Study protocol of a randomised, double-blind, placebo-controlled, two-arm parallel-group, multi-centre phase 3 pivotal trial to investigate the efficacy and safety of recombinant human alkaline phosphatase for treatment of patients with sepsis-associated acute kidney injury

INTRODUCTION

Sepsis, the leading cause of acute kidney injury (AKI), is associated with a high morbidity and mortality. Alkaline phosphatase (ALP) is an endogenous detoxifying enzyme. A recombinant human ALP compound, ilofotase alfa, showed no safety or tolerability concerns in a phase 2 trial. Renal function improvement over 28 days was significantly greater in the ilofotase alfa group. Moreover, a significant relative reduction in 28-day all-cause mortality of >40% was observed. A follow-up trial has been designed to confirm these findings.

METHODS AND ANALYSIS

This is a phase 3, global, multi-centre, randomised, double-blind, placebo-controlled, sequential design trial in which patients are randomly assigned to either placebo or 1.6 mg/kg ilofotase alfa. Randomisation is stratified by baseline modified Sequential Organ Failure Assessment (mSOFA) score and trial site. The primary objective is to confirm the survival benefit with ilofotase alfa by demonstrating a reduction in 28-day all-cause mortality in patients with sepsis-associated AKI requiring vasopressors. A maximum of 1400 patients will be enrolled at ∼120 sites in Europe, North America, Japan, Australia and New Zealand. Up to four interim analyses will take place. Based on predefined decision rules, the trial may be stopped early for futility or for effectiveness. In addition, patients with COVID-19 disease and patients with 'moderate to severe' chronic kidney disease are analysed as 2 separate cohorts of 100 patients each. An independent Data Monitoring Committee evaluates safety data at prespecified intervals throughout the trial.

ETHICS AND DISSEMINATION

The trial is approved by relevant institutional review boards/independent ethics committees and is conducted in accordance with the ethical principles of the Declaration of Helsinki, guidelines of Good Clinical Practice, Code of Federal Regulations and all other applicable regulations. Results of this study will determine the potential of ilofotase alfa to reduce mortality in critically ill patients with sepsis-associated AKI and will be published in a peer-reviewed scientific journal.

TRIAL REGISTRATION NUMBER

EudraCT CT Number 2019-0046265-24. US IND Number 117 605 Pre-results.

CLINICALTRIALS

gov number: NCT04411472.

Risk stratification parameters as assessed by continuous long-term cardiac monitoring in pulmonary hypertension – heart rate variability, heart rate, and physical activity

Background

Pulmonary hypertension (PH) is a progressive disease affecting both the pulmonary vasculature and the heart. In the current ESC/ERS guidelines nine variables are used in PH risk assessment, and have been proven to be independent predictors of survival in PH. The risk assessment parameters include clinical symptoms, exercise capacity and imaging. The present study is the first to assess continuous 24/7 heart rate variability (HRV), heart rate (HR) and physical activity monitoring in patients with PH.

Purpose

To identify risk stratification parameters by continuous cardiac monitoring in PH.

Methods

Patients diagnosed with PH were included in this prospective single-centre study. Patients had a Reveal LINQ insertable cardiac monitor implanted to continuously monitor heart rate variability (HRV), heart rate at day and night and physical activity. HRV was expressed as the mean HRV in sinus rhythm during each full day (SDANN method). Pearson and Spearman correlations between the loop recorder variables and ESC/ERS risk stratification variables were calculated and compared with the loop recorder data in 30-days intervals.

Results

A total of 41 patients were prospectively enrolled, 27 patients with pulmonary arterial hypertension (PAH) and 14 patients with chronic thromboembolic pulmonary hypertension (CTPEH). The patients were monitored continuously in a total of 82 patient-years, had a mean age of 58 years and were primarily in a stable disease phase with a mean WHO functional class (FC) of 2.2. HRV and physical activity divided by heart rate at daytime showed the highest correlations respectively with current risk parameters. In particular, high correlations were found between HRV and NT-proBNP (R=−0,69 p≤2.2e-16), WHO FC (R=−0,65 p=2.4e-5), RVEF (R=0,61 p=0,00012) and right atrial pressure (RAP) (R=−0.67 p=0.0023) (Figure 1).

Conclusion

This study demonstrates the potential of HRV, and physical activity divided by heart rate daytime as risk parameters in pulmonary hypertension. Progression of symptoms in PH are often delayed compared with pathophysiological changes, and continuous monitoring offers a potential to early recognition of disease progression and optimization of PAH therapy.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The study was supported by the Heart Centre Research Council,Rigshospitalet and an investigator initiated study research grant fromJansson Pharmaceuticals.

An explorative metabolomic analysis of the endothelium in pulmonary hypertension

Pulmonary hypertension (PH) is classified into five clinical diagnostic groups, including group 1 [idiopathic pulmonary arterial hypertension (IPAH) and connective tissue disease-associated PAH (CTD-aPAH)] and group 4 (chronic thromboembolic pulmonary hypertension (CTEPH)). PH is a progressive, life-threatening, incurable disease. The pathological mechanisms underlying PH remain elusive; recent evidence has revealed that abnormal metabolic activities in the endothelium may play a crucial role. This research introduces a novel approach for studying PH endothelial function, building on the genome-scale metabolic reconstruction of the endothelial cell (EC) to investigate intracellular metabolism. We demonstrate that the intracellular metabolic activities of ECs in PH patients cluster into four phenotypes independent of the PH diagnosis. Notably, the disease severity differs significantly between the metabolic phenotypes, suggesting their clinical relevance. The significant metabolic differences between the PH phenotypes indicate that they may require different therapeutic interventions. In addition, diagnostic capabilities enabling their identification is warranted to investigate whether this opens a novel avenue of precision medicine.

Heart rate variability in patients with pulmonary hypertension as assessed with long-term continuous cardiac monitoring correlates with other established risk assessment parameters

Background

A few short-term monitoring studies (10 minutes–24 hours) have revealed lower heart rate variability (HRV) in patients with pulmonary hypertension (PH). This is the first study to apply continuous heart rate variability monitoring in pulmonary hypertension.

Purpose

Assessment of HRV as a non-invasive risk marker in pulmonary hypertension (PH) using long-term continuous monitoring.

Methods

Patients diagnosed with PH according to international guidelines were included in this prospective single-centre study. Patients were implanted with a Reveal LINQ (Medtronic) insertable cardiac monitor to record HRV. HRV was expressed as the mean of HRV in sinus rhythm during the full day for all days per patient (SDANN method). Pearson and Spearman correlations between HRV and established risk determinants were estimated.

Results

Thirty-two patients with PH were included. Twenty-two patients had pulmonary arterial hypertension (PAH) and 10 had chronic thromboembolic PH. During 50 patient-years of continuous monitoring (median: 654 (range: 394–714) days per patient), HRV was significantly correlated to the following risk determinants in PH (variable 1–3) in addition to other variables (variable 4–8): (1) WHO functional class (FC) (r=−0.55, p = <0.001) (Figure 1), (2) NT-proBNP (r=−0.5, p=0.003), (3) cardiac index (r=−0.45, p=0.03), (4) heart rate at night time (0 am–4 am) (r=−0.68, p=<0.001) (Figure 1), (5) TAPSE (r=0.41, p=0.025), (6) right ventricle ejection fraction (r=−0.37, p=0.014), (7) tricuspid regurgitation gradient (r=−0.38, p=0.045) and (8) right ventricle end diastolic volume (ml) (r=−0.37, p=0.035).

Conclusions

This is the first study to apply continuous monitoring of HRV in patients with PH. HRV was significantly correlated with several variables already being used in risk stratification. HRV may be an additional non-invasive variable in risk assessment in PH aiding in optimization of treatment.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Janssen

Ultrasound Vascular Elastography as a Tool for Assessing Atherosclerotic Plaques - A Systematic Literature Review

Atherosclerosis is a widespread disease that accounts for nearly 3-quarters of deaths due to cardiovascular disease. Ultrasound elastography might be able to reliably identify characteristics associated with vulnerable plaques. There is a need for the evaluation of elastography and its ability to distinguish between vulnerable and stable plaques. The aim of this paper is to provide an overview of the literature on vascular elastography. A systematic search of the available literature for studies using elastography for assessing atherosclerotic plaques was conducted using the MEDLINE, Embase, Cochrane Library and Web of Science databases. A standardized template was used to extract relevant data following the PRISMA 2009 checklist. 20 articles were included in this paper. The studies were heterogeneous. All studies reported that elastography was a feasible technique and provided additional information compared to B-mode ultrasound alone. Most studies reported higher strain values for vulnerable plaques. Ultrasound elastography has potential as a clinical tool in the assessment of atherosclerotic plaques. Elastography is able to distinguish between different plaque types, but there is considerable methodological variation between studies. There is a need for larger studies in a clinical setting to determine the full potential of elastography.

Ultrasound Elastography in Breast Cancer Diagnosis

Ultrasound elastography is an established method for characterization of focal lesions in the breast. Different techniques and analyses of the images may be used for the characterization. This article addresses the use of ultrasound elastography in breast cancer diagnosis. In the first part of the article the techniques behind both strain- and shear-wave-elastography are explained and followed by a section on how to obtain adequate elastography images and measurements. In the second part of the article the application of elastography as an adjunct to B-mode ultrasound in clinical practice is described, and the potential diagnostic gains and limitations of elastography are discussed.

Amyloid-PET predicts inhibition of de novo plaque formation upon chronic γ-secretase modulator treatment

In a positron-emission tomography (PET) study with the β-amyloid (Aβ) tracer [(18)F]-florbetaben, we previously showed that Aβ deposition in transgenic mice expressing Swedish mutant APP (APP-Swe) mice can be tracked in vivo. γ-Secretase modulators (GSMs) are promising therapeutic agents by reducing generation of the aggregation prone Aβ42 species without blocking general γ-secretase activity. We now aimed to investigate the effects of a novel GSM [8-(4-Fluoro-phenyl)-[1,2,4]triazolo[1,5-a]pyridin-2-yl]-[1-(3-methyl-[1,2,4]thiadiazol-5-yl)-piperidin-4-yl]-amine (RO5506284) displaying high potency in vitro and in vivo on amyloid plaque burden and used longitudinal Aβ-microPET to trace individual animals. Female transgenic (TG) APP-Swe mice aged 12 months (m) were assigned to vehicle (TG-VEH, n=12) and treatment groups (TG-GSM, n=12), which received daily RO5506284 (30 mg kg(-1)) treatment for 6 months. A total of 131 Aβ-PET recordings were acquired at baseline (12 months), follow-up 1 (16 months) and follow-up 2 (18 months, termination scan), whereupon histological and biochemical analyses of Aβ were performed. We analyzed the PET data as VOI-based cortical standard-uptake-value ratios (SUVR), using cerebellum as reference region. Individual plaque load assessed by PET remained nearly constant in the TG-GSM group during 6 months of RO5506284 treatment, whereas it increased progressively in the TG-VEH group. Baseline SUVR in TG-GSM mice correlated with Δ%-SUVR, indicating individual response prediction. Insoluble Aβ42 was reduced by 56% in the TG-GSM versus the TG-VEH group relative to the individual baseline plaque load estimates. Furthermore, plaque size histograms showed differing distribution between groups of TG mice, with fewer small plaques in TG-GSM animals. Taken together, in the first Aβ-PET study monitoring prolonged treatment with a potent GSM in an AD mouse model, we found clear attenuation of de novo amyloidogenesis. Moreover, longitudinal PET allows non-invasive assessment of individual plaque-load kinetics, thereby accommodating inter-animal variations.

Strain Elastography for Prediction of Malignancy in Soft Tissue Tumours--Preliminary Results

PURPOSE

To evaluate the ability of strain elastography to predict malignancy in patients with soft tissue tumors, and to compare three evaluation methods of strain elastography: strain ratios, strain histograms and visual scoring.

MATERIALS AND METHODS

60 patients with 61 tumors were analyzed in the study. All patients were referred due to suspicion of malignant soft tissue tumors after diagnostic imaging (contrast-enhanced MRI, CT or PET-CT). Ultrasound-guided biopsy was preceded by the recording of strain elastography video clips, which were evaluated in consensus between three investigators. Strain ratio, strain histogram analysis and visual scoring using a five-point visual scale were compared with the final pathology from either biopsy or resection of the tumors.

RESULTS

The difference between the mean strain ratio for malignant and benign tumors was significant (p = 0.043). The mean strain ratios for malignant and benign tumors were 1.94 (95% CI [0.37; 10.21]) and 1.35 (95% CI [0.32; 5.63]), respectively. There were no significant differences for strain histograms or visual scoring. Liposarcomas had lower mean strain ratio, strain histogram values, and visual scoring than other malignant tumors. When analyzing a subgroup of patients without fat-containing tumors (n = 46), based on appearance on MRI or CT, the difference between the mean strain ratios for malignant and benign tumors increased (p = 0.014).

CONCLUSION

The mean strain ratios of malignant tumors were significantly higher than the mean strain ratios of benign tumors. There was no significant difference for strain histograms and visual scoring. Strain ratios may be used as an adjunct in soft tissue tumor diagnosis, possibly minimizing the number of biopsies.

Recurrence of sarcoid granulomas in lung transplant recipients is common and does not affect overall survival

BACKGROUND

Sarcoidosis represents 2,5% of all indications for lung transplantation and criteria are generally assumed to be the same as for pulmonary fibrosis. Recurrence of granulomas in transplanted lungs has earlier been proved to derive from recipient immune cells, but its role in relation to lung function and overall survival after lung transplantation remains uncertain.

OBJECTIVE

To identify recurrent granuloma in transbronchial biopsies in patients receiving lung transplant because of sarcoidosis, and relate the findings to overall survival and lung function.

DESIGN

A total of 620 patients were transplanted at this centre from 1992 until august 2012. This study comprised all patients (n=25) transplanted due to pulmonary sarcoidosis. Lung functions, trans-bronchial biopsies, and survival were compared in patients with and without recurrence of granulomas. Granulomas were defined as non-necrotizing epitheloid granulomas with multinucleated giant cells according to standard criteria (formation of epitheloid giant cells) without presence of infection.

CONCLUSIONS

Approximately 30% of lung transplant recipients due to sarcoidosis have recurrence of sarcoid granulomas. Recurrence of granulomas does not affect overall survival or lung function.

Acute administration of the small-molecule p75(NTR) ligand does not prevent hippocampal neuron loss or development of spontaneous seizures after pilocarpine-induced status epilepticus

Neurotrophins, such as brain-derived neurotrophic factor (BDNF), are initially expressed in a precursor form (e.g., pro-BDNF) and cleaved to form mature BDNF (mBDNF). After pilocarpine-induced status epilepticus (SE), increases in neurotrophins regulate a wide variety of cell-signaling pathways, including prosurvival and cell-death machinery in a receptor-specific manner. Pro-BDNF preferentially binds to the p75 neurotrophin receptor (p75(NTR) ), whereas mBDNF is the major ligand of the tropomyosin-related kinase receptor. To elucidate a potential role for p75(NTR) in acute stages of epileptogenesis, rats were injected prior to and at onset of SE with LM11A-31, a small-molecule ligand that binds to p75(NTR) to promote survival signaling and inhibit neuronal cell death. Modulation of early p75(NTR) signaling and its effects on electrographic SE, SE-induced neurodegeneration, and subsequent spontaneous seizures were examined after LM11A-31 administration. Despite an established neuroprotective effect of LM11A-31 in several animal models of neurodegenerative disorders (e.g., Alzheimer's disease, traumatic brain injury, and spinal cord injury), high-dose LM11A-31 administration prior to and at onset of SE did not reduce the intensity of electrographic SE, prevent SE-induced neuronal cell injury, or inhibit the progression of epileptogenesis. Further studies are required to understand the role of p75(NTR) activation during epileptogenesis and in seizure-induced cell injury in the hippocampus, among other potential cellular pathologies contributing to the onset of spontaneous seizures. Additional studies utilizing more prolonged treatment with LM11A-31 are required to reach a definite conclusion on its potential neuroprotective role in epilepsy.

Rapid decline in 51Cr-EDTA measured renal function during the first weeks following lung transplantation

We previously described a 54% decline in renal function at 6 months after lung transplantation (LTx). We hypothesized that this decline is a very early event following LTx. Thirty-one consecutive patients (16 females/15 males), mean age 49 (+/-13) years, with emphysema, cystic fibrosis/bronchiectasis or idiopathic pulmonary fibrosis were included in an analysis of renal function before and after LTx. The glomerular filtration rate (GFR) was measured using the (51)Cr-ethylenediaminetetra acetic acid plasma clearance single injection technique (mGFR) at baseline before transplantation and at 1, 2, 3 and 12 weeks postoperatively. Mean mGFR declined from 103 +/- 18 to 65 +/- 22, 53 +/- 16 and 57 +/- 18 mL/min/1.73m(2) at 1-, 3- and 12-weeks post-LTx (p < 0.0001), respectively. In a time-dependent repeated measures ANOVA, risk factors for a decline in mGFR posttransplant included: time (p < 0.0001), acute renal failure within 2 weeks post-LTx (p = 0.0003), use of heart and lung machine (p = 0.04), and the use of ephedrine (p = 0.048), as well as increasing age, older than 18 years at LTx (p = 0.006). These data demonstrate that renal function, measured with an isotope method, decreases dramatically during the first week after LTx.

Increased mortality after dronedarone therapy for severe heart failure

BACKGROUND

Dronedarone is a novel antiarrhythmic drug with electrophysiological properties that are similar to those of amiodarone, but it does not contain iodine and thus does not cause iodine-related adverse reactions. Therefore, it may be of value in the treatment of patients with heart failure.

METHODS

In a multicenter study with a double-blind design, we planned to randomly assign 1000 patients who were hospitalized with symptomatic heart failure and severe left ventricular systolic dysfunction to receive 400 mg of dronedarone twice a day or placebo. The primary end point was the composite of death from any cause or hospitalization for heart failure.

RESULTS

After inclusion of 627 patients (310 in the dronedarone group and 317 in the placebo group), the trial was prematurely terminated for safety reasons, at the recommendation of the data and safety monitoring board, in accordance with the board's predefined rules for termination of the study. During a median follow-up of 2 months, 25 patients in the dronedarone group (8.1%) and 12 patients in the placebo group (3.8%) died (hazard ratio in the dronedarone group, 2.13; 95% confidence interval [CI], 1.07 to 4.25; P=0.03). The excess mortality was predominantly related to worsening of heart failure--10 deaths in the dronedarone group and 2 in the placebo group. The primary end point did not differ significantly between the two groups; there were 53 events in the dronedarone group (17.1%) and 40 events in the placebo group (12.6%) (hazard ratio, 1.38; 95% CI, 0.92 to 2.09; P=0.12). More increases in the creatinine concentration were reported as serious adverse events in the dronedarone group than in the placebo group.

CONCLUSIONS

In patients with severe heart failure and left ventricular systolic dysfunction, treatment with dronedarone was associated with increased early mortality related to the worsening of heart failure. (ClinicalTrials.gov number, NCT00543699.)

Aspergillus infection in lung transplant patients: incidence and prognosis

Lung transplant recipients experience a particularly high incidence of Aspergillus infection in comparison with other solid-organ transplantations. This study was conducted to determine the incidence of Aspergillus colonisation and invasive aspergillosis, and the impact on long-term survival associated with Aspergillus infection. A retrospective study of 362 consecutive lung transplant patients from a single national centre who were transplanted 1992-2003 were studied. Twenty-seven patients were excluded due to incomplete or missing files. A total of 105/335 (31%) patients had evidence of Aspergillus infection (colonisation or invasion), including 83 (25%) patients with colonisation and 22 (6%) patients with radiographic or histological evidence of invasive disease. Most of the infections occurred within the first 3 months after transplantation. Cystic fibrosis (CF) patients had higher incidences of colonisation and invasive disease [15 (42%) and 4 (11%) of 36 patients] than non-CF patients [68 (23%) and 18 (6%) of 299 patients] (P = 0.01). Invasive aspergillosis was associated with 58% mortality after 2 years, whereas colonisation was not associated with early increased mortality but was associated with increased mortality after 5 years compared to non-infected patients (P < 0.05). An analysis of demographic factors showed that donor age [OR 1.40 per decade (95% CI 1.10-1.80)], ischaemia time [OR 1.17 per hour increase (95% CI 1.01-1.39)], and use of daclizumab versus polyclonal induction [OR 2.05 (95% CI 1.14-3.75)] were independent risk factors for Aspergillus infection. Invasive aspergillosis was associated with early and high mortality in lung transplant patients. Colonisation with Aspergillus was also associated with a significant increase in mortality after 5 years. CF patients have a higher incidence of Aspergillus infection than non-CF patients.

Results of European post-marketing surveillance of bosentan in pulmonary hypertension

After the approval of bosentan for the treatment of pulmonary arterial hypertension (PAH), European authorities required the introduction of a post-marketing surveillance system (PMS) to obtain further data on its safety profile. A novel, prospective, internet-based PMS was designed, which solicited reports on elevated aminotransferases, medical reasons for bosentan discontinuation and other serious adverse events requiring hospitalisation. Data captured included demographics, PAH aetiology, baseline functional status and concomitant PAH-specific medications. Safety signals captured included death, hospitalisation, serious adverse events, unexpected adverse events and elevated aminotransferases. Within 30 months, 4,994 patients were included, representing 79% of patients receiving bosentan in Europe. In total, 4,623 patients were naïve to treatment; of these, 352 had elevated aminotransferases, corresponding to a crude incidence of 7.6% and an annual rate of 10.1%. Bosentan was discontinued due to elevated aminotransferases in 150 (3.2%) bosentan-naïve patients. Safety results were consistent across subgroups and aetiologies. The novel post-marketing surveillance captured targeted safety data ("potential safety signals") from the majority of patients and confirmed that the incidence and severity of elevated aminotransferase levels in clinical practice was similar to that reported in clinical trials. These data complement those from randomised controlled clinical trials and provide important additional information on the safety profile of bosentan.

Hyperinsulinaemia is associated with increased long-term mortality following acute myocardial infarction in non-diabetic patients

AIMS

To study the impact of disturbances in glucose metabolism on total mortality in non-diabetic patients with acute myocardial infarction.

METHODS AND RESULTS

Four hundred and ninety four patients with a verified myocardial infarction and no history of diabetes were studied. The study population comprised a subgroup of patients screened for participation in the Trandolapril Cardiac Evaluation (TRACE) study. At baseline, fasting insulin, fasting glucose, glycosylated haemoglobin (HbA1c), and urinary albumin excretion were measured. Survival status was determined after 6-8 years. Patients with hyperinsulinaemia were more obese and more frequently suffered from hypertension, previous myocardial infarction and congestive heart failure. In a univariate regression analysis, values in the upper quartile of insulin, glucose, HbA1c, and urinary albumin were associated with an excess mortality risk (RR=1.8 (1.2-2.7), p=0.002; RR=1.6 (1.2-2.1), p=0.001; RR= 1.9 (1.3-2.9), p=0.001; RR=1.6 (1.2-2.1), p=0.02 respectively). However, only a high insulin level remained significant in a multivariable analysis (RR=1.54 (1.03-2.31), p=0.04) including baseline variables, left ventricular systolic function and in-hospital complications.

CONCLUSIONS

High fasting plasma insulin is an independent risk factor of all-cause mortality in non-diabetic patients with acute myocardial infarction. This justifies future intervention studies aiming at reducing insulin resistance and using fasting insulin as the target variable.

Randomized controlled trial of yoga and exercise in multiple sclerosis

OBJECTIVE

To determine the effect of yoga and of aerobic exercise on cognitive function, fatigue, mood, and quality of life in multiple sclerosis (MS).

METHODS

Subjects with clinically definite MS and Expanded Disability Status Score less than or equal to 6.0 were randomly assigned to one of three groups lasting 6 months: weekly Iyengar yoga class along with home practice, weekly exercise class using a stationary bicycle along with home exercise, or a waiting-list control group. Outcome assessments performed at baseline and at the end of the 6-month period included a battery of cognitive measures focused on attention, physiologic measures of alertness, Profile of Mood States, State-Trait Anxiety Inventory, Multi-Dimensional Fatigue Inventory (MFI), and Short Form (SF)-36 health-related quality of life.

RESULTS

Sixty-nine subjects were recruited and randomized. Twelve subjects did not finish the 6-month intervention. There were no adverse events related to the intervention. There were no effects from either of the active interventions on either of the primary outcome measures of attention or alertness. Both active interventions produced improvement in secondary measures of fatigue compared to the control group: Energy and Fatigue (Vitality) on the SF-36 and general fatigue on the MFI. There were no clear changes in mood related to yoga or exercise.

CONCLUSION

Subjects with MS participating in either a 6-month yoga class or exercise class showed significant improvement in measures of fatigue compared to a waiting-list control group. There was no relative improvement of cognitive function in either of the intervention groups.

The long-term impact of the angiotensin-converting enzyme inhibitor trandolapril on mortality and hospital admissions in patients with left ventricular dysfunction after a myocardial infarction: follow-up to 12 years

AIMS

To investigate the long-term benefits of treatment with angiotensin-converting enzyme (ACE)-inhibitors in patients with myocardial infarction (MI) and left ventricular dysfunction (LVD).

METHODS AND RESULTS

In the trandolapril cardiac evaluation (TRACE) study, 1749 patients with LVD (ejection fraction< or =35%) were randomized to trandolapril (n=876) or placebo (n=873) 3-7 days post-MI. Enrolment lasted from 1990 to 1994; on-treatment follow-up ranged from 2 to 4 years. At study closure, all patients were recommended continued ACE-inhibitor use. National registries were used to track deaths and hospitalizations until 2002. Mortality was analysed with Cox proportional hazard models and hospitalization with Poisson regression models (models adjusted for observation time). Over 10-12 years of follow-up, a total of 1283 deaths and 9220 hospitalizations were registered. Compared with the placebo group, the trandolapril group had a significantly reduced risk of all-cause mortality (relative risk 0.89, 95% CI 0.80-0.99, P=0.03), all-cause hospitalizations (rate ratio 0.92, 95% CI 0.88-0.96, P<0.001), and cardiovascular hospitalizations (rate ratio 0.95, 95% CI 0.91-1.00, P=0.047), including congestive heart failure hospitalizations (rate ratio 0.85, 95% CI 0.77-0.93, P<0.001).

CONCLUSION

In patients with LVD, use of trandolapril shortly after an MI for 2-4 years has long-term benefits. The beneficial effect on mortality and hospitalization rates is maintained for at least 10-12 years.

The incomplete bucindolol evaluation in acute myocardial infarction Trial (BEAT)

The aim of this study was to evaluate the efficacy of adding the beta-blocker bucindolol to standard therapy shortly after a myocardial infarction in a high-risk population with reduced left ventricular function.

METHODS

The study was planned to include 2000 patients with an enzyme confirmed myocardial infarction and severely reduced left ventricular function determined by echocardiography (corresponding to ejection fraction < or =0.35). The primary endpoint was all cause mortality and the secondary endpoints were time to first event of death, progression of heart failure or reinfarction-and the components. The study was closed early due to discontinuation of development of bucindolol by the manufacturer. Therefore, 170 patients were randomised to receive bucindolol and 173 to receive placebo.

RESULTS

There were 27 deaths in the bucindolol group and 30 in the placebo group, hazard ratio of bucindolol 0.88 (95% confidence limits 0.5-1.5; P=0.6). There were 9/4 (bucindolol/placebo, P=0.16) heart failure events and 5/17 (P=0.01) reinfarctions in the bucindolol/placebo groups.

CONCLUSION

Due to early closure it is unknown whether bucindolol changes mortality in high-risk post myocardial infarct patients when added to best medical therapy. The frequency of reinfarction was significantly reduced.

Facial reanimation surgery utilizing the Mitek anchor system: A case report

A flaccid hemi-face is frequently the most noticeable and cosmetically unacceptable consequence of facial nerve palsy, whether due to trauma, Bell's palsy or other etiologies. A variety of face-lift and reanimation techniques have been utilized in the past, but with time, these frequently require further surgery. We describe the use of Mitek (Norwood, MA) suture anchors for cheek resuspension in a patient with facial palsy. This system is composed of a drill guide, drill, inserter, and anchor. Although the titanium alloy anchors come in multiple sizes, the Mini GII Anchor is typically most appropriate for use in facial procedures. The actual size of the Mini GII Anchor is 1.8 mm in diameter and 5.4 mm in length. Two small arched prongs extend from the body of the anchor, and an eyelet at the superior surface is used for suture placement. When placed into a pre-drilled hole with the insertion tool, the prongs extend, effectively fixing the anchor in place. The drill guide protects adjacent soft tissues during the drilling process and allows drilling to a predetermined fixed depth. Sutures attached to the anchor may then be used for soft tissue fixation to bone.

A 60-kDa protein abundant in adipocyte caveolae

To search for caveolar proteins, mice were immunised with rat adipocyte membranes. Hybridoma supernatants were screened for antibodies to proteins on the cytosolic face of caveolae by indirect immunoelectron microscopy of immunogold-labelled adipocyte plasma membrane sheets adsorbed on electron-microscope (EM) grids. One of the hybridoma supernatants (2F11) produced a specific labelling of caveolae which was much more intense than that obtained with caveolin-1 antibodies. In Western blots of sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) separated proteins in crude membrane fractions from different rat tissues, 2F11 labelled a band corresponding to 60 kDa. The intensity of 2F11 labelling was high in adipose tissue and in other tissues varied in parallel to caveolin- labelling. In blots of plasma membrane (PM) and light-microsomal (LM) fractions from a homogenate of adipocytes, prior insulin stimulation of the adipocytes translocated GLUT-4 from the LM to the PM fraction, but was without effect on the distribution of the 60-kDa protein labelled by 2F11. Digestion with endoproteinase lys-C produced the same pattern of immunoreactive fragments of the protein in the vesicular PM and LM fractions, indicating similar membrane topology of the 2F11-reactive, 60-kDa protein in vesicles of PM and LM fractions.

Effect of dofetilide in patients with recent myocardial infarction and left-ventricular dysfunction: a randomised trial

BACKGROUND

Arrhythmias cause much morbidity and mortality after myocardial infarction, but in previous trials, antiarrhythmic drug therapy has not been convincingly effective. Dofetilide, a new class III agent, was investigated for effects on all-cause mortality and morbidity in patients with left-ventricular dysfunction after myocardial infarction.

METHODS

In 37 Danish coronary-care units, 1510 patients with severe left-ventricular dysfunction (wall motion index < or = 1.2, corresponding to ejection fraction < or = 0.35) were enrolled in a randomised, double-blind study comparing dofetilide (n=749) with placebo (n=761). The primary endpoint was all-cause mortality. Secondary endpoints included cardiac and arrhythmic mortality and total arrhythmic deaths. Analyses were by intention to treat.

FINDINGS

No significant differences were found between the dofetilide and placebo groups in all-cause mortality (230 [31%] vs 243 [32%]), cardiac mortality (191 [26%] vs 212 [28%]), or total arrhythmic deaths (129 [17%] vs 140 [18%]). Atrial fibrillation or flutter was present in 8% of the patients at study entry. In these patients, dofetilide was significantly better than placebo at restoring sinus rhythm (25 of 59 vs seven of 56; p=0.002). There were seven cases of torsade de pointes ventricular tachycardia, all in the dofetilide group.

INTERPRETATION

In patients with severe left-ventricular dysfunction and recent myocardial infarction, treatment with dofetilide did not affect all-cause mortality, cardiac mortality, or total arrhythmic deaths. Dofetilide was effective in treating atrial fibrillation or flutter in this population.

Myocardial perfusion scintigraphy as a screening method for significant coronary artery stenosis in cardiac transplant recipients

BACKGROUND

Several studies have explored the feasibility of using myocardial perfusion imaging to detect allograft vasculopathy after heart transplantation. We undertook the present prospective consecutive study to comparatively evaluate the role of serial myocardial perfusion single-photon emission computed tomography (SPECT) scanning and coronary arteriography (CAG) in detecting coronary artery stenosis suitable for coronary angioplasty in heart transplant recipients.

METHODS

Within a 2-week interval during a follow-up period of 5.6 (95% confidence limits 2.1 to 12) years, 255 serial CAGs and myocardial perfusion scintigraphies were performed in 67 patients. Arteriography and scintigraphy were performed once yearly after heart transplantation. We retrospectively analyzed the data.

RESULTS

Myocardial scintigraphy showed pathologic reversible defects in 9 out of 67 patients. Four of these patients had significant (>50% and also >70%) focal segmental stenosis in the middle and proximal parts of the coronary arteries (Type A lesions), 1 had diffuse and circumferential narrowing in the distal parts (Type B lesions), whereas CAG showed no lesions in the remaining 4 patients. The patients with significant Type A lesions were revascularized with percutaneous coronary angioplasty. Coronary arteriography showed that 1 patient had extensive Type A and Type B lesions, whereas myocardial perfusion scans detected no. The predictive value of a negative (normal) SPECT was 98% (95% confidence limits 94% to 100%) for the detection of lesions suited for revascularization.

CONCLUSIONS

Annual myocardial SPECT seems well suited to screen for significant coronary artery stenosis. A SPECT study without reversible defects virtually excludes lesions suitable for coronary artery revascularization.

Involvement of PI 3-kinase and activated ERK in facilitating insulin-stimulated triacylglycerol synthesis in hepatocytes

Triacylglycerol synthesis was studied in hepatocytes isolated from fasted/refed rats by EDTA perfusion. Insulin induced a 1.5-fold increase in glucose incorporation into triacylglycerol. Insulin-stimulated triacylglycerol synthesis and insulin-stimulated protein kinase B/Akt activity were inhibited by the phosphatidylinositol 3-kinase inhibitors wortmannin and LY 294002, and the mitogen-activated protein kinase kinase inhibitor PD 98059. Inhibition of p70 ribosomal protein-S6 kinase with rapamycin was without effect. Insulin-stimulated pyruvate dehydrogenase activity was abolished by phosphatidylinositol 3-kinase inhibitors. No effect of insulin on acetyl CoA carboxylase activity was observed.

Dofetilide in patients with congestive heart failure and left ventricular dysfunction. Danish Investigations of Arrhythmia and Mortality on Dofetilide Study Group

BACKGROUND

Atrial fibrillation occurs frequently in patients with congestive heart failure and commonly results in clinical deterioration and hospitalization. Sinus rhythm may be maintained with antiarrhythmic drugs, but some of these drugs increase the risk of death.

METHODS

We studied 1518 patients with symptomatic congestive heart failure and severe left ventricular dysfunction at 34 Danish hospitals. We randomly assigned 762 patients to receive dofetilide, a novel class III antiarrhythmic agent, and 756 to receive placebo in a double-blind study. Treatment was initiated in the hospital and included three days of cardiac monitoring and dose adjustment. The primary end point was death from any cause.

RESULTS

During a median follow-up of 18 months, 311 patients in the dofetilide group (41 percent) and 317 patients in the placebo group (42 percent) died (hazard ratio, 0.95; 95 percent confidence interval, 0.81 to 1.11). Treatment with dofetilide significantly reduced the risk of hospitalization for worsening congestive heart failure (risk ratio, 0.75; 95 percent confidence interval, 0.63 to 0.89). Dofetilide was effective in converting atrial fibrillation to sinus rhythm. After one month, 22 of 190 patients with atrial fibrillation at base line (12 percent) had sinus rhythm restored with dofetilide, as compared with only 3 of 201 patients (1 percent) given placebo. Once sinus rhythm was restored, dofetilide was significantly more effective than placebo in maintaining sinus rhythm (hazard ratio for the recurrence of atrial fibrillation, 0.35; 95 percent confidence interval, 0.22 to 0.57; P<0.001). There were 25 cases of torsade de pointes in the dofetilide group (3.3 percent) as compared with none in the placebo group.

CONCLUSIONS

In patients with congestive heart failure and reduced left ventricular function, dofetilide was effective in converting atrial fibrillation, preventing its recurrence, and reducing the risk of hospitalization for worsening heart failure. Dofetilide had no effect on mortality.