Standard vs. intensified management of heart failure to reduce healthcare costs: results of a multicentre, randomized controlled trial.

AIMS: To determine if an intensified form of heart failure management programme (INT-HF-MP) based on individual profiling is superior to standard management (SM) in reducing health care costs during 12-month follow-up (primary endpoint). METHODS AND RESULTS: A multicentre randomized trial involving 787 patients (full analysis set) discharged from four tertiary hospitals with chronic HF who were randomized to SM (n = 391) or INT-HF-MP (n = 396). Mean age was 74 ± 12 years, 65% had HF with a reduced ejection fraction (31.4 ± 8.9%) and 14% were remote-dwelling. Study groups were well matched. According to Green, Amber, Red Delineation of rIsk And Need in HF (GARDIAN-HF) profiling, regardless of location, patients in the INT-HF-MP received a combination of face-to-face (home visits) and structured telephone support (STS); only 9% (`low risk') were designated to receive the same level of management as the SM group. The median cost in 2017 Australian dollars (A$1 equivalent to ∼EUR €0.7) of applying INT-HF-MP was significantly greater than SM ($152 vs. $121 per patient per month; P < 0.001), However, at 12 months, there was no difference in total health care costs for the INT-HF-MP vs. SM group (median $1579, IQR $644 to $3717 vs. $1450, IQR $564 to $3615 per patient per month, respectively). This reflected minimal differences in all-cause mortality (17.7% vs. 18.4%; P = 0.848) and recurrent hospital stay (18.6 ± 26.5 vs. 16.6 ± 24.8 days; P = 0.199) between the INT-HF-MP and SM groups, respectively. CONCLUSION: During 12-months follow-up, an INT-HF-MP did not reduce healthcare costs or improve health outcomes relative to SM.

Long-term tolerance and efficacy of adjunctive exenatide therapy on glycaemic control and bodyweight in type 2 diabetes: a retrospective study from a specialist diabetes outpatient clinic.

BACKGROUND: Weight gain and hypoglycaemia are common adverse effects associated with anti-diabetic treatments. AIM: Our aim was to evaluate the long-term effects of adjunctive exenatide therapy on weight loss and glycaemic control in patients with type 2 diabetes. METHODS: A review of medical records in a specialist diabetes clinic over 5 years identified 446 patients who were prescribed exenatide therapy. We examined change in glycosylated haemoglobin (HbA1c), weight, albumin-creatinine ratio and hypoglycaemic medication during 24 months follow up. RESULTS: Subjects were aged 59 ± 10 years (49% women) and received exenatide in combination with oral agents and insulin (47%). During an average of 17 ± 14 months follow up, 51% (more women than men; odds ratio 1.69, 95% confidence interval 1.14­2.49) remained on treatment. Lack of efficacy (33%) and/or gastrointestinal (27%) side-effects were the main reasons for treatment cessation. At 24 months, there was a reduction in HbA1c of 0.7 ± 1.2% and weight loss of 4.3 ± 5.2 kg. Change in HbA1c was similar regardless of concurrent insulin therapy, yet insulin was associated with greater weight reduction (4.8 ± 5.3 vs 3.8 ± 5.1 kg, P = 0.016). Independent predictors of HbA1c response were higher baseline HbA1c, longer duration of diabetes and use of insulin or sulfonylureas at study end. Predictors of weight response were baseline use of insulin or thiazolidinediones, increased age, female sex and sulfonylurea or thiazolidinediones at study end. Longer exenatide treatment duration was favourable for reducing HbA1c and weight. CONCLUSIONS: Exenatide is effective in reducing HbA1c and weight, regardless of concurrent insulin, and in a specialist diabetes outpatient clinic, is recommended for use in clinical practice.

New solutions for combatting implant bacterial infection based on silver nano-dispersed and gallium incorporated phosphate bioactive glass sputtered films: A preliminary study.

Ag/Ga were incorporated into resorbable orthopaedic phosphate bioactive glasses (PBG, containing P, Ca, Mg, Na, and Fe) thin films to demonstrate their potential to limit growth of Staphylococcus aureus and Escherichia coli in post-operative prosthetic implantation. Dual target consecutive co-sputtering was uniquely employed to produce a 46 nm Ag:PBG composite observed by high resolution TEM to consist of uniformly dispersed ~5 nm metallic Ag nano-particles in a glass matrix. Ga3+ was integrated into a phosphate glass preform target which was magnetron sputtered to film thicknesses of ~400 or 1400 nm. All coatings exhibited high surface energy of 75.4-77.3 mN/m, attributed to the presence of hydrolytic P-O-P structural surface bonds. Degradation profiles obtained in deionized water, nutrient broth and cell culture medium showed varying ion release profiles, whereby Ga release was measured in 1400 nm coating by ICP-MS to be ~6, 27, and 4 ppm respectively, fully dissolving by 24 h. Solubility of Ag nanoparticles was only observed in nutrient broth (~9 ppm by 24 h). Quantification of colony forming units after 24 h showed encouraging antibacterial efficacy towards both S. aureus (4-log reduction for Ag:PBG and 6-log reduction for Ga-PBG≈1400 nm) and E. coli (5-log reduction for all physical vapour deposited layers) strains. Human Hs27 fibroblast and mesenchymal stem cell line in vitro tests indicated good cytocompatibility for all sputtered layers, with a marginal cell proliferation inertia in the case of the Ag:PBG composite thin film. The study therefore highlights the (i) significant manufacturing development via the controlled inclusion of metallic nanoparticles into a PBG glass matrix by dual consecutive target co-sputtering and (ii) potential of PBG resorbable thin-film structures to incorporate and release cytocompatible/antibacterial oxides. Both architectures showed prospective bio-functional performance for a future generation of endo-osseous implant-type coatings.

Sleep influences on cardio-metabolic health in Indigenous populations.

Indigenous populations continue to be among the world's most marginalized population groups. Studies in Indigenous populations from high income countries (including the United States, Canada, Australia, and New Zealand) indicate increased risk of sleep disorders compared to non-Indigenous populations. Poor sleep, whether it be short sleep duration or fragmented sleep, is a well-established risk factor for cardio-metabolic diseases. Given the implications, targeted improvement of poor sleep may be beneficial for the health and well-being of Indigenous people. In this narrative review, we will: (1) discuss the effects of sleep on the cardio-metabolic processes; (2) examine sleep in Indigenous populations; (3) review the association between sleep and cardio-metabolic risk in Indigenous populations; and (4) review the potential role of sleep in cardiovascular disease risk detection and interventions to improve sleep and cardio-metabolic health in Indigenous people. In particular, this review highlights that the assessment of sleep quality and quantity may be a beneficial step toward identifying Indigenous people at risk of cardio-metabolic diseases and may represent a key intervention target to improve cardio-metabolic outcomes.

Changes in cardiovascular function during the sleep onset period in young adults.

Blood pressure (BP) and heart rate (HR) are influenced by the sleep-wake cycle, with relatively abrupt falls occurring in association with sleep onset (SO). However, the pattern and rate of fall in BP and HR during SO and the processes that contribute to the fall in these variables have not been fully identified. Continuous BP and HR recordings were collected beginning 1 h before lights out (LO) until the end of the first non-rapid eye movement sleep period in 21 young, healthy participants maintained in a supine position. Five consecutive phases were defined: 1) the 30 min of wakefulness before LO; 2) LO to stage 1 sleep; 3) stage 1 to stage 2 sleep; 4) stage 2 sleep to the last microarousal before stable sleep; and 5) the first 30 min of undisturbed stable sleep. The data were analyzed on a beat-by-beat basis and reported as 2-min periods for phases 1 and 5 and 10% epochs for phases 2, 3, and 4 (as participants had variable time periods in these phases). The level of baroreflex (BR) activity was assessed by the sequence technique and an autoregressive multivariate model. Furthermore, during phases 3 and 4, the BP and HR responses to arousal from sleep were determined. There were substantial falls in BP and HR after LO before the initial onset of theta;-activity (phase 3) and again after the onset of stable sleep after the cessation of spontaneous arousals. During phases 3 and 4 when there were repeated arousals from sleep, the fall in both variables was retarded. Furthermore, both the rate and magnitude of the fall in BP were negatively associated with the number of arousals during phases 3 and 4. There was a small increase in the sensitivity of the BR and indirect evidence of a substantial fall in its set point.

Biochemical and ultrastructural study of the effects of proline analogues on collagen synthesis in 3T6 fibroblasts.

The effects of proline analogues, L-3,4-dehydroproline and L-azetidine-2-carboxylic acid, on collagen synthesis by cultured 3T6 fibroblasts have been studied. Prolyl hydroxylase activity was partially inhibited in cells cultured with dehydroproline for 24 h, resulting in the synthesis of collagen in which the proline was underhydroxylated. Azetidine had no effect on prolyl hydroxylase and less effect on the degree of hydroxylation of proline. Fibroblasts grown in the presence of either analogue and fixed in-situ contained greatly distended cisternae of the rough endoplasmic reticulum. Proline analogues otherwise caused few ultrastructural changes in the cells. Treated cells which had been handled more roughly during preparation for electron microscopy contained many large cytoplasmic vacuoles in addition to dilated cisternae. Our results indicate that the major effect of the proline analogues was the inhibition of prolyl hydroxylation. However, electron microscopy of the treated cells revealed hitherto unreported cytoplasmic damage.

The inhibition of protein-lysine 6-oxidase by various lathyrogens. Evidence for two different mechanisms.

Lathyrogens decrease collagen and elastin cross-linking by inhibiting lysine oxidase. The lathyrogens isoniazid and semicarbazide decrease liver pyridoxal phosphate and are teratogenic; all their effects are reversed by pyridoxal. beta-Aminopropionitrile, another lathyrogen, does not affect liver pyridoxal phosphate, and its lathyrogenic and teratogenic effects are not reversed by pyridoxal. Time courses of these effects differ greatly, suggesting enzyme inhibition by different mechanisms.

The inhibition of lysyl oxidase in vivo by isoniazid and its reversal by pyridoxal. Effect on collagen cross-linking in the chick embryo.

Isonicotinic acid hydrazide (isoniazid) causes a large increase in the salt-solubility of collagen when injected into chick embryos; this change is accompanied by the inactivation of lysyl oxidase (EC 1.4.3.13), the enzyme responsible for initiating cross-link formation in collagen and elastin. In addition, isoniazid markedly decreases the liver content of pyridoxal phosphate. The depletion of pyridoxal phosphate takes approx. 6 h, whereas the inhibition of lysyl oxidase and the increase in collagen solubility occur more slowly. A reversal of these effects of isoniazid can be produced by the subsequent injection of a stoichiometric amount of pyridoxal, supporting the role of pyridoxal as a cofactor for lysyl oxidase. Treatment of chick embryos with beta-aminopropionitrile, an irreversible inhibitor of lysyl oxidase, causes an inhibition of the enzyme, which begins to recover within 24 h but which is not affected by the administration of pyridoxal; with isoniazid inhibition, however, lysyl oxidase activity does not show any sign of recovery by 48 h. It is proposed that isoniazid may cause the inhibition of lysyl oxidase by competing for its obligatory cofactor, pyridoxal phosphate. The potential clinical implications in the therapeutic control of fibrosis are briefly discussed.

Protein lysine 6-oxidase (lysyl oxidase) cofactor: methoxatin (PQQ) or pyridoxal?

1. Treatment of chick embryos with two lathyrogens lowered lysyl oxidase and increased collagen extractability. 2. Subsequent treatment with pyridoxal restored both parameters towards normal, whereas PQQ treatment was less effective. 3. These results suggest the requirement of a pyridoxal derivative for the formation of the enzyme, acting either as cofactor or because its formation requires some pyridoxal-dependent enzyme. The cochromatography of the enzyme with [3H]pyridoxine-derived radioactivity supports the cofactor role. 4. The conclusions of other authors that lysyl oxidase contains PQQ relates to enzymes from other species or to amine oxidases not characterised as lysyl oxidase.

Selective labeling of intracellular parasite proteins by using ricin.

Studies focused on the synthesis by intracellular parasites of developmentally regulated proteins have been limited due to the lack of a simple method for selectively labeling proteins produced by the parasite. A method has now been developed in which ricin is employed to selectively inhibit host-cell protein synthesis. Ricin is a heterodimer composed of two subunits, a lectin and a glycosidase, and it binds to terminal galactose residues on the cell surface via the lectin. Following endocytosis of the intact molecule, a disulfide bond linking the two subunits is cleaved, and only the glycosidase subunit enters the cytoplasm, where it inhibits cytoplasmic protein synthesis by catalyzing the cleavage of the 28S rRNA. Due to the loss of the receptor-binding lectin subunit, ricin cannot permeate host-cell mitochondria or intracellular parasites, and, therefore, protein synthesis within these compartments continues uninterrupted. This system has been used to selectively label parasite proteins from Eimeria tenella and Toxoplasma gondii by using the avian cell line DU-24. In these cells, mitochondrial protein synthesis was inhibited by using chloramphenicol. The use of the avian rho0 cell line DUS-3 provided an additional advantage, because these cells lack mitochondrial DNA. Therefore, those proteins radiolabeled with [35S]methionine/cysteine in ricin-treated, parasite-infected rho0 cells are exclusively those of the intracellular parasite. This technique should be applicable for studying protein synthesis by other intracellular parasites.