Efficacy and safety of certolizumab pegol for Crohn's disease in clinical practice

BACKGROUND

Certolizumab pegol (CZP) is Food and Drug Administration (FDA)-approved to treat Crohn's disease (CD). However, the efficacy and safety of CZP outside clinical trials are not well established.

AIM

To report the efficacy, safety and predictors of response to CZP in CD patients treated during a 6-year period since FDA-approval at a tertiary care centre.

METHODS

All CD patients who received CZP at our institution between 2008 and 2013 were evaluated through retrospective medical record-based review of steroid-free complete response (SCR), loss of response and safety.

RESULTS

A total of 358 patients were included. One hundred twelve patients (31.3%) and 189 (52.8%) received CZP as their second and third biological agent, respectively. The probability of SCR at 26 week was 19.9% (95% CI, 15.9-24.5). The probability of survival free of loss of response at 2 year was 45.7% (95% CI, 32.5-59.5). A predictor of SCR was age at CD diagnosis of >40 years old (hazard ratio, HR relative to those <17, 4.69; 95% CI, 1.75-12.61). Negative predictors included present perianal fistula (HR, 0.39; 95% CI, 0.16-0.98) and prior primary nonresponse to adalimumab (ADA; HR relative to secondary loss of response, 0.18; 95% CI, 0.04-0.76). Twenty-three patients (6.4%) experienced serious adverse events and 19 patients (5.3%) discontinued CZP due to adverse events.

CONCLUSIONS

Certolizumab pegol was both effective and well tolerated for the treatment of Crohn's disease in this large tertiary care centre enriched with biologics-exposed patients. It may be more effective in patients without early-aged Crohn's disease diagnosis, prior primary nonresponse to adalimumab and present perianal fistula.

A tale of two city blocks: differences in immature and adult mosquito abundances between socioeconomically different urban blocks in Baltimore (Maryland, USA)

Infrastructure degradation in many post-industrial cities has increased the availability of potential mosquito habitats, including container habitats that support infestations of invasive disease-vectors. This study is unique in examining both immature and adult mosquito abundance across the fine-scale variability in socio-economic condition that occurs block-to-block in many cities. We hypothesized that abundant garbage associated with infrastructure degradation would support greater mosquito production but instead, found more mosquito larvae and host-seeking adults (86%) in parcels across the higher socio-economic, low-decay block. Aedes albopictus and Culex pipiens were 5.61 (p < 0.001) and 4.60 (p = 0.001) times more abundant, respectively. Most discarded (garbage) containers were dry during peak mosquito production, which occurred during the 5th hottest July on record. Containers associated with human residence were more likely to hold water and contain immature mosquitoes. We propose that mosquito production switches from rain-fed unmanaged containers early in the season to container habitats that are purposefully shaded or watered by mid-season. This study suggests that residents living in higher socioeconomic areas with low urban decay may be at greater risk of mosquito-borne disease during peak mosquito production when local container habitats are effectively decoupled from environmental constraints.

Potential trends in Attention Deficit Hyperactivity Disorder (ADHD) drug use on a college campus: wastewater analysis of amphetamine and ritalinic acid

Attention Deficit Hyperactivity Disorder (ADHD) medication use is on the rise in the United States. The most widely used ADHD medications are the amphetamine-type compounds Adderall (mixed amphetamine salts) and Ritalin (methylphenidate). According to survey data ADHD medications are used as a study drug or "Smart Drug" by students without a prescription on college campuses. Survey data of non-prescribed drug use has limitations with accurate reporting and no empirical data of usage exists in the literature. This study looks for trends in the use of these drugs on a college campus among low-stress and high stress periods. The metabolites of these two drugs, amphetamine and ritalinic acid, are quantified in campus wastewater using solid phase extraction (SPE) and liquid chromatography-tandem mass spectrometry (LC-MS/MS). Trends show a possible increase in amphetamine levels during periods of high stress such as midterms, the last week of classes and finals week over levels from the baseline low stress weeks such as the first week of classes. Both semesters from the 2011-12 academic year were studied and the highest increase over baseline (760%) occurred during finals week of the second semester. Ritalinic acid levels gradually climbed first semester but had no obvious periodic trend second semester.

Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation

Obese patients with end-stage renal disease (ESRD) are often excluded from kidney transplantation due to concerns about surgical site infections. To reduce infections, we developed a robotic kidney transplantation method for obese recipients. From June 2009-December 2011, a prospective cohort of 39 obese patients underwent robotic kidney transplantation at a single center. The outcomes of patients with at least six months of follow-up (n=28) were compared to a frequency-matched retrospective cohort of obese patients who underwent open kidney transplantation from 2004-2009 (n=28). The 28 robotic patients were predominately African-American (46.4%) or Hispanic (35.7%), with a mean age of 47.9±10.7 years, similar to the control group. BMI in the robotic group was 42.6±7.8 kg/m2 compared to 38.1±5.4 kg/m2 in the control group (p=0.02). There were no surgical site infections in the robotic group (0/28), while 28.6% (8/28) in the control group developed an infection (p=0.004). Six-month creatinine (1.5±0.4 vs.1.6±0.6 mg/dL; p=0.47), and patient and graft survival (100%) were comparable between the two groups. Outcomes following robotic surgery compared favorably to conventional transplantation. Robotic surgery may therefore enable obese patients with ESRD to access kidney transplantation and may thereby reduce health disparities in groups with a high prevalence of obesity and ESRD.

Natalizumab for moderate to severe Crohn's disease in clinical practice: the Mayo Clinic Rochester experience

BACKGROUND

Not all patients with Crohn's disease (CD) respond or maintain response to anti-tumor necrosis factor (TNF) agents and alternative treatment is necessary. Natalizumab, a monoclonal antibody to alpha-4 integrin approved for CD, has demonstrated efficacy in randomized clinical trials. We describe our experience with natalizumab in clinical practice at Mayo Clinic Rochester.

METHODS

Consecutive patients prescribed natalizumab for active CD were invited to participate and were followed prospectively. Incidence of infection, hospitalization, neoplasm, or other adverse events were recorded. Clinical activity was assessed using the Harvey-Bradshaw Index at each 30-day infusion visit.

RESULTS

Between April 2008 and September 2010, 36 patients were prescribed natalizumab and 30 (83.3%) agreed to participate. Median disease duration was 9 years (range, 3-43). Twenty-three patients had prior exposure to two anti-TNF agents, seven to one agent. All patients experienced at least one adverse event; none of the 13 patients in whom natalizumab was stopped (43%) discontinued due to adverse events. Five patients had infusions held for infection. No patient developed progressive multifocal leukoencephalopathy (PML). Fourteen patients (46%) had clinical response. The cumulative probability of achieving complete response within 1 year was 56% (28%-73%). Four of seven patients were weaned off corticosteroids.

CONCLUSIONS

In our experience with natalizumab in clinical practice, adverse events were manageable and did not result in treatment cessation. No PML cases were seen and clinical response was similar to that in clinical trials. Natalizumab results in clinical benefit in patients who have active disease and have failed anti-TNF therapy.

A complementary Doppler Broadening formalism and its impact on nuclear reactor simulation

The Boltzmann Transport equation is the governing formalism upon which simulations of nuclear reactors are performed, in particular when strong absorption or anisotropic scattering are significant. On the left (loss) hand side of the balance equation one finds the absorption and the scattering cross section Σa(E′), Σs(E′) respectively. Those cross sections are energy and temperature dependent i.e. Doppler Broadened. The scattering cross section appears explicitly again on the right (production) hand side of the equation in its differential form ∫∫0 ∞Σ(E → E′); Ω → Ω′)dE dΩ. However, this term is commonly evaluated at 0 K and it does not account for the existing resonances which are the underlying characteristic for Doppler Broadening. Evidently one gets an inherent inconsistency between the integral and differential scattering cross section within the transport solver codes. In this study this missing Doppler Broadened formalism for the differential scattering cross section is introduced in its stochastic and deterministic form. The impact on core criticality is shown to be up to 600 pcm and the change in the nuclides' inventory significant, in particular the 239PU content can be changed by several percents.

Midrapidity antiproton-to-proton ratio in pp collisons at sqrt[s]=0.9 and 7 TeV measured by the ALICE experiment

The ratio of the yields of antiprotons to protons in pp collisions has been measured by the ALICE experiment at sqrt[s]=0.9 and 7 TeV during the initial running periods of the Large Hadron Collider. The measurement covers the transverse momentum interval 0.45<p_{t}<1.05  GeV/c and rapidity |y|<0.5. The ratio is measured to be R_{|y|<0.5}=0.957±0.006(stat)±0.014(syst) at 0.9 TeV and R_{|y|<0.5}=0.991±0.005(stat)±0.014(syst) at 7 TeV and it is independent of both rapidity and transverse momentum. The results are consistent with the conventional model of baryon-number transport and set stringent limits on any additional contributions to baryon-number transfer over very large rapidity intervals in pp collisions.

[Problems in microbial safety of advanced therapy medicinal products. Squaring the circle]

Today, sterility of parenteral drugs is practically guaranteed. Well-defined procedures in the pharmaceutical industry enable effective protection against contamination by bacteria and fungi. In contrast, problems regarding microbial safety of advanced therapy medicinal products (ATMPs), especially of cell therapeutics, are at best only partially solved. The latter should be understood as a challenge for manufacturers, regulators, and physicians. Many of the manufacturing principles mentioned above are not applicable in production of cell therapeutics. Sterility of source materials cannot be guaranteed and the hitherto known procedures for sterilization are, as a rule, not feasible. Thus, the sterility of the final product cannot be guaranteed. Considering the extremely short shelf life of many cell therapeutics, sometimes only a few hours, the results from established methods for sterility testing are often available too late. Furthermore, the sterility of a test sample does not indicate sterility of the whole product. In most cases, conventional methods for pyrogen testing are not applicable for ATMPs. This paper demonstrates relevant limitations regarding microbial safety and pyrogenicity. Possibilities to overcome these problems are discussed and some novel solutions are proposed.

Evaluation of the safety of high-frequency chest wall oscillation (HFCWO) therapy in blunt thoracic trauma patients

BACKGROUND

Airway clearance is frequently needed by patients suffering from blunt chest wall trauma. High Frequency Chest Wall Oscillation (HFCWO) has been shown to be effective in helping to clear secretions from the lungs of patients with cystic fibrosis, bronchiectasis, asthma, primary ciliary dyskinesia, emphysema, COPD, and many others. Chest wall trauma patients are at increased risk for development of pulmonary complications related to airway clearance. These patients frequently have chest tubes, drains, catheters, etc. which could become dislodged during HFCWO. This prospective observational study was conducted to determine if HFCWO treatment, as provided by The Vesttrade mark Airway Clearance System (Hill-Rom, Saint Paul, MN), was safe and well tolerated by these patients.

METHODS

Twenty-five blunt thoracic trauma patients were entered into the study. These patients were consented. Each patient was prescribed 2, 15 minute HFCWO treatments per day using The Vest(R) Airway Clearance System (Hill-Rom, Inc., St Paul, MN). The Vest(R) system was set to a frequency of 10-12 Hz and a pressure of 2-3 (arbitrary unit). Physiological parameters were measured before, during, and after treatment. Patients were free to refuse or terminate a treatment early for any reason.

RESULTS

No chest tubes, lines, drains or catheters were dislodged as a result of treatment. One patient with flail chest had a chest tube placed after one treatment due to increasing serous effusion. No treatments were missed and continued without further incident. Post treatment survey showed 76% experienced mild or no pain and more productive cough. Thirty days after discharge there were no deaths or hospital re-admissions.

CONCLUSION

This study suggests that HFCWO treatment is safe for trauma patients with lung and chest wall injuries. These findings support further work to demonstrate the airway clearance benefits of HFCWO treatment.

Transcranial sonography findings in a large family with homozygous and heterozygous PINK1 mutations

OBJECTIVE

To investigate substantia nigra (SN) echogenicity in members of a family with homozygous and heterozygous PTEN induced kinase (PINK1) mutations with or without signs of Parkinson's disease (PD).

METHODS

Transcranial sonography (TCS) was used to investigate 20 members of a family with PINK1 mutations, including four homozygous and 11 heterozygous mutation carriers and five individuals with no mutation. For comparison, a healthy control group of 18 subjects without a positive family history of PD (control group) and a healthy control group of 15 subjects with a positive family history of sporadic PD (relative group) were investigated. For statistical analysis, the larger area of the two SNs echogenicity (aSNmax) of each individual was selected.

RESULTS

A significantly increased aSNmax was found for all subgroups compared with the control group. The group of homozygous carriers of a PINK1 mutation had a significantly increased aSNmax compared with all of the other subgroups, except the group of heterozygous mutation carriers.

CONCLUSIONS

These findings in carriers of a PINK1 mutation are comparable with those in carriers of Parkin mutations and non-genetic PD. The increased aSNmax in family members without a mutation suggests an additional contributing factor independent of the PINK1 mutation that may also play a role in relatives of patients with sporadic PD.

[Epidemiology of listeriosis in Germany: a changing but ignored pattern]

Listeriosis is emerging as a food-borne disease. Although the incidence of clinical presentations is low, this infectious disease with a rather poor prognosis deserves attention. Approximately 20-30% of patients with recognized listeriosis die in spite of an appropriate antibiotic regimen. In the last two years the number of registered cases of listeriosis in Germany has more than doubled. This increase is clearly due exclusively to the rising number of infections in elderly persons, while the number of infections in newborns has remained constant. Genotyping does not show a conclusive correlation between human and food isolates. Since the human isolates belong to numerous different clones. There is no specific food or group of food items that can be held responsible for the infections. This view is also supported by the fact that listeriosis cases occur sporadically and not in outbreaks, making it highly unlikely that industrially produced and widely distributed food items are the cause. Furthermore, even within the food isolates there is a large diversity of clones. A comprehensive explanation for the changes in the epidemiology of human listeriosis has yet to be given.

Oral graft vs. host disease in children--treatment with topical tacrolimus ointment

Oral chronic graft vs. host disease (GVHD) frequently presents in patients with sclerotic features of skin GVHD and is often associated with considerable limitations of oral food intake and decreased quality of life. Systemic tacrolimus is efficacious for prophylaxis and treatment of acute and chronic GVHD and topical tacrolimus has shown activity in chronic GVHD skin lesions. We therefore initiated a pilot study to investigate the safety and efficacy of topical tacrolimus ointment in children with oral GVHD. Six patients suffering from oral GVHD (five chronic and one acute) were included in the study. Tacrolimus ointment 0.1% was applied twice daily using sterile gauze. The only side-effects observed were a slight burning discomfort after the first application in one patient and after food intake in another patient. Tacrolimus was absorbed systemically in four of six patients. Of six patients, we observed a complete response in two, a very good partial response (VGPR) in two, and a PR in two patients, respectively. We conclude that topical application of tacrolimus ointment holds promise as a safe and efficacious treatment for oral GVHD in children. The Food and Drug Administration has recently issued a health advisory about a potential cancer risk associated with topical tacrolimus treatment of the skin; therefore, its benefits should be weighed against its potential risks and diligent long-term follow-up should be carried out especially in children.

Measures of dyspnea in patients with amyotrophic lateral sclerosis

Respiratory symptoms are not well characterized in amyotrophic lateral sclerosis (ALS). The baseline dyspnea index (BDI) and transition dyspnea index (TDI) are indices designed to measure change in dyspnea over time. They are easy to administer and do not inquire about specific physical tasks. The latter makes these scales particularly well suited for use in ALS. This study evaluated the ability of the BDI and TDI to measure dyspnea in 46 subjects with ALS. The BDI/TDI had excellent reproducibility. The TDI detected worsening dyspnea by 4 weeks and declined significantly more over the subsequent 8 weeks. The TDI was significantly associated with changes in forced vital capacity and appeared more sensitive to changes in dyspnea than the ALS functional rating scale-respiratory subscale (ALS-FRS R) and a visual analog scale of breathlessness. The BDI and TDI thus appear to be useful measures in ALS and may have both clinical and research applications.

High-frequency chest wall oscillation in ALS: An exploratory randomized, controlled trial

OBJECTIVES

To evaluate changes in respiratory function in patients with ALS after using high-frequency chest wall oscillation (HFCWO).

METHODS

This was a 12-week randomized, controlled trial of HFCWO in patients with probable or definite ALS, an Amyotrophic Lateral Sclerosis Functional Rating Scale respiratory subscale score < or = 11 and > or = 5, and forced vital capacity (FVC) > or = 40% predicted.

RESULTS

We enrolled 46 patients (58.0 +/- 9.8 years; 21 men, 25 women); 22 used HFCWO and 24 were untreated. Thirty-five completed the trial: 19 used HFCWO and 16 untreated. HFCWO users had less breathlessness (p = 0.021) and coughed more at night (p = 0.048) at 12 weeks compared to baseline. At 12 weeks, HFCWO users reported a decline in breathlessness (p = 0.048); nonusers reported more noise when breathing (p = 0.027). There were no significant differences in FVC change, peak expiratory flow, capnography, oxygen saturation, fatigue, or transitional dyspnea index. When patients with FVC between 40 and 70% predicted were analyzed, FVC showed a significant mean decrease in untreated patients but not in HFCWO patients; HFCWO patients had significantly less increased fatigue and breathlessness. Satisfaction with HFCWO was 79%.

CONCLUSION

High-frequency chest wall oscillation was well tolerated, considered helpful by a majority of patients, and decreased symptoms of breathlessness. In patients with impaired breathing, high-frequency chest wall oscillation decreased fatigue and showed a trend toward slowing the decline of forced vital capacity.

Cognitive dysfunction, brain-derived neurotrophic factor and IL-6 levels in cancer patients with depression

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Background: Increased proinflammatory cytokines (IL-6) and decreased brain-derived neurotrophic factor (BDNF) levels have been implicated in the pathophysiology of depression. Depression has been shown to be associated with cognitive dysfunction. The objective of this study was to assess the correlations between cognitive dysfunction, IL-6 and BDNF in cancer patients (pts) with depression. Methods: Depression was assessed in 55 patients with metastatic cancer by the Hospital Anxiety and Depression Scale (HADS) and diagnosis was established according to DSM-IV criteria. Cognitive function was assessed by the Auditory Verbal Learning Test (AVLT). Plasma concentrations of Interleukin-6 and BDNF were measured at 8 AM the same day. In the statistical analysis the Mann-Whitney test and the Pearson correlation were applied. Results: Pts characteristics (n=55): median age 60 y (25–85); 76.9% Females, 23.1% males. 52% of pts had depression. There were no significant differences in mean age or Karnofsky-index between pts with and without depression. Depression was associated with a significant higher median IL-6 level (14.8 vs. 3.7 pg/ml; p<0,001). For Cognitive function only the longterm memory was significantly reduced in depression (p=0.01). However, there was no difference in BDNF levels between both groups (p=0.164). There were correlations between HADS-D score and IL6 (r=4.11; p=0.002), IL-6 and BDNF (r= −0.42; p=0.001), BDNF and longterm memory (r=0.48; p=0.02). No correlations were found for level of depression (HADS-D score) and BDNF levels (r= −0.20; P=0.14). Conclusions: Depression and increased plasma IL-6 concentrations are strongly associated in pts with cancer. There seems to be no association between BDNF and depression in cancer pts. However there is a positive correlation between the cognitive function, at least for longterm memory, with BDNF.

No significant financial relationships to disclose.

Effect of high-frequency chest wall oscillation on the central and peripheral distribution of aerosolized diethylene triamine penta-acetic acid as compared to standard chest physiotherapy in cystic fibrosis

BACKGROUND AND OBJECTIVES

High-frequency chest wall oscillation (HFCWO) has been shown to be as effective as standard chest physiotherapy (SCPT) for removal of pulmonary secretions as well as increasing FEV(1) in cystic fibrosis (CF) patients. Patients using HFCWO often administer aerosolized medications simultaneously, reducing time required for daily care. While peripheral pulmonary distribution of tracer in normal subjects has been shown to be unaffected by HFCWO, this has not been studied in CF patients. We evaluated distribution of aerosolized (99m)Tc diethylene triamine penta-acetic acid (DTPA) administered simultaneously with HFCWO and compared this with DTPA aerosolized after SCPT.

STUDY DESIGN

Ten CF patients, ages 22 to 38 years, with moderate-to-severe obstructive disease were studied in a crossover design after documentation of stable lung function. (133)Xe was administered to delineate total lung volume. DTPA was aerosolized (Pari LC Plus nebulizer and Pulmo-Aide compressor; Pari Respiratory Equipment Inc.; Richmond, VA) to delineate airway deposition. The central to peripheral deposition ratio (C/P ratio) of each lung was analyzed in each study group. Central regions were represented by the inner one third of the (133)Xe scan as demonstrated in previous research models.

RESULTS

The mean C/P ratio (+/- SD) for both lungs was 1.45 +/- 0.31 with HFCWO and 1.46 +/- 0.28 following SCPT (p = not significant [NS]). Right lung mean C/P ratio was 1.74 +/- 0.43 with HFCWO and 1.85 +/- 0.63 after SCPT (p = NS). Left lung mean C/P ratio was 1.25 +/- 0.29 with HFCWO and 1.21 +/- 0.35 after SCPT (p = NS). There was no correlation between C/P ratio and FEV(1) or FVC.

CONCLUSIONS

Use of HFCWO in combination with aerosolized DTPA did not result in increased central deposition as compared with aerosolized DTPA administered after SCPT. Further study is required to determine if combining HFCWO with aerosolized medications can be modified to improve peripheral deposition.