician and an orthopedic surgeon focused on in-hospital treatment. The different investigations were categorized into four groups defined by the type of intervention. The main outcome parameters were pooled across the studies and weighted by sample size. Out of 656 potentially relevant citations, 21 could be extracted and categorized into four groups. Regarding the main outcome parameters, the group with integrated care could show the lowest in-hospital mortality rate (1.14%), the lowest length of stay (7.39 days), and the lowest mean time to surgery (1.43 days). No clear statement could be found for the medical complication rates and the activities of daily living due to their inhomogeneity when comparing the models. The review of these investigations cannot tell us the best model, but there is a trend toward more recent models using an integrated approach. Integrated care summarizes all the positive features reported in the various investigations like integration of a Geriatrician in the trauma unit, having a multidisciplinary team, prioritizing the geriatric fracture patients, and developing guidelines for the patients' treatment. Each hospital implementing a special model for geriatric hip fracture patients should collect detailed data about the patients, process of care, and outcomes to be able to participate in audit processes and avoid peerlessness.

Indoleamine 2,3-dioxygenase, an emerging target for anti-cancer therapy.

The inability of the host immune system to control tumor growth appears to result from dominant mechanisms of immune suppression that prevent the immune system from effectively responding in a way that consistently results in tumor rejection. Among the many possible mediators of tumoral immune escape, the immunoregulatory enzyme, indoleamine 2,3-dioxygenase (IDO), has recently gained considerable attention. IDO is a heme-containing, monomeric oxidoreductase that catalyzes the first and rate-limiting step in the degradation of the essential amino acid tryptophan to N formyl-kynurenine. Tryptophan depletion as well as the accumulation of its metabolites results in a strongly inhibitory effect on the development of immune responses by blocking T cell activation, inducing T cell apoptosis and promoting the differentiation of naïve T cells into cells with a regulatory phenotype (T(regs)). Recent data obtained from preclinical tumor models demonstrate that IDO inhibition can significantly enhance the antitumor activity of various chemotherapeutic and immunotherapeutic agents. These results, coupled with data showing that increased IDO expression is an independent prognostic variable for reduced overall survival in cancer patients, suggest that IDO inhibition may represent an effective strategy to treat malignancies, either alone or in combination with chemotherapeutics or other immune based therapies. This review will focus on the role of IDO as a mediator of peripheral immune tolerance, evidence that IDO becomes dysregulated in human cancers, and the latest progress on the development of IDO inhibitors as a novel anti-cancer therapy.

Dietas desequilibradas en niños preescolares: estudio en un jardín integral de la provincia de Buenos Aires, Argentina / Imbalance diets in preschool children: study in a day-care center in the Province of Buenos Aires, Argentina

The purpose of this study was to investigate the impact of low fat diets in children aged 2 to 5. Eighty two children (40 females and 42 males) attending a school cafeteria (Province of Buenos Aires, Argentina), in a cross sectional study, were evaluated. Body weight (W), height (H) and body composition (BC) by bioimpedance were recorded. The anthropometric raw data were processed as Z-score of the weight-for-age (WEZ) and of the height-for-age (HAZ). Serum insulin-like growth factor 1 (IGF-1) and Zinc/haemoglobin ratio (Zn/Hb) were also measured. Results showed that 73.2 per cent of children were adequate (A) according WEZ, 13.4 per cent were lean (L) and 13.4 per cent overweight (O). 8.5 per cent presented simultaneously impairment in WEZ and HAZ. Body fat percentage and energy metabolism were higher in O than in L and A (p < 0.05). Serum IGF-1's children--aged 4 to 5 years--with HAZ deficit were low than adequate HAZ ones. No statistical differences in Zn/Hb ratio between A, L and O were found. This cross sectional study suggests metabolic disorders in young children attending school cafeterias. These conclusions will allow to design balanced diets in order to optimize the resources, promote optimal growth and development and prevent adult diseases through dietary practices in childhood.

Role of crevice in the occurrence of hemoglobin in saliva.

The aim of the present study was to analyze the role of the gingival-periodontal component in the presence of blood in saliva. We studied a population of 184 adult patients composed of 101 totally edentulous patients with no oral mucosa lesions and 83 dentulous patients with clinically healthy gums. Saliva samples obtained by spontaneous salivation were collected in sterile containers. Qualitative and quantitative evaluation of each of the samples was performed. 67% of the dentulous patients tested positive for hemoglobin in saliva. None of the patients in the totally edentulous group exhibited hemoglobin in saliva. These data suggest that the periodontal condition is an essential factor for the presence of hemoglobin in saliva.

Role of crevice in the occurrence of hemoglobin in saliva

The aim of the present study was to analyze the role of the gingival-periodontal component in the presence of blood in saliva. We studied a population of 184 adult patients composed of 101 totally edentulous patients with no oral mucosa lesions and 83 dentulous patients with clinically healthy gums. Saliva samples obtained by spontaneous salivation were collected in sterile containers. Qualitative and quantitative evaluation of each of the samples was performed. 67

of the dentulous patients tested positive for hemoglobin in saliva. None of the patients in the totally edentulous group exhibited hemoglobin in saliva. These data suggest that the periodontal condition is an essential factor for the presence of hemoglobin in saliva.

Role of crevice in the occurrence of hemoglobin in saliva.

The aim of the present study was to analyze the role of the gingival-periodontal component in the presence of blood in saliva. We studied a population of 184 adult patients composed of 101 totally edentulous patients with no oral mucosa lesions and 83 dentulous patients with clinically healthy gums. Saliva samples obtained by spontaneous salivation were collected in sterile containers. Qualitative and quantitative evaluation of each of the samples was performed. 67

of the dentulous patients tested positive for hemoglobin in saliva. None of the patients in the totally edentulous group exhibited hemoglobin in saliva. These data suggest that the periodontal condition is an essential factor for the presence of hemoglobin in saliva.

Photochemically enhanced binding of small molecules to the tumor necrosis factor receptor-1 inhibits the binding of TNF-alpha.

The binding of tumor necrosis factor alpha (TNF-alpha) to the type-1 TNF receptor (TNFRc1) plays an important role in inflammation. Despite the clinical success of biologics (antibodies, soluble receptors) for treating TNF-based autoimmune conditions, no potent small molecule antagonists have been developed. Our screening of chemical libraries revealed that N-alkyl 5-arylidene-2-thioxo-1,3-thiazolidin-4-ones were antagonists of this protein-protein interaction. After chemical optimization, we discovered IW927, which potently disrupted the binding of TNF-alpha to TNFRc1 (IC(50) = 50 nM) and also blocked TNF-stimulated phosphorylation of Ikappa-B in Ramos cells (IC(50) = 600 nM). This compound did not bind detectably to the related cytokine receptors TNFRc2 or CD40, and did not display any cytotoxicity at concentrations as high as 100 microM. Detailed evaluation of this and related molecules revealed that compounds in this class are "photochemically enhanced" inhibitors, in that they bind reversibly to the TNFRc1 with weak affinity (ca. 40-100 microM) and then covalently modify the receptor via a photochemical reaction. We obtained a crystal structure of IV703 (a close analog of IW927) bound to the TNFRc1. This structure clearly revealed that one of the aromatic rings of the inhibitor was covalently linked to the receptor through the main-chain nitrogen of Ala-62, a residue that has already been implicated in the binding of TNF-alpha to the TNFRc1. When combined with the fact that our inhibitors are reversible binders in light-excluded conditions, the results of the crystallography provide the basis for the rational design of nonphotoreactive inhibitors of the TNF-alpha-TNFRc1 interaction.

Differential regulation of IL-1beta and TNF-alpha RNA expression by MEK1 inhibitor after focal cerebral ischemia in mice.

Activation of the extracellular-signal-responsive kinase (ERK 1/2) by MAP kinase/ERK kinase (MEK1/2) following ischemia/reperfusion in the brain has been associated with cell death since inhibition of MEK1/2 provides neuroprotection in cerebral ischemia injury. Since inflammation has been implicated in ischemic brain injury, the present study investigated whether MEK1/2 modifies expression of two key inflammatory cytokines, IL-1beta and TNFalpha, that have been shown to exacerbate ischemic brain injury. A mouse model of transient cerebral ischemia was deployed to test the effect of selective MEK1/2 inhibitor (SL327) on infarct size and cytokine expression. SL327 (100 mg/kg, i.p.) administered 15 min prior to ischemia resulted in 64% reduction in infarct size over controls (n = 8, P < 0.01). Under the same condition, SL327 significantly reduced peak expression of IL-1beta mRNA (59% reduction compared to vehicle, P < 0.01, n = 4) but not TNF-alpha mRNA. A parallel reduction in IL-1beta protein (67%, P < 0.05, n = 6) was also observed using ELISA analysis. These data suggest that the neuroprotective effect of MEK1/2 inhibition may be mediated by suppression of IL-1beta. The study also demonstrates for the first time that these two cytokines are differentially regulated by kinase mediated signaling pathways.

Mutation in the DNA gyrase A Gene of Escherichia coli that expands the quinolone resistance-determining region.

In three Escherichia coli mutants, a change (Ala-51 to Val) in the gyrase A protein outside the standard quinolone resistance-determining region (QRDR) lowered the level of quinolone susceptibility more than changes at amino acids 67, 82, 84, and 106 did. Revision of the QRDR to include amino acid 51 is indicated.

Growth deceleration and bone metabolism in nutritional dwarfing rats.

Nutritional status as well as energy and protein intake are critical regulators of IGF-1 and IGFBP-3 and contribute to the modulation of bone remodeling and formation. The purpose of this study was to investigate on an experimental model with nutritional dwarfing (ND), whether the alterations on body growth velocity, energy metabolism and body composition could affect serum concentrations of IGF-1 and IGFBP-3 and bone (tibiae and mandible) histology and histomorphometry. Twenty-one male weanling Wistar rats (body weight = 38.20 +/- 0.94 g) were randomized to three groups: seven of them were killed at day = 0 (CO, n = 7); control (C, n = 7); and experimental 80 (E80, n = 7). During 4 weeks, C was fed ad libitum with a 1:1 carbohydrate to fat diet. E80 was being underfed with the same diet by 80% and the following parameters were measured: weight (Wt) for length (L) ratio z-score; oxygen consumption (VO2); body composition (BC) by EM-SCAN SA 3000. At t = 28, E80 and C were killed. Serum IGF-1 and IGFBP-3 and bone histology and histomorphometry were performed on C0, E80 and C. E80 showed Wt for L z-score between lean and adequate, a decrease in VO2 according to body proportions, a BC of a delayed puberty individual, IGF-1 and IGFBP-3 decreased by 56 and 53%, respectively. Tibiae's hematopoyetic and adipose bone marrow areas were combined, with sealing trabeculae on metaphyseal areas. This study suggests that there is a relationship among growth deceleration in ND rats and structural alterations on tibiae.

Biology of TACE inhibition.

Studies conducted over the past decade have demonstrated a central role for tumour necrosis factor alpha (TNFalpha) in inflammatory diseases. As a result of this work, a number of biological agents that neutralise the activity of this cytokine have entered the clinic. The recent clinical data obtained with etanercept and infliximab highlight the relevance of this strategy. TNFalpha converting enzyme (TACE) is the metalloproteinase that processes the 26 kDa membrane bound precursor of TNFalpha (proTNFalpha) to the 17 kDa soluble component. Although a number of proteases have been shown to process proTNFalpha, none do so with the efficiency of TACE. A series of orally bioavailable, selective, and potent TACE inhibitors are currently in clinical development. These inhibitors effectively block TACE mediated processing of proTNFalpha and can reduce TNF production by lipopolysaccharide stimulated whole blood by >95%. Through a series of studies it is shown here that >80% of the unprocessed proTNFalpha is degraded intracellularly. The remainder appears to be transiently expressed on the cell surface. Although, in vitro, TACE inhibition has also been implicated in shedding of p55 and p75 surface TNFalpha receptors, the in vivo data cast doubt on the consequences of this finding. In a mouse model of collagen-induced arthritis, the inhibitors are efficacious both prophylactically and therapeutically. The efficacy seen is equivalent to strategies that neutralise TNFalpha. In many studies greater efficacy is observed with the TACE inhibitors, presumably owing to greater penetration to the site of TNFalpha production.

Choroidal neovascular membranes: reproducibility of angiographic interpretation.

PURPOSE: To determine interobserver agreement for classifying choroidal neovascular membranes in age-related macular degeneration. METHODS: Six fluorescein angiograms of choroidal neovascular membranes were interpreted by 21 retina specialists. Reliability was measured by percent agreement and kappa coefficient. RESULTS: Interobserver agreement of membrane types ranged from perfect concordance for a small, classic membrane to near-random classification for a complex pattern. Mean kappa coefficient was.64. Interobserver agreement of membrane size was most variable for intermediate size lesions (mean kappa coefficient =.40). CONCLUSION: Fluorescein angiographic interpretation of choroidal neovascular membrane type and size can vary considerably. Interobserver agreement is better for membrane type than for membrane size.

Ocular findings in aplastic anemia.

OBJECTIVE: To analyze the ocular findings in aplastic anemia. DESIGN: Eighteen patients with aplastic anemia were examined. RESULTS: Ocular findings included cotton wool spots (38%), nerve fiber layer or preretinal hemorrhages (67%), vitreous hemorrhages (13%), a picture resembling central retinal vein occlusion (13%) and optic disk edema (6%). Preretinal hemorrhages were the presenting sign of aplastic anemia in 2 patients (13%). CONCLUSIONS: A blood profile is needed in patients with unexplained retinal hemorrhages. Patients with aplastic anemia need to avoid ocular massage and Valsalva maneuvers to decrease ocular morbidity.

The development of the inventory of countertransference behavior.

A measure was developed to assess supervisor-perceived countertransference (CT) behavior during counseling sessions. Eleven experts provided face validity for the items, indicating that each item was at least somewhat an expression of countertransference. Exploratory factor analysis of ratings of 126 supervisors of supervisee counseling sessions revealed, as expected, the existence of two factors. However, rather than reflecting the dimensions of overinvolvement and underinvolvement as hypothesized, the factors were better captured by the terms Negative Countertransference and Positive Countertransference. The total scale and each subscale demonstrated high internal consistency. In addition, both positive and negative CT were found to relate positively with an existing one-item index of countertransference behavior and negatively with an existing measure of countertransference management ability. Research and clinical implications are discussed.

Mixed lens opacities and subsequent mortality.

BACKGROUND: Previous studies have found an association between cataract or lens opacity and increased risk of mortality. Further work on determining explanatory factors for this association is needed. OBJECTIVES: To determine, in a population-based cohort of older persons, the 2-year risk of death associated with different types of lens opacities; whether an association of mortality and lens opacity is explained by confounding risk factors such as smoking, diabetes, age, race, and sex, which are known to be related to opacity and mortality; whether lens opacity is a marker for health status; and whether there are differences in cause-specific mortality for persons with and without lens opacity. MAIN OUTCOME MEASURE: Two-year mortality rate. METHODS: The Salisbury Eye Evaluation Project consists of a random sample of 2520 residents of Salisbury, Md, aged 65 to 84 years. At baseline, lens photographs were taken to document nuclear, cortical, posterior subcapsular cataract, and mixed opacities. Data on education, smoking, alcohol use, hypertension, diabetes and other comorbid conditions, handgrip strength, and body mass index were also collected. Two-year follow-up was conducted for mortality and cause of death. RESULTS: Nuclear opacity, particularly severe nuclear opacity, and mixed opacities with nuclear were significant predictors of mortality independent of body mass index, comorbid conditions, smoking, age, race, and sex (mixed nuclear: odds ratio, 2.23; 95% confidence interval, 1.26-3.95). CONCLUSION: Lens opacity status is an independent predictor of 2-year mortality, an association that could not be explained by potential confounders.