Five-year efficacy and safety of tildrakizumab in patients with moderate-to-severe psoriasis who respond at week 28: pooled analyses of two randomized phase III clinical trials (reSURFACE 1 and reSURFACE 2)

BACKGROUND

The phase III reSURFACE 1 and reSURFACE 2 (NCT01722331/NCT01729754) trials of the anti-interleukin-23p19 monoclonal antibody tildrakizumab (TIL) for psoriasis treatment are complete.

OBJECTIVES

We present 5-year pooled data from reSURFACE 1 and reSURFACE 2.

METHODS

reSURFACE 1 and reSURFACE 2 were double-blind, randomized, controlled studies with optional long-term extensions. Adults with moderate-to-severe chronic plaque psoriasis were randomized 2 : 2 : 1 to TIL 100 mg (TIL 100) or 200 mg (TIL 200) or placebo at weeks 0 and 4, and every 12 weeks thereafter [reSURFACE 2 included an etanercept (ETN) arm]. Efficacy outcomes included proportions of patients achieving absolute and relative improvement from baseline Psoriasis Area and Severity Index (PASI) score through week 244 in TIL responders (≥ 75% improvement from baseline PASI; PASI 75 response) continuously receiving the same dose and ETN partial responders and nonresponders (PASI < 75 response) switched to TIL 200 at week 28. Safety was assessed from adverse events (AEs) in all patients as treated.

RESULTS

Efficacy analyses included 329 and 227 week 28 responders to TIL 100 and TIL 200, respectively, and 121 ETN partial responders/nonresponders switched to TIL 200 at week 28. Of TIL 100 or TIL 200 responders and ETN partial responders/nonresponders entering the extensions, 235/302, 176/213 and 85/107, respectively, were evaluated at week 244, and 88·7%, 92·5% and 81·3%, respectively, achieved PASI 75 response. Exposure-adjusted rates of serious AEs were 6·3 and 6·0 patients with events per 100 patient-years of TIL 100 and TIL 200, respectively.

CONCLUSIONS

TIL treatment provided sustained disease control over 5 years in week 28 TIL responders and ETN partial responders/nonresponders, with a reassuring safety profile.

Data on vildagliptin and vildagliptin plus metformin combination in type-2 diabetes mellitus management

It is of interest to evaluate the clinical effectiveness and safety of vildagliptin as monotherapy and combination therapy of vildagliptin and metformin for the management of type 2 diabetes mellitus (T2DM) patients in Indian settings. The study included patients with T2DM (aged >18 years) receiving vildagliptin monotherapy and vildagliptin in combination with metformin therapy of various strengths. Data related to demographics, risk factors, medical history, glycated hemoglobin (HbA1c) levels, and medical therapies were retrieved from medical records. Out of 9678 patients (median age, 52.0 years), 59.1% were men. A combination of vildagliptin and metformin (50/500 mg) was the most commonly used therapy (54.8%), and the median duration of therapy was 24.0 months. The predominant reason for selecting vildagliptin therapy was to improve HbA1c levels (87.8%). A total of 87.5% of patients required dosage up-titration. Vildagliptin therapy was used in patients with T2DM and associated complications (peripheral neuropathy, CAD, nephropathy, retinopathy, autonomous neuropathy, stroke/TIA, and peripheral artery disease). Among 5175 patients who experienced body weight changes, a majority of patients showed a loss of weight (68.6%). The target glycemic control was achieved in 95.3% of patients. The mean HbA1c levels were significantly decreased post-treatment (mean change: 1.34%; p<0.001). Adverse events were reported in 0.4% of patients. Physicians rated the majority of patients as good to excellent on the global evaluation of efficacy and tolerability scale (98.9%, each). Vildagliptin as monotherapy and combination therapy of vildagliptin and metformin was an effective therapy in reducing HbA1c helps in achieving target glycemic control, and was well tolerated in Indian patients with T2DM continuum.

Nondermatophyte mould onychomycosis

Nondermatophyte moulds (NDMs) onychomycosis is often difficult to diagnose as NDMs have been considered contaminants of nails. There are several diagnostic methods used to identify NDMs, however, repeated laboratory isolation is recommended to validate pathogenicity. With NDM and mixed infection (dermatophytes plus NDM) onychomycosis on the rise, accurate clinical diagnosis along with mycological tests is recommended. Systemic antifungal agents such as itraconazole and terbinafine (e.g. pulse regimen: 1 pulse = every day for one week, followed by no treatment for three weeks) have shown efficacy in treating onychomycosis caused by various NDMs such as Aspergillus spp., Fusarium spp., Scopulariopsis brevicaulis, and Onychocola canadensis. Studies investigating topical therapy and devices for NDM onychomycosis are limited. The emergence of antifungal resistance necessitates the incorporation of antifungal susceptibility testing into diagnosis when possible, for the management of recalcitrant infections. Case studies documented in the literature show newer azoles such as posaconazole and voriconazole as sometimes effective in treating resistant NDM onychomycosis. Treatment with broad-spectrum antifungal agents (e.g. itraconazole and efinaconazole) and other combination therapy (oral + oral and/or oral + topical) may be considerations in the management of NDM onychomycosis.

Validity and effectiveness of augmented reality in surgical education: A systematic review

BACKGROUND

Current challenges in surgical training have led to the investigation of augmented reality as a potential method of supplementary education. However, its value for this purpose remains uncertain. The aim of this study was to perform a systematic review of the published literature to evaluate the validity and effectiveness of augmented reality in surgical education, and to compare it with other simulation modalities.

METHODS

Electronic literature searches were performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Two authors independently extracted pertinent data and assessed study quality. The primary outcome measures of interest were the validity and effectiveness of augmented reality as an educational tool.

RESULTS

Of 6,500 articles, 24 studies met eligibility criteria for inclusion, of which 2 were randomized. Ten studies investigated validity, with 7 establishing both face and content validity and an additional 1 just content validity. Construct validity was demonstrated in 9 of 11 studies. Of the 11 studies that examined the effectiveness of augmented reality in skills acquisition, 9 demonstrated enhanced learning. Of the 5 studies in which the effectiveness of augmented reality as an educational tool was compared with other modes of simulation, augmented reality was found to be superior in 2 and equivalent in the others.

CONCLUSION

Overall, the majority, including 2 high-quality randomized controlled trials, demonstrated the validity and effectiveness of augmented reality in surgical education. However, the quality of published studies was poor with marked heterogeneity. Although these results are encouraging, additional high-quality studies, preferably in the real-life environment, are required before the widespread implementation of augmented reality within surgical curricula can be recommended.

Prosthetic Satisfaction and Body Image among Lower Limb Amputee: A Cross-sectional Study

Introduction: Limb amputation not only brings functional and sensory loss, but also leads to loss or change of body image. These changes have significant effect on the Quality of Life (QoL) of an individual. Amputee adaptation varies widely between individuals. For an amputee a prosthesis not only bring back near normal physical appearance but also it significantly repair his disturbed body image. There is a significant correlation between body image and life satisfaction. Aim: To investigate the correlation between body image and prosthetic satisfaction among lower limb amputee. Materials and Methods: This cross-sectional study was conducted from July 2018 to January 2020 at King George’s Medical University, Lucknow, Uttar Pradesh, India. Participants with unilateral lower limb prosthesis using amputees of either sex from Regional Artificial Limb Centre, Lucknow were included in the study. Each participant was subjected offline questionnaire based assessment of satisfaction with respect to their prosthesis related to it`s function, aesthetic (cosmesis), weight of prosthesis and general (overall) by Revised Trinity Amputation and Prosthesis Experience Scale (R-TAPES). Change in body image was assessed by Amputee Body Image Scale (ABIS). Results were analysed by computer-based software Statistical Package for the Social Sciences (SPSS) windows version 20.0. Analysis of Variance (ANOVA) t-test was used for normally distributed and Mann-Whitney U test was used for abnormally distributed variables. Results: The study enrolled 119 patients in which the most common cause of amputation was an accident (69). Statistically significant difference was found for satisfaction between males and females for weight of prosthesis (p-value=0.038). Statistically significant difference was found between male and female for amputee body image with ABIS score (p-value=0.001). Significant correlation was found between ABIS and functional satisfaction (p-value=0.001; r=-0.38)) and between ABIS and weight satisfaction (p-value=0.001; r=-0.36). Conclusion: Amputation causes significantly deterioration of body image among the amputee, with such deteriorated body image prosthetic satisfaction remains a big challenge for healthcare worker and prosthetist.

Physical Frailty Phenotype and Depression are Associated with More Severe Disease in Older Subjects Presenting with Acute Coronary Syndrome

Objective

The primary objective was to determine the occurrence of frailty in elderly patients presenting with the acute coronary syndrome (ACS). The secondary objective was to study the association between the deficits in health with the severity of ACS at presentation among them.

Methods

A cross-sectional study conducted in the Departments of Medicine, Community Medicine and Biochemistry in a tertiary care teaching hospital, Delhi, India between November 2014 and April 2016. Patients (≥60 years age) presenting with any one of the spectra of ACS (STEMI, UA, NSTEMI) and giving informed written consent were assessed for frailty and health deficits using questionnaires. ACS assessed by ECG within 24 h and other relevant investigations. Appropriate statistical tests of significance like the Chi-square test were used and correlation coefficients were analyzed. A value of P < 0.05 was considered significant.

Results

Seven risk factors apart from old age were studied, in which smoking and dyslipidemia played a major role. 44% of the subjects were frail with the range of frailty scores between 3 and 5. Every one-unit increase in hemoglobin was associated with a reduction in the odds (OR 0.72) for being frail. No association was noted between the severity of ACS and established risk factors like smoking, hypertension, diabetes, family history of CAD, increased waist circumference, dyslipidemia, and male gender. On multivariable linear regression, presence of frailty and depression were associated with severe disease.

Conclusions

Nearly one in two patients presenting with ACS were found frail. Depression and frailty were associated with poorer ejection fraction and severe disease. Correction of anemia and improvement of low-normal hemoglobin levels could reduce frailty and in-turn improve outcomes in ACS.

Variation in training requirements within general surgery: comparison of 23 countries

Background

Many differences exist in postgraduate surgical training programmes worldwide. The aim of this study was to provide an overview of the training requirements in general surgery across 23 different countries.

Methods

A collaborator affiliated with each country collected data from the country's official training body website, where possible. The information collected included: management, teaching, academic and operative competencies, mandatory courses, years of postgraduate training (inclusive of intern years), working‐hours regulations, selection process into training and formal examination.

Results

Countries included were Australia, Belgium, Canada, Colombia, Denmark, Germany, Greece, Guatemala, India, Ireland, Italy, Kuwait, the Netherlands, New Zealand, Russia, Saudi Arabia, South Africa, South Korea, Sweden, Switzerland, UK, USA and Zambia. Frameworks for defining the outcomes of surgical training have been defined nationally in some countries, with some similarities to those in the UK and Ireland. However, some training programmes remain heterogeneous with regional variation, including those in many European countries. Some countries outline minimum operative case requirement (range 60–1600), mandatory courses, or operative, academic or management competencies. The length of postgraduate training ranges from 4 to 10 years. The maximum hours worked per week ranges from 38 to 88 h, but with no limit in some countries.

Conclusion

Countries have specific and often differing requirements of their medical profession. Equivalence in training is granted on political agreements, not healthcare need or competencies acquired during training.

Magnesium Aluminate Nanoparticles for Chemical Detoxification of Sarin and Soman

The solutions of Mg(NO₃)₂, Al(NO₃)₃, and (NH₄)₂CO₃ were mixed at pH 8 and then heated at 95 °C for 4 h, aged at room temperature for 16 h, and calcined at 650 °C for 4 h to obtain magnesium aluminate nanoparticles. The obtained materials exhibited spinel structure with the particle size being 6 to 26 nm. The nanoparticles demonstrated type IV nitrogen adsorption isotherm, typical of mesoporosity with a surface area of 325 m²/g. They were utilized for studies on chemical detoxification of deadly chemical warfare agents such as sarin and soman. Our results showed that the magnesium aluminate nanoparticles effectively decontaminated more than 99% of sarin and soman within 8-10 min when used at a ratio of 1:50-60% w/w.

Pulmonary protective efficacy of S-2[2-aminoethylamino] ethyl phenyl sulphide (DRDE-07) and its analogues against sulfur mustard induced toxicity in mice

Our previous study showed that percutaneous sulfur mustard (SM) exposure induced pulmonary toxicity, which was attenuated by DRDE-07 (S-2[2-aminoethylamino] ethyl phenyl sulphide) pretreatment. The present study aimed to evaluate the protective efficacy of DRDE-07 and its analogues viz., DRDE-30 (S-2(2-aminoethyl amino)ethyl propyl sulphide) and DRDE-35 (S-2(2-aminoethyl amino)ethyl butyl sulphide) against SM. Thirty minutes before percutaneous SM (0.8 LD₅₀) exposure, female Swiss mice were orally gavaged with DRDE-07 and its analogues(0.2 LD₅₀). Animals were sacrificed on day 3 and 7, BAL fluid (BALF) and lung tissue were collected for biochemical, histopathological studies. As results, DRDE-07 and its analogues were beneficial in reducing the number of BALF inflammatory cells, protein level, lactate dehydrogenase (LDH) activity, myeloperoxidase (MPO) and β-glucuronidase activity, while content of BALF and lung reduced glutathione level (GSH) were significantly protected. The pretreatment of DRDE-07 and its analogues inhibited the recruitment of inflammatory cells into the lung. The beneficial effects of DRDE-07 and its analogues were attributed to their antioxidant and anti-inflammatory activity. Among the analogues, DRDE-30 exhibited significant beneficial effects as compared to the other two compounds. These analogues may be considered as prototype candidate molecules as there is no effective antidote for SM toxicity.

Rooting behaviour and soil properties in different bamboo species of Western Himalayan Foothills, India

Due to extensive root system, connected rhizome bamboos are considered suitable for improving soil properties within a short period, though most of the claims are anecdotal and need to be supported with quantified data. The study evaluates seven bamboo species viz., Bambusa balcooa, Bambusa bambos, Bambusa vulgaris, Bambusa nutans, Dendrocalamus hamiltonii, Dendrocalamus stocksii and Dendrocalamus strictus for their rooting pattern and impact on soil health properties. Coarse and fine root intensity was maximum in B. vulgaris. Coarse root biomass ranged from 0.6 kg m⁻³ in B. nutans to 2.0 kg m⁻³ in B. vulgaris and B. bambos. Fine root biomass ranged from 1.1 kg m⁻³ in B. nutans to 4.5 kg m⁻³ in D. hamiltonii. Contribution of fine roots in terms of intensity and biomass was much higher than coarse roots. Fine root biomass showed declining trend with increase in soil depth in all the species. During sixth year, the litter fall ranged from 8.1 Mg ha⁻¹ in D. stocksii to 12.4 Mg ha⁻¹ in D. hamiltonii. Among soil physical properties significant improvement were recorded in hydraulic conductivity, water stable aggregates and mean weight diameter. Soil pH, organic carbon and available phosphorus under different species did not reveal any significant changes, while significant reduction was observed in total nitrogen and potassium. Significant positive correlation was observed between WSA and iron content. Soil microbial population and enzyme activities were higher in control plot. Considering root distribution, biomass, soil hydraulic conductivity and water stable aggregates, B. bambos, B. vulgaris and D. hamiltonii are recommended for rehabilitation of degraded lands prone to soil erosion.

Gingival health status in individuals using different types of toothpaste

OBJECTIVES

To examine the relationship between the medium term use (>1 year) of a toothpaste containing natural enzymes and proteins (Zendium™) upon gingival index, plaque index and bleeding index compared to medium term use of toothpastes without antimicrobial/antiinflammatory ingredients.

METHODS

A total of 305 participants eligible for inclusion were grouped according to their toothpaste use and matched with regard to gender and age (18-30, 31-55 and 56+ years of age). A total of 161 persons were using a toothpaste which contained enzymes and proteins (Zendium™, test group), and 144 persons were using a toothpaste without these ingredients (control group). The amount of dental plaque and the gingival condition were assessed at six sites of each tooth using the modified gingival index (MGI), plaque index (Modified Quigley and Hein plaque index, PI), and bleeding index (BI). Mean values of MGI, PI and BI were compared using analysis of covariance.

RESULTS

The test group had significantly less gingival inflammation than the control group (adjusted mean scores (SD); 1.80 (0.65) vs. 2.27 (0.63),p < 0.0001), as well as lower levels of plaque (2.03 (0.33) vs. 2.12 (0.33), p = 0.0168) and gingival bleeding (0.74 (0.45) vs. 1.08 (0.45), p < 0.0001). Females had significantly less gingival inflammation (p < 0.0001), plaque (p = 0.0005) and bleeding (p = 0.0118) than males. Participants aged 18-30 years had significantly higher levels of inflammation and bleeding than the older age groups (p < 0.001), and also higher plaque levels compared to participants aged 31-55 years (p = 0.0069). Potential confounding factors including oral hygiene practices and consistency of dental visits did not differ between groups.

CONCLUSIONS

Our findings indicate that medium term use of fluoride toothpaste containing enzymes and proteins (Zendium™) is associated with a better gingival health than the use of other types of fluoride toothpastes without antimicrobial active ingredients.

CLINICAL SIGNIFICANCE

Medium term (> 1 year) use of toothpaste containing naturally occurring enzymes and proteins (Zendium™) in an unsupervised home setting is associated with better gingival health compared to the unsupervised use of other commercially available toothpastes without antimicrobial/antiinflammatory active ingredients.

Potentially avoidable issues in urology mortality cases in Australia: identification and improvements

BACKGROUND

This study aimed to identify the most common potentially avoidable factors in urology deaths, focusing on the lessons that can be learnt.

METHODS

This study analysed data from a well-established and comprehensive peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2015, focusing on urology cases with identified areas for improvement in patient management. Of all audited deaths, 11% (79/719) had serious clinical management issues with a total of 109 individual clinical management issues identified. These were categorized based on perioperative stage (preoperative, intraoperative or post-operative), followed by thematic analysis within each stage.

RESULTS

The study found preoperative issues to be the most common (n = 48), followed by post-operative issues (n = 32) with intraoperative issues less common (n = 13). Communication issues were seen at all three stages (n = 16). Overall, the most common theme was at the preoperative stage; inadequate preoperative assessment (n = 27). More specifically, the most common preoperative assessment issues involved a failure to order necessary preoperative investigations, or to administer necessary preoperative treatment (e.g. prophylactic antibiotics). The most common communication issue was between teams and at handover, often involving failure by junior medical staff to communicate issues to the responsible surgical consultant.

CONCLUSION

Urological surgical cases with potentially avoidable mortality constitute a small, but important subset of deaths. The analysis of these cases can inform various stakeholders to improve the quality and safety of urological surgical care.

Reduced risk of suicidal behaviours associated with the treatment of hidradenitis suppurativa with tumour necrosis factor alpha antagonists: results from the US FDA Adverse Events Reporting System pharmacovigilance database

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, recurrent condition that presents as painful, suppurating lesions in the apocrine gland-bearing skin regions. HS has been associated with increased suicidal behaviours (SB), independent of any treatment. TNF-alpha antagonists are used to treat moderate-to-severe HS and have also been associated with SB, a factor that could confound the decision to use the TNF-α antagonists in the moderately to severely affected HS patients, who may already be experiencing increased SB risk.

OBJECTIVES

To determine presence or absence of a safety signal for SB when HS is treated with TNF-α antagonists.

METHODS

We calculated the reporting odds ratios (ROR) with 95% CI of SB associated with treatment for HS with TNF-α antagonists vs. the reference group of all other treatments for HS in the US Food and Drug Administration pharmacovigilance database from 1 January 2004 to 31 March 2019. A second analysis excluded isotretinoin (which has been used to treat HS and has also been associated with SB) from the reference group.

RESULTS

There was a signal for decreased risk of SB with TNF-α antagonists (ROR = 0.1959, 95% CI 0.1247-0.3079; z = 7.071, P < 0.0001] vs. all other HS treatments; the ROR did not change significantly after isotretinoin was excluded from the reference group.

CONCLUSIONS

Treatment of HS with TNF-α antagonists is associated with a decreased risk of SB.

The efficacy and safety of pulse vs. continuous therapy for dermatophyte toenail onychomycosis

BACKGROUND

Onychomycosis is a chronic, fungal infection of the nails. Complete cure remains challenging, but oral antifungal medications have been successful in managing the fungus for a significant proportion of patients. Treatment with these drugs can be continuous or intermittent, albeit the evidence on their relative efficacies remains unclear.

OBJECTIVE

To determine the relative effectiveness and safety of pulse versus continuous administration, of three common oral therapies for dermatophyte onychomycosis, by conducting multiple-treatment meta-analysis.

METHODS

This systematic review and network meta-analysis compared the efficacy (as per mycological cure) and adverse event rates of three oral antifungal medications in the treatment of dermatophyte toenail onychomycosis, namely terbinafine, itraconazole and fluconazole. A total of 30 studies were included in the systematic review, while 22 were included in the network meta-analysis.

RESULTS

The likelihood of mycological cure was not significantly different between continuous and pulse regimens for each of terbinafine and itraconazole. Use of continuous terbinafine for 24 weeks - but not 12 weeks - was significantly more likely to result in mycological cure than continuous itraconazole for 12 weeks or weekly fluconazole for 9-12 months. Rank probabilities demonstrated that 24-week continuous treatment of terbinafine was the most effective. There were no significant differences in the likelihood of adverse events between any continuous and pulse regimens of terbinafine, itraconazole and fluconazole. Drug treatments were similar to placebo in terms of their likelihood of producing adverse events.

CONCLUSION

More knowledge about the fungal life cycle and drugs' pharmacokinetics in nail and plasma could further explain the relative efficacy and safety of the pulse and continuous treatment regimens. Our results indicate that in the treatment of dermatophyte toenail onychomycosis, the continuous and pulse regimens for terbinafine and itraconazole have similar efficacies and rates of adverse events.

Meta-analysis of 308-nm excimer laser therapy for alopecia areata

Background: Alopecia areata (AA) is an autoimmune disease that can result in spontaneous hair loss. Currently, there is no US Food and Drug Administration (FDA) approved treatment, however new treatments are being investigated. Excimer laser and excimer lamp treatment have been suggested and have the benefit of mild/few adverse effects.Methods: A literature search and meta-analysis was performed to investigate the efficacy of the excimer laser and lamp for treatment of AA. Results: No controlled trials were found which utilized the 308-nm excimer lamp. Four controlled trials (N = 105) testing the efficacy of the 308-nm excimer laser were identified. When laser treatment was compared to control measured through the number of responders to treatment, the standardized mean difference was 18.37 (95% CI: 3.28, 102.77) in favor of treatment (p < .0009, I² = 36%). Conclusion: Our results suggest that use of the 308-nm excimer laser can be effective in AA therapy however more studies are required observing both the 308-nm excimer laser and lamp.

2131Pragmatic clinical trials in cardiovascular medicine: trends over time in major medical journals

Background

Pragmatic trials provide results that may be more applicable to the population in which the intervention will be eventually applied and are discussed extensively in the current healthcare environment. The aim of this study was to investigate how pragmatic or explanatory cardiovascular (CV) randomized controlled trials (RCT) are, if this was changing over time, and if they were more or less likely to meet their primary endpoint.

Methods

Using the six top-ranked (based on impact factors) medical and CV journals, all CV-related RCTs that were published during the years of 2000, 2005, 2010 and 2015 were identified, data extracted and reviewed by 2 adjudicators. The PRECIS-2 tool was used to evaluate the level of pragmatism. PRECIS-2 uses a 5-point ordinal scale (ranging from very pragmatic to very explanatory) across 9 domains of trial design, including eligibility, recruitment, setting, organization, intervention delivery, intervention adherence, follow-up, primary outcome, and analysis. A higher score indicates a more pragmatic score on an individual domain, and aggregated scores are a simplified formula across all domains. Cohen's D was used to quantify the mean difference relative to the variation.

Results

There were 616 RCTs, distributed evenly over the 2 decades, and 64% achieved their primary endpoint. The mean (±SD) PRECIS-2 score was 3.26±0.70 among 616 included RCTs. The level of pragmatism increased over time from a score of 3.07±0.74 in 2000 to 3.47±0.67 in 2015 (p<0.0001 for trend; Cohen's D relative effect size 0.57). The increase in pragmatism occurred mainly in the domains of eligibility, setting, intervention delivery, and primary endpoint (Figure). PRECIS-2 score was higher for neutral trials than those with positive results (p=0.0015) and in phase III/IV trials as compared to phase I/II trials (p<0.0001) (Figure). Furthermore, trials that involve more sites, with larger sample sizes, longer follow-ups, and those with mortality as the primary endpoint were found to be more pragmatic. There was no difference in the level of pragmatism between different sources of funding (public, industry, or both; p=0.52).

Study characteristics and pragmatism

Conclusion

The PRECIS-2 tool can be used for appraising trials to assess their placement in the pragmatic-explanatory continuum. The level of pragmatism increased over time in CV trials. Greater focus on the design and delivery of CV trials will be required for the broad application.

Acknowledgement/Funding

Dr. Sepehrvand receives scholarship from Alberta Innovates Health Solutions.

"Nobody told me": Communication Issues Affecting Australian Cardiothoracic Surgery Patients

BACKGROUND

Failure of communication can have potentially severe results in cardiothoracic surgery. Previous literature regarding patient safety highlighted communication as a common area for improvement. This study utilized a qualitative approach to analyze a national mortality audit data set to identify and describe communication issues that could potentially contribute to patient mortality following cardiothoracic surgery.

METHODS

We utilized a peer-reviewed audit of surgical deaths after cardiothoracic surgery in Australian hospitals from 2009 to 2015 via the Australian and New Zealand Audit of Surgical Mortality. Cases were identified with clinical management issues then individual analysis of cases highlighting communication issues was undertaken. A total of 91 reports from surgeons and assessors were analysed using a thematic analytic approach.

RESULTS

A total of 908 cases of potentially avoidable mortality were identified as being associated with clinical management issues, and communication issues were identified in 91 (10%) of these cases, which served as the basis for this analysis. The study found that failure to achieve shared decision making was the most common theme (n = 38, 41.8%), followed by failure to notify patient deterioration (n = 22, 24.1%), misreporting of patient condition (n = 10, 11.0%) and issues related to informed consent (n = 9, 10.0%). The most frequent communication issues occurred between surgeons and the intensive care unit.

CONCLUSIONS

Poor communication was identified in patients who died after cardiothoracic surgery. Communication is an important modifiable factor in patient mortality. Efforts to address teamwork and communication have the potential to improve safety and quality of care for patients undergoing cardiothoracic surgery.

Technical factors affecting cardiac surgical mortality in Australia

Aim

Examination of potentially avoidable issues in surgical deaths can provide a basis for quality improvement. Perioperative technical factors in cardiac surgery may lead or contribute to patient mortality. Using data from a well-established and comprehensive national surgical mortality audit, we aimed to identify and describe clinical management issues leading to mortality in Australian cardiac surgical patients.

Methods

Retrospective analysis of a cardiac surgical dataset from the Australian and New Zealand Audit of Surgical Mortality (February 2009 to December 2015) was undertaken. Clinical management issues related to technical factors were analyzed using a thematic analysis approach. Technical clinical management issues were categorized based on the most common themes, followed by qualitative analysis of each theme.

Results

We identified 256 patients with least one technical management issues (total 270). Injury to structures was the most common theme ( n = 115, 44.9%), followed by unaddressed surgical pathology ( n = 39, 15.2%) and inadequate myocardial protection ( n = 34, 13.2%). More specifically, the most common structural injury involved the right ventricle, with the aorta and femoral vessels also commonly injured. The most common unaddressed surgical pathology was incomplete coronary revascularization, followed by systolic anterior motion of the mitral valve during mitral repair. Graft failure occurred during coronary artery bypass graft surgery, with a poor target vessel being a common issue.

Conclusion

Technical factors in cardiac surgery resulting in potentially avoidable mortality constitute an important subset of deaths. These findings can inform various stakeholders to improve the quality and safety of surgical care.

Finasteride for androgenetic alopecia is not associated with sexual dysfunction: a survey-based, single-centre, controlled study

BACKGROUND

The occurrence of sexual dysfunction side-effects associated with finasteride use in men with androgenetic alopecia (AGA) is thought to be less prevalent than is publicized. There is a need to investigate sexual dysfunction among finasteride users with population-based controls.

OBJECTIVE

To evaluate the presence of sexual dysfunction in men using finasteride or not using finasteride.

METHOD

Adult men visiting a dermatologist's office for any reason were asked to complete a survey including a modified version of the Arizona Sexual Experience Scale (ASEX) to assess the presence of sexual dysfunction with and without finasteride use.

RESULTS

Data from 762 men aged 18-82 were collected: 663 finasteride users and 99 non-finasteride users. There were no significant differences between finasteride users and non-user controls in reporting sexual dysfunction using the ASEX. Regression analysis indicated that self-reporting libido loss and reduced sexual performance, not finasteride use, predict a higher ASEX score.

CONCLUSION

The use of finasteride does not result in sexual dysfunction in men with AGA. These data are consistent with other large survey-based controlled studies.

Multifocal Electroretinography in Diabetic Retinopathy With and Without Macular Edema

BACKGROUND AND OBJECTIVES

To characterize the electroretinographic response of the macula by multifocal electroretinography (mfERG) in nonproliferative diabetic retinopathy (NPDR) with and without diabetic macular edema (DME) and correlate it with best-corrected visual acuity (BCVA) and foveal thickness on spectral-domain optical coherence tomography (SD-OCT).

PATIENTS AND METHODS

Prospective, observational case series. Forty eyes of 22 patients with treatment-naïve NPDR underwent recording of BCVA, fundus fluorescein angiography (FFA), and SD-OCT. Groups A and B were classified as 20 eyes each having NPDR with DME (central foveal thickness [CFT] ≥ 275 μm) and without DME (CFT < 275 μm), respectively. First-order kernel mfERG responses recorded according to ISCEV guidelines were grouped into five concentric rings centered on the fovea for analysis.

RESULTS

Mean P1 and N1 amplitudes (nv/deg²) were significantly decreased compared to normal values in each of the five rings in both groups (P < .01); however, the values between the two groups were comparable. BCVA was significantly and positively correlated with P1 (r = 0.454, P = .003) and N1 amplitude (r = 0.468, P = .002) and significantly and negatively correlated with P1 (r= -0.534, P < .01) and N1 implicit times (r= -0.570, P < .01) in all patients. P1 (r= -0.531, P < .01) and N1 amplitude (r= -0.367, P = .02) in the central ring of mfERG had a significant negative correlation with macular thickness in the corresponding foveal ring of SD-OCT in all patients.

CONCLUSIONS

mfERG reflects retinal dysfunction irrespective of the occurrence of DME in patients with NPDR. Correlation with BCVA reinforces that mfERG should be used to objectively assess the macular function in these patients. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:780-786.].