Kidney and cardiovascular protection with SGLT2 inhibitors: lessons from cardiovascular outcome trials and CREDENCE.

The burden of diabetic kidney disease is rising rapidly worldwide, and new therapies are of vital importance to reduce the risk of kidney failure and major cardiovascular events. Of the newer glucose-lowering agents, sodium-glucose co-transporter 2 (SGLT2) inhibitors have shown exciting potential in preventing these adverse events. The results of several large cardiovascular outcome trials, a single dedicated kidney outcome trial and a dedicated heart failure trial, demonstrate substantial clinical benefits for several different SGLT2 inhibitors. Emerging evidence raises the possibility that these benefits may extend to those with non-diabetic chronic kidney disease. This review summarises the current evidence for SGLT2 inhibitor benefits and harms, and examines which patients are most likely to gain from these therapies.

Prophylactic effect of egualen sodium, a stable azulene derivative, on gastrointestinal damage induced by ischemia/reperfusion, double antiplatelet therapy and loxoprofen in rats.

We examined the effect of egualen, a stable azulene derivative, against gastric damage induced by ischemia/reperfusion (I/R), gastric bleeding induced by double antiplatelet therapy with aspirin (ASA) plus clopidogrel, and small intestinal damage generated by loxoprofen, and investigated the possible mechanisms involved in its protective action. Male C57BL/6 mice or SD rats were used under urethane anesthesia (gastric lesions) or in a conscious (intestinal lesions) state. I/R-induced gastric injury was produced in mice by clamping the celiac artery for 30 min, followed by reperfusion for 60 min. Gastric bleeding was induced in rats by luminal perfusion with 25 mM ASA+50 mM HCl for 2 hours in the presence of clopidogrel (30 mg/kg). To produce small intestinal lesions the rats were given loxoprofen (60 mg/kg) p.o. and killed 24 hours later. Egualen was given i.d. 60 min before I/R or ASA perfusion, while given p.o. twice 30 min before and 6 hours after loxoprofen. Egualen significantly prevented the I/R-induced gastric damage, and the effect was equivalent to that of seratrodast (TXA2 antagonist). This agent also significantly suppressed gastric bleeding induced by ASA plus clopidogrel, similar to PGE2. Likewise, egualen significantly prevented loxoprofen-induced damage in the small intestine, accompanied by an increase in the secretion of mucus and suppression of bacterial invasion as well as iNOS expression. These results suggest that egualen has a prophylactic effect against various lesions in the gastrointestinal mucosa, probably through its characteristic pharmacological properties, such as TXA2 antagonistic action, local mucosal protection, and stimulation of mucus secretion.

Derivation of the uncontrolled donation after circulatory determination of death protocol for New York city.

Evidence from Europe suggests establishing out-of-hospital, uncontrolled donation after circulatory determination of death (UDCDD) protocols has potential to substantially increase organ availability. The study objective was to derive an out-of-hospital UDCDD protocol that would be acceptable to New York City (NYC) residents. Participatory action research and the SEED-SCALE process for social change guided protocol development in NYC from July 2007 to September 2010. A coalition of government officials, subject experts and communities necessary to achieve support was formed. Authorized NY State and NYC government officials and their legal representatives collaboratively investigated how the program could be implemented under current law and regulations. Community stakeholders (secular and religious organizations) were engaged in town hall style meetings. Ethnographic data (meeting minutes, field notes, quantitative surveys) were collected and posted in a collaborative internet environment. Data were analyzed using an iterative coding scheme to discern themes, theoretical constructs and a summary narrative to guide protocol development. A clinically appropriate, ethically sound UDCDD protocol for out-of-hospital settings has been derived. This program is likely to be accepted by NYC residents since the protocol was derived through partnership with government officials, subject experts and community participants.

Second brain death examination may negatively affect organ donation.

BACKGROUND: Little is known about the impact of the requirement for a second brain death examination on organ donation. In New York State, 2 examinations 6 hours apart have been recommended by a Department of Health panel. METHODS: We reviewed data for 1,229 adult and 82 pediatric patients pronounced brain dead in 100 New York hospitals serviced by the New York Organ Donor Network from June 1, 2007, to December 31, 2009. We reviewed the time interval between the 2 clinical brain death examinations and correlated this brain death declaration interval to day of the week, hospital size, and organ donation. RESULTS: None of the patients declared brain dead were found to regain brainstem function upon repeat examination. The mean brain death declaration interval between the 2 examinations was 19.2 hours. A 26% reduction in brain death examination frequency was seen on weekends when compared to weekdays (p = 0.0018). The mean brain death interval was 19.9 hours for 0-750 bed hospitals compared to 16.0 hours for hospitals with more than 750 beds (p = 0.0015). Consent for organ donation decreased from 57% to 45% as the brain death declaration interval increased. Conversely, refusal of organ donation increased from 23% to 36% as the brain death interval increased. A total of 166 patients (12%) sustained a cardiac arrest between the 2 examinations or after the second examination. CONCLUSION: A single brain death examination to determine brain death for patients older than 1 year should suffice. In practice, observation time to a second neurologic examination was 3 times longer than the proposed guideline and associated with substantial intensive care unit costs and loss of viable organs.

Therapeutic action and underlying mechanisms of a combination of two pentacyclic triterpenes, alpha- and beta-amyrin, in a mouse model of colitis.

BACKGROUND AND PURPOSE: alpha- and beta-amyrin are pentacyclic triterpenes found in plants and are known to exhibit pronounced anti-inflammatory effects. Here, we evaluated the effects of a 1:1 mixture of alpha- and beta-amyrin (alpha,beta-amyrin) on an experimental model of colitis in mice. EXPERIMENTAL APPROACH: Colitis was induced in Swiss male mice by trinitrobenzene sulphonic acid (TNBS) and followed up to 72 h; animals were treated systemically with alpha,beta-amyrin, dexamethasone or vehicle. Macro- and microscopic damage, myeloperoxidase activity and cytokine levels were assessed in colons. Histological sections were immunostained for cyclooxygenase-2 (COX-2), vascular endothelial growth factor, phospho-p65 nuclear factor-kappaB (NF-kappaB) and phospho-cyclic AMP response element-binding protein (CREB). KEY RESULTS: TNBS-induced colitis was associated with tissue damage, neutrophil infiltration and time-dependent increase of inflammatory mediators. Treatment with alpha,beta-amyrin (3 mg x kg(-1), i.p.) or dexamethasone (1 mg x kg(-1), s.c.) consistently improved tissue damage scores and abolished polymorphonuclear cell infiltration. alpha,beta-Amyrin, like dexamethasone, significantly diminished interleukin (IL)-1beta levels and partially restored IL-10 levels in colon tissues 72 h after colitis induction, but only alpha,beta-amyrin reduced vascular endothelial growth factor expression by immunohistochemistry. The colonic expression of COX-2 at 24 h and that of phospho-NF-kappaB and phospho-CREB (peaking at 6 h) after colitis induction were consistently inhibited by both alpha,beta-amyrin and dexamethasone. CONCLUSIONS AND IMPLICATIONS: Systemic administration of alpha,beta-amyrin exerted a marked and rapid inhibition of TNBS-induced colitis, related to the local suppression of inflammatory cytokines and COX-2 levels, possibly via inhibition of NF-kappaB and CREB-signalling pathways. Taken together, our data suggest a potential use of alpha,beta-amyrin to control inflammatory responses in bowel disease.

Protease-activated receptor-4 (PAR 4): a role as inhibitor of visceral pain and hypersensitivity.

Protease-activated receptor-4 (PAR(4)) belongs to the family of receptors activated by the proteolytic cleavage of their extracellular N-terminal domain and the subsequent binding of the newly released N-terminus. While largely expressed in the colon, the role of PAR(4) in gut functions has not been defined. We have investigated the effects of PAR(4) agonist on colonic sensations and sensory neuron signalling, and its role in visceral pain. We observed that a single administration of the PAR(4) agonist peptide (AYPGKF-NH(2)), but not the control peptide (YAPGKF-NH(2)) into the colon lumen of mice significantly reduced the visceromotor response to colorectal distension at different pressures of distension. Further, intracolonic administration of the PAR(4) agonist, but not the control peptide, was able to significantly inhibit PAR(2) agonist- and transcient receptor potential vanilloid-4 (TRPV4) agonist-induced allodynia and hyperalgesia in response to colorectal distension. Protease-activated receptor-4 was detected in sensory neurons projecting from the colon, and isolated from the dorsal root ganglia, where it co-expressed with PAR(2) and TRPV4. In total sensory neurons, PAR(4) agonist exposure inhibited free intracellular calcium mobilization induced by the pro-nociceptive agonists of PAR(2) and TRPV4. Finally, PAR(4)-deficient mice experienced increased pain behaviour in response to intracolonic administration of mustard oil, compared with wild-type littermates. These results show that PAR(4) agonists modulate colonic nociceptive response, inhibit colonic hypersensitivity and primary afferent responses to pro-nociceptive mediators. Endogenous activation of PAR(4) also plays a major role in controlling visceral pain. These results identify PAR(4) as a previously unknown modulator of visceral nociception.

The relevance of kinin B1 receptor upregulation in a mouse model of colitis.

BACKGROUND AND PURPOSE: Kinins are implicated in many pathophysiological conditions, and recent evidence has suggested their involvement in colitis. This study assessed the role of the kinin B1 receptors in a mouse model of colitis. EXPERIMENTAL APPROACH: Colitis was induced in mice by 2,4,6-trinitrobenzene sulphonic acid (TNBS), and tissue damage and myeloperoxidase activity were assessed. B1 receptor induction was analysed by organ bath studies, binding assay and reverse transcription PCR. KEY RESULTS: TNBS-induced colitis was associated with tissue damage, neutrophil infiltration and time-dependent increase of colon B1 receptor-mediated contraction, with the maximal response observed at 72 h. The upregulation of the B1 receptor at this time point was also confirmed by means of binding studies. B1 receptor mRNA levels were elevated as early as 6 h after colitis induction and remained high for up to 48 h. TNBS-evoked tissue damage and neutrophil influx were reduced by the selective B1 receptor antagonist SSR240612, and in B1 receptor knockout mice. In vivo treatment with inhibitors of protein synthesis, nuclear factor-kappaB activation, inducible nitric oxide synthase (iNOS) or tumour necrosis factor alpha (TNFalpha) significantly reduced B1 receptor agonist-induced contraction. Similar results were observed in iNOS and TNF receptor 1-knockout mice. CONCLUSIONS AND IMPLICATIONS: These results provide convincing evidence on the role of B1 receptors in the pathogenesis of colitis. Therefore, the blockade of kinin B1 receptors might represent a new therapeutic option for treating inflammatory bowel diseases.

Interferon-gamma receptor deficiency mimicking Langerhans' cell histiocytosis.

Two patients who were initially given a diagnosis of Langerhans' cell histiocytosis on the basis of the clinical, radiologic, and biopsy findings had mycobacterial infection subsequently identified. The correct diagnosis of dominant partial interferon-gamma receptor deficiency was established.

Avian reovirus major mu-class outer capsid protein influences efficiency of productive macrophage infection in a virus strain-specific manner.

We determined that the highly pathogenic avian reovirus strain 176 (ARV-176) possesses an enhanced ability to establish productive infections in HD-11 avian macrophages compared to avian fibroblasts. Conversely, the weakly pathogenic strain ARV-138 shows no such macrophagotropic tendency. The macrophage infection capability of the two viruses did not reflect differences in the ability to either induce or inhibit nitric oxide production. Moderate increases in the ARV-138 multiplicity of infection resulted in a concomitant increase in macrophage infection, and under such conditions the kinetics and extent of the ARV-138 replication cycle were equivalent to those of the highly infectious ARV-176 strain. These results indicated that both viruses are apparently equally capable of replicating in an infected macrophage, but they differ in the ability to establish productive infections in these cells. Using a genetic reassortant approach, we determined that the macrophagotropic property of ARV-176 reflects a post-receptor-binding step in the virus replication cycle and that the ARV-176 M2 genome segment is required for efficient infection of HD-11 cells. The M2 genome segment encodes the major mu-class outer capsid protein (muB) of the virus, which is involved in virus entry and transcriptase activation, suggesting that a host-specific influence on ARV entry and/or uncoating may affect the likelihood of the virus establishing a productive infection in a macrophage cell.

The evaluation of a precordial ECG BELT: technologist satisfaction and accuracy of recording.

The standard method for performing electrocardiogram (ECG) recordings presents a challenge to technicians because of the need to correctly position the individual precordial electrodes according to 6 bony thoracic landmarks. A proposed new method using a 6-lead ECG BELT for precordial application was compared to the standard method to determine the level of agreement among automated interpretations. A comparison of automated interpretations from repeat standard recordings served as the control. Results indicate that BELT and standard automated interpretations disagreed significantly more frequently than repeat standard recording automated interpretations of the cardiac rhythm. The BELT's most obvious weakness was the inability to obtain a recording with a stable ECG baseline, triggering automated detection of "baseline artifact or wander," and requiring a repeat recording. These findings suggest that the ECG BELT is not adequate for clinical application in its current form.

Survey of nutritional status in newly hospitalized patients with stage III or stage IV pressure ulcers.

OBJECTIVE: To examine the nutritional status of newly hospitalized patients with Stage III or Stage IV pressure ulcers. DESIGN: Descriptive survey. STUDY PARTICIPANTS: 405 newly admitted hospitalized non-ICU patients were eligible for inclusion in the study. Patients included in the study had Stage III or Stage IV pressure ulcers on their trunk, had weight indices available, and had prealbumin levels measured. One hundred and twenty patients were included in the analysis. INTERVENTIONS AND MAIN OUTCOME MEASURES: Measurements of weight, prealbumin and albumin levels, nutritional intake, type of diet, gender, age, type of pressure ulcer, and type of residence prior to admission. RESULTS: Analysis of the data revealed that a majority of the patients were elderly, had a Stage III sacral ulcer, were below their usual body weight, had a low prealbumin level, and were not taking in enough nutrition to meet their needs. CONCLUSION: The results of this study suggest that a majority of newly hospitalized patients with severe pressure ulcers are malnourished and aggressive nutritional therapy may be warranted.

Developmental regulation of the L-type calcium channel alpha1C subunit expression in heart.

We used Northern analyses, RNase protection assays and immunoblot analyses to examine the relationship among developmental age of the heart, abundance of mRNA and L-type calcium channel alpha1C subunit protein, and to establish the size of the native protein in heart. Northern analysis, RNase protection assays, and immunoblots were used to study RNA and protein from rat heart of various ages. In fetal and adult ventricles there was a predominant 8.3-kb transcript for the alpha1C subunit with no change in transcript size during development. RNase protection assays demonstrated a 2-fold increase in abundance of the DHP receptor message during postnatal development. Immunoblots identified a 240 kD protein, corresponding to the predicted molecular mass of the full length alpha1C subunit. No change in size of protein for the alpha1C subunit was observed at any developmental stage and there was no evidence for a truncated isoform. There was an approximate 2-fold increase in alpha1C subunit protein in ventricular homogenates during postnatal development. Thus, in the developing rat heart, alterations in calcium channel properties during development appear to result neither from alternative splicing that produces a smaller transcript for the alpha1C subunit nor from expression of a truncated protein, but at least in part from transcriptionally-regulated expression of the 240 kDa polypepde.

The effect of anesthetic technique on postoperative outcomes in hip fracture repair.

BACKGROUND: The impact of anesthetic choice on postoperative mortality and morbidity has not been determined with certainty. METHODS: The authors evaluated the effect of type of anesthesia on postoperative mortality and morbidity in a retrospective cohort study of consecutive hip fracture patients, aged 60 yr or older, who underwent surgical repair at 20 US hospitals between 1983 and 1993. The primary outcome was defined as death within 30 days of the operative procedure. The secondary outcomes were postoperative 7-day mortality, postoperative myocardial infarction, postoperative pneumonia, postoperative congestive heart failure, and postoperative change in mental status. Numerous comorbid conditions were controlled for individually and by several comorbidity indices using logistic regression. RESULTS: General anesthesia was used in 6,206 patients (65.8%) and regional anesthesia in 3,219 patients (3,078 spinal anesthesia and 141 epidural anesthesia). The 30-day mortality rate in the general anesthesia group was 4.4%, compared with 5.4% in the regional anesthesia group (unadjusted odds ratio = 0.80; 95% confidence interval = 0.66-0.97). However, the adjusted odds ratio for general anesthesia increased to 1.08 (0.84-1.38). The adjusted odds ratios for general anesthesia versus regional anesthesia for the 7-day mortality was 0.90 (0.59-1.39) and for postoperative morbidity outcomes were as follows: myocardial infarction: adjusted odds ratio = 1.17 (0.80-1.70); congestive heart failure: adjusted odds ratio = 1.04 (0.80-1.36); pneumonia: adjusted odds ratio = 1.21 (0.87-1.68); postoperative change in mental status: adjusted odds ratio = 1.08 (0.95-1.22). CONCLUSIONS: The authors were unable to demonstrate that regional anesthesia was associated with better outcome than was general anesthesia in this large observational study of elderly patients with hip fracture. These results suggest that the type of anesthesia used should depend on factors other than any associated risks of mortality or morbidity.

A retrospective study of changes in physical symptoms and body image after reduction mammaplasty.

Reduction mammaplasty is performed typically to alleviate the painful physical symptoms of macromastia. Women who suffer from macromastia also frequently present to the plastic surgeon with heightened body image dissatisfaction and maladaptive behavioral changes in response to their breast size. Numerous investigations have demonstrated improvement in physical symptoms after breast reduction surgery. Studies have also suggested that psychological improvement occurs postoperatively; however, they have not used well-validated, standardized psychological measures. The present study is a retrospective analysis of the physical and psychological status of women who underwent reduction mammaplasty. One hundred ten patients who underwent a reduction mammaplasty between 1982 and 1996 were mailed a packet of questionnaires designed to assess current physical symptoms and body image. Sixty-one of the 110 patients (55 percent) responded. The vast majority reported substantial improvement or elimination of neck, back, shoulder, and breast pain, grooving from bra straps, poor posture, skin irritation, and social embarrassment. In addition, they reported significantly less dissatisfaction with their breasts as compared with a sample of breast reduction patients assessed preoperatively. Symptom relief and improved body image occurred independently of preoperative body weight, as we found few significant differences between obese and non-obese women concerning the resolution of physical symptoms or improvement in body image. Results provide further evidence of the efficacy of reduction mammaplasty not only for relief of physical symptoms but also for alleviation of body image dissatisfaction.

Development of cytochrome P450 as a biomarker of organic pollution in Mytilus sp.: field studies in United Kingdom ('Sea Empress' oil spill) and the Mediterranean Sea.

Literature on the properties, forms and regulation of cytochrome P450 (CYP) in digestive gland of Mytilus sp., including studies indicating the existence of an organic contaminant-inducible CYP1A-like protein, are briefly reviewed. Laboratory and field studies show increases in digestive gland microsomal CYP1A-immunopositive protein levels and/or benzo[a]pyrene hydroxylase (BPH) activity (i.e. metabolism of benzo[a]pyrene to phenols) with exposure of Mytilus sp. to certain polycyclic aromatic hydrocarbons (PAHs) and polychlorobiphenyls. In order to examine further the relationship between these two parameters, M. edulis were collected 25 and 130 days after the release of oil following the grounding of the tanker 'Sea Empress' in South Wales, UK (15 February 1996); and M. galloprovincialis were sampled from sites in south-western France and south-eastern Spain during a cruise aboard the IFREMER Research Vessel 'L'Europe' (2-18 August 1996). In both studies, sites with higher levels of CYP1A-immunopositive protein showed higher levels of BPH activities. Positive correlations were observed between the two measurements - R=0.65 (M. edulis) and 0.68 (M. galloprovincialis), and both fitted linear regression models (P < 0.05). The CYP1A-immunopositive protein levels and BPH activities tended to be highest at sites with greatest PAH body burden for the Mediterranean study. It is concluded that development of the CYP1A-like protein into a robust biomarker of exposure to organic contaminants will depend upon sequencing of the gene/protein and the subsequent production of Mytilus-specific cDNA and antibody probes. Such probes will then allow a full characterization of the enzyme's properties and gene regulation.

Complications of diabetes in the hospitalized population in Victoria, 1993-95.

A retrospective analysis of computerized data from the Victorian Inpatient Minimum Database (VIMD) was undertaken in order to describe the prevalence of diabetes and its associated complications in the hospitalized population over a 2-year period. While diabetes was rarely recorded as a principal cause of hospitalization (less than 0.5% of admissions), this condition was present in 4% (95,091) of the hospitalized population with a slight male excess. Cardiovascular disease was present in 60% of these diabetes-related admissions and was the principal diagnosis in a quarter of all cases. The prevalence of hypertension was 28%. Cardiovascular disease (CVD) was the principal diagnosis in 40% of in-hospital deaths, and in women, the risk of CVD death was 22% greater than it was for men. Diabetes-related complications were noted in 22%; 3.3% recorded renal disease, 2.7% peripheral vascular disease, and ophthalmic and neurological complications were recorded in 2.1% and 1.4%, respectively. Of all lower limb amputations carried out in Victoria over the period, 40% (1281) were in people with diabetes. Eye surgery was carried out on (6.8%) 6463 diabetes-related separations. There are recognized limitations of using routinely collected computerized data. Nevertheless, data relating to number of amputations and eye surgery in those with diabetes can be used as indicators of the success of diabetes care and national strategies for prevention.