Who approves/pays for additional monitoring?

Major considerations in the provision of healthcare are availability, affordability, accessibility, and appropriateness, especially in the setting of heart failure where disease burden is growing, developments have been rapid and newer biomarkers, diagnostic and imaging techniques, monitoring systems, devices, procedures, and drugs have all been developed in a relatively short period of time. Many monitoring and diagnostic systems have been developed but the disproportionate cost of conducting trials of their effectiveness has limited their uptake. There are added complexities, in that the utilization of doctors for the supervision of the monitoring results may be optimal in one setting and not in another because of differences in the characteristics of organization of healthcare provision, making even interpretation of the trials we have had, still difficult to interpret. New technologies are continuously changing the approach to healthcare and will reshape the structure of the healthcare systems in the future. Mobile technologies can empower patients and carers by giving them more control over their health and social care needs and reducing their dependence on healthcare professionals for monitoring their health, but a significant problem is the integration of the multitude of monitored parameters with clinical data and the recognition of intervention thresholds. Digital technology can help, but we need to prove its cost/efficacy and how it will be paid for. Governments in many European countries and worldwide are trying to establish frameworks that promote the convergence of standards and regulations for telemedicine solutions and yet simultaneously health authorities are closely scrutinizing healthcare spending, with the objective of reducing and optimizing expenditure in the provision of health services. There are multiple factors to be considered for the reimbursement models associated with the implementation of physiological monitoring yet it remains a challenge in cash-strapped health systems

Hyperkalemia and Renin-Angiotensin-Aldosterone System Inhibitors Dose Therapy in Heart Failure With Reduced Ejection Fraction.

Renin-angiotensin-aldosterone system inhibitors (RAASi) are known to improve outcomes in patients who have heart failure with reduced ejection fraction (HFrEF). To reduce mortality in these patients, RAASi should be uptitrated to the maximally tolerated dose. However, RAASi may also cause hyperkalemia. As a result of this side-effect, doses of RAASi are reduced, discontinued and seldom reinstated. Thus, the therapeutic target needed in these patients is often not reached because of hyperkalemia. Also, submaximal dosing of RAASi may be a result of symptomatic hypotension, syncope, hypoperfusion, reduced kidney function and other factors. The reduction of RAASi dose leads to adverse outcomes, such as an increased risk of mortality. Management of these side-effects is pivotal to maximise the use of RAASi in HFrEF, particularly in high-risk patients

Assessing the Water Energy Nexus and Sustainability Benefits of a Closed Loop Water Treatment System in Qatar

Qatar has very limited freshwater resources. This paper assesses the sustainability implications of using bore water and treated sewage effluent (TSE) for residential water supply (for non-drinking purposes) in a residential compound in Doha, Qatar. The treated bore water was considered for non-drinking domestic applications in kitchens and bathrooms, while the TSE was considered for use in air conditioning cooling systems. Excess TSE was also considered for irrigation use. Water quality from the aquifer in the Al Waab area of Doha was used to design a pre-treatment and desalination process to produce potable water for a local residential compound consisting of 113 villas. The wastewater from these villas consisted of both grey and black water and was proposed to be treated in a sewage treatment plant to produce TSE to operate the cooling systems in the compound. The reject brine from the desalination process was designed to be discharged to sea through the storm water network and the blowdown water from the cooling systems was considered for use in irrigation in surrounding areas. A lifecycle assessment of this closed loop water recycling system was conducted to assess the potential sustainability benefits of reduced greenhouse gas emissions, embodied energy consumption, and water consumption, together with cost savings and employment generation from these water recycling options

Elevated pulse pressure is associated with hemolysis, proteinuria and chronic kidney disease in sickle cell disease

A seeming paradox of sickle cell disease is that patients do not suffer from a high prevalence of systemic hypertension in spite of endothelial dysfunction, chronic inflammation and vasculopathy. However, some patients do develop systolic hypertension and increased pulse pressure, an increasingly recognized major cardiovascular risk factor in other populations. Hence, we hypothesized that pulse pressure, unlike other blood pressure parameters, is independently associated with markers of hemolytic anemia and cardiovascular risk in sickle cell disease. We analyzed the correlates of pulse pressure in patients (n 5 661) enrolled in a multicenter international sickle cell trial. Markers of hemolysis were analyzed as independent variables and as a previously validated hemolytic index that includes multiple variables. We found that pulse pressure, not systolic, diastolic or mean arterial pressure, independently correlated with high reticulocyte count (beta 5 2.37, p 5 0.02) and high hemolytic index (beta 5 1.53, p50.002) in patients with homozygous sickle cell disease in two multiple linear regression models which include the markers of hemolysis as independent variables or the hemolytic index, respectively. Pulse pressure was also independently associated with elevated serum creatinine (beta 5 3.21, p 5 0.02), and with proteinuria (beta 5 2.52, p 5 0.04). These results from the largest sickle cell disease cohort to date since the Cooperative Study of Sickle Cell Disease show that pulse pressure is independently associated with hemolysis, proteinuria and chronic kidney disease. We propose that high pulse pressure may be a risk factor for clinical complications of vascular dysfunction in sickle cell disease. Longitudinal and mechanistic studies should be conducted to confirm these hypotheses

Simple thalidomide analogs in melanoma: Synthesis and biological activity

Thalidomide is an old well-known drug that is still of clinical interest, despite its terato-genic activities, due to its antiangiogenic and immunomodulatory properties. Therefore, efforts to design safer and effective thalidomide analogs are continually ongoing. Research studies on thalidomide analogs have revealed that the phthalimide ring system is an essential pharmacophoric fragment; thus, many phthalimidic compounds have been synthesized and evaluated as anticancer drug candidates. In this study, a panel of selected in vitro assays, performed on a small series of phthalimide derivatives, allowed us to characterize compound 2k as a good anticancer agent, acting on A2058 melanoma cell line, which causes cell death by apoptosis due to its capability to inhibit tubulin polymerization. The obtained data were confirmed by in silico assays. No cytotoxic effects on normal cells have been detected for this compound that proves to be a valid candidate for further investigations to achieve new insights on possible mechanism of action of this class of compounds as anticancer drugs

INTERACCIÓN ENTRE TROGIDOS (COLEOPTERA: TROGIDAE) Y TORTUGAS MARINAS (REPTILIA: CHELONIIDAE) EN EL PACIFICO MEXICANO

From 1987 to 2000, great embryo and hatchling mortality (>70%) of sea turtles (Lepidochelys) has been reported in the nesting beach La Escobilla, Oaxaca, México. The embryo death in this beach was attributed by some authors mainly to the egg predation by a beetle belonging to the family Trogidae. Taxonomic examination confirmed that the beetle at La Escobilla was Omorgus suberosus Fabricius. This species has been also reported in some other nesting beaches of the Pacific, but in none of the Atlantic Ocean. The present paper, based on the literature published about both Omorgus and marine turtles (Lepidochelys), describes the interaction between Omorgus and sea turtles, and discusses the predatory role of Omorgus suberosus. Based in our research, there was insufficient evidence to point O. suberosus as a predator especialist in turtle eggs; the beetle seems to be a highly efficient and facultative necrophagous- saprophagous organism.Desde 1987 a 2000 se ha reportado gran mortalidad (>70%) de tortugas marinas del género Lepidochelys en la playa La Escobilla, en Oaxaca, México. Aunque la causa de tal mortalidad se debe a factores diversos, algunos autores la atribuyen mayormente a la depredación de embriones y crías que hace un escarabajo de la familia Trogidae. La revisión taxonómica confirmó que el escarabajo presente en La Escobilla es Omorgus suberosus Fabricius. Este escarabajo habita también otras playas de anidación de tortugas marinas del Pacífico, pero no del Atlántico. El presente trabajo, basado en la revisión y síntesis de la literatura publicada sobre el tema, describe la interacción Omorgus-tortugas marinas (Lepidochelys) y cuestiona el papel depredador de O. suberosus. No se encontró evidencia suficiente de que Omorgus sea un depredador especialista en embriones de tortugas marinas; por el contrario, parece ser un necrófago- saprófago facultativo muy eficiente en la remoción de materiales orgánicos en playas de anidación de tortugas marinas

Precision Cardiology: Phenotype-targeted Therapies for HFmrEF and HFpEF.

Heart failure with mid-range ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF) represent over half of heart failure cases but lack proven effective therapies beyond sodium-glucose cotransporter 2 inhibitor and diuretics. HFmrEF and HFpEF are heterogeneous conditions requiring precision phenotyping to enable tailored therapies. This review covers concepts on precision medicine approaches for HFmrEF and HFpEF. Areas discussed include HFmrEF mechanisms, anti-inflammatory and antifibrotic treatments for obesity-related HFpEF, If inhibition for HFpEF with atrial fibrillation, and mineralocorticoid receptor antagonism for chronic kidney disease-HFpEF. Incorporating precision phenotyping and matched interventions in HFmrEF and HFpEF trials will further advance therapy compared to blanket approaches

Brain natriuretic peptide: Much more than a biomarker.

Brain natriuretic peptide (BNP) modulates several biological processes by activating the natriuretic peptide receptor A (NPR-A). Atria and ventricles secrete BNP. BNP increases natriuresis, diuresis and vasodilatation, thus resulting in a decreased cardiac workload. BNP and NT-proBNP, which is the biologically inactive N-terminal portion of its pro-hormone, are fast and sensitive biomarkers for diagnosing heart failure. The plasma concentrations of both BNP and NT-proBNP also correlate with left ventricular function in patients with acute exacerbation of COPD, even without history of heart failure. Several studies have been conducted in vitro and in vivo, both in animals and in humans, in order to assess the potential role of the NPR-A activation as a novel therapeutic approach for treating obstructive pulmonary disorders. Unfortunately, these studies have yielded conflicting results. Nevertheless, further recent specific studies, performed in ex vivo models of asthma and COPD, have confirmed the bronchorelaxant effect of BNP and its protective role against bronchial hyperresponsiveness in human airways. These studies have also clarified the intimate mechanism of action of BNP, represented by an autocrine loop elicited by the activation of NPR-A, localized on bronchial epithelium, and the relaxant response of the surrounding ASM, which does not expresses NPR-A. This review explores the teleological activities and paradoxical effects of BNP with regard to chronic obstructive respiratory disorders, and provides an excursus on the main scientific findings that explain why BNP should be considered much more than a biomarker