Reducing carbon footprint of inhalers: analysis of climate and clinical implications of different scenarios in five European countries.

BACKGROUND: Inhaled therapies are key components of asthma and chronic obstructive pulmonary disease (COPD) treatments. Although the use of pressurised metered-dose inhalers (pMDIs) accounts for <0.1% of global greenhouse gas emissions, their contribution to global warming has been debated and efforts are underway to reduce the carbon footprint of pMDIs. Our aim was to establish the extent to which different scenarios led to reductions in greenhouse gas emissions associated with inhaler use, and their clinical implications. METHODS: We conducted a series of scenario analyses using asthma and COPD inhaler usage data from 2019 to model carbon dioxide equivalent (CO2e) emissions reductions over a 10-year period (2020-2030) in the UK, Italy, France, Germany and Spain: switching propellant-driven pMDIs for propellant-free dry-powder inhalers (DPIs)/soft mist inhalers (SMIs); transitioning to low global warming potential (GWP) propellant (hydrofluoroalkane (HFA)-152a) pMDIs; reducing short-acting ß2-agonist (SABA) use; and inhaler recycling. RESULTS: Transition to low-GWP pMDIs and forced switching to DPI/SMIs (excluding SABA inhalers) would reduce annual CO2e emissions by 68%-84% and 64%-71%, respectively, but with different clinical implications. Emission reductions would be greatest (82%-89%) with transition of both maintenance and SABA inhalers to low-GWP propellant. Only minimising SABA inhaler use would reduce CO2e emissions by 17%-48%. Although significant greenhouse gas emission reductions would be achieved with high rates of end-of-life recycling (81%-87% of the inhalers), transition to a low-GWP propellant would still result in greater reductions. CONCLUSIONS: While the absolute contribution of pMDIs to global warming is very small, substantial reductions in the carbon footprint of pMDIs can be achieved with transition to low-GWP propellant (HFA-152a) inhalers. This approach outperforms the substitution of pMDIs with DPI/SMIs while preserving patient access and choice, which are essential for optimising treatment and outcomes. These findings require confirmation in independent studies.

Impact of Religion on Opinions About Organ Donation and Transplantation in University Students From a Single University in Turkey.

OBJECTIVES: The objective of the present report was to analyze the opinions, attitudes, and practices of Baskent University students with regard to the impact of religion on organ donation and transplantation. MATERIALS AND METHODS: We sent a web-based, 5-point Likert scale questionnaire (1: strongly disagree; 5: strongly agree) to capture the opinions and attitudes toward organ donation and transplantation after participants attended or did not a panel discussion on these topics. RESULTS: We sent 361 E-mails and received 69 responses, of which 46 students attended the panel discussion. Most of the participants who attended were part of the faculty of medicine. Participants who did not attend were composed of students from other faculties at Baskent University. Religion played less of a role with regard to opinions on organ donation in those who did not attend. Of the attendees, 54.3% strongly agreed to become organ donors, 50% believed in the important role of religion in organ donation, and 54.3% believed that media sources play important roles in shaping public opinion on organ donation. The majority felt comfortable discussing organ donation with family and friends. CONCLUSIONS: Although religion has an undeniable effect on the decision-making process, our survey showed that more than half of the participants were willing to become organ donors. Education, through the joint efforts of medical and religious scholars, as well as the media, should contribute to raising awareness on organ donation, thus contributing to increased access to transplantation worldwide.

The role of antioxidant vitamins and selenium in patients with obstructive sleep apnea.

PURPOSE: Obstructive sleep apnea (OSA) is a disorder characterized by recurrent episodes of obstruction of the upper respiratory tract during sleep often accompanied by oxygen desaturations. Antioxidant defense mechanisms are important to prevent OSA-associated diseases and decrease mortality. We aimed to determine the levels of selenium and vitamins A, C, and E in patients with OSA but without any comorbidities and compare the results with a control group, theorizing that the findings may be helpful to understand the antioxidant mechanisms in the pathogenesis of OSA and associated diseases. METHODS: We designed a case-control study with 146 subjects. Subjects were categorized into four groups by apnea-hypopnea index (AHI) scores: control (n = 32; AHI < 5), mild OSA (n = 32; 5 ≤ AHI < 15), moderate OSA (n = 34; 15 ≤ AHI < 30), and severe OSA (n = 48; AHI ≥ 30) groups. Serum levels of selenium were measured by atomic absorption spectrometer. Vitamin A, C, and E levels were measured by high-performance liquid chromatography and ultraviolet (HPLC-UV) detector. RESULTS: After adjusting for age, BMI, and gender, serum selenium and vitamin A levels were found to be higher in patients with OSA compared with controls (ANCOVA, p < 0.008, and p = 0.014 respectively), and levels of these markers increased with the severity of the disease. AHI was positively correlated with selenium (r = 0.289; p < 0.001), and vitamin A levels (r = 0.276; p < 0.001). CONCLUSION: These results demonstrated that antioxidant response with increased vitamin A, and selenium concentrations, may be important defense mechanisms in patients with OSA patients who do not have other comorbidities. Antioxidant nutrients or supplements may be implemented as a complementary treatment of OSA to support antioxidant defense.

Obstructive sleep apnea syndrome in patients with chronic idiopathic urticaria.

Urticaria is a disease which progresses with itchy papules and plaques called urtica, obstructive sleep apnea syndrome (OSAS) is defined as daytime sleepiness and obstructive apnea and hypopnea attacks during sleep. In this study, we aimed to investigate the relationship between urticaria and OSAS. Thirty-one patients with chronic idiopathic urticaria were included in the study. Body mass indexes (BMIs) were calculated and polysomnography findings were recorded. Epworth Sleepiness Scale and Pittsburgh Sleep Quality Index were used to evaluate daytime sleepiness. The prevalence and severity of urticaria were calculated using the urticaria activity score (UAS). Chronic Urticaria Quality of Life Questionnaire was applied to patients. OSAS was detected in 13 (41.9%) of 31 patients. Then, 11 of the 13 patients had mild, 1 had moderate, and 1 had severe OSAS in the patient group. OSAS was not detected in the control group. A positive correlation was found between apnea-hypopnea index and BMI, the UAS scores in the patient group (respectively, r = .537, P = .002, r = .407, P = .023). In this study, we found that the frequency of OSAS in patients with urticaria was more than that in the normal population. Doctors treating urticaria should consider a comorbidity disease such as OSAS and regulate the treatment according to these two diseases.

The effect of FOXO gene family variants and global DNA metylation on RRMS disease.

Multiple sclerosis is a chronic disease that usually occurs with exacerbations and remissions in young adults, affects the central nervous system white matter in multiple localization, and is thought to be the result of complex interactions of genetic and environmental factors, the most common form is relapsing-remitting MS. Forkhead transcription factors O class (FOXO) are responsible for the regulation of various cellular processes including cell cycle, apoptosis, DNA repair, cellular resistance and metabolism. DNA methylation is such an epigenetic change and has been shown to be associated with almost any biological process. The aim of our study to show the relation between the genetic variants of FOXO3a (rs2253310 rs4966936) and FOXO1 (rs3900833, rs4581585) and global DNA methylation in RRMS. We analyzed DNA obtained from 79 RRMS patients and 104 healthy individuals by PCR-RFLP method for the detection of genetic variants. For the determination of global DNA methylation, results were obtained using ELISA method. The data were evaluated statistically. As a result of our analysis; global DNA methylation is higher in RRMS patients compared to control individuals and it can be effective on the disease. In addition, it has been determined that variants of FOXO3a (rs2253310, rs4966936) and FOXO1 (rs3900833), which have been genotyped, may be effective in disease pathogenesis. These results suggest that DNAmethylation and FOXO gene variants may be effective in neuronal loss in RRMS.

The association of low levels of nesfatin-1 and glucagon-like peptide-1 with oxidative stress in Parkinson's disease.

AIM: In Parkinson's disease (PD), oxidative stress plays a substantial role in degeneration of dopaminergic neurons at the substantia nigra. Recent reports describe nesfatin-1 and glucagon-like peptide-1 (GLP-1) as molecules with neuroprotective property that relieve oxidative stress. In this study, we aimed to determine the blood levels of nesfatin-1, GLP-1 and oxidative stress status in patients with PD. MATERIAL AND METHOD: Forty patients with PD, followed-up at the Department of Neurology of Mugla Sitki Kocman University Training and Research Hospital, were enrolled, as well as 40 age- and sex-matched participants as a control group. We determined and compared nesfatin-1, GLP-1, total antioxidant status (TAS), and total oxidant status (TOS) levels in patients with PD and control group. RESULTS: The mean GLP-1 and nesfatin-1 values of patients with PD were lower than those of the control group, whereas their mean TOS value was higher. The mean TAS values, on the other hand, did not reveal any significant difference between the patient and the control groups. CONCLUSION: The lower nesfatin-1 and GLP-1 levels, in addition to higher TOS levels, in patients with PD compared to those of control group suggest that the neuroprotective effects of these molecules might be related to the oxidative processes. Further studies are required to search for the impact of abovenamed molecules on the treatment option and the likelihood that they may slow down disease progression.

The methylation status of NKCC1 and KCC2 in the patients with refractory temporal lobe epilepsy.

BACKGROUND AND PURPOSE: Methylation is a key epigenetic modification of DNA and regarding its impact on epilepsy, it is argued that "DNA methylation may play an important role in seizure susceptibility and maintenance of the disorder". DNA methylation status of KCC2 (SCL12A5) and NKCC1 (SCL12A2) associated with refractory temporal lobe epilepsy was investigated in our study. METHODS: Thirty-eight patients with temporal lobe epilepsy (TLE) who were diagnosed by video EEG monitoring and 32 healthy control subjects were included in the study. Twenty-three patients in TLE group were men and the remaining 15 were women. Among them, 27 had unilateral temporal focus (9 with right; 18 with left) and 11 patients had bilateral TLE. We analyzed promoter region methylation status of the KCC2 (SCL12A5) and NKCC1 (SCL12A2) genes in the case and control groups. Gene regions of interest were amplified through PCR and sequencing was accomplished with pyro-sequencing. RESULTS: We found a significant relationship between TLE and methylation on the NKCC1. However, there was no association between TLE and methylation on the KCC2 gene. Also, we found no association between right or left and unilateral or bilateral foci of TLE. There was no relationship between TLE and methylation on the NKCC1and KCC2 genes in terms of mesial temporal sclerosis in cranial MRI, head trauma or febrile convulsions. CONCLUSION: The methylation of NKCC1 can be a mecha-nism of refractory temporal lobe epilepsy. There are limited findings about DNA methylation in TLE. Therefore, further studies with large sample sizes are necessary.

Methylation of cation-chloride cotransporters NKCC1 and KCC2 in patients with juvenile myoclonic epilepsy.

The etiology of juvenile myoclonic epilepsy (JME) is still unknown and the process of elaboration of multiple genetic mechanisms is ongoing. The aim of this study was to investigate the potential role of NKCC1 (SCL12A2) and KCC2 (SCL12A5) in JME by comparing their DNA methylation status in patients with JME versus healthy controls. Forty-nine patients with JME and 39 healthy individuals were compared for DNA methylation at the 5CpG islands. A total of 71 (81%) samples were found to have methylation in the NKCC1 gene, 36 (73%) from patients and 35 (90%) from healthy individuals. Out of the KCC2 samples, 50 (57%) were found to have methylation, 33 (67%) from patients and 17 (44%) from healthy individuals. In patients with JME, methylation of NKCC1 (73%) was lower than its methylation in the controls (90%) (p = 0.047). On the other hand, methylation of KCC2 in patients with JME (67%) was greater than the methylation in the controls (44%) (p = 0.022). Twenty-eight patients were treated with VPA and ongoing medications were not found to be associated with methylation (p > 0.05). In the present study, we determined significantly lower NKCC1 DNA methylation and significantly higher KCC2 DNA methylation levels in patients with JME compared with the healthy controls. This implies that NKCC1 expression can be higher and KCC2 expression can be reduced in affected people. Further studies that investigate the potential effect of DNA methylation mechanisms regulating gene expression on seizure activity and how they change JME network activity will be helpful.

Association between obstructive sleep apnea syndrome and waist-to-height ratio.

PURPOSE: Obesity is among the known risk factors for obstructive sleep apnea syndrome (OSAS). In this study, our aim was to investigate the correlation of waist-to-height ratio, an indicator of central obesity, with presence and severity of OSAS; to compare the use of this ratio with the use of waist circumference and body mass index (BMI); and to determine OSAS-related cutoff values. METHODS: The patient records were retrospectively analyzed for whom a polysomnography was conducted at our sleep. Sex, age, Apnea-Hypopnea Index (AHI), waist circumference, height, and BMI values of those patients were recorded. AHI scores were used to classify severity of OSAS. RESULTS: The study included 437 OSAS patients and 72 control cases. Out of the patient group, OSAS was severe in 208 (47%) patients, moderate in 124 (28%), and mild in 105 (24%) of them. In the group of OSAS patients, waist-to-height ratio, waist circumference, and BMI were higher compared to the control group with a further difference of all three parameters among severe, moderate, mild OSAS, and controls both in males and females. Cutoff values for OSAS of females were 95.5 cm for waist circumference, 0.595 for waist-to-height ratio, and 27.75 for BMI whereas the cutoff values of males were 100.5 cm, 0.575, and 27.75, respectively. CONCLUSIONS: A high value of waist circumference, waist-to-height ratio, and BMI is associated with the presence and severity of OSAS. We have determined the cutoff values of the studied anthropometric measurements in both sexes for OSAS and severe OSAS.

Do mentalization skills affect the perception of stigma in patients with epilepsy?

PURPOSE: We aimed to study the relationship between the mentalizing ability and stigma in patients with epilepsy. METHODS: Patients with epilepsy were administered the following battery of tests: Mini-International Neuropsychiatric Interview (MINI) form, Reading the Mind in the Eyes Test (Eyes Test), Stigma Scale of Epilepsy (SSE), Internalized Stigma of Mental Illness (ISMI) Scale, Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). RESULTS: Assessment of an association between the Eyes Test score, ISMI Scale total score, and subscale scores revealed a negative significant correlation of Eyes Test scores with approval of stereotypes, perceived discrimination, stigma resistance, and total score. Eyes Test score and BDI scores appears to be significant predictor of internalized stigma among the clinical variables that were studied. A positive significant correlation was detected between BDI score and alienation, perceived discrimination, and total score. CONCLUSION: The presence of a correlation between the mentalization and stigma perception in our study demonstrates that these two concepts are connected and that this connection needs further study. In particular, mentalization-based therapy can have an effect on the reduction of the stigma perceptions and in this way can improve the course of the disease, potentially improving the patients' quality of life.

The Evaluation Acute Traumatic Stress Level in Close Relatives of Stroke Patients.

OBJECTIVE: Stroke is the second most common cause of death and the leading cause of adult disability. Both stroke patients and their family can therefore experience increased traumatic stress level. METHODS: The participants are close relatives of patients (n=65) who had a first time stroke (CRPWS) hospitalized. A control group (CG) (n=61), who had no history of chronic illness in their family and had at least one traumatic life event experience. The National Institutes of Health Stroke Scale, Modified Rankin Scale, Personal Information Form, Life Events Checklist, Traumatic Stress Symptom Scale, and Multidimensional Scale of Perceived Social Support, were used in the study. RESULTS: We found no significant association between NIHSS and MRS of patients and traumatic stress level of the family member. The traumatic stress level was significantly higher in the CRPWS group than in the CG group. Traumatic stress level was higher in women than men and was not associated with perceived social support in the CRPWS group. CONCLUSION: The traumatic stress level of the relatives was not associated with the clinical features of the stroke patients. In the early phase, after the diagnosis of stroke, psychological support may be important to prevent CRPWS from PTSD.

The frequency of buccopalpebral reflex in Parkinson disease.

BACKGROUND/AIM: This study aimed to define the frequency of a primitive reflex, the buccopalpebral reflex (BPR), and its association with the clinical situation in patients with Parkinson disease. MATERIALS AND METHODS: Between May 2010 and May 2011, 222 patients, 115 with Parkinson disease and 107 patients without any sign of neurodegenerative disease, were included in the study. All included patients were examined for BPR and snout reflex and were also evaluated with the Mini Mental State Examination. All patients with Parkinson disease were classified with the Unified Parkinson's Disease Rating Scale (UPDRS) and the Hoehn and Yahr Score to determine their clinical severity. RESULTS: Sixteen patients with Parkinson disease (13.9%) had a BPR (+) and 4 patients in the control group (3.7%) (P < 0.001). The UPDRS score, UPDRS daily life activities score, and UPDRS motor system score were all higher in the group with BPR (+). All patients with a BPR also had a positive snout reflex. CONCLUSION: BPR is more frequent in patients with Parkinson disease than in patients without a neurodegenerative disease.

Increased Epicardial Fat Thickness Correlates with Aortic Stiffness and N-Terminal Pro-Brain Natriuretic Peptide Levels in Acute Ischemic Stroke Patients.

Epicardial fat, a metabolically active tissue, has emerged as a risk factor and active player in metabolic and cardiovascular diseases. We investigated epicardial fat thickness in patients who had sustained an acute ischemic stroke, and we evaluated the relationship of epicardial fat thickness with other prognostic factors. We enrolled 61 consecutive patients (age, ≥18 yr) who had sustained a first acute ischemic stroke and had been admitted to our hospital within 24 hours of the onset of stroke symptoms. The control group comprised 82 consecutive sex- and age-matched patients free of past or current stroke who had been admitted to our cardiology clinics. Blood samples were taken for measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP) levels at admission. Aortic stiffness indices and epicardial fat thickness were measured by means of transthoracic echocardiography within the first 48 hours. In comparison with the control group, the patients with acute ischemic stroke had significantly higher epicardial fat thickness (4.8 ± 0.9 vs 3.8 ± 0.7 mm; P <0.001), lower aortic distensibility (2.5 ± 0.8 vs 3.4 ± 0.9 cm(2) ·dyn(-1); P <0.001) and lower aortic strain (5.5% ± 1.9% vs 6.4% ± 1.8%; P=0.003). We found a significant association between epicardial fat thickness, NT-proBNP levels, and arterial dysfunction in patients who had sustained acute ischemic stroke. Increased epicardial fat thickness might be a novel risk factor and might enable evaluation of subclinical target-organ damage in these patients.

Buccopalpebral reflex in Parkinson disease and blink reflex study.

OBJECTIVE: To define a new primitive reflex named the buccopalpebral reflex (BPR), and to investigate this reflex clinically and neurophysiologically in patients with Parkinson disease. METHODS: This prospectively designed study included 17 patients, 9 BPR positive patients, and 8 BPR negative patients in Ankara Research and Training Hospital, Ankara, Turkey, and was carried out between January and December 2008. All patients had Parkinson disease without any medication. Using the blink reflex technique, 3 branches of the trigeminal nerve were stimulated. Additionally, the Mini Mental State Examination (MMSE), the Unified Parkinson`s Disease Rating Scale (UPDRS), the Hoehn and Yahr Score (HYS), the blink frequency, and the duration of Parkinson disease was also matched between the 2 groups. RESULTS: In patients with positive BPR, 5 had tremor and the remaining 4 had bradykinesia as a dominant symptom, while all other patients with negative BPR had only tremor. When blink reflex findings were compared between the 2 groups, R2 and contralateral R2 latencies that were taken by supraorbital stimulus were significantly shorter in the BPR positive patients. There were no statistically significant differences in terms of MMSE, UPDRS, HYS, and frequency of blinking, and duration of illness between the 2 groups. CONCLUSION: This reflex may be an indicator of sensitivity or decrease of threshold level such as Myerson`s sign, in which there is no inhibition in glabella reflex. The blink reflex findings support this hypothesis.

Levetiracetam monotherapy for late poststroke seizures in the elderly.

Stroke is the most common cause of seizures in the elderly. Antiepileptic drugs are used to treat most patients with late poststroke seizures. The aim of this study was to evaluate the efficacy and tolerability of levetiracetam (LEV) in patients aged 60 or older with late-onset poststroke seizures. This prospective study evaluated patients 60 years of age or older, who had at least two late-onset poststroke seizures and were given LEV monotherapy. Demographic data and seizure and stroke characteristics were recorded. Outpatient visits were made after 2, 4, 6, 9, and 12 months and every 3 months thereafter, and the effectiveness and tolerability of LEV were investigated. Thirty-four patients with a mean age of 69.76+/-6.41 were included in this study. Average seizure frequency before treatment was 3.61+/-3.02/month. Mean follow-up time was 17.68+/-3.24 months. At daily doses of 1000-2000 mg, 82.4% of the patients were seizure free, and 7 patients (20.6%) had side effects. LEV was discontinued in one patient because of severe somnolence. Two patients were switched to another antiepileptic drug because of uncontrolled seizures despite an increase in dose up to 3000 mg/day. LEV monotherapy can be effective and well tolerated in elderly patients with late-onset poststroke seizures.