DN 9693: A Phosphodiesterase Inhibitor with a Platelet Membrane Effect

We have examined the in vitro effects of DN 9693 (piperidinylimidazo-quinazolinone) on various aspects of platelet reactivity. Our results are consistent with its known function as a phosphodiesterase inhibitor in that it increased platelet cyclic AMP, particularly in conjunction with an adenylate cyclase stimulator, and exerted a profound inhibitory effect on platelet aggregation responses to a variety of agonists. DN 9693 also inhibited ristocetin-induced platelet agglutination (RIPA). We therefore examined its effect on ristocetin co-factor assays and on the binding of a monoclonal antibody (McAb) to platelet membrane glycoprotein lb (GPIb). The drug inhibited the binding of the monoclonal antibody in a dose-dependent manner. This suggests an effect of the drug on the platelet surface membrane with reduced expression of GPIb. Our results indicate that in addition to its anticipated inhibitory effect on platelet aggregation, DN 9693 may also inhibit platelet adhesion.

Standard vs. intensified management of heart failure to reduce healthcare costs: results of a multicentre, randomized controlled trial

Aims

To determine if an intensified form of heart failure management programme (INT-HF-MP) based on individual profiling is superior to standard management (SM) in reducing health care costs during 12-month follow-up (primary endpoint).

Methods and results

A multicentre randomized trial involving 787 patients (full analysis set) discharged from four tertiary hospitals with chronic HF who were randomized to SM (n = 391) or INT-HF-MP (n = 396). Mean age was 74 ± 12 years, 65% had HF with a reduced ejection fraction (31.4 ± 8.9%) and 14% were remote-dwelling. Study groups were well matched. According to Green, Amber, Red Delineation of rIsk And Need in HF (GARDIAN-HF) profiling, regardless of location, patients in the INT-HF-MP received a combination of face-to-face (home visits) and structured telephone support (STS); only 9% (`low risk') were designated to receive the same level of management as the SM group. The median cost in 2017 Australian dollars (A$1 equivalent to ∼EUR €0.7) of applying INT-HF-MP was significantly greater than SM ($152 vs. $121 per patient per month; P < 0.001), However, at 12 months, there was no difference in total health care costs for the INT-HF-MP vs. SM group (median $1579, IQR $644 to $3717 vs. $1450, IQR $564 to $3615 per patient per month, respectively). This reflected minimal differences in all-cause mortality (17.7% vs. 18.4%; P = 0.848) and recurrent hospital stay (18.6 ± 26.5 vs. 16.6 ± 24.8 days; P = 0.199) between the INT-HF-MP and SM groups, respectively.

Conclusion

During 12-months follow-up, an INT-HF-MP did not reduce healthcare costs or improve health outcomes relative to SM.

Sex Differences in the Impact of Body Mass Index on the Risk of Future Atrial Fibrillation: Insights From the Longitudinal Population-Based Tromsø Study

Background

Atrial fibrillation (AF) prevalence is increasing, and body mass index (BMI) is a risk factor for AF. However, sex differences in the impact of BMI on AF risk have not been fully elucidated.

Methods and Results

Data from the fourth survey (1994–1995) of the Tromsø Study (Norway) were used to investigate the association of single‐measurement BMI on future AF risk. To analyze the influence of BMI changes on AF risk, data from individuals who attended the third and fourth study surveys were used. AF diagnosis was derived from record linkage and end point adjudication. Cox regression analysis was conducted using fractional polynomials of BMI and BMI change with models adjusted for age, baseline BMI (change analyses), risk factors, comorbidities, and antihypertensive medications.

Data were available for 24 799 individuals from the fourth survey (mean age, 45.5±14.2 years; 52.9% women). Over 15.7±5.5 years, 811 women (6.2%) and 918 men (7.9%) developed AF. In men, lower BMI decreased AF risk and higher BMI increased risk (hazard ratios [95% confidence intervals] for BMI 18 or 40 kg/m² compared with 23 kg/m² were 0.75 [0.70–0.81] and 4.42 [3.00–6.53], respectively). The same pattern was identified in women. Two surveys were attended by 14 652 individuals. In men and women, a decrease in BMI over time was associated with decreased AF risk and an increase in BMI was associated with increased AF risk.

Conclusions

Within a population cohort, BMI was positively associated with AF risk. Change in BMI over time influenced AF risk in both men and women.

Impact of body mass index on mortality and hospitalisation of patients with atrial fibrillation

BACKGROUND

Atrial fibrillation represents a substantial clinical and public health issue. The definitive impact of body mass index on prognosis of patients with chronic (persistent or permanent) atrial fibrillation remains undetermined.

AIM

The purpose of this study was to investigate the association of body mass index with health outcomes (mortality and re-hospitalisation) of patients with chronic atrial fibrillation.

METHODS

Using data from the Standard versus Atrial Fibrillation spEcific managemenT strategY (SAFETY) trial (a randomised controlled trial of home-based, atrial fibrillation-specific disease management), we performed post-hoc analyses of mortality and re-hospitalisation outcomes during minimum 24-month follow-up according to baseline body mass index profile.

RESULTS

Of 297 participants (mean age 71±11 years, 47% female, mean body mass index 29.6±6.7 kg/m²), 35.0% of participants were overweight (body mass index 25.0-29.9 kg/m²) and 43.1% were obese (body mass index≥30 kg/m²). During follow-up, n=42 died including 16/65 (24.6%) classified as normal body mass index, 16/104 (15.4%) classified as overweight and 10/128 (7.8%) classified as obese. Increasing body mass index was not associated with increased mortality but was associated with re-hospitalisation due to cardiovascular disease with greater length-of-stay (odds ratio 1.05; 95% confidence interval 1.00-1.09, p=0.032). Obese individuals experienced increased unplanned admissions compared to overweight individuals (incidence rate ratio 0.71; 95% confidence interval 0.53-0.96, p=0.028), and increased cardiovascular-related (incidence rate ratio 0.58; 95% confidence interval 0.39-0.86, p=0.007) and all-cause admissions (incidence rate ratio 0.63; 95% confidence interval 0.45-0.89, p=0.008) compared to those classified as normal body mass index.

CONCLUSION

Overweight and obesity were not associated with survival in patients with chronic atrial fibrillation but were associated with more frequent hospital care and prolonged stay.

Measurement of the Q^{2} Dependence of the Deuteron Spin Structure Function g_{1} and its Moments at Low Q^{2} with CLAS

We measured the g_{1} spin structure function of the deuteron at low Q^{2}, where QCD can be approximated with chiral perturbation theory (χPT). The data cover the resonance region, up to an invariant mass of W≈1.9  GeV. The generalized Gerasimov-Drell-Hearn sum, the moment Γ_{1}^{d} and the spin polarizability γ_{0}^{d} are precisely determined down to a minimum Q^{2} of 0.02  GeV^{2} for the first time, about 2.5 times lower than that of previous data. We compare them to several χPT calculations and models. These results are the first in a program of benchmark measurements of polarization observables in the χPT domain.

Mild cognitive impairment impacts health outcomes of patients with atrial fibrillation undergoing a disease management intervention

Objective

Mild cognitive impairment (MCI) is prevalent in atrial fibrillation (AF) and has the potential to contribute to poor outcomes. We investigated the influence of MCI on survival and rehospitalisation in patients with chronic forms of AF undergoing a home-based, AF-specific disease management intervention (home-based intervention (HBI)) or standard management (SM).

Methods

The Montreal Cognitive Assessment tool was administered at baseline (a score of <26/30 indicated MCI) in patients with AF randomised to HBI versus SM. Post hoc analyses of mortality and rehospitalisations during a minimum 24-month follow-up were conducted in the overall cohort and in each study group separately.

Results

Of 260 patients (mean age 72±11, 47% female), 65% demonstrated MCI on screening (34% in SM; 31% in HBI). Overall, the number of days spent alive and out-of-hospital during follow-up (P=0.012) and all-cause rehospitalisation were influenced by MCI during follow-up (OR 3.16 (95% CI 1.46 to 6.84)) but MCI did not influence any outcomes in the SM group. However, survival was negatively influenced by MCI in the HBI group (P=0.036); those with MCI in this group were 5.6 times more likely to die during follow-up (OR 5.57 (95% CI 1.10 to 28.1)). Those with MCI in the HBI group also spent less days alive and out-of-hospital than those with no MCI (P=0.022). MCI was also identified as a significant independent correlate of shortest duration of event-free survival (OR 3.48 (95% CI 1.06 to 11.4)), all-cause rehospitalisation (OR 3.30 (95% CI 1.25 to 8.69)) and cardiovascular disease (CVD)-related rehospitalisation (OR 2.35 (95% CI 1.12 to 4.91)) in this group.

Conclusions

The effectiveness of home-based, disease management for patients with chronic forms of AF is negatively affected by comorbid MCI. The benefit of adjunctive support for patients with MCI on CVD-related health outcomes requires further investigation.

First Exclusive Measurement of Deeply Virtual Compton Scattering off ^{4}He: Toward the 3D Tomography of Nuclei

We report on the first measurement of the beam-spin asymmetry in the exclusive process of coherent deeply virtual Compton scattering off a nucleus. The experiment uses the 6 GeV electron beam from the Continuous Electron Beam Accelerator Facility (CEBAF) accelerator at Jefferson Lab incident on a pressurized ^{4}He gaseous target placed in front of the CEBAF Large Acceptance Spectrometer (CLAS). The scattered electron is detected by CLAS and the photon by a dedicated electromagnetic calorimeter at forward angles. To ensure the exclusivity of the process, a specially designed radial time projection chamber is used to detect the recoiling ^{4}He nuclei. We measure beam-spin asymmetries larger than those observed on the free proton in the same kinematic domain. From these, we are able to extract, in a model-independent way, the real and imaginary parts of the only ^{4}He Compton form factor, H_{A}. This first measurement of coherent deeply virtual Compton scattering on the ^{4}He nucleus, with a fully exclusive final state via nuclear recoil tagging, leads the way toward 3D imaging of the partonic structure of nuclei.

Beam-Target Helicity Asymmetry for γ[over →]n[over →]→π^{-}p in the N^{*} Resonance Region

We report the first beam-target double-polarization asymmetries in the γ+n(p)→π^{-}+p(p) reaction spanning the nucleon resonance region from invariant mass W=1500 to 2300 MeV. Circularly polarized photons and longitudinally polarized deuterons in solid hydrogen deuteride (HD) have been used with the CEBAF Large Acceptance Spectrometer (CLAS) at Jefferson Lab. The exclusive final state has been extracted using three very different analyses that show excellent agreement, and these have been used to deduce the E polarization observable for an effective neutron target. These results have been incorporated into new partial wave analyses and have led to significant revisions for several γnN^{*} resonance photocouplings.

Increased fronto-striatal reward prediction errors moderate decision making in obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) has been linked to functional abnormalities in fronto-striatal networks as well as impairments in decision making and learning. Little is known about the neurocognitive mechanisms causing these decision-making and learning deficits in OCD, and how they relate to dysfunction in fronto-striatal networks.

METHOD

We investigated neural mechanisms of decision making in OCD patients, including early and late onset of disorder, in terms of reward prediction errors (RPEs) using functional magnetic resonance imaging. RPEs index a mismatch between expected and received outcomes, encoded by the dopaminergic system, and are known to drive learning and decision making in humans and animals. We used reinforcement learning models and RPE signals to infer the learning mechanisms and to compare behavioural parameters and neural RPE responses of the OCD patients with those of healthy matched controls.

RESULTS

Patients with OCD showed significantly increased RPE responses in the anterior cingulate cortex (ACC) and the putamen compared with controls. OCD patients also had a significantly lower perseveration parameter than controls.

CONCLUSIONS

Enhanced RPE signals in the ACC and putamen extend previous findings of fronto-striatal deficits in OCD. These abnormally strong RPEs suggest a hyper-responsive learning network in patients with OCD, which might explain their indecisiveness and intolerance of uncertainty.

Current and projected burden of heart failure in the Australian adult population: a substantive but still ill-defined major health issue

BACKGROUND

Comprehensive epidemiological data to describe the burden of heart failure (HF) in Australia remain lacking despite its importance as a major health issue. Herewith, we estimate the current and future burden of HF in Australia using best available data.

METHODS

Australian-specific and the most congruent international epidemiological and health utilisation data were applied to the Australian population (adults aged ≥ 45 years, 8.9 of 22.7 million total population in 2014) on an age and sex-specific basis. We estimated the current incident and prevalent cases of clinically overt/symptomatic HF (predominately those with reduced ejection fraction), hospital activity (diagnosis of HF as a primary or secondary reason for admission) and health care costs in 2014 and future prevalence and burden of HF projected to 2030.

RESULTS

We estimated that over 61,000 (6.9 per 1000 person-years) adult Australians aged ≥ 45 years (58 % women) are diagnosed with HF with clinically overt signs and symptoms every year. On a conservative basis, 480,000 (6.3 %, 95 % CI 2.6 to 10.0 %) Australians (66 % men) are now affected by the syndrome with > 150,000 hospitalisations in excess of 1 million days in hospital per annum. The annual cost of managing HF in the community is approximately $900 million and nearly $2.7 billion ($1.5 versus $1.2 billion, men versus women) when considering the additional cost of in-patient care. We predict that the prevalence and future burden of HF will continue to increase over the next 10-15 years to nearly 750,000 people with an estimated annual health care cost of $3.8 billion.

CONCLUSIONS

Australia is not immune to the growing magnitude and implications of a sustained epidemic of HF in an ageing population. However, its public health and economic burden will remain ill-defined until more definitive Australian-specific data are generated.

A systematic review and meta-analysis of primary prevention programmes to improve cardio-metabolic risk in non-urban communities

INTRODUCTION

Although cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) prevention programmes have been effective in urban residents, their effectiveness in non-urban settings, where cardio-metabolic risk is typically elevated, is unknown. We systematically reviewed the effectiveness of primary prevention programmes aimed at reducing risk factors for CVD/T2DM, including blood pressure, body mass index (BMI), blood lipid and glucose, diet, lifestyle, and knowledge in adults residing in non-urban areas.

METHODS

Twenty-five manuscripts, globally, from 1990 were selected for review (seven included in the meta-analyses) and classified according to: 1) study design (randomised controlled trial [RCT] or pre-/post-intervention); 2) intervention duration (short [<12months] or long term [≥12months]), and; 3) programme type (community-based programmes or non-community-based programmes).

RESULTS

Multiple strategies within interventions focusing on health behaviour change effectively reduced cardio-metabolic risk in non-urban individuals. Pre-/post-test design studies showed more favourable improvements generally, while RCTs showed greater improvements in physical activity and disease and risk knowledge. Short-term programmes were more effective than long-term programmes and in pre-/post-test designs reduced systolic blood pressure by 4.02mmHg (95% CI -6.25 to -1.79) versus 3.63mmHg (95% CI -7.34 to 0.08) in long-term programmes. Community-based programmes achieved good results for most risk factors except BMI and (glycated haemoglobin) HbA1c.

CONCLUSION

The setting for applying cardio-metabolic prevention programmes is important given its likelihood to influence programme efficacy. Further investigation is needed to elucidate the individual determinants of cardio-metabolic risk in non-urban populations and in contrast to urban populations.

Impact of Nurse-Led, Multidisciplinary Home-Based Intervention on Event-Free Survival Across the Spectrum of Chronic Heart Disease: Composite Analysis of Health Outcomes in 1226 Patients From 3 Randomized Trials

Background—

We sought to determine the overall impact of a nurse-led, multidisciplinary home-based intervention (HBI) adapted to hospitalized patients with chronic forms of heart disease of varying types.

Methods and Results—

Prospectively planned, combined, secondary analysis of 3 randomized trials (1226 patients) of HBI were compared with standard management. Hospitalized patients presenting with heart disease but not heart failure, atrial fibrillation but not heart failure, and heart failure, as well, were recruited. Overall, 612 and 614 patients, respectively, were allocated to a home visit 7 to 14 days postdischarge by a cardiac nurse with follow-up and multidisciplinary support according to clinical need or standard management. The primary outcome of days-alive and out-of-hospital was examined on an intention-to-treat basis. During 1371 days (interquartile range, 1112–1605) of follow-up, 218 patients died and 17 917 days of hospital stay were recorded. In comparison with standard management, HBI patients achieved significantly prolonged event-free survival (90.1% [95% confidence interval, 88.2–92.0] versus 87.2% [95% confidence interval, 85.1–89.3] days-alive and out-of-hospital; P=0.020). This reflected less all-cause mortality (adjusted hazard ratio, 0.67; 95% confidence interval, 0.50–0.88; P=0.005) and unplanned hospital stay (median, 0.22 [interquartile range, 0–1.3] versus 0.36 [0–2.1] days/100 days follow-up; P=0.011). Analyses of the differential impact of HBI on all-cause mortality showed significant interactions (characterized by U-shaped relationships) with age (P=0.005) and comorbidity (P=0.041); HBI was most effective for those aged 60 to 82 years (59%–65% of individual trial cohorts) and with a Charlson Comorbidity Index Score of 5 to 8 (36%–61%).

Conclusions—

These data provide further support for the application of postdischarge HBI across the full spectrum of patients being hospitalized for chronic forms of heart disease.

Clinical Trial Registration—

URL: http://www.anzctr.org.au. Unique identifiers: 12610000221055, 12608000022369, 12607000069459.

Effectiveness of a care bundle to reduce surgical site infections in patients having open colorectal surgery

Introduction In 2010 a care bundle was introduced by the Department of Health (DH) to reduce surgical site infections (SSIs) in England. To date, use of the care bundle has not been evaluated despite incorporating interventions with resource implications. The aim of this study was to evaluate the DH SSI care bundle in open colorectal surgery. Methods A prospective cohort design was used at two teaching hospitals in England. The baseline group consisted of 127 consecutive patients having colorectal surgery during a 6-month period while the intervention group comprised 166 patients in the subsequent 6 months. SSI and care bundle compliance data were collected using dedicated surveillance staff. Results Just under a quarter (24%) of the patients in the baseline group developed a SSI compared with just over a quarter (28%) in the care bundle group (p>0.05). However, compliance rates with individual interventions, both before and after the implementation of the bundle, were similar. Interestingly, in only 19% of cases was there compliance with the total care bundle. The single intervention that showed an associated reduction in SSI was preoperative warming (p=0.032). Conclusions The DH care bundle did not reduce SSIs after open colorectal surgery. Despite this, it is not possible to state that the bundle is ineffective as compliance rates before and after bundle implementation were similar. All studies evaluating the effectiveness of care bundles must include data for compliance with interventions both before and after implementation of the care bundle; poor compliance may be one of the reasons for the lower than expected reduction of SSIs.

Controlling nanowire nucleation and growth with a negative substrate bias

Applying a voltage bias to silicon nanowires during growth can influence wire density, diameter and length.

Cross Sections for the Exclusive Photon Electroproduction on the Proton and Generalized Parton Distributions

Unpolarized and beam-polarized fourfold cross sections (d^{4}σ/dQ^{2}dx_{B}dtdϕ) for the ep→e^{'}p^{'}γ reaction were measured using the CLAS detector and the 5.75-GeV polarized electron beam of the Jefferson Lab accelerator, for 110 (Q^{2},x_{B},t) bins over the widest phase space ever explored in the valence-quark region. Several models of generalized parton distributions (GPDs) describe the data well at most of our kinematics. This increases our confidence that we understand the GPD H, expected to be the dominant contributor to these observables. Through a leading-twist extraction of Compton form factors, these results support the model predictions of a larger nucleon size at lower quark-momentum fraction x_{B}.

Subtle renal dysfunction and bleeding risk in atrial fibrillation: symmetric dimethylarginine predicts HAS-BLED score

BACKGROUND

Risk of substantial haemorrhage represents a critically important limitation to effective anti-thrombotic treatment in patients with atrial fibrillation (AF). While it is known that this risk is increased in anticoagulated patients either in the presence of anti-aggregatory drugs or concomitant renal insufficiency, there are currently few data on the potential interactions between endogenous platelet aggregability and bleeding risk.

OBJECTIVE

We therefore evaluated in a cohort of AF patients: (1), the putative relationship between platelet aggregability and HAS-BLED score; (2), the potential biochemical bases for such a relationship.

METHODS

Patients were included as part of SAFETY, a randomised controlled trial evaluating outpatient management of AF patients. Platelet response to ADP was evaluated via whole blood impedance aggregometry; clinical and biochemical correlates of platelet aggregation were sought via univariate and multivariate analysis.

RESULTS

Platelet aggregation correlated inversely (r=-0.220, p<0.05) with HAS-BLED score. Univariate biochemical correlates of decreased platelet aggregation were plasma concentrations of symmetric dimethylarginine (SDMA) and asymmetric dimethylarginine (ADMA). On multivariate analyses, plasma SDMA concentration (β=-0.318, p<0.01), platelet content of thioredoxin-interacting protein (Txnip, β=0.261, p<0.05) and plasma thrombospondin-1 (TSP-1, β=0.249, p<0.05) concentration were predictive of platelet ADP response. Consistent with previous reports, plasma SDMA concentrations were strongly and inversely correlated with estimated glomerular filtration rate (eGFR, r=-0.780, p<0.001).

CONCLUSIONS

These data therefore suggest that (1), physiologically impaired, like pharmacologically impaired, platelet aggregability may increase bleeding risk in anticoagulated AF patients; (2), the biochemical basis for this may include impaired effects of nitric oxide (via Txnip, TSP-1) but also concomitant renal dysfunction.