Real-World Effectiveness in Hypertension and Hyperlipidemia Collaborative Management between Pharmacies and Primary Care in Portugal: A Multicenter Pragmatic Controlled Trial (USFarmácia®).

There is evidence of the efficacy of collaborative health interventions with pharmacies and primary care providers but little of its real-world effectiveness. We aimed to assess the effectiveness and discuss the design and challenges of hypertension and hyperlipidemia management between pharmacies and primary care providers using real-world data exchange between providers and experimental bundled payment. This was a pragmatic, quasi-experimental controlled trial. We collected patient-level data from primary care prescription claims and Electronic Medical Record databases, a pharmacy claims database, and patient telephone surveys at several time points. The primary outcomes were changes in blood pressure and total cholesterol. We used matched controls with difference-in-differences estimators in a Generalized Linear Model (GLM) and controlled interrupted time series (CITS). We collected additional data for economic and qualitative studies. A total of 6 Primary Care Units, 20 pharmacies, and 203 patients entered the study. We were not able to observe significant differences in the effect of intervention vs. control. We experienced challenges that required creative strategies. This real-world trial was not able to show effectiveness, likely due to limitations in the primary care technology which affected the sample size. It offers, however, valuable lessons on methods, strategies, and data sources, paving the way for more real-world effectiveness trials to advance value-based healthcare.

Characteristics of Oral Corticosteroid Users Among Persons with Asthma on GINA Step 3 Therapy and Above: A Cross-Sectional Study in Portuguese Community Pharmacies.

Purpose: Oral corticosteroids (OCS) are frequently used in asthma management but have an important risk-profile. The aim of the study is to characterize and compare the sociodemographic and clinical characteristics, treatment regimen and asthma control between OCS users and non-users among the population of asthma patients (≥18 years) at GINA step 3 and above treated with a fixed combination of an inhaled corticosteroid and a long-acting beta-agonist (ICS/LABA). Methods: Cross-sectional study in Portuguese community pharmacies. Data was collected via paper-based interview delivered at the pharmacy (sociodemographic characteristics and asthma treatment regimen, namely ICS/LABA and OCS utilization), followed by a telephonic interview collecting smoking history, comorbidities, body mass index (BMI), history of exacerbations and asthma-related healthcare resource utilization (HCRU) in the previous 12 months, as well as asthma control using the Control of Allergic Rhinitis and Asthma Test (CARAT®). Results: A total of 347 patients recruited in 98 pharmacies were included in the analysis. Of those, 328 had completed both questionnaires. A quarter of the individuals reported OCS use in the previous 12 months (OCS users), either as add-on therapy (6%) or exacerbation treatment (19%). Patients were mostly females (72%), with an average age of 59.5 years (SD=15.4). OCS users were significantly older and reported more frequently having conjunctivitis (25.9% vs 15.0%), osteoporosis (25.9% vs 13.4%), arthritis (14.6% vs 6.9%), and gastrointestinal disease (16.1% vs 8.1%). OCS users also reported greater urgent HCRU: unscheduled consultations (33.3% vs 9.3%) and emergency department (ED) visits (32.1% vs 12.1%). Both groups presented poor disease control (85.2% of OCS users vs 72.9% of non-OCS users). Conclusion: These results highlight the burden of OCS therapy to asthma patients and the need to improve asthma management, by adopting OCS sparing strategies in this subgroup of patients.

Zinc-binding metallophores protect Pseudomonas aeruginosa from calprotectin-mediated metal starvation.

Pseudomonas aeruginosa is known to exhibit considerable resistance to the antimicrobial activity of the metal-sequestering protein calprotectin (CP). In this study, we demonstrate that although CP induces zinc deficiency in P. aeruginosa, a strain unable to import zinc through the two most important metal acquisition systems, namely ZnuABC and ZrmABCD, maintains significant growth capacity in the presence of high concentrations of CP. Furthermore, we have shown that nicotianamine, a molecule structurally similar to the metallophore pseudopaline, can favor the acquisition of the metal even in the presence of CP. To gain insights into the mechanisms through which metallophores can promote zinc acquisition, we analyzed the effect of nicotianamine on the activity of the metallo-ß-lactamase VIM-1. Our data suggest that metallophores released by bacteria in response to zinc deficiency can extract the protein-bound metal. The ability to interfere with the binding of metals to proteins, as well as favoring the acquisition of zinc, may contribute to increasing the resistance of P. aeruginosa to the antimicrobial action of CP.

Compliance with Regulatory Standard 32 in the units of a general hospital.

Introduction: In Brazil, the Ministry of Labor and Employment created Regulatory Standard number 32 (Norma Regulamentadora 32, NR-32), instituted by Ordinance 485, of November 11th, 2005. It establishes measures to protect workers' safety and health in any health service. Objectives: To quantify employees' compliance with NR-32 in the several units of a general hospital in the inland of the state of São Paulo, Brazil, reducing accidents related to work activity and allowing for the establishment of its fulfillment. Methods: This is an exploratory study with a qualitative and quantitative approach of data. Semi-structured questionnaires were applied to the volunteers. Results: Thirty-eight volunteers participated, who were divided into a group of professionals with a higher education degree (53.5%), consisting of nurses, physicians, and resident students, and another group of professionals with technical and high school degree and nursing assistants. Among the volunteers, 96.4% reported that they knew NR-32 and 39.2% reported having experienced an occupational accident in the period before the study. The use of personal protective equipment was reported by 88% of volunteers, and needle recapping by 7.1% of them. Conclusions: Assimilation of NR-32 by health care professionals, regardless of schooling, as well as its application within the hospital, may be a way of protection against occupational accidents during the development of work activities. Allied to this, protection may be extended with constant training of these workers.

Introdução: No Brasil, o Ministério do Trabalho e Emprego criou a Norma Regulamentadora número 32 (NR-32), instituída pela Portaria 485, de 11 de novembro de 2005. Ela estabelece as medidas para proteger a segurança e a saúde dos trabalhadores em qualquer serviço de saúde. Objetivos: Quantificar a adesão dos funcionários à NR-32 nos diversos setores de um hospital geral no interior do estado de São Paulo, reduzindo os acidentes relacionados à atividade laboral e permitindo o estabelecimento do cumprimento da norma. Métodos: Estudo exploratório de abordagem qualitativa e quantitativa dos dados. Foram aplicados questionários semiestruturados aos voluntários. Resultados: Totalizaram 28 voluntários, divididos em um grupo de profissionais atuantes com curso superior (53,5%), composto por enfermeiros, médicos e estudantes de residências, e em outro grupo de profissionais com nível de ensino médio e técnico e auxiliares de enfermagem. Entre os voluntários, 96,4% disseram conhecer a NR-32, e ocorreram 39,2% acidentes de trabalho no período anterior ao estudo. O uso de equipamento de proteção individual foi relatado por 88% dos voluntários, e o reencape de agulhas, por 7,1%. Conclusões: A assimilação da NR-32 entre os profissionais da área da saúde, independentemente da escolaridade, assim como sua aplicação dentro do hospital, parece ser uma maneira de proteção contra acidentes de trabalho durante o desenvolvimento das atividades laborais. Aliado a isso, a proteção pode ser estendida com a constante capacitação desses trabalhadores.

Pharmacy interventions on COVID-19 in Europe: Mapping current practices and a scoping review.

BACKGROUND: The COVID-19 pandemic has put community pharmacists at the frontline of prevention, preparedness, response, and recovery efforts. Pharmacies had to reorganize and implement several different interventions and measures within a very short time frame. OBJECTIVES: 1) To map the current reported practice and trends and to review the literature on pharmacy-based interventions on COVID-19 provided in Europe; 2) To identify knowledge gaps and future avenues for pharmacy research, policy, and practice in response to public health emergencies. METHODS: We used a mixed methods approach combining country mapping of current practices of pharmacy interventions on COVID-19 reported by pharmacy associations in Europe with a scoping review of published literature. RESULTS: We mapped current practices on 31 pharmacy interventions on COVID-19 in 32 countries in Europe. Almost all preventive measures to reduce health risks have been provided in most countries. Other frequent interventions reflected preparedness for stockpiling, increased demand for services and products, and important patient care interventions exceeding dispensing role. Expanded powers granted to pharmacies and legislation passed in view of COVID-19 enabled services that improve access to medicines and relevant products, patient screening and referral including point-of-care antigen testing, support to vulnerable patients, and COVID-19 vaccination. We identified 9 studies conducted in pharmacies in 7 countries in Europe. Most studies are cross-sectional and/or descriptive. Pharmacy associations played an important supporting role by developing and updating guidance and emergency plans to assist community pharmacists. CONCLUSIONS: A wide array of pharmacy interventions on COVID-19 was implemented in several countries within a very short time frame. Research on pharmacy interventions on COVID-19 is still in its infancy but confirmed the wide array of interventions provided and expanded powers granted to pharmacies. These findings may provide a significant impact to improve pharmacy research, policy, and practice in response to future public health emergencies in Europe and globally.

Hypercholesterolemia and 27-Hydroxycholesterol Increase S100A8 and RAGE Expression in the Brain: a Link Between Cholesterol, Alarmins, and Neurodegeneration.

Alterations in cholesterol metabolism in the brain have a major role in the physiology of Alzheimer's disease (AD). Oxysterols are cholesterol metabolites with multiple implications in memory functions and in neurodegeneration. Previous studies have shown detrimental effects of cholesterol metabolites in neurons, but its effect in glial cells is unknown. We used a high-fat/high-cholesterol diet in mice to study the effects of hypercholesterolemia over the alarmin S100A8 cascade in the hippocampus. Using CYP27Tg, a transgenic mouse model, we show that the hypercholesterolemia influence on the brain is mediated by the excess of 27-hydroxycholesterol (27-OH), a cholesterol metabolite. We also employed an acute model of 27-OH intraventricular injection in the brain to study RAGE and S100A8 response. We used primary cultures of neurons and astrocytes to study the effect of high levels of 27-OH over the S100A8 alarmin cascade. We report that a high-fat/high-cholesterol diet leads to an increase in S100A8 production in the brain. In CYP27Tg, we report an increase of S100A8 and its receptor RAGE in the hippocampus under elevated 27-OH in the brain. Using siRNA, we found that 27-OH upregulation of RAGE in astrocytes and neurons is mediated by the nuclear receptor RXRγ. Silencing RXRγ in neurons prevented 27-OH-mediated upregulation of RAGE. These results show that S100A8 alarmin and RAGE respond to high levels of 27-OH in the brain in both neurons and astrocytes through RXRγ. Our study supports the notion that 27-OH mediates detrimental effects of hypercholesterolemia to the brain via alarmin signaling.

Characteristics of Reliever Inhaler Users and Asthma Control: A Cross-Sectional Multicenter Study in Portuguese Community Pharmacies.

PURPOSE: SABA overuse might indicate poorly managed or uncontrolled asthma and be responsible for poor health outcomes. The aim of this study integrated in new fourth multi-design SABINA+ pillar was to characterize the population using short-acting ß2-agonists for asthma and examine the patterns of its use among community pharmacy customers in Portugal, as well as identify characteristics associated with disease control and explore potential differences between GINA treatment steps. PATIENTS AND METHODS: This cross-sectional multicenter study was conducted in Portuguese community pharmacies between 29 May 2018 and 15 August 2018. Participants were adults (age ≥18 years) self-reporting asthma diagnosis recruited in the context of a short-acting ß2-agonist dispense. A two-part questionnaire (pharmacist interview and self-administered) was used to collect information about sociodemographic characteristics, comorbidities, reliever inhaler use, healthcare resource consumption and self-reported disease control (assessed by the Control of Allergic Rhinitis and Asthma Test - CARAT®). Descriptive statistics was done to characterize the study sample. After categorizing patients according to GINA steps, based on their therapeutic regimen, we performed an exploratory subgroup analysis to evaluate if there were any differences between such groups in terms of the variables collected. A logistic regression was used to identify the potential determinants of overall disease control. RESULTS: Around 50.8% of patients were male, and the average age was 52 years old. Half of the patients never smoked, and 51.9% were employed. More than half of the patients report inhaler overreliance - purchasing more than 1 pack in 3 months (65.0%) or using the inhaler on more than 8 days over the previous 4 weeks (50.2%). Of the total number of patients in the study, 79.1% had poorly controlled asthma symptoms, and 78.7% had overall poorly controlled respiratory symptoms. We found statistically significant differences between GINA treatment steps in all sociodemographic characteristics (sex, mean age, education level, employment status); maximum number of SABA uses in 24h, CARAT score (total an asthma sub-score); history of exacerbations requiring ED visits or treatment with OCS for at least 3 days in the previous 12 months. Logistic regression revealed that patients reporting SABA use in more than 8 days in the previous 4 weeks and patients with at least 1 exacerbation requiring treatment with OCS for at least 3 days in the previous 12 months have greater odds of poor disease control [adjusted OR (95% CI): 2.6 (1.3-5.2) and 3.0 (1.3-6.6)]. CONCLUSION: Based on the results of this study, it can be inferred that the asthma population using SABA is largely uncontrolled and uses reliever inhalers excessively.

Effectiveness of a pharmacist-led intervention on inhalation technique for asthma and COPD patients: The INSPIRA pilot cluster-randomized controlled trial.

INTRODUCTION: Asthma and COPD are leading causes of disability-adjusted life-years worldwide representing a huge burden on the health system and among patients. One of the reasons for the lack of disease control is poor inhalation technique, with impact on quality of life and symptom control. OBJECTIVE: To assess the effectiveness of a community pharmacist-led educational intervention on asthma and COPD patients' inhalation technique. METHODS: The INspira study is a 6-month pilot cluster randomized controlled trial, conducted in community pharmacies of Portugal, enrolling adults aged 18 years or older, with a self-reported diagnosis of asthma or COPD and on inhaled therapy. Pharmacies were randomly allocated to Intervention or Control group. Intervention focused mainly on inhalation technique education via demonstration and repetition. Primary outcome was the proportion of patients scoring 100% in at least one inhaler. RESULTS: From January to November 2019, 48 pharmacies recruited 201 asthma and COPD patients, of which 132 completed the 6-month follow-up. At the end of follow-up, the odds of intervention group patients score 100% compared to the control group were 5.63 (95% CI, [2.21; 14.35]) in all inhalers in use and 6.77 (95% CI, [2.52; 18.20]) considering at least one inhaler. Intervention group patients reported having a significantly lower number of scheduled appointments compared with the control group (OR = 0.17; 95% CI, [0.037; 0.79]; p = 0.0135). No other significant differences were found between groups. CONCLUSION: This pilot study suggested that pharmacist interventions can improve patients' inhalation technique, with possible positive impact in healthcare resource use.

Targeting S100B with Peptides Encoding Intrinsic Aggregation-Prone Sequence Segments.

S100 proteins assume a diversity of oligomeric states including large order self-assemblies, with an impact on protein structure and function. Previous work has uncovered that S100 proteins, including S100B, are prone to undergo ß-aggregation under destabilizing conditions. This propensity is encoded in aggregation-prone regions (APR) mainly located in segments at the homodimer interface, and which are therefore mostly shielded from the solvent and from deleterious interactions, under native conditions. As in other systems, this characteristic may be used to develop peptides with pharmacological potential that selectively induce the aggregation of S100B through homotypic interactions with its APRs, resulting in functional inhibition through a loss of function. Here we report initial studies towards this goal. We applied the TANGO algorithm to identify specific APR segments in S100B helix IV and used this information to design and synthesize S100B-derived APR peptides. We then combined fluorescence spectroscopy, transmission electron microscopy, biolayer interferometry, and aggregation kinetics and determined that the synthetic peptides have strong aggregation propensity, interact with S100B, and may promote co-aggregation reactions. In this framework, we discuss the considerable potential of such APR-derived peptides to act pharmacologically over S100B in numerous physiological and pathological conditions, for instance as modifiers of the S100B interactome or as promoters of S100B inactivation by selective aggregation.

Who are the ostomy patients and caregivers attending Portuguese community pharmacies? A cross-sectional study.

BACKGROUND: In 2017, ostomy patients gained access to ostomy products in community pharmacies that are fully reimbursed by the Portuguese National Health Service. This impacted the daily lives of people with ostomy and opened a new market of products and services for pharmacies. However, little is known about the sociodemographic and clinical profile of ostomy patients. This study aims to characterize people with ostomy and their caregivers, evaluate access and satisfaction with the pharmacy and explore participants' expectations regarding services and counselling. METHODS: This was an observational, cross-sectional, multicentre study involving pharmacy users who acquired ostomy products in Portuguese community pharmacies. Data were collected through a confidential self-report questionnaire between June and August 2019. RESULTS: Approximately 56% of the participants were ostomy patients, of whom 65.9% were men. The average age of participating ostomy patients was 65.5 years old (SD = 12.9), and near 80% were retired/pensioners. Caregivers were mostly women (81.7%). More than half of the caregivers were employed and acquired products for a direct family member. Three in every four surgical interventions were consequences of cancer. Intestinal ostomy was the most common intervention (78.3%). More than 93% were satisfied with the acquisition of ostomy products at the pharmacy. Approximately 48.2% of ostomy patients received care from a specialized nurse. CONCLUSION: This study describes the profile of people with ostomy and their caregivers who attend community pharmacies in Portugal. Participants' perceptions of the utility of different proposed services and pharmacist knowledge, as well as the low coverage of ostomy nursing care, highlight the opportunity for an extended role of pharmacists among this group.

Distribution and Relative Abundance of S100 Proteins in the Brain of the APP23 Alzheimer's Disease Model Mice.

Increasing evidence links proteins of the S100 family to the pathogenesis of Alzheimer's disease (AD). S100 proteins are EF-hand calcium-binding proteins with intra- and extracellular functions related to regulation of proliferation, differentiation, apoptosis, and trace metal homeostasis, and are important modulators of inflammatory responses. For example, S100A6, S100A8, and S100B expression levels were found increased in inflammatory diseases, but also neurodegenerative disorders, and S100A8/A9 complexes may provide a mechanistic link between amyloid-beta (Aß) plaque formation and neuroinflammation. On the other hand, S100B, a proinflammatory protein that is chronically up-regulated in AD and whose elevation precedes plaque formation, was recently shown to suppress Aß aggregation. Here, we report expression of S100A6 and S100B in astrocytes and less so in neurons, and low level of expression of S100A8 in both neurons and glial cells in vitro. In vivo, S100A8 expression is almost absent in the brain of aged wildtype mice, while S100A6 and S100B are expressed in all brain regions and most prominently in the cortex and cerebellum. S100B seems to be enriched in Purkinje cells of the cerebellum. In contrast, in the brain of APP23 mice, a mouse model for Alzheimer's disease, S100B, S100A6, and S100A8 show co-localization with Aß plaques, compatible with astrocyte activation, and the expression level of S100A8 is increased in neural cells. While S100A6 and S100B are enriched in the periphery of plaques where less fibrillar Aß is found, S100A8 is more intense within the center of the inclusion. In vitro assays show that, similarly to S100B, S100A6, and S100A8 also delay Aß aggregation suggesting a regulatory action over protein aggregation. We posit that elevated expression levels and overlapping spatial distribution of brain S100 proteins and plaques translates functional relationships between these inflammatory mediators and AD pathophysiology processes that uncover important molecular mechanisms linking the aggregation and neuroinflammation cascades.

Endogenous and Uric Acid-Induced Activation of NLRP3 Inflammasome in Pregnant Women with Preeclampsia.

Preeclampsia (PE) is a specific syndrome of pregnancy, characterized by hypertension and proteinuria. This pathology is associated with hyperuricemia and elevated serum levels of inflammatory cytokines. Uric acid crystals may activate an intracellular complex called inflammasome, which is important for processing and release of inflammatory cytokines. This study investigated the state of monocyte activation, both endogenous and stimulated with monosodium urate (MSU), by gene expression of NLRP1 and NLRP3 receptors as well as their association with inflammatory cytokines expression. Monocytes were obtained from peripheral blood of 23 preeclamptic pregnant women, 23 normotensive pregnant women (NT) and 23 healthy non-pregnant women (NP). Inflammasome activation was evaluated by the gene expression of NLRP1, NLRP3, caspase-1, IL-1ß, IL-18 and TNF-α by RT-qPCR in unstimulated monocytes (endogenous expression), or after cell stimulation with MSU (stimulated expression). The concentration of cytokines was assessed by ELISA. In preeclamptic pregnant women, gene expression of NLRP1, NLRP3, caspase-1, IL-1ß and TNF-α by monocytes stimulated or not with MSU was significantly higher than in NT and NP groups. Stimulation of monocytes from preeclamptic and non-pregnant women with MSU induced increased gene expression of NLRP3, caspase-1 and TNF-α in relation to the endogenous expression in these groups, while this was not observed in the NT group. The cytokine determination showed that monocytes from women with PE produced higher endogenous levels of IL-1ß, IL-18 and TNF-α compared to the other groups, while the stimulus with MSU led to higher production of these cytokines in preeclamptic group than in the NT group. In conclusion, the results showed increased basal gene expression of NLRP1 and NLRP3 receptors in monocytes from PE group. These cells stimulation with MSU demonstrates that uric acid plays a role in NLRP3 inflammasome activation, suggesting the participation of this inflammatory complex in the pathogenesis of preeclampsia.

Monocytes from pregnant women with pre-eclampsia are polarized to a M1 phenotype.

PROBLEM: This study evaluated whether the monocyte inflammatory state in pre-eclampsia (PE) might be associated with polarization to either M1 classically or M2 alternatively activated monocyte subsets. METHOD OF STUDY: Eighty-five women with (PE) and 52 normotensive (NT) pregnant women matched for gestational age were included. Expression of surface receptors characteristic of M1, such as Toll-like receptor (TLR)2, TLR4, and CD64, or M2, such as CD163 and CD206 monocyte subsets were evaluated in peripheral blood monocytes by flow cytometry. Tumour necrosis factor-alpha (TNF-α), interleukin-(IL)-12p40, IL-12p70, and IL-10 were evaluated in the supernatant of monocyte cultures by ELISA. RESULTS: Expression of TLR4 and CD64 by monocytes from pre-eclamptic women was significantly higher, while the expression of CD163 and CD206 expression was significantly lower compared with NT pregnant women. Endogenous production of TNF-α, IL-12p40, and IL-12p70 by monocytes was increased, while synthesis of IL-10 was lower in women with PE than in NT pregnant women. CONCLUSIONS: Monocytes from women with PE are classically activated, producing higher levels of pro-inflammatory cytokines, and express surface receptors characteristic of the M1 subset. These results provide evidence that the systemic inflammatory environment in PE may differentiate and polarize these cells to the M1 phenotype.

Elevated hyaluronan and extracellular matrix metalloproteinase inducer levels in women with preeclampsia.

PURPOSE: Preeclampsia (PE) is a specific syndrome of pregnancy clinically identified by hypertension and proteinuria from the 20th week of gestation associated with a systemic inflammatory response and oxidative stress. While pro-inflammatory cytokines have been extensively studied in PE, other factors in the circulation that also influence the magnitude of inflammation have received much less attention. The present study compared serum concentrations of five immune-regulatory compounds in normotensive pregnant women and in women with gestational hypertension (GH) or PE. METHODS: Sixty women with PE, 53 with GH and 40 normotensive women paired by gestational age were evaluated. Sera were evaluated for concentrations of extracellular matrix metalloproteinase inducer (EMMPRIN), hyaluronan, gelsolin, visfatin and histone 2B by ELISA. Differences between groups were analyzed by nonparametric tests, with a significance level of 5%. RESULTS: Increased levels of EMMPRIN and hyaluronan were present in preeclamptic women as compared to the GH and normotensive groups. There was no difference between groups in gelsolin, visfatin or histone 2B. CONCLUSION: Increased release of EMMPRIN and hyaluronan may contribute to an elevated pro-inflammatory response and tissue damage in women with PE.

High levels of heat shock protein 70 are associated with pro-inflammatory cytokines and may differentiate early- from late-onset preeclampsia.

Preeclampsia (PE), a specific syndrome of pregnancy, can be classified into early and late onset, depending on whether clinical manifestations occur before or after 34 weeks' gestation. We determined whether plasma concentrations of Hsp60 and Hsp70 were related to circulating cytokine levels, as well as kidney and liver functions, in early- and late-onset PE. Two hundred and thirty-seven preeclamptic women (95 with early- and 142 with late-onset PE) were evaluated. Plasma levels of Hsp60, Hsp70, and their specific antibodies, tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1, IL-10, IL-12, and soluble TNF-α-receptor I (sTNFRI) concentrations, were determined by enzyme-linked immunosorbent assay (ELISA). Concentrations of Hsp70, TNF-α, IL-1ß, IL-12, and sTNFRI were significantly elevated in patients with early-onset PE compared with women with late-onset PE; IL-10 levels were significantly lower in the early-onset PE group. Concentrations of urea, uric acid, proteinuria, glutamic oxaloacetic transaminase (GOT), glutamic pyruvic transaminase (GPT), and lactate dehydrogenase (LDH) were also significantly higher in early-onset PE. The percentage of infants with intrauterine growth restriction was also significantly higher in women with early-onset PE. There were positive correlations between Hsp70 levels and TNF-α, TNFRI, IL-1ß, IL-12, GOT, GPT, LDH, and uric acid concentrations in early-onset PE group. Thus, early-onset PE was associated with greater maternal and fetal impairment. There are differences in pathophysiology between early- and late-onset PE, highlighting by the difference in Hsp70 levels.

Hepatoprotective and anti-inflammatory effects of silibinin on experimental preeclampsia induced by L-NAME in rats.

AIMS: Inhibition of nitric oxide synthase with N-omega-nitro-l-arginine methyl ester (l-NAME) has been employed as an experimental model of human preeclampsia. This study determined the protective effect of silibinin, a flavonoid with anti-inflammatory and hepatoprotective properties on the deleterious effects observed in experimentally induced preeclampsia in rats. MAIN METHODS: Pregnant Wistar rats were treated during gestation (days 10-20) with l-NAME (70-80mg/kg/day) in drinking water or with l-NAME plus silibinin (100mg/kg/day, orally) starting at day 0, day 7 or day 14 of pregnancy. Systolic blood pressure was recorded from gestation days 0 to 21. A control group of pregnant non-treated rats was analyzed similarly. On day 21 the rats were euthanized and the following parameters were evaluated: proteinuria, platelet count, liver histopathology and reproductive outcome. Tumor necrosis factor-alpha (TNF-α), interleukin-1 (IL-1ß), IL-6, IL-10 and interferon-gamma (IFN-γ) were determined in liver homogenate by enzyme immunoassay. KEY FINDINGS: In comparison with the l-NAME group the silibinin treatment reduced the values of systolic blood pressure, proteinuria, TNF-α, IL-1ß and IFN-γ in liver, normalized the platelet count and improved fetal outcomes. Histopathological lesions in liver of the l-NAME group showed intense mononuclear inflammatory infiltrate and thickening of muscle tunica of arterial vessel, mainly in the periportal area. Silibinin treatment induced attenuation of periportal inflammatory infiltrate, showing an association between inflammatory infiltrate and TNF-α, IL-1ß and IFN-γ levels in liver homogenate. SIGNIFICANCE: Silibinin administration to l-NAME-treated rats displays anti-inflammatory and immunomodulatory actions that may contribute to its hepatoprotective effects and improve reproductive outcomes in experimental preeclampsia.

Vitamin D deficiency and insufficiency in patients with chronic kidney disease.

INTRODUCTION: Vitamin D deficiency is common among patients with chronic kidney disease (CKD). A higher level of serum vitamin D is expected in residents of the tropics in relation to inhabitants of non-tropical regions, due to greater sun exposure and increased production of vitamin D. OBJECTIVE: To analyze serum levels of vitamin D, such as 25-hydroxyvitamin D - 25(OH)D, in Brazilian patients at the predialytic stage with CKD. METHODS: We studied 125 patients (aged 57.4 ± 16.2 years, 78 were white and 55.2%, male), with creatinine 2.67 ± 1.73 mg/dL and creatinine clearance 43.7 ± 34.5 mL/min. Body mass index was 27.4 ± 4.7 kg/m², and waist circumference was 95.0 ± 14.0 cm. Calcium was 9.3 ± 0.6 mg/dL, intact parathormone (iPTH) 212.6 ± 221.2 pg/mL and serum albumin 4.2 ± 0.6 g/dL. The mean 25(OH)D was 23.9 ± 10.7 ng/mL. RESULTS: Out of the 125 patients, we found that 92 (72.6%) had suboptimal levels of 25(OH)D < 30 ng/mL, and 65 (52%) had vitamin D insufficiency (15-29 ng/mL); 27 (21.5%) had deficiency (5-14 ng/mL) and only one patient had severe vitamin D deficiency <5 ng/mL. No differences were observed among the levels of 25 (H)D in stratified patients as to the CKD stage. Levels of 25(OH)D were higher among males (38.1 ± 20.6 versus 22.4 ± 9.7 ng/mL; p < 0.0001), and there was an inverse correlation between levels 25(OH)D and iPTH, proteinuria and abdominal circumference, and a positive correlation between 25(OH)D and calcium and serum albumin. Multivariate analysis only showed inverse correlation between serum 25(OH)D and iPTH and abdominal circumference. CONCLUSION: Even though the Brazilian population live in a tropical region, most patients had suboptimal levels of serum vitamin D, and this pattern may play a role in the development of hyperparathyroidism.

Insuficiência e deficiência de vitamina D em pacientes portadores de doença renal crônica / Vitamin D deficiency and insufficiency in patients with chronic kidney disease

INTRODUÇÃO: Hipovitaminose D é bem documentada em pacientes portadores de doença renal crônica (DRC). Espera-se níveis inferiores em habitantes de regiões não tropicais em relação aos habitantes de regiões tropicais, pela inferição de uma maior exposição solar e maior produção de vitamina D. OBJETIVO: Analisar os níveis séricos de vitamina D, como 25-hidroxivitamina D - 25(OH)D, de 125 pacientes brasileiros portadores de DRC em fase pré-dialítica. MÉTODOS: Foram estudados 125 pacientes (57,4 ± 16,2 anos, 78 brancos e 55,2% homens), com creatinina de 2,67 ± 1,73 mg/dL e o clearance estimado 43,7 ± 34,5 mL/min. O índice de massa corporal era de 27,4 ± 4,7 kg/m² e a circunferência abdominal de 95,0 ± 14,0 cm. O cálcio era de 9,3 ± 0,6 mg/dL, o paratormônio intacto (PTHi) 212,6 ± 221,2 pg/mL e a albumina sérica 4,2 ± 0,6 g/dL. A média de 25(OH)D era de 23,9 ± 10,7 ng/mL. RESULTADOS: Dos 125 pacientes, 92 (72,6%) apresentavam níveis de 25(OH)D < 30 ng/mL, sendo que 65 (52%) apresentavam insuficiência (15-29 ng/mL); 27 (21,5%) apresentavam deficiência (5-14 ng/mL) e apenas um paciente apresentava deficiência severa < 5 ng/mL. Não foram observadas diferenças entre os níveis de 25(OH)D nos pacientes estratificados quanto ao estágio de DRC. Os níveis de 25(OH)D foram maiores nos homens (38,1 ± 20,6 versus 22,4 ± 9,7 ng/ml; p < 0,0001), havendo também uma correlação inversa entre os níveis de 25(OH)D e de PTHi, proteinúria e circunferência abdominal, e uma correlação positiva entre 25(OH)D e cálcio total e albumina sérica. Na análise multivariada, encontrou-se apenas correlação inversa entre 25(OH)D e circunferência abdominal e PTHi. CONCLUSÃO: A despeito de a população do Brasil estar em um clima tropical, a maioria dos pacientes analisados apresentou níveis séricos subótimos de vitamina D, podendo este achado estar relacionado ao desenvolvimento de hiperparatireoidismo.

INTRODUCTION: Vitamin D deficiency is common among patients with chronic kidney disease (CKD). A higher level of serum vitamin D is expected in residents of the tropics in relation to inhabitants of non-tropical regions, due to greater sun exposure and increased production of vitamin D. OBJECTIVE: To analyze serum levels of vitamin D, such as 25-hydroxyvitamin D - 25(OH)D, in Brazilian patients at the predialytic stage with CKD. METHODS: We studied 125 patients (aged 57.4 ± 16.2 years, 78 were white and 55.2%, male), with creatinine 2.67 ± 1.73 mg/dL and creatinine clearance 43.7 ± 34.5 mL/min. Body mass index was 27.4 ± 4.7 kg/m², and waist circumference was 95.0 ± 14.0 cm. Calcium was 9.3 ± 0.6 mg/dL, intact parathormone (iPTH) 212.6 ± 221.2 pg/mL and serum albumin 4.2 ± 0.6 g/dL. The mean 25(OH)D was 23.9 ± 10.7 ng/mL. RESULTS: Out of the 125 patients, we found that 92 (72.6%) had suboptimal levels of 25(OH)D < 30 ng/mL, and 65 (52%) had vitamin D insufficiency (15-29 ng/mL); 27 (21.5%) had deficiency (5-14 ng/mL) and only one patient had severe vitamin D deficiency <5 ng/mL. No differences were observed among the levels of 25 (H)D in stratified patients as to the CKD stage. Levels of 25(OH)D were higher among males (38.1 ± 20.6 versus 22.4 ± 9.7 ng/mL; p < 0.0001), and there was an inverse correlation between levels 25(OH)D and iPTH, proteinuria and abdominal circumference, and a positive correlation between 25(OH)D and calcium and serum albumin. Multivariate analysis only showed inverse correlation between serum 25(OH)D and iPTH and abdominal circumference. CONCLUSION: Even though the Brazilian population live in a tropical region, most patients had suboptimal levels of serum vitamin D, and this pattern may play a role in the development of hyperparathyroidism.

Downregulation of nuclear factor-kappa B (NF-kappaB) pathway by silibinin in human monocytes challenged with Paracoccidioides brasiliensis.

AIMS: Silibinin is the major active component of silymarin, a polyphenolic plant flavonoid that has anti-inflammatory effects. The modulatory effect of silibinin on monocyte function against Paracoccidioides brasiliensis (Pb18) has not yet been demonstrated. The present study investigated whether the effect of silibinin on nuclear factor-kappa B (NF-kappaB) pathways may affect the production of tumor necrosis factor-alpha (TNF-alpha), interleukin-10 (IL-10), transforming growth factor beta (TGF-beta1), prostaglandin E(2) (PGE(2)), nitric oxide (NO) and fungicidal activity of human monocytes challenged in vitro with Pb18. MAIN METHODS: Peripheral blood monocytes from healthy individuals were treated with silibinin and challenged with Pb18 for 18h. TNF-alpha, IL-10, TGF-beta1 and PGE(2) expression were determined by immunoenzymatic assay (ELISA) and NO release was determined by the accumulation of nitrite in culture supernatants. Fungicidal activity of monocytes was analyzed after treatment with interferon-gamma plus silibinin and challenge with Pb18. NF-kappaB activation in cultured monocytes was evaluated by flow cytometry and ELISA. KEY FINDINGS: Silibinin partially inhibited p65NF-kappaB activation as the number of cells expressing this factor was reduced and the concentration of nuclear p65NF-kappaB was low, compared to untreated controls. The addition of silibinin also resulted in suppression of TNF-alpha, IL-10, TGF-beta1, PGE(2) and NO production but did not affect the fungicidal activity of monocytes against Pb18. SIGNIFICANCE: Silibinin exerts anti-inflammatory and anti-fibrotic effects on CD14+/- human monocytes challenged by Pb18 by partial inhibition of p65NF-kappaB activation.