Effectiveness of a Referral Program for rheumatoid arthritis and axial spondyloarthritis Diagnosis at Primary Care Centers in Portugal - SIARA STUDY.

OBJECTIVES: Early diagnosis and treatment of Rheumatoid Arthritis (RA) and axial Spondylarthritis (axial SpA) can limit the impact of disease outcomes. This study evaluated the effectiveness of a referral program on the identification of patients with RA and axial SpA. METHODS: This was an observational, prospective, randomized (by clusters) study conducted in Portugal to evaluate the impact of the implementation of a set of referral support actions (RSA). The study was divided in two sub-studies, the RA sub-study and the axial SpA sub-study. 28 participating primary care units were randomly (by clusters) assigned to RSA or control group (with no intervention). Both RSA and control groups identified and referred patients with suspected RA or axial SpA to the rheumatology unit of the reference hospital. The primary objective was to evaluate the correct diagnosis of RA or axial SpA cases confirmed by the rheumatologist of the reference hospital. RESULTS: RA-Substudy: A total of 340 patients were recruited (144 in the RSA-exposed group; 196 in the control). RA diagnosis confirmation was 7.3% (95%CI, 2.1-12.5%) in RSA group versus 2.7% (95%CI, 0.0-5.7%) in control group RSA effect was positive but moderate (4.6%) and not statistically significant (95% CI, 0.0%-11.8%; p=0.222, adjusted for clustering effect). Rate of confirmed arthritis of any type was 16.9% (n=14/83) in the RSA group and 6.0% (n=5/83) in the control group. This difference was statistically significant and favorable to RSA group (OR=3.2; 95% CI 1.1-9.2; p=0.028). Axial SpA-Substudy: A total of 231 patients were recruited (108 in the RSA-exposed group; 123 in the control). Axial SpA diagnosis confirmation was 8.7% (95% CI, 2.1-15.4%) in RSA group versus 5.6% (95% CI, 0.0-11.73%) in control group. RSA effect was positive (3.1%) but not statistically significant (95% CI, -7.5- 12.9%; p=0.568, adjusted for clustering effect). CONCLUSIONS: This study showed a positive tendency for the RSA program, most relevantly on the diagnosis of patients with any type of arthritis in the RA sub-study. It is possible that a referral program more comprehensive than the one herein tested might improve early diagnosis of RA and SpA.

[Democracy and conflict in pluralist contexts: an interview with Chantal Mouffe]. / Democracia y conflicto en contextos pluralistas: entrevista con Chantal Mouffe.

Chantal Mouffe, along with Argentinian political theorist Ernesto Laclau (1935-2014), laid down the bases of discourse theory in 1985. She later developed her work by exploring in more detail how discourse theory formulations influence the analysis of contemporary democracies. Approaching conflict as a product of the encounter with difference, Mouffe sees it as an indelible part of the constitution of social relationships. In this encounter with the author, we seek to reflect upon certain themes and problematics that are central to her work, and upon the implications of her theory for the field of contemporary education.

Democracia y conflicto en contextos pluralistas: entrevista con Chantal Mouffe / Democracy and conflict in pluralist contexts: an interview with Chantal Mouffe

Chantal Mouffe, junto al teórico político argentino Ernesto Laclau (1935-2014), lanzó, en 1985, las bases de la teoría del discurso. Luego, desarrolló su trabajo en el sentido de profundizar como influyen las formulaciones de la teoría del discurso en el análisis de las democracias contemporáneas. Abordando el conflicto como una producción del encuentro de la diferencia, Mouffe lo comprende como un aspecto indeleble en la constitución del social. En este encuentro con la autora, buscamos reflexionar algunos temas y problemáticas centrales de su trabajo, y las implicaciones de su teoría en el campo educacional contemporáneo.

Chantal Mouffe, along with Argentinian political theorist Ernesto Laclau (1935-2014), laid down the bases of discourse theory in 1985. She later developed her work by exploring in more detail how discourse theory formulations influence the analysis of contemporary democracies. Approaching conflict as a product of the encounter with difference, Mouffe sees it as an indelible part of the constitution of social relationships. In this encounter with the author, we seek to reflect upon certain themes and problematics that are central to her work, and upon the implications of her theory for the field of contemporary education.

Protein kinase Cε-calcineurin cosignaling downstream of toll-like receptor 4 downregulates fibrosis and induces wound healing gene expression in cardiac myofibroblasts.

The pathways which regulate resolution of inflammation and contribute to positive remodeling of the myocardium following injury are poorly understood. Here we show that protein kinase C epsilon (PKCε) cooperates with the phosphatase calcineurin (CN) to potentiate induction of cardioprotective gene expression while suppressing expression of fibrosis markers. This was achieved by detailed analysis of the regulation of cyclooxygenase 2 (COX-2) expression as a marker gene and by using gene expression profiling to identify genes regulated by coexpression of CN-Aα/PKCε in adult rat cardiac myofibroblasts (ARVFs) on a larger scale. GeneChip analysis of CN-Aα/PKCε-coexpressing ARVFs showed that COX-2 provides a signature for wound healing and is associated with downregulation of fibrosis markers, including connective tissue growth factor (CTGF), fibronectin, and collagens Col1a1, Col3a1, Col6a3, Col11a1, Col12a1, and Col14a1, with concomitant upregulation of cardioprotection markers, including COX-2 itself, lipocalin 2 (LCN2), tissue inhibitor of metalloproteinase 1 (TIMP-1), interleukin-6 (IL-6), and inducible nitric oxide synthase (iNOS). In primary rat cardiomyocyte cultures Toll-like receptor 4 (TLR4) agonist- or PKCε/CN-dependent COX-2 induction occurred in coresident fibroblasts and was blocked by selective inhibition of CN or PKC α/ε or elimination of fibroblasts. Furthermore, ectopic expression of PKCε and CN in ARVFs showed that the effects on COX-2 expression are mediated by specific NFAT sites within the COX-2 promoter as confirmed by site-directed mutagenesis and chromatin immunoprecipitation (ChIP). Therefore, PKCε may negatively regulate adverse myocardial remodeling by cooperating with CN to downregulate fibrosis and induce transcription of cardioprotective wound healing genes, including COX-2.

Patient's access to healthcare and treatment in rheumatoid arthritis: the views of stakeholders in Portugal.

BACKGROUND: The access to healthcare and treatment by rheumatoid arthritis (RA) patients, particularly to biologics, differs significantly among European countries.We aimed to explore the views and experiences of Portuguese healthcare stakeholders on key barriers which limit the access to treatment, and ultimately to biologics, by RA patients and to find potential solutions (leverage points) to overcome the identified barriers. METHODS: This was a qualitative research consisting of semi-structured face-to-face interviews with key stakeholders in RA framework. Thirty four individuals from eight groups of stakeholders were interviewed: rural and urban general practitioners (GPs), rheumatologists, hospital managers, hospital pharmacists, budget holders, representatives from the Portuguese Rheumatology Society and the RA Patient Association. Interviews were conducted between May and June 2011. Conventional content analysis with research triangulation was used. RESULTS: The key barriers identified were related to the accessibility to primary healthcare services, difficulties in RA diagnosis among GPs, inefficient referral to secondary healthcare and controlled process of biologics prescription in public hospitals. The leverage points identified included the improvement of epidemiological and clinical knowledge about RA in Portugal, a better understanding of the disease among patients and GPs, the clarification of biologics benefits among budget holders and a raised awareness of the current treatment guidelines. In order to further address the leverage points, the following key initiatives were proposed: optimization of RA national registry; dissemination of information on rheumatic symptoms in primary care facilities and among the general public; increase interaction between rheumatologists and GPs through clinical discussions of successfully treated patients or workshops; broader utilization of disease diagnosis and monitoring tools, such as DAS28, and implementation of hospital-based research to collect real-world data. CONCLUSIONS: Most of the key barriers limiting the access to treatment, including biologics, in RA in Portugal are upstream of rheumatology practice. Our findings suggest that future actions should be focused on the primary care level to improve referral to rheumatologists. In addition, the collection of real-world data seems essential to characterise the RA population, to improve disease management and to increase compliance with current treatment guidelines.

Calcineurin regulates NFAT-dependent iNOS expression and protection of cardiomyocytes: co-operation with Src tyrosine kinase.

OBJECTIVE: To determine the role of calcineurin and Src tyrosine kinase in the regulation of inducible nitric oxide synthase (iNOS) expression and protection in cardiomyocytes. METHODS: iNOS expression was studied in isolated neonatal rat ventricular myocyte cultures in response to bacterial lipopolysaccharide (LPS) or following transfection with constitutively active calcineurin or Src and in hearts isolated from wild-type or calcineruin Abeta knockout mice. Cell injury in response to simulated ischemia-reperfusion was studied following overexpression of active calcineurin. Regulation of the iNOS gene promoter by calcineurin was studied using promoter-luciferase reporter and chromatin immunoprecipitation assays. RESULTS: Overexpression of constitutively active Src co-operated with [Ca2+]c elevation to induce iNOS expression, and LPS-induced iNOS expression was abrogated by pharmacological inhibition of calcineurin or tyrosine kinase. LPS also induced tyrosine kinase-dependent but calcineurin-independent phosphorylation of Src Tyr418. LPS induced myocardial iNOS expression in wild-type but not calcineurin Abeta knockout mice. Overexpression of constitutively active calcinuerin in isolated cardiomyocytes caused dephosphorylation and nuclear accumulation of the c1 isoform of nuclear factor of activated T-cells (NFATc1), induced strong iNOS expression, and induced NOS-dependent protection against simulated ischemia-reperfusion prior to cardiomyocyte hypertrophy. Co-transfection of a mouse iNOS promoter-luciferase reporter in combination with active calcineurin and wild-type or dominant negative Src confirmed that constitutive activation of calcineurin was sufficient for transactivation. Chromatin immunoprecipitation confirmed calcineurin-dependent in vivo binding of NFATc1 to consensus sites within the iNOS promoter. CONCLUSIONS: These results support a cardioprotective role for calcineurin mediated by NFAT-dependent induction of iNOS expression and co-operativity between calcineurin and Src.

Effects of food restriction on synthesis and expression of brain-derived neurotrophic factor and tyrosine kinase B in dentate gyrus granule cells of adult rats.

We have previously found that the dendritic trees of dentate gyrus granule cells are selectively vulnerable to food restriction but there are reorganizational morphological events that minimize functional impairments. As the neurotrophin brain-derived neurotrophic factor (BDNF) and the cognate receptor tyrosine kinase B (TrkB) are involved in the maintenance of the structure of dendritic trees, we thought of interest to verify if there are alterations in its synthesis and expression in granule cells. To investigate this issue, 2-month-old rats were submitted to 40% caloric restriction for 6 months and compared to controls fed ad libitum. The numbers of granule cells containing BDNF and TrkB proteins were estimated from immunostained sections and the respective mRNA levels of individual neurons evaluated using nonradioactive in situ hybridization. After dietary treatment there was a 15% reduction of BDNF-immunoreactive granule cells with no changes of the number of TrkB-immunostained neurons. No alterations were found in the levels of BDNF and TrkB mRNAs of individual granule cells. As caloric restriction extends the lifespan of animals, the restrictive dietary regimens are generally regarded as beneficial to the organisms, but the present results suggest that caution is needed when extrapolating to some neuronal populations.

Acetylcholine and choline effects on erythrocyte nitrite and nitrate levels.

Acetylcholine has been detected in human blood. Acetylcholine receptors and acetylcholinesterase are present in erythrocyte membranes. We tested the acetylcholine and choline effects on nitric oxide metabolites (NOx), namely nitrites and nitrates, and observed if they are dependent on interactions with muscarinic receptors and acetylcholinesterase. Human erythrocyte suspensions were incubated with acetylcholine and choline in the absence or presence of 10 microM atropine or 10 microM velnacrine maleate. The nitrite and nitrate concentrations were determined by the Griess method. Acetylcholine or choline increased NOx control concentrations (P <0.001). The nitrite concentrations decreased in the presence of atropine or velnacrine maleate (P <0.03). The nitrate concentrations only decreased when velnacrine maleate was incubated with acetylcholine or choline (10 microM, P <0.03). These results demonstrated that acetylcholine and choline modulate nitric oxide metabolites on erythrocytes and this effect is mediated by interactions with erythrocyte membrane muscarinic receptors and membrane enzyme acetylcholinesterase. A hypothesis for the signal transduction mechanism has been discussed for acetylcholinesterase and muscarinic receptor (M1) participation.

Effects of choline on hemorheological properties and NO metabolism of human erythrocytes.

PURPOSE OF THE STUDY: To determine the effects of choline on red blood cell membrane properties and NO metabolism. MATERIAL AND METHODS: Aliquots of venous blood from eleven healthy subjects were incubated in vitro with choline concentrations 10(-10) to 10(-3) M. The following parameters were determined: erythrocyte deformability, aggregation and membrane lipid fluidity, plasma K+, Na+, Ca2+, total blood haemoglobin and methemoglobin concentrations. Additionally, plasma and intra-erythrocyte nitrites concentrations were measured. RESULTS: Choline increases erythrocyte deformability at lower shear stresses, decreases erythrocyte aggregation, increases membrane lipid fluidity, and decreases of Na+ plasma concentrations. We also find an increase of nitrites concentration both in the plasma and in the intra-erythrocyte compartment. CONCLUSION: Choline induces changes on erythrocyte membrane properties, Na+ plasma concentration, and NO metabolites concentrations.

Low levels of brain-derived neurotrophic factor and tyrosine kinase receptor B are related to loss of dentate granule cells after prolonged low-protein feeding in the rat.

Protein deprivation leads to neuronal and synaptic loss in the hippocampal formation, and to behavioral changes. We suggested that these effects could result from alterations in the levels of brain-derived neurotrophic factor (BDNF) and tyrosine kinase receptor B (TrkB). To investigate this issue, adult rats were submitted to protein deprivation for 6 months and compared with controls. The number of neurons of the dentate gyrus granular layer containing BDNF and TrkB was estimated from immunostained sections and the mRNA levels of BDNF and TrkB evaluated using in situ hybridization. After treatment, there was a loss of BDNF- and TrkB-immunoreactive cells and a reduction of the mRNA levels. Thus, it is likely that the decreased neurotrophic activity in the dentate gyrus of malnourished animals underpins neuronal degeneration and the ensuing behavioral alterations.

Nitric oxide effects on human erythrocytes structural and functional properties--an in vitro study.

NO is present in the blood at 10(-7) M under physiological conditions, but at concentrations higher than 10(-6) M during inflammatory disease states. The aim of this study was to characterize what are the effects of these different NO concentrations on erythrocyte structural and functional properties. Blood was collected from eleven healthy men and incubated with SpermineNONOate in order to expose it during incubation time to NO concentrations between 10(-7) M and 10(-3) M. We measured erythrocyte aggregation and deformability, membrane lipid peroxidation and fluidity, p50, hemoglobin, oxyhemoglobin, methemoglobin concentrations and plasma pH, pO(2), pCO(2), Na(+), K(+) and Ca(2+). When blood was exposed to NO 10(-7) M erythrocyte deformability increase and p50 decrease. In presence of NO 10(-5) M lipid fluidity and p50 decrease. When blood was exposed to NO 10(-3) M methemoglobin concentration increase and erythrocyte deformability and p50 decrease but membrane fluidity and lipid peroxidation were similar to control. In conclusion, dependent of NO concentrations there is different effects on erythrocytes structural and functional properties.

Restricted feeding facilitates time-place learning in adult rats.

Many species can acquire time-of-day discrimination when tested in food reinforced place learning tasks. It is believed that this type of learning is dependent upon the ability of animals to consult their internal circadian pacemakers entrained by various environmental zeitgebers, such as light-dark cycles and scheduled restricted feeding. In the present study, we examined, (1) whether rats can acquire time-of-day discrimination in an aversively motivated water maze task wherein an escape platform is located in one position in the morning and in another position in the afternoon; (2) whether time-of-day cues provided by the light- and feeding-entrainable pacemakers may have divergent impacts upon the ability of rats to learn this task. Two groups of rats, both maintained on 12-h light:12-h dark cycle, were used; in one group, animals had free access to food, whereas in the other, they were subjected to a restricted feeding protocol (60% of food consumed by rats fed ad libitum, once daily). Despite the heightened difficulty of the task, food-restricted rats were apparently able to acquire associations between two different platform positions and two different times of day, as indicated by the fact that the percentage of discrimination errors in this group declined progressively, as a function of training, and stabilized at the level of 22+/-9%. In contrast, rats that were fed ad libitum, even after extensive training, failed to perform the task above level of chance. These data indicate that time-place learning is a universal, reward-nonspecific, cognitive phenomenon. They furthermore suggest that the ability of animals to integrate spatial and temporal information can be dependent on the access to timing stimuli provided by the feeding-entrainable circadian system.