EPIdemiology of Surgery-Associated Acute Kidney Injury (EPIS-AKI) : Study protocol for a multicentre, observational trial

More than 300 million surgical procedures are performed each year. Acute kidney injury (AKI) is a common complication after major surgery and is associated with adverse short-term and long-term outcomes. However, there is a large variation in the incidence of reported AKI rates. The establishment of an accurate epidemiology of surgery-associated AKI is important for healthcare policy, quality initiatives, clinical trials, as well as for improving guidelines. The objective of the Epidemiology of Surgery-associated Acute Kidney Injury (EPIS-AKI) trial is to prospectively evaluate the epidemiology of AKI after major surgery using the latest Kidney Disease: Improving Global Outcomes (KDIGO) consensus definition of AKI. EPIS-AKI is an international prospective, observational, multicentre cohort study including 10 000 patients undergoing major surgery who are subsequently admitted to the ICU or a similar high dependency unit. The primary endpoint is the incidence of AKI within 72 hours after surgery according to the KDIGO criteria. Secondary endpoints include use of renal replacement therapy (RRT), mortality during ICU and hospital stay, length of ICU and hospital stay and major adverse kidney events (combined endpoint consisting of persistent renal dysfunction, RRT and mortality) at day 90. Further, we will evaluate preoperative and intraoperative risk factors affecting the incidence of postoperative AKI. In an add-on analysis, we will assess urinary biomarkers for early detection of AKI. EPIS-AKI has been approved by the leading Ethics Committee of the Medical Council North Rhine-Westphalia, of the Westphalian Wilhelms-University Münster and the corresponding Ethics Committee at each participating site. Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and used to design further AKI-related trials. Trial registration number NCT04165369

Albiglutide and cardiovascular outcomes in patients with type 2 diabetes and cardiovascular disease (Harmony Outcomes): a double-blind, randomised placebo-controlled trial

Background: Glucagon-like peptide 1 receptor agonists differ in chemical structure, duration of action, and in their effects on clinical outcomes. The cardiovascular effects of once-weekly albiglutide in type 2 diabetes are unknown. We aimed to determine the safety and efficacy of albiglutide in preventing cardiovascular death, myocardial infarction, or stroke. Methods: We did a double-blind, randomised, placebo-controlled trial in 610 sites across 28 countries. We randomly assigned patients aged 40 years and older with type 2 diabetes and cardiovascular disease (at a 1:1 ratio) to groups that either received a subcutaneous injection of albiglutide (30–50 mg, based on glycaemic response and tolerability) or of a matched volume of placebo once a week, in addition to their standard care. Investigators used an interactive voice or web response system to obtain treatment assignment, and patients and all study investigators were masked to their treatment allocation. We hypothesised that albiglutide would be non-inferior to placebo for the primary outcome of the first occurrence of cardiovascular death, myocardial infarction, or stroke, which was assessed in the intention-to-treat population. If non-inferiority was confirmed by an upper limit of the 95% CI for a hazard ratio of less than 1·30, closed testing for superiority was prespecified. This study is registered with ClinicalTrials.gov, number NCT02465515. Findings: Patients were screened between July 1, 2015, and Nov 24, 2016. 10 793 patients were screened and 9463 participants were enrolled and randomly assigned to groups: 4731 patients were assigned to receive albiglutide and 4732 patients to receive placebo. On Nov 8, 2017, it was determined that 611 primary endpoints and a median follow-up of at least 1·5 years had accrued, and participants returned for a final visit and discontinuation from study treatment; the last patient visit was on March 12, 2018. These 9463 patients, the intention-to-treat population, were evaluated for a median duration of 1·6 years and were assessed for the primary outcome. The primary composite outcome occurred in 338 (7%) of 4731 patients at an incidence rate of 4·6 events per 100 person-years in the albiglutide group and in 428 (9%) of 4732 patients at an incidence rate of 5·9 events per 100 person-years in the placebo group (hazard ratio 0·78, 95% CI 0·68–0·90), which indicated that albiglutide was superior to placebo (p<0·0001 for non-inferiority; p=0·0006 for superiority). The incidence of acute pancreatitis (ten patients in the albiglutide group and seven patients in the placebo group), pancreatic cancer (six patients in the albiglutide group and five patients in the placebo group), medullary thyroid carcinoma (zero patients in both groups), and other serious adverse events did not differ between the two groups. There were three (<1%) deaths in the placebo group that were assessed by investigators, who were masked to study drug assignment, to be treatment-related and two (<1%) deaths in the albiglutide group. Interpretation: In patients with type 2 diabetes and cardiovascular disease, albiglutide was superior to placebo with respect to major adverse cardiovascular events. Evidence-based glucagon-like peptide 1 receptor agonists should therefore be considered as part of a comprehensive strategy to reduce the risk of cardiovascular events in patients with type 2 diabetes. Funding: GlaxoSmithKline

Evaluation of education, attitude, and practice of the Turkish anesthesiologists in regional block techniques

Background: The demand for regional blocks from both patients and surgeons has significantly increased in anesthesia practice during the last 30 years. Although the studies show that the complications are rare, regional blocks still have serious difficulties which can be prevented by training programs. Objectives: The purpose of this study was to determine the factors affecting the educational methods, attitude and practice of the Turkish anesthesiologists in regional blocks during and following residency programs. Patients and Methods: Anesthesiologists were asked to answer a questionnaire. Educational proficiency was determined by at least 50 spinal, 50 epidural and 50 peripheral block applications during residency. Specialists were asked for the numbers of spinal, epidural and peripheral blocks (PBs) they applied in 2009. The mean and median values were calculated. Results: One hundred and eighty-eight anesthesiologists (84.3 %) agreed to participate in the study. While all participants had made their first attempts in neuraxial blocks (NBs) when they were residents, this ratio was detected as 96.8% for PBs. All participants learned neuraxial and PBs on patients in the operating theater. Education proficiency ratios for spinal, epidural and PBs were 98.1 %, 92.5 % and 62.3 %, respectively. Age, perception of adequate training, nerve block rotation, adequate application in education, following innovations were the factors which significantly affected the number of PBs in practice according to univariate analysis. The participants who consider their applications on NBs were adequate (P = 0.029) and the ones working in state or private hospitals (P = 0.017), applied NBs significantly above the median number. Conclusions: Anesthesiologists had adequate education and practice of NB applications but a significant proportion of participants (51.8%) lacked both in PBs applications. We believe that NBs are more easily learned than PBs during residency training program. © 2013 Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM); Published by Kowsar Corp

Advanced biofuels to decarbonise European transport by 2030: markets, challenges, and policies that impact their successful market uptake

Advanced biofuels are among the available options to decarbonise transport in the short to medium term especially for aviation, marine and heavy-duty vehicles that lack immediate alternatives. Their production and market uptake, however, is still very low due to several challenges arising across their value chain. So far policy has established targets and monitoring frameworks for low carbon fuels and improved engine performance but has not yet been sufficient to facilitate their effective market uptake. Their market roll-out must be immediate if the 2030 targets are to be met. Analysis in this paper reiterates that the future deployment of these fuels, in market shares that can lead to the desired decarbonisation levels, still depends largely on the integration of tailored policy interventions that can overcome challenges and improve upstream and downstream performance. The work presented aims to i) inform on policy relevant challenges that restrict the flexible, reliable and cost-efficient market uptake of sustainable advanced biofuels for transport, and ii) highlight policy interventions that, have strong potential to overcome the challenges and are relevant to current policy, Green Deal and the Sustainable Development Goals (SDGs)

Activites neurochirurgicales a Mopti (Mali) ans le cadre des actions civilo-militaires au cours d’une mission de maintien de la paix.

Introduction : Le Togo à travers les Forces Armées Togolaises, a déployé au Mali, un hôpital niveau 2 dans le cadre du maintien de la paix. Sa mission, est de soutenir médicalement les troupes et le personnel civil des institutions engagées sur le terrain. En plus de cette activité, le personnel de l’hôpital, apportait un soutien médical à la population locale dans le cadre des actions civilo-militaires. Ainsi, nous avons pris en charge des patients neurochirurgicaux à l’Hôpital Somino Dolo de Mopti que nous rapportons, tout en relevant les problèmes médico-légaux de cette assistance.Matériel et méthode : De juillet 2013 à Avril 2014, nous avons pris en charge 28 patients souffrant d’une pathologie neurochirurgicale à l’hôpital Somino Dolo de Mopti. Ont été exclues de cette série, tous les militaires engagés où le personnel onusien.Résultats : Vingt-huit patients ont été admis pendant cette période. L’âge moyen des patients était de 26, 4 ans (1 mois et 65 ans). On notait une prédominance masculine (89,3%). Les urgences traumatologiques dominaient les pathologies (57,1%). Les accidents de circulation (87,5%) constituaient la principale étiologie. Nous avons opérés 15 patients (53,6%) et en référé à Bamako 6 (21,4%).Conclusion : Cette expérience illustre bien la bonne collaboration entre les soldats de la paix et les populations locales dont les rapports peuvent parfois être conflictuels. Les instances internationales devraient définir un cadre légal de ces types d’activités afin de mieux les encourager.Mots clés : Neurochirurgie, Mopti, Action civilo-militaire