If you ever wonder to yourself whether butter or margarine is the healthiest option, Dr Mosley has settled the debate. Once placed on a pedestal for being a “healthy version” of butter, scientific evidence now suggests otherwise. “Margarine itself is processed and made from vegetable oil,” explained Dr Mosley. “As vegetable oil is liquid at room temperature, a process called hydrogenation takes place, which resultantly creates trans-fat.”
Trans fats “should be avoided where possible”, urged Dr Mosley.
“There is a plethora of scientific evidence linking increased intake of trans fats with inflammation, heart disease, stroke and poor cholesterol”.
While margarine does have less saturated fat than butter, Dr Mosley pointed out that “saturated fat is not necessarily a bad thing”.
In the past, margarine was linked to raised cholesterol and heart disease, but new research has turned this on its head.
With new outgoings announced almost every single day in north London, it is shaping up to be a busy summer of transfer dealings for Arsenal and technical director Edu. With a dramatic improvement required on their eighth place finish last season, the pressure is on for the Gunners to get the squad in a position where they can realistically challenge for the top four next time out.
Such a disappointing domestic finish leaves Mikel Arteta’s side without any form of European football for the first time in 25 years.
Aside from upsetting the fans, its absence is also set to make their summer of business exponentially more difficult.
First and foremost, attracting the world’s best players, as Arsenal have done in the past, is made that much harder when you cannot offer European football.
Naturally, the cream of the crop like to play in the biggest of games, and it does not come any bigger than the Champions League.
Without it on the table, the Gunners will logically have to provide incentives to transfer targets in different ways, chiefly in the form of long-term contracts and high wages.
However, the added difficulty with this is that without European football, the club is also set to miss out on revenue from European football.
In a painful double-whammy, the Arsenal boardroom is therefore tasked with providing bigger financial incentives than their Champions League-qualified rivals, despite having less money to work with.
Their situation is illustrated perfectly through their pursuit of Italy midfielder Manuel Locatelli.
The 23-year-old has dazzled at Euro 2020, helping his national side all the way to the final, and although Arsenal are now pushing hard to sign him they are facing stiff competition from Italian giants Juventus.
Some reports indicate that a deal is close for the north London side, but journalist Paolo Bargiggia suggests that the player plans to reject Arsenal in favour of Juve.
Unless Edu can put more money on the table than their opposition, they are always going to be facing an uphill battle.
Similar situations can be found with fellow midfield targets Yves Bissouma and Renato Sanches.
Both players are also being tailed by Liverpool who, once again, will be strutting their stuff in Europe’s premier competition next campaign, so the extra incentives will surely need to be offered by Arsenal.
All of this points to the fact that, if every major signing is going to be a significant long-term investment for the Gunners, they simply have to get them spot on.
With Matteo Guendouzi, David Luiz and Martin Odegaard just three of a handful of players to have already departed the Emirates so far, Edu could face the pressure of getting a whole series of transfers bang on the money.
The last thing the club need is another Mesut Ozil situation, where the classy German midfielder ended up completely frozen out of the side despite being one of the highest earners in the Premier League.
Clearly, Arsenal are going to have to pull out all the stops if they are to execute many of their more ambitious signings over the coming weeks.
The pressure is certainly on for Edu and Arteta, who not only need to recruit in numbers, but need to recruit extremely well with financial pressure hanging over their heads.
Use of transcatheter aortic valve replacement/implantation (TAVR or TAVI) swiftly expanded from the high surgical risk to the low surgical risk settings, the necessary clinical trials following one after the other. But a good understanding of optimal post-TAVR antithrombotic therapy has been slower coming.
Now, a 1500-patient trial has offered greater insight but also a few puzzles, including a concerning, unexplained signal of risk relating to the choice of post-TAVR antithrombotic agent.
Management with the factor Xa inhibitor apixaban (Eliquis, Pfizer/Bristol-Myers Squibb) after TAVR was not superior to standard management at 1 year for the study’s composite clinical endpoint, which included mortality, myocardial infarction (MI), bleeding, and a variety of thrombotic events. Standard care consisted of antiplatelet therapy or oral anticoagulation (OAC) with warfarin, the choice hinging on whether there was a separate OAC indication.
The overall parity also applied to two subanalyses: one of patients without a standard OAC indication and the other of those with an OAC indication other than TAVR.
But among those lacking an established OAC indication, patients assigned to apixaban showed an 86% jump in mortality driven by a tripling of risk for noncardiovascular death compared with those given standard care in the trial, ATLANTIS. Principal investigator Jean-Philippe Collet, MD, Groupe Hospitalier Pitié-Salpêtrière in Paris, France, presented the trial results at the American College of Cardiology (ACC) 2021 Scientific Session.
Dr Jean-Philippe Collet
The excess noncardiovascular deaths weren’t associated with bleeding events. Indeed, “most of these noncardiovascular deaths were related to sepsis or end-stage renal failure,” Collet told theheart.org | Medscape Cardiology after his presentation.
The risk for bleeding, whether major or minor, was unaffected by treatment assignment overall and in both subanalyses.
The trial can’t recommend apixaban as a default post-TAVR antithrombotic agent in all comers, Collet said. “But given its ease of use, the good safety profile of the drug, and the lack of difference versus vitamin K antagonists, it could be a first-choice therapy in those patients who have an indication for oral anticoagulation other than TAVI itself.”
However, “the question remains open” for patients without an OAC indication, he added. Apixaban “may be an option. But we need more data, especially with respect to noncardiovascular deaths. We had that same signal in the GALILEO trial.”
In the 2019 GALILEO trial, the risk for death, thromboembolic events, and bleeding went up for post-TAVR patients who received rivaroxaban (Xarelto, Bayer/Janssen), another direct factor Xa inhibitor, compared with dual antiplatelet therapy.
Favorable but Inconclusive
There was a tantalizing but inconclusive signal favoring apixaban in the separately presented ATLANTIS 4-dimensional (4D) CT substudy, comprising 379 patients receiving apixaban and 392 assigned to standard care with evaluable scans.
The risk for subclinical valve thrombosis was cut significantly by 49% among patients assigned to apixaban vs standard care among the 558 patients with no OAC indication. There was no significant effect, either way, among those with an OAC indication.
Subclinical valve thrombosis has been a concern especially since the 2015 publication of a worrisome observational analysis of registry and single-center data pointing to the risk after TAVR. Although no effect from such leaflet thrombosis on outcomes was reported, the findings sharpened the field’s focus on adjuvant antithrombotic therapy in patients who have undergone TAVR.
The trial defined subclinical valve thrombosis, a component of the primary endpoint, according to abnormal flow gradients or impaired leaflet mobility by transthoracic echocardiography (TTE), 4D CT, or both, performed after about 3 months.
“I think we can summarize the field right now by saying that valve thrombosis is common” after TAVR, surgeon Michael J. Mack, MD, Baylor Scott & White Health, Dallas, Texas, said as a panelist after the presentation.
“It’s a dynamic process that some patients develop by 30 days, and resolve by a year,” he added. “Other patients develop it after 30 days. It does not seem to be associated with clinical events, and there’s no evidence,” given the ATLANTIS findings, “that anything other than aspirin is beneficial to these patients.”
The risk for subclinical valve thrombosis “was clearly reduced between apixaban versus standard of care, although we cannot draw any statistical conclusion because we failed to show any superiority with respect to the primary outcome,” Collet told theheart.org | Medscape Cardiology.
Still, Collet said, “There are anatomical considerations which may drive the decision as to whether patients should be on oral anticoagulation or antiplatelet therapy. I think we have now evidence that valve-in-valve procedures are associated with more subclinical valve thrombosis, leaving the patient at risk, and it is the same for patients with small aortic-valve annulus.”
And that, he said, could potentially “drive the decision to choose one over the other, irrespective of the underlying bleeding risk.”
ATLANTIS researchers randomly assigned 1510 patients (mean age, about 82 years), who had successfully undergone TAVR in France, Spain, Germany, and Italy from 2016 to 2019, using any approved TAVR valve, to receive the factor Xa inhibitor or standard care.
About a third of the population had an OAC indication unrelated to their aortic valve disease, including atrial fibrillation in 28.3% of patients in the apixaban group and 26.5% of those assigned to standard care.
Those with and without an OAC indication were randomly assigned separately; the first group was assigned to apixaban or standard care with warfarin, the latter to apixaban or standard care with antiplatelet therapy. Those getting warfarin made up about 21% of the total standard-care group.
Apixaban was primarily given at 5 mg twice daily; the dosage was 2.5 mg twice daily for about 34% of the group based on poor renal function, advanced age, or low body weight.
The two groups overall fared similarly for the primary endpoint at 1 year: 18.4% of those receiving apixaban and 20.1% of those assigned to standard care (hazard ratio [HR], 0.92; 95% CI, 0.73 – 1.16). Nor were there significant differences in the two stratification groups: those with and without an OAC indication.
Life-threatening, disabling, or major bleeding — the primary safety endpoint — developed in 8.5% of patients regardless of whether they received apixaban or standard care.
Patients receiving apixaban showed a significant benefit on two secondary outcomes; their risk for prosthetic thrombosis dropped 77% and risk for DVT by 91%; no such benefit was seen among those receiving warfarin in the standard-care group.
In post hoc analyses by stratification group, there were no significant differences between apixaban and standard care for any of the primary and secondary endpoints among patients with an OAC indication. But among those without an OAC indication (that is, in the apixaban vs antiplatelet comparison), the factor Xa inhibitor was associated with elevated risks for the following:
Death or any stroke, TIA, or systemic embolism: HR, 1.56 (95% CI, 1.01 – 2.43)
But there were fewer instances of valve thrombosis in the apixaban group: 1.1% vs 6.1% (HR, 0.19; 95% CI, 0.08 – 0.47).
In the prospectively defined 4D CT substudy, which included 370 patients assigned to apixaban and 392 in the standard-care group, the odds ratio (OR) was 0.65 (95% CI, 0.41 – 1.04), favoring the factor Xa inhibitor for the primary endpoint: at least one prosthetic valve leaflet with grade 3 or 4 reduced leaflet mobility or grade 3 or 4 hypoattenuated leaflet thickening.
The OR was 0.51 (95% CI, 0.30 – 0.86; P for interaction = .011) among the substudy’s 558 patients with no OAC indication, reported Gilles Montalescot, MD, PhD, Sorbonne Université and Hôpital Pitié-Salpêtrière, Paris, France, in his presentation of the substudy during the virtual ACC session.
If such imaging were to be performed periodically in post-TAVR patients, Collet told theheart.org | Medscape Cardiology, it would likely detect even a higher prevalence of subclinical thrombosis, which “probably” would increase the risk for events such as stroke. “This is especially relevant for low-risk patients in whom subclinical valve thrombosis may be a key player in valve degeneration and valve durability.”
It may be that such serial imaging, he said, could identify patients for whom OAC may be the best post-TAVR choice even in the absence of other indications.
ATLANTIS was partially funded by the Pfizer/Bristol-Myers Squibb alliance. Collet discloses receiving consulting fees or honoraria from AstraZeneca, Bayer Healthcare, Bristol-Myers Squibb, and Medtronic. Montalescot discloses consultant fees or honoraria from Amgen, AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer-Ingelheim, Eli Lilly, Medtronic, Pfizer, and Sanofi-Aventis and conducting research for or receiving research grants from AstraZeneca, Bayer, Bristol-Myers Squibb, Pfizer, and Sanofi-Aventis.
American College of Cardiology (ACC) 2021 Scientific Session. Presented May 15, 2021.
AUSTIN (Texas Tribune) — The gaming empire Las Vegas Sands is launching a multimillion-dollar advertising blitz to build support for its campaign to bring casinos to Texas.
The company will begin airing TV and radio ads Thursday in the state’s biggest markets, according to an announcement first shared with The Texas Tribune. News of the ads comes the same day that a state House committee was set to review proposals expanding gambling in Texas, including one being backed by Las Vegas Sands.
Casinos in Texas? Las Vegas Sands gambling empire pushes forward with goal
The ads tell Texans that “billions of tourism and gambling dollars” leave the state every year for neighboring states that allow more gaming.
“This November, the Legislature can allow Texans to vote to build four world-class destination resorts and casinos, bringing those dollars back to Texas,” a narrator says in one of the half-minute TV spots. “Let’s boost our economy, create tens of thousands of jobs and help fund vital services like schools and public safety.”
Las Vegas Sands is funding the ads under the banner of its new Texas Destination Resort Alliance, which has unveiled a website and social media accounts to coincide with the ad campaign.
The company is backing legislation that would let Texans vote on whether to create special casino licenses for four “destination resorts” in the state’s four largest metropolitan areas: Dallas-Fort Worth, Houston, San Antonio and Austin. The ads will air in those markets as well as some others.
Las Vegas Sands has spent millions of dollars to hire dozens of lobbyists this session, hoping to persuade a Legislature that has been reluctant to expand gambling options in the past.
The Sands push has made little progress in the Legislature so far. The Senate version has been referred to a committee but has not been scheduled for a hearing yet.
Wednesday’s hearing in the House will also include a discussion of a bill that would allow sports gambling in the state.
This article originally appeared in The Texas Tribune at www.texastribune.org. The Texas Tribune is a nonprofit, nonpartisan media organization that informs Texans – and engages with them – about public policy, politics, government and statewide issues.
This article originally appeared on KXAN Austin