The Role of Proprotein Convertase Subtilisin-Kexin Type 9 Inhibitors in the Management of Dyslipidemia

BACKGROUND

Treatment with statins substantially reduces cardiovascular morbidity and mortality both in patients with and without established cardiovascular disease. Accordingly, statins represent the cornerstone of lipid-lowering treatment. However, there are still unmet clinical needs in the management of dyslipidemia. Indeed, it is difficult to achieve low-density lipoprotein cholesterol (LDL-C) targets in many patients, particularly in those at very high cardiovascular risk or in those with very high baseline LDL-C levels [e.g. with heterozygous familial hypercholesterolemia (FH)]. Moreover, a sizable proportion of patients are not able to tolerate high doses of statins, mostly due to muscle-related adverse effects. In these patient populations, inhibition of proprotein convertase subtilisin-kexin type 9 (PCSK9) with monoclonal antibodies appears to represent a useful tool for achieving LDL-C targets.

METHODS

In the present review, we summarize the current knowledge on the effects of the PCSK9 inhibitors alirocumab and evolocumab on lipid levels in various populations and discuss the role of these agents in the management of dyslipidemia.

RESULTS

In addition to a substantial reduction in LDL-C levels (by 50-60%), PCSK9 inhibitors also lower triglyceride, non-high-density lipoprotein cholesterol (non-HDL-C) and lipoprotein (a) levels and increase HDL-C levels. Preliminary data suggest that PCSK9 inhibitors are safe. However, ongoing randomized, placebo-controlled trials will provide definitive evidence on the safety of these novel agents and on their effects on cardiovascular morbidity and mortality.

CONCLUSION

Given the high cost of PCSK9 inhibitors, their use should be restricted to carefully selected, veryhigh risk patients until the results of these trials are available.

Alcohol consumption in patients with nonalcoholic fatty liver disease: yes, or no?

Excessive alcohol intake is an established risk factor for chronic liver disease. At the same time, moderate alcohol intake appears to reduce cardiovascular morbidity. Accordingly, recommendations for alcohol intake in patients with nonalcoholic fatty liver disease (NAFLD), who are at increased risk for liver-related and cardiovascular events, are a point of debate. Some studies have shown beneficial effects of alcohol on cardiovascular and overall mortality in this specific subset of patients. Nonetheless, even light alcohol intake appears to aggravate liver disease and increase the risk of hepatocellular cancer. Therefore, patients with nonalcoholic steatohepatitis or advanced fibrosis should be advised against consuming alcohol. On the other hand, only light alcohol consumption (<10 g/day) might be permitted in patients without significant hepatic fibrosis, provided that they are carefully followed-up. As the research field focusing on NAFLD keeps widening, more prospective studies regarding this specific subject are expected, and may provide a basis for less ambiguous recommendations.

Treatment of heterozygous familial hypercholesterolemia: what does the future hold?

INTRODUCTION

Heterozygous familial hypercholesterolemia (heFH) is a common metabolic disease associated with increased cardiovascular risk. Despite treatment with the currently available lipid-lowering agents (statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 inhibitors), a substantial proportion of patients with heFH does not achieve low-density lipoprotein cholesterol (LDL-C) targets.

AREAS COVERED

The PubMed database was reviewed for relevant papers published up to August 2020. The safety and efficacy of novel agents, namely inclisiran and bempedoic acid, that lower LDL-C levels and might be useful in the management of patients with heFH are discussed.

EXPERT OPINION

The prolonged lipid-lowering effect of inclisiran might improve adherence to treatment in patients with heFH. Bempedoic acid provides additional reductions in LDL-C levels in patients on high-intensity statin treatment; oral administration of this agent might be attractive to some patients. However, it is important to evaluate the effects of these agents on cardiovascular morbidity before they are incorporated in the management of heFH. The cost/benefit of treatment should also be considered, given the increasing complexity of lipid-lowering treatment.

Effects of antiviral treatment on the risk of hepatocellular cancer in patients with chronic viral hepatitis

Hepatocellular carcinoma (HCC) is a major complication of chronic hepatitis B (CHB) and chronic hepatitis C (CHC). Accumulating data suggest that antiviral treatment in both CHB and CHC reduces the incidence of HCC. Evidence is more consistent for interferon-based treatment in both CHB and CHC and for lamivudine in patients with CHB. However, more limited data suggest that other nucleos(t)ide analogues might also reduce the risk of HCC. In contrast, conflicting data have been reported on the effects of direct-acting antivirals on the incidence of HCC.

Oral Semaglutide, A New Option in the Management of Type 2 Diabetes Mellitus: A Narrative Review

According to current guidelines, glucagon-like peptide-1 (GLP-1) receptor agonists are the antidiabetic agent of choice in patients with type 2 diabetes mellitus (T2DM) and established cardiovascular disease (CVD) and are also the preferable antidiabetic agent in patients with T2DM without CVD but with indicators of high cardiovascular risk. A limitation in the use of GLP-1 receptor agonists is that they are delivered by subcutaneous injections. In this context, the development of an orally administered formulation of semaglutide offers an additional option in the management of patients with T2DM. In the present review, we discuss the findings of the main trials that evaluated the safety and efficacy of oral semaglutide. Oral semaglutide appears to be more effective in reducing HbA1c levels and body weight than other antidiabetic agents and similarly effective to other GLP-1 receptor agonists. The safety profile of oral semaglutide is also comparable with other members of its class. Even though oral semaglutide did not reduce the incidence of the composite primary endpoint in a randomized controlled trial, a reduction in cardiovascular and all-cause mortality was observed. Therefore, oral semaglutide appears to represent a useful tool in the management of patients with TD2M, particularly those with established CVD or high cardiovascular risk and unwilling to receive injectable GLP-1 receptor agonists.

Is there a role for glucagon-like peptide-1 receptor agonists in the management of diabetic nephropathy?

Chronic kidney disease constitutes a major microvascular complication of diabetes mellitus. Accumulating data suggest that glucagon-like peptide-1 receptor agonists (GLP-1 RAs) might have a role in the management of diabetic kidney disease (DKD). GLP-1 RAs appear to reduce the incidence of persistent macro-albuminuria in patients with type 2 diabetes mellitus. This beneficial effect appears to be mediated not only by the glucose-lowering action of these agents but also on their blood pressure lowering, anti-inflammatory and antioxidant effects. On the other hand, GLP-1 RAs do not appear to affect the rate of decline of glomerular filtration rate. However, this might be due to the relatively short duration of the trials that evaluated their effects on DKD. Moreover, these trials were not designed nor powered to assess renal outcomes. Given than macrolbuminuria is a strong risk factor for the progression of DKD, it might be expected that GLP-1 RAs will prevent the deterioration in renal function in the long term. Nevertheless, this remains to be shown in appropriately designed randomized controlled trials in patients with DKD.

Acetyl-CoA carboxylase inhibitors in non-alcoholic steatohepatitis: Is there a benefit?

De novo lipogenesis (DNL) plays an important role in the pathogenesis of hepatic steatosis and also appears to be implicated in hepatic inflammation and fibrosis. Accordingly, the inhibition of acetyl-CoA carboxylase, which catalyzes the rate-limiting step of DNL, might represent a useful approach in the management of patients with nonalcoholic fatty liver disease (NAFLD). Animal studies and preliminary data in patients with NAFLD consistently showed an improvement in steatosis with the use of these agents. However, effects on fibrosis were variable and an increase in plasma triglyceride levels was observed. Therefore, more long-term studies are needed to clarify the role of these agents in NAFLD and to determine their risk/benefit profile.

LETTER TO THE EDITOR: Pomegranate Juice is Useful for the Management of Hypertension and the Improvement of Cardiovascular Health

DEAR EDITOR

We thank Prof. Liberopoulos and Dr Barkas you for their letter [1], which helps to enhance the understanding of the message of the associated Editorial.

Price and availability of pomegranate juice (PJ) are indeed two major issues. The daily cost of PJ consumption is ranging from 0.5 to 1 $ per day, according to the dose used. PJ is available in almost all Western and several Asian countries. PJ is preserved in deep refrigeration and is readily available during the entire year. PJ circulates mainly in two forms: pure juice in 200 to 500 mL bottles (adulteration is practically impossible, because the color and the taste are unique) and in 1 L bottles, blended with purple grape juice without added sugar. The later contains resveratrol, a type of natural phenol and a phytoalexin, found in the skin of red grapes with definite antidiabetic effects and proposed but not proved yet anti-aging and anticancer effects. Resveratrol treatment has shown beneficial effects on glucose and lipid metabolism in some, but not all studies [2,3]. Study population, resveratrol source, and dose vary widely, potentially explaining inconsistency of findings among studies. Enhancement in endothelial function, systolic blood pressure, and markers of oxidative stress and inflammation in several studies have been reported [2,3].

The quantity and calorie intake is not a problem. Most studies (performed by Prof Aviram team) used a 50 mL PJ intake [4], mainly from the “wonderful” variety [5]. The juice has a 10% content of sugar (5 g/d). Thus, calorie intake is not significant. In regard to diabetes mellitus the use of PJ, especially if this is mixed with purple crape juice, substantially reduces blood glucose and the risk of diabetes, and not the other way around [2-5]. As a matter of fact PJ has more antiatherogenic effects on patients with diabetes than in non-diabetic individuals [4-6].

The studies showing a beneficial effect of PJ on cardiovascular risk factors indeed included a small number of participants, were mostly not double blinded and evaluated only surrogate end-points. This is why we suggest that PJ might be only used as an adjunctive therapy for arterial hypertension (HTN) on top of other non-pharmacological interventions or drug therapy [7], and mainly in patients with HTN and high oxidative burden such as this caused by diabetes, obesity, metabolic syndrome or smoking [7]. This is not a first line therapy and is not suggested for monotherapy [7]. It is unfortunate that up to day there have been no sponsors or grants available to clear this issue once and for all, regardless of the findings, with a large scale, prospective, randomized, controlled survival study in humans.

The effect of PJ on blood pressure is reported by some studies to be as high as a 21% reduction in systolic blood pressure, which is rather sizable reduction [8]. The long term (3-years) effects of PJ on a surrogate endpoint (carotid atherosclerosis) were shown in a clinical study [8]. There were no adverse effects as reported with other antioxidants, such as alpha-tocopherol and beta-carotene [8]. Finally, PJ was shown to have the highest antioxidant potential than any other functional food or supplementary treatment [9].

Common sense suggests that all appropriate pharmacological or non-pharmacological interventions should be implemented for the optimal control of HTN, however, the use of PJ (the other parts of the fruit have no antioxidant actions) could be considered as an adjunctive therapy to improve the control of HTN and the related, mainly cardiovascular, adverse events.

Effect of antihypertensive treatment on the long-term outcome of patients discharged after acute ischemic stroke

We aimed to evaluate the effects of the five main classes of antihypertensive agents on the long-term outcome of 313 consecutive patients discharged after acute ischemic stroke (36.4% males, age 78.5 ± 6.3 years). One year after discharge, the functional status [evaluated with the modified Rankin scale (mRS)], the occurrence of cardiovascular events, and vital status were recorded. Patients prescribed angiotensin receptor blockers (ARBs) had lower mRS than patients not prescribed ARBs (1.7 ± 2.0 vs. 2.9 ± 2.5, respectively; p = 0.006). The rates of adverse outcome (mRS 2-6) and cardiovascular events did not differ between patients prescribed each one of the major classes of antihypertensive agents and those not prescribed the respective class. Patients who were prescribed ARBs had lower risk of death during follow-up than patients who did not receive ARBs (9.4 and 26.9%, respectively; p < 0.05). In binary logistic regression analysis, the only independent predictor of all-cause mortality during follow-up was the mRS at discharge (relative risk 1.69, 95% confidence interval 1.25-2.28; p < 0.001). In conclusion, in patients discharged after acute ischemic stroke, administration of ARBs appears to have a more beneficial effect on long-term functional outcome and all-cause mortality than treatment with other classes of antihypertensive agents.

LETTER TO THE EDITOR Pay-for-performance Versus a Budget-Restrictive System for the Management of Dyslipidemia. Should this Approach also be Applied in Hypertension?

The results of the Dyslipidemia International Study (DYSIS) were reported yesterday in the European Society of Cardiology (ESC) congress held at Amsterdam, Netherlands [1]. DYSIS compared low density lipoprotein cholesterol (LDL-C) target achievement in two West European Countries, UK, with an incentive-driven reimbursement system and Germany, with a budget-restrictive healthcare system. Overall, 80% of UK patients achieved the LDL-C target of <100 mg/dL (mean levels 82 mg/dL), compared with just 42% of patients in Germany (mean levels 111 mg/dL), despite the higher use of ezetimibe in the German population than in the UK population (11 vs. 3%). Dyslipidemic patients in the UK were more likely to be treated with potent statins whereas German doctors were more concerned with insurance restrictions than UK physicians [1]. Thus, it seems that lipid targets are more likely to be achieved in clinical practice in pay-for-performance than in budget-restrictive systems, like in Germany [1]. The UK healthcare system makes physicians participate in a clinical audit, and these results are used to assess the quality of care provided. There are no specific quality-improvement strategies in Germany. Interestingly, the German reimbursement for atorvastatin changed in recent years, and many patients were subsequently switched to the less potent simvastatin [1]. A total of 85% of German patients were treated with simvastatin (average dose 27 mg/d) compared with just 66% of UK patients (average simvastatin dose 37 mg/d), while nearly 25% of UK patients were treated with atorvastatin (average dose 34 mg/d) vs. just 4% of Germans who received this higher-potency statin [1]. These despite the fact that the German population had a higher baseline incidence of cerebrovascular disease, peripheral arterial disease and diabetes mellitus; more secondary prevention patients that should achieve even lower LDL-C targets. Since 2005 there is abundant data suggesting a close relation of LDL-C levels with cardiovascular disease (CVD) events, even between two groups on active statin treatment [2]. The Treating to New Targets study showed a significant 22% further reduction in CVD events achieved with 80 mg/d of atorvastatin (mean LDL-C level 77 mg/dL) compared with 10 mg/d of atorvastatin (mean LDL-C level 100 mg/dL) in high risk patients [2]. This was confirmed in the Pravastatin or Atorvastatin Evaluation and Infection (PROVE-IT) Thrombolysis In Myocardial Infarction (PROVE IT)-TIMI- 22 study in patients with acute coronary syndromes [3]. This was also verified in March 2013 (in the ACC Congress) by the results of the Ibaraki Cardiovascular Assessment Study (ICAS) in CVD patients with initially low LDL-C [4]. These findings suggest that if you save money today from prescribing a cheaper (and less potent) statin you will pay tomorrow twice as much in costs from CVD fatal and non-fatal events. This was confirmed in The Health Improvement Network (THIN) registry [5,6]. Switching from atorvastatin to simvastatin was significantly associated with increased risk for all CVD events [hazards ratio (HR) 1.30, 95% confidence interval (CI) 1.02-1.64], major CVD events (HR 1.43, 95% CI 1.10-1.87), and stroke (HR 2.14, 95% CI 1.21-3.81). Interestingly, these increased risks were partly attributed to differences in lipid levels and partly to the pleitropic effects of statins [5, 6].

Arterial hypertension (AH) is a major risk factor for CVD, accounting globally for 51% of stroke and 45% of ischemic heart disease deaths [7]. The important question is whether treatment results are similar in antihypertensive treatment as in hypolipidaemic treatment if the pay-forperformance approach is used. In UK, the inclusion of renalspecific indicators in a primary care pay for performance (P4P) system has promoted identification and better management of risk factors related to chronic kidney disease (CKD) since April 2006 [8]. The P4P framework, also known as the Quality and Outcomes Framework (QOF), aims at control of CVD risk factors; one of its key targets is AH. It is clear that AH is a major risk factor for CKD, and consequently CVD [8]. Thus, achieving better blood pressure (BP) control is likely to have a positive impact on both CKD and CVD [9]. BP control was improved since the introduction of P4P and this improvement has been sustained [9]. This was associated with a significant increase in the use of antihypertensive medication, resulting in increased prescription cost (€25/month) [9]. Longer-term follow-up will establish whether or not this translates into improved outcomes in terms of progression of CKD and CVD events [9].

But why to restrict this policy only in hypertensive patients with CKD? AH is a prevalent CVD risk factor with rather disappointing control results. A recent systematic review evaluated data regarding AH control from 35 countries [10]. AH control was achieved in about third of treated patients. In particular, AH control rates were higher in women than in men (36.8% versus 31.9%), and in developed countries compared to developing countries (33.3% versus 29.6% for men, and 38.4 versus 34.0% for women, respectively) [10]. However, when the awareness and treatment of hypertension were taken into account, the true hypertension control rates were substantially lower (16.9% for women versus 10.5% for men) and rather similar in developed and developing countries (17.3% versus 16.2% for men, and 10.8% versus 9.8% for women, respectively) [10]. These incredibly disappointing AH control rates were verified in the Copenhagen City Heart Study, a prospective longitudinal study. During the 25-year follow up period AH control increased from 21% to 26% [11]. Once again however, when control rates were adjusted for AH awareness and treatment, the true AH control rates were improved but remained unacceptably low (4.7% vs. 1.4%). It is therefore of no surprise that 7.6 million premature deaths (about 13.5% of the global total) are attributed to high BP [12].

A study evaluated an intensive protocol-based strategy for achieving BP control in family practice in the Centre for Studies in Primary Care, Queen's University, Kingston, Ontario [13]. There was an improvement between baseline and 12-month follow-up. BP control was significantly better for the intervention group as assessed with both systolic and diastolic mean BP on 24-hour ambulatory BP monitoring [13]. This suggests that an intensive, protocol-based approach to achieve BP control in hypertensive patients in family practice is effective and works even when there is flexibility built into the algorithm to allow family physicians to use their judgment in individual patients [13].

Moreover, data from the REACH Registry, Austrian Chapter, determined the extent of lost therapeutic benefit (LTB) in hypertensive patients, and investigated the relationship between the presence of LTB and clinical outcomes [14]. Presence of heart failure, previous myocardial infarction and being male decreased the likelihood of LTB, while presence of diabetes, age > 65 and ankle brachial index < 0.90 increased the risk of LTB. Patients with LTB in the age category 55-64 had higher incidence of vascular events compared to those with non-LTB [14].

The pay-for-performance system was introduced in the new General Medical Services contract in the United Kingdom since April 2004, and general practitioners are awarded for the achievement of various clinical targets, including hypertension control [15]. Some reports questioned the effectiveness of the pay-for-performance system on blood pressure control [16,17], however several lines of evidence point towards a beneficial effect of the P4P system on blood pressure management. A large longitudinal survey in over 8,500 general practices in England demonstrated that both blood pressure monitoring and blood pressure control have improved substantially after the implementation of the P4P system [18]. In particular, a mean increased of 6% to 8% in blood pressure control rates was observed in hypertensive patients with or without coronary artery disease, cerebrovascular disease, and diabetes [18]. Another recent study evaluated the effects of pay-for-performance system in Wandswort, London at 2007 [19]. This interrupted time series study showed that both systolic and diastolic blood pressure were constantly decreasing after the implementation of the pay-for-performance system, for a mean reduction of 5.8 mmHg for systolic and 2.9 mmHg for diastolic between 2003 and 2007 [19]. More importantly, robust epidemiological data confirm the improvements in hypertension control rates in England. The results of the 2006 Health Survey in England revealed that hypertension control rates increased from 22% at 2003 to 28% at 2006, especially in women (from 23% to 32%) [20]. Although several factors might have contributed to this improvement in control rates, it seems very likely that the pay-for-performance system might have exerted beneficial effects.

The pay-for-performance system might also affect the inequalities in primary care delivery. The quality of health services is usually compromised in deprived areas. It has been shown that the financial incentives of the pay-forperformance system have substantially reduced the inequalities in clinical care delivery due to area deprivation, narrowing the gap between the least deprived and the most deprived areas from 4.0% to 0.8% [21]. Similar beneficial effects of the pay-for-performance system might also apply for the ethnic disparities in hypertension management. Although some older studies reported the persistence of ethnic disparities in the management of hypertension [22], more recent studies demonstrate attenuation of ethnic disparities in blood pressure control [19].

In contrast, the removal of financial incentives carries the risk of worsening performance levels. Indeed, a study from the Kaiser Permanente Insurance System in Northern California reveals that when financial incentives for some conditions were removed from some facilities, the level of performance for the detection and control of these conditions declined significantly by about 3% per year [23], while the reattachment of financial incentives was associated with significant improvements.

To conclude, it appears that pay-for-performance, especially based on treatment protocols, may substantially increase BP control with considerable clinical benefits and in a cost-effective way.

Treating Arterial Stiffness Associated with Features of Metabolic Syndrome Not Included in its Diagnostic Criteria: Cutting Off the Heads of Lernaean Hydra, Keeper of the Underworld

The clustering of cardio-metabolic risk factors, regardless if this is called metabolic syndrome (MetS) or not, substantially increases the risk of cardiovascular disease (CVD) and all-cause mortality. One of the possible mechanisms of the rise in CVD incidence is the increase in arterial stiffness (AS), which is a significant and independent CVD risk factor. Hypertension has long been connected to AS. Besides MetS components (obesity, dyslipidaemia, hypertension, dysglycaemia), MetS-associated disease states, not included in the MetS diagnostic criteria (renal dysfunction, hyperuricaemia, non alcoholic fatty liver disease, obstructive sleep apnea, polycystic ovary syndrome and hypercoaglutability) have been implicated in the increase of CVD risk through the increase of AS, among other mechanisms. Treatment options for AS induced by these non-diagnostic features of MetS are discussed. The impact of lifestyle changes is analyzed. Among pharmacological interventions, statin treatment seams to hold a pivotal role. Furthermore, we discuss specific measures for each disease state separately.

Acenocoumarol vs. low-dose dabigatran in real-world patients discharged after ischemic stroke

The aim of this study was to compare the efficacy of dabigatran 110 mg twice daily and acenocoumarol in patients with atrial fibrillation discharged after ischemic stroke. We prospectively studied 436 consecutive patients who were discharged after acute ischemic stroke (39.2% males, age 78.6 ± 6.7 years). Approximately 1 year after discharge, the functional status was assessed with the modified Rankin scale (mRS). Adverse outcome was defined as mRS between 2 and 6. The occurrence of ischemic stroke, myocardial infarction (MI) and death during the 1-year follow-up was also recorded. At discharge, 142 patients had atrial fibrillation. Acenocoumarol and dabigatran 110 mg twice daily were prescribed to 52.1 and 6.3% of these patients, respectively. At 1 year after discharge, there was a trend for patients treated with acenocoumarol to have lower mRS than patients prescribed dabigatran (2.3 ± 2.4 and 4.1 ± 2.2, respectively; P = 0.060). Adverse outcome rates and the incidence of stroke during follow-up did not differ between the two groups. The incidence of MI was almost three times higher in patients prescribed dabigatran than in those prescribed acenocoumarol, but this difference did not reach significance (11.1 and 4.0%, respectively; P = 0.254). The incidence of cardiovascular death was also almost three times higher in the former, but again this difference was not significant (33.3 and 12.2%, respectively; P = 0.237). In real-world patients with acute ischemic stroke, dabigatran 110 mg twice daily is as effective as acenocoumarol in preventing stroke but appears to be associated with worse long-term functional outcome and higher incidence of MI.

Using Serum Biomarkers for Identifying Unstable Carotid Plaque: Update of Current Evidence

Carotid atherosclerosis is responsible for a great proportion of ischemic strokes. Early identification of unstable or vulnerable carotid plaques, and therefore, of patients at high risk for stroke, is of significant medical and socioeconomical value. We reviewed the current literature and discussed the potential role of the most important serum biomarkers in identifying patients with carotid atherosclerosis who are at high risk for atheroembolic stroke.

Management of type 2 diabetes mellitus in youth

The rising rates of obesity in youth have concurrently led to an increase in the rates of type 2 diabetes mellitus (T2DM) in this age group. However, there are limited data on the efficacy of different antidiabetic agents in youth. In this context, the Treatment Options for Type 2 Diabetes in Adolescents and Youth trial recently reported that the majority of obese children and adolescents 10-17-years old with newly diagnosed T2DM (T2DM duration less than 2 years) could not achieve HbA1c levels < 8% for more than 1 year with metformin monotherapy, metformin plus rosiglitazone combination, or metformin and lifestyle changes. These findings suggest that, in the majority of youth with T2DM, tight long-term glycemic control with oral agents is an elusive goal and that most patients will require treatment with insulin within a few years of diagnosis to achieve HbA1c targets and reduce the risk of macro- and microvascular complications. Therefore, reducing the incidence of T2DM by preventing pediatric obesity through the implementation of lifestyle changes in the community should be the primary objective of healthcare systems.

Gynecology healthcare professionals towards safety procedures in operation rooms aiming to enhanced quality of medical services in Greece

PURPOSE

The purpose of this paper is to investigate the attitudes of healthcare professionals in Greece toward safety practices in gynecological Operation Rooms (ORs).

DESIGN/METHODOLOGY/APPROACH

An anonymous self-administered questionnaire was distributed to surgical personnel asking for opinions on safety practices during vaginal deliveries (VDs) and gynecological operations (e.g. sponge/suture counting, counting documentation, etc.). The study took place in Hippokration Hospital of Thessaloniki including 227 participants. The team assessed and statistically analyzed the questionnaires.

FINDINGS

Attitude toward surgical counts and counting documentation, awareness of existence and/or implementation in their workplace of other surgical safety objectives (e.g. WHO safety control list) was assessed. In total, 85.2 percent considered that surgical counting after VDs is essential and 84.9 percent admitted doing so, while far less reported counting documentation as a common practice in their workplace and admitted doing so themselves (50.5/63.3 percent). Furthermore, while 86.5 percent considered a documented protocol as necessary, only 53.9 percent admitted its implementation in their workplace. Remarkably, 53.1 percent were unaware of the WHO safety control list for gynecological surgeries.

ORIGINALITY/VALUE

Most Greek healthcare professionals are well aware of the significance of surgical counting and counting documentation in gynecology ORs. However, specific tasks and assignments are unclear to them. Greek healthcare professionals consider surgical safety measures as important but there is a critical gap in knowledge when it comes to responsibilities and standardized processes during implementation. More effective implementation and increased personnel awareness of the surgical safety protocols and international guidelines are necessary for enhanced quality of surgical safety in Greece.

An up-to-date evaluation of sotagliflozin for the treatment of type 1 diabetes

INTRODUCTION

The majority of patients with type 1 diabetes mellitus (T1DM) do not achieve glycemic targets. In addition, treatment with insulin is associated with increased risk for hypoglycemia and weight gain. Accordingly, there is an unmet need for new safe and effective glucose-lowering agents in this population. Sotagliflozin, a dual inhibitor of sodium-glucose co-transporters 1 and 2, has been recently approved for use in patients with T1DM.

AREAS COVERED

The authors review the major trials that have evaluated the safety and efficacy of sotagliflozin and provide their expert opinion.

EXPERT OPINION

Even though sotagliflozin reduces HbA1 c levels and does not appear to increase the risk for hypoglycemia in most patients, the substantially increased risk for diabetic ketoacidosis limits the use of this agent to a carefully selected subgroup of patients with T1DM. Based on the existing evidence, sotagliflozin should be considered only in patients who have failed to achieve adequate glycemic control despite optimal insulin therapy, are at low risk for diabetic ketoacidosis, have been adequately trained to recognize this complication and are able to be in close contact with their physician.

The association of in vitro fertilization/intracytoplasmic sperm injection results with anxiety levels and stress biomarkers: An observational, case-control study✰

INTRODUCTION

Anxiety has been considered to exert a negative influence on fecundity. However, it remains unclear whether it is a cause or a consequence and whether it is associated with the treatment outcome. This observational case control study evaluated the levels of state anxiety and various stress biomarkers and assessed their association with in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes.

MATERIALS AND METHODS

We allocated 109 infertile nulliparous women aged 25-45 years in their first IVF/ICSI fresh treatment cycle into two groups according to the final outcome: group A (PTP = pregnancy-test positive, n = 49) and group B (PTN = pregnancy-test negative, n = 60). State anxiety levels were measured with the Spielberger Trait Anxiety Inventory (STAI) questionnaire (Marteau and Bekker modification) on the days of oocyte retrieval (OR) and embryo transfer (ET). Serum stress biomarkers (cortisol, adrenaline, noradrenaline, α-amylase, and prolactin) were measured at the same time points. Blood samples were collected at 9 am.

RESULTS

Most women in both groups showed comparable mild-to-moderate degrees of state anxiety on the days of OR and ET (p = 0.183 and p = 0.760, respectively). The stress biomarker measurements did not differ between the two groups, except for noradrenaline that was higher in group B (p = 0.015) and associated with significant cardiovascular changes.

DISCUSSION

Women in both groups showed comparable levels of state anxiety, which were unlikely to influence the chance of pregnancy. Noradrenaline levels were higher in the non-pregnant group, with significant cardiovascular changes. Other stress biomarkers did not reflect the different treatment outcomes between the groups.

Role of sodium-glucose co-transporter-2 inhibitors in the management of heart failure in patients with diabetes mellitus

Heart failure (HF) is a major complication of diabetes mellitus (DM). Patients with DM have considerably higher risk for HF than non-diabetic subjects and HF is also more severe in the former. Given the rising prevalence of DM, the management of HF in diabetic patients has become the focus of increased attention. In this context, the findings of several randomized, placebo-controlled trials that evaluated the effects of sodium-glucose co-transporter-2 inhibitors on the risk of hospitalization for HF in patients with type 2 DM represent a paradigm shift in the management of HF. These agents consistently reduced the risk of hospitalization for HF both in patients with and in those without HF. These benefits appear to be partly independent from glucose-lowering and have also been reported in patients without DM. However, there are more limited data regarding the benefit of sodium-glucose co-transporter-2 inhibitors in patients with HF and preserved left ventricular ejection fraction, which is the commonest type of HF in diabetic patients.