Epidemiology of clinically significant forms of alpha- and beta-thalassemia: A global map of evidence and gaps

This systematic literature review assessed the global prevalence and birth prevalence of clinically significant forms of alpha- and beta-thalassemia. Embase, MEDLINE, and the Cochrane Library were searched for observational studies published January 1, 2000, to September 21, 2021. Of 2093 unique records identified, 69 studies reported across 70 publications met eligibility criteria, including 6 records identified from bibliography searches. Thalassemia prevalence estimates varied across countries and even within countries. Across 23 population-based studies reporting clinically significant alpha-thalassemia (e.g., hemoglobin H disease and hemoglobin Bart's hydrops fetalis) and/or beta-thalassemia (beta-thalassemia intermedia, major, and/or hemoglobin E/beta-thalassemia), prevalence estimates per 100 000 people ranged from 0.2 in Spain (over 2014-2017) to 27.2 in Greece (2010-2015) for combined beta- plus alpha-thalassemia; from 0.03 in Spain (2014-2017) to 4.5 in Malaysia (2007-2018) for alpha-thalassemia; and from 0.2 in Spain (2014-2017) to 35.7 to 49.6 in Iraq (2003-2018) for beta-thalassemia. Overall, the estimated prevalence of thalassemia followed the predicted pattern of being higher in the Middle East, Asia, and Mediterranean than in Europe or North America. However, population-based prevalence estimates were not found for many countries, and there was heterogeneity in case definitions, diagnostic methodology, type of thalassemia reported, and details on transfusion requirements. Limited population-based birth prevalence data were found. Twenty-seven studies reported thalassemia prevalence from non-population-based samples. Results from such studies likely do not have countrywide generalizability as they tended to be from highly specific groups. To fully understand the global prevalence of thalassemia, up-to-date, population-based epidemiological data are needed for many countries.

Do patient access schemes for high-cost cancer drugs deliver value to society?-lessons from the NHS Cancer Drugs Fund

BACKGROUND

The NHS Cancer Drugs Fund (CDF) was established in 2010 to reduce delays and improve access to cancer drugs, including those that had been previously appraised but not approved by NICE (National Institute for Health and Care Excellence). After 1.3 billion GBP expenditure, a UK parliamentary review in 2016 rationalized the CDF back into NICE.

METHODS

This paper analyses the potential value delivered by the CDF according to six value criteria. This includes validated clinical benefits scales, cost-effectiveness criteria as defined by NICE and an assessment of real-world data. The analysis focuses on 29 cancer drugs approved for 47 indications that could be prescribed through the CDF in January 2015.

RESULTS

Of the 47 CDF approved indications, only 18 (38%) reported a statistically significant OS benefit, with an overall median survival of 3.1 months (1.4-15.7 months). When assessed according to clinical benefit scales, only 23 (48%) and 9 (18%) of the 47 drug indications met ASCO and ESMO criteria, respectively. NICE had previously rejected 26 (55%) of the CDF approved indications because they did not meet cost-effectiveness thresholds. Four drugs-bevacizumab, cetuximab, everolimus and lapatinib-represented the bulk of CDF applications and were approved for a total of 18 separate indications. Thirteen of these indications were subsequently delisted by the CDF in January 2015 due to insufficient evidence for clinical benefit-data which were unchanged since their initial approval.

CONCLUSIONS

We conclude the CDF has not delivered meaningful value to patients or society. There is no empirical evidence to support a 'drug only' ring fenced cancer fund relative to concomitant investments in other cancer domains such as surgery and radiotherapy, or other noncancer medicines. Reimbursement decisions for all drugs and interventions within cancer care should be made through appropriate health technology appraisal processes.

Active galaxies. A fast and long-lived outflow from the supermassive black hole in NGC 5548

Supermassive black holes in the nuclei of active galaxies expel large amounts of matter through powerful winds of ionized gas. The archetypal active galaxy NGC 5548 has been studied for decades, and high-resolution x-ray and ultraviolet (UV) observations have previously shown a persistent ionized outflow. An observing campaign in 2013 with six space observatories shows the nucleus to be obscured by a long-lasting, clumpy stream of ionized gas not seen before. It blocks 90% of the soft x-ray emission and causes simultaneous deep, broad UV absorption troughs. The outflow velocities of this gas are up to five times faster than those in the persistent outflow, and, at a distance of only a few light days from the nucleus, it may likely originate from the accretion disk.

Does the cancer drugs fund lead to faster uptake of cost-effective drugs? A time-trend analysis comparing England and Wales

Background:

The Cancer Drugs Fund (CDF) provides £200 million annually in England for ‘anti-cancer' drugs.

Methods:

We used a controlled pre-/post-intervention design to compare IMS Health dispensing data for 15 cancer drugs (2007–2012) in England vs Wales, stratified by pre-CDF NICE drug approval status (rejected, mixed recommendations, recommended, not appraised).

Results:

The CDF was associated with increased prescribing in England for three of five drugs rejected or with mixed NICE recommendations. The prescribing volume ratios (PVR) ranged from 1.29 (95% CI 1.00, 1.67) for sorafenib to 3.28 (2.59, 4.14) for bevacizumab (NICE rejected) and 0.93 (0.81, 1.06) and 1.35 (1.21, 1.49) for sunitinib and imatinib respectively (mixed recommendations). Post CDF prescribing in England increased for both drugs awaiting NICE appraisal pre-CDF (lapatinib PVR=7.44 (5.81, 9.54), panitumumab PVR=5.40 (1.20, 24.42)) and subsequently rejected. The CDF was not associated with increased prescribing in England of NICE-recommended drugs. The three most recently launched, subsequently recommended drugs were adopted faster in Wales (from pazopanib PVR=0.51 (0.28, 0.96) to abiraterone PVR=0.78 (0.61–0.99)).

Interpretation:

These data indicate that the CDF is used to access drugs deemed not cost-effective by NICE. The CDF did not expedite access to new cost-effective cancer agents prior to NICE approval.

Donor-derived organ transplant transmission of coccidioidomycosis

Coccidioidomycosis in solid organ transplant recipients most often occurs as a result of primary infection or reactivation of latent infection. Herein, we report a series of cases of transplant-related transmission of coccidioidomycosis from a single donor from a non-endemic region whose organs were transplanted to 5 different recipients. In all, 3 of the 5 recipients developed evidence of Coccidioides infection, 2 of whom had disseminated disease. The degree of T-cell immunosuppression and timing of antifungal therapy initiation likely contributed to development of disease and disease severity in these recipients. This case series highlights the importance of having a high index of suspicion for Coccidioides infection in solid organ transplant recipients, even if the donor does not have known exposure, given the difficulties of obtaining a detailed and accurate travel history from next-of-kin.

Phase II breast cancer chemoprevention trial of the third generation selective estrogen receptor modulator arzoxifene

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Background: Arzoxifene (ARZ) is a third generation SERM with efficacy in metastatic breast cancer but lacking uterine agonist activity. Methods: We conducted a randomized, double-blind, placebo-controlled Phase II prevention trial in 199 high risk women assessing the effects of ARZ 20 mg/day on several risk biomarkers. Biomarkers, including cytomorphology of breast epithelial cells obtained by random periareolar FNA (RPFNA) were assessed at baseline and following 6 months of placebo or ARZ. Subjects were stratified by presence or absence of atypia, ER expression, BRCA1/2 mutation, as well as menopause status. Results: At entry, mean age was 47, 52% were premenopausal and 47% of postmenopausal women were taking HRT. Mean 10 year Gail was 6.8% and mean Masood cytology index score was 14.3. The ARZ and placebo groups were well matched. The protocol defined primary endpoint was a decrease in RPFNA cytology Masood index score by ≥3 points at 6 months and required 160 evaluable subjects for 81% power to detect a change from 30% to 52% of subjects showing improvement. For the 181 evaluable subjects, there was no significant difference in the proportion of women achieving ≥3 point improvement (19% placebo vs. 24% ARZ, p=0.46); or in change in mean index score (0.6 placebo vs. 0.9 ARZ, p=0.53). There was also no difference in grade 3 or 4 side effects or dropout prior to 6 months. However, comparing ARZ to placebo, there was favorable modulation of the two risk biomarkers, mammographic breast density (p=0.001) and IGF-1:IGFBP-3 ratio (p=0.001), and reduction in bone turnover biomarker osteocalcin (p= 0.002), but without an increase in endometrial thickness. Conclusions: Although improvement in cytomorphology after 6 months of ARZ was not shown, the acceptable side effect profile and favorable modulation of other biomarkers (breast density, IGF-1:IGFBP-3, osteocalcin) provides support for continued evaluation of ARZ as a breast cancer prevention agent.

No significant financial relationships to disclose.

Effect of the third generation selective estrogen receptor modulator arzoxifene on mammographic breast density

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Background: Arzoxifene (ARZ) is currently being studied for treatment of breast cancer patients in a Phase II trial because of tamoxifen-like efficacy but lack of uterine agonist effect. We conducted a Phase II chemoprevention trial in women at high risk for development of breast cancer on the basis of personal or family history. Methods: Potential subjects had multiple biomarkers assessed, including random periareolar fine needle aspiration (RPFNA) with breast epithelial cells processed for cytomorphology and immunocytochemistry. Women who exhibited cytologic hyperplasia ± atypia were eligible for enrollment. Subjects were stratified on the basis of atypia, estrogen receptor expression, menopause status, germline BrCa1/2 mutation status, and accrual site. Subjects were randomized (double-blind) between placebo and ARZ (LY353381.HCI, 20 mg daily) for 6 mo, with an option to continue on study for another 6 mo while receiving open-label ARZ. Assessments conducted at baseline, 6 mo, and 12 mo included mammographic breast density. Mammograms were digitized to image files which were cropped to remove labels and dates, and then identified by a study subject ID number and a random coding for baseline, 6 or 12 mo. This allowed the reader (GU) to view the three files for a subject, but to remain blinded as to the sequence of the films or the study agent. The files were assessed for mammographic density using the Madena computer-assisted system. Results: Of 199 subjects enrolled on the study, 52% were pre-menopausal; with 101 women randomized to placebo and 98 to ARZ. At baseline, mean values were comparable for placebo and ARZ groups for breast area (∼244 cm2), total dense area (∼100 cm2), and the percent of the breast at increased density (41.3% vs 46.2%). After 6 mo, there were minimal changes in total breast area (P=0.13); but statistically significant decreases (P<0.001) for the comparison of placebo vs ARZ (2-sided T-test) for change in both dense area (+3.8 vs −12.9 cm2) and percent breast density (+0.8% vs −4.6%). Conclusions: The 3rd generation SERM arzoxifene administered for 6 mo produces statistically significant decreases in mammographic breast density relative to placebo in women at high risk for development of breast cancer.

No significant financial relationships to disclose.

Interventions for promoting smoking cessation during pregnancy

BACKGROUND

Smoking remains one of the few potentially preventable factors associated with low birthweight, preterm birth and perinatal death.

OBJECTIVES

To assess the effects of smoking cessation programs implemented during pregnancy on the health of the fetus, infant, mother, and family.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Tobacco Addiction Group trials register (July 2003), MEDLINE (January 2002 to July 2003), EMBASE (January 2002 to July 2003), PsychLIT (January 2002 to July 2003), CINAHL (January 2002 to July 2003), and AUSTHEALTH (January 2002 to 2003). We contacted trial authors to locate additional unpublished data. We handsearched references of identified trials and recent obstetric journals.

SELECTION CRITERIA

Randomised and quasi-randomised trials of smoking cessation programs implemented during pregnancy.

DATA COLLECTION AND ANALYSIS

Four reviewers assessed trial quality and extracted data independently.

MAIN RESULTS

This review included 64 trials. Fifty-one randomised controlled trials (20,931 women) and six cluster-randomised trials (over 7500 women) provided data on smoking cessation and/or perinatal outcomes. Despite substantial variation in the intensity of the intervention and the extent of reminders and reinforcement through pregnancy, there was an increase in the median intensity of both 'usual care' and interventions over time. There was a significant reduction in smoking in the intervention groups of the 48 trials included: (relative risk (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.95), an absolute difference of six in 100 women continuing to smoke. The 36 trials with validated smoking cessation had a similar reduction (RR 0.94, 95% CI 0.92 to 0.95). Smoking cessation interventions reduced low birthweight (RR 0.81, 95% CI 0.70 to 0.94) and preterm birth (RR 0.84, 95% CI 0.72 to 0.98), and there was a 33 g (95% CI 11 g to 55 g) increase in mean birthweight. There were no statistically significant differences in very low birthweight, stillbirths, perinatal or neonatal mortality but these analyses had very limited power. One intervention strategy, rewards plus social support (two trials), resulted in a significantly greater smoking reduction than other strategies (RR 0.77, 95% CI 0.72 to 0.82). Five trials of smoking relapse prevention (over 800 women) showed no statistically significant reduction in relapse.

REVIEWERS' CONCLUSIONS

Smoking cessation programs in pregnancy reduce the proportion of women who continue to smoke, and reduce low birthweight and preterm birth. The pooled trials have inadequate power to detect reductions in perinatal mortality or very low birthweight.

A community based, patient-centred, longitudinal medical curriculum

The School of Rural Health is an initiative of the Australian Commonwealth Government, the University of New South Wales, Australia, and the Greater Murray Area Health Service. The school was established in February 2000 to facilitate the recruitment of doctors to and their retention in rural areas. The school is responsible for providing an education program for half of the three-year clinical component of the six-year undergraduate course. This article outlines the educational philosophies and methodologies employed in the development of a community-based, patient-centred, longitudinal approach to medical education. Although developed for and delivered in a rural setting, the curriculum could easily be adapted for implementation in an urban setting. The article presents a synopsis of experiences during the initial implementation of the curriculum, and it provides recommendations for future developments.

Localized Rac activation dynamics visualized in living cells

Signaling proteins are thought to be tightly regulated spatially and temporally in order to generate specific and localized effects. For Rac and other small guanosine triphosphatases, binding to guanosine triphosphate leads to interaction with downstream targets and regulates subcellular localization. A method called FLAIR (fluorescence activation indicator for Rho proteins) was developed to quantify the spatio-temporal dynamics of the Rac1 nucleotide state in living cells. FLAIR revealed precise spatial control of growth factor-induced Rac activation, in membrane ruffles and in a gradient of activation at the leading edge of motile cells. FLAIR exemplifies a generally applicable approach for examining spatio-temporal control of protein activity.

Watching proteins in the wild: fluorescence methods to study protein dynamics in living cells

The advent of GFP imaging has led to a revolution in the study of live cell protein dynamics. Ease of access to fluorescently tagged proteins has led to their widespread application and demonstrated the power of studying protein dynamics in living cells. This has spurred development of next generation approaches enabling not only the visualization of protein movements, but correlation of a protein's dynamics with its changing structural state or ligand binding. Such methods make use of fluorescence resonance energy transfer and dyes that report changes in their environment, and take advantage of new chemistries for site-specific protein labeling.

Ubiquitin-dependent pathway is up-regulated in differentiating lens cells

The mammalian eye lens is composed of two distinct types of cells, epithelial cells and fiber cells. The fiber cells are generated throughout life via continuous differentiation of epithelial cells. Differentiation of lens cells involves dramatic changes in cellular components including altered activity of the ubiquitin dependent pathway. The concentration of high mass ubiquitin conjugates in the mitotically active-, differentiating-equatorial epithelial cells was 5-10 fold higher than that observed in mitotically quiescent, non-differentiated, central epithelial cells, even though there was a significant dilution of non-crystallin proteins due to an increase in level of crystallins in the differentiating cells. Similar observations were made when differentiation was modeled by exposure of lens epithelial explants to bFGF in culture. Activities of ubiquitin-activating enzyme (E1) and ubiquitin-conjugating enzymes (E2s) in the differentiating equatorial epithelial cells were also up to 100% higher than those noted in non-differentiated central epithelial cells and E1 appears to be rate controlling for ubiquitinylation. Consistent with the higher concentrations of high mass ubiquitin conjugates, there was a trend of enhanced ability to execute ATP-dependent protein degradation in the differentiating equatorial epithelial cells as compared with degradation in the non-differentiated central epithelial cells. These data indicate that the ubiquitin dependent pathway is up-regulated during differentiation of lens cells. In the differentiated fibers, the concentration of high mass ubiquitin conjugates and relative activities of E1 and E2s were 50% lower than in the non-differentiated central epithelial cells. In comparison, the concentration of the 110 kDa E1 was unchanged in differentiated fibers. However, if the factor of dilution by the significant increase in the level of crystallins was taken into account, the level or activities of the components of ubiquitin pathway in the differentiated cells was higher than the level noted in non-differentiated cells. These data indicate that, as compared with other non-crystallin proteins, there is differential stabilization and/or synthesis of the 110 kDa E1 and some other components of the ubiquitin dependent pathway in differentiated fibers.

A self-assessment tool to measure older adults' perceptions regarding physical fitness and exercise activity

The purpose of this research was to qualitatively generate and psychometrically assess an instrument which assesses the self-perceived physical fitness and exercise activity levels of community-dwelling older adults and examines perceived factors which enhance or impede their exercise activity level. This research was carried out in two stages: qualitative and quantitative. Items for the instrument were generated through qualitative interviews with 23 community-dwelling older adults, 9 males and 14 females, with an age range of 63 to 82 years. From this qualitative study, 50 items were generated, representing nine categories of elements which enhance or impede physical activity. The 50 items were incorporated into a 4-point, forced-choice, Likert format instrument which was pilot tested for clarity and ease of administration with a convenience sample of community-dwelling older adults. Following the pilot testing, 41 items were retained. The 41-item instrument, entitled Physical Fitness and Exercise Activity Levels of Older Adults Scale, was categorized into the following subscales: Physical Fitness, Barriers, Motivators, and Exercise Frequency. Initial testing of the Physical Fitness and Exercise Activity Levels of Older Adults Scale seems to indicate adequate validity and reliability. Correlation coefficients for the total instrument, as well as the subscales, were significantly positive for both stability and internal consistency. Results with respect to predictive validity were mixed. The Physical Fitness and Motivators subscales were significant predictors of Exercise Frequency. Although the correlation between the Barriers subscale and Exercise Frequency was negative, it was non-significant.

Perceptions of physical fitness and exercise activity among older adults

The purpose of this research was to examine older adults' perceptions of physical fitness and exercise. This qualitative study was divided into four stages as described by Berg (1989): identification of the concept of the study; development of the interview guide; collection of data; and data analysis. Twenty-three older adults, aged 63-82 years (9 females, 14 males), participated in the interviews. Transcripts were analysed using content analysis. Three major themes emerged as the participants viewed physical fitness in terms of: functional independence ('being able to do'); holism ('mind-body works together'); and age reference (-for people my age'). Nine elements which impeded or enhanced physical activity were identified. Implications for education, research and practice are discussed.

Judicial decision-making in contested custody cases: the influence of reported child abuse, spouse abuse, and parental substance abuse

This study examined the relationship between allegations of maltreatment and substance abuse, and custody awards in Florida. Information concerning the presence, or absence, of these reports was collected on 60 contested initial disposition, or disposition modification cases, and was used to model judicial decision-making. Substantiated reports of child and spouse abuse occurred very infrequently in our sample. Conversely, substance abuse allegations occurred much more frequently. Judges appeared responsive to allegations of abuse with regard to awards of primary physical residence, despite the lack of substantiated evidence. Maltreatment allegations had no apparent impact, however, on awards of shared, versus sole, custody. Additionally, reports of parental substance abuse also had no apparent impact on judicial decision-making. Implications of these results are discussed.

Self-report of Guardians Ad Litem: provision of information to judges in child abuse and neglect cases

Reporting patterns of Guardians Ad Litem to judges in cases on child abuse and neglect were studied. Guardians indicated which information they had included in reports to judges in recently adjudicated cases of child abuse and neglect. Information reported in child abuse cases was compared with information reported in neglect cases, and the pattern of reporting was found to be the same in both types of cases. Guardians most frequently included information concerning the child's physical safety, the interaction between the parent(s) and the child, and personality characteristics of the parent(s). Less frequently reported was information regarding conflict in the home and family enmeshment.

Resistance to the Bacillus sphaericus toxin in cultured mosquito cells

Increasing doses of Bacillus sphaericus toxin were used to select a toxin-resistant cell line from the Culex quinquefasciatus line. This resistant cell line was proven to be C. quinquefasciatus in origin by isozyme analysis and karyotype. The resistant line bound fluorescent-labeled toxin as did the unselected susceptible line. A high level of resistance was quickly achieved, and this level was maintained after 4 mo. culture in the absence of toxin.

Molecular studies of Pseudomonas exotoxin A gene

A 2.7-kilobase DNA fragment carrying the entire exotoxin A (ETA) structural gene was divided into three nonoverlapping probes. Two probes covering the ETA structural gene were used in colony hybridization experiments to determine whether sequences homologous to the ETA gene could be detected in genera other than Pseudomonas or in Pseudomonas species other than Pseudomonas aeruginosa. The majority of strains examined other than the P. aeruginosa strains failed to react in the colony hybridization assays. Some Pseudomonas spp. other than P. aeruginosa and some Bordetella spp. did react in colony hybridization assays with the probes. However, additional studies in which we used Southern hybridization methods indicated that these reactions were apparently nonspecific and that the ETA gene is limited to P. aeruginosa. Studies in which we used all three ETA-related probes in Southern hybridization experiments to analyze the ETA gene and surrounding sequences in P. aeruginosa strains isolated from diverse sources revealed the following: (i) the incidence of the ETA gene in P. aeruginosa is approximately equal to 95%; (ii) there are strains which have been isolated from human infections that do not carry the ETA structural gene; (iii) there is a maximum of one copy of the ETA gene per genome in any given strain; (iv) sequences within and 4 to 5 kilobases downstream of the ETA structural gene appear to be well conserved in different strains of P. aeruginosa; and (v) in contrast, sequences immediately upstream of the ETA structural gene are considerably rearranged from strain to strain. A multicopy plasmid carrying the entire cloned ETA gene was transferred to a tox- P. aeruginosa strain. This strain synthesized and secreted mature, full-length ETA, but the amount produced was small considering the multicopy nature of the plasmid. Synthesis of toxin in this strain was only minimally affected by iron. Our data suggest that the synthesis of ETA is positively regulated. Finally, we found that the presence of the ETA gene is independent of the ability of P. aeruginosa to produce several other recognized virulence factors, supporting the concept of the multifactorial nature of P. aeruginosa virulence.

Psychiatric service to the juvenile court. A model

The interface between psychiatry and the law developed unevenly and the greatest concentration has been in the area of criminal behaviour—family law and juvenile deliquency have been relatively ignored. When developing a clinical service in relation to a Family Court, the lack of literature on the subject became obvious. This paper gives an account of the historical development of the Family Court Clinic in Toronto beginning in 1920 at the time of the appointment of the first full-time Juvenile Court Judge. In terms of the problems and limitations the development of this clinic was typical of similar ventures elsewhere in North America. These problems include insufficient funding and staffing, unrealistic demands for service by the Courts, and incomplete understanding of the operation and needs of Courts on the part of mental health workers. A Family Court Clinic at the Clarke Institute of Psychiatry is offered as an example of a survivor of these and other vicissitudes, with the hope that some of its policies and practices may be useful to those involved in this work. It is felt that several ingredients are responsible for the success of the clinic, among them being attachment to a university clinical setting, a flexible appointment schedule such as evening office hours and the avoidance of a solely diagnostic approach to the work. In the past many clinics have failed because they were chiefly assessment-oriented, offering formulations of the problems but very little in the way of remedies. While unable to provide ongoing treatment for its very large clientele, the clinic operates in such a way as to provide a very broad range of service including a referral policy which treats the process of referral to other services more as a ‘service brokerage’ than the more conventional procedure of a referral letter. This is a much more active involvement which does not cease until the patient has begun receiving a service.

Other programs of the clinic in relation to the Juvenile Court are mentioned in the paper and include training programs for judges and other court staff and also research activity. Experience over the past five years with the clinic is discussed in terms of the difficulties encountered in development and the attempts to resolve these. There is a need for clinicians involved in such enterprises to share problems and solutions and to anticipate increasing demands upon psychiatrists for service in relation to family law and family courts.