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.

Rumen digesta and products of fermentation in cows fed varying proportions of fodder beet (Beta vulgaris) with fresh pasture or silage or straw

Context Fodder beet (FB) is a popular feed for dairy cows in temperate climates due to its high yields, high digestibility, low nitrogen (N) content in the dry matter (DM) and convenience of feeding (grazing in situ). However, the risk of ruminal acidosis requires research to design feeding regimes that capture these benefits without compromising animal health. Aims To understand aspects of rumen function when FB is offered in conditions representative of practical feeding in temperate pastoral systems. Methods Two indoor experiments were undertaken; one with cows in late lactation fed fresh perennial ryegrass with three proportions of FB (0, 0.23 and 0.45) and another with non-lactating cows fed pasture silage with 0.65 FB or barley straw with 0.86 FB. Measurements included rumen pH, short-chain fatty acid (SCFA) and ammonia concentrations determined at 2-h intervals, as well as daily individual cow intakes, estimates of microbial growth and rumen dynamics. Key results The inclusion of 0, 0.23 and 0.45 FB with fresh pasture in the did not affect daily DM intakes (~14.6 kg), milk yield (~10.7 kg), microbial synthesis (129 g of N/d) or fractional outflow rates of digesta (0.16/h; 11.2 L/h) of lactating cows. The non-lactating cow ration comprising 0.86 FB with straw was inappropriate and resulted in low intakes and insufficient dietary N. Microbial growth was approximately one-third of that in cows fed pasture silage with 0.65 FB. The ruminal pH reached lower values in all treatments where FB was offered. Rumen ammonia concentrations averaged 4.4 mmol/L in cows fed pasture but was sometimes undetectable in lactating cows fed 0.45 FB and in non-lactating cows. The amount of FB in the diet affected the extent of the circadian changes in molar proportions of SCFA. Conclusions Based on the results presented here, feeding fresh FB to dairy cows should not exceed ~0.4 of their DMI with pasture (late lactation), or ~0.6 of their intake with silage (non-lactating). Implications These findings could support evidence-based recommendations for FB use, considering its effects on aspects of rumen function, such as microbial protein synthesis and pH.

Use of progression criteria to support monitoring and commissioning decision making of public health services: lessons from Better Start Bradford

BACKGROUND

Commissioning and monitoring of community-based interventions is a challenge due to the complex nature of the environment and the lack of any explicit cut-offs to guide decision making. At what point, for example, is participant enrolment to interventions, course completion or satisfaction deemed to be acceptable or sufficient for continued funding? We aimed to identify and quantify key progression criteria for fourteen early years interventions by (1) agreeing the top three criteria for monitoring of successful implementation and progress; and (2) agreeing boundaries to categorise interventions as 'meeting anticipated target' (green); 'falling short of targets' (amber) and 'targets not being met' (red).

METHODS

We ran three workshops in partnership with the UK's Big Lottery Fund commissioned programme 'Better Start Bradford' (implementing more than 20 interventions to improve the health, wellbeing and development of children aged 0-3) to support decision making by agreeing progression criteria for the interventions being delivered. Workshops included 72 participants, representing a range of professional groups including intervention delivery teams, commissioners, intervention-monitoring teams, academics and community representatives. After discussion and activities, final decisions were submitted using electronic voting devices. All participants were invited to reconsider their responses via a post-workshop questionnaire.

RESULTS

Three key progression criteria were assigned to each of the 14 interventions. Overall, criteria that participants most commonly voted for were recruitment, implementation and reach, but these differed according to each intervention. Cut-off values used to indicate when an intervention moved to 'red' varied by criteria; the lowest being for recruitment, where participants agreed that meeting less than 65% of the targeted recruitment would be deemed as 'red' (falling short of target).

CONCLUSIONS

Our methodology for monitoring the progression of interventions has resulted in a clear pathway which will support commissioners and intervention teams in local decision making within the Better Start Bradford programme and beyond. This work can support others wishing to implement a formal system for monitoring the progression of public health interventions.

Digestion and nitrogen excretion by Holstein–Friesian cows in late lactation offered ryegrass-based pasture supplemented with fodder beet

Recent changes in New Zealand dairying have included incorporation of fodder beet (FB) into rations. The present trial explored the impact of substituting different proportions of ryegrass-based pasture with FB for cows fed ad libitum in late lactation. The objective was to measure effects of FB on intake, digestion and urinary nitrogen (N) excretion using 16 Holstein–Friesian cows with a permanent rumen fistula. Before the 9-day indoor measurement period, cows were adapted to feeding 0%, 20%, 40% or 60% FB (bulbs and tops) with medium quality ryegrass-based pasture (191 g CP and 517 g neutral detergent fibre (aNDF)/kg DM; DM digestibility 0.634) over 2 weeks. However, it became apparent that a diet of 60% FB was detrimental to cow health, with two cows developing acidosis. The allocation of FB was reduced and the actual intakes were 23% and 45% of DM intake during the trial. Feeding FB substantially reduced N intake and urinary N excretion. The lower level (23%) of FB resulted in greater DM digestibility, albeit with a small reduction in N and aNDF digestibility. However, the higher level (45%) of FB reduced N and aNDF digestibility by 7.1 and 12.1 percentage units respectively, relative to pasture. Daily creatinine excretion was lower than published measurements from cattle fed dry diets, and circadian variation in urinary N:creatinine ratios suggests a need for caution when attempting to predict daily urinary N excretion from spot samples.

Association of food security status with overweight and dietary intake: exploration of White British and Pakistani-origin families in the Born in Bradford cohort

BACKGROUND

Food insecurity has been associated with dietary intake and weight status in UK adults and children although results have been mixed and ethnicity has not been explored. We aimed to compare prevalence and trajectories of weight and dietary intakes among food secure and insecure White British and Pakistani-origin families.

METHODS

At 12 months postpartum, mothers in the Born in Bradford cohort completed a questionnaire on food security status and a food frequency questionnaire (FFQ) assessing their child's intake in the previous month; at 18 months postpartum, mothers completed a short-form FFQ assessing dietary intake in the previous 12 months. Weights and heights of mothers and infants were assessed at 12-, 24-, and 36-months postpartum, with an additional measurement of children taken at 4-5 years. Associations between food security status and dietary intakes were assessed using Wilcoxon-Mann-Whitney for continuous variables and χ2 or Fisher's exact tests for categorical variables. Quantile and logistic regression were used to determine dietary intakes adjusting for mother's age. Linear mixed effects models were used to assess longitudinal changes in body mass index (BMI) in mothers and BMI z-scores in children.

RESULTS

At 12 months postpartum, White British mothers reported more food insecurity than Pakistani-origin mothers (11% vs 7%; p < 0.01) and more food insecure mothers were overweight. Between 12 and 36 months postpartum, BMI increased more among food insecure Pakistani-origin mothers (β = 0.77 units, [95% Confidence Interval [CI]: 0.40, 1.10]) than food secure (β = 0.44 units, 95% CI: 0.33, 0.55). This was also found in Pakistani-origin children (BMI z-score: food insecure β = 0.40 units, 95% CI: 0.22, 0.59; food secure β = 0.25 units, 95% CI: 0.20, 0.29). No significant increases in BMI were observed for food secure or insecure White British mothers while BMI z-score increased by 0.17 (95% CI: 0.13, 0.21) for food secure White British children. Food insecure mothers and children had dietary intakes of poorer quality, with fewer vegetables and higher consumption of sugar-sweetened drinks.

CONCLUSIONS

Food security status is associated with body weight and dietary intakes differentially by ethnicity. These are important considerations for developing targeted interventions.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

[Drug therapy in interventional radiology]

In the context of pre-interventional drug therapy, a premedication is given to patients who are known to have an allergy to contrast media, have renal impairment or hyperthyroidism. An already existing anticoagulation therapy, in anticipation of the planned intervention, must be reviewed and changed or even suspended as required. For peri-interventional drug therapy it is important to consider how strenuous the procedure will be as well as the general condition of the patient. Further discussion with anesthetists may be required for the planning of pain therapy or sedation during the procedure. These factors help to ensure maximum patient comfort as well as the success of the intervention. Post-interventional anticoagulation therapy, usually started peri-interventionally, plays an important role in minimizing the risk of acute thrombosis as well as in maintaining long-term functioning of the implanted material. The form of the anticoagulation therapy is set according to the type of intervention.

Agreement between routine and research measurement of infant height and weight

In many countries, routine data relating to growth of infants are collected as a means of tracking health and illness up to school age. These have potential to be used in research. For health monitoring and research, data should be accurate and reliable. This study aimed to determine the agreement between length/height and weight measurements from routine infant records and researcher-collected data.

METHODS

Height/length and weight at ages 6, 12 and 24 months from the longitudinal UK birth cohort (born in Bradford; n=836-1280) were compared with routine data collected by health visitors within 2 months of the research data (n=104-573 for different comparisons). Data were age adjusted and compared using Bland Altman plots.

RESULTS

There was agreement between data sources, albeit weaker for height than for weight. Routine data tended to underestimate length/height at 6 months (0.5 cm (95% CI -4.0 to 4.9)) and overestimate it at 12 (-0.3 cm (95% CI -0.5 to 4.0)) and 24 months (0.3 cm (95% CI -4.0 to 3.4)). Routine data slightly overestimated weight at all three ages (range -0.04 kg (95% CI -1.2 to 0.9) to -0.04 (95% CI -0.7 to 0.6)). Limits of agreement were wide, particularly for height. Differences were generally random, although routine data tended to underestimate length in taller infants and underestimate weight in lighter infants.

CONCLUSIONS

Routine data can provide an accurate and feasible method of data collection for research, though wide limits of agreement between data sources may be observed. Differences could be due to methodological issues; but may relate to variability in clinical practice. Continued provision of appropriate training and assessment is essential for health professionals responsible for collecting routine data.

Framework of outcome measures recommended for use in the evaluation of childhood obesity treatment interventions: the CoOR framework

INTRODUCTION

Consensus is lacking in determining appropriate outcome measures for assessment of childhood obesity treatments. Inconsistency in the use and reporting of such measures impedes comparisons between treatments and limits consideration of effectiveness. This study aimed to produce a framework of recommended outcome measures: the Childhood obesity treatment evaluation Outcomes Review (CoOR) framework.

METHODS

A systematic review including two searches was conducted to identify (1) existing trial outcome measures and (2) manuscripts describing development/evaluation of outcome measures. Outcomes included anthropometry, diet, eating behaviours, physical activity, sedentary time/behaviour, fitness, physiology, environment, psychological well-being and health-related quality of life. Eligible measures were appraised by the internal team using a system developed from international guidelines, followed by appraisal from national external expert collaborators.

RESULTS

A total of 25,486 papers were identified through both searches. Eligible search 1 trial papers cited 417 additional papers linked to outcome measures, of which 56 were eligible. A further 297 outcome development/evaluation papers met eligibility criteria from search 2. Combined, these described 191 outcome measures. After internal and external appraisal, 52 measures across 10 outcomes were recommended for inclusion in the CoOR framework.

CONCLUSION

Application of the CoOR framework will ensure greater consistency in choosing robust outcome measures that are appropriate to population characteristics.

A comparison of South Asian specific and established BMI thresholds for determining obesity prevalence in pregnancy and predicting pregnancy complications: findings from the Born in Bradford cohort

OBJECTIVE

To describe how maternal obesity prevalence varies by established international and South Asian specific body mass index (BMI) cut-offs in women of Pakistani origin and investigate whether different BMI thresholds can help to identify women at risk of adverse pregnancy and birth outcomes.

DESIGN

Prospective bi-ethnic birth cohort study (the Born in Bradford (BiB) cohort).

SETTING

Bradford, a deprived city in the North of the UK.

PARTICIPANTS

A total of 8478 South Asian and White British pregnant women participated in the BiB cohort study.

MAIN OUTCOME MEASURES

Maternal obesity prevalence; prevalence of known obesity-related adverse pregnancy outcomes: mode of birth, hypertensive disorders of pregnancy (HDP), gestational diabetes, macrosomia and pre-term births.

RESULTS

Application of South Asian BMI cut-offs increased prevalence of obesity in Pakistani women from 18.8 (95% confidence interval (CI) 17.6-19.9) to 30.9% (95% CI 29.5-32.2). With the exception of pre-term births, there was a positive linear relationship between BMI and prevalence of adverse pregnancy and birth outcomes, across almost the whole BMI distribution. Risk of gestational diabetes and HDP increased more sharply in Pakistani women after a BMI threshold of at least 30 kg m(-2), but there was no evidence of a sharp increase in any risk factors at the new, lower thresholds suggested for use in South Asian women. BMI was a good single predictor of outcomes (area under the receiver operating curve: 0.596-0.685 for different outcomes); prediction was more discriminatory and accurate with BMI as a continuous variable than as a binary variable for any possible cut-off point.

CONCLUSION

Applying the new South Asian threshold to pregnant women would markedly increase those who were referred for monitoring and lifestyle advice. However, our results suggest that lowering the BMI threshold in South Asian women would not improve the predictive ability for identifying those who were at risk of adverse pregnancy outcomes.

Idiopathic chondrolysis condition in two young, wild-caught Cynomolgus monkeys (Macaca fascicularis) reared in captivity

Idiopathic chondrolysis is a human clinical entity typically reported in adolescent individuals. In this brief communication, we report 2 cases of presumptive idiopathic chondrolysis of the femoral head in Cynomolgus macaques and discuss the clinical symptomatology and pathology of the disease. In detail, we describe the histomorphologic changes of idiopathic chondrolysis and compare these findings with those typically observed in the primary differential diagnoses of Legg-Calve-Perthes disease and nonspecific osteoarthritis. Consideration of this entity among differential diagnoses in young Cynomolgus macaques with unilateral osteoarthritis could be important both for laboratory animal veterinarians and pathologists.

Intravenous oxytocin bolus of 2 units is superior to 5 units during elective Caesarean section

BACKGROUND

The optimal dose of oxytocin at Caesarean section is unclear. Oxytocin may cause adverse cardiovascular effects, including tachycardia and hypotension, whereas an inadequate dose can result in increased uterine bleeding. We compared the effects of two doses of oxytocin in a randomized double-blind trial.

METHODS

Eighty patients undergoing elective Caesarean section received an i.v. bolus of either 2 or 5 units (u) of oxytocin after delivery, followed by an oxytocin infusion of 10 u h(-1). All received combined spinal-epidural anaesthesia with arterial pressure maintained by a phenylephrine infusion. We compared changes in heart rate (HR), mean arterial pressure (MAP), blood loss, uterine tone, the need for additional uterotonic drugs, and emetic symptoms.

RESULTS

There was a greater increase in mean (sd) HR in patients who received 5 u of oxytocin [32 (17) beats min(-1)] than in those who received 2 u [24 (13) beats min(-1)] (P=0.015). There was a larger decrease in MAP in patients who received 5 u [13 (15) mm Hg] than in those who received 2 u [6 (10) mm Hg] (P=0.030). The frequency of nausea and antiemetic use was higher after 5 u (32.5%) than 2 u (5%) (P=0.003). There were no differences in blood loss, uterine tone, or requests for additional uterotonic drugs (17.5% in both groups).

CONCLUSIONS

In elective Caesarean section, a 2 u bolus of oxytocin results in less haemodynamic change than 5 u, with less nausea and no difference in the need for additional uterotonics.

Human ventilatory efficiency and respiratory sinus arrhythmia during head-up tilt

Cardiac vagal withdrawal when moving from supine to an upright posture may be independent of respiratory sinus arrhythmia. Further, ventilatory efficiency of an upright lung may improve with clustering of heart beats during inhalation. We studied healthy human subjects (n=8, 6 male) during supine rest (SUP) and 80 degrees head-up tilt (HUT). ECG and expired breath were sampled continuously to determine heart rate, mean and end-tidal (ET) fractional content (F) of O2 and CO2, tidal volume (V(T)) and breathing frequency (Bf). HUT increased heart rate (47+/-3 vs. 59+/-9 beats min(-1), p<0.01), decreased the high frequency component of heart rate variability (8.76+/- vs. 7.07+/-1.12, p<0.05), and increased the ratio of low to high frequency components in the heart rate (0.62+/-0.6 vs. 1.79+/-2.07, p<0.05). HUT did not change VT, Bf, or minute ventilation (V'E), but decreased FCO2 (4.90+/-0.48 vs. 4.56+/-0.42 %, p<0.05) and FETCO2 (6.64+/-0.24 vs. 6.30+/-0.27 %, p<0.01). HUT increased the CO2 ventilatory equivalent (24.88+/-2.50 vs. 26.74+/-2.61, p<0.01). Mean heart rate during inhalation increased with HUT (26+/-3 vs. 34+/-6 beats min-1), with no change during exhalation. Increased clustering of heart beats during inhalation independent of a decrease in HF cardiac variability may partly offset decreases in ventilatory efficiency of an upright lung.

Modest changes in dietary intake across the menstrual cycle: implications for food intake research

Food intake varies across the menstrual cycle in mammals, energy intake usually being greater in the premenstrual phase compared with the postmenstrual phase. Premenstrual increments in energy intake and a preferential selection of carbohydrate have been suggested to be greater in women with premenstrual syndrome (PMS), who may be more sensitive to cyclical hormonal or neurotransmitter fluctuations. This has direct implications for research within populations of women, especially where the primary outcome is diet or a change in energy balance. We aimed to determine whether: the premenstrual intake of energy and macronutrients differed from the postmenstrual intake; the change in intake across the menstrual cycle differed in women with PMS compared with controls; and the change in intake was related to the severity of premenstrual symptoms. We collected 3 d dietary intake data during the postmenstrual and premenstrual phases of the menstrual cycle in thirty-one women with PMS and twenty-seven control women. The consumption of energy and macronutrient intake were similar between the phases of the cycle in women with PMS. Conversely, intakes were usually greater premenstrually in control women, although not all differences were statistically significant. Exceptions were with non-milk extrinsic sugars and alcohol, which were both consumed in greater amounts in the premenstrual phase in women with PMS. Significant correlations were observed between the severity of symptoms and the change in the consumption of these nutrients. These data suggest that a consideration of the menstrual cycle phase and PMS in diet may not be warranted, especially in cross-sectional analysis, although it may need to be taken into account when examining change in intake during dietary interventions.

Mice with conditional inactivation of fibroblast growth factor receptor-2 signaling in oligodendrocytes have normal myelin but display dramatic hyperactivity when combined with Cnp1 inactivation

Fibroblast growth factor receptors (Fgfr) comprise a widely expressed family of developmental regulators implicated in oligodendrocyte (OL) maturation of the CNS. Fgfr2 is expressed by OLs in myelinated fiber tracks. In vitro, Fgfr2 is highly upregulated during OL terminal differentiation, and its activation leads to enhanced growth of OL processes and the formation of myelin-like membranes. To investigate the in vivo function of Fgfr2 signaling by myelinating glial cells, we inactivated the floxed Fgfr2 gene in mice that coexpress Cre recombinase (cre) as a knock-in gene into the OL-specific 2',3'-cyclic nucleotide phosphodiesterase (Cnp1) locus. Surprisingly, no obvious defects were detected in brain development of these conditional mutants, including the number of OLs, the onset and extent of myelination, the ultrastructure of myelin, and the expression level of myelin proteins. However, unexpectedly, a subset of these conditional Fgfr2 knock-out mice that are homozygous for cre and therefore are also Cnp1 null, displayed a dramatic hyperactive behavior starting at approximately 2 weeks of age. This hyperactivity was abolished by treatment with dopamine receptor antagonists or catecholamine biosynthesis inhibitors, suggesting that the symptoms involve a dysregulation of the dopaminergic system. Although the molecular mechanisms are presently unknown, this novel mouse model of hyperactivity demonstrates the potential involvement of OLs in neuropsychiatric disorders, as well as the nonpredictable role of genetic interactions in the behavioral phenotype of mice.

Circadian function in patients with advanced non-small-cell lung cancer

This study aimed to evaluate whether patients with advanced non-small-cell lung cancer experience disrupted rest–activity daily rhythms, poor sleep quality, weakness, and maintain attributes that are linked to circadian function such as fatigue. This report describes the rest–activity patterns of 33 non-small-cell lung cancer patients who participated in a randomised clinical trial evaluating the benefits of melatonin. Data are reported on circadian function, health-related quality of life (QoL), subjective sleep quality, and anxiety/depression levels prior to randomisation and treatment. Actigraphy data, an objective measure of circadian function, demonstrated that patients' rest–activity circadian function differs significantly from control subjects. Our patients reported poor sleep quality and high levels of fatigue. Ferrans and Powers QoL Index instrument found a high level of dissatisfaction with health-related QoL. Data from the European Organization for Research and Treatment for Cancer reported poor capacity to fulfil the activities of daily living. Patients studied in the hospital during or near chemotherapy had significantly more abnormal circadian function than those studied in the ambulatory setting. Our data indicate that measurement of circadian sleep/activity dynamics should be accomplished in the outpatient/home setting for a minimum of 4–7 circadian cycles to assure that they are most representative of the patients' true condition. We conclude that the daily sleep/activity patterns of patients with advanced lung cancer are disturbed. These are accompanied by marked disruption of QoL and function. These data argue for investigating how much of this poor functioning and QoL are actually caused by this circadian disruption, and, whether behavioural, light-based, and or pharmacologic strategies to correct the circadian/sleep activity patterns can improve function and QoL.

Effect of consumption of soy isoflavones on behavioural, somatic and affective symptoms in women with premenstrual syndrome

Up to 80 % of the Western female population experience premenstrual syndrome (PMS). Long-term pharmacological therapy is unacceptable to most women, and is not warranted for moderate symptoms. Nutritional therapies are popular, but lack a clear evidence base. Anecdotal evidence suggests beneficial effects of soy isoflavones because of their influence on endogenous oestrogen and actions on specific tissues. The effect of isolated soya protein (ISP) containing 68 mg/d (aglycone equivalents) soy isoflavones (IF) on premenstrual symptom severity was studied in a seven-menstrual cycle, double-blind, placebo-controlled, crossover intervention study in twenty-three women with prospectively confirmed PMS aged 18-35 years and BMI 19-30 kg/m(2). ISP containing IF or milk protein placebo was consumed for two complete menstrual cycles. ISP containing IF (genistein, daidzein, equol) were measured in 24 h urine samples. After two cycles of ISP containing IF intervention, total symptoms (F(2,36) 8.20, P=0.000) and physical symptoms (F(2,36) 8.18, P=0.000) were significantly reduced compared with baseline after both active and placebo treatments, although differences between active and placebo treatment were non-significant. Specific premenstrual symptoms, headache (F(2,32) 4.10, P=0.026) and breast tenderness (F(2,32) 4.59, P=0.018), were reduced from baseline after soy IF, but not milk protein placebo. Cramps (F(2,32) 4.15, P=0.025) and swelling (F(2,32) 4.64, P=0.017) were significantly lower after active treatment compared with placebo. Concentrations of genistein and daidzein were increased following soy IF consumption, but equol production did not enhance symptom reduction. The present study showed that ISP containing IF may have potential to reduce specific premenstrual symptoms via non-classical actions.

Estimation of bioavailability of DL-methionine hydroxy analogue relative to DL-methionine in layers with exponential and slope-ratio models

An experiment was conducted using molted hens to estimate the bioavailability of DL-methionine hydroxy analogue-free acid (MHA-FA) relative to DL-methionine (DLM). In this experiment, 5 supplemental levels (0.012, 0.024, 0.036, 0.048, and 0.060%) of DLM or equimolar concentrations of MHA-FA were added to a basal diet containing 14.97% protein and 0.27% methionine. The low protein diet was used to increase the sensitivity of laying hens to methionine deficiency. Feed consumption, egg production, egg mass, and egg weight increased (P < 0.05), and feed conversion decreased (P < 0.05) when DLM or MHA-FA was added to the basal diet for some supplemental methionine levels. There was no difference (P > 0.05) in feed consumption between hens fed DLM and hens fed MHA-FA. Regression analysis showed that the bioavailability of MHA-FA relative to DLM on a molar basis was 88.7% (egg production), 88.0% (egg mass), and 84.6% (egg weight) with the exponential model, and was 89.7% (egg production), 89.6% (egg mass), and 86.8% (egg weight) with the slope-ratio model. The average bioavailability of MHA-FA relative to DLM was 88% on a molar basis.

A comparison of the anti-inflammatory activities of conjugated estrogens and 17-? estradiol

OBJECTIVE AND DESIGN

Unregulated chronic inflammatory process partly due to an estrogen deficiency may render postmenopausal women vulnerable to degenerative conditions such as arthritis, osteoporosis, atherosclerosis, and Alzheimer's disease. Current confusion regarding therapeutic efficacy of estrogen replacement therapy may be due to different estrogen formulations used, short term therapy, as well as advanced stage of the disease.

MATERIALS AND METHODS

We compared anti-inflammatory activities of two major estrogen preparations, conjugated equine estrogen (CEE) and 17-beta estradiol, using an animal model (rat mesentery) of in vivo inflammatory reaction to intravenously infused amyloid-beta, examined by video recording and subsequently analyzed by transmission electron microscopy. Cellular markers of inflammation were monitored: leukocyte migration, platelet activation, mast cell activation/degranulation, and endothelial disruption.

RESULTS

Low doses of CEE (0.3 mg/kg for 3 weeks) demonstrated significant anti-inflammatory activity, whereas even at high doses (2.0 mg) 17-beta estradiol had only minimal activity.

CONCLUSION

CEE, a mixture of several compounds, may have some component(s) with significant anti-inflammatory activity. The anti-inflammatory activity of CEE may have a role in prevention of several degenerative diseases associated with menopause.

Evaluation of PCR to detect Theileria parva in field-collected tick and bovine samples in Tanzania

The ability of PCR to detect infections of Theileria parva, the cause of East Coast Fever, in field-collected tick and bovine samples from Tanzania was evaluated. PCR-detected infection prevalence was high (15/20, 75%) in unfed adult Rhipicephalus appendiculatus ticks that fed as nymphs on an acutely-infected calf, but low (22/836, 2.6%) in unfed adult R. appendiculatus collected from field sites in Tanzania. Tick infection prevalence was comparable to that in previous studies that used salivary gland staining to detect T. parva infection in field-collected host-seeking ticks. Of 282 naturally-exposed zebu calves, seven had PCR-positive buffy coat samples prior to detection of Theileria spp. parasites in stained buffy coat cells or lymph node biopsies. Evidence of Theileria spp. infections was detected in stained smears of lymph node biopsies from 109 calves (38.6%) and buffy coat samples from 81 (28.7%), while buffy coat samples from 66 (23.4%) were PCR-positive for T. parva. Implications of these findings for the sensitivity and specificity of the PCR are discussed.

Enhanced endothelium-dependent vasodilation in Fabry disease

BACKGROUND AND PURPOSE

Fabry disease is an X-linked lysosomal storage disease secondary to deficiency of alpha-galactosidase A with resulting glycolipid accumulation, particularly globotriaosylceramide in arterial smooth muscle and endothelial cells. A systemic vasculopathy, including early-onset stroke, is prevalent without a clear pathogenesis.

METHODS

Seventeen normotensive and normocholesterolemic hemizygous Fabry patients (aged 21 to 49 years) and 13 control subjects (aged 21 to 48 years) were investigated by venous plethysmography, allowing assessment of forearm blood flow. Plethysmographic measurements were obtained at baseline and during intra-arterial infusion of acetylcholine and sodium nitroprusside both with and without N(G)-monomethyl-L-arginine (L-NMMA).

RESULTS

Forearm blood flow was significantly higher in patients than in control subjects at all 3 acetylcholine doses (P=0.014). Patients had a greater response to acetylcholine even after the addition of L-NMMA (P=0.036).

CONCLUSIONS

These results demonstrate an increased endothelium-mediated vascular reactivity in Fabry disease. The increased vessel response to acetylcholine with and without L-NMMA suggests altered functionality of non-NO endothelium-dependent vasodilatory pathways.

Point of entry treatment gives best time to thrombolysis for acute myocardial infarction

The aim was to compare time to thrombolysis for patients treated via three treatment pathways: thrombolysis in theemergency department (ED), thrombolysis following direct admission by ambulance officers to coronary care (CCU)and thrombolysis after transfer from ED to CCU. We used a retrospective study of time to thrombolysis for all patientsreceiving thrombolysis for acute myocardial infarction (AMI) at Western Hospital during 1999.The median time to thrombolysis in the ED group was 30 minutes (mean 40 minutes), compared with 60 minutesfor the CCU group (mean 63 minutes) and 40 minutes (mean 43 minutes) for the direct CCU admission group.Eighty-five percent of patients treated in ED received thrombolysis in less than 60 minutes compared with 21% ofthose transferred from the ED for treatment in CCU and 52%of those directly admitted to CCU. We conclude thatpoint of entry thrombolysis, be it in ED or in CCU after direct admission, gives shorter times to thrombolysis thanprocesses that require transfer of patients between departments.

Estrogen and raloxifene activities on amyloid-beta-induced inflammatory reaction

The prevalence of Alzheimer's disease (AD) in women is double that of men. Several studies indicate that use of estrogen after menopause by women may reduce the risk of developing AD. The risk of estrogen-dependent tumors associated with estrogen replacement therapy has prompted the use of alternatives, like the SERM raloxifene, which exert estrogen agonist effects on selected target tissues. Whether SERMS provide cognitive and cardiovascular benefits comparable to those of estrogens is an active area of investigation in women's health. A chronic inflammatory process is central to the pathology of Alzheimer's disease. Using an animal model we compared the anti-inflammatory activity of orally administered estrogens (2 mg/kg) and raloxifene (3 mg/kg) in ovariectomized rats. Morphological analysis of Abeta(1-40)-induced inflammatory reaction featured adhesion and transmigration of leukocytes across the vessel wall, endothelial disruption, and platelet activation. Estrogen showed remarkable anti-inflammatory action, whereas raloxifene had no significant beneficial effect. Inhibition of the inflammatory process may contribute to the reported efficacy of estrogen in the treatment of AD.

Tissue repair with a therapeutic transcription factor

The healing of tissue involves a wide range of molecular, cellular, and physiological events that are coordinated in a temporally specific manner. The cellular transcription factor early growth response factor 1 (Egr-1) is expressed minutes after acute injury and serves to stimulate the production of a class of growth factors whose role is to promote tissue repair. We have studied the effects of Egr-1 expression at the site of dermal wounding in rodents. We find that Egr-1 promotes angiogenesis in vitro and in vivo, increases collagen production, and accelerates wound closure. These results show that Egr-1 gene therapy accelerates the normal healing process and raises the potential use of this therapeutic transcription factor for any aspect of tissue repair.