User Manual for Coping Strategies Inventory Short Form (CSI-SF)-The Jackson Heart Study

Researchers have asserted that patients who generally rely on powerful external sources to control their disorders can benefit from examining their coping mechanisms, which can potentially lead to a better understanding of the initiation and progression of some chronic diseases. By trusting their own internal powers and virtues, it is possible for some people to discover and navigate available strategies to balance and enhance their psycho-spiritual well-being and possibly their treatment and recovery. This review serves as a user manual for investigators who choose to use the CSI-SF to conduct their research on coping behaviors. The CSI-SF, which measures four coping strategies based on 16 items, was first assessed using the Jackson Heart Study (JHS) cohort in 2007. The reliability and construct validity of the CSI-SF was also later assessed among hemodialysis patients across 13 countries. In this study, the CSI-SF was assessed to be a reliable and valid instrument for measuring coping strategies. The CSI-SF serves the purpose of developing an inner voice that can assist with understanding how people cope with everyday life. The information gathered from the administration of the CSI-SF can inform investigators about environmental cues and triggers that can also impact individual health.

Mortality Trends in Alzheimer's Disease in Mississippi, 2011-2021

Alzheimer's disease is the sixth most common cause of death in the United States (U.S.), with one in three adults 65 years of age and older dying of the disease each year. Deaths from Alzheimer's have more than doubled between 2000 and 2019, killing more adults than both breast cancer and prostate cancer. In 2021, Alzheimer's disease resulted in 36 deaths per 100,000 in the U.S. In Mississippi, deaths from Alzheimer's have almost doubled between 2011 and 2021, resulting in 52.9 deaths per 100,000. Women have a higher mortality rate from Alzheimer's than men. Alzheimer's is a progressive disease that develops through seven stages. There are effective strategies to prevent the onset of Alzheimer's.

METHODS

This paper reviews the risk factors, mortality trends, etiology, and prognosis of Alzheimer's in Mississippi with a focus on prevention.

RESULTS

The southern diet with foods high in sugar and sodium, along with sedentary and poor lifestyle choices, increases mortality risk from Alzheimer's disease for women in Mississippi, specifically due to women over 65 having higher rates of obesity and hypertension.

CONCLUSION

Understanding the epidemiology and risk factors of Alzheimer's in Mississippi will help inform communities, policies, and programs to prevent disease occurrence.

Treatment of neurogenic detrusor overactivity and overactive bladder with Botox (onabotulinumtoxinA): Development, insights, and impact

Neurogenic detrusor overactivity (NDO) is a complication of multiple sclerosis, spinal cord injury (SCI), stroke, head injury, and other conditions characterized by damage to the upper motor neuronal system. NDO often leads to high bladder pressure that may cause upper urinary tract damage and urinary incontinence (UI). Prior to the use of onabotulinumtoxinA, oral anticholinergics and surgical augmentation cystoplasty were the treatment options. Overactive bladder (OAB) is non-neurogenic and affects a much larger population than NDO. Both NDO and OAB negatively impact patients' quality of life (QOL) and confer high health care utilization burdens. Early positive results from pioneering investigators who injected onabotulinumtoxinA into the detrusor of patients with SCI caught the interest of Allergan, which then initiated collaborative clinical trials that resulted in FDA approval of onabotulinumtoxinA 200U in 2011 for NDO and 100U in 2013 for patients with OAB who inadequately respond to or are intolerant of an anticholinergic. These randomized, double-blind, placebo-controlled trials for NDO showed significant improvements in UI episodes, urodynamic parameters, and QOL; the most frequent adverse events were urinary tract infection (UTI) and urinary retention. Similarly, randomized, double-blind, placebo-controlled trials of onabotulinumtoxinA 100U for OAB found significant improvements in UI episodes, treatment benefit, and QOL; UTI and dysuria were the most common adverse events. Long-term studies in NDO and OAB showed sustained effectiveness and safety with repeat injections of onabotulinumtoxinA, the use of which has profoundly improved the QOL of patients failing anticholinergic therapy and has expanded the utilization of onabotulinumtoxinA into smooth muscle.

Long-term Safety and Tolerability of Repeated Treatments With OnabotulinumtoxinA in Children With Neurogenic Detrusor Overactivity

PURPOSE

OnabotulinumtoxinA is an approved treatment for neurogenic detrusor overactivity in adults inadequately managed with anticholinergics, and more recently was approved in children on the basis of a phase 3, 48-week, single-treatment study (NCT01852045). Given the paucity of long-term pediatric data, we report on the continued safety in these patients after repeated onabotulinumtoxinA treatment.

MATERIALS AND METHODS

This was a multicenter, double-blind, repeat-treatment extension study (NCT01852058) in patients who entered from the preceding single-treatment study. Data were integrated across both studies. All patients (5-17 years) used clean intermittent catheterization and could receive dose escalations based on response to preceding treatment (50 U, 100 U, or 200 U onabotulinumtoxinA [not to exceed 6 U/kg]).

RESULTS

Overall, 95, 90, 55, and 11 patients received 1, 2, 3, and 4 treatments with onabotulinumtoxinA, respectively, and median (quartiles) duration of follow-up was 82 (65, 94) weeks. The safety profile was similar across doses and after repeat treatments. The most common treatment-emergent adverse event during cycles 1, 2, and 3 was urinary tract infection (31%, 34%, 22%). Three serious treatment-emergent adverse events related to study treatment (3/95; 3.2%) were reported during the study, which were all cases of urinary tract infection. Annualized urinary tract infection rates post-treatment were similar to pre-screening rates. There were no cases of autonomic dysreflexia, neutralizing antibodies, and treatment-emergent adverse events related to distant spread of toxin.

CONCLUSIONS

OnabotulinumtoxinA continued to be well tolerated after repeated treatments in pediatric neurogenic detrusor overactivity patients with similar safety profiles across dose groups. Treatment-emergent adverse events were primarily urological with no new safety concerns.

Results of the c-TRAK TN trial: a clinical trial utilising ctDNA mutation tracking to detect molecular residual disease and trigger intervention in patients with moderate- and high-risk early-stage triple-negative breast cancer

BACKGROUND

Post-treatment detection of circulating tumour DNA (ctDNA) in early-stage triple-negative breast cancer (TNBC) patients predicts high risk of relapse. c-TRAK TN assessed the utility of prospective ctDNA surveillance in TNBC and the activity of pembrolizumab in patients with ctDNA detected [ctDNA positive (ctDNA+)].

PATIENTS AND METHODS

c-TRAK TN, a multicentre phase II trial, with integrated prospective ctDNA surveillance by digital PCR, enrolled patients with early-stage TNBC and residual disease following neoadjuvant chemotherapy, or stage II/III with adjuvant chemotherapy. ctDNA surveillance comprised three-monthly blood sampling to 12 months (18 months if samples were missed due to coronavirus disease), and ctDNA+ patients were randomised 2 : 1 to intervention : observation. ctDNA results were blinded unless patients were allocated to intervention, when staging scans were done and those free of recurrence were offered pembrolizumab. A protocol amendment (16 September 2020) closed the observation group; all subsequent ctDNA+ patients were allocated to intervention. Co-primary endpoints were (i) ctDNA detection rate and (ii) sustained ctDNA clearance rate on pembrolizumab (NCT03145961).

RESULTS

Two hundred and eight patients registered between 30 January 2018 and 06 December 2019, 185 had tumour sequenced, 171 (92.4%) had trackable mutations, and 161 entered ctDNA surveillance. Rate of ctDNA detection by 12 months was 27.3% (44/161, 95% confidence interval 20.6% to 34.9%). Seven patients relapsed without prior ctDNA detection. Forty-five patients entered the therapeutic component (intervention n = 31; observation n = 14; one observation patient was re-allocated to intervention following protocol amendment). Of patients allocated to intervention, 72% (23/32) had metastases on staging at the time of ctDNA+, and 4 patients declined pembrolizumab. Of the five patients who commenced pembrolizumab, none achieved sustained ctDNA clearance.

CONCLUSIONS

c-TRAK TN is the first prospective study to assess whether ctDNA assays have clinical utility in guiding therapy in TNBC. Patients had a high rate of metastatic disease on ctDNA detection. Findings have implications for future trial design, emphasising the importance of commencing ctDNA testing early, with more sensitive and/or frequent ctDNA testing regimes.

Feasibility of a Self-Measured Blood Pressure Monitoring Program to Reduce Uncontrolled Hypertension

BACKGROUND

Hypertension is a common, serious condition affecting about one-third of adults in the United States. Self-measured blood pressure (SMBP) monitoring, combined with clinical support, is recommended to improve hypertension control and patient outcomes.

METHODS

We conducted a retrospective analysis of a SMBP monitoring program that supported recruited patients in using wireless Bluetooth monitors to track their blood pressure at home and gave outpatient practices real-time access to patients' measurements. We analyzed SMBP measurements, practice-user log data, and patient and practice experience evaluations.

RESULTS

Project staff recruited 17 outpatient practices and 187 patients. After four weeks, 64% of participants consistently monitored their blood pressure at least three times per week. A majority of patients (79%) reported an increased ability to manage their hypertension. In total, clinicians received 1,849 alerts and documented 409 actions.

CONCLUSIONS

This analysis demonstrates the feasibility of combining SMBP with real-time access to home measurements by outpatient practices.

Innovative Use of a Mobile Web Application to Remotely Monitor Nonhospitalized Patients with COVID-19

Introduction: Most patients with COVID-19 do not require hospitalization but may need close monitoring, which can strain primary care practices. Our objective was to describe the implementation of a mobile web application to monitor COVID-19 signs and symptoms among nonhospitalized primary care patients and to assess the feasibility and acceptability of the application. Study Design: Retrospective analysis of (1) mobile web application data from March through December 2020 and (2) cross-sectional surveys administered in June 2020. Materials and Methods: We enrolled nonhospitalized patients and staff from nine New England primary care practices across 29 sites. Outcomes included feasibility and acceptability of the application as measured by the proportion of texts that resulted in a response, proportion of patients who agreed using the application was easy, and proportion of practice staff who agreed the application reduced outreach burden and that they would recommend use. Results: Five thousand five hundred thirty-two patients used the mobile web application, with 26,466 total responses. Overall, 78% of the daily texts resulted in a response from patients. Most patients agreed that responding to texts was easy (95%) and that they would be willing to participate in other texting programs (78%). Most staff agreed that the program reduced burden of outreach (94%) and that they would recommend use to other practices (100%). Conclusions: Use of a COVID-19 symptom tracking application was feasible and acceptable to patients and primary care practice staff. Outpatient practices should consider use of mobile web applications to monitor nonhospitalized patients with other acute illnesses.

Malignant hyperthermia 2020: Guideline from the Association of Anaesthetists

Malignant hyperthermia is defined in the International Classification of Diseases as a progressive life-threatening hyperthermic reaction occurring during general anaesthesia. Malignant hyperthermia has an underlying genetic basis, and genetically susceptible individuals are at risk of developing malignant hyperthermia if they are exposed to any of the potent inhalational anaesthetics or suxamethonium. It can also be described as a malignant hypermetabolic syndrome. There are no specific clinical features of malignant hyperthermia and the condition may prove fatal unless it is recognised in its early stages and treatment is promptly and aggressively implemented. The Association of Anaesthetists has previously produced crisis management guidelines intended to be displayed in all anaesthetic rooms as an aide memoire should a malignant hyperthermia reaction occur. The last iteration was produced in 2011 and since then there have been some developments requiring an update. In these guidelines we will provide background information that has been used in updating the crisis management recommendations but will also provide more detailed guidance on the clinical diagnosis of malignant hyperthermia. The scope of these guidelines is extended to include practical guidance for anaesthetists dealing with a case of suspected malignant hyperthermia once the acute reaction has been reversed. This includes information on care and monitoring during and after the event; appropriate equipment and resuscitative measures within the operating theatre and ICU; the importance of communication and teamwork; guidance on counselling of the patient and their family; and how to make a referral of the patient for confirmation of the diagnosis. We also review which patients presenting for surgery may be at increased risk of developing malignant hyperthermia under anaesthesia and what precautions should be taken during the peri-operative management of the patients.

OnabotulinumtoxinA for the treatment of neurogenic detrusor overactivity in children

AIMS

This study evaluated whether one (or more) of three doses of onabotulinumtoxinA were safe and effective to treat neurogenic detrusor overactivity (NDO) in children.

METHODS

This was a 48-week prospective, multicenter, randomized, double-blind study in children (aged 5-17 years) with NDO and urinary incontinence (UI) receiving one onabotulinumtoxinA treatment (50, 100, or 200 U; not to exceed 6 U/kg). Primary endpoint: change from baseline in daytime UI episodes. Secondary endpoints: change from baseline in urine volume at first morning catheterization, urodynamic measures, and positive response on the treatment benefit scale. Safety was also assessed.

RESULTS

There was a similar reduction in urinary incontinence from baseline to Week 6 for all doses (-1.3 episodes/day). Most patients reported positive responses on the treatment benefit scale (75.0%-80.5%). From baseline to Week 6, increases were observed in urine volume at first morning clean intermittent catheterization (50 U, 21.9 ml; 100 U, 34.9 ml; 200 U, 87.5 ml; p = 0.0055, 200 U vs. 50 U) and in maximum cystometric capacity (range 48.6-63.6 ml) and decreases in maximum detrusor pressure during the storage phase (50 U, -12.9; 100 U, -20.1; 200 U, -27.3 cmH₂ O; p = 0.0157, 200 U vs. 50 U). The proportion of patients experiencing involuntary detrusor contractions dropped from baseline (50 U, 94.4%; 100 U, 88.1%; 200 U, 92.6%) to Week 6 (50 U, 61.8%; 100 U, 44.7%; 200 U, 46.4%). Safety was similar across doses; urinary tract infection was most frequent.

CONCLUSIONS

OnabotulinumtoxinA was well tolerated and effective for the treatment of NDO in children; 200 U showed greater efficacy in reducing bladder pressure and increasing bladder capacity.

An Innovative Simulation-based Community-engaged Intervention for Training Research Assistants in Culturally Appropriate Informed Consent

BACKGROUND

Enrolling under-represented groups in biomedical research remains challenging owing to limited health literacy, historic medical abuses, and mistrust. Addressing such barriers requires scrutiny of informed consent processes and training of research assistants (RAs). Applying simulation methods that are well-established in medical education, Simulation-based Community-engaged Research Intervention for Informed Consent Protocol Testing and Training (SCRIIPTT) engages community members as community advisors (CAs) to train RAs in implementing culturally appropriate approaches, such as addressing difficult issues related to race and power dynamics, into the informed consent training process.

OBJECTIVES

To present SCRIIPTT's development, implementation, and preliminary findings.

METHODS

Over 12 months, our community-academic partnership 1) introduced SCRIIPTT to the greater community using the Truth & Reconciliation Model, which acknowledges the wrongs of research and offers an apology; 2) deepened understanding of community concerns; 3) developed the intervention; 4) conducted a pilot; and 5) disseminated findings.

RESULTS

SCRIIPTT included a comprehensive training manual, scenarios for simulated informed consent encounters, and a 37-item checklist to measure performance. Outcomes include CA and RA satisfaction surveys, and RA performance rating. The checklist adequately measured observable behaviors. RAs reported important gains in knowledge, self-confidence, and cultural competence in conducting informed consent. CAs reported positive experiences, being fully engaged and valued as members of the research team and participants during simulation encounters.

CONCLUSIONS

This pilot study demonstrated the feasibility of SCRIIPTT, with preliminary evidence of effectiveness and acceptability. SCRIIPTT offers an innovative approach for community engagement in research training and advancing the skills of RAs in culturally appropriate informed consent.

Helping Ambulatory Practices Succeed: Reflections from Practice Transformation Facilitators

Healthcare reform efforts implemented to optimize primary and specialty care delivery require practices to undertake considerable transformation. To support change efforts, many private insurers and federal and state health-reform efforts provide practices and clinicians with access to practice-transformation facilitators. Healthcentric Advisors provides practice-transformation support and technical assistance to practices in Rhode Island and across New England. From this work we know that strategies and approaches to support transformation and achievement of program recognitions differ by practice characteristics, resource access, and patient panels. Understanding practice attitudes and beliefs about change, recognizing that change occurs on a spectrum, acknowledging that program recognition is only the beginning, and aligning quality-improvement initiatives, are domains that support success regardless of practice type. However, working with a facilitator who engages your entire care team to integrate a culture of quality improvement and process ownership, has the greatest impact on overall transformation.

The Global Health Security Agenda and the role of the World Organisation for Animal Health

The World Organisation for Animal Health (OIE) plays an important leadership role in global efforts to prevent, detect and respond to infectious disease threats. Since 1924, the OIE has helped Member Countries to prevent the spread of animal diseases, while facilitating safe agricultural trade. In recent years, the OIE has also increasingly focused on the biosecurity objectives of preventing unauthorised access to and loss, theft, misuse or diversion of dangerous pathogens, including their intentional release. Preventing the intentional introduction of animal disease is critical not only because of the significant economic impact that animal diseases can have on a nation's economy, but also because a number of animal diseases can affect humans. Over 60% of human diseases are of animal origin. Therefore, the OIE, working in conjunction with its partner organisations, the Food and Agriculture Organization of the United Nations and the World Health Organization, has become a leading international organisation for the control of global infectious disease in humans as well as in animals.

Low-dose onabotulinumtoxinA improves urinary symptoms in noncatheterizing patients with MS

Objective

To evaluate the efficacy and safety of onabotulinumtoxinA 100 U in noncatheterizing patients with multiple sclerosis (MS) with urinary incontinence (UI) due to neurogenic detrusor overactivity (NDO).

Methods

In this randomized, double-blind phase III study, patients received onabotulinumtoxinA 100 U (n = 66) or placebo (n = 78) as intradetrusor injections via cystoscopy. Assessments included changes from baseline in urinary symptoms, urodynamics, and Incontinence–Quality of Life (I-QOL) total score. Adverse events (AEs) were assessed, including initiation of clean intermittent catheterization (CIC) due to urinary retention.

Results

OnabotulinumtoxinA vs placebo significantly reduced UI at week 6 (−3.3 episodes/day vs −1.1 episodes/day, p < 0.001; primary endpoint). Significantly greater proportions of onabotulinumtoxinA-treated patients achieved 100% UI reduction (53.0% vs 10.3%, p < 0.001). Significant improvements in urodynamics (p < 0.01) were observed with onabotulinumtoxinA. Improvements in I-QOL score were significantly greater with onabotulinumtoxinA (40.4 vs 9.9, p < 0.001) and ≈3 times the minimally important difference (+11 points). The most common AE was urinary tract infection (25.8%). CIC rates were 15.2% for onabotulinumtoxinA and 2.6% for placebo.

Conclusion

In noncatheterizing patients with MS, onabotulinumtoxinA 100 U significantly improved UI and quality of life with lower CIC rates than previously reported with onabotulinumtoxinA 200 U.

ClinicalTrials.gov identifier:

NCT01600716.

Classification of evidence

This study provides Class I evidence that compared with placebo, 100 U onabotulinumtoxinA intradetrusor injections significantly reduce UI and improve quality of life in noncatheterizing patients with MS and NDO.

AAGBI: Safer pre-hospital anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland

Pre-hospital emergency anaesthesia with oral tracheal intubation is the technique of choice for trauma patients who cannot maintain their airway or achieve adequate ventilation. It should be carried out as soon as safely possible, and performed to the same standards as in-hospital emergency anaesthesia. It should only be conducted within organisations with comprehensive clinical governance arrangements. Techniques should be straightforward, reproducible, as simple as possible and supported by the use of checklists. Monitoring and equipment should meet in-hospital anaesthesia standards. Practitioners need to be competent in the provision of in-hospital emergency anaesthesia and have supervised pre-hospital experience before carrying out pre-hospital emergency anaesthesia. Training programmes allowing the safe delivery of pre-hospital emergency anaesthesia by non-physicians do not currently exist in the UK. Where pre-hospital emergency anaesthesia skills are not available, oxygenation and ventilation should be maintained with the use of second-generation supraglottic airways in patients without airway reflexes, or basic airway manoeuvres and basic airway adjuncts in patients with intact airway reflexes.

Abstract 214: Is Goal-Striving Stress Associated With Cardiovascular Disease Among Jackson Heart Study Participants?

Introduction: It is known that psychosocial stress is associated with cardiovascular disease (CVD). Recent research has reported that goal-striving stress (GSS) is associated with poor health outcomes for African Americans. GSS is the “¼discrepancy between aspiration and achievement, and the level of disappointment experienced if goals are not reached.” As far as we know, no research has examined the relationship between GSS and CVD prevalence among African Americans. Thus, the purpose of the current study was to investigate the association between GSS and CVD prevalence among a large sample of African Americans.

Methods: The Jackson Heart Study (JHS) includes 5,181 men (37%) and women who completed a baseline survey to capture data on psychosocial variables, CVD history, demographic variables, and CVD risk factors. It was hypothesized that higher levels of GSS would be associated with CVD prevalence. The average GSS level was 4.49. GSS was categorized into tertiles with CVD prevalence and associations assessed cross-sectionally by multivariable logistic regression analysis that adjusted for demographic, behavioral and clinical risk factors.

Results: It was found that GSS was significantly associated with CVD for tertiles 1, 2, and 3 at 41.26%, 36.25%, and 22.49% respectively. Additionally, GSS was significantly associated with CVD prevalence per unit increase after adjusting for age and sex (OR 1.03, 95% CI 1.02-1.05), SES (OR 1.03, 95% CI 1.02-1.05), and smoking, diet, physical activity, and sleep (OR 1.03, 95% CI 1.01-1.05). However, there was slight attenuation after adjustment for CVD risk factors (OR 1.01, 95% CI 0.99-1.04).

Conclusions: The present study represents an important contribution to the literature in that it appears to be the first to empirically investigate the link between GSS and CVD prevalence among African American men and women.

Efficacy and safety of onabotulinumtoxinA therapy are sustained over 4 years of treatment in patients with neurogenic detrusor overactivity: Final results of a long-term extension study

AIMS

To present final efficacy/safety results from a prospective, long-term extension trial of onabotulinumtoxinA for urinary incontinence (UI) due to neurogenic detrusor overactivity (NDO); patients received treatment for up to 4 years.

METHODS

Patients who completed a 52-week, phase III trial of onabotulinumtoxinA for NDO were eligible to enter a 3-year, multicenter, open-label extension study of intradetrusor onabotulinumtoxinA (200U or 300U). Patients were treated "as needed" based on their request and fulfillment of prespecified qualification criteria (≥12 weeks since previous treatment and a UI episode threshold). Assessments included change from study baseline in UI episodes/day (primary efficacy measure), volume/void, and Incontinence Quality of Life (I-QOL) total score (week 6); duration of effect; adverse events (AEs); and initiation of de novo clean intermittent catheterization (CIC). Data are presented for up to six treatments.

RESULTS

OnabotulinumtoxinA 200U consistently reduced UI episodes/day; reductions from baseline ranged from -3.2 to -4.1 across six treatments. Volume/void consistently increased, nearly doubling after treatment. I-QOL improvements were consistently greater than twice the minimally important difference (+11 points). Overall median duration of effect was 9.0 months (200U). Results were similar for onabotulinumtoxinA 300U. Most common AEs were urinary tract infections and urinary retention. De novo CIC rates were 29.5, 3.4, and 6.0% (200U), and 43.0, 15.0, and 4.8% (300U) for treatments 1-3, respectively; de novo CIC rates were 0% for treatments 4-6.

CONCLUSIONS

OnabotulinumtoxinA treatments consistently improve UI, volume/void, and QOL in patients with UI due to NDO in this 4-year study, with no new safety signals. Neurourol. Urodynam. 36:368-375, 2017. © 2015 The Authors. Neurourology and Urodynamics Published by Wiley Periodicals, Inc.

Sensorimotor gating and spatial learning in α7-nicotinic receptor knockout mice

The role of acetylcholine and specific nicotinic receptors in sensorimotor gating and higher cognitive function has been controversial. Here, we used a commercially available mouse with a null mutation in the Chrna7(tm1Bay) gene [α7-nicotinic acetylcholine receptor (nAChR) knockout (KO) mouse] in order to assess the role of the α7-nAChR in sensorimotor gating and spatial learning. We examined prepulse inhibition (PPI) of startle and nicotine-induced enhancement of PPI. We also tested short- and long-term habituation of the startle response as well as of locomotor behaviour in order to differentiate the role of this receptor in the habituation of evoked behaviour (startle) vs. motivated behaviour (locomotion). To address higher cognition, mice were also tested in a spatial learning task. Our results showed a mild but consistent PPI deficit in α7-nAChR KO mice. Furthermore, they did not show nicotine-induced enhancement of startle or PPI. Short- and long-term habituation was normal in KO mice for both types of behaviours, evoked or motivated, and they also showed normal learning and memory in the Barnes maze. Thorough analysis of the behavioural data indicated a slightly higher degree of anxiety in α7-nAChR KO mice; however, this could only be partially confirmed in an elevated plus maze test. In summary, our data suggest that α7-nAChRs play a minor role in PPI, but seem to mediate nicotine-induced PPI enhancement. We found no evidence to suggest that they are important for habituation or spatial learning.

Phase 3 efficacy and tolerability study of onabotulinumtoxinA for urinary incontinence from neurogenic detrusor overactivity

PURPOSE

We assessed the efficacy, safety and effects on quality of life of onabotulinumtoxinA in patients with neurogenic detrusor overactivity.

MATERIALS AND METHODS

In this 52-week, international, multicenter, double-blind, randomized, placebo controlled trial 416 patients with neurogenic detrusor overactivity and urinary incontinence (14 or more episodes per week) resulting from multiple sclerosis (227) and spinal cord injury (189) were treated with intradetrusor injections of onabotulinumtoxinA (200 or 300 U) or placebo. The primary end point was the change from baseline in the mean number of urinary incontinence episodes per week at week 6. Maximum cystometric capacity, maximum detrusor pressure during the first involuntary detrusor contraction and Incontinence Quality of Life total score were secondary end points. Adverse events were monitored.

RESULTS

OnabotulinumtoxinA at a dose of 200 U in 135 patients and 300 U in 132 decreased mean urinary incontinence at week 6 by 21 and 23 episodes per week, respectively, vs 9 episodes per week in 149 on placebo (each dose p<0.001). Also, maximum cystometric capacity, maximum detrusor pressure during the first involuntary detrusor contraction and Incontinence Quality of Life score were significantly improved over values in the placebo group (each dose p<0.001). Median time to patient re-treatment request was greater for onabotulinumtoxinA 200 and 300 U than for placebo (256 and 254 days, respectively, vs 92). The most common adverse events were urinary tract infection and urinary retention. Of patients who did not catheterize at baseline 10% on placebo, 35% on 200 U and 42% on 300 U initiated catheterization due to urinary retention.

CONCLUSIONS

OnabotulinumtoxinA significantly improved neurogenic detrusor overactivity symptoms vs placebo. Clean intermittent catheterization initiation due to urinary retention appeared to increase in a dose dependent fashion. No clinically relevant benefit in efficacy or duration was identified for the 300 U dose over the 200 U dose.

Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review

Non-opioid analgesics, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), or cyclo-oxygenase 2 (COX-2) inhibitors are often given along with morphine as part of multimodal analgesia after major surgery. We have undertaken a systematic review and a mixed treatment comparison (MTC) analysis in order to determine explicitly which class of non-opioid analgesic, paracetamol, NSAIDs, or COX-2 inhibitors is the most effective in reducing morphine consumption and morphine-related adverse effects. Sixty relevant studies were identified. The MTC found that when paracetamol, NSAIDs, or COX-2 inhibitors were added to patient-controlled analgesia (PCA) morphine, there was a statistically significant reduction in morphine consumption: paracetamol [mean difference (MD) -6.34 mg; 95% credibility interval (CrI) -9.02, -3.65], NSAIDs (MD -10.18; 95% CrI -11.65, -8.72), and COX-2 inhibitors (MD -10.92; 95% CrI -12.77, -9.08). There was a significant reduction in nausea and postoperative nausea and vomiting with NSAIDs compared with placebo (odds ratio 0.70; 95% CrI 0.53, 0.88) but not for paracetamol or COX-2 inhibitors, nor for NSAIDs compared with paracetamol or COX-2 inhibitors. There was no statistically significant difference in sedation between any intervention and comparator. On the basis of six trials (n=695), 2.4% of participants receiving an NSAID experienced surgical-related bleeding compared with 0.4% with placebo. The MTC found that there is a decrease in 24 h morphine consumption when paracetamol, NSAID, or COX-2 inhibitors are given in addition to PCA morphine after surgery, with no clear difference between them. Similarly, the benefits in terms of reduction in morphine-related adverse effects do not strongly favour one of the three non-opioid analgesics.

Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for the reduction of morphine-related side effects after major surgery: a systematic review

OBJECTIVES

To determine which class of non-opioid analgesics - paracetamol (acetaminophen), NSAIDs or COX-2 inhibitors - is the most effective at reducing morphine consumption and associated adverse effects when used as part of multimodal analgesia following major surgery.

DATA SOURCES

A systematic literature review was conducted using MEDLINE, EMBASE and CENTRAL databases, searched from January 2003 to February 2009 and updating an earlier review.

REVIEW METHODS

Randomised controlled trials comparing paracetamol, NSAIDs or COX-2 inhibitors to each other or placebo, in adults receiving patient-controlled analgesia (PCA) with morphine following major surgery, were included. The COX-2 inhibitors rofecoxib and valdecoxib were excluded. Only trials that reported 24-hour morphine consumption were included. Other outcomes of interest were morphine-related adverse effects and adverse effects related to the non-opioids. Adequacy of randomisation, concealment of allocation, double blinding, and the flow of patients within the trial was assessed. The main analysis was a mixed treatment comparison (MTC) evaluating the relative effects of the four treatment classes. Four main outcomes were prioritised: 24-hour morphine consumption, sedation, nausea and vomiting, and surgical bleeding. Studies reporting nausea alone were pooled with studies reporting postoperative nausea and vomiting (PONV). Comparisons were described as statistically significant (at 5% level) when the credibility interval (CrI) did not cross 1 for odds ratio (OR) and zero for mean difference (MD). Trials making direct comparisons between the active interventions were also pooled in a meta-analysis using a random effects model. Sensitivity analyses were performed to assess the effects of study quality, individual drugs, and baseline morphine consumption.

RESULTS

Sixty relevant studies were identified. When paracetamol, NSAIDs or COX-2 inhibitors were added to PCA morphine, there was a statistically significant reduction in morphine consumption: paracetamol (MD -6.34 mg; 95% CrI -9.02 to -3.65); NSAIDs (MD -10.18; 95% CrI -11.65 to -8.72); and COX-2 inhibitors (MD -10.92; 95% CrI -12.77 to -9.08). NSAIDs and COX-2 inhibitors were both significantly better than paracetamol, and there was no significant difference between NSAIDs and COX-2 inhibitors (MD -0.74; 95% CrI -3.03 to 1.56). There was a significant reduction in nausea and PONV with NSAIDs compared to placebo (OR 0.70; 95% CrI 0.53 to 0.88) but not for paracetamol or COX-2 inhibitors, nor for NSAIDs compared to paracetamol or COX-2 inhibitors.

CONCLUSIONS

24-hour morphine consumption decreased by 6.3 mg to 10.9 mg, compared to placebo, when paracetamol, NSAID or COX-2 inhibitors were added to PCA morphine following surgery. Differences in effect between the three drug classes were small and unlikely to be of clinical significance. There does not appear to be a strong case for recommending routine addition of any of the three non-opioids to PCA morphine in the 24 hours immediately after surgery, or for favouring one drug class above the others.