Bone canonical Wnt signaling is downregulated in type 2 diabetes and associates with higher advanced glycation end-products (AGEs) content and reduced bone strength

Type 2 diabetes (T2D) is associated with higher fracture risk, despite normal or high bone mineral density. We reported that bone formation genes (SOST and RUNX2) and advanced glycation end-products (AGEs) were impaired in T2D. We investigated Wnt signaling regulation and its association with AGEs accumulation and bone strength in T2D from bone tissue of 15 T2D and 21 non-diabetic postmenopausal women undergoing hip arthroplasty. Bone histomorphometry revealed a trend of low mineralized volume in T2D (T2D 0.249% [0.156-0.366]) vs non-diabetic subjects 0.352% [0.269-0.454]; p=0.053, as well as reduced bone strength (T2D 21.60 MPa [13.46-30.10] vs non-diabetic subjects 76.24 MPa [26.81-132.9]; p=0.002). We also showed that gene expression of Wnt agonists LEF-1 (p=0.0136) and WNT10B (p=0.0302) were lower in T2D. Conversely, gene expression of WNT5A (p=0.0232), SOST (p<0.0001), and GSK3B (p=0.0456) were higher, while collagen (COL1A1) was lower in T2D (p=0.0482). AGEs content was associated with SOST and WNT5A (r=0.9231, p<0.0001; r=0.6751, p=0.0322), but inversely correlated with LEF-1 and COL1A1 (r=-0.7500, p=0.0255; r=-0.9762, p=0.0004). SOST was associated with glycemic control and disease duration (r=0.4846, p=0.0043; r=0.7107, p=0.00174), whereas WNT5A and GSK3B were only correlated with glycemic control (r=0.5589, p=0.0037; r=0.4901, p=0.0051). Finally, Young's modulus was negatively correlated with SOST (r=-0.5675, p=0.0011), AXIN2 (r=-0.5523, p=0.0042), and SFRP5 (r=-0.4442, p=0.0437), while positively correlated with LEF-1 (r=0.4116, p=0.0295) and WNT10B (r=0.6697, p=0.0001). These findings suggest that Wnt signaling and AGEs could be the main determinants of bone fragility in T2D.

Irisin inhibits tenocyte response to inflammation in vitro: New insights into tendon-muscle cross-talk

Tendinopathy is one of the most common musculoskeletal disorders with significant repercussions on quality of life and sport activities. Physical exercise (PE) is considered the first-line approach to treat tendinopathy due renowned mechanobiological effects on tenocytes. Irisin, a recently identified myokine released during PE, has been recognized for several beneficial effects towards muscle, cartilage, bone, and intervertebral disc tissues. The aim of this study was to evaluate the effects of irisin on human primary tenocytes (hTCs) in vitro. Human tendons were harvested from specimens of patients undergoing anterior cruciate ligament reconstruction (n = 4). After isolation and expansion, hTCs were treated with RPMI medium (negative control), interleukin (IL)-1β or tumor necrosis factor-α (TNF-α) (positive controls; 10 ng/mL), irisin (5, 10, 25 ng/mL), IL-1β or TNF-α pretreatment and subsequent co-treatment with irisin, pretreatment with irisin and subsequent co-treatment with IL-1β or TNF-α. hTC metabolic activity, proliferation, and nitrite production were evaluated. Detection of unphosphorylated and phosphorylated p38 and ERK was performed. Tissue samples were analyzed by histology and immunohistochemistry to evaluate irisin αVβ5 receptor expression. Irisin significantly increased hTC proliferation and metabolic activity, while reducing the production of nitrites both before and after the addition of IL-1β and TNF-α. Interestingly, irisin reduced p-p38 and pERK levels in inflamed hTCs. The αVβ5 receptor was uniformly expressed on hTC plasma membranes, supporting the potential binding of irisin. This is the first study reporting the capacity of irisin to target hTCs and modulating their response to inflammatory stresses, possibly orchestrating a biological crosstalk between the muscle and tendon.

The burden of low back pain in children and adolescents with overweight and obesity: from pathophysiology to prevention and treatment strategies

Nonspecific low back pain (LBP) is one of the most common causes of disability, affecting all individuals at least once in their lifetime. Such a condition is also becoming increasingly frequent in the pediatric population, especially in children and adolescents with overweight/obesity. Furthermore, new-onset LBP during adolescence has been demonstrated to be a strong predictor of developing LBP later in life, contributing to poorer outcomes and increasing social and medical costs. Several causes and different mechanisms have been considered for the development of LBP in pediatric individuals affected by obesity. For this reason, planning adequate prevention and treatment strategies, mainly through conservative lifestyle changes, would be crucial to anticipate the negative consequences of persisting LBP in adulthood. The aim of this narrative review was to characterize the relationship between LBP and overweight/obesity in the pediatric population, highlighting epidemiological and pathophysiological aspects. In addition, prevention and treatment approaches will be reviewed considering the need to reduce the burden of LBP on this population. According to our search, LBP was more frequent in children and adolescents with overweight and obesity and has been associated with several anthropometric and lifestyle factors, including lumbar hyperlordosis, sedentary habits, physical inactivity, carrying a heavy schoolbag, low vitamin D levels, psychosocial ill-being, and premature intervertebral disc degeneration. Most of these conditions may be addressed with conservative strategies mainly consisting of dietary adjustments, physical exercise, education programs, and physical therapy.

Oxidative Stress in Postmenopausal Women with or without Obesity

Oxidative stress, a key mediator of cardiovascular disease, metabolic alterations, and cancer, is independently associated with menopause and obesity. Yet, among postmenopausal women, the correlation between obesity and oxidative stress is poorly examined. Thus, in this study, we compared oxidative stress states in postmenopausal women with or without obesity. Body composition was assessed via DXA, while lipid peroxidation and total hydroperoxides were measured in patient's serum samples via thiobarbituric-acid-reactive substances (TBARS) and derivate-reactive oxygen metabolites (d-ROMs) assays, respectively. Accordingly, 31 postmenopausal women were enrolled: 12 with obesity and 19 of normal weight (mean (SD) age 71.0 (5.7) years). Doubled levels of serum markers of oxidative stress were observed in women with obesity in women with obesity compared to those of normal weight (H₂O₂: 32.35 (7.3) vs. 18.80 (3.4) mg H₂O₂/dL; malondialdehyde (MDA): 429.6 (138.1) vs. 155.9 (82.4) mM in women with or without obesity, respectively; p < 0.0001 for both). Correlation analysis showed that both markers of oxidative stress increased with an increasing body mass index (BMI), visceral fat mass, and trunk fat percentage, but not with fasting glucose levels. In conclusion, obesity and visceral fat are associated with a greater increase in oxidative stress in postmenopausal women, possibly increasing cardiometabolic and cancer risks.

Micro-fragmented and nanofat adipose tissue derivatives: In vitro qualitative and quantitative analysis

Introduction: Adipose tissue is widely exploited in regenerative medicine thanks to its trophic properties, mainly based on the presence of adipose-derived stromal cells. Numerous devices have been developed to promote its clinical use, leading to the introduction of one-step surgical procedures to obtain minimally manipulated adipose tissue derivatives. However, only a few studies compared their biological properties. This study aimed to characterize micro-fragmented (MAT) and nanofat adipose tissue (NAT) obtained with two different techniques. Methods: MAT, NAT and unprocessed lipoaspirate were collected from surgical specimens. RNA extraction and collagenase isolation of stromal vascular fraction (SVF) were performed. Tissue sections were analysed by histological and immunohistochemical (collagen type I, CD31, CD34 and PCNA) staining to assess tissue morphology and cell content. qPCR was performed to evaluate the expression of stemness-related (SOX2, NANOG and OCT3/4), extracellular matrix (COL1A1) and inflammatory genes (IL1β, IL6 and iNOS). Furthermore, multilineage differentiation was assessed following culture in adipogenic and osteogenic media and staining with Oil Red O and Alizarin red. ASC immunophenotype was assessed by flow cytometric analysis of CD90, CD105, CD73 and CD45. Results: Histological and immunohistochemical results showed an increased amount of stroma and a reduction of adipocytes in MAT and NAT, with the latter displaying the highest content of collagen type I, CD31, CD34 and PCNA. From LA to MAT and NAT, an increasing expression of NANOG, SOX2, OCT3/4, COL1A1 and IL6 was noted, while no significant differences in terms of IL1β and iNOS emerged. No statistically significant differences were noted between NAT and SVF in terms of stemness-related genes, while the latter demonstrated a significantly higher expression of stress-related markers. SVF cells derived from all three samples (LA, MAT, and NAT) showed a similar ASC immunoprofile as well as osteogenic and adipogenic differentiation. Discussion: Our results showed that both MAT and NAT techniques allowed the rapid isolation of ASC-rich grafts with a high anabolic and proliferative potential. However, NAT showed the highest levels of extracellular matrix content, replicating cells, and stemness gene expression. These results may provide precious clues for the use of adipose tissue derivatives in the clinical setting.

A multicentric observational study of patients affected by advanced heart failure with implantable cardioverter defibrillator and left ventricular assist devices

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular assist device (LVAD) implantation is increasingly used in patients with end-stage heart failure. Most patients already have an implantable defibrillator (ICD) at the time of L-VAD implantation. Studies on this patient population are limited by the small sample size and the short duration of follow-up.

Purpose

The aim of this study was to retrospectively describe the real-world management of patients implanted with both ICD and LVAD. The main objective was to evaluate the incidence and predictors of appropriate and inappropriate therapies of the ICD and the incidence and predictors of ICD related complications.

Methods

212 patients were enrolled in four Centers in the period between July 2006 and November 2020. The inclusion criteria were age&gt; 18 years, advanced heart failure, patients with ICD and concomitant or subsequent continuous flow LVAD implantation. ICD therapy was defined as antitachycardia pacing therapy or shock.

The data available at the last visit with a median follow up of 21 months were analyzed.

Outcome predictors were assessed by univariate logistic regression and the variables of interest included in a multivariate model.

Results

The rate of appropriate ICD therapies was 29.7%, while the incidence of inappropriate therapies was 10.4%; in the multivariate analysis the presence of a zone therapy with low detection rate (VT zone with median detection rate of 164.5 bpm) was found to be an independent predictor of the composite of appropriate and inappropriate therapies (OR = 19.05; CI = 2.19-165.21; p = 0.007). Interference between ICD and LVAD occurred in 7.5% of cases; the incidence of infectious complications related to the ICD was 7.1% and bleeding complications of 5.2%; in the multivariate analysis, ICD generator replacement was an independent predictor of total complications related to the ICD (interference, infectious and bleeding; OR = 4.45; IC = 1.60-12.36; p = 0.004). 103 patients had CRT defibrillator (48,6%). At follow up there was no statistically significant difference in the incidence of appropriate therapies between those who had CRT-on (n=74) and those who had CRT-off (n=29; p = 0.61).

Conclusions

Patients with LVAD implanted with an ICD experience a high rate of appropriate and inappropriate ICD therapies. An active VT zone at low heart rate was found to be an independent predictor of ICD therapies. Of more, ICD generator replacement was found to be an independent predictor of total complications related to the ICD. Our findings suggest the importance of tailoring device programming in order to minimize the incidence of ICD therapies, thus sparing the need for generator replacement in this population.

C78 PREVALENCE AND MECHANISMS OF SEVERE MITRAL AND TRICUSPID REGURGITATION IN A HEART FAILURE OUTPATIENTS POPULATION

Introduction

Mitral regurgitation (MR) and tricuspid regurgitation (TR) are a known cause of morbidity and mortality in heart failure (HF) patients. Maximal up–titration of guideline–directed medical therapy (GDMT) for HF may not be enough to reduce the severity of the valve’s incompetence and patients’ symptoms. The development and successful results of transcatheter therapies for mitral/tricuspid disease have opened new therapeutic opportunities when surgery is not feasible. Accurate valve regurgitation’s mechanisms evaluation is essential to choose the best treatment option. This study aims at evaluating the prevalence and underlying mechanisms of at least moderate–to–severe (≥3+/4+) MR and/or TR in a cohort of HF outpatients.

Methods

We retrospectively analyzed the medical records of 1260 outpatients evaluated by our HF unit between January 2020 and June 2021. All patients with echocardiographic evidence of ≥ 3+/4+ MR and/or TR were included (treated ones were excluded), and a thorough echocardiographic images review was conducted. A full collection of patients’ clinical, laboratory and therapy regimens details was performed as well.

Results

Of the 1260 analyzed patients, 173 (13.7%) exhibited ≥3+/4+ MR and/or TR and were included in the registry. Table 1 shows the main clinical/echocardiographic characteristics. Mean age was 80±7 years, median ejection fraction was 45% (IQR=33–55). All patients were treated with maximal tolerated doses of GDMT and, if appropriate, with cardiac devices/myocardial revascularization. ≥3+/4+ MR and/or TR was observed in 92 (7.3%) and 117 (9.3%) patients, respectively. Patients with isolated significant MR were 56 (4.4%), with isolated significant TR were 81 (6.4%); the remaining 36 (2.8%) had both MR/TR. Among patients with significant MR, 50 (54%) had functional/secondary valvular defect (details in Figure 2): the majority (41,82%) presented a ventricular etiology (asymmetric tethering in 18/41) while 9 (18%) an atrial one (atriogenic tethering in 3/9).

Conclusion

Despite optimized GDMT, the prevalence of patients with hemodynamically significant valvular defects was considerably high in our HF population. This is the first registry to comprehensively detail atrioventricular valve regurgitations’ mechanisms in a wide real–life cohort of HF outpatients. Further studies are needed to identify reasons for potential undertreatment and patients who would benefit the most from percutaneous correction of their valvular defects.

The Association of Body Mass Index with Surgical Time Is Mediated by Comorbidity in Patients Undergoing Total Hip Arthroplasty

Overweight represents a major issue in contemporary orthopaedic practice. A higher body mass index (BMI) is associated with an increase of perioperative complications following several orthopaedic procedures, in particular total hip arthroplasty (THA). However, the influence of overweight on THA surgical time is controversial. In this study, we investigated the association between BMI and surgical time analyzing the role of patients’ comorbidities. We conducted a retrospective study on 748 patients undergoing THA at our institutions between 2017 and 2018. Information regarding medical diseases was investigated and the burden of comorbidity was quantified using the Charlson score (CCI). Surgical time and blood loss were also recorded. Median surgical time was 76.5 min. Patients with surgical time above the median had both a higher BMI (28.3 vs. 27.1 kg/m²; p = 0.002); and CCI (1 vs. 0; p = 0.016). According to linear regression, surgical time was associated with BMI in the unadjusted model (p < 0.0001), after adjusting for age and sex (p < 0.0001), and in the multivariable model (p = 0.005). Furthermore, BMI was associated with increased surgical time only in patients with a Charlson score above the median, but not in others. Obesity is associated with increased surgical time during THA, especially in pluricomorbid patients, with a higher risk of perioperative complications.

Clinical effects of early sacubitril/valsartan administration in patients with ST-segment elevation myocardial infarction: a systematic review and meta-analysis

Introduction

The combination of sacubitril, a neprilysin inhibitor and valsartan, an angiotensin receptor blocker, has been proven to be a game-changer in reducing morbidity and mortality in patients with chronic heart failure with reduced ejection fraction. Recent evidence regarding the early use of sacubutril/valsartan in patients after ST-segment Elevation Myocardial Infarction (STEMI) are emerging.

Purpose

To provide a comprehensive synthesis of effect estimates, we performed a systematic review and meta-analysis of randomized controlled trials (RCTs) directly comparing sacubitril/valsartan and an ACE-inhibitor early after successful primary percutaneous coronary intervention (pPCI) in patients presenting with STEMI

Methods

We searched the PubMed, EMBASE and Cochrane databases from inception to March 28, 2021 to identify RCTs that report clinical outcomes and compare sacubitril/valsartan versus an ACE-inhibitor in patients presenting with STEMI after pPCI. The primary efficacy endpoint was the risk of hospitalization for heart failure. Secondary efficacy endpoints were major adverse cardiac events (MACE) and left ventricle ejection fraction (LVEF). Safety endpoints were hypotension, hyperkalemia, worsening renal function and angioedema. Pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CIs) were used as summary statistics for endpoints of interest and were calculated using a random-effects model according to DerSimonian and Laird.

Results

A total of three studies with 493 patients randomly allocated to sacubitril/valsartan (n=247) or ACE-inhibitor (n=246) were included for analysis. Main study and patient characteristics are reported in figure1. Heterogeneity between studies was low. Individual trial definitions of MACE and adverse events were used in the analysis (figure 1). Sacubitril/valsartan was associated with a significant reduction in the risk of heart failure hospitalizations (RR, 0.55; 95% CI 0.39–0.79, P&lt;0.01, event rate 15.4% vs 28.5%, number needed to treat 8), MACE (RR, 0.64; 95% CI, 0.48–0.84, P&lt;0.01, event rate 20.2% vs 33.3%, number needed to treat 8), and with a significant improvement of LVEF (MD, 3.09; 95% CI, 1.70–4.49, P&lt;0.01), (figure 2). No significant difference was found between sacubitril/valsartan and ACE-inhibitors regarding the incidence of hypotension (RR, 1.42; 95% CI, 0.74–2.72, P=0.29), hyperkalemia (RR, 0.44; 95% CI 0.06–3.08, P=0.41) and worsening renal function (RR, 0.70; 95% CI 0.22–2.24, P=0.55), (figure2). No angioedema was observed in included studies.

Conclusion

This is the first systematic review and meta-analysis comparing sacubitril/valsartan and ACE inhibitors in STEMI patients. Based on the presented findings and larger data on the horizon, we may soon find sacubitril/valsartan to be an important addition to our arsenal in improving care to STEMI patients.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Italian Ministry of Education Figure 1Figure 2

Transcatheter aortic valve replacement in severe aortic stenosis and cardiac amyloidosis: a systematic review and meta-analysis

Background

Aortic stenosis (AS) and cardiac amyloidosis (CA) are typical degenerative diseases of the elderly. According to recent studies, up to 16% of patients referred to transcatheter aortic valve replacement (TAVR) have a concomitant diagnosis of CA. Until recently, TAVR in patients with CA and AS has been considered futile, following the results of small observational studies. However, few studies recently suggested a beneficial impact of TAVR in patients with AS and CA as compared with medical therapy alone.

Purpose

To clarify the efficacy and safety profile of TAVR in CA-AS patients.

Methods

We performed a systematic review and meta-analysis of studies evaluating the risk of mortality after TAVR in CA-AS patients as compared with medical therapy. Moreover, we performed a systematic review and descriptive meta-analysis of studies reporting outcomes and complication rates of TAVR in CA-AS patients as compared with patients with AS alone.

Results

We identified 4 observational studies reporting data on mortality in CA-AS patients treated with either TAVR or medical therapy. Mortality was significantly lower in patients undergoing TAVR (OR 0.23, 95% CI 0.07–0.73, I2=0%, NNT=2.6) as compared with medical therapy. A sensitivity analysis with hazard ratio as effect estimate showed consistent results. Then, we identified 4 observational studies reporting data on mortality, re-hospitalizations and periprocedural complications of TAVR in CA-AS patients as compared with patients with AS alone. We found higher rates of mortality, cardiovascular hospitalization and need for permanent pacemaker implantation in CA-AS patients as compared to lone AS patients undergoing TAVR. Conversely, no differences were found in terms of stroke, acute kidney injury and vascular complications.

Conclusions

Our analysis rejects the idea of futility of TAVR in CA-AS patients showing a clear survival benefit of CA-AS patients undergoing TAVR as compared with medical therapy. Moreover, these patients may undergo TAVR with an acceptable procedural risk, that is substantially comparable to lone AS patients, except for a higher incidence of permanent pacemaker implantation.

Funding Acknowledgement

Type of funding sources: None.

Weight Loss in Patients Waiting for Total Hip Arthroplasty: Fiber-Enriched High Carbohydrate Diet Improves Hip Function and Decreases Pain before Surgery

The impact of obesity on clinical outcomes following joint replacement procedures is resounding. Therefore, multiple strategies to achieve a substantial weight loss before surgery are needed in obese patients. The aim of the study was to test the effect of a fiber-enriched high carbohydrate (FEHC) diet on the reduction in body weight and pain in elderly obese patients undergoing total hip arthroplasty (THA). Sixty-one candidates for THA were included in our study. Prior to the procedure, the participants have been randomly assigned to a 3-month diet intervention (FEHC diet or free diet). Anthropometric measures and food questionnaires were collected at the enrollment and after 3 months. The Oxford Hip Score (OHS), the Hip disability and Osteoarthritis Outcome Score (HOOS) and the Western Ontario McMaster Universities OA Index (WOMAC) were administered at baseline and before surgery. A statistically significant variation of weight was found in the FEHC diet group (-3.7 kg, -4.4--2.5) compared to the control group (-0.2 kg; -1.4-1.7; p < 0.0001), as well as significant improvements in the OHS (p < 0.0001), the HOOS (p < 0.0001) and the WOMAC (p < 0.0001) questionnaires. According to the results of the study, the FEHC diet in obese patients undergoing THA might help weight loss and improve related anthropometric parameters as well as hip function and pain.

The impact of type 2 diabetes on the development of tendinopathy

Tendinopathy is a chronic and often painful condition affecting both professional athletes and sedentary subjects. It is a multi-etiological disorder caused by the interplay among overload, ageing, smoking, obesity (OB) and type 2 diabetes (T2D). Several studies have identified a strong association between tendinopathy and T2D, with increased risk of tendon pain, rupture and worse outcomes after tendon repair in patients with T2D. Moreover, consequent immobilization due to tendon disorder has a strong impact on diabetes management by reducing physical activity and worsening the quality of life. Multiple investigations have been performed to analyse the causal role of the individual metabolic factors occurring in T2D on the development of tendinopathy. Chronic hyperglycaemia, advanced glycation end-products, OB and insulin resistance have been shown to contribute to the development of diabetic tendinopathy. This review aims to explore the relationship between tendinopathy and T2D, in order to define the contribution of metabolic factors involved in the degenerative process and to discuss possible strategies for the clinical management of diabetic tendinopathy.

Sclerostin Regulation, Microarchitecture, and Advanced Glycation End-Products in the Bone of Elderly Women With Type 2 Diabetes

Increased circulating sclerostin and accumulation of advanced glycation end-products (AGEs) are two potential mechanisms underlying low bone turnover and increased fracture risk in type 2 diabetes (T2D). Whether the expression of the sclerostin-encoding SOST gene is altered in T2D, and whether it is associated with AGEs accumulation or regulation of other bone formation-related genes is unknown. We hypothesized that AGEs accumulate and SOST gene expression is upregulated in bones from subjects with T2D, leading to downregulation of bone forming genes (RUNX2 and osteocalcin) and impaired bone microarchitecture and strength. We obtained bone tissue from femoral heads of 19 T2D postmenopausal women (mean glycated hemoglobin [HbA1c] 6.5%) and 73 age- and BMI-comparable nondiabetic women undergoing hip replacement surgery. Despite similar bone mineral density (BMD) and biomechanical properties, we found a significantly higher SOST (p = .006) and a parallel lower RUNX2 (p = .025) expression in T2D compared with non-diabetic subjects. Osteocalcin gene expression did not differ between T2D and non-diabetic subjects, as well as circulating osteocalcin and sclerostin levels. We found a 1.5-fold increase in total bone AGEs content in T2D compared with non-diabetic women (364.8 ± 78.2 versus 209.9 ± 34.4 μg quinine/g collagen, respectively; p < .001). AGEs bone content correlated with worse bone microarchitecture, including lower volumetric BMD (r = -0.633; p = .02), BV/TV (r = -0.59; p = .033) and increased trabecular separation/spacing (r = 0.624; p = .023). In conclusion, our data show that even in patients with good glycemic control, T2D affects the expression of genes controlling bone formation (SOST and RUNX2). We also found that accumulation of AGEs is associated with impaired bone microarchitecture. We provide novel insights that may help understand the mechanisms underlying bone fragility in T2D. © 2020 American Society for Bone and Mineral Research (ASBMR).

Nutritional Therapy for Athletes with Diabetes

Diabetes is a worldwide disease also affecting the sports field. The two main forms of diabetes, namely type 1 diabetes (T1D) and type 2 diabetes (T2D), differ in both their pathological and pharmacological characteristics and thus require a distinct nutritional treatment. Diet plays an important role in the management of athletes with diabetes and is crucial to achieving their best performance. This review aims to investigate the objectives of nutritional therapy before, during and after training, in order to improve the best composition of macronutrients during meals. In this review, we provide a brief overview of recent studies about nutritional approaches to people with diabetes for performance optimization and for the control of diabetes-related complications. Thereafter, we discuss the differences between macronutrients and dietary intake before, during and after training. It can be concluded that each sport has particular characteristics in terms of endurance and power, hence demanding a specific energy expenditure and consequent nutritional adjustments. Therefore, the management of athletes with diabetes must be personalized and supported by medical professionals, including a diabetologist, physiologist and a nutritionist.

Predictors of haemodynamic performance in patients with aortic stenosis and small annulus undergoing TAVI with self-expandable valves

Background

Small aortic annular size is one of the most important predictor of poor hemodynamic and clinical outcomes in patients treated for aortic stenosis. Post-hoc analyses of pivotal trials showed that transcatheter aortic valve intervention (TAVI) offer better outcomes then surgery in patients with small aortic annulus, especially with self-expandable valves (SEV). However, data about SEVs comparison in this population are limited.

Purpose

Our aim is to assess how valve design and oversizing, with anatomical and echographic features, impact on the hemodynamic performance of SEVs in TAVI patients with small aortic annulus.

Methods

The TAVI SMALL registry enrolled 859 patients with small aortic annulus (CT-scan annular perimeter≤72 mm or area ≤400 mm2) treated for aortic stenosis with currently available SEVs (Evolut R=397; Evolut PRO =84; Acurate Neo=140; Acurate TA= 61; Portico=177) at 9 European centers between 2011 and 2018. We performed multivariable backward logistic regression analyses to identify predictors of high postprocedural mean gradient, moderate-to-severe PPM, and moderate-to-severe para-valvular leak (PVL).

Results

After adjustment for LVEF, we identified annular perimeter and percentage of oversizing as independent predictors of lower post-procedural mean gradient.

Implantation of intra-annular rather than supra-annular bioprosthesis was the only independent predictor of moderate-to-severe PPM.

Predictors of moderate-to-severe PVL are reported in the Table.

Conclusions

Among patients with aortic stenosis and small aortic annulus treated with transcatheter SEVs, use of supra-annular bioproshtesis and oversizing were associated with improved valve performance.

Funding Acknowledgement

Type of funding source: None

Irisin Recovers Osteoarthritic Chondrocytes In Vitro

Physical exercise favors weight loss and ameliorates articular pain and function in patients suffering from osteoarthritis. Irisin, a myokine released upon muscle contraction, has demonstrated to yield anabolic effects on different cell types. This study aimed to investigate the effect of irisin on human osteoarthritic chondrocytes (hOAC) in vitro. Our hypothesis was that irisin would improve hOAC metabolism and proliferation. Cells were cultured in growing media and then exposed to either phosphate-buffered saline (control group) or human recombinant irisin (experimental group). Cell proliferation, glycosaminoglycan content, type II/X collagen gene expression and protein quantification as well as p38/extracellular signal-regulated kinase (ERK) mitogen-activated protein kinase (MAPK), protein kinase B (Akt), c-Jun N-terminal kinase (JNK), and nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB) involvement were evaluated. Furthermore, gene expression of interleukin (IL)-1 and -6, matrix metalloproteinase (MMP)-1 and -13, inducible nitric oxide synthase (iNOS), and tissue inhibitor of matrix metalloproteinases (TIMP)-1 and -3 were investigated following irisin exposure. Irisin increased hOAC cell content and both type II collagen gene expression and protein levels, while decreased type X collagen gene expression and protein levels. Moreover, irisin decreased IL-1, IL-6, MMP-1, MMP-13 and iNOS gene expression, while increased TIMP-1 and TIMP-3 levels. These effects seemed to be mediated by inhibition of p38, Akt, JNK and NFκB signaling pathways. The present study suggested that irisin may stimulate hOAC proliferation and anabolism inhibiting catabolism through p38, Akt, JNK, and NFκB inactivation in vitro, demonstrating the existence of a cross-talk between muscle and cartilage.

Osteoarthritis and type 2 diabetes: From pathogenetic factors to therapeutic intervention

Over the last decades, osteoarthritis (OA) and type 2 diabetes (T2D) prevalence increased due to the global ageing population and the pandemic obesity. They currently affect a substantial part of the Western world population and are characterized by enhancing the risk of disability and reduction of quality of life. OA is a multifactorial condition whose development derives from the interaction between individual and environmental factors: The best known primarily include age, female gender, genetic determinants, articular biomechanics, and obesity (OB). Given the high prevalence of OA and T2D and their association with OB and inflammation, several studies have been conducted to investigate the causative role of biological characteristics proper to T2D on the development of OA. This review aims to analyse the relationship between of OA and T2D, in order to explain the pathophysiological drivers of the degenerative process and to delineate possible targets to which appropriate treatments may be addressed in the near future.

Intervertebral disc degeneration: A focus on obesity and type 2 diabetes

Obesity (OB) and type 2 diabetes (T2D) are among the most prevalent metabolic diseases. They currently affect a substantial part of the world population and are characterized by several systemic co-morbidities, including cardiovascular diseases, stroke, cancer, liver steatosis, and musculoskeletal disorders, by increasing the risk of developing osteoarthritis and intervertebral disc degeneration (IVDD). IVDD is a chronic, progressive process whose main features are disc dehydration, loss of disc height, and changes of load distribution across the spine, resulting in disc structure disruption and leading to low back pain onset. Given the high prevalence of these metabolic disorders and their association with IVDD, several studies have been conducted in order to investigate the causative role of biological and biomechanical characteristics proper to these conditions in the development of IVDD. This review aims to analyse the role of OB and T2D on IVDD, in order to clarify the pathophysiological drivers of the degenerative process and to delineate possible targets to which appropriate treatments may be addressed in the near future.

The cytokinome in osteoarthritis, a new paradigm in diagnosis and prognosis of cartilage disease

At present, diagnosis and progression monitoring of osteoarthritis (OA) is made through radiological and clinical assessment. Several studies investigated the role of synovial fluid analysis, to find out whether joint disease could be characterized by the pattern of cytokines, which acts during the pathogenic process or in specific stages of it. Online PubMed-Medline search was performed in order to retrieve evidence concerning synovial fluid analysis of cytokines involved in OA degenerative process. Concerning pro-inflammatory cytokines, it has been shown that interleukin (IL)-6, TNF-α and IL-17 are mainly over-expressed in the synovial fluid of OA joints, as well as anti-inflammatory cytokine IL-10. Variations of cytokines levels occur with radiological and clinical progression. It was also reported that metalloproteinases are involved. Synovial fluid analysis may be helpful in defining stage and type of OA, but more research is needed, especially focusing on the variation of sets of cytokines during OA stages and correlating these patterns with clinical features.

Total intravenous anesthesia using remifentanil in extracorporeal shock wave lithotripsy (ESWL). Comparison of two dosages: a randomized clinical trial

BACKGROUND

Extracorporeal Shock Wave Lithotripsy is usually performed in day surgery setting, consequently people who undergo to this procedure need a safe and fast recovery. Conscious sedation with remifentanil can relieve from pain and keep patients in touch with anaesthesiologists. Few publications tell about infusion rates administered to perform this procedure7. The aim of this study is to assess which is the most appropriate infusion rate.

METHODS

Patients were randomly assigned to two groups. Two different infusion rates were compared: 0,05 mcg/kg/min, GROUP A (N.=114), vs. 0.1 µg/kg/min, GROUP B (N.=114). Patients' vital signs, additional analgesic requests, PONV (postoperative nausea and vomiting) and other side effects were registered. The deepness of sedation and patient's satisfaction were evaluated referring to Obsever's Assessment of Alertness and Sedation scale (O/ASS) and using a Likert's scale respectively. Pain intensity was assessed with a 11-points VAS (visual analogue scale). Differences between groups were analyzed using Student t test for independent variables. The χ2 test was used to analyze categorical variables.

RESULTS

The study enrolled 228 patients and assigned them to two groups (N.=114). No significant differences were found regarding Likert's scale values (P=0.20), additional analgesic request (P=0.30) and mean VAS values (P>0.05) between the two groups. The difference between the two groups about PONV, hypotension, oxygen desaturation and respiratory depression was statistically significant (P<0.05), as a matter of fact in group A these side effects occurred less frequently. The fifth degree of O/ASS was estimated in about 1.61±0.19 min and 2.987±0.20 min in group A and in group B respectively (P<0.05).

CONCLUSION

According with previous results remifentanil at the infusion rate of 0.05 µg/kg/min provides an effective analgesia, causing a lower incidence of side effect than 0.1 µg/kg/min, granting a fast and safe recovery.

Safety and efficacy of transdermal buprenorphine and transdermal fentanyl in the treatment of neuropathic pain in AIDS patients

BACKGROUND

Multifactor neuropathic pain is one of the most frequent symptoms in AIDS patients and analgesic treatment is primarily based on the use of drug combination of opioids, tricyclic antidepressants and antiepileptics. However, the chronic use of opioids in AIDS patients presents a risk due to the immunosuppressive action of these drugs. Until now, buprenorphine has been regarded as one of the safest opioid analgesics for the treatment of patients with compromised immune systems. To assess the suitability of transdermal fentanyl for the treatment of neuropathic pain in AIDS patients, the present study compares the efficacy, tolerability and the immunosuppressive effects of transdermal buprenorphine vs. fentanyl.

METHODS

Forty advanced AIDS patients (28 male and 12 female) with chronic peripheral neuropathic pain were enrolled onto this clinical trial. Neuropathic pain was assessed for its constituent types of pain (burning, stabbing and shooting), its overall intensity and allodynia; scores were awarded using the Neuropathic Pain Scale, expressed as 10 item VAS scores.

RESULTS

Both treatment groups showed statistically significant reductions in each of the individual types of neuropathic pain and allodynia (P<0.05; 95% CI: -14.7, -3.1) and significant improvements in Karnofsky Performance Status (P<0.05; mean value, 69; range: 40-90). Both buprenorphine and fentanyl were well tolerated. Neither buprenorphine nor fentanyl affected CD4+ or CD8+levels and both treatments, but particularly buprenorphine group, resulted in more stable CD4+ concentrations.

CONCLUSION

The high efficacy, tolerability and patient compliance of both buprenorphine and fentanyl make both these two opioids valid therapeutic options for the treatment of neuropathic pain in patients with AIDS.

Risk factors for acute renal failure in trauma patients

OBJECTIVE

To elucidate the risk factors for the development of acute renal failure (ARF) in severe trauma.

DESIGN

Prospective observational study.

SETTING

A general intensive care unit (ICU) of a university hospital.

PATIENTS

A cohort of 153 consecutive trauma patients admitted to the ICU over a period of 30 months.

RESULTS

Forty-eight (31%) patients developed ARF. They were older than the 105 patients without ARF (p = 0.002), had a higher Injury Severity Score (ISS) (p < 0.001), higher mortality (p < 0.001), a more compromised neurological condition (p = 0.007), and their arterial pressure at study entry was lower (p = 0.0015). In the univariate analysis, the risk of ARF increased by age, ISS > 17, the presence of hemoperitoneum, shock, hypotension, or bone fractures, rhabdomyolysis with creatine phosphokinase (CPK) > 10000 IU/l, presence of acute lung injury requiring mechanical ventilation, and Glasgow Coma Score < 10. Sepsis and use of nephrotoxic agents were not associated with an increased risk of ARF. In the logistic model, the need for mechanical ventilation with a positive end-expiratory pressure > 6 cm H2O, rhabdomyolysis with CPK > 10000 IU/l, and hemoperitoneum were the three conditions most strongly associated with ARF.

CONCLUSIONS

The identified risk factors for post-traumatic acute renal failure may help the provision of future strategies.