Long-term drug survival of biological agents in patients with rheumatoid arthritis in clinical practice

OBJECTIVES

To assess and compare the long-term drug survival (time to drug discontinuation) of biological agents (BA) in patients with rheumatoid arthritis (RA) in clinical practice. Factors associated with discontinuation of BAs were also investigated.

METHOD

We conducted an observational longitudinal study of RA patients taking BAs from 1999 to 2013. The primary endpoint was BA discontinuation due to: adverse drug reactions (ADRs), inefficacy, and other causes. Incidence rates of discontinuation (IRs) per 100 patient-years were estimated using survival techniques. Comparisons between BA discontinuation rates and other associated factors were made using Cox regression models.

RESULTS

We included 851 courses of BA therapy (1869 patient-years). Adalimumab (33%) was the BA most frequently used, followed by etanercept (24.4%), infliximab, and rituximab. Treatment was suspended in 558 cases [IR 29.8, 95% confidence interval (CI) 27-32]. In the first year of therapy 68% continued on BAs, and after 10 years the retention rate did not exceed 10%. The IR due to inefficacy was 12.1 (95% CI 10.6-13.8) and the IR of ADRs was 13.6 (95% CI 12-15). The unadjusted IR was higher for rituximab than for tumour necrosis factor (TNF) antagonists. In multivariate analysis, infliximab was the BA with the highest risk of discontinuation, compared to adalimumab. Calendar period, taking subsequent courses of BAs, concomitant therapy, and specific comorbidities were also independent factors associated with discontinuation.

CONCLUSIONS

After several years of BA treatment in clinical practice, the survival rate was low, mainly as a result of ADRs and inefficacy. We also found differences between the discontinuation rates of BAs and other clinical factors that modify their survival.

A novel methodology for personalized simulations of ventricular hemodynamics from noninvasive imaging data

Current state-of-the-art imaging techniques can provide quantitative information to characterize ventricular function within the limits of the spatiotemporal resolution achievable in a realistic acquisition time. These imaging data can be used to personalize computer models, which in turn can help treatment planning by quantifying biomarkers that cannot be directly imaged, such as flow energy, shear stress and pressure gradients. To date, computer models have typically relied on invasive pressure measurements to be made patient-specific. When these data are not available, the scope and validity of the models are limited. To address this problem, we propose a new methodology for modeling patient-specific hemodynamics based exclusively on noninvasive velocity and anatomical data from 3D+t echocardiography or Magnetic Resonance Imaging (MRI). Numerical simulations of the cardiac cycle are driven by the image-derived velocities prescribed at the model boundaries using a penalty method that recovers a physical solution by minimizing the energy imparted to the system. This numerical approach circumvents the mathematical challenges due to the poor conditioning that arises from the imposition of boundary conditions on velocity only. We demonstrate that through this technique we are able to reconstruct given flow fields using Dirichlet only conditions. We also perform a sensitivity analysis to investigate the accuracy of this approach for different images with varying spatiotemporal resolution. Finally, we examine the influence of noise on the computed result, showing robustness to unbiased noise with an average error in the simulated velocity approximately 7% for a typical voxel size of 2mm(3) and temporal resolution of 30ms. The methodology is eventually applied to a patient case to highlight the potential for a direct clinical translation.

Incidence and risk factors for hemorrhagic cystitis in unmanipulated haploidentical transplant recipients

BACKGROUND

Hemorrhagic cystitis (HC) is a common complication after hematopoietic allogeneic stem cell transplantation (HSCT) associated with intensity of the conditioning regimen, cyclophosphamide (Cy) therapy, and BK polyomavirus (BKPyV) infection.

METHODS

We analyzed 33 consecutive haploidentical (haplo) HSCT recipients transplanted for hematologic diseases. Eleven patients had a previous transplant. Median follow-up was 11 months. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine + mycophenolate mofetil and post-HSCT Cy.

RESULTS

Thirty-two of 33 patients achieved neutrophil recovery. Cumulative incidence (CI) of platelet recovery was 65%. CI grade II-IV acute GVHD was 44%. Twenty patients developed HC in a median time of 38 days. CI of HC at day 180 was 62%. BKPyV was positive in blood and urine of 91% of patients at HC onset. HC resolved in 18/20 patients. Factors associated with HC were previous transplant (P = 0.01) and occurrence of cytomegalovirus reactivation before HC (P = 0.05). Grade II-IV acute GVHD was not associated with HC (P = 0.62). CI of day 180 viral infections was 73%. Two-year overall survival (OS) was 50%; HC did not impact OS (P = 0.29).

CONCLUSION

The incidence of HC after haplo with post-HSCT Cy is high and is associated with morbidity, especially in high-risk patients such as those with a previous transplant history and with impaired immune reconstitution.

Superconducting/magnetic Three-state Nanodevice for Memory and Reading Applications

We present a simple nanodevice that can operate in two modes: i) non-volatile three-state memory and ii) reading device. The nanodevice can retain three well defined states −1, 0 and +1 and can operate in a second mode as a sensor for external magnetic fields. The nanodevice is fabricated with an array of ordered triangular-shaped nanomagnets embedded in a superconducting thin film gown on Si substrates. The device runs based on the combination of superconducting vortex ratchet effect (superconducting film) with the out of plane magnetization (nanomagnets). The input signals are ac currents and the output signal are dc voltages. The memory mode is realized without applying a magnetic field and the nanomagnet stray magnetic fields govern the effect. In the sensor mode an external magnetic field is applied. The main characteristic of this mode is that the output signal is null for a precise value of the external magnetic field that only depends on the fabrication characteristics of the nanodevice.

DNMT3A mutations mediate the epigenetic reactivation of the leukemogenic factor MEIS1 in acute myeloid leukemia

Close to half of de novo acute myeloid leukemia (AML) cases do not exhibit any cytogenetic aberrations. In this regard, distortion of the DNA methylation setting and the presence of mutations in epigenetic modifier genes can also be molecular drivers of the disease. In recent years, somatic missense mutations of the DNA methyltransferase 3A (DNMT3A) have been reported in ~20% of AML patients; however, no obvious critical downstream gene has been identified that could explain the role of DNMT3A in the natural history of AML. Herein, using whole-genome bisulfite sequencing and DNA methylation microarrays, we have identified a key gene undergoing promoter hypomethylation-associated transcriptional reactivation in DNMT3 mutant patients, the leukemogenic HOX cofactor MEIS1. Our results indicate that, in the absence of mixed lineage leukemia fusions, an alternative pathway for engaging an oncogenic MEIS1-dependent transcriptional program can be mediated by DNMT3A mutations.

Investigating the genetic background of bovine digital dermatitis using improved definitions of clinical status

Bovine digital dermatitis (DD) is an increasing claw health problem in all cattle production systems worldwide. The objective of this study was to evaluate the use of an improved scoring of the clinical status for DD via M-scores accounting for the dynamics of the disease; that is, the transitions from one stage to another. The newly defined traits were then subjected to a genetic analysis to determine the genetic background for susceptibility to DD. Data consisted of 6,444 clinical observations from 729 Holstein heifers in a commercial dairy herd, collected applying the M-score system. The M-score system is a classification scheme for stages of DD that allows a macroscopic scoring based on clinical inspections of the bovine foot, thus it describes the stages of lesion development. The M-scores were used to define new DD trait definitions with different complexities. Linear mixed models and logistic models were used to identify fixed environmental effects and to estimate variance components. In total, 68% of all observations showed no DD status, whereas 11% were scored as infectious for and affected by DD, and 21% of all observations exhibited an affected but noninfectious status. For all traits, the probability of occurrence and clinical status were associated with age at observation and period of observation. Risk of becoming infected increased with age, and month of observation significantly affected all traits. Identification of the optimal month concerning DD herd status was consistent for all trait definitions; the last month of the trial was identified. In contrast, months exhibiting the highest least squares means of transformed scores differed depending on trait definition. In this respect, traits that can distinguish between healthy, infectious, and noninfectious stages of DD can account for the infectious potential of the herd and can serve as an alert tool. Estimates of heritabilities of traits studied ranged between 0.19 (±0.11) and 0.52 (±0.17), revealing a tendency for higher values for more complex trait definitions. In terms of genetic selection, all trait definitions identified the best (i.e., most resistant) animals, but only the new trait definitions were able to distinguish between animals with average and high predispositions for DD. Considering repeated measurements resulted in heritability estimates ranging between 0.13 (±0.05) and 0.29 (±0.10).

First-lactation performance in cows affected by digital dermatitis during the rearing period

The long-term effects of prepartum digital dermatitis (DD) on first-lactation performance were evaluated in a cohort of 719 pregnant heifers. All heifers were followed for a period of 6 mo until calving and classified on the basis of the number of DD events diagnosed during this period as type I, type II, or type III (no DD, one DD event, and multiple DD events, respectively). Health during the initial 60d in milk (DIM), reproductive and hoof health outcomes, and milk production were compared between the 3 heifer type groups. All logistic and linear models were adjusted for age, height, and girth circumference at enrollment, and the type of trace mineral supplementation during the prepartum period. Overall, cows experiencing DD during the rearing period showed worse production and health outcomes compared with healthy heifers during the first lactation. The percentages of assisted calvings, stillbirths, culled before 60 DIM, and diseased cows during the fresh period were numerically higher in type III cows compared with type I cows. However, none of these differences were statistically significant at the 95% confidence level. Significantly lower conception at first service [odds ratio (OR)=0.55, 95% confidence interval (95% CI): 0.33, 0.89] and increased number of days open (mean=24d, 95% CI: 5.2, 43) were observed in type III cows compared with type I cows. In relation to hoof health, a significantly increased risk of DD during the first lactation was found in type II and III cows (OR=5.16, 95% CI: 3.23, 8.29; and OR=12.5, 95% CI: 7.52, 21.1, respectively), as well as earlier occurrence of DD following calving (OR=59d, 95% CI=20, 96, and OR=74d, 95% CI: 37, 109). Compared with type I cows, statistically significant milk production losses during the initial 305 DIM of 199 and 335kg were estimated in type II and III cows, respectively. This difference was due to a greater rate of production decline (less persistence) after peak yield. No differences in monthly fat and protein percentages or somatic cell counts were observed between the heifer types. Given the long-term effects of DD on health, reproduction, and production, one of the priorities during the rearing period of dairy heifers should be efficient DD prevention and control programs. Such intensive intervention programs based on active long-term DD surveillance, mitigation of risk factors, and prompt treatment are expected to increase overall animal well-being and farm profitability by minimizing the effect of DD during the first lactation.

Deficits in egocentric-updating and spatial context memory in a case of developmental amnesia

Patients with developmental amnesia usually suffer from both episodic and spatial memory deficits. DM, a developmental amnesic, was impaired in her ability to process self-motion (i.e., idiothetic) information while her ability to process external stable landmarks (i.e., allothetic) was preserved when no self-motion processing was required. On a naturalistic and incidental episodic task, DM was severely and predictably impaired on both free and cued recall tasks. Interestingly, when cued, she was more impaired at recalling spatial context than factual or temporal information. Theoretical implications of that co-occurrence of deficits and those dissociations are discussed and testable cerebral hypothesis are proposed.

Measurement of coherent production of π(±) in neutrino and antineutrino beams on carbon from Eν of 1.5 to 20 GeV

Neutrino-induced coherent charged pion production on nuclei νμA→μ(±)π(∓)A is a rare, inelastic interaction in which a small squared four-momentum |t| is transferred to the recoil nucleus, leaving it intact in the reaction. In the scintillator tracker of MINERvA, we remove events with evidence of particles from nuclear breakup and reconstruct |t| from the final-state pion and muon. We select low |t| events to isolate a sample rich in coherent candidates. By selecting low |t| events, we produce a model-independent measurement of the differential cross section for coherent scattering of neutrinos and antineutrinos on carbon. We find poor agreement with the predicted kinematics in neutrino generators used by current oscillation experiments.

The effect of digital dermatitis on hoof conformation

Digital dermatitis (DD) is the most prevalent cause of lameness of infectious origin in cattle. However, little is known about the effects of DD on hoof conformation (HC) during the clinical disease. The objectives of the present study were to (1) evaluate the changes in HC observed in feet affected with clinical DD lesions and (2) investigate the temporal relationship between DD and heel horn erosion (HHE). A longitudinal study was carried out including a cohort of 644 Holstein heifers. Digital dermatitis, HC, and presence of HHE in the rear feet of each heifer were assessed during a period of 6 mo. A total of 1,979 feet evaluations were included in the data set, of which 157 corresponded to feet presenting DD lesions >20mm [mean (SD) size of 27.2 (8.2) mm]. Age, days of pregnancy, hip height, and girth circumference were also recorded at cow level. Significant HC changes were observed in DD-affected feet. Results standardized to a period of 90d of follow-up showed an increase in heel height [mean (95% CI) 3.4 (2.5, 4.4) and 2.8 (2.0, 3.7) mm] and claw angle [0.8 (0.2, 1.4) and 1.4 (0.7, 2.0) degrees] of the medial and lateral claws, respectively. In addition, an increase in depth of the interdigital cleft [3.2 (2.7, 3.7) mm] and on debris accumulation [14% (7, 21) of feet] was also observed. Feet affected with clinical DD lesions also experienced a 46% point increase in the presence of severe HHE. In the short term, HC changes returned to normal levels when clinical cure of DD was achieved after topical treatment. In conclusion, significant HC changes occur in heifers affected by clinical DD before lameness symptoms are detected. The transformation of the heel area in feet affected by DD likely promotes the creation of a local environment that favors the persistence of the disease and the occurrence of severe HHE. To avoid further hoof damage, active surveillance and early intervention to reduce HC changes are recommended to improve DD control programs. Successful restoration of HC can be achieved upon clinical cure of DD. The long-term effects in lifetime performance of the HC changes due to DD remain to be further investigated.

Towards a fast and efficient approach for modelling the patient-specific ventricular haemodynamics

Computer modelling of the heart has emerged over the past decade as a powerful technique to explore the cardiovascular pathophysiology and inform clinical diagnosis. The current state-of-the-art in biophysical modelling requires a wealth of, potentially invasive, clinical data for the parametrisation and validation of the models, a process that is still too long and complex to be compatible with the clinical decision-making time. Therefore, there remains a need for models that can be quickly customised to reconstruct physical processes difficult to measure directly in patients. In this paper, we propose a less resource-intensive approach to modelling, whereby computational fluid-dynamics (CFD) models are constrained exclusively by boundary motion derived from imaging data through a validated wall tracking algorithm. These models are generated and parametrised based solely on ultrasound data, whose acquisition is fast, inexpensive and routine in all patients. To maximise the time and computational efficiency, a semi-automated pipeline is embedded in an image processing workflow to personalise the models. Applying this approach to two patient cases, we demonstrate this tool can be directly used in the clinic to interpret and complement the available clinical data by providing a quantitative indication of clinical markers that cannot be easily derived from imaging, such as pressure gradients and the flow energy.