Prescription medication use during pregnancy in the United States from 2011 to 2020: trends and safety evidence

BACKGROUND

Medication use during pregnancy has increased in the United States despite the lack of safety data for many medications.

OBJECTIVE

This study aimed to inform research priorities by examining trends in medication use during pregnancy and identifying gaps in safety information on the most commonly prescribed medications.

STUDY DESIGN

We identified population-based cohorts of commercially (MarketScan 2011-2020) and publicly (Medicaid Analytic eXtract/Transformed Medicaid Statistical Information System Analytic Files 2011-2018) insured pregnancies ending in live birth from 2 health care utilization databases. Medication use was based on filled prescriptions between the date of last menstrual period through delivery, as well as the period before the last menstrual period and during specific trimesters. We also included a cross-sectional representative sample of pregnancies ascertained by the National Health and Nutrition Examination Survey (2011-2020), with information on prescription medication use during the preceding month obtained through maternal interviews. Teratogen Information System was used to classify the available evidence on teratogenic risk.

RESULTS

Among over 3 million pregnancies, the medications most commonly dispensed at any time during pregnancy were analgesics, antibiotics, and antiemetics. The top medications were ondansetron (16.8%), amoxicillin (13.5%), and azithromycin (12.4%) in MarketScan, nitrofurantoin (22.2%), acetaminophen (21.3%; mostly as part of acetaminophen-hydrocodone products), and ondansetron (19.5%) in Medicaid Analytic eXtract/Transformed Medicaid Statistical Information System Analytic Files, and levothyroxine (5.0%), sertraline (2.9%), and insulin (2.9%) in the National Health and Nutrition Examination Survey group. The most commonly dispensed suspected teratogens during the first trimester were antithyroid medications. The use of antidiabetic and psychotropic medications has continued to increase in the United States during the last decade, opioid dispensation has decreased by half, and antibiotics and antiemetics continue to be common. For one-quarter of medications, there is insufficient evidence available to characterize their safety profile in pregnancy.

CONCLUSION

There is a need for more drug research in pregnant patients. Future research should focus on anti-infectives with high utilization and limited level of evidence on safety for use during pregnancy. Although lack of evidence is not evidence of safety concerns, it does not indicate risk either. In many instances, the benefits outweigh the risks when these medications are used clinically, and some of the medications with no proven safety may be necessary to treat patients.

Bone marrow embolism: should it result from traumatic bone lesions? A histopathological human autopsy study

Bone marrow embolism (BME) is likely a consequence of fractures in which pulmonary vessels are the most affected. However, some cases of BME were reported in the absence of trauma. Thus, a traumatic injury might not be necessary for developing BME. This study discusses BME cases in patients without signs of fractures or blunt trauma. The discussion addresses various possible mechanisms for the appearance of BME. Options include cancer in which bone marrow metastasis is a suggestive cause. Another proposal is the chemical theory where bone marrow fats are released via lipoprotein lipase in a pro-inflammatory state, resulting in vascular/pulmonary obstruction. Other cases discussed in this study are hypovolemic shock and drug-abuse related BME. All autopsy cases with BME were included regardless of the cause of death for a period of 2 years. Autopsies involved complete dissection with the macroscopic evaluation of the affected organs, including the heart, lungs, and brain. Tissues were also prepared for microscopic examination. Of the 11 cases, eight showed non-traumatic BME (72%). These findings conflict with theories in the literature that BME most commonly occurs after fractures or trauma. One of the eight cases exhibited mucinous carcinoma; one is presented with hepatocellular carcinoma; and two cases showed severe congestion. Lastly, one case was found to be associated with each of the following conditions: liposuction, drug abuse, pulmonary hypertension, and heart failure. Each case suggests a different pathophysiology for developing BME, yet the exact mechanisms are not fully understood. Further study of non-traumatic associated BME is recommended.

A Novel Chronic Kidney Disease Phenotyping Algorithm Using Combined Electronic Health Record and Claims Data

Purpose

Because chronic kidney disease (CKD) is often under-coded as a diagnosis in claims data, we aimed to develop claims-based prediction models for CKD phenotypes determined by laboratory results in electronic health records (EHRs).

Patients and Methods

We linked EHR from two networks (used as training and validation cohorts, respectively) with Medicare claims data. The study cohort included individuals ≥65 years with a valid serum creatinine result in the EHR from 2007 to 2017, excluding those with end-stage kidney disease or on dialysis. We used LASSO regression to select among 134 predictors for predicting continuous estimated glomerular filtration rate (eGFR). We assessed the model performance when predicting eGFR categories of <60, <45, <30 mL/min/1.73m2 in terms of area under the receiver operating curves (AUC).

Results

The model training cohort included 117,476 patients (mean age 74.8 years, female 58.2%) and the validation cohort included 56,744 patients (mean age 73.8 years, female 59.6%). In the validation cohort, the AUC of the primary model (with 113 predictors and an adjusted R2 of 0.35) for predicting eGFR <60, eGFR<45, and eGFR <30 mL/min/1.73m2 categories was 0.81, 0.88, and 0.92, respectively, and the corresponding positive predictive values for these 3 phenotypes were 0.80 (95% confidence interval: 0.79, 0.81), 0.79 (0.75, 0.84), and 0.38 (0.30, 0.45), respectively.

Conclusion

We developed a claims-based model to determine clinical phenotypes of CKD stages defined by eGFR values. Researchers without access to laboratory results can use the model-predicted phenotypes as a proxy clinical endpoint or confounder and to enhance subgroup effect assessment.

mRNA COVID-19 vaccination early in pregnancy and the risk of spontaneous abortion in an international pregnancy registry

PURPOSE

mRNA COVID-19 vaccines are used in pregnant populations whether advertently or inadvertently. However, evidence on the safety of these vaccines during pregnancy is limited. The objective of this study is to evaluate the effect of BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna) vaccination during the first 20 weeks of gestation on the risk of spontaneous abortion (SAB).

METHODS

All pregnant women who received at least one dose of BNT162b2 or mRNA-1273 and enrolled in the COVID-19 Vaccines International Pregnancy Exposure Registry (C-VIPER) were prospectively followed from enrollment until 20 weeks of gestation, SAB, or loss to follow-up. Baseline demographics, vaccination information, and pregnancy outcomes were collected via monthly online self-administered questionnaires, vaccination certificates, and medical records. Life tables were used to calculate the cumulative risk of SAB. Cox regression was used to estimate the hazard ratio (HR) comparing the two vaccines groups stratified by country of residence and gestational age at enrollment.

RESULTS

Among 6840 participants who received at least one dose of BNT162b2 or mRNA-1273 at any time in pregnancy between Jan-Sep, 2021, 2129 met the inclusion criteria (1576 received BNT162b2 and 553 mRNA-1273). The two groups were balanced in terms of baseline characteristics. There were 37 SABs, with an overall 13.4% estimated cumulative risk by 20 weeks of gestation, which is similar to the expected risk in the population. The HR of SAB comparing mRNA-1273 to BNT162b2 was 1.46 (95% CI: 0.66, 3.22).

CONCLUSION

The C-VIPER data show no evidence that mRNA COVID-19 vaccines increase the risk of SAB.

Distribution of Abatement Funds Arising From US Opioid Litigation

This Viewpoint discusses the settlement agreements reached against several major pharmaceutical distributors resulting from the US opioid epidemic and how those funds will be distributed amongst the states.

Psychiatric comorbidity in a sample of Egyptian women with vaginismus

Background

Vaginismus is a female sexual dysfunction affecting the quality of women and the couple’s relationship. It is considered the main feminine cause of unconsummated marriage in Egypt. The study aims in assessment of comorbid psychiatric disorders, personality disorders, and levels of alexithymia among a sample of women with vaginismus. It is a case-control study where 30 women diagnosed with vaginismus following up in the psychosexual clinic in Ain Shams University Hospitals were enrolled in the study in comparison to 30 controls. Assessment was done based on the socio-demographic data, Toronto Alexithymia scale (TAS-20), Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I), and Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II).

Results

It was found that women having vaginismus had significant below university level of education (P = 0.026) together with their partners (P = 0.006). It was also found that women having vaginismus are showing high levels of alexithymia (p < 0.001), more than one anxiety and/or depressive disorder (P = 0.032) in comparison to the control group. Also, borderline personality disorder/traits and avoidant personality traits were significantly more frequent among cases (P = 0.026, P = 0.001, and P = 0.045 respectively). Moreover, it was found that having two or more of either of rigidity, perfectionism, dramatization, mood swings, and impulsivity was significantly more frequent among cases (P < 0.001) showing a unique personality pattern of women with vaginismus.

Conclusions

Women with vaginismus were having higher levels of alexithymia, more developing anxiety, and depressive disorders than controls and they have specific personality characteristics.

Effect of reductions in opioid prescribing on opioid use disorder and fatal overdose in the United States: a dynamic Markov model

BACKGROUND AND AIMS

Despite prescribing declines between 2011 and 2019, opioid morbidity and mortality in the United States continued to rise during this period. We estimated the relationship between opioid prescribing, opioid use disorder (OUD) and fatal opioid overdose in the United States.

DESIGN

Dynamic Markov model.

SETTING

United States, using data from the National Survey on Drug Use and Health, Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey and National Epidemiologic Survey on Alcohol and Related Conditions III.

PARTICIPANTS

Simulated US individuals 12+ years of age from the general population or with prescription opioid medical use, prescription opioid non-medical use, illicit opioid (e.g. heroin, illicit fentanyl) use, prescription OUD, illicit OUD with a history of prior prescription opioid non-medical use or non-fatal or fatal opioid overdose.

MEASUREMENTS

Active OUD cases and fatal prescription opioid overdoses.

FINDINGS

Between 2010 and 2019, opioid prescribing declined 42.5%. Although fatal opioid overdoses increased by 103.2%, these reductions in opioid prescribing averted an estimated 9600 [95% uncertainty interval (UI) = 7205, 15 478] deaths starting in 2011 relative to continued prescribing at 2010 levels-and are projected to avert another 50 918 (95% UI = 38 829, 79 795) overdose deaths between 2020 and 2029. The median time from initial opioid prescription to fatal opioid overdose was 5.2 years. Of the 2.4 million (95% UI = 2.2 million, 2.7 million) individuals in the United States with estimated active OUD in 2019, 65% (95% UI = 59%, 71%) were attributable to initial opioid use occurring prior to 2011, whereas 14% (95% UI = 12%, 17%) were attributable to initial opioid use occurring between 2017 and 2019. The impact, by 2029, of additional reductions in prescribing initiated in 2020 would be more than three times greater than that of similar reductions initiated in 2025.

CONCLUSIONS

Observed reductions in opioid prescribing volume in the United States from 2010 to 2019 appear to have saved approximately 9600 lives by 2019 and are anticipated to avert more than 50 000 fatal overdoses by 2029.

Use of Hydroxychloroquine, Remdesivir, and Dexamethasone Among Adults Hospitalized With COVID-19 in the United States : A Retrospective Cohort Study

BACKGROUND

Relatively little is known about the use patterns of potential pharmacologic treatments of COVID-19 in the United States.

OBJECTIVE

To use the National COVID Cohort Collaborative (N3C), a large, multicenter, longitudinal cohort, to characterize the use of hydroxychloroquine, remdesivir, and dexamethasone, overall as well as across individuals, health systems, and time.

DESIGN

Retrospective cohort study.

SETTING

43 health systems in the United States.

PARTICIPANTS

137 870 adults hospitalized with COVID-19 between 1 February 2020 and 28 February 2021.

MEASUREMENTS

Inpatient use of hydroxychloroquine, remdesivir, or dexamethasone.

RESULTS

Among 137 870 persons hospitalized with confirmed or suspected COVID-19, 8754 (6.3%) received hydroxychloroquine, 29 272 (21.2%) remdesivir, and 53 909 (39.1%) dexamethasone during the study period. Since the release of results from the RECOVERY (Randomised Evaluation of COVID-19 Therapy) trial in mid-June, approximately 78% to 84% of people who have had invasive mechanical ventilation have received dexamethasone or other glucocorticoids. The use of hydroxychloroquine increased during March 2020, peaking at 42%, and started declining by April 2020. By contrast, remdesivir and dexamethasone use gradually increased over the study period. Dexamethasone and remdesivir use varied substantially across health centers (intraclass correlation coefficient, 14.2% for dexamethasone and 84.6% for remdesivir).

LIMITATION

Because most N3C data contributors are academic medical centers, findings may not reflect the experience of community hospitals.

CONCLUSION

Dexamethasone, an evidence-based treatment of COVID-19, may be underused among persons who are mechanically ventilated. The use of remdesivir and dexamethasone varied across health systems, suggesting variation in patient case mix, drug access, treatment protocols, and quality of care.

PRIMARY FUNDING SOURCE

National Center for Advancing Translational Sciences; National Heart, Lung, and Blood Institute; and National Institute on Aging.

Dipeptidyl peptidase-4 inhibitor cardiovascular safety in patients with type 2 diabetes, with cardiovascular and renal disease: a retrospective cohort study

Clinical trials investigating cardiovascular safety of dipeptidyl peptidase-IV inhibitors (DPP-4i) among patients with cardiovascular and renal disease rarely recruit patients with renal impairment, despite associations with increased risk for major adverse cardiovascular events (MACE). We investigated the risk of MACE associated with the use of DPP-4i among these high-risk patients. Using a new-user, retrospective, cohort design, we analyzed 2010–2015 IBM MarketScan Commercial Claims and Encounters for patients with diabetes, comorbid with cardiovascular disease and/or renal impairment. We compared time to first MACE for DPP-4i versus sulfonylurea and versus metformin. Of 113,296 individuals, 9146 (8.07%) were new DPP-4i users, 17,481 (15.43%) were new sulfonylurea users, and 88,596 (78.20%) were new metformin users. Exposure groups were not mutually exclusive. DPP-4i was associated with lower risk for MACE than sulfonylurea (aHR 0.84; 95% CI 0.74, 0.93) and similar risk for MACE to metformin (aHR 1.07; 95% CI [1.04, 1.16]). DPP-4i use was associated with lower risk for MACE compared to sulfonylureas and similar risk for MACE compared to metformin. This association was most evident in the first year of therapy, suggesting that DPP-4i is a safer choice than sulfonylurea for diabetes treatment initiation in high-risk patients.

Changes in Short-term, Long-term, and Preventive Care Delivery in US Office-Based and Telemedicine Visits During the COVID-19 Pandemic

Question

Has the COVID-19 pandemic been associated with any changes in the clinical content of ambulatory care in the US?

Findings

In this cross-sectional study of serial data from the IQVIA National Disease and Therapeutic Index, there was a moderate rebound in office-based care during the second half of 2020, while telemedicine accounted for 23.9% of care observed. Office-based care during the pandemic (quarters 2-4 of 2020) involved 58.0% long-term, 23.0% short-term, and 25.6% preventive diagnoses, while telemedicine care involved substantially greater long-term (77.2%), modestly greater short-term (26.8%), and almost no preventive (2.7%) diagnoses.

Meaning

In contrast to office-based care, telemedicine was more commonly used for established patients and substantially greater delivery of psychiatric or behavioral treatments than preventive care.

Importance

While the COVID-19 pandemic has been associated with some substitution of telemedicine for office-based care in the US, to our knowledge, little is known regarding the pandemic’s association with the clinical content of ambulatory care.

Objective

To characterize changes in the clinical content of ambulatory care among office-based vs telemedicine encounters in the US before vs during the COVID-19 pandemic.

Design, Settings, and Participants

This analysis of serial cross-sectional data from the IQVIA National Disease and Therapeutic Index was a 2-stage, stratified nationally representative audit of outpatient care in the US from January 1, 2018, through December 31, 2020. The National Disease and Therapeutic Index generates approximately 33 617 quarterly visits that are projected to 306.7 million national visits based on the survey design.

Main Outcomes and Measures

(1) Prevalence of common diagnoses and (2) mix of long-term, short-term, and preventive care.

Results

The mean (SD) number of projected quarterly, in-person, office-based visits was 282.1 (1.4) million in 2018 and 284.7 (10.3) in 2019 before declining to 250.8 million in quarter 1 of 2020 and 147.8 million in quarter 2 of 2020 and then increasing moderately to 181.5 million in quarter 3 of 2020 and 180.2 million in quarter 4 of 2020. The mean (SD) number of telemedicine visits was 2.8 (0.4) million in 2018 and 3.0 (0.1) million in 2019 before increasing to 8.6 million in quarter 1 of 2020 and 72.2 million in quarter 2 of 2020 and then declining notably to 43.8 million in quarter 3 of 2020 and 44.2 million in quarter 4 of 2020. Office-based care during the second through fourth quarters of 2020 involved 58.0% long-term, 23.0% short-term, and 25.6% preventive care. In contrast to office-based care, 4 of the top 10 diagnoses that were treated by telemedicine during 2020 were for psychiatric or behavioral conditions: depression, attention deficit/hyperactivity, anxiety, and bipolar disorders. Throughout this period, approximately half of office-based visits and nearly two-thirds of telemedicine visits were for established rather than new patients.

Conclusions and Relevance

This cross-sectional study’s findings suggest that while telemedicine rapidly increased early during course of the COVID-19 pandemic, its use declined modestly since then. In contrast to office-based care, telemedicine was more commonly used for established patients and substantially greater delivery of psychiatric or behavioral treatments rather than preventive care.

Fetus in fetu: two case reports from North African country

Background

Fetus in fetu is a rare congenital anomaly. The exact etiology is unclear; one of the mostly accepted theories is the occurrence of an embryological insult occurring in a diamniotic monochorionic twin leading to asymmetrical division of the blastocyst mass. Commonly, they present in the infancy with clinical picture related to their mass effect. About 80% of cases are in the abdomen retroperitoneally.

Case presentation

We present two cases of this rare condition. The first case was for a 10-year-old girl that presented with anemia and abdominal mass, while the second case was for a 4-month-old boy that was diagnosed antenatally by ultrasound. Both cases had vertebrae, recognizable fetal organs, and skin coverage. Both had a distinct sac. The second case had a vascular connection with the host arising from the superior mesenteric artery. Both cases were intra-abdominal and showed normal levels of alpha-fetoprotein. Histopathological examination revealed elements from the three germ layers without any evidence of immature cells ruling out teratoma as a differential diagnosis.

Conclusions

Owing to its rarity, fetus in fetu requires a high degree of suspicion and meticulous surgical techniques to avoid either injury of the adjacent vital structures or bleeding from the main blood supply connection to the host. It should be differentiated from mature teratoma.

Modeling Mitigation Strategies to Reduce Opioid-Related Morbidity and Mortality in the US

IMPORTANCE

The US opioid epidemic is complex and dynamic, yet relatively little is known regarding its likely future impact and the potential mitigating impact of interventions to address it.

OBJECTIVE

To estimate the future burden of the opioid epidemic and the potential of interventions to address the burden.

DESIGN, SETTING, AND PARTICIPANTS

A decision analytic dynamic Markov model was calibrated using 2010-2018 data from the National Survey on Drug Use and Health, Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey, the US Census, and National Epidemiologic Survey on Alcohol and Related Conditions-III. Data on individuals 12 years or older from the US general population or with prescription opioid medical use; prescription opioid nonmedical use; heroin use; prescription, heroin, or combined prescription and heroin opioid use disorder (OUD); 1 of 7 treatment categories; or nonfatal or fatal overdose were examined. The model was designed to project fatal opioid overdoses between 2020 and 2029.

EXPOSURES

The model projected prescribing reductions (5% annually), naloxone distribution (assumed 5% reduction in case-fatality), and treatment expansion (assumed 35% increase in uptake annually for 4 years and 50% relapse reduction), with each compared vs status quo.

MAIN OUTCOMES AND MEASURES

Projected 10-year overdose deaths and prevalence of OUD.

RESULTS

Under status quo, 484 429 (95% confidence band, 390 543-576 631) individuals were projected to experience fatal opioid overdose between 2020 and 2029. Projected decreases in deaths were 0.3% with prescribing reductions, 15.4% with naloxone distribution, and 25.3% with treatment expansion; when combined, these interventions were associated with 179 151 fewer overdose deaths (37.0%) over 10 years. Interventions had a smaller association with the prevalence of OUD; for example, the combined intervention was estimated to reduce OUD prevalence by 27.5%, from 2.47 million in 2019 to 1.79 million in 2029. Model projections were most sensitive to assumptions regarding future rates of fatal and nonfatal overdose.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the opioid epidemic is likely to continue to cause tens of thousands of deaths annually over the next decade. Aggressive deployment of evidence-based interventions may reduce deaths by at least a third but will likely have less impact for the number of people with OUD.

Use and Content of Primary Care Office-Based vs Telemedicine Care Visits During the COVID-19 Pandemic in the US

Importance

Little is known about the association between the coronavirus disease 2019 (COVID-19) pandemic and the level and content of primary care delivery in the US.

Objective

To quantify national changes in the volume, type, and content of primary care delivered during the COVID-19 pandemic, especially with regard to office-based vs telemedicine encounters.

Design, Setting, and Participants

Analysis of serial cross-sectional data from the IQVIA National Disease and Therapeutic Index, a 2-stage, stratified nationally representative audit of outpatient care in the US from the first calendar quarter (Q1) of 2018 to the second calendar quarter (Q2) of 2020.

Main Outcomes and Measures

Visit type (office-based or telemedicine), overall and stratified by patient population and geographic region; assessment of blood pressure or cholesterol measurement; and initiation or continuation of prescription medications.

Results

In the 8 calendar quarters between January 1, 2018, and December 31, 2019, between 122.4 million (95% CI, 117.3-127.5 million) and 130.3 million (95% CI, 124.7-135.9 million) quarterly primary care visits occurred in the US (mean, 125.8 million; 95% CI, 121.7-129.9 million), most of which were office-based (92.9%). In 2020, the total number of encounters decreased to 117.9 million (95% CI, 112.6-123.2 million) in Q1 and 99.3 million (95% CI, 94.9-103.8 million) in Q2, a decrease of 21.4% (27.0 million visits) from the average of Q2 levels during 2018 and 2019. Office-based visits decreased 50.2% (59.1 million visits) in Q2 of 2020 compared with Q2 2018-2019, while telemedicine visits increased from 1.1% of total Q2 2018-2019 visits (1.4 million quarterly visits) to 4.1% in Q1 of 2020 (4.8 million visits) and 35.3% in Q2 of 2020 (35.0 million visits). Decreases occurred in blood pressure level assessment (50.1% decrease, 44.4 million visits) and cholesterol level assessment (36.9% decrease, 10.2 million visits) in Q2 of 2020 compared with Q2 2018-2019 levels, and assessment was less common during telemedicine than during office-based visits (9.6% vs 69.7% for blood pressure; P < .001; 13.5% vs 21.6% for cholesterol; P < .001). New medication visits in Q2 of 2020 decreased by 26.0% (14.1 million visits) from Q2 2018-2019 levels. Telemedicine adoption occurred at similar rates among White individuals and Black individuals (19.3% vs 20.5% of patient visits, respectively, in Q1/Q2 of 2020), varied by region (low of 15.1% of visits [East North Central region], high of 26.8% of visits [Pacific region]), and was not correlated with regional COVID-19 burden.

Conclusions and Relevance

The COVID-19 pandemic has been associated with changes in the structure of primary care delivery, with the content of telemedicine visits differing from that of office-based encounters.

Interaction of Low Molecular Weight Poly(diallyldimethylammonium chloride) and Sodium Dodecyl Sulfate in Low Surfactant-Polyelectrolyte Ratio, Salt-Free Solutions

Coacervation is widely used in formulations to induce a beneficial character to the formulation, but nonequilibrium effects are often manifest. Electrophoretic NMR (eNMR), pulsed-gradient spin-echo NMR (PGSE-NMR), and small-angle neutron scattering (SANS) have been used to quantify the interaction between low molecular cationic poly(diallyldimethylammonium chloride) (PDADMAC) and the anionic surfactant sodium dodecyl sulfate (SDS) in aqueous solution as a model for the precursor state to such nonequilibrium processes. The NMR data show that, within the low surfactant concentration one-phase region, an increasing surfactant concentration leads to a reduction in the charge on the polymer and a collapse of its solution conformation, attaining minimum values coincident with the macroscopic phase separation boundary. Interpretation of the scattering data reveals how the rodlike polymer changes over the same surfactant concentration window, with no discernible fingerprint of micellar type aggregates, but rather with the emergence of disklike and lamellar structures. At the highest surfactant concentration, the emergence of a weak Bragg peak in both the polymer and surfactant scattering suggests these precursor disk and lamellar structures evolve into paracrystalline stacks which ultimately phase separate. Addition of the nonionic surfactant hexa(ethylene glycol) monododecyl ether (C₁₂E₆) to the system seems to have little effect on the PDADMAC/SDS interaction as determined by NMR, merely displacing the observed behavior to lower SDS concentrations, commensurate with the total SDS present in the system. In other words, PDADMAC causes the disruption of the mixed SDS/C₁₂E₆ micelle, leading to SDS-rich PDADAMC/surfactant complexes coexisting with C₁₂E₆-rich micelles in solution.

Outpatient Parenteral Antimicrobial Therapy in the Time of COVID-19: The Urgent Need for Better Insurance Coverage

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it causes, coronavirus disease 2019 (COVID-19), are placing unprecedented pressure on every health care system. Patients who require weeks of intravenous antibiotic therapy after hospital discharge due to severe bacterial infections, generally referred to as outpatient parenteral antibiotic therapy (OPAT), are at increased risk for contracting and/or transmitting COVID-19 due to extensive contact with the health care system. To reduce the risk of COVID-19 among this vulnerable patient population, providers overseeing OPAT care need to consider the relative safety of the different OPAT sites of care. Home-based OPAT should be emphasized to minimize hospital stays and prevent skilled nursing facility admissions. Medicare reimbursement policies need to urgently change to provide comprehensive coverage of home infusion services.

Association between sodium-glucose cotransporter 2 (SGLT2) inhibitors and lower extremity amputation: A systematic review and meta-analysis

Background

The association between sodium-glucose cotransporter 2 inhibitors (SGLT2i’s) and lower extremity amputation is unclear.

Purpose

To systematically review randomized control trials (RCTs) and observational studies quantifying risk of lower extremity amputations associated with SGLT2i use.

Data sources and study selection

We searched PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials from January 2011 to February 2020 for RCTs and observational studies including lower extremity amputation outcomes for individuals with type 2 diabetes mellitus treated with SGLT2i’s vs. alternative treatments or placebo.

Data extraction and synthesis

Two reviewers independently extracted data.

Main outcomes and measures

Our primary outcome was risk of lower limb amputation. Secondary outcomes included peripheral arterial disease, peripheral vascular disease, venous ulcerations, and diabetic foot infections. We also evaluated the risk of bias. We conducted random and fixed effects relative risk meta-analysis of RCTs.

Results

After screening 2,006 studies, 12 RCTs and 18 observational studies were included, of which 7 RCTs and 18 observational studies had at least one event. The random effects meta-analysis of 7 RCTs suggested the absence of a statistically significant association between SGLT2i exposure with evidence of substantial statistical heterogeneity (n = 424/23,716 vs n = 267/18,737 in controls; RR 1.28, CI’s 0.93–1.76; I² = 62.0%; p = 0.12) whereas fixed effects analysis showed an increased risk with statistical heterogeneity (RR 1.27, 1.09–1.48; I² = 62%; p = 0.003). Subgroup analysis of canagliflozin vs placebo showed a statistically significantly increased risk in a fixed effects meta-analysis (n = 2 RCTs, RR 1.59, 1.26–2.01; I² = 88%; p = 0.0001) whereas the meta-analysis of dapagliflozin or empagliflozin (n = 2 RCTs each) and a single RCT for ertugliflozin did not show a significantly increased risk. The findings from observational studies were too heterogeneous to be pooled in a meta-analysis and draw meaningful conclusions. Both randomized and observational studies were of generally good methodological quality.

Conclusions

Overall, there was no consistent evidence of SGLT2i exposure and increased risk of amputation. The increased risk of amputation seen in the large, long-term Canagliflozin Cardiovascular Assessment Study (CANVAS) trial for canagliflozin, and select observational studies, merits continued exploration.

Disparities in mortality among adults with and without diabetes by sex and race

OBJECTIVE

The aim of this study was to examine whether the reduction in the mortality gap between individuals with and without diabetes varies by sex and race/ethnicity.

METHODS

We analyzed data in adults from the National Health and Nutrition Examination Survey (NHANES) 1999-2010 and their linked mortality data through 2015. Cox proportional hazards models were used to examine the risk of all-cause and cause-specific mortality among participants with diabetes as compared to those without diabetes by sex and race/ethnicity in 1999-2004 and 2005-2010.

RESULTS

The risk of all-cause mortality was significantly higher in women with diabetes compared to those without diabetes in both study periods (HR 1.6, 95% CI: 1.2, 2.2; HR 1.5, 95% CI: 1.1, 2.0). Among men, the risk of all-cause mortality was significantly higher in men with compared to men without diabetes in 1999-2004 but not in 2005-2010. There was no significant association between diabetes and CVD mortality among men in 2005-2010, while the association was significant among women in both study periods (HR 2.5, 95% CI: 1.6, 3.7; HR 2.8, 95% CI: 1.3, 5.9). The association between diabetes and all-cause mortality was similar across racial/ethnic groups in 1999-2004, but was significantly higher among non-Hispanic blacks and Mexican Americans in 2005-2010.

CONCLUSIONS

Progress in reducing mortality among individuals with diabetes has been more significant among men and non-Hispanic whites. Sex and racial/ethnic disparities in mortality among individuals with diabetes still persist.

Environmental gas impact on the emission volume of X-rays near the interface in the variable pressure scanning electron microscopy

In this paper, our previously developed model to account for the secondary X-ray fluorescence and absorption effects near the interface of two adjacent materials in a high-vacuum scanning electron microscope (Zoukel & Khouchaf, 2014) is adapted and extended to experimental conditions of low-vacuum mode (in the presence of a gaseous environment in the SEM analysis chamber). The position shifting effect of the two Gaussian peaks issued from the first derivative equation that can fit the experimental low-vacuum EDS profiles is investigated. The impact of the medium gas on the emission volume of secondary X-rays near the interface is qualitatively discussed. Water vapour and helium are successively used as gas environment, in order to link the resolution of microanalysis profiles with the effects of the X-ray fluorescence and absorption phenomenon. A close agreement between Monte Carlo simulation and experimental results is found.

Patient Experiences With Outpatient Parenteral Antibiotic Therapy: Results of a Patient Survey Comparing Skilled Nursing Facilities and Home Infusion

Objective

This work compares overall patient satisfaction with outpatient parenteral antibiotic therarpy (OPAT) care across the skilled nursing facility (SNF) and home healthcare company (HHC) settings; identifies barriers to patient satisfaction in OPAT; and develops a model for OPAT patient satisfaction that can help programs improve the patient experience across both sites of care.

Method

We developed and administered a patient experience survey to 100 patients returning to a single clinic for follow up. The survey consisted of 15 items (Likert scale, multiple choice, and free text responses). Patient characteristics and responses to the survey for patients who received care at home and at SNFs were analyzed and compared.

Results

Of the 100 patients surveyed, 98 completed the survey. Overall, HHC patients were satisfied more with their care than patients in SNFs, with a greater proportion stating they would recommend the site to others (71.7% for HHC and 32.7% for SNFs, P < .01). Patients in SNFs had a larger number of complaints about lapses in medical care, infection prevention, and the physical environment than HHC patients.

Conclusions

Patient satisfaction in OPAT is higher for home infusion than SNFs. In order to improve the patient experience, OPAT programs need to engage stakeholders in HHCs and SNFs to improve communication and care delivery.

Impact of the implementation of a nurse-managed outpatient parenteral antibiotic therapy (OPAT) system in Baltimore: a case study demonstrating cost savings and reduction in re-admission rates

Objectives

Evidence supports the safety and effectiveness of outpatient parenteral antibiotic therapy (OPAT). A registered nurse (RN)-managed multidisciplinary team OPAT model was implemented at our hospital. We evaluated the impact of the new OPAT model on readmissions during OPAT and other core OPAT processes.

Methods

All potential OPAT cases from 1 November 2013 to 31 June 2017 discharged from the Johns Hopkins Bayview Medical Center were followed up in a retrospective cohort study. Relevant clinical and patient characteristics were collected for the first OPAT course per patient. The primary outcome was all-cause readmission to any facility part of the Johns Hopkins Health System within 30 days of OPAT discharge. Proportions of OPAT patients readmitted before and after the implementation of the new OPAT model were compared. A log-binomial regression was used to compare the risk of readmission, adjusted for age, sex, race/ethnicity, site of OPAT care, opioid dependence and OPAT treatment duration.

Results

Five hundred and seventeen OPAT patients were included in the analysis; 51.1% were discharged after the implementation of the new OPAT model. Readmission rates decreased from 20.2% to 13.3% following the RN-managed OPAT programme (P = 0.04). The results of the adjusted model indicated that nurse management was associated with a 39% reduction in the risk of readmission (adjusted relative risk 0.61; 95% CI 0.41-0.91; P = 0.01). Our financial evaluation estimated that the reduction in readmissions achieved by the RN-managed model saved the hospital $649 416 over 15 months.

Conclusions

The RN-managed OPAT programme was associated with a significant reduction in readmissions.

Impact of a national nutritional support programme on loss to follow-up after tuberculosis diagnosis in Kenya

SETTING

Undernourishment is prevalent among tuberculosis (TB) patients. Nutritional support is given to TB patients to prevent and treat undernourishment; it is also used to improve treatment outcomes and as an incentive to keep patients on treatment.

OBJECTIVE

To determine whether nutritional support is associated with a reduction in the risk of loss to follow-up (LTFU) among TB patients in Kenya.

DESIGN

This was a retrospective cohort study using national programmatic data. Records of 362 685 drug-susceptible TB patients from 2012 to 2015 were obtained from Treatment Information from Basic Unit (TIBU), a national case-based electronic data recording system. Patients who were LTFU were compared with those who completed treatment.

RESULTS

Nutrition counselling was associated with an 8% reduction in the risk of LTFU (RR 0.92, 95%CI 0.89-0.95), vitamins were associated with a 7% reduction (adjusted RR [aRR] 0.93, 95%CI 0.90-0.96) and food support was associated with a 10% reduction (aRR 0.90, 95%CI 0.87-0.94). Among patients who received food support, the addition of nutrition counselling was associated with a 23% reduction in the risk of LTFU (aRR 0.77, 95%CI 0.67-0.88).

CONCLUSION

Nutritional support was associated with a reduction in the risk of LTFU. Providing nutrition counselling is important for patients receiving food support.

Electrophoretic NMR Characterization of Charged Side Chain Cationic Polyelectrolytes and Their Interaction with the Anionic Surfactant, Sodium Dodecyl Sulfate

Oppositely charged polymers and surfactants show a complex phase behavior with large regions of solubility and insolubility dependent on the concentrations of the species present. Here, a series of quaternized hydroxyethyl cellulose (cationic) polymers have been characterized by pulsed-gradient spin-echo NMR (PGSE-NMR) and electrophoretic NMR (eNMR) in simple aqueous (D₂O) solutions and in combination with the oppositely charged (anionic) surfactant, sodium dodecyl sulfate (SDS). Analysis of the effective charge on the polymer derived from both the eNMR and PGSE-NMR results yields a readily interpretable insight into the polymer behavior; the effective charge on the polymer at infinite dilution shows a linear relationship with the degree of modification. On addition of low concentrations of SDS, typically C_surf < 5 mM, the surfactant interacts with the charged polymers, leading to substantial changes in the dynamics of the system (polymer diffusion, viscosity). At these levels of surfactant addition, there is no macroscopic phase separation. Further, with the absence of an interaction with the parent, the uncharged polymer strongly suggests that the SDS only interacts with the charged moieties present on the functionalized side groups and not the polymer backbone. Ultimately, the charge on the soluble polymer/surfactant complex was found to depend linearly on the level of surfactant binding across a series of polymers with differing levels of modification with the charge becoming effectively zero at the macroscopic phase separation boundary.

Evaluation of antibiotic mix in Non-instrumentation Endodontic Treatment of necrotic primary molars

AIM

To compare the clinical and radiographic success rates of an antibiotic mix consisting of metronidazole, minocycline and ciprofloxacin (3Mix-MP) and another mix where minocycline was replaced with clindamycin (3Mix-MP-R) in non-instrumentation endodontic treatment (NIET) of necrotic primary molars and to determine the effect of root resorption on the success of the treatment.

MATERIALS AND METHODS

Forty-two necrotic mandibular primary molars from 22 healthy children were randomly assigned to either mixture. Blinded clinical evaluation was conducted after 1, 3, 6 and 12 months by the operator, and blinded radiographic evaluation was conducted at 6 and 12 months follow-ups by other two investigators with inter-examiner reproducibility of 0.95.

RESULTS

Overall success rates of 3Mix-MP and 3Mix-MP-R were 80.96% and 76.20% respectively, with no statistically significant difference. Radiographically, resorption of more than one third of the root length had a lower failure rate with no statistically significant difference (p<0.5).

CONCLUSION

Primary teeth with necrotic pulp can be treated with 3Mix-MP or 3Mix-MP-R irrespective of the degree of root resorption.

Association of new opioid continuation with surgical specialty and type in the United States

BACKGROUND

The consequences of opioids-including post-surgical prescriptions-remain a critical public health issue. We sought to determine how procedure type and subspecialty group influence new opioid use after procedures.

METHODS

We analyzed 2011-2015 IBM MarketScan Research Databases to identify opioid-naïve adults prescribed opioids for single surgical procedures. We defined new opioid continuation (primary outcome) a priori as receipt of prescription opioids between 90 and 180 days after the procedure.

RESULTS

Among 912,882 individuals, new opioid continuation was higher for non-operating room compared to operating room procedures (13.1% versus 9.2%; aOR 1.61; 95% CI 1.59-1.64) and higher for subspecialties including colorectal surgery (aOR 1.35; 95% CI 1.26-1.43) and cardiovascular surgery (aOR 1.30; 95% CI 1.12-1.50) compared to urology as a referent. New opioid continuation was also associated with perioperative opioid prescription dosage, days' supply, preoperative receipt, and multiple prescriptions.

CONCLUSIONS

Opioids prescriptions associated with non-operating room surgical exposures appear to confer higher risk regarding conversion to new long-term opioid use.

Outpatient Parenteral Therapy for Complicated Staphylococcus aureus Infections: A Snapshot of Processes and Outcomes in the Real World

Background

In the United States, patients discharged on outpatient parenteral antimicrobial therapy (OPAT) are often treated by home health companies (HHCs) or skilled nursing facilities (SNFs). Little is known about differences in processes and outcomes between these sites of care.

Methods

We performed a retrospective study of 107 patients with complicated Staphylococcus aureus infections discharged on OPAT from 2 academic medical centers. Clinical characteristics, site of posthospital care, process measures (lab test monitoring, clinic follow-up), adverse events (adverse drug events, Clostridium difficile infection, line events), and clinical outcomes at 90 days (cure, relapse, hospital readmission) were collected. Comparisons between HHCs and SNFs were conducted.

Results

Overall, 33% of patients experienced an adverse event during OPAT, and 64% were readmitted at 90 days. Labs were received for 44% of patients in SNFs and 56% of patients in HHCs. At 90 days after discharge, a higher proportion of patients discharged to an SNF were lost to follow-up (17% vs 3%; P = .03) and had line-related adverse events (18% vs 2%; P < .01). Patients discharged to both sites of care experienced similar clinical outcomes, with favorable outcomes occurring in 61% of SNF patients and 70% of HHC patients at 90 days. There were no differences in rates of relapse, readmission, or mortality.

Conclusions

Patients discharged to SNFs may be at higher risk for line events than patients discharged to HHCs. Efforts should be made to strengthen basic OPAT processes, such as lab monitoring and clinic follow-up, at both sites of care.

Association Between Sodium-Glucose Cotransporter 2 Inhibitors and Lower Extremity Amputation Among Patients With Type 2 Diabetes

IMPORTANCE

Results of clinical trials suggest that canagliflozin, a sodium-glucose cotransporter 2 (SGLT-2) inhibitor for treating type 2 diabetes, may be associated with lower extremity amputation.

OBJECTIVE

To quantify the association between the use of oral medication for type 2 diabetes and 5 outcomes (lower extremity amputation, peripheral arterial disease, critical limb ischemia, osteomyelitis, and ulcer).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted using Truven Health MarketScan Commercial Claims and Encounters data on new users between September 1, 2012, and September 30, 2015. The study focused on 2.0 million commercially insured individuals and used propensity score weighting to balance baseline differences among groups. Sensitivity analyses varied statistical models, assessed the effect of combining dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagon-like peptide 1 (GLP-1) agonists as a single referent group, adjusted for baseline use of older oral agents, and included people with baseline amputation.

EXPOSURES

New use of SGLT-2 inhibitors alone, DPP-4 inhibitors alone, GLP-1 agonists alone, or other antidiabetic agents (sulfonylurea, metformin hydrochloride, or thiazolidinediones).

MAIN OUTCOMES AND MEASURES

Foot and leg amputation, defined by validated International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes.

RESULTS

Among 2.0 million potentially eligible individuals, a total of 953 906 (516 046 women and 437 860 men; mean [SD] age, 51.8 [10.9] years) were included in the final analyses, including 39 869 new users of SGLT-2 inhibitors (4.2%), 105 023 new users of DPP-4 inhibitors (11.0%), and 39 120 new users of GLP-1 agonists (4.1%). The median observation time ranged from 99 days for new users of GLP-1 agonists to 127 days for those using metformin, sulfonylureas, and thiazolidinediones, while the crude incident rates ranged from 4.90 per 10 000 person-years for those using metformin, sulfonylureas, and thiazolidinediones to 10.53 per 10 000 person-years for new users of SGLT-2 inhibitors. After propensity score weighting and adjustment for demographics, severity of diabetes, comorbidities, and medications, there was a nonstatistically significant increased risk of amputation associated with new use of SGLT-2 inhibitors compared with DPP-4 inhibitors (adjusted hazard ratio, 1.50; 95% CI, 0.85-2.67) and GLP-1 agonists (adjusted hazard ratio, 1.47; 95% CI, 0.64-3.36). New use of SGLT-2 inhibitors was statistically significantly associated with amputation compared with sulfonylureas, metformin, or thiazolidinediones (adjusted hazard ratio, 2.12; 95% CI, 1.19-3.77). These results persisted in sensitivity analyses.

CONCLUSIONS AND RELEVANCE

Use of SGLT-2 inhibitors may be associated with increased risk of amputation compared with some oral treatments for type 2 diabetes. Further observational studies are needed with extended follow-up and larger sample sizes.

Promising sub-100 nm tailor made hollow chitosan/poly(acrylic acid) nanocapsules for antibiotic therapy

Herein, we report on the preparation of ultra-low sized (<100 nm in diameter) biodegradable polymeric capsules for potential applications as nanocontainers in antibiotic therapy. Hollow nanospheres based on the chitosan/poly(acrylic acid) pair are elaborated via (i) the layer-by-layer technique using gold nanoparticles (20 and 60 nm in size) as sacrificial templates, (ii) loading with amoxicillin, a betalactam antibiotic, and (iii) removal of the gold core via cyanide-assisted hydrolysis. Size, dispersity and concentration of the resulting nanocapsules are easily tuned by the nanoparticle templates, while wall thickness is controlled by the number of polyelectrolyte bilayers. Electrostatic interactions between the protonated amine groups of chitosan and the carboxyl groups of poly(acrylic acid) act as the driving attraction force allowing easy and fast design of robust and well-ordered multilayer films. Successful hydrolysis of the gold core is evidenced by time-dependent monitoring of the gold spectroscopic signature (absorbance at 519 nm and 539 nm for the gold nanoparticles with 20 and 60 nm, respectively). Crosslinked capsules are also prepared through crosslinking of the chitosan chains with glutaraldehyde. Chitosan-based nanocapsules are finally evidenced to be promising drug delivery vehicles of amoxicillin trihydrate with tuneable properties such as entrapment efficiency in the range of 62-75% and 3.5-5.5% concerning the drug loading.

Do model polymer therapeutics sufficiently diffuse through articular cartilage to be a viable therapeutic route?

The ability of a polymer therapeutic to access the appropriate subcellular location is crucial to its efficacy and is defined to a large part by the many and complex cellular biological and biochemical barriers such that a construct must traverse. It is shown here that model dextrin conjugates are able to pass through a cartilaginous extracellular matrix into chondrocytes, with little perturbation of the matrix structure, indicating that targeting of potential therapeutics through a cartilaginous extracellular matrix should be proven possible. Rapid chondrocytic targeting of drugs which require intra cellularisation for their activity and uniform extracellular concentrations of drugs with an extracellular target, is thus enabled though polymer conjugation.

Endocytic Uptake, Transport and Macromolecular Interactions of Anionic PAMAM Dendrimers within Lung Tissue

Purpose

Polyamidoamine (PAMAM) dendrimers are a promising class of nanocarrier with applications in both small and large molecule drug delivery. Here we report a comprehensive evaluation of the uptake and transport pathways that contribute to the lung disposition of dendrimers.

Methods

Anionic PAMAM dendrimers and control dextran probes were applied to an isolated perfused rat lung (IPRL) model and lung epithelial monolayers. Endocytosis pathways were examined in primary alveolar epithelial cultures by confocal microscopy. Molecular interactions of dendrimers with protein and lipid lung fluid components were studied using small angle neutron scattering (SANS).

Results

Dendrimers were absorbed across the intact lung via a passive, size-dependent transport pathway at rates slower than dextrans of similar molecular sizes. SANS investigations of concentration-dependent PAMAM transport in the IPRL confirmed no aggregation of PAMAMs with either albumin or dipalmitoylphosphatidylcholine lung lining fluid components. Distinct endocytic compartments were identified within primary alveolar epithelial cells and their functionality in the rapid uptake of fluorescent dendrimers and model macromolecular probes was confirmed by co-localisation studies.

Conclusions

PAMAM dendrimers display favourable lung biocompatibility but modest lung to blood absorption kinetics. These data support the investigation of dendrimer-based carriers for controlled-release drug delivery to the deep lung.

Electronic supplementary material

The online version of this article (doi:10.1007/s11095-017-2190-7) contains supplementary material, which is available to authorized users.

Gender-specific determinants of asthma among U.S. adults

BACKGROUND

Asthma, a chronic respiratory disease affecting over 18.7 million American adults, has marked disparities by gender, race/ethnicity and socioeconomic status. Our goal was to identify gender-specific demographic and socioeconomic determinants of asthma prevalence among U.S. adults using data from the Behavioral Risk Factors Surveillance System (BRFSS) and the National Health and Nutrition Examination Survey (NHANES).

METHODS

Gender-specific regression analyses were performed to model the relationship between asthma prevalence with age, race/ethnicity, income, education level, smoking status, and body mass index (BMI), while taking into account the study designs.

RESULTS

Based on BRFSS data from 1,003,894 respondents, weighted asthma prevalence was 6.2% in males and 10.6% in females. Asthma prevalence among grade 2 obese and grade 3 obese vs. not overweight or obese women was 2.5 and 3.5 times higher, respectively, while that in men was 1.7 and 2.4 times higher; asthma prevalence among current vs. never smoker women was 1.4 times higher, while that in men was 1.1 times higher. Similar results were obtained with NHANES data from 13,364 respondents: asthma prevalence among grade 2 obese and grade 3 obese vs. not overweight or obese respondents was 2.0 and 3.3 times higher for women, though there was no significant difference for men; asthma prevalence among current vs. never smokers was 1.8 times higher for women and not significantly different in men. Asthma prevalence by race/ethnicity and income levels did not differ considerably between men and women.

CONCLUSIONS

Our results underscore the importance of obesity and smoking as modifiable asthma risk factors that most strongly affect women.

Spread-Spectrum Beamforming and Clutter Filtering for Plane-Wave Color Doppler Imaging

Plane-wave imaging is desirable for its ability to achieve high frame rates, allowing the capture of fast dynamic events and continuous Doppler data. In most implementations of plane-wave imaging, multiple low-resolution images from different plane wave tilt angles are compounded to form a single high-resolution image, thereby reducing the frame rate. Compounding improves the lateral beam profile in the high-resolution image, but it also acts as a low-pass filter in slow time that causes attenuation and aliasing of signals with high Doppler shifts. This paper introduces a spread-spectrum color Doppler imaging method that produces high-resolution images without the use of compounding, thereby eliminating the tradeoff between beam quality, maximum unaliased Doppler frequency, and frame rate. The method uses a long, random sequence of transmit angles rather than a linear sweep of plane wave directions. The random angle sequence randomizes the phase of off-focus (clutter) signals, thereby spreading the clutter power in the Doppler spectrum, while keeping the spectrum of the in-focus signal intact. The ensemble of randomly tilted low-resolution frames also acts as the Doppler ensemble, so it can be much longer than a conventional linear sweep, thereby improving beam formation while also making the slow-time Doppler sampling frequency equal to the pulse repetition frequency. Experiments performed using a carotid artery phantom with constant flow demonstrate that the spread-spectrum method more accurately measures the parabolic flow profile of the vessel and outperforms conventional plane-wave Doppler in both contrast resolution and estimation of high flow velocities. The spread-spectrum method is expected to be valuable for Doppler applications that require measurement of high velocities at high frame rates.

Correlates of default from anti-tuberculosis treatment: a case study using Kenya's electronic data system

BACKGROUND

In 2012, the World Health Organization estimated that there were 120,000 new cases and 9500 deaths due to tuberculosis (TB) in Kenya. Almost a quarter of the cases were not detected, and the treatment of 4% of notified cases ended in default.

OBJECTIVE

To identify the determinants of anti-tuberculosis treatment default.

DESIGN

Data from 2012 and 2013 were retrieved from a national case-based electronic data recording system. A comparison was made between new pulmonary TB patients for whom treatment was interrupted vs. those who successfully completed treatment.

RESULTS

A total of 106,824 cases were assessed. Human immunodeficiency virus infection was the single most influential risk factor for default (aOR 2.7). More than 94% of patients received family-based directly observed treatment (DOT) and were more likely to default than patients who received DOT from health care workers (aOR 2.0). Caloric nutritional support was associated with lower default rates (aOR 0.89). Males were more likely to default than females (aOR 1.6). Patients cared for in the private sector were less likely to default than those in the public sector (aOR 0.86).

CONCLUSION

Understanding the factors contributing to default can guide future program improvements and serve as a proxy to understanding the factors that constrain access to care among undetected cases.

Ageing is a risk factor in imatinib mesylate cardiotoxicity

AIMS

Chemotherapy-induced heart failure is increasingly recognized as a major clinical challenge. Cardiotoxicity of imatinib mesylate, a highly selective and effective anticancer drug belonging to the new class of tyrosine kinase inhibitors, is being reported in patients, some progressing to congestive heart failure. This represents an unanticipated challenge that could limit effective drug use. Understanding the mechanisms and risk factors of imatinib mesylate cardiotoxicity is crucial for prevention of cardiovascular complications in cancer patients.

METHODS AND RESULTS

We used genetically engineered mice and primary rat neonatal cardiomyocytes to analyse the action of imatinib on the heart. We found that treatment with imatinib (200 mg/kg/day for 5 weeks) leads to mitochondrial-dependent myocyte loss and cardiac dysfunction, as confirmed by electron microscopy, RNA analysis, and echocardiography. Imatinib cardiotoxicity was more severe in older mice, in part due to an age-dependent increase in oxidative stress. Mechanistically, depletion of the transcription factor GATA4 resulting in decreased levels of its prosurvival targets Bcl-2 and Bcl-XL was an underlying cause of imatinib toxicity. Consistent with this, GATA4 haploinsufficient mice were more susceptible to imatinib, and myocyte-specific up-regulation of GATA4 or Bcl-2 protected against drug-induced cardiotoxicity.

CONCLUSION

The results indicate that imatinib action on the heart targets cardiomyocytes and involves mitochondrial impairment and cell death that can be further aggravated by oxidative stress. This in turn offers a possible explanation for the current conflicting data regarding imatinib cardiotoxicity in cancer patients and suggests that cardiac monitoring of older patients receiving imatinib therapy may be especially warranted.

Sphincter saving and abdomino-perineal resections following neoadjuvant chemoradiation in locally advanced low rectal cancer

BACKGROUND

The improvement in surgical techniques alongside neoadjuvant chemoradiation enabled more patients with low rectal cancer to have sphincter preservation.

STUDY AIM

To compare the oncologic and functional outcome in patients with locally advanced low rectal cancer treated by neoadjuvant chemoradiation followed by sphincter saving resection (SSR) against those who underwent abdomino-perineal resection (APR).

PATIENTS AND METHODS

A total of 111 patients with low rectal cancer were included in the study. Sixty-one consented patients who prospectively underwent SSR, from Jan 2008 to Jan 2013, and a retrospective group, formed of 50 patients, selected from cases seen at NCI, with comparable demographic, clinical and pathologic criteria, who underwent APR from Jan 2003 to Jan 2008. All lesions were <5 cm from anal verge. All 111 patients received preoperative chemoradiation and total mesorectal excision.

RESULTS

All tumors were located at a median of 3.6 cm (range 2.5-4.5 cm) for the SSR group, and 3.5 cm (range 2.5-4.6 cm) for the APR group, from the anal verge. The median follow-up was 34 months (range 1-60 months) for both groups. The difference in disease recurrence and OS between the APR and SSR groups were both statistically insignificant.

CONCLUSION

In low rectal cancer, the sphincter preservation appears to have nearly the same oncologic outcome compared to APR, this might be attributed to the small sample size and short follow up period. However, patients with sphincter preservation have certainly demonstrated an indisputable better functional outcome, in terms of stoma avoidance and adequate continence.

Evaluation of the frequency and pattern of local recurrence following intersphincteric resection for ultra-low rectal cancer

INTRODUCTION

Abdomino-perineal resection has been the standard treatment for rectal tumors located ≤5cm from the anal verge. Recently, intersphincteric resection became a valid option which preserves the bowel continuity with better functional outcome.

AIM

Is to evaluate the oncological and functional outcome alongside the associated surgical morbidity in patients with T1-3 rectal cancer, who underwent intersphincteric resection (ISR).

PATIENTS & METHODS

Between the years 2006 and 2011, 55 patients with invasive rectal adenocarcinoma, T1-3 lesions, located 2-5cm from the anal verge underwent ISR with total mesorectal excision. When inevitable, complete. ISR was performed, otherwise partial ISR was done. All T3 patients underwent total meso-rectal excision (TME) while some had lateral lymph node dissection (LND) with concomitant pelvic autonomic nerve preservation (PANP).

RESULTS

Among the 55 patients, 21 (38.1%) patients were T1-2 and 34 (61.9%) patients were T3. The tumor location range was 0-5cm from the anal verge (median 2.3cm). Partial or complete ISR was done for 35 (63.6%) and 20 (36.4%), respectively. Patients were followed for a median of 1.5 years (range 1-4.6 years). The 3 year local recurrence and distant metastasis free rates were 85.2% and 85.6%, respectively. All the 3 local recurrences occurred in T3 patients group, and had positive circumferential resection margins. Overall 3-year disease-free survival was 82.6%; while the overall 3-year survival was 88.7%.

CONCLUSION

Intersphincteric resection with TME does not affect the local recurrence or overall survival rate in early rectal cancer T1-2 & 3, with preservation of bowel continuity and better life quality.

Coiling of ruptured tiny cerebral aneurysms, feasibility, safety, and durability at midterm follow-up, and individual experience

BACKGROUND AND PURPOSE

The tiny size of cerebral aneurysms represents one of the challenging facets for endovascular treatment, with a high risk for intraoperative rupture (IOR). We report on the treatment of tiny ruptured saccular cerebral aneurysms by coil embolization. All cases were that of £ 2-3 mm aneurysms with at least one of the dimensions < 2 mm.

MATERIALS AND METHODS

Between April 2008 and December 2010, we performed a retrospective analysis of nine consecutive cases of tiny aneurysms treated by coil embolization in our institution.

RESULTS

Coil embolization was successfully performed in nine cases, whereas in one case, intraoperative rupture (IOR) of the fundus was encountered before complete obliteration of the aneurysm expected to be achieved with two coils. Complete occlusion (in n = 7 aneurysms) or near-complete immediate occlusion (in n = 2 aneurysms) was achieved. A total of 18 coils was used for coiling of the nine aneurysms, wherein five aneurysms were coiled with two coils each, two aneurysms with three coils each, and two aneurysms with only one coil each to achieve accepted results. Balloon assistance was used in three cases. Although a minimal coil projection in the parent vessel was seen in three cases, no untoward clinical complications were seen. At mean follow-up (6.7 months, interquartile range (IQR) 3-12 months), digital subtraction angiography (DSA) and magnetic resonance angiography (MRA) in nine patients demonstrated persistent complete occlusion in six of the aneurysms; one aneurysm showed marked filling of the fundus, and two showed neck remnant but did not need retreatment. All patients with available follow-up were independent in day-to-day activities with a modified Rankin score (mRS) of 0 or 1.

CONCLUSIONS

Coil embolization of tiny ruptured cerebral aneurysms is feasible. Careful consideration of the technical issues in treatment of such aneurysms is essential to achieve technical success while avoiding complications.

A phase 2 study of the combination of gemcitabine and cisplatin in patients with locally advanced or metastatic breast cancer previously treated with anthracyclines with/without taxanes

BACKGROUND AND OBJECTIVES

Many patients with relapsed metastatic breast cancer are pre-treated with taxanes and anthracyclines, which are usually given in the neoadjuvant/adjuvant setting or as first-line treatment for metastatic disease. The primary objective of this study was to determine the overall response rate for combination treatment with gemcitabine and cisplatin in patients with locally advanced or metastatic breast cancer who had relapsed after receiving one adjuvant/neoadjuvant or first-line metastatic chemotherapy regimen containing an anthracycline with/without a taxane. Secondary endpoints included duration of response, time to progression, one-year survival probability, and toxicity.

DESIGN AND SETTING

A single-arm, open-label, phase 2 study conducted at 17 investigative sites in Egypt.

PATIENTS AND METHODS

treatment consisted of gemcitabine (1250 mg/m2) on Days 1 and 8 and cisplatin (70 mg/m2) on Day 1 of each 21-day cycle. Treatment continued until disease progression or a maximum of 6 cycles.

RESULTS

Of 144 patients all were evaluable for safety and 132 patients were evaluable for efficacy. The overall response rate was 33.3% and 45.5% of the patients with stable disease as their best response. The median time-to-progression was 5.1 months and the one-year survival probability was 73%. The most common grade 3/4 adverse events were nausea/vomiting (20.1%), neutropenia (19.4%), anemia (13.9%), asthenia (11.1%), diarrhea (9.7%), stomatitis (7.6%), leucopenia (7.6%), and thrombocytopenia (6.2%). twelve (8.3%) patients had serious adverse events.

CONCLUSIONS

The results of this study indicate that gemcitabine and cisplatin were active and generally well tolerated in pretreated patients with locally advanced or metastatic breast cancer.

Alternate routes for children with difficult central venous access

BACKGROUND

Some children requiring chemotherapy, total parenteral nutrition, or repeated blood sampling for long periods have no more axillary, internal jugular, external jugular, saphenous, or femoral veins available for cannulation. In such patients, the central venous system can still be accessed via alternate routes e.g. the azygos vein, the gonadal vein or the inferior epigastric vein.

PATIENTS AND METHODS

We report the use of: 1) The inferior epigastric vein for placement of the catheter into the IVC in 20 patients. 2) The right gonadal vein for placement of the catheter using a retroperitoneal approach in five pediatric patients. 3) The second and third right intercostal veins for placement of the catheter by right intrapleural thoracotomy in five pediatric patients. Pre-procedural assessment of the patency of these veins was done using colour Doppler ultrasonography and confirmation of occlusion of common sites used for central venous access.

RESULTS

A total of 38 implantable venous access devices (IVAD) were inserted in 30 patients. The average age at operation was 1.4 years (range 1 month to 12 years). Infection was seen in two patients, venous thrombosis in two. The average longevity of IVAD is 6.5 months. Recovery from the procedure was uncomplicated and the patients were able to receive complete intravenous medication or nutritive mixtures after the insertion of the catheter.

CONCLUSION

The knowledge of alternate routes to obtain central venous access for children requiring chemotherapy, total parenteral nutrition, or repeated blood sampling for long periods is critically important, and the azygos system, right gonadal vein or the inferior epigastric vein can be used when standard accessible veins are unavailable.

Consumer impact of an interactive decision aid for rectal cancer patients offered adjuvant therapy

OBJECTIVE

There is increasing interest in the use of decision aids (DAs) to facilitate patient involvement in clinical decisions. This study explored the views of patients with colorectal cancer and participants in a community bowel screening service regarding an interactive DA concerning adjuvant treatment for rectal cancer, and the impact of the aid on knowledge, anxiety, attitudes and preferences for treatment options.

METHOD

Fourteen patients with colorectal cancer participated in four focus groups. Eighty-nine participants in a community bowel screening service completed a questionnaire before and 1 week after viewing the DA. Thirty were randomly selected to participate in a telephone interview to obtain qualitative feedback about the DA.

RESULTS

Focus group participants reported using information to evaluate their doctor's care and expertise, or to prepare themselves for future symptoms and side-effects. Most supported the use of a DA and preferred pie charts to convey risk information. Within the community sample, anxiety remained stable and knowledge increased after exposure to the DA. Almost all participants found the DA useful and easy to understand, and felt it would make the process of decision making easier.

CONCLUSION

A DA regarding adjuvant therapy for rectal cancer appears to be valued and to produce positive outcomes. A randomized controlled trial of this intervention is now required.

Diuretic contrast-enhanced magnetic resonance urography versus intravenous urography for depiction of nondilated urinary tracts

Diuretic contrast-enhanced magnetic resonance urography (MRU) is analogous to conventional intravenous urography (IVU) and, hence, designated as excretory MRU. It is performed with a T1-weighted fast gradient-echo sequence to obtain breath-hold, dynamic MRU after intravenous injection of low-dose furosemide (5-10 mg) and gadolinium (Gd) chelate. The combination of Gd and furosemide is the key for achieving a uniform distribution of the contrast material inside the entire urinary tract. It provides high-resolution images of nondilated urinary tracts and information about the renal function. This pictorial essay reviews the technical aspects and practical consideration of diuretic Gd-enhanced MRU and underlines its diagnostic capability in comparison with IVU in the depiction of nondilated collecting systems. We discuss its potential applications, as in young patients with anatomic anomalies, patients with renal transplants, patients allergic to iodinated contrast medium, and avoiding multimodality work-up in the evaluation of kidney donors and patients with renal and extrarenal tumor diseases.