Evaluating the effectiveness of rosuvastatin in preventing the progression of diastolic dysfunction in aortic stenosis: A substudy of the aortic stenosis progression observation measuring effects of rosuvastatin (ASTRONOMER) study

Background

The aim of this study was to verify the benefits and limitations of repeated bedside echocardiographic examinations in children during mechanical ventilation. For the purposes of this study, we selected the data of over a time period from 2006 to 2010.

Methods

A total of 235 children, average age 3.21 (SD 1.32) years were included into the study and divided into etiopathogenic groups. High-risk groups comprised: Acute lung injury and acute respiratory distress syndrome (ALI/ARDS), return of spontaneous circulation after cardiopulmonary resuscitation (ROSC), bronchopulmonary dysplasia (BPD), cardiomyopathy (CMP) and cardiopulmonary disease (CPD). Transthoracic echocardiography was carried out during mechanical ventilation. The following data were collated for statistical evaluation: right and left ventricle myocardial performance indices (RV MPI; LV MPI), left ventricle shortening fraction (SF), cardiac output (CO), and the mitral valve ratio of peak velocity of early wave (E) to the peak velocity of active wave (A) as E/A ratio. The data was processed after a period of recovery, i.e. one hour after the introduction of invasive lines (time-1) and after 72 hours of comprehensive treatment (time-2). The overall development of parameters over time was compared within groups and between groups using the distribution-free Wilcoxons and two-way ANOVA tests.

Results

A total of 870 echocardiographic examinations were performed. At time-1 higher average values of RV MPI (0.34, SD 0.01 vs. 0.21, SD 0.01; p < 0.001) were found in all groups compared with reference values. Left ventricular load in the high-risk groups was expressed by a higher LV MPI (0.39, SD 0.13 vs. 0.29, SD 0.02; p < 0.01) and lower E/A ratio (0.95, SD 0.36 vs. 1.36, SD 0.64; p < 0.001), SF (0.37, SD 0.11 vs. 0.47, SD 0.02; p < 0.01) and CO (1.95, SD 0.37 vs. 2.94, SD 1.03; p < 0.01). At time-2 RV MPI were lower (0.25, SD 0.02 vs. 0.34, SD 0.01; p < 0.001), but remained higher compared with reference values (0.25, SD 0.02 vs. 0.21, SD 0.01; p < 0.05). Other parameters in high-risk groups were improved, but remained insignificantly different compared with reference values.

Conclusion

Echocardiography complements standard monitoring of valuable information regarding cardiac load in real time. Chest excursion during mechanical ventilation does not reduce the quality of the acquired data.     

A quantitative histological study of the aortic nerve and the aortic body in the buffalo (Bubalus bubalis)

In the buffalo, the left aortic nerve ramifies in the periarterial connective tissue between the ventral surface of the aortic arch and the truncus pulmonalis. The right aortic nerve ramifies over the dorsal and right aspects of the aorta ascendens near its origin. The histograms of myelinated fibres of both left and right aortic nerve are distinctly unimodal with peak around 4-6 micron (64.2-67.8%). The left aortic body is situated in the periarterial connective tissue between the ventral surface of the aortic arch and the truncus pulmonalis, while the right aortic body is located in the tunica adventitia of the dorsal and right aspects of the aorta ascendens near its origin. The greatest sagittal section area of the left aortic body is 0.102 +/- 0.009 mm2 and that of the right aortic body is 0.041 +/- 0.002 mm2. The organ is highly vascular. The mean size of the glomus cells from the left aortic body is 7.68 +/- 0.9 micron x 9.37 +/- 0.13 micron (short diameter x long diameter), whereas the corresponding value for the right aortic body is 7.84 +/- 0.14 micron x 9.86 +/- 0.21 micron; and their density values are (11,417 +/- 301.7)/mm2 and (9,839 +/- 213.3)/mm2 respectively.     

High HbA1c levels correlate with reduced plaque regression during statin treatment in patients with stable coronary artery disease: Results of the coronary atherosclerosis study measuring effects of rosuvastatin using intravascular ultrasound in Japanese subjects (COSMOS)

ABSTRACT: BACKGROUND: The incidence of cardiac events is higher in patients with diabetes than in people without diabetes. The Coronary Atherosclerosis Study Measuring Effects of Rosuvastatin Using Intravascular Ultrasound in Japanese Subjects (COSMOS) demonstrated significant plaque regression in Japanese patients with chronic coronary disease after 76?weeks of rosuvastatin (2.5?mg once daily, up-titrated to a maximum of 20?mg/day to achieve LDL cholesterol <80?mg/dl). METHODS: In this subanalysis of COSMOS, we examined the association between HbA1c and plaque regression in 40 patients with HbA1c ≥6.5% (high group) and 86 patients with HbA1c <6.5% (low group). RESULTS: In multivariate analyses, HbA1c and plaque volume at baseline were major determinants of plaque regression. LDL cholesterol decreased by 37% and 39% in the high and low groups, respectively, while HDL cholesterol increased by 16% and 22%, respectively. The reduction in plaque volume was significantly (p?=?0.04) greater in the low group (from 71.0?±?39.9 to 64.7?±?34.7?mm3) than in the high group (from 74.3?±?34.2 to 71.4?±?32.3?mm3). Vessel volume increased in the high group but not in the low group (change from baseline: +4.2% vs -0.8%, p?=?0.02). Change in plaque volume was significantly correlated with baseline HbA1c. CONCLUSIONS: Despite similar improvements in lipid levels, plaque regression was less pronounced in patients with high HbA1c levels compared with those with low levels. Tight glucose control during statin therapy may enhance plaque regression in patients with stable coronary disease. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier NCT00329160.     

Evaluating the effectiveness of different treatments of uterine infections in female camels (Camelus dromedarius)

A total of 480 female camels with a history of conception failure were examined through transrectal palpation, ultrasonography, and vaginal exploration. Animals were categorized according to parity (nulliparous n = 200 vs. multiparous n = 280), and type of uterine infection (endometritis n = 360 vs. metritis n = 120). They were randomly assigned to receive one of three intrauterine treatments: (i) 100 mL acriflavin 0.1% (group 1, n = 170), (ii) 100 mL lotagen 4% (group 2, n = 200), or (iii) 300 mg/100 mL gentamicin sulphate (group 3, n = 110). All groups received 500 μg cloprostenol IM at infusion. Animals were exposed for breeding 7 d later and received 5000 IU hCG im at mating. The criteria for efficacy of treatment were 90 days non-return rate (90 d NRR) and calving rate (CR). The results showed that the 90 d NRR and CR were significantly influenced by parity, type of uterine infection, regime of treatment, and their interactions, P < 0.05. Treatment regimes were approximately equally efficient in treating females with endometritis (90 d NRR were 64%, 53.1% and 53.3% and CR were 58.9%, 49.3%, and 42.5% for groups 1, 2, and 3, respectively, P > 0.05). In contrast, regimes differed in treating those with metritis (90 d NRR were 55.6%, 75%, and 28.6% and CR were 31.6%, 54.8%, and 12.5% for groups 1, 2, and 3, respectively, P < 0.05). In conclusion, a regime consisted of intrauterine lotagen infusion and administration of PGF₂α at infusion and hCG at mating was more efficient for treating female camels with metritis.     

A multiscale computational comparison of the bicuspid and tricuspid aortic valves in relation to calcific aortic stenosis

Patients with bicuspid aortic valve (BAV) are more likely to develop a calcific aortic stenosis (CAS), as well as a number of other ailments, as compared to their cohorts with normal tricuspid aortic valves (TAV). It is currently unknown whether the increase in risk of CAS is caused by the geometric differences between the tricuspid and bicuspid valves or whether the increase in risk is caused by the same underlying factors that produce the geometric difference. CAS progression is understood to be a multiscale process, mediated at the cell level. In this study, we employ multiscale finite-element simulations of the valves. We isolate the effect of one geometric factor, the number of cusps, in order to explore its effect on multiscale valve mechanics, particularly in relation to CAS. The BAV and TAV are modeled by a set of simulations describing the cell, tissue, and organ length scales. These simulations are linked across the length scales to create a coherent multiscale model. At each scale, the models are three-dimensional, dynamic, and incorporate accurate nonlinear constitutive models of the valve leaflet tissue. We compare results between the TAV and BAV at each length scale. At the cell-scale, our region of interest is the location where calcification develops, near the aortic-facing surface of the leaflet. Our simulations show the observed differences between the tricuspid and bicuspid valves at the organ scale: the bicuspid valve shows greater flexure in the solid phase and stronger jet formation in the fluid phase relative to the tricuspid. At the cell-scale, however, we show that the region of interest is shielded against strain by the wrinkling of the fibrosa. Thus, the cellular deformations are not significantly different between the TAV and BAV in the calcification-prone region. This result supports the assertion that the difference in calcification observed in the BAV versus TAV may be due primarily to factors other than the simple geometric difference between the two valves.     

Nebivolol improves diastolic dysfunction and myocardial remodeling through reductions in oxidative stress in the transgenic (mRen2) rat

Angiotensin II contributes to myocardial tissue remodeling and interstitial fibrosis through NADPH oxidase-mediated generation of oxidative stress in the progression of heart failure. Recent data have suggested that nebivolol, a third-generation β-blocker, improves diastolic dysfunction by targeting nitric oxide (NO) and metabolic pathways that decrease interstitial fibrosis. We sought to determine if targeting NO would improve diastolic function in a model of tissue renin-angiotensin system overactivation. We used the transgenic (TG) (mRen2)27 rat, which overexpresses the murine renin transgene and manifests insulin resistance and left ventricular dysfunction. We treated 6- to 7-wk-old TG (mRen2)27 rats and age-matched Sprague-Dawley control rats with nebivolol (10 mg·kg(-1)·day(-1)) or placebo via osmotic minipumps for a period of 21 days. Compared with Sprague-Dawley control rats, TG (mRen2)27 rats displayed a prolonged diastolic relaxation time and reduced initial filling rate associated with increased interstitial fibrosis and left ventricular hypertrophy. These findings were temporally related to increased NADPH oxidase activity and subunits p47(phox) and Rac1 and increased total ROS and peroxynitrite formation in parallel with reductions in the antioxidant heme oxygenase as well as the phosphorylation/activation of endothelial NO synthase and PKB/Akt. Treatment with nebivolol restored diastolic function and interstitial fibrosis through increases in the phosphorylation of 5'-AMP-activated protein kinase, Akt, and endothelial NO synthase and reductions in oxidant stress. These results support that targeting NO with nebivolol treatment improves diastolic dysfunction through reducing myocardial oxidative stress by enhancing 5'-AMP-activated protein kinase and Akt activation of NO biosynthesis.     

A simple setup for measuring scattering in testing the photodynamic effectiveness of dyes

An experimental setup for the determination of the photodynamic activity of dyes on the basis of scattering measurements is described. With its aid, photochemically induced morphological changes and the process of cell lysis can be registered, and action spectra measured by varying the irradiation wavelength. Different photoproducts of the photosensitizer hematoporphyrin derivative (HPD) were tested in human erythrocyte suspensions. The photodynamic activity of these products was found to depend on absorption behavior, but is lower than that of HPD.     

A calcified sinutubular junction: the discovery of a supravalvular aortic stenosis in an elderly woman

We report a case of a 64 year old woman with a calcified ring at the level of the sinotubular junction. Echocardiography and Computed Tomography showed a supravalvular aortic stenosis, without known associated lesions, except for the existence of an aberrant right subclavian artery. These combination of abnormalities makes it an unique case. Differential diagnosis of sinutubular calcification is added. From the literature a short review of supravalvular aortic stenosis is presented with indications for surgical intervention. Lifelong and regular follow up is necessary.     

Clinical course of patients diagnosed with severe aortic stenosis in the Rotterdam area: insights from the AVARIJN study

Objective

To prospectively evaluate the clinical course of patients with severe aortic stenosis (AS) and identify factors associated with treatment selection and patient outcome.

Methods

Patients diagnosed with severe AS in the Rotterdam area were included between June 2006 and May 2009. Patient characteristics, echocardiogram, brain natriuretic peptide (NT-proBNP), and treatment strategy were assessed at baseline, and after 6, 12, and 24 months. Endpoints were aortic valve replacement (AVR) / transcatheter aortic valve implantation (TAVI) and death.

Results

The study population comprised 191 patients, 132 were symptomatic and 59 asymptomatic at study entry. Two-year cumulative survival of symptomatic patients was 89.8 % (95 % CI 79.8–95.0 %) after AVR/TAVI and 72.6 % (95 % CI 59.7–82.0 %) with conservative treatment. Two-year cumulative survival of asymptomatic patients was 91.5 % (95 % CI 80.8–96.4 %). Two-year cumulative incidence of AVR/TAVI was 55.9 % (95 % CI 47.5–63.5 %) in symptomatic patients. Sixty-eight percent of asymptomatic patients developed symptoms, median time to symptoms was 13 months; AVR/TAVI cumulative incidence was 38.3 % (95 % CI 23.1–53.3 %). Elderly symptomatic patients with multiple comorbidities were more likely to receive conservative treatment.

Conclusions

In contemporary Dutch practice many symptomatic patients do not receive invasive treatment of severe AS. Two-thirds of asymptomatic patients develop symptoms within 2 years, illustrating the progressive nature of severe AS. Treatment optimisation may be achieved through careful individualised assessment in a multidisciplinary setting.     

Comparative effectiveness of angiotensin-receptor blockers for preventing macrovascular disease in patients with diabetes: a population-based cohort study

Background:

Telmisartan, unlike other angiotensin-receptor blockers, is a partial agonist of peroxisome proliferator–activated receptor-γ, a property that has been associated with improvements in surrogate markers of cardiovascular health in small trials involving patients with diabetes. However, whether this property translates into a reduced risk of cardiovascular events and death in these patients is unknown. We sought to explore the risk of myocardial infarction, stroke and heart failure in patients with diabetes who were taking telmisartan relative to the risk of these events occurring in patients taking other angiotensin-receptor blockers.

Methods:

We conducted a population-based, retrospective cohort study of Ontario residents with diabetes aged 66 years and older who started treatment with candesartan, irbesartan, losartan, telmisartan or valsartan between Apr. 1, 2001, and Mar. 31, 2011. Our primary outcome was a composite of admission to hospital for acute myocardial infarction, stroke or heart failure. We examined each outcome individually in secondary analyses, in addition to all-cause mortality.

Results:

We identified 54 186 patients with diabetes who started taking an angiotensin-receptor blocker during the study period. After multivariable adjustment, patients who took either telmisartan (adjusted hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.74–0.97) or valsartan (adjusted HR 0.86, 95% CI 0.77–0.95) had a lower risk of the composite outcome compared with patients who took irbesartan. In contrast, no significant difference in risk was seen between other angiotensin-receptor blockers and irbesartan. In secondary analyses, we found a reduced risk of admission to hospital for heart failure with telmisartan compared with irbesartan (adjusted HR 0.79, 95% CI 0.66–0.96), but no significant differences in risk were seen between angiotensin-receptor blockers in our other secondary analyses.

Interpretation:

Compared with other angiotensin-receptor blockers, telmisartan and valsartan were both associated with a lower risk of admission to hospital for acute myocardial infarction, stroke or heart failure among older adults with diabetes and hypertension. Telmisartan and valsartan may therefore be the preferred angiotensin-receptor blockers for use in these patients.About 366 million people worldwide live with diabetes, a number that is projected to increase to 552 million by 2030.¹ Because disease-attributable macrovascular complications are the principal causes of death for people with type 2 diabetes, many therapies have the goal of reducing vascular events among these patients.^2,3 Blockade of the renin–angiotensin–aldosterone system with angiotensin-receptor blockers is a commonly used and particularly appealing strategy in this regard, given the multiple mechanisms through which angiotensin II contributes to a heightened risk of diabetes-related macrovascular disease and the superior tolerability profile of these drugs relative to angiotensin-converting enzyme (ACE) inhibitors.^4–6Although angiotensin-receptor blockers are considered largely interchangeable in clinical practice, evidence from experimental studies and small comparative trials suggest that telmisartan exhibits several pleoiotropic properties that distinguish it from other members of this drug class.⁷ Most notably, telmisartan is a partial agonist of peroxisome proliferator–activated receptor-γ (PPARγ), a property associated with improvements in surrogate markers of cardiovascular health in small trials involving patients with type 2 diabetes.^8–13 However, whether telmisartan-mediated activation of PPARγ is associated with a reduced risk of macrovascular events in patients with diabetes relative to angiotensin-receptor blockers that do not share this property is unknown.We sought to compare the risk of acute myocardial infarction, heart failure and stroke in older patients whose diabetes was also managed with either telmisartan or any of candesartan, irbesartan, losartan and valsartan. We speculated that, owing to its pleiotropic effects, telmisartan would be associated with a lower risk of macrovascular events in these patients relative to other angiotensin-receptor blockers.     

Evaluation of Crocus sativus L. (saffron) on male erectile dysfunction: A pilot study

In this study, the effect of Crocus sativus (saffron) was studied on male erectile dysfunction (ED). Twenty male patients with ED were followed for ten days in which each morning they took a tablet containing 200 mg of saffron. Patients underwent the nocturnal penile tumescence (NPT) test and the international index of erectile function questionnaire (IIEF-15) at the start of the treatment and at the end of the ten days. After the ten days of taking saffron there was a statistically significant improvement in tip rigidity and tip tumescence as well as base rigidity and base tumescence. ILEF-15 total scores were significantly higher in patients after saffron treatment (before treatment 22.15±1.44; after treatment 39.20±1.90, p<0.001). Saffron showed a positive effect on sexual function with increased number and duration of erectile events seen in patients with ED even only after taking it for ten days.     

In vitro study of the effects of Angiostrongylus cantonensis larvae extracts on apoptosis and dysfunction in the blood-brain barrier (BBB)

It has been hypothesized that blood-brain barrier (BBB) dysfunction in Angiostrongylus cantonensis infection might be due to the apoptosis of the hosts' BBB cells. Here, we evaluated this hypothesis through several methods, all based on an in vitro mouse BBB model consisting of primary culture brain microvascular endothelial cells (BMECs) and brain astrocytic cells (BACs). In the present study, a four-hour percolation and HRP permeability experiment showed that A. cantonensis larvae extracts can increase the permeability of the BBB. Apoptosis among BMECs and BACs after exposure to larvae extracts was monitored by TUNEL and annexin-V-FITC/PI double staining. A. cantonensis larvae extracts were found to induce apoptosis in both BMECs and BACs. For this reason, we concluded that the induction of apoptosis might participate in the BBB dysfunction observed during angiostrongyliasis. Improved fundamental understanding of how A. cantonensis induces apoptosis may lead to new approaches to the treatment or prevention of this parasitic disease.     

Landscape structure versus the effectiveness of nature conservation: Roztocze region case study (Poland)

The objective of the study was to examine the extent to which landscape metrics could be used as an indicator of efficient management of protection areas. The selected sampling areas were natural–landscape units distinguished within the Roztocze Region located in the central-east Poland. Among 446 units, those representing three typological groups determined by three factors were selected. The factors included (1) the area of the unit; (2) the dominant or characteristic type of ecosystem; and (3) the form of protection. Subsequently, thirteen landscape metrics were calculated with the application of the Fragstats software. The analysis revealed high correlation between the form of nature protection and the majority of the calculated indexes. National park units show the highest landscape diversity and stability of various types of ecosystems. This suggests high conservation efficiency. Landscape park units are distinguished by fragmented patchy composition, and spatial structure even less stable than that of the non-protected areas. The study results show that landscape metrics could be used as an indicator of efficient management of different forms of nature protection. They provide an insight into the structure and functioning of the environment at various levels of its organisation. We particularly found diversity metrics to be useful for indicating whether nature conservation goals are archived, and the size and density metric for measuring human interference in the landscape. The selection and interpretation of indexes should be determined by the specific character of a given area.     

钱江源国家公园体制试点区功能分区对黑麂保护的有效性评估

功能分区是统一协调国家公园不同保护管理目标的主要措施, 对于国家公园的有效管理有重要意义。钱江源国家公园是我国首批国家公园体制试点区之一, 被分为核心保护区、生态保育区、游憩展示区和传统利用区4个部分, 对应不同的保护管理措施。本研究分析了钱江源国家公园体制试点区现有功能分区与其首要保护对象黑麂(Muntiacus crinifrons)的适宜栖息地之间的空间关系。在红外相机调查获取的94个黑麂分布点的基础上, 结合海拔、地形、植被特征、人为活动干扰等15个环境特征变量, 采用MaxEnt模型预测国家公园内黑麂适宜栖息地的空间分布。结果表明, 黑麂倾向于出现在森林较为原始和道路密度较低的区域, 其适宜栖息地面积42.5 km ², 占国家公园总面积的16.9%。其中, 69.3%的黑麂适宜栖息地位于核心保护区, 30.4%位于生态保育区, 表明国家公园现有功能分区能很好地满足黑麂栖息地保护的需求。此结果也证明黑麂可以作为其分布范围内保存较好的亚热带森林生态系统的指示性物种。通过生境恢复、廊道建设和跨省共建促进黑麂栖息地的完整性保护, 是加强该区域黑麂栖息地保护的关键措施。     

Two randomized controlled clinical trials to study the effectiveness of prednisolone treatment in preventing and restoring clinical nerve function loss in leprosy: the TENLEP study protocols

Background

Nerve damage in leprosy often causes disabilities and deformities. Prednisolone is used to treat nerve function impairment (NFI). However, optimal dose and duration of prednisolone treatment has not been established yet. Besides treating existing NFI it would be desirable to prevent NFI. Studies show that before NFI is clinically detectable, nerves often show subclinical damage. Within the ‘Treatment of Early Neuropathy in LEProsy’ (TENLEP) study two double blind randomized controlled trials (RCT) will be carried out: a trial to establish whether prednisolone treatment of 32 weeks duration is more effective than 20 weeks in restoring nerve function in leprosy patients with clinical NFI (Clinical trial) and a trial to determine whether prednisolone treatment of early sub-clinical NFI can prevent clinical NFI (Subclinical trial).

Methods

Two RCTs with a follow up of 18 months will be conducted in six centers in Asia. In the Clinical trial leprosy patients with recent (< 6 months) clinical NFI, as determined by Monofilament Test and Voluntary Muscle Test, are included. The primary outcomes are the proportion of patients with restored or improved nerve function. In the Subclinical trial leprosy patients with subclinical neuropathy, as determined by Nerve Conduction Studies (NCS) and/or Warm Detection Threshold (WDT), and without any clinical signs of NFI are randomly allocated to a placebo group or treatment group receiving 20 weeks prednisolone. The primary outcome is the proportion of patients developing clinical NFI. Reliability and normative studies are carried out before the start of the trial.

Discussion

This study is the first RCT testing a prednisolone regimen with a duration longer than 24 weeks. Also it is the first RCT assessing the effect of prednisolone in the prevention of clinical NFI in patients with established subclinical neuropathy. The TENLEP study will add to the current understanding of neuropathy due to leprosy and provide insight in the effectiveness of prednisolone on the prevention and recovery of NFI in leprosy patients. In this paper we present the research protocols for both Clinical and Subclinical trials and discuss the possible findings and implications.

Trial registration

Netherlands Trial Register: NTR2300Clinical Trial Registry India: CTRI/2011/09/002022

     

The FOLLOWPACE study: a prospective study on the (cost-)effectiveness of routine follow-up visits in patients with a pacemaker

In the Netherlands, following implantation of a pacemaker (PM) commonly two or three out-patient follow-up visits are scheduled in the first year to check the patient''s health and the PM programme, in order to guarantee optimal patient outcome. Anually, about 200,000 follow-up visits of 20 minutes are performed, in total about 80,000 working hours. The question arises whether and to what extent these regular follow-up checks are truly necessary for the prognosis of the patient and whether they are cost-effective. Yet no information is available on how frequently and extensively a routine PM follow-up visit should be performed. This is probably because it is largely unknown which factors — either documented at PM implantation or at the follow-up visits - predict the occurrence of complications. The FOLLOWPACE study is designed to address these issues. Below we briefly discuss the rationale, objectives and expected results of FOLLOWPACE.