Lifestyle Approach and Medical Therapy of Lower Extremity Peripheral Artery Disease

Lower extremity peripheral artery disease (PAD) is common among patients with several risk factors, such as elderly, smoking, hypertension, and diabetes mellitus. Notably, PAD is associated with a higher risk of cardiovascular complications. Non-invasive interventions are beneficial to improve morbidity and mortality among patients with PAD. Traditional risk factors like smoking, diabetes mellitus, hypertension, and dyslipidemia play a significant role in the development of PAD. Still, additional factors such as mental health, glycemic control, diet, exercise, obesity management, lipid-lowering therapy, and antiplatelet therapy have emerged as important considerations. Managing these factors can help improve outcomes and reduce complications in PAD patients. Antiplatelet therapy with aspirin or clopidogrel is recommended in PAD patients, with clopidogrel showing more significant benefits in symptomatic PAD individuals. Managing several risk factors is crucial for improving outcomes and reducing complications in patients with PAD. Further research is also needed to explore the potential benefits of novel therapies. Ultimately, a comprehensive approach to PAD management is essential for improving morbidity and mortality among patients with this condition.

Carotid and Renal Vascular Disease

This article review covers carotid artery disease, abdominal aortic aneurysm, and atherosclerotic renal artery disease. It overviews each condition's clinical presentation, diagnosis, medical management, and interventional approach. Carotid artery disease is characterized by hemispheric and neuropsychological manifestations, which can help detect this condition. Screening for carotid artery stenosis is recommended in high-risk individuals and can be performed using different methods, with carotid duplex ultrasonography being the preferred option. Carotid endarterectomy and carotid artery stenting are indicated based on specific criteria and patient characteristics. An abdominal aortic aneurysm is often asymptomatic, but abdominal, back, or flank pain may sometimes be present. Ultrasonography is an effective method for screening and monitoring abdominal aortic aneurysms, with high sensitivity and specificity. Smoking cessation is a crucial intervention for preventing further enlargement of small aortic aneurysms. Repair of abdominal aortic aneurysm is recommended based on the aneurysm size, growth rate, and the presence of symptoms. Endovascular repair is preferred when suitable anatomy is present. Atherosclerotic renal artery disease is associated with resistant hypertension, renal failure, and occasionally pulmonary edema. Doppler ultrasonography is a valuable diagnostic tool for detecting it, while the renal resistive index provides additional insights into disease severity and treatment response. Revascularization is not routinely recommended for atherosclerotic renal artery disease, but it may be considered in specific cases, such as renal arterial fibromuscular dysplasia or unexplained congestive heart failure.

Non-Coronary Atherosclerotic Arterial Disease: Where Are We Now?

Lower extremity peripheral artery and upper extremity artery disease are significant vascular conditions with distinct clinical presentations and diagnostic and therapeutic approaches. The lower extremity peripheral artery is associated with worse major adverse cardiovascular events compared with coronary artery disease, but often remains underdiagnosed and undertreated. Upper extremity artery disease encompasses a range of clinical presentations resulting from atherosclerosis and other obstructive lesions in arteries such as the subclavian artery and brachiocephalic trunk. While atherosclerosis is a common cause, non-atherosclerotic factors can also influence distal lesions. This review aims to synthesize existing knowledge on both conditions, encompassing risk factors, clinical manifestations, diagnostic modalities, and treatment options. Improved awareness and early intervention can mitigate complications and enhance patient outcomes for lower extremity peripheral artery and upper extremity artery disease.

Comparison of Outcomes Between Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers in Patients With Myocardial Infarction: A Meta-Analysis

Patients with acute myocardial infarction (AMI) are usually treated with angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARB). The aim of this meta-analysis is to compare outcomes between ACEi and ARB in patients with myocardial infarction (MI). This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Three major online databases, including PubMed, EMBASE, and the Cochrane Library, were thoroughly searched to find studies comparing ACEi and ARB in patients with MI from January 1, 2000, onwards, without language or publication restrictions. Outcomes assessed in this meta-analysis included major adverse cardiovascular events (MACE), all-cause mortality, cardiovascular mortality, stroke, and hospitalization due to heart failure. A total of 16 studies were included in this meta-analysis. Pooled estimates showed no significant differences between the two groups in terms of MACE (risk ratio (RR): 1.03, 95% confidence interval (CI): 0.88-1.20), all-cause mortality (RR: 1.03, 95% CI: 0.88-1.20), cardiovascular mortality (RR: 1.00, 95% CI: 0.89-1.12), stroke (RR: 1.03, 95% CI: 0.80-1.32), and hospitalization due to heart failure (RR: 0.99, 95% CI: 0.90-1.09). These results suggest that ACEi and ARB have similar impacts on clinical outcomes across a broad spectrum of MI patients, reinforcing their roles in post-MI treatment.

Safety and Efficacy of Efpeglenatide in Patients With Type 2 Diabetes: A Meta-Analysis of Randomized Controlled Trials

The aim of this study was to assess the efficacy and safety of efpeglenatide in patients with type 2 diabetes (T2D). The study was reported according to the 2020 guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Web of Science, PubMed, and Scopus databases were searched by two authors independently, with no restriction on language and year of publication, using the following key terms: (efpeglenatide) OR (glucagon-like peptide-1 receptor agonist) AND (type 2 diabetes) OR (diabetes) OR (T2DM) AND (HbA1c) OR (FSG) OR (fasting serum glucose) OR (weight) OR (bodyweight) OR (adverse events) OR (safety) OR (AE). Outcomes assessed in this meta-analysis included change in hemoglobin A1C (HbA1C) from baseline (%), change in weight from baseline (Kg), and change in fasting serum glucose (FSG) from baselines. For the safety analysis, we assessed total adverse events and gastrointestinal (GI) adverse events. A total of four studies fulfilled the inclusion and exclusion criteria and were included in this meta-analysis, encompassing six randomized controlled trials (RCTs). Compared with a control group, efpeglenatide lowered the HbA1c (mean difference (MD): -0.81, 95% confidence interval (CI): -1.01 to -0.60), body weight (MD: -1.15, 95% CI: -1.82 to -0.47), and FSG (MD: -0.98, 95% CI: -1.19 to -0.77). However, the risk of GI-related adverse events was significantly higher in the efpeglenatide group compared to the control group.

Dual Antiplatelet Therapy: A Concise Review for Clinicians

Dual antiplatelet therapy (DAPT) combines two antiplatelet agents to decrease the risk of thrombotic complications associated with atherosclerotic cardiovascular diseases. Emerging data about the duration of DAPT is being published continuously. New approaches are trying to balance the time, benefits, and risks for patients taking DAPT for established cardiovascular diseases. Short-term dual DAPT of 3-6 months, or even 1 month in high-bleeding risk patients, is equivalent in terms of efficacy and effectiveness compared to long-term DAPT for patients who experienced percutaneous coronary intervention in an acute coronary syndrome setting. Prolonged DAPT beyond 12 months reduces stent thrombosis, major adverse cardiovascular events, and myocardial infarction rates but increases bleeding risk. Extended DAPT does not significantly benefit stable coronary artery disease patients in reducing stroke, myocardial infarction, or cardiovascular death. Ticagrelor and aspirin reduce cardiovascular events in stable coronary artery disease with diabetes but carry a higher bleeding risk. Antiplatelet therapy duration in atrial fibrillation patients after percutaneous coronary intervention depends on individual characteristics and bleeding risk. Antiplatelet therapy is crucial for post-coronary artery bypass graft and transcatheter aortic valve implantation; Aspirin (ASA) monotherapy is preferred. Antiplatelet therapy duration in peripheral artery disease depends on the scenario. Adding vorapaxar and cilostazol may benefit secondary prevention and claudication, respectively. Carotid artery disease patients with transient ischemic attack or stroke benefit from antiplatelet therapy and combining ASA and clopidogrel is more effective than ASA alone. The optimal duration of DAPT after carotid artery stenting is uncertain. Resistance to ASA and clopidogrel poses an incremental risk of deleterious cardiovascular events and stroke. The selection and duration of antiplatelet therapy in patients with cardiovascular disease requires careful consideration of both efficacy and safety outcomes. The use of combination therapies may provide added benefits but should be weighed against the risk of bleeding. Further research and clinical trials are needed to optimize antiplatelet treatment in different patient populations and clinical scenarios.

Aortic Stenosis Phenotypes and Precision Transcatheter Aortic Valve Implantation

Patients with a clinical indication for aortic valve replacement can either undergo surgical aortic valve replacement (SAVR) or Transcatheter Aortic Valve Implantation (TAVI). There are many different factors that go into determining which type of replacement to undergo, including age, life expectancy, comorbidities, frailty, and patient preference. While both options offer significant benefits to patients in terms of clinical outcomes and quality of life, there is growing interest in expanding the indications for TAVI due to its minimally invasive approach. However, it is worth noting that there are several discrepancies in TAVI outcomes in regards to various endpoints, including death, stroke, and major cardiovascular events. It is unclear why these discrepancies exist, but potential explanations include the diversity of etiologies for aortic stenosis, complex patient comorbidities, and ongoing advancements in both medical therapies and devices. Of these possibilities, we propose that phenotypic variation of aortic stenosis has the most significant impact on post-TAVI clinical outcomes. Such variability in phenotypes is often due to a complex interplay between underlying comorbidities and environmental and inherent patient risk factors. However, there is growing evidence to suggest that patient genetics may also play a role in aortic stenosis pathology. As such, we propose that the selection and management of TAVI patients should emphasize a precision medicine approach.

POS1342 DEPLETION OF KLRG1+ T CELLS IN A FIRST-IN-HUMAN CLINICAL TRIAL OF ABC008 IN INCLUSION BODY MYOSITIS (IBM)

Background

Inclusion body myositis (IBM), a relentlessly progressive autoimmune skeletal muscle disease, has no effective available pharmacological therapy. A prominent feature of IBM on microscopy is highly differentiated effector CD8+ cytotoxic T (Tc) cells invading non-necrotic myofibers [1]. These Tc cells, known to be relatively resistant to apoptosis, express markers including killer cell lectin-like receptor G1 (KLRG1) [2]. ABC008, a first-in-class humanized, afucosylated monoclonal antibody (mAb) specific for KLRG1, selectively depletes these highly differentiated Tc cells while sparing other blood cell populations, e.g., naïve, central memory, and regulatory T cells and B cells. ABC008 has been designed to treat diseases mediated by these Tc cells, including IBM and T-cell large granular lymphocytic leukemia (T-LGLL). IBM and rheumatoid arthritis overlap clinically with T-LGLL and share similar expansions of large granular lymphocytes (LGLs), which also express KLRG1. We report here our preliminary data from our ongoing trial of ABC008 in IBM (NCT04659031).

Objectives

Evaluate the safety, pharmacodynamics (PD), and pharmacokinetics (PK) of ABC008 administered subcutaneously (SC) in adults with IBM.

Methods

In this first-in-human, open-label, single ascending dose trial with 3 + 3 design evaluating ABC008 SC, eligible participants must have clinicopathologically defined, clinically defined, or probable IBM according to the European Neuromuscular Centre 2011 research diagnostic criteria [3] and an IBM Functional Rating Scale (IBMFRS) score ≤38. Four dose cohorts are planned: ABC008 0.1, 0.5, 2.0, and 5.0 mg/kg. PD, PK, safety, and disease severity assessments are performed pre-dose (Day 0) and during the 6-month follow-up period.

Results

Five of the 6 (83.3%) participants were male with baseline mean age = 65.7 years, mean IBM disease duration = 6.8 years, and mean IBMFRS score = 27.5 (Table 1). Each received a single dose of ABC008 SC: Cohorts 1 (C1) and 2 (C2) received 0.1 and 0.5 mg/kg and have completed 168 and 56 days of follow-up, respectively.

Table 1.

Baseline Demographics

Baseline CharacteristicsABC008 SC Treatment GroupsCohort 10.1 mg/kg SC (n=3)Cohort 20.5 mg/kg SC (n=3)ABC008 Overall (N=6)Age (years), mean ± SD64.0 ± 11.3667.3 ± 6.6665.7 ± 8.52Male sex, n (%)3 (100)2 (66.7)5 (83.3)Caucasian3 (100)3 (100)6 (100)Body Mass Index (kg/m2)28.5 ± 3.5828.3 ± 4.2528.4 ± 3.52Disease Duration (years), mean ± SD9.7 ± 5.973.9 ± 4.486.8 ± 5.70IBMFRS score, mean ± SD30.0 ± 4.0825.0 ± 6.1627.5 ± 5.80

Abbreviations: IBMFRS, Inclusion Body Myositis Functional Rating Scale; n or N, number; SC, subcutaneous; SD, standard deviation.

Maximum depletion of CD8+KLRG1+ cells for C1 and C2 ranged from 46-96% and 98-99%, respectively (Figure 1A), with depletion evident by the next assessment on Day 1. Recovery in C1 began at Day 84 with Day 168 depletion at 29-71%. Other hematologic parameters generally were stable (e.g., T regulatory and B cells). CD8+CD57+ LGLs, mostly KLRG1+, were also depleted (Figure 1B). Preliminary PK showed that ABC008 SC displays a long absorption phase and slow clearance properties typical of mAb therapies. No severe adverse events (AEs) or discontinuations due to AEs have been reported. One unrelated serious AE of fall with muscle tear in a C1 participant with a prior history of falls occurred.

Figure 1.

Key pharmacodynamic parameters in Study ABC008-IBM-101. Baseline and change (A) of KLRG1+CD8+ T cells and (B) CD8+CD57+ large granular lymphocytes (LGLs). C1 and C2 are Cohorts 1 and 2; P1, P2, and P3 are Participants 1, 2, and 3.

Conclusion

In study participants with IBM, single SC doses of 0.1 and 0.5 mg/kg of ABC008 resulted in the depletion of CD8+KLRG1+ cells and CD8+CD57+ LGLs with clear evidence of a dose response for KLRG1+ T cell depletion and no apparent safety signals. Based on these results, a study evaluating ABC008 for the treatment of T-LGLL is planned.

References

[1]Engel AG, et al. Ann Neurol. 1984;16:209-15.

[2]Greenberg SA, et al. Brain. 2016;139:1348-60.

[3]Rose MR, et al. Neuromuscul Disord. 2013;23:1044-55.

Disclosure of Interests

Niti Goel Shareholder of: UCB, Abcuro, Inc, Employee of: Abcuro, Inc, Merrilee Needham Consultant of: Abcuro, Inc, Grant/research support from: Abcuro, Inc, Dulce Soler-Ferran Shareholder of: Abcuro, Inc, Employee of: Abcuro, Inc, Monette M. Cotreau Consultant of: Abcuro, Inc, Jorge Escobar Shareholder of: Abcuro, Employee of: Abcuro, Steven Greenberg Shareholder of: Abcuro, Inc, Consultant of: Abcuro, Inc

Dietary supplementation with anti-IL-10 antibody during a severe Eimeria challenge in broiler chickens

Attenuation of host IL-10 activity during Eimeria infection may elicit a robust Th1 response to eliminate the parasite from the gut epithelium. An experiment was conducted to study the effects of feeding IL-10 neutralizing antibody delivered via a dried egg product (DEP) on growth performance, immune responsivity, and gut health outcomes during a severe challenge with either Eimeria acervulina (study 1) or Eimeria tenella (study 2) following FDA CVM #217 protocol to test anticoccidial products. A total of 720 male Ross 308 chicks were used in each study, with 15 replicate cages of 12 birds and the following 4 treatments: sham-inoculated (uninfected) control diet (UCON), Eimeria-infected control diet (ICON), and Eimeria-infected control diet supplemented with DEP at 2 levels (165 [I-165] or 287 [I-287] U/tonne in study 1 and 143 [I-143] or 287 [I-287] U/tonne in study 2). Individual birds assigned to infected treatment groups received a single oral dose of either 200,000 E. acervulina (study 1) or 80,000 E. tenella (study 2) oocysts at 12 d of age (i.e., d post inoculation [DPI] 0), whereas uninfected birds were sham-inoculated with tap water. A one-way ANOVA was performed on outcomes including growth performance, hematology, serum chemistry profiles, immunophenotyping profiles, and intestinal lesion scores. In both studies, DPI 0 to 7 weight gain, feed intake, and feed conversion ratio were worse (P < 0.05) in all infected groups compared with the UCON group. Compared with ICON, DEP supplementation elicited no differences on overall growth performance. Histopathology and lesion scores revealed severe damage to the gut epithelium owing to the Eimeria challenge, yet DEP supplementation did not improve these outcomes or oocyst shedding, hematological measurements, or serum chemistry. However, DEP supplementation improved (P < 0.05) the percentage of circulating CD3⁺ cells at 6 DPI in study 2. These results indicate that DEP does not appear to elicit a coccidiostatic effect during a severe infection with E. acervulina or E. tenella.

Total knee arthroplasty for treatment of osteoarthritis associated with extra-articular deformity

OBJECTIVE

Our purpose was to review senior author results of TKA in patients with extra-articular angular deformities (correction of mechanical axis was performed without an additional procedure for osteotomy).

METHODS

Results of TKA in nine knees with osteoarthritis and associated extra-articular angular deformity of femur were reviewed retrospectively. This group was compare with a with a control group of 20 patients diagnosed with osteoarthritis that underwent TKA without extra-articular deformity. Angulation of deformity in patients was 19° in coronal plane (range 15°-25°) and 12° in sagittal plane (range 8°-5°). Knee Score (KS) and Functional Score (FS) were measured pre and post-surgery, likewise arc flexion was reported. Results in KS and FS were correlationed with extra-articular angulation.

RESULTS

Duration of follow-up averaged 55 months (range, 48-63 months). KS Average and FS increased from 50.5 and 38.4 points, preoperatively, to 96.5 and 84.4 points, respectively, at time of following-up. No statistically significant differences in any postoperative parameters were found between the postoperative group of extra-articular deformities and the control group were found. Positive correlation was obtained between deformity degrees and KS. Arc of motion averaged 86° preoperatively and 118° at time of following-up. No total knee arthroplasty was revised.

CONCLUSION

In our opinion, best management for extra-articular deformities associated to osteoarthritis is to carry out a knee replacement without corrective osteotomy on condition that planification allow to us avoid ligaments insertions, using an extensive soft-tissue balancing in conjunction with a minimally constrained TKA.

Management of severe valgus knee by total unconstrained arthroplasty: A comparative study with long-term follow-up

OBJECTIVE

To evaluate the use of unconstrained implants in the correction of large valgus deformities using total knee arthroplasty (TKA).

MATERIAL AND METHOD

A total of 817 primary TKA operated between 1998 and 2006 were retrospectively assessed. 50 TKA were selected (group A) in 49 patients, with a minimum deformity of 15° of valgus, 41 cases were included. Another 50 ATR were selected (group B), with a maximum deformity of 15° of varus, finally including 44 cases in 42 patients. The same surgeon performed every operation. The minimum follow-up time was 10 years. The Knee Society Score (KS and FS), the Oxford Knee Score (OKS) and the Range of Mobility (ROM), both preoperative and postoperative at 1,.5 and 10 years, as well as radiographic evolution and complications were evaluated.

RESULTS

Preoperative values of KS, FS and OKS were lower in group A (P<.0001, P<.01 and P<.05, respectively), but not ROM. Postoperatively, KS, FS, OKS and ROM were not different between the groups, neither year, nor 5, nor 10 years. There were also no radiological or complications between the two groups.

DISCUSSION

The use of non-constricted implants in severe valgus was not inferior to the mild varus, implying, in addition, a saving in economic terms, with excellent postoperative results.

CONCLUSIONS

Correction of severe valgus deformities can be performed with non-constrained primary implants, without obtaining worse results than those obtained in mild deformities.

Thiol-induced hemoglobin oxidation

Addition of cysteine in the mM range to purified oxyhemoglobin, red blood cell lysate or red blood cell suspensions leads to oxidation of the hemoprotein. The rate and extent of the process depend on the initial hemoglobin and cysteine concentrations, and the reaction is limited by the total destruction of the sulfhydryl groups. Similar results are obtained employing glutathione, but the rate of the process is considerably slower. Oxidation of the purified hemoprotein is faster than in the red blood cell lysate. This difference is mainly due to the inhibitory effect of catalase present in the lysate. Addition of sodium azide increases the rate of oxyhemoglobin oxidation in the lysate, while addition of catalase reduces the rate of oxidation of the purified hemoprotein. The results are interpreted in terms of a mechanism comprising the oxidation of the oxyhemoglobin by the -SH group, with concomitant formation of superoxide anion and hydrogen peroxide. These species further contribute to the oxyhemoglobin oxidation. A chain oxidation of the thiol, catalyzed by the hemoprotein, explains the extensive cysteine destruction.

Multitrial analysis of the effects of copper level and source on performance in nursery pigs

A multitrial analysis was conducted to evaluate the effect of different levels of Cu from either Cu(2-hydroxy-4-(methylthio)butanoic acid [HMTBa])2 or CuSO4 on growth performance in nursery pigs. Six nursery trials were conducted from 2007 to 2012 under the same commercial conditions with initial BW of 5.75 ± 0.41 kg at 21 ± 3 d of age; the trials lasted for 42 d with a 3-phase feeding program (7 d in Phase I, 14 d in Phase II, and 21 d in Phase III). Diets were medicated with antibiotics and supplemented with 3,000 mg/kg Zn as ZnO during phases I and/or II. Treatments included a basal diet without added Cu or according to the NRC (1998) and supplemental levels of Cu (50 to 250 mg Cu/kg diet) from either Cu(HMTBa)2 or CuSO4; HMTBa was supplemented to make diets isomethionine. Treatments from each trial included 6 or 9 replicate pens/treatment with 22 to 25 piglets/pen. Mixed model analysis was conducted in which trial was considered a random effect, Cu level was considered a continuous fixed effect, and Cu source was a fixed effect. The basal diet within trial and statistical tests of the intercept between sources were not different, resulting in fitting a common intercept mixed model to the overall responses across phases. Cumulative ADG and ADFI quadratically responded (P < 0.05) with increasing Cu supplementation; predicted optimal ADG and ADFI occurred at 174 and 119 mg/kg, respectively. Increasing Cu supplementation linearly improved G:F (P = 0.054). No differences between sources were observed in ADG or ADFI. Numerically, pigs fed Cu(HMTBa)2 had higher ADG and lower ADFI compared to pigs fed CuSO4, resulting in better G:F for pigs supplemented with Cu(HMTBa)2 compared to pigs supplemented with CuSO4 (P < 0.01). The linear slope for increasing Cu supplementation on G:F was 2.1-fold higher for Cu(HMTBa)2 than that of CuSO4, with larger differences occurring in Phase II. In conclusion, Cu supplementation in nursery diets resulted in improved performance and Cu(HMTBa)2 is more effective than CuSO4 in improving feed efficiency.

Detection of batch effects in liquid chromatography-mass spectrometry metabolomic data using guided principal component analysis

Metabolomics based on liquid chromatography-mass spectrometry (LC-MS) is a powerful tool for studying dynamic responses of biological systems to different physiological or pathological conditions. Differences in the instrumental response within and between batches introduce unwanted and uncontrolled data variation that should be removed to extract useful information. This work exploits a recently developed method for the identification of batch effects in high throughput genomic data based on the calculation of a δ statistic through principal component analysis (PCA) and guided PCA. Its applicability to LC-MS metabolomic data was tested on two real examples. The first example involved the repeated analysis of 42 plasma samples and 6 blanks in three independent batches, and the second data set involved the analysis of 101 plasma and 18 blank samples in a single batch with a total runtime of 50h. The first and second data set were used to evaluate between and within-batch effects using the δ statistic, respectively. Results obtained showed the usefulness of using the δ statistic together with other approaches such as summary statistics of peak intensity distributions, PCA scores plots or the monitoring of IS peak intensities, to detect and identify instrumental instabilities in LC-MS.

Fracturas del extremo distal de la falange proximal

Las fracturas del extremo distal de la falange proximal, localizadas en la cabeza o cuello de la misma, son con frecuencia inestables y por su complejidad, suelen ser fracturas difíciles de tratar correctamente. No es por ello infrecuente que se produzcan complicaciones tales como consolidaciones en mala posición, seudoartrosis, artrosis postraumática o rigideces de los dedos afectados. El conocimiento de los distintos patrones de fractura, así como su diagnóstico y tratamiento adecuados, son esenciales para conseguir los mejores resultados posibles.

Exponemos en este artículo nuestra experiencia con este tipo de lesiones, realizando una revisión de la literatura de las mismas, tanto en niños como en adultos, analizando los diferentes tipos de fracturas, los tratamientos posibles, las complicaciones más frecuentes que hemos observado y nuestras recomendaciones para evitarlas y tratarlas.

Effects of the rate of insulin infusion during isoglycemic, hyperinsulinemic clamp procedures on measures of insulin action in healthy, mature thoroughbred mares

The objective of this study was to determine whether the rate of insulin infusion during isoglycemic hyperinsulinemic clamp procedures affected measures of insulin action, including glucose disposal and plasma non-esterified fatty acid, endothelin-1, and nitric oxide concentrations, in mature, healthy horses. Eight thoroughbred mares were studied during a 2-h hyperinsulinemic clamp procedure, conducted at each of 4 rates of insulin infusion: 0 (CON), 1.2 (LOWINS), 3 (MEDINS), and 6 (HIGHINS) mU · kg(-1) · min(-1). The infusion rate of a dextrose solution was adjusted throughout the clamp procedures to maintain blood glucose levels within 10% of baseline glucose concentrations. Plasma insulin concentrations were measured throughout the clamp procedures, and used with the rate of glucose infusion to calculate the plasma insulin concentration-to-rate of glucose infusion ratio, a measure of insulin action on glucose disposal. The rate of glucose infusion increased with rate of insulin infusion (P < 0.05). The plasma insulin concentration-to-rate of glucose infusion ratio was highest for the LOWINS treatment (P < 0.05) and decreased by 62% (P < 0.05) and 84% (P < 0.05) for the MEDINS and HIGHINS treatments, respectively. Although plasma non-esterified fatty acid concentrations were lower than baseline by t = 30 min of the clamp procedures in the LOWINS, MEDINS, and HIGHINS treatments (P < 0.05), the decline was similar for all 3 rates of insulin infusion. Jugular vein plasma nitric oxide and endothelin-1 concentrations were not affected by insulin infusion rate (P > 0.05). The data indicate that it is important to standardize insulin infusion rate if data are to be compared between hyperinsulinemic clamp studies.

Insulin infusion stimulates whole-body protein synthesis and activates the upstream and downstream effectors of mechanistic target of rapamycin signaling in the gluteus medius muscle of mature horses

Little is known about the role insulin plays in regulating whole-body and muscle protein metabolism in horses. The objective of this study was to determine the effects of graded rates of insulin infusion on plasma amino acid concentrations and the activation of factors in the mechanistic target of rapamycin signaling pathway in the skeletal muscle of horses. Isoglycemic, hyperinsulinemic clamp procedures were conducted in 8 mature, thoroughbred mares receiving 4 rates of insulin infusion: 0 mU · kg(-1) · min(-1) (CON), 1.2 mU · kg(-1) · min(-1) (LOWINS), 3 mU · kg(-1) · min(-1) (MEDINS), and 6 mU · kg(-1) · min(-1) (HIGHINS). Blood samples were taken throughout the clamp procedures to measure plasma amino acid concentrations, and a biopsy from the gluteus medius muscle was collected at the end of the 2-h clamp to measure phosphorylation of protein kinase B, eukaryotic initiation factor 4E-binding protein 1, and riboprotein S6. Plasma concentrations of most of the essential amino acids decreased (P < 0.05) after 120 min of insulin infusion in horses receiving the LOWINS, MEDINS, and HIGHINS treatments, with the largest decreases occurring in horses receiving the MEDINS and HIGHINS treatments. Phosphorylation of protein kinase B, 4E-binding protein 1, and riboprotein S6 increased with all 3 rates of insulin infusion (P > 0.05), relative to CON, with maximum phosphorylation achieved with MEDINS and HIGHINS treatments. These results indicate that insulin stimulates whole-body and muscle protein synthesis in mature horses.

Effects of jugular-infused lysine, methionine, and branched-chain amino acids on milk protein synthesis in high-producing dairy cows

In addition to lysine and methionine, current ration-balancing programs suggest that branched-chain amino acid (BCAA) supply may also be limiting in dairy cows. The objective of this study was to investigate whether BCAA, leucine, isoleucine, and valine become limiting for milk protein synthesis when methionine and lysine supply were not limiting. Nine multiparous Holstein cows with an average milk production of 53.5±7.1 kg/d were randomly assigned to 7-d continuous jugular infusions of saline (CTL), methionine and lysine (ML; 12 g and 21 g/d, respectively), or ML plus leucine, isoleucine, and valine (ML+BCAA; 35 g, 15 g, and 15 g/d, respectively) in a 3×3 Latin square design with 3 infusion periods separated by 7-d noninfusion periods. The basal diet consisted of 40% corn silage, 14% alfalfa hay, and a concentrate mix, and respectively supplied lysine, methionine, isoleucine, leucine, and valine as 6.1, 1.8, 4.7, 8.9, and 5.3% of metabolizable protein. Dry matter intake (23.9 kg/d), milk yield (52.8 kg/d), fat content (2.55%), fat yield (1.33 kg/d), lactose content (4.77%), lactose yield (2.51 kg/d), and milk protein efficiency (0.38) were similar across treatments. Protein yield and protein content were not significantly different between ML (1.52 kg/d and 2.88%, respectively) and ML+BCAA (1.51 kg/d and 2.83%, respectively), but they were significantly greater than that of CTL (1.39 kg/d and 2.71%). Cows that received ML+BCAA had less milk urea nitrogen content (10.9 mg/dL) compared with milk of CTL cows (12.4 mg/dL) and ML cows (11.8 mg/dL). Whereas high-producing cows responded positively to methionine and lysine supplementation, no apparent benefits of BCAA supplementation in milk protein synthesis were found. Infusion of BCAA may have stimulated synthesis of other body proteins, probably muscle proteins, as evidenced by decreased milk urea nitrogen.

Regulation of protein synthesis in mammary glands of lactating dairy cows by starch and amino acids

The objective of this study was to evaluate local molecular adaptations proposed to regulate protein synthesis in the mammary glands. It was hypothesized that AA and energy-yielding substrates independently regulate AA metabolism and protein synthesis in mammary glands by a combination of systemic and local mechanisms. Six primiparous mid-lactation Holstein cows with ruminal cannulas were randomly assigned to 4 treatment sequences in a replicated incomplete 4 x 4 Latin square design experiment. Treatments were abomasal infusions of casein and starch in a 2 x 2 factorial arrangement. All animals received the same basal diet (17.6% crude protein and 6.61 MJ of net energy for lactation/kg of DM) throughout the study. Cows were restricted to 70% of ad libitum intake and abomasally infused for 36 h with water, casein (0.86 kg/d), starch (2 kg/d), or a combination (2 kg/d starch+0.86 kg/d casein) using peristaltic pumps. Milk yields and composition were assessed throughout the study. Arterial and venous plasma samples were collected every 20 min during the last 8h of infusion to assess mammary uptake. Mammary biopsy samples were collected at the end of each infusion and assessed for the phosphorylation state of selected intracellular signaling molecules that regulate protein synthesis. Animals infused with casein had increased arterial concentrations of AA, increased mammary extraction of AA from plasma, either no change or a trend for reduced mammary AA clearance rates, and no change in milk protein yield. Animals infused with starch had increased milk and milk protein yields, increased mammary plasma flow, reduced arterial concentrations of AA, and increased mammary clearance rates and net uptake of some AA. Infusions of starch increased plasma concentrations of glucose, insulin, and insulin-like growth factor-I. Starch infusions increased phosphorylation of ribosomal protein S6 and endothelial nitric oxide synthase, consistent with changes in milk protein yields and plasma flow, respectively. Phosphorylation of the mammalian target of rapamycin was increased in response to starch only when casein was also infused. Thus, cell signaling molecules involved in the regulation of protein synthesis differentially responded to these nutritional stimuli. The hypothesized independent effects of casein and starch on animal metabolism and cell signaling were not observed, presumably because of the lack of a milk protein response to infused casein.

Use of Saccharomyces cerevisiae fermentation product on growth performance and microbiota of weaned pigs during Salmonella infection

Anaerobically fermented yeast products are a rich source of nutritional metabolites, mannanoligosaccharides, and β-glucans that may optimize gut health and immunity, which can translate into better growth performance and a reduced risk of foodborne pathogens. The objective of this study was to quantify the effects of Saccharomyces cerevisiae fermentation product (Diamond V Original XPC) inclusion in nursery diets on pig performance and gastrointestinal microbial ecology before, during, and after an oral challenge with Salmonella. Pigs (n = 40) were weaned at 21 d of age, blocked by BW, and assigned in a 2 × 2 factorial arrangement consisting of diet (control or 0.2% XPC) and inoculation (sterile broth or Salmonella). Pigs were fed a 3-phase nursery diet (0 to 7 d, 7 to 21 d, and 21 to 35 d) with ad libitum access to water and feed. On d 14, pigs were orally inoculated with 10(9) cfu of Salmonella enterica serovar Typhimurium DT104 or sterile broth. During d 17 to 20, all pigs were treated with a 5 mg/kg of BW intramuscular injection of ceftiofur-HCl. Growth performance and alterations in the gastrointestinal microbial ecology were measured during preinoculation (PRE; 0 to 14 d), sick (SCK; 14 to 21 d), and postinoculation (POST; 21 to 35 d). Body weight and ADG were measured weekly. Rectal temperature (RT) was measured weekly during PRE and POST, and every 12 h during SCK. Diet had no effect on BW, ADG, or RT during any period (P = 0.12 to 0.95). Inclusion of XPC tended (P < 0.10) to increase Salmonella shedding in feces during SCK. Consumption of XPC altered the composition of the gastrointestinal microbial community, resulting in increased (P < 0.05) populations of Bacteroidetes and Lactobacillus after Salmonella infection. Pigs inoculated with Salmonella had decreased ADG and BW, and increased RT during SCK (P < 0.001). Furthermore, fecal Salmonella cfu (log(10)) was modestly correlated (P = 0.002) with BW (r = -0.22), ADFI (r = -0.27), ADG (r = -0.36), G:F (r = -0.18), and RT (r = 0.52) during SCK. After antibiotic administration, all Salmonella-infected pigs stopped shedding. During POST, an interaction between diet and inoculation (P = 0.009) on ADG indicated that pigs infected with Salmonella grew better when eating XPC than the control diet. The addition of XPC to the diets of weanling pigs resulted in greater compensatory BW gains after infection with Salmonella than in pigs fed conventional nursery diets. This increase in BW gain is likely associated with an increase in beneficial bacteria within the gastrointestinal tract.

Oral Ulcers Produced by Mycophenolate Mofetil in Two Liver Transplant Patients

Oral ulcers are a frequent problem in transplant medicine. It is important to consider infectious etiologies, exacerbated by the immunosuppressive treatment, but other etiologies are also possible, like adverse drug reactions. Mycophenolate mofetil (MMF) is an immunosuppressive medication that has been used in combination with calcineurin inhibitors and steroids. Reports of renal transplant patients with oral ulcers related to MMF have appeared lately and herein we have described 2 cases in liver transplant patients. Their oral ulcers resolved quickly after suspension of the medication. Our 2 cases in liver transplant patients represented a unique setting for this type of complication.