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.

The Manchester experience – a novel technique for supra-annular placement of the Edwards SAPIEN 3 Ultra TVH prosthesis in severe bicuspid aortic valve stenosis

Background

Bicuspid AV disease has been excluded from the seminal trials evaluating transcatheter heart valve (THV) placement in severe aortic stenosis. Although registry data has shown good results overall, case selection likely involves more challenging anatomical subsets being treated either surgically or medically in this very heterogenous condition. Conventional annular placement, as well as high annular placement in tapered anatomies remain the commonest deployment techniques. We reasoned that marked supra-annular placement with the mid-portion of the SAPIEN 3 Ultra (S3U) valve sealing skirt placed at the narrowest opening point at commissural level could be an alternative strategy allowing treatment of additional patient groups. This proposed technique takes advantage of elliptical expansion at commissural level with more circular expansion above and below this point to prevent embolisation, as well as sealing skirt positioning at the narrowest opening point to prevent paravalvular leak.

Aims

We examined the feasibility of marked supra-annular placement of the balloon-expandable S3U prosthesis with the mid-point of the sealing skirt placed at commissural level in patients with severe bicuspid aortic valve stenosis and relative contra-indications to annular placement.

Methods

We assessed patients with severe bicuspid aortic stenosis undergoing TAVI at our centre over a 9-month period and identified those with relative contra-indications to conventional annular placement. These included: (i) excessive annular size (ii) severe leaflet and raphe calcification with risk of rupture into the right ventricle (iii) excessive leaflet length with potential leaflet overhang. CT imaging was used to define the narrowest opening location at commissural level, typically 10–15mm supra-annular. The diameter at this level was used to select THV size. Calculations were made to approximate the mid skirt level to this supra-annular position. In most cases this involved supra-annular positioning with the lower THV border 5–8mm supra-annular. This was achieved in most cases by aligning the unexpanded border with the annulus.

Results

Out of 9 patients with biscupid AV, 4 had relative contra-indications for annular placement. In all 4 cases, excellent valvular expansion with only minimal paravaulvar leak was achieved with placement of the S3U prosthesis at 5–7mm above the annulus and with supra-annular sealing at commissural level. Annular dimensions of 35.5mm and 31.5mm were successfully treated with 29mm and 26mm valves due to significant tapering at commissural level in 2 patients. There were no procedural complications, incidences of AV blocks or valve embolisation.

Conclusion

As a proof of concept, we have demonstrated excellent outcomes with marked supra-annular TAVI placement in patients with severe bicuspid AV stenosis and anatomy unfavourable for conventional annular placement. This is the first description of this completely novel deployment technique.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Manchester Royal Infirmary

The effect of animal shelter sound on cat behaviour and welfare

This study assessed how sound affected fear- and maintenance-related behaviour in singly housed cats (Felis silvestris catus) in an animal shelter. Two daily 30-min observation sessions (morning and evening) were made for 98 cats from admittance for ten days or until the cat was removed. Cat behaviour and presence of sound (classified by the source) were recorded by instantaneous and onezero sampling with 15-s intervals. Each 30-min observation session was classified as 'quiet' or 'noisy' if the one-zero score for presence of sound was above or below the median of sessions at that time of day. To ensure that cats had at least two complete days of comparable observations, statistical analysis was restricted to the 70 cats (30 females, 40 males) present for two or more weekdays. Cats varied widely in the amount of fear and maintenance behaviour they performed. Males showed less fear and maintenance behaviour than females. Morning sessions consistently had much more sound than evenings, and cats showed more fear behaviour and less maintenance behaviour in the mornings. Cats showed more fear behaviour in noisy morning sessions than quiet ones, with no comparable difference in maintenance behaviour. Where sessions included a pronounced transition in sound, fear-related behaviour was more common after a transition from quiet to noisy and less common after a transition from noisy to quiet. The results show that shelter cats vary greatly in their responses and suggest that sound in shelter environments can substantially affect their behaviour. Lowering sound levels in shelters may help improve cat welfare.

Animal welfare during a period of intensification: The views of confinement and alternative pig producers

In Hungary, where intensive and non-intensive pig production co-exist, in-depth interviews were used to explore the views and priorities of pig producers regarding animal welfare and ethical animal production. Farmers using confinement systems and those with alternative, non-confinement systems shared certain core values such as attachment to animals and to traditional community values. Both groups agreed on most key elements of animal welfare (health, nutrition, etc) but had different priorities for how to achieve these within their production systems. Alternative producers considered unconfined, semi-natural environments important for animal welfare, and confinement producers with medium-sized operations (400–600 sows) generally agreed. Only the three largest producers (>1,000 sows) expressed strong confidence in confinement methods. Different producers emphasised different features for ensuring animal welfare. Producers with large-scale confinement systems depend strongly on staff and automation and require the means to find and retain good staff. Those with medium-scale confinement systems see automation and personal involvement with animals as crucial, and they need economic conditions that allow herd size to remain within their personal capacity. Those operating alternative systems see small herds and non-confinement systems as crucial for animal welfare and need markets that encourage such systems. Subsidies, regulatory systems and technological developments would need to be tailored to meet the different needs in order for producers to improve animal welfare in the different systems and according to their own values and priorities. Medium-scale confinement producers could better act on their values if economic conditions allowed them to use more natural systems.

Can eye surface temperature be used to indicate a stress response in harbour seals (Phoca vitulina)?

Infra-red thermography (IRT) is increasingly being used to estimate physiological stress responses in animals via changes in eye surface temperature. The aim of this study was to determine whether eye temperature of harbour seals (Phoca vitulina) changes in response to routine handling and the potentially painful procedure of flipper-tagging, and if responses to tagging can be mitigated by subcutaneous injection of lidocaine. Orphaned pups (n = 52) at a rehabilitation facility were assigned to one of four treatments: Lidocaine (handled twice, once for injection and once for tagging); Saline (also handled twice); Tag Only (handled once); Sham Tag (handled once). Eye temperature increased more when pups were first handled compared to pups that were not handled and increased further in pups that underwent a second handling. Eye temperature of pups that were tagged without any previous treatment (Tag Only) increased compared to pups that were sham-tagged. Eye temperature also tended to increase after pups were injected with lidocaine but not saline. These results suggest that: (i) handling causes a physiological stress response; (ii) increased eye temperature arising from the second handling suggests the first handling was likely aversive, resulting in sensitisation to further handling; (iii) the rise in eye temperature after tagging, but not sham-tagging, may reflect pain from tagging; and (iv) lidocaine, at the dosage tested, did not appear to reduce the physiological response to tagging. These results show promise for the use of eye temperature to monitor stress responses and for evaluating the potential aversiveness of routine procedures in seals.

Protecting farm animal welfare during intensification: Farmer perceptions of economic and regulatory pressures

Pig (Sus scrofa) production in Hungary provides a case study in how external pressures influence animal production, animal welfare and intensification. External pressures were explored in 24 in-depth, semi-structured interviews with Hungarian pig farmers operating either confinement or alternative systems. Confinement producers reported intense economic pressure because of a power imbalance with the large meat-processing companies that buy their animals. These companies, in the view of the farmers, can source internationally and largely dictate prices. When prices paid by the companies fall below the cost of production, farmers cannot respond by reducing production because of the long time-lags between breeding and marketing; and with their large investment in confinement buildings that are difficult to modify, farmers see little option except to reduce production costs further. Alternative farmers reported being more resilient to economic pressures because they sell into niche markets, use inexpensive technologies, and typically produce a diversity of agricultural products which buffer periods of low profit in any one commodity. The current regulatory system was seen as inadequate to protect animal welfare from economic pressure because it focuses on certain inputs rather than welfare outcomes, does not cover some important determinants of animal welfare, and does not accommodate certain realities of farming. Current subsidies were also seen as an inadequate remedy, and were viewed as inequitable because they are difficult for alternative producers to access. Consumer-choice options, while used by alternative producers, are not available in mainstream markets which demand uniform 'commodity' production. The economic constraints that influence animal welfare might be better mitigated by a regulatory system developed with greater consultation with producers, a more equitable subsidy programme, and more developed consumer-choice programmes.

Management of cull dairy cows: Culling decisions, duration of transport, and effect on cow condition

Many cows culled from dairy farms arrive at livestock markets or abattoirs in compromised condition, but it is unknown whether cows are compromised at the time of culling or deteriorate during the marketing process. This study followed cull cows from farm to abattoir, monitored any deterioration, and tested the effect of providing such information on subsequent culling. For 11 mo, data were collected from 20 dairy farms, livestock markets, and abattoirs. Cows' body condition, lameness, and udder condition (as binary outcomes) were assessed at 4 points: when placed on the culling list, before leaving the farm, at auction, and at the abattoir. Based on the first 5 mo of data (baseline period), information materials were provided to 10 randomly selected farms (Informed treatment), and the other 10 served as a Control. Logistic mixed models were used to test differences in cows' condition at the 4 points of assessment, using the assessment before leaving the farm as a reference value and cow-within-farm as a random effect. The effects of providing information on outcome measures (proportion thin, severely lame, with udder edema, poor fitness for transport, euthanized, and died) were tested with a general linear model. As demand for milk increased during the baseline period, additional linear mixed models were fitted to test whether the same outcome measures were affected by time (baseline or treatment period) and treatment (Informed or Control) using farm as a random effect. While cows were on the culling list (before shipping) the odds of being thin or having poor fitness for transport increased. After leaving the farms, cows spent (mean ± standard deviation) 82 ± 46 h in the marketing system before being slaughtered. Shipping from farm to abattoir increased the odds of being thin, having udder edema, or showing poor fitness for transport [odds ratio (OR) 5.8, 95% confidence interval 4.2 to 8.1; OR 14.7, 10.7 to 20.2; and OR 7.3, 5.7 to 9.5, respectively]. Providing this information to farmers (Informed treatment) did not affect the outcome measures. Compared with the baseline, during the treatment period fewer cows were shipped when thin (4.9 versus 9.0%) and with poor fitness for transport (15.7 versus 25.8%), and fewer cows died (5.4 versus 11.9%) or were euthanized (13.3 versus 20.5%). Increased demand for milk appeared to lead to delayed culling, such that more compromised cows were sent to slaughter. The results of this study show a need for clear and specific guidelines to assess fitness for transport of cull dairy cows.

Fitness for transport of cull dairy cows at livestock markets

Cows are regularly removed from dairy herds and sold at livestock markets. Many cows are removed because of health problems, and their fitness for transport may vary because of seasonal variation, delayed or poor on-farm culling decisions, injuries during transport, and other factors. However, many dairy producers lack feedback about the condition of their cows during the marketing process and how cow condition influences sale price. This study evaluated the condition of cull dairy cows sold at livestock markets, tested how changing demand for milk influenced fitness for transport, and quantified how cow condition affected the price paid. For 12 mo, 2 livestock markets in British Columbia, Canada, were visited during 137 auction events when cull dairy cows were sold; 3 trained assessors observed 6,263 cull dairy cows while they were marketed in a sale ring. Observers recorded the cows' body condition score (BCS), locomotion score (LS), udder condition, quality defects (e.g., injuries, illness), and price. Logistic regression was used to test how month-to-month changes in demand for milk affected cows' fitness for transport, and a linear mixed model assessed how the animals' condition influenced the price. About 10% of the cows were thin (BCS ≤2), 7% were severely lame (locomotion score ≥4), 13% had engorged or inflamed udders, and 6% had other quality defects including abscesses, injuries, and signs of sickness (e.g., pneumonia). Cows culled during months with increased milk demand had much higher odds of poor fitness for transport (odds ratio 8.6, 95% confidence interval: 4.02-18.22). The price was most reduced if cows were thin (BCS ≤2) or visibly sick (-$0.63 ± 0.01/kg and -$0.56 ± 0.02/kg, respectively). Prices were reduced to a lesser degree by locomotion score ≥4 (-$0.35 ± 0.02/kg) and by udder condition (udder inflammation; -$0.30 ± 0.02/kg). Overall fitness for transport reduced the price by $0.51 ± 0.01/kg. In summary, about 30% of the cows sold at livestock markets had poor fitness for transport, which was partially influenced by increased milk demand and resulted in reduced market prices.

INVITED REVIEW: Farm size and animal welfare

Critics of agricultural intensification have argued that the transition from smaller to larger farms has compromised animal welfare. To critically examine evidence relevant to this claim, we reviewed more than 150 publications that examined the relationship between farm size and at least one animal welfare indicator. Although much of this literature focuses on dairy cattle, we also reference other farmed species where appropriate. We found little evidence of any simple relationship, negative or positive, between farm size and animal welfare. Instead, the evidence suggests that larger farms provide some opportunities to improve animal welfare but may also create welfare risks. For example, larger farms permit more specialized and professional management of animal health but can make it more difficult to accommodate outdoor access that some view as integral to animal welfare. Future research should attempt to specify the underlying casual mechanisms by which statistical associations between farm size and indicators of welfare are believed to occur. We also suggest that policy and advocacy efforts aimed at reversing increases in farm size would be better directed toward improving welfare on farms of all sizes.

Continuous flow hydrogenations using novel catalytic static mixers inside a tubular reactor

Continuous flow reactor for the hydrogenation of organic substrates using novel catalytic static mixers.

Public Attitudes to Housing Systems for Pregnant Pigs

Understanding concerns about the welfare of farm animals is important for the development of socially sustainable production practices. This study used an online survey to test how views on group versus stall housing for pregnant sows varied when Canadian and US participants were provided information about these systems, including access to scientific papers, YouTube videos, Google images, and a frequently-asked-questions page (S1 Appendix). Initial responses and changes in responses after accessing the information were analyzed from Likert scores of 242 participants and from their written comments. Participants were less willing to accept the use of gestation stalls after viewing information on sow housing. For example, initially 30.4% of respondents indicated that they supported the use of gestation stalls; this declined to 17.8% after participants were provided additional information. Qualitative analysis of comments showed that supporters of gestation stalls expressed concern about the spread of disease and aggression between animals in less confined systems, whereas supporters of group housing placed more emphasis on the sow’s ability to interact socially and perform natural behaviors. These results point to public opposition to the use of gestation stalls, and indicate that the more that the public learns about gestation stalls the less willing they will be to accept their use.

Five population-based interventions for smoking cessation: a MOST trial

Little is known about the relative, additive, and interactive effects of different population-based treatments for smoking cessation. The goal of this study was to evaluate the main and interactive effects of five different smoking interventions. Using the multiphase optimization strategy (MOST), 1,034 smokers who entered a Web site for smokers (smokefree.gov) were randomly assigned to the "on" and "off" conditions of five smoking cessation interventions: the National Cancer Institute's (NCI) Web site (www.smokefree.gov vs a "lite" Web site), telephone quitline counseling (vs none), a smoking cessation brochure (vs a lite brochure), motivational e-mail messages (vs none), and mini-lozenge nicotine replacement therapy (NRT vs none). Analyses showed that the NCI Web site and NRT both increased abstinence; however, the former increased abstinence significantly only when it was not used with the e-mail messaging intervention (messaging decreased Web site use). The other interventions showed little evidence of effectiveness. There was evidence that mailed nicotine mini-lozenges and the NCI Web site (www.smokefree.gov) provide benefit as population-based smoking interventions.

Welfare of non-traditional pets

The keeping of non-traditional or 'exotic' pets has been growing in popularity worldwide. In addition to the typical welfare challenges of keeping more traditional pet species like dogs and cats, ensuring the welfare of non-traditional pets is complicated by factors such as lack of knowledge, difficulties meeting requirements in the home and where and how animals are obtained. This paper uses examples of different species to highlight three major welfare concerns: ensuring that pets under our care i) function well biologically, ii) are free from negative psychological states and able to experience normal pleasures, and iii) lead reasonably natural lives. The keeping of non-traditional pets also raises ethical concerns about whether the animal poses any danger to others (e.g. transmission of zoonotic diseases) and whether the animal might cause environmental damage (e.g. invading non-native habitats when released). The authors used these considerations to create a checklist, which identifies and organises the various concerns that may arise over keeping non-traditional species as pets. An inability to address these concerns raises questions about how to mitigate them or even whether or not certain species should be kept as pets at all. Thus, the authors propose five categories, which range from relatively unproblematic pet species to species whose keeping poses unacceptable risks to the animals, to humans, or to the environment. This approach to the evaluation and categorisation of species could provide a constructive basis for advocacy and regulatory actions.

The globalisation of farm animal welfare

Animal welfare has achieved significant global prominence for perhaps three reasons. First, several centuries of scientific research, especially in anatomy, evolutionary biology and animal behaviour, have led to a gradual narrowing of the gap that people perceive between humans and other species; this altered perception has prompted grass-roots attention to animals and their welfare, initially in Western countries but now more globally asthe influence of science has expanded. Second, scientific research on animal welfare has provided insights and methods for improving the handling, housing and management of animals; this 'animal welfare science' is increasingly seen as relevant to improving animal husbandry worldwide. Third, the development and use of explicit animal welfare standards has helped to integrate animal welfare as a component of national and international public policy, commerce and trade. To date, social debate about animal welfare has been dominated bythe industrialised nations. However, as the issue becomes increasingly global, it will be important for the non-industrialised countries to develop locally appropriate approaches to improving animal welfare, for example, by facilitating the provision of shelter, food, water and health care, and by improving basic handling, transportation and slaughter.

Depressive symptoms are associated with food insufficiency and nutritional deficiencies in poor community-dwelling elderly people

Depression is associated with nutritional deterioration in older persons and is highly prevalent among people of low socioeconomic status (LSES).

OBJECTIVES

To determine the prevalence of depressive symptoms and food insufficiency, and to examine the relationship between dietary intake, food insufficiency and depression, in LSES community dwelling elderly.

DESIGN

Cross-sectional study.

SETTING

Lod, a town in the central Israel.

PARTICIPANTS

Community-dwelling welfare recipients aged 60 to 92.

MEASUREMENTS

Depression was assessed by 15-item Geriatric Depression Scale (GDS-short version), using a score ≥ 10 as the cut off point for clinically important depressive symptoms. Dietary intake was evaluated using a 24-hour dietary recall. Food insufficiency was defined by participants reporting that they did not have enough food to eat " sometimes " or " often " .

RESULTS

This study reports on 112 persons aged 60 years and above (27.1% men). The prevalence of depression in this population was 47%; 25% of the study sample was classified as " food insufficient " . Macronutrients intake was similar for depressed and non-depressed persons, except for polyunsaturated fats which was lower among the depressed group (7.9 ± 4.9 vs.11.0 ± 7.5 g/day in the non-depressed, p=0.03). Vitamins and minerals intake was lower than recommended for both groups; vitamin E intake was associated with depression. In regression models controlling for confounding variables, an increase of 1 mg in vitamin E intake and 1 gram in polyunsaturated fatty acids (PUFA) intake was associated with lower risk for depression (OR=0.73, p=0.008 and OR=0.86, p=0.007 respectively) Participants who reported food insufficiency were 10 times more likely to be depressed compared with those who reported sufficient food.

CONCLUSIONS

Given the evaluated adverse association between depressive symptoms and food insufficiency, more efforts are needed to guarantee adequate food intake, particularly foods rich in vitamin E and PUFA, in poor elderly people. Further studies are needed to clarify the temporal relationship between the emotional and nutritional domains in this vulnerable population.

Risk factors for the initial symptomatic giardia infection in a cohort of young Arab-Bedouin children

BACKGROUND

Giardiasis is a common protozoan infection with clinical manifestations in children ranging from asymptomatic carriage to persistent diarrhoea with malabsorption. It can lead to growth and developmental retardation.

AIM

The study evaluated risk factors for the initial symptomatic giardiasis (SG) episode among Arab-Bedouin children in Israel.

METHODS

A community-based, prospective cohort study was conducted in Rahat, a Bedouin township in southern Israel. Infants (n=238) were followed by weekly visits from birth to age 18 months. Giardia infection was identified by antigen detection in faecal specimens.

RESULTS

Approximately 26% of children experienced one or more SG episode. Mean (SD) age for first SG episode was 12.3 (3.3) months, with 95% of episodes occurring in children >6 months of age. Risk for the first SG in children >6 months of age was associated with it being spring or summer [odds ratio (OR) 6.16, p<0.001], exposure to livestock (OR 4.89, p=0.002) and prior infection with entero-aggregative Escherichia coli (EAEC) (OR 1.12 for each additional percentage in stool prevalence, p=0.02). Weight-for-age Z-scores at age 6 months were inversely related to SG risk (OR 0.62 for each unit increase in Z-score, p=0.029).

CONCLUSIONS

Giardiasis is an important cause of diarrhoea in Bedouin children. Increased risk of SG in spring/summer might be linked to environmental conditions or seasonal dietary practices which increase virulence or transmission. SG in those exposed to livestock suggests that there are zoonotic risk factors or that hygiene is a causal factor. The association between EAEC infection and SG warrants further investigation.

Intra-vaginal hydrosonography and cervical length assessment in pregnant women before induction of labour: A modified technique

The objective of this study was to demonstrate a new simple technique in introducing saline into the vagina during trans-vaginal scan. This technique will help to identify the cervical length properly when it is difficult to delineate the cervix. This is a prospective study, which included 104 pregnant women who booked to have induction of labour at term over a period of 3 years. Women who were included in the study underwent a transvaginal scan to measure cervical length. Sterile saline was introduced into the vagina using either an ordinary syringe or an Endosampler and the cervical length re-measured. When the outer border of the cervix was not clearly visualised, there was a highly statistically significant difference (p < 0.001) between the medians of pre-and post-saline cervical length measurements. In contrast, no significant difference between the medians (p > 0.05) was detected when the outer border of the cervix was clearly delineated. In those women, who had previous surgery to the cervix, it was very difficult to identify the cervix at all without the saline injection during transvaginal scanning. We conclude that intra-vaginal saline can be used as a contrast medium to help delineate the cervix if it is difficult to identify during transvaginal scan. The Endosampler makes the introduction of the saline into the vagina easy, controlled and well tolerated.

Increased rate of small-for-gestational-age neonates in pre-eclamptic women with preterm deliveries

We sought to determine whether hypertensive pregnancies can be considered a distinct subgroup of premature births. All women in our centre who had had singleton preterm spontaneous deliveries over an 8-year period were divided into hypertensive and normotensive groups and compared for maternal characteristics and neonatal outcome. Of the 4175 eligible women, 9.8% (n = 410) had pre-eclampsia. These patients had higher rates of small-for-gestational-age neonates (19%, 78/410), abruptio placenta (7.8%, 32/410) and caesarean section rate (52.7%, 216/410) than the normotensive women (4.3%, 158/3765; 4.6%, 172/3765; and 19.6%, 739/3765, P < 0.001, respectively. The rate of preterm premature rupture of membranes was significantly lower in the hypertensive than in the normotensive group (5.9% vs. 17%, respectively; P < 0.001). We concluded that hypertensive women who deliver prematurely belong to a subgroup with particular characteristics. The increased rate of small-for-gestational-age neonates in pre-eclamptic women suggests that reduced uteroplacental perfusion may cause fetal growth impairment before the onset of the hypertensive disorder.