Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Herbicide residues in soil decrease microbe-mediated plant protection

The residues of glyphosate are found to remain in soils longer than previously reported, affecting rhizosphere microbes. This may adversely affect crop and other non-target plants because the plant's resilience and resistance largely rely on plant-associated microbes. Ubiquitous glyphosate residues in soil and how they impact mutualistic microbes inhabiting the aboveground plant parts are largely unexplored. We studied the effects of herbicide residues in soil on Epichloë sp., which are common endophytic symbionts inhabiting aerial parts of cool-season grasses. In this symbiosis, the obligate symbiont subsists entirely on its host plant, and in exchange, it provides alkaloids conferring resistance to herbivores for the host grass that invests little in its own chemical defence. We first show decreased growth of Epichloë endophytes in vitro when directly exposed to two concentrations of glyphosate or glyphosate-based herbicides. Second, we provide evidence for a reduction of Epichloë-derived, insect-toxic loline alkaloids in endophyte-symbiotic meadow fescue (F. pratensis) plants growing in soil with a glyphosate history. Plants were grown for 2 years in an open field site, and natural herbivore infestation was correlated with the glyphosate-mediated reduction of loline alkaloid concentrations. Our findings indicate that herbicides residing in soil not only affect rhizosphere microbiota but also aerial plant endophyte functionality, which emphasizes the destructive effects of glyphosate on plant symbiotic microbes, here with cascading effects on plant-pest insect interactions.

Combined interdisciplinary treatment of metastatic bone lesions – embolization, biopsy, ablation, and surgery in one operative sitting

Objective

As a result of modern cancer treatment and thereby improved survival, many cancers spread to bone. Bone metastases may cause immobilizing pain and increase the risk of fracture even by inadequate or no trauma. Treatment of these patients should promptly address confirmation of the tumor entity, local control as well as adequate and lasting surgical stabilisation of the affected bone or joint. We present a setup to perform all the above in a single operative sitting.

Methods

Required imaging is completed before initial consultation. The treatment plan is discussed in an interdisciplinary team according to the primary tumor and thereof resulting survival estimation, the imaging evaluation and patient's expectations and needs.

In a single operative setup, the patients are treated by an interventional radiologist and an orthopaedic surgeon in a hybrid operating room. Thus, in one single setup the patient may undergo arteriogram to diagnose hypervascularity of the tumor followed by embolization if needed, CT-guided biopsy, percutaneous radiofrequency or cryotherapy ablation of the metastases for local tumor control and eventually surgical treatment with resection of the tumor, joint replacement or minimally-invasive stabilization as needed. Biopsy results may be discussed at inhouse tumor boards and adjuvant radio- or chemotherapy may be planned for the postoperative course.

Results

Five combined procedures were performed in 5 patients (3 female, 2 male patients; median age 65 years (range 61–77)) each in one single operative sitting since October 2021. Three patients suffered from metastases of renal cell carcinoma, one each from thyroid carcinoma and breast cancer respectively. Metastases were located in the femoral meta- and diaphysis in 3 cases and in the acetabulum in 2 cases. Median duration of this multidisciplinary intervention was 375 min (251–426). Median length of hospital stay was 5 days (3–10). Median time from referral to definitive treatment was 24 days (17–32). All patients were able to walk with crutches immediately after treatment. No complications occurred.

Conclusion

Combined multidisciplinary treatment of patients with metastatic bone disease is possible and may be favourable in respect of minimising the number of consultations, anaesthesias and interventions. This should lead to accelerated and pain-free mobilisation, thus maximising the patients’ quality of life.

Time to treatment initiation: An analysis of sarcoma patients treated at Multidisciplinary-Team/Sarcoma-Board (MDT/SB's) over a four-year period

Objective

It is hypothesized that in the treatment of patients with soft tissue sarcomas (STS) the interval from establishing the diagnosis until initiation of treatment is relevant for the overall survival. Therefore, time to treatment initiation (TTI) was defined as a quality indicator for monitoring the treatment standard. The primary objective of this study was to find out how long (in days) it takes from establishing the sarcoma diagnosis through biopsy until initiation of treatment in patients suffering from STS. Secondary objectives were defined as the comparison between the different dignities, the different institutions and how the Swiss Sarcoma Network (SSN) cohort compares to the international standard.

Methods

This is a retrospective analysis of prospectively collected data from the SSN. All patients being presented to the MDT/SB within a four-year period from 2018 to 2022 were included in this study. TTI and secondary objectives were determined using non-parametric summary statistics and presented as median and interquartile range. Ethic approval was granted for this study.

Results

In total 383 patients were recorded in the respective time period in the SSN. In this study 278 patients with a malignant or intermediate STS according to WHO2020 were included. There were 66% (n=185) with a malignant and 44% (n=93) with an intermediate STS. The median TTI was 23 (8-52) days. In the malignant group, the median TTI was 21 (5-43) days and in the intermediate group 32 (11-59) days. In the different institutions the median TTI's were 10 (-6-30), 28 (12-78), 24 (10-58), 24 (10-53) and 12 (-12-54) days.

Conclusion

In the SSN cohort the overall median TTI was 23 days. In the literature, a TTI delay of more than 42 days led to a slightly reduced overall survival. Compared to the international standard, we conclude that within the SSN network, patients face an adequate waiting time until treatment initiation with no potential restrictions to overall survival.

Stopping Hospital Infections With Environmental Services (SHINE): A Cluster-randomized Trial of Intensive Monitoring Methods for Terminal Room Cleaning on Rates of Multidrug-resistant Organisms in the Intensive Care Unit

BACKGROUND

Multidrug-resistant organisms (MDROs) frequently contaminate hospital environments. We performed a multicenter, cluster-randomized, crossover trial of 2 methods for monitoring of terminal cleaning effectiveness.

METHODS

Six intensive care units (ICUs) at 3 medical centers received both interventions sequentially, in randomized order. Ten surfaces were surveyed each in 5 rooms weekly, after terminal cleaning, with adenosine triphosphate (ATP) monitoring or an ultraviolet fluorescent marker (UV/F). Results were delivered to environmental services staff in real time with failing surfaces recleaned. We measured monthly rates of MDRO infection or colonization, including methicillin-resistant Staphylococcus aureus, Clostridioides difficile, vancomycin-resistant Enterococcus, and MDR gram-negative bacilli (MDR-GNB) during a 12-month baseline period and sequential 6-month intervention periods, separated by a 2-month washout. Primary analysis compared only the randomized intervention periods, whereas secondary analysis included the baseline.

RESULTS

The ATP method was associated with a reduction in incidence rate of MDRO infection or colonization compared with the UV/F period (incidence rate ratio [IRR] 0.876; 95% confidence interval [CI], 0.807-0.951; P = .002). Including the baseline period, the ATP method was associated with reduced infection with MDROs (IRR 0.924; 95% CI, 0.855-0.998; P = .04), and MDR-GNB infection or colonization (IRR 0.856; 95% CI, 0.825-0.887; P < .001). The UV/F intervention was not associated with a statistically significant impact on these outcomes. Room turnaround time increased by a median of 1 minute with the ATP intervention and 4.5 minutes with UV/F compared with baseline.

CONCLUSIONS

Intensive monitoring of ICU terminal room cleaning with an ATP modality is associated with a reduction of MDRO infection and colonization.

Predictors of Cisatracurium Continuous Infusion Dose in Acute Respiratory Distress Syndrome

Neuromuscular blockade (NMB) with cisatracurium may improve outcomes in the acute respiratory distress syndrome (ARDS) population; however, optimal dosing strategy remains unknown. Factors affecting pharmacokinetics and pharmacodynamics of cisatracurium may impact the dose required to achieve adequate train-of-four (TOF) response. The aims of this study were to determine cisatracurium dose requirements in a critically ill ARDS population and to identify clinical factors that affect dosing. This was a single-center, retrospective cohort study of medical intensive care patients who received cisatracurium infusion for treatment of ARDS. "Stable dose" was defined as the infusion rate producing 2 consecutive TOFs of 1/4 to 2/4. Factors examined for association with dose were temperature, pH, age, and the presence of acute kidney injury (AKI). The analysis included 39 patients. The median stable dose of cisatracurium was 2.8 (2.0, 3.1) μg/kg/min. Multivariable linear regression model for weight-normalized dose identified AKI as a factor independently associated with steady-state dose requirements (% change -31.4, 95% confidence interval [CI]: -51.9, -2.3). Our study provides information on cisatracurium doses required in patients with ARDS to reduce time required to reach goal TOF. Further studies are needed to determine effect of AKI on cisatracurium dose requirements and clinical outcomes.

A global cline in a colour polymorphism suggests a limited contribution of gene flow towards the recovery of a heavily exploited marine mammal

Evaluating how populations are connected by migration is important for understanding species resilience because gene flow can facilitate recovery from demographic declines. We therefore investigated the extent to which migration may have contributed to the global recovery of the Antarctic fur seal (Arctocephalus gazella), a circumpolar distributed marine mammal that was brought to the brink of extinction by the sealing industry in the eighteenth and nineteenth centuries. It is widely believed that animals emigrating from South Georgia, where a relict population escaped sealing, contributed to the re-establishment of formerly occupied breeding colonies across the geographical range of the species. To investigate this, we interrogated a genetic polymorphism (S291F) in the melanocortin 1 receptor gene, which is responsible for a cream-coloured phenotype that is relatively abundant at South Georgia and which appears to have recently spread to localities as far afield as Marion Island in the sub-Antarctic Indian Ocean. By sequencing a short region of this gene in 1492 pups from eight breeding colonies, we showed that S291F frequency rapidly declines with increasing geographical distance from South Georgia, consistent with locally restricted gene flow from South Georgia mainly to the South Shetland Islands and Bouvetøya. The S291F allele was not detected farther afield, suggesting that although emigrants from South Georgia may have been locally important, they are unlikely to have played a major role in the recovery of geographically more distant populations.

Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score

Pulmonary embolism (PE) is a major cause of morbidity and mortality world-wide, and the use of thrombolytic therapy has been associated with favourable clinical outcomes in certain patient subsets. These potential benefits are counterbalanced by the risk of bleeding complications, the most devastating of which is intracranial haemorrhage (ICH). We retrospectively evaluated 9703 patients from the 2003–2012 nationwide in-patient sample database (NIS) who received thrombolytics for PE. All patients with ICH during the PE hospitalisation were identified and a clinical risk score model was developed utilizing demographics and comorbidities. The dataset was divided 1:1 into derivation and validation cohorts. During 2003–2012, 176/9705 (1.8 %) patients with PE experienced ICH after thrombolytic use. Four independent prognostic factors were identified in a backward logistic regression model, and each was assigned a number of points proportional to its regression coefficient: pre-existing Peripheral vascular disease (1 point), age greater than 65 years (Elderly) (1 point), prior Cerebrovascular accident with residual deficit (5 points), and prior myocardial infarction (Heart attack) (1 point). In the derivation cohort, scores of 0, 1, 2 and ≥ 5 points were associated with ICH risks of 1.2 %, 1.9 %, 2.4 % and 17.8 %, respectively. Rates of ICH were similar in the validation cohort. The C-statistic for the risk score was 0.65 (0.61–0.70) in the derivation cohort and 0.66 (0.60–0.72) in the validation cohort. A novel risk score, derived from simple clinical historical elements was developed to predict ICH in PE patients treated with thrombolytics.

Supplementary Material to this article is available online at www.thrombosis-online.com.

Interaction of plasmenylcholine with free radicals in selected model systems

Plasmalogens (Plg) - naturally occurring glycerophospholipids with the vinyl-ether group in the sn-1 position are generally viewed as physiological antioxidants. Although there are numerous examples of antioxidant action of plasmalogen in cell cultures and in experimental animals, this hypothesis is far from being satisfactorily proven due to substantial limitations of such studies. Thus, plasmalogen reactivity in cells results in the accumulation of toxic byproducts and the experimental design is usually too complicated to evaluate the protective function of solely one type of lipid molecular species. In this study, experiments were performed in homogenous and heterogeneous model systems consisting of solutions in organic solvents as well as micelles and liposomes containing pure synthetic plasmenylcholines. Under the experimental conditions used, chemical reactivity of plasmalogens could be attributed to specific fatty acid esterification pattern. This is important because the chemical reactivity cannot be separated from physico-chemical properties of the lipids. Time-dependent formation of phospholipid and cholesterol hydroperoxides were determined by iodometric assay and HPLC-EC. EPR oximetry and Clark electrode were employed to detect the accompanying changes in oxygen concentration. Oxidation of the studied lipids was monitored by standard colorimetric TBARS method as well as MALDI-TOF mass spectrometry. Our data indicate that the reactivity of sn-2 monounsaturated vinyl ether lipids in peroxyl radical-induced or iron-catalyzed peroxidation reactions is comparable with that of their diacyl analogs. In samples containing cholesterol and plasmalogens, oxidative processes lead to accumulation of the radical oxidation product of cholesterol. It can be concluded that the antioxidant action of plasmalogens takes place intramolecularly rather than intermolecularly and depends on the degree of unsaturation of esterified fatty acids. Thus, it is questionable if plasmalogens can really be viewed as "endogenous antioxidant", even though they may exhibit, under special conditions, protective effect.

The interleukin-33 receptor ST2 is important for the development of peripheral airway hyperresponsiveness and inflammation in a house dust mite mouse model of asthma

BACKGROUND

Several clinical and experimental studies have implicated IL-33 and its receptor ST2 in the development of asthma. However, the effect of IL-33/ST2 signalling on airway responses and inflammation in allergic asthma is not well established.

OBJECTIVE

To investigate the role of IL-33/ST2 signalling in promoting allergen-induced airway hyperresponsiveness (AHR), airway inflammation, antigen-specific IgE production and mast cell activity in a mouse model of asthma.

METHODS

ST2-deficient (ST2(-/-)) mice and control BALB/c mice were given house dust mite (HDM) extract over a 6-week period. Forty-eight hours after the final HDM administration, lung function and airway inflammation were evaluated. Airway responsiveness was determined in the central airways and peripheral lung. Cellular infiltration and mast cell protease mMCP-1 levels were quantified in bronchoalveolar lavage fluid (BALF). Recruitment of inflammatory cells and inflammatory cytokine profiles were assessed in pulmonary tissue, and HDM-specific IgE was measured in serum.

RESULTS

ST2 deficiency diminished HDM-induced AHR in the peripheral lung, while AHR in the central airways was unaffected. Inflammatory responses to HDM were also reduced in ST2(-/-) mice as reflected by the lower induction of HDM-specific serum IgE, inhibition of HDM-induced eosinophilia and reduced macrophage count in BALF, and a diminished influx of inflammatory cells and reduced goblet cell hyperplasia around the peripheral airways. Furthermore, the levels of the inflammatory cytokines IL-1β, IL-5, IL-13, IL-33, GM-CSF, thymic stromal lymphopoietin and mast cell protease mMCP-1 were reduced in HDM-treated ST2(-/-) mice compared with wild-type controls.

CONCLUSIONS

In addition to promoting Th2 inflammation, we now suggest a role for the IL-33/ST2 pathway for the induction of peripheral inflammation and mucus production that causes AHR in the peripheral lung. This mechanism for inducing AHR at distal parts of the lung may be of specific importance as asthma is considered as a small airway disease.

[Physical Therapy for Chemotherapy-induced Peripheral Neuropathy in Pediatric Oncology]

Background: Chemotherapy-induced peripheral neuropathy is a frequent side-effect of drugs that are used in the treatment of cancer. Affected individuals can suffer from motor, sensory or autonomy nerve damage. Further medication is used for the treatment of CIPN which can cause further side-effects. Patients should be offered physical therapy treatment to relieve the symptoms. Objective: The aim of this article is to give an overview of available literature investigating physical therapy in CIPN in pediatric oncology. Methods: To determine relevant literature, a systematic review was conducted in the databases CINAHL, The Cochrane Library, ERIC, MEDPILOT, PEDro, PsycARTICLES, PsycINFO, PubMed and DIMDI. Besides the methodological quality of the identified literature is supposed to be reviewed. Results: There is no current literature regarding the subject of this article, so no evaluation of the quality could be carried out. Although several publications concerning adults could be identified and transfer could be established for pediatrics. Conclusion: Acupuncture appeared to be effective in the treatment of CIPN in adults. Good results appeared especially regarding pain. Sensorimotor training, balance training, electrotherapy and alternative methods like Reiki and Yoga showed good results for patients symptoms. These treatment methods give a future prospect how CIPN in children can be treated successfully - but further pediatric research is necessary.

[Exercise Therapy for Children with Cancer Related Fatigue]

Cancer Related Fatigue (CRF) is known as one of the strongest and incriminating side effects of cancer for adults and children. By now there is a lack of valid assessments and sufficient therapy in pediatric oncology. For children it is a tough challenge to accept this overwhelming tiredness and lower activity level in their daily life routines. First positive effects in CFR therapy were found by adults, but this specific scientific field is very young and therefore mostly unexplored. 4 databases for medical and therapeutic journals were systematically searched for RCTs, CCTs and CTs. Systematic reviews were analyzed as well. All studies were carried out in pediatric oncology and deal with exercise therapy. The enclosed studies were valued by PEDro-Scale. Only a handful papers about a potential reduction of CRF in pediatrics could be found, one RCT, 2 CCTs and one CT. No additional results could be found. To summarize the 4 papers, it can be stated that the duration of intervention depends between 2 days and 12 weeks. Also there are differences between the option inpatient and outpatient programs, as well as with or without supervising. The exercise therapy mostly consists of strength and endurance training in combination with warm-up and cool-down programs. This review underlines the importance of developing new assessments. Especially bigger groups of participants should be analyzed with the scope on individualized, supervised program. So far, CRF is underestimated in pediatric oncology and it is very crucial to identify the symptoms. This could lead to an improvement in quality of life.

Desmopressin treatment improves platelet function under flow in patients with postoperative bleeding

BACKGROUND

Patients undergoing major cardiothoracic surgery are subjected to dilution, owing to massive fluid infusion and blood component transfusion. These patients may experience bleeding perioperatively, and are frequently treated with the endothelium-activating agent desmopressin.

OBJECTIVES

To investigate the effect of desmopressin administration on von Willebrand factor (VWF)-dependent coagulant and platelet functions under flow conditions.

PATIENTS/METHODS

Blood from 16 patients with postoperative bleeding was obtained before and after desmopressin treatment (0.3 μg kg(-1) body weight), and assessed for coagulant properties and platelet function. Furthermore, VWF antigen levels and multimer composition were determined in both samples.

RESULTS

Desmopressin treatment did not change thrombin generation in plasma or whole blood thromboelasticity. Also coagulation factor levels (other than factor VIII) and coagulation times were unchanged, suggesting that desmopressin treatment did not have a major effect on the coagulant activity. On the other hand, desmopressin treatment raised the already high plasma levels of VWF from a median of 116 IU mL(-1) (interquartile range [IQR] 102-154 IU mL(-1) ) to a median of 160 IU mL(-1) (IQR 126-187 IU mL(-1) ) (P = 0.007), owing to accumulation of the high molecular weight VWF multimers. Furthermore, desmopressin treatment caused an increase in collagen-dependent thrombus formation and platelet phosphatidylserine exposure. Markers of thrombus formation correlated with the plasma levels of VWF. In vitro control experiments confirmed a major contribution of VWF to thrombus formation and procoagulant activity under conditions of blood dilution.

CONCLUSIONS

Desmopressin treatment of patients with bleeding complications after cardiothoracic surgery induces the release of high molecular weight VWF multimers, which enhance platelet activation and thrombus formation under flow conditions.

Search for patterns by combining cosmic-ray energy and arrival directions at the Pierre Auger Observatory

Energy-dependent patterns in the arrival directions of cosmic rays are searched for using data of the Pierre Auger Observatory. We investigate local regions around the highest-energy cosmic rays with [Formula: see text] eV by analyzing cosmic rays with energies above [Formula: see text] eV arriving within an angular separation of approximately 15[Formula: see text]. We characterize the energy distributions inside these regions by two independent methods, one searching for angular dependence of energy-energy correlations and one searching for collimation of energy along the local system of principal axes of the energy distribution. No significant patterns are found with this analysis. The comparison of these measurements with astrophysical scenarios can therefore be used to obtain constraints on related model parameters such as strength of cosmic-ray deflection and density of point sources.

Discovery and pharmacological characterization of a novel potent inhibitor of diacylglycerol-sensitive TRPC cation channels

BACKGROUND AND PURPOSE

The cation channel transient receptor potential canonical (TRPC) 6 has been associated with several pathologies including focal segmental glomerulosclerosis, pulmonary hypertension and ischaemia reperfusion-induced lung oedema. We set out to discover novel inhibitors of TRPC6 channels and investigate the therapeutic potential of these agents.

EXPERIMENTAL APPROACH

A library of potential TRPC channel inhibitors was designed and synthesized. Activity of the compounds was assessed by measuring intracellular Ca(2+) levels. The lead compound SAR7334 was further characterized by whole-cell patch-clamp techniques. The effects of SAR7334 on acute hypoxic pulmonary vasoconstriction (HPV) and systemic BP were investigated.

KEY RESULTS

SAR7334 inhibited TRPC6, TRPC3 and TRPC7-mediated Ca(2+) influx into cells with IC50 s of 9.5, 282 and 226 nM, whereas TRPC4 and TRPC5-mediated Ca(2+) entry was not affected. Patch-clamp experiments confirmed that the compound blocked TRPC6 currents with an IC50 of 7.9 nM. Furthermore, SAR7334 suppressed TRPC6-dependent acute HPV in isolated perfused lungs from mice. Pharmacokinetic studies of SAR7334 demonstrated that the compound was suitable for chronic oral administration. In an initial short-term study, SAR7334 did not change mean arterial pressure in spontaneously hypertensive rats (SHR).

CONCLUSIONS AND IMPLICATIONS

Our results confirm the role of TRPC6 channels in hypoxic pulmonary vasoregulation and indicate that these channels are unlikely to play a major role in BP regulation in SHR. SAR7334 is a novel, highly potent and bioavailable inhibitor of TRPC6 channels that opens new opportunities for the investigation of TRPC channel function in vivo.

Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trial

BACKGROUND

Acute kidney injury often goes unrecognised in its early stages when effective treatment options might be available. We aimed to determine whether an automated electronic alert for acute kidney injury would reduce the severity of such injury and improve clinical outcomes in patients in hospital.

METHODS

In this investigator-masked, parallel-group, randomised controlled trial, patients were recruited from the hospital of the University of Pennsylvania in Philadelphia, PA, USA. Eligible participants were adults aged 18 years or older who were in hospital with stage 1 or greater acute kidney injury as defined by Kidney Disease Improving Global Outcomes creatinine-based criteria. Exclusion criteria were initial hospital creatinine 4·0 mg/dL (to convert to μmol/L, multiply by 88·4) or greater, fewer than two creatinine values measured, inability to determine the covering provider, admission to hospice or the observation unit, previous randomisation, or end-stage renal disease. Patients were randomly assigned (1:1) via a computer-generated sequence to receive an acute kidney injury alert (a text-based alert sent to the covering provider and unit pharmacist indicating new acute kidney injury) or usual care, stratified by medical versus surgical admission and intensive care unit versus non-intensive care unit location in blocks of 4-8 participants. The primary outcome was a composite of relative maximum change in creatinine, dialysis, and death at 7 days after randomisation. All analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01862419.

FINDINGS

Between Sept 17, 2013, and April 14, 2014, 23,664 patients were screened. 1201 eligible participants were assigned to the acute kidney injury alert group and 1192 were assigned to the usual care group. Composite relative maximum change in creatinine, dialysis, and death at 7 days did not differ between the alert group and the usual care group (p=0·88), or within any of the four randomisation strata (all p>0·05). At 7 days after randomisation, median maximum relative change in creatinine concentrations was 0·0% (IQR 0·0-18·4) in the alert group and 0·6% (0·0-17·5) in the usual care group (p=0·81); 87 (7·2%) patients in the alert group and 70 (5·9%) patients in usual care group had received dialysis (odds ratio 1·25 [95% CI 0·90-1·74]; p=0·18); and 71 (5·9%) patients in the alert group and 61 (5·1%) patients in the usual care group had died (1·16 [0·81-1·68]; p=0·40).

INTERPRETATION

An electronic alert system for acute kidney injury did not improve clinical outcomes among patients in hospital.

FUNDING

Penn Center for Healthcare Improvement and Patient Safety.

Primary tumour growth in an orthotopic osteosarcoma mouse model is not influenced by analgesic treatment with buprenorphine and meloxicam

Little is known about the treatment of bone pain in animal models of bone cancer. In the present study, the orthotopic 143-B human osteosarcoma xenotransplantation model was used to address the following questions: (1) Can repetitive analgesic treatment extend the experimental period by prolonging the time to reach humane endpoints and (2) Does repetitive analgesic treatment affect bone tumour development and metastasis? The analgesics, buprenorphine and meloxicam, were either applied individually or in combination at 12 h intervals as soon as the animals began to avoid using the tumour cell injected leg. While control mice treated with NaCl showed continuous body weight loss, the major criterion previously for terminating the experiments, animals treated with analgesic substances did not. The control mice had to be sacrificed 26 days after tumour cell injection, whereas the groups of animals with the different pain treatments were euthanized after an additional eight days. Importantly, primary intratibial tumour growth was not affected in any of the experimental groups by any of the pain treatment procedures. Between days 26 and 34 after tumour cell injection an increase of about 100% of the number of lung metastases was found for the groups treated with buprenorphine alone or together with meloxicam, but not for the group treated with meloxicam alone. In summary, the results indicated that both buprenorphine and meloxicam are suitable analgesics for prolonging the experimental periods in an experimental intratibial osteosarcoma mouse model.

First Experimental Characterization of Microwave Emission from Cosmic Ray Air Showers

We report the first direct measurement of the overall characteristics of microwave radio emission from extensive air showers. Using a trigger provided by the KASCADE-Grande air shower array, the signals of the microwave antennas of the Cosmic-Ray Observation via Microwave Emission experiment have been read out and searched for signatures of radio emission by high-energy air showers in the GHz frequency range. Microwave signals have been detected for more than 30 showers with energies above 3×10^{16}  eV. The observations presented in this Letter are consistent with a mainly forward-directed and polarized emission process in the GHz frequency range. The measurements show that microwave radiation offers a new means of studying air showers at E≥10^{17}  eV.

A trial of in-hospital, electronic alerts for acute kidney injury: design and rationale

BACKGROUND

Acute kidney injury is common in hospitalized patients, increases morbidity and mortality, and is under-recognized. To improve provider recognition, we previously developed an electronic alert system for acute kidney injury. To test the hypothesis that this electronic acute kidney injury alert could improve patient outcome, we designed a randomized controlled trial to test the effectiveness of this alert in hospitalized patients. The study design presented several methodologic, ethical, and statistical challenges.

PURPOSE

To highlight the challenges faced and the solutions employed in the design and implementation of a clinical trial to determine whether the provision of an early electronic alert for acute kidney injury would improve outcomes in hospitalized patients. Challenges included how to randomize the delivery of the alert system and the ethical framework for waiving informed consent. Other methodologic challenges included the selection and statistical evaluation of our study outcome, a ranked-composite of a continuous covariate (creatinine) and two dichotomous outcomes (dialysis and death), and the use of the medical record as a source of trial data.

METHODS

We have designed a randomized trial to assess the effectiveness of an electronic alert system for acute kidney injury. With broad inclusion criteria, and a waiver of informed consent, we enroll and randomize virtually every patient with acute kidney injury in our hospital.

RESULTS

As of 31 March 2014, we have enrolled 2373 patients of 2400 targeted. Pre-alert data demonstrated a strong association between severity of acute kidney injury and inpatient mortality with a range of 6.4% in those with mild, stage 1 acute kidney injury, to 29% among those with stage 3 acute kidney injury (p < 0.001). We judged that informed consent would undermine the scientific validity of the study and present harms that are out of proportion to the very low risk intervention.

CONCLUSION

Our study demonstrates the feasibility of designing an ethical randomized controlled trial of an early electronic alert for acute kidney injury without obtaining informed consent from individual participants. Our study outcome may serve as a model for other studies of acute kidney injury, insofar as our paradigm accounts for the effect that early death and dialysis have on assessment of acute kidney injury severity as defined by maximum achieved serum creatinine.

Factors that predict short-term intensive care unit mortality in patients with cirrhosis

BACKGROUND & AIMS

Despite advances in critical care medicine, the mortality rate is high among critically ill patients with cirrhosis. We aimed to identify factors that predict early (7 d) mortality among patients with cirrhosis admitted to the intensive care unit (ICU) and to develop a risk-stratification model.

METHODS

We collected data from patients with cirrhosis admitted to the ICU at Indiana University (IU-ICU) from December 1, 2006, through December 31, 2009 (n = 185), or at the University of Pennsylvania (Penn-ICU) from May 1, 2005, through December 31, 2010 (n = 206). Factors associated with mortality within 7 days of admission (7-d mortality) were determined by logistic regression analyses. A model was constructed based on the predictive parameters available on the first day of ICU admission in the IU-ICU cohort and then validated in the Penn-ICU cohort.

RESULTS

Median Model for End-stage Liver Disease (MELD) scores at ICU admission were 25 in the IU-ICU cohort (interquartile range, 23-34) and 32 in the Penn-ICU cohort (interquartile range, 26-41); corresponding 7-day mortalities were 28.3% and 53.6%, respectively. MELD score (odds ratio, 1.13; 95% confidence interval [CI], 1.07-1.2) and mechanical ventilation (odds ratio, 5.7; 95% CI, 2.3-14.1) were associated independently with 7-day mortality in the IU-ICU. A model based on these 2 variables separated IU-ICU patients into low-, medium-, and high-risk groups; these groups had 7-day mortalities of 9%, 27%, and 74%, respectively (concordance index, 0.80; 95% CI, 0.72-0.87; P < 10(-8)). The model was applied to the Penn-ICU cohort; the low-, medium-, and high-risk groups had 7-day mortalities of 33%, 56%, and 71%, respectively (concordance index, 0.67; 95% CI, 0.59-0.74; P < 10(-4)).

CONCLUSIONS

A model based on MELD score and mechanical ventilation on day 1 can stratify risk of early mortality in patients with cirrhosis admitted to the ICU. More studies are needed to validate this model and to enhance its clinical utility.

Third Åland islands conference on von Willebrand disease, 26-28 September 2012: meeting report

The first meeting of international specialists in the field of von Willebrand disease (VWD) was held in the Åland islands in 1998 where Erik von Willebrand had first observed a bleeding disorder in some members of a family from Föglö and a summary of the meeting was published in 1999. The second meeting was held in 2010 and a report of the meeting was published in 2012. Topics covered included progress in understanding of VWD over the last 50 years; multimers; classification of VWD; pharmacokinetics and laboratory assays; genetics; treating the paediatric patient; prophylaxis; geriatrics; gene therapy and treatment guidelines. This third meeting held over 3 days covered the structure and function of von Willebrand factor (VWF); type 1 VWD, the most common form of the disease; a lifespan of pharmacokinetics in VWD; detecting inhibitors in VWD patients; and special challenges in understanding and treating the female VWD patient.

Management of delirium in critically ill older adults

Delirium in older adults in critical care is associated with poor outcomes, including longer stays, higher costs, increased mortality, greater use of continuous sedation and physical restraints, increased unintended removal of catheters and self-extubation, functional decline, new institutionalization, and new onset of cognitive impairment. Diagnosing delirium is complicated because many critically ill older adults cannot communicate their needs effectively. Manifestations include reduced ability to focus attention, disorientation, memory impairment, and perceptual disturbances. Nurses often have primary responsibility for detecting and treating delirium, which can be extraordinarily complicated because patients are often voiceless, extremely ill, and require high levels of sedatives to facilitate mechanical ventilation. An aggressive, appropriate, and compassionate management strategy may reduce the suffering and adverse outcomes associated with delirium and improve relationships between nurses, patients, and patients' family members.

Functional consequences of sphingomyelinase-induced changes in erythrocyte membrane structure

Inflammation enhances the secretion of sphingomyelinases (SMases). SMases catalyze the hydrolysis of sphingomyelin into phosphocholine and ceramide. In erythrocytes, ceramide formation leads to exposure of the removal signal phosphatidylserine (PS), creating a potential link between SMase activity and anemia of inflammation. Therefore, we studied the effects of SMase on various pathophysiologically relevant parameters of erythrocyte homeostasis. Time-lapse confocal microscopy revealed a SMase-induced transition from the discoid to a spherical shape, followed by PS exposure, and finally loss of cytoplasmic content. Also, SMase treatment resulted in ceramide-associated alterations in membrane–cytoskeleton interactions and membrane organization, including microdomain formation. Furthermore, we observed increases in membrane fragility, vesiculation and invagination, and large protein clusters. These changes were associated with enhanced erythrocyte retention in a spleen-mimicking model. Erythrocyte storage under blood bank conditions and during physiological aging increased the sensitivity to SMase. A low SMase activity already induced morphological and structural changes, demonstrating the potential of SMase to disturb erythrocyte homeostasis. Our analyses provide a comprehensive picture in which ceramide-induced changes in membrane microdomain organization disrupt the membrane–cytoskeleton interaction and membrane integrity, leading to vesiculation, reduced deformability, and finally loss of erythrocyte content. Understanding these processes is highly relevant for understanding anemia during chronic inflammation, especially in critically ill patients receiving blood transfusions.

Practical implementation of therapeutic hypothermia after cardiac arrest

INTRODUCTION

Survival after out-of-hospital cardiac arrest (OHCA) remains unacceptably low. Therapeutic hypothermia (TH) is the most efficacious treatment option available for comatose survivors of cardiac arrest. However, clearly delineated instructions for how to induce, maintain, and conclude TH have not been published in a codified format.

OBJECTIVE

We assembled 11 clinicians from the University of Pennsylvania Schools of Medicine and Nursing for a day-long moderated discussion to review our institution's TH protocol and reach consensus on a step-by-step management plan of the comatose survivor of OHCA. We attempted to systematically work our way through the existing University of Pennsylvania TH protocol. The goal was to address critical decisions at each stage of care of the post-arrest patient, including whom to cool, how to cool, how long to cool, how to rewarm, neuroprognostication, and other fundamental aspects of patient management. We made every effort to include relevant scientific evidence with appropriate citations. However, given the paucity of data in certain areas, we have relied heavily on expert opinion.

SUMMARY

We present a step-by-step management plan for incorporation of TH in the care of the comatose survivor of OHCA, which can be adapted to a variety of clinical settings with diverse resources. This article is intended to supplement current care provided by health care providers and should be adopted in concert with current standards of post-arrest and intensive care unit care.

Measurement of the proton-air cross section at √s=57 TeV with the Pierre Auger Observatory

We report a measurement of the proton-air cross section for particle production at the center-of-mass energy per nucleon of 57 TeV. This is derived from the distribution of the depths of shower maxima observed with the Pierre Auger Observatory: systematic uncertainties are studied in detail. Analyzing the tail of the distribution of the shower maxima, a proton-air cross section of [505±22(stat)(-36)(+28)(syst)] mb is found.

Febrile neutropenia in hematologic malignancies: Validation of a model to select patients manageable in the outpatient setting safely

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Background: Febrile neutropenia (FN) is usually treated in an inpatient setting with empiric IV antibiotics. Accurate identification of low-risk hematologic malignancy (HM) pts (highest risk for life-threatening events) appropriate for outpatient management may reduce healthcare costs without impacting outcomes adversely. Prior studies using predictive models to identify low risk FN pts have not been validated in HM pts. Aim: To identify low risk HM pts as candidates for safe outpatient management. Methods: To determine parameters associated with an uncomplicated FN course in HM pts we tested the association between Talcott’s criteria (Talcott et al JCO Oct 2011) and additional candidate risk factors with the development of a medical event (ME) requiring urgent intervention. We conducted a retrospective cohort study of stable HM pts, admitted for FN management. Utilizing Cox regression, we examined the following factors: Talcott criteria, age, insurance status, prophylactic G-CSF/antibiotics, vitals signs and organ function. Results: We identified 97 consecutively admitted pts who met eligibility criteria of whom 27 pts developed a ME during the admission (validated by 2 investigators blinded to exposure status). In univariate analysis, Talcott’s criteria successfully identified pts at low risk for developing a ME (HR .4, p=.04 CI .17-.97). Additionally a preserved DPB (>65 mmHg) was also protective (HR .22 p<.01 CI .11-.51). Talcott’s criteria and DBP remained independent predictors of uncomplicated FN in a multivariate cox regression (AUROC curve=75%). Conclusions: This study provides support for the use of Talcott’s criteria in HM pts. The addition of DBP to Talcott’s model further improves its ability to identify low risk HM pts. Once prospectively validated, this approach may have important clinical and financial implications. [Table: see text]