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.

Symmetry groupoids for pattern-selective feedback stabilization of the Chafee-Infante equation

Reaction-diffusion equations are ubiquitous in various scientific domains and their patterns represent a fascinating area of investigation. However, many of these patterns are unstable and, therefore, challenging to observe. To overcome this limitation, we present new noninvasive feedback controls based on symmetry groupoids. As a concrete example, we employ these controls to selectively stabilize unstable equilibria of the Chafee-Infante equation under Dirichlet boundary conditions on the interval. Unlike conventional reflection-based control schemes, our approach incorporates additional symmetries that enable us to design new convolution controls for stabilization. By demonstrating the efficacy of our method, we provide a new tool for investigating and controlling systems with unstable patterns, with potential implications for a wide range of scientific disciplines.

Geometric invariance of determining and resonating centers: Odd- and any-number limitations of Pyragas control

In the spirit of the well-known odd-number limitation, we study the failure of Pyragas control of periodic orbits and equilibria. Addressing the periodic orbits first, we derive a fundamental observation on the invariance of the geometric multiplicity of the trivial Floquet multiplier. This observation leads to a clear and unifying understanding of the odd-number limitation, both in the autonomous and the non-autonomous setting. Since the presence of the trivial Floquet multiplier governs the possibility of successful stabilization, we refer to this multiplier as the determining center. The geometric invariance of the determining center also leads to a necessary condition on the gain matrix for the control to be successful. In particular, we exclude scalar gains. The application of Pyragas control on equilibria does not only imply a geometric invariance of the determining center but surprisingly also on centers that resonate with the time delay. Consequently, we formulate odd- and any-number limitations both for real eigenvalues together with an arbitrary time delay as well as for complex conjugated eigenvalue pairs together with a resonating time delay. The very general nature of our results allows for various applications.

Assessing spirometry competence through certification in community-based healthcare settings in Australia and New Zealand: A position paper of the Australian and New Zealand Society of Respiratory Science

Spirometry has been established as an essential test for diagnosing and monitoring respiratory disease, particularly asthma and COPD, as well as in occupational health surveillance. In Australia and New Zealand, there is currently no pathway for spirometry operators in community‐based healthcare settings to demonstrate spirometry competence. The Australia and New Zealand Society of Respiratory Science (ANZSRS) has identified a need for developing a pathway for operators working in community‐based practices in Australia and New Zealand to demonstrate spirometry competence and certification. Spirometry certification provides evidence to patients, clients, employers and organizations that an individual has participated in an assessment process that qualifies them to perform spirometry to current international spirometry standards set out by the American Thoracic Society and the European Respiratory Society (ATS/ERS). This document describes a competence assessment pathway that incorporates a portfolio and practical assessment. The completion of this pathway and the award of certification confer an individual is competent to perform spirometry for 3 years, after which re‐certification is required. The adoption of this competency assessment and certification process by specialist organizations, and the commitment of operators performing spirometry to undergo this process, will enhance spirometry quality and practice in community‐based healthcare settings.

An integrative correlation of myopathology, phenotype and genotype in late onset Pompe disease

AIMS

Pompe disease is caused by pathogenic mutations in the alpha 1,4-glucosidase (GAA) gene and in patients with late onset Pome disease (LOPD), genotype-phenotype correlations are unpredictable. Skeletal muscle pathology includes glycogen accumulation and altered autophagy of various degrees. A correlation of the muscle morphology with clinical features and the genetic background in GAA may contribute to the understanding of the phenotypic variability.

METHODS

Muscle biopsies taken before enzyme replacement therapy were analysed from 53 patients with LOPD. On resin sections, glycogen accumulation, fibrosis, autophagic vacuoles and the degree of muscle damage (morphology-score) were analysed and the results were compared with clinical findings. Additional autophagy markers microtubule-associated protein 1A/1B-light chain 3, p62 and Bcl2-associated athanogene 3 were analysed on cryosections from 22 LOPD biopsies.

RESULTS

The myopathology showed a high variability with, in most patients, a moderate glycogen accumulation and a low morphology-score. High morphology-scores were associated with increased fibrosis and autophagy highlighting the role of autophagy in severe stages of skeletal muscle damage. The morphology-score did not correlate with the patient's age at biopsy, disease duration, nor with the residual GAA enzyme activity or creatine-kinase levels. In 37 patients with LOPD, genetic analysis identified the most frequent mutation, c.-32-13T>G, in 95%, most commonly in combination with c.525delT (19%). No significant correlation was found between the different GAA genotypes and muscle morphology type.

CONCLUSIONS

Muscle morphology in LOPD patients shows a high variability with, in most cases, moderate pathology. Increased pathology is associated with more fibrosis and autophagy.

Adults with Philadelphia chromosome-like acute lymphoblastic leukemia frequently have IGH-CRLF2 and JAK2 mutations, persistence of minimal residual disease and poor prognosis

Philadelphia-like B-cell precursor acute lymphoblastic leukemia (Ph-like ALL) is characterized by distinct genetic alterations and inferior prognosis in children and younger adults. The purpose of this study was a genetic and clinical characterization of Ph-like ALL in adults. Twenty-six (13%) of 207 adult patients (median age: 42 years) with B-cell precursor ALL (BCP-ALL) were classified as having Ph-like ALL using gene expression profiling. The frequency of Ph-like ALL was 27% among 95 BCP-ALL patients negative for BCR-ABL1 and KMT2A-rearrangements. IGH-CRLF2 rearrangements (6/16; P=0.002) and mutations in JAK2 (7/16; P<0.001) were found exclusively in the Ph-like ALL subgroup. Clinical and outcome analyses were restricted to patients treated in German Multicenter Study Group for Adult ALL (GMALL) trials 06/99 and 07/03 (n=107). The complete remission rate was 100% among both Ph-like ALL patients (n=19) and the "remaining BCP-ALL" cases (n=40), i.e. patients negative for BCR-ABL1 and KMT2A-rearrangements and the Ph-like subtype. Significantly fewer Ph-like ALL patients reached molecular complete remission (33% versus 79%; P=0.02) and had a lower probability of continuous complete remission (26% versus 60%; P=0.03) and overall survival (22% versus 64%; P=0.006) at 5 years compared to the remaining BCP-ALL patients. The profile of genetic lesions in adults with Ph-like ALL, including older adults, resembles that of pediatric Ph-like ALL and differs from the profile in the remaining BCP-ALL. Our study is the first to demonstrate that Ph-like ALL is associated with inferior outcomes in intensively treated older adult patients. Ph-like adult ALL should be recognized as a distinct, high-risk entity and further research on improved diagnostic and therapeutic approaches is needed. (NCT00199056, NCT00198991).

Lateral compression type B 2-1 pelvic ring fractures in young patients do not require surgery

PURPOSE

According to Young and Burgess, type B 2-1 pelvic fractures are a type of lateral compression fracture (LC-1) and are the most common pelvic injury at all ages. Although they are considered unstable in rotation and despite biomechanical recommendations for anterior stabilization, most authors recommend non-operative treatment. However, studies comparing outcomes and complications regarding operative versus non-operative treatment are still scarce.

METHODS

Seventy-one patients aged under 65 years with a type B 2-1 pelvic fracture were treated between 2006 and 2011. Patients in Group I (n = 35) were treated non-operatively and patients in Group II (n = 36) were treated operatively. Postoperative complications, clinical course, and follow-up (VAS for Pain, SF 36, EQ-5D) of at least 1 year postoperatively were evaluated.

RESULTS

Our data show that operatively treated patients had a significantly higher complication rate. Preoperatively, the only significant difference between the non-operative and operative groups was the amount of anterior fracture dislocation and the presence of an isolated pelvic ring fracture. In the postoperative follow-up, no significant differences were found regarding pain or quality of life.

CONCLUSION

Type B 2-1 pelvic ring fractures in young patients should be treated non-operatively.

Waste Separation Press (WSP): a mechanical pretreatment option for organic waste from source separation

An efficient biological treatment of source separated organic waste from household kitchens and gardens (biowaste) requires an adequate upfront mechanical preparation which possibly includes a hand sorting for the separation of contaminants. In this work untreated biowaste from households and gardens and the screen overflow >60mm of the same waste were mechanically treated by a Waste Separation Press (WSP). The WSP separates the waste into a wet fraction for biological treatment and a fraction of dry contaminants for incineration. The results show that it is possible to replace a hand sorting of contaminants, the milling and a screening of organic waste before the biological treatment by using the WSP. A special focus was put on the contaminants separation. The separation of plastic film from the untreated biowaste was 67% and the separation rate of glass was about 92%. About 90% of the organics were transferred to the fraction for further biological treatment. When treating the screen overflow >60mm with the WSP 86% of the plastic film and 88% of the glass were transferred to the contaminants fraction. 32% of the organic was transferred to the contaminants fraction and thereby lost for a further biological treatment. Additionally it was calculated that national standards for glass contaminants in compost can be met when using the WSP to mechanically treat the total biowaste. The loss of biogas by transferring biodegradable organics to the contaminants fraction was about 11% when preparing the untreated biowaste with the WSP.

[Treatability of sporadic late onset nemaline myopathy]

Sporadic late onset nemaline myopathy (SLONM) is an extremely rare disorder which can be associated with monoclonal gammopathy of unclear significance (MGUS). Clinically SLONM appears mostly after the fourth decade of life as rapidly progressing tetraparesis, respiratory insufficiency and features, such as dropped head syndrome, facial and bulbar involvement. Diagnosis is confirmed by muscle biopsy with detection of nemaline bodies and also frequently lobulated fibres. Immunosuppressant and immunomodulating therapies have been shown to be ineffective but clinical improvement accompanied by disappearance of monoclonal gammopathy and even nemaline bodies was reported following autologous stem cell transplantation and chemotherapy with melphalan. This article presents the case of a 53-year-old man with a 4-year history of SLOMN with MGUS in which administration of intravenous immunoglobulin therapy (IVIG) was not successful in reversing gammopathy, histopathological changes or clinical symptoms.

Cytoplasmic sequestration of p53 promotes survival in leukocytes transformed by Theileria

The function of the p53 protein as the central effector molecule of the p53 apoptotic pathway was investigated in a reversible model of epigenetic transformation. The infection of bovine leukocytes by the intracellular protozoan parasite Theileria annulata results in parasite-dependent transformation and proliferation of the host cells. We found p53 to be largely localized in the host cell cytoplasm and associated with the parasite membrane of isolated schizonts. Curing infected cells of the parasite with the theilericidal drug buparvaquone resulted in a time-dependent translocation of p53 into the host cell nucleus and the upregulation of the proapoptotic Bax and Apaf-1 and the downregulation of the anti-apoptotic Bcl-2 proteins. Although buparvaquone treatment led to apoptosis of the host cell, inhibition of either p53 or Bax significantly reduced buparvaquone-induced apoptosis of the transformed cells. Thus, the p53 apoptotic pathway of host cells is not induced by infection and transformation with Theileria by a mechanism involving cytoplasmic sequestration of p53. The close association of host cell p53 with the parasite membrane implies that the parasite either interacts directly with p53 or mediates cytoplasmic sequestration of p53 by interacting with other host cell proteins regulating p53 localization.

Treatment during primary HIV infection does not lower viral set point but improves CD4 lymphocytes in an observational cohort

Objective

To investigate if early treatment of primary HIV-1 infection (PHI) reduces viral set point and/or increases CD4 lymphocytes.

Methods

Analysis of two prospective multi-centre PHI cohorts. HIV-1 RNA and CD4 lymphocytes in patients with transient treatment were compared to those in untreated patients. Time to CD4 lymphocyte decrease below 350/μl after treatment stop or seroconversion was calculated using Kaplan-Meier and Cox-PH-regression analyses.

Results

156 cases of PHI were included, of which 100 had received transient HAART (median treatment time 9.5 months) and 56 remained untreated. Median viral load (563000 cop/ml vs 240000 cop/ml; p < 0.001) and median CD4 lymphocyte (449/μl vs. 613/μl; p < 0.01) differed significantly between treated and untreated patients. Median viral load was 38056 copies/ml in treated patients (12 months after treatment stop) and 52880 copies/ml in untreated patients (12 months after seroconversion; ns). Median CD4 lymphocyte change was +60/μl vs. -86/μl (p = 0.01). Median time until CD4 lymphocytes decreased to < 350/μl (including all patients with CD4 lymphocytes < 500/μl during seroconversion) was 20.7 months in treated patients after treatment stop and 8.3 months in untreated patents after seroconversion (p < 0.01). Cox-PH analyses adjusting for baseline VL, CD4 lymphocytes, stage of early infection and symptoms confirmed these differences.

Conclusions

Treatment during PHI did not lower viral set point. However, patients treated during seroconversion had an increase in CD4 lymphocytes, whereas untreated patients experienced a decrease in CD4 lymphocytes. Time until reaching CD4 lymphocytes < 350/μl was significantly shorter in untreated than in treated patients including patients with CD4 lymphocytes < 500/μl during seroconversion.

[Carboplatin and paclitaxel induction chemotherapy for patients with oropharynx carcinoma]

BACKGROUND

Between June 1998 and January 2005 64 patients of the department of oto-rhino-laryngology, head and neck surgery in Kassel with primary resectable squamous cell carcinoma of the oropharynx underwent neoadjuvant induction therapy. Carboplatin and Paclitaxel were given 6 times once weekly. This combination has proofed to be successful in downstaging and extend survival in patients suffering from head and neck cancer. Afterwards tumor resection was performed in the initial extension of the carcinoma. Dependent on histological findings radiation therapy or radiochemotherapy was carried out.

METHOD

Retrospective data were collected to analyse the effect on the tumor site and cervical lymph node metatasis based on post-chemotherapy clinical and postoperative histological results. In addition correlation between clinical findings and histological outcome and a possible survival advantage in patients with under induction chemotherapy remitted carcinomas was performed.

RESULTS

The data showed no improvement in disease free survival in patients with complete remission of the primary tumor site but a significant prolonged survival time for patients with complete remission of the cervical lymph node metastasis.

No significant increase within a 3-year interval in the prevalence of atopic dermatitis among schoolchildren in Baranya County, Hungary

BACKGROUND

The prevalence of atopic dermatitis (AD) in children has significantly increased worldwide in the past decades. Although it is well known that the number of AD patients has also been growing in Hungary, there are only a few published prevalence studies that allow international comparisons.

OBJECTIVES

The aim of this study was to estimate the prevalence of AD among schoolchildren in Baranya County in 2005 and to compare the data with those from 2002.

METHODS

The data from the 1454 children (771 girls, 683 boys) surveyed in 2002, and 1454 children (760 girls, 694 boys) surveyed in 2005, respectively, aged 7-14 years were analysed. The distinct populations of the 7- to 9-year-old age groups were separately compared in relation to their lifetime AD prevalence.

RESULTS

The prevalence of AD accounted for 15.1% in 2002, and 16.1% in 2005. In the compared distinct 7- to 9-year-old populations the prevalence rates were 17.0% in 2002 and 17.1% in 2005. There were no statistically significant differences between the data of the two surveys.

CONCLUSIONS

The results indicate the high prevalence rate of AD nearly approaching the markedly high values registered in the welfare countries, and could indicate that AD has reached a plateau in Hungary.

The classification of antiseptic products to be administered to wounds--another borderline case between medicinal products and medical devices?

The importance of a correct demarcation between a Medicinal Product (MP) and a Medical Device (MD) is undisputedly one of the major topics related to the development and launch of a new healthcare product. However, for some products the correct demarcation between MPs and MDs can turn out to be somewhat complicated. This article aims to provide an overview on the existing legislation and its adequate application based on a suitable example at hand. Article 2 (2) of the European Directive 2001/83/EC as amended by Directive 2004/27/EC on the Community code relating to medicinal products for human use stipulates that the respective Medicinal Products Legislation must be applied whenever a product can be covered by both the definitions for MPs and for products regulated by other legal provisions enacted by the European Community, e.g. Cosmetic Products (CPs) or MDs. This basic principle implies that the decision to base the risk-benefit assessment of the product in question on the Medical Device Directive (MDD) would contradict the aforementioned constitutional principle, pursuant to which the stricter of the regulatory procedures theoretically possible is to apply in cases of doubt. In contrast to the approval procedure established for MPs, the MDD requires a Conformity Assessment Procedure to be performed by the manufacturer himself and a "Notified Body". Thus, in the majority of cases the responsibility for the risk assessment of MDs lies solely with the manufacturer and is prior to launch not subject to further scrutiny by regulators. Only in specific cases, i.e. for the Conformity Assessment Procedure of Class III MDs which contain an Active Pharmaceutical Ingredient one of the Member States competent authorities designated in accordance with Directive 65/ 65/EEC has to be involved before taking a decision. It is therefore important that the classification of the product is carried out carefully in full compliance with existing legal provisions, also taking into account the related guidance documents issued by the European Commission. The adequate application of these rules is explained using the example of the antiseptic compound polihexanide, which is used both in approved medicinal products (wound antiseptics) and wound irrigation solutions labelled as medical devices.

Creatine improves health and survival of mice

The supplementation of creatine (Cr) has a marked neuroprotective effect in mouse models of neurodegenerative diseases. This has been assigned to the known bioenergetic, anti-apoptotic, anti-excitotoxic, and anti-oxidant properties of Cr. As aging and neurodegeneration share pathophysiological pathways, we investigated the effect of oral Cr supplementation on aging in 162 aged C57Bl/6J mice. Outcome variables included "healthy" life span, neurobehavioral phenotyping, as well as morphology, biochemistry, and expression profiling from brain. The median healthy life span of Cr-fed mice was 9% higher than in control mice, and they performed significantly better in neurobehavioral tests. In brains of Cr-treated mice, there was a trend towards a reduction of reactive oxygen species and significantly lower accumulation of the "aging pigment" lipofuscin. Expression profiling showed an upregulation of genes implicated in neuronal growth, neuroprotection, and learning. These data show that Cr improves health and longevity in mice. Cr may be a promising food supplement to promote healthy human aging.

Familiar and environmental factors influencing atopic dermatitis in the childhood

BACKGROUND

The increase in the incidence of atopic dermatitis (AD) in developed countries has been related to familiar and environmental factors. This survey was undertaken to investigate the family background, birthweight and the home environment of children suffering from AD in order to point out the possible factors that provoke the development of the disease.

METHODS

The study uses data collected by means of self-administered questionnaires and discusses 461 cases of children (age 0-12) with active skin signs of AD. The control group comprised of 343 children (age 0-12) with no skin signs or positive lifetime history of AD. Associations between familiar and various home environmental factors and the risk of AD were calculated by means of odds ratios.

RESULTS

There were statistically significant positive associations between atopic eczema symptoms and higher birthweight, small households, wall-to-wall carpets, as well as indoor-kept pets. Day-nursery attendance, heating system and indoor smoking, however, did not significantly alter the risk of the disease.

CONCLUSIONS

Because of the limitations of a retrospective questionnaire study, further research is needed to confirm these associations and clarify whether they are causative.

Training in GI endoscopy: can we objectively predict the performance of trainees? A prospective correlation study

BACKGROUND

No objective criteria have hitherto been available for assessing the individual talents and skills of trainees involved in GI endoscopy. The aim of our study was to compare the correlation of various psychological, psychomotor and cognitive tests (psy-tests) and of the subjective assessment of the trainer (expert assessment) at the beginning of the training with the objective performance of the trainees at the end of a one-week training period in upper GI endoscopy.

METHODS

In a prospective study including 12 endoscopic centers, a total of 58 participants without any prior endoscopic experience were analyzed. During a practical training week in each center with the "Erlangen Endo-Trainer," an assessment using a "score card" protocol was used as reference method. Prior to the start of the training, various psy-tests (personality test, vigilance endurance test, test of spatial thinking and two tests of sensorimotor coordination) as well as assessment of the trainer were obtained. These parameters were compared with a blinded analysis of the performance at the end of the training.

RESULTS

There was significant overall improvement during the training course. Multiple logistic regression analysis revealed that testing sensorimotoric coordination was significantly associated with defined improvement margins (odds ratio 11.46, p = 0.035). An expert's judgment on the prognosis correlated also significantly with the trainee's improvement (OR = 41.46; p = 0.018). Self-assessments were not significantly associated with performance or progress.

CONCLUSIONS

Sensorimotoric tests may provide a reliable prediction of the trainee's learning progress. In contrast to self-assessment, the judgement of an experienced endoscopist provides the best guidance for the young candidate endoscopists prior to the start of his/her endoscopic training program.

[Unclear per anum bleeding during pregnancy]

A 30-year-old, 7-months pregnant woman presented with per anum bleeding. Rectoscopy showed the cause to be a polyp the size of a fingertip 9 cm from the anus. Since the bleeding stopped spontaneously and therefore the need for radical intervention, and due to the advanced pregnancy stage, no biopsy was done. About 1 year later, the same patient experienced sharp pains and anal bleeding during defecation. A poorly defined neuroendocrine carcinoma was diagnosed. Seeking a prognosis optimal for the newborn child, the interdisciplinary decision was made for primary surgery with adjuvant chemotherapy. Other options for this malignancy during and after pregnancy are also discussed.

„Erlanger Broncho-Trainer” - Neuentwicklung eines Trainingsmodells mit physiologischer Ventilation für die interventionelle Bronchoskopie

BACKGROUND

Biosimulation models have proved their value in numerous training courses for endoscopic procedures and play an important role in education and further training, as well as in the introduction of new techniques. In the field of interventional bronchoscopy, the level of realism is increased when biological lung tissue is available not only in a collapsed state, but also with physiological expansion.

METHODS/RESULTS

A new modification of the well-known Erlangen Endo-Trainer has been developed, involving a transparent cover that provides airtight closure of the thoracic cavity. An integrated vacuum pump creates low pressure in the interior of the model. This allows a training lung from the pig to be fully expanded and "physiologically ventilated", with adjustable intermittent inspiration and expiration phases. The breathing and completely expandable biological training lung from the pig not only provides better anatomical orientation thanks to the lung's full three-dimensional expansion, but with the convincing and realistic quality of the tissue it also provides a good practice facility for various types of bronchoscopic intervention.

CONCLUSIONS

In an initial training course, the new system successfully allowed various diagnostic techniques to be practiced, such as bronchoalveolar lavage (BAL), transbronchial needle aspiration (TBNA), and peripheral forceps biopsies with transillumination guidance and interventional techniques such as foreign-body removal and electrocautery as well. These initial positive results are also encouraging for the future provision of training facilities in additional interventional techniques.

Nosocomial bloodstream infections with Burkholderia stabilis

Burkholderia stabilis was grown from blood cultures of seven patients presenting with signs and symptoms of septicaemia in the intensive care unit at Mersin University Hospital, Mersin, Turkey between July and October 2002. Four patients had one B. stabilis-positive blood culture, two patients had two, and one patient had four. Isolates from six of seven patients had the same resistotype and random amplified polymorphic DNA analysis type. Despite treatment with ciprofloxacin and imipenem, to which the strains were susceptible, all patients died one to eight days after isolation of B. stabilis from their blood. B. stabilis should be regarded as an opportunistic pathogen that may cause nosocomial bloodstream infections.