A randomized, placebo- and active-controlled, multi-country, multi-center parallel group trial to evaluate the efficacy and safety of a fixed-dose combination of 400 mg ibuprofen and 100 mg caffeine compared with ibuprofen 400 mg and placebo in patients with acute lower back or neck pain

Background

Ibuprofen is a well-established analgesic for acute pain symptoms. In several acute pain models, caffeine has demonstrated an analgesic adjuvant effect. This randomized trial (NCT03003000) was designed to compare the efficacy of a fixed-dose combination of ibuprofen and caffeine with ibuprofen or placebo for the treatment of acute lower back/neck pain.

Methods

Patients with acute lower back/neck pain resulting in pain on movement (POM) ≥5 on a 10-point numerical rating scale were randomized 2:2:1 to receive orally, three times daily for 6 days, 400 mg ibuprofen+100 mg caffeine, 400 mg ibuprofen or placebo, respectively. The primary endpoint was change in POM_WP (POM triggering highest pain score at baseline [worst procedure]) between baseline and the morning of day 2. Key secondary endpoints included POM_WP area under curve (AUC) between baseline and the morning of day 4 (POM_WPAUC_72h) and day 6 (POM_WPAUC_120h).

Results

In total, 635 patients were randomized (256 ibuprofen + caffeine: 253 ibuprofen: 126 placebo). Active treatments exhibited similar reductions in POM_WP, with an adjusted mean reduction of 1.998 (standard error [SE]: 0.1042) between baseline and day 2 for ibuprofen, 1.869 (SE: 0.1030) for ibuprofen + caffeine and 1.712 (SE: 0.1422) for placebo. Similar results were observed for POM_WPAUC_72h and POM_WPAUC_120h. Safety and tolerability was as expected.

Conclusion

A decrease in lower back/neck pain, indicated by reduced POM_WP, was shown in all active treatment arms; however, treatment effects were small versus placebo. Ibuprofen plus caffeine was not superior to ibuprofen alone or placebo for the treatment of acute lower back/neck pain in this setting.

P913What can we expect after valve-in-valve procedures in failed transcatheter aortic valves?

Background/Purpose

With the growing use of transcatheter aortic valve replacement (TAVR), we need to determine if repeat TAVR (TAV-in-TAV) is comparable or even superior to surgical aortic valve replacement followed by TAVR (TAV-in-SAV). Although TAV-in-SAV procedures were shown to provide an almost complete sealing of paravalvular leakage at the expense of elevated gradients, data for TAV-in-TAV are lacking. Hence, we compared echocardiographic and clinical outcome in all TAV-in-TAV and TAV-in-SAV procedures in our institution between Oct. 2007 and July 2017.

Methods

130 consecutive valve-in-valve patients out of 2351 TAVR-patients were identified. 24 patients were excluded. Patient data were analysed from our prospectively collected, institutional database. 93% underwent routine out-patient follow-up at 12 months.

Results

75 TAV-in-SAV (75±8 years, male 60%; STS score 5.2±4.0%) and 31 TAV-in-TAV patients (78±8 years, male 65%; STS score 4.6±2.8%) formed the final study population. The type of TAV was similarly distributed in both groups (self-/balloon-expandable valves [%] 57/43 vs. 61/39) with transfemoral being the most frequent access site (68% vs. 87%). The mode of prosthesis failure was mainly stenosis in the TAV-in-SAV group (77%), whereas it was mainly intraoperative paravalvular regurgitation (90%) in the TAV-in-TAV group. 10% TAV-in-TAV patients (78±10 years, 33% male, STS score 5.1±1.5%) underwent redo-TAVR for prosthesis-degeneration after a mean time of 2614±862 days. The TAV-in-TAV group (90% single session vs. 10% staged: mean gradient 10±4 mmHg vs. 15±3 mmHg, p=0.096; aortic valve area 1.62±0.36 cm2 vs. 1.45±0.18 cm2, p=0.240) showed lower gradients and larger aortic valve areas (Table 1). No major intraprocedural complications occurred in either group. 30-day mortality was 0%.

Table 1 75 TAV-in-SAV discharge 31 TAV-in-TAV discharge p-value 69 TAV-in-SAV 12mFU 30 TAV-in-TAV 12mFU p-value AVA (cm2) * 1.18±0.32 1.61±0.35 <0.001† 1.21±0.36 1.63±0.43 <0.001† Peak Gradient (mmHg) 33±14 23±8 <0.001† 31±14 21±8 <0.001† Mean Gradient (mmHg) 19±8 12±5 <0.001† 18±9 11±4 <0.001† AR (0–3)** 0.4±0.5 0.8±0.7 0.003† 0.4±0.5 0.8±0.6 0.001† LV ejection fraction (%) 49±12 49±16 0.970 54±12 50±10 0.081 *AVA = Aortic valve area; **AR = Aortic regurgitation. 0 = none, 1 = mild, 2 = moderate, 3 = severe. †p<0,05 significant.

Conclusion

Indications for TAV-in-TAV differ from those for TAV-in-SAV. TAV-in-TAV results in significantly lower gradients and larger aortic valve areas with no relevant aortic regurgitation. Accordingly, failed TAV valves may be treated with TAV-in-TAV in the future.

Biogenic Sources of Ice Nucleating Particles at the High Arctic Site Villum Research Station

The radiative balance in the Arctic region is sensitive to in-cloud processes, which principally depend on atmospheric aerosols, including ice nucleating particles (INPs). High temperature INPs (active at ≥-15 °C) are common in the Arctic. While laboratory and limited in situ studies show that the high-temperature active INPs are associated with bioaerosols and biogenic compounds, there is still little quantitative insight into the Arctic biogenic INPs and bioaerosols. We measured concentrations of bioaerosols, bacteria, and biogenic INPs at the Villum Research Station (VRS, Station Nord) in a large number of snow (15) and air (51) samples. We found that INPs active at high subzero temperatures were present both in spring and summer. Air INP concentrations were higher in summer (18 INP m^-3 at ≥-10 °C) than in spring (<4 INP m^-3 at ≥-10 °C), when abundant INPs were found in snowfall (1.4 INP mL^-1 at ≥-10 °C). Also, in summer, a significantly higher number of microbial and bacterial cells were present compared to the spring. A large proportion (60%-100%) of INPs that were active between -6 °C and -20 °C could be deactivated by heating to 100 °C, which was indicative of their predominantly proteinaceous origin. In addition, there was a significant linear regression between the summer air concentrations of INPs active at ≥-10 °C and air concentrations of bacterial-marker-genes (p < 0.0001, R² = 0.999, n = 6), pointing at bacterial cells as the source of high-temperature active INPs. In conclusion, the majority of INPs was of proteinaceous, and possibly of bacterial, origin and was found in air during summer and in snowfall during springtime.

B-57 Post-traumatic Stress Disorder is a Stronger Predictor of Long-term Neurobehavioral Outcome than Traumatic Brain Injury Severity in U.S. Military Service Members

Objective

The purpose of this study was to examine long-term neurobehavioral outcome in SMVs with versus without PTSD following TBI of all severities.

Methods

Participants were 536 SMVs recruited into three experimental groups (TBI, injured controls [IC], non-injured controls [NIC]). Participants completed the PTSD Checklist and the TBI-Quality of Life (TBI-QOL). Participants were divided into six subgroups based on the three experimental categories, two PTSD categories (i.e., present/absent), and two broad TBI severity categories (i.e., ‘unMTBI’ [includes uncomplicated mild TBI]; and ‘smcTBI’ [includes severe TBI, moderate TBI, and complicated mild TBI): (1) NIC/PTSD-Absent, (2) IC/PTSD-Absent, (3) unMTBI/PTSD-Absent, (4) unMTBI/PTSD-Present, (5) smcTBI/PTSD-Absent, and (6) smcTBI/PTSD-Present.

Results

There were significant main effects across the six groups for all TBI-QOL measures (p < .001). Select pairwise comparisons revealed significantly worse scores (p < .001) on all TBI-QOL measures in all PTSD-Present groups compared to the PTSD-Absent groups (i.e., Group 3v4 and 5v6; d = 0.90 to 2.11). In contrast, when controlling for PTSD, there were no significant differences between the TBI severity groups for all TBI-QOL measures (i.e., Group 3v5 and 4v6). In the TBI sample, a series of step-wise regression analyses revealed that PTSD, but not TBI severity, was consistently a strong predictor of all TBI-QOL scales (all p’s < .001), accounting for up to 64% of the variance.

Conclusions

These results provide support for the very strong influence of PTSD, but not TBI severity, on long-term neurobehavioral outcome following TBI. Concurrent PTSD and TBI of all severities should be considered a risk factor for poor long-term neurobehavioral outcome that requires ongoing monitoring.

B-58 Post-traumatic Stress Symptoms Are Associated with Worse Neuropsychological Functioning, but not Diffusion Tensor Imaging Findings, in Military Service Members Following Mild Traumatic Brain Injury

Objective

The purpose of this study was to examine neurobehavioral and neurocognitive functioning, and white matter integrity (using Diffusion Tensor Imaging [DTI]), in service members with versus without PTSD following mild traumatic brain injury (MTBI).

Method

Participants were 101 U.S. military service members who had sustained an uncomplicated MTBI (n = 80) or an injury without TBI (i.e., Injured Control [IC], n = 21) prospectively enrolled from the Walter Reed National Military Medical Center (Bethesda, Maryland). Participants completed a battery of neuropsychological tests, as well as DTI of the brain, on average 4-years post-injury. Measures of FA, MD, AD, and RD were generated for 18 regions of interest [ROIs]. Participants in the MTBI group were divided into two sub-groups based on DSM-IV-TR diagnostic criteria for PTSD: MTBI/PTSD-Present (n = 22) and MTBI/PTSD-Absent (n = 58).

Results

The MTBI/PTSD-Present group reported a significantly higher number of postconcussion symptoms, had higher scores on the majority of MMPI-2-RF scales, and had worse scores on the vast majority of cognitive domains (i.e., Attention, Processing Speed, Immediate Memory, Delayed Memory, Executive Functioning, Visuospatial Ability) compared to both the MTBI/PTSD-Absent group (all p’s < .05) and IC/PTSD-Absent group (all p’s < .05). For the DTI variables, there were no significant group differences for all DTI measures in all regions of the brain, with the exception of a handful of measures (i.e., right cingulum–cingulate gyrus, and bilaterally in the corticospinal tract).

Conclusion

These results provide support for a (a) strong relationship between PTSD and poor neurobehavioral and neurocognitive outcome following MTBI, and (b) weak relationship between PTSD and white matter integrity following MTBI.

B-46 Caring for a Service Member or Veteran following Traumatic Brain Injury Influences Caregiver Mental Health

Objective

To examine factors related to poor mental health in a sample of caregivers assisting service members/veterans (SMV) following a traumatic brain injury (TBI).

Methods

Caregivers (N = 201, 96.0% female; 86.1% spouse; Age: M = 39.2 years, SD = 10.2) of SMVs following a mild, moderate, severe, or penetrating TBI were recruited from Walter Reed National Military Medical Center (Maryland) and community outreach to participate in the Defense and Veterans Brain Injury Center 15-Year Longitudinal TBI Study (Sec721 NDAA FY2007). Caregivers completed the SF-36v2 Health Survey (SF-36v2), Caregiver Appraisal Scale (CAS), Mayo-Portland Adaptability Inventory-4 (MPAI-4), and Caregiver Questionnaire. The sample was divided into two mental health groups: Poor (n = 108) and Good Mental Health (n = 93).

Results

A higher proportion of caregivers in the Poor Mental Health group reported worse functioning on the SF-36v2 and CAS scales (d = .43 to d = 2.09), except CAS Ideology; helping with symptoms of depression, post-traumatic stress disorder (PTSD), and physical expressions of irritability, anger, or aggression (p’s < .01); less time for themselves (d = .42); more unmet needs (d = .87); an impact on employment (p = .00); and burdensome out-of-pocket caregiving expenses (p = .04). A higher proportion of SMVs of caregivers in the Poor Mental Health group had a mild TBI; worse scores on the MPAI-4 scales (d = .29 to d = .64); PTSD, depression, or other anxiety; received mental health and physical rehabilitation treatment; and did not have significant hospitalization post-injury (p = .04 to p = < .001).

Conclusions

Services for caregivers helping SMVs with comorbid mental health problems are required to ensure the burden of care does not undermine the caregiver’s health and impact the SMV’s recovery and reintegration.

B-60 Resilience is Associated with Overall Health-related Quality of Life in Caregivers of Service Members and Veterans Following Traumatic Brain Injury

Objective

To examine the influence of caregiver resilience on health-related quality of life (HRQOL) in caregivers of service members/veterans (SMVs) following a traumatic brain injury (TBI).

Methods

Caregivers (N = 346, Female = 96.2%; Spouse = 91.0%%; Age: M = 40.6 years) of SMVs following a mild, moderate, severe, or penetrating TBI were recruited from Walter Reed National Military Medical Center and via community outreach to participate in the Defense and Veterans Brain Injury Center 15-Year Longitudinal TBI Study (Sec721 NDAA FY2007). Caregivers completed the Caregiver Appraisal Scale and 15 HRQOL measures. Caregivers were divided into three groups using the Resilience scale from the TBI-QOL: (1) Low Resilience [n = 125], (2) Moderate Resilience [n = 122], and (3) High Resilience [n = 99].

Results

There were significant main effects across groups for all HRQOL measures (ps < .001). The Low Resilience group had consistently worse scores compared to both the Moderate and High Resilience groups (d = .50-1.60). The largest effect sizes were found for the Caregiving Satisfaction, Anxiety, Depression, Anger, Social Isolation, Perceived Stress, Caregiver Strain, and Feelings of Loss-Self scales (d = .91-1.60). Step-wise regression analyses revealed that Perceived Stress was the most significant predictor of resilience (R2 = 33.3%), with Caregiver Satisfaction (R2change = 5.0%), Depression (R2change = 1.8%), Caregiver Mastery (R2change = 1.7), Caregiver Specific Anxiety (R2change = 1.2) and Feelings of Loss-Self (R2change = 1.1%) contributing some additional variance in subsequent steps.

Conclusions

There was a moderate to high relationship between resilience and overall HRQOL in caregivers of SMVs following TBI. Targeted interventions to increase caregiver resilience may be warranted to ensure that burden of care does not undermine the caregiver’s heath and impact the SMV’s recovery and reintegration.

Pharmacokinetic Properties of Ibuprofen (IBU) From the Fixed-Dose Combination IBU/Caffeine (400/100 mg; FDC) in Comparison With 400 mg IBU as Acid or Lysinate Under Fasted and Fed Conditions-Data From 2 Single-Center, Single-Dose, Randomized Crossover Studies in Healthy Volunteers

Rapid onset of analgesic action is linked with rapid absorption of analgesics (high maximum concentration [C_max] and short time to maximum concentration [t_max]). After overnight fasting, ibuprofen lysinate reaches higher peak plasma levels (C_max) earlier than ibuprofen acid (t_max) with comparable exposure (area under the plasma concentration–time curve [AUC]); however, subjects usually take ibuprofen with or within a short time of a meal. Therefore, pharmacokinetic (PK) studies under fed conditions may better characterize properties under real‐life conditions. We investigated a new fixed‐dose combination (FDC) of ibuprofen acid 400 mg and caffeine 100 mg in 2 single‐dose, randomized, crossover PK studies in healthy subjects (both N = 36). The FDC was compared with ibuprofen 400 mg as acid and as lysinate after an overnight fast in Study 1, and with ibuprofen lysinate after a meal in Study 2. After fasting, results for ibuprofen in the FDC were comparable with those from ibuprofen acid alone. Caffeine did not affect the C_max, t_max, and AUC. As expected, a higher C_max and shorter t_max were observed with ibuprofen lysinates vs the FDC. Compared with administration after fasting, C_max and t_max for ibuprofen lysinate administered postprandially were markedly different, while with FDC, these parameters were less sensitive to food intake. Taken after a meal, ibuprofen in the FDC reached t_max earlier than ibuprofen lysinate (median 1.25 vs 1.63 hours), and C_max was approximately 13% higher, with comparable AUC, suggesting that the profile of ibuprofen was in favor of the FDC compared with ibuprofen lysinate. Thus, under real‐life conditions, ibuprofen lysinate had no PK advantage over the FDC. All preparations were well tolerated.

[Tricuspid valve regurgitation : Indications and operative techniques]

Functional tricuspid valve (TV) regurgitation secondary to left heart disease (e.g. mitral insufficiency and stenosis) is observed in 75% of the patients with TV regurgitation and is thus the most common etiology; therefore, the majority of patients who require TV surgery, undergo concomitant mitral and/or aortic valve surgery. Uncorrected moderate and severe TV regurgitation may persist or even worsen after mitral valve surgery, leading to progressive heart failure and death. Patients with moderate to severe TV regurgitation show a 3-year survival rate of 40%. Surgery is indicated in patients with severe TV regurgitation undergoing left-sided valve surgery and in patients with severe isolated primary regurgitation without severe right ventricular (RV) dysfunction. For patients requiring mitral valve surgery, tricuspid valve annuloplasty should be considered even in the absence of significant regurgitation, when severe annular dilatation (≥40 mm or >21 mm/m²) is present. Functional TV regurgitation is primarily treated with valve reconstruction which carries a lower perioperative risk than valve replacement. Valve replacement is rarely required. Tricuspid valve repair with ring annuloplasty is associated with better survival and a lower reoperation rate than suture annuloplasty. Long-term results are not available. The severity of the heart insufficiency and comorbidities (e.g. renal failure and liver dysfunction) are the essential determinants of operative mortality and long-term survival. Tricuspid valve reoperations are rarely necessary and associated with a considerable mortality.