Glucose and lipid effects of the ileal apical sodium-dependent bile acid transporter inhibitor GSK2330672: double-blind randomized trials with type 2 diabetes subjects taking metformin

AIMS

To investigate the pharmacodynamics, pharmacokinetics and safety/tolerability of blocking reuptake of bile acids using the inhibitor GSK2330672 (GSK672) in patients with type 2 diabetes (T2D).

METHODS

Subjects with T2D taking metformin were enrolled in two studies in which they took metformin 850 mg twice daily for 2 weeks prior to and during the randomized treatment periods. In the first crossover study (n = 15), subjects received GSK672 45 mg, escalating to 90 mg, twice daily, or placebo for 7 days. The second parallel-group study (n = 75) investigated GSK672 10-90 mg twice daily, placebo or sitagliptin for 14 days.

RESULTS

In both studies, GSK672 reduced circulating bile acids and increased serum 7-α-hydroxy-4-cholesten-3-one (C4), an intermediate in the hepatic synthesis of bile acids. Compared with placebo, in the parallel-group study 90 mg GSK672 twice daily reduced fasting plasma glucose [FPG; -1.21 mmol/l; 95% confidence interval (CI) -2.14, -0.28] and weighted-mean glucose area under the curve (AUC)0-24 h (-1.33 mmol/l; 95% CI -2.30, -0.36), as well as fasting and weighted-mean insulin AUC0 -24 h . GSK672 also reduced cholesterol (LDL, non-HDL and total cholesterol) and apolipoprotein B concentrations; the maximum LDL cholesterol reduction was ∼40%. There was no change in HDL cholesterol but there was a trend towards increased fasting triglyceride levels in the GSK672 groups compared with placebo. In both studies, the most common adverse events associated with GSK672 were gastrointestinal, mostly diarrhoea (22-100%), which appeared to be independent of dose.

CONCLUSIONS

In subjects with T2D on metformin, GSK672 improved glucose and lipids, but there was a high incidence of gastrointestinal adverse events.

Does delay in referral of proliferative diabetic retinopathy from the diabetic eye screening programme lead to visual loss?

AimsTo ascertain the effect on visual acuity (VA) of a delay in Hospital Eye Service (HES) consultation for patients referred with proliferative diabetic retinopathy (PDR; R3) from the Diabetic Eye Screening Programme (DESP).MethodsAll patients referred to Moorfields Eye Hospital from DESP between April and December 2013 with a referral diagnosis of PDR in at least one eye were eligible. Screening programme VA was compared with VA at first HES appointment and final follow-up appointment. Reasons for any VA loss were noted.ResultsA total of 86 patients were included. Of these, 28 (33%) were seen in more than 4 weeks after their DESP referral. At first HES appointment, 39 (45%) patients were graded as having active PDR in at least one eye. Delay in referral did not significantly predict the likelihood of vision loss in all patients referred (χ(2), P=0.49) or in just those patients with a definitive HES diagnosis of active PDR (χ(2), P=1.00). In only 3 patients with active PDR was a delay in presentation thought to have led directly to VA loss.ConclusionsThere may be minimal short-term visual consequence in several weeks of delayed referral for many patients with a diagnosis of R3. However, the national guidance remains important. This is due to the occasional patient at very high risk of vision loss and the many gains for the patients in terms of time to properly assess medical and ocular conditions and counsel and consent them for treatment where necessary.

Diagnostic accuracy of placental growth factor and ultrasound parameters to predict the small-for-gestational-age infant in women presenting with reduced symphysis-fundus height

OBJECTIVES

To assess the diagnostic accuracy of placental growth factor (PlGF) and ultrasound parameters to predict delivery of a small-for-gestational-age (SGA) infant in women presenting with reduced symphysis-fundus height (SFH).

METHODS

This was a multicenter prospective observational study recruiting 601 women with a singleton pregnancy and reduced SFH between 24 and 37 weeks' gestation across 11 sites in the UK and Canada. Plasma PlGF concentration < 5(th) centile, estimated fetal weight (EFW) < 10(th) centile, umbilical artery Doppler pulsatility index > 95(th) centile and oligohydramnios (amniotic fluid index < 5 cm) were compared as predictors for a SGA infant < 3(rd) customized birth-weight centile and adverse perinatal outcome. Test performance statistics were calculated for all parameters in isolation and in combination.

RESULTS

Of the 601 women recruited, 592 were analyzed. For predicting delivery of SGA < 3(rd) centile (n = 78), EFW < 10(th) centile had 58% sensitivity (95% CI, 46-69%) and 93% negative predictive value (NPV) (95% CI, 90-95%), PlGF had 37% sensitivity (95% CI, 27-49%) and 90% NPV (95% CI, 87-93%); in combination, PlGF and EFW < 10(th) centile had 69% sensitivity (95% CI, 55-81%) and 93% NPV (95% CI, 89-96%). The equivalent receiver-operating characteristics (ROC) curve areas were 0.79 (95% CI, 0.74-0.84) for EFW < 10(th) centile, 0.70 (95% CI, 0.63-0.77) for low PlGF and 0.82 (95% CI, 0.77-0.86) in combination.

CONCLUSIONS

For women presenting with reduced SFH, ultrasound parameters had modest test performance for predicting delivery of SGA < 3(rd) centile. PlGF performed no better than EFW < 10(th) centile in determining delivery of a SGA infant.

Randomised clinical trial: the long-term safety and tolerability of naloxegol in patients with pain and opioid-induced constipation

BACKGROUND

Opioid-induced constipation (OIC) is a common adverse effect of opioid therapy.

AIM

To evaluate the long-term safety and tolerability of naloxegol, an oral, peripherally acting μ-opioid receptor antagonist (PAMORA), in patients with noncancer pain and OIC.

METHODS

A 52-week, multicenter, open-label, randomised, parallel-group phase 3 study was conducted in out-patients taking 30-1000 morphine-equivalent units per day for ≥4 weeks. Patients were randomised 2:1 to receive naloxegol 25 mg/day or usual-care (UC; investigator-chosen laxative regimen) treatment for OIC.

RESULTS

The safety set comprised 804 patients (naloxegol, n = 534; UC, n = 270). Mean exposure duration was 268 days with naloxegol and 297 days with UC. Frequency of adverse events (AEs) was 81.8% with naloxegol and 72.2% with UC. Treatment-emergent AEs occurring more frequently for naloxegol vs. UC were abdominal pain (17.8% vs. 3.3%), diarrhoea (12.9% vs. 5.9%), nausea (9.4% vs. 4.1%), headache (9.0% vs. 4.8%), flatulence (6.9% vs. 1.1%) and upper abdominal pain (5.1% vs. 1.1%). Most naloxegol-emergent gastrointestinal AEs occurred early, resolving during or after naloxegol discontinuation and were mild or moderate in severity; 11 patients discontinued due to diarrhoea and nine patients owing to abdominal pain. Pain scores and mean daily opioid doses remained stable throughout the study; no attributable opioid withdrawal AEs were observed. Two patients in each group had an adjudicated major adverse cardiovascular event unrelated to study drug; no AEs were reported nor adjudicated as bowel perforations.

CONCLUSION

In patients with noncancer pain and opioid-induced constipation, naloxegol 25 mg/day up to 52 weeks was generally safe and well tolerated.

Cancer Screening among immigrants living in urban and regional Australia: results from the 45 and up study

Over 25% of the Australian population are immigrants, and are less active participants in cancer screening programmes. Most immigrants live in urban areas of Australia, but a significant proportion (~20%), live in regional areas. This study explored differences in cancer screening participation by place of birth and residence. Self-reported use of mammogram, faecal occult blood test (FOBT), and/or prostate specific antigen (PSA) tests was obtained from 48,642 immigrants and 141,275 Australian-born participants aged 50 years or older in the 45 and Up Study (New South Wales, Australia 2006-2010). Poisson regression was used to estimate relative risks of test use, adjusting for key socio-demographic characteristics. Overall, immigrants from Asia and Europe were less likely to have had any of the tests in the previous two years than Australian-born participants. Regional Australian-born participants were more likely to have had any of the tests than those living in urban areas. Regional immigrant participants were more likely to have had an FOBT or PSA test than those living in urban areas, but there were no differences in mammograms. This report identifies key immigrant groups in urban and regional areas that policymakers and healthcare providers should target with culturally appropriate information to promote cancer screening.

Tacrolimus is an effective treatment for lupus nephritis in pregnancy

Lupus nephritis during pregnancy increases morbidity and mortality for mother and baby. Flares are difficult to treat as many therapeutic options are teratogenic or fetotoxic. Steroids alone may be unable to control disease activity and are associated with higher rates of preterm delivery, sepsis and gestational diabetes. Reports of using tacrolimus to treat lupus nephritis in pregnancy are limited. We describe the pregnancies of nine women in whom tacrolimus was successfully used to treat lupus nephritis flare (six patients) or maintain stable disease (three patients). Introduction or dose escalation of oral steroids was avoided in five of the patients who developed active disease and steroid dose was rapidly reduced in the sixth patient. All women with disease flare attained partial or complete remission after starting tacrolimus. None of the women on maintenance treatment developed active disease. We propose tacrolimus as an effective adjuvant or alternative therapy to steroids for treating lupus nephritis flare or maintaining stable disease during pregnancy.

An update to depression case management by practice nurses in primary care: a service evaluation

There is a recognized need to enhance non-pharmaceutical interventions in a way that is more accessible to the primary care population. Collaborative care has been shown to have a positive impact upon depression symptoms and a core element of the collaborative care approach is the case manager. This paper is a service evaluation of a collaborative care intervention that uses primary care nurses as the depression case manager and is a follow-up to the service audit carried out by Ekers and Wilson. The results support the notion that primary care nurses are ideally placed for delivering care to depressed patients; especially in cases were a patient also has a comorbid long-term medical condition. There is a recognized need to enhance non-pharmaceutical interventions for depression in the primary care. This service evaluation of collaborative care for depression by primary care practice nurses is an update of Ekers and Wilson (2008), reporting outcomes 5 years following initial training. From an initial 13 trained practice nurses, three provided anonymized data. Mean post-treatment Patient Health Questionnaire-9 (PHQ9) score was 8 [standard deviation (SD) 6.53, n = 185], indicating a mean positive change in depression symptom level of 8.9 [SD 7.01, 95% confidence interval (CI) 7.89-9.93, P < 0.001]. Subgroup analysis for patients identified with a comorbid long-term conditions (LTC) mean post-treatment PHQ9 score was 9 (SD 7.72, n = 33), indicating a mean positive change in depression symptom level of 8.1 (SD 5.79, 95% CI 6.04-10.41, P < 0.001). Nurses provided feedback on the intervention showing potential areas that would benefit from further detailed qualitative review. It was concluded that primary care practice nurses would be ideally placed to deliver collaborative care to depression patients with comorbid LTCs.

Interactive mobile learning: a pilot study of a new approach for sport science and medical undergraduate students

Mobile learning has increasingly become interwoven into the fabric of learning and teaching in the United Kingdom higher education sector, and as technological issues become addressed, this phenomena has accelerated. The aim of the study was to examine whether learning using a mobile learning device (Samsung NC10 Netbook) loaded with interactive exercises promoted learning compared with a traditional library exercise. Using a randomized trial, 55 students from an undergraduate sports science course (n = 28) and medical course (n = 27) volunteered to participate in this study. A mixed-model design ANOVA was used to examine the percent change in test score after a 3-wk intervention. Results showed that there was a significant difference between the two courses (P < 0.001), methods (P = 0.01), and trials (P < 0.001). The findings suggested that both methods augmented student knowledge and understanding in sports science and medical students. The sports science group demonstrated proportionally greater increases in test performance when exposed to the mobile interactive intervention compared with the traditional library approach. Qualitative data suggest an increased level of engagement with the Netbooks due to the stimulating interactive content. In conclusion, the Netbooks were an effective additional learning tool, significantly enhancing knowledge and understanding in students. Further research should ensure that participants are assessed for preferred learning styles, the subjective task value of expectancy value, and readiness for mobile learning to ascertain if this has an effect on the potential for using mobile learning and interactivity.

Long-term fate of polycyclic aromatic hydrocarbons (PAH) in sediments from Loch Leven after closure of an aluminium smelter

An aluminium smelter discharged polycyclic aromatic hydrocarbons (PAHs) into Loch Leven on the west of Scotland from 1907 until it closed in 2000, resulting in elevated PAH concentrations in the sediment. A temporal monitoring programme to investigate any recovery in sediment concentrations began in 2004, with sampling each year until 2008 and again in 2010. Cores were also collected to investigate temporal trends over a longer time scale and to estimate the sedimentation rate in the loch. The loch is divided into two basins, and PAH concentrations were significantly higher in the upper basin, closer to the smelter, than in the lower basin. The PAH distribution and concentration ratios were consistent with a pyrolytic source of PAHs, with a high proportion of heavier parent PAHs. There was no evidence of any recovery in PAH concentrations, perhaps due to the mixing and disturbances of the sediment, and the persistence of PAHs. Concentrations of all PAHs were above the Background Assessment Concentrations (BACs) in both basins. In the lower basin only the 5- and 6-ring PAHs were above the Effects Range Low (ERL) values, but in the upper basin all but naphthalene were above the ERLs. There is therefore still an unacceptable risk of chronic effects in marine species. Concentrations decreased down the cores, falling below BACs in the deepest sections. However, ERLs were exceeded as far down the core as 30 cm for some PAHs.

Dichloroacetate (DCA) as a potential metabolic-targeting therapy for cancer

The unique metabolism of most solid tumours (aerobic glycolysis, i.e., Warburg effect) is not only the basis of diagnosing cancer with metabolic imaging but might also be associated with the resistance to apoptosis that characterises cancer. The glycolytic phenotype in cancer appears to be the common denominator of diverse molecular abnormalities in cancer and may be associated with a (potentially reversible) suppression of mitochondrial function. The generic drug dichloroacetate is an orally available small molecule that, by inhibiting the pyruvate dehydrogenase kinase, increases the flux of pyruvate into the mitochondria, promoting glucose oxidation over glycolysis. This reverses the suppressed mitochondrial apoptosis in cancer and results in suppression of tumour growth in vitro and in vivo. Here, we review the scientific and clinical rationale supporting the rapid translation of this promising metabolic modulator in early-phase cancer clinical trials.

Preliminary assessment of polybrominated diphenyl ethers (PBDEs) in the Scottish aquatic environment, including the Firth of Clyde

This paper presents preliminary data on polybrominated diphenyl ethers (PBDEs) in the Scottish aquatic environment. Sediment and biota (fish liver, fish muscle and mussels) from a number of locations around Scotland were analysed for PBDEs with samples being from both remote and from potentially contaminated areas such as the former sewage sludge dump site at Garroch Head in the Clyde. PBDEs were measured in both cultivated, rope grown mussels and wild mussels collected from 5 sites around Scotland in 2006. Total PBDE concentrations (sum of tri- to hepta-BDEs) ranged from <limit of detection (LoD) to 2.36 microg kg(-1) wet weight, with the highest concentrations being found in mussels close to Aberdeen harbour. Most PBDE congeners were below detection limits but where they were detected, BDE47 and BDE99 were the main congeners. PBDEs were detected at low concentrations in flatfish muscle from 11 localities around Scotland, with total PBDE concentrations ranging from <LoD to 1.67 microg kg(-1) wet weight, with BDE47 being the dominant congener. Total PBDEs concentrations ranged from <LoD to 1.22 microg kg(-1) wet weight in brown trout muscle from 4 mountain lochs with the highest in fish from Lochnagar, a high level loch in the eastern Cairngorms. In contrast to the marine fish, BDE99 was the main congener in the brown trout. PBDEs were also measured in fish liver collected from the former sewage sludge dump site at Garroch Head in the Clyde, with total PBDE concentrations ranging from 4.1-536.1 microg kg(-1) wet weight. Concentrations were highest prior to the cessation of sewage sludge dumping in 1998. Total PBDE concentrations (sum of tri- to hepta-BDEs) in sediment cores collected in 2003 from Garroch Head and at a site 2.3 km south of Garroch Head ranged from <LoD to 23.4 microg kg(-1) dry weight. BDE209 was found at very high concentrations in the cores (2.3 to 98 125 microg kg(-1) dry weight). Highest PBDE concentrations were found in the top 4 cm of all cores, reflecting their more recent use.

The multikinase inhibitor midostaurin (PKC412A) lacks activity in metastatic melanoma: a phase IIA clinical and biologic study

Midostaurin (PKC412A), N-benzoyl-staurosporine, potently inhibits protein kinase C alpha (PKCalpha), VEGFR2, KIT, PDGFR and FLT3 tyrosine kinases. In mice, midostaurin slows growth and delays lung metastasis of melanoma cell lines. We aimed to test midostaurin's safety, efficacy and biologic activity in a Phase IIA clinical trial in patients with metastatic melanoma. Seventeen patients with advanced metastatic melanoma received midostaurin 75 mg p.o. t.i.d., unless toxicity or disease progression supervened. Patient safety was assessed weekly, and tumour response was assessed clinically or by CT. Tumour biopsies and plasma samples obtained at entry and after 4 weeks were analysed for midostaurin concentration, PKC activity and multidrug resistance. No tumour responses were seen. Two (12%) patients had stable disease for 50 and 85 days, with minor response in one. The median overall survival was 43 days. Seven (41%) discontinued treatment with potential toxicity, including nausea, vomiting, diarrhoea and/or fatigue. One patient had >50% reduction in PKC activity. Tumour biopsies showed two PKC isoforms relatively insensitive to midostaurin, out of three patients tested. No modulation of multidrug resistance was demonstrated. At this dose schedule, midostaurin did not show clinical or biologic activity against metastatic melanoma. This negative trial reinforces the importance of correlating biologic and clinical responses in early clinical trials of targeted therapies.