Designing a public access naloxone program for public transportation stations

The opioid overdose epidemic has caused over 600,000 deaths in the U.S. since 1999. Public access naloxone programs show great potential as a strategy for reducing opioid overdose-related deaths. However, their implementation within public transit stations, often characterized as opioid overdose hotspots, has been limited, partly because of a lack of understanding in how to structure such programs. Here, we propose a comprehensive framework for implementing public access naloxone programs at public transit stations to curb opioid overdose-related deaths. The framework, tailored to local contexts, relies on coordination between local public health organizations to provide naloxone at public access points and bystander training, local academic institutions to oversee program evaluation, and public transit organizations to manage naloxone maintenance. We use the city of Cambridge, Massachusetts as a case study to demonstrate how it and other municipalities may implement such an initiative.

Adverse events associated with PentaRay Mapping Catheter – MAUDE database analysis

Background

The 20 pole PentaRay Mapping Catheter is a high-definition mapping catheter with five soft, flexible spines providing better and faster acquisition. Despite its design, the catheter is not without glitches.

Objective

We queried the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database for adverse events related to the use of the PentaRay mapping catheter.

Methods

The Manufacturer and User Facility Device Experience (MAUDE) database was searched for reports received between October 1, 2019, to October 31, 2021, to capture all adverse events associated with PentaRay mapping catheter using the term “PentaRay” in the “brand name” section. The adverse events were adjudicated to various categories based on the review of the event description for each medical device report (MDR).

Results

A total of 159 events were reported in 148 MDRs during the study period. The most common device related issues were: damaged splines 18.2% (n=29), device entrapment 17% (n=27), thrombus on device 15.1% (n=24), foreign material on splines 8.8% (n=14), sensor error 3.8% (n=6). Of the patient related events, 13.8% (n=22) were pericardial effusion, 5% (n=8) cardiac arrest, 1.2% (n=2) coronary vasospasm/STEMI, 0.6% (n=1) heart block, 0.6% (n=1) air embolism, 0.6% (n=1) tear in pulmonary veins. These events lead to procedure abortion 27.7% (n=44) and procedural delay 11.3% (n=18).

Conclusion

Several issues have been reported with the PentaRay mapping catheter leading to to procedure abortion, delay and patients related adverse events. Understanding and troubleshooting may help improve patient outcomes.

Funding Acknowledgement

Type of funding sources: None.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

OP0166 ALTERNATIVE RENAL RESPONSE DEFINITIONS IN A RANDOMIZED, CONTROLLED TRIAL OF OBINUTUZUMAB FOR PROLIFERATIVE LUPUS NEPHRITIS

Background:

Obinutuzumab, a type II anti-CD20 mAb, resulted in rapid and complete B-cell depletion and improved renal responses in proliferative lupus nephritis (LN) in the Phase 2 NOBILITY trial and will be further evaluated in the Phase 3 REGENCY trial. Recent analyses suggest alternative urinary sediment, serum creatinine (SCr), and urine protein/creatinine ratio (UPCR) requirements may be better measures of response in LN than those used in NOBILITY [1,2].

Objectives:

To evaluate the NOBILITY response definitions and to report the results of NOBILITY using alternative definitions of renal response.

Methods:

126 patients with active Class III/IV LN were randomized to obinutuzumab or placebo in combination with mycophenolate and glucocorticoids. NOBILITY complete renal response (CRR) required UPCR < 0.5, SCr ≤ the upper limit of normal (ULN) of the reference laboratory and not increased > 15% from baseline SCr, and inactive urinary sediment. Exploratory analyses were conducted, and alternative response definitions were evaluated post hoc.

Results:

NOBILITY CRR was increased with obinutuzumab over placebo at Week 52 (35% vs. 23%, P = 0.11) and Week 76 (40% vs. 18%, P = 0.007). Response rates were low among patients with baseline SCr < 0.65 mg/dL (n = 45) due to the requirement that SCr not increase > 15% from baseline; increasing this threshold to 25% increased the response rate to a level similar to other groups (Figure). Alternative response definitions demonstrated increased rates of response in both treatment groups and similar benefits of obinutuzumab over placebo at Weeks 52 and 76 (Table).

Conclusion:

Obinutuzumab resulted in consistent treatment benefits across a range of renal response definitions in NOBILITY and will be further evaluated in REGENCY. A requirement that SCr not increase > 15% from baseline may be overly restrictive in patients with low baseline SCr (< 0.65 mg/dL), where a change of 15% represents < 0.1 mg/dL and is of questionable clinical relevance. These findings may inform LN clinical trial design and more accurately reflect clinical practice.

References:

[1]Dall’era M et al.Arthritis Rheumatol. 2015;67:1305-13.

[2]Almaani S et al.J Am Soc Nephrol. 2019;30:669 [abstract].

Table.

Data from NOBILITY at weeks 52 and 76 using several response definitions

Definition of responseWeek 52Week 76OBI (n = 63)PBO (n = 62)Diff.OBI (n = 63)PBO (n = 62)Diff.NOBILITY complete responseUPCR < 0.5, SCr ≤ ULN and not increased > 15% from baseline SCr, and < 10 RBC/hpf without casts35%23%12%*40%18%22%**REGENCY complete responseUPCR < 0.5, SCr ≤ ULN and not increased > 25% from baseline SCr43%29%14%*54%31%23%**UPCR < 0.8 only64%48%15%*64%47%17%*UPCR < 0.8 with SCr requirementUPCR < 0.8 and SCr ≤ ULNornot increased > 15% from baseline SCr60%48%12%*64%45%18%**NOBILITY overall responseCRR or ≥ 50% reduction in UPCRawith SCr not increased > 15% from baseline and urinary RBCs not increased > 50% from baseline56%36%20%**51%29%22%**REGENCY overall responseCRR or ≥ 50% reduction in UPCRawith SCr not increased > 25% from baseline68%45%23%**67%50%17%**

OBI, obinutuzumab; PBO, placebo.

* P < 0.2 vs. placebo group. ** P < 0.05 vs. placebo group.

a≥ 50% reduction in UPCR to a value < 1 (< 3 if the baseline UPCR was ≥ 3). All response definitions required no use of rescue medications or early withdrawal.

Acknowledgments:

This study was funded by F. Hoffmann-La Roche.

Disclosure of Interests:

Zahir Amoura Grant/research support from: GSK, Roche, Consultant of: GSK, Astra Zeneca, Amgen, Philippe Rémy: None declared, Luis Fernando Quintana Porras: None declared, Laurent Chiche: None declared, Dominique Chauveau: None declared, Dario Roccatello: None declared, Richard Furie Grant/research support from: AstraZeneca, Biogen, Consultant of: AstraZeneca, Biogen, Thomas Schindler Employee of: F. Hoffmann-La Roche, Jay Garg Employee of: Genentech, Matthew D. Cascino Employee of: Genentech, Brad H Rovin Grant/research support from: GSK, Consultant of: GSK, Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS

SAT0166 BIOMARKERS OF B-CELL DEPLETION AND RESPONSE IN A RANDOMIZED, CONTROLLED TRIAL OF OBINUTUZUMAB FOR PROLIFERATIVE LUPUS NEPHRITIS

Background:

Incomplete B-cell and plasmablast depletion, as measured using highly sensitive flow cytometry (HSFC), is associated with lower response rates following rituximab in SLE [1]. Enhanced B-cell depletion with the type II anti-CD20 mAb obinutuzumab resulted in increased renal responses in proliferative lupus nephritis (LN) in the NOBILITY trial (NCT02550652) and will be further evaluated in the Phase 3 REGENCY trial (NCT04221477).

Objectives:

To measure peripheral B-cells, B-cell subsets (naïve, memory and plasmablast) and B-cell activating factor (BAFF) levels and to assess associations between B-cell depletion and renal response in LN patients in a clinical trial of obinutuzumab.

Methods:

126 patients with active Class III/IV LN were randomized to obinutuzumab or placebo infusions in combination with mycophenolate and glucocorticoids. Peripheral B-cells were measured using a HSFC method with a lower limit of quantitation of 0.441 cells/μL. Serum levels of BAFF were evaluated using ELISA. Sustained depletion was defined by total B-cells below the limit of detection at both weeks 24 and 52. Renal response definitions from Phase 2 NOBILITY and Phase 3 REGENCY trials were used.

Results:

Obinutuzumab resulted in rapid and complete depletion of total B-cells, memory and naïve B-cells, and plasmablasts from peripheral blood, with 88% of obinutuzumab patients depleted to < 0.441 total B-cells/μL at week 2 (Figure). Mean serum BAFF increased from 4,585 pg/mL at baseline to 14,601 pg/mL at week 52 in the obinutuzumab group. Sustained B-cell depletion was achieved in 32/52 (62%) of patients with complete data and was associated with higher renal response rate at week 76 (Table), although patients who achieved sustained depletion also had lower baseline proteinuria and serum creatinine.

Conclusion:

Obinutuzumab, a type II anti-CD20 mAb, mediated rapid, complete and sustained depletion of peripheral B-cells and plasmablasts and large increases in serum BAFF. Similar to previous reports, sustained B-cell depletion was associated with increased renal response though there may be confounding factors. REGENCY is being conducted to further evaluate the therapeutic hypothesis with obinutuzumab in LN.

References:

[1]Md Yusof MY et al.Ann Rheum Dis. 2017;76:1829-36.

Table.

Data from NOBILITY at week 76 by depletion status at weeks 24 and 52

Definition of responseObinutuzumab sustained depletion (N = 32)aObinutuzumab detectable B-cells (N = 20)aPlacebo group detectable B-cells (N = 62)NOBILITY complete responseUPCR < 0.5, SCr ≤ ULN and not increased > 15% from baseline SCr, and < 10 RBC/hpf without casts50%**35%*18%NOBILITY overall responseCRR or ≥ 50% reduction in UPCRb with SCr not increased > 15% from baseline and urinary RBCs not increased > 50% from baseline66%***45%*29%REGENCY complete responseUPCR < 0.5, SCr ≤ ULN and not increased > 25% from baseline SCr69%**45%31%REGENCY overall responseCRR or ≥ 50% reduction in UPCRb with SCr not increased > 25% from baseline84%***55%50%

* P < 0.2 vs. placebo group.

** P < 0.05 vs. placebo group.

*** P < 0.001 vs. placebo group.

aEleven patients in the obinutuzumab group with insufficient data to determine depletion status were excluded.

b≥ 50% reduction in UPCR to a value < 1 (< 3 if the baseline UPCR was ≥ 3).

Acknowledgments :

This study was funded by F. Hoffmann-La Roche.

Disclosure of Interests: :

Edward Vital Grant/research support from: AstraZeneca, Roche/Genentech, and Sandoz, Consultant of: AstraZeneca, GSK, Roche/Genentech, and Sandoz, Speakers bureau: Becton Dickinson and GSK, Philippe Rémy: None declared, Luis Fernando Quintana Porras: None declared, Laurent Chiche: None declared, Dominique Chauveau: None declared, Richard Furie Grant/research support from: AstraZeneca, Biogen, Consultant of: AstraZeneca, Biogen, Thomas Schindler Employee of: F. Hoffmann-La Roche, Jay Garg Employee of: Genentech, Matthew D. Cascino Employee of: Genentech, Zahir Amoura Grant/research support from: GSK, Roche, Consultant of: GSK, Astra Zeneca, Amgen, Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS, Cary Michael Donna Looney Employee of: Genentech, Dario Roccatello: None declared

Outcome of participants with nephrotic syndrome in combined clinical trials of lupus nephritis

Objective

The outcome of participants with nephrotic syndrome in clinical trials of lupus nephritis has not been studied in detail.

Methods

Collated data from two randomised controlled trials in lupus nephritis, Lupus Nephritis Assessment of Rituximab (LUNAR) and A Study to Evaluate Ocrelizumab in Patients With Nephritis due to Systemic Lupus Erythematosus (BELONG) were analysed. Nephrotic syndrome was defined as albumin <3 g/dL and urine protein/creatinine ratio ≥3.5 g/g at start of trial. Renal response was defined as a first morning urine protein/creatinine ratio ≤0.5 g/g in addition to ≤25% increase in creatinine from trial entry assessed at week 48. Logistic regression was used to evaluate the association of nephrotic syndrome with renal response while adjusting for treatment received and ACE inhibitor or angiotensin receptor blocker use.

Results

28 (26%) participants with nephrotic syndrome achieved renal response as compared with 130 (52.5%) of those without (p<0.001). Having nephrotic syndrome at baseline significantly lowered the likelihood of achieving renal response (OR 0.32, 95 % CI 0.19 to 0.54, p<0.001). 125 (80%) participants achieved resolution of their nephrotic syndrome in a median time of 16 weeks.

Conclusions

Nephrotic syndrome at baseline decreases the likelihood of renal response at 1 year. Longer clinical trials or better short-term predictors of long-term outcomes may better assess the effect of novel therapeutic approaches on subjects with nephrotic syndrome.

Peripheral Blood B Cell Depletion after Rituximab and Complete Response in Lupus Nephritis

BACKGROUND AND OBJECTIVES

Incomplete peripheral blood B cell depletion after rituximab in lupus nephritis might correlate with inability to reduce tubulointerstitial lymphoid aggregates in the kidney, which together could be responsible for inadequate response to treatment. We utilized data from the Lupus Nephritis Assessment with Rituximab (LUNAR) study to characterize the variability of peripheral blood B cell depletion after rituximab and assess its association with complete response in patients with lupus nephritis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We analyzed 68 participants treated with rituximab. Peripheral blood B cell depletion was defined as 0 cells/µl, termed "complete peripheral depletion," assessed over 78 weeks. Logistic regression was used to estimate the association between characteristics of complete peripheral depletion and complete response (defined as urine protein-to-creatinine ratio <0.5 mg/mg, and normal serum creatinine or an increase in creatinine <15%, if normal at baseline), assessed at week 78.

RESULTS

A total of 53 (78%) participants achieved complete peripheral depletion (0 cells/µl) in a median time of 182 days (interquartile range, 80-339).The median duration of complete peripheral depletion was 71 days (interquartile range, 14-158). Twenty-five (47%) participants with complete peripheral depletion achieved complete response, compared with two (13%) without. Complete peripheral depletion was associated with complete response (unadjusted odds ratio [OR], 5.8; 95% confidence interval [95% CI], 1.2 to 28; P=0.03). Longer time to achieving complete peripheral depletion was associated with a lower likelihood of complete response (unadjusted OR, 0.89; 95% CI, 0.81 to 0.98; P=0.02). Complete peripheral depletion lasting >71 days (the median) was associated with complete response (unadjusted OR, 4.1; 95% CI, 1.5 to 11; P=0.008).

CONCLUSIONS

There was substantial variability in peripheral blood B cell depletion in patients with lupus nephritis treated with rituximab from the LUNAR trial. Achievement of complete peripheral depletion, as well as the rapidity and duration of complete peripheral depletion, were associated with complete response at week 78.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_09_06_CJASNPodcast_18_10_.mp3.

Gender and age differences in cardiovascular complications in anorexia nervosa patients

BACKGROUND

Anorexia nervosa (AN) is characterized by severe malnutrition and electrolyte imbalances. Differences in cardiovascular complications between males and females with AN have not been studied. Additionally, coronary artery disease (CAD) prevalence and cardiovascular complications in patients with AN >65years have not been reported.

METHODS

AN patients>18years were identified in the Nationwide Inpatient Sample 2009-2010 database using the Ninth Revision of International Classification of Disease code 307.1. Demographics, risk factors, and cardiovascular event rates were compared to general population data.

RESULTS

CAD incidence was lower in all AN patients compared to the general population (4.4% vs 18.4%, p<0.001). Despite AN males having higher prevalences of hypertension and diabetes than AN females, there was no difference in CAD. AN males had higher rates of cardiac arrests, arrhythmias, and heart failure. Interestingly, 4.3% of patients with AN were >65years old. When compared to the general population>65years, older AN patients had lower rates of CAD (35% vs 16%; p<0.001). Older AN patients still had higher CAD rates compared to the general population under 65 (8.6%) and AN patients under 65 (4%; p<0.001). Older AN patients had a lower incidence of heart failure (24% vs 16%; p=0.04), and a trend towards less arrhythmias (30% vs 21%; p=0.08).

CONCLUSIONS

Our data suggests that male AN patients experienced more cardiac arrests, arrhythmias, and heart failure than female AN patients. Additionally, older AN patients have a decreased incidence of CAD and heart failure compared to the general population>65years old.

Intrinsic to extrinsic phonon lifetime transition in a GaAs-AlAs superlattice

We have measured the lifetimes of two zone-center longitudinal acoustic phonon modes, at 320 and 640 GHz, in a 14 nm GaAs/2 nm AlAs superlattice structure. By comparing measurements at 296 and 79 K we separate the intrinsic contribution to phonon lifetime determined by phonon-phonon scattering from the extrinsic contribution due to defects and interface roughness. At 296 K, the 320 GHz phonon lifetime has approximately equal contributions from intrinsic and extrinsic scattering, whilst at 640 GHz it is dominated by extrinsic effects. These measurements are compared with intrinsic and extrinsic scattering rates in the superlattice obtained from first-principles lattice dynamics calculations. The calculated room-temperature intrinsic lifetime of longitudinal phonons at 320 GHz is in agreement with the experimentally measured value of 0.9 ns. The model correctly predicts the transition from predominantly intrinsic to predominantly extrinsic scattering; however the predicted transition occurs at higher frequencies. Our analysis indicates that the 'interfacial atomic disorder' model is not entirely adequate and that the observed frequency dependence of the extrinsic scattering rate is likely to be determined by a finite correlation length of interface roughness.

Post LASIK progressive astigmatism in a child with partially accommodative esotropia

INTRODUCTION

Refractive surgery is considered a safe and effective method for correction of refractive errors in adults.

OBJECTIVE

To report an unusual case of a young child with partially accommodative esotropia presenting with deterioration of vision and worsening of esotropia following refractive surgery.

CASE REPORT

Unanticipated and progressive irregular corneal astigmatism along with deterioration of visual acuity and loss of stereopsis developed post- LASIK in a seven-year-old Indian child with partially accommodative esotropia.

CONCLUSION

Keratorefractive surgery in young children has to be undertaken with caution, especially in such cases where there is no medical indication for refractive surgery and waiting beyond teenage years is a viable option.

Economic outcomes in patients diagnosed with systemic lupus erythematosus with versus without nephritis: results from an analysis of data from a US claims database

BACKGROUND

Based on a literature search, there are limited data on the economic burden of systemic lupus erythematosus (SLE), particularly in patients with lupus nephritis.

OBJECTIVE

The objective of this study was to compare health care resource utilization and direct medical care costs over a period of 12 months in patients with a history of SLE with or without nephritis.

METHODS

Patients aged >or=18 years with >or=1 claim for an immunosuppressive/disease-modifying antirheumatic drug, antimalarial agent, NSAID/cyclooxygenase-2 inhibitor, or other SLE-related treatment (eg, opioid and combination analgesic, antianxiety agent, antihyperlipidemic agent, antihypertensive agent, bisphosphonate, vitamin D) dated between January 1, 2007, and December 31, 2007, were identified using a nationally representative, US commercial insurance claims database. The date of the first dispensation of the treatment represented the index date. Patients were required to have >or=2 claims containing a diagnosis of SLE during a 6-month preindex period through 3 months postindex and to have continuous health plan enrollment for 6 months before and 12 months after the index date. Patients with >or=1 claim containing a diagnosis of nephritis during the preindex period were identified. Health care resource utilization and direct medical care cost data were assessed over a period of 12 months; paid amounts were used as a proxy for costs and were expressed in year-2008 US dollars.

RESULTS

A total of 15,590 patients with SLE were identified (13,828 women, 1762 men; mean age, 48 years); 1068 (6.9%) had a history of nephritis. The mean age of patients with SLE without nephritis was significantly greater compared with the group with nephritis (47.9 vs 46.5 years, respectively; P < 0.001), and a greater proportion of this group were women (89.0% vs 84.7%; P < 0.001). Over a period of 12 months, 30.3% of patients with nephritis were hospitalized compared with 13.6% of those without nephritis (P < 0.001); the mean lengths of hospital stays were 16.52 and 9.69 days (P < 0.001) in patients with and without nephritis, respectively. Patients with nephritis also underwent more outpatient laboratory tests (mean, 64.42 vs 30.96; P < 0.001) and had a significantly higher mean number of intravenous infusions (mean, 1.7 vs 1.1; P < 0.001), and total 12-month follow-up costs were significantly greater in patients with nephritis compared with those without nephritis (mean, $30,652 vs $12,029; P < 0.001). Costs associated with inpatient and outpatient care were 252% and 146% higher in patients with SLE with nephritis, respectively. Outpatient costs were associated with approximately half of the total costs in patients with or without nephritis; pharmacy costs accounted for 20% of the total costs in patients with SLE and nephritis and 27% of total costs among those without nephritis. Significantly higher costs also were found in patients with nephritis when only SLE-related costs were assessed and after differences in patient characteristics and comorbidities were adjusted through multivariate analyses (all, P < 0.05).

CONCLUSIONS

The present data analysis found that patients with SLE with nephritis consumed significantly more health care resources, with >2.5-fold the costs, compared with those without nephritis. The majority (84%) of added costs were attributable to inpatient hospitalizations and outpatient services, and 16% were attributable to pharmacy services.

Thiazide diuretics, potassium, and the development of diabetes: a quantitative review

National guidelines and a recent clinical trial have supported the use of thiazide diuretics as the preferred initial pharmacological treatment for hypertension. However, evidence from this and other clinical trials have also found an increased incidence of new onset diabetes among those patients receiving thiazide diuretics. The mechanisms responsible for the increased incidence of diabetes with thiazide diuretics have not been fully elucidated. This article provides a review of intervention studies that included data on the relation between thiazide-induced hypokalemia and glucose intolerance. We conducted a literature search from 1966 to June 2004 to identify clinical trials using thiazide diuretics where the metabolic effects on potassium and glucose are reported. A total of 59 clinical trials constituting 83 thiazide diuretic study arms were identified. Trial size, length, type of thiazide diuretic, and dose varied substantially among the studies. The association between average changes in potassium and glucose in the study arms is considered jointly in a weighted statistical model. The Pearson's correlation coefficient, weighted by study sample size, for the relationship between glucose and potassium was -0.54 (95% CI, -0.67 to -0.36; P < 0.01). A sensitivity analysis, which considered subset analyses and effect of covariates, as well as inverse-variance weighting, supported this finding. These data suggest that thiazide-induced hypokalemia is associated with increased blood glucose. Treatment of thiazide-induced hypokalemia may reverse glucose intolerance and possibly prevent the future development of diabetes.

Treatment of hypertension in patients with renal disease

Management of hypertension in people with kidney disease is challenging and generally requires at least three different and complementary acting antihypertensive agents to achieve the recommended blood pressure goal by the JNC VI and WHO guidelines of <130/85 mmHg. This is also true for the recent blood pressure goal for diabetes of <130/80 mmHg recommended by both the National Kidney Foundation and American Diabetes Association for reduction of cardiovascular risk and preservation of kidney function. Commonly used combinations include an ACE inhibitor, which has compelling indications for use in people with kidney disease with a diuretic, generally a thiazide type agent. Angiotensin receptor blockers have clearly shown effectiveness for slowing nephropathy progression in Type 2 diabetes and clearly have a role as first-line agents in that disease. If additional therapy is required, either a beta blocker or calcium antagonist may be added to this antihypertensive 'cocktail'. Beta blockers are particularly effective in people with a high sympathetic drive, i.e. high pulse rates, to lower pressure and reduce cardiovascular risk. Moreover, in recent studies their benefits on kidney function both by reducing proteinuria and slowing decline of kidney function make them good agents to add in the appropriate clinical setting. Given recent data from an analysis of the NHANES III database showing only 11% of people being treated for hypertension with diabetic kidney disease have achieved the blood pressure goal of <130/85 mmHg, it's no wonder the incidence of people starting dialysis continues to climb. Physicians need to work harder and educate patients on the importance of achieving these lower blood pressure guidelines.

Angiotensin converting enzyme inhibitors or angiotensin receptor blockers in nephropathy from type 2 diabetes

Type 2 diabetes is the most common cause of end-stage renal disease in the United States, and type 2 diabetes has been shown to be a myocardial infarction equivalent in regard to risk of death from a cardiovascular event. Proteinuria is a surrogate marker for renal disease progression, and although data favor both the angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in reducing proteinuria, data for renal outcomes, such as time to dialysis, only exist for the ARBs, which clearly increase the duration to dialysis. Conversely, ACE inhibitors have overwhelming data that show substantial risk reduction from cardiovascular events and death in people with type 2 diabetes. Similar data on cardiovascular risk reduction are not yet available with ARBs, although two trials of renal disease progression did have cardiovascular endpoints as secondary outcomes. There were no significant differences between the ARB and control group except for first hospitalization with heart failure, where losartan reduced the risk by 32%, but there was a trend, albeit not significant, toward reduction of myocardial infarction. The first information regarding ARB effects on cardiovascular events as primary outcomes will come from the Losartan Intervention for Endpoint (LIFE) Reduction in Hypertension study. Therefore, as of this writing, all patients with type 2 diabetes and no evidence of nephropathy, ie, proteinuria and an elevated creatinine > 1.5 mg/dL, should be placed on an ACE inhibitor for cardiovascular risk reduction. If nephropathy is present, the evidence would support an ARB for therapy in concert with a b-blocker for cardiovascular risk reduction and renoprotection.

The LysE superfamily: topology of the lysine exporter LysE of Corynebacterium glutamicum, a paradyme for a novel superfamily of transmembrane solute translocators

In Corynebacterium glutamicum the LysE carrier protein exhibits the unique function of exporting L-lysine. We here analyze the membrane topology of LysE, a protein of 236 amino acyl residues, using PhoA- and LacZ-fusions. The amino-terminal end of LysE is located in the cytoplasm whereas the carboxy-terminal end is found in the periplasm. Although 6 hydrophobic domains were identified based on hydropathy analyses, only five transmembrane spanning helices appear to be present. The additional hydrophobic segment may dip into the membrane or be surface localized. We show that LysE is a member of a family of proteins found, for example, in Escherichia coil, Bacillus subtilis, Mycobacterium tuberculosis and Helicobacter pylori. This family, which we have designated the LysE family, is distantly related to two additional protein families which we have designated the YahN and CadD families. These three families, the members of which exhibit similar sizes, hydropathy profiles, and sequence motifs comprise the LysE superfamily. Functionally characterized members of the LysE superfamily export L-lysine, cadmium and possibly quarternary amines. We suggest that LysE superfamily members will prove to catalyze export of a variety of biologically important solutes.

Phylogenetic characterization of novel transport protein families revealed by genome analyses

As a result of recent genome sequencing projects as well as detailed biochemical, molecular genetic and physiological experimentation on representative transport proteins, we have come to realize that all organisms possess an extensive but limited array of transport protein types that allow the uptake of nutrients and excretion of toxic substances. These proteins fall into phylogenetic families that presumably reflect their evolutionary histories. Some of these families are restricted to a single phylogenetic group of organisms and may have arisen recently in evolutionary time while others are found ubiquitously and may be ancient. In this study we conduct systematic phylogenetic analyses of 26 families of transport systems that either had not been characterized previously or were in need of updating. Among the families analyzed are some that are bacterial-specific, others that are eukaryotic-specific, and others that are ubiquitous. They can function by either a channel-type or a carrier-type mechanism, and in the latter case, they are frequently energized by coupling solute transport to the flux of an ion down its electrochemical gradient. We tabulate the currently sequenced members of the 26 families analyzed, describe the properties of these families, and present partial multiple alignments, signature sequences and phylogenetic trees for them all.

Epidermal calmodulin levels in psoriasis before & after therapy

Epidermal calmodulin (CaM) levels were measured in the involved and uninvolved skin in 26 psoriasis patients before and after treatment either with dithranol topically or methotrexate orally. The mean epidermal calmodulin levels (+/- SD) in the involved and uninvolved psoriatic skin before treatment were 21.99 +/- 10.22 and 11.97 +/- 3.50 in the patients to be treated with short contact dithranol therapy (SCDT) while it was 19.46 +/- 8.13 and 11.27 +/- 7.23 in the patients to be treated with systemic methotrexate. Clearance of psoriatic lesions was associated with a significant fall (P less than 0.05) in epidermal calmodulin, activity irrespective of the treatment modality used. Also, there was a significant reduction (P less than 0.05) in the calmodulin levels in the epidermis of uninvolved skin following successful treatment.