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.

Feasibility of individualised patient modelling for continuous vancomycin infusions in outpatient antimicrobial therapy, a retrospective study

BACKGROUND

The area under the curve (AUC) to minimum inhibitory concentration (MIC) ratio is proposed as a therapeutic drug-monitoring parameter for dosing vancomycin continuous infusion in methicillin-resistant Staphylococcus aureus (MRSA) infection. Individualised pharmacokinetic-pharmacodynamic (PK/PD) calculation of AUC24 may better represent therapeutic dosing than current Therapeutic Drug Monitoring (TDM) practices, targeting a Steady State Concentration of 15-25 mg/L.

AIM

To compare real world TDM practice to theoretical, individualised, PK/PD target parameters utilising Bayesian predictions to steady state concentrations (Css) for outpatients on continuous vancomycin infusions.

METHOD

A retrospective single centre study was conducted at a tertiary hospital on adult patients, enrolled in an outpatient parenteral antimicrobial therapy (OPAT) program, receiving vancomycin infusions for MRSA infection. Retrospective Bayesian dosing was modelled to target PK/PD parameters and compared to real world data.

RESULTS

Fifteen patients were evaluated with 53% (8/15) achieved target CSS during hospitalisation, and 83% (13/15) as outpatient. Median Bayesian AUC/MIC was 613 mg.h/L with CSS 25 mg/L. Patients suffering an Acute Kidney Injury (33%) had higher AUC0-24/MIC values. Retrospective Bayesian modelling demonstrated on median 250 mg/24 h lower doses than that administered was required (R2 = 0.81) which achieved AUC24/MIC median 444.8 (range 405-460) mg.h/L and CSS 18.8 (range 16.8-20.4) mg/L.

CONCLUSION

Bayesian modelling could assist in obtaining more timely target parameters at lower doses for patients receiving continuous vancomycin infusion as part of an OPAT program, which may beget fewer adverse effects. Utilisation of personalised predictive modelling may optimise vancomycin prescribing, achieving earlier target concentrations as compared to empiric dosing regimens.

mTOR-dependent loss of PON1 secretion and antiphospholipid autoantibody production underlie autoimmunity-mediated cirrhosis in transaldolase deficiency

Transaldolase deficiency predisposes to chronic liver disease progressing from cirrhosis to hepatocellular carcinoma (HCC). Transition from cirrhosis to hepatocarcinogenesis depends on mitochondrial oxidative stress, as controlled by cytosolic aldose metabolism through the pentose phosphate pathway (PPP). Progression to HCC is critically dependent on NADPH depletion and polyol buildup by aldose reductase (AR), while this enzyme protects from carbon trapping in the PPP and growth restriction in TAL deficiency. Although AR inactivation blocked susceptibility to hepatocarcinogenesis, it enhanced growth restriction, carbon trapping in the non-oxidative branch of the PPP and failed to reverse the depletion of glucose 6-phosphate (G6P) and liver cirrhosis. Here, we show that inactivation of the TAL-AR axis results in metabolic stress characterized by reduced mitophagy, enhanced overall autophagy, activation of the mechanistic target of rapamycin (mTOR), diminished glycosylation and secretion of paraoxonase 1 (PON1), production of antiphospholipid autoantibodies (aPL), loss of CD161+ NK cells, and expansion of CD38+ Ito cells, which are responsive to treatment with rapamycin in vivo. The present study thus identifies glycosylation and secretion of PON1 and aPL production as mTOR-dependent regulatory checkpoints of autoimmunity underlying liver cirrhosis in TAL deficiency.

Management of comatose survivors of out-of-hospital cardiac arrest in Europe: current treatment practice and adherence to guidelines. A joint survey by the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Resuscitation Council (ERC), the European Society for Emergency Medicine (EUSEM), and the European Society of Intensive Care Medicine (ESICM)

AIMS

International guidelines give recommendations for the management of comatose out-of-hospital cardiac arrest (OHCA) survivors. We aimed to investigate adherence to guidelines and disparities in the treatment of OHCA in hospitals in Europe.

METHODS AND RESULTS

A web-based, multi-institutional, multinational survey in Europe was conducted using an electronic platform with a predefined questionnaire developed by experts in post-resuscitation care. The survey was disseminated to all members of the societies via email, social media, websites, and newsletters in June 2021. Of 252 answers received, 237 responses from different units were included and 166 (70%) were from cardiac arrest centres. First-line vasopressor used was noradrenaline in 195 (83%) and the first-line inotrope was dobutamine in 148 (64%) of the responses. Echocardiography is available 24/7 in 204 (87%) institutions. Targeted temperature management was used in 160 (75%) institutions for adult comatose survivors of OHCA with an initial shockable rhythm. Invasive or external cooling methods with feedback were used in 72 cardiac arrest centres (44%) and 17 (24%) non-cardiac arrest centres (P < 0.0003). A target temperature between 32 and 34°C was preferred by 46 centres (21%); a target between 34 and 36°C by 103 centres (52%); and <37.5°C by 35 (16%). Multimodal neuroprognostication was poorly implemented and a follow-up at 3 months after discharge was done in 71 (30%) institutions.

CONCLUSION

Post-resuscitation care is not well established and varies among centres in European hospitals. Cardiac arrest centres have a higher coherence with guidelines compared with respondents from non-cardiac arrest centres. The overall inconsistency in approaches and deviation from recommendations could be a focus for improvement.

Impact of pre-existing vascular disease on clinical outcomes in patients with non-ST-segment myocardial infarction: a nationwide cohort study

Aims

Little is known about the outcomes and processes of care of patients with non ST-segment myocardial infarction (NSTEMI) who present with “polyvascular” disease.

Methods

We analysed 287,279 NSTEMI patients using the Myocardial Infarction National Audit Project (MINAP) registry. Clinical characteristics and outcomes were analysed according to history of affected vascular bed; coronary artery disease (CAD), cerebrovascular disease (CeVD) and peripheral vascular disease (PVD), with comparison to a historically disease-free control group; comprising 167,947 patients (59%). Further analyses compared cumulative number of affected beds with our control.

Results

After adjusting for demographics and management, vascular bed disease was associated with increased likelihood of MACE (CAD OR: 1.06, 95% CI: 1.01–1.12, P=0.02) (CeVD OR: 1.19, 95% CI: 1.12–1.27, P&lt;0.001) (PVD OR: 1.22, 95% CI: 1.13–1.33, P&lt;0.001) and in-hospital mortality (CeVD OR: 1.24, 95% CI: 1.16–1.32, P&lt;0.001) (PVD OR: 1.33, 95% CI: 1.21–1.46, P&lt;0.001). Patients with no vascular disease were less likely to be discharged on statins (PVD 88%, CeVD 86%, CAD 90% and control 78%), and those with moderate (EF 30–49%) or severe left ventricular systolic dysfunction (LVSD) (EF&lt;30%) were less likely to be discharged on ACE inhibitors (CAD 82%, CeVD 77%, PVD 77%, control 74%). Patients with polyvascular disease were less likely to be discharged on DAPT (PVD 78%, CeVD 77%, CAD 80%, control 87%).

Conclusion

Polyvascular disease patients had a higher adjusted incidence of in-hospital mortality and MACE. Patients with no history of vascular disease were less likely to receive statins or ACE inhibitors/ARBs, but more likely to receive DAPT.

Funding Acknowledgement

Type of funding sources: None.

OR17. Clinical characteristics and risk factors of reduced ejection fraction in coronary artery disease patients undergoing percutaneous coronary intervention at sanglah hospital denpasar, bali, indonesia in 2021: a cross-sectional hospital-based study

Aims

This study was conducted to determine the clinical characteristics and risk factors of reduced ejection fraction (EF) in coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI).

Methods and Results

Analytical observational study with a cross-sectional study design was conducted. All patients diagnosed with CAD and had a history of PCI at Sanglah Hospital from December 2020 – June 2021 were enrolled. Univariate analysis was performed to demonstrate the baseline characteristics of the patients. Chi-Square analysis was performed to determine the association between variables. Kruskal-Wallis analysis was performed to determine the differences in clinical characteristics between groups of patients based on the EF. There were 196 patients included in this study. Most of the patients were male (n = 135, 68.9%), with median age of 59 (22-81). The median of the EF was 59.2% (22-81). The most common comorbid found in the patients was hypertension (n = 108, 55.1%). Chi-Square analysis showed a significant association between hyperuricemia (p = 0.019; PR = 1.815; 95%CI= 1.163-2.831), arrhythmias (p = 0.002; PR = 2.271; 95%CI=1.491-3.459), and cardiomegaly (p = 0.011; PR = 1.722; 95%CI=1.151-2.577) with the reduced EF. In logistic regression analysis, arrhythmia (p = 0.009; PR = 4.191; 95%CI=1.426-12.320) was significantly associated with reduced EF. Kruskal-Wallis analysis showed a significant difference in white blood cell (p = 0.021), neutrophil (p = 0.027), and serum glutamic pyruvic transaminase (p = 0.013) in patients based on the EF.

Conclusion

The comorbidity of CAD had a significant association with the reduced EF. Early intervention against this factor can improve the quality of management in the patient.

Sleep and Physical Performance: A Case Study of Collegiate Women's Division 1 Basketball Players

In this work, we present a case study to evaluate the connections between sleep, training load, and the perceptions of physical/emotional state of a collegiate, division 1 Women's basketball team. The study took place during the off- (3 weeks) and pre-season (6 weeks) while sleep was tracked using WHOOP wearable straps. Training load was recorded by the strength coach and athletes. Short Recovery and Short Stress (SRSS) questionnaire was used to evaluate the perceptions of athletes on their own emotional and physical states. Our results showed that heart rate measurements are associated with stress levels and recovery perception. We also discovered that the training load was not linked to the sleep variables without the considerations of athletic performance. However, training load may alter perceived stress and recovery which requires further exploration.

Adrenaline to improve survival in out-of-hospital cardiac arrest: the PARAMEDIC2 RCT

BACKGROUND

Adrenaline has been used as a treatment for cardiac arrest for many years, despite uncertainty about its effects on long-term outcomes and concerns that it may cause worse neurological outcomes.

OBJECTIVES

The objectives were to evaluate the effects of adrenaline on survival and neurological outcomes, and to assess the cost-effectiveness of adrenaline use.

DESIGN

This was a pragmatic, randomised, allocation-concealed, placebo-controlled, parallel-group superiority trial and economic evaluation. Costs are expressed in Great British pounds and reported in 2016/17 prices.

SETTING

This trial was set in five NHS ambulance services in England and Wales.

PARTICIPANTS

Adults treated for an out-of-hospital cardiac arrest were included. Patients were ineligible if they were pregnant, if they were aged < 16 years, if the cardiac arrest had been caused by anaphylaxis or life-threatening asthma, or if adrenaline had already been given.

INTERVENTIONS

Participants were randomised to either adrenaline (1 mg) or placebo in a 1 : 1 allocation ratio by the opening of allocation-concealed treatment packs.

MAIN OUTCOME MEASURES

The primary outcome was survival to 30 days. The secondary outcomes were survival to hospital admission, survival to hospital discharge, survival at 3, 6 and 12 months, neurological outcomes and health-related quality of life through to 6 months. The economic evaluation assessed the incremental cost per quality-adjusted life-year gained from the perspective of the NHS and Personal Social Services. Participants, clinical teams and those assessing patient outcomes were masked to the treatment allocation.

RESULTS

From December 2014 to October 2017, 8014 participants were assigned to the adrenaline (n = 4015) or to the placebo (n = 3999) arm. At 30 days, 130 out of 4012 participants (3.2%) in the adrenaline arm and 94 out of 3995 (2.4%) in the placebo arm were alive (adjusted odds ratio for survival 1.47, 95% confidence interval 1.09 to 1.97). For secondary outcomes, survival to hospital admission was higher for those receiving adrenaline than for those receiving placebo (23.6% vs. 8.0%; adjusted odds ratio 3.83, 95% confidence interval 3.30 to 4.43). The rate of favourable neurological outcome at hospital discharge was not significantly different between the arms (2.2% vs. 1.9%; adjusted odds ratio 1.19, 95% confidence interval 0.85 to 1.68). The pattern of improved survival but no significant improvement in neurological outcomes continued through to 6 months. By 12 months, survival in the adrenaline arm was 2.7%, compared with 2.0% in the placebo arm (adjusted odds ratio 1.38, 95% confidence interval 1.00 to 1.92). An adjusted subgroup analysis did not identify significant interactions. The incremental cost-effectiveness ratio for adrenaline was estimated at £1,693,003 per quality-adjusted life-year gained over the first 6 months after the cardiac arrest event and £81,070 per quality-adjusted life-year gained over the lifetime of survivors. Additional economic analyses estimated incremental cost-effectiveness ratios for adrenaline at £982,880 per percentage point increase in overall survival and £377,232 per percentage point increase in neurological outcomes over the first 6 months after the cardiac arrest.

LIMITATIONS

The estimate for survival with a favourable neurological outcome is imprecise because of the small numbers of patients surviving with a good outcome.

CONCLUSIONS

Adrenaline improved long-term survival, but there was no evidence that it significantly improved neurological outcomes. The incremental cost-effectiveness ratio per quality-adjusted life-year exceeds the threshold of £20,000-30,000 per quality-adjusted life-year usually supported by the NHS.

FUTURE WORK

Further research is required to better understand patients' preferences in relation to survival and neurological outcomes after out-of-hospital cardiac arrest and to aid interpretation of the trial findings from a patient and public perspective.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN73485024 and EudraCT 2014-000792-11.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 25. See the NIHR Journals Library website for further project information.

The predictive value of CHA2DS2-VASc score on adverse in-hospital outcomes among patients with the acute coronary syndrome and atrial fibrillation who undergo PCI

Background

Patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) and having concomitant atrial fibrillation (AF) have a greater risk of adverse short- and long-term outcomes and death compared with patients in the same setting but without AF. On the other hand, the predictive value of CHA2DS2-VASc score in terms of in-hospital mortality and periprocedural adverse events following PCI among patients with ACS and AF is unknown.

Purpose

We retrospectively analyzed data of patients with the main admission diagnosis of ACS that underwent PCI and had AF during the 2004–2014 period from the large nationwide US National Inpatient Sample (NIS) database.

Methods

A CHA2DS2-VASc score was calculated for each patient and incorporated into a multivariable-adjusted logistic regression to determine its independent impact on in-hospital outcomes consisting of death, acute kidney injury (AKI), bleeding, vascular injury, and stroke/transient ischemic attack (TIA).

Results

A total of 283,890 patients with AF who underwent PCI following ACS were included in the analysis. The average reported prevalence of the AF in the whole cohort was 10.0% with a significant trend (p&lt;0.001) of increase during the observed 10-year period. The average age of the cohort was 72.1±11 years, 63.4% were male while the median CHA2DS2-VASc score was 3 (IQR 2–4). Crude rates of adverse in-hospital outcomes were significantly higher among patient groups with higher CHA2DS2-VASc score (Table 1). Following adjustment for baseline covariates, incremental increase in CHA2DS2-VASc score was independently associated with an increased odds of in-hospital death (OR 1.20, CI 95% 1.18–1.22), periprocedural vascular injury (OR 1.18, 95% CI 1.17–1.20), bleeding (OR 1.17, 95% CI 1.16–1.18), stroke/TIA (OR 1.17, 95% CI 1.15–1.19), and AKI (OR 1.05, 95% CI 1.04–1.06) (Figure 1).

Conclusions

The CHA2DS2-VASc score provides important prognostic information in ACS patients with AF undergoing PCI and is independently associated with in-hospital death and periprocedural adverse events. Therefore, CHA2DS2-VASc score could be used as a practical and inexpensive tool for risk stratification in this population.

Figure 1

Funding Acknowledgement

Type of funding source: None

Type of Track and Trigger system and incidence of in-hospital cardiac arrest: an observational registry-based study

BACKGROUND

Failure to recognise and respond to patient deterioration on hospital wards is a common cause of healthcare-related harm. If patients are not rescued and suffer a cardiac arrest as a result then only around 15% will survive. Track and Trigger systems have been introduced into the NHS to improve both identification and response to such patients. This study examines the association between the type of Track & Trigger System (TTS) (National Early Warning Score (NEWS) versus non-NEWS) and the mode of TTS (paper TTS versus electronic TTS) and incidence of in-hospital ward-based cardiac arrests (IHCA) attended by a resuscitation team.

METHODS

TTS type and mode was retrospectively collected at hospital level from 106 NHS acute hospitals in England between 2009 to 2015 via an organisational survey. Poisson regression and logistic regression models, adjusted for case-mix, temporal trends and seasonality were used to determine the association between TTS and hospital-level ward-based IHCA and survival rates.

RESULTS

The NEWS was introduced in England in 2012 and by 2015, three-fifths of hospitals had adopted it. One fifth of hospitals had instituted an electronic TTS by 2015. Between 2009 and 2015 the incidence of IHCA fell. Introduction or use of NEWS in a hospital was associated with a reduction of 9.4% in the rate of ward-based IHCA compared to non-NEWS systems (incidence rate ratio 0.906, p < 0.001). The use of an electronic TTS was also associated with a reduction of 9.8% in the rate of IHCA compared with paper-based TTS (incidence rate ratio 0.902, p = 0.009). There was no change in hospital survival.

CONCLUSIONS

The introduction of standardised TTS and electronic TTS have the potential to reduce ward-based IHCA. This is likely to be via a range of mechanisms from early intervention to institution of treatment limits. The lack of association with survival may reflect the complexity of response to triggering of the afferent arm of the rapid response system.

Evaluation of reproducible and transparent research practices in pulmonology

BACKGROUND

Study reproducibility is valuable for validating or refuting results. Provision of reproducibility indicators, such as materials, protocols, and raw data in a study improve its potential for reproduction. Efforts to reproduce noteworthy studies in the biomedical sciences have resulted in an overwhelming majority of them being found to be unreplicable, causing concern for the integrity of research in other fields, including medical specialties. Here, we analyzed the reproducibility of studies in the field of pulmonology.

METHODS

500 pulmonology articles were randomly selected from an initial PubMed search for data extraction. Two authors scoured these articles for reproducibility indicators including materials, protocols, raw data, analysis scripts, inclusion in systematic reviews, and citations by replication studies as well as other factors of research transparency including open accessibility, funding source and competing interest disclosures, and study preregistration.

FINDINGS

Few publications included statements regarding materials (10%), protocols (1%), data (15%), and analysis script (0%) availability. Less than 10% indicated preregistration. More than half of the publications analyzed failed to provide a funding statement. Conversely, 63% of the publications were open access and 73% included a conflict of interest statement.

INTERPRETATION

Overall, our study indicates pulmonology research is currently lacking in efforts to increase replicability. Future studies should focus on providing sufficient information regarding materials, protocols, raw data, and analysis scripts, among other indicators, for the sake of clinical decisions that depend on replicable or refutable results from the primary literature.

Dietary nitrate metabolism and enteric methane mitigation in sheep consuming a protein-deficient diet

It was hypothesised that the inclusion of nitrate (NO3–) or cysteamine hydrochloride (CSH) in a protein deficient diet (4.8% crude protein; CP) would improve the productivity of sheep while reducing enteric methane (CH4) emissions. A complete randomised designed experiment was conducted with yearling Merino sheep (n = 24) consuming a protein-deficient wheaten chaff control diet (CON) alone or supplemented with 1.8% nitrate (NO3–; DM basis), 0.098% urea (Ur, DM basis) or 80 mg cysteamine hydrochloride/kg liveweight (CSH). Feed intake, CH4 emissions, volatile fatty acids (VFA), digesta kinetics and NO3–, nitrite (NO2–) and urea concentrations in plasma, saliva and urine samples were measured. There was no dietary effect on animal performance or digesta kinetics (P &gt; 0.05), but adding NO3– to the CON diet reduced methane yield (MY) by 26% (P = 0.01). Nitrate supplementation increased blood MetHb, plasma NO3– and NO2– concentrations (P &lt; 0.05), but there was no indication of NO2– toxicity. Overall, salivary NO3– concentration was greater than plasma NO3– (P &lt; 0.05), indicating that NO3– was concentrated into saliva. Our results confirm the role of NO3– as an effective additive to reduce CH4 emissions, even in a highly protein-deficient diet and as a source of additional nitrogen (N) for microbial protein synthesis via N-recycling into saliva and the gut. The role of CSH as an additive in low quality diets for improving animal performance and reducing CH4 emissions is still unclear.

Glycaemic stability of a cyclist with Type 1 diabetes: 4011 km in 20 days on a ketogenic diet

BACKGROUND

Maintaining glycaemic control during exercise presents a significant challenge for people living with Type 1 diabetes. Significant glycaemic variability has been observed in athletes with Type 1 diabetes in competitive contexts. While very-low-carbohydrate ketogenic diets have been shown to minimize glycaemic excursions, no published data have examined if this translates to exercise.

CASE REPORT

We report the case of a 37-year-old man with Type 1 diabetes who successfully undertook a 4011 km cycle across Australia over 20 consecutive days whilst consuming a very-low-carbohydrate ketogenic diet. Continuous glucose monitoring data capture was 98.4% for the ride duration and showed remarkable glycaemic stability, with a standard deviation of 2.1 mmol/l (average interstitial glucose 6.1 mmol/l) and 80.4% of time spent within a range of 3.9-10 mmol/l. Interstitial glucose was <3 mmol/l for 2.1% of this time, with only a single episode of symptomatic hypoglycaemia prompting brief interruption of exercise for carbohydrate administration.

CONCLUSION

This case demonstrates the viability of a very-low-carbohydrate ketogenic diet in an individual with Type 1 diabetes undertaking exercise. While the effect of a very-low-carbohydrate ketogenic diet is yet to be examined more broadly in athletes with Type 1 diabetes, the glycaemic stability observed suggests that fat adaptation may attenuate glycaemic swings and reduce reliance on carbohydrate consumption during exercise for maintaining euglycaemia.

The Presence of a High Peak Feature Within Low-Average Shear Stimuli Induces Quiescence in Venous Endothelial Cells

Wall shear stress (WSS) is an important stimulus in vascular remodelling and vascular lesion development. The current methods to assess and predict the risk associated with specific unsteady WSS consider the WSS mean values or the presence of reverse phases described by the oscillatory shear index. Recent evidence has shown that the accuracy of these methods is limited, especially with respect to the venous environment. Unsteady WSS are characterised by several features that may individually affect endothelial cells. Consequently, we assessed the effects of averaged WSS (TAWSS), temporal WSS gradient (TWSSG), maximum WSS (WSS peak) and reverse phase (OSI) by applying different WSS profiles to venous EC in-vitro, using a real-time controlled cone-and-plate cell-shearing device for 24 h. We found that TWSSG and WSS peak affect cell elongation and alignment respectively. We also found that the WSS waveforms with a peak of 1.5 Pa or higher significantly correlate with the induction of a protective phenotype. Cell phenotype induced by these high peak waveforms does not correlate to what is predicted by the hemodynamic indices currently used. The definition of reliable hemodynamic indices can be used to inform the computational models aimed at estimating the hemodynamic effects on vascular remodelling.

The Emergence of New Psychoactive Substance (NPS) Benzodiazepines. A Survey of their Prevalence in Opioid Substitution Patients using LC-MS

Benzodiazepines have a wide range of clinical uses being among the most commonly prescribed medicines globally. The EU Early Warning System on new psychoactive substances (NPS) has over recent years detected new illicit benzodiazepines in Europe’s drug market1. Additional reference standards were obtained and a multi-residue LCMS method was developed to test for 31 benzodiazepines or metabolites in urine including some new benzodiazepines which have been classified as New Psychoactive Substances (NPS) which comprise a range of substances, including synthetic cannabinoids, opioids, cathinones and benzodiazepines not covered by international drug controls. 200 urine samples from patients attending the HSE National Drug Treatment Centre (NDTC) who are monitored on a regular basis for drug and alcohol use and which tested positive for benzodiazepine class drugs by immunoassay screening were subjected to confirmatory analysis to determine what Benzodiazepine drugs were present and to see if etizolam or other new benzodiazepines are being used in the addiction population currently. Benzodiazepine prescription and use is common in the addiction population. Of significance we found evidence of consumption of an illicit new psychoactive benzodiazepine, Etizolam.

Mode of presentation and mortality amongst patients hospitalized with heart failure? A report from the First Euro Heart Failure Survey

BACKGROUND

Heart failure is heterogeneous in aetiology, pathophysiology, and presentation. Despite this diversity, clinical trials of patients hospitalized for HF deal with this problem as a single entity, which may be one reason for repeated failures.

METHODS

The first EuroHeart Failure Survey screened consecutive deaths and discharges of patients with suspected heart failure during 2000-2001. Patients were sorted into seven mutually exclusive hierarchical presentations: (1) with cardiac arrest/ventricular arrhythmia; (2) with acute coronary syndrome; (3) with rapid atrial fibrillation; (4) with acute breathlessness; (5) with other symptoms/signs such as peripheral oedema; (6) with stable symptoms; and (7) others in whom the contribution of HF to admission was not clear.

RESULTS

The 10,701 patients enrolled were classified into the above seven presentations as follows: 260 (2%), 560 (5%), 799 (8%), 2479 (24%), 1040 (10%), 703 (7%), and 4691 (45%) for which index-admission mortality was 26%, 20%, 10%, 8%, 6%, 6%, and 4%, respectively. Compared to those in group 7, the hazard ratios for death during the index admission were 4.9 (p ≤ 0.001), 4.0 (p < 0.001), 2.2 (p < 0.001), 2.1 (p < 0.001), 1.4 (p < 0.04) and 1.4 (p = 0.04), respectively. These differences were no longer statistically significant by 12 weeks.

CONCLUSION

There is great diversity in the presentation of heart failure that is associated with very different short-term outcomes. Only a minority of hospitalizations associated with suspected heart failure are associated with acute breathlessness. This should be taken into account in the design of future clinical trials.

Effectiveness of antiarrhythmic drugs for shockable cardiac arrest: A systematic review

PURPOSE

The purpose of this systematic review is to provide up-to-date evidence on effectiveness of antiarrhythmic drugs for shockable cardiac arrest to help inform the 2018 International Liaison Committee on Resuscitation Consensus on Science with Treatment Recommendations.

METHODS

A search was conducted in electronic databases Medline, Embase, and Cochrane Library from inception to August 15, 2017.

RESULTS

Of the 9371 citations reviewed, a total of 14 RCTs and 17 observational studies met our inclusion criteria for adult population and only 1 observational study for pediatric population. Based on RCT level evidence for adult population, none of the anti-arrhythmic drugs showed any difference in effect compared with placebo, or with other anti-arrhythmic drugs for the critical outcomes of survival to hospital discharge and discharge with good neurological function. For the outcome of return of spontaneous circulation, the results showed a significant increase for lidocaine compared with placebo (RR = 1.16; 95% CI, 1.03-1.29, p = 0.01).

CONCLUSION

The high level evidence supporting the use of antiarrhythmic drugs during CPR for shockable cardiac arrest is limited and showed no benefit for critical outcomes of survival at hospital discharge, survival with favorable neurological function and long-term survival. Future high quality research is needed to confirm these findings and also to evaluate the role of administering antiarrhythmic drugs in children with shockable cardiac arrest, and in adults immediately after ROSC.

An X-ray investigation of synthetic pyroxenes in the system acmite--diopside-water at 1000 kg/cm2 watervapour pressure

An X-ray investigation has been made of synthetic pyroxenes in the system acmite-diopside, crystallized at 750° C and 1000 kg/cm2 water-vapour pressure. Lattice parameters of these pyroxenes have been determined by least squares analyses of powder diffraction patterns and show an approximately linear relationship with composition, plotted as weight per cent. A rapid X-ray method has also been devised for the determination of the compositions of pyroxenes of this series.

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.

Risk of hospitalization and death following prostate biopsy in Scotland

OBJECTIVE

To investigate the risk of hospitalization and death following prostate biopsy.

STUDY DESIGN

Retrospective cohort study.

METHODS

Our study population comprised 10,285 patients with a record of first ever prostate biopsy between 2009 and 2013 on computerized acute hospital discharge or outpatient records covering Scotland. Using the general population as a comparison group, expected numbers of admissions/deaths were derived by applying age-, sex-, deprivation category-, and calendar year-specific rates of hospital admissions/deaths to the study population. Indirectly standardized hospital admission ratios (SHRs) and mortality ratios (SMRs) were calculated by dividing the observed numbers of admissions/deaths by expected numbers.

RESULTS

Compared with background rates, patients were more likely to be admitted to hospital within 30 days (SHR 2.7; 95% confidence interval 2.4, 2.9) and 120 days (SHR 4.0; 3.8, 4.1) of biopsy. Patients with prior co-morbidity had higher SHRs. The risk of death within 30 days of biopsy was not increased significantly (SMR 1.6; 0.9, 2.7), but within 120 days, the risk of death was significantly higher than expected (SMR 1.9; 1.5, 2.4). The risk of death increased with age and tended to be higher among patients with prior co-morbidity. Overall risks of hospitalization and of death up to 120 days were increased both in men diagnosed and those not diagnosed with prostate cancer.

CONCLUSIONS

Higher rates of adverse events in older patients and patients with prior co-morbidity emphasizes the need for careful patient selection for prostate biopsy and justifies ongoing efforts to minimize the risk of complications.

Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study

BACKGROUND

Internationally, hospital survival is lower for patients admitted at weekends and at night. Data from the UK National Cardiac Arrest Audit (NCAA) indicate that crude hospital survival was worse after in-hospital cardiac arrest (IHCA) at night versus day, and at weekends versus weekdays, despite similar frequency of events.

OBJECTIVE

To describe IHCA demographics during three day/time periods-weekday daytime (Monday to Friday, 08:00 to 19:59), weekend daytime (Saturday and Sunday, 08:00 to 19:59) and night-time (Monday to Sunday, 20:00 to 07:59)-and to compare the associated rates of return of spontaneous circulation (ROSC) for >20 min (ROSC>20 min) and survival to hospital discharge, adjusted for risk using previously developed NCAA risk models. To consider whether any observed difference could be attributed to differences in the case mix of patients resident in hospital and/or the administered care.

METHODS

We performed a prospectively defined analysis of NCAA data from 27 700 patients aged ≥16 years receiving chest compressions and/or defibrillation and attended by a hospital-based resuscitation team in response to a resuscitation (2222) call in 146 UK acute hospitals.

RESULTS

Risk-adjusted outcomes (OR (95% CI)) were worse (p<0.001) for both weekend daytime (ROSC>20 min 0.88 (0.81 to 0.95); hospital survival 0.72 (0.64 to 0.80)), and night-time (ROSC>20 min 0.72 (0.68 to 0.76); hospital survival 0.58 (0.54 to 0.63)) compared with weekday daytime. The effects were stronger for non-shockable than shockable rhythms, but there was no significant interaction between day/time of arrest and age, or day/time of arrest and arrest location. While many daytime IHCAs involved procedures, restricting the analyses to IHCAs in medical admissions with an arrest location of ward produced results that are broadly in line with the primary analyses.

CONCLUSIONS

IHCAs attended by the hospital-based resuscitation team during nights and weekends have substantially worse outcomes than during weekday daytimes. Organisational or care differences at night and weekends, rather than patient case mix, appear to be responsible.

Improving documentation of treatment escalation decisions in acute care

The aim of this project was to improve the documentation of treatment escalation decisions at a district general hospital in southwest England. A pilot “Ceiling of Treatment” proforma was trialled on the care of the elderly wards at the Royal United Hospital (RUH), Bath. Successive PDSA cycles enabled revision of the proforma for use across the Trust. Data were collected on the proportion of patients with a documented treatment escalation decision. Formative feedback was collected via questionnaire from trainees and discussion with special interest groups of consultants within the hospital. This approach involved collaboration between acute medicine, intensive care, elderly care, the resuscitation department, palliative care and the legal department. Documentation of ceiling of treatment decisions rose from 30% to 90% during the study. A survey of medical trainees showed 67% (n=36) had seen the ceiling of treatment form, of which, 100% found it useful on on-call shifts. Initiating a proforma to record treatment escalation decisions and combining this with the existing ‘Do not attempt cardiopulmonary resuscitation’ (DNAR) paperwork, increased decision making and documentation. This intervention ensures patients receive the appropriate level of care, as indicated by their consultant, and reduces anxiety for junior doctors during on-call shifts.

Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort

OBJECTIVE

Brain injury is well established as a cause of early mortality after out-of-hospital cardiac arrest (OHCA), but postresuscitation shock also contributes to these deaths. This study aims to describe the respective incidence, risk factors, and relation to mortality of post-cardiac arrest (CA) shock and brain injury.

DESIGN

Retrospective analysis of an observational cohort.

SETTING

24-bed medical intensive care unit (ICU) in a French university hospital.

PATIENTS

All consecutive patients admitted following OHCA were considered for analysis. Post-CA shock was defined as a need for infusion of vasoactive drugs after resuscitation. Death related to brain injury included brain death and care withdrawal for poor neurological evolution.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Between 2000 and 2009, 1,152 patients were admitted after OHCA. Post-CA shock occurred in 789 (68%) patients. Independent factors associated with its onset were high blood lactate and creatinine levels at ICU admission. During the ICU stay, 269 (34.8%) patients died from post-CA shock and 499 (65.2%) from neurological injury. Age, raised blood lactate and creatinine values, and time from collapse to restoration of spontaneous circulation increased the risk of ICU mortality from both shock and brain injury, whereas a shockable rhythm was associated with reduced risk of death from these causes. Finally, bystander cardiopulmonary resuscitation (CPR) decreased the risk of death from neurological injury.

CONCLUSIONS

Brain injury accounts for the majority of deaths, but post-CA shock affects more than two-thirds of OHCA patients. Mortality from post-CA shock and brain injury share similar risk factors, which are related to the quality of the rescue process.

Impact of objectively measured sedentary behaviour on changes in insulin resistance and secretion over 3 years in the RISC study: interaction with weight gain

AIMS

The importance of reducing sedentary time is increasingly being recognized in the prevention of diabetes and cardiovascular disease. Despite this, the prospective association between sedentary time and physical activity with insulin sensitivity and cardiometabolic risk factors has been little studied.

METHODS

In an analysis of data from the European RISC study, sedentary time and time spent in activity of moderate or vigorous intensity were assessed by accelerometry at baseline in 313 men and 414 women, aged 30-60 years, with insulin sensitivity as measured by euglycaemic-hyperinsulinaemic clamp. Three years later, cardiometabolic risk factors (anthropometry, glucose, insulin, lipids) were available for 549 participants.

RESULTS

In cross-sectional analyses using baseline data, after adjusting for age, gender, recruitment centre and time spent in activity of moderate or vigorous intensity, significant unfavourable associations were observed between higher sedentary time with body weight, HDL cholesterol, triglycerides, clamp-measured insulin sensitivity and insulin secretion (all P(trend)<0.002). Sedentary time remained significantly associated with insulin secretion after adjusting for insulin sensitivity (P(trend)=0.02). In longitudinal analyses, higher baseline sedentary time was associated with 3-year increases in fasting glucose, fasting insulin and the HOMA insulin-resistance index score for the 50% of the study population who increased their BMI by at least 0.3 kg/m(2) (all P(trend)<0.01); these relationships remained significant after adjusting for time spent in activity of moderate or vigorous intensity. The 3-year increase in insulin secretion was lower in those spending more time doing activity of moderate or vigorous intensity (P(trend)=0.03).

CONCLUSION

These prospective data suggest that less sedentary behaviour may partly counteract some of the negative effects of increasing body weight on glucose-insulin homoeostasis.

Randomised comparison of the effectiveness of the laryngeal mask airway supreme, i-gel and current practice in the initial airway management of prehospital cardiac arrest (REVIVE-Airways): a feasibility study research protocol

INTRODUCTION

Effective cardiopulmonary resuscitation with appropriate airway management improves outcomes following out-of-hospital cardiac arrest (OHCA). Historically, tracheal intubation has been accepted as the optimal form of OHCA airway management in the UK. The Joint Royal Colleges Ambulance Liaison Committee recently concluded that newer supraglottic airway devices (SADs) are safe and effective devices for hospital procedures and that their use in OHCA should be investigated. This study will address an identified gap in current knowledge by assessing whether it is feasible to use a cluster randomised design to compare SADs with current practice, and also to each other, during OHCA.

METHODS AND ANALYSIS

The primary objective of this study is to assess the feasibility of a cluster randomised trial to compare the ventilation success of two newer SADs: the i-gel and the laryngeal mask airway supreme to usual practice during the initial airway management of OHCA. The secondary objectives are to collect data on ventilation success, further airway interventions required, loss of a previously established airway during transport, airway management on arrival at hospital (or termination of the resuscitation attempt), initial resuscitation success, survival to intensive care admission, survival to hospital discharge and patient outcome at 3 months. Ambulance paramedics will be randomly allocated to one of the three methods of airway management. Adults in medical OHCA attended by a trial paramedic will be eligible for the study.

ETHICS AND DISSEMINATION

Approval for the study has been obtained from a National Health Service Research Ethics Committee with authority to review proposals for trials of a medical device in incapacitated adults. The results will be made publicly available on an open access website, and we will publish the findings in appropriate journals and present them at national and international conferences relevant to the subject field.

TRIAL REGISTRATION

ISRCTN: 18528625.