Elaboração e implementação de protocolo de controle glicêmico em pacientes não críticos hospitalizados em hospital terciário

Introduction: Hyperglycemia in diabetic and non-diabetic patients hospitalized in noncritically ill condition is common in general hospitals. Several observational studies with inpatients show a strong correlation between hyperglycemia and increased risk of adverse clinical outcomes, such as prolonged hospitalization, higher infections rates, increased morbidity and mortality and increased hospital costs. Although current guidelines recommend that hyperglycemic patients should be treated with basal-bolus insulin regimen, a more physiological and effective method, in most hospitals it still prevails the use of the sliding scale, treatment associated with increased glycemic variability and poor prognosis. Purpose: Develop and implement an institutional protocol for glycemic control in noncritically ill inpatients. Methods: The study was conducted at Hospital São Paulo of the Paulista School of Medicine - Federal University of São Paulo. The project was developed in three phases. The first phase consisted of the theoretical foundation and development of a pilot protocol according to the current guidelines and based on existing protocols at other institutions. In the second phase, meetings were held with the Clinical and Technical Directors and with the management teams of nutrition, laboratory and nursing to adapt the pilot protocol to the needs and technical and human conditions of the hospital. The last phase was based on an outreach program for the professionals involved in the inpatients care. Results: a protocol for glycemic control for noncritically ill patients customized according to the complexity and the material and human resources of the Hospital São Paulo was prepared. The protocol was designed in the form of flow charts, one for the treatment of hyperglycemia, using the basal-bolus insulin therapy regimen, and a second one for the treatment of hypoglycemia. It was approved by the board of the Hospital São Paulo. The outreach plan included training of professionals involved in the care of hospitalized patients through printed materials, lectures and teaching materials available on the Internet. After training, the project was implemented in 30 medical and surgical wards of the institution. Conclusion: The development and implementation of an institutional protocol for glycemic control is a potentially effective way to increase security by treating hyperglycemic patients and improve the quality of care provided by health professionals. This deployment model can guide other hospitals in their initiatives for the management of blood glucose levels in hospitalized patients.Introdução: A hiperglicemia em pacientes diabéticos e não diabéticos internados em estado não crítico é comum em hospitais gerais. Vários estudos observacionais em pacientes hospitalizados apontam forte correlação entre hiperglicemia e maior risco de desfechos clínicos desfavoráveis, tais como internações prolongadas, maiores taxas de infecções, aumento da morbimortalidade e aumento de custos hospitalares. Embora as diretrizes atuais recomendem que os pacientes hiperglicêmicos sejam tratados com esquema de insulinização basal-bolus, método este mais fisiológico e eficaz, na grande maioria dos hospitais ainda prevalece o uso de escalas progressivas de insulina de acordo com a glicemia, regime associado com maior variabilidade glicêmica e pior prognóstico. Objetivo: Elaborar e implementar um protocolo institucional para controle glicêmico em pacientes não críticos internados. Métodos: O estudo foi conduzido no Hospital São Paulo da Escola Paulista de Medicina - Universidade Federal de São Paulo. Este projeto foi desenvolvido em três fases. A primeira fase consistiu na fundamentação teórica e elaboração de um protocolo piloto de acordo com as diretrizes atuais e baseado em protocolos já existentes em outras instituições. Na segunda fase foram realizadas reuniões com as Diretorias Clínica e Técnica e equipes de gestão de nutrição, laboratório e enfermagem para adequação do protocolo piloto às necessidades e condições técnicas e humanas do hospital. A última fase fundamentou-se em organizar um programa de divulgação para os profissionais envolvidos no cuidado do paciente hospitalizado. Resultados: Foi elaborado um protocolo para controle glicêmico de pacientes não xii críticos customizado de acordo com a complexidade e com os recursos materiais e humanos do Hospital São Paulo. O protocolo foi desenvolvido na forma de dois fluxogramas, sendo um para o tratamento da hiperglicemia, com o esquema de insulinoterapia basal-bolus, e um segundo para o tratamento da hipoglicemia. Este protocolo foi aprovado pela diretoria do hospital. O plano de divulgação contou com treinamento dos profissionais envolvidos no atendimento dos pacientes internados através de material impresso, aulas expositivas e material didático disponibilizado via internet. Após o treinamento, o projeto foi implementado em 30 enfermarias clínicas e cirúrgicas da instituição. Conclusão: A elaboração e implementação de um protocolo institucional para controle glicêmico consiste em uma forma potencialmente eficiente de aumentar a segurança ao tratar os pacientes hiperglicêmicos e melhorar a qualidade do atendimento prestado pelos profissionais de saúde. Este modelo de implementação poderá guiar outros hospitais nas suas iniciativas para o manejo da glicemia em pacientes internados.Dados abertos - Sucupira - Teses e dissertações (2013 a 2016

De Novo VPS4A Mutations Cause Multisystem Disease with Abnormal Neurodevelopment.

The endosomal sorting complexes required for transport (ESCRTs) are essential for multiple membrane modeling and membrane-independent cellular processes. Here we describe six unrelated individuals with de novo missense variants affecting the ATPase domain of VPS4A, a critical enzyme regulating ESCRT function. Probands had structural brain abnormalities, severe neurodevelopmental delay, cataracts, growth impairment, and anemia. In cultured cells, overexpression of VPS4A mutants caused enlarged endosomal vacuoles resembling those induced by expression of known dominant-negative ATPase-defective forms of VPS4A. Proband-derived fibroblasts had enlarged endosomal structures with abnormal accumulation of the ESCRT protein IST1 on the limiting membrane. VPS4A function was also required for normal endosomal morphology and IST1 localization in iPSC-derived human neurons. Mutations affected other ESCRT-dependent cellular processes, including regulation of centrosome number, primary cilium morphology, nuclear membrane morphology, chromosome segregation, mitotic spindle formation, and cell cycle progression. We thus characterize a distinct multisystem disorder caused by mutations affecting VPS4A and demonstrate that its normal function is required for multiple human developmental and cellular processes.This work was supported by: UK Medical Research Council Project Grants [MR/M00046X/1], [MR/R026440/1] and Project grant from National Institute of Health Research Biomedical Research Centre at Addenbrooke's Hospital (to E.R.), Fondazione Bambino Gesù (Vite Coraggiose) and Italian Ministry of Health (CCR-2017-23669081) (to M.T.), National Institute for Health Research (NIHR) for the Cambridge Biomedical Research Centre and NIHR BioResource (Grant Number RG65966) (to F.L.R.), and a Sir Henry Dale Fellowship jointly funded by the Wellcome Trust and the Royal Society (Grant Number 216370/Z/19/Z) (to J.E.). CIMR was supported by a Wellcome Trust Strategic Award [100140] and Equipment Grant [093026]. This research was made possible through access to the data and findings generated by the 100,000 Genomes Project. The 100,000 Genomes Project is managed by Genomics England Limited (a wholly owned company of the Department of Health and Social Care). The 100,000 Genomes Project is funded by the National Institute for Health Research and NHS England. The Wellcome Trust, Cancer Research UK and the Medical Research Council have also funded research infrastructure. The 100,000 Genomes Project uses data provided by patients and collected by the National Health Service as part of their care and support

Hyperactive HRAS dysregulates energetic metabolism in fibroblasts from patients with Costello syndrome via enhanced production of reactive oxidizing species

Germline-activating mutations in HRAS cause Costello syndrome (CS), a cancer prone multisystem disorder characterized by reduced postnatal growth. In CS, poor weight gain and growth are not caused by low caloric intake. Here, we show that constitutive plasma membrane translocation and activation of the GLUT4 glucose transporter, via reactive oxygen species-dependent AMP-activated protein kinase α and p38 hyperactivation, occurs in primary fibroblasts of CS patients, resulting in accelerated glycolysis and increased fatty acid synthesis and storage as lipid droplets. An accelerated autophagic flux was also identified as contributing to the increased energetic expenditure in CS. Concomitant inhibition of p38 and PI3K signaling by wortmannin was able to rescue both the dysregulated glucose intake and accelerated autophagic flux. Our findings provide a mechanistic link between upregulated HRAS function, defective growth and increased resting energetic expenditure in CS, and document that targeting p38 and PI3K signaling is able to revert this metabolic dysfunction.n

Zimmerman Laband syndrome: identification of novel disease causative genes and characterization of the underlying molecular mechanisms

Zimmermann-Laband syndrome (ZLS; MIM135500) is a rare developmental disorder characterized by facial dysmorphism, including coarsening of the face, bulbous soft nose and gingival enlargement, and nail aplasia or hypoplasia, hypertrichosis, and intellectual disability, with or without seizures. Recently, our group reported that heterozygous missense mutations in KCNH1 and ATP6V1B2 genes account for a significant proportion of ZLS cases (Kortüm & Caputo et al., 2015). KCNH1 encodes the voltage-gated K+ channel Eag1 (Kv10.1) (Garg et al., 2012), that is highly expressed in brain. ATP6V1B2 encodes the B2 subunit of the multimeric vacuolar H+ ATPase. Notably, while biochemical and functional studies shed light on the molecular mechanisms underlying KCNH1 mutations, no data has been collected on the consequences of the ATP6V1B2 mutation on the assembly/function of the ATPase complex. Based on these considerations, major goals of my PhD project are to identify the “missing” disease-gene(s) implicated in ZLS and to explore the functional impact of the ATP6V1B2 mutations by using cellular and yeast models. With the aim of identifying novel ZLS causative gene(s), a selected panel of clinically well-characterized ZLS patients was enrolled to be analyzed by WES. WES analysis was performed in five subjects negative for mutations in KCNH1 and ATP6V1B2. This approach allowed us to identify a de novo missense mutation in ATP6V1C1 (c.865G>A; p.Glu289Lys) in a patient showing coarse face, gingival hyperplasia and aplasia/hypoplasia of nails and terminal phalanges. Interestingly, these clinical features resembles the cardinal signs observed in the ATP6V1B2 mutation-positive subjects that has been described by our group (Kortüm & Caputo et al., 2015). Of note, mosaicism for the ATP6V1C1 mutant allele was recognized in the father’s proband, consistent with the relatively mild clinical ZLS features observed in this subject. ATP6V1C1 encodes the C1 subunit of the V1 subcomplex of the V-ATPase (the same complex involving ATP6V1B2). 3D modeling indicated a probably deleterious effect of the Glu289Lys amino acid substitution on proper assembly and activity of the ATPase complex. To test this hypothesis and explore the impact of the ATP6V1B2 and ATP6V1C1 mutations on subcellular localization, lysosomal function, and autophagy, we performed functional studies. These assays allowed to demonstrate that in fibroblasts derived from the patient carrying the Arg485Pro change, the ATP6V1B2 subunit co-localize predominantly with perinuclear lysosomes, suggesting that the V-ATPase containing the mutant subunit does not work properly and might prevent the lysosomes to reach the right pH required for proper localization within the cell. Confocal microscopy analysis revealed defects in the de-quenching process of DQ-BSA in fibroblasts from ZLS patients, indicating impaired lysosomal function. Furthermore, ceramide and cholesterol were strongly enhanced in patient’s fibroblasts compared to control cells, indicating a disruptive effect of the disease-causing mutations on ceramide and cholesterol catabolism. Finally, fibroblasts from ZLS patients displayed high levels of LC3-II in basal condition, and higher levels of this protein compared to control cells at any times after starvation. In the presence of the vacuolar V-ATPase inhibitor bafilomycin A1, we did not observe a significant LC3 increase in ZLS starved cells. These data indicate impaired autophagic flux in ZLS. Yeast data confirmed the deleteriousness of both the ATP6V1B2 mutations, with a stronger disrupting effect of the Arg485 change, while no effect of the mutant ATP6V1C1 subunit was observed in this system. Overall, these findings provide first evidence that ZLS caused by dysregulated V-ATPase function underlies a previously unrecognized metabolic disorder characterized by aberrant storage of undigested material inside the cell

Management of postprandial hypoglycemia after bariatric surgery: Empagliflozin, a new therapeutic option?

Introdução: A cirurgia bariátrica é uma opção de tratamento para a obesidade grave, porém algumas complicações podem ocorrer após a cirurgia. A hipoglicemia pós prandial (HPP) após a cirurgia bariátrica é uma complicação frequente que pode acontecer a partir de 6 meses após o procedimento. A fisiopatologia é complexa e multifatorial e alguns pacientes podem apresentar sintomas debilitantes, enquanto outros são assintomáticos. As opções terapêuticas disponíveis são limitadas e nem sempre apresentam bons resultados, sendo muitas vezes associadas a efeitos colaterais indesejados. Objetivo: Entender o mecanismo de ação das diferentes opções terapêuticas para o tratamento da HPP após a cirurgia bariátrica e avaliar o efeito da droga empagliflozina em reduzir a ocorrência de hipoglicemia nestes pacientes. Métodos: Uma revisão bibliográfica sobre o tratamento atual da HPP após a cirurgia bariátrica foi realizada e um ensaio clínico foi conduzido com pacientes submetidos à cirurgia bariátrica no Ambulatório de Obesidade da Universidade Federal de São Paulo. Os pacientes foram submetidos ao teste oral da refeição líquida e foi feita a avaliação das curvas de glicemia e insulina em jejum e a cada 30 minutos após a ingestão da refeição líquida, por 120 minutos, antes e após a administração de empagliflozina (Jardiance 25mg), um inibidor do cotransportador 2 de sódio e glicose (iSGLT2) no túbulo proximal renal, por três dias consecutivos. Os pacientes foram comparados entre os que apresentavam sintomas sugestivos de hipoglicemia versus pacientes assintomáticos. Resultados: Foram elaborados dois artigos científicos relacionados ao tema. O primeiro artigo elucidou as diferentes opções terapêuticas testadas para o manejo da HPP após a cirurgia bariátrica. O segundo artigo evidenciou uma melhora significativa nos níveis glicêmicos após o tratamento com empagliflozina nos pacientes com hipoglicemia após a cirurgia bariátrica provavelmente por aumento da produção hepática de glicose. Conclusão: O tratamento da HPP após a cirurgia bariátrica é desafiador e as opções terapêuticas disponíveis agem por diferentes mecanismos, atuando na complexa fisiopatologia desta complicação. A empagliflozina foi testada para este fim em nosso estudo e apresentou resultados promissores. No entanto, são necessários ensaios clínicos randomizados de longo prazo com um número maior de pacientes para testar o efeito da administração de empagliflozina nesta condição.Introduction: Bariatric surgery is an option for severe obesity treatment, but some complications may occur after surgery. Postprandial hypoglycemia (PPH) after bariatric surgery is a frequent late complication that may occur at least 6 months after the procedure. The pathophysiology is complex and multifactorial, and some patients may experience debilitating symptoms, while others are asymptomatic. The therapeutic options available are limited and do not always present good results, being often associated with adverse side effects. Objective: To describe the mechanisms of action of the different therapeutic options for the treatment of PPH after bariatric surgery and to evaluate the effect of empagliflozin in reducing the episodes of hypoglycemia in these patients. Methods: A review of the literature on the current treatment of PPH after bariatric surgery was performed and a clinical trial was conducted with patients undergoing bariatric surgery at the Obesity Outpatient Clinic of the Federal University of São Paulo. Patients were submitted to an oral liquid meal tolerance test, and blood glucose and serum insulin levels were measured in fasting and every 30 minutes after ingestion of the liquid meal, for 120 minutes, before and after the administration of empagliflozin (Jardiance 25mg), a renal sodium-glucose cotransporter 2 inhibitor (iSGLT2), for three consecutive days. Patients were compared between those with symptoms suggestive of hypoglycemia versus asymptomatic patients. Results: Two scientific articles related to the topic were prepared. The first article describes the different therapeutic options tested for the management of PPH after bariatric surgery. The second article showed a significant improvement in glycemic levels after treatment with empagliflozin in patients with hypoglycemia after bariatric surgery, probably due to increased hepatic glucose production. Conclusion: Treating PPH after bariatric surgery is challenging and the available therapeutic options act through different mechanisms, acting on the complex pathophysiology of this complication. Empagliflozin was tested for this purpose in our study and showed promising results. However randomized long-term clinical trials with a larger number of patients are needed to test the long-term effect of empagliflozin administration in this condition.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES

All-natural wheat gliadin-gum arabic nanocarriers for encapsulation and delivery of grape by-products phenolics obtained through different extraction procedures

Grape pomace (GP), the major winery by-product, is still rich in phenolic compounds, scarcely applied in food systems due to physicochemical instability issues. This work aimed at fabricating gliadin (G)-based nanoparticles through antisolvent precipitation, for delivery of GP extracts, investigating different extraction strategies with ethanol/water solution (70:30 v/v). Interestingly, the fabricated nanoparticles were characterized by a nanometric size range with hydraulic diameter values around 100 nm and zeta-potential of 18-22 mV. The addition of gum arabic (GA), at the optimized G/GA ratio 1:1, improved particle stability and encapsulation efficiency of GP polyphenols. The two-step extraction of GP in the G-rich solvent retrieved from G extraction, as evidenced by total phenolics (1.24 times higher than the two separately obtained extracts G/GP10:10), HPLC-PDA analysis, encapsulation efficiency (62.9% in terms of epicatechin), and simulated digestion (95.6% release of epicatechin), represented the most promising approach to obtain G nanoparticles for efficient delivery of GP extracts

Pulsed electric fields-assisted extraction of valuable compounds from red grape pomace: Process optimization using response surface methodology

Background: The application of Pulsed electric fields as a mild and easily scalable electrotechnology represents an effective approach to selectively intensify the extractability of bioactive compounds from grape pomace, one of the most abundant residues generated during the winemaking process. Objective: This study addressed the optimization of the pulsed electric fields (PEF)-assisted extraction to enhance the extraction yields of bioactive compounds from red grape pomace using response surface methodology (RSM). Methods: The cell disintegration index (Zp) was identified as response variable to determine the optimal PEF processing conditions in terms of field strength (E = 0.5–5 kV/cm) and energy input (WT = 1–20 kJ/kg). For the solid-liquid extraction (SLE) process the effects of temperature (20–50 °C), time (30–300min), and solvent concentration (0–50% ethanol in water) on total phenolic content (TPC), flavonoid content (FC), total anthocyanin content (TAC), tannin content (TC), and antioxidant activity (FRAP) of the extracts from untreated and PEF-treated plant tissues were assessed. The phenolic composition of the obtained extracts was determined via HPLC-PDA. Results: Results demonstrated that the application of PEF at the optimal processing conditions (E=4.6 kV/cm, WT=20 kJ/kg) significantly enhanced the permeabilization degree of cell membrane of grape pomace tissues, thus intensifying the subsequent extractability of TPC (15%), FC (60%), TAC (23%), TC (42%), and FRAP values (31%) concerning the control extraction. HPLC-PDA analyses showed that, regardless of the application of PEF, the most abundant phenolic compounds were epicatechin, p-coumaric acid, and peonidin 3-O-glucoside, and no degradation of the specific compounds occurred upon PEF application. Conclusion: The optimization of the PEF-assisted extraction process allowed to significantly enhance the extraction yields of high-value-added compounds from red grape pomace, supporting further investigations of this process at a larger scale

A Comprehensive Overview of Tomato Processing By-Product Valorization by Conventional Methods versus Emerging Technologies

The tomato processing industry can be considered one of the most widespread food manufacturing industries all over the world, annually generating considerable quantities of residue and determining disposal issues associated not only with the wasting of invaluable resources but also with the rise of significant environmental burdens. In this regard, previous studies have widely ascertained that tomato by-products are still rich in valuable compounds, which, once recovered, could be utilized in different industrial sectors. Currently, conventional solvent extraction is the most widely used method for the recovery of these compounds from tomato pomace. Nevertheless, several well-known drawbacks derive from this process, including the use of large quantities of solvents and the difficulties of utilizing the residual biomass. To overcome these limitations, the recent advances in extraction techniques, including the modification of the process configuration and the use of complementary novel methods to modify or destroy vegetable cells, have greatly and effectively influenced the recovery of different compounds from plant matrices. This review contributes a comprehensive overview on the valorization of tomato processing by-products with a specific focus on the use of “green technologies”, including high-pressure homogenization (HPH), pulsed electric fields (PEF), supercritical fluid (SFE-CO2), ultrasounds (UAE), and microwaves (MAE), suitable to enhancing the extractability of target compounds while reducing the solvent requirement and shortening the extraction time. The effects of conventional processes and the application of green technologies are critically analyzed, and their effectiveness on the recovery of lycopene, polyphenols, cutin, pectin, oil, and proteins from tomato residues is discussed, focusing on their strengths, drawbacks, and critical factors that contribute to maximizing the extraction yields of the target compounds. Moreover, to follow the “near zero discharge concept”, the utilization of a cascade approach to recover different valuable compounds and the exploitation of the residual biomass for biogas generation are also pointed out

Effect of replacing durum wheat semolina with Tenebrio molitor larvae powder on the techno-functional properties of the binary blends

Tenebrio molitor (TM) larvae, due to their high nutritional value, are gaining growing attention in food and feed sectors. Although few studies dealt with wheat-based products functionalized with TM larvae powder, there is a lack of comprehensive characterization of the raw materials to optimize the formulations for end-product recommendation.This study aimed at investigating the effects of partial replacement of durum wheat semolina with increasing amounts of TM larvae powder (5–30%) on the techno-functional properties of the binary blends. Color, granulometry, hydration properties, pasting characteristics, spectral characteristics (FTIR), reducing sugar content, and bioactivity in terms of total phenolic content (TPC) and antioxidant activity (FRAP, DPPH, ABTS) were assessed in the resulting blends.The increasing insect powder decreased the lightness (L*) and yellowness (b*) but increased the redness (a*) of the samples. In turn, the addition of insect powder did not negatively alter the hydration properties, which were comparable to those detected for semolina. Higher amounts of insect powder led to increased protein and lipid contents, as corroborated by the FTIR spectra, and decreased pasting parameters, with stronger starch granule stability detected when 20% and 30% of insect powder were added to the formulation.Significant increases in TPC and antioxidant activity were observed with increasing amount of insect powder (up to 87%, 78%, 2-fold, 67%, for TPC, FRAP, DPPH, and ABTS, respectively, compared to semolina).Therefore, these promising results have highlighted the possibility of using TM larvae powder as an unconventional ingredient for wheat-based products, by enhancing the nutritional and health-promoting values

Pulsed Electric Field-Assisted Extraction of Aroma and Bioactive Compounds From Aromatic Plants and Food By-Products

In this work, the effect of pulsed electric field (PEF) pre-treatment on the extractability in green solvents (i. e., ethanol–water mixture and propylene glycol) of target aroma and bioactive compounds, such as vanillin from vanilla pods, theobromine and caffeine from cocoa bean shells, linalool from vermouth mixture, and limonene from orange peels, was investigated. The effectiveness of PEF as a cell disintegration technique in a wide range of field strength (1–5 kV/cm) and energy input (1–40 kJ/kg) was confirmed using impedance measurements, and results were used to define the optimal PEF conditions for the pre-treatment of each plant tissue before the subsequent solid–liquid extraction process. The extracted compounds from untreated and PEF-treated samples were analyzed via GC-MS and HPLC-PDA analysis. Results revealed that the maximum cell disintegration index was detected for cocoa bean shells and vanilla pods (Zp = 0.82), followed by vermouth mixture (Zp = 0.77), and orange peels (Zp = 0.55). As a result, PEF pre-treatment significantly enhanced the extraction yield of the target compounds in both solvents, but especially in ethanolic extracts of vanillin (+14%), theobromine (+25%), caffeine (+34%), linalool (+114%), and limonene (+33%), as compared with untreated samples. Moreover, GC-MS and HPLC-PDA analyses revealed no evidence of degradation of individual compounds due to PEF application. The results obtained in this work suggest that the application of PEF treatment before solid–liquid extraction with green solvents could represent a sustainable approach for the recovery of clean labels and natural compounds from aromatic plants and food by-products