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.

Abdominal aortic aneurysm volume and relative intraluminal thrombus volume might be auxiliary predictors of rupture-an observational cross-sectional study

Objectives

The study aimed to identify differences and compare anatomical and biomechanical features between elective and ruptured abdominal aortic aneurysms (AAAs).

Methods

Data (clinical, anatomical, and biomechanical) of 98 patients with AAA, 75 (76.53%) asymptomatic (Group aAAA) and 23 (23.46%) ruptured AAA (Group rAAA), were prospectively collected and analyzed. Anatomical, morphological, and biomechanical imaging markers like peak wall stress (PWS) and rupture risk equivalent diameter (RRED), comorbid conditions, and demographics were compared between the groups. Biomechanical features were assessed by analysis of Digital Imaging and Communication in Medicine images by A4clinics (Vascops), and anatomical features were assessed by 3Surgery (Trimensio). Binary and multiple logistic regression analysis were used and adjusted for confounders. Accuracy was assessed using receiving operative characteristic (ROC) curve analysis.

Results

In a multivariable model, including gender and age as confounder variables, maximal aneurysm diameter [MAD, odds ratio (OR) = 1.063], relative intraluminal thrombus (rILT, OR = 1.039), and total aneurysm volume (TAV, OR = 1.006) continued to be significant predictors of AAA rupture with PWS (OR = 1.010) and RRED (OR = 1.031). Area under the ROC curve values and correct classification (cc) for the same parameters and the model that combines MAD, TAV, and rILT were measured: MAD (0.790, cc = 75%), PWS (0.713, cc = 73%), RRED (0.717, cc = 55%), TAV (0.756, cc = 79%), rILT (0.656, cc = 60%), and MAD + TAV + rILT (0.797, cc = 82%).

Conclusion

Based on our results, in addition to MAD, other important predictors of rupture that might be used during aneurysm surveillance are TAV and rILT. Biomechanical parameters (PWS, RRED) as valuable predictors should be assessed in prospective clinical trials. Similar studies on AAA smaller than 55 mm in diameter, even difficult to organize, would be of even greater clinical value.

Treatment of concurrent etizolam and tianeptine withdrawal following accidental overdose

Background

The availability of nonapproved psychoactive substances with addiction potential from internet sources poses a significant threat to public health. Polysubstance abuse or inadvertent contamination of preparations may result in clinically challenging intoxication and withdrawal syndromes.

Case Report

We report a case of a 32-year-old male with an approximate 2-year history of taking internet-obtained etizolam and tianeptine who presented to the hospital following an overdose. He experienced subsequent withdrawal symptoms consistent with benzodiazepine and opioid withdrawal. Initial attempts at managing symptoms with chlordiazepoxide 25 mg every 6 hours did not relieve his symptoms. On day 3 of admission, addiction medicine was consulted and his regimen was changed to diazepam 80 mg daily with additional as-needed diazepam based on etizolam equivalence. He also received a 5-day methadone taper with plans to transition to buprenorphine in the outpatient setting. Upon discharge he was referred to an addiction medicine specialist who was willing to continue a slow diazepam taper and initiate medications for opioid use disorder to manage both substance use disorders.

Discussion

This case report demonstrates the effectiveness of diazepam in managing benzodiazepine withdrawal from etizolam while concurrently using methadone to manage opioid withdrawal symptoms from tianeptine in a hospitalized patient following overdose. We highlight the importance of a warm handoff in considering the outpatient discharge plan.

Employment status of patients with schizophrenia spectrum disorder treated with long acting injectable paliperidone palmitate: Real world mirror image study

Introduction

Schizophrenia spectrum disorders may severely limit ability to achieve and maintain gainful employment of affected working-age individuals.

Objectives

Assess the employment status in patients with schizophrenia spectrum disorders treated with long acting injectable paliperidone palmitate after the switch from oral antipsychotics.

Methods

A single centre mirror image design study of 115 patients with schizophrenia spectrum disorder was conducted in a tertiary level psychiatric hospital. Data were collected for period of 12 months prior toand 12 months after switching from oral antipsychotic to long acting injectable paliperidone.Employment status for 6 enrolled patients was missing.

Results

Mean age of enrolled patients was 38,4±11,6 years. Of the 109 patients analyzed for employment status, 44,4% remained employed for 12 months after switching to long acting injectable paliperidone while 4,6% patients changed their employment status from unemployed to employed after the switch. No patient changed their employment status from employed to unemployed after the switch. 9,2% patients were already retired at the beginning of study period and 5,5% of patients maintained their student status. 36,7% patients remained unemployed for the whole study period. The correlation between employment status of employed and unemployed patients and duration of illness was borderline significant with p=0,049.

Conclusions

The data from this study suggest that use of long acting injectable paliperidone contributed to preservation of working ability of working-age patients suffering from schizophrenia spectrum disorders.

Disclosure

No significant relationships.

Titin kinase ubiquitination aligns autophagy receptors with mechanical signals in the sarcomere

Striated muscle undergoes remodelling in response to mechanical and physiological stress, but little is known about the integration of such varied signals in the myofibril. The interaction of the elastic kinase region from sarcomeric titin (A168-M1) with the autophagy receptors Nbr1/p62 and MuRF E3 ubiquitin ligases is well suited to link mechanosensing with the trophic response of the myofibril. To investigate the mechanisms of signal cross-talk at this titin node, we elucidated its 3D structure, analysed its response to stretch using steered molecular dynamics simulations and explored its functional relation to MuRF1 and Nbr1/p62 using cellular assays. We found that MuRF1-mediated ubiquitination of titin kinase promotes its scaffolding of Nbr1/p62 and that the process can be dynamically down-regulated by the mechanical unfolding of a linker sequence joining titin kinase with the MuRF1 receptor site in titin. We propose that titin ubiquitination is sensitive to the mechanical state of the sarcomere, the regulation of sarcomere targeting by Nbr1/p62 being a functional outcome. We conclude that MuRF1/Titin Kinase/Nbr1/p62 constitutes a distinct assembly that predictably promotes sarcomere breakdown in inactive muscle.

Mechanical dispersion is associated with clinical and subclinical coronary artery disease in patients on chronic renal replacement therapy with normal left ventricular ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Introduction

Since coronary artery disease (CAD) is the leading cause of mortality in patients with end-stage renal failure, early detection of CAD in these patients presenting with still normal left ventricular (LV) systolic function is of clinical importance.

Aim

To investigate the correlation between electrical and mechanical dispersion and CAD in dialysis patients with normal LV systolic function.

Material and methods: This prospective study included 78 dialysis patients who underwent a 12-channel electrocardiogram and echocardiographic examination to determine electrical and mechanical myocardial dispersion. A coronary calcium score using cardiac computed tomography was also assessed in a group of 20 patients without known CAD. Electrical dispersion was defined as the difference between the longest and shortest corrected QT interval (QTc). Mechanical dispersion (MD) was defined as either standard deviation of mechanical contraction duration of all LV segments (MD_SD) or the difference between the longest and shortest duration of mechanical contraction (MD_delta). The duration of mechanical contraction was determined by myocardial strain analysis.

Results

Previously known CAD was present in 11 (14%) patients, while pathologic Q wave was absent in all patients. No significant correlation was observed between QTc dispersion and both MD parameters (p &gt; 0.05 for both). Both MD parameters (p = 0.007 for MD_SD; p = 0.026 for MD_delta), but not electrical dispersion (p = 0.584), showed a discriminative power for detecting previously known CAD (Figure). In patients without known CAD, neither QTc dispersion nor MD_SD showed a correlation with coronary calcium score (p &gt; 0.05 for both). MD_delta showed a strong correlation with both total and coronary calcium score in the territory of the left anterior descending coronary artery (r = 0.62; p = 0.004) in patients without previously known CAD.

Conclusion

Mechanical dispersion is associated with known CAD in dialysis patients with normal LV systolic function. The range of mechanical myocardial contraction duration (MD_delta) correlates with subclinical coronary atherosclerosis.

Figure. Discriminative power of mechanical and electrical dispersion for the detection of coronary artery disease

Abstract Figure.

Adverse childhood experiences, childhood relationships and associated substance use and mental health in young Europeans

Background

Adverse childhood experiences (ACEs) can increase risks of health-harming behaviours and poor health throughout life. While increases in risk may be affected by resilience resources such as supportive childhood relationships, to date few studies have explored these effects.

Methods

We combined data from cross-sectional ACE studies among young adults (n = 14 661) in educational institutions in 10 European countries. Nine ACE types, childhood relationships and six health outcomes (early alcohol initiation, problem alcohol use, smoking, drug use, therapy, suicide attempt) were explored. Multivariate modelling estimated relationships between ACE counts, supportive childhood relationships and health outcomes.

Results

Almost half (46.2%) of participants reported ≥1 ACE and 5.6% reported ≥4 ACEs. Risks of all outcomes increased with ACE count. In individuals with ≥4 ACEs (vs. 0 ACEs), adjusted odds ratios ranged from 2.01 (95% CIs: 1.70–2.38) for smoking to 17.68 (95% CIs: 12.93–24.17) for suicide attempt. Supportive childhood relationships were independently associated with moderating risks of smoking, problem alcohol use, therapy and suicide attempt. In those with ≥4 ACEs, adjusted proportions reporting suicide attempt reduced from 23% with low supportive childhood relationships to 13% with higher support. Equivalent reductions were 25% to 20% for therapy, 23% to 17% for problem drinking and 34% to 32% for smoking.

Conclusions

ACEs are strongly associated with substance use and mental illness. Harmful relationships are moderated by resilience factors such as supportive childhood relationships. Whilst ACEs continue to affect many children, better prevention measures and interventions that enhance resilience to the life-long impacts of toxic childhood stress are required.

Support to responsive parenting through communication tools

Issue

Counselling unit for positive parenting “Halobeba” has been established at Institute of Public Health of Belgrade with support of UNICEF in order to enable continuum of mother and child health care. Availability of information on child care and development was noticed as significant factor for parental confidence and practice.

Description of the problem

Trained nurses provide responses to parental questions through 24/7 phone and e mail communication to assist in problem solving and offer emotional support. Nurses are skilled in active listening, proper questioning, counselling and effective encouragement. Free mob app on breastfeeding was developed as knowledge base for parents. New interactive mob app was recently launched as parenting tool for child health and development monitoring.

Results

Since 2002, more than 1,700,000 responses were provided through phone communication and over 20,000 via email and number of beneficiaries has increased over the years. Most common topics were about breastfeeding, introducing solid food, treatment of fever and respiratory infections, gastrointestinal problems, injuries, immunization, and developmental milestones. Less than 15% of cases were referred to pediatric clinic. Level of parental overall satisfaction was very high and availability and effectiveness of service were especially valued as well as nurses communication skills.

Lessons

Family centered service that corresponds to caregivers needs is effective approach to support nurturing care for young children. Personalized M-health tools make child care more accessible and build capacities of caregivers.

Key messages

Sending consistent and trusted messages through different communication channels contribute to enhancing users' knowledge and skills. Knowledgeable and responsive caregivers properly interpret child’s needs, respond appropriately, facilitate the child’s social and emotional development, and provide proper care.

Brexpiprazole in the treatment of schizophrenia and agitation in Alzheimer's disease

Schizophrenia is a disabling psychiatric disorder marked by progressive loss of functionality in activities of daily living with each relapse. Antipsychotics, the mainstay of therapy for schizophrenia, treat hallucinations and delusions but may have intolerable side effects, including metabolic disturbances and extrapyramidal symptoms. Brexpiprazole, a second-generation antipsychotic with dopamine partial agonist properties, was approved by the US FDA in 2015 for the treatment of schizophrenia and adjunctive treatment of major depressive disorder and by the EU in 2018 for adults with schizophrenia. Additionally, brexpiprazole has recently been studied for the treatment of agitation in Alzheimer's dementia, an area of largely unmet need. Overall, well-tolerated brexpiprazole expands the armamentarium of treatment options available for these conditions.

AB0207 CLINICAL IMPACT OF ANTI-CARP ANTIBODIES IN RHEUMATOID ARTHRITIS

Background:

Antibodies directed against carbamylated proteins (anti-CarP) have been recently introduced for the first time as a new biomarker in rheumatoid arthritis (RA) (1). Their presence is predictive for the development of RA (2). Anti-CarP antibodies are associated with the development of more severe forms of the disease in overall and anti-citrullinated peptide antibodies negative population of patients with RA (3). In the literature is still current the research which associate these antibodies with disease activity and functional status of patients.

Objectives:

This study investigated the incidence of anti-CarP positive findings in patients with RA on synthetic and biologic disease-modifying therapy (DMT) and the relationship between anti-CarP antibody status and both disability and disease activity.

Methods:

It was an open-label, observational, cross-sectional study. The trial included 70 patients with RA diagnosed on the basis of ACR 1987 and ACR / EULAR 2010 criteria, on treatment with synthetic and biological DMT, who attended the Clinic of Rheumatology, Military Medical Academy, from September to December 2018.The control group consisted of 18 healthy individuals. After approval of the institutional Ethical Committee and after patients have signed Informed Consent,the study was conducted. Disease activity score (DAS28) was determined for the assessment of RA activity, and the assessment of patients’ functional ability was performed using the Health assessment questionnaire disability index (HAQ-DI). Concentration of anti-CarP antibodies was determined by commercial ELISA anti-CarP quantitative sandwich immunoassay. The methods of descriptive and analytical statistics were used in statistical data processing.

Results:

Based on the cut-off value (5.9 ng / ml), no one in the control group had positive anti-CarP antibodies, while 34.7% of the subjects with RA were positive. The positive correlation was found between anti-CarP antibody concentration and DAS28 in all RA patients (p = 0.0003; Pearson r = 0.4829). The positive correlation was also found between anti-CarP antibody concentration and HAQ-DI in all RA patients (p = 0.0003; Pearson r = 0.4253).

Conclusion:

Anti-CarP antibodies were present in a significant number of patients with RA. This study demonstrated that patients with RA with higher concentrations of anti-CarP antibodies have higher disease activity and impaired functional status. It is undisputed that further and larger studies are needed to better determine the clinical significance of these antibodies.

References:

[1]Shi J, Knevel R et al. Autoantibodies recognizing carbamylated proteins are present in sera of patients with rheumatoid arthritis and predict joint damage. Proc Natl AcadSci U S A. 2011 Oct 18;108(42):17372-7.

[2]Yee A, Webb T et al. Anti-CarP antibodies as promising marker to measure joint damage and disease activity in patients with rheumatoid arthritis. Immunol Res. 2015 Feb;61(1-2):24-30.

[3]Brink M, Verheul MK et al. Anti-carbamylated protein antibodies in thepresymptomatic phase of rheumatoid arthritis, their relationship with multiple anticitrulline peptide antibodies and association with radiological damage. Arthritis Res Ther. 2015 Feb 7;17:25.

Graphs 1 and 2.

Correlation of anti-CarP antibody concentration with DAS28 and HAQ-DI in all RA patients

Disclosure of Interests:

None declared

Capacity Building in Nurturing Care in Serbia

Background

Training program for home visitors on early child development was developed and implemented within UNICEF supported projects involving 25 primary health centers. Training content was notably based on resource modules “Supporting Families for Nurturing Care”, adapted according to the local context. Health professionals are seen as the critical actors to support development of young children and their families. Family-centered approach that addresses social as well as medical dimensions of problems became priority in their practice with a special focus on working with children from socially deprived settings and children with disabilities.

Objectives

The main objective was to improve knowledge and practice of home visitors on early child development based on most recent scientific evidence. Broad spectrum of topics was covered including engaging fathers, early detection of postpartum depression, attachment, developmental monitoring, age-appropriate play, home safety, stigma and discrimination. Training were organized as interactive face to face sessions and online courses and attendees were actively engaged in reflection. Comprehensive check list with various assessment instruments was developed to provide guidance to home visitors in implementation of gained skills.

Results

Increase in knowledge of 150 home visitors was between 57.6% and 82.9%. Enhanced knowledge and skills have been applied in 14912 families of which socially deprived was 34.5% during 2-year period of implementation. Parent-child interactions, assessed by visiting nurses, were improved by 32.6%, responsive feeding practices by 27.4%, while age-appropriate play by 34.4% after interventions during home visits.

Conclusions

Well-developed monitoring system was crucial for implementation of gained knowledge and skills in practice of home visitors.

Key messages

Home visitors were empowered to take a strengths-based approach in their work with families. Developed tools facilitated prioritization of most vulnerable families and tailoring support according to needs.

The efficacy of raw and concentrated bentonite clay in reducing the toxic effects of aflatoxin in broiler chicks

The objective of this study was to evaluate the efficacy of two adsorbents, a raw bentonite clay (RC) and a concentrated bentonite clay (CC), in ameliorating the toxic effects of aflatoxin B1 (AFB1). Results of the in vitro study (pH 3.0) indicated the CC adsorbed more AFB1 than RC (93.39 mg/g vs. 79.30 mg/g) suggesting that CC may be more effective than RC in reducing the toxic effects of AFB1. One hundred and eighty day-old straight run broiler chicks were assigned to 6 replicate pens of 5 chicks each and assigned to 6 dietary treatments from hatch to day 21. Dietary treatments included: 1) basal diet (BD) containing no AFB1 or adsorbents; 2) BD plus 0.50% RC; 3) BD plus 0.50% CC; 4) BD plus 2.0 mg AFB1/kg; 5) BD plus 2.0 mg AFB1/kg plus 0.50% RC; and 6) BD plus 2.0 mg AFB1/kg plus 0.50% CC. Dietary AFB1 concentrations were confirmed by analysis and diets were screened for other mycotoxins prior to the start of the experiment. The addition of AFB1 to the feed reduced (P < 0.05) growth performance and increased (P < 0.05) relative liver weight (RLW) and kidney weight (RKW) of chicks fed AFB1 compared to control chicks on day 21. These changes were ameliorated (P < 0.05) by the addition of RC and CC to the AFB1 diet. Mild to moderate lesions of aflatoxicosis (2.25) were observed in chicks fed AFB1 alone on day 21. The addition of both RC and CC to the AFB1 diet decreased (P < 0.05) but did not prevent liver lesions (0.92 and 1.42, respectively). Results indicate that both RC and CC were effective in reducing the toxic effects of AFB1, however the cost of processing of CC would make the RC a more economical product for reducing the effects of AFB1 in young broiler chicks.

A Comparison of Medication Histories Obtained by a Pharmacy Technician Versus Nurses in the Emergency Department

PURPOSE

To compare the medication history error rate of the emergency department (ED) pharmacy technician with that of nursing staff and to describe the workflow environment.

METHODS

Fifty medication histories performed by an ED nurse followed by the pharmacy technician were evaluated for discrepancies (RN-PT group). A separate 50 medication histories performed by the pharmacy technician and observed with necessary intervention by the ED pharmacist were evaluated for discrepancies (PT-RPh group). Discrepancies were totaled and categorized by type of error and therapeutic category of the medication. The workflow description was obtained by observation and staff interview.

RESULTS

A total of 474 medications in the RN-PT group and 521 in the PT-RPh group were evaluated. Nurses made at least one error in all 50 medication histories (100%), compared to 18 medication histories for the pharmacy technician (36%). In the RN-PT group, 408 medications had at least one error, corresponding to an accuracy rate of 14% for nurses. In the PT-RPh group, 30 medications had an error, corresponding to an accuracy rate of 94.4% for the pharmacy technician (P < 0.0001). The most common error made by nurses was a missing medication (n = 109), while the most common error for the pharmacy technician was a wrong medication frequency (n = 19). The most common drug class with documented errors for ED nurses was cardiovascular medications (n = 100), while the pharmacy technician made the most errors in gastrointestinal medications (n = 11).

CONCLUSION

Medication histories obtained by the pharmacy technician were significantly more accurate than those obtained by nurses in the emergency department.

Brexpiprazole

OBJECTIVE

To review the pharmacology and clinical data for brexpiprazole in schizophrenia and major depressive disorder (MDD).

DATA SOURCES

An English-language literature search using PubMed and MEDLINE was performed using the term brexpiprazole. All articles containing human clinical trial data published up to September 2016 were evaluated for inclusion as well as information from the manufacturer's product labeling.

STUDY SELECTION/DATA EXTRACTION

Phase 3 trials for brexpiprazole were evaluated. Key in vitro and animal data were incorporated into the pharmacology and pharmacokinetic sections where appropriate.

DATA SYNTHESIS

Four phase 3 trials have evaluated the use of brexpiprazole as a primary therapy for schizophrenia or as an antidepressant adjunct for MDD. For its schizophrenia indication, brexpiprazole was studied in 2 placebo-controlled trials of approximately 1300 patients, with 4 mg of brexpiprazole consistently showing superiority over placebo. For MDD, brexpiprazole was compared with placebo as an adjunct to antidepressants in approximately 1000 patients who had failed trials of 1 to 3 prior antidepressants. The 2-mg and 3-mg dosages of brexpiprazole showed consistent superiority over placebo in the MDD trials. Common treatment emergent adverse effects included akathisia and weight gain.

CONCLUSIONS

Brexpiprazole showed efficacy for the treatment of schizophrenia in the range of 2 to 4 mg/d and as an adjunct to antidepressant therapy in MDD when dosed at 2 to 3 mg/d. Advantages of this drug include once-daily dosing, good tolerability, and lack of effect on sexual function. Disadvantages include the lack of long-term safety data and potentially high cost.

Prognostic value of peritumoral edema and angiogenesis in intracranial meningioma surgery

PURPOSE

In a series of 78 consecutive patients we analyzed the influence of peritumoral edema (PTE) and angiogenesis (vascular endothelial growth factor/ VEGF expression) on the prognosis of morbidity and postoperative complications after intracranial meningioma surgery.

METHODS

A retrospective analysis was performed of clinical, neuroradiological and histological data of 78 microsurgically treated patients with intracranial supratentorial meningioma, with follow-up period of at least one year.

RESULTS

The severity of PTE showed significant correlation with VEGF expression, and all patients with large PTE (>40 mm) had strong VEGF expression (>50%). Treatment outcome was significantly better in patients with low VEGF expression (p<0.05). All of the monitored postoperative complications were more frequent in the group with PTE.The duration of intensive care treatment in the group with PTE (mean 6.85 days) was significantly longer than in the group without PTE (mean 3.68 days) (p=0.003). In the group without PTE, the outcome was significantly better than in patients with PTE (p<0.01).

CONCLUSION

PTE in intracranial meningiomas has significant influence on the prognosis in surgically treated patients in terms of increased risk of morbidity and postoperative complications. VEGF expression is strongly correlated with PTE formation, which also affects the outcome in the management of patients with intracranial meningioma.

Effect of a single pool dive on pulmonary function in asthmatic and non-asthmatic divers

INTRODUCTION

The aim of this study was to evaluate the effect of a single, shallow, swimming pool scuba dive on pulmonary function in divers with asthma as compared to controls. Opinions concerning the risks of diving with asthma are still contradictory and inconclusive in the diving community.

METHODS

Baseline pulmonary function tests (PFTs) were performed on a group of 22 divers with asthma and on a control group of 15 healthy divers. The same PFTs were repeated within 10 minutes after a single pool dive, at 5 metres' depth for 10 minutes. PFTs were measured using a portable Jaeger SpiroPro™ device. Student's paired t-tests and linear mixed effects model comparisons and interactions within the groups were used in the data analysis.

RESULTS

Divers with asthma initially presented significantly lower values of FEV1/FVC%* (P < 0.01), FEF25* (P < 0.01), FEF50* (P < 0.001), FEF75* (P < 0.01) and FEF25-75* (P < 0.001) compared to controls. There were significant reductions in FEV1 (P < 0.01), FEV1/FVC% (P < 0.05), FEF50* (P < 0.01), FEF75* (P < 0.05) and FEF25-75* (P < 0.001) in the asthma group after the dive as compared to the control group. PEF was initially lower, although not significantly, in the asthma group and did not change significantly after the dive in either group (P > 0.05).

CONCLUSIONS

A single, shallow, pool scuba dive to 5 metres' depth may impair function of small airways in asthmatic divers. More studies are necessary to estimate the risks when divers with asthma practise scuba diving. PFT results should be analysed after replicated dives in deeper pools and controlled open-water conditions.

Arachidonic acid-metabolizing cytochrome P450 enzymes are targets of {omega}-3 fatty acids

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) protect against cardiovascular disease by largely unknown mechanisms. We tested the hypothesis that EPA and DHA may compete with arachidonic acid (AA) for the conversion by cytochrome P450 (CYP) enzymes, resulting in the formation of alternative, physiologically active, metabolites. Renal and hepatic microsomes, as well as various CYP isoforms, displayed equal or elevated activities when metabolizing EPA or DHA instead of AA. CYP2C/2J isoforms converting AA to epoxyeicosatrienoic acids (EETs) preferentially epoxidized the ω-3 double bond and thereby produced 17,18-epoxyeicosatetraenoic (17,18-EEQ) and 19,20-epoxydocosapentaenoic acid (19,20-EDP) from EPA and DHA. We found that these ω-3 epoxides are highly active as antiarrhythmic agents, suppressing the Ca(2+)-induced increased rate of spontaneous beating of neonatal rat cardiomyocytes, at low nanomolar concentrations. CYP4A/4F isoforms ω-hydroxylating AA were less regioselective toward EPA and DHA, catalyzing predominantly ω- and ω minus 1 hydroxylation. Rats given dietary EPA/DHA supplementation exhibited substantial replacement of AA by EPA and DHA in membrane phospholipids in plasma, heart, kidney, liver, lung, and pancreas, with less pronounced changes in the brain. The changes in fatty acids were accompanied by concomitant changes in endogenous CYP metabolite profiles (e.g. altering the EET/EEQ/EDP ratio from 87:0:13 to 27:18:55 in the heart). These results demonstrate that CYP enzymes efficiently convert EPA and DHA to novel epoxy and hydroxy metabolites that could mediate some of the beneficial cardiovascular effects of dietary ω-3 fatty acids.

An Octacalcium Phosphate Forming Cement

The osteoconductive and possibly osteoinductive characteristics of OCP increased the interest in preparation of bone graft materials that contain OCP in its composition. Calcium phosphate cements (CPCs) were prepared using a mixture of α-tricalcium phosphate (α-TCP) and dicalcium phosphate anhydrous (DCPA), with α-TCP / DCPA molar ratio of 1/1 and distilled water or 0.5 mol / L phosphate aqueous solution (pH = 6.1 ± 0.1) as the cement liquid. Hardening time was (30 ± 1) min for the CPC mixed with water and (5 ± 1) min for the CPC mixed with phosphate solution. Diametral tensile strength (DTS), porosity (P), and phase composition (powder x-ray diffraction) were determined after the hardened specimens had been immersed in a physiological-like solution (PLS) for 1 d, 3 d, and 7 d. In CPC specimens prepared with water, calcium hydroxyapatite (HA) was formed and DTS and P were (9.03 ± 0.48) MPa and (37.05 ± 0.20) vol % after 1 d, respectively, and (9.15 ± 0.45) MPa and (37.24 ± 0.63) vol % after 3 d, respectively. In CPC specimens prepared with phosphate solution OCP and HA were formed and DTS and P were (4.38 ± 0.49) MPa and (41.44 ± 1.25) vol % after 1 d, respectively,(4.38 ± 0.29) MPa and (42.52 ± 2.15) vol % after 3 d, respectively, and (4.30 ± 0.60) MPa and (41.38 ± 1.65) vol % after 7 d, respectively. For each group DTS and P did not change with PLS immersion time. DTS was significantly higher and P was significantly lower for CPCs prepared with water. HA formation slightly increased with immersion time from 40 mass % after 1 d to 50 mass % after 3 d in CPCs prepared with water. OCP + HA formation increased with immersion time from 30 mass % after 1 d to 35 mass % after 3 d and to 45 mass % after 7 d in CPCs prepared with 0.5 mol / L phosphate solution.

Calcium Fluoride Precipitation and Deposition From 12 mmol/L Fluoride Solutions With Different Calcium Addition Rates

The effects of different Ca-addition rates on calcium fluoride (CaF2) precipitation and deposition were investigated in 12 mmol/L sodium fluoride solutions to which 0.1 mol/L calcium chloride solution was continuously added at average rates of (5, 7.5, 10, 12.5, 15 or 20) mmol L(-1) min(-1). The changes in ionic fluoride and calcium concentrations, as well as turbidity, were continuously recorded by F and Ca electrodes, and a fiber optic based spectrophotometer, respectively. The F(-) concentration decreased and turbidity increased with time indicating precipitation of CaF2. For the systems with Ca-addition rates of (5, 7.5, 10, 12.5, 15, and 20) mmol L(-1) min(-1), the 1 min CaF2 depositions in the model substrate (cellulose filter paper, pores 0.2 µm) expressed as mean ± SD of deposited F per substrate surface area were (3.78 ± 0.31, 11.45 ± 0.89, 9.31 ± 0.68, 8.20 ± 0.56, 6.63 ± 0.43, and 2.09 ± 0.28) µg/cm(2), respectively (n = 10 for each group). The 1-min F depositions did not show positive correlation to Ca-addition rates. The lowest 1-min F deposition was obtained in the systems with the highest Ca-addition rate of 20 mmol L(-1) min(-1) for which CaF2 precipitation rate reached the maximum value of 0.31 mmol L(-1) s(-1) almost immediately after beginning of reaction (6 s). The largest 1-min F depositions were obtained from the systems with Ca addition rates of (7.5 to 12.5) mmol L(-1) min(-1) in which CaF2 precipitation rates continuously increased reaching the maximum values of (0.13 to 0.20) mmol L(-1) s(-1) after (18 to 29) s, respectively. The 1-min F depositions were greatly enhanced in comparison with the control F solutions that did not have continuous Ca-addition. This indicates that continuous Ca addition that controls the rate of CaF2 formation could be a critical factor for larger F depositions from F solutions. The efficacy of conventional F mouthrinses could be improved with addition of a substance that continuously releases Ca.

Dietary n-3 Polyunsaturated Fatty Acids and Direct Renin Inhibition Improve Electrical Remodeling in a Model of High Human Renin Hypertension

We compared the effect n-3 polyunsaturated fatty acids (PUFAs) with direct renin inhibition on electrophysiological remodeling in angiotensin II–induced cardiac injury. We treated double-transgenic rats expressing the human renin and angiotensinogen genes (dTGRs) from week 4 to 7 with n-3 PUFA ethyl-esters (Omacor; 25-g/kg diet) or a direct renin inhibitor (aliskiren; 3 mg/kg per day). Sprague-Dawley rats were controls. We performed electrocardiographic, magnetocardiographic, and programmed electrical stimulation. Dietary n-3 PUFAs increased the cardiac content of eicosapentaenoic and docosahexaenoic acid. At week 7, mortality in dTGRs was 31%, whereas none of the n-3 PUFA- or aliskiren-treated dTGRs died. Systolic blood pressure was modestly reduced in n-3 PUFA-treated (180±3 mm Hg) compared with dTGRs (208±5 mm Hg). Aliskiren-treated dTGRs and Sprague-Dawley rats were normotensive (110±3 and 119±6 mm Hg, respectively). Both n-3 PUFA–treated and untreated dTGRs showed cardiac hypertrophy and increased atrial natriuretic peptide levels. Prolonged QRS and QT c intervals and increased T-wave dispersion in dTGRs were reduced by n-3 PUFAs or aliskiren. Both treatments reduced arrhythmia induction from 75% in dTGRs to 17% versus 0% in Sprague-Dawley rats. Macrophage infiltration and fibrosis were reduced by n-3 PUFAs and aliskiren. Connexin 43, a mediator of intermyocyte conduction, was redistributed to the lateral cell membranes in dTGRs. n-3 PUFAs and aliskiren restored normal localization to the intercalated disks. Thus, n-3 PUFAs and aliskiren improved electrical remodeling, arrhythmia induction, and connexin 43 expression, despite a 70-mm Hg difference in blood pressure and the development of cardiac hypertrophy.

Mouse Cyp4a isoforms: enzymatic properties, gender- and strain-specific expression, and role in renal 20-hydroxyeicosatetraenoic acid formation

AA (arachidonic acid) hydroxylation to 20-HETE (20-hydroxyeicosatetraenoic acid) influences renal vascular and tubular function. To identify the CYP (cytochrome P450) isoforms catalysing this reaction in the mouse kidney, we analysed the substrate specificity of Cyp4a10, 4a12a, 4a12b and 4a14 and determined sex- and strain-specific expressions. All recombinant enzymes showed high lauric acid hydroxylase activities. Cyp4a12a and Cyp4a12b efficiently hydroxylated AA to 20-HETE with V(max) values of approx. 10 nmol x nmol(-1) x min(-1) and K(m) values of 20-40 microM. 20-Carboxyeicosatetraenoic acid occurred as a secondary metabolite. AA hydroxylase activities were approx. 25-75-fold lower with Cyp4a10 and not detectable with Cyp4a14. Cyp4a12a and Cyp4a12b also efficiently converted EPA (eicosapentaenoic acid) into 19/20-OH- and 17,18-epoxy-EPA. In male mice, renal microsomal AA hydroxylase activities ranged between approx. 100 (NMRI), 45-55 (FVB/N, 129 Sv/J and Balb/c) and 25 pmol x min(-1) x mg(-1) (C57BL/6). The activities correlated with differences in Cyp4a12a protein and mRNA levels. Treatment with 5alpha-dihydrotestosterone induced both 20-HETE production and Cyp4a12a expression more than 4-fold in male C57BL/6 mice. All female mice showed low AA hydroxylase activities (15-25 pmol x min(-1) x mg(-1)) and very low Cyp4a12a mRNA and protein levels, but high Cyp4a10 and Cyp4a14 expression. Renal Cyp4a12b mRNA expression was almost undetectable in both sexes of all strains. Thus Cyp4a12a is the predominant 20-HETE synthase in the mouse kidney. Cyp4a12a expression determines the sex- and strain-specific differences in 20-HETE generation and may explain sex and strain differences in the susceptibility to hypertension and target organ damage.