Effects of repeated administration of Levosimendan in advanced heart failure in the elderly patient

Introduction

Advanced heart failure (AHF) is characterized by repeated episodes of hemodynamic instability, frequent hospitalizations with progressive reduction in quality of life. The aim of the study was to verify in a small group of patients, no longer susceptible to heart transplantation (HT) and left ventricular assistance (LVAD), the effectiveness of monthly treatment with Levosimendan for a period of at least 6 months on quality of life and hospitalization.

Materials and methods

29 elderly patients (≥65 years) with AHF, excluded from the waiting list for HT or no longer eligible for inclusion on the waiting list were enrolled. 12 patients practiced at least 1 infusion of Levosimendan and were considered as cases, while 17 patients with maximized treatment were used as controls. All patients underwent a multidimensional evaluation in which Fraity was assessed according to Fried criteria, cognitive function with Mini-Mental State Examination (MMSE), depressive symptoms with Geriatric Depression Scale (GDS).

Results

The 29 patients were followed up monthly and the 12 patients of Levosimendan group practiced an average of 4.6±2.7 infusions in absence of adverse events. The mean age was 73.3±6.2, 87.5% males, with a NYHA class of 3.4±0.4, an ejection fraction of 26.6±4.9 and NT-pro-BNP value of 7016.8±4876.1. Renal function was impaired with eGFR (ml / min) = 36.8±20.1. These patients had been hospitalized 1.8±0.7 times in the previous year. The data are not statistically different compared to the control group although a greater severity of the clinical condition of the case group is evident. The 6 minute walking test (6MWT) was 201.4±118.1 meters. The mean values of Frailty was 4.6±0.5, the GDS 6.4±4.2 and the MMSE 23.8±4.3. Only the MMSE was lower in the case group than in the controls (26.9±1.9, p=0.022). The results in terms of pre-post treatment difference identify an improvement of 35.3±136.3 meters at 6MWT in patients treated with Levosimendan compared to −72.2±94.2 meters in controls (p=0.030), Frailty is reduced by 1.4±1.6 points compared to 0.1±1.1 in controls (p=0.030), the GDS decreases by 0.9±1.5 in cases and increases by 2±2.1 in the control group (p=0.020), the MMSE score increases by 2.12±4.1 in treated patients, while it is reduced by 2.75±2.3 in the control group; p=0.003. The eGFR is reduced in both groups although more in the controls (−1.87±5.8 vs −10.8±11.1; p=0.043). There are no significant differences in mortality while there was less hospitalization during the follow-up period 0.9±0.6 vs 2.4±1.5; p=0.016). Multiple regression analysis shows that hospitalizations reduction is correlated with the recovery of frailty. This association is independent by age and disease severity.

Conclusion

Levosimendan improves physical and cognitive function, at the same time a minor decrease in renal function is observed, with a reduction of unscheduled visits to the hospital.

Funding Acknowledgement

Type of funding sources: None.

Microvascular ischemia in patients with successful percutaneous coronary intervention: effects of ranolazine and isosorbide-5-mononitrate

OBJECTIVE

About one-third of patients undergoing percutaneous coronary interventions (PCIs) for flow-limiting coronary stenosis continue to develop signs of myocardial ischemia (MI) during exercise stress test [EST], despite successful coronary revascularization. Coronary microvascular dysfunction is a likely major cause of the persistence of EST-induced MI in these patients.

PATIENTS AND METHODS

We studied 15 patients (14 men, age 67±5 years) fulfilling the following strict inclusion criteria: (1) recent PCI (<6 months), with drug-eluting stent, of coronary artery stenoses for stable angina, with evidence of full success (no residual stenosis >20% in any vessel); (2) persistence of ST-segment depression induction during EST. After a basal investigation, patients received either ranolazine (375 mg bid) or isosorbide-5-mononitrate (ISMN, 20 mg bid) for 3 weeks in a single-blind, randomized crossover study. Clinical assessment, symptom-limited EST, echocardiographic color-Doppler, with tissue-Doppler examination, and coronary microvascular dilator response to adenosine (CFR-ADO) and cold pressor test (CFR-CPT), assessed by transthoracic echo-Doppler, were obtained at baseline and the end of the 3-week therapy with each drug.

RESULTS

Compared to both baseline and ISMN, ranolazine showed a longer time to 1 mm ST-segment depression (404±116 s vs. 317±98 and 322±70 s, respectively; p<0.01). No differences were observed in coronary microvascular function and diastolic left ventricular function between the 2 drugs and compared to baseline.

CONCLUSIONS

Our data show that ranolazine, but not ISMN, improved time to ischemia during EST. This effect, however, was independent of any effects on coronary microvascular and diastolic function.

Diagnostic role of echocardiography in patients admitted to the emergency room with suspect no-ST-segment elevation acute myocardial infarction

OBJECTIVE

We investigated whether echocardiography may help identify, among patients admitted with a suspect of non-ST-segment elevation acute myocardial infarction (NSTEMI), those with athero-thrombotic coronary artery disease (CAD).

PATIENTS AND METHODS

We studied consecutive patients admitted with a clinical suspect of first NSTEMI. Echocardiography was assessed within 24 hours from admission. Patients were divided into two groups, according to the results of coronary angiography: 1) patients with obstructive stenosis (≥ 50%) and/or images of thrombosis in one or more coronary arteries (CAD group); 2) patients with no evidence of obstructive coronary arteries (NOCAD group).

RESULTS

Of 101 patients enrolled in the study, 53 (52.5%) showed obstructive CAD and 48 (47.5%) NOCAD. At echocardiographic examination, regional wall motion abnormalities were found in 52.8% of patients in the CAD group and 43.7% in the NOCAD group (p=0.43). Left ventricle ejection fraction was 56.4±6.8 vs. 54.7±9.8% (p=0.30) and wall motion score index was 1.16±0.26 vs. 1.21±0.32 (p=0.39) in the two groups, respectively. A multivariable logistic regression independent predictors of obstructive CAD included age, male gender, typical angina, diabetes and hypertension.

CONCLUSIONS

Our data showed that, in patients with acute chest pain and increased serum troponin T concentration, routine standard echocardiography does not significantly improve the diagnostic accuracy for the presence of obstructive CAD.

Re-evaluating how charge transfer modifies the conformation of adsorbed molecules

The archetypal electron acceptor molecule, TCNQ, is generally believed to become bent into an inverted bowl shape upon adsorption on the coinage metal surfaces on which it becomes negatively charged. New quantitative experimental structural measurements show that this is not the case for TCNQ on Ag(111). DFT calculations show that the inclusion of dispersion force corrections reduces not only the molecule-substrate layer spacing but also the degree of predicted molecular bonding. However, complete agreement between experimentally-determined and theoretically-predicted structural parameters is only achieved with the inclusion of Ag adatoms into the molecular layer, which is also the energetically favoured configuration. The results highlight the need for both experimental and theoretical quantitative structural methods to reliably understand similar metal-organic interfaces and highlight the need to re-evaluate some previously-investigated systems.

Correlation between benzene and testosterone in workers exposed to urban pollution

AIM

Many studies have examined the effects of benzene on testosterone. The purpose of this study was to evaluate the possible correlation between the blood levels of benzene and the levels of testosterone.

MATERIALS AND METHODS

The study involved a group of 148 subjects. For every worker have been made out a blood sample for the evaluation of benzene and testosterone levels and an urine analysis for the evaluation of the levels of trans, trans-muconic acid and S-phenylmercapturic acid. We estimated the Pearson correlation coefficient between the variables in the sample and the urinary metabolites, age, length of service, gender, BMI. For the analysis of the major confounding factors it was performed a multiple linear regression.

RESULTS

The Pearson correlation coefficiet showed: 1. a significant inverse correlation between the S-phenyl mercapturic acid and free testosterone; 2. a significant direct correlation between trans-trans muconic acid and BMI. After dividing the sample according to the median of blood benzene (161.0 ng / L), Pearson correlation coefficient showed a significant inverse correlation between the S-phenyl mercapturic acid and free testosterone in the group with values below this median.

CONCLUSIONS

Our results, to be considered preliminary, suggest that occupational exposure to low levels of benzene, present in urban pollution, affect the blood levels of testosterone. These results need to be confirmed in future studies, with the eventual possibility of including more specific fertility tests.

Two-dimensional core-shell donor-acceptor assemblies at metal-organic interfaces promoted by surface-mediated charge transfer

Organic charge transfer (CT) complexes obtained by combining molecular electron donors and acceptors have attracted much interest due to their potential applications in organic opto-electronic devices. In order to work, these systems must have an electronic matching - the highest occupied molecular orbital (HOMO) of the donor must couple with the lowest unoccupied molecular orbital (LUMO) of the acceptor - and a structural matching, so as to allow direct intermolecular CT. Here it is shown that, when molecules are adsorbed on a metal surface, novel molecular organizations driven by surface-mediated CT can appear that have no counterpart in condensed phase non-covalent assemblies of donor and acceptor molecules. By means of scanning tunneling microscopy and spectroscopy it is demonstrated that the electronic and self-assembly properties of an electron acceptor molecule can change dramatically in the presence of an additional molecular species with marked electron donor character, leading to the formation of unprecedented core-shell assemblies. DFT and classical force-field simulations reveal that this is a consequence of charge transfer from the donor to the acceptor molecules mediated by the metallic substrate.

Biomimetic proteolipid vesicles for targeting inflamed tissues

A multitude of micro- and nanoparticles have been developed to improve the delivery of systemically administered pharmaceuticals, which are subject to a number of biological barriers that limit their optimal biodistribution. Bioinspired drug-delivery carriers formulated by bottom-up or top-down strategies have emerged as an alternative approach to evade the mononuclear phagocytic system and facilitate transport across the endothelial vessel wall. Here, we describe a method that leverages the advantages of bottom-up and top-down strategies to incorporate proteins derived from the leukocyte plasma membrane into lipid nanoparticles. The resulting proteolipid vesicles-which we refer to as leukosomes-retained the versatility and physicochemical properties typical of liposomal formulations, preferentially targeted inflamed vasculature, enabled the selective and effective delivery of dexamethasone to inflamed tissues, and reduced phlogosis in a localized model of inflammation.

Neurotrophic factors and neurodegenerative diseases: a delivery issue

Neurotrophic factors (NTFs) represent one of the most stimulating challenge in neurodegenerative diseases, due to their potential in neurorestoring and neuroprotection. Despite the large number of proofs-of-concept and evidences of their activity, most of the clinical trials, mainly regarding Parkinson's disease and Alzheimer's disease, demonstrated several failures of the therapeutic intervention. A large number of researches were conducted on this hot topic of neuroscience, clearly evidencing the advantages of NTF approach, but evidencing the major limitations in its application. The inability in crossing the blood-brain barrier and the lack of selectivity actually represent some of the most highlighted limits of NTFs-based therapy. In this review, beside an overview of NTF activity versus the main neuropathological disorders, a summary of the most relevant approaches, from invasive to noninvasive strategies, applied for improving NTF delivery to the central nervous systems is critically considered and evaluated.

Disease management of type 2 diabetes: a follow-up analysis in a sanitary district of Sicily

AIM

The aim of this paper was to analyze the Disease management of type 2 diabetes in a sanitary district of the Sicily Region (Italy).

METHODS

In a population of 9 698 subjects, we selected patients with known type 2 diabetes: a cohort of 385 subjects, (206 women and 179 men) following up for one year. Prevalence of type 2 diabetes in the analyzed population was 3.97%. A great lot of cohort was on a diet.

RESULTS

After one year, a per cent reduction of obese and overweight subjects was observed. No differences were observed for Body Mass Index (BMI) at the beginning and at the end of the study. After one year, through educational meetings with the doctor, a significant increase of knowledge on the patient's conditions and on the diabetes complications was verified, but our data showed persistent poor attention by doctors. The poor knowledge of patients led to a difficult disease management. After one year, a great lot of cohort used antistroke and cardiovascular disease therapy, reducing significantly the cardiovascular disease risk. However, our study also highlights a gap between the therapeutic guidelines and the actual treatment, with wide variability in the delivery of secondary prevention. CONCLUSION. Our study showed that a persevering warning and a constant adjournment of doctors improves the disease management, reducing complications risk in type 2 diabetes patients.

Enhanced Creep Resistance via Ion Exchange Processes in Al/Mgal2O4 Composites

Discontinuously reinforced aluminium (DRA) composites were prepared by a novel ion exchange process in which the reinforcing phase, aluminium oxide, was introduced by exchanging the magnesium ions in magnesium aluminate spinel with aluminium [1]. The exchange reaction occurs by the diffusion of magnesium and aluminium ions across the interface in opposite directions. The process led to the formation of DRA composites with a remarkable resistance to high temperature deformation. We present an ab-initio density functional study of the coherent cube-on-cube interfaces between spinel (MgAl2O4) and Al metal and relevant X-ray diffraction studies of the DRA composite. We find that the presence of surface electric dipoles near the interface, originated by the ion exchange process, leads to a lowering of the Al/MgAl2O4 interface toughness, and an increased residual surface stress, which does not support the hypothesis that the ion exchange process is directly responsible for the increased creep resistance of the DRA composite. We propose instead that deep diffusion of the Al atoms into MgAl2O4, resulting in the formation of γ-Al2O3 nanograins, is the mechanism that impedes dislocation movement and thus increases the interface toughness.

[A pilot study on adolescents of both sexes. Correlation between phenotype, athletic performances and family history to type 2 diabetes]

The authors have studied the influence of family history of type 2 diabetes on the physical phenotype of 47 health adolescents. In both sexes groups with positive family history (FH+) had the highest values of stature and body weight (P<0.05 for males, not significant for females), waist circumference (P<0.05 for males, not significant for females), and wrist circumference (P=0.05 for males, not significant for females). Considering athletic performance, FH+ males showed a significant higher performance in power exercises than FH- males; no significant differences were found between FH+ and FH- female groups. The study confirms that family history of type 2 diabetes can induce in both sexes precocious phenotype and athletic performances linked-related variations; larger studies are necessary to confirm these data and to verify preventive interventions promoting significant life-style changes.

Molecular dynamics studies of the dissociated screw dislocation in silicon

Characterizing the motion of dislocations through covalent, high Peierls barrier materials is a key problem in materials science, while despite the progress in experimental studies the actual observation of the atomistic behaviour involved in core migration remains limited. We have applied a hybrid embedding scheme to investigate the dissociated screw dislocation in silicon, consisting of two 30° partials separated by a stacking fault ribbon, under the influence of a constant external strain. Our 'learn on the fly' hybrid technique allows us to calculate the forces on atoms in the vicinity of the core region using the tight binding Kwon potential, whilst the remainder of the bulk matrix is treated within a classical approximation. Applying a 5% strain to the dissociated screw dislocation, for a simulation time of 100 ps at a temperature of 600 K, we observe movement of the partials through two different mechanisms: double kink formation and square ring diffusion at the core. Our results suggest that in these conditions, the role of solitons or anti-phase defects in seeding kink formation and subsequent migration is an important one, which should be taken into account in future studies.

Investigating genetic diversity and habitat dynamics in Plantago brutia (Plantaginaceae), implications for the management of narrow endemics in Mediterranean mountain pastures

Many factors have contributed to the richness of narrow endemics in the Mediterranean, including long-lasting human impact on pristine landscapes. The abandonment of traditional land-use practices is causing forest recovery throughout the Mediterranean mountains, by increasing reduction and fragmentation of open habitats. We investigated the population genetic structure and habitat dynamics of Plantago brutia Ten., a narrow endemic in mountain pastures of S Italy. Some plants were cultivated in the botanical garden to explore the species' breeding system. Genetic diversity was evaluated based on inter-simple sequence repeat (ISSR) polymorphisms in 150 individuals from most of known stands. Recent dynamics in the species habitat were checked over a 14-year period. Flower phenology, stigma receptivity and experimental pollinations revealed protogyny and self-incompatibility. With the exception of very small and isolated populations, high genetic diversity was found at the species and population level. amova revealed weak differentiation among populations, and the Mantel test suggested absence of isolation-by-distance. Multivariate analysis of population and genetic data distinguished the populations based on genetic richness, size and isolation. Landscape analyses confirmed recent reduction and isolation of potentially suitable habitats. Low selfing, recent isolation and probable seed exchange may have preserved P. brutia populations from higher loss of genetic diversity. Nonetheless, data related to very small populations suggest that this species may suffer further fragmentation and isolation. To preserve most of the species' genetic richness, future management efforts should consider the large and isolated populations recognised in our analyses.

Exposure setup to study potential adverse effects at GSM 1800 and UMTS frequencies on the auditory systems of rats

To investigate possible biological effects of exposure to electromagnetic (EM) fields at the frequencies of global system for mobile communication (GSM) 1800 system and universal mobile telecommunication system (UMTS) on the auditory system of rats, an exposure setup for in vivo experiments is presented. The study was carried out in the framework of two European research projects. The target of the investigation was the cochlea. A dosimetric study was performed, both numerically and through direct measurements, to assess the interaction of the radiated fields and the dose distribution in the biological target. For the local exposure of rats, a loop antenna operating at the frequency bands of interest was designed, realised and characterised through numerical and experimental dosimetric procedures. Moreover, an exposure apparatus was set up, consisting of three arrays of four loop antennas, placed on three levels, thus allowing simultaneous exposure of 12 rats to give statistical power to the experiments. To isolate the exposure arrays, the setup was assembled by a wooden rack with EM field absorbing panels, inserted among the levels and at the four sides of the rack. Isolation was verified by direct measurements. Two exposure arrays were simultaneously supplied, whereas the third one was used for sham exposure. Blind exposure was achieved through a black box, hiding physical connections to the microwave power supply. During exposure sessions, rats were restrained in special plastic jigs for repeatable positioning, thus assuring the fixed level of dose in the target.

"Learn on the fly": a hybrid classical and quantum-mechanical molecular dynamics simulation

We describe and test a novel molecular dynamics method which combines quantum-mechanical embedding and classical force model optimization into a unified scheme free of the boundary region, and the transferability problems which these techniques, taken separately, involve. The scheme is based on the idea of augmenting a unique, simple parametrized force model by incorporating in it, at run time, the quantum-mechanical information necessary to ensure accurate trajectories. The scheme is tested on a number of silicon systems composed of up to approximately 200 000 atoms.

Mesoscopic chiral reshaping of the Ag(110) surface induced by the organic molecule PVBA

We report scanning tunneling microscopy observations on the restructuring of a Ag(110) surface induced by the molecule 4-[trans-2-(pyrid-4-yl-vinyl)]benzoic acid (PVBA). Our data reveal that the surface undergoes a mesoscopic step faceting following exposure to submonolayer coverages and thermal activation. A sawtooth arrangement evolves implying long-range mass transport of substrate atoms and forming a regular arrangement of kink sites. Its formation is associated with the molecules' functional headgroups forming carboxylates with [100] Ag microfacets at step edges, and eventually operating to reshape the surface morphology. Interestingly, the resulting microfacets act as chiral templates for the growth of supramolecular PVBA structures. Theoretical modeling based on ab initio results indicates that chiral recognition processes discriminating between the two enantiomers of adsorbed PVBA molecules occur in this process.

Adatom-vacancy mechanisms for the C6)/Al111-(6 x 6) reconstruction

The irreversible (6x6) reconstruction of the C(60)/Al(111) system from the (2sqrt[3]x2sqrt[3])R30 degrees phase is studied by first-principles techniques. We find that C60 binds optimally to the surface if an Al vacancy is created directly underneath. The removed Al atoms form a (6x6) array of ad-dimers in the interstices below the C60 overlayer, to which they strongly bind. This spontaneous local process, rather than the compression state of the unreconstructed C60 overlayer, explains why one molecule out of three protrudes from the surface upon reconstruction.

Insulator at the ultrathin limit: MgO on Ag(001)

The electronic structure and morphology of ultrathin MgO films epitaxially grown on Ag(001) were investigated using low-temperature scanning tunneling spectroscopy and scanning tunneling microscopy. Layer-resolved differential conductance (dI/dU) measurements reveal that, even at a film thickness of three monolayers, a band gap of about 6 eV is formed corresponding to that of the MgO(001) single-crystal surface. This finding is confirmed by layer-resolved calculations of the local density of states based on density functional theory.

Mesoscopic correlation of supramolecular chirality in one-dimensional hydrogen-bonded assemblies

The ordering of 4-[trans-2-(pyrid-4-yl-vinyl)] benzoic acid, a two-dimensional chiral species, was studied by scanning tunneling microscopy at noble metal surfaces. Homochiral molecules self-assemble in supramolecular chiral hydrogen-bonded twin chains, which order in nanogratings where the supramolecular chirality is strictly correlated over the entire microm domains without intimate molecular contact. Model simulations indicate that the underlying mesoscopic chiral resolution is associated with twin chains acting as chiroselective templates for transient molecular attachment, which process mediates the gratings' evolution.

Initial nucleation of platinum clusters after reduction of K(2)PtCl(4) in aqueous solution: a first principles study

The initial nucleation of platinum clusters after the reduction of K(2)PtCl(4) in aqueous solution is studied by means of first principles molecular dynamics simulations. A reaction mechanism leading to a Pt dimer is revealed both by gas-phase simulations and by simulations which model the solution environment. The key step of the observed reaction process is the formation of a Pt-Pt bond between a Pt(I) complex and an unreduced Pt(II) complex. In light of this result, we discuss the reduction process leading to the formation of platinum nanoparticles. In the generally accepted model, the nucleation of Pt particles starts only when a critical concentration of Pt(0) atoms is reached. Here, we discuss a complementary mechanism where metal-metal bonds form between Pt complexes in higher oxidation states. This is consistent with a number of experimental results which show that a high concentration of zerovalent atoms is not necessary to start the nucleation.

[Forme fruste of Gorlin's syndrome with a left ventricular neoplasm]

We report on a 25-year-old man, referred for atypical chest pain and negative T waves in leads V5-V6. A cardiac tumor, localized in the posterolateral left ventricular wall was diagnosed in this patient by nuclear techniques and bidimensional echocardiography. A complex form of pluridistrectual dysmorphic disorder (hypertelorism, prognathism, frontal bossing, multiple cysts of the mandible, calcification in falx cerebri, etc) was also present, suggesting a limited form of Gorlin's syndrome (nevoid basal cell carcinoma syndrome).

Importance of showing HBsAg and HBcAg positivity in the liver for better aetiological definition of chronic liver disease

Serum and tissue hepatitis B virus (HBV) markers were compared in 35 alcoholic and 23 non-alcoholic subjects affected by chronic liver disease. Seventeen point one per cent of alcoholic and 21.7% of non-alcoholic subjects had HBV tissue markers, but not serum markers, for this virus. It is therefore concluded that showing the presence of HBV tissue markers permits a better aetiological definition of hepatitis B surface antigen (HBsAg) negative chronic liver disease, both in alcoholic and non-alcoholic subjects.