Review article: consensus statements on therapeutic drug monitoring of anti-tumour necrosis factor therapy in inflammatory bowel diseases

BACKGROUND

Therapeutic drug monitoring (TDM) in inflammatory bowel disease (IBD) patients receiving anti-tumour necrosis factor (TNF) agents can help optimise outcomes. Consensus statements based on current evidence will help the development of treatment guidelines.

AIM

To develop evidence-based consensus statements for TDM-guided anti-TNF therapy in IBD.

METHODS

A committee of 25 Australian and international experts was assembled. The initial draft statements were produced following a systematic literature search. A modified Delphi technique was used with 3 iterations. Statements were modified according to anonymous voting and feedback at each iteration. Statements with 80% agreement without or with minor reservation were accepted.

RESULTS

22/24 statements met criteria for consensus. For anti-TNF agents, TDM should be performed upon treatment failure, following successful induction, when contemplating a drug holiday and periodically in clinical remission only when results would change management. To achieve clinical remission in luminal IBD, infliximab and adalimumab trough concentrations in the range of 3-8 and 5-12 μg/mL, respectively, were deemed appropriate. The range may differ for different disease phenotypes or treatment endpoints-such as fistulising disease or to achieve mucosal healing. In treatment failure, TDM may identify mechanisms to guide subsequent decision-making. In stable clinical response, TDM-guided dosing may avoid future relapse. Data indicate drug-tolerant anti-drug antibody assays do not offer an advantage over drug-sensitive assays. Further data are required prior to recommending TDM for non-anti-TNF biological agents.

CONCLUSION

Consensus statements support the role of TDM in optimising anti-TNF agents to treat IBD, especially in situations of treatment failure.

Effectiveness and Impact of the Walking Bleach Technique on Esthetic Self-perception and Psychosocial Factors: A Randomized Double-blind Clinical Trial

OBJECTIVE

This trial evaluates the impact of psychosocial and esthetic self-perceptions of patients undergoing nonvital tooth bleaching using the walking bleach technique. We also assessed the clinical effectiveness of bleaching tooth discoloration.

METHODS

Fifty volunteers with nonvital tooth discoloration were enrolled. Teeth were randomized into two groups: 35% hydrogen peroxide (n=25) and 37% carbamide peroxide (n=25). Intracoronal bleaching was performed over four sessions using the walking bleach technique. Tooth color was evaluated at each session to measure total color variation. The shade guide was arranged from highest (B1) to lowest (C4) values to assess the color and calculate the color change in the number of shade guide units. Subjective and objective assessments were compared with the tooth counterpart. Esthetic self-perception and psychosocial factors were assessed before and after treatment.

RESULTS

Color change was 15.48<5.17 for hydrogen peroxide and 14.02<4.85 for carbamide peroxide. There was no significant difference at any time point (p>0.05) except at sessions 3 and 4 (p<0.05). Overall, whitened teeth values were similar to those of counterpart teeth (p>0.05). There was a decrease in Oral Health Impact Profile and Psychosocial Impact of Dental Esthetics questionnaire scores after treatment compared with baseline (p<0.05).

CONCLUSION

The walking bleach technique was highly effective on nonvital teeth and had a positive effect on self-esthetic perception and psychological impact for the patients.

Investigating the genetic underpinnings of early-life irritability

Severe irritability is one of the commonest reasons prompting referral to mental health services. It is frequently seen in neurodevelopmental disorders that manifest early in development, especially attention-deficit/hyperactivity disorder (ADHD). However, irritability can also be conceptualized as a mood problem because of its links with anxiety/depressive disorders; notably DSM-5 currently classifies severe, childhood-onset irritability as a mood disorder. Investigations into the genetic nature of irritability are lacking although twin studies suggest it shares genetic risks with both ADHD and depression. We investigated the genetic underpinnings of irritability using a molecular genetic approach, testing the hypothesis that early irritability (in childhood/adolescence) is associated with genetic risk for ADHD, as indexed by polygenic risk scores (PRS). As a secondary aim we investigated associations between irritability and PRS for major depressive disorder (MDD). Three UK samples were utilized: two longitudinal population-based cohorts with irritability data from childhood (7 years) to adolescence (15-16 years), and one ADHD patient sample (6-18 years). Irritability was defined using parent reports. PRS were derived from large genome-wide association meta-analyses. We observed associations between ADHD PRS and early irritability in our clinical ADHD sample and one of the population samples. This suggests that early irritability traits share genetic risk with ADHD in the general population and are a marker of higher genetic loading in individuals with an ADHD diagnosis. Associations with MDD PRS were not observed. This suggests that early-onset irritability could be conceptualized as a neurodevelopmental difficulty, behaving more like disorders such as ADHD than mood disorders.

Regulatory experience of TOPS: an internet-based system to prevent healthy subjects from over-volunteering for UK clinical trials

PURPOSE

The aim was to review the use of The Over-volunteering Prevention System (TOPS) since the HRA began hosting it in 2013, and the Medicines and Healthcare products Regulatory Agency (MHRA) experience of monitoring its use by UK clinical research units.

METHODS

The HRA searched the TOPS database for the number, type and location of units and the number of entries. The MHRA inspectors reviewed their findings from routine inspections.

RESULTS

Twenty-two additional UK units registered to use TOPS during 2013-2016, making a total of 84 units since TOPS was established in 2002. Use of TOPS is now a condition of research ethics committee approval of a phase 1 study and fulfils MHRA accreditation requirements for preventing over-volunteering. The total number of entries by all active units during 2013-2016 was 89,335, of which 84% were UK citizens and 16% non-UK citizens. The total number of entries during 2002-2016 was 249,612. Only 15 of 24,531 subjects (1/1600) and 18 of 18,745 subjects (1/1040) entered in 2015 and 2016, respectively, were deemed potential over-volunteers.

CONCLUSIONS

The findings continue to support the concept that TOPS not only helps to prevent over-volunteering, but also deters subjects from trying to do so. Regulation of TOPS by the HRA and MHRA has enhanced its effectiveness, benefited all users and helped to improve the safety of volunteers who participate in non-therapeutic trials in the UK. The UK is still the only country with a national database to prevent over-volunteering that has published data on its widespread use and effectiveness.

The Deposition and Accumulation of Microplastics in Marine Sediments and Bottom Water from the Irish Continental Shelf

Microplastics are widely dispersed throughout the marine environment. An understanding of the distribution and accumulation of this form of pollution is crucial for gauging environmental risk. Presented here is the first record of plastic contamination, in the 5 mm-250 μm size range, of Irish continental shelf sediments. Sixty-two microplastics were recovered from 10 of 11 stations using box cores. 97% of recovered microplastics were found to reside shallower than 2.5 cm sediment depth, with the area of highest microplastic concentration being the water-sediment interface and top 0.5 cm of sediments (66%). Microplastics were not found deeper than 3.5 ± 0.5 cm. These findings demonstrate that microplastic contamination is ubiquitous within superficial sediments and bottom water along the western Irish continental shelf. Results highlight that cores need to be at least 4-5 cm deep to quantify the standing stock of microplastics within marine sediments. All recovered microplastics were classified as secondary microplastics as they appear to be remnants of larger items; fibres being the principal form of microplastic pollution (85%), followed by broken fragments (15%). The range of polymer types, colours and physical forms recovered suggests a variety of sources. Further research is needed to understand the mechanisms influencing microplastic transport, deposition, resuspension and subsequent interactions with biota.

Lessons learned from a pilot study of an Indigenous patient navigator intervention in Queensland, Australia

Indigenous patient navigator (IPN) programmes show promise in addressing barriers to cancer care and facilitation of patient self-efficacy. The purpose of this paper is to describe and reflect upon the experience of training an IPN and implementation of the intervention in the Australian context with Indigenous cancer patients. Randomised clinical trial might provide the best available evaluation measure of an intervention but caution should be taken in the implementation process. Socio-cultural aspects and training can affect the conduct of this type of intervention. We report here five issues needing consideration prior to implementing such intervention. Specifically: (1) recognition of the collective bonds within Indigenous community and understanding by IPN of the degree of personal assistance perceived as not intrusive by the patient; (2) conduct ongoing evaluation of the different role of an IPN involved in this intervention care provider vs. researcher. (3) meaningful engagement develops from a trusting/collaborative relationship between research team and study site staff which may not occur in the study time frame; (4) existing skills as well as training provided may not translate in the IPN understanding and aligning with the study objectives/research values; (5) recruitment of participants requires innovative and highly flexible strategies to be successful.

Scaling Theory of the Anderson Transition in Random Graphs: Ergodicity and Universality

We study the Anderson transition on a generic model of random graphs with a tunable branching parameter 1<K<2, through large scale numerical simulations and finite-size scaling analysis. We find that a single transition separates a localized phase from an unusual delocalized phase that is ergodic at large scales but strongly nonergodic at smaller scales. In the critical regime, multifractal wave functions are located on a few branches of the graph. Different scaling laws apply on both sides of the transition: a scaling with the linear size of the system on the localized side, and an unusual volumic scaling on the delocalized side. The critical scalings and exponents are independent of the branching parameter, which strongly supports the universality of our results.

Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study

BACKGROUND

Project Re-Engineered Discharge (RED) is an evidence-based strategy to reduce readmissions disseminated and adapted by various health systems across the country. To date, little is known about how adapting Project RED from its original protocol impacts RED implementation and/or sustainability. The goal of this study was to identify and characterize contextual factors influencing how five California hospitals adapted and implemented RED and the subsequent impact on RED program sustainability.

METHODS

Participant observation and key informant and focus group interviews with 64 individuals at five California hospitals implementing RED in 2012 and 2013 were conducted. These involved hospital leadership, personnel responsible for Project RED implementation, hospital staff, and clinicians. Interview transcripts were coded and analyzed using a modified grounded theory approach and constant comparative analysis.

RESULTS

Both internal and external contextual factors were identified that influenced hospitals' decisions on RED adaptation and implementation. These also impacted RED sustainability. External factors included: impending federal penalties for hospitals with high readmission rates targeting specific diagnoses, and access to external funding and technical support to help hospitals implement RED. Internal or organizational level contextual factors included: committed leadership prioritizing Project RED; RED adaptations; depth, accountability and influence of the implementation team; sustainability planning; and hospital culture. Only three of the five hospitals continued Project RED beyond the implementation period.

CONCLUSIONS

The sustainability of RED in participating hospitals was only possible when hospitals approached RED implementation as a transformational process rather than a patient safety project, maintained a high level of fidelity to the RED protocol, and had leadership and an implementation team who embraced change and failure in the pursuit of better patient care and outcomes. Hospitals who were unsuccessful in implementing a sustainable RED process lacked all or most of these components in their approach.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Social Network Mapping with Transplant Recipients

Social support can have great influence on health, well-being, and general quality of life To promote awareness of the social network that surrounds each transplant recipient, transplant social workers are now using the Social Network Map as an intervention. Because perceptions of availability and accessibility of support are key elements in the use of social network resources, awakening an individual's awareness of available resources is a significant first step in enhancing social support and, ultimately, quality of life. The Social Network Map is used to establish dialogue regarding individuals' needs and sources of support, and then how the support system can meet those needs. Transplant social workers thus foster active use of those people in transplant recipients' networks who can meet the particular needs recipients identify.

Radiation delivered to patients during endourological surgery – are they overexposed?

Introduction:

Ionising radiation is commonly used in urological practice in the form of fluoroscopy. To date there is a remarkable scarcity of information concerning patient exposure to ionising radiation during urological procedures and the potential risk of developing of a lethal malignancy due to excessive radiation exposure.

Objectives:

We aimed to determine the radiation exposure for a patient during the most commonly performed urological procedures, and to assess the potential risk of developing a fatal cancer as a result of endourological fluoroscopy.

Methods:

Data was collected prospectively in two institutions on endoscopic urological operations. Procedures were classified as retrographic, semi-rigid ureteroscopic and flexible ureterorenoscopic (FURS). Data collected included procedure type and difficulty, Dose Area Product [DAP (Gy*Cm2)]. The effective dose (ED) measured in millisievert (mSv) was determined from the DAP by using the Monte Carlo calculation.

Results:

In total 395 consecutive operations from two institutions were assessed. The mean ED for all procedures in this study was 0.394 mSv, IQR (0.1184–0.7583). The maximum ED was 5.93 mSv. The radiation exposure for all procedures was relatively small; for diagnostic retrographic procedures the median ED was 0.112 mSv. For retrograde procedures that involved stent insertion, the median ED was 0.438 mSv. The median ED for all ureteroscopic surgeries was 0.295 mSv, and the median ED for all FURS procedures was 0.491.

Conclusion:

The findings of this study are reassuring. Endoscopic urological procedures appear to expose patients to relatively small radiation compared with other procedures requiring fluoroscopy, thus conferring a very low lifetime risk of malignancy.

Comparing surgical trays with redundant instruments with trays with reduced instruments: a cost analysis

BACKGROUND

When prearranged standard surgical trays contain instruments that are repeatedly unused, the redundancy can result in unnecessary health care costs. Our objective was to estimate potential savings by performing an economic evaluation comparing the cost of surgical trays with redundant instruments with surgical trays with reduced instruments ("reduced trays").

METHODS

We performed a cost-analysis from the hospital perspective over a 1-year period. Using a mathematical model, we compared the direct costs of trays containing redundant instruments to reduced trays for 5 otolaryngology procedures. We incorporated data from several sources including local hospital data on surgical volume, the number of instruments on redundant and reduced trays, wages of personnel and time required to pack instruments. From the literature, we incorporated instrument depreciation costs and the time required to decontaminate an instrument. We performed 1-way sensitivity analyses on all variables, including surgical volume. Costs were estimated in 2013 Canadian dollars.

RESULTS

The cost of redundant trays was $21 806 and the cost of reduced trays was $8803, for a 1-year cost saving of $13 003. In sensitivity analyses, cost savings ranged from $3262 to $21 395, based on the surgical volume at the institution. Variation in surgical volume resulted in a wider range of estimates, with a minimum of $3253 for low-volume to a maximum of $52 012 for high-volume institutions.

INTERPRETATION

Our study suggests moderate savings may be achieved by reducing surgical tray redundancy and, if applied to other surgical specialties, may result in savings to Canadian health care systems.

Dengue vaccine: an update on recombinant subunit strategies

Dengue is an increasing public health problem worldwide, with the four serotypes of the virus infecting over 390 million people annually. There is no specific treatment or antiviral drug for dengue, and prevention is largely limited to controlling the mosquito vectors or disrupting the human-vector contact. Despite the considerable progress made in recent years, an effective vaccine against the virus is not yet available. The development of a dengue vaccine has been hampered by many unique challenges, including the need to ensure the absence of vaccine-induced enhanced severity of disease. Recombinant protein subunit vaccines offer a safer alternative to other vaccine approaches. Several subunit vaccine candidates are presently under development, based on different structural and non-structural proteins of the virus. Novel adjuvants or immunopotentiating strategies are also being tested to improve their immunogenicity. This review summarizes the current status and development trends of subunit dengue vaccines.

Longitudinal Aneurysm Shrinkage following Endovascular Aortic Aneurysm Repair: A Source of Intermediate and Late Complications

Purpose:

To report the incidence of delayed complications following endovascular abdominal aortic aneurysm (AAA) repair and the relationship of these sequelae to morphological changes in the sac and endograft.

Methods:

Twenty-six AAA patients treated with Vanguard endografts had completed ≥1-year follow-up. Postoperative angiograms and spiral computed tomographic (CT) scans with 3-dimensional reconstruction were compared to the 1-year images to determine morphological changes in the aneurysm sac and the endograft. These changes were then related to complications occurring between 1 and 12 months postoperatively in the study group.

Results:

Comparison of angiograms uncovered endograft buckling in 18 (69%) patients and acutely angled or kinked endografts in 10 (38%). Measurements from the CT scans found that undistorted endografts had a mean change in sac length of +6.6 mm. Mean sac length change in buckled endografts was −3.1 mm, while kinked endografts displayed a mean change of −6.2 mm (p < 0.002, Student's t-test). Five (19%) patients, all with distorted endografts, demonstrated late (1 to 12 months) complications (4 endoleaks and 1 graft limb thrombosis) owing to component separation, distal stent migration, and acute angulation. No movement in the proximal stent was observed. Elongation of the endograft (flow line measurement) was observed in one tube graft only.

Conclusions:

In this study, longitudinal shrinkage of the sac following endovascular aortic aneurysm repair led to buckling or kinking of the endograft within 1 year in 69% of patients. This appears to be an important source of delayed complications.

Inexperienced examiners and the Foot Posture Index: A reliability study

The Foot Posture Index (FPI-6) is a reliable (experienced examiners) assessment tool used in clinical practice to classify foot posture. No work has been completed to determine the reliability of the FPI-6 between novice examiners. Therefore, the aim was to determine the inter-examiner reliability of the FPI-6 using two novice examiners (graduate level osteopathy students). The FPI-6 was used to classify the feet of 83 students recruited as part of a larger study. Data were collected simultaneously by both examiners, but there was no communication between them. The scoring system provided by the FPI-6 manual was used to assess all feet. Collated data were assessed between examiners for reliability based on raw, transformed and foot type scores. The inter-examiner reliability was high for both left (intra-class correlation coefficient ICC_2,1 = 0.86) and right (ICC_2,1 = 0.85) feet for the novice examiners. When data were assessed based on foot type classification the examiners agreed on 76% of the left feet and 82% of the right feet with Kappa values of 0.73 and 0.72 respectively. The FPI-6 is a robust clinical tool that can be reliably utilised by inexperienced clinicians.