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.

Extrapulmonary Small Cell Carcinoma: A Single Institution Review of Brain Metastases, Treatment Paradigms and Patient Outcomes

PURPOSE/OBJECTIVE(S)

Extrapulmonary small cell carcinoma (EPSCC) is a rare entity with 1,000 cases reported annually in the U.S. It can originate in a variety of sites outside of the lung, and even with locoregional disease, relapse is common, and survival is poor. Prophylactic cranial irradiation (PCI) can improve survival in small cell lung carcinoma, however in the setting of EPSCC its role has not been clearly defined. We offer a single institution retrospective review of EPSCC, outlining the incidence of brain metastases, treatment paradigms, and patient outcomes.

MATERIALS/METHODS

Patients with available records were identified from an institutional database. Demographic, disease-related, and treatment details were abstracted from the electronic medical record. Clinical outcomes were obtained by medical record review and brain metastases were identified through diagnostic imaging. Patients were classified as having brain metastases at diagnosis or in follow-up. Brain metastasis-free survival (BMFS) was defined as the duration of time from diagnosis to the development of brain metastases, and extracranial progression-free survival (ePFS), as the duration of time from diagnosis to progression of disease outside the brain. Time to event outcomes were summarized using the Kaplan-Meier method. Analyses were performed using R version 3.6.

RESULTS

In total, 68 patients met eligibility criteria for analysis. The majority were male (66%) and median age was 68. The most common primary sites were genitourinary (32%) and gastrointestinal/hepatobiliary (22%). Thirty-eight patients (56%) had diagnostic brain imaging at time of diagnosis, with brain metastases present in 5 (13%). Treatment was delivered to 53 patients (80%) and treatment modalities included chemotherapy (n = 46), radiotherapy (n = 21), and surgery (n = 18). Median follow-up was 9.3 months for all patients and 10.3 months for surviving patients. Overall, 12 patients were observed to have brain metastases: 5 at diagnosis and 7 in follow-up. The competing risk of death without brain metastases at 1 year was 51.5%. Four of 5 patients with de novo brain metastases received WBRT. Of the 7 patients with subsequent brain metastases, 1 received salvage WBRT and 3 received salvage SRS. In total, 49 patients died and median OS was 10.0 months. Those with brain metastases had no significant difference in OS when compared to those without brain metastases (10.8 months v. 9.4 months). There was no association between primary type and survival.

CONCLUSION

EPSCC is a rare entity that is most commonly diagnosed in the genitourinary system. In contrast to SCLC, the incidence of brain metastases is uncommon. No difference in survival was observed between patients with or without brain metastases. While retrospective studies must be interpreted with caution, our data suggest that the risks of PCI may outweigh the benefits. Further studies investigating the role of brain imaging surveillance, as well as the optimal management of brain metastases, is warranted.

Effect of thrombocytopenia in patients with infective endocarditis: an insight from the National Inpatient Sample database

Introduction

Infective endocarditis (IE) is one of the feared diseases in septic patients, and incidences are rising due to the intravenous drug abuse epidemic. Sepsis causes an escalation of the platelet destructions leading to thrombocytopenia (1). Few independent hospital-based studies have proposed increase mortality with thrombocytopenia in patients with IE (2–5). We aim to evaluate the significance of thrombocytopenia in IE subjects from the national inpatient sample (NIS) database.

Method

We analyzed the NIS database from Jan-2016 to Dec-2018 using Stata 16.0. NIS is the largest publicly available all-payer inpatient care database in the United States, containing data on more than seven million hospital stays per year. We identified patients with IE with or without thrombocytopenia using ICD-10 codes. The primary outcome of interest was in-hospital mortality comparison. We adjusted potential confounders (age, sex, diabetes, hypertension, etc.) with multivariate logistic regression analysis. Further analysis was done after balancing the population co-morbidity using a Greedy propensity match for accuracy.

Results

A total of 174,495 subjects were included in this study with a diagnosis of IE. Among these individuals, 33,285 patients had a concurrent diagnosis of thrombocytopenia. The mean ages were 53±19.5 years for the thrombocytopenia group and 55±19.8 years for others. Females were equally represented in both cohorts. There were 4,945 (14.86%) vs 2,835 (2.01%) mortalities reported in with and without thrombocytopenia group respectively. After propensity matching, there was a pronounced increase in mortality [Odds ratio (OR): 1.93 (1.72 – 2.15), p-value: &lt;0.001] in the group with thrombocytopenia comparing to others. Complications such as Major bleeding requiring blood transfusion [OR: 1.45 (1.35–1.57)], acute myocardial infarction [OR: 1.56 (1.35–1.70)], complete heart block [OR: 1.44 (1.16–1.53)], cardiac arrest [OR: 1.44 (1.25–1.72)], acute respiratory failure [OR: 1.51 (1.39–1.73)] and pressor support requirement [(OR: 1.73 (1.57–2.01)] were notably higher in the cohort of thrombocytopenia with statistically significant p-value (&lt;0.001). The difference in length of stay between both cohorts after propensity match wasn't statistically significant.

Conclusion

In conclusion, IE patients with thrombocytopenia have higher incidences of in-patient mortality and poor outcomes than cohort without thrombocytopenia. Some of the adverse consequences could be temporally explained by complications related to underlying thrombocytopenia. Further investigations are needed to delineate the outcome in this group of subjects.

Funding Acknowledgement

Type of funding sources: None.

Impact of atrial fibrillation in patients with colorectal cancer: a national inpatient sample database analysis

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia affecting approximately 1–2% overall population (1). Its causal relationship with colorectal cancer (CRC) is much for debate. According to one hypothesis, the presence of autoantibodies directed against ionic channels or acetylcholine receptors can predispose to the development of atrial fibrillation (2–3). Thus, AF may be regarded as an inflammatory complication in patients with colon cancer. Our study objective was to determine if AF impacts the outcome of patients with CRC.

Method

We analyzed the National Inpatient Sample (NIS) database from Oct-2015 to Dec 2018 using Stata 16.0. The NIS databases are released under the Healthcare Cost and Utilization Project, which includes inpatient admissions from the United States' participating hospitals. Total population with CRC were identified using their respective ICD-10 diagnostic codes then divided based on AF. To determine atrial fibrillation association with mortality and complications, we used multivariate logistic regression analysis using weights to generate nationally representative results. Later, a propensity-matched population analysis was done for the accuracy of the results.

Result

We found 245,305 patients admitted with CRC between Oct 2015 to Dec-2018 in the USA, out of which 28,170 (11.5%) were having AF. The mean age for the patients with AF was 77±10 compare to 65±14 years in those without AF. Patients with AF were associated with higher comorbidities and had a high population percentage with Carlson category three or above. There were 1,456 (5.2%) mortalities in the AF group compared to 5,689 (2.6%) in the other. The higher odds of mortality in patients with AF was present in multivariate logistic regression analysis in both non-propensity matched [1.71 (1.45–2.02), P-value: &lt;0.000] and propensity-matched [1.44 (1.18–1.75), P-value: &lt;0.001] cohorts. Patients with AF were hospitalized longer (9.20±7.8 vs. 6.85±7.0 days), leading to a high admission costs (US$ 25,875±22,875 vs. 20,087±19,314). Odds of complications such as need for blood transfusions [1.61 (1.05–1.29), P-value: 0.005], hemorrhage requiring blood transfusion [1.17 (1.05–1.29), P-value: 0.003], lower-GI bleed [1.31 (1.21–1.43), P-value: &lt;0.001], sepsis [1.45 (1.30–1.62), P-value: &lt;0.001], respiratory failure [1.39 (1.15–1.67), P-value: 0.001] etc. were also higher in group of patients with CRC and AF.

Conclusion

In our retrospective, propensity-matched national inpatient sample analyses of patients admitted with colorectal cancer, atrial fibrillation is associated with higher morbidity and mortality. AF was associated with a high burden of complications with prolonged hospital stay leading to increased health care expenditures.

Funding Acknowledgement

Type of funding sources: None.

Gender based outcome of IABP implantation in patients with acute coronary syndrome and cardiogenic shock: a national inpatient sample database analysis

Background

Intra-Aortic Balloon counter-pulsation is frequently used as a circulatory support device in patients requiring hemodynamic support - in cardiogenic shock and in patients at risk of hemodynamic decompensation during a high-risk coronary intervention. Impact of IABP in this patient population has been variable. Certain studies have shown a beneficial effect of IABP on selected populations having acute coronary syndrome with cardiogenic shock (1–3). Our objective was to compare the outcomes based on gender in the ACS population with cardiogenic shock and IABP placement.

Methods

We analyzed the National Inpatient Sample database from Oct-2015 to Dec-2017 released under Healthcare Cost utilization Project in the USA using Stata 16.0. The population was identified using respective ICD-10 codes. We excluded the population with sudden cardiac arrest, pulmonary embolism, and patients with anatomical post-MI complications. Multivariate logistic regression analysis was done to determine the difference in outcomes based on gender using clinically relevant variables. Later, propensity-matched cohort analysis was performed based on the regression variables.

Results

Of 36, 990 patients who met our inclusion criteria 25,670 (69%) were male and 11,320 (31%) were female. The average age for male and female populations was 66±11 and 69±12 years. Femnales were more likely to have higher Charlson co-morbidity index three or above. We found higher mortality in the female population [3,146 (27.79%)] compared to male [5,884 (22.92%)] in univariate analyses. Propensity-matched multivariate regression analysis showed no difference [OR: 1.06 (0.91–1.22) with P-value: 0.482] in mortality after adjusting for clinically relevant variables. Subgroup analysis in STEMI and NSTEMI populations did not show a difference. The average hospital stay was similar in both cohorts, with the male having a higher cost per stay. We found no difference in most of the complications included in our study except for higher coronary artery dissection [OR: 2.98 (1.73–5.13), P-value: &lt;0.001] and lower rates of AKI [OR: 0.72 (0.63–0.83), P-value: &lt;0.001], AKI requiring hemodialysis [OR: 0.74 (0.56–0.97), P-value:0.031] and ventricular tachycardia [OR: 0.73 (0.64–0.84), P-value: &lt;0.001] in the female population.

Conclusion

The inpatient population of ACS with Cardiogenic shock and IABP insertion showed no significant difference in mortality between males and females which was valid for subgroup analysis of NSTEMI and STEMI groups. Complications such as coronary artery dissection were higher, whereas AKI, AKI requiring hemodialysis, and ventricular tachycardias, were lower in females than males.

Funding Acknowledgement

Type of funding sources: None.

Competition between Allowed and First-Forbidden β Decay: The Case of ^{208}Hg→^{208}Tl

The β decay of ^{208}Hg into the one-proton hole, one neutron-particle _{81}^{208}Tl_{127} nucleus was investigated at CERN-ISOLDE. Shell-model calculations describe well the level scheme deduced, validating the proton-neutron interactions used, with implications for the whole of the N>126, Z<82 quadrant of neutron-rich nuclei. While both negative and positive parity states with spin 0 and 1 are expected within the Q_{β} window, only three negative parity states are populated directly in the β decay. The data provide a unique test of the competition between allowed Gamow-Teller and Fermi, and first-forbidden β decays, essential for the understanding of the nucleosynthesis of heavy nuclei in the rapid neutron capture process. Furthermore, the observation of the parity changing 0^{+}→0^{-}β decay where the daughter state is core excited is unique, and can provide information on mesonic corrections of effective operators.

Sequential Nature of (p,3p) Two-Proton Knockout from Neutron-Rich Nuclei

Twenty-one two-proton knockout (p,3p) cross sections were measured from neutron-rich nuclei at ∼250  MeV/nucleon in inverse kinematics. The angular distribution of the three emitted protons was determined for the first time, demonstrating that the (p,3p) kinematics are consistent with two sequential proton-proton collisions within the projectile nucleus. Ratios of (p,3p) over (p,2p) inclusive cross sections follow the trend of other many-nucleon removal reactions, further reinforcing the sequential nature of (p,3p) in neutron-rich nuclei.

Metastable States of ^{92,94}Se: Identification of an Oblate K Isomer of ^{94}Se and the Ground-State Shape Transition between N=58 and 60

Here we present new information on the shape evolution of the very neutron-rich ^{92,94}Se nuclei from an isomer-decay spectroscopy experiment at the Radioactive Isotope Beam Factory at RIKEN. High-resolution germanium detectors were used to identify delayed γ rays emitted following the decay of their isomers. New transitions are reported extending the previously known level schemes. The isomeric levels are interpreted as originating from high-K quasineutron states with an oblate deformation of β∼0.25, with the high-K state in ^{94}Se being metastable and K hindered. Following this, ^{94}Se is the lowest-mass neutron-rich nucleus known to date with such a substantial K hindrance. Furthermore, it is the first observation of an oblate K isomer in a deformed nucleus. This opens up the possibility for a new region of K isomers at low Z and at oblate deformation, involving the same neutron orbitals as the prolate orbitals within the classic Z∼72 deformed hafnium region. From an interpretation of the level scheme guided by theoretical calculations, an oblate deformation is also suggested for the ^{94}Se_{60} ground-state band.

A Multilayer Monte Carlo Model for the Investigation of Optical Path and Penetration Depth at Different Perfusion States of the Colon

There is a great interest in monitoring the oxygen supply delivered to the colon. Insufficient oxygen delivery may lead to hypoxia, sepsis, multiorgan dysfunction and death. For assessing colonic perfusion, more information and understanding is required relating to the light-interaction within the colonic tissue. A multilayer Monte Carlo model of a healthy human colon has been developed to investigate the light-tissue behavior during different perfusion states within the mucosal layer of the colon. Results from a static multilayer model of optical path and reflectance at two wavelengths, 660 nm and 880 nm, through colon tissue, containing different volume fractions of blood with a fixed oxygen saturation are presented. The effect on the optical path and penetration depth with varying blood volumes within the mucosa for each wavelength has been demonstrated. The simulation indicated both wavelengths of photons penetrated similar depths, entering the muscularis layer.

Improved Value for the Gamow-Teller Strength of the ^{100}Sn Beta Decay

A record number of ^{100}Sn nuclei was detected and new isotopic species toward the proton dripline were discovered at the RIKEN Nishina Center. Decay spectroscopy was performed with the high-efficiency detector arrays WAS3ABi and EURICA. Both the half-life and the β-decay end point energy of ^{100}Sn were measured more precisely than the literature values. The value and the uncertainty of the resulting strength for the pure 0^{+}→1^{+} Gamow-Teller decay was improved to B_{GT}=4.4_{-0.7}^{+0.9}. A discrimination between different model calculations was possible for the first time, and the level scheme of ^{100}In is investigated further.

Proton Shell Evolution below ^{132}Sn: First Measurement of Low-Lying β-Emitting Isomers in ^{123,125}Ag

The β-delayed γ-ray spectroscopy of neutron-rich ^{123,125}Ag isotopes is investigated at the Radioactive Isotope Beam Factory of RIKEN, and the long-predicted 1/2^{-} β-emitting isomers in ^{123,125}Ag are identified for the first time. With the new experimental results, the systematic trend of energy spacing between the lowest 9/2^{+} and 1/2^{-} levels is extended in Ag isotopes up to N=78, providing a clear signal for the reduction of the Z=40 subshell gap in Ag towards N=82. Shell-model calculations with the state-of-the-art V_{MU} plus M3Y spin-orbit interaction give a satisfactory description of the low-lying states in ^{123,125}Ag. The tensor force is found to play a crucial role in the evolution of the size of the Z=40 subshell gap. The observed inversion of the single-particle levels around ^{123}Ag can be well interpreted in terms of the monopole shift of the π1g_{9/2} orbitals mainly caused by the increasing occupation of ν1h_{11/2} orbitals.

Prominence of Pairing in Inclusive (p,2p) and (p,pn) Cross Sections from Neutron-Rich Nuclei

Fifty-five inclusive single nucleon-removal cross sections from medium mass neutron-rich nuclei impinging on a hydrogen target at ∼250  MeV/nucleon are measured at the RIKEN Radioactive Isotope Beam Factory. Systematically higher cross sections are found for proton removal from nuclei with an even number of protons as compared to odd-proton number projectiles for a given neutron separation energy. Neutron removal cross sections display no even-odd splitting, contrary to nuclear cascade model predictions. Both effects are understood through simple considerations of neutron separation energies and bound state level densities originating in pairing correlations in the daughter nuclei. These conclusions are supported by comparison with semimicroscopic model predictions, highlighting the enhanced role of low-lying level densities in nucleon-removal cross sections from loosely bound nuclei.

Proceeding report of the Second Symposium on Hidradenitis Suppurativa Advances (SHSA) 2017

The 2nd Annual Symposium on Hidradenitis Suppurativa Advances (SHSA) took place on 03-05 November 2017 in Detroit, Michigan, USA. This symposium was a joint meeting of the Hidradenitis Suppurativa Foundation (HSF Inc.) founded in the USA, and the Canadian Hidradenitis Suppurativa Foundation (CHSF). This was the second annual meeting of the SHSA with experts from different disciplines arriving from North America, Europe and Australia, in a joint aim to discuss most recent innovations, practical challenges and potential solutions to issues related in the management and care of Hidradenitis Suppurativa patients. The last session involved clinicians, patients and their families in an effort to educate them more about the disease.

Erratum: Persistence of the Z=28 Shell Gap Around ^{78}Ni: First Spectroscopy of ^{79}Cu [Phys. Rev. Lett. 119, 192501 (2017)]

This corrects the article DOI: 10.1103/PhysRevLett.119.192501.

β-γ and isomeric decay spectroscopy of 168Dy

This contribution will report on the experimental work on the level structure of 168Dy. The experimental data have been taken as part of the EURICA decay spectroscopy campaign at RIBF, RIKEN in November 2014. In the experiment, a 238U primary beam is accelerated up to 345 MeV/u with an average intensity of 12 pnA. The nuclei of interest are produced by in-flight fission of 238U impinging on Be target with a thickness of 5 mm. The excited states of 168Dy have been populated through the decay from a newly identified isomeric state and via the β decay from 168Tb. In this contribution, scientific motivations, experimental procedure and some preliminary results for this study are presented.

Discovery of ^{72}Rb: A Nuclear Sandbank Beyond the Proton Drip Line

In this Letter, the observation of two previously unknown isotopes is presented for the first time: ^{72}Rb with 14 observed events and ^{77}Zr with one observed event. From the nonobservation of the less proton-rich nucleus ^{73}Rb, we derive an upper limit for the ground-state half-life of 81 ns, consistent with the previous upper limit of 30 ns. For ^{72}Rb, we have measured a half-life of 103(22) ns. This observation of a relatively long-lived odd-odd nucleus, ^{72}Rb, with a less exotic odd-even neighbor, ^{73}Rb, being unbound shows the diffuseness of the proton drip line and the possibility of sandbanks to exist beyond it. The ^{72}Rb half-life is consistent with a 5^{+}→5/2^{-} proton decay with an energy of 800-900 keV, in agreement with the atomic mass evaluation proton-separation energy as well as results from the finite-range droplet model and shell model calculations using the GXPF1A interaction. However, we cannot explicitly exclude the possibility of a proton transition between 9^{+}(^{72}Rb)→9/2^{+}(^{71}Kr) isomeric states with a broken mirror symmetry. These results imply that ^{72}Kr is a strong waiting point in x-ray burst rp-process scenarios.

Persistence of the Z=28 Shell Gap Around ^{78}Ni: First Spectroscopy of ^{79}Cu

In-beam γ-ray spectroscopy of ^{79}Cu is performed at the Radioactive Isotope Beam Factory of RIKEN. The nucleus of interest is produced through proton knockout from a ^{80}Zn beam at 270  MeV/nucleon. The level scheme up to 4.6 MeV is established for the first time and the results are compared to Monte Carlo shell-model calculations. We do not observe significant knockout feeding to the excited states below 2.2 MeV, which indicates that the Z=28 gap at N=50 remains large. The results show that the ^{79}Cu nucleus can be described in terms of a valence proton outside a ^{78}Ni core, implying the magic character of the latter.

Dual targeting of the cancer antioxidant network with 1,4-naphthoquinone fused Gold(i) N-heterocyclic carbene complexes

To achieve a systems-based approach to targeting the antioxidant pathway, 1,4-naphthoquinone annulated N-heterocyclic carbene (NHC) [bis(1,3-dimesityl-4,5-naphthoquino-imidazol-2-ylidene)-gold(i)] [silver(i) dichloride] (1), [bis(1,3-dimesityl-4,5-naphthoquino-imidazol-2-ylidene)-gold(i)] chloride (2), and 1,3-dimesityl-4,5-naphthoquino-imidazol-2-ylidene)-gold(i) chloride (3)) were designed, synthesized, and tested for biological activity in a series of human cancer cell lines. The solution phase of complexes 1-3 were assigned using several spectroscopy techniques, including NMR spectroscopic analysis. Complexes 1 and 3 were further characterized by single crystal X-ray diffraction analysis. Electrochemical and spectroelectrochemical studies revealed that quinone reductions are reversible and that the electrochemically generated semiquinone and quinone dianions are stable under these conditions. Complex 1, containing two NHC-quinone moieties (to accentuate exogenous ROS via redox cycling) centered around a Au(i) center (to inactivate thioredoxin reductase (TrxR) irreversibly), was found to inhibit cancer cell proliferation to a much greater extent than the individual components (i.e., Au(i)-NHC alone or naphthoquinone alone). Treatment of A549 lung cancer cells with 1 produced a 27-fold increase in exogenous reactive oxygen species (ROS) which was found to localize to the mitochondria. The inhibition of TrxR, an essential mediator of ROS homeostasis, was achieved in the same cell line at low administrated concentrations of 1. TrxR inhibition by 1 was similar to that of auranofin, a gold(i) containing complex known to inhibit TrxR irreversibly. Complex 1 was found to induce cell death via an apoptotic mechanism as confirmed by annexin-V staining. Complex 1 was demonstrated to be efficacious in zebrafish bearing A549 xenografts. These results provide support for the suggestion that a dual targeting approach that involves reducing ROS tolerance while concurrently increasing ROS production can perturb antioxidant homeostasis, enhance cancer cell death in vitro, and reduce tumor burden in vivo, as inferred from preliminary zebra fish model studies.

Shape Evolution in Neutron-Rich Krypton Isotopes Beyond N=60: First Spectroscopy of ^{98,100}Kr

We report on the first γ-ray spectroscopy of low-lying states in neutron-rich ^{98,100}Kr isotopes obtained from ^{99,101}Rb(p,2p) reactions at ∼220  MeV/nucleon. A reduction of the 2_{1}^{+} state energies beyond N=60 demonstrates a significant increase of deformation, shifted in neutron number compared to the sharper transition observed in strontium and zirconium isotopes. State-of-the-art beyond-mean-field calculations using the Gogny D1S interaction predict level energies in good agreement with experimental results. The identification of a low-lying (0_{2}^{+}, 2_{2}^{+}) state in ^{98}Kr provides the first experimental evidence of a competing configuration at low energy in neutron-rich krypton isotopes consistent with the oblate-prolate shape coexistence picture suggested by theory.

Combined KIT and CTLA-4 Blockade in Patients with Refractory GIST and Other Advanced Sarcomas: A Phase Ib Study of Dasatinib plus Ipilimumab

Purpose: A phase Ib study of dasatinib plus ipilimumab in patients with gastrointestinal stromal tumor (GIST) and other sarcomas was performed on the basis of preclinical data demonstrating that combined KIT and CTLA-4 blockade is synergistic.Experimental Design: A standard 3 + 3 design was used to evaluate the safety, efficacy, and immune correlates of treatment. Dose escalation cohorts received ipilimumab 10 or 3 mg/kg every 3 weeks, followed by maintenance every 12 weeks with escalating doses of dasatinib (70 mg daily, 100 mg daily, or 70 mg twice daily). Response was assessed by RECIST 1.1, Choi, and immune-related RECIST criteria (irRC).Results: A total of 28 patients (17 male) were enrolled. Histologic subtypes included GISTs (n = 20) and other sarcomas (n = 8.) Dasatinib 70 mg/day with ipilimumab 10 mg/kg or dasatinib 140 mg/day with ipilimumab 3 mg/kg can be safely administered. Dose-limiting toxicities included grade 3 gastric hemorrhage and anemia. No partial or complete responses were noted by RECIST or irRC. There were 7 of 13 partial responses in the GIST patients by Choi criteria, and 3 of 13 patients each had stable and progressive disease, respectively.Conclusions: Dasatinib and ipilimumab can be safely administered to GIST and sarcoma patients. However, dasatinib was not synergistic with ipilimumab, as there was limited clinical efficacy with the combination. This limited cohort provides prospective data that indoleamine-2,3-dioxygenase (IDO) suppression may potentially correlate with antitumor efficacy in GIST. Given the small cohort, it is only hypothesis generating and additional data would be required. In the era of more modern and effective checkpoint inhibitors, next steps could be consideration of tyrosine kinase inhibitors or IDO inhibitors in combination with anti-PD-1 therapy. Clin Cancer Res; 23(12); 2972-80. ©2016 AACR.

94 β-Decay Half-Lives of Neutron-Rich _{55}Cs to _{67}Ho: Experimental Feedback and Evaluation of the r-Process Rare-Earth Peak Formation

The β-decay half-lives of 94 neutron-rich nuclei ^{144-151}Cs, ^{146-154}Ba, ^{148-156}La, ^{150-158}Ce, ^{153-160}Pr, ^{156-162}Nd, ^{159-163}Pm, ^{160-166}Sm, ^{161-168}Eu, ^{165-170}Gd, ^{166-172}Tb, ^{169-173}Dy, ^{172-175}Ho, and two isomeric states ^{174m}Er, ^{172m}Dy were measured at the Radioactive Isotope Beam Factory, providing a new experimental basis to test theoretical models. Strikingly large drops of β-decay half-lives are observed at neutron-number N=97 for _{58}Ce, _{59}Pr, _{60}Nd, and _{62}Sm, and N=105 for _{63}Eu, _{64}Gd, _{65}Tb, and _{66}Dy. Features in the data mirror the interplay between pairing effects and microscopic structure. r-process network calculations performed for a range of mass models and astrophysical conditions show that the 57 half-lives measured for the first time play an important role in shaping the abundance pattern of rare-earth elements in the solar system.

Are There Signatures of Harmonic Oscillator Shells Far from Stability? First Spectroscopy of ^{110}Zr

The first measurement of the low-lying states of the neutron-rich ^{110}Zr and ^{112}Mo was performed via in-beam γ-ray spectroscopy after one proton removal on hydrogen at ∼200  MeV/nucleon. The 2_{1}^{+} excitation energies were found at 185(11) keV in ^{110}Zr, and 235(7) keV in ^{112}Mo, while the R_{42}=E(4_{1}^{+})/E(2_{1}^{+}) ratios are 3.1(2), close to the rigid rotor value, and 2.7(1), respectively. These results are compared to modern energy density functional based configuration mixing models using Gogny and Skyrme effective interactions. We conclude that first levels of ^{110}Zr exhibit a rotational behavior, in agreement with previous observations of lighter zirconium isotopes as well as with the most advanced Monte Carlo shell model predictions. The data, therefore, do not support a harmonic oscillator shell stabilization scenario at Z=40 and N=70. The present data also invalidate predictions for a tetrahedral ground state symmetry in ^{110}Zr.

Role of the Δ Resonance in the Population of a Four-Nucleon State in the ^{56}Fe→^{54}Fe Reaction at Relativistic Energies

The ^{54}Fe nucleus was populated from a ^{56}Fe beam impinging on a Be target with an energy of E/A=500  MeV. The internal decay via γ-ray emission of the 10^{+} metastable state was observed. As the structure of this isomeric state has to involve at least four unpaired nucleons, it cannot be populated in a simple two-neutron removal reaction from the ^{56}Fe ground state. The isomeric state was produced in the low-momentum (-energy) tail of the parallel momentum (energy) distribution of ^{54}Fe, suggesting that it was populated via the decay of the Δ^{0} resonance into a proton. This process allows the population of four-nucleon states, such as the observed isomer. Therefore, it is concluded that the observation of this 10^{+} metastable state in ^{54}Fe is a consequence of the quark structure of the nucleons.

New Isotopes and Proton Emitters-Crossing the Drip Line in the Vicinity of ^{100}Sn

Several new isotopes, ^{96}In, ^{94}Cd, ^{92}Ag, and ^{90}Pd, have been identified at the RIKEN Nishina Center. The study of proton drip-line nuclei in the vicinity of ^{100}Sn led to the discovery of new proton emitters ^{93}Ag and ^{89}Rh with half-lives in the submicrosecond range. The systematics of the half-lives of odd-Z nuclei with T_{z}=-1/2 toward ^{99}Sn shows a stabilizing effect of the Z=50 shell closure. Production cross sections for nuclei in the vicinity of ^{100}Sn measured at different energies and target thicknesses were compared to the cross sections calculated by epax taking into account contributions of secondary reactions in the primary target.

Extension of the N=40 Island of Inversion towards N=50: Spectroscopy of (66)Cr, (70,72)Fe

We report on the measurement of the first 2(+) and 4(+) states of (66)Cr and (70,72)Fe via in-beam γ-ray spectroscopy. The nuclei of interest were produced by (p,2p) reactions at incident energies of 260  MeV/nucleon. The experiment was performed at the Radioactive Isotope Beam Factory, RIKEN, using the DALI 2γ-ray detector array and the novel MINOS device, a thick liquid hydrogen target combined with a vertex tracker. A low-energy plateau of 2(1)(+) and 4(1)(+) energies as a function of the neutron number was observed for N≥38 and N≥40 for even-even Cr and Fe isotopes, respectively. State-of-the-art shell model calculations with a modified Lenzi-Nowacki-Poves-Sieja (LNPS) interaction in the pfg(9/2)d(5/2) valence space reproduce the observations. Interpretation within the shell model shows an extension of the island of inversion at N=40 for more neutron-rich isotopes towards N=50.

β-Decay Half-Lives of 110 Neutron-Rich Nuclei across the N=82 Shell Gap: Implications for the Mechanism and Universality of the Astrophysical r Process

The β-decay half-lives of 110 neutron-rich isotopes of the elements from _{37}Rb to _{50}Sn were measured at the Radioactive Isotope Beam Factory. The 40 new half-lives follow robust systematics and highlight the persistence of shell effects. The new data have direct implications for r-process calculations and reinforce the notion that the second (A≈130) and the rare-earth-element (A≈160) abundance peaks may result from the freeze-out of an (n,γ)⇄(γ,n) equilibrium. In such an equilibrium, the new half-lives are important factors determining the abundance of rare-earth elements, and allow for a more reliable discussion of the r process universality. It is anticipated that universality may not extend to the elements Sn, Sb, I, and Cs, making the detection of these elements in metal-poor stars of the utmost importance to determine the exact conditions of individual r-process events.

Isomer decay spectroscopy of 164Sm and 166Gd: midshell collectivity around N=100

Excited states in the N=102 isotones 166Gd and 164Sm have been observed following isomeric decay for the first time at RIBF, RIKEN. The half-lives of the isomeric states have been measured to be 950(60) and 600(140) ns for 166Gd and 164Sm, respectively. Based on the decay patterns and potential energy surface calculations, including β6 deformation, a spin and parity of 6- has been assigned to the isomeric states in both nuclei. Collective observables are discussed in light of the systematics of the region, giving insight into nuclear shape evolution. The decrease in the ground-band energies of 166Gd and 164Sm (N=102) compared to 164Gd and 162Sm (N=100), respectively, presents evidence for the predicted deformed shell closure at N=100.

Monopole-driven shell evolution below the doubly magic nucleus 132Sn explored with the long-lived isomer in 126Pd

A new isomer with a half-life of 23.0(8) ms has been identified at 2406 keV in (126)Pd and is proposed to have a spin and parity of 10(+) with a maximally aligned configuration comprising two neutron holes in the 1h(11/2) orbit. In addition to an internal-decay branch through a hindered electric octupole transition, β decay from the long-lived isomer was observed to populate excited states at high spins in (126)Ag. The smaller energy difference between the 10(+) and 7(-) isomers in (126)Pd than in the heavier N=80 isotones can be interpreted as being ascribed to the monopole shift of the 1h(11/2) neutron orbit. The effects of the monopole interaction on the evolution of single-neutron energies below (132)Sn are discussed in terms of the central and tensor forces.

1p3/2 proton-hole state in 132Sn and the shell structure along N = 82

A low-lying state in 131In82, the one-proton hole nucleus with respect to double magic 132Sn, was observed by its γ decay to the Iπ=1/2- β-emitting isomer. We identify the new state at an excitation energy of Ex=1353  keV, which was populated both in the β decay of 131Cd83 and after β-delayed neutron emission from 132Cd84, as the previously unknown πp3/2 single-hole state with respect to the 132Sn core. Exploiting this crucial new experimental information, shell-model calculations were performed to study the structure of experimentally inaccessible N=82 isotones below 132Sn. The results evidence a surprising absence of proton subshell closures along the chain of N=82 isotones. The consequences of this finding for the evolution of the N=82 shell gap along the r-process path are discussed.

Isomers in 128Pd and 126Pd: evidence for a robust shell closure at the neutron magic number 82 in exotic palladium isotopes

The level structures of the very neutron-rich nuclei 128Pd and 126Pd have been investigated for the first time. In the r-process waiting-point nucleus 128Pd, a new isomer with a half-life of 5.8(8) μs is proposed to have a spin and parity of 8(+) and is associated with a maximally aligned configuration arising from the g(9/2) proton subshell with seniority υ=2. For 126Pd, two new isomers have been identified with half-lives of 0.33(4) and 0.44(3) μs. The yrast 2(+) energy is much higher in 128Pd than in 126Pd, while the level sequence below the 8(+) isomer in 128Pd is similar to that in the N=82 isotone 130Cd. The electric quadrupole transition that depopulates the 8(+) isomer in 128Pd is more hindered than the corresponding transition in 130Cd, as expected in the seniority scheme for a semimagic, spherical nucleus. These experimental findings indicate that the shell closure at the neutron number N=82 is fairly robust in the neutron-rich Pd isotopes.

Magnetic resonance imaging: current and emerging applications in the study of the central nervous system

Neuroimaging is presently utilised in clinical practice for initial diagnosis and mapping of disease extent and distribution, noninvasive, preoperative grading of tumours, biopsy planning, surgery and radiation portal planning for tumors, judging response to therapy and finally, prognostication. Newer advances include magnetic resonance (MR) diffusion and diffusion tensor imaging with tractography, perfusion imaging, MR spectroscopy and functional imaging using the blood oxygen level-dependent contrast technique. Neuroimaging plays a pivotal role in various degenerative and neoplastic diseases, improving diagnostic accuracy, affecting patient care, monitoring dynamic changes within the brain during therapy, and establishing them as the arbiter of novel therapy that may one day prove cure of various brain diseases a reality.

Genetic basis of differential opsin gene expression in cichlid fishes

Visual sensitivity can be tuned by differential expression of opsin genes. Among African cichlid fishes, seven cone opsin genes are expressed in different combinations to produce diverse visual sensitivities. To determine the genetic architecture controlling these adaptive differences, we analysed genetic crosses between species expressing different complements of opsin genes. Quantitative genetic analyses suggest that expression is controlled by only a few loci with correlations among some genes. Genetic mapping identifies clear evidence of trans-acting factors in two chromosomal regions that contribute to differences in opsin expression as well as one cis-regulatory region. Therefore, both cis and trans regulation are important. The simple genetic architecture suggested by these results may explain why opsin gene expression is evolutionarily labile, and why similar patterns of expression have evolved repeatedly in different lineages.

Transfer of isoniazid from circulation to breast milk in lactating women on chronic therapy for tuberculosis

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Isoniazid is the most widely used first line antituberculosis drug. It is considered safe during lactation, but limited data are available on the transfer of isoniazid from circulation to milk in lactating women, which can provide an assessment of extent of exposure to the nursling.

WHAT THIS STUDY ADDS

The study documents the transfer pattern and milk to plasma (M : P) ratio of isoniazid at a steady state. Peak plasma and milk concentrations of isoniazid were reached within 1 h and the projected exposure of the drug to the infant is much lower than the prophylactic dose, supporting its safety during breast feeding.

AIM

To determine milk to plasma (M : P) ratios and infant dose (absolute and relative) for isoniazid in lactating women on antituberculosis therapy.

METHODS

Concentrations of isoniazid in plasma and milk were measured in exclusively breast feeding women taking 300 mg day(-1) as treatment for tuberculosis.

RESULTS

Peak plasma and milk concentrations of isoniazid were observed at 1 h. A mean M : P(AUC) value of 0.89 (95% CI 0.7, 1.1) was calculated for isoniazid from seven women over 24 h. The mean absolute infant dose was estimated to be 89.9 mug kg day(-1) (95% CI 65.6, 114) and the relative infant dose was 1.2% of the weight adjusted maternal dose.

CONCLUSIONS

The mean relative dose of isoniazid (1.2%) transmitted to the infant via breast milk is below the 10% notional level of concern. These data suggest that isoniazid therapy is safe during breastfeeding.

Feasibility of community neonatal death audits in rural Uttar Pradesh, India

OBJECTIVE

Medical audit is a widely promoted strategy in hospitals, but experience within community settings is scant. Community neonatal death audit is a form of audit, which involves a systematic analysis of the quality of care provided in the home, danger sign recognition and care seeking decision making for neonatal illness. This research was conducted in Uttar Pradesh, India, to investigate the feasibility and cultural acceptability of community neonatal death audits.

STUDY DESIGN

During November-December 2004, we conducted three in-depth interviews with family members of deceased neonates, and six focus group discussions with family and community members. Three approaches were evaluated: in-depth interview with the family before engaging them in an audit with the community; preliminary meeting to build rapport with the family and community before conducting an audit; and audit with the family and community in a single focus group. Approaches were interactive processes, involving the community, to identify avoidable factors in a particular death and discuss solutions.

RESULT

Carried out in a culturally sensitive and non-punitive manner, community neonatal death audit was found to be acceptable and feasible. All approaches provoked formal investigation by community members, and stimulated sharing of views, leading to the self-discovery that community perception was a cumulatively amplified effect of individual perceptions. Presence of an educated/experienced community member or health worker served as a catalyst. No one optimal approach was identified.

CONCLUSION

Community neonatal audit is an acceptable approach that shows promise as an effective intervention for improving neonatal health outcomes.

The role of dietary protein restriction in Indian patients with chronic renal failure

OBJECTIVE

To determine dietary protein intake in Indian patients with chronic renal failure and the impact of prescribing protein restricted diets to these patients.

METHODS

Baseline dietary protein intake was estimated in forty five patients with chronic renal failure on an unrestricted diet. Of these 45 patients, 27 were vegetarian and 18 were non-vegetarian. Then the patients were divided into 2 comparable groups. Twenty group I patients were allowed to continue unrestricted diet while 25 group II patients were advised 0.6 g/kg/day (50% high biological value) protein. Protein intake was estimated at 1 and 2 month follow up.

RESULTS

The baseline dietary protein intake in 45 patients was 0.65 +/- 0.15 (mean +/- 1 SD) g/kg/day. There was no significant difference in protein intake of group I and group II patients at 1 and 2 month follow up. Also, the protein intake in group II patients was not different at 1 and 2 month follow up compared to baseline value.

CONCLUSION

Protein intake of Indian patients with CRF is usually low even on an unrestricted diet. The usual practice of advising dietary protein restriction has no significant impact on the protein intake.