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.

A realist approach to understanding alliancing within Local Government public health and social care service provision

BACKGROUND

Within the current context of continued austerity and post-pandemic recovery, it remains important that Local Government services address the increasing needs of residents as cost-effectively as possible. Alliancing, whereby services work collaboratively focusing on the 'whole-system', has gained popularity as a tool with the potential to support collaborative whole systems approaches. This synthesis aims to identify how alliancing can be successfully operationalised in the commissioning of public health, wider National Health Service (NHS) and social care-related services.

METHODS

A realist literature synthesis was undertaken in order to identify underlying generative mechanisms associated with alliancing, the contextual conditions surrounding the implementation and operationalisation of the alliancing approach mechanisms, and the outcomes produced as a result. An iterative approach was taken, using a recent systematic review of the effectiveness of Alliancing, online database searches, and grey literature searches.

RESULTS

Three mechanistic components were identified within the data as being core to the successful implementation of alliances in public health and social care-related services within Local Government: (i) Achieving a system-level approach; (ii) placing local populations at the heart of the system; and (iii) creating a cultural shift. Programme theories were postulated within these components.

CONCLUSIONS

The alliancing approach offers an opportunity to achieve system-level change with the potential to benefit local populations. The realist synthesis approach taken within this study has provided insights into the necessary contextual and mechanistic factors of the Alliancing approach, above and beyond effectiveness outcomes typically collected through more conventional evaluation methodologies.

The prevalence of potential drug-drug interactions in adults with intellectual disability

BACKGROUND

There is a high use of medications in adults with intellectual disability (ID). One implication of taking multiple medications is the potential for drug-drug interactions (DDIs). However, despite this being well highlighted in the mainstream literature, little is known about the incidence or associations of DDIs in the ID population.

METHODS

This study describes the prevalence, patterns and associations of potential DDIs in a total administrative sample of adults with ID known to services in Jersey. Demographic, health-related and medication data were collected from 217 adults known to ID services. Data were collected using a face-to-face survey. The Anatomical Therapeutic Chemical classification system was used to categorise medications, and Stockley's Drug Interaction Checker was used to classify potential DDIs. Drug-drug pairings were considered to be of clinical significance if they were to be 'avoided, adjusted, monitored or required further information'.

RESULTS

Potential DDIs of clinical significance were common. Exposure to potential DDIs of clinical significance was associated with being female, taking more than five medications (polypharmacy), living in residential care and having more health conditions. A simple regression was used to understand the effect of number of prescribed medications on potential DDIs of clinical significance. Every prescribed drug led to a 0.87 (95% confidence interval: 0.72-1.00) increase in having a potential DDI of clinical significance.

CONCLUSION

Adults with ID who live in residential care, who are female, exposed to polypharmacy and have more health conditions may be more likely to have potential DDIs of clinical significance. Urgent consideration needs to be given to the potential of DDIs in this population given their exposure to high levels of medication.

The concerns of oncology professionals during the COVID-19 pandemic: results from the ESMO Resilience Task Force survey II

Background

The COVID-19 pandemic has resulted in significant changes to professional and personal lives of oncology professionals globally. The European Society for Medical Oncology (ESMO) Resilience Task Force collaboration aimed to provide contemporaneous reports on the impact of COVID-19 on the lived experiences and well-being in oncology.

Methods

This online anonymous survey (July-August 2020) is the second of a series of global surveys launched during the course of the pandemic. Longitudinal key outcome measures including well-being/distress (expanded Well-being Index—9 items), burnout (1 item from expanded Well-being Index), and job performance since COVID-19 were tracked.

Results

A total of 942 participants from 99 countries were included for final analysis: 58% (n = 544) from Europe, 52% (n = 485) female, 43% (n = 409) ≤40 years old, and 36% (n = 343) of non-white ethnicity. In July/August 2020, 60% (n = 525) continued to report a change in professional duties compared with the pre-COVID-19 era. The proportion of participants at risk of poor well-being (33%, n = 310) and who reported feeling burnout (49%, n = 460) had increased significantly compared with April/May 2020 (25% and 38%, respectively; P < 0.001), despite improved job performance since COVID-19 (34% versus 51%; P < 0.001). Of those who had been tested for COVID-19, 8% (n = 39/484) tested positive; 18% (n = 7/39) felt they had not been given adequate time to recover before return to work. Since the pandemic, 39% (n = 353/908) had expressed concerns that COVID-19 would have a negative impact on their career development or training and 40% (n = 366/917) felt that their job security had been compromised. More than two-thirds (n = 608/879) revealed that COVID-19 has changed their outlook on their work-personal life balance.

Conclusion

The COVID-19 pandemic continues to impact the well-being of oncology professionals globally, with significantly more in distress and feeling burnout compared with the first wave. Collective efforts from both national and international communities addressing support and coping strategies will be crucial as we recover from the COVID-19 crisis. In particular, an action plan should also be devised to tackle concerns raised regarding the negative impact of COVID-19 on career development, training, and job security.

•

Compared with survey I, more oncology professionals were at risk of poor well-being (33% versus 25%) and burnout (49% versus 38%).

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Job performance since COVID-19 (JP-CV) has improved from 34% to 51%.

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About 1 in 5 who tested positive for COVID-19 felt they had not been given adequate time to recover before return to work.

•

Some 39% expressed concerns that COVID-19 would have a negative impact on their career development or training.

•

More than two-thirds revealed that COVID-19 had changed their outlook on work-personal life balance.

The impact of COVID-19 on oncology professionals: results of the ESMO Resilience Task Force survey collaboration

BACKGROUND

The impact of the coronavirus disease 2019 (COVID-19) pandemic on well-being has the potential for serious negative consequences on work, home life, and patient care. The European Society for Medical Oncology (ESMO) Resilience Task Force collaboration set out to investigate well-being in oncology over time since COVID-19.

METHODS

Two online anonymous surveys were conducted (survey I: April/May 2020; survey II: July/August 2020). Statistical analyses were performed to examine group differences, associations, and predictors of key outcomes: (i) well-being/distress [expanded Well-being Index (eWBI; 9 items)]; (ii) burnout (1 item from eWBI); (iii) job performance since COVID-19 (JP-CV; 2 items).

RESULTS

Responses from survey I (1520 participants from 101 countries) indicate that COVID-19 is impacting oncology professionals; in particular, 25% of participants indicated being at risk of distress (poor well-being, eWBI ≥ 4), 38% reported feeling burnout, and 66% reported not being able to perform their job compared with the pre-COVID-19 period. Higher JP-CV was associated with better well-being and not feeling burnout (P < 0.01). Differences were seen in well-being and JP-CV between countries (P < 0.001) and were related to country COVID-19 crude mortality rate (P < 0.05). Consistent predictors of well-being, burnout, and JP-CV were psychological resilience and changes to work hours. In survey II, among 272 participants who completed both surveys, while JP-CV improved (38% versus 54%, P < 0.001), eWBI scores ≥4 and burnout rates were significantly higher compared with survey I (22% versus 31%, P = 0.01; and 35% versus 49%, P = 0.001, respectively), suggesting well-being and burnout have worsened over a 3-month period during the COVID-19 pandemic.

CONCLUSION

In the first and largest global survey series, COVID-19 is impacting well-being and job performance of oncology professionals. JP-CV has improved but risk of distress and burnout has increased over time. Urgent measures to address well-being and improve resilience are essential.

Understanding the Effect of Thermal Treatment on the Physico-Mechanical Properties of Light-Cured Composites for use in Indirect Restorations

OBJECTIVES

To study the potential benefits of a post-cure thermal treatment on key physico-mechanical properties of light-cured resin-based composites for use in indirect restorations, a CAD/CAM composite block being used as control.

MATERIAL AND METHODS

Six commercial composites were light-cured before being thermally treated in a furnace at 90°C during 15 minutes (CAD/CAM composite used as a control). The properties measured with or without thermal treatment were: degree of conversion, flexural strength, elastic modulus, Vickers microHardness, organic mass content and eluted and absorbed mass before and after storage in ethanol. The data were analysed using one-way ANOVA, and Weibull distributions.

RESULTS

A general increase in the properties measured was observed for all materials after thermal treatment, except a general decrease in mass elution and absorption (most statistically significant: p⟨0.05). Weibull analysis showed a tendency (p⟩0.05) of increased reliability of the flexural strength after thermal treatment for all materials.

CONCLUSION

The present data revealed clear physico-mechanical improvements after thermal treatment of light-cured composites. Such method could hence be beneficially used to produce indirect restorations as compared to stratifying and light-curing the same composites in situ. However, most properties of the control CAD/CAM composite were higher, but CAD/CAM technologies aren't available everywhere.

Combined endocardial and epicardial ventricular tachycardia ablation for ischemic and nonischemic dilated cardiomyopathy

Background

Patients with ischemic (IHD) and nonischemic (NICM) dilated heart disease and reduced left ventricular ejection fraction are at increased risk of ventricular tachycardias (VTs) or sudden cardiac death. VT catheter ablation is an invasive treatment modality for antiarrhythmic drugs-resistant VT that reduces arrhythmic episodes, improves quality of life and improves survival in patients with electrical storm. Direct comparison of the outcomes from combined and non-combined endoepicardial ablations is limited by patient characteristics, follow-up durations, protocols heterogeneity and scarcity of randomized trials. We aim to investigate the long-term clinical outcomes of these 2 strategies in the IHD and NICM populations.

Methods

Multicentric observational registry including 316 consecutive patients who underwent combined (C-ABL) and non-combined (NC-ABL) endoepicardial ventricular tachycardia (VT) ablation for drug-resistant VT between January 2008 and July 2019. Chagas' disease patients were excluded. Primary and secondary efficacy endpoints were defined as VT-free survival and all-cause death after ablation. Safety outcomes were defined by 30-days mortality and procedure-related complications.

Results

Most of the patients were male (85%), with IHD (67%) and a mean age of 63±13 years. During a mean follow-up of 3±2 years, 117 (37%) patients had VT recurrence and 73 (23%) died. Multivariate survival analysis identified storm (ES) at presentation (HR=2.17; 95% CI 1.44–3.25), IHD (HR=0.53, 95% CI 0.36–0.78), left ventricular ejection fraction (LEVF) (HR=0.97, 95% CI 0.95–0.99), New York Heart Association (NYHA) functional class III or IV (HR=1.79, 95% CI 1.13–2.85) and C-ABL (HR=0.49, 95% CI 0.27–0.92) as independent predictors of VT recurrence. In 135 patients undergoing two or more ablation procedures only C-ABL (HR=0.36, 95% CI 0.17–0.80) and ES at presentation (HR=2.42, 95% CI 1.24–4.70) were independent predictors of arrhythmia recurrence. The independent predictors of all-cause mortality were ES (HR=2.17, 95% CI 1.33–3.54), LVEF (HR=0.95, 95% CI 0.92–0.98), age (HR=1.03, 95% CI 1.01–1.05), NYHA functional class III or IV (HR=2.04, 95% CI 1.12–3.73), and C-ABL (HR=0.22, 95% CI 0.05–0.91). The survival benefit was only seen in patients with a previous ablation (P for interaction=0.04) – Figure 1. Mortality at 30-days was similar between NC-ABL and C-ABL (4% vs. 2%, respectively, P=0.777), as was the complication rate (10.3% vs. 15.1% respectively, P=0.336).

Conclusion

A combined endo-epicardial approach appears to be associated with greater VT-free survival and overall survival in ischemic and nonischemic patients undergoing repeated VT catheter ablations. Both strategies seem equally safe.

Survival analysis for C-ABL vs NC-ABL

Funding Acknowledgement

Type of funding source: None

Menopause and work: an overview of UK guidance

Background

Recent evidence suggests that some women experience menopausal symptoms that impact on their working lives, and that work environments can impact upon the experience of menopause. As a result, guidance for employers and other key stakeholders about this potential occupational health issue has emerged. To date there has not been a review of these documents to identify their main recommendations for policy and practice.

Aims

To provide a narrative overview of such guidance and summary of content.

Methods

Documents published in the UK and available in a major UK trade union library were searched systematically to identify guidance on the topic of menopause and work. An inductive thematic analysis was performed to identify the main themes addressed.

Results

Twenty-five relevant documents, on average eight pages long, were identified. A minority indicated that the use of scientific evidence informed the content. Five overarching themes were identified: (i) legislation; (ii) policy; (iii) information and training needs; (iv) workplace support; and (v) the physical work environment.

Conclusions

This overview of UK guidance revealed common areas of concern about reducing and managing difficulties experienced by working menopausal women. Possible areas for action were identified. Some recommendations were common across much of the guidance, whereas others were exclusive. Future guidance might include consideration of all these issues, while making reference both to the evidence base and sources of further information.

Bone and joint infections with Staphylococcus aureus strains producing Panton-Valentine Leukocidin in French Guiana

The aim of this study was to describe the clinical features of bone and joint infections (BJI) due to Panton-Valentine Leukocidin producing (PVL+) Staphylococcus aureus (SA) in French Guiana.A multicenter study that consists of a retrospective charts review of children admitted for PVL+ S. aureus BJI between January 2010 and December 2015.Six patients with SA-PVL BJI were identified during the study period: 2 osteomyelitis, 1 septic arthritis, and 3 disseminated BJI. The median age was 11 years old (4-14 years), and fever lasted for 3.2 days (2-5 days) before diagnosis. An open skin wound preceded the BJI in 5/6 patients. One patient presented with a septic thrombophlebitis of the femoral-popliteal vein on admission. Methicillin-susceptible Staphylococcus aureus (MSSA) were identified for all patients. Three patients had complications: 2 cases of necrotizing pneumonia and 2 pericarditis, with 1 death caused by cardiac tamponade.SA-PVL BJI was not frequent. Strains were susceptible to methicillin, but responsible of severe BJI. Early diagnosis and a multidisciplinary management of these infections are essential to prevent further complications.

Conduct, Oversight, and Ethical Considerations of Clinical Trials in Companion Animals with Cancer: Report of a Workshop on Best Practice Recommendations

Development of effective and safe treatments for companion animals with cancer requires the collaboration of numerous animal health professionals and the full engagement of animal owners. Establishing ‘Best Practice Recommendations’ for clinical trials in veterinary oncology represents an important step toward meeting the goal of rigorous clinical trial design and conduct that is required to establish valid evidence. Likewise, optimizing patient welfare and owner education and advocacy is crucial to meet the unique ethical obligations to both owners and animals enrolled in these clinical trials and to ensure trust in the team conducting the research. To date, ‘Best Practice Recommendations’ for clinical trial conduct have not been reported for veterinary oncology. This document summarizes the consensus of a workshop held in November, 2014 to identify relevant ethical principles and to ensure responsible conduct of clinical research in companion animals with cancer. It is intended as a working document that will be updated as advances in science and ethical considerations require. To the extent possible, existing guidelines for the conduct and oversight of clinical trials in humans have been adapted for veterinary trials to avoid duplicative effort and to facilitate integration of clinical trials such that translational research with benefits for both companion animals and humans are encouraged.

[Improving the esthetic results and patient satisfaction in orthognatic surgery]

The objectives of dental and maxillary defect management have changed over the last decade. Occlusal improvement is required, but it is expected to come with a good esthetic result for patients, especially for adults, and mentioned or not preoperatively. Thus, the maxillofacial surgeon must include complementary data in his therapeutic scheme, beyond the one provided by the cephalometric analysis. This chapter was drafted in pluridisciplinary mode to this end. A psychological approach and post-operative satisfaction are crucial factors that were studied prospectively (MD Battini and Courtois) and are a part of this chapter. Esthetic labial standard are also described, based on the results of a retrospective study (MD Hardy, Laure and Goga). Doctor Belhaouari presents solutions to embellish lips with filling products, initially or later. Finally, the complementary surgical techniques that can be used during orthognatic surgery are listed: lipofilling, rhinoplasty, surgery of mandibular angles, apposition of piriform aperture.

PLA2G6-associated neurodegeneration (PLAN): further expansion of the clinical, radiological and mutation spectrum associated with infantile and atypical childhood-onset disease

Phospholipase A2 associated neurodegeneration (PLAN) is a major phenotype of autosomal recessive Neurodegeneration with Brain Iron Accumulation (NBIA). We describe the clinical phenotypes, neuroimaging features and PLA2G6 mutations in 5 children, of whom 4 presented with infantile neuroaxonal dystrophy (INAD). One other patient was diagnosed with the onset of PLAN in childhood, and our report highlights the diagnostic challenges associated with this atypical PLAN subtype. In this series, the neuroradiological relevance of classical PLAN features as well as apparent claval hypertrophy' is explored. Novel PLA2G6 mutations were identified in all patients. PLAN should be considered not only in patients presenting with a classic INAD phenotype but also in older patients presenting later in childhood with non-specific progressive neurological features including social communication difficulties, gait disturbance, dyspraxia, neuropsychiatric symptoms and extrapyramidal motor features.

[Post-operative evaluation of 63 cases of rhinoseptoplastie by nasal frameworks]

INTRODUCTION

The rhinoplasty is a difficult operation in plastic surgery of the face. The principles of the extracorporeal septoplasty were launched in the 50's, consisting of the treatment of the septal framework outside the nose. The most recent evolution, which is the creation of nasal frameworks required a precise evaluation of the results.

PATIENTS AND METHODS

The patients having benefited from a rhinoseptoplasty by nasal frameworks are included. Eleven criteria are studied. Every patient is rated before and after rhinoplasty procedure, one point if improvement of the criterion, zero if no modification and -1 if degradation of the criterion.

RESULTS

Sixty three patients were operated, 54 women and 9 men. The postoperative average follow-up is of 5 months.

CONCLUSIONS

The cartilaginous nasal frameworks, allows on complex noses (diverted, traumatic), an improvement of the righteousness of the dorsum (88%), of the projection of the tip (82.5%), of the naso-labial angle (84%), lines of Sheen (63%). An extension of the middle nose is observed in 28% of the patients, counterparty of a functional and inhaling nose.

Is PATCHED an important candidate gene for neural tube defects? Cranial and thoracic neural tube defects in a family with Gorlin syndrome: a case report

. The relationship of mutations in the patched gene PTCH and nevoid basal cell carcinoma (NBCC) or Gorlin syndrome is well established. Animal studies have implicated the hedgehog-patched signalling pathway in neurulation and neural tube defects (NTDs). Spina bifida occulta and bifid vertebrae are well recognized in NBCCS, but there appears to be only one report of open spina bifida. We report a father and two sons with a truncating PTCH mutation and the major features of NBCCS. One son had open thoracic spina bifida and the other had an occipital meningocoele. We believe this to be the first report of cranial NTD in NBCCS and suggest that consideration be given to including PTCH analysis in genetic association studies in NTDs as the hedgehog pathway is integral to normal human neurulation.

Presumed tuberculous uveitis: diagnosis, management, and outcome

PURPOSE

To assess the effectiveness of anti-tuberculous treatment in patients with chronic uveitis and either active systemic or latent tuberculosis (TB) in a non-endemic community.

METHODS

Retrospective study of patients with chronic uveitis, non-ocular evidence of latent or active TB and no other identified cause of uveitis who underwent a 6-month course of standard anti-tuberculous chemotherapy. Response to treatment was assessed at 6 and 12 months after initiation of treatment.

RESULTS

A total of 27 patients were included of whom 59% were female. In all, 19 were Asian, 4 Caucasian, and 4 Black. More than half of patients had a history of contact with another person treated for TB. Inflammation resolved after chemotherapy in 70.3% of patients, 18.5% had a change in the nature of their inflammation and 11.1% had no benefit.

CONCLUSIONS

There were no uveitis features characteristic of TB uveitis and a wide range of manifestations was seen ranging from non-granulomatous anterior uveitis to occlusive retinal vasculitis. TB is not endemic in the United Kingdom, therefore consideration of ethnicity, immigration, and history of TB contact remain important to direct investigations. In a patient with uveitis and latent TB, a full 6-month course of anti-tuberculous chemotherapy is recommended although it may not be curative of the uveitis.

Dynamics of PHA-induced immune response and plasma carotenoids in birds: should we have a closer look?

Allocation trade-offs of limited resources are thought to ensure the honesty of sexual signals and are often studied using controlled immune challenges. One such trade-off between immunity and ornaments is that involving carotenoids. Phytohemagglutinin (PHA)-induced immune response is a widely used immune challenge, yet more details on the underlying physiological mechanisms and potential costs are needed. We investigated the temporal dynamics of PHA-induced immune response and associated changes in blood carotenoids, body mass and a carotenoid-based coloured signal. We found variation in individual response patterns to PHA after peak swelling was reached, with birds showing either a rapid or a slow subsequent decrease in swelling, suggesting variation in the duration of the immune response and/or inflammation. Body mass did not affect immune response. Plasma carotenoids followed a transient decrease closely matching the dynamics of the swelling. The peak of the immune response was negatively related to initial plasma carotenoid levels and positively correlated to the relative decrease in plasma carotenoids. Individual variation in duration of the swelling could be partly explained by plasma carotenoids; high initial carotenoid levels were associated with a slower decrease of the swelling. These contradictory effects of carotenoids suggest a complex role in the immune response. Bill colour was positively correlated to initial plasma carotenoid concentration but it did not predict or change as a consequence of immune response to PHA. Bill colour thus reflects medium- or long-term quality rather than immediate quality. Taking into account the dynamics of the immune response and that of associated physiological parameters would thus yield new insights into our interpretation of variation in PHA response.

[Technical note:simple tools in preimplant surgery]

Osteotomes, the bone scraper, and the bone trap are simple tools used for preprosthetic surgery. They are not very invasive, present little risks, and they can be used in private surgical practice with local anaesthesia. The osteotome preserves, dilates, and condenses the alveolar bone instead of eliminating it like drilling does. It does not require any motor or irrigation. It increases the width and the height of the alveolar crest. It allows the localized expansion of narrow or misshapen alveolar crest when its width ranges between 3 and 4.5mm. It also allows performing a localized sinus lift, when the sinus floor height ranges between 4 and 8mm. The bone scraper is used to retrieve cortical chips of parietal bone for sinus lift. The bone trap is connected to the suction tube. It is used to collect bone powder after milling or bone drilling. These simple tools should be available for all maxillofacial surgeons in specific indications.