Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Dermoscopic Findings in Intraepidermal Carcinoma: an Interobserver Agreement Study

INTRODUCTION

A wide range of descriptive terms have been used for dermoscopic findings in intraepidermal carcinoma (IEC) and the clinical diagnostic accuracy of IEC can be challenging. Furthermore, dermoscopic findings in IEC have only rarely been evaluated in fair-skinned populations.

OBJECTIVES

To measure the interobserver agreement between dermatologists for dermoscopic findings in IEC. Furthermore, to describe the frequency of these findings in a predominantly fair-skinned population.

METHODS

One hundred dermoscopic images of histopathologically verified IECs were collected. The 11 most common dermoscopic findings described in previous studies were re-defined in a new terminology in a pre-study consensus meeting. Images were assessed by eight experienced international dermoscopists. The frequency of findings and the interobserver agreement was analyzed.

RESULTS

Scales (83%), dotted/glomerular vessels (77%), pinkish-white areas (73%) and hemorrhage (46%) were the most commonly present dermoscopic findings. Pigmented structures were found in 32% and shiny white structures (follicular or stromal) in 54% of the IEC. Vascular structures (vessels and/or hemorrhage) could be seen in 89% of the lesions. Overall, the interobserver agreement for the respective dermoscopic findings was poor to moderate, with the highest kappa values noted for scales (0.55) and hemorrhage (0.54) and the lowest for pinkish-white areas (0.015).

CONCLUSION

Our results confirm those of previous studies on dermoscopy in IEC, including the frequency of pigmented structures despite the fair-skinned population. The interobserver agreement was relatively low. The proposed new terminology and our findings can hopefully serve as a guideline for researchers, teachers and students on how to identify IEC.

Dermoscopic Evaluation of Inflammatory Nail Disorders and Their Mimics

Nail dermoscopy (onychoscopy) is a valuable diagnostic tool for evaluating diseases in the nail apparatus. It is non-invasive, allowing clinicians to prioritize particular nails for biopsy. Thus, it can improve diagnostic accuracy and expedite treatment. Evaluating inflammatory nail disorders using onychoscopy is a relatively new approach to clinical assessment and has the potential to augment clinical care. This review highlights key dermoscopic features of major inflammatory nail disorders, including trachyonychia, nail psoriasis, nail lichen planus, onychotillomania, nail lichen striatus and allergic contact dermatitis due to artificial nails. It also illustrates their management and differential diagnoses, including onychomycosis, onycholysis, nail dystrophy due to systemic amyloidosis and malignant nail tumours. Limitations of this review included the low amount of literature on this topic and non-standardized terminology used among researchers. As onychoscopy is a relatively new technique, further studies and standardization of terminology are warranted to consolidate the role of dermoscopy in evaluating inflammatory nail disorders.

The impact of incomplete clinical information and initial biopsy technique on the histopathological diagnosis of cutaneous melanoma

BACKGROUND/OBJECTIVES

Increased rates of histopathological misdiagnosis of melanoma have been associated with incisional punch more so than shave biopsy when compared with complete excisional biopsy. It is unknown how the increasing utilisation of shave biopsy may impact melanoma diagnosis. The extent to which the provision of clinical information to the pathologist may improve diagnostic accuracy remains unclear. This study assessed the impact of both initial biopsy technique and provision of adequate clinical information to pathologists on the accuracy of histopathological diagnosis of melanoma and disease progression.

METHODS

We conducted a retrospective cohort with nested case-control study of all histopathological false-negative and false-positive melanoma diagnoses from January 2014 to May 2019 from the Victorian Melanoma Service electronic database. Cases were assessed for the initial biopsy type, provision of clinical information on pathology request forms and disease progression associated with false-negative diagnosis.

RESULTS

Partial shave biopsy had higher odds of false-negative (OR 5.19, 95% CI 2.89-9.32; P < 0.001) and false-positive diagnoses (OR 1.95, 95% CI 1.45-2.63; P < 0.001) of melanoma when compared with elliptical excisional biopsy. These odds ratios were comparable with those found with incisional punch biopsy. Providing the suspected clinical diagnosis to pathologists also reduced the odds of false-negative diagnosis with melanoma progression by 3.8-fold (P = 0.02).

CONCLUSION

The choice of initial biopsy technique and providing the suspected clinical diagnosis to pathologists are important for correct histopathological diagnosis of cutaneous melanoma and prevention of further disease progression.

Continuous interscalene brachial plexus blockade is associated with reduced length of stay after shoulder arthroplasty

BACKGROUND

Catheter-delivered continuous interscalene anesthesia has demonstrated improved pain control in randomized clinical trials. The purpose of this study is to determine whether the introduction of continuous catheter anesthesia was associated with a change in length of stay (LOS), readmission, rates of discharge home without home health or nursing services, or opioid administration. We hypothesized that the introduction of continuous catheter anesthesia would be associated with a decrease in LOS, readmission, non-home discharge, and opioid administration.

METHODS

During 2012, our center transitioned from ultrasound-guided single-dose interscalene regional anesthesia to combined single-dose anesthesia and additional continuous catheter anesthesia over 48-72hours. This retrospective chart review compared primary shoulder arthroplasties with single-dose anesthesia to those with continuous catheter anesthesia, after excluding the learning curve, with univariate and multivariate analyses.

RESULTS

In total, 1697 patients met criteria, 41% with single-dose anesthesia and 59% with continuous catheter anesthesia. On univariate analysis, the continuous catheter group LOS was 2.2±0.7 day and single-dose group LOS was 2.5±0.8 days (P≤0.001). One day LOS's comprised 1% of the single-dose group and 27% of the continuous catheter group (P<0.001). Anesthesia type remained a significant predictor on multivariate analysis (P<0.001) Readmission at 30 and 90 days (P=0.091 and 0.576), and home discharge (P=0.456) were not different. Opioid administration was higher in the continuous catheter group on univariate analysis (P<0.001), but not on multivariate analysis (P=0.607).

CONCLUSION

In this retrospective review of 1697 primary shoulder arthroplasties performed at our high-volume, referral center, continuous catheter anesthesia was associated with reduced length of stay when compared to single-dose anesthesia.

LEVEL OF EVIDENCE

Therapeutic, level IV.

The kinematics of load carrying in humans and great apes: implications for the evolution of human bipedalism

We present a comparison of loaded and unloaded carrying kinematics in humans, common chimpanzees (Pan troglodytes), bonobos (Pan paniscus), western lowland gorillas (Gorilla gorilla gorilla) and Bornean and Sumatran orang-utans (Pongo pygmaeus and Pongo abelii). Human hindlimb joint and segment angles were collected during treadmill locomotion using infrared motion analysis cameras. Non-human primate fore- and hindlimb joint and segment angles were collected at zoos during free-ranging locomotion using a standard video camera. In quadrupedal locomotion there were small but potentially important changes associated with load carriage leading to a more upright trunk and a shift in shoulder excursion. These changes were exacerbated as locomotion shifts from quadrupedal to tripedal and bipedal gaits when carrying more awkward loads suggesting a possible adaptive sequence. However, food carrying may favour a highly flexed bent-hip bent-knee bipedal gait since it allows simultaneous foraging and hoarding. In bipedal humans no changes in limb kinematics were seen associated with type of load, although asymmetric loads may lead to lateral postural shifts. Carrying may therefore be an important component of the evolutionary shift to habitual bipedalism, although further work is needed to understand the full biomechanical implications.

Autoimmune pancreatitis results from loss of TGFbeta signalling in S100A4-positive dendritic cells

BACKGROUND AND AIMS

Autoimmune pancreatitis (AIP) is a poorly understood human disease affecting the exocrine pancreas. The goal of the present study was to elucidate the pathogenic mechanisms underlying pancreatic autoimmunity in a murine disease model.

METHODS

A transgenic mouse with an S100A4/fibroblast-specific protein 1 (FSP1) Cre-mediated conditional knockout of the transforming growth factor beta (TGFbeta) type II receptor, termed Tgfbr2(fspKO), was used to determine the direct role of TGFbeta in S100A4(+) cells. Immunohistochemical studies suggested that Tgfbr2(fspKO) mice develop mouse AIP (mAIP) characterised by interlobular ductal inflammatory infiltrates and pancreatic autoantibody production. Fluorescence-activated cell sorting (FACS)-isolated dendritic cells (DCs) from diseased pancreata were verified to have S100A4-Cre-mediated DNA recombination.

RESULTS

The Tgfbr2(fspKO) mice spontaneously developed mAIP by 6 weeks of age. DCs were confirmed to express S100A4, a previously reported protein expressed by fibroblasts. Adoptive transfer of bone marrow-derived DCs from Tgfbr2(fspKO) mice into 2-week-old syngenic wild-type C57BL/6 mice resulted in reproduction of pancreatitis within 6 weeks. Similar adoptive transfer of wild-type DCs had no effect on pancreas pathology of the host mice. The inability to induce pancreatitis by adoptive transfer of Tgfbr2(fspKO) DCs in adult mice suggested a developmental event in mAIP pathogenesis. Tgfbr2(fspKO) DCs undergo elevated maturation in response to antigen and increased activation of naïve CD4-positive T cells.

CONCLUSION

The development of mAIP in the Tgfbr2(fspKO) mouse model illustrates the role of TGFbeta in maintaining myeloid DC immune tolerance. The loss of immune tolerance in myeloid S100A4(+) DCs can mediate mAIP and may explain some aspects of AIP disease pathogenesis.

Cutaneous melanoma--atypical variants and presentations

BACKGROUND

The incidence of melanoma continues to rise in Australia. General practitioners treat the majority of skin cancers affecting Australians. In the past decade, there has been improved uptake of dermoscopy by GPs who realise its value in the assessment of pigmented and nonpigmented lesions.

OBJECTIVE

This article outlines those variants or presentations of melanoma that create diagnostic difficulty for all clinicians. Practice tips regarding clinical features or useful dermoscopic clues are included.

DISCUSSION

A clinical overview of lentigo maligna, acral lentiginous and subungual melanoma, nodular melanoma, desmoplastic melanoma, verrucous melanoma and hypomelanotic melanoma is presented. Dermoscopy has become a vital diagnostic aid in the assessment of all skin lesions. Its value in the diagnosis of melanoma is highlighted where relevant. Expert dermatopathology assessment is equally as crucial in reaching a correct diagnosis, especially for some of these atypical variants.

Dermal-binding linear IgA disease: an uncommon subset of a rare immunobullous disease

BACKGROUND

Linear IgA disease (LAD) is an acquired subepidermal blistering disorder, characterized clinically by urticated plaques, papules, vesicles and bullae. Scarring is not usually observed. Direct immunofluorescence on clinically uninvolved skin shows linear deposition of IgA at the basement membrane zone (BMZ). Indirect immunofluorescence on salt-split skin shows dermal binding in a minority of cases.

AIM

To identify and characterize patients with LAD who have IgA anti-BMZ autoantibodies directed against the dermal side of salt-split human skin (dermal-binding autoantibodies).

METHODS

This was a retrospective study of patients with a diagnosis of LAD referred to the dermatology department in Oxford between 1986 and 2004, who demonstrated dermal-binding circulating IgA autoantibodies on indirect immunofluorescence. Clinical features were reviewed and target antigens identified by immunoblotting.

RESULTS

In total, 17 of 101 patients with LAD were found to have dermal-binding autoantibodies. This subset of LAD was relatively more common in adults than in children. There were no other clinical features that distinguished these patients from others with LAD. Collagen VII, the target antigen in epidermolysis bullosa acquisita (EBA), was identified in two of our cohort, but none of the classic clinical features of mechanobullous EBA was observed.

CONCLUSION

This is the largest cohort of patients with dermal-binding LAD to date. Our patients were clinically indistinguishable from those with non dermal-binding LAD, and showed no evidence of the classic mechanobullous EBA phenotype.

Anti-EpCAM XmAb antibodies with improved cytotoxicity

12506

Background: The epithelial cell adhesion molecule (EpCAM), also known as epithelial protein 2 (EGP-2) or 17–1A antigen, is a trans-membrane protein expressed on the surfaces of most carcinomas, including those of pancreatic, colorectal, prostate, breast, kidney, lung, and ovarian origins. Moderate affinity antibodies (Abs) such as 17–1A (Kd ∼ 10−7 nM) have been safe in humans albeit with limited clinical efficacy. Attempts to improve clinical efficacy by enhancing antigen affinity (Kd ∼ 10−9 nM) have led to serious clinical toxicity, including pancreatitis. These observations raise the question of whether a moderate affinity Ab with enhanced effector function will be both safe and clinically efficacious. Methods: We applied our proprietary XmAb™ technologies to humanize the 17–1A variable domain and engineer a human IgG1 Fc domain to increase affinity for the activating receptor FcγRIIIa. Ab binding to Ep-CAM or to Fc receptors was tested with Biacore and/or AlphaScreen binding assays. In vitro cytotoxic activity against representative cancer cell lines was measured with Antibody Dependent Cell-mediated Cytotoxicity (ADCC) assays, using human PBMC as effector cells. Results: Humanized anti-EpCAM Abs have affinity for EpCAM similar to the parent 17–1A. Affinity for the activating FcγRIIIa was increased 100-fold relative to a control Ab with an IgG1 Fc domain. As expected, these Abs exhibit dramatically enhanced ADCC against multiple cancer cell lines relative to 17–1A and IgG1 control Abs. Despite their moderate affinity for EpCAM, these novel Abs have in vitro cytotoxicity comparable to the high affinity Ab ING-1. CDC activities of these Abs were similar to chimeric 17–1A. Conclusions: We have demonstrated that antibodies with moderate affinity for EpCAM and increased FcγRIIIa affinity exhibit superior cancer cell killing via an ADCC mechanism. The humanized nature and the increased cytotoxicity of anti-EpCAM XmAb™ antibodies make them promising candidates for clinical development of a novel pan-carcinoma Ab that is superior to 17–1A.

[Table: see text]

A methodology for the evaluation of disinfection technologies

There are several concerns associated with the use of chlorine for potable water disinfection. These are the resistance of certain pathogens, the formation of toxic disinfection by-products and the adverse effects on aesthetic water quality. Owing to these concerns the water industry is continually reviewing alternative disinfection technologies. A methodology has been devised that will aid the water industry in evaluating the potential of these technologies. The methodology uses seven criteria to evaluate the technologies, these are: inactivation efficiency, disinfection byproduct (DBP) formation, toxicity, aesthetic water quality, cost, scalability and residual maintenance. Each criterion is assessed by associated questions in order of importance in accordance with a protocol. The criteria are evaluated using UK water quality regulations as standards. Ultraviolet (UV) disinfection was used as an example to demonstrate the methodology. UV was shown to meet all the criteria apart from the provision of a residual disinfectant. Several other disinfection technologies were evaluated using the methodology. Direct electrochemical disinfection and mixed oxidant generators were identified as having the most potential for replacing chlorination.

Expectations and experiences of newly recruited Filipino nurses

This article reports the preliminary results of a small study into the changing expectations of newly migrated Filipino nurses at a London hospital. The aim was to identify initial expectations and experiences. Focus group interviews were conducted with two groups of nurses shortly after their arrival. Career prospects and salaries were key factors influencing the decision to come to the UK. Differences emerged between the nurses' expectations of the nursing role and their actual experience on the wards. Adjusting to the new system of health care proved stressful but was helped by the provision of support services. Factors that may promote successful adaptation and retention included equal opportunities with respect to training and promotion and the use of culturally sensitive orientation programmes. Strategies to reduce social isolation may also be important. The results will be used to inform the trust's retention strategy and will also be of interest to other NHS trusts recruiting Filipino nurses and nurses from other countries.

The Pathways study: a model for lowering the fat in school meals

We describe the development and implementation of the Pathways school food service intervention during the feasibility phase of the Pathways study. The purpose of the intervention was to lower the amount of fat in school meals to 30% of energy to promote obesity prevention in third- through fifth-grade students. The Pathways nutrition staff and the food service intervention staff worked together to develop 5 interrelated components to implement the intervention. These components were nutrient guidelines, 8 skill-building behavioral guidelines, hands-on materials, twice yearly trainings, and monthly visits to the kitchens by the Pathways nutrition staff. The components were developed and implemented over 18 mo in a pilot intervention in 4 schools. The results of an initial process evaluation showed that 3 of the 4 schools had implemented 6 of the 8 behavioral guidelines. In an analysis of 5 d of school menus from 3 control schools, the lunch menus averaged from 34% to 40% of energy from fat; when the menus were analyzed by using the food preparation and serving methods in the behavioral guidelines, they averaged 31% of energy from total fat. This unique approach of 5 interrelated food service intervention components was accepted in the schools and is now being implemented in the full-scale phase of the Pathways study in 40 schools for 5 y.

An encyclopedia of mouse genes

The laboratory mouse is the premier model system for studies of mammalian development due to the powerful classical genetic analysis possible (see also the Jackson Laboratory web site, http://www.jax.org/) and the ever-expanding collection of molecular tools. To enhance the utility of the mouse system, we initiated a program to generate a large database of expressed sequence tags (ESTs) that can provide rapid access to genes. Of particular significance was the possibility that cDNA libraries could be prepared from very early stages of development, a situation unrealized in human EST projects. We report here the development of a comprehensive database of ESTs for the mouse. The project, initiated in March 1996, has focused on 5' end sequences from directionally cloned, oligo-dT primed cDNA libraries. As of 23 October 1998, 352,040 sequences had been generated, annotated and deposited in dbEST, where they comprised 93% of the total ESTs available for mouse. EST data are versatile and have been applied to gene identification, comparative sequence analysis, comparative gene mapping and candidate disease gene identification, genome sequence annotation, microarray development and the development of gene-based map resources.

The use of a ward-based educational teaching package to enhance nurses' compliance with infection control procedures

Obtaining study leave is becoming difficult for clinical nurses in the current economic climate, but the need to develop new clinical skills and to maintain existing good practice remains of prime importance to patient care and will become mandatory with the advent of post-registration education and practice (PREP) in the UK. The ward is widely acknowledged as the best venue for learning clinical skills by nurse educationalists and for many nurses is the preferred learning environment. The feasibility of using a ward-based teaching package to enhance nurses' compliance with key infection control precautions (hand decontamination, the use of gloves and the safe handling and disposal of sharp instruments) was tested in a quasi-experimental research study conducted on matched surgical wards in a teaching hospital, controlling for variables likely to influence performance (knowledge, availability of resources to perform infection control, previous opportunity to develop infection control expertise and nursing workload). Nurses on two wards received the intervention (experimental group). The remaining wards, which received no intervention, operated as controls. The ward-based sessions consisted of a carefully planned sequence of theory and practical demonstration delivered to qualified nurses in the clinical environment at convenient times selected by the ward managers. Performance of infection control precautions was audited before the intervention and 3 months afterwards. The sessions were well evaluated and the clinical environment was considered suitable for teaching by the nurses, but heavy and unpredictable workload prevented the teaching programme from being implemented as planned. The analysis of covariance failed to detect any changes in performance between nurses in the control and experimental groups. The implications of the study findings are discussed to help develop creative new ways of strengthening ward-based educational programmes.

Communication aids for the speech impaired. Cost and quality-of-life outcomes of assessment programs provided by specialist Communication Aids Centers in the United Kingdom

An evaluation was conducted of the approaches, costs, and quality-of-life outcomes associated with communication aid assessment programs for the speech-impaired provided by specialist Communication Aids Centres (CACs) in the United Kingdom. The average costs of CAC assessment programs was 410 pounds per client, which is not excessive. There was evidence of moderate quality-of-life benefits from clients' use of the recommended aids.

Gram-negative bacteria. The challenge of preventing cross-infection in hospital wards: a review of the literature

Gram-negative bacteria are responsible for a high proportion of nosocomial infections, particularly among the critically ill and those in hospital for long periods. Colonization (asymptomatic carriage on the skin) occurs before the emergence of overt clinical infection (appearance of the signs and symptoms of disease) and is therefore worth reducing. Spread is principally via the hands of staff, so handwashing is the chief method of prevention. Gram-negative bacteria survive best in a moist environment and are more readily transferred via damp than dry surfaces; hands and equipment should therefore be kept as dry as possible. Good skin can also help prevent cross-infection as Gram-negative bacteria colonize damaged skin more readily than if it is in good condition.

Infection control as a topic for ward-based nursing education

The link between nursing theory and practice remains a topic of ongoing debate. Related to this issue is the best place to effectively combine the two. The solution may be ward-based teaching programmes as part of formal continuing staff development, involving collaboration between college-based lecturers and acknowledged clinical experts. Using infection control as an example of a topic in need of regular and continual updating for qualified practitioners, it is argued that such programmes would be desirable because they would afford sufficient flexibility to fulfil individual learning needs and could be assessed to indicate whether nursing practice had been enhanced. Participants could be accredited for successful completion of ward-based programmes.

Pharmacokinetics of ampicillin and sulbactam in pregnancy

OBJECTIVE

This study evaluated the effects pregnancy had on pharmacokinetic parameters of ampicillin and sulbactam.

STUDY DESIGN

Twenty-two women undergoing cesarean section for obstetric indications were randomly assigned to receive a single intraoperative dose of either 1 gm of ampicillin intravenously or 1 gm of ampicillin plus 0.5 gm of sulbactam intravenously after umbilical cord clamping. Blood was drawn from an indwelling intravenous catheter at 15, 30, 45, 60, 120, 240, and 360 minutes after infusion of the antibiotic for determination of serum ampicillin and/or sulbactam levels. Pharmacokinetic parameters were determined by fitting data (serum concentrations versus time) to a single-compartment model that provided elimination rate constants, beta-intercept (calculated concentration at 0 minutes), area under the time-versus-concentration curve, half-life of the drug, total body clearance, and volume of distribution. After the examination 6 weeks post partum, each subject was given an additional dose of the drug she had received during cesarean section, and a second pharmacokinetic study was performed and compared with the previous results.

RESULTS

Pregnancy significantly increased the elimination rate constant, decreased the area under the drug-versus-time curve, shortened the serum half-life, and increased the total body clearance in comparison with these parameters in the nonpregnant state for ampicillin. Sulbactam kinetics were similarly affected, although these changes failed to attain statistical significance.

CONCLUSION

Because pregnancy is associated with more rapid elimination of beta-lactam drugs, physicians treating infections in pregnant or newly parturient women should consider using shorter intervals between antibiotic doses when a range of dosage intervals is under consideration.

Evaluation of Communication Aid Centres in England and Wales

This paper reports the findings of an evaluation (funded by the Department of Health) of six Communication Aid Centres established in 1983. The evaluation was undertaken to assess the effectiveness of these Centres in meeting their set objectives, and to examine service costs and client satisfaction. The findings show that the work of each Centre was effective in meeting its stated objectives, but that the work of individual Centres reflected its own specialised interests. Two problems with current funding arrangements were highlighted. First, the need to replace the original funding by locally based finance, and second, the funding of communication aids for clients. The findings also show that the specialist service provided by these Centres can be managed at costs per person assessed at, or below, non-specialist services in health districts. Client satisfaction with the services provided by the Centres was high.

Home parenteral nutrition in chronic intestinal failure

In children with severe failure of intestinal function, intravenous nutrition is at present the only treatment able to maintain adequate nutrition for prolonged periods of time. Over the last five years we have discharged 10 patients home on parenteral nutrition for a total of 25 patient years and here the outcome of these children is presented. Of the 10 patients, one has discontinued home parenteral nutrition (HPN), seven patients remain well, one patient has recently moved to the USA, and one patient has died after major abdominal surgery. All children had either normal or an accelerated rate of growth on HPN and developmentally all have progressed well. All the children over 5 years attend normal schools. The major complication of treatment was line sepsis with an overall rate of one episode in 476 days and a total of nine central lines (five patients) have required replacement giving an average line life of 680 days. For those children unfortunate enough to suffer from severe intestinal failure, HPN is preferable to prolonged hospital treatment and offers the chance of a good quality of life with prolonged survival.

Targeting the smoker in an anti-smoking campaign

Between May and September 1983, 1,661 smokers from a random sample of the populations of Sydney and Melbourne were interviewed in their homes. Of the first group, 219 were followed up 12 months later, representing a 75% response rate. Intention, measured by perceived likelihood to quit, was validated as a predictor of a later attempt to quit smoking in the cohort study. Males reported likelihood to quit more often than females. Perceived importance of smoking as a community health problem was also important in predicting attempts to change smoking status, indicating the possible importance of an agenda-setting role for the mass media in promoting change. The key finding was the interaction between health beliefs and social influence in predicting level of intention. On their own, health beliefs showed no relationship to perceived likelihood to quit, and social influence could be counterproductive. However, taken together, these two variables were strongly predictive of change. This suggests that a combination of these two messages should be used in anti-smoking campaigns.

Evaluation of the Sydney "Quit. For Life" anti-smoking campaign. Part 1. Achievement of intermediate goals

The "Quit. For Life" campaign was a media-based programme that was aimed at reducing the prevalence of smoking in Sydney. The programme committee set four intermediate goals which it felt had to be met for such a change in prevalence to occur. From households selected at random in Sydney and Melbourne, 5713 people were interviewed to assess whether the campaign attained these goals. The television commercials that were designed for the campaign, their frequency and the timing of their screening produced a higher recall of the commercial's message and the use of campaign back-up services than were specified originally in the goals. During the campaign there was a progressive increase in the number of smokers in Sydney who reported that they were likely to quit; this was significantly different from Melbourne data by the end of the campaign and thus fulfilled another campaign goal. However, shortly after the campaign ended, the proportion of smokers who intended to quit smoking was the same in the two cities. A cohort study of 949 people from the baseline study showed that, during the 12-month period of follow-up, 66% of Sydney smokers tried to stop or to reduce their smoking. In the control city, Melbourne, 60% of smokers reported making such attempts. Of the original smokers, 23% in Sydney and 9% in Melbourne quit during the follow-up period--a statistically significant difference. As well, 10% of the original ex-smokers in Sydney and 11% in Melbourne relapsed, while 4% of nonsmokers in both cities began smoking by the end of the second survey.

Pulmonary epithelial permeability after inhaling saline, distilled water "fog" and cold air

It is recognized that hyperventilation of cold air and the inhalation of fine mists of distilled water provoke significant bronchoconstriction in the asthmatic individual, yet little is known as to how these provocations affect the structural integrity of the alveolar epithelial membrane. In 11 normal subjects, the following effects have been studied: cold air hyperventilation for three minutes, inhalation of 80 L of ultrasonically nebulized distilled water "fog," and 80 L of isotonic saline "fog" on the half time clearance (T1/2) from the alveoli of technetium 99m diethylene triamine penta acetate (DTPA), inhaled as an aerosol. The DTPA T1/2 provided a measurement of pulmonary epithelial permeability.