Casimiro Javierre

Other relevant components of nuts: phytosterols, folate and minerals

Nuts contain significant amounts of essential micronutrients that are associated with an improved health status when consumed at doses beyond those necessary to prevent deficiency states. Nuts do not contain cholesterol, but they are rich in chemically related phytosterols, a class of compounds that interfere with intestinal cholesterol absorption and thus help lower blood cholesterol. Nuts also contain folate, a B-vitamin necessary for normal cellular function that plays an important role in detoxifying homocysteine, a sulphur-containing amino acid with atherothrombotic properties that accumulates in plasma when folate status is subnormal. Compared to other common foodstuffs, nuts have an optimal nutritional density with respect to healthy minerals, such as calcium, magnesium and potassium. Like that of most vegetables, the sodium content of nuts is very low. A high intake of calcium, magnesium and potassium, together with a low sodium intake, is associated with protection against bone demineralisation, arterial hypertension, insulin resistance, and overall cardiovascular risk. Phytosterols might justify part of the cholesterol-lowering effect of nut intake beyond that attributable to fatty acid exchange, while the mineral richness of nuts probably contributes to the prevention of diabetes and coronary heart disease observed in epidemiological studies in association with frequent nut consumption.

Impact of non-neurological complications in severe traumatic brain injury outcome

IntroductionNon-neurological complications in patients with severe traumatic brain injury (TBI) are frequent, worsening the prognosis, but the pathophysiology of systemic complications after TBI is unclear. The purpose of this study was to analyze non-neurological complications in patients with severe TBI admitted to the ICU, the impact of these complications on mortality, and their possible correlation with TBI severity.MethodsAn observational retrospective cohort study was conducted in one multidisciplinary ICU of a university hospital (35 beds); 224 consecutive adult patients with severe TBI (initial Glasgow Coma Scale (GCS) < 9) admitted to the ICU were included. Neurological and non-neurological variables were recorded.ResultsSepsis occurred in 75% of patients, respiratory infections in 68%, hypotension in 44%, severe respiratory failure (arterial oxygen pressure/oxygen inspired fraction ratio (PaO2/FiO2) < 200) in 41% and acute kidney injury (AKI) in 8%. The multivariate analysis showed that Glasgow Outcome Score (GOS) at one year was independently associated with age, initial GCS 3 to 5, worst Traumatic Coma Data Bank (TCDB) first computed tomography (CT) scan and the presence of intracranial hypertension but not AKI. Hospital mortality was independently associated with initial GSC 3 to 5, worst TCDB first CT scan, the presence of intracranial hypertension and AKI. The presence of AKI regardless of GCS multiplied risk of death 6.17 times (95% confidence interval (CI): 1.37 to 27.78) (P < 0.02), while ICU hypotension increased the risk of death in patients with initial scores of 3 to5 on the GCS 4.28 times (95% CI: 1.22 to15.07) (P < 0.05).ConclusionsLow initial GCS, worst first CT scan, intracranial hypertension and AKI determined hospital mortality in severe TBI patients. Besides the direct effect of low GCS on mortality, this neurological condition also is associated with ICU hypotension which increases hospital mortality among patients with severe TBI. These findings add to previous studies that showed that non-neurological complications increase the length of stay and morbidity in the ICU but do not increase mortality, with the exception of AKI and hypotension in low GCS (3 to 5).

A new approach to the assessment of anaerobic metabolism: measurement of lactate in saliva.

OBJECTIVE: To test the hypothesis that saliva lactate concentrations may reflect those present in blood and that saliva lactate can be used as a very convenient and useful variable in the study of anaerobic metabolism. METHODS: Parallel determinations were made of lactate in saliva and in capillary blood samples, obtained at 3 min intervals from nine individuals during the performance of a maximum graded exercise test on a cycle ergometer against increasing workloads (from 25 up to a maximum of 300 W). Lactate determinations were done by means of an electroenzymatic method using 25 microliters samples in both types of fluids. RESULTS: For each situation, the concentration of lactate in saliva was shown to be about 15% of that in plasma but it followed the same pattern of evolution during the exercise test. A good correlation (r = 0.81) between blood and saliva lactate concentrations was found. The precision of the method was very good, with a coefficient of variation ranging (n = 10) between 2.2% for samples with very low lactate concentrations and 0.7% for sample with moderate lactate concentrations. Lactate appeared to be very stable in saliva over a period of 40 days after collection, when kept at 4 degrees C. The values obtained after this period were virtually identical to those shown in fresh samples. CONCLUSIONS: Determination of lactate in saliva can be used as an alternative to determination in blood, overcoming most of the drawbacks of the procedures being used at present, since the collection of the samples required no special expertise.

Improvement in GOS and GOSE scores 6 and 12 months after severe traumatic brain injury.

Primary objective: To assess improvements in Glasgow Outcome Scale (GOS) and GOS extended (GOSE) scores between 6 months and 1 year following severe traumatic brain injury (TBI). Methods and procedures: One studied 214 adult patients with severe TBI with Glasgow Coma Scale (GCS) <9 admitted to Intensive Care Unit (ICU). GOS scores were obtained 6 and 12 months after injury in 195 subjects. Patients were predominantly male (84%) and median age was 35 years. Main outcomes and results: Outcome (GOS and GOSE at 6 months and 1 year) was better in the high GCS score at admission (6–8) group than in the low score group (3–5). The improvement in GOS scores between 6 months and 1 year was greater in the high GCS score at admission group than in the low score group. At 6 months, 75 patients had died and 120 survived. None died between the 6–12-month assessments; at 12 months, 36% had improved GOS score. Conclusions: GOS scores improved between 6–12 months after severe TBI in 36% of survivors and it is concluded that the expectancy of improvement is incomplete at 6 months. This improvement was greater in patients with better GCS scores (6–8) at admission than in those with worse GCS scores (3–5).

Nitric Oxide Metabolite Production During Exercise in Chronic Fatigue Syndrome: A Case-Control Study

BACKGROUND Chronic fatigue syndrome (CFS) is a disabling illness of unknown etiology that is characterized by fatigue associated with a reduced ability to work, lasting for more than 6 months, and accompanied by a specific set of symptoms. The diagnosis remains difficult because of the absence of laboratory tests and is, therefore, made largely on the basis of the symptoms reported by the patient. The aim of this study was to analyze differences in blood nitrate levels in CFS patients and a matched control group after a physical exercise test. METHODS Forty-four consecutive female patients with CFS and 25 healthy women performed an exercise test using a cycle ergometer with monitoring of cardiopulmonary response. Blood samples were obtained for biochemical analyses of glucose, lactate, and nitrates at the beginning (under resting conditions) and after the maximal and supramaximal tests. RESULTS Plasma nitrates differed between the groups, with higher values in the CFS group (F = 6.93, p = 0.003). Nitrate concentration increased in relation to workload and reached higher values in the CFS group, the maximum difference with respect to the control group being 295% (t = 4.88, p < 0.001). CONCLUSIONS The main result of the present study is that nitric oxide (NO) metabolites (nitrates) showed a much higher increase after a maximal physical test in CFS patients than in a group of matched subjects. This combination (exercise plus NO response evaluation) may be useful in the assessment of CFS.

Effects of aerobic, resistance and balance training in adults with intellectual disabilities

Adults with intellectual disability (ID) have decreased cardiovascular fitness and strength present with lower rates of physical activity (PA), and often have balance and functional impairments. The purpose of this study was to investigate the effect of a combined PA program (CPAP) utilizing aerobic, strength and balance training on cardiovascular fitness, strength, balance and functional measures in a controlled clinical trial. Adults with mild to moderate ID were assigned into either the intervention group (IG; n=37) or the control group (CG; n=29). The IG trained 3 day/week, 1 h/day over 14 weeks, while the CG did not participate in any exercise program. Cardiovascular fitness, strength, balance, flexibility and functional ability were assessed pre-post training. The IG increased cardiovascular fitness (26.8 vs. 29.3 ml kg(-1) min(-1)), handgrip strength (19.2 vs. 21.9 kg), leg strength, and balance following the training period (p<.05). Body weight (70.1 vs. 68.1 kg) and body mass index (27.4 vs. 26.6 kg m(-2)) decreased (p<.05) in the IG group. The CG showed no changes in any parameter. These data suggest a combined aerobic, strength and balance exercise training program is beneficial among individuals with ID.

Short-term independent mortality risk factors in patients with cirrhosis undergoing cardiac surgery

OBJECTIVES Cirrhosis represents a serious risk in patients undergoing cardiac surgery. Several preoperative factors identify cirrhotic patients as high risk for cardiac surgery; however, a patients preoperative status may be modified by surgical intervention and, as yet, no independent postoperative mortality risk factors have been identified in this setting. The objective of this study was to identify preoperative and postoperative mortality risk factors and the scores that are the best predictors of short-term risk. METHODS Fifty-eight consecutive cirrhotic patients requiring cardiac surgery between January 2004 and January 2009 were prospectively studied at our institution. Forty-two (72%) patients were operated on for valve replacement, 9 (16%) for a CABG and 7 (12%) for both (CABG and valve replacement). Thirty-four (58%) patients were classified as Child-Turcotte-Pugh class A, 21 (36%) as class B and 3 (5%) as class C. We evaluated the variables that are usually measured on admission and during the first 24 h of the postoperative period together with potential operative predictors of outcome, such as cardiac surgery scores (Parsonnet, EuroSCORE), liver scores (Child-Turcotte-Pugh, model for end-stage liver disease, United Kingdom end-stage liver disease score) and ICU scores (acute physiology and chronic health evaluation II and III, simplified acute physiology score II and III, sequential organ failure assessment). RESULTS Seven patients (12%) died in-hospital, of whom 5 were Child-Turcotte-Pugh class B and 2 class C. Comparing survivors vs non-survivors, univariate analysis revealed that variables associated with short-term outcome were international normalized ratio (1.5 ± 0.24 vs 2.2 ± 0.11, P < 0.0001), presurgery platelet count (171 ± 87 vs 113 ± 52 l nl(-1), P = 0.031), presurgery haemoglobin count (11.8 ± 1.8 vs 10.2 ± 1.4 g dl(-1), P = 0.021), total need for erythrocyte concentrates (2 ± 3.4 vs 8.5 ± 8 units, P < 0.0001), PaO(2)/FiO(2) at 12 h after ICU admission (327 ± 84 vs 257 ± 78, P = 0.04), initial central venous pressure (11 ± 3 vs 16 ± 4 mmHg, P = 0.02) and arterial blood lactate concentration 24 h after admission (1.8 ± 0.5 vs 2.5 ± 1.3 mmol l(-1), P = 0.019). Multivariate analysis identified initial central venous pressure as the only independent factor associated with short-term outcome (P = 0.027). The receiver operating characteristic curve showed that the model for end-stage Liver disease score had a better predictive value for short-term outcome than other scores (AUC: 90.5 ± 4.4%; sensitivity: 85.7%; specificity: 83.7%), although simplified acute physiology score III was acceptable. CONCLUSIONS We conclude that central venous pressure could be a valuable predictor of short-term outcome in patients with cirrhosis undergoing cardiac surgery. The model for end-stage liver disease score is the best predictor of cirrhotic patients who are at high risk for cardiac surgery. Sequential organ failure assessment and simplified acute physiology score III are also valuable predictors.

Combined intermittent hypoxia and surface muscle electrostimulation as a method to increase peripheral blood progenitor cell concentration.

BackgroundOur goal was to determine whether short-term intermittent hypoxia exposure, at a level well tolerated by healthy humans and previously shown by our group to increase EPO and erythropoiesis, could mobilize hematopoietic stem cells (HSC) and increase their presence in peripheral circulation.MethodsFour healthy male subjects were subjected to three different protocols: one with only a hypoxic stimulus (OH), another with a hypoxic stimulus plus muscle electrostimulation (HME) and the third with only muscle electrostimulation (OME). Intermittent hypobaric hypoxia exposure consisted of only three sessions of three hours at barometric pressure 540 hPa (equivalent to an altitude of 5000 m) for three consecutive days, whereas muscular electrostimulation was performed in two separate periods of 25 min in each session. Blood samples were obtained from an antecubital vein on three consecutive days immediately before the experiment and 24 h, 48 h, 4 days and 7 days after the last day of hypoxic exposure.ResultsThere was a clear increase in the number of circulating CD34+ cells after combined hypobaric hypoxia and muscular electrostimulation. This response was not observed after the isolated application of the same stimuli.ConclusionOur results open a new application field for hypobaric systems as a way to increase efficiency in peripheral HSC collection.

Physiological adaptations to exercise in people with spinal cord injury.

The number of patients that suffer some type of spinal cord lesion in recent years are high and have increased because of factors such as traffic accidents. Although their life expectancy has increased, cardiovascular illnesses is one of the main causes of morbidity and mortality. Since the degree of physical fitness is an important factor regarding the risk of cardiovascular disease, the objective of the present study was to examine the global adaptation (cardiorespiratory, metabolic and thermoregulatory response) of the organism to exercise and the application of this data to the habitual practice of physical activity to improve state of health. A group of 42 patients with spinal injury, 85% of whom were paraplegic and the remaining 15% tetraplegic performed 42 exercise tests on a cycloergometer. Body temperature (tympanum, surface of the deltoids and surface of the back), metabolic parameters (plasma uric acid, glycemia, plasma lactate), cardiocirculatory adaptation (heart rate, blood pressure arm, blood pressure leg) and ventilatory adaptation (VO2, VCO2, fr Vt, VE) were monitored. Blood pressure in the arm, blood concentrations of lactate and ventilatory parameters showed an evolution statistically dependent on the work to which the subject was submitted. Heart rate showed a statistically significant correlation with the ventilatory parameters and work load. The proportional response of the cardioventilatory parameters to the increase in the work load allowed us to evaluate the repercussion of a given exercise and thus avoid exercise of an excessive intensity that could produce cardiocirculatory changes that might entail an added risk. Heart rate presents an excellent correlation, shown in this work, with the oxygen consumption and could therefore be used to quantify the cardiorespiratory and metabolic repercussion of the exercise carried out. Furthermore, this quantification may allow for the adaptation of exercise intensity to the patient thus improving the results obtained from the practice of exercise that has been proven so necessary in these patients.La lesión medular es una dramática situación que, en general, ocurre tras un accidente de tráfico. La esperanza de vida en estos pacientes ha aumentado en los últimos años, siendo en la actualidad las enfermedades cardiovasculares una de las causas principales de morbimortalidad. El objetivo del presente estudio consiste en conocer la adaptación (respuesta cardiorrespiratoria, metabólica y de termorregulación) del organismo al ejercicio y su posible aplicación a la práctica habitual de actividad física para mejorar su estado de salud.Un grupo de 42 lesionados medulares, el 85% parapléjicos y el 15% tetrapléjicos, realizaron una prueba de esfuerzo con brazos en cicloergómetro. Se monitorizó la temperatura en diferentes lugares (timpánica, cutánea en la región deltoidea, cutánea en la región escapular), los parámetros metabólicos (ácido úrico, glucemia, lactato sanguíneo), la adaptación cardiocirculatoria (frecuencia cardíaca, presión arterial en brazo y pierna) y la ventilatoria (VO2, VCO2, fr, Vt, VE).La presión arterial en el brazo aumenta significativamente al aumentar la carga. La frecuencia cardíaca presenta un aumento estadísticamente significativo dependiente del aumento del trabajo. Se observa un aumento estadísticamente significativo en la concentración de lactato sanguíneo al aumentar la carga. Los parámetros ventilatorios muestran una evolución que es estadísticamente dependiente de la carga a la que son sometidos los sujetos. La frecuencia cardíaca refleja una correlación estadísticamente significativa con los parámetros ventilatorios y la carga de trabajo.La respuesta proporcional de los parámetros cardioventilatorios al aumento de la carga permite evaluar la repercusión de un ejercicio, evitando una intensidad excesiva que produzca cambios cardiocirculatorios que podrían traer consigo un riesgo añadido. La frecuencia cardíaca presenta una excelente correlación, en el grupo estudiado, con el consumo de oxígeno, pudiendo ser una variable que permita el seguimiento de la repercusión cardiorrespiratoria y metabólica de la carga a la que es sometido el paciente. Además, permitirá adaptar el nivel de actividad física al sujeto, mejorando los resultados obtenidos por la práctica de ejercicio en estos pacientes.

Influence of cirrhosis in cardiac surgery outcomes.

Liver cirrhosis has evolved an important risk factor for cardiac surgery due to the higher morbidity and mortality that these patients may suffer compared with general cardiac surgery population. The presence of contributing factors for a poor outcome, such as coagulopathy, a poor nutritional status, an adaptive immune dysfunction, a degree of cirrhotic cardiomyopathy, and a degree of renal and pulmonary dysfunction, have to be taken into account for surgical evaluation when cardiac surgery is needed, together with the degree of liver disease and its primary complications. The associated pathophysiological characteristics that liver cirrhosis represents have a great influence in the development of complications during cardiac surgery and the postoperative course. Despite the population of cirrhotic patients who are referred for cardiac surgery is small and recommendations come from small series, since liver cirrhotic patients have increased their chance of survival in the last 20 years due to the advances in their medical care, which includes liver transplantation, they have been increasingly considered for cardiac surgery. Indeed, there is an expected rise of cirrhotic patients within the cardiac surgical population due to the increasing rates of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis, especially in western countries. In consequence, a more specific approach is needed in the assessment of care of these patients if we want to improve their management. In this article, we review the pathophysiology and outcome prediction of cirrhotic patients who underwent cardiac surgery.