Detrimental Effects of Testosterone Addition to Estrogen Therapy Involve Cytochrome P-450-Induced 20-HETE Synthesis in Aorta of Ovariectomized Spontaneously Hypertensive Rat (SHR), a Model of Postmenopausal Hypertension.

Postmenopausal period has been associated to different symptoms such as hot flashes, vulvovaginal atrophy, hypoactive sexual desire disorder (HSDD) and others. Clinical studies have described postmenopausal women presenting HSDD can benefit from the association of testosterone to conventional hormonal therapy. Testosterone has been linked to development of cardiovascular diseases including hypertension and it also increases cytochrome P-450-induced 20-HETE synthesis which in turn results in vascular dysfunction. However, the effect of testosterone plus estrogen in the cardiovascular system is still very poorly studied. The aim of the present study is to evaluate the role of cytochrome P-450 pathway in a postmenopausal hypertensive female treated with testosterone plus estrogen. For that, hypertensive ovariectomized rats (OVX-SHR) were used as a model of postmenopausal hypertension and four groups were created: SHAM-operated (SHAM), ovariectomized SHR (OVX), OVX treated for 15 days with conjugated equine estrogens [(CEE) 9.6 µg/Kg/day/po] or CEE associated to testosterone [(CEE+T) 2.85 mg/kg/weekly/im]. Phenylephrine-induced contraction and generation of reactive oxygen species (ROS) were markedly increased in aortic rings from OVX-SHR compared to SHAM rats which were restored by CEE treatment. On the other hand, CEE+T abolished vascular effects by CEE and augmented both systolic and diastolic blood pressure of SHR. Treatment of aortic rings with the CYP/20-HETE synthesis inhibitor HET0016 (1 µM) reduced phenylephrine hyperreactivity and the augmented ROS generation in the CEE+T group. These results are paralleled by the increased CYP4F3 protein expression and activity in aortas of CEE+T. In conclusion, we showed that association of testosterone to estrogen therapy produces detrimental effects in cardiovascular system of ovariectomized hypertensive females via CYP4F3/20-HETE pathway. Therefore, our findings support the standpoint that the CYP/20-HETE pathway is an important therapeutic target for the prevention of cardiovascular disease in menopausal women in the presence of high levels of testosterone.

Intestinal Epithelial Stem Cells: Distinct Behavior After Surgical Injury and Teduglutide Administration.

BACKGROUND: Previous studies suggest that intestinal epithelial stem cells (IESC), critical drivers of homeostasis and regeneration, include two subpopulations: crypt-based columnar and "position +4" stem cells, identified by Lgr5 and Bmi1 biomarkers, respectively. Teduglutide is an enterotrophic counterpart of glucagon-like peptide 2. This study aimed to investigate the response of putative IESC to surgical injury and teduglutide administration on an animal model of intestinal resection and anastomosis. METHODS: Wistar rats (n = 59) were distributed into four groups: "Ileal Resection" versus "Laparotomy", subsequently subdivided into "Postoperative Teduglutide Administration" versus "No Treatment"; and sacrificed at third or seventh days, with ileal sample harvesting. Flow cytometry was used to analyze epithelial stem cells with monoclonal antibodies against Lgr5, Bmi1 and also CD44, CD24, CD166, and Grp78 surface markers. RESULTS: Surgical trauma induced an increase of epithelial stem cells population at third day (9.0 ± 0.3 versus 5.7 ± 0.3%, p = 0.0001), which was more intense and involved all subpopulations after ileal resection. At seventh day, teduglutide was significantly associated with higher proportion of Lgr5+/Bmi1- cells (5.8 ± 0.1 versus 2.9 ± 0.3%, p = 0.005) and, on the contrary, lower percentage of Lgr5-/Bmi1+ cells (0.03 ± 0.01 versus 1.9 ± 0.1%, p = 0.049) after ileal resection; and higher proportion of Lgr5+/Bmi1+ cells (1.7 ± 0.1 versus 1.1 ± 0.2%, p = 0.028) after isolated laparotomy. After surgery, Lgr5+/Bmi1- and Lgr5-/Bmi1+ subpopulations demonstrated an inverse correlation and both correlated negatively with Grp78 labeling index. Lgr5-/Bmi1+ and CD44+/CD24low/CD166+/Grp78+ cells proportions exhibited a high grade positive correlation. CONCLUSION: Those observations support the existence of two epithelial stem cells subpopulations with distinct behavior after surgical injury and teduglutide treatment.

Teduglutide effects on gene regulation of fibrogenesis on an animal model of intestinal anastomosis.

BACKGROUND: Teduglutide is an enterotrophic analog of glucagon-like peptide 2 approved for the rehabilitation of short-bowel syndrome. This study aims to analyze the effects of teduglutide administration on the gene regulation of fibrogenesis during the intestinal anastomotic healing on an animal model. METHODS: Wistar rats (n = 62) were assigned into four groups: "Ileal Resection and Anastomosis" or "Laparotomy," each one subdivided into "Postoperative Teduglutide Administration" or "No Treatment," and sacrificed at the third or at the seventh days, with ileal sample harvesting. Gene expression of matrix components and remodeling factors (matrix metalloproteinases [Mmp] and tissue inhibitors of metalloproteinases [Timp]) and growth factors was studied by real-time polymerase chain reaction. Net collagen deposition was assessed through the Collagen-to-Mmp-to-Timp ratio of fold change of relative gene expression. RESULTS: Gene expression profiles revealed a balance toward net degradation of collagen at the third day of the intestinal anastomotic healing. Teduglutide appeared to be associated with an overall accumulation of collagen at the third day of the anastomotic repair, attributable to the upregulation of Collagen type 1 alpha 1, Collagen type 3 alpha 1, and Collagen type 4 alpha 1, Timp1, and Timp2 and downregulation of Mmp13 and to a net degradation of collagen at the seventh day, derived from repression of Collagen type 3 alpha 1, Collagen type 5 alpha 1 and Timp1 expression. CONCLUSIONS: Teduglutide appeared to be associated with a favorable influence on fibrogenesis at the third day of the intestinal anastomotic repair and to a trend to fibrolysis at the seventh day.

Glutaminemia prognostic significance in critical surgical patients. An analysis of plasma aminogram profile / Significado pronóstico de la glutaminemia en pacientes quirúrgicos críticos. Análisis del perfil del aminograma plasmático

Background: Glutamine depletion is common in the critically-ill patients. Glutaminemia lower than 420 μmol/l has been considered as an independent predictive factor of mortality, but the indications for exogenous glutamine supplementation remain controversial. This study intends to determine the glutaminemia profile in critical surgical patients and to investigate its correlation with the severity indexes and the prognosis. Methods: A prospective study of 28 adult critical surgical patients was performed. Plasma amino acid concentrations were quantified, by ion exchange chromatography, at the moment of admission and at the first and third days, and compared with those of 11 reference healthy individuals. Severity indexes and parameters of prognosis were registered. Results: In critical surgical patients, mean glutaminemia at admission was lower than that of control individuals (385.1 ± 123.1 versus 515 ± 57.9 μmol/l, p = 0.002) and decreased until the third day (p = 0.042). Prevalence of severe hypoglutaminemia (< 420 μmol/l) at admission was 64.3%. Baseline glutaminemia correlated with the Simplified Acute Physiology Score II (SAPS II score) (Pearson’s correlation coefficient r = -39.4%, p = 0.042), and it was lower in cases of erythrocytes transfusion (339.9 ± 78.8 versus 454.9 ± 148.8 μmol/l, p = 0.013). Glutaminemia at the third day correlated with the duration of invasive ventilation support (r = -65%, p = 0 .012) and ICU stay (r = -66.5%, p = 0.009). Glutaminemia below 320 μmol/l, observed in 25% of the patients, was associated with higher in-hospital mortality (42.9 versus 19%, statistically not significant [n.s.]) and lower actuarial survival (212.1 ± 77.9 versus 262.3 ± 32.4 days, n.s.). Conclusions: Those results underscore the relevance of hypoglutaminemia as an adverse predictive factor in the critical surgical patients. Determination of glutaminemia may contribute to a better definition of the indications for glutamine supplementation (AU)

Introducción: la hipoglutaminemia es común en los pacientes críticos, pero las indicaciones para la suplementación con glutamina exógena siguen siendo controvertidas. Este estudio pretende determinar el perfil de glutaminemia en pacientes quirúrgicos críticos e investigar su correlación con los índices de gravedad y el pronóstico. Métodos: se realizó un estudio prospectivo de 28 pacientes quirúrgicos críticos adultos. Las aminoacidemias se cuantificaron mediante cromatografía de intercambio iónico en el momento del ingreso y en el primer y tercer día, y se compararon con las de 11 individuos sanos. Se registraron índices de gravedad y de pronóstico. Resultados: en pacientes quirúrgicos críticos, la glutaminemia media en el ingreso fue inferior a la de los controles (385,1 ± 123,1 versus 515 ± 57,9 μmol/l, p = 0,002) y disminuyó hasta el tercer día (p = 0,042). La prevalencia de hipoglutaminemia severa (< 420 μmol/l) en el ingreso fue de 64,3%. La glutaminemia basal se correlacionó con el SAPS II (r = -39,4%, p = 0,042), y fue menor en los casos de transfusión de eritrocitos (339,9 ± 78,8 versus 454,9 ± 148,8 μmol/l, p = 0,013). La glutamina al tercer día se correlacionó con la duración de la ventilación invasiva (r = -65%, p = 0,012) y de la estancia en la UCI (r = -66,5%, p = 0,009). La glutaminemia < 320 μmol/l, observada en el 25% de los pacientes, se asoció con mayor mortalidad hospitalaria (42,9 versus 19%, n.s.) y menor supervivencia actuarial (212,1 ± 77,9 versus 262,3 ± 32,4 días, n.s.). Conclusiones: estos resultados refuerzan la importancia de hipoglutaminemia como un factor predictivo adverso en los pacientes quirúrgicos críticos. La determinación de glutaminemia puede contribuir a una mejor definición de las indicaciones para la suplementación (AU)

Intestinal dysfunction in the critical trauma patients - An early and frequent event / Disfunción intestinal en los traumatizados críticos. Un suceso precoz y frecuente

Background: Small-bowel dysfunction exerts a relevant prognostic impact in the critically ill patients. Citrullinemia has been used in the evaluation of the intestinal function and it is considered an objective parameter of the functional enterocyte mass. Present study proposes to determine the intestinal dysfunction prevalence and the citrullinemia kinetic profi le in severe trauma patients and to investigate its correlation with severity indicators and clinical outcome. Methods: A prospective study including 23 critical trauma patients was performed. Aminoacidemias were quantified, by ion exchange chromatography, at the admission and at the first and third days. Severity and outcome parameters were registered. Results: In severe trauma patients, severe hypocitrullinemia (< 20 μmol/L) prevalence at admission was high (69.6%) and mean citrullinemia was low (19.5 ± 11.1 μmol/L). Baseline citrullinemia was inversely and significantly correlated with shock index (r = -55.1%, p = 0.008) and extent of invasive ventilation support (r = -42.7%, p = 0.042). Citrullinemia < 13.7 μmol/L at admission, observed in 17.4% of patients, was associated with higher shock index (1.27 ± 0.10 versus 0.75 ± 0.18, p = 0.0001) and longer duration of invasive ventilation support (20.3 ± 7 versus 11.2 ± 7.1 days, p = 0.029) and intensive care unit stay (22 ± 5.9 versus 12.2 ± 8.8 days, p = 0.048). A citrullinemia decrease in the first day after admittance superior to 12.7% constituted a significant predictive factor of in-hospital mortality (75 versus 14.3%, p = 0.044; odds ratio = 7.8; accuracy = 65.2%; specificity = 92.3%; negative predictive value = 85.7%] and lower actuarial survival (69.8 ± 41.6 versus 278.1 ± 37.4 days, p = 0.034). Conclusions: Those results confirm the high prevalence and the prognostic relevance of hypocitrullinemia, considered a biomarker of enterocyte dysfunction, in severe trauma patients (AU)

Introducción: la disfunción intestinal ejerce un importante impacto pronóstico en los pacientes críticamente enfermos. La citrulinemia se ha utilizado en la evaluación de la función intestinal. El presente estudio propone determinar la prevalencia de la disfunción intestinal y el perfil cinético de la citrulinemia en enfermos con trauma grave e investigar su correlación con la gravedad y la evolución clínica. Métodos: se realizó un estudio prospectivo incluyendo 23 pacientes traumatizados críticos. Las aminoacidemias se cuantificaron, mediante cromatografía de intercambio iónico, en la admisión y en el primer y tercer días. Se registraron los parámetros de gravedad y evolución clínica. Resultados: la prevalencia de la hipocitrulinemia grave (< 20 μmol/L) en la admisión fue alta (69,6%) y citrulinemia media fue baja (19,5 ± 11,1 μmol/L). La citrulinemia basal se correlacionó con el índice de choque (r = -55,1%, p = 0,008) y la duración de asistencia ventilatoria invasiva (r = -42,7%, p = 0,042). La citrulinemia < 13,7 μmol/L en la admisión se asoció con mayor índice de choque (1,27 ± 0,1 versus 0,75 ± 0,18, p = 0,0001) y mayor duración de ventilación invasiva (20,3 ± 7 versus 11,2 ± 7,1 días, p = 0,029) y hospitalización en la unidad de cuidados intensivos (22 ± 5,9 versus 12,2 ± 8,8 días, p = 0,048). La disminución de la citrulinemia en el primer día superior al 12,7% fue un factor predictor signifi cativo de mortalidad hospitalaria (75 versus 14,3%, p = 0,044; odds ratio = 7,8; precisión = 65,2%; especificidad = 92,3%; valor predictivo negativo = 85,7%] y menor supervivencia actuarial (69,8 ± 41,6 versus 278,1 ± 37,4 días, p = 0,034). Conclusiones: estos resultados confirman la alta prevalencia y la importancia pronóstica de la hipocitrulinemia, biomarcador de disfunción enterocitaria, en los pacientes con trauma severo (AU)

Argininemia and plasma arginine bioavailability - predictive factors of mortality in the severe trauma patients?

BACKGROUND: Arginine is an amino acid determinant in the metabolic, immune and reparative responses to severe trauma. The present study aims to determine argininemia and plasma arginine bioavailability (PAB) in critical trauma patients and to analyze its correlation with prognosis. METHODS: A prospective study of 23 critical trauma patients was undertaken. Aminoacidemias were determined, by ion exchange chromatography, at admission and in the first and third days and compared with those of 11 healthy individuals. PAB was calculated. Severity indexes and outcome parameters were recorded. RESULTS: Values of argininemia, citrullinemia and ornithinemia at the admission were significantly lower than those of the controls (arginine: 41.2 ± 20.6 versus 56.1 ± 11.9 µmol/L, P = 0.034). Hipoargininemia (<60 µmol/L) prevalence was 82.6 %. Mean PAB was 62.4 ± 25.6 %. Argininemia < 26 µmol/L constituted a significant predictive factor of in-hospital mortality [n = 4 (17.4 %); 75 versus 15.8 %, P = 0.04; odds ratio = 4.7; accuracy = 87 %] and lower actuarial survival (63.5 ± 43.9 versus 256.1 ± 33.3 days, P = 0.031). PAB <42 % [n = 6 (26.1 %)] was associated with higher lactacidemia levels (P = 0.033), higher in-hospital mortality (66.7 versus 11.8 %, P = 0.021; odds ratio = 5.7, accuracy = 82.6 %) and lower actuarial survival (87.2 ± 37.5 versus 261.4 ± 34.7 days, n.s.). Probability of in-hospital mortality was inversely and significantly related with PAB [61.8 ± 8.8 % (95 % CI 50.8-72.7) when PAB <41 % and 2.8 ± 1.9 % (95 % CI 1.9-8.3) when PAB > 81 %, P = 0.0001]. Charlson's index ≥1, APACHE II ≥19.5, SOFA ≥7.5, and glutaminemia < 320 µmol/L were also predictive factors of actuarial survival. CONCLUSIONS: Those results confirm the high prevalence of arginine depletion in severe trauma patients and the relevance of argininemia and PAB as predictive factors of mortality in this context.

Value of MELD and MELD-based indices in surgical risk evaluation of cirrhotic patients: retrospective analysis of 190 cases.

BACKGROUND: Recent studies have suggested that the Model for End-Stage Liver Disease (MELD) may represent a promising alternative to the Child-Turcotte-Pugh classification as a predictive factor of operative mortality and morbidity. This study was designed to evaluate the value of MELD and four MELD-based indices (iMELD: integrated MELD; MESO: MELD to sodium ratio; MELD-Na: MELD with incorporation of sodium; MELD-XI: MELD excluding the International Normalized Ratio) in the quantification of surgical risk for patients with cirrhosis and compare its prognostic value with the Child-Turcotte-Pugh classification and two derived scores (proposed by Huo and Giannini, respectively). METHODS: A retrospective study of 190 patients with cirrhosis, operated on in our department between 1993 and 2008, was undertaken. RESULTS: Forty-three percent of patients were included in Child-Turcotte-Pugh A class, and their mean MELD score was 12.2 +/- 4.9 (range, 6.4-35.2). Mortality and morbidity rates were 13% and 24%, respectively. In global analysis of mortality, MELD-based indices presented an acceptable prognostic performance (auROC = 71-77%), similar to the three analyzed Child-Turcotte-Pugh-derived scores. iMELD demonstrated the highest prognostic capacity (auROC = 77%; 95% confidence interval (CI), 66-88; p = 0.0001); operative death probability was 4% (95% CI, 3.6-4.4) when the score was inferior to 35, 16.1% (95% CI, 14.4-17.9) between 35 and 45, and 50.1% (95% CI, 42.2-58.1) when superior to 45. In elective surgical procedures, iMELD represented a useful prognostic factor of operative mortality (auROC = 80%; 95% CI, 63-97; p = 0.044) with significant correlation and better accuracy then MELD and Child-Turcotte-Pugh-derived indices. CONCLUSIONS: In this study, iMELD was a useful predictive parameter of operative mortality for patients with cirrhosis submitted to elective procedures. Further studies are necessary to define the relevance of MELD-based indices in the individual surgical risk evaluation.