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.

Childhood adversity and recurrence of psychotic experiences during adolescence: the role of mediation in an analysis of a population-based longitudinal cohort study

BACKGROUND

Psychotic experiences (PEs) are relatively common in childhood and adolescence and are associated with increased risk of functional issues and psychiatric illness in young adulthood, and PEs that recur are associated with increased risk of poorer psychiatric and functional outcomes. Childhood adversity is a well-established risk factor for PEs. The aim of this study was to investigate (1) the relationship between childhood adversity and recurring PEs in adolescence and (2) candidate mediators of that relationship.

METHODS

We used data from Cohort '98 of the Growing Up in Ireland study (n = 6039) at three time points (ages 9, 13 and 17) to investigate the relationship between childhood adversity (parent-reported at age 9), recurring PEs (measured using a subset of the Adolescent Psychotic-like Symptoms Screener at ages 13 and 17). The mediating roles of parent-child relationship, internalising and externalising difficulties, self-concept, physical activity, dietary quality, perceived neighbourhood safety and friendship quantity were investigated using the KHB path decomposition method.

RESULTS

Childhood adversity was associated with an increased risk of recurring PEs with a population attributable fraction of 23%. Internalising difficulties and self-concept explained 13% of the relationship between childhood adversity and PEs suggesting a partial mediation. A significant direct effect remained between childhood adversity and recurring PEs.

CONCLUSIONS

The established relationship between childhood adversity and PEs may be mainly driven by the relationship between childhood adversity and recurring PEs. Internalising difficulties and self-concept together mediate part of the relationship between childhood adversity and recurring PEs.

154 ANALYSIS OF ELIGIBILITY FOR THROMBOLYSIS IN ISCHAEMIC STROKE PRESENTATIONS IN A UNIVERSITY TEACHING HOSPITAL IN 2021

Background

Since the National Institute of Neurological Disorders and Stroke (NINDS) tissue-type Plasminogen Activator (tPA) trial was published in 1995, thrombolysis has been a mainstay of treatment for ischaemic stroke presenting within the appropriate age-adjusted timeframe, in the absence of contraindications. In the Irish National Audit of Stroke (INAS) National Report 2020, a nationwide thrombolysis rate of 10.6% (Range of 4-22%) was achieved. Aims: (1) This study was designed to compare this centre’s rate in 2021; (2) Identifying any missed potentially suitable presentations.

Methods

A retrospective chart review of 2021 stroke presentations in this centre was performed using medical admission notes and electronic emergency department records. Excluding haemorrhagic causes, we looked at the presenting National Institutes of Health Stroke Scale (NIHSS), the presenting timeframe and any contraindications of thrombolysis therapy, in order to identify any potentially missed eligible presentations. We also compared the percentage of thrombolysed patients in this centre to the national average.

Results

Of the 425 stroke presentations, 74 (17.4%) were excluded as intra-cerebral haemorrhages. Of the remaining 351 presentations, 32 (9.1%) underwent thrombolysis therapy. 225 (64.1%) were not eligible for therapy due to a low or recovering NIHSS (score 0-4). A further 72 (20.5%) with a NIHSS&gt;5, were outside of the window of thrombolysis therapy. Of the remaining presentations, 13 (3.7%) were unsuitable due to anticoagulation use. The final 9 presentations (2.6%) were unsuitable due to other contraindications (previous intracranial haemorrhage, baseline modified Rankin ≥ 4). 18 (5.1%) of non-thrombolysed presentations had no contraindications to thrombolysis therapy aside from late presentation (excluding wake-up events).

Conclusion

While this centre’s thrombolysis percentage is lower than the national average in 2020, a review of presentations suggests no eligible candidates were missed. Therefore, variations in thrombolysis rates across Irish hospitals may reflect case mix variations rather than decision variations.

788 Caecal Duplication Cyst: An Unexpected Cause of Bowel Obstruction in a 12-Year-Old

We report the case of a rare cause of bowel obstruction in a 12-year-old girl who presented with a short history of abdominal distension and vomiting after a month of unexplained urinary frequency and weight loss. Abdominal radiographs demonstrated small bowel obstruction with an unknown pelvic mass. A raised CA125 suggested a possible ovarian lesion and a magnetic resonance scan was interpreted as supportive of this pathology. Intra-operatively a 120x90x70mm cystic mass was found attached to the caecal serosa, immediately adjacent to the ileocaecal valve. There was an associated 180-degree twist of the terminal ileum and ascending colon. A limited right hemicolectomy was performed, and histopathology confirmed the diagnosis of a caecal intestinal duplication cyst. Post-operatively she has recovered well, with resolution of her obstructive and urinary symptoms. Given the unusual age of presentation, uncommon location of the cyst and the diagnostic challenges incurred, the authors wish to share their experience of managing an atypical duplication cyst.

The association between transient childhood psychotic experiences and psychosocial outcomes in young adulthood: examining the role of mental disorder and attachment

Introduction

Psychotic experiences (PE) occur most often in childhood, at the same age many mental disorders (MD) develop. There is growing evidence that those who report PE and MD show poorer health outcomes. If this occurs in psychosocial outcomes e.g. self-esteem, stress, mental distress, or social support, is under examined. Attachment anxiety and avoidance are the dimensions of attachment, which is hypothesized to develop in infancy as a mechanism for interpersonal relationships in times of need.

Objectives

To examine the role of transient childhood PE in adult psychosocial outcomes, in those with and without MD. Additionally, to examine if the dimensions of attachment attenuate this model.

Methods

One hundred and three participants attended baseline (age 11 – 13) and 10-year follow-up. PE and MD were collected using the Schedule for Affective Disorders and Schizophrenia for School-aged Children, Present & Lifetime Version. Attachment and outcomes were collected using self-report measures. Analysis compared those with PE, MD and PE and MD, to healthy controls.

Results

PE in childhood was associated with lower self-esteem and lower perceived social support from friends. Lower self-esteem in adulthood was more pronounced in those reporting PE and MD, and was additionally associated with stress in relationships, daily life, and mental distress. Childhood MD without PE was not significantly associated with any psychosocial outcomes. Attachment dimensions significantly attenuated the relationship between PE and self-esteem.

Conclusions

This paper illustrates the significant association of childhood PE on adult outcomes, independent of the effect of co-occurring MD, and demonstrate attachment dimensions role in this model.

Disclosure

No significant relationships.

1345 A Punch Above the Rest: A High Yield Modification of The Diagnostic Nailbed Biopsy

Aim

Diagnostic nailbed biopsy is indicated for pathology including malignancy, persistent and suspected mycomial infection and rheumatological disease. Operatively, the challenge resides in establishing an equilibrium between harvesting ample histological sample for diagnostic value without the creation of a functionally and aesthetically unacceptable nail due to significant disruption of the nailbed. We illustrate a simple and reproducible biopsy technique through one small forgiving defect without disruption of surrounding soft tissue.

Method

The procedure is carried out under normal sterile conditions with local anaesthetic and a ring tourniquet. A 5mm punch biopsy is taken of the nail, adjacent to the eponychium, followed by a 4mm punch biopsy of the underlying nailbed at a 45-degree angle. The subungual surface of the nail is tangentially transected generating a mycomial sample and the nailbed is sent for histology. The remaining nail is replaced if not required for histology, and cyanoacrylate glue applied followed by a finger dressing.

Results

Figures show an example of how the nail biopsy is carried out. Biopsy sample and the resulting defect in the nail is also displayed.

Conclusions

The double punch technique reliably harvests adequate diagnostic specimens through one wound, without the disruption of adjacent nail plate, nailbed and perionychium. This is even more a priority when histology identifies no pathology requiring further operative resection. Whilst the nail undergoes its normal growth cycle post-operatively, aesthetically, the fingertip does not draw undue patient dissatisfaction once the dressing is removed in comparison to alternative biopsy techniques.

529 Safeguarding Skin Grafts: A 21st Century Algorithm for Fixation Techniques

Aim

Effective skin graft fixation is fundamental in preventing sheering forces, seroma and haematoma from compromising graft take. However, determining the ideal method of graft fixation remains a contentious subject. Currently, there is significant variation in fixation techniques used, based not only on clinical requirement, but also surgeon preference. Evidence-based recommendations are necessary to guide the decision-making process.

Method

We undertook a PRISMA-based assessment of the literature to define all fixation techniques and analyse their outcomes. Inclusion and exclusion criteria were composed. A search of Medline and Embase was performed, yielding 399 articles. After abstract screening, 96 were included for qualitative data analysis.

Results

Nine fixation techniques were identified: ‘tie over bolster’, ‘staple fixation’, ‘simple dressings’, ‘quilting sutures’, ‘re-look methods’, ‘foam sponge bolster’, ‘adhesive glues’, ‘negative pressure wound therapy’ and ‘less common techniques. We analyse the available evidence for each technique, identifying 13 studies with level I/II evidence. We summarise the research that underpins these nine categories, proposing an algorithm to facilitate technique selection based on anatomical and patient-specific factors.

Conclusions

An array of skin graft fixation techniques are used in plastic surgery, without clear guidelines. To our knowledge, this is the first time all fixation techniques have been defined. Our suggested algorithm is intended to aid surgeons in selecting an appropriate fixation technique and should be challenged by future research, particularly randomised control trials.

Prenatal tobacco exposure and psychiatric outcomes in adolescence: is the effect mediated through birth weight?

OBJECTIVE

This study aims to examine the associations between prenatal exposure to maternal smoking, birth weight and persistent offspring psychiatric symptoms. Additionally, we aim to examine whether the relationship between prenatal maternal smoking and persistent offspring psychiatric symptoms is mediated by offspring birth weight.

METHODS

This study used the Growing Up in Ireland (GUI) longitudinal cohort. The GUI is a nationally representative longitudinal study of children which consisted of three data collection waves, at ages 9, 13, and 17 years. Logistic regression analysis was used to examine associations between prenatal tobacco exposure, and offspring psychiatric symptoms. Linear regression was used to examine associations between prenatal tobacco exposure and offspring birth weight. We conducted a mediation analysis examining potential etiological pathways linking maternal smoking during pregnancy, offspring birth weight, and later offspring psychiatric symptoms. All analyses were adjusted for confounders including household income, maternal level of education, and family psychiatric history. Additionally, examination of birth weight and subsequent psychiatric symptoms also was controlled for prematurity.

RESULTS

We found that the association between prenatal tobacco exposure and later psychiatric symptoms is mediated by birth weight.

CONCLUSIONS

This work provides further evidence that maternal smoking during pregnancy is an important modifiable lifestyle factor that has an impact not just on the physical health of offspring but also their mental wellbeing. Supporting women with structured smoking cessation programs at the earliest stages of pregnancy should be a public health priority.

Holocephalan (Chondrichthyes) dental plates with hypermineralized dentine as a substitute for missing teeth through developmental plasticity

All extant holocephalans (Chimaeroidei) have lost the ability to make individual teeth, as tooth germs are not part of the embryonic development of the dental plates or of their continuous growth. Instead, a hypermineralized dentine with a unique mineral, whitlockin, is specifically distributed within a dentine framework into structures that give the dental plates their distinctive, species-specific morphology. Control of the regulation of this distribution must be cellular, with a dental epithelium initiating the first outer dentine, and via contact with ectomesenchymal tissue as the only embryonic cell type that can make dentine. Chimaeroids have three pairs of dental plates within their mouth, two in the upper jaw and one in the lower. In the genera Chimaera, Hydrolagus and Harriotta, the morphology and distribution of this whitlockin within each dental plate differs both between different plates in the same species and between species. Whitlockin structures include ovoids, rods and tritoral pads, with substantial developmental changes between these. For example, rods appear before the ovoids and result from a change in the surrounding trabecular dentine. In Harriotta, ovoids form separately from the tritoral pads, but also contribute to tritor development, while in Chimaera and Hydrolagus, tritoral pads develop from rods that later are perforated to accommodate the vasculature. Nevertheless, the position of these structures, secreted by the specialized odontoblasts (whitloblasts), appears highly regulated in all three species. These distinct morphologies are established at the aboral margin of the dental plate, with proposed involvement of the outer dentine. We observe that this outer layer forms into serially added lingual ridges, occurring on the anterior plate only. We propose that positional, structural specificity must be contained within the ectomesenchymal populations, as stem cells below the dental epithelium, and a coincidental occurrence of each lingual, serial ridge with the whitlockin structures that contribute to the wear-resistant oral surface.

First nations people's perspectives on barriers and supports for enhancing HPV vaccination: Foundations for sustainable, community-driven strategies

OBJECTIVE

In Canada, Indigenous people have higher human papillomavirus (HPV) infection rates, lower screening rates for cervical cancer, and higher rates of invasive cancer, leading to worse cervical cancer-related outcomes than observed in non-Indigenous Canadian women. Lingering harms from European colonization drive these health inequities and create public health challenges. Policy guidance is needed to optimize HPV vaccination rates and, thereby, decrease the burden of HPV-related illness, including high-morbidity surgical procedures and chemo-radiotherapy. The Enhancing HPV Vaccination In First Nations Populations in Alberta (EHVINA) project focuses on First Nations, a diverse subset of recognized Indigenous people in Canada, and seeks to increase HPV vaccination among girls and boys living in First Nation communities.

METHODS

Developing an effective strategy requires partnership with affected communities to better understand knowledge and perceptions about cancer, healthcare, and the HPV vaccine. A 2017 community gathering was convened to engage First Nations community members, health directors, and health services researchers in dialogue around unique barriers and supports to HPV vaccination in Alberta. Voices of community Elders, parents, health directors, and cancer survivors (n=24) are presented as qualitative evidence to help inform intervention design.

RESULTS

Key findings from discussions indicate barriers to HPV vaccination include resource constraints and service infrastructure gaps, historical mistrust in healthcare systems, impacts of changing modes of communication, and community sensitivities regarding sexual health promotion. Supports were identified as strengthened inter-generational relationships in communities.

CONCLUSIONS AND FUTURE DIRECTION

Ongoing dialogue and co-development of community-based strategies to increase HPV vaccine uptake are required. The identification of possible barriers to HPV vaccination in a Canadian Indigenous population contributes to limited global literature on this subject and may inform researchers and policy makers who work with Indigenous populations in other regions.

Childhood psychotic experiences are associated with poorer global functioning throughout adolescence and into early adulthood

BACKGROUND

Psychotic experiences (PEs) are common in childhood and have been associated with concurrent mental disorder and poorer global functioning. Little is known about the effects of childhood PEs on future functioning. We investigated the effects of childhood PEs on global functioning from childhood into early adulthood.

METHOD

Fifty-six participants from a community sample completed all three waves of the Adolescent Brain Development study (T1x¯ Age: 11.69, T2x¯ Age: 15.80 T3x¯Age: 18.80). At each phase, participants completed a clinical interview assessing for PEs, mental disorder and global function. Repeated measures models, adjusted for mental disorder and gender, were used to compare current (C-GAF) and most severe past (MSP-GAF) functioning in participants who had reported PEs in childhood and controls.

RESULTS

Participants with a history of PEs had significantly poorer C-GAF (P < 0.001) and MSP-GAF scores (P < 0.001). Poorer functioning was evident in childhood (C-GAF: P = 0.001; MSP-GAF: P < 0.001), adolescence (C-GAF: P < 0.001; MSP-GAF: P = 0.004) and early adulthood (C-GAF: P = 0.001; MSP-GAF: P = 0.076).

DISCUSSION

Children who report PEs have persistently poorer functioning through to early adulthood. The longitudinal association between childhood PEs and global functioning highlights the underlying global vulnerability in children reporting PEs, beyond what can be explained by mental disorder.

Radiographic and Clinical Assessment of Intramedullary Nail Fixation for the Treatment of Unstable Metacarpal Fractures

BACKGROUND

The purpose of the article was to evaluate clinical and radiographic outcomes in a case series of unstable metacarpal fractures treated with flexible intramedullary nail (IMN) fixation.

METHODS

A total of 55 patients with unstable metacarpal fractures between 2003 and 2010 were treated with IMN fixation and followed for a minimum of 1 year. The outcomes were assessed via a radiological study of longitudinal and angular collapse, Disabilities of the Arm, Shoulder, and Hand (DASH) score, total active range of motion (ROM) of the wrist, and grip strength testing.

RESULTS

In the 55 patients, metacarpal fractures were healed by clinical and radiographic assessment at an average of 12.7 weeks. IMNs were removed in all cases at an average of 13.9 weeks. Patients regained full finger ROM at the final follow-up and were capable of 72.4% of motion at 2 weeks postoperatively. The mean DASH score at the final follow-up was 6.5. Complications included 3 cases of extensor tendon irritation that resolved without functional impairment and 2 cases of "backing out" that required reoperation to replace the pin. In one case, a bony exostosis formed on the affected metacarpal that led to tendon irritation and required operative excision.

CONCLUSIONS

We found that this technique allowed for the stabilization of fractures, early ROM, resumption of usual activities, reduced immobilization, and minimal complications. A removable orthosis, instead of a cast, allowed for earlier mobilization of the wrist, metacarpophalangeal, and proximal interphalangeal joints.

Estimation of subject coregistration errors during multimodal preclinical imaging using separate instruments: origins and avoidance of artifacts

We use high-resolution [Formula: see text] data in multiple experiments to estimate the sources of error during coregistration of images acquired on separate preclinical instruments. In combination with experiments with phantoms, we completed in vivo imaging on mice, aimed at identifying the possible sources of registration errors, caused either by transport of the animal, movement of the animal itself, or methods of coregistration. The same imaging cell was used as a holder for phantoms and animals. For all procedures, rigid coregistration was carried out using a common landmark coregistration system, placed inside the imaging cell. We used the fiducial registration error and the target registration error to analyze the coregistration accuracy. We found that moving an imaging cell between two preclinical devices during a multimodal procedure gives an error of about [Formula: see text] at most. Therefore, it could not be considered a source of coregistration errors. Errors linked to spontaneous movements of the animal increased with time, to nearly 1 mm at most, excepted for body parts that were properly restrained. This work highlights the importance of animal intrinsic movements during a multiacquisition procedure and demonstrates a simple method to identify and quantify the sources of error during coregistration.

Effects of Transendocardial Stem Cell Injection on Ventricular Proarrhythmia in Patients with Ischemic Cardiomyopathy: Results from the POSEIDON and TAC-HFT Trials

Transendocardial stem cell injection in patients with ischemic cardiomyopathy (ICM) improves left ventricular function and structure but has ill-defined effects on ventricular arrhythmias. We hypothesized that mesenchymal stem cell (MSC) implantation is not proarrhythmic. Post hoc analyses were performed on ambulatory ECGs collected from the POSEIDON and TAC-HFT trials. Eighty-eight subjects (mean age 61 ± 10 years) with ICM (mean EF 32.2% ± 9.8%) received treatment with MSC (n = 48), Placebo (n = 21), or bone marrow mononuclear cells (BMC) (n = 19). Heart rate variability (HRV) and ventricular ectopy (VE) were evaluated over 12 months. VE did not change in any group following MSC implantation. However, in patients with ≥ 1 VE run (defined as ≥ 3 consecutive premature ventricular complexes in 24 hours) at baseline, there was a decrease in VE runs at 12 months in the MSC group (p = .01), but not in the placebo group (p = .07; intergroup comparison: p = .18). In a subset of the MSC group, HRV measures of standard deviation of normal intervals was 75 ± 30 msec at baseline and increased to 87 ± 32 msec (p =.02) at 12 months, and root mean square of intervals between successive complexes was 36 ± 30 msec and increased to 58.2 ± 50 msec (p = .01) at 12 months. In patients receiving MSCs, there was no evidence for ventricular proarrhythmia, manifested by sustained or nonsustained ventricular ectopy or worsened HRV. Signals of improvement in ventricular arrhythmias and HRV in the MSC group suggest a need for further studies of the antiarrhythmic potential of MSCs. Stem Cells Translational Medicine 2017;6:1366-1372.

ICD discrimination of SVT versus VT with 1:1 V-A conduction: A review of the literature

Inappropriate ICD shocks are associated with increased mortality. They also impair patients' quality of life, increase hospitalizations, and raise health-care costs. Nearly 80% of inappropriate ICD shocks are caused by supraventricular tachycardia. Here we report the case of a patient who received a single-lead dual-chamber sensing ICD for primary prevention of sudden cardiac death and experienced inappropriate ICD shocks. V-A time, electrogram morphology, and response to antitachycardia pacing suggested atrioventricular nodal reentry tachycardia, which was confirmed in an electrophysiology study. Inspired by this case, we performed a literature review to discuss mechanisms for discrimination of supraventricular tachycardia with 1:1 A:V relationship from ventricular tachycardia with 1:1 retrograde conduction.

Effect of Ramipril on Urinary Protein Excretion in Maintenance Renal Transplant Patients Converted to Sirolimus

This prospective, randomized, double-blind, placebo-controlled study evaluated the effects of ramipril on urinary protein excretion in renal transplant patients treated with sirolimus following conversion from a calcineurin inhibitor. Patients received ramipril or placebo for up to 6 weeks before conversion and 52 weeks thereafter. Doses were increased if patients developed proteinuria (urinary protein/creatinine ratio ≥0.5); losartan was given as rescue therapy for persistent proteinuria. The primary end point was time to losartan initiation. Of 295 patients randomized, 264 met the criteria for sirolimus conversion (ramipril, 138; placebo, 126). At 52 weeks, the cumulative rate of losartan initiation was significantly lower with ramipril (6.2%) versus placebo (23.2%) (p < 0.001). No significant differences were observed between ramipril and placebo for change in glomerular filtration rate from baseline (p = 0.148) or in the number of patients with biopsy-confirmed acute rejection (13 vs. 5, respectively; p = 0.073). One patient in the placebo group died due to cerebrovascular accident. Treatment-emergent adverse events were consistent with the known safety profile of sirolimus and were not potentiated by ramipril co-administration. Ramipril was effective in reducing the incidence of proteinuria for up to 1 year following conversion to sirolimus in maintenance renal transplant patients.

Activated WNT signaling in postnatal SOX2-positive dental stem cells can drive odontoma formation

In common with most mammals, humans form only two dentitions during their lifetime. Occasionally, supernumerary teeth develop in addition to the normal complement. Odontoma represent a small group of malformations containing calcified dental tissues of both epithelial and mesenchymal origin, with varying levels of organization, including tooth-like structures. The specific cell type responsible for the induction of odontoma, which retains the capacity to re-initiate de novo tooth development in postnatal tissues, is not known. Here we demonstrate that aberrant activation of WNT signaling by expression of a non-degradable form of β-catenin specifically in SOX2-positive postnatal dental epithelial stem cells is sufficient to generate odontoma containing multiple tooth-like structures complete with all dental tissue layers. Genetic lineage-tracing confirms that odontoma form in a similar manner to normal teeth, derived from both the mutation-sustaining epithelial stem cells and adjacent mesenchymal tissues. Activation of the WNT pathway in embryonic SOX2-positive progenitors results in ectopic expression of secreted signals that promote odontogenesis throughout the oral cavity. Significantly, the inductive potential of epithelial dental stem cells is retained in postnatal tissues, and up-regulation of WNT signaling specifically in these cells is sufficient to promote generation and growth of ectopic malformations faithfully resembling human odontoma.

Arrhythmias in chagasic cardiomyopathy

Chagas disease, a chronic parasitosis caused by the protozoa Trypanosoma cruzi, is an increasing worldwide problem because of the number of cases in endemic areas and the migration of infected individuals to more developed regions. Chagas disease affects the heart through cardiac parasympathetic neuronal depopulation, immune-mediated myocardial injury, parasite persistence in cardiac tissue with secondary antigenic stimulation, and coronary microvascular abnormalities causing myocardial ischemia. A lack of knowledge exists for risk stratification, management, and prevention of ventricular arrhythmias in patients with chagasic cardiomyopathy. Catheter ablation can be effective for the management of recurrent ventricular tachycardia.

Botulinum toxin use in paediatric colorectal surgery

PURPOSE

To evaluate outcomes of intrasphincteric botulinum toxin injection (ISBTI) in children with intractable constipation.

METHODS

Retrospective case-note review of patients ≤ 16 years of age undergoing ISBTI between January 2010 and February 2014. Data collected included patient demographics, diagnosis, complications, follow-up duration and functional outcomes. Successful outcome was defined as resolution/improvement in symptoms and failed when there was no change in symptoms. Statistical analyses were performed using PRISM (GraphPad, CA, USA). p values <0.05 were considered as significant.

RESULTS

43 patients [male 29, median age 5 years 9 months (range 13 months-13 years 5 months)] underwent 86 ISBTIs. Underlying diagnoses were idiopathic constipation (67 %), Hirschsprung disease (26 %), anorectal malformation (5 %), gastrointestinal dysmotility (2 %). 72 % (31/43) reported improvement in symptoms after the first ISBTI. 39 % of patients had recurrence of symptoms at 12-month median follow-up. 10 patients non-responsive to ISBTI required an antegrade continence enema or stoma. There was no correlation between age (p = 0.3), gender (p = 0.7), diagnosis (p  = 0.84), or number of ISBTIs (p = 0.17) with successful outcome.

CONCLUSION

Successful outcomes occurred in 72 % patients after the first ISBTI. 25 % required further surgical management of their symptoms. Further work is required to help predict which patients will benefit from ISBTI.

The untold truth about "bath salt" highs: A case series demonstrating local tissue injury

The epidemic of injecting cathinone derivatives, marketed as "bath salts", by intravenous drug users among inner city Dubliners led to an associated rise in soft tissue complications. The spectrum of the cases encountered, ranging from self-limiting cellulitis to extensive abscess formation, at a single institution is described.

Abstract P182: Comparing Blood Pressure Control in Diabetic Versus Nondiabetic Veterans Following Percutaneous Coronary Intervention

Background: Blood pressure control in patients with coronary artery disease (CAD) or diabetes is essential to decrease morbidity and mortality. The US Joint National Committee VII (JNC-7) recommends systolic blood pressure (SBP) <130 and diastolic blood pressure (DBP) <80. These values can be attained using beta-blockers, angiotensin antagonists, calcium channel blockers, diuretics and nitrates.

Methods: We conducted a retrospective cohort study focusing on the attainment of the JNC-7 guidelines, comparing 331 diabetic to 524 non-diabetic patients who underwent percutaneous coronary intervention (PCI) between September 2004 and December 2009 at the Jesse Brown Veterans Hospital in Chicago, IL.

Results: Among the diabetic population, the mean SBP decreased 135 to 131mmHg (p = 0.0014) and mean DBP decreased 72 to 70mmHg (p= 0.0014). In non-diabetics, the mean SBP decreased 133 to 128mmHg (p<0.0001) and mean DBP decreased 73 to 71mmHg (p<0.0007). The percent of diabetics at JNC-7 SBP goal increased from 41 to 50% (136 to 166 of 331) (p= 0.0041), however the percent change at DBP goal was not significant. In non-diabetics, percent at goal for SBP increased 45 to 57% (236 to 299 of 524) (p<0.0001) and for DBP increased 69 to 76% (362 to 398 of 524) (p=0.0075). At six months, among diabetics, the medication usage increased for beta-blockers, from 80 to 92% (265 to 305 of 331) (p<0.0001) and for nitrates from 32 to 37% (106 to 122 of 302) (p=0.0465). Among non-diabetics, use of beta-blockers increased from 68 to 87% (356 to 456 of 524) (p<0.0001) and nitrates from 20 to 25% (105 to 131 of 524) (p=0.0054). Use of angiotensin antagonists also increased from 52 to 71% (272 to 372 if 524) (p<0.0001) among non-diabetics.

Conclusions: There were improvements in blood pressure among both populations at six months post-PCI. Both groups attained JNC-7 SBP goals; only non-diabetics achieved DBP goal. Medication use increased for both groups with beta-blockers and nitrates. Angiotensin antagonists only increased significantly among non-diabetics. This demonstrates that post-intervention, tighter control of blood pressure is attempted however levels are not yet optimal.

Abstract P183: Lipid Control in Veterans Following Percutaneous Intervention

Background: Management of lipids is vital in patients with underlying coronary artery disease (CAD). According to the American College of Cardiology (ACC) guidelines, all patients with CAD should have low density lipoproteins (LDL) goals to be less than 100 mg/dl with the therapeutic option of treatment to less than 70 mg/dl. This can be achieved using multiple lipid lowering agents, however statin use is encouraged in CAD patients due to its multiple beneficial effects.

Methods: We conducted a retrospective cohort study focusing on lipid management and statin use in 857 veterans undergoing percutaneous coronary intervention (PCI) between September 2004 and December 2009 at the Jesse Brown Veterans Hospital in Chicago, IL. Values were collected both pre-intervention as well as at six month follow up.

Results: Both pre and post PCI, focus was maintained on the total cholesterol as well as the LDL levels. The mean total cholesterol prior to intervention was 166mg/dl and decreased to150mg/dl at six month follow up. The LDL mean pre-PCI was 98mg/dl and at six months the mean LDL decreased to 86mg/dl. With regards to ACC guidelines, the percent at goal for LDL less than 100mg/dl increased from 59% pre-PCI to 74% post-PCI Furthermore, treatment to less than 70mg/dl increased from 22 to 32% at six months. Lastly, the use of statins increased from 72 to 89%.

Conclusions: There were in improvements in both total cholesterol and LDL values at six months post-PCI. There were also improvements in the percentage of patients who met the ACC recommended goal of LDL cholesterol less than 100mg/dl and the suggested goal of 70mg/dl. At six months, there was also an increase in usage of statin therapy.

Abstract P166: Blood Pressure Control Following Percutaneous Coronary Intervention at a VA Hospital

Background: Blood pressure (BP) control in patients with coronary artery disease (CAD) decreases morbidity and mortality. The US Joint National Committee VII (JNC-7) recommends patients with underlying CAD have a goal systolic blood pressure (SBP) < 130 and a diastolic blood pressure (DBP) < 80. These goals can be achieved by using multiple classes of drugs, including beta-blockers (BB), angiotensin antagonists (ACE-I/ARB), calcium channel blockers (CCB), diuretics, and nitrates.

Methods: We conducted a retrospective cohort study focusing on the attainment of JNC-7 recommended BP goals in a diverse population of 857 veterans undergoing Percutaneous Coronary Intervention (PCI) between September 2004 and December 2009 at the Jesse Brown Veterans Hospital in Chicago, IL. Data was collected comparing both BP measurements and anti-hypertensive regimens pre and post PCI.

Results: In the 857 patients studied, the mean SBP decreased from 134 mm Hg to 129 mm Hg (p<0.0001), and the mean DBP decreased from 73 mm Hg to 71 mm Hg (p<0.0001). In regards to the JNC-7 guidelines, the percent of patients who achieved SBP goals increased from 44% to 54% (377 to 463 of 857) (p<0.0001), and the percent of patients who achieved DBP goals increased from 71% to 78% (608 to 668 of 857) (p<0.0001). There was a change in the use of each drug class; the use of ACE-I/ARB increased from 72% to 89% (617 to 763 out of 857) (p<0.0001), the use of BB increased from 63% to 76% (540 to 651 out of 857) (p<0.0001), the use of diuretics increased from 41% to 43% (351 to 369 out of 857) (p=0.2997), and the use nitrates increased from 24% to 29% (206 to 249 out of 857) (p=0.0007). The use of CCB, however, decreased from 34% to 30% (291 to 257 out of 857) (p=0.0121).

Conclusions: There was improvement in both mean BP and percentage of patients achieving JNC-7 recommended goals for SBP & DBP at six months post PCI, though overall percentages still remain suboptimal. Additionally, medication use improved in most drug classes, with the exception of calcium channel blockers. In particular, both beta-blocker and angiotensin antagonist use increased significantly.

Abstract P253: Lipid Control in Minority and Nonminority Veterans Following Percutaneous Intervention

Background: Control of lipids is vital in patients with Coronary Artery Disease (CAD). According to the American College of Cardiology (ACC) guidelines, all patients with CAD should have low density lipoprotein (LDL) goals of less than 100 mg/dl. It is unclear whether race plays a role in lipid control.

Methods: We conducted a retrospective cohort study focusing on lipid management and statin use in 857 veterans, 41% minority (M) & 59% non-minority (NM), undergoing percutaneous coronary intervention (PCI) between September 2004 and December 2009 at the Jesse Brown Veterans Hospital in Chicago, IL. Values were collected both pre-intervention and at six month follow up.

Results: The mean total cholesterol and LDL decreased from prior to intervention to six month follow up in both groups. The mean total cholesterol pre-PCI and at six month follow up was 166 mg/dl & 150 mg/dl, respectively, in the minority group and 165 mg/dl & 150 mg/dl, respectively, in the non-minority group. The mean LDL pre-PCI and at six month follow up was 100 mg/dl & 88 mg/dl, respectively, in the minority group and 94 mg/dl & 82 mg/dl, respectively in the non-minority group. The percent of patients at LDL goals of 100 mg/dl pre-PCI and at six month follow up were 55% and 73% in the minority group and 64% and 77% in the non-minority group. The percent of patients on a statin pre-PCI and at six month follow up were 70% and 91% in the minority group and 75% and 88% in the non-minority group.

Conclusions: There were improvements in both total cholesterol and LDL values at six months post-PCI in both the minority and non-minority groups. There were also improvements in the percentage of patients who met the ACC recommended goal of LDL cholesterol less than 100 mg/dl at six months in both groups. At six months, there was also an increase in usage of statin therapy in both groups. Race did not appear to play a significant role in lipid management.

Analysis of methods of providing anonymity in facial photographs; a randomised controlled study

Clinical images are invaluable in medical teaching and research publications. In the past efforts to conceal patient identity, if any, were limited to a black bar concealing the eyes. However, there is no consensus on this among major journals and publishing houses. This research analyses the effectiveness of blacking out the eyes in facial photographs and evaluates alternative techniques. 126 questionnaires were completed. The average numbers of correct responses out of 30 was 24.64 (82.13%) in the control group, 20.59 (68.63%) in the eyes, 20.42 (68.07%) in the eyes and nose group, and 17.53 (58.43%) in the T-shaped group (eyes, nose and mouth). The traditional method of covering the eyes does significantly decrease recognition, however it is only as effective as covering the nose and mouth. The more of the face that is covered the less likely it is that the person is recognised. However, there are people who remain identifiable no matter how much of the face is covered. This work highlights the importance of obtaining consent prior to publication as well as attempting to hide identity.

Familial atypical cold urticaria: description of a new hereditary disease

BACKGROUND

Acquired cold urticaria (ACU) is usually a self-limited, sporadic, cutaneous disease diagnosed based on history and a positive cold stimulation time test (CSTT) result. We describe 3 unrelated families (A, B, and C) with lifelong atypical cold urticaria distinguished from ACU and familial cold autoinflammatory syndrome.

OBJECTIVE

We sought to describe a new hereditary disease of cold urticaria and study its pathogenesis.

METHODS

Questionnaires, interviews, physical examinations, skin testing, and biopsies were performed. Absolute values, means, and prevalence percentages of data are reported.

RESULTS

Thirty-five subjects are described with familial atypical cold urticaria (FACU; family A, 17; family B, 8; and family C, 10) displaying an autosomal dominant pattern of inheritance. All tested subjects had negative CSTT results. Completed questionnaires from affected and unaffected members of families A and B (n = 35) revealed that all affected subjects had lifelong symptoms that began in early childhood with pruritus, erythema, and urticaria after cold exposure. Angioedema (family A, 23%; family B, 42%) and syncope, near syncope, or both (family A, 46%; family B, 86%) were also present. Triggers included cold atmosphere (100%), aquatic activities (family A, 92%; family B, 100%), handling cold objects (family A, 54%; family B, 71%), and ingestion of cold foods or beverages (family A, 69%; family B, 100%). Skin biopsy specimens demonstrated a mast cell infiltrate with the appearance of degranulation after cold challenge.

CONCLUSIONS

FACU is a new cold-induced inherited disease that is different than ACU in its natural history, atmospheric cold elicitation, severity of systemic reactions, and CSTT results. FACU differs from familial cold autoinflammatory syndrome in symptom timing and the absence of fever, chills, and joint pain. The cause is suspected to be mast cell related. Treatment of reactions is similar to that for ACU. Further evaluation of pathogenesis and genetics is warranted.

Informational needs of patients with melanoma and their views on the utility of investigative tests

BACKGROUND

The aim of the study was to identify the informational needs of patients with melanoma on disease status and prognosis, and to ascertain their views on the utility of positron emission tomography (PET) and sentinel node biopsy (SNB).

PATIENTS AND METHODS

Patients attending the weekly melanoma outpatient clinic at St Thomas' Hospital London UK between February and August 2007 participated in this cross-sectional survey. Views of 106 melanoma patients were elicited using a face-to face semi-structured questionnaire.

RESULTS

The majority of participants wanted to know everything about their disease (88%). Prognostic information (> 85%) and information on palliative care input (97%) were highly valued. More than 50% expected the doctor to impart this information without negotiation. Nearly 70% of the responders who had previously had a PET scan felt they should decide if and when the scans should be performed. Fifty three percentage had undergone the SNB because the doctor had suggested it.

CONCLUSIONS

Patients with melanoma want detailed and prompt information about their disease including prognosis. Regular PET scans provide reassurance. The role of SNB is not clear to all patients.

Skeletal analysis of the Fgfr3(P244R) mouse, a genetic model for the Muenke craniosynostosis syndrome

Muenke syndrome, defined by heterozygosity for a Pro250Arg substitution in fibroblast growth factor receptor 3 (FGFR3), is the most common genetic cause of craniosynostosis in humans. We have used gene targeting to introduce the Muenke syndrome mutation (equivalent to P244R) into the murine Fgfr3 gene. A rounded skull and shortened snout (often skewed) with dental malocclusion was observed in a minority of heterozygotes and many homozygotes. Development of this incompletely penetrant skull phenotype was dependent on genetic background and sex, with males more often affected. However, these cranial abnormalities were rarely attributable to craniosynostosis, which was only present in 2/364 mutants; more commonly, we found fusion of the premaxillary and/or zygomatic sutures. We also found decreased cortical thickness and bone mineral densities in long bones. We conclude that although both cranial and long bone development is variably affected by the murine Fgfr3(P244R) mutation, coronal craniosynostosis is not reliably reproduced.