Nurse-led titration of angiotensin converting enzyme inhibitors, beta-adrenergic blocking agents, and angiotensin receptor blockers for people with heart failure with reduced ejection fraction

BACKGROUND: Heart failure is associated with high mortality and hospital readmissions. Beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) can improve survival and reduce hospital readmissions and are recommended as first-line therapy in the treatment of heart failure. Evidence has also shown that there is a dose-dependent relationship of these medications with patient outcomes. Despite this evidence, primary care physicians are reluctant to up-titrate these medications. New strategies aimed at facilitating this up-titration are warranted. Nurse-led titration (NLT) is one such strategy. OBJECTIVES: To assess the effects of NLT of beta-adrenergic blocking agents, ACEIs, and ARBs in patients with heart failure with reduced ejection fraction (HFrEF) in terms of safety and patient outcomes. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL Issue 11 of 12, 19/12/2014), MEDLINE OVID (1946 to November week 3 2014), and EMBASE Classic and EMBASE OVID (1947 to 2014 week 50). We also searched reference lists of relevant primary studies, systematic reviews, clinical trial registries, and unpublished theses sources. We used no language restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing NLT of beta-adrenergic blocking agents, ACEIs, and/or ARBs comparing the optimisation of these medications by a nurse to optimisation by another health professional in patients with HFrEF. DATA COLLECTION AND ANALYSIS: Two review authors (AD & JC) independently assessed studies for eligibility and risk of bias. We contacted primary authors if we required additional information. We examined quality of evidence using the GRADE rating tool for RCTs. We analysed extracted data by risk ratio (RR) with 95% confidence interval (CI) for dichotomous data to measure effect sizes of intervention group compared with usual-care group. Meta-analyses used the fixed-effect Mantel-Haenszel method. We assessed heterogeneity between studies by Chi(2) and I(2). MAIN RESULTS: We included seven studies (1684 participants) in the review. One study enrolled participants from a residential care facility, and the other six studies from primary care and outpatient clinics. All-cause hospital admission data was available in four studies (556 participants). Participants in the NLT group experienced a lower rate of all-cause hospital admissions (RR 0.80, 95% CI 0.72 to 0.88, high-quality evidence) and fewer hospital admissions related to heart failure (RR 0.51, 95% CI 0.36 to 0.72, moderate-quality evidence) compared to the usual-care group. Six studies (902 participants) examined all-cause mortality. All-cause mortality was also lower in the NLT group (RR 0.66, 95% CI 0.48 to 0.92, moderate-quality evidence) compared to usual care. Approximately 27 deaths could be avoided for every 1000 people receiving NLT of beta-adrenergic blocking agents, ACEIs, and ARBs. Only three studies (370 participants) reported outcomes on all-cause and heart failure-related event-free survival. Participants in the NLT group were more likely to remain event free compared to participants in the usual-care group (RR 0.60, 95% CI 0.46 to 0.77, moderate-quality evidence). Five studies (966 participants) reported on the number of participants reaching target dose of beta-adrenergic blocking agents. This was also higher in the NLT group compared to usual care (RR 1.99, 95% CI 1.61 to 2.47, low-quality evidence). However, there was a substantial degree of heterogeneity in this pooled analysis. We rated the risk of bias in these studies as high mainly due to a lack of clarity regarding incomplete outcome data, lack of reporting on adverse events associated with the intervention, and the inability to blind participants and personnel. Participants in the NLT group reached maximal dose of beta-adrenergic blocking agents in half the time compared with participants in usual care. Two studies reported on adverse events; one of these studies stated there were no adverse events, and the other study found one adverse event but did not specify the type or severity of the adverse event. AUTHORS' CONCLUSIONS: Participants in the NLT group experienced fewer hospital admissions for any cause and an increase in survival and number of participants reaching target dose within a shorter time period. However, the quality of evidence regarding the proportion of participants reaching target dose was low and should be interpreted with caution. We found high-quality evidence supporting NLT as one strategy that may improve the optimisation of beta-adrenergic blocking agents resulting in a reduction in hospital admissions. Despite evidence of a dose-dependent relationship of beta-adrenergic blocking agents, ACEIs, and ARBs with improving outcomes in patients with HFrEF, the translation of this evidence into clinical practice is poor. NLT is one strategy that facilitates the implementation of this evidence into practice.

Understanding physicochemical changes in pretreated and enzyme hydrolysed hemp (Cannabis sativa) biomass for biorefinery development

The physicochemical properties of hemp biomass structure to pretreatment and enzymatic hydrolysis were investigated to improve upon reducing sugar production for biofuel development. Sodium hydroxide pretreated biomass (SHPB) yielded maximum conversion of holocellulose into reducing sugar (72 %). Scanning electron microscopy (SEM) revealed that enzymatic hydrolysis generated regular micropores in the fragmented biomass structure. The thermogravimetric analysis (TGA) curve suggested the degradation of hemicellulose and cellulose, which conformed well to the subsequent nuclear magnetic resonance (NMR) studies indicating the presence of α- and β-glucose (28.4 %) and α- and β-xylose (10.7 %), the major carbohydrate components commonly found in hydrolysis products of hemicellulose and cellulose. Attenuated total reflection Fourier transform infrared (ATR-FTIR) spectra showed stretching modes of the lignin acetyl group, suggesting the loosening of the polymer matrix and thus the exposure of the cellulose polymorphs. X-ray diffraction pattern indicated that enzymatic hydrolysis caused a higher crystallinity index (36.71), due to the fragmentation of amorphous cellulose leading to the reducing sugar production suitable for biofuel development.

Curso evolutivo e fatores de progressão da nefropatia diabética em pacientes com diabete melito tipo 2

A nefropatia diabética (ND) é uma complicação microvascular freqüente, que acomete cerca de 40% dos indivíduos com diabete melito (DM). A ND associa-se a significativo aumento de morte por doença cardiovascular. É a principal causa de insuficiência renal terminal em países desenvolvidos e em desenvolvimento, representando, dessa forma, um custo elevado para o sistema de saúde. Os fatores de risco para o desenvolvimento e a progressão da ND mais definidos na literatura são a hiperglicemia e a hipertensão arterial sistêmica. Outros fatores descritos são o fumo, a dislipidemia, o tipo e a quantidade de proteína ingerida na dieta e a presença da retinopatia diabética. Alguns parâmetros de função renal também têm sido estudados como fatores de risco, tais como a excreção urinária de albumina (EUA) normal-alta e a taxa de filtração glomerular excessivamente elevada ou reduzida. Alguns genes candidatos têm sido postulados como risco, mas sem um marcador definitivo. O diagnóstico da ND é estabelecido pela presença de microalbuminúria (nefropatia incipiente: EUA 20-199 μg/min) e macroalbuminúria (nefropatia clínica: EUA ≥ 200 μg/min). À medida que progride a ND, aumenta mais a chance de o paciente morrer de cardiopatia isquêmica. Quando o paciente evolui com perda de função renal, há necessidade de terapia de substituição renal e, em diálise, a mortalidade dos pacientes com DM é muito mais significativa do que nos não-diabéticos, com predomínio das causas cardiovasculares. A progressão nos diferentes estágios da ND não é, no entanto, inexorável. Há estudos de intervenção que demonstram a possibilidade de prevenção e de retardo na evolução da ND principalmente com o uso dos inibidores da enzima conversora da angiotensina, dos bloqueadores da angiotensina II e do tratamento intensivo da hipertensão arterial. Os pacientes podem entrar em remissão, ou até mesmo regredir de estágio. A importância da detecção precoce e da compreensão do curso clínico da ND tem ganhado cada vez mais ênfase, porque a doença renal do DM é a principal causa de diálise no mundo e está associada ao progressivo aumento de morte por causas cardiovasculares.

Crystallization, preliminary X-ray analysis and molecular-replacement solution of haemoglobin-II from the fish matrinxa (Brycon cephalus)

Haemoglobins constitute a set of proteins with interesting structural and functional properties, especially when the two large animal groups reptiles and fishes are focused on. Here, the crystallization and preliminary X-ray analysis of haemoglobin-II from the South American fish matrinxa (Brycon cephalus) is reported. X-ray diffraction data have been collected to 3.0 Angstrom resolution using synchrotron radiation (LNLS). Crystals were determined to belong to space group P2(1) and preliminary structural analysis revealed the presence of two tetramers in the asymmetric unit. The structure was determined using the standard molecular-replacement technique.

Biochemical and functional properties of a thrombin-like enzyme isolated from Bothrops pauloensis snake venom

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Intestinal and pancreas enzyme activity of broilers exposed to thermal stress

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Development and application of a Saccharomyces cerevisiae-expressed nucleocapsid protein-based enzyme-linked immunosorbent assay for detection of antibodies against infectious bronchitis virus

A Saccharomyces cerevisiae-expressed nucleocapsid (N) polypeptide of the M41 strain of infectious bronchitis virus (IBV) was used as antigen in a recombinant yeast-expressed N protein-based enzyme-linked immunosorbent assay (Y-N-ELISA). The Y-N-ELISA was rapid, sensitive, and specific for detecting chicken serum antibodies to IBV, and it compared favorably with a commercial ELISA.

An enzyme-linked immunosorbent assay for the detection of IgG antibodies against Babesia equi in horses

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

An enzyme-linked immunosorbent assay (ELISA) for the detection of IgM antibodies against Leishmania chagasi in dogs

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Chemical properties and enzyme activity in a sewage sludge-treated soil

A soil sample was taken from the top 0-20cm at Jaboticabal county, São Paulo State, Brazil, air dried, sieved to 5mm, and placed into pots (2700g per pot). Sewage sludge was air-dried, ground to 2mm, and thoroughly mixed to the top 0-10cm soil of each pot, which were irrigated with distilled water in a total volume equivalent to the last 30years average rainfall in the region. Sorghum was sowed 120days after sewage sludge incorporation and then the irrigation was made according to the plants' requirement. When the plants were about 10 cm high, they were thinned to two per pot. Soil samples (0-10, 10-20, and 20-30 cm depth) were obtained immediately after the incorporation of sewage sludge and at 30, 60, 120, and 170 days after, air dried, sieved to 2 mm and analyzed for organic matter (OM), pH (0,01 mol L-1 CaCl2), extractable P (resin), potassium (K), calcium (Ca), and magnesium (Mg), amylase and cellulase activity. Sewage sludge increased soil OM, pH, extractable phosphorus (P), K. Ca. amylase and cellulase activity, especially at the rate 16 t ha(-1). Organic matter, extractable P, K, Ca, Mg. and amylase activity were higher in the top 0-10cm, while pH was higher in the 20-30cm layer. Amylase activity was not affected by sampling depth. Organic matter, pH, extractable P. K, Ca, and Mg decreased during the experimental period. Amylase activity decreased until sorghum was sowed and increased afterwards. Cellulase activity increased until 90 days after sewage sludge application and then decreased. Sewage sludge used in the experiment should already contain some amylase activity or a substance that was a soil enzyme activator and also a substance that was an inhibitor of soil cellulase inhibitor. Sonic of the plant nutrients contained in sewage sludge, mainly P, did not migrate down the soil column. an indication that sewage sludge should be incorporated into the soil to improve nutrient bioavailability. Sorghum roots increased amylase activity but did not affect cellulase activity.

The zymogen-enteropeptidase system: A practical approach to study the regulation of enzyme activity by proteolytic cleavage

The present research describes an efficient procedure to obtain high levels of trypsinogen and chymotrypsinogen by using a simple, rapid, and easily reproducible method. The extraction process and the time-course of activation of zymogens can be carried out in a single laboratory period, without sophisticated equipment. The main objective was to prepare a laboratory class that would stimulate student interest in enzyme regulation, exploring the fact that the catalytic activity of some enzymes is regulated by different mechanisms. The regulation of proteolytic enzymes requires the synthesis of an inactive zymogen and its being irreversibly switched on by specific proteolytic cleavage.

Optimization of fibrolytic enzyme production by Aspergillus japonicus C03 with potential application in ruminant feed and their effects on tropical forages hydrolysis

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Sugarcane bagasse ash as a potential quartz replacement in red ceramic

Sugarcane bagasse ash (SCBA) is an industrial waste that contains silicon and aluminum oxides as the major components and iron, calcium, magnesium, and potassium oxides as the main minor components. In this paper, SCBA from one Brazilian factory was characterized and tested for its influence on the ceramic properties of clay/ash ceramic probes. Prismatic probes were pressed (18 MPa) using a ceramic mass mixed with 0%, 5%, 8%, and 10% ash. The probes were fired at temperatures between 800 degrees and 1200 degrees C. X-ray diffraction, X-ray fluorescence, thermal analysis (differential thermal analysis, thermo-gravimetric analysis/differential thermogravimetric analysis), and tests for texture (particle-size analysis), flexural strength, and linear shrinkage were carried out to characterize the samples. The results showed that the amount of ash to be incorporated will depend on mainly the composition of clay but also ash, and indicated that the clay used in this work can incorporate up to 10% weight of ash to produce solid bricks. The results also showed an improvement in ceramic/ash properties up to sintering temperatures higher than 1000 degrees C.

Population dynamics of DENV-1 genotype V in Brazil is characterized by co-circulation and strain/lineage replacement

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Enzyme Biomarkers of Renal Tubular Injury in Arterial Surgery Patients

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)