Early Initiation of Sacubitril/Valsartan in Patients With Acute Heart Failure and Renal Dysfunction: An Analysis of the TRANSITION Study

BACKGROUND

Treatment of patients with heart failure with reduced ejection fraction (HFrEF) and renal dysfunction (RD) is challenging owing to the risk of further deterioration in renal function, especially after acute decompensated HF (ADHF).

METHODS AND RESULTS

We assessed the effect of RD (estimated glomerular filtration rate of ≥30 to <60 mL/min/1.73 m2) on initiation, up-titration, and tolerability of sacubitril/valsartan in hemodynamically stabilized patients with HFrEF admitted for ADHF (RD, n = 476; non-RD, n = 483). At week 10, the target dose of sacubitril/valsartan (97/103 mg twice daily) was achieved by 42% patients in RD subgroup vs 54% in non-RD patients (P < .001). Sacubitril/valsartan was associated with greater estimated glomerular filtration rate improvements in RD subgroup than non-RD (change from baseline least squares mean 4.1 mL/min/1.73 m2, 95% confidence interval 2.2-6.1, P < .001). Cardiac biomarkers improved significantly in both subgroups; however, compared with the RD subgroup, the improvement was greater in those without RD (N-terminal pro-brain natriuretic peptide, -28.6% vs -44.8%, high-sensitivity troponin T -20.3% vs -33.9%) (P < .001). Patients in the RD subgroup compared with those without RD experienced higher rates of hyperkalemia (16.3% vs 6.5%, P < .001), investigator-reported cardiac failure (9.7% vs 5.6%, P = .029), and renal impairment (6.4% vs 2.1%, P = .002).

CONCLUSIONS

Most patients with HFrEF and concomitant RD hospitalized for ADHF tolerated early initiation of sacubitril/valsartan and showed significant improvements in estimated glomerular filtration rate and cardiac biomarkers.

CLINICAL TRIAL REGISTRATION

NCT02661217.

The implementation and utility of clinical exome sequencing in a South African infant cohort

Genetic disorders are significant contributors to infant hospitalization and mortality globally. The early diagnosis of these conditions in infants remains a considerable challenge. Clinical exome sequencing (CES) has shown to be a successful tool for the early diagnosis of genetic conditions, however, its utility in African infant populations has not been investigated. The impact of the under-representation of African genomic data, the cost of testing, and genomic workforce shortages, need to be investigated and evidence-based implementation strategies accounting for locally available genetics expertise and diagnostic infrastructure need to be developed. We evaluated the diagnostic utility of singleton CES in a cohort of 32 ill, South African infants from two State hospitals in Johannesburg, South Africa. We analysed the data using a series of filtering approaches, including a curated virtual gene panel consisting of genes implicated in neonatal-and early childhood-onset conditions and genes with known founder and common variants in African populations. We reported a diagnostic yield of 22% and identified seven pathogenic variants in the NPHS1, COL2A1, OCRL, SHOC2, TPRV4, MTM1 and STAC3 genes. This study demonstrates the utility value of CES in the South African State healthcare setting, providing a diagnosis to patients who would otherwise not receive one and allowing for directed management. We anticipate an increase in the diagnostic yield of our workflow with further refinement of the study inclusion criteria. This study highlights important considerations for the implementation of genomic medicine in under-resourced settings and in under-represented African populations where variant interpretation remains a challenge.

Comparing post-traumatic stress severity in professional and volunteer Australian firefighters

BACKGROUND

While extensive research has highlighted increased risk for post-traumatic stress disorder (PTSD) in firefighters, previous research has yielded mixed results regarding the role of work status (professional versus volunteer) in the development of psychopathological symptoms.

AIMS

To explore the predictive strength of work status on PTSD or post-traumatic stress symptom severity in a large sample of professional (PFFs) and volunteer (VFFs) Australian firefighters exposed to operational work-related trauma.

METHODS

The stratified random sample comprised 1317 PFFs (n = 1148 (87%) males and 13%, n = 169 (13%) females) and 898 VFFs (n = 744 (83%) males and n = 154 (17%) females) who reported having experienced trauma while working or volunteering. Participants completed demographic, health and work-related questions and mental health measures of stress, trauma, PTSD, social support and use of mental health prevention programmes.

RESULTS

The results revealed a significant relationship between work status and PTSD, with PFFs reporting higher levels of PTSD symptom severity compared to VFFs. This association persisted after controlling for demographics, health, stress away from work, social support and use of organizational mental health support programmes (debriefing and face-to-face training for mental and physical self-care).

CONCLUSIONS

This study suggests the importance of work status in PTSD amongst Australian firefighters exposed to operational trauma. Future research is needed to substantiate our findings and examine why PFFs may be more prone to developing PTSD. Implications for the provision of mental health programmes offered by fire organizations to their members are discussed.

Precision measurement of the neutral pion lifetime

The explicit breaking of the axial symmetry by quantum fluctuations gives rise to the so-called axial anomaly. This phenomenon is solely responsible for the decay of the neutral pion π⁰ into two photons (γγ), leading to its unusually short lifetime. We precisely measured the decay width Γ of the [Formula: see text] process. The differential cross sections for π⁰ photoproduction at forward angles were measured on two targets, carbon-12 and silicon-28, yielding [Formula: see text], where stat. denotes the statistical uncertainty and syst. the systematic uncertainty. We combined the results of this and an earlier experiment to generate a weighted average of [Formula: see text] Our final result has a total uncertainty of 1.50% and confirms the prediction based on the chiral anomaly in quantum chromodynamics.

Streptococcus intermedius masquerading as fungal infective endocarditis

Infective endocarditis remains an important clinical entity with an incidence of 1.7–10/100 000 person years (Marks et al, 2015). Despite improvements in health care, it still results in significant morbidity and in-hospital mortality approaches 16% (Marks et al, 2015). There are likely multiple causes including late diagnosis, poor response to therapy and the challenges in identifying the causative pathogen and instigating the correct treatment. This is particularly the case for causative organisms that are difficult to culture or identify using routine laboratory methods. An example of this is Streptococcus intermedius, which belongs to the S. milleri group along with other two species (S. anginosus group and S. constellatus). It is a commensal organism that can turn into an opportunistic pathogen (Whiley et al, 1992). It is a rare cause of infective endocarditis and may initially present with abscesses in the liver, spleen or brain which may mimic fungal infection (Woo et al, 2004; Rashid et al, 2007; Tran et al, 2008). Difficulty in identifying this organism has led to the development of molecular testing to aid diagnosis. To the authors' knowledge, there are very few cases in the literature of infective endocarditis caused by S. intermedius that have been confirmed using 16S polymerase chain reaction (Woo et al, 2004). This article describes a patient presenting with S. intermedius infective endocarditis which was diagnosed using this method.

First Measurement of Near-Threshold J/ψ Exclusive Photoproduction off the Proton

We report on the measurement of the γp→J/ψp cross section from E_{γ}=11.8  GeV down to the threshold at 8.2 GeV using a tagged photon beam with the GlueX experiment. We find that the total cross section falls toward the threshold less steeply than expected from two-gluon exchange models. The differential cross section dσ/dt has an exponential slope of 1.67±0.39  GeV^{-2} at 10.7 GeV average energy. The LHCb pentaquark candidates P_{c}^{+} can be produced in the s channel of this reaction. We see no evidence for them and set model-dependent upper limits on their branching fractions B(P_{c}^{+}→J/ψp) and cross sections σ(γp→P_{c}^{+})×B(P_{c}^{+}→J/ψp).

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

EDS IV (Acrogeria): New Autosomal Dominant and Recessive Types

Evidence is presented that type IV of the Ehlers-Danlos syndrome (EDS IV) is genetically variable. A benign autosomal dominant form and two autosomal recessive variants are described with clinical and biochemical features that are distinct from classical acrogeria.

Atomic-scale age resolution of planetary events

Resolving the timing of crustal processes and meteorite impact events is central to understanding the formation, evolution and habitability of planetary bodies. However, identifying multi-stage events from complex planetary materials is highly challenging at the length scales of current isotopic techniques. Here we show that accurate U-Pb isotopic analysis of nanoscale domains of baddeleyite can be achieved by atom probe tomography. Within individual crystals of highly shocked baddeleyite from the Sudbury impact structure, three discrete nanostructural domains have been isolated yielding average ²⁰⁶Pb/²³⁸U ages of 2,436±94 Ma (protolith crystallization) from homogenous-Fe domains, 1,852±45 Ma (impact) from clustered-Fe domains and 1,412±56 Ma (tectonic metamorphism) from planar and subgrain boundary structures. Baddeleyite is a common phase in terrestrial, Martian, Lunar and asteroidal materials, meaning this atomic-scale approach holds great potential in establishing a more accurate chronology of the formation and evolution of planetary crusts.

Constraining the timing of crustal processes and impact events remains challenging. Here, the authors show that atom probe tomography can produce highly accurate U-Pb isotopic age constraints in baddeleyite crystals, which is a common phase in terrestrial, Martian, Lunar and asteroidal materials.

Randomized assessment of imatinib in patients with acute ischaemic stroke treated with intravenous thrombolysis

BACKGROUND

Imatinib, a tyrosine kinase inhibitor, has been shown to restore blood-brain barrier integrity and reduce infarct size, haemorrhagic transformation and cerebral oedema in stroke models treated with tissue plasminogen activator. We evaluated the safety of imatinib, based on clinical and neuroradiological data, and its potential influence on neurological and functional outcomes.

METHODS

A phase II randomized trial was performed in patients with acute ischaemic stroke treated with intravenous thrombolysis. A total of 60 patients were randomly assigned to four groups [3 (active): 1 (control)]; the active treatment groups received oral imatinib for 6 days at three dose levels (400, 600 and 800 mg). Primary outcome was any adverse event; secondary outcomes were haemorrhagic transformation, cerebral oedema, neurological severity on the National Institutes of Health Stroke Scale (NIHSS) at 7 days and at 3 months and functional outcomes on the modified Rankin scale (mRS).

RESULTS

Four serious adverse events were reported, which resulted in three deaths (one in the control group and two in the 400-mg dose group; one patient in the latter group did not receive active treatment and the other received two doses). Nonserious adverse events were mostly mild, resulting in full recovery. Imatinib ameliorated neurological outcomes with an improvement of 0.6 NIHSS points per 100 mg imatinib (P = 0.02). For the 800-mg group, the mean unadjusted and adjusted NIHSS improvements were 4 (P = 0.037) and 5 points (P = 0.012), respectively, versus controls. Functional independence (mRS 0-2) increased by 18% versus controls (61 vs. 79; P = 0.296).

CONCLUSION

This phase II study showed that imatinib is safe and tolerable and may reduce neurological disability in patients treated with intravenous thrombolysis after ischaemic stroke. A confirmatory randomized trial is currently underway.

Role of Community in Swachh Bharat Mission. Their Knowledge, Attitude and Practices of Sanitary Latrine Usage in Rural Areas, Tamil Nadu

BACKGROUND

In most developing countries, open defecation is the 'way of life'. This practice is considered as the most serious health and environmental hazard. Prime Minister of India launched the "Swachh Bharat Mission" to accelerate the efforts for achieving universal sanitation coverage and to put focus on sanitation.

OBJECTIVE

To find the knowledge, attitude and practices of sanitary latrines usage in rural area, Tamil Nadu.

MATERIALS AND METHODS

This was a cross sectional study conducted among rural population in Kuthambakkam village, Tamil Nadu. There were a total of 1175 households in Kuthambakkam village. These households were serially numbered and of these a sample of 275 households were selected for the study using simple random sampling technique by lottery method. A structured questionnaire was used to collect information regarding the background characteristics, their knowledge, attitude and practices towards sanitary latrines usage. Descriptive statistics were calculated for background variables, the prevalence of sanitary latrines usage and open air defecation. Association between factors responsible for open air defecation was found by using chi square test.

RESULTS

The prevalence of usage of household sanitary latrine and community latrines was 62.5% and 4.3% respectively. The prevalence of open air defecation among the study participants was 33.1%.Significant association was found between low standard of living and open air defecation practice.

CONCLUSIONS

To solve the problem of underutilization of sanitary latrines, planning and conducting Information Education Communication activities is very essential. Effective political and administrative support is needed to scale up the sanitation program.

Investigating factors for increased gonorrhoea re-infection in men who have sex with men attending a genitourinary clinic: a qualitative study

The number of confirmed cases of gonorrhoea increased by one-third in England from 2013 to 2014 and the incidence increased by 32% in men who have sex with men (MSM). In our clinic, annual incidence increased by 28.8% (2013) and re-infection (second infection within one-year of initial infection) rose from 6.7% as a proportion of total infections (2009) to 19.4% (2013). The aim of this study was to explore reasons for repeat gonorrhoea infections among MSM. We interviewed 16 MSM about knowledge and awareness of gonorrhoea, antibiotic resistance and attitudes towards safe sex. We used qualitative methods to investigate the potential causes for the rise in gonorrhoea re-infection. Mobile applications were used to meet casual sex partners and arrange impromptu group-sex parties with partner anonymity making contact tracing difficult. The use of recreational drugs was widespread. It was suggested that new technologies could also be used to increase awareness of STI trends and services for at-risk individuals. Participants were concerned about global antibiotic resistance, but felt that behaviour would not change unless there was local evidence of this. Despite knowing gonorrhoea prevalence was high, participants felt their behaviour was unlikely to change and frequently felt resigned to repeat infections. The use of geosocial networking applications to arrange sexual encounters may be contributing to a rise in STIs, as well as recreational drugs, alcohol and sex parties. Networking applications could increase awareness and advertise testing opportunities. In some cases, risk-taking behaviours are unlikely to change, and for these men, regular sexual health screens should be encouraged to detect and treat infections earlier and reduce onward spread.

Development and validation of the Australian Aboriginal racial identity and self-esteem survey for 8-12 year old children (IRISE_C)

INTRODUCTION

In Australia, there is little empirical research of the racial identity of Indigenous children and youth as the majority of the current literature focuses on adults. Furthermore, there are no instruments developed with cultural appropriateness when exploring the identity and self-esteem of the Australian Aboriginal population, especially children. The IRISE_C (Racial Identity and Self-Esteem of children) inventory was developed to explore the elements of racial identity and self-esteem of urban, rural and regional Aboriginal children. This paper describes the development and validation of the IRISE_C instrument with over 250 Aboriginal children aged 8 to 12 years.

METHODS

A pilot of the IRISE C instrument was combined with individual interviews and was undertaken with 35 urban Aboriginal children aged 8-12 years. An exploratory factor analysis was performed to refine the survey and reduce redundant items in readiness for the main study. In the main study, the IRISE C was employed to 229 Aboriginal children aged 6-13 years across three sites (rural, regional and urban) in Western Australia. An exploratory factor analysis using Principal axis factoring was used to assess the fit of items and survey structure. A confirmatory factor analysis was then employed using LISREL (diagonally weighted least squares) to assess factor structures across domains. Internal consistency and reliability of subscales were assessed using Cronbach's co-efficient alpha.

RESULTS

The pilot testing identified two key concepts - children's knowledge of issues related to their racial identity, and the importance, or salience, that they attach to these issues. In the main study, factor analyses showed two clear factors relating to: Aboriginal culture and traditions; and a sense of belonging to an Aboriginal community. Principal Axis Factoring of the Knowledge items supported a 2-factor solution, which explained 38.7% of variance. Factor One (Aboriginal culture) had a Cronbach's alpha of 0.835; Factor 2 (racial identity) had a Cronbach's alpha of 0.800, thus demonstrating high internal reliability of the scales.

CONCLUSION

The IRISE_C has been shown to be a valid instrument useful of exploring the development of racial identity of Australian Aboriginal children across the 8-12 year old age range and across urban, rural and regional geographical locations.