Comparative efficacy of non-statin lipid-lowering therapies in patients with hypercholesterolemia at increased cardiovascular risk: a network meta-analysis

OBJECTIVE

Network meta-analysis was used to derive estimates of the relative efficacy of inclisiran, evolocumab, alirocumab, bempedoic acid, and ezetimibe in patients with hypercholesterolemia and/or at increased cardiovascular risk due to elevated low-density lipoprotein cholesterol taking maximum tolerated dose statins.

METHODS

Clinical trials published through February 2021 comparing percent change from baseline in low-density lipoprotein cholesterol were identified via a systematic review. Bayesian network meta-analyses were performed for patients with atherosclerotic cardiovascular disease and/or high cardiovascular risk on maximally tolerated statins in the base case, which included 23 trials.

RESULTS

Results from the base-case analyses demonstrated that inclisiran, evolocumab, and alirocumab provide superior efficacy over placebo, bempedoic acid, and ezetimibe in terms of reduction in low-density lipoprotein cholesterol. Inclisiran was also comparable to alirocumab (mean difference: 0.78% [95% CrI: -8.35, 9.88]) and evolocumab (8.16%, [95% CrI: -1.82, 18.49]). Findings of a scenario which also included trials conducted in patients with heterozygous familial hypercholesterolemia were consistent with the base case. There was evidence of statistical heterogeneity across the included trials, roughly equivalent to variation of 5-10% change in low-density lipoprotein cholesterol, suggesting that any differences between treatments that were greater than 5-10% are generalizable.

CONCLUSIONS

This study provides insight regarding the comparative efficacy of drugs for which no head-to-head trials exist and suggests that inclisiran, alirocumab, and evolocumab are expected to provide similar clinically meaningful improvements in low-density lipoprotein cholesterol in patients with hypercholesterolemia on maximally tolerated statins who are at increased cardiovascular risk.

Fasting plasma glucose to avoid a full OGTT in the diagnosis of gestational diabetes

AIMS

To evaluate the performance of fasting plasma glucose (FPG) in determining the need for a full oral glucose tolerance test (OGTT) to diagnose gestational diabetes (GDM) by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria.

METHODS

A multicenter cohort study of 4926 pregnant women 20 years or older consecutively enrolled in prenatal care clinics of the Brazilian National Health Service from 1991 to 1995. All women underwent a single 2 h 75 g OGTT by weeks 24-28 of pregnancy and were followed to detect adverse pregnancy outcomes.

RESULTS

A FPG cut-off value of 80 mg/dl indicated that only 38.7% of all women needed to undergo a complete OGTT, while detecting 96.9% of all GDM cases. When the 85 mg/dl cut-off was used, the corresponding percentages were 18.7% and 92.5%, respectively. The fraction of women labeled with GDM who had adverse pregnancy outcomes was nearly identical when using FPG strategies and universal full testing.

CONCLUSIONS

Using a FPG cut-off to diagnose GDM and to determine the need for post-load OGTT measurements is a valid strategy to diagnose GDM by IADPSG criteria. This approach may improve feasibility of applying IADPSG diagnostic criteria by reducing costs and increasing convenience.

[Acute jaw-thoracic pain and syncope in a 41-year-old man]

A 41-year-old physically active man with no significant past medical history presented with sudden thoracic pain. The patient was referred to the next tertiary care hospital. A CT scan showed an ectasia of the ascending aorta with irregularities of the aortic wall without dissection. Despite initial refusal, the patient was referred to a university hospital with experience in aortic surgery. A triphase ECG-synchronized cardiothoracic flash protocol performed on a 256 line CT scanner confirmed an aortic intramural hematoma and a covered aortic perforation. Shortly afterwards the patient collapsed and had to be resuscitated.

Synthesis and structure-activity relationship of trisubstituted thiazoles as Cdc7 kinase inhibitors

The Cell division cycle 7 (Cdc7) protein kinase is essential for DNA replication and maintenance of genome stability. We systematically explored thiazole-based compounds as inhibitors of Cdc7 kinase activity in cancer cells. Our studies resulted in the identification of a potent, selective Cdc7 inhibitor that decreased phosphorylation of the direct substrate MCM2 in vitro and in vivo, and inhibited DNA synthesis and cell viability in vitro.

The optimization of aminooxadiazoles as orally active inhibitors of Cdc7

A series of aminooxadiazoles was optimized for inhibition of Cdc7. Early lead isoquinoline 1 suffered from modest cell potency (cellular IC50=0.71 μM measuring pMCM2), low selectivity against structurally related kinases, and high IV clearance in rats (CL=18 L/h/kg). Extensive optimization resulted in azaindole 26 (Cdc7 IC50=1.1 nM, pMCM2 IC50=32 nM) that demonstrated robust lowering of pMCM2 in a mouse pharmacodynamic (PD) model when dosed orally. Modifications to improve the pharmacokinetic profile of this series were guided by trapping experiments with glutathione in rat hepatocytes.

[Migration of a retained intra-abdominal foreign body into the colon]

Even in the era of correct precautions and risk management culture adverse and preventable adverse events, such as intraoperatively residual foreign bodies remain a hot topic. Due to legal considerations and possible image loss many cases may remain unpublished leading to an underestimation of the real incidence in literature. The following casuistic is an example for a rarely documented and in this case a partial migration of a retained surgical sponge into the colon. The causes for the delayed foreign body detection, accounting for the relative good health even during chemoradiotherapy are analyzed in order to sharpen the awareness of such serious complications.

MRI-based breast volumetry-evaluation of three different software solutions

As lipofilling of the female breast is becoming more popular in plastic surgery, the use of MRI to assess breast volume has been employed to control postoperative results. Therefore, we sought to evaluate the accuracy of magnetic resonance imaging (MRI)-based breast volumetry software tools by comparing the measurements of silicone implant augmented breasts with the actual implant volume specified by the manufacturer. MRI-based volume analysis was performed in eight bilaterally augmented patients (46 ± 9 years) with three different software programs (Brainlab© I plan 2.6 neuronavigation software; mass analysis, version 5.3, Medis©; and OsiriX© v.3.0.2. 32-bit). The implant volumes analysed by the BrainLab© software had a mean deviation of 2.2 ± 1.7% (r = 0.99) relative to the implanted prosthesis. OsiriX© software analysis resulted in a mean deviation of 2.8 ± 3.0% (r = 0.99) and the Medis© software had a mean deviation of 3.1 ± 3.0% (r = 0.99). Overall, the volumes of all analysed breast implants correlated very well with the real implant volumes. Processing time was 10 min per breast with each system and 30 s (OsiriX©) to 5 min (BrainLab© and Medis©) per silicone implant. MRI-based volumetry is a powerful tool to calculate both native breast and silicone implant volume in situ. All software solutions performed well and the measurements were close to the actual implant sizes. The use of MRI breast volumetry may be helpful in: (1) planning reconstructive and aesthetic surgery of asymmetric breasts, (2) calculating implant size in patients with missing documentation of a previously implanted device and (3) assessing post-operative results objectively.

Consistent behavioral phenotype differences between inbred mouse strains in the IntelliCage

The between-laboratory effects on behavioral phenotypes and spatial learning performance of three strains of laboratory mice known for divergent behavioral phenotypes were evaluated in a fully balanced and synchronized study using a completely automated behavioral phenotyping device (IntelliCage). Activity pattern and spatial conditioning performance differed consistently between strains, i.e. exhibited no interaction with the between-laboratory factor, whereas the gross laboratory effect showed up significantly in the majority of measures. It is argued that overall differences between laboratories may not realistically be preventable, as subtle differences in animal housing and treatment will not be controllable, in practice. However, consistency of strain (or treatment) effects appears to be far more important in behavioral and brain sciences than the absolute overall level of such measures. In this respect, basic behavioral and learning measures proved to be highly consistent in the IntelliCage, therefore providing a valid basis for meaningful research hypothesis testing. Also, potential heterogeneity of behavioral status because of environmental and social enrichment has no detectable negative effect on the consistency of strain effects. We suggest that the absence of human interference during behavioral testing is the most prominent advantage of the IntelliCage and suspect that this is likely responsible for the between-laboratory consistency of findings, although we are aware that this ultimately needs direct testing.

Palladium-catalyzed chemoselective monoarylation of hydrazides for the synthesis of [1,2,4]triazolo[4,3-a]pyridines

An efficient and convenient method for the synthesis of [1,2,4]triazolo[4,3-a]pyridines was exemplified by the synthesis of 20 analogues bearing a variety of substituents at the 3-position. The methodology involves a palladium-catalyzed addition of hydrazides to 2-chloropyridine, which occurs chemoselectively at the terminal nitrogen atom of the hydrazide, followed by dehydration in acetic acid under microwave irradiation.

Discovery and optimization of chromenotriazolopyrimidines as potent inhibitors of the mouse double minute 2-tumor protein 53 protein-protein interaction

Tumor protein 53 (p53) is a critical regulator of cell cycle and apoptosis that is frequently disabled in human tumors. In many tumor types, p53 is deleted or mutated, but in others p53 is inactivated by overexpression or amplification of its negative regulator mouse double minute 2 (MDM2). A high-throughput screening effort identified 6,7-bis(4-bromophenyl)-7,12-dihydro-6H-chromeno[4,3-d][1,2,4]triazolo[1,5-a]pyrimidine as a potent inhibitor of the MDM2-p53 protein-protein interaction. This screening hit was found to be chemically unstable and difficult to handle due to poor DMSO solubility. Co-crystallization with the target protein helped to direct further optimization and provided a tractable lead series of novel MDM2-p53 inhibitors. In cellular assays, these compounds were shown to upregulate p53 protein levels and p53 signaling and to cause p53-dependent inhibition of proliferation and apoptosis.

An aldol-based synthesis of (+)-peloruside a, a potent microtubule stabilizing agent

A convergent synthesis of the marine natural product (+)-peloruside has been reported. This target has been assembled through the successive application of two methyl ketone boron aldol addition reactions to the latent C(7)-C(11) dialdehyde synthon. This approach afforded a 22-step synthesis of this natural product. The influence of resident stereocenters on aldol reaction diastereoselection has been examined in detail.

Discovery of highly selective and potent p38 inhibitors based on a phthalazine scaffold

Investigations into the structure-activity relationships (SAR) of a series of phthalazine-based inhibitors of p38 are described. These efforts originated from quinazoline 1 and through rational design led to the development of a series of orally bioavailable, potent, and selective inhibitors. Kinase selectivity was achieved by exploiting a collection of interactions with p38alpha including close contact to Ala157, occupation of the hydrophobic gatekeeper pocket, and a residue flip with Gly110. Substitutions on the phthalazine influenced the pharmacokinetic properties, of which compound 16 displayed the most desirable profile. Oral dosing (0.03 mg/kg) of 16 in rats 1 h prior to LPS challenge gave a >50% decrease in TNFalpha production.

Isovist analysis captures properties of space relevant for locomotion and experience

In a series of exploratory experiments we investigated interrelations between structure and shape of architectural indoor spaces on the one hand, and affective experience and navigation behaviour on the other hand. For this, isovist-based descriptions of 16 virtual indoor scenes were correlated with behavioural data from the experimental tasks. For all tasks-two active navigation tasks and an introspective appraisal of experiential qualities--strong correlations between subjects' behaviour and a small set of quantitative measurands derived from the isovists were found. The outcomes suggest that isovist analysis captures behaviourally relevant properties of space and is therefore a promising general means for predicting central experiential qualities of architecture and navigation behaviour.

Synthesis and properties of cyclopropane-derived peptidomimetics

Small peptides exhibit a wide range of biological activities, but although there are some notable exceptions, they are not generally useful as drugs. This has spurred widespread interest in designing peptidomimetics and introducing them as replacements of portions of native peptides to enhance their biological properties. Special attention has been focused upon rigid replacements because of their potential to preorganize the resulting pseudopeptide in a conformation corresponding to its bound structure. Toward this goal, we invented trisubstituted cyclopropanes as novel peptidomimetics, anticipating that the cyclopropane ring would locally orient the backbone and the corresponding amino acid side chain in the biologically active conformation. Selected aspects of the syntheses and applications of these cyclopropane-derived peptidomimetics are presented in this Account.

Skeletal metastasis in tricholemmal carcinoma

Tricholemmal carcinoma is an extremely rare cutaneous adnexal tumor, not exceeding 1-2 cm in diameter in some reported cases. The few reports describe only a greater histologic malignancy. Some cases of recurrences have been reported, and metastasis of the soft tissue was described once by Amaral et al in 1984. In the current patient with tricholemmal carcinoma of the right distal thigh, the primary tumor was unusually large. The first detected metastasis was localized in the right inguinal lymph nodes. Five years after diagnosis of tricholemmal carcinoma a metastasis of the left tibia and fibula were diagnosed. To our knowledge, an osseous metastasis in tricholemmal carcinoma has not been described. It is possible that a relationship between the extraordinary size and the osseous metastasis exists in the current patient.

[Aplasia of the posterior tibial artery in a child with idiopathic clubfoot]

A case of a completely absent posterior tibial artery discovered during a procedure for congenital clubfoot correction in a 6 month old male infant is reported. Anomalies of the anterior tibial artery associated with the clubfoot-deformity are common, the absence of the posterior tibial artery is, however, very rare.

[Proven and unproven hygiene measures in orthopedics]

Postoperative wound infections develop in approximately 2-5% of all patients after orthopedic surgery. After urinary tract infection and pneumonia, such wound infections (15%) are the third most frequent type of hospital-acquired infection. In this review we summarize all proven and unproven hygiene measures available in orthopedics, giving special attention to those implemented with the aim of preventing and controlling postoperative wound infections. Routine application only of hygiene procedures of proven efficacy will be an important contribution to economic and ecological quality assurance in hospital.

Design, synthesis, and evaluation of matrix metalloprotease inhibitors bearing cyclopropane-derived peptidomimetics as P1' and P2' replacements

We have previously used trisubstituted cyclopropanes as peptide replacements to induce conformational constraints in known pseudopeptide inhibitors of a number of important enzymes. Cyclopropane-derived peptide mimics are novel in that they are among the few replacements that locally orient the peptide backbone and the amino acid side chain in a predefined manner. Although these dipeptide isosteres have been employed to orient amino acid side chains mimicking the gauche(-) conformation of chi(1)-space, their ability to project the side chains into an anti orientation has not been evaluated. As a first step toward this goal, the conformationally constrained pseudopeptides 8 and 10 and their corresponding flexible analogues 9 and 11 were prepared and tested as inhibitors of matrix metalloproteinases (MMPs). These compounds are analogues of 4 and 5, which were known to be potent MMP inhibitors. The anti orientations of the isopropyl side chain in 8 and the aromatic ring in 10 relative to the peptide backbone substituents on the cyclopropane were predicted to correspond to the known orientations of the P1' and P2' side chains of 5 when bound to MMPs. Hence, 8 and 10 were designed explicitly to probe topological features of the S1' or the S2' binding pockets of the MMPs. They were also designed to explore the importance of the P1'-P2' amide group, which is known to form highly conserved hydrogen bonds in several MMP-inhibitor complexes, and the viability of introducing a retro amide linkage between P2' and P3'. Pseudopeptides 8 and 9 were found to be weak competitive inhibitors of a series of MMPs. Any entropically favorable conformational constraints that were induced by the cyclopropane in 8 were thus overwhelmed by the loss of the hydrogen bonding capability associated with the P1'-P2' amide group. On the other hand, compounds 10 and 11, which contain a P2'-P3' retro amide group, were modest competitive inhibitors of a series of MMPs. The results obtained for 10 and 11 suggest that there may be a loss of hydrogen bonding capability associated with introducing the P2'-P3' retro amide group. However, because the conformationally constrained pseudopeptide 10 was significantly more potent than its flexible analogue 11, trisubstituted cyclopropanes related to 3 may serve as useful rigid dipeptide replacements in some biologically active pseudopeptides.

The operative treatment of full thickness cartilage defects in the knee joint with autologous chondrocyte transplantation

OBJECTIVE

The high clinical and socio-economical impact of cartilage defects and chondral degeneration is well-known. After trauma or without a known etiology, often young patients suffer from pain and a loss of function leading into a decrease of physical activity and, more severe, into long term disability and unemployment. The clinical use of autologous chondrocyte transplantation was introduced in 1994 reporting the data of a pilot study. The objective of this study is to evaluate the efficacy of this method of surgery.

METHODS

Autologous chondrocyte transplantation has been established in our department since 1995 for the treatment of large, full thickness cartilage defects which can be completely covered with hyaline-like cartilage without harming the subchondral bone plate. Our first patients (n=24) all showed Grade IV lesions and an average defect size of 6.27 cm2. All but 4 of the patients had at least 1 cartilage defect related operation on the knee.

RESULTS

The patients and the clinicians rating indicated an increase of a modified Cincinnati Knee score from 3.6 point pre-operation to 6.9 points after 6 months and 8.1 points at 12 months on a scale from 1 (bad) to 10 (excellent). These results support the data of an international multicenter study with almost 2000 patients. The 5 year results described by the originate authors are good to excellent in 85%-95% with an adverse event rate of 5%.

CONCLUSION

Autologous chondrocyte transplantation has to be considered a safe and effective method for the treatment of large full thickness cartilage defects. Alternative treatments are symptomatical: drilling, abrasion, lavage, chondroplasty, or osteotomies. The short term results are promising but a lot of patients have to be treated for osteoarthritis as a consequence of failure with total joint arthroplasty. Osteochondral transplantations have the disadvantage of limited harvesting sites and the impairment of the subchondral bone plate.

Arthroscopic management of osteochondral lesions of the talus: results of drilling and usefulness of magnetic resonance imaging before and after treatment

Since the advent of operative ankle arthroscopy and magnetic resonance imaging (MRI) specific treatment of osteochondritis dissecans of the talus has progressed rapidly. Drilling is still the treatment of choice in early stages of osteochondritis dissecans of the talus. Rear-entry guides and preoperative planning with MRI have led to better results with this kind of treatment. Within 5 years, 42 patients (26 male and 16 female) underwent arthroscopic treatment of osteochondritis dissecans of the talus, 22 underwent percutaneous drilling, 13 cancellous bone grafting, 4 refixation, and 3 curettage. The average age of the patients was 28 years (range, 11 to 53 years). A clinical score system was used in a clinical and MRI follow-up of 19 of the patients with K-wire drilling. Up to 100 points are given in the categories pain, stability/insecurity, efficiency/pain-free walking distance, gait, differences in circumference, range of motion, and power. There was a history of trauma in 31 of the 42 patients. The majority of lesions (24 cases) were localized at the lateral talus, and these patients all had trauma. In 11 of the 18 lesions at the medial talus, there was no evidence of trauma. The 19 patients in the follow-up achieved an average of 87 points. K-wire drilling represents the chief component of early stages with intact or partially fractured cartilage surface, whereas arthroscopically controlled cancellous bone grafts after curettage are used in grade II stages only. Results of K-wire drilling are not worse than those of cancellous bone grafts; this is attributable to a generous perforation of the sclerosis. This has contributed to an improved preoperative diagnosis with MRI.

Postoperative ossifications of the shoulder. Incidence and clinical impact

Periarticular ossifications of the shoulder after surgery have been described since the beginning of the century. Risk factors and the clinical impact of heterotopic bone formation have been discussed controversially. After open surgery on the shoulder, 131 patients (rotator cuff repair n = 106, acromioplasty n = 25) were included in a retrospective study if pre- and postoperative X-rays were available. The age of the 90 men and 41 women averaged 51 years (range 29-67 years). The minimum follow-up was 2 years. Also, 108 patients were interviewed by questionnaire to estimate the subjective outcome of the procedure (5 patients were reported dead). A clinical examination was carried out on 86 patients using the Constant score for evaluation of the objective outcome. Heterotopic ossifications were found in 35 cases (26.7%), 28 of them after rotator cuff reconstruction and 7 after acromioplasty. A good to excellent result was reported by 89% (n = 65) of the patients without and by 80% (n = 28) of the patients with ossifications. The Constant score averaged 69 points and 74 points (n = 60), respectively. A significant difference between the two collectives could not be calculated. As significant risk factors for the formation of heterotopic bone, the existence of osteoarthritis and the duration and complexity of the procedure could be cited. The appearance of periarticular ossifications after surgery of the shoulder seems to be of minor clinical impact. Severe cases with major functional deficits should and can be prevented by a fast and atraumatic operation technique.