Unravelling the utility of modern sulfonylureas from cardiovascular outcome trials and landmark trials: expert opinion from an international panel

AIM

The primary objective of this review is to develop practice-based expert group opinions on the cardiovascular (CV) safety and utility of modern sulfonylureas (SUs) in cardiovascular outcome trials (CVOTs).

BACKGROUND

The United States Food and Drug Administration issued new guidance to the pharmaceutical industry in 2008 regarding the development of new antihyperglycemic drugs. The guidance expanded the scope for the approval of novel antihyperglycemic drugs by mandating CVOTs for safety. A few long-term CVOTs on dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors have been completed, while others are ongoing. SUs, which constitute one of the key antihyperglycemic agents used for the management of type 2 diabetes mellitus (T2DM), have been used as comparator agents in several CVOTs. However, the need for CVOTs on modern SUs remains debatable. In this context, a multinational group of endocrinologists convened for a meeting and discussed the need for CVOTs of modern SUs to evaluate their utility in the management of patients with T2DM. At the meeting, CVOTs of modern SUs conducted to date and the hypotheses derived from the results of these trials were discussed.

REVIEW RESULTS

The expert group analyzed the key trials emphasizing the CV safety of modern SUs and also reviewed the results of various CVOTs in which modern SUs were used as comparators. Based on literature evidence and individual clinical insights, the expert group opined that modern SUs are cardiosafe and that since they have been used as comparators in other CVOTs, CVOTs of SUs are not required.

CONCLUSION

Modern SUs can be considered a cardiosafe option for the management of patients with diabetes mellitus and CV disease; thus CVOTs among individuals with T2DM are not required.

UNCERTAINTY EVALUATION IN DOSE ASSESSMENT DUE TO SPATIAL DISTRIBUTION OF NORM IN BEACH SANDS OF SOUTHEAST COAST OF INDIA: A PROBABILISTIC APPROACH

A study on radionuclide distribution along coastal stretch in high background areas is constantly attracted to many researchers around the world. In the present study, the concentration of radionuclides in beach sands along the southeast coastal region of India has been studied in detail. Concentration of radionuclides is measured using gamma spectrometry at 148 pre-determined locations. It is found that 238U and 232Th concentrations are varying in the range from 3 (BDL) to 298.9 and 1150.2 Bq kg-1, respectively. Concentration of 40K in beach sand varied from 11 to 1743.4 Bq kg-1. The measured activity levels of radionuclides were compared with earlier studies carried out by various researchers in the same region under study. The related radiological parameters of interest were also determined and compared with the internationally recommended values. With an increase in emphasis on quality in dose assessment methods, dose to human population living in the vicinity requires uncertainty evaluation, which is carried out by taking into account variation in the activity values. This study would serve as a baseline radiological mapping for the southeast coast region of India for environmental impact assessment prior to plan of nuclear facility in the future.

A REVIEW ON 210Po AND 210Pb IN INDIAN SEAFOOD AND DOSE TO CONSUMERS

India is the second largest seafood producer in the world marketing more than 7000 edible species. In this regard, commendable studies have been conducted since the 1970s by different research groups and more data are reported. In this work, all the studies on 210Po and 210Pb measurements in abiotic and biotic components of India have been combined and reviewed. The concentrations of 210Po and 210Pb are estimated by radiochemical separation followed by alpha counting. Grain size, season, Tsunami waves and place of sampling have a decisive bearing on 210Po and 210Pb concentration in abiotic components. Plankton shows a higher Kd factor (104) compared to seaweeds and sea grass (103). Pond ecosystems recorded the highest Kd factor (4·3 × 104) compared to other freshwater and marine ecosystems. Bioaccumulation of 210Po and 210Pb varies with respect to variety of seafood. The committed effective dose (CED) calculated for shellfish species maintained a higher range of 2.5 × 10-2 mSv/y to 9.8 × 10-1 mSv/y and for fish species fluctuated from 3.8 × 10-4 mSv/y to 2.0 × 10-1 mSv/y. The studies conducted so far are scattered, and need to be gathered for future reference and planning (i.e. There is not much information available for Kerala, Karnataka, Maharashtra, Gujarat, Andhra, West Bengal and Odessa coast). Therefore, it is strongly recommended that further and more complete research is undertaken to study the bioaccumulation of 210Po and 210Pb from seafood. Overall, the present review concludes that Indian seafood is radiologically safe.

Abortion knowledge and experiences among young women and men in Accra, Ghana

Background : Despite the presence of legal abortion services in Ghana, unsafe abortion remains common, particularly among young women. Little is understood about what young people know about safe and legal abortion, and if and how they are utilizing it. Methods : To characterize abortion use and address gaps in safe access, from September-December 2013, we conducted a cross-sectional survey with 100 men and 250 women aged 18-24 in Accra, Ghana. Participants were asked about abortion experiences, including prior services, providers, methods, satisfaction, perceived support, and knowledge of laws. Descriptive statistics, Fisher's exact tests, and chi-square tests were performed. Results : Among surveyed youth, most (87% of women, 64% of men) thought abortion was illegal or did not know the law. In total, 30% of women and 14% of men ever had an abortion and partner who had an abortion, respectively. Among women's most recent abortions, medication abortion (61%), surgical methods (26%), and unsafe methods categorized "least safe" (14%) were the initial or only methods used. Most women who accessed medication abortion initially or as their only method saw a pharmacist (40%) or no one (33%). Nearly one-quarter of women (n=16, 24%) who initially took tablets used more than one method. Conclusions : Despite experiences with abortion, most young people in this study were unaware of its legality and unsafe abortions occurred. More needs to be done to ensure young people understand the law and have access to safe methods, and that pharmacists are trained to provide appropriate doses and formulations of medication abortion.

Utilization of induction furnace steel slag in concrete as coarse aggregate for gamma radiation shielding

The present investigation highlights the utilization of Induction Furnace (IF) steel slag as a partial replacement for coarse aggregate in concrete. The concrete blocks of size 150 × 150 × 50 mm were casted and the effect of density, compressive strength, linear attenuation coefficient, Gamma Attenuation Factor (GAF) and Half Value Layer (HVL) has been explored. Gamma attenuation measurements were carried out using NaI (Tl) based gamma detector. Gamma ray source ⁶⁰Co emitting two gamma energies 1.17 and 1.33 MeV was used for radiation measurements. The results of this present study shows that 50% of IF steel slag replacement increases the density (2.81 g/cm³) and compressive strength (29.11 N/mm²). The Linear attenuation coefficient (0.1953 cm^-1-0.2236 cm^-1) and GAF (0.6343-0.6710) is higher at 50% replacement of IF steel slag than conventional concrete. HVL values were also having positive impact in 50% replacement of IF steel slag (3.10 cm) in concrete than conventional concrete (3.55 cm). The partial replacement of IF steel slag as coarse aggregate in concrete is effective in gamma shielding.

Benefits of a Physician-Scientist-Tailored Curriculum at a Medical Student-Run Free Clinic

We designed a curriculum to help sustain pre-clinical knowledge for MD/PhD trainees in their graduate training phase while securing regular providers for our student-run free clinic. MD/PhD involvement increased from 1.91 to 2.45 students-per-clinic-day following implementation, and participants affirmed increased preparedness and comfort entering medical school clinical clerkships.

A multicentre study evaluating the risk and prevalence of diabetic retinopathy in children and young people with type 1 diabetes mellitus

INTRODUCTION

There is currently limited data published on the prognostic factors and prevalence of diabetic eye disease in children and young people (CYP) with Type 1 diabetes mellitus (T1DM), yet diabetic retinopathy remains one of the commonest causes of blindness in young adults. The aim of this study was to determine the risk and prevalence of diabetic retinopathy (DR) and to evaluate the risk factors associated with diabetic retinopathy in CYP with T1DM.

METHODS

All CYP with Type 1 diabetes between 12 and 18 years of age, registered with the regional diabetic retinopathy screening programme were evaluated from 2012 to 2013 in four diabetes units within the north west region of the United Kingdom. Patients who had evidence of diabetic retinopathy were reviewed to identify risk factors for presence or absence of diabetic retinopathy.

RESULTS

237 patients between the ages 12-18 years were included in the. The prevalence of diabetic retinopathy was 11%. Out of 27 patients with evidence of diabetic retinopathy, 44% were reported as background changes and 56% had pre-proliferative DR. Significant risk factors for diabetic retinopathy disease in the population using univariate analyses were duration of diabetes, puberty, age at diagnosis and mean HbA1c in the preceding 12 months. Multivariate logistic regression analysis found age of diagnosis (p = 0.04) and mean HbA1c as significant independent risk factors for presence of diabetic retinopathy (p = 0.02).

CONCLUSIONS

The prevalence of diabetic retinopathy in this paediatric population was 11%. Early age at diagnosis and poor metabolic control are independent risk factors for diabetic retinopathy.

Contraceptive use and unintended pregnancy among young women and men in Accra, Ghana

The objective of this study was to determine factors associated with modern contraceptive use and unintended pregnancy among young women and men in Accra, Ghana. From September-December 2013, we conducted a cross-sectional survey with 250 women and 100 men aged 18–24. We explored determinants of modern contraceptive use among males and females and unintended pregnancy among females. Descriptive statistics, chi-square tests, Fisher’s exact tests, and multivariable logistic regression were used. Participants had an average of three lifetime sexual partners, and 91% had one current partner. Overall, 44% reported current modern contraceptive use. In multivariate modeling, modern contraceptive use was associated with higher education compared to primary (AORs 2.1–4.3); ever talking with someone about contraception (AOR 4.7); feeling unsupported by a healthcare provider for contraception (AOR 2.2); and not feeling at risk of unintended pregnancy (AOR 2.7). While ≥70% of participants recognized most contraceptive methods, awareness of some methods was lacking. Nearly all respondents (91%) felt at least one modern method was unsafe. Nearly half of all females (45%) reported their last pregnancy was unintended, and 63% of females and 58% of males felt at risk for future unintended pregnancy. Women were more likely to experience unintended pregnancy if they had ever given birth (AOR 6.7), their sexual debut was 8–14 years versus 20–24 years (AOR 3.4), or they had 3–4 lifetime sexual partners versus 1–2 (AOR 2.4). Targeted interventions are needed to improve understanding of the safety of modern contraceptive methods, increase awareness of long-acting methods, and consequently increase modern contraceptive access and use.

A REVIEW ON VARIATION OF NATURAL RADIOACTIVITY ALONG THE SOUTHEAST COAST OF TAMIL NADU FOR THE PAST 4 DECADES (1974-2016)

This review deals with natural radioactivity variation along the southeast coast of Tamil Nadu for the past four decades (1974-2016). About 40 research works have been conducted along the coast since 1974 in various environmental matrices using a variety of experimental methods. For these measurements researchers are adopted different experimental methods. The measured gamma dose rate ranged from 30 to 8700 nGy/h. The mean specific activity of 238U, 232Th and 40K was found to be 58.8 ± 28.7, 465.2 ± 147.3 and 311.2 ± 27.8 Bq/kg, respectively. The calculated annual exposure rate ranged from 0.29 to 12.8 mSv/y with the mean value of 3.7 mSv/y which is above the global average of 2.4 mSv/y as reported by United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) (Report to General Assembly, Annex B Exposures of the public and workers from various sources of radiation. United Nations, New York (2008)). Plant food items recorded low 210Po activities as compared to seafood organisms. Grain size, season and place of sampling have a decisive bearing on coastal radioactivity. Therefore, it is concluded from the review data that there is an appreciable elevation in background radiation level in the coastal region. This review suggests that new radiological surveys using improved methodology that cover the entire coastal stretch are needed.

Evaluation of Oxacillin and Cefoxitin Disk Diffusion and MIC Breakpoints Established by the Clinical and Laboratory Standards Institute for Detection of mecA-Mediated Oxacillin Resistance in Staphylococcus schleiferi

Staphylococcus schleiferi is a beta-hemolytic, coagulase-variable colonizer of small animals that can cause opportunistic infections in humans. In veterinary isolates, the rate of mecA-mediated oxacillin resistance is significant, with reported resistance rates of >39%. The goal of this study was to evaluate oxacillin and cefoxitin disk diffusion (DD) and MIC breakpoints for detection of mecA-mediated oxacillin resistance in 52 human and 38 veterinary isolates of S. schleiferi Isolates were tested on multiple brands of commercial media and according to Clinical and Laboratory Standards Institute (CLSI) methods. Zone diameters and MIC values were interpreted using CLSI breakpoints (CLSI, Performance Standards for Antimicrobial Susceptibility Testing. M100-S27, 2017) for Staphylococcus aureus/Staphylococcus lugdunensis, coagulase-negative staphylococci (CoNS), and Staphylococcus pseudintermedius Results were compared to those of mecA PCR. Twenty-nine of 90 (32%) isolates were mecA positive. Oxacillin inhibition zone sizes and MICs interpreted by S. pseudintermedius breakpoints reliably differentiated mecA-positive and mecA-negative isolates, with a categorical agreement (CA) of 100% and no very major errors (VMEs) or major errors (MEs) for all media. For cefoxitin DD results interpreted using S. aureus/S. lugdunensis and CoNS breakpoints, CA values were 85% and 75%, respectively, and there were 72% and 64% VMEs, respectively, and 0 MEs. For cefoxitin MICs interpreted using S. aureus/S. lugdunensis breakpoints, CA was 81%, and there were 60% VMEs and no MEs. Our data demonstrate that oxacillin DD or MIC testing methods using the current S. pseudintermedius breakpoints reliably identify mecA-mediated oxacillin resistance in S. schleiferi, while cefoxitin DD and MIC testing methods perform poorly.

Altered pharmacokinetics of rosiglitazone in a mouse model of non-alcoholic fatty liver disease

BACKGROUND

Severe forms of non-alcoholic fatty liver disease (NAFLD) adversely affect the liver physiology and hence the pharmacokinetics of drugs. Here, we investigated the effect of NAFLD on the pharmacokinetics of rosiglitazone, an insulin sensitizer used in the treatment of type 2 diabetes.

METHODS

Male C57BL/6 mice were divided into two groups. The first group (n=14) was fed with normal chow feed and the second group (n=14) was fed with 60% high-fat diet (HFD) and 40% high fructose liquid (HFL) for 60 days to induce NAFLD. The development of NAFLD was confirmed by histopathology, liver triglyceride levels and biochemical estimations, and used for pharmacokinetic investigations. Rosiglitazone was administered orally at 30 mg/kg dose. At predetermined time points, blood was collected and rosiglitazone concentrations were determined using LC/MS/MS. Plasma concentrations were subjected to non-compartmental analysis using Phoenix WinNonlin (6.3), and the area under the plasma concentration-time curve (AUC) was calculated by the linear-up log-down method.

RESULTS

HFD and HFL diet successfully induced NAFLD in mice. Rosiglitazone pharmacokinetics in NAFLD animals were altered significantly as compared to healthy mice. Rosiglitazone exposure increased significantly in NAFLD mice (2.5-fold higher AUC than healthy mice). The rosiglitazone oral clearance was significantly lower and the mean plasma half-life was significantly longer in NAFLD mice as compared to healthy mice.

CONCLUSIONS

The NAFLD mouse model showed profound effects on rosiglitazone pharmacokinetics. The magnitude of change in rosiglitazone pharmacokinetics is similar to that observed in humans with moderate to severe liver disease. The present animal model can be utilized to study the NAFLD-induced changes in the pharmacokinetics of different drugs.

Dissipation kinetics of beta-cyfluthrin and imidacloprid in tea and their transfer from processed tea to infusion

Dissipation kinetics of mixed formulation consisting beta-cyfluthrin and imidacloprid in tea crop under an open field ecosystem was investigated. The mixed formulation was applied on tea plant at recommended (27 + 63) and double the recommended (54 + 126g a.i./ha) dose and residues were determined using gas chromatography-electron capture detector and high performance liquid chromatography-photodiode array detector for beta-cyfluthrin and imidacloprid, respectively. The limit of quantification of analytical method was 0.05µg/g and the average recoveries were ranged from 88.36% to 103.49% with relative standard deviations of less than 6% at three spiked levels. The experimental results showed that in the green tea leaves imidacloprid dissipated faster than beta-cyfluthrin with the half-life ranging between 1.20-1.39 and 2.89-3.15days, respectively. The beta-cyfluthrin residues present in the processed tea not transferred into the tea infusion during the infusion process and imidacloprid transferred in the range 43.12-49.7%. On the basis of the transfer of residues from processed tea to infusion, a waiting period of 17 days for tea plucking after pesticide application at recommended dose may be suggested.

Enrolment and retention of people who inject drugs in the Needle & Syringe Exchange Programme in Malaysia

Setting: Needle and Syringe Exchange Programme (NSEP) implemented by non-governmental organisations in Malaysia. Objectives: To determine enrolment, characteristics and retention in the NSEP of people who inject drugs (PWID) between 2013 and 2015. Design: Retrospective cohort study. Results: There were 20 946 PWID, with a mean age of 38 years. The majority were male (98%) and of Malay ethnicity (92%). Follow-up data were available for 20 761 PWID. Annual retention of newly enrolled PWID for each year was respectively 85%, 87% and 78% for 2013, 2014 and 2015, although annual enrolment over these years declined from 10 724 to 6288 to 3749. Total person-years (py) of follow-up were 27 806, with loss to follow-up of 40 per 100 py. Cumulative probability of retention in NSEP was 66% at 12 months, 45% at 24 months and 26% at 36 months. Significantly higher loss to follow-up rates were observed in those aged 15-24 years or ⩾50 years, females, transgender people and non-Malay ethnic groups. Conclusion: Annual retention of new PWID on NSEP was impressive, although enrolment declined over the 3 years of the study and cumulative loss to follow-up was high. A better understanding of these programmatic outcomes is required.

Multifocal Tuberculosis

Multifocal Tuberculosis represents the many faces of an age old disease. It is characterized by the presence of large multifocal tuberculous areas in same or different organs. A 50 year old male patient, presented with features suggestive of renal failure, low grade fever and cough with mucoid expectoration. He was found to have pulmonary TB, genitourinary TB and tuberculous lymphadenitis. He was started on antituberculous treatment to which he showed good response.