Determinants of aspirin resistance in patients with type 2 diabetes.

BACKGROUND: Cardiovascular disease is a leading cause of mortality among patients with type 2 diabetes mellitus (T2DM). Numerous patients with T2DM show resistance to aspirin treatment, which may explain the higher rate of major adverse cardiovascular events observed compared with non-diabetes patients, and it has recently been shown that aspirin resistance is mainly related to accelerated platelet turnover with persistent high platelet reactivity (HPR) 24h after last aspirin intake. The mechanism behind HPR is unknown. The aim of this study was to investigate the precise rate and mechanisms associated with HPR in a population of T2DM patients treated with aspirin. METHODS: Included were 116 consecutive stable T2DM patients who had attended our hospital for their yearly check-up. HPR was assessed 24h after aspirin intake using light transmission aggregometry (LTA) with arachidonic acid (AA) and serum thromboxane B2 (TXB2) measurement. Its relationship with diabetes status, insulin resistance, inflammatory markers and coronary artery disease (CAD) severity, using calcium scores, were investigated. RESULTS: Using LTA, HPR was found in 27 (23%) patients. There was no significant difference in mean age, gender ratio or cardiovascular risk factors in patients with or without HPR. HPR was significantly related to duration of diabetes and higher fasting glucose levels (but not consistently with HbA1c), and strongly related to all markers of insulin resistance, especially waist circumference, HOMA-IR, QUICKI and leptin. There was no association between HPR and thrombopoietin or inflammatory markers (IL-6, IL-10, indoleamine 2,3-dioxygenase activity, TNF-α, C-reactive protein), whereas HPR was associated with more severe CAD. Similar results were found with TXB2. CONCLUSION: Our results reveal that 'aspirin resistance' is frequently found in T2DM, and is strongly related to insulin resistance and severity of CAD, but weakly related to HbA1c and not at all to inflammatory parameters. This may help to identify those T2DM patients who might benefit from alternative antiplatelet treatments such as twice-daily aspirin and thienopyridines.

Observationally Weak TGFs in the RHESSI Data.

Terrestrial gamma ray flashes (TGFs) are sub-millisecond bursts of high energetic gamma radiation associated with intracloud flashes in thunderstorms. In this paper we use the simultaneity of lightning detections by World Wide Lightning Location Network to find TGFs in the Reuven Ramaty High Energy Solar Spectroscopic Imager (RHESSI) data that are too faint to be identified by standard search algorithms. A similar approach has been used in an earlier paper, but here we expand the data set to include all years of RHESSI + World Wide Lightning Location Network data and show that there is a population of observationally weak TGFs all the way down to 0.22 of the RHESSI detection threshold (three counts in the detector). One should note that the majority of these are "normal" TGFs that are produced further away from the subsatellite point (and experience a 1/r 2 effect) or produced at higher latitudes with a lower tropoause and thus experience increased atmospheric attenuation. This supports the idea that the TGF production rate is higher than currently reported. We also show that compared to lightning flashes, TGFs are more partial to ocean and coastal regions than over land.

Mycobacterium bovis BCG killed by extended freeze-drying induces an immunoregulatory profile and protects against atherosclerosis.

OBJECTIVES: Atherosclerosis is an inflammatory disease of the arterial wall that leads to myocardial infarction and stroke. Regulatory T cells (Tregs) and IL-10 exert significant anti-atherogenic effects in experimental models of atherosclerosis by modulating vascular inflammation. We have previously shown that Mycobacterium bovis BCG killed by extended freeze-drying (EFD BCG) decreases lung and colon inflammation by recruiting IL-10-producing Tregs. Therefore, the aim of this study was to investigate the effect of EFD BCG on the development of atherosclerosis. DESIGN: We used two strains of atherosclerosis-prone mice: Ldlr(-/-) (four or six EFD BCG injections) and Apoe(-/-) (six injections). RESULTS: In both models, EFD BCG significantly reduced the size of atherosclerotic lesions, increased IL-10 production and reduced the serum levels of pro-inflammatory cytokines (IL-6, IL-13, KC and tumour necrosis factor-α). Shortly after treatment with EFD BCG, the number of plasmacytoid dendritic cells (pDCs) and Foxp3(+) Tregs in the draining lymph nodes increased. EFD BCG also led to accumulation of Tregs, but not of pDCs in the spleen, and reduced activity of NF-κB and increased activity of PPAR-γ in both the spleen and vascular tissue of treated mice. CONCLUSION: EFD BCG has atheroprotective effects through IL-10 production and Treg expansion. These findings support a novel approach to the prevention and treatment of atherosclerosis.

Activity of a synthetic hexadecasaccharide (SanOrg123781A) in a pig model of arterial thrombosis.

The activity of SanOrg123781A, a new synthetic antithrombotic drug inhibiting both factor Xa and thrombin through antithrombin (AT), was compared to that of unfractionated heparin (UFH) and of the synthetic pentasaccharide (fondaparinux, SP) in an ex vivo arterial thrombosis model in the pig. Six groups of four pigs were administered intravenously with SanOrg123781A (1, 3, 10 and 30 nmol kg(-1)), UFH (30 nmol kg(-1)) or SP (30 nmol kg(-1)). In this arterial model in which platelet thrombus was formed on a thrombogenic surface under a constant high shear rate, UFH and SP had moderate antithrombotic effects while SanOrg123781A exhibited a strong, dose-dependent inhibitory activity on platelet adhesion and platelet thrombus formation. In contrast to UFH, SanOrg123781A did not modify the activated partial thromboplastin time (aPTT) even at 30 nmol kg(-1), but strongly inhibited thrombin generation. At the same dose, despite a lower antithrombotic activity than SanOrg123781A, UFH significantly affected all the coagulation parameters. Taken together, these results show that SanOrg123781A, due to its potent and selective antifactor Xa and antifactor IIa activities is a promising new antithrombotic agent even in arterial setting.

Clopidogrel-induced qualitative changes in thrombus formation correlate with stent patency in injured pig cervical arteries.

Thienopyridines (ticlopidine or clopidogrel) alone or in combination with aspirin are now the reference antiplatelet therapy after stent implantation. To better understand the high efficacy and low risk of bleeding with these agents, we tested clopidogrel alone or with aspirin in an acute ex vivo flow chamber model and in a subacute in vivo arterial thrombosis model. Clopidogrel induced a dose-dependent increase in bleeding time (BT), inhibited ADP-induced platelet aggregation and in the flow chamber reduced thrombus size, and changed thrombus structure to broad-based structure composed of nondegranulated loosely attached platelets contrasting with the tight clumps of degranulated platelets seen without clopidogrel. The in vivo model involved angioplasty and stenting at the site of a preinduced arterial lesion and thrombosis in pig carotid arteries. Clopidogrel alone or with aspirin (but not aspirin alone) decreased the number of stented vessels occluded for more than 24 h and conversely reduced the number of occluding thrombus. At 96 h after stenting, 100% and 90% of the arteries were patent with clopidogrel/aspirin and clopidogrel alone, respectively (vs. 67% and 44% with aspirin and saline, respectively). Clopidogrel destabilizes thrombus without complete abolishment of platelet reactivity.

Adhesion-induced intracellular signalling in endothelial cells depends on the nature of the matrix.

The adhesion of a human microvascular endothelial cell line to its own matrix was studied in comparison with adhesion of the same cells to fibronectin or thrombospondin-1. These endothelial cells adhered preferentially to their matrix whereas an equal cell number was attached to fibronectin or thrombospondin-1. The adhesion of cells to thrombospondin-1 was mediated by the N-terminal heparin binding domain of thrombospondin-1 as shown by the use of a recombinant fragment, N18. Cells adhering to their matrix displayed a morphology and a cytoskeleton organization very similar to that observed in vivo with an apical immunostaining for actin stress fibers and a fine basal labeling for vinculin. Cells on fibronectin were extensively spread and rapidly assembled stress fibers and focal contacts. Cells adherent to thrombospondin-1 presented large lamellae rich in actin but devoid of vinculin and only few actin fibers were observed. Depending on the substratum used, adhering endothelial cells displayed also different tyrosine phosphorylation patterns on electrophoresis. Our observations indicate that endothelial cells adhering to their matrix present an activation state intermediate between that induced by a "hyperadhesive" protein like fibronectin and that generated by a moderate, indeed anti-adhesive, protein like thrombospondin-1.

Endothelial cell proliferation regulated by cytokines modulates thrombospondin-1 secretion into the subendothelium.

Endothelial cells activation and proliferation are induced by cytokines and modulated by adhesive molecules of the extracellular matrix. In a previous study, we showed that IL-1beta and TNF-alpha inhibited thrombospondin-1 (TSP) secretion by human umbilical vein endothelial cells. This work was carried on by studying the effects of other cytokines [interleukin 6 (IL-6), IL-8, basic fibroblast growth factor (bFGF), transforming growth factor beta (TGF-beta)] known to modulate endothelial cell proliferation. We show here that TSP incorporation into the subendothelial matrix is inversely proportional to cell density. Proliferative cytokines such as IL-6 and bFGF inhibit TSP secretion, whereas the anti-proliferative TGF-beta enhances it. IL-8 has no effect either on cell proliferation or TSP secretion. Thus, the modulation of TSP secretion by these cytokines is apparently due to changes in cell proliferation. Therefore, when studying the effects of cytokines on TSP secretion, it is important to correlate the concentration of subendothelial matrix TSP to the cell density.

Formation of GSH-derivatives as a pathway for inactive intermediates in vinylidene chloride-treated rats.

The two conjugates, S-[N-(2-hydroxyethyl)carbamoylmethyl]glutathione (GSAAE), and its corresponding mercapturic derivative N-acetyl-S-[N-(2-hydroxyethyl)carbamoylmethyl]cysteine (NCySAAE) were administered to fasted Sprague-Dawley rats as putative metabolites of vinylidene chloride (VDC). Methylthioacetylaminoethanol (MAAE) was identified in the urine of GSAAE- or NCySAAE-treated rats (0.5-2.0 mmol/kg, i.p.), as well as in the urine of VDC-treated rats (0.5-2.0 mmol/kg, p.o.). The effects of VDC, GSAAE and NCySAAE on the kidney and liver were also examined using aspartate aminotransferase (ASAT). N-acetyl-beta-D-glucosaminidase (NAG) and beta 2-microglobulin (beta 2-m) as urinary parameters of nephrotoxicity, and glutamate dehydrogenase (GLDH), sorbitol dehydrogenase (SDH) and alanine aminotransferase (ALAT) as serum parameters of hepatotoxicity. Unlike treatment with VDC, treatment with both GSAAE and NCySAAE failed to cause kidney and liver toxicity. The results support the hypothesis that MAAE originates from the formation of GSAAE and further metabolization to NCySAAE, and that MAAE excretion does not reveal a pathway of reactive intermediates.

Clinical results of percutaneous implants in the temporal bone.

The bone-anchored hearing aid is an alternative to the conventional bone-conduction hearing aid, without the disadvantages of pressure pain or skin irritation and with direct sound transmission to the skull. The bone-anchored hearing aid is coupled to a percutaneous titanium implant, which is placed in the mastoid process in two surgical stages. We analyzed the clinical results of 68 percutaneous implants in 65 patients. After a follow-up period of 8 to 45 months, 97% of the implants were anchored in the bone. In 86% of the implants, no potentially dangerous skin reactions occurred. The occurrence of skin reactions was not time dependent. Movement of the skin, thick skin, and poor skin condition around the implant were related to the onset of skin reactions. This study showed that the percutaneous titanium implant forms a stable link between the bone-anchored hearing aid and the skull.

The super-bass bone-anchored hearing aid compared to conventional hearing aids. Audiological results and the patients' opinions.

Twelve patients with severe mixed hearing loss (PTA ranging from 70 to 108 dB HL) were provided with the percutaneous 'super-bass HC 220' bone-anchored hearing aid (BAHA) to replace their former hearing aid. Five had previously worn an air-conduction hearing aid (behind-the-ear type, BTE) which could no longer be used because of recurrent otorrhoea; the others had previously worn a conventional (transcutaneous) bone-conduction hearing aid (CBHA) which had caused serious complaints, such as headaches or skin irritation. Free-field speech audiometry in the subgroup of patients who used to wear a CBHA revealed that the maximum intelligibility score with the BAHA was equal to or better than that obtained with the CBHA (range from 0 to +27%). In three of the five patients who used to wear a BTE, the speech scores were poorer with the BAHA than with the BTE (range from -13 to -40%). For the remaining two patients, the difference in scores was 0 and +10%. In conclusion, speech recognition with the BAHA HC220 in the patients with severe mixed hearing loss was comparable to, or better than, that with a CBHA. Compared to an air-conduction hearing aid, the results may be considerably poorer. The results of the questionnaire were in good agreement with the measurements and support the conclusions.