Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

The effect of photodynamic therapy on the salivary flow rate, IgA concentration and C-reactive protein levels in active smokers: a case-control study

OBJECTIVE

This study aimed to evaluate the effect of photodynamic therapy (PDT) on the salivary flow rate, secretory immunoglobulin A, and C-reactive protein levels in active smokers.

PATIENTS AND METHODS

The present study is a prospective case-control study. Twenty active smokers were allocated to two groups randomly of ten participants each: the experimental group was irradiated while the control was exposed to sham irradiation by turning off the equipment. In the experimental group, methylene blue mediated PDT was applied both intra- and extra-orally over the major and minor salivary glands using a diode laser. 780 nm wavelength and 4 J/cm2 of energy were used to irradiate the 10 points of major salivary glands (6 for parotid and 2 for submandibular glands and 2 for sublingual glands). On the other hand, 660 nm was used to apply 10 J/cm2 of energy over the minor salivary glands at numerous points. The samples of the stimulated and unstimulated saliva were collected from both groups to assess the SFR. ELISA method was used to assess the level of salivary IgA levels, statistical analysis was done using a one-way ANOVA, and a p-value of <0.05 was considered significant.

RESULTS

The results showed a significant increment in salivary and secretory immunoglobulin A levels of subjects undergone photodynamic therapy. C-reactive protein levels were significantly decreased in subjects exposed to irradiation.

CONCLUSIONS

The present study concludes that photodynamic therapy significantly improves the salivary flow rate, secretory Immunoglobulin A, and oral health quality of life in smokers. The inflammatory salivary marker C-reactive protein, which is usually raised in smokers, is also reduced.

Provision of smoking cessation support for patients following a diagnosis of cancer in Ireland

There is growing evidence that smoking cessation (SC) improves outcomes following diagnosis of cancer. Notwithstanding adverse outcomes, a significant number of those diagnosed with cancer continue to smoke. Our objective was to document the SC services provided for patients with cancer by specialist adult cancer hospitals across Ireland, a country with a stated tobacco endgame goal. A cross-sectional survey based on recent national clinical guidelines was used to determine SC care delivery across eight adult cancer specialist hospitals, and one specialist radiotherapy centre. Qualtrics was used. The response rate was 88.9% with data reported from seven cancer hospitals and one specialist radiotherapy centre, all indicating they had some SC related provision (100%). Stop smoking medications were provided to cancer inpatients in two hospitals, at outpatients and attending day ward services in one hospital. Smokers with cancer were referred automatically to the SC service in two hospitals at diagnosis. While stop smoking medications were available 24 h a day in five hospitals, most did not stock all three (Nicotine Replacement Therapy, Bupropion, Varenicline). One hospital advised they had data on uptake of SC services for smokers with cancer but were unable to provide detail. There is considerable variation in SC information and services provided to cancer patients across adult cancer specialist centres in Ireland, reflecting the suboptimal practice of smoking cessation for patients with cancer found in the limited international audits. Such audits are essential to demonstrate service gaps and provide a baseline for service improvement.

Smoking cessation for cancer patients through the lens of cancer specialists: challenges & solutions

Background

The benefits of smoking cessation (SC) for cancer patients are widely recognised. However, there has been a limited emphasis on SC in this context and it continues to be a challenge for cancer patients. As part of a larger feasibility study aiming to develop a structured SC pathway for cancer patients in Ireland, this qualitative study explored the SC practices, experiences and opinions of oncology healthcare professionals (HCPs).

Methods

Semi-structured interviews were conducted with 18 HCPs from lung, breast, cervical, head and neck and general oncology, across 4 specialist adult cancer hospitals in Ireland. Interview transcripts were analysed using thematic analysis.

Results

Four key themes emerged:

(1) Frequently ask and advise but infrequently assist: most HCPs ask about smoking and many advise about available supports, but few refer patients to SC services. Where offered, referrals were to hospital SC services and/or nicotine replacement therapy was prescribed; no HCP prescribed varenicline or bupropion. Barriers included lack of time, ill-defined referral pathways and lack of knowledge.

(2) Increased willingness but differing ability to quit: most patients were interested in quitting post diagnosis and had varying support needs, linked to cancer stage, social circumstances and stress levels.

(3) Need for an integrated or parallel service: all HCPs suggested that a structured and defined referral pathway will facilitate SC.

(4) Motivational counselling and pharmacotherapy combination: many HCPs suggested face to face as the best mode of intervention initially, with regular follow ups and ongoing support virtually, started pre-treatment, with an empathetic and empowering approach with provision of both motivational counselling and SC pharmacotherapy.

Conclusions

Smoking post cancer diagnosis has serious implications for cancer treatment and prognosis but is frequently overlooked. These findings will inform the design of a SC pathway for cancer patients.

Key messages

• Despite increased willingness to quit, there is inadequate and inconsistent SC support provision for cancer patients.

• Tailored SC support should be an integral part of comprehensive cancer care.

Good perception of own lifestyle associated with poor attendance at Diabetic RetinaScreen Programme

Background

Untreated diabetic retinopathy is the most common cause of sight loss in people of working age. The Diabetic RetinaScreen programme (DRS) is the national diabetic retinopathy screening programme in Ireland which commenced in 2013 with aim to prevent diabetic retinopathy and subsequent blindness, through free screening and ophthalmology services. High uptake is crucial for the effectiveness of the programme. This study aimed to determine the sociodemographic, lifestyle and healthcare factors associated with attendance at the DRS programme in Ireland, using data from a national cohort study, the Irish Longitudinal Study on Ageing (TILDA).

Methods

The TILDA wave-4 dataset (anonymised) was utilised for the current study. Questions on DRS invitation and attendance formed part of the wave 4 study questionnaire. Multivariate logistic regression was used to examine independent factors associated with attendance. SPSS was used for analysis.

Results

418 respondents (7.3%) were invited to DRS and 373 (89.2%) attended. Among all those who were invited to DRS, 244 (58.4%) were male and 174 (41.6%) were female. The mean age was 69.8 years (53-84 years). Following multivariate logistic regression, following a good diet/taking exercise (OR = 0.29, 95% CI 0.10-0.82) was negatively associated with attendance, after adjustment for age, male gender, higher education and medical card.

Conclusions

Recognising factors linked with uptake is important to develop goal directed strategies. Interestingly those who stated they followed a good diet & took exercise and were compliant with DM prevention were less likely to attend DRS. Previous research has also indicated that a higher physical activity level is associated with higher self-perceived health status

Key messages

Persons with DM with good compliance to diet and exercise were found to have poor attendance at the DRS programme. Targeted advertising is required to raise awareness of diabetic retinopathy.

Safety of emergency, elective and day case operating during the winter period at East Suffolk and North Essex NHS Foundation Trust: lessons from the outcomes of 4,254 surgical patients from the first COVID-19 wave

BACKGROUND

There is limited evidence on perioperative outcomes of surgical patients during the COVID-19 pandemic to inform continued operating into the winter period.

METHODS

We retrospectively analysed the rate of 30-day COVID-19 transmission and mortality of all surgical patients in the three hospitals in our trust in the East of England during the first lockdown in March 2020. All patients who underwent a swab were swabbed on or 24 hours prior to admission.

RESULTS

There were 4,254 patients and an overall 30-day mortality of 0.99%. The excess surgical mortality in our region was 0.29%. There were 39 patients who were COVID-19 positive within 30 days of admission, 12 of whom died. All 12 were emergency admissions with a length of stay longer than 24 hours. There were three deaths among those who underwent day case surgery, one of whom was COVID-19 negative, and the other two were not swabbed but not suspected to have COVID-19. There were two COVID-19 positive elective cases and none in day case elective or emergency surgery. There were no COVID-19 positive deaths in elective or day case surgery.

CONCLUSIONS

There was a low rate of COVID-19 transmission and mortality in elective and day case operations. Our data have allowed us to guide patients in the consent process and provided the evidence base to restart elective and day case operating with precautions and regular review. A number of regions will be similarly affected and should perform a review of their data for the winter period and beyond.

Adolescents' knowledge of a peer's non-suicidal self-injury and own non-suicidal self-injury and suicidality

OBJECTIVE

Some research suggests that suicidal ideation and attempt among adolescents may be contagious - that is adolescents who are exposed to peers' suicidal behaviour are more likely to experience suicidal ideation or attempt suicide themselves. Less is known about the potential contagion effect of non-suicidal self-injury (NSSI). Our objective was to determine whether knowledge of a friend's NSSI is associated with adolescent's own non-suicidal self-injury and suicidal behaviours.

METHODS

Data from 1483 youth ages 14-17 years were obtained from the 2014 Ontario Child Health Study, a cross-sectional population-based survey of children and adolescents in Ontario, Canada. Logistic regression models were used to examine associations between knowledge of a friend's NSSI and adolescents' own self-reported self-injurious and suicidal behaviours. Interactions with gender, age group and presence of a mental disorder were investigated.

RESULTS

Knowledge of a friend's non-suicidal self-injury was significantly associated with the adolescent's own non-suicidal self-injury (OR = 2.03, 95% CI 1.05-3.90), suicidal ideation (OR = 3.08, 95% CI 1.50-6.30) and suicide attempt (OR = 2.87, 95% CI 1.20-6.87).

CONCLUSION

These findings suggest an apparent contagion effect for non-suicidal self-injury. Awareness of a friend's self-injurious behaviours is associated with an adolescent's own self-injury and suicidality. Interventions aimed at preventing NSSI and suicidality should consider prevention of possible contagion at the school and/or community level.

How close is the axillary nerve to the inferior glenoid? A magnetic resonance study of normal and arthritic shoulders

INTRODUCTION

Axillary nerve injury is a major complication of shoulder surgery during glenoid exposure. The aim of this study was to measure the mean distance between the inferior glenoid and the axillary nerve in healthy shoulders and then to compare this distance between osteoarthritic and rotator cuff deficient glenohumeral joints.

METHODS

The magnetic resonance images of 50 patients with normal glenohumeral joints were reviewed. The infra-glenoid tubercle was determined as a fixed point and the distance to the axillary nerve was measured. Two separate assessors measured on the same sagittal sections. With a study power of 80%, the sample needed in each comparison group was 28 patients. Measurements were then performed on scans in patients with osteoarthritis and cuff tear arthropathy. The mean distance was compared between groups.

RESULTS

The mean distance between the infra-glenoid tubercle and axillary nerve was 12mm (standard deviation, SD, 5.6mm) in normal shoulders, 10.6mm (SD 5.4mm) in shoulders with osteoarthritis and 9.7mm (SD 3.7mm) in those with cuff tear arthropathy. For this sample size of 50 patients with a confidence interval of 95%, the mean range is 12mm (95% CI 10.4-13.6). A comparison between normal shoulder and osteoarthritis showed a p-value of 0.3, and between normal and cuff tear arthropathy a p-value of 0.06. This was not statistically significant.

CONCLUSIONS

The axillary nerve lies on average 12mm from the infra-glenoid tubercle. The presence of inferior osteophytes in glenohumeral osteoarthritis and the proximal migration of humeral head in cuff tear arthropathy does not seem to alter the course of the nerve significantly in relation to the inferior glenoid tubercle.

Why has the caesarean rate increased dramatically in Bangladesh?

OBJECTIVE

The objective is to assess the reasoning by families in deciding between a home vs. facility delivery and vaginal vs. caesarean.

STUDY DESIGN

The authors selected a convenience sample of 16 villages in Sathkira district in southwest Bangladesh. Evidence was drawn from detailed in-home post-delivery interviews with all mothers in these villages who delivered in 2015 or 2016.

METHODS

Local family health workers and paramedics used a structured questionnaire that enabled gathering of relevant quantitative and qualitative evidence. Mothers' reasons for selection of delivery location and type were categorized, and regression analysis was conducted to assess significance of variables that proxy supply and demand factors.

RESULTS

Among 492 completed interviews, 48% were home deliveries, 52% facility deliveries; two-thirds of facility deliveries in private clinics. Overall, sample caesarean rate is 39%, public hospital rate 53%, private clinic rate 86%. Over half of reasons for home delivery refer to pregnancy without complication or access to trusted birth attendant. Over half of reasons for facility delivery refer to medical complications allegedly precluding home delivery, or requiring home-to-facility transfer during labour for reasons not clear to the mother. The decision depends on both 'demand' factors originating with the family (proxied by family income, birth order and education levels) and 'supply' factors originating with obstetric care providers (proxied by number of antenatal visits and variation of caesarean rate by village). In a regression controlling for both demand and supply variables, the above proxy variables are all significant.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Bangladesh has inadequate nursing support for vaginal delivery in either home or facility. Hence, physicians frequently recommend that women deliver in a facility (usually a physician's clinic). Physicians are reluctant to hire adequate nurses to attend vaginal deliveries. Hence, families with some discretionary income are increasingly opting for a caesarean over vaginal delivery. Facility deliveries reduce incidence of obstructed labour fistula, but probably contribute to rising incidence of iatrogenic fistula. Reducing caesarean rates requires a large increase in numbers of nurses and midwives, and acceptance by physicians of a broad scope of practice for nurses/midwives in vaginal deliveries.

Changes in essential salivary parameters in patients undergoing fixed orthodontic treatment: A longitudinal study

Objective

Orthodontic treatment using fixed appliances is known to alter the oral environment and encourage plaque retention around orthodontic brackets and bands, resulting in enamel demineralization and gingival inflammation. This study aimed to evaluate the changes in essential salivary parameters in patients undergoing fixed orthodontic treatment.

Materials and Methods

Saliva samples were collected from 60 patients before and 2 months after commencing fixed orthodontic treatment. The salivary flow rate, pH, buffering capacity, and levels of amylase, total protein, and glucose were determined. Parametric and nonparametric tests for paired samples were used for comparing the mean differences before and after commencing treatment.

Results

Significant reductions in the salivary flow rate, pH, and buffering capacity were noted 2 months after commencing treatment (P < 0.05). Total protein concentrations and calcium levels decreased significantly and amylase and glucose levels increased after commencing treatment (P < 0.05). Significant correlations were observed between salivary total protein concentrations and buffering capacity as well as calcium levels (P < 0.05).

Conclusion

These findings indicate that the biochemical properties of saliva are altered after introducing fixed orthodontic appliances into the oral cavity, thereby promoting plaque retention and increasing the susceptibility to tooth demineralization and gingival inflammation.

The association between platelet dysfunction and adverse outcomes in cardiac surgical patients

Haemostatic activation during cardiopulmonary bypass is associated with prothrombotic complications. Although it is not possible to detect and quantify haemostatic activation directly, platelet dysfunction, as measured with point-of-care-assays, may be a useful surrogate. In this study, we assessed the association between cardiopulmonary bypass-associated platelet dysfunction and adverse outcomes in 3010 cardiac surgical patients. Platelet dysfunction, as measured near the end of the rewarming phase of cardiopulmonary bypass, was calculated as the proportion of non-functional platelets after activation with collagen. Logistic regression and multivariable analyses were applied to assess the relationship between platelet dysfunction and a composite of in-hospital death; myocardial infarction; stroke; deep vein thrombosis or pulmonary embolism; and acute kidney injury (greater than a two-fold increase in creatinine). The outcome occurred in 251 (8%) of 3010 patients. The median (IQR [range]) percentage platelet dysfunction was less for those without the outcome as compared with those with the outcome; 14% (8-28% [1-99%]) vs. 19% (11-45% [2-98%]), p < 0.001. After risk adjustment, platelet dysfunction was independently associated with the composite outcome (p < 0.001), such that for each 1% increase in platelet dysfunction there was an approximately 1% increase in the composite outcome (OR 1.012; 95%CI 1.006-1.018). This exploratory study suggests that cardiopulmonary bypass-associated platelet dysfunction has prognostic value and may be a useful clinical measure of haemostatic activation in cardiac surgery.

Pseudorapidity Dependence of Particle Production and Elliptic Flow in Asymmetric Nuclear Collisions of p+Al, p+Au, d+Au, and ^{3}He+Au at sqrt[s_{NN}]=200 GeV

Asymmetric nuclear collisions of p+Al, p+Au, d+Au, and ^{3}He+Au at sqrt[s_{NN}]=200  GeV provide an excellent laboratory for understanding particle production, as well as exploring interactions among these particles after their initial creation in the collision. We present measurements of charged hadron production dN_{ch}/dη in all such collision systems over a broad pseudorapidity range and as a function of collision multiplicity. A simple wounded quark model is remarkably successful at describing the full data set. We also measure the elliptic flow v_{2} over a similarly broad pseudorapidity range. These measurements provide key constraints on models of particle emission and their translation into flow.

Measurements of Multiparticle Correlations in d+Au Collisions at 200, 62.4, 39, and 19.6 GeV and p+Au Collisions at 200 GeV and Implications for Collective Behavior

Recently, multiparticle-correlation measurements of relativistic p/d/^{3}He+Au, p+Pb, and even p+p collisions show surprising collective signatures. Here, we present beam-energy-scan measurements of two-, four-, and six-particle angular correlations in d+Au collisions at sqrt[s_{NN}]=200, 62.4, 39, and 19.6 GeV. We also present measurements of two- and four-particle angular correlations in p+Au collisions at sqrt[s_{NN}]=200  GeV. We find the four-particle cumulant to be real valued for d+Au collisions at all four energies. We also find that the four-particle cumulant in p+Au has the opposite sign as that in d+Au. Further, we find that the six-particle cumulant agrees with the four-particle cumulant in d+Au collisions at 200 GeV, indicating that nonflow effects are subdominant. These observations provide strong evidence that the correlations originate from the initial geometric configuration, which is then translated into the momentum distribution for all particles, commonly referred to as collectivity.

Nuclear Dependence of the Transverse-Single-Spin Asymmetry for Forward Neutron Production in Polarized p+A Collisions at sqrt[s_{NN}]=200 GeV

During 2015, the Relativistic Heavy Ion Collider (RHIC) provided collisions of transversely polarized protons with Au and Al nuclei for the first time, enabling the exploration of transverse-single-spin asymmetries with heavy nuclei. Large single-spin asymmetries in very forward neutron production have been previously observed in transversely polarized p+p collisions at RHIC, and the existing theoretical framework that was successful in describing the single-spin asymmetry in p+p collisions predicts only a moderate atomic-mass-number (A) dependence. In contrast, the asymmetries observed at RHIC in p+A collisions showed a surprisingly strong A dependence in inclusive forward neutron production. The observed asymmetry in p+Al collisions is much smaller, while the asymmetry in p+Au collisions is a factor of 3 larger in absolute value and of opposite sign. The interplay of different neutron production mechanisms is discussed as a possible explanation of the observed A dependence.

Silver recovery aqueous techniques from diverse sources: Hydrometallurgy in recycling

The demand of silver is ever increasing with the advance of the industrialized world, whereas worldwide reserves of high grade silver ores are retreating. However, there exist large stashes of low and lean grade silver ores that are yet to be exploited. The main impression of this work was to draw attention to the most advance technologies in silver recovery and recycling from various sources. The state of the art in recovery of silver from different sources by hydrometallurgical and bio-metallurgical processing and varieties of leaching, cementing, reducing agents, peeling, electro-coagulants, adsorbents, electro-dialysis, solvent extraction, ion exchange resins and bio sorbents are highlighted in this article. It is shown that the major economic driver for recycling of depleted sources is for the recovery of silver. In order to develop an nature-friendly technique for the recovery of silver from diverse sources, a critical comparison of existing technologies is analyzed for both economic viability and environmental impact was made in this amendment and silver ion toxicity is highlighted.

Effectiveness of platelet inhibition on major adverse cardiac events in non-cardiac surgery after percutaneous coronary intervention: a prospective cohort study

BACKGROUND

Platelet inhibition is mandatory therapy after percutaneous coronary intervention (PCI). Withdrawal of oral antiplatelet agents has been linked to increased incidence of postoperative adverse cardiac events in post-PCI patients having non-cardiac surgery (NCS). There is limited knowledge of temporal changes in platelet inhibition in this high-risk surgical population. We therefore performed a multicentre prospective cohort study evaluating perioperative platelet function and its association with postoperative major adverse cardiac events (MACE).

METHODS

In 201 post-PCI patients having NCS, we assessed the association between platelet function and postoperative MACE. We performed perioperative platelet function testing using a platelet mapping assay (PMA). Troponin-I was measured every 8 h for 2 days, then daily until day 5. Myocardial infarction was assessed using the third universal definition. We used multivariable logistic regression to assess the association between platelet inhibition and MACE.

RESULTS

Major adverse cardiac events occurred in 40 patients within 30 days of surgery. Thirty-two of these events were non-ST-elevation myocardial infarction, four ST-elevation myocardial infarction, and four exacerbation of congestive heart failure. We were unable to show an association between platelet inhibition and MACE. The PMA showed declining levels of platelet inhibition the longer the antiplatelet therapy was withheld before surgery. Logistic regression did not show an association between preoperative platelet function or the type of stent and MACE. We found an increased cardiac risk of MACE after surgery within 6 weeks of PCI.

CONCLUSIONS

The incidence of MACE in patients undergoing NCS after previous PCI is high in spite of adequate perioperative antiplatelet therapy.

CLINICAL TRIAL REGISTRATION

NCT 01707459 (registered at http://www.clinicaltrials.gov).

Diarrheal Diseases

An estimated 700 000 children die annually due to diarrhea with majority of these occurring in children under the age of 5 years. Morbidity from diarrhea includes poor growth and development. The global diarrhea burden is primarily due to infections secondary to rotavirus, cryptosporidium, enterotoxigenic Escherichia coli, and Shigella species. Known interventions to effectively treat and prevent diarrhea include vaccines against rotavirus and cholera, zinc supplementation, and therapy with oral rehydration solution. The achievement of the fourth Millennium Development Goal requires reductions in mortality from diarrhea, and can only be accomplished by implementing evidence-based strategies.

Effect of standardized perioperative dabigatran interruption on the residual anticoagulation effect at the time of surgery or procedure

ESSENTIALS: Anticoagulants need to be stopped preprocedure so there is little or no remaining anticoagulant effect. We assessed the residual anticoagulant effect with standardized interruption for patients on dabigatran. With this protocol, 80-86% of patients had no residual anticoagulant effect at the time of a procedure. A standardized perioperative dabigatran protocol appears to be safe, but requires further study.

BACKGROUND

In patients taking dabigatran who require treatment interruption for a surgery/procedure, a sufficient interruption interval is needed so that there is little or no residual anticoagulant effect at the time of the surgery/procedure.

METHODS

A prospective cohort study of patients receiving dabigatran (110 mg or 150 mg twice daily) who required an elective surgery/procedure and received a standardized dabigatran interruption protocol based on surgery/procedure bleeding risk and renal function was performed. Before the surgery/procedure, a blood sample was taken for measurement of the prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), and dilute thrombin time (dTT). We determined the proportion of all patients and those having a high bleeding risk surgery/procedure with normal coagulation test results at the time of the surgery/procedure. The APTT and dTT were considered to be most likely to reflect a dabigatran anticoagulant effect. Patients were followed up for 30 days postprocedure to assess for bleeding and thromboembolism.

RESULTS

One hundred and eighty-one patients were studied: 118 with low bleeding risk, and 63 with high bleeding risk. For all patients, the proportions with normal PT, APTT, TT dTT levels were 92.8%, 79.6%, 33.1%, and 80.7%, respectively. In patients with high bleeding risk, the proportions with normal PT, APTT, TT dTT levels were 93.7%, 85.7%, 57.1%, and 87.3%, respectively. During follow-up, there was one (0.6%) major bleed, there were nine (5.0%) minor bleeds, and there was one (0.6%) transient ischemic attack.

CONCLUSIONS

In patients receiving dabigatran who require an elective surgery/procedure, a standardized interruption protocol yielded 80-86% of patients with no residual anticoagulant effect at the time of surgery/procedure, and with a low incidence of bleeding.

Microbial colonization of Provox voice prosthesis in the Indian scenario

INTRODUCTION

Tracheoesophageal speech using the voice prosthesis is considered to be the "gold standard" with success rates as high as 90%. Despite significant developments, majority eventually develop dysfunction due to microbial deterioration. We did a pilot study of 58 laryngectomy patients who developed prosthesis dysfunction.

MATERIALS AND METHODS

A total of 58 laryngectomy patients who had their dysfunctional prosthesis removed were included in this study. Dysfunctional prostheses were removed and examined. Esophageal and tracheal flanges were examined separately. After obtaining pure fungal and bacterial cultures, the yeast strains were identified. Bacteria were identified with the light microscope and gram staining. We analyzed prosthesis lifespan and probable factors affecting it.

RESULTS

Central leak was found in 43% cases while in 57% peri-prosthetic leakage was the most common reason for prosthesis replacement. Microbial analysis revealed a combination of yeast and bacteria in approximately 55% culture samples. Out of these, almost 90% had the presence of single yeast species with bacteria. Pure fungal culture was identified in rest of the 45% cultures while none detected pure bacterial forms. Candida tropicalis was the solitary yeast in 81% while Candida albicans was seen in 10% as the solitary yeast. Bacterial isolates revealed Klebsiella pneumonia in 19%, Escherichia coli in 8% while Staphylococcus aureus was grown in 1% cultures. The consumption of curd (P = 0.036, 95% confidence intervals [CI]: 2.292-64.285) to have a significant correlation of the mean prosthesis lifespan. Consumption of curd (P = 0.001, 95% CI: 0.564-2.008) and history of prior radiotherapy (P = 0.015, 95% CI: 0.104-0.909) had a significant bearing on the Provox prosthesis lifespan.

CONCLUSIONS

Candida is the most common organism grown on voice prosthesis in Indian scenario. Consumption of curd and history of prior radiotherapy significantly affect Provox prosthesis lifespan.

Limb length discrepancy in cutis marmorata telangiectatica congenita: an audit of assessment and management in a multidisciplinary setting

BACKGROUND

Cutis marmorata telangiectatica congenita (CMTC) is a vascular malformation, diagnosed based on cutaneous manifestations. It is associated with limb length discrepancy (LLD) and asymmetry, but the exact extent of this and its relationship to the site of the cutaneous manifestations have not been delineated.

OBJECTIVES

To review the orthopaedic problems associated with CMTC, concentrating on the assessment and management of the LLD.

METHODS

This study is a retrospective analysis of orthopaedic, dermatological and vascular data that were collected prospectively at our tertiary referral centre. We identified 80 patients with an initial diagnosis of CMTC; 57/69 patients with a confirmed diagnosis had lower-limb involvement.

RESULTS

An LLD was identified in 51% of cases. The discrepancy was significant (defined as ≥ 2 cm) in nine patients and was confirmed using standing leg-length radiographs. Of these patients, three had epiphysiodesis to correct the discrepancy, and surgery is planned in five others.

CONCLUSIONS

Limb length discrepancy and asymmetry are common in CMTC; however, this is below the significant threshold in most cases. It is therefore recommended that any discrepancy be initially monitored clinically. This should be followed by standing leg-length radiographs at the age of 10 years (girls) or 12 years (boys), or if the LLD is ≥ 2 cm. If this is confirmed radiologically, orthopaedic referral is advised to consider surgical intervention such as epiphysiodesis.

Genotypes and phenotypes of 162 families with a glomulin mutation

A decade ago, we identified a novel gene, glomulin (GLMN) in which mutations cause glomuvenous malformations (GVMs). GVMs are bluish-purple cutaneous vascular lesions with characteristic glomus cells in the walls of distended venous channels. The discovery of the genetic basis for GVMs allowed the definition of clinical features to distinguish GVMs from other venous anomalies. The variation in phenotype was also highlighted: from a single punctate blue dot to a large plaque-like lesion. In this study, we screened GLMN in a large cohort of patients to broaden the spectrum of mutations, define their frequency and search for possible genotype-phenotype correlations. Taking into account 6 families published by others, a mutation in GLMN has been found in 162 families. This represents 40 different mutations; the most frequent one being present in almost 45% of them. Expressivity varies largely, without a genotype/phenotype relationship. Among 381 individuals with a mutation, we discovered 37 unaffected carriers, implying a penetrance of 90%. As nonpenetrant individuals may transmit the disease to their descendants, knowledge on the mutational status is needed for appropriate genetic counseling.

Limitations of current definitions of miscarriage using mean gestational sac diameter and crown-rump length measurements: a multicenter observational study

OBJECTIVES

There is significant variation in cut-off values for mean gestational sac diameter (MSD) and embryo crown-rump length (CRL) used to define miscarriage, values suggested in the literature ranging from 13 to 25 mm for MSD and from 3 to 8 mm for CRL. We aimed to define the false-positive rate (FPR) for the diagnosis of miscarriage associated with different CRL and MSD measurements with or without a yolk sac in a large study population of patients attending early pregnancy clinics. We also aimed to define cut-off values for CRL and MSD that, on the basis of a single measurement, can definitively diagnose a miscarriage and so exclude possible inadvertent termination of pregnancy.

METHODS

This was an observational cross-sectional study. Data were collected prospectively according to a predefined protocol. Intrauterine pregnancy of uncertain viability (IPUV) was defined as an empty gestational sac or sac with a yolk sac but no embryo seen with MSD < 20 or < 30 mm or an embryo with an absent heartbeat and CRL < 6 mm or < 8 mm. We recruited to the study 1060 consecutive women with IPUV. The endpoint was presence or absence of a viable pregnancy at the time of first-trimester screening ultrasonography between 11 and 14 weeks. The sensitivity, specificity, positive and negative predictive values were calculated for potential cut-off values to define miscarriage from MSD 8 to 30 mm with or without a yolk sac and from CRL 3 to 8 mm.

RESULTS

Of the 1060 women with a diagnosis of IPUV, 473 remained viable and 587 were non-viable by the time of the 11-14-week scan. In the absence of both embryo and yolk sac, the FPR for miscarriage was 4.4% when an MSD cut-off of 16 mm was used and 0.5% for a cut-off of 20 mm. There were no false-positive test results for miscarriage when a cut-off of MSD ≥ 21 mm was used. If a yolk sac was present but an embryo was not, the FPR for miscarriage was 2.6% for an MSD cut-off of 16 mm and 0.4% for a cut-off of 20 mm, with no false-positive results when a cut-off of MSD ≥ 21 mm was used. When an embryo was visible with an absent heartbeat, using a CRL cut-off of 4 mm the FPR for miscarriage was 8.3%, and for a CRL cut-off of 5 mm it was also 8.3%. There were no false-positive results using a CRL cut-off of ≥ 5.3 mm.

CONCLUSIONS

These data show that some current definitions used to diagnose miscarriage are potentially unsafe. Current national guidelines should be reviewed to avoid inadvertent termination of wanted pregnancies. An MSD cut-off of > 25 mm and a CRL cut-off of > 7 mm could be introduced to minimize the risk of a false-positive diagnosis of miscarriage.

Gestational sac and embryonic growth are not useful as criteria to define miscarriage: a multicenter observational study

OBJECTIVES

We studied changes in mean gestational sac diameter (MSD) and embryonic crown-rump length (CRL) in intrauterine pregnancies of uncertain viability (IPUVs). We aimed to establish cut-off values for MSD and CRL growth that could be definitively associated with either viability or miscarriage, and to establish the relationship between growth in MSD and appearance of embryonic structures in the gestational sac.

METHODS

One thousand and sixty consecutive IPUVs were recruited prospectively from four London University hospitals: 462 with no yolk sac or embryo, 419 with a yolk sac but no embryo, and 179 with an embryo but no heartbeat visible. IPUV was defined as an empty gestational sac with or without a yolk sac but no embryo seen with MSD < 20 or < 30 mm (depending on center) or an embryo with no heartbeat and CRL < 6 mm or < 8 mm (depending on center). Scans were repeated 7-14 days later. The endpoint was viability at first-trimester screening ultrasonography between 11 and 14 weeks. Change in MSD and CRL between the first and second scans of each pregnancy was compared with respect to viability and appearance of embryonic structures using the two-sample t-test.

RESULTS

The study included 359 pregnancies in which a gestational sac with or without embryo was identified at the follow-up scan 7-14 days later. Of these, 192 were viable and 167 non-viable at the 11-14-week scan. MSD growth was significantly higher in viable than non-viable pregnancies (mean 1.003 vs. 0.503 mm/day; P < 0.001, 95% CI of difference 0.403-0.596). A difference in CRL growth was found between the two groups (mean 0.673 vs. 0.148 mm/day; P < 0.001, 95% CI of difference 0.345-0.703). MSD growth of 0.6 mm/day was associated with a specificity for diagnosing miscarriage of 90.1%, a sensitivity of 61.7% and 19 false-positive test results. A cut-off of CRL growth rate of 0.2 mm/day gave a sensitivity of 76.3% and there were no false-positive test results for miscarriage. On repeat scan the failure of either a yolk sac or embryo to be visualized was always associated with miscarriage.

CONCLUSION

There is an overlap in MSD growth rates between viable and non-viable IPUV. No cut-off exists for MSD growth below which a viable pregnancy could be safely excluded. A cut-off value for CRL growth of 0.2 mm/day was always associated with miscarriage. These data suggest that criteria to diagnose miscarriage based on growth in MSD and CRL are potentially unsafe. However, finding an empty gestational sac on two scans more than 7 days apart is highly likely to indicate miscarriage, irrespective of growth.

Phase I dose-escalation study to determine the safety, pharmacokinetics and pharmacodynamics of brivanib alaninate in combination with full-dose cetuximab in patients with advanced gastrointestinal malignancies who have failed prior therapy

Background:

The objectives of this phase I study were to determine the safety, pharmacokinetics (PK), pharmacodynamics and efficacy of brivanib combined with full-dose cetuximab in patients with advanced gastrointestinal malignancies.

Methods:

Patients with advanced gastrointestinal malignancies who had failed prior therapies received brivanib (320, 600 or 800 mg daily) plus cetuximab (400 mg m^–2 loading dose then 250 mg m^–2 weekly). Assessments included adverse events, PK, tumour response, 2[18F]fluoro-2-deoxyglucose positron-emitting tomography and K-Ras mutation analyses.

Results:

Toxicities observed were manageable; the most common treatment-related toxicities (>10% of patients) were fatigue, diarrhoea, anorexia, increase in aspartate aminotransferase and alanine aminotransferase, acneiform dermatitis, headache, mucosal inflammation, nausea, dry skin, vomiting, hypertension, pruritus, proteinuria and weight loss. Of 62 patients, 6 (9.7%) had objective radiographic partial responses, with an overall response rate of 10%. Median duration of response was 9.2 months; median progression-free survival was 3.9 months.

Conclusions:

The acceptable toxicity profile and efficacy of brivanib observed in this study were promising. These findings are being further evaluated in a phase III study of brivanib plus cetuximab vs cetuximab alone in patients previously treated with combination chemotherapy for K-Ras wild-type advanced metastatic colorectal cancer.

Outcome following mesenteric artery revascularisation for chronic mesenteric ischemia

AIM

The purpose of this study was to review the clinical presentation and diagnosis of chronic mesenteric ischaemia (CMI) and to evaluate the early results and late outcome of mesenteric revascularisation.

METHODS

This retrospective study included 15 patients with CMI diagnosed between January 2000 and September 2006. Mesenteric revascularisation was done using either transluminal angioplasty, stenting, endarterectomy or bypass graft. Patients were followed up with Duplex scan and/or computed tomographic angiogram to confirm graft patency.

RESULTS

Sixteen revascularisation procedures were done in 15 patients. Aorto-superior mesenteric artery (SMA) bypass in 9 patients, SMA endarterectomy in 2 patients, transluminal angioplasty in 2 patients, stenting in 2 patients and right common iliac to common hepatic artery bypass in 1 patient with previous failed aorto-SMA graft. There were no perioperative deaths or early procedural complication. Two patients had late graft thrombosis and symptomatic recurrence. One of the three late deaths was due to graft thrombosis and bowel infarction, and the other two died of acute myocardial infarction and disseminated bronchogenic carcinoma respectively.

CONCLUSION

We conclude that mesenteric revascularisation for CMI is successful for most patients with symptomatic relief, low mortality and a good long term graft patency.

Evaluation of the syndesmotic-only fixation for Weber-C ankle fractures with syndesmotic injury

BACKGROUND

With the length of the fibula restored and the syndesmosis reduced anatomically, internal fixation using a plating device may not be necessary for supra-syndesmotic fibular fractures combined with diastasis of inferior tibio-fibular joint. A retrospective observational study was performed in patients who had this injury pattern treated with syndesmosis-only fixation.

MATERIALS AND METHODS

12 patients who had Weber type-C injury pattern were treated with syndesmosis only fixation. The treatment plan was followed only if the fibular length could be restored and if the syndesmosis could be anatomically reduced. Through a percutaneous or mini-open reduction and clamp stabilization of the syndesmosis, all but one patient had a single tricortical screw fixation across the syndesmosis. Patients were kept non-weight-bearing for 6 weeks, followed by screw removal at an average of 8 weeks. Outcomes were assessed using an objective ankle scoring system (Olerud and Molander scale) and by radiographic assessment of the ankle mortise.

RESULTS

At a mean follow-up of 13 months, the functional outcome score was 75. Excellent to good outcomes were noted in 83% of the patients. Ankle mortise was reduced in all cases, and all but one fibular fracture united without loss of fixation. Six patients had more than one malleolar injury, needing either screw or anchor fixations. One patient had late diastasis after removal of the syndesmotic screw and underwent revision surgery with bone grafting of the fibula. This was probably due to early screw removal, before union of the fibular fracture had occurred.

CONCLUSION

We recommend syndesmosis-only fixation as an effective treatment option for a combination of syndesmosis disruption and Weber type-C lateral malleolar fractures.

A phase I study to determine the safety, pharmacokinetics and pharmacodynamics of a dual VEGFR and FGFR inhibitor, brivanib, in patients with advanced or metastatic solid tumors

BACKGROUND

This study was designed to determine the safety, pharmacokinetics (PK) and pharmacodynamics (PD) of brivanib in patients with advanced/metastatic solid tumors.

PATIENTS AND METHODS

Ninety patients enrolled in this two-part, phase I open-label study of oral brivanib alaninate. The primary objectives of this study were (in part A) dose-limiting toxicity, maximum tolerated dose (MTD) and the lowest biologically active dose level and (in part B) the optimal dose/dose range. The secondary objectives of this study were preliminary evidence of antitumor activity, PK and PD.

RESULTS

Across part A (open-label dose escalation and MTD) and part B (open-label dose optimization), 68 patients received brivanib alaninate. Brivanib demonstrated a manageable toxicity profile at doses of 180-800 mg. Most toxic effects were mild. Systemic exposure of the active moiety brivanib increased linearly ≤1000 mg/day. The MTD was 800 mg/day. Forty-four patients were treated at the MTD: 20 with 800 mg continuously, 11 with 800 mg intermittently and 13 with 400 mg b.i.d. doses. Partial responses were confirmed in two patients receiving brivanib ≥600 mg. Dynamic contrast-enhanced magnetic resonance imaging demonstrated statistically significant decreases in parameters reflecting tumor vascularity and permeability after multiple doses in the 800-mg continuous q.d. and 400-mg b.i.d. dose cohorts.

CONCLUSION

In patients with advanced/metastatic cancer, brivanib demonstrates promising antiangiogenic and antitumor activity and manageable toxicity at doses ≤800 mg orally q.d., the recommended phase II study dose.