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.

Can AI learn to identify systematic reviews on the effectiveness of public health interventions?

Issue/problem

Health Evidence™ aims to make it easier for public health professionals and decision-makers to use evidence in their programs and policies. We provide access to over 7,000 critically appraised systematic reviews on the effectiveness of public health interventions. On average, 8,000-10,000 records are screened each month to identify around 50 relevant reviews that are critically appraised and uploaded to the registry. As the number of published reviews continues to grow each year, maintaining an up-to-date Registry is becoming increasingly resource intensive.

Description of the problem

Artificial intelligence (AI) may be one way to ensure maintenance of this Registry continues to be feasible. It is important that the use of AI is accurate and efficient to support monthly relevance screening for the Health Evidence ™ Registry. To assess if the use of AI is appropriate in this context, the team uploaded a large, labelled training set (n = 43,273) of relevant and non-relevant records to DistillerSR and used the AI Preview and Rank function to predict the probability of relevance to the Registry. We identified an optimal threshold (0.17) that automatically removes the greatest number of records with minimal classification errors. We then tested this threshold on one year of manually screened records (n = 89,832) from May 2019 to June 2020 to ensure continued accuracy.

Results

Using AI to support our monthly relevance screening has reduced our monthly manual screening burden by over 77% (from ∼9,000 references manually screened per month to ∼2,000) saving upwards of 10 hours staff time per month!

Lessons

The use of AI shows promise to help improve the feasibility of maintaining a large Registry of quality appraised synthesis level evidence relevant for public health decision making.

Key messages

Health Evidence™ provides easy access to high quality synthesis evidence relevant for public health. The use of AI shows promise for helping to automate the Health Evidence™ monthly update and improve the feasibility of maintaining a public health registry of quality appraised synthesis evidence.

Help! Working with change: An organizational change process model and online registry of resources

Background

The health system is continuously undergoing change in response to various internal and external drivers. The organizational change literature is complex and multi-disciplinary, making it challenging for health professionals to utilize efficiently. To support practitioners through times of change, The National Collaborating Centre for Methods and Tools (NCCMT) developed a health sector-specific model of organizational change, by synthesizing existing models and frameworks, and developed an online registry of resources to help guide practitioners through the change process.

Objectives

Existing change process models were identified through a scoping review of reviews published from 2000-2015, supplemental searches using a snowball method, and contact with key informants. A thematic analysis identified key themes and activities. To support the use of the model, a search of the academic and grey literature was conducted to identify practical organizational change tools. Resources were tagged with specific stages in the model and added to an online interactive Registry.

The online Registry is available for practitioners to gain knowledge and understanding of processes of change relevant to the health sector, identify facilitators and barriers to change, and use methods and tools to support practitioners throughout the change process.

Results

A total of 30 organizational change process models were identified and synthesized to create a new five-stage model: assessing the NEED for change; PLANning for change; IMPLEMENTing change initiatives; SUSTAINing change within the organization; and EVOLVing to continuously meet drivers for change. The easy to use and interactive platform hosts over 100 practical tools linked to stages in the model to support organization and systems change.

Conclusions

This new resource will support the implementation of evidence-informed practices, policies and programs in public health and the broader health care system.

Key messages

The health system is continuously undergoing change and can be challenging to navigate. A health sector-specific organizational change process model and online registry of resources can help guide public health professionals throughout the change process.

Embracing the value of research data: introducing the JCHLA/JABSC Data Sharing Policy

Health sciences researchers are being asked to share their data more frequently due to funder policies, journal requirements, or interest from their peers. Health sciences librarians (HSLs) have simultaneously begun to provide support to researchers in this space through training, participating in RDM efforts on research grants, and developing comprehensive data services programs. If supporting researchers' data sharing efforts is a worthwhile investment for HSLs, it is crucial that we practice data sharing in our own research endeavours. Sharing data is a positive step in the right direction, as it can increase the transparency, reliability, and reusability of HSL-related research outputs. Furthermore, being able to identify and connect with researchers in relation to the challenges associated with data sharing can help HSLs empathize with their communities and gain new perspectives on improving support in this area. To that end, the Journal of the Canadian Health Libraries Association / Journal de l’Association des bibliothèques de la santé du Canada (JCHLA/JABSC) has developed a Data Sharing Policy to improve the transparency and reusability of research data underlying the results of its publications. This paper will describe the approach taken to inform and develop this policy.

The Medical Library Association Data Services Competency: a framework for data science and open science skills development

Increasingly, users of health and biomedical libraries need assistance with challenges they face in working with their own and others’ data. Librarians have a unique opportunity to provide valuable support and assistance in data science and open science but may need to add to their expertise and skill set to have the most impact. This article describes the rationale for and development of the Medical Library Association Data Services Competency, which outlines a set of five key skills for data services and provides a course of study for gaining these skills.

A new hat for librarians: providing REDCap support to establish the library as a central data hub

Background

REDCap, an electronic data capture tool, supports good research data management, but many researchers lack familiarity with the tool. While a REDCap administrator provided technical support and a clinical data management support unit provided study design support, a service gap existed.

Case Presentation

Librarians with REDCap expertise sought to increase and improve usage through outreach, workshops, and consultations. In collaboration with a REDCap administrator and the director of the clinical data management support unit, the role of the library was established in providing REDCap training and consultations. REDCap trainings were offered to the medical center during the library’s quarterly data series, which served as a springboard for offering tailored REDCap support to researchers and research groups.

Conclusions

Providing REDCap support has proved to be an effective way to associate the library with data-related activities in an academic medical center and identify new opportunities for offering data services in the library. By offering REDCap services, the library established strong partnerships with the Information Technology Department, Clinical Data Support Department, and Compliance Office by filling in training gaps, while simultaneously referring users back to these departments when additional expertise was required. These new partnerships continue to grow and serve to position the library as a central data hub in the institution.

Essential but Not Vulnerable: Indazole Sulfonamides Targeting Inosine Monophosphate Dehydrogenase as Potential Leads against Mycobacterium tuberculosis

A potent, noncytotoxic indazole sulfonamide was identified by high-throughput screening of >100,000 synthetic compounds for activity against Mycobacterium tuberculosis (Mtb). This noncytotoxic compound did not directly inhibit cell wall biogenesis but triggered a slow lysis of Mtb cells as measured by release of intracellular green fluorescent protein (GFP). Isolation of resistant mutants followed by whole-genome sequencing showed an unusual gene amplification of a 40 gene region spanning from Rv3371 to Rv3411c and in one case a potential promoter mutation upstream of guaB2 (Rv3411c) encoding inosine monophosphate dehydrogenase (IMPDH). Subsequent biochemical validation confirmed direct inhibition of IMPDH by an uncompetitive mode of inhibition, and growth inhibition could be rescued by supplementation with guanine, a bypass mechanism for the IMPDH pathway. Beads containing immobilized indazole sulfonamides specifically interacted with IMPDH in cell lysates. X-ray crystallography of the IMPDH-IMP-inhibitor complex revealed that the primary interactions of these compounds with IMPDH were direct pi-pi interactions with the IMP substrate. Advanced lead compounds in this series with acceptable pharmacokinetic properties failed to show efficacy in acute or chronic murine models of tuberculosis (TB). Time-kill experiments in vitro suggest that sustained exposure to drug concentrations above the minimum inhibitory concentration (MIC) for 24 h were required for a cidal effect, levels that have been difficult to achieve in vivo. Direct measurement of guanine levels in resected lung tissue from tuberculosis-infected animals and patients revealed 0.5-2 mM concentrations in caseum and normal lung tissue. The high lesional levels of guanine and the slow lytic, growth-rate-dependent effect of IMPDH inhibition pose challenges to developing drugs against this target for use in treating TB.

Consensus guidelines for the investigation and management of encephalitis in adults and children in Australia and New Zealand

Encephalitis is a complex neurological syndrome caused by inflammation of the brain parenchyma. The management of encephalitis is challenging because: the differential diagnosis of encephalopathy is broad; there is often rapid disease progression; it often requires intensive supportive management; and there are many aetiologic agents for which there is no definitive treatment. Patients with possible meningoencephalitis are often encountered in the emergency care environment where clinicians must consider differential diagnoses, perform appropriate investigations and initiate empiric antimicrobials. For patients who require admission to hospital and in whom encephalitis is likely, a staged approach to investigation and management is preferred with the potential involvement of multiple medical specialties. Key considerations in the investigation and management of patients with encephalitis addressed in this guideline include: Which first-line investigations should be performed?; Which aetiologies should be considered possible based on clinical features, risk factors and radiological features?; What tests should be arranged in order to diagnose the common causes of encephalitis?; When to consider empiric antimicrobials and immune modulatory therapies?; and What is the role of brain biopsy?

Enteric fever in the Pacific: a regional retrospective study from Auckland, New Zealand

BACKGROUND

There are limited clinical data on enteric fever in the Pacific and New Zealand (NZ) compared with the Indian subcontinent (ISC) and South-East Asia (SEA). Our objective was to describe enteric fever in Auckland - a large Pacific city, focusing on disease acquired in these regions.

METHODS

We reviewed enteric fever cases hospitalised in Auckland from January 2005 to December 2010.

RESULTS

Microbiologically confirmed EF was identified in 162 patients. Travel regions: Pacific, 40 cases (25%) (Samoa, 38; Fiji, two), ISC, 72 (44%), SEA, seven (4%), other, three (2%), no travel, 40 (25%). Enteric fever rates for Auckland resident travellers were: India 50.3/100 000; Samoa 19.7/100 000.All Pacific cases were Salmonella Typhi. Of local isolates (without travel history), 38 were S. Typhi (36 fully susceptible, one multi-drug resistant (MDR) + nalidixic acid resistant (NAR), one unknown) and two S. Paratyphi (both NAR). Of non-Pacific travel, 56/82 (69%) isolates were S. Typhi, the remainder S. Paratyphi (15 isolates were fully susceptible, only 1% were MDR). Significant associations of serotype and antibiotic resistance with different travel regions and similarity of phage types (local and Pacific) were observed. Headache, vomiting and acute kidney injuries were more frequent with Pacific travel, while abdominal distension and cholecystitis with local disease. Shorter duration of treatment in the Pacific group was seen despite length of stay in hospital not being reduced. Local cases were associated with longer hospital admissions.

CONCLUSIONS

One half of cases in Auckland are acquired either from Pacific or locally. Similarities mean that disease acquired locally is likely of Pacific origin.

Promoting Data Reuse and Collaboration at an Academic Medical Center

A need was identified by the Department of Population Health (DPH) for an academic medical center to facilitate research using large, externally funded datasets. Barriers identified included difficulty in accessing and working with the datasets, and a lack of knowledge about institutional licenses. A need to facilitate sharing and reuse of datasets generated by researchers at the institution (internal datasets) was also recognized. The library partnered with a researcher in the DPH to create a catalog of external datasets, which provided detailed metadata and access instructions. The catalog listed researchers at the medical center and the main campus with expertise in using these external datasets in order to facilitate research and cross-campus collaboration. Data description standards were reviewed to create a set of metadata to facilitate access to both externally generated datasets, as well as the internally generated datasets that would constitute the next phase of development of the catalog. Interviews with a range of investigators at the institution identified DPH researchers as most interested in data sharing, therefore targeted outreach to this group was undertaken. Initial outreach resulted in additional external datasets being described, new local experts volunteering, proposals for additional functionality, and interest from researchers in inclusion of their internal datasets in the catalog. Despite limited outreach, the catalog has had ~250 unique page views in the three months since it went live. The establishment of the catalog also led to partnerships with the medical center’s data management core and the main university library. The Data Catalog in its present state serves a direct user need from the Department of Population Health to describe large, externally funded datasets. The library will use this initial strong community of users to expand the catalog and include internally generated research datasets. Future expansion plans will include working with DataCore and the main university library.

Expression, purification, and evaluation of recombinant LecA as a candidate for an amebic colitis vaccine

Entamoeba histolytica, which causes amebic colitis and liver abscess, is considered a major enteric pathogen in residents and travelers to developing countries where the disease is endemic. Interaction of this protozoan parasite with the intestine is mediated through the binding of the trophozoite stage to intestinal mucin and epithelium via a galactose and N-acetyl-d-galactosamine (Gal/GalNAc) lectin comprised of a disulfide linked heavy (ca. 180 kDa) and light chain (ca. 35 kDa) and a noncovalently bound intermediate subunit (ca. 150 kDa). Our efforts to develop a vaccine against this pathogen have focused on an internal 578 amino acid fragment, designated LecA, located within the cysteine-rich region of the heavy chain subunit because: (i) it is a major target of adherence-blocking antibodies of seropositive individuals and (ii) vaccination with his-tagged LecA provides protection in animal models. We developed a purification process for preparing highly purified non-tagged LecA using a codon-optimized gene expressed in Escherichia coli. The process consisted of: (i) cell lysis, collection and washing of inclusion bodies; (ii) solubilization and refolding of denatured LecA; and (iii) a polishing gel filtration step. The purified fragment existed primarily as a random coil with β-sheet structure, contained low endotoxin and nucleic acid, was highly immunoreactive, and elicited antibodies that recognized native lectin and that inhibited in vitro adherence of trophozoites to CHO cells. Immunization of CBA mice with LecA resulted in significant protection against cecal colitis. Our procedure yields sufficient amounts of highly purified LecA for future studies on stability, immunogenicity, and protection with protein-adjuvant formulations.

Effects of hydrogen sulphide in an experimental model of renal ischaemia-reperfusion injury

BACKGROUND

Renal ischaemia-reperfusion injury (IRI) is a major cause of acute renal failure and renal transplant dysfunction. The aim of this study was to investigate the efficacy of the endogenous gaseous signalling molecule hydrogen sulphide in protecting against renal IRI.

METHODS

Large White female pigs underwent laparotomy and cross-clamping of the left renal pedicle for 60 min. Animals were allocated randomly to treatment with either intravenous hydrogen sulphide (n = 6) or saline control (n = 6) 10 min before clamp release, and then underwent a right nephrectomy. Staff were blinded to treatment allocation and animals were recovered for 7 days.

RESULTS

Hydrogen sulphide therapy resulted in a marked reduction in kidney injury with reduced serum creatinine levels on days 1-5, in a reduced area under the creatinine-time curve, and a halving of the time to achieve a creatinine level of less than 250 µmol/l, compared with the control. Hydrogen sulphide also preserved glomerular function, as shown by the urinary protein/creatinine ratio, which, compared with baseline, increased on days 1 and 3 in the control group (mean(s.e.m.) 3·22(1·43), P = 0·016 and 2·59(1·27), P = 0·031), but not in the treatment group (0·99(0·23), P = 0·190 and 1·06(0·44), P = 0·110, respectively). Mean(s.e.m.) tumour necrosis factor α levels at 6 h postreperfusion increased in the control animals (56(6) versus 115(21) pg/ml; P = 0·026), but not in the hydrogen sulphide-treated animals (61(7) versus 74(11) pg/ml; P = 0·460). Renal neutrophil infiltration at 30 min (myeloperoxidase staining) was also significantly reduced by treatment with hydrogen sulphide (P = 0·016).

CONCLUSION

Hydrogen sulphide offers a promising new approach to ameliorating renal IRI with potential translation into a number of clinical settings, including renal transplantation.

Central nervous system drug disposition: the relationship between in situ brain permeability and brain free fraction

The dispositions of 50 marketed central nervous system (CNS) drugs into the brain have been examined in terms of their rat in situ (P) and in vitro apparent membrane permeability (P(app)) alongside lipophilicity and free fraction in rat brain tissue. The inter-relationship between these parameters highlights that both permeability and brain tissue binding influence the uptake of drugs into the CNS. Hydrophilic compounds characterized by low brain tissue binding display a strong correlation (R(2) = 0.82) between P and P(app), whereas the uptake of more lipophilic compounds seems to be influenced by both P(app) and brain free fraction. A nonlinear relationship is observed between logP(oct) and P over the 6 orders of magnitude range in lipophilicity studied. These findings corroborate recent reports in the literature that brain penetration is a function of both rate and extent of drug uptake into the CNS.

Causes and outcomes of mild traumatic brain injury: an analysis of CIREN data

Approximately one-half of vehicle occupants with traumatic brain injury (TBI) have a mild TBI (admission Glasgow Coma Scale (GCS) score of 13-15 with transient loss of consciousness). However, despite the label of "mild", many of these injuries result in long-term consequences; frequently these sequelae go unrecognized, as the patients are lost to medical follow-up. The Crash Injury Research Engineering Network (CIREN) project affords us the opportunity to examine the crash circumstances, injury sources and outcomes of mild TBI cases in greater detail.

Molecular phylogeny of the Australian frog genera Crinia, Geocrinia, and allied taxa (Anura: Myobatrachidae)

We present a mitochondrial gene tree for representative species of all the genera in the subfamily Myobatrachinae, with special emphasis on Crinia and Geocrinia. This group has been the subject of a number of long-standing taxonomic and phylogenetic debates. Our phylogeny is based on data from approximately 780 bp of 12S rRNA and 676 bp of ND2, and resolves a number of these problems. We confirm that the morphologically highly derived monotypic genera Metacrinia, Myobatrachus, and Arenophryne are closely related, and that Pseudophryne forms the sister group to these genera. Uperoleia and the recently described genus Spicospina are also part of this clade. Our data show that Assa and Geocrinia are reciprocally monophyletic and together they form a well-supported clade. Geocrinia is monophyletic and the phylogenetic relationships with the genus are fully resolved with two major species groups identified: G. leai, G. victoriana, and G. laevis; and G. rosea, G. alba, and G. vitellina (we were unable to sample G. lutea). We confirm that Taudactylus forms the sister group to the other myobatrachine genera, but our data are equivocal on the phylogenetic position of Paracrinia. The phylogenetic relationships among Crinia species are well resolved with strong support for a number of distinct monophyletic clades, but more data are required to resolve relationships among these major Crinia clades. Crinia tasmaniensis and Bryobatrachus nimbus form the sister clade to the rest of Crinia. Due to the lack of generic level synapomorphies for a Bryobatrachus that includes C. tasmaniensis, we synonymize Bryobatrachus with Crinia. Crinia georgiana does not form a clade distinct from other Crinia species and so our data do not support recognition of the genus Ranidella for other Crinia species. Crinia subinsignifera, C. pseudinsignifera, and C. insignifera are extremely closely related despite differences in male advertisement call. A preliminary investigation of phylogeographic substructure within C. signifera revealed significant divergence between samples from across the range of this species.

Exposure of transformed and non-transformed phagocytic cells to novel glass ionomers in culture

The use of glass ionomers as a novel bone cement is currently being investigated. Although acceptable for use as a dental restorative material, there is little information regarding how ionomers interact with inflammatory macrophage cell types. The specific objective of this experiment was to investigate the possible interrelationship between RAW and human monocyte/macrophage cells at the biochemical and morphological level after being in contact with three different dental cement ionomers (Fuji Duet, Fuji IX, and GC-Fuji-Ortho, GC America Inc., Chicago IL) for 72 hours. Transformed RAW macrophages were obtained from the American Type Culture collection (ATCC), and the non-transformed human macrophages were obtained from the peripheral blood of 25 male and female volunteers. The cells were plated at a density of 4 x 10(6) cells/ml in twenty-four well plates. Each plate was divided into four groups of six cells/group. Twenty-four hours after plating, the cells in groups I-III were incubated with Fuji Duet, Fuji IX, GC Fuji Ortho, respectively, and cells in Group IV were incubated with media alone to serve as controls. Immediately after addition of the ionomers, the cellular morphology was monitored for both transformed and non-transformed cells. Cell number data revealed that normal non-transformed cells were similar in number to control cells in media alone. This result suggests that the polymer treatment did significantly alter cellular viability. On the other hand, RAW cell number was markedly reduced in cells treated with ionomers in comparison to cell growing in media alone. The data suggests that the prescence of the ionomer may reduce the proliferation rate of RAW cells. Biochemical analysis of cellular supernatants to determine cellular alterations at 72 hours revealed increased levels of lactate dehydrogenase activity and levels of malionaldehyde bis diethyl acetal in all ionomer-treated groups of RAW cells compared with media alone. Non-transformed macrophages treated with the same ionomers did not differ significantly from the control cells in media alone. However, when comparing the levels of lactate dehydrogenase activity between the transformed and non-transformed cells it was apparent that the normal cells exhibited statistically higher activity than the RAW transformed cells. The results of this study suggest that although the three ionomers tested were found to be highly biocompatible with fully differentiated non-transformed macrophages, the behavior of transformed and non-transformed phagocytic cells towards these ionomers may not be similar under similar conditions.

Semi-inclusive lambda and K(S) production in p-Au collisions at 17.5 GeV/c

The first detailed measurements of the centrality dependence of strangeness production in p-A collisions are presented. Lambda and K(S) dn/dy distributions from 17.5 GeV/ c p-Au collisions are shown as a function of "grey" track multiplicity and the estimated number of collisions, nu, made by the proton. The nu dependence of the Lambda yield deviates from a scaling of p-p data by the number of participants, increasing faster than this scaling for nu</=5 and saturating for larger nu. A slower growth in K(S) multiplicity with nu is observed, consistent with a weaker nu dependence of K&Kmacr; production than YK production.

Mental health. Back from the brink

Mental healthcare in Wolverhampton had sunk to such depths that two years ago the purchasing authority was openly discussing commissioning its services from another town. Today the situation is transformed. David Jolley and colleagues explain how such marked progress was achieved.

Low-threshold operation of an ultrashort-pulse mode-locked Ti:sapphire laser

We demonstrate low-pump-power operation of a self-mode-locked Ti:sapphire laser. Stable, sub-20-fs duration pulses, with output powers of 35-100 mW, were obtained for pump powers in the range of 400 mW-1 W. Our design uses a tight focusing geometry for both the argon-ion and Ti:sapphire beams within the Ti:sapphire crystal, which significantly reduces the pump-power requirements.

Safety belt restraints and compartment intrusions in frontal and lateral motor vehicle crashes: mechanisms of injuries, complications, and acute care costs

A 3-year prospective study examined 76 frontal (F) and 45 lateral (L) motor vehicle crash (MVC) patients with regard to seatbelt restraint use and occupant compartment contact and intrusion injuries. These 121 MVC victims with multiple injuries (39 belted [B] and 82 non-belted [NB]), admitted to a level I trauma center, were studied by accident reconstruction and medical data analysis. They had a MVC mean impact velocity (delta V) of 30 +/- 11 mph and an injury Severity Score of 29 +/- 12. Proper restraint use reduced brain injury in F MVCs (30% FB vs. 47% FNB) but had no effect in L MVCs (63% LB vs. 30% FB [p < 0.06]). Belt use did not protect against lung, liver, spleen, pelvis, or lower extremity (LE) injury. These appeared to be more a function of crash direction, with LE injuries higher in F crashes (p < 0.04) and pelvis injuries (p < 0.001) higher in L crashes. In FB crashes, however, properly used safety restraints were the primary cause of bowel or colon injuries (p < 0.006). Belts did not prevent thoracic or abdominal solid organ injuries in L crashes. Contact-intrusions (CI) of the car occupant compartment in F crashes were the main cause of brain (A-pillar), lung and liver (steering wheel and instrument panel), and LE (toepan) injuries; but in L crashes, side-door CI caused lung, aorta, liver, and pelvic injuries. In contrast, contact-only (CO) injuries of the steering assembly were mainly responsible for injuries to the lung, heart, and liver in F crashes, and side-door CO for lung, liver, and spleen injuries in L crashes. Deaths and complications after injury were higher among F MVC occupants, or when delta V was > or = 30 mph. Hospital and professional costs reflect the complex care needed for victims of multiple injuries: FB, $99,000; FNB, $95,000; LB, $75,000; LNB, $79,000; total, $10.7 million. Present vehicle safety standards are not adequate, and structural design changes are needed to improve restraints and protect occupants from intrusion-related injuries.

Curing the system: what ails health care?

Spiraling costs of high-technology medicine and gaps in insurance are creating a gulf in the nation's healthcare system. Solving problems in the U.S. healthcare system may seem an overwhelming task, but leaders in academics, bioethics, medical technology, and within HFMA discuss guidelines and specific aspects of the system warranting concern. Their analysis of the issues clarifies the questions to ask, but the decisions ultimately must come from the public.