410Heart failure risk stratification and efficacy of dapagliflozin in patients with type 2 diabetes mellitus

Background

Patients with type 2 diabetes mellitus (T2DM) are at increased risk of developing heart failure (HF). Treatment with sodium-glucose cotransporter-2 (SGLT2) inhibitors reduces the risk of hospitalization for HF (HHF) in patients with T2DM.

Purpose

To develop and validate a practical, multivariable clinical risk score for HHF in patients with T2DM and assess whether this score can identify high-risk patients with T2DM who have the greatest reduction in risk for HHF with an SGLT2 inhibitor.

Methods

We developed a clinical risk score for centrally-adjudicated HHF using independent clinical risk indicators of HHF in 8212 patients with T2DM in the placebo arm of SAVOR-TIMI 53. Candidate variables were assessed using multivariable Cox regression and independent clinical risk indicators achieving statistical significance of p<0.001 were included in the risk score and given weights proportional to the regression coefficients. We externally validated the score in 8578 patients with T2DM in the placebo arm of DECLARE-TIMI 58. Discrimination was assessed using Harrell's c-index. The relative and absolute risk reductions in HHF with the SGLT2 inhibitor dapagliflozin were assessed by baseline HHF risk.

Results

The 5 independent clinical risk indicators were prior heart failure, atrial fibrillation, coronary artery disease, estimated glomerular filtration rate (eGFR), and urine albumin/creatinine ratio (UACR) (Figure, left). A simple integer-based scheme using these predictors identified a strong >16-fold gradient of HHF risk (p-trend <0.001) in both the derivation and validation cohorts, with c-indices of 0.81 and 0.78, respectively. Whereas relative risk reductions were similar across the risk score (25–34%), absolute risk reductions were greater in those at higher baseline risk (interaction p-value for absolute risk reduction <0.01), with high-risk (2 points) and very high-risk patients (≥3 points) having 1.5% and 2.7% absolute risk reductions in HHF at 4 years with dapagliflozin, translating into NNTs of only 65 and 36, respectively (Figure, right).

Conclusion(s)

Risk stratification using a novel clinical risk score for HHF in patients with T2DM identifies patients at higher risk for HHF who derive greater benefit from treatment with the SGLT2 inhibitor dapagliflozin.

Acknowledgement/Funding

SAVOR-TIMI 53 and DECLARE-TIMI 58 were sponsored by AstraZeneca.

Genome-wide analysis of canine oral malignant melanoma metastasis-associated gene expression

Oral malignant melanoma (OMM) is the most common canine melanocytic neoplasm. Overlap between the somatic mutation profiles of canine OMM and human mucosal melanomas suggest a shared UV-independent molecular aetiology. In common with human mucosal melanomas, most canine OMM metastasise. There is no reliable means of predicting canine OMM metastasis, and systemic therapies for metastatic disease are largely palliative. Herein, we employed exon microarrays for comparative expression profiling of FFPE biopsies of 18 primary canine OMM that metastasised and 10 primary OMM that did not metastasise. Genes displaying metastasis-associated expression may be targets for anti-metastasis treatments, and biomarkers of OMM metastasis. Reduced expression of CXCL12 in the metastasising OMMs implies that the CXCR4/CXCL12 axis may be involved in OMM metastasis. Increased expression of APOBEC3A in the metastasising OMMs may indicate APOBEC3A-induced double-strand DNA breaks and pro-metastatic hypermutation. DNA double strand breakage triggers the DNA damage response network and two Fanconi anaemia DNA repair pathway members showed elevated expression in the metastasising OMMs. Cross-validation was employed to test a Linear Discriminant Analysis classifier based upon the RT-qPCR-measured expression levels of CXCL12, APOBEC3A and RPL29. Classification accuracies of 94% (metastasising OMMs) and 86% (non-metastasising OMMs) were estimated.

The acceptability of fluoride varnish and fissure sealant treatments in children aged 6-9 delivered in a school setting

OBJECTIVE

To assess the acceptability of fluoride varnish and fissure sealant treatments for children. To investigate the acceptability of delivering this treatment in a school setting for children, parents, clinicians and school staff.

BASIC RESEARCH DESIGN

Semi-structured interviews (with children, parents, clinicians and school staff) and a questionnaire (for school staff) as part of a two-arm, randomised clinical trial.

PARTICIPANTS

Children aged 6-9, their parents, clinical staff and school staff.

INTERVENTIONS

Fluoride varnish or fissure sealant was delivered to children from the ages of 6 to 9 years for 36 months, by a community dental service in a school setting. Fluoride varnish was re-applied every 6 months; fissure sealant was applied once to first permanent molars and re-applied as required.

RESULTS

Interviews with children a few days after treatment indicated little difference in preference; acceptability at this point was driven by factors such as finding it fun to visit 'the van' (i.e. mobile dental unit) and receiving a "sticker" rather than specific treatment received. Interviews with parents, clinicians and school staff indicated high acceptability of delivering this type of intervention in a school setting; this may have been partly due to the service being delivered by a well-established, child-oriented community dental service which delivered the clinical trial.

CONCLUSIONS

Preventive fluoride varnish and fissure sealant treatments in a school setting has high overall acceptability.

Owners' perception of their dogs' quality of life during and after radiotherapy for cancer

OBJECTIVES

To determine the owners' perception of dogs' quality of life before, immediately after and 6 weeks after radiotherapy treatments for a variety of neoplasms and assess owner satisfaction over their decision to treat.

MATERIALS AND METHODS

Questionnaires were given to owners whose dogs completed a radiotherapy treatment at a referral radiation oncology centre. Questionnaires were given at three time points: before treatment, on the last day of treatment and more than 6 weeks after the treatment was finished. Owners were asked questions regarding their perception of radiotherapy and the quality of life of their pets before, during and after treatment with radiation therapy. Quality of life was scored from 1 (could not be worse) to 10 (could not be better).

RESULTS

Seventy-one owners met the inclusion and exclusion criteria. Results showed that 6 weeks or more after treatment, most owners were happy that they had chosen to treat their dogs (92%) and would treat another pet again, if indicated (88%). Across the three time points, median quality of life perception score was 9.

CLINICAL SIGNIFICANCE

Radiotherapy was well tolerated by owners and dogs in this study. The great majority of clients were happy to have pursued radiotherapy, would choose to do it again (if indicated) and would recommend it to a friend.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.

'There is such a thing as too healthy!' The impact of minimum nutritional guidelines on school food practices in secondary schools

BACKGROUND

Pressure to improve school meals has resulted in stringent nutritional guidelines across the UK. In Wales, the 'Appetite for Life' guidelines of 2008 resulted in significant changes to the provision of food in Welsh schools. Although evaluation of these changes has focussed on nutritional quality, there is little evidence of how pupils perceive these changes and their impact on school food practices. Using a Collective Lifestyles approach, the present study reports how secondary school pupils perceive and negotiate menu changes and the implications for lunchtime practices.

METHODS

Seven focus groups (52 pupils) were undertaken in four secondary schools within one local authority in Wales. Participatory techniques were used to facilitate discussion, and the focus groups were recorded, transcribed and analysed using a framework approach. Analysis was underpinned by a Collective Lifestyles approach, which provides a framework to understand behaviour in context using three domains: (i) patterns of consumption; (ii) the construction and maintenance of identity; and (iii) power relationships.

RESULTS

Pupils reported that the new menus were unpopular in terms of content and meal type; the preference was for portable and snack style foods. In terms of power relationships, pupils' ability to negotiate within the school setting was constrained by the institutional nature of school dining. As a result, pupils tended to opt out of school food provision, accessing alternatives where possible.

CONCLUSIONS

The development of the healthy eating agenda within the school setting needs to consider the complexities of adolescent consumption preferences, identities and social networks if they are to be successful.

The American Orthopaedic Association's Own the Bone® database: a national quality improvement project for the treatment of bone health in fragility fracture patients

The American Orthopaedic Association initiated the Own the Bone (OTB) quality improvement program in 2009. Herein we show that the data collected through this program is similar to that collected in other large studies. Thus, the OTB registry functions as an externally valid cohort for studying fragility fracture patients.

INTRODUCTION

The American Orthopedic Association initiated the Own the Bone (OTB) quality improvement program in 2009 to improve secondary prevention of fragility fractures. In this study, we present a summary of the data collected by the OTB program and compare it to data from other large fragility fracture registries with an aim to externally validate the OTB registry.

METHODS

The OTB registry contained 35,038 unique cases of fragility fracture as of September, 2016. We report the demographics, presenting fracture characteristics, past fracture history, and bone mineral density (BMD) data and compare these to data from large fragility fracture studies across the world.

RESULTS

Seventy-three percent of the patients in the OTB registry were female, Caucasian, and post-menopausal. In 54.4% of cases, patients had a hip fracture; spine fractures were the second most common fracture type occurring in 11.1% of patients. Thirty-four percent of the patients had a past history of fragility fracture, and the most common sites were the spine and hip. The average femoral neck T-score was - 2.06. When compared to other studies, the OTB database showed similar findings with regard to patient age, gender, race, BMI, BMD profile, prior fracture history, and family history of fragility fractures.

CONCLUSION

OTB is the first and largest multi-center voluntary fragility fracture registry in the USA. The data collected through the OTB program is comparable to that collected in international studies. Thus, the OTB registry functions as an externally valid cohort for further studies assessing the clinical characteristics, interventions, and outcomes achieved in patients who present with a fragility fracture in the USA.