Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

The Mediator complex regulates enhancer-promoter interactions

Enhancer-mediated gene activation generally requires physical proximity between enhancers and their target gene promoters. However, the molecular mechanisms by which interactions between enhancers and promoters are formed are not well understood. Here, we investigate the function of the Mediator complex in the regulation of enhancer-promoter interactions, by combining rapid protein depletion and high-resolution MNase-based chromosome conformation capture approaches. We show that depletion of Mediator leads to reduced enhancer-promoter interaction frequencies, which are associated with a strong decrease in gene expression. In addition, we find increased interactions between CTCF-binding sites upon Mediator depletion. These changes in chromatin architecture are associated with a redistribution of the Cohesin complex on chromatin and a reduction in Cohesin occupancy at enhancers. Together, our results indicate that the Mediator and Cohesin complexes contribute to enhancer-promoter interactions and provide insights into the molecular mechanisms by which communication between enhancers and promoters is regulated.

Psychosocial stress and cannabinoid drugs affect acetylation of α-tubulin (K40) and gene expression in the prefrontal cortex of adult mice

The dynamics of neuronal microtubules are essential for brain plasticity. Vesicular transport and synaptic transmission, additionally, requires acetylation of α-tubulin, and aberrant tubulin acetylation and neurobiological deficits are associated. Prolonged exposure to a stressor or consumption of drugs of abuse, like marihuana, lead to neurological changes and psychotic disorders. Here, we studied the effect of psychosocial stress and the administration of cannabinoid receptor type 1 drugs on α-tubulin acetylation in different brain regions of mice. We found significantly decreased tubulin acetylation in the prefrontal cortex in stressed mice. The impact of cannabinoid drugs on stress-induced microtubule disturbance was investigated by administration of the cannabinoid receptor agonist WIN55,212–2 and/or antagonist rimonabant. In both, control and stressed mice, the administration of WIN55,212–2 slightly increased the tubulin acetylation in the prefrontal cortex whereas administration of rimonabant acted antagonistically indicating a cannabinoid receptor type 1 mediated effect. The analysis of gene expression in the prefrontal cortex showed a consistent expression of ApoE attributable to either psychosocial stress or administration of the cannabinoid agonist. Additionally, ApoE expression inversely correlated with acetylated tubulin levels when comparing controls and stressed mice treated with WIN55,212–2 whereas rimonabant treatment showed the opposite.

389 The Benefit of Pre-Emptive Peri-Incisional Local Anesthesia in Day-Case Open Hernia Repair

Introduction

Hernia repair is one of the common operations performed in the United Kingdom. The novel technique of intra-operative local anaesthesia has improved the outcomes in recovery and has reduced overnight hospital stay. The aim of the study was to compare the postoperative pain, LOS and overall satisfaction in the group where local anaesthesia (LA) was injected peri incisional versus LA at the end of the procedure.

Method

In this prospective observational study, 70 consecutive unselected men underwent open inguinal hernia repair as a day case. Of these, 35 underwent repair under GA + peri-incisional LA solution (an equal mixture of 0.5% bupivacaine and 1% lignocaine with 1:200,000 adrenaline) (Group A) and 35 with GA with LA injected at the end of the procedure (Group B). Pain score assessed postoperatively at 2 hours and the next day after the procedure telephonically. A validated patient questionnaire was used to get the satisfaction level of the patients.

Results

The median age of group A was 57.1 years, and, in group B, it was 59.7 years. All of them underwent Lichenstein hernia repair. None of them in group A had a pain score of more than three. 4 patients in group B had a pain score of more than 3 post-operatively (11%). On postoperative day 1, only one patient had pain score of 4, whereas, in Group B 14 patients (40%) had pain score &gt; 4 (P-value 0.042). Six patients (14.2%) in group B failed day-case discharge criteria. None of the patients in both groups were dissatisfied.

Conclusions

Patients undergoing day-case GA inguinal hernioplasty with peri-incisional pre-emptive LA solution infiltration have adequate postoperative pain control and a good satisfaction level. These patients are unlikely to fail discharge for planned day-case surgery.

173 Causes of Death in Patients with Pancreatic Adenocarcinoma: A SEER-Based Study

Aim

To identify the commonest causes of non-cancer mortality in patients with PAC and compare their mortality risk with the general population.

Method

This population-based study analyzed data of PAC patients registered in the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2016. Patients were followed up until 2016.We studied cancer and non-cancer causes of death and investigated their possible association with age, sex, race, tumor stage at presentation, and treatment modality; each according to the time interval from diagnosis during which death events occurred (intervals included &lt; 1 year, 1–5 years, 5–10 years, and &gt; 10 years after diagnosis).We estimated the standardized mortality ratio (SMR) with the 95% confidence interval (CI) for each mortality cause in each time interval. Analysis was conducted using SEER*Stat software version 8.3.9.

Result

A total of 67,694 PAC patients included in the analysis; of these patients, 64,347 (95.06%) died during the follow-up period. Most deaths occurred due to cancers (61,685; 95.86% of deaths), while non-cancer mortality causes represented only 4.14%.The commonest causes of non-cancer mortality were heart diseases (SMR = 2.79;95%CI,2.6–2.98),cerebrovascular diseases (SMR = 3.11;95% CI, 2.71–3.56), and septicemia (SMR = 8.2;95%CI,6.9–9.68).PAC patients had a higher mortality risk than the general population for all studied mortality causes except Alzheimer's disease (SMR = 0.5;95% CI, 0.3–0.78) and homicide and legal intervention (SMR = 2.29; 95%CI, 0.47–6.68).

Conclusions

About 96% of PAC patients' deaths are due to cancers. While the dominant non-cancer causes of death in these patients include heart diseases, cerebrovascular diseases, and septicemia, with a higher risk of mortality for most non-cancer causes than the general population.

301 Blood Grouping and Save in Day Case Laparoscopic Surgery – Potential for Resource Savings?

Introduction

Currently, patients listed for Laparoscopic cholecystectomy and Laparoscopic Appendicectomy undergo routine Blood Grouping and Saving (G&S) pre-operatively. Blood transfusion administration in this context is a rare occurrence. Processing of G&S samples takes approximately 45 minutes and costs £31 per sample. This excludes the phlebotomy and junior doctor resources for sample collection, which incurs additional costs.

We retrospectively assessed the blood transfusion requirements in those patients who underwent either a laparoscopic appendicectomy or cholecystectomy in the last 18 months at a busy District General Hospital (Milton Keynes Hospital) to determine if there were any potential costs and resource savings that could have been made.

Method

Retrospective case notes analysis of patients who had laparoscopic cholecystectomy and laparoscopic appendicectomy from January 2019 to June 2020 focusing on timing of G&S, preoperative and postoperative haemoglobin, the timing of blood transfusion and the number of units transfused.

Results

Of a total of 613 patients, 323 patients had laparoscopic cholecystectomy. 256 (78.8%) of these had 1 G&S sample and 96 (29.7%) had 2 samples.

290 patients had laparoscopic appendicectomy. 190 (65.5%) of these laparoscopic appendicectomy patients had 1 G&S sample and 89 (30.6%) had two G&S samples.

None of the 613 patients was transfused. The total cost of G&S was £22,196.

Conclusions

Our study illustrates that in this group there was no requirement for blood transfusion. Routine group and save samples result in a significant waste of resources and finances. Targeted groups and save samples should be reserved for high-risk groups only.

260 Comparison of Patient Satisfaction and Outcomes of Day Case Mastectomy Versus Inpatient Model, Using a Validated Questionnaire

Introduction

Many women undergoing simple mastectomy have an overnight hospital stay. Offering a day case procedure for simple mastectomy has the potential to improve outcomes in terms of patient safety, feasibility, and reduction in associated costs. We aimed to study the proportion of day case mastectomies over a 2-year period and assessed relative readmission and complication rates alongside patient reported outcome measures (PROMs). Following this, we wanted to analyse whether a day case procedure should be routinely offered.

Method

A retrospective audit was conducted on all patients undergoing a simple mastectomy. Data were collected from patient and pathology records. PROMs were obtained via telephone conversation using the validated BREAST-Q survey. Patient demographics, reason for mastectomy and readmission for complications were all assessed.

Results

Out of the 202 patients analysed, over 75% had an overnight stay. The most common complications for both groups of patients were readmission due to infection and haematoma evacuation, with similar rates across the two (p = 0.26, p = 0.69). Data from PROMs also suggested that patients had similar outcome and satisfaction levels (p = 0.27).

Conclusions

The result from this study shows that it is safe as well as acceptable to patients to offer simple mastectomies as a day case procedure. This has become more important since COVID-19 reduced inpatient theatre capacity, and it is anticipated that these outcomes will allow a routine day case mastectomy pathway to be established even when normal operations recommence as encouraged by the association of day case surgery.

Removal of mercury(II) by tri n-butyl phosphate based supported liquid membrane

ABSTRACT. Mercury even at a trace level poses a significant threat to the environment and the ecosystem. Thus, prompting the need to develop a technology to separate mercury(II) selectively from aqueous solutions. The removal of mercury(II) from aqueous solutions using tri n-butyl phosphate (TBP) based supported liquid membrane (SLM) was investigated in this study. HCl and NaOH were used as feed and strip phases, respectively. Factors considered for designing the experiments using the Taguchi method include feed phase acid concentration, strip phase alkali concentration, carrier concentration and initial feed phase mercury(II) concentration. The results indicated that carrier concentration was the most influential factor on the removal efficiency. The percentage contribution of each factor was calculated. The results show that carrier concentration and initial feed phase mercury(II) concentration have a maximum contribution. For the maximum removal of 91.7% of mercury(II) (initial concentration - 10 mg/L) in the feed phase, the optimum conditions were 0.3 M of HCl, 0.2 M of NaOH, and 90% of TBP. SEM analysis was performed to evidence the transportation process through the membrane. The research study indicated the potential use of TBP as a carrier in the SLM system for the selective separation of mercury in trace concentration.                     KEY WORDS: Removal of mercury(II), Tri n-butyl phosphate, Taguchi method, Supported liquid membrane   Bull. Chem. Soc. Ethiop. 2021, 35(2), 273-286. DOI: https://dx.doi.org/10.4314/bcse.v35i2.5

Applying interprofessional simulation to improve knowledge, attitude and practice in hospital- acquired infection control among health professionals

BACKGROUND

This study aimed at determining the effectiveness of an innovative approach using interprofessional simulation scenarios (IPSS) in improving knowledge, attitude, and practice (KAP) of hospital-acquired infection control (HAIC) among health professionals.

METHODS

The interventional study was conducted in a teaching hospital in Malaysia. Purposive sampling was used to recruit participants from surgical, intensive care, and other units. Thirty-six health professionals in the experimental and forty in the control group completed the study. All subjects participated in an interactive lecture and demonstrated four IPSS on HAIC i.e. (i) taking blood specimen (ii) bedsore dressing (iii) collecting sputum for acid-fast bacilli and (iv) intermittent bladder catheterization. Each team consisted of a doctor and a nurse. A self-administered questionnaire on KAP on HAIC was completed by respondents during the pre-, immediately and, post-intervention. An independent t-test was conducted to measure the significance between the experimental and control group.

RESULTS

The mean scores for KAP among the experimental group increased following the intervention. Significant differences in scores were seen between the two groups post-intervention (p < 0.05). Overall, using the four procedures as surrogates, the interprofessional learning approach in HAIC intervention showed improvement among the participants in the experimental group following structured instructions. The IPSS approach in HAIC clearly shows its relevance in improving learning outcomes.

CONCLUSIONS

Well-designed interprofessional simulated scenarios can be effective in skills training in improving KAP in HAIC among health professionals.

Entrapped appendicitis in post TAPP mesh repair

Transabdominal preperitoneal (TAPP) repair is a common laparoscopic inguinal hernia repair technique performed worldwide. A rare long-term complication of TAPP is mesh-induced appendicitis, of which only four cases have been described in the literature to date. We report a case of appendicitis due to appendix entrapped in the TAPP mesh.

Self-assessment, attitude and perception of interprofessional learning in hospital acquired infection control practices among health professionals in Klang Valley, Malaysia

BACKGROUND

Interprofessional learning (IPL) is a key challenge in Malaysia in incorporating the current profession-specific medical education into the interprofessional learning curriculum. Safe practices would be enhanced with improved collaboration among the health professionals when they learn with, from, and about each other. The main objective of this study was to determine the significant differences in self-assessment, attitude, and perception of interprofessional learning among doctors and nurses in a teaching hospital in Klang Valley, Malaysia. The second objective was to determine if there is any significant difference in the selected demography factors, mean and total scores between doctors and nurses in self-assessment, attitude, and perceptions of IPL aspects.

METHODS

A total of doctors (39) and nurses (37) were recruited for an interventional study on the interprofessional learning approach on hospital acquired infection control. The participants responded to the University of West England Interprofessional (UWEIP) questionnaire at baseline consisting of four dimensions in IPL aspects; Self-assessment on communication and teamwork skills (CTW), interprofessional learning (IPL), interprofessional interaction (IPI), and interprofessional relationship (IPR). The Cronbach alpha value for the total questionnaire was established at 0.79.

RESULTS

The majority of doctors scored positive in CTW, IPL, IPR, and neutral in IPI. Nurses' also recorded the highest positive scores in CTW, IPL, and IPR, and neutral in IPI. Negative scores were found in CTW and IPI. A significant difference was revealed between doctors and nurses in IPL attitude; p = 0.024 and there was no significant difference in other dimensions (p > .05). Results also found a significant difference between participants' and non-participants of IPL training sessions; p = 0.009.

CONCLUSIONS

This study revealed the infusion of interprofessional learning training among the health professionals displayed better self-assessments, attitudes, and perceptions towards collaborative practices.

Radiotherapy for Oropharyngeal Carcinoma With an Uninvolved Contralateral Neck: The Safety of Omission of Contralateral High Level II and Retropharyngeal Lymph Nodes From Elective Target Volumes

AIMS

To analyse outcomes and patterns of failure in patients with oropharyngeal carcinoma (OPC) treated with definitive volumetric modulated arc therapy with omission of contralateral high level II lymph nodes (HLII) and retropharyngeal lymph nodes (RPLN) in the contralateral uninvolved neck.

MATERIALS AND METHODS

Patients with OPC treated between January 2016 and July 2019 were retrospectively identified. In the absence of contralateral neck disease, institutional protocols allowed omission of contralateral HLII and contralateral RPLN in the additional absence of ipsilateral RPLN, soft palate/posterior pharyngeal wall primary.

RESULTS

In total, 238 patients with OPC and an uninvolved contralateral neck received definitive (chemo)radiotherapy with bilateral neck treatment. The median follow-up was 30.6 months. Two-year local control, regional control and overall survival were 91.0, 91.6 and 86.5%, respectively. Contralateral HLII were omitted in 159/238 (66.8%) patients; this included 106 patients in whom the primary tumour was at/crossed the midline. The contralateral RPLN region was omitted from elective target volumes for 175/238 (73.5%); this included 114 patients with a primary tumour at/crossed the midline. The mean contralateral parotid dose when contralateral HLII and RPLN were both omitted was 24.4 Gy, compared with 28.3 Gy without HLII/RPLN omission (P < 0.001). Regional progression occurred in 18/238 (7.6%) patients, all involving the ipsilateral neck with one bilateral. There were no recurrences in the contralateral HLII or RPLN regions.

CONCLUSION

In patients with OPC and an uninvolved contralateral neck receiving bilateral (chemo)radiotherapy, the omission of contralateral RPLN and HLII from elective target volumes was safe and could lead to reduced contralateral parotid doses.

Effects of Host Age and Density on the Performance of Apanteles hemara (Hymenoptera: Braconidae), a Larval Endoparasitoid of Spoladea recurvalis (Lepidoptera: Crambidae)

The amaranth leaf-webber, Spoladea recurvalis (Fabricius; Lepidoptera: Crambidae), is a serious pest of Amaranthus sp. in Africa and Asia. Apanteles hemara (Nixon; Hymenoptera: Braconidae) is by far the most important larval endoparasitoid of the amaranth leaf-webber. We examined the effects of host density and age on the biological characteristics of A. hemara. The regression model of the number of hosts supplied to A. hemara against the number of larvae parasitized resulted in a curve corresponding to type II functional response, with a significant increase in the number of hosts parasitized up to the density of 30 hosts before being constant up to 40 hosts. In contrast, the parasitism rate decreased linearly with increasing host densities. Development time, sex ratio, and adult longevity were not significantly affected by host density. The immature parasitoid mortality was significantly higher at higher host densities. Apanteles hemara did not parasitize 7-d-old larvae and beyond, while parasitism was significantly higher among 1- to 2-d-old compared with 3- to 4-d-old larvae. Immature parasitoid mortality was 2.6 times higher in 1- to 2-d-old larvae compared with 5- to 6-d-old larvae. The developmental period of the parasitoid from egg to adult was longest among 1- to 2-d-old larvae and least among 5- to 6-d-old larvae. Nonreproductive mortality was markedly higher among 1- to 2-d-old larvae compared with the older larvae. Adult female A. hemara were significantly larger on 3- to 4-d-old larvae compared with either 1- to 2-d-old or 5- to 6-d-old larvae. We discuss the implications of our results for the interpretation of functional response in parasitoids, mass rearing, conservation, and augmentative biological control of S. recurvalis.

The role of the skin microbiota in acne pathophysiology

BACKGROUND

The role of skin microbiota in acne remains to be fully elucidated. Initial culture-based investigations were hampered by growth rate and selective media bias. Even with less biased genomic methods, sampling, lysis and methodology, the task of describing acne pathophysiology remains challenging. Acne occurs in sites dominated by Cutibacterium acnes (formerly Propionibacterium acnes) and Malassezia species, both of which can function either as commensal or pathogen.

OBJECTIVES

This article aims to review the current state of the art of the microbiome and acne.

METHODS

The literature regarding the microbiome and acne was reviewed.

RESULTS

It remains unclear whether there is a quantitative difference in microbial community distribution, making it challenging to understand any community shift from commensal to pathogenic nature. It is plausible that acne involves (i) change in the distribution of species/strains, (ii) stable distribution with pathogenic alteration in response to internal (intermicrobe) or external stimuli (host physiology or environmental) or (iii) a combination of these factors.

CONCLUSIONS

Understanding physiological changes in bacterial species and strains will be required to define their specific roles, and identify any potential intervention points, in acne pathogenesis and treatment. It will also be necessary to determine whether any fungal species are involved, and establish whether they play a significant role. Further investigation using robust, modern analytic tools in longitudinal studies with a large number of participants, may make it possible to determine whether the microbiota plays a causal role, is primarily involved in exacerbation, or is merely a bystander. It is likely that the final outcome will show that acne is the result of complex microbe-microbe and community-host interplay.

Paediatric cataract surgery in Hospital Kuala Lumpur - A 5-year review of visual outcomes

INTRODUCTION

Paediatric cataract surgery is challenging with reported post-operative visual acuity (VA) of 0.3LogMar or better varying between 33% to 68% of patients.

OBJECTIVE

The aim is to document the post-operative refraction, VA and complications of non-traumatic pediatric cataract surgery performed in a tertiary referral center in Malaysia.

METHODOLOGY

This retrospective study reviewed case notes of all consecutive patients aged 12 years and below who underwent cataract surgery from January 2010 to December 2015. Patients were recruited if they had a minimum of six months post-operative follow-up. Exclusion criteria included traumatic cataract, central nervous system abnormalities, incomplete medical records or pre-existing ocular pathology. Subjects were divided into two groups based on refraction at one month. Subjects with refraction within 1- dioptre of the targeted spherical equivalent were in the success group and the rest were in the failure group.

RESULTS

A total of 111 subjects were recruited (65 subjects in success group and 46 subjects in the failure group). Mean age at surgery was 33.14 (SD: 33.47) months. The success group had significantly longer axial length (p:0.0045, CI: 0.566-0.994, OR: 0.750). At final review, 44.1%(49/111) subjects had visual acuity of 0.3LogMar or better. The success group had better final mean VA in comparison to the failure group (p:0.034, CI:1.079-7.224, OR: 2.791).

CONCLUSION

The outcome of non-traumatic paediatric cataract surgery was acceptable with 58.6% achieved targeted refractive correction at 1-month post-operative period. Longer axial length was associated with better refractive outcome. Capsule related complications was the most common intra-operative complication.

Is nonsurgical management effective in temporomandibular joint disorders? - A systematic review and meta-analysis

BACKGROUND

Various nonsurgical interventions have been used for the management of patients with temporomandibular joint (TMJ) disorders, but their clinical effectiveness remains unclear. Hence, the purpose of this systematic review and meta-analyses was to assess the evidence of the effectiveness of nonsurgical interventions in the management of TMJ disorders.

MATERIALS AND METHODS

A literature search on five databases such as PubMed, PubMed Central Cochrane, TRIP, NGCH databases and hand searching was conducted for a period from October 1995 to 2015. Randomized control trials (RCTs) on the nonsurgical management of TMJ disorders were included and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The quality of the articles was assessed by JADAD scoring. Finally, out of 23 RCTs, 11 articles having any of the primary outcomes (pain pressure threshold [PPT], pain, maximal pain-free mouth opening, and level of dysfunction) were selected. The extracted data were analyzed using NCSS software.

RESULTS

The results showed the evidence of pain reduction (P = 0.00), maximal pain-free mouth opening (P = 0.0138), and decrease in level of dysfunction (P = 0.0007) but no improvement in PPT to a significant level (P = 0.6600).

CONCLUSION

Our results suggest that the simplest, cost-effective nonsurgical treatments have a positive therapeutic effect on the initial management of TMJ disorders. However, a consistent methodology recording both the objective and subjective outcomes would be a better choice for added reliability.

Juvenile primary extranasopharyngeal angiofibroma, presenting as cheek swelling

Angiofibroma is a locally advancing immensely vascular tumor that essentially arises from the nasopharynx. The clinical characteristics of extranasopharyngeal angiofibroma (ENA) do not accord to that of nasopharyngeal angiofibroma and can present a diagnostic confront. We describe a case of primary juvenile ENA in a 19-year-old patient who presented with a rapidly enlarging mass of the cheek region. The case is unusual because of its anatomic location. The diagnostic and management particulars are sketched.

Geospatial risk assessment and trace element concentration in reef associated sediments, northern part of Gulf of Mannar biosphere reserve, Southeast Coast of India

Fifty two surface sediments were collected from the northern part of the Gulf of Mannar biosphere reserve to assess the geospatial risk of sediments. We found that distribution of organic matter and CaCO₃ distributions were locally controlled by the mangrove litters and fragmented coral debris. In addition, Fe and Mn concentrations in the marine sediments were probably supplied through the riverine input and natural processes. The Geo-accumulation of elements fall under the uncontaminated category except Pb. Lead show a wide range of contamination from uncontaminated-moderately contaminated to extremely contaminated category. The sediment toxicity level of the elements revealed that the majority of the sediments fall under moderately to highly polluted sediments (23.07-28.84%). The grades of potential ecological risk suggest that predominant sediments fall under low to moderate risk category (55.7-32.7%). The accumulation level of trace elements clearly suggests that the coral reef ecosystem is under low to moderate risk.

Trace element concentrations in reef associated sediments of Koswari Island, Gulf of Mannar biosphere reserve, southeast coast of India

Extensive field work was conducted in order to assess the sediment pollution level and potential ecological risk on coral reef ecosystem. Thirty three surface sample was collected using grid sampling technique. The calcium carbonate and organic matter were primarily controlled by the distribution of coral rubbles and seagrass meadows. The concentration of trace elements is higher than the crustal average in few locations and the same result was derived from index calculations. However, the significant concentration of lead was observed throughout the study area. The elevated level of lead is probably due to coal incinerating power plants, and confluence of urban runoff from the nearby coastal areas. Based on the sediment pollution index, the majority of the sediments belongs to highly polluted to dangerously polluted category. The ecological risk indicates that the sediments are under low risk to moderate risk category and this result was proved by correlation analysis.

Spatial risk assessment and trace element concentration in reef associated sediments of Van Island, southern part of the Gulf of Mannar, India

Forty eight surface sediment samples were collected from the vicinity of Van Island in order to assess the sediment pollution level and potential ecological risk on coral reef ecosystem. The analytical and correlation results indicate a distribution of elements is chiefly controlled by the CaCO₃ and OM. The enrichment factor and geoaccumulation index show the elevated level of Pb in the surface sediments is due to application of lead petrol and coal incinerating power plants. The sediment pollution index reveals that majority of the sediments falling under highly polluted sediment category (35.4%) followed by moderately polluted (25%) and dangerous sediment category (14.58%). The potential ecological risk suggests that nearly 66.6% of the samples falling under the low risk category, moderate risk category (20.8%) followed by considerable risk category (8.33%) and very high risk category (4.1%). The accumulation level of trace elements clearly suggests that the coral reef ecosystem is under low risk.

Reliability of lip prints in personal identification: An inter-racial pilot study

CONTEXT

Forensic science is a branch of science that deals with the application of science and technology in solving a crime and this requires a multidisciplinary team effort. The word "Forensic" is derived from the Latin word, "Forensis" which means the study of public. Dental professionals should develop interests in contributing to legal issues.

AIMS

To study the lip prints among people of different races.

SETTINGS AND DESIGN

Descriptive study.

SUBJECTS AND METHODS

The present study comprised of ninety subjects of which Group A comprised of Africans, Group B comprised of Dravidian, and Group C of Mongoloid race. Each group was then further divided into 15 males and 15 females for whom the lip prints were recorded and evaluated.

STATISTICAL ANALYSIS USED

ANOVA test.

RESULTS

ANOVA statistical analysis was used to compare three races of African, Dravidian, and Mongoloid races. The observed data among male and female were found to be significant with a P = 0.000492.

CONCLUSION

The present study showed a significant difference in lip pattern among the three races. Perhaps future studies with a larger sample size and comparison between many other races may be done for better personal identification.

Superiority of Deformable Image Co-registration in the Integration of Diagnostic Positron Emission Tomography-Computed Tomography to the Radiotherapy Treatment Planning Pathway for Oesophageal Carcinoma

AIMS

To investigate the use of image co-registration in incorporating diagnostic positron emission tomography-computed tomography (PET-CT) directly into the radiotherapy treatment planning pathway, and to describe the pattern of local recurrence relative to the PET-avid volume.

MATERIALS AND METHODS

Fourteen patients were retrospectively identified, six of whom had local recurrence. The accuracy of deformable image registration (DIR) and rigid registration of the diagnostic PET-CT and recurrence CT, to the planning CT, were quantitatively assessed by comparing co-registration of oesophagus, trachea and aorta contours. DIR was used to examine the correlation between PET-avid volumes, dosimetry and site of recurrence.

RESULTS

Positional metrics including the dice similarity coefficient (DSC) and conformity index (CI), showed DIR to be superior to rigid registration in the co-registration of diagnostic and recurrence imaging to the planning CT. For diagnostic PET-CT, DIR was superior to rigid registration in the transfer of oesophagus (DSC=0.75 versus 0.65, P<0.009 and CI=0.59 versus 0.48, P<0.003), trachea (DSC=0.88 versus 0.65, P<0.004 and CI=0.78 versus 0.51, P<0.0001) and aorta structures (DSC=0.93 versus 0.86, P<0.006 and CI=0.86 versus 0.76, P<0.006). For recurrence imaging, DIR was superior to rigid registration in the transfer of trachea (DSC=0.91 versus 0.66, P<0.03 and CI=0.83 versus 0.51, P<0.02) and oesophagus structures (DSC=0.74 versus 0.51, P<0.004 and CI=0.61 versus 0.37, P<0.006) with a non-significant trend for the aorta (DSC=0.91 versus 0.75, P<0.08 and CI=0.83 versus 0.63, P<0.06) structure. A mean inclusivity index of 0.93 (range 0.79-1) showed that the relapse volume was within the planning target volume (PTVPET-CT); all relapses occurred within the high dose region.

CONCLUSION

DIR is superior to rigid registration in the co-registration of PET-CT and recurrence CT to the planning CT, and can be considered in the direct integration of PET-CT to the treatment planning process. Local recurrences occur within the PTVPET-CT, suggesting that this is a suitable target for dose-escalation strategies.

Risk of recurrent venous thromboembolism and major hemorrhage in cancer-associated incidental pulmonary embolism among treated and untreated patients: a pooled analysis of 926 patients

ESSENTIALS: We performed a pooled analysis of 926 patients with cancer-associated incidental pulmonary embolism (IPE). Vitamin K antagonists (VKA) are associated with a higher risk of major hemorrhage. Recurrence risk is comparable after subsegmental and more proximally localized IPE. Our results support low molecular weight heparins over VKA and similar management of subsegmental IPE.

BACKGROUND

Incidental pulmonary embolism (IPE) is defined as pulmonary embolism (PE) diagnosed on computed tomography scanning not performed for suspected PE. IPE has been estimated to occur in 3.1% of all cancer patients and is a growing challenge for clinicians and patients. Nevertheless, knowledge about the treatment and prognosis of cancer-associated IPE is scarce. We aimed to provide the best available evidence on IPE management.

METHODS

Incidence rates of symptomatic recurrent venous thromboembolism (VTE), major hemorrhage, and mortality during 6-month follow-up were pooled using individual patient data from studies identified by a systematic literature search. Subgroup analyses based on cancer stage, thrombus localization, and management were performed.

RESULTS

In 926 cancer patients with IPE from 11 cohorts, weighted pooled 6-month risks of recurrent VTE, major hemorrhage and mortality were 5.8% (95% confidence interval [CI] 3.7-8.3%), 4.7% (95% CI 3.0-6.8%), and 37% (95% CI 28-47%). VTE recurrence risk was comparable under low molecular weight heparins (LMWH) and vitamin K antagonists (VKAs) (6.2% vs. 6.4%; hazard ratio [HR] 0.9; 95% CI 0.3-3.1), while 12% in untreated patients (HR 2.6; 95% CI 0.91-7.3). Risk of major hemorrhage was higher under VKAs than under LMWH (13% vs. 3.9%; HR 3.9; 95% CI 1.6-10). VTE recurrence risk was comparable in patients with an subsegmental IPE and those with a more proximally localized IPE (HR 1.1; 95% CI 0.50-2.4).

CONCLUSION

These results support the current recommendation to anticoagulate cancer-associated IPE with LMWH and argue against different management of subsegmental IPE.

Metal concentrations in the growth bands of Porites sp.: A baseline record on the history of marine pollution in the Gulf of Mannar, India

The present study was carried out on the Porites coral growth bands (1979 to 2014) to measure the metal accumulation for assessing the environmental pollution status. The concentrations of studied metals are compared with similar global studies, which indicate that the metals are probably derived from natural sources. The identical peaks of Fe and Mn are perfectly matched with Cu, Cr and Ni concentrations. However, the metal profile trend is slightly depressed from a regular trend in Zn, Cd and Pb peaks. The metal accumulation affinity of the reef skeleton is ranked in the following order Cr>Cd>Pb>Fe>Mn>Cu>Ni>Zn. The distribution of metal constituents in coral growth bands is primarily controlled by Fe and Mn in the reef skeleton. Other reef associated metals such as Pb and Cd are derived from other sources like coastal developments and anthropogenic sources.

Stereotactic Ablative Radiotherapy (SABR) in Patients with Medically Inoperable Peripheral Early Stage Lung Cancer: Outcomes for the First UK SABR Cohort

AIMS

To report outcomes for the first UK cohort treated for early stage peripheral lung cancer using stereotactic ablative radiotherapy (SABR).

MATERIALS AND METHODS

Patients were included who received SABR between May 2009 and May 2012. Electronic medical records were reviewed for baseline characteristics, treatment details and outcomes. Patients were treated according to the UK SABR Consortium Guidelines. Univariate and multivariate Cox regression was used to determine factors that influenced overall survival and local control.

RESULTS

In total, 273 patients received SABR for 288 lesions in the time period examined. The median follow-up was 19.7 months. The median overall survival for all patients was 27.3 months, with 1, 2 and 3 year overall survival of 78.0, 54.9 and 38.6%, respectively. The 1, 2 and 3 year rates of local control were 98.2, 95.7 and 95.7%, respectively. All patients completed the planned course of treatment and rates of Common Toxicity Criteria grade 3+ toxicity were low. On multivariate analysis, patients with Medical Research Council (MRC) breathlessness scores of 3-5 had worse overall survival compared with patients with scores of 1-2 (hazard ratio: 2.10; 95% confidence interval: 1.25-3.59) and the presence of histological diagnosis conferred improved overall survival (hazard ratio: 0.54; 95% confidence interval: 0.31-0.93), probably reflecting that patients who are considered well enough to undergo biopsy are generally fitter overall. No factors were identified that significantly influenced local control.

CONCLUSIONS

SABR is an effective and well-tolerated treatment option for patients with early stage peripheral lung cancer who are not suitable for surgery. No patient cohort was identified in whom SABR was considered inappropriate. This series adds to the existing positive data that support SABR for this patient group.

Acute and subchronic toxicity analysis of surface modified paclitaxel attached hydroxyapatite and titanium dioxide nanoparticles

Nanoparticles are widely used for targeted drug delivery applications. Surface modification with appropriate polymer and ligands is carried out to target the drug to the affected area. Toxicity analysis is carried out to evaluate the safety of the surface modified nanoparticles. In this study, paclitaxel attached, folic acid functionalized, polyethylene glycol modified hydroxyapatite and titanium dioxide nanoparticles were used for targeted drug delivery system. The toxicological behavior of the system was studied in vivo in rats and mice. Acute and subchronic studies were carried out. Biochemical, hematological, and histopathological analysis was also done. There were no significant alterations in the biochemical parameters at a low dosage. There was a small change in alkaline phosphatase (ALP) level at a high dosage. The results indicate a safe toxicological profile.

Impact of HMG-CoA reductase inhibitors on the incidence of polyomavirus-associated nephropathy in renal transplant recipients with human BK polyomavirus viremia

BACKGROUND

Up to 20% of renal transplant recipients (RTR) will develop human BK polyomavirus (BKPyV) viremia. BKPyV viremia is a pre-requisite of polyomavirus-associated nephropathy (PyVAN). Risk of BKPyV infections increases with immunosuppression. Currently, the only effective therapy against PyVAN is reductions in immunosuppression, but this may increase the risk of rejection. In vitro data have shown that pravastatin dramatically decreased caveolin-1 expression in human renal proximal tubular epithelial cells (HRPTEC) and suppressed BKPyV infection in these cells. Based on these data, we postulated that statin therapy may prevent the progression of BKPyV viremia to PyVAN.

PATIENTS AND METHODS

A multicenter, retrospective study was conducted in adult RTR transplanted between July 2005 and March 2012. All patients with documented BKPyV viremia (viral load >500 copies/mL on 2 consecutive tests) were included. Group I consisted of patients taking a statin before the BKPyV viremia diagnosis (n = 32), and Group II had no statin exposure before or after the BKPyV viremia diagnosis (n = 36). The primary endpoint was the incidence of PyVAN.

RESULTS

Demographic data, transplant characteristics, and the degree of immunosuppression (i.e., induction/maintenance therapies, rejection treatment) were similar between the groups, with the exception of more diabetics in Group I. The incidence of PyVAN was comparable between the 2 groups (Group I = 28.1% vs. Group II = 41.7%; P = 0.312).

CONCLUSIONS

Despite the proven in vitro effectiveness of pravastatin preventing BKPyV infection in HRPTEC, statins at doses maximized for cholesterol lowering, in RTR with BKPyV viremia, did not prevent progression to PyVAN.

Assessment of outcomes with delayed (18)F-FDG PET-CT response assessment in head and neck squamous cell carcinoma

OBJECTIVE

To assess the accuracy of a 4-month post-(chemo)radiotherapy 18-fludeoxyglucose ((18)F-FDG) positron emission tomography (PET)-CT for head and neck squamous cell carcinoma (HNSCC).

METHODS

105 patients who underwent a baseline and response assessment (18)F-FDG PET-CT scan between 2008 and April 2013 were identified. (18)F-FDG PET-CT outcomes were analysed with reference to clinicopathological outcomes.

RESULTS

79 of 105 (75%) (18)F-FDG PET-CT scans demonstrated a complete metabolic response; 19 of 101 (19%) for assessable primary tumours were positive; and 19 of 93 (20%) for patients with nodal disease were equivocal (n = 10) or positive (n = 9). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for primary and nodal disease were 90%, 89%, 47%, 99% and 91%, 89%, 53% and 99%, respectively. Eight of nine patients with a positive nodal response scan had clinicopathological evidence of residual nodal disease (PPV, 89%). 2 of 10 patients with equivocal nodal responses had clinicopathological evidence of residual nodal disease (PPV, 20%).

CONCLUSION

(18)F-FDG PET-CT 4 months post treatment has a very high NPV. A positive (18)F-FDG PET-CT has a high PPV for residual nodal disease. By contrast, patients who have an equivocal nodal response have a low PPV.

ADVANCES IN KNOWLEDGE

Response assessment (18)F-FDG PET-CT is a valuable tool in guiding the selective use of neck dissection following (chemo)radiotherapy for HNSCC. An equivocal lymph node response has a limited predictive value for persistent disease, and optimal management remains a clinical challenge.

Phosphine resistance in India is characterised by a dihydrolipoamide dehydrogenase variant that is otherwise unobserved in eukaryotes

Phosphine (PH3) fumigation is the primary method worldwide for controlling insect pests of stored commodities. Over-reliance on phosphine, however, has led to the emergence of strong resistance. Detailed genetic studies previously identified two loci, rph1 and rph2, that interact synergistically to create a strong resistance phenotype. We compared the genetics of phosphine resistance in strains of Rhyzopertha dominica and Tribolium castaneum from India and Australia, countries having similar pest species but widely differing in pest management practices. Sequencing analysis of the rph2 locus, dihydrolipoamide dehydrogenase (dld), identified two structurally equivalent variants, Proline49>Serine (P49S) in one R. dominica strain and P45S in three strains of T. castaneum from India. These variants of the DLD protein likely affect FAD cofactor interaction with the enzyme. A survey of insects from storage facilities across southern India revealed that the P45/49S variant is distributed throughout the region at very high frequencies, in up to 94% of R. dominica and 97% of T. castaneum in the state of Tamil Nadu. The abundance of the P45/49S variant in insect populations contrasted sharply with the evolutionary record in which the variant was absent from eukaryotic DLD sequences. This suggests that the variant is unlikely to provide a strong selective advantage in the absence of phosphine fumigation.

In vitro and in vivo anticancer activity of surface modified paclitaxel attached hydroxyapatite and titanium dioxide nanoparticles

Targeted drug delivery using nanocrystalline materials delivers the drug at the diseased site. This increases the efficacy of the drug in killing the cancer cells. Surface modifications were done to target the drug to a particular receptor on the cell surface. This paper reports synthesis of hydroxyapatite and titanium dioxide nanoparticles and modification of their surface with polyethylene glycol (PEG) followed by folic acid (FA). Paclitaxel, an anticancer drug, is attached to functionalized hydroxyapatite and titanium dioxide nanoparticles. The pure and functionalised nanoparticles are characterised with XRD, TEM and UV spectroscopy. Anticancer analysis was carried out in DEN induced hepatocarcinoma animals. Biochemical, hematological and histopathological analysis show that the surface modified paclitaxel attached nanoparticles have an higher anticancer activity than the pure paclitaxel and surface modified nanoparticles without paclitaxel. This is due to the targeting of the drug to the folate receptor in the cancer cells.