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.

The impact of CFTR modulator triple therapy on type 2 inflammatory response in patients with cystic fibrosis

BACKGROUND

Treatment of cystic fibrosis (CF) has been revolutionized by the use of cystic fibrosis transmembrane conductance regulator (CFTR) protein modulators such as elexacaftor/tezacaftor/ivacaftor (ETI) triple therapy. Prior studies support a role for type 2 (T2) inflammation in many people with CF (PwCF) and CF-asthma overlap syndrome (CFAOS) is considered a separate clinical entity. It is unknown whether initiation of ETI therapy impacts T2 inflammation in PwCF. We hypothesized that ETI initiation decreases T2 inflammation in PwCF.

METHODS

A single center retrospective chart review was conducted for adult PwCF. As markers of T2 inflammation, absolute eosinophil count (AEC) and total immunoglobulin E (IgE) data were collected longitudinally 12 months prior to ETI therapy initiation and 12 months following therapy initiation. Multivariable analyses adjusted for the age, gender, CFTR mutation, disease severity, inhaled steroid use, and microbiological colonization.

RESULTS

There was a statistically significant reduction (20.10%, p < 0.001) in 12-month mean total IgE following ETI initiation; this change remained statistically significant in the multivariate model. The longitudinal analysis demonstrated no change in AEC following therapy initiation.

CONCLUSION

This study demonstrates that there is a statistically significant percent reduction in mean total IgE but no change in AEC following ETI initiation. ETI may lead to decreased antigen and superantigen load in the airway as a result of improved mucociliary clearance and these changes may drive the decline in total IgE, without influencing the epigenetic drivers of eosinophilic inflammation. Further studies are warranted to determine the underlying mechanism of ETI impact on T2 inflammation and possible role for asthma immunomodulator therapy post ETI initiation in CFAOS.

A randomized controlled trial of an oral probiotic to reduce antepartum group B Streptococcus colonization and gastrointestinal symptoms

BACKGROUND

Probiotics have been suggested as a strategy to reduce antenatal group B Streptococcus colonization. Although probiotics are known to improve gastrointestinal symptoms, this has not been studied during pregnancy.

OBJECTIVE

This study aimed to evaluate the efficacy of a probiotic to reduce: (1) standard-of-care antenatal group B Streptococcus colonization and colony counts and (2) gastrointestinal symptoms of pregnancy.

STUDY DESIGN

In a double-blind fashion, 109 healthy adult pregnant people were randomized to Florajen3 probiotic or placebo capsules once daily from 28 weeks' gestation until labor onset. Baseline vaginal and rectal study swabs for group B Streptococcus colony-forming units and microbiome analysis were collected at 28 and 36 weeks' gestation. Standard-of-care vaginal to rectal group B Streptococcus swabs were collected from all participants at 36 weeks' gestation and determined the need for intrapartum antibiotic prophylaxis. Data collection included solicitation of adverse events, demographic information, Antepartum Gastrointestinal Symptom Assessment score, yogurt ingestion, sexual activity, and vaginal cleaning practices.

RESULTS

A total of 83 participants completed the study to 36 weeks' gestation with no adverse events. Standard-of-care group B Streptococcus colonization was 20.4% in the control group and 15.4% in probiotic group participants (-5%; P=.73). The relative risk for positive standard-of-care vaginal-rectal group B Streptococcus colonization was 1.33 (95% confidence interval, 0.5-3.40) times higher in the control group than in the probiotic group (P=.55). There were no differences in median vaginal (P=.16) or rectal (P=.20) group B streptococcus colony-forming units at baseline or at 36 weeks (vaginal P>.999; rectal P=.56). Antepartum Gastrointestinal Symptom Assessment scores were similar at baseline (P=.19), but significantly decreased in probiotic group participants at 36 weeks (P=.02). No covariates significantly altered group B Streptococcus colonization. Significantly more Florajen3 bacteria components were recovered from the vaginal-rectal samples of probiotic group participants (32%; P=.04) compared with controls.

CONCLUSION

The findings of this study provided insufficient evidence for the clinical application of the Florajen3 probiotic intervention to reduce standard-of-care vaginal-rectal group B Streptococcus colonization. The prevalence of group B Streptococcus was lower than expected in the study population, and intervention adherence was poor. Probiotic bacteria colonization of the genitourinary tract occurred more in intervention group participants than in controls and significantly reduced gastrointestinal symptoms of pregnancy.

Unseen, unheard: a qualitative analysis of women's experiences of exclusively expressing breast milk

BACKGROUND

Breast milk feeding has numerous benefits for women and infants. Positive maternal experiences with breast milk feeding impacts exclusivity, duration, and maternal mental health. Most research focuses on women feeding directly at the breast. Some women elect to feed exclusively expressed milk to their healthy, term infants rather than feed directly at the breast. Little is known about what constitutes a positive experience among this population. Therefore, the aim of this study was to explore women's experiences of exclusive expression (EE).

METHODS

Interviews were conducted via Microsoft Teams to collect qualitative data from a purposive sample of 21 women practicing EE. Interviews were analyzed for themes.

RESULTS

Three themes: Unseen and Unheard, Doing it My Way, and Getting into the Groove, and 8 subthemes: Breast is Best, Missed Opportunities for Healthcare Provider Support, Fighting for it, What Works for Us, A Sense of Control, Preparation, Tricks of the Trade, and Making it Manageable were identified. Despite challenges, including a lack of support from healthcare providers and a lack of acknowledgement as breastfeeding mothers, exclusive expression offered participants a method to continue breast milk feeding in a way that they found to be satisfying.

CONCLUSION

This study provides insight into experiences of exclusive expression that clinicians can use to improve their support of breast milk feeding during perinatal encounters. Societal pressure to feed from the breast may have negative emotional consequences for women electing to exclusively express. There is a need for more information and support for breast milk expression from healthcare providers along with a reframing of how breast milk feeding is discussed and promoted.

Probiotic interventions to reduce antepartum Group B streptococcus colonization: A systematic review and meta-analysis

OBJECTIVE

To systematically review and meta-analyse studies of the efficacy of probiotics to reduce antenatal Group B Streptococcus (GBS) colonisation.

PARTICIPANTS

Antenatal participants with known positive GBS colonisation or unknown GBS status.

INTERVENTION

Probiotic interventions containing species of Lactobacillus or Streptococcus.

DESIGN

Systematic review and meta-analysis.

MEASUREMENTS AND FINDINGS

The systematic review included 10 studies. Five articles contained in vitro studies of probiotic interventions to determine antagonistic activity against GBS. Six clinical trials of probiotics to reduce antenatal GBS were systematically reviewed and meta-analysed. The meta-analysis revealed that the use of an antenatal probiotic increased the probability of a negative GBS result by 79% (OR = 0.56, 95% CI = 8.7%, 194.1%, p = 0.02) (n = 709). However, only one clinical trial of 6 had a low risk of bias.

KEY CONCLUSIONS

The probiotic interventions subjected to in vitro testing showed antagonistic activity against GBS through the mechanisms of acidification, immune modulation, and adhesion. The findings of the meta-analysis of the clinical trials revealed that probiotics are a moderately effective intervention to reduce antenatal GBS colonisation. More well-controlled trials with diverse participants and with better elucidation of variables influencing GBS colonisation rates are needed.

IMPLICATIONS FOR PRACTICE

Probiotic interventions appear to be a safe and effective primary prevention strategy for antenatal GBS colonisation. Application of this low-risk intervention needs more study but may reduce the need for intrapartum antibiotic prophylaxis in countries or regions where antenatal GBS screening is used. Midwives can be instrumental in conducting and supporting larger well-controlled clinical trials.

Probiotics for the Management of Infantile Colic: A Systematic Review

BACKGROUND

Colic is defined as periods of inconsolable crying, fussing, or irritability that have no apparent cause and present in healthy infants under 5 months of age. Although colic is a benign and self-limiting condition, it can be distressing to parents and there are few robust treatment interventions. This systematic review explored the evidence for administration of probiotics to prevent or decrease symptoms of colic.

METHODS

Literature searches were conducted in PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Library, and Web of Science.

SAMPLE

Twenty articles were included: 15 randomized controlled trials and 5 meta-analyses.

RESULTS

Based on the evidence in this systematic review, the oral administration of probiotics to breastfed infants with colic resulted in at least a 50% reduction in crying time compared with placebo. Efficacy of probiotics to reduce colic symptoms in formula-fed infants needs further study. In this review, we did not find evidence to support or refute efficacy of probiotics to prevent infantile colic. Clinical Implication: Probiotics (especially the strain Lactobacillus reuteri DSM 17938) can safely be recommended if parents desire a treatment option for their infants with colic.

Archetypal meanings of being a paramedic: A hermeneutic review

BACKGROUND

Interpretations of being a paramedic are normally unspoken in the literature and easily overlooked in the busyness of everyday work. The premise of this study was to explicate historical and cultural archetypes of the paramedic from within relevant literature.

METHODS

A hermeneutic review was conducted to explore meanings associated with being a paramedic. This was a novel approach to exploring meanings of being and provided a rich depiction of the cultural and historical nuances inherent in paramedic work.

RESULTS

Six paramedic archetypes were identified and related broadly to the principles of service, care and stoicism. These archetypes provided glimpses of how the paramedic is theorised both within and external to the profession, as well as gaps related to how the phenomenon of being a paramedic is experienced amid everyday practice situations.

CONCLUSION

Historical archetypes of the paramedic need to be recognised by paramedics as important in shaping the inherited cultural meanings of the work they do. However, due to the limited ability of fixed archetypes to capture the dynamic meanings of being a paramedic further research is required to understand how paramedics experience their caring work as meaningful across diverse contexts.

SAT0409 BIOLOGIC TREATMENT IN PSORIATIC ARTHRITIS AND AXIAL SPONDYLOPATHY REDUCES SICKNOTES ISSUED BY GPS, DESPITE DELAYS IN DIAGNOSIS: A REAL-LIFE STUDY IN WALES

Background:

Seronegative inflammatory arthritis including psoriatic arthritis (PsA) and axial spondyloarthropathies (AxS) are chronic inflammatory diseases associated with significant morbidities. The National Institute of Health and Clinical Excellence (NICE) has produced several pieces of guidance on disease management including the use of biologic therapies which have been shown to improve patient outcomes and quality of life. However, there are limited real-life data on patient journey from symptom onset to diagnosis and treatment including with biologics in the UK.

Objectives:

The purpose of this study is to examine the real-life patient journey from symptom onset to diagnosis and treatment.

Methods:

Data from the Secure Anonymised Information Linkage (SAIL) databank in Wales, which holds over a billion anonymised records, were used to assess the treatment of patients with PsA or AxS, aged 18 years or over with at least one READ code present for PsA or AxS in their primary care records. We examined the drug use of patients across primary, secondary care and specialist rheumatology clinics to explore the use of NSAIDs, DMARDs and biologics in the real-life setting while exploring demographics, comorbidities and surgical procedures of 1829 PsA and 908 AxS patients.

Results:

The AxS patients were significantly younger at diagnosis and were predominantly male. Typical delays in diagnosis of 8-9 years from symptom onset were observed. The rate of stopping or switching a biologic medication was similar for AxS and PsA patients (Table 1). There was a significant reduction in sicknotes issued following biologic initiation for PsA (Difference: 14.6%, 95% CI: 8.7% to 20.4%) and AxS (Difference 16.9%, 95% CI: 10.5% to 23.3%)

Table 1.

Characteristics of treatment of PsA and AxS patients

PsA (n=1829)AxS (n=908)Difference (95% CI)Female (%, n)55.1% (1007)29.1% (264)26 (22.2 to 29.6)*Mean age at diagnosis (years, SD)46.9 (14)43.5 (14.4)3.4 (2.3 to 4.5)*BMI (Index, SD)30.3 (6.3)28 (5.8)2.3 (1.8 to 2.8)*Time from symptom to diagnosis (years, SD)8.9 (5.5)8.0 (5.6)0.9 (0.5 to 1.3)Hypertension at diagnosis (%, n)24.2% (442/1829)19.4% (176/908)4.8 (1.5 to 8.0)*Time from diagnosis to biologic (years, SD)6.3 (4.7)6.1 (5.0)0.2 (-0.9 to 0.5)Used a Biologic (%, n)23% (420/1829)36.8% (334/908)13.8 (10.2 to 17.5)*NSAIDs used pre-biologic (SD)11.3 (3.2)11.6 (3.2)0.3 (-0.2 to 0.8)Number of DMARDs used pre-biologic (SD)3.1 (1.5)2.5 (1.7)0.6 (0.4 to 0.8)*Biologic treatment change/failure (%, n)21.6% (92/425)22% (74/336)0.4 (-6.4 to 5.5)Sicknotes issued by GPᵻpre-biologic (SD)33.9% (144/425)33.6% (113/336)0.3 (-6.5 to 7.0)Sicknotes issued by GPᵻpost-biologic (SD)(%, n)19.3% (82/425)16.7% (56/336)2.6 (-2.9 to 8.0)Hospitalised for serious infection pre- diagnosis (%, n)7.2% (131/1829)6.3% (57/908)0.9 (-1.2 to 2.8)Hospitalised for serious infection post- diagnosis (%, n)10.4% (190/1829)11.6% (105/908)1.2 (-1.3 to 3.8)Hospitalised for serious infection post- biologic (%, n)5.6% (24/425)6.3% (21/336)0.7 (-2.8 to 4.2)

* Significant at p<0.05

ᵻ General practioner/Primary care physician

Conclusion:

Patients with PsA and AxS were treated with NSAIDs and DMARDs prior to receiving biologic medication in accordance with NICE guidelines. However, there was a long delay from symptom onset to diagnosis. Biologic treatment reduced sicknotes issued by GPs confirming the benefit of biologic treatment on work productivity observed in clinical trials.

Acknowledgments:

The work is funded by a Investigator-led grant from Novartis Pharmaceuticals UK Limited

Disclosure of Interests:

Ernest Choy Grant/research support from: Amgen, Bio-Cancer, Chugai Pharma, Ferring Pharmaceuticals, Novimmune, Pfizer, Roche, UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Chelsea Therapeutics, Chugai Pharma, Daiichi Sankyo, Eli Lilly, Ferring Pharmaceuticals, GlaxoSmithKline, Hospita, Ionis, Janssen, Jazz Pharmaceuticals, MedImmune, Merck Sharp & Dohme, Merrimack Pharmaceutical, Napp, Novartis, Novimmune, ObsEva, Pfizer, R-Pharm, Regeneron Pharmaceuticals, Inc., Roche, SynAct Pharma, Sanofi Genzyme, Tonix, UCB, Speakers bureau: Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Chugai Pharma, Eli Lilly, Hospira, Merck Sharp & Dohme, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Sanofi-Aventis, UCB, Sinead Brophy: None declared, Roxanne Cooksey: None declared, Lindsey Hanson Employee of: Lindsey Hanson is a permanent employee of Novartis Pharmaceuticals UK Limited, Anna Halliday Shareholder of: Anna Halliday owns Novartis share, Employee of: Anna Halliday is a permanent employee of Novartis Pharmaceuticals UK Ltd.

Validity and Reliability of the Antepartum Gastrointestinal Symptom Assessment Instrument

OBJECTIVE

To examine the psychometric properties of the nine-item Antepartum Gastrointestinal Symptom Assessment (AP-GI-SA) instrument.

DESIGN

Single-group prospective design.

SETTING

Urban prenatal clinic serving a diverse population.

PARTICIPANTS

Convenience sample of 45 pregnant women.

METHODS

Participants completed the AP-GI-SA before a scheduled prenatal care appointment. We used Bayesian structural equation modeling to evaluate the construct validity of the scale and assessed known-groups validity. We assessed reliability through maximal reliability coefficient estimate and measured internal consistency with Cronbach's alpha coefficient.

RESULTS

Participants completed the instrument in 2 minutes or less. Construct validity was supported by confirmatory factor analysis (posterior predictive p value = 0.49, gamma-hat = 0.970, and root mean square error of approximation = 0.065), which indicated that the single-factor model is a plausible data-generative model for GI symptoms. The maximal reliability coefficient of 0.75 and Cronbach's alpha coefficient of 0.67 supported reliability. Average AP-GI-SA scores were the highest for women in the third trimester. Of all nine GI symptoms, heartburn in the third trimester received the highest score.

CONCLUSION

Our findings provide preliminary support for the validity and reliability of the AP-GI-SA. The instrument may be used as a measure in intervention studies where GI symptoms of pregnancy are an outcome. The AP-GI-SA could also be useful in clinical settings to quickly evaluate GI symptoms.

Racism, Bias, and Discrimination as Modifiable Barriers to Breastfeeding for African American Women: A Scoping Review of the Literature

INTRODUCTION

Although breastfeeding has been shown to improve health outcomes for infants, African American women initiate and continue breastfeeding at lower rates than women from other racial groups. This scoping review was conducted to assess the effect racism, bias, and discrimination have on breastfeeding care, support, and outcomes for African American women.

METHODS

A scoping review was performed of the literature published between January 2010 through December 2019 using databases MEDLINE via PubMed, CINAHL, Cochrane Library, PsycINFO, and Sociological Abstracts. Studies that examined racism, bias, or discrimination with breastfeeding as an outcome were included. After a review of titles and abstracts of the articles using exclusion and inclusion criteria, 5 full-text articles were included in the scoping review.

RESULTS

The qualitative and quantitative studies reviewed provide the perspectives of pregnant and postpartum African American women as well as those of health care providers. African American women's experiences of racism adversely affected both breastfeeding initiation and duration. Health care providers' biased assumption that African American women would not breastfeed affected the quality of breastfeeding support provided to them. Specifically, African American women received fewer referrals for lactation support and more limited assistance when problems developed. This scoping review provides evidence that African American women experience racism, bias, and discrimination affecting breastfeeding care, support, and outcomes.

DISCUSSION

Racism, bias, and discrimination are modifiable barriers that adversely affect breastfeeding among African American women. Researchers and health care providers are encouraged to consider the effect of racism, bias, and discrimination on breastfeeding care, support, and outcomes.

PSVI-3 Estimation of the optimal standardized ileal digestible valine to lysine ratio required for growing-finishing pigs in low crude protein diets

Aim was to determine standardized ileal digestible Val to Lys ratios for growing - finishing pigs fed low CP diets on performance, BUN and carcass characteristics. SID Val to Lys ratios for BW 42.5 to 70.3 kg, 70.3 to 98.1 kg and 98.1 to 128.7 kg pigs. Pigs (n = 400, 10 pens / treatment, 8 pigs / pen) blocked by BW and randomly assigned to 1 of 5 treatments. Diets were SID Val to Lys of 0.55, 0.60, 0.65, 0.70 and 0.75. Data analyzed as a RCBD with PROC MIXED procedure of SAS with pen (experimental unit), treatment (fixed effect), and BW block (random effect). In phase 1, linear and quadratic increase of ADG (Linear, P = 0.03; Quadratic, P = 0.04), BUN decreased (Linear, P = 0.01; Quadratic, P = 0.04). SID Val:Lys for ADG, linear broken-line and quadratic model were 0.64 and 0.66, respectively. BUN for SID Val:Lys were 0.63 (P = 0.01) and 0.70 (P = 0.04). In phase 2, ADG increased (Linear, P = 0.04; Quadratic, P = 0.01) and G:F increased (Linear, P = 0.02; Quadratic, P = 0.04). a linear (P = 0.04) and quadratic (P = 0.01) increase in ADG. SID Val:Lys ADG were 0.66 and 0.70. with the increase of SID Val:Lys ratios. SID Val:Lys for G:F were 0.70 and 0.75, respectively. In phase 3, the SID Val:Lys to maximize ADG were 0.67 (Linear, P = 0.04) and 0.72 (Quadratic, P < 0.01). as the SID Val:Lys increased. Supplementation of low CP diets with high levels of SID Val:Lys increase decreased (Linear, P = 0.02) fat depth, at 0.65. but no effect on other carcass characteristics. In conclusion, SID Val:Lys requirement for ADG in three phases were 0.64, 0.66, 0.67, and 0.66, 0.70, 0.72, using a linear broken-line and quadratic model respectively. BUN and fat thickness appears to be minimized at Val:Lys ratio of 0.65 and a potential to increase lean percentage.

PSV-24 Effects of non-animal protein in nursery diets on wean to finish pig performance and carcass characteristics

The aim of this study was to investigate the effects of a non-animal protein source in nursery diets on performance and carcass characteristics of wean to finish pigs. A total of 432 piglets with initial BW 6.31 ± 0.13 kg were blocked by BW and randomly assigned to 1 of 6 treatments. Treatments included PC1AP1: animal protein, nursery nutrient specifications without additives; PC2AP2: animal protein, growernutrientspecification without additives; NC1NP1: Non-animal protein, nursery specification without additives; NC2NP2: Non-animal protein, grower specification without additives; NC1 NP1 + FA[(Feed Additives)]: NC1 NP1 with additives; NC2 NP2 + FA: NC2 NP2 with additives. Feed Additives [Enzymes (Xylanase, β-Glucanase, Invertaseused), Oregano Essential Oil] were used in Treatments NP1 +FA and NP2 +FA. A linear model was used via the GLM procedure of SAS 9.4, with treatment as fixed effect and block as random effect. Pigs fed on the non-animal protein source and supplemented with feed additives had similar ADF, ADG, and G:F at finishing compared with treatment group on animal protein source (P > 0.05). No treatment differences (P > 0.05) for digesta, liver and serum based on a principal component AA analysis. (P>o.o5)[H2] No positive carry-over effects (P > 0.05) were found for performance except that pigs fed onthe animal protein source had greaterhad greater hot carcass weight (P < 0.05) than the non-animal protein group. In conclusion, wean pigs fed either animal or non-animal protein source at nursery had similar performance at finishing stage and similar carcass characteristics even though pigs on animal protein source had greater hot carcass weight relative to those on plant protein. [H1]Define FA [H2]Do not mention digesta, liver, or serum. Rather state the variables you analyzed in those samples.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Supporting youth wellbeing with a focus on eating well and being active: views from an Aboriginal community deliberative forum

OBJECTIVE

Including and prioritising community voice in policy development means policy is more likely to reflect community values and priorities. This project trialled and evaluated a storyboard approach in a deliberative community forum to engage Australian Aboriginal people in health policy priority setting.

METHODS

The forum was co-constructed with two Aboriginal community-controlled organisations. A circle storyboard was used to centre Aboriginal community knowledge and values and encourage the group to engage with broader perspectives and evidence. The forum asked a diverse (descriptively representative) group of Aboriginal people in a rural town what governments should do to support the wellbeing of children and youth, particularly to encourage them to eat well and be active.

RESULTS

The storyboard provided a tactile device to allow shared stories and identification of community issues. The group identified policies they believed governments should prioritise, including strategies to combat racism and provide local supports and outlets for young people.

CONCLUSIONS

An informed deliberative storyboard approach offers a novel way of engaging with Aboriginal communities in a culturally appropriate and inclusive manner. Implications for public health: The identification of racism as a major issue of concern in preventing children from living healthy lifestyles highlights the need for policy responses in this area.

How do low back pain patients conceptualize their expectations regarding treatment? Content analysis of interviews

PURPOSE

The purpose of this study was to gain insight into how low back pain (LBP) patients conceptualize the construct of expectations regarding treatment.

METHODS

This study was nested within a mixed-method randomized clinical trial comparing three primary care interventions for LBP. A total of 77 participants with LBP lasting longer than 6 weeks were included; semi-structured interviews were conducted querying patients about their expectations for treatment. Also factors influencing their expectations were explored. Interviews were administered following enrollment into the study, but prior to study treatment. Two researchers independently conducted a content analysis using NVIVO 9 software.

RESULTS

LBP patients' expectations could be categorized in two main domains: outcome and process expectations, each with subdomains. Patients expressed expectations in all subdomains both as values (what they hoped) and probabilities (what they thought was likely). In multiple subdomains, there were differences in the nature (positive vs. negative) and frequency of value and probability expectations. Participants reported that multiple factors influenced their expectations of which past experience with treatment appeared to be of major influence on probability expectations.

CONCLUSION AND RECOMMENDATIONS

This study showed that LBP patients' expectations for treatment are multifaceted. Current measurement instruments do not cover all domains and subdomains of expectations. Therefore, we recommend the development of new or improved measures that make a distinction between value and probability expectations and assess process and/or outcome expectations covering multiple subdomains. Some of the influencing factors found in this study may be useful targets for altering patients' treatment expectations and improving health outcomes.

Perforin expression is required for fatal blood-brain barrier disruption in the Plasmodium berghei ANKA model of cerebral malaria (P3061)

The most severe clinical complication of Plasmodium falciparum infection is cerebral malaria (CM). Plasmodium berghei ANKA (PbA) infection of C57BL/6 mice is an established model of CM. Previous work has implied a role for CD8 T cells and perforin expression in fatal stages of PbA infection. We therefore infected C57BL/6 and C57BL/6 Perforin-/- mice with PbA and assessed the CNS for cerebral endothelial cell blood-brain barrier (BBB) disruption using FITC albumin leakage into tissue, confocal microscopy and 3D volumetric T2 and T1 gadolinium enhanced MRI. PbA infected C57BL/6 mice: 1.) had extensive disruption of BBB tight junction proteins Occludin and Claudin 5, 2.) developed severe CNS vascular permeability of FITC albumin and gadolinium leakage, and 3.) became moribund. We also observed increased VEGF cytokine expression coinciding with CNS vascular permeability in these animals. Despite having similar CD8 T cell infiltration into the brain, PbA infected C57BL/6 Perforin-/- mice had intact BBB tight junction, were devoid of CNS vascular permeability, presented with normal brain MRI, and had normal behavioral scores on the rotarod assay. This study is therefore the first to demonstrate the critical importance of perforin expression in promoting BBB tight junction alteration during PbA infection. Therefore, development of therapies to block factors related perforin mediated delivery could have significant benefit to the treatment of CM.

Advantage of rapamycin over mycophenolate mofetil when used with tacrolimus for simultaneous pancreas kidney transplants: randomized, single-center trial at 10 years

Simultaneous pancreas kidney transplantation (SPKT) is the treatment of choice for patients with type 1 diabetes and end-stage renal disease. Rapamycin and mycophenolate mofetil (MMF) have been used for maintenance immunosuppression with tacrolimus in SPKT; however, long-term outcomes are lacking. From September 2000 through December 2009, 170 SPKT recipients were enrolled in a randomized, prospective trial receiving Rapamycin (n = 84) or MMF (n = 86). All patients received dual induction therapy with thymoglobulin and daclizumab, and low-dose maintenance tacrolimus and corticosteroids. Compared to MMF, rates of freedom from first biopsy-proven acute kidney or pancreas rejection were superior for Rapamycin at year 1 (kidney: 100% vs. 88%; P = 0.001; pancreas: 99% vs. 92%; P = 0.04) and at year 10 (kidney: 88% vs. 71%, P = 0.01; pancreas: 99% vs. 89%, P = 0.01). The higher rates of rejection were associated with withholding MMF (vs. Rapamycin, p = 0.009), generally for gastrointestinal or bone marrow toxicity. There was no significant difference in creatinine, proteinuria, c-peptide, viral infections, lymphoproliferative disorders or posttransplant diabetes. HbA1C and lipid levels were normal in both groups, although higher in the Rapamycin arm. There were no significant differences in patient or allograft survival. In this 10-year SPKT study, Rapamycin in combination with tacrolimus was better tolerated and more effective than MMF. Overall, the patient and allograft survival were equivalent.

Directive versus supportive approaches used by midwives when providing care during the second stage of labor

INTRODUCTION

Although the risks associated with using sustained and forceful maternal bearing-down efforts during the second stage of labor have been well documented, most women who give birth in the United States bear down in response to direction from care providers about when and how to push rather than in response to their own physiologic urges. The purpose of this study was to describe the practices used by certified nurse-midwives/certified midwives (CNMs/CMs) in response to maternal bearing-down efforts when caring for women in second-stage labor and to identify factors associated with the use of supportive approaches to second-stage labor care.

METHODS

A national survey of 705 CNMs/CMs was conducted using mailed questionnaires. The instrument was an 84-item, fixed-choice questionnaire using Likert type scales that had been validated. A 72.6% response rate was achieved, and 375 of the respondents cared for women during the second stage of labor.

RESULTS

Most CNMs/CMs (82.4%) often or almost always supported women without epidural anesthesia to initiate bearing-down efforts only when the woman felt an urge to do so. When caring for women without an epidural, most of the respondents (67%) reported that they often or almost always supported a woman's spontaneous bearing-down efforts without providing direction. Most participants reported using more directive practices when caring for women with epidural anesthesia. Whether caring for women with or without an epidural, most respondents (77.1% and 79.6%, respectively) often or almost always provided more direction as the fetal head emerged and the final stretching of the perineum was taking place. A change in fetal heart tones that led the midwife to believe the birth needed to occur quickly was the circumstance that had the greatest degree of influence on the participant's (90.6%) decision to provide more direction during bearing-down efforts. Many participants indicated that they also were influenced to provide more direction when women in labor asked for more direction (73.3%) or appeared to be fatigued (74.6%).

DISCUSSION

The majority of CNMs/CMs use supportive approaches to bearing-down efforts during second-stage labor care and most used directive approaches as an intervention aimed at avoiding potential problems.

In vivo three dimensional MRI of GL261 syngeneic gliomas concurrently with analysis of CNS infiltrating tumor-specific killer T cell responses (127.15)

Glioblastoma multiforme (GBM) is among the most lethal of cancers. Enhancing anti-tumor killer T cell responses via dendritic cell vaccines has correlated with a positive outcome in selected GBM patients. Nevertheless, the mechanisms by which killer T cell responses to GBM are inhibited or enhanced remain poorly defined. We therefore developed the GL261 “Quad Cassette” glioma cell line that expresses model T cell epitopes in the immunocompetent C57BL/6 mouse. Tumor size and inflammatory profiles observed in these animals was then compared to C57BL/6 mice administered the parent GL261 glioma cell line. Resulting tumors present with a tumor mass surrounded by considerable edema visible by gadolinium enhanced T1 and T2 weighted MRI. Both edema and tumor mass visible by MRI were quantified using Analyze 10.0 software which enables 3D volumetric analysis of MRI images. C57BL/6 mice with GL261 “Quad Cassette”, but not parent GL261 gliomas, presented with smaller tumor mass and significant brain infiltrating tumor specific Kb:ova specific CD8 T cells. We therefore conclude that the GL261 Quag Cassette system is suitable for studying tumor epitope specific CD8 T cell responses using the vast genetic and immunologic resources available for the C57BL/6 mouse background. Furthermore, incorporation of the first true 3D volumetric analysis of GL261 glioma size with small animal MRI will enable investigation of immunotherapeutic treatments in vivo without euthanizing the animal.

Immunosuppressive effects of red blood cells on monocytes are related to both storage time and storage solution

BACKGROUND

Reduced monocyte function is associated with adverse outcomes from critical illness. Red blood cells (RBCs) are thought to impair monocyte function but relationships between RBC storage solution and monocyte suppression are unknown. This study was designed to test the hypothesis that immunosuppressive effects of RBCs on monocytes are related to both storage time and preservative solution.

STUDY DESIGN AND METHODS

Monocytes from healthy adult donors were co-cultured with RBCs that had been stored in AS-1, AS-3, or CPD only for 7, 14, or 21 days. Cells were then stimulated with lipopolysaccharide (LPS) and their supernatants assayed for tumor necrosis factor (TNF)-α and interleukin (IL)-10. Transwell experiments were performed to evaluate the role of cell-to-cell contact. Monocyte mRNA expression was quantified by real-time-polymerase chain reaction.

RESULTS

LPS-induced TNF-α production capacity was reduced compared to controls for all groups, but CPD-only RBCs suppressed monocyte function more than RBCs stored in AS-1 (p = 0.007) and AS-3 (p = 0.006). IL-10 production was preserved or augmented in all groups. A longer storage time was associated with reduced TNF-α production capacity for AS-1 and AS-3 groups but not CPD. Preventing cell-to-cell contact did not eliminate the inhibitory effect of RBCs on monocyte responsiveness. RBC exposure was associated with decreased LPS-induced TNFA mRNA expression (p < 0.05 for all groups).

CONCLUSIONS

CPD-only RBCs suppressed monocyte function more than RBCs stored with additive solutions. TNF-α production was reduced even in the absence of cell-to-cell contact and was impaired at the mRNA level. Further work is needed to understand the role of preservative solutions in this process.

First Report of Fusarium torulosum Causing Dry Rot of Seed Potato Tubers in the United States

Fusarium dry rot of potato (Solanum tuberosum L.) is a postharvest disease caused by several Fusarium species and is of worldwide importance. Thirteen species of Fusarium have been implicated in fungal dry rots of potatoes worldwide. Among them, eight species have been reported in the northern United States (2). In Michigan potato production, F. sambucinum was the predominant species reported to be affecting seed potato in storage and causing seed piece decay after planting (3). Some previous identifications of F. sambucinum as dry rot may have been F. torulosum since F. torulosum was previously classified within F. sambucinum (4). To further investigate this, dry rot symptomatic tubers were collected from Michigan seed lots in the summers of 2009 and 2010. Small sections from the margins of necrotic regions were cut with a scalpel, surface sterilized in 0.5% sodium hypochlorite for 10 s, rinsed twice in sterile distilled water, and blotted with sterile filter paper. The tissue pieces were plated on half-strength potato dextrose agar (PDA) amended with 0.5 g/liter of streptomycin sulfate and incubated at 23°C for 5 to 7 days. Cultures resembling Fusarium species were transferred onto water agar, and single hyphal tips from actively growing isolates were removed and plated either on carnation leaf agar (CLA) or on half-strength PDA to generate pure cultures. Among the Fusarium isolates obtained, five isolates were identified as F. torulosum (GenBank Accessions Nos. JF803658-JF803660). Identification was based on colony and conidial morphology on PDA and CLA, respectively. These features included slow growth (2.8 ± 0.2 cm in 5 days), white mycelium that became pigmented with age, narrow concentric rings, red or white pigmentation on agar, macroconidia (32.4 ± 0.4 μm average length) with five septa, a pointed apical cell, and a foot-shaped basal cell (4). The identity was confirmed through DNA extraction followed by amplification and sequencing of the translation elongation factor (EF-1α) gene region (1). The Fusarium-ID.v (1) and the NCBI database were used to obtain the closest match (99%) to previously sequenced materials (GenBank Accession No. AJ543611). Pathogenicity testing was done on disease-free potato tubers cv. Red Norland. Tubers were surface sterilized for 10 min in 0.5% sodium hypochlorite and rinsed twice in distilled water. Three tubers per isolate were injected with 20 μl of a conidial suspension (10⁶ conidia/ml) made from F. torulosum cultures grown on PDA for 7 to 10 days. Control tubers were injected with 20 μl of sterile distilled water. All tubers inoculated with F. torulosum developed typical potato dry rot symptoms consisting of a brown and dry decay. There was no disease incidence on the control tubers. F. torulosum was reisolated from the symptomatic tubers. To our knowledge, this is the first report of F. torulosum causing potato dry rot in the United States. References: (1) D. Geiser et al. Eur. J. Plant Pathol. 110:473, 2004. (2) L. E. Hanson et al. Phytopathology 86:378, 1996. (3) M. L. Lacy and R. Hammerschmidt. Fusarium dry rot. Extension Bulletin. Retrieved from http://web1.msue.msu.edu/msue/iac/onlinepubs/pubs/E/E2448POT , 23 May 2010. (4) J. F. Leslie and B. A. Summerell. The Fusarium Laboratory Manual. Wiley-Blackwell, Hoboken, NJ, 2006.

First Report of in vitro Fludioxonil-Resistant Isolates of Fusarium spp. Causing Potato Dry Rot in Michigan

Fusarium dry rot of potato (Solanum tuberosum) is a postharvest disease caused by several Fusarium spp. Dry rot is managed primarily by reducing tuber bruising and promoting rapid wound healing. Dry rot symptomatic tubers were collected from Michigan seed lots in 2009 and 2010. The isolates may not have been exposed to fludioxonil because currently applications are restricted to seed not intended for seed production (3). Small sections were cut from the margins of necrotic regions with a scalpel, surface sterile in 10% sodium hypochlorite for 10 s, rinsed twice in sterile distilled water, and blotted with sterile filter paper. The tissue pieces were plated on half-strength potato dextrose agar (PDA) amended with 0.5 g/liter of streptomycin sulfate. The dishes were incubated at 23°C for 5 to 7 days. Cultures resembling Fusarium spp. were transferred onto water agar and hyphal tips from the margin of actively growing isolates were removed with a sterile probe and plated either on carnation leaf agar (CLA) or on half-strength PDA to generate pure cultures. Fusarium isolates were obtained and used for further studies. Among them, 54 were identified as Fusarium oxysporum and 23 as F. sambucinum. Identification was based on colony and conidial morphology on PDA and CLA, respectively. The identity was confirmed through DNA extraction followed by amplification and sequencing of the translation elongation factor (EF-1α) gene region. The Fusarium-ID v. (2) and the NCBI database were used to obtain the closest match to previously sequenced materials. Pathogenicity testing was done on disease-free potato tubers, cv. FL 1879. Tubers were surface sterilized for 10 min in 10% sodium hypochlorite and rinsed twice in distilled water. Three tubers per isolate were injected with 20 μl of a conidial suspension (10⁶ conidia/ml) made from cultures grown on PDA for 7 days. Control tubers were injected with 20 μl of sterile distilled water. All tubers inoculated with F. sambucinum and F. oxysporum developed typical potato dry rot symptoms consisting of dry brown decay lesions. F. sambucinum and F. oxysporum were reisolated from all symptomatic tubers. An effective concentration for 50% reduction in growth (EC₅₀) was determined for each F. sambucinum and F. oxysporum isolate for thiabendazole (TBZ), fludioxonil, and difenoconazole using the spiral gradient endpoint method (1). Sensitive and resistant F. sambucinum and F. oxysporum isolates were reported. Fifteen isolates of F. sambucinum and thirty-four of F. oxysporum were resistant to fludioxonil with EC₅₀ greater than 130 mg/liter. The remainder was sensitive to fludioxonil with EC₅₀ ranging from 0.8 to 4.9 mg/liter. To our knowledge, this is the first report of resistance to fludioxonil in isolates of F. sambucinum and F. oxysporum in Michigan. Fusarium insensitivity in laboratory studies may not translate directly to commercial production. This disparity may result from interactions not experienced in mixed populations or within a living host. There has been no compelling evidence to suggest that fludioxonil has failed to perform because of insensitivity to Fusarium. The occurrence of such isolated strains necessitates the development and registration of partner chemistries that can preempt any future concerns on lack of performance of products in use. References: (1) H. Förster et al. Phytopathology 94:163, 2004. (2) D. Geiser et al. Eur. J. Plant Pathol. 110:473, 2004. (3) R. D. Peters et al. Plant Dis. 92:172, 2008.

Best Practices in Second Stage Labor Care: Maternal Bearing Down and Positioning

Despite evidence of adverse fetal and maternal outcomes from the use of sustained Valsalva bearing down efforts, current second-stage care practices are still characterized by uniform directions to "push" forcefully upon complete dilatation of the cervix while the woman is in a supine position. Directed pushing might slightly shorten the duration of second stage labor, but can also contribute to deoxygenation of the fetus; cause damage to urinary, pelvic, and perineal structures; and challenge a woman's confidence in her body. Research on the second stage of labor care is reviewed, with a focus on recent literature on maternal bearing down efforts, the "laboring down" approach to care, second-stage duration, and maternal position. Clinicians can apply the scientific evidence regarding the detrimental effects of sustained Valsalva bearing down efforts and supine positioning by individualizing second stage labor care and supporting women's involuntary bearing down sensations that can serve to guide her behaviors.