Características de pacientes con SARS-CoV-2 en estado crítico en un centro COVID-19 de referencia en Uruguay

Introducción: la pandemia de COVID-19 produjo una alta mortalidad en el mundo. Sin embargo, las presentaciones más críticas de la enfermedad han sido poco caracterizadas en nuestra región. Objetivo: estudiar la presentación clínica, evolución y mortalidad en pacientes ingresados en la unidad de medicina intensiva de un centro COVID-19 de referencia. Pacientes y método: estudio clínico, prospectivo, observacional de SARS-CoV-2 durante las primeras etapas de la pandemia en Uruguay. Se definió mortalidad en unidad de cuidados intensivos (UCI) como desenlace primario. Resultados: en 274 pacientes, la edad mediana fue de 65 años (IQR 54-73), el sexo masculino representó el 57% y el índice de Charlson tuvo una mediana de 3 (IQR 2-5). La mortalidad en UCI fue 59,9%. Las principales causas de muerte fueron: hipoxemia refractaria, disfunción orgánica múltiple y shock refractario. La edad (Odds Ratio (OR) = 1,06; IC de 95% 1,03 - 1,09), ocupación de camas (OR = 1,04, IC 95%: 1,02 - 1,07), sexo masculino (OR = 2,14, IC 95%: 0,93 - 5,06), ventilación mecánica invasiva (OR = 51,7, IC 95%: 16,5 - 208,6), coinfección al ingreso (OR = 2,34, IC 95%: 0,88 - 6,77) y enfermedad renal crónica previa (OR = 13,1, IC 95%: 2,29 - 129,2) fueron predictores independientes de mortalidad. La primera ola de la pandemia se produjo por la circulación de las variantes P.6 y P.1 del coronavirus, en una población con muy bajo porcentaje de vacunación (8%). Conclusiones: estos resultados en pacientes críticos aportan una descripción detallada del impacto de la pandemia por SARS-CoV-2 en un centro de referencia y constituyen una base para enfrentar futuros eventos epidémicos.

Introduction: COVID-19 has caused high mortality worldwide. However, the most critical presentations of the disease have been poorly characterized in our region. Objective: to study the clinical presentation, progression, and mortality in patients admitted to the Intensive Care Unit (ICU) of a COVID-19 Reference Center. Patients and methods: clinical, prospective, observational study of SARS-CoV-2 during the early stages of the pandemic in Uruguay. ICU mortality was defined as the primary outcome. Results: in 274 patients, the median age was 65 years (IQR 54-73), male gender accounted for 57%, and the Charlson Index was 3 (IQR 2-5). ICU mortality was 59.9%. The main causes of death were refractory hypoxemia, multiple organ dysfunction, and refractory shock. Age (Odds Ratio (OR) = 1.06; 95% CI 1.03 - 1.09), bed occupancy (OR= 1.04, 95% CI: 1.02 -1.07), male gender (OR= 2.14, 95% CI 0.93 - 5.06), invasive mechanical ventilation (OR= 51.7, 95% CI 16.5 - 208.6), coinfection at admission (OR= 2.34, 95% CI 0.88 - 6.77), and pre-existing chronic kidney disease (OR= 13.1, 95% CI 2.29 - 129.2) were independent predictors of mortality. The first wave of the pandemic was driven by the circulation of the P.6 and P.1 variants of the coronavirus in a population with a very low vaccination percentage (8%). Conclusions: these results in critical patients provide a detailed description of the impact of the SARS-CoV-2 pandemic in a reference center and serve as a foundation for addressing future epidemic events.

Introdução: a COVID-19 causou alta morbimortalidade em todo o mundo, embora as formas graves da doença tenham sido pouco caracterizadas nos países da América Latina. Objetivos: analisar o quadro clínico, a evolução e a mortalidade em pacientes com COVID-19 atendidos em uma unidade de terapia intensiva (UTI) em um Centro de Referência. Métodos: Estudo clínico, prospectivo e observacional de pacientes com SARS-CoV-2 durante a primeira onda da pandemia no Uruguai. A mortalidade na UTI foi o resultado primário. Resultados: oram estudados 274 pacientes, com uma mediada de idade de 65 anos (IQR 54-73), sendo a maioria do sexo masculino (57%). O índice de Charlson foi de 3 (IQR 2-5). A mortalidade geral na UTI foi de 59,9%. As principais causas de morte foram hipoxemia refratária, disfunção orgânica múltipla e choque refratário. A idade (Odds Ratio (OR) = 1,06; IC 95% 1,03-1,09), ocupação de leitos (OR = 1,04; IC 95%: 1,02-1,07), sexo masculino (OR = 2,14; IC 95%: 0,93-5,06), ventilação mecânica invasiva (OR = 51,7; IC 95%: 16,5-208,6), coinfecção na admissão (OR = 2,34; IC 95%: 0,88-6,77) e doença renal crônica pré-existente (OR = 13,1; IC 95%: 2,29-129,2) foram preditores independentes de mortalidade. A primeira onda da pandemia foi impulsionada pela circulação das variantes P.6 e P.1 do SARS-CoV-2 em uma população com uma taxa de vacinação muito baixa (8%). Conclusões: esses resultados em pacientes críticos fornecem uma descrição detalhada do impacto da pandemia SARS-CoV-2 em um Centro de Referência e constituem uma base para o enfrentamento de futuros eventos epidêmicos.

What have we learned from a case of convalescent plasma treatment in a two-time kidney transplant recipient COVID-19 patient? A case report from the perspective of viral load evolution and immune response.

Coronavirus disease 2019 (COVID-19), an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, can have a wide range of clinical manifestations, ranging from asymptomatic disease to potentially life-threatening complications. Convalescent plasma therapy has been proposed as an effective alternative for the treatment of severe cases. The aim of this study was to follow a two-time renal transplant patient with severe COVID-19 treated with convalescent plasma over time from an immunologic and virologic perspective. A 42-year-old female patient, who was a two-time kidney transplant recipient, was hospitalized with COVID-19. Due to worsening respiratory symptoms, she was admitted to the intensive care unit, where she received two doses of convalescent plasma. We analyzed the dynamics of viral load in nasopharyngeal swab, saliva, and tracheal aspirate samples, before and after convalescent plasma transfusion. The levels of pro-inflammatory cytokines and antibody titers were also measured in serum samples. A significant decrease in viral load was observed after treatment in the saliva and nasopharyngeal swab samples, and a slight decrease was observed in tracheal aspirate samples. In addition, we found evidence of an increase in antibody titers after transfusion, accompanied by a decrease in the levels of several cytokines responsible for cytokine storm.

One-year monitoring SARS-CoV-2 RNA surface contamination in hospitals reveals no correlation with organic material and negative pressure as a limiting factor for contamination.

Understanding transmission routes of SARS-CoV-2 is crucial to establish effective interventions in healthcare institutions. Although the role of surface contamination in SARS-CoV-2 transmission has been controversial, fomites have been proposed as a contributing factor. Longitudinal studies about SARS-CoV-2 surface contamination in hospitals with different infrastructure (presence or absence of negative pressure systems) are needed to improve our understanding of their effectiveness on patient healthcare and to advance our knowledge about the viral spread. We performed a one-year longitudinal study to evaluate surface contamination with SARS-CoV-2 RNA in reference hospitals. These hospitals have to admit all COVID-19 patients from public health services that require hospitalization. Surfaces samples were molecular tested for SARS-CoV-2 RNA presence considering three factors: the dirtiness by measuring organic material, the circulation of a high transmissibility variant, and the presence or absence of negative pressure systems in hospitalized patients' rooms. Our results show that: (i) There is no correlation between the amount of organic material dirtiness and SARS-CoV-2 RNA detected on surfaces; (ii) SARS-CoV-2 high transmissible Gamma variant introduction significantly increased surface contamination; (iii) the hospital with negative pressure systems was associated with lower levels of SARS-CoV-2 surface contamination and, iv) most environmental samples recovered from contaminated surfaces were assigned as non-infectious. This study provides data gathered for one year about the surface contamination with SARS-CoV-2 RNA sampling hospital settings. Our results suggest that spatial dynamics of SARS-CoV-2 RNA contamination varies according with the type of SARS-CoV-2 genetic variant and the presence of negative pressure systems. In addition, we showed that there is no correlation between the amount of organic material dirtiness and the quantity of viral RNA detected in hospital settings. Our findings suggest that SARS CoV-2 RNA surface contamination monitoring might be useful for the understanding of SARS-CoV-2 dissemination with impact on hospital management and public health policies. This is of special relevance for the Latin-American region where ICU rooms with negative pressure are insufficient.

Compromiso renal en pacientes con COVID-19 severa y crítica / Kidney involvement in patients with severe and critical COVID-19 / Comprometimento renal em pacientes com COVID-19 grave e crítico

Introducción: la injuria renal aguda fue una complicación observada en forma frecuente en los pacientes críticos durante la pandemia por COVID-19. Objetivos: 1) determinar la incidencia de injuria renal aguda asociada a COVID-19 severa y crítica; 2) determinar la implicancia pronóstica en términos de morbimortalidad del compromiso renal. Materiales y métodos: estudio prospectivo, observacional y analítico de una cohorte de pacientes con COVID-19 severa y crítica ingresados a la Unidad de Medicina Intensiva del Hospital Español. Se realizó un análisis descriptivo y analítico (univariado y mutivariado) y se empleo un nivel estadístico de significación menor a 0,05. Resultados: n=233 pacientes con COVID-19 severa y crítica ingresados a la Unidad de Medicina Intensiva del Hospital Español entre 9/20 y 5/21. Injuria renal aguda asociada a COVID-19: 47,9% (107/233), injuria renal aguda severa (estadios KDIGO 2 y 3): 79,4% (85/107), injuria renal aguda nosocomial: 47,7% (52/107), enfermedad renal aguda: 41,1% (44/107), requerimiento de técnica de reemplazo renal: 29,9% (32/107). La mortalidad al alta de medicina intensiva en pacientes con injuria renal aguda: 72,9% (78/107) versus sin injuria renal aguda: 48,4% (61/126) (p=0,000). El análisis multivariado mostró como factor predictivo protectivo de riesgo de muerte al alta de medicina intensiva a la función renal normal al egreso (OR 0,055, IC 95%: 0,014-0,213, p= 0,000). Conclusiones: la incidencia de injuria renal aguda asociada a COVID-19 en medicina intensiva fue elevada, con un predominio de estadios 2-3 y se asoció con una mortalidad significativamente mayor. La normalización de la función renal se comportó como un factor predictivo protectivo de riesgo de muerte. El grado de soporte multiorgánico se asoció con un aumento progresivo de la mortalidad.

Introduction: acute renal injury was a frequently observed complication in critical patients during the COVID-19 pandemic. Objectives: 1) to determine the incidence of acute renal injury associated to severe and critical COVID-19; 2) to determine prognostic implications in terms of mobimortality of renal involvement. Method: prospective, observational and analytical study of a cohort of patients with severe and critical COVID-19 who were hospitalized in the Intensive Care Unit at Hospital Español. A descriptive and analytical study (single and multivariate) was performed using statistical significance level lower than 0.05. Results: there were 233 patients with severe and critical COVID-19 hospitalized in the Intensive Care Unit at Hospital Español between September 9 and May 21. Acute renal injury associated to COVID-19: 47.9% (107/233), severe acute renal injury (stages KDIGO 2 and 3): 79.4% (85/107), nosocomial acute renal injury: 47.7% (52/107), acute renal injury: 41.1% (44/107), renal replacement techniques requirement: 29.9% (32/107). Mortality upon discharge from Intensive Medicine in patients with acute renal injury was 72.9% (78/107), versus absence of acute renal injury: 48.4% (62/ 126)(p=.000). The multivariate analysis showed normal renal function upon discharge from hospital was the protective predictive factor for death upon discharge from Intensive Medicine (OR .055, IC 95%: 213-. 014/000). Conclusions: incidence of acute renal injury associated to COVID-19 was high in Intensive Medicine, with predominance of stages 2-3, and it was related to a significantly higher mortality. Normalization of renal function was a protective predictive factor for the risk of death. The degree of multi-organ support was associated to a progressive increase of mortality.

Introdução: a lesão renal aguda foi uma complicação frequentemente observada em pacientes críticos durante a pandemia de COVID-19. Objetivos: 1) determinar a incidência de lesão renal aguda associada à COVID-19 grave e crítica; 2-determinar a implicação prognóstica em termos de morbilidade e mortalidade do envolvimento renal. Materiais e métodos: estudo prospectivo, observacional e analítico de uma coorte de pacientes com COVID-19 grave e crítico internados na Unidade de Medicina Intensiva do Hospital Espanhol. Realizou-se análise descritiva e analítica (uni e multivariada) e um nível de significância estatística inferior a 0,05. Resultados: 233 pacientes com COVID-19 grave e crítico foram internados na Unidade de Terapia Intensiva do Hospital Espanhol entre 20 de setembro de 2020 e 21 de maio de 2021. Observou-se lesão renal aguda associada a COVID-19: 47,9 % (107/233), lesão renal aguda grave (KDIGO estágios 2 e 3): 79,4% (85/107), lesão renal aguda nosocomial: 47,7% (52/107), doença renal aguda: 41,1% (44/107), necessidade de técnica de substituição renal: 29,9% (32/107). A mortalidade na alta da terapia intensiva foi de 72,9% (78/107) em pacientes com lesão renal aguda versus 48,4% (61/126) sem lesão renal aguda com ( p= ,000). A análise multivariada mostrou função renal normal na alta como preditor protetor de risco de morte na alta da Unidade de Terapia Intensiva (OR 0,055, IC 95%: 0,014-0,213, p= 0,000). Conclusões: a incidência de lesão renal aguda associada à COVID-19 em terapia intensiva foi alta, com predominância dos estágios 2-3, e foi associada a mortalidade significativamente maior. A normalização da função renal comportou-se como um preditor protetor de risco de morte. O grau de suporte multiorgânico foi associado a um aumento progressivo da mortalidade.

The HASTER lncRNA promoter is a cis-acting transcriptional stabilizer of HNF1A.

The biological purpose of long non-coding RNAs (lncRNAs) is poorly understood. Haploinsufficient mutations in HNF1A homeobox A (HNF1A), encoding a homeodomain transcription factor, cause diabetes mellitus. Here, we examine HASTER, the promoter of an lncRNA antisense to HNF1A. Using mouse and human models, we show that HASTER maintains cell-specific physiological HNF1A concentrations through positive and negative feedback loops. Pancreatic ß cells from Haster mutant mice consequently showed variegated HNF1A silencing or overexpression, resulting in hyperglycaemia. HASTER-dependent negative feedback was essential to prevent HNF1A binding to inappropriate genomic regions. We demonstrate that the HASTER promoter DNA, rather than the lncRNA, modulates HNF1A promoter-enhancer interactions in cis and thereby regulates HNF1A transcription. Our studies expose a cis-regulatory element that is unlike classic enhancers or silencers, it stabilizes the transcription of its target gene and ensures the fidelity of a cell-specific transcription factor program. They also show that disruption of a mammalian lncRNA promoter can cause diabetes mellitus.

Molecular basis of cyclic tetra-oligoadenylate processing by small standalone CRISPR-Cas ring nucleases.

Standalone ring nucleases are CRISPR ancillary proteins, which downregulate the immune response of Type III CRISPR-Cas systems by cleaving cyclic oligoadenylates (cA) second messengers. Two genes with this function have been found within the Sulfolobus islandicus (Sis) genome. They code for a long polypeptide composed by a CARF domain fused to an HTH domain and a short polypeptide constituted by a CARF domain with a 40 residue C-terminal insertion. Here, we determine the structure of the apo and substrate bound states of the Sis0455 enzyme, revealing an insertion at the C-terminal region of the CARF domain, which plays a key role closing the catalytic site upon substrate binding. Our analysis reveals the key residues of Sis0455 during cleavage and the coupling of the active site closing with their positioning to proceed with cA4 phosphodiester hydrolysis. A time course comparison of cA4 cleavage between the short, Sis0455, and long ring nucleases, Sis0811, shows the slower cleavage kinetics of the former, suggesting that the combination of these two types of enzymes with the same function in a genome could be an evolutionary strategy to regulate the levels of the second messenger in different infection scenarios.

Peripheral and respiratory muscle impairment during murine acute lung injury.

Acute respiratory distress syndrome is associated with skeletal muscle compromise, which decreases survival and impairs functional capacity. A comparative analysis of peripheral and respiratory muscles' atrophy and dysfunction in acute lung injury (ALI) has not been performed. We aimed to evaluate diaphragmatic and peripheral muscle mass and contractility in an ALI animal model. ALI was induced in C57BL/6 mice by intratracheal lipopolysaccharides instillation. Muscle mass and in vitro contractility were evaluated at different time points in hindlimb soleus (slow-twitch) and extensor digitorum longus (EDL, fast-twitch), as well as in the main respiratory muscle diaphragm. Myogenic precursor satellite cell-specific transcription factor Pax7 expression was determined by Western blot. Lung injury was associated with atrophy of the three studied muscles, although it was more pronounced and persistent in the diaphragm. Specific contractility was reduced during lung injury in EDL muscle but restored by the time lung injury has resolved. Specific force was not affected in soleus and diaphragm. A persistent increase in Pax7 expression was detected in diaphragm and EDL muscles after induction of ALI, but not in soleus muscle. Different peripheral and respiratory skeletal muscles are distinctly affected during the course of ALI. Each of the studied muscles presented a unique pattern in terms of atrophy development, contractile dysfunction and Pax7 expression.

Genetic regulation of RNA splicing in human pancreatic islets.

BACKGROUND: Non-coding genetic variants that influence gene transcription in pancreatic islets play a major role in the susceptibility to type 2 diabetes (T2D), and likely also contribute to type 1 diabetes (T1D) risk. For many loci, however, the mechanisms through which non-coding variants influence diabetes susceptibility are unknown. RESULTS: We examine splicing QTLs (sQTLs) in pancreatic islets from 399 human donors and observe that common genetic variation has a widespread influence on the splicing of genes with established roles in islet biology and diabetes. In parallel, we profile expression QTLs (eQTLs) and use transcriptome-wide association as well as genetic co-localization studies to assign islet sQTLs or eQTLs to T2D and T1D susceptibility signals, many of which lack candidate effector genes. This analysis reveals biologically plausible mechanisms, including the association of T2D with an sQTL that creates a nonsense isoform in ERO1B, a regulator of ER-stress and proinsulin biosynthesis. The expanded list of T2D risk effector genes reveals overrepresented pathways, including regulators of G-protein-mediated cAMP production. The analysis of sQTLs also reveals candidate effector genes for T1D susceptibility such as DCLRE1B, a senescence regulator, and lncRNA MEG3. CONCLUSIONS: These data expose widespread effects of common genetic variants on RNA splicing in pancreatic islets. The results support a role for splicing variation in diabetes susceptibility, and offer a new set of genetic targets with potential therapeutic benefit.

Pancreas agenesis mutations disrupt a lead enhancer controlling a developmental enhancer cluster.

Sequence variants in cis-acting enhancers are important for polygenic disease, but their role in Mendelian disease is poorly understood. Redundancy between enhancers that regulate the same gene is thought to mitigate the pathogenic impact of enhancer mutations. Recent findings, however, have shown that loss-of-function mutations in a single enhancer near PTF1A cause pancreas agenesis and neonatal diabetes. Using mouse and human genetic models, we show that this enhancer activates an entire PTF1A enhancer cluster in early pancreatic multipotent progenitors. This leading role, therefore, precludes functional redundancy. We further demonstrate that transient expression of PTF1A in multipotent progenitors sets in motion an epigenetic cascade that is required for duct and endocrine differentiation. These findings shed insights into the genome regulatory mechanisms that drive pancreas differentiation. Furthermore, they reveal an enhancer that acts as a regulatory master key and is thus vulnerable to pathogenic loss-of-function mutations.

Renal histopathology in critically ill patients with Septic Acute Kidney Injury(S-AKI).

PURPOSE: To describe the kidney histopathology of patients with S-AKI and correlate the histological findings with AKI severity, presence of septic shock, and the degree of multiple organic dysfunction (MOD) using the SOFA score. MATERIALS AND METHODS: This was a prospective, observational, and analytical study of a cohort of critically ill patients with S-AKI who died from sepsis at the "Hospital Español" intensive care unit (ICU). Kidney necropsies were performed within 2 h after death. RESULTS: We considered twenty (20) patients, with all of them exhibiting S-AKI stage 3 at the same time. In renal histopathology analysis, nonspecific tubulointerstitial (TI) lesions were found in almost all patients (95%). The more frequently found nonspecific TI lesions involved leukocyte infiltration (85%). Necrotic TI lesions were found in 6 patients (30%), and necrotic tubular cell casts were the most frequent lesions (50% of patients). It was not possible to demonstrate an association between the presence of necrotic TI lesions and factors such as the APACHE II score, the global SOFA score, ICU stays, AKI length and renal replacement therapy (RRT). CONCLUSIONS: The main histopathological findings in kidney necropsies in patients with S-AKI KDIGO 3, showed nonspecific TI lesions, and TI necrosis was only observed in 30% of the cases; therefore, S-AKI cannot be considered to be synonymous with acute tubular necrosis (ATN).

Structural basis of cyclic oligoadenylate degradation by ancillary Type III CRISPR-Cas ring nucleases.

Type III CRISPR-Cas effector systems detect foreign RNA triggering DNA and RNA cleavage and synthesizing cyclic oligoadenylate molecules (cA) in their Cas10 subunit. cAs act as a second messenger activating auxiliary nucleases, leading to an indiscriminate RNA degradation that can end in cell dormancy or death. Standalone ring nucleases are CRISPR ancillary proteins which downregulate the strong immune response of Type III systems by degrading cA. These enzymes contain a CRISPR-associated Rossman-fold (CARF) domain, which binds and cleaves the cA molecule. Here, we present the structures of the standalone ring nuclease from Sulfolobus islandicus (Sis) 0811 in its apo and post-catalytic states. This enzyme is composed by a N-terminal CARF and a C-terminal wHTH domain. Sis0811 presents a phosphodiester hydrolysis metal-independent mechanism, which cleaves cA4 rings to generate linear adenylate species, thus reducing the levels of the second messenger and switching off the cell antiviral state. The structural and biochemical analysis revealed the coupling of a cork-screw conformational change with the positioning of key catalytic residues to proceed with cA4 phosphodiester hydrolysis in a non-concerted manner.

Emergence and Spread of a B.1.1.28-Derived P.6 Lineage with Q675H and Q677H Spike Mutations in Uruguay.

Uruguay controlled the viral dissemination during the first nine months of the SARS-CoV-2 pandemic. Unfortunately, towards the end of 2020, the number of daily new cases exponentially increased. Herein, we analyzed the country-wide genetic diversity of SARS-CoV-2 between November 2020 and April 2021. We identified that the most prevalent viral variant during the first epidemic wave in Uruguay (December 2020-February 2021) was a B.1.1.28 sublineage carrying Spike mutations Q675H + Q677H, now designated as P.6, followed by lineages P.2 and P.7. P.6 probably arose around November 2020, in Montevideo, Uruguay's capital department, and rapidly spread to other departments, with evidence of further local transmission clusters; it also spread sporadically to the USA and Spain. The more efficient dissemination of lineage P.6 with respect to P.2 and P.7 and the presence of mutations (Q675H and Q677H) in the proximity of the key cleavage site at the S1/S2 boundary suggest that P.6 may be more transmissible than other lineages co-circulating in Uruguay. Although P.6 was replaced by the variant of concern (VOC) P.1 as the predominant lineage in Uruguay since April 2021, the monitoring of the concurrent emergence of Q675H + Q677H in VOCs should be of worldwide interest.

REST is a major negative regulator of endocrine differentiation during pancreas organogenesis.

Multiple transcription factors have been shown to promote pancreatic ß-cell differentiation, yet much less is known about negative regulators. Earlier epigenomic studies suggested that the transcriptional repressor REST could be a suppressor of endocrinogenesis in the embryonic pancreas. However, pancreatic Rest knockout mice failed to show abnormal numbers of endocrine cells, suggesting that REST is not a major regulator of endocrine differentiation. Using a different conditional allele that enables profound REST inactivation, we observed a marked increase in pancreatic endocrine cell formation. REST inhibition also promoted endocrinogenesis in zebrafish and mouse early postnatal ducts and induced ß-cell-specific genes in human adult duct-derived organoids. We also defined genomic sites that are bound and repressed by REST in the embryonic pancreas. Our findings show that REST-dependent inhibition ensures a balanced production of endocrine cells from embryonic pancreatic progenitors.

Neonatal diabetes mutations disrupt a chromatin pioneering function that activates the human insulin gene.

Despite the central role of chromosomal context in gene transcription, human noncoding DNA variants are generally studied outside of their genomic location. This limits our understanding of disease-causing regulatory variants. INS promoter mutations cause recessive neonatal diabetes. We show that all INS promoter point mutations in 60 patients disrupt a CC dinucleotide, whereas none affect other elements important for episomal promoter function. To model CC mutations, we humanized an ∼3.1-kb region of the mouse Ins2 gene. This recapitulated developmental chromatin states and cell-specific transcription. A CC mutant allele, however, abrogated active chromatin formation during pancreas development. A search for transcription factors acting through this element revealed that another neonatal diabetes gene product, GLIS3, has a pioneer-like ability to derepress INS chromatin, which is hampered by the CC mutation. Our in vivo analysis, therefore, connects two human genetic defects in an essential mechanism for developmental activation of the INS gene.

Hyperoxia and Lungs: What We Have Learned From Animal Models.

Although oxygen (O2) is essential for aerobic life, it can also be an important source of cellular damage. Supra-physiological levels of O2 determine toxicity due to exacerbated reactive oxygen species (ROS) production, impairing the homeostatic balance of several cellular processes. Furthermore, injured cells activate inflammation cascades, amplifying the tissue damage. The lung is the first (but not the only) organ affected by this condition. Critically ill patients are often exposed to several insults, such as mechanical ventilation, infections, hypo-perfusion, systemic inflammation, and drug toxicity. In this scenario, it is not easy to dissect the effect of oxygen toxicity. Translational investigations with animal models are essential to explore injuring stimuli in controlled experimental conditions, and are milestones in understanding pathological mechanisms and developing therapeutic strategies. Animal models can resemble what happens in critical care or anesthesia patients under mechanical ventilation and hyperoxia, but are also critical to explore the effect of O2 on lung development and the role of hyperoxic damage on bronchopulmonary dysplasia. Here, we set out to review the hyperoxia effects on lung pathology, contributing to the field by describing and analyzing animal experimentation's main aspects and its implications on human lung diseases.

Central venous minus arterial carbon dioxide pressure to arterial minus central venous oxygen content ratio as an indicator of tissue oxygenation: a narrative review. / Proporção entre pressão venosa central menos arterial de dióxido de carbono e conteúdo arterial menos venoso central de oxigênio como indicador de oxigenação tissular: uma revisão narrativa.

The central venous minus arterial carbon dioxide pressure to arterial minus central venous oxygen content ratio (Pcv-aCO2/Ca-cvO2) has been proposed as a surrogate for respiratory quotient and an indicator of tissue oxygenation. Some small observational studies have found that a Pcv-aCO2/Ca-cvO2 > 1.4 was associated with hyperlactatemia, oxygen supply dependency, and increased mortality. Moreover, Pcv-aCO2/Ca-cvO2 has been incorporated into algorithms for tissue oxygenation evaluation and resuscitation. However, the evidence for these recommendations is quite limited and of low quality. The goal of this narrative review was to analyze the methodological bases, the pathophysiologic foundations, and the experimental and clinical evidence supporting the use of Pcv-aCO2/Ca-cvO2 as a surrogate for respiratory quotient. Physiologically, the increase in respiratory quotient secondary to critical reductions in oxygen transport is a life-threatening and dramatic event. Nevertheless, this event is easily noticeable and probably does not require further monitoring. Since the beginning of anaerobic metabolism is indicated by the sudden increase in respiratory quotient and the normal range of respiratory quotient is wide, the use of a defined cutoff of 1.4 for Pcv-aCO2/Ca-cvO2 is meaningless. Experimental studies have shown that Pcv-aCO2/Ca-cvO2 is more dependent on factors that modify the dissociation of carbon dioxide from hemoglobin than on respiratory quotient and that respiratory quotient and Pcv-aCO2/Ca-cvO2 may have distinct behaviors. Studies performed in critically ill patients have shown controversial results regarding the ability of Pcv-aCO2/Ca-cvO2 to predict outcome, hyperlactatemia, microvascular abnormalities, and oxygen supply dependency. A randomized controlled trial also showed that Pcv-aCO2/Ca-cvO2 is useless as a goal of resuscitation. Pcv-aCO2/Ca-cvO2 should be carefully interpreted in critically ill patients.

Proporção entre pressão venosa central menos arterial de dióxido de carbono e conteúdo arterial menos venoso central de oxigênio como indicador de oxigenação tissular: uma revisão narrativa / Central venous minus arterial carbon dioxide pressure to arterial minus central venous oxygen content ratio as an indicator of tissue oxygenation: a narrative review

RESUMO A proporção entre pressão venosa central menos arterial de dióxido de carbono e conteúdo de oxigênio arterial menos venoso central (Pcv-aCO2/Ca-cvO2) foi proposta como marcador substituto para quociente respiratório e indicador de oxigenação tissular. Alguns pequenos estudos observacionais identificaram que Pcv-aCO2/Ca-cvO2 acima de 1,4 se associa com hiperlactatemia, dependência de suprimento de oxigênio e maior mortalidade. Mais ainda, a Pcv-aCO2/Ca-cvO2 foi incorporada a algoritmos para avaliação da oxigenação tissular e ressuscitação. Contudo, a evidência para estas recomendações é bastante limitada e de baixa qualidade. O objetivo desta revisão narrativa foi analisar as bases metodológicas, os fundamentos fisiopatológicos e a evidência experimental e clínica para dar suporte à utilização da Pcv-aCO2/Ca-cvO2 como marcador substituto para quociente respiratório. De um ponto de vista fisiopatológico, o aumento do quociente respiratório secundariamente a reduções críticas no transporte de oxigênio é um evento dramático e com risco à vida. Entretanto, este evento é facilmente observável e provavelmente não demandaria maiores monitoramentos. Visto que o início do metabolismo anaeróbico é indicado pelo aumento súbito do quociente respiratório e que a faixa normal do quociente respiratório é ampla, o uso do ponto de corte definido como 1,4 para Pcv-aCO2/Ca-cvO2 não faz sentido. Estudos experimentais demonstraram que a Pcv-aCO2/Ca-cvO2 é mais dependente de fatores que modificam a dissociação do dióxido de carbono da hemoglobina do que do quociente respiratório, e o quociente respiratório e Pcv-aCO2/Ca-cvO2 podem ter comportamentos distintos. Estudos conduzidos em pacientes críticos demonstraram resultados controvertidos com relação à capacidade da Pcv-aCO2/Ca-cvO2 para predizer o desfecho, hiperlactatemia, anomalias microvasculares e dependência de suprimento de oxigênio. Um estudo randomizado controlado também demonstrou que a Pcv-aCO2/Ca-cvO2 é inútil como alvo para ressuscitação. A Pcv-aCO2/Ca-cvO2 deve ser interpretada com cautela em pacientes críticos.

ABSTRACT The central venous minus arterial carbon dioxide pressure to arterial minus central venous oxygen content ratio (Pcv-aCO2/Ca-cvO2) has been proposed as a surrogate for respiratory quotient and an indicator of tissue oxygenation. Some small observational studies have found that a Pcv-aCO2/Ca-cvO2 > 1.4 was associated with hyperlactatemia, oxygen supply dependency, and increased mortality. Moreover, Pcv-aCO2/Ca-cvO2 has been incorporated into algorithms for tissue oxygenation evaluation and resuscitation. However, the evidence for these recommendations is quite limited and of low quality. The goal of this narrative review was to analyze the methodological bases, the pathophysiologic foundations, and the experimental and clinical evidence supporting the use of Pcv-aCO2/Ca-cvO2 as a surrogate for respiratory quotient. Physiologically, the increase in respiratory quotient secondary to critical reductions in oxygen transport is a life-threatening and dramatic event. Nevertheless, this event is easily noticeable and probably does not require further monitoring. Since the beginning of anaerobic metabolism is indicated by the sudden increase in respiratory quotient and the normal range of respiratory quotient is wide, the use of a defined cutoff of 1.4 for Pcv-aCO2/Ca-cvO2 is meaningless. Experimental studies have shown that Pcv-aCO2/Ca-cvO2 is more dependent on factors that modify the dissociation of carbon dioxide from hemoglobin than on respiratory quotient and that respiratory quotient and Pcv-aCO2/Ca-cvO2 may have distinct behaviors. Studies performed in critically ill patients have shown controversial results regarding the ability of Pcv-aCO2/Ca-cvO2 to predict outcome, hyperlactatemia, microvascular abnormalities, and oxygen supply dependency. A randomized controlled trial also showed that Pcv-aCO2/Ca-cvO2 is useless as a goal of resuscitation. Pcv-aCO2/Ca-cvO2 should be carefully interpreted in critically ill patients.

Los seniors en la publicidad española: tensiones entre la investigación, planificación y la representación de los mayores en los anuncios / Senior citizens in Spanish advertising: tensions between research, planning and representation of the elderly in advertisements / Idosos na publicidade espanhola: tensões entre pesquisa, planejamento e representação dos mais velhos nos anúncios

El presente artículo analiza las continuidades y discontinuidades que se producen entre la investigación, la planificación de medios y la construcción de las representaciones sobre los mayores en la publicidad española. El estudio, centrado en los anuncios sobre envejecimiento, mayores y salud, se ha implementado desde una triangulación metodológica que incluye técnicas como el análisis del discurso, la encuesta y la revisión de literatura sobre segmentación publicitaria. Las conclusiones apuntan a una restricción de las representaciones puestas en juego en los anuncios respecto a la diversidad planteada por los profesionales y en la literatura científica. Se plantea el reto de superar las visiones excesivamente individualistas del mayor y de la gestión de su salud, al tiempo que emerge como alternativa la concepción de la salud como un espacio simbólico de conflicto y negociación.(AU)

The article analyzes the continuities and descontinuities that occur between research, media planning and the construction of representations of senior citizens in Spanish advertising. The study, centered on advertisements about aging, senior citizens and health, employed a methodological triangulation that included techniques like discourse analysis, research, and a literature review on segmentation in advertising. The conclusions point to a limitation of the representations called into play in advertisements regarding the diversity established by professionals and in the scientific literature. It is necessary to face the challenge of overcoming the excessively individualistic views of the elderly and of the management of their health. At the same time, the conception of health as a symbolic space of conflict and negotiation emerges as an alternative..(AU)

O presente artigo analisa as continuidades e descontinuidades que ocorrem entre a pesquisa, o planejamento de mídia e a construção das representações dos idosos na publicidade espanhola. O estudo, centrado nos anúncios sobre envelhecimento, idosos e saúde, foi implementado a partir de uma triangulação metodológica que incluiu técnicas como a análise do discurso, a pesquisa e a revisão de literatura sobre segmentação publicitária. As conclusões apontam para uma limitação das representações postas em jogo nos anúncios a respeito da diversidade estabelecida pelos profissionais e na literatura científica. Constitui-se o desafio de superar as visões excessivamente individualistas sobre o idoso e da gestão de sua saúde, ao tempo que emerge como alternativa a concepção da saúde como um espaço simbólico de conflito e negociação..(AU)

Human pancreatic islet three-dimensional chromatin architecture provides insights into the genetics of type 2 diabetes.

Genetic studies promise to provide insight into the molecular mechanisms underlying type 2 diabetes (T2D). Variants associated with T2D are often located in tissue-specific enhancer clusters or super-enhancers. So far, such domains have been defined through clustering of enhancers in linear genome maps rather than in three-dimensional (3D) space. Furthermore, their target genes are often unknown. We have created promoter capture Hi-C maps in human pancreatic islets. This linked diabetes-associated enhancers to their target genes, often located hundreds of kilobases away. It also revealed >1,300 groups of islet enhancers, super-enhancers and active promoters that form 3D hubs, some of which show coordinated glucose-dependent activity. We demonstrate that genetic variation in hubs impacts insulin secretion heritability, and show that hub annotations can be used for polygenic scores that predict T2D risk driven by islet regulatory variants. Human islet 3D chromatin architecture, therefore, provides a framework for interpretation of T2D genome-wide association study (GWAS) signals.

Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial.

Importance: Abnormal peripheral perfusion after septic shock resuscitation has been associated with organ dysfunction and mortality. The potential role of the clinical assessment of peripheral perfusion as a target during resuscitation in early septic shock has not been established. Objective: To determine if a peripheral perfusion-targeted resuscitation during early septic shock in adults is more effective than a lactate level-targeted resuscitation for reducing mortality. Design, Setting, and Participants: Multicenter, randomized trial conducted at 28 intensive care units in 5 countries. Four-hundred twenty-four patients with septic shock were included between March 2017 and March 2018. The last date of follow-up was June 12, 2018. Interventions: Patients were randomized to a step-by-step resuscitation protocol aimed at either normalizing capillary refill time (n = 212) or normalizing or decreasing lactate levels at rates greater than 20% per 2 hours (n = 212), during an 8-hour intervention period. Main Outcomes and Measures: The primary outcome was all-cause mortality at 28 days. Secondary outcomes were organ dysfunction at 72 hours after randomization, as assessed by Sequential Organ Failure Assessment (SOFA) score (range, 0 [best] to 24 [worst]); death within 90 days; mechanical ventilation-, renal replacement therapy-, and vasopressor-free days within 28 days; intensive care unit and hospital length of stay. Results: Among 424 patients randomized (mean age, 63 years; 226 [53%] women), 416 (98%) completed the trial. By day 28, 74 patients (34.9%) in the peripheral perfusion group and 92 patients (43.4%) in the lactate group had died (hazard ratio, 0.75 [95% CI, 0.55 to 1.02]; P = .06; risk difference, -8.5% [95% CI, -18.2% to 1.2%]). Peripheral perfusion-targeted resuscitation was associated with less organ dysfunction at 72 hours (mean SOFA score, 5.6 [SD, 4.3] vs 6.6 [SD, 4.7]; mean difference, -1.00 [95% CI, -1.97 to -0.02]; P = .045). There were no significant differences in the other 6 secondary outcomes. No protocol-related serious adverse reactions were confirmed. Conclusions and Relevance: Among patients with septic shock, a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality. Trial Registration: ClinicalTrials.gov Identifier: NCT03078712.