Sex Differences in Cardiovascular Outcomes in Patients With Kidney Failure

BACKGROUND

Cardiovascular disease is the leading cause of mortality in patients with kidney failure, and their risk of cardiovascular events is 10 to 20 times higher as compared with the general population.

METHODS AND RESULTS

We evaluated 508 822 patients who initiated dialysis between January 1, 2005 and December 31, 2014 using the United States Renal Data System with linked Medicare claims. We determined hospitalization rates for cardiovascular events, defined by acute coronary syndrome, heart failure, and stroke. We examined the association of sex with outcome of cardiovascular events, cardiovascular death, and all-cause death using adjusted time-to-event models. The mean age was 70±12 years and 44.7% were women. The cardiovascular event rate was 232 per thousand person-years (95% CI, 231-233), with a higher rate in women than in men (248 per thousand person-years [95% CI, 247-250] versus 219 per thousand person-years [95% CI, 217-220]). Women had a 14% higher risk of cardiovascular events than men (hazard ratio [HR], 1.14 [95% CI, 1.13-1.16]). Women had a 16% higher risk of heart failure (HR, 1.16 [95% CI, 1.15-1.18]), a 31% higher risk of stroke (HR, 1.31 [95% CI, 1.28-1.34]), and no difference in risk of acute coronary syndrome (HR, 1.01 [95% CI, 0.99-1.03]). Women had a lower risk of cardiovascular death (HR, 0.89 [95% CI, 0.88-0.90]) and a lower risk of all-cause death than men (HR, 0.96 [95% CI, 0.95-0.97]).

CONCLUSIONS

Among patients undergoing dialysis, women have a higher risk of cardiovascular events of heart failure and stroke than men. Women have a lower adjusted risk of cardiovascular mortality and all-cause mortality.

Women's health and kidney protective medications

PURPOSE OF REVIEW

We discuss the sex-based differences in the pharmacokinetics and pharmacodynamics of kidney protective medications and their implications on women's health.

RECENT FINDINGS

A critical examination of adverse drug reactions highlights the underrepresentation of women in clinical trials for kidney and cardiovascular protective drugs, such as SGLT2 inhibitors, ACE inhibitors, and endothelin receptor antagonists. This underscores the need for sex-specific analyses in clinical studies to accurately assess medication efficacy and safety.

SUMMARY

The research demonstrates that women are more likely to experience adverse events and less likely to benefit from certain treatments, emphasizing the urgent need for healthcare providers to adopt a sex-informed approach in prescribing practices. Future research should prioritize sex differences from the outset to enhance understanding and improve clinical outcomes for women with chronic kidney disease and cardiovascular conditions.

A clinical score to predict recovery in end-stage kidney disease due to acute kidney injury

Background

Acute kidney injury (AKI) is a major contributor to end-stage kidney disease (ESKD). About one-third of patients with ESKD due to AKI recover kidney function. However, the inability to accurately predict recovery leads to improper triage of clinical monitoring and impacts the quality of care in ESKD.

Methods

Using data from the United States Renal Data System from 2005 to 2014 (n = 22 922), we developed a clinical score to predict kidney recovery within 90 days and within 12 months after dialysis initiation in patients with ESKD due to AKI. Multivariable logistic regressions were used to examine the effect of various covariates on the primary outcome of kidney recovery to develop the scoring system. The resulting logistic parameter estimates were transformed into integer point totals by doubling and rounding the estimates. Internal validation was performed.

Results

Twenty-four percent and 34% of patients with ESKD due to AKI recovered kidney function within 90 days and 12 months, respectively. Factors contributing to points in the two scoring systems were similar but not identical, and included age, race/ethnicity, body mass index, congestive heart failure, cancer, amputation, functional status, hemoglobin and prior nephrology care. Three score categories of increasing recovery were formed: low score (0-6), medium score (7-9) and high score (10-12), which exhibited 90-day recovery rates of 12%, 26% and 57%. For the 12-month scores, the low, medium and high groups consisted of scores 0-5, 6-8 and 9-11, with 12-month recovery rates of 16%, 33% and 62%, respectively. The internal validation assessment showed no overfitting of the models.

Conclusion

A clinical score derived from information available at incident dialysis predicts renal recovery at 90 days and 12 months in patients with presumed ESKD due to AKI. The score can help triage appropriate monitoring to facilitate recovery and begin planning long-term dialysis care for others.

Handling 'carbon footprint' in orthopaedics

INTRODUCTION

The National Health Service contributes 4%-5% of England and Wales' greenhouse gases and a quarter of all public sector waste. Between 20% and 33% of healthcare waste originates from a hospital's operating room, and up to 90% of waste is sent for costly and unneeded hazardous waste processing. The goal of this study was to quantify the amount and type of waste produced during a selection of common trauma and elective orthopaedic operations, and to calculate the carbon footprint of processing the waste.

METHODS

Waste generated for both elective and trauma procedures was separated primarily into clean and contaminated, paper or plastic, and then weighed. The annual carbon footprint for each operation at each site was subsequently calculated.

RESULTS

Elective procedures can generate up to 16.5kg of plastic waste per procedure. Practices such as double-draping the patient contribute to increasing the quantity of waste. Over the procedures analysed, the mean total plastic waste at the hospital sites varied from 6 to 12kg. One hospital site undertook a pilot of switching disposable gowns for reusable ones with a subsequent reduction of 66% in the carbon footprint and a cost saving of £13,483.89.

CONCLUSIONS

This study sheds new light on the environmental impact of waste produced during trauma and elective orthopaedic procedures. Mitigating the environmental impact of the operating room requires a collective drive for a culture change to sustainability and social responsibility. Each clinician can have an impact upon the carbon footprint of their operating theatre.

The carbon footprint of arthroscopic procedures

INTRODUCTION

The healthcare sector contributes the equivalent of 4.4% of global net emissions to the climate carbon footprint; between 20% and 70% of healthcare waste originates from a hospital's operating theatre and up to 90% of waste is sent for costly and unneeded hazardous waste processing. This study aimed to quantify the amount and type of waste produced during an arthroscopic anterior cruciate ligament reconstruction (ACLR) and an arthroscopic rotator cuff repair (RCR), calculate the carbon footprint and assess the cost of the waste disposal.

METHODS

The amount of waste generated from ACLR and RCR procedures was calculated across a range of hospital sites. The waste was separated primarily into clean and contaminated, paper or plastic. Both carbon footprint and cost of disposal across the hospital sites was subsequently calculated.

RESULTS

RCR generated 3.3-15.5kg of plastic waste and 0.9-2.3kg of paper waste. ACLR generated 2.4-9.6kg of plastic waste and 1.1-1.6kg of paper waste. The cost to process waste varies widely between hospital sites, waste disposal contractors and method of waste disposal. The annual burden of the included hospital sites for the arthroscopic procedures undertaken was 6.2 tonnes of carbon dioxide.

CONCLUSIONS

The data collected demonstrated a significant variability in waste production and cost for waste disposal between hospital sites. At a national level, consideration should be given to the procurement of appropriate products such that waste can be efficiently recycled or disposed of by environmentally sustainable methods.

Impact and process evaluation of a primary-school Food Education and Sustainability Training (FEAST) program in 10-12-year-old children in Australia: pragmatic cluster non-randomized controlled trial

BACKGROUND

Environmentally sustainable food initiatives accompanying nutrition education, such as the Food Education and Sustainability Training (FEAST) program, have gained traction in school settings. The aim of this trial was to conduct an impact and process evaluation of FEAST, to evaluate its effect on children's fruit and vegetable (F&V) intakes, and secondary outcomes: F&V variety consumed, nutrition knowledge, food preparation/cooking skills, self-efficacy and behaviours, food waste knowledge and behaviours, and food production knowledge.

METHODS

FEAST was a 10-week curriculum-aligned program, designed to educate children about healthy eating, food waste, and sustainability, while teaching cooking skills. It was implemented by classroom teachers, face-to-face and online, during COVID-19 school closures, in Australia in 2021. A custom designed survey was used to collect baseline and post-intervention data from students. Generalised linear mixed models (GLMM) estimated group differences in pre-post changes for primary and secondary outcomes. Surveys were also administered to students and teachers to evaluate intervention implementation.

RESULTS

Twenty schools participated and self-selected to be either intervention schools (n = 10) or wait-list control (WLC) schools (n = 10). A total of 977, 5th and 6th grade children participated in the trial with a mean age of 11.1 years (SD ± 0.7). The FEAST intervention, compared to WLC, did not result in significant increases in primary outcomes nor secondary outcomes. The process evaluation revealed FEAST was well-received by students and teachers, but COVID-19 school closures hindered implementation fidelity with a less intense program delivered under the constraints of pandemic lockdowns.

CONCLUSIONS

This is the first cluster non-randomized controlled trial designed to independently evaluate FEAST in the primary-school setting. No evidence was found for improved F&V intakes in children, nor secondary outcomes. However, the positive process evaluation results suggest that further trials of the program are warranted. If implemented as originally designed (pre-pandemic), with increased duration and complemented by supporting school policies, such programs have the potential to improve children's daily F&V intakes, cooking skills and food waste behaviours. This would support the Australian curriculum and contribute to: health promotion within schools and sustainable schools initiatives, the national agenda to reduce food waste and sustainable development goals. AUSTRALIAN AND NEW ZEALAND CLINICAL TRIALS REGISTRY: [ACTRN12620001347954]- Registered prospectively on 14/12/2020.

Cardiovascular Outcomes in Patients on Home Hemodialysis and Peritoneal Dialysis

Key Points

Home hemodialysis is associated with decreased risk of stroke and acute coronary syndrome relative to peritoneal dialysis. Home hemodialysis is associated with decreased risk of cardiovascular death and all-cause death relative to peritoneal dialysis.

Background

Cardiovascular disease is the leading cause of morbidity and mortality in patients with ESKD. Little is known about differences in cardiovascular outcomes between home hemodialysis (HHD) and peritoneal dialysis (PD).

Methods

We evaluated 68,645 patients who initiated home dialysis between January 1, 2005, and December 31, 2018, using the United States Renal Data System with linked Medicare claims. Rates for incident cardiovascular events of acute coronary syndrome, heart failure, and stroke hospitalizations were determined. Using adjusted time-to-event models, the associations of type of home dialysis modality with the outcomes of incident cardiovascular events, cardiovascular death, and all-cause death were examined.

Results

Mean age of patients in the study cohort was 64±15 years, and 42.3% were women. The mean time of follow-up was 1.8±1.6 years. The unadjusted cardiovascular event rate was 95.1 per thousand person-years (PTPY) (95% confidence interval [CI], 93.6 to 96.8), with a higher rate in patients on HHD than on PD (127.8 PTPY; 95% CI, 118.9 to 137.2 versus 93.3 PTPY; 95% CI, 91.5 to 95.1). However, HHD was associated with a slightly lower adjusted risk of cardiovascular events than PD (hazard ratio [HR], 0.92; 95% CI, 0.85 to 0.997). Compared with patients on PD, patients on HHD had 42% lower adjusted risk of stroke (HR, 0.58; 95% CI, 0.48 to 0.71), 17% lower adjusted risk of acute coronary syndrome (HR, 0.83; 95% CI, 0.72 to 0.95), and no difference in risk of heart failure (HR, 1.05; 95% CI, 0.94 to 1.16). HHD was associated with 22% lower adjusted risk of cardiovascular death (HR, 0.78; 95% CI, 0.71 to 0.86) and 8% lower adjusted risk of all-cause death (HR, 0.92; 95% CI, 0.87 to 0.97) as compared with PD.

Conclusions

Relative to PD, HHD is associated with decreased risk of stroke, acute coronary syndrome, cardiovascular death, and all-cause death. Further studies are needed to better understand the factors associated with differences in cardiovascular outcomes by type of home dialysis modality in patients with kidney failure.

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.

Amivantamab plus chemotherapy with and without lazertinib in EGFR-mutant advanced NSCLC after disease progression on osimertinib: primary results from the phase III MARIPOSA-2 study

BACKGROUND

Amivantamab plus carboplatin-pemetrexed (chemotherapy) with and without lazertinib demonstrated antitumor activity in patients with refractory epidermal growth factor receptor (EGFR)-mutated advanced non-small-cell lung cancer (NSCLC) in phase I studies. These combinations were evaluated in a global phase III trial.

PATIENTS AND METHODS

A total of 657 patients with EGFR-mutated (exon 19 deletions or L858R) locally advanced or metastatic NSCLC after disease progression on osimertinib were randomized 2 : 2 : 1 to receive amivantamab-lazertinib-chemotherapy, chemotherapy, or amivantamab-chemotherapy. The dual primary endpoints were progression-free survival (PFS) of amivantamab-chemotherapy and amivantamab-lazertinib-chemotherapy versus chemotherapy. During the study, hematologic toxicities observed in the amivantamab-lazertinib-chemotherapy arm necessitated a regimen change to start lazertinib after carboplatin completion.

RESULTS

All baseline characteristics were well balanced across the three arms, including by history of brain metastases and prior brain radiation. PFS was significantly longer for amivantamab-chemotherapy and amivantamab-lazertinib-chemotherapy versus chemotherapy [hazard ratio (HR) for disease progression or death 0.48 and 0.44, respectively; P < 0.001 for both; median of 6.3 and 8.3 versus 4.2 months, respectively]. Consistent PFS results were seen by investigator assessment (HR for disease progression or death 0.41 and 0.38 for amivantamab-chemotherapy and amivantamab-lazertinib-chemotherapy, respectively; P < 0.001 for both; median of 8.2 and 8.3 versus 4.2 months, respectively). Objective response rate was significantly higher for amivantamab-chemotherapy and amivantamab-lazertinib-chemotherapy versus chemotherapy (64% and 63% versus 36%, respectively; P < 0.001 for both). Median intracranial PFS was 12.5 and 12.8 versus 8.3 months for amivantamab-chemotherapy and amivantamab-lazertinib-chemotherapy versus chemotherapy (HR for intracranial disease progression or death 0.55 and 0.58, respectively). Predominant adverse events (AEs) in the amivantamab-containing regimens were hematologic, EGFR-, and MET-related toxicities. Amivantamab-chemotherapy had lower rates of hematologic AEs than amivantamab-lazertinib-chemotherapy.

CONCLUSIONS

Amivantamab-chemotherapy and amivantamab-lazertinib-chemotherapy improved PFS and intracranial PFS versus chemotherapy in a population with limited options after disease progression on osimertinib. Longer follow-up is needed for the modified amivantamab-lazertinib-chemotherapy regimen.

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.

Yield, carbon stock, and price dynamics of agroforestry tree species in district Mardan, Khyber Pakhtunkhwa, Pakistan

Abstract A socio-economic study was conducted in district Mardan of the Khyber Pakhtunkhwa (KP) province of Pakistan to get a comprehensive knowledge of the agroforestry tree species grown on the farmlands, their yield, and carbon stock. For yield and carbon stock estimation, data were collected from 59 sample plots by measuring the diameter, height, volume, and biomass of selected agroforestry tree species through D-tape and Haga altimeter. A total of 59 sample plots were inventoried using 2.5 percent sampling intensity. Each sample plot has an area of 0.5 ha, where each tree with a Diameter at Breast Height (DBH) ≥ 5 cm was inventoried. The calculated amount of volume of each tree species was then converted to biomass by multiplying it by the density of wood and the Biomass Expansion Factor (BEF). Total yield and C stock for the selected agroforestry tree species were 11535.2 metric tons and 2102.2 metric tons, respectively. Populus euroamericana is classified as the main tree with 28% growing stock prior to Morus alba by 21%, while Melia azedarach, Eucalyptus camaldulensis, Dalbergia sissoo, Acacia nilotica, Salix tetrasperma, and Bombax ceiba consist of 15%, 12%, 8%, 6%,7% and 3% growing stock respectively. Among the species found in different sampling plots the yield of Populus euroamericana was found to be 4747.5 metric tons and it was followed by the species Morus alba found at 2027.3 metric tons. Similarly, the volume for Melia azedarach, Eucalyptus camaldulensis, Dalbergia sissoo, Salix spp, Boombox ceiba, and Acacia nilotica was 1532.2 tons,1503 ton,745.7,203.5ton, 555.4ton and 220.5ton, respectively. The carbon stock for Populus euroamericana was calculated as 777.8 ton/ha, while for Eucalyptus camaldulensis, Melia azedarach, Morus alba, Dalbergia sissoo, Acacia nilotica, Salix species, and Bombax ceiba it was calculated as 312.3ton/ha, 272.1ton/ha, 363ton/ha, 245.1ton/ha, 51.4ton/ha, 27.3ton/ha and 53.2ton/ha, respectively. The questionnaire survey conducted for price dynamics showed that the majority of respondents purchase timber from the market for construction. But they use farm trees with low-quality city construction. They dislike using local timber in the conventional building as timber from farm trees is liable to insect attack. Rs. 50,000-100000, (33.33%) of daily sales was concluded from 50% of the trader while (16.7%) of the traders have their sales between Rs.150,000-200,000. Therefore, it is concluded by the authors that both provincial and federal government should promote agroforestry in Pakistan through different incentives because it has the potential to cope with dilemma of deforestation of natural forests and improve the livelihood of local peoples. It is strongly recommended that special projects just like the Ten Billion Tree Afforestation Project (T-BTTP) should be launched for agroforestry plantation and promotion in the country to sustain the ecological harmony and uplift the socio-economic condition of the peoples of Pakistan.

Contraceptive Use in Females With Advanced CKD: A Qualitative Study

Rationale & Objective

Pregnancy in females with kidney disease is not uncommon and is associated with adverse maternal and fetal outcomes. The use of contraception in females with chronic kidney disease remains low. We sought to describe the perspectives of female patients with advanced chronic kidney disease on the use of contraception.

Study Design

Qualitative study.

Setting & Participants

We conducted 5 focus group interviews involving 16 adult female patients with advanced chronic kidney disease (n = 3 nondialysis nontransplant chronic kidney disease, n = 9 kidney transplant, and n = 4 kidney failure receiving dialysis) in the United States, following which thematic saturation was reached.

Analytical Approach

Interview transcripts were analyzed thematically.

Results

We identified the following 5 themes: 1) variable knowledge regarding reproductive health with kidney disease, 2) inadequate counseling about contraceptive use, 3) lack of interdisciplinary coordination regarding contraceptive use, 4) insufficient educational resources available to guide the contraceptive discussion, and 5) need for research to better understand reproductive needs in females with kidney disease.

Limitations

Patients were from a single center in the United States, and the study is limited by the transferability of findings to other settings.

Conclusions

Patients with chronic kidney disease report emotional challenges with reproductive health, lack of counseling and care coordination, and insufficient resources for contraceptive use. Strategies to strengthen these factors may improve the quality of reproductive care and increase contraceptive use for females with chronic kidney disease.

Plain-Language Summary

Pregnancy in females with kidney disease is common and associated with a higher risk of adverse maternal and fetal outcomes, but the use of contraception remains low. Little is known about female patients' experiences in contraceptive use that may contribute to low contraceptive use in this high-risk population. In the present study using focus group interviews, patients with chronic kidney disease reported emotional challenges with reproductive health, lack of counseling and care coordination, and insufficient resources for contraceptive use. Interventions are needed to strengthen these factors to improve the quality of reproductive care and increase contraceptive use for females with chronic kidney disease.

Exploring the use of masks for protection against the effects of wildfire smoke among people with preexisting respiratory conditions

BACKGROUND

The impact of wildfire smoke is a growing public health issue, especially for those living with preexisting respiratory conditions. Understanding perceptions and behaviors relevant to the use of individual protective strategies, and how these affect the adoption of these strategies, is critical for the development of future communication and support interventions. This study focused on the use of masks by people living in the Australian community with asthma or chronic obstructive pulmonary disease (COPD).

METHODS

Semi-structured phone interviews were undertaken with people living in the community aged 18 years and over. Participants lived in a bushfire-prone area and reported having been diagnosed with asthma or COPD.

RESULTS

Twenty interviews were undertaken between July and September 2021. We found that, during wildfire episodes, there was an overwhelming reliance on closing windows and staying inside as a means of mitigating exposure to smoke. There was limited use of masks for this purpose. Even among those who had worn a mask, there was little consideration given to the type of mask or respirator used. Reliance on sensory experiences with smoke was a common prompt to adopting an avoidance behavior. Participants lacked confidence in the information available from air-quality apps and websites, however they were receptive to the idea of using masks in the future.

CONCLUSIONS

Whilst COVID-19 has changed the nature of community mask use over the last couple of years, there is no guarantee that this event will influence an individual's mask behavior during other events like bushfires. Instead, we must create social support processes for early and appropriate mask use, including the use of air quality monitoring.

Bothersome Hot Flashes Following Neoadjuvant Androgen Deprivation Therapy and Stereotactic Body Radiotherapy for Localized Prostate Cancer

PURPOSE/OBJECTIVE(S)

Androgen deprivation therapy (ADT) may improve cancer control in unfavorable localized prostate cancer treated with stereotactic body radiotherapy (SBRT). ADT is known to cause hormonally related symptoms that resolve with testosterone recovery. Hot flashes are particularly burdensome. This study sought to evaluate the timeline of hot flashes following short-course ADT and SBRT as well as its relationship with testosterone recovery.

MATERIALS/METHODS

Institutional IRB approval was obtained for this retrospective review of prospectively collected data (IRB#: 2009-510). ADT was initiated three months prior to the start of SBRT. Hot flashes were self-reported via question 13a a healthcare software prior to ADT initiation, the first day of robotic SBRT, and at each follow-up (1, 3, 6, 9, 12, 18, 24 and 36 months). The responses were grouped into three relevant categories (no problem, very small-small problem and moderate-big problem). Scores were transformed to a 0-100 scale with higher scores reflecting less bother. Testosterone levels were measured at each follow-up.

RESULTS

From 2007 to 2010, 122 localized prostate cancer patients (9 low-, 64 intermediate-, and 49 high-risk according to the D'Amico classification) at a median age of 72 years (range 54.5-88.3) were treated with short course ADT (3-6 months) and SBRT (35-36.25 Gy) at Georgetown University Hospital. Thirty-two percent were black and 27% were obese. 77% of patient received three months of ADT. At baseline, 2% of men experienced hot flashes that were a "moderate to big problem" and that proportion peaked at the start of SBRT (45%) before returning to baseline 9 months post-SBRT with a cumulative incidence of 52.4%. The median baseline healthcare software hot flash score of 94 declined to 50 at the start of SBRT but this returned to baseline by six months post SBRT. These changes were both statistically and clinically significant (MID = 9.5083). Testosterone recovery (> 230 ng/dL) occurred in approximately 70% of patients by 12 months post SBRT. Resolution of hot flashes correlated with testosterone recovery.

CONCLUSION

Bothersome hot flashes occur in greater than 50% of men treated with neoadjuvant ADT. Resolution of hot flashes occurs in the majority of patients within one year after treatment. Reassurance of the temporary nature of hot flashes may assist in reducing patient anxiety. Measuring testosterone levels at follow-up visits may allow for anticipatory counseling that may limit the associated bother.

Bothersome Gynecomastia Following Neoadjuvant GnRH Agonists and Stereotactic Body Radiotherapy for Localized Prostate Cancer

PURPOSE/OBJECTIVE(S)

Androgen deprivation therapy (ADT) is increasingly utilized in combination with stereotactic body radiotherapy (SBRT) for unfavorable prostate cancer. ADT such as gonadotropin releasing hormone (GnRH) agonists are known to cause hormonal-related side effects such as gynecomastia. The incidence of bothersome breast tenderness and/or enlargement following short course GnRH agonists and SBRT is unknown. This study sought to evaluate the timeline of gynecomastia as well as its relationship with testosterone recovery.

MATERIALS/METHODS

Gynecomastia was self-reported via question 13b of a healthcare software prior to ADT initiation, the first day of robotic SBRT, and at each follow-up (1, 3, 6, 9, 12, 18, 24 and 36 months). The responses were grouped into three relevant categories (no problem, very small-small problem, and moderate-big problem). Scores were transformed to a 0-100 scale with higher scores reflecting less bother. Testosterone levels were measured at each follow-up.

RESULTS

From 2007 to 2010, 122 localized prostate cancer patients (9 low-, 64 intermediate-, and 49 high-risk according to the D'Amico classification) at a median age of 72 years (range 54.5-88.3) were treated with short course ADT (3-6 months) and SBRT (35-36.25 Gy) at Georgetown University Hospital. Of the participants, 48% percent were non-white and 48% were overweight. 77% of patients received three months of ADT. At baseline, 2% of men experienced gynecomastia that was a "moderate to big problem" and that proportion peaked at 3 and 12 months post-SBRT (7%) before returning to less than baseline (0%) 24 months post-SBRT with a cumulative incidence of 14.75%. The median baseline healthcare software hot flash score of 98 declined to 90 at 3 months post-SBRT but this returned to baseline by 24 months post SBRT. These changes were both statistically and clinically significant (MID = 6.5). Testosterone recovery (> 230 ng/dL) occurred in approximately 70% of patients by 12 months post SBRT. The development and resolution of gynecomastia fluctuated at various timepoints and did not directly correlate with testosterone recovery.

CONCLUSION

Bothersome gynecomastia occurs in less than 15% of men treated with neoadjuvant ADT. Resolution of gynecomastia occurs in most patients within two years after treatment. Reassurance of the temporary nature of gynecomastia may assist in reducing patient anxiety. Institutional IRB (IRB#: 2009-510) approval was obtained for retrospective review of prospectively collected data.

Female Reproductive Health and Contraception Use in CKD: An International Mixed-Methods Study

Rationale & Objective

Female reproductive health is recognized as a predictor of morbidity, mortality, and quality of life, although data in the setting of chronic kidney disease (CKD) are limited.

Study Design

A mixed-methods study was employed. Phase 1 was an anonymous, internet-based survey. Phase 2 was semistructured interviews offered to all respondents upon survey completion.

Setting & Participants

The survey was disseminated internationally from October 4, 2021, to January 7, 2022, to individuals aged 18-50 years with both a uterus and CKD diagnosis.

Outcomes

Menstrual health and contraceptive use by CKD stage (dialysis, nondialysis CKD, and transplant).

Analytical Approach

Survey data were analyzed using descriptive statistics. Interview data were analyzed using the framework method of analysis.

Results

Of 152 respondents, 98 (mean age 33 ± 0.7 years; n = 20 dialysis, n = 59 nondialysis CKD, n = 19 transplant) satisfied the inclusion criteria, representing 3 continents. The most common causes of CKD among survey respondents were hereditary causes in dialysis (n = 6, 30%) and glomerulonephritis in nondialysis CKD (n = 22, 37%) and transplant (n = 6, 32%). The majority reported heavy menstrual bleeding (n = 12, 86% dialysis; n = 46, 94% nondialysis CKD; n = 14, 100% transplant). Less than half of participants were consistently able to afford period products. Condoms were the most common contraceptive reported. Most participants reported no contraceptive use (n = 10, 50% dialysis; n = 37, 63% nondialysis CKD; n = 7, 37% transplant), primarily because of "fear". Interviews (n = 6) revealed a perception of a relationship between kidney function and menstrual health, concerns about contraceptive use, and a desire for greater multidisciplinary care to improve kidney and reproductive health.

Limitations

Self-reported outcomes, need for internet access and a device.

Conclusions

Abnormal menstruation and period poverty (ie, inability to afford period products and the socioeconomic consequences of menstruation) were common, and contraceptive use was low among female individuals with CKD, highlighting an important gap in the sex-specific care of this population.

Plain-Language Summary

Chronic kidney disease (CKD) in female individuals is accompanied by menstrual disorders and low contraceptive use. However, most data are limited to the dialysis and transplant populations. Therefore, this mixed-methods study aimed to describe self-assessed menstruation and contraceptive use across all stages of CKD. People aged 18-50 years with a uterus and CKD diagnosis were invited to participate in an online survey shared internationally as well as an optional telephone interview. Abnormal menstruation and period poverty (ie, inability to afford period products and the socioeconomic consequences of menstruation) were common, and contraceptive use was low among female individuals with CKD, highlighting an important gap in the sex-specific care of this population.

Evaluation and Management of Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy complicate up to 10% of pregnancies and remain the major cause of maternal and neonatal morbidity and mortality. Hypertensive disorders of pregnancy can be classified into four groups depending on the onset of hypertension and the presence of target organ involvement: chronic hypertension, preeclampsia, gestational hypertension, and superimposed preeclampsia on chronic hypertension. Hypertension during pregnancy is associated with a higher risk of cardiovascular disease and kidney failure. Early diagnosis and proper treatment for pregnant women with hypertension remain a priority since this leads to improved maternal and fetal outcomes. Labetalol, nifedipine, methyldopa, and hydralazine are the preferred medications to treat hypertension during pregnancy. In this comprehensive review, we discuss the diagnostic criteria, evaluation, and management of pregnant women with hypertension.

Audit of middle-ear surgery outcomes in a tertiary referral Australian teaching hospital

OBJECTIVE

This study aimed to audit middle-ear surgical procedures, provide a record of Australian experiences and allow comparisons with other published audits.

METHOD

A retrospective continuous series audit was conducted on 274 patients who underwent tympanoplasty, mastoidectomy and stapedotomy surgery at Westmead Hospital, Sydney. All consecutive surgical procedures, performed by multiple operators at various stages of training but under the care of a single surgeon, were included.

RESULTS

Graft uptake was 86.9 per cent in tympanoplasty. Well healed cavities were seen in 72 per cent of mastoidectomies. Although 42 per cent of the patients had one or more co-morbidities, this did not influence the outcome. Hearing improvement was dramatic in stapedotomy and minimally changed in mastoidectomy. Post-operative complications were minimal.

CONCLUSION

All forms of middle-ear surgery were effective in achieving their surgical goals. Aural discharge and inflammatory diseases were well controlled with tympanoplasty and mastoid surgery.

β-hydroxybutyrate is a metabolic regulator of proteostasis in the aged and Alzheimer disease brain

Loss of proteostasis is a hallmark of aging and Alzheimer disease (AD). Here, we identify β-hydroxybutyrate (βHB), a ketone body, as a regulator of protein solubility in the aging brain. βHB is a small molecule metabolite which primarily provides an oxidative substrate for ATP during hypoglycemic conditions, and also regulates other cellular processes through covalent and noncovalent protein interactions. We demonstrate βHB-induced protein insolubility across in vitro, ex vivo, and in vivo mouse systems. This activity is shared by select structurally similar metabolites, is not dependent on covalent protein modification, pH, or solute load, and is observable in mouse brain in vivo after delivery of a ketone ester. Furthermore, this phenotype is selective for pathological proteins such as amyloid-β, and exogenous βHB ameliorates pathology in nematode models of amyloid-β aggregation toxicity. We have generated a comprehensive atlas of the βHB-induced protein insolublome ex vivo and in vivo using mass spectrometry proteomics, and have identified common protein domains within βHB target sequences. Finally, we show enrichment of neurodegeneration-related proteins among βHB targets and the clearance of these targets from mouse brain, likely via βHB-induced autophagy. Overall, these data indicate a new metabolically regulated mechanism of proteostasis relevant to aging and AD.

THE GUT-BRAIN AXIS: IMPLICATIONS FOR NEUROLOGICAL DISORDERS, MENTAL HEALTH, AND IMMUNE FUNCTION

A gut-brain axis (GBA) has a long history of conceptual development. Intestinal dysbiosis has now been recognized as a key player in the development of adult neurodevelopmental disorders, obesity, and inflammatory bowel disease. Recent developments in metagenomics suggest those nutrition and gut microbiotas (GM) are important regulators of the gut-brain communication pathways that cause neurodevelopmental and psychiatric problems in adulthood. Intestinal dysbiosis and neurodevelopmental disease outcomes in preterm newborns are being linked by recent research. Recent clinical investigations demonstrate that in critical care units, intestinal dysbiosis occurs before late-onset newborn sepsis and necrotizing enterocolitis. Strong epidemiologic data also shows a connection between necrotizing enterocolitis and extremely low birth weight babies' long-term psychomotor impairments and late-onset neonatal sepsis. The GBA theory suggests that intestinal bacteria may indirectly affect preterm newborns' developing brains. In this review, we emphasize the structure and function of the GBA and discuss how immune-microbial dysfunction in the gut affects the transmission of stress signals to the brain. Preterm babies who are exposed to these signals develop neurologic disorders. Understanding neuronal and humoral communication through the GBA may provide insight into therapeutic and nutritional strategies that may enhance the results of very low-birth-weight babies.

Solid organ graft-versus-host disease in a recipient of a COVID-19 positive liver graft

A 66-year-old male with end-stage liver disease (ESLD) secondary to non-alcoholic fatty liver disease (NAFLD), complicated by hepatocellular carcinoma (HCC), underwent deceased donor liver transplantation from a Coronavirus disease 2019 (COVID-19) positive donor. He presented a month later with fever, diarrhea and pancytopenia which led to hospitalization. The hospital course was notable for respiratory failure, attributed to invasive aspergillosis, as well as a diffuse rash. A bone marrow biopsy revealed hypocellular marrow without specific findings. In the following days, laboratory parameters raised concern for secondary hemophagocytic lymphohistiocytosis (HLH). Clinical concern also grew for solid organ transplant graft-versus-host-disease (SOT-GVHD) based on repeat marrow biopsy with elevated donor-derived CD3+ T cells on chimerism. After, a multidisciplinary discussion, the patient was started on ruxolitinib, in addition to high dose steroids, to address both SOT-GVHD and secondary HLH. Patient developed symptoms concerning for hemorrhagic stroke and was transitioned to comfort care. Although GVHD has been studied extensively in hematopoietic stem cell transplant (HSCT) patients, it is a rare entity in SOT with a lack of guidelines for management. Additionally, whether COVID-19 may play a role in development of SOT-GVDH has not been explored.

Sex and Racial/Ethnic Differences in Home Hemodialysis Mortality

Key Points

Women on home hemodialysis have higher 1-year mortality than men, and women and men have comparable survival on long-term follow-up. Compared with White patients on home hemodialysis, there was no difference in all-cause mortality for Black patients, Hispanics, or Native Americans. Among patients undergoing home hemodialysis, Asians had a lower risk of all-cause mortality than White patients.

Background

Women and minorities constitute substantial portions of the prevalent population of patients with kidney failure. Little is known about sex and racial/ethnic differences in mortality among patients with kidney failure on home hemodialysis in the United States.

Methods

Using the United States Renal Data System, we retrospectively evaluated a cohort of 42,849 patients who started home hemodialysis between January 1, 2005, and December 31, 2015. We examined the association of sex and race/ethnicity with the outcome of all-cause mortality using adjusted Cox proportional hazard models and logistic regression models.

Results

In the study cohort, 40.4% were women, and 57.4% were White. Women on home hemodialysis had higher unadjusted death rates (26.9 versus 22.4 per 100 person-years) compared with men. There was no difference in adjusted all-cause mortality between men and women, but women had an 8% higher adjusted risk of all-cause mortality at 1 year after initiating home hemodialysis (odds ratio 1.08, 95% confidence interval [CI], 1.01 to 1.15). Regarding race/ethnicity, Hispanic, White, and Black patients had higher unadjusted death rates compared with Asians and Native Americans (25.1 versus 24.8 versus 23.2 versus 17.4 versus 16.6 per 100 person-years). There was no difference in adjusted all-cause mortality in Black, Hispanic, and Native Americans compared with White patients, while Asians had a lower risk of all-cause mortality than did White patients (hazard ratio, 0.81; 95% CI, 0.72 to 0.92). There was no difference in adjusted 1-year mortality for Asian, Black, Hispanic, and Native American patients compared with White patients.

Conclusions

Among patients undergoing home hemodialysis, women have higher 1-year mortality than men, and women and men have comparable survival on long-term follow-up after adjusting for other covariates. Compared with White patients, there was no difference in adjusted survival on long-term follow-up for Black patients, Hispanics, or Native Americans, while Asians had better survival. Our results suggest the need for population-wide strategies to overcome differences in home hemodialysis care.

Unraveling the invisible demon: a study of the oxidative stress markers, antioxidant activities and inflammatory markers in patients admitted with complete heart block

Funding Acknowledgements

Type of funding sources: None.

Introduction

Despite the recent advancements in the management of Complete Heart Block (CHB), the aetiology of CHB is still idiopathic in most of the cases. Our study explores this hitherto untouched aspect of complete heart block.

Purpose

We aimed to assess the aetiological profile of Complete Heart Block patients in our study.

Methods

The study population consisted of 60 patients with complete heart block aged between 30 to 80 years, attending as an inpatient in ER. Oxidative stress was measured by serum MDA, serum GSH, serum Catalase activity and serum SOD activity. Antioxidant activity was obtained by measuring the levels of serum total antioxidant capacity. Inflammatory stress was measured by IL-5 and TNF-alpha levels. These values were compared to 30 healthy controls with no prior history of smoking and diabetes mellitus.

Results

The mean age of the patient was 62.48 ± 7.98 years and the gender distribution was 37 males and 23 females out of 60 patients. The mean value of serum MDA (ng/mL) in cases is 1451.26 ± 206.32, and in controls, the mean value is 1197.98 ± 234.71 (p=&lt;0.001). The mean value of serum GSH (mcg/mL) in cases is 46.982 ± 18.613, and in controls, the mean value is 54.155 ± 10.762 (p=0.027). The mean value of serum Catalase Activity (U/min/mg protein) in cases is 10.763 ± 4.038 and in controls, the mean value is 19.878 ± 7.787 (p=0.003). The mean value of serum SOD Activity (U/g) in cases is 24.950 ± 5.4565, and in controls, the mean value is 46.214 ± 14.6309 (p=0.891). The mean value of serum Total Antioxidant Capacity (U/mL) in cases is 5.546 ± 0.620 and in controls, the mean value is 8.346 ± 2.781 (p=0.025). The mean value of serum IL-5 (pg/mL) in cases is 481.442 ± 28.8995, and in controls, the mean value is 67.347 ± 20.445 (p&lt;0.001). The mean value of serum TNF-ALFA (pg/mL) in cases is 196.741 ± 73.771, and in controls, the mean value is 144.530 ± 42.599 (p= 0.081).

Conclusions

During a complete heart block, SOD (p=0.891), CAT (p=0.003), GSH (p=0.027) and total antioxidant (TAOC) (p=0.025) were significantly decreased in cases, compared to healthy controls, thus suggesting that the elevated levels of oxidative free radicals causes endothelial dysfunctioning. The increase in ROS was observed by a highly significant increase of malondialdehyde (MDA) (p=&lt;0.001) showing high ROS-mediated tissue damage. Besides damage by oxidative stress, our study suggests that there are certain inflammatory markers like TNF-α and IL-5 that actively participate in causing heart block. There was a significant increase in the concentration of IL-5 (p&lt;0.001) in the cases as compared to the controls.

Treatment outcomes 12 months after antiretroviral therapy initiation in Oman: a nationwide study from the Middle East

ABSTRACTWe used routinely collected programme data on people living with HIV in Oman who started ART in 2014-2018 to assess retention on ART, viral suppression, attrition (mortality or loss to follow-up [LTFU]) and treatment failure (attrition or HIV viral load of > 1000 copies/mL) 12 months after antiretroviral therapy (ART) initiation. We identified 726 patients; 72% were male. Overall, 12 months retention on ART and viral suppression (intention-to-treat [ITT] analysis) were 85.7% and 74.5%, respectively. Attrition occurred in 14.3% (mortality of 7% and LTFU of 7.3%). Retention increased from 78.8% (93/118) to 90.6% (144/159) among patients who started ART in 2014 and 2018, respectively. Similarly, ITT and on-treatment analyses revealed that viral suppression 12 months after ART initiation increased from 57.6% (68/118) and 73.1% (68/93) among patients who initiated therapy in 2014-80.5% (128/159) and 88.8% (128/144) among patients started treatment in 2018, respectively. On multivariate analysis, older age, having "Other" as an HIV risk factor (compared to heterosexual) and receiving HIV care outside the capital Muscat independently predicted both attrition and treatment failure. Our findings have been useful in identifying factors at the individual and programme level that influenced the risk of attrition and treatment failure.

Sex and gender disparity in kidney transplantation: Historical and future perspectives

Sex and gender disparity exist in various stages of kidney transplantation. Females were found to be less likely to be referred for kidney transplant, complete pre-transplant evaluation, be placed on the waitlist, and receive a kidney transplant compared to their male counterparts. Interestingly, females comprise the majority of living kidney donors. This review explores the biological and psychosocial factors that contribute to sex and gender disparity in kidney transplantation and proposes ways to address the disparity.

Clinical pharmacy service evaluation of hepatology services at a large tertiary centre

Introduction

Kings College Hospital (KCH) provides tertiary level care to patients with liver disease across the UK. These patients are often under the joint care of primary and/or secondary care centres. As a result, several medications related enquires are received from patients and healthcare professionals including, doctors, nurses, and pharmacists to continue and optimise pharmacotherapy. The KCH liver pharmacy team does not provide a formal medicines information service, although a large amount of pharmacy resource is used to provide high level medicines information locally, regionally, and nationally by the team. In addition, significant time and input is provided in optimising access to hospital only medication.

Aim

To describe activities conducted by a specialist clinical pharmacy team out with an inpatient or formal outpatient setting which contribute to medicines optimisation and improve access to specialist medication.

Methods

Retrospective data collection was carried out over 2 separate four-week periods in November 2020 and November 2021 by the specialist liver pharmacy team. The data was analysed on an 8-week average using Microsoft Excel. Ethical approval was not required as this is a service evaluation data collection.

Results

Over eight weeks, the specialist clinical pharmacy team (pharmacists and pharmacy technicians) received 206 queries, of which (72%) were received by email and (28%) by phone. The team spends an average of 15 hours per week on clinical activities outside of formal inpatient and outpatient settings. Most of the queries received were from patients (64%), followed by healthcare professionals including doctors (11%), nurses (9.5%), and pharmacy staff (7.7%). The clinical interventions made by the team included supply of medications (37%), prescribing events (36%) and medicines intervention (20%) which included drug selection, administration, optimisation, deprescribing, therapeutic drug monitoring, drug-drug interaction, transfer of care and advice given following adverse drug reactions.

Discussion/Conclusion

The ease of accessibility to the specialist clinical pharmacy team plays a significant role in providing access to specialist medications to patients and a positive impact on other healthcare services, including decreasing the burden upon primary care. A structured medicines information line provided by the specialist team would be effective for patients and healthcare professionals as the specialist team spends substantial amount of time providing medicines intervention and medicines information. The involvement of specialist pharmacy technicians in medicines information services and interventions, provides an opportunity for role development and up-skill the pharmacy technician role in a specialist team. A formal and structured medicine information service for hepatology by the specialist clinical pharmacy team should be considered to improve access to specialist medication and medicines optimisation.

References

1. Williams M, Jordan A, Scott J, Jones MD, A systematic review examining the effectiveness of medicines information services for patients and the general public. International Journal of Pharmacy Practice, 2020;28(1):26-40.

2. Hayward K, Patel P, Valery P, Horsfall L, Catherine L, Penny W. Medication-related problems in outpatients with decompensated cirrhosis: opportunities for harm prevention. Hepatology Communications, 2019;3(5):620-663.

3. Newby B. Expanding the role of pharmacy technicians to facilitate a proactive pharmacist practice. American Journal of Health-System Pharmacy, 2019;76(6):398-402.

Diagnostic Dilemma of a Widely Metastatic Gastric-type Cervical Adenocarcinoma

Introduction/Objective

Gastric-type cervical adenocarcinoma is an HPV-independent neoplasm accounting for 0.5-0.6% of cervical carcinomas, typically in women aged 50-55 years presenting with bleeding or watery vaginal discharge. The immunophenotypic and molecular overlap with mucinous pancreatic carcinomas presents a diagnostic dilemma in metastatic cases.

Methods/Case Report

We report the case of a 50 year-old female with a remote history of cervical dysplasia who presented with abdominal pain in December 2020 with CT notable for an incidental prominent, heterogeneous appearing cervix. Follow-up in February-August 2021 showed two unsatisfactory pap smears and an ultrasound of the cervix revealed Nabothian cysts. A friable cervix and vaginal discharge were noted on physical exam, however, no malignancy was identified on endometrial and endocervical biopsies. The patient re-presented in March 2022 with a persistent cough and was found to have a metastatic process of unknown origin involving bilateral ovaries/lungs, abdominal mesentery, pancreas, and pelvis. Lung, cervical, endometrial, and pancreatic sampling demonstrated well- differentiated mucinous adenocarcinoma with an immunophenotype positive for CK7 and MUC6 and negative for PAX-8, CDX-2, ER, Vimentin, TTF1/Napsin, GATA-3, CK20, and p16 with wildtype p53 staining compatible with endocervical, upper gastrointestinal, or pancreaticobiliary origin. Labs were notable for elevations in CA125 (198 U/mL) and CA19-9 (4,939 U/mL), further supporting pancreatic or gynecologic primaries. A retrospective review of all gynecologic cytology and histology specimens collected from the uterus and cervix in 2021 revealed similar bland mucinous epithelium, without overt atypia or features of malignancy. Next generation sequencing demonstrated a nonspecific and complex mutational burden including STK11 D23fs*25, SMAD4 N107fs*3, CDKN2A/B loss, KRAS G12V, and MTAP loss.

Results (if a Case Study enter NA)

NA

Conclusion

The treatment regimens for metastatic mucinous carcinoma from the cervix and pancreas differ significantly. Ultimately, the diagnosis of widely metastatic gastric type endocervical carcinoma was made possible through extensive clinical/radiographic and retrospective pathologic correlation with the incorporation of molecular studies.

Use of remdesivir for COVID-19 pneumonia in patients with advanced kidney disease: A retrospective multicenter study

Background and objectives

Remdesivir, an antiviral drug routinely used in the treatment of COVID-19 has not yet received FDA approval for use in patients with advanced kidney disease defined as GFR < 30 mL/min/1.73 m². There is concern that an excipient in Veklury (Gilead's proprietary name for remdesivir) called sulfobutylether-beta-cyclodextrin (SBECD), which is renally cleared, may accumulate and reach toxic levels in patients with advanced kidney disease. The aim of this study was to summarize characteristics and incidence of adverse events of chronic kidney disease (CKD) patients who received remdesivir during hospitalization.Design, setting, participants, and measurements.We retrospectively studied patients admitted to one of several hospitals of the Mayo Clinic Foundation with the diagnosis of COVID-19 pneumonia and CKD. Laboratory values were also measured when remdesivir was first administered and stopped. All analyses were performed in the overall patient group and three separate subgroups of patients with a GFR ≥ 15, a GFR < 15 and dialysis, and a GFR < 15 and no dialysis.

Results

A total of 444 CKD patients who were admitted to the hospital with COVID-19 pneumonia between May 2020 and September 2021 were included. Information was collected on patient characteristics, hospitalization, and adverse events. In the overall cohort, median age was 72 years (Range: 21-100 years), 55.2 % of patients were male, and most (86.5 %) were Caucasian. CKD stage was 3 for 114 patients (25.7 %), 4 for 229 patients (51.6 %), and 5 for 101 patients (22.7 %). A total of 146 patients (32.9 %) were admitted to the ICU, 103 (23.2 %) died in the hospital, and 120 (27.0 %) were on dialysis. The proportion of patients with an adverse event did not differ dramatically between the GFR ≥ 15 (20.9 %), GFR < 15 and dialysis (30.2 %), and GFR < 15 and no dialysis (32.3 %) groups (P = 0.12).

Conclusion

Our results suggest that the use of remdesivir in patients with very severe CKD is safe, even in those who are not on renal replacement therapy.

Can honey improve the quality of cryopreserved cross bred ram semen added to tris egg yolk extender?

BACKGROUND

Honey can improve the quality of cryopreserved ram semen because of its multinutrient and cryoprotective nature added to standard tris egg yolk extender.

OBJECTIVE

Different concentrations of honey were added to the standard tris egg yolk extender to improve the post-thaw quality of crossbred ram semen.

METHOD

Thirty six (36) ejaculates from eight healthy cross bred rams were pooled and divided into four aliquots. Standard tris egg yolk extender without any alteration acted as Control (C) and was supplemented with different concentrations of honey, viz. T1 (honey 1.5%), T2 (2.5%), and T3 (3.5%).

RESULTS

The percent (mean ± S.E.M) sperm motility at pre-freeze was significantly (P < 0.05) higher in Group T2 and at post-thaw in Group T3 in comparison to T1 and C treatment groups. The percent (mean ± S.E.M) HOST reacted spermatozoa at post-thaw was significantly (P < 0.05) higher in Group C and at pre-freeze the value was significantly (P < 0.05) higher in the same treatment group than Group T1. The mean MDA level (mean ± S.E.M) at post thaw was significantly (P < 0.05) lower in Group T3 than the treatment groups C and Group T1.

CONCLUSION

From this study it is concluded that the addition of 3.5% honey to the standard tris egg yolk extender provides better protection to ram semen than the addition of 1.5% honey (i.e., Control). doi.org/10.54680/fr22610110212.

Black carbon and elemental characterization of PM2.5 in dense traffic areas in two cities in Fiji, a Small Island Developing State

PM_2.5 characterizations are essential in understanding its impact on the health of the exposed population. Sampled PM_2.5 by Mani et al. (2020) was characterized to determine atmospheric metal concentration and inhalation health risk in Suva and Lautoka Cities, the only two cities in Fiji and one of the largest in the South Pacific Islands. Twenty-two elements (Al, As, Ba, Ca, Cd, Co, Cr, Cu, Fe, K, Mg, Mn, Mo, Na, Ni, P, Pb, S, Si, Sr, V, Zn) were analyzed using ICP-OES. Black Carbon (BC) sampling was also done at three different sites in Suva City, namely, Fiji National University Samabula Intersection site, Suva City Bus Station site and the Reservoir Road Community Settlement Site as well as at Lautoka City Bus Station. Mean BC concentrations over the sampling period were found to be 3.9 ± 2.9 (median = 3.3 μg/m³), 2.6 ± 2.7 μg/m³ (median = 1.7 μg/m³), 2.4 ± 2.3 μg/m³ (median = 1.7 μg/m³) and 4.0 ± 4.7 μg/m³ (median = 2.4 μg/m³) respectively. Health risk assessments (Carcinogenic Risk (CR) and Non-Carcinogenic Risk (HQ)) were also done to assess the risk of inhalation exposure in adults and children. The Hazard Index for children in Lautoka (HI = 1.03) was found to slightly exceed the safe level of 1. This study provides the first inventory of atmospheric particulate bound metal concentrations and diurnal BC profiles in Fiji and informs policy makers and scientists for further studies.

Anticoagulant treatment patterns and thromboembolic events by tumor type among patients with VTE and cancer

Background

Patients with venous thromboembolism (VTE) and cancer are at higher risk of adverse outcomes (mortality, recurrent VTE etc.) versus patients with cancer alone; as such, clinical guidelines recommend anticoagulant treatment for patients with VTE and cancer. There is limited real world data about how anticoagulant treatment and thromboembolic outcomes differ by tumor type in patients with VTE and cancer. Understanding such differences may help identify appropriate anticoagulant treatment for specific tumor types.

Purpose

To describe anticoagulant treatment patterns and thromboembolic outcomes by tumor type among patients with VTE and cancer.

Methods

Patients with VTE and cancer age ≥65 were identified from the Surveillance, Epidemiology and End Results (SEER) Medicare database from 1/1/2014–12/31/2019. Patients were required to be enrolled for ≥6-months prior to their first VTE diagnosis (index) and without evidence of other conditions requiring anticoagulant (i.e., atrial fibrillation) prior to index. Cancer status and tumor type were identified from SEER or Medicare database in the 6-months prior through 30-days post VTE. This analysis focused on the following specific tumor types: high risk (brain, pancreas, and stomach) and common tumor types (breast, and prostate). Patients treated with an anticoagulant within 30-days after index were included in the final population. Major bleeding (MB) and recurrent VTE events were measured during follow-up (index date through earliest of disenrollment, death or 12/31/2019).

Results

A total of 3,546 anticoagulated patients with VTE and cancer of interest met all study criteria (breast [n=1,197], prostate [n=849], pancreatic [n=995], brain [n=248] and stomach [n=257] cancer). Patient mean age ranged from 73 (brain) to 76 (stomach) at index. Anticoagulant treatment patterns varied by tumor type (Figure 1). LMWH was more likely to be used in the 3 high risk tumor types whereas apixaban and rivaroxaban were more likely to be used in the 2 common tumor types. The incidence rate of recurrent VTE and major bleeding events also varied among different tumor types: ranging from 1.4 (breast) to 6.4 (pancreatic) per 100 person-years for recurrent VTE and from 4.3 (prostate) to 15.1 (pancreatic) per 100 person-years for major bleeding (Figure 2).

Conclusion

There are notable variations in anticoagulant treatment patters and the risks of major bleeding and recurrent VTE events by tumor type among patients with VTE and cancer. Further research is needed to understand which anticoagulant treatment option is more appropriate for VTE patients with specific tumor type.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Pfizer Inc. and Bristol Myers Squibb Company

Caregiver willingness to give TPT to children living with drug-resistant TB patients

BACKGROUND Pediatric household contacts (HHCs) of patients with multidrug-resistant TB (MDR-TB) are at high risk of infection and active disease. Evidence of caregiver willingness to give MDR-TB preventive therapy (TPT) to children is limited.METHODS This was a cross-sectional study of HHCs of patients with MDR-TB to assess caregiver willingness to give TPT to children aged <13 years.RESULTS Of 743 adult and adolescent HHCs, 299 reported caring for children aged <13 years of age. The median caregiver age was 35 years (IQR 27-48); 75% were women. Among caregivers, 89% were willing to give children MDR TPT. In unadjusted analyses, increased willingness was associated with TB-related knowledge (OR 5.1, 95% CI 2.3-11.3), belief that one can die of MDR-TB (OR 5.2, 95% CI 1.2-23.4), concern for MDR-TB transmission to child (OR 4.5, 95% CI 1.6-12.4), confidence in properly taking TPT (OR 4.5, 95% CI 1.6-12.6), comfort telling family about TPT (OR 5.5, 95% CI 2.1-14.3), and willingness to take TPT oneself (OR 35.1, 95% CI 11.0-112.8).CONCLUSIONS A high percentage of caregivers living with MDR- or rifampicin-resistant TB patients were willing to give children a hypothetical MDR TPT. These results provide important evidence for the potential uptake of effective MDR TPT when implemented.

Pregnancy-Associated Acute Kidney Injury in Low-Resource Settings: Progress Over the Last Decade

Despite immense global effort, the maternal mortality rate in low-resource settings remains unacceptably high. Globally, this reflects the grave inequalities in access to health and reproductive services. Pregnancy-associated acute kidney injury (PRAKI) is an independent risk factor for mortality. The reported incidence of PRAKI in low- and middle-income countries is higher than that of high-income countries (4%-26% versus 1%-2.8%, respectively). Hypertensive disorders are now the leading cause of PRAKI in many regions, followed by hemorrhage and sepsis. PRAKI in low-resource settings carries a high mortality for both mother and child. Outcome studies suggest that PRAKI is associated with residual kidney dysfunction and may lead to dialysis dependence. This can be a death sentence in many regions with limited kidney replacement therapy. This review will summarize data on PRAKI on the African, Latin American, and Asian continents over the past decade. It will include the progress in published data, mortality, and treatment interventions and provide recommendations for the next decade.

159 Current Practice of Intra-Operative Sampling During Revision Surgery of the Knee for Prosthetic Joint Infection at a High-Volume District General Hospital

Aim

Successful treatment of prosthetic joint infection (PJI) involves surgical interventions and identification of infecting organisms to enable targeted antimicrobial therapy. Current PHE guidelines recommend 3–5 intra-operative samples to be taken using separate instruments for each, swabs are discouraged. We audited the revision arthroplasty practice at Barking, Havering, Redbridge University Trust (BHRUT), specifically comparing intra-operative sampling for infected revision knee procedures with these guidelines.

Method

Retrospective cohort study of all prosthetic knee infection cases, as defined by the Musculoskeletal Infection Society criteria, at BHRUT between December 2011 to May 2020. A review of case notes collected various key data points, focusing on intraoperative sample, type, number, and technique. Point biserial correlation analysis was performed to determine statistical significance.

Results

119 revision knee arthroplasty procedures were performed in the 8.5-year study period. 31 (26%) were for prosthetic joint infection (n=29 patients), n=2 patients had re-revision procedures for second PJI. Number of samples taken ranged from 1–12 with a mode of 6. N=27 (87%) cases had the recommended number of total samples taken, of these n= 20 (65%) had five or more samples taken, N=24 (77%) cases had three or more samples taken and n=18 (58%) had five or more samples.

Conclusions

Current management of infected knee arthroplasty presents great variability in intra-operative sampling technique. Sample collection adheres to national guidelines in 77% of cases. We recommend implementation of a standardised approach to sampling through inclusion of a five scalpel and five forceps pack specifically for sampling in theatre for all suspected PJI's.

Sex differences in rTMS treatment response: A deep learning-based EEG investigation

INTRODUCTION

The present study aimed to investigate sex differences in response to repetitive transcranial magnetic stimulation (rTMS) in Major Depressive Disorder (MDD) patients. Identifying the factors that mediate treatment response to rTMS in MDD patients can guide clinicians to administer more appropriate, reliable, and personalized interventions.

METHODS

In this paper, we developed a novel pipeline based on convolutional LSTM-based deep learning (DL) to classify 25 female and 25 male patients based on their rTMS treatment response.

RESULTS

Five different classification models were generated, namely pre-/post-rTMS female (model 1), pre-/post-rTMS male (model 2), pre-rTMS female responder versus pre-rTMS female nonresponders (model 3), pre-rTMS male responder vs. pre-rTMS male nonresponder (model 4), and pre-rTMS responder versus nonresponder of both sexes (model 5), achieving 93.3%, 98%, 95.2%, 99.2%, and 96.6% overall test accuracy, respectively.

CONCLUSION

These results indicate the potential of our approach to be used as a response predictor especially regarding sex-specific antidepressant effects of rTMS in MDD patients.

Implementing a Health Utility Assessment Platform to Acquire Health Utilities in a Hemodialysis Outpatient Setting: Feasibility Study

BACKGROUND

Patients with end-stage kidney disease (ESKD) wait roughly 4 years for a kidney transplant. A potential way to reduce wait times is using hepatitis C virus (HCV)-viremic kidneys.

OBJECTIVE

As preparation for developing a shared decision-making tool to assist patients with ESKD with the decision to accept an HCV-viremic kidney transplant, our initial goal was to assess the feasibility of using The Gambler II, a health utility assessment tool, in an ambulatory dialysis clinic setting. Our secondary goals were to collect health utilities for patients with ESKD and to explore whether the use of race-matched versus race-mismatched exemplars impacted the knowledge gained during the assessment process.

METHODS

We used The Gambler II to elicit utilities for the following ESKD-related health states: hemodialysis, kidney transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney. We created race exemplar video clips describing these health states and randomly assigned patients into the race-matched or race-mismatched video arms. We obtained utilities for these 3 health states from each patient, and we evaluated knowledge about ESKD and HCV-associated health conditions with pre- and postintervention knowledge assessments.

RESULTS

A total of 63 patients with hemodialysis from 4 outpatient Dialysis Center Inc sites completed the study. Mean adjusted standard gamble utilities for hemodialysis, transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney were 82.5, 89, and 75.5, respectively. General group knowledge assessment scores improved by 10 points (P<.05) following utility assessment process. The use of race-matched exemplars had little effect on the results of the knowledge assessment of patients.

CONCLUSIONS

Using The Gambler II to collect utilities for patients with ESKD in an ambulatory dialysis clinic setting proved feasible. In addition, educational information about health states provided as part of the utility assessment process tool improved patients' knowledge and understanding about ESKD-related health states and implications of organ transplantation with HCV-viremic kidneys. A wide variation in patient health state utilities reinforces the importance of incorporating patients' preferences into decisions regarding use of HCV-viremic kidneys for transplantation.