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.

P11.53.B Efficacy and tolerability of regorafenib in pretreated patients with progressive CNS grade 3 or 4 gliomas

Background

The phase 2 REGOMA trial suggested an encouraging overall survival benefit in glioblastoma patients at first relapse treated with the multikinase inhibitor regorafenib. Here, we evaluated the efficacy and side effects of regorafenib in a real-life setting.

Material and Methods

From 2018-2021, 30 patients with progressive WHO CNS grade 3 or 4 gliomas treated with regorafenib (160 mg/d; first 3 weeks of each 4-week cycle) with individual dose adjustment depending on toxicity were retrospectively identified. Side effects were evaluated according to the Common Terminology Criteria for Adverse Events (version 5.0). MRI was obtained at baseline and after every second cycle. Tumor progression was assessed according to RANO criteria. After regorafenib initiation, the median progression-free survival (PFS) and overall survival (OS) were calculated.

Results

The median number of treatment lines before regorafenib was 2 (range, 1-4). The majority of patients (73%) had two or more pretreatment lines. At first relapse, 27% of patients received regorafenib. A total of 94 regorafenib cycles were administered (median number of cycles, 2; range, 1-9 cycles). Grade 3 and 4 side effects were observed in 47% and 7% of patients, respectively, and were not significantly increased in patients with two or more pretreatments (P&gt;0.05). The most frequent grade 3 or 4 side effects were laboratory abnormalities (62%). PFS was 2.6 months (range, 0.8-8.2 months), and the OS was 6.2 months (range, 0.9-24 months).

Conclusion

In patients with progressive WHO grade 3 or 4 gliomas, predominantly with two pretreatment lines or more, regorafenib seems to be effective despite considerable grade 3 or 4 side effects.

Does the presence of conspecifics facilitate exploratory behaviour in a cichlid fish (Etroplus suratensis)?

Animals confronted with any kind of novelty show behavioural responses driven by avoidance and exploration. The expression of both tendencies is modulated by anxiety. Especially in group-living animals, the presence of conspecifics can reduce anxiety in novel situations and hence increase exploratory tendency. Such intensified behavioural responses triggered by the social environment of an individual are called social facilitation. Here, we tested for social facilitation on the exploratory tendency of group-living juvenile Green chromide cichlid fish (Etroplus suratensis) by assessing each individual twice in an open field test: once alone and once together with a conspecific. Contrary to our expectations, we found no difference in exploratory behaviour between the groups. However, our results suggest that changes in exploratory tendency across the two treatments were highly individual, both in extent and direction, and are likely driven by the presence of the conspecific and the focal individual’s own behavioural type.

Pseudo contrastive labeling for predicting IVF embryo developmental potential

In vitro fertilization is typically associated with high failure rates per transfer, leading to an acute need for the identification of embryos with high developmental potential. Current methods are tailored to specific times after fertilization, often require expert inspection, and have low predictive power. Automatic methods are challenged by ambiguous labels, clinical heterogeneity, and the inability to utilize multiple developmental points. In this work, we propose a novel method that trains a classifier conditioned on the time since fertilization. This classifier is then integrated over time and its output is used to assign soft labels to pairs of samples. The classifier obtained by training on these soft labels presents a significant improvement in accuracy, even as early as 30 h post-fertilization. By integrating the classification scores, the predictive power is further improved. Our results are superior to previously reported methods, including the commercial KIDScore-D3 system, and a group of eight senior professionals, in classifying multiple groups of favorable embryos into groups defined as less favorable based on implantation outcomes, expert decisions based on developmental trajectories, and/or genetic tests.

Immunobiology of Cellular Transplantation

The goal of cellular transplantation is to allow long-term function of the grafted cells using minimal host immunosuppression. To this end, the major strategies to implant cells and tissues are through: (i) the pretreatment of the graft to reduce tissue immunogenicity; (ii) the application of immunoisolation technologies to prevent host sensitization to implanted cells; and (iii) the induction of immunological tolerance to the donor tissues. Further, a major dilemma facing clinical tissue grafting is the shortage of donor tissue for transplantation. This problem requires the consideration of tissues from other species (xenografts) as a potential source of donor material. In light of these issues, the focus of this discussion is on the T cell-dependent response to allogeneic and xenogeneic transplants and the implications of this reactivity on the field of cellular replacement therapy.

IL-17C mediates the recruitment of tumor-associated neutrophils and lung tumor growth

Chronic obstructive pulmonary disease (COPD) is associated with an increased risk for lung cancer and an aberrant microbiota of the lung. Microbial colonization contributes to chronic neutrophilic inflammation in COPD. Nontypeable Haemophilus influenzae (NTHi) is frequently found in lungs of stable COPD patients and is the major pathogen triggering exacerbations. The epithelial cytokine interleukin-17C (IL-17C) promotes the recruitment of neutrophils into inflamed tissues. The purpose of this study was to investigate the function of IL-17C in the pulmonary tumor microenvironment. We subjected mice deficient for IL-17C (IL-17C^-/-) and mice double deficient for Toll-like receptor 2 and 4 (TLR-2/4^-/-) to a metastatic lung cancer model. Tumor proliferation and growth as well as the number of tumor-associated neutrophils was significantly decreased in IL-17C^-/- and TLR-2/4^-/- mice exposed to NTHi. The NTHi-induced pulmonary expression of IL-17C was dependent on TLR-2/4. In vitro, IL-17C increased the NTHi- and tumor necrosis factor-α-induced expression of the neutrophil chemokines keratinocyte-derived chemokine and macrophage inflammatory protein 2 in lung cancer cells but did not affect proliferation. Human lung cancer samples stained positive for IL-17C, and in non-small cell lung cancer patients with lymph node metastasis, IL-17C was identified as a negative prognostic factor. Our data indicate that epithelial IL-17C promotes neutrophilic inflammation in the tumor microenvironment and suggest that IL-17C links a pathologic microbiota, as present in COPD patients, with enhanced tumor growth.

Accumulation of pharmaceuticals in groundwater under arid climate conditions - Results from unsaturated column experiments

Intense reuse of treated wastewater in agriculture is practiced all over the world, especially in arid and water-scarce regions. In doing so, pharmaceutical residues in the water are irrigated to the soil and subsequently can percolate into the local aquifers. Since evaporation rates in these areas are typically high, persistent substances might enrich in the groundwater recharge of closed catchments like the Jordan Valley. Against this background, unsaturated column tests were conducted to investigate the potential for evaporative accumulation of the two pharmaceuticals bezafibrate and carbamazepine under simulated arid climate conditions. Parallel tests were conducted with inhibited microbiological activity where both substances showed an increase in the effluent concentrations proportional to the evaporation loss of the inflow solution. The mean accumulation factors of the pharmaceuticals correspond to the evaporated water loss. The experiments indicate the accumulation potential for pharmaceuticals with high persistence against biodegradation. For the first time, the overall potential for evaporative enrichment could be demonstrated for pharmaceuticals. Under the given experimental conditions, the two investigated pharmaceuticals did not enrich faster than chloride, which might result in soil salting prior to reaching harmful pharmaceutical concentrations in soil water. The findings are relevant to future assessments of environmental impacts of persistent trace substances, which need to take into account that concentrations in the aquatic cycle might increase further due to evaporative enrichment.

Cigarette smoke-induced disruption of pulmonary barrier and bacterial translocation drive tumor-associated inflammation and growth

Microorganisms have an important role in tumorgenesis by the induction of inflammation and by a direct impact on tumor cells. Chronic obstructive pulmonary disease (COPD) is associated with an increased risk for lung cancer and microbial colonization. We asked whether bacterial pathogens act as tumor promoters during CS-induced pulmonary inflammation. In a metastatic lung cancer (LC) model, Lewis lung carcinoma (LLC) cells were injected in mice to initiate the growth of tumors in the lung. Exposure to the combination of cigarette smoke (CS) and nontypeable Haemophilus influenzae (NTHi) synergistically increased metastatic growth. Lung levels of albumin and LDH, translocation of bacterial factors into tumor tissue, tumor inflammation, and tumor proliferation were significantly increased in mice exposed to CS in combination with NTHi. Bacterial pathogens increased the proliferation of cultured LLC cells and human cancer cell lines. Metastatic growth induced by the exposure to CS in combination with NTHi was reduced in mice deficient for IL-17. Our data provide evidence that CS-induced loss of pulmonary barrier integrity allows bacterial factors to translocate into tumor tissue and to regulate tumor-associated inflammation and tumor proliferation. Translocation of bacterial factors in tumor tissue links CS-induced inflammation with tumor proliferation.

Enhancing neurosteroid synthesis--relationship to the pharmacology of translocator protein (18 kDa) (TSPO) ligands and benzodiazepines

INTRODUCTION

The treatment of anxiety disorders is still a challenge; novel pharmacological approaches that combine rapid anxiolytic efficacy with fewer side effects are needed. A promising target for such compounds is the mitochondrial translocator protein (18 kDa) (TSPO). TSPO plays an important role for the synthesis of neurosteroids, known to modulate GABAA receptors, thereby exerting anxiolytic effects.

METHODS

We investigated the pharmacological profile of 2 well established TSPO ligands (XBD173 and etifoxine) compared to the benzodiazepine diazepam with regard to TSPO binding affinity, TSPO expression and neurosteroidogenesis.

RESULTS

In BV-2 microglia and C6 glioma cells all compounds significantly enhanced TSPO protein expression. Radioligand binding assays revealed the highest binding affinity to TSPO for XBD173, followed by diazepam and etifoxine. Pregnenolone synthesis was most potently enhanced by etifoxine.

DISCUSSION

Etifoxine turned out to be the most potent enhancer of neurosteroidogenesis, although its binding affinity to TSPO was lowest. These results indicate that the efficacy of TSPO ligands to stimulate neurosteroid synthesis, thereby leading to anxiolytic effects cannot be concluded from their binding affinity to TSPO.

Microemulsions with a HIPME (high internal phase microemulsion) structure

We report a phase diagram for a novel microemulsion that consists of oil and water and of 15% of a surfactant mixture of an anionic and a nonionic surfactant. The phase diagram shows an optically isotropic channel that passes from the water-rich side to the oil-rich side. In contrast to the isotropic channel in microemulsions of nonionic surfactants, the reported system undergoes an abrupt transition of the structure in the isotropic channel with increasing oil content. The structural transition is reflected in the conductivity and the viscosity of the channel. Between the L(3) phase and the sample with 6% of oil the conductivity decreases 3 orders of magnitude. Thus, the bicontinuous structure at the origin of the channel transforms already with 6% of oil to a w/o structure. The viscosity shows a strong maximum at the transition. The w/o structures with low oil content were successful directly imaged by cryo-TEM. It can be seen that water is contained inside a polyhedral foam-like structure, where the polyhedral film is formed of the oil and the surfactant. The dimensions of the polyhedra are in the range of 20-100 nm. We call this structure "high internal phase microemulsion" (HIPME).

Consideration of emerging pollutants in groundwater-based reuse concepts

Elimination of pathogens and emerging pollutants represents a key factor in integrated water resources management in arid regions. Within the SMART Jordan Valley project it is the objective of this study to assess the occurrence and examine the elimination of selected emerging pollutants and pathogens in waste water treatment and aquifer recharge. In batch and soil column studies non-chlorinated organophosphorous compounds (tri-n-butylphosphate, triphenylphosphate) and endocrine disruptors (e.g. 17-ß-estradiol, bisphenol A) proved to be biodegradable, while the X-ray contrast agents iomeprol and iopromide were eliminated in the soil columns only, and the chlorinated trialkylphosphates showed persistency. Treating waste water in a membrane bioreactor (MBR) in combination with powdered activated carbon (PAC) resulted in considerable removal rates also for the more persistent compounds such as the antiepileptic carbamazepine. Viruses were shown to be present in most of the Jordan Valley surface water samples. MBR treatment resulted in a decrease of MS2 bacteriophages used as model viruses.

Methodological challenges in evaluating performance, impact and ranking of IWRM strategies in the Jordan Valley

The philosophy of integrated water resource management (IWRM), as formulated in several international summits, yielded numerous interpretations and extensions over the last decade but always focused on the overall objective of maximizing the welfare and livelihood of the people concerned. One of the major constraints of this concept is the gap between the well-defined philosophy and the fuzzy definition of operational and testable indicators for the achievement of its goals. This leads to difficulties in the evaluation of potential contributions from technological and managerial improvements. The experience of the multi-lateral IWRM research initiative SMART in the lower Jordan Valley shows that the evaluation and ranking of alternative IWRM strategies and their elements relies simultaneously on the identification of local goals and their interfaces with the superordinate national water sector policies. The documentation of the, still ongoing, development process of suitable assessment procedures describes their methodological embedding and conclusions drawn for the heterogeneous situation of water-related settings in this transboundary watershed.

Ocular Morbidity among Orphanages

INTRODUCTION: The study assesses the spectrum of ocular morbidity and predictors of morbidity in children living in orphanages in the Kathmandu Valley. METHODS: A descriptive, cross-sectional survey was performed at 12 orphanages over a period of three months. The survey included a questionnaire and a complete eye examination, which included measurement of refraction, ocular deviation, and a fundus exam. Prevalence of ocular morbidity was calculated. Factors associated with ocular morbidity were examined using logistic regression. RESULTS: A total of 660 children were included in the study (median age nine years [range 0.25-15]; 53% male). The prevalence of ocular morbiditywas 17.9% (118). Of those with ocular morbidity, 88.1% (104) had similar ocular problems bilaterally. The most common type of morbidity was refractive error, found in 70.3% (83) of those with ocular morbidity (12.6% overall). CONCLUSIONS: Refractive errors, which are largely correctable, are the greatest source of morbidity. In order to reduce childhood blindness, children living in orphanages are an appropriate group to target for future ocular screening in Nepal. Keywords: children, Nepal, ocular morbidity, ocular screening, orphanage

Impact of experience with a retrograde-viewing device on adenoma detection rates and withdrawal times during colonoscopy: the Third Eye Retroscope study group

BACKGROUND

Colonoscopy has been adopted as the preferred method to screen for colorectal neoplasia in the United States. However, lesions can be missed because of numerous factors, including location on the proximal aspect of folds or flexures, where they may be difficult to detect with the forward-viewing colonoscope. The Third Eye Retroscope (TER) is a disposable device that is passed through the instrument channel of a standard colonoscope to provide a retrograde view that complements the forward view of the colonoscope during withdrawal.

OBJECTIVE

To evaluate whether experience with the TER affects polyp detection rates and procedure times in experienced endoscopists who had not previously used the equipment.

DESIGN, SETTING, PATIENTS

This was an open-label, prospective, multicenter study at 9 U.S. sites, involving 298 patients presenting for colonoscopy, evaluating the use of the TER in combination with a standard colonoscope.

INTERVENTIONS

After cecal intubation, the TER was inserted through the instrument channel of the colonoscope. During withdrawal, the forward and retrograde video images were observed simultaneously on a wide-screen monitor.

MAIN OUTCOME MEASUREMENTS

Primary outcome measures were the number and size of adenomas and all polyps detected with the standard colonoscope and with the colonoscope combined with the TER. Secondary outcome measures were withdrawal phase time and total procedure time. Each endoscopist examined 20 subjects, divided into quartiles according to the order of their procedures, and results were compared among quartiles.

RESULTS

Overall, 182 polyps were detected with the colonoscope and 27 additional polyps with the TER, a 14.8% increase (P < .001). A total of 100 adenomas were detected with the colonoscope and 16 more with the TER, a 16.0% increase (P < .001). For procedures performed after each endoscopist had completed 15 procedures while using the TER, the mean additional detection rates with the TER were 17.0% for all polyps (P < .001) and 25.0% for adenomas (P < .001). For lesions 6 mm or larger, the overall additional detection rates with the TER for all polyps and for adenomas were 23.2% and 24.3%, respectively. For lesions 10 mm or larger, the overall additional detection rates with the TER for all polyps and for adenomas were 22.6% and 19.0%, respectively. The mean withdrawal times in the first and fourth quartiles were 10.6 and 9.2 minutes, respectively (P = .044).

LIMITATIONS

There was no randomization or separate control group. The endoscopists judged whether each lesion could have been detected with the colonscope alone by using their standard technique.

CONCLUSIONS

Polyp detection rates improved significantly with the TER, especially after 15 procedures, when the mean additional detection rate for adenomas was 25.0%. Additional detection rates with the TER for medium-size and large adenomas were greater than for smaller lesions. These results suggest that, compared with a colonoscope alone, a retrograde-viewing device can increase detection rates for clinically significant adenomas without detriment to procedure time or procedure complications. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00969124.).

Ocular morbidity among orphanages

INTRODUCTION

The study assesses the spectrum of ocular morbidity and predictors of morbidity in children living in orphanages in the Kathmandu Valley.

METHODS

A descriptive, cross-sectional survey was performed at 12 orphanages over a period of three months. The survey included a questionnaire and a complete eye examination, which included measurement of refraction, ocular deviation, and a fundus exam. Prevalence of ocular morbidity was calculated. Factors associated with ocular morbidity were examined using logistic regression.

RESULTS

A total of 660 children were included in the study (median age nine years [range 0.25-15]; 53% male). The prevalence of ocular morbidity was 17.9% (118). Of those with ocular morbidity, 88.1% (104) had similar ocular problems bilaterally. The most common type of morbidity was refractive error, found in 70.3% (83) of those with ocular morbidity (12.6% overall).

CONCLUSIONS

Refractive errors, which are largely correctable, are the greatest source of morbidity. In order to reduce childhood blindness, children living in orphanages are an appropriate group to target for future ocular screening in Nepal.

Utility of alkylaminoquinolinyl methanols as new antimalarial drugs

Mefloquine has been one of the more valuable antimalarial drugs but has never reached its full clinical potential due to concerns about its neurologic side effects, its greater expense than that of other antimalarials, and the emergence of resistance. The commercial development of mefloquine superseded that of another quinolinyl methanol, WR030090, which was used as an experimental antimalarial drug by the U.S. Army in the 1970s. We evaluated a series of related 2-phenyl-substituted alkylaminoquinolinyl methanols (AAQMs) for their potential as mefloquine replacement drugs based on a series of appropriate in vitro and in vivo efficacy and toxicology screens and the theoretical cost of goods. Generally, the AAQMs were less neurotoxic and exhibited greater antimalarial potency, and they are potentially cheaper than mefloquine, but they showed poorer metabolic stability and pharmacokinetics and the potential for phototoxicity. These differences in physiochemical and biological properties are attributable to the "opening" of the piperidine ring of the 4-position side chain. Modification of the most promising compound, WR069878, by substitution of an appropriate N functionality at the 4 position, optimization of quinoline ring substituents at the 6 and 7 positions, and deconjugation of quinoline and phenyl ring systems is anticipated to yield a valuable new antimalarial drug.

Integrating groundwater into urban water management

The management of urban groundwater resources is directly linked to urban water supply and drainage concepts. A proper integration of groundwater into urban water management plans is recommended for long-term planning. The paper describes the development of a new modelling suite which addresses the urban water and solute balance in a holistic way. Special focus has been placed on the assessment of the impact of sewer leakage on groundwater in four case study cities. Tools for the prediction of sewer leakage including the assessment of uncertainties are now available. Field investigations in four European case study cities were able to trace the influence of sewer leakage on urban groundwater using microbiological indicators and pharmaceutical residues.

Sustainable management of leakage from wastewater pipelines

Wastewater pipeline leakage is an emerging concern in Europe, especially with regards to the potential effect of leaking effluent on groundwater contamination and the effects infiltration has on the management of sewer reticulation systems. This paper describes efforts by Australia, in association with several European partners, towards the development of decision support tools to prioritize proactive rehabilitation of wastewater pipe networks to account for leakage. In the fundamental models for the decision support system, leakage is viewed as a function of pipeline system deterioration. The models rely on soil type identification across the service area to determine the aggressiveness of the pipe environment and for division of the area into zones based on pipe properties and operational conditions. By understanding the interaction between pipe materials, operating conditions, and the pipe environment in the mechanisms leading to pipe deterioration, the models allow the prediction of leakage rates in different zones across a network. The decision support system utilizes these models to predict the condition of pipes in individual zones, and to optimize the utilization of rehabilitation resources by targeting the areas with the highest leakage rates.

Effect of different water management strategies on water and contaminant fluxes in Doncaster, United Kingdom

In Europe, large volumes of public water supply come from urban aquifers and so efficient urban water management and decision tools are essential to maintain quality of life both in terms of health, personal freedom and environment. In the United Kingdom, this issue gained increased importance with the last year's low volumes of groundwater replenishment that resulted in increased water shortages all over the country. An urban water volume and quality model (UVQ) was applied to a suburb of Doncaster (United Kingdom) to assess the current water supply system and to compare it with new potential scenarios of water management. The initial results show considerable changes in both water and solute fluxes for some scenarios and rather limited changes for others. Changing impermeable roads and paved areas to permeable areas, for example, would lead to higher infiltration rates that may be welcome from a water resources viewpoint but less so from a water quality point of view due to high concentrations of heavy metals. The biggest impact on water quality and quantity leaving the system through sewer, storm water and infiltration system was clearly obtained by re-using grey water from kitchen, bathroom and laundry for irrigation and toilet flush. The testing of this strategy led to lower volumes and higher concentrations of sewerage, a considerable decrease in water consumption and an increase in groundwater recharge. The scenarios were tested neither in terms of costs nor social acceptance for either water supplier or user.

Use of mechanical patient lifts decreased musculoskeletal symptoms and injuries among health care workers

OBJECTIVE

To evaluate the effectiveness of mechanical patient lifts in reducing musculoskeletal symptoms, injuries, lost workday injuries, and workers' compensation costs in workers at a community hospital.

DESIGN

Pre-post intervention study.

SETTING

Three nursing units of a small community hospital. Patients or

SUBJECTS

Nursing personnel.

INTERVENTIONS

Mechanical patient lifts were made available and nursing staff trained in their use between August 2000 and January 2001.

MAIN OUTCOME MEASURES

Workers completed symptom surveys at baseline and six months after lift training. Pre-intervention and post-intervention rates of injuries and lost workday injuries using Occupational Safety and Health Administration logs of the three study units, from the period July 1999 through March 2003 were analyzed. Injuries potentially related to lifting patients were included in the analyses. Using workers' compensation data from the same time period, the compensation paid ($ per full time equivalent [FTE]) due to injuries during the pre-intervention and post-intervention period was calculated.

RESULTS

Sixty one staff members were surveyed pre-intervention; 36 (59%) completed follow up surveys. Statistically significant improvements in musculoskeletal comfort (p<0.05) were reported for all body parts, including shoulders, lower back, and knees. Injury rates decreased post-intervention, with a relative risk (RR) of 0.37 (95% confidence interval (CI) 0.16 to 0.88); decreased injury rates persisted after adjustment for temporal trends in injury rates on non-intervention units of the study hospital (RR = 0.50, 95% CI 0.20 to 1.26). Adjusted lost day injury rates also decreased (RR = 0.35, 95% CI 0.10 to 1.16). Annual workers' compensation costs averaged $484 per FTE pre-intervention and $151 per FTE post-intervention.

CONCLUSION

Reductions were observed in injury rates, lost workday injury rates, workers' compensation costs, and musculoskeletal symptoms after deployment of mechanical patient lifts. Strengths of this study include the community hospital setting and the inclusion of a variety of different outcomes. Limitations include the pre-post study design and the small sample size.

An evaluation of a "best practices" musculoskeletal injury prevention program in nursing homes

OBJECTIVE

To conduct an intervention trial of a "best practices" musculoskeletal injury prevention program designed to safely lift physically dependent nursing home residents.

DESIGN

A pre-post intervention trial and cost benefit analysis at six nursing homes from January 1995 through December 2000. The intervention was established in January 1998 and injury rates, injury related costs and benefits, and severity are compared for 36 months pre-intervention and 36 months post-intervention.

PARTICIPANTS

A dynamic cohort of all nursing staff (n = 1728) in six nursing homes during a six year study period.

INTERVENTION

"Best practices" musculoskeletal injury prevention program consisting of mechanical lifts and repositioning aids, a zero lift policy, and employee training on lift usage.

MAIN OUTCOME MEASURES

Injury incidence rates, workers' compensation costs, lost work day injury rates, restricted work day rates, and resident assaults on caregivers, annually from January 1995 through December 2000.

RESULTS

There was a significant reduction in resident handling injury incidence, workers' compensation costs, and lost workday injuries after the intervention. Adjusted rate ratios were 0.39 (95% confidence interval (CI) 0.29 to 0.55) for workers' compensation claims, 0.54 (95% CI 0.40 to 0.73) for Occupational Safety and Health Administration (OSHA) 200 logs, and 0.65 (95% CI 0.50 to 0.86) for first reports of employee injury. The initial investment of $158 556 for lifting equipment and worker training was recovered in less than three years based on post-intervention savings of $55 000 annually in workers' compensation costs. The rate of post-intervention assaults on caregivers during resident transfers was down 72%, 50%, and 30% based on workers' compensation, OSHA, and first reports of injury data, respectively.

CONCLUSIONS

The "best practices" prevention program significantly reduced injuries for full time and part time nurses in all age groups, all lengths of experience in all study sites.