Reduction of cardiovascular events in patients with cardiovascular disease with the CV-polypill: a retrospective and propensity score matching study

Background

Previous clinical trials suggested that a strategy based on a cardiovascular (CV) polypill improves risk factor control and reduces the incidence of CV events. The CNIC-Polyill (aspirin (ASA) 100mg, atorvastatin 20/40mg (or simvastatin 40mg) and ramipril 2,5–10mg) has shown to improve adherence and risk factors control.

Methods

The NEPTUNO study is a retrospective, non-interventional analysis of an anonymized medical history dataset in the BIG-PAC administrative database in the years 2015–2018. Patients at age ≥18 years with previous CV disease were allocated in four different cohorts according to their therapy: CNIC-polypill containing ASA 100mg, R 2.5/5/10mg and A 20/40mg (1:case cohort), identical mono-components (ASA,R,A) (C2), equipotent medication (ASA 100mg, simvastatin 40/80mg or rosuvastatin 5/10mg, enalapril 5–20mg or valsartan 40–160mg) (C3) and usual care (C4) (control cohorts) and were followed for 2 years. To ensure comparability of the study cohorts, a propensity score matching (PSM) was performed. The primary endpoint was the incidence first major cardiovascular event (MACE) including: myocardial infarction, angina, ischemic stroke, transitory ischemic attack, peripheral artery disease and CV mortality.

Results

8,946 patients were recruited. After the PSM, 4 well-balanced cohorts of 1,614 patients were obtained. The mean age was 63.3 years and 60.4% were men. Cohort 1 (Case cohort, CNIC-polypill) compared with cohorts 2, 3 and 4 showed a significant reduction in MACEs (19.8% vs. 23.3%, 25.5% and 26.8%; p<0.001), respectively although the CV death rate (8.1% vs. 8.1%, 8.9% and 9.2%; p=0.357) did not show differences. The hazard ratio (HR) for a MACE in the CV polypill cohort vs cohort 2 was 0.761 (IC95%; 0.657–0.881), p=0.001; vs Cohort 3 was 0.821 (IC95%; 0.714–0.944), p=0.006 and vs. Cohort 4 was 0.834 (IC95%; 0.716–0,950), p=0.008. Time to the event was also longer in the CV-polypill cohort compared the other 3 cohorts (274.8 days vs 249.2 days; 226.4 days and 217 days; p<0.001). There was a significant greater reduction in the case cohort vs the 3 control cohorts in the absolute levels of all the analyzed lipidic variables (LDL (−19.6 vs. −12.9, −12.3 and −9.1 mg/dL; p<0.001), triglycerides (−67.5 vs. −59.9, −56.1 and −54.4 mg/dL; p<0.001)) and in reduction of blood pressure (PAS (−14.1 vs. −11.7, −10.4 and −10.4 mmHg; p<0.001) and PAD (−4.5 vs −2.5, −2.1, −1.2 mmHg; p<0.001)). Higher persistence to treatment in the CNIC- polypill cohort (72.1% vs. 62. 2%, 60.0% and 54.2%; p<0.001) was also found.

Conclusion

This study shows the reduction of clinical events by the CNIC-polypill in a large population of real-life patients. In spite of the retrospective design of this study, the results of our analysis support the use of a CV-polypill in secondary prevention of cardiovascular events. These results need to be confirmed by prospective randomized clinical trials with major clinical outcomes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Ferrer International Figure 1

NIST Interlaboratory Study on Glycosylation Analysis of Monoclonal Antibodies: Comparison of Results from Diverse Analytical Methods

Glycosylation is a topic of intense current interest in the development of biopharmaceuticals because it is related to drug safety and efficacy. This work describes results of an interlaboratory study on the glycosylation of the Primary Sample (PS) of NISTmAb, a monoclonal antibody reference material. Seventy-six laboratories from industry, university, research, government, and hospital sectors in Europe, North America, Asia, and Australia submitted a total of 103 reports on glycan distributions. The principal objective of this study was to report and compare results for the full range of analytical methods presently used in the glycosylation analysis of mAbs. Therefore, participation was unrestricted, with laboratories choosing their own measurement techniques. Protein glycosylation was determined in various ways, including at the level of intact mAb, protein fragments, glycopeptides, or released glycans, using a wide variety of methods for derivatization, separation, identification, and quantification. Consequently, the diversity of results was enormous, with the number of glycan compositions identified by each laboratory ranging from 4 to 48. In total, one hundred sixteen glycan compositions were reported, of which 57 compositions could be assigned consensus abundance values. These consensus medians provide community-derived values for NISTmAb PS. Agreement with the consensus medians did not depend on the specific method or laboratory type. The study provides a view of the current state-of-the-art for biologic glycosylation measurement and suggests a clear need for harmonization of glycosylation analysis methods.

Optimization of digital image processing to determine quantum dots' height and density from atomic force microscopy

An optimized method of digital image processing to interpret quantum dots' height measurements obtained by atomic force microscopy is presented. The method was developed by combining well-known digital image processing techniques and particle recognition algorithms. The properties of quantum dot structures strongly depend on dots' height, among other features. Determination of their height is sensitive to small variations in their digital image processing parameters, which can generate misleading results. Comparing the results obtained with two image processing techniques - a conventional method and the new method proposed herein - with the data obtained by determining the height of quantum dots one by one within a fixed area, showed that the optimized method leads to more accurate results. Moreover, the log-normal distribution, which is often used to represent natural processes, shows a better fit to the quantum dots' height histogram obtained with the proposed method. Finally, the quantum dots' height obtained were used to calculate the predicted photoluminescence peak energies which were compared with the experimental data. Again, a better match was observed when using the proposed method to evaluate the quantum dots' height.

Efficacy of celecoxib in treating symptoms of viral pharyngitis: a double-blind, randomized study of celecoxib versus diclofenac

This study compared the efficacy and safety of the cyclooxygenase-2 specific inhibitor celecoxib with the conventional non-steroidal anti-inflammatory drug diclofenac in the symptomatic treatment of viral pharyngitis. Adult patients from 27 study centers in Latin America were treated with oral doses of celecoxib 200 mg once daily or 200 mg twice daily, or diclofenac 75 mg twice daily for 5 days in a double-blind, randomized study. The primary efficacy assessment was 'Throat Pain on Swallowing' on day 3. In addition, secondary quality-of-life assessments were performed on days 3 and 5. All adverse events and treatment-emergent signs and symptoms were recorded. Data from 313 patients were evaluable for efficacy (105 celecoxib 200 mg once daily, 107 celecoxib 200 mg twice daily, 101 diclofenac 75 mg twice daily). The upper 95% confidence limits for the visual analog scale of 'Throat Pain on Swallowing' on day 3 for celecoxib 200 mg once daily relative to diclofenac 75 mg twice daily, and celecoxib 200 mg twice daily relative to diclofenac 75 mg twice daily were 9.26 and 7.83, respectively. All secondary efficacy and quality-of-life measures were clinically similar for the three treatment groups, and no statistically significant differences were detected. The incidences of treatment-emergent adverse events and withdrawals due to adverse events were similar for all groups, but numerically higher among patients taking diclofenac than celecoxib. More patients in the diclofenac group reported gastrointestinal complaints (7.3%) compared with those in the celecoxib groups (4.3% in the celecoxib 200 mg once-daily group and 3.4% in the celecoxib 200 mg twice-daily group). In conclusion, 5 days of treatment with celecoxib 200 mg once daily is as effective as diclofenac 75 mg twice daily in the symptomatic treatment of viral pharyngitis. Celecoxib 200 mg once daily is also as effective as celecoxib 200 mg twice daily in this condition.

Acute fulminant hepatic failure in a woman treated with phenytoin and trimethoprim-sulfamethoxazole

Massive hepatic necrosis following exposure to phenytoin and trimethoprim-sulfamethoxazole is a rare occurrence and to the best of our knowledge has not been reported previously. Acute hepatic failure following administration of trimethoprim-sulfamethoxazole has rarely been seen, and only 4 cases have been well documented pathologically. We report a case of acute liver failure in a 60-year-old woman following ingestion of phenytoin and trimethoprim-sulfamethoxazole concomitantly over a 9-day period. Autopsy findings revealed acute fulminant hepatic failure. This case demonstrates the effects of chemical-chemical interactions in the potentiation of hepatotoxicity of single agents and specifically illustrates the need for discontinuing trimethoprim-sulfamethoxazole in the presence of early liver injury.

Angiogenesis in early-invasive and low-malignant-potential epithelial ovarian carcinoma

OBJECTIVE

To evaluate angiogenesis in ovaries of women with stage I invasive and low-malignant-potential epithelial ovarian carcinoma.

METHODS

Ovarian specimens of 49 consecutive women with primary stage I invasive (n = 15) or stage I low-malignant-potential epithelial ovarian carcinoma (n = 34) were stained immunohistochemically for factor VIII-related antigen. Microvessel counts were tested for correlation with patient age, race, parity, previous oral contraceptive use, histologic type, tumor grade, tumor size, ascites, tumor excrescences, and disease-free and overall survival. Statistical analysis included multiple linear regression, Student t tests, factorial analysis of variance, and Cox proportional hazards regression, with P <.05 considered statistically significant.

RESULTS

Microvessel counts of ovarian specimens of women with stage I invasive epithelial ovarian carcinoma (median 30, range 17-73) were significantly higher than those of women with stage I low-malignant-potential epithelial ovarian carcinoma (median 10, range 5-23), (P <.001). Among women with low-malignant-potential disease, microvessel counts did not differ significantly between serous and mucinous carcinomas (median 10, range 5-23 versus median 11, range 5-20, respectively, P =.78). There was no correlation between microvessel counts and age, tumor grade, tumor size, ascites, or tumor excrescences.

CONCLUSION

Angiogenesis as assessed by microvessel counts is more intense in stage I invasive ovarian epithelial carcinoma compared with stage I low-malignant-potential carcinoma, and might assist in differentiating between these histopathologic entities.

Effect of intravenous immunoglobulin G on natural killer cell cytotoxicity in vitro in women with recurrent spontaneous abortion

Intravenous immunoglobulin (IVIg) has been used to treat women with recurrent spontaneous abortion (RSA), particularly for women with elevated natural killer (NK) cells. We investigated the effect of IVIg on peripheral blood NK cell activity in vitro in women with RSA. 51Cr-release assays using K562 in the presence of varying concentrations of IVIg were performed using PBL from 16 women with RSA. Antibody dependent cellular cytotoxicity (ADCC) was evaluated using Daudi cells. Effectors and targets were preincubated with IVIg. Binding of IVIg to K562 and Daudi was evaluated by flow cytometry. The effect of K562 absorbed IVIg on NK activity was compared to that of non-absorbed IVIg. NK cytotoxicity and ADCC in the presence of F(ab')2 fragments were compared with those in the presence of intact IVIg. IVIg produced a significant, dose dependent inhibition of NK activity in vitro. Inhibition of NK activity occurred when effectors but not targets were preincubated with IVIg. IVIg binds to K562 and Daudi. IVIg increased ADCC when targets but not effectors were incubated with IVIg. K562 absorbed IVIg produced more inhibition of NK cytotoxicity than non-absorbed IVIg. Suppression of NK cytotoxicity by F(ab')2 was as effective as that of IVIg. However, F(ab')2 did not increase ADCC. IVIg effectively reduces peripheral blood NK cytotoxicity in vitro. Inhibition of NK cytotoxicity is mediated at the effector cell level through the antigen binding portion of the immunoglobulins. Women with RSA and elevated NK cells may benefit from IVIg treatment.

Intravenous immunoglobulin inhibits natural killer cell activity in vivo in women with recurrent spontaneous abortion

We previously reported elevation of natural killer (NK) cells in women with recurrent spontaneous abortion (RSA) of immune etiology. In this study, we investigated the effect of intravenous immunoglobulin G (IVIg) on peripheral blood NK activity in vivo in women with RSA. Blood was drawn prior to and 7-11 days after IVIg therapy in eight women with RSA. NK activity was measured using K562 as target cells for 51Cr-release assays. Serum IgG concentrations were also measured. All received 400 mg/kg/day of IVIg for 3 consecutive days. 1) Seven of eight women became pregnant. Five delivered a live born infant. Three out of five women (60%) who delivered a live born infant showed a significant inhibition of NK cytotoxicity post IVIg and the rest did not show any changes; 2) NK cytotoxicity was significantly increased in a woman who miscarried again; 3) A woman who miscarried a chromosomally abnormal fetus showed a significant inhibition of NK cytotoxicity after IVIg; and 4) Serum IgG concentration increased significantly from 9.3 +/- 3.0 mg/ml to 23.5 +/- 5.1 mg/ml post IVIg therapy. IVIg effectively inhibits peripheral blood NK activity in vivo. These results are consistent with our previous finding showing that IVIg inhibits NK cell activity in vitro. Women with RSA and elevated NK cells may benefit from IVIg treatment.

Immunophenotypic profiles of peripheral blood lymphocytes in women with recurrent pregnancy losses and in infertile women with multiple failed in vitro fertilization cycles

In summary (1) Nonpregnant women with RSAs of unknown etiology have higher levels of CD56+ lymphocytes when compared to normal controls; (2) The levels of CD19+, CD56+, and CD56+/CD16+ PBL of pregnant women with RSA are significantly higher than those of multiparous pregnant normal controls; (3) Women with autoantibodies to phospholipids have significantly higher levels of elevated CD56+ and CD56+/CD16+ lymphocytes when compared to women without antiphospholipid antibodies; (4) Women with autoantibodies to nuclear components demonstrate higher numbers of CD19+/CD5+ cells compared to women without autoantibodies to nuclear components; (5) Idiopathic infertile women with multiple prior IVF failures demonstrate significantly higher levels of CD56+ pBL than normal fertile controls and the conception rate is much higher in those with CD56+ levels less than 12%; (6) Elevations of CD56+ lymphocytes to over 18% during a pregnancy is a good prognostic indicator of impending pregnancy loss. We have not seen a liveborn infant in women with levels of 18% or higher without IVIg therapy; and (7) Infertile and RSA women who fail alloimmune and autoimmune therapy have significant alterations in cellular and humoral immunity involving NK cells and CD19+/CD5+ B cells.

Up-regulated expression of CD56+, CD56+/CD16+, and CD19+ cells in peripheral blood lymphocytes in pregnant women with recurrent pregnancy losses

PROBLEM

To analyze immunophenotypic profiles of peripheral blood and humoral autoimmune responses in women with a history of recurrent spontaneous abortions (RSA).

METHOD

Peripheral blood lymphocyte subsets by flow cytometry and autoantibodies to phospholipids and nuclear components by ELISA were measured in nonpregnant and pregnant women with RSA of unknown etiology. Thirty-five pregnant and eighty-one nonpregnant women with RSA were studied. Seventeen nonpregnant and twenty-two pregnant normal controls were included.

RESULTS

Natural killer (NK) cells (CD56+) were significantly elevated in nonpregnant women with RSA as compared with nonpregnant controls. Pregnant women with RSA demonstrated significantly increased NK (CD56+, CD56+/CD16+) and B cells (CD19+) as compared with pregnant controls. Women who miscarried the index pregnancy demonstrated significantly lower CD3+ cells in comparison with normal controls. Women with RSA and antiphospholipid antibodies showed significantly elevated NK cells when compared with women without antiphospholipid antibodies. Women with autoantibodies to nuclear components demonstrated significantly elevated CD19+/CD5+ cells when compared to women without autoantibodies to nuclear components.

CONCLUSIONS

Women with RSA demonstrate an abnormal cellular immune response by increasing peripheral natural killer cells and B cells as compared with normal controls.

Autoantibodies to phospholipids and nuclear antigens in non-pregnant and pregnant Colombian women with recurrent spontaneous abortions

Autoantibodies to negatively charged phospholipids have been reported to be associated with thrombotic events, thrombocytopenia and adverse pregnancy outcome, such as intrauterine growth retardation and recurrent spontaneous abortions (RSAs). In this study, autoantibodies to 6 phospholipid antigens and antinuclear antibody (ANA) were tested in Colombian women with a history of RSAs. Sixty-eight non-pregnant and 25 pregnant women with a history of RSAs comprised the study group. Twenty-five non-pregnant normal healthy women and thirty-one normal pregnant women served as controls. The non-pregnant women with RSAs showed a higher incidence of autoantibodies to cardiolipin (23% positive) as compared with non-pregnant normal controls (0% positive; P < 0.005). The incidence of autoantibodies to cardiolipin (28%; P < 0.005), phosphatidylethanolamine (16%; P < 0.005), phosphatidylserine (16%; P < 0.05), phosphatidylglycerol (16%; P < 0.05), phosphatidic acid (16%; P < 0.01) and phosphatidylinositol (20%; P < 0.01), in the pregnant women with RSAs was significantly higher than that of normal pregnant controls. There was no difference in the incidence of ANA in either group. In conclusion, women with a history of RSAs have a higher incidence of autoantibodies to phospholipids when compared to pregnant and non-pregnant normal controls. Autoimmune serological work-up is indicated during pregnancy in women with a history of RSAs.

[Effect of primary ovarian insufficiency on the molecular heterogeneity of pituitary gonadotropins]

It is known that hypophysial gonadotropins circulate in different molecular forms which are provided with different biological activity and that the proportion of such varieties keep a relation with the concentrations of estrogens in circulation. In physiological menopause predominate the great molecular forms which have a lesser biological activity and when estrogens are administrated a change is produced to smaller molecular forms. The present study tries to determine if in cases of ovarian insufficiency of long duration as in precocious menopause and the syndrome of refractory ovary the chromatographic conduct of gonadotropin is similar. Six patients with precocious menopause, and three with the syndrome of refractory ovary, were studied, in order to make a comparison of chromatographic pattern of FSF and LH in serum, with the one found in women with normal ovarian function and with physiologic menopause. The chromatographic analysis was done by filtration in gel of the serum and the subsequent determination of LH and FSH by RIA of double antibody. It was found that the chromatographic pattern of patients with ovarian insufficiency of long duration, characteristically presents larger molecular forms, specially in the refractory ovary syndrome with a greater alteration in the profile of LH. With base on these results it is concluded that the duration of ovarian insufficiency determine the type of molecular form, predominant, of gonadotropins. Also it is suggested that for the syndrome of refractory ovary, the greater heterogenicity of gonadotropins may explain part of physiopathogeny.

Distribution of follicle-stimulating hormone and luteinizing hormone isoforms in sera from women with primary ovarian failure compared with that of normal reproductive and postmenopausal women

OBJECTIVE

To demonstrate if molecular heterogeneity of gonadotropins correlates with the type of primary gonadal failure.

DESIGN AND METHODS

Aliquots of sera from women with hypogonadism were subjected to gel filtration chromatography to be assayed for follicle-stimulating hormone (FSH) and luteinizing hormone (LH) by the use of radioimmunoassay. Molecular weight (MW) of isoforms was calculated on a calibration curve obtained with molecular markers. The molecular variants were characterized on the basis of elution volume, MW, and partition coefficient.

RESULTS

Chromatographic profile of sera from four women with natural menopause exhibited two FSH peaks of immunoreactivity and a heavier LH isoform. This pattern was different from that obtained in sera from women of reproductive age who presented a single peak that eluted after the corresponding standard. In six cases of idiopathic premature menopause and three more with gonadotropin-resistant ovary, the chromatographic profile showed a marked and remarkable molecular heterogeneity, particularly LH, and this was more apparent in women with resistant ovary.

CONCLUSIONS

Our investigation confirms the relationship between the gonadotropin heterogeneity with the gonadal failure. The duration of the ovarian failure may influence the molecular proportion of gonadotropins and the predominance of heavier MW isohormones.

[The distribution of adipose tissue is related to the levels of insulin in the obese woman]

We studied 51 patients aged 20-35 years, with overweight or obesity evaluated by the body mass index (BMI = weight height2) when it was higher than 25 (normal 20-25), and a control group of six women with the same age and normal BMI. In all patients waist and hip circumferences were measured, to calculate the waist/hip ratio (WHR). Also serum insulin was measured in basal conditions and as response to 75 g oral glucose load, taking samples at 30, 60, 90, 120 and 180 minutes after. The test were performed 3 to 6 days following a spontaneous or induced genital bleeding with progestin. The WHR showed a normal distribution with the greatest frequency at 0.87. The patients were classified with predominance of adiposity in the upper body segment, when the WHR was equal or more than 0.85, and with adipose predominance in the lower body segment when it was equal or less than 0.84. The average insulin values in response to oral glucose load of patients with upper body segment obesity were significantly higher (Mann-Whitney's U = 0, p less than 0.02) than the corresponding cases with lower body segment obesity. Besides, there was a significant correlation between WHR and serum insulin values at 30 minutes after the oral glucose load (Pearson's r = 0.331, p less than 0.02). These results suggest a relation between the distribution of adiposity and insulin values, which were higher in patients with adipose predominance in the upper body segment.

[Prolactin variants in serum and amniotic fluid of women with ovulatory hyperprolactinemia]

There is enough evidence that prolactin (PRL), like many other pituitary hormones, is composed by multiple forms that differ from each other by size charge. Although they can be seen in the pituitary glands of a variety of species, their biological significance, identity and chemical nature still remain poorly understood. Recently, a new syndrome characterized by normal ovarian function in the presence of sustained hyperprolactinemia has been reported by our group. In these women, highly abnormal percentages of serum big big PRL have been consistently demonstrated. This observation suggests that big big PRL is immunologically similar, but biologically less active than monomeric or little PRL. In this study we have determined then molecular size heterogeneity of immunoreactive PRL in serum and amniotic fluid from two ovulatory hyperprolactinemic subjects (subjects A and B) who had, under non-pregnant conditions, large amounts of serum big big PRL, throughout different stages of parturition. Control subjects consisted of two women at the end of pregnancy in whom PRL species demonstrated a normal size distribution (subjects C and D). Mean basal levels of PRL were the highest in subjects A and B and remained constant during labor. In the control subjects a remarkable decline in PRL levels was observed during the periparturitional period. This pattern of PRL release was not correlated with changes in steroid hormone concentrations. The relative proportions of PRL size variants throughout delivery showed no apparent changes in all four subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative observations on effects of carbon dioxide laser-induced peripheral nerve lesions in the rat

This study was conducted to determine any changes that might occur in the associated cell bodies and proximal nerve stumps of sciatic nerves cut with carbon dioxide laser radiation. These changes were then compared with the changes that occur when performed with cutting cautery and scalpel. Both the proximal stump and the related dorsal root ganglia were examined with light and electron microscopy. The sciatic nerve was severed in 10 rats with the carbon dioxide laser, a cutting cautery, or a scalpel. Subsequent histopathologic examinations revealed: (a) both myelin and axonal degeneration in scalpel cuts; (b) less degeneration of proximal stump myelin in laser cuts compared with cautery cuts; and (c) no abnormalities in the associated dorsal root ganglia of nerves cut with the carbon dioxide laser. It was concluded that both the carbon dioxide laser and cutting cautery result in less damage and degeneration than a scalpel when used to sever peripheral nerves. The difference between the laser and cautery lesions was more quantitative than qualitative in that both impart thermal energy to the nerve. The carbon dioxide laser resulted in the least amount of injury.