A systematic review and meta-analysis of diagnostic delay in pulmonary embolism.

BACKGROUND: Diagnostic delay in patients with pulmonary embolism (PE) is typical, yet the proportion of patients with PE that experienced delay and for how many days is less well described, nor are determinants for such delay. OBJECTIVES: This study aimed to assess the prevalence and extent of delay in diagnosing PE. METHODS: A systematic literature search was performed to identify articles reporting delays in diagnosing PE. The primary outcome was mean delay (in days) or a percentage of patients with diagnostic delay (defined as PE diagnosis more than seven days after symptom onset). The secondary outcome was determinants of delay. Random-effect meta-analyses were applied to calculate a pooled estimate for mean delay and to explore heterogeneity in subgroups. RESULTS: The literature search yielded 10,933 studies, of which 24 were included in the final analysis. The pooled estimate of the mean diagnostic delay based on 12 studies was 6.3 days (95% prediction interval 2.5 to 15.8). The percentage of patients having more than seven days of delay varied between 18% and 38%. All studies assessing the determinants of coughing (n = 3), chronic lung disease (n = 6) and heart failure (n = 8) found a positive association with diagnostic delay. Similarly, all studies assessing recent surgery (n = 7) and hypotension (n = 6), as well as most studies assessing chest pain (n = 8), found a negative association with diagnostic delay of PE. CONCLUSION: Patients may have symptoms for almost one week before PE is diagnosed and in about a quarter of patients, the diagnostic delay is even longer.

Combination treatment with mirabegron and solifenacin in patients with overactive bladder: exploratory responder analyses of efficacy and evaluation of patient-reported outcomes from a randomized, double-blind, factorial, dose-ranging, Phase II study (SYMPHONY).

PURPOSE: This large dose-ranging study explored the benefits of different combinations of mirabegron and solifenacin on health-related quality of life (HRQoL), based on patient-reported outcomes (PROs), and patients ('responders') achieving clinically meaningful improvements in efficacy and HRQoL. METHODS: SYMPHONY (NCT01340027) was a Phase II, placebo- and monotherapy-controlled, dose-ranging, 12-week trial. Adult patients with overactive bladder (OAB) for ≥3 months were randomized to 1 of 12 groups: 6 combination (solifenacin 2.5/5/10 mg + mirabegron 25/50 mg), 5 monotherapy (solifenacin 2.5/5/10 mg, or mirabegron 25/50 mg), or placebo. Change from baseline to end of treatment was assessed, versus placebo and solifenacin 5 mg in: PROs (OAB-q [Symptom Bother/total HRQoL] and Patient Perception of Bladder Condition score), and responders achieving minimally important differences (MIDs) in PROs and predetermined clinically meaningful improvements in efficacy (e.g. <8 micturitions/24 h). Changes in PROs and responders were analysed using an ANCOVA model and logistic regression, respectively. RESULTS: The Full Analysis Set included 1278 patients. Combination therapy of solifenacin 5/10 mg + mirabegron 25/50 mg significantly improved PROs versus solifenacin 5 mg and placebo, and significantly more responders achieved MIDs in PROs and efficacy. Micturition frequency normalization was approximately twofold greater with 10 + 25 mg (OR 2.06 [95 % CI 1.11, 3.84; p = 0.023]) and 5 + 50 mg (OR 1.91 [95 % CI 1.14, 3.21; p = 0.015]) versus solifenacin 5 mg. CONCLUSION: Combining mirabegron 25/50 mg and solifenacin 5/10 mg improves objective and subjective efficacy outcomes compared with placebo or solifenacin 5 mg.

Patient and physician preferences for oral pharmacotherapy for overactive bladder: two discrete choice experiments.

OBJECTIVE: We examined patient and treating physician (general practitioners, urologists, and [uro]gynecologists) preferences for oral pharmacotherapy (antimuscarinics and beta-3 adrenoceptor agonists) for overactive bladder to gain a deeper understanding of which attributes drive their treatment decision-making and to quantify to what extent. RESEARCH DESIGN AND METHODS: Two separate discrete choice experiments were developed and validated using the input of patients and physicians. The patient experiment contained the following attributes: micturition frequency, incontinence, nocturia, urgency, dry mouth, constipation, increased heart rate, and increased blood pressure. The physician experiment contained two additional attributes: coping and atrial fibrillation. Both were fielded in five European countries. To allow for preference heterogeneity, utility functions were estimated using a mixed multinomial logit model. RESULTS: A total of 442 patient and 318 physician responses were analyzed. Patients ranked the attributes based on their largest potential impact on treatment value as follows: incontinence, nocturia, risk of an increased heart rate, urgency, frequency, risk of increased blood pressure, risk of constipation, and risk of dry mouth; and physicians as follows: incontinence, urgency, nocturia, frequency, risk of dry mouth, coping, risk of increased heart rate, risk of increased blood pressure, risk of atrial fibrillation, and risk of constipation. CONCLUSION AND LIMITATIONS: In their valuations, physicians put more emphasis on increasing benefits, whereas patients put more emphasis on limiting risks of side effects. Another contrast that emerged was that patients' valuations of side effects were found to be fairly insensitive to the presented risk levels (with the exception of risk of dry mouth), whereas physicians' evaluated all side effects in a risk-level dependent manner. The obtained utility functions can be used to predict whether, to what extent, and for which reasons patients and physicians would choose one oral pharmacotherapy over another, as well as to advance shared decision-making.

A quantitative benefit-risk assessment approach to improve decision making in drug development: Application of a multicriteria decision analysis model in the development of combination therapy for overactive bladder.

A multicriteria decision analysis (MCDA) approach was developed and used to estimate the benefit-risk of solifenacin and mirabegron and their combination in the treatment of overactive bladder (OAB). The objectives were 1) to develop an MCDA tool to compare drug effects in OAB quantitatively, 2) to establish transparency in the evaluation of the benefit-risk profile of various dose combinations, and 3) to quantify the added value of combination use compared to monotherapies. The MCDA model was developed using efficacy, safety, and tolerability attributes and the results of a phase II factorial design combination study were evaluated. Combinations of solifenacin 5 mg and mirabegron 25 mg and mirabegron 50 (5+25 and 5+50) scored the highest clinical utility and supported combination therapy development of solifenacin and mirabegron for phase III clinical development at these dose regimens. This case study underlines the benefit of using a quantitative approach in clinical drug development programs.

The analysis of incontinence episodes and other count data in patients with overactive bladder by Poisson and negative binomial regression.

Clinical studies in overactive bladder have traditionally used analysis of covariance or nonparametric methods to analyse the number of incontinence episodes and other count data. It is known that if the underlying distributional assumptions of a particular parametric method do not hold, an alternative parametric method may be more efficient than a nonparametric one, which makes no assumptions regarding the underlying distribution of the data. Therefore, there are advantages in using methods based on the Poisson distribution or extensions of that method, which incorporate specific features that provide a modelling framework for count data. One challenge with count data is overdispersion, but methods are available that can account for this through the introduction of random effect terms in the modelling, and it is this modelling framework that leads to the negative binomial distribution. These models can also provide clinicians with a clearer and more appropriate interpretation of treatment effects in terms of rate ratios. In this paper, the previously used parametric and non-parametric approaches are contrasted with those based on Poisson regression and various extensions in trials evaluating solifenacin and mirabegron in patients with overactive bladder. In these applications, negative binomial models are seen to fit the data well.

The degradation of N,N',N"-triethylenephosphoramide in aqueous solutions: a qualitative and kinetic study.

The degradation of N,N',N"-triethylenephosphoramide (TEPA) in aqueous solutions has been investigated over a pH range of 3-14. Samples were analyzed using a gas chromatographic system with nitrogen/phosphorus selective detection. The degradation kinetics were studied as function of pH, sodium chloride concentration and temperature. The degradation of TEPA in buffers follows pseudo first order kinetics. The logk(obs)8 the methoxy derivative of TEPA was formed, as a consequence of the applied procedure.

Qualitative and quantitative aspects of the degradation of several tripeptides derived from the antitumour peptide antagonist [Arg(6), D-Trp(7,9), MePhe(8)] substance P[6-11].

The tripeptides Arg-Trp-Phe, Arg-Trp-Phe-NH2, Phe-Trp-Arg and Phe-Trp-Arg-NH2 were subjected to a degradation study to get a more detailed insight into the degradation processes of the antitumor hexapeptide antagonist [Arg(6), D-Trp(7,9), MePhe(8)] substance P¿6-11¿ which was investigated in earlier research. Degradation kinetics as well as identities of degradation products of the tripeptides emerging in alkaline and acidic media were studied. The amidated forms (Arg-Trp-Phe-NH2, Phe-Trp-Arg-NH2) appear to be less stable than the carboxylic forms (Arg-Trp-Phe, Phe-Trp-Arg). Deamidation of the amide C-terminus, racemization of the Phe and Arg residues, ornithine formation, hydrolysis of the peptide backbone and diketopiperazine formation with elimination of the N-terminal fragments were the major degradative processes. Comparing these reactions with the reactions of antagonist [Arg(6), D-Trp(7,9), MePhe(8)] substance P¿6-11¿ it appeared that racemization of Phe and Arg, hydrolysis of the peptide backbone and diketopiperazine formation did not occur in detectable amounts in the hexapeptide. probably due to lower reaction rates of these reactions compared to the overall degradation rate of antagonist [Arg(6), D-Trp(7,9) MePhe(8)] substance P¿6-11¿.

Determination of N,N',N"-triethylenethiophosphoramide and its active metabolite N,N',N"-triethylenephosphoramide in plasma and urine using capillary gas chromatography.

A sensitive assay for the determination of N,N',N"-triethylenethiophosphoramide (thioTEPA) and its metabolite N,N',N"-triethylenephosphoramide (TEPA) in micro-volumes human plasma and urine has been developed. ThioTEPA and TEPA were analysed using gas chromatography with selective nitrogen-phosphorus detection or mass spectrometry after extraction with a mixture of 1-propanol-chloroform from the biological matrix. Diphenylamine was used as internal standard. The limit of detection was 1.5 ng/ml for thioTEPA and 2.5 ng/ml for TEPA, using 100 microl of biological sample; recoveries ranged between 70 and 90% and both accuracy and precision were less than 10%. Linearity was accomplished in the range of 10-1000 ng/ml for plasma and 100-10000 ng/ml for urine using thermionic nitrogen-phosphorus detection. With mass spectrometry a linear range of 100-25000 ng/ml TEPA in plasma or urine was obtained. For thioTEPA a second-order polynomial function describes the relationship between the analyte concentration in the range of 500-25000 ng/ml and detection response. TEPA proved to be stable in plasma and urine for at least 10 weeks at -80 degrees C. ThioTEPA and TEPA plasma concentrations of two patients treated with thioTEPA are presented demonstrating the applicability of the assay for clinical samples.

Analytical techniques used to study the degradation of proteins and peptides: chemical instability.

Instability of peptides and proteins can be divided into two forms: chemical and physical instability. Chemical instability is due to modification/alteration of amino acid residues. There are several types of degradation reactions responsible for this instability. Most frequently described reactions are oxidation, reduction, deamidation, hydrolysis, arginine conversion, beta-elimination and racemisation. However, any study of the degradation of a chemical substance lacks reliability when the analytical methodology, that is used is not properly validated. Especially in the investigation, where degradation processes lead to their parent compounds, validation of the analysis is pivotal for the correct interpretation of the results. It is therefore appropriate and useful to assemble an overview of degradation processes in relation to the analytical methods to monitor them. An overview like this can help investigators to make the right choices in their analytical approach of stability problems. The degradation reactions involved in peptide/protein degradation as well as the methods to monitor them are summarized and discussed.

Analytical techniques used to study the degradation of proteins and peptides: physical instability.

The physical instability of proteins and peptides as well as the various analytical techniques used to study the various aspects of physical instability have been reviewed. Physical instability of proteins and peptides involve changes in secondary, tertiary and quaternary structures of these compounds. After a general introduction of the subject the literature data of these changes and their analytical aspects have been summarized in a Table.

Determination of N,N',N"-triethylenthiophosphoramide in biological samples using capillary gas chromatography.

A sensitive assay for the determination of N,N',N"-triethylenthiophosphoramide (thioTEPA) in microvolumes of human plasma and urine has been developed. ThioTEPA was analysed using gas chromatography with selective nitrogen-phosphorus detection, after extraction with ethyl acetate from the biological matrix. Diphenylamine is the internal standard. The limit of quantitation was 0.1 ng/ml, using only 100 microl of sample; recoveries ranged between 85 and 100% and both accuracy and precision were less than 10%. Using a flame ionisation nitrogen-phosphorus detector, the assay was not linear over the concentration range of 2-1000 ng/ml for plasma and 10-1000 ng/ml for urine. Linearity was accomplished in the range of 1-1000 ng/ml for plasma and urine when a thermionic nitrogen/phosphorous detector was used. The stability of thioTEPA in plasma proved to be satisfactory over a period of 3 months, when kept at -20 degrees C, whereas it was stable in urine for at least 1 month at -80 degrees C. ThioTEPA plasma concentrations of two patients treated with thioTEPA are presented demonstrating the applicability of the assay.

Effects of monensin on in vivo rumen propionate production and blood glucose kinetics in cattle.

Four rumen-fistulated steers (154 to 253 kg), fed two different diets in succession, were used to determine effects of monensin on rumen propionate production rates and blood glucose kinetics as determined by single-injection isotope-dilution techniques. A high-roughage and a high-grain diet, with and without 150 mg of monensin daily, were fed isoenergetically at 2-hour intervals. Monensin increased rumen propionate pool sizes from 32 to 57 g for the high-roughage diet and from 37 to 66 g for the high-grain diet and increased rumen propionate production rates from 441 to 659 g/day for the high-roughage diet and from 510 to 899 g/day for the high-grain diet. Molar percentages of rumen propionate were increased significantly by monensin in the high-grain diet. Blood glucose pool sizes were not changed significantly by either monensin or isoenergetic diets. Monensin increased irreversible losses of glucose from 582 to 677 g/day for the high-grain diet. Monensin tended to increase glucose total entry rates for both diets and to increase irreversible loss of glucose for the high-roughage diet but the differences were not significant. Thus, increases in glucose kinetics are minor in contrast to major increases of rumen propionate production caused by monensin.

Rumen propionate and blood glucose kinetics in growing cattle fed isoenergetic diets.

The relationship between rumen propionate production and blood glucose kinetics was examined in four rumen-fistulated Holstein steers fed isoenergetic amounts of 80/20 (G) and 30/70 (R) grain/chopped alfalfa hay diets at 2-hour intervals. Single-injection rumen propionate and blood glucose kinetics were determined in consecutive 4-hour periods by using [6-3H]glucose intravenously then [1-14C]propionate intraruminally. Rumen propionate specific activity was determined after isolation and quantitation by high-pressure liquid chromatography. Average rumen propionate production rates and pool sizes were 441 g/day and 32.0 g when diet R was fed but increased to 510 g/day (P less than 0.05) and 36.5 g (P less than 0.10), respectively, when diet G was fed. Propionate production as related to digestible energy (DE) intake, averaged 0.56 mole/Mcal DE for R and 0.64 mole/Mcal DE for G. Rumen propionate turnover times were similar for both diets. Despite differences in propionate availability, there were no significant dietary differences in glucose kinetic parameters. Average glucose pool sizes and irreversible losses were 27.0 g and 585 g/day for R and 27.0 g and 582 g/day for G.