Plasma HMGB-1 and Nucleosome Concentrations in Horses with Colic and Healthy Horses

Background

Acute gastrointestinal disease occurs commonly in horses. Novel biomarkers might improve the understanding of SIRS and aid diagnosis and determination of prognosis.

Hypotheses

Increased plasma concentrations of the biomarkers HMGB‐1 and nucleosomes are associated with severity of gastrointestinal lesions in horses; concentrations of these biomarkers will be greater in horses with lesions more likely to cause SIRS; and will provide additional information compared with standard biomarkers fibrinogen and SAA.

Animals

Thirty horses with gastrointestinal disease, 22 healthy horses.

Methods

Prospective study. Plasma samples taken on admission were used for measurement of HMGB‐1, nucleosomes, fibrinogen, and SAA. Values were compared between healthy horses and those with gastrointestinal disease, and between horses with gastrointestinal disease grouped by lesion type (inflammatory, strangulating, and nonstrangulating). Correlations between biomarkers were assessed.

Results

Plasma concentrations of all biomarkers were significantly higher in horses with gastrointestinal disease compared to healthy horses (P ≤ .001). HMGB‐1 and nucleosomes were significantly higher in inflammatory and strangulating groups compared to healthy horses (3.5‐fold and 5.4‐fold increases, respectively, for HMGB‐1 (P < .05) and 4.8‐fold and 5.6‐fold increases for nucleosomes (P < .05)), but concentrations in the group with nonstrangulating disease did not differ from healthy horses. There was significant correlation between HMGB‐1 and nucleosomes (Spearman's r = 0.623; P < .001), and fibrinogen and SAA (Spearman's r = 0.801; P < .001) but not between other biomarkers.

Conclusions and Clinical Importance

High mobility group box‐1 and nucleosomes might have use as biomarkers for horses with gastrointestinal disease. Further studies are required to determine kinetics and prognostic value of serial measurements of these biomarkers in horses.

Effect of increased adiposity on insulin sensitivity and adipokine concentrations in horses and ponies fed a high fat diet, with or without a once daily high glycaemic meal

REASONS FOR PERFORMING STUDY

The relative influences of obesity and adaptation to high glycaemic diets on the development of insulin dysregulation in equids are unclear.

OBJECTIVES

To determine whether increased adiposity per se is responsible for the decreased insulin sensitivity often observed in obese horses or whether a dietary glycaemic response is critically important.

STUDY DESIGN

Randomised controlled trial.

METHODS

Eighteen horses and ponies were studied over a 20-week period. They received ad libitum hay plus either a high fat (low glycaemic) diet (FAT; n = 6) or a similar (isocaloric) diet containing 1.5 g/kg bwt once daily glucose (GLU; n = 6) to induce obesity. A third group received a control ration (CON; n = 6). Adiposity was monitored using body condition score (BCS) and total body fat mass percentage (TBFM) determined using a deuterium oxide dilution technique. Insulin sensitivity was assessed using a frequently sampled i.v. glucose tolerance test. Plasma concentrations of glucose, insulin, leptin, adiponectin, tumour necrosis factor-α (TNF-α) and serum amyloid A (SAA) were measured.

RESULTS

The FAT and GLU groups became obese (BCS ≥7) whereas the CON group maintained moderate condition (BCS ≤6). Total body fat mass and leptin concentrations were increased in the FAT and GLU groups than in the CON group (P<0.001 and P = 0.003, respectively). Values for both insulin-dependent (SI) and insulin-independent (Sg) glucose disposal were higher in the GLU group compared with the FAT and CON groups (P = 0.006 and P = 0.03, respectively). There were no differences in adiponectin, TNF-α or SAA between groups (all P≥0.4).

CONCLUSIONS

Increased adiposity did not reduce insulin sensitivity in either the FAT or the GLU diet groups, suggesting that obesity per se might not be responsible for the lower SI values reported in previous studies. Contrary to expectations, once daily glucose appeared to increase insulin sensitivity. Further work is required into the dietary causes of insulin resistance in equids.

Glucose Control and Cardiovascular Outcomes in Clinical Trials of Sodium Glucose Co-transporter 2 Inhibitor Treatments in Type 2 Diabetes

Currently available medications for the treatment of type 2 diabetes have limitations, and many patients do not achieve glycaemic control. Recently, a new approach has emerged using sodium glucose co-transporter 2 (SGLT2) inhibitors that decrease glucose reabsorption in the kidneys, increasing urinary glucose excretion. These agents offer the potential to improve glycaemic control independently of insulin pathways while avoiding hypoglycaemia. Two drugs of this class, canagliflozin and dapagliflozin, have been approved by the US Food and Drug Administration (FDA); another, empagliflozin, has been filed for regulatory approval and several others are in advanced development. These drugs have been shown to effectively reduce blood glucose, fasting plasma glucose and glycated haemoglobin (HbA_1C) levels in phase III clinical trials when used as monotherapy and as add-on therapy to other diabetes medications, including insulin. Another advantage of the SGLT2 inhibitors over existing treatments is the improvement in cardiovascular risk factors, particularly in terms of reductions in blood pressure and body weight. SGLT2 inhibitors have been generally well tolerated. While more long-term safety data are required to elucidate the benefit-risk profile of SGLT2 inhibitors, the rationale for their use in type 2 diabetes therapy is strong.

Breed differences in insulin sensitivity and insulinemic responses to oral glucose in horses and ponies of moderate body condition score

Breed-related differences may occur in the innate insulin sensitivity (SI) of horses and ponies, an important factor believed to be associated with the risk of laminitis. The aim of this study was to measure the glucose and insulin responses of different breeds of horses and ponies in moderate body condition to a glucose-containing meal and to compare these responses with the indices of SI as determined by a frequently sampled intravenous glucose tolerance test (FSIGT). Eight Standardbred horses, 8 mixed-breed ponies, and 7 Andalusian-cross horses with a mean ± SEM BCS 5.0 ± 0.3 of 9 were used in this study. Each animal underwent an oral glucose tolerance test (OGTT) in which they were fed a fiber-based ration (2.0 g/kg BW) containing 1.5 g/kg BW added glucose, as well as a standard FSIGT with minimal model analysis. The glucose response variables from the OGTT were similar between groups; however, the peak insulin concentration was higher in ponies (94.1 ± 29.1 μIU/mL; P = 0.003) and Andalusians (85.3 ± 18.6; P = 0.004) than in Standardbreds (21.2 ± 3.5). The insulin area under the curve was also higher in ponies (13.5 ± 3.6 IU · min · L(-1); P = 0.009) and Andalusians (15.0 ± 2.7; P = 0.004) than in Standardbreds (3.1 ± 0.6). Insulin sensitivity, as determined by the FSIGT, was lower in Andalusians (0.99 ± 0.18 × 10(-4)/[mIU · min]) than in Standardbreds (5.43 ± 0.94; P < 0.001) and in ponies (2.12 ± 0.44; P = 0.003) than in Standardbreds. Peak insulin concentrations from the OGTT were negatively correlated with SI (P < 0.001; rs = -0.75). These results indicate that there are clear breed-related differences in the insulin responses of horses and ponies to oral and intravenous glucose. All animals were in moderate body condition, indicating that breed-related differences in insulin dynamics occurred independent of obesity.

ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons

The American College of Cardiology Foundation along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical presentations for stable ischemic heart disease (SIHD) to consider use of stress testing and anatomic diagnostic procedures. This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging (RNI), stress echocardiography (Echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. A major innovation in this document is the rating of tests side by side for the same indication. The side-by-side rating removes any concerns about differences in indication or interpretation stemming from prior use of separate documents for each test. However, the ratings were explicitly not competitive rankings due to the limited availability of comparative evidence, patient variability, and range of capabilities available in any given local setting. The indications for this review are limited to the detection and risk assessment of SIHD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Eighty clinical scenarios were developed by a writing committee and scored by a separate rating panel on a scale of 1-9, to designate Appropriate, May Be Appropriate, or Rarely Appropriate use following a modified Delphi process following the recently updated AUC development methodology. The use of some modalities of testing in the initial evaluation of patients with symptoms representing ischemic equivalents, newly diagnosed heart failure, arrhythmias, and syncope was generally found to be Appropriate or May Be Appropriate, except in cases where low pre-test probability or low risk limited the benefit of most testing except exercise electrocardiogram (ECG). Testing for the evaluation of new or worsening symptoms following a prior test or procedure was found to be Appropriate. In addition, testing was found to be Appropriate or May Be Appropriate for patients within 90 days of an abnormal or uncertain prior result. Pre-operative testing was rated Appropriate or May Be Appropriate only for patients who had poor functional capacity and were undergoing vascular or intermediate risk surgery with 1 or more clinical risk factors or an organ transplant. The exercise ECG was suggested as an Appropriate test for cardiac rehabilitation clearance or for exercise prescription purposes. Testing in asymptomatic patients was generally found to be Rarely Appropriate, except for calcium scoring and exercise testing in intermediate and high-risk individuals and either stress or anatomic imaging in higher-risk individuals, which were all rated as May Be Appropriate. All modalities of follow-up testing after a prior test or percutaneous coronary intervention (PCI) within 2 years and within 5 years after coronary artery bypass graft (CABG) in the absence of new symptoms were rated Rarely Appropriate. Pre-operative testing for patients with good functional capacity, prior normal testing within 1 year, or prior to low-risk surgery also were found to be Rarely Appropriate. Imaging for an exercise prescription or prior to the initiation of cardiac rehabilitation was Rarely Appropriate except for cardiac rehabilitation clearance for heart failure patients.

ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons

The American College of Cardiology Foundation along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical presentations for stable ischemic heart disease (SIHD) to consider use of stress testing and anatomic diagnostic procedures. This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging (RNI), stress echocardiography (Echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. A major innovation in this document is the rating of tests side by side for the same indication. The side-by-side rating removes any concerns about differences in indication or interpretation stemming from prior use of separate documents for each test. However, the ratings were explicitly not competitive rankings due to the limited availability of comparative evidence, patient variability, and range of capabilities available in any given local setting. The indications for this review are limited to the detection and risk assessment of SIHD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Eighty clinical scenarios were developed by a writing committee and scored by a separate rating panel on a scale of 1 to 9, to designate Appropriate, May Be Appropriate, or Rarely Appropriate use following a modified Delphi process following the recently updated AUC development methodology. The use of some modalities of testing in the initial evaluation of patients with symptoms representing ischemic equivalents, newly diagnosed heart failure, arrhythmias, and syncope was generally found to be Appropriate or May Be Appropriate, except in cases where low pre-test probability or low risk limited the benefit of most testing except exercise electrocardiogram (ECG). Testing for the evaluation of new or worsening symptoms following a prior test or procedure was found to be Appropriate. In addition, testing was found to be Appropriate or May Be Appropriate for patients within 90 days of an abnormal or uncertain prior result. Pre-operative testing was rated Appropriate or May Be Appropriate only for patients who had poor functional capacity and were undergoing vascular or intermediate risk surgery with 1 or more clinical risk factors or an organ transplant. The exercise ECG was suggested as an Appropriate test for cardiac rehabilitation clearance or for exercise prescription purposes. Testing in asymptomatic patients was generally found to be Rarely Appropriate, except for calcium scoring and exercise testing in intermediate and high-risk individuals and either stress or anatomic imaging in higher-risk individuals, which were all rated as May Be Appropriate. All modalities of follow-up testing after a prior test or percutaneous coronary intervention (PCI) within 2 years and within 5 years after coronary artery bypass graft (CABG) in the absence of new symptoms were rated Rarely Appropriate. Pre-operative testing for patients with good functional capacity, prior normal testing within 1 year, or prior to low-risk surgery also were found to be Rarely Appropriate. Imaging for an exercise prescription or prior to the initiation of cardiac rehabilitation was Rarely Appropriate except for cardiac rehabilitation clearance for heart failure patients.

Safety and efficacy of device closure for patent foramen ovale for secondary prevention of neurological events: Comprehensive systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Controversy persists regarding the management of patients with cryptogenic stroke and patent foramen ovale (PFO). We performed a meta-analysis of randomized controlled trials comparing PFO closure with medical therapy.

METHODS AND RESULTS

A prospective protocol was developed and registered using the following data sources: PubMed, Cochrane Register of Controlled Trials, conference proceedings, and Internet-based resources of clinical trials. Primary analyses were performed using the intention-to-treat method. Three randomized trials comparing percutaneous PFO closure vs. medical therapy for secondary prevention of embolic neurological events formed the data set. Baseline characteristics were similar. During long-term follow-up, the pooled incidence of the primary endpoint (composite of stroke, death, or fatal stroke) was 3.4% in the PFO closure arm and 4.8% in the medical therapy group [risk-reduction (RR) 0.7 (0.48-1.06); p=0.09]. The incidence of recurrent neurological events (secondary endpoint) was 1.7% for PFO closure and 2.7% for medical therapy [RR 0.66 (0.35-1.24), p=0.19]. There was no difference in terms of death or adverse events between the two groups.

CONCLUSIONS

While this meta-analysis of randomized clinical trials demonstrated no statistical significance in comparison to medical therapy, there was a trend towards overall improvement in outcomes in the PFO closure group.

The effect of exercise on plasma concentrations of inflammatory markers in normal and previously laminitic ponies

REASONS FOR PERFORMING STUDY

The mechanisms underlying predisposition to pasture-associated laminitis remain unclear; chronic inflammation is implicated, and this may be exacerbated by physical inactivity.

OBJECTIVES

To determine whether exercise affects the inflammatory profile of normal and previously laminitic ponies.

STUDY DESIGN

Prospective case-control study.

METHODS

The short (1 day) and longer term (14 days) effects of low intensity (10 min walking and 5 min trotting) exercise on plasma inflammatory marker concentrations in normal (NL) and previously laminitic (PL) nonobese ponies (n = 6/group) was determined. Plasma concentrations of TNF-α, serum amyloid A (SAA), haptoglobin, insulin, adiponectin and fibrinogen were assayed by validated/standard methods. Data were analysed using a linear mixed effects model.

RESULTS

Before exercise, plasma [adiponectin] was significantly (P = 0.0001) lower in PL (mean ± s.d. 2.4 ± 0.1 ng/l) than in NL (4.03 ± 0.2 ng/l), but exercise had no effect. Previous laminitis and exercise had no effect on plasma [TNF-α] or [fibrinogen]. Serum amyloid A concentrations in all ponies were significantly (P = 0.00001) reduced after longer term exercise compared to Day 1 values. Plasma [haptoglobin] was significantly (P = 0.00001) higher in PL compared to NL on Day 1. This difference was no longer apparent after longer term exercise, such that [haptoglobin] in PL had decreased to concentrations similar to NL. Following short-term exercise, all ponies had an initial decrease in serum [insulin] immediately after exercise, followed by an increase peaking 10 min after exercise cessation, before returning to pre-exercise values. On Day 14 these fluctuations were significantly (P = 0.001) reduced in all ponies.

CONCLUSIONS

Fourteen days of low intensity exercise significantly decreased [SAA] in all ponies and plasma [haptoglobin] in PL such that it was no longer increased compared to NL. Regular low intensity exercise appears to have an anti-inflammatory effect, which is possibly greater in PL and so may be beneficial in reducing this putative risk factor in pasture-associated laminitis.

A review of recent advances and current hypotheses on the pathogenesis of acute laminitis

With the increasing number of studies being published on the different experimental models used to induce and study acute laminitis, the pathophysiological events associated with these various models (i.e. starch overload, oligofructose overload, black walnut extract and hyperinsulinaemia) can be compared more realistically. Within this review, the mechanisms for metabolic vs. inflammatory laminitis are discussed, and the question of how pasture laminitis may fit into any of the proposed mechanisms is addressed.

Seasonal and annual influence on insulin and cortisol results from overnight dexamethasone suppression tests in normal ponies and ponies predisposed to laminitis

REASONS FOR PERFORMING STUDY

A simple, accurate test for identifying individual animals at increased risk of laminitis would aid prevention. Laminitis-prone ponies have a greater serum insulin response to dexamethasone administration than normal ponies in the summer, but the response during different seasons is unknown.

OBJECTIVE

To test the hypothesis that previously laminitic ponies have a greater insulin response to dexamethasone than normal ponies, which is present during all seasons.

STUDY DESIGN

Prospective longitudinal study.

METHODS

Overnight dexamethasone suppression tests were performed on 7 normal ponies and 5 previously laminitic ponies in spring 2009 and 2010, summer 2008 and 2010, autumn 2009 and winter 2008, while the ponies were at pasture. In spring 2010, a dexamethasone suppression test was performed after the ponies had been fed only hay for 3 weeks. Serum cortisol and insulin concentrations pre- and post dexamethasone were measured. Linear mixed models were used to analyse the data.

RESULTS

Insulin concentrations pre- and post dexamethasone were significantly higher in previously laminitic ponies than in normal ponies during spring 2009 and summer 2008, but there was no difference between groups in spring 2010, summer 2010, autumn 2009 or winter 2008. Insulin concentration varied significantly with season. Diet had no apparent effect on insulin concentration pre- or post dexamethasone in spring 2010. Cortisol concentrations post dexamethasone were significantly higher in previously laminitic ponies than in normal ponies in autumn 2009, with concentrations above the reference range (<25 nmol/l) in both groups in summer 2008 and autumn 2009. Individual ponies had insufficient cortisol suppression in all seasons.

CONCLUSIONS

There were significant differences between groups in insulin and cortisol concentrations post dexamethasone during some seasons, but this was not present in all years. Wide interindividual variation in response limits the usefulness of a dexamethasone suppression test for predicting the susceptibility of an individual animal to laminitis.

POTENTIAL RELEVANCE

Abnormal insulin and cortisol responses to dexamethasone must be interpreted in the light of the individual animal, seasonal and annual variation reported here.

Effects of oral clenbuterol on the clinical and inflammatory response to endotoxaemia in the horse

Pro-inflammatory cytokines, such as IL-1β and TNFα, play a major role in activating leukocytes and endothelial cells during the systemic inflammatory response to endotoxin in the horse. β2 agonist drugs, such as clenbuterol, inhibit leukocyte activation. This study aimed to determine the effects of oral clenbuterol on clinical and leukocyte responses, including production of TNFα, in an in vivo endotoxin challenge model. In a randomised crossover design, horses received either clenbuterol or a placebo product prior to the administration of low dose endotoxin (30 ng/kg over 30 min). Clinical signs were measured and leukocyte counts and serial blood samples were obtained over 6 h. Pre-treatment with oral clenbuterol (0.8 μg/kg) significantly reduced (P=0.046) the peak rectal temperature and the peak plasma TNFα concentration (P=0.026) following endotoxin challenge. These data suggest that oral clenbuterol at the therapeutic dose has anti-inflammatory effects in horses challenged with a low dose of endotoxin.

Seasonal variation in maintenance of phenylephrine-induced tone in isolated equine digital arteries under hypoxic or hyperoxic conditions in vitro

Digital vasoconstriction, ischaemia and hypoxia may predispose to acute laminitis. Laminitis incidence varies seasonally, peaking in spring and summer. Direct seasonal influences on equine digital artery (EDA) contractility have not been investigated. This study assessed seasonal variation in maintenance of phenylephrine (PHE)-induced tone in isolated EDAs under hypoxic (95% nitrogen) and hyperoxic (95% oxygen) conditions. The objective was to measure change in arterial tone over time after constriction to a plateau with PHE. Tone was measured at plateau and over time and percentage change calculated. Hyperoxic EDAs maintained PHE-induced tone over 1 h with no seasonal variation. Hypoxic EDAs relaxed in fall (median [inter-quartile range] 59% [44-77%] decrease from plateau; P=0.008), contracted in spring (65% [20-192%] increase from plateau; P=0.03) and did not significantly change tone in winter (18% [0-28%] decrease; P=0.13). Continued contraction under hypoxic conditions in spring may contribute to digital vasoconstriction.