Out-of-hospital cardiac arrests in a large metropolitan area : synergistic effect of exposure to air particulates and high temperature

Aims: Air pollution and climate change are intrinsically linked to emerging hazards for global health. High air particulate matter (PM) levels may trigger out-of-hospital cardiac arrest (OHCA). High temperature could act synergistically with PM in determining OHCA. The aim of the present study was to investigate the effect of PM exposure alone, and in combination with temperature, on the risk of OHCA, in a large European metropolitan area with population >4 million. Methods: We evaluated the association between short-term PM exposure, temperature, and the risk of OHCA over a two-year study period, allowing us to investigate 5761 events using a time-stratified case-crossover design combined with a distributed lag non-linear model. Results: Higher risk of OHCA was associated with short-term exposure to PM10. The strongest association was experienced three days before the cardiac event where the estimated change in risk was 1.70% (0.48\u20132.93%) per 10 \ub5g/m3 of PM. The cumulative exposure risk over the lags 0\u20136 was 8.5% (0.0\u201317.9%). We observed a joint effect of PM and temperature in triggering cardiac arrests, with a maximum effect of 14.9% (10.0\u201320.0%) increase, for high levels of PM before the cardiac event, in the presence of high temperature. Conclusion: The present study helps to clarify the controversial role of PM as OHCA determinant. It also highlights the role of increased temperature as a key factor in triggering cardiac events. This evidence suggests that tackling both air pollution and climate change might have a relevant impact in terms of public health

Genotypic variability and antifungal susceptibility of Candida spp. isolated from hospital surfaces and hands of healthcare professionals

Objectives Candida spp. are responsible for 9095% of hematogenous fungal infections. In Brazil and Latin America, C. albicans is the most common specie, followed by C. parapsilosis and C. tropicalis. Infections caused by Candida spp. may have their origin in exogenous sources, transmitted to patients via contaminated infusions, biomedical devices or even by the hands of the hospital staff members. Molecular biology techniques such as Randomly Amplified Polymorphic DNA (RAPD) can show that the strains found in anatomical sites or abi- otic surfaces have the same pattern genome.Moreover, in the last decades it has been observed increasing the number of yeasts isolated from hospital environment resistant to antifungals. Thus, the aim of this study was to determine the susceptibility to antifungals and intraspecies similarity among isolates of different hospital surfaces and hands of healthcare professionals. Methods The study was conducted with 25 isolates of Candida spp.: 5 strains of C. albicans and 5 strains of C. parapsilosis isolated from hospital surfaces. 5 strains of C. albicans, 5 strains of C. parapsilosis and 5 strains of C. tropicalis isolated from hands of healthcare professionals. Professionals and surfaces belonged to intensive care units. The minimal inhibitory concentration (MIC) was determined to voriconazole (VOR), fluconazole (FLZ), amphotericin B (AMB) and micafungin (MFG) according to M27-A3 of the Clinical and Labora- tory Standards Institute (CLSI). To determine the intra-species similarity, 3 primers were used: P4 (50 -AAGAGCCCGT-30 ), OPA-18 (50AGCTGACCGT30) and OPE-18 (50GGACTGCAGA 30). RAPD pro- files were analyzed using BioNumerics software version 4.6. The study was approved by the Ethics in research involving human subjects, CAAE 0448.0.093.000-11 protocol. Results In relation to susceptibility testing (Table 1), it is important to highlight that C. parapsilosis showed 80% of MFG resistance. C. albicans and C. tropicalis showed reduced susceptibility to VOR, and resistence of the AMB was observed for C. albicans (20%). All amplifi- cations revealed distinct polymorphic bands. Genetic distances between each of the isolates were calculated and cluster analysis was used to generate a dendrogram showing relationships between them. The analysis of all primers showed similarity greater than 80% between strains of hands and hospital surfaces for intraspecies. Conclusion Our work shows that, healthy people and hospital surfaces may be colonized by different species yeast. Furthermore, the strains studied had relative resistance to antifungal drugs most frequently used in clinical practice. Finally, there was a high similarity between samples from hands (hospital staff members) and surfaces, providing an infection risk to susceptible individuals. Healthy people working in hospitals can carry yeasts on their hands with the same potential virulence, and which therefore offer the same risk of infection. This information should be considered when preventive measures are established. Attention to the colonization of hands and surfaces should not be restricted to high-risk units such as NICUs, but should also include other sections of hospitals

Particulate Air Pollution, Clock Gene Methylation, and Stroke : Effects on Stroke Severity and Disability

Circadian rhythm disturbances have been consistently associated with the development of several diseases, particularly cardiovascular diseases (CVDs). A central clock in the brain maintains the daily rhythm in accordance with the external environment. At the molecular level, the clock is maintained by \u201cclock genes\u201d, the regulation of which is mainly due to DNA methylation, a molecular mechanism of gene expression regulation, able to react to and be reprogrammed by environmental exposure such as exposure to particulate matter (PM). In 55 patients with a diagnosis of acute ischemic stroke, we showed that PM2.5 exposure experienced before the event influenced clock genes methylation (i.e., circadian locomotor output cycles protein kaput CLOCK, period 2 PER2, cryprochrome 1 CRY1, Neuronal PAS Domain Protein 2 NPAS2), possibly modulating the patient prognosis after the event, as cryptochrome 1 CRY1 and period 1 PER1 methylation levels were associated with the Rankin score. Moreover, if PM2.5 annual average was low, CRY1/CRY2 methylation levels were positively associated with the National Institutes of Health Stroke Scale (NIHSS) score, whereas they were negatively associated if PM2.5 exposure was high. Whether epigenetic changes in clock genes need to be considered as a prognostic marker of stroke or rather a causal agent in stroke development remains to be determined. Further studies are needed to determine the role of clock gene methylation in regulating the response to and recovery after a stroke event

Assessment of in vitro biofilm formation and antifungal susceptibility of Candida albicans isolates from vulvovaginal candidiasis

Objectives Vulvovaginal candidiasis (VVC) is an inflammation of the genital mucosa, which mainly affects the vulva and vagina. Candida spp. are considered commensal fungus, however, when there is imbalance in the microbiota or the host immune system is compromised, these can become pathogenic. C. albicans is responsible for most cases of VVC and is able of expressing mechanisms which allow the colonization or infection in the host. These factors related yeasts, including the growth of strains resistant to antifungal agents and virulence attributes (such as biofilm formation) are important in the development of VVC. In this sense, the objective of this study was to evaluate the in vitro biofilm formation and susceptibility to antifungal of C. albicans isolates from patients with vulvovaginal candidiasis. Methods For the study were analyzed 30 clinical isolates of Candida albicans. The clinical isolates were separated in groups of 10 samples of the according to symptoms presented by the patients: asymptomatic (AS), vulvovaginal candidiasis (VVC) and recurrent vulvo- vaginal candidiasis (RVVC). For all isolates were analyzed biofilm formation and minimal inhibitory concentration (MIC) for fluconazole and nystatin. The MIC was performed according to M27-A3 protocol of the Clinical Laboratory Standards Institute. Biofilm forming ability was assessed through quantification of total biomass by crystal violet (CV) staining, performed on 96-well microplates containing a cellular suspension of 1 9 107 cells ml1 and incubated for 24 h at 37°C. Results Antifungal susceptibility testing is showed in table 1. The isolates were tested to the two antifungals. The MIC raging from 0.125 to 2 lg ml1 for fluconazole and 1 to 4 lg ml1 to nystatin. The figure 1 show the quantification of the total biomass. It was evident that all the C. albicans isolates were able to form biofilm, although differences occurred depending on the isolated and consequently the group. Importantly it was noted that, in general, VVC and RVVC groups had similar capacity biofilm formation. On the other hand, these groups had less total biomass (average Abs = 1,091 ` 0.88) compared with AS group (average Abs = 1,521 ` 1.32). Conclusion Although all the samples analyzed are sensitive to anti- fungals tested research of resistant strains is relevant, since recurrences are related to cases of VVC. Nystatin and fluconazole were effective in small concentrations for the isolates analysed. All samples were able to form biofilm and the average of the group of asymptomatic patients greater than the others. Thus, the capacity to form- ing biofilm is an important virulence factor in the persistence of microorganisms in infectious processes and represent an increase in resistance to antifungal and host defense

Virulence potential of Candida albicans isolated from oral cavity of patients with chronic renal failure on hemodialysis

Objective In patients with chronic renal failure (PCRF), the frequency of colonization of the oral cavity by yeasts of genus Candida spp. is high compared with healthy individuals. These yeasts have virulence factors that may contribute to the persistence of colonization and the development of these infections. The aim of this study was evaluate aspects of virulence from Candida albicans isolated from oral cavity of PCRF on dialysis. Methods This study was initially conducted with 49 clinical samples of C. albicans. The virulence factors assayed were produce of biofilm, germ tube, determination of adherence in oral epithelial cells and evaluation of resistance to the antimicrobial action of neutrophils and mononuclear cells. Results All isolates were highly efficient in forming biofilms on poly- styrene microplates, where 94% of the samples formed 4 + biofilm. Used as a screening test, of which three isolates were selected with different degrees of ability to form biofilm to assess other indicators of virulence. Overall, the isolates exhibited different characteristics regarding the virulence factors analyzed. It was also observed that the hypophosphorous acid (HOCl), production, one of leading inflammatory mediators with fungicidal action, also varied especially when the neutrophils, and not mononuclear cells, were stimulated with different samples. (Figure 1). Conclusion Therefore, our results indicate that C. albicans, is not only the most common species in the oral cavity of CRFP on dialysis, but also it presents the main virulence attributes, which reinforces the importance of monitoring of these patients towards the prevention of fungal infections

Evaluation of propolis and its subproduct as an inhibitor of growth and biofilm formation in vaginal yeast from pregnant women

Objectives The treatment of vulvovaginal candidiasis (VVC) is still unsatisfactory, especially in pregnant women, being promising to the utilization of alternative therapies. Propolis extract solution (PES) has demonstrated antifungal efficacy and low toxicity. In addition, the subproduct of propolis extract solution (SPES) is produced during the process of preparing PES and is usually discarded, but can still sub- mit substances responsible for biological effects, such as the polyphenols, responsible for the therapeutic activity of propolis. SPES have not been investigated or used as an antimicrobial agent. Thus, the objective of the present study was to investigate the effect of PES and SPES on Candida spp. isolated from the vaginal material of pregnant women. Methods Vaginal samples from 291 pregnant women were collected and cultivated for yeasts, which were identified by the classical method and performing susceptibility tests against PES, SPES and conventional antifungal agents. The anti-biofilm effect and cytotoxicity tests of the PES and SPES were evaluated. Results In 38.48% (112/291) of culture was positive for Candida species. There were patients with two different species, being a total of 115 yeasts (82.61% C. albicans; 6.08% C. glabrata; 5.22% C. tropi- calis; 5.22% C. parapsilosis and 0.87% C. krusei). PES and SPES were effective, even against isolates resistant to conventional antifungal (Table 1) and reduced about 25% C. tropicalis biofilm, besides presenting its low toxicity in the concentrations of fungicides. Conclusion Thus, in addition to the PES, SPES can also be a promising alternative treatment, especially in this population

Cardiac autonomic control and complexity during sleep are preserved after chronic sleep restriction in healthy subjects

Acute sleep deprivation (SD) alters cardiovascular autonomic control (CAC) and is associated with an increased risk of cardiovascular disorders. However, the effects of partial SD on CAC are unclear. Thus, we aimed to investigate the effects of partial SD on CAC during sleep. We randomized seventeen healthy subjects to a restriction group (RES, n\ua0=\ua08, subjects slept two-thirds of normal sleep time based on individual habitual sleep duration for 8 days and 8 nights) or a Control group (CON, n\ua0=\ua09, subjects were allowed to sleep their usual sleep time). Attended polysomnographic (PSG) studies were performed every night; a subset of them was selected for the analysis at baseline (day 3-D3), the first night after sleep restriction (day 5-D5), at the end of sleep restriction period (day 11-D11), and at the end of recovery phase (day 14-D14). We extracted electrocardiogram (ECG) and respiration from the PSG and divided into wakefulness (W), nonrapid eye movements (REM) sleep (N2 and N3) and REM sleep. CAC was evaluated by means of linear spectral analysis, nonlinear symbolic analysis and complexity indexes. In both RES and CON groups, sympathetic modulation decreased and parasympathetic modulation increased during N2 and N3 compared to W and REM at D3, D5, D11, D14. Complexity analysis revealed a reduction in complexity during REM compared to NREM sleep in both DEP and CON. After 8\ua0days of moderate SD, cardiac autonomic dynamics, characterized by decreased sympathetic, and increased parasympathetic modulation, and higher cardiac complexity during NREM sleep, compared to W and REM,\ua0are preserved

Cardiac Autonomic Derangement is Associated with Worse Neurological Outcome in the Very Early Phases of Ischemic Stroke

Background: Acute ischemic stroke (AIS) is associated with autonomic dysfunction. We evaluated the prognostic value of heart rate variability (HRV) and the role of stroke localization and reperfusion treatment (RT) on autonomic control. Methods: Patients with AIS and sinus rhythm were enrolled in the emergency department. Autonomic parameters were recorded at the onset and after a potential RT. Neurological deficit was assessed using the National Institute of Health Stroke Scale (NIHSS) at the onset and residual disability with modified Rankin Scale (mRS) at 3 months. Two analyses were used to assess HRV. Low frequency (LF) and high frequency (HF) are, respectively, markers of sympathetic and respiratory vagal modulation in spectral analysis. Symbolic analysis provides pattern with no variation (0V%) as an index of sympathetic modulation and pattern with two like variations (2LV%) and pattern with two unlike variations (2UV%) as markers of vagal modulation. Results: We enrolled 41 patients. Twenty-seven underwent RT. A prevalent parasympathetic modulation was found in patients with NIHSS 6514. The group with mRS 3\u20136 exhibited a higher 2UV% and lower 0V%. Right-sided strokes were associated with a higher respiratory vagal control. RT had no effects on HRV parameters. Conclusions: In the very early phases of AIS, a decreased 0V% and an increased 2UV% may reflect a loss of sympathetic oscillation, predicting a poorer 3 month-outcome

Sympatho-Vagal Dysfunction in Patients with End-Stage Lung Disease Awaiting Lung Transplantation

Although the literature demonstrates that cardiac autonomic control (CAC) might be impaired in patients with chronic pulmonary diseases, the interplay between CAC and disease severity in end-stage lung disease has not been studied yet. We investigated the effects of end-stage lung disease on CAC through the analysis of heart rate variability (HRV) among patients awaiting lung transplantation. Forty-nine patients on the waiting list for lung transplantation (LTx; 19 men, age 38 \ub1 15 years) and 49 healthy non-smoking controls (HC; 22 men, age 40 \ub1 16 years) were enrolled in a case-control study at Policlinico Hospital in Milan, Italy. LTx patients were divided into two groups, according to disease severity evaluated by the Lung Allocation Score (LAS). To assess CAC, electrocardiogram (ECG) and respiration were recorded at rest for 10 min in supine position and for 10 min during active standing. Spectral analysis identified low and high frequencies (LF, sympathetic, and HF, vagal). Symbolic analysis identified three patterns, i.e., 0V% (sympathetic) and 2UV% and 2LV% (vagal). Compared to HCs, LTx patients showed higher markers of sympathetic modulation and lower markers of vagal modulation. However, more severely affected LTx patients, compared to less severely affected ones, showed an autonomic profile characterized by loss of sympathetic modulation and predominant vagal modulation. This pattern can be due to a loss of sympathetic rhythmic oscillation and a subsequent prevalent respiratory modulation of heart rate in severely affected patients

Hereditary angioedema: Assessing the hypothesis for underlying autonomic dysfunction

Background Attacks of Hereditary Angioedema due to C1-inhibitor deficiency (Cl-INH-HAE) are often triggered by stressful events/hormonal changes. Objective Our study evaluates the relationship between autonomic nervous system (ANS) and contact/complement system activation. Methods Twenty-three HAE patients (6 males, mean age 47.5 +/- 11.4 years) during remission and 24 healthy controls (8 males, mean age 45.3 +/- 10.6 years) were studied. ECG, beat-by-beat blood pressure, respiratory activity were continuously recorded during rest (10') and 75degrees- head-up tilt (10'). C1-INH, C4, cleaved high molecular weight kininogen (cHK) were assessed; in 16 patients and 11 controls plasma catecholamines were also evaluated. Spectral analysis of heart rate variability allowed extraction of low-(LF) and high-(HF)frequency components, markers of sympathetic and vagal modulation respectively. Results HAE patients showed higher mean systolic arterial pressure (SAP) than controls during both rest and tilt. Tilt induced a significant increase in SAP and its variability only in controls. Although sympathetic modulation (LFnu) increased significantly with tilt in both groups, LF/HF ratio, index of sympathovagal balance, increased significantly only in controls. At rest HAE patients showed higher noradrenaline values (301.4 +/- 132.9 pg/ml vs 210.5 +/- 89.6 pg/ml, p = 0.05). Moreover, in patients tilt was associated with a significant increase in cHK, marker of contact system activation (49.5 +/- 7.5% after T vs 47.1 +/- 7.8% at R, p = 0.01). Conclusions Our data are consistent with altered ANS modulation in HAE patients, i.e. increased sympathetic activation at rest and blunted response to orthostatic challenge. Tilt test-induced increased HK cleavage suggests a link between stress and bradykinin production