A pilot clinical study to Evaluate Liraglutide-mediated Anti-platelet activity in patients with type-2 Diabetes (ELAID study)

BACKGROUND

Liraglutide is an effective treatment for the management of type 2 diabetes mellitus (T2DM). In addition to glycemic control and potential cardioprotective effects, recent studies suggest a possible role for liraglutide in the inhibition of platelet reactivity, further attenuating atherothrombotic risk in patients with T2DM. We evaluated the in-vivo antiplatelet effect of liraglutide in T2DM patients without macrovascular disease or concurrent anti-platelet therapy.

METHODS

A double-blind, placebo-controlled pilot study of 16 T2DM patients, 51-69 y/o, (mean age 60.4 y/o, 63.0% male) randomised to receive liraglutide (1.8 mg/day) or placebo (saline) for 6 months was conducted. Platelet aggregation studies at baseline and after initiation of the study intervention: days 1, 7, and 14 and months 1, 3 and 6 were performed.

RESULTS

Liraglutide (n = 7) and placebo (n = 9) treated patients demonstrated normal platelet aggregation responses although transient and significant attenuation in maximum slope of platelet aggregation in response to collagen (p ≤ 0.05), arachidonic acid (p ≤ 0.05) and ADP (p ≤ 0.02) was observed in liraglutide compared to placebo treated patients in the first week.

CONCLUSIONS

In this pilot study of patients with T2DM liraglutide treatment was associated with a significant, early and transient decrease in maximum slope of platelet aggregation. The clinical significance of this effect is currently unknown and may warrant further investigation.

CLINICAL TRIAL REGISTRATION NUMBER

UTN 1111-1181-9567.

Do Patient Expectations of Discharge Affect Length of Stay after Deep Inferior Epigastric Perforator Flap for Breast Reconstruction?

INTRODUCTION

 Deep inferior epigastric artery perforator (DIEP) flap is a common method of breast reconstruction. Enhanced recovery after surgery (ERAS) postoperative protocols have been used to optimize patient outcomes and facilitate shorter hospital stays. The effect of patient expectations on length of stay (LOS) after DIEP has not been evaluated. The purpose of this study was to investigate whether patient expectations affect LOS.

METHODS

 A retrospective chart review was performed for patients undergoing DIEP flaps for breast reconstruction from 2017 to 2020. All patients were managed with the same ERAS protocol. Patients were divided in Group I (early expectations) and Group II (standard expectations). Group I patients had expectations set for discharge postoperative day (POD) 2 for unilateral DIEP and POD 3 for bilateral DIEP. Group II patients were given expectations for POD 3 to 4 for unilateral DIEP and POD 4 to 5 for bilateral. The primary outcome variable was LOS.

RESULTS

 The study included 215 DIEP flaps (45 unilateral and 85 bilateral). The average age was 49.8 years old, and the average body mass index (BMI) was 31.4. Group I (early expectations) included 56 patients (24 unilateral DIEPs, 32 bilateral). Group II (standard expectations) had 74 patients (21 unilateral, 53 bilateral). LOS for unilateral DIEP was 2.9 days for Group I compared with 3.7 days for Group II (p = 0.004). Group I bilateral DIEP patients had LOS of 3.5 days compared with 3.9 days for Group II (p = 0.02). Immediate timing of DIEP (Group I 42.9 vs. Group II 52.7%) and BMI (Group I 32.1 vs. Group II 30.8) were similar (p = 0.25).

CONCLUSION

 Our study found significantly shorter hospital stay after DIEP flap for patients who expected an earlier discharge date despite similar patient characteristics and uniform ERAS protocol. Patient expectations should be considered during patient counseling and as a confounding variable when analyzing ERAS protocols.

Tourniquet Use in Wide-Awake Carpal Tunnel Release

Background: Carpal tunnel syndrome is a common cause of upper extremity discomfort. Surgical release of the median nerve can be performed under general or local anesthetic, with or without a tourniquet. Wide-awake carpal tunnel release (CTR) (local anesthesia, no sedation) is gaining popularity. Tourniquet discomfort is a reported downside. This study reviews outcomes in wide-awake CTR and compares tourniquet versus no tourniquet use. Methods: Wide-awake, open CTRs performed from February 2013 to April 2016 were retrospectively reviewed. Patients were divided into 2 cohorts: with and without tourniquet. Demographics, comorbidities, tobacco use, operative time, estimated blood loss, complications and outcomes were compared. Results: A total of 304 CTRs were performed on 246 patients. The majority of patients were male (88.5%), and the mean age was 59.9 years. One hundred patients (32.9%) were diabetic, and 92 patients (30.2%) were taking antithrombotics. Seventy-five patients (24.7%) were smokers. A forearm tourniquet was used for 90 CTRs (29.6%). Mean operative time was 24.97 minutes with a tourniquet and 21.69 minutes without. Estimated blood loss was 3.16 mL with a tourniquet and 4.25 mL without. All other analyzed outcomes were not statistically significant. Conclusion: Operative time was statistically longer and estimated blood loss was statistically less with tourniquet use, but these findings are not clinically significant. This suggests that local anesthetic with epinephrine is a safe and effective alternative to tourniquet use in CTR. The overall rate of complications was low, and there were no major differences in postoperative outcomes between groups.

Comparing mail-in self-collected specimens sent via United States Postal Service versus clinic-collected specimens for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae in extra-genital sites

Objectives

To evaluate the concordance between clinic-collected extra-genital specimens and self-collected mailed-in extra-genital specimens among participants seeking sexually transmitted infection testing at a free clinic in Hollywood, CA.

Methods

A convenience sample of 210 men who have sex with men were enrolled between February 29, 2016 and December 21, 2016 and received mail-in testing kits for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). All testing was performed using the GeneXpert® CT/NG (Cepheid, Sunnyvale, CA).

Results

From the 210 mail-in kits distributed, 149 mail-in kits (71.0%) were returned to the laboratory, resulting in 145 pairs (clinic-collected and mail-in) of rectal test results and 148 pairs of pharyngeal test results for both CT and NG detection. The concordance was 95.0% for all CT rectal tests, 99.3% for all CT pharyngeal tests, 95.7% for all NG rectal tests, and 97.2% for all NG pharyngeal tests.

Conclusion

Roughly two-thirds of mail-in test kits were returned and concordance was generally high, however more than one-third of positive results were missed in mail-in samples. The prevalence of potential false-negative results among mail-in samples warrants caution when implementing mail-in STI testing strategies.

Comparative Evaluation of 2 Nucleic Acid Amplification Tests for the Detection of Chlamydia trachomatis and Neisseria gonorrhoeae at Extragenital Sites

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections are frequently asymptomatic, requiring highly accurate diagnostic tests and proper management to prevent further transmission. We compared two nucleic acid tests, Xpert® CT/NG (Cepheid, Sunnyvale, CA) point-of-care platform and at an offsite clinical laboratory with Aptima Combo 2® (Hologic, Inc., San Diego, CA) assay, for the detection of extragenital infection in patients at an STI clinic in Hollywood, CA.We calculated concordance between the two assays and used the exact binomial method to calculate 95% confidence intervals (CIs) for each specimen type and pathogen.The concordance between the two assays was 97.7% (95% CI: 95.7%,99.0%) for 393 paired CT rectal results, 98.2% (95% CI: 96.4%,99.3%) for 391 paired NG rectal results and 98.4% (95% CI: 96.8%,99.4%) for 448 paired NG pharyngeal results.The performance of Xpert® CT/NG assay in point-of-care testing in extragenital specimens was highly similar to the laboratory-based platform.

Decomposition of Concealed and Exposed Porcine Remains in the North Carolina Piedmont

We examined the decomposition and subsequent insect colonization of small pig carrion (Sus scrofa (L.)) placed in concealed and open environments during spring, summer, and fall in Raleigh, North Carolina, as a model for juvenile human remains. Remains were concealed in simulated attics in three manners, ranging from minimal to well-concealed. Concealment had a significant effect on the insect community colonizing the remains across all three seasons; the beetles Necrobia rufipes (DeGeer) (Cleridae) and Dermestes maculatus (DeGeer) (Coleoptera: Dermestidae) were the only species indicative of remains located indoors, whereas numerous fly (Diptera: Calliphoridae, Muscidae, Sepsidae, and Piophilidae) and beetle (Coleoptera: Silphidae, Staphylinidae, and Histeridae) species and an ant species (Hymenoptera: Formicidae, Prenolepis sp.) were indicative of remains located outdoors. Season also significantly affected the insect species, particularly the blow flies (Diptera: Calliphoridae) colonizing remains: Lucilia illustris (Meigen) was indicative of the spring, Cochliomyia macellaria (F.) and Chrysomya megacephala (F.) were indicative of the summer, and Calliphora vicina Robineau-Desvoidy and Calliphora vomitoria (L.) were indicative of the fall. In addition, across all seasons, colonization was delayed by 35–768 h, depending on the degree of concealment. These differences among the insect communities across seasons and concealment treatments, and the effects of concealment on colonization indicate that such information is important and should to be considered when analyzing entomological evidence for criminal investigations.

It's good to talk! Changes in coronary revascularisation practice in PCI centres without onsite surgical cover and the impact of an angiography video conferencing system

INTRODUCTION

Percutaneous coronary intervention (PCI) activity has increased more than 6 fold in the last 15 years. Increased demand has been met by PCI centres without on-site surgical facilities. To improve communication between cardiologists and surgeons at a remote centre, we have developed a video conferencing system using standard internet links. The effect of this video data link (VDL) on referral pattern and patient selection for revascularisation was assessed prospectively after introduction of a joint cardiology conference (JCC) using the system.

METHODS

Between 1st October 2005 and 31st March 2007, 1346 patients underwent diagnostic coronary angiography (CA). Of these, 114 patients were discussed at a cardiology conference (CC) attended by three consultant cardiologists (pre-VDL). In April 2007, the VDL system was introduced. Between 1st April 2007 and 30th September 2008, 1428 patients underwent diagnostic CA. Of these, 120 patients were discussed at a JCC attended by four consultant cardiologists and two consultant cardiothoracic surgeons (post-VDL). Following case-matching for patient demographics and coronary artery disease (CAD) severity and distribution, we assessed the effect upon management decisions arising from both the pre- and post-VDL JCC meetings.

RESULTS

When comparing decision-making outcomes of post-VDL JCC with pre-VDL CC, significantly fewer patients were recommended for PCI (36.8% vs. 17.2% respectively, p = 0.001) and significantly more patients were recommended for surgery (21.1% vs. 48.4% respectively, p < 0.001). There were no significant differences in waiting times for PCI following JCC discussion; however, waiting times for surgical revascularisation were significantly reduced (140.9 ± 71.8 days vs. 99.4 ± 56.6 days respectively, p = 0.045).

CONCLUSIONS

  The VDL system provides a highly practical method for PCI centres without onsite surgical cover to discuss complex patients requiring coronary revascularisation and significantly increases the number of patients referred for surgical revascularisation rather than PCI.

Chronic gestational exposure to ethanol causes insulin and IGF resistance and impairs acetylcholine homeostasis in the brain

In fetal alcohol syndrome (FAS), cerebellar hypoplasia is associated with impaired insulin-stimulated survival signaling. This study characterizes ethanol dose-effects on cerebellar development, expression of genes required for insulin and insulin-like growth factor (IGF) signaling, and the upstream mechanisms and downstream consequences of impaired signaling in relation to acetylcholine (ACh) homeostasis. Pregnant Long Evans rats were fed isocaloric liquid diets containing 0%, 2%, 4.5%, 6.5%, or 9.25% ethanol from gestation day 6. Ethanol caused dose-dependent increases in severity of cerebellar hypoplasia, neuronal loss, proliferation of astrocytes and microglia, and DNA damage. Ethanol also reduced insulin, IGF-I, and IGF-II receptor binding, insulin and IGF-I receptor tyrosine kinase activities, ATP, membrane cholesterol, and choline acetyltransferase (ChAT) expression. In vitro studies linked membrane cholesterol depletion to impaired insulin receptor binding and insulin-stimulated ChAT. In conclusion, cerebellar hypoplasia in FAS is mediated by insulin/IGF resistance with attendant impairments in energy production and ACh homeostasis.

Topical ibopamine in the treatment of chronic ocular hypotony attributable to vitreoretinal surgery, uveitis, or penetrating trauma

PURPOSE

To study whether topical ibopamine effectively increases the intraocular pressure in patients with ocular hypotony after vitreoretinal surgery, uveitis, or penetrating trauma.

DESIGN

A prospective randomized, double-blind, placebo controlled, crossover study.

METHODS

In ten patients with ocular hypotony, an ibopamine 2% solution or placebo eyedrop was administered at 8 am and frequent applanation tonometry was performed during 10 hours on 2 days, 2 weeks apart.

RESULTS

The mean IOP integral after administration of ibopamine was 2.4 mm Hg higher (95% CI for median difference in AUC over 480 minutes [P = .010]) compared with placebo.

CONCLUSIONS

The results of the study show that an ibopamine 2% eyedrop twice a day may increase the IOP for a period of over 8 hours in patients with hypotony.

Influence of antimicrobial agents on the spoilage of a meat-based entomophage diet

The microbial decomposition of a meat-based entomophage diet presented in Parafilm packets was investigated. Considerable bacteria but not fungi were associated with components used to prepare the diet (i.e., hens' eggs, liver, and ground beef). At the initial sampling time, there were no differences among diet treatments in the size of bacterial or fungal populations. Bacterial populations in diets not containing antibacterial agents rapidly increased and reached an asymptote by 24 h (approximately 10(10) colony-forming units per gram). Bacterial populations also increased in diets containing antibacterial agents, but they were significantly smaller than in diets not containing antibacterial agents. The most prevalent bacteria isolated were Carnobacterium piscicola, Carnobacterium divergens, Lactobacillus curvatus, Lactobacillus sakei, Leuconostoc mesenteroides, and Enterococcus spp., regardless of the antibacterial treatment used. The proliferation of fungi was delayed relative to bacteria, but significant differences were observed among the diet treatments. Fungi were most inhibited by sorbic acid and propionic acid in the absence of antibacterial agents. The most common fungi isolated were the yeasts Candida zeylanoides, Torulaspora globosa, and Yarrowia lipolytica. The pH of diets not containing antibacterial agents decreased rapidly and was highly correlated with increases in bacteria but not fungi. The results of this study demonstrate that antimicrobial agents significantly inhibit spoilage microorganisms in a meat-based diet and that alternative management strategies to delay the decomposition of such diets presented in Parafilm packets should target lactic acid spoilage bacteria, particularly Carnobacterium and Lactobacillus species.

Demonstration of amylase from the zoophytophagous anthocorid Orius insidiosus

To better understand facultative phytophagy in the zoophytophagous anthocorid, Orius insidiosus, tests for amylase were conducted and the enzyme was partially purified. Three activity bands were detected with polyacrylamide-starch gel electrophoretic analysis of amylase in O. insidiosus. The major amylase was found to have a mean isoelectric point (pI) of 4.53. The presence of amylase indicates the ability of O. insidiosus to use starch, a nutrient, derived from plants, either by direct ingestion or by ingestion of plant material from the digestive system of their prey. The presence of amylase suggests that these predators are more committed to plant feeding than other species of predators that lack this enzyme.

Partial characterization of alpha-amylase in the salivary glands of Lygus hesperus and L. lineolaris

The alpha-amylases in the salivary glands of Lygus hesperus Knight and L. lineolaris (Palisot de Beauvois) were isolated and purified by ion exchange chromatography, and by isoelectric focusing, respectively. The alpha-amylase from L. hesperus had an isoelectric point (pI) of 6.25, and a pH optimum of 6.5. The specific activity of alpha-amylases in the salivary glands of L. hesperus was 1.2 U/mg/ml. The alpha-amylase from L. lineolaris had a pI of 6.54, and a pH optimum of 6.5. The specific activity of alpha-amylase from L. lineolaris was 1.7 U/mg/ml. The activity of alpha-amylase in both species was significantly inhibited by alpha-amylase inhibitor from wheat and also by EDTA and SDS. Sodium chloride enhanced alpha-amylase activity for both species. The enzyme characteristics and relative activities are discussed in the context of differences phytophagous versus zoophagous habits in these two congeneric species.

Comparison of alpha-amylase and protease activities of a zoophytophagous and two phytozoophagous Heteroptera

To better understand the nature of facultative phytophagy in the zoophytophagous Geocoris punctipes (Say), and facultative zoophagy in phytozoophagous Lygus hesperus (Knight) and Lygus lineolaris (Palisot de Beauvois), we compared the activities of both the starch digesting enzyme alpha-amylase and of general proteases in these species. The alpha-amylases and proteases were demonstrated in L. hesperus, L. lineolaris and G. punctipes. The presence of alpha-amylase in the salivary gland complexes of G. punctipes indicates a disposition of this species toward utilization of nutrients that can be derived only from plants, either directly from ingestion of plant macromolecules or from second-hand ingestion of plant material from the digestive system of their prey. The alpha-amylase activity in G. punctipes was much less than those of phytozoophagous L. hesperus and L. lineolaris. The relative importance of amylolytic activity and proteolytic activity is also discussed.

Crystal structure of botulinum neurotoxin type A and implications for toxicity

Botulinum neurotoxin type A (BoNT/A) is the potent disease agent in botulism, a potential biological weapon and an effective therapeutic drug for involuntary muscle disorders. The crystal structure of the entire 1,285 amino acid di-chain neurotoxin was determined at 3.3 A resolution. The structure reveals that the translocation domain contains a central pair of alpha-helices 105 A long and a approximately 50 residue loop or belt that wraps around the catalytic domain. This belt partially occludes a large channel leading to a buried, negative active site--a feature that calls for radically different inhibitor design strategies from those currently used. The fold of the translocation domain suggests a mechanism of pore formation different from other toxins. Lastly, the toxin appears as a hybrid of varied structural motifs and suggests a modular assembly of functional subunits to yield pathogenesis.

Osseointegrated implants for single tooth replacement in general practice: a 1-year report from a multicentre prospective study

The single tooth implant is a treatment option for the replacement of missing single teeth and in many cases is the treatment of choice. It is, however, an expensive treatment requiring a co-ordinated approach to the surgical and restorative aspects of treatment. In this study, a group of dentists in general and restorative dental practice and with no previous experience in implant surgery underwent an intensive training course in all aspects of implant treatment for single teeth. Using a system of simplified instrumentation with a strict adherence to protocol, the group installed and restored single tooth implants ad modum Brånemark in a wide range of clinical situations. At the one year follow-up period following crown insertion, the success rate of treatment compared favourably with results reported from centres using the specialist team approach to treatment. The results of this study indicate that further consideration should be given to the training of general dentists so that improved delivery of dental health care can be provided at a more economic level.

Alterations of fluid and electrolyte balance in thoroughbred racehorses following strenuous exercise during training

Alterations of acid-base status, and fluid and electrolyte balance subsequent to exercise in Thoroughbred racehorses in North America have not been well-characterized. Des-cribed here are the results of an observational study conducted to characterize changes in fluid and electrolytes following strenuous exercise of 16 Thoroughbreds under routine training conditions. Changes following strenuous exercise were determined for the following variables: serum concentrations of sodium (Na), potassium (K), chloride (Cl) and protein; pH of blood; osmolality of plasma and urine; body weight; and, fractional urinary excretion (FE) of Na, K and Cl. The following changes occurred during exercise: increased concentration of Na in blood; increased FE of Na; decreased concentration of Cl in blood; decreased FE of Cl; increased urinary and plasmal osmolality; weight-loss; decreased pH of blood; and, increased concentration of lactic acid. The concurrent decreased concentration of chloride in plasma and acidemia in these horses differed from the hypochloremic, metabolic alkalosis previously described among endurance horses. Acidemia was attributed to production of lactic acid by anaerobic glycolysis.

Residual, unresectable, or recurrent colorectal cancer: external beam irradiation and intraoperative electron beam boost +/- resection

While combinations of external beam radiation (XRT) and surgery decrease pelvic recurrence and improve survival in the subgroups with residual disease (postop XRT) or initially unresectable disease (preop XRT), local recurrence is still unacceptably high, and survival could be improved. In view of this, pilot studies were instituted at Massachusetts General Hospital in which 32 patients received the standard previous treatment of external beam irradiation and surgery but in addition had an intraoperative electron beam boost of 1000-1500 rad to the remaining tumor or tumor bed. For the 16 patients who presented with unresectable primary lesions, the addition of intraoperative radiotherapy has resulted in a total absence of local recurrence with a minimum 20 month follow-up, and survival rates are statistically better than for the previous group treated with only external beam irradiation and surgical resection. In the group with residual disease, again there have not been any local recurrences in the 7 patients who received all treatment modalities versus 54% and 26% for the group with gross and microscopic residual treated with only external beam techniques. The remaining 9 patients presented with recurrent unresectable lesions--3 are alive (2 NED) at greater than or equal to 3 years.

Low-dose preoperative irradiation, surgery, and elective postoperative radiation therapy for resectable rectum and rectosigmoid carcinoma

A regimen of low-dose preoperative radiation therapy (RT), surgery, and elective postoperative RT for resectable carcinomas of the rectum and rectosigmoid is presented. Initial results in a group of 36 patients is discussed. In four patients clinically silent metastatic disease was discovered. Of 16 patients without indications for postoperative RT, only one died with disease. Indications for postoperative irradiation were found in 15 patients and four relapses (26%) subsequently occurred. Since the surgicopathologic stage of the tumor is the best prognostic predictor for rectal cancer, this regimen allows for the delivery of high-dose adjuvant irradiation only to those at high risk of local recurrence. Thus, this combination selects patients likely to benefit from postoperative RT while preserving the advantages of preoperative RT.

Combined modality treatment of gastric cancer

In a series of 46 patients with localized gastric cancer treated at Massachusetts General Hospital, problems with excessive acute or chronic toxicity due to combination treatment with irradiation (XRT) and chemotherapy (CT) were not seen. Forty of the 46 received combined treatment with 2 regimens: 1) Irradiation plus concomitant 3 days of 5-FU followed by maintenance 5-FU or combined drugs--26 patients; 2) In the other 14 patients, the sequence of irradiation and chemotherapy was altered. A single course of combined drug chemotherapy was given prior to irradiation and 5-6 additional courses were administered after completion of XRT (CT-XRT-CT). The drug combination was initially 5-FU-BCNU but this was changed to FAM (5-FU, Adriamycin, Mitomycin C). Irradiation was delivered to tightly contoured portals using shaped blocks to spare as much small bowel, kidney and marrow as possible while giving 4500-5200 rad in 25 to 29 fractions over 5 to 6 weeks. In this series, there were no cases of septicemia or any deaths related to treatment. A 3 year survival rate of about 20% was achieved for the total group of patients and 43% in the group with resection but at high risk for later failure. Our inability to improve these numbers is undoubtedly a result of dose limitations with external beam irradiation combined with a systemic failure problem. When irradiation is combined with surgical resection of all or a majority of tumor, both survival and local control appear to be better than in the unresected patient group. Only 4 of 29 patients (14%) with curative resection, or resection but residual disease, had later evidence of failure within the irradiation field as opposed to 6 of 9 or 66% in the group with unresectable disease.