Cardiovascular effects of sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists: The P value and beyond

Despite growing awareness of the dangers of a dichotomous interpretation of trial results based on the ‘statistical significance’ of a treatment effect, the uptake of new approaches has been slow in diabetes medicine. We showcase a number of ways to interpret the evidence for a treatment effect applied to the cardiovascular outcome trials of glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose co-transporter-2 inhibitors (SGLT-2is): the P value function (or confidence curves), which depicts the treatment effect across the whole spectrum of confidence levels; the counternull value, which is the hazard ratio (i.e. treatment effect size) supported by the same amount of evidence as the null value (i.e. no treatment effect); and the S value, which quantifies the strength of the evidence against the null hypothesis in terms of the number of coin tosses yielding the same side. We show how this approach identifies potential treatment effects, highlights similarities among trials straddling the threshold of statistical significance, and quantifies differences in the strength of the evidence from trials reporting statistically significant results. For example, while REWIND, CANVAS and CREDENCE failed to reach statistical significance at the .05 level for all-cause mortality, their counternull values indicate that reduced death rates by 19%, 24% and 31%, respectively, are supported by the same amount of evidence as that indicating no treatment effect. Moreover, similarities among results emerge in trials of GLP-1RAs (REWIND, EXSCEL and LEADER) lying closely around the threshold of ‘statistical significance’. Lastly, several S values, such as for the primary outcome in HARMONY Outcomes (S value 10.9) and all-cause death in EMPAREG-OUTCOME (S value 15.0), stand out compared with values for other outcomes and other trials, suggesting much larger differences in the evidence between these studies and several others that cluster around the .05 significance threshold. P value functions, counternull values and S values should complement the standard reporting of the treatment effect to help interpret clinical trials and make decisions among competing glucose-lowering medications.     

Egyptian Fruit Bats (Rousettus aegyptiacus) Were Resistant to Experimental Inoculation with Avian-Origin Influenza A Virus of Subtype H9N2, But Are Susceptible to Experimental Infection with Bat-Borne H9N2 Virus

Influenza A viruses (IAV) of subtype H9N2, endemic in world-wide poultry holdings, are reported to cause spill-over infections to pigs and humans and have also contributed substantially to recent reassortment-derived pre-pandemic zoonotic viruses of concern, such as the Asian H7N9 viruses. Recently, a H9N2 bat influenza A virus was found in Egyptian fruit bats (Rousettus aegyptiacus), raising the question of whether this bat species is a suitable host for IAV. Here, we studied the susceptibility, pathogenesis and transmission of avian and bat-related H9N2 viruses in this new host. In a first experiment, we oronasally inoculated six Egyptian fruit bats with an avian-related H9N2 virus (A/layer chicken/Bangladesh/VP02-plaque/2016 (H9N2)). In a second experiment, six Egyptian fruit bats were inoculated with the newly discovered bat-related H9N2 virus (A/bat/Egypt/381OP/2017 (H9N2)). While R. aegyptiacus turned out to be refractory to an infection with H9N2 avian-type, inoculation with the bat H9N2 subtype established a productive infection in all inoculated animals with a detectable seroconversion at day 21 post-infection. In conclusion, Egyptian fruit bats are most likely not susceptible to the avian H9N2 subtype, but can be infected with fruit bat-derived H9N2. H9-specific sero-reactivities in fruit bats in the field are therefore more likely the result of contact with a bat-adapted H9N2 strain.     

Characterization of Open-Cell Sponges via Magnetic Resonance and X-ray Tomography

The applications of polymeric sponges are varied, ranging from cleaning and filtration to medical applications. The specific properties of polymeric foams, such as pore size and connectivity, are dependent on their constituent materials and production methods. Nuclear magnetic resonance imaging (MRI) and X-ray micro-computed tomography (µCT) offer complementary information about the structure and properties of porous media. In this study, we employed MRI, in combination with µCT, to characterize the structure of polymeric open-cell foam, and to determine how it changes upon compression, µCT was used to identify the morphology of the pores within sponge plugs, extracted from polyurethane open-cell sponges. MRI T₂ relaxation maps and bulk T₂ relaxation times measurements were performed for 7° dH water contained within the same polyurethane foams used for µCT. Magnetic resonance and µCT measurements were conducted on both uncompressed and 60% compressed sponge plugs. Compression was achieved using a graduated sample holder with plunger. A relationship between the average T₂ relaxation time and maximum opening was observed, where smaller maximum openings were found to have a shorter T₂ relaxation times. It was also found that upon compression, the average maximum opening of pores decreased. Average pore size ranges of 375–632 ± 1 µm, for uncompressed plugs, and 301–473 ± 1 µm, for compressed plugs, were observed. By determining maximum opening values and T₂ relaxation times, it was observed that the pore structure varies between sponges within the same production batch, as well as even with a single sponge.     

CYP450-derived oxylipins mediate inflammatory resolution

Resolution of inflammation has emerged as an active process in immunobiology, with cells of the mononuclear phagocyte system being critical in mediating efferocytosis and wound debridement and bridging the gap between innate and adaptive immunity. Here we investigated the roles of cytochrome P450 (CYP)-derived epoxy-oxylipins in a well-characterized model of sterile resolving peritonitis in the mouse. Epoxy-oxylipins were produced in a biphasic manner during the peaks of acute (4 h) and resolution phases (24–48 h) of the response. The epoxygenase inhibitor SKF525A (epoxI) given at 24 h selectively inhibited arachidonic acid- and linoleic acid-derived CYP450-epoxy-oxlipins and resulted in a dramatic influx in monocytes. The epoxI-recruited monocytes were strongly GR1⁺, Ly6c^hi, CCR2^hi, CCL2^hi, and CX3CR1^lo. In addition, expression of F4/80 and the recruitment of T cells, B cells, and dendritic cells were suppressed. sEH (Ephx2)^−/− mice, which have elevated epoxy-oxylipins, demonstrated opposing effects to epoxI-treated mice: reduced Ly6c^hi monocytes and elevated F4/80^hi macrophages and B, T, and dendritic cells. Ly6c^hi and Ly6c^lo monocytes, resident macrophages, and recruited dendritic cells all showed a dramatic change in their resolution signature following in vivo epoxI treatment. Markers of macrophage differentiation CD11b, MerTK, and CD103 were reduced, and monocyte-derived macrophages and resident macrophages ex vivo showed greatly impaired phagocytosis of zymosan and efferocytosis of apoptotic thymocytes following epoxI treatment. These findings demonstrate that epoxy-oxylipins have a critical role in monocyte lineage recruitment and activity to promote inflammatory resolution and represent a previously unidentified internal regulatory system governing the establishment of adaptive immunity.Monocytes and monocyte-derived macrophages play a critical role in chronic inflammation, in part via the production and release of lipid mediators (1). One such lipid precursor, arachidonic acid, is metabolized into families of biologically active mediators by the cyclooxygenase, lipoxygenase, and cytochrome P450 (CYP) pathways (2, 3). CYPs metabolize arachidonic acid by: (i) an epoxygenase activity that catalyzes the conversion of arachidonic acid to epoxyeicosatrienoic acids (EETs); (ii) a lipoxygenase-like activity that metabolizes arachidonic acid to midchain hydroxyeicosatetraenoic acids (HETEs); and (iii) ω- and ω-1-hydroxylase activity, which produces ω-terminal HETEs (3). In addition to arachidonic acid, CYPs with epoxygenase activity can also metabolize alternative polyunsaturated fatty acids such as linoleic acid and docosahexaenoic acid into a series of products including epoxyoctadacamonoenoic acids (EpOMEs) and 19,20-epoxydocosapentaenoic acid (EpDPE), respectively, whose functions remain poorly understood (3–5).The main polyunsaturated fatty acid-metabolizing CYPs belong to the CYP2 family, in particular the CYP2J and CYP2C subfamilies (3, 4, 6, 7). Moreover, these CYP-lipid–metabolizing enzymes are the primary sources of eicosanoids in small blood vessels, the kidney, liver, lung, intestines, heart, and pancreas (3, 7). In most organs, EETs and related epoxygenase products are metabolically unstable and are rapidly metabolized. The major pathway that regulates EET metabolism is that catalyzed by epoxide hydrolases (8), which convert EETs to less biologically active dihydroxyeicosatrienoic acids (DHETs) (9). EpOMEs similarly get converted into dihydroxyoctadecenoic acids (DiHOMEs), whereas 19,20-EpDPE gets converted into 19,20-dihydroxydocosapentaenoic acid (DiHDPA). Elevating the levels of endogenous CYP products by disrupting (knockout) or inhibiting soluble epoxide hydrolase (sEH) reduces neointima formation (10), atherosclerosis, abdominal aortic aneurysm, dyslipidemia (11), hypertension (12), and diabetes (13) in different mouse models, all of which to some extent one could argue have a degree of nonresolving inflammation.Over the last 15 y there has been a vast increase in our knowledge of fatty acid mediators that regulate inflammatory processes, particularly newly identified mediators such as the resolvins that mediate the resolution of inflammation (14–16). However, unlike cyclooxygenase and lipoxygenase products, the roles of CYP450 pathways in chronic inflammation remain unclear. The arachidonic acid products of the CYP epoxygenases, the EETs, can regulate vascular tone, smooth muscle cell mitogenesis, platelet aggregation, steroidogenesis, and endothelial and vascular smooth muscle cell activation (4, 5, 7, 17–19). We recently published that in human monocytes and macrophages, epoxygenases and some of their arachidonic acid products were antiinflammatory through their ability to activate the peroxisome proliferator-activated receptor (PPAR), in particular PPARα (20, 21). Overexpression of epoxygenase enzymes CYP2J2 and CYP2C8 or genetic disruption of sEH (sEH^−/−) inhibits LPS-induced pulmonary inflammation (22, 23), and sEH^−/− mice or treatment with sEH inhibitors is highly effective against inflammatory and neuropathic pain (24–27).Monocytes are heterogeneous in mice and in humans (28). In mice, monocyte subsets can be divided based on the expression of Ly6c, Gr1, CC-chemokine receptor 2 (CCR2), and CX3C-chemokine receptor 1 (CX3CR1). Ly6c^hi monocytes are Gr1⁺, CCR2⁺, and CX3CR1^lo, whereas Ly6c^lo monocytes are Gr1⁻, CCR2⁻, and CX3CR1^hi (29, 30). Lipid mediators that regulate the recruitment and phenotype of monocytes are poorly understood.Herein, using a sterile model of inflammatory resolution dependent on monocyte recruitment, we found that CYP-epoxygenase products not only accumulate in a temporal manner with monocyte recruitment but also limit proinflammatory monocyte recruitment and promote a proresolution phenotype in cells of the monocyte lineage.     

Biochemical markers of cardiac dysfunction in children with obstructive sleep apnoea (OSA)

Objectives

We explored relationships between biochemical markers and cardiac responses of children with and without obstructive sleep apnoea (OSA) during exercise. We hypothesised that serum markers of sympathetic nervous system activity and low-grade inflammation would correlate with cardiac responses to exercise in children with or without OSA.

Methodology

The study included 40 of 71 children with previously characterised responses to cardiopulmonary exercise testing. Measures included serum cytokine levels using a multiplex bead-based assay (interleukins IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, TNF-α and IFN-γ). Serum amyloid A (SAA) was quantified by nephelometry, and metanephrine/normetanephrine levels were measured by liquid chromatography, mass-spectroscopy. Comparisons were made between children with and without OSA, and with and without obesity. Relationships between biomarkers and various cardiac parameters were explored by linear regression.

Results

Amongst the 40 children in this study, OSA was present in 23. Compared to the 17 children without OSA, those with OSA had higher resting serum IL-6 levels compared to those without (median 3.22 pg/ml vs. 2.31, p?<?0.05). Regarding correlations with cardiac function after adjusting for OSA, IL-8 negatively correlated to heart rate (HR) response following exercise (p?=?0.03) and IFN-γ negatively correlated with Stroke Volume Index (SVI) (p?=?0.03). Both metanephrine and normetanephrine levels positively correlated with SVI (p?=?0.04, p?=?0.047; respectively) and QI (p?=?0.04, p?=?0.04; respectively) during exercise when adjusting for OSA.

Conclusions

Children with OSA have raised morning levels of serum IL-6. Separately, higher levels of IFN-γ and IL-8 and lower levels of metanephrine and normetanephrine related to poorer cardiac function during exercise.

     

Primary stability of unicompartmental knee arthroplasty under dynamic compression-shear loading in human tibiae

BackgroundThe objective of our study was to evaluate the impact of a single- (“implant only”) versus a double-layer (“implant & bone”) cementing technique on the primary stability of unicompartmental tibial plateaus under dynamic compression-shear loading conditions in human tibiae.MethodsTwelve fresh-frozen human knees of a mean donor age of 72.3 years were used to perform medial UKA under a less invasive parapatellar surgical approach. The tibiae were divided into two groups of matched pairs based on comparable trabecular bone mineral density. To assess the primary stability, a new method based on a combination of dynamic compression-shear testing, kinematic analysis of the tibial plateau migration relative to the bone and evaluation of the cement layer by CT-scans and fragments cut through the implant–cement–bone interface in the frontal plane was introduced.FindingsFor the “implant only” cementation technique the mean load to failure was 2600 (SD 675) N and for “implant & bone” it was 2820 (SD 915) N. Between the final load level at failure and the bone mineral density a significant correlation was found for the groups “implant only” (r_s = 0.875) and “implant & bone” (r_s = 0.907).InterpretationFrom our observations, we conclude that there is no significant difference between a single- (“implant only”) and double-layer (“implant & bone”) cementing technique in the effect on the primary stability of unicompartmental tibia plateaus, in terms of failure load, correlation between final load at failure and bone mineral density, migration characteristics, cement layer thickness and penetration depth.     

Washing of banked blood by three different blood salvage devices

BACKGROUND: Storage lesions in red blood cells (RBCs) lead to an accumulation of soluble contaminants that can compromise the patient. Organ failures, coagulopathies, and cardiovascular events including lethal cardiac arrest have been reported, especially with massive transfusion or in pediatric patients. Washing improves the quality of stored RBCs, and autotransfusion devices have been proposed for intraoperative processing, but these devices were designed for diluted wound blood, and limited data on their performance with RBCs are available. STUDY DESIGN AND METHODS: Three autotransfusion devices (Electa, Sorin; CATS, Fresenius; OrthoPAT, Haemonetics) differing in function of their centrifugation chambers were evaluated with RBCs at the end of their shelf life and with dilutions thereof. Elimination rates of potassium, plasma free hemoglobin, total protein, citrate, acid equivalents, and iomeprol added as a marker substance were analyzed, in addition to RBC recoveries. RESULTS: Product hematocrit (Hct) levels ranged between 54.8 and 72.6%. RBC recovery rates were between 62.7 and 95.0%, the lowest being with the OrthoPAT processing of undiluted RBCs. Plasma elimination rates increased with predilution and ranged from 46.6% to 99.5%, the lowest being with the CATS and undiluted RBCs. Washing did not change pH and buffering capacity of RBCs. CONCLUSION: Autotransfusion devices offer a practical and obviously economical option to wash banked RBCs intraoperatively to prevent hyperkalemia and other disturbances in massive transfusion or pediatric patients. Predilution improves elimination rates, especially in devices that produce high product Hct levels. With a Y‐tubing the RBCs should bypass reservoir and vacuum, and the procedure should be guarded by a policy and procedure manual and a quality management system.