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.

Impact of preoperative hemodynamic optimization on right ventricular failure after left ventricular assist device implantation

Background

Preoperative hemodynamic parameters are linked to higher rates of right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation. It is unclear if preoperative hemodynamic optimization decreases the incidence of RVF after LVAD.

Methods

Single-center retrospective analysis of consecutive LVAD recipients between 2015 and 2020. Pre-operative right heart catheterization and a strategy of hemodynamic optimization were performed in all patients. Pre-operative right ventricular dysfunction (RVD) was defined by a CVP ≥16 mmHg and pulmonary artery pulsatility index (PAPi) &lt;1.85. The optimization goal was defined as CVP &lt;16 mmHg, PAPi ≥1.85, and Cardiac Index of ≥2.0. The main outcome was RVF (inotropes &gt;14 days, discharge on home inotropes, or right ventricular mechanical support device).

Results

128 LVAD recipients (age 58 years, 74% male, 68% had non-ischemic cardiomyopathy, 45% were on home inotropes, HeartMate 2 in 61%, HeartMate 3 in 31%, and HVAD in 9%) were analyzed. Pre-operative RV dysfunction was present in 48% and these patients were younger, with higher rates of home inotropes, and intra-aortic balloon pump (IABP) pre-LVAD. Postoperative RVF occurred in 60% of patients with RV dysfunction and 40% of the patients without pre-operative RV dysfunction (p&lt;0.002). 40% of patients with RV dysfunction achieved RV optimization goals (32% required IABP). Among those, 53% developed RVF-Post LVAD. RVF was numerically but not significantly higher among those with RV dysfunction who achieved hemodynamic goals (66% vs. 34%, p=0.37) vs. those that did not. Patients with RVF-post LVAD had 10% (n=5) in-hospital mortality.

Conclusion

Pre-LVAD RV dysfunction based on hemodynamic markers is associated with RVF after LVAD implantation. In patients with RV dysfunction, a strategy of pre-LVAD “optimization” to achieve RV hemodynamic optimization goals did not affect the incidence of post-operative RVF.

Funding Acknowledgement

Type of funding sources: None.

Association between inflammation and neural plasticity biomarkers in olfactory neuroepithelium – derived cells and cognitive performance in patients with major depressive disorder

Introduction

Inflammation and neural plasticity play a significant role in major depressive disorder (MDD) pathogenesis and cognitive dysfunction. The olfactory neuroepithelium (ON), closely related to the central nervous system (CNS), allows a non-invasive, low-cost study of neuropsychiatric disorders. However, few studies have used ON cells to ascertain them as biomarkers for MDD.

Objectives

Determine the relationship between inflammatory/neural plasticity markers and cognitive functioning in MDD patients and healthy controls.

Methods

Sample: 9 MDD patients and 7 healthy controls. Exclusion criteria: other Axis I mental disorders (patients) or any mental disorder (controls) and any inflammatory, autoimmune, or CNS diseases. Assessment: sociodemographic, clinical, and cognitive variables (CANTAB) were recorded. mRNA was isolated from ON cells and MAPK14, IL6, TNF-α, Mecp2, BDNF, GSK3, GRIA2, and FosB gene expression levels were quantified using quantitative polymerase chain reaction.

Results

MDD patients showed decreased levels of BDNF (p=0.022), GSK3 (p=0.027), and working memory (p=0.024) compared with healthy controls. In healthy controls, planning was positively correlated with NRF2, BDNF, and MAPK14 gene expression. In MDD patients no correlation between cognitive parameters and inflammation/neural plasticity biomarkers was found.

Conclusions

These results reveal that: (1) Plasticity biomarkers such as BDNF and GSK3 could be useful diagnostic tools for MDD (2) MDD is associated with working memory deficits; (3) no association could be determined between planning and NRF2, BDNF, and MAPK14 gene expression in MDD and (4) the ON is a promising model in the study of neuropsychiatric disorders.

Disclosure

No significant relationships.

Impact of induction therapy on outcomes after heart transplantation

Introduction

Approximately 50% of heart transplant (HT) programs currently employ a strategy of induction therapy (IT) with either interleukin-2 receptor antagonists (IL2RA) or polyclonal anti-thymocyte antibodies (ATG) during the early postoperative period. However, the overall utility of such therapy is uncertain and data comparing induction protocols are limited.

Methods

Adult HT recipients were identified in the United Network for Organ Sharing (UNOS) registry between 1990 and 2020. Patients were grouped according to administration of induction in the post-operative period after HT. Accounting for re-transplantation, Fine and Gray's test compared cumulative incidences of all-cause mortality between groups. Univariate and multivariate analysis were performed using the competing risk model. The risk of treated rejection and hospitalization for infection or rejection was analyzed with multivariable logistic regression.

Results

A total of 63,849 HT recipients were included in the study and among those 59% did not receive induction, 16.6% received ATG, 19.1% IL2RA, 0.7% alemtuzumab, and 4.6% OKT3. Since 2000 IL2RA is the most frequently used form of induction therapy whereas OK3 is not used in the past decade. In multivariable logistic regression models, use of ATG is associated with lower risk of treated rejection at one year after HT (relative risk ratio 0.55, 95% CI 0.47–0.63, p&lt;0.001) compared with no induction whereas IL2RA had similar risk of treated rejection. Similarly, the risk of rejection requiring hospitalization was significantly lower with ATG than no induction. No significant differences in rates of infection requiring hospitalization were noted between groups. Moreover, no differences in rates of post-transplant lymphoproliferative disease and any malignancy were noted between those receiving induction versus no induction. Adjusted all-cause mortality was significantly lower among those treated with ATG than patients that did not receive induction therapy (sub-hazard ratio 0.72, 95% CI 0.63–0.82, p&lt;0.001) (Figure).

Conclusion

Induction therapy with IL2RA is the most used approach. ATG is associated with lower risk of treated rejection and all-cause mortality than no induction and IL2RA.

Funding Acknowledgement

Type of funding sources: None.

Trends, risk factors and mortality of unplanned 30-day readmission after heart transplantation

Introduction

Outcomes after heart transplantation have improved, but the burden of readmissions is understudied. We sought to examine the incidence, risk factors, and associated mortality of unplanned 30-day readmissions following heart transplantation.

Methods

This cohort study examined patient data from the United States population-based Nationwide Readmissions Database. All adults (age ≥18 years) who underwent isolated heart transplantation in US hospitals between January to November of 2012 to 2018 were included. The primary outcomes were 30-day readmission rates and readmission mortality.

Results

A total of 14,784 patients who underwent heart transplantation from 2012 to 2018 were included in our analysis. A total of 3299 (22.3%) patients were readmitted within 30 days after discharge. The median time from discharge to readmission was 9 days, and approximately 70% of the readmissions occurred within 15 days. After multivariable analysis, only CKD (Hazard ratio (HR): 1.11 95% CI 1.00–1.23) and length of stay (HR: 1.002; 95% CI 1.001–1.003; p&lt;0.001) were associated with increased 30-day post-heart transplantation readmission. Readmissions diagnoses were heart transplantation complications, heart transplant rejection, postoperative infection, acute kidney injury, heart failure, pulmonary embolism, pneumonia, and pericardial effusion. The overall incidence of infection as a cause of readmission was 24.9%, with an associated mortality of 2.6% and a Median LOS of 7 days (4–14). The overall incidence of rejection was 38.0%, with a mortality of 1.2% and a median LOS of 5 days (3–8).

Conclusion

Approximately 1 in 5 patients will be readmitted within 30 days after heart transplantation, and most of those readmissions will occur during the first two weeks after discharge. Readmissions were associated with a low mortality rate.

Funding Acknowledgement

Type of funding sources: None.

Outcomes of diabetic patients with end-stage heart failure listed for heart transplantation: a propensity-matched analysis

Background

There are on-going concerns about offering heart transplants to patients with diabetes due to the risk of poor outcomes. We investigated the current trends and outcomes of patients listed for heart transplants in the U.S. and provided a method for risk-stratification.

Methods

Using data from the United Network for Organ Sharing (UNOS), we identified heart failure patients listed for heart transplants between 2010 and 2019. Diabetic patients were propensity-matched with non-diabetes, and waitlist mortality as well as post-transplant graft survival were compared between the two matched groups. Further risk-stratification of the diabetic cohort was done based on the risk factors that independently predict the risk of graft failure.

Results

28,928 adult patients (30% diabetic) with end-stage heart failure were added to the waitlist over the study period. In the propensity-matched cohort, waitlist mortality was higher with diabetics compared to non-diabetics: 19.3 vs 17.1 deaths per 100 person-years, respectively, (HR=1.13 (95% CI=1.04–1.22, p=0.002). Over the study period, 5739 diabetics (mean age 57.6 years, 21.9% female) were transplanted. A total of 1308 (23.3%) and 1143 (20.4%) graft failures occurred in diabetic and non-diabetic recipients, respectively. Compared to non-diabetics, diabetics experienced worse graft survival (HR=1.17, 95% CI=1.08–1.26, p&lt;0.001). We developed a risk score based on the 12 risk factors/markers that independently predict worse graft survival and a risk score of 4 reasonably differentiates between low and high-risk diabetics. Low risk diabetics (score≤4) had similar graft survival as non-diabetics with 1- and 5-year survival of 92.7% and 80.5%, respectively, (HR=0.91, 95% CI=0.82–1.01, p=0.06). On the other hand, high-risk diabetics had worse graft survival compared to non-diabetics (HR=1.52, 95% CI=1.38–1.67, P&lt;0.001) with 1- and 5-year graft survival of 86.8% and 69.8%, respectively.

Conclusion

Diabetic patients with end-stage heart failure listed for heart transplantation experience higher waitlist mortality and worse post-transplant graft survival compared to non-diabetics. However, a simple risk score can be used for further risk-stratification in these patients to maximize survival benefit.

Funding Acknowledgement

Type of funding sources: None.

Trends, risk factors and prognostic implications of postoperative stroke after heart transplantation: an analysis of the UNOS database

Background

Post-operative stroke increases morbidity and mortality after cardiac surgery. Data on characteristics and outcomes of stroke after heart transplantation (HT) are limited.

Methods

We conducted a retrospective analysis of the UNOS database from 2009 to 2020 to identify adults who developed stroke after orthotropic HT. HT recipients were divided according to the presence or absence of postoperative stroke. The primary endpoint was all-cause mortality after HT.

Results

A total of 25,015 HT recipients were analyzed, including 719 (2.9%) patients who suffered perioperative stroke. The rates of stroke increased from 2.1% in 2009 to 3.7% in 2019 and the risk of stroke was higher after the implantation of the new allocation system (odds ratio 1.29, 1.29, 95% Confidence Intervals [CI] 1.06–1.56, p=0.01). HT recipients with postoperative stroke were older (p=0.008), with higher rates of prior cerebrovascular accident (CVA) (p=0.004), prior cardiac surgery (p&lt;0.001), longer waitlist time (p=0.04), higher rates of extracorporeal membrane oxygenation support (ECMO) (p&lt;0.001), left ventricular assist devices (LVAD) (p&lt;0.001), mechanical ventilation (p=0.003) and longer ischemic time (p&lt;0.001). After multivariable adjustment for recipient and donor characteristics, age, prior cardiac surgery, CVA, support with LVAD, ECMO, ischemic time and mechanical ventilation at the time of HT were independent predictors of postoperative stroke. Stroke was associated with increased risk of 30-day and all-cause mortality after HT (hazard ratio [HR] 1.49, CI 1.12–1.99, p=0.007).

Conclusion

Perioperative stroke after HT is infrequent but associated with higher mortality. Redo sternotomy, LVAD and ECMO support at HT are among the risk factors identified.

Funding Acknowledgement

Type of funding sources: None. Risk factors for stroke

Changing demographics, temporal trend in waitlist and post-transplant outcomes after heart transplantation in the United States: analysis of unos database 1991–2019

Background

The landscape of heart transplantation (HT) has changed significantly with respect to patient selection, surgical techniques, and patient outcomes. We sought to investigate temporal trends in patient characteristics, waitlist and post-transplant outcomes after HT in the U.S.

Methods

We queried the national database of the United Network of Organ Sharing (UNOS) to identify adults listed for HT in the U.S. between 1991 and 2019. Patients were divided into four eras based on the three time points in which changes were made to the patient selection/allocation policy (1999, 2006, and 2018), and patient characteristics as well as waitlist and post-transplant outcomes were evaluated for each era.

Results

Between 1991 and 2019, a total of 95,179 patients were added to the waitlist for HT in the U.S. Compared to era 1, patients listed in era 4 were older (mean age: 52.4 years), more female (27.6%) and ethnic minorities (40%), and with higher-risk comorbidities (28.8% diabetes, 35.6% obese). Over the study period, there were 22,070 waitlist deaths and 61,687 transplants.

Compared to the preceding era, there was significant decrease in waitlist mortality in the last 2 eras (e.g., sub-hazard ratio for era 4 vs era 3 =0.37, 95% CI=0.32–0.44). For each year, only 27.1% to 40.5% of those on the waitlist were transplanted. Among those who were transplanted, there was increase in the rates of in-hospital stroke (2.8% in era 1 to 3.7% in era 4), renal failure requiring dialysis (7.2% to 17.1%), and hospital length of stay (14 to 17 days), p-values&lt;0.001 for all. However, this has not negatively impacted short-term survival when compared to the preceding era (1-year graft survival = 89.7% in era 4). Based on a projection model, we predict a 47% increase in living adult heart transplant recipients to to 44,366 in 2040.

Conclusion

There have been significant changes in the characteristics of patients listed for HT in the U.S., including an increasing proportion of high-risk co-morbidities. Although the transplant volume has increased, the wide supply-demand gap persisted. The last 2 changes in the allocation policy in 2006 and 2018 achieved their primary objective of reducing waitlist mortality.

Funding Acknowledgement

Type of funding sources: None.

Short and long term outcomes of cardiac amyloidosis patients listed for heart transplantation in the united states: a propensity-matched analysis

Background

Heart transplantation (HT) in cardiac amyloidosis (CA) patients has been historically controversial due to the risk of amyloid recurrence. However, recent single-center experiences suggest good outcomes in carefully selected patients. We sought to evaluate contemporary outcomes of CA patients listed for HT in the U.S. and evaluate predictors of survival

Methods

Using data from the United Network for Organ Sharing database on adult patients listed for a donor heart in the U.S. between 2010 and 2019, we identified 3 cohorts of patients, namely CA, dilated cardiomyopathy (DCM), and non-CA restrictive cardiomyopathy (RCM). Propensity-match analysis was used to compare primary outcomes of waitlist mortality and post-transplant graft survival between CA and DCM.

Results

Over the study period, 411 CA patients (mean age 62.7 years, 16.1% female) were added to the waitlist. In the propensity-matched cohorts, the rates of waitlist mortality were 33.7, 15.8, and 15.6 per 100 person-years for CA, DCM, and non-CA RCM, respectively. Compared to DCM, there was significantly higher waitlist mortality for CA (HR=1.75, 95% CI=1.16–2.65). Over the study period, 330 CA patients were transplanted with donor hearts. The 1-year graft survival rates for CA, DCM, and non-CA RCM were 89%, 92%, and 86%, respectively; and 5-year graft survival rates were 78%, 82%, and 76%, respectively. Graft survival for CA was significantly worse than DCM (HR=1.46, 1.03–2.08), and the two most significant risk factors for poor graft survival among CA patients were renal failure requiring dialysis while on the waitlist (HR=5.4, 1.6–17) and prior history of malignancy (HR=1.7, 1.0–29). CA patients with neither of the risk factor had 1- and 5-year graft survival that is comparable to those of DCM (HR=1.18, 0.81–1.74). On the other hand, CA patients with either of the risk factor had 1- and 5-year graft survival of 81% and 65%, respectively, (HR=2.33, 1.40–3.87, compared to DCM).

Conclusion

CA patients experience higher waitlist mortality and worse post-transplant graft survival compared to DCM. However, we identified two risk factors that can be used for further risk-stratification in these patients to achieve comparable graft survival as DCM.

Funding Acknowledgement

Type of funding sources: None.

Performance of SARS-CoV-2 rapid antigen test compared with real-time RT-PCR in asymptomatic individuals

Screening, testing and contact tracing plays a pivotal role in control of the COVID-19 pandemic. To enable this it is necessary to increase the testing capacity. This study compared a SARS-CoV-2 rapid antigen test (RAT) and RT-PCR in 842 asymptomatic individuals from Tarapacá, Chile. A sensitivity of 69.86%, specificity of 99.61%, PPV of 94.44% and NPP of 97.22% with Ct values (Ct > 27) that were significantly higher among individuals with false-negative RAT were reported. These results support the fact that RAT might have a significant impact on the identification of asymptomatic carriers in areas that lack suitable laboratories to perform SARS-CoV-2 real-time RT-PCR diagnostics, or the results take more than 24-48 h, as well as zones with high traffic of individuals such as border/customs, airports, interregional bus, train stations or in any mass testing campaign requiring rapid results.

Completed suicide in bipolar i patients after their first hospitalisation

Introduction

Bipolar disorder is a mental disorder that has one of the greatest risk of completed suicide (CS)

Objectives

Determine the rate and the risk factors of CS in a cohort of Bipolar I patients followed after their first hospitalization

Methods

We choose all Bipolar I patients (DSM-IV) who were first time hospitalized in our Psychiatric unit between 1996 and 2016. We reviewed the charts of first hospitalization and recorded multiple baseline variables. In the follow-up we updated the database recording all patients who CS. We compared the different baseline variables between Bipolar patients who CS and the rest.

Results

Of a total of 254 bipolar I patients 9 (3,5%) CS in the mean of 13 years of follow up (rate 40 times higher than General Population). The average age at CS was 41.1 years (range between 26 and 71 years old) so there was a 9 years gap on average between the first psychiatric hospitalization and suicide. CS was characterized by a violent act (8 out of 9 cases, 89 %). When we compared BP patients who CS with the rest, only history of suicide in first-degree relatives was detected as a risk factor significantly associated (P<0.01) with CS. Conversely baseline treatment with anticonvulsants (mainly valproate) was detected as a significantly (P<0.004) protective factor of CS.

Conclusions

1-Bipolar I patients after first hospitalization completed suicide 40 times higher than general population almost always by violent method 2-History of CS in first-degree relatives is predictor of completed suicide

Disclosure

No significant relationships.

Completed suicide in bipolar ii patients after their first hospitalization

Introduction

Bipolar disorder, especially Bipolar II subtype, is a mental disorder that has one of the greatest risk of completed suicide (CS).

Objectives

Determine the rate and the risk factors of CS in a cohort of Bipolar II patients followed after their first hospitalization

Methods

We choose all Bipolar II patients (DSM-IV) who were hospitalized for first time in our Psychiatric unit between 1996 and 2016. We reviewed the charts of first hospitalization and recorded multiple baseline variables. In the follow-up we updated the database recording all patients who CS. We compared the different baseline variables between Bipolar II patients who CS and the rest

Results

Of a total of 59 bipolar II patients 6 (10 %) CS in the mean of 13 years of follow up (rate 120 times higher than General Population). The average age at CS was 45.3 years (range between 33 and 57 years old) so there was a 2 years gap on average between the first psychiatric hospitalization and suicide. CS was characterized by a violent act (5 out of 6 cases, 83 %). When we compared BP II patients who CS with the rest, only history of previous violent suicide attempt was detected as a risk factor significantly associated (P<0.04) with CS.

Conclusions

Bipolar II patients CS early after their first hospitalization and at very high rate (120 times than GP) almost always by violent method. History of previous violent suicide attempt is predictor of completed suicide

Disclosure

No significant relationships.

MRIgRT head and neck anthropomorphic QA phantom: Design, development, reproducibility, and feasibility study

PURPOSE

The purpose of this paper was to design, manufacture, and evaluate a tissue equivalent, dual magnetic resonance/computed tomography (MR/CT) visible anthropomorphic head and neck (H&N) phantom. This phantom was specially designed as an end-to-end quality assurance (QA) tool for MR imaging guided radiotherapy (MRIgRT) systems participating in NCI-sponsored clinical trials.

METHOD

The MRIgRT H&N phantom was constructed using a water-fillable acrylic shell and a custom insert that mimics an organ at risk (OAR) and target structures. The insert consists of a primary and secondary planning target volume (PTV) manufactured of a synthetic Clear Ballistic gel, an acrylic OAR and surrounding tissue fabricated using melted Superflab. Radiochromic EBT3 film and thermoluminescent detectors (TLDs) were used to measure the dose distribution and absolute dose, respectively. The phantom was evaluated by conducting an end-to-end test that included: imaging on a GE Lightspeed CT simulator, planning on Monaco treatment planning software (TPS), verifying treatment setup with MR, and irradiating on Elekta's 1.5 T Unity MR linac system. The phantom was irradiated three times using the same plan to determine reproducibility. Three institutions, equipped with either ViewRay MRIdian 60 Co or ViewRay MRIdian Linac, were used to conduct a feasibility study by performing independent end-to-end studies. Thermoluminescent detectors were evaluated in both reproducibility and feasibility studies by comparing ratios of measured TLD to reported TPS calculated values. Radiochromic film was used to compare measured planar dose distributions to expected TPS distributions. Film was evaluated by using an in-house gamma analysis software to measure the discrepancies between film and TPS.

RESULTS

The MRIgRT H&N phantom on the Unity system resulted in reproducible TLD doses (SD < 1.5%). The measured TLD to calculated dose ratios for the Unity system ranged from 0.94 to 0.98. The Viewray dose result comparisons had a larger range (0.95-1.03) but these depended on the TPS dose calculations from each site. Using a 7%/4 mm gamma analysis, Viewray institutions had average axial and sagittal passing rates of 97.3% and 96.2% and the Unity system had average passing rates of 97.8% and 89.7%, respectively. All of the results were within the Imaging and Radiation Oncology Core in Houston (IROC-Houston) standard credentialing criteria of 7% on TLDs, and >85% of pixels passing gamma analysis using 7%/4 mm on films.

CONCLUSIONS

An MRIgRT H&N phantom that is tissue equivalent and visible on both CT and MR was developed. The results from initial reproducibility and feasibility testing of the MRIgRT H&N phantom using the tested MGIgRT systems suggests the phantom's potential utility as a credentialing tool for NCI-clinical trials.

Acute kidney injury after cardiac surgery: prevalence, impact and management challenges

Acute kidney injury (AKI) is a major medical problem that is of particular concern after cardiac surgery. Perioperative AKI is independently associated with an increase in short-term morbidity, costs of treatment, and long-term mortality. In this review, we explore the definition of cardiac surgery-associated acute kidney injury (CSA-AKI) and identify diverse mechanisms and risk factors contributing to the renal insult. Current theories of the pathophysiology of CSA-AKI and description of its clinical course will be addressed in this review. Data on the most promising renal protective strategies in cardiac surgery, from well-designed studies, will be scrutinized. Furthermore, diagnostic tools such as novel biomarkers of AKI and their potential utility will be discussed.

Multi-faceted Characterization of Wet-milled Griseofulvin Nanosuspensions for Elucidation of Aggregation State and Stabilization Mechanisms

Characterization of wet-milled drug suspensions containing neutral polymer-anionic surfactant as stabilizers poses unique challenges in terms of assessing the aggregation state and examining the stabilization mechanisms. Using a multi-faceted characterization method, this study aims to assess the aggregation state of wet-milled griseofulvin (GF) nanosuspensions and elucidate the stabilization mechanisms and impact of stabilizers. Two grades, SSL and L, of hydroxypropyl cellulose (HPC) with molecular weights of 40 and 140 kg/mol, respectively, were used as a neutral stabilizer at concentrations varying from 0 to 7.5% (w/w) without and with 0.05% (w/w) sodium dodecyl sulfate (SDS). The aggregation state was examined via laser diffraction, scanning electron microscope (SEM) imaging, and rheometry. Zeta potential, stabilizer adsorption, surface tension, and drug wettability were used to elucidate the stabilization mechanisms. The results suggest that deviation from a uni-modal PSD and pronounced pseudoplasticity with power-law index lower than one signify severe aggregation. Polymer or surfactant alone was not able to prevent GF nanoparticle aggregation, whereas HPC-SDS combination led to synergistic stabilization. The effect of polymer concentration was explained mainly by the stabilizer adsorption and partly by surface tension. The synergistic stabilization afforded by HPC-SDS, traditionally explained by electrosteric mechanism, was attributed to steric stabilization provided by HPC and enhanced GF wettability/reduced surface tension provided by SDS. Zeta potential results could not explain the mitigation of aggregation by HPC-SDS. Overall, this study has demonstrated that the elucidation of the complex effects of HPC-SDS on GF nanosuspension stability entails a multi-faceted and comprehensive characterization approach.

TLD and OSLD dosimetry systems for remote audits of radiotherapy external beam calibration

The Imaging and Radiation Oncology Core QA Center in Houston (IROC-H) performs remote dosimetry audits of more than 20,000 megavoltage photon and electron beams each year. Both a thermoluminescent dosimeter (TLD-100) and optically stimulated luminescent dosimeter (OSLD; nanoDot) system are commissioned for this task, with the OSLD system being predominant due to the more time-efficient read-out process. The measurement apparatus includes 3 TLD or 2 OSLD in an acrylic mini-phantom, which are irradiated by the institution under reference geometry. Dosimetry systems are calibrated based on the signal-to-dose conversion established with reference dosimeters irradiated in a Co-60 beam, using a reference dose of 300 cGy for TLD and 100 cGy for OSLD. The uncertainty in the dose determination is 1.3% for TLD and 1.6% for OSLD at the one sigma level. This accuracy allows for a tolerance of ±5% to be used.

Modulation of autoimmune arthritis severity in mice by apolipoprotein E (ApoE) and cholesterol

Apolipoprotein E (ApoE) deficiency promoted an exacerbation of autoimmune arthritis in mice by inducing proinflammatory immune responses. In this study we analysed the contribution of hypercholesterolaemia and/or the absence of ApoE anti-inflammatory properties, unrelated to its function in the control of cholesterol metabolism, towards the acceleration of arthritis in these mutant animals. The induction and severity of collagen type II-induced arthritis (CIA) were compared for B10.RIII wild-type (WT), B10.RIII.ApoE^+/- , B10.RIII.ApoE^-/- and B10.RIII.low-density lipoprotein receptor (LDLR^-/- ) mice with different concentrations of circulating ApoE and cholesterol. A 50-70% reduction in serum levels of ApoE was observed in heterozygous B10.RIII.ApoE^+/- mice in comparison to B10.RIII.WT, although both strains of mice exhibited similar circulating lipid profiles. This ApoE reduction was associated with an increased CIA severity that remained lower than in homozygous B10.RIII.ApoE^-/- mice. An important rise in circulating ApoE concentration was observed in hypercholesterolaemic B10.RIII.LDLR^-/- mice fed with a normal chow diet, and both parameters increased further with an atherogenic hypercholesterolaemic diet. However, the severity of CIA in B10.RIII.LDLR^-/- mice was similar to that of B10.RIII.WT controls. In conclusion, by comparing the evolution of CIA between several strains of mutant mice with different levels of serum ApoE and cholesterol, our results demonstrate that both hypercholesterolaemia and ApoE regulate the intensity of in-vivo systemic autoimmune responses.

Antihyperalgesic effect of tetrodotoxin in rat models of persistent muscle pain

Persistent muscle pain is a common and disabling symptom for which available treatments have limited efficacy. Since tetrodotoxin (TTX) displays a marked antinociceptive effect in models of persistent cutaneous pain, we tested its local antinociceptive effect in rat models of muscle pain induced by inflammation, ergonomic injury and chemotherapy-induced neuropathy. While local injection of TTX (0.03-1 μg) into the gastrocnemius muscle did not affect the mechanical nociceptive threshold in naïve rats, exposure to the inflammogen carrageenan produced a marked muscle mechanical hyperalgesia, which was dose-dependently inhibited by TTX. This antihyperalgesic effect was still significant at 24h. TTX also displayed a robust antinociceptive effect on eccentric exercise-induced mechanical hyperalgesia in the gastrocnemius muscle, a model of ergonomic pain. Finally, TTX produced a small but significant inhibition of neuropathic muscle pain induced by systemic administration of the cancer chemotherapeutic agent oxaliplatin. These results indicate that TTX-sensitive sodium currents in nociceptors play a central role in diverse states of skeletal muscle nociceptive sensitization, supporting the suggestion that therapeutic interventions based on TTX may prove useful in the treatment of muscle pain.