Plasma oxylipins and unesterified precursor fatty acids are altered by DHA supplementation in pregnancy: Can they help predict risk of preterm birth?

Oxidized lipids derived from omega-6 (n-6) and omega-3 (n-3) polyunsaturated fatty acids, collectively known as oxylipins, are bioactive signaling molecules that play diverse roles in human health and disease. Supplementation with n-3 docosahexaenoic acid (DHA) during pregnancy has been reported to decrease the risk of preterm birth in singleton pregnancies, which may be due to effects of DHA supplementation on oxylipins or their precursor n-6 and n-3 fatty acids. There is only limited understanding of the levels and trajectory of changes in plasma oxylipins during pregnancy, effects of DHA supplementation on oxylipins and unesterified fatty acids, and whether and how oxylipins and their unesterified precursor fatty acids influence preterm birth. In the present study we used liquid chromatography-tandem mass spectrometry to profile oxylipins and their precursor fatty acids in the unesterified pool using plasma samples collected from a subset of pregnant Australian women who participated in the ORIP (Omega-3 fats to Reduce the Incidence of Prematurity) study. ORIP is a large randomized controlled trial testing whether daily supplementation with n-3 DHA can reduce the incidence of early preterm birth compared to control. Plasma was collected at study entry (≈pregnancy week 14) and again at ≈week 24, in a subgroup of 48 ORIP participants-12 cases with spontaneous preterm (<37 weeks) birth and 36 matched controls with spontaneous term (≥40 weeks) birth. In the combined preterm and term pregnancies, we observed that in the control group without DHA supplementation unesterified AA and AA-derived oxylipins 12-HETE, 15-HETE and TXB2 declined between weeks 14-24 of pregnancy. Compared to control, DHA supplementation increased unesterified DHA, EPA, and AA, DHA-derived 4-HDHA, 10-HDHA and 19,20-EpDPA, and AA-derived 12-HETE at 24 weeks. In exploratory analysis independent of DHA supplementation, participants with concentrations above the median for 5-lipoxygenase derivatives of AA (5-HETE, Odds Ratio (OR) 8.2; p = 0.014) or DHA (4-HDHA, OR 8.0; p = 0.015) at 14 weeks, or unesterified AA (OR 5.1; p = 0.038) at 24 weeks had higher risk of spontaneous preterm birth. The hypothesis that 5-lipoxygenase-derived oxylipins and unesterified AA could serve as mechanism-based biomarkers predicting spontaneous preterm birth should be evaluated in larger, adequately powered studies

Weight loss dynamics during combined fluoxetine and olanzapine treatment

BACKGROUND: Fluoxetine and olanzapine combination therapy is rapidly becoming an effective strategy for managing symptoms of treatment-resistant depression. Determining drug-drug interactions, drug metabolism and pharmacokinetics is of particular interest for revealing potential liabilities associated with drug augmentation in special patient populations. In the current studies, we chronically administered fluoxetine and olanzapine in non-stressed rats to extend our previous findings regarding body weight dynamics. RESULTS: Chronic fluoxetine (10 mg/kg) and olanzapine (5 mg/kg and 0.5 mg/kg) treatment decreased weight gain irrespective of olanzapine dosing. At the 10 mg/kg and 5 mg/kg dose, respectively, fluoxetine and olanzapine also significantly reduced food and water consumption. This pharmacodynamic event-related effect, however, was not observed at the 10 mg/kg and 0.5 mg/kg dosing paradigm suggesting differences in tolerability rates as a function of olanzapine dose. The decrease in weight gain was not associated with apparent changes in glucose metabolism as vehicle- and drug-treated rats showed undistinguishable serum glucose levels. The combination of fluoxetine and olanzapine in rats yielded drug plasma concentrations that fell within an expected therapeutic range for these drugs in psychiatric patients. CONCLUSIONS: These data suggest that fluoxetine and olanzapine treatment decreases weight gain in rats; a pharmacodynamic event-related effect that differs considerably from what is observed in the clinical condition. The possibility of mismatched models regarding body weight changes during drug augmentation therapy should be seriously considered

USE OF PERIPHERAL VASOPRESSORS IN EARLY SEPSIS-INDUCED HYPOTENSION ACROSS MICHIGAN HOSPITALS

INTRODUCTION: Recent data suggest it may be safe to administer vasopressors via peripheral IV (PIV), challenging convention that vasopressors must be delivered centrally. Surviving Sepsis Campaign 2021 guidelines suggest using peripheral vasopressors as a bridge to central access. However, little is known about vasopressor initiation in practice. METHODS: Cohort study of patients hospitalized with community-onset sepsis at 12 hospitals in the Hospital Medicine Safety Consortium (HMS) sepsis initiative. HMS is a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan. A random sample of adult sepsis hospitalizations between 11/2020-1/2022 were included. Data were abstracted by trained abstractors. We sought to determine how commonly vasopressors were initiated via PIV vs central access across hospitals. HMS-Sepsis is expanding to 69 hospitals. Here we present pilot data; full cohort analysis is in process. RESULTS: of 1,901 patients in the HMS-Sepsis registry at the time of pilot data analysis, 440 (23.1%) had hypotension (defined by mean arterial pressure\u3c 65mmHg, systolic blood pressure\u3c 90mmHg, and/or vasopressor initiation) within 3 hours of hospital arrival. of these, 160 (36.4%) received vasopressors within 6 hours of hospital arrival. Route of initial vasopressor was PIV in 122 (76.3%), central access in 30 (18.8%), midline catheter in 1 (0.6%), oral (ie, midodrine) in 5 (3.1%), and unknown in 2 (1.3%). Across all hospitals, 50.0% to 91.7% of vasopressor initiation was via PIV (median 83.3%). Among 122 patients with vasopressor initiation via PIV, 66 (54.1%) received a 2nd vasopressor, after a median of 2.8 hrs [IQR 1, 8] from 1st vasopressor. Route of 2nd vasopressor was PIV in 27 (40.9%) and central access in 30 (45.4%). Time from hypotension to vasopressor initiation did not differ between patients receiving initial vasopressor via PIV vs central access (median 1.9 vs 2.1 hrs, p=0.79). Likewise, IV fluids within 6 hrs (median 2.0 vs 2.1L, p=0.78), hospitalization length (median 7 vs 6 days, p=0.31), and inhospital mortality (33.6% vs 40.0%, p=0.51) were similar. CONCLUSIONS: In this 12-hospital cohort, vasopressors were most frequently initiated peripherally. Outcomes were similar between patients in whom vasopressors were initiated via peripheral vs central access

NRG Oncology/RTOG 0921: A phase 2 study of postoperative intensity-modulated radiotherapy with concurrent cisplatin and bevacizumab followed by carboplatin and paclitaxel for patients with endometrial cancer.

BACKGROUND: The current study was conducted to assess acute and late adverse events (AEs), overall survival (OS), pelvic failure, regional failure, distant failure, and disease-free survival in a prospective phase 2 clinical trial of bevacizumab and pelvic intensity-modulated radiotherapy (IMRT) with chemotherapy in patients with high-risk endometrial cancer. METHODS: Patients underwent a hysterectomy and lymph node removal, and had ≥1 of the following high-risk factors: grade 3 carcinoma with \u3e50% myometrial invasion, grade 2 or 3 disease with any cervical stromal invasion, or known extrauterine extension confined to the pelvis. Treatment included pelvic IMRT and concurrent cisplatin on days 1 and 29 of radiation and bevacizumab (at a dose of 5 mg/kg on days 1, 15, and 29 of radiation) followed by adjuvant carboplatin and paclitaxel for 4 cycles. The primary endpoint was grade ≥3 AEs occurring within the first 90 days (toxicity was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events [version 4.0]). RESULTS: A total of 34 patients were accrued from November 2009 through December 2011, 30 of whom were eligible and received study treatment. Seven of 30 patients (23.3%; 1-sided 95% confidence interval, 10.6%-36.0%) developed grade ≥3 treatment-related nonhematologic toxicities within 90 days; an additional 6 patients experienced grade ≥3 toxicities between 90 and 365 days after treatment. The 2-year OS rate was 96.7% and the disease-free survival rate was 79.1%. No patient developed a within-field pelvic failure and no patients with International Federation of Gynecology and Obstetrics stage I to IIIA disease developed disease recurrence after a median follow-up of 26 months. CONCLUSIONS: Postoperative bevacizumab added to chemotherapy and pelvic IMRT appears to be well tolerated and results in high OS rates at 2 years for patients with high-risk endometrial carcinoma

Seasonal budgets of reactive nitrogen species and ozone over the United States, and export fluxes to the global atmosphere

A three-dimensional, continental-scale photochemical model is used to investigate seasonal budgets of O3 and NOy species (including NOx and its oxidation products) in the boundary layer over the United States and to estimate the export of these species from the U.S. boundary layer to the global atmosphere. Model results are evaluated with year-round observations for O3, CO, and NOy species at nonurban sites. A seasonal transition from NOx to hydrocarbon-limited conditions for O3 production over the eastern United States is found to take place in the fall, with the reverse transition taking place in the spring. The mean NOx/NOy molar ratio in the U.S. boundary layer in the model ranges from 0.2 in summer to 0.6 in winter, in accord with observations, and reflecting largely the seasonal variation in the chemical lifetime of NOx. Formation of hydroxy organic nitrates during oxidation of isoprene, followed by decomposition of these nitrates to HNO3, is estimated to account for 30% of the chemical sink of NOx in the U.S. boundary layer in summer. Model results indicate that peroxyacylnitrates (PANs) are most abundant in the U.S. boundary layer in spring (25% of total NOy.), reflecting a combination of active photochemistry and low temperatures. About 20% of the NOx emitted from fossil fuel combustion in the United States in the model is exported out of the U.S. boundary layer as NOx or PANs (15% in summer, 25% in winter). This export responds less than proportionally to changes in NOx emissions in summer, but more than proportionally in winter. The annual mean export of NOx and PANs from the U.S. boundary layer is estimated to be 1.4 Tg N yr−1, representing an important source of NOx on the scale of the northern hemisphere troposphere. The eventual O3 production in the global troposphere due to the exported NOx and PANs is estimated to be twice as large, on an annual basis, as the direct export of O3 pollution from the U.S. boundary layer. Fossil fuel combustion in the United States is estimated to account for about 10% of the total source of O3 in the northern hemisphere troposphere on an annual basis

Association of Infectious Disease Physician Approval of Peripherally Inserted Central Catheter With Appropriateness and Complications

Importance: Peripherally inserted central catheters (PICCs) are frequently used to deliver intravenous antimicrobial therapy. However, inappropriate PICC use may lead to patient harm. Objective: To evaluate whether infectious disease physician approval prior to PICC placement for intravenous antimicrobials is associated with more appropriate device use and fewer complications. Design, Setting, and Participants: This cohort study of 21 653 PICCs placed for a primary indication of intravenous antimicrobial therapy between January 1, 2015, and July 26, 2019, was conducted in 42 hospitals participating in a quality collaborative across Michigan among hospitalized medical patients. Main Outcomes and Measures: Appropriateness of PICCs was defined according to the Michigan Appropriateness Guide for Intravenous Catheters as a composite measure of (1) single-lumen catheter use, (2) avoiding use of PICCs for 5 days or less, and (3) avoiding use of PICCs for patients with chronic kidney disease (defined as an estimated glomerular filtration rate/min/1.73 m2). Complications related to PICCs included catheter occlusion, deep vein thrombosis, and central line-associated bloodstream infection. The association between infectious disease physician approval, device appropriateness, and catheter complications was assessed using multivariable models, adjusted for patient comorbidities and hospital clustering. Results were expressed as odds ratios with 95% CIs. Results: A total of 21 653 PICCs were placed for intravenous antimicrobials (11 960 PICCs were placed in men [55.2%]; median age, 64.5 years [interquartile range, 53.4-75.4 years]); 10 238 PICCs (47.3%) were approved by an infectious disease physician prior to placement. Compared with PICCs with no documented approval, PICCs with approval by an infectious disease physician were more likely to be appropriately used (72.7% [7446 of 10 238] appropriate with approval vs 45.4% [5180 of 11 415] appropriate without approval; odds ratio, 3.53; 95% CI, 3.29-3.79; P \u3c .001). Furthermore, approval was associated with lower odds of a PICC-related complication (6.5% [665 of 10 238] with approval vs 11.3% [1292 of 11 415] without approval; odds ratio, 0.55; 95% CI, 0.50-0.61). Conclusions and Relevance: This cohort study suggests that, when PICCs were placed for intravenous antimicrobial therapy, infectious disease physician approval of PICC insertion was associated with more appropriate device use and fewer complications. Policies aimed at ensuring infectious disease physician approval prior to PICC placement for antimicrobials may improve patient safety

Did giraffe cardiovascular evolution solve the problem of heart failure with preserved ejection fraction?

The evolved adaptations of other species can be a source of insight for novel biomedical innovation. Limitations of traditional animal models for the study of some pathologies are fueling efforts to find new approaches to biomedical investigation. One emerging approach recognizes the evolved adaptations in other species as possible solutions to human pathology. The giraffe heart, for example, appears resistant to pathology related to heart failure with preserved ejection fraction (HFpEF)-a leading form of hypertension-associated cardiovascular disease in humans. Here, we postulate that the physiological pressure-induced left ventricular thickening in giraffes does not result in the pathological cardiovascular changes observed in humans with hypertension. The mechanisms underlying this cardiovascular adaptation to high blood pressure in the giraffe may be a bioinspired roadmap for preventive and therapeutic strategies for human HFpEF