Thalidomide and the Titanic: reconstructing the technology tragedies of the twentieth century

Drug repurposing: Misconceptions, challenges, and opportunities for academic researchers

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When special populations intersect with drug-drug interactions: Application of physiologically-based pharmacokinetic modeling in pregnant populations

Pregnancy results in significant physiological changes that vary across trimesters and into the postpartum period, and may result in altered disposition of endogenous substances and drug pharmacokinetics. Pregnancy represents a unique special population where physiologically-based pharmacokinetic modeling (PBPK) is well suited to mechanistically explore pharmacokinetics and dosing paradigms without subjecting pregnant women or their fetuses to extensive clinical studies. A critical review of applications of pregnancy PBPK models (pPBPK) was conducted to understand its current status for prediction of drug exposure in pregnant populations and to identify areas of further expansion. Evaluation of existing pPBPK modeling efforts highlighted improved understanding of cytochrome P450 (CYP)-mediated changes during pregnancy and identified knowledge gaps for non-CYP enzymes and the physiological changes of the postpartum period. Examples of the application of pPBPK beyond simple dose regimen recommendations are limited, particularly for prediction of drug-drug interactions (DDI) or differences between genotypes for polymorphic drug metabolizing enzymes. A raltegravir pPBPK model implementing UGT1A1 induction during the second and third trimesters of pregnancy was developed in the current work and verified against clinical data. Subsequently, the model was used to explore UGT1A1-related DDI risk with atazanavir and rifampicin along with the effect of enzyme genotype on raltegravir apparent clearance. Simulations of pregnancy-related induction of UGT1A1 either exacerbated UGT1A1 induction by rifampicin or negated atazanavir UGT1A1 inhibition. This example illustrated the advantages of pPBPK modeling for mechanistic evaluation of complex interplays of pregnancy- and drug-related effects in support of model-informed approaches in drug development.

Ethnicity-Specific Drug Safety Data in European Medicines Agency Registration Dossiers, European Public Assessment Reports, and European and Singapore Drug Labels: Lost in Translation?

BACKGROUND

Information on drug safety in different ethnic populations reported in public documents such as the European Public Assessment Reports (EPARs), European Summary of Product Characteristics (SmPCs) or Singapore Package Inserts (SGPIs) generally appears limited.

OBJECTIVE

This study aimed to clarify the extent of drug safety data in ethnic populations that is available in drug registration dossiers used for registration in the European Union (EU) and Singapore, and how much of this information is then included in the EPARs and SmPCs or SGPIs.

METHODS

For this purpose, drug registration dossiers and these public documents for a selection of 25 drugs authorized both in the EU and Singapore were compared (note, the number of available full registration dossiers was only 24 due to a technical issue).

RESULTS

Detailed safety data in ethnic groups were present in 23/24 (96%) of the drug registration dossiers, but was only present in 12/25 (48%) of the EPARs, 8/25 (32%) of the SmPCs, and 9/25 (36%) of the SGPIs. Furthermore, in many cases where ethnicity-specific safety information was provided in the SmPC or SGPIs, details on the ethnic subpopulations was not provided.

CONCLUSIONS

Despite the fact that safety data analyzed with respect to ethnic populations are available in almost all screened registration dossiers, this information is often unknown to patients or prescribers as it was often not included in the EPARs, EU SmPCs or SGPIs. In order to increase the availability of such potentially important safety information, it is recommended to at least provide ethnic populations and group size in these public documents. In this way, trust in the registered drugs in different ethnic populations may be increased, and more robust treatment decisions may be obtained in clinical practice.

The Submissive Relationship of Public Health to Government, Politics, and Economics: How Global Health Diplomacy and Engaged Followership Compromise Humanitarian Relief

This paper describes efforts by public health practitioners to address a health crisis caused by economic development policies that are unrestrained by either environmental, public health, or human rights mandates. Economic development projects funded by international funding institutions like the Inter-American Development Bank that reduce poverty when measured in terms of Gross Domestic Product (GDP) per capita in the transborder region between Suriname and French Guiana harm minority populations where commercial activities destroy, alter, and remove the resources upon which local communities depend. In this study, the structural causes of a community health crisis affecting Indigenous people in the transborder region between Suriname and French Guiana was addressed by seeking gatekeepers in government who have access to policy-making processes. We found that deeply rooted economic development policies structured social, economic, and political alliances and made them resistant to feedback and reform. We concluded that work must be focused beyond the simple exchange of public health information. Public health practitioners must become politically active to create new policy commitments and new patterns of governance that advance development as well as improve health outcomes. Failure to do so may result in public health practitioners becoming 'engaged followers' that are complicit in the inhumanity that springs from their acquiescence to the authority of government officials when their policies are the cause of preventable death, disease, and disability.

Mental Disorders in People Affected by Thalidomide

BACKGROUND

More than 50 years after the withdrawal of thalidomide from the market, subsequent orthopedic damages and psychosocial impairments dominate the complaints of thalidomide-affected individuals. The aim of the study was to determine the prevalence of mental disorders in this group.

METHODS

A total of 193 thalidomide-affected individuals from North Rhine-Westphalia (mean age 50.5 years, 56.5% women) underwent personal and comprehensive psychodiagnostic testing, which was based on the Structured Clinical Interview for DSM-IV disorders (SCID-I & SCID-II) and self-reporting questionnaires.

RESULTS

Overall, the four-week prevalence of mental disorders was 47.2%. Multiple mental disorders were present in 45.1% among the 91 participants with diagnosed mental disorders. The most frequent diagnoses were unipolar depressive disorders (16.5%), somatoform disorders (14.0%), phobic disorders (12.4%), and alcohol-related disorders (6.2%). Immediate mental health care was indicated in 80.2% of participants with current mental disorders, but only 29.7% had used some form of psychosocial treatment in the 12 months preceding the study.

CONCLUSION

Mental disorders occur approximately twice as often (relative risk [RR]: 1.77; 95% confidence interval [1.49; 2.10]) in thalidomide-affected individuals as in the age-matched German population. Together with a very low rate of utilization of mental health care, this finding implies an underuse of psychosocial healthcare. The development of specialized psychosocial treatment services may remove barriers that impede access to the healthcare system.

Epidemiology of birth defects based on surveillance data from 2011-2015 in Guangxi, China: comparison across five major ethnic groups

BACKGROUND

The causes of birth defects (BDs) are complex and include genetic and environmental factors and/or their interactions. More research is needed to describe the epidemiology of BDs within specific regions of China. This study focused on differences in the prevalence of BDs based on ethnicity in a large city in Guangxi Province, China.

METHODS

Surveillance data of infants born in 114 registered hospitals in Liuzhou between 2011 and 2015 were analyzed to determine the epidemiology of BDs across five major ethnic groups. We calculated the prevalence of BDs and relative risk of BDs by ethnicity.

RESULTS

There were 260,722 perinatal infants of which 6581 had BDs, with the average prevalence of 25.24 per 1000 perinatal infants (PIs). Prevalence data showed an obvious uptrend over the past 5 years. Han had the highest prevalence of total BDs (28.98‰), followed by Zhuang (25.19‰), Yao (18.50‰), Miao (15.78‰) and Dong (14.24‰). Relative to the Han; Zhuang, Miao, Yao, and Dong had a lower risk of musculoskeletal and urogenital malformations; Miao and Yao had a lower risk of cardiovascular malformation; and Dong had a lower risk of cardiovascular and craniofacial malformation. Several maternal risk factors were found to be associated with BDs (e.g., maternal and gestational age, number of antenatal care visits).

CONCLUSION

This study provided a comprehensive description of ethnic differences in the risk of BDs in Liuzhou City, China. Observed ethnic differences in the risk of BDs may be related to genetic susceptibilities, environment, cultural customs, or to potential combinations of these factors.

Epidemiology and major subtypes of congenital heart defects in Hunan Province, China

Congenital heart defects (CHDs) are the most common birth defects (BDs) and account for nearly one-third of all BDs. The aim of this article was to investigate the epidemiology and major subtypes of CHDs in Hunan Province, China in the last 5 years.CHD surveillance data from 2012 to 2016 were collected from 52 registered hospitals in Hunan. The prevalence rates of CHDs, incidence rates of CHDs combined with other BDs, and rates of termination of pregnancy (TOP) for CHDs among different regions, infant sexes, and maternal ages were calculated for both early fetuses (<28 weeks of gestation) and perinatal infants (PIs) (between 28 weeks of gestation and 7 days after birth). Both the constituent ratio and prevalence rates were computed among subtypes.CHDs were found in 6289 out of 673,060 births. The overall prevalence was 93.44 per 10,000 PIs, with 19.27 and 74.17 per 10,000 in early fetuses and PIs, respectively. The risks of CHDs were higher in infants from urban areas than those from rural areas during the whole gestation and were higher in male infants than in female infants during the perinatal period. The total prevalence of CHDs increased significantly with maternal age (χ trend = 141.84, P < .05). Among fetuses in early gestation, there were 288 cases (22.21%) of CHDs combined with other BDs and 1292 cases (99.61%) of TOP for CHD. The 3 major subtypes of CHDs were ventricular septal defect (VSD) (22.06%), Tetralogy of Fallot (TOF) (9.43%), and atrioventricular septal defect (AVSD) (6.69%). Among PIs, there were 1541 cases (30.87%) of CHD diagnosed before delivery and 1184 cases (76.83%) were TOP. The 3 major subtypes were atrial septal defect (ASD) (42.81%), patent ductus arteriosus (PDA) (16.07%), and VSDs (15.21%).The total prevalence of CHD in Hunan Province and the rate of TOP for CHD was high, especially for early-gestation fetuses. Pregnancies in urban women, male PIs, and maternal age were the risk factors for CHDs. Among early-gestation fetuses, the most common types were VSD, TOF, and ASD, and among PIs, the most common types were ASD, PDA, and VSD.

Vaccines and Antibodies in Relation to Pregnancy and Lactation

With the rapid pace of immunologic research, it is more important than ever for readers to understand rational immunodiagnosis, immunopro-phylaxis, and immunotherapy. This column is intended to help you ensure proper immunologic drug use in your practice.

Epidemiology of Birth Defects Based on a Birth Defect Surveillance System from 2005 to 2014 in Hunan Province, China

Objective

To describe the epidemiology of birth defects (BDs) in perinatal infants in Hunan Province, China, between 2005 and 2014.

Methods

The BD surveillance data of perinatal infants (for stillbirth, dead fetus or live birth between 28 weeks of gestation and 7 days after birth) were collected from 52 registered hospitals of Hunan between 2005 and 2014. The prevalence rates of BDs with 95% confidence interval (CI) and crude odds ratio (ORs) were calculated to examine the associations of infant gender, maternal age, and region (urban vs rural) with BDs.

Results

From 2005 to 2014, there were a total of 925413 perinatal infants of which 17753 had BDs, with the average prevalence of 191.84 per 10000 PIs (perinatal infants), showing a significant uptrend. The risks of BDs are higher in urban areas versus rural areas (OR = 1.20), in male infants versus female infants (OR = 1.19), and in mothers above age 35 versus those below age 35 (OR = 1.24). The main five types of BDs are Congenital heart defects (CHD), Other malformation of external ear (OMEE), Polydactyly, Congenital malformation of kidney (CMK), and Congenital talipes equinovarus (CTE). From 2005 to 2014, the prevalence rates (per 10000 PIs) of CHD and CMK increased significantly from 22.56 to 74 (OR = 3.29, 95%CI: 2.65–4.11) and from 7.61 to 14.62 (OR = 1.92, 95%CI:1.30–2.84), respectively; the prevalence rates of congenital hydrocephalus and neural tube defects (NTDs) decreased significantly from 11.8 to 5.29 (OR = 0.45, 95%CI: 0.31–0.65) and from 7.87 to 1.74 (OR = 0.22, 95%CI: 0.13–0.38), respectively.

Conclusions

The prevalence rates of specific BDs in perinatal infants in Hunan have changed in the last decade. Urban pregnant women, male perinatal infants, and mothers above age 35 present different prevalence rates of BDs. Wider use of new diagnosis technology, improving the ability of monitoring, strengthening the publicity and education are important to reduce the prevalence of BDs.

The survey of birth defects rate based on birth registration system

Background:

To investigate the surveillance trend of birth defects, incidence, distribution, occurrence regularity, and their relevant factors in Xi’an City in the last 10 years for proposing control measures.

Methods:

The birth defects monitoring data of infants during perinatal period (28 weeks of gestation to 7 days after birth) were collected from obstetrics departments of all hospitals during 2003–2012. Microsoft Excel 2003 was used for data input, and Statistical Package for the Social Sciences version 16.0 (International Business Machines Corporation, New York, NY, USA) was used for descriptive analysis. χ² test, Spearman correlation and linear-by-linear association trend test were used for statistical analyses.

Results:

The birth defect rate declined from 9.18% in 2003 to 7.00% in 2012 (χ² = 45.001, P < 0.01) with a mean value of 7.85%, which is below the Chinese national average level (χ² = 20.451, P < 0.01). The order of five most common birth defects has changed. The incidence of congenital heart disease (CHD) increased with time, particularly after 2012, it became the most frequent type (r_s = 0.808, P < 0.001). Till then, the number of neural tube defects (NTDs) declined significantly (χ² = 76.254, P < 0.01). The average birth defects rate of 8.11% in rural areas was higher than that in urban areas (7.56%, χ² = 7.919, P < 0.01) and much higher in males (8.28%) than that in females (7.18%, χ² = 32.397, P < 0.01). Maternal age older than 35 years (χ² = 35.298, P < 0.01) is the most dangerous age bracket of birth defects than maternal age younger than 20 years (χ² = 7.128, P < 0.01).

Conclusions:

A downward trend of birth defects was observed in Xi’an City from 2003 to 2012. NTDs significantly decreased after large-scale supplemental folic acid intervention, while the incidence rate of CHD significantly increased.

Chiral xenobiotics bioaccumulations and environmental health prospectives

The chiral xenobiotics are very dangerous for all of us due to the different enantioselective toxicities of the enantiomers. Besides, these have different enantioselective bioaccumulations and behaviors in our body and other organisms. It is of urgent need to understand the enantioselective bioaccumulations, toxicities, and the health hazards of the chiral xenobiotics. The present article describes the classification, sources of contamination, distribution, enantioselective bioaccumulation, and the toxicities of the chiral xenobiotics. Besides, the efforts are also made to discuss the prevention and remedial measures of the havoc of the chiral xenobiotics. The challenges of the chiral xenobiotics have also been highlighted. Finally, future prospectives are also discussed.

Birth defects surveillance in China

BACKGROUND

Birth defects are a global public health problem because of their large contribution to infant mortalities and disabilities. It is estimated that 4%-6% of Chinese newborns are affected by birth defects every year. Surveillance is a basic approach to understanding the occurrence and associated factors of birth defects. The Ministry of Health of China initiated a national hospital-based birth defects monitoring system 20 years ago. Nearly every province in this country has established its own surveillance system in the past. The authors reviewed the result of the monitoring system at different administrative levels in China.

DATA SOURCES

Available publications on the surveillance of birth defects and data from national and provincial birth defects surveillance systems were reviewed to evaluate the effectiveness of the surveillance systems.

RESULTS

According to the 2009 data, the national hospital-based birth defects surveillance system monitored over 1.3 million births, which accounted for more than 8% of births in China. In addition, 30 provincial hospital-based surveillance programs covered a birth population of more than 3.6 million (22% of births in China). Great achievements have been made in terms of case ascertainment, data quality control, and online reporting. But the surveillance systems in China still have some limitations. A short ascertainment period may miss some internal anomalies, inherited metabolic diseases, and malformed fetus aborted before the 28th gestational week. Discrepancies in antenatal or postnatal diagnosis of birth defects between surveillance institutes may affect the detection rate and introduce biases. Absence of baseline data and lack of integrated database systems limit the application of surveillance data to etiological studies and affect the process of decision-making.

CONCLUSIONS

The surveillance system for birth defects is prerequisite to propose, conduct and assess any interventions for the disease. To meet the need of study and prevention of birth defects, measures should be taken to improve the national and provincial birth defects surveillance systems in China.

American medicine as religious practice: care of the sick as a sacred obligation and the unholy descent into secularization

Modern medicine serves a religious function for modern Americans as a conduit through which science can be applied directly to the human body. The first half of this paper will focus on the theoretical foundations for viewing medicine as a religious practice arguing that just as a hierarchical structured authoritarian church historically mediated access to God, contemporary Western medicine provides a conduit by which the universalizable truths of science can be applied to the human being thereby functioning as a new established religion. I will then illustrate the many parallels between medicine and religion through an analysis of rituals and symbols surrounding and embedded within the modern practice of medicine. This analysis will pay special attention to the primacy placed on secret interior knowledge of the human body. I will end by responding to the hope for a "secularization of American medicine," exploring some of the negative consequences of secularization, and arguing that, rather than seeking to secularize, American medicine should strive to use its religious features to offer hope and healing to the sick, in keeping with its historically religious legacy.

Thalidomide for treatment of intestinal involvement of juvenile-onset Behçet disease

BACKGROUND

Thalidomide has been identified and its anti-inflammatory and immunomodulatory properties clarified. This report expands our report of 2 entero-Behçet disease children who developed significant steroid toxicity and improved dramatically with thalidomide.

METHODS

We studied the effects of thalidomide in 7 juvenile-onset patients with severe, recurrent intestinal involvement of Behçet disease. Thalidomide was given at an initial dose of 2 mg/kg per day, and the dose was increased to 3 mg/kg per day if necessary (3 of 7 patients) or decreased to 1-0.5 mg/kg per day according to the responses to the drug.

RESULTS

All 7 patients showed dramatic improvement in clinical symptoms with thalidomide therapy, and they successfully discontinued steroid therapy. Patients receiving thalidomide were monitored for prolonged neurotoxicity, and the treatment and a few side effects were well tolerated by all patients.

CONCLUSIONS

Our results indicate that thalidomide can be an efficacious medication in appropriately selected patients with some inflammatory bowel diseases with many chances of success.

Drug transport across the placenta, role of the ABC drug efflux transporters

The placenta serves an important role both as a protective barrier as well as in normal fetal development. The ATP-binding cassette (ABC) proteins perform crucial functions in the distribution of nutrients and exchange of waste metabolites across the placenta. They also protect the developing fetus from xenobiotics to which the pregnant mother is exposed. Recent studies in P-glycoprotein (P-gp) deficient mdr1a and mdr1b (-/-) CF-1 mice have shown pronounced increases in fetal exposure to P-gp substrates due to increased transplacental penetration demonstrating the important protective role of P-gp to the developing fetus. The role of placental ABC transporter proteins in protecting the fetus against maternal exposure to drugs, toxins and other xenobiotics is discussed. Overall, the paucity of information available on the transplacental transfer of drugs emphasizes the need to further employ preclinical in vivo models for drug development in order to best predict fetal outcomes of drug administration to pregnant mothers.

Common complaints, difficult diagnosis: Multiple myeloma

PURPOSE

To review the presenting signs and symptoms of multiple myeloma, its pathophysiology, diagnostic evaluation, and treatment options.

DATA SOURCES

A literature review of research articles and publications by oncology experts who specialize in multiple myeloma, supplemented by a case study.

CONCLUSIONS

Multiple myeloma is a cancer of the geriatric population, with the average age at diagnosis between 65 and 68 years. As the population of those over age 65 is predicted to double by the year 2050, the incidence of myeloma is expected to increase. Nurse practitioners (NPs) must become familiar with the signs, symptoms, and complications of myeloma for patients to be diagnosed and referred to specialists in a timely manner.

IMPLICATIONS FOR PRACTICE

Patients with multiple myeloma often present with vague, common symptoms such as back pain, bony pain, fatigue, and anemia. These symptoms may be treated as separate medical conditions if NPs fail to include multiple myeloma in their differential diagnosis. If NPs are educated on this malignancy, they will have the expertise to look for other signs of the disease such as hypercalcemia, pathological fractures, osteopenia, or renal failure. Without early recognition of multiple myeloma and referrals to oncology specialists, patients are left with a delayed diagnosis and poor symptom control.

Placental Transfer of Ondansetron during Early Human Pregnancy

BACKGROUND AND OBJECTIVE

Nausea and vomiting are common conditions that occur during early pregnancy and can be disabling. Ondansetron had been used in pregnant women when treatment with conventional antiemetics has failed; however, the safety and tolerability of this relatively new antiemetic drug during pregnancy is still uncertain. The objective of this study was to quantify the placental transfer of ondansetron in the first trimester of human pregnancy.

PATIENTS AND METHODS

This was a prospective, observational study. Forty-one patients who requested surgical termination of pregnancy at the first trimester were administered three doses of ondansetron 8 mg before surgery. Maternal venous blood, coelomic fluid, amniotic fluid and fetal tissue were collected from each patient for analysis of ondansetron by liquid chromatography-mass spectometry.

RESULTS

Ondansetron was found in all samples. Drug concentration in fetal tissue was significantly higher than that in the amniotic fluid and similar to that in the coelomic fluid. The median (interquartile range) fetal/maternal ratio was 0.41 (0.31-0.52) and there were no significant correlations between ondansetron concentrations in each compartment and gestational age.

CONCLUSIONS

A significant amount of ondansetron was present in all embryonic compartments. The developmental significance of this drug exposure requires further investigation, i.e. whole embryo culture.

Thalidomide: current therapeutic uses and management of its toxicities

Thalidomide currently is used to treat relapsed and refractory multiple myeloma. The drug also is being actively investigated in patients newly diagnosed with multiple myeloma. The therapeutic applications of thalidomide are expected to grow as clinical trials document its activity in treating other neoplastic disorders and diseases. Healthcare providers need to be well informed of its toxicities and able to identify their signs and symptoms immediately. They must have adequate knowledge about thalidomide administration and provide comprehensive patient education regarding thalidomide and its toxicities to ensure patient safety and compliance.

Thalidomide use in pediatric patients

OBJECTIVE

To provide a detailed overview of thalidomide use in pediatric patients.

DATA SOURCES

English-language articles were identified through a MEDLINE search (1966-February 2001); key terms included thalidomide, child, graft-versus-host disease, cancer, HIV, Crohn's disease, Behçet's disease, and lupus erythematosus. References cited in those articles were also evaluated.

DATA SYNTHESIS

Thalidomide appears to be effective in patients with chronic, not acute, graft-versus-host disease (GVHD) and in healing aphthous ulcers in patients with HIV infection. Limited case reports suggest efficacy of thalidomide in the treatment of cutaneous manifestations of Behçet's disease, Crohn's disease, and lupus in children; however, the recurrence of disease is almost universal on drug discontinuation.

CONCLUSIONS

Thalidomide should be used as a last resort when all other therapies fail, preferably in male or prepubescent female patients.

Thalidomide in cancer: potential uses and limitations

In addition to immunomodulatory and cytokine-modulatory properties, thalidomide has antiangiogenic activity. It has been investigated in a number of cancers including multiple myeloma, myelodysplastic syndromes, gliomas, Kaposi's sarcoma, renal cell carcinoma, advanced breast cancer, and colon cancer. Its role has been best explored in myeloma, where, at daily doses of 100 to 800 mg, it is remarkably active, causing clinically meaningful responses in one-third of extensively pretreated patients and in over half of patients treated early in the course of the disease. It also acts synergistically with corticosteroids and chemotherapy in myeloma. Thalidomide produces improvement of cytopenias characteristic of myelodysplastic syndrome, resulting in the reduction or elimination of transfusion dependence in some patients. Responses have also been seen in one-third of patients with Kaposi's sarcoma, in a small proportion of patients with renal cell carcinoma and high grade glioma and, in combination with irinotecan, in some patients with colon cancer. Thalidomide is being investigated currently in a number of clinical trials for cancer. Drowsiness, constipation and fatigue are common adverse effects seen in 75% of patients. Symptoms of peripheral neuropathy and skin rash are seen in 30%. A minority of patients experience bradycardia and thrombotic phenomena. Despite the high frequency of adverse effects, those severe enough to necessitate cessation of therapy are seen in only 10 to 15% of patients. A therapeutic trial of thalidomide should be considered in all patients with myeloma who are unresponsive to or relapse after standard therapy. In other malignant diseases, the most appropriate way to use the drug is in the setting of well designed clinical trials. In the absence of access to such studies, thalidomide could be considered singly or in combination with standard therapy in patients with no meaningful therapeutic options.

The re-emergence of thalidomide: results of a scientific conference

BACKGROUND

The use of thalidomide during the 1950s resulted in teratogenic effects in thousands of infants. Although thalidomide is currently approved for the treatment of a complication of leprosy, it is commercially available to treat other diseases through a controlled distribution system. This article presents a summary of a scientific conference organized to assess clinical research on thalidomide, its new clinical applications, and the social and ethical implications for its use.

METHODS

Summaries of 10 presentations and two panel discussions were developed from the authors's, oral presentations, conference slides, responses to questions, and supporting literature.

RESULTS

Thalidomide shows promise in treating several diseases, including HIV/AIDS, rheumatoid arthritis, Crohn's disease, and multiple myeloma. The STEPStrade mark (System for Thalidomide Education and Prescribing Safety) Program has been developed by Celgene, the commercial manufacturer of thalidomide, to ensure compliance with prescription and usage protocols. A surveillance system is also in place to monitor and report compliance patterns.

CONCLUSIONS

Despite the tragic past associated with thalidomide, the drug shows promise as a treatment for many clinical disorders. The challenge is to answer lingering questions of risks and benefits through clinical trials and discovery, to monitor participation and compliance with protocols developed to avoid use of the drug during pregnancy, and to continue to search for safer and more effective treatment options.

New therapies for heart failure: is thalidomide the answer?

The syndrome of advanced heart failure is associated with considerable morbidity and mortality. Ideas about the reasons for the progressive nature of the heart failure syndrome have changed over the years, with the initial view that progression was principally due to pump failure (the 'haemodynamic' hypothesis), giving way to more modern views, which implicate neuro-endocrine activation (including catecholamine excess, renin-angiotensin system activation, etc.). More recently, an excess of inflammatory cytokines has been found in advanced heart failure and implicated in the progression of the disease. Amongst the cytokines found, TNF-alpha seems to be particularly important. The principle therapeutic action of thalidomide appears to be reduction of TNF-alpha levels. We therefore suggest that there may be a role for thalidomide, or its derivatives, in the management of advanced heart failure.