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.

Comparison of Opioid Consumption Patterns of Three Interbody Fusion Surgical Techniques

STUDY DESIGN

Retrospective review.

OBJECTIVES

With increased awareness of the opioid crisis in spine surgery, the focus postoperatively has shifted to managing surgical site pain while minimizing opioid use. Numerous studies have compared outcomes and fusion status of different interbody fusion techniques; however, there is limited literature evaluating opioid consumption postoperatively between techniques. The aim of this study was to assess in-house and postoperative opioid consumption across 3 surgical techniques.

METHODS

Patients were stratified by technique: posterior lumbar interbody fusion (PLIF), minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), and cortical screw (CS) instrumentation with interbody fusion. Age, ASA, BMI, depression, preoperative opioid use, EBL, and OR time were recorded and compared across surgical groups using Welch's ANOVA and chi-square analysis. Total morphine equivalent dose (MED) was tabulated for both in-house consumption and postoperative prescriptions and was compared across surgical techniques using Welch's ANOVA analysis, Mann Whitney U tests, and linear regression.

RESULTS

Two hundred and thirty nine patients underwent one- or two-level posterior lumbar interbody fusion between 2016 and 2020. One hundred and twenty one patients underwent CS instrumentation, 95 underwent PLIF, and 83 underwent MIS-TLIF. There was a significantly higher percentage of patients who had a history of depression and preoperative opioid consumption in the CS group (P = .001, P = .009). CS instrumentation required significantly less total post-op opioids per kilogram bodyweight compared to MIS-TLIF and PLIF surgeries (P = .029).

CONCLUSIONS

Patients who underwent CS instrumentation required less opioids postoperatively. CS instrumentation may be associated with less postoperative pain due to the less invasive approach, however, patient education and prescriber practice also play a role in postoperative opioid consumption.

Ursodeoxycholic acid is associated with a reduction in SARS-CoV-2 infection and reduced severity of COVID-19 in patients with cirrhosis

BACKGROUND AND AIMS

Studies have demonstrated that reducing farnesoid X receptor activity with ursodeoxycholic acid (UDCA) downregulates angiotensin-converting enzyme in human lung, intestinal and cholangiocytes organoids in vitro, in human lungs and livers perfused ex situ, reducing internalization of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into the host cell. This offers a potential novel target against coronavirus disease 2019 (COVID-19). The objective of our study was to compare the association between UDCA exposure and SARS-CoV-2 infection, as well as varying severities of COVID-19, in a large national cohort of participants with cirrhosis.

METHODS

In this retrospective cohort study among participants with cirrhosis in the Veterans Outcomes and Costs Associated with Liver cohort, we compared participants with exposure to UDCA, with a propensity score (PS) matched group of participants without UDCA exposure, matched for clinical characteristics, and vaccination status. The outcomes included SARS-CoV-2 infection, symptomatic, at least moderate, severe, or critical COVID-19, and COVID-19-related death.

RESULTS

We compared 1607 participants with cirrhosis who were on UDCA, with 1607 PS-matched controls. On multivariable logistic regression, UDCA exposure was associated with reduced odds of developing SARS-CoV-2 infection (adjusted odds ratio [aOR] 0.54, 95% confidence interval [CI] 0.41-0.71, p < 0.0001). Among patients who developed COVID-19, UDCA use was associated with reduced disease severity, including symptomatic COVID-19 (aOR 0.54, 95% CI 0.39-0.73, p < 0.0001), at least moderate COVID-19 (aOR 0.51, 95% CI 0.32-0.81, p = 0.005), and severe or critical COVID-19 (aOR 0.48, 95% CI 0.25-0.94, p = 0.03).

CONCLUSIONS

In participants with cirrhosis, UDCA exposure was associated with both a decrease in SARS-CoV-2 infection, and reduction in symptomatic, at least moderate, and severe/critical COVID-19.

Caffeine intake does not appear to impair tendon-to-bone healing strength in a rat rotator cuff repair model

Background

Tendon-to-bone (TtB) healing is essential for successful rotator cuff repair (RCR). This study aimed to investigate if caffeine intake impaired TtB healing in a rat RCR model.

Methods

Seventy-two rats were randomized into a caffeinated group or a noncaffeinated group. Specimens received one week of oral caffeine solution or normal saline before RCR. All rats then underwent bilateral RCR. Caffeination or saline gavages continued until rats were sacrificed at 2, 4, and 8 weeks postoperatively. Load-to-failure (primary outcomes measure), maximum stress, and stiffness of the TtB interface were measured for one shoulder of each specimen. Six random shoulders from each group underwent histological assessment of TtB healing.

Results

Load-to-failure and maximum stress of RCR did not appear to differ between groups at any time point. No difference in RCR stiffness was found between groups at 2 and 4 weeks; however, stiffness in the caffeinated group did appear to lower at 8 weeks (P = .04).

Conclusion

Perioperative caffeine intake did not appear to affect load-to-failure strength of RCR in an animal model. Although our secondary outcome measures of maximum stress and stiffness also did not appear to be influenced by perioperative caffeine intake, there did appear to be a trend toward decreased RCR stiffness at 8 weeks postoperatively in specimens that received caffeine.

A high-need, high-impact educational session on firearms and death by suicide

BACKGROUND

The suicide rate among Veterans is 1.5 times greater than that for civilians, partly a result of the high use of firearms as the means for suicide. One effective strategy to reduce Veteran suicide by firearms is to provide counseling on firearm safety as a method of means reduction. However, many clinicians do not discuss firearm safety with Veterans.

AIMS

This study evaluates a one-hour educational seminar for clinicians on lethal means safety.

MATERIALS AND METHODS

One hundred and ninety clinicians from the Veterans Health Administration, including social workers, psychologists, psychiatrists, and nurses, participated in the training. The seminar was streamed during the South Central Mental Health Illness Research, Education and Clinical Center's Community-Based Outpatient Clinic Mental Health Grand Rounds, for which participants were eligible for continuing education units. Data were collected immediately after the training and four months later.

RESULTS

After completing the training, participants believed that it was important to speak with Veterans about firearm safety and felt knowledgeable and empowered to do so. Four months after the seminar, participants had counseled, on average, over half of Veterans treated about lethal means safety.

DISCUSSION

Participants reported the value of normalizing discussions about firearm safety with their Veterans and focusing on the safety aspect while discussing firearms.

CONCLUSIONS

This webinar was effective in providing clinicians the skills to talk with Veterans about firearm safety and continued to impact their practice four months after training. The training is available for free on our website at https://www.mirecc.va.gov/visn16/public-health-approach-to-firearms-and-death-by-suicide.asp.

Therapies for hepatocellular carcinoma: overview, clinical indications, and comparative outcome evaluation-part one: curative intention

Hepatocellular carcinoma (HCC) offers unique management challenges as it commonly occurs in the setting of underlying chronic liver disease. The management of HCC is directed primarily by the clinical stage. The most commonly used staging system is the Barcelona-Clinic Liver Cancer system, which considers tumor burden based on imaging, liver function and the patient's performance status. Early-stage HCC can be managed with therapies of curative intent including surgical resection, liver transplantation, and ablative therapies. This manuscript reviews the various treatment options for HCC with a curative intent, such as locablative therapy types, surgical resection, and transplant. Indications, contraindications and outcomes of the various treatment options are reviewed. Multiple concepts relating to liver transplant are discussed including Milan criteria, OPTN policy, MELD exception points, downstaging to transplant and bridging to transplant.

Therapies for hepatocellular carcinoma: overview, clinical indications, and comparative outcome evaluation. Part two: noncurative intention

Locoregional therapies can be offered to hepatocellular carcinoma patients as a bridge to transplant, to downstage disease burden for transplant eligibility, or for disease control to prolong survival. Systemic therapies also play a large role in HCC treatment, occasionally in conjunction with other methods. This manuscript reviews the various treatment options for HCC with a historically noncurative intent.

Structures at Risk During Percutaneous Screw Fixation for Talonavicular Fusion

BACKGROUND:

Talonavicular (TN) fusion using screws dorsomedially and dorsolaterally can cause neurovascular injury. The purpose of our cadaveric study was to evaluate the safety of percutaneous screw insertion in relation to dorsal neurovascular structures.

METHODS:

Ten fresh-frozen cadaver legs were used for this study. Percutaneous cannulated screws were inserted to perform isolated TN arthrodesis. The screws were inserted at 3 consistent sites: a "medial screw" at the dorsomedial navicular where it intersected at the medial plane of the first cuneiform, a "central screw" at the edge of the dorsal navicular between the medial and intermediate cuneiforms, and a "lateral screw" at the edge of the dorsal navicular between the intermediate and lateral cuneiforms. Superficial and deep dissections were carried out to identify any injured nerves, arteries, and/or tendons.

RESULTS:

The medial screw injured the anterior tibialis tendon in 2 cases (20%), the central screw injured the extensor hallucis longus tendon in 3 cases (30%), and the lateral screw injured the anterior branch of the superior peroneal nerve (SPN), the lateral branch of the SPN, and the medial branch of the distal peroneal nerve (DPN) once each in a total of 3 cases (30%). Despite no direct injury, the central screw indicated a potential risk of neurovascular injury: closest distance to the anterior SPN was 2 mm and to the medial DPN 2 mm.

CONCLUSION:

Although neurovascular injury risk exists for all of these screw placements, TN fusion with a central screw introduced a potentially decreased risk of neurovascular injury at the expense of increased risk of tendon injury compared to the lateral screw.

CLINICAL RELEVANCE:

Based on these results, we recommend a careful dissection be performed prior to percutaneous screw insertion.

Safe Zone for Percutaneous Screw Fixation - Talonavicular Fusion

Category:

Hindfoot

Introduction/Purpose:

Talonavicular fusion has been established as a reliable intervention for degenerative, inflammatory, and traumatic joint lesions as well as hindfoot deformities. In order to achieve optimal fusion, various versions of the procedure have been introduced in literature and have remained a topic of contention, with the most common variation involving the insertion of 1 to 3 screws dorsomedially and dorsolaterally. Dorsolateral screw placements commonly cause neurovasculature injury. The purpose of our cadaveric study was first to establish the safety of the dorsolateral percutaneous screw insertion in relation to these dorsal neurovascular structures, and then subsequently to standardize the ideal placement of the dorsolateral screw by comparing two insertion sites based on consistent bony landmarks.

Methods:

Ten fresh-frozen cadaver legs amputated at the knee were used for this study. Percutaneous cannulated screws were inserted to perform isolated talonavicular arthrodesis. The screws were inserted at 3 consistent sites: “medial screw” at dorsomedial navicular where it intersected at the medial plane of the first cuneiform, “central screw” at the edge of dorsal navicular between medial and intermediate cuneiforms, and “lateral screw” at the edge of dorsal navicular between intermediate and lateral cuneiforms. Superficial and deep dissections were carried out to identify any injured nerves, arteries, and tendons.

Results:

The mean age at death in our sample of cadavers was 80.1 ± 7.5 years (range 68 to 92) and had the BMI of 21.8 ± 2.4 (range 18.1 to 25.1). There were 5 males (50.0%) and 5 females (50.0%). The medial screw injured the anterior tibialis tendon in 2 cases (20.0%), the central screw injured the extensor hallucis longus tendon in 3 cases (30.0%), and the lateral screw injured the anterior branch of SPN, lateral branch of SPN, and medial branch of DPN once each in a total of 3 cases (30.0%).

Conclusion:

TN fusion with central screw placement at the interspace between the medial and intermediate cuneiforms protects the neurovasculatures of the foot to a superior extent than lateral screws between the intermediate and lateral cuneiforms.

A Comparative Analysis of Risk and Cost-effectiveness of Outpatient versus Inpatient Hindfoot Fusion

Category:

Hindfoot

Introduction/Purpose:

Hindfoot fusion procedures are increasingly being performed in the outpatient setting. However, the cost-effectiveness of hindfoot fusion procedures compared with risk and benefit have not been clearly investigated. The primary objective of this study was to investigate the cost-effectiveness of outpatient versus inpatient hindfoot arthrodesis. Secondary objectives were to compare patient characteristics and short-term complications of patients in each cohort.

Methods:

This was a retrospective review of all patients who underwent inpatient and outpatient hindfoot fusion procedures at a single institution from 2013-2017. Data collected for each patient included demographic information, operative variables, comorbidities, complications, and any subsequent emergency department visits, readmissions or reoperations. Cost data was collected for each inpatient or outpatient encounter, as well as any subsequent encounters related to the index procedure.

Results:

Of 151 total hindfoot procedures performed over the study period, 37 were inpatient and 114 were performed in the outpatient setting. There were 3 more readmissions, 22 more ED visits, and 0 more reoperations after outpatient surgery vs inpatient surgery. The average total cost for an outpatient hindfoot fusion procedure was significantly lower than the average total cost for inpatient hindfoot fusion, without a significant increase in complication rate. We are currently in the process of performing the total cost analysis, and will have the completed cost and risk/benefit information within the next two weeks.

Conclusion:

Outpatient hindfoot fusion surgery may be more cost-effective when compared to inpatient fusion surgery without a significant increase in complications, ED visits, or readmissions.

Is Interposition Arthroplasty a Viable Option for Treatment of Moderate to Severe Hallux Rigidus? A Systematic Review and Meta-analysis

Category:

Midfoot/Forefoot

Introduction/Purpose:

Hallux rigidus is a painful arthritis of the first metatarsophalangeal joint that causes progressive loss of mobility. Treatment options include activity modifications, analgesics, corticosteroids, and surgery. Arthrodesis of the MTP joint is considered the gold standard treatment for hallux rigidus, but it is often reserved for advanced. Interposition arthroplasty uses a spacer taken from an autograft, allograft, or synthetic material. For patients with severe arthritic diseases who would like to preserve MTP joint function, interposition arthroplasty may be a viable option. The purpose of this systematic review is to investigate patient outcomes after undergoing interposition arthroplasty of the MTP joint. The objectives are to determine if this technique is practical for patients who would prefer to avoid arthrodesis, and to systematically analyze post-operative improvement.

Methods:

The systematic review was performed following PRISMA (Preferred Reporting Items for Systematic Review and Meta-analyses) guidelines. Medline, pubmed, Embase, and Cohrane Database of Systematic Reviews (CDRS) were searched for publications from 2000 to 2017. Duplicates were then removed, and titles and abstracts were reviewed to confirm the relevance f the study. Studies were included if they reported results of first MTP joint interposition arthroplasty in one of the well-known scoring systems: AOFAS, FFI, or SF-36. Studies also were also required to have a 12 month follow up. Systematic review and data extraction were performed on all selected studies. Means were recorded and placed in tables for all variables including scoring results and complication rates. A linear regression model comparing the change in preoperative to postoperative AOFAS scores between the autogenous versus allogenous interposition materials was performed.

Results:

Database searches produced 574 articles for review. 15 of these were included in the systematic review. Mean AOFAS score was improved from 41.35 preoperatively to 83.17 postoperatively. Mean pain, function, and alignment scores improved from preoperative values of 14.9, 24.9, and 10 to postoperative values of 33.3, 35.8, and 14.5. Mean dorsiflexion increased from 21.27 degrees (5-30) to 42.03 degrees (25-71). Mean ROM improved from 21.06 to 46.43 degrees. Eighty-seven percent of patients were satisfied to highly satisfied with their surgery and would choose surgery again. Joint space increased by 0.8 mm to 2.5 mm. The most common complications included metatarsalgia (13.9%), loss of ground contact (9.7%), osteonecrosis (5.4%), great toe weakness (4.8%), hypoesthesia (4.2%), decreased push off power (4.2%), and callous formation (4.2%).

Conclusion:

The management of hallux rigidus remains heavily debated. This systematic review of the current literature suggests that interposition arthroplasty is a viable short and intermediate term treatment for hallux rigidus in terms of patient satisfaction, pain scores, and AOFAS scores. Further studies with greater sample sizes, more uniform methods, and longer follow-up times are needed to further support the superiority of interposition arthroplasty.

Hemi vs. Total joint arthroplasty for hallux rigidus

Category:

Midfoot/Forefoot

Introduction/Purpose:

Advanced-stage arthritis of the first metatarsophalangeal joint (MTPJ), or “Hallux Rigidus” (HR) is a common forefoot pathology. When surgery is indicated, arthroplasty is an alternative to arthrodesis, which aims to preserve MTPJ dorsiflexion. Since it is unclear whether total-toe or hemi-toe devices are preferred implants in MTPJ arthroplasty, we completed a systematic review of the literature and did a meta analysis to test which type of implants clinically outperform in hallux rigidus.

Methods:

A systematic review of MTPJ arthroplasty was performed using Pubmed, EMBASE, SCOPUS, and Cochrane library for the years 2000 to 2017. Data was extracted from articles containing both preoperative and postoperative endpoints for either hemi or total MTPJ arthroplasty cases. To be eligible for inclusion, studies must have had a mean follow-up window of at least 24 months and standard deviation of outcome. Total eleven studies were included for review, seven studies with hemi replacement and six studies with total arthroplasty. Pooled mean values were calculated, and a forest plot was created comparing pre-and post-operative American Orthopedic Foot and Ankle Score (AOFAS), visual analogue scale (VAS), and range of motion (ROM) results for both hemi-toe and total-toe arthroplasty. Statistical analysis was performed using SPSS.

Results:

Mean postoperative AOFAS scores in patients undergoing hemiarthroplasty improved by 50.7 points (95%CI: 48.5, 52.8), which was higher than the mean postoperative AOFAS improvement of 40.6 points (95%CI: 38.5, 42.8) seen in total-toe patients. Mean postoperative VAS improvement in hemiarthroplasty was 6.05 points (95%CI: 5.92, 6.18), which was comparable to the mean VAS improvement of 6.29 points (95%CI: 6.02, 6.55) seen in total arthroplasty. Mean postoperative MTPJ ROM improved by 43.0 degrees (95%CI: 39.3, 46.6) in hemi-toe patients, which exceeded the mean ROM improvement of 32.5 degrees (95%CI: 29.9, 35.1) found in total-toe cases. A meta-analysis of the data revealed non-significant statistical trends for AOFAS and ROM in favor of hemiarthroplasty.

Conclusion:

Hemi-surface implants in MTPJ arthroplasty may improve postoperative AOFAS and ROM results to a greater extent than total-toe devices. High-quality randomized controlled studies are needed to confirm long-term surgical outcomes in these patients.

Urinary tract infection management – do the guidelines agree?

Urinary tract infection (UTI) is defined as the inflammatory response of the urothelium to bacterial invasion. UTI in adults is one of the most prevalent infectious diseases worldwide with a substantial financial burden on society. There is mounting concern surrounding the ongoing development of microbial resistance. In addition, the increasing resistance of organisms to broad-spectrum antibiotics is worrying. There is a continuing drive for antibiotic stewardship and more prudent prescribing of antimicrobial agents. There is currently no national UK guideline on the management of UTI in adults but the EAU, AUA and SIGN all have their separate recommendations. In this review, we discuss the existing guideline recommendations particularly relating to lower UTIs (cystitis and epididymo-orchitis), upper UTIs (pyelonephritis) and catheter-associated infections (due to their large healthcare burden). The aims are to identify common recommendations and assess how they may apply for the UK setting. This review has highlighted considerable differences in practice recommendations between the major UK, European and American guidelines. Discrepancy exists in the choice of antibiotics and for some types of infection, whether or not any guidance for treatment is offered. Antibiotic avoidance and prudent antibiotic prescribing will be key components of future strategies in reducing antimicrobial resistance.

Urothelial carcinomas of the upper urinary tract – how does UK practice compare with European guidelines: is there a difference?

Upper urinary tract urothelial carcinomas (UUT-UCs) are relatively rare tumours that present a challenge to urologists, both in terms of diagnosis and treatment. The diagnostic pathway is often complex and the surgical options continue to generate controversy. The outcomes of treatment are mixed, with invasive tumours having a particularly poor prognosis. In this article we compare UK practice with the most recent European Association of Urology (EAU) guidelines for the management of UUT-UCs.

Publication rate of abstracts presented at the British Association of Urological Surgeons Annual Meeting – 10 years on

Introduction:

Acceptance of abstracts at the BAUS Annual Meeting is sought after by trainees and encouraged by trainers; however, it is the publication of this research in a peer-reviewed journal that validates the significance of the work. We aimed to compare current publication rates with those detailed in a previous study 10 years ago to examine for changes on the rate and time to peer-reviewed publications of abstracts presented. We also assessed whether there was a difference in the presentation and publication rates between UK deaneries.

Methods:

All abstracts accepted for presentation at the annual BAUS 2012 and 2013 meetings were identified from the published supplements in the BJU International journal. Listed abstracts were searched for in October 2015 using the Medline Plus (PubMed) database to assess for successful conversion to a peer-reviewed paper listed on the Medline database.

Results:

In total 281 abstracts were presented; of these, 265 (94.3%) were from the UK. A total of 24.2% of the abstracts presented over the two-year period resulted in a successful conversion to a peer-reviewed publication. Mean time to publication was 11.59 months and mean impact factor of the publishing journal was 3.854. There appeared to be no correlation between the number of abstracts presented per deanery and the subsequent successful conversion to peer-reviewed publication.

Conclusions:

There has been a decline over the past decade in the number of BAUS abstracts being successfully converted into peer-reviewed publications, from 42% to 24.2%. The quality of any scientific meeting can be quantified by the number of peer-reviewed publications arising from its abstracts. Possible reasons for this observed reduction include a lack of time to prepare manuscripts, the actual quality and relevance of work being presented and data that may be of questionable validity. In addition, indicative numbers set for publications to enable successful awarding of Certificate of Completion of Training are low.

Reduced tissue osmolarity increases TRPV4 expression and pro-inflammatory cytokines in intervertebral disc cells

The mechanical behaviour and cellular metabolism of intervertebral discs (IVDs) and articular cartilage are strongly influenced by their proteoglycan content and associated osmotic properties. This osmotic environment is a biophysical signal that changes with disease and may contribute to the elevated matrix breakdown and altered biologic response to loading observed in IVD degeneration and osteoarthritis. This study tested the hypothesis that changes in osmo-sensation by the transient receptor potential vallinoid-4 (TRPV4) ion channel occur with disease and contribute to the inflammatory environment found during degeneration. Immunohistochemistry on bovine IVDs from an inflammatory organ culture model were used to investigate if TRPV4 is expressed in the IVD and how expression changes with degeneration. Western blot, live-cell calcium imaging, and qRT-PCR were used to investigate whether osmolarity changes or tumour necrosis factor α (TNFα) regulate TRPV4 expression, and how altered TRPV4 expression influences calcium signalling and pro-inflammatory cytokine expression. TRPV4 expression correlated with TNFα expression, and was increased when cultured in reduced medium osmolarity and unaltered with TNFα-stimulation. Increased TRPV4 expression increased the calcium flux following TRPV4 activation and increased interleukin-1β (IL-1β) and IL-6 gene expression in IVD cells. TRPV4 expression was qualitatively elevated in regions of aggrecan depletion in degenerated human IVDs. Collectively, results suggest that reduced tissue osmolarity, likely following proteoglycan degradation, can increase TRPV4 signalling and enhance pro-inflammatory cytokine production, suggesting changes in TRPV4 mediated osmo-sensation may contribute to the progressive matrix breakdown in disease.

Oncological outcomes in low-, intermediate- and high D'Amico-risk patients undergoing laparoscopic radical prostatectomy at a single UK centre

Background and purpose

Laparoscopic radical prostatectomy (LRP) is an established treatment option for patients with prostate cancer in selected centres with appropriate expertise. The goal of LRP is to achieve excellent cancer control whilst attempting to preserve normal urinary continence and erectile function. We studied our single-centre experience evaluating the oncological outcomes in patients undergoing LRP.

Patients and methods

Three hundred and six patients underwent LRP between 2005 and 2011. Patients were divided into D'Amico low-, intermediate- and high-risk groups.

Results

The mean age was 61.9 years (range 46-74 years). The two most important factors predictive of positive surgical margins (PSMs) at LRP were the initial prostate-specific antigen (PSA) level and tumour stage at diagnosis. The overall PSM rate was 26.7%. For low D'Amico-risk patients, the PSM was 24.5%, intermediate-risk patients had a PSM of 32.4%, while high-risk patients had a PSM of 13.6%; 6.4% (nine of 139) of patients sampled had evidence of lymph node-positive disease. Five-year PSA progression-free survival rates were 83% in low-risk patients, 57% in intermediate-risk and 41% in high-risk patients.

Conclusion

LRP offers good oncological outcomes in the low- and intermediate-risk groups with low incidence of biochemical recurrence for patients with localised disease. Our high-risk group has a low incidence of PSM and a five-year PSA progression-free survival rate of 41%. Patients with high-risk, but non-metastatic, prostate cancer can be offered a minimally invasive prostatectomy in an experienced centre.

Annular puncture with tumor necrosis factor-alpha injection enhances painful behavior with disc degeneration in vivo

BACKGROUND CONTEXT

Painfulintervertebral disc degeneration is extremely common and costly. Effective treatments are lacking because the nature of discogenic pain is complex with limited capacity to distinguish painful conditions from age-related changes in the spine. Hypothesized sources of discogenic pain include chronic inflammation, neurovascular ingrowth, and structural disruption.

PURPOSE

This study aimed to investigate inflammation, pro-neurovascular growth factors, and structural disruption as sources of painful disc degeneration

STUDY DESIGN/SETTING

This study used an in vivo study to address these hypothesized mechanisms with anterior intradiscal injections of tumor necrosis factor-alpha (TNFα), pro-neurovascular growth factors: nerve growth factor and vascular endothelial growth factor (NGF and VEGF), and saline with additional sham surgery and naïve controls. Depth of annular puncture was also evaluated for its effects on structural and painful degeneration.

METHODS

Rat lumbar discs were punctured (shallow or deeper puncture) and intradiscally injected with saline, TNFα, or NGF and VEGF. Structural disc degeneration was assessed using X-ray, magnetic resonance imaging (MRI), and histology. The rat painful condition was evaluated using Von Frey hyperalgesia measurements, and substance P immunostaining in dorsal root ganglion (DRG) was performed to determine the source of pain.

RESULTS

Saline injection increased painful responses with degenerative changes in disc height, MRI intensity, and morphologies of disc structure and cell. TNFα and NGF/VEGF accelerated painful behavior, and TNFα-injected animals had increased substance P in DRGs. Deeper punctures led to more severe disc degeneration. Multiple regression analysis showed that the painful behavior was correlated with disc height loss.

CONCLUSIONS

We concluded that rate and severity of structural disc degeneration was associated with the amount of annular disruption and puncture depth. The painful behavior was associated with disc height loss and discal inflammatory state, whereas pro-inflammatory cytokines might play a more important role in the level of pain, which might have resulted from enhanced DRG sensitization. These in vivo painful disc degeneration models with different severities of structural changes may be useful for investigating discogenic pain mechanisms and for screening therapies, although interpretations must note the differences between all surgically induced animal models and the human condition.

Assessment of functional and behavioral changes sensitive to painful disc degeneration

The development of an in vivo rodent discogenic pain model can provide insight into mechanisms for painful disc degeneration. Painful disc degeneration in rodents can be inferred by examining responses to external stimuli, observing pain-related behaviors, and measuring functional performance. This study compared the sensitivity of multiple pain and functional assessment methods to disc disruption for identifying the parameters sensitive to painful disc degeneration in rats. Disc degeneration was induced in rats by annular injury with saline injection. The severity of disc degeneration, pain sensitivity, and functional performance were compared to sham and naïve control rats. Saline injection induced disc degeneration with decreased disc height and MRI signal intensity as well as more fibrous nucleus pulposus, disorganized annular lamellae and decreased proteoglycan. Rats also demonstrated increased painful behaviors including decreased hindpaw mechanical and thermal sensitivities, increased grooming, and altered gait patterns with hindpaw mechanical hyperalgesia and duration of grooming tests being most sensitive. This is the first study to compare sensitivities of different pain assessment methods in an in vivo rat model of disc degeneration. Hindpaw mechanical sensitivity and duration of grooming were the most sensitive parameters to surgically induced degenerative changes and overall results were suggestive of disc degeneration associated pain.

Classification, epidemiology and therapies for testicular germ cell tumours

Testicular germ cell tumours (TGCT) account for between 1% and 1.5% of male neoplasms and 5% of urological tumours in general. They are classified broadly into Seminoma, which resemble primordial germ cells (PGCs), and Non-Seminoma, which are either undifferentiated (embryonal carcinoma) or differentiated (exhibiting a degree of embryonic (teratoma) or extra-embryonic (yolk sac choriocarcinoma) patterning). We present the current details of the latest classification, epidemiology and treatment aspects of TGCT in the UK in our review.

Continent urinary diversion

We present a review on the current options for continent urinary diversion and their different indications on the basis of patient selection. In current clinical practice continent urinary diversion is being used world-wide in patients undergoing radical cystectomy and in severe cases of benign bladder pathologies. We also discuss the specific complications of continent urinary diversion and highlight the need to rigorously monitor these patients in the long- term specifically in terms of their renal function and cancer recurrence.

Metabolic complications of urinary intestinal diversion

Patients with a urinary bladder malignancy or severe anatomical/functional bladder abnormalities may be candidates for urinary diversion at the time of cystectomy. Most urinary diversions are constructed from intestinal segments. Urological surgeons who perform urinary diversion surgery should be aware of the physiological and metabolic changes that can occur when intestinal segments are in direct contact with urine. The complications associated with urinary diversion are both acute and chronic. The most important factor associated with the development of metabolic complications following urinary diversion is the length of time that the urine is in contact with the bowel and the type of bowel segment used for urinary diversion. In this review, we describe the metabolic complications associated with urinary diversion, their characteristic clinical presentation, follow-up, and specific treatment.

Anal sphincter fibrillation: is this a new finding that identifies resistant chronic anal fissures that respond to botulinum toxin?

AIM

Anal fissures can be resistant to treatment and some patients may undergo several trials of medical therapy before definitive surgery. It would be useful to identify predictors of poor response to medical therapy. This study assesses the role of anorectal physiological criteria to identify patients with anal fissure predicted to fail botulinum toxin (BT) treatment.

METHOD

A retrospective analysis of anorectal physiological data collected for patients with resistant chronic anal fissures, referred to one consultant surgeon between 2007 and 2011, was undertaken. These were correlated with treatment plans and healing rates.

RESULTS

Twenty-five patients with idiopathic chronic anal fissures underwent anorectal physiology studies and were subsequently treated with BT injection. Eleven had a characteristic high-frequency low-amplitude 'saw tooth' waveform or anal sphincter fibrillation (ASF) and higher anal sphincter pressures. Nine (82%) of these patients had resolution of their anal fissure symptoms following treatment with BT. Of 14 patients with no evidence of ASF and a greater range of anal sphincter pressures, only one (7%) had resolution following BT.

CONCLUSION

ASF appears to be an anorectal physiological criterion that helps predict response of anal fissures to BT injection. This could help streamline fissure management.

Challenging Pyogenic Cerebral Abscess Complicated by Subdural Empyema

Brain abscesses develop in response to a parenchymal infection with pyogenic bacteria, beginning as a localized area of cerebritis and evolving into a suppurative lesion surrounded by a well-vascularized fibrotic capsule. The leading etiologic agents of brain abscess are the streptococcal strains and S. aureus. Abscesses may also be secondary to fungal or parasitic organisms. Brain abscess represents a significant medical problem, accounting for one in every 10,000 hospital admissions in the United States, and remains a serious situation despite recent advances made in detection and therapy. These lesions often produce complex clinical and radiologic findings and require prompt recognition and treatment to avoid a fatal neurologic outcome. Subdural empyema represents an important type of intracranial suppurative infectious-inflammatory disorder. Clinically, these patients initially have signs and symptoms of meningitis, but this course might be complicated later by the development of seizures and focal neurologic signs.

Diffusion tensor imaging based network analysis detects alterations of neuroconnectivity in patients with clinically early relapsing-remitting multiple sclerosis

Although it is inarguable that conventional MRI (cMRI) has greatly contributed to the diagnosis and assessment of multiple sclerosis (MS), cMRI does not show close correlation with clinical findings or pathologic features, and is unable to predict prognosis or stratify disease severity. To this end, diffusion tensor imaging (DTI) with tractography and neuroconnectivity analysis may assist disease assessment in MS. We, therefore, attempted this pilot study for initial assessment of early relapsing-remitting MS (RRMS). Neuroconnectivity analysis was used for evaluation of 24 early RRMS patients within 2 years of presentation, and compared to the network measures of a group of 30 age-and-gender-matched normal control subjects. To account for the situation that the connections between two adjacent regions may be disrupted by an MS lesion, a new metric, network communicability, was adopted to measure both direct and indirect connections. For each anatomical area, the brain network communicability and average path length were computed and compared to characterize the network changes in efficiencies. Statistically significant (P < 0.05) loss of communicability was revealed in our RRMS cohort, particularly in the frontal and hippocampal/parahippocampal regions as well as the motor strip and occipital lobes. Correlation with the 25-foot Walk test with communicability measures in the left superior frontal (r = -0.71) as well as the left superior temporal gyrus (r = -0.43) and left postcentral gyrus (r = -0.41) were identified. Additionally identified were increased communicability between the deep gray matter structures (left thalamus and putamen) with the major interhemispheric and intrahemispheric white matter tracts, the corpus callosum, and cingulum, respectively. These foci of increased communicability are thought to represent compensatory changes. The proposed DTI-based neuroconnectivity analysis demonstrated quantifiable, structurally relevant alterations of fiber tract connections in early RRMS and paves the way for longitudinal studies in larger patient groups.

Neck of Femur Fractures in Patient's Aged More Than 85 Years-are They a Unique Subset?

Background. The UK population is ageing with the largest increase expected to occur in people aged more than 85 years (85+). We have examined the hypothesis that neck of femur (NOF) fractures in the 85+ group exhibit demonstrable key outcome measurement differences after surgery when compared to a standard NOF population. Patients and Methods. A prospective observational cohort study of the demographics, clinical features, and key clinical outcome measurements for 2 groups of patients (65-84 and 85+ years of age at presentation) was performed in a single trauma unit over a 3-year period. Results. A total of 699 patients with a median age of 78 in the 65 to 84 cohort were compared with 523 patients with a median age of 88 in the 85+ cohort. Despite a dedicated orthogeriatric service and no difference in time to surgery between the 2 groups, the 30-day and 1-year mortality rates were significantly higher in the 85+ cohort at 10% and 30%, respectively, compared with 5% and 19% in the younger patient group. In our 85+ group, 34% had evidence of significant measured cognitive impairment compared to only 19% in the 65 to 84 group (P < .001). The length of hospital inpatient stay was also longer in the 85+ cohort with a median of 20 days compared to 16 days in the younger cohort (P = .001). In the 85+ cohort, 60% of patients were discharged back to their usual (preinjury) place of residence compared to 72% in the 65 to 84 cohort (P = .001). Conclusions. Patients in 85+ group presenting with an NOF fracture represent a unique high-risk patient group. Despite adherence to published key principles of care, this group is at higher risk and as such merits focused clinical attention, with adequate patient and family member counseling with regard to prognosis and overall expectation.

An eight year audit before and after the introduction of modified early warning score (MEWS) charts, of patients admitted to a tertiary referral intensive care unit after CPR

AIMS

To determine whether cardiac arrest calls, the proportion of adult patients admitted to intensive care after CPR and their associated mortalities were reduced, in a four year period after the introduction of a 24/7 Critical Care Outreach Service and MEWS (Modified Early Warning System) Charts.

METHODS

A retrospective analysis of prospectively collected data during two four-year periods, (2002-05 and 2006-09) in a UK University Teaching Hospital Comparisons were via χ(2) test. A p value of ≤0.05 was regarded as being significant.

RESULTS

In the second audit period, compared to the first one, the number of cardiac arrest calls relative to adult hospital admissions decreased significantly (0.2% vs. 0.4%; p<0.0001), the proportion of patients admitted to intensive care having undergone in-hospital CPR fell significantly (2% vs. 3%; p=0.004) as did the in-hospital mortality of these patients (42% vs. 52%; p=0.05).

CONCLUSION

The four years following the introduction of a 24/7 Critical Care Outreach Service and MEWS Charts were associated with significant reductions in the incidence of cardiac arrest calls, the proportion of patients admitted to intensive care having undergone in-hospital CPR and their in-hospital mortality.

Caspase-3 activation as a key factor for HBx-transformed cell death

OBJECTIVES

Nuclear factor-kappa B (NF-kappaB) activation has been associated with the tumorigenic growth of hepatitis B virus X protein (HBx)-transformed cells. This study was aimed to find a key target for treatment of HBx-mediated cancers.

MATERIALS AND METHODS

NF-kappaB activation, endoplasmic reticulum-stress (ER-stress), caspase-3 activation, and cell proliferation were evaluated after Chang/HBx cells permanently expressing HBx viral protein were treated with inhibitors of NF-kappaB, proteasome and DNA topoisomerase.

RESULTS

Inhibition of NF-kappaB transcriptional activity by transient transfection with mutant plasmids encoding Akt1 and glycogen synthase kinase-3beta (GSK-3beta), or by treatment with chemical inhibitors, wortmannin and LY294002, showed little effect on the survival of Chang/HBx cells. Furthermore, IkappaBalpha (S32/36A) mutant plasmid or other NF-kappaB inhibitors, 1-pyrrolidinecarbonidithioic acid and sulphasalazine, were also shown to have little effect on the cell proliferation. By contrast, proteasome inhibitor-1 (Pro1) and MG132 enhanced the HBx-induced ER-stress response and the subsequent activation of caspase-12, -9 and -3 and reduced cell proliferation. Camptothecin (CPT), however, triggered activation of caspase-3 without induction of caspase-12, and reduced cell proliferation. In addition, CPT-induced cell death was reversed by pre-treatment with z-DEVD, a caspase-3-specific inhibitor.

CONCLUSIONS

Detailed exploitation of the regulators of caspase-3 activation could open the gate for finding an efficient target for development of anticancer therapeutics against HBx-transformed hepatocellular carcinoma.