Role of a multidisciplinary program in improving outcomes in cognitively impaired heart failure older patients.

Background: Cognitive impairment (CI) frequently complicates Heart failure (HF) and is associated with increased mortality and morbidity. Previous studies reported that nurse-lead home-based multidisciplinary program (MP) may not improve the prognosis of this high-risk group. In the present study, we analysed the relative effectiveness of an integrated hospital-based MP in patients with cognitive impairment. Methods: Consecutive (n=173) community-living outpatients aged >70 years (mean 77+6, 48% women) randomized to a MP (n=86) or usual care (UC) (n=87) were enrolled in stable clinical conditions. Cognitive status was assessed by means of Folstein Mini Mental State Examination (MMSE). Results: CI (MMSE<24) was present in 41.6% (42,5% UC vs 40.7% MP p=ns). The variables independently associated to CI were: older age, education level <5 years, anemia and severe renal dysfunction. During a 2-year follow-up, 59 patients died (31.4%) with no significant difference between intervention group. At multivariate analysis, in the entire cohort, CI was independently associated to death (HR 2,077[95%CI 1,097- 3,931]), HF admissions (2,133[1,346-3,381]), death/HF admissions (1,784[1,132-2,811]) and all-cause admissions (1,473[1,008-2,153]. When considered according to intervention groups, CI was independently associated to all-cause death (3,603 [1,553-8,358], death/HF admissions (2,029[1,200-3,432]) and HF admissions (2,474[1,406-4,353]) but not to all-cause admissions. The assignment of patients with CI to MP was associated to a significant reduction in HF admissions vs UC (0,503[0,253-0,999] (all interaction tests p=ns). Conclusions: This study suggests that CI is very common and associated to worse prognosis in heart failure and that hospital-based MP seems to improve outcomes in these patients through reduction of heart failure hospital admission

Association of kidney disease measures with risk of renal function worsening in patients with type 1 diabetes

Background: Albuminuria has been classically considered a marker of kidney damage progression in diabetic patients and it is routinely assessed to monitor kidney function. However, the role of a mild GFR reduction on the development of stage 653 CKD has been less explored in type 1 diabetes mellitus (T1DM) patients. Aim of the present study was to evaluate the prognostic role of kidney disease measures, namely albuminuria and reduced GFR, on the development of stage 653 CKD in a large cohort of patients affected by T1DM. Methods: A total of 4284 patients affected by T1DM followed-up at 76 diabetes centers participating to the Italian Association of Clinical Diabetologists (Associazione Medici Diabetologi, AMD) initiative constitutes the study population. Urinary albumin excretion (ACR) and estimated GFR (eGFR) were retrieved and analyzed. The incidence of stage 653 CKD (eGFR < 60 mL/min/1.73 m2) or eGFR reduction > 30% from baseline was evaluated. Results: The mean estimated GFR was 98 \ub1 17 mL/min/1.73m2 and the proportion of patients with albuminuria was 15.3% (n = 654) at baseline. About 8% (n = 337) of patients developed one of the two renal endpoints during the 4-year follow-up period. Age, albuminuria (micro or macro) and baseline eGFR < 90 ml/min/m2 were independent risk factors for stage 653 CKD and renal function worsening. When compared to patients with eGFR > 90 ml/min/1.73m2 and normoalbuminuria, those with albuminuria at baseline had a 1.69 greater risk of reaching stage 3 CKD, while patients with mild eGFR reduction (i.e. eGFR between 90 and 60 mL/min/1.73 m2) show a 3.81 greater risk that rose to 8.24 for those patients with albuminuria and mild eGFR reduction at baseline. Conclusions: Albuminuria and eGFR reduction represent independent risk factors for incident stage 653 CKD in T1DM patients. The simultaneous occurrence of reduced eGFR and albuminuria have a synergistic effect on renal function worsening

The conservation status of the world’s reptiles

MB and MR were funded by a grant from the Esmee Fairbairn Foundation, BC by the Rufford Foundation. North American and Mexican species assessments were funded by the Regina Bauer Frankenberg Foundation for Animal Welfare. Species assessments under the Global Reptile Assessment (GRA) initiative are supported by: Moore Family Foundation, Gordon and Betty Moore Foundation, Conservation International, Critical Ecosystem Partnership Fund (CEPF), and European Commission. Additional acknowledgements are included in the online supplementary material. The assessment workshop for Mexican reptiles was kindly hosted by Ricardo Ayala and the station personnel of the Estacion de Biologia Chamela, Institut de Biologia, Universidad Nacional Autonoma de Mexico. Workshop and logistical organisation of the Philippines assessments was provided by the Conservation International Philippines Office, in particular Ruth Grace Rose Ambal, Melizar V. Duya and Oliver Coroza. Workshop and logistical organisation for the European Reptile and Amphibian Assessments was provided by Doga Dernegi, in particular Ozge Balkiz and Ozgur Koc. Workshop and logistical organisation for assessments of sea snakes and homalopsids was provided by the International Sea Turtle Symposium and Dr. Colin Limpus (Australian Government Environmental Protection Agency). Special thanks to Jenny Chapman (EPA) and Chloe Schaub le (ISTS). Thank you also to Dr. Gordon Guymer (Chief Botanist Director of Herbarium) for accommodating us at the Herbarium in the Brisbane Botanical Gardens, and Mark Read and Kirsten Dobbs (Great Barrier Reef Marine Parks Association) and Dave Pollard and Brad Warren (Ocean Watch Australia) for institutional support. Mohamed Bin Zayed Species Conservation Fund, Conservation International Madagascar and the Darwin Initiative contributed to funding the costs of the Madagascar reptile workshop.Effective and targeted conservation action requires detailed information about species, their distribution, systematics and ecology as well as the distribution of threat processes which affect them. Knowledge of reptilian diversity remains surprisingly disparate, and innovative means of gaining rapid insight into the status of reptiles are needed in order to highlight urgent conservation cases and inform environmental policy with appropriate biodiversity information in a timely manner. We present the first ever global analysis of extinction risk in reptiles, based on a random representative sample of 1500 species (16% of all currently known species). To our knowledge, our results provide the first analysis of the global conservation status and distribution patterns of reptiles and the threats affecting them, highlighting conservation priorities and knowledge gaps which need to be addressed urgently to ensure the continued survival of the world’s reptiles. Nearly one in five reptilian species are threatened with extinction, with another one in five species classed as Data Deficient. The proportion of threatened reptile species is highest in freshwater environments, tropical regions and on oceanic islands, while data deficiency was highest in tropical areas, such as Central Africa and Southeast Asia, and among fossorial reptiles. Our results emphasise the need for research attention to be focussed on tropical areas which are experiencing the most dramatic rates of habitat loss, on fossorial reptiles for which there is a chronic lack of data, and on certain taxa such as snakes for which extinction risk may currently be underestimated due to lack of population information. Conservation actions specifically need to mitigate the effects of human-induced habitat loss and harvesting, which are the predominant threats to reptiles.Esmee Fairbairn FoundationRufford FoundationRegina Bauer Frankenberg Foundation for Animal WelfareMoore Family FoundationGordon and Betty Moore FoundationConservation International, Critical Ecosystem Partnership Fund (CEPF)European Commission Joint Research CentreZayed Species Conservation FundConservation International MadagascarDarwin Initiativ

c-Fos expression in preoptic nuclei as a marker of sleep rebound in the rat.

Thermoregulation is known to interfere with sleep, possibly due to a functional interaction at the level of the preoptic area (POA). Exposure to low ambient temperature (T(a)) induces sleep deprivation, which is followed by sleep rebound after a return to laboratory T(a). As two POA subregions, the ventrolateral preoptic nucleus (VLPO) and the median preoptic nucleus (MnPO), have been proposed to have a role in sleep-related processes, the expression of c-Fos and the phosphorylated form of the cAMP/Ca(2+)-responsive element-binding protein (P-CREB) was investigated in these nuclei during prolonged exposure to a T(a) of -10 degrees C and in the early phase of the recovery period. Moreover, the dynamics of the sleep rebound during recovery were studied in a separate group of animals. The results show that c-Fos expression increased in both the VLPO and the MnPO during cold exposure, but not in a specific subregion within the VLPO cluster counting grid (VLPO T-cluster). During the recovery, concomitantly with a large rapid eye movement sleep (REMS) rebound and an increase in delta power during non-rapid eye movement sleep (NREMS), c-Fos expression was high in both the VLPO and the MnPO and, specifically, in the VLPO T-cluster. In both nuclei, P-CREB expression showed spontaneous variations in basal conditions. During cold exposure, an increase in expression was observed in the MnPO, but not in the VLPO, and a decrease was observed in both nuclei during recovery. Dissociation in the changes observed between c-Fos expression and P-CREB levels, which were apparently subject to state-related non-regulatory modulation, suggests that the sleep-related changes observed in c-Fos expression do not depend on a P-CREB-mediated pathway