Effectiveness of the low-density lipoprotein cholesterol goals in secondary cardiovascular prevention.

BACKGROUND: The effectiveness of statin treatment to reduce coronary events and mortality has been hardly examined considering goals of LDL-C. We aimed to analyse such association in secondary cardiovascular prevention. METHODS: Retrospective cohort analysis of electronic health records from the SIDIAP database, Catalonia-Spain. Recruitment period was from 2006 to 2017 and study period finished at the end of 2018. We included 54,175 people aged ≥35 years in cardiovascular secondary prevention starting statin treatment. We analysed the association of achieved LDL-C goals after statin initiation with coronary heart disease and all-cause mortality. RESULTS: Mean age was 69 years and 20,146 (37.2%) were women. Coronary heart disease occurred in 5687 (10.5%) participants, and 10,676 (19.7%) persons passed away. Median follow-up lasted 5.7 years (interquartile range, 3.4-8.1). The coronary heart disease HRs (95% CI) for the LDL-C goals of 70-100, <70-55 and <55 mg/dL were .86 (.81-.92), .83 (.76-.9) and .8 (.72-.88), respectively. They were .89 (.83-.96) in the group with 30%-40% reduction and .86 (.8-.93) in the groups with 40%-50% and ≥50% reduction. We observed no association with mortality. We observed no relevant differences by sex or age. CONCLUSIONS: This population-level retrospective analysis of real-world data observed that treatment with statins is effective to achieve certain LDL-C goals and CHD reduction. The lack of significant difference between LDL-C goals needs confirmation in additional studies with real-world data. The LDL-C target should consider the magnitude of the decrease in coronary events.

Twelve tips for developing and implementing a medical education Twitter chat.

Live discussions on the social media site Twitter or Twitter chats are gaining popularity as powerful tools for engaging a broad audience in an interactive discussion. Medical education, in particular, is experiencing an increase in the use of this modality to support informal learning, as a means to encourage collaboration and share best practices, and as a platform for large-scale mentorship. Despite this growth in popularity, there are limited data to guide medical educators on the fundamentals of organizing a Twitter chat. In this Twelve Tips article, we discuss strategies relevant to potential Twitter chat organizers. We have arranged the tips chronologically, beginning with a discussion of initial considerations when planning and formulating a chat topic and publicizing the chat to potentially interested people and groups, followed by practical considerations while hosting the chat, and finally strategies for evaluating and extending a Twitter chat's impact.

Decoupling of soil nutrient cycles as a function of aridity in global drylands.

The biogeochemical cycles of carbon (C), nitrogen (N) and phosphorus (P) are interlinked by primary production, respiration and decomposition in terrestrial ecosystems. It has been suggested that the C, N and P cycles could become uncoupled under rapid climate change because of the different degrees of control exerted on the supply of these elements by biological and geochemical processes. Climatic controls on biogeochemical cycles are particularly relevant in arid, semi-arid and dry sub-humid ecosystems (drylands) because their biological activity is mainly driven by water availability. The increase in aridity predicted for the twenty-first century in many drylands worldwide may therefore threaten the balance between these cycles, differentially affecting the availability of essential nutrients. Here we evaluate how aridity affects the balance between C, N and P in soils collected from 224 dryland sites from all continents except Antarctica. We find a negative effect of aridity on the concentration of soil organic C and total N, but a positive effect on the concentration of inorganic P. Aridity is negatively related to plant cover, which may favour the dominance of physical processes such as rock weathering, a major source of P to ecosystems, over biological processes that provide more C and N, such as litter decomposition. Our findings suggest that any predicted increase in aridity with climate change will probably reduce the concentrations of N and C in global drylands, but increase that of P. These changes would uncouple the C, N and P cycles in drylands and could negatively affect the provision of key services provided by these ecosystems.

Chronic Arsenic Exposure Increases Aß(1-42) Production and Receptor for Advanced Glycation End Products Expression in Rat Brain.

Chronic arsenic exposure during development is associated with alterations of chemical transmission and demyelination, which result in cognitive deficits and peripheral neuropathies. At the cellular level, arsenic toxicity involves increased generation of reactive species that induce severe cellular alterations such as DNA fragmentation, apoptosis, and lipid peroxidation. It has been proposed that arsenic-associated neurodegeneration could evolve to Alzheimer disease in later life.1,2 In this study, the effects of chronic exposure to inorganic arsenic (3 ppm by drinking water) in Wistar rats on the production and elimination of Amyloid-ß (Aß) were evaluated. Male Wistar rats were exposed to 3 ppm of arsenic in drinking water from fetal development until 4 months of age. After behavioral deficits induced by arsenic exposure through contextual fear conditioning were verified, the brains were collected for the determination of total arsenic by inductively coupled plasma-mass spectrometry, the levels of amyloid precursor protein and receptor for advanced glycation end products (RAGE) by Western blot analysis as well as their transcript levels by RT-qPCR, Aß(1-42) estimation by ELISA assay and the enzymatic activity of ß-secretase (BACE1). Our results demonstrate that chronic arsenic exposure induces behavioral deficits accompanied of higher levels of soluble and membranal RAGE and the increase of Aß(1-42) cleaved. In addition, BACE1 enzymatic activity was increased, while immunoblot assays showed no differences in the low-density lipoprotein receptor-related protein 1 (LRP1) receptor among groups. These results provide evidence of the effects of arsenic exposure on the production of Aß(1-42) and cerebral amyloid clearance through RAGE in an in vivo model that displays behavioral alterations. This work supports the hypothesis that early exposure to metals may contribute to neurodegeneration associated with amyloid accumulation.

Overweight and Obesity Are Positively Associated with Serum Copper Levels in Mexican Schoolchildren.

Due to its relationship with oxidative stress and inflammation responses, obesity and its cardiometabolic implications have been related with serum copper (Cu). Hence, we analyzed the association of overweight (OW) and obesity (OB) status and cardiometabolic traits with serum Cu level in Mexican schoolchildren. Anthropometrical data and cardiometabolic traits were analyzed in this cross-sectional study. Serum Cu level was measured by inductively coupled plasma mass spectrometry. The study involved 191 schoolchildren (93 girls and 98 boys) with a mean age of 8.054 ± 1.170 years. Children with OW and OB had higher serum Cu levels than children with normal weight (NW) (mean difference: OW vs NW = 51.85 µg dL-1, OB vs NW = 47.22 µg dL-1, p < 0.001). In a multiple linear regression model, OW and OB status were positively associated with serum Cu levels (ßOW = 49.85, 95% confidence interval (95% CI) 35.84-63.87, p < 0.001; ßOB = 44.38, 95% CI 27.70-61.05, p < 0.001). We did not identify any significant association between cardiometabolic traits and serum Cu level. In conclusion, our results show an association of the presence of OW and OB with higher serum Cu levels, for the first time in Mexican schoolchildren. However, further functional studies are needed to better understand the role of Cu in the pathophysiology of obesity.

Unique spatiotemporal fMRI dynamics in the awake mouse brain.

Human imaging studies have shown that spontaneous brain activity exhibits stereotypic spatiotemporal reorganization in awake, conscious conditions with respect to minimally conscious states. However, whether and how this phenomenon can be generalized to lower mammalian species remains unclear. Leveraging a robust protocol for resting-state fMRI (rsfMRI) mapping in non-anesthetized, head-fixed mice, we investigated functional network topography and dynamic structure of spontaneous brain activity in wakeful animals. We found that rsfMRI networks in the awake state, while anatomically comparable to those observed under anesthesia, are topologically configured to maximize interregional communication, departing from the underlying community structure of the mouse axonal connectome. We further report that rsfMRI activity in wakeful animals exhibits unique spatiotemporal dynamics characterized by a state-dependent, dominant occurrence of coactivation patterns encompassing a prominent participation of arousal-related forebrain nuclei and functional anti-coordination between visual-auditory and polymodal cortical areas. We finally show that rsfMRI dynamics in awake mice exhibits a stereotypical temporal structure, in which state-dominant coactivation patterns are configured as network attractors. These findings suggest that spontaneous brain activity in awake mice is critically shaped by state-specific involvement of basal forebrain arousal systems and document that its dynamic structure recapitulates distinctive, evolutionarily relevant principles that are predictive of conscious states in higher mammalian species.

Relationship of thorium, uranium isotopes and uranium isotopic ratios with physicochemical parameters in cenote water from the Yucatán Peninsula.

Uranium (U) and Thorium (Th) concentrations are normally low in the water (<30 and 5 ng mL-1, respectively). However, we performed a direct analysis of 232Th, 234U, 235U and 238U in cenote water from the Yucatán Peninsula using Inductively Coupled Plasma Mass Spectrometry (ICP-MS) as a rapid response technique to perform environmental radioactivity monitoring. Water samples were collected in 2021 from the cenotes and these were certificated by zones (PYNO, PYNE and PYSE) and monitoring depth [surface water (n = 52) and depth water (n = 48)]. Moreover, physicochemical parameters such as pH, electrical conductivity (EC), total dissolved solids (TDS), and temperature were measured in situ. Results obtained were total U and Th levels below permissible for human consumption. However, physicochemical parameters must be considered before use because it is outside the permissible limits in most cenotes. The median concentration value for 234U, 235U, 238U and 232Th in surface + depth water were 0.0001 ng mL-1, 0.0130 ng mL-1, 1.76 ng mL-1, and 0.062 ng mL-1, respectively. In addition, isotopic ratio of 235U/238U in surface + depth water was 0.00730. In addition, the PYNO zone showed a correlation between 232Th with EC and TDS. The PYSE zone showed a correlation between 232Th and temperature, and 235U/234U with pH, while PYEN did not show correlations. In conclusion, the first time evaluated U isotope concentrations and isotopic ratios of U and 232Th in cenote water from the Yucatán Peninsula, where U and Th concentrations were found below the permissible limits mentioned by guidelines for drinking-water quality. The average of 235U/238U is similar to isotopic ratios in "natural" water.

Improving Patient Experience Scores Using Simultaneous Interpretation on Family-Centered Rounds.

OBJECTIVES: Patients speaking a primary language other than English face barriers to equitable care, particularly patient-provider communications. There is no gold standard for providing inpatient medical interpretation on family-centered rounds (FCR). We aimed to implement simultaneous, in-person interpretation of FCR for Spanish-speaking families and hypothesized improved satisfaction in care. METHODS: In-person, Spanish Equipment-Assisted Simultaneous Medical Interpretation (EASMI) was implemented in March 2018 on FCR. Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) experience scores on communication domains were analyzed for Spanish and English-speaking families pre- (n = 118) and postimplementation (n = 552). Postimplementation, we conducted medical team surveys (n = 104) and semistructured interviews with Spanish-speaking families (n = 25) to determine satisfaction with interpretation modalities (phone, video, and EASMI). RESULTS: Spanish-speaking families exhibited statistically significant improvements in Child HCAHPS top box scores compared to English-speaking families in multiple communication and informed care-related domains. For example, "How often did your child's doctors explain things to you in a way that was easy to understand?" top box scores improved from 58% to 95% for Spanish-speaking families, compared to 85% to 83% for English speakers, with the differential effect of the intervention showing statistical significance (P = .001). Medical team surveys demonstrated high satisfaction with EASMI. Qualitative themes from interviews and open-ended survey responses emphasized multiple care benefits with EASMI, including a perceived reduction of communication errors and increased family participation. CONCLUSIONS: EASMI was associated with significant improvements in Child HCAHPS scores in communication domains and increased medical team and family members' satisfaction with interpretation. EASMI presents a novel method for equitable FCR for Spanish-speaking families.

Relationship Between Serum Levels of Arsenic, Cadmium, and Mercury and Body Mass Index and Fasting Plasma Glucose in a Mexican Adult Population.

In Mexico, few studies have analyzed the associations between toxic elements and metabolic diseases. In the present study, we analyzed the associations between serum arsenic (As), cadmium (Cd), and mercury (Hg) levels and body mass index (BMI) and fasting plasma glucose (FPG) in a Mexican adult population. Anthropometric data corresponding to 86 Mexican healthy adults (59 females and 27 men) were analyzed. FPG was analyzed by an enzymatic colorimetric method, and serum As, Cd, and Hg levels were analyzed by inductively coupled plasma-mass spectrometry (ICP-MS). The data show that the median serum As, Cd, and Hg levels were relatively higher in females (As = 1.78 ng mL-1, Cd = 1.00 ng mL-1, Hg = 0.96 ng mL-1) than those in males (As = 1.22 ng mL-1, Cd = 0.91 ng mL-1, Hg = 0.95 ng mL-1). However, these differences were not statistically significant (p ≥ 0.097). We also found that the median level of As significantly increased with an increase in the body weight categories (normal weight = 1.08; overweight = 1.50; obesity = 2.75; p < 0.001). In addition, a positive association between serum As levels and FPG before and after adjustment for BMI was demonstrated (RhoUnadjusted = 0.012; (RhoAdjusted = 0.243, p = 0.032). Serum As levels are positively associated with BMI and FPG in the adult population of Mexico. Nevertheless, these results need to be replicated and confirmed with a larger sample size.

Serum lead levels and its association with overweight and obesity.

BACKGROUND: Lead (Pb) exposure has been associated with cardiovascular diseases and metabolic syndrome, nevertheless its association with obesity, type 2 diabetes, and dyslipidemia markers has been little explored in Mexico. Therefore, we evaluated the association of serum Pb levels (Pb-S), with body mass index (BMI), fasting plasma glucose (FPG), total cholesterol (TC), and triglycerides (TG). METHODS: A cross-sectional study was performed on 85 Mexican adults (57 women and 28 men). BMI was calculated, while FPG, TC, and TG were measured by the enzymatic colorimetric method. Total Pb-S levels were measured using inductively coupled plasma mass spectrometry (ICP-MS). RESULTS: The study population was 20.3 ± 1.9 years old, showed an average of Pb-S of 0.0982 ± 0.068 µg dL-1, and presented a frequency of overweight (OW) and obesity (OB) of 50.5% and 18.8%, respectively. Men had higher average FPG than women (Women= 83.930 ± 5.662 vs Men= 84.953 ± 6.495; p = 0.037). When we analyzed anthropometric and clinical variables, Pb-S and frequency of OW and OB were observed to increase within the categories of Pb-S tertiles (<0.001). The averages of Pb-S were 0.051 ± 0.035 µg dL-1, 0.107 ± 0.067 µg dL-1, and 0.151 ± 0.063 µg dL-1 for individuals with normal weight (NW), OW, and OB, respectively. In addition, an analysis adjusted for age and sex shows Pb-S is positively associated with BMI (ß = 2.76 ± 0.498, p = <0.001). CONCLUSION: Our results evidence a significant association between Pb-S and the increase of BMI in Mexican adults and highlight the important health impact that may represent environmental Pb exposure.

Sex-Specific Association between Fasting Plasma Glucose and Serum Selenium Levels in Adults from Southern Mexico.

Selenium (Se) is an essential trace element that by its antioxidant properties has been studied to elucidate its participation in the development of obesity and type 2 diabetes. We evaluated the association between cardiometabolic traits and serum Se levels in a sample of adults from southern Mexico. In 96 nondiabetic individuals, anthropometric data and clinical biochemistry measurements were analyzed. Serum total Se levels were measured with inductively coupled plasma mass spectrometry (ICP-MS). Serum Se level in the whole sample was 10.309 ± 3.031 µg mL-1 and no difference between the women and men was observed (p = 0.09). Additionally, fasting plasma glucose (FPG) was significantly associated with serum Se level (ß = -0.07 ± 0.03, p = 0.02, analysis adjusted for age, sex and BMI). Furthermore, sex shows significant interaction with FPG on the serum Se levels (p = 0.01). A follow-up analysis revealed the particular association between FPG and Se levels in women (ß = -0.10 ± 0.04, p = 0.01). In conclusion, our data evidenced a women-specific association between FPG and serum Se levels in a sample of adults from southern Mexico.

ATS Core Curriculum 2021. Adult Pulmonary Medicine: Thoracic Oncology.

The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine at the annual international conference. The 2021 Pulmonary Core Curriculum focuses on lung cancer and include risks and prevention, screening, nodules, therapeutics and associated pulmonary toxicities, and malignant pleural effusions. Although tobacco smoking remains the primary risk factor for developing lung cancer, exposure to other environmental and occupational substances, including asbestos, radon, and burned biomass, contribute to the global burden of disease. Randomized studies have demonstrated that routine screening of high-risk smokers with low-dose chest computed tomography results in detection at an earlier stage and reduction in lung cancer mortality. On the basis of these trials and other lung cancer risk tools, screening recommendations have been developed. When evaluating lung nodules, clinical and radiographic features are used to estimate the probability of cancer. Management guidelines take into account the nodule size and cancer risk estimates to provide recommendations at evaluation. Newer lung cancer therapies, including immune checkpoint inhibitors and molecular therapies, cause pulmonary toxicity more frequently than conventional chemotherapy. Treatment-related toxicity should be suspected in patients receiving these medications who present with respiratory symptoms. Evaluation is aimed at excluding other etiologies, and treatment is based on the severity of symptoms. Malignant pleural effusions can be debilitating. The diagnosis is made by using simple pleural drainage and/or pleural biopsies. Management depends on the clinical scenario and the patient's preferences and includes the use of serial thoracentesis, a tunneled pleural catheter, or pleurodesis.

ATS Core Curriculum 2021. Adult Sleep Medicine: Sleep Apnea.

The American Thoracic Society Sleep Core Curriculum updates clinicians on important sleep topics, presented during the annual meeting, and appearing in summary here. This year's sleep core theme is sleep-disordered breathing and its management. Topics range from pathophysiological mechanisms for the association of obstructive sleep apnea (OSA) and metabolic syndrome, surgical modalities of OSA treatment, comorbid insomnia and OSA, central sleep apnea, and sleep practices during a pandemic. OSA has been associated with metabolic syndrome, independent of the role of obesity, and the pathophysiology suggests a role for sleep fragmentation and intermittent hypoxia in observed metabolic outcomes. In specific patient populations, surgical treatment modalities for OSA have demonstrated large reductions in objective disease severity compared with no treatment and may facilitate adherence to positive airway pressure treatment. Patient-centered approaches to comorbid insomnia and sleep apnea include evaluating for both OSA and insomnia simultaneously and using shared-decision making to determine the order and timing of positive airway pressure therapy and cognitive behavioral therapy for insomnia. The pathophysiology of central sleep apnea is complex and may be due to the loss of drive to breathe or instability in the regulatory pathways that control ventilation. Pandemic-era sleep practices have evolved rapidly to balance safety and sustainability of care for patients with sleep-disordered breathing.

Immunometabolic signatures predict risk of progression to sepsis in COVID-19.

Viral sepsis has been proposed as an accurate term to describe all multisystemic dysregulations and clinical findings in severe and critically ill COVID-19 patients. The adoption of this term may help the implementation of more accurate strategies of early diagnosis, prognosis, and in-hospital treatment. We accurately quantified 110 metabolites using targeted metabolomics, and 13 cytokines/chemokines in plasma samples of 121 COVID-19 patients with different levels of severity, and 37 non-COVID-19 individuals. Analyses revealed an integrated host-dependent dysregulation of inflammatory cytokines, neutrophil activation chemokines, glycolysis, mitochondrial metabolism, amino acid metabolism, polyamine synthesis, and lipid metabolism typical of sepsis processes distinctive of a mild disease. Dysregulated metabolites and cytokines/chemokines showed differential correlation patterns in mild and critically ill patients, indicating a crosstalk between metabolism and hyperinflammation. Using multivariate analysis, powerful models for diagnosis and prognosis of COVID-19 induced sepsis were generated, as well as for mortality prediction among septic patients. A metabolite panel made of kynurenine/tryptophan ratio, IL-6, LysoPC a C18:2, and phenylalanine discriminated non-COVID-19 from sepsis patients with an area under the curve (AUC (95%CI)) of 0.991 (0.986-0.995), with sensitivity of 0.978 (0.963-0.992) and specificity of 0.920 (0.890-0.949). The panel that included C10:2, IL-6, NLR, and C5 discriminated mild patients from sepsis patients with an AUC (95%CI) of 0.965 (0.952-0.977), with sensitivity of 0.993(0.984-1.000) and specificity of 0.851 (0.815-0.887). The panel with citric acid, LysoPC a C28:1, neutrophil-lymphocyte ratio (NLR) and kynurenine/tryptophan ratio discriminated severe patients from sepsis patients with an AUC (95%CI) of 0.829 (0.800-0.858), with sensitivity of 0.738 (0.695-0.781) and specificity of 0.781 (0.735-0.827). Septic patients who survived were different from those that did not survive with a model consisting of hippuric acid, along with the presence of Type II diabetes, with an AUC (95%CI) of 0.831 (0.788-0.874), with sensitivity of 0.765 (0.697-0.832) and specificity of 0.817 (0.770-0.865).

Association of Serum Zinc Levels in Overweight and Obesity.

Low levels of zinc (Zn) have adverse effects on physiological and metabolic functions in humans, especially in processes linked with obesity. In this work, serum Zn levels and their associations with biochemical parameters (glucose, triglycerides, and total cholesterol), sex, and body mass index (BMI) were determined. The distribution of the study sample by sex was homogeneous: 52.6% were women and 47.4% were men. Women had higher BMI and Zn levels (normal weight and obesity) than men, but the differences in BMI and serum Zn levels by sex were not significant (p > 0.05). Nevertheless, the results obtained showed a decrease in serum Zn levels in overweight and obese individuals (p < 0.05) and a negative correlation between BMI and serum Zn levels (r = - 0.663 and p < 0.001); additionally, a significant correlation was identified between cholesterol and triglyceride values (r = 0.493 and p < 0.001). In conclusion, this study demonstrated decreased serum Zn levels in overweight and obese individuals.

ATS Core Curriculum 2020. Adult Sleep Medicine.

The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine, in a 3-4-year recurring cycle of topics. These topics will be presented at the 2020 Virtual Conference. Below is the adult sleep medicine core that includes topics pertinent to sleep-disordered breathing and insomnia.

Evaluation of the release of nickel and titanium under orthodontic treatment.

The metal alloys used in dentistry are made mainly of nickel (Ni), titanium (Ti), and other elements such as molybdenum (Mo), zirconium (Zr), iron (Fe), tin (Sn), chrome (Cr), carbon (C), copper (Cu) and niobium (Nb) which can release metal ions in unstable environments. The aim of this work was determine the salivary pH before and during orthodontic treatment; evaluate the release of metal ions, mainly Ni and Ti, in urine and saliva using Inductively Coupled Plasma Optical Emission Spectroscopy (ICP-OES); and evaluate the corrosion using Scanning Electronic Microscopy (SEM). In this study, we selected 35 individuals under orthodontic treatment, from whom saliva and urine samples were collected in 3 stages: (a) basal, (b) at 3 and (c) 6 months after the placement of the fixed appliances. SEM analyzed the Ni-Ti (0.016″) and stainless steel (SS) (0.016 × 0.022″) archs after 1 month of being in contact with the oral cavity. Statistical analysis was performed with Stata using the ANOVA model of repeated measures with a p < 0.05. A statistically significant difference in the concentration of Ni in saliva were found between 3 and 6 months of intervention and Ti in urine was found 3 and 6 months.

Answer to Comment on article "Professionalism in physicians in a second-level hospital" / Respuesta a Comentario al artículo "Profesionalismo en médicos de un hospital de segundo nivel"

In relation to the letter to the editor on the article "Professionalism in physicians in a second-level hospital" this reply is issued.

En relación a la carta al editor sobre el artículo "Profesionalismo en médicos de segundo nivel" se emite esta réplica.