Alirocumab safety in people with and without diabetes mellitus: pooled data from 14 ODYSSEY trials

AIM

To evaluate the safety of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor alirocumab according to diabetes mellitus status.

METHODS

Safety data from 14 trials (8-104-week durations) were analysed by treatment (alirocumab or placebo/ezetimibe control) and diabetes status (yes/no, defined by medical history). Adverse event data were assessed using descriptive statistics and Cox models.

RESULTS

Of the 5234 trial participants, 1554 (29.7%) had diabetes. Overall, treatment-emergent adverse events were similar in the alirocumab and control groups, except for more frequent local injection site reactions with alirocumab. Fewer people with diabetes experienced local injection site reactions [alirocumab, 3.5%, control, 2.9%; hazard ratio 1.24 (95% CI 0.68-2.25)] than those without diabetes [alirocumab, 7.5%; control, 4.9%; hazard ratio 1.51 (95% CI 1.13-2.01)]. Those with diabetes reported a greater number of serious adverse events (alirocumab, 19.4%; control, 19.7%) than those without diabetes (alirocumab, 14.5%; control, 13.5%). In people with diabetes, major adverse cardiac events occurred in 2.7% of alirocumab-treated people [control, 3.3%; hazard ratio 0.74 (95% CI 0.41-1.35)]; in those without diabetes, 1.8% of alirocumab-treated people had major adverse cardiac events [control, 1.7%; hazard ratio 0.95 (95% CI 0.56-1.62)]. Overall, no increase in HbA1c or fasting plasma glucose vs control treatment groups was observed, regardless of diabetes status.

CONCLUSION

This pooled analysis across 14 trials demonstrated similar safety for alirocumab vs control treatment, irrespective of diabetes status, except for more frequent local injection site reactions with alirocumab. People with diabetes reported fewer local injection site reactions than those without diabetes.

Scaling Up of Cervical Cancer Screening at Primary Health Care Level in Rwanda

Background: Rwanda is a high cervical cancer-burden country, with an age standardized rate (ASR) of cervical cancer incidence of 41.8 cases per 100,000 people in 2012. In the same year, cervical cancer mortality lay at 26.2 deaths per 100,000 people. Aim: To address this burden, Rwanda initiated the vision inspection with acetic acid (VIA) screening-based strategy in 2013 in line with WHO recommendations for low- and middle-income countries. The target audience of the program was set for women between the ages of 30 and 49 and remains today. Here, we describe the implementation status of the program at the primary health care level; health centers and district hospitals in Rwanda. Methods: Integrating into Rwanda's existing health system, the program was purposefully rooted in health centers, with a pathway designed for women who screen positive to be referred to the district hospital for cryotherapy or LEEP, according to the lesions' size. Nurses, midwives and medical officers from health centers and district hospitals are trained through a 10-day curriculum (5 days for theory and 5 days for practice) before initiating the provision of services to clients in routine care. Monitoring of the program is conducted through both quarterly, on-site mentorship and screening indicators that are integrated into Rwanda's Health Management Information System (HMIS), through which facilities report on monthly basis. Results: Since its initiation in August 2013, Rwanda's cervical cancer screening program has been established in 21 of 38 (55%) district hospitals and 256 health centers in their catchment area. Training has been an integral component as well, with at least two nurses/midwives trained at implementing health centers and a medical officer with two nurses/midwives trained on cervical cancer screening and the treatment of precancerous lesions at district hospital. In addition, district hospitals have been equipped with cryotherapy, LEEP, and colposcopy machines. Over this program's implementation three-and-a-half-year course, 38,000 women have been screened for cervical cancer. Conclusion: Using a simple VIA-based strategy, Rwanda has been able to swiftly and effectively increase the number of health facilities implementing cervical cancer screening program. Though additional innovative implementation strategies are still needed to proportionally increase women's screening coverage, these initial steps hold great promise in Rwanda's ability to effectively implement a sustainable cervical cancer screening program.

Different but similar: personality traits of​ surgeons and internists-results of a cross-sectional observational study

OBJECTIVES

Medical practice may attract and possibly enhance distinct personality profiles. We set out to describe the personality profiles of surgical and medical specialties focusing on board-certified physicians.

DESIGN

Prospective, observational.

SETTING

Online survey containing the Ten-Item Personality Inventory (TIPI), an internationally validated measure of the Five Factor Model of personality dimensions, distributed to board-certified physicians, residents and medical students in several European countries and Canada. Differences in personality profiles were analysed using multivariate analysis of variance and Canonical Linear Discriminant Analysis on age-standardised and sex-standardised z-scores of the personality traits. Single personality traits were analysed using robust t-tests.

PARTICIPANTS

The TIPI was completed by 2345 board-certified physicians, 1453 residents and 1350 medical students, who also provided demographic information.

RESULTS

Normal population and board-certified physicians' personality profiles differed (p<0.001). The latter scored higher on conscientiousness, extraversion and agreeableness, but lower on neuroticism (all p<0.001). There was no difference in openness to experience. Board-certified surgical and medical doctors' personality profiles were also different (p<0.001). Surgeons scored higher on extraversion (p=0.003) and openness to experience (p=0.002), but lower on neuroticism (p<0.001). There was no difference in agreeableness and conscientiousness. These differences in personality profiles were reproduced at other levels of training, that is, in students and training physicians engaging in surgical versus medical practice.

CONCLUSION

These results indicate the existence of a distinct and consistent average 'physician personality'. Despite high variability within disciplines, there are moderate but solid and reproducible differences between surgical and medical specialties.

How unemployment scarring affects skilled young workers: evidence from a factorial survey of Swiss recruiters

We ask how employers contribute to unemployment scarring in the recruitment process in the German-speaking part of Switzerland. By drawing on recruitment theories, we aim to better understand how recruiters assess different patterns of unemployment in a job candidate's CV and how this affects the chances of young applicants being considered for a vacancy. We argue that in contexts with tight school-work linkage and highly standardised Vocational Education and Training systems, the detrimental effect of early unemployment depends on how well the applicant's profile matches the requirements of the advertised position. To test this assumption, we surveyed Swiss recruiters who were seeking to fill positions during the time of data collection. We employed a factorial survey experiment that tested how the (un)employment trajectories in hypothetical young job applicants' CV affected their chances of being considered for a real vacancy. Our results show that unemployment decreases the perceived suitability of an applicant for a specific job, which implies there is a scarring effect of unemployment that increases with the duration of being unemployed. But we also found that these effects are moderated by how well the applicant's profile matches the job's requirements. Overall, the worse the match between applicant's profile and the job profile, the smaller are the scarring effects of unemployment. In sum, our findings contribute to the literature by revealing considerable heterogeneity in the scarring effects of unemployment. Our findings further suggest that the scarring effects of unemployment need to be studied with regard to country-specific institutional settings, the applicants' previous education and employment experiences, and the job characteristics.

Efficacy and safety of alirocumab in people with prediabetes vs those with normoglycaemia at baseline: a pooled analysis of 10 phase III ODYSSEY clinical trials

AIM

To assess the lipid-lowering efficacy and safety of alirocumab, a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, in people with hypercholesterolaemia and prediabetes at baseline vs people with normoglycaemia at baseline in a pooled analysis of 10 ODYSSEY phase III trials.

METHODS

People classified as having prediabetes had baseline HbA1c ≥39 mmol/mol (5.7%) and <48 mmol/mol (6.5%), or two baseline fasting plasma glucose values ≥5.6 mmol/l (100 mg/dl) but no more than one fasting plasma glucose value ≥7.0 mmol/l (126 mg/dl), or had specific terms reported in their medical history; people diagnosed with diabetes at baseline were excluded, and the remainder were classified as having normoglycaemia. Participants received alirocumab or control (placebo/ezetimibe) for 24-104 weeks, with maximally tolerated statin in most cases. The primary efficacy endpoint was LDL cholesterol reductions from baseline to week 24 in the intention-to-treat population using the mixed-effect model with a repeated measures approach.

RESULTS

Reductions in LDL cholesterol from baseline to week 24 with alirocumab were 44.0-61.8% (prediabetes group) and 45.8-59.5% (normoglycaemia group). In both subgroups, LDL cholesterol reductions were generally similar in those with and without baseline triglycerides ≥1.7 mmol/l (150 mg/dl). Alirocumab was not associated with changes in HbA1c or fasting plasma glucose over time in either subgroup (up to 24 months' follow-up). Adverse event rates were generally similar in those with and without prediabetes.

CONCLUSIONS

Over a mean follow-up of 24-104 weeks, alirocumab treatment resulted in significant LDL cholesterol reductions from baseline that were similar in participants with prediabetes and those with normoglycaemia at baseline, with no effect on glycaemia and a safety profile similar to that of the control.

Sexual Dysfunction After Good-Grade Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

To assess the consequences of aneurysmal subarachnoid hemorrhage (aSAH) on sexual pleasure in patients with an otherwise favorable neurologic outcome.

METHODS

Anonymous, standardized questionnaires concerning sexual function, including the International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI), and a statement on subjective change in sexual pleasure after aSAH, were completed by 33 patients treated at the Cantonal Hospital St Gallen between 2005 and 2013. All had favorable neurologic outcomes (Glasgow Outcome Scale score 4 or 5).

RESULTS

Ten patients (31.3%) reported a subjective worsening of sexual pleasure after aSAH. Sexual dysfunction according to FSFI criteria affected 9 of the 19 female patients (47.4%). All 19 women had a hypoactive sexual desire disorder. Erectile dysfunction was present in 7 of the 14 male patients (50%). Patients with World Federation of Neurosurgical Societies (WFNS) grade 2 aSAH were significantly more likely to report a subjective worsening of sexual experience after hemorrhage than those with WFNS grade 1.

CONCLUSIONS

This is the first known evaluation of sexual health following aSAH with otherwise favorable neurologic outcomes, and confirms that sexual dysfunction is common in this population. Sexual health should be explored during follow-up with these patients.

The Role of Perceived Stress and Self-Efficacy in Young People's Life Satisfaction: A Longitudinal Study

Life satisfaction is an important indicator of successful development. However, adolescents' life satisfaction tends to be relatively unsteady, and environmental influences play a critical role in shaping life satisfaction among adolescents in the transition to young adulthood. Given the paramount importance that education plays in adolescents' lives, adolescents' life satisfaction may vary as a function of school-related stress experience. At the same time, coping resources may help reduce adverse effects of stress on life satisfaction. With this in mind, we examined whether, and to what extent, perceived stress in education and general self-efficacy (a resource that facilitates coping) affect the life satisfaction of adolescents in transition to young adulthood. We distinguished between baseline levels of stress and self-efficacy and within-person change in stress and self-efficacy to determine whether life satisfaction is sensitive to fluctuations in stress and self-efficacy when person-specific levels of stress and self-efficacy are taken into account. Estimating growth curve models on data from a panel study on the life trajectories of compulsory-school leavers (n = 5126, 55.3 % female), we found that baseline levels of stress and self-efficacy, as well as within-person change in stress and self-efficacy, affected adolescents' life satisfaction. Moreover, our results showed that baseline self-efficacy mitigated the negative effect of baseline stress on life satisfaction. These findings improve our understanding of two major psychological determinants of adolescents' life satisfaction and extend our knowledge of life satisfaction trajectories during the transition to young adulthood.

Cognitive impairment and reduced quality of life among old-age groups in Southern Urban India: home-based community residents, free and paid old-age home residents

AIM

The purpose of the study were (i) to screen for cognitive impairment using Mini-Mental Status Examination among three old-age groups based on dwelling types in Chennai, India i.e. residential paid old-age homes, residential free (charitable) homes and home-based community-dwelling residents; (ii) secondly to investigate factors (demographic, psychological, medical and disability) associated with cognitive impairment in the these old-age; (iii) third, to investigate the independent association between cognitive impairment and health-related quality of life (QOL) among elderly across aged care dwelling types.

METHODS

A total of 499 elderly from three old-age groups were interviewed in this cross-sectional study (173 elderly home-based community-dwellers, 176 paid-home and 150 free-home residents). All the participants were interviewed for their socio-economic condition, medical morbidity, self-reported worry and anxiety, disability and QOL.

RESULTS

42.7% free-home elderly residents were found to have cognitive impairment, whereas 32.4% of paid-home and 21.9% of community-dwelling elderly had cognitive impairment. The residents of free-home were less educated, had lower income and reported higher incidence of worry, anxiety, disability and poor QOL than community-dwelling or paid-home residents. Increasing age, low education, female gender, high blood pressure and disability were associated with cognitive impairment. Cognitive impairment had significant negative effect on their health-related QOL (b = -0.10, P = 0.01), independent of age, gender, education, chronic illness and dwelling type.

CONCLUSION

The burden of cognitive impairment was high in all aged-care dwelling types in urban India; with free charitable home residents being worse affected. Cognitive impairment was associated with disability and poor health-related QOL in these age-care settings.

Membrane phase characteristics control NA-CATH activity

Our studies presented in this report focus on the behavior of NA-CATH, an α-helical cathelicidin antimicrobial peptide, originally discovered in the Naja atra snake. It has demonstrated high potency against gram-positive and gram-negative bacteria with minimal hemolysis. Here we examine the kinetics, behaviors and potential mechanisms of the peptide in the presence of membrane liposome, modeling Escherichia coli, whose membrane exhibits distinct lipid phases. To understand NA-CATH interactions, the role of lipid phases is critical. We test three different lipid compositions to detangle the effect of phase on NA-CATH's activity using a series of leakage experiments. From these studies, we observe that NA-CATH changes from membrane disruption to pore-based lysing, depending on phases and lipid composition. This behavior also plays a major role in its kinetics.

How does hybridization influence the decision making process in conservation? The genus Orchis (Orchidaceae) as a case history

Hybridization is a fundamental process in biology and can lead to new evolutionary lineages. However, if the parental taxa involved are rare, difficult decisi- ons may have to be made regarding the conservation of the biological process versus the conservation of the parental taxa. The genus Orchis in Europe is a good example of a group of species in which these types of questions arise as several of the species hybridize where they co-occur. The example used here relates to O. militaris, O. purpurea and O. simia in the anthropomorphic group (so called because the labellum has lobes thought to resemble arms and legs). All three species are widespread in Europe, al- though they are rare in large parts of their ranges, and they have substantial areas of overlap in distribution. All three are rare in Britain, occurring predominantly in south east England. Orchis militaris and O. simia and are only known from two and three natural sites in England, respectively. Orchis purpurea is less rare, but is still geographically localized.