Phase 3, multicentre, randomised, placebo-controlled study evaluating the efficacy and safety of ustekinumab in patients with systemic lupus erythematosus

OBJECTIVE

Evaluate the efficacy and safety of ustekinumab, an anti-interleukin-12/23 p40 antibody, in a phase 3, randomised, placebo-controlled study of patients with active systemic lupus erythematosus (SLE) despite receiving standard-of-care.

METHODS

Active SLE patients (SLE Disease Activity Index 2000 (SLEDAI-2K) ≥6 during screening and SLEDAI-2K ≥4 for clinical features at week 0) despite receiving oral glucocorticoids, antimalarials, or immunomodulatory drugs were randomised (3:2) to receive ustekinumab (intravenous infusion ~6 mg/kg at week 0, followed by subcutaneous injections of ustekinumab 90 mg at week 8 and every 8 weeks) or placebo through week 48. The primary endpoint was SLE Responder Index (SRI)-4 at week 52, and major secondary endpoints included time to flare through week 52 and SRI-4 at week 24.

RESULTS

At baseline, 516 patients were randomised to placebo (n=208) or ustekinumab (n=308). Following the planned interim analysis, the sponsor discontinued the study due to lack of efficacy but no safety concerns. Efficacy analyses included 289 patients (placebo, n=116; ustekinumab, n=173) who completed or would have had a week 52 visit at study discontinuation. At week 52, 44% of ustekinumab patients and 56% of placebo patients had an SRI-4 response; there were no appreciable differences between the treatment groups in the major secondary endpoints. Through week 52, 28% of ustekinumab patients and 32% of placebo patients had a British Isles Lupus Assessment Group flare, with a mean time to first flare of 204.7 and 200.4 days, respectively. Through week 52, 70% of ustekinumab patients and 74% of placebo patients had ≥1 adverse event.

CONCLUSIONS

Ustekinumab did not demonstrate superiority over placebo in this population of adults with active SLE; adverse events were consistent with the known safety profile of ustekinumab.

TRIAL REGISTRATION NUMBER

NCT03517722.

From Patient to Provider: How Personal Medical Trauma Can Inform Supervision and Clinical Practice

Two predoctoral psychology interns share their personal reflections of neurological injuries they experienced during their adolescence and how it has informed and shaped their clinical work. Through their reflections, they provide insights and lessons learned as they have the unique first-hand experience of being a patient and now a rehabilitation psychology trainee and provider. Additionally, they describe how they have applied such knowledge during their clinical work with clients experiencing neurological and chronic health conditions. Issues involving communication with clients, families, and the treatment teams, the benefits and risks of self-disclosure, and the role of hope, meaning in life, and spirituality are discussed. The clinical practice implications of these insights are invaluable for trainees and healthcare specialists at all levels of experience, including the crucial role of supervision during the predoctoral internship year. Recommendations are made for clinical practice including providing developmentally appropriate communication and promoting an environment for growth and recovery. The authors are hopeful that the reflections provided in this article can inspire other trainees to feel comfortable in sharing their personal medical and psychological challenges as appropriate and relevant to help integrate their professional development.

Efficacy and Safety of Ustekinumab in Patients with Active Systemic Lupus Erythematosus: Results Through 2 Years of an Open-Label Extension in a Phase 2 Study

OBJECTIVE

To evaluate long-term efficacy and safety of ustekinumab through 2 years in patients with active systemic lupus erythematosus (SLE).

METHODS

This was a placebo-controlled (Week24) phase 2 study in 102 patients with seropositive active SLE. Patients were randomized to ustekinumab (~6 mg/kg single IV infusion, then 90 mg SC every 8 weeks) or placebo, added to background therapy. Placebo patients initiated ustekinumab (90mg SC Q8W) at Week24. Patients could enter an optional open-label study extension after Week40 (final ustekinumab administration at Week104). Efficacy assessments included SRI-4, SLEDAI-2K, PGA, and CLASI. Observed data are reported for the extension period. The final efficacy assessment was at Week112; safety was monitored through Week120.

RESULTS

In this subset of patients who entered the study extension, 24 in the ustekinumab group and 14 in the placebo-crossover group completed study treatment. At Week112, 79% and 92%, respectively, had an SRI-4 response, 92% in both groups had ≥4-point improvement from baseline in SLEDAI-2K score, 79% and 93%, respectively, had ≥30% improvement from baseline in PGA, 86% and 91%, respectively, had ≥50% improvement in active joint (pain and inflammation) count, and 79% and 100%, respectively, had ≥50% improvement in CLASI activity score. No deaths, malignancies, opportunistic infections, or tuberculosis cases occurred. Safety events were consistent with the known ustekinumab safety profile.

CONCLUSION

In the 46 patients who entered the voluntary extension of this phase 2 study, clinical benefit in global and organ-specific SLE-activity measures was observed with ustekinumab through 2years with no new or unexpected safety findings. clinicaltrials.gov: NCT02349061.

An International Survey of the Concept of Effective Psychodynamic Treatment During the Pandemic

Introduction: Most psychotherapists had no choice during the COVID-19 pandemic but to offer teletherapy in order to provide needed treatment. Several psychoanalytic theorists wondered if the very concept of treatment would change without an embodied relationship in an office setting. Methods: To attempt to understand the current concept of effective psychodynamic treatment in the new norm of teletherapy, we surveyed practitioners from 56 countries and regions who remotely treated patients psychodynamically during the beginning months of the pandemic. We asked the practitioners to rank six factors felt to be important to psychodynamic treatment: use of the couch during sessions, session in-office or via teletherapy, cultural similarity between therapist and patient, number of sessions a week, patient factors (motivation, insightfulness, and high functioning) and therapist factors (empathy, warmth, wisdom, and skillfulness). Results: We received 1,490 survey responses. As predicted, we found that the therapist and patient variables were considered much more important (both tied as highest rankings) to effective treatment than any of the other variables, including if the therapy was in-office or by teletherapy. Discussion: Psychodynamic practitioners worldwide confirmed that the empathy, warmth, wisdom, and skillfulness of the therapist and the motivation, insightfulness, and level of functioning of the patient are most important to treatment effectiveness regardless if the treatment is remote or embodied.

Suppression of Serum Interferon-γ Levels as a Potential Measure of Response to Ustekinumab Treatment in Patients With Systemic Lupus Erythematosus

OBJECTIVE

In a previously reported phase II randomized, placebo-controlled, interventional trial, we demonstrated that treatment with ustekinumab, an anti-interleukin-12 (IL-12)/IL-23 p40 neutralizing monoclonal antibody, improved global and organ-specific measures of disease activity in patients with active systemic lupus erythematosus (SLE). Utilizing the biomarker data from this phase II clinical study, we sought to determine whether modulation of the expression of IL-12, IL-23, or both cytokines by ustekinumab is associated with clinical efficacy in patients with SLE.

METHODS

This phase II randomized, placebo-controlled study enrolled 102 patients with autoantibody-positive SLE whose disease remained active despite standard-of-care therapy. Patients were randomized at a 3:2 ratio to receive ~6 mg/kg ustekinumab intravenously or placebo at week 0, followed by subcutaneous injections of 90 mg ustekinumab or placebo every 8 weeks, with placebo crossover to 90 mg ustekinumab every 8 weeks. The SLE Responder Index 4 (SRI-4) at week 24 was used to determine which patients could be classified as ustekinumab responders and which could be classified as nonresponders. In addition to measurements of p40 and IL-23, serum levels of interferon-γ (IFNγ), IL-17A, IL-17F, and IL-22, as a proxy for the IL-12 and IL-23 pathways, were quantified by immunoassay.

RESULTS

Changes in the serum levels of IL-17A, IL-17F, and IL-22 at different time points after treatment were not consistently significantly associated with an SRI-4 clinical response to ustekinumab in patients with SLE. In contrast, an SRI-4 response to ustekinumab was significantly associated (P < 0.01) with durable reductions in the serum IFNγ protein levels at several time points relative to baseline, which was not observed in ustekinumab nonresponders or patients who received placebo.

CONCLUSION

While not diminishing a potential role of IL-23, these serum biomarker assessments indicate that IL-12 blockade has an important role in the mechanism of action of ustekinumab treatment in patients with SLE.

Comparing Chinese and US practitioners' attitudes towards teletherapy during the COVID-19 pandemic

INTRODUCTION

The China American Psychoanalytic Alliance (CAPA) has been offering psychoanalytic psychotherapy training and treatment to Chinese mental health professionals entirely over the Internet since 2006. When the COVID-19 pandemic began, most practitioners worldwide had to turn to teletherapy. US psychoanalytic practitioners were more negative towards teletherapy than those from other theoretical orientations. We predicted that CAPA practitioners as compared to US psychoanalytic practitioners would be more prepared for teletherapy services during the pandemic, since they their training and treatment had been on-line.

METHOD

We compared survey results from 164 CAPA practitioners with 165 US psychoanalytic practitioners (matched for age) who had recently psychoanalytically treated a patient on-line. CAPA participants were recruited from CAPA email lists and the US sample were recruited from the Society for Psychoanalysis and Psychoanalytic Psychology of the American Psychological Association, the American Psychoanalytic Association and International Psychotherapy Institute.

RESULTS

CAPA practitioners as compared to US psychoanalytic practitioners had more positive opinions about teletherapy before the pandemic; had more positive opinions about teletherapy during the pandemic; and had more positive opinions about the effectiveness of teletherapy in working with transference, relational issues and resistance. The CAPA practitioners were more prepared to do psychoanalytic psychotherapy during the pandemic than the US psychoanalytic practitioners.

DISCUSSION

Xiubing Wang discusses these findings in terms of her own experience as a CAPA graduate and treater before, during and after the COVID-19 pandemic in China.

Existential–Humanistic and Relational Psychotherapy During COVID-19 With Patients With Preexisting Medical Conditions

Unexpected traumatic events, including life-threatening medical conditions, brain injuries, and pandemics, can be catalysts for patients and clinicians to consider existential issues, including meaning in life. The existential–humanistic and relational perspectives on therapeutic interventions emphasize creating meaning, taking responsibility for one’s own life and self-narratives, choosing and actualizing ways of being in the world that are consistent with values, and expanding the capacity for agency, commitment, and action. Myriad factors have made the COVID-19 pandemic upsetting and potentially traumatic for individuals, including the novel experience of self and other as possibly infectious and dangerous, a sense that anyone is vulnerable, and protracted uncertainty about the duration of the crisis and its consequences. The vignettes included in this article explore risk and reliance factors relevant to patients with preexisting medical conditions during COVID-19 and highlight the benefits of exploring values, priorities, and assumptions, asking open-ended questions about meaning in life and posttraumatic growth, learning for each emotion, and interpretation of dreams. The existential–humanistic and relational approaches offer unique insights into how practitioners might help their patients to reflect on the unanticipated changes and anxieties ignited by COVID-19, while reinforcing the potential to live with greater purpose and intention.

Maintenance of Efficacy and Safety of Ustekinumab Through One Year in a Phase II Multicenter, Prospective, Randomized, Double-Blind, Placebo-Controlled Crossover Trial of Patients With Active Systemic Lupus Erythematosus

OBJECTIVE

To evaluate the efficacy and safety of ustekinumab through 1 year in a phase II trial in patients with systemic lupus erythematosus (SLE).

METHODS

Eligible patients were diagnosed as having clinically active SLE (based on Systemic Lupus International Collaborating Clinics criteria), despite standard background therapy. Active disease was defined by an SLE Disease Activity Index 2000 (SLEDAI-2K) score of ≥6 as well as having ≥1 British Isles Lupus Assessment Group (BILAG) A organ domain score and/or ≥2 BILAG B organ domain scores present at screening. Patients (n = 102) were randomized (3:2) to receive either ustekinumab (~6 mg/kg of single intravenous infusion at week 0, then 90-mg subcutaneous injections every 8 weeks beginning at week 8) or a matching placebo added to standard therapy. At week 24, the placebo group crossed over to receive a subcutaneous 90-mg dose of ustekinumab every 8 weeks, and the original ustekinumab group continued to receive therapy through week 40. Maintenance of efficacy was assessed using the SLEDAI-2K, the SLE Responder Index 4 (SRI-4), physician global assessment, and mucocutaneous and joint disease measures in a modified intent-to-treat population.

RESULTS

SRI-4 response rates were significantly greater in the ustekinumab group (62%) versus the placebo group (33%) in the week 24 primary end point analysis (P = 0.006) and were maintained at week 48 (63.3%) in the ustekinumab group. In the ustekinumab group, response rates across other disease measures were also maintained through week 48. Among patients in the placebo group who crossed over to ustekinumab treatment (n = 33), increased response rates across efficacy measures were noted. Among all ustekinumab-treated patients, 81.7% had ≥1 adverse event (AE), and 15.1% had ≥1 serious AE through week 56. No deaths, malignancies, opportunistic infections, or tuberculosis cases were observed.

CONCLUSION

Ustekinumab provided sustained clinical benefit in patients with SLE through 1 year, with a safety profile consistent with other indications.

Efficacy and safety of ustekinumab, an IL-12 and IL-23 inhibitor, in patients with active systemic lupus erythematosus: results of a multicentre, double-blind, phase 2, randomised, controlled study

BACKGROUND

Ustekinumab is a monoclonal antibody targeting interleukin (IL)-12 and IL-23 and is approved for the treatment of plaque psoriasis, psoriatic arthritis, and Crohn's disease. IL-12 and IL-23 have been implicated in systemic lupus erythematosus. We aimed to assess the efficacy and safety of ustekinumab for the treatment of systemic lupus erythematosus in patients with moderate-to-severe disease activity despite conventional treatment.

METHODS

This was a multicentre, double-blind, phase 2, randomised, controlled trial of adult patients with active, seropositive systemic lupus erythematosus, done at 44 private practices and academic centres in Argentina, Australia, Germany, Hungary, Mexico, Poland, Spain, Taiwan, and the USA. Eligible adults were aged 18-75 years, weighed at least 35 kg, and had a diagnosis of systemic lupus erythematosus at least 3 months before the first administration of study drug. Eligible patients were randomly assigned (3:2) to the ustekinumab or placebo group using an interactive web response system with stratification by skin biopsy, lupus nephritis presence, baseline systemic lupus erythematosus medications and systemic lupus erythematosus disease activity index 2000 (SLEDAI-2K) score combined factor, site, region, and race. Patients and investigators were masked to treatment allocation. Patients received an intravenous infusion of ustekinumab (260 mg for patients weighing 35-55 kg, 390 mg for patients weighing >55 kg and ≤85 kg, and 520 mg for patients weighing >85 kg) followed by subcutaneous injections of ustekinumab 90 mg every 8 weeks or intravenous infusion of placebo at week 0 followed by subcutaneous injections of placebo every 8 weeks, both in addition to standard-of-care therapy. The primary endpoint was the proportion of patients achieving a SLEDAI-2K responder index-4 (SRI-4) response at week 24. Efficacy analyses were done in a modified intention-to-treat population of patients who received at least one dose (partial or complete, intravenous or subcutaneous) of their randomly assigned study treatment. Safety analyses were done in all patients who received at least one dose of study treatment, regardless of group assignment. This study is registered at ClinicalTrials.gov, number NCT02349061.

FINDINGS

Between Oct 6, 2015, and Nov 30, 2016, 166 patients were screened, of whom 102 were randomly assigned to receive ustekinumab (n=60) or placebo (n=42). At week 24, 37 (62%) of 60 patients in the ustekinumab group and 14 (33%) of 42 patients in the placebo group achieved an SRI-4 response (percentage difference 28% [95% CI 10-47], p=0·006). Between week 0 and week 24, 47 (78%) of 60 patients in the ustekinumab group and 28 (67%) of 42 patients in the placebo group had at least one adverse event. Infections were the most common type of adverse event (27 [45%] in the ustekinumab group vs 21 [50%] in the placebo group). No deaths or treatment-emergent opportunistic infections, herpes zoster, tuberculosis, or malignancies occurred between weeks 0-24.

INTERPRETATION

The addition of ustekinumab to standard-of-care treatment resulted in better efficacy in clinical and laboratory parameters than placebo in the treatment of active systemic lupus erythematosus and had a safety profile consistent with ustekinumab therapy in other diseases. The results of this study support further development of ustekinumab as a novel treatment in systemic lupus erythematosus.

FUNDING

Janssen Research & Development, LLC.

Assessing Distance Training: How Well Does It Produce Psychoanalytic Psychotherapists?

How effective is psychoanalytic/psychodynamic distance training over the Internet? To assess this, we surveyed graduates of the 2-year and 4-year programs of the China America Psychoanalytic Alliance (CAPA). The main results of the 90 graduates' surveys showed that 77% of their work involves a psychoanalytic formulation of their cases as compared to other theoretical orientations. Graduates highly rated the effectiveness of their own psychoanalytic therapy over videoconferencing (VCON). Graduates' ratings of treatment with their patients over VCON positively correlated with years of psychoanalytic education, number of days a week in own treatment, years doing psychoanalytic treatment, and degree working with a psychoanalytic orientation. Graduates thought that therapist variables (skillfulness, warmth, empathy, and wisdom) were much more important in the effectiveness of their treatment than whether the treatment was in-person or with VCON, or the presence of cultural differences with their therapist. The graduates' ratings of how they are practicing psychoanalytic treatment were highly correlated with how their own therapists practiced psychoanalytic psychotherapy, as measured by the psychodynamic/interpersonal process items on the Comparative Psychotherapy Process Scale (CPPS).

False Assumptions about Psychopathology, Hysteria and the MMPI-2 Restructured Clinical Scales

The MMPI-2 Restructured Clinical scales rest on the common behavioral assumption that consistent items can be added to assess all psychopathologies. This may be the case for some unitary symptoms such as anxiety or anger, but not for complex diagnostic conditions such as Hysteria, Post Traumatic Stress Disorder, and Borderline Personality Disorder. These are better understood with a psychodynamic formulation. Psychodynamic theory assumes that internal conflicts and contradictions are a significant feature of many psychopathologies. For example, the new MMPI-2 Restructured Clinical scales eliminated a measure of hysteria. The RC3 Cynicism scale is not an improvement over the MMPI-2 Hysteria scale, as the new scale serves as an example of a failure of the behaviorism to account for complex psychopathology. Making scales more internally consistent and distinct from each other has not produced more external validity and useful measures for many of the psychopathologies found in clinical practice.

Reliability Study of the Defense Mechanism Inventory

Aims of this study are to replicate and elucidate reliability characteristics of the Defense Mechanism Inventory (Gleser & Ihilevich, 1969). College students (Men = 47, Women = 47) were administered the Defense Mechanism Inventory on two occasions separated by a 17-day interval. Whereas test-retest reliabilities for both the total and the women approximated the ranges reported by Gleser and Ihilevich (1969), the range of correlations for the men had a much lower limit. Significant sex differences were found on four of the five dimensions.

Reliability and Validity of the Southern California Ordinal Scales of Development for a Sample of Young Children with Disabilities

The primary purpose of this study was to investigate the reliability and validity of the Southern California Ordinal Scales of Development (SCOSD). The SCOSD is a criterion-referenced test that assesses six domains of development and was designed for use with children with disabilities. Results found that the SCOSD alpha internal consistency coefficients ranged from .94 to .98; percent agreement between raters ranged from 85% to 100%; and interrater correlations ranged from .96 to .99. Strong intercorrelations were found between the SCOSD and standardized domain-specific instruments (.65 to .92), providing evidence of concurrent validity. The secondary purpose was to investigate patterns of development across domains of the children's functioning. As expected, results revealed a hierarchy of skill development, with the children showing relatively less development in gross-motor skills and practical abilities.

Comparing Psychodynamic Teaching, Supervision, and Psychotherapy Over Videoconferencing Technology with Chinese Students

How do experts compare teaching, supervision, and treatment from a psychodynamic perceptive over the Internet with in-person work? Our methodology was based on the expert opinions of 176 teachers, supervisors, and therapists in the China American Psychoanalytic Alliance (CAPA) who use videoconferencing (VCON) with Chinese students. The results from our online survey indicate: (1), The longer teachers teach, the more effective they rate teaching over VCON; (2), Teaching, supervision, and treatment were all rated in the range of "slightly less effective" than in-person, with supervision rated significantly more effective than teaching and treatment over VCON; (3), When doing psychodynamic treatment over VCON the issues of symptom reduction, exploring mental life, working on transference, relational problems, resistance, privacy issues, countertransference, are all equally rated in the range of "slightly less effective" than in-person treatment; (4), The highest significantly rated indications for treatment over VCON are: "To offer high quality treatment to underserved or remote patients" and "When patient is house-bound or travel would be impractical"; and (5), The highest significantly rated contraindication for treatment over VCON is: "Patient needs close observation due to crisis or decompensation." Overall, this survey suggests that VCON teaching, supervision, and treatment from a psychodynamic perceptive is a worthwhile option when considering its unique contribution to extending services where needed.

Type III home sleep testing versus pulse oximetry: is the respiratory disturbance index better than the oxygen desaturation index to predict the apnoea-hypopnoea index measured during laboratory polysomnography?

OBJECTIVES

In its guidelines on the use of portable monitors to diagnose obstructive sleep apnoea, the American Academy of Sleep Medicine endorses home polygraphy with type III devices recording at a minimum airflow the respiratory effort and pulse oximetry, but advises against simple pulse oximetry. However, oximetry is widely available and simple to use in the home. This study was designed to compare the ability of the oxygen desaturation index (ODI) based on oximetry alone with a stand-alone pulse oximeter (SPO) and from the oximetry channel of the ApneaLink Plus (ALP), with the respiratory disturbance index (RDI) based on four channels from the ALP to predict the apnoea-hypopnoea index (AHI) from laboratory polysomnography.

DESIGN

Cross-sectional diagnostic accuracy study.

SETTING

Sleep medicine practice of a multispecialty clinic.

PARTICIPANTS

Patients referred for laboratory polysomnography with suspected sleep apnoea. We enrolled 135 participants with 123 attempting the home sleep testing and 73 having at least 4 hours of satisfactory data from SPO and ALP.

INTERVENTIONS

Participants had home testing performed simultaneously with both a SPO and an ALP. The 2 oximeter probes were worn on different fingers of the same hand. The ODI for the SPO was calculated using Profox software (ODI(SOX)). For the ALP, RDI and ODI were calculated using both technician scoring (RDI(MAN) and ODI(MAN)) and the ALP computer scoring (RDI(RAW) and ODI(RAW)).

RESULTS

The receiver-operator characteristic areas under the curve for AHI ≥ 5 were RDI(MAN) 0.88 (95% confidence limits 0.81-0.96), RDI(RAW) 0.86 (0.76-0.94), ODI(MAN) 0.86 (0.77-0.95), ODI(RAW) 0.84 (0.75-0.93) and ODI(SOX) 0.83 (0.73-0.93).

CONCLUSIONS

We conclude that the RDI and the ODI, measured at home on the same night, give similar predictions of the laboratory AHI, measured on a different night. The differences between the two methods are small compared with the reported night-to-night variation of the AHI.

The Relationship between Theoretical Orientation and Countertransference Expectations: Implications for Ethical Dilemmas and Risk Management

Countertransference (CT) awareness is widely considered valuable for differential diagnosis and the proactive management of ethical dilemmas. We predicted that the more practitioners' theoretical orientation (TO) emphasizes insight into the dynamics of subjective mental life, the better they will be at using their CT expectations in differential diagnosis with high-risk patients. To test this hypothesis, we compared psychodynamic therapy (PDT) practitioners who emphasize insight into subjective mental life with practitioners who do not emphasize this epistemology. Results indicated that PDT practitioners expected significantly more CT than practitioners of cognitive-behavioural therapy (CBT) and other practitioners (e.g., family systems, humanistic/existential and eclectic) to patients with borderline personality organization overall. PDT practitioners had significantly more CT expectations to patients with borderline-level pathologies as compared with neurotic-level patients than both CBT and other practitioners. PDT practitioners were significantly more expectant of CT issues than CBT practitioners with respect to the personality disorders most associated with acting out and risk management problems (e.g., paranoid, psychopathic, narcissistic, sadistic, sadomasochistic, masochistic, hypomanic, passive-aggressive, counterdependent and counterphobic). The other practitioners generally had CT expectations between PDT and CBT. These findings suggest that clinical training into CT may be useful in differential diagnoses and in helping to avoid ethical dilemmas regardless of one's theoretical preference. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Insight into countertransference can be used to help with differential diagnoses and to help prevent possible management problems with acting out patients. The Psychodynamic Diagnostic Manual is a useful taxonomy in that it includes countertransference as a diagnostic aid.

PP164. Magnesium sulphate for prevention and treatment of eclampsia in low and middle income countries: Systematic review of tested regimens

INTRODUCTION

Magnesium sulphate (MgSO4) is regarded as the most effective prophylactic and therapeutic agent for eclampsia. Although well studied and widely used in high income countries (HICs), MgSO4 is under utilized in low and middle income countries (LMICs) due to many factors including lack of adequately trained health care providers, supplies for administration, or the MgSO4 itself, in addition to fear of potential adverse effects.

OBJECTIVES

To systematically review the dosing and effectiveness of MgSO4 regimens administered in LMICs to women with pre-eclampsia or eclampsia.

METHODS

We searched Medline, EMBASE, IPA, CINAHL, CDSR and CENTRAL databases for English language randomized controlled trials (RCT) and observational studies of MgSO4 regimens administered in LMICs to women with pre-eclampsia or eclampsia. Two authors independently reviewed search results and extracted relevant data from eligible studies. No quality assessment was performed.

RESULTS

Twenty two papers (7 RCT and 15 observational studies) from 12 LMIC met our inclusion criteria, of which 21 were conducted in hospital settings. Two studied MgSO4 for eclampsia prevention ,14 for eclampsia treatment and 6 studied MgSO4 for both. In 20 studies, both loading and maintenance MgSO4 dosing was administered, with intravenous (IV) or combined IV and intramuscular (IM) loading doses of 4-15g and IV or IM maintenance doses up to 2g/h. Five studies used only the IV route of administration, while the remainder coupled IV with IM administration. All studies were effective at preventing the initiation and/or recurrence of eclamptic seizures. One study of 265 women with eclampsia found that MgSO4 loading dose administration in the community (4g IV over 20min plus 3g IM in each buttock) before referral and administration of maintenance therapy in hospital was more effective in decreasing recurrent eclampsia compared with the standard practice of referral to hospital where the initial dose of MgSO4 was administered [RR of 0.23, 95% CI 0.11, 0.49]. The two studies of 4g IV plus 10g IM loading dose-only regimens did not show a significant reduction in eclamptic seizures compared with identical loading dose plus 5g/4h IM maintenance dose regimens [RR of 1.38, 95% CI of 0.23, 8.45]. However the combined sample size was small (N=180 women).

CONCLUSION

In LMICs, most studies of MgSO4 for pre-eclampsia or eclampsia were conducted in high level health care facilities and administered MgSO4 by the IV route, at least in part. The one study of community administration of a MgSO4 loading dose showed this approach to be effective. There are limited data to support loading dose-only regimens.

A massive phytoplankton bloom induced by an ecosystem-scale iron fertilization experiment in the equatorial Pacific Ocean

The seeding of an expanse of surface waters in the equatorial Pacific Ocean with low concentrations of dissolved iron triggered a massive phytoplankton bloom which consumed large quantities of carbon dioxide and nitrate that these microscopic plants cannot fully utilize under natural conditions. These and other observations provide unequivocal support for the hypothesis that phytoplankton growth in this oceanic region is limited by iron bioavailability.

Characteristics of successful fakers versus unsuccessful fakers: is empathy, intelligence, or personality associated with faking PTSD on the MMPI-2?

Moyer, Burkhardt, and Gordon found in 2002 that some individuals could fake PTSD on the MMPI-2. In light of these results, a follow-up study was conducted to assess whether attributes such as empathy, intelligence, subjectivity, or insightfulness influenced ability to fake a PTSD profile on the MMPI-2. 35 subjects from the previous study were divided into two groups, successful fakers and unsuccessful fakers. Analysis indicated no significant differences between groups on the measures of empathy or intelligence. However, a significant difference was found between groups on the Schizophrenia and Cynicism scales and falling just short of significance on the Hypochondriasis scale. These results suggested that individuals able to fake PTSD are more insightful and less subjective, which makes them better at role-playing.

Magnetization transfer histograms in clinically isolated syndromes suggestive of multiple sclerosis

In established multiple sclerosis, magnetization transfer ratio (MTR) histograms reveal abnormalities of normal-appearing white matter (NAWM) and grey matter (NAGM). The aim of this study was to investigate for such abnormalities in a large cohort of patients presenting with clinically isolated syndromes suggestive of multiple sclerosis. Magnetization transfer imaging was performed on 100 patients (67 women, 33 men, median age 32 years) a mean of 19 weeks (SD 3.8, range 12-33 weeks) after symptom onset with a clinically isolated syndrome and in 50 healthy controls (34 women, 16 men, median age 32.5 years). SPM99 software was used to generate segmented NAWM and NAGM MTR maps. The volumes of T2 lesions, white matter and grey matter were calculated. Eighty-one patients were followed up clinically and with conventional MRI after 3 years (n = 61) or until they developed multiple sclerosis if this occurred sooner (n = 20). Multiple regression analysis was used to investigate differences between patients and controls with age, gender and volume measures as covariates to control for potential confounding effects. The MTR histograms for both NAWM and NAGM showed a reduction in the mean (NAWM, 38.14 versus 38.33, P = 0.001; NAGM 32.29 versus 32.50, P = 0.009; units in pu) and peak location, with a left shift in the histogram. Mean NAWM and NAGM MTR were also reduced in the patients who developed clinically definite multiple sclerosis and multiple sclerosis according to the McDonald criteria but not in the 24 patients with normal T2-weighted brain magnetic resonance imaging (MRI). MTR abnormalities occur in the NAWM and NAGM at the earliest clinical stages of multiple sclerosis.

Elevated white matter myo-inositol in clinically isolated syndromes suggestive of multiple sclerosis

Normal-appearing white matter (NAWM) in established multiple sclerosis has been shown to be abnormal using a variety of magnetic resonance (MR) techniques, including proton MR spectroscopy ((1)H-MRS), although the stage at which these changes first appear is less clear. Using a 1.5 T scanner and single-voxel (1)H-MRS [TR 3000 ms, TE 30 ms, point-resolved spectroscopy (PRESS) localization], we determined NAWM metabolite concentrations in 96 patients a mean of 19 weeks (range 12-28 weeks) after onset of a clinically isolated syndrome (CIS) suggestive of multiple sclerosis and in 44 healthy control subjects. Absolute concentrations of N-acetyl-aspartate, total creatine and phosphocreatine (Cr), choline-containing compounds, glutamate plus glutamine, and myo-inositol (Ins) were estimated automatically using the LCModel. Compared with control subjects, the concentration of Ins was elevated in CIS NAWM (mean 3.31 mM, SD 0.86 versus mean 3.82 mM, SD 1.06; P = 0.001). The increase in Ins was also seen in the patient subgroup with abnormal T2-weighted MRI (mean 3.88 mM, SD 1.10; P = 0.001) and in those who satisfied the McDonald criteria for multiple sclerosis (mean 4.04 mM, SD 1.31; P = 0.001). An increase in Cr was also observed in CIS NAWM (P = 0.023), but other metabolites did not significantly differ between the whole CIS group and control subjects. There was no significant correlation between NAWM Ins and T2 lesion load. The early increase in Ins may reflect a process of pathogenic importance in multiple sclerosis NAWM. Follow-up studies will investigate whether the increase in NAWM Ins is of prognostic importance for future relapses and disability.

Team approaches to treating children with disabilities: a comparison

OBJECTIVE

To investigate differences in team functioning between the multidisciplinary and transdisciplinary models when treating children with disabilities.

DESIGN

A crossover trial.

SETTING

An outpatient educational and rehabilitation program in a rehabilitation institute based at a university medical center.

PARTICIPANTS

A population-based sample of 19 rehabilitation specialists and educators.

INTERVENTION

Participants attended four team meetings using the multidisciplinary approach and then attended four team meetings using the transdisciplinary approach.

OUTCOME MEASURES

Behavioral ratings of team participation (Transdisciplinary Team Rating Scale) and self-report instruments of team development (Team Assessment Questionnaire) and treatment planning and goal development (Staff Perception Questionnaire).

RESULTS

Results of t tests confirmed the hypothesis that there was more team member participation during transdisciplinary meetings than during multidisciplinary meetings (p=.027). There were no differences in levels of team development (p=.329); however, staff members favored the transdisciplinary model for treatment planning and goal development (p < .001).

CONCLUSION

This study provides evidence of the effectiveness of the transdisciplinary model. Further research is now needed to investigate outcome variables such as rate of success in attaining treatment goals when using this model.

Out to pasture: a case for the retirement of Canadian mental health legislation

The emergence of new adult guardianship and related legislation and systems in British Columbia, Ontario, and other jurisdictions has generated questions about the utility of separate mental health legislation. Mental health statutes are the descendents of legislation that once created and regulated separate institutions and systems for the insane (later known as the mentally diseased and, more recently, the mentally ill). Such legislation is no longer consistent with the dominant community care and treatment strategies in the mental health field and the growing trend to recognize and respect consumer involvement in care and treatment decision making. Emerging legislation in the guardianship field makes provision for a range of options and mechanisms that can replace separate mental health statutes (e.g., general consent to health care legislation, and provision for enduring powers of attorney of the person and Ulysses agreements) and produce a new and more effective legal framework for the provision of mental health care and treatment.

Stress, appraisal, and coping in mothers of disabled and nondisabled children

The cognitive-behavioral model of stress and coping provided the framework for this study of mothers of physically disabled children (n = 69) and mothers of nondisabled children (n = 63). The first aim was to test for differences between groups in responses to stressful parenting events. As hypothesized, mothers of disabled children reported higher levels of depressive symptomatology. Differences in psychological distress and health status approached significance. The second aim was to explore the mediating influences of coping strategies and cognitive appraisals. As predicted, emotion-focused coping was related to increased psychological distress in mothers of disabled children whereas problem-focused coping was associated with decreased distress. Both relationships were significant even after controlling for differences in type of parenting stressor. Hierarchical regressions showed that 58 and 25% of the variance in psychological distress was explained by the independent variables; however, the predictors were different for the two groups of mothers. Factors that may explain the differential effectiveness of coping and appraisal, and clinical implications of this study are discussed.

The impact of the Canadian Charter of Rights and Freedoms upon Canadian mental health law: the dawn of a new era or business as usual?

Canadian mental health law has traditionally held many themes in common with the mental health law of other Commonwealth countries such as Britain, Australia, and New Zealand. Until recently, this body of law bore only a passing resemblance to the system of mental health law that has emerged in the United States.

The existence of an entrenched Bill of Rights in the United States has meant that many major issues relating to the rights of mental health patients have been dealt with as constitutional matters of great import. Consequently, the 1960s and 1970s witnessed the burgeoning of an exciting body of case law establishing a number of critical rights for a constituency that had hitherto been powerless and tragically neglected. While many of the rights established in the so-called landmark cases were subsequently limited in their scope or were just not affirmed by the appellate courts, the widespread use of constitutional challenges by mental health advocates wrought wholesale changes in both federal and state legislation and permanently altered the balance of power between mental health professionals and their patients.