Efficacy and Safety of Ticagrelor for Long-term Secondary Prevention of Atherothrombotic Events in Relation to Renal Function: Insights from the PEGASUS TIMI-54 trial

Aims: We evaluated the relationship of renal function and ischaemic and bleeding risk as well as the efficacy and safety of the P2Y12 platelet receptor inhibitor ticagrelor in stable patients with prior myocardial infarction (MI). Methods & Results: Patients with a history of MI 1-3 years prior from the Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin (PEGASUS)-TIMI 54 were stratified based on estimated glomerular filtration rate (eGFR), with<60 ml/min/1.73m2 prespecified for analysis of the effect of ticagrelor on the primary efficacy composite of cardiovascular death, MI, or stroke (MACE) and the primary safety endpoint of TIMI major bleeding. Of 20,898 patients, those with eGFR<60 (N=4,849, 23.2%) had a greater risk of MACE at 3 years relative to those without, which remained significant after multivariable adjustment (HRadj 1.54, 95% CI 1.27–1.85, p<0.001). The relative risk reduction in MACE with ticagrelor was similar in those with eGFR<60 (ticagrelor pooled vs. placebo: HR 0.81; 95% CI 0.68–0.96) vs. ≥60 (HR 0.88; 95% CI 0.77–1.00, pinteraction=0.44). However, due to the greater absolute risk in the former group, the absolute risk reduction with ticagrelor was higher: 2.7% vs. 0.63%. Bleeding tended to occur more frequently in patients with renal dysfunction. The absolute increase in TIMI major bleeding with ticagrelor was similar in those with and without eGFR<60 (1.19% vs. 1.43%), whereas the excess of minor bleeding tended to be more pronounced (1.93% vs. 0.69%). Conclusion: In patients with a history of MI, patients with renal dysfunction are at increased risk of MACE and consequently experience a particularly robust absolute risk reduction with long-term treatment with ticagrelor.

Monitoring inflammation and airway remodeling by FMT in a chronic asthma model

Asthma is a multifactorial disease for which a variety of mouse models have been developed. A major drawback of these models is represented by the transient nature of the airway pathology peaking 24 to 72 hours after challenge and resolving in 1 to 2 weeks. The objective of this study is to characterize the temporal evolution of pulmonary inflammation and remodeling in a recently described mouse model of chronic asthma (8 week treatment with 3 allergens relevant for the human pathology: Dust mite, Ragweed, and Aspergillus; DRA). We studied the DRA model taking advantage of fluorescence molecular tomography (FMT) imaging using near-infrared probes to non-invasively evaluate lung inflammation and airway remodeling. At 4, 6, 8 or 11 weeks, cathepsin- and metalloproteinase-dependent fluorescence was evaluated in vivo. A subgroup of animals, after 4 weeks of DRA, was treated with Budesonide (100 µg/kg intranasally) daily for 4 weeks. Cathepsin-dependent fluorescence in DRA-sensitized mice resulted significantly increased at 6 and 8 weeks, and was markedly inhibited by budesonide. This fluorescent signal well correlated with ex vivo analysis such as bronchoalveolar lavage eosinophils and alveolar cell infiltration. Metalloproteinase-dependent fluorescence was significantly increased at 8 and 11 weeks, nicely correlated with collagen deposition, as evaluated histologically by Masson’s Trichrome staining, and airway epithelium hypertrophy, and was also partly inhibited by budesonide. In conclusion, FMT proved suitable for longitudinal study to evaluate asthma progression, both in terms of inflammatory cell infiltration and airway remodeling, allowing the determination of treatment efficacy in a chronic asthma model in mice.

Caratterizzazione dei fenotipi e della risposta infiammatoria delle vie aeree nell'asma da isocianati

RIASSUNTO Premesse: Nonostante l’asma sia stata considerata per anni come un’unica malattia, studi recenti ne dimostrano l’eterogeneità. L’intento di caratterizzare tale eterogeneità ha condotto a studiare molteplici sottogruppi ovvero “fenotipi”. Nell’asma comune questo approccio è stato utilizzato da svariati anni, meno invece nell’asma occupazionale. Poco è noto anche riguardo alle caratteristiche della risposta infiammatoria nel corso dei test di provocazione bronchiale specifici (SIC) con isocianati valutata con metodiche non invasive; in particolare l’origine dell’incremento di ossido nitrico misurato ad un flusso espiratorio di 50 ml/s (FeNO50) precedentemente riscontrato, se sia alveolare o bronchiale, i livelli di dimetilarginina asimmetrica (ADMA) e la temperatura dell’aria espirata (EBT). Scopi dello studio: 1) verificare se anche per l’asma occupazionale (OA) da isocianati siano individuabili dei fenotipi o se essa ne rappresenti uno unico 2) studiare l’infiammazione delle vie aeree sperimentalmente indotta tramite:  la misurazione dell’NO frazionato mediante i parametri “flow-independent” che stimano sia la regione alveolare, ovvero la concentrazione di NO alveolare (CaNO), che la regione bronchiale ovvero il flusso di NO a livello bronchiale (JawNO), la concentrazione di NO a livello della parete bronchiale (CawNO) e la diffusione di NO all’interfaccia lume-parete bronchiale (DawNO);  la misurazione dell’ADMA nel condensato dell’aria esalata (EBC);  la misurazione dell’EBT. Materiali e metodi: Per lo studio sulla fenotipizzazione dell’asma da isocianati sono stati esaminati pazienti risultati positivi al test di provocazione bronchiale specifico con isocianati nel periodo compreso tra il 1988 e il 2013. Mediante l’utilizzo di un approccio multivariato dato dall’analisi gerarchica dei cluster e di un ampio pool di variabili appropriate abbiamo studiato se i soggetti affetti da asma professionale da isocianati rappresentino uno o più cluster. Mediante un altro approccio multivariato, dato dall’analisi delle k-medie, si sono individuate le caratteristiche che differenziano in maniera significativa i soggetti distribuiti nei diversi cluster. Per il secondo scopo dello studio dal 2012 al 2015 abbiamo reclutato soggetti afferiti presso il nostro centro per sospetta asma professionale. In questi pazienti in corso di sham-test e di SIC con isocianati fino a 24 post test sono stati monitorati e misurati: la funzionalità respiratoria incluso il test di provocazione bronchiale aspecifico con metacolina, l’NO frazionato, l’ADMA nell’EBC e l’EBT. Risultati: L’utilizzo dell’analisi gerarchica dei cluster ci ha portati a stabilire che i 187 pazienti studiati non costituiscono un unico gruppo omogeneo ma possono essere suddivisi in 3 cluster. L’applicazione poi del metodo multivariato delle k-medie, su tre cluster, ci ha consentito di individuare due cluster di pazienti sensibilizzati a TDI con prevalente risposta late al SIC e un cluster di pazienti sensibilizzati a MDI con prevalente risposta early al SIC. I soggetti appartenenti ai due cluster dei TDI differiscono fra di loro in maniera significativa per l’età alla diagnosi e all’esordio dei sintomi respiratori, la distribuzione per sesso, il BMI, la distribuzione in quanto abitudine al fumo, l’IT, il FEV1 basale % del predetto, l’età di inizio esposizione, gli anni di latenza e la durata dell’esposizione. Per quanto riguarda invece lo studio del profilo infiammatorio delle vie aeree abbiamo reclutato 25 pazienti, 18 maschi e 7 femmine. Nel gruppo dei SIC-positivi FeNO50 è aumentato significativamente a 24 ore dal test (mediana 111.8 ppb [IQR, 167.5]; p<0.05) se confrontato con lo sham (58.6 ppb [74.7]). I livelli di JawNO hanno manifestato il medesimo time-course con un incremento significativo post 24 ore dall’esposizione (6.6 nL/s [81]; p <0.05) se confrontato con lo sham (3.3 nL/s [3.7]). Non sono state riscontrate significative variazioni negli altri parametri. Non sono state riscontrate significative variazioni dell’ADMA nell’EBC e dell’EBT in entrambi i gruppi. Conclusioni: L’asma da isocianati è una patologia eterogenea come l’asma comune. Gli elementi principali che differenziano i cluster di asma professionale da isocianati sono l’agente sensibilizzante e il tipo di risposta al SIC (cluster 3 vs cluster 1 e 2). Anche nell’ambito dell’asma indotta dallo stesso agente (TDI) si sono evidenziati due cluster in cui quello con peggiore funzionalità respiratoria è rappresentato da soggetti più anziani alla diagnosi e con maggiore durata dell’esposizione. I motivi per cui l’asma occupazionale risulta essere eterogenea possono essere un differente meccanismo d’azione dei monomeri o una diversa suscettibilità degli individui appartenenti ai diversi cluster sia in termini di insorgenza della malattia sia in termini di evoluzione della stessa. L’assetto infiammatorio delle vie aeree nel corso del SIC non si caratterizza nei soggetti sensibilizzati ad isocianati né con un incremento dell’ADMA né con un incremento dell’EBT. Si riscontra invece un aumento di FeNO50 dovuto esclusivamente ad un aumentato flusso di NO dalla parete bronchiale al lume. Abbiamo perciò dimostrato che la misurazione del FeNO50 nel corso del SIC può fornire informazioni aggiuntive al monitoraggio funzionale spirometrico, anche perché la broncoostruzione e la risposta infiammatoria delle vie aeree si sono rivelate dissociate.

Asma, abitudini e stile di vita "Analisi retrospettiva di un campione di pazienti asmatici seguito in ambulatorio di terzo livello"

Growing evidence suggest the importance of different environments in promoting the pathogenesis and/or exacerbation of asthma. Indoor air pollution is a major contributor to human exposure, since people spend up to 90% of their day indoors. Apart from active smoking, indoor pollution is considered one of the major preventable risk factors of chronic respiratory diseases. The professional activity can also be dangerous because it exposes the subject to environments that can promote the onset of asthma or worsening of the latter in those already affected. Even bad habits such as incorrect diet, lead to more difficulty in controlling their disease. However asthma is a multifactorial disease in nature so it is not easy to distinguish the role of occupational exposure, pollution and normal habits such as smoking, nutrition, sports, etc. This retrospective study was conducted on a sample of asthma patients residing in the metropolitan area of Parma. 116 patients were selected among those who are followed up at least two years at the Asthma outpatient Clinic of Parma University Hospital. The sample in question is therefore closely controlled and monitored; it comes to patients who are well educated on the control of their disease, are able to take appropriate measures to minimize the symptomatology. With this tight approach is proposed to minimize the effect of confounding and then traced with greater certainty the possible cause of the failure to control the disease. For this purpose, each patient was subjected to regular checkups; we took as a reference the period of time between April and October 2015. During each visit, in addition to general data for each patient, we were collected personal information about their habits and way of life through a validated questionnaire delivered and completed by the patient during the visit in the presence of the permanent staff. The questionnaire covers mainly the qualification of the patient, its possible occupational exposure, his home, with information about nearby traffic, time spent outside, physical activity (place and time), exposure to chemicals, exposure to various fumes (fireplace or stove) and cigarette smoke, comorbidities and any drugs taken during the visits considered. Regarding the respiratory conditions of patients during every examination we were considered: Asthma Control Test (a test performed by patients to assess the state of the disease during the month preceding the test), the measurement of exhaled nitric oxide (FeNO) as an index of airways inflammation, measuring the resistance level of small airways (R5-R20) and some spirometric values observed in experiment; in particular the forced vital capacity (FVC), forced expiratory volume in the first second (FEV 1), FEV1/FVC ratio, forced expiratory flow rate over the middle 50% of the FVC (FEF25–75) and FEF25-75/FVC were recorded. The sample has been studied considering both the changes of the respiratory parameters for every patient in their examinations, and the respiratory parameters of all the examinations took as a whole in relation with the variables considered. From the results obtained, the patients are clinically stable; their adopted lifestyle and the exposure to possible sources of outdoor pollution, seems not affect the overall control of their disease. Some findings of our study are of interest. First, the subjects who carry a steroid therapy show a clinical worst, as revealed by the decrease of most spirometric indices, particularly FEF25, FEF75, FEF25-75 and R5-R20; also, the presence of comorbidities and the subsequent intake of other drugs, in addition to normal therapy for asthma, seem to be conditions associated with poorer performance in the functional respiratory parameters in particular FEV1/FVC, FEF75 and FEF25-75. Spirometric indexes that are down are mainly those related to obstruction imposed on small airways; this suggests a neglect to the latter on the contrary should be further explored and treated accordingly. It is also observed that both patients are overweight than those living on the lower floors and/or who have the most windows exposed to traffic, showed a decrease of pulmonary function, especially those relate to an obstruction at the small airways level. In conclusion, our results provided the evidence that a most appropriate therapy, specific to reach the small airways, associated with a healthy lifestyle, can help improve the management of asthma.

The exchange rate exposure of UK non-financial companies

Purpose – The purpose of this paper is to investigate the exchange rate exposure of UK nonfinancial companies from January 1981 to December 2001. Design/methodology/approach – The study employs different exchange rate measures and adopts an equally weighted exchange rate. The analyses are conducted at the firm level. All analyses are conducted by regressing the firm’s exchange rate exposure coefficients on its size, foreign activity variables and financial hedging proxies over the whole sample period. Findings – The findings show that a higher percentage of UK non-financial companies are exposed to exchange rate changes than those reported in previous studies. Generally, the results provide a stronger support for the suggested equally weighted rate as an economic variable, which affects firms’ stock returns. The results also show a high proportion of positive exposure coefficients among firms with significant exchange rate exposure, indicating a higher proportion of firms benefiting from an appreciation of the pound. Finally, the results also indicate evidence that firms’ foreign operations and hedging variables affect their sensitivity to exchange rate exposure. Practical implications – This study provides important implications for public policymakers who wish to understand links between policies that affect exchange rates and relative wealth effects. Originality/value – The empirical results of this study should help investors to examine how common stock returns react to exchange rate fluctuations when making financial decisions, and prove useful for financial managers when measuring exposure to foreign exchange rate changes.

Development and evaluation of a non-destructive adhesion test

The object of this work was to further develop the idea introduced by Muaddi et al (1981) which enables some of the disadvantages of earlier destructive adhesion test methods to be overcome. The test is non-destructive in nature but it does need to be calibrated against a destructive method. Adhesion is determined by measuring the effect of plating on internal friction. This is achieved by determining the damping of vibrations of a resonating specimen before and after plating. The level of adhesion was considered by the above authors to influence the degree of damping. In the major portion of the research work the electrodeposited metal was Watt's nickel, which is ductile in nature and is therefore suitable for peel adhesion testing. The base metals chosen were aluminium alloys S1C and HE9 as it is relatively easy to produce varying levels of adhesion between the substrate and electrodeposited coating by choosing the appropriate process sequence. S1C alloy is the commercially pure aluminium and was used to produce good adhesion. HE9 aluminium alloy is a more difficult to plate alloy and was chosen to produce poorer adhesion. The "Modal Testing" method used for studying vibrations was investigated as a possible means of evaluating adhesion but was not successful and so research was concentrated on the "Q" meter. The method based on the use of a "Q" meter involves the principle of exciting vibrations in a sample, interrupting the driving signal and counting the number of oscillations of the freely decaying vibrations between two known preselected amplitudes of oscillations. It was not possible to reconstruct a working instrument using Muaddi's thesis (1982) as it had either a serious error or the information was incomplete. Hence a modified "Q" meter had to be designed and constructed but it was then difficult to resonate non-magnetic materials, such as aluminium, therefore, a comparison before and after plating could not be made. A new "Q" meter was then developed based on an Impulse Technique. A regulated miniature hammer was used to excite the test piece at the fundamental mode instead of an electronic hammer and test pieces were supported at the two predetermined nodal points using nylon threads. This instrument developed was not very successful at detecting changes due to good and poor pretreatments given before plating, however, it was more sensitive to changes at the surface such as room temperature oxidation. Statistical analysis of test results from untreated aluminium alloys show that the instrument is not always consistent, the variation was even bigger when readings were taken on different days. Although aluminium is said to form protective oxides at room temperature there was evidence that the aluminium surface changes continuously due to film formation, growth and breakdown. Nickel plated and zinc alloy immersion coated samples also showed variation in Q with time. In order to prove that the variations in Q were mainly due to surface oxidation, aluminium samples were lacquered and anodised Such treatments enveloped the active surfaces reacting with the environment and the Q variation with time was almost eliminated especially after hard anodising. This instrument detected major differences between different untreated aluminium substrates.Also Q values decreased progressively as coating thicknesses were increased. This instrument was also able to detect changes in Q due to heat-treatment of aluminium alloys.

Formulation of topical non-steroidal anti-inflammatory agents

Reversed-pahse high-performance liquid chromatographic (HPLC) methods were developed for the assay of indomethacin, its decomposition products, ibuprofen and its (tetrahydro-2-furanyl)methyl-, (tetrahydro-2-(2H)pyranyl)methyl- and cyclohexylmethyl esters. The development and application of these HPLC systems were studied. A number of physico-chemical parameters that affect percutaneous absorption were investigated. The pKa values of indomethacin and ibuprofen were determined using the solubility method. Potentiometric titration and the Taft equation were also used for ibuprofen. The incorporation of ethanol or propylene glycol in the solvent resulted in an improvement in the aqueous solubility of these compounds. The partition coefficients were evaluated in order to establish the affinity of these drugs towards the stratum corneum. The stability of indomethacin and of ibuprofen esters were investigated and the effect of temperature and pH on the decomposition rates were studied. The effect of cetyltrimethylammonium bromide on the alkaline degradation of indomethacin was also followed. In the presence of alcohol, indomethacin alcoholysis was observed and the kinetics of decomposition were subjected to non-linear regression analysis and the rate constants for the various pathways were quantified. The non-isothermal, sufactant non-isoconcentration and non-isopH degradation of indomethacin were investigated. The analysis of the data was undertaken using NONISO, a BASIC computer program. The degradation profiles obtained from both non-iso and iso-kinetic studies show that there is close concordance in the results. The metabolic biotransformation of ibuprofen esters was followed using esterases from hog liver and rat skin homogenates. The results showed that the esters were very labile under these conditions. The presence of propylene glycol affected the rates of enzymic hydrolysis of the ester. The hydrolysis is modelled using an equation involving the dielectric constant of the medium. The percutaneous absorption of indomethacin and of ibuprofen and its esters was followed from solutions using an in vitro excised human skin model. The absorption profiles followed first order kinetics. The diffusion process was related to their solubility and to the human skin/solvent partition coefficient. The percutaneous absorption of two ibuprofen esters from suspensions in 20% propylene glycol-water were also followed through rat skin with only ibuprofen being detected in the receiver phase. The sensitivity of ibuprofen esters to enzymic hydrolysis compared to the chemical hydrolysis may prove valuable in the formulation of topical delivery systems.

The exchange rate exposure of UK non-financial companies

Purpose – The purpose of this paper is to investigate the exchange rate exposure of UK nonfinancial companies from January 1981 to December 2001. Design/methodology/approach – The study employs different exchange rate measures and adopts an equally weighted exchange rate. The analyses are conducted at the firm level. All analyses are conducted by regressing the firm’s exchange rate exposure coefficients on its size, foreign activity variables and financial hedging proxies over the whole sample period. Findings – The findings show that a higher percentage of UK non-financial companies are exposed to exchange rate changes than those reported in previous studies. Generally, the results provide a stronger support for the suggested equally weighted rate as an economic variable, which affects firms’ stock returns. The results also show a high proportion of positive exposure coefficients among firms with significant exchange rate exposure, indicating a higher proportion of firms benefiting from an appreciation of the pound. Finally, the results also indicate evidence that firms’ foreign operations and hedging variables affect their sensitivity to exchange rate exposure. Practical implications – This study provides important implications for public policymakers who wish to understand links between policies that affect exchange rates and relative wealth effects. Originality/value – The empirical results of this study should help investors to examine how common stock returns react to exchange rate fluctuations when making financial decisions, and prove useful for financial managers when measuring exposure to foreign exchange rate changes.

Formation of Singularities for Weakly Non-Linear N×N Hyperbolic Systems

We present some results on the formation of singularities for C^1 - solutions of the quasi-linear N × N strictly hyperbolic system Ut + A(U )Ux = 0 in [0, +∞) × Rx . Under certain weak non-linearity conditions (weaker than genuine non-linearity), we prove that the first order derivative of the solution blows-up in finite time.

Continuous Dependence of Solutions of Quasidifferential Equations with Non-Fixed Time of Impulses

In this article on quasidifferential equation with non-fixed time of impulses we consider the continuous dependence of the solutions on the initial conditions as well as the mappings defined by these equations. We prove general theorems for quasidifferential equations from which follows corresponding results for differential equations, differential inclusion and equations with Hukuhara derivative.

A Mean Value Theorem for non Differentiable Mappings in Banach Spaces

We prove that if f is a real valued lower semicontinuous function on a Banach space X and if there exists a C^1, real valued Lipschitz continuous function on X with bounded support and which is not identically equal to zero, then f is Lipschitz continuous of constant K provided all lower subgradients of f are bounded by K. As an application, we give a regularity result of viscosity supersolutions (or subsolutions) of Hamilton-Jacobi equations in infinite dimensions which satisfy a coercive condition. This last result slightly improves some earlier work by G. Barles and H. Ishii.

Fractional Powers of Almost Non-Negative Operators

Mathematics Subject Classification: Primary 47A60, 47D06.

Finite Symmetric Functions with Non-Trivial Arity Gap

Given an n-ary k-valued function f, gap(f) denotes the essential arity gap of f which is the minimal number of essential variables in f which become fictive when identifying any two distinct essential variables in f. In the present paper we study the properties of the symmetric function with non-trivial arity gap (2 ≤ gap(f)). We prove several results concerning decomposition of the symmetric functions with non-trivial arity gap with its minors or subfunctions. We show that all non-empty sets of essential variables in symmetric functions with non-trivial arity gap are separable. ACM Computing Classification System (1998): G.2.0.

Corrigendum for "Weierstrass Points with first Non-Gap four on a Double Covering of a Hyperelliptic Curve"

In the proof of Lemma 3.1 in [1] we need to show that we may take the two points p and q with p ≠ q such that p+q+(b-2)g21(C′)∼2(q1+… +qb-1) where q1,…,qb-1 are points of C′, but in the paper [1] we did not show that p ≠ q. Moreover, we hadn't been able to prove this using the method of our paper [1]. So we must add some more assumption to Lemma 3.1 and rewrite the statements of our paper after Lemma 3.1. The following is the correct version of Lemma 3.1 in [1] with its proof.

On The Cauchy Problem for Non Effectively Hyperbolic Operators, The Ivrii-Petkov-Hörmander Condition and the Gevrey Well Posedness

2000 Mathematics Subject Classification: 35L15, Secondary 35L30.