A randomized trial of teriflunomide added to glatiramer acetate in relapsing multiple sclerosis

Background

Teriflunomide is a once-daily oral immunomodulator for the treatment of relapsing−remitting MS.

Objective

To evaluate the safety and tolerability of teriflunomide as add-on therapy to a stable dose of glatiramer acetate (GA) in patients with relapsing forms of MS (RMS).

Methods

Phase II, randomized, double-blind, add-on, placebo-controlled study. The primary objective was to assess safety and tolerability; secondary objectives were to evaluate effects of treatment on disease activity assessed by MRI and relapse.

Results

Patients with RMS on GA (N = 123) were randomized 1:1:1 to receive teriflunomide 14 mg (n = 40), 7 mg (n = 42), or placebo (n = 41) for 24 weeks; 96 patients entered the 24-week extension, remaining on original treatment allocation. Teriflunomide was well tolerated over 48 weeks. The frequency of adverse events (AEs) was low across all groups; 5 (12.2%), 3 (7.1%), and 2 (5.0%) patients in the 14 mg, 7 mg, and placebo groups, respectively, discontinued treatment due to AEs. Teriflunomide reduced the number of T1-Gd lesions vs placebo (14 mg: 46.6% relative reduction, p = 0.1931; 7 mg: 64.0%: relative reduction, p = 0.0306).

Conclusions

Teriflunomide added to stable-dose GA had acceptable safety and tolerability, and reduced some MRI markers of disease activity compared with GA alone.

NCT00475865 (core study); NCT00811395 (extension).

Diagnosing lung cancer in the 21st century: are we ready to meet the challenge of individualized care?

BACKGROUND

Histologic and molecular subtyping have become increasingly important as predictors of treatment benefit in lung cancer. The objective of the present study was to determine whether current diagnostic approaches provide adequate tissue to allow for individualized treatment decisions.

METHODS

Our retrospective cohort study of new lung cancer patients seen at an academic centre between July 2007 and June 2008 collected baseline demographic and diagnostic information, including mode of diagnosis, type of diagnostic material, and pathology diagnosis.

RESULTS

Of the 431 study patients, 20% had stage i or ii non-small-cell lung cancer (nsclc), 24% stage iii disease, and 39% stage iv nsclc. Three quarters of the small-cell lung cancer (sclc) cases were extensive stage. Diagnostically, 18% of patients had sclc; 30%, adenocarcinoma; 27%, squamous-cell cancer; 2%, large-cell carcinoma; 1%, bronchoalveolar carcinoma; 1%, mixed histology; 18%, nsclc not otherwise specified; 4%, other; and 2%, no pathology diagnosis. Surgical pathology material was available in 80% of cases, and cytology material alone in 20%. Surgical pathology material was more common in patients with early-stage than with advanced disease (89% for stages i and ii vs. 74% for stages iii and iv, p < 0.0001). The pathology report included ambiguous terms in 24% of cases: "consistent" (12%), "suspicious" (3%), "favour" (2%), "suggestive" (2%), "likely" (1%), "compatible" with malignancy (1%), "at least" (1%), "atypical" (0.5%), and "no pathology" (1.5%).

CONCLUSIONS

Current diagnostic approaches in most lung cancer patients appear adequate, but complete histopathologic identification is missing in nearly 20% of cases, and some uncertainty as to the final diagnosis is expressed in 24% of pathology reports. Some improvement in diagnostic sampling and pathology reporting are required to allow for implementation of current treatment approaches.

A theory led narrative review of one-to-one health interventions: the influence of attachment style and client-provider relationship on client adherence

A theory-led narrative approach was used to unpack the complexities of the factors that enable successful client adherence following one-to-one health interventions. Understanding this could prepare the provider to anticipate different adherence behaviours by clients, allowing them to tailor their interventions to increase the likelihood of adherence. The review was done in two stages. A theoretical formulation was proposed to explore factors which influence the effectiveness of one-to-one interventions to result in client adherence. The second stage tested this theory using a narrative synthesis approach. Eleven studies across the health care arena were included in the synthesis and explored the interplay between client attachment style, client-provider interaction and client adherence with health interventions. It emerged that adherence results substantially because of the relationship that the client has with the provider, which is amplified or diminished by the client's own attachment style. This occurs because the client's attachment style shapes how they perceive and behave in relationships with the health-care providers, who become the 'secure base' from which the client accepts, assimilates and adheres with the recommended health intervention. The pathway from one-to-one interventions to adherence is explained using moderated mediation and mediated moderation models.

Tumor factors predictive of response to hypofractionated radiotherapy in a randomized trial following breast conserving therapy

PURPOSE

To determine whether tumor grade, molecular subtype and hypoxia predict response to hypofractionated versus standard radiotherapy (RT) following breast-conserving surgery (BCS) for node-negative breast cancer in a randomized controlled trial (RCT).

PATIENTS AND METHODS

Formalin-fixed paraffin-embedded (FFPE) tumor blocks were available on 989 of 1234 patients enrolled in the Hypofractionation Whole Breast Irradiation (HWBI) Trial. A central pathology review and assessment of tumor grade using the Nottingham grading system was carried out. Tumors were classified by molecular subtype as luminal A, luminal B, HER2 enriched, basal-like or unclassified using a six-biomarker panel; ER, PR, HER-2, Ki67, CK5/6 and EGFR. Tumors were also classified as hypoxic based on the expression of HIF1α, CAIX or GLUT-1. The primary end point was local recurrence (LR).

RESULTS

Median follow-up was 12 years. In the multivariable Cox model, molecular subtype was the only factor predictive of LR, the 10-year cumulative incidence was 4.5% for luminal A and basal-like, 7.9% for luminal B and 16.9% for HER-2 enriched tumors (P < 0.01). Tumor grade, molecular subtype or hypoxia did not predict response to hypofractionation.

CONCLUSIONS

In women enrolled in the HWBI trial following BCS tumor molecular subtype predicted LR. However tumor grade, molecular subtype and hypoxia did not predict response to hypofractionation suggesting that patients with node-negative breast tumors of all grades and molecular subtypes may be safely treated with hypofractionated RT regimens.

The accuracy of magnetic resonance imaging (MRI) in detecting meniscal pathology

AIMS

The purpose of this study was to determine the accuracy of Magnetic Resonance Imaging (MRI) scanning in the detection of meniscal pathology in a district general hospital.

METHODS

We retrospectively analysed a single-surgeon series of 240 knee arthroscopic investigations for all indications. The arthroscopic reports included an outline diagram of the meniscus upon which the surgeon could record his operative findings. 112 of these patients had also had a recent MRI scan. We compared the MRI findings with the arthroscopy findings.

RESULTS

66 patients had a positive MRI scan. 64 of these were found to have a meniscal tear at surgery. 37 MRI scans were reported as "no tear", of which four were found to have a meniscal tear at surgery. Nine MRI scans were descriptive, e.g. "signal change, possible tear", or "tear cannot be ruled out." These tended to correspond with equivocal arthroscopic findings of "degeneration" or "fibrillation". In our series of 112 patients with meniscal pathology, MRI scanning was 90.5% sensitive, 89.5% specific and 90.1% accurate.

CONCLUSIONS

False positive MRI scans may lead to unnecessary surgery. Patients with negative MRI scans had a mean delay to surgery of 33 weeks compared to 18 weeks for patients with positive MRI scans. Patients with false negative MRI results may wait longer for their surgery. Two of the false negative MRI scan reports clearly showed meniscus tears, which were not identified by the reporting radiologist. In our series, the MRI scan itself was more accurate than the reporting. It is important to have an experienced musculoskeletal radiologist to minimise the number of missed meniscal tears. It is also important for the surgeon to review the MRI scan itself, as well as the report.

Canterbury Health, Ageing and Life Course (CHALICE) study: rationale, design and methodology

AIMS

New Zealand's ageing population threatens the financial sustainability of our current model of health service delivery. The Canterbury Health, Ageing and Life Course (CHALICE) study aims to develop a comprehensive and flexible database of important determinants of health to inform new models. This paper describes the design, methodology, and first 300 participants of CHALICE.

METHODS

Commencing August 2010, CHALICE is a multidisciplinary prospective random cohort study and biobank of 1,000 Canterbury adults aged 49-51 years at inception, stratified by self-identified Maori (n=200) and non-Maori (n=800) ethnicity. Assessment covers sociodemographic, physical, cognition, mental health, clinical history, family and social, cardiovascular, and lifestyle domains. Detailed follow-up assessment occurs every 5 years, with a brief postal follow-up assessment undertaken annually.

RESULTS

For the first 300 participants (44 Maori, 256 non-Maori), the participation rate is 63.7%. Overall, 53.3% of participants are female, 75.3% are living in married or de facto relationships, and 19.0% have university degrees. These sociodemographic profiles are comparable with the 2006 Census, Canterbury region, 50-54 years age group percentages (50.7%, 77.2%, and 14.3%, respectively).

CONCLUSIONS

CHALICE has been designed to provide quality data that will inform policy development and programme implementation across a broad spectrum of health indicators.

How much does international normalized ratio monitoring cost during oral anticoagulation with a vitamin K antagonist? A systematic review

Next-generation oral anticoagulants offer the potential for effective prevention and treatment of thrombosis without the need for repeated monitoring of the international normalized ratio (INR). This systematic review evaluated the costs associated with INR monitoring tests performed as part of the standard management of oral anticoagulation with vitamin K antagonists. Studies published in or after 1990 reporting the costs of INR monitoring were identified from bibliographic databases and manual searches of reference lists. Cost data were extracted and inflated to the year 2006 before purchasing power parity conversion to US dollars. A total of 29 studies reported the cost of one INR test, which was shown to range from $6.19 to $145.70. Cost estimates were based on various combinations of direct medical costs, such as healthcare contacts, equipment, laboratory tests, clerical costs (postage and stationery), telephone calls, quality control, training/education and patient transportation, and indirect costs, such as time lost from work. In conclusion, the cost of INR monitoring varied substantially between studies depending on the monitoring modality and setting, and the cost categories included. When selecting a published estimate, healthcare decision makers should ensure that the chosen estimate reflects local service provision as closely as possible.

Serious infections in British patients with systemic lupus erythematosus: hospitalisations and mortality

This retrospective study determined the prevalence and nature of hospitalisations secondary to infection, and examined the mortality from infection in our large British cohort of patients with systemic lupus erythematosus (SLE). Casenote and database information of 104 consecutive patients attending the UCLH specialised SLE clinic were reviewed for the number of hospitalisations due to infection and the clinical and serological features of affected patients. Cohort mortality data were examined to identify deaths secondary to infectious diseases. Infection serious enough to result in hospitalisation occurred in 15% of the patients in the selected sample of our whole cohort. Six patients had more than one admission due to infection, with pneumonia being the most frequent. Typical bacterial pathogens were most commonly identified. A significant association between admissions for infection and nephritis ( P < 0.05 by Chi-square) was identified; however, the use of high dose prednisolone or other immunosuppressants did not increase the risk for infection requiring hospitalisation ( P > 0.5 by Chi-square) in our study. Between 1978 and 2007, 17 of 67 (25%) deaths in our SLE cohort of 470 patients were because of infection. Patients who died from infectious causes were more likely to have existing or previous renal disease than those who died from non-infectious causes ( P < 0.01 by Chi-square). The majority who died from infection were on high dose prednisolone plus at least one other immunosuppressive agent and had serologically active disease. The study highlights the significant problem of infection in British patients with SLE. Early recognition and treatment of infectious diseases in these patients together with considered use of immunosuppressant medications and vaccinations may help to reduce the impact of these complications.

Diabetes mellitus complicating systemic lupus erythematosus – analysis of the UCL lupus cohort and review of the literature

Systemic lupus erythematosus (SLE) often coexists with other diseases. Diabetes mellitus (DM) is an example and patients with overlap SLE-DM can present with clinical features common to both disorders. In this review, we describe the patients with overlap SLE-DM, focussing on the clinical features common to both diseases that these patients can present, and on the challenges of managing such complications. A detailed review of the patients’ notes ( n = 485) was performed. At every outpatient appointment the patients’ urine was tested for glucose, protein and blood. Patients with persistent glycosuria were investigated with fasting blood glucose and a glucose tolerance test to help make the diagnosis of DM. Particular note was made of those patients whose symptoms could be due to SLE, DM or both. Nine patients with DM were identified. Three had type 1 DM, four had type 2 DM and two were considered to have steroid-induced DM. Among these patients, three had renal involvement (two with WHO class IV lupus nephritis); two had peripheral neuropathy (one had a mixed sensory and motor neuropathy, one had a sensory peripheral neuropathy); two patients had retinopathy and cataracts and one had angina. The combination of SLE and DM is uncommon but the predisposition to renal, peripheral neuropathy and retinal disease means that great care must be taken when deciding which clinical feature is due to which disease, because active SLE requires additional immunosuppression whereas DM requires optimization of the metabolic control. Interestingly, although in theory patients with SLE and DM are in double-jeopardy of developing atherosclerosis, to date, only one of our overlap patients has developed angina.

Factors influencing adherence to medications in a group of patients with systemic lupus erythematosus in Jamaica

The objective of this study was to examine the factors influencing adherence to medications in a group of patients with systemic lupus erythematosus (SLE) in Jamaica. A qualitative study was designed using a screening questionnaire and semi-structured interviews. The study was conducted in the rheumatology clinic at the University Hospital of the West Indies, Kingston, Jamaica. 75 patients with SLE including 20 interviewees, who had SLE for at least 1 year participated in the study. The main outcome measures were: (i) level of self-reported adherence in a sample of the clinic attendees and (ii) interviewees explanations of the reasons for taking or not taking drugs as prescribed by their physician. 56% of the 75 study participants reported taking their medications more than 85% of the time. High cost and poor availability of medications were the main reasons for poor adherence, but some patients chose not to take their medications because of side effects, perceived mild severity of their disease and/or a preference to take drugs only when symptomatic. Patients used herbal medicines to counteract side effects of Western medicines, to ‘purge the blood’ and to manage lupus symptoms when they had no medications. Religious beliefs were used as a coping strategy. Traditional use of herbal medicines is common particularly in patients from rural Jamaica, and may explain the observed use of herbal medicines in those who have emigrated to developed countries. Socio-economic constraints and poor drug availability are particularly important influences on poor adherence in Jamaican patients with SLE. Religious beliefs and use of herbal remedies do not seem to affect adherence adversely but are used when drugs cannot be obtained.

Gerard Manley Hopkins and the kinesthetics of conviction

This essay explores the link in Gerard Manley Hopkins's imagination between sensations of the body and the changing textures of intensity that characterize experiences of the mind. I argue that one of the first functions of Hopkins's stylistic experiments in The Wreck of the Deutschland and later poems is to call attention to the ways in which our experiences of knowing, reasoning, and believing have parallels in bodily sensations. Hopkins's manipulations of the kinesthetic properties of language - especially the capacity of syntax to evoke sensations of pressure, balance, momentum, and tension - are directed toward a mimesis of consciousness, in which the poet strives to represent the feeling in the mind as it cranes toward an insight or relishes the renewal of conviction.

Acute lead poisoning associated with backyard lead smelting in Jamaica

Long-term backyard smelting of lead in a district known as Mona Commons, Kingston, Jamaica, has produced lead burdens as high as 30 000 mg/kg in soils near to the smelter, and indoor dust loadings of 373 microg/f2 in the residents' home. The blood lead levels (BPb) of 107 children from the district were in the range 2.2-202 microg/dL. Fifty-nine per cent of these had BPb levels above 10 microg/dL and the population mean was an unacceptably high 25.1 microg/dL. The highest levels were observed for five siblings, two of whom presented with lead encephalopathy. This severe chronic exposure to lead was exacerbated by a significant history of pica, and chronic nutritional anaemia. Chelation therapy significantly reduced the BPb levels but due to lead storage in other organs, the values after several months were still higher than desirable. This study emphasizes the importance of reducing the exposure of children to lead.