Systematic literature review and assessment of patient-reported outcome instruments in sickle cell disease

Background

Sickle cell disease (SCD) is a chronic condition associated with high mortality and morbidity. It is characterized by acute clinical symptoms such as painful vaso-occlusive crises, which can impair health-related quality of life (HRQL). This study was conducted to identify validated patient-reported outcome (PRO) instruments for use in future trials of potential treatments for SCD.

Methods

A systematic literature review (SLR) was performed using MEDLINE and EMBASE to identify United States (US)-based studies published in English between 1997 and 2017 that reported on validated PRO instruments used in randomized controlled trials and real-world settings. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was used to assess the quality of PRO instruments.

Results

The SLR included 21 studies assessing the psychometric properties of 24 PRO instruments. Fifteen of those instruments were developed and validated for adults and 10 for children (one instrument was used in both children and young adults aged up to 21 years). Only five of the 15 adult instruments and three of the 10 pediatric instruments were developed specifically for SCD. For most instruments, there were few or no data on validation conducted in SCD development cohorts. Of the 24 PRO instruments identified, 16 had strong internal reliability (Cronbach’s α ≥0.80). There was often insufficient information to assess the content validity, construct validity, responsiveness, or test-retest reliability of the instruments identified for both child and adult populations. No validated PRO instruments measuring caregiver burden in SCD were identified.

Conclusions

The evidence on the psychometric properties of PRO instruments was limited. However, the results of this SLR provide key information on such tools to help inform the design of future clinical trials for patients with SCD in the US.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0930-y) contains supplementary material, which is available to authorized users.

TRIENNIAL LACTATION SYMPOSIUM/BOLFA: Adipokines affect mammary growth and function in farm animals

The essential role of mammary fat pads in mammary growth and morphogenesis was the first indication that biologically active molecules, secreted from adipocytes or other stromal cells, could regulate endocrine cues for growth and function of the mammary gland. The presence of leptin and adiponectin receptors in mammary tissues suggested that locally produced or circulating adipokines could affect mammary growth and function. Herein, we present the current knowledge on the role of adipokines in mammary cell proliferation and differentiation and in lactogenesis and galactopoiesis in farm animals. We also address the role of milk adipokines in the neonate. Accumulating evidence suggests that adipokines could act as metabolic sensors, regulating mammary growth and function in periods of metabolic adaptations such as late pregnancy and early lactation. Indeed, different experiments reported that adiponectin and leptin expression varies according to physiological stages and nutritional status of the animal. The current review also demonstrates that adipokines, such as leptin and adiponectin, are important regulators of the action of lactogenic hormones in the mammary gland. Findings also suggest important roles for adipokines in growth and intestinal maturation of the neonate.

Comparison of major bleeding risk in patients with non-valvular atrial fibrillation receiving direct oral anticoagulants in the real-world setting: a network meta-analysis

OBJECTIVE

To conduct a systematic literature review (SLR) and network meta-analysis (NMA) of real-world studies comparing major bleeding risk among patients with non-valvular atrial fibrillation (NVAF) on direct oral anticoagulants (DOACs) or warfarin.

METHODS

Systematic searches were conducted in MEDLINE and Embase for full-text articles published between January 1, 2003 and March 18, 2017. Eligible studies compared at least two of the following in a real-world setting: warfarin, apixaban, dabigatran, rivaroxaban, or edoxaban. A Bayesian NMA was conducted to estimate hazard ratios (HRs) for major bleeding using a random-effects model.

RESULTS

Eleven studies were included in the NMA. Nine studies included DOACs vs Warfarin comparisons, and four studies included DOACs vs DOACs comparisons (two studies included both comparisons). Median follow-up duration ranged from 2.6-31.2 months. No evidence was identified for edoxaban. Apixaban was associated with a significantly lower risk of major bleeding compared to other oral anticoagulants (warfarin HR = 0.58; 95% credible interval [CrI] = 0.48-0.69; dabigatran = 0.73; 0.61-0.87; rivaroxaban = 0.55; 0.46-0.66). Dabigatran was associated with a significantly lower risk than warfarin (0.79; 0.71-0.88) and rivaroxaban (0.76; 0.67-0.85), and rivaroxaban was not statistically different from warfarin (1.05; 0.91-1.19). Sensitivity analyses with standard dose and sponsorship showed consistent results.

CONCLUSION

DOACs were associated with lower or similar risk of major bleeding compared with warfarin in NVAF patients. Apixaban was associated with a significantly lower risk of major bleeding than other DOACs. Dabigatran was associated with a significantly lower risk of major bleeding compared to rivaroxaban and warfarin.

Oxytocin injections in the postpartal period affect mammary tight junctions in sows

The potential impacts of injecting oxytocin (OXY) to sows in the early postpartum period on the quality of mammary tight junctions, milk composition, and immune status of sows and piglets were studied. Postparturient sows received i.m. injections of either saline (control [CTL]; = 10) or 75 IU of OXY ( = 10). Injections were given twice daily (0800 and 1630 h) starting on d 2 of lactation (i.e., between 12 and 20 h after birth of the last piglet), totaling 4 injections. Milk samples were obtained before the first injection (d 2 morning [AM]), before the second injection (d 2 afternoon [PM]), and on d 4 PM and d 5 PM. Blood samples were obtained from sows before milking on d 2 AM, d 2 PM, and d 5 PM. On d 5 of lactation, a blood sample was obtained from 3 piglets per litter. Circulating concentrations of prolactin, IGF-I, lactose, and IgA in sows did not differ between treatments at any time ( > 0.10), but OXY sows had less IgG than CTL sows ( < 0.01) on d 2 PM before the second OXY injection. There were differences in milk composition on d 2 PM, with OXY sows having more IGF-I ( < 0.01), solids ( < 0.05), protein ( < 0.01), energy ( < 0.05), and IgA ( < 0.01) and a greater Na:K ratio ( < 0.01) than CTL sows. These differences were not seen in the next 2 milk samples, except for protein and IgA that still tended ( < 0.10) to be greater in OXY vs. CTL sows on d 4 PM (for protein) and on d 5 PM (for IgA) after the last injection. Milk lactose content was lower in OXY vs. CTL sows on d 5 PM ( < 0.01). Values for immunoglobulin immunocrit, IgG, IgA, and IGF-I in piglet blood did not differ between treatments ( > 0.10). Injecting OXY to sows in the early postpartum period increased leakiness of the mammary tight junctions, improved composition of early milk, and may potentially affect immune status of neonatal piglets.

In vivo measures of mammary development in gestating gilts

Potential links between measures of udder morphology obtained in live pregnant gilts and mammary gland development and composition measured in mammary tissue collected at slaughter were studied. Thirty-three gilts were used. In vivo measures of gland morphology using a tape or ultrasound imaging (parenchymal area measured by ultrasound [AREA]) were obtained on d 108 ± 1 of gestation. Gilts were then slaughtered on d 110 ± 1 of gestation to collect mammary glands for dissection and compositional analyses. The various tape measures were the distance between each teat on one side of the udder (DIST-TEAT), the distance between each teat pair (DIST-PAIR), the length of the udder (sum of all DIST-TEAT), the distance between the base of the teat and the ventral midline section of the udder (MID), and the distance between the base of the teat and the exterior junction of the udder with the abdomen (EXT). The variables MID, DIST-TEAT, DIST-PAIR, and length had very poor correlations with parenchymal weight, extraparenchymal weight, or any of the measured compositional variables. On the other hand, both AREA and EXT were correlated ( < 0.01) with the weight of parenchymal tissue, total parenchymal protein, total DNA, and total RNA. The ultrasound measure AREA and the tape measure EXT were also correlated with each other ( < 0.05). These measures could, therefore, be helpful to estimate mammary development in studies where animals cannot be slaughtered. The tape measure EXT seemed to better reflect the volume of the gland than MID, and it provided as reliable an estimate of parenchymal weight as the measure of parenchymal area using ultrasound while being much easier and cheaper to obtain.

Risk of major bleeding in patients with non-valvular atrial fibrillation treated with oral anticoagulants: a systematic review of real-world observational studies

OBJECTIVE

To conduct a systematic review of real-world (RWD) studies comparing the risk of major bleeding (MB) among patients with non-valvular atrial fibrillation (NVAF) on direct oral anticoagulants (DOACs) or warfarin.

METHODS

MEDLINE, Embase, NHS-EED, and EconLit were searched for RWD studies published between January 2003 and November 2016 comparing MB risk among DOACs and warfarin. Proceedings of clinical conferences from 2012 to 2016 were reviewed.

RESULTS

A total of 4218 citations were identified, 26 of which met eligibility criteria. Most studies were retrospective analyses of administrative claims databases and patient registries (n = 23 of 26); about half were based in the United States (n = 15). Apixaban showed a significantly lower risk of MB versus warfarin in all eight included studies. MB risk was either significantly lower (n = 9 of 16) or not significantly different (n = 7 of 16) between dabigatran and warfarin; there was no significant difference between rivaroxaban and warfarin in all seven included studies. The risk was significantly lower with apixaban versus rivaroxaban (n = 7 of 7) but not significantly different from dabigatran (n = 6 of 7). MB risk was significantly lower (n = 3 of 4) or not significantly different (n = 1 of 4) with dabigatran versus rivaroxaban. No evidence was identified for edoxaban.

CONCLUSION

DOACs were associated with similar or lower risks of MB versus warfarin. A lower MB risk was consistently observed for apixaban, but less consistently for dabigatran; MB risk was similar between rivaroxaban and warfarin. Among DOACs, the risk of MB with apixaban was consistently lower than with rivaroxaban, but similar to dabigatran.

Does duration of teat use in first parity affect milk yield and mammary gene expression in second parity?

It was recently shown that a teat that is not used in the first lactation will have a reduced development and milk yield in the second lactation. In the current study, the impact of imposing a suckling period of 2, 7, or 21 d during the first lactation on piglet performance, milk composition, endocrine status, and mammary gene expression of sows in their second lactation was studied. Pregnant Yorkshire gilts were divided into 3 groups according to lactation length: 1) 2-d lactation (2D; = 20), 2) 7-d lactation (7D; = 20), and 3) 21-d lactation (21D; = 21). After weaning, sows were bred and kept for a second parity. In both lactations, litters were standardized to 12 piglets with 12 functional teats and surplus teats were sealed. In the second lactation, piglets were weighed on d 2, 7, 14, 21 (weaning), 31, and 56 postpartum, and sow feed intake was recorded. On d 110 of gestation and on d 21 of lactation, mammary biopsies were performed on 10 sows per treatment to obtain parenchymal tissue samples for determination of mRNA abundance for , , , , , and genes. Milk samples and jugular blood samples were also obtained from sows on d 21 of lactation. Standard composition analyses (DM, fat, protein, and lactose) were done in milk. Concentrations of prolactin, IGF-1, glucose, and urea were measured in blood. There was a tendency for 21D sows to consume more feed than 2D or 7D sows during the first week of lactation ( < 0.10). There was no treatment effect on BW of piglets at any time until d 56 ( > 0.10). Concentrations of prolactin, IGF-1, urea, and glucose in sows on d 21 of lactation were not affected by treatment ( > 0.10). Dry matter, fat, protein, and lactose contents in milk were not altered by treatment ( > 0.10). On d 110 of gestation, gene expression was greater ( = 0.05) in 21D sows than in 7D sows. On d 21 of lactation, gene expression of was greater ( = 0.05) and that of tended to be lower ( < 0.10) in 7D sows than in 2D sows. The mRNA abundance of also tended to be lower ( < 0.10) in 2D sows than in 7D sows. Results indicate that increasing the duration of lactation from 2 d to 7 d or to 21 d in first-parity sows did not improve growth rate of their piglets in the subsequent lactation. This suggests that suckling of a teat for 2 d during the first lactation is sufficient to ensure optimal mammary development.

Comparative study on the relations between backfat thickness in late-pregnant gilts, mammary development and piglet growth

The potential relation between body condition of gilts in late-pregnancy and litter BW gain as well as mammary development was studied using 2 sets of data. Gilts either from a commercial herd (Part 1, n = 182) or from a series of trials looking at mammary development (Part 2, n = 172) were separated in 3 groups according to backfat thickness (BF) on d 110 of gestation. Group categorization was similar for Parts 1 and 2 of the study and was: low (LOW), 13.6 ± 1.6 mm (mean ± SD); medium (MED), 17.6 ± 1.0 mm (mean ± SD); and high BF (HIGH), 21.8 ± 1.8 mm (mean ± SD) for Part 1, and LOW, 14.2 ± 1.3 mm (mean ± SD); MED, 18.1 ± 1.0 mm (mean ± SD), and HIGH 23.4 ± 2.6 mm (mean ± SD) for Part 2. The effects of BF group on piglet BW gain (Part 1) or on various mammary gland characteristics (Part 2) were determined using ANOVA. Litters from HIGH sows tended to have a greater lactation BW gain than those from LOW sows (P < 0.10). Sows with HIGH BF had more mammary parenchymal tissue and more total protein and total DNA than MED and LOW sows (P < 0.05), which led to greater total protein and total DNA contents (P < 0.05). There were strong positive correlations (P < 0.0001) between parenchymal weight and total protein, total DNA, and total RNA. Results suggest that it is beneficial for primiparous sows to have greater BF (i.e., 20 to 26 mm) at the end of gestation to achieve optimal mammary development and greater litter BW gain in the subsequent lactation.

Altering prolactin concentrations in sows

Prolactin has a multiplicity of actions, but it is of particular importance in gestating and lactating animals. In sows, it is involved in the control of mammary development and also holds essential roles in the lactogenic and galactopoietic processes. Furthermore, low circulating concentrations of prolactin are associated with the agalactia syndrome. The crucial role of prolactin makes it important to understand the various factors that can alter its secretion. Regulation of prolactin secretion is largely under the negative control of dopamine, and dopamine agonists consistently decrease prolactin concentrations in sows. On the other hand, injections of dopamine antagonists can enhance circulating prolactin concentrations. Besides pharmacologic agents, many other factors can also alter prolactin concentrations in sows. The use of Chinese-derived breeds, for instance, leads to increased prolactin concentrations in lactating sows compared with standard European white breeds. Numerous husbandry and feeding practices also have a potential impact on prolactin concentrations in sows. Factors, such as provision of nest-building material prepartum, housing at farrowing, high ambient temperature, stress, transient weaning, exogenous thyrotropin-releasing factor, exogenous growth hormone-releasing factor, nursing frequency, prolonged photoperiod, fasting, increased protein and/or energy intake, altered energy sources, feeding high-fiber diets, sorghum ergot or plant extracts, were all studied with respect to their prolactinemic properties. Although some of these practices do indeed affect circulating prolactin concentrations, none leads to changes as drastic as those brought about by dopamine agonists or antagonists. It appears that the numerous factors regulating prolactin concentrations in sows are still not fully elucidated, and that studies to develop novel applicable ways of increasing prolactin concentrations in sows are warranted.

Relative prolactin-to-progesterone concentrations around farrowing influence colostrum yield in primiparous sows

In swine, colostrum production is induced by the drop of progesterone (P4) concentrations which leads to the prepartum peak of prolactin (PRL). PRL regulates mammary cell turnover and stimulates lacteal nutrient synthesis. P4 inhibits PRL secretion and downregulates the PRL receptor in the mammary gland. The aim of the present study was to determine if the relative prepartum concentrations of P4 and PRL (PRL/P4 ratio) influence sow colostrum production. The performance of 29 Landrace × Large White primiparous sows was analyzed. Colostrum yield was estimated during 24 h starting at the onset of parturition (T0) using litter weight gains. Colostrum was collected at T0 and 24 h later (T24). Repeated jugular blood samples were collected during the peripartum period, that is, from -72 to +24 h related to farrowing and were assayed for P4 and PRL. Sows were retrospectively categorized in 2 groups according to their PRL/P4 ratio 24 h before farrowing being either <2 (low PRL/P4, n = 16) or >3 (high PRL/P4, n = 13). During the peripartum period, the circulating concentrations of P4 were lower (P < 0.05) and those of PRL tended to be greater (P < 0.10) in high PRL/P4 compared with low PRL/P4 sows. Colostrum yield was greater in high PRL/P4 compared with low PRL/P4 sows (4.11 vs 3.48 kg [root mean square error = 0.69], P < 0.05). Colostrum composition (dry matter, energy, protein, lipid, and lactose contents) and IgG and IgA concentrations did not differ between the 2 groups of sows (P > 0.10). The Na/K ratio in colostrum 24 h after the onset of farrowing was lower in high PRL/P4 compared with low PRL/P4 sows (P < 0.05). Piglet mortality between birth and T24 averaged 10.0% in low PRL/P4 litters and 7.0% in high PRL/P4 litters (P = 0.29). In conclusion, a greater PRL/P4 ratio 24 h prepartum, characterized by lower P4 concentrations and a trend for greater PRL concentrations peripartum, led to increased colostrum yield in primiparous sows.

Do gastroenterologists monitor their patients taking 5-amino-salicylates following initiation of treatment

BACKGROUND

5-Amino salicylate (5-ASA) medications may rarely be associated with a significant decline in renal function and interstitial nephritis. British Society of Gastroenterology guidelines advise regular renal function monitoring for patients taking these drugs.

AIM

To assess whether gastroenterologists in Kent were following best practice guidelines regarding the monitoring of their patients on 5-ASA therapy.

METHODS

Using longitudinal community and regional pathology databases for the Kent population, our renal unit regularly screens a total population of 300 000 for evidence of renal disease. The data extracted are analysed using an automated computerised system to identify patients requiring intervention for kidney disease. All patients taking 5-ASA medication were identified from a population of 300 000. The pathology database was studied to identify the patients on 5-ASA treatment and whether they had had renal function tests.

RESULTS

800 adult patients were identified taking 5-ASA therapy. 612 patients received 5-ASAs for 3 months or more, and these were included in the final analysis. 293 patients had no renal function checks while on treatment. 79 patients had renal function tests less than once every 4 years and 36 patients once every 2-4 years. 204 patients had renal function measurements in 50% or more of years of treatment, of whom 116 were checked every year. Some patients were started on treatment with abnormal results at baseline and some with identified kidney disease continued on their 5-ASAs.

CONCLUSIONS

The majority of patients receiving 5-ASA compounds do not have regular renal function monitoring. Clinicians are failing to follow best practice guidelines.

Plasma amino acids, prolactin, insulin and glucose concentrations in lactating sows following venous infusion of isoleucine, leucine, lysine, threonine or valine

de Ridder, K. A. G., Farmer, C., de Lange, C. F. M., Shoveller, A. K. and Luimes, P. H. 2014. Plasma amino acids, prolactin, insulin and glucose concentrations in lactating sows following venous infusion of isoleucine, leucine, lysine, threonine or valine. Can. J. Anim. Sci. 94: 323–330. The amino acid supply to lactating sows affects their milk yield, and the current study aims at establishing whether this is mediated via increases in concentrations of insulin and prolactin, two hormones that are important for lactation. Six multiparous Yorkshire sows (252.8±18.5 kg body weight) were fitted with an ear vein catheter and were used in a 6×6 Latin square design experiment from days 7 to 10 of lactation (am and pm infusions on 3 consecutive days). Sows were fed a commercial corn and soybean meal diet (17.1% crude protein) three times daily (1.5 kg at 0600 and 1200, 3.0 kg at 1830). Starting 2 h after the 0600 or 1200 feeding, sows received an infusion of saline (control), isoleucine, leucine, lysine, threonine or valine at a rate of 33 mL min−1during 30 min. The infused dose was equivalent to 18±0.9% of true ileal digestible intake for each of the amino acids. Serial blood samples were taken, starting 30 min prior to infusion and until 240 min after infusion. Plasma concentrations of amino acids, prolactin, insulin, and glucose were determined. Data were analyzed as repeated measurements and also using areas under the curve. Intravenous infusion with each of the five amino acids studied increased the corresponding free plasma amino acid concentrations (P<0.05). However, concentrations of prolactin, insulin, and glucose were not affected by infusion of any of the amino acids studied (P>0.10). Therefore, supplying intravenously 18% of the daily intake of isoleucine, leucine, lysine, threonine or valine brings about expected increases in amino acids, but does not alter the short-term response in prolactin, insulin or glucose concentrations of lactating sows.