Effect of Empagliflozin with or without the Addition of Evolocumab on HDL Subspecies in Individuals with Type 2 Diabetes Mellitus: A Post Hoc Analysis of the EXCEED-BHS3 Trial.

Evolocumab and empagliflozin yield a modest rise in plasma high-density lipoprotein cholesterol (HDL-C) through unknown mechanisms. This study aims to assess the effect of evolocumab plus empagliflozin vs. empagliflozin alone on HDL subspecies isolated from individuals with type 2 diabetes mellitus (T2D). This post hoc prespecified analysis of the EXCEED-BHS3 trial compared the effects of a 16-week therapy with empagliflozin (E) alone or in combination with evolocumab (EE) on the lipid profile and cholesterol content in HDL subspecies in individuals with T2D divided equally into two groups of 55 patients. Both treatments modestly increased HDL-C. The cholesterol content in HDL subspecies 2a (7.3%), 3a (7.2%) and 3c (15%) increased from baseline in the E group, while the EE group presented an increase from baseline in 3a (9.3%), 3b (16%) and 3c (25%). The increase in HDL 3b and 3c was higher in the EE group when compared to the E group (p < 0.05). No significant interactive association was observed between changes in hematocrit and HDL-C levels after treatment. Over a 16-week period, empagliflozin with or without the addition of evolocumab led to a modest but significant increase in HDL-C. The rise in smaller-sized HDL particles was heterogeneous amongst the treatment combinations.

Diabetes-related distress and quality of life among people with type 2 diabetes at primary care level in Brazil.

PURPOSE: Living with diabetes can be challenging, particularly when it comes to dealing with psychological distress and requiring self-care directives. Patients may feel frustrated, angry, overwhelmed, and discouraged. This study aimed to investigate the diabetes-related distress and quality of life among people with type 2 diabetes mellitus (T2DM). METHODS: A cross-sectional study carried out at the Clinical Research Centre at the University of Campinas, Brazil, between September 2020 and April 2021. Patients answered data regarding demographic and clinical variables, the Brazilian version of the Diabetes Distress Scale and the Diabetes Quality of Life (QOL) Measure by telephone contact. The data were managed using the RedCap System. For statistical analysis of the data, the Mann-Whitney and Kruskal-Wallis tests were applied for comparisons, and the Chi-square test for associations. The correlations were evaluated using the Spearman correlation coefficient. RESULTS: Out of the 302 participants we recruited, 50.33% exhibited significant diabetes-related distress. Those with elevated diabetes-related distress scores had shorter education levels (p < 0.05), lower HbA1c levels (p < 0.05), and lower total scores in Diabetes QOL Measure (p < 0.0001), particularly in the QOL impact (p < 0.0001), social/vocational worry (p < 0.05), and diabetes worry (p < 0.0001) subscales compared to the group with the lowest diabetes-related distress. CONCLUSION: Elevated diabetes-related stress scores significantly affect patients' QOL. Therefore, early screening of individuals at risk for this condition, using well-coordinated protocols, could mitigate adverse QOL effects and enhance their overall experience during disease management.

Evolocumab on top of empagliflozin improves endothelial function of individuals with diabetes: randomized active-controlled trial.

BACKGROUND: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve endothelial dysfunction and reduce cardiovascular events in individuals with type 2 diabetes (T2D). Proprotein convertase subtilisin/kexin 9 (PCSK9i) inhibitors reduce cardiovascular events in high-risk patients. Whether the addition of PCSK9i to SGLT2i treatment adds benefits is not known. OBJECTIVES: To assess the PCSK9-i effect on the endothelial function of T2D individuals under treatment with SGLT2-i. METHODS: Individuals with T2D were randomized in a 1:1 ratio to a 16-week treatment with either empagliflozin (E) or empagliflozin plus evolocumab (EE). The primary endpoint was post-treatment change from baseline in flow-mediated dilation (FMD) at 1-min. Secondary outcomes included changes in plasma levels of nitric oxide metabolites and isoprostane. RESULTS: A total of 110 patients were enrolled, the mean age was 58 years, and 71% were men. The median post-treatment change in FMD at 1-min was 2.7% (interquartile range [IQR]: 0.9%) and 0.4% (IQR: 0.9%) in the EE and E groups, respectively (p < 0.001). There was a greater increase in plasma levels of nitrate [5.9 (16.5) vs. 2.6 (11.8); p = 0.001] and nitrite [0.14 (0.72) vs. 0.02 (0.74); p = 0.025] in the EE group than in the E group, respectively. Isoprostane reduction was more pronounced in the EE group when compared to the E group [-1.7 (5.9) vs. -1.1 (5.3); p < 0.001). CONCLUSIONS: In individuals with T2D, the addition of evolocumab on top of empagliflozin improves endothelial function.

Dapagliflozin increases retinal thickness in type 2 diabetic patients as compared with glibenclamide: A randomized controlled trial.

AIM: In patients with type 2 diabetes mellitus (T2DM) a progressive thinning in the central retinal thickness (CRT) is mainly related to neuroretinal degeneration and occurs before the decline in visual acuity or capillary density. We investigated the change in CRT by optical coherence tomography (OCT) in T2DM patients after 12 weeks of treatment with dapagliflozin or glibenclamide. METHODS: Ninety-seven patients (57 ± 7 years) with T2DM and clinical or subclinical atherosclerosis were randomized 1:1 to dapagliflozin (10 mg/day) or glibenclamide (5 mg/day) on top of metformin XR 1.5 g/day. OCT was obtained in all patients enrolled in the study, both at the time of randomization and at the end of the study. RESULTS: Baseline and post-treatment values of fasting glucose and glycated hemoglobin were equivalent in the two arms. There was no difference in change in diabetic retinopathy status after therapy. The center subfield thickness changed by +2(6)µm in the dapagliflozin group and by -1(7) µm in the glibenclamide group (P = 0.001). CONCLUSION: A short-term treatment with dapagliflozin may increase CRT as compared with equivalent glycemic control with glibenclamide.

Dapagliflozin effect on endothelial dysfunction in diabetic patients with atherosclerotic disease: a randomized active-controlled trial.

BACKGROUND: The glucose-lowering independent effect of sodium glucose cotransporter-2 inhibitors (SGLT2i) on arterial wall function has not yet been clarified. This study aims to assess whether SGLT2i treatment can attenuate endothelial dysfunction related to type 2 diabetes mellitus (T2D) compared with glucose-lowering equivalent therapy. METHODS: In a prospective, open-label, single-center, randomized clinical trial, 98 patients with T2DM and carotid intima-media thickness above the 75th percentile were randomized 1:1 to 12 weeks of therapy with dapagliflozin or glibenclamide in addition to metformin in glucose-lowering equivalent regimens. The coprimary endpoints were 1-min flow-mediated dilation (FMD) at rest and 1-min FMD after 15 min of ischemia followed by 15 min of reperfusion time (I/R). RESULTS: Ninety-seven patients (61% males, 57 ± 7 years) completed the study. The median HbA1c decreased by - 0.8 (0.7)% and -0.7 (0.95)% following dapagliflozin and glibenclamide, respectively. The first coprimary endpoint, i.e., rest FMD changed by + 3.3(8.2)% and - 1.2(7.5)% for the dapagliflozin and glibenclamide arms, respectively (p = 0.0001). Differences between study arms in the second coprimary endpoint were not significant. Plasma nitrite 1 min after rest FMD was higher for dapagliflozin [308(220) nmol/L] than for glibenclamide (258[110] nmol/L; p = 0.028). The resistive indices at 1 min [0.90 (0.11) vs. 0.93 (0.07); p = 0.03] and 5 min [0.93 (0.07) vs. 0.95 (0.05); p = 0.02] were higher for the glibenclamide group than for the dapagliflozin group. Plasma biomarkers for inflammation and oxidative stress did not differ between the treatments. CONCLUSIONS: Dapagliflozin improved micro- and macrovascular endothelial function compared to glibenclamide, regardless of glycemic control in patients with T2DM and subclinical carotid atherosclerotic disease.

The Effect of Plantago major on Wound Healing in Preclinical Studies: A Systematic Review.

BACKGROUND: Plantago major is a medicinal plant that has been used for centuries to treat various health conditions including wounds. PURPOSE: To investigate the effectiveness of the topical use of P major in healing skin wounds in animal models. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was conducted. Seven (7) electronic databases (Virtual Health Library, Public/Publisher MEDLINE, Scopus, Web of Science, Embase, Cumulative Index of Nursing and Allied Health Literature, and CAB Direct) were searched for controlled studies published in English from January 2006 to March 2020. The Collaborative Approach to Meta Analysis and Review of Animal Data from Experimental Studies tools guided the evaluation of the studies and determined their quality. The Systematic Review Center for Laboratory Animal Experimentation was used to assess the risk of bias. RESULTS: Of the 176 publications identified, 4 met the inclusion criteria. Studies included 20 to 100 animals and varying concentrations of P major. There were no reports of losses during research. Wound healing was assessed between 17 and 21 days following wounding. The best response in terms of wound contraction rate occurred with 10%, 20%, and 50% concentrations when compared with control groups. One (1) study did not have an animal ethics committee review. All studies had a high risk of bias and a lack of methodological rigor. CONCLUSION: The results of this review did not find evidence about the in vivo effectiveness of P major for wound healing. More rigorous preclinical studies with adequate sample sizes are required to identify the best concentrations and formulations as well as increase understanding about the mechanisms of action of P major in wound healing.

Surgical Wound Dehiscence Treatment With Low-Level Laser Therapy and Barbatimão: A Case Report.

BACKGROUND: Low-level laser therapy (LLLT) and a gel containing an extract of Barbatimão, a native Brazilian tree, have shown promising results in both preclinical and clinical wound healing studies. PURPOSE: To describe the treatment of surgical wound dehiscence with LLLT and Barbatimão gel. CASE STUDY: A 54-year-old woman without comorbidities underwent abdominoplasty at another health facility. Three (3) weeks later she presented to the authors' clinic after an episode of syncope, abrupt dyspnea, purulent exudate, and necrotic tissue in the surgical incision. She reported that wound redness, warmth, and swelling started 8 days postoperatively. The patient was admitted; on day 3 of that hospital stay, her condition improved and surgical debridement was performed. Follow-up care of wound dehiscence was provided in the outpatient clinic. The treatment involved daily application of Barbatimão gel and weekly application of LLLT. The wound healed after 84 days. CONCLUSION: This case report suggests that LLLT may be a beneficial adjunctive therapy, together with Barbatimão gel, for the treatment of surgical wound dehiscence.

Rationale and design of the expanded combination of evolocumab plus empagliflozin in diabetes: EXCEED-BHS3 trial.

BACKGROUND: Patients with type 2 diabetes mellitus (T2DM) remain at increased cardiovascular residual risk and endothelial dysfunction, even after optimizing metabolic control and treatment by sodium-glucose-2 transporter inhibitors (SGLT2-is). The present study was based on the hypothesis that proprotein convertase subtilisin/kexin 9 inhibitor (PCSK9i) therapy may mitigate endothelial dysfunction in T2DM patients who are on regular treatment by SGLT2-i. METHODS: The EXCEED-BHS3 is a prospective, single-center, investigator-blinded, open-label, randomized clinical trial. Participants (n = 110) will be randomized (1:1) to either empagliflozin 25 mg/day alone or empagliflozin 25 mg/day plus evolocumab 140 mg every 2 weeks in addition to optimal medical care. The primary endpoint was defined as the change in the 1-min flow-mediated dilation (FMD) after 16 weeks of treatment. The secondary endpoint is the FMD change after ischemia/reperfusion injury protocol (reserve FMD) after 16 weeks of treatment. Exploratory outcomes comprise the change in FMD and reserve FMD after 8 weeks of treatment and the change after 16 weeks of treatment in the following parameters: plasma levels of nitric oxide, vascular cell adhesion molecule-1 and isoprostane, high-density lipoprotein (HDL) and low-density lipoprotein subfractions profile, HDL function, blood pressure, body mass index, waist circumference and adipokines. CONCLUSION: This will be the first study to evaluate the add-on effect of PCSK9i on endothelial function of T2DM patients under regular use of empagliflozin. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03932721.

Effects of Electrospun Fibrous Membranes of PolyCaprolactone and Chitosan/Poly(Ethylene Oxide) on Mouse Acute Skin Lesions.

Polycaprolactone (PCL) is a synthetic polymer with good mechanical properties that are useful to produce biomaterials of clinical application. It can be successfully combined with chitosan, which enhances the biomaterial properties through the modulation of molecular and cellular mechanisms. The objective of this study was to evaluate the effects of the use of electrospun fibrous membranes consisting of polycaprolactone (PCL) or polycaprolactone coated with chitosan and poly(ethylene oxide) (PCL+CHI/PEO) on mouse skin lesions. Sixty four Black-57 mice were divided into PCL and PCL+CHI/PEO groups. A 1 cm2 lesion was made on the animals' backs, and the membranes were sutured in place. The tissues were extracted on the 3rd, 7th, and 14th days after the lesion. The tissues were analyzed by histology with Hematoxylin and Eosin (H&E) and Sirius Red stains, morphometry, immunohistochemistry, and Western blot. On the 3rd, 6th, and 9th days after the lesion, the PCL+CHI/PEO group showed a higher wound-healing rate (WHR). On the 3 day, the PCL+CHI/PEO group showed a greater amount of inflammatory infiltrate, greater expression of proliferating cell nuclear antigen (PCNA), and smooth muscle actin (α-SMA) (p < 0.05) compared to the PCL group. On the 7th day after the lesion, the PCL+CHI/PEO group showed a greater amount of inflammatory infiltrate, expression of Tumor Necrosis Factor (TNF-α) and PCNA (p < 0.05). In addition, it showed a greater immunolabeling of Monocyte Chemoattractant Protein-1 (MCP-1) and deposition of collagen fibers compared to the PCL group. The PCL+CHI/PEO membrane modulated the increase in the inflammatory infiltrate, the expression of MCP-1, PCNA, and α-SMA in lesions of mice.

A protocol for systematic review of Plantago major L. effectiveness in accelerating wound-healing in animal models.

BACKGROUND: Studies have indicated that Plantago major L. (P. major) has therapeutic properties, such as anti-inflammatory, antioxidant, antifungal, immunostimulatory, and tissue regeneration. This plant species is assumed to provide potent tissue repair and healing in treatments of skin wound injuries, but the understanding of its effectiveness is still unclear. The systematic review proposed herein aims to assess effectiveness of P. major for wound healing in animal models. METHODS: We will conduct database searches in BVS, PubMed, Scopus, Web of Science, CINAHL, and CABDirect. Reviewers will independently evaluate titles, abstracts, and full-text articles retrieved from databases to identify potentially eligible studies. Relevant articles will be assessed for risk of bias and quality. The database searches will include analysis of wound healing rate through macroscopic evaluation, photo images, or calculation of the wound area retraction until the wound closure. Relevant data will be compiled for the capability and effectiveness of P. major treatments in accelerating wound healing. Random effects meta-analysis models will be employed to compare among groups based on outcome variables from studies reporting sufficient high-quality data. DISCUSSION: Results of this systematic review will be presented in a narrative synthesis form. They will provide a summary and clear understanding of the relevant current questions and evidences directly related to P. major effective tissue repair and healing. Outcomes of this systematic review will contribute with important information that could benefit future research efforts and potential applicability in humans. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019121962.

Assessment of dapagliflozin effect on diabetic endothelial dysfunction of brachial artery (ADDENDA-BHS2 trial): rationale, design, and baseline characteristics of a randomized controlled trial.

BACKGROUND: Endothelial dysfunction (ED) is a hallmark in type 2 diabetes mellitus (T2DM) that favor both atherogenesis and ischemia and reperfusion injury (IRI). Sodium-glucose-2 co-transporter inhibitors (SGLT2i) may hypothetically improve microvascular and macrovascular functions via a broad spectrum of mechanisms, being superior to traditional antidiabetic therapy such as sulfonylurea, even in subjects under equivalent glycemic control. Hence, the present clinical trial was designed to compare the effect of these two treatments on markers of arterial wall function and inflammation in T2DM patients as well as on the potential mediating parameters. METHOD AND RESULTS: ADDENDA-BHS2 is a prospective, single-center, active-controlled, open, randomized trial. Ninety-eight participants (40-70 years old) with HbA1c 7-9% were randomized (1:1, stratified by gender, BMI and HbA1c levels) to either dapagliflozin 10 mg/day or glibenclamide 5 mg/day on top of metformin. The primary endpoint was the change of flow-mediated dilation (FMD) after a 12-week period of treatment evaluated at rest and after IRI between dapagliflozin and glibenclamide arms. Secondary outcomes were defined as the difference between treatments regarding: plasma nitric oxide (NO) change after FMD, plasma isoprostane, plasma levels of vascular inflammatory markers and systemic inflammatory markers, plasma levels of adipokines, anthropometric measures, glucose control parameters, office and ambulatory BP control. Safety endpoints were defined as systolic and diastolic function assessed by echocardiography and retinopathy change. Serious adverse events were recorded. The study protocol was approved by the Independent Scientific Advisory Committee. CONCLUSION: The ADDENDA-BHS2 trial is an investigator-initiated clinical trial comparing the effect of dapagliflozin versus glibenclamide on several aspects of vascular function in high cardiovascular risk T2DM patients. Besides, a large clinical and biochemical phenotype assessment will be obtained for exploring potential mediations and associations.Trial registration Clinical trial registration: NCT02919345 (September, 2016).

Endogenous peripheral hydrogen sulfide is propyretic: its permissive role in brown adipose tissue thermogenesis in rats.

NEW FINDINGS: What is the central question of this study? In fever, the most striking response in the acute phase reaction of systemic inflammation, plasma H2 S concentration increases. However, the role of endogenous peripheral H2 S in fever is unknown. What is the main finding and its importance? Endogenous peripheral H2 S is permissive for increased brown adipose tissue thermogenesis to maintain thermal homeostasis in cold environments as well as to mount fever. This finding expands the physiological role of the gaseous modulator as a key regulator of thermal control in health (thermal homeostasis) and disease (fever in systemic inflammation). ABSTRACT: In recent years, hydrogen sulfide (H2 S) has been reported as a gaseous modulator acting in several tissues in health and disease. In animal models of systemic inflammation, the plasma H2 S concentration increases in response to endotoxin (bacterial lipopolysaccharide, LPS). The most striking response in the acute phase reaction of systemic inflammation is fever, but we found no reports of the peripheral action of H2 S on this thermoregulatory response. We aimed at investigating whether endogenous systemic H2 S modulates LPS-induced fever. A temperature datalogger capsule was inserted in the abdominal cavity of male Wistar rats (220-270 g) to record body core temperature. These animals received an i.p. injection of a systemic H2 S inhibitor (propargylglycine; 50 or 75 mg kg-1 ), immediately followed by an i.p. injection of LPS (50 or 2500 µg kg-1 ), and were exposed to different ambient temperatures (16, 22 or 27°C). At 22°C, but not at 27°C, propargylglycine at 75 mg kg-1 significantly attenuated (P < 0.0001) the fever induced by LPS (50 µg kg-1 ), indicating a modulatory (permissive) action of endogenous peripheral H2 S on brown adipose tissue (BAT) thermogenesis. Evidence on the modulatory role of peripheral H2 S in BAT thermogenesis was strengthened when we discarded (i) the possible influence of the gas on febrigenic signalling (when measuring plasma cytokines), and (ii) its interaction with the nitric oxide pathway, and mainly when (iii) we carried out physiological and pharmacological activations of BAT. Endogenous peripheral H2 S modulates (permits) BAT activity not only in fever but also during maintenance of thermal homeostasis in cold environments.

Efeito da quitosana e alginato na cicatrização de feridas: revisão integrativa / Effect of chitosan and alginate on wound healing: integrative review

Objetiva-se identificar e analisar a produção de conhecimento sobre o efeito do alginato e da quitosana na cicatrização de feridas. Trata-se de uma revisão integrativa realizada nas bases de dados eletrônicas PubMed/Medline, Web of Science e CINAHL, no período de 01 de janeiro 2011 a 31 de dezembro de 2016. Foram utilizados os seguintes descritores associados: "wound healing" OR "regeneration" OR "granulation tissue" AND "chitin" OR "chitosan" AND "alginate" AND "membrane" OR "wound dressing". Os critérios de exclusão foram: artigos duplicados, artigos de revisão, artigos que não respondiam à pergunta de pesquisa ou que referenciavam o uso separado dos polímeros, sendo incluídos 10 artigos. As membranas com quitosana e alginato aceleraram o processo de cicatrização em suas fases mais precoces, com a promoção da proliferação de fibroblastos e de capilares, síntese de colágeno, avanço na formação de tecido de granulação, absorção de água, além de atividade antimicrobiana. Conclui-se que o uso do complexo quitosana-alginato apresenta potencial para acelerar o processo de cicatrização com melhora da fase inflamatória, como também a ação antimicrobiana, indicando seu uso em coberturas para acelerar a cura de feridas

The aim is to identify and analyze a production of knowledge about the effect of alginate and chitosan on wound healing. This is an integrative revision in the electronic databases PubMed / Medline, Web of Science and CINAHL, in period from 1 January 2011 to 31 December 2016. The following associated descriptors were used: "wound healing" OR "regeneration" OR "granulation tissue" AND "chitin" OR "chitosan" AND "alginate" AND "membrane" OR "wound dressing". Exclusion criteria: duplicate articles, review articles, articles that do not answer research questions, or refer to the singe use of polymers, included 10 articles. The membranes with chitosan and alginate accelerated the healing process in its earliest stages, with a promotion of fibroblast and capillary proliferation, collagen synthesis, advancement in granulation tissue formation, water absorption, and antimicrobial activity. It concludes that the use of the chitosan and alginate complex has the potential to accelerate the healing process with improvement of the inflammatory phase, as well as the antimicrobial action, which indicates its use in coatings to accelerate a wound healing