Aflibercept for Gastrointestinal Bleeding in Hereditary Hemorrhagic Telangiectasia: A Case Report.

Herein, we present the first described hereditary hemorrhagic telangiectasia (HHT) patient treated with aflibercept for severe GI involvement after tachyphylaxis to bevacizumab, with promising results. HHT is a rare genetic disease characterized by systemic vascular malformations. Gastrointestinal telangiectasia is one of the major involvements that can produce chronic severe iron-deficiency anemia. Nowadays, support treatment with iron replacement therapy, red blood cell transfusions, and antiangiogenic drugs-mainly bevacizumab, a monoclonal antibody against vascular endothelial growth factor (VEGF)-are the main therapeutic options for this complication. The evidence of alternative drugs in patients with failure to this approach, such as tachyphylaxis to bevacizumab, is scarce. Aflibercept is a VEGF inhibitor with antiangiogenic properties approved for the treatment of different types of cancer and ocular neovascularization diseases.

Long-term use of somatostatin analogs for chronic gastrointestinal bleeding in hereditary hemorrhagic telangiectasia.

Background: Chronic bleeding due to gastrointestinal (GI) involvement in patients with hemorrhagic hereditary telangiectasia (HHT) can provoke severe anemia with high red blood cells (RBC) transfusion requirements. However, the evidence about how to deal with these patients is scarce. We aimed to assess the long-term efficacy and safety of somatostatin analogs (SA) for anemia management in HHT patients with GI involvement. Methods: This is a prospective observational study including patients with HHT and GI involvement attended at a referral center. SA were considered for those patients with chronic anemia. Anemia-related variables were compared in patients receiving SA before and during treatment. Patients receiving SA were divided into responders (patients with minimal hemoglobin levels improvement >10 g/L and maintaining hemoglobin levels ≥80 g/L during treatment), and non-responders. Adverse effects during follow-up were collected. Results: Among 119 HHT patients with GI involvement, 67 (56.3%) received SA. These patients showed lower minimal hemoglobin levels (73 [60-87] vs. 99 [70.2-122.5], p < 0.001), and more RBC transfusion requirements (61.2% vs. 38.5%, p = 0.014) than patients without SA therapy. Median treatment period was 20.9 ± 15.2 months. During treatment, there was a statistically significant improvement in minimum hemoglobin levels (94.7 ± 29.8 g/L vs. 74.7 ± 19.7, p < 0.001) and a reduction of patients with minimal hemoglobin levels <80 g/L (39 vs. 61%, p = 0.007) and RBC transfusions requirement (33.9% vs. 59.3%, p < 0.001). Sixteen (23.9%) patients showed mild adverse effects, mostly diarrhea or abdominal pain, leading to treatment discontinuation in 12 (17.9%) patients. Fifty-nine patients were eligible for efficacy assessment and 32 (54.2%) of them were considered responders. Age was associated with non-responder patients, OR 95% CI; 1.070 (1.014-1.130), p = 0.015. Conclusion: SA can be considered a long-term effective and safe option for anemia management in HHT patients with GI bleeding. Older age is associated with poorer response.

Improving Hereditary Hemorrhagic Telangiectasia Molecular Diagnosis: A Referral Center Experience.

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a rare vascular disease inherited in an autosomal dominant manner. Disease-causing variants in endoglin (ENG) and activin A receptor type II-like 1 (ACVRL1) genes are detected in more than 90% of the patients undergoing molecular testing. The identification of variants of unknown significance is often seen as a challenge in clinical practice that makes family screening and genetic counseling difficult. Here, we show that the implementation of cDNA analysis to assess the effect of splice site variants on mRNA splicing is a powerful tool. METHODS: Gene panel sequencing of genes associated with HHT and other arteriovenous malformation-related syndromes was performed. To evaluate the effect of the splice site variants, cDNA analysis of ENG and ACVRL1 genes was carried out. RESULTS: three novel splice site variants were identified in ENG (c.68-2A > T and c.1311+4_1311+8del) and ACVLR1 (c.526-6C > G) genes correspondingly in three individuals with HHT that met ≥ 3 Curaçao criteria. All three variants led to an aberrant splicing inducing exon skipping (ENG:c.68-2A > T and ACVRL1:c.526-6C > G) or intron retention (ENG:c.1311+4_1311+8del) allowing the confirmation of the predicted effect on splicing and the reclassification from unknown significance to pathogenic/likely pathogenic of two of them. CONCLUSIONS: RNA analysis should be performed to assess and/or confirm the impact of variants on splicing. The molecular diagnosis of HHT patients is crucial to allow family screening and accurate genetic counseling. A multidisciplinary approach including clinicians and geneticists is crucial when dealing with patients with rare diseases.

Production of PETase by engineered Yarrowia lipolytica for efficient poly(ethylene terephthalate) biodegradation.

There has been a growing interest in poly(ethylene terephthalate) PET degradation studies in the last few years due to its widespread use and large-scale plastic waste accumulation in the environment. One of the most promising enzymatic methods in the context of PET degradation is the use of PETase from Ideonella sakaiensis, which has been reported to be an efficient enzyme for hydrolysing ester bonds in PET. In our study, we expressed a codon-optimized PETase gene in the yeast Yarrowia lipolytica. The obtained strain was tested for its ability to degrade PET directly in culture, and a screening of different supplements that might raise the level of PET hydrolysis was performed. We also carried out long-term cultures with PET film, the surface of which was examined by scanning electron microscopy. The efficiency of PET degradation was tested based on the concentration of degradation products released, and the results showed that supplementation of the culture with olive oil resulted in 66 % higher release of terephthalic acid into the medium compared to the mutant culture without supplementation. The results indicate the possibility of ethylene glycol uptake by both strains, and, additionally, the PETase produced by the newly engineered strain hydrolyses MHET. The structure of the PET film after culture with the modified strain, meanwhile, had numerous surface defects, cracks, and deformations.

Cost comparison of full-scale water reclamation technologies with an emphasis on membrane bioreactors.

The paper assesses the costs of full-scale membrane bioreactors (MBRs). Capital expenditures (CAPEX) and operating expenses (OPEX) of Spanish MBR facilities have been verified and compared to activated sludge plants (CAS) using water reclamation treatment (both conventional and advanced). Spanish MBR facilities require a production of 0.6 to 1.2 kWh per m3, while extended aeration (EA) and advanced reclamation treatment require 1.2 kWh per m3. The energy represents around 40% of the OPEX in MBRs. In terms of CAPEX, the implementation costs of a CAS facility followed by conventional water reclamation treatment (physical-chemical + sand filtration + disinfection) ranged from 730 to 850 €.m-3d, and from 1,050 to 1,250 €.m-3d in the case of advanced reclamation treatment facilities (membrane filtration) with a capacity of 8,000 to 15,000 m3d-1. The MBR cost for similar capacities ranges between 700 and 960 €.m-3d. This study shows that MBRs that have been recently installed represent a cost competitive option for water reuse applications for medium and large capacities (over 10,000 m3d-1), with similar OPEX to EA and conventional water reclamation treatment. In terms of CAPEX, MBRs are cheaper than EA, followed by advanced water reclamation treatment.

Positive correlation between etanercept concentration and the decrease in Psoriasis Area and Severity Index scale value.

Background In the case of psoriatic patients, only a limited number of studies have related serum biological therapies and antidrug antibodies levels to clinical response. With respect to etanercept, the available evidence has not shown any relationship yet. Objective The aim of this study was to determine if there is any correlation among etanercept serum levels, the presence of anti-etanercept antibodies and clinical response to this treatment in psoriatic patients. Setting A 1500-bed hospital (A Coruña University Hospital Complex). Method A retrospective observational study in psoriatic patients treated with etanercept (50 mg once weekly) was carried out. Psoriasis Area and Severity Index scale and adverse reactions were recorded at the time of the extraction sample. The pharmacokinetic monitoring was evaluated at the previous time points by extracting peripheral blood samples before the dose administration. Etanercept and anti-etanercept antibodies concentrations were quantified by two sandwich-type ELISA immunoassays. The patients were classified into three groups (good, partial and nonresponders) in accordance with the treatment efficacy at the blood assessment moments. The Kruskall-Wallis test and Spearman correlation assay were used to assess the efficacy and incidence of adverse effects according to the etanercept concentration and anti-etanercept antibodies, considering p values of <0.05 as statistically significant. This statistical analysis was conducted using SPSS software (version19.0). Main outcome measures Etanercept and anti-etanercept antibodies trough serum levels and clinical response. Results 38 patients were included. 26 patients (68.4 %) were good, 5 (13.2 %) were partial and 7 (18.4 %) were non-responders. There was no significant difference with respect to etanercept levels: 2.7 µg/mL (range 0.7-5.6) versus 2.2 µg/mL (range 1.0-3.5) versus 1.73 µg/mL (range 0.1-2.3), respectively (p = 0.085). Nevertheless, a positive correlation between percentage decrease in the Psoriasis Area and Severity Index scale value with respect to the baseline value and etanercept concentration was found (p = 0.011). No anti-etanercept antibodies were detected; nor was there a significant difference in the incidence of adverse effects (p = 0.8523). Conclusions Our results showed a positive correlated between etanercept concentration and the percentage decrease in the Psoriasis Area and Severity Index scale value. The incidence of anti-etanercept antibodies in psoriatic patients was low.

Efficacy and safety of adalimumab in psoriatic patients previously treated with etanercept in a real-world setting.

INTRODUCTION: Knowledge on the efficacy and safety of adalimumab in psoriasis patients switching from etanercept is scarce, especially on the influence that causes of etanercept discontinuation may have on adalimumab response. OBJECTIVES: To evaluate the response, adverse effects and factors that may influence the efficacy and safety of adalimumab in psoriasis patients who failed on etanercept therapy in a real-world setting. METHODS: Data from all moderate to severe plaque psoriasis patients who switched from etanercept to adalimumab were extracted from a registry of biological therapies of our department. Primary endpoint was the percentage of patients achieving PASI 50 at weeks 12, 24, and 52. Secondary endpoints were the percentages of patients achieving PASI 75 and PASI 90, patients who maintained PASI values <5 and <3, and the safety of adalimumab. RESULTS: Of 35 patients who fulfilled the study criteria, 82.9% achieved PASI 50 at week 12, 74.3% at week 24, and 74.3% at week 52 on adalimumab treatment. Eleven of 16 primary and 11 of 17 secondary nonresponders to etanercept responded to adalimumab. There were no treatment discontinuations due to side effects. CONCLUSIONS: Previous etanercept failure seems not influence the success and safety of adalimumab treatment in moderate to severe plaque psoriasis.

La unidad de corta estancia (UCE) como herramienta para la mejora de la gestión hospitalaria / No disponible

Resumen. Analizar el coste -utilidad y la eficiencia de las Unidades de Corta Estancia (UCE) entendidascomo alternativa a la hospitalización las 24 horaslos 7 días de la semana y su impacto sobre los resultadosen salud. Material y métodos. Búsqueda sistemática en Medlinee Índice Médico Español para evaluar datos relativos a estancia media, resultados clinicos y tasas dereingreso, entre otros. Resultados. Se observó que las UCE proporcionan cuidados de salud con efectividad. Además, se encontróevidencia de calidad baja que apoya que las UCE reducen la estancia media en el conjunto del hospital o del servicio considerado, sin encontrar evidencias que apoyen otros beneficios al compararlas con otro tipo de unidades de hospitalización.Conclusiones. Así, existen datos que indican la potencialidad de las UCEs para mejorar los circuitos de lasexploraciones complementarias, prescripción, realización e informe, y de aumentar la oferta de atenciónsociosanitaria extrahospitalaria en pacientes con enfermedad médica aguda o crónica agudizada (AU)

Aims. To analyze the cost -usefulness and the efficiencyof the Units of Short Stay (UCE) understood as alternative to the hospitalization 24 hours 7 days ofthe week and his impact on the results in health. Material and methods. We retrieved studies analysing clinical effectiveness, efficiency and quality andrevision of selected references.Results. Low-quality evidence supports the hypothesis that SSUs are able to reduce overall length of stay in the whole hospital or department where they werecreated. There are not enough data to support any other advantages or benefits of SSUs when comparedwith other hospital units.Conclusions. This way, there exist information that indicatethe potential of the UCEs to improve the circuits of the complementary explorations, prescription,accomplishment and report, and of increasing the offer of attention health and social care in patients with medical sharp disease or chronicle sharpened. Furtherresearch is needed in order to define their exact role and to establish their optimal model (AU)

El Paraguay y el Sentido de la Vida, en la Post Guerra de la Triple Alianza / "Paraguay and the Meaning of Life in the Post War of the Triple Alliance"

El presente artículo teórico tiene por objetivo hacer un paralelo entre el casi exterminio del pueblo paraguayo en la guerra de la Triple Alianza y la de los judíos en los campos de concentración, desde la visión del fundador de la Logoterapia, considerada la tercera escuela vienesa de psicoterapia, del Dr. Viktor E. Frankl (1996), quien a partir de su propia experiencia en Auschwitz afirmó: "El hombre puede conservar un reducto de libertad espiritual, de independencia mental, incluso en aquellos crueles estados de tensión psíquica y de indigencia física". (p. 37) La autora reflexiona además, sobre la cultura y el carácter de los paraguayos de hoy, a quienes, de acuerdo a los distintos autores consultados, se los describen muy distintos al carácter de coraje, la actitud de lucha por su libertad física y de la independencia mental que tuvieron que desarrollar aquellos para sobrevivir y reconstruir el Paraguay de la post guerra.

Targeted gene-silencing reveals the functional significance of myocardin signaling in the failing heart.

BACKGROUND: Myocardin (MYOCD), a potent transcriptional coactivator of smooth muscle (SM) and cardiac genes, is upregulated in failing myocardium in animal models and human end-stage heart failure (HF). However, the molecular and functional consequences of myocd upregulation in HF are still unclear. METHODOLOGY/PRINCIPAL FINDINGS: The goal of the present study was to investigate if targeted inhibition of upregulated expression of myocd could influence failing heart gene expression and function. To this end, we used the doxorubicin (Dox)-induced diastolic HF (DHF) model in neonatal piglets, in which, as we show, not only myocd but also myocd-dependent SM-marker genes are highly activated in failing left ventricular (LV) myocardium. In this model, intra-myocardial delivery of short-hairpin RNAs, designed to target myocd variants expressed in porcine heart, leads on day 2 post-delivery to: (1) a decrease in the activated expression of myocd and myocd-dependent SM-marker genes in failing myocardium to levels seen in healthy control animals, (2) amelioration of impaired diastolic dysfunction, and (3) higher survival rates of DHF piglets. The posterior restoration of elevated myocd expression (on day 7 post-delivery) led to overexpression of myocd-dependent SM-marker genes in failing LV-myocardium that was associated with a return to altered diastolic function. CONCLUSIONS/SIGNIFICANCE: These data provide the first evidence that a moderate inhibition (e.g., normalization) of the activated MYOCD signaling in the diseased heart may be promising from a therapeutic point of view.

Exon-skipping brain natriuretic peptide variant is overexpressed in failing myocardium and attenuates brain natriuretic peptide production in vitro.

Brain natriuretic peptide/natriuretic peptide precursor B (NPPB) is one of the most studied genes in relation to heart failure (HF) conditions. However, it is still unclear as to whether alternative splicing could create NPPB mRNA variants, which may be expressed in normal and diseased myocardium. We aimed to identify and characterize a novel alternatively spliced variant of porcine and human NPPB resulting from exon 2 skipping (designated as DeltaE2-NPPB). A variety of conventional molecular, biochemical and immunochemical methods were used to examine the expression and functional consequences of DeltaE2-NPPB in vitro and in vivo. The pig DeltaE2-NPPB mRNA is effectively translated into stable protein in cell-based assays but, in contrast to normally spliced NPPB, the DeltaE2-NPPB protein is not secreted into the media. Co-transfection assays demonstrate that DeltaE2-NPPB attenuates production and secretion of normally spliced NPPB, suggesting a negative feedback loop of NPPB signaling through generation of DeltaE2-NPPB. The inhibitory effects of DeltaE2-NPPB on the expression of NPPB are associated with sequence elements residing in exon 3 of DeltaE2-NPPB. In piglets, DeltaE2-NPPB gene expression is downregulated in both ventricles after birth, but it is markedly re-activated in the postnatal myocardium in experimental diastolic heart failure. In addition, we demonstrate that the exon-skipped NPPB variants are expressed in the postnatal and adult human myocardium and upregulated at end-stage HF due to dilated cardiomyopathy. Our work uncovers an important role of alternative exon skipping in the regulation of NPPB gene expression, thereby pinpointing a putative new mechanism for post-transcriptional regulation of NPPB production and secretion.

Identification of candidate genes potentially relevant to chamber-specific remodeling in postnatal ventricular myocardium.

Molecular predisposition of postnatal ventricular myocardium to chamber-dependent (concentric or eccentric) remodeling remains largely elusive. To this end, we compared gene expression in the left (LV) versus right ventricle (RV) in newborn piglets, using a differential display reverse transcription-PCR (DDRT-PCR) technique. Out of more than 5600 DDRT-PCR bands, a total of 153 bands were identified as being differentially displayed. Of these, 96 bands were enriched in the LV, whereas the remaining 57 bands were predominant in the RV. The transcripts, displaying over twofold LV-RV expression differences, were sequenced and identified by BLAST comparison to known mRNA sequences. Among the genes, whose expression was not previously recognized as being chamber-dependent, we identified a small cohort of key regulators of muscle cell growth/proliferation (MAP3K7IP2, MSTN, PHB2, APOBEC3F) and gene expression (PTPLAD1, JMJD1C, CEP290), which may be relevant to the chamber-dependent predisposition of ventricular myocardium to respond differentially to pressure (LV) and volume (RV) overloads after birth. In addition, our data demonstrate chamber-dependent alterations in expression of as yet uncharacterized novel genes, which may also be suitable candidates for association studies in animal models of LV/RV hypertrophy.

Intron retention generates ANKRD1 splice variants that are co-regulated with the main transcript in normal and failing myocardium.

The cardiac ankyrin repeat domain 1 protein (ANKRD1, also known as CARP) has been extensively characterized with regard to its proposed functions as a cardio-enriched transcriptional co-factor and stress-inducible myofibrillar protein. The present results show the occurrence of alternative splicing by intron retention events in the pig and human ankrd1 gene. In pig heart, ankrd1 is expressed as four alternatively spliced transcripts, three of which have non-excised introns: ankrd1-contained introns 6, 7 and 8 (i.e., ankrd1-i6,7,8), ankrd1-contained introns 7 and 8 (i.e., ankrd1-i7,8), and ankrd1 retained only intron 8 (i.e., ankrd1-i8). In the human heart, two orthologues of porcine intron-retaining ankrd1 variants (i.e., ankrd1-i8 and ankrd1-i7,8) are detected. We demonstrate that these newly-identified intron-retaining ankrd1 transcripts are functionally intact, efficiently translated into protein in vitro and exported to the cytoplasm in cardiomyocytes in vivo. In the piglet heart, both the intronless and intron-retaining ankrd1 mRNAs are co-expressed in a chamber-dependent manner being more abundant in the left as compared to the right myocardium. Our data further indicate co-upregulation of the ankrd1 spliced variants in myocardium in the porcine model of diastolic heart failure. Most significantly, we demonstrate that in vivo forced expression of recombinant intronless ankrd1 markedly increases the levels of intron-retaining ankrd1 variants (but not of the endogenous main transcript) in piglet myocardium, suggesting that ANKRD1 may positively regulate the expression of its own intron-containing RNAs in response to cardiac stress. Overall, our findings demonstrate that in cardiomyocytes ANKRD1 can exist in multiple isoforms which may contribute to the functional diversity of this factor in heart development and disease.

Detection of protein interactions based on GFP fragment complementation by fluorescence microscopy and spectrofluorometry.

We have developed a set of simple modifications of the green fluorescent protein (GFP)fragment reassembly assay in bacteria that permits: (i)fluorescent microscopy visualization of GFP reassembly only 1-2 h after induction of protein expression, thus approximating the detection of GFP reassembly to the real-time dynamics of protein complex formation in living cells; (ii) spectrofluorometric detection of reassembled GFP fluorescent signals directly in lysates from cell suspension thereby avoiding, in many cases, the need for tag-affinity isolation of protein complexes; and (iii) comparative quantification of signal intensity in numerous cell-sample lysates using a Bio-Rad IQ5 spectrofluorometric detection system (Bio-Rad Laboratories, Madrid, Spain). Collectively, the results demonstrate that the combination of microscopic and spectrofluorometric detection provides a time-saving and sensitive alternative to existing methods of fluorescence complementation analysis.

Diagnóstico comunitario y perfíl social y epidemiológico de la comunidad "Matilde Alvarez" Sector I Area Sur - Guamaní / Social communitarian diagnosis and perfíl and epidemiologist of the community

La problemática en que se encuentra nuestro país a causa de los factores determinantes en el proceso salud enfermedad como: la deficiente e inadecuada estructura política, factores sociales, económicos, ocupacionales y geográficos. Sentimos la necesidad de realizar un diagnóstico comunitario y epidemiológico de la comunidad Matilde Alvarez Sector 1, ubicado en el sur de Quito Parroquia Guamaní Kilómetro 14 de la panamericana sur. El objetivo fundamental de nuestra investigación es detectar los problemas mas frecuentes a nivel social y de salud para buscar soluciones viables y concientizar a la población la importancia de mejorar las condiciones de vida, respetando sus hábitos y costumbres, ya que siempre la enfermera trata de ampliar metas en los aspectos de prevención, promoción y conservación de la salud prestando ayuda al individuo, familia y grupos expuestos a riesgo...