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 We also searched reference lists of relevant primary studies, systematic reviews, clinical trial registries, and unpublished theses sources.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.

A tandem liquid chromatography–mass spectrometry (LC–MS) method for profiling small molecules in complex samples

Liquid chromatography–mass spectrometry (LC–MS) methods using either aqueous normal phase (ANP) or reversed phase (RP) columns are routinely used in small molecule or metabolomic analyses. These stationary phases enable chromatographic fractionation of polar and non-polar compounds, respectively. The application of a single chromatographic stationary phase to a complex biological extract results in a significant proportion of compounds which elute in the non-retained fraction, where they are poorly detected because of a combination of ion suppression and the co-elution of isomeric compounds. Thus coverage of both polar and non-polar components of the metabolome generally involves multiple analyses of the same sample, increasing the analysis time and complexity. In this study we describe a novel tandem in-line LC–MS method, in which compounds from one injection are sequentially separated in a single run on both ANP and RP LC-columns. This method is simple, robust, and enables the use of independent gradients customized for both RP and ANP columns. The MS signal is acquired in a single chromatogram which reduces instrument time and operator and data analysis errors. This method has been used to analyze a range of biological extracts, from plant and animal tissues, human serum and urine, microbial cell and culture supernatants. Optimized sample preparation protocols are described for this method as well as a library containing the retention times and accurate masses of 127 compounds.

Mineralogy of the clay fraction of alfisols in two slope curvatures: IV - spatial correlation with physical properties

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

Stratified Sampling Applied to Estimation of the Volumetric Fraction of Alumina in Cast Metal Matrix Composites

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

The volumetric fraction of inorganic particles and the flexural strength of composites for posterior teeth

Objective. To evaluate the content of inorganic particles and the flexural strength of new condensable composites for posterior teeth in comparison to hybrid conventional composites.Method. The determination of the content of inorganic particles was performed by mass weighing of a polymerized composite before and after the elimination of the organic phase. The volumetric particle content was determined by a practical method based on Archimedes' principle, which calculates the volume of the composite and their particles by differential mass measured in the air and in water. The flexural. strength of three points was evaluated according to the norm ISO 4049:1988.Results. The results showed the following filter content: Alert, 67.26%; Z-100, 65.27%; Filtek P 60, 62.34%; Ariston pHc, 64.07%; Tetric Ceram, 57.22%; Definite, 54.42%; Solitaire, 47.76%. In the flexural strength test, the materials presented the following decreasing order of resistance: Filtek P 60 (170.02 MPa) > Z-100 (151.34 MPa) > Tetric Ceram (126.14 MPa) = Alert (124.89 MPa) > Ariston pHc (102.00 MPa) = Definite (93.63 MPa) > Solitaire (56.71 MPa).Conclusion. New condensable composites for posterior teeth present a concentration of inorganic particles similar to those of hybrid composites but do not necessarily present higher flexural strength. (C) 2003 Elsevier B.V. Ltd. Alt rights reserved.

Correlation between the spectroscopic and structural properties with the occupation of Eu3+ sites in powdered Eu3+-doped LiTaO3 prepared by the Pechini method

In this work we studied the structural and optical properties of lithium tantalate (LiTaO3) powders doped with Eu3+ ions. We have examined the different sites occupied by the rare earth ion through the correlation of the DRX data analyzed with the Rietveld method and some spectroscopic parameters derived from the Eu3+ luminescence. Adirect relation was established between the lattice parameters and the occupation fraction of Eu3+ in each LiTaO3 site. The occupation fraction was set as the relative population of Eu3+ ions for each site obtained by means of the intensity, baricenter, and the spontaneous emission coefficients of the D-5(0)-> F-7(0) transitions. We concluded that the unit cell parameter a presents the same behavior of the Eu3+ occupation fraction in Ta5+ sites as a function of the Eu3+ content in LiTaO3. The same was observed for the variation in Eu3+ occupation fraction in the Li+ site and the unit cell parameter c with the Eu3+ content. (C) 2009 American Institute of Physics. [doi: 10.1063/1.3204967]

Study of electrical, chemical and structural characteristics of superconductor thin film obtained by polymeric precursors method

Superconductor films of the BSCCO system have been grown by dip coating technique with good success. The chemical method allows us to grow high temperature superconductor thin films to get better control of stoichiometry, large areas and is cheaper than other methods. There is a great technological interest in growth oriented superconductor films due anisotropic characteristics of superconductor materials of high critical temperature, specifically the cuprates, as we know that the orientation may increase the electrical transport properties. Based on this, the polymeric precursor method has been used to obtain thin films of the BSCCO system. In this work we have applied that method together with the deposition technique known as dip coating to obtain Bi-based superconductor thin films, specifically, Bi1.6Pb0.4Sr2.0C2.0Cu3.0Ox+8, also known as 2223 phase with a critical temperature around 110 K. The films with multilayers have been grown on crystalline substrates of LaAlO3 and orientated (100) after being heat treated around 790 degrees C - 820 degrees C in lapse time of 1 hour in a controlled atmosphere. XRD measurements have shown the presence of a crystalline phase 2212 with a critical temperature around 85 K with (001) orientation, as well as a small fraction of 2223 phase. SEM has shown a low uniformity and some cracks that maybe related to the applied heat treatment. WDS has also been used to study the films composition. Different heat treatments have been used with the aim to increase the percentage of 2223 phase. Measurements of resistivity confirmed the presence of at least two crystalline phases, 2212 and 2223, with T-c around 85 K and 110 K, respectively.

Estimation of growth fraction in fine needle aspirates from non-Hodgkin's lymphoma using anti-proliferating cell nuclear antigen - Correlation with the Kiel classification

OBJECTIVE: This study was undertaken to assess whether fine needle aspirates from non-Hodgkins lymphoma (NHL) could be used for growth fraction analysis with proliferating cell nuclear antigen (PCNA) staining and if there was a relationship between the growth fraction and cytomorphologic classification according to the Kiel classification.STUDY DESIGN: the study group consisted of 40 patients with NHL diagnosed by fine needle aspiration (FNA) cytology. The cytologic classification of the lymphomas was made by two cytopathologists on May-Grunwald-Giemsa-stained slides using the Kiel classification. There were 27 cases of low and 13 of high grade lymphoma. The estimation of the growth fraction was made by PCNA immunoreactivity. The PCNA index was quantitated in smears by counting an average of 1,000 cells, and the count teas correlated with the cytomorphologic classification.RESULTS: There was It strong correlation between the PCNA index and lymphoma grading. High grade lymphomas exhibited a mean PCNA positivity of 74.0%, which was significantly higher (P <.001) than that of low grade lymphomas (17.6%).CONCLUSION: Our study showed that PCNA evalua tion is suitable for smears obtained by FNA on NHL, correlates with increasing grades of lymphoma according to the Kiel classification and may offer a method of monitoring treatment of lymphoma.

Evaluation of in vitro gas production of roughages and their mixtures using the curves subtraction method

The in vitro gas production of four single roughages and their paired combinations (1:1 on dry matter basis) were evaluated. Two roughage samples (100 mg) per treatment were fermented with ruminal fluid during a 48 h incubation period. Total 48 h gas volumes of fermentation dry matter (DM), neutral detergent fiber (NDF) and soluble compounds in neutral detergent (NDS) were for sugarcane = 16.8, 11.2, 6.9 mL; sugarcane + corn silage = 20.1, 12.6, 9.1 mL; sugarcane + 60-day elephantgrass = 16.5, 17.6 mL; sugarcane + 180-day elephantgrass = 13.8, 8.2, 5.9 mL; corn silage = 18.8, 16.8, 4.7 mL; corn silage + 60-day elephantgrass = 16.3, 15.4, 2.4 mL; corn silage + 180-day elephantgrass = 16.1, 11.8, 4.2 mL; 60-day elephantgrass = 16.9, 19.0 mL and 180-day elephantgrass = fermented 10.7, 12.2 mL, respectively. The NDS gas production was not possible to estimate for sugarcane + 60-day elephantgrass, 60-day elephantgrass and 180-day elephantgrass. The present data shows that the curves subtraction method can be an option to evaluate the contribution of the soluble fractions in roughages to digestion kinetics. However, this method underestimates the NDS gas contribution when roughages are low in crude protein and soluble carbohydrates. It is advisable to directly apply the two-compartmental mathematical model to the digestion curves for roughage DM, when determining the NDS gas volume and the digestion rate. This method is more straightforward and accurate when compared to the curve subtraction method. Non-structural carbohydrates combined with fiber and protein promoted a positive associative effect in sugarcane + corn silage (50:50) mixture. Therefore, it can be concluded that the soluble fraction of roughages greatly contributes to gas production. (C) 2004 Elsevier B.V. All rights reserved.

CeO2 nanoparticles synthesized by a microwave-assisted hydrothermal method: evolution from nanospheres to nanorods

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

Standardized plant extract, method for preparing an extract from plants of the Sclerolobium Genus, cosmetic composition, pharmaceutical composition and use of said extract

Extracts of plants of the Sclerolobium genus are disclosed, as well as methods for preparing same and cosmetic and pharmaceutical formulations containing these extracts. These extracts can be obtained by polar and/or apolar extraction, each fraction containing different anti-oxidants, all of which are useful for topical treatment. Also disclosed is the use of this extract in cosmetic and/or pharmaceutical formulations for topical use.

Cardiomyopathy and cell therapy: ejection fraction improvement and cardiac muscle mass increasing, after a year of bone marrow stem cells transplantation, by magnetic resonance image

The idiopathic dilated cardiomyopathy (IDC) is one of the major public health problems in the western world. Patients with IDC in functional class IV (New York Health Association - NYHA), even after therapeutic optimization, have high mortality. Stem cell therapy has emerged as a potential therapeutic option for cell death-related heart diseases and several positive effects were assigned to cell therapy in cardiomyopathy. The aim of this study was identify short-term result of cell transplantation in idiopathic dilated cardiomyopathy patients (IDC) who were treated by transplantation of autologous bone marrow mononuclear cells (BMMC). Intracoronary injections of autologous BMMC were performed in eight patients with severe ventricle dysfunction (mean of left ventricle ejection fraction – LEVF=20.03%), cardiac mass muscle around 156.2 g and NYHA between III and IV grades, other 8 IDC patients received placebo. The IDCs were followed - up for one and two years, by magnetic resonance imaging (MRI). The results after one year showed significant improvement in LVEF (mean=181.4) and muscle mass increasing (mean=181.4 g), after two years the LVEF continued improving, reaching a mean of 32.69% and the cardiac muscle mass kept stable (mean=179.4 g). Excepted for one patient, all the other had improvement in the NYHA functional class. The placebo group did not show any improvement. We believe that BMMC implant may be a beneficial therapeutic option for IDC patients.

Renal and vascular effects of Crotalus durissus cumanensis venom and its crotoxin fraction

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Graded meshes in bio-thermal problems with transmission-line modeling method

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

Isotope analysis method (δ¹³C) in clarified apple juice

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