Journal articles on the topic 'LJ. Software'

AbstractIn sequent calculi, cut elimination is a property that guarantees that any provable formula can be proven analytically. For example, Gentzen’s classical and intuitionistic calculi LK and LJ enjoy cut elimination. The property is less studied in coinductive extensions of sequent calculi. In this paper, we use coinductive Horn clause theories to show that cut is not eliminable in a coinductive extension of LJ, a system we call CLJ. We derive two further practical results from this study. We show that CoLP by Gupta et al. gives rise to cut-free proofs in CLJ with fixpoint terms, and we formulate and implement a novel method of coinductive theory exploration that provides several heuristics for discovery of cut formulae in CLJ.

The article is devoted to defining the peculiarities and focus of translating English neologisms in the software engineering terminology. As part of the study the role of vocabulary is explored, the features of neologism derivations are classified; the main methods of their interpreting into Russian are examined, the ways of neologism word-building in the software engineering terminology are identified and the most frequent interlingual transformations used in conveying their meaning into Russian are determined. Results of the study reveal that the majority of neologisms are formed predominantly by stem-composition and affixation and the most common method of translating neologisms in the software engineering terminology is the loan-translation, transcription and translation method, grammatical substitutions and descriptive translation.

The Montenegrin sheep population mostly consists of local breeds and their crossbreeds that are very valuable from their genome preservation point of view. The aim of this study was the investigation of the genetic diversity of seven Montenegrin sheep breeds (Jezeropivska—JP, Sora—SOR, Zetska zuja—ZZ, Bardoka—BAR, Sjenička—SJ, Ljaba—Lj, and Piperska zuja—PIP) using 18 microsatellite sets of markers. The genotyping was done for 291 samples from seven populations using the multiplex amplification of sequences with polymerase chain reaction (PCR). The parameters of genetic diversity were estimated using several software tools. In total, 243 alleles were found, with a range of 6 to 25 by locus. The mean observed heterozygosity (Ho), polymorphism information content (PIC), and Fis values (fixation index) per marker were 0.728, 0.781, and −0.007, respectively. The mean number of alleles per breed varied from 4.889 in ZZ to 10.056 in JP. The highest Ho was estimated for JP (0.763) and the lowest for ZZ (0.640). The genetic structure showed close relations between SOR and JP, and both of them with SJ, while ZZ, LJ, and PIP were more distanced. This study provides useful indicators for the development of further in-depth studies and the creation of appropriate conservation programs.

Each trade segment has its own requirements for information systems. And the information technology market fully satisfies them. Software products for building information systems for managing commercial enterprises take into account the best practices of domestic and global business.

The article is devoted to the issue of choosing a DBMS for teaching university students to database technologies. The advantages and disadvantages of using only licensed software in the educational process are considered, an overview and comparative analysis of free DBMS is given.

The problem of the best recovery in the sense of Sard of a linear functional Lf on the basis of information T(f) = {Ljf,j = 1, 2,... N} is studied. It is shown that in the class of bivariate functions with restricted (n,m) -derivative, known on the (n,m)-grid lines, the problem of the best recovery of a linear functional leads to the best approximation of L(KnKm) in the space S = span Lj(Kn_Km), j=1; 2,...N}, where Kn(x,t) = K(x,t)- Lxn(K(.,t):x) is the difference between the truncated power kernel K(x,t) = (x-t)n-1+ =(n-1)! and its Lagrange interpolation formula. In particular, the best recovery of a bivariate function is considered, if scattered data points and blending grid are given. An algorithm is designed and realized using the software product MATLAB.

The article discusses the problem of creating an algorithmic and informational support for the pharmaceutical development of ready-made medicines (GLF) medicines in solid form. For the system implementation of the algorithms for the development of GLF on the basis of the principle of QbD (quality-by-design - quality planned during development) it is proposed to apply the methodology of system design based on the principle (diagrams) of Demming. The algorithms for modeling and optimizing the selection of the technology platform for the pharmaceutical development of GLF medicines in solid form are given. The block scheme of the developed algorithm of the simulation and optimization process based on multi-tissue regression models and the online algorithm of optimization of Huka-Jeeves is presented. Testing of the developed algorithmic and software on the example of the development of the drug diphenhydramine.

SummaryBackground: Height is a critical variable for many biomedical analyses because it is an important component of Body Mass Index (BMI). Transforming EHR height measures into meaningful research-ready values is challenging and there is limited information available on methods for “cleaning” these data.Objectives: We sought to develop an algorithm to clean adult height data extracted from EHR using only height values and associated ages.Results: The algorithm we developed is sensitive to normal decreases in adult height associated with aging, is implemented using an open-source software tool and is thus easily modifiable, and is freely available. We checked the performance of our algorithm using data from the Northwestern biobank and a replication sample from the Marshfield Clinic biobank obtained through our participation in the eMERGE consortium. The algorithm identified 1262 erroneous values from a total of 33937 records in the Northwestern sample. Replacing erroneous height values with those identified as correct by the algorithm resulted in meaningful changes in height and BMI records; median change in recorded height after cleaning was 7.6 cm and median change in BMI was 2.9 kg/m2. Comparison of cleaned EHR height values to observer measured values showed that 94.5% (95% C.I 93.8-% – 95.2%) of cleaned values were within 3.5 cm of observer measured values.Conclusions: Our freely available height algorithm cleans EHR height data with only height and age inputs. Use of this algorithm will benefit groups trying to perform research with height and BMI data extracted from EHR.Citation: Muthalagu A, Pacheco JA, Aufox S, Peissig PL, Fuehrer JT, Tromp G, Kho AN, Rasmussen-Torvik LJ. A rigorous algorithm to detect and clean inaccurate adult height records within EHR systems. Appl Clin Inf 2014; 5: 118–126 http://dx.doi.org/10.4338/ACI-2013-09-RA-0074

Background:Sjögren’s syndrome (SS) is characterized by decreased saliva secretion. It is regulated mainly by parasympathetic nervous system. The genes involved in xerostomia can play a neuroprotective role [1]. The expression profiling is helpful to understand the mechanisms of SS related xerostomia.Objectives:We aimed to investigate and compare gene expression in labial salivary glands from SS patients with xerostomia SS(+) and without xerostomia SS(-) and healthy subjects (HS) by microarray analysis and to find genes potentially involved in xerostomia.Methods:The study group comprised 11 SS patients (3 SS(+) and 8 SS(-)) and 9 HS. Labial salivary gland samples were processed according to the protocol [2]. Database for Annotation, Visualization and Integrated Discovery (DAVID) and Search Tool for the Retrieval of Interacting Genes (STRING10) were used for the interactions between study groups [3].Results:Among the genes belonging to “secretion” ontology group, expression of Amyloid Beta Precursor Protein (APP) and Cholinergic Receptor Muscarinic 3 (CHRM3) in both SS(+) and SS(-) groups were lower than in HS. The expression of Visinin Like 1 (VSNL1) in SS(+) and SS(-) was higher than in HS. The expression of Serum Amyloid A1 (SAA1) and Amyloid Beta Precursor like Protein 2 (APLP2) were decreased in SS(+) group and increased in SS(-) compared to HS group. There was no differences between the SS(+) and SS(-) in expression of mentioned genes.Table 1.Fold changes, adjusted p values of differentially expressed genes in SS(+) and SS(-) groupsGene symbolRatio SS(-)Ratio SS(+)adjusted p.value.SS(-)adjusted p.value.SS(+)APP-1,230085-4,002010,98240560,00029089SAA11,446255611-2,2223292250,8318722320,046639694APLP21,118778-2,2326460,91213550,01132797CHRM3-1,745830276-5,3594315930,8679315750,000023VSNL11,6085048523,1275270260,9162289640,000513257Figure 1.STRING-generated interaction network among differentially expressed genes belonging to the „secretion” ontology group.Conclusion:Decreased expression of APP, SAA1, APLP2 and CHRM3 in SS(+) sufferers compared to HS can reflect the loss of their neuroprotective function and the cholinergic deficiency in xerostomia. STRING10 software indicates for a cenral role of APP and genes involved in β-amyloid peptide formation and neurodevelopment and for a close relationships between SS and neurodegenerative diseases [4,5].References:[1]Bhattarai KR, Junjappa R, Handigund M, et al. The imprint of salivary secretion in autoimmune disorders and related pathological conditions. Autoimmunity Reviews. 2018, 17:376-390[2]Celichowski P, Nawrocki MJ, Dyszkiewicz-Konwińska M, et al. „Positive regulation of RNA metabolic proces” ontology group highly regulated in porcine oocytes matured in vitro: a microarray approach. BioMed Research International 2018, ID2863068.[3]Von Mering C, Jensen LJ, Snel B. „STRING: known and predicted protein-protein associations, integrated and transffered across organisms” Nucleic Acids Research. 2005, 33, suplement 1, pp DD433-D437.[4]Montibeller L, de Belleroche J. Amyotrophic lateral sclerosis (ALS) and Alzheimer’s disease (AD) are characterised by differentia activation of ER stress pathways: Focus on UPR target genes. Cell Stress and Chaperones. 2018, 23:897-912.[5]Fisher A, Pittel Z, Haring R, et al. M1 Muscarinic Agonists can modulate some of the hallmarks in Alzheimer’s disease. J Molecular Neuroscience. 2003, 20:349-356.Disclosure of Interests:None declared

Background: Identifying perioperative bleeding risk in pediatric patients undergoing major surgery is challenging because personal history is often not sufficiently informative and laboratory tests are also more susceptible to pre-analytical variables. Children with low Willebrand add further uncertainty in the treatment options. The aim of this study was to evaluate practices to assess hemorrhagic risk and manage bleeding prophylaxis in children with low von Willebrand factor levels (30 and 50 IU/dL; low VWF), known von Willebrand disease (VWD) or healthy controls undergoing ear, nose and throat (ENT) surgery. Methods: In this retrospective observational study, data from consecutive paediatric patients undergoing ENT surgery between January 1, 2010 and December 31, 2017 at the Turin Paediatric Hospital were analysed. All statistical analyses were performed using STATA (StataCorp. 2013. Been Statistical Software: Release 13. College Station, TX: StataCorp LP). Demographic and clinical characteristics of patients were assessed using the absolute frequencies and percentages for qualitative variables and percentiles for quantitative variables. The risk of bleeding was estimated from the number of patients who experienced bleeding within 21 days as a proportion of the number of patients subjected to surgery. 90% confidence intervals (90% CIs) were estimated for the evaluation of bleeding risk, using the Jeffreys method and any differences in the risk of bleeding between patient groups were tested using a proportions test. To investigate any factors associated with the therapeutic strategy used, multinomial logistic regression models were conducted. Results: Major perioperative bleeding was seen in 6.3% (5/79) of low VWF patients, 3.0% (35/1152) of healthy controls and 20.0% (5/25) of patients with VWD. In low VWF patients, perioperative bleeding prophylaxis was given to 59.5% and included subcutaneously desmopressin (n=21) and VWF-containing concentrate (n=26). Oral or intravenous tranexamic acid was administered to all low VWF patients. Of these patients, one major hemorrhagic event occurred in patients who did not receive prophylaxis and the remaining events occurred in patients treated with VWF-containing concentrate. In patients who received a VWF-containing concentrate, lower VWF ristocetin cofactor levels were observed compared with patients who received desmopressin or were untreated during surgery. No differences in clinical and laboratory features were observed between patients with low VWF treated with desmopressin and those who were untreated. Conclusions: Patients with low VWF have a higher risk of perioperative bleeding compared with healthy controls but a significantly lower risk compared with patients with VWD. The perioperative management of these patients is complex with a high risk of overtreatment. In our experience the caution of keeping the VWF-containing concentrate in the operating room available for use in case of bleeding appears to be a balanced approach. Prospective randomized studies to identify accurate methods of assessing bleeding risk and evaluate the most effective perioperative bleeding prevention are warranted. Essential bibliography: Ruchika Sharma and Veronica H. Flood. Advances in the diagnosis and treatment of Von Willebrand disease. Hematology American Society of Hematology Education Program 2017:379-384 Sadler JE. Low von Willebrand factor: sometimes a risk factor and sometimes a disease. Hematology American Society of Hematology Education Program 2009:106-112 Rodeghiero F, Tosetto A, Abshire T, et al. ISTH/SSC bleeding assessment tool: a standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders. J Thromb Haemost. 2010;8(9):2063-2065. Casey LJ, Tuttle A, Grabell J, et al. Generation and optimization of the self-administered pediatric bleeding questionnaire and its validation as a screening tool for von Willebrand disease. Pediatr Blood Cancer. 2017;64(10) Mannuccio Mannucci P, Kyrle PA, Schulman S, Di Paola J, Schneppenheim R, Cox Gill J. Prophylactic efficacy and pharmacokinetically guided dosing of a von Willebrand factor/factor VIII concentrate in adults and children with von Willebrand's disease undergoing elective surgery: a pooled and comparative analysis of data from USA and European Union clinical trials. Blood Transfus. 2013;11(4):533-540 Disclosures No relevant conflicts of interest to declare.

Introducción: El cáncer de próstata (CP) el segundo cáncer diagnosticado en hombres, con mayor incidencia a los 66 años. La obesidad, el tabaquismo, alcoholismo y antecedentes familiares de CP se han encontrado asociados al riesgo de metástasis. El objetivo del presente estudio fue medir la asociación entre factores y el estado metastásico en pacientes con CP en un centro único de referencia en Ecuador. Metodología: El presente estudio analítico, se realizó en el Hospital “Teodoro Maldonado Carbo”, en Guayaquil-Ecuador, en el período enero-diciembre del 2019. El cálculo muestral fue no probabilístico, tipo censo. Se incluyeron casos con CP. Las variables fueron: edad, PSA, escala de Gleason, presencia de metástasis, sintomatología, tabaquismo, obesidad y antecedentes. Se presenta Odds Ratio como medida de asociación con intervalo de confianza del 95% y valor P. Resultados: El estudio incluyó 363 pacientes, con edad promedio de 75.2 ± 9.6 años. El grupo con metástasis fue de 202 casos (55.65%). Metástasis ósea 32.5%, pulmonar 9.6%, ganglionar 8.8% y hepático 4.75%. En la sintomatología la más frecuente fue, disuria (44.4%); el 33.6% con polaquiuria, un 13.2% hematuria y 8.8% tenesmo. El estadio Gleason-9 OR=24.85 (IC 95% 1.47-419.8) P=0.0259. El nivel de PSA >19 ng/ml OR= 6.996 (IC 95% 2.68-18.29) P=0.0001. El tabaquismo OR=2.34 (IC 95% 1.52-3.60) P=0.0001. Fueron factores protectores el valor de PSA <19 ng/ml OR=0.082 (IC 95% 0.043-0.157) P<0.0001, acudir a consulta de Hipertensión arterial OR=0.33 (IC 95% 0.161-0.691) P=0.0032 y el estadío Gleason-6 OR=0.108 (IC 95% 0.0665-9.1736) P<0.0001. Conclusión: Los niveles de PSA >19 ng/ml y el estadio Gleason >9 se asocian a la presencia de metástasis en pacientes con CP. Recibido: Julio 14, 2022 Aceptado: Octubre 27, 2022 Publicado: Diciembre 2, 2022 Editor: Dra. Evelyn Valencia Espinoza. Introducción El cáncer de próstata es el segundo cáncer más diagnosticado en hombres alrededor del mundo, con mayor incidencia promedio a los 66 años [1]. En países desarrollados, el cáncer de próstata se diagnostica a edades más tempranas cuando este se confina a la glándula prostática, debido al uso del antígeno prostático específico (PSA) [2]. El antígeno prostático específico es proteína creada por el epitelio prostático, el cual, es específico de órgano, más no de cáncer, debido a que el mismo puede estar elevado en patologías como prostatitis, hiperplasia prostática benigna, entre otras. Sin embargo, es el mejor biomarcador hasta ahora para el diagnóstico temprano del cáncer de próstata. Según la American Academy of Family Physicians, se ha determinado que 3 de cada 10 hombres con elevado PSA, tienen un alto riesgo de sufrir de cáncer de próstata que va a depender de la edad y el nivel del PSA que se encuentre. Algunos estudios demuestran que las pruebas de rutina de PSA en hombres entre 55 a 66 años disminuyen la mortalidad por cáncer de próstata, de manera significativa. Sin embargo, la baja especificidad para Cáncer de Próstata de la prueba, hace que la interpretación de ella no sea concluyente [3]. La Escala de Gleason es un sistema de graduación que sirve, una vez establecido el diagnóstico de adenocarcinoma de próstata, para medir la agresividad histopatológica de la neoplasia [4]. Está plenamente establecido que la escala de Gleason, de acuerdo a los hallazgos histopatológicos del tumor, nos permite categorizar a los pacientes de una manera más precisa y de esta manera tener una idea clara del pronóstico de dicho paciente. Con estos antecedentes se estableció el objetivo de determinar los factores de riesgo asociados a metástasis en pacientes con cáncer de próstata en un centro de referencia regional en Guayaquil-Ecuador. Materiales y métodos Diseño del estudio El presente estudio es observacional-analítica. La fuente es retrospectiva. Área de estudio El estudio se realizó en el servicio de urología del Hospital de Especialidades “Teodoro Maldonado Carbo”, del Instituto Ecuatoriano de Seguridad Social, en Guayaquil-Ecuador. El período de estudio fue del 1ro de Enero del 2019 hasta el 31 de diciembre del 2019. Universo y muestra El universo fue conformado por todos los pacientes registrados en la institución. El cálculo del tamaño muestral fue no probabilístico, tipo censo, en donde se incluyeron todos los casos incidentes en el período de estudio. Participantes Se incluyeron casos de pacientes adultos diagnosticados con cáncer de próstata en quienes se contó con valoración de PSA y la escala de Gleason. Se excluyeron registros incompletos para el análisis. Variables Las variables fueron edad, PSA, escala de Gleason, presencia de metástasis, sintomatología, métodos diagnósticos. Procedimientos, técnicas e instrumentos. Los datos fueron recogidos de la historia clínica en un formulario diseñado exclusivamente para tal propósito. Los diagnósticos de CP se realizaron por punción aspiración por aguja fina (PAAF) guiada por ecografía. Las placas fueron leídas por Patólogos distintos. Se usó el sistema AS400 para la pesquisa de casos usando los diagnósticos codificados: C61. Evitación de sesgos Para garantizar la confiabilidad de la información los investigadores fueron entrenados sobre la recolección de los datos. Se usó una lista de doble chequeo para incluir los casos. Los datos fueron validados y curados por el investigador principal. Análisis estadístico Recopilada la información en una hoja electrónica Excel, se ingresó en una matriz de datos del software SPSS™ 22.0 (IBM, Chicago, USA). Se utilizó estadística descriptiva en base a frecuencias y porcentajes para las variables cualitativas y para las cuantitativas medidas de tendencia central. Se presenta Odds Ratio como medida de asociación con intervalo de confianza del 95% y valor P. Resultados El estudio incluyó 363 pacientes. Caracterización clínica Fueron 363 pacientes, con edad promedio de 75.2 ± 9.6 años. La edad mínima fue de 49 años, y la máxima de 98 años. Los pacientes con metástasis fueron 202 casos (55.65%). Con respecto al lugar de diseminación metastásica, se encontró mayor predilección a desarrollar metástasis ósea en el 32.5% de los pacientes, seguido de metástasis pulmonar con el 9.6%, metástasis ganglionar con el 8.8% y a nivel hepático 4.75% de los casos. En la sintomatología la más frecuente fue, disuria con el 44.4%; el 33.6% con polaquiuria, un 13.2% hematuria y 8.8% tenesmo. El estudio más frecuente utilizado, fue el eco prostático, con un 42.7%; la tomografía 20.4%), gammagrafía prostática 25.6%, la resonancia magnética con el 11.3%. Factores clínicos El 44.4% de los pacientes padecía alcoholismo, el 27.5% presentaba tabaquismo, el 23.1% eran consumidores de carnes y lácteos; otros hábitos poco frecuentes se relacionaron con el 4.7%; 0.3% no refería ningún hábito de importancia. Dentro de los antecedentes patológicos se evidenció que, 54.5% de los pacientes tenían antecedentes familiares de Cáncer de próstata, 29.2% presentaba obesidad y sobrepeso, en tercer lugar, con 9.9% de los pacientes padecía de hipertensión arterial y entre otros antecedentes asociados tenían un porcentaje del 5.5% (Tabla 1). De la totalidad de los evaluados, el 45.2% tuvieron Gleason 6, mientras que aquellos con valores en la Escala de Gleason de 10, alcanzaban el 1.4%. La medición del riesgo se presenta en la tabla 1. Se constituyeron factores de riesgo para el desarrollo de metástasis el tabaquismo, y el estadío clínico Gleason 7, 8 y 9, los valores de PSA en rangos de 19-49 ng/ml, de 50 a 99 ng/ml y 100-299 ng/ml. Se establecieron como factores de protección estadísticamente significativos al antecedente personal de Hiperplasia prostática benigna, a la condición de hipertensión arterial, al estadio clínico Gleason 6, al valor de PSA <19 ng/ml (Tabla 1). Discusión Al comparar el presente estudio con investigaciones previas se constató que la edad constituye un factor de riesgo no modificable para padecer cáncer prostático, según el Instituto Nacional de Cáncer en Estados Unidos, en su programa estadístico de Vigilancia, Epidemiología y Resultados (SEER) entre los años 2015-2019 se encontró una mayor incidencia de casos en los pacientes que tenían entre 70-74 años de edad [5], así también lo describió el trabajo de Leitzmann et al, en los años correspondientes a 2000-2008 donde la incidencia comienza a aumentar desde los 40-44 años de edad para llegar a su pico máximo de 984.8 pacientes por cada 100.000 hombres con edades entre 70-74 años [6], similarmente en este estudio el mínimo de edad fue 49 años en la población con un máximo de 98 y un media de 75.15 respectivamente. En cuanto a la distribución de regiones anatómicas donde se suele presentar la metástasis en el cáncer prostático; en primer lugar se determinó a los huesos (84%) en segundo lugar a nódulos linfáticos distantes (10.6%) y hepático (10.2%) [7] según un estudio conducido por Gandaglia et al. lo cual en similitud a este estudio el sitio más frecuente fue a nivel óseo con un 32.5% de todos los pacientes, seguido de la metástasis pulmonar con 9.6% y ganglionar 8.8%. A su vez Auz y Brito (2018) encontraron en su investigación realizada en el Hospital Solca Núcleo de Quito-Ecuador que incluyó a 1713 pacientes donde el sitio más frecuente de metástasis fue el óseo en un 82.25%, seguido del ganglionar linfático con 7.05% y luego 2.8% a nivel pulmonar [8]. En lo que corresponde a los hábitos de los pacientes, un 44.4% de pacientes en este estudio consumía de alcohol regularmente, mientras que el 27.5% consumía tabaco y el 23.1% eran consumidores de carnes y lácteos, lo cual se contrasta con el estudio de Auz y Brito (2018) detallado anteriormente donde 31.1% de los pacientes consumían alcohol regularmente y el 28.3% de los pacientes consumían tabaco al momento de diagnóstico, no se midieron datos en relación al consumo de lácteos y carnes rojas [8]. Un factor de riesgo no modificable muy importante fue la presencia de antecedentes familiares de cáncer de próstata en este estudio con un 54.5% de los pacientes lo cual en el trabajo de Auz y Brito (2018) solamente 9% tuvieron antecedentes familiares de cáncer prostático y un 23.2% de otros tipos de cánceres [23]. Según Barber et al. en su estudio se identificó que pacientes con historia familiar de cáncer prostático únicamente, tienen un riesgo aumentado del 68% de padecer lo mismo (95% CI 1.53-1.83) y un 72% de enfermedad letal [9]. Así también lo describió Powell IJ (2011) en su publicación que dice que hombres con relativos de primer grado (Padre, hermano, hijo) tienen un riesgo de desarrollar cáncer prostático que es aproximadamente del doble a la población general [10]. En el presente estudio 29.2% de los pacientes presentaba sobrepeso y 9.9% de los pacientes padecía hipertensión arterial, así mismo en el estudio de Möller et al. se encontró que un IMC alto (26) en comparación a 20-22 a la edad de 21 años fue asociada con riesgo menor de cáncer prostático letal o avanzado y Gleason 7 [11], también se habla sobre que de los componentes del síndrome metabólico incluyendo la hipertensión arterial ninguno tiene relación con el desarrollo de cáncer prostático [10]. Dentro de los síntomas más frecuentes en esta investigación se encontraron la disuria con un 44.4% de todos los pacientes, le siguió la polaquiuria (33.6%) y finalmente la hematuria (13.2%). De manera similar el estudio de Birtle et al. llevado a cabo entre los años 2000-2001 con bases de datos de la Asociación Británica de Cirujano Urológicos determinó que de 33 pacientes con cáncer metastásico de próstata con PSA <10 ng/ml 51% se presentó con síntomas urinarios y/o dolor pélvico, 21% presentó dolor óseo, 18% retención urinaria y 10% caquexia y malasia [12]. En el presente estudio de la totalidad de pacientes, 45.2% de ellos tuvieron puntajes de Gleason de 6 y en menor medida con 1.4% de los pacientes puntajes de Gleason 10, esto se puede comparar con el estudio de Thomsen et al. donde se encontró que altos puntajes en la escala de Gleason se relacionaron a la presencia de metástasis, así en ese estudio los pacientes que presentaron metástasis a distancia según la escala TNM (M1), 41% tenía un puntaje de Gleason 5, mientras que solo el 3% tenía Gleason 1 [13]. El método de imagen más utilizado en este estudio fue el de la ecografía prostática con un 42.7% y en menor medida la resonancia magnética con el 11.3%. En la investigación de Huang et al. se encontró que el uso de la Resonancia Magnética con el sistema PI-RADS v2 fue el sistema más preciso para predecir la metástasis a nódulos linfáticos en la zona pélvica, los pacientes con PI-RADs <5 fueron asociados con un riesgo muy bajo de metástasis ganglionar [14]. La ecografía prostática 3D se demostró un 84% de sensibilidad y 96% de especificidad para identificar extensión tumoral extra capsular macroscópica y fue capaz de identificar a 14/16 diseminaciones a la vesícula seminal según Mitterberger et al. en el año 2008 [15]. Finalmente con respecto a valoraciones de PSA que se presentaron en los pacientes diagnosticados con cáncer de próstata, se pudo evidenciar, que el 100% de los pacientes con PSA mayor de 500 ng/ml tuvo metástasis, así como el grupo de pacientes con 300-499 ng/ml PSA, a diferencia del grupo con menos de 19 ng/ml PSA donde solo el 40.6% tuvo metástasis, lo cual se puede comparar al estudio de Thomsen et al. donde de los pacientes con más de 400 ng/ml, el 64.9% presentó metástasis, le sigue el grupo con valores de 200-399 ng/ml donde el 54% desarrolló metástasis y al final el grupo con menos de 19 ng/ml tuvo solo al 1.45% de pacientes con metástasis, podemos así deducir que el valor de PSA es directamente proporcional al riesgo de metástasis, sin embargo, recomendamos tomar en cuenta más factores de riesgos de manera conjunta para una evaluación integral del paciente [13]. Conclusiones En orden de importancia estadística los factores asociados a metástasis en cáncer prostático son el estadio clínico Gleason 9 y 8, Los niveles de PSA entre 50 a 299 ng/ml, y el tabaquismo. Fueron factores protectivos el antecedente clínico de Hiperplasia Prostática benigna, hipertensión y el nivel de PSA <19 ng/ml. Nota del Editor La Revista Oncología Ecu permanece neutral con respecto a los reclamos jurisdiccionales en mapas publicados y afiliaciones institucionales. Agradecimientos Los autores agradecen a todas las personas de la Institución que colaboraron en el desarrollo de esta investigación. Información administrativa Abreviaturas APP: antecedentes patológicos personales. APF: Antecedentes patológicos familiares. HPB: hiperplasia prostática benigna. Ca: Cáncer. PSA: Antígeno prostático específico. OR: Odds ratio. IC: intervalo de confianza Archivos Adicionales Ninguno declarado por los autores. Fondos Los autores no recibieron ningún tipo de reconocimiento económico por este trabajo de investigación. Disponibilidad de datos y materiales Existe la disponibilidad de datos bajo solicitud al autor de correspondencia. No se reportan otros materiales. Contribuciones de los autores Emily Gabriela Chimbo Acuña: conceptualización, validación, visualización, metodología, administración de proyecto, escritura: revisión y edición. Karen Gabriela Valverde Zambrano: conceptualización, curación de datos, análisis formal, adquisición de fondos, investigación, recursos, software, redacción - borrador original. Iván Altamirano: conceptualización, curación de datos, análisis formal, adquisición de fondos, investigación, recursos, software. Todos los autores leyeron y aprobaron la versión final del manuscrito. Aprobación del comité de ética No aplica a estudios de bases de datos o historias clínicas. Consentimiento para publicación El presente estudio es un análisis de base de datos, no aplica para este tipo de estudio. Referencias Professionals S-O. EAU Guidelines: Prostate Cancer [Internet]. [citado 20 de octubre de 2021]. Disponible en: https://uroweb.org/guideline/prostate-cancer/#note_11 Barry MJ, Nelson JB. Patients Present with More Advanced Prostate Cancer since the USPSTF Screening Recommendations. J Urol. diciembre de 2015;194(6):1534-6. DOI: 1016/j.juro.2015.09.033 PMid: 26384450 Catalona WJ, Richie JP, Ahmann FR, Hudson MA, Scardino PT, Flanigan RC, et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men. J Urol. mayo de 1994;151(5):1283-90. 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The precise role of ethnicity and family history on aggressive prostate cancer: a review analysis. Arch Esp Urol. 2011 Oct;64(8):711-9. PMID: 22052754; PMCID: PMC3859428. Möller E, Wilson KM, Batista JL, Mucci LA, Bälter K, Giovannucci E. Body size across the life course and prostate cancer in the Health Professionals Follow-up Study: Body size and prostate cancer. Int J Cancer. 15 de febrero de 2016;138(4):853-65. DOI: 1002/ijc.29842 PMid: 26355806 PMCid: PMC5042346 Birtle AJ, Freeman A, Masters JRW, Payne HA, Harland SJ, BAUS Section of Oncology Cancer Registry. Clinical features of patients who present with metastatic prostate carcinoma and serum prostate-specific antigen (PSA) levels < 10 ng/mL: the «PSA negative» patients. Cancer. 1 de diciembre de 2003;98(11):2362-7. DOI: 1002/cncr.11821 PMid: 14635070 Thomsen FB, Westerberg M, Garmo H, Robinson D, Holmberg L, Ulmert HD, et al. 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Introduction Methods Resuts Discussion Conclusions Acknowledgments Authors' contributions Competing interests Ethical approval References Effect of Methotrexate and Omega-3 Combination on Cytogenetic Changes of Bone Marrow and Some Enzymatic Antioxidants: An Experimental Study Inaam N. Ali1, Muthana M. Awad2, Alaa S. Mahmood2,* 1 Water and Environment Directorate, Ministry of Sciences and Technology, Baghdad, Iraq 2 Department of Biology, College of Science, University of Anbar, Anbar, Iraq * Corresponding author: A. S. Mahmood (alaashm91@gmail.com) Abstract: Objective: To assess the effect of methotrexate and omega-3 combination on cytogenetic changes of bone marrow and activities of some enzymatic antioxidants. Methods: Fifty-six mature male Wistar rats were divided into two experimental groups and a control group. The first experimental group was sub-divided into three sub-groups depending on the concentration of methotrexate (MTX): X1 (0.05 mg/kg MTX), X2 (0.125 mg/kg MTX) and X3 (0.250 mg/kg MTX), which were given intraperitoneally on a weekly basis for eight weeks. The second experimental group (MTX and omega-3 group) was also sub-divided into three sub-groups (Y1, Y2 and Y3), which were injected intraperitoneally with 0.05, 0.125 and 0.25 mg/kg MTX, respectively, weekly for eight weeks accompanied by the oral administration of 300 mg/kg omega-3. The rats of the control group were given distilled water. The enzymatic activity of catalase (CAT), superoxide dismutase (SOD) and glutathione reductase (GR) were measured in the sera of rats. In addition, the mitotic index (MI) and chromosomal aberrations of bone marrow were also studied. Results: MTX resulted in a significant decrease in the activities of CAT, SOD and GR compared to the controls. It also increased the MI and chromosomal aberrations of rat bone marrows. On the other hand, omega-3 significantly increased the activities of the investigated enzymatic antioxidants and reduced the MI and chromosomal aberrations in treated mice when given in combination with MTX. Conclusions: MTX has a genotoxic effect on the bone marrow by increasing the MI and all types of chromosomal aberrations and decreasing the enzymatic activity of CAT, SOD and GR. The addition of omega-3 can lead to a protective effect by reducing the toxic and mutagenic effects of MTX. Keywords: Methotrexate, Omega-3, Antioxidant, Wistar rat, Chromosomal aberration, Mitotic index 1. Introduction Methotrexate (MTX) is a folic acid antagonist because of their chemical similarity [1]. Vezmar et al. [2] showed that MTX affects the synthesis of nucleic acids deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) by interfering with the biosynthesis of thymine and purines. It also directly affects the rapidly dividing and intact cells, especially those in the mucous membranes of the mouth, intestine and bone marrow [3]. Omega-3 is a type of unsaturated fats, which are classified as essential fatty acids that cannot be manufactured by the body and should be taken with food [4]. Sources of omega-3 include fish oils, such as salmon, sardines and tuna, as well as soybeans, walnuts, raisins and linseed, almonds and olive oils [5]. Omega-3 is used in the prevention of a number of diseases such as rheumatoid arthritis, ulcerative colitis, asthma, atherosclerosis, cancer, and cardiovascular diseases [6]. A large amount of evidence indicates that omega-3 fatty acids have significant health benefits, including anti-inflammatory and antioxidant properties besides their effect on blood cholesterol levels [7]. Antioxidants retard the oxidation process by different mechanisms such as the removal of free radicals [8]. Enzymatic antioxidants include catalase (CAT), which is the first line of defense in the cell that removes hydrogen peroxide formed during biological processes by converting it into an aldehyde, and superoxide dismutase (SOD). There are three major families of SOD enzymes: manganese SOD (Mn-SOD) in the mitochondria and peroxisomes, iron SOD (Fe-SOD) in prokaryote cells and copper/zinc SOD (Cu-Zn SOD) in the cytoplasm of eukaryote cells [9]. Therefore, changes in the metal co-factors (manganese, iron, copper and zinc) can alter the effectiveness of SOD and may lead to diseases as a result of oxidative stress [10]. Glutathione reductase (GR) is also an enzymatic antioxidant that converts the oxidized glutathione to the reduced glutathione in the presence of NADPH, which is oxidized to NADP [11]. Therefore, the aim of the present study was to assess the effects of MTX and omega-3 on the cytogenetic changes of bone marrow as well as the activities of CAT, SOD and GR enzymatic antioxidants in male rats. 2. Method 2.1. Laboratory animals and experimental design Fifty-six mature male Wistar rats (Rattus norvegicus), aged 10–12 weeks old and weighing 250–300 gm, were used in the present study. The rats were kept in separate cages, with natural 13- hour light and 11-hour dark periods in a contamination-free environment with a controlled temperature (28.0 ± 1.0°C). In addition, rats were maintained on a standard diet and tap water ad libitum. The rats were randomly allocated to two experimental groups and a control group. The first experimental group (MTX group) included 24 rats injected intraperitoneally with different MTX dilutions with distilled water [12]. It was sub-divided into three sub-groups (eight rats per sub-group) according to MTX concentration as follows: X1 (0.05 mg/kg MTX), X2 (0.125mg/kg MTX) and X3 (0.25 mg/kg MTX). All rats were given a single dose of the specified MTX concentration weekly for eight weeks. The second experimental group (MTX and omega-3 group) included 24 rats allocated to three sub-groups (Y1, Y2 and Y3), which were injected intraperitoneally with 0.05, 0.125 and 0.25 mg/kg MTX, respectively, weekly for eight weeks accompanied by the oral administration of 300 mg/kg omega-3. The control group included eight rats that were intraperitoneally injected with distilled water and given a single dose of distilled water orally weekly for eight weeks. 2.2. Blood collection and processing After the end of the dosing period, 5 ml of blood were withdrawn from the heart (by cardiac puncture) using a 5 cc disposable syringe. The collected blood was immediately poured into a clean sterile screw-capped tube (plain tube) and left for coagulation in a water bath at 37°C for 15 minutes. After coagulation of blood, the plain tube was centrifuged for 5 minutes at 1500 rpm. Then the samples were stored at -20°C for subsequent analysis. 2.3. Measurement of the activity of antioxidant enzymes The antioxidant activities of CAT, SOD and GR were measured using enzyme-linked immunosorbent assay kits purchased from Kamiya Biomedical Company (Seattle, WA, US), according to the manufacturer's instructions. 2.4. Cytogenetic study of bone marrow Rats were killed by cervical dislocation, and their hip bones were cleaned from surrounding muscles and then dissected by cutting both ends of the bone. Five milliliters of physiological buffered saline were injected inside the bone to withdraw bone marrow into a test tube. Tubes were centrifuged at 2000 rpm/10 minutes. The supernatant was then removed, and 10 ml of KCL solution (0.075 M) were added to the sediment. The mixture was then incubated at 37 °C in a water bath for 30 minutes, with shaking from time to time. The tubes were then centrifuged at 2000rpm/10 minutes to remove the supernatant. However, 5 ml of a freshly prepared fixative solution (methanol: glacial acetic acid 1:3) were added gradually in the form of droplets into the inner wall of the tube with constant mixing. After that, the tubes were placed at 4 °C for half an hour to fix the cells. This process was repeated for three times, and the cells were then suspended in 2 ml of the fixative solution. The tubes were centrifuged at 2000 rpm for 5 minutes, and the supernatant was then removed while the cells were re-suspended in 1-2 ml of cold fixative solution. After shaking the tubes, 4–5 drops were then taken from each tube onto a clean slide from a height of about three feet to provide an opportunity for the cells and nuclei to spread well. The slides were stained with acridine orange solution (0.01%) for 4–5 minutes, incubated in Sorensen’s buffer (0.06M, pH 6.5) for a minute. and then examined using a fluorescence microscope Olympus BX 51 America at a wavelength of 450–500 nm [13, 14]. A total of 1000 cells were examined, and both dividing and non-dividing cells were calculated [13]. Mitotic index (MI) was calculated according to the following formula [13]: MI= No. of dividing cells / 1000 × 100 2.5. Analysis of chromosomal aberrations of bone marrow cells A total of 1000 dividing cells were examined on the stained slides under a fluorescence microscope at a wavelength of 45–500 nm. The examined cells were at the first metaphase of the mitotic division, where chromosomal aberrations are clear and can be easily seen [13]. 2.6. Statistical analysis Data were analyzed using the Statistical Analysis System (SAS®) software, version 9.1 (Cary, NC, USA) [15]. Effects were expressed as mean ± standard error (SE) and statistically compared using a completely randomized design analysis of variance and least significant differences. Differences at P values <5 were considered statistically significant. 3. Results 3.1. Effects of MTX and MTX-omega-3 combination on antioxidant enzymatic activities Table (1) shows significantly lower SOD activities among rats treated with MTX or MTX-omega-3 compared to controls. Moreover, sera of rats receiving relatively high doses of MTX (sub-groups X2 and X3) showed the lowest enzymatic activities of 4.29 ± 0.01 IU and 3.93 ± 0.11 IU, respectively. On the other hand, CAT activity differed significantly between treated and control rats as well as among treated rats themselves, In this respect, the controls showed the highest activity of 39.38 ±0.02 IU, while those receiving the highest MTX concentration, either alone or in combination with omega-3 (sub-groups X3 and Y3), showed the lowest activities of 30.97 ± 0.03 IU and 32.12± 0.06 IU, respectively. Regarding GR activity, control rats showed a higher activity of 53.09± 0.05 IU compared to treated ones; however, the differences in GR activities in rats given low doses of MTX, either alone or in combination with omega-3 (sub-groups X1 and Y1), were not statistically significant. On the other hand, rats in sub-groups X3 and Y3 showed the lowest GR activities of 34.59 ± 0.63 IU and 37.15 ±0.01, respectively, with statistically significant differences from other sub-groups. 3.2. Effects of MTX and MTX-omega-3 combination on mitotic index of bone marrow cells Figure (1) shows a significant decrease in the MI in all treated groups compared to control. In addition, there was a reverse association between MTX concentration and MI, where rats treated with the highest dose of MTX (sub-group X3) showed a significant decrease in MI compared to all other treated rat sub-groups. In addition, rats in sub-groups treated with MTX and omega-3 (sub-groups Y1, Y2 and Y3) showed a significant increase in MI compared to their counterpart rats receiving MTX only. Table 1. Activity of antioxidant enzymes in rats treated with MTX and MTX-omega-3 Group Enzymatic activity (mean± SE) SOD (IU) CAT (IU) GR (µmol) Control 6.41±0.02 a 39.38±0.02 a 53.09±0.05 a X1 (0.05 mg MTX/ kg) 5.33±0.01 b 37.81±0.01 c 51.12±0.06 a Y1 (0.05 mg MTX + 300 mg omega-3/ kg) 6.08±0.04 a 38.40±0.02 b 51.97±0.03 a X2 (0.125 mg MTX/ kg) 4.29±0.01 cd 33.13±0.01 e 42.34±0.03 b Y2 (0.125 mg MTX + 300 mg omega-3/ kg) 4.99±0.40 b 36.68±0.02 d 43.02±3.04 b X3 (0.25 mg MTX/ kg) 3.93±0.11 d 30.97±0.03 g 34.59±0.63 c Y3 (0.25 mg MTX + 300 mg omega-3/ kg) 4.47±0.02 c 32.12±0.06 f 37.15±0.01 c SE, Standard error; IU, international unit; SOD, superoxide dismutase; CAT, catalase; GR, glutathione reductase; *statistically significant at P < 0.05; **statistically significant at P < 0.01. Means with different letters within the same column showed a statistically significant difference. 3.3. Effects of MTX and MTX-omega-3 combination on chromosomal aberrations of bone marrow cells Rats receiving higher concentrations of MTX (sub-group X3) showed a significant increase in all types of chromosomal aberrations, i.e., chromatid gaps, chromosome gaps, chromatid breaks, chromosome breaks, deletions and simple fragments (Figure 2 and Table 2) than those of the control group or other treated sub-groups. All rats treated with MTX-omega-3 combination showed a significant decrease in almost all types of chromosomal aberrations compared to their counterpart rats receiving MTX alone (Table 2). Figure 1. Effect of MTX and MTX-omega-3 on the MI of bone marrow cells of treated rats compared to the controls. The groups X1 (0.05 MTX), X2 (0.125 MTX) and X3 (0.250 MTX) were compared to the control group, while the groups Y1 (0.05 MTX+ omega-3), Y2 (0.125 MTX+ omega-3) and Y3 (0.25 MTX+ omega-3) were compared to X1, X2 and X3, respectively. Figure 2. Effect of MTX and MTX-omega-3 on chromosomal aberration as seen under fluorescence microscope after staining with acridine orange: (1) a simple fragment; (2) a chromatid gap; (3) a chromosomal gap (A) and a chromosomal break (B). 4. Discussion The present experiment reveals that the addition of omega-3 to MTX alleviates its effects on the activities of the antioxidant enzymes CAT, SOD and GR, and decreases the MI as well as all types of chromosomal aberrations in the bone marrow cells. Daham et al. [16] showed that the decline in antioxidants associated with chemotherapy is attributed to the increase in lipid peroxidation caused by these kinds of drugs, which increase the level of free radicals. In addition, Weijl et al. [17] showed that some chemotherapeutic drugs have a negative effect on the antioxidant levels such as GR, whose activity decreases as a result of its involvement in many cellular processes such as cell defenses against the toxicity of some compounds. Al-Dalawy et al. [18] found that the decrease in the level of SOD is an evidence of its increased activity due to the increased release of free radicals. MTX causes an increase in the release of free radicals, including the OH radical that causes direct damage to DNA [16]. Al-Helaly [19] showed that the amount of food taken has an effect on antioxidants, where nutritional deficiency decreases the antioxidant levels, thus increasing free radicals that cause damage to DNA. Table 2. Chromosomal aberrations of bone marrow cells in rats treated with MTX and MTX-omega-3 Group Type of chromosomal aberration(mean ± SE) Chromatid gap Chromosome Gap Chromatid breaks Chromosome breaks Deletion Simple Fragments Chromosomal aberration (%) Control 1.33±0.33 e 0.00±0.00 e 1.67±0.33 c 0.33±0.15 c 0.00±0.00 0.67±0.33 cd 0.04±0.005 f X1 2.75±0.47 cd 1.50±0.28 cd 2.50±0.64 bc 1.00±0.41 bc 0.50±0.28 bc 0.75±0.25 bcd 0.09±0.02 de Y1 1.75±0.47 de 0.75±0.25 de 1.50±0.28 c 1.00±0.00 bc 0.75±0.25 abc 0.75±0.25 abc 0.065±0.005 ef X2 4.67±0.33 b 2.67±0.33 ab 2.67±0.33 bc 1.67±0.33 ab 0.67±0.33 abc 1.67±0.33 ab 0.14±0.006 bc Y2 3.00±0.00 c 2.00±0.00 bc 3.00±0.057 bc 1.33±0.33 b 0.67±0.33 abc 0.33±0.15 d 0.106±0.003 cd X3 6.80±0.37 a 3.00±0.31 a 4.60±0.74 a 2.40±0.24 a 1.40±0.24 a 1.80±0.37 a 0.20±0.017 a Y3 5.60±0.40 ab 2.40±0.24 ab 3.60±0.24 ab 1.80±0.20 ab 1.20±0.20 ab 1.40±0.24 abc 0.16±0.003 b LSD 1.231** 0.814** 0.602** 0.841** 0.774* 0.941** 3.499* SE, Standard error; * statistically significant at P < 0.05; ** statistically significant at P < 0.01. Means with different letters within the same column showed a statistically significant difference. X1 (0.05 mg MTX/ kg); X2 (0.125 mg MTX/ kg); X3 (0.25 mg MTX/ kg); Y1 (0.05 mg MTX + 300 mg omega-3/ kg); Y2 (0.125 mg MTX + 300 mg omega-3/ kg); Y3 (0.25 mg MTX + 300 mg omega-3/ kg). In the present study, the intraperitoneal administration of MTX to rats also caused a decrease in the MI of bone marrow and a significant increase in the rate of abnormal chromosomal aberration compared to the control rats. This finding is consistent with those reported previously [20], [21]. The effect of MTX can be attributed to its ability to interfere with the genetic material, leading to the appearance of toxic and mutagenic consequences. Rushworth et al. [22] reported that MTX leads to a lack of dihydrofolate reductase, which is the key to the growth and cell division processes. This, in turn, leads to a reduction of the nucleotides involved in the building of DNA and, therefore, to a stop or obstruction of the repair mechanisms of the damaged DNA. In addition, Wong and Choi [23] concluded that MTX inhibits the action of enzymes controlling the purine metabolism, which leads to the accumulation of adenosine in addition to the damage of the molecule itself and to the occurrence of chromosomal aberrations. Jafer et al. [24] reported the ability of MTX to induce chromosomal aberration in humans or animals by preventing the repair of DNA and affecting the proteins found in chromosomes. These findings were also confirmed by Hussain et al. [25], who found that MTX causes an increase in chromosomal aberrations. In the present study, the MI showed a significant increase in rat sub-groups treated with MTX-omega-3 combination, but there was a decrease in the rate of chromosomal aberration, which confirms the role of omega-3 unsaturated fatty acids in protecting the cell from the impact of free radicals [26], [27]. Attia and Nasr [28] reported the antioxidant effect of omega-3, which was attributed to the reduction in lipid peroxidation and the increase in SOD and CAT or the stimulation of GR. It is noteworthy that GR leads to the synthesis of reduced glutathione, which is important in the defense of the cell against toxic substances and the prevention of the occurrence of mutations [29]. 5. Conclusions MTX significantly decreases the activity of enzymatic antioxidants, reduce the MI and increase the chromosomal aberrations of all types in bone marrow. This gives further evidence on the genotoxic effects of MTX on the bone marrow. 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DOI - Google Scholar Rushworth D, Mathews A, Alpert A, Cooper Dihydrofolate reductase and thymidylate synthase transgenes resistant to methotrexate interact to permit novel transgene regulation. J Biol Chem 2015; 290: 22970–9. DOI - PubMed - Google Scholar Wong PT, Choi SK. Mechanisms and implications of dual-acting methotrexate in folate-targeted nanotherapeutic delivery. Int J Mol Sci 2015; 16: 1772–90. DOI - PubMed - Google Scholar Jafer ZMT, Shubber EK, Amash HS. Cytogenetic analysis of Chinese hamster lung fibroblasts spontaneously resistant to methotrexate. Nucleus 2001; 44: 28–35. Google Scholar Hussain ZK, AL-Mhdawi F, AL-Bakri N. Effect of methotrexate drug on some parameters of kidney in newborn mice. Iraqi J Sci 2014; 55: 968–73. Google Scholar Ghazi-Khansari M, Mohammadi-Bardbori A. Captopril ameliorates toxicity induced by paraquat in mitochondria isolated from the rat liver. Toxicol in Vitro 2007; 21: 403–7. DOI - PubMed - Google Scholar Dinic-olivira RJ, Sousa C, Remiao F, Durte JA, Navarro SA, Bastos L, et al. Full survival of paraquat-exposed rats after treatment with sodium salicylate. Free Radic Biol Med 2007; 42: 1017–28. DOI - PubMed - Google Scholar Attia AM, Nasr HM. Dimethoate-induced changes in biochemical parameters of experimental rat serum and its neutralization by black seed (Nigella sativa) oil. Slovak J Anim Sci 2009; 42: 87–94. Google Scholar Al-Rubaie AH.M. Effect of natural honey and mitomycin C on the effectiveness of the enzyme glutathione reductase in mice Mus musculus. Babylon Uni J 2008; 15: 1385–91.

Introduction Methods Resuts Discussion Conclusions Acknowledgments Authors' contributions Competing interests Ethical approval References Effect of Methotrexate and Omega-3 Combination on Cytogenetic Changes of Bone Marrow and Some Enzymatic Antioxidants: An Experimental Study Inaam N. Ali1, Muthana M. Awad2, Alaa S. Mahmood2,* 1 Water and Environment Directorate, Ministry of Sciences and Technology, Baghdad, Iraq 2 Department of Biology, College of Science, University of Anbar, Anbar, Iraq * Corresponding author: A. S. Mahmood (alaashm91@gmail.com) Abstract: Objective: To assess the effect of methotrexate and omega-3 combination on cytogenetic changes of bone marrow and activities of some enzymatic antioxidants. Methods: Fifty-six mature male Wistar rats were divided into two experimental groups and a control group. The first experimental group was sub-divided into three sub-groups depending on the concentration of methotrexate (MTX): X1 (0.05 mg/kg MTX), X2 (0.125 mg/kg MTX) and X3 (0.250 mg/kg MTX), which were given intraperitoneally on a weekly basis for eight weeks. The second experimental group (MTX and omega-3 group) was also sub-divided into three sub-groups (Y1, Y2 and Y3), which were injected intraperitoneally with 0.05, 0.125 and 0.25 mg/kg MTX, respectively, weekly for eight weeks accompanied by the oral administration of 300 mg/kg omega-3. The rats of the control group were given distilled water. The enzymatic activity of catalase (CAT), superoxide dismutase (SOD) and glutathione reductase (GR) were measured in the sera of rats. In addition, the mitotic index (MI) and chromosomal aberrations of bone marrow were also studied. Results: MTX resulted in a significant decrease in the activities of CAT, SOD and GR compared to the controls. It also increased the MI and chromosomal aberrations of rat bone marrows. On the other hand, omega-3 significantly increased the activities of the investigated enzymatic antioxidants and reduced the MI and chromosomal aberrations in treated mice when given in combination with MTX. Conclusions: MTX has a genotoxic effect on the bone marrow by increasing the MI and all types of chromosomal aberrations and decreasing the enzymatic activity of CAT, SOD and GR. The addition of omega-3 can lead to a protective effect by reducing the toxic and mutagenic effects of MTX. Keywords: Methotrexate, Omega-3, Antioxidant, Wistar rat, Chromosomal aberration, Mitotic index 1. Introduction Methotrexate (MTX) is a folic acid antagonist because of their chemical similarity [1]. Vezmar et al. [2] showed that MTX affects the synthesis of nucleic acids deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) by interfering with the biosynthesis of thymine and purines. It also directly affects the rapidly dividing and intact cells, especially those in the mucous membranes of the mouth, intestine and bone marrow [3]. Omega-3 is a type of unsaturated fats, which are classified as essential fatty acids that cannot be manufactured by the body and should be taken with food [4]. Sources of omega-3 include fish oils, such as salmon, sardines and tuna, as well as soybeans, walnuts, raisins and linseed, almonds and olive oils [5]. Omega-3 is used in the prevention of a number of diseases such as rheumatoid arthritis, ulcerative colitis, asthma, atherosclerosis, cancer, and cardiovascular diseases [6]. A large amount of evidence indicates that omega-3 fatty acids have significant health benefits, including anti-inflammatory and antioxidant properties besides their effect on blood cholesterol levels [7]. Antioxidants retard the oxidation process by different mechanisms such as the removal of free radicals [8]. Enzymatic antioxidants include catalase (CAT), which is the first line of defense in the cell that removes hydrogen peroxide formed during biological processes by converting it into an aldehyde, and superoxide dismutase (SOD). There are three major families of SOD enzymes: manganese SOD (Mn-SOD) in the mitochondria and peroxisomes, iron SOD (Fe-SOD) in prokaryote cells and copper/zinc SOD (Cu-Zn SOD) in the cytoplasm of eukaryote cells [9]. Therefore, changes in the metal co-factors (manganese, iron, copper and zinc) can alter the effectiveness of SOD and may lead to diseases as a result of oxidative stress [10]. Glutathione reductase (GR) is also an enzymatic antioxidant that converts the oxidized glutathione to the reduced glutathione in the presence of NADPH, which is oxidized to NADP [11]. Therefore, the aim of the present study was to assess the effects of MTX and omega-3 on the cytogenetic changes of bone marrow as well as the activities of CAT, SOD and GR enzymatic antioxidants in male rats. 2. Method 2.1. Laboratory animals and experimental design Fifty-six mature male Wistar rats (Rattus norvegicus), aged 10–12 weeks old and weighing 250–300 gm, were used in the present study. The rats were kept in separate cages, with natural 13- hour light and 11-hour dark periods in a contamination-free environment with a controlled temperature (28.0 ± 1.0°C). In addition, rats were maintained on a standard diet and tap water ad libitum. The rats were randomly allocated to two experimental groups and a control group. The first experimental group (MTX group) included 24 rats injected intraperitoneally with different MTX dilutions with distilled water [12]. It was sub-divided into three sub-groups (eight rats per sub-group) according to MTX concentration as follows: X1 (0.05 mg/kg MTX), X2 (0.125mg/kg MTX) and X3 (0.25 mg/kg MTX). All rats were given a single dose of the specified MTX concentration weekly for eight weeks. The second experimental group (MTX and omega-3 group) included 24 rats allocated to three sub-groups (Y1, Y2 and Y3), which were injected intraperitoneally with 0.05, 0.125 and 0.25 mg/kg MTX, respectively, weekly for eight weeks accompanied by the oral administration of 300 mg/kg omega-3. The control group included eight rats that were intraperitoneally injected with distilled water and given a single dose of distilled water orally weekly for eight weeks. 2.2. Blood collection and processing After the end of the dosing period, 5 ml of blood were withdrawn from the heart (by cardiac puncture) using a 5 cc disposable syringe. The collected blood was immediately poured into a clean sterile screw-capped tube (plain tube) and left for coagulation in a water bath at 37°C for 15 minutes. After coagulation of blood, the plain tube was centrifuged for 5 minutes at 1500 rpm. Then the samples were stored at -20°C for subsequent analysis. 2.3. Measurement of the activity of antioxidant enzymes The antioxidant activities of CAT, SOD and GR were measured using enzyme-linked immunosorbent assay kits purchased from Kamiya Biomedical Company (Seattle, WA, US), according to the manufacturer's instructions. 2.4. Cytogenetic study of bone marrow Rats were killed by cervical dislocation, and their hip bones were cleaned from surrounding muscles and then dissected by cutting both ends of the bone. Five milliliters of physiological buffered saline were injected inside the bone to withdraw bone marrow into a test tube. Tubes were centrifuged at 2000 rpm/10 minutes. The supernatant was then removed, and 10 ml of KCL solution (0.075 M) were added to the sediment. The mixture was then incubated at 37 °C in a water bath for 30 minutes, with shaking from time to time. The tubes were then centrifuged at 2000rpm/10 minutes to remove the supernatant. However, 5 ml of a freshly prepared fixative solution (methanol: glacial acetic acid 1:3) were added gradually in the form of droplets into the inner wall of the tube with constant mixing. After that, the tubes were placed at 4 °C for half an hour to fix the cells. This process was repeated for three times, and the cells were then suspended in 2 ml of the fixative solution. The tubes were centrifuged at 2000 rpm for 5 minutes, and the supernatant was then removed while the cells were re-suspended in 1-2 ml of cold fixative solution. After shaking the tubes, 4–5 drops were then taken from each tube onto a clean slide from a height of about three feet to provide an opportunity for the cells and nuclei to spread well. The slides were stained with acridine orange solution (0.01%) for 4–5 minutes, incubated in Sorensen’s buffer (0.06M, pH 6.5) for a minute. and then examined using a fluorescence microscope Olympus BX 51 America at a wavelength of 450–500 nm [13, 14]. A total of 1000 cells were examined, and both dividing and non-dividing cells were calculated [13]. Mitotic index (MI) was calculated according to the following formula [13]: MI= No. of dividing cells / 1000 × 100 2.5. Analysis of chromosomal aberrations of bone marrow cells A total of 1000 dividing cells were examined on the stained slides under a fluorescence microscope at a wavelength of 45–500 nm. The examined cells were at the first metaphase of the mitotic division, where chromosomal aberrations are clear and can be easily seen [13]. 2.6. Statistical analysis Data were analyzed using the Statistical Analysis System (SAS®) software, version 9.1 (Cary, NC, USA) [15]. Effects were expressed as mean ± standard error (SE) and statistically compared using a completely randomized design analysis of variance and least significant differences. Differences at P values <5 were considered statistically significant. 3. Results 3.1. Effects of MTX and MTX-omega-3 combination on antioxidant enzymatic activities Table (1) shows significantly lower SOD activities among rats treated with MTX or MTX-omega-3 compared to controls. Moreover, sera of rats receiving relatively high doses of MTX (sub-groups X2 and X3) showed the lowest enzymatic activities of 4.29 ± 0.01 IU and 3.93 ± 0.11 IU, respectively. On the other hand, CAT activity differed significantly between treated and control rats as well as among treated rats themselves, In this respect, the controls showed the highest activity of 39.38 ±0.02 IU, while those receiving the highest MTX concentration, either alone or in combination with omega-3 (sub-groups X3 and Y3), showed the lowest activities of 30.97 ± 0.03 IU and 32.12± 0.06 IU, respectively. Regarding GR activity, control rats showed a higher activity of 53.09± 0.05 IU compared to treated ones; however, the differences in GR activities in rats given low doses of MTX, either alone or in combination with omega-3 (sub-groups X1 and Y1), were not statistically significant. On the other hand, rats in sub-groups X3 and Y3 showed the lowest GR activities of 34.59 ± 0.63 IU and 37.15 ±0.01, respectively, with statistically significant differences from other sub-groups. 3.2. Effects of MTX and MTX-omega-3 combination on mitotic index of bone marrow cells Figure (1) shows a significant decrease in the MI in all treated groups compared to control. In addition, there was a reverse association between MTX concentration and MI, where rats treated with the highest dose of MTX (sub-group X3) showed a significant decrease in MI compared to all other treated rat sub-groups. In addition, rats in sub-groups treated with MTX and omega-3 (sub-groups Y1, Y2 and Y3) showed a significant increase in MI compared to their counterpart rats receiving MTX only. Table 1. Activity of antioxidant enzymes in rats treated with MTX and MTX-omega-3 Group Enzymatic activity (mean± SE) SOD (IU) CAT (IU) GR (µmol) Control 6.41±0.02 a 39.38±0.02 a 53.09±0.05 a X1 (0.05 mg MTX/ kg) 5.33±0.01 b 37.81±0.01 c 51.12±0.06 a Y1 (0.05 mg MTX + 300 mg omega-3/ kg) 6.08±0.04 a 38.40±0.02 b 51.97±0.03 a X2 (0.125 mg MTX/ kg) 4.29±0.01 cd 33.13±0.01 e 42.34±0.03 b Y2 (0.125 mg MTX + 300 mg omega-3/ kg) 4.99±0.40 b 36.68±0.02 d 43.02±3.04 b X3 (0.25 mg MTX/ kg) 3.93±0.11 d 30.97±0.03 g 34.59±0.63 c Y3 (0.25 mg MTX + 300 mg omega-3/ kg) 4.47±0.02 c 32.12±0.06 f 37.15±0.01 c SE, Standard error; IU, international unit; SOD, superoxide dismutase; CAT, catalase; GR, glutathione reductase; *statistically significant at P < 0.05; **statistically significant at P < 0.01. Means with different letters within the same column showed a statistically significant difference. 3.3. Effects of MTX and MTX-omega-3 combination on chromosomal aberrations of bone marrow cells Rats receiving higher concentrations of MTX (sub-group X3) showed a significant increase in all types of chromosomal aberrations, i.e., chromatid gaps, chromosome gaps, chromatid breaks, chromosome breaks, deletions and simple fragments (Figure 2 and Table 2) than those of the control group or other treated sub-groups. All rats treated with MTX-omega-3 combination showed a significant decrease in almost all types of chromosomal aberrations compared to their counterpart rats receiving MTX alone (Table 2). Figure 1. Effect of MTX and MTX-omega-3 on the MI of bone marrow cells of treated rats compared to the controls. The groups X1 (0.05 MTX), X2 (0.125 MTX) and X3 (0.250 MTX) were compared to the control group, while the groups Y1 (0.05 MTX+ omega-3), Y2 (0.125 MTX+ omega-3) and Y3 (0.25 MTX+ omega-3) were compared to X1, X2 and X3, respectively. Figure 2. Effect of MTX and MTX-omega-3 on chromosomal aberration as seen under fluorescence microscope after staining with acridine orange: (1) a simple fragment; (2) a chromatid gap; (3) a chromosomal gap (A) and a chromosomal break (B). 4. Discussion The present experiment reveals that the addition of omega-3 to MTX alleviates its effects on the activities of the antioxidant enzymes CAT, SOD and GR, and decreases the MI as well as all types of chromosomal aberrations in the bone marrow cells. Daham et al. [16] showed that the decline in antioxidants associated with chemotherapy is attributed to the increase in lipid peroxidation caused by these kinds of drugs, which increase the level of free radicals. In addition, Weijl et al. [17] showed that some chemotherapeutic drugs have a negative effect on the antioxidant levels such as GR, whose activity decreases as a result of its involvement in many cellular processes such as cell defenses against the toxicity of some compounds. Al-Dalawy et al. [18] found that the decrease in the level of SOD is an evidence of its increased activity due to the increased release of free radicals. MTX causes an increase in the release of free radicals, including the OH radical that causes direct damage to DNA [16]. Al-Helaly [19] showed that the amount of food taken has an effect on antioxidants, where nutritional deficiency decreases the antioxidant levels, thus increasing free radicals that cause damage to DNA. Table 2. Chromosomal aberrations of bone marrow cells in rats treated with MTX and MTX-omega-3 Group Type of chromosomal aberration(mean ± SE) Chromatid gap Chromosome Gap Chromatid breaks Chromosome breaks Deletion Simple Fragments Chromosomal aberration (%) Control 1.33±0.33 e 0.00±0.00 e 1.67±0.33 c 0.33±0.15 c 0.00±0.00 0.67±0.33 cd 0.04±0.005 f X1 2.75±0.47 cd 1.50±0.28 cd 2.50±0.64 bc 1.00±0.41 bc 0.50±0.28 bc 0.75±0.25 bcd 0.09±0.02 de Y1 1.75±0.47 de 0.75±0.25 de 1.50±0.28 c 1.00±0.00 bc 0.75±0.25 abc 0.75±0.25 abc 0.065±0.005 ef X2 4.67±0.33 b 2.67±0.33 ab 2.67±0.33 bc 1.67±0.33 ab 0.67±0.33 abc 1.67±0.33 ab 0.14±0.006 bc Y2 3.00±0.00 c 2.00±0.00 bc 3.00±0.057 bc 1.33±0.33 b 0.67±0.33 abc 0.33±0.15 d 0.106±0.003 cd X3 6.80±0.37 a 3.00±0.31 a 4.60±0.74 a 2.40±0.24 a 1.40±0.24 a 1.80±0.37 a 0.20±0.017 a Y3 5.60±0.40 ab 2.40±0.24 ab 3.60±0.24 ab 1.80±0.20 ab 1.20±0.20 ab 1.40±0.24 abc 0.16±0.003 b LSD 1.231** 0.814** 0.602** 0.841** 0.774* 0.941** 3.499* SE, Standard error; * statistically significant at P < 0.05; ** statistically significant at P < 0.01. Means with different letters within the same column showed a statistically significant difference. X1 (0.05 mg MTX/ kg); X2 (0.125 mg MTX/ kg); X3 (0.25 mg MTX/ kg); Y1 (0.05 mg MTX + 300 mg omega-3/ kg); Y2 (0.125 mg MTX + 300 mg omega-3/ kg); Y3 (0.25 mg MTX + 300 mg omega-3/ kg). In the present study, the intraperitoneal administration of MTX to rats also caused a decrease in the MI of bone marrow and a significant increase in the rate of abnormal chromosomal aberration compared to the control rats. This finding is consistent with those reported previously [20], [21]. The effect of MTX can be attributed to its ability to interfere with the genetic material, leading to the appearance of toxic and mutagenic consequences. Rushworth et al. [22] reported that MTX leads to a lack of dihydrofolate reductase, which is the key to the growth and cell division processes. This, in turn, leads to a reduction of the nucleotides involved in the building of DNA and, therefore, to a stop or obstruction of the repair mechanisms of the damaged DNA. In addition, Wong and Choi [23] concluded that MTX inhibits the action of enzymes controlling the purine metabolism, which leads to the accumulation of adenosine in addition to the damage of the molecule itself and to the occurrence of chromosomal aberrations. Jafer et al. [24] reported the ability of MTX to induce chromosomal aberration in humans or animals by preventing the repair of DNA and affecting the proteins found in chromosomes. These findings were also confirmed by Hussain et al. [25], who found that MTX causes an increase in chromosomal aberrations. In the present study, the MI showed a significant increase in rat sub-groups treated with MTX-omega-3 combination, but there was a decrease in the rate of chromosomal aberration, which confirms the role of omega-3 unsaturated fatty acids in protecting the cell from the impact of free radicals [26], [27]. Attia and Nasr [28] reported the antioxidant effect of omega-3, which was attributed to the reduction in lipid peroxidation and the increase in SOD and CAT or the stimulation of GR. It is noteworthy that GR leads to the synthesis of reduced glutathione, which is important in the defense of the cell against toxic substances and the prevention of the occurrence of mutations [29]. 5. Conclusions MTX significantly decreases the activity of enzymatic antioxidants, reduce the MI and increase the chromosomal aberrations of all types in bone marrow. This gives further evidence on the genotoxic effects of MTX on the bone marrow. On the other hand, omega-3 shows a protective effect by reducing the toxic and mutagenic effects of MTX. Acknowledgments The authors thank the staff of the Water and Environment Directorate, Ministry of Science and Technology, Baghdad, Iraq for their cooperation. They also thank Dr. Jasim Al-Niami for his technical and scientific guidance. Authors' contributions INA, MMA and ASM contributed to the study design and analyzed data. All authors contributed to the manuscript drafting and revising and approved the final submission. Competing interests The authors declare that they have no competing interests associated with this article. Ethical approval The ethical clearance of this study was obtained from the Ethics Committee of the College of Science, University of Anbar (Reference No. A. D. 51 in 30/8/2015). References Yuen CW, Winter ME. Methotrexate (MTX). In: Basic clinical pharmacokinetics, Winter ME, editor. Philadelphia, USA: Lippincott Williams & Wilkins; 2010. p.p. 304–25. 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DOI - Google Scholar Rushworth D, Mathews A, Alpert A, Cooper Dihydrofolate reductase and thymidylate synthase transgenes resistant to methotrexate interact to permit novel transgene regulation. J Biol Chem 2015; 290: 22970–9. DOI - PubMed - Google Scholar Wong PT, Choi SK. Mechanisms and implications of dual-acting methotrexate in folate-targeted nanotherapeutic delivery. Int J Mol Sci 2015; 16: 1772–90. DOI - PubMed - Google Scholar Jafer ZMT, Shubber EK, Amash HS. Cytogenetic analysis of Chinese hamster lung fibroblasts spontaneously resistant to methotrexate. Nucleus 2001; 44: 28–35. Google Scholar Hussain ZK, AL-Mhdawi F, AL-Bakri N. Effect of methotrexate drug on some parameters of kidney in newborn mice. Iraqi J Sci 2014; 55: 968–73. Google Scholar Ghazi-Khansari M, Mohammadi-Bardbori A. Captopril ameliorates toxicity induced by paraquat in mitochondria isolated from the rat liver. Toxicol in Vitro 2007; 21: 403–7. DOI - PubMed - Google Scholar Dinic-olivira RJ, Sousa C, Remiao F, Durte JA, Navarro SA, Bastos L, et al. Full survival of paraquat-exposed rats after treatment with sodium salicylate. Free Radic Biol Med 2007; 42: 1017–28. DOI - PubMed - Google Scholar Attia AM, Nasr HM. Dimethoate-induced changes in biochemical parameters of experimental rat serum and its neutralization by black seed (Nigella sativa) oil. Slovak J Anim Sci 2009; 42: 87–94. Google Scholar Al-Rubaie AH.M. Effect of natural honey and mitomycin C on the effectiveness of the enzyme glutathione reductase in mice Mus musculus. Babylon Uni J 2008; 15: 1385–91.

Introducción: La enfermedad renal crónica asociada a la obesidad (ERC-AO) es una enfermedad con aumento en la prevalencia en las últimas décadas. Se caracteriza por un exceso de desequilibrios hormonales adipocíticos (adipoquinas), desregulación del sistema de equilibrio energético y desequilibrios en la homeostasis metabólica. Propósito de la revisión: El objetivo de la revisión es delinear el papel de los diferentes mecanismos fisiopatológicos para el desarrollo de enfermedad renal funcional o anatómica en pacientes con obesidad. Buscamos reportes actualizados en donde se incluye los resultados de mejor supervivencia para los pacientes con ERC-AO. Recientes hallazgos: Actualmente sabemos la ERC-AO tiene un comportamiento pro inflamatorio crónico. La obesidad y sobrepeso se asocian alteraciones hemodinámicas, estructurales e histopatológicas en el riñón, así como alteraciones metabólicas y bioquímicas que predisponen a la enfermedad renal, aun cuando la función renal y las pruebas convencionales sean normales. Conclusiones: Clasificamos a la ERC-AO en Tipo 1: Obesidad y alteraciones funcionales potencialmente reversibles. Tipo 2: Obesidad y alteraciones estructurales histopatológicas potencialmente no reversibles (Incluye la Glomerulopatía asociada a obesidad y glomeruloesclerosis focal y segmentaria). Tipo 3: Obesidad en relacionada con enfermedades crónicas (Diabetes, Hipertensión, Hipertensión pulmonar. Insuficiencia Cardíaca). Tipo 4: Obesidad en el paciente con terapia sustitutiva de la función renal. Recibido: Agosto 03, 2022 Aceptado: Septiembre 30, 2022 Publicado: Septiembre 30, 2022 Editor: Dr. Franklin Mora Bravo. Introducción La obesidad es una enfermedad en crecimiento con un aumento en su prevalencia en las últimas décadas, asociándose a un elevada carga asistencial y económica para los sistemas sanitaros derivado de su relación con enfermedades cardiovasculares, endocrinas, psicológicas, renales entre otras [1, 2]. El incremento en las tasas de obesidad en distintos grupos etarios, desde niños hasta adultos jóvenes conlleva a asumir que en el futuro veremos más enfermedad renal relacionada con la obesidad (ERC-AO) en la población general, con implicaciones relevantes para los sistemas de atención [3]. Por ello el conocimiento y comprensión de esta interacción podría tener implicaciones en la prevención y tratamiento de las enfermedades renales. Dentro de la población general la obesidad se asocia a incremento en el riesgo de diversas condiciones patológicas, como la hipertensión arterial crónica (HTA), enfermedad renal crónica (ERC), artrosis, infecciones, síndrome de apnea hipopnea obstructiva del sueño (SAHOS) y diabetes mellitus (DM) entre otras [3]. No obstante, en el escenario de la ERC, la obesidad juega un rol dual y paralelo en el desarrollo de la enfermedad, tradicionalmente se ha denominado “paradoja de la obesidad”, donde por un lado actúa como un factor de riesgo modificable para el desarrollo de la enfermedad renal crónica (ERC) y por otro se ha asocia de manera consistente con mejores resultados de supervivencia en pacientes con enfermedad renal terminal [1]. Por lo anterior, en las próximas páginas describimos aspectos fisiopatológicos que involucran la obesidad en el desarrollo de la ERC. Definición y epidemiología La obesidad es una condición que se caracteriza por la acumulación anormal o excesiva de tejido adiposo con consecuencias patológicas adversas e incremento del riesgo cardiovascular [4]. Utilizando para su definición y diagnostico un indicador simple como es la relación entre el peso y la talla denominado índice de masa corporal (IMC), se calcula dividiendo el peso de una persona en kilos por el cuadrado de su talla en metros (kg/m2). Un IMC entre 18.5 y 25 kg/m2 es considerado por la Organización Mundial de la Salud (OMS) como peso normal, un IMC entre 25 y 30 kg/m2 como sobrepeso y un IMC > 30 kg/m2, como obesidad [5-7]. Además, la obesidad puede ser clasificada en tres niveles de severidad: clase I (IMC 30.0 – 34.9), clase II (IMC 35.0 – 39.9) y clase III (IMC > 40) [8]. Durante las últimas tres décadas, la prevalencia de adultos con sobrepeso y obesidad (IMC ≥ 25 kg/m2) en todo el mundo ha aumentado sustancialmente, convirtiendo a la obesidad en una epidemia y se prevé que su prevalencia crezca un 40% en la próxima década [6]. Actualmente, el problema de obesidad se ha visto en mayor aumento debido al incremento en la afectación en niños, lo que ocasiona una mayor prevalencia de patologías a edad temprana. En 2016, según las estimaciones de la OMS unos 41 millones de niños menores de cinco años tenían sobrepeso o eran obesos [7]. Esto afectando a todos los países, independiente de su nivel de ingresos [7]. La prevalencia del sobrepeso y la obesidad en niños y adolescentes (de 5 a 19 años) ha aumentado de forma espectacular, del 4% en 1975 a más del 18% en 2016. Este aumento ha sido similar en ambos sexos: un 18% de niñas y un 19% de niños con sobrepeso en 2016. Mientras que en 1975 había menos de un 1% de niños y adolescentes de 5 a 19 años con obesidad, en 2016 eran 124 millones (un 6% de las niñas y un 8% de los niños) [7]. La creciente prevalencia de la obesidad tiene implicaciones para las enfermedades cardiovasculares (ECV) y también para la ERC. Un IMC alto es uno de los factores de riesgo más fuertes para la ERC de nueva aparición [6]. Epidemiología de la enfermedad renal crónica asociada a obesidad (ERC-AO) La enfermedad renal crónica (ERC) es una condición de interés en salud pública, asociada a una elevada morbilidad y mortalidad a nivel mundial. Las guías KDIGO (Kidney Disease: Improving Global Outcomes), definen la ERC como la presencia de alteraciones en la estructura o función renal durante al menos tres meses y con implicaciones para la salud [9, 10]. Los principales elementos clasificatorios para definir la presencia de ERC son la tasa de filtración glomerular (TFG) estimada (G1 a G5) utilizando como umbral definitorio una TFG 60 ml/min/1,73m2 y la tasa de excreción de albúmina en orina (A1 a A3) según el cociente albúmina/creatinina en una muestra aislada de orina sea < 30, 30-300 o > 300 mg/g, respectivamente [9, 10]. Si bien inicialmente existía cierta controversia sobre el uso de la TFG para el diagnóstico de la ERC en fases iniciales, trabajos recientes han puesto en evidencia que tanto una TFG< 60 ml/min/1.73 m2 como un cociente albúmina/creatinina (CAC) ≥ 1.1 mg/mmol (10 mg/g) son predictores independientes del riesgo de mortalidad e insuficiencia renal terminal (IRT) en población general [11, 12]. En consecuencia, debido a estas categorías podemos determinar el pronóstico de cada paciente. Los datos globales sugieren que la prevalencia de la ERC se encuentra entre el 10 y el 16 %, pero la información sobre la prevalencia de la población por categoría de TFG y ACR es escasa [13]. La ERC es una afección asociada a una elevada carga de morbilidad, mortalidad y enfermedad cardiovascular (ECV). A medida que disminuye la función renal, surgen trastornos metabólicos y hemodinámicos que aumentan las tasas de hospitalización, ECV y muerte [4]. El conjunto de factores de riesgo conocidos para la progresión de la ERC es relativamente pequeño, y las terapias y estrategias efectivas para retrasar la progresión de la ERC son limitadas [14]. Por lo cual resulta necesario conocer y entender los diferentes factores de riesgo y su impacto en el daño renal, en aras de lograr minimizar la progresión del mismo, sobre todo en aquellos en los cuales se puede realizar intervenciones activas, evaluables, controlables y con seguimiento continuo como es la obesidad. A la fecha existe suficiente evidencia para asociar la obesidad con el desarrollo y progresión de la enfermedad renal crónica. Los datos granulares sobre la prevalencia de la obesidad en personas con ERC son limitados pero consistentes en todo el espectro de la enfermedad renal. En la Encuesta Nacional de Examen de Salud y Nutrición de 2011–2014, el 44.1 % de los pacientes con ERC en los Estados Unidos también tenían obesidad (21.9 % con obesidad de clase 1 y 11.1 % con clase 2 y obesidad clase 3, habiéndose incrementado el porcentaje global un 5% en los últimos 12 años [15]. La glomeruloesclerosis focal y segmentaria (GEFS) es el tipo de glomerulonefritis que se asocia con mayor frecuencia a la obesidad [16]. La enfermedad glomerular habitualmente asociada a la obesidad se denomina glomerulopatía relacionada con la obesidad (GRO). Esta condición suele presentarse con síndrome nefrótico y pérdida progresiva de la función renal. Con la epidemia mundial de obesidad, se produjo un aumento progresivo de la GRO del 0.2% entre 1986 y 1990 al 2% entre 1996 y 2000, y se ha convertido en un tema emergente en el ámbito de la nefrología [15]. Etiología y patogénesis de la ERC-AO La obesidad se caracteriza por un exceso de desequilibrios hormonales adipocíticos (adipoquinas), desregulación del sistema de equilibrio energético y desequilibrios en la homeostasis metabólica [12]. Hay dos tipos de tejido adiposo presentes en los humanos: tejido adiposo blanco (WAT) y tejido adiposo marrón (BAT) [17-19]. El depósito de grasa ectópica primariamente ocurre en lugares donde no se almacena fisiológicamente, como el hígado, el páncreas, el corazón y el músculo esquelético; secundariamente hay un cambio en la distribución del tejido adiposo visceral con almacenamiento de tejido adiposo en los espacios intraperitoneal y retroperitoneal; luego se presenta la desregulación inflamatoria y de adipoquinas; y por último la resistencia a la insulina [20]. Tejido adiposo blanco (WAT) El tejido adiposo blanco (WAT) se caracteriza por ser un tejido blanco o amarillo con menor vascularización e inervación que el tejido marrón. Las células grasas tienen un tamaño que oscila entre 20 y 200 µm y contienen una única vacuola lipídica (uniloculares). En dicha vacuola se almacenan lípidos para su uso cuando hay demanda energética. De la totalidad de los lípidos que abarca la vacuola lipídica del adipocito blanco, del 90 al 99% son triacilgliceroles. El tejido adiposo blanco genera una gran cantidad de adipocinas y lipocinas. Las adipocinas son péptidos que actúan como hormonas o mensajeros que regulan el metabolismo. El tejido adiposo blanco se localiza en el tejido omental, mesentérico, retroperitoneal, perirrenal, gonadal y pericárdico [19]. Este tejido al igual que el tejido adiposo de otros sitios, está compuesto por una variedad de células que incluyen macrófagos, neutrófilos, células T CD4 y CD8, células B, neutrófilos, mastocitos, células T reguladoras y células T asesinas naturales (NK) [21, 22]. El tejido adiposo es responsable de la secreción de muchas moléculas de señalización, incluidas adipocinas, hormonas, citocinas y factores de crecimiento, como leptina, adiponectina, resistina, factor de necrosis tumoral-α (TNF-α), interleucina 6 (IL-6), monocito, proteína quimioatrayente-1 (MCP-1), factor de crecimiento transformante-β (TGF-β) y angiotensina II [23]. Tejido adiposo marrón o pardo (BAT) La coloración marrón del tejido adiposo se debe a que está más vascularizado y tiene un alto contenido de mitocondrias, las células grasas que componen el tejido adiposo pardo son multiloculares o tienen varias vacuolas lipídicas. Estas células tienen forma poligonal y miden de 15 a 50 µm. A diferencia del tejido adiposo blanco, el tejido marrón no tiene la función de almacenar energía, sino que la disipa a través de la termogénesis. Para lograr la regulación de la temperatura corporal, el tejido adiposo pardo se localiza en sitios superficiales y profundos [18]. Clasificación de la ERC-AO Se ha establecido que la obesidad es una enfermedad con un comportamiento pro inflamatorio crónico con múltiples comorbilidades asociadas [19]. El tejido adiposo como se describió previamente funciona como un órgano con actividad endocrina y esta infiltrado por diferentes poblaciones celulares que incluyen macrófagos y otras células con actividad inmune como linfocitos T, B y células dendríticas [19]. La mayor parte de la grasa corporal total, se considera como un sistema de órganos endocrinos, la perturbación de este tejido tiene como resultado una respuesta patológica al balance calórico positivo en individuos susceptibles que directa e indirectamente contribuye a la enfermedad cardiovascular y metabólica, se tiene conocimiento de tres principales mecanismos de disfunción del tejido adiposo “adiposopatía” [20]. Estos mecanismos incluyen alteraciones hemodinámicas, metabólicas e inflamatorias, lo que es la base de la clasificación de la ERC-AO propuesta en esta revisión (Tabla 1). ERC-AO tipo 1 La obesidad produce un daño renal de forma directa a través de alteraciones hemodinámicas, inflamatorias, y desregulación de factores de crecimiento y adipocitoquinas, además de aumento de leptina y disminución de adiponectina, aun cuando la función renal y las pruebas convencionales sean normales [16]. La obesidad desencadena una serie de eventos, que incluyen resistencia a la insulina, intolerancia a la glucosa, hiperlipidemia, aterosclerosis e hipertensión, todos los cuales están asociados con un mayor riesgo cardiovascular [4, 16] (Figura 1). La obesidad conduce a un incremento en la reabsorción tubular de sodio, alterando la natriuresis y provocando una expansión de volumen extracelular debido a la activación del sistema nervioso simpático (SNS) y el sistema renina-angiotensina-aldosterona (SRAA)(16). El aumento en la reabsorción tubular de sodio y la consiguiente expansión de volumen extracelular es un evento central en el desarrollo de HTA en la obesidad [4, 16]. Algunos estudios sugieren que se produce un aumento de la reabsorción de sodio en algunos segmentos además del túbulo proximal, posiblemente en el asa de Henle. Además, hay un aumento del flujo sanguíneo renal, la tasa de filtración glomerular (TFG) y la fracción de filtración [16]. La hiperfiltración glomerular, asociada con el aumento de la presión arterial y otras alteraciones metabólicas como la resistencia a la insulina y la DM, finalmente resultan en daño renal y disminución del filtrado glomerular [16]. Por otro lado, la activación del SNS también contribuye a la hipertensión relacionada con la obesidad [4]. Hay evidencia de que la denervación renal reduce la retención de sodio y la hipertensión en la obesidad, lo que sugiere que la activación del SNS inducida por la obesidad aumenta la presión arterial principalmente debido al estímulo de retención de sodio, más que a la vasoconstricción [16]. Los mecanismos que conducen a la activación del SNS en la obesidad aún no se conocen por completo, pero se han propuesto varios factores como desencadenantes de este estímulo, entre ellos la hiperinsulinemia, la hiperleptinemia, el aumento de los niveles de ácidos grasos, los niveles de angiotensina II y las alteraciones del reflejo barorreceptor. El aumento de los niveles de leptina está asociado a la activación del SNS y su efecto sobre el aumento de los niveles de presión arterial incluye también la inhibición de la síntesis de óxido nítrico (potente vasodilatador) [16, 24, 25].También se ha descrito un aumento de la producción de endotelina-1 en sujetos obesos, lo que contribuye aún más a la elevación de los niveles de presión arterial y, en consecuencia, a la disfunción renal. Estudios recientes han demostrado que la endotelina-1 está aumentada en pacientes con hipertensión intradiálisis, lo que sugiere que esta sustancia juega un papel clave en la génesis de la hipertensión en pacientes con ERC y posiblemente esté asociada con la hipertensión en pacientes obesos [16, 25]. Por lo anterior, las alteraciones hemodinámicas en los pacientes con obesidad conllevan a progresión de la ERC e incremento del riesgo cardiovascular derivado del desarrollo de enfermedades adicionales como la HTA, potencialmente estos cambios son reversibles con el control de la obesidad. ERC-AO Tipo 2 Mantener el estado de obesidad más allá de los efectos renales funcionales produce cambios estructurales irreversibles a nivel glomerular [25]. El estudio de pacientes con ERC y obesidad ha permitido identificar la presencia de enfermedad glomerular asociada a la obesidad, denominada glomerulopatía relacionada con la obesidad (GRO). En esta condición la hipertrofia glomerular parece ser la lesión inicial que estimula el borramiento de los podocitos y desencadena la respuesta inflamatoria local [25, 26]. Es relevante mencionar que las señales profibrogénicas inducen la formación de depósitos en la matriz extracelular de las nefronas, que conduce al engrosamiento de la membrana basal glomeruloesclerosis y fibrosis tubulointersticial [26]. Dentro del curso patogénico de la enfermedad la expansión de la superficie glomerular conduce a que los podocitos sean incapaces de cubrirla, esto lleva a disfunción y borramiento de los mismos, generando ruptura de la barrera de filtración glomerular con sobrecarga de las células restantes, lo que finalmente conduce a hiperfiltración y proteinuria [25, 26]. No obstante, no todos los pacientes con obesidad o IMC aumentado desarrollan ERC, lo cual sugiere que el incremento del IMC por sí solo no genera aumento en la incidencia o progresión de la ERC, ameritando alteraciones metabólicas adicionales. En los siguientes apartados se describen algunas de estas vías fisiopatológicas comunes a todos los tipos de ERC-AO. ERC-AO Tipo 3 La obesidad produce daño renal de forma secundaria ya que aumenta el riesgo de diabetes mellitus, hipertensión y daño cardiovascular, estas patologías causan enfermedad renal diabética (ERD), nefroangioesclerosis, y glomerulopatía asociada a hipertensión pulmonar e insuficiencia cardíaca. La mortalidad no solo se ve afectada por la presencia de la obesidad sino por la presencia de diabetes tipo 2, hipertensión arterial, hipertensión pulmonar e insuficiencia cardíaca. Los peores resultados en supervivencia lo padecen los pacientes con falla cardíaca, obesidad e insuficiencia renal. ERC-AO Tipo 4 En pacientes en hemodiálisis los niveles más elevados de adiponectina se asocian paradójicamente con tres veces más riesgo de muerte [24]. La obesidad se asocia a niveles muy bajos adiponectina por lo que la obesidad en el grupo poblacional que se realiza hemodiálisis es un fuerte factor protector con mejores resultados de supervivencia a 3 años comparados con pacientes con índice de masa corporal normal o baja. Mecanismos fisiopatológicos comunes en la ERC-AO Lipotoxicidad derivada del tejido adiposo En pacientes obesos el exceso de energía conduce a un microambiente sometido a estrés crónico, lo cual resulta en hipertrofia del tejido adiposo hasta que los adipocitos alcanzan su límite de crecimiento [25]. En ese momento, el exceso de especies toxicas lipídicas se acumula ectópicamente en diferentes órganos, induciendo un efecto nocivo conocido como lipotoxicidad; especialmente a nivel renal [27]. La lipotoxicidad se asocia a cambios estructurales y funcionales de las células mesangiales, podocitos y células tubulares proximales [28]. En los podocitos, esto interferiría con la vía de la insulina, crítica para la supervivencia y el mantenimiento de la estructura de los podocitos, lo que conduciría a la apoptosis de los podocitos e induciría una respuesta hipertrófica compensatoria en los podocitos restantes [25]. En el riñón, los depósitos de lípidos ectópicos contribuyen tanto a la inflamación local como al estrés oxidativo [27]. En modelos de ERD, la dislipidemia puede favorecer la acumulación de lípidos ectópicos e intermediarios lipídicos, no solo en el riñón sino también en tejidos extrarrenales como hígado, páncreas y corazón [27]. La acumulación de lípidos en el parénquima renal, genera daño en varias poblaciones celulares, incluídos podocitos, células epiteliales tubulares proximales y el tejido tubulointersticial a través de distintos mecanismos descritos en las siguientes apartados, pudiendo general compromiso a largo plazo de la función renal [27]. El tejido adiposo es una fuente importante de producción de diferentes factores proteicos activos, conocidos como adipocitocinas, las cuales participan en diferentes procesos metabólicos. Alteraciones en la secreción y señalización de moléculas derivadas del tejido adiposo durante la obesidad en gran medida puede mediar en la patogenia de los trastornos metabólicos [25]. A continuaciones se describe el rol de las adipocinas en la patogenia de la ERC y obesidad. Adiponectina La adiponectina es una proteína secretada principalmente por los adipocitos WAT, las principales funciones biológicas de la adiponectina incluyen una mayor biosíntesis de ácidos grasos y la inhibición de la gluconeogénesis hepática [17]. Es probablemente la adipocina secretada más abundantemente, forma alrededor del 0.05 % de las proteínas séricas y mide de 3 a 30 mg/ml en humanos, para su activación utiliza dos isoformas del receptor (AdipoR1 y AdipoR2) son receptores de siete transmembranas y tienen una homología del 66.7 % en su estructura [17]. Sin embargo, AdipoR1 y AdipoR2 son estructural y funcionalmente distintos de los receptores acoplados a proteína G porque su terminal N es intracelular, mientras que el terminal C es extracelular [29, 30]. La señalización de adiponectina se basa principalmente en interacciones de tipo receptor-ligando, en las que la adiponectina se une a sus receptores afines e inicia la activación de varias cascadas de señalización intracelular a través de las vías AMPK, mTOR, NF-κB, STAT3 y JNK [17]. La adiponectina inicia la activación de la señalización de AMPK mediada por la proteína adaptadora APPL1, que se une al dominio intracelular de AdipoR. Eso produce la activación de la biosíntesis de moléculas, otras proteínas reguladoras e importantes factores de transcripción. AMPK es un regulador que participa principalmente en la proliferación celular [17]. Hay dos tipos de macrófagos, M1 participan en la estimulación de los factores pro inflamatorios e induce la resistencia a la insulina y M2 bloquean una respuesta inflamatoria y promueve el metabolismo oxidativo; En los macrófagos, la adiponectina promueve la diferenciación celular de monocitos a macrófagos M2 y suprime su diferenciación a macrófagos M1, lo que muestra efectos pro inflamatorios y antiinflamatorios. Además, también activa los factores antiinflamatorios IL-10 pero reduce las citoquinas pro inflamatorias como IFN-γ, IL-6 y TNF-α en los macrófagos humanos [17]. Los pacientes con ERC muestran niveles elevados de proteína C reactiva (PCR), IL-6 y TNF-α y tienen una activación aberrante de receptor tipo toll (TLR)-4 [25]; en un estudio realizado en el año 2005 en 29 pacientes con ERC no diabéticos en etapa 5 y 14 controles sanos, se identificó que los pacientes con ERC tenían una expresión elevada del gen y la proteína TLR4, la estimulación de TLR-4 in vitro indujo la activación de TNF-α y NF-κB en células C2C12. Esto sugiere indirectamente que la activación de TLR-4 podría promover la inflamación muscular de los pacientes con ERC [31]. Los niveles de adiponectina se consideran predictivos de ERC, dado que estos se encuentran aumentados en pacientes con etapa pre diálisis [17, 29, 32]. Adicionalmente, en un estudio prospectivo realizado en el año 2008 en pacientes con ERC primaria no diabética identificó niveles elevados de adiponectina como un predictor novedoso de progresión de la ERC en hombres [33]. En estudios realizados en animales (ratones) muestran que la deficiencia de adiponectina se relaciona con varias alteraciones histológicas, incluida la fusión segmentaria procesos podocitarios, albuminuria y aumento del estrés oxidativo en los riñones [34]. Por otro lado, en pacientes obesos la producción de adiponectina se encuentra disminuida por lo que se cree que puede generar una función protectora sobre el riñón [29]. No obstante, paradójicamente, algunos estudios muestran que los pacientes con ERC y enfermedad renal crónica en diálisis (ERCT) tienen altos niveles de adipocinas, las explicaciones a esta situación son controversiales, se ha planteado podrían corresponder a un mecanismo compensatorio, otras consideraciones sugieren una disminución de la sensibilidad a la adiponectina o una reducción en el aclaramiento de la misma [35]. Leptina En pacientes con ERC independiente de la presencia de obesidad o no, se asocian a niveles elevados de leptina sérica. La leptina es una proteína de 167 aminoácidos, con una masa molecular de aproximadamente 16 kDa que está codificada por el gen LEP [23] secretada principalmente por los adipocitos, es una adipocina pleiotrópica. La leptina circulante llega a los órganos diana, donde se une a receptores específicos (conocidos como ObR, LR o LEPR), se conocen cinco isoformas del receptor de leptina en humanos (ObRa, ObRb, ObRc, ObRd y ObRe), de estas solo la isoforma ObRb (isoforma larga) se considera un receptor completamente activo, ya que es capaz de transducir completamente una señal de activación en la célula. Esta isoforma se encuentra altamente expresada en el sistema nervioso central (SNC), especialmente en el hipotálamo, donde participa en la regulación de la actividad secretora de este órgano. Los efectos de la leptina están mediados por cinco vías principales de señalización. Estas vías incluyen las vías de señalización JAK-STAT, PI3K, MAPK, AMPK y mTOR [23]. Por esta razón la principal función fisiológica de la leptina es transmitir información al hipotálamo sobre la cantidad de energía almacenada, como la masa de tejido adiposo, e influir en el gasto de energía al reducir el apetito. Regula el metabolismo energético, tiene efecto sobre la ingesta de alimentos, procesos de coagulación, angiogénesis, funciones relacionadas con la insulina y la remodelación vascular, además funciona como un pro inflamatorio molecular [36]. La leptina tiene efectos sobre el apetito y se ha demostrado que la hiperleptinemia contribuye a la hipertensión asociada a la obesidad por sobre activación del sistema nervioso simpático [37]. En cuanto al curso de la ERC, la leptina puede modular diferentes vías de señalización en el riñón, debido a que las células endoteliales glomerulares y mesangiales expresan abundantes receptores de leptina [25]. La leptina inducirá un incremento en la expresión de genes profibróticos, como TGF-β1 y citocinas pro inflamatorias [25]. El aumento en la expresión de TGF-β1, también contribuirá al desarrollarlo de la fibrosis renal, al unirse a receptores específicos a nivel renal, estimulara la expresión de factores profibróticos en un ciclo de retroalimentación positiva. Además, TGF-β1 es un potente iniciador de proliferación de células mesangiales renales [25]. Debido a su tamaño relativamente pequeño, la leptina atraviesa libremente el filtro glomerular de los riñones y luego se reabsorbe en la parte proximal de los túbulos contorneados [23]. Por lo que el estado elevado de leptina puede indicar una función renal deficiente [36]. Promueve la inflamación y trastorno de los lípidos, que contribuyen al riesgo de ERC [36]; se considera como “toxina urémica”, estando implicada tanto en la progresión de la enfermedad renal a través de efectos pro-hipertensivos y profibróticos, como en el desarrollo de complicaciones relacionadas con la ERC (inflamación crónica, pérdida de proteínas) [38]. Como se mencionó previamente, la leptina estimula la proliferación de células endoteliales glomerulares renales y aumenta la expresión de TGF-β1, un mediador clave de la hidrogénesis en estas células, el aumento de los niveles de leptina también contribuye al aumento de la expresión de colágeno tipo IV en el riñón, induce la proliferación de células mesangiales glomerulares mediante la activación de la vía PI3K, la hipertrofia de las células mesangiales aumenta la cantidad de proteína filtrada y albúmina que llega a las células del túbulo proximal y, como resultado, activa las vías inflamatorias y la fibrosis [23]. Puede presentarse un aumento en la síntesis del receptor TGFβ-1 secretado por las células endoteliales, este actúa de manera parácrina sobre el mesangio uniéndose a su receptor y activando la síntesis de proteínas de la matriz extracelular (ECM), incluyendo colágeno, fibronectina, tenazina y proteoglicanos; consiguientemente, un aumento en el nivel de TGFβ-1 conduce a la acumulación de MEC y, en consecuencia, a fibrosis glomerular y glomeruloesclerosis. En los podocitos, la leptina contribuye a la disminución de la expresión de las proteínas responsables de la filtración glomerular adecuada, incluidas la podocina, la nefrina, la podoplanina y la podocalixina. En las células del túbulo contorneado proximal (PTC), la leptina reduce la actividad metabólica de las células al activar la vía de señalización de mTOR [23]. Por otro lado, la leptina inhibe el apetito y aumenta el gasto de energía conduciendo a anorexia y desnutrición en pacientes con ERC, particularmente en casos de hemodiálisis de mantenimiento [36]. Por ende, una elevación de la leptina no solo nos indicaría daño renal, sino que además nos indica mayor progresión de complicaciones secundarias [39]. La obesidad aumenta la carga sobre los riñones y es un factor de riesgo de lesión renal, además de contribuir en los trastornos metabólicos asociados. Por lo que, teniendo en cuenta los efectos inhibitorios de la leptina sobre la obesidad, se puede considerar que puede proteger contra la lesión renal [39, 40]. Un estudio experimental publicado en el año 2017 demostró que la leptina disminuyó la ingesta calórica y los niveles de glucosa en ratas diabéticas [41], ese mismo año se publicó un estudio retrospectivo donde demostraron que la metreleptina, una metionil leptina humana recombinante, reduce el peso corporal y la dosis diaria de insulina en la diabetes mellitus tipo 1 [42]. La metreleptina ejerce efectos terapéuticos en la lipodistrofia [43], lo que indica que es probable que la leptina se aplique en los trastornos metabólicos [36]. Otras adipocinas Las principales adipocinas corresponden a la adiponectina y leptina como se ha descrito previamente. Además de estas, se distinguen la actividad de la visfatina y resistina, las cuales muestran propiedades pro-inflamatorias y efectos aterogénicos [25]. La visfatina estimula la expresión de TGF-β1, inhibidor del activador del plasminógeno-1 (PAI-1) y colágeno tipo I, los cuales han demostrado un rol importante como agentes profibróticos. Por otro lado, la resistina estimula la producción de las moléculas de adhesión como la molécula de adhesión intracelular 1 (ICAM-1) y la proteína de adhesión celular vascular 1 (VCAM-1) y promueve la activación del sistema renal simpático. Los niveles de estas adipocinas están marcadamente elevados en la obesidad y ERC correlacionándose con parámetros proinflamatorios y disminución de la tasa de filtración glomerular (TFG) [25, 37]. Durante el curso de la obesidad se presenta una sobre activación del SRAA, el tejido adiposo también estaría involucrado en la producción o estimulación de algunos de los componentes del RAS. Por ello la sobre estimulación del SRAA en obesos, asociado a la glomerulomegalia y desregulación de la reabsorción de sodio/glucosa, generalmente conlleva a hipertensión glomerular e hiperfiltración [25]. Otra adipocina a considerar, es la actividad de la adipocina proinflamatoria lipocalina 2 (LCN2), también denominada lipocalina asociada con la gelatinasa de neutrófilo (NGAL), estudiada como biomarcador funcional tanto para la enfermedad renal aguda como ERC(25). LCN2 es conocido por su papel en la respuesta inmune innata a través de su unión a sideróforos derivados de una infección bacteriana. Sin embargo, LCN2 no es secretada únicamente por neutrófilos sino también por otros tejidos como hígado, pulmones y de interés para este artículo, a nivel renal [25]. Se han informado niveles elevados de LCN2 en suero y orina en la lesión renal, debido a una expresión aumentada de LCN2 en el túbulo distal renal y una reabsorción alterada en el túbulo proximal [44]. El tejido adiposo, también puede producir factores angiogénicos como el factor de crecimiento del endotelio vascular (VEGF). Este elemento podría inducir la formación de novo de capilares glomerulares en gran parte defectuosos dentro del riñón, lo que contribuye a la hipertrofia glomerular característica de GRO [25] (Figura 2). Conclusiones La obesidad y el sobrepeso se asocian a alteraciones hemodinámicas, estructurales e histopatológicas en el riñón, así como alteraciones metabólicas y bioquímicas que predisponen a la enfermedad renal, aun cuando la función renal y las pruebas convencionales sean normales. Por lo tanto, los efectos renales de la obesidad son estructurales y funcionales. Hay varios mecanismos actualmente descritos que involucran a la obesidad como generador de alteraciones renales. Teniendo en cuenta las bases fisiopatológicas, proponemos una clasificación de la ERC-AO basadas en 4 tipos. Abreviaturas ERC: enfermedad renal crónica. ERC-AO: enfermedad renal crónica-asociada a enfermedad. VEGF: factor de crecimiento del endotelio vascular. OR: Odds ratio. Información suplementaria Materiales suplementarios no han sido declarados. Agradecimientos No aplica. Contribuciones de los autores Jorge Rico-Fontalvo: Conceptualización, Curación de datos, Análisis formal, Adquisición de fondos, Investigación, Metodología, Administración de proyecto, Recursos, Software, Escritura – borrador original. Rodrigo Daza-Arnedo: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. Tomás Rodríguez-Yanez: Metodología, validación, supervisión, redacción: Revisión y edición. Washington Osorio: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. Beatriz Suarez-Romero: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. Oscar Soto: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. Juan Montejo-Hernandez: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. María Cardona-Blanco: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. Juan Camilo Gutiérrez: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. Todos los autores leyeron y aprobaron la versión final del manuscrito. Financiamiento Los autores proveyeron los gastos de la investigación. Disponibilidad de datos o materiales Los conjuntos de datos generados y analizados durante el estudio actual no están disponibles públicamente debido a la confidencialidad de los participantes, pero están disponibles a través del autor correspondiente a pedido académico razonable. Declaraciones Aprobación del comité de ética y consentimiento para participar No aplica para revisiones narrativas. Consentimiento para publicación No aplica cuando no se publican imágenes o fotografías del examen físico o radiografías/tomografías/resonancias de pacientes. Conflictos de interés Los autores reportan no tener conflictos de interés. 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Introduction: Sputum negative pulmonary Tuberculosis (TB) is a major public health problem. So, the emergence of new techniques for a more precise and rapid microbiological identification of Mycobacterium tuberculosis in clinical samples is of great importance to improve the management of TB. Aim: To determine and compare the sensitivity and turnaround time for Mycobacterium tuberculosis detection by the BACTEC Mycobacteria Growth Indicator Tube (MGIT) 960 system, Lowenstein Jensen (LJ) medium and Ziehl-Neelsen (ZN) staining. Materials and Methods: An Institution based, observational, cross-sectional study was conducted at Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India, from July 2013-March 2016. Sputum, pericardial fluid, pleural fluid, peritoneal fluid, pus and endometrial tissue samples were collected from 80 patients of suspected TB cases. All were Acid-Fast stained by ZN staining method and cultured on solid culture LJ medium and on liquid medium (MGIT). Data was analysed using Statistical Package for the Social Sciences (SPSS) software, Version 20.0 (SPSS Inc, Chicago, IL, USA). Fisher’s-Exact test was used to show association of categorical variables. Non-parametric Mann-Whitney U test was used to show median difference of non-normally distributed continuous variables of two groups. Results: Out of the 80 samples, 41 cases were positive by either of the all methods. The positive specimen for ZN staining, LJ media and MGIT were 21, 29 and 41 cases respectively. The mean Time To Detection (TTD) was shorter for MGIT system than LJ media. Both LJ medium and MGIT 960 detected all cases of sputum smear positive cases and in addition significantly higher number than ZN stain in sputum smear negative cases. MGIT 960 detected significantly higher number of cases of sputum negative cases than LJ Media. The mean TTD was also significantly shorter in case of smear positive cases than the smear negative cases by both the solid and liquid culture mediums. Conclusion: The use of liquid media (MGIT) is more accurate and rapid method for the diagnosis of TB. The combination of more than one method is also highly recommended for rapid detection and early treatment of TB.

Auch heute noch führen physiologische und parasitäre Schäden welche sich während der Lagerung von Apfelfrüchten entwickeln können, zu erheblichen wirtschaftlichen Verlusten. Um den Lagerungsprozess von Äpfeln effizienter zu gestalten, wurde dank eines dreijährigen Interreg-V EU-Projektes, ein Software-gestütztes Bestimmungssystem zur Reduzierung von Lagerschäden im Obstbau entwickelt: Frudistor, aus 'fruit disorders storage'. Diese Web-Applikation kann durch ihre einfache, praktische und kostenlose Anwendung –zugänglich unter http://www.frudistor.de von jeglichem digitalen Endgerät aus (PC, Tablet bzw. Smartphone)– Produzenten, Lagertechniker, Handelsorganisationen und Konsumenten dabei begleiten, die verschiedenen Schäden, die während der Lagerung von Früchten entstehen können, zu identifizieren und zu erkennen, um ihnen vorbeugen zu können und sie zu vermeiden. Dies wird mit Hilfe eines ausgeklügelten, einfachen Filtersystems realisiert. Die Software enthält mehr als 40 technische Datenblätter (derzeit in Italienisch, Deutsch, Englisch und Niederländisch) und Bilder, die es ermöglichen, den Ursprung von Schäden schnell zu erkennen und somit eine Vermeidung zu gewährleisten.

Empirical methods for determining the length of hydraulic jump, including USBR graphical method are not accurate. In addition to reduced errors, providing an analytical equation will result in the possibility of programming and development of hydraulic software application. In this research, based on the principles of dimensional analysis, an analytical equation was achieved for estimating the length of hydraulic jump of E and classical type. Dimensionless coefficient of this equation was determined as a function of slope and Froude number using Table Curve software. For this purpose, 387 data series (258 calibration data and 129 validation data) of experiments conducted in this research, USBR studies, results of a research in the laboratory of Ohio University and in an appropriate range of the flume width, discharge, Froude number, the velocity before jump as well as the slope were used. At calibration stage, a simple equation was provided that indicates the hydraulic jump length in values Lj /y1 depends on the slope of the flume and Fr2 with determination coefficient of 94% and standard error less than 8%. Also at validation stage, the observed data and computed values was close to identity line with a determination coefficient of 0.97. Presenting the hydraulic jump length in values Lj /y1 versus Fr1 (which is very similar to USBR graphical method) was not satisfactory even with zoning Fr1 .

The article showed the result of investigation of the length of hydraulic jump in trapezoidal channel. In this study, the basic factors that affect the length (Lj) and roller length (Lr) of hydraulic jump were investigated by physical trapezoidal channel’s model. The experiment carried out in purpose to establish a new empirical equation for calculating the roller length (Lr) of the jump in the horizontal trapezoidal channel with the upstream flow Froude number 4.0 to 9.0 (the steady jump). The hydraulic characteristics of forced jump were measured and statistically calculated by excel software. The results of data analysis showed that the MAPE was relatively small (< 5%), and R2 > 0.9 (strong correlation between predicted and observed values) and other statistical indicators are less than 0.1 (MSE = 0.004, RMSE = 0.062 và MEA = 0.047). Therefore, the equation found could be appropriated and applied to calculate characteristics of hydraulic jump trapezoidal channel.

Background: Tuberculosis is the communicable infectious disease usually caused by Mycobacterium Tuberculosis Bacteria (MTB). Tuberculosis generally affects lungs, but can also affect other parts of the body. ADA has been found to be useful parameter to conclude the tubercular etiology. Tuberculous Pleural effusion is diagnosed by demonstration of tubercular bacilli in pleural fluid or granuloma in pleural biopsy specimen. Objectives of this study: The objectives of this study were to estimate ADA levels and to study AFB culture in subjects with and without tubercular pleural effusion. Materials and Methods: Biochemical analysis for Protein and Glucose were performed on Automated Biochemistry Analyser and ADA was estimated by ADA-MTB kit method. Cytological examination and ADA Microbiological demonstration of AFB by ZN stain and AFB culture was done by conventional LJ method. Statistical Analysis: Data were expressed as mean ± SD. The Student t test was used for the comparison. Statistical analysis was done using Microsoft Excel spreadsheet, and statistical package for the social sciences (SPSS) version 20.0 software.

Digital technologies have become an integral part of our everyday life. Today the application of digital technologies surrounds us at home, at work, in education, transport or leisure. Digital transformation is not only about the technological shift. New technologies, software and hardware solutions are emerging every day. The importance of digital technology in vocational education cannot be ignored. In fact, with the advent of computers in education, it has become easier for teachers to transfer knowledge and for students to acquire it. The use of technology has made the teaching and learning process even more enjoyable. But the negative aspects of the use of digital educational technologies in training highly qualified specialists on the labor market are also not excluded.

Abstract Shear viscosity, though being a fundamental property of all fluids, is computationally expensive to calculate from equilibrium molecular dynamics simulations. Recently, Machine Learning (ML) methods have been used to augment molecular simulations in many contexts, thus showing promise to estimate viscosity too in a relatively inexpensive manner. However, ML methods face significant challenges - such as overfitting, when the size of the data set is small, as is the case with viscosity. In this work, we train seven ML models to predict the shear viscosity of a Lennard-Jones (LJ) fluid, with particular emphasis on addressing issues arising from a small data set. Specifically, the issues related to model selection, performance estimation and uncertainty quantification were investigated. First, we show that the widely used performance estimation procedure of using a single unseen data set shows a wide variability small data sets. In this context, the common practice of using Cross validation (CV) to select the hyperparameters (model selection) can be adapted to estimate the generalization error (performance estimation) as well. We compare two simple CV procedures for their ability to do both model selection and performance estimation, and find that k-fold CV based procedure shows a lower variance of error estimates. We discuss the role of performance metrics in training and evaluation and propose a method to rank the ML models based on multiple metrics. Finally, two methods for uncertainty quantification - Gaussian Process Regression (GPR) and ensemble method - were used to estimate the uncertainty on individual predictions. The uncertainty estimates from GPR were also used to construct an applicability domain using which the ML models provided even more reliable predictions on an independent viscosity data set generated in this work. Overall, the procedures prescribed in this work, together, lead to robust ML models for small data sets.

Background and aimsCyclic guanosine monophosphate (GMP)-adenosine monophosphate (AMP) (cGAMP) synthase (cGAS) and stimulator of interferon genes (STING) are key components of the innate immune system. This study aims to evaluate the research of cGAS-STING pathway and predict the hotspots and developing trends in this field using bibliometric analysis.MethodsWe retrieved publications from Science Citation Index Expanded (SCI-expanded) of Web of Science Core Collection (WoSCC) in 1975-2021 on 16 March 2022. We examined the retrieved data by bibliometrix package in R software, VOSviewer and CiteSpace were used for visualizing the trends and hotspots of research on the cGAS-STING pathway.ResultsWe identified 1047 original articles and reviews on the cGAS-STING pathway published between 1975 and 2021. Before 2016, the publication trend was increasing steadily, but there was a significant increase after 2016. The United States of America (USA) produced the highest number of papers (Np) and took the highest number of citations (Nc), followed by China and Germany. The University of Texas System and Frontiers in Immunology were the most prolific affiliation and journal respectively. In addition, collaboration network analysis showed that there were tight collaborations among the USA, China and some European countries, so the top 10 affiliations were all from these countries and regions. The paper published by Sun LJ in 2013 reached the highest local citation score (LCS). Keywords co-occurrence and co-citation cluster analysis revealed that inflammation, senescence, and tumor were popular terms related to the cGAS-STING pathway recently. Keywords burst detection suggested that STING-dependent innate immunity and NF-κB-dependent broad antiviral response were newly-emerged hotspots in this area.ConclusionsThis bibliometric analysis shows that publications related to the cGAS-STING pathway tend to increase continuously. The research focus has shifted from the mechanism how cGAS senses dsDNA and cGAMP binds to STING to the roles of the cGAS-STING pathway in different pathological state.

Objetivo: verificar a distribuição espacial e o perfil epidemiológico dos casos notificados da violência contra a mulher em um município do nordeste brasileiro, no biênio 2012-2013. Metodologia: foi realizado um estudo transversal, de base populacional, quantitativo, descritivo, no município de Campina Grande – PB, com base nas notificações da violência junto ao SINAN. O instrumento para a coleta dos dados foi construído com base nos campos disponíveis para as respostas da ficha de notificação, dividido em sete blocos. A análise estatística dos dados foi desenvolvida baseando-se em frequências absolutas e relativas, sendo construído um gráfico de espalhamento de Moran a fim de verificar a distribuição espacial da violência nos bairros de Campina Grande. As análises foram realizadas com auxílio do software estatístico R (RStudio) Resultados: Foram analisadas 109 notificações de violência contra a mulher. Prevaleceram mulheres adultas, não gestantes, pardas, com baixa escolaridade. Houve predominância da violência psicológica e física. Os bairros mais afetados pela violência foram Velame, Malvinas, Bodocongó, Dinamérica, Santa Rosa, Centenário, Catolé e José Pinheiro. Conclusão: foi possível traçar o perfil mais envolvido com a violência contra a mulher na cidade de Campina Grande, devendo ser voltado um olhar mais atencioso à violência doméstica, sobretudo entre pares, com o objetivo de encorajar essas mulheres a denunciarem violências vivenciadas.Descritores: Violência; Notificação de Abuso; Prevalência.ReferênciasMalta DC, Minayo MCS, Soares Filho AM, Silva MMA, Montenegro MMS, Ladeira RM et al. Mortalidade e anos de vida perdidos por violências interpessoais e autoprovocadas no Brasil e Estados: análise das estimativas do Estudo Carga Global de Doença, de 1990 e 2015. Rev bras epidemiol.2017;20(suppl 1):142-56,Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC et al. 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