Increasing quality of life in pulmonary arterial hypertension: is there a role for nutrition?

Pulmonary arterial hypertension (PAH) is a progressive disease primarily affecting the pulmonary vasculature and heart. PAH patients suffer from exercise intolerance and fatigue, negatively affecting their quality of life. This review summarizes current insights in the pathophysiological mechanisms underlying PAH. It zooms in on the potential involvement of nutritional status and micronutrient deficiencies on PAH exercise intolerance and fatigue, also summarizing the potential benefits of exercise and nutritional interventions. Pubmed/Medline, Scopus, and Web of Science were searched for publications on pathophysiological mechanisms of PAH negatively affecting physical activity potential and nutritional status, and for potential effects of interventions involving exercise or nutritional measures known to improve exercise intolerance. Pathophysiological processes that contribute to exercise intolerance and impaired quality of life of PAH patients include right ventricular dysfunction, inflammation, skeletal muscle alterations, and dysfunctional energy metabolism. PAH-related nutritional deficiencies and metabolic alterations have been linked to fatigue, exercise intolerance, and endothelial dysfunction. Available evidence suggests that exercise interventions can be effective in PAH patients to improve exercise tolerance and decrease fatigue. By contrast, knowledge on the prevalence of micronutrient deficiencies and the possible effects of nutritional interventions in PAH patients is limited. Although data on nutritional status and micronutrient deficiencies in PAH are scarce, the available knowledge, including that from adjacent fields, suggests that nutritional intervention to correct deficiencies and metabolic alterations may contribute to a reduction of disease burden.

Tendon elongation with bovine pericardium (Tutopatch®) when conventional strabismus surgery is not possible.

PURPOSE: Sometimes, a conventional recess-resect surgery may not be sufficient to obtain satisfactory ocular alignment. Patients who have previously undergone surgery and/or have a large difference in visual acuity between both eyes and do not wish to undergo surgery on the sound eye provide a surgical challenge. In these cases, tendon elongation with bovine pericardium may be an option. METHODS: We retrospectively reviewed the charts of 38 patients who underwent strabismus surgery with tendon elongation. Before surgery, 31 had exotropia (angle -21.8 ± 5.7 degrees) and 7 esotropia (angle +19.1 ± 5.4 degrees). Reasons for tendon elongation included the following: 15 patients refused surgery on their sound eye; in 15 patients, conventional recess-resect was not possible; and in 7 patients, the elongation best fitted the motility pattern. In one patient, tendon elongation was preferred over conventional recession because of a thin sclera. Follow-up was 0.5 to 4 years. RESULTS: At last follow-up visit, in patients with previous exotropia, the angle was -3.3 ± 5.9 degrees; in patients with previous esotropia, +0.2 ± 0.5 degrees. Most had some duction limitation in the direction of the elongated muscle. All patients but one were satisfied with the result. In the patients with previous exotropia, there was a small but nonsignificant regression to recurrence of the exodeviation (on average 0.5 degree per year). CONCLUSIONS: Tendon elongation is a valuable addition to our strabismus surgery repertoire. However, because of duction limitations after surgery, it should be reserved for those cases in which conventional surgery is not an option.

ErbB2 and ErbB4 Cbl binding sites can functionally replace the ErbB1 Cbl binding site.

Poor downregulation of ErbB receptors is associated with enhanced downstream signaling and tumorigenesis. It has been suggested that poor downregulation of ErbB-2, -3 and -4 receptors when compared to ErbB1 is due to decreased recruitment of Cbl E3 ligase proteins. However, a highly conserved Cbl binding site is not only present in ErbB1/EGFR (FLQRpY(1045)SSDP), but also in ErbB2 (PLQRpY(1091)SEDP) and ErbB4 (STQRpY(1103)SADP). We therefore replaced the ErbB1 Cbl binding site by that of ErbB2 and ErbB4. Whereas retrovirally infected NIH3T3 cells containing the EGFR Y1045F mutation showed dramatically impaired Cbl recruitment, EGFR ubiquitination and delayed EGFR degradation, replacement of the EGFR Cbl binding site by that of ErbB2 or ErbB4 did not affect Cbl recruitment, receptor-ubiquitination, -degradation, -downregulation or ligand degradation. We conclude that poor downregulation of ErbB2 and ErbB4 receptors is not due to sequence variations in the Cbl binding site of these receptors.

Diaphragm dysfunction in chronic obstructive pulmonary disease.

RATIONALE: Hypercapnic respiratory failure because of inspiratory muscle weakness is the most important cause of death in chronic obstructive pulmonary disease (COPD). However, the pathophysiology of failure of the diaphragm to generate force in COPD is in part unclear. OBJECTIVES: The present study investigated contractile function and myosin heavy chain content of diaphragm muscle single fibers from patients with COPD. METHODS: Skinned muscle fibers were isolated from muscle biopsies from the diaphragm of eight patients with mild to moderate COPD and five patients without COPD (mean FEV(1) % predicted, 70 and 100%, respectively). Contractile function of single fibers was assessed, and afterwards, myosin heavy chain content was determined in these fibers. In diaphragm muscle homogenates, the level of ubiquitin-protein conjugation was determined. RESULTS: Diaphragm muscle fibers from patients with COPD showed reduced force generation per cross-sectional area, and reduced myosin heavy chain content per half sarcomere. In addition, these fibers had decreased Ca2+ sensitivity of force generation, and slower cross-bridge cycling kinetics. Our observations were present in fibers expressing slow and 2A isoforms of myosin heavy chain. Ubiquitin-protein conjugation was increased in diaphragm muscle homogenates of patients with mild to moderate COPD. CONCLUSIONS: Early in the development of COPD, diaphragm fiber contractile function is impaired. Our data suggest that enhanced diaphragm protein degradation through the ubiquitin-proteasome pathway plays a role in loss of contractile protein and, consequently, failure of the diaphragm to generate force.